Expert opinion: efficacy of superficial chemical peels in active acne management--what can we learn from the literature today? Evidence-based recommendations.

BACKGROUND: Superficial chemical peels offer therapeutic results in a convenient, affordable treatment. Many clinicians use these peels in the treatment of acne and acne-prone oily skin. OBJECTIVES: This article examines the evidence base that supports the widespread use of superficial peels in this setting. METHODS: A search of the English language medical literature was performed to identify clinical trials that formally evaluated the use of chemical peeling in active acne. RESULTS: Search of the literature revealed very few clinical trials of peels in acne (N=13); a majority of these trials included small numbers of patients, were not controlled and were open label. The evidence that is available does support the use of chemical peels in acne as all trials had generally favourable results despite differences in assessments, treatment regimens and patient populations. Notably, no studies of chemical peels have used an acne medication as a comparator. As not every publication specified whether or not concomitant acne medications were allowed, it is hard to evaluate clearly how many of the studies evaluated the effect of peeling alone. This may be appropriate, however, given that few clinicians would use superficial chemical peels as the sole treatment for acne except in rare instances where a patient could not tolerate other treatment modalities. CONCLUSIONS: In the future, further study is needed to determine the best use of chemical peels in this indication.

Comparison of reliability in anatomical landmark identification using two-dimensional digital cephalometrics and three-dimensional cone beam computed tomography in vivo.

OBJECTIVES: To compare reliability for landmark identification on patient images from three-dimensional (3D) cone beam CT (CBCT) and digital two-dimensional (2D) lateral cephalograms. METHODS: Ten lateral cephalometric digital radiographs and their corresponding CBCT images were randomly selected. 27 observers digitally identified 27 landmarks in both modes. The x- and y-coordinates for each landmark, indicating the horizontal and vertical positions, were analysed for interobserver reliability by comparing each measurement to the best estimate of the true value. Intraobserver reliability was also assessed. Linear models and intraclass correlation coefficients (ICCs) were used for analyses. RESULTS: For interobserver reliability, the following locations were farther from the best estimate for 2D than 3D: x-location in subspinale (A-point), anterior tip of the nasal spine (ANS), L1 lingual gingival border and L1 root; y-location in porion, ramus point and orbitale; x- and y-locations in basion, condylion, midramus, sigmoid notch and U6 occlusal. 3D y-locations were farther in the gonion, L1 tip, sella and U1 tip. For intraobserver reliability, 2D locations were farther in y-locations in orbitale and sigmoid notch, and both x- and y-locations in basion. 3D locations were farther in the x-location in U1 labial gingival border and y-locations in L1 tip, L6 occlusal, menton and sella. For intraobserver ICCs, greater variations in 2D than 3D included: A-point, ANS, midramus, orbitale, ramus point, sigmoid notch and U1 root. CONCLUSIONS: 3D imaging, as in CBCT, allows for overall improved interobserver and intraobserver reliability in certain landmarks in vivo when compared with two-dimensional images.

Density value means in the evaluation of external apical root resorption: an in vitro study for early detection in orthodontic case simulations.

OBJECTIVES: The purpose of this study was to develop an alternative diagnostic tool for the early detection of external apical root resorption (EARR). METHODS: Mandibular incisors (n=36) with and without simulated EARR lesions were used. 18 teeth with facial and proximal windows, each with a range of 2 sizes, were placed in 6 N hydrochloric acid (HCl) baths for 10 min. A sample of the acid solution was analysed for calcium concentration by atomic absorption spectrophotometry. Incisors were imaged at 80 degrees, 90 degrees and 100 degrees under 3 test conditions (bracketed, non-bracketed and with subtraction registration templates (SRTs)). The images were reconstructed and subtracted to determine the accuracy and sensitivity of the method. Quantified histograms for each subtracted image were constructed. RESULTS: At either an angle of 80 degrees or 100 degrees, the bracketed group had the largest mean standard deviation of the subtraction histograms while the SRT group had the smallest. Density values as a function of total calcium removed were plotted indicating a linear relationship between subtraction density units and calcium loss. CONCLUSION: The use of the SRTs was significantly more accurate than the use of the brackets alone for digital subtraction radiography reconstructions. This model shows promise for detecting EARR prior to a noticeable decrease in root length. It may be useful for early detection of resorptive lesions during routine orthodontic treatment.

Frequency of nursing, physician and hospital interventions in women at risk for preterm delivery.

OBJECTIVE: To determine the frequency of nursing intervention, physician treatment and hospital evaluation for women receiving outpatient management services for preterm labor. METHODS: Outpatient services included: patient education; daily and as-needed nursing assessment of monitored uterine activity (MUA) and patient symptoms; treatment compliance; and physician notification for values exceeding established limits. We analyzed service data from women with singleton gestations at 20.0-34.9 weeks. RESULTS: Overall, 307 249 days of data from 10 660 women were reviewed, and 634 983 hours of MUA was assessed. On 53 665 (17.5%) of monitored days, patients exhibited increased MUA and/or symptoms of preterm labor with nursing intervention and reassessment. Physician notification/intervention was required 7316 (13.6%) times, and hospital admission was needed for 3163 (43.2%) of these patients. In the hospital 1400 (44.3%) patients received tocolysis. The mean ( +/- standard deviation) length of hospital stay was 3.2 +/- 7.2 days, and 428 (13.5%) of women remained hospitalized until delivery, with 324 (10.2%) delivering within 48 h. CONCLUSION: In this population of women receiving outpatient preterm-labor management services, 95.1% of excessive MUA or patient-reported symptoms of preterm labor were managed on an outpatient basis. Outpatient management allowed for appropriate identification and triage of women requiring hospital admission.

Genetic predisposition to external apical root resorption in orthodontic patients: linkage of chromosome-18 marker.

External apical root resorption (EARR) is a common orthodontic treatment sequela. Previous studies implicate a substantial genetic component for EARR. Using a candidate gene approach, we investigated possible linkage of EARR associated with orthodontic treatment with the TNSALP, TNFalpha, and TNFRSF11A gene loci. The sample was comprised of 38 American Caucasian families with a total of 79 siblings who completed comprehensive orthodontic treatment. EARR was assessed by means of pre- and post-treatment radiographs. Buccal swab cells were collected for extraction and analysis of DNA. No evidence of linkage was found with EARR and the TNFalpha and TNSALP genes. Non-parametric sibling pair linkage analysis identified evidence of linkage (LOD = 2.5; p = 0.02) of EARR affecting the maxillary central incisor with the microsatellite marker D18S64 (tightly linked to TNFRSF11A). This indicates that the TNFRSF11A locus, or another tightly linked gene, is associated with EARR.

The use of small titanium screws for orthodontic anchorage.

The use of conventional dental implants for orthodontic anchorage is limited by their large size. The purpose of this study was to quantify the histomorphometric properties of the bone-implant interface to analyze the use of small titanium screws as an orthodontic anchorage and to establish an adequate healing period. Overall, successful rigid osseous fixation was achieved by 97% of the 96 implants placed in 8 dogs and 100% of the elastomeric chain-loaded implants. All of the loaded implants remained integrated. Mandibular implants had significantly higher bone-implant contact than maxillary implants. Within each arch, the significant histomorphometric indices noted for the "three-week unloaded" healing group were: increased labeling incidence, higher woven-to-lamellar-bone ratio, and increased osseous contact. Analysis of these data indicates that small titanium screws were able to function as rigid osseous anchorage against orthodontic load for 3 months with a minimal (under 3 weeks) healing period.

Labor and membrane rupture in twin gestation. Can they affect the ability to estimate fetal weight?

OBJECTIVE: To determine whether labor or fetal membrane rupture adversely affects the ability of ultrasound to accurately estimate fetal weight (EFW) in a twin gestation. STUDY DESIGN: A medical record audit was performed of the two-year experience of women delivering live born twins and undergoing a complete ultrasound examination within 72 hours of delivery. Those patients experiencing labor or membrane rupture at the time of the previous ultrasound examination were compared to those without these factors to determine if there was any detrimental impact on the accuracy of ultrasound to EFW. RESULTS: The overall ability of ultrasound to accurately EFW was in the range of 64-76%. This was not significantly different from the accuracy in women experiencing labor (62-80%) or in women with membrane rupture (63-81%). The ability of ultrasound to detect fetal discordance is this series ranged from 78% to 100%, with specificity that ranged from 84% to 89%. CONCLUSION: The ability of sonography to accurately EFW as well as detect discordant twin gestation is not altered by the presence of labor or membrane rupture.

Single umbilical artery is associated with an increased incidence of structural and chromosomal anomalies and growth restriction.

The objective to characterize neonatal outcome associated with ultrasonographic identification of a single umbilical artery. Pregnancies diagnosed with single umbilical artery antenatally were identified. All prenatal/antenatal and pediatric records were reviewed for maternal demographics, associated anomalies, karyotypic analysis, pregnancy complications, and neonatal outcome. Twenty-seven pregnancies complicated by fetal single umbilical artery were identified. Of the 27 pregnancies, 5 (18.5%) underwent pregnancy termination and 1 (3.7%) experienced fetal demise. Of the 21 liveborn infants, 4 (19%) died within the first year of life. Sixty-seven percent of fetuses had an associated structural anomaly. Sixteen of the 27 pregnancies underwent amniocentesis and 7 of these were chromosomally abnormal. All of the karyotypically abnormal fetuses had a structural defect in addition to the single umbilical artery. Of the six fetuses without any associated structural or chromosomal anomalies, three (50%) demonstrated growth restriction. Single umbilical artery is relatively rare finding. When a single umbilical artery is identified, a vigilant search for associated anomalies should be undertaken. Pregnancies identified as having fetuses with associated structural anomalies should be offered amniocentesis. Pregnancies with isolated single umbilical artery should be carefully monitored for evidence of fetal growth restriction.

Randomized trial of intermittent or continuous amnioinfusion for variable decelerations.

OBJECTIVE: To determine whether continuous or intermittent bolus amnioinfusion is more effective in relieving variable decelerations. METHODS: Patients with repetitive variable decelerations were randomized to an intermittent bolus or continuous amnioinfusion. The intermittent bolus infusion group received boluses of 500 mL of normal saline, each over 30 minutes, with boluses repeated if variable decelerations recurred. The continuous infusion group received a bolus infusion of 500 mL of normal saline over 30 minutes and then 3 mL per minute until delivery occurred. The ability of the amnioinfusion to abolish variable decelerations was analyzed, as were maternal demographic and pregnancy outcome variables. Power analysis indicated that 64 patients would be required. RESULTS: Thirty-five patients were randomized to intermittent infusion and 30 to continuous infusion. There were no differences between groups in terms of maternal demographics, gestational age, delivery mode, neonatal outcome, median time to resolution of variable decelerations, or the number of times variable decelerations recurred. The median volume infused in the intermittent infusion group (500 mL) was significantly less than that in the continuous infusion group (905 mL, P =.003). CONCLUSION: Intermittent bolus amnioinfusion is as effective as continuous infusion in relieving variable decelerations in labor. Further investigation is necessary to determine whether either of these techniques is associated with increased occurrence of rare complications such as cord prolapse or uterine rupture.

Second-trimester uterine evacuation: A comparison of intra-amniotic (15S)-15-methyl-prostaglandin F2alpha and intravaginal misoprostol.

OBJECTIVE: Our purpose was to compare the efficacy, safety, and adverse effects of intra-amniotically administered (15S)-15-methyl-prostaglandin F(2alpha) and intravaginally administered misoprostol for second-trimester uterine evacuation. STUDY DESIGN: Fifty-one patients were randomly assigned to receive either a single 2.5-mg intra-amniotic injection of (15S)-15-methyl-prostaglandin F(2)(alpha) (n = 26) or two 200-microg intravaginal doses of misoprostol (n = 25) at 12-hour intervals. The primary outcome measured was evacuation of the uterus within 24 hours. RESULTS: The mean time from initiation of termination to uterine evacuation was less in the prostaglandin group than in the misoprostol group (17.5 +/- 8.6 hours vs 22.3 +/- 12.5 hours), but this was not statistically significant (P >.05). The rate of successful fetal evacuation at 24 hours was significantly higher in the prostaglandin group than in the misoprostol group (88% vs 60%, P =.02). The complete-abortion rate and the incidence of adverse effects were similar in both groups. CONCLUSION: The use of an intra-amniotic injection of (15S)-15-methyl-prostaglandin F(2alpha) for midtrimester pregnancy termination is safe and is associated with a greater number of successful uterine evacuations within 24 hours, without an increase in adverse effects, than intravaginal administration of misoprostol.

Microdamage adjacent to endosseous implants.

Intense remodeling occurs in lamellar bone adjacent to osseointegrated endosseous implants. The purpose of this study was to compare microdamage accumulation subsequent to ex vivo fatigue loading of bone that surrounds an endosseous implant, (a) immediately after placement (nonadapted bone) and (b) following a 12 week healing period after placement (adapted bone). We hypothesize that there is less microdamage in the more compliant adapted bone than in the older nonadapted bone. Nonthreaded titanium plasma sprayed (TPS)-coated endosseous implants were placed into dog mid-femoral diaphyses and allowed to heal for 12 weeks. Block sections of bone, each containing one implant, were cut anteroposteriorly, resulting in an implant containing lateral cortex, and a medial cortex that was used for testing the nonadapted specimens. Control specimens (n = 14 each for adapted and nonadapted) were loaded at 0 N. Experimental specimens (n = 13, adapted; n = 14, nonadapted) were loaded at 100 N in cantilever bending for 150,000 cycles at 2 Hz, at 37 degrees C on a Bionix 858 testing machine. Specimens were bulk stained with basic fuchsin and 120-140 microm sections were obtained. Crack numerical density (Cr.Dn = Cr.N/ B.Ar, #/mm2), crack surface density (Cr.S.Dn = Tt.Cr.Le/ B.Ar, mm/mm2), and percent damage area (Dm.Ar = Cr.Ar x 100/B.Ar, mm2/mm2) were measured at x 250. Statistically significant differences (p < 0.0001) were seen for Cr.Dn, Cr.S.Dn, and Dm.Ar on the compressed cortices suggesting that adapted bone near the implant accumulated significantly less microdamage than nonadapted bone. Also, the adapted nonloaded control specimens had approximately 20-fold less damage than the respective nonadapted specimens. This study suggests that the compliant adapted bone adjacent to endosseous implants is relatively resistant to fatigue loads. The high success rates of endosseous implants may be due to the presence of a rapidly remodeling region that maintains tissue compliance and limits microdamage initiation.

Implant-borne suture expansion in rabbits: a histomorphometric study of the supporting bone.

Osseointegrated implants have a large potential for diverse clinical applications, including support for sutural expansion and facial prostheses. The objectives of this study were to evaluate: (1) the histomorphometric response of thin cortical bone to implant placement and (2) whether loading of the bone surrounding these implants affects osseointegration as evaluated by histomorphometry. Eighteen New Zealand White rabbits had two titanium implants placed bilaterally in the anterior surface of their nasal bones. The rabbits were divided into an unloaded control group, one experimental group loaded at 1 Newton (N), and another loaded at 3 N. Fluorescent labels were used to mark areas of active bone formation. All rabbits were euthanized after 12 weeks of loading. Stereological point-hit and line-intercept methods were used to measure bone volume, direct bone-implant contact, new bone volume, and bone turnover rate in the bone surrounding the implants. All the implants remained stable during the loading period. A factorial ANOVA with repeated measures was used to compare the variables. The only significant difference among the three groups was a higher bone volume in the lateral coronal far region in the control group (p < 0. 05). Within all groups, bone volume (p < 0.002), turnover rate (p < 0.001), and percent of new bone (p < 0.05) were higher within 1 mm of the implant compared to 1-3 mm away. This may be due to the increased stress and strain in the bone adjacent to the implant. This study indicates that there are no detrimental effects of loading on osseointegration when implants placed in the thin facial cortices are used as anchors for sutural expansion.

Modern obstetric management and outcome of infants with gastroschisis.

OBJECTIVE: To determine whether outcomes of infants with gastroschisis differed by mode or site of delivery, diagnostic method, or when maternal-fetal medicine consultation was given. METHODS: Charts of 32 infants born at the University of Mississippi Medical Center or admitted to the neonatal intensive care unit between September 1992 and June 1998 were reviewed for maternal demographic characteristics and neonatal outcomes. Statistical analysis was done using Student t test, analysis of variance, chi2, and Kruskal-Wallis test with P<.05 considered statistically significant. RESULTS: There were no statistically significant differences in neonatal outcomes by method or site of delivery, diagnostic method, or maternal-fetal medicine consultation before delivery. Infants delivered vaginally had higher Apgar scores at 1 and 5 minutes (9 versus 7 and 9 versus 8, respectively, P<.05). Vaginally delivered infants required more days of antibiotic therapy than those delivered abdominally (10 versus 3 days, P<.05) but had a shorter interval to enteral feedings (15 versus 30 days, P<.05). CONCLUSION: Outcomes of infants with isolated gastroschisis were not significantly affected by method or site of delivery, diagnostic method, or maternal-fetal surveillance. Although the findings of this investigation were largely negative and the statistical power limited due to the rarity of this fetal disruption, small series of cases of gastroschisis need to be analyzed to resolve current controversies surrounding optimal treatment of gastroschisis.

Multiple courses of betamethasone to enhance fetal lung maturation do not suppress neonatal adrenal response.

OBJECTIVE: Our purpose was to evaluate the neonatal adrenal gland by provocative testing in neonates of mothers who had received multiple courses of betamethasone to enhance fetal lung maturity. STUDY DESIGN: Infants of mothers who had received >/=3 courses of betamethasone for fetal lung maturation were enrolled in the study. Twenty-four hours after delivery a baseline serum cortisol concentration was obtained. A synthetic adrenocorticotropic hormone (Cortrosyn) was administered (0.25 mg/1.73 m2). Two hours later a second serum cortisol concentration was obtained. An increase in serum cortisol in response to Cortrosyn was considered a positive test result. Nominal data were compared by means of the Student t test. RESULTS: There were 9 infants enrolled in the study. The mean number of betamethasone treatment cycles was 4.8 +/- 1.09. The mean baseline cortisol level was 2.23 +/- 0.52 microgram/dL, and the mean post-adrenocorticotropic hormone cortisol level was 9.86 +/- 1.70 microgram/dL. All neonates had a positive adrenocorticotropic hormone test result. Stepwise linear regression showed no association between the number of courses of betamethasone treatment cycles and the post-adrenocorticotropic hormone cortisol concentration. CONCLUSION: Multiple weekly treatment cycles of betamethasone for fetal lung maturity administered between 24 and 34 weeks' gestation do not appear to cause adrenal suppression.

Planned cesarean hysterectomy: A preferred alternative to separate operations.

OBJECTIVE: The aim of this study was to evaluate our institutional experience with planned cesarean hysterectomy. STUDY DESIGN: In this retrospective case-control investigation of a 16-year experience, 100 pregnant women who underwent planned cesarean hysterectomy were compared with 37 patients who underwent cesarean delivery followed by a hysterectomy performed within 6 months. RESULTS: Women undergoing planned cesarean hysterectomy did not have any demonstrable increase in intraoperative or postoperative complications when compared with the cesarean delivery plus later hysterectomy group. Primarily as a result of significantly reduced hospital stay and shorter total operative time, there was a significant financial advantage associated with a single planned cesarean hysterectomy with respect to separate operations. CONCLUSIONS: A policy to undertake planned cesarean hysterectomy for carefully selected patients appeared to produce advantages without increasing risks for these patients. Secondarily, it provided resident physicians the opportunity to learn the operation with supervision and under controlled circumstances.

Familial inheritance of mandibular arch malformations affecting three individuals in one family.

Mandibular aplasia is defined as incomplete development of the mandibular process of the first brachial arch. Its prevalence is less than 1:70,000. It is usually associated with low-set ears, transposition of the viscera, congenital heart defects, and rib abnormalities, and is incompatible with life. In this case report, fetal demise at 26 weeks' gestation in a previous pregnancy revealed the phenotypic features listed. The second pregnancy described here resulted in therapeutic termination of a similar appearing fetus. Because of this recurrence and a positive family history, familial inheritance is postulated.

Mechanical response to functional loading around the threads of retromolar endosseous implants utilized for orthodontic anchorage: coordinated histomorphometric and finite element analysis.

A 3-dimensional bone-implant finite element model was created. The objective was to further investigate the mechanical environment of cortical bone adjacent to the threads of a retromolar endosseous implant used for orthodontic anchorage to mesially translate mandibular molars in response to normal functional loading. This study emphasizes the stress invariants around and between the threads of the implant for future comparison to histomorphometric data from an ongoing clinical study. A strong stress pattern change was found immediately around the implant, which was reflected by a moderate change of stresses between the threads and a significant increase in stress at the tips of the threads.

The impact of leiomyomas on pregnancy.

In this retrospective case control investigation, 51 pregnant patients who were diagnosed by ultrasound with uterine myomas were compared to 102 randomly selected control patients to determine if the ultrasound diagnosis of one or more leiomyoma is associated with increased untoward pregnancy outcomes compared to controls. Women with uterine myomas were older (p = 0.001), more likely to be African American (p = 0.001), and undergo Caesarean delivery (p = 0.03) than controls. However, when women who underwent abdominal delivery for previous myomectomy (n = 5) were excluded from analysis, there was no significant difference in the incidence of Caesarean delivery. Overall, there was no difference in the incidence of obstetric complications between groups even when the data was stratified for large and/or multiple leiomyomas. The discovery of uterine leiomyomas by gestational ultrasound does not appear to place the patient at increased risk for preterm labour, early delivery, or other untoward pregnancy outcomes.

Amniotic fluid index in normal pregnancy: a longitudinal study.

OBJECTIVE: This longitudinal study was undertaken to characterize the change in the amniotic fluid volume in normal pregnancy. METHODS: Prospectively, patients with uncomplicated gestations underwent serial amniotic fluid index by a single sonographer. RESULTS: Fifty-six patients underwent a total of 378 determinations of amniotic fluid volume (6.8 +/- 2.5 examinations per patient). The variation in mean amniotic fluid index between 24 and 40(+6) weeks was not significantly different (p = 0.381). Among the 42 patients who delivered at term there was no significant decrease in the amniotic fluid index between their first and last measurement (p = 0.86). However, in the 14 patients who delivered after 41 weeks, there was a significant decrease in the index over time (p = 0.04). CONCLUSION: The longitudinal study on amniotic fluid volume in normal pregnancy reveals that amniotic fluid index does not change significantly with gestational age.