Magneto-dynamic tool for full arch immediate loading in post-traumatic restoration with narrow implants: A case report.

New surgical techniques using narrow, tilted implants positioned through a magneto-dynamic tool in guided surgery for a Toronto restoration. A 69-year-old woman wanted fixed rehabilitation to replace her removable complete dentures. A cone-beam computed tomography showed significant bone resorption in both the maxillary and mandibular regions. The plan was to load the entire upper arch with six implants immediately, while removable partial dentures were recommended for the lower jaw. The guided surgery project was aligned with the new dentures, and the laboratory created a printed cast with dental implant analogues in planned positions. A metal-reinforced denture was constructed, and surgery was performed to place six narrow implants using the magneto-dynamic instrument. The denture was directly screwed onto multi-unit abutments. Final rehabilitation was completed after 6 months. Narrow implants can be a good option for fixed, full-arch rehabilitations. Further research is needed to confirm these findings on a larger scale.

Multidrug-Resistant Bacterial Colonization and Infections in Large Retrospective Cohort of Mechanically Ventilated COVID-19 Patients1.

Few data are available on incidence of multidrug-resistant organism (MDRO) colonization and infections in mechanically ventilated patients, particularly during the COVID-19 pandemic. We retrospectively evaluated all patients admitted to the COVID-19 intensive care unit (ICU) of Hub Hospital in Milan, Italy, during October 2020‒May 2021. Microbiologic surveillance was standardized with active screening at admission and weekly during ICU stay. Of 435 patients, 88 (20.2%) had MDROs isolated ≤48 h after admission. Of the remaining patients, MDRO colonization was diagnosed in 173 (51.2%), MDRO infections in 95 (28.1%), and non-MDRO infections in 212 (62.7%). Non-MDRO infections occurred earlier than MDRO infections (6 days vs. 10 days; p<0.001). Previous exposure to antimicrobial drugs within the ICU was higher in MDRO patients than in non-MDRO patients (116/197 [58.9%] vs. 18/140 [12.9%]; p<0.001). Our findings might serve as warnings for future respiratory viral pandemics and call for increased measures of antimicrobial stewardship and infection control.

Risk factors for intubation in severe bronchiolitis: a useful tool to decide on an early intensive respiratory support.

BACKGROUND: Bronchiolitis is the most frequent lower airway infection leading hospitalization in children younger than 2 years. RSV is the typical common cause, followed by rhinovirus. Criteria for Pediatric Intensive Care Unit (PICU) admission are not defined by guidelines. METHODS: A retrospective analysis of children with severe bronchiolitis admitted from 2013 to 2016 to our PICU was performed to identify the risk factors associated with intubation in this population. Fourteen variables were studied: sex, weight, age, nationality, provenience, duration of symptoms, risk factors for bronchiolitis development, recurrence, apnea, SpO2 in air, Modified Wood's Clinical Asthma score (M-WCAS), microbiological results, medical treatment, CPAP therapy. The relationship between these variables and the need for mechanical ventilation were explored using univariate and multivariate logistic regression analysis. A ROC analysis was used to identify cut-off for the continuous variables identified as risk factors for intubation in multivariate analysis. RESULTS: We enrolled 93 patients: 19 of them (20.4%) were intubated. Univariate and multivariate analysis demonstrated that a M-WCAS Score ≥7, SpO2 ≤75% and apnea were significantly associated to intubation in children with severe bronchiolitis. CONCLUSIONS: Cut-off values of the variables identified as risk factors for intubation may represent an important tool for pediatricians to decide a prompt and appropriate intensive respiratory support.

Comment on Kesic et al. Early Diagnostics of Vulvar Intraepithelial Neoplasia. Cancers 2022, 14, 1822.

We have read with great interest the paper by Kesic, V. et al. entitled "Early Diagnostics of Vulvar Intraepithelial Neoplasia" [...].

Dissemination of patient blood management practices in Swiss intensive care units: a cross-sectional survey.

BACKGROUND: Patient blood management (PBM) promotes the routine detection and treatment of anaemia before surgery, optimising the management of bleeding disorders, thus minimising iatrogenic blood loss and pre-empting allogeneic blood utilisation. PBM programmes have expanded from the elective surgical setting to nonsurgical patients, including those in intensive care units (ICUs), but their dissemination in a whole country is unknown. METHODS: We performed a cross-sectional, anonymous survey (10 October 2018 to 13 March 2019) of all ordinary medical members of the Swiss Society of Intensive Care Medicine and the registered ICU nurses from the 77 certified adult Swiss ICUs. We analysed PBM-related interventions adopted in Swiss ICUs and related them to the spread of PBM in Swiss hospitals. We explored blood test ordering policies, blood-sparing strategies and red blood cell-related transfusion practices in ICUs. RESULTS: A total of 115 medical doctors and 624 nurses (response rates 27% and 30%, respectively) completed the surveys. Hospitals had implemented a PBM programme according to 42% of physicians, more commonly in Switzerland's German-speaking regions (Odds Ratio [OR] 3.39, 95% confidence interval [CI] 1.23-9.35; p = 0.018) and in hospitals with more than 500 beds (OR 3.91, 95% CI 1.48-10.4; p = 0.006). The PBM programmes targeted the detection and correction of anaemia before surgery (79%), minimising perioperative blood loss (94%) and optimising anaemia tolerance (98%). Laboratory tests were ordered in 70.4% by the intensivist during morning rounds; the nurses performed arterial blood gas analyses autonomously in 48.4%. Blood-sparing techniques were used by only 42.1% of nurses (263 of 624, missing: 6) and 47.0% of physicians (54 of 115). Approximately 60% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin threshold for the nonbleeding ICU population was 70 g/l and, therefore, was at the lower limit of current guidelines. CONCLUSIONS: Based on this survey, the estimated proportion of the intensivists working in hospitals with a PBM initiative is 42%, with significant variability between regions and hospitals of various sizes. The risk of iatrogenic anaemia is relevant due to liberal blood sample collection practices and the underuse of blood-sparing techniques. The reported transfusion threshold suggests excellent adherence to current international ICU-specific transfusion guidelines.

Cutaneous immune-related adverse events and photodamaged skin in patients with metastatic melanoma: could nicotinamide be useful?

Cutaneous immune-related adverse events (irAEs) occur in more than one-third of patients treated with immune checkpoint inhibitors; they are often the first clinical manifestation, although they may occur months after initiation of therapy. We noticed that our patients usually have these cutaneous AEs on photodamaged skin. In fact, out of 19 patients being treated for metastatic melanoma, 8 (42%), all of whom had significant cutaneous actinic damage, developed cutaneous irAEs earlier and in a more serious form than those without such damage. Thus, we gave a high oral dose of nicotinamide (500 mg twice daily) to the patients with metastatic melanoma who had photodamaged skin, and continued this for the entire duration of the immunotherapy. The appearance of the first signs of cutaneous irAEs was 180 days after starting therapy in nicotinamide-treated patients, compared with 65 days for patients not treated with nicotinamide.

Atypical Spitz tumours: an epidemiological, clinical and dermoscopic multicentre study with 16 years of follow-up.

BACKGROUND: Atypical Spitz tumours (ASTs) are regarded as an intermediate category distinguished from prototypical Spitz naevus by presenting one or more atypical features and often by an uncertain malignant potential. Clinical and dermoscopic features may play a relevant role in the diagnostic approach. AIM: To evaluate the clinical and dermoscopic features of ASTs, and their evolution over time. METHODS: This was a descriptive, multicentre study of the clinical and dermoscopic characteristics of ASTs. Data on clinical and dermoscopic characteristics, histopathology, local extension, therapy and follow-up, lymph node staging, complete lymph node dissection, and outcome were collected from the databases of four Italian Dermatology Units for the period 2004-2021. RESULTS: The study population consisted of 99 patients (62 female, 37 male) with a histologically confirmed diagnosis of AST, including age at presentation ranged from 2 to 70 years (mean 28.1 years, median 24 years). Of the 99 patients, 29 (29.3%) underwent sentinel lymph node biopsy, which showed evidence of micrometastases in three cases (10.3%); all three patients underwent complete lymph node dissection with no evidence of further metastasis. Considering the whole study population, the clinical outcome was excellent, as all of the patients have no evidence of recurrence or distant metastasis. The follow-up period ranged from 6 to 216 months (mean 81.6 months, median 78 months). In addition, we collected data on the clinical and dermoscopic features of 26 lesions. The most frequent dermoscopic pattern observed was the multicomponent pattern (34.6%), followed by homogeneous (26.9%) and nonspecific (23.2%). In 66.7% of amelanotic ASTs, we observed glomerular (coiled) vessels uniformly distributed within the entire lesion, without asymmetry. CONCLUSION: The results of our study with a long follow-up show no recurrence or distant metastases, confirming the good clinical outcome, even in the case of sentinel lymph node positivity. From a diagnostic point of view, our series identified a typical dermoscopic picture for amelanotic ASTs, with a glomerular vascular pattern throughout the lesion in the absence of other dermoscopic parameters, making the correct diagnosis possible.

Roughness and SEM Analysis of Manual and Ultrasonic Instrumentation over Different Crown Materials for Dental Implants Restorations.

The use of new prosthetic materials makes it necessary to establish adequate hygienic protocols. It was decided to make prosthetic crowns from four different materials: composite, lithium disilicate, metal ceramic, and zirconium, and to evaluate the effects on the surfaces of four different instruments through SEM and roughness analysis: manual steel curette, manual titanium curette, ultrasonic steel insert, and ultrasonic peek insert. Forty crowns were made, ten of each type of material. For each material, five crowns were manually instrumented with steel inserts (curette 11-12, PDT, Missoula, MT, USA) and titanium (Wingrove 3-4, PDT, Missoula, MT, USA) on the lingual and buccal surfaces, respectively, and the other five crowns were instrumented with an ultrasonic peek insert (ICS-IC1, Mectron, Carasco, Italy) on the buccal surface and steel (PS, EMS, Nyon, Switzerland) on the lingual surface. At this point, surface roughness analysis was carried out. The data were analyzed with a Kolmogorov-Smirnov test. Therefore, it was decided to conduct two analyses with a Kruskal-Wallis test and Bonferroni post hoc test. Then, the instrumented crowns were analyzed by SEM. The analysis of the data shows that the highest average roughness was within the composite group, while the best material appeared to be disilicate. Significant differences existed between the groups, between the materials, and between the different instruments (p-value < 0.05). In the qualitative analysis carried out by SEM, the classic steel insert eliminated the residues of golden finishing. The peek insert created alterations on all tested surfaces. The steel curette did not create particular problems, with the exception of zirconium, where it was possible to observe some scratch lines. Instrumentation with the titanium curette created deeper incisions than the steel curette in the composite and disilicate. The best results came from the ultrasonic steel insert, while the best material appeared to be disilicate.

Biomolecular, Histological, Clinical, and Radiological Analyses of Dental Implant Bone Sites Prepared Using Magnetic Mallet Technology: A Pilot Study in Animals.

BACKGROUND: A new instrumentation exploiting magneto-dynamic technology (mallet) proposed for implant site preparation was investigated. METHODS: In the tibias of three minipigs, two sites were prepared by mallet and two by drill technique. Primary stability (ISQ) was detected after implant positioning (T0) and at 14 days (T14). X-rays and computed tomography were performed. At T14, bone samples were utilized for histological and biomolecular analyses. RESULTS: In mallet sites, histological evaluations evidenced a significant increase in the newly formed bone, osteoblast number, and a smaller quantity of fibrous tissue. These results agree with the significant BMP-4 augmentation and the positive trend in other osteogenic factors (biological and radiological investigations). Major, albeit IL-10-controlled, inflammation was present. For both techniques, at T14 a significant ISQ increase was evidenced, but no significant difference was observed at T0 and T14 between the mallet and drill techniques. In mallet sites, lateral bone condensation was observed on computed tomography. CONCLUSIONS: Using biological, histological, clinical, and radiological analyses, this study first shows that the mallet technique is effective for implant site preparation. Based on its ability to cause osseocondensation and improve newly formed bone, mallet technology should be chosen in all clinical cases of poor bone quality.

SARS-CoV-2 RNA in plasma samples of COVID-19 affected individuals: a cross-sectional proof-of-concept study.

BACKGROUND: Recent studies showed that plasma SARS-CoV-2 RNA seems to be associated with worse COVID-19 outcome. However, whether specific population can be at higher risk of viremia are to date unexplored. METHODS: This cross-sectional proof-of-concept study included 41 SARS-CoV-2-positive adult individuals (six affected by haematological malignancies) hospitalized at two major hospital in Milan, for those demographic, clinical and laboratory data were available. SARS-CoV-2 load was quantified by ddPCR in paired plasma and respiratory samples. To assess significant differences between patients with and patients without viremia, Fisher exact test and Wilcoxon test were used for categorical and continuous variables, respectively. RESULTS: Plasma SARS-CoV-2 RNA was found in 8 patients (19.5%), with a median (IQR) value of 694 (209-1023) copies/mL. Viremic patients were characterized by an higher mortality rate (50.0% vs 9.1%; p = 0.018) respect to patients without viremia. Viremic patients were more frequently affected by haematological malignancies (62.5% vs. 3.0%; p < 0.001), and had higher viral load in respiratory samples (9,404,000 [586,060-10,000,000] vs 1560 [312-25,160] copies/mL; p = 0.002). CONCLUSIONS: Even if based on a small sample population, this proof-of-concept study poses the basis for an early identification of patients at higher risk of SARS-CoV-2 viremia, and therefore likely to develop severe COVID-19, and supports the need of a quantitative viral load determination in blood and respiratory samples of haematologic patients with COVID-19 in order to predict prognosis and consequently to help their further management.

Detection and quantification of SARS-CoV-2 by droplet digital PCR in real-time PCR negative nasopharyngeal swabs from suspected COVID-19 patients.

Since SARS-CoV-2-based disease (COVID-19) spreads as a pandemic, the necessity of a highly sensitive molecular diagnosis that can drastically reduce false negatives reverse transcription PCR (rtPCR) results, raises as a major clinical need. Here we evaluated the performance of a ddPCR-based assay to quantify SARS-CoV-2 titer in 55 suspected COVID-19 cases with negative rtPCR results thanks to in-house ddPCR assay (targeting RdRp and host RNaseP). Samples were collected at ASST-GOM Niguarda between February and May 2020 at hospital admission. Clinical and imaging data were obtained for clinical staging and definition of disease severity. Patients were mainly female (45.5%) with a median age of 73 (57-84) years. ddPCR-based assay detected SARS-CoV-2 genome in nasopharyngeal samples of 19 (34.5%) patients (median viral-load: 128 copies/mL, IQR: 72-345). In 15 of them (78.9%), chest CT showed a classical COVID-19 bilateral interstitial pneumonia; 14 patients (73.7%) showed severe COVID-19 manifestations. ddPCR did not identify any trace of SARS-CoV-2 genome in the respiratory samples of the remaining 36 patients. The serological assay performed in a subgroup of 34 patients at the later stage of illness (from 3 days to 90 days after) confirmed the presence of SARS-CoV-2 antibodies in all patients tested positive for SARS-CoV-2 in ddPCR (100%). Contrariwise, negative tests were observed in 95.0% ddPCR negative patients (P<0.001). Thanks to a ddPCR-based assay, we achieved a rapid and accurate SARS-CoV-2 diagnosis in rtPCR-negative respiratory samples of individuals with COVID-19 suspect, allowing the rapid taking care and correct management of these patients.

Detection of strong inspiratory efforts from the analysis of central venous pressure swings: a preliminary clinical study.

BACKGROUND: Swings of central venous pressure (ΔCVP) may reflect those of pleural and esophageal (ΔPES) pressure and, therefore, the strength of inspiration. Strong inspiratory efforts can produce some harm. Herein we preliminarily assessed the diagnostic accuracy of ΔCVP for strong inspiratory efforts in critically-ill subjects breathing spontaneously. METHODS: We measured ΔCVP and ΔPES in 48 critically-ill subjects breathing spontaneously with zero end-expiratory pressure (ZEEP) or 10 cmH2O of continuous positive airway pressure (CPAP). The overall diagnostic accuracy of ΔCVP for strong inspiratory efforts (arbitrarily defined as ΔPES >8 mmHg) was described as the area under the receiver operating characteristic (ROC) curve, with 0.50 indicating random guess. The agreement between ΔCVP and ΔPES was assessed with the Bland-Altman analysis. RESULTS: ΔCVP recognized strong inspiratory efforts with an area under the ROC curve of 0.95 (95% confidence intervals, 0.85-0.99) with ZEEP and 0.89 (0.76-0.96) with CPAP, both significantly larger than 0.50 (P<0.001). With the best cut-off value around 8 mmHg, the diagnostic accuracy of ΔCVP was 0.92 (0.80-0.98) with ZEEP and 0.94 (0.83-0.99) with CPAP. With ZEEP, the median difference between ΔCVP and ΔPES (bias) was -0.2 mmHg, and the 95% limits of agreement (LoA) were -3.9 and +5.5 mmHg. With CPAP, bias was -0.1 mmHg, and 95%-LoA were -5.8 and +4.5 mmHg. In both cases, ΔCVP correlated with ΔPES (rs 0.81 and 0.67; P<0.001 for both). CONCLUSIONS: In critically-ill subjects breathing spontaneously, ΔCVP recognized strong inspiratory efforts with acceptable accuracy. Even so, it sometimes largely differed from ∆PES.

Quantification of 1,3-ß-d-glucan by Wako ß-glucan assay for rapid exclusion of invasive fungal infections in critical patients: A diagnostic test accuracy study.

OBJECTIVES: Rapid and reliable exclusion of invasive fungal infections (IFI) by markers able to avoid unnecessary empirical antifungal treatment is still a critical unmet clinical need. We investigated the diagnostic performance of a newly available ß-d-Glucan (BDG) quantification assay, focusing on the optimisation of the BDG cut-off values for IFI exclusion. METHODS: BDG results by Wako ß-glucan assay (lower limit of detection [LLOD] = 2.16 pg/mL, positivity ≥ 11 pg/mL) on two consecutive serum samples were retrospectively analysed in 170 patients, admitted to haematological wards (N = 42), intensive care units (ICUs; N = 80), or other wards (N = 48), exhibiting clinical signs and/or symptoms suspected for IFI. Only patients with proven IFI (EORTC/MSG criteria) were considered as true positives in the assessment of BDG sensitivity, specificity and predictive values. RESULTS: Patients were diagnosed with no IFI (69.4%), proven IFI (25.3%) or probable IFI (5.3%). Two consecutive BDG values < LLOD performed within a median of 1 (interquartile range: 1-3) day were able to exclude a proven IFI with 100% sensitivity and negative predictive value (primary study goal). Test's specificity improved by using two distinct positivity and negativity cut-offs (7.7 pg/mL and LLOD, respectively), but remained suboptimal in ICU patients (50%), as compared to haematological or other patients (93% and 90%, respectively). CONCLUSIONS: The classification of Wako's results as negative when < LLOD, and positive when > 7.7 pg/mL, could be a promising diagnostic approach to confidently rule out an IFI in both ICU and non-ICU patients. The poor specificity in the ICU setting remains a concern, due to the difficulty to interpret positive results in this fragile population.

Pulp vitality during ultrasonic tooth preparation. Part 2.

BACKGROUND: Ultrasonic devices have a lot of dental application specially in hygiene and surgery. However there are some disadvantages like cut slowness and heat production. Prosthodontics application is less investigated. In particular the heat production could be an important factor for the clinician. In fact more than 5.5 °C temperature increasing could determine pulp necrosis during tooth preparation. The aim of this study is to investigate the increasing of temperature during finishing line repositioning and polishing phases using ultrasounds inserts and to verify if it remains within the limit of 5.5 °C. METHODS: A sample of 32 human molars (extracted for periodontal reasons) was selected. The teeth were endodontically treated and prepared with burs in order to obtain a prosthetic round chamfer preparation, leaving the apical portion pervious for inserting the thermocouple probe. Then, they were inserted in plaster cubes up to the cement-enamel junction. A wall has been selected for each tooth for margin repositioning and finishing and prepared with the piezoelectric instrument (Multipiezo Touch with TipHolder DB2, Mectron, Carasco, Genoa, Italy). A mechanical arm was used to standardize the operator-dependent parameters. These parameters were: the pressure exerted on the dental wall, the cutting length and the time required for margin repositioning and finishing. The test phase consisted in a first stage of margin repositioning using an regular ultrasound tip with a diamond grain of 120 micron (DB120, Mectron, Carasco, Italy) (group 1), followed by a second finishing step conducted by a extra fine ultrasound tip with a diamond grain of 60 micron (DB60, Mectron, Carasco, Italy) (group 2). Each test lasted 60 seconds: this was the time that the mechanical arm needed to accomplish 32 rides. During these stages the intrapulpal temperature has been recorded thanks to a thermocouple. The obtained temperature data were analyzed by Kruskal-Wallis test and Mann-Withney post-hoc test, without Bonferroni correction (P<0.001). RESULTS: The average pulpal temperature increase was 4.65 °C with a standard deviation of 0.99 °C for the DB 120 ultrasonic tip and 5.40 °C with a standard deviation of 0.84 °C for the DB 60 ultrasonic tip. However, neither of the instruments reach the medium critical level of 5.5°C reported in the literature, there are some single values who exceed it. There is statistically significant difference using tips with different granulometries within the two groups (P value =0.013). CONCLUSIONS: Ultrasonic tools are very performing to achieve results in repositioning and polishing of prepared tooth. The in-vitro analysis show that the pulp temperature increasing remains within the safe limits literature shows. It is important underline the polishing phase is the most critical and the clinicians have to pay attention to irrigation and pression to avoid pulp damages. Additional clinical studies have to be performed to confirm these results.

Clinical osseointegration of bone level implants with conical shape and textured surface with low primary stability.

BACKGROUND: Evidence shows lower chance for osseointegration of implants without sufficient primary stability. The present retrospective study observed bone level conical screw implants with textured surface without primary stability. METHODS: Twenty-six Stark conical screw implants, with V-Blast (Vanish Blast) surface treatment were placed with low primary stability, (insertion torque lower than 10 N/cm and visible mobility at lateral load of 250 g). A soft diet was prescribed. osseointegration was assessed applying 30 Ncm of reverse torque 6 months after placement. RESULTS: The 26 implants that did not achieve primary stability still had a survival rate of 96% after the observation period and were classified as successful according with ICOI Pisa consensus conference success, survival, failure classification .96% of the implants showed clinical osteointegration and were successfully restored. After 12 months, all implants remained functional. CONCLUSIONS: It can be concluded that bone-level implants with V-Blast surface in absence of functional loading are able to achieve osteointegration, even with low primary stability.

Temperature variations in pulp chamber: an in-vitro comparison between ultrasonic and rotating instruments in tooth preparation. Part 1.

BACKGROUND: The purpose of this study was to analyze pulpal temperature increase generated by prosthodontic margin repositioning and finishing with ultrasonic and rotating instruments. The temperature changes recorded were also correlated with the residual dentin thickness. METHODS: A sample of 32 human extracted molars was selected. The teeth were endodontically treated and prepared with prosthetic round chamfer preparation. Then, they were inserted in plaster cubes up to the cement-enamel junction, leaving the apical portion pervious for inserting the thermocouple probe. The conventional technique, which involves the use of a high-speed contra-angle handpiece, was compared with an ultrasonic method (Crown Prep, Mectron, Carasco, Italy). For margin repositioning and finishing, two walls were randomly selected for each tooth: one was included in the test group and cut with the piezoelectric instrument (Multipiezo Touch TipHolder DB2, Mectron, Carasco, Genoa, Italy), the other one was inserted in the control group and cut with the high speed contra-angle handpiece (Kavo, Biberach, Germany). To standardize the operator-dependent parameters, it was used a mechanical arm controlled by a computer. These parameters were the pressure exerted on the dental wall, the cutting length and the time required for margin repositioning and finishing. For both test and control group, test phase consisted in a first stage of margin repositioning using an ultrasound tip or a diamond bur with a greater granulometry (120 µm for the ultrasound tip and 125 µm for the diamond bur), followed by a second finishing step conducted by an ultrasound tip or a diamond bur with smaller granulometry (60 µm for the ultrasound tip and 30 µm for the diamond bur). During these stages the intrapulpal temperature was recorded thanks to a thermocouple. Before and after these steps, the thickness of the remaining dental walls was measured with a caliber. RESULTS: The average pulpal temperature increase was 5.03±0.98 °C for the ultrasonic preparation (test group) and 3.55±0.95 °C for the conventional technique (control group). The difference was statistically significant (P value <0.001). However, neither of the instruments reached the critical level of 5.5 °C reported in the literature. The mean initial dentin thicknesses was 1.82±0.47 mm for the control group and 1.59±0.54 mm for the test group but the analysis of the residual dentin thicknesses revealed a greater reduction of the walls worked up with high speed contra-angle handpiece (mean 0.9±0.5 mm), which was therefore more aggressive than the ultrasonic instrument (mean 1.1±0.5 mm). A very weak negative correlation was present between the thickness of the wall at baseline and the increment of temperature. CONCLUSIONS: Within limitations of this study, temperature increasing of ultrasonic instruments shows a statistical difference related to rotary ones. But, as literature shows, the ultrasonic advantages are margin precision, preservation of soft tissues and reduction of operating times. Furthermore, in relation with results of this study, they could be considered safe for pulp vitality because the increase in pulpal temperature is similar to traditional instruments and it does not exceed the critical level of 5.5 °C.

Malnutrition and Perioperative Nutritional Support in Retroperitoneal Sarcoma Patients: Results from a Prospective Study.

INTRODUCTION: Retroperitoneal soft tissue sarcomas (RPSs) are mesenchymal neoplasms. The prevalence of protein energetic malnutrition (PEM) and its impact in RPS patients who were candidates for surgery is unknown. MATERIALS AND METHODS: A prospective feasibility study enrolled 35 patients with primary RPS who were candidates for extended multivisceral resection. PEM was screened at enrollment. Preoperative high protein ß-hydroxy-ß-methyl butyrate oral nutritional support (ONS) was provided according to the degree of PEM. After surgery, nutritional support followed standard practice, targeting at least 1 g/kg/day protein and 20 kcal/kg/day caloric intake within the third postoperative day (POD). PEM was re-evaluated before surgery on POD 10, and at 4 and 12 months after surgery. Primary outcomes were the patient's compliance to preoperative ONS and the physician's compliance to postoperative nutritional targets. RESULTS: PEM was documented in 46% of patients at baseline; ONS met a 91% adherence (overall well tolerated). After ONS, PEM reduced to 38% (p = 0.45). The postoperative caloric target was reached on day 4.1 (standard error ± 2.7), with a protocol adherence rate of 52%. On POD 10, 91% of patients experienced PEM, the worsening of which was greater after resection of four or more organs (p = 0.06). At 4 and 12 months after surgery, almost all patients had fully recovered. A significant correlation between PEM at surgery and postoperative complications was found (p = 0.04). CONCLUSIONS: Relevant PEM prevalence in RPS is documented for the first time. PEM correlates with greater morbidity. In this setting, preoperative ONS was feasible and well-tolerated. Disease-related factors for PEM and the ideal perioperative caloric target in the context of extended multivisceral resection need to be further investigated. Nutritional support should be included in enhanced recovery after surgery programs for RPS. TRIAL REGISTRY: ClinicalTrials.gov identifier: NCT03877588.