Early Progressive Maxillary Changes with Nasoalveolar Molding: Randomized Controlled Clinical Trial.

OBJECTIVES: Quantitative assessment of 3-dimensional progressive changes of the maxillary geometry in unilateral cleft lip palate (UCLP) with and without nasoalveolar molding (NAM). METHODS: The study was designed as a prospective 2-arm randomized controlled clinical trial conducted in parallel. Forty infants with nonsyndromic UCLP were randomly assigned into a NAM-treated group (n = 20) and non-NAM treated group (n = 20). A total of 120 laser-scanned maxillary casts were collected and blindly analyzed via a modified algorithm at T0 (initial visit; baseline), T1 (after 3 wk; first interval), and T2 (after 6 wk; second interval). The main outcome measures were the amount and rate of cleft gap changes, the midline position, and the transverse, sagittal, and vertical growth through intervals. RESULTS: More than 50% of the cleft gap (56.42%; P < 0.001) was reduced in the first 3 wk of alveolar molding (AM). The end point of the AM was obtained in 6 wk (86.25%; P < 0.001); then, the kinks of the greater segment were noticed. The AM effect decreased as far as posterior; the anterior arch width reduced slightly (1.23%; P < 0.001), while the middle and posterior arches increased slightly (P > 0.999 and P = 0.288, respectively). The posterior arch width was the least changing and was considered a baseline, while the anterior was the pivot of the segment rotation. Both groups showed different patterns of segment rotation and sagittal growth. The non-NAM treated group showed a slight increase in cleft gap length, arch width, and midline position. CONCLUSION: Based on this study, it was concluded that the NAM treatment is effective in minimizing cleft severity and realigning maxillary segments without the deterioration of the transverse and vertical arch growth. Near follow-up visits are recommended to monitor the rapid gap reduction within the first 3 wk. Further trials are recommended to compare the outcomes regarding the sagittal growth to reference values (ClinicalTrials.gov NCT03029195). KNOWLEDGE TRANSFER STATEMENT: The results of this study will help clinicians understand nasoalveolar molding biomechanics that may improve the treatment outcomes for patients with unilateral cleft lip and palate. The trial data can be a valuable guide to the qualitative and quantitative predictive virtual molding in computer aided design-simulated nasoalveolar molding therapy. The modified algorithm can be used by researchers to quantify the rate, the sequence, and the direction of the maxillary segments movement in unilateral cleft lip and palate.

Sacrificing the internal carotid artery in infiltrating neck tumours: a study of four clinical cases.

Tumour infiltration of the carotid arteries, especially the common carotid artery (CCA) and the internal carotid artery (ICA), is a great challenge in maxillofacial surgery. Cases in which the malignant tumour and/or lymph node is stuck to the carotid artery, especially the ICA, have previously been considered inoperable. Four such cases, two with recurrent metastatic nodal neck masses encasing the ICA, one with aggressive fibromatosis, and one with a carotid body tumour, are described herein. Successful resection of the mass along with the ICA was performed in all cases after a positive balloon occlusion test. All patients made an uneventful recovery with no signs or symptoms of any neurological deficits. In addition, all of the patients were free of disease for the whole postoperative period of 18 months.

Heparin bonding increases patency of long microvascular prostheses.

The high thrombogenicity of synthetic biomaterials has limited their use for reconstructive microsurgery. Prime factors in the thrombogenicity of synthetic materials in contact with blood include gas nuclei at the blood gas interface as well as the inherent thrombogenicity of the materials themselves. Expanded polytetrafluoroethylene (ePTFE) vascular prostheses were denucleated by placement in acetone and ethanol followed by degassed saline or by placement in degassed saline subjected to hydrostatic pressure. Heparinized grafts were prepared by coating with tridodecylmethylammonium chloride (TDMAC), followed by immersion in heparin. Grafts were installed to reconstruct the femoral artery (1 x 10 mm) or as renal-iliac bypasses (1 x 50 mm) in rats. In the femoral artery reconstruction model, control grafts thrombosed within 10 minutes of implantation. All acetone denucleated femoral grafts remained patent for 60 minutes but were occluded at day 1. All pressure denucleated femoral grafts remained patent for 60 minutes, whereas six were patent at 1 month. In contrast, 11 of 15 heparinized femoral grafts were patent at 1 month. In the renal iliac bypass model, all control grafts were thrombosed within 10 minutes, whereas all heparin bonded grafts remained patent at 1 month. This finding confirms that removal of air from small diameter ePTFE grafts decreases acute thrombogenicity and that heparin bonding further decreases thrombogenicity, suggesting that clinically useful lengths of microvascular prostheses may be possible.

Cross-validating factors associated with discharges against medical advice.

Between six percent and 35% of psychiatric patients discharge themselves from hospital against medical advice (AMA). The discharges may prevent patients from deriving the full benefit of hospitalization and may result in rapid rehospitalization. We examined sociodemographic and clinical characteristics of 195 irregular discharges from a 237 bed psychiatric hospital over a five year period and found that AMA discharges increased over the study period to a peak of 25% in 1986. There was a strong negative correlation between AMA discharge rates and the willingness of physicians to commit patients involuntarily. Multiple discriminant analysis revealed a set of nine variables that accurately classified 78% of cases into regular or irregular discharge categories. Further analysis revealed that there are two distinct subgroups of patients who discharge themselves AMA: those who repeatedly left the hospital AMA in a regular "revolving back door" pattern and those who left AMA only once. The repeat group exceeded the one-time group in terms of prior admissions, appearances before review boards, and percentage of Natives. The repeat group also spent twice as long in hospital, and 27% were readmitted within one-week of the index AMA discharge. Less than three percent of the one-time AMA group was readmitted within a week. These results were cross-validated on a new sample of irregular discharges and matched controls.

Effects of digoxin and acetyl-digitoxin on basal and CO2-stimulated ventilation.

Eight healthy volunteers were studied to ascertain the effect of digoxin and the relatively more lipophylic cardiac glycoside, acetyl-digitoxin on ventilation. Baseline ventilation as well as the response to the inspiration of 2.2% and 4.8% carbon dioxide were assessed. Digoxin produced a depression of minute volume and oxygen consumption whereas acetyl-digitoxin produced the opposite effect. This could be the result of a relatively greater vagomimetic effect with digoxin and a greater symphatomimetic effect with acetyl-digitoxin. These findings might have clinical implications in cardiac patients who have pulmonary disease.