Mercury in Populations of River Dolphins of the Amazon and Orinoco Basins.

In the Amazon and Orinoco basins, mercury has been released from artisanal and industrial gold mining since the Colonial time, as well as a result of deforestation and burning of primary forest, that release natural deposits of methyl mercury, affecting the local aquatic vertebrate fauna. This study reports the presence of mercury in river dolphins' genera Inia and Sotalia. Mercury concentrations were analysed in muscle tissue samples collected from 46 individuals at the Arauca and Orinoco Rivers (Colombia), the Amazon River (Colombia), a tributary of the Itenez River (Bolivia) and from the Tapajos River (Brazil). Ranges of total mercury (Hg) concentration in muscle tissue of the four different taxa sampled were: I. geoffrensis humboldtiana 0.003-3.99 mg kg-1 ww (n = 21, Me = 0.4), I. g. geoffrensis 0.1-2.6 mg kg-1 ww (n = 15, Me = 0.55), I. boliviensis 0.03-0.4 mg kg-1 ww (n = 8, Me = 0.1) and S. fluviatilis 0.1-0.87 mg kg-1 ww (n = 2, Me = 0.5). The highest Hg concentration in our study was obtained at the Orinoco basin, recorded from a juvenile male of I. g. humboldtiana (3.99 mg kg-1 ww). At the Amazon basin, higher concentrations of mercury were recorded in the Tapajos River (Brazil) from an adult male of I. g. geoffrensis (2.6 mg kg-1 ww) and the Amazon River from an adult female of S. fluviatilis (0.87 mg kg-1 ww). Our data support the presence of total Hg in river dolphins distributed across the evaluated basins, evidencing the role of these cetaceans as sentinel species and bioindicators of the presence of this heavy metal in natural aquatic environments.

HPV vaccination coverage in the federal state of Belgium according to regions and their impact.

Long-term results of the HPV vaccination programs in Australia and Scotland have shown a tremendous impact on the reduction of HPV infection rates and precancerous diseases. Both countries started mass vaccination ten years (Australia) and eight years (Scotland) ago and achieved a vaccination coverage of more than 80 %. Within 20 to 30 years a reduction in cervical cancer by more than 75 % is expected. Furthermore, there will be a reduction in other HPV related cancers like vaginal, vulva, perineal, anal and oropharyngeal cancers. In order to be successful, a high vaccination coverage is needed. In Belgium, the vaccination was introduced in 2010 in the Flemish community and in 2011 in the French community. In the first vaccinated cohorts the coverage in Flemish and French Communities was respectively 84% (2010) and 29% (2012-2013). The latest data suggest that the Flemish Community (Flanders Region) attained a coverage of 91 % while the French Community (Walloon Region) attained a coverage of around 36 %. The regional difference in coverage offers a real-life case. The worst-case scenario could end up with proportionally one half of country having more HPV related cancers than the other half. Currently efforts are performed to increase the coverage rates in both regions and consequently decreasing this difference. Additionally, the updated recommendations regarding the HPV vaccination by the Belgian NITAG (National Immunization Technical Advisory Group) stated that the HPV vaccination should be gender neutral. This could stimulate the vaccination program and increase the coverage. The coverage rate in Flanders is among the highest in the world and the rate in the French Community is increasing. Efforts should be continued in order to maintain trust and increase the coverage rate.

An African woman with pulmonary cavities: TB or not TB?

Cavitary lung lesions in patients from developing countries are mostly caused by tuberculosis (TB). However, when TB cannot be confirmed, a primary lung abscess caused by anaerobic bacteria from the mouth should be considered, especially in patients with poor dentition. We present a case of a Sudanese woman with a cavitary lung lesion and severe gingivitis. Bulleidia extructa was isolated as a single pathogen from the pulmonary cavity.

Acute upper airway failure and mediastinal emphysema following a wire-guided percutaneous cricothyrotomy in a patient with severe maxillofacial trauma.

BACKGROUND: In the presence of severe maxillofacial trauma, management of the airway is important because this condition poses a significant threat to airway patency. That securing the airway is not always straightforward is described and illustrated in this paper. CASE: We present the case of a 23-year-old patient who sustained severe maxillofacial injury for which airway control was necessary. A wire-guided percutaneous dilation cricothyrotomy was performed, which was most probably the cause of an acute loss of airway patency. The literature regarding the role of percutaneous techniques in an elective and emergency setting is reviewed.

[Mouthguards: a difficult choice?]. / Mondbeschermers: een lastige keuze?

It is the dentists' task to advise their patients what type of mouthguard grants the best possible protection. It is generally accepted that off-the-counter mouthguards are not sufficiently protective. These mouthguards are usually ill-fitting and not worn in the mouth but in the sporting shorts' pocket instead. A custom-fabricated mouthguard is proven to offer maximal protection. A mouthguard has to offer adequate protection with high comfort. A composite laminate construction and space between the inner surface of the mouthguard and the labial surface of the upper front teeth are essential for adequate protection. Transitional dentition and/or orthodontic appliances are no limitation to fabricate a custom-formed mouthguard.

[Serious complications following removal of an ingested partial denture]. / Ernstige complicaties door verwijdering van ingeslikte gebitsprothesen.

Complications occurred in a 41-year-old woman following an attempt to remove a partial denture by oesophagoscopy. These were: laceration of the oesophagus with subsequent mediastinitis, pneumothorax, and pneumopericardium. At a second oesophagoscopy the denture was removed from the oesophagus using a flexible hood. Following antibiotic treatment the patient recovered. In a 45-year-old man who had also swallowed a denture, the denture could not initially be localized. It was eventually recovered from the antrum using a flexible scope with a flexible hood. The patient was discharged from hospital in a good condition. Psychiatric and mentally handicapped patients run a high risk of denture ingestion. Ingested dental prostheses are often radiolucent, and are difficult to visualize using radiological methods. Extraction of the ingested foreign objects can lead to severe complications. This is why in this type of case, we recommend the use of a flexible scope and a flexible hood attachment.

A case of imported paracoccidioidomycosis: an awkward infection in The Netherlands.

Paracoccidioidomycosis is an important endemic mycosis in South America. In Europe the disease is very rare and only found as infections in travelers to Latin America. We report here the first case encountered in the Netherlands for which the appropriate diagnosis was not attained for several months. A Dutch 60-year-old man presented with a painful ulceration in the buccal mandibular vestibular mucosa of three months duration. While his medical history was uneventful, he had worked, until 8 years prior to his presentation, as a carpenter for 25 years in the jungles of Peru and Ecuador. An aberrant chest radiograph, CT-scan of the lungs and increased erythrocyte sedimentation rate were suggestive of sarcoidosis or a bronchiolitis obliterans organizing pneumonia. There was no improvement in the patient's symptoms despite the use of budesonide and prednisone medication, as well as tuberculosis prophylaxis with isoniazide and rifampicin, and local use of miconazole. Quite to the contrary, as an irritated, irregular hyperemic mucosa and gingiva with ulceration were noticed during this period of time. These precipitated an incisional biopsy through which a mixed inflammatory cellular infiltrate and large yeast cells were found on histopathologic examination. Based on the patient's travel history and the multiple budding yeastlike cells revealed in the biopsy tissue, the diagnosis of paracoccidioidomycosis was finally made. This was supported by the isolation of Paracoccidioides brasiliensis in culture. Antimycotic oral therapy with itraconazole was started and continued for 15 months. At two and five year follow-ups, the patient was asymptomatic. In Europe, it may be expected that diseases that are endemic in other areas will be seen more frequently in countries where the diseases are not routinely encountered. It is most likely that the use of corticosteroid medication, with its inherent immunosuppressive effect, resulted in the reactivation of an infection acquired many years before in Latin America. The etiologic agent then disseminated from the initial focal point to cause the ensuing oral mucous membrane lesions. The importance of the patient's prolonged residence in Latin America was overlooked. The very long latency of endemic mycoses emphasizes the need for a meticulous history which should include not only recent trips, but also past residence in foreign countries.

The synergistic value of focus score and IgA% score of sublabial salivary gland biopsy for the accuracy of the diagnosis of Sjögren's syndrome: a 10-year comparison.

OBJECTIVE: Increasing the accuracy of the diagnosis of Sjögren's syndrome (SS) by placing emphasis on objective findings such as the presence of anti-Ro and anti-La autoantibodies and abnormal salivary gland tissue (SGT) histology is a current issue. In order to obtain optimal disease sensitivity and specificity of SGT findings, histological and immunohistological SGT examinations were compared. The first describes the extent of the lymphocytic infiltrate as a focus score (LFS), whereas the latter describes the composition of the infiltrate as a percentage of IgA-containing plasma cells (IgA%). METHODS: Both the LFS and IgA% score were assessed in 279 SGT biopsies taken from patients with symptoms suggestive of SS. In case histological conclusions did not match immunohistological conclusions patients were assigned to so-called mismatch groups. Patients in the mismatch groups were further classified using objective, serological parameters [rheumatoid factor (RF), anti-Ro, anti-La, anti-nuclear antibodies, gammaglobulin level]. RESULTS: In 249 samples (89%), LFS and IgA% resulted in the same conclusion. Within this group a total of 63 SGT samples (25%) were characteristic for SS showing LFS >1.0 and IgA% <70. In the mismatch groups after serological classification, both false positive as well as false negative scores were observed less frequently for IgA% as compared with LFS (50 vs 75% and 25 vs 50%, respectively). CONCLUSIONS: Additional immunohistological SGT examination provides greater disease sensitivity and specificity than histological SGT examination alone, thereby increasing accuracy of SS diagnosis.

Two-dimensional cephalometric analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats.

The feasibility and possible effects of palatal soft-tissue expansion in palatal repair were studied. A prospective longitudinal animal experiment was performed in 75 growing cats assigned to 5 groups. In 31 cats, a midline defect was made, and bipediced flaps were raised at the age of 8 weeks (stimulated Langenbeck operation) in order to create palatal scars. At the age of 14 weeks, custom-made tissue expanders were inserted palatally in 61 animals. Tissue expansion was performed by weekly inflation in 33 cats (16 without and 17 with scars) for an 8-week period. The remaining 28 cats (14 without and 14 with scars) served as sham groups. A control group was formed by 14 animals (without scars and without tissue expanders). Soft-tissue gain and its effects on maxillofacial growth and development were measured in the midsagittal plane on tracings from standardized lateral radiographs. The effects of the experimental interventions were evaluated for 8 weeks after removal of the tissue expanders. Not all the cats yielded results at all time periods. This study showed that soft-tissue expansion of palatal mucoperiosteum is feasible. The surgically induced scars did not cause significant differences between the different groups in the midsagittal plane, and the data from both expansion and sham groups could be pooled. Significant soft-tissue gain was achieved by the tissue-expansion technique. Iatrogenic side effects were significant anteroposterior growth retardation at the level of the bony palate and an increase in vertical growth of the anterior nasomaxillary height and the posterior skull height during active tissue expansion. After removal of the tissue expanders, some accelerated growth was found in the tissue expansion in the scarred tissue group, with initial correction of the abnormal growth at the cranial base level. It is concluded that palatal soft-tissue expansion is possible in growing cats. This technique, however, impaired maxillofacial growth and development.

Three-dimensional morphometric analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats.

A prospective longitudinal study in 75 growing cats was conducted to evaluate palatal soft-tissue expansion in cleft lip and palate surgery. In 31 cats, palatal scars were induced by simulated Langenbeck surgery at the age of 8 weeks. At the age of 14 weeks, custom-made tissue expanders were inserted in 61 animals. Tissue expansion was performed by weekly inflation in 33 cats (16 without and 17 with scars) for an 8-week period. The remaining 28 cats (14 without and 14 with scars) served as sham groups. A control group was formed by 14 animals (without scars and without tissue expander). The effects of the experimental interventions were evaluated on a series of dental casts during the inflation period and until 8 weeks after removal of the tissue expander. The results indicate that soft-tissue expansion of the palatal mucoperiosteum is feasible. Until 20 weeks of age, no differences were found between both expansion and sham groups. Thereafter, significant soft-tissue surface-area gain was quantified in relation to the base surface and base diameter of the tissue expander. Iatrogenic side-effects of active tissue expansion consisted of significant transversal growth retardation in the anterior part of the bony palate and dentoalveolar structures. After removal of the tissue expanders, some accelerated growth in the tissue-expansion, scarred-tissue group was seen. It is concluded that palatal soft-tissue expansion is possible in growing cats, with and without the presence of palatal scars; however, this technique, like other kinds of palatal surgery, impairs dentomaxillary growth and development.

Evaluation of the anatomical position of the lateral canthal ligament: clinical implications and guidelines.

Controversy exists in the literature as to the precise anatomical location of the lateral canthal ligament. The ligament is a 3 mm-wide, two-tailed band; its average length is approximately 13 mm, while the width of the rima palpebralis is about 26 mm. The authors evaluated three different groups to pinpoint the anatomical position of the ligament's attachment to the lateral orbital wall, and to establish guidelines for placement of the ligament during surgery. In 90% of the cases, the ligament was attached to Whitnall's tubercle, which is located approximately 4 mm posterior to the lateral orbital rim, and 17 mm above the intersection of the lateral and inferior margins; this area is 9 mm below the zygomaticofrontal suture. Based on these anatomical criteria, a standardized procedure is suggested.

Orbitometer-ophthalmometer: new surgical and clinical device.

On the basis of analysis of the orbital bony architecture and the locations of the medial and lateral canthi, as well as the pupillary position, a new orthomorphic linear scale was devised for orbital surgery. The measuring device was designed to facilitate hard- and soft-tissue repositioning during mono-orbital and biorbital surgery. The device is useful for craniofacial, reconstructive, and periorbital trauma surgery and, to the best of our knowledge, is the first one described.

Neurofibroma in the articular disc of the temporomandibular joint: a case report.

In classical Von Recklinghausen neurofibromatosis (Type I), skeletal defects occur as a result of abnormalities of derivatives of the neuroectoderm and mesoderm. Temporomandibular joint (TMJ) disorders caused by neurofibroma in the joint capsule or disc have not been reported previously in the English language literature. A case of neurofibroma in the TMJ articular disc in a 29-year-old woman with neurofibromatosis Type I is presented.

A modification of the tibial bone-graft-harvesting technique.

A modified method of tibial bone-graft harvesting is presented. A hollow, cylindric, hand-driven instrument is used to harvest the graft at the medial slope of the tibial tuberosity. Satisfactory amounts of autogenous cancellous bone graft are available to bridge osteotomy gaps and facial fractures, fill smaller defects, and even obliterate a frontal sinus. There is minimal donor-site morbidity, and complications have not been seen in a series of nine consecutive patients.