The hue of temporomandibular joint arthroscopy under local versus general anaesthesia.

BACKGROUND: Temporomandibular joint arthroscopy (TMJA) is often performed under general anaesthesia (GA) worldwide on an inpatient basis, whereas local anaesthesia (LA) is not equally considered as the standard procedure. OBJECTIVES: To compare the efficacy between LA and GA when performing TMJA. METHODS: This study retrospectively reviewed a total of 182 patients in LA group and 91 patients in GA group who underwent TMJA for the management of disc displacement. Patients were divided into two groups based on type of anaesthesia used for surgery; LA group and GA group. Comparisons were made based on operative time, intubation and extubation time (for GA only), hospital stay duration, total cost and post-operative clinical and radiological outcomes. RESULTS: The demographics and pre-operative clinical assessments were matched in both groups. No post-operative significant difference was found in outcomes when performing TMJA under LA compared to GA in terms of pain reduction (p = .016) and improvement in mouth opening (p = .866). The median operative time and hospital stay duration for LA group were significantly less compared to GA group (p < .001). GA group required an additional intubation and extubation time, whereas LA group patients were waived from it. TMJA for LA group was performed in the minor procedure setup, which reduced the costs for surgery (p < .001). Post-operative disc position was excellent and good with an overall success rate of 95%. CONCLUSION: The use of LA performing TMJA reduces operating time, costs, hospital stay and recovery room time than GA group. Furthermore, TMJA performed under LA shared similar post-operative clinical and radiological outcomes with those performed under GA.

Effect of Eruption Status of the Mandibular Third Molar on Distal Caries in the Adjacent Second Molar.

PURPOSE: To analyze the effect of the eruption status of the mandibular third molar (MTM) on distal caries in the mandibular second molar (MSM) by cone-beam computed tomography (CBCT). MATERIALS AND METHODS: Five hundred CBCT images of MTMs from 469 patients were evaluated. Presence of distal caries in MSMs, impaction depths and angulations of MTMs, cementoenamel junction (CEJ) distances between distal MSMs and mesial MTMs, presence of pericoronitis in MTMs, and patient characteristics (age and gender) were assessed. Data were analyzed by χ(2) test, univariate and multivariate logistic regression analyses, and Spearman correlation analysis. Descriptive and bivariate statistics were computed and the P value was set at .05. RESULTS: The overall prevalence of distal caries in the MSM was 52.0%. According to the classification of Pell and Gregory, position A was the impaction depth at which most distal caries in MSMs were present (P = .036). For angulation of the MTM, when mesial angulations were 43° to 73°, MSMs developed more distal caries (P < .0001). For the CEJ distance between the distal MSM and the mesial MTM, when distances ranged from 6 to 15 mm, distal caries in MSMs occurred more frequently (6 to 8 mm, P < .0001; 8 to 15 mm, P = .037). Furthermore, there was a linear correlation between angulation of the MTM and the CEJ distance between the distal MSM and the mesial MTM (P < .0001). CONCLUSIONS: Impaction depth and angulation of the MTM are associated with distal caries in the MSM. Angulation of the MTM is more stable and reliable than the CEJ distance between the distal MSM and the mesial MTM for the estimation of risk factors related to the MTM.

Comparing cross-sectional and longitudinal approaches to tuberculosis patient cost surveys using Nepalese data.

The World Health Organization has supported the development of national tuberculosis (TB) patient cost surveys to quantify the socio-economic impact of TB in high-burden countries. However, methodological differences in the study design (e.g. cross-sectional vs longitudinal) can generate different estimates making the design and impact evaluation of socio-economic protection strategies difficult. The objective of the study was to compare the socio-economic impacts of TB estimated by applying cross-sectional or longitudinal data collections in Nepal. We analysed the data from a longitudinal costing survey (patients interviewed at three time points) conducted between April 2018 and October 2019. We calculated both mean and median costs from patients interviewed during the intensive (cross-sectional 1) and continuation (cross-sectional 2) phases of treatment. We then compared costs, the prevalence of catastrophic costs and the socio-economic impact of TB generated by each approach. There were significant differences in the costs and social impacts calculated by each approach. The median total cost (intensive plus continuation phases) was significantly higher for the longitudinal compared with cross-sectional 2 (US$119.42 vs 91.63, P < 0.001). The prevalence of food insecurity, social exclusion and patients feeling poorer or much poorer were all significantly higher by applying a longitudinal approach. In conclusion, the longitudinal design captured important aspects of costs and socio-economic impacts, which were missed by applying a cross-sectional approach. If a cross-sectional approach is applied due to resource constraints, our data suggest that the start of the continuation phase is the optimal timing for a single interview. Further research to optimize methodologies to report patient-incurred expenditure during TB diagnosis and treatment is needed.

Comparing Additionality of Tuberculosis Cases Using GeneXpert or Smear-Based Active TB Case-Finding Strategies among Social Contacts of Index Cases in Nepal.

This study compares the yield and additionality of community-based active tuberculosis (TB) active case-finding strategies using either smear microscopy or GeneXpert as the TB diagnostic test. Active case-finding strategies screened social contacts of index cases and high-risk groups in four districts of Nepal in July 2017-2019. Two districts (Chitwan and Dhanusha) applied GeneXpert testing and two districts (Makwanpur and Mahotarri) used smear microscopy. Two control districts implemented standard national TB program activities. Districts implementing GeneXpert testing screened 23,657 people for TB, tested 17,114 and diagnosed 764 TB cases, producing a yield of 4.5%. Districts implementing smear microscopy screened 19,961 people for TB, tested 13,285 and diagnosed 437 cases, producing a yield of 3.3%. The screening numbers required were 31 for GeneXpert and 45.7 for smear districts. The test numbers required were 22.4 and 30.4 for GeneXpert and smear. Using the TB REACH additionality method, social contact tracing for TB through GeneXpert testing contributed to a 20% (3958/3322) increase in district-level TB notifications, smear microscopy 12.4% (3146/2798), and -0.5% (2553/2566) for control districts. Therefore, social contact tracing of TB index cases using GeneXpert testing should be implemented throughout Nepal within the TB FREE initiative to close the notification gap and accelerate progress toward END TB strategy targets.

Prognostic indicators of arthroscopic discopexy for management of temporomandibular joint closed lock.

In order to optimize patient selection for temporomandibular joint (TMJ) arthroscopic discopexy to achieve favorable outcomes, prognostic indicators impacting the results are important to analyze. This longitudinal retrospective study aimed to analyze various prognostic factors impacting surgical outcomes following arthroscopic discopexy for management of TMJ closed lock using success criteria based on pain, maximal interincisal opening, diet, and quality of life. Furthermore, a quantitative MRI assessment was performed pre- and post-operatively. Multivariate analysis was used to evaluate various prognostic variables including gender, age, side, duration of illness, Wilkes staging, parafunctional habits, splint therapy and orthodontic treatment. A total of 147 patients (201 joints) were included. The outcome was categorized as excellent (n = 154/76.61%), good (n = 34/16.91%), or poor (n = 13/6.46%) with a success rate of 93.54%. Patients aged > 30 years old (p = 0.048), longer duration of illness (12-24 months: p = 0.034) and (> 24 months: p = 0.022), and patients with Wilkes stage IV (p = 0.002) were all significantly more likely to be in the poor outcome group. Finally, orthodontic treatment showed a significant association with excellent outcomes (p = 0.015). Age, duration of illness, Wilkes staging, and orthodontic treatment are considered significant prognostic factors that can predict the outcomes following the arthroscopic discopexy for management of TMJ closed lock.

Interstitial Pregnancy Managed with Single-dose Systemic Methotrexate: A Case Report.

Interstitial pregnancy is a rare type of ectopic pregnancy with a high risk of massive hemorrhage on rupture as compared to ectopic on other sites. The mortality rate for the ruptured interstitial pregnancy is high. Therefore, early diagnosis of such pregnancy before the rupture occurs facilitates appropriate management and avoids life-threatening complications. With the advancement in diagnostic imaging modalities, early diagnosis and more conservative management for interstitial pregnancy have become possible. Here, we report a case of primigravida diagnosed with interstitial pregnancy with ultrasonography and successfully managed with a single dose of methotrexate.

Barriers and facilitators to accessing tuberculosis care in Nepal: a qualitative study to inform the design of a socioeconomic support intervention.

OBJECTIVE: Psychosocial and economic (socioeconomic) barriers, including poverty, stigma and catastrophic costs, impede access to tuberculosis (TB) services in low-income countries. We aimed to characterise the socioeconomic barriers and facilitators of accessing TB services in Nepal to inform the design of a locally appropriate socioeconomic support intervention for TB-affected households. DESIGN: From August 2018 to July 2019, we conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) with purposively selected multisectoral stakeholders. The data were managed in NVivo V.12, coded by consensus and analysed thematically. SETTING: The study was conducted in four districts, Makwanpur, Chitwan, Dhanusha and Mahottari, which have a high prevalence of poverty and TB. PARTICIPANTS: Seven FGDs were conducted with 54 in-country stakeholders, grouped by stakeholders, including people with TB (n=21), community stakeholders (n=13) and multidisciplinary TB healthcare professionals (n=20) from the National TB Programme. RESULTS: The perceived socioeconomic barriers to accessing TB services were: inadequate TB knowledge and advocacy; high food and transportation costs; income loss and stigma. The perceived facilitators to accessing TB care and services were: enhanced championing and awareness-raising about TB and TB services; social protection including health insurance; cash, vouchers and/or nutritional allowance to cover food and travel costs; and psychosocial support and counselling integrated with existing adherence counselling from the National TB Programme. CONCLUSION: These results suggest that support interventions that integrate TB education, psychosocial counselling and expand on existing cash transfer schemes would be locally appropriate and could address the socioeconomic barriers to accessing and engaging with TB services faced by TB-affected households in Nepal. The findings have been used to inform the design of a socioeconomic support intervention for TB-affected households. The acceptability, feasibility and impact of this intervention on TB-related costs, stigma and TB treatment outcomes, is now being evaluated in a pilot implementation study in Nepal.

How to reduce household costs for people with tuberculosis: a longitudinal costing survey in Nepal.

The aim of this study was to compare costs and socio-economic impact of tuberculosis (TB) for patients diagnosed through active (ACF) and passive case finding (PCF) in Nepal. A longitudinal costing survey was conducted in four districts of Nepal from April 2018 to October 2019. Costs were collected using the WHO TB Patient Costs Survey at three time points: intensive phase of treatment, continuation phase of treatment and at treatment completion. Direct and indirect costs and socio-economic impact (poverty headcount, employment status and coping strategies) were evaluated throughout the treatment. Prevalence of catastrophic costs was estimated using the WHO threshold. Logistic regression and generalized estimating equation were used to evaluate risk of incurring high costs, catastrophic costs and socio-economic impact of TB over time. A total of 111 ACF and 110 PCF patients were included. ACF patients were more likely to have no education (75% vs 57%, P = 0.006) and informal employment (42% vs 24%, P = 0.005) Compared with the PCF group, ACF patients incurred lower costs during the pretreatment period (mean total cost: US$55 vs US$87, P < 0.001) and during the pretreatment plus treatment periods (mean total direct costs: US$72 vs US$101, P < 0.001). Socio-economic impact was severe for both groups throughout the whole treatment, with 32% of households incurring catastrophic costs. Catastrophic costs were associated with 'no education' status [odds ratio = 2.53(95% confidence interval = 1.16-5.50)]. There is a severe and sustained socio-economic impact of TB on affected households in Nepal. The community-based ACF approach mitigated costs and reached the most vulnerable patients. Alongside ACF, social protection policies must be extended to achieve the zero catastrophic costs milestone of the End TB strategy.

Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome Rare Obstructive Uterovaginal Anomaly: A Case Report.

Obstructed Hemivagina and Ipsilateral Renal Anomaly syndrome is a rare obstructive uterovaginal anomaly involving both mesonephric and paramesonephric ducts. It usually presents after menarche with non-specific symptoms like pelvic pain, dysmenorrhea, or paravaginal mass and examination findings of paravaginal or pelvic mass. Because of non-specific symptoms and signs, the diagnosis is usually overlooked, which leads to complications like endometriosis, tubo-ovarian abscess compromising patient’s fertility, and quality of life. Therefore, in presence of these nonspecific clinical features along with imaging findings of uterine didelphys and unilateral renal agenesis, this syndrome should be considered in the diagnosis. We present a case of a 17-year-old lady with Obstructed Hemivagina and Ipsilateral Renal Anomaly syndrome, diagnosed by finding of paravaginal mass on examination and uterine didelphys with ipsilateral renal agenesis in USG and managed successfully by resection of vaginal septum. Keywords: ipsilateral renal anomaly;paravaginal mass;uterovaginal anomaly.

Diagnostic accuracy of synovial chondromatosis of the temporomandibular joint on magnetic resonance imaging.

The purpose of this study was to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for synovial chondromatosis (SC) of the temporomandibular joint (TMJ). In this study, 1415 patients (2109 joints) with temporomandibular joint disorders were collected between January 2012 and January 2017. All patients had a preoperative MRI examination and were treated by either arthroscopy or open surgery. On reviewing all MRI images, the number of "positive", "suspicious", and "negative" cases was collected afterwards, then the number of reported SC cases in operative data was recorded. The SPSS software was used to process all collected data. The kappa coefficient and ROC curve (AUC-index) with sensitivity and specificity were calculated to evaluate the consistency between MRI and arthroscopy/open surgery. Compared to 156 joints with SC detected by arthroscopy and open surgery, the results of MRI examination showed "positive" in 117 joints, and "negative" in 1938 joints. The number of "true positive", and "true negative" cases was 95, and 1897 respectively. The AUC-index was 0.86 (0.82-0.90) with a kappa coefficient of 0.74 (P < 0.05). In conclusion, the incidence of synovial chondromatosis diagnosed on MRI was in accordance with the arthroscopic and open surgery. Therefore, being a relatively non-invasive tool, MRI could be recommended as an effective diagnostic modality for SC.

The effect of vascular endothelial growth factor (VEGF) on mouse condylar articular cartilage cultured in vitro.

In this study, we explored the direct effect of vascular endothelial growth factor (VEGF) on temporomandibular joint osteoarthritis (TMJ-OA) by analyzing the transformation of mouse condylar cartilage treated in vitro with various concentrations of VEGF. Tissue samples from 126 condyles of four-week-old male C57 mice were randomly divided into 21 groups and treated with VEGF (0 ng/mL, 100 ng/mL, 500 ng/mL, 1 µg/mL, or 2 µg/mL). Furthermore, the samples were treated at different time points (1 d, 2 d, 4 d, and 7 d) and stained with hematoxylin and eosin (HE) and Safranin O and Fast Green stains to observe their morphology. The Mankin score was used to evaluate changes to the condylar cartilage tissues, and immunohistochemistry was performed to observe the expressions of VEGF receptor 2 (VEGFR2), matrix metallopeptidase 9 (MMP9), matrix metallopeptidase 13 (MMP13), and tumor necrosis factor-related activation-induced cytokine (TRANCE). An HE staining analysis revealed that the experimental groups treated with VEGF exhibited the destruction of their condylar cartilage and a proliferation of their hypertrophic cells, in comparison to the control group. Safranin O and Fast Green staining showed that the experimental groups had decreased levels of proteoglycan and degenerative changes in their condylar cartilage. The Mankin score of the samples increased with increasing concentration and treatment time of VEGF, and the differences between the groups were statistically significant (P < 0.05). Immunohistochemistry demonstrated that the expression levels of VEGFR2, MMP9, MMP13, and TRANCE significantly increased in the experimental groups, in comparison to those in the control group, suggesting that VEGF promoted TMJ-OA in mice in vitro.

Changes in temporomandibular joint spaces after arthroscopic disc repositioning: a self-control study.

Disc repositioning is a common procedure for patients with anterior disc displacement (ADD). The purpose of this retrospective record-based study was to evaluate changes in the widths of joint spaces and condylar position changes in patients with unilateral ADD following arthroscopic disc repositioning, with the healthy sides as self-control, using magnetic resonance images (MRI).Widths of anterior, superior, and posterior joint spaces (AS, SS, and PS) were measured. The condylar position was described as anterior, centric or posterior, expressed as . Paired-t test and Chi-square test were used to analyze the data. Fifty-four records conformed to the inclusion criteria (mean age of 21.02 years). Widths of SS and PS increased significantly after surgery (P < 0.001) on the operative sides, while joint spaces of healthy sides and AS of operative sides had no significant changes. Dominant location of condyles of operative sides changed from a posterior position to an anterior position, while healthy sides were mostly centric condylar position no matter preoperatively or postoperatively. Therefore, the results of this study indicate that unilateral arthroscopic disc repositioning significantly increases the posterior and superior spaces of the affected joints, without affecting spaces of the healthy sides.