Multidiciplinary treatment of complicated subgingivally fractured permanent central incisors: two case reports

Abstract – Subgingival crown fractures with pulp exposure in permanent teeth present both endodontic and restorative problems with unfavorable prognosis. Numerous restorative techniques such as resin composite restorations with and without pins, crowns and reattachment of the fractured dental fragment could be listed as the treatment options. There are several successful cases in the literature where advantages of less microleakage and proper gingival biocompatibility in cases with reattachment of the tooth fragment were reported. Two cases of palatinal subgingival crown fractures are reported. Both had been restored by reattachment of the fragment and composite with the help of the flap surgery. Follow up visits (Case 1 for 4 years and Case 2 for 1 year) revealed satisfactory esthetics and function.     

Heat-shock proteins in autoimmune arthritis: a critical contribution based on the adjuvant arthritis model

Recognition of self protein epitopes, apart from those engaged in idiotypic network interactions and MHC restriction, is probably a physiological event in the normal functioning immune system. Furthermore T and B cells recognizing self antigens can be easily cloned from healthy individuals and sometimes be shown to confer autoimmune disease by passive transfer in the experimental situation. The issue is how potentially autoaggressive cells can become activated and how such activity can be contained safely. Experimentally, autoimmune disease can be evoked by immunization with autoantigens (encephalomyelitis, thyroiditis etc.) or with foreign antigens that feature antigenic relationships with self antigens (adjuvant arthritis). In both situations transfer of disease has been shown with cloned T cells of a single specificity. In addition, specific control of disease using the same cloned T cells has been achieved. Adjuvant arthritis has been illustrative in these respects. By means of specificity analysis of cloned T cells, a 65 kD heat shock protein of mycobacteria was identified as crucial in the disease. Immunization with this antigen has been found to prevent the development of disease, including forms elicited without mycobacterial involvement. Furthermore, vigorous immunological responses to HSP65 were found both in experimental animals and also in humans as a consequence of exposition to various infectious organisms. By their conserved nature HSPs have ample potential for dangerous mimicry. Recent evidence accumulated suggesting that the same HPS65 may be crucial in human chronic arthritis as well. Therefore it is hoped that extrapolation of the experimental findings to the human situation will help the development of specific means, either T cells or antigens, to control spontaneous autoimmune arthritis in man.     

An autoradiographic and HRP study of vestibulocollic pathways in the pigeon

This study examines the connections underlying the vestibulocollic system in the adult pigeon by using retrogradely transported horseradish peroxidase (HRP) to identify neck muscle motoneurons in one set of animals, and transneural anterograde transport of tritiated proline-fucose to delineate the descending medial (MVST) and lateral (LVST) vestibulospinal tracts in a second set of animals. Correlations of location and distribution of HRP-labeled motoneurons and autoradiographically labeled fiber tracts and terminal fields were performed between the two sets of experiments. The right biventer cervicis and complexus neck muscles were subdivided into rostral and caudal halves in ten animals and HRP injected into only half of one of the two muscles in each experiment. Following a 16–48-hour survival, the brain was fixed by intracarotid catheterization and perfusion and the HRP in the brain sections reacted with the tetramethylbenzidine (TMB) blue reaction process. Three groups of HRP-labeled motoneurons were identified in the ipilateral ventral horn of the upper cervical spinal cord: a ventromedial and ventrolateral group within lamina VIII innervating the biventer cervicis and the more rostral part of the complexus muscle, and a dorsolateral group of motoneurons within lamina VII innervating the caudal part of the complexus muscle. The dorsolateral motoneurons with their HRP-labeled axons leaving the cord through the dorsal root are homologous to the spinal accessory nucleus of mammals. Labeled motoneurons were also noted in the ipsilateral medulla adjacent to the medial longitudinal fasiculus (ELM) in a location previously identified as the hy-poglossal nucleus. Additional experiments were performed in which HRP was injected directly into the base of the tongue. The resultant HRP-labeled hypoglossal motoneurons were separate and dorsolateral to the collic motoneurons. Descending vestibulospinal projections from one vestibular labyrinth were identified autoradiographicalry (ARG) by transneural anterograde transport of ³H-proline-fucose injected into the left labyrinthine endolytine endolymph in five animals. Heavily labeled MVST fibers were observed crossing the midline of the brain to enter and descend in the contralateral ELM. Labeled MVST fibers were noted to leave the contralateral FLM and surround the previously identified collie motoneurons in the medulla with intense terminal fields suggestive of synaptic contact. Labeled MVST fibers in the contralateral ventral funiculus of the cord were also noted to innervate the HRP-identified ventromedial and ventrolateral cervical motoneurons, but not the dorsolateral motoneurons in lamina VII. Ipsilateral (left) descending MVST and LVST fibers were less heavily labeled at all levels in the medulla and upper cervical cord. Labeled ipsilateral (left) vestibulospinal fibers were also observed to leave the lateralmost aspect of the left ventrolateral funiculus in the upper cervical cord to terminate among left ventrolateral motoneurons. Our findings are compared and contrasted with previous studies of vestibulocollic pathways.     

Balancing high accrual and ethical recruitment in paediatric oncology: a qualitative study of the 'look and feel' of clinical trial discussions

Background  

High accrual to clinical trials enables new treatment strategies to be tested rapidly, accurately and with generalisability. Ethical standards also must be high so that participation is voluntary and informed. However, this can be difficult to achieve in trials with complex designs and in those which are closely embedded in clinical practice. Optimal recruitment requires a balance of both ethical and accrual considerations. In the context of a trial of stratified treatments for children with acute lymphoblastic leukaemia (UKALL2003) we examined how recruitment looked to an observer and how it felt to the parents, to identify how doctors' communication could promote or inhibit optimal recruitment.     

Cleft palate and hypopituitarism in a patient with Noonan‐like syndrome with loose anagen hair‐1

Noonan syndrome (NS), the most common of the RASopathies, is a developmental disorder caused by heterozygous germline mutations in genes encoding proteins in the RAS‐MAPK signaling pathway. Noonan‐like syndrome with loose anagen hair (NSLH, including NSLH1, OMIM #607721 and NSLH2, OMIM #617506) is characterized by typical features of NS with additional findings of macrocephaly, loose anagen hair, growth hormone deficiency in some, and a higher incidence of intellectual disability. All NSLH1 reported cases to date have had an SHOC2 c.4A>G, p.Ser2Gly mutation; NSLH2 cases have been reported with a PPP1CB c.146G>C, p.Pro49Arg mutation, or c.166G>C, p.Ala56Pro mutation. True cleft palate does not appear to have been previously reported in individuals with NS or with NSLH. While some patients with NS have had growth hormone deficiency (GHD), other endocrine abnormalities are only rarely documented. We present a female patient with NSLH1 who was born with a posterior cleft palate, micrognathia, and mild hypotonia. Other findings in her childhood and young adulthood years include hearing loss, strabismus, and hypopituitarism with growth hormone, thyroid stimulating hormone (TSH), and gonadotropin deficiencies. The SHOC2 mutation may be responsible for this patient's additional features of cleft palate and hypopituitarism.     

Re-engineering the interpretation of electronic fetal monitoring to identify reversible risk for cerebral palsy: a case control series

Background: Even key opinion leaders now concede that electronic fetal monitoring (EFM) cannot reliably identify fetal acidemia which many vouch as the only labor mediated pathophysiologic precursor for cerebral palsy (CP). We have developed the “Fetal Reserve Index” – an algorithm combining five dynamic components of EFM (1. Rate, 2. Variability, 3. Accelerations, 4. Decelerations, and 5. Excessive uterine activity) considered individually that are combined with the presence of: 6. maternal, 7. obstetrical, and 8. fetal risk factors.

Objective: Here, we compare this 8-point fetal reserve index (FRI) against the performance of ACOG monograph criteria and ACOG Category systems for predicting risk for both CP and the need for emergency operative delivery (EOD). We then studied how varied management for screen positives (Red zone-defined below) impacts the outcome of such cases.

Study design: Four hundred twenty term patients were studied: all entered labor with normal EFMs and no apparent cause of harm except events of labor and delivery. Sixty subsequently developed CP, and 360 were apparently normal controls. An FRI, normal on all eight parameters scored 100%, 4 of the 8 was 50%, etc. We divided cases into Green zone >50%, Yellow 50–26%, and Red ≤25%. An FRI in the Red zone was considered a positive screen. We then compared performance metrics for the three evaluation schemes and differences between controls that reached Red against those controls whose worst scores were Green/Yellow.

Results: For detection of injury during labor, the FRI performed much better than the ACOG Category criteria (sensitivity 28%), and Category III (45%) (p?Conclusions: FRI shows better discrimination for adverse fetal outcome and EOD than traditional EFM interpretation. The Category system is a very poor, subjective screening method as the vast majority of CP babies never reach the “action point” result of Category III. While reaching the Red zone does not ordain a bad outcome, how it is managed, does. Compared to CP cases, Red controls were delivered faster, had higher FRIs, and often had prompt management including IR maneuvers, which improved the FRI and lowered the risk of EODs even for cases with normal outcomes. With further study and validation, the quantitative FRI approach may replace the current, very subjective interpretation with a quantitative “lab test” approach.