Subacute cutaneous lupus erythematosus leukoderma treated with melanocyte‐keratinocyte transplantation procedure

Depigmented lesions may occur as postinflammatory sequelae of subacute cutaneous lupus erythematosus (SCLE), leading to great psychosocial impact. A 53‐year‐old male patient presented with post‐SCLE depigmented facial lesions after five years of disease stability. We proposed surgical treatment with melanocyte‐keratinocyte transplantation procedure (MKTP), and after five months the patient achieved 90% repigmentation, without Koebner phenomenon (KP). In theory, KP is a possible complication of MKTP procedure since the preparation of the receptor area involves the use of dermabrasion. In an attempt to avoid it, we suggest to maintain the treatment of the underlying disease and wait for a minimum period of disease stability before the procedure.     

Formulating goals in occupational therapy: State of the art in Switzerland

Background: The contemporary occupational therapy literature suggests that different quality criteria exist for setting goals in occupational therapy: a focus on occupation; a link to the International Classification of Functioning, Disability, and Health (ICF); and adherence to the SMART recommendations, which advises goals to be specific, measurable, agreed, realistic, and timed. Aim: To identify the extent to which Swiss occupational therapists (OTs) adhere to the criteria cited above. Material: A total of 1 129 goals formulated with the Goal Attainment Scale (GAS) collected in 2008. Results: In slightly more than half the investigated cases at least one goal addressed an aspect of occupation. Nearly two-thirds of the goals related to the ICF component “activity and participation”. Nearly 90% of the goals were specific, measurable, and/or realistic. Conclusions: Goals mirror, to some extent, what is done in everyday practice. Several influences on goal formulations of OTs were identified, including the practice models traditionally used in different specialist fields; the cultural contexts in which OTs were trained; and the legal framework that obliges OTs to formulate their goals in a certain way in order to obtain funding for their services. Significance: Based on these results evidence-based products have been developed (a further education course; written recommendations for practice).     

Retrospective evaluation of complete-arch fixed partial dentures connecting teeth and implant abutments in patients with normal and reduced periodontal support

STATEMENT OF PROBLEM: The clinical outcome of complete-arch fixed prostheses supported by implants and natural tooth abutments in patients with normal or reduced periodontal support has been reported by few studies, with controversial results. PURPOSE: The purpose of this study was to report on the implant success rate, prosthetic complications, and the occurrence of tooth intrusion, when complete-arch fixed prostheses, supported by a combination of implants and teeth, were fabricated for patients with normal and reduced periodontal support. MATERIAL AND METHODS: Nineteen patients with residual teeth that served as abutments were consecutively treated with combined tooth- and implant-supported complete-arch fixed prostheses and were retrospectively evaluated after a period varying from 24 to 94 months. Nine patients showed reduced periodontal support as a result of periodontal disease and treatment (RPS group), and 10 patients had normal periodontal support of the abutment teeth (more than 2/3 of periodontal support [NPS group]). Ninety implants and 72 tooth abutments were used to support 19 fixed partial dentures. Screw- and cement-retained metal-ceramic and metal-resin prostheses were fabricated with rigid and nonrigid connectors. Implant survival and success rates, occurrence of caries and tooth intrusion, and prosthetic complications were recorded. The number of teeth, implants, prosthetic units, fixed partial dentures, and nonrigid connectors were compared with a t test to assess differences between the 2 groups, while data for the occurrence of intrusions and prosthetic complications were compared with the Fisher exact test (alpha=.05). RESULTS: One of the 90 implants was lost (99% survival rate) over 24 to 94 months, while 3 implants showed more than 2 mm of crestal bone loss (96% success rate) over the same period. No caries were detected, but 5.6% (4/72) of the abutment teeth exhibited intrusion. Intrusion of abutment teeth was noted in 3 patients who had normal periodontal support (13% of teeth in NPS group) of the abutment teeth and was associated with nonrigid connectors. No intrusion of teeth was noted in the patients exhibiting reduced periodontal support regardless of the type of connector or when a rigid connector was used for either group. The number of intruded teeth was significantly greater in patients with intact periodontal support (P=.03). CONCLUSIONS: Complete-arch fixed prosthesis supported by implant and tooth abutments may be associated with intrusion of teeth with intact periodontal support when nonrigid connectors are used to join the implant- and tooth-supported sections of the prostheses. However, fixed partial dentures supported by implants and teeth with reduced periodontal support were not associated with tooth intrusion, regardless of the type of connectors used.     

Retrospective evaluation of mandibular incisor replacement with narrow neck implants

The authors have retrospectively evaluated the clinical results of mandibular incisors replacement with narrow neck implants (NNI). Thirty-one patients treated consecutively for single or multiple lower incisor replacement with NNI with a mean follow-up of 23 months (range 18-42 months) were included in the study and were divided into three groups: single tooth, multiple unit restoration and restorations on adjacent implants. Survival and success rates and soft tissue parameters such as modified plaque index (mPI), peri-implant probing depth (PPD), bleeding on probing (BOP) and the papilla index were analyzed. Subjective evaluation was performed by patients and clinicians on visual analogue scales. The implants and prostheses showed a survival rate of 100% and an overall success rate of 94%. The distribution of mPI outcomes showed better results for the single tooth group. BOP was present in four of eight implants (50%) in the adjacent implant group, in one out of 20 implants in the single tooth group (5%) and in one out of 16 implants in the multi unit group (6%). The adjacent implant group showed a statistically significant increase in PPD. The Papilla Index showed a better outcome distribution in single tooth and multi unit groups. Patients' evaluation of treatment outcome was satisfactory in all groups, even though the best esthetic and functional results were found in single tooth and multi unit groups. The professional evaluation showed good outcomes for the single tooth and multi unit groups and statistically significant poorer results in the adjacent implants group. With the limitations of this study, it may be concluded that the replacement of lower incisors with NNI leads to favorable functional and esthetic results in cases of single-tooth or multiple-unit replacement. Worse results are achieved if two adjacent mandibular incisors are replaced with adjacent implants.     

Fracture and displacement of lingual cortical plate of mandibular symphysis following bone harvesting: case report

This article describes a unique complication after chin bone harvesting. The complication consisted of fracture and posterior displacement of the lingual cortical plate that did not occur at the time of the operation but during the healing phase. The bone was harvested for a bilateral sinus lift procedure. Diagnosis was made by chance with the aid of a postoperative CT scan that was taken to study the sinus area. The mandibular scans revealed a bony fragment 2 to 4 mm in width and 3 cm in length fractured and displaced 1 cm posteriorly. This bony fragment was pedicled to the geniohyoid and genioglossus muscles. The patient was asymptomatic, and no treatment was carried out. The patient is still symptom-free 16 months after the initial diagnosis of the fracture.     

Estimation of the cortical functional connectivity with the multimodal integration of high-resolution EEG and fMRI data by directed transfer function

Nowadays, several types of brain imaging device are available to provide images of the functional activity of the cerebral cortex based on hemodynamic, metabolic, or electromagnetic measurements. However, static images of brain regions activated during particular tasks do not convey the information of how these regions communicate with each other. In this study, advanced methods for the estimation of cortical connectivity from combined high-resolution electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) data are presented. These methods include a subject's multicompartment head model (scalp, skull, dura mater, cortex) constructed from individual magnetic resonance images, multidipole source model, and regularized linear inverse source estimates of cortical current density. Determination of the priors in the resolution of the linear inverse problem was performed with the use of information from the hemodynamic responses of the cortical areas as revealed by block-designed (strength of activated voxels) fMRI. We estimate functional cortical connectivity by computing the directed transfer function (DTF) on the estimated cortical current density waveforms in regions of interest (ROIs) on the modeled cortical mantle. The proposed method was able to unveil the direction of the information flow between the cortical regions of interest, as it is directional in nature. Furthermore, this method allows to detect changes in the time course of information flow between cortical regions in different frequency bands. The reliability of these techniques was further demonstrated by elaboration of high-resolution EEG and fMRI signals collected during visually triggered finger movements in four healthy subjects. Connectivity patterns estimated for this task reveal an involvement of right parietal and bilateral premotor and prefrontal cortical areas. This cortical region involvement resembles that revealed in previous studies where visually triggered finger movements were analyzed with the use of separate EEG or fMRI measurements.     

Integrated technology for evaluation of brain function and neural plasticity

The study of neural plasticity has expanded rapidly in the past decades and has shown the remarkable ability of the developing, adult, and aging brain to be shaped by environmental inputs in health and after a lesion. Robust experimental evidence supports the hypothesis that neuronal aggregates adjacent to a lesion in the sensorimotor brain areas can take over progressively the function previously played by the damaged neurons. It definitely is accepted that such a reorganization modifies sensibly the interhemispheric differences in somatotopic organization of the sensorimotor cortices. This reorganization largely subtends clinical recovery of motor performances and sensorimotor integration after a stroke. Brain functional imaging studies show that recovery from hemiplegic strokes is associated with a marked reorganization of the activation patterns of specific brain structures. To regain hand motor control, the recovery process tends over time to bring the bilateral motor network activation toward a more normal intensity/extent, while overrecruiting simultaneously new areas, perhaps to sustain this process. Considerable intersubject variability exists in activation/hyperactivation pattern changes over time. Some patients display late-appearing dorsolateral prefrontal cortex activation, suggesting the development of "executive" strategies to compensate for the lost function. The AH in stroke often undergoes a significant "remodeling" of sensory and motor hand somatotopy outside the "normal" areas, or enlargement of the hand representation. The UH also undergoes reorganization, although to a lesser degree. Although absolute values of the investigated parameters fluctuate across subjects, secondary to individual anatomic variability, variation is minimal with regards to interhemispheric differences, due to the fact that individual morphometric characters are mirrored in the two hemispheres. Excessive interhemispheric asymmetry of the sensorimotor hand areas seems to be the parameter with highest sensitivity in describing brain reorganization after a monohemispheric lesion, and mapping motor and somatosensory cortical areas through focal TMS, fMRI, PET, EEG, and MEG is useful in studying hand representation and interhemispheric asymmetries in normal and pathologic conditions. TMS and MEG allow the detection of sensorimotor areas reshaping, as a result of either neuronal reorganization or recovery of the previously damaged neural network. These techniques have the advantage of high temporal resolution but also have limitations. TMS provides only bidimensional scalp maps, whereas MEG, even if giving three-dimensional mapping of generator sources, does so by means of inverse procedures that rely on the choice of a mathematical model of the head and the sources. These techniques do not test movement execution and sensorimotor integration as used in everyday life. fMRI and PET may provide the ideal means to integrate the findings obtained with the other two techniques. This multitechnology combined approach is at present the best way to test the presence and amount of plasticity phenomena underlying partial or total recovery of several functions, sensorimotor above all. Dynamic patterns of recovery are emerging progressively from the relevant literature. Enhanced recruitment of the affected cortex, be it spared perilesional tissue, as in the case of cortical stroke, or intact but deafferented cortex, as in subcortical strokes, seems to be the rule, a mechanism especially important in early postinsult stages. The transfer over time of preferential activation toward contralesional cortices, as observed in some cases, seems, however, to reflect a less efficient type of plastic reorganization, with some aspects of maladaptive plasticity. Reinforcing the use of the affected side can cause activation to increase again in the affected side with a corresponding enhancement of clinical function. Activation of the UH MI may represent recruitment of direct (uncrossed) corticospinal tracts and relate more to mirror movements, but it more likely reflects activity redistribution within preexisting bilateral, large-scale motor networks. Finally, activation of areas not normally engaged in the dysfunctional tasks, such as the dorsolateral prefrontal cortex or the superior parietal cortex in motor paralysis, might reflect the implication of compensatory cognitive strategies. An integrated approach with technologies able to investigate functional brain imaging is of considerable value in providing information on the excitability, extension, localization, and functional hierarchy of cortical brain areas. Deepening knowledge of the mechanisms regulating the long-term recovery (even if partial), observed for most neurologic sequelae after neural damage, might prompt newer and more efficacious therapeutic and rehabilitative strategies for neurologic diseases.     

Movement-related electroencephalographic reactivity in Alzheimer disease

Event-related desynchronization/synchronization (ERD/ERS) of alpha and beta electroencephalographic (EEG) rhythms was investigated in normal subjects and mild Alzheimer Disease patients (AD), performing unilateral right finger movements (about 10 s intermovement interval). Electroencephalographic data were sampled based on 10-20 system electrode montage. Surface Laplacian estimate of the potential reduced the head-volume conductor effects and annulled electrode reference variations. Results showed that EEG reactivity (i.e., ERD/ERS) of modeled contralateral rolandic cortex and motor performance were preserved in mild to moderate AD. In contrast, modeled activity (i.e., ERD/ERS) of frontolateral, centromedial, and ipsilateral rolandic areas was abnormal. Furthermore, interrelatedness of cortical response and movement timing was abnormal in AD patients. These results would support the working hypothesis that mild to moderate AD is a global brain network disease, including processing of sensorimotor information (despite no overt movement disorder). Further investigations will ascertain the clinical relevance of these results.