Nephrology and Hypertension

Cardiovascular disease in children with chronic kidney disease Purpose of review Cardiovascular disease (CVD) is a significant cause of morbidity and mortality in children with chronic kidney disease (CKD). The cause of CVD in children with CKD is multifactorial and there are new and emerging data regarding prevalence and risk factors for CVD in this population. Recent findings A number of recent publications from longitudinal cohort studies of children with CKD have greatly increased our knowledge about the prevalence and risk factors for CVD including hypertension, obesity and dyslipidaemia. Masked hypertension and isolated nocturnal hypertension both correlate with surrogate markers of CVD in children. Obesity and adiposity are associated with an increased risk of CVD. Markers other than BMI such as waist to height ratio and fat-free tissue to fat tissue ratio better correlate with the presence of CVD in children. Dyslipidaemia is extremely prevalent in the paediatric CKD population, but there is a lack of consensus on treatment. More data on the relationship between bone mineral disease and CVD continue to emerge including an association between hyperparathyroidism and isolated nocturnal hypertension. Summary Children with CKD have multiple potentially modifiable risk factors for CVD. Research focused on CVD outcomes in children is needed. Correspondence to Michelle N. Rheault, MD, Division of Pediatric Nephrology, 2450 Riverside Ave, MB680, Minneapolis, MN 55454, USA. Tel: +1 612 626 2922; fax: +1 612 626 2791; e-mail: rheau002@umn.edu Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Disparities in chronic kidney disease-the state of the evidence Purpose of review The purpose of this review was to assess the prevalence of United States chronic kidney disease (CKD) health disparities, focusing on racial/ethnic groups, immigrants and refugees, sex or gender, and older adults. Recent findings There are major racial/ethnic disparities in CKD, with possible contributions from the social determinants of health, socioeconomics, and racial discrimination. Racial/ethnic minority patients experience faster progression to end-stage kidney disease (ESKD) and higher mortality predialysis, however, once on dialysis, appear to live longer. Similarly, men are quicker to progress to ESKD than women, with potential biological, behavioral, and measurement error factors. There is a lack of substantial evidence for intersex, nonbinary, or transgender patients. There are also strikingly few studies about US immigrants or older adults with CKD despite the fact that they are at high risk for CKD due to a variety of factors. Summary As providers and scientists, we must combat both conscious and unconscious biases, advocate for minority patient populations, and be inclusive and diverse in our treatment regimens and provision of care. We need to acknowledge that sufficient evidence exists to change treatment guidelines, and that more is required to support the diversity of our patient population. Correspondence to Maya N. Clark-Cutaia, PhD, ACNP-BC, RN, NYU Meyers College of Nursing, 433 First Avenue, Room 664, New York, New York 10010, USA. Tel: +212 998 5280; fax: +212 995 3143; e-mail: MC7009@NYU.EDU Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Gut–kidney axis in oxalate homeostasis Purpose of review The gut–kidney axis plays a critical role in oxalate homeostasis, and better understanding of oxalate transport regulatory mechanisms is essential for developing novel therapies. Recent findings Oxalate potentially contributes to chronic kidney disease (CKD) progression, CKD - and end stage renal disease (ESRD)-associated cardiovascular diseases, polycystic kidney disease (PKD) progression, and/or poor renal allograft survival, emphasizing the need for plasma and urinary oxalate lowering therapies. One promising strategy would be to enhance the bowel's ability to secrete oxalate, which might be facilitated by the following findings. Oxalobacter formigenes (O. formigenes)-derived factors recapitulate O. formigenes colonization effects by reducing urinary oxalate excretion in hyperoxaluric mice by inducing colonic oxalate secretion. Protein kinase A activation stimulates intestinal oxalate transport by enhancing the surface expression of the oxalate transporter SLC26A6 (A6). Glycosylation also stimulates A6-mediated oxalate transport. The colon adapts to chronic acidosis in rats through increased colonic oxalate secretion as previously reported in CKD rats, and A6-mediated enteric oxalate secretion is critical in reducing the body oxalate burden in CKD mice. Intestinal oxalate transport is negatively regulated by proinflammatory cytokines and cholinergic, purinergic, and adenosinergic signaling. Summary These findings could facilitate the development of novel therapeutics for hyperoxalemia, hyperoxaluria, and related disorders if similar regulatory mechanisms are confirmed in humans. Correspondence to Hatim A. Hassan, MD, PhD, Section of Nephrology, Department of Medicine, The University of Chicago, 5841S. Maryland Ave, MC5100, Chicago, Illinois 60637, USA. Tel: +773 834 0374; fax: +773 702 5818; e-mail: hhassan@medicine.bsd.uchicago.edu Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Regulation of vascular tone and blood pressure by singlet molecular oxygen in inflammation Purpose of review The principle aim of this review is to prompt vascular researchers interested in vascular inflammation and oxidative stress to consider singlet molecular oxygen (1O2) as a potentially relevant contributor. A secondary goal is to propose novel treatment strategies to address haemodynamic complications associated with septic shock. Recent findings Increased inflammation and oxidative stress are hallmarks of a range of vascular diseases. We recently showed that in systemic inflammation and oxidative stress associated with models of inflammation including sepsis, the tryptophan catabolizing enzyme indoleamine 2,3-dioxygenase-1 (Ido1) contributes to hypotension and decreased blood pressure through production of singlet molecular oxygen (1O2). Once formed, 1O2 converts tryptophan bound to Ido1 to a vasoactive hydroperoxide which decreases arterial tone and blood pressure via oxidation of a specific cysteine residue of protein kinase G1α. Summary These works show, for the first time, that 1O2 contributes to arterial redox signalling and that Ido1 contributes to the regulation of blood pressure through production of a novel tryptophan-derived hydroperoxide, thus presenting a new signalling pathway as novel target in the treatment of blood pressure disorders such as sepsis. Correspondence to Roland Stocker, PhD, Heart Research Institute, Newtown, NSW 2042, Australia. E-mail: roland.stocker@hri.org.au Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Managing hyperuricemia and gout in chronic kidney disease: a clinical conundrum Purpose of review There is controversy regarding the impact of hyperuricemia on the progression of chronic kidney disease (CKD), and gout remains sub optimally managed in this population. We discuss the prescribing of drugs for the treatment of gout in patients with CKD. Recent findings There is a lack of consensus from expert guidelines, and prescribers have concerns regarding the risk of adverse reactions from medicines used to treat gout. These situations appear to contribute to suboptimal management of gout in this cohort. Recent data have challenged the role of urate lowering therapy (ULT) in the management of asymptomatic hyperuricemia in CKD. Summary ULT should be commenced in all patients with severe, recurrent disease, tophaceous gout and evidence of joint damage. Most international guidelines recommend a treat-to-target approach for the management of gout. In CKD, ULT should be started at low dose with up titration adjusted to serum urate levels, rather than being based on the creatinine clearance. If patients fail first-line therapy, alternative agents are utilized, the specific agent depending on ease of access, burden of disease and other comorbidities. This approach should be incorporated into routine practice to ensure optimal treatment of gout in CKD. More research is required to investigate whether treatment of asymptomatic hyperuricemia has clinical benefits. Correspondence to Darren M. Roberts, Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia. Tel: +61 283821111; fax: +61 283822032; e-mail: Darren.roberts@svha.org.au Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular autonomic nervous system dysfunction in chronic kidney disease and end-stage kidney disease: disruption of the complementary forces Purpose of review Several nontraditional risk factors have been the focus of research in an attempt to understand the disproportionately high cardiovascular morbidity and mortality in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) populations. One such category of risk factors is cardiovascular autonomic dysfunction. Its true prevalence in the CKD/ESKD population is unknown but existing evidence suggests it is common. Due to lack of standardized diagnostic and treatment options, this condition remains undiagnosed and untreated in many patients. In this review, we discuss current evidence pointing toward the role of autonomic nervous system (ANS) dysfunction in CKD, building off of crucial historical evidence and thereby highlighting the areas in need for future research interest. Recent findings There are several key mediators and pathways leading to cardiovascular autonomic dysfunction in CKD and ESKD. We review studies exploring the mechanisms involved and discuss the current measurement tools and indices to evaluate the ANS and their pitfalls. There is a strong line of evidence establishing the temporal sequence of worsening autonomic function and kidney function and vice versa. Evidence linking ANS dysfunction and arrhythmia, sudden cardiac death, intradialytic hypotension, heart failure and hypertension are discussed. Summary There is a need for early recognition and referral of CKD and ESKD patients suspected of cardiovascular ANS dysfunction to prevent the downstream effects described in this review. There are many unknowns in this area and a clear need for further research. Correspondence to David M. Charytan, MD, MSc, Chief, Nephrology Division, NYU Langone Medical Center, 462 1st Avenue C & D 689, New York, New York 10010, USA. Tel: +646 501 9086; e-mail: David.charytan@nyulangone.org Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Challenges in communication, prognostication and dialysis decision-making in the COVID-19 pandemic: implications for interdisciplinary care during crisis settings Purpose of review Using case vignettes, we highlight challenges in communication, prognostication, and medical decision-making that have been exacerbated by the coronavirus disease-19 (COVID-19) pandemic for patients with kidney disease. We include best practice recommendations to mitigate these issues and conclude with implications for interdisciplinary models of care in crisis settings. Recent findings Certain biomarkers, demographics, and medical comorbidities predict an increased risk for mortality among patients with COVID-19 and kidney disease, but concerns related to physical exposure and conservation of personal protective equipment have exacerbated existing barriers to empathic communication and value clarification for these patients. Variability in patient characteristics and outcomes has made prognostication nuanced and challenging. The pandemic has also highlighted the complexities of dialysis decision-making for older adults at risk for poor outcomes related to COVID-19. Summary The COVID-19 pandemic underscores the need for nephrologists to be competent in serious illness communication skills that include virtual and remote modalities, to be aware of prognostic tools, and to be willing to engage with interdisciplinary teams of palliative care subspecialists, intensivists, and ethicists to facilitate goal-concordant care during crisis settings. Correspondence to Devika Nair, MD, MSCI, Instructor of Medicine, Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Health Services Research, 2525 West End Avenue, Suite 450, Office 416, Nashville, Tennessee 37203, USA. Tel: +615 322 7285; e-mail: Devika.nair@vumc.org Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Angiotensin-converting enzyme 2: from a vasoactive peptide to the gatekeeper of a global pandemic Purpose of review We provide a comprehensive overview of angiotensin-converting enzyme 2 (ACE2) as a possible candidate for pharmacological approaches to halt inflammatory processes in different pathogenic conditions. Recent findings ACE2 has quickly gained prominence in basic research as it has been identified as the main entry receptor for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This novel pathogen causes Coronavirus Disease 2019 (COVID-19), a pathogenic condition that reached pandemic proportion and is associated with unprecedented morbidity and mortality. Summary The renin–angiotensin system is a complex, coordinated hormonal cascade that plays a pivotal role in controlling individual cell behaviour and multiple organ functions. ACE2 acts as an endogenous counter-regulator to the pro-inflammatory and pro-fibrotic pathways triggered by ACE through the conversion of Ang II into the vasodilatory peptide Ang 1–7. We discuss the structure, function and expression of ACE2 in different tissues. We also briefly describe the role of ACE2 as a pivotal driver across a wide spectrum of pathogenic conditions, such as cardiac and renal diseases. Furthermore, we provide the most recent data concerning the possible role of ACE2 in mediating SARS-CoV-2 infection and dictating COVID-19 severity. Correspondence to Luca Perico, PhD, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy. Tel: +39 035 42131; fax: +39 035 319331; e-mail: luca.perico@marionegri.it Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Sodium bicarbonate therapy for acute respiratory acidosis Purpose of review Respiratory acidosis is commonly present in patients with respiratory failure. The usual treatment of hypercapnia is to increase ventilation. During the recent surge of COVID-19, respiratory acidosis unresponsive to increased mechanical ventilatory support was common. Increasing mechanical ventilation comes at the expense of barotrauma and hemodynamic compromise from increasing positive end-expiratory pressures or minute ventilation. Treating acute respiratory acidemia with sodium bicarbonate remains controversial. Recent findings There are no randomized controlled trials of administration of sodium bicarbonate for respiratory acidemia. A recent review concluded that alkali therapy for mixed respiratory and metabolic acidosis might be useful but was based on the conflicting and not conclusive literature regarding metabolic acidosis. This strategy should not be extrapolated to treatment of respiratory acidemia. Low tidal volume ventilation in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) has beneficial effects associated with permissive hypercapnia. Whether the putative benefits will be negated by administration of alkali is not known. Hypercapnic acidosis is well tolerated, with few adverse effects as long as tissue perfusion and oxygenation are maintained. Summary There is a lack of clinical evidence that administration of sodium bicarbonate for respiratory acidosis has a net benefit; in fact, there are potential risks associated with it. Correspondence to David S. Goldfarb, MD, Clinical Chief, Nephrology Division, NYU Langone Health, Professor of Medicine and Physiology, New York University School of Medicine, Nephrology Section 111G, 423 E. 23 Street, New York, NY 10010, USA. Tel: +1 212 686 7500, x3877; fax: +1 212 951 6842; e-mail: david.goldfarb@nyulangone.org Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Controversies in nephrologic covidology No abstract available

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Conservative Dentistry

From the Desk of the Editor … The new dawn - Hope in the pandemic Shishir Singh Journal of Conservative Dentistry 2020 23(4):319-319

Preferred Reporting Items for study Designs in Endodontology (PRIDE): Guiding authors to produce high.quality manuscripts Venkateshbabu Nagendrababu, Paul M H. Dummer Journal of Conservative Dentistry 2020 23(4):320-324 Implementing evidence-based dentistry involves a systematic process that includes collecting and analyzing evidence to address a clinical question. However, the inadequacy of many manuscripts and the incomplete and often misleading information they provide when published in healthcare journals are of major concern. The literature confirms that reporting guidelines improve the overall completeness and transparency of manuscripts in the field of oral health research. To improve the overall quality and clinical translation of studies in Endodontology, a new suite of guidelines under the umbrella of the Preferred Reporting Items for study Designs in Endodontology (PRIDE) project has been developed. Under the PRIDE project, five reporting guidelines focusing on specific study designs within the specialty either have or are in the process of being developed: (Case reports: Preferred Reporting Items for Case reports in Endodontics (PRICE); Randomized clinical trials: Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE); Laboratory studies: Preferred Reporting Items for Laboratory studies in Endodontology (PRILE); Animal studies: Preferred Reporting Items for Animal Studies in Endodontology (PRIASE) and Observational studies: Preferred Reporting items for OBservational studies in Endodontics (PROBE). For each guideline, the project leaders (VN, PD) formed a steering committee made up of experts from across the globe. Each steering committee developed an initial draft checklist containing a list of proposed items related to the specific study design to fit the specialty of Endodontology. In addition, a flowchart to graphically illustrate the process involved in the development of a manuscript was created to accompany each individual guideline. Each steering committee then formed a Delphi panel that included approximately 30 experts from across the globe who commented individually and anonymously upon the items to be included in each checklist and flowchart until a consensus was achieved. The draft checklists and flowcharts were then discussed during face-to-face or online meetings of approximately 20 experts to further debate and refine each guideline, which were then piloted by several authors while writing a manuscript. Eventually, each guideline (checklist and flowchart) will be published along with supporting material as well as being freely accessible on the PRIDE website (www.pride-endodonticguidelines.org). The PRIDE guidelines will help authors produce high-quality manuscripts in the discipline of Endodontology.

India's contribution to regenerative endodontics: A bibliometric analysis Arunakshi Krishnan, Aakriti Saini, Sidhartha Sharma, Vijay Kumar, Amrita Chawla, Ajay Logani Journal of Conservative Dentistry 2020 23(4):325-329 Regenerative endodontics (RE) is a dynamic field with widespread global impact. The aim of this bibliometric analysis is to highlight India's contribution in the field. Electronic search was performed in PubMed and Web of Science database till December 2019 using the search terms “Dental pulp regeneration,” “Pulp revascularisation,” “Revitalisation,” “Regenerative endodontic,” and their permutation. Articles of Indian authors with affiliation to Indian institutes were included. The following data were extracted: first author, institute and state of affiliation, year and journal of publication, study design, level of evidence (LOE), and number of citations. A total of 76 articles (case reports [n = 29, 38.15%], review [n = 25, 32.8%]) were published between 2008 and 2019. Majority (42.6%) were categorized as LOE 4. 7.4% articles were in LOE1 category. Eight percent articles had citations above 100 (highest cited-354 citations). The average yearly growth rate between 2011 and 2019 was 33.28% and highest number of publications was in the year 2015. The south zone had the maximum publications. At an institutional level, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, had the maximum publications. Journal of Conservative Dentistry published the highest number of articles. India contributed 7.6% of the global PubMed indexed publications and reported 22% of clinical trials. This analysis reveals increasing trend of research in RE in India. However, it highlights the need to generate articles with higher LOE by conducting quality multicenter trials and promote national and international collaborations.

Evaluation of remineralization potential and cytotoxicity of a novel strontium-doped nanohydroxyapatite paste: An in vitro study Ratheesh Rajendran, K Radhakrishnan Nair, Raghu Sandhya, P Mohammed Ashik, Rakhi Pattuvanmar Veedu, Shinu Saleem Journal of Conservative Dentistry 2020 23(4):330-336 Background: The focus of caries management has shifted to the early detection of caries and noninvasive methods of management of incipient lesions with novel remineralizing agents. Aim: The aim of this study is to evaluate and compare the remineralization potential of a novel laboratory synthesized strontium-doped nanohydroxyapatite (SrnHAp) paste to a commercially available regular dentifrice. Materials and Methods: Sixty enamel specimens (4 mm × 4 mm × 1 mm) were divided into two groups based on the type of dentifrice applied: Group I – regular toothpaste and Group II – SrnHAp paste. Calcium/phosphorous ratio of all sound specimens was evaluated using Scanning Electron Microscopy-Energy Dispersive X-ray analysis. Samples in both groups were subjected to demineralization, and the calcium/phosphorous ratio was analyzed. The samples were then subjected to remineralization using the specific agents in each group, and the mean calcium–phosphorus ratio was assessed. Cytotoxic evaluation of both pastes was done by direct microscopic observation and MTT assay. Statistical Analysis: Comparison of mean calcium and phosphorous values of sound enamel, demineralized, and remineralized specimen in Groups I and II was done using the one-way ANOVA and Tukeys post hoc test. Intergroup comparison after remineralization was done using the Student's t-test. Results and Conclusion: Group II showed higher remineralization potential than Group I and was statistically significant. Cytotoxicity of novel paste was less compared to the regular toothpaste. SrnHAp showed better remineralization than regular toothpaste and can be considered for enamel repair in incipient carious lesions.

Association of hormonal fingerprints and dental caries: A pilot study Akansha Rajawat, Chandrakanth Majeti, Uday Kumar Podugu, Mamta Kaushik, X Nagamaheshwari, Neha Mehra Journal of Conservative Dentistry 2020 23(4):337-340 Context: Dental caries remains the most widespread oral disease among all age groups. Hormonal fingerprints (second digit: fourth digit ratio or 2D:4D ratio) are biomarkers displaying sexual dimorphism and diverse human phenotypic traits. A person's genetic makeup may influence the occurrence of dental caries. Aim: The present study aimed to evaluate the influence of digit ratio on the incidence of dental caries. Settings and Design: Two hundred patients between 18 and 55 years, reporting for restorations or endodontic therapy, participated in the study. Subjects and Methods: Hormonal fingerprints (2D:4D ratio) were measured with the help of a digital vernier caliper. Caries incidence was recorded using the DMFT index. Statistical Analysis used: Data obtained were tabulated and statistically analyzed using Independent t-test and Chi-square test. Results: Males had a less mean 2D:4D ratio than females, which was statistically significant (p-value = 0.003). Chi-square test was applied, and there was a statistically significant correlation between high digit ratio and caries experience (p-value = 0.002). Females with a high digit ratio and males with a low digit ratio were in the moderate and low caries risk groups with a p-value of 0.029 and 0.001 in the respective risk groups. Conclusion: The present study displayed a correlation between hormonal fingerprints (2D:4D ratio) and dental caries. An indicator of caries risk will help prevent caries by implementing oral hygiene measures, which will reduce its incidence as the most occurring oral disease.

Influence of desensitizing agents in management of noncarious cervical lesion and bonded restorations: A preliminary 12-week report J Joyson Joe Asir, I Anand Sherwood, Bennett T Amaechi, M Vaanjay, S Swathipriyadarshini, P Ernest Prince Journal of Conservative Dentistry 2020 23(4):341-347 Objectives: The primary objective of this study was to investigate the effectiveness in reducing dentin hypersensitivity in noncarious cervical lesions (NCCLs) by home-based desensitizing toothpaste (TP), in-office Gluma desensitizer application, and resin-modified glass-ionomer cement (RMGIC) restoration. The secondary objective was to evaluate the long-term outcome of the? glass-ionomer cement restoration following the application of bioactive glass-containing desensitizer TP. Materials and Methods: A total of 73 patients or 151 teeth were included in the study and randomly allotted to one of the four different treatment groups. Pre- and postoperative symptom and air-blast/tactile sensitivity scores were recorded for statistical analysis. Postoperative sensitivity was analyzed at 1, 4, and 12 weeks after treatment. Nonparametric statistical tests were employed. Results: Kruskal–Wallis test noted a significant reduction in postoperative sensitivity at all time periods with the RMGIC group compared to other treatment options. Significantly higher patient dropout was observed in desensitizing TP regimen. Conclusions: This interim 12-week report on dentin hypersensitivity management of NCCLs concludes that resin-modified glass-ionomer restoration was able to achieve a significant instant reduction in sensitivity and patient satisfaction compared to other noninvasive at-home and in-office procedures. Clinical relevance: This interim 12-week report on dentin hypersensitivity management of noncarious cervical lesions concludes that resin-modified glass-ionomer restoration was able to achieve a significant reduction in sensitivity, and patient satisfaction was higher compared to other noninvasive at-home and in-office procedures.

Comparative analysis of platelet.rich fibrin, platelet-rich fibrin with hydroxyapatite and platelet-rich fibrin with alendronate in bone regeneration: A cone-beam computed tomography analysis Urvashi Ojha Tiwari, Ramesh Chandra, Supratim Tripathi, Jyoti Jain, Sanjay Jaiswal, Rahul Kumar Tiwari Journal of Conservative Dentistry 2020 23(4):348-353 Aim: This clinical study was designed to evaluate the volumetric healing of periapical (PA) bone defect after PA surgery, using platelet-rich fibrin (PRF), and its combination with hydroxyapatite and alendronate. Subjects and Methods: Twenty male patients of age between 25 and 35 years, having PA pathology (>5 mm on intraoral periapical radiograph (IOPA)) with intraoral sinus opening, were included in this study. Cone-beam computed tomography (CBCT) imaging of all patients was done. Root canal treatment with PA surgery was done. Patients were divided into four groups (5 in each group), on the basis of material placed in PA bone defect. After 1 year, CBCT imaging was done. Linear measurement of maximal dimensions in all three orthogonal planes was done in both pre- and post-CBCT image. These measurements were used to estimate the volume of the lesion healed after 1 year of surgery. Statistical Analysis: Analysis of variance and Post hoc Tukey's test were used for statistical analysis. Results: Change in volume were significantly different between Group 1 vs Group 3; Group 2 vs Group 3 and Group 3 vs Group 4. The Group Order for change in volume 1 year post surgery Group 3> Group 4 ≈Group 2> Group 1. Conclusions: PA bone healing after surgery is enhanced by placing combination of bone regenerative materials. PRF with hydroxyapatite provides best healing outcomes in comparison to PRF with alendronate or PRF alone.

Comparative evaluation of platelet-rich fibrin, platelet-rich fibrin + 50 wt% nanohydroxyapatite, platelet-rich fibrin + 50 wt% dentin chips on odontoblastic differentiation - An in vitro study-part 2 Kottuppallil Girija, Mahendran Kavitha Journal of Conservative Dentistry 2020 23(4):354-358 Aim: The purpose of this study was to investigate the effects of platelet-rich fibrin (PRF) modified with bioactive radiopacifiers–nanohydroxyapatite (nHA) and dentin chips (DC) on odontoblastic differentiation in human dental pulp cells (HDPCs). Subjects and Methods: PRF was modified with 50wt% of nHA (G bone-SHAG31, Surgiwear Company) and 50 wt% of DC. HDPSCs differentiation and mineralization by the groups ([Group A - Control (Dimethyl sulfoxide), Group B - PRF, Group C – PRF + nHA, Group D – PRF + DC]) were assessed. ELISA was done to quantify the interleukin (IL)-6 and IL-8 cytokine expression. The odontoblastic differentiation was determined by the expression of odontogenesis-related genes and the extent of mineralization using alizarin red S staining. Statistical Analysis Used: One-way ANOVA with post hoc Tukey-honestly significant difference tests were applied to assess the significance among various groups. Results: The level of inflammatory cytokines (IL-6 and IL-8) expression by Group D (PRF + 50 wt% DC) was higher compared to Group B (PRF) and Group C (PRF + 50 wt% DC). Group C (PRF + 50 wt% nHA) induced more mineralization nodules compared to other groups. The integrated density value for the DSPP and DMP-1 protein expression by Group C (PRF + 50 wt% nHA) and Group D (PRF + 50 wt% DC) was higher compared to Group B (PRF). Conclusions: The results suggest that the addition of bioactive radiopacifiers into PRF has a synergistic effect on the stimulation of odontoblastic differentiation of HDPCs, hence inducing mineralization.

Evaluation of vascular endothelial growth factor - A release from platelet-rich fibrin, platelet-rich fibrin matrix, and dental pulp at different time intervals Shruthi Nagaraja, Sylvia Mathew, Anil Abraham, Poornima Ramesh, Shashank Chandanala Journal of Conservative Dentistry 2020 23(4):359-363 Background: Lack of collateral blood supply and the low compliance environment of pulp makes its healing, a challenge. Vascular endothelial growth factor (VEGF) is a primary angiogenic growth factor. Knowledge of dose and time-dependent expression of VEGF from platelet concentrates, namely platelet-rich fibrin (PRF) and PRF matrix (PRFM), along with vital pulp can aid in developing strategies to improve the outcome of vital pulp therapy and regenerative procedures. Hence, the aim of this study was to compare VEGF kinetics of PRF, PRFM, and dental pulp. Materials and Methods: The PRF, PRFM, and vital dental pulp were placed in culture media for a week; the supernatant was collected from these samples at days 1, 4, and 7. VEGF-A expression was evaluated using ELISA and compared with the weight of the sample so as to quantify the release of VEGF-A per milligram of sample. Results: PRF exhibited maximum VEGF-A release on day 4 and was sustained till day 7. In contrast, PRFM and dental pulp showed no significant release of VEGF-A till day 7. However, on day 7, there was a rapid increase in VEGF-A expression from dental pulp that was comparable to PRF. On comparing the release of VEGF-A per milligram of tissue, pulp exhibited the maximum values. Conclusion: Among the platelet concentrates, differential expression of VEGF-A was superior in PRF. The use of PRF in partial pulpitis should be explored in order to restore pulp vascularity and hasten pulpal healing.

Cyclic fatigue, torsional failure, and flexural resistance of rotary and reciprocating instruments Carlos Henrique Ribeiro Camargo, Tatiane Sampaio Bittencourt, Amjad Abu Hasna, Renato Miotto Palo, Claudio Antonio Talge Carvalho, Marcia Carneiro Valera Journal of Conservative Dentistry 2020 23(4):364-369 Aim: The aim was to compare cyclic fatigue, torsional failure, and flexural resistance of NiTi endodontic files: Hyflex CM (HYF), Genius files (GEN), WaveOne Gold (WOG), and ProTaper Universal (PTU). Materials and Methods: Fifteen files of each brand were used in cyclic fatigue test and other fifteen files for flexural test and torsional failure test. To the cyclic fatigue test, used torque limit and revolutions per minute were set according to the respective manufacturer guidelines. The test was performed under deionized water at 36°C, and all files were tested in a 3 mm radius of curvature with an angle of curvature of 60°, time of the fracture was recorded. Torsional fatigue test was performed in the torsional machine (Instron MT, USA), recording the fractured time and torque data by the machine software. Flexural fatigue test was performed in 60° of curvature. All data were statistically analyzed by one-way analysis of variance, and Tukey test for multiple comparisons. Results: Cyclic fatigue (seconds)= HYF: 744.1 ± 231.9/GEN: 477.3 ± 220.5/WO: 278.4 ± 57.0/PTU: 152.4 ± 65.2; torsional failure (N × cm)= HYF: 6.85 ± 1.484/GEN: 6.55 ± 0.828/WOG: 5.73 ± 0.360/PTU: 4.43 ± 0.900; flexural resistance (N × mm)= HYF: 0.33 ± 0.294/GEN: 0.19 ± 0.136/WOG: 0.98 ± 0.216/PTU: 1.85 ± 0.276. Conclusion: HYF and GEN showed the best results for cyclic fatigue, torsional failure, and flexural resistance, followed by WOG and PTU.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Thoracic Imaging

Visually Estimated RESOLVE Score Based on Coronary Computed Tomography to Predict Side Branch Occlusion in Percutaneous Bifurcation Intervention Purpose: The quantitative RESOLVE (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion) score derived from coronary computed tomography angiography (coronary CTA) was developed as a noninvasive and accurate prediction tool for side branch (SB) occlusion in coronary bifurcation intervention. We aimed to determine the ability of a visually estimated CTA-derived RESOLVE score (V-RESOLVE score) to predict SB occlusion in coronary bifurcation intervention. Materials and Methods: The present study included 363 patients with 400 bifurcation lesions. CTA-derived V-RESOLVE score was derived and compared with the quantitative CTA-derived RESOLVE score. The scoring systems were divided into quartiles, and classified as the high-risk and non–high-risk groups. SB occlusion was defined as any decrease in thrombolysis in myocardial infarction flow grade after main vessel stenting. Results: In total, 28 SB occlusions (7%) occurred. The concordance between visual and quantitative CTA analysis showed poor to excellent agreement (weighted κ range: 0.099 to 0.867). The area under the receiver operating curve for the prediction of SB occlusion was significantly higher for the CTA-derived V-RESOLVE score than for quantitative CTA-derived RESOLVE score (0.792 vs. 0.709, P=0.049). The total net reclassification index was 42.7% (P=0.006), and CTA-derived V-RESOLVE score showed similar capability to discriminate between high-risk group (18.6% vs. 13.8%, P=0.384) and non–high-risk group (3.8% vs. 4.9%, P=0.510) as compared with quantitative CTA-derived RESOLVE score. Conclusions: Visually estimated CTA-derived V-RESOLVE score is an accurate and easy-to-use prediction tool for the stratification of SB occlusion in coronary bifurcation intervention. A.M.M., and K.G. contributed equally to this work. This study was supported by a statutory grant of the National Institute of Cardiology in Warsaw (ID: 2.43/III/16). The authors declare no conflicts of interest. Correspondence to: Maksymilian P. Opolski, MD, Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Alpejska 42, Warsaw 04-628, Poland (e-mail: opolski.mp@gmail.com). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Review of Technical Advancements and Clinical Applications of Photon-counting Computed Tomography in Imaging of the Thorax Photon-counting computed tomography (CT) is a developing technology that has the potential to address some limitations of CT imaging and bring about improvements and potentially new applications to this field. Photon-counting detectors have a fundamentally different detection mechanism from conventional CT energy-integrating detectors that can improve dose efficiency, spatial resolution, and energy-discrimination capabilities. In the past decade, promising human studies have been reported in the literature that have demonstrated benefits of this relatively new technology for various clinical applications. In this review, we provide a succinct description of the photon-counting detector technology and its detection mechanism in comparison with energy-integrating detectors in a manner understandable for clinicians and radiologists, introduce benefits and some of the existing challenges present in this technology, and provide an overview of the current status and potential clinical applications of this technology in imaging of the thorax by providing example images acquired with an investigational whole-body photon-counting CT scanner. This work was originated at: National Institutes of Health (NIH), 9000 Rockville Pike, Bethesda, MD 20892, 301-496-4000, TTY 301-402-9612. This research was supported, in part, by the Intramural Research Program of the National Institutes of Health Clinical Center. The National Institutes of Health and Siemens Medical Solutions have a Cooperative Research and Development Agreement providing financial and material support including the photon-counting CT system. Authors unaffiliated with Siemens had full control over data and information presented in this paper. The clinical images were acquired under a protocol approved by the Institutional Review Board using an investigational photon-counting computed tomography system. The authors declare no conflicts of interest. Correspondence to: Marcus Y. Chen, MD, National Heart, Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892 (e-mail: marcus.chen@nih.gov). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Early Left Ventricular Diastolic Dysfunction and Abnormal Left Ventricular-left Atrial Coupling in Asymptomatic Patients With Hypertension: A Cardiovascular Magnetic Resonance Feature Tracking Study Purpose: Hypertension (HTN) patients suffer from increased risk of left ventricular (LV) diastolic dysfunction and LV hypertrophy (LVH). Evaluation of early LV diastolic function requires accurate noninvasive diagnostic tools. The aim of this study was to evaluate whether cardiovascular magnetic resonance feature-tracking (CMR-FT) could detect early LV dysfunction and evaluate LV-left atrium (LA) correlation in HTN patients. Materials and Methods: In all, 89 HTN patients and 38 age-matched and sex-matched controls were retrospectively enrolled and underwent CMR examination. HTN patients were divided into LVH (n=38) and non-LVH (n=51) groups. All LV deformation parameters were analyzed in radial, circumferential, and longitudinal directions, including peak strain, peak systolic strain rate and peak diastolic strain rate (PDSR), LA strain and strain rate (SR), including LA reservoir function (εs, SRs), conduit function (εe, SRe), and booster pump function (εa, SRa). Results: Compared with controls, the LV PDSR in radial, circumferential, and longitudinal directions and the LA reservoir and conduit function were significantly impaired in HTN patients regardless of LVH (all P<0.05). LV longitudinal and radial PDSR were correlated with LA reservoir and conduit function (all P<0.01). Among all LV and LA impaired deformation parameters, the longitudinal PDSR (in LV) and εe (in LA) were the most sensitive parameter for the discrimination between non-LVH and healthy volunteers, with an area under the curve of 0.70 (specificity 79%, sensitivity 55%) and 0.76 (specificity 95%, sensitivity 49%), respectively. The area under the curve reached 0.81 (specificity 82%, sensitivity 75%) combined with the longitudinal PDSR and εe. Conclusion: CMR-FT could detect early LV diastolic dysfunction in HTN patients, which might be associated with LA reservoir and conduit dysfunction. S.Z. and J.C. contributed equally to this work and should be considered co-corresponding authors. The study was supported by grant No. 81930044 and No. 81620108015 from the key projects of National Natural Science Foundation of China. The authors declare no conflicts of interest. Correspondence to: Shihua Zhao, MD, MR Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China (e-mail: cjrzhaoshihua2009@163.com). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Assessment of Intramyocardial Fat Content Using Computed Tomography: Is There a Relationship With Obesity? Background: Fat deposition in the liver and the skeletal muscle are linked to cardiovascular risk factors. Fat content in tissues can be estimated by measuring attenuation on noncontrast computed tomography (CT). Quantifying intramyocardial fat content is of interest as it may be related to myocardial dysfunction or development of heart failure. We hypothesized that myocardial fat content would correlate with severity of obesity, liver fat, and components of the metabolic syndrome. Methods: We measured attenuation values on 121 noncontrast CT scans from the spleen, liver, erector spinae muscle, and myocardial septum. A chart review was performed for patient demographics and clinical characteristics. We tested for correlations between attenuation values in each of the tissues and various clinical parameters. Results: We studied 78 females and 43 males, with a mean age of 54.5±11.2 years. Weak, but significant inverse Spearman correlation between body mass index and attenuation values were found in the liver (ρ=−0.228, P=0.012), spleen (ρ=−0.225, P=0.017), and erector spinae muscle (ρ=−0.211, P=0.022) but not in the myocardial septum (ρ=0.012, P=0.897). Mean attenuation in the nonobese group versus obese group (body mass index >30 kg/m2) were 41.1±5.0 versus 42.3±6.9 (P=0.270) in myocardial septum, 56.1±8.7 versus 51.7±10.9 (P=0.016) in the liver, 43.9±8.9 versus 40.1±10.4 (P=0.043) in the spleen, and 41.7±8.3 versus 39.0±8.8 (P=0.087) in the erector spinae muscle. Conclusions: Although CT is a theoretically appealing modality to assess fat content of the myocardium, we did not find a relationship between myocardial CT attenuation and obesity, or other cardiovascular risk factors. These findings suggest that the degree of myocardial fat accumulation in obesity or metabolic syndrome is too small to be detected with this modality. U.J.S. has received institutional research support and/or honoraria for speaking and consulting from Astellas, Bayer, Bracco, Elucid BioImaging, General Electric, Guerbet, HeartFlow Inc., and Siemens Healthineers. The remaining authors declare no conflicts of interest. Correspondence to: Sheldon E. Litwin, MD, 114 Doughty Street, Charleston, SC 29425 (e-mail: litwins@musc.edu). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Computed Tomography-based Lung Residual Volume and Mortality of Patients With Coronavirus Disease-19 (COVID-19) Rationale and Objectives: To assess the effect of computed tomography (CT)-based residual lung volume (RLV) on mortality of patients with coronavirus disease 2019 (COVID-19). Materials and Methods: A single-center, retrospective study of a prospectively maintained database was performed. In total, 138 patients with COVID-19 were enrolled. Baseline chest CT scan was performed in all patients. CT-based automated and semi-automated lung segmentation was performed using the Alma Medical workstation to calculate normal lung volume, lung opacities volume, total lung volume, and RLV. The primary end point of the study was mortality. Univariate and multivariate analyses were performed to determine independent predictors of mortality. Results: Overall, 84 men (61%) and 54 women (39%) with a mean age of 47.3 years (±14.3 y) were included in the study. Overall mortality rate was 21% (29 patients) at a median time of 7 days (interquartile range, 4 to 11 d). Univariate analysis demonstrated that age, hypertension, and diabetes were associated with death (P<0.01). Similarly, patients who died had lower normal lung volume and RLV than patients who survived (P<0.01). Multivariate analysis demonstrated that low RLV was the only independent predictor of death (odds ratio, 1.042; 95% confidence interval, 10.2-10.65). Furthermore, receiver operating characteristic curve analysis demonstrated that a RLV ≤64% significantly increased the risk of death (odds ratio, 4.8; 95% confidence interval, 1.9-11.7). Conclusion: Overall mortality of patients with COVID-19 may reach 21%. Univariate and multivariate analyses demonstrated that reduced RLV was the principal independent predictor of death. Furthermore, RLV ≤64% is associated with a 4-fold increase on the risk of death. Present address: David Ernesto Timaran-Montenegro, MD, MSCS, Felix Cuevas 540, Col del Valle Sur, Benito Juarez, Ciudad de Mexico 03100, Mexico. The authors declare no conflicts of interest. Correspondence to: David Ernesto Timaran-Montenegro, MD, MSCS, National Medical Center "20 de Noviembre", National Autonomous University of Mexico (UNAM), Mexico City, Mexico 03229 (e-mail: david_timaran@yahoo.com). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Quantitative Differentiation of Left Atrial Performance in Hypertrophic Cardiomyopathy: Comparison Between Nonobstruction and Occult Obstruction With 4-dimensional Volume-strain Objective: The objective of this study was to describe the different components of left atrial (LA) dysfunction predictors in nonobstructive and occult obstructive hypertrophy cardiomyopathy (HCM) patients especially with preserved left ventricular (LV) ejection fraction, particularly using LA 4-dimensional (D) longitudinal and circumferential strains. Methods: Twenty-eight nonobstructive HCM patients and 30 occult obstructive HCM patients according to LV outflow tract gradient at rest and after exercise were prospectively enrolled. 4D echocardiographic evaluation was performed in 58 HCM patients, both nonobstructive and occult obstructive, and 38 control subjects. LA reservoir, conduit, contractile functions were performed by 4D volume-strain with volumes and longitudinal, circumferential strains. Results: Optimal correlation coefficients obtained between LV 4D mass (index) and LA 4D longitudinal/circumferential strain (r=−0.860 to 0.518, all P<0.001). Both nonobstructive and occult obstructive HCM patients had increased volumes and significantly decreased longitudinal, circumferential strain values with lower reservoir, conduit, contractile functions than the controls (all P<0.001). Occult obstructive HCM patients presented incremented volumes compared with nonobstructive ones (P<0.001 to 0.003). Lower conduit function and higher contractile function indicated with lower reservoir function revealed by circumferential strain in occult obstructive HCM patients than nonobstructive ones (P<0.001 to 0.017). Interclass correlation coefficients of intraobserver and interobserver in the LV and LA 4D value evaluations were >0.75 and >0.85, respectively. Conclusions: LA volumes were significantly increased and LA reservoir, conduit, and contractile functions were significantly impaired in HCM patients. Furthermore, different performances of LA functional analyses in nonobstruction and occult obstruction patients with 4D volume-strain echocardiography may facilitate the recognition of subtle LA dysfunctional differentiation in HCM patients. M.S. is a co-first author and contributed equally as H.R. The research protocol was approved by the regional ethics committee, and all included patients provided written informed consent. H.R.: was involved in compilation of the data collected, drafting, and writing the manuscript. M.S. and P.-y.Z.: were the supervisors responsible for echocardiography and revision of the manuscript. L.-l.W., J.-y.R., and X.-w.M.: assisted in the measurement and monitoring the patients' examination. Supported by Nanjing Medical Science and Technique Development Foundation 2017(8). The authors declare no conflict of interest. Correspondence to: Ping-yang Zhang, MD, PhD, Department of Echocardiography, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing 210006, Jiangsu Province, China (e-mail: zhpy28@hotmail.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/ Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Cardiac Magnetic Resonance Imaging in Coronavirus Disease 2019 (COVID-19): A Systematic Review of Cardiac Magnetic Resonance Imaging Findings in 199 Patients Objective: Cardiac magnetic resonance imaging (CMR) with its new quantitative mapping techniques has proved to be an essential diagnostic tool for detecting myocardial injury associated with coronavirus disease 2019 (COVID-19) infection. This systematic review sought to assess the important imaging features on CMR in patients diagnosed with COVID-19. Materials and Methods: We performed a systematic literature review within the PubMed, Embase, Google Scholar, and WHO databases for articles describing the CMR findings in COVID-19 patients. Results: A total of 34 studies comprising 199 patients were included in the final qualitative synthesis. Of the CMRs 21% were normal. Myocarditis (40.2%) was the most prevalent diagnosis. T1 (109/150; 73%) and T2 (91/144; 63%) mapping abnormalities, edema on T2/STIR (46/90; 51%), and late gadolinium enhancement (LGE) (85/199; 43%) were the most common imaging findings. Perfusion deficits (18/21; 85%) and extracellular volume mapping abnormalities (21/40; 52%), pericardial effusion (43/175; 24%), and pericardial LGE (22/100; 22%) were also seen. LGE was most commonly seen in the subepicardial location (81%) and in the basal-mid part of the left ventricle in inferior segments. In most of the patients, ventricular functions were normal. Kawasaki-like involvement with myocardial edema without necrosis/LGE (4/6; 67%) was seen in children. Conclusion: CMR is useful in assessing the prevalence, mechanism, and extent of myocardial injury in COVID-19 patients. Myocarditis is the most common imaging diagnosis, with the common imaging findings being mapping abnormalities and myocardial edema on T2, followed by LGE. As cardiovascular involvement is associated with poor prognosis, its detection warrants prompt attention and appropriate treatment. The authors declare no conflicts of interest. Correspondence to: Sanjiv Sharma, MD, Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi 110029, India (e-mail: meetisv@yahoo.com). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Smooth Muscle Conditions of the Chest: A Clinical, Radiologic, and Pathologic Review Smooth muscle conditions of the chest have diverse clinical and imaging manifestations and may involve nearly every thoracic structure. Differentiation among these conditions requires the integration of clinical, radiologic, and histopathologic data. Histologic examination in conjunction with immunohistochemistry is essential for differentiation from other spindle cell neoplastic mimics. Familiarity with these entities will ensure the inclusion of smooth muscle conditions in the differential diagnosis of thoracic soft tissue lesions and potentially guide the clinician in appropriate management. We review the clinical, imaging, and histopathologic features of thoracic smooth muscle-related conditions organized by the anatomic structures affected. The authors declare no conflicts of interest. Correspondence to: Justin T. Stowell, MD, Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 (e-mail: stowell.justin@mayo.edu). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Influence of Asthma Onset on Airway Dimensions on Ultra–high-resolution Computed Tomography in Chronic Obstructive Pulmonary Disease Purpose: Asthma onset before the age of 40 years is associated with distinct clinical manifestations in chronic obstructive pulmonary disease (COPD) patients, but its morphologic features remain unestablished. This study aimed to explore airway morphology in COPD patients with asthma onset before 40 years of age using ultra–high-resolution computed tomography (U-HRCT), which allows a more accurate quantitation of the lumen and the wall in smaller airways than using conventional CT. Materials and Methods: Clinical data of 500 consecutive patients undergoing full inspiratory U-HRCT (1024×1024 matrix and 0.25 mm slice thickness) were retrospectively analyzed. COPD patients without asthma, COPD patients with asthma onset at age below or 40 years and above, and non-COPD smoker controls (N=137, 29, 34, and 22, respectively) were enrolled. The length, lumen area (LA), wall thickness and area (WA), and wall area percent (WA%) of the segmental (third-generation) to sub-subsegmental (fifth-generation) bronchus and the low attenuation volume percent (LAV%) were measured. Results: LA and WA were smaller in the fourth and fifth generation in COPD patients than in non-COPD controls, regardless of the age of asthma onset. LA was smaller and WA% was larger in the fourth-generation and fifth-generation airways in COPD with asthma onset before 40 years than COPD without asthma, whereas WA did not differ between them. In multivariate analyses, asthma onset before 40 years was associated with smaller LA in COPD patients independent of demographics, use of inhaled corticosteroids and long-acting bronchodilators, airflow limitation, and LAV%. Conclusions: Asthma onset before 40 years of age could be associated with greater lumen narrowing of the airways in COPD. This study was partially supported by the Japan Society for the Promotion of Science (JSPS) [Grants-in-Aid for Scientific Research 19K08624]. N.T., S.S, T.O., and T.H. were supported by a grant from FUJIFILM Co., Ltd. K.T. was supported by Canon Medical Systems Corporation. None of these companies had a role in the design or analysis of the study or in the writing of the manuscript. The authors declare no conflicts of interest. Correspondence to: Naoya Tanabe, MD, Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan (e-mail: ntana@kuhp.kyoto-u.ac.jp). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

Accessory and Incomplete Lung Fissures: Clinical and Histopathologic Implications Objective: This article reviews the anatomy, histology, and disease processes of pulmonary fissures, with emphasis on clinical implications of accessory and incomplete fissures. Conclusion: Accessory and incomplete pulmonary fissures are often overlooked during routine imaging but can have profound clinical importance. Knowledge of fissure anatomy could improve diagnostic accuracy and inform prognosis for oncologists, interventional pulmonologists, and thoracic surgeons. P.A.B.: primary manuscript author, retrieval and analysis of literature, design and production of tables, and editing and approval of the manuscript. R.A.G., G.M.L., and C.M.W.: data collection, critical review, and editing and approval of the manuscript. D.I.S.: pathologic data collection and analysis, pathologic slide preparation, literature analysis, and editing and approval of the manuscript. R.E.G.: critical review and editing and approval of the manuscript. M.D.G.: project supervision and editing and approval of the manuscript. M.L.: surgical data collection and analysis, surgical photography and video preparation, and editing and approval of the manuscript. J.T.S.: conception and design, senior manuscript author, study coordination, literature review; data collection and analysis, project oversight, and leadership. C.M.W. receives royalties from Amirsys and Elsevier. C.M.W. is a part of the speaker's bureau for Boehringer Ingelheim. The remaining authors declare no conflicts of interest. Correspondence to: Justin T. Stowell, MD, Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 (e-mail: stowell.justin@mayo.edu). Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved

 

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Craniofacial Surgery

The Conundrum of Human Osteoinduction: Is the Bone Induction Principle Failing Clinical Translation? No abstract available

Transoral Approach to the Giant Deep Lobe Parotid Gland Pleomorphic Adenoma Parapharyngeal space tumors are rare tumors that make up about 0.5% to 1% of all head and neck neoplasms. The majority of parapharyngeal space tumors, which are usually benign, consist of salivary gland tumors and neurogenic tumors. Although the transcervical, transparotid or transmandibular approach is generally preferred for the excision of these tumors, the transoral approach, which is more advantageous in terms of cosmetics and function, can be applied in selected cases. This article presents a case in which the giant pleomorphic adenoma originating from the deep lobe of the parotid gland is removed by transoral approach. Address correspondence and reprint requests to Omer Vural, MD, Department of Otolaryngology, Head and Neck Surgery, Baskent University, Bahcelievler Mh. Maresal Fevzi Cakmak Cad. 5. Sokak, No: 48 Cankaya/Ankara 06490, Turkey; E-mail: dromervural@gmail.com Received 1 August, 2020 Accepted 5 December, 2020 This is a case presentation study and it does not need ethical approval in our institution. Informed written consent was obtained from the patient before abscess drainage. The authors report no conflicts of interest. © 2021 by Mutaz B. Habal, MD.

Is Le Fort I Distraction Enough to Treat Severe Midface Hypoplasia? Background: In severe cases of maxillary hypoplasia, Le Fort I distraction may be required for treatment. This study describes our experience with internal distraction devices and assesses our outcomes in patients with a negative overjet on average >15 mm. Methods: A retrospective review of patients with a history of cleft lip and/or palate who underwent Le Fort I distraction at our institution from 11/2007-11/2017 was performed. Data regarding demographics, procedural details and outcomes were collected and analyzed. Results: Twenty patients, 13 (65.0%) male and 7 (30.0%) female, were included. All (100%) patients had a history of cleft lip and/or palate and 2 (10.0%) of them had associated syndromes. All 20 patients underwent internal distraction. The average age at surgery was 17.8 years (range 15.2–20.7, SD 1.6 years). The average preoperative negative overjet was 19.27 mm (range 10–30, SD 5.63 mm). The mean total distraction length was 15.3 mm (range 0–30, SD 6.72 mm). There were no intraoperative complications, however, there were a total of 4 (20.0%) postoperative complications, 2 of which required reoperation due to device malfunction or displacement. 14 (70.0%) patients had repeat procedures to complete occlusal correction or correct relapse. Conclusions: Maxillary distraction alone was insufficient for correction of maxillary discrepancies averaging >15 mm. Instead, it's utility may be in positioning the maxilla for a more viable final advancement and fixation procedure, rather than being solely responsible for achieving normal occlusion during distraction. Address correspondence and reprint requests to Jeffrey A. Hammoudeh, MD, DDS, USC Keck School of Medicine, Associate Chief, Plastic and Maxillofacial Surgery, Associate Professor of Surgery, Craniofacial Surgeon, Director, Jaw Deformities Center, Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard MS#96, Los Angeles, CA 90027; E-mail: Jhammoudeh@chla.usc.edu Received 15 September, 2020 Accepted 4 December, 2020 Dr. Jeffrey A. Hammoudeh has served as a KLS Le Fort I Internal Distraction Design Consultant. Presented at: ACPA's 76th Annual Meeting in Tucson, Arizona, April 9 – 13, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2021 by Mutaz B. Habal, MD.

Auricular Arteriovenous Malformation With Macrotia Treated With Transcatheter Arterial Embolization, Polidocanol Foam Sclerotherapy and Subsequent Otoplasty Following Resection Auricular arteriovenous malformation (AVM) occasionally accompanies macrotia. Here, the authors report a case of AVM with macrotia that was treated with transcatheter arterial embolization, percutaneous sclerotherapy, and subsequent otoplasty following partial resection. A 46-year-old man presented with Schobinger stage III AVM. After transcatheter arterial embolization of the feeding arteries using n-butyl-2-cyanoacrylate, 9 sessions of sclerotherapy were performed using 3% polidocanol foam. Partial resection of the AVM nidus and subsequent otoplasty for ear reduction were performed at the age of 50 years. Two years later, the remnant nidus was resected and the protruding ear was surgically corrected. No recurrence was observed, and the enlarged ear was reduced at follow-up 6 months after the final operation. Address correspondence and reprint requests to Satoru Sasaki, MD, PhD, Department of Plastic and Reconstructive Surgery, Center for Vascular Anomalies, Tonan Hospital, Kita 4, Nishi 7, Chuo-ku, Sapporo, Hokkaido 060-0004, Japan; E-mail: satoru-s@tonan.gr.jp Received 28 October, 2020 Accepted 4 December, 2020 The authors have no conflicts of interest to disclose. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2021 by Mutaz B. Habal, MD.

Overlooked Piece of Wood Served as a Vector Transmitting Clostridium Perfringens: A Case Report Emphasizing the Awareness of Gas-Forming Organisms in Posttraumatic Pneumocephalus The radiological depiction of posttraumatic pneumocephalus is due to trapped air in most cases. Although rarely reported, it can also be the result of a gas-forming organism, requiring immediate treatment due to high mortality. Here, we report on an elderly patient with radiological appearance of posttraumatic intracranial pneumocephalus after a wound was closed without recognition of a retained tree branch. The piece of wood served as a vector for transmission of Clostridium perfringens causing the collection of abnormal intracranial air. Radical excision of temporal muscle tissue along with extensive evacuation of the brain abscess and targeted intravenous antibiotics resulted in minor morbidity. Although a piece of wood can easily be missed with current diagnostic imaging, it is crucial that both clinicians and radiologists are aware of the presence of air and its differential diagnosis in posttraumatic pneumocephalus, in order to allow timely treatment in this fatal disease. Address correspondence and reprint requests to PD Dr Lukas Andereggen, MD, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland; E-mail: lukas.andereggen@dbmr.unibe.ch Received 15 August, 2020 Accepted 4 December, 2020 This work is original and has not been published elsewhere nor is it currently under consideration for publication elsewhere. The authors report no conflicts of interest. Informed consent was obtained from the patient. A copy of the written consent is available for review by the Editor of this journal. This study fulfills the requirements of the Ethics Commission of the canton of Bern, Switzerland, and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. © 2021 by Mutaz B. Habal, MD.

Effectiveness of Different Surgical Flap Delay Methods and Their Systemic Toxicities Objective: The surgical flap delaying has been shown to be effective in preventing partial flap loss or in preparing larger flaps. However, there is no gold standard flap delay method in the literature. In this study, the authors aimed to compare 3 types of surgical delay methods to determine which model would increase more flap survival. The authors also investigated the effect of delay methods on circulating mononuclear leukocytes as a parameter of DNA damage. Methods: Twenty-four Sprague-Dawley male rats were divided into 4 groups. All subjects had a 10 × 3 cm modified McFarlane flap. Surface area measurements, biopsies, and blood samples were taken on the day of sacrification; 7th day for the control group and 14th day for delay groups. Results: Between incisional surgery delay groups, a significant difference was found in necrosis and apoptosis in the bipedicled group, and only necrosis in the tripedicled group compared to the control. In terms of DNA damage, it was found higher in all experimental groups than in the control group. Conclusions: Both incisional surgical delay procedures' results were meaningfully effective when only incisions were made without the elevation of flaps. In conclusion, bipedicled incisional surgical delay seems to be the most effective method in McFarlane experimental flap model whereas two-staged surgeries may increase the risk of systemic toxicity. Address correspondence and reprint requests to Kemalettin Yildiz, Associate Professor, Medical Faculty, Department of Plastic Reconstructive and Aesthetic Surgery, Bezmialem Vakif University; E-mail: yildizkemalettin@gmail.com Received 9 August, 2020 Accepted 4 December, 2020 The authors report no conflicts of interest. This study was approved by the Animal Experimentation Ethics Committee of University. (Approval codes: 2013–39). All applicable international, national, and/or institutional guidelines for the care and use of animals were followed. © 2021 by Mutaz B. Habal, MD.

Infraorbital Nerve Decompression for Chronic Post Traumatic Neuralgia: A Novel Approach and Review of the Safety and Efficacy of Piezoelectric Surgery on Soft Tissues and Nerves Chronic post traumatic infraorbital nerve (ION) hyperesthesia is a rare complication of orbital floor fractures. Surgical decompression of the ION has been reported to relieve chronic post traumatic infraorbital neuralgia. This case report describes a novel approach for ION decompression in a patient who suffered from chronic infraorbital neuralgia associated with a healed displaced orbital floor fracture. We used an intraoperative 3D image-guided navigation system to accurately localize the fracture site and employed piezoelectric surgery for nerve decompression. We further review the literature on the safety and efficacy of piezoelectric surgery on soft tissue and nerves. Address correspondence and reprint requests to Lambros K. Viennas, MD, Department of Surgery, Division of Plastic Surgery, Eastern Virginia Medical School, 825 Fairfax Avenue 6th floor, Norfolk, VA 23507; E-mail: viennalk@evms.edu Received 28 April, 2020 Accepted 4 December, 2020 Dr. Viennas has received honoraria as educational consultant for LifeNet Health. He is on the Speaker's Bureau for Stryker Endoscopy and has never received funding, shares, financial interest, honoraria or support from Stryker. Maxwell Wagner report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2021 by Mutaz B. Habal, MD.

Fronto-Orbital Advancement and Posterior Cranial Vault Expansion Using Distraction Osteogenesis in Patients With Multiple Craniosynostosis This study aimed to evaluate the treatment outcomes and the efficiency of techniques of fronto-orbital advancement (FOA) and posterior cranial vault expansion (PCVE) using distraction osteogenesis in patients with multiple craniosynostosis. We assessed the treatment results and outcomes of 8 patients with multiple craniosynostosis at the Kagoshima University Hospital between 2005 and 2019. Each 4 patients underwent FOA and PCVE, respectively, using distraction osteogenesis. The cranial volume and developmental quotient (DQ) were measured at the preoperative period and 1 year after surgery. The mean patient age at surgery was 22 months. The mean preoperative cranial volume was 1027 and 1071 cm3 in the FOA and PCVE groups, respectively. The mean preoperative DQ scores were 74 and 67, respectively. After 1-year of follow-up, the corresponding mean cranial volume became 1108 and 1243 cm3, respectively. The corresponding mean DQ scores also improved to 74 and 81, respectively. The postoperative follow-ups in all cases were uneventful, except for persistent epilepsy in 1 patient. Fronto-orbital advancement and PCVE using distraction osteogenesis might contribute to good outcomes in expanding cranial volume, cosmetic osteogenesis, and infantile development in patients with multiple craniosynostosis. Regarding the cranial volume expansion, especially, PCVE using distraction osteogenesis is more effective than FOA. Address correspondence and reprint requests to Tatsuki Oyoshi, MD, PhD, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, 890-8520, Kagoshima, Japan; E-mail: tatsuki@m2.kufm.kagoshima-u.ac.jp Received 5 August, 2020 Accepted 4 December, 2020 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2021 by Mutaz B. Habal, MD.

Photobiomodulation to Treat Necrotizing Fasciitis The spread of odontogenic infections associated with comorbidities, such as diabetes mellitus, can result in a potentially lethal complication, with rapid necrosis of the superficial fascia, necrotizing fasciitis. In this case report, a female patient, 52 years old, fasting blood glucose of 303 mg/dL with necrotizing fasciitis associated with type 2 diabetes mellitus in the left cervical-thoracic region. She was treated with antibiotics, cervicotomy, abscess drainage, and underwent 10 photobiomodulation sessions with 2 weekly applications of the red wavelength laser to correct tissue loss in the left cervical region. With the development of tissue healing, the formation of granulation tissue increased, absence of necrotic areas, contraction of the edges, and total wound repair. This case emphasizes the effectiveness of photobiomodulation to optimize healing and modulate the inflammatory pattern in the treatment of necrotizing fasciitis sequelae. Address correspondence and reprint requests to Dr Abrahão Cavalcante Gomes De Souza Carvalho, Alexandre Baraúna Street, 949, Rodolfo Teófilo, ZIP code: 60430-160, Dental Clinic 05, Fortaleza, Brazil; e-mail: abrahao@ufc.br Received 14 November, 2020 Accepted 2 December, 2020 The authors report no conflicts of interest. © 2021 by Mutaz B. Habal, MD.

Time Reduction by Prebending Osteosynthesis Plates Using 3D-Printed Anatomical Models, In Patients Treated With Open Reduction and Internal Fixation Introduction: The incidence of facial bones fractures is 18 to 32 for each 100,000 inhabitants. The most affected population are young working people. Fractures are most commonly caused by assaults and motor vehicle accidents. Its cost of care reaches 1.06 billion dollars. Premodeling osteosynthesis plates with anatomical models can decrease surgical time, bleeding, and increase patient satisfaction. This study aims to evaluate the impact of premodeled osteosynthesis plates, using anatomical models in patients with facial fractures. Material and Methods: Patients with facial fractures treated by open reduction and internal fixation were included—Group A without premolding plates and Group B with premolding. The variables studied were: age, sex, etiology of the fractures, number of fractures, among other variables that reflect the quality of the results. Results: A total of 17 osteosynthesis plates were included in 6 patients. The age was 22 to 47 years; all patients were male. The maximum surgery time was 129 to 300 minutes. The average time to start work was 4.8 weeks. When comparing the variables between the groups, we found no difference between the groups for bleeding P = 0.24, the start of work P = 0.19, the time of surgery P = 0.082, or for osteosynthesis time P = 0.15. There was only a significant difference in patient satisfaction, P = 0.04. Conclusions: The evidence collected shows that premodeling the plates only improves patients' satisfaction among facial fractures treated by open reduction and internal fixation. Address correspondence and reprint requests to Marco Aurelio Rendón-Medina, MD, Hospital General "Dr. Rubén Leñero," Plan de San Luis -Salvador Díaz Mirón no number, Col. Santo Tomás, Miguel Hidalgo. ZC. México City, México; E-mail: dr.rendon1989@gmail.com, md_marm@hotmail.com Received 2 November, 2020 Accepted 2 December, 2020 All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of the Hospital Ruben Leñero. The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2021 by Mutaz B. Habal, MD.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Pediatric Cardiology

Use of strain, strain rate, tissue velocity imaging, and endothelial function for early detection of cardiovascular involvement in young diabetics Atul Kaushik, Aditya Kapoor, Preeti Dabadghao, Roopali Khanna, Sudeep Kumar, Naveen Garg, Satyendra Tewari, Pravin K Goel, Archana Sinha Annals of Pediatric Cardiology 2021 14(1):1-9 Background: Subtle structural and functional changes may precede the onset of overt global left ventricular (LV) dysfunction. Data pertaining to tissue velocity imaging (TVI)and strain imaging to assess regional myocardial function and flow mediated vasodilatation are limited in young patients with diabetes. Materials: Conventional echocardiography, TVI parameters along with strain (S), and strain rate (SR) were measured in 50 young diabetics (15.16 ± 2.95 years, mean HBA1c 8.15 ± 1.37 g %) and 25 controls (15.60 ± 2.51 years). Flow-mediated dilation (FMD), nitrate--mediated dilatation (NMD), and carotid intima–media thickness were also assessed. Results: Conventional echocardiography parameters were similar in patients and controls; however, deceleration time of the mitral inflow velocity (early deceleration time) was significantly shorter in patients when compared with controls (149.06 ± 31.66 vs. 184.56 ± 19.27 ms, P =0.001). Patients had lower strain values at the basal lateral LV (21.39 ± 4.12 vs. 23.78 ± 2.02; P =0.001), mid-lateral LV (21.43 ± 4.27 vs. 23.17 ± 1.92 P =0.02), basal septum (20.59 ± 5.28 vs. 22.91 ± 2.00; P = 0.01), and midseptum (22.06 ± 4.75 vs. 24.10 ± 1.99; P = 0.01) as compared to controls. SR at the basal and midsegments of the lateral LV wall and at the basal septum was also significantly lower in diabetic patients. Diabetic children also had endothelial dysfunction with significantly lower FMD (8.36 ± 4.27 vs. 10.57 ± 4.12, P = 0.04). Conclusions: LV strain indices and flow--mediated dilatation are impaired in asymptomatic children and adolescents with type 1 diabetes mellitus despite absence of overt heart failure and normal ejection fraction. Early detection of subclinical regional myocardial dysfunction by deformation analysis including strain and strain rate may be useful in the asymptomatic diabetic population.

Pulmonary arteriovenous malformations in children after the Kawashima procedure: Risk factors and midterm outcome Ibrahim J Alibrahim, Mohammed H A Mohammed, Mohamad S Kabbani, Abdulraouf M Z. Jijeh, Omar R Tamimi, Abdullah A Alghamdi, Fahad Alhabshan Annals of Pediatric Cardiology 2021 14(1):10-17 Background : Pulmonary arteriovenous malformations (PAVMs) are the major cause of progressive cyanosis in patients palliated with bidirectional cavopulmonary connection (BCPC). The aim of our study is to analyze the occurrence of PAVMs in patients after Kawashima procedure, to study the effect of total cavopulmonary connection (TCPC) on PAVMs, to evaluate the effect of axillary arteriovenous fistula (AAVF) creation on PAVMs, and to study the risk factors for PAVMs. Methods : In this retrospective cohort study, all patients with left isomerism and azygous continuation of an interrupted inferior vena cava who underwent Kawashima procedure from July 2001 to December 2017 were included. Results : Twenty.six patients after Kawashima procedure were included in our study. PAVMs were diagnosed in 12 patients (46%). Five of these 12 patients underwent TCPC with complete resolution of hypoxemia. Three patients underwent AAVF creation, 2 had complete resolution, while 1 had partial resolution of hypoxemia. Fourteen patients (54%) did not develop PAVMs. Nakata index below 267 mm2/m2 and McGoon ratio below 1.9 predicted the development of PAVMs with high sensitivity and specificity. Conclusions : PAVMs represent a serious complication in patients who undergo Kawashima procedure. Small size of pulmonary arteries is an important risk factor for the development of PAVMs. Resolution of hypoxemia after TCPC completion supports the hepatic factor hypothesis. Early TCPC completion in these patients may help to avoid the development of PAVMs by restoring the hepatic factor. Resolution of hypoxemia after AAVF creation may support the lack of pulsatile flow hypothesis.

Comparison of right ventricular outflow tract gradient under anesthesia with post-operative gradient in patients undergoing tetralogy of Fallot repair Dheemta Toshkhani, Virendra Kumar Arya, Kamal Kajal, Shyam K S Thingnam, Sandeep Singh Rana Annals of Pediatric Cardiology 2021 14(1):18-25 Background : Intra-cardiac repair for tetralogy of Fallot has some degree of residual right ventricular outflow tract (RVOT) obstruction. However, the measurement of this gradient intra-operatively might get affected by the depth of anesthesia which is important for the long-term outcome. Aims : The primary aim was to compare intraoperative RVOT gradient post repair under two different anesthetic depths of 1% and 2% end-tidal sevoflurane. The secondary objective was to follow up the changes in RVOT gradient till 1 month postoperatively. Design : Observational study. Setting : Advanced Cardiac Centre of PGIMER, Chandigarh. Methods : Following intracardiac repair, RVOT gradient was measured directly by placing needle into the right ventricle and pulmonary artery at sevoflurane 1%, and subsequently, at 2% end.tidal concentration while maintaining hemodynamic stability. These gradients were also measured using transesophageal echocardiography (TEE) (ClinicalTrials.gov NCT03234582). Results : Twenty-one patients were included in this study that had intra-cardiac repair, of which pulmonary annulus was preserved for 15 cases. Mean RVOT gradients measured invasively and by TEE at end-tidal sevoflurane concentration of 1% and 2% were not significantly different (6.67 ± 4.16 mmHg vs. 6.76 ± 3.82 mmHg, P > 0.05 invasively and 13.01 ± 7.40 mmHg vs. 12.53 ± 7.11 mmHg, P > 0.05 by TEE, respectively). RVOT gradient measured by trans-thoracic echocardiography (TTE) postoperatively at the time of extubation and during follow-up at 1 month showed significant reduction (11.37 ± 6.00 mmHg, P < 0.05 and 9.23 ± 4.92 mmHg, P < 0.01 respectively). Six patients who underwent repair with transannular patch had significant pulmonary regurgitation (PR) following surgery, with no significant change in PR severity or RVOT gradient on increasing anesthetic depth. Conclusions : Postoperative RVOT gradient was not altered by changing depth of anesthesia provided systemic blood pressure was maintained. One month postrepair RVOT gradients were significantly reduced as compared to the intraoperative values.

Utility of late pulmonary artery banding in single-ventricle physiology: A mid-term follow-up Aritra Mukherji, Sanjiban Ghosh, Nihar Pathak, Jayita Nandi Das, Nilanjan Dutta, Debasis Das, Amitabha Chattopadhyay Annals of Pediatric Cardiology 2021 14(1):26-34 Background: The standard first stage palliation for univentricular heart with unrestricted pulmonary blood flow (PBF) is surgical pulmonary artery (PA) banding for which the ideal age is within the first 8 weeks of life. This study aimed to look for the utility of PA band done beyond 3 months of age for patients presenting beyond the stipulated period. Materials and Methods: This is a retrospective analysis of the outcome of twenty patients with single ventricle (SV) physiology with unrestricted PBF who presented late and were selected on the basis of clinical, radiological, and echocardiographic parameters for PA banding. Results: The median age of the patients was 5.5 months (3.5–96 months), and the median body weight was 4.7 kg (3.2–22.0 kg). The patients were divided into three groups as follows: ten patients between 3 and 6 months of age (Group A), seven patients between 6 months to 1 year of age (Group B), and three patients > 1 year of age with additional features of pulmonary venous hypertension (Group C). The mean reduction of PA pressures following PA band was 60.9%, 48.8%, and 58.3% and the mean fall in oxygen saturation was 10.4%, 8.0%, and 6.6% in the three groups, respectively. The postoperative mortality rate was 10%. The mean follow up duration was 13.5 months (7–23 months). There was a statistically significant improvement in weight for age Z scores following PA band (P = 0.0001). On follow up cardiac catheterization, the mean PA pressures were 16.6 (±3.6), 22.7 (±5.7), and 33.3 (±12.4) mmHg, respectively, in the three groups, and the mean pulmonary vascular resistance index was 1.86 (±0.5), 2.45 (±0.7), and 3.5 (±1.6) WU.m2, respectively. Subsequently, seven patients in Group A, three patients in Group B, and one patient from Group C underwent successful bidirectional Glenn (BDG) surgery. Conclusions: Late PA band in selected patients with SV physiology can have definite benefit in terms of correction of heart failure symptoms and subsequent conversion to BDG and can potentially change the natural history of disease both in terms of survival and quality of life.

Melody valve to replace the mitral valve in small children: Lessons learned Vilius Dranseika, Rene Pretre, Oliver Kretschmar, Hitendu Dave Annals of Pediatric Cardiology 2021 14(1):35-41 Objective: Infants requiring mitral valve replacement have few viable options. Recently, stented bovine jugular vein graft (Melody) has been surgically implanted in such cases. Herein, we report our experience, elaborating on evolution of implantation technique, pitfalls, as well as long-term outcome (including late dilatability). Methods: Seven Melody valves were implanted (2013–2019). The median patient age and weight were 6.7 (1.8–30.5) months and 5.8 (4.6–9.5) kg, respectively. The indications for implantation were mitral stenosis and/or regurgitation postatrioventricular septal defect (AVSD) repair (5), congenital mitral valve dysplasia (1), and Shone's complex (1). Operative technique involved shortening the valve and creating a neo-sewing ring at 2/3 (atrial)–1/3 (ventricular) junction. Implantation was followed by intraoperative balloon dilatation. Results: Five out of seven patients survived the perioperative period (one death due to technical failure and the other due to acute respiratory distress syndrome postcardiopulmonary bypass). Two out of five medium-term survivors got transplanted (1) or died due to acute myeloid leukemia (1). No valves were replaced. The mean echo gradient at discharge was a median 4 (2–6) mmHg. None of the patients showed left ventricular outflow tract or pulmonary venous obstruction. Two Melody valves were dilated late (5 months and 3 years postoperatively), resulting in decreasing mean gradients from 6 to 1 and from 17 to 4 mmHg. At last follow-up, surviving Melody had a mean gradient of 4 (1–9) mmHg. Conclusions: Mitral valve replacement with a Melody valve is feasible in infants, is reproducible, shows good immediate results, and offers the possibility of later dilatation. This technique offers a better solution compared to the existing alternatives for infants requiring a prosthetic mitral valve.

Clinical profiles and risk factors for early and medium-term mortality following heart transplantation in a pediatric population: A single-center experience Komarakshi R Balakrishnan, Kemundel Genny Suresh Rao, Ganapathy Krishnan Subramaniam, Murali Krishna Tanguturu, Ajay Arvind, Veena Ramanan, Jagdish Dhushyanthan, K Ramasubramanian, K Suresh Kumaran, Gunalan Sellamuthu, Mohan Rajam, Senthil Mettur, Pradeep Gnansekharan, Ravikumar Ratnagiri Annals of Pediatric Cardiology 2021 14(1):42-52 Aims and Objectives: There is a paucity of data regarding the outcomes of Heart transplantation in children from the Indian subcontinent. The data of patients under the age of 18 undergoing an isolated heart transplantation was analyzed for patient clinical profiles and risk factors for early and medium-term mortality. Hospital mortality was defined as death within 90 days of transplantation and medium-term survival as follow up of up to 6 years. Materials and Methods: A total of 97 patients operated between March 2014 and October 2019 were included in this study .Data was collected about their INTERMACS status, pulmonary vascular resistance, donor heart ischemic times, donor age, donor to recipient weight ratio and creatinine levels. Results: The age range was from 1 to 18 with a mean of 10.6 ± 4.6 years. 67 % patients were in INTERMACS category 3 or less.12 children were on mechanical circulatory support at the time of transplant. The 90 day survival was 89 %.The risk factors for hospital mortality was lower INTERMACS category (odd’s ratio 0.2143, P = 0.026), elevated creatinine (odd’s ratio 5.42, P = 0.076) and elevated right atrial pressure ( odd’s ratio 1.19, P = 0.015).Ischemic time, pulmonary vascular resistance (PVR) and PVR index (PVRI) had no effect on 90 day survival. Kaplan Meier estimates for 5 year survival was 73 %.The medium term survival was affected by INTERMACS category (Hazard ratio 0.7, P = .078) , donor age > 25 ( Hazard ratio 1.6, P = 0.26) and raised serum creatinine values.(Hazard ratio 2.7, P = 0.012). All the survivors are in good functional class. Conclusions: Excellent outcomes are possible after heart transplantation in a pediatric population even in a resource constrained environment of a developing economy. More efforts are needed to promote pediatric organ donation and patients need to be referred in better INTERMACS category for optimal outcomes.

Tetralogy of fallot with coronary crossing the right ventricular outflow tract: A tale of a bridge and the artery Sachin Talwar, Sanjoy Sengupta, Supreet Marathe, Pradeep Vaideeswar, Balram Airan, Shiv Kumar Choudhary Annals of Pediatric Cardiology 2021 14(1):53-62 A coronary artery crossing the right ventricular outflow tract is a subset of a larger pathomorphological cohort known as an anomalous coronary artery (ACA) in the tetralogy of Fallot (TOF). The best possible outcome in a patient with TOF and ACA is decided by judicious selection of optimum preoperative investigative information, the timing of surgery, astute assessment of preoperative surgical findings, and appropriate surgical technique from a wide array of choices. In most instances, the choice of surgical technique is determined by the size of the pulmonary annulus and the anatomical relation of ACA to the pulmonary annulus. In the present era, complete, accurate preoperative diagnosis and primary repair is a routine procedure with strategies to avoid a right ventricle-to-pulmonary artery conduit.

Defining transposition: What have we learnt? Max E Roderick, Nikita Maria, Adrian Crucean, John Stickley, David J Barron, Robert H Anderson Annals of Pediatric Cardiology 2021 14(1):63-66 Understanding transposition is important for all who hope to effectively treat patients with the condition. The variants of the condition are frequently debated in the literature. We describe an unusual variant of transposition, in which despite the arterial roots being supported by morphologically inappropriate ventricles, the roots themselves were normally related, with the intrapericardial arterial trunks spiraling as they extended into the mediastinum. The specimen was identified following the re-categorization of our archive, and we subsequently conducted a detailed analysis of the underlying morphology. Using the principles of sequential segmental analysis, we compared the morphology with standard examples previously described. We show how it was the recognition of such hearts that promoted that concept that the combination of connections across the atrioventricular and ventriculo-arterial junctions was the essence of transposition. In the most common variant, the arrangements are concordant at the atrioventricular junctions, but discordant at the ventriculo-arterial junctions. We suggest that the overall arrangement of discordant ventriculo-arterial connections is best described simply as “transposition.” When the discordant ventriculo-arterial connections are combined with similarly discordant connections at the atrioventricular junctions, the transposition is congenitally corrected. We point out that the use of “d” and “l” as prefixes does not distinguish between transposition and its congenitally corrected variant. For those using segmental notations, the correct description for the rare variant found in the setting of a posteriorly located aortic root with the usual atrial arrangement is transposition (S, D, NR).

Video-assisted thoracoscopic pacemaker lead placement in children with atrioventricular block Sergey Termosesov, Ekaterina Kulbachinskaya, Ekaterina Polyakova, Dmitriy Khaspekov, Ivan Grishin, Vera Bereznitskaya, Maria Shkolnikova Annals of Pediatric Cardiology 2021 14(1):67-71 Background: The pacemaker lead placement is presented as one of the most appropriate procedures in children with a complete atrioventricular block (AVB). Despite the fact that video-assisted thoracic surgery (VATS) for epicardial lead placement has demonstrated positive results as to the feasibility, safety, and efficacy in adults, its role in pacemaker implantation in children remains unclear. Aim: This study sought to assess the intermediate-term outcomes of video-assisted thoracoscopic pacemaker lead placement in children with complete AVB Materials and Methods: From May 2017 to November 2019, five children with complete AVB underwent minimally invasive left ventricular (LV) lead placements via thoracoscopic video assistance approach. The procedure was performed under complex intratracheal anesthesia with single-lung ventilation, all pacing parameters were evaluated in perioperative and follow-up periods. Results: The median age of children at implantation was 3 years (range: 2 to 4 years), the median weight was 13 kg (range: 12–15 kg). All procedures were completed successfully, pacing thresholds for the active lead measured 0.3-1.1V, with R-wave amplitude of 8-18 mV and impedance of 560-1478 Ohm. Conclusion: Thoracoscopic pacemaker lead placement may provide a potential alternative to the transthoracic approach of epicardial lead placement in children with AVB.

Myocardial infarction due to thrombosis of native aorta late after Fontan procedure for hypoplastic left heart syndrome Bhavi Patel, Tacy Downing, Lourdes Prieto, Darline Santana-Acosta Annals of Pediatric Cardiology 2021 14(1):72-74 Patients with single ventricle physiology who have undergone the Fontan procedure are at risk for long-term complications such as thrombus formation. Thrombus formation in the native aortic root (NAR) can be life-threatening if retrograde filling of the coronary arteries (CAs) is impaired. We present three cases of NAR thrombus with embolization to the CA, resulting in myocardial infarction. Thromboembolic events are well-documented complications of Fontan physiology, and optimal prevention and treatment strategies are poorly defined.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,