Efficacy of a Mandibular Advancement Appliance on Sleep Disordered Breathing in Children

Background: Sleep-Disordered Breathing (SDB) varies from habitual snoring to partial or complete obstruction of the upper airway, and can be found in up to 10% of children. SDB can significantly affect children’s wellbeing, as it can cause growth disorders, educational and behavioural problems, and even life-threatening conditions, such as cardiorespiratory failure. Adenotonsillectomy represents the primary treatment for paediatric SDB where adeno-tonsillar hypertrophy is indicated. For those with craniofacial anomalies, for whom adenotonsillectomy or other treatment modalities have failed, or surgery is contra-indicated, mandibular advancement splints (MAS) may represent a viable treatment option. Whilst the efficacy of these appliances has been consistently demonstrated in adults, there is little information about their effectiveness in children. Study objective: The aims of this research are first, to define the most accepted appliance from different designs of MAS to be used in the main study and second, to determine the efficacy of mandibular advancement appliances (MAS) for the management of Sleep-Disordered Breathing (SDB) and related health conditions in children. Methods: The first part of this research was a pilot study designed as a randomized controlled study with crossover application of four different MAS designs. Questionnaires filled out by the patient and parent were used to gauge effectiveness of the different MAS designs regarding: the effects on speech, the initial acceptance, and the acceptance after wearing the appliance for a full night. A clinical examination then followed to test the appliance retention. One volunteer (11 year old male with class II dental and skeletal jaw relationships) participated in this pilot study and he was suitable for functional appliance treatment. Appliances tested were: 1) traditional Twin-Block with vertical elastics added to ensure the anteroposterior and vertical predetermined position of the mandible when wearing the appliance during sleep; 2) Twin-Block with a metallic fastener in the anterior area to test the function of mandibular advancement; 3) Clear elastic Twin-block which has the same traditional Twin-Block design with vertical elastics but uses vacuum formed retainers instead of the acrylic material; 4) a sham Twin-Block with upper and lower vacuum formed retainers without any mandibular repositioning. This pilot study showed that traditional Twin-Block was the best design to be used in the main study as it was highly accepted by the patient and showed the highest levels of retention in comparison to the other designs. The main study was designed as a single-blind crossover randomised controlled trial with administration of both an ‘Active MAS’ (Twin-block) and a ‘Sham MAS’ (two Hawley retainers). Eligible participants were children aged 8 to 12 years, whose parents reported them snoring ≥ 3 nights per week. Exclusion criteria included class III incisor and/or skeletal relationship, confirmed by lateral cephalometric radiograph. 18 children participated in the study. Each child was randomly assigned to a treatment sequence, starting with either the Active or the Sham MAS. Participants wore the appliances for three weeks, separated by a two-week washout period. For each participant, home-based polysomnographic (PSG) data was collected four times, once before and once after each treatment period. The Apnoea Hypopnoea Index (AHI) represented the main outcome variable. Secondary outcomes, assessed at the same time with PSG recordings, included serum levels of Insulin-like Growth Factor 1 (IGF-1), obstructive sleep-related breathing symptoms, as assessed by the Paediatric Sleep Questionnaire (PSQ), quality of life, as assessed by the OSA-18 questionnaire, and childhood behaviour, as assessed by the Behavioural Assessment System for Children (BASC-2) Behavioural and Emotional Screening System (BESS), and nocturnal enuresis. In addition, blood samples were collected at the end of each treatment period to assess growth hormone changes by measuring blood levels of insulin-like growth factor-1 (IGF-1). Results: Compared to a Sham MAS, wearing an Active MAS resulted in a significant reduction in AHI of 40% (p=0.002) with a decrease in AHI when using the Active MAS, and a tendency for an increase in AHI when using the Sham MAS. The separate assessment of AHI in supine and non-supine sleeping positions revealed that only the former was significantly influenced by treatment, with a reduction of 4.1 events per hour (95% CI=1.8-6.4; p<0.001). Snoring time was 46.3 minutes shorter with the Twin-Block than with the Sham appliance (95% CI=14.5-78.1; p=0.004). The lowest oxygen saturation showed significant improvement of 3.4% (95% CI=0.9-5.9; p=0.007) with the Twin-block in comparison to the Sham MAS. Compared to a Sham MAS, the Active MAS also reduced SDB symptoms. Subjective assessment by parents showed significant improvement, as represented by PSQ, OSA-18, and BASC-2 scores (p≤0.028). IGF-1 levels, however, did not differ between the two treatment periods (p=0.172). There were no reports of nocturnal enuresis incidents during the study periods. Conclusion: The short-term use of mandibular advancement splints significantly reduced AHI, supine AHI. The decrease in the overall AHI resulted from a combination of a decrease in AHI when using the Active MAS, and a tendency towards an increase in AHI when using the Sham MAS. Snoring time decreased significantly when using MAS in children with SDB, and participants showed improvement in subjectively assessed SDB symptoms and quality of life. In addition, significant improvement was detected in parent-reported child behaviour

Habitat suitability analysis in a natural peat swamp forest on Sumatran elephants using remote sensing and GIS

Context: It is essential to assess the suitable habitat for elephants in order to mitigate the effects of forest fragmentation on conservation. Aims: This study aimed to estimate the potential suitable habitats for Sumatran elephants in the fragmented forest in the Padang Sugihan wildlife reserve area in southern Sumatra, Indonesia. Methods: The habitat suitability was analyzed using some environmental factors such as slope, elevation, land cover, distance to rivers, and distance to agricultural areas. The remote sensing, geographic information system (GIS), and MaxEnt model were used to determine the potential habitat suitability for Sumatran elephants. Results: This study revealed areas of suitable habitat were evenly distributed throughout the study area, with the composition being suitable (45%), highly suitable (5%), and less suitable (50%). This study revealed the most suitable habitats were found in dense forest areas (gelam or Melaleuca cajuputi forest), which were highly affected by river adjacency, whereas agricultural areas resulted in constrained suitability and fragmentation of forested areas. Conclusions: As a whole, the estimation of elephant habitat using remote sensing and GIS may guide the development of conservation strategies for elephant conservation in this region

Design and baseline characteristics of the finerenone in reducing cardiovascular mortality and morbidity in diabetic kidney disease trial

Background: Among people with diabetes, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality and progression of their underlying kidney disease. Finerenone is a novel, nonsteroidal, selective mineralocorticoid receptor antagonist that has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD) while revealing only a low risk of hyperkalemia. However, the effect of finerenone on CV and renal outcomes has not yet been investigated in long-term trials. Patients and Methods: The Finerenone in Reducing CV Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important CV and renal outcomes in T2D patients with CKD. FIGARO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 6 years. FIGARO-DKD randomized 7,437 patients with an estimated glomerular filtration rate >= 25 mL/min/1.73 m(2) and albuminuria (urinary albumin-to-creatinine ratio >= 30 to <= 5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of the primary outcome (overall two-sided significance level alpha = 0.05), the composite of time to first occurrence of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. Conclusions: FIGARO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of CV and renal events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen. Trial Registration: EudraCT number: 2015-000950-39; ClinicalTrials.gov identifier: NCT02545049

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Eating Fast and Body Mass Index in Young Adolescents. Is there a relationship?

Behavioural aspects of chewing may influence food intake, nutritional status, and, in turn body weight. Obesity is highly prevalent among New Zealand adolescents, it is also a concern globally, as it impacts negatively on children’s health. The aims of the current study were: 1) To study the chewing features in a group of adolescents, as they naturally occur in home-based settings 2) To test for a possible association between chewing features and body weight Forty-two participants (20 females and 22 males) aged 15.3 ± 1.3 year were recruited for this study. Based on a Z-score for Body Mass Index (BMI), half of the study participants (n = 21) were classified as being in a healthy weight range, while the other half were considered overweight-to-obese. Using a smartphone-assisted wearable electromyographic (EMG) device and a wearable camera, the participants’ chewing features were assessed for one evening, including the evening meal, in their homes. The outcome variables included chewing pace, chewing duration, and the number and power (intensity) of chewing strokes. Eating episodes could be accurately detected by both the EMG device and the wearable camera, with accuracy values ranging from 0.8 to 0.92. The EMG device, however, was more sensitive and could identify chewing episodes not detected by the camera. The chewing features (mean ± SD), as evaluated by EMG, showed a chewing pace of 1.53 ± 0.22 Hz, a chewing time of 11.0 ± 7.7 minutes and a frequency of chewing episodes of 63.1 ± 36.7 per evening (from + 5:00 pm until bedtime). The mean chewing power was 30.1 ± 4.8 %. There was a negative correlation between BMI and chewing pace (R= -0.42; P < 0.001) and between the BMI and chewing time (R = -0.32; P = 0.026). The results of the current study indicate that overweight-to-obese adolescents tend to eat in a shorter time and at a slower pace than their healthy weight counterparts

Efficacy of a Mandibular Advancement Appliance on Sleep Disordered Breathing in Children

Background: Sleep-Disordered Breathing (SDB) varies from habitual snoring to partial or complete obstruction of the upper airway, and can be found in up to 10% of children. SDB can significantly affect children’s wellbeing, as it can cause growth disorders, educational and behavioural problems, and even life-threatening conditions, such as cardiorespiratory failure. Adenotonsillectomy represents the primary treatment for paediatric SDB where adeno-tonsillar hypertrophy is indicated. For those with craniofacial anomalies, for whom adenotonsillectomy or other treatment modalities have failed, or surgery is contra-indicated, mandibular advancement splints (MAS) may represent a viable treatment option. Whilst the efficacy of these appliances has been consistently demonstrated in adults, there is little information about their effectiveness in children. Study objective: The aims of this research are first, to define the most accepted appliance from different designs of MAS to be used in the main study and second, to determine the efficacy of mandibular advancement appliances (MAS) for the management of Sleep-Disordered Breathing (SDB) and related health conditions in children. Methods: The first part of this research was a pilot study designed as a randomized controlled study with crossover application of four different MAS designs. Questionnaires filled out by the patient and parent were used to gauge effectiveness of the different MAS designs regarding: the effects on speech, the initial acceptance, and the acceptance after wearing the appliance for a full night. A clinical examination then followed to test the appliance retention. One volunteer (11 year old male with class II dental and skeletal jaw relationships) participated in this pilot study and he was suitable for functional appliance treatment. Appliances tested were: 1) traditional Twin-Block with vertical elastics added to ensure the anteroposterior and vertical predetermined position of the mandible when wearing the appliance during sleep; 2) Twin-Block with a metallic fastener in the anterior area to test the function of mandibular advancement; 3) Clear elastic Twin-block which has the same traditional Twin-Block design with vertical elastics but uses vacuum formed retainers instead of the acrylic material; 4) a sham Twin-Block with upper and lower vacuum formed retainers without any mandibular repositioning. This pilot study showed that traditional Twin-Block was the best design to be used in the main study as it was highly accepted by the patient and showed the highest levels of retention in comparison to the other designs. The main study was designed as a single-blind crossover randomised controlled trial with administration of both an ‘Active MAS’ (Twin-block) and a ‘Sham MAS’ (two Hawley retainers). Eligible participants were children aged 8 to 12 years, whose parents reported them snoring ≥ 3 nights per week. Exclusion criteria included class III incisor and/or skeletal relationship, confirmed by lateral cephalometric radiograph. 18 children participated in the study. Each child was randomly assigned to a treatment sequence, starting with either the Active or the Sham MAS. Participants wore the appliances for three weeks, separated by a two-week washout period. For each participant, home-based polysomnographic (PSG) data was collected four times, once before and once after each treatment period. The Apnoea Hypopnoea Index (AHI) represented the main outcome variable. Secondary outcomes, assessed at the same time with PSG recordings, included serum levels of Insulin-like Growth Factor 1 (IGF-1), obstructive sleep-related breathing symptoms, as assessed by the Paediatric Sleep Questionnaire (PSQ), quality of life, as assessed by the OSA-18 questionnaire, and childhood behaviour, as assessed by the Behavioural Assessment System for Children (BASC-2) Behavioural and Emotional Screening System (BESS), and nocturnal enuresis. In addition, blood samples were collected at the end of each treatment period to assess growth hormone changes by measuring blood levels of insulin-like growth factor-1 (IGF-1). Results: Compared to a Sham MAS, wearing an Active MAS resulted in a significant reduction in AHI of 40% (p=0.002) with a decrease in AHI when using the Active MAS, and a tendency for an increase in AHI when using the Sham MAS. The separate assessment of AHI in supine and non-supine sleeping positions revealed that only the former was significantly influenced by treatment, with a reduction of 4.1 events per hour (95% CI=1.8-6.4; p<0.001). Snoring time was 46.3 minutes shorter with the Twin-Block than with the Sham appliance (95% CI=14.5-78.1; p=0.004). The lowest oxygen saturation showed significant improvement of 3.4% (95% CI=0.9-5.9; p=0.007) with the Twin-block in comparison to the Sham MAS. Compared to a Sham MAS, the Active MAS also reduced SDB symptoms. Subjective assessment by parents showed significant improvement, as represented by PSQ, OSA-18, and BASC-2 scores (p≤0.028). IGF-1 levels, however, did not differ between the two treatment periods (p=0.172). There were no reports of nocturnal enuresis incidents during the study periods. Conclusion: The short-term use of mandibular advancement splints significantly reduced AHI, supine AHI. The decrease in the overall AHI resulted from a combination of a decrease in AHI when using the Active MAS, and a tendency towards an increase in AHI when using the Sham MAS. Snoring time decreased significantly when using MAS in children with SDB, and participants showed improvement in subjectively assessed SDB symptoms and quality of life. In addition, significant improvement was detected in parent-reported child behaviour

The Accuracy of Digital Impressions versus Conventional Impressions in Neonates with Cleft Lip and/or Palate: A Laboratory-Based Study

Cleft lip and palate (CL/P) are a common congenital craniofacial anomaly requiring precise impressions for effective treatment. Conventional impressions (CIs) pose challenges in neonates with CL/P due to their delicate oral anatomy. While digital impressions (DIs) are increasingly recognised for their potential benefits over conventional methods in dentistry, their accuracy and application in neonates with cleft lip and palate (CL/P) remain underexplored. This study aimed to assess the accuracy of DIs compared to CIs in neonates with CL/P, using alginate and putty materials as references. A laboratory-based case–control study was conducted, utilising soft acrylic models resembling neonatal mouths with CL/P. Alginate and putty impressions were obtained conventionally, while digital impressions were captured using an intraoral scanner (IOS). A total of 42 models were analysed, divided evenly into three groups, with each group comprising 14 models. Superimposition and surface discrepancy analyses were performed to evaluate impression accuracy. The results revealed no statistically significant differences between the digital and conventional impressions in their intra-arch measurements and surface discrepancies. The mean measurement values did not significantly differ among groups, with p values indicating no significant variations (p > 0.05), confirmed by an analysis of variance. High intra-examiner reliability with Intra Class Coefficient (ICC) values close to 1 indicated consistent measurements over time. The current study demonstrates that DIs are equally accurate as conventional alginate and putty impressions in neonates with cleft lip and palate, offering a viable and less invasive alternative for clinical practise. This advancement holds promise for improving the treatment planning process and enhancing patient comfort, particularly in vulnerable neonatal populations. Further research is warranted to explore the clinical implications and factors affecting DI accuracy in this population

Corporate financial reporting in Qatar: a study of individual investors’ assessment of annual reports

In this paper, an attempt is made to investigate a particular group of investors – namely individual investors’ perceptions of corporate annual reports in Qatar. A total of 400 surveys were distributed to individual investors based in Qatar. Surveys were distributed over a period of two months. The response rate was 89% (356 returned surveys), with 313 usable questionnaires (78.25%). Findings show that annual reports represent a very important source of information for investors. Almost 67% of the respondents see annual reports as a very important source of information to assess company’s performance and for investment decisions. Compared to other company’s sources of information annual reports rank first. Similar to Al-Attar and Al-Khater (2008), investors rank the set of financial statements on the top. The balance sheet is ranked first. Income statement and cash flow statement are also important and ranked receptively third and second. Auditor’s report comes in the fourth position. The results of this study comfort well the idea that the financial reporting environment in Qatar is evolving at the image of the country

Corporate financial reporting in Qatar: a study of individual investors' assessment of annual reports

In this paper, an attempt is made to investigate a particular group of investors - namely individual investors' perceptions of corporate annual reports in Qatar. A total of 400 surveys were distributed to individual investors based in Qatar. Surveys were distributed over a period of two months. The response rate was 89% (356 returned surveys), with 313 usable questionnaires (78.25%). Findings show that annual reports represent a very important source of information for investors. Almost 67% of the respondents see annual reports as a very important source of information to assess company's performance and for investment decisions. Compared to other company's sources of information annual reports rank first. Similar to Al-Attar and Al-Khater (2008), investors rank the set of financial statements on the top. The balance sheet is ranked first. Income statement and cash flow statement are also important and ranked receptively third and second. Auditor's report comes in the fourth position. The results of this study comfort well the idea that the financial reporting environment in Qatar is evolving at the image of the country

Efficacy of a mandibular advancement appliance on sleep-disordered breathing in children: a study protocol of a crossover randomized controlled trial

Background: Sleep-Disordered Breathing (SDB) varies from habitual snoring to partial or complete obstruction of the upper airway and can be found in up to 10% of children. SDB can significantly affect children’s wellbeing, as it can cause growth disorders, educational and behavioral problems, and even life-threatening conditions, such as cardiorespiratory failure. Adenotonsillectomy represents the primary treatment for pediatric SDB where adeno-tonsillar hypertrophy is indicated. For those with craniofacial anomalies, or for whom adenotonsillectomy or other treatment modalities have failed, or surgery is contra-indicated, mandibular advancement splints (MAS) may represent a viable treatment option. Whilst the efficacy of these appliances has been consistently demonstrated in adults, there is little information about their effectiveness in children.Aims: To determine the efficacy of mandibular advancement appliances for the management of SDB and related health problems in children. Methods/design: The study will be designed as a single-blind crossover randomized controlled trial with administration of both an ‘Active MAS’ (Twin-block) and a ‘Sham MAS’. Eligible participants will be children aged 8 to 12 years whose parents report they snore ≥ 3 nights per week. Sixteen children will enter the full study after confirming other inclusion criteria, particularly Skeletal class I or class II confirmed by lateral cephalometric radiograph. Each child will be randomly assigned to either a treatment sequence starting with the Active or the Sham MAS. Participants will wear the appliances for three weeks separated by a two-week washout period. For each participant, home-based polysomnographic data will be collected four times; once before and once after each treatment period. The Apnea Hypopnea Index (AHI) will represent the main outcome variable. Secondary outcomes will include, snoring frequency, masseter muscle activity, sleep symptoms, quality of life, daytime sleepiness, children behavior, and nocturnal enuresis. In addition, blood samples will be collected to assess growth hormone changes.Trial registration: This study was registered in the Australian New Zealand Clinical Trials Registry (ANZCTR): [ACTRN12614001013651