Age-specific incidence of joint disease in paediatric patients with haemophilia: A single-centre real-world outcome based on consecutive US examination.

INTRODUCTION: Joint health is one of the most important factors contributing to a healthy life in patients with haemophilia. Recent study revealed that starting early prophylaxis was not enough to prevent joint disease in most paediatric patients with haemophilia. AIM: In this study, we aimed to determine the age-specific incidence of acute joint disease during childhood at single haemophilia treatment centre (HTC). METHOD: The joint health in 48 patients was evaluated based on consecutive US testing for 5 years at annual multidisciplinary comprehensive care. RESULTS: During the study period, 23 patients (47.9%) had no joint disease since the initial examination, whereas 13 patients (27.0%) showed development from negative to positive findings. The incidence of joint disease increased with age: 0% in preschool, 5.3% in elementary school, 14.3% in junior high school and 35% beyond high school age. Among the 13 patients who developed joint disease, two experienced acquired synovitis that resolved during the follow-up period. Statistical analysis revealed that the patients who routinely underwent follow-up by the HTC exhibited a significantly lower incidence of joint disease than did those followed up at other institutions (p < .001). CONCLUSION: These results indicated that close check-up, including routine joint examination using US as well as frequent assessment of pharmacokinetic profile at the HTC, might play an important role in avoiding joint disease among paediatric patients with haemophilia.

Advanced CT techniques for assessing hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the sixth-most common cancer in the world, and hepatic dynamic CT studies are routinely performed for its evaluation. Ongoing studies are examining advanced imaging techniques that may yield better findings than are obtained with conventional hepatic dynamic CT scanning. Dual-energy CT-, perfusion CT-, and artificial intelligence-based methods can be used for the precise characterization of liver tumors, the quantification of treatment responses, and for predicting the overall survival rate of patients. In this review, the advantages and disadvantages of conventional hepatic dynamic CT imaging are reviewed and the general principles of dual-energy- and perfusion CT, and the clinical applications and limitations of these technologies are discussed with respect to HCC. Finally, we address the utility of artificial intelligence-based methods for diagnosing HCC.

Molecular epidemiologic and clinical analysis of Helicobacter cinaedi bacteremia in Japan.

BACKGROUND: Helicobacter cinaedi is an important pathogen that causes bloodstream infections. Owing to the challenges in its culture and identification, its clinical and bacterial characteristics remain unknown. Our study aimed to investigate the molecular epidemiology and antimicrobial susceptibility of H cinaedi. MATERIALS AND METHODS: From 2003 to 2016, we analyzed 16 non-repetitive H cinaedi strains, isolated from blood, at the medical hospital of Tokyo Medical and Dental University. Multilocus sequence typing was performed to analyze the genetic relationship across the different isolates. The minimum inhibitory concentrations (MIC) of antibiotics were determined by the agar dilution method. RESULTS: The median age of subjects in this study was 61 years (range, 18-84 years). The most common risk factors included the use of steroids (75.0%) and immunosuppressant drugs (37.5%). In addition, the most common symptoms of H cinaedi bacteremia included colitis (37.5%) and cellulitis (31.3%). The infection recurred in three of seven cases (42.8%) that underwent antibiotic therapy for <10 days. The strains were classified into five sequence types (ST), of which, ST 10 (43.8%) and ST 4 (31.3%) were predominant. The MIC90 values of amoxicillin, gentamycin, imipenem, ciprofloxacin, and clarithromycin were 4, 0.5, 0.25, 64, and 128 mg/L, respectively. CONCLUSIONS: Since there is no recommended guideline yet for the choice or duration of antibiotic therapy and antimicrobial break points, our results suggested, for the first time, that prolonged antibiotic therapy, except with ciprofloxacin and clarithromycin, would be required to ensure resolution of symptoms and prevention of recurrence.

A Case Report of a Japanese Boy with Morquio A Syndrome: Effects of Enzyme Replacement Therapy Initiated at the Age of 24 Months.

BACKGROUND: Morquio A syndrome, mucopolysaccharidosis type IVA (MPS IVA), is a lysosomal storage disorder caused by the deficient activity of N-acetylgalactosamine-6-sulfatase (GalNac6S), due to alterations in the GALNS gene. This disorder results in marked abnormalities in bones and connective tissues, and affects multiple organs. Here, we describe the clinical course of a Japanese boy with MPS IVA who began enzyme replacement therapy (ERT) at the age of 24 months. PATIENT: the patient presented for kyphosis treatment at 22 months of age. An X-ray examination revealed dysostosis multiplex. Uronic acids were elevated in the urine and the keratan sulfate (KS) fraction was predominant. The leukocyte GalNac6S enzyme activity was extremely low. The patient exhibited the c.463G > A (p.Gly155Arg) mutation in GALNS. Based on these findings, his disease was diagnosed as classical (severe) Morquio A syndrome. An elosulfase alfa infusion was initiated at the age of 24 months. The patient's body height improved from -2.5 standard deviation (SD) to -2 SD and his physical activity increased during the first 9 months on ERT. However, he gradually developed paralysis in the lower legs with declining growth velocity, which required cervical decompression surgery in the second year of the ERT. The mild mitral regurgitation, serous otitis media, and mild hearing loss did not progress during treatment. CONCLUSION: early initiation of the elosulfase alfa to our patient showed good effects on the visceral system and muscle strength, while its effect on bones appeared limited. Careful observation is necessary to ensure timely surgical intervention for skeletal disorders associated with neurological symptoms. Centralized and multidisciplinary management is essential to improve the prognosis of pediatric patients with MPS IVA.

Radiation dose reduction at MDCT with iterative reconstruction for prenatal diagnosis of skeletal dysplasia: preliminary study using normal fetal specimens.

OBJECTIVE: The purpose of this study was to investigate to what degree the radiation dose can be reduced without affecting the ability to evaluate normal fetal bones at MDCT with iterative reconstruction. MATERIALS AND METHODS: Fifteen normal fetal specimens immersed in containers (30- and 35-cm diameter) were scanned with a 64-MDCT scanner, with tube voltage of 100 kVp and tube current of 600, 300, 150, 100, and 50 mA. Images were subjected to adaptive statistical iterative reconstruction (ASIR). The fetal dose was measured using glass dosimeters. We calculated the relative ratio of the dose at 600 mA. Image quality was evaluated on maximum-intensity-projection and volume-rendering images. Two radiologists recorded the visualization scores of five regions. Images at 600 mA were considered to be standard. RESULTS: With the 30-cm-diameter container, the fetal dose was 10.15 mGy (relative ratio, 100%) at a tube current of 600, 51% at 300, 25% at 150, 17% at 100, and 9% at 50 mA. With the 35-cm-diameter container the fetal dose was 10.01 mGy (relative ratio, 100%) at 600, 47% at 300, 24% at 150, 17% at 100, and 8% at 50 mA. Visual evaluation showed that in both containers, with ASIR 90%, there was a statistically significant difference between 50-and 600-mA images (p<0.01) but not between 600-mA images and those acquired at 100, 150, and 300 mA (p=0.08-1.00). CONCLUSION: The fetal radiation dose for the evaluation of normal fetal bones can be reduced by 83% with ASIR 90%.

Iodine maps derived from sparse-view kV-switching dual-energy CT equipped with a deep learning reconstruction for diagnosis of hepatocellular carcinoma.

Deep learning-based spectral CT imaging (DL-SCTI) is a novel type of fast kilovolt-switching dual-energy CT equipped with a cascaded deep-learning reconstruction which completes the views missing in the sinogram space and improves the image quality in the image space because it uses deep convolutional neural networks trained on fully sampled dual-energy data acquired via dual kV rotations. We investigated the clinical utility of iodine maps generated from DL-SCTI scans for assessing hepatocellular carcinoma (HCC). In the clinical study, dynamic DL-SCTI scans (tube voltage 135 and 80 kV) were acquired in 52 patients with hypervascular HCCs whose vascularity was confirmed by CT during hepatic arteriography. Virtual monochromatic 70 keV images served as the reference images. Iodine maps were reconstructed using three-material decomposition (fat, healthy liver tissue, iodine). A radiologist calculated the contrast-to-noise ratio (CNR) during the hepatic arterial phase (CNRa) and the equilibrium phase (CNRe). In the phantom study, DL-SCTI scans (tube voltage 135 and 80 kV) were acquired to assess the accuracy of iodine maps; the iodine concentration was known. The CNRa was significantly higher on the iodine maps than on 70 keV images (p < 0.01). The CNRe was significantly higher on 70 keV images than on iodine maps (p < 0.01). The estimated iodine concentration derived from DL-SCTI scans in the phantom study was highly correlated with the known iodine concentration. It was underestimated in small-diameter modules and in large-diameter modules with an iodine concentration of less than 2.0 mgI/ml. Iodine maps generated from DL-SCTI scans can improve the CNR for HCCs during hepatic arterial phase but not during equilibrium phase in comparison with virtual monochromatic 70 keV images. Also, when the lesion is small or the iodine concentration is low, iodine quantification may result in underestimation.

Utility of Wavelet Denoising with Geometry Factor Weighting for Gadoxetic Acid-enhanced Hepatobiliary-phase MR Imaging.

PURPOSE: The wavelet denoising with geometry factor weighting (g-denoising) method can reduce the image noise by adapting to spatially varying noise levels induced by parallel imaging. The aim of this study was to investigate the clinical applicability of g-denoising on hepatobiliary-phase (HBP) images with gadoxetic acid. METHODS: We subjected 53 patients suspected of harboring hepatic neoplastic lesions to gadoxetic acid-enhanced HBP imaging with and without g-denoising (g+HBP and g-HBP). The matrix size was reduced for g+HBP images to avoid prolonging the scanning time. Two radiologists calculated the SNR, the portal vein-, and paraspinal muscle contrast-to-noise ratio (CNR) relative to the hepatic parenchyma (liver-to-portal vein- and liver-to-muscle CNR). Two other radiologists independently graded the sharpness of the liver edge, the visibility of intrahepatic vessels, the image noise, the homogeneity of liver parenchyma, and the overall image quality using a 5-point scale. Differences between g-HBP and g+HBP images were determined with the two-sided Wilcoxon signed-rank test. RESULTS: The liver-to-portal- and liver-to-muscle CNR and the SNR were significantly higher on g+HBP- than g-HBP images (P < 0.01), as was the qualitative score for the image noise, homogeneity of liver parenchyma, and overall image quality (P < 0.01). Although there were no significant differences in the scores for the sharpness of the liver edge or the score assigned for the visibility of intrahepatic vessels (P = 0.05, 0.43), with g+HBP the score was lower in three patients for the sharpness of the liver edge and in six patients for the visibility of intrahepatic vessels. CONCLUSION: At gadoxetic acid-enhanced HBP imaging, g-denoising yielded a better image quality than conventional HBP imaging although the anatomic details may be degraded.

Understanding CT imaging findings based on the underlying pathophysiology in patients with small bowel ischemia.

Because acute small bowel ischemia has a high mortality rate, it requires rapid intervention to avoid unfavorable outcomes. Computed tomography (CT) examination is important for the diagnosis of bowel ischemia. Acute small bowel ischemia can be the result of small bowel obstruction or mesenteric ischemia, including mesenteric arterial occlusion, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. The clinical significance of each CT finding is unique and depends on the underlying pathophysiology. This review describes the definition and mechanism(s) of bowel ischemia, reviews CT findings suggesting bowel ischemia, details factors involved in the development of small bowel ischemia, and presents CT findings with respect to the different factors based on the underlying pathophysiology. Such knowledge is needed for accurate treatment decisions.

Iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) imaging of multiple myeloma: initial clinical efficiency results.

OBJECTIVES: To evaluate the effectiveness of the iterative decomposition of water and fat with echo asymmetric and least-squares estimation (IDEAL) MRI to quantify tumour infiltration into the lumbar vertebrae in myeloma patients without visible focal lesions. METHODS: The lumbar spine was examined with 3 T MRI in 24 patients with multiple myeloma and in 26 controls. The fat-signal fraction was calculated as the mean value from three vertebral bodies. A post hoc test was used to compare the fat-signal fraction in controls and patients with monoclonal gammopathy of undetermined significance (MGUS), asymptomatic myeloma or symptomatic myeloma. Differences were considered significant at P < 0.05. The fat-signal fraction and ß(2)-microglobulin-to-albumin ratio were entered into the discriminant analysis. RESULTS: Fat-signal fractions were significantly lower in patients with symptomatic myelomas (43.9 ±19.7%, P < 0.01) than in the other three groups. Discriminant analysis showed that 22 of the 24 patients (92%) were correctly classified into symptomatic or non-symptomatic myeloma groups. CONCLUSIONS: Fat quantification using the IDEAL sequence in MRI was significantly different when comparing patients with symptomatic myeloma and those with asymptomatic myeloma. The fat-signal fraction and ß(2)-microglobulin-to-albumin ratio facilitated discrimination of symptomatic myeloma from non-symptomatic myeloma in patients without focal bone lesions. KEY POINTS: • A new magnetic resonance technique (IDEAL) offers new insights in multiple myeloma. • Fat-signal fractions were lower in patients with symptomatic myelomas than in those with asymptomatic myelomas. • The ß2-microglobulin-to-albumin ratio also aided discrimination of symptomatic myeloma. • The fat-signal fraction may provide information about the myeloma cell mass.

Multiple myeloma: microstructural analysis of lumbar trabecular bones in patients without visible bone lesions--preliminary results.

PURPOSE: To evaluate the accuracy of trabecular analysis of the lumbar spine by using multidetector computed tomography (CT) in differentiating multiple myeloma patients without spinal fractures from control subjects. MATERIALS AND METHODS: This retrospective single-institution study was approved by the institutional review board, with a waiver of informed consent. Spinal microarchitecture was examined by using 64-detector row CT in 29 patients with multiple myeloma and 51 control subjects. The patients were 13 men and 16 women (mean ages, 71.1 and 69.2 years, respectively). By using multidetector CT data, eight parameters were calculated for the L3 vertebral trabeculae with a three-dimensional image analysis system. The χ(2) test was used to select a preliminary set of predictors for multiple myeloma. A multivariable generalized linear model was constructed to identify parameters that could be used to differentiate between patients and controls. Parameters with findings of P < .05 were included in the multivariable model. RESULTS: Generalized linear models showed that mean trabecular thickness (TbTh) (patients, 703.7 µm ± 46.7 [standard deviation]; controls, 661.1 µm ± 35.7) and fractal dimension (FD) (patients, 2.23 ± 0.24; controls, 2.41 ± 0.15) in men (P = .05 and .03, respectively) and degree of anisotropy (DA) (patients, 1.63 ± 0.23; controls, 1.38 ± 0.10) in women (P = .02) had significant effects in differentiation between patients and controls. CONCLUSION: Significant differences were observed in spinal microarchitecture between control subjects and multiple myeloma patients without pathologic fractures. Independent predictors of multiple myeloma included TbTh and FD in male patients and DA in female patients.

Effect of lapatinib on hepatic parenchymal enhancement on gadoxetate disodium (EOB)-enhanced MRI scans.

We present changes seen on hepatobiliary phase (HBP)-gadoxetate disodium (EOB)-enhanced magnetic resonance image of a woman with liver metastases who was treated with lapatinib. After treatment, the HBP images appeared like portal venous phase images. This suggests that lapatinib, an inhibitor of organic anion transporting polypeptide 1B1, one of the substrates of EOB, inhibits EOB uptake by hepatocytes. In patients treated with lapatinib, the ability to diagnose liver tumors on HBP images may be compromised.

Portal-systemic shunt between the inferior mesenteric vein and inferior vena cava in a patient with hepatic encephalopathy: successful occlusion by balloon-occluded retrograde transvenous obliteration.

A large shunt between the inferior mesenteric vein (IMV) and the inferior vena cava (IVC) is a rare type of portosystemic shunt in patients with hepatic encephalopathy. We report a patient with hepatic encephalopathy due to a large IMV-IVC shunt who was successfully treated by balloon-occluded retrograde transvenous obliteration. The procedure involved a combination of 11 metallic coils and 5 ml of 5% ethanolamine oleate with iopamidol as the sclerosing agent. After complete obliteration of the shunt, his symptoms disappeared. At 2-years follow-up he was free of clinical symptoms, the size of his liver had slightly increased, and his liver function was preserved.

Demonstration of Human Fetal Bone Morphology with MR Imaging: A Preliminary Study.

PURPOSE: CT is a useful modality for the evaluation of fetal skeletal dysplasia but radiation exposure is unavoidable. The purpose of this study is to compare the usefulness of MRI and CT for evaluating the fetal skeletal shape. METHODS: This study was approved by our Institutional Review Board. Fetal specimens (n = 14) were scanned on a 3T MRI scanner using our newly-developed sequence. It is based on T2*-weighted imaging (TR, 12 ms; TE for opposed-phase imaging, 6.1 ms, for in-phase imaging, 7.3 ms; flip angle, 40°). The specimens were also scanned on a 320 detector-row CT scanner. Four radiologists visually graded and compared the visibility of the bone shape of eight regions on MRI- and CT-scans using a 5-point grading system. RESULTS: The diagnostic ability of MRI with respect to the 5th metacarpals, femur, fibula, and pelvis was superior to CT (all, P < 0.050); there was no significant difference in the evaluation results of observers with respect to the cervical and lumbar spine, and the 5th metatarsal (0.058 ≤ P ≤ 1.000). However, the diagnostic ability of MRI was significantly inferior to CT for the assessment of the bone shape of the thoracic spine (observers A and C: P = 0.002, observers B and D: P = 0.001). CONCLUSION: The MRI method we developed represents a potential alternative to CT imaging for the evaluation of the fetal bone structure.

Spontaneous perforation of choledochal cyst: a case with unusual distribution of fluid in the retroperitoneal space.

Images of perforated choledochal cysts typically show an intraperitoneal fluid collection. We report a case with, in addition to free intraperitoneal fluid, fluid collection in the right-side anterior pararenal and perirenal spaces. Surgery confirmed the presence of a perforation at the junction of the cystic duct and the common bile duct. This perforation may explain the biliary leakage extending into the free peritoneal space as well as into the anterior pararenal space and the hepatoduodenal ligament. Anterior pararenal and perirenal spaces communicate with the infrarenal space, and this may result in extension of the fluid into the perirenal space from the anterior pararenal space.

Clinical Indication for Computed Tomography During Hepatic Arteriography (CTHA) in Addition to Dynamic CT Studies to Identify Hypervascularity of Hepatocellular Carcinoma.

PURPOSE: To identify factors benefiting from computed tomography during hepatic arteriography (CTHA) in addition to dynamic CT studies at the preoperative evaluation of the hypervascularity of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: We retrospectively divided 45 patients with HCC, who underwent both dynamic CT (dCT) and CTHA, into two groups based on the number of hypervascular HCCs identified on dCT and CTHA studies. In group A, the number of HCCs identified by dCT and CTHA was the same and additive CTHA had not been indicated. In group B, fewer HCCs were counted on dCT than on CTHA images, indicating that additive CTHA studies had been appropriate. We compared the patient characteristics, the serum alpha-fetoprotein level, and the tumor-liver contrast (TLC) of the main tumor on dCT scans of both groups. To identify factors alerting to the benefit of additional CTHA studies, we performed univariate logistic regression analysis. Statistically significant parameters were subjected to receiver operating characteristic analysis for obtaining the optimal cutoff value indicative of the benefit of CTHA. RESULTS: Univariate analysis identified only the TLC of the main tumor on dCT images as a significant factor for the benefit of CTHA images (P < 0.01). At the optimal cutoff value for the TLC of the main tumor on dCT images (15.9 Hounsfield units), the sensitivity and specificity for the benefit of CTHA were 85.0 and 92.0%, respectively. CONCLUSION: Evaluation of the TLC of the main tumor on dCT scans identifies patients in whom additive CTHA studies are beneficial.

Guinea Pig Maximization Test of tri-ethylene glycol mono-methacrylate.

The aim of this study was to evaluate tri-ethylene glycol mono-methacrylate (TEGMA) in terms of dermatological allergic reaction using a Guinea Pig Maximization Test. Skin reaction was evaluated according to the criteria of International Contact Dermatitis Research Group. TEGMA, as a constituent in new primers, has been reported to contribute to a priming ability similar to that of highly purified glyceryl mono-methacrylate (GM). In this study, it was found that its adverse effect was less than that of 2-hydroxy ethyl methacrylate (2-HEMA), but similar to that of highly purified GM. In conclusion, it was anticipated that TEGMA would hereafter replace 2-HEMA as a primer, as it posed a lower risk of triggering dermatological allergic reaction.

Individual Clinically Diagnosed with CHARGE Syndrome but with a Mutation in KMT2D, a Gene Associated with Kabuki Syndrome: A Case Report.

We report a Japanese female patient presenting with classic features of CHARGE syndrome, including choanal atresia, growth and development retardation, ear malformations, genital anomalies, multiple endocrine deficiency, and unilateral facial nerve palsy. She was clinically diagnosed with typical CHARGE syndrome, but genetic analysis using the TruSight One Sequence Panel revealed a germline heterozygous mutation in KMT2D with no pathogenic CHD7 alterations associated with CHARGE syndrome. Kabuki syndrome is a rare multisystem disorder characterized by five cardinal manifestations including typical facial features, skeletal anomalies, dermatoglyphic abnormalities, mild to moderate intellectual disability, and postnatal growth deficiency. Germline mutations in KMT2D underlie the molecular pathogenesis of 52-76% of patients with Kabuki syndrome. This is an instructive case that clearly represents a phenotypic overlap between Kabuki syndrome and CHARGE syndrome. It suggests the importance of considering the possibility of a diagnosis of Kabuki syndrome even if patients present with typical symptoms and meet diagnostic criteria of CHARGE syndrome. The case also emphasizes the impact of non-biased exhaustive genetic analysis by next-generation sequencing in the genetic diagnosis of rare congenital disorders with atypical manifestations.

Compatibility between self-etching adhesive and self-curing resin by addition of anion exchange resin.

OBJECTIVE: The aim was to investigate whether anion exchange resin powder in the OH(-) form, added to the amine component of self-cured resin can deprotonize acid groups of a self-etching adhesive and thus eliminate incompatibility caused by amine neutralization. METHODS: Shear bond strength (SBS) of a self-cured CorePaste (COP), bonded either with all-in-one adhesive iBond (IBO) or with IBO coated with a self-cured experimental resin (SCR), loaded with 0, 8, 16, or 32 wt% of anion exchange resin powder (AER) in OH- form, were determined on 80 enamel and dentin surfaces each after 24 h water storage. IBO specimens were either light-activated or not. Flexural modulus and strength of the four SCR resins were determined by three-point bending. Data was analyzed by one-way ANOVA and Duncan's post hoc test (p<0.05). RESULTS: Enamel SBSs of COP on IBO were 20-25 MPa, in combination with SCR (0 up to 32%) >25 MPa for activated or non-activated IBO. COP on IBO produced no bond on dentin, with the non-loaded SCR 5-10 MPa SBS was achieved, and 15 and 21 MPa were measured with the three AER-loaded SCRs on activated and non-activated IBO, respectively. Flexural moduli of SCR with 0 and 8% AER were higher than with 16 and 32%. Flexural strengths were not significantly different. SIGNIFICANCE: Addition of anion exchange resin to the amine component of self-cured resin is an effective means of enhancing the bond strength on dentin and to prevent amine neutralization through the acid groups of self-etching primer adhesives.

Effect of application mode on bonding performance of self-etching adhesives.

PURPOSE: To investigate effects of static vs. dynamic application of self-etching adhesives on bond strengths to enamel and dentin and marginal adaptation in dentin cavities. METHODS: Products: AC Bond experimental (ACB), AQ Bond (AQB), Fluorobond (FLB), and One-Up Bond F (OUB). Shear bond strengths (SBS) to enamel and dentin were determined on human molars. Primer applications: 1. undisturbed, 2. brush agitation, 3. ultrasonic agitation (Cavitron, lowest setting), or 4. ultrasonic agitation (5 seconds). A 3.5 x 2 mm mold was mounted for application of the resin-based composite Charisma. Six specimens for each condition were stored for 24 hours and loaded until failure. STATISTICS: ANOVA and Scheffé test (P= 0.05). Marginal adaptation was determined in cylindrical dentin cavities (4 x 1.5 mm) 15 minutes after curing of Charisma. Eight specimens/adhesive were produced following application modes 1, 2, and 4. Kruskal-Wallis and Mann-Whitney showed a P= 0.05. RESULTS: Application modes showed no differences in shear bond strengths (SBS) on enamel and dentin by adhesive. SBSs on enamel were not different from those on dentin. Average SBSs for ACB, AQB, FLB, and OUB were 21.0, 21.9, 20.8, and 13.7 MPa. Ranking of adhesives for SBS on enamel and dentin was: AQB, ACB > ACB, FLB > OUB. Application modes had no influence on marginal adaptation. From the 24 cavities each, all ACB, 21 AQB, 13 FLB, and 1 OUB were gap-free. Mann-Whitney ranking: ACB, AQB, FLB > OUB.