Complications of total temporomandibular joint replacement: a systematic review and meta-analysis.

The aim of this systematic review was to determine the most prevalent complications resulting from total temporomandibular joint (TMJ) replacement. An electronic search was performed using the Embase, LILACS, MEDLINE (via PubMed), SciELO, Scopus, and Web of Science databases up to June 2022. Prospective and retrospective clinical studies on patients who underwent TMJ replacement were included. Two reviewers performed the study selection, data extraction, and individual risk of bias assessment using the Joanna Briggs Institute Critical Appraisal Tools. The pooled prevalence of each complication was calculated through a proportion meta-analysis using the random-effects model. Twenty-eight studies met the eligibility criteria and were included in the review. All of the eligible studies had a low risk of bias. The results of the meta-analysis revealed that the most prevalent complication was paresis or paralysis of the facial nerve branches (7.8%; 95% confidence interval (CI) 2.6-15.1%, I2 = 94.5%), followed by sensory alterations (1.8%; 95% CI 0.6-4.9%, I2 = 88.8%), heterotopic bone formation (1.0%; 95% CI 0.1-2.5%, I2 = 75.8%), and infection (0.7%; 95% CI 0.1-1.6%, I2 = 22.7%). In conclusion, TMJ replacement has a low prevalence of complications, and most of them can be managed successfully.

Long-term care professionals' views on pharmacists: a qualitative study using Role Theory.

BACKGROUND: Qualitative research investigating pharmacists' participation in Long-Term Care (LTC) within interdisciplinary teams is scarce. AIM: To characterize how pharmacists' participation in a national network of LTC is perceived by healthcare professionals and other key stakeholders. METHOD: Individual, in-depth, semi-structured interviews of participants (nurses, physicians, pharmacists, and LTC researchers) enrolled purposively or through snowballing sampling techniques, with the final sample being comprised of fourteen participants. Data analysis followed a deductive coding approach framed by Role Theory and supplemented with an inductive coding for additional themes. RESULTS: Four Role Theory constructs were identified from the primary data-role identity, overqualification, ambiguity, underqualification. Clinical pharmacy services, logistics and educational activities were pointed out as representing the identity of pharmacists' interventions. Despite the clear identification of LTC pharmacists' interventions, pharmacist expertise on medicine optimization seemed to be underused (role overqualification), as a result of lack of time, lower proactivity in healthcare teams' integration, and the absence of a legal framework targeted to LTC pharmacy practice (role ambiguity). Additional clinical training, including in the management of older people's health conditions, nutrition, and palliative care were missing (role underqualification). CONCLUSION: LTC pharmacists can provide essential services (e.g., clinical pharmacy, logistics, educational interventions), although additional training and a clearer legal framework are missing to better define pharmacists' roles in LTC pharmacy practice.

Quantitative bone imaging biomarkers to diagnose temporomandibular joint osteoarthritis.

Bone degradation of the condylar surface is seen in temporomandibular joint osteoarthritis (TMJ OA); however, the initial changes occur in the subchondral bone. This cross-sectional study was performed to evaluate 23 subchondral bone imaging biomarkers for TMJ OA. The sample consisted of high-resolution cone beam computed tomography scans of 84 subjects, divided into two groups: TMJ OA (45 patients with TMJ OA) and control (39 asymptomatic subjects). Six regions of each mandibular condyle scan were extracted for computation of five bone morphometric and 18 grey-level texture-based variables. The groups were compared using the Mann-Whitney U-test, and the receiver operating characteristics (ROC) curve was determined for each variable that showed a statically significance difference. The results showed statistically significant differences in the subchondral bone microstructure in the lateral and central condylar regions between the control and TMJ OA groups (P< 0.05). The area under the ROC curve (AUC) for these variables was between 0.620 and 0.710. In conclusion, 13 imaging bone biomarkers presented an acceptable diagnostic performance for the diagnosis of TMJ OA, indicating that the texture and geometry of the subchondral bone microarchitecture may be useful for quantitative grading of the disease.

Carcass characteristics and meat quality of Nellore bulls submitted to different nutritional strategies during cow-calf and stocker phase.

There have been few studies realized that evaluate the effects of adopting different nutritional systems in more than one phase of cattle production on carcass and meat characteristics. This study was realized to evaluate carcass and meat characteristics from bulls submitted to different nutritional systems during two production phases. The experiment was conducted at Figueira's farm during two production phases: I (cow-calf) - 80 calves (99.6±2.72 days of age and 109.7±2.99 kg of BW) with their mothers were randomly assigned into two supplemental diets: cow-calf mineral supplement (n=40) or cow-calf creep-feeding (n=40); II (stocker) - the same 80 calves (201.2±2.11 days of age and 190.2±3.37 kg of BW) were redistributed into two production systems: stocker pasture (n=40) or stocker feedlot (SF; n=40). After, all 80 animals were kept on a pasture system (III) for 290 days, and then finished in a feedlot system (IV) for more 33 days. Then, they were slaughtered at an average 764.2±3.06 days of age and at 499.2±3.33 kg of final BW. After slaughter, the average daily gain was calculated, and the carcass and meat characteristics were measured. The statistical model design used was completely randomized in a 2×2 factorial arrangement (two treatment groups on cow-calf phase and two treatment groups on stocker phase). The single effects between the groups in each phase and the interactions between both phases (cow-calf v. stocker) were analyzed. The results were compared by Fisher's test, using the R statistical software. A cow-calf by stocker phases interaction occurred for carcass conformation and fiber diameter. For single effects, the greatest influences observed were in the stocker phase. The feedlot group was slaughtered 17 days earlier, with greater final BW (3.8%), hot carcass weight (5.7%), average daily gain (6.9%), dressing percentage (1.8%), carcass length (1.8%), carcass width (1.5%), longissimus muscle area (4.8%) and muscle depth (2.3%) than pasture group. The SF group also had influence on fat color; showing higher L* and lower b* values. These results reveal that bulls reared in feedlot at the stocker phase have higher muscle development and that the stocker phase has the greatest potential to influence carcass characteristics and meat quality.

Counterclockwise maxillomandibular advancement surgery and disc repositioning: can condylar remodeling in the long-term follow-up be predicted?

This study investigated predictive risk factors of condylar remodeling changes after counterclockwise maxillomandibular advancement (CCW-MMA) and disc repositioning surgery. Forty-one female patients (75 condyles) treated with CCW-MMA and disc repositioning had cone beam computed tomography (CBCT) scans taken pre-surgery, immediately after surgery, and at an average 16 months post-surgery. Pre- and post-surgical three-dimensional models were superimposed using automated voxel-based registration on the cranial base to evaluate condylar displacements after surgery. Regional registration was performed to assess condylar remodeling in the follow-up period. Three-dimensional cephalometrics, shape correspondence (SPHARM-PDM), and volume measurements were applied to quantify changes. Pearson product-moment correlations and multiple regression analysis were performed. Highly statistically significant correlation showed that older patients were more susceptible to overall condylar volume reduction following CCW-MMA and disc repositioning (P≤0.001). Weak but statistically significant correlations were observed between condylar remodeling changes in the follow-up period and pre-surgical facial characteristics, magnitude of the surgical procedure, and condylar displacement changes. After CCW-MMA and disc repositioning, the condyles moved mostly downwards and medially, and were rotated medially and counterclockwise; displacements in the opposite direction were correlated with a greater risk of condylar resorption. Moreover, positional changes with surgery were only weakly associated with remodeling in the follow-up period, suggesting that other risk factors may play a role in condylar resorption.

Cone beam computed tomography evaluation of midpalatal suture maturation in adults.

The aim of this study was to evaluate midpalatal suture maturation in adults, as observed in cone beam computed tomography (CBCT) images. CBCT scans from 78 subjects (64 female and 14 male, age range from 18 to 66 years) were evaluated. Midpalatal suture maturation was verified on the central cross-sectional axial slice in the superior-inferior dimension of the palate, using methods validated previously. Intra-examiner agreement was analyzed by weighted kappa test. Multinomial logistic regression was used to test whether sex and chronological age (adults <30 years or ≥30 years) could be used as a predictor for the maturational stages of the midpalatal suture. The majority of the adults presented a fused midpalatal suture in the palatine (stage D) and/or maxillary bones (stage E). However, the midpalatal suture was not fused in 12% of the subjects. Sex and chronological age were not significant predictors of the maturational stages of the midpalatal suture. The individual assessment of midpalatal suture maturation by way of CBCT images may provide reliable information critical to making the clinical decision between rapid maxillary expansion and surgically assisted rapid maxillary expansion for the treatment of maxillary atresia in adults.

3D superimposition and understanding temporomandibular joint arthritis.

OBJECTIVES: To investigate the 3D morphological variations in 169 temporomandibular ioint (TMJ) condyles, using novel imaging statistical modeling approaches. SETTING AND SAMPLE POPULATION: The Department of Orthodontics and Pediatric Dentistry at the University of Michigan. Cone beam CT scans were acquired from 69 subjects with long-term TMJ osteoarthritis (OA, mean age 39.1±15.7 years), 15 subjects at initial consult diagnosis of OA (mean age 44.9±14.8 years), and seven healthy controls (mean age 43±12.4 years). MATERIALS AND METHODS: 3D surface models of the condyles were constructed, and homologous correspondent points on each model were established. The statistical framework included Direction-Projection-Permutation (DiProPerm) for testing statistical significance of the differences between healthy controls and the OA groups determined by clinical and radiographic diagnoses. RESULTS: Condylar morphology in OA and healthy subjects varied widely with categorization from mild to severe bone degeneration or overgrowth. DiProPerm statistics supported a significant difference between the healthy control group and the initial diagnosis of OA group (t=6.6, empirical p-value=0.006) and between healthy and long-term diagnosis of OA group (t=7.2, empirical p-value=0). Compared with healthy controls, the average condyle in OA subjects was significantly smaller in all dimensions, except its anterior surface, even in subjects with initial diagnosis of OA. CONCLUSION: This new statistical modeling of condylar morphology allows the development of more targeted classifications of this condition than previously possible.

3D osteoarthritic changes in TMJ condylar morphology correlates with specific systemic and local biomarkers of disease.

OBJECTIVE: To assess 3D morphological variations and local and systemic biomarker profiles in subjects with a diagnosis of temporomandibular joint osteoarthritis (TMJ OA). DESIGN: Twenty-eight patients with long-term TMJ OA (39.9 ± 16 years), 12 patients at initial diagnosis of OA (47.4 ± 16.1 years), and 12 healthy controls (41.8 ± 12.2 years) were recruited. All patients were female and had cone beam CT scans taken. TMJ arthrocentesis and venipuncture were performed on 12 OA and 12 age-matched healthy controls. Serum and synovial fluid levels of 50 biomarkers of arthritic inflammation were quantified by protein microarrays. Shape Analysis MANCOVA tested statistical correlations between biomarker levels and variations in condylar morphology. RESULTS: Compared with healthy controls, the OA average condyle was significantly smaller in all dimensions except its anterior surface, with areas indicative of bone resorption along the articular surface, particularly in the lateral pole. Synovial fluid levels of ANG, GDF15, TIMP-1, CXCL16, MMP-3 and MMP-7 were significantly correlated with bone apposition of the condylar anterior surface. Serum levels of ENA-78, MMP-3, PAI-1, VE-Cadherin, VEGF, GM-CSF, TGFßb1, IFNγg, TNFαa, IL-1αa, and IL-6 were significantly correlated with flattening of the lateral pole. Expression levels of ANG were significantly correlated with the articular morphology in healthy controls. CONCLUSIONS: Bone resorption at the articular surface, particularly at the lateral pole was statistically significant at initial diagnosis of TMJ OA. Synovial fluid levels of ANG, GDF15, TIMP-1, CXCL16, MMP-3 and MMP-7 were correlated with bone apposition. Serum levels of ENA-78, MMP-3, PAI-1, VE-Cadherin, VEGF, GM-CSF, TGFß1, IFNγ, TNFα, IL-1α, and IL-6 were correlated with bone resorption.

Regional 3D superimposition to assess temporomandibular joint condylar morphology.

OBJECTIVES: To investigate the reliability of regional three-dimensional registration and superimposition methods for assessment of temporomandibular joint condylar morphology across subjects and longitudinally. METHODS: The sample consisted of cone beam CT scans of 36 patients. The across-subject comparisons included 12 controls, mean age 41.3 ± 12.0 years, and 12 patients with temporomandibular joint osteoarthritis, mean age 41.3 ± 14.7 years. The individual longitudinal assessments included 12 patients with temporomandibular joint osteoarthritis, mean age 37.8 ± 16.7 years, followed up at pre-operative jaw surgery, immediately after and one-year post-operative. Surface models of all condyles were constructed from the cone beam CT scans. Two previously calibrated observers independently performed all registration methods. A landmark-based approach was used for the registration of across-subject condylar models, and temporomandibular joint osteoarthritis vs control group differences were computed with shape analysis. A voxel-based approach was used for registration of longitudinal scans calculated x, y, z degrees of freedom for translation and rotation. Two-way random intraclass correlation coefficients tested the interobserver reliability. RESULTS: Statistically significant differences between the control group and the osteoarthritis group were consistently located on the lateral and medial poles for both observers. The interobserver differences were ≤0.2 mm. For individual longitudinal comparisons, the mean interobserver differences were ≤0.6 mm in translation errors and 1.2° in rotation errors, with excellent reliability (intraclass correlation coefficient >0.75). CONCLUSIONS: Condylar registration for across-subjects and longitudinal assessments is reliable and can be used to quantify subtle bony differences in the three-dimensional condylar morphology.

Airway space changes after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: three-dimensional assessment.

This study focused on three-dimensional (3D) airway space changes and stability following simultaneous maxillomandibular counterclockwise rotation, mandibular advancement, and temporomandibular joint (TMJ) reconstruction with custom-made total joint prostheses (TMJ Concepts(®)). Cone beam computed tomography (CBCT) scans of 30 consecutive female patients with irreversibly compromised TMJs were obtained at the following intervals: T1, presurgery; T2, immediately after surgery; and T3, at least 6 months after surgery. The CBCT volumetric datasets were analysed with Dolphin Imaging(®) software to evaluate surgical and postsurgical changes to oropharyngeal airway parameters. The average changes in airway surface area (SA), volume (VOL), and minimum axial area (MAA) were, 179.50 mm(2), 6302.60 mm(3), and 92.23 mm(2), respectively, at the longest follow-up (T3-T1) (P≤0.001). Significant correlations between the amount of mandibular advancement and counterclockwise rotation of the occlusal plane and 3D airway changes were also found (P≤0.01). The results of this investigation showed a significant immediate 3D airway space increase after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses, which remained stable over the follow-up period.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part I--skeletal and dental stability.

The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total joint prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9+/-8.0 degrees. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9+/-3.5 mm at the lower incisor tips, 12.4+/-5.4 mm at Point B, 17.3+/-7.0 mm at menton, 18.4+/-8.5 mm at pogonion, and 11.0+/-5.3 mm at gonion. Vertically, the lower incisors moved upward -2.9+/-4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the maxillo-mandibular complex was a stable procedure for these patients at the longest follow-up.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part IV--soft tissue response.

The purpose of this study was to evaluate soft tissue response to maxillo-mandibular counter-clockwise rotation, with TMJ reconstruction and mandibular advancement using TMJ Concepts total joint prostheses, and maxillary osteotomies in 44 females. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Eighteen patients had genioplasties with either porous block hydroxyapatite or hard tissue replacement implants (Group 2) 26 had no genioplasty (Group 1). Surgically, the maxilla moved forward and upward by counter-clockwise maxillo-mandibular rotation with greater horizontal movement in Group 2. Vertically, both groups showed diversity of maxillo-mandibular mean movement. Group 1 showed a consistent 1: 0.97 ratio of hard to soft tissue advancement at pogonion; Group 2 results were less consistent, with ratios between 1: 0.84 and 1: 1.02. Horizontal changes in upper lip morphology after maxillary advancement/impaction, VY closure, and alar base cinch sutures showed greater movement in both groups, than observed in hard tissue. Counter-clockwise rotation of the maxillo-mandibular complex using TMJ Concepts total joint prostheses resulted in similar soft tissue response as previously reported for traditional maxillo-mandibular advancement without counter-clockwise rotation of the occlusal plane. The association of chin implants, in the present sample, showed higher variability of soft tissue response.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part II--airway changes and stability.

The purpose of this study was to evaluate the anatomical changes and stability of the oropharyngeal airway and head posture following TMJ reconstruction and mandibular advancement with TMJ Concepts custom-made total joint prostheses and maxillary osteotomies with counter-clockwise rotation of the maxillo-mandibular complex. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). The lateral cephalograms of 47 patients were analyzed to determine surgical and post-surgical changes of the oropharyngeal airway, hyoid bone and head posture. Surgery increased the narrowest retroglossal airway space 4.9 mm. Head posture showed flexure immediately after surgery (-5.6+/-6.7 degrees) and extension long-term post surgery (1.8+/-6.7 degrees); cervical curvature showed no significant change. Surgery increased the distances between the third cervical vertebrae and the menton 11.7+/-9.1 mm and the third cervical vertebrae and hyoid 3.2+/-3.9 mm, and remained stable. The distance from the hyoid to the mandibular plane decreased during surgery (-3.8+/-5.8 mm) and after surgery (-2.5+/-5.2 mm). Maxillo-mandibular advancement with counter-clockwise rotation and TMJ reconstruction with total joint prostheses produced immediate increase in oropharyngeal airway dimension, which was influenced by long-term changes in head posture but remained stable over the follow-up period.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part III--pain and dysfunction outcomes.

47 end-stage TMJ patients with high occlusal plane angulation, treated with TMJ custom-fitted total joint prostheses and simultaneous maxillo-mandibular counter-clockwise rotation were evaluated for pain and dysfunction presurgery (T1) and at the longest follow-up (T2). Patients subjectively rated their facial pain/headache, TMJ pain, jaw function, diet and disability. Objective functional changes were determined by measuring maximum interincisal opening (MIO) and laterotrusive movements. Patients were divided according to the number of previous failed TMJ surgeries: Group 1 (0-1), Group 2 (2 or more). Significant subjective pain and dysfunction improvements (37-52%) were observed (

Field study on nematode resistance in Nelore-breed cattle.

The present study evaluated Nelore cattle with different degrees of resistance to natural infections by gastrointestinal nematodes. One hundred weaned male cattle, 11-12 months of age, were kept on the same pasture and evaluated from October 2003 to February 2004. Faecal and blood samples were collected for parasitological, haematological and immunological tests. In February 2004, the 10 most resistant and the 10 most susceptible animals were selected based on individual means of nematode faecal egg counts (FEC). Such animals were slaughtered for worm burden determination and nematode species identification. The repeatability estimates for FEC (+/-S.D.), log-transformed FEC and packed-cell volume (PCV) in all animals were 0.3 (+/-0.05), 0.26 (+/-0.04) and 0.42 (+/-0.05), respectively. The resistant group showed lower FEC and worm burdens than the susceptible group (P<0.05). There were no significant differences between groups regarding mean body weight, weight gain, PCV and total serum protein values (P>0.05). The resistant group showed higher total serum IgE levels (P<0.05) and higher mean eosinophil blood counts. However, the latter was statistically significant only 42 days after the beginning of the study. Nematodes Cooperia punctata and Haemonchus placei were predominant and the correlation between Cooperia and Haemonchus burdens was 0.64 (P<0.05), which indicated that animals presenting increased numbers of one of those genera probably had increased numbers of the other. The current study provides further evidence of IgE active role in nematode immunity and suggests that total serum IgE level might serve as an additional marker to select Nelore cattle that are responsive to H. placei and C. punctata infections.

Low-dose aprotinin in heart valve reoperations.

BACKGROUND AND AIM OF THE STUDY: Aprotinin is effective in promoting hemostasis, notably in cardiac surgery with cardiopulmonary bypass. Its efficacy has been shown in coronary bypass graft operations. However, few reports exist of aprotinin use in valve operations, and in those studies only the full dose was used. Thus, our aim was to evaluate the effects of low-dose aprotinin in patients undergoing heart valve reoperation. METHODS: Eighteen patients having reoperative valve surgery received 10(6) KIU aprotinin after induction of anesthesia, and a further 10(6) KIU in the pump prime. A group of 18 similar patients who were operated on but did not receive aprotinin were used as controls. RESULTS: A significant reduction in postoperative blood loss (approximately 470 ml) occurred in patients receiving aprotinin. These patients also presented less postoperative bleeding than untreated patients in 70.4% of cases. No adverse effects of the drug were noted, except for one case of allergic reaction. CONCLUSION: The systematic use of low-dose aprotinin should be considered in valve reoperation, except in cases of re-exposure to the drug, or allergic reaction.

[The microbiological profile of nosocomial infection in a respiratory intensive care unit]. / Perfil microbiológico da infecção nosocomial numa unidade de cuidados intensivos respiratórios.

In 1987, in the Respiratory Intensive Care Unit of Santa Maria Hospital we developed a nosocomial surveillance program with specially created software that provides knowledge of NI in the ICU at any moment. The information gathered along the time is particularly useful in the correlation of the risk factors, the most frequent microorganisms and in the institution of empiric antibiotic therapy. Out of 2528 patients admitted in our ICU for the last 6 years (87/92), 10% had bacteriologically identified NI. Almost (93%) of them had occurred in mechanically ventilated patients, which corresponds to 20.7% NI in those patients. The gram-negative appeared in 63.37%, with the predominance of Enterobacteriaceae. From the gram-positives the most frequent were Staphylococcus spp. Their meticiline resistance was worrisome. NI patients had significantly higher severity and therapeutic intervention scores. Mechanical ventilation period was 4 fold higher and mortality 2.5 times higher in the patients with this complication.

Aeromonas hydrophila fulminant pneumonia in a fit young man.

A previously healthy 24 year old athletic man became ill suddenly with pneumonia the day after swimming in the sea. Despite intensive support measures in the intensive care unit he died three hours after admission and 21 hours after his first symptom. Necropsy showed bilateral haemorrhagic necrotising pneumonia. Aeromonas hydrophila was isolated from a blood culture taken at admission and from the lungs at necropsy. The infection may have come from contaminated sea water.

Hypothalamic lesions increase saline ingestion induced by injection of angiotensin II into AV3V in rats.

Water and 3% NaCl intake were increased by the injection of 4 ng angiotensin II (ANG II) into the anteroventral third ventricle (AV3V) region of rats. Pretreatment with two specific ANG II receptor antagonists, [octanoyl-Leu8]ANG II and [Leu8]ANG II, significantly reduced ANG II-induced water and saline intake. This inhibition lasted approximately 30 min, with partial recovery at 60 min. In rats with electrolytic lesion of the bilateral ventromedial nucleus of hypothalamus (VMH), the effect of ANG II on water intake was not different from that observed in sham rats, but saline ingestion increased. In summary, the present results show that the AV3V region is an important central structure for ANG II-induced saline ingestion. Lesion of the VMH increases the response to ANG II, showing an interaction between the AV3V region and the VMH in the regulation of salt ingestion.