Periodontal maintenance following active specialist treatment: Should patients stay put or return to primary dental care for continuing care? A comparison of outcomes based on the literature.

OBJECTIVES: To review the evidence for the efficacy of periodontal maintenance (PM) carried out in primary dental care (PDC) compared to the specialist setting for patients previously treated in a specialist setting for chronic (ChP) or aggressive (AgP) periodontitis. METHODS: A focused PICO question and search protocol were developed. Online databases including MEDLINE, EMBASE, WEB OF SCIENCE™ and COCHRANE LIBRARY were searched along with specialist journals in the subject area of periodontal research. Selection criteria included studies that investigated delivery of PM in both specialist and PDC settings for patients with ChP or AgP over a minimum 12 months. We looked for studies that reported changes in clinical attachment levels (CAL), tooth loss, pocket probing depths (PPDs) and bleeding on probing (BoP) as outcome measures. RESULTS: Eight cohort studies were chosen for inclusion. There was considerable heterogeneity found between the eight studies, which did not allow for quantitative (meta) analysis and statistical testing of differences between groups. Clinical attachment levels remained relatively stable in patients who received specialist PM with mean changes of -0.42 mm to +0.2 mm, while for those enrolled in PDC-based PM for periods >12 months, mean CAL losses were between -0.13 mm and -2.80 mm. PPD reduction for those subjects receiving specialist PM was between 0.05 and 1.8 mm for five studies but two cohorts experienced increases of 0.32 and 0.80 mm, respectively. Increases of up to 2.90 mm (range: -0.1 to +2.90) and a higher proportion of deeper pockets were noted among PDC PM cohorts. Higher rates of BoP among those in receipt of PDC PM were reported in half of all studies. There were insufficient long-term data to make any firm conclusions about the effect of the delivery of PM on tooth loss. CONCLUSION: Within the limitations of the data available, it appears that specialist PM is effective in sustaining periodontal stability following active specialist intervention. There is limited evidence that PDC provides the same level of care; however, the limited comparative data available suggest that outcomes could be slightly worse in PDC.

Primary xanthoma of thoracic spine presenting with myelopathy.

STUDY DESIGN: This retrospective case study reports on a patient with an isolated primary xanthoma arising in the second thoracic vertebra with paravertebral and spinal canal extension. OBJECTIVE: The possibility of this lesion's occurrence in the spine is presented with radiologic and pathologic findings appropriate for the diagnosis of spinal xanthoma. SUMMARY OF BACKGROUND DATA: Primary xanthoma of bone is an extremely rare but benign entity. It has not been previously described in this location, and has been described only once in the spine at all. METHODS: The mass was resected by curettage, and posterior instrumentation was successfully performed. Preoperative radiographs and magnetic resonance imaging of the thoracic spine were performed, as was histologic examination of the lesion. RESULTS: Radiographs of the upper thoracic spine revealed a lytic defect. Magnetic resonance imaging revealed a heterogeneous lesion that was enhanced upon the administration of gadolinium-diethylenetriaminetetraacetic acid. Histologic examination revealed a cellular lesion consisting of lipid-laden macrophages, fibroblasts, and scattered Touton giant cells. These features correspond to descriptions of primary xanthoma of bone. Two years after surgery, the patient was neurologically intact with no evidence the lesion would recur. CONCLUSIONS: Primary xanthoma of bone is considered a benign lesion and can be successfully treated by local resection without adjuvant therapy. It should be considered part of the differential diagnosis of a mass lesion, with appropriate signal characteristics presenting in a thoracic vertebra.

Scalp hibernoma: case report and literature review.

Hibernomas are uncommon, benign neoplasms derived from the remnants of fetal brown adipose tissue. A review of the world literature revealed 105 cases, with the interscapular location the most common. Typically, hibernomas are asymptomatic and slow-growing. Adequate treatment usually consists of simple excision. We describe the second documented case of a scalp hibernoma.

Video-assisted endoscopic thoracic ganglionectomy.

Sympathetic nerve disorders of the upper extremities can be treated by neurosurgeons using upper thoracic sympathectomy via a posterior approach. Descriptions have been published of alternative endoscopic procedures involving thermocoagulation, laser coagulation, or nonvideo-assisted ganglionectomy using equipment not widely available, with low morbidity and excellent results. The authors describe the use of an endoscopic approach to the thoracic sympathetic ganglia with systems designed for laparoscopic cholecystectomy. Thoracic ganglionectomy is reported in 22 patients with primary palmar hyperhidrosis and eight patients with reflex sympathetic dystrophy. The patients underwent double-lumen endotracheal intubation, after which 11- and 5.5-mm trocars were introduced into the chest cavity. Pneumothorax was produced with CO2 insufflation. Fiberoptic closed-circuit television was used to visualize the structures to be dissected. The parietal pleura over the heads of the first and second ribs was excised using 5-mm blunt and sharp insulated coagulating microscissors. The stellate and upper thoracic ganglia were clearly identified and dissected. The T-2 and T-3 ganglia were grasped with forceps and excised. A No. 16 French chest tube was introduced through a trocar, placed under water seal after the lungs were reinflated, and removed in the recovery room. The average hospital stay was 15.4 hours. There were no intraoperative complications. The average operating time was 30 minutes per side. Five patients had mild pleuritic pain which resolved within 2 weeks after surgery. Six (75%) of the eight patients with reflex sympathetic dystrophy had complete or partial relief of their symptoms (average follow-up period 5 months), and all patients had complete relief of hyperhidrosis (average follow-up period 8 months). Endoscopic ganglionectomy requires readily available and easily used instrumentation and provides a well-tolerated, cost-effective alternative to posterior thoracic sympathectomy for primary palmar hyperhidrosis and reflex sympathetic dystrophy.

Penetrating injuries restricted to the cauda equina: a retrospective review.

Thirty-three patients with penetrating injuries to the cauda equina were admitted to Ben Taub General Hospital (1980-1989). Thirty received gunshot injuries, and three had stab wounds. The average age was 30 years, and 30 patients were male. All patients had been admitted within 1 hour of injury and received spine films, myelography, or computed tomography. Deficits were "complete" if total loss of function existed and were "incomplete" if any function remained below the level of injury. Improvement at the end of followup was defined as any recovery of motor strength or regaining of a unilateral sensory level. Twenty-nine (88%) patients had incomplete neurological deficits. Of these, 15 (52%) had surgery, and of this patient group, 7 (47%) improved, 7 (47%) showed no change, and 1 (6%) worsened. Fourteen (48%) patients with incomplete deficits were treated conservatively; 10 (71%) improved, and 4 (29%) had no change. Four patients (12%) had complete deficits, 3 of whom had surgery, and all improved. One patient with a complete deficit was treated conservatively and did not improve. Ten (34%) patients had bowel or bladder dysfunction, and none improved regardless of the type of treatment. Complications (cerebrospinal fluid leak, pseudomeningocele, or wound infection) occurred in 5 (28%) operative patients and 1 (7%) conservatively treated patient. Early neurosurgical intervention for penetrating injuries of the cauda equina may be beneficial but carries an increased risk of complication.

Intraoperative endomyelography during syrinx drainage: technical note.

There is no currently available noninvasive technique to ascertain with certainty the continuity of the cavity of a septated syrinx. A technique is described that allows the confirmation of the continuity before the surgical drainage of a syrinx. This technique may prevent the failure of the drainage because of septations and double cavities. Intraoperative endomyelography is simple to perform and requires no special equipment. Pressure measurements made before the injection of the contrast agent may provide insights into the pathogenesis of the syrinx and may be of prognostic and therapeutic significance.

Respiratory epithelial cyst ventral to the brain stem. Report of a case and review of the literature.

We present the case of a 30-year-old woman who suddenly developed intense occipital headaches. Computed tomography and magnetic resonance imaging demonstrated a cyst located ventrally to the brain stem at the pontomedullary junction. The lesion was resected. Histologically, it was lined by a pseudostratified, ciliated, columnar epithelium indistinguishable from respiratory epithelium. Immunohistochemistry and electron microscopy confirmed the epithelial differentiation of the lining. This case is briefly compared with the few other brain-stem cysts presented in the literature and the concept of their "origin" is discussed.

Spinal intramedullary ependymal cyst. Report of three cases.

Three cases of spinal intramedullary ependymal cyst, two at the thoracolumbar junction and one in the cervical spinal cord, are reported in women in their fifth to seventh decades. Neurological signs and symptoms were extremity dysesthesias, paresthesias, and weakness. Plain cervical and lumbothoracic x-ray films were normal for the patients' age. Magnetic resonance (MR) imaging demonstrated a rounded cystic intramedullary mass at the thoracolumbar junction in two cases and at C3-7 in one case. The signal intensity of the cyst contents approximated that of cerebrospinal fluid on T1- and T2-weighted images. Upon administration of gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA), MR imaging showed no enhancement in the cyst wall or cavity. Myelotomy and cyst drainage were performed in each case, and the neurological status of each patient improved. The lining of the cyst was biopsied in one of the three patients undergoing surgery and was composed of a single layer of cuboidal cells supported by glial tissue. Periodic acid-Schiff staining of the tissue did not reveal a basement membrane. The findings in these cases suggest that the Gd-DTPA-enhanced MR imaging appearance of intramedullary spinal ependymal cyst is consistent and allows for accurate preoperative diagnosis with or without biopsy.

ATPase pump site density in human dysfunctional corneal endothelium.

Proper corneal hydration is maintained by a Na, K-ATPase pump located in the lateral membranes of the endothelial cells. In dysfunctional corneas this pumping action appears to break down as the corneas become edematous. In order to provide quantitative and qualitative data on the Na, K-ATPase pump site density on dysfunctional and functional human corneal endothelial cells, the present study has employed both autoradiographic and histochemical techniques. Computer-assisted morphometrics and statistical analysis showed that there was a significant reduction (P less than 0.001) in 3H-ouabain binding, and thus ATPase pump sites, in the three types of corneas (Fuchs' endothelial dystrophy, aphakic and pseudophakic bullous keratopathy) with dysfunctional endothelia as compared to both types of corneas (eye bank, keratoconus) with functional endothelial cells. There were no significant differences amongst the dysfunctional types or between the two functional types of corneal endothelial cells in respect to density of silver grains. Histochemical staining for ATPase showed less p-nitro-phenylphosphatase histochemical reaction product present on dysfunctional endothelial lateral membranes than in the functional cells.