Inter-observer and intra-observer agreement of cervical vertebral maturation staging: A systematic review and meta-analysis.

INTRODUCTION: The accurate assessment of active growth is pivotal for the correction of skeletal malocclusion in growing patients. Cervical vertebral maturation (CVM) staging is easy and devoid of unnecessary radiation, but its inter- and intra-observer agreement is still debatable. OBJECTIVE: This study aims to assess inter-observer (reliability) and intra-observer agreement (reproducibility) for CVM staging. METHODS: A comprehensive literature search across five databases up to October 2023 was conducted. Inclusion criteria comprised observational studies that specifically reported intra-rater, inter-rater, or both agreements as their primary objectives for cervical vertebral maturation (CVM) staging. Studies with a sample size exceeding 15 participants were considered for inclusion. After duplicate study selection, data extraction, and risk-of-bias assessment, random-effects meta-analyses of kappa (k)/correlation coefficient (r) and their 95% confidence intervals (CIs) were performed, followed by meta-regressions, sensitivity analyses, and subgroup analyses. RESULTS: Seventeen observational studies (comprising 1437 lateral cephalograms and 110 assessors) were included. The reliability (8 studies; k=0.62 [95% CI: 0.44, 0.78]) and reproducibility (9 studies; k=0.708 [95% CI: 0.59, 0.82]) were substantial. The inter-observer correlation was almost perfect (in 9 studies; r=0.86 [95% CI: 0.82, 0.89]) while intra-observer correlation was substantial (in 2 studies; r=0.75 [95% CI: 0.62, 0.84]). Tracing of lateral cephalograms significantly increased inter-observer reliability (ß=0.29 [0.57, 0.0031]) but cropping and time of assessment (initial vs. follow-up) had no significant impact. The reliability (P<0.001) and reproducibility (P=0.049) of high-quality studies were superior to those observed in low-quality studies. CONCLUSION: Assessment of the CVM staging is accurate and reproducible to a satisfactory level. The accuracy and reproducibility of CVM are higher in studies utilizing traced cephalograms and those with a low-risk of bias. REGISTRATION: PROSPERO registration (CRD42023468521). Data is openly available at https://doi.org/10.5281/zenodo.10599129.

Vertical effects of cervical headgear in growing patients with Class II malocclusion: a systematic review and meta-analysis.

BACKGROUND: Cervical headgear (cHG) has been shown to be effective in Class II correction both with dental and orthopaedic effects but has traditionally been associated with vertical adverse effects in terms of posterior mandibular rotation. OBJECTIVE: To assess the treatment effects of cHG treatment in the vertical dimension. SEARCH METHODS: Unrestricted literature search of five databases up to May 2023. SELECTION CRITERIA: Randomized/non-randomized clinical studies comparing cHG to untreated controls, high-pull headgear (hp-HG), cHG adjuncts, or other Class II treatment alternatives (functional appliances or distalisers). DATA COLLECTION AND ANALYSIS: After duplicate study selection, data extraction, and risk-of-bias assessment according to Cochrane, random-effects meta-analyses of mean differences (MD)/standardized mean diffences (SMD) and their 95% confidence intervals (CIs) were performed, followed by meta-regressions, sensitivity analyses, and assessment of certainty on existed evidence. RESULTS: Two randomized/16 non-randomized studies (12 retrospective/4 prospective) involving 1094 patients (mean age 10.9 years and 46% male) were included. Compared to natural growth, cHG treatment was not associated on average with increases in mandibular (eight studies; SMD 0.22; 95% CI -0.06, 0.49; P = 0.11) or maxillary plane angle (seven studies; SMD 0.81; 95% CI -0.34, 1.95; P=0.14). Observed changes translate to MDs of 0.48° (95% CI -0.13, 1.07°) and 1.22° (95% CI -0.51, 2.94°) in the SN-ML and SN-NL angles, respectively. No significant differences were seen in y-axis, facial axis angle, or posterior face height (P > 0.05). Similarly, no significant differences were found between cHG treatment and (i) addition of a lower utility arch, (ii) hp-HG treatment, and (iii) removable functional appliance treatment (P > 0.05 for all). Meta-regressions of patient age, sex, or duration and sensitivity analyses showed relative robustness, while our confidence in these estimates was low to very low due to the risk of bias, inconsistency, and imprecision. CONCLUSIONS: cHG on average is not consistently associated with posterior rotation of the jaws or a consistent increase in vertical facial dimensions among Class II patients. REGISTRATION: PROSPERO registration (CRD42022374603).

Healthcare workers safety in the COVID-19 era: the impact of pre-pandemic personal protective equipment (PPE) training in Pakistan.

BACKGROUND: The COVID-19 pandemic has revealed vulnerabilities in healthcare systems worldwide, emphasizing the importance of healthcare worker safety through adequate utilization of personal protective equipment (PPE). This study aims to assess the impact of pre-pandemic PPE training on the practices and other associated factors among frontline healthcare workers during the COVID-19 pandemic in Pakistan and provide insights into the implications of such training programs for future initiatives. METHODS: A cross-sectional study from May 9th to June 5th, 2020 was conducted among the frontline healthcare workers against COVID-19 in Pakistan, utilizing an online structured questionnaire shared via WhatsApp and Facebook by using purposive sampling. Statistical analyses, including chi-square tests for proportion and logistic regression for the association while multi-logistic regression for potential confounders, were performed using SPSS version 22. RESULTS: A total of 453 healthcare staff participated, with 68.9% (n = 312) reporting no prior PPE training and 31.1% (n = 141) having received training. Significant associations were found between prior training and healthcare group distribution (p = 0.006), with doctors exhibiting the highest proportion of training 82 (37.61%), followed by nurses 50 (27.32%) and paramedics 9 (17.31%). Those who didn't receive any prior training in PPEs showed a higher perceived professional risk of 216 (69.23%) compared to those who received prior PPE training 96 (30.77%, p-value 0.005). Similarly, a higher frequency 137 (63.72%) of Perceived Personal risk was observed in those who didn't receive training, labeled as "high risk" compared to those who were trained 78 (36.28%, P value 0.02). Multi-logistic regression analysis identified paramedics as 0.26 times less likely to have received prior PPE training (Adjusted OR 0.26, 95% CI 0.10-0.65, p = 0.01) compared to medical doctors. Healthcare workers in tertiary care hospitals were 0.46 times less likely to undergo PPE training (Adjusted OR 0.46, 95% CI 0.25-0.87,p = 0.01) compared to those working at COVID-19 facilities/hospitals/quarantine centers. Likewise, individuals who doffed disposable gowns [Adjusted OR 3.86, (95% CI, 1.23-12.08, p = 0.02] were 3.86 times more interested in getting prior training in PPE compared to those who don't have skills to wear them. CONCLUSION: Our findings highlight that healthcare levels, type of healthcare, and doffing skills are important predictors of whether healthcare workers have taken prior training in PPE. These findings imply developing effective training programs for healthcare workers to ensure safety while providing care during pandemics like COVID-19.

Late Presentation of Acute Coronary Syndrome Complicated by Ventricular Septal Rupture.

Acquired ventricular septal rupture (VSR) is a rare but potentially fatal complication of late-presenting myocardial infarction (MI). In the era of revascularization and reperfusion therapy, the incidence of VSR has significantly decreased. Ruptures occur predominantly in patients with late-presenting ST elevation MI. Patients may present with a wide variety of symptoms ranging from chest pain and mild hemodynamic instability to profound cardiogenic shock. Inotropes, vasopressors, and mechanical support with intra-aortic balloon pumps and extracorporeal membrane oxygenation can be used to bridge patients to surgery. Despite treatment with ventricular septal repair, postsurgical mortality remains high. There is a wide variety of complications that can occur in the postoperative period. A multidisciplinary approach is vital in these patients who develop VSR. Improving awareness among healthcare professionals regarding the symptoms of acute coronary syndrome can hopefully help prevent delayed presentation of patients to healthcare facilities.

Effect Of Elastomeric Separator On Microbial Count In Gingival Crevicular Fluid.

BACKGROUND: The separators are a preliminary step for band insertion, but there is a potential risk of bacteraemia during their placement, particularly in susceptible patients. The objective of the study is to determine the effect of separators on the bacterial count in gingival crevicular fluid (GCF) and to assess the efficacy of chlorhexidine mouth rinse and saline irrigation in the reduction of the bacterial count. METHODS: This randomized controlled trial was conducted on 51 participants who were divided into three equal g roups randomly (brushing only/control, saline irrigation, and 2% chlorhexidine mouthwash rinse). The inclusion criteria were age between 18-25 years, good oral hygiene, gingival and plaque index <1, no previous orthodontic treatment, and healthy individuals. The bacterial count was obtained from GCF samples after two hours, on the third day, and on the seventh day. Kruskal Wallis test was used to compare the bacterial count among the three groups, and post hoc analysis was done using Dunn's test. Friedman test was applied to see the difference at three-time points in each group. RESULTS: In both saline and chlorhexidine groups the mean bacterial count decreased significantly from baseline to 3rd day and 7th day after separator placement (p<0.001). For the third day, a significant difference was found in control versus saline and control versus chlorhexidine. No significant difference was found between saline and chlorhexidine on the third day. Similar results were found on the 7 thday. For controls, the bacterial count increased with time and for both saline and chlorhexidine groups the bacterial count decreased. The highest decrease in the bacterial count was found for the chlorhexidine group. CONCLUSIONS: After the placement of separators, there was an increase in the bacterial count in GCF. Notably, chlorhexidine was found to be more effective than saline irrigation in reducing the bacterial count.

Effects of chlorhexidine use on periodontal health during fixed appliance orthodontic treatment: a systematic review and meta-analysis.

BACKGROUND: Proper oral hygiene and absence of periodontal inflammation is pre-requisite for orthodontic treatment. Chlorhexidine (CHX) is an established oral antiseptic used in the treatment of periodontal disease, but its role in orthodontic therapy is unclear. OBJECTIVES: To assess the efficacy of adjunct use of CHX-containing products in maintaining gingival health among orthodontic patients with fixed appliances. SEARCH METHODS: Five databases were searched without limitations up to August 2021. SELECTION CRITERIA: Randomized clinical trials (RCTs) assessing Gingival Index (GI) (primary outcome), Plaque Index (PI), Bleeding Index (BI), or Pocket Probing Depth (PPD). DATA COLLECTION AND ANALYSIS: Study selection, data extraction, and risk of bias assessment were done independently in duplicate. Random-effects meta-analyses of mean differences (MDs) or standardized mean differences (SMDs) with their 95% confidence intervals (CIs) were conducted, followed by sensitivity and Grades of Recommendations, Assessment, Development and Evaluation analysis. RESULTS: Twenty RCTs (1001 patients) were included assessing CHX-containing mouthwashes (n = 11), toothpastes (n = 2), gels (n = 3), or varnishes (n = 4) compared to placebo/control (n = 19) or sodium fluoride-products (n = 4). In the short-term, CHX-containing mouthwash was associated with lower GI (n = 9; MD = -0.68; 95% CI = -0.97 to -0.38; P < 0.001; high quality), lower PI (n = 9; MD = -0.65; 95% CI = -0.86 to -0.43; P < 0.001; high quality), lower BI (n = 2; SMD = -1.61; 95% CI = -2.99 to -0.22; P = 0.02; low quality), and lower PPD (n = 2; MD = -0.60 mm; 95% CI = -1.06 to -0.14 mm; P = 0.01; low quality). No considerable benefits were found from the use of CHX-gel or CHX-varnish in terms of GI, PI, or PPD (P > 0.05/low quality in all instances). Use of a CHX-containing toothpaste was more effective in lowering PI (Heintze-index) than adjunct use of fluoride-containing mouthwash (n = 2; MD = -5.24; 95% CI = -10.46 to -0.02; P = 0.04), but not GI (P = 0.68) or BI (P = 0.27), while sensitivity analyses indicated robustness. CONCLUSIONS: Adjunct use of CHX mouthwash during fixed-appliance treatment is associated with improved gingival inflammation, plaque control, and pocket depths, but caution is warranted and recommendations about CHX use during orthodontic treatment of children/adults should consider the heterogeneous patient response, cost-effectiveness, and potential adverse effects. REGISTRATION: PROSPERO registration (CRD42021228759).

Short Stature and Celiac Disease in Children (5 to 16 Years) Presenting at a Tertiary Care Hospital in Peshawar.

BACKGROUND: Malabsorption is the typical presentation of celiac disease in early childhood, whereas older children can present with extra-intestinal symptoms including short stature and delay in pubertal development. OBJECTIVE: To determine the frequency of celiac disease in shortening of stature in children. MATERIAL AND METHODS: This descriptive, cross-sectional study was conducted at the Pediatric Department in Lady Reading Hospital, Peshawar, on 152 short stature children of both genders aged 5 to 16 years. Children with dysmorphic faces, syndromes, endocrine disorders, and children or their parents who refused to give consent were excluded. Anthropometric measurement was done on standard equipment. Height and weight were plotted on WHO centile charts. All the children fulfilling inclusion criteria were advised serologic anti-tissue transglutaminase antibodies tests. RESULTS: Overall the frequency of celiac disease was 33.77% (n=51) among the children with short stature. The mean age of the study was 6.71±1.52 years. There were 76 males (50.3%), while there were 75 females 49.7%. The frequency of celiac disease among short stature females was higher (n=28, 54.9%) than short stature males (n=23, 45.1%). However, the results were not statistically significant (P=0.358). The frequency of celiac disease stratified by age group was not statistically significant (P=0.491). CONCLUSION: One-third of children having short stature have celiac disease. The frequency of celiac disease in children with short stature has no association with gender and age.