Midpalatal miniscrew insertion: The accuracy of digital planning and surgical placement.

INTRODUCTION: The objective of this study was to investigate the accuracy of palatal miniscrew insertion, evaluating the effect of guide fabrication and surgical placement. METHODS: Guided insertion of bilateral paramedian palatal miniscrews was undertaken using Appliance Designer software (3Shape, Copenhagen, Denmark). A resin surgical guide (P Pro Surgical Guide; Straumann AG, Basel, Switzerland) was used. Superimposition of the miniscrew position relative to the digital design was undertaken using bespoke software (Inspect 3D module, OnyxCeph; Image Instruments GmbH, Chemnitz, Germany) to assess surgical inaccuracy. Miniscrew position relative to the surgical guide was also assessed to isolate the effect of planning inaccuracies. Both horizontal and vertical discrepancies were evaluated at both implant locations. RESULTS: Twenty-seven patients having bilateral palatal insertions were examined. Mean discrepancies were <0.5 mm, both in the horizontal and vertical planes. The mean overall horizontal and vertical discrepancy between the digital design and final miniscrew position on the left side was 0.32 ± 0.15 mm and 0.34 ± 0.17 mm, respectively. The maximum horizontal discrepancy observed was 0.72 mm. No significant differences were observed in relation to the accuracy of mini-implant positioning on the basis of sidedness, either for horizontal (P = 0.29) or vertical (P = 0.86) discrepancy. CONCLUSIONS: High levels of accuracy associated with guided insertion of paramedian palatal implants were recorded with mean discrepancies of less than 0.5 mm both in the horizontal and vertical planes. No difference in accuracy was noted between the left and right sides. Very minor levels of inaccuracy associated both with surgical techniques and surgical guide fabrication were recorded.

Bilateral accessory middle turbinate presenting as double middle turbinate: A unique case report.

Many anatomical variations of the middle turbinate (MT), including pneumatized, paradoxically curved, bifurcate, trifurcate, secondary, and accessory, have been described. The most common is pneumatized MT (concha bullosa), but other less common variations may also impact the outcome of clinical management. Anatomical variations of the MT, particularly with a concomitant deviated nasal septum, tend to obstruct the middle meatus leading to disruption of the normal sinus drainage and worsening the symptoms of rhinosinusitis. By recognizing the unique anatomical variant by endoscopy or imaging will help us to improve the management. We report an endoscopic presentation of a rare accessory MT.

Levothyroxine effects on depressive symptoms and limbic glucose metabolism in bipolar disorder: a randomized, placebo-controlled positron emission tomography study.

Adding supraphysiologic doses of levothyroxine (L-T4) to standard treatment for bipolar depression shows promise, but the mechanisms underlying clinical improvement are unknown. In a previous pilot study, L-T4 treatment reduced depression scores and activity within the anterior limbic network. Here we extended this work in a randomized, double-blind, placebo-controlled study of patients with bipolar depression. Cerebral glucose metabolism was assessed with positron emission tomography and [F-18]fluorodeoxyglucose before and after 6 weeks of treatment with L-T4 (n=15) or placebo (n=10) in 12 volumes of interest (VOIs): the bilateral thalamus, amygdala, hippocampus, dorsal striatum and ventral striatum, and midline cerebellar vermis and subgenual cingulate cortex. Radioactivity in the VOIs, normalized to whole-brain radioactivity was taken as a surrogate index of glucose metabolism, and markers of thyroid function were assayed. Changes in brain activity and their association with clinical response were assessed using statistical parametric mapping. Adjunctive L-T4 treatment produced a significant decline in depression scores during the 6-week treatment. In patients treated with L-T4, we found a significant decrease in regional activity at P<0.05 after Bonferroni correction in the left thalamus, right amygdala, right hippocampus, left ventral striatum and the right dorsal striatum. Decreases in the left thalamus, left dorsal striatum and the subgenual cingulate were correlated with a reduction in depression scores (P<0.05 after Bonferroni correction). Placebo treatment was associated with a significant decrease in activity only in the right amygdala, and no region had a change in activity that was correlated with change in depression scores. The groups differed significantly in the relationship between the changes in depression scores and in activity in the thalamus bilaterally and the left ventral striatum. The findings provide evidence that administration of supraphysiologic thyroid hormone improves depressive symptoms in patients with bipolar disorder by modulating function in components of the anterior limbic network.

[Depression and epilepsy : Two clinical pictures with common causes?]. / Depression und Epilepsie : Zwei Krankheitsbilder mit gemeinsamen Ursachen?

BACKGROUND: Epilepsy and depressive disorders show a high rate of comorbidity. Thus, neurobiological similarities and a bidirectional relationship in terms of pathogenesis have been suggested. OBJECTIVES: The aim of this article is to present the common neurobiological features of both disorders, to characterize the bidirectional relationship and to provide an overview of therapeutic consequences. MATERIAL AND METHODS: A review of the current literature and evaluation of studies on the topics of depression and epilepsy are presented. RESULTS: Epilepsy and depression share common neurobiological features. In epileptic patients depression should be diagnosed early and reliably as the successful treatment has a great influence on the prognosis, quality of life and suicide risk in these individuals. In therapeutic doses, antidepressive medication with noradrenergic and specific serotonergic antidepressants (NaSSA) or selective serotonin reuptake inhibitors (SSRI) imparts no clinically relevant epileptogenic potential; however, it increases the quality of life and could have anticonvulsant effects in patients with epilepsy. Clomipramine, bupropion and maprotiline, however, should not be administered to patients with epilepsy as they are known to lower the seizure threshold.

Prediction of antidepressant response to venlafaxine by a combination of early response assessment and therapeutic drug monitoring.

INTRODUCTION: Early assessment of a therapeutic response is a central goal in antidepressant treatment. The present study examined the potential for therapeutic drug monitoring and symptom rating to predict venlafaxine treatment efficacy (measured by overall patient response and remission). METHODS: 88 patients were uptitrated homogenously to 225 mg/day venlafaxine. Serum concentrations of venlafaxine (VEN) and its active metabolite O-desmethylvenlafaxine (ODV) were measured at week 2. Continuous psychopathometric ratings were measured for up to 6 weeks by independent study raters. RESULTS: An early improvement was significantly more common in venlafaxine responders than non-responders (χ(2); p=0.007). While ODV serum levels were significantly higher in responders (t test; p=0.006), VEN serum levels, sum level of VEN+ODV and the ratio of ODV/VEN levels were not. Moreover, patients who showed an early response combined with an ODV serum level above the median of 222 ng/mL were significantly more likely to achieve full response (binary logistic model; p<0.01). Sensitivity (84% for early response) and specificity (81% for combination of early response and therapeutic drug monitoring) were sufficient to qualify as a reasonable screening instrument. CONCLUSION: Our results indicate that early improvement and ODV serum concentration are predictive of therapeutic outcome and can thus be used to guide use of the antidepressant venlafaxine.

Hormone receptor and HER2 status in patients with breast cancer by races in southeastern Turkey.

PURPOSE: Hormone receptor (HR) status is a prognostic factor in women with breast cancer and differs among different ethnic groups. HR status among Turkish, Kurdish and Arabic women with breast cancer living in Turkey is unknown and in this study we investigated the relationship between HR and HER2 status and race. METHODS: FA total of 648 women with breast cancer (Turkish 438, Kurdish 174, Arabic 35 and Armenian 1) living in southeastern Turkey and referred to the Department of Radiation Oncology between July 2006-July 2012 were included in the study. Patients were categorized into 4 groups according to their HR status. Estrogen receptor (ER) and progesterone receptor (PR) positive (ER+/PR+), ER positive and PR negative (ER+/PR-), ER negative and PR positive (ER-/PR+) and ER and PR negative (ER-/PR-). Human epidermal growth factor receptor 2 (HER2) status was recorded immunohistochemically (IHC) as negative (0 and 1+), and positive (3+). Statistical analysis included ER, PR, HER2, triple subtypes (combination of ER, PR and HER2), and race. RESULTS: The median age at diagnosis was 48 years (range 20-83). ER+, PR+ and HER2+ patients were 453 (70%), 470 (72.6%) and 206 (32.1%), respectively. ER+/PR+ rates among Turkish and Arabic patients were similar, but were higher than Kurdish patients (p<0.002). Triple-negative (ER-/PR-/HER2-) rates among Kurdish and Arabic patients were similar, but were higher than Turkish patients (p=0.04). CONCLUSION: Turkish, Kurdish and Arabic women with breast cancer in southeastern Turkey differed by HR status. Compared to Turkish and Arabic patients, Kurdish patients had more unfavorable prognostic factors.

Access of emotional information to visual awareness in patients with major depressive disorder.

BACKGROUND: According to cognitive theories of depression, negative biases affect most cognitive processes including perception. Such depressive perception may result not only from biased cognitive appraisal but also from automatic processing biases that influence the access of sensory information to awareness. METHOD: Twenty patients with major depressive disorder (MDD) and 20 healthy control participants underwent behavioural testing with a variant of binocular rivalry, continuous flash suppression (CFS), to investigate the potency of emotional visual stimuli to gain access to awareness. While a neutral, fearful, happy or sad emotional face was presented to one eye, high-contrast dynamic patterns were presented to the other eye, resulting in initial suppression of the face from awareness. Participants indicated the location of the face with a key press as soon as it became visible. The modulation of suppression time by emotional expression was taken as an index of unconscious emotion processing. RESULTS: We found a significant difference in the emotional modulation of suppression time between MDD patients and controls. This difference was due to relatively shorter suppression of sad faces and, to a lesser degree, to longer suppression of happy faces in MDD. Suppression time modulation by sad expression correlated with change in self-reported severity of depression after 4 weeks. CONCLUSIONS: Our finding of preferential access to awareness for mood-congruent stimuli supports the notion that depressive perception may be related to altered sensory information processing even at automatic processing stages. Such perceptual biases towards mood-congruent information may reinforce depressed mood and contribute to negative cognitive biases.

Relationship between baseline severity of depression and antidepressant treatment outcome.

INTRODUCTION: Assessment of depression severity is of key importance, since several clinical guidelines recommend choice of treatment dependent on the depression severity grade. Using different tools to assess baseline severity may result in different outcomes. METHODS: This paper describes the results of a multicentre, naturalistic study investigating the relationship between depression symptom severity (using 4 different measures of symptom severity) and clinical outcome among patients hospitalised for depression (N=1 014). Moreover, the impact of differences between methods of measuring depression severity has been investigated. Statistical analyses (univariate measurements, logistic regression models) were conducted to detect coherences and differences between the various methods of severity categorisation. RESULTS: Results revealed different associations between outcome and classification methods. Response or remission rates varied if baseline severity was assessed by different instruments. Moreover, the number of responders increased with higher baseline severity grades of depression, whereas the number of remitters decreased. Additional analyses dependent on outcome criteria using continuous instead of categorical data revealed similar results. DISCUSSION: Baseline severity may be only one of many other important clinical variables that mediate clinical outcome, but it is surely an important one deserving further research and consideration.

[Molecular biological aspects of neuroplasticity: approaches for treating tinnitus and hearing disorders]. / Molekularbiologische Aspekte der Neuroplastizität: Ansätze für die Therapie bei Tinnitus und Hörstörungen.

Peripheral and central structures are involved in the onset of tinnitus. Neuronal plasticity is of special importance for the occurrence of central tinnitus and its persistent form. Neuronal plasticity is the ability of the brain to adapt its own structure (synapses, nerve cells, or even whole areas of the brain) and its organization to modified biological requirements. Neuroplasticity is an ongoing dynamic process. Generally speaking, there are two types of plasticity: synaptic and cortical. Cortical plasticity involves activity-dependent changes in size, connectivity, or in the activation pattern of cortical networks. Synaptic plasticity refers to the activity-dependent change in the strength of synaptic transmission and can affect both the morphology and physiology of the synapse. The stimulation of afferent fibers leads to long-lasting changes in synaptic transmission. This phenomenon is called long-term potentiation (LTP) or long-term depression (LTD). From the perspective of molecular biology, synaptic plasticity is of particular importance for the development of tinnitus and its persistence. Ultimately, the damage to the hair cells, auditory nerve, and excitotoxicity results in an imbalance between LTP and LTD and thus in changes of synaptic plasticity. After excessive acoustic stimulation, LTP can be induced by the increase of afferent inputs, whereas decreased afferent inputs generate LTD. The imbalance between LTP and LTD leads to changes in gene expression and involves changes in neurotransmission, in the expression of the receptors, ion channels, regulatory enzymes, and in direct changes on the synapses. This causes an increase of activity on the cellular level. As a result, the imbalance can lead to hyperactivity in the dorsal cochlear nucleus, inferior colliculus, and in the auditory cortex and, later on, to changes in cortical plasticity leading to tinnitus.

[The significance of stress: its role in the auditory system and the pathogenesis of tinnitus]. / Bedeutung von Stress : Seine Rolle im auditorischen System und bei der Tinnitusentstehung.

Emotional stress is often associated with auditory phenomena such as hyperacusis, tinnitus, Ménière's disease and vertigo. Stress develops as a result of a person's attempts to come to terms with the increased or unexpected demands of his or her environment. Stress serves to protect one from physical danger and to temporarily increase one's performance in order to increase the probability of survival. Sleep and appetite are particularly reduced, while anxiety increases. The mental changes induced by stress may contribute to the onset or exacerbation of tinnitus. The following links exist between the auditory and stress systems: the limbic system, which regulates instinctive behavior and emotions, is linked to the auditory system via the medial geniculate body (amygdala). The hypothalamus, which is the integrative center of the endocrine and autonomic systems, is linked to the auditory system via the inferior colliculus. The reticular system, which is focused on the behavior pattern of attention and excitement, projects serotonergic fibers to all pathways of the auditory system, ranging from the cochlea to the auditory cortex.

Effect of PET/CT standardized uptake values on complete response to treatment before definitive chemoradiotherapy in stage III non-small cell lung cancer.

PURPOSE: The standard treatment for patients with stage III non-small cell lung cancer (NSCLC), unsuitable for resection and with good performance, is definitive radiotherapy with cisplatin-based chemotherapy. Our aim is to evaluate the effect of the maximum value of standardized uptake values (SUVmax) of the primary tumor in positron emission tomography-computed tomography (PET/CT) before treatment on complete response (CR) and overall survival. METHODS: The data of 73 stage III NSCLC patients treated with concurrent definitive chemoradiotherapy (CRT) between 2008 and 2017 and had PET/CT staging in the pretreatment period were evaluated. ROC curve analysis was performed to determine the ideal cut-off value of pretreatment SUVmax to predict CR. RESULTS: Median age was 58 years (range 27-83 years) and 66 patients were male (90.4%). Median follow-up time was 18 months (range 3-98 months); median survival was 23 months. 1-year overall survival (OS) rate and 5-year OS rate were 72 and 19%, respectively. Median progression-free survival (PFS) was 9 months; 1-year PFS rate and 5-year PFS rate were 38 and 19%, respectively. The ideal cut-off value of pretreatment SUVmax that predicted the complete response of CRT was 12 in the ROC analysis [AUC 0.699 (0.550-0.833)/P < 0.01] with a sensitivity of 83%, and specificity of 55%. In patients with SUVmax < 12, CR rate was 60%, while, in patients with SUV ≥ 12, it was only 19% (P = 0.002). Median OS was 26 months in patients with pretreatment SUVmax < 12, and 21 months in patients with SUVmax ≥ 12 (HR = 2.93; 95% CI 17.24-28.75; P = 0.087). CR rate of the whole patient population was 26%, and it was the only factor that showed a significant benefit on survival in both univariate and multivariate analyses. CONCLUSION: Pretreatment SUVmax of the primary tumor in PET/CT may predict CR in stage III NSCLC patients who were treated with definitive CRT. Having clinical CR is the only positive predictive factor for prolonged survival.

A randomised, controlled study on the effects of a short-term endurance training programme in patients with major depression.

OBJECTIVE: To evaluate the short-term effects of exercise in patients with major depression. DESIGN: Prospective, randomised, controlled study. SETTING: A university hospital. PATIENTS: A consecutive series of 38 inpatients with a major depression episode undergoing standard clinical antidepressant drug treatment. INTERVENTIONS: Patients were randomly assigned to an exercise (walking, n = 20) or placebo (low-intensity stretching and relaxation exercises, n = 18) group. Training was carried out for 10 days. MAIN OUTCOME MEASUREMENTS: Severity of depression assessed with the Bech-Rafaelsen Melancholy Scale (BRMS) and the Center for Epidemiologic Studies Depression scale (CES-D). RESULTS: After 10 days, reduction of depression scores in the exercise group was significantly larger than in the placebo group (BRMS: 36% v 18%; CES-D: 41% v 21%; p for both = 0.01); the proportion of patients with a clinical response (reduction in the BRMS scores by more than six points) was also larger for the exercise group (65% v 22%, p<0.01). CONCLUSIONS: Endurance exercise may help to achieve substantial improvement in the mood of selected patients with major depression in a short time.

Discharge management strategies and post-discharge care interventions for depression - Systematic review and meta-analysis.

BACKGROUND: Patients with depression require treatment continuity when discharged from inpatient care. Interventions aimed at optimizing transition into outpatient care may be effective in preventing symptom deterioration and readmission. We aimed to evaluate the effectiveness of care transition interventions for patients with depression after psychiatric hospitalization. METHODS: Systematic review and random-effects meta-analysis of controlled trials. Primary outcomes were readmissions and symptoms of depression. The control condition was treatment as usual. RESULTS: We included 16 publications reporting the results of 13 different studies. Studies were heterogeneous concerning patient selection and interventional approach. Effects on readmissions and depression symptoms were non-significant in meta-analysis of 8 studies/710 patients and 7 studies/592 patients, respectively. Overall risk ratio for readmission during follow-up was 0.65 (95% CI [0.42;1.01], p=0.06), standardized mean difference for depression symptoms was -0.09 (95% CI [-0.37;0.19], p=0.53). Subgroup analyses indicated no preference for a specific interventional strategy. Data point to considerable risk for selection and publication bias. LIMITATIONS: Included studies are heterogeneous; subgroups are often small and may not attain the power to detect effects. Reasonable classification of interventions into groups of comparable approaches was a challenge and may be arbitrary in some cases. CONCLUSIONS: This systematic review and meta-analysis could not identify any convincingly effective interventional transition approach for patients with depression after psychiatric hospitalization. Current evidence regarding discharge management for depression is limited, heterogeneous and potentially prone to bias. Interventions might be more appropriate for patients with other diagnoses than depression. Further high-quality randomized studies are required.

Treatment results and prognostic factors in inoperable carcinoma of the cervix treated with external plus high dose brachytherapy.

Patients with inoperable carcinoma of the cervix treated with external plus high dose rate brachytherapy (HDRB), between 1988 and 1995 were evaluated retrospectively. According to stage, 5 year survival rates were 67.3% in stage IIb and 52.6% in stage III (P = 0001) and disease free survival (DFS) rates were 54.0% in stage IIb and 43.9% in stage III (P = 0.01). The following parameters were studied: age; stage; external beam dose; brachytherapy dose; total dose to point A; tumor mass; tumor response rate; bilateral or unilateral invasion of parametria in stage IIb; and bilateral or unilateral invasion of pelvic wall in stage IIIb; and the existence of hydronephrosis. The only significant parameter of 5 year survival and local control was tumor mass (P = 0.003).

Adding concurrent low dose continuous infusion of cisplatin to radiotherapy in locally advanced cervical carcinoma: a prospective randomized pilot study.

The tolerability and efficacy of the continuous infusion of cisplatin during radiotherapy was studied by tumour response, survival and pelvic control, in carcinoma of the cervix. 44 patients with stage IIB-IIIB cervical carcinoma were prospectively randomized into two groups: radiation alone (control group) versus radiation plus cisplatin (study group). While there was no significant difference in diarrhoea and urinary complication scores, emesis and appetite changes were significantly greater in the study group. Tumour responses were no different at the end of the treatment and 3 months after completion of treatment. After 40 months median follow-up, 40/44 patients were assessed (one had a second primary tumour and three were lost to follow-up). Persistent disease was found in 3 patients: one in the study arm and two in the control arm. Recurrence was seen in 10 patients in the first 2 years. 5-year pelvic control rates were; 69.4% and 63.9% (p=0.7), survival rates were 52.0% and 48.9% (p=0.7) and disease-free survival rates were 67.5% and 58.7% (p=0.3) for the control and the study groups, respectively. Although the continuous infusion of cisplatin during radiotherapy was well tolerated, this additional treatment did not appear to show an improvement in pelvic control, survival, or disease-free survival.

Spinal cord ependymomas in adults: analysis of 15 cases.

This retrospective analysis was performed to examine the outcome of patients with spinal cord ependymomas treated with surgery and postoperative radiation therapy between 1982 and 1998. There were 10 male and 5 female patients, ranging from 16 to 74 years of age with a median age of 38 years. Surgery was gross total resection in 2 patients, subtotal resection in 10, biopsy in 3. All patients received radiation therapy with a total dose of 40-56 Gy. The 5 and 10 year overall survival rates were 83.3 and 83.3%, respectively. Twelve patients are still alive at a median follow-up period of 70 months. Of the 15 patients, 6 developed recurrent disease on follow-up. The median time to recurrence was 45 months (range: 24-80 months). Local failure within the initial irradiated volume occurred in 3 out of 6 patients who received less than 45 Gy and 2 out of 8 patients treated with more than 45 Gy. Four out of the six failures were salvaged with additional treatment. Re-irradiation was used as a part of salvage or sole treatment in 3 cases. The patient who was salvaged with radiation therapy only died of disease progression 41 months following recurrence and the other two who received a combination of surgery, radiotherapy or chemotherapy were still alive 57 and 30 months following relapse. The present study shows that surgery and post-operative radiation treatment for spinal ependymoma patients resulted in high survival rates. Patients with residual disease after surgery should be treated with radiation therapy with a dose of more than 45 Gy. Re-irradiation may be the treatment of choice for recurrent patients having less than complete resection or no surgery.

Intrathoracic desmoid tumor of the posterior mediastinum with transdiaphragmatic extension. Report of a case.

We report on a de novo desmoid tumor of the posterior mediastinum with transdiaphragmatic extension in a 40-year-old man. The tumor was inoperable because of its location and the invasion of adjacent structures. Although extremely rare, desmoid tumors of the posterior mediastinum should be considered in the differential diagnosis of posterior mediastinal masses.

Benefit of adjuvant radiotherapy in surgically staged stage I-II endometrial carcinoma.

AIMS AND BACKGROUND: This study was performed to determine the treatment outcomes and patterns of failure following external beam therapy in patients with pathological stage I-II endometrial carcinoma. STUDY DESIGN: Eighty-three patients with stage I-II endometrial carcinoma surgically staged who were found to have high risk factors and who received postoperative radiation therapy are the subject of this report. High risk factors were: histologic grade II-III, depth of myometrial invasion (DMI) > or =1/2, stage II, poor prognostic histology (clear cell, papillary serous cell) and lymphovascular invasion. RESULTS: Recurrences were observed in six patients. The recurrences were located in the vagina (1), lung (2), liver (1), and paraaortic lymph nodes (1). Five of the six recurrences were stage IC and II. The overall survival (OS), cause-specific survival (CSS) and disease-free survival (DFS) at five years were 82.9%, 85.0% and 81.3%, respectively. DMI, grade, age and cervical stromal invasion had a significant impact on CSS. CONCLUSION: Adjuvant radiotherapy decreases the rate of relapse in pathologically staged high-risk stage I-II endometrial carcinoma patients. After reviewing the other studies on this subject we conclude that vaginal cuff brachytherapy alone could be used in stage IA grade III and stage IB grade I-II patients because the recurrence rate is low; pelvic radiotherapy + vaginal cuff brachytherapy should be used for stage IC-II disease. Distant metastases occurred in five of our patients and represent a significant type of failure.