Surface electromyography before and after orthognathic surgery and condylectomy in active laterognathia: a case report.

BACKGROUND: Condylar hyperplasia is a rare bone disease characterised by excessive development of mandibular condyle, which can lead to the development of asymmetric facial deformity together with malocclusion, mandibular deviation, TMJ and masticatory musculoskeletal system dysfunction. There is not a treatment protocol universally accepted. In order to determine the correct management, treatment and intervention timing of these patients, morphological examinations should be coupled with functional assessments. CASE REPORT: In the present case report, morphological (bone scintigraphy; orthopantomography; posteroanterior and lateral cephalograms; 3D facial photographs) and functional (surface electromyography of masseter and temporalis muscles) quantitative data of a 20-year-old male patient affected by unilateral condylar hyperplasia are presented. The patient underwent a surgical treatment with high unilateral condylectomy associated to a maxillary Le Fort I osteotomy; as well as orthodontic treatment before and after surgery. Facial morphology and masticatory muscles activity were assessed before surgery and followed-up 6, 12 and 24 months after surgery. Twenty-four months after surgery, all electromyographic values were normal, and soft-tissue facial asymmetry was negligible at 3D assessment. CONCLUSION: Surface electromyography joins a set of clinical and morphological diagnostic tests that help the surgeon in planning the operation and managing the post-surgical patient.

Three-dimensional analysis of jaw kinematic alterations in patients with chronic TMD - disc displacement with reduction.

The study investigated whether chronic TMD patients with disc displacement with reduction (DDR), performing non-assisted maximum jaw movements, presented any changes in their mandibular kinematics with respect to an age-matched control group. Moreover, it was examined whether jaw kinematics and a valid clinic measure of oro-facial functional status have significant associations. Maximum mouth opening, mandible protrusion and bilateral laterotrusions were performed by 20 patients (18 women, 2 men; age, 18-34 years) and 20 healthy controls (17 women, 3 men; age, 20-31 years). The three-dimensional coordinates of their mandibular interincisor and condylar reference points were recorded by means of an optoelectronic motion analyser and were used to quantitatively assess their range of motion, velocity, symmetry and synchrony. Three functional indices (opening-closing, mandibular rototranslation, laterotrusion - right and left - and protrusion) were devised to summarise subject's overall performance, and their correlation with the outcome of a clinical protocol, the oro-facial myofunctional evaluation with scores (OMES), was investigated. TMD patients were able to reach maximum excursions of jaw movements comparable to healthy subjects' performances. However, their opening and closing mandibular movements were characterised by remarkable asynchrony of condylar translation. They had also reduced jaw closing velocity and asymmetric laterotrusions. The functional indices proved to well summarise the global condition of jaw kinematics, highlighting the presence of alterations in TMD-DDR patients, and were linearly correlated with the oro-facial functional status. The jaw kinematic alterations seem to reflect both oro-facial motor behaviour adaptation and a DDR-related articular impairment.

Three-dimensional longitudinal evaluation of facial mimicry in orthognathic class III surgery.

The effect of bimaxillary orthognathic surgery on facial mimicry was assessed longitudinally in 15 patients with dentoskeletal class III facial dysmorphism (seven men, eight women, mean age 28 years). The patients were analysed pre-surgery and at 6, 12, and 24 months post-surgery while performing verbal (five vowels) and non-verbal (open and closed mouth smile, lip purse) soft tissue facial movements. The three-dimensional motions of right and left nasogenian, crista philtri, cheilion, and lower lip landmarks were detected by an optoelectronic instrument, and a total mobility index was obtained. Differences between the sides were quantified by the symmetry index. Patient values were compared to those collected previously from healthy volunteers by computing z-scores. On average, no significant differences were found in the mobility of the buccal soft tissues at 24 months after surgery (ANOVA P-value, range 0.075-0.808), with positive median z-scores (pooled mean value close to 0.6). Symmetry indices ranged around the control reference values, showing no stage-related differences (Friedman test P-value, range 0.252-0.937), and exceeding 90% for all movements at 24 months after surgery. Bimaxillary osteotomy does not compromise facial mimicry in either verbal or non-verbal facial movements.

Evaluation of three-dimensional mandibular movements after reconstruction with free fibula flap.

Seven patients who underwent mandibular reconstruction with a fibula free flap (one on the midline, six on either right or left side) and were rehabilitated with implant supported prostheses, performed free mandibular border movements (maximal mouth opening and closing, right and left lateral excursions, protrusion) that were recorded by a non-invasive motion analyser. Temporomandibular joint (TMJ) kinematic parameters were compared to those calculated in healthy control subjects using z-scores. Maximum mouth opening was reduced in all patients, with z-scores ranging from -2.742 to -0.106, and performed with a reduced sagittal plane mandibular rotation. Interincisal point forward movement during protrusion was reduced in all but one patient. Lateral mandibular movements (displacement of the interincisal point) and bilateral condylar movements during mouth opening were very variable and sometimes asymmetrical. Mandibular rotation was also variable, with z-scores ranging from -1.265 to 1.388. Together with mandibular range of motion, we investigated biomechanical characteristics of TMJ motion that can provide further information about the joint without submitting the patient to harmful procedures, and that can be followed-up during healing. The investigation indicates those areas that need to be given special attention in preoperative planning, patient information and rehabilitation.

A new method for separate lung ventilation.

Separate lung ventilation is obtained with selective intubation of the main bronchus by an appropriate cuffed tube inserted through a standard orotracheal tube. Ventilation is carried out separately through the bronchial tube on one side and the residual tracheal tube lumen on the other side. This method, used in 144 patients, greatly simplifies the technique of bronchial intubation and offers many advantages over commercially available double-lumen tubes.

Cefotaxime therapy of lower respiratory tract infections in intensive-care patients.

Cefotaxime is one of two third-generation cephalosporins (the other being ceftriaxone) that undergo significant metabolism and is the only third-generation cephalosporin for which an active metabolite has been identified. Cefotaxime was administered intravenously in doses of 6 g per day to 20 patients with serious infections of the lower respiratory tract due to organisms susceptible to cefotaxime (isolates of Enterobacteriaceae and of Pseudomonas aeruginosa). It was administered with gentamicin in some high-risk patients. Cefotaxime resulted in mean peak concentrations of 32 mu/ml (cv% = 53) and of 29.5 micrograms/ml (cv% = 65) respectively after the first and after the last dose of a regimen of 2 g every 8 hours. The half-life value averaged 1.8 h and 6.4 h for cefotaxime and its desacetyl metabolite respectively. The average value of the metabolite at the end of short infusion was 11.5 micrograms/ml (cv% = 31) after the initial dose and 15.5 micrograms/ml (cv% = 37) after the last administered dose. Overall results were 75% patients cured or improved; 83% of the patients with nosocomial pulmonary infections due to Enterobacteriaceae were cured; 50% of the patients with Pseudomonas aeruginosa infections were cured and 25% improved despite the pathogen not being eradicated. No serious toxicity was observed.

Dosing problems of gentamicin in critically ill patients.

Twenty critically ill patients with a diagnosis of possible or documented Gram-negative sepsis received gentamicin sulphate by i.v. short infusion (30 min). The same daily dose was administered in a variable frequency regimen (ten were treated by an 8 h frequency regimen and ten by a 12 h frequency regimen). Repeated measurements of gentamicin plasma levels and of serum creatinine, albumin, total proteins and haematocrit were performed simultaneously, with measurements of tubular casts, alkaline phosphatase, leucine aminopeptidase and gamma-glutamyl-transpeptidase activity in urine. There was a considerable variation in plasma gentamicin concentrations among individuals patients and in the same patient from day to day with each dosage regimen. Despite the daily administration of at least 5 mg/kg/day of gentamicin, nephrotoxicity occurred in only one patient. The mean duration of therapy was about ten days. Although the series of patients was small, no significant difference was reported in either the 8 or 12 h dosage regimen in respect to favourable response to treatment among the patients. Probably a high peak concentration greatly exceeding the minimal inhibitory concentration (MIC) for a short duration, kills Gram-negative bacteria as effectively as a long concentration exceeding the MIC for a longer period of time. The reported half-lives and area under curve values for gentamicin in our patients varied widely even in the same patient.

[Problems in anesthesia and resuscitation in the surgical treatment of brain neoplasms]. / Problemi di anestesia e rianimazione nel trattamento chirurgico delle neoplasie cerebrali.

The Authors analyse and discuss some particular problems related to anaesthesia in neurosurgery according to the patient's clinical and neurological status and to the surgical treatment. The evaluation of systemic and neurological physiopathology during pre-, per- and post-operative periods are important for this analysis. Therefore anaesthesia and intensive care methods are attentively discussed. Intracranial pressure, cerebral blood flow, metabolism, intracranial space-occupying lesions and surgical techniques are the main factors interfering with anaesthesia in neurological surgery.

[Anesthesiological considerations in surgery of cerebral aneurysms]. / Problemi anestesiologici nella chirurgia degli aneurismi cerebrali.

A well integrated and coordinated team between Neurosurgeon and Anesthetist is necessary to achieved the best results in aneurysm surgery. Drugs-induced hypotension, cerebral metabolic depressant drugs (such as thiopentone), new anaesthetic drugs, hypocapnia are the anaesthetic techniques of choice in intracranial aneurysm surgery.

Considerations on 200 cases of percutaneous cricothyroidotomy (minitracheotomy).

More than 10 yrs ago, minitracheotomy was suggested as an elective method in the treatment of sputum retention, resulting from impaired ability to cough, in many medical and surgical diseases. We report our experience of 200 cases of percutaneous cricothyroidotomy in our Intensive Care Unit (145 patients), and in other wards (55 patients). The results confirm that minitracheotomy is easy and quick to perform, well-accepted by patients, and free of relevant complications when the technique is performed correctly and sufficient care is adopted. About 60-70% of treated patients benefited by minitracheotomy and did not require more invasive interventions. A better control of technique, moreover, allowed other possible applications to be discovered.

Blood transfusion during cesarean section. A 12 years' retrospective analysis.

Transfusional practice over the last 12 years was investigated retrospectively in 1618 women submitted to lower-segment cesarean section. The overall percentage of transfused patients was low (2.4%) and it has become lower in the last four years (1.1%), in concomitance with the development of better knowledge of tissue oxygenation and with the fear of transmitting infectious diseases, factors which have led anesthesiologists to employ blood only when strictly required. Three conditions greatly increased the risk of bleeding: placenta previa, abruptio placentae and coagulation disorders. Previous cesarean section, fetal distress, dystocias and hypertensive disorders of pregnancy did not increase the risk of bleeding and no difference was found between elective and non-elective surgery. Since for elective surgery two units of blood were crossmatched, the crossmatched/transfused ratio (C/T ratio) was very high (60.8/1). To improve blood bank service efficiency, for surgical operations like cesarean section which rarely require blood, it is possible simply to recur to a type and screen (TS) procedure instead of crossmatching blood, but for categories of patients identified as being at high risk of bleeding--placenta previa, abruptio placentae, coagulation disorders--it is advisable to have crossmatched blood available in the operating theatre.

Fibrinolytic (rt-PA) therapy for superior vena cava thrombosis in a multiple trauma patient.

An adult multiple trauma patient (head injury with coma, blunt chest trauma, bone and pelvis fractures) developed superior vena cava thrombosis which extended to the right atrium as a complication of central venous catheterism. Since a four day heparin therapy was unsuccessful, the patient was treated with recombinant tissue-type plasminogen activator (rt-PA), 100 mg over three hours. Thrombolysis with rt-PA was not associated with cutaneous or internal bleeding and was partially effective (improvement of the clinical picture, disappearance of the right atrium thrombus, superior vena cava still occluded). Although our patient could have benefited from an additional administration of rt-PA, we did not start a second course because the risk of major hemorrhage increases over 100 mg. For its relative clot-selectivity rt-PA could be indicated when fibrinolytic treatment is required in multiple trauma patient, but safe and more efficacious regimens have still to be defined.

Facial mimicry after conservative parotidectomy: a three-dimensional optoelectronic study.

Facial nerve paralysis is one of several possible complications following conservative parotidectomy. To assess three-dimensional facial movements non-invasively in patients with unilateral facial palsy following parotidectomy for benign tumours, the three-dimensional coordinates of 21 soft-tissue facial landmarks were recorded in 32 patients (21 HB I, 5 HB II, 6 HB III-IV; 3 months post-surgery follow-up), and 40 control subjects, during the performance of facial movements (smile, 'surprise', eye closure, single eye closure). For all symmetric animations, control subjects had larger total mobility than patients; mobility progressively decreased in patients with larger clinical grades. For asymmetric eye closures, HB I patients and control subjects had similar total movements, while HB II patients had smaller movements, especially for the paretic side eye closure; smaller total movements were found in HB III-IV patients. The method allowed the quantitative detection of alterations in facial movements. Significant differences between patients and control subjects in the magnitude and asymmetry of movements were found.

Age changes of facial measurements in European young adult males: implications for the identification of the living.

Metric and morphological analyses of facial features are currently applied in cases of personal identification of the living on images acquired from video surveillance systems. However, facial assessment in the forensic context needs to be based on reliable comparative data for facial measurements. Facial changes in the age range of early adulthood (20-30 years) have been rarely described so far, although such knowledge would be beneficial for comparative personal identification on images. This study investigates changes in facial measurements in European males aged between 20 and 30 years in order to identify metric characters that can be used for personal identification in young adults. A sample of 404 males of European ancestry, aged between 20 and 30 years from Germany, Italy and Lithuania were recruited for this project. Fourteen facial measurements were taken and correlation coefficients were calculated for each cranial measurement with age. Only two measurements - labial width and physiognomic ear length - seem to change between 20 and 30 years with a positive statistically significant correlation (p<0.05). These results suggest caution for what may concern personal identification by assessment of ear and mouth morphology.

Three-dimensional analysis of labial morphology: effect of sex and age.

Morphological changes in the lips during ageing, including labial volume, area and thickness were assessed in healthy individuals. 40 healthy volunteers (20 men and 20 women) were selected and divided into two groups according to age: 21-34 years ('youthful' group) and 45-65 years ('aged' group). Three-dimensional (3D) stone labial models were made, digitized, and 3D virtual reproductions obtained. Labial thickness, vermilion area, and volume of the upper and lower lips were measured from the digital reconstructions. The data were compared using three-way ANOVA. All data were significantly larger in men than in women (p<0.05), the lower lip was thicker than the upper lip (p<0.001). A significant effect of age for labial thickness and area were found (p<0.001 and p=0.014): the youthful group had higher values than the aged group. Upper to lower lip ratios were not significantly different between sexes or ages. Generally, young people have a larger lip area and thickness than aged ones and men had larger lips than women. The upper/lower lip ratios for area and volume were similar in the two genders.

The effect of age and sex on facial mimicry: a three-dimensional study in healthy adults.

To assess sex- and age-related characteristics in standardized facial movements, 40 healthy adults (20 men, 20 women; aged 20-50 years) performed seven standardized facial movements (maximum smile; free smile; "surprise" with closed mouth; "surprise" with open mouth; eye closure; right- and left-side eye closures). The three-dimensional coordinates of 21 soft tissue facial landmarks were recorded by a motion analyser, their movements computed, and asymmetry indices calculated. Within each movement, total facial mobility was independent from sex and age (analysis of variance, p>0.05). Asymmetry indices of the eyes and mouth were similar in both sexes (p>0.05). Age significantly influenced eye and mouth asymmetries of the right-side eye closure, and eye asymmetry of the surprise movement. On average, the asymmetry indices of the symmetric movements were always lower than 8%, and most did not deviate from the expected value of 0 (Student's t). Larger asymmetries were found for the asymmetric eye closures (eyes, up to 50%, p<0.05; mouth, up to 30%, p<0.05 only in the 20-30-year-old subjects). In conclusion, sex and age had a limited influence on total facial motion and asymmetry in normal adult men and women.

[The preventive minitracheotomy as support in difficult intubations: a proposition. Description of a clinical case]. / La minitracheotomia preventiva quale supporto nella intubazione difficile: una proposta. Descrizione di un caso clinico.

The authors suggest preventive minitracheotomy as a support technique in difficult endotracheal intubation, and report their experience in a case of surgical operation to remove a bony neoformation of C1 and C2 posterior arcs. Endotracheal intubation, difficult because no part of the glottis could be seen, was made possible by preventive minitracheotomy. In this way sedation, myorelaxation and excellent oxygenation during following manoeuvre that resulted atraumatic, were obtained. The small cannula of minitracheotomy was maintained closed during the operation and open for 24 hours thereafter to prevent obstructive complications. It was then removed.

Ceftazidime in the treatment of Pseudomonas infections in intensive-care patients.

The present study was designed to define the clinical activity and pharmacokinetics of ceftazidime in Pseudomonas sp. infections. The intensive care patients included in this study were hospitalized for at least 2 weeks and have frequently received antibiotic treatment which contributed with poor host resistance to the infections with highly resistant Pseudomonas strains. Sixteen adult patients entered the study. Their age ranged from 18 to 70 years. Ceftazidime was administered in a dose of 2 g three times daily by a constant infusion over 20-30 min. Frequent clinical assessment multiple cultures and determination of renal, hepatic and bacteriological functions were performed. Bacterial cultures were obtained prior to the beginning of therapy and every 2-3 days thereafter with a follow-up period of about 1-2 weeks. Pharmacokinetics in the blood were performed. Measurements of ceftazidime were made by using HPLC. Mean peak serum concentration of ceftazidime was 58.5 micrograms/ml after administration of 2.0 g of ceftazidime and eight hours after dosing the mean plasma concentration was about 5 micrograms/ml. No accumulation of ceftazidime could be observed during the treatment period. Mean plasma half-life was 2.1 hours at the beginning and 2.2 hours at the end of therapy. The mean apparent volume distribution was 0.35 l/kg. No severe adverse effects were reported throughout the study. Ceftazidime may be effectively used as single antiinfective agent in various conditions and higher plasma concentrations are an important predictor of bacteriological and clinical response in pulmonary infections caused by Pseudomonas species.

[Electric cardioversion in pregnant patients with obstructive hypertrophic cardiomyopathy. A clinical case]. / Cardioversione elettrica in paziente gravida affetta da miocardiopatia ipertrofica ostruttiva. Caso clinico.

A case of atrial fibrillation during pregnancy in a woman at 30 weeks of gestation is described. She was affected by obstructive hypertrophic myocardiopathy, a rare disease usually non interfering with the normal course of pregnancy. The mortality rate is of 2-4% per year. The most frequent cause is "cardiac sudden death". High frequency atrial fibrillation can lead to right and left cardiac failure. The treatment of atrial fibrillation is to be chosen between a pharmacological or electrical therapy. However, during pregnancy, pharmacological cardioversion, although not excluded, could cause damaging side effects to the fetus. Conversely, according to literature, electrical cardioversion is effective on the mother and safer for the fetus. At admission the patient showed dyspnea, palpitations, tachycardia and hypotensions; ECG showed an atrial fibrillation at high frequency that required an immediate therapeutic decision. In the case we studied, we reported the recovery of cardiac rhythm with a single synchronized electric shock. Non alteration of fetal cardiac rhythm or uterine contractility was observed. Pregnancy went on without accidents until the 36th week, when a cesarean section was performed under general anaesthesia. We described our experience reviewing previous literature on the account of the rareness of the disease, its association to a pregnancy and the serious alterations of cardiac rhythm at the admission, which led us to take an immediate decision, safeguarding both the mother and the fetus.