Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique.

Nowadays, upper denture instability secondary to severe maxillary atrophy is treated, in most cases, with dental implants. However, a significant number of patients cannot afford this procedure. Palatal bone deepening through a U-shaped osteotomy has been described previously. The procedure increases retention by improving the suction effect of the palate and prevents anteroposterior and lateral movement of the denture. By combining this procedure with a secondary epithelialization vestibuloplasty, the labial aspect of the ridge is also extended and it does not require a skin graft. This article describes a modification of the palatal vault osteotomy through the presentation of a case.

[Quadrivalent meningococcal conjugate vaccine]. / Vaccin quadrivalent conjugué contre la méningite.

Meningoccocal meningitis is still a severe disease. In Switzerland the predominant serotypes are serotype B and C, but this could change as other groups predominate elsewhere. The indications for immunizing against meningococcal infections as described in the Swiss recommendations will be reviewed. New quadrivalent vaccines conjugated with a protein and efficient against serogroup ACWY will soon be available in our country. They show a number of advantages in term of type of protection and should simplify the current vaccination schedule while giving a better coverage against various serogroups, especially for travellers, but also for children at risk for complications.

[Tuberculosis detection and immunization of long-term travellers]. / Vaccins pour les longs séjours et tuberculose chez les voyageurs.

Reasons why long-term travel (> or =3 months) increases health risks are many, but mainly related to travellers' behaviour. On top of immunizations proposed to all travellers, those against hepatitis B, rabies and typhoid fever should be encouraged, but require time and money. Some vaccines like meningococcal vaccine and japanese encephalitis need to be discussed according to the destination. Tuberculosis is a rare disease in travellers in general but the incidence in health care workers reaches the one of the local population at risk, and therefore tuberculosis detection is recommended.

[Security and travel]. / Sécurité et voyages.

Hijacking, crime, aggression and theaft when people travel abroad are regularly reported by the media. This increases travellers' fears. As there is little research that quantifies risks, subjectivity and preconceived ideas prevail. A survey done among travellers in Geneva, Lausanne and Lyon showed that the risk of incidents was lower in countries located outside of Europe, usually in cities. Most frequently it was baggage stealing, or stealing in the street, during the day. In Europe, stealing by breaking into cars was most frequent. Without becoming paranoid about aggression and burglary, some simple rules can be followed. Keep constant situational awareness, be respectful of the people in countries visited, avoid provocative attitudes and avoid insecure areas.

[Immunization against yellow fever]. / Vaccination contre la fièvre jaune.

Yellow fever is a potentially epidemic arboviral disease, submitted to the international health regulation. The disease is severe but rare in travellers. Immunization protects the individual and prevents transmission to non immune populations. Neurological side effects of the vaccine are rare and already known. More recently severe systemic side effects have been reported, with a seemingly age increasing incidence (1,8/100,000 in the over 60 years old). They seem related to host immunity rather than to an increased virulence of the vaccines. The indication and contra indications to the vaccine must be followed strictly according to the benefit/side effects ratio and to the epidemiology.

[Diarrhea and vaccines: current developments]. / Diarrhées et vaccins: morceaux choisis.

Diarrhoea is a main concern for travellers, populations of developing countries and children. Causative pathogens are numerous. An efficient vaccine against cholera is available, also offering a 50% cross-protection against E. Coli enterotoxin (ETEC), however its efficacy is only 23% against all-causes traveller's diarrhoea. Rotavirus can be responsible for severe diarrhoea in infants but rarely causes traveller's diarrhoea. Two new vaccines being under development appear effective and well-tolerated but too expensive for developing countries which most need them. To date, the live oral Ty21a vaccine remains frequently prescribed in Switzerland, with limited indications and suboptimal efficacy. A new oral vaccine is under development.

Evaluation of an inference-based approach to treating obsessive-compulsive disorder.

This study evaluated an inference-based approach (IBA) to the treatment of obsessive-compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. "Maybe the door is open", "My hands could be dirty") as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty-four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y-BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.

[Neutropenia in a patient treated with clozapine in combination with other psychotropic drugs]. / Neutropénie chez un patient traité avec la clozapine dans le contexte d'une polypharmacie.

Clozapine is an atypical antipsychotic known for its efficacy in refractory schizophrenia. However, according to different epidemiological studies clozapine can induce neutropenia in less than 3% of patients and may represent a major problem for the management of treatment-resistant patients not responding to conventional or other atypical antipsychotics. Recently, a few case of neutropenia have been reported following the addition of other medications to clozapine, notably paroxetine, risperidone, trimethoprim-sulfamethoxazole and erythromycin. In our report we present the case of Mr A., a 40-year-old Caucasian patient with a 20-year history of paranoid schizophrenia. After numerous trials with conventional antipsychotics, partial remission of psychotic symptoms was obtained with clozapine. Over the past eight years during his treatment with clozapine, the patient presented 2 episodes of neutropenia. The first episode came five years after starting clozapine and was attributed to the addition 6 weeks earlier of haloperidol (2 mg/day) to clozapine (250 mg/day) and divalproex (1,500 mg/day). Recently, one week after the addition of risperidone (2 mg/day) to clozapine (550 mg/day), leukocytes count dropped from 12 100/mm(3) to 5 700/mm(3) and neutrophils from 7 400/mm(3) to 900/mm(3). The patient was also taking haloperidol (4 mg/day), methotrimeprazine (35 mg/day), procyclidine (5 mg/day) and valproic acid (1,500 mg/day). Twelve days after discontinuation of risperidone, leukocytes and neutrophils count increased to 11,100/mm(3) and 6,300/mm(3) respectively while the treatment with clozapine was continued. The first eighteen weeks of treatment represent the period where the risk of neutropenia is the highest. In our patient neutropenia occurred 5 and 7 years after starting clozapine. It is proposed that the two neutropenic episode were precipitated by adding respectively haloperidol and risperidone to clozapine. Also, divalproex can potentially cause a decrease in white blood cell count and may have contributed to the two neutropenic episode. It is suggested that drug interactions may be responsible for neutropenia in clozapine treated patients and that clozapine should not necessarily be discontinued in the presence of neutropenia. Also we propose that hematological surveillance should be done on a weekly basis for 4 to 6 weeks following the addition of psychotropic drugs known for their potential to cause neutropenia when associated with clozapine. Therefore polypharmacy may contribute to cause neutropenia in clozapine treated patients and that discontinuation of an antipsychotic should be done before introducing another one.

Arteriovenous malformation of the mandible: review of literature and case history.

Vascular malformations of the jaws can lead to disastrous complications, but there seems to be no consensus as to their treatment. The literature presents the pathophysiology and clinical aspects of these lesions, as well as the divergent views of the authors. Treatment by catheterization and embolization, with direct transosseous injection of cyanoacrylate, appears to be the least harmful and most permanent treatment in certain conditions, as evidenced by the case of this 9-year-old patient having a high-flow mandibular vascular malformation

Inactivated hepatitis A vaccine booster given >/=24 months after the primary dose.

We investigated what happens with the immune response when people come back for their booster dose of inactivated hepatitis A vaccine later than the recommended time of 6-12 months after the primary dose. We recruited a group of 124 travellers who received either the primary doses of Havrix 720 (two doses) or of Havrix 1440 (one dose) >/=24 months before study entry. They received a booster dose of Havrix 1440 and blood was drawn 1 month later. As a control group, we recruited a group of 125 travellers who followed a recommended schedule with a primary dose at month 0 and a booster dose at months 6-12. For both study groups, the GMTs increased dramatically and similarly upon the booster immunisation. Although significantly more late travellers (32%) had lost detectable antibodies than controls (11%) before administration of the booster dose, all these subjects showed an anamnestic response to the booster dose. Delaying the booster dose up to 66 months after primary vaccination did not seem to influence the immunogenicity of the booster dose. However, the recommended 6-12-month interval remains if detectable antibody titers are to be warranted constantly.

Effect of soft-tissue trauma on the early periosteal response of bone to injury.

OBJECTIVE: To determine whether the periosteal response to skeletal trauma is impaired when muscle is also injured, thereby providing a possible explanation for why fractures with extensive soft-tissue damage may take longer to heal. METHODS: A bone defect was made in the tibia of male Fisher rats, and the proliferative response, osteoblast concentration, and callus formation that occurred within 7 days were measured in the presence and absence of simultaneously administered model soft-tissue injury (removal of 10% of the anterior tibialis muscle from a region within 2 to 3 mm of the bone defect). Measurements were made by using autoradiography, quantitative histology, and morphometry. RESULTS: Addition of the muscle injury increased proliferation in the cambium and in the fibrous periosteum on day 1, but had no effect thereafter; proliferation of fibroblasts in the loose connective tissue above the periosteum was not affected. Addition of the muscle injury resulted in increased osteoblast levels 2 to 5 days after injury but had no effect on the amount of callus produced. CONCLUSION: The inflammatory milieu created by the muscle injury unexpectedly resulted in an increased periosteal response to skeletal trauma, suggesting that inflammatory mediators generated in response to wounding of soft tissues are unlikely to account for delayed fracture healing. These findings may indicate that surgical trauma associated with internal fixation by using plates and screws may not be as deleterious to the fracture-healing response as previously thought.

Programmed cell death in post-traumatic bone callus.

Some osteoblasts in the expanded population of periosteal cells that occurs following bone injury are removed from the callus by apoptosis. Our objective was to study whether the consequences of activation of the death program could include feedback control of the healing response. Transforming growth factor beta and interleukin-1beta were delivered together continuously to a standardized tibial defect in rats for 3 days using implanted micro-osmotic pumps. The bones were recovered at 1, 2, 3, 5, 7, 10 and 14 days after injury (n = 6 in each treated and control group) and concentrations of proliferating cells, osteoblasts and apoptotic bodies were determined. The injury-induced apoptotic component of the healing response was shifted in time due to the combined cytokines, compared with vehicle only, with the result that the peak in the concentration of apoptotic bodies occurred 2-3 days earlier in the treated animals. Neither osteoprogenitor proliferation nor osteoblast concentration was affected by addition of the cytokines. The results suggested that activation of apoptosis during injury repair was not necessarily a passive consequence of the cellular response to injury. Programmed cell death could therefore have an active role in modulating bone repair.

Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures.

BACKGROUND: The submental route for endotracheal intubation has been proposed as an alternative to tracheotomy in the surgical management of patients with maxillofacial trauma. The purpose of this study was to review our experience with this procedure. METHODS: Medical records of 25 patients who had surgical reduction of midfacial or panfacial fractures while securing their airway with submental intubation were reviewed. After standard orotracheal intubation, a passage was created by blunt dissection with a hemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed with minimal interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. RESULTS: Mean duration of surgery was 7.9 hours (range, 2-16 hours). Mean duration of postoperative mechanical ventilation was 5.2 days (range, 1-24 days). Fourteen of these patients required prolonged (>24 hours) postoperative mechanical ventilation because of associated injuries. Two patients later required a tracheotomy because of prolonged respiratory failure. One patient died of multiple organ failure. One complication of the submental intubation was observed: a superficial infection of the submental wound. CONCLUSION: Submental intubation is a simple technique associated with a low morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of maxillofacial trauma.

Compliance to live oral Ty21a typhoid vaccine, and its effect on viability.

BACKGROUND: Concerns have been expressed that in travelers the efficacy of the live oral Ty21a typhoid vaccine Vivotif could be lower than reported, maybe due to a lack of compliance. The purpose of this study was to examine the level of compliance with the recommendations regarding dosing, timing of dosing with respect to food intake, and storage. METHODS: Travelers were randomized into two groups: one received oral information only, and the second, a combination of oral and written information. Four criteria of compliance were applied to travelers: 3 capsules needed to be swallowed (criterion 1) on day 1, 3 and 5 (criterion 2), at least 1 hour before or 2 hours after a meal (criterion 3) and the vaccine had to be kept refrigerated (2-8 degrees C) (criterion 4). Compliance was evaluated using three different methods: a questionnaire, pill counting, and electronic monitoring using the Medication Event Monitoring System (MEMS). Storage conditions were checked by temperature tags, and viability of the vaccine was assessed by culturing the content of remaining capsules. RESULTS: The data of 115 travelers were analyzed. All the travelers took the 3 capsules. Compliance to all four criteria was complete in 68% of travelers according to the questionnaire, and 53% according to the MEMS (p =.05). Sixty-seven percent of all the doses intervals were of 48 hours +/- 6 hours, 12% being shorter than 36 hours and 7% longer than 60 hours. Eighty-seven travelers (76%) took their capsules on each alternate day. The method of information had no significant impact on compliance. Forty-two percent of tags showed exposure to temperature over 10 degrees C for more than 24 hours. Yet, no difference could be found in the viability of the vaccine compared with controls. CONCLUSIONS: Most travelers take their 3 capsules on alternate days, but many did not follow the other recommendations. Electronic monitoring of compliance provides more accurate results than questionnaires. Emphasis must be put on motivating the travelers to take the vaccine as recommended.

Somnambulistic-like behaviour in patients attending a lithium clinic.

The prevalence of somnambulistic-like behaviour related to treatment with lithium alone or in combination with other psychotropic medications was evaluated in patients attending a lithium clinic. A written questionnaire on somnambulistic-like behaviour was completed by 389 patients. Information was provided on the time of occurrence, frequency and severity of the episodes, the presence of childhood somnambulism, and the temporal relationship between psychiatric treatment and somnambulistic-like behaviour. Twenty-seven (27) patients (6.9%) presented sleepwalking behaviour related to the onset of treatment with lithium alone or in combination with other psychotropic drugs. Forty-five patients (11.6%) reported childhood somnambulism and 12 of them (27%) had their childhood somnambulism reactivated by the medication. Most patients had a diagnosis of bipolar affective disorder but somnambulistic-like behaviour also occurred in patients with other axis 1 diagnosis. Sleep-related violence was seldomly reported. Therefore, lithium alone or in combination with other psychotropic drugs may induce somnambulistic-like behaviour. A history of childhood somnambulism may increase the risk of developing sleepwalking behaviour while under psychotropic drugs treatment.