Dental implants as risk factors for patients with medication-related osteonecrosis of the jaws (MRONJ)

An increasing number of patients with medication-related osteonecrosis of the jaws (MRONJ) has recently been reported. It is still being debated whether the presence or placement of dental implants can lead to MRONJ, so the aim of this study was to find out whether dental implants are a risk factor for MRONJ. From January 2003-January 2019 180 patients with MRONJ were seen at the Leiden University Medical Center. Luxating moments for the onset of MRONJ were calculated retrospectively. We collected clinical data and details of antiresorptive medication and found 22 patients with both dental implants and MRONJ. In 18 patients the implants were in the region of the MRONJ and they were included in this study, 14 who had had implants before using antiresorptive drugs and four who had had antiresorptive drugs before or at the time that the implants were placed. The median times between the placement of implants and the diagnosis of MRONJ in these two groups were 24 months and 6 months, respectively. Among the 47 implants, 30 were located in the necrotic region, and all 30 were either lost spontaneously or had to be removed during treatment of MRONJ. Our results show an increased risk for developing MRONJ in patients with dental implants. Both peri-implantitis around previously placed implants, and insertion of dental implants, are risk factors. Prevention of peri-implantitis and caution when inserting dental implants in patients who take antiresorptive medication are therefore important.     

Clinical outcomes in patients on preinjury ibuprofen with traumatic brain injury

Background

The aim of our study was to evaluate the clinical outcomes in patients on preinjury Ibuprofen with traumatic brain injury.

Methods

We performed a 2-year analysis of all patients on prehospital Ibuprofen with traumatic brain injury and intracranial hemorrhage. Patients on preinjury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale, head-abbreviated injury scale, injury severity score, International Normalized Ratio, and neurologic examination. Outcome measures were progression on repeat head computed tomography (RHCT) and neurosurgical intervention.

Results

A total of 195 matched (Ibuprofen 65, no-Ibuprofen 130) patients were included. There was no difference in the progression on RHCT (Ibuprofen 18% vs no-Ibuprofen 24%; P = .50). The neurosurgical intervention rate was 18.9% (n = 37). There was no difference for need for neurosurgical intervention (26% vs 16%; P = .10) between the 2 groups.

Conclusions

In a matched cohort of trauma patients, preinjury Ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Preinjury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan.     

The impact of intracranial pressure monitoring on mortality after severe traumatic brain injury

Background

The effect of intracranial pressure (ICP) monitoring on mortality after severe traumatic brain injury (sTBI) remains unclear. We hypothesized that ICP monitoring would not be associated with improved survival in patients with sTBI.

Methods

A retrospective analysis was performed on sTBI patients, defined as admission Glasgow Coma Scale score of 8 or less with intracranial hemorrhage. Patients who underwent ICP monitoring were compared with patients who did not. The primary outcome measure was inhospital mortality.

Results

Of 123 sTBI patients meeting inclusion criteria, 40 (32.5%) underwent ICP monitoring. On bivariate and multivariate regression analyses, ICP monitoring was associated with decreased mortality (odds ratio = .32, 95% confidence interval = .10 to .99, P = .049). This finding persisted on propensity-adjusted analysis.

Conclusions

ICP monitoring is associated with improved survival in adult patients with sTBI. In addition, significant variability exists in the use of ICP monitoring among patients with sTBI.     

Clinical Factors and Perioperative Strategies Associated with Outcome in Preinjury Antiplatelet and Anticoagulation Therapy for Patients with Traumatic Brain Injuries

Objective

Long-term oral anticoagulation or antiplatelet therapy has been used with increasing frequency in the elderly. These patients are at increased risk of morbidity and mortality from expansion of intracranial hemorrhage. We conducted a single-center retrospective case control study to evaluate risk factors associated with outcomes and to identify the differences in outcome in traumatic brain injury between preinjury anticoagulation use and without anticoagulation.

Methods

A retrospective study of patients who underwent craniotomy or craniectomy for acute traumatic cerebral hemorrhage, between January 2005 and December 2014 was performed.

Results

A consecutive series of 50 patients were evaluated. The factors significantly differed between the two groups were initial Prothrombin Time-International Normalized Ratio, initial platelet count, initial Glasgow Coma Scale score, and postoperative intracranial bleeding. Mean Glasgow Outcome Scale (GOS) score were similar between the two groups. In the patient with low-energy trauma only, no significant differences in GOS score, postoperative bleeding and many other factors were observed. The contributing factors to postoperative bleeding was preinjury anticoagulation and its adjusted odds ratio was 12 [adjusted odds ratio (OR), 12.242; p=0.0070]. The contributing factors to low GOS scores, which mean unfavorable neurological outcomes, were age (adjusted OR, 1.073; p=0.039) and Rotterdam scale score for CT scans (adjusted OR, 3.123; p=0.0020).

Conclusion

Preinjury anticoagulation therapy contributed significantly to the occurrence of postoperative bleeding. However, preinjury anticoagulation therapy in the patients with low-energy trauma did not contribute to the poor clinical outcomes or total hospital stay. Careful attention should be given to older patients and severity of hemorrhage on initial brain CT.     

电视胸腔镜与传统开胸手术治疗外伤性血气胸的效果比较

目的 比较电视胸腔镜(VATS)和传统开胸手术治疗外伤性血气胸的临床效果.方法 血气胸患者41例随机分为实验组和对照组,对照组26例,采用传统开胸手术方法;实验组15例,采用VATS治疗,对两组患者一般临床资料、术中出血量、手术时间、术后胸管放置时间、术后引流量等进行比较.结果 41例患者均无手术死亡、二次开胸止血,术后均未呼吸机辅助呼吸.实验组术中出血量[(176.5 ±78.5) ml]明显少于对照组[(401.3±90.7)ml],手术时间[实验组(64.7-±21.3) min,对照组(129.4±30.3) min]、术后胸管放置时间[实验组(2.3±0.9)d,对照组(4.5±1.0)d]、住院时间[实验组(9.1±2.1)d,对照组(12.7±2.2)d]及术后并发症发生率等方面均少于对照组,两组比较差异有统计学意义(P＜0.05).结论 VATS治疗外伤性血气胸与传统开胸手术比较,诊断快速准确,安全可靠,并发症少.     

Therapeutic temperature modulation is associated with pulmonary complications in patients with severe traumatic brain injury

AIM: To examine complications associated with the use of therapeutic temperature modulation(mild hypothermia and normothermia) in patients with severe traumatic brain injury(TBI). METHODS: One hundred and fourteen charts were reviewed. Inclusion criteria were: severe TBI with Glasgow Coma Scale(GCS) 9, intensive care unit(ICU) stay 24 h and non-penetrating TBI. Patients were divided into two cohorts: the treatment group received therapeutic temperature modulation(TTM) with continuous surface cooling and indwelling bladder temperature probes. The control group received standard treatment with intermittent acetaminophen for fever. Information regarding complications during the time in the ICU was collected as follows: Pneumonia was identified using a combination of clinical and laboratory data. Pulmonary embolism, pneumothorax and deep venous thrombosis were identified based onimaging results. Cardiac arrhythmias and renal failure were extracted from the clinical documentation. acute respiratory distress syndrome and acute lung injury were determined based on chest imaging and arterial blood gas results. A logistic regression was conducted to predict hospital mortality and a multiple regression was used to assess number and type of clinical complications. RESULTS: One hundred and fourteen patients were included in the analysis(mean age = 41.4, SD = 19.1, 93 males), admitted to the Jackson Memorial Hospital Neuroscience ICU and Ryder Trauma Center(mean GCS = 4.67, range 3-9), were identified and included in the analysis. Method of injury included motor vehicle accident(n = 29), motor cycle crash(n = 220), blunt head trauma(n = 212), fall(n = 229), pedestrian hit by car(n = 216), and gunshot wound to the head(n = 27). Ethnicity was primarily Caucasian(n = 260), as well as Hispanic(n = 227) and African American(n = 223); four patients had unknown ethnicity. Patients received either TTM(43) or standard therapy(71). Within the TTM group eight patients were treated with normothermia after TBI and 35 patients were treated with hypothermia. A logistic regression predicting in hospital mortality with age, GCS, and TM demonstrated that GCS(Beta = 0.572, P 0.01) and age(Beta =-0.029) but not temperature modulation(Beta = 0.797, ns) were significant predictors of in-hospital mortality [χ2(3) = 22.27, P 0.01] A multiple regression predicting number of complications demonstrated that receiving TTM was the main contributor and was associated with a higher number of pulmonary complications(t =-3.425, P = 0.001). CONCLUSION: Exposure to TTM is associated with an increase in pulmonary complications. These findings support more attention to these complications in studies of TTM in TBI patients.     

Comparison of fondaparinux sodium and low molecular weight heparin in the treatment of hypercoagulability secondary to traumatic infection

Purpose: To compare the effects and side-effects of fondaparinux sodium and low molecular weight heparin in patients with hypercoagulability accompanied with traumatic infection. Methods: Thirty-six patients with post-traumatic infections in our hospital intensive care center were diagnosed with hypercoagulability from February 2012 to February 2013. These patients were randomly divided into 2 groups. In group F (18 patients), the patients were treated with fondaparinux sodium, 2.5 mg, 1/d for 11 d. In group L (18 patients), the patients were treated with low molecular weight heparin, 4100 U, 1/12 h for 11 d. The incidence of deep vein thrombosis, bleeding events and multiple organ dysfunction syndrome (MODS) and mortality of two groups after anticoagulation therapy were analyzed. Fibrinogen, D-dimer level and activity of antithrombin III were measured by the coagulation analyzer. Results: The incidence of deep vein thrombosis, MODS incidence and mortality were not significantly different between the two groups. The rate of bleeding evens in group F was lower than group L (p < 0.05). Antithrombin III got an upward trend after anticoagulant therapy, in which it was higher in group F than in group L on the 5th d and 11th d (p<0.05). Fibrinogen levels were gradually increased, and there was no significant difference between two groups (p>0.05). D-dimer was significantly decreased after anticoagulant therapy for 5 d (p<0.01), and there were significant differences between two groups on the 5th d and 7th d (p < 0.05). It showed no significant difference on the 11th d (p>0.05). Conclusion: Fondaparinux sodium and low molecular weight heparin can effectively improve coagulopathy in patients with traumatic infection. Compared with low molecular weight heparin, fondaparinux sodium may reduce the risk of bleeding events in patients with hypercoagulability accompanied by traumatic infection.     

Axonal fusion via conduit-based delivery of hydrophilic polymers

Background

Hydrophilic polymers have been shown to improve physiologic recovery following repair of transected nerves with microsutures. Our study was designed to combine hydrophilic polymer therapy with nerve tubes (NT) to enhance polymer delivery to the site of nerve injury.

Methods

Using a rat sciatic nerve injury model, a single transection injury was repaired in an end-to-end fashion with NT + polyethylene glycol (PEG) to NT alone. Compound action potentials (CAPs) were recorded before nerve transection and after repair. Behavioral testing was performed for 5 weeks.

Results

PEG therapy restored CAPS in all, but one, animals, while no CAPS were recorded in animals not receiving PEG. Behavioral nerve function was measured using the standardized functional assessment technique and foot fault asymmetry scores (FF). FF scores were improved for the PEG therapy groups on postoperative days 7, 14, and 21. However, after expected eventual axonal outgrowth, the benefit was less noticeable at days 28 and 35. Immunohistochemistry of the distal axon segments showed an increase number of sensory and motor axons in the NT + PEG group as compared to NT alone.

Conclusion

These data suggest that PEG delivery via a conduit may provide a simple, effective way to fuse severed axons and regain early nerve function. For proximal nerve injuries in large animals, recovery of axonal continuity could dramatically improve outcomes, even if fusion only occurs in a small percentage of axons.