Anatomical Possibilities of the Alveolar Bone at the Upper Second Premolar Level.

Background and Objectives: The upper posterior teeth are typically regarded as being exclusively inferior to the maxillary sinus (MS). The expansion of the nasal fossa above the maxillary alveolar base (MAB) needs better investigation. The hypothesis was raised that the MAB in the upper premolar region, which is usually addressed by surgeons for the elevation of the antral floor, is not exclusively beneath the MS. Therefore, we aimed to document the possible upper relations of the MAB as antral, nasal, or both. Materials and Methods: A total of 145 CBCT scans were used to study four types of MAB: type 1-antral; type 2-antral with a palatal recess; type 3-antral and nasal; type 4-nasal. In type 2, the orthoradial width of the alveolar bone, the rectilinear width of the antral floor, and the maximum depth of the palatal recess were measured. For type 3, the MAB width and the straight widths of the antral and nasal segments of the MAB were measured. Results: Type 1 was found in 67.24%, type 2 in 13.45%, type 3 in 16.21%, and type 4 in 3.1% of the 290 MSs investigated. Palatal recesses were found in 11.72% of the MSs on the right side and 15.17% of the MSs on the left side. Types 1 and 2 exhibited strongly statistically significant bilateral symmetry (Pearson's Chi2 = 86.42, p < 0.001). Type 3 correlated equally with contralateral types 1 and 3. The bilateral symmetry for types 1-3 was stronger in the males (Pearson's Chi2 = 47.83, p < 0.001) than in the females (Pearson's Chi2 = 56.96, p < 0.001). There were no statistically significant associations between sex and the unilateral anatomical type. Conclusions: The MAB in the upper second premolar area should not be considered to be exclusively antral during surgeries or in anatomical teaching.

Middle meatal nasal recesses of the maxillary sinuses and dangerously modified nasal anatomy.

Pneumatisation of the maxillary sinus (MS) is variable. The archived cone-beam computed tomography file of a 54-year-old female was retrospectively evaluated anatomically. Nasal or retrobullar recesses of the MSs (NRMS) were found. The MSs were bicameral. NRMSs extended from the postero-lateral chambers of the MSs into the lateral nasal walls. The right NRMS was reached superior to the middle turbinate and the ethmoidal bulla was applied on its anterior side. The left NRMS had two medial pouch-like ends, one beneath the ethmoidal bulla and the other on the anterior side of the basal lamella of the middle turbinate. Additional anatomical findings were the uncinate bulla, infraorbital recesses of the MS, maxillary recess of the sphenoidal sinus, and atypical posterior insertions of the superior nasal turbinates, maxillo-ethmoido-sphenoidal and ethmoido-sphenoidal. The NRMS is a novel finding and could lead to erroneous endoscopic corridors if not documented before the interventions.

Estrategia invasiva frente a conservadora en pacientes frágiles con IAMSEST. Diseño del ensayo clínico MOSCA-FRAIL / Invasive versus conservative strategy in frail patients with NSTEMI: the MOSCA-FRAIL clinical trial study design

Introducción y objetivos: Aunque las guías de práctica clínica recomiendan una estrategia invasiva para el infarto agudo de miocardio sin elevación del segmento ST (IAMSEST), en la práctica clínica esta estrategia se infrautiliza en ancianos frágiles. Además estos enfermos habitualmente quedan excluidos de los ensayos clínicos, por lo que la evidencia es escasa. Nuestra hipótesis es que una estrategia invasiva para el anciano con fragilidad y IAMSEST mejorará el pronóstico. Métodos: Se trata de un estudio prospectivo, multicéntrico y aleatorizado que compara una estrategia invasiva frente a una conservadora en ancianos frágiles con IAMSEST. Los criterios de inclusión son: IAMSEST, edad ≥ 70 años y fragilidad definida por al menos 4 criterios de la escala Clinical Frailty Scale. Se aleatorizará a los participantes a una estrategia invasiva (coronariografía y revascularización si se considera anatómicamente indicada) o conservadora (tratamiento médico y coronariografía solo en caso de inestabilidad clínica persistente). El objetivo principal será el número de días vivo fuera del hospital durante el primer año. El objetivo coprincipal será el tiempo hasta la presentación de muerte cardiovascular, reinfarto agudo de miocardio o revascularización tras el alta. El tamaño de la muestra estimado es de 178 pacientes (89 por grupo), asumiendo un incremento del 20% en la proporción de días vivo fuera del hospital con la estrategia invasiva. Resultados: Los resultados del estudio aportarán información novedosa para el tratamiento del anciano frágil con IAMSEST. Conclusiones: Nuestra hipótesis es que una estrategia invasiva mejorará el pronóstico de los pacientes ancianos frágiles con IAMSEST. Si esta hipótesis se confirmara, la situación de fragilidad no debería disuadir al cardiólogo de indicar un tratamiento invasivo. Ensayo registrado en ClinicalTrials.gov (Identificador: NCT03208153)

Introduction and objectives: Although clinical guidelines recommend invasive management in non-ST-segment elevation myocardial infarction (NSTEMI), this strategy is underused in frail elderly patients in the real world. Furthermore, these patients are underrepresented in clinical trials and therefore the evidence is scarce. Our hypothesis is that an invasive strategy will improve prognosis in elderly frail patients with NSTEMI. Methods: This will be a prospective, multicenter, randomized trial, in which the conservative and invasive strategies will be compared in patients meeting all of the following inclusion criteria: NSTEMI diagnosis, age ≥ 70 years, and frailty defined by a category ≥ 4 in the Clinical Frailty Scale. Participants will be randomized to an invasive (coronary angiogram and revascularization if anatomically amenable) or conservative (medical treatment and coronary angiogram only if persistent clinical instability) strategy. The primary endpoint will be the number of days alive out of hospital during the first year. The coprimary endpoint will be the time until the first cardiac event (cardiac death, reinfarction or postdischarge revascularization). We estimate a sample size of 178 patients (89 per arm), considering an increase of 20% in the proportion of days alive out of hospital with the invasive management. Results: The results of this study will add important knowledge to inform the management of frail elderly patients hospitalized with NSTEMI. Conclusions: We hypothesize that the invasive strategy will improve outcomes in frail elderly patients with NSTEMI. If this is confirmed, frailty status should not dissuade physicians from implementing an invasive management strategy. Clinical trial registration: URL: http://www.clinicaltrials.gov .Identifier: NCT03208153

Invasive Versus Conservative Strategy in Frail Patients With NSTEMI: The MOSCA-FRAIL Clinical Trial Study Design.

INTRODUCTION AND OBJECTIVES: Although clinical guidelines recommend invasive management in non-ST-segment elevation myocardial infarction (NSTEMI), this strategy is underused in frail elderly patients in the real world. Furthermore, these patients are underrepresented in clinical trials and therefore the evidence is scarce. Our hypothesis is that an invasive strategy will improve prognosis in elderly frail patients with NSTEMI. METHODS: This will be a prospective, multicenter, randomized trial, in which the conservative and invasive strategies will be compared in patients meeting all of the following inclusion criteria: NSTEMI diagnosis, age ≥ 70 years, and frailty defined by a category ≥ 4 in the Clinical Frailty Scale. Participants will be randomized to an invasive (coronary angiogram and revascularization if anatomically amenable) or conservative (medical treatment and coronary angiogram only if persistent clinical instability) strategy. The primary endpoint will be the number of days alive out of hospital during the first year. The coprimary endpoint will be the time until the first cardiac event (cardiac death, reinfarction or postdischarge revascularization). We estimate a sample size of 178 patients (89 per arm), considering an increase of 20% in the proportion of days alive out of hospital with the invasive management. RESULTS: The results of this study will add important knowledge to inform the management of frail elderly patients hospitalized with NSTEMI. CONCLUSIONS: We hypothesize that the invasive strategy will improve outcomes in frail elderly patients with NSTEMI. If this is confirmed, frailty status should not dissuade physicians from implementing an invasive management strategy. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov.Identifier: NCT03208153.