Evaluation of bacterial flora composition on teeth and periodontal tissues in patients in treatment with rapid palatal expander.

Patients in treatment with rapid palatal expander (RPE) require professional assistance and more meticulous instructions on oral hygiene, since this appliance predisposes to gingivitis and caries. The aim of this work is to analyse the variability of the oral microbial flora found in patients in treatment with RPE with occlusal acrylic splint. It was also investigated whether the association of an antimicrobial mouthwash was useful during orthodontic treatment or whether regular and specific home oral hygiene manoeuvres were sufficient to maintain a good plaque control. The last goal was to highlight which of the different mouthwashes was the most effective in reducing the bacterial load. The patients were divided into 3 test groups and each one of them had a different mouthwash (chlorhexidine and sodium fluoride, fluorine, essential oils) randomly assigned. There was also a control group. Plaque samples were analysed through cultural analysis and PCR from T0 to T4 (8 months). Chlorhexidine mouthwash reduces the bacterial count by 96.08%, the fluorine by 94.50% and the essential oils by 95.74%. The results of the three mouthwashes are superimposable and although chlorhexidine gives the highest rate of bacteria reduction, its side effects lead the authors to prefer the essential oils.

Clinical predictors of fever in stroke patients: relevance of nasogastric tube.

OBJECTIVES: Fever frequently occurs in stroke patients and worsens their prognosis. However, only few studies have assessed the determinants of fever in acute stroke, and no study has specifically addressed the possible prediction of the development of fever. MATERIALS AND METHODS: This investigation included 536 patients with acute stroke and a body temperature <=37°C during the first 24 h of stay. Ninety-two of them (17.2%) subsequently developed fever (defined as a temperature >=37.5°C starting after 24 h). Among the clinical variables available during the first 24 h from admission, those predictive of the subsequent appearance of fever were searched for. One hundred further patients had a temperature >37°C during the first 24 h. RESULTS: In univariate analysis, many variables were predictive of the subsequent development of fever, but in multivariate analysis, only the following four predictors remained significant (odds ratio [95% confidence interval], P value): nasogastric tube (4.0 [2.2-7.4], <0.0001), atrial fibrillation (2.3 [1.4-3.8], 0.001), total anterior circulation syndrome (2.0 [1.2-3.5], 0.01), and urinary catheter (1.9 [1.1-3.3], 0.01). Among the 52 (9.7%) patients with three or four predictors, 31 (59.6%) subsequently developed fever. In addition, the factors independently associated with a temperature >37°C during the first 24 h were as follows: National Institutes of Health Stroke Scale (P < 0.0001), hemorrhagic stroke (P = 0.0008), atrial fibrillation (P = 0.002), and total parenteral nutrition (P = 0.03). CONCLUSIONS: In patients with acute stroke, four clinical variables were found to be independently associated with the risk of developing fever and, of them, nasogastric tube was the strongest and most significant one.

Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures.

UNLABELLED: Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. The field of cartilage repair is seeing the rapid development of new technologies that promise greater ease of application, less demanding rehabilitation and better outcomes. Concurrent procedures such as meniscal transplantation and osteotomy, however, remain of crucial importance to provide a normalized biomechanical environment for these new technologies. LEVEL OF EVIDENCE: Systematic review, Level II.

A simple scoring system for outcome prediction of ischemic stroke.

OBJECTIVES: According to most existing models, a computer is usually needed for predicting stroke outcome. Our purpose was to construct a simple and reliable prognostic scale not requiring the use of a calculating machine. MATERIALS AND METHODS: The scale [the Bologna Outcome Algorithm for Stroke (BOAS)] was obtained in 221 patients with ischemic stroke not undergoing thrombolysis and was then validated in a test group of 100 different patients. Outcome was assessed at 9 months as the number of dependent or dead patients (modified Rankin scale - mRS > 2). RESULTS: By a preliminary systematic univariate analysis, 25 of 415 baseline variables were found to be associated with a mRS > 2 independently of stroke severity and age. Subsequent multivariable analyses led to a final model based on five dichotomous risk factors (RF): National Institutes of Health Stroke Scale score ≥10, age ≥78, need of urinary catheter, oxygen administration, and persistence of upper limb paralysis at discharge from stroke unit. The patients with two or more RF (53%) had a mRS > 2 in 91% of cases and were dead in 42% of cases. With 0-1 RF, the two percentages were 24% and 2%, respectively (overall accuracy of prediction 83.9%, area under ROC curve [AUC] 0.891). In the test group, the accuracy was 79.0% and the AUC was 0.839. CONCLUSIONS: The need of urinary catheter, oxygen administration, and persistence of upper limb paralysis, together with stroke severity and advanced age, allow a simple and accurate prediction of dependency or death after ischemic stroke.

Correlations between serum lipids and complement components in adults without demonstrated atherosclerotic disease.

The variability due to age and sex and the reciprocal relations of serum IgG, IgA, IgM, C3, C4, total cholesterol (TC), HDL-cholesterol (HDL-C) and triglycerides (TG) were studied in 87 subjects (46 men and 41 women, aged 20-75 years) selected for the absence of significant atherosclerotic lesions. Serum IgA and C3 were higher in men than in women (P less than 0.05) mainly in the age group 41-60, while IgM and HDL-C were higher in women than in men (P less than 0.05 and P less than 0.01, respectively), especially in the age group 20-40. Direct univariate correlations with age were found for serum TC (P less than 0.0001), IgA (P less than 0.001), and C4 (P less than 0.01) but the latter correlations was confirmed only in women by multivariate analysis. These 3 variables had the major increment in the age group 41-60 in men, while in women the increase associated with age was more progressive or late. Univariate analysis showed a 'ring' of highly significant correlations (P less than 0.0001) involving serum lipids and complement components (TC-C4-C3-TG-TC). The correlation between TC and C4 was present only in men in multivariate analysis and improved with increasing age. These findings might represent a clue to explain the previously reported association between serum C4 and atherosclerosis.

Association of serum IgA antibodies to milk antigens with severe atherosclerosis.

The presence of antibodies of the IgA class against dietary antigens (bovine IgG (BGG), beta-lactoglobulin, casein, alpha-lactalbumin and xanthine oxidase, chicken ovalbumin and crude gliadin) was checked in the sera of 23 severely atherosclerotic subjects (ATS) and 20 highly selected controls (C). In these subjects an association between serum IgA levels and atherosclerosis had previously been shown. Determinations were performed by a micro-ELISA method and results were expressed as absorbances at 405 nm x 1000. Higher levels of IgA antibodies were found in ATS with respect to C against beta-lactoglobulin (respectively, 113.4 +/- 152.4 (1 SD) vs. 40.0 +/- 34.2; P less than 0.005) and casein (69.8 +/- 35.5 vs. 52.4 +/- 27.5; P less than 0.05). There was no difference in IgG and IgM against these 2 proteins between the 2 groups. Significant differences of prevalence of IgA antibodies were found for the following antigens: beta-lactoglobulin (4 C and 16 ATS over the limit value of 51; P less than 0.002), xanthine oxidase (1 C and 9 ATS over 289; P less than 0.01), BGG (7 C and 17 ATS over 87; P less than 0.02) and casein (5 C and 14 ATS over 60; P less than 0.02). These data suggest an association between anti-milk IgA antibodies and atherosclerosis. Its relevance and significance deserves further investigation.

Association of serum C3 levels with the risk of myocardial infarction.

PURPOSE: Serum complement and IgA levels have been found to be retrospectively associated with the presence of diffuse atherosclerosis. This study was performed to assess whether serum immunoglobulins and complement components are predictive of future ischemic events. PATIENTS AND METHODS: The baseline values of IgG, IgA, IgM, C3, and C4 were measured in the sera from a cohort of 860 inhabitants of the town of Brisighella, Italy. They were 444 men and 416 women, mean age 53.9 years (SD 12.4, range 23 to 84), who had not had any ischemic events (myocardial infarction [MI], angina pectoris, stroke, transient ischemic attack, or intermittent claudication) at the time of blood sampling in 1984. Their baseline values for the main recognized risk factors for atherosclerosis were known at baseline and for 4 years of follow-up. Multiple logistic regression analysis was performed for associations between ischemic events and immunologic variables (including serum IgG, IgA, IgM, C3, and C4) and risk factors for atherosclerosis (including age, sex, diastolic blood pressure, cigarette consumption, Quetelet index, total cholesterol, HDL cholesterol, triglycerides and blood glucose). RESULTS: During follow-up, 57 subjects experienced ischemic events, including 28 cases of coronary heart disease (17 MI and 11 angina pectoris). Of the immunologic variables studied, only serum C3 was found to be independently associated with ischemic events (P < 0.005 for any ischemic events, coronary heart disease, and MI). The population was divided into thirds according to C3 values. The cumulative incidence of MI was 7.1/1,000 in the low third, 10.6/1,000 in the middle third and 40.8/1,000 in the high third (risk ratio for high versus middle plus low = 4.2 after adjustment for age and sex; 95% CI 1.5 to 11.7). A separate analysis for the sexes showed that serum C3 was a particularly powerful predictor of MI in men. Men whose C3 levels were in the top third had a 72.6/1,000 incidence of MI while the incidence in the rest of the male population was 6.2/1,000 (risk ratio 10.7 after adjustment for age; 95% CI 2.3 to 49.0). When similar analyses were performed for angina pectoris, stroke, and intermittent claudication, no significant increase in risk was found to be associated with serum C3. CONCLUSION: C3 levels measured in sera from male subjects without previous ischemic events are independently associated with the risk of MI.

Method for reconstruction of the anterior cruciate ligament using the semitendinosus tendon.

There is still considerable difference of opinion as to the advisability of reconstructing the anterior cruciate ligament in chronic rotatory instability. This paper presents a simple method of anterior cruciate reconstruction using the semitendinosus tendon in 12 cases of chronic combined anteromedial-anterolateral rotatory instability along with preliminary results. In all cases the reconstruction of the anterior cruciate was associated with extraarticular reconstruction. Posterior oblique ligament and semimembranosus advancement was used for the medial compartment and biceps advancement for the lateral compartment. The initial results, with an average followup of 8 months, showed an anterior drawer sign with the tibia in neutral rotation of less than 1+ in all cases compared to a previous series in which, at the same point in time, 36 of 42 patients had a 2+ drawer sign and 6 had a 3+. There has been inadequate time for evaluation of the long-term results. Further comparison with longer followups are needed to determine how well this type of anterior cruciate ligament reconstruction works for extraarticular reconstructions.

Hemathrosis treated by aspiration and casting. How to condemn the knee.

Eighty-eight athletes treated for an acute hemarthrosis of the knee without any demonstrable ligament tear were evaluated. Analysis of the clinical data from these cases, all treated between 1970 and 1975 with aspiration and casting, revealed that the injury was apparently worse than had been thought at the time of first treatment. Surgery was subsequently performed in 32 (37%) because of meniscus tear, and 28 demonstrated anterior cruciate ligament insufficiency. In the 56 who did not have surgical treatment, 38 (43% of the entire group) had significant symptoms and disability causing them to decrease sports participation, and only 18 (20% of the overall group) returned to sports without symptoms or disability. Objective findings at followup suggested that in 70% of the patients injury of the anterior cruciate ligament occurred during the original trauma. A precise diagnosis is needed in every knee ligament sprain with hemarthrosis before one decides upon conservative treatment such as aspiration and casting.

Jumper's knee.

Jumper's knee (patellar or quadriceps tendon tendonitis) is found in a high number of athletes, especially in volleyball and basketball players. Conservative treatment (rest, stretching, physical therapy and antiinflammatory drugs) is usually successful. The athletes often recover completely and resume their sports activity. The purpose of this study is to present the histologic findings and our surgical repair of 18 knees of patients who underwent surgery after failure of conservative treatment. Histologic findings confirm that the so-called "jumper's knee" is a pathology localized at the bone-tendon junction. In all cases the following abnormalities were found: pseudocystic cavities at the borderline between mineralized fibrocartilage and bone, disappearance of the "blue line," increased thickness of the insertional fibrocartilage with myxomatous and hyaline metaplasia, mineralization, and ossification of the fibrocartilage far from the "blue line." Abnormalities of the patellar tendon were observed only in one patient who received local injection of corticosteroids. Eleven of the 18 surgically treated knees obtained a satisfactory result with complete resumption of sports activity.

Evaluation of the results of extensor mechanism reconstruction.

One hundred sixteen patients underwent extensor mechanism reconstruction. Ninety-four returned at followup (3 to 11 years after surgery). Twenty-two patients were lost to followup. Subjectively, 74% of the patients had either an excellent or good result and 26% either a fair or poor result. We found retrospectively, that the patients with either fair or poor results had a stable or only mildly unstable patella preoperatively.

Meniscal tears and associated anterior cruciate ligament tears in athletes: course of treatment.

Sixty-two athletes whose injured knees had negligible instability were found to have an absent or functionless anterior cruciate ligament (ACL) at the time of medial meniscectomy. After a mean of 52 months of followup, 51 patients were examined; 24 (47%) had returned to full sports activities, whereas 27 (53%) acknowledged incidents of the knee "giving way" or having completely given up sports because of instability. By analyzing the following variables, the jerk test, the type of meniscal lesion, and the type of sports engaged, we formulated a rating system to be used intraoperatively for determining the need for combining meniscectomy with a ligament reconstruction.

Chondromalacia and chronic anterior instabilities of the knee.

In this study, we surveyed a consecutive series of 500 patients who had undergone an open procedure for chronic anteromedial and/or anterolateral instabilities. Those patients who had an open arthrotomy were separated for analysis. All of the patients were examined before and during surgery. A knee sheet, based on the kind used at the Hughston Orthopaedic Clinic in Columbus, Georgia, was used to record all clinical findings. Chondromalacia of the articular surface of the femur was detected at surgery in 161 patients (32%). A statistical analysis showed that the variables directly influencing degenerative changes of the cartilage are: a previous surgery that did not sufficiently restore joint kinematics (chi square = 20.238, P less than 0.001) and a time lapse of more than 30 months between first trauma and surgery (chi square = 21.736; P = 0.001). A higher score on dynamic (jerk or pivot shift) and static (internal and external anterior drawer) tests, indicating instability, or a meniscal tear alone do not statistically correlate with chondromalacia, but together they influence degenerative changes of the cartilage.

Coronary and cerebrovascular atherosclerosis: two aspects of the same disease or two different pathologies?

Cerebrovascular and coronary disease are characterized by some common aspects. Indeed the same risk factors relate to coronary heart disease and to cerebrovascular disease. However, there may be differences in the pathogenesis of atherosclerotic lesions in coronary and cerebral arteries. In fact some populations are characterized by a high incidence of ischaemic stroke and a low incidence of myocardial infarction, while in other populations there is an opposite trend. These differences could be explained on the basis of: genetic risk factors; a different prevalence of risk factors; a different reactivity of the coronary and cerebral arteries to risk factors; anatomical differences concerning coronary and extracranial cerebral arteries with respect to intracranial cerebral arteries. Atherosclerosis is undoubtedly a systemic disorder and its genetic and environmental causal factors are only partly known. The variable incidence of cerebrovascular and coronary heart disease in the same population or in different populations as well as the different nature of atherosclerotic plaques are probably related to the different prevalence of the causal factors, even though these may not always be identified.

Current thinking in statin therapy.

The HMG-CoA reductase inhibitors (statins) are now considered the most potent lipid-lowering drugs. Treatment with statins reduces both morbidity and mortality rates due to coronary artery disease. There is now increasing evidence that the clinical benefits obtained with statins cannot be solely attributed to a decrease in low-density lipoprotein (LDL) level. These drugs may also have beneficial effects on endothelial dysfunction, LDL oxidation, rheological and thrombogenic factors, cellular inflammation and plaque formation and stability. Further, there are differences among the various statins on these non-lipid variables. The biochemical effects of statins, as well as their clinical benefits, should be taken into consideration.

Endothelial dysfunction in hypertension.

Endothelial cells release both relaxing and contracting factors that modulate vascular smooth muscle tone and also participate in the pathophysiology of essential hypertension. Endothelium-dependent vasodilation is regulated primarily by nitric oxide but also by an unidentified endothelium-derived hyperpolarizing factor and by prostacyclin. Endothelium-derived contracting factors include endothelin-1, vasoconscrictor prostanoids, angiotensin II and superoxide anions. Under physiological conditions, there is a balanced release of relaxing and contracting factors. The balance can be altered in cardiovascular diseases such as hypertension, atherosclerosis, diabetes and other conditions, thereby contributing to further progression of vascular and end-organ damage. In particular, endothelial dysfunction leading to decreased bioavailability of nitric oxide impairs endothelium-dependent vasodilation in patients with essential hypertension and may also be a determinant for the premature development of atherosclerosis. Different mechanisms of reduced nitric oxide activity have been shown both in hypertensive states and several cardiovascular diseases, and endothelial dysfunction is likely to occur prior to vascular dysfunction. Thus, the strategies currently used to improve endothelial dysfunction may result in decreased morbidity and mortality in hypertensive patients.

Relationship between serum C3 levels and traditional risk factors for myocardial infarction.

OBJECTIVE: Serum C3, a complement component produced by macrophages, the liver and the adipose tissue, is associated with the risk of myocardial infarction in men. This study was performed to ascertain the relationships between serum C3 and traditional risk factors in an unselected population sample. METHODS AND RESULTS: A random population of 1,068 subjects (537 men and 531 women, 23 to 90 years old) was examined for risk factor assessment. Serum C3 was measured by nephelometry. C3 was independently associated with body mass index (P < 0.0005, especially in women), LDL-cholesterol (P = 0.0014 in men and 0.0215 in women), systolic blood pressure (P < 0.05) and, in women, with triglycerides (P = 0.0133) and blood glucose (P = 0.0383), as assessed by multivariate analysis (multiple linear regression). The overall R2 were 0.07 and 0.21 for men and women, respectively. Women over 50 years of age had significantly higher C3 levels, LDL-cholesterol and body mass index than younger women. The correlation of C3 with LDL-cholesterol was present after the age of 40 in men, and 2 decades later in women. CONCLUSIONS: These data show that serum C3 correlates with a cluster of conventional risk factors for myocardial infarction resembling insulin resistance. Such correlations may be either independent of, or mediated by the development of coronary atherosclerosis.

[Cardiac tamponade and rheumatoid arthritis: medical approach or pericardiectomy?]. / Tamponamento cardiaco e artrite reumatoide: approccio medico o pericardiectomia?

The authors report the case of a sixty-seven-year-old man with seronegative rheumatoid arthritis since 1967. After the treatment was discontinued, a symptomatic pericardial effusion developed during an exacerbation of rheumatoid arthritis. Histological findings suggested a rheumatoid origin. Consecutive pericardiocentesis and a concomitant adequate treatment resolved cardiac tamponade, at least during short-term follow-up. However, a long term observation will be necessary to exclude recurrent effusion or evolutive constrictive pericarditis.

Subcutaneous rupture of the Achilles tendon.

A series of 27 ruptures of the tendo Achillis are reported. Samples of tendon tissue, taken both at the site of rupture and at a distance from it, were histologically examined. Four different surgical procedures were performed. All patients showed marked degenerative changes of the tendon tissue. No definite relationship was found between the surgical procedure employed and functional results obtained. These were rated as excellent in 12 cases, good in 11 and fair in four. Only minor complications attending the operation occurred. We emphasize the superiority of open repair over conservative treatment.

Anterior cruciate ligament reconstruction and augmentation with PDS graft.

The article briefly explains the biomechanical properties of the PDS and the most important ways of its use in anterior cruciate ligament (ACL) reconstruction. The different techniques of ACL reconstruction with gracilis and semitendinosus tendons are outlined. The authors explain their technique of ACL reconstruction with gracilis and semitendinosus plus PDS-band. The possible variations and pitfalls are pointed out. The results of this surgery are expounded.