Comparison of Radiographic Measurement Parameters of the Wrist in Patients with and without Scaphoid Fracture after Fall on an Outstretched Hand.

PURPOSE OF THE STUDY: To investigate the effects of anatomical variations on the mechanism of scaphoid fracture by comparing the radiologic parameters of the wrist of patients with and without scaphoid fracture after a fall on an outstretched hand. MATERIAL AND METHODS: Cross-sectional comparative retrospective analysis of radiographs of patients with (Group 1, n=169) and without scaphoid fracture (Group 2, n=188). Morphometric data were measured including radial inclination (RI), radial height (RH), ulnar variance (UV), carpal height (CH) ratio, revised carpal height (RCH) ratio and palmar tilt of the distal radius (PT). Receiver operating characteristics (ROC) curve analysis was used to assess the diagnostic performance for each variable with statistically significant difference. RESULTS: The mean RI and PT degrees and RH length were statistically significantly higher, and the mean UV was lower in Group 1 compared to Group 2. No difference was determined between the groups with respect to the CH ratio and RCH ratio. With ROC curve analysis, the cut-off value with the highest odds ratio was determined as RH (Cut-off value=10.77 mm, OR=21.886). CONCLUSIONS: Although higher RI, RH, PT values and more negative ulnar variance were observed in the scaphoid fracture group compared to the non-fracture group, ROC curve analysis showed that only increased RH can be considered as a possible risk factor for scaphoid fractures after fall on an outstretched hand. KEY WORDS: radiographs, risk factor, scaphoid fracture, wrist morphology.

Designing spin and orbital sources of Berry curvature at oxide interfaces.

Quantum materials can display physical phenomena rooted in the geometry of electronic wavefunctions. The corresponding geometric tensor is characterized by an emergent field known as the Berry curvature (BC). Large BCs typically arise when electronic states with different spin, orbital or sublattice quantum numbers hybridize at finite crystal momentum. In all the materials known to date, the BC is triggered by the hybridization of a single type of quantum number. Here we report the discovery of the first material system having both spin- and orbital-sourced BC: LaAlO3/SrTiO3 interfaces grown along the [111] direction. We independently detect these two sources and probe the BC associated to the spin quantum number through the measurements of an anomalous planar Hall effect. The observation of a nonlinear Hall effect with time-reversal symmetry signals large orbital-mediated BC dipoles. The coexistence of different forms of BC enables the combination of spintronic and optoelectronic functionalities in a single material.

The role of line-orientation processing in the production of the Poggendorff illusion: A dual-task study.

Using a dual-task paradigm, the present investigation examined whether processes related to line orientation play a critical role in the production of the Poggendorff illusion. In Experiment 1, we assessed the magnitude of the Poggendorff illusion under three different task conditions. In the single-task condition, participants were asked to report how they perceive the alignment of transversal lines in the Poggendorff figure. In two different dual-task conditions, the participants were asked to read aloud the time displayed on a digital or analogue clock while also performing the Poggendorff perception task. The method of constant stimuli was used to calculate the point of subjective equality (PSE) and bistability width values, which represent illusion strength and perceptual uncertainty, respectively. PSEs indicated that the magnitude of the illusion did not vary between single, dual-analogue, and dual-digital task conditions, which suggests that the additional demands placed by the dual tasks had no effect on the illusion strength. Perceptual uncertainty and clock-reading errors were greater in the dual-analogue task condition. Experiment 2 revealed that the analogue clockface was more difficult to read than the digital clockface. Based on these results, we conclude that having participants perform a secondary task does not influence the magnitude of the Poggendorff illusion.

Evaluation of miR-526b-3p, miR-1179, miR-3529-3p, miR-5011-5p as potential diagnostic biomarkers in isolated cervical dystonia.

BACKGROUND: Cervical dystonia (CD) also named spasmodic torticollis is the most common type of focal dystonias and characterized by abnormal head, neck, and shoulder movements due to involuntary muscular spasm. Although CD is mostly idiopathic, to date, several genes have been associated with CD. However, to the best of our knowledge, microRNAs (miRNAs) which are interacted with CD-associated genes have been not evaluated yet. miRNAs are regulatory small non-coding RNAs and are suggested as potential biomarkers for many diseases through their stability in clinical samples. Therefore, we aimed to assess the expression levels of miRNAs (miR-526b-3p, miR-1179, miR-3529-3p, miR-5011-5p) which are targeted the CD-associated genes, and evaluate their performance as diagnostic biomarkers. METHODS: Peripheral blood samples were obtained from 30 patients with isolated CD (ICD) and 25 healthy controls. The expression levels of miR-526b-3p, miR-1179, miR-3529-3p, and miR-5011-5p were analyzed via quantitative real-time PCR (qRT-PCR), and receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic values. RESULTS: miR-526b-3p, miR-1179, and miR-3529-3p were significantly up-regulated while miR-5011-5p was significantly down-regulated in ICD patients compared to healthy controls. ROC analysis revealed that all miRNAs, especially miR-1179 and miR-3529-3p were statistically significant with the area under the curve (AUC) of 0.905 and 0.933, respectively. CONCLUSION: Altered expression levels of aforementioned miRNAs may be associated with CD pathogenesis. Our findings suggest using these four miRNAs as remarkable biomarkers in the diagnosis of ICD.

V-NOTES hysterectomy under spinal anaesthesia: A pilot study.

Background: Spinal anaesthesia has not been widely adopted for laparoscopic surgeries until now. There are a few studies that have shown that spinal anaesthesia is at least as safe as general anaesthesia. The need for additional analgesics can be reduced by utilising early postoperative analgesic effects of spinal anaesthesia, and maximum benefit can be obtained from minimally invasive approaches when V-NOTES surgery is performed under spinal anaesthesia. Objective: Combining V-NOTES with spinal anaesthesia to improve minimally invasive surgical techniques and provide maximum benefit to patients. Materials and Methods: Patients who were found to have benign pelvic organ pathologies, required a hysterectomy and were considered suitable for V-NOTES hysterectomy under spinal anaesthesia were included in this study. Spinal anaesthesia was achieved with 12.5 mg 0.5% hyperbaric bupivacaine in the sitting position. Perioperative events and complications related to spinal anaesthesia were noted. Postoperatively, the pain was evaluated using a visual analogue scale at the 6th, 12th, and 24th hours. Main outcome measures: To evaluate the feasibility and safety of spinal anaesthesia in VNOTES hysterectomy and to increase the advantages of minimally invasive surgical procedures. Results: No conversion to conventional laparoscopy or laparotomy was required in all six operated patients. Conversion from spinal anaesthesia to general anaesthesia was unnecessary, and no major perioperative incident occurred in any of the cases. Conclusion: In the current study by our team, we demonstrated that V-NOTES hysterectomy could be performed safely under spinal anaesthesia in well-selected patients. The need for additional analgesics can be reduced by utilising early postoperative analgesic effects of spinal anaesthesia, and maximum benefit can be obtained from minimally invasive approaches when VNOTES surgery is performed under spinal anaesthesia. What is new?: V-NOTES hysterectomy could be performed safely under spinal anaesthesia in well-selected patients.

Type-H, and Type-L COVID-19: are they different subtypes or the same?

OBJECTIVE: SARS-CoV-2 infection, which causes severe pneumonia, caused an epidemic that started in Wuhan, China in December 2019 and spread to the whole world. COVID-19 mainly affects the respiratory system and causes the development of severe pneumonia and related acute respiratory distress syndrome (ARDS) in some patients. We aimed to investigate whether COVID-19 pneumonia cases can be evaluated in different categories in clinical and radiological terms. PATIENTS AND METHODS: COVID-19 associated ARDS cases being treated with the diagnosis of severe pneumonia between March 21, 2020 and June 15, 2020 in Anesthesia Intensive Care Unit were examined and divided into 2 groups (type-L and type-H, total 29 cases) according to their clinical findings (according to whether they benefited from high PEEP and their lung compliance) and lung computed tomography findings (according to the severity of the ground glass appearance). The groups were compared with each other in terms of inflammatory markers [CRP (C reactive protein), ferritin, D Dimer, PCT (procalcitonin), white blood cell, lymphocyte count, arterial blood gas analysis] and imaging findings. RESULTS: It was observed that the prone position was beneficial in improving oxygenation in both H-type and L-type patients. 7 of 22 L-type patients were intubated and 5 of these patients died. There was no statistical difference between the two groups in terms of intubation times, hospital stays, cytokine levels, prone position application responses and mortality rates. CONCLUSIONS: Are there two separate forms of COVID-19 pneumonia, such as h-type and l-type, or are they intertwined and describe the early and late stages of the disease? This question needs to be discussed. In addition, we believe that subtyping COVID-19 pneumonia patients does not make a difference in the treatments to be applied.

A simple and rapid spectrofluorometric determination of pomalidomide in spiked plasma and urine. Application to degradation studies.

A rapid and accurate spectrofluorimetric method for the determination of pomalidomide was developed and validated based on the measurement of its native fluorescence without the need for any derivatization and separation for the first time. The fluorescence intensity of the drug in acetonitrile solution allowed precise detection at 460 nm after excitation at 296 nm. The calibration curve was linear in the concentration range 31.0-500.0 ng/ml. Limit of detection and limit of quantification were found to be 8.04 and 24.36 ng/ml, respectively. Sensitive results allowed the drug to be detected with good recovery (75.46-109.72%) in human plasma and urine using the developed method. The proposed method was validated in terms of linearity, sensitivity, precision, accuracy, recovery, and stability parameters. Pomalidomide was subjected to degradation under various stress conditions (hydrolytic, oxidative and thermal) to demonstrate that the method was stable, indicating and identifying possible degradation products. In addition, the drug was exposed to electrochemical degradation using the chronoamperometry technique for the first time. Characterization of pomalidomide degradation products obtained because of oxidative degradation and electrochemical degradation was carried out using attenuated total reflection Fourier transform infrared spectroscopy, mass spectrometry and high performance liquid chromatography - mass spectrometry methods and possible structures were proposed.

Bimodal Phase Diagram of the Superfluid Density in LaAlO_{3}/SrTiO_{3} Revealed by an Interfacial Waveguide Resonator.

We explore the superconducting phase diagram of the two-dimensional electron system at the LaAlO_{3}/SrTiO_{3} interface by monitoring the frequencies of the cavity modes of a coplanar waveguide resonator fabricated in the interface itself. We determine the phase diagram of the superconducting transition as a function of the temperature and electrostatic gating, finding that both the superfluid density and the transition temperature follow a dome shape but that the two are not monotonically related. The ground state of this two-dimensional electron system is interpreted as a Josephson junction array, where a transition from long- to short-range order occurs as a function of the electronic doping. The synergy between correlated oxides and superconducting circuits is revealed to be a promising route to investigate these exotic compounds, complementary to standard magnetotransport measurements.

Donkey milk kefir induces apoptosis and suppresses proliferation of Ehrlich ascites carcinoma by decreasing iNOS in mice.

Donkey milk and donkey milk kefir exhibit antiproliferative, antimutagenic and antibacterial effects. We investigated the effects of donkey milk and donkey milk kefir on oxidative stress, apoptosis and proliferation in Ehrlich ascites carcinoma (EAC) in mice. Thirty-four adult male Swiss albino mice were divided into four groups as follows: group 1, administered 0.5 ml water; group 2, administered 0.5 ml water + EAC cells; group 3, administered 0.5 ml donkey milk + EAC cells; group 4, administered 0.5 ml donkey milk kefir + EAC cells. We introduced 2.5 x 106 EAC cells into each animal by subcutaneous injection. Tap water, donkey milk and donkey milk kefir were administered by gavage for 10 days. Animals were sacrificed on day 11. After measuring the short and long diameters of the tumors, tissues were processed for histology. To determine oxidative stress, cell death and proliferation iNOS and eNOS, active caspase-3 and proliferating cell nuclear antigen were assessed using immunohistochemistry. A TUNEL assay also was used to detect apoptosis. Tumor volume decreased in the donkey milk kefir group compared to the control and donkey milk groups. Tumor volume increased in the donkey milk group compared to the control group. Proliferating cell nuclear antigen levels were higher in the donkey milk kefir group compared to the control and donkey milk groups. The number of apoptotic cells was less in the donkey milk group, compared to the control, whereas it was highest in the donkey milk kefir group. Donkey milk administration increased eNOS levels and decreased iNOS levels, compared to the control group. In the donkey milk kefir group, iNOS levels were significantly lower than those of the control and donkey milk groups, while eNOS levels were similar to the control group. Donkey milk kefir induced apoptosis, suppressed proliferation and decreased co-expression of iNOS and eNOS. Donkey milk promoted development of the tumors. Therefore, donkey milk kefir appears to be more beneficial for treating breast cancer than donkey milk.

Clinical performance of a combined approach for the esthetic management of fluorosed teeth: Three-year results.

OBJECTIVE: The long-term clinical performance of combined therapy including enamel microabrasion and vital bleaching is debatable due to the abrasion of outer enamel surface. The aim of this longitudinal cohort study was to evaluate the 3-year clinical performance of enamel microabrasion in combination with vital tooth bleaching for the esthetic management of fluorosed teeth. MATERIALS AND METHODS: Fifteen patients with 176 fluorosed incisors and canines were included in this study. All the teeth were treated with enamel microabrasion (Opalustre, Ultradent), and at-home bleaching technique (10% Opalescence PF, Ultradent). Fluorosed teeth were evaluated at baseline, after microabrasion, after combined therapy, and at 3-year follow-up in terms of esthetic criteria (esthetic appearance, brown stains, and opaque white areas), side effects, and patient satisfaction using visual analog scales. The data were statistically analyzed (α = 0.05). RESULTS: Fluorosed teeth revealed significantly better esthetic appearance after microabrasion and combined therapy and at 3-year follow-up compared to those at baseline (P P Conclusions: The combined therapy was effective in the esthetic management of fluorosed teeth. However, a significant relapse was observed in the esthetic appearance and brown stains of these patients after 3 years, which also reduced patient satisfaction.

Update in urethral stents.

Urethral stents were first introduced in 1988, and since then, they have undergone significant improvements. However, they did not gain a wide popularity and their use is limited to a small number of centers around the world. Urethral stents can be used in the entire urethra and for various and diverse indications. In the anterior urethra, it can be used to treat urethral strictures. In the prostatic urethra, they can be used for the treatment of prostatic obstruction, including benign, malignant and iatrogenic prostatic obstruction. Moreover, although not widely used, it can be also applied for the treatment of posterior urethral stricture and bladder neck contracture, usually resulting in urinary incontinence and the need for subsequent procedures. Our main experience are with Allium urethral stents, and as such, we provide the latest updates in urethral stents with special emphasis on the various types of Allium urethral stents: bulbar, prostatic and bladder neck stents.

Determinants of felt stigma in epilepsy.

The present study aimed to determine the level of felt stigma, overprotection, concealment, and concerns related to epilepsy in different life domains by using culturally-specific scales for Turkish individuals with epilepsy. Also, it aimed to detect relations among the study variables and to determine the variables which predict felt stigma. For this purpose, felt stigma scale, overprotection scale, concealment of epilepsy scale, and concerns of epilepsy scale were administered to two hundred adult persons with epilepsy (PWE). The results showed that almost half of the participants reported felt stigma, overprotection, concealment of epilepsy, concerns related to future occupation, and concerns related to social life. Almost all the study variables show correlations with each other. Concealment of epilepsy, concerns related to social life, and concerns related to future occupation were found as the predictors of felt stigma.

Gene-environment Interactions in the Etiology of Dental Caries.

Dental caries is a multifactorial disease that can be conceptualized as an interaction between genetic and environmental risk factors. The aim of this study is to examine the effects of AMELX, CA6, DEFB1, and TAS2R38 gene polymorphism and gene-environment interactions on caries etiology and susceptibility in adults. Genomic DNA was extracted from the buccal mucosa, and adults aged 20 to 60 y were placed into 1 of 2 groups: low caries risk (DMFT ≤ 5; n = 77) and high caries risk (DMFT ≥ 14; n = 77). The frequency of AMELX (+522), CA6 (T55M), DEFB1 (G-20A), and TAS2R38 (A49P) single-nucleotide polymorphisms was genotyped with the polymerase chain reaction-restriction fragment length polymorphism method. Environmental risk factors examined in the study included plaque amount, toothbrushing frequency, dietary intake between meals, saliva secretion rate, saliva buffer capacity, mutans streptococci counts, and lactobacilli counts. There was no difference between the caries risk groups in relation to AMELX (+522) polymorphism (χ(2) test, P > 0.05). The distribution of CA6 genotype and allele frequencies in the low caries risk group did not differ from the high caries risk group (χ(2) test, P > 0.05). Polymorphism of DEFB1 (G-20A) was positively associated, and TAS2R38 (A49P) negatively associated, with caries risk (χ(2) test, P = 0.000). There were significant differences between caries susceptibility and each environmental risk factor, except for the saliva secretion rate (Mann-Whitney U test, P = 0.000). Based on stepwise multiple linear regression analyses, dental plaque amount, lactobacilli count, age, and saliva buffer capacity, as well as DEFB1 (G-20A), TAS2R38 (A49P), and CA6 (T55M) gene polymorphism, explained a total of 87.8% of the variations in DMFT scores. It can be concluded that variation in CA6 (T55M), DEFB1 (G-20A), and TAS2R38 (A49P) may be associated with caries experience in Turkish adults with a high level of dental plaque, lactobacilli count, and age and when saliva buffer capacity is low.

Role of matrix metalloproteinases and tissue inhibitor of matrix metalloproteinases-1 in Crimean-Congo hemorrhagic fever disease.

AIM: Crimean-Congo hemorrhagic fever is a potentially fatal viral disease in humans caused by CCHF virus. We aimed to demonstrate change in serum levels of matrix metallopeinase/tissue matrix metalloproteinase inhibitor (MMP/TIMP) associated with CCHF. PATIENTS AND METHODS: Blood specimens were collected in acute and convalescence periods from the patients presented to Cumhuriyet University Hospital, Department of Emergency and Infection Diseases with presumed as CCHF between May 2010 and September 2010. Forty-one age and gender matched healthy individuals had not any viral, bacterial, acute or chronic disease were enrolled as the controls. Blood specimens were centrifuged at 4000 rpm for 5 min with in "Hettich universal 32" centrifuge. Serum samples obtained were kept at -80°C. All the specimens were brought to room temperature during the study and MMP-1, 2, 7, 9, 10 and TIMP-1 tests were studied at one time using "RayBiotech" brand kit in "Grifols" brand "Triturus" model ELISA device. Acute, convalescence and control groups were compared in terms of the serum levels of MMP-1, 2, 7, 9, 10 and TIMP-1. RESULTS: There was a statistically significant increase in serum levels of MMP-1, 7, 9, 10 and TIMP-1 in the convalescence period (p < 0.05) compared to the controls, while the increase in levels of MMP-2 was not statistically significant (p > 0.05). In acute period of CCHF, mean TIMP-1 levels of severe patients was significantly lower than that of the non-severe patients (207913 ± 31051 versus 231300 ± 13267, respectively, p = 0.023). CONCLUSIONS: High serum levels of MMP and TIMP in CCHF disease were found to decrease as progressed to convalescence from the acute period. It is thought MMP and TIMP plays a significant role in pathogenesis of CCHF.

Influence of single hemodialysis session on serum paraoxonase-1, arylesterase activity, total oxidant status and total antioxidant status.

AIM: Chronic kidney disease(CKD) and hemodialysis (HD) are associated with increased oxidative stress. Cardiovascular diseases (CVD) are the most important cause of mortality in these patients. Increased cardiovascular risk is associated with oxidative stress. The aim of this study was to evaluate whether the duration of single session hemodialysis may affect oxidative stress parameters on the patients with end-stage renal disease (ESRD). METHODS: Total oxidant status (TOS) and oxidative stress index (OSI) as oxidative markers and total antioxidant status (TAOS), paraoxonase1 (PON1) and arylesterase (ARES) as antioxidant markers were compared hemodialysis therapy before and after the treatment. RESULTS: TOS levels before hemodialysis were found as 4.4±2.4 µmol H2O2 Equiv/L, TAOS 2.1±0.3 µmol trolox Equiv./L, OSI 0.2±0.1%, PON1 levels 58.5±35.6 U/L and ARES levels 22±0.2 U/L while after the HD the respective values were 1.4±1.2 µmol H2O2 Equiv/L, 1.4±0.5 µmol trolox Equiv./L, 0.1±0.1%, 54.3±31.3 U/L, 21.8±0.1 U/L. A significant decreasing was observed in TOS TAOS OSI and ARES values before the HD compared to after the HD (P=0.0001, P=0.0001, P=0.0001, P=0.031, respectively). CONCLUSION: This study shows oxidant (TOS, OSI) and antioxidant (TAOS, ARES) markers were found to be significantly decrease after the HD compared to pre-hemodialysis. Although reverse is expected it is found that oxidants (indirectly ROS) did not increase and antioxidant reserve decreased in HD.

Glomerular filtration rate: which method should we measure in daily clinical practice?

AIM: In this study, we compared estimated glomerular filtration rate (eGFR) calculated with the formulas of Cockcroft-Gault (C&G), Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Mayo Clinic Quadratic (Mayo Q) and, GFR (mGFR) that was scintigraphically measured with creatinine clearance (CrCl) and technetium-99m diethylene triamine penta-acetic acid (99mTc-DTPA). Objective of this study was to define the correlations between the formulas, provide a reliable method for measurement and estimation of GFR in daily clinical practice and demonstrate the potential errors. METHODS: C&G, CKD-EPI, Mayo Q and MDRD eGFR of 84(37 males, 47 females) patients diagnosed with chronic kidney disease were calculated. Values of 99mTc-DTPA based on mGFR were compared with eGFR values of the formulas. RESULTS: Significant correlations were found with the values of 99mTc-DTPA mGFR, CrCl, MDRD, CKD-EPI, Mayo Q and C&G eGFR. The highest correlation was found between LBM(lean body mass) corrected C&G, MDRD-6, Mayo Q and CKD-EPI eGFR. The best estimate was made with MDRD-6 in the cases with 99mTc-DTPA mGFR<30 mL/min/1.73 m(2) and with MDRD-4 in the cases with 99mTc-DTPA mGFR≥30 mL/min/1.73 m(2), while the worst estimate was made with uncorrected C&G formula in both groups. CONCLUSION: All eGFR formulas can be used in daily clinical practice. However, using MDRD-6 in the cases with GFR<30 mL/min/1.73 m(2) and MDRD-4 in the cases with GFR≥30 mL/min/1.73m(2) as well as using LBM for C&G eGFR or correction according to LBM when AW (actual weight) is used, might provide a more accurate estimation.

[Diabetes and fasting during Ramadan. A observational study among Turkish immigrants in Belgium]. / Diabète et jeûne pendant le ramadan. Etude observationnelle parmi les migrants d'origine turque en Belgique.

AIMS: To investigate (i) Ramadan participation, (ii) provision of Ramadan related advice by healthcare providers (iii) medication use during Ramadan fasting among Turkish migrants with diabetes in Belgium. METHODS: This pilot observational study was conducted among a convenience sample of 52 Turkish migrants with diabetes in Belgium. Two questionnaires collected information on socio-demographic characteristics, diabetes related characteristics, current hypoglycaemic medication with dosing regimen, participation in the past Ramadan, reasons for (non)participation, use of hypoglycaemic medication during the past Ramadan, advice from their healthcare providers about fasting during Ramadan and follow up of this advice. RESULTS: Sixteen patients (31%) had fasted during the past Ramadan. Main reason for Ramadan participation was reinforcement of faith (12/15), while the main reason for non participation was having diabetes (34/36). About 56% of the study population had received recommendations from their healthcare provider(s) about fasting and diabetes during Ramadan. The most commonly provided advice was not to participate in Ramadan, followed by modification of drug therapy. Only 3 patients ignored the advice of their healthcare professionals. In addition, only 60% of those who actually fasted received recommendations about intake of diabetes medication during the ramadan. Most fasters continued their medication dose unchanged (87% of OHA users and 80% of the insulin users). CONCLUSIONS: This pilot study found a low prevalence of Ramadan fasting among Turkish migrants with diabetes in Belgium. We also found that provision of advice by healthcare providers could be improved. Larger scale studies are warranted to confirm these findings.

Comparison of enamel microabrasion with a combined approach to the esthetic management of fluorosed teeth.

OBJECTIVE: To compare in vivo the efficacy of enamel microabrasion alone or in combination with vital tooth bleaching for the management of tooth discoloration caused by fluorosis. METHODS: A total of 118 maxillary and mandibular fluorosed incisors and canines in 10 patients, scored from 1 to 7 according to the Tooth Surface Index of Fluorosis, were included in this study. All of the teeth were initially treated with enamel microabrasion (Opalustre, Ultradent Products Inc, South Jordan, UT, USA), and after 24 hours, an in-office bleaching technique (Opalescence Boost, Ultradent) was utilized (n=118). Standardized images of the teeth were taken using a digital camera prior to treatment and 24 hours after the enamel microabrasion and after the in-office bleaching therapy. The study groups were assigned according to evaluation time: a) after enamel microabrasion (Group 1) and b) after the combined approach (enamel microabrasion and in-office bleaching) (Group 2). Two calibrated and blinded examiners scored Group 1 and Group 2 images by comparing each with baseline images for "improvement in appearance," "changes in brown stains," and "changes in white opaque areas" using the visual analogue scales (VAS) that range from 1 to 7. "Patient satisfaction," "tooth sensitivity," and "gingival problems" were also recorded. The data were analyzed using two sample paired Wilcoxon signed-rank, Kruskal-Wallis, and Mann-Whitney U-tests (α=0.05). RESULTS: The combined therapy revealed significantly higher scores than the enamel microabrasion procedure in terms of all of the evaluated criteria (p<0.001). Enamel microabrasion provoked less tooth sensitivity but led to lower patient satisfaction scores than the combined therapy (p<0.001); however, in terms of gingival problems, no differences were found between both groups. CONCLUSION: The combined therapy, including enamel microabrasion and in-office bleaching, was more effective than enamel microabrasion alone in the esthetic management of fluorosed teeth.