Short term effects of interceptive expansion treatment: a prospective study.

OBJECTIVES: This prospective cohort study investigated the short term effects of interceptive orthodontic treatment with a removable expansion plate, evaluating the changes in occlusion in all its dimensions: transversal, sagittal and vertical. SUBJECTS AND METHODS: A total of 226 patients treated with a removable expansion plate (slow maxillary expansion, SME) by orthodontic residents at the Department of Orthodontics, University Hospitals Leuven, Belgium were included. The patients had a mean age of 8.5 years at the start of the treatment. The mean treatment time was 6.9 months. Transversal measurements (intercanine and intermolar width) and occlusal characteristics (molar occlusion, overjet, overbite and functional shift) were collected before (T0) and after active treatment (T1). Statistical analysis was performed using the Wilcoxon signed rank test, Sign test and McNemar test for assessing changes between T0 and T1. Linear models were used to assess the associations between patient factors and the amount of expansion. RESULTS: A significant increase in transversal width at different occlusal landmarks was found. Correction of unilateral, bilateral and frontal crossbites was successful in 99.0%, 95.2% and 93.6% of the cases respectively. Changes in sagittal molar occlusion were significant: 64.9% (right side) and 62.6% (left side) remained stable, 28.4% (right) and 29.3% (left) improved and 6.7% (right) and 8.1% (left) deteriorated. Overbite changes were found to be statistically significant, though clinically irrelevant. Overjet changes were non-significant. CONCLUSIONS: A removable expansion plate is successful in improving the transversal dental dimensions of the maxilla. Statistically significant sagittal effects on molar occlusion were found. Long-term follow-up is needed to evaluate the long-term stability of this treatment.

Usability of dexmedetomidine for deep sedation in infants and small children with respiratory morbidities.

BACKGROUND: Children with respiratory morbidities are at increased risk of developing adverse respiratory events while undergoing deep sedation. Dexmedetomidine possesses sedative properties with minimal respiratory depression. This report aimed to determine the usability of dexmedetomidine in children with significant respiratory morbidities who require deep sedation. METHODS: Medical records of children with ASA classification III who had at least three characteristics of respiratory morbidities and who received dexmedetomidine sedation for magnetic resonance imaging (MRI) between January 2014 and May 2015 were retrospectively reviewed. Dexmedetomidine was administered as a bolus of 1 µg/kg over 10 min followed by 1 µg/kg/h infusion. If necessary, an additional bolus dose was given and the infusion rate was increased to 2 µg/kg/h. Respiratory morbidities, haemodynamic parameters, total dexmedetomidine dose, adverse cardiorespiratory events and sedation characteristics were analysed. RESULTS: Nineteen out of 642 children who underwent MRI were eligible for evaluation. Seventeen children (89%) had at least four characteristics of respiratory morbidities. The median [IQR] age was 9 months [3.5-14]. All patients completed MRI scans while breathing spontaneously via the native airway. No episodes of adverse respiratory events or haemodynamic instability were observed. Children who were administered a lower dexmedetomidine dose and had a shorter sedation time were more likely to be younger than 1 year of age. CONCLUSION: These data demonstrate that dexmedetomidine deep sedation was well-tolerated in children with significant respiratory morbidities. Moreover, children younger than 1 year of age were administered lower dexmedetomidine dose than children older than 1 year of age for the same sedation level. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02555605.

Burkitt Lymphoma Mimicking an Acute Appendicitis in a 17 Years Old Boy: a Case Report.

Burkitt lymphoma belongs to the B cell non-Hodgkin tumors and is known as the fastest growing human tumor. It is mostly seen in children and young adults. Typically for this type of lymphoma is the chromosomal translocation that leads to a deregulated expression of the c-myc oncogene. Our case report describes a 17 year old patient who presents with atypical right lower quadrant pain. He underwent an explorative laparoscopy and a Burkitt lymphoma was discovered. Subsequently several imaging studies were performed to stage the disease. Intensive systemic chemotherapy is the choice of treatment. Surgery can have a role in early stages and acute complications of the tumor but frequently the role of surgery is restricted to histological biopsy.

Trends in embryo disposition decisions: patients' responses to a 15-year mailing program.

BACKGROUND: This study examined the responses of patients of a Belgian fertility center to mailed requests to make or renew an embryo disposition decision (EDD), over a period of 15 years, to investigate trends in the decisions. METHODS: A retrospective analysis was performed on a mailing program from 1992 to 2006, for patients, of the Department of Reproductive Medicine, Ghent University Hospital (Belgium), from whom embryos had been cryopreserved at least 2 years. RESULTS: In 15 years, 3840 EDD forms were prepared for 2334 couples or female patients. The number of forms increased from 21 in 1992 to 558 in 2006. Each year, around a third of the forms were not returned. In general, a quarter of patients who received more than one form never answered. Donation to others for reproduction was overall the least popular option and decreased over the years. The rising trend in decisions to discard reversed into a negative trend from the introduction of donation for science (1997). Since then, donation for science has been the most popular option and its popularity increased with time. In 15 years, 2504 embryos were donated for science. More than a quarter of the patients who chose more than one final EDD in different years did not select the same EDD the second time. CONCLUSIONS: This study showed a positive trend in donation for science and a negative trend in donation to others and discarding. A substantial number of individual patients chose different types of EDDs in consecutive mailings, which shows that advance EDD directives should be used with caution.

To continue or discontinue storage of cryopreserved embryos? Patients' decisions in view of their child wish.

OBJECTIVE Cryopreservation of supernumerary embryos resulting from IVF treatment offers extra chances to conceive. The objective of this study is to describe patients' decisions to continue or discontinue storage of their embryos after a minimum storage period of 2 years. METHODS Female patients who had embryos stored at the Infertility Centre of the Ghent University Hospital (Belgium) were sent a mail questionnaire to be completed anonymously. RESULTS The questionnaire had a response rate of 79% (326/412). After an embryo storage period of at least 2 years, 40% of the couples who were still together wished to continue storage of their embryos. Half of these had no concrete plans for a transfer and wanted to postpone the decision or keep all options open. For those who decided to discontinue storage (60%), the main reason was the completion of their families. Despite the fact that the patients' child wish was the main factor in their storage decision, two groups of patients with distinct profiles made decisions that were inconsistent with their child wish: those who wanted to continue storage while not wanting a(nother) child (7% of those with no child wish), and those who wanted a(nother) child but decided to discontinue storage (25% of those with a child wish). Overall, these patients more often expressed emotional difficulties regarding this decision. CONCLUSIONS This study demonstrates the importance of gaining more insight into patients' embryo storage decisions (along with their embryo disposition decisions) and into the emotional factors playing a role in patients' decision-making.

Patients' conceptualization of cryopreserved embryos used in their fertility treatment.

BACKGROUND: Although IVF treatments using cryopreserved embryos are offered by most infertility centres, little is known about patients' opinions regarding treatment using these embryos. The objective of this study is to describe how patients think about (treatment with) cryopreserved embryos. METHODS: In-depth interviews based on the method of interpretative phenomenological analysis were conducted with patients undergoing IVF/ICSI treatment at the Department of Reproductive Medicine of the Ghent University Hospital between May and July 2006. Seven couples (one couple considered as one participant) and 11 female patients who attended the clinic without their partner were interviewed. RESULTS: Most participants knew little about medical-technical procedures involved in treatment with cryopreserved embryos. This was compensated by a high confidence in the medical team. However, seven of the eighteen participants thought the quality of cryopreserved embryos diminished during the storage period. A lack of knowledge about medical-technical procedures was compensated by metaphors related to other domains of experience, especially kitchen metaphors: this might add to the belief that frozen embryos have an expiry date. However, none of the patients who considered treatment with cryopreserved embryos as less effective ever thought of refusing this type of treatment or discussed this with medical staff. In addition, patients rarely discussed the moral status of their cryopreserved embryos. CONCLUSIONS: The beliefs of infertile patients about (the effectiveness of treatment with) cryopreserved embryos encompass misconceptions, and doubts and fears which may influence their decision-making but which are seldom discussed with the medical staff.

Reflections by patients who undergo IVF on the use of their supernumerary embryos for science.

Interviews were conducted with patients undergoing treatment at the department for reproductive medicine at the University Hospital of Ghent, Belgium to describe how patients think about the use of embryos for science and how patients' views are related to their decision whether or not to donate their supernumerary embryos for science. Most participants knew little about the use of embryos for science. The perception of science and scientists, rather than the perception of the embryo, played an important role in the disposition decision making. The feeling of not having control over what would happen to their embryo and the fear that scientists would allow their embryo to develop into children were the main arguments against donation. This showed the importance of information about scientific research with embryos, such as the 14-day limit to keep embryos alive. Half of the participants pictured the medical team as the requesting party for their embryos and those who were not willing to donate indicated that they could be persuaded when asked directly by their caregivers. In conclusion, this study suggests that the perception of science, rather than the perception of the embryo, plays an important role in the decision to donate for science.

Infertility patients' beliefs about their embryos and their disposition preferences.

BACKGROUND: Little research has been done on how beliefs of infertility patients about their embryos are related to their disposition decisions. The objective of this study was to describe how patients speak about their embryos, in moral (e.g. status) and non-moral terms, and to investigate how patients' narratives are related to their disposition preferences. METHODS: In-depth interviews based on the method of interpretative phenomenological analysis were conducted with patients undergoing IVF/ICSI treatment between May and July 2006. RESULTS: Seven couples and 11 female patients were interviewed. Six major themes emerged from the narratives of the participants when they spoke about their embryos: (i) a medical-technical perspective; (ii) feelings; (iii) genetic link to oneself and/or one's partner; (iv) symbolic meaning of the relationship between the infertile partners; (v) moral status and (vi) instrumental value. All but two participants spontaneously considered the embryo disposition options as a two-stage decision sequence. In the first step, they considered donation to another couple for reproductive purposes. At this stage, the presence of the themes 'genetic link' and 'symbol of the relationship' was linked with a clear reluctance to donate. In the second step of the decision-making process, the option of donation for research and discarding were considered. At this stage, participants' confidence in medical science and the instrumental value they attached to the embryo were related to their decisions. CONCLUSIONS: Patients' conceptualization of their embryos plays an important role in embryo disposition decisions. Our research showed that patients deal with these decisions in a two-stage decision sequence.

Proinflammatory response of human leukemic cells to dsRNA transfection linked to activation of dendritic cells.

Leukemic cells exert immunosuppressive effects that interfere with dendritic cell (DC) function and hamper effective antileukemic immune responses. Here, we sought to enhance the immunogenicity of leukemic cells by loading them with the double-stranded (ds) RNA Toll-like receptor 3 (TLR3) ligand polyriboinosinic polyribocytidylic acid (poly(I:C)), mimicking viral infection of the tumor cells. Given the responsiveness of DC to TLR ligands, we hypothesized that the uptake of poly(I:C)-loaded leukemic cells by immature DC (iDC) would lead to DC activation. Primary acute myeloid leukemia (AML) cells and AML cell lines markedly responded to poly(I:C) electroporation by apoptosis, upregulation of TLR3 expression, enhanced expression of major histocompatibility complex (MHC) and costimulatory molecules and by production of type I interferons (IFN). Upon phagocytosis of poly(I:C)-electroporated AML cells, DC maturation and activation were induced as judged by an increased expression of MHC and costimulatory molecules, production of proinflammatory cytokines and an increase of T helper 1 (T(H)1)-polarizing capacity. These immune effects were suboptimal when AML cells were passively pulsed with poly(I:C), indicating the superiority of poly(I:C) transfection over pulsing. Our results demonstrate that poly(I:C) electroporation is a promising strategy to increase the immunogenicity of AML cells and to convert iDC into activated mature DC following the phagocytosis of AML cells.

Medical costs of treatment and survival of patients with acute myeloid leukemia in Belgium.

The advent of new cell-based immunotherapies for leukemia offers treatment possibilities for certain leukemia subgroups. The wider acceptability of these new technologies in clinical practice will depend on its impact on survival and costs. Due to the small patient groups who have received it, these aspects have remained understudied. This non-randomized single-center study evaluated medical costs and survival for acute myeloid leukemia between 2005 and 2010 in 50 patients: patients treated with induction and consolidation chemotherapy (ICT) alone; patients treated with ICT plus allogeneic hematopoietic stem cell transplantation (HCT), which is the current preferred post-remission therapy in patients with intermediate- and poor-risk AML with few co-morbidities, and patients treated with ICT plus immunotherapy using autologous dendritic cells (DC) engineered to express the Wilms' tumor protein (WT1). Total costs including post- consolidation costs on medical care at the hematology ward and outpatient clinic, pharmaceutical prescriptions, intensive care ward, laboratory tests and medical imaging were analyzed. Survival was markedly better in HCT and DC. HCT and DC were more costly than ICT. The median total costs for HCT and DC were similar. These results need to be confirmed to enable more thorough cost-effectiveness analyses, based on observations from multicenter, randomized clinical trials and preferably using quality-adjusted life-years as an outcome measure.

Bortezomib-induced Sweet's syndrome.

Sweet's syndrome is an uncommon acute skin disease, associated with a variety of medical problems. The drug-induced variant is even rarer. We describe two cases of this syndrome associated with the administration of the proteasome inhibitor bortezomib. The diagnostic criteria for drug-induced Sweet's syndrome as proposed by Walker and Cohen were fulfilled. Vasculitis and neutrophilic eccrine hidradenitis were excluded.

Plerixafor prescription modalities in autologous haematopoietic stem cell mobilization in Belgium.

OBJECTIVES: The efficacy and safety of plerixafor, an antagonist of the CXCR4 receptor, in combination with G-CSF has been demonstrated in patients suffering from Iymphoma and multiple myeloma (MM) eligible for autologous haematopoietic stem cell collection. However, different reimbursement criteria have been applied in different countries to select patients eligible for treatment with plerixafor. The objective of this observational study was to describe the plerixafor prescription modalities in daily practice in Belgium. METHODS: This open-label, prospective, observational study was conducted in 11 Belgian centres in 114 patients with lymphoma (Hodgkin's and non-Hodgkin's lymphoma) or MM who were treated with plerixafor according to the SmPC between April 2011 and October 2012. Patients included in another clinical trial with plerixafor were excluded from the study. RESULTS: The use of plerixafor in patients with MM or lymphoma was effective, with a success rate (defined as a total yield >2×10(6) CD34+ cells/kg) of 77%, and well tolerated (one SAE reported). Optimal collection (defined as a total yield >4×10(6) CD34+ cells/kg) was obtained for 43% of the study population (31% in lymphoma patients, compared to 61% in patients with MM). The use of plerixafor was in line with the SmPC and the Belgian reimbursement criteria for all patients. CONCLUSION: This study is showing that the use of plerixafor according to Belgian reimbursement criteria results in similar efficacy and safety as in other centres and countries worldwide.

Endoscopic unroofing of a bronchogenic cyst.

Flexible fiberoptic bronchoscopy (FFB) has become common practice for pediatric pulmonologists, allowing easier detection of certain abnormalities at an earlier stage. We report the endoscopic diagnosis of a large mediastinal bronchogenic cyst and its successful endoscopic unroofing in a symptomatic baby.

Folate and Vitamin B(12) deficiency presenting as pancytopenia in pregnancy: a case report and review of the literature.

We present a case of extreme pancytopenia in a 27-year-old pregnant woman. The initial picture was compatible with a severe hematological problem in the category of aplastic anemia, paroxysmal nocturnal hemoglobinuria or even acute leukemia. The further biochemical investigations revealed, however, a folate deficiency. Nowadays this is a very rare cause of pancytopenia. Next to this she also had a Vitamin B(12) deficiency due to intrinsic factor failure. The recent literature is discussed.

Sucrose-induced shrinkage of in vitro produced bovine morulae: effect on viability, morphology and ease of evaluation.

Sucrose (0.3 M) was used to cause artificial compaction of the embryonic cell mass of in vitro produced bovine embryos to facilitate morphological evaluation. Embryos were produced using routine in vitro maturation (IVM) and fertilization (IVF) techniques. The time necessary to induce shrinkage in 0.3 M sucrose to 75% of the original volume of Day 5 morulae was found to be less than l min, and 95% of the volume was regained in PBS after 2.5 min. No detrimental effect was observed after a 5- to 10-min sucrose treatment on subsequent blastocyst formation at Days 6 and 7 (P > 0.05). Furthermore, no significant differences were observed in the total number of cells, or in the mitotic and pycnotic cell index of blastocysts in different treatment groups. Agreement among 7 evaluators grading 40 Day 6 embryos was examined using the kappa coefficient of agreement (kappa). Overall agreement among evaluators for classification of quality grade was poor (48.2 %, kappa = 0.31) for embryos evaluated in PBS, but the rate improved when the same embryos were scored in sucrose (62.5 %, kappa = 0.49). Evaluating less compact in vitro produced bovine morulae in sucrose increases agreement among evaluators, since embryos in sucrose mimick the appearance of in vivo produced embryos. Thus, we conclude that scoring in vitro produced embryos in sucrose improves agreement among evaluators.

Efficacy of lorazepam oral fast dissolving drug formulation (FDDF) in anesthesia premedication in adults: a double-blind placebo controlled comparison.

Lorazepam 4 mg oral fast dissolving drug formulation was compared to placebo in a double-blind study as premedicant in adult anesthesia. Lorazepam induced in this trial a marked relief of anxiety after 60 minutes without changes in vital parameters nor in reflex activity or muscle tonus. Anterograde amnesia was present in about 60 percent of the patients. The clinical anesthetists rated the quality of premedication as satisfactory or better in 77 percent of lorazepam treated patients. The rating as "good" or "excellent" by patients reached 93 percent. The incidence of side effects was low. Postoperative residual effects on attention, cognitive, somatic and visceral functions were present till 5 hours postmedication. Lorazepam FDDF (fast dissolving drug formulation) appeared to be an effective and clinically safe premedicant for its good anxiolytic and amnestic effect and its high acceptance by the patients. Its use is not recommended for outpatient anesthesia because it prolongs recovery from anesthesia.

Clinical assessment of midazolam for induction of anesthesia.

Intravenous midazolam was tried as a hypnotic agent for induction of anesthesia in 63 surgical patients. Three dosages were used: 0.2, 0.3 and 0.4 mg/kg body weight. Indices of induction, changes of vital parameters, incidence of apnea and side effects and the duration of the drug effect on central nervous system functions were evaluated. No significant differences were observed between the effects of the different doses of midazolam on the cardiac and respiratory parameters. The drug provided a satisfactory degree of sleep in all patients of maximal intensity at three minutes but anesthetic induction was not achieved in several patients of each dose group (overall failure rate 11%). A short-lasting apnea was seen in 13% of the patients and seemed not related to the administered dose of midazolam. The awareness of the surroundings was satisfactorily obtunded by the anti-recall effect of the drug. The sedative effects of midazolam on central nervous system functions lasted fairly long. Indeed, mental arousal, sensory functions and muscle tone still had not returned to preinjection values 20 min after midazolam administration. A reliable relationship between dose of midazolam and intensity of cerebral depressive effect was not evident.

Nonsteroidal anti-inflammatory drugs and paracetamol in children.

The cyclooxygenase enzymes produce large amounts of prostaglandins in presence of tissue injury and inflammation. Prostaglandins exert their influence on nerve membrane excitability both at the peripheral site and at the spinal dorsal horn. Their key role in peripheral tissue inflammation and central sensitization warrants their incorporation in pain management strategies for children. As the COX2 isoenzyme is the main target for controlling hyperalgesia, nonsteroidal anti-inflammatory drugs (NSAIDs) with high affinity for this enzyme will provide reliable antihyperalgesic effects. The benefits of NSAIDs for postsurgical pain therapy must be balanced against the risk of postoperative bleeding in children in whom any derangement of hemostasis could adversely affect outcome. If contraindications for NSAID use exist, paracetamol is the alternative. Paracetamol has potent antipyretic and analgesic effects, but no anti-inflammatory effect. The rectal route of administration is notoriously unreliable for eliciting an analgesic effect and the oral route is to be preferred. The dosage of paracetamol must take into account the pharmacokinetic properties of the drug in children. The maximum daily dosage should not be exceeded to avoid excessive production of a hepatotoxic metabolite.

A double-blind comparison of the efficacy of lorazepam FDDF versus placebo for anesthesia premedication in children.

Lorazepam was tried in a new formulation (FDDF) as premedication in twenty children, aged between 5-10 years. The study was performed in a double-blind fashion using lorazepam 1 mg and placebo in identical FDDF preparations. No significant differences were observed between the two treatment groups except for the recall of the venipuncture and awakening. Because of the lack of sedation observed the study was completed with an open trial on ten new subjects receiving 2 mg lorazepam FDDF. The quality of premedication was not found improved while more secretions were observed in the 2 mg lorazepam group. Recall of venipuncture and awakening was significantly less frequent in the 2 mg lorazepam group as compared to placebo. In both lorazepam groups awakening from anesthesia was prolonged. Side effects were reported in several patients receiving lorazepam. As lorazepam FDDF performed not better than a placebo as premedication for children its use is not recommended in pediatric anesthesia.

Midazolam for intramuscular premedication: dose-effect relationships compared to diazepam, fentanyl and fentanyl-droperidol in a placebo controlled study.

The clinical effects of midazolam (7.5, 10 and 15 mg), diazepam 10 mg, fentanyl 0.1 mg and fentanyl 0.1 mg-droperidol 5 mg, administered intramuscularly for surgical premedication, were compared in a double-blind placebo-controlled study. The degree of sedation provided by midazolam was significantly superior to diazepam, fentanyl or placebo. The largest dose of midazolam also impaired the lucidity of the patients and induced a moderate degree of muscular hypotony. A dose-effect relationship was observed only for the sedative effects of midazolam 60 min after administration. Midazolam scored consistently better than diazepam, fentanyl, placebo and fentanyl-droperidol for incidence of amnesia, stability of cardiovascular measurements and physician's acceptance. In all treatment groups, including placebo, anxiety decreased significantly with time. However, if expressed as percentage change, the greatest decrease occurred in the midazolam 15 mg group compared to all other treatments. Midazolam appeared to be a more effective premedicant than diazepam, analgesics or placebo. The intensity of the combined central nervous system effects suggested the dose of 10 mg might be the most suitable for intramuscular premedication.