Accuracy, intra- and inter-rater reliability of three scoring systems for the glottic view at videolaryngoscopy.

An accurate and reproducible recording of laryngoscopic view at tracheal intubation is an important aspect of anaesthetic practice. Unlike direct laryngoscopy, in which the view achieved by the line of sight directly relates to the ease of intubating the trachea, videolaryngoscopy can create a situation in which the view is good, but intubation difficult or impossible. Communicating this to a subsequent anaesthetist is important. We compared three scoring systems: Cormack and Lehane; POGO (percentage of glottic opening); and the Fremantle score, as used by 74 critical care doctors rating 30 anonymised videos of videolaryngoscopic intubations. Accuracy (degree of agreement of score with an expert panel assessment) was higher for POGO (75.5%) and the Fremantle score (73.9%) than for Cormack and Lehane (65.4%; p < 0.001). Intra-rater reliability (mean free marginal Kappa for ordinal scores and mean Cronbach's Alpha for continuous score) was higher for Fremantle score (0.796) and Cormack and Lehane (0.773) than POGO (0.693). Inter-rater reliability for Fremantle score (0.618) and POGO (0.614) were similar and higher than the inter-rater reliability of Cormack and Lehane 0.464 (p < 0.001). The higher accuracy and inter-rater reliability of POGO and the Fremantle score suggest they are preferable to Cormack and Lehane for use when documenting videolaryngoscopy. The additional information about ease of intubation conveyed by the Fremantle score may support its routine use in recording videolaryngoscopic intubation.

Evaluation of three-dimensional root surface changes and resorption following rapid maxillary expansion: a cone beam computed tomography investigation.

OBJECTIVES: To evaluate root surface changes and resorption following toothborne rapid maxillary expansion (RME) using cone beam computed tomography (CBCT). SETTING AND SAMPLE POPULATION: The Department of Orthodontics at The University of Texas Health Science Center. Twenty-four consecutively treated patients (mean age: 12.8 years) requiring maxillary expansion. MATERIAL AND METHODS: An observational cohort included 48 CBCT images collected prior to (T1) and 4.8 months after (T2) RME from the study sample. Maxillary (study group) and mandibular (control group) first molars (n=48) and first premolars (n=48) were segmented and digitally registered using a 'best-fit' algorithm. Linear surface and volumetric changes between the study and control groups were compared using independent sample t-tests. Additionally, individual root length measurements were compared between the T1 and T2 images in each group using paired t-tests. RESULTS: All study teeth had significant changes for the evaluation of maximum linear surface area and volumetric changes as compared to control teeth (p<0.05). On average, premolars and molars in the study group experienced a root shortening of 0.36-0.52 mm (p<0.05). Color-coded diagrams demonstrated thinning and resorption occurring primarily at the apex and buccal aspects of the roots. Severity of these changes was individual-specific, as root resorption patterns were non-uniform. CONCLUSION: Significant volume loss, linear surface area changes, and thinning/shortening of maxillary first molar and premolar roots were common findings with the use of toothborne RME therapy.

Clinical feasibility evaluation of digital dental articulation for three-piece maxillary orthognathic surgery: a proof-of-concept study.

Digital dental articulation for three-piece maxillary orthognathic surgery is challenging. The purpose of this proof-of-concept study was to evaluate the clinical feasibility of a newly developed mathematical algorithm to digitally establish the final occlusion for three-piece maxillary surgery. Five patients with jaw deformities who had undergone a three-piece double-jaw surgery that was planned virtually were randomly selected for this study. The final occlusion had been hand-articulated using stone casts, scanned into the computer and used in the surgery. These hand-articulated occlusions served as the control group. To form the experimental group, the three-piece maxillary dental arch was articulated again automatically from the patient's original occlusion using the mathematical algorithm. The hand- and algorithm-articulated occlusions were then evaluated qualitatively by two experienced orthodontists. A quantitative evaluation was also performed. The results of the qualitative evaluation showed that all of the three-piece occlusions, hand- and algorithm-articulated, were clinically acceptable based on the American Board of Orthodontics grading system. When compared, two of the algorithm-articulated occlusions were clearly better (40%), one was the same (20%), and two were slightly worse (40%) than the hand-articulated occlusions. All of the quantitative measurements were comparable between the two articulation methods. In conclusion, the results of this study demonstrate that it is clinically feasible to digitally articulate the three-piece maxillary arch to the intact mandibular dental arch.

Facial morphology of Finnish children with and without developmental hip dysplasia using 3D facial templates.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a condition that affects the femoral head and the acetabulum and leads to hip subluxation and dislocation. Infants with DDH are usually treated using splints that immobilize their hip joint and are forced on their back for long periods of time. The link between positioning and facial asymmetries is poorly understood. OBJECTIVE: To compare the facial morphologies of children with DDH to a group of healthy controls. SUBJECTS AND METHODS: Fifty-six Finnish patients born with DDH were matched on the basis of gender and age to a control group. Three-dimensional surface images were captured using the 3dMDface system. Using RF6 PP2 software, anthropometric landmarks were plotted and used to calculate asymmetry based on 3D co-ordinates in a reference framework. RESULTS: There was statistically significant difference between all paired facial shells. Relative to the control group, DDH boys and girls presented a chin-point deviation to the right, a more prominent left orbital ridge, a more protrusive nose and upper lip. The gender-specific subgroups show a similarity of 66.54 and 65.22% in girls and boys, respectively. CONCLUSIONS: Patients with DDH present a facial asymmetry when compared to healthy controls. Gender characteristics are marked whether subjects are affected with DDH or not. Three-dimensional surface imaging is a powerful diagnostic and research tool.

Fluctuating asymmetry of the normal facial skeleton.

The purpose of this study was to produce reliable estimations of fluctuating facial asymmetry in a normal population. Fifty-four computed tomography (CT) facial models of average-looking and symmetrical Chinese subjects with a class I occlusion were used in this study. Eleven midline landmarks and 12 pairs of bilateral landmarks were digitized. The repeatability of the landmark digitization was first evaluated. A Procrustes analysis was then used to measure the fluctuating asymmetry of each CT model, after all of the models had been scaled to the average face size of the study sample. A principal component analysis was finally used to establish the direction of the fluctuating asymmetries. The results showed that there was excellent absolute agreement among the three repeated measurements. The mean fluctuating asymmetry of the average-size face varied at each anthropometric landmark site, ranging from 1.0mm to 2.8mm. At the 95% upper limit, the asymmetries ranged from 2.2mm to 5.7mm. Most of the asymmetry of the midline structures was mediolateral, while the asymmetry of the bilateral landmarks was more equally distributed. These values are for the average face. People with larger faces will have higher values, while subjects with smaller faces will have lower values.

There is variability in our perception of the standard head orientation.

The purposes of this study were to determine: (1) whether an observer's perception of the correct anatomical alignment of the head changes with time, and (2) whether different observers agree on the correct anatomical alignment. To determine whether the perception of the correct anatomical alignment changes with time (intra-observer comparison), a group of 30 observers were asked to orient, into anatomical alignment, the three-dimensional (3D) head photograph of a normal man, on two separate occasions. To determine whether different observers agree on the correct anatomical alignment (inter-observer comparison), the observed orientations were compared. The results of intra-observer comparisons showed substantial variability between the first and second anatomical alignments. Bland-Altman coefficients of repeatability for pitch, yaw, and roll, were 6.9°, 4.4°, and 2.4°, respectively. The results of inter-observer comparisons showed that the agreement for roll was good (sample variance 0.4, standard deviation (SD) 0.7°), the agreement for yaw was moderate (sample variance 2.0, SD 1.4°), and the agreement for pitch was poor (sample variance 15.5, SD 3.9°). In conclusion, the perception of correct anatomical alignment changes considerably with time. Different observers disagree on the correct anatomical alignment. Agreement among multiple observers was bad for pitch, moderate for yaw, and good for roll.

The mitogen-activated protein kinase cascade couples PKA and PKC to cAMP response element binding protein phosphorylation in area CA1 of hippocampus.

Activation of the mitogen-activated protein kinase (MAPK) cascade recently was discovered to play an important role in synaptic plasticity in area CA1 of rat hippocampus. However, the upstream mechanisms regulating MAPK activity and the downstream effectors of MAPK in the hippocampus are uncharacterized. In the present studies we observed that hippocampal MAPK activation is regulated by both the PKA and PKC systems; moreover, we found that a wide variety of neuromodulatory neurotransmitter receptors (metabotropic glutamate receptors, muscarinic acetylcholine receptors, dopamine receptors, and beta-adrenergic receptors) couple to MAPK activation via these two cascades. In additional studies we observed that PKC is a powerful regulator of CREB phosphorylation in area CA1. MAPK plays a critical role in transcriptional regulation by PKC, because MAPK activation is a necessary component for increased CREB phosphorylation in response to the activation of this kinase. Surprisingly, we also observed that MAPK activation is necessary for PKA coupling to CREB phosphorylation in area CA1. Overall, these studies indicate an unexpected richness of diversity in the regulation of MAPK in the hippocampus and suggest the possibility of a broad role for the MAPK cascade in regulating gene expression in long-term forms of hippocampal synaptic plasticity.

Engineering of a functional interleukin-5 monomer: a paradigm for redesigning helical bundle cytokines with therapeutic potential in allergy and asthma.

Interleukin (IL) 5 specifically induces the differentiation of eosinophils which are central to the pathogenesis of allergies and asthma. Structurally, IL-5 is a unique member of the short-chain helical bundle subfamily of cytokines. In contrast to other subfamily members which fold unimolecularly into a single helical bundle, IL-5 forms a pair of helical bundles by the interdigitation of two identical monomers covalently linked by a pair of intermolecular disulfide bonds. Although a native IL-5 monomer lacks bioactivity, we recently reported the engineering of an insertional mutant of IL-5 (designated mono5) which folds unimolecularly into a single helical bundle and has biological activity similar to that of native IL-5. Here we demonstrate no differences in signal transduction pathways utilized by mono5 and IL-5, as determined by western blot analysis of early tyrosine phosphorylation events, Jak2 activation, and mitogen-activated protein kinase activation. However, binding studies utilizing conformationally dependent neutralizing anti-IL-5 monoclonal antibodies localized a tertiary structural perturbation near the insert of mono5. This perturbation enabled localization of a limited region of the tertiary structure of IL-5 that engages the IL-5 receptor alpha-chain. Fluorescent labeling studies further revealed that the cysteines of mono5 contained free sulfhydryl groups, thereby demonstrating that the role of the disulfide bonds of IL-5 is the structural maintenance of other functional domains. The retention of conformation epitopes by mono5, but not IL-5, under reducing conditions and the equivalent thermostability of mono5 and IL-5 despite the absence of a disulfide bond in mono5 indicated that the conformation assumed by mono5 is very stable. In addition to providing the structural framework for designing novel IL-5 agonists and antagonists, the knowledge gained from the development of mono5 will enable other helical bundle proteins to be redesigned with therapeutic potential.

MAPK regulation of gene expression in the central nervous system.

Long-term potentiation (LTP), a cellular model for long-term memory, is generally acknowledged to consist of both a short-term phase that is characterized by a dependence on autonomous protein kinase activity, and a long-term phase that is characterized by a dependence on changes in gene expression and new protein synthesis. Similarly, long-term memory exhibits a dependence on gene expression and altered protein synthesis. Recent evidence indicates that the mitogen-activated protein kinase (MAPK) cascade plays a role in both LTP and long-term memory. The MAPK cascade has heretofore largely been studied in the context of cell division and proliferation and as such, mechanisms for the regulation of gene expression by the MAPK cascade have received considerable attention. Given the possible role of altered gene expression in the late phase of LTP and in long-term memory, we evaluated the capacity of the MAPK ERK (extracellular signal-regulated kinase) to regulate phosphorylation of the transcription factor cAMP response element binding protein (CREB) in hippocampal area CA1. Our studies indicate a critical role for the MAPK cascade in the regulation of CREB phosphorylation in the hippocampus.

Spontaneous rupture of a splenic artery aneurysm in the third trimester.

Due to the difficulties in the diagnosis of ruptured splenic artery aneurysm in pregnancy both maternal and fetal mortality continue to be high. A case is presented of a 37 year old woman who ruptured a splenic artery aneurysm at 29 weeks gestation. The presentation of the disease, its risk factors and treatment, as well as a review of the literature are presented here.

Perinatal mortality at the North West Armed Forces Hospital, Tabuk, Saudi Arabia and the potential benefits of the biophysical profile score.

Relatively little information is available in the literature regarding perinatal mortality in Saudi Arabia and none concerning the value of a full fetal assessment screening program in its reduction. This study analyzes all deliveries with a birth weight of greater than 500 grams at the North West Armed Forces Hospital (NWAFH) for the year 1992. It investigates the causes of perinatal death, ascertaining those which could potentially have been avoided and assessing the role which a fetal assessment screening program might have played in its reduction. There were 4387 babies born during this period. The combined perinatal mortality rate was 16.3%. Of these, 6.5% comprised babies weighing less than 1000 grams. Fifty-one (71%) of the deaths occurred among high risk patients and of these, 28 might have been saved had they been referred for fetal assessment screening. This study shows that the perinatal mortality rate at the NWAFH is comparable to figures obtained in other major centers in the country and that the introduction of a fetal assessment screening program could potentially result in a decrease in the perinatal mortality rate to less than 10/1000.

Normal neonatal biometry in the northwest region of Saudi Arabia.

Low birthweight does not always imply intrauterine growth retardation and other methods, including the ponderal index (PI), have been employed in its identification. Previous research has demonstrated that a low PI is associated with adverse neonatal outcome. The purpose of this study was to establish normal neonatal biometry for an Arab population and to determine the relationship between PI nad both gestation and birthweight. This is a prospective cross-sectional study carried out in the postnatal wards of the North West Armed Forces Hospital, Tabuk, Saudi Arabia. Three hundred and eighty babies who were delivered between 37 and 42 weeks' gestation following uncomplicated pregnancy were recruited. All patients were managed according to established local practice. The mean birthweight of the study population is lower than that found by comparable studies. There was a strong positive correlation between the PI and birthweight and gestation and the lines describing the regression were significant (P < 0.0001, P = 0.00002 respectively). This study was that the PI depends on gestation and birthweight and these other factors must be taken into account when determining neonatal risk.

The demographic outlook for orthodontists in Texas at the start of the next millennium.

Like all health care professionals, orthodontists are concerned about the need and demand for their services. Orthodontists should experience an increase in demand for their services as a result of an increasing population and an aging orthodontist population. How many additional orthodontic graduates do we need per year in Texas? Based on many factors, Texas dental schools could graduate additional students per year to be consistent with those factors. In conclusion, it appears that Texas can easily support three graduate orthodontic residency programs. As we enter the next millennium, the future of orthodontics has never looked better.

Symptom differences and pretreatment asymptomatic interval affect outcomes of stenting for intracranial atherosclerotic disease.

BACKGROUND AND PURPOSE: Different types of symptomatic intracranial stenosis may respond differently to interventional therapy. We investigated symptomatic and pathophysiologic factors that may influence clinical outcomes of patients with intracranial atherosclerotic disease who were treated with stents. MATERIALS AND METHODS: A retrospective analysis was performed of patients treated with stents for intracranial atherosclerosis at 4 centers. Patient demographics and comorbidities, lesion features, treatment features, and preprocedural and postprocedural functional status were noted. χ(2) univariate and multivariate logistic regression analysis was performed to assess technical results and clinical outcomes. RESULTS: One hundred forty-two lesions in 131 patients were analyzed. Lesions causing hypoperfusion ischemic symptoms were associated with fewer strokes by last contact [χ(2) (1, n = 63) = 5.41, P = .019]. Nonhypoperfusion lesions causing symptoms during the 14 days before treatment had more strokes by last contact [χ(2) (1, n = 136), 4.21, P = .047]. Patients treated with stents designed for intracranial deployment were more likely to have had a stroke by last contact (OR, 4.63; P = .032), and patients treated with percutaneous balloon angioplasty in addition to deployment of a self-expanding stent were less likely to be stroke free at point of last contact (OR, 0.60; P = .034). CONCLUSIONS: More favorable outcomes may occur after stent placement for lesions causing hypoperfusion symptoms and when delaying stent placement 7-14 days after most recent symptoms for lesions suspected to cause embolic disease or perforator ischemia. Angioplasty performed in addition to self-expanding stent deployment may lead to worse outcomes, as may use of self-expanding stents rather than balloon-mounted stents.

Stent-assisted coiling versus coiling alone in unruptured intracranial aneurysms in the matrix and platinum science trial: safety, efficacy, and mid-term outcomes.

BACKGROUND AND PURPOSE: Stent-assisted coiling may result in less aneurysm recanalization but more complications than coiling alone. We evaluated outcomes of coiling with and without stents in the multicenter Matrix and Platinum Science Trial. MATERIALS AND METHODS: All patients in the Matrix and Platinum Science Trial with unruptured intracranial aneurysms treated per protocol were included. Baseline patient and aneurysm characteristics, procedural details, neurologic outcomes, angiographic outcomes, and safety data were analyzed. RESULTS: Overall, 137 of 361 (38%) patients were treated with a stent. Stent-coiled aneurysms had wider necks (≥4 mm in 62% with stents versus 33% without, P < .0001) and lower dome-to-neck ratios (1.3 versus 1.8, P < .0001). Periprocedural serious adverse events occurred infrequently in those treated with and without stents (6.6% versus 4.5%, P = .39). At 1 year, total significant adverse events, mortality, and worsening of mRS were similar in treatment groups, but ischemic strokes were more common in stent-coiled patients than in coiled patients (8.8% versus 2.2%, P = .005). However, multivariate analysis confirmed that at 2 years after treatment, prior cerebrovascular accident (OR, 4.7; P = .0089) and aneurysm neck width ≥4 mm (OR, 4.5; P = .02) were the only independent predictors of ischemic stroke. Stent use was not an independent predictor of ischemic stroke at 2 years (OR, 1.1; P = .94). Stent use did not predict target aneurysm recurrence at 2 years, but aneurysm dome size ≥10 mm (OR, 9.94; P < .0001) did predict target aneurysm recurrence. CONCLUSIONS: Stent-coiling had similar outcomes as coiling despite stented aneurysms having more difficult morphology than coiled aneurysms. Increased ischemic events in stent-coiled aneurysms were attributable to baseline risk factors and aneurysm morphology.

Comparison of facial morphologies between adult Chinese and Houstonian Caucasian populations using three-dimensional imaging.

The objective of this study was to compare the facial morphologies of an adult Chinese population to a Houstonian white population. Three-dimensional (3D) images were acquired via a commercially available stereophotogrammetric camera system, 3dMDface™. Using the system, 100 subjects from a Houstonian population and 71 subjects from a Chinese population were photographed. A complex mathematical algorithm was performed to generate a composite facial average (one for males and one for females) for each subgroup. The computer-generated facial averages were then superimposed based on a previously validated superimposition method. The facial averages were evaluated for differences. Distinct facial differences were evident between the subgroups evaluated. These areas included the nasal tip, the peri-orbital area, the malar process, the labial region, the forehead, and the chin. Overall, the mean facial difference between the Chinese and Houstonian female averages was 2.73±2.20mm, while the difference between the Chinese and Houstonian males was 2.83±2.20mm. The percent similarity for the female population pairings and male population pairings were 10.45% and 12.13%, respectively. The average adult Chinese and Houstonian faces possess distinct differences. Different populations and ethnicities have different facial features and averages that should be considered in the planning of treatment.

The development and preliminary evaluation of a proposed new scoring system for videolaryngoscopy.

Clear documentation of anaesthetic technique, difficulties and complications is an essential part of good anaesthetic practice, particularly in the area of airway management. The current convention of describing intubation using a videolaryngoscope only in terms of a Cormack and Lehane score is at best unhelpful and at worst dangerous. In an attempt to address the inadequacy of a Cormack and Lehane score to describe videoscopic intubation, we propose a three part scoring system: view, ease and device - the 'Fremantle Score'. Preliminary evaluation of this system in a diverse group of anaesthetists utilising four available videolaryngoscopes in a simulated normal and difficult airway manikin has demonstrated that the system is easy to use, easy to understand and relevant. In three of the eight device and manikin combinations studied, the videolaryngoscopic view correlated with the ease of intubation. This highlights the need for an alternative tool to describe intubation with a videolaryngoscope. We consider this development of a specific videoscopic scoring system a first step in better describing intubation by a videolaryngoscope and improving patient care.

Delayed transcutaneous extrusion of embolic coils after embolization of facial artery pseudoaneurysm.

External carotid artery (ECA) pseudoaneurysm is a known complication of treatment for head and neck cancer. We report a case of facial artery pseudoaneurysm arising after irradiation and salvage surgery for advanced tonsillar cancer, that was treated with endovascular embolization. The case was complicated by delayed transcutaneous extrusion of embolization coils through the skin of the anterior neck. We review the literature for related cases of coil extrusion in the head and neck, and discuss the implications for pseudoaneurysm surveillance.

Pediatric intracranial nongalenic pial arteriovenous fistulas: clinical features, angioarchitecture, and outcomes.

BACKGROUND AND PURPOSE: NGAVFs are rare vascular malformations usually presenting in infancy or childhood. We sought to identify clinical and angiographic predictors of clinical outcome for these lesions. MATERIALS AND METHODS: Retrospective review of a neurointerventional data base identified 386 pediatric patients with intracranial AVFs and AVMs, from which a cohort of 25 patients with NGAVF were selected for medical record and imaging analysis. RESULTS: NGAVFs constituted 7.3% of pediatric intracranial vascular lesions with a nondural arteriovenous shunt. Seven of 8 patients who presented in the first month of life had CHF and harbored large, complex fistulas with multiple sites of arteriovenous shunting. Single-hole fistulas predominated later in childhood and more frequently presented with seizures, hemorrhage, or focal neurologic deficits. More treatment procedures were performed in subjects presenting at ≤ 2 years of age compared with older children (median = 3 versus 2, P = .041), and in those harboring a multi-hole fistula versus those with a single-hole fistula (median = 3 versus 2, P = .003). Eighteen patients (72%) had complete posttreatment elimination of NGAVF shunting. Compared with patients presenting at >2 years of age, patients presenting in the first 2 years of life were more likely to have a multi-hole fistula (100% versus 25%, P = .0001) and to have a poor clinical outcome (54% versus 0%, P = .0052), defined as a pediatric mRS of ≥ 3. CONCLUSIONS: The morbidity of NGAVF appears higher than previously reported despite a somewhat higher rate of angiographic cure. Poor clinical outcome occurred primarily in patients with multi-hole NGAVFs presenting at ≤ 2 years of age.