Oral appliance therapy in obstructive sleep apnea: Long-term adherence and patients experiences.

BACKGROUND: Despite the advances in the treatment of obstructive sleep apnea (OSA) with mandibular advancement appliances (MAA), their effectiveness is dependent on the patients compliance. Our aims were to evaluate the long-term adherence to MAA therapy and patients experiences of the treatment in OSA. MATERIAL AND METHODS: Sixty-nine patients (52 males, 17 females; Mean age: 54.4±10.8 years) were included in the study. The subjects were mild (56%) and moderate (44%) OSA patients who had been treated using MAA at least 4 years prior to the study. A phone survey was used to determine the demographic characteristics of the patients, as well as to assess self-reported adherence to therapy, subjective long-term effectiveness, and patient experiences with the appliance. Descriptive statistics, Pearson Chi-square test, and independent samples t-test were used for data analysis. RESULTS: Only 22 (32%) patients reported using the appliance regularly. Most of the non-adherent patients had stopped using their appliances in the first year (55%). The mean duration of appliance use was 33.5 months (Median: 12 months). No significant differences in appliance type, OSA severity, educational level, gender, marital status, income status, employment status or place of residence existed between adherent and non-adherent subjects. Adherent subjects were significantly younger than non-adherent subjects (Age: 50.6 ± 11.9 versus 56.1 ± 9.9, p < 0.05). The most common reasons reported by patients were inability to adapt to the appliance (62%) and pain in the temporomandibular joint (38%). The most common factors associated with continued usage were effectiveness (100%) and ease of use (64%). CONCLUSIONS: The overall long-term nonadherence to MAA therapy in mild-to moderate OSA patients was high suggesting that barriers to MAA therapy adherence should be prevented to increase the efficiency of oral appliance treatment in OSA and achieve better outcomes for this disease.

Genotypes of hepatitis a virus in Turkey: first report and clinical profile of children infected with sub-genotypes IA and IIIA.

BACKGROUND: Hepatitis A virus (HAV) is a food and water-borne virus causing clinical (mainly hepatitis) and subclinical disease in humans. It is important to characterize circulating strains of HAV in order to prevent HAV infections using efficacious vaccines. The aim of this study was the detection and characterization of the circulating strains of HAV in Turkey by performing serology, RT-PCR, sequencing and phylogenetic analysis. METHODS: In this study, 355 HAV suspected cases were analysed by ELISA for the presence of antibodies to HAV. RNA was extracted from 54 HAV IgM positive human sera. None of the suspect cases were vaccinated against HAV and they never received blood transfusions. Samples found positive by RT-PCR using primers targeting the VP1/VP2A junction and VP1/VP3 capsid region of HAV, were subjected to sequencing and phylogenetic analyses. RESULTS: IgM type antibodies to HAV were detected in 54 patients. Twenty one of them were students. The age of IgM positive cases was between 3 and 60 years. IgM positivity differed in age groups and was higher in the age group 3 to 10 years. Phylogenetic analysis showed that the majority of HAV strains detected in this study belong to the "HAV 1B" cluster. In addition, the HAV sub-genotypes IA (KT874461.1) and IIIA (KT222963.1) were found in 2 children. These sub-genotypes were not previously reported in Turkey. The child who carried sub-genotype IIIA travelled to Afghanistan and presented with abdominal pain, icterus and vomitus. He was positive for anti-HAV IgM and IgG but negative for hepatitis B and C. Liver enzymes like aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transferase and lactate dehydrogenase were severely elevated. Bilirubin levels were also increased. White blood cells, neutrophils and hemoglobin were decreased while lymphocytes and monocytes were increased. Similar clinical signs and laboratory findings were reported for the child infected with sub-genotype IA but aspartate aminotransferase and alanine aminotransferase were not severely elevated. CONCLUSIONS: The results indicate that molecular studies determining the HAV genotype variation in Turkey are timely and warranted. The majority of IgM positive cases in 3-10 year old patients indicate that childhood vaccination is important. Sub-genotype IB is the most prevalant genotype in Turkey. Surprisingly, sub-genotype IA and IIIA are also present in Turkey; future diagnostic efforts need to include diagnostic methods which can identify this emerging HAV genotypes. Our results also show that one important risk factor for contracting hepatitis A virus is international travel since genotype IIIA was detected in a child who had travelled to Afghanistan.

Liver Allograft Provides Immunoprotection for the Cardiac Allograft in Combined Heart-Liver Transplantation.

When transplanted simultaneously, the liver allograft has been thought to have an immunoprotective role on other organs; however, detailed analyses in simultaneous heart-liver transplantation (SHLT) have not been done to date. We analyzed patient outcomes and incidence of immune-mediated injury in 22 consecutive SHLT versus 223 isolated heart transplantation (IHT) recipients between January 2004 and December 2013, by reviewing 3912 protocol- and indication-specific cardiac allograft biopsy specimens. Overall survival was similar (86.4%, 86.4%, and 69.1% for SHLT and 93.3%, 84.7%, and 70.0% for IHT at 1, 5, and 10 years; p = 0.83). Despite similar immunosuppression, the incidence of T cell-mediated rejection (TCMR) was lower in SHLT (31.8%) than in IHT (84.8%) (p < 0.0001). Although more SHLT patients had preexisting donor-specific HLA antibody (22.7% versus 8.1%; p = 0.04), the incidence of antibody-mediated rejection was not different in SHLT compared with IHT (4.5% versus 14.8%, p = 0.33). While the left ventricular ejection fraction was comparable in both groups at 5 years, the incidence and severity of cardiac allograft vasculopathy were reduced in the SHLT recipients (42.9% versus 66.8%, p = 0.03). Simultaneously transplanted liver allograft was associated with reduced risk of TCMR (odds ratio [OR] 0.003, 95% confidence interval [CI] 0-0.02; p < 0.0001), antibody-mediated rejection (OR 0.04, 95% CI 0-0.46; p = 0.004), and cardiac allograft vasculopathy (OR 0.26, 95% CI 0.07-0.84; p = 0.02), after adjusting for other risk factors. These data suggest that the incidence of alloimmune injury in the heart allograft is reduced in SHLT recipients.

Prevalence, course and impact of HLA donor-specific antibodies in liver transplantation in the first year.

The presence of preformed donor-specific HLA antibodies (DSA) in liver transplant recipients is increasingly recognized; however, the prevalence of DSA and their impact on early allograft function remains unknown. We prospectively followed serum DSA levels of 90 consecutive liver transplant recipients from baseline to 4 months. Twenty recipients (22.2%) had preformed DSA. No antibody-targeting treatments were undertaken. Seven days after transplantation, DSA levels decreased markedly in all but three patients. Day 7 protocol biopsies showed diffuse C4d deposition along the portal stroma, central vein, subendothelial and stromal space in the patients with persistent high DSA levels. The rate of acute cellular rejection was not significantly different in patients with DSA. The transaminase and bilirubin levels remained comparable during the first year despite the presence of DSA. The three patients with persistently high DSA levels continue to have normal allograft function. We conclude that in most cases, DSA disappear after liver transplant, however in rare instances where they persist, there is evidence of complement activation in the liver allograft, without significant clinical impact in the first year.

Orthodontic and surgical treatment of a patient with Apert syndrome.

The aim of this case report was to present the combined orthodontic and surgical treatment of a patient with Apert syndrome in an adult stage. A 15 years old male patient with Apert syndrome was concerned about the appearance of his face and malocclusion. His profile was concave with a retruded maxilla and prominent lower lip. He had an Angle class I molar relationship with a 9.5 mm anterior open bite. The amount of crowding was 20.4 mm in the maxilla and 6 mm in the mandible. Cephalometric analysis revealed a skeletal Class III relationship due to maxillary hypoplasia with a dolichofacial growth pattern. Orthodontic treatment and orthognathic surgery were planned for the patient. After 45 months of presurgical orthodontics, the patient underwent two surgeries sequentially. The first surgery was performed to advance the maxilla and the second surgery was performed to correct the mandibular rotation and increase the overbite at the time of removing halo device. The amount of maxillary advencement was 8 mm. Mandibula was moved 1.5 mm anteriorly and rotated 1° to 1.5° (SNB and facial depth) in a counterclockwise direction. After a relatively long treatment, an esthetically pleasing and functional occlusion and correction of the skeletal problem was achieved in this adult case.

Routine Stenting of Extravesical Ureteroneocystostomy in Kidney Transplantation: A Systematic Review and Meta-analysis.

BACKGROUND: Although rare, major urologic complications (MUC) in kidney transplantation can cause significant morbidity, increased cost, and may even lead to graft loss. Ureteric stents are routinely used to prevent MUC, although complications related to their use have been reported. Here, we systematically reviewed the role of routine stenting in preventing MUC in kidney transplantation with extravesical ureteric implantation and performed a meta-analysis of 6 randomized controlled trials. METHODS: A PubMed search was performed for studies on MUC and stents in kidney transplant recipients. Randomized controlled trials were shortlisted for the review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RevMan 5 was used for statistical analysis, and outcome analysis was done with Cochran-Mantel-Haenszel test using random effect model. RESULTS: Six trials meeting the criteria were identified. Although stent use did not decrease the incidence of urinary leak (odds ratio [OR], 0.39; 95% CI, 0.14-1.11; P = .08) or obstruction (OR, 0.41; 95% CI, 0.13-1.24; P = .11), it was associated with a higher incidence of urinary tract infection (OR, 3.59; 95% CI, 1.33-9.75; P = .01). CONCLUSION: In the present era of extravesical ureterovesical anastomosis, routine stenting has a limited role in decreasing major urologic complications and may be associated with higher incidence of urinary tract infections.

Sublingual Tacrolimus in Liver Transplantation: A Valid Option?

BACKGROUND: Oral tacrolimus (Tac) is currently the pillar of maintenance immunosuppression after solid organ transplantation. Recent studies proposed sublingual (SL) administration as an alternative; however, data regarding its use in adult liver transplant (LT) recipients are limited. METHODS: Three LT recipients were included. Two (patients 1 and 2) were transitioned from oral to SL Tac owing to persistently erratic serum concentrations and 1 (patient 3) because of severe oral intolerance. SL Tac was started in a 1:2 dose-conversion rate. RESULTS: All patients tolerated the SL Tac well without any side effects requiring dose reduction or discontinuation. In patients 1 and 2, the therapeutic trough concentrations improved significantly after switching to SL Tac: 20% (10/50) on oral Tac to 50% (7/14) on SL Tac in patient 1 (P = .04), and from 0% (0/15) oral Tac vs 40% (4/10) on SL Tac in patient 2 (P = .02). Patient 2, who had consistently subtherapeutic trough levels on oral Tac (mean trough of 2.6 ± 0.7 ng/mL), achieved a stable therapeutic level on SL Tac (mean trough 8.1 ± 2.7 ng/mL; P < .001). In patients 1 and 3, the mean trough levels remained unchanged: 5.1 ± 1.9 ng/mL on oral Tac versus 5.3 ± 1.6 ng/mL on SL Tac (P = .76), and 4.3 ± 1.3 ng/mL on oral Tac versus 4.2 ± 1.9 ng/mL on SL Tac (P = .76), respectively. CONCLUSIONS: Oral administration of Tac is the criterion standard route for drug delivery; however SL administration should be considered as a safe alternative when the oral method is not an option.

Is There a Role for Desmopressin in Liver Transplantation? A Case Report.

Living donor liver transplantation reduces time and mortality on the waiting list. Bleeding is a serious complication; however, "overcorrection" of coagulopathy may lead to hepatic artery thrombosis. We report a case where desmopressin (DDAVP) was used in the management of persistent postreperfusion bleeding (44 red blood cell units transfused). After 1 dose of DDAVP, bleeding improved significantly and the recipient had an unremarkable recovery. DDAVP should be considered for persisting bleeding after correcting common coagulation abnormalities where complexity of the anastomosis may preclude the use of more aggressive procoagulant drugs in liver transplantation.

The assessment of quality in medical diagnostic tests: a comparison of ROC/Youden and Taguchi methods.

Diagnostic tests are widely used in many areas of modern technological society, but they are of particular importance in medicine, where early and accurate diagnosis can decrease morbidity and mortality rates of disease. How the quality of diagnostic information and decisions should be measured in a meaningful way has become increasingly important in recent years as an abundance of new diagnostic tests have been introduced. A number of seemingly independent indices are studied for evaluating diagnostic performance such as the receiver operating characteristic curves and signal-to-noise ratios. Designing robustness into diagnostic tests can only be achieved by minimizing the variation in the total number of false diagnosis. This article has undertaken a comparison of signal-to-noise ratios developed by Taguchi in quality engineering and system performance in manufacturing industry. A hybrid is also computed and its relevance to physicians as an efficient assessment method is proposed and strongly encouraged.

Orthodontic treatment of a patient with multiple supernumerary teeth and mental retardation.

Supernumerary teeth may lead to impaction or ectopic eruption of maxillary incisors, crowding, oronasal fistula, follicular cyst, migration of adjacent teeth and root resorption. In this presentation, an 11-year-old male patient with 4 supernumerary teeth in the maxillary anterior region and a slight mental retardation problem will be presented. After extraction of the supernumerary teeth, the large space created by distal migration of central incisors was closed by orthodontic treatment. Although initial patient compliance was weak and caused difficulties in the course of treatment, orthodontic treatment was completed successfully.

Sanglifehrin a blocks key dendritic cell functions in vivo and promotes long-term allograft survival together with low-dose CsA.

Sanglifehrin A (SFA) is a novel compound with unsurpassed cyclophilin-binding affinity, but relatively low direct antilymphocytic activity. Here, we report the capacity of SFA to selectively inhibit key dendritic cell (DC) functions in vivo and to suppress acute and chronic heart allograft rejection. We show that in vivo, SFA profoundly decreases DC receptor-mediated endocytosis and macropinocytosis and DC-T-cell allostimulatory activity. Furthermore, SFA abrogates >90% of IL-12p70 production in vivo while having no significant effect on IL-10 and TNF-alpha production. In a rat vascularized heart transplant model, SFA alone did not prevent graft rejection and rejection occurred within 23 days after low-dose CsA, whereas addition of SFA to low-dose CsA promoted long-term graft survival (median survival time >100 days; p = 0.0007). With respect to chronic rejection, SFA + CsA almost completely prevented graft arteriosclerosis compared to animals treated with CsA alone and controls. We propose that SFA represents a novel class of immunophilin-binding immunosuppressants with high activity against DCs and the development of graft vasculopathy in CsA-treated recipients.

Orthodontic management of mandibular lateral incisor-canine transpositions: reports of cases.

This article presents different treatment aspects in three mandibular lateral incisor-canine transposition cases. The early identification of transposed teeth simplifies orthodontic correction. Incomplete transposition cases can be managed successfully by interceptive orthodontic treatment. If complete transposition occurs, two treatment alternatives may be possible: Extraction of the transposed tooth or keep the teeth in their transposed positions.

Analysis of soft tissue profile changes associated with mandibular setback and double-jaw surgeries.

The soft tissue profile changes resulting from double-jaw surgery (maxillary advancement and mandibular setback) and mandibular setback alone were evaluated. The measurements were evaluated on the preoperative and postoperative cephalometric radiographs of 24 skeletal Class III patients. The results demonstrated significant correlations and suggested that the soft tissue ratios seen in double-jaw surgery were similar to those in mandibular setback surgery alone, with the exception of the changes in nasal tip projection and the upper lip area.

Evaluation of apical root resorption following extraction therapy in subjects with Class I and Class II malocclusions.

The purpose of this study was to determine the amount of root resorption during orthodontic treatment, and to examine the relationship between tooth movement and apical root resorption. Twenty-seven Class I and 27 Class II patients treated with edgewise mechanics following first premolar extractions were selected. The following measurements were made on the pre- and post-treatment cephalograms: upper central incisor to palatal plane distance, the inclination of upper central incisor to the FH and AP planes, the perpendicular distances from the incisor tip to the AP and PTV planes, and incisor apex to PTV. The amount of apical root resorption of the maxillary central incisors was determined for each patient by subtracting the post-treatment tooth length from the pre-treatment tooth length measured directly on cephalograms. Intra-group differences were evaluated by the Student's t-test and inter-group differences by the Mann-Whitney U-test. For correlations the Pearson correlation coefficient was used. The results show that there was a mean of approximately 1 mm (P < 0.01) of apical root shortening in Class I patients, but in Class II division I subjects the mean root resorption was more than 2 mm (P < 0.001). The inter-group differences were statistically significant. No significant correlations were found between the amount of apical root resorption and tooth inclination, or the duration of active treatment.

Effects of single- or double-jaw surgery on vertical dimension in skeletal Class III patients.

The vertical facial proportions resulting from bimaxillary surgery (maxillary advancement and mandibular setback) and mandibular setback alone were evaluated. The measurements were evaluated on the preoperative and postoperative cephalometric radiographs of 20 skeletal Class III patients. The results showed that sagittal correction of the jaws caused no change in the vertical relationship of the jaws. The only significant change was an increase in occlusal plane inclination in bimaxillary surgical patients.

Short-term effects of fiberotomy on relapse of anterior crowding.

The effects of fiberotomy were evaluated in alleviating dental relapse of incisors after orthodontic treatment. The study sample consisted of 23 patients with crowded maxillary and mandibular incisors before orthodontic treatment. The amount of initial crowding was determined according to Little's irregularity index. Fiberotomy procedures were performed on 11 of the patients 1 week before debonding. The other 12 subjects served as the control group. All patients wore Hawley retainers. Lateral cephalometric headfilms and dental casts of the patients were taken at the beginning (T1) and at the end (T2) of treatment, 6 months into the retention phase (T3), and 1 year after orthodontic treatment (T4). Significant increase of irregularity index was noted in the control group at T3 and T4 for both maxillary and mandibular anterior segments (P <.05, P <.01). Meanwhile, in the group where circumferential supracrestal fiberotomy was performed, no significant increase of the irregularity index was noted.

Radiographic evaluation of third-molar development in a group of Turkish children.

The aim of this investigation was to evaluate the crypt formation and calcification of the maxillary and mandibular third molars according to age and gender on panoramic radiographs in a group of Turkish children. Four hundred panoramic radiographs of 188 female and 212 male dental patients, ages six to thirteen years, were examined by two observers. The interrater reliability was tested by Kappa statistics. The earliest age for maxillary third molar crypt formation was eight years; mandibular third molars could be seen radiographically as early as seven years.