Blood stream infections during the first wave of COVID-19. A short microbiological retrospective picture at Papa Giovanni XXIII Hospital, Bergamo, Italy.

This paper aims to describe the etiology of bloodstream infections in COVID-19, Papa Giovanni XXIII Hospital, Bergamo, Italy. Two periods were evaluated: February 22-May 21, 2019/2020. We considered: the number of patients and blood culture sets, species of isolates (bacteria, specifically those indicated by EARS criteria; CoNS; Candida albicans) and their antibiotic sensitivity. In 2020 Escherichia coli and Carbapenemase-producing Klebsiella pneumoniae disappeared. Candida albicans and MDR Pseudomonas aeruginosa, Enterococcus faecium and Acinetobacter baumannii were largely present. The analysis shows: 1. BSIs number was the same; 2. In the first month of the COVID-19 period, BSIs were uncommon; 3. Microbial etiologies were different; 4. MDR isolates were less common.

Utility of routine evaluation of sterility of cellular therapy products with or without extensive manipulation: Best practices and clinical significance.

BACKGROUND: We analyzed the results of routine sterility testing performed in our center over the last 10 years, in the context both hematopoietic stem cell transplantation (HSCT) and Advanced Therapeutic Medicinal Products (ATMPs). METHODS: For sterility tests 14-day cultures were performed in culture media detecting aerobic and anaerobic microorganisms. RESULTS: In this study, 22/1643 (1.3%) of apheretic products for autologous or allogeneic HSCT were contaminated, whereas 14/73 bone marrow (BM) harvests (17.8%) were positive. In 22 cases, the contaminated HSCs were infused to patients, but there was no evidence of any adverse impact of contamination on the hematologic engraftment or on infections. Indeed none of the five positive hemocultures detected in patients following infusion could be linked to the contaminated stem cell product. Our Cell Factory also generated 286 ATMPs in good manufacturing practice (GMP) conditions since 2007 and all final products were sterile. In three cases of mesenchymal stromal cell expansions, the starting BM harvests were contaminated, but the cell products at the end of expansion were sterile, presumably thanks to the presence of an antibiotic in the culture medium. DISCUSSION: The decreased rate of contamination of cell harvests observed with time suggests that routine sterility testing and communication of the results to the collecting centers may improve clinical practices. Furthermore, we recommend the use of antibiotics in the medium for ATMP expansion, to decrease the likelihood of expanding microorganisms within clean rooms. Finally we discuss the costs of sterility testing of ATMPs by GMP-approved external laboratories.

Four-unit fixed dental prostheses replacing the maxillary incisors supported by two narrow-diameter implants - a five-year case series.

OBJECTIVES: (1) To determine the survival rate of 10 four-unit fixed dental prostheses (FDPs) replacing the four maxillary incisors, supported by 20 narrow-diameter implants (NDIs), (2) to assess the incidence of mechanical and biological complications, and (3) to evaluate bone level changes longitudinally after final FDP insertion. MATERIALS AND METHODS: Ten patients (six women, four men), mean age 49.4 ± 12.6 years, were treated with a four-unit anterior maxillary FDP (six screw-retained; four cemented). Biological parameters, eventual technical complications, radiographic measurements, and study casts were assessed at 1 (baseline), 3, and 5 years after implant placement. A multilevel logistic regression test was performed on clinical parameters and bone level changes (significance level P < 0.05). RESULTS: The 5-year implant and FDP survival rate was 100%. Mean modified plaque index (mPI) values were 0.03 and 0.02 at 3 and 5 years, significantly lower when compared to mPI (0.11 ± 0.31) at 1 year. Mean modified sulcus bleeding index (mSBI) was 0.08, 0.08, and 0.15 over time. Probing depth (PD) values were 1.57, 1.64, and 2.03 mm. Statistically significant differences were found between 1 vs. 5 year (P = 0.0003) and 3 vs. 5 year (P = 0.001). Keratinized mucosa (3.65 mm) remained stable during observation period. DIB mean values were 2.01 ± 0.34, 2.13 ± 0.13, and 2.17 ± 0.38 mm. Patient satisfaction based on visual analog scale revealed favorable fulfillment of overall treatment and esthetic expectations. CONCLUSIONS: Two NDIs supporting a four-unit FDP to replace the four missing maxillary incisors may be considered a predictable treatment modality.

Direct identification of microorganisms from positive blood cultures using the lysis-filtration technique and matrix assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS): a multicentre study.

Microbial identification from blood cultures is essential to institute optimal antibiotic therapy and improve survival possibilities. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has been successfully applied to identify bacteria and yeasts from positive blood cultures broths. The aim of this multicentre study was to evaluate the reliability of the lysis-filtration technique associated with MALDI-TOF MS to directly identify microorganisms from 765 positive blood cultures collected in six Italian hospitals. Overall, 675/765 (78.1%) blood isolates were correctly identified at the species level, with significant differences between Gram-negative and Gram-positive bacteria (92.6%, and 69.8%, respectively). Some difficulties arise in identifying Streptococcus pneumoniae, Staphylococcus aureus, yeasts and anaerobes. The lysis-filtration protocol is a suitable procedure in terms of performance in identifying microorganisms, but it is quite expensive and technically time-consuming since the time of filtration is not regular for all the samples. The application of the MALDI-TOF MS technique to the direct microbial identification from positive blood cultures is a very promising approach, even if more experience must be gained to minimize errors and costs.

Prevalence of urinary colonization by extended spectrum-beta-lactamase Enterobacteriaceae among catheterised inpatients in Italian long term care facilities.

BACKGROUND: Long Term Care Facilities (LTCFs) play a key role in guaranteeing care to patients in developed countries. Many patients, mostly elderly, access LTCFs at some time in their lives, and their healthcare pathways often require them to move back and forth between hospital and outpatient settings. These patterns bring about new challenges regarding infection control, especially healthcare associated infections. METHODS: A point prevalence study was conducted in 23 Italian LTCFs, to identify colonization in patients with urinary catheter (>24 hours). Species identification, susceptibility tests and extended spectrum beta lactamase (ESBL) production screenings were performed using Vitek 2 System. Enterobacteria identified by Vitek 2 System as ESBL-producers or suspected AmpC hyperproducers on the basis of cephamycin resistance, were sent to a research laboratory where they underwent a double-disk synergy test. Finally, ESBL-producers were screened for bla resistance genes by PCR assay. RESULTS: 211 patients with catheter were screened, 185 out of 211 patients showed positive samples for the presence of Enterobacteriaceae, 114 of these 185 patients were colonized by extended spectrum cephalosporins resistant microorganisms. We identified a total of 257 Gram negative pathogens, of which 51.8% (133/257) were extended spectrum cephalosporins resistant. 7 out of 133 cephamycin not susceptible strains proved to be AmpC-type beta-lactamases and 125/133 ESBL-producers; 1 was not further characterized. 43 out of 257 (16.7%) E. coli, 37/257 (14.4%) P. mirabilis, 20/257 (7.8%), P. stuartii, 14/257 (5.4%) M. morganii, 7/257 (2.7%), K. pneumoniae, 4/257 (1.6%) C. koseri proved to be overall ESBL-producers by double-disk synergy test. Third and fourth generation cephalosporin resistant P. mirabilis, P. stuartii and M. morganii strains mainly harboured a blaTEM gene (95.9%), while 89.1% of E. coli were positive for the blaCTX-M determinant by PCR and sequencing. Patients with decubitus had a higher risk of colonization by at least one resistant isolate (p < 0.01). Samples of patients undergoing antibiotic therapy and patients with decubitus showed a higher risk (p < 0.05) of colonization by beta-lactam resistant microorganisms. CONCLUSIONS: These data confirm the presence of high percentages of ESBL-positive Enterobacteria in Italian LTCFs and the predominance of CTX-M type ESBL in E. coli. The alarming presence of ESBL-producing Enterobacteriaceae in Italian LTCFs can seriously compromise the effectiveness of antibiotic therapy.acilities (LTCFs), Antimicrobial resistance.

Water Safety Plan, Monochloramine Disinfection and Extensive Environmental Sampling Effectively Control Legionella and Other Waterborne Pathogens in Nosocomial Settings: The Ten-Year Experience of an Italian Hospital.

Legionella contamination control is crucial in healthcare settings where patients suffer an increased risk of disease and fatal outcome. To ensure an effective management of this health hazard, the accurate application of a hospital-specific Water Safety Plan (WSP), the choice of a suitable water disinfection system and an extensive monitoring program are required. Here, the ten-year experience of an Italian hospital is reported: since its commissioning, Legionellosis risk management has been entrusted to a multi-disciplinary Working Group, applying the principles of the World Health Organization's WSP. The disinfection strategy to prevent Legionella and other waterborne pathogens relies on the treatment of domestic hot water with a system ensuring the in situ production and dosage of monochloramine. An average of 250 samples/year were collected and analyzed to allow an accurate assessment of the microbiological status of water network. With the aim of increasing the monitoring sensitivity, in addition to the standard culture method, an optimized MALDI-ToF MS-based strategy was applied, allowing the identification of Legionella species and other relevant opportunistic pathogens. Data collected so far confirmed the effectiveness of this multidisciplinary approach: the fraction of positive samples never overcame 1% on a yearly basis and Legionnaires' Disease cases never occurred.

Full-mouth minimally invasive adhesive rehabilitation to treat severe dental erosion: a case report.

Dental erosion is increasing, and only recently are clinicians starting to acknowledge the problem. A prospective clinical trial investigating which therapeutic approach must be undertaken to treat erosion and when is under way at the University of Geneva (Geneva Erosion Study). All patients affected by dental erosion who present with signs of dentin exposure are immediately treated using only adhesive techniques. In this article, the full-mouth adhesive rehabilitation of one of these patients affected by severe dental erosion (ACE class IV) is illustrated. By the end of the therapy, a very pleasing esthetic outcome had been achieved (esthetic success), all of the patient's teeth maintained their vitality, and the amount of tooth structure sacrificed to complete the adhesive full-mouth rehabilitation was negligible (biological success).

Retrospective clinical study of minimally invasive full-mouth rehabilitations of patients with erosions and/or abrasions following the "3-step technique". Part 1: 6-year survival rates and technical outcomes of the restorations.

PURPOSE: To evaluate the survival rates and technical outcomes of minimally invasive full-mouth rehabilitations in patients affected by dental erosion and attrition. MATERIALS AND METHODS: For this retrospective study, 28 subjects (8 women, 20 men; mean age: 45.6 years) who suffered from generalized erosions and attrition and who were treated according to the 3-step technique were invited to participate. The patient records were reviewed, and the restorations were clinically and radiographically examined. This part of the study (part 1) evaluated restoration survival and technical outcomes using the modified United States Public Health Service criteria (mUSPHS). Survival analysis was performed using Kaplan-Meier survival statistics, and comparison between subgroups was made using log-rank test. For all other comparisons, cross-tabulations of occurrence were performed, and significance was tested using Pearson chi-square test. The level of statistical significance was set at P < .05. RESULTS: A total of 19 patients (3 women, 16 men; mean age: 45.6 years) agreed to participate. In these patients, 406 restorations (149 direct composites, 110 onlays, 147 veneers) supported by 365 teeth were examined. The mean time in service was 71.8 ± 28.6 months. Six failed restorations were identified; all were direct composites. The 6-year survival rates were 97.3% for direct composites, 98.2% for onlays, and 100% for veneers (P > .05). No differences were found among materials and locations of the restorations. Nineteen technical complications included 14 partial fractures, 3 fissures, 1 wear, and 1 decementation. The mUSPHS evaluation showed good technical outcomes. Presence or absence of a nightguard influenced restoration survival (P = .003). CONCLUSION: Minimally invasive rehabilitations of patients with erosions/attrition with the 3-step technique are a reliable treatment option in the medium term. Protective nightguards are recommended.

Biological outcomes and patient-reported outcome measures (PROMs) of minimally invasive full-mouth rehabilitations of patients with erosions and/or abrasions by means of the "3-step technique": part 2 of the 6-year outcomes of a retrospective clinical study.

PURPOSE: To evaluate biologic and esthetic outcomes, as well as the patient-reported outcome measures (PROMs), of full-mouth rehabilitations in patients suffering from generalized erosive and/or abrasive tooth wear following the 3-step technique. MATERIALS AND METHODS: Patients who received a minimally invasive full-mouth rehabilitation according to the 3-step technique and who were treated at the University of Geneva and/or in a private practice were considered for inclusion. The minimum service time of the restorations was 12 months. The biologic outcomes were analyzed by assessing pocket probing depth (PPD), Plaque Index (PI), and bleeding on probing (BOP). Furthermore, secondary caries, tooth vitality, and sensitivity to temperature were evaluated using the modified United States Public Health Service (USPHS) criteria. The esthetic outcomes were rated with the White Esthetic Score (WES). Finally, PROMs were evaluated using visual analog scales (VAS). RESULTS: A total of 19 patients with 406 restorations (149 direct composite resins, 110 indirect composite resin/ceramic onlays, and 147 composite resin/ceramic veneers) were examined after a mean follow-up of 71.8 ± 28.6 months. Periodontal parameters were good (mPPD = 2.9 ± 0.4; mPI = 0.1 ± 0.2; and mBOP = 0.05 ± 0.1). No secondary caries were found, and no abutment tooth had lost vitality. A total of 36 abutment teeth had moderate sensitivity, but none presented pronounced sensitivity. The rehabilitations exhibited good esthetic outcomes (mWES = 8.4 ± 1.9). Patients reported satisfying esthetic results of their rehabilitations (mean VAS = 9.2 ± 1.6) and considered their treatment as comfortable (mean VAS = 8.2 ± 2.1), while the least favorably rated parameter was the cost of treatment (mean VAS = 4.1 ± 3.2). CONCLUSION: Minimally invasive full-mouth rehabilitations of patients with generalized tooth wear by means of the 3-step technique exhibit very good clinical medium-term results with respect to biologic and objective/subjective esthetic outcomes. The patient satisfaction with this treatment was high.

Hypervariable-Locus Melting Typing: a Novel Approach for More Effective High-Resolution Melting-Based Typing, Suitable for Large Microbiological Surveillance Programs.

Pathogen typing is pivotal to detecting the emergence of high-risk clones in hospital settings and to limit their spread. Unfortunately, the most commonly used typing methods (i.e., pulsed-field gel electrophoresis [PFGE], multilocus sequence typing [MLST], and whole-genome sequencing [WGS]) are expensive or time-consuming, limiting their application to real-time surveillance. High-resolution melting (HRM) can be applied to perform cost-effective and fast pathogen typing, but developing highly discriminatory protocols is challenging. Here, we present hypervariable-locus melting typing (HLMT), a novel approach to HRM-based typing that enables the development of more effective and portable typing protocols. HLMT types the strains by assigning them to melting types (MTs) on the basis of a reference data set (HLMT-assignment) and/or by clustering them using melting temperatures (HLMT-clustering). We applied the HLMT protocol developed on the capsular gene wzi for Klebsiella pneumoniae on 134 strains collected during surveillance programs in four hospitals. Then, we compared the HLMT results to those obtained using wzi, MLST, WGS, and PFGE typing. HLMT distinguished most of the K. pneumoniae high-risk clones with a sensitivity comparable to that of PFGE and MLST+wzi. It also drew surveillance epidemiological curves comparable to those obtained using MLST+wzi, PFGE, and WGS typing. Furthermore, the results obtained using HLMT-assignment were consistent with those of wzi typing for 95% of the typed strains, with a Jaccard index value of 0.9. HLMT is a fast and scalable approach for pathogen typing, suitable for real-time hospital microbiological surveillance. HLMT is also inexpensive, and thus, it is applicable for infection control programs in low- and middle-income countries. IMPORTANCE In this work, we describe hypervariable-locus melting typing (HLMT), a novel fast approach to pathogen typing using the high-resolution melting (HRM) assay. The method includes a novel approach for gene target selection, primer design, and HRM data analysis. We successfully applied this method to distinguish the high-risk clones of Klebsiella pneumoniae, one of the most important nosocomial pathogens worldwide. We also compared HLMT to typing using WGS, the capsular gene wzi, MLST, and PFGE. Our results show that HLMT is a typing method suitable for real-time epidemiological investigation. The application of HLMT to hospital microbiology surveillance can help to rapidly detect outbreak emergence, improving the effectiveness of infection control strategies.

Bactericidal activity of oxacillin and glycopeptides against Staphylococcus aureus in patients with endocarditis: looking for a relationship between tolerance and outcome.

BACKGROUND: There is no clear relationship between in vitro bactericidal activity tests and clinical outcome. We studied bactericidal activity of oxacillin, vancomycin and teicoplanin against Staphylococcus aureus isolates in patients with endocarditis and then we sought to determine if there was a relationship between in vitro bactericidal activity and clinical outcome. METHODS: Minimal bacteriostatic and minimal bactericidal concentrations were determined for Staphylococcus aureus strains isolated from patients with endocarditis following standardized methods. Medical records were reviewed retrospectively to collect data on antimicrobial susceptibility at admission, antimicrobial therapy, need for surgery, embolic events and outcome. RESULTS AND DISCUSSION: Sixty-two Staphylococcus aureus strains were studied in 62 patients with endocarditis. Overall, 91.9% definite, 21% methicillin resistant and 72.6% cured. Surgery was performed in 32.3% and embolic events were documented in 64.5%. Tolerance to oxacillin and teicoplanin was more common than vancomycin tolerance among methicillin susceptible Staphylococcus aureus. Among methicillin resistant Staphylococcus aureus teicoplanin was shown to have a higher rate of tolerance than vancomycin. No statistically significant differences on clinical outcome between oxacillin tolerant and oxacillin non tolerant Staphylococcus aureus infections were observed. Tolerance to oxacillin did not adversely affect clinical outcomes of patients with methicillin susceptible Staphylococcus aureus endocarditis treated with a combination of antimicrobials including oxacillin. The cure rate was significantly lower among patients with methicillin resistant Staphylococcus aureus endocarditis. CONCLUSIONS: In vitro bactericidal test results were not valid predictors of clinical outcome. Physicians need to use additional parameters when treating patients with staphylococcal endocarditis.

Rapid identification of non-tuberculous mycobacteria with MALDI-TOF mass spectrometry.

Rapid and accurate identification of non-tuberculous mycobacteria (NTM) is important for a prompt start to antibiotic therapy. The aim of this study was to obtain accurate identification of NTM quickly by analyzing the performance of the MALDI-TOF mass spectrometry (MS) system VITEK® MS in identifying various NTM species from solid medium and MGIT 960 liquid medium. The study was performed in two phases: preliminary and perspective. Overall, 41/42 species and 33/34 species were correctly identified from the MGIT medium in the preliminary and perspective phases, respectively. The VITEK® MS system includes in its database part of the mycobacteria from the Mycobacterium fortuitum complex but is unable to discriminate among the various species belonging to the complex. Although the VITEK® MS system does not have the protein spectrum of Mycobacterium chimaera, it is not able to distinguish between Mycobacterium chimaera and Mycobacterium intracellulare. Since the VITEK® MS includes the separate protein spectrum of both M. chelonae and M. abscessus, it can discriminate between the two microorganisms. Thanks to these studies we show that the VITEK® MS system is a reliable method for identification of NTMs directly from MGIT liquid medium, instead of the use of solid media.

Classification and treatment of the anterior maxillary dentition affected by dental erosion: the ACE classification.

Erosive tooth wear is a serious problem with very costly consequences. Intercepting patients at the initial stages of the disease is critical to avoid significant irreversible damages to their dentition and to benefit from still favorable conditions when it comes to clinical performance of the restorative measures proposed. In this article, a new classification is proposed to quantify the severity of the dental destruction and to guide clinicians and patients in the therapeutic decision-making process. The classification is based on several parameters relevant for both the selection of treatment and the assessment of the prognosis, such as dentin exposure in the palatal tooth contact areas, alterations at the level of the incisal edges, and ultimately, loss of pulp vitality.

Development of a clinically validated bulk failure test for ceramic crowns.

STATEMENT OF PROBLEM: Traditional testing of ceramic crowns creates a stress state and damage modes that differ greatly from those seen clinically. There is a need to develop and communicate an in vitro testing protocol that is clinically valid. PURPOSE: The purpose of this study was to develop an in vitro failure test for ceramic single-unit prostheses that duplicates the failure mechanism and stress state observed in clinically failed prostheses. This article first compares characteristics of traditional load-to-failure tests of ceramic crowns with the growing body of evidence regarding failure origins and stress states at failure from the examination of clinically failed crowns, finite element analysis (FEA), and data from clinical studies. Based on this analysis, an experimental technique was systematically developed and test materials were identified to recreate key aspects of clinical failure in vitro. MATERIAL AND METHODS: One potential dentin analog material (an epoxy filled with woven glass fibers; NEMA grade G10) was evaluated for elastic modulus in blunt contact and for bond strength to resin cement as compared to hydrated dentin. Two bases with different elastic moduli (nickel chrome and resin-based composite) were tested for influence on failure loads. The influence of water during storage and loading (both monotonic and cyclic) was examined. Loading piston materials (G10, aluminum, stainless steel) and piston designs were varied to eliminate Hertzian cracking and to improve performance. Testing was extended from a monolayer ceramic (leucite-filled glass) to a bilayer ceramic system (glass-infiltrated alumina). The influence of cyclic rate on mean failure loads was examined (2 Hz, 10 Hz, 20 Hz) with the extremes compared statistically (t test; α=.05). RESULTS: Failure loads were highly influenced by base elastic modulus (t test; P<.001). Cyclic loading while in water significantly decreased mean failure loads (1-way ANOVA; P=.003) versus wet storage/dry cycling (350 N vs. 1270 N). G10 was not significantly different from hydrated dentin in terms of blunt contact elastic behavior or resin cement bond strength. Testing was successful with the bilayered ceramic, and the cycling rate altered mean failure loads only slightly (approximately 5%). CONCLUSIONS: Test methods and materials were developed to validly simulate many aspects of clinical failure.

EasyPrimer: user-friendly tool for pan-PCR/HRM primers design. Development of an HRM protocol on wzi gene for fast Klebsiella pneumoniae typing.

In this work we present EasyPrimer, a user-friendly online tool developed to assist pan-PCR and High Resolution Melting (HRM) primer design. The tool finds the most suitable regions for primer design in a gene alignment and returns a clear graphical representation of their positions on the consensus sequence. EasyPrimer is particularly useful in difficult contexts, e.g. on gene alignments of hundreds of sequences and/or on highly variable genes. HRM analysis is an emerging method for fast and cost saving bacterial typing and an HRM scheme of six primer pairs on five Multi-Locus Sequence Type (MLST) genes is already available for Klebsiella pneumoniae. We validated the tool designing a scheme of two HRM primer pairs on the hypervariable gene wzi of Klebsiella pneumoniae and compared the two schemes. The wzi scheme resulted to have a discriminatory power comparable to the HRM MLST scheme, using only one third of primer pairs. Then we successfully used the wzi HRM primer scheme to reconstruct a Klebsiella pneumoniae nosocomial outbreak in few hours. The use of hypervariable genes reduces the number of HRM primer pairs required for bacterial typing allowing to perform cost saving, large-scale surveillance programs.

Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores.

BACKGROUND: To validate the concept of early implant placement for use in the esthetically sensitive anterior maxilla, clinical trials should ideally include objective esthetic criteria when assessing outcome parameters. METHODS: In this cross-sectional, retrospective 2- to 4-year study involving 45 patients treated with maxillary anterior single-tooth implants according to the concept of early implant placement, a novel comprehensive index, comprising pink esthetic score and white esthetic score (PES/WES; the highest possible combined score is 20), was applied for the objective esthetic outcome assessment of anterior single-tooth implants. RESULTS: All 45 anterior maxillary single-tooth implants fulfilled strict success criteria for dental implants with regard to osseointegration, including the absence of peri-implant radiolucency, implant mobility, suppuration, and pain. The mean total PES/WES was 14.7 +/- 1.18 (range: 11 to 18). The mean total PES of 7.8 +/- 0.88 (range: 6 to 9) documents favorable overall peri-implant soft tissue conditions. The two PES variables facial mucosa curvature (1.9 +/- 0.29) and facial mucosa level (1.8 +/- 0.42) had the highest mean values, whereas the combination variable root convexity/soft tissue color and texture (1.2 +/- 0.53) proved to be the most difficult to fully satisfy. Mean scores were 1.6 +/- 0.5 for the mesial papilla and 1.3 +/- 0.5 for the distal papilla. A mean value of 6.9 +/- 1.47 (range: 4 to 10) was calculated for WES. CONCLUSIONS: This study demonstrated that anterior maxillary single-tooth replacement, according to the concept of early implant placement, is a successful and predictable treatment modality, in general, and from an esthetic point of view, in particular. The suitability of the PES/WES index for the objective outcome assessment of the esthetic dimension of anterior single-tooth implants was confirmed. However, prospective clinical trials are needed to further validate and refine this index.

Treatment planning of adhesive additive rehabilitations: the progressive wax-up of the three-step technique.

A full-mouth rehabilitation should be correctly planned from the start by using a diagnostic wax-up to reduce the potential for remakes, increased chair time, and laboratory costs. However, determining the clinical validity of an extensive wax-up can be complicated for clinicians who lack the experience of full-mouth rehabilitations. The three-step technique is a simplified approach that has been developed to facilitate the clinician's task. By following this technique, the diagnostic wax-up is progressively developed to the final outcome through the interaction between patient, clinician, and laboratory technician. This article provides guidelines aimed at helping clinicians and laboratory technicians to become more proactive in the treatment planning of full-mouth rehabilitations, by starting from the three major parameters of incisal edge position, occlusal plane position, and the vertical dimension of occlusion.

CAD/CAM monolithic restorations and full-mouth adhesive rehabilitation to restore a patient with a past history of bulimia: the modified three-step technique.

Due to an increasing awareness about dental erosion, many clinicians would like to propose treatments even at the initial stages of the disease. However, when the loss of tooth structure is visible only to the professional eye, and it has not affected the esthetics of the smile, affected patients do not usually accept a full-mouth rehabilitation. Reducing the cost of the therapy, simplifying the clinical steps, and proposing noninvasive adhesive techniques may promote patient acceptance. In this article, the treatment of an ex-bulimic patient is illustrated. A modified approach of the three-step technique was followed. The patient completed the therapy in five short visits, including the initial one. No tooth preparation was required, no anesthesia was delivered, and the overall (clinical and laboratory) costs were kept low. At the end of the treatment, the patient was very satisfied from a biologic and functional point of view.

Asaia lannensis bacteremia in a 'needle freak' patient.

The genus Asaia has gained much interest lately owing to constant new species discoveries and its role as a potential opportunistic pathogen to humans. Here we describe a transient bacteremia due to Asaia lannensis in a patient with a psychiatric disorder (compulsive self-injection of different substances). Common phenotypic methods of identification failed to identify this organism, and only restriction fragment lenght polymorphism of PCR-amplified 16S rRNA gene allowed for proper identification. The isolate was highly resistant to most antibiotics. The paper also discusses the currently available medical literature, acknowledges the potential problems linked to the isolation of these strains and proposes an approach to species identification that can be applied in a clinical microbiology laboratory.

Malpositioned implants in the anterior maxilla: a novel restorative approach to reestablish peri-implant tissue health and acceptable esthetics. Part II: Case report and discussion.

This two-part case presentation describes the prosthetic challenge of managing complications in a 50-year-old female patient after inadequate esthetic risk assessment, treatment planning, and implant placement in the anterior maxilla. In Part I, the clinical situation was described, and different restorative solutions were proposed to correct the extreme facial inclination of the implants, excluding major surgical procedures, namely implant removal. In Part II, different prosthetic options are discussed, and the final treatment is revealed. A noninvasive treatment protocol was applied to transform a severely compromised postsurgical situation into an esthetically acceptable result. An unconventional prosthesis design was implemented, including the use of ceramic veneers bonded to the CAD/CAM-generated screw-retained zirconia- based fixed dental prosthesis (FDP), to correct major axis-related problems and spatial discrepancies.