Cardio-Pulmonary Histopathology with Clinical Correlations of Deceased Patients with COVID-19: A Case Series in Tehran, Iran.

BACKGROUND: SARS-CoV-2 may affect vital organs. The present study investigated the histopathology of pulmonary and cardiac tissues with clinical correlation in deceased patients with COVID-19. METHODS: We obtained pulmonary and cardiac tissues from 30 deceased patients with COVID-19 in Tehran, Iran, from January to May 2021. Sampling was performed through a percutaneous needle biopsy. After slide preparation, two expert pathologists studied them. We assessed the correlation between clinical and pathological data by Fisher's exact test. RESULTS: The mean age of the patients was 73.8±13.4 years, and the male-to-female ratio was 23/7. The most common underlying disease was hypertension (HTN) in 25 patients (83%). Fifty-five tissue samples were achieved, including 28 pulmonary and 27 cardiac samples. Our results showed that all patients (100%) developed diffuse alveolar damage (DAD), and 26 (93%) developed hyaline membrane formation. The most common phase of DAD was the exudative-proliferative phase in 16 (57.1%). Three cardiac samples (11%) revealed myocarditis, and seven (26%) showed cardiomyocyte hypertrophy. In univariate analysis using Fischer's exact test, myocarditis had significant relationships with C-reactive protein (CRP) levels higher than 80 mg/dL (P=0.008) and elevated cardiac troponin levels higher than two-fold (P=0.01). CONCLUSION: COVID-19 can affect the major vital organs. However, only myocarditis had a significant relationship with the circulating levels of inflammatory factors.

Thalamic hemi-chorea: a rare complication after receiving the adenoviral vector-based COVID-19 vaccine: a case report.

Lacunar strokes occur when a branch of a large cerebral artery is blocked. The thalamus is often affected, causing uncontrollable motions. A 72-year-old previously healthy man presented with involuntary motions in the right limbs, which were present at rest, and exacerbated during voluntary actions. He had received the first dose of the adenoviral vector-based coronavirus disease 2019 vaccine (ChAdOx1 nCoV-19) 9 days ago. Severe thrombocytopenia and elevated levels of lactate dehydrogenase, ferritin, C-reactive protein, and D-dimer were found, without any evidence of connective tissue disease. Electromyography demonstrated typical choreiform movements, and the brain magnetic resonance imaging indicated a small high signal lesion on the left side of the thalamus. Detection of the immunoglobulin G antibodies against platelet factor 4 in the blood, negative heparin-induced platelet activation (HIPA) test, and positive modified HIPA test confirmed the thalamic stroke due to the vaccine-induced prothrombotic immune thrombocytopenia (VIPIT). He was admitted to the intensive care unit and received nadroparin, sodium ozagrel, edaravone, methylprednisolone, and haloperidol. His hemi-chorea improved gradually over 2 weeks, and he was discharged after 21 days with rehabilitation advice. VIPIT due to the ChAdOx1 nCoV-19 is a novel immune-mediated response that needs clinicians' awareness and further investigations.

Colonoscopy Complications in an Iranian Teaching Hospital.

BACKGROUND: Colonoscopy is generally a safe procedure with a limited number of adverse events. Few studies have addressed the rate of adverse events in teaching hospitals. This study aimed to investigate the rate of complications after colonoscopy performed by gastroenterology fellows in a teaching hospital in Tehran. METHODS: A historical cohort study was carried out to link the colonoscopy reports and the hospital information system to identify serious adverse events leading to unplanned hospitalization, unplanned procedures or interventions (e.g. surgery), prolongation of existing hospitalization, or death within 30 days after colonoscopy. RESULTS: We included 9928 colonoscopies (mean age of the patients 53.0±15.9 years, 52.3% men) in this study. In-hospital patients comprised (34.8%) of the procedures. The indications of colonoscopy included 7137 diagnostic (71.9%), and 2519 screening (25.4%) reasons. Colorectal polyps were found in 2005 (20.2%) patients. Major complications were seen in 17 patients (0.2%), including serious bleeding in seven patients, cardiopulmonary complications in five patients, perforation in four patients, and sepsis in one patient. CONCLUSION: Serious adverse events after colonoscopy are relatively rare. The rate of complications does not appear to be higher in an academic teaching hospital when performed by fellows under supervision.

The Psychometric Properties of the Meaning in Life Questionnaire (MLQ) in Patients with Life-Threatening Illnesses.

BACKGROUND: Meaning in life is one of the psychological domains that is most severely affected in patients with life-threatening illnesses. The importance of meaning-making mandates the development of reliable tools to assess this construct. Steger's Meaning in Life Questionnaire (MLQ) is one of the most valid and reliable instruments that determines the search for and presence of meaning in life. The present study was conducted to provide psychometric data on the MLQ in a sample of patients with life-threatening illnesses. METHODS: The MLQ was completed by 301 patients (aged 20-80 years) diagnosed with life-threatening illnesses (cancer and multiple sclerosis) and referred to hospitals. Confirmatory factor analysis and Pearson's correlation test were used to determine the construct validity of the questionnaire. RESULTS: The confirmatory factor analysis supported the original two-factor model of the MLQ, comprised of the presence of meaning (five items) and search for meaning (five items). The responses to the MLQ did not differ by sociodemographic factors. Most importantly, contrary to previous findings, the correlation between the two subscales, i.e., search for meaning and presence of meaning, was significant and positive. CONCLUSION: The results showed that the MLQ is a valid and reliable measure for assessing meaning in life that can be applied in research on meaning in life among other patient populations.

Esophageal Aperistalsis in a Patient with Lipoid Proteinosis.

Lipoid proteinosis is a rare disorder with autosomal recessive inheritance, characterized by progressive deposition of hyaline material in the skin, mucous membrane, and different organs of the body, resulting in a multitude of clinical manifestations. A 34-year-old woman presented with hoarseness, dysphagia, eyelid beeding, and acneiform scars on the facial skin and extremities. The patient was diagnosed clinically as having lipoid proteinosis, which was confirmed by laryngeal biopsy. The objective of the present report is to describe this rare entity. This case report also illustrates that lipoid proteinosis may show protean clinical features and yet may remain undiagnosed for many years.

Using the Rasch Model to Develop a Measure of Participation Capturing the Full Range of Participation Characteristics for the Patients with Hand Injuries.

Objective The purpose of this paper was to report on the first step in the development of a new instrument to measure participation including the full range of its characteristics. Methods The 30-item participation behavior questionnaire (PBQ) was developed from four main sources (a literature review of the theatrical basis of participation, available participation measures, and interviews with patients and experts about participation). Item selection and the reliability and validity of the measure were explored using Rasch measurement modeling for analysis. Participants A total of 404 individuals referred to rehabilitation after hand, wrist, or upper extremity surgery to reduce impairment from trauma, at least 2 months post-injury. Results An initial pool of 100 items; reflecting 14 characteristics of participation was initially reduced to 91 items after review by 15 participation experts and then further reduced to 30 items by three rounds of Rasch analysis removing misfitting items. The final PBQ has a person reliability of 0.91 with separation of 3.22, indicating it can reliably differentiate four levels of participation. There are no misfitting items and the instrument is unidimensional. All 14 characteristics of participation were retained in the PBQ, and none of the 30 items refer specifically to upper extremity issues. Conclusion The 30 participation behavior items of the PBQ show promise of being a psychometrically sound measure of participation. Further research is needed to validate the PBQ in samples of people with a range of other disabilities.

Iranian Voice Quality of Life Profile (IVQLP): Factor Analysis.

OBJECTIVES: An important domain in health-related quality of life evaluations is quality of life perceptions due to having a voice disorder. The objective of this study was to examine the factor structure of the Iranian Voice Quality of Life Profile (IVQLP) based on Exploratory Factor Analysis and confirmatory factor analysis. METHODS: The study sample consisted of 280 patients (174 males and 106 females) diagnosed with MTD, benign organic disorders such as polyps and nodules, and unilateral vocal fold paralysis and cancer. To evaluate the different dimensions of the IVQLP, a principal component analysis (PCA) was conducted. Confirmatory factor analysis (CFA) was used to investigate the fitting of extracted dimensions and construct validity of the IVQLP. RESULTS: The results showed that the IVQLP has a 4-factor structure. The first factor has 17 items and refers to Emotions. The second factor has 12 items and refers to Individual/Social Relations. The third factor with 6 items refers to Occupation, and the forth with 5 items relates to Psychosomatic characteristics. CONCLUSIONS: The conclusion of this study is that the concept of quality of life in Iranian patients with voice disorders is somewhat different from that of Western patients. This difference can be seen in. the large number of items related to an Emotional factor and the identification of a Psychosomatic factor.

The effect of high intensity interval training on cardioprotection against ischemia-reperfusion injury in wistar rats.

The aims of the present study were to determine whether short term high intensity interval training (HIIT) could protect the heart against ischemia reperfusion (IR) injury; and if so, to evaluate how long the exercise-associated protection can be lasted. Sixty-three rats were randomly assigned into sedentary (n = 15), sham (n = 7), and exercise groups (n = 41). Rats in the exercise groups performed 5 consecutive days of HIIT on treadmill: 5 min warm up with 50 % VO2max, 6×2 min with 95-105 % VO2max (about 40 to 45 m/min), 5×2 min recovery with 65-75 % VO2max (about 28 to 32 m/min), and 3 min cool down with 50 % VO2max, all at 0 % grade. Animals exposed to an in vivo cardiac IR surgery, performed at days 1, 7, and 14 following the final exercise session. Ischemia-induced arrhythmias, myocardial infarct size (IS), plasma lactate dehydrogenase (LDH) and creatine kinase (CK) activities were measured in all animals. Compared to sedentary rats, exercised animals sustained less IR injury as evidenced by a lower size of infarction and lower levels of LDH and CK at day one and day 7 post exercise. In comparison of sedentary group, IS significantly decreased in EX-IR1 and EX-IR7 groups (50 and 35 %, respectively), but not in EX-IR14 group (19 %). The exercise-induced cardioprotection disappeared 14 days following exercise cessation. There were no significant changes in ischemia-induced arrhythmia between exercised and sedentary rats. The results clearly demonstrate that HIIT protects the heart against myocardial IR injury. This protective effect can be sustained for at least one week following the cessation of the training.

Association between Hepatitis G and Unknown Chronic Hepatitis.

BACKGROUND: Hepatitis G virus (HGV) is a hepatotrope virus with unknown importance. The genome of the virus has been detected in patients with acute or chronic non-A-E hepatitis, cirrhosis, and hepatocellular carcinoma. The aim of this study was to determine the association between hepatitis G and unknown chronic hepatitis. METHODS: This case-control study was performed in Ebne-Sina military hospital in Hamadan, Iran. The cases were 35 military staff with unknown chronic hepatitis. The control group consisted of 59 healthy subjects who had normal levels of serum alanine aminoteransferase (ALT). The data were analyzed by SPSS, version18, using Fisher's exact test, the Student's t-test, and multivariate logistic regression analysis. RESULTS: Only one patient in the case group (2.9%) tested positive for HGV antibodies, and no one was infected in the control group. There was no association between HGV infection and unknown chronic hepatitis in our study (P=0.37). A significant association was found between the male gender and unknown chronic hepatitis (OR=14.9, P=0.01). CONCLUSION: No association between HGV infection and unknown chronic hepatitis was found in our study, so it was not necessary to evaluate these patients for HGV infection.

Does Disability Correlate With Impairment After Hand Injury?

BACKGROUND: Any loss or deviation in body function and structure is considered impairment, whereas limitations on activities are fundamental to the definition of disability. Although it seems intuitive that the two should be closely related, this might not be the case; there is some evidence that psychosocial factors are more important determinants of disability than are objective impairments. However, the degree to which this is the case has been incompletely explored. QUESTIONS/PURPOSES: The purpose of this study was to determine if disability (as measured by the Disabilities of the Arm, Shoulder and Hand [DASH] and the Michigan Hand Questionnaire [MHQ]) and pain intensity correlate with impairment (as measured by the American Medical Association [AMA] impairment guide). Secondary study questions addressed the effect of pain intensity and symptom of depression on predicting disability. METHODS: Impairment and disability were evaluated in a sample of 107 hand-injured patients a mean of 11 months after injury. Impairment rating was performed prospectively. From the patients who came for therapy, they were invited to fill out the questionnaire and evaluated for impairment rating. Response variables of DASH, MHQ, and visual analog scale pain intensity values were collected at the same setting. Other explanatory variables included demographic, injury-related, and psychological factors (symptoms of depression measured with the Beck Depression Inventory). Initial bivariate and multivariate analyses were performed to determine correlations of disability and pain to impairment rating and other exploratory variables. RESULTS: Disability as measured by the DASH showed intermediate correlation with AMA impairment (r = 0 .38, beta = 0.36, p = 0.000). Together with gender, it accounted for only 22% of the variability in DASH scores. Similarly, MHQ score correlated with impairment rating (r = -0.24, beta = -0.23, p < 0.05). However, together with age, injured hand accounted for only 19% of the variability in MHQ scores. However, pain intensity did not correlate with impairment (r = -0.46, p > 0.05). Interestingly, pain intensity did correlate with the time passed from surgery but it was correlated with symptom of depression (r(2) = 0.10, beta = 0.33, p = 0.001). CONCLUSIONS: The limited correlation between impairment and disability emphasizes the importance of factors other than pathophysiology in human illness behavior. These may include physical (pain, dominant injured hand) and conditional factors (time since surgery) or psychological factors such as depression and adapting; all mentioned can be considered as personal factors that may be different in each patient. So considering personal difference and any other condition except the impairment alone can help to better plan interventions and also diminish disability level. LEVEL OF EVIDENCE: Level III, therapeutic study.

Estradiol attenuates spinal cord injury-related central pain by decreasing glutamate levels in thalamic VPL nucleus in male rats.

Central neuropathic pain (CNP) is a complicated medical problem that involves both the spinal and supraspinal regions of the central nervous system. Estrogen, a neuroprotective agent, has been considered a possible candidate for CNP treatment. In this study, we examined the effects of a single dose of 17ß-estradiol on glutamate levels in the ventral posterolateral (VPL) nucleus of the rat thalamus. Furthermore, we determined whether there was a correlation between glutamate levels and neuropathic pain induced by unilateral electrolytic spinothalamic tract (STT) lesion. STT lesioning was performed in male Wistar rats at the T8-T9 vertebrae; rats were then administered 17ß-estradiol (4 mg/kg, i.p.) 30 min after injury. Glutamate samples were collected using a microdialysis probe and quantified by high performance liquid chromatography. Mechanical allodynia (MA) and thermal hyperalgesia (TH) thresholds were measured pre-injury and 7, 14, and 28 days post-injury. We found that STT lesion significantly increased glutamate levels in the ipsilateral VPL nucleus 14 and 28 days post-injury; this was accompanied by allodynia and hyperalgesia in the hind paws of the rats. Administering 17ß-estradiol to the rats decreased glutamate levels in the ipsilateral VPL nucleus and significantly increased MA and TH thresholds. These results suggest that glutamate in the VPL nucleus of the thalamus is involved in the pathology of neuropathic pain after STT injury; furthermore, 17ß-estradiol may attenuate this neuropathic pain by decreasing glutamate levels.

A prospective randomized controlled trial of controlled passive mobilization vs. place and active hold exercises after zone 2 flexor tendon repair.

PURPOSE: The rehabilitation program after flexor tendon repair of zone II laceration varies. We designed a Prospective Randomized Controlled Trial of controlled passive mobilization (modified Kleinert) vs. Place and active hold exercises after zone 2-flexor tendon repair by two-strand suture (Modified kessler). METHODS: Sixty-four fingers in 54 patients with zone 2 flexor tendon modified Kessler repairs were enrolled in a prospective randomized controlled trial comparing place and active hold exercises to controlled passive mobilization (modified Kleinert). The primary outcome measure was total active motion eight weeks after repair as measured by an independent and blinded therapist. RESULTS: Patients treated with place and active hold exercises had significantly greater total active motion (146) eight weeks after surgery than patients treated with controlled passive mobilization (114) (modified Klinert). There were no ruptures in either group. CONCLUSIONS: Place and hold achieves greater motion than controlled passive mobilization after a two-strand repair for zone 2 flexor tendon repairs.

Fulminant Hepatic Failure due to Primary Hepatic Lymphoma: a Case Report.

Primary hepatic lymphoma is a rare malignancy usually presenting withsymptoms of fever, hepatomegaly, jaundice and weight loss. This picture mimicsinfectious and inflammatory disorders and thus delays the diagnosis. Here,we present a 47-year old man with prolonged fever who underwent several investigationsand, in the meantime, developed fulminant hepatic failure beforethe diagnosis could be reached.

Diagnostic accuracy of endoscopic ultrasonography in patients with inconclusive magnetic resonance imaging diagnosis of biliopancreatic abnormalities.

AIM: To determine the sensitivity and specificity of endoscopic ultrasonography (EUS) in patients with inconclusive magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) in pancreatobiliary abnormalities. METHODS: During 10 months, patients with pancreatobiliary diseases referred to endoscopic retrograde cholangiopancreatography (ERCP) because of inconclusive MRI/MRCP diagnosis were scheduled to undergo endoscopic ultrasonography. Patients were divided into four major groups: patients with (i) resectable periampullary neoplasms who were referred to a surgeon, (ii) unresectable periampullary cancer who underwent ERCP for biliary stenting, (iii) bile duct stone who were referred to ERCP for stone extraction, and (iv) normal pancreatobiliary tract. Reference standards for comparison were ERCP, surgery, a biopsy confirming malignancy, or the clinical course during follow up (at least 12 months) in cases without evidences of malignancy. RESULTS: One hundred and seven patients (51 men; mean [SD] age 60.0 [15.5]) were included in the study. Final diagnoses were common bile duct (CBD) stone (n = 24), periampullary neoplasms (n = 46), others (n = 23) and no pathologic findings (n = 14). EUS determined the staging for clinical decision-making in 47 patients with neoplasms which showed that tumors in 34 patients (79.1%) were unresectable (advanced stage). After EUS, 47 patients (43.9%) did not require ERCP. The accuracy of EUS for the diagnosis of CBD stone and periampullary neoplasms were 96.3% and 99.1%, respectively. CONCLUSIONS: EUS is a useful modality in cases of inconclusive MRI/MRCP indicating pancreatobiliary disorders.

Comparative effects of daily and weekly boron supplementation on plasma steroid hormones and proinflammatory cytokines.

Boron possesses widespread properties in biochemistry and nutrition. Acute supplementation with 11.6 mg of boron resulted in a significant increase in plasma boron concentration. Given such a fast bioavailability, the objective was to determine whether acute (hourly or daily), and weekly supplementation could have any significant biological effects on the steroid hormones and further on some inflammatory biomarkers. Eight healthy male volunteers attended the laboratory on three occasions (days 0, 1 and 7). On the first day (day 0), a blood sample collection at 8.00 A.M was followed by ingestion of placebo with the breakfast. On the next day (supplementation-day 1), similar procedure was followed by ingestion of a capsule containing 10mg of boron. On both occasions blood was collected every 2h for the next 6h. Subjects were requested to consume a capsule of 10mg boron every day with their breakfast, and on the day 7, the blood collection was carried out at 8.00 A.M, again. Boron in plasma increased significantly following hours and weekly consumption. Six hours supplementation showed a significant decrease on sex hormone binding globulin (SHBG), high sensitive CRP (hsCRP) and TNF-α level. After one week (in samples taken at 8.00 A.M, only), the mean plasma free testosterone increased and the mean plasma estradiol decreased significantly. Dihydrotestosterone, cortisol and vitamin D was elevated. Also, concentrations of all three inflammatory biomarkers decreased after supplementation. Of note, despite decreased proinflammatory cytokines, based on recent clinical data, this must be the first human study report to show an increase level of free testosterone after boron consumption.

Colonoscopic evaluation of minimal rectal bleeding in average-risk patients for colorectal cancer.

AIM: To assess the prevalence of clinically significant lesions in patients with minimal bright red bleeding per rectum (BRBPR). METHODS: Consecutive outpatients prospectively underwent colonoscopy at Loghman Hakim Hospital, Tehran. Minimal BRBPR was defined as small amounts of red blood after wiping or in the toilet bowl. Patients with the following alarm signs were excluded: Positive personal history of colorectal neoplasms or inflammatory bowel disease (IBD), positive first degree family history of colorectal neoplasms, history of altered bowel habits, recent significant weight loss, and presence of iron deficiency anemia. Neoplastic polyps, colorectal carcinoma, and IBD were defined as significant lesions. RESULTS: A total of 402 patients (183 female and 219 male, aged 43.6 +/- 15.7 years) were studied. Hemorrhoids (54.2%), anal fissures (14.2%) and ulcerative colitis (14.2%) were the most common lesions and colonoscopy was normal in 8.0%. Significant lesions were found in 121 (30.1%) patients, including 26 patients (6.5%) with adenocarcinoma and 30 (7.5%) with adenomatous polyps. Almost all patients with significant lesions had at least one lesion in the distal colon; an adenocarcinoma and an adenomatous polyp in the proximal colon were found in 2 patients with hemorrhoids. CONCLUSION: Flexible sigmoidoscopy appears to be sufficient for the evaluation of average risk patients with minimal BRBPR. Rigid sigmoidoscopy may be used as an alternative in patients less than 40 years of age in settings where the former is not available. The choice of colonoscopy over flexible sigmoidoscopy in patients aged over 50 years should be individualized.

Normobaric hyperoxia induces ischemic tolerance and upregulation of glutamate transporters in the rat brain and serum TNF-alpha level.

Recent studies suggest that intermittent and prolonged normobaric hyperoxia (HO) results in ischemic tolerance to reduce ischemic brain injury. In this research, we attempted to see changes in excitatory amino acid transporters (EAATs) and TNF-alpha levels following prolonged and intermittent hyperoxia preconditioning. Rats were divided into four experimental groups, each of 21 animals. The first two were exposed to 95% inspired HO for 4 h/day for 6 consecutive days (intermittent HO, InHO) or for 24 continuous hours (prolonged HO, PrHO). The second two groups acted as controls, and were exposed to 21% oxygen in the same chamber. Each main group was subdivided to middle cerebral artery occlusion (MCAO-operated), sham-operated (without MCAO), and intact (without any surgery) subgroups. After 24 h from pretreatment, MCAO-operated subgroups were subjected to 60 min of right MCAO. After 24 h reperfusion, neurologic deficit score (NDS) and infarct volume were measured in MCAO-operated subgroups. EAATs expression and serum TNF-alpha levels were assessed in sham-operated and intact subgroups. Preconditioning with prolonged and intermittent HO decreased NDS and upregulated EAAT1, EAAT2, and EAAT3 and increased serum TNF-alpha levels significantly. Although further studies are needed to clarify the mechanisms of ischemic tolerance, the intermittent and prolonged HO seems to partly exert their effects via increase serum TNF-alpha levels and upregulation of EAATs.

Management of cystic craniopharyngiomas with intracavitary irradiation with 32P.

BACKGROUND: Cystic craniopharyngiomas are the most frequent intracranial neoplasm of nonglial origin in children. Follow-up data were analyzed to assess the value of intracavitary irradiation with stereotactically applied 32P radioisotopes for the treatment of patients with craniopharyngioma cysts admitted to Shohada Tajrish Hospital, Tehran, Iran, between 1998 and 2005. METHODS: Patients with predominantly cystic craniopharyngiomas, who underwent stereotactic intracavitary irradiation, were followed for tumor response and complications. Beta-emitting 32P isotopes were injected into cysts using a computed tomography-guided and computer-assisted three-dimensional stereotactic treatment planning and application system. The cumulative dose to the inner surface of the cyst wall was 250 Gy. RESULTS: Twenty-two (12 females and 10 males) patients with a mean+/-SD age of 14.0+/-6.6 (range: six to 35) years were studied. The tumor response rate gained with 32P-labeled chromic phosphate was 73% (16 of 22 cysts). The mean+/-SD survival after intracavitary irradiation was 25.4+/-6.8 (95% CI: 12.0 - 38.7) months. CONCLUSION: Intracavitary irradiation using 32P is highly effective in the treatment of cystic craniopharyngiomas. In patients with solitary cyst treated exclusively with this method, it has been the only necessary therapy over a long period. It seems reasonable to recommend intracavitary irradiation as the initial treatment for selected patients and as palliative therapy in those with recurrence.

Restorative dentistry for children using a hard tissue laser.

This article will describe how a hard tissue laser is used in various restorative procedures. The erbium family of lasers (Er,Cr:YSGG and Er:YAG) are highly absorbed in water and, to a lesser extent, in tooth mineral. Because a carious lesion contains significantly more water than healthy enamel or dentin, the laser can offer some selectivity in removing the diseased material. Furthermore, these lasers can offer some degree of anesthesia. In these clinical photos, an Er,Cr:YSGG laser (Waterlase or Waterlase MD, 2780-nm; Biolase Technologies, Irvine, CA) was used.