Long-term evaluation of soft-tissue changes after miniscrew-assisted and conventional rapid palatal expansion using voxel-based superimposition of cone-beam computed tomography scans.

INTRODUCTION: This study aimed to evaluate the soft-tissue changes in the long-term after miniscrew-assisted rapid palatal expansion (MARPE) and conventional rapid palatal expansion (RPE) appliances compared with a matched control group using voxel-based superimposition of cone-beam computed tomography (CBCT) scans. METHODS: A total of 180 CBCTs for 60 patients at 3-time points were evaluated: pretreatment (T1), postexpansion (T2), and posttreatment (T3) for 3 groups: (1) MARPE, (2) RPE, and (3) controls (time-period T1 to T3: MARPE, 2 years 8 months; RPE, 2 years 9 months; control, 2 years 7 months). The voxel-based superimposition technique was used to superimpose the CBCT scans, after which the soft-tissue surfaces were extracted from the superimposed T1-CBCT, T2-CBCT, and T3-CBCT scans. Nine landmarks were identified on the CBCT scans: nasion, A-point, pogonion, right and left alar base, right and left zygoma, and right and left gonion. The coordinates of the 9 parameters were obtained in the x-axis, y-axis, and z-axis for the CBCT scans and subjected to statistical analyses. The changes in the soft-tissue surfaces were also evaluated by color-coded maps for short-term (T2) and long-term (T3) changes. The mean changes from T1 to T2 and T1 to T3 were tested against no change within the groups by paired t test, and the mean changes among the 3 groups were compared with analysis of variance F test with Tukey's Honest significant difference used for adjusting P values for multiple testing. RESULTS: In the short term, both MARPE and RPE led to a significant downward movement of pogonion, left gonion, and lateral movement of the right and left alar base compared with controls at T2 (P <0.05). In addition, MARPE led to a significant downward movement of right gonion than controls at T2 (P <0.05). Moreover, RPE led to a significant downward and forward movement of A-point and downward movement of the right and left alar base than controls at T2 (P <0.05). However, in the long-term, there were no significant differences in the soft-tissue changes among the MARPE, RPE, and control groups. CONCLUSIONS: MARPE and RPE do not lead to significant soft-tissue changes in the long term when compared with controls.

Three-dimensional Assessment of Temporomandibular Joint Volume, and Condylar and Glenoid-fossa Morphology: A Cone-beam Computed Tomography Study.

Background: The condylar and glenoid fossa morphology can alter in patients with temporomandibular disorders (TMD), which can lead to changes in the temporomandibular joint (TMJ) space volume. Volumetric evaluation of TMJ can represent the entire three-dimensional (3D)-joint space between the condyle and glenoid fossa. Aims: To perform 3D assessment of TMJ volume, condylar, and glenoid-fossa morphology using cone-beam computed tomography and evaluate the correlation between these parameters. Settings and Design: Thirty-four patients (age: 13.50 years) who had no previous history of TMD were included. Materials and Methods: The volume of TMJ space was measured and divided into anterior, posterior, medial, and lateral TMJ volume. The antero-posterior (AP) and medio-lateral (ML) condylar width, AP and ML glenoid-fossa width, and glenoid-fossa depth were evaluated. Statistical Analysis Used: Statistical analyses were performed with R software at a 0.05 significance level. Each parameter was compared between the left and right sides using a paired-t test. The correlations between the parameters were obtained by the Pearson correlation coefficient. Results: There was no significant difference between lateral and medial TMJ volume; however, posterior TMJ volume was significantly greater than anterior TMJ volume. A significant correlation was observed between AP glenoid-fossa width and TMJ volume, glenoid-fossa depth and TMJ volume, AP position of the condyle and anterior TMJ volume, ML position of the condyle and medial TMJ volume, glenoid-fossa width and condyle width in AP and ML dimension, glenoid-fossa depth and AP glenoid-fossa width. Conclusions: In addition to the evaluation of condylar and glenoid-fossa morphology, assessment of TMJ space volume is important for comprehensive evaluation of the joint.

Evaluating the Efficacy of Employing Local Anesthetic Prostatic Blocks During Rezum Procedure.

Introduction Rezum is a minimally invasive, outpatient procedure using convective water vapor to relieve outlet obstruction from benign prostatic hyperplasia (BPH). Evidence on the technical approach of Rezum therapy, particularly pain control, is lacking. The purpose of this study was to evaluate the efficacy of utilizing a local anesthetic prostate block for postoperative pain control during Rezum therapy for BPH. A multimodal approach is typically utilized for pain control during and after Rezum. However, little is known about which elements are most critical. Methods This is a single-center retrospective study of 109 patients who underwent Rezum for BPH. Patients were then divided into two groups: Local anesthetic prostatic block verse no local anesthetic prostatic block for the procedure. A phone survey was performed to assess the patients' subjective pain scores and postoperative analgesics usage. A comparison of reported pain scores on a 0-10 Likert scale as well as usage of prescription and non-prescription analgesics medications was performed. Results There were 109 patients who underwent Rezum therapy, and 86 (79%) of patients responded to phone surveys. There was no significant difference in postoperative pain scores between patients who received local anesthetic prostatic block vs those who did not (2.10 vs 3.03). Similarly, there were no significant differences in postoperative narcotics or non-prescription analgesic medications usage. Conclusion Our data suggest that when performing Rezum using conscious sedation in the operating room or cystoscopy suite, it is unnecessary to perform a local anesthetic prostate block as it has no significant effect on patient-reported pain or the use of analgesics in the postoperative period.

Diagnostic dilemmas: a multi-institutional retrospective analysis of adrenal incidentaloma pathology based on radiographic size.

INTRODUCTION/BACKGROUND: Adrenal incidentalomas (AIs) are masses > 1 cm found incidentally during radiographic imaging. They are present in up to 4.4% of patients undergoing CT scan, and incidence is increasing with usage and sensitivity of cross-sectional imaging. Most result in diagnosis of adrenal cortical adenoma, questioning guidelines recommending removal of all AIs with negative functional workup. This retrospective study analyzes histological outcome based on size of non-functional adrenal masses. MATERIAL AND METHODS: 10 years of data was analyzed from two academic institutions. Exclusion criteria included patients with positive functional workups, those who underwent adrenalectomy during nephrectomy, < 18 years, and incomplete records. AI radiologic and histologic size, histologic outcome, laterality, imaging modality, gender, and age were collected. T-test was used for comparison of continuous variables, and the two-sided Fisher's exact or chi-square test were used to determine differences for categorical variables. Univariate analysis of each independent variable was performed using simple logistic regression. RESULTS: 73 adrenalectomies met the above inclusion criteria. 60 were detected on CT scan, 12 on MRI, and one on ultrasound. Eight of 73 cases resulted in malignant pathology, 3 of which were adrenocortical carcinoma (ACC). Each ACC measured > 6 cm, with mean radiologic and pathologic sizes of 11.2 cm and 11.3 cm. Both radiologic and pathologic size were significant predictors of malignancy (p = 0.008 and 0.011). CONCLUSIONS: Our results question the generally-accepted 4 cm cutoff for excision of metabolically-silent AIs. They suggest a 6 cm threshold would suffice to avoid removal of benign lesions while maintaining sensitivity for ACC.

Change in Medication-Associated Fall Risk Among Older Adults After Admission for Fall-Related Trauma.

BACKGROUND: As the population ages, it is predicted that approximately 40% of all patients who experience fall-related trauma will be 65 years of age and older. Most injuries in older adults are caused by falls that are the result of multiple contributing factors including home hazards, comorbidities, frailty, and medications. A variety of medications have been associated with falls, specifically those with sedating and anticholinergic effects. The drug burden index can be used to quantify sedating and anticholinergic drug burden, with higher scores being associated with reduced psychomotor function. OBJECTIVE: Assess the medication-associated fall risk on admission and discharge for older patients admitted to a trauma nurse practitioner service. METHODS: Retrospective, observational study of patients managed by trauma nurse practitioners at a Level 1 trauma center between January 1, 2018, and December 31, 2019. Patients were included if they were at least 65 years of age, the primary diagnosis for the admission was fall-related trauma, and length of stay was at least 7 days. RESULTS: A total of 172 patients were included in the study. The drug burden index was significantly higher at discharge than admission (M = 1.4, SD = 0.9 vs. M = 1.9, SD = 0.9) as was the total number of medications (M = 11.0, SD = 5.2 vs. M = 15.1, SD = 5.8). CONCLUSIONS: Medication-related fall risk was increased during admission due to fall-related trauma. Patients were discharged with a higher sedating and anticholinergic burden than on admission, which increases risk for future falls.

Reducing Radiation Exposure to Patients and Staff During Routine Ureteroscopic Stone Surgery: Adopting a Fluoroless Technique.

Purpose Urologists have an obligation to limit radiation exposure during routine stone surgery. We therefore sought to evaluate the impact of our technique for fluoroless ureteroscopy on perioperative outcomes. Methods Medical records of 44 patients who underwent ureteroscopy with laser lithotripsy without the use of fluoroscopy between October 2017 and December 2018 were examined. Multiple variables were collected, including age, body mass index (BMI), mean stone volume and density, operative times, complications, and stone-free rates. These patients were then compared to a cohort of 44 patients who underwent stone surgery with a conventional technique prior to the adoption of a fluoroless technique by the same surgeons. The primary study outcome was reduction of intraoperative fluoroscopy. Secondary outcomes included complications, operative time, and stone-free rates. Results Of the 44 patients undergoing a fluoroless technique, 38 (86.4%) were able to receive ureteroscopy without the use of fluoroscopy. A significant difference was observed in mean fluoroscopy times for the fluoroless group (2.8 seconds) and the conventional group (33.7 seconds). No complications were observed in either group. Operative length was 38.9 minutes in the fluoroless group versus 42.2 minutes in the conventional group. Age, BMI, stone characteristics, and stone-free rates were similar in both. Conclusions The use of a fluoroless technique for the treatment of uncomplicated stones is not only safe but also effective and efficient. This technique eliminates extraneous radiation doses to the patient and operative staff in most cases.

Allelic characterization and protein structure analysis reveals the involvement of splice site mutation for growth habit differences in Lablab purpureus (L.) Sweet.

BACKGROUND: Interrelationship between growth habit and flowering played a key role in the domestication history of pulses; however, the actual genes responsible for these traits have not been identified in Indian bean. Determinate growth habit is desirable due to its early flowering, photo-insensitivity, synchronous pod maturity, ease in manual harvesting and short crop duration. The present study aimed to identify, characterize and validate the gene responsible for growth habit by using a candidate gene approach coupled with sequencing, multiple sequence alignment, protein structure prediction and binding pocket analysis. RESULTS: Terminal flowering locus was amplified from GPKH 120 (indeterminate) and GNIB-21 (determinate) using the primers designed from PvTFL1y locus of common bean. Gene prediction revealed that the length of the third and fourth exons differed between the two alleles. Allelic sequence comparison indicated a transition from guanine to adenine at the end of the third exon in GNIB 21. This splice site single-nucleotide polymorphism (SNP) was validated in germplasm lines by sequencing. Protein structure analysis indicated involvement of two binding pockets for interaction of terminal flowering locus (TFL) protein with other proteins. CONCLUSION: The splice site SNP present at the end of the third exon of TFL locus is responsible for the transformation of shoot apical meristem into a reproductive fate in the determinate genotype GNIB 21. The splice site SNP leads to absence of 14 amino acids in mutant TFL protein of GNIB 21, rendering the protein non-functional. This deletion disturbed previously reported anion-binding pocket and secondary binding pocket due to displacement of small ß-sheet away from an external loop. This finding may enable the modulation of growth habit in Indian bean and other pulse crops through genome editing.

Hospital-Level Care at Home for Acutely Ill Adults: a Qualitative Evaluation of a Randomized Controlled Trial.

BACKGROUND: Substitutive hospital-level care in a patient's home ("home hospital") has been shown to lower cost, utilization, and readmission compared to traditional hospital care. However, patients' perspectives to help explain how and why interventions like home hospital accomplish many of these results are lacking. OBJECTIVE: Elucidate and explain patient perceptions of home hospital versus traditional hospital care to better describe the different perceptions of care in both settings. DESIGN: Qualitative evaluation of a randomized controlled trial. PARTICIPANTS: 36 hospitalized patients (19 home; 17 control). INTERVENTION: Traditional hospital ("control") versus home hospital ("home"), including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing. APPROACH: We conducted a thematic content analysis of semi-structured interviews. Team members developed a coding structure through a multiphase approach, utilizing a constant comparative method. KEY RESULTS: Themes clustered around 3 domains: clinician factors, factors promoting healing, and systems factors. Clinician factors were similar in both groups; both described beneficial interactions with clinical staff; however, home patients identified greater continuity of care. For factors promoting healing, home patients described a locus of control surrounding their sleep, activity, and environmental comfort that control patients lacked. For systems factors, home patients experienced more efficient processes and logistics, particularly around admission and technology use, while both noted difficulty with discharge planning. CONCLUSIONS: Compared to control patients, home patients had better experiences with their care team, had more experiences promoting healing such as better sleep and physical activity, and had better experiences with systems factors such as the admission processes. Potential explanations include continuity of care, the power and familiarity of the home, and streamlined logistics. Future improvements include enhanced care transitions and ensuring digital interfaces are usable. TRIAL REGISTRATION: NCT03203759.

An isolated case of an incidentally discovered neurofibroma of the urinary bladder.

Neurofibromas of the bladder are extremely rare tumors formed in peripheral nerves and are generally considered to occur in-conjunction with neurofibromatosis type 1 (NF-1). The following is an isolated case of a 19-year-old, asymptomatic male patient presenting with bladder tumor discovered incidentally on CT-scan. The patient had no known family history or any exam findings consistent with NF-1. The patient underwent transurethral resection of the tumor and pathologic analysis confirmed the final diagnosis of neurofibroma of the bladder. The patient's course, procedure and treatment are reported.

The COVID-19 Catalyst: Analysis of a Tertiary Academic Institution's Rapid Assimilation of Telemedicine.

INTRODUCTION: The COVID-19 pandemic forced all urology practices to reconsider the necessity of face-to-face office encounters. Seeking to reduce patient exposure, our urologic oncology office made an immediate transition to telemedicine and this study reports our experience. METHODS: Beginning March 17, 2020 the urologic oncology department committed to see all patients via telemedicine, unless they needed a cystoscopy for high grade urothelial cell carcinoma or recent gross hematuria, or required removal of a Foley catheter or surgical drain. March 17 was assigned day 1, and for the next 14 days rates of face-to-face, audio and audiovisual encounters were recorded. A telephone survey was conducted with all patients who participated in an audiovisual encounter. RESULTS: In analyzing the numbers of face-to-face, audio and audiovisual encounters, after day 5 more patients participated in audiovisual encounters than any other modality. By day 10 no nonessential face-to-face encounter occurred. There was an 80.4% response rate to our survey. Average patient account setup time was 10.5 minutes and 35.1% required assistance from our office to set up their account, averaging 7.1 minutes. No-show rates of face-to-face encounters were significantly higher than for audiovisual encounters (face-to-face 67%, audiovisual 17%, p <0.001). Overall 82% of patients surveyed were likely to elect for a telemedicine encounter over a face-to-face encounter for a routine visit during future flu seasons. CONCLUSIONS: The current study describes the initial adoption, early clinical experience and patient impressions of rapid implementation of telemedicine during the COVID-19 pandemic.

Development of a validated stability-indicating HPTLC method for rufinamide in bulk and its pharmaceutical dosage form.

A sensitive, selective, precise and stability indicating a high-performance thin layer chromatographic method for the analysis of rufinamide (Rf) in bulk drug and its formulations was developed and validated. The method employed thin layer chromatography aluminum plates precoated with silica gel 60 F254 as the stationary phase. The solvent system consisted of chloroform : methanol : glacial acetic acid (9 : 1 : 0.1 v/v/v). This system was found to give compact spots for Rf (Rf value of 0.68 ± 0.02). Rf was subjected to acid and alkali hydrolysis, oxidation, photodegradation and dry heat treatment. Also, the degraded products were well separated from the pure drug. Densitometric analysis of Rf was carried out in the absorbance mode at 210 nm, which is wavelength maxima for the degradant. The linear regression data for the calibration plots showed a good linear relationship with an r(2) of 0.9989 in the concentration range of 1,000-3,500 ng. The method was validated for precision, accuracy, ruggedness and recovery. The limits of detection and quantitation were 196.59 and 595.74 ng spot(-1), respectively. The drug undergoes degradation under acidic and basic conditions. All the peaks of degraded products were resolved from the standard drug with significantly different Rf values.