ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update.

Osteoporosis constitutes a significant public health risk. An estimated 10.2 million adults in the United States >50 years of age have osteoporosis, a systemic condition that weakens the bones increasing the susceptibility for fractures. Approximately one-half of women and nearly one-third of men >50 years of age will sustain an osteoporotic fracture. These fractures are associated with a decrease in quality of life, diminished physical function, and reduced independence. Dual-energy X-ray absorptiometry (DXA) is the primary imaging modality used to screen for osteoporosis in women >65 years of age and men >70 years of age. DXA may be used in patients <65 years of age to evaluate bone mass density if there are additional risk factors. In certain situations, vertebral fracture assessment and trabecular bone score may further predict fracture risk, particularly in patients who are not yet osteoporotic but are in the range of osteopenia. Quantitative CT is useful in patients with advanced degenerative changes in the spine. Given the proven efficacy of pharmacologic therapy, the role of imaging to appropriately identify and monitor high-risk individuals is critical in substantially reducing osteoporosis-associated morbidity and mortality, and reducing the considerable cost to the health care system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Ambulatory Pulmonary Artery Pressures After Transcatheter Edge-to-Edge Repair of the Mitral Valve in Patients With Heart Failure and Mitral Regurgitation.

The objective of this study was to assess ambulatory hemodynamics after transcatheter edge-to-edge repair (TEER) of the mitral valve. Pulmonary artery pressure (PAP) measurements from implanted sensors were collected through a remote monitoring database and linked to Medicare fee-for-service claims data. Among patients with linked data, those undergoing TEER were included if the ambulatory PAP monitor was implanted ≥3 months before TEER and ≥3 months of PAP data after TEER were available. The primary end point was diastolic PAP (dPAP) at 3 months after TEER compared with baseline. A total of 50 patients undergoing TEER between July 2014 and March 2020 were included, with an average age of 75 ± 8 years and 70% were men. dPAP was significantly lower at 3 months after TEER than baseline, -1.8 ± 4.8 mm Hg, p = 0.010. The cumulative reduction in dPAP (area under the curve) was significantly lower at 3 months after TEER, 113 ± 267 mm Hg-days, p = 0.004. A reduction in dPAP at 3 months after TEER was independently associated with a significantly lower risk of heart failure hospitalization (p = 0.023). TEER of the mitral valve is associated with a clinically relevant and sustained reduction in dPAP.

ACR Appropriateness Criteria® Imaging After Shoulder Arthroplasty: 2021 Update.

Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Biological substrate modification suppresses ventricular arrhythmias in a porcine model of chronic ischaemic cardiomyopathy.

AIMS: Cardiomyopathy patients are prone to ventricular arrhythmias (VA) and sudden cardiac death. Current therapies to prevent VA include radiofrequency ablation to destroy slowly conducting pathways of viable myocardium which support re-entry. Here, we tested the reverse concept, namely that boosting local tissue viability in zones of slow conduction might eliminate slow conduction and suppress VA in ischaemic cardiomyopathy. METHODS AND RESULTS: Exosomes are extracellular vesicles laden with bioactive cargo. Exosomes secreted by cardiosphere-derived cells (CDCEXO) reduce scar and improve heart function after intramyocardial delivery. In a VA-prone porcine model of ischaemic cardiomyopathy, we injected CDCEXO or vehicle into zones of delayed conduction defined by electroanatomic mapping. Up to 1-month post-injection, CDCEXO, but not the vehicle, decreased myocardial scar, suppressed slowly conducting electrical pathways, and inhibited VA induction by programmed electrical stimulation. In silico reconstruction of electrical activity based on magnetic resonance images accurately reproduced the suppression of VA inducibility by CDCEXO. Strong anti-fibrotic effects of CDCEXO, evident histologically and by proteomic analysis from pig hearts, were confirmed in a co-culture assay of cardiomyocytes and fibroblasts. CONCLUSION: Biological substrate modification by exosome injection may be worth developing as a non-destructive alternative to conventional ablation for the prevention of recurrent ventricular tachyarrhythmias.

Assessment of arrhythmia mechanism and burden of the infarcted ventricles following remuscularization with pluripotent stem cell-derived cardiomyocyte patches using patient-derived models.

AIMS: Direct remuscularization with pluripotent stem cell-derived cardiomyocytes (PSC-CMs) seeks to address the onset of heart failure post-myocardial infarction (MI) by treating the persistent muscle deficiency that underlies it. However, direct remuscularization with PSC-CMs could potentially be arrhythmogenic. We investigated two possible mechanisms of arrhythmogenesis-focal vs. re-entrant-arising from direct remuscularization with PSC-CM patches in two personalized, human ventricular computer models of post-MI. Moreover, we developed a principled approach for evaluating arrhythmogenicity of direct remuscularization that factors in the VT propensity of the patient-specific post-MI fibrotic substrate and use it to investigate different conditions of patch remuscularization. METHODS AND RESULTS: Two personalized, human ventricular models of post-MI (P1 and P2) were constructed from late gadolinium enhanced (LGE)-magnetic resonance images (MRIs). In each model, remuscularization with PSC-CM patches was simulated under different treatment conditions that included patch engraftment, patch myofibril orientation, remuscularization site, patch size (thickness and diameter), and patch maturation. To determine arrhythmogenicity of treatment conditions, VT burden of heart models was quantified prior to and after simulated remuscularization and compared. VT burden was quantified based on inducibility (i.e. weighted sum of pacing sites that induced) and severity (i.e. the number of distinct VT morphologies induced). Prior to remuscularization, VT burden was significant in P1 (0.275) and not in P2 (0.0, not VT inducible). We highlight that re-entrant VT mechanisms would dominate over focal mechanisms; spontaneous beats emerging from PSC-CM grafts were always a fraction of resting sinus rate. Moreover, incomplete patch engraftment can be particularly arrhythmogenic, giving rise to particularly aberrant electrical activation and conduction slowing across the PSC-CM patches along with elevated VT burden when compared with complete engraftment. Under conditions of complete patch engraftment, remuscularization was almost always arrhythmogenic in P2 but certain treatment conditions could be anti-arrhythmogenic in P1. Moreover, the remuscularization site was the most important factor affecting VT burden in both P1 and P2. Complete maturation of PSC-CM patches, both ionically and electrotonically, at the appropriate site could completely alleviate VT burden. CONCLUSION: We identified that re-entrant VT would be the primary VT mechanism in patch remuscularization. To evaluate the arrhythmogenicity of remuscularization, we developed a principled approach that factors in the propensity of the patient-specific fibrotic substrate for VT. We showed that arrhythmogenicity is sensitive to the patient-specific fibrotic substrate and remuscularization site. We demonstrate that targeted remuscularization can be safe in the appropriate individual and holds the potential to non-destructively eliminate VT post-MI in addition to addressing muscle deficiency underlying heart failure progression.

Computational modeling of aberrant electrical activity following remuscularization with intramyocardially injected pluripotent stem cell-derived cardiomyocytes.

Acute engraftment arrhythmias (EAs) remain a serious complication of remuscularization therapy. Preliminary evidence suggests that a focal source underlies these EAs stemming from the automaticity of immature pluripotent stem cell-derived cardiomyocytes (PSC-CMs) in nascent myocardial grafts. How these EAs arise though during early engraftment remains unclear. In a series of in silico experiments, we probed the origin of EAs-exploring aspects of altered impulse formation and altered impulse propagation within nascent PSC-CM grafts and at the host-graft interface. To account for poor gap junctional coupling during early PSC-CM engraftment, the voltage dependence of gap junctions and the possibility of ephaptic coupling were incorporated. Inspired by cardiac development, we also studied the contributions of another feature of immature PSC-CMs, circumferential sodium channel (NaCh) distribution in PSC-CMs. Ectopic propagations emerged from nascent grafts of immature PSC-CMs at a rate of <96 bpm. Source-sink effects dictated this rate and contributed to intermittent capture between host and graft. Moreover, ectopic beats emerged from dynamically changing sites along the host-graft interface. The latter arose in part because circumferential NaCh distribution in PSC-CMs contributed to preferential conduction slowing and block of electrical impulses from host to graft myocardium. We conclude that additional mechanisms, in addition to focal ones, contribute to EAs and recognize that their relative contributions are dynamic across the engraftment process.

Mechanisms of Sinoatrial Node Dysfunction in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: The ability to increase heart rate during exercise and other stressors is a key homeostatic feature of the sinoatrial node (SAN). When the physiological heart rate response is blunted, chronotropic incompetence limits exercise capacity, a common problem in patients with heart failure with preserved ejection fraction (HFpEF). Despite its clinical relevance, the mechanisms of chronotropic incompetence remain unknown. METHODS: Dahl salt-sensitive rats fed a high-salt diet and C57Bl6 mice fed a high-fat diet and an inhibitor of constitutive nitric oxide synthase (Nω-nitro-L-arginine methyl ester [L-NAME]; 2-hit) were used as models of HFpEF. Myocardial infarction was created to induce HF with reduced ejection fraction. Rats and mice fed with a normal diet or those that had a sham surgery served as respective controls. A comprehensive characterization of SAN function and chronotropic response was conducted by in vivo, ex vivo, and single-cell electrophysiologic studies. RNA sequencing of SAN was performed to identify transcriptomic changes. Computational modeling of biophysically-detailed human HFpEF SAN was created. RESULTS: Rats with phenotypically-verified HFpEF exhibited limited chronotropic response associated with intrinsic SAN dysfunction, including impaired ß-adrenergic responsiveness and an alternating leading pacemaker within the SAN. Prolonged SAN recovery time and reduced SAN sensitivity to isoproterenol were confirmed in the 2-hit mouse model. Adenosine challenge unmasked conduction blocks within the SAN, which were associated with structural remodeling. Chronotropic incompetence and SAN dysfunction were also found in rats with HF with reduced ejection fraction. Single-cell studies and transcriptomic profiling revealed HFpEF-related alterations in both the "membrane clock" (ion channels) and the "Ca2+ clock" (spontaneous Ca2+ release events). The physiologic impairments were reproduced in silico by empirically-constrained quantitative modeling of human SAN function. CONCLUSIONS: Chronotropic incompetence and SAN dysfunction were seen in both models of HF. We identified that intrinsic abnormalities of SAN structure and function underlie the chronotropic response in HFpEF.

Patient Satisfaction in Outpatient Radiology: Effects of Modality and Patient Demographic Characteristics.

Objective: To characterize predictors of patient satisfaction in outpatient radiology, we examined whether patient satisfaction differs across radiology modalities and demographic groups. Methods: A random sampling of Press-Ganey outpatient services surveys for radiology and non-radiology visits from September 2008 to September 2017 were retrospectively analyzed. Composite scores averaged across all Likert items were analyzed as both a continuous variable and a dichotomous variable of dissatisfaction (defined as ≤3 on the 5-point scale). Results: Among 9983 radiology surveys, mammography had higher composite scores than MRI, CT, radiography, US, and NM/PET (p < 0.001) and lower dissatisfaction (3.9%) than CT (6.7%), MRI (7.3%), and radiography (8.2%). Low-scoring responses were most common in the Facilities domain (7.8%) and least common in Overall Assessment (3.8%). Satisfaction metrics were lowest for ages 20-29 and highest for ages 70-79. Lower dissatisfaction rates were seen among Hispanics (3%) and whites (6%), compared to blacks (10%) and Asians (18%). Conclusion: Significant differences in patient satisfaction were found across imaging modalities and demographic variables. Further investigations to identify contributing factors may help improve patient experiences.

ACR Appropriateness Criteria® Chronic Foot Pain.

Chronic foot pain is a frequent clinical complaint, which can significantly impact the quality of live in some individuals. These guidelines define best practices with regards to requisition of imaging studies based on specific clinical scenarios, which have been grouped into different variants. Each variant is accompanied by a brief description of the usefulness, advantages, and limitations of different imaging modalities. The present narrative is the result of an exhaustive assessment of the available literature and a thorough review process by a panel of experts on Musculoskeletal Imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Synthesis of the Taxol Core via Catalytic Asymmetric 1,4-Addition of an Alkylzirconium Nucleophile.

The Taxol core was prepared in five steps via a key copper-catalyzed asymmetric conjugate addition trapping sequence. The use of a bromodiene-derived alkylzirconium nucleophile followed by trapping with POCl3/DMF gave a highly functionalized intermediate featuring a quaternary center in 69% yield with 92% ee. After 1,2-addition, Suzuki-Miyaura cross-coupling, allylic oxidation, and a type II intramolecular Diels-Alder reaction, the taxol core was obtained in 11% overall yield with 92% ee.

A comprehensive, multiscale framework for evaluation of arrhythmias arising from cell therapy in the whole post-myocardial infarcted heart.

Direct remuscularization approaches to cell-based heart repair seek to restore ventricular contractility following myocardial infarction (MI) by introducing new cardiomyocytes (CMs) to replace lost or injured ones. However, despite promising improvements in cardiac function, high incidences of ventricular arrhythmias have been observed in animal models of MI injected with pluripotent stem cell-derived cardiomyocytes (PSC-CMs). The mechanisms of arrhythmogenesis remain unclear. Here, we present a comprehensive framework for computational modeling of direct remuscularization approaches to cell therapy. Our multiscale 3D whole-heart modeling framework integrates realistic representations of cell delivery and transdifferentiation therapy modalities as well as representation of spatial distributions of engrafted cells, enabling simulation of clinical therapy and the prediction of emergent electrophysiological behavior and arrhythmogenensis. We employ this framework to explore how varying parameters of cell delivery and transdifferentiation could result in three mechanisms of arrhythmogenesis: focal ectopy, heart block, and reentry.

ß-Chloroaldehydes from Trapping Zirconium Enolates Produced in Asymmetric 1,4-Additions.

Zirconium enolates, derived from copper-catalyzed asymmetric conjugate additions, are trapped with the Vilsmeier-Haack reagent. Asymmetric additions generate quaternary carbon centers with high enantioselectivity (generally ∼90% ee), and the enolates are converted to unsaturated ß-chloroaldehydes (41-57% yields). The reaction tolerates changes to the nucleophile, can be used to form five-, six-, or seven-membered ring products, and is scalable to 5 mmol, and the products are readily elaborated by condensation, cross coupling, and addition reactions.

A User Interface for Optimizing Radiologist Engagement in Image Data Curation for Artificial Intelligence.

PURPOSE: To delineate image data curation needs and describe a locally designed graphical user interface (GUI) to aid radiologists in image annotation for artificial intelligence (AI) applications in medical imaging. MATERIALS AND METHODS: GUI components support image analysis toolboxes, picture archiving and communication system integration, third-party applications, processing of scripting languages, and integration of deep learning libraries. For clinical AI applications, GUI components included two-dimensional segmentation and classification; three-dimensional segmentation and quantification; and three-dimensional segmentation, quantification, and classification. To assess radiologist engagement and performance efficiency associated with GUI-related capabilities, image annotation rate (studies per day) and speed (minutes per case) were evaluated in two clinical scenarios of varying complexity: hip fracture detection and coronary atherosclerotic plaque demarcation and stenosis grading. RESULTS: For hip fracture, 1050 radiographs were annotated over 7 days (150 studies per day; median speed: 10 seconds per study [interquartile range, 3-21 seconds per study]). A total of 294 coronary CT angiographic studies with 1843 arteries and branches were annotated for atherosclerotic plaque over 23 days (15.2 studies [80.1 vessels] per day; median speed: 6.08 minutes per study [interquartile range, 2.8-10.6 minutes per study] and 73 seconds per vessel [interquartile range, 20.9-155 seconds per vessel]). CONCLUSION: GUI-component compatibility with common image analysis tools facilitates radiologist engagement in image data curation, including image annotation, supporting AI application development and evolution for medical imaging. When complemented by other GUI elements, a continuous integrated workflow supporting formation of an agile deep neural network life cycle results.Supplemental material is available for this article.© RSNA, 2019.

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic.

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Cardiac regeneration following cryoinjury in the adult zebrafish targets a maturation-specific biomechanical remodeling program.

Cardiac regeneration post-injury is a tantalizing feature of many lower vertebrates such as fishes and urodeles, but absent in adult humans. Restoration of pumping function is a key endpoint of cardiac regeneration, but very little is known about the biomechanical remodeling process. Here, we quantify and compare the evolution of cellular composition and mechanical stiffness of the zebrafish ventricular myocardium during maturation and following cryoinjury during regeneration to better understand the dynamics of biomechanical remodeling during these two processes. With increasing age, normal myocardial trabecular density and cardiomyocyte fraction increased, while non-myocyte cell fractions decreased. Cell density remained constant during maturation. Cardiomyocyte sarcomeres shortened to a minimum reached at 7.5 months of age, but lengthened with additional age. Concomitantly, ventricular wall stiffness increased up until 7.5 months before plateauing with additional age. Endothelial, myofibroblast/smooth muscle, and cardiomyocyte cell fractions were disrupted following cryoinjury, but were progressively restored to age-specific natural norms by 35 days post infarct (DPI). Infarcted myocardium stiffened immediately following cryoinjury and was a 100-fold greater than non-infarcted tissue by 3 DPI. By 14 DPI, stiffness of the infarcted myocardium had fallen below that of 0 DPI and had completely normalized by 35 DPI. Interestingly, cardiomyocyte sarcomere length increased until 14 DPI, but subsequently shortened to lengths below age-specific natural norms, indicating recovery from a volume overloaded condition. These observations are consistent with the view that regenerating myocardium requires biomechanical stimulation (e.g. strain) to rescue from a volume overloaded condition. Intriguingly, the biomechanical progression of the infarcted adult myocardial wall mirrors that of normal remodeling during aging. The biomechanical progression of the infarcted myocardium targets the values of age-specific norms despite a large divergence in initial conditions. These findings identify a novel biomechanical control of heart regeneration that may orchestrate cellular and tissue level remodeling responses.

Degradation and Mineralization of Carbamazepine Using an Electro-Fenton Reaction Catalyzed by Magnetite Nanoparticles Fixed on an Electrocatalytic Carbon Fiber Textile Cathode.

Pharmaceutical wastes are considered to be important pollutants even at low concentrations. In this regard, carbamazepine has received significant attention due to its negative effect on both ecosystem and human health. However, the need for acidic conditions severely hinders the use of conventional Fenton reagent reactions for the control and elimination of carbamazepine in wastewater effluents and drinking water influents. Herein, we report of the synthesis and use of flexible bifunctional nanoelectrocatalytic textile materials, Fe3O4-NP@CNF, for the effective degradation and complete mineralization of carbamazepine in water. The nonwoven porous structure of the composite binder-free Fe3O4-NP@CNF textile is used to generate H2O2 on the carbon nanofiber (CNF) substrate by O2 reduction. In addition, ·OH radical is generated on the surface of the bonded Fe3O4 nanoparticles (NPs) at low applied potentials (-0.345 V). The Fe3O4-NPs are covalently bonded to the CNF textile support with a high degree of dispersion throughout the fiber matrix. The dispersion of the nanosized catalysts results in a higher catalytic reactivity than existing electro-Fenton systems. For example, the newly synthesized Fe3O4-NPs system uses an Fe loading that is 2 orders of magnitude less than existing electro-Fenton systems, coupled with a current efficiency that is higher than electrolysis using a boron-doped diamond electrode. Our test results show that this process can remove carbamazepine with high pseudo-first-order rate constants (e.g., 6.85 h-1) and minimal energy consumption (0.239 kW·h/g carbamazepine). This combination leads to an efficient and sustainable electro-Fenton process.

ACR Appropriateness Criteria® Chronic Wrist Pain.

Radiographs are indicated as the first imaging test in all patients with chronic wrist pain, regardless of the suspected diagnosis. When radiographs are normal or equivocal, advanced imaging with MRI (without or without intravenous contrast or following arthrography), CT (usually without contrast), and ultrasound each has a role in establishing a diagnosis. Furthermore, these examinations may contribute to staging disease, treatment planning, and prognostication, even when radiographs are diagnostic of a specific condition. Which examination or examinations are best depends on the specific location of pain and the clinically suspected conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Lateral open bite and crossbite correction in a Class III patient with missing maxillary first premolars.

Posterior and Class III elastics were used to correct lateral open bite and anterior crossbite in a 29-year-old man. His occlusion, smile esthetics, and soft tissue profile were significantly improved after 25 months of active orthodontic treatment combined with 4 anterior restorations.

ACR Appropriateness Criteria® Chronic Hip Pain.

Chronic hip pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic hip pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Camouflage treatment of skeletal Class III malocclusion with conventional orthodontic therapy.

Nonextraction camouflage treatment along with Class III elastics was used to treat a 39-year-old woman with a skeletal Class III pattern and a low mandibular plane angle and short lower anterior facial height. The total active treatment time was 26 months. Her occlusion, smile esthetics, and soft tissue profile were significantly improved after treatment.