Apex Area Research Articles

Microsurgical Treatment of a Large Through-and-Through Periapical Lesion with Apicomarginal Defect using Guided Tissue Regeneration (GTR): A Case Report of a Two-Year Follow-Up

In case of a long-term periapical lesion, destruction of both vestibular and oral cortical plates is sometimes observed and even a through-and-through periapical lesion occurs. The success of the treatment decreases when an apicomarginal defect is added to the through-and-through periapical lesion. Large periapical lesions should be treated initially by orthograde root canal therapy. When the signs and symptoms of the infection don’t recede after the treatment, then surgical approaches should be considered. In this case report, a 22-year-old female with previously initiated therapy was referred for an endodontic microsurgery of tooth 22 (i.e., upper left lateral incisor). After the endodontic treatment the patient was referred to the oral surgeon for apicoectomy with augmentation of the bone defect. The sinus tract in the apex area of the tooth 22 remained active since the surgical intervention. Endodontic microsurgery and guided tissue regeneration were performed. The article presents diagnostic data, namely pre- and post-operative images of cone beam computed tomography (after 2 years), as well as pre-, intra- and post-operative clinical images. All pre- and intraoperative procedures and stages are detailed. In particular, separation of platelet-rich fibrin (PRF) from venous blood, retrograde preparation with an ultrasonic tip and a device using a dental operating microscope and the use of a collagen membrane. After two-year follow-up, radiographic examination revealed significant bone reconstruction and clinical signs and symptoms were absent. The patient hasn’t reported any symptoms since. The paper also analyzes scientific sources on the use of PRF and collagen membranes in bone defects of the jaws. Attention is also paid to the formation of a flap during operations of this type. The main six success factors in the treatment of such complex cases are highlighted. Rethinking the previously performed surgery (apicoectomy) in this patient, attention was paid to the main five factors that could contribute to the failure.

A novel surgical technique to resolve mucosal fenestration of a root apex: Apical tunnel surgery: A case report.

Endodontic surgery, which includes apex resection, retro-fill and some regeneration procedures, is a traditional way to deal with apex fenestration. The endodontic surgery could bring large flap, curtate root length, non-healing mucosa and soft tissue deficiency in the apex area. Other treatment options might be considered according to different etiological factors. Mucogingival surgery provides some ideas in accumulation of soft and hard tissues, especially some unique methods such as "tunnel technique" bringing us a view of minimal invasive surgery approach. A novel surgery named "apical tunnel surgery" was reported here to resolve a root apex exposure with the tunnel-like technique. A young female complained about root exposure of upper right anterior tooth without history of trauma or orthodontic treatment. The intraoral examination revealed a buccal root apex exposure about 3mm in diameter of #12 (FDI teeth numbering system). The tooth was slightly dark with Class 1 mobility. The periodontal situation was good and the occlusion check revealed no traumatic bite on #12. The cone-beam computed tomography (CBCT) showed a bone fenestration from the buccally lower 1/2 root surface to the apex and bone absorption around the apex. It also revealed a bone contour deficiency in #12 area. Root canal treatment, root surface debridement, and soft tissue combined with hard tissue accumulation were carried out in one tunnel-like surgery. Examination of 12-month follow-up showed a healed and thickened mucosa in the buccally apical region and CBCT showed the continuous lamina dura occupied the buccal aspect of #12 root apex. This new apical tunnel surgery provided soft and hard tissue accumulation in one minimal invasive way in the apex exposure case caused by bone fenestration and thin mucosa.

Endoscopic transorbital approach to the petrous apex: is orbital rim removal worthwhile for the exposure? An anatomical study with illustrative case.

The endoscopic transorbital approach (ETOA) has been demonstrated to be a feasible ventral route to the petrous apex. Yet, it has been pointed to as a deep and narrow corridor for anterior petrosectomy; particularly, medialization of the instruments can become an issue when targeting the petroclival area. To overcome this limitation, an ETOA with orbital rim removal (ETOA-OR) has been suggested, but not de facto compared, with a transorbital approach without removal of the rim. This addition could augment the surgical exposure and freedom of movement when accessing the petrous apex area. Five human cadaveric heads (10 sides) were dissected. First, anterior petrosectomy was performed via a conventional ETOA (without orbital rim removal). Second, en bloc removal of the orbital rim was performed, with enlargement of the orbital craniectomy and, subsequently, further drilling of the medial petrous apex. Qualitative and quantitative comparisons are provided. An illustrative surgical case is also shown. The transorbital route allowed the authors to perform an anterior petrosectomy in all specimens. The landmarks of bone removal are superposed onto those in the transcranial route. The ETOA-OR increased the volume of craniectomy (from 4.0 mL to 5.5 mL), the lateromedial angulation, and superoinferior angulation of the instruments within the petrous area. Thus, this approach improved the exposure of the medial petroclival area, allowing for an augmented petrosectomy (from 1.4 mL to 2.0 mL, 39.5% increase) and for increased maneuverability, both in the petrous area (from 44.1 cm2 to 76.5 cm2, 73.3% increase) and in the posterior fossa (from 20.2 cm2 to 52.0 cm2, 158% increase). The ETOA-OR was also pragmatically applied to treat a recurrent petroclival meningioma. Complete removal was achieved, the abducens nerve palsy improved, and the trigeminal neuralgia decreased in severity, yet still required medication. The authors provide the first formal anatomical comparison between the transorbital approach with preservation of the orbital rim and a transorbital approach with removal of the rim to access the petrous apex. In addition, an illustrative case is used as a proof of concept and feasibility. According to the authors' data, the ETOA-OR significantly improves surgical exposure and the surgeon's comfort in this deep region. The bony defect can be reconstructed to avoid cosmetic deformities, maintaining the minimally disruptive concept of transorbital surgery.

Development of Air Cell System Following Canal Wall Up Mastoidectomy for Pediatric Cholesteatoma.

Background: The development of temporal bone pneumatization is related to the postnatal middle ear environment, where the development of air cells is suppressed with otitis media in early childhood. However, whether air cell formation restarts when mastoidectomy is performed during temporal bone pneumatization remains unclear. Herein, we evaluated temporal bone pneumatization after canal wall up (CWU) tympanomastoidectomy for middle ear cholesteatoma in children. Methods: In total, 63 patients, including 29 patients with congenital cholesteatoma (CC) and 34 patients with acquired cholesteatoma (AC), were assessed using a set of pre- and postoperative computed tomography images. The air cells of the temporal bone were divided into five areas: periantral (anterior), periantral (posterior), periantral (medial), peritubal, and petrous apex. The number of areas with air cells before and after surgery was compared to evaluate temporal bone pneumatization after surgery. Results: A total of 63 patients, comprising 29 with CC and 34 with AC (pars flaccida; 23, pars tensa; 7, unclassified; 4), were evaluated. The median age of patients (18 males and 11 females) with CC was 5.0 (range, 2-15 years), while that of the AC group (23 males and 11 females) was 8 (range, 2-15 years). A significant difference in air cell presence was identified in the CC and AC groups after surgery (Mann-Whitney U, p < 0.001 and p = 0.003, respectively). Between the two groups, considerably better postoperative pneumatization was observed in the CC group. A correlation between age at surgery and gain of postoperative air cell area development was identified in the CC group (Spearman's rank-order correlation coefficient, r = -0.584, p < 0.001). In comparison with the postoperative pneumatization rate of each classified area, the petrous apex area was the lowest in the CC and AC groups. Conclusions: Newly developed air cells were identified in the temporal bones after CWU mastoidectomy for pediatric cholesteatoma. These findings may justify CWU tympanomastoidectomy, at least for younger children and CC patients, who may subsequently develop air cell systems after surgery.

The difference distance between the apical foramen and the anatomical apex in primary teeth-An in vitro study.

The apex area in the primary teeth changes continuously due to the physiologic resorption, therefore; the apical foramen (AF) may not correspond to the anatomic apex (AA), which gives a big challenge to achieve successful endodontic treatment. The aim of this research was to study the difference distance (DD) between the position of the AA and AF, besides the difference acceptance (DA) in primary teeth, and the effect of the following variables: root canal curvature, resorption degree, and canal size on DD and DA separately. In this research, 180 root canals from 60 primary teeth were studied. Two lengths of each canal were measured by a K-file from a certain point in the crown; the first length was until the AA and the second was until the AF. Then DD was obtained by calculating the difference between those two lengths. Statistical analysis tests were done. A p value of <.05 was considered significant at a 95% confidence level. The percentage of canals with 0 mm DD was 34.4%, while it was 1.1% with DD of 6 mm. The percentages of acceptable ( ≤ 2 mm) and unacceptable ( > 2 mm) difference were 84.4% and 15.6%, respectively. There was a significant difference in the DD value between the three groups of curvature degree and the three groups of canal size. There was a significant difference between the DA in the three groups of canal size. DD has a wide variation value in primary teeth regardless of the degree of root resorption, which has not affected this value or the accepted difference; however, DD and acceptable difference values are somehow affected by the degree of root curvature and canal size. We recommend adding acceptable difference as a criterion when considering pulpectomy treatment in primary teeth.

Findings of Intravenous Gadolinium Inner Ear Magnetic Resonance Imaging in Patients With Acute Low-Tone Sensorineural Hearing Loss.

Acute low-tone sensorineural hearing loss (ALHL) is thought to have a different etiology from that of idiopathic sudden sensorineural hearing loss. We hypothesized that endolymphatic hydrops (EH) in the inner ear organ contributes to ALHL, even in patients without vertigo. This study investigated the presence of EH in ALHL and compared the clinical characteristics of patients with or without EH. We retrospectively reviewed 38 patients diagnosed with ALHL without vertigo from January 2017 to March 2022. EH was measured in all patients using inner ear magnetic resonance imaging (MRI). In addition, we selected patients who showed only mid- or high-frequency hearing loss and had available MRI data as a control group and compared the ALHL and control groups. After treatment, the pure-tone average at low frequencies significantly improved compared to the initial hearing (P<0.001). Hearing recovery was observed in 63.1% of patients; however, the recovery rate did not differ based on the treatment method. During the follow-up period, six patients (15.8%) progressed to Meniere's disease, and 18 (47.4%) experienced recurrence. In the ALHL group, the cochlear hydrops ratio on the affected side (0.34±0.09) was significantly higher than on the contralateral side (0.29±0.12) (P=0.005), and most patients showed hydrops in the apex area of the cochlea. Compared with the control group (0.25±0.15), the ALHL group showed a significantly higher cochlear hydrops ratio (P=0.043). The correlation analysis showed a tendency for hearing thresholds at low frequencies to increase as the hydrops ratio increased, albeit without statistical significance. The cochlear hydrops ratio, especially in the apex area on the affected side, was significantly higher in patients with ALHL, suggesting that EH in the cochlea contributes to the pathogenesis of ALHL.

In Vivo Fibroblast Activation of Systemic Sarcoidosis: A 68Ga-FAPI-04 PET/CT Imaging Study

A 47-year-old female with cardiac dysfunction and lymphadenopathy underwent 18FDG PET/CT and 68Ga-FAPI-04 imaging for tumor screening. Mild uptake in the left ventricular wall was detected on the oncology 18FDG PET/CT. True myocardiac-involvement could not be distinguished with physiological uptake. The following 68Ga-FAPI-04 showed intense heterogeneous uptake in the left ventricular wall, particularly in the septum and apex area, corresponding with the late gadolinium enhancement regions shown by cardiac MR. Intense uptake was also noted in the mediastinal and bilateral hilar lymph nodes. Endomyocardial biopsy demonstrated sarcoidosis.

Primary Squamous Cell Lung Cancer With Frequent Episodes of Sustained Ventricular Tachycardia due to Myocardial Metastasis

Myocardial metastasis from lung cancer rarely occurs. We encountered a patient with squamous cell lung cancer who was diagnosed with myocardial metastasis before death and sustained ventricular tachycardia during the course of the disease. The patient was a 56-year-old woman. A tumor was noted in the apex area of the left lung and was diagnosed as stage IVA of squamous cell lung cancer after a detailed examination. She underwent concurrent chemoradiotherapy with weekly treatment of carboplatin + paclitaxel. A 12-lead electrocardiogram performed upon admission for additional chemotherapy showed negative T waves in leads III, aVF, and V1-4. Transthoracic echocardiography and computed tomography showed a tumor lesion in the right ventricular wall, which was diagnosed as myocardial metastasis from lung cancer. During the course of the disease, the patient had frequent episodes of sustained ventricular tachycardia, which were refractory to treatment with antiarrhythmic drugs. However, the sinus rhythm was restored with cardioversion. Subsequently, the patient received palliative treatment and eventually died 4 months after the diagnosis of cardiac metastasis and 3 weeks after the diagnosis of ventricular tachycardia. Myocardial metastasis might reflect poor prognosis due to serious arrhythmia or some other complications. Therefore, the early diagnosis and appropriate treatment of cardiac metastasis by chemotherapy, cardiac radiotherapy, or surgery, are necessary prior to the development of symptoms in tolerant cases. J Med Cases. 2023;14(4):111-117 doi: https://doi.org/10.14740/jmc4066

Influence of implant diameter on accuracy of static implant guided surgery: An in vitro study

Statement of problemStatic guided implant surgery may be the most accurate method of implant placement to date. However, within the same guided implant system, whether accuracy is affected when placing a larger diameter implant that requires more drills than a smaller diameter implant is unclear. PurposeThe purpose of this in vitro study was to evaluate the influence of implant diameter on the angulation and 3-dimensional (3D) deviations of posterior single implant placement using static guided surgery. Material and methodsA polyurethane dental cast was made with an edentulous site at the maxillary right first molar position. Identical implant planning for each of 3 dental implant diameters 3.3, 4.1, and 4.8 mm (Straumann BLT) were made, and surgical guides for each implant diameters were fabricated by stereolithography. Fifteen implants of each diameter (N=45) were placed in simulated casts. A scan body was placed and the cast was scanned using an intraoral scanner. The positional discrepancies of implant placement, including angulation as well as 3D implant cervical and apex area deviations, were compared with the planned position. Linear ANOVA single factor analysis (ɑ=.05) was used, and box plots were made. ResultsThe ranges of angulation deviations for 3.3-, 4.1-, and 4.8-mm implants were 3.6 degrees to 6.0 degrees, 3.7 degrees to 7.7 degrees, and 3.1 degrees to 6.7 degrees, respectively. The ranges of 3D implant entry deviations of 3.3-, 4.1-, and 4.8-mm implants were 0.96 to 1.4, 0.85 to 1.72, and 0.89 to 1.78 mm, respectively. The ranges of 3D implant apex of 3.3-, 4.1-, and 4.8-mm implants were 0.63 to 1.21, 0.64 to 1.48, and 0.48 to 1.27 mm, respectively. No statistically significant differences were found in any of the 3 measurements: P=.67 for deviation in angulation; P=.27 for 3D implant deviation of entry; and P=.3 for 3D implant deviation of the apex. ConclusionsImplant diameters had no significant effect on placement deviations when a single posterior static guided surgery was used.

A predictive scoring system for small diaphragmatic defects in infants with congenital diaphragmatic hernia.

To develop a predictive score for small diaphragmatic defects in infants with congenital diaphragmatic hernia (CDH) for determining thoracoscopic surgery indication. The Japanese CDH Study Group cohort was randomly divided into derivation (n = 397) and validation (n = 396) datasets. Using logistic regression, a prediction model and weighted scoring system for small diaphragmatic defects were created from derivation dataset and validated with validation dataset. Six weighted variables were selected: no hydramnios, 1 point; 1min Apgar score of 5-10, 1 point; apex type of the lung (left lung is detected radiographically in apex area), 1 point; oxygenation index < 8, 1 point; abdominal nasogastric tube (tip of the nasogastric tube is detected radiographically in the abdominal area), 2 points; no right-to-left flow of ductus arteriosus, 1 point. In validation dataset, rates of small diaphragmatic defects for Possible (0-3 points), Probable (4-5 points), and Definite (6-7 points) groups were 36%, 81%, and 94%, respectively (p < 0.001). Additionally, sensitivity, specificity, positive predictive value, and C statistics were 0.78, 0.79, 0.88, 0.76, and 0.45, 0.94, 0.94, 0.70 for Probable and Definite groups, respectively. Our scoring system effectively predicted small diaphragmatic defects in infants with CDH.

Dependence of electrodontometry indicators on the configuration of the root canal

Aim. To assess the dependence of electrodontometry indicators on the configuration of the root canal and to determine the value of the resultant action of the current at which patients have a response to electrodontometry.Materials and methods. The research consisted in the creation of computer models of teeth and their analysis by the finite element method in the COMSOL Multiphysics program. The removed tooth 2.2 was chosen as a prototype for 3D computer models. The tooth was dissected into fragments 2 millimeters thick, from which the geometric parameters of hard tissues and the position of the root canal were removed. Based on these data, a 3D model of the tooth was built. Based on the 2.2 tooth model, 5 models of the same tooth were constructed, simulating the stages of its root formation.Results. In all models, with an increase in the channel width in the apex area from 0.3 mm to 2.55 mm, the current density in this area decreased from 26.92 A/m2 to 0.63 A/m2. The maximum current density in the models was recorded in the narrowest part of the root canal and ranged from 26.01 A/m2 to 26.75 A/m2.Conclusions. The strength of the diagnostic current that causes a response in patients during electrodontometry depends on the configuration of the root canal, namely, on the cross–sectional area in the narrowest part of the root canal, where the maximum current density is recorded. The current density at which patients have a response to electrodontometry is 26-27 A/m2.

Assessment of Buccal and Palatal Alveolar Bone Thickness in Maxillary Anterior Teeth on Cone Beam Computed Tomography

Introduction: Evaluating the dimensions of buccal and palatal alveolar bone in the anterior maxillary teeth is very important in patients who are candidates for immediate implant replacement. The aim of this study was Assessment of buccal and palatal alveolar bone thickness in maxillary anterior teeth on cone beam computed tomography (CBCT).&#x0D; Materials &amp; Methods: In this descriptive-analytical study, 78 CBCT images of patients referred to Radiology Department of Khorasgan Dental Faculty were evaluated. The collected data included the measurement of the bone thickness of the alveolar buccal and palatal anterior maxillary teeth at three locations of the crest, the middle region of the root and apex with the Sidexis software. Then, the measurements were compared between males and females. The data were analyzed by T-test statistical methods.&#x0D; Results: The mean thickness of the buccal alveolar bone in the crest region and the middle region of the central, lateral and canine teeth was less than 1 mm. The mean thickness of the buccal alveolar bone at the apex site of the central, lateral and canine teeth was more than one mm. The mean thickness of the palatal alveolar bone in the crest region of the central, lateral and canine teeth was less than one millimeters. The mean thickness of the palatal alveolar bone in the middle region of the root and apex was more than one mm. There was no statistically significant difference between the sex and thickness of the buccal alveolar bone, except at the apex of the central and lateral teeth (p value &gt; 0.05). Between sex and thickness of palatal alveolar bone, in the crest of lateral and canine teeth and in the middle root and apex area of all three central, lateral and canine teeth in men were significantly more than women (p value &lt; 0.05).&#x0D; Conclusion: The buccal alveolar bone was present in most of the points examined at the crest and mid-root site, and the palatal alveolar bone was at the crest site at most checked points with a thickness of less than 1 mm.&#x0D;

Paleohydraulic analysis of an ancient distributive fluvial system

ABSTRACTReconstructing the paleohydraulics of ancient fluvial systems has important implications when determining channel-body dimensions in the subsurface as well as aiding source-to-sink studies and quantitatively determining the impact of changing climatic conditions. We undertake a paleohydraulic analysis of the Upper Jurassic Salt Wash distributive fluvial system (DFS) of the Morrison Formation, SW USA, to determine if downstream trends such as decreasing channel size and discharge, inferred in studies of DFS, are present. Channel depth was estimated using cross-set height values and preserved bar thickness. Nine localities across the exposed part of the Salt Wash system were studied. In total, 49 bars were measured, full bar thickness was determined from 12 complete bars, and average cross-set height was calculated for 37 bars. Estimates of maximum bankfull channel depth were derived from measured bar thicknesses. Bar height was then obtained and converted to mean bankfull channel depth using a shape adjustment factor of 0.65. The bar-derived mean bankfull channel depths were then used to derive a factor for which dune cross-set heights could be converted to mean bankfull channel depth (4.6) and maximum bankfull channel depth (7.1). These factors were then applied to localities where only cross-set height data were available, thus allowing consistent comparison and extrapolation of mean bankfull channel depth over the preserved DFS area. The use of measured bar thicknesses to calibrate estimates of mean channel depth from reconstructed dune heights is considered a useful approach, with the factor of 4.6 estimated here being lower than that (6 to 10) commonly used in comparable studies.The datasets for the Salt Wash DFS record systematic downstream trends in cross-set height, bar thickness, calculated channel depth, estimated channel width, and estimated Q, with variability and overlap between the proximal to medial, and medial to distal parts. The variability superimposed on the regional downstream trends is attributed to a combination of autocyclic processes such as variations in discharge, depth of scour, and avulsion as well as more regional-scale channel-belt switching together with allocyclic controls. The wide spatial distribution of the dataset in this study allows distinction between local autocyclic controls and regional downstream trends. Formative discharge shows no downstream trend across the entire Salt Wash DFS, with a wide range in coefficient of variation of preserved cross set thickness (CV(dst) values of 0.1 to 1.1) indicative of flashy (variable) discharge.The spatial distribution of the Salt Wash dataset allows extrapolation of trends upstream to the unexposed part of the system that allows insights into the characteristics of the channel system in the apex area (∼ 150 km to the southwest and removed by post depositional erosion). The fluvial system would have a mean depth of 9 m, and a bankfull-depth discharge of around 1450 m3/s with mean cross-set heights of between 50 and 70 cm. These estimates are in line with those from present-day DFSs in the Himalayan and Andean foreland basins that have a scale similar to that estimated for the Salt Wash system.

Understanding the influence of hydraulic conditions on colloidal fouling development by using the micro-patterned nanofiltration membrane: Experiments and numerical simulation

Surface patterning has emerged as a promising method to control membrane fouling by disturbing the flow field on the membrane surface. In this study, fouling development was non-destructively characterized by optical coherence tomography (OCT), while the micro hydraulic conditions and particle migration trajectories were investigated by using Computational Fluid Dynamics (CFD). Preliminary results demonstrated remarkable anti-fouling performance of the MNF membrane, and CFD simulation revealed that the local flow velocity on the apex area of patterns was greatly accelerated and the vortex among the valley regions was continuously generated. These hydraulic characteristics resulted in the enhancement of the hydrodynamic lift force (fL) and decrease of the permeation drag (fD) enforced on the retained foulants by the MNF membrane. Moreover, particle trajectories simulation integrated with comprehensive forces allowed to understand the influence mechanism of the flow field around MNF membrane surface on particle deposition. This study presents a new understanding of the anti-fouling mechanism of the MNF membranes and provides new insights into the design of self-cleaning membranes.

Semaphorin 7A Accelerates the Inflammatory Osteolysis of Periapical Lesions

IntroductionSemaphorin 7A (SEMA7A), the only class VII semaphorin member, has been considered as a potent immunomodulatory regulator whose function in periapical lesions remains unclear. In our previous study, we found that SEMA7A was up-regulated in human periapical periodontitis and might be involved in the immune response and tissue destruction of periapical lesions. In this research, we aimed to further explore the specifical regulatory role of SEMA7A as well as its regulatory mechanisms in the inflammatory progression of periapical lesions. MethodsHuman periodontal ligament cells (hPDLCs) were collected from intact, caries-free, and healthy third molars and stimulated with recombinant human/mouse SEMA7A (rSEMA7A). Real-time quantitative polymerase chain reaction (RT-qPCR), Western blot analysis, and enzyme-linked immunosorbent assay were used to detect the messenger RNA and protein levels of inflammatory cytokines and matrix metalloproteinases (MMPs) in hPDLCs. Twenty C57BL/6 mice were randomly divided into 4 groups: the healthy control group, pulp exposure group, pulp exposure and saline treatment group, and pulp exposure and rSEMA7A treatment group. Twenty microliters of sterile saline or 4 μg rSEMA7A were injected respectively into the buccal mucosa around the root apex at day 0, 7, and 14. Mandibular tissues were collected at day 21. Micro–computed tomographic and immunohistochemical staining were used to identify the bone destruction and inflammatory infiltration in periapical areas. Finally, an AKT inhibitor (LY294002) was used to pretreat hPDLCs before rSEMA7A stimulation to determine the role of AKT signaling activation in this process. ResultsAfter treatment with rSEMA7A, the messenger RNA and protein levels of interleukin (IL)-1β, IL-18, cyclooxygenase-2, MMP-1, and MMP-3 were remarkably up-regulated in hPDLCs. For in vivo experiments, compared with the other 3 groups, the treatment of rSEMA7A aggravated the osteolysis of alveolar bone and promoted the infiltration of immune cells into the apex area, along with increased expression levels of IL-1β, IL-18, MMP-1, and MMP-3. Furthermore, we found that the proinflammatory role of SEMA7A could be inhibited by the application of the AKT inhibitor (LY294002). ConclusionsSEMA7A likely aggravates the inflammatory reaction and bone destruction of existing periapical lesions. The proinflammatory role of SEMA7A in hPDLCs could partially be mediated through the AKT signaling transduction pathway.

Prognosis Analysis and Clinical Features of Orbital Cavernous Venous Malformations With Refractory Insidious Onset.

ObjectiveThe present study aims to analyse the clinical presentation, treatment and prognosis of a group of patients with orbital cavernous venous malformation (OCVM) with an insidious onset.MethodThe clinical data of 35 patients with OCVM treated at our centre between 2003 and 2020 were retrospectively analysed. The OCVMs were classified as one of six types (I–VI) according to the orbital position of the tumour. The clinical characteristics, treatment methods and follow-up results were recorded.ResultsA total of 35 patients with OCVM under the optic nerve sheath in the orbital apex area or the common tendon ring (Types I and II) were included in the present study. In 20 cases (57.1%), patients were misdiagnosed with optic neuritis, and in 20 cases (57.1%), the tumour was not identified based on imaging. The presentation was acute or subacute in 23 cases (65.7%). All patients underwent surgery: transnasal surgery in 22 cases (62.9%) and craniotomy in 13 cases (37.1%). A total of 9 patients (25.7%) experienced postoperative complications, and 17 patients (48.6%) experienced vision improvement. The average patient age at first diagnosis was 43.3 ± 10.3 years, and the median follow-up period was 64.5 months. Overall, 14 patients (40%) experienced postoperative complications: postoperative blindness in 6 cases, postoperative vision loss in 8 cases and orbital apex syndrome in 7 cases.ConclusionPatients with Type I and Type II OCVMs are the most complex cases. They have an insidious onset and are associated with a high rate of misdiagnosis and missed diagnosis. Acute and subacute decreases in visual acuity are mainly caused by OCVM haemorrhage. The difficulty of surgical treatment and the poor prognosis of postoperative vision are characteristics of this tumour. Transnasal surgery and craniotomy can be used to remove OCVMs located in the common tendon ring or optic canal as well as those involving the intracranial area through the supraorbital fissure. Meanwhile, the orbital approach (orbitotomy) has proven to be an effective method of treating OCVMs not involving the deep orbital apex and intracranial area.

691 Distribution of wall motion abnormalities in young patients presenting with acute coronary syndrome

Abstract Aims Distribution of wall motion abnormalities (WMA) in young patients presenting with acute coronary syndrome (ACS) is not well described. Methods and results We included 91 consecutive young patients (≤45 years at presentation) with ACS with obstructive or without obstructive coronary artery disease referred from October 2013 until March 2021 to our clinic. Wall motion abnormalities, wall motion score index (WMSI) and left ventricle ejection fraction (LVEF) were evaluated. A wall motion abnormality in at least one segment was present in 78.7% of patients. Mean LVEF was 50.9 ± 8.8% and mean WMSI was 1.38 ± 0.37%. Akinesia of at least one segment was present in 49.4%, dyskinesia and aneurysm were rare (1.1%, respectively). Ventricular thrombus was observed in 4.7%. Distribution of wall motion abnormalities is presented in Figure A. Most frequently WMA affected the apex and the basal inferior wall. The severity of WMA for each segment is presented in Figure B. The mean highest severity of WMA affected the apex, and the inferior and infero-septal wall. In the subgroup of patients presenting without obstructive coronary artery disease, WMA were less prevalent (37.5%), LVEF was higher (57.1% vs. 50.4% P = 0.032), and WMSI was lower (1.16% vs. 1.40% P = 0.07), but similarly affected with higher frequency the apex area. Conclusions In conclusion, WMA are frequent in young patients presenting with ACS, mostly affecting the apex. More severe abnormalities of wall kinesis affect the apex and the inferior and infero-septal wall.

Balloon-Augmented Leaflet Modification With Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction and Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction: Benchtop Validation and First In-Man Experience.

Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) and laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON) reduce the risk of coronary and left ventricular outflow obstruction obstruction during transcatheter aortic valve replacement and transcatheter mitral valve replacement. Despite successful laceration, BASILICA or LAMPOON may fail to prevent obstruction caused by inadequate leaflet splay in patients having challenging anatomy such as very small valve-to-coronary distance, diffusely calcified, rigid leaflets, or undergoing transcatheter aortic valve replacement inside existing transcatheter aortic valve replacement. We describe a novel technique of balloon-augmented (BA) leaflet laceration to enhance leaflet splay. We measured the incremental leaflet splay from BA-BASILICA in vitro. From November 2019 to March 2021, 16 patients underwent BA-BASILICA and 4 BA-LAMPOON at 3 centers. BA-BASILICA increased benchtop leaflet tip splay 17%, maximum splay angle 30%, and splay area 23%, resulting in a more rounded apex and larger effective area. Sixteen patients at risk for inadequate BASILICA leaflet splay, including 4 transcatheter aortic valve replacement inside existing transcatheter aortic valve replacement, underwent BA-BASILICA. All had successful leaflet laceration. One had coronary obstruction requiring immediate orthotopic stenting. Two underwent elective orthotopic coronary stenting through the transcatheter valve cells for leaflet prolapse without coronary ischemia. There were no deaths during the procedure or at 30 days. Four patients at risk for inadequate anterior mitral leaflet splay underwent BA-LAMPOON. All had successful target leaflet laceration without left ventricular outflow obstruction obstruction or procedural death. One died within 30 days. BA leaflet laceration enhances leaflet splay in vitro and may allow transcatheter aortic valve replacement and transcatheter mitral valve replacement in patients otherwise ineligible for traditional BASILICA or LAMPOON due to challenging anatomy. Graphic Abstract: A graphic abstract is available for this article.

Retrograde penetration pacing into the conduction system as an alternative approach of his-bundle pacing

BackgroundThe optimal right ventricular (RV) pacing site during pacemaker implantation is still unclear due to left ventricular (LV) dyssynchrony by traditional RV pacing. His-bundle (HIS) pacing has achieved narrow QRS and maintained LV synchrony but high failure rate. RV septal pacing occasionally has QRS waveform with wide and narrow component in the early and late phase, respectively, and maintains LV synchrony, reflecting the normal conduction system. We aimed to define this QRS waveform as retrograde penetration pacing into the conduction system (RPP-CS) and compared its effect on LV synchrony as an alternative approach of HIS pacing. Methods and ResultsWe enrolled 42 patients with atrio ventricular block (AVB) or bradycardia atrial fibrillation (AF) requiring pacemaker implantation (RPP-CS, n = 27; no RPP-CS, n = 15). Baseline characteristics were similar between the groups. RPP-CS was observed in 96% and 26% of the RV septum and apex area, respectively. RPP-CS had a significantly shorter QRS width (p < 0.001). The frequency of maintaining LV synchrony was significantly higher in RPP-CS (67% vs. 20%, p = 0.003). The QRS interval's optimal cut-off value during RPP-CS was 132 ms for prediction of LV synchrony (sensitivity 83%, specificity 89%, positive predictive value 94%, and negative predictive value 73%). During RPP-CS, shorter QRS intervals (QRS ≤ 132 ms) had better postoperative LV ejection fraction than longer intervals (p < 0.001). ConclusionsRPP-CS, especially with short QRS intervals (≤132 ms), had a high frequency of LV synchrony, maintained postoperative cardiac function, and may be an adequate first-line RV pacing site strategy for AVB or bradycardia AF as an alternative approach of HIS pacing.

Structural and immunological characterization of an epitope within the PAN motif of ectodomain I in Babesia bovis apical membrane antigen 1 for vaccine development.

BackgroundBovine babesiosis caused by Babesia bovis (B. bovis) has had a significant effect on the mobility and mortality rates of the cattle industry worldwide. Live-attenuated vaccines are currently being used in many endemic countries, but their wide use has been limited for a number of reasons. Although recombinant vaccines have been proposed as an alternative to live vaccines, such vaccines are not commercially available to date. Apical membrane antigen-1 (AMA-1) is one of the leading candidates in the development of a vaccine against diseases caused by apicomplexan parasite species. In Plasmodium falciparum (P. falciparum) AMA-1 (PfAMA-1), several antibodies against epitopes in the plasminogen, apple, and nematode (PAN) motif of PfAMA-1 domain I significantly inhibited parasite growth. Therefore, the purpose of this study was to predict an epitope from the PAN motif of domain I in the B. bovis AMA-1 (BbAMA-1) using a combination of linear and conformational B-cell epitope prediction software. The selected epitope was then bioinformatically analyzed, synthesized as a peptide (sBbAMA-1), and then used to immunize a rabbit. Subsequently, in vitro growth- and the invasion-inhibitory effects of the rabbit antiserum were immunologically characterized.ResultsOur results demonstrated that the predicted BbAMA-1 epitope was located on the surface-exposed α-helix of the PAN motif in domain I at the apex area between residues 181 and 230 with six polymorphic sites. Subsequently, sBbAMA-1 elicited antibodies capable of recognizing the native BbAMA-1 in immunoassays. Furthermore, anti-serum against sBbAMA-1 was immunologically evaluated for its growth- and invasion-inhibitory effects on B. bovis merozoites in vitro. Our results demonstrated that the rabbit anti-sBbAMA-1 serum at a dilution of 1:5 significantly inhibited (p < 0.05) the growth of B. bovis merozoites by approximately 50–70% on days 3 and 4 of cultivation, along with the invasion of merozoites by approximately 60% within 4 h of incubation when compared to the control groups.ConclusionOur results indicate that the epitope predicted from the PAN motif of BbAMA-1 domain I is neutralization-sensitive and may serve as a target antigen for vaccine development against bovine babesiosis caused by B. bovis.