Surface Microhardness Of Microhybrid And Nanocomposite After Storage In Mouth Washes.

BACKGROUND: Dental composites are aesthetic direct restorative material. However, the effect of mouthwashes on the durability of the material is controversial. This study evaluated and compared the influence of mouthwash composition on the surface hardness of nanofilled (Z350XT) and microhybrid (P60) resin composites. METHODS: Comparative in-vitro study was conducted over 6 months at Multan Medical & Dental College. Sixty-four disc-shape specimens of each {nanofilled (Z350XT) and microhybrid (P60)} resin composite were prepared and stored in distilled water at 37°C for 24 hours. The baseline microhardness reading (To) was recorded by Vickers micro-hardness tester. Samples were then randomly divided into four groups (n=16) and stored in Listerine Cool Mint, Colgate Plax, Clinica and distilled water (control). The hardness test was repeated after 12 hours and 24 hours of storage. RESULTS: Nanocomposite (Z350XT) had statistically (p<0.01) higher surface hardness. A significant reduction (p≤0.05) in microhardness was observed after immersion of samples in mouthwashes. The reduction in surface hardness was dependent on the immersion time and composition of mouthwashes. Listerine Cool Mint (alcohol-based mouthwash) had greatest degradation effect. CONCLUSIONS: Mouth rinses negatively impacted the surface microhardness of the tested resin-based materials. Alcohol-based mouthwashes had greater potential for reducing microhardness. Microhybrid composite appears to be a more suitable material for restoring teeth in patients accustomed to using regular mouthwashes.

Case Report: Laser Ablation Guided by State of the Art Source Imaging Ends an Adolescent's 16-Year Quest for Seizure Freedom.

Epilepsy surgery is the most effective therapeutic approach for children with drug resistant epilepsy (DRE). Recent advances in neurosurgery, such as the Laser Interstitial Thermal Therapy (LITT), improved the safety and non-invasiveness of this method. Electric and magnetic source imaging (ESI/MSI) plays critical role in the delineation of the epileptogenic focus during the presurgical evaluation of children with DRE. Yet, they are currently underutilized even in tertiary epilepsy centers. Here, we present a case of an adolescent who suffered from DRE for 16 years and underwent surgery at Cook Children's Medical Center (CCMC). The patient was previously evaluated in a level 4 epilepsy center and treated with multiple antiseizure medications for several years. Presurgical evaluation at CCMC included long-term video electroencephalography (EEG), magnetoencephalography (MEG) with simultaneous conventional EEG (19 channels) and high-density EEG (256 channels) in two consecutive sessions, MRI, and fluorodeoxyglucose - positron emission tomography (FDG-PET). Video long-term EEG captured nine focal-onset clinical seizures with a maximal evolution over the right frontal/frontal midline areas. MRI was initially interpreted as non-lesional. FDG-PET revealed a small region of hypometabolism at the anterior right superior temporal gyrus. ESI and MSI performed with dipole clustering showed a tight cluster of dipoles in the right anterior insula. The patient underwent intracranial EEG which indicated the right anterior insular as seizure onset zone. Eventually LITT rendered the patient seizure free (Engel 1; 12 months after surgery). Retrospective analysis of ESI and MSI clustered dipoles found a mean distance of dipoles from the ablated volume ranging from 10 to 25 mm. Our findings highlight the importance of recent technological advances in the presurgical evaluation and surgical treatment of children with DRE, and the underutilization of epilepsy surgery in children with DRE.

Liposuction in Gynecomastia: An Assessment of the Suction-assisted Arthroscopic Shaver Versus Open Disc Excision Techniques.

Introduction Gynecomastia is a common problem of the male breasts, which imposes a great psychological burden on patients. It is mostly bilateral and frequently asymmetrical. Surgical management of gynecomastia has undergone significant changes over the past few decades. Currently, the predominant mode of treatment includes liposuction of the fibro-fatty tissue either alone or in combination with the removal of the glandular tissue by the open excision technique or arthroscopic shaver. This study aims to compare both techniques in terms of hematoma formation, nipple necrosis, reoperation, contour irregularities, acceptability of scarring, asymmetry, and patient satisfaction. Methods The study has been conducted at Shifa International Hospital, Islamabad, from May 2018 to September 2019. Sixty patients were included in the study. All the patients had bilateral gynecomastia and Simon's Grade II-A or II-B. The study sample was divided into two equal groups. Group A underwent liposuction combined with open disc excision while Group B underwent liposuction coupled with disc excision via suction-assisted arthroscopic shaver. Postoperatively, all the patients received follow-up for a minimum period of six months. Results In a cohort of 60 patients, the mean age was 25.76±5.38 years. There were minor differences noted in terms of hematoma formation, nipple necrosis, rates of re-operation, and contour irregularities between open disc excision and arthroscopic disc excision, respectively (p-value > 0.05). About eight patients reported asymmetry in open disc excision as compared to 10 in arthroscopic disc excision. The acceptability of scarring was reported as equal in both groups. Mean patient satisfaction was based on the visual analog scale (VAS) scale was 8.25 in both groups. No statistical difference regarding patient satisfaction was noted in both groups (p-value 0.126). Conclusion Our study concludes that arthroscopic shaver-assisted disc excision despite being a novel and minimally invasive technique does not hold superiority over conventional open disc excision for the management of gynecomastia. Furthermore, in a developing country like Pakistan, there is a lack of expertise with the procedure and a need for more training among plastic surgeons.

Determining the Optimal Number of MEG Trials: A Machine Learning and Speech Decoding Perspective.

Advancing the knowledge about neural speech mechanisms is critical for developing next-generation, faster brain computer interface to assist in speech communication for the patients with severe neurological conditions (e.g., locked-in syndrome). Among current neuroimaging techniques, Magnetoencephalography (MEG) provides direct representation for the large-scale neural dynamics of underlying cognitive processes based on its optimal spatiotemporal resolution. However, the MEG measured neural signals are smaller in magnitude compared to the background noise and hence, MEG usually suffers from a low signal-to-noise ratio (SNR) at the single-trial level. To overcome this limitation, it is common to record many trials of the same event-task and use the time-locked average signal for analysis, which can be very time consuming. In this study, we investigated the effect of the number of MEG recording trials required for speech decoding using a machine learning algorithm. We used a wavelet filter for generating the denoised neural features to train an Artificial Neural Network (ANN) for speech decoding. We found that wavelet based denoising increased the SNR of the neural signal prior to analysis and facilitated accurate speech decoding performance using as few as 40 single-trials. This study may open up the possibility of limiting MEG trials for other task evoked studies as well.

Does the Duration and Severity of Symptoms Have an Impact on Relief of Symptoms after Carpal Tunnel Release?

Rationale Carpal tunnel syndrome (CTS) is the most frequently encountered compressive neuropathy of the upper limb. The treatment of CTS ranges from conservative management to carpal tunnel release. Many patients with misconception about the potential morbidity and with the hope of successful conservative treatment delay the surgical release of carpal tunnel. This delay results in reduced recovery of sensory and motor median nerve function. Objective The aim of this study was to evaluate the influence of preoperative duration and severity of symptom on the outcome of carpal tunnel surgery. Method It included 45 cases of CTS, all treated with limited access open carpal tunnel release. The duration of symptoms (i.e., pain, numbness, tingling, waking up at night because of pain/numbness, difficulty in grasping small objects, and their preoperative severity) was noted using Boston CTS questionnaire. To investigate the outcome, patients were divided into three groups based on their duration of symptoms. Result Group1: The severity of symptoms was reduced to normal in a short period of time in patients who presented with duration of symptoms less than 6 months. Group 2: Patients in whom symptoms lasted for 6 to 12 months had reduced or delayed recovery of hand function as compared with first group. Group 3: Patients who had symptoms for more than 12 months had incomplete recovery of grip strength. Return to normal function took the longest time (median: 16 weeks) in this group. Conclusion This study suggests that patients who present late have delayed/incomplete relief of symptoms after carpal tunnel release.

De Novo Mutations Affecting the Catalytic Cα Subunit of PP2A, PPP2CA, Cause Syndromic Intellectual Disability Resembling Other PP2A-Related Neurodevelopmental Disorders.

Type 2A protein phosphatases (PP2As) are highly expressed in the brain and regulate neuronal signaling by catalyzing phospho-Ser/Thr dephosphorylations in diverse substrates. PP2A holoenzymes comprise catalytic C-, scaffolding A-, and regulatory B-type subunits, which determine substrate specificity and physiological function. Interestingly, de novo mutations in genes encoding A- and B-type subunits have recently been implicated in intellectual disability (ID) and developmental delay (DD). We now report 16 individuals with mild to profound ID and DD and a de novo mutation in PPP2CA, encoding the catalytic Cα subunit. Other frequently observed features were severe language delay (71%), hypotonia (69%), epilepsy (63%), and brain abnormalities such as ventriculomegaly and a small corpus callosum (67%). Behavioral problems, including autism spectrum disorders, were reported in 47% of individuals, and three individuals had a congenital heart defect. PPP2CA de novo mutations included a partial gene deletion, a frameshift, three nonsense mutations, a single amino acid duplication, a recurrent mutation, and eight non-recurrent missense mutations. Functional studies showed complete PP2A dysfunction in four individuals with seemingly milder ID, hinting at haploinsufficiency. Ten other individuals showed mutation-specific biochemical distortions, including poor expression, altered binding to the A subunit and specific B-type subunits, and impaired phosphatase activity and C-terminal methylation. Four were suspected to have a dominant-negative mechanism, which correlated with severe ID. Two missense variants affecting the same residue largely behaved as wild-type in our functional assays. Overall, we found that pathogenic PPP2CA variants impair PP2A-B56(δ) functionality, suggesting that PP2A-related neurodevelopmental disorders constitute functionally converging ID syndromes.

Magnetic resonance imaging-guided laser interstitial thermal therapy as treatment for intractable insular epilepsy in children.

OBJECTIVE Seizure onset within the insula is increasingly recognized as a cause of intractable epilepsy. Surgery within the insula is difficult, with considerable risks, given the rich vascular supply and location near critical cortex. MRI-guided laser interstitial thermal therapy (LiTT) provides an attractive treatment option for insular epilepsy, allowing direct ablation of abnormal tissue while sparing nearby normal cortex. Herein, the authors describe their experience using this technique in a large cohort of children undergoing treatment of intractable localization-related epilepsy of insular onset. METHODS The combined epilepsy surgery database of Cook Children's Medical Center and Dell Children's Hospital was queried for all cases of insular onset epilepsy treated with LiTT. Patients without at least 6 months of follow-up data and cases preoperatively designated as palliative were excluded. Patient demographics, presurgical evaluation, surgical plan, and outcome were collected from patient charts and described. RESULTS Twenty patients (mean age 12.8 years, range 6.1-18.6 years) underwent a total of 24 LiTT procedures; 70% of these patients had normal findings on MRI. Patients underwent a mean follow-up of 20.4 months after their last surgery (range 7-39 months), with 10 (50%) in Engel Class I, 1 (5%) in Engel Class II, 5 (25%) in Engel Class III, and 4 (20%) in Engel Class IV at last follow-up. Patients were discharged within 24 hours of the procedure in 15 (63%) cases, in 48 hours in 6 (24%) cases, and in more than 48 hours in the remaining cases. Adverse functional effects were experienced following 7 (29%) of the procedures: mild hemiparesis after 6 procedures (all patients experienced complete resolution or had minimal residual dysfunction by 6 months), and expressive language dysfunction after 1 procedure (resolved by 3 months). CONCLUSIONS To their knowledge, the authors present the largest cohort of pediatric patients undergoing insular surgery for treatment of intractable epilepsy. The patient outcomes suggest that LiTT can successfully treat intractable seizures originating within the insula and offers an attractive alternative to open resection. This is the first description of LiTT applied to insular epilepsy and represents one of only a few series describing the use of LiTT in children. The results indicate that seizure reduction after LiTT compares favorably to that after conventional open surgical techniques.

Coregistration of multimodal imaging is associated with favourable two-year seizure outcome after paediatric epilepsy surgery.

Multimodal coregistration uses multiple image datasets coregistered to an anatomical reference (i.e. MRI), allowing multiple studies to be viewed together. Commonly used in intractable epilepsy evaluation and generally accepted to improve localization of the epileptogenic zone, data showing that coregistration improves outcome is lacking. We compared seizure freedom following epilepsy surgery in paediatric patients, evaluated before and after the use of coregistration protocols at our centre, to determine whether this correlated with a change in outcome. We included paediatric epilepsy surgery patients with at least one anatomical and one functional neuroimaging study as part of their presurgical evaluation. Preoperatively designated palliative procedures and repeat surgeries were excluded. Multiple pre-, peri-, and postoperative variables were compared between groups with the primary outcome of seizure freedom. In total, 115 were included with an average age of 10.63 years (0.12-20.7). All evaluations included video-EEG (VEEG) and MRI. Seven (6%) had subtraction single-photon emission CT (SPECT), 46 (40%) had positron emission tomography (PET), and 62 (54%) had both as part of their evaluation. Sixty (52%) had extratemporal epilepsy and 25 (22%) were MRI-negative. Sixty-eight (59%) had coregistration. Coregistered patients were less likely to undergo invasive EEG monitoring (p=0.045) and were more likely to have seizure freedom at one (p=0.034) and two years (p<0.001) post-operatively. A logistic regression accounting for multiple covariates supported an association between the use of coregistration and favourable post-surgical outcome. Coregistered imaging contributes to favourable postoperative seizure reduction compared to visual analysis of individual modalities. Imaging coregistration is associated with improved outcome, independent of other variables after surgery. Coregistered imaging may reduce the need for invasive EEG monitoring, likely due to improved confidence in presurgical localization. These findings support the use of multimodal coregistered imaging as part of the presurgical assessment in patients evaluated for surgical treatment of intractable epilepsy.

Mutations in HIVEP2 are associated with developmental delay, intellectual disability, and dysmorphic features.

Human immunodeficiency virus type I enhancer binding protein 2 (HIVEP2) has been previously associated with intellectual disability and developmental delay in three patients. Here, we describe six patients with developmental delay, intellectual disability, and dysmorphic features with de novo likely gene-damaging variants in HIVEP2 identified by whole-exome sequencing (WES). HIVEP2 encodes a large transcription factor that regulates various neurodevelopmental pathways. Our findings provide further evidence that pathogenic variants in HIVEP2 lead to intellectual disabilities and developmental delay.

Atypical imaging evolution of sturge-weber syndrome without facial nevus.

We report a patient with Sturge-Weber syndrome without facial angioma, who presented with seizures and normal initial imaging results. The patient experienced several years without seizures before a sudden increase in seizure frequency, followed by an atypical evolution of imaging findings prompting biopsy to establish the diagnosis. This case highlights not only the rare presentation of isolated leptomeningeal angiomatosis, but also the potential for atypical evolution of imaging findings through the course of the disease. We detail the imaging findings of our case and review the potential pathophysiological basis for this appearance. Our experience suggests that repeat imaging is warranted in patients with suspected Sturge-Weber syndrome or those with intractable cryptogenic epilepsy, because some imaging features of Sturge-Weber syndrome may manifest over time.

Clobazam for the treatment of intractable epilepsy in children.

We describe our experience using clobazam, examining efficacy for individual seizure types and analyzing for factors contributing to initial and sustained response. We retrospectively reviewed medical charts of children treated with clobazam. We collected patient and treatment characteristics and compared response to therapy at 6, 12, and >12 months' duration. One hundred eight patients with a variety of seizure types and etiologies of epilepsy were treated. Response rates for >50% seizure reduction were 59%, 39%, and 30% of patients at 6, 12, and >12 months' therapy, respectively. No seizure type responded more favorably and there were no patient predictors of favorable response. Patients tended to respond early and at low dosing, and half the patients maintained this response for 15 months or more. Clobazam has efficacy against a wide spectrum of seizure types and epilepsy etiologies. An early, low-dose response is a favorable indicator for sustained response.

Epilepsy surgery for early infantile epileptic encephalopathy (ohtahara syndrome).

Early infantile epileptic encephalopathy or Ohtahara syndrome is the earliest form of the age-dependent epileptic encephalopathies. Its manifestations include tonic spasms, focal motor seizures, suppression burst pattern, pharmaco-resistance, and dismal prognosis. The purpose of this study was to evaluate the effectiveness of epilepsy surgery in selected infants. We identified 11 patients, 9 from the literature and 2 from our institution that fulfilled diagnostic criteria of Ohtahara syndrome and had undergone epilepsy surgery in infancy. Seven of the 11 infants have remained seizure free (Engel class IA) and four are reportedly having rare to infrequent seizures (Engel class IIB). All patients experienced "catch up" development. In contrast to Ohtahara's15 pharmacotherapy managed patients, who had a mortality rate of approximately fifty percent, and those that survived continued to have seizures and were severely impaired, the outcome of selected surgically managed patients is much more favorable.

Amantadine for the treatment of refractory absence seizures in children.

Amantadine has demonstrated efficacy in small series for absence and myoclonic type seizures. We examined the efficacy of amantadine for treating refractory absence seizures in a cohort of pediatric patients. We retrospectively reviewed medical records for patients with absence seizures treated with amantadine at Cook Children's Medical Center after January 2007. Abstracted data included sex, age at initiation, concomitant antiepileptic drugs, amantadine dosing, and seizure frequency. Outcomes at 3, 6, and 12 months after initiation were categorized as >90%, ≥50%, or <50% reduction in seizure frequency. Of 13 patients included in the study, many were exposed to multiple antiepileptic drugs (median, 3; range, 1-6). Three were implanted with a vagus nerve stimulator. A response of at least 50% seizure reduction was reported in more than 50% of patients reviewed at 3, 6, and 12 months after initiating treatment. Among responders, a majority had >90% reduction in seizure frequency. Amantadine may constitute an efficacious alternative treatment for refractory absence seizures.

Risk of invasive Haemophilus influenzae type b (Hib) disease in adults with secondary immunodeficiency in the post-Hib vaccine era.

Prior to the introduction of Haemophilus influenzae type b (Hib) conjugate vaccines, invasive Hib disease affected almost exclusively children. According to some recent studies, in the postvaccine era, adults, the elderly, and immunocompromised persons can be affected more often than children. As the production of type-specific anti-capsular polysaccharide antibodies is the major defense mechanism against Hib, individuals with defects in humoral immune responses have high susceptibility to infections caused by Hib. We hypothesized that nonvaccinated adults with chronic conditions causing immunosuppression may lack protective antibody to Hib. We assessed serum anti-Hib IgG levels and bactericidal activity in 59 patients with chronic renal failure, 30 patients with type 2 diabetes mellitus, 28 patients with chronic obstructive pulmonary disease (COPD), and 20 patients with multiple myeloma compared to 32 healthy controls of similar age. Considering antibody at >0.15 µg/ml as the protective correlate in unvaccinated individuals, we detected subprotective Hib antibody levels in 29% of chronic renal failure, 20% of diabetes, 14% of COPD, and 55% of myeloma patients compared to 3% of healthy controls. Additionally, 70% of myeloma and 58% of chronic renal failure patients did not have detectable serum bactericidal activity against Hib. Among individuals with severe diseases causing secondary immunodeficiency, patients with multiple myeloma and chronic renal failure are at an increased risk of invasive Hib disease. Considering that Hib continues to circulate in the population, this study provides a rationale for the immunization of some adult patients with secondary immunodeficiency with the pediatric Hib vaccine to achieve protective immunity.

Needle-stick injury: a rising bio-hazard.

BACKGROUND: Needle stick injury has been identified as the foremost health allied concern and the specialty of dentistry is not an exception. Its incidence can be reduced when a dental practitioner is completely proverbial to the standard cross-infection control measures. This study was intended to assess the knowledge, attitude and practices among the dental practitioners regarding Needle Stick Injuries and associated risk factors. METHODS: This survey was carried out in the Oral Surgery Department, Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Karachi. Dental practitioners of different job categories were conveniently approached by the BDS students. They all were provided with a structured and validated, self-administered questionnaire. Descriptive statistics and Chi-square test was applied with 5% level of significance. RESULTS: All 100 (55 females and 45 males) practitioners agreed to participate in the study. Prevalence of Needle Stick Injury observed was 30% with no significant relationship with the demographic characteristics. Seventy-four percent of the participants were aware of the universal guidelines. Majority (88%) of the dental personnel believed that recapping of needles should be performed soon after use and 53% knew about needle-less safety devices. These injuries were experienced by 30% of the respondents, of which just 28% were reported. CONCLUSION: Dental practitioners were at high risk of getting Needle Stick Injuries in dental offices. Most of them had knowledge about it but there was lack of practice of universal precautions.

Palliative functional hemispherectomy for treatment of refractory status epilepticus associated with Alpers' disease.

PURPOSE: Palliative epilepsy surgery is considered for patients that would benefit from surgical therapy for intractable epilepsy but are not candidates for curative procedures. In many cases, the goals of therapy focus on improved quality of life more than seizure freedom. We discuss the use of epilepsy surgery for refractory status epilepticus, as well as the rationale and ethical considerations for employing a palliative procedure in otherwise fatal diseases. METHODS: We present a child with Alpers' disease presenting with refractory status epilepticus which was treated with functional hemispherectomy after failure of multiple typical therapies. Hemispherectomy allowed for the child to be extubated and ultimately discharged to home with her family. Unfortunately, the child died several months later after developing new-onset liver failure in the setting of a viral illness. CONCLUSION: Functional hemispherectomy was effective for the treatment of refractory status epilepticus in Alpers' disease. We believe that the procedure resulted in improved quality of life which was the primary outcome goal. Palliative procedures should be considered in diseases with ultimate fatal outcome when the short-term benefits outweigh the risks. The ethical aspects of treatment must be carefully considered to insure treatment is provided in the best interest of the patient.

Clinical applications of the pedicled anterolateral thigh flap in penile reconstruction.

BACKGROUND: Penile reconstruction remains a major challenge in plastic surgery and, over the years, a myriad of techniques has been employed to achieve a functional phalloplasty. Unfortunately, the more commonly used forearm free flaps also have significant drawbacks. The pedicled anterolateral thigh flap (ALTF) has numerous attributes, which make it a comparable, if not a better option, for penile reconstruction. METHODS: Between January 2007 and December 2009, 14 patients with partial or complete penile loss underwent reconstruction with a pedicled ALTF. The demographic data of the patients, cause of the defects, technique of reconstruction and the details about different flap parameters are presented here. RESULTS: All the 14 patients were males, and the age range was between 27 and 60 years. Nine flaps were used for total penile reconstruction and five for partial penile reconstruction. The size of the flap ranged from 5 × 4 cm to 15 × 15 cm and was based on two perforators in four cases, while a single perforator was used in the rest. The perforators were musculocutaneous in 11 and septocutaneous in three patients. Primary urethral anastomosis was performed in three cases of total phalloplasty and all cases of partial phalloplasty (n=8), while in the rest, urethral continuity was established in a second stage. All the flaps survived completely. CONCLUSIONS: We have found the pedicled ALTF to be a very versatile flap with wide range of applicability for partial as well as total phalloplasty.