Single implant-supported two-unit cantilever fixed partial dentures in the posterior region:a retrospective case series with a mean follow-up of 6.5 years

BACKGROUND: The aim of this retrospective study was to evaluate the implant survival, clinical and radiographic outcomes, and patient satisfaction of single implant-supported two-unit cantilever fixed partial dentures in the posterior region.METHODS: Patients who received a single implant-supported fixed partial denture with a cantilever in the posterior region between January 2004 and February 2018 were included. Survival rate of the implants and the fixed partial dentures and data regarding the marginal bone level, presence of plaque, calculus, bleeding on probing, mucosa health, pocket probing depth, and patient satisfaction were collected during an evaluation visit. Complications were recorded from the medical records.RESULTS: Twenty-three patients (mean age 64 ± 13 years) with 28 implants could be included in the study. The mean follow-up period was 6.5 ± 4.8 years at the time of data collection. The survival rate of the implants and fixed partial dentures was 100%. Mean marginal bone loss for the mesial and distal side of the implants was 0.41 mm (SD 1.18 mm) and 0.63 mm (SD 0.98 mm) respectively. A high prevalence of peri-implant-mucositis (89.3%) and peri-implantitis (17.9%) was observed as well as a limited number of technical complications. Patients were quite satisfied, as reflected by a mean VAS score of 94.0 ± 7.2 points (range 0-100) and a OHIP-NL49 score of 10.8 (range 0-196).CONCLUSIONS: Single implant-supported fixed partial dentures with a mesial or distal cantilever can be a predictable treatment option in the posterior region, with stable peri-implant bone levels, minor technical complications, and very content patients. However, the prevalence of peri-implant mucositis and peri-implantitis was high.TRIAL REGISTRATION: ISRCTN, ISRCTN79055740 , Registered on March 14, 2021 - -Retrospectively registered.</p

Interactions Between the Amazonian Rainforest and Cumuli Clouds: A Large‐Eddy Simulation, High‐Resolution ECMWF, and Observational Intercomparison Study

The explicit coupling at meter and second scales of vegetation's responses to the atmospheric‐boundary layer dynamics drives a dynamic heterogeneity that influences canopy‐top fluxes and cloud formation. Focusing on a representative day during the Amazonian dry season, we investigate the diurnal cycle of energy, moisture and carbon dioxide at the canopy top, and the transition from clear to cloudy conditions. To this end, we compare results from a large‐eddy simulation technique, a high‐resolution global weather model, and a complete observational data set collected during the GoAmazon14/15 campaign. The overall model‐observation comparisons of radiation and canopy‐top fluxes, turbulence, and cloud dynamics are very satisfactory, with all the modeled variables lying within the standard deviation of the monthly aggregated observations. Our analysis indicates that the timing of the change in the daylight carbon exchange, from a sink to a source, remains uncertain and is probably related to the stomata closure caused by the increase in vapor pressure deficit during the afternoon. We demonstrate quantitatively that heat and moisture transport from the subcloud layer into the cloud layer are misrepresented by the global model, yielding low values of specific humidity and thermal instability above the cloud base. Finally, the numerical simulations and observational data are adequate settings for benchmarking more comprehensive studies of plant responses, microphysics, and radiation

Paroxysmal autonomic instability with dystonia in a patient with tuberculous meningitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>This case report describes an extremely rare combination of paroxysmal autonomic instability with dystonia and tuberculous meningitis. Paroxysmal autonomic instability with dystonia is normally associated with severe traumatic brain injury.</p> <p>Case presentation</p> <p>A 69-year-old man of Indonesian descent was initially suspected of having a community-acquired pneumonia, which was seen on chest X-ray and computed tomography of the chest. However, a bronchoscopy showed no abnormalities. He was treated with amoxicillin-clavulanic acid in combination with ciprofloxacin. However, nine days after admission he was disorientated and complained of headache. Neurological examination revealed no further abnormalities. A lumbar puncture revealed no evidence of meningitis. He was then transferred to our hospital. At that time, initial cultures of bronchial fluid for <it>Mycobacterium tuberculosis </it>turned positive, as well as polymerase chain reaction for <it>Mycobacterium tuberculosis</it>. Later, during his stay in our intensive care unit, he developed periods with hypertension, sinus tachycardia, excessive transpiration, decreased oxygen saturation with tachypnea, pink foamy sputum, and high fever. This constellation of symptoms was accompanied by dystonia in the first days. These episodes lasted approximately 30 minutes and improved after administration of morphine, benzodiazepines or clonidine. Magnetic resonance imaging showed an abnormal signal in the region of the hippocampus, thalamus and the anterior parts of the lentiform nucleus and caudate nucleus.</p> <p>Conclusions</p> <p>In patients with (tuberculous) meningitis and episodes of extreme hypertension and fever, paroxysmal autonomic instability with dystonia should be considered.</p

Irreversible encephalopathy after treatment with high-dose intravenous metronidazole.

BACKGROUND: Encephalopathy associated with metronidazole is rare and, in most cases, reversible following discontinuation. OBJECTIVE: We describe a case of fatal encephalopathy after treatment with high-dose intravenous metronidazole and the potential causes of the irreversibility. CASE SUMMARY: A 38-year-old white woman (weight, 45 kg) received metronidazole among other medications to treat osteomyelitis for 74 days after surgery to correct a spinal neuroarthropathy. An initial dose of 500 mg IV QID was administered. After 6 weeks, the patient was discharged and the dose was changed to 1500 mg IV administered once daily (over 90 minutes) by a visiting nurse. Other treatments included teicoplanin 400 mg once daily and trimethoprimsulfamethoxazole 480 mg BID for the infection, baclofen 25 mg TID for pain associated with a congenital spinal cord lesion with paraplegia, and omeprazole 20 mg once daily for pyrosis. Ten weeks after the start of metronidazole, the patient developed somnolence and dysarthria, changing to encephalopathy with coma on admission 2 weeks later. Despite discontinuation of all medication, including metronidazole, 2 days after admission, the patient's condition appeared to be irreversible. After 8 weeks, her coma was considered permanent, mechanical ventilation was discontinued, and she died. Evaluating all medicines administered, metronidazole, with a Naranjo adverse drug reaction score of 5 (probable), was the most plausible cause of the encephalopathy. The other medicines, including baclofen, had a negative score of -3 to -2 (doubtful). All tests on infections, metabolic disorders, or interactions between medications were negative. CONCLUSION: This patient had a fatal encephalopathy, probably associated with long-standing exposure to high plasma concentration peaks of metronidazole, due to a once-daily dose of 1500 mg IV over several weeks

Extracorporeal membrane oxygenation in the treatment of poisoned patients

CONTEXT : Although extracorporeal membrane oxygenation (ECMO) was used in many patients following its introduction in 1972, most hospitals had abandoned this experimental treatment for adult patients. Recently, improvements in the ECMO circuitry rendered it more biocompatible. The surprisingly low mortality in patients with severe acute respiratory distress syndrome who were treated with ECMO in the influenza A/H1N1 pandemic of 2009 resurrected interest in ECMO in many intensive care units around the world. OBJECTIVES: This article reviews the different techniques of ECMO, the indications, contraindications and complications of its use, its role in poisoned patients and the ethics of its use. METHODS: We searched Pubmed, Toxnet, Cochrane database and Embase from 1966 to September 2012 using the search terms (''extracorporeal membrane oxygenation'', 'extracorporeal life support', 'ECMO', 'ECLS', 'assist-device', and 'intox*' or 'poison*'). These searches identified 242 papers of which 116 described ECMO in conditions other than intoxications or were reviews. In total 46 publications selected for this manuscript were case reports or case series involving poisoned patients. ECMO TECHNIQUES: Two types of ECMO are used: veno-venous ECMO (VV-ECMO) or veno-arterial ECMO (VA-ECMO). VV-ECMO is used for patients with severe ARDS to secure adequate oxygenation of the organs while protecting the lungs from harmful ventilation pressures or prolonged inspiratory fraction of oxygen. VA-ECMO can be used whenever the patient remains in shock despite adequate fluid resuscitation and is refractory to administration of inotropes and vasopressors. INDICATIONS: The organ support that can be applied with ECMO makes it especially useful in patients with severe poisoning as the clinical impact of the intoxication is often temporary; ECMO can be used as a 'bridge to recovery'. CONTRAINDICATIONS: Absolute contraindications are uncontrolled coagulopathy and severe intracranial bleeding, which precludes the use of anticoagulation therapy. Relative contraindications to ECMO include advanced age, severe irreversible brain injury, untreatable metastatic cancer, severe organ dysfunction (some suggest a Sequential Organ Failure Assessment (SOFA) score > 15), and high pressure positive pressure ventilation for more than 7 days. COMPLICATIONS: The most common complication of ECMO is either bleeding at the cannulation site (in VV-ECMO) or bleeding at the surgical entry site (in VA-ECMO). Overall bleeding complications currently occur in 10-36% patients, and intracranial haemorrhage is seen in up to 6% of patients. ECMO should be reserved, therefore, for the most severely ill poisoned patients with a high risk of death. ECMO in poisoned patients. There are no randomised trials of ECMO in poisoned patients with refractory shock or who have ARDS caused by an intoxication. VV-ECMO can be considered in patients with type l and ll respiratory failure. In patients with life-threatening haemodynamic instability, VA-ECMO can be considered when shock persists despite volume administration, inotropes and vasoconstrictors, and (sometimes) intra-aortic balloon counterpulsation. Typical examples include poisoning due to calcium channel antagonists, beta-blockers, tricyclic antidepressants, chloroquine and colchicine. ETHICS OF ECMO USE: It is only ethical to use such a costly intervention (£19,252 and US$ 31,000 per quality-adjusted life year) if the treatment has a real purpose such as a 'bridge to recovery', a 'bridge to transplant', or a 'bridge to permanent assist device' (in the case of persistent cardiac failure). CONCLUSIONS: In the last decade, ECMO equipment has improved considerably, rendering it more biocompatible, and it has been used more frequently as an assist device for patients needing oxygenation as well as circulatory support. ECMO is considered a good salvage therapy for patients who are severely poisoned with ARDS or refractory circulatory shock

A breakthrough in cryosurgery.

Item does not contain fulltextLiver cryosurgery is one of the treatment options for unresectable liver metastases. Indications for the use of this treatment instead of classic surgery are bilobar disease, location of the tumor at an irresectable anatomic site, and comorbid conditions of the patient. Possible complications of cryosurgery are hemorrhage, coagulopathy, pneumonia, pleural effusion, abdominal abscess, and bile fistula. We describe a patient in whom a hepatobronchial fistula developed after cryosurgery. The patient had cryosurgery because of an unresectable liver metastasis in a Dukes' C rectal carcinoma. More details are given in the case report. To our knowledge, a hepatobronchial fistula as a complication of cryosurgery has never been reported. It therefore should be added to the list of possible cryosurgery complications

Cloud Shading Effects on Characteristic Boundary-Layer Length Scales

We studied the effects of shading by shallow cumulus (shallow Cu) and the subsequent effect of inducing heterogeneous conditions at the surface on boundary-layer characteristics. We placed special emphasis on quantifying the changes in the characteristic length and time scales associated with thermals, shallow Cu and induced thermal circulation structures. A series of systematic numerical experiments, inspired by Amazonian thermodynamic conditions, was performed using a large-eddy simulation model coupled to a land-surface model. We used four different experiments to disentangle the effects of shallow Cu on the surface and the response of clouds to these surface changes. The experiments include a 'clear case', 'transparent clouds', 'shading clouds' and a case with a prescribed uniform domain and reduced surface heat flux. We also performed a sensitivity study on the effect of introducing a weak background flow. Length and time scales were calculated using autocorrelation and two-dimensional spectral analysis, and we found that shading controlled by shallow Cu locally lowers surface temperatures and consequently reduces the sensible and latent heat fluxes, thus inducing spatial and temporal variability in these fluxes. The length scale of this surface heterogeneity is not sufficiently large to generate circulations that are superimposed on the boundary-layer scale, but the heterogeneity does disturb boundary-layer dynamics and generates a flow opposite to the normal thermal circulation. Besides this effect, shallow Cu shading reduces turbulent kinetic energy and lowers the convective velocity scale, thus reducing the mass flux. This hampers the thermal lifetime, resulting in a decrease in the shallow Cu residence time (from 11 to 7 min). This reduction in lifetime, combined with a decrease in mass flux, leads to smaller clouds. This is partially compensated for by a decrease in thermal cell size due to a reduction in turbulent kinetic energy. As a result, inter-cloud distance is reduced, leading to a larger population of smaller clouds, while maintaining cloud cover similar to the non-shading clouds experiment. Introducing a background wind speed increases the thermal size in the sub-cloud layer, but the diagnosed surface-cloud coupling, quantified by characteristic time and length scales, remains