The effect of gingival wall location on the marginal seal of class ii restorations prepared with a flowable bulk-fill resin-based composite.

SureFil SDR is a flowable resin-based composite that allows a single incremental bulk placement. The marginal seal of SureFil SDR at the gingival margins of class II restorations located apical to the cemento-enamel-junction (CEJ) has not been adequately evaluated compared to those located occlusal to the CEJ. Forty class II cavities were prepared in human molars. The gingival margins of 20 preparations were located 0.5 mm occlusal to the CEJ, and the other 20 preparations were located 0.5 mm apical to the CEJ. The cavities surfaces were bonded with XenoV dental adhesive and filled with SDR in one bulk increment up to 4 mm, after which they were covered with CeramX. The teeth were subjected to thermo-and load-cycling, and their gingival margins were exposed to 0.5% basic-fuchsin solution. The specimens were sectioned mesio-distally and scored for microleakage. A Wilcoxon test for pairwise comparison was performed to determine significance. Dye penetration was observed in 30% of the 20 restorations with cavo-surface margins located occlusal to the CEJ and in 55% of the 20 restorations with cavo-surface margins located apical to the CEJ. The bulk-fill flowable resin base SureFil SDR with XenoV dental adhesive provided a better marginal seal in class II restorations with gingival margins above the CEJ compared to restorations with gingival margins below the CEJ. SDR should not be recommended for class II cavity preparations with gingival margins located below the CEJ.

Bilateral symmetry of anterior maxillary incisors: evaluation of a community-based population.

The final outcome of dental treatment needs to be not only clinically sufficient, but also esthetically pleasing. Bilateral symmetry in the maxillary incisor teeth is of significant importance in esthetic dentistry. In restorative dentistry, symmetry refers to the appearance of balance around the dental midline. The purpose of this study was to measure and compare the maxillary incisor teeth dimensions from both sides of the dental midline, in order to asses if this symmetry occurs naturally. From the student community population at Tel Aviv University, 66 students between the ages of 20-35 (35 males, 31 females) were enrolled and gave consent. The inclusion criteria for this study were: upper maxillary incisors that have never undergone restorative or rehabilitative treatment, and no history of orthodontic treatment. Standardized digital photographs were taken, and the length and width of the maxillary central and lateral incisors were measured and proportions were calculated. SPSS was used to compare the measured differences between teeth on the left versus right of the midline. Tooth proportions were not significantly different between the left and right sides. Asymmetry was found only between the lengths of the maxillary lateral incisors (p=0.009); the width for these teeth was symmetrical. A significant statistical difference was not found on most parameters when evaluating symmetry of the upper incisors. Therefore, when treating the esthetically important anterior of the mouth, care must be taken to ensure bilateral symmetry to mirror the natural symmetry found in most patients.

Interest of workplace support for returning to work after a traumatic brain injury: a retrospective study.

OBJECTIVE: To analyse usefulness of the SPASE programme, a coordinated facility programme to assist traumatic brain injury (TBI) persons in returning to work and retaining their job in the ordinary work environment. DESIGN: A retrospective study including 100 subjects aged over 18 who had suffered traumatic brain injury (GOS 1 or 2). The criterion for return to work (RTW) success was the ability to return to the job he/she had before the accident or to a new professional activity. RESULTS: Factors associated with RTW success were at short-term (2-3 years): the presence of significant workplace support OR=15.1 [3.7-61.7], the presence of physical disabilities OR=0.32 [0.12-0.87] or serious traumatic brain injury OR=0.22 [0.07-0.66]. At medium-term (over 3 years) these factors were: significant workplace support OR=3.9 [1.3-11.3] and presence of mental illness OR=0.15 [0.03-0.7]. CONCLUSION: This study suggests that a case coordination vocational programme may facilitate the return and maintain to work of TBI persons. It reveals that the workplace support is a key factor for job retention in the medium-term.

Characteristics and outcome of crescentic glomerulonephritis in patients with both antineutrophil cytoplasmic antibody and anti-glomerular basement membrane antibody.

A subset of patients with crescentic glomerulonephritis (CGN) is characterized serologically by the presence of antineutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane antibody (anti-GBM) called "double positive" disease. The clinical significance of the occurrence of both antibodies is not clear. This study aims to describe the clinical and histologic characteristics and outcomes of CGN in a US cohort of double positive (DP) patients and compare them to patients with anti-GBM disease only or ANCA only (ANCA-associated vasculitis (AAV)). Renal biopsies with a diagnosis of CGN with either pauci-immune or linear immunofluorescence were selected and classified as AAV, anti-GBM disease, or DP based on serologic testing at the time of biopsy. Data on demographics, clinical presentation, treatment, and outcome were obtained by chart review. Six patients with anti-GBM disease, 9 with DP disease, and 18 AAV patients matched for year of diagnosis with DP were identified. Extrarenal disease manifestations were more prominent in the DP patients. The DP patients had severe renal dysfunction at presentation with eight of nine patients requiring dialysis at presentation. Renal biopsy findings of DP patients were similar to anti-GBM disease with majority of glomeruli showing cellular crescents. Eighty-nine percent of patients were treated with immunosuppressive therapy and 78 % with plasmapheresis. At 1 year, all nine DP patients reached end-stage renal disease. We conclude that the DP patients share extrarenal manifestations similar to AAV patients while the renal manifestations resemble anti-GBM patients clinically and histologically. The renal prognosis of DP patients remains poor despite treatment.

[High tibial open-wedge osteotomy using a tricalcium phosphate substitute: 70 cases with 18 months mean follow-up]. / Valgisation tibiale par ouverture médiale utilisant un coin de céramique de phosphate tricalcique: á propos de 70 cas revus avec un recul moyen de 18 mois.

PURPOSE OF THE STUDY: We report our experience with a B tricalcium phosphate ceramic to fill open-wedge tibial osteotomy gaps. MATERIAL AND METHODS: Seventy high tibial open-wedge osteotomies were performed in 70 patients (47 men and 23 women). Ostotomy was performed for osteoarthritis in 56 knees, Ahlback classification stage I (n = 18), stage II (n = 32), stage III (n = 6) and for congenital varus in 14. Mean patient age was 45.2 years (16-69). We used a wedge-shaped piece of ceramic with an appropriate angle, which was associated with granulated material to complete the gap filling for the last 20 cases. One or two staples were used for fixation. Clinical and radiological outcome was assessed at 6 weeks, 3 months, 6 months, and at last follow-up. Mean follow-up was 18 months. RESULTS: There were no biological or clinical complications related to biomaterial intolerance. Tolerance to the osteosynthesis material was mediocre since we observed one infection and 12 cases of pain related to the staples which required material removal in 8 patients. Bone healing was achieved in 98.5%. Final correction was between 3 degrees and 6 degrees valgus in 80.5%. There was a loss of correction angle between the postoperative film and the bone healing film. Factors related to sustained correction were: non-fractured wedge, intact lateral tibial cortical, osteosynthesis with two staples. Osteointegration was good and rapid in 96%. We found two complete lucent lines at last follow-up but with variable resorption depending on the shape of the bone substitute. CONCLUSION: Use of a ceramic wedge to fill high tibial medial open-wedge osteotomy gap is a reliable reproducible technique providing correction without formation of a malalignment callus. Bone healing is achieved in 98.5% of the cases at about three months. Osteointegration is good in 96%. Resorption is complete and rapid when the substitute is implanted in granular form in a cancellous zone and is partial and slow when implanted as a massive wedge.

[Pertrochanteric fractures: a randomized prospective study comparing dynamic screw plate and intramedullary fixation]. / Comparaison vis-plaque dynamique et ostéosynthèse intra-médullaire antérograde dans les fractures pertrochantériennes: une étude prospective randomisée.

PURPOSE OF THE STUDY: The objective of this study was to compare the dynamic hip screw (Synthes) and intramedullary fixation (Targon PF, Aesculap) for the treatment of pertrochanteric fractures in terms of stability, complications and cost effectiveness. MATERIAL AND METHODS: This prospective randomized study included 60 patients hospitalized in an emergency setting for pertrochanteric fractures between December 2003 and June 2004. All surgeons in our unit participated in the study. Two fixation systems were used: the Targon proximal femoral nail (Aesculap) and the screw-plate dynamic hip screw (Synthes). We noted: patient status (ASA classification), operative data (type of implant, duration), postoperative data (blood loss, radiographic findings, early complications), and outcome (Harris score, time to walking, mortality). All patients were assessed three months after surgery. The series included 60 patients, 14 men (23%) and 46 women (77%). The Targon PF nail was used for 34 patients and the DHS for 26. In the intramedullary fixation group mean age was 81 years (SD = 12.8, range 23-96); it was 82 years (SD 9.8, range 47-97) in the screw-plate group. The AO classification was: intramedullary fixation 31A1 (n = 11), 31A2 (n = 20), 31A3 (n = 3); screw-plate 31A1 (n = 14), 31A2 (n = 11), 31A3 (n = 1). Thirty-one fractures were stable, 29 unstable. Unstable fractures were treated with the Targon PF nail (n = 18) and the DHS screw-plate (n = 11). Stable fractures were treated with the Targon PF nail (n = 15) and the DHS screw-plate (n = 15). RESULTS: Mean operative time was 35 minutes for intramedullary nailing and 42 mintues for screw-plate fixation. Mean blood loss was 410 ml for intramedullary nailing and 325 ml for screw-plate fixation (p = 0.07). Mean hospital stay was the same (11 days) in both groups. At three months, mechanical complications involved migration of the cervical screw outside the femoral head for three Targon PF fixations and for two DHS fixations. Screw migration was favored by fracture instability and presence of osteoporosis. There were two deaths in the intramedullary nailing group and one in the screw-plate group. Time to walking was 20 days on average in the intramedullary nailing group and 25 days in the screw-plate group. The mean Harris hip score was 60 in the intramedullary group and 59 in the screw-plate group. DISCUSSION AND CONCLUSION: Data in the literature report an advantage for intramedullary nailing, particularly a mechanical advantage, for the treatment of pertrochanteric fractures. Our findings show that good results are obtained with the screw-plate fixation using the DHS with less blood loss and at a lower cost.

[Knee arthrodesis using a customized intramedullary nail: 14 cases]. / Arthrodèse du genou par implant intra-médullaire sur mesure. A propos de 14 cas.

We report our experience with knee arthrodesis using a customized intramedullary nail implanted in 14 patients. Indications for knee arthrodesis were: recurrent prosthesis infection (n=11), post-traumatic septic arthritis (n=1), aseptic loosening of a hinge prosthesis (n=1), and nonunion (n=1). A two-stage procedure was used for the 12 patients with infected joints. Mean follow-up was 19 months. Weight bearing began during the first week after arthrodesis in 13 patients. First intention bone healing was achieved in 13 patients. Mean time to healing was three months. All patients rapidly recovered full independence. Complications were: one misinsertion of the tibial stem, one nonunion which fused after repeated grafting, and two recurrent infections (controlled chronic fistulae) which required skin flaps for cover. We have found that this customized nail is a useful method for achieving bone fusion in patients with difficult indications for arthrodesis, particularly recurrent prosthesis infection.

Postprandial dysmetabolism and large-vessel disease.

The increased cardiovascular disease morbidity and mortality in people with Type 2 diabetes mellitus (T2DM) is not explained by the prevalence of cardiovascular disease risk factors and is often attributed to poor glycaemic control. Epidemiological studies have shown fasting and especially postprandial or post-challenge hyperglycaemia to be strong predictors of cardiovascular disease morbidity and mortality in people with either T2DM or prediabetic states. Post-challenge hyperglycaemia in people with impaired glucose tolerance has been associated with increased cardiovascular disease mortality, regardless of the fasting blood glucose (FBG) concentration, but the relationship between FBG and cardiovascular disease was dependent on post-challenge glycaemia. Improving blood glucose and HbA1c concentrations by intensive insulin treatment reduced the risk of cardiovascular disease in a small group of Japanese patients with T2DM and, in another study, improved the outcome in patients with T2DM who had suffered a myocardial infarction. However, on the basis of currently available data, there is no evidence that improved glycaemic control results in a significant reduction of cardiovascular disease risk in people with T2DM. The aim in the present article is to review existing information on the relationship between glycaemia, particularly postprandial glucose concentrations, and cardiovascular disease in people with T2DM or impaired glucose tolerance, and to point at possible mechanisms by which postprandial hyperglycaemia could lead to cardiovascular disease.

Miglitol combined with metformin improves glycaemic control in type 2 diabetes.

AIM: To investigate the efficacy and safety of miglitol vs. placebo in type 2 diabetic outpatients insufficiently controlled (HbA1c between 7.5 and 10.5%) with diet and metformin. METHODS: Patients treated with diet and metformin (1500-2250 mg/day) were randomized to receive additional treatment with either miglitol or placebo for 32 weeks. The dosages were force-titrated: 4 weeks at 25 mg miglitol t.i.d., 12 weeks at 50 mg miglitol t.i.d., and 16 weeks at 100 mg miglitol t.i.d. or matching placebo. If the highest dosage could not be tolerated, patients could be down-titrated to 50 mg t.i.d. The primary efficacy criterion was the change in glycated haemoglobin (HbA1c). Secondary efficacy parameters included fasting and 1 h postprandial blood glucose, serum insulin, and fasting and 1 h postprandial triglyceride levels. Safety and tolerability were evaluated by the incidence of adverse events and changes in vital signs or routine biochemical and haematological parameters. RESULTS: One hundred and fifty-two patients were valid for the intent-to-treat (ITT) analysis. There was a significant decrease in HbA1c on adding miglitol to metformin compared to adding placebo (miglitol treatment effect, - 0.21%; placebo treatment effect, + 0.22%; p = 0.011). Postprandial blood glucose declined in both the miglitol/metformin and placebo/metformin groups with a statistically significant difference in favour of miglitol/metformin (end of treatment adjusted means 13.8 mmol/l for miglitol vs. 15.8 mmol/l for placebo, p = 0.0007). Adverse events (AEs) were reported by only 8% more patients in the miglitol/metformin group than placebo/metformin. No cases of hypoglycaemia were reported. CONCLUSIONS: Miglitol can safely and effectively be added to diet and metformin in patients whose type 2 diabetes is insufficiently controlled, and improves glycaemic control by significantly reducing HbA1c and postprandial blood glucose levels.

The diabetes education study group and its activities to improve the education of people with diabetes in Europe.

In this article the activities of the diabetes education study group (DESG) are presented. It is an important example of the coordination of the European patient education in the field of diabetes. Given the therapeutic role of patient education, doctors must be involved in the entire process, as members of the multi-professional team, who carry the responsibility for the planning and implementation of the educational process. Based on these assumptions, the DESG concentrated on the following activities: workshops, congresses, teaching letters, a 5-min education kit, a web-site, and a basic curriculum in therapeutic patient education. The future of therapeutic patient education in the field of diabetes is discussed.

Displacement of the incisive foramen in conjunction with implant placement in the anterior maxilla without jeopardizing vitality of nasopalatine nerve and vessels: a novel surgical approach.

Accurate implant placement in the anterior maxilla is essential in achieving optimal prosthetic rehabilitation with proper function and acceptable esthetic and phonetic demands. One of the preferable prosthetic solutions to restore a missing maxillary incisor in young adults is by an implant-supported crown. Bone resorption together with an enlarged incisive foramen, challenge proper implant placement. A simultaneous procedure where the implant osteotomy site penetrated the incisive canal is presented. A configurated cortico-cancellous block graft core was adjusted to fit the foramen while its soft tissue content was pushed back posteriorly but not removed. This procedure was followed by an immediate implant placement. Re-entry at 9 months revealed solid bone support embracing the implant body. Although the size of the incisive foramen diminished significantly, the nasopalatine branches were still evident. No complications and/or loss of sensation were observed.

[Type 2 diabetes and large vessel disease]. / Diabète de type 2 et maladie des gros vaisseaux.

Meal and post-meal period define the post-prandial state, which overall covers a little bit more than half daytime period. The post-prandial state is characterized by transient plasma variations in carbohydrates, lipids and hormones in direct relation with nutrient intake. These variations have an impact on the metabolism of several tissues. The post-prandial state in type 2 diabetic patients is considered as a crucial period, mainly due to the tissular toxicity of glucose. The established links between hyperglycemia and the rise of triglycerides-enriched particles can favor atherogenesis.

[Biomaterials in an osteo-articular environment. Report of 129 anatomoclinical cases]. / Biomatériaux en milieu ostéo-articulaire. A propos de 129 observations anatomocliniques.

Actually, there is a range of biomaterials which are synthetic or metallic (or the both). They are employed as prosthesis (biostability property) or as bone graft (bioresorbability property). To understand the interactions between cells and such materials, we studied with human bone cellular cultures the cytologycal, immunohistochemical, cytogenetical and ultrastructural aspects of biomaterials in cell cultures. This paper concerns bioceramics like Pyrost, coral, biosorb, oxbone and polymers like polyethylene and silicones. The aim of this work is to evaluate the efficiency of some biomaterials. We found that porosity is primordial to promote biodegradation of bone substitutes. In fact, the biomaterials is integrated and lead to an osteoconduction, an osteoformation and finally an osteoinduction. Our observations show the implant resorption and ossification occurring in the matrix which penetrate it.

Subretinal fibrosis in diabetic macular edema. ETDRS report 23. Early Treatment Diabetic Retinopathy Study Research Group.

OBJECTIVE: To describe the characteristics of and risk factors for subretinal fibrosis (SRF) in patients with diabetic macular edema. PATIENTS AND METHODS: A total of 109 eyes (in 96 persons) with SRF, defined as a mound or sheet of gray to white tissue beneath the retina at or near the center of the macula, were identified during the Early Treatment Diabetic Retinopathy Study, which is a randomized clinical trial of photocoagulation and aspirin treatment in patients with mild to severe nonproliferative or early proliferative diabetic retinopathy. The patients and the ocular characteristics of these 109 eyes, all of which had clinically significant macular edema, were compared with those of 5653 eyes in which clinically significant macular edema, but not SRF, was observed during the trial. RESULTS: In 9 of 109 eyes, the development of SRF may have been directly related to focal photocoagulation. Seventy-four percent of the eyes in which SRF developed had very severe hard exudates in the macula prior to the development of SRF, while this level of hard exudates was seen in only 2.5% of the eyes with clinically significant macular edema in which SRF did not develop (P < .001). Of the 264 eyes with this level of hard exudates at baseline (n = 29) or during follow-up (n = 235), SRF developed in 30.7% of the eyes, while this complication developed in only 0.05% of 5498 eyes with clinically significant macular edema without this level of hard exudates. CONCLUSIONS: Subretinal fibrosis is an infrequent complication of diabetic macular edema. Although it has been reported to be associated with photocoagulation burn intensity, in only 9 of 109 eyes in which SRF developed was it located adjacent to a photocoagulation-related scar (among 4823 eyes that received focal photocoagulation for treatment of macular edema). The strongest risk factor for the development of SRF is very severe hard exudate.

The efficacy and safety of miglitol therapy compared with glibenclamide in patients with NIDDM inadequately controlled by diet alone.

OBJECTIVE: To compare the therapeutic effects of the alpha-glucosidase inhibitor miglitol (BAY m 1099), the sulfonylurea glibenclamide, and placebo on parameters of metabolic control and safety in patients with NIDDM that is inadequately controlled by diet alone. RESEARCH DESIGN AND METHODS: After a 4-week placebo run-in period, 201 patients in 18 centers in 4 countries were randomized in a double-blind manner to miglitol (50 mg t.i.d., followed by 100 mg t.i.d.), glibenclamide (3.5 mg q.d/b.i.d.), or placebo for 24 weeks. Efficacy criteria were changes from baseline of HbA1c, fasting and postprandial blood glucose and insulin levels, body weight, and serum triglycerides. RESULTS: Efficacy was assessed in 119 patients who completed the full protocol, and the results were similar to those obtained in 186 patients who fulfilled the validity criteria for analysis. Compared with placebo, mean baseline-adjusted HbA1c decreased by 0.75% (P = 0.0021) and 1.01% (P = 0.0001) in the miglitol and glibenclamide treatment groups, respectively. Blood glucose decreased slightly in the fasting state and considerably in the postprandial state in both treatment groups but not in the placebo group. Fasting insulin levels increased slightly (NS) in all treatment groups; however, postprandial insulin levels decreased with miglitol, while increasing markedly with glibenclamide (P = 0.0001 between all treatment groups). Gastrointestinal side effects (flatulence and diarrhea) occurred mostly in the miglitol-treated patients, while some glibenclamide-treated patients had symptoms suggestive of hypoglycemia. CONCLUSIONS: Miglitol monotherapy is effective and safe in NIDDM patients. Compared with glibenclamide, it reduced HbA1c less effectively and caused more gastrointestinal side effects. On the other hand, glibenclamide, unlike miglitol, tended to cause hypoglycemia, hyperinsulinemia, and weight gain, which are not desirable in patients with NIDDM.

Bone regeneration around an osseointegrated implant. A simultaneous approach in a fenestrated defect: a case report.

The use of a barrier membrane, with or without osseous allograft, has been shown to establish regeneration of osseous tissue around dental implants. Following three episodes of persistent symptomatic failed apicoectomy and subsequent tooth extraction, an osseointegrated implant was placed in a wide fenestrated defect. Demineralized freeze-dried bone allograft was covered by an occlusive expanded polytetrafluorethylene membrane. The reentry procedure revealed complete bone fill that followed the texture of the augmentation material beyond the previous buccal bony envelope.

[Embolism and intramedullary femoral surgery]. / Embolies et chirurgie fémorale intra-médullaire.

All intramedullary femoral surgery entails embolic phenomena which explain peroperative collapses formally known as bone cement implantation syndrome, as well as perioperative fat embolism syndromes. Locally, the bigger the cavity is, the higher the number of accidents: 2.5-5 per cent for GUEPAR hinged-knee prosthesis, 1.75 per cent for total hip arthroplasty with long stem, and 0.1 per cent during classic THA with cement limited to the metaphysis. Anomalies in bone vascularization also increase risk: 10.5-13 per cent during prophylactic nailing for shaft metastases, 1-11.5 per cent during hemiarthroplasty cemented in osteoporotic bone of femoral neck fractures, and only 0.1 per cent during THA implanted because of arthrosis. Not only cement, but also rods, reamers, nails, implants, ultrasonic tool for cement extraction, increase the pressure inside the cavity. Methylmethacrylate is no longer the only incriminated factor, even if it is responsible for a major part of the compressive load. The intensity and duration of the pressure are correlated with the number of embolic phenomena and with measured cardiopulmonary parameters. The intracavity fat content is expelled (an empty cavity, as in THA revision, does not lead to embolic phenomena). Then filters through the intraosseous veins whose diameter limit the size of the extruded embolic phenomena. The ultrasonography of the inferior vena cava shows innumerable fine particles and thrombi which are already organized under the influence of procoagulant factors released from the operative shield and which remain crumbly. These emboli cross the cardiac cavities. Transesophageal echocardiography (TEE), of recent use, does quantify the amount of right atrial filling, duration of echogenesis and size of particles: the result is higher in patients who underwent cemented versus noncemented THA: however the embolism score is no an indicator of seriousness because it is not correlated with cardiorespiratory manifestations; TEE shows only one fourth of the patent foramen ovale, whereas the atrial septal defect is surely one of the most efficient systemic invasion mechanisms to produce perioperative fat embolism. Lung response is most often asymptomatic, even if all patients undergoing intramedullary surgery display an increase in pulmonary vascular resistance which is managed by the right heart only, as well as pulmonary (and sometimes systemic) microvascular fat obstruction. Common operating room monitoring procedures do not detect successive embolic phenomena before they cause pulmonary arterial hypertension which then has repercussions on the left heart and in turn causes peroperative hemodynamic accidents. Only pulmonary arterial pressure measurement with a Swan-Ganz catheter gives early and durable signs of an intolerance to embolic load. Preventive treatment is surgical as there is an inverse relation between embolic marrow and marrow eliminated by large volume washes (which is often more effective than draining). Cement indications in older patients as well as the choice of fixation techniques in femoral fractures must take into account the cardio-pulmonary condition of the patient. Resuscitation procedures dealing with these complications end in the patient's death in half of the cases.