Important Clinical Improvement Research Articles

ISONIAZID-RESISTANT TUBERCULOUS SPONDYLODISCITIS ASSOCIATED WITH SCROFULODERMA

The extrapulmonary forms of tuberculosis are responsible for about 20% of cases. Scrofuloderma is the cutaneous manifestation secondary to infection in some subcutaneous foci. A 33-year-old patient was admitted to the Clinical Hospital with exudative skin lesions on the back and thorax, initiated 10 months previously, associated with daily fever, and constipation. Spine resonance showed a paravertebral pseudotumoral lesion with T4 and T9 invasion, including vertebral canal and sub-ligament extension. The lesions presented fistulas for paravertebral muscles, lung and skin. Polimerase chain reaction (PCR) proved positive for Mycobacterium tubeculosis in the thorax wound secretion, caracterizing tuberculous spondilodiscitis with scrofuloderma. Treatment was initiated with rifampicin, isoniazid, pyrazinamide and ethambutol with important clinical improvement after the first week. The febrile peaks came to an end and there was improvement in the pattern of the cutaneous lesions. The susceptibility test showed resistance to isoniazid.

A case of disseminated sporotrichosis caused by Sporothrix brasiliensis

This paper presents a case of disseminated sporotrichosis in a 13-year-old female, originating from a rural area in Minas Gerais state, Brazil. The patient was hospitalized in Santa Casa hospital of Belo Horizonte, with hyporexia, prostration, fever and disseminated ulcerative lesions, besides anemia, leucopenia and sepsis of probable cutaneous focus. The patient was admitted without proven immunosuppression. She was diagnosed with cutaneous-disseminated sporotrichosis. The drug therapy chosen was itraconazole during 12 months, leading to important clinical improvement and healing of cutaneous lesions.

A New Papilla Preservation Technique for Periodontal Regeneration of Severely Compromised Teeth

IntroductionPeriodontal regeneration of hopeless teeth represents a major concern for clinicians, especially when these teeth are associated with the esthetic zone.Case PresentationThe case presented describes a non‐incised papillae surgical approach (NIPSA) to improve regenerative parameters in hopeless teeth. After treatment of a mandibular right canine with severe periodontal bone loss, clinical attachment loss to the apex, minimal keratinized tissue, and Class III mobility, there were important clinical improvements with no marginal soft tissue shrinkage and minimal morbidity for the patient.ConclusionNIPSA represents a promising minimally invasive technique even in hopeless teeth, facilitating the treatment of deep intrabony defects associated with high risk of soft tissue collapse and post‐surgical soft tissue shrinkage.

Adalimumab efficacy in enteropathic spondyloarthritis: A 12-mo observational multidisciplinary study.

AIMTo report adalimumab (Ada) efficacy on articular-gastrointestinal disease and health-related quality of life (HRQoL) in patients with enteropathic spondyloarthritis (ES).METHODSA cohort of 52 patients with ES was evaluated in the departments of gastroenterology and internal medicine. At baseline, all patients underwent assessment by an integrated gastro-rheumatologic evaluation of articular and gastrointestinal activity, as well patient reported outcomes (PROs) of the HRQoL questionnaires. After this integrated evaluation and following a specific working flowchart, the Ada anti-tumor necrosis factor (TNF)-inhibitor was assigned to a cohort of 30 patients and its clinical efficacy was evaluated at baseline and after 6-mo and 12-mo treatment by the following tests: (1) Ankylosing Spondylitis Disease Activity Score-C-Reactive Protein (ASDAS-CRP); Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Metrology Index (BASMI) for articular activity; (2) Inflammatory Bowel Disease Questionnaire (IBDQ), Crohn’s Disease Activity Index (CDAI) and partial Mayo (pMayo) score for gastrointestinal symptoms and activity; and (3) Health Assessment Questionnaire (HAQ), Patient Global Assessment (PGA) and Short Form-36 health survey (SF-36) questionnaires for PROs of the HRQoL.RESULTSIntegrated evaluation and management of the patients affected by ES, carried out simultaneously by a gastroenterologist and a rheumatologist, allowed clinicians to choose the optimal therapeutic strategy. In a cohort of 30 ES patients affected by active articular and gastrointestinal disease, or axial active articular inflammation, Ada led to fast and sustained improvement of both articular and gastrointestinal disease activities. In fact, all the clinimetric evaluation tests exploring articular or gastrointestinal activity, as well as all the HRQoL scores, showed a significant improvement having been achieved at the earliest (6-mo) assessment. This important clinical improvement was maintained at the 12-mo follow-up. Importantly, global and gastrointestinal quality of life significantly correlated with articular disease activity, providing evidence to support that the integrated evaluation is the best option to manage patients with ES.CONCLUSIONAda treatment, upon multidisciplinary (gastro-rheumatologic) evaluation, significantly improves both articular and gastrointestinal inflammation, thereby improving the HRQoL in patients affected by ES.

Benefits of different postoperative treatments in patients undergoing knee arthroscopic debridement.

PurposeTo assess the effectiveness of viscosupplementation or platelet-rich plasma (PRP), compared to standard care, for pain relief after knee arthroscopic debridement in patients with meniscal pathology and osteoarthritis (OA), under normal clinical practice conditions.Patients and methodsWe conducted a prospective, randomized, evaluator-blind, pilot study. After arthroscopy, patients were randomized to receive 1) five injections of HA1 (Suprahyal®/Adant®); 2) four injections of HA2 (Orthovisc®); 3) three injections of HA3 (Synvisc®); 4) a single injection of PRP (GPS™ II); or 5) standard care (control). Patients were followed up for 18 months. Clinical outcomes were evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) at 3, 6, 12, and 18 months. Minimally Clinical Important Improvement (MCII), as relative improvement ≥20 for pain and function, was also calculated.ResultsFifty patients were included. At early follow-up (3 months), total WOMAC scores improved in all groups compared to baseline with reductions of 44.79% (HA1), 24.02% (HA2), 40.38% (HA3), 39.77% (PRP), and 27.64% (control) (p=0.002 HA1 compared to HA2). At 18 months, the higher improvement in total WOMAC was in HA1 with a 65.20% reduction, followed by PRP (55.01%), HA3 (49.57%), and HA2 (29.82%), whereas the control group had a 14.55% increase over baseline (p=0.001 control compared to HA1 and HA3). The percentage of patients achieving the MCII for both pain and function at 18 months was 100% (HA1), 80% (HA3), 60% (HA2), and 60% (PRP), whereas, in the control group, all patients returned to pre-arthroscopy levels. There were no adverse events attributable to surgery or to intraarticular administration.ConclusionViscosupplementation following arthroscopy is more effective than PRP in adequately selected patients with meniscal lesions occurring concomitantly with OA. Further controlled studies with a larger sample size and/or alternative regimens would be of interest for the scientific community.

A 12-week supervised exercise therapy program for young adults with a meniscal tear: Program development and feasibility study

ObjectiveTo describe the development and feasibility of an exercise therapy program for treatment of young adults (18–40 years of age) with a meniscal tear. MethodsResearchers and experienced physical therapists developed a 12-week supervised neuromuscular and strengthening exercise therapy program based on clinical expertise and available evidence. Six patients (age range 22–39 years) considered eligible for meniscal surgery by an orthopedic surgeon underwent the program. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and evaluated the program during a semi-structured qualitative interview. Feedback from patients was included to finalize the exercise therapy program. ResultsMedian improvements (Range) in KOOS subscales were 15 (0–33) for Pain, 11 (−11 to 50) for Symptoms, 16 (3–37) for Function in daily living, 23 (10–45) for Function in sport and recreation, and 9 (−6 to 31) for Quality of life. The patients found the program relevant and effective with only a few short-lasting adverse events and important clinical improvements after four to ten weeks. Physical therapist supervision was considered important. No patients wanted surgery up to 6 month after the exercise therapy program. ConclusionA neuromuscular and strengthening exercise therapy program was feasible and showed important improvement in a small group of young adults with meniscal tears.

Tracheoesophageal fistula managed with tracheal stent through flexible bronchoscopy without fluoroscopy

Inoperable malignant tracheoesophageal fistula (TEF) is characterised by an extremely poor prognosis. Tracheal or double (tracheal-esophageal) stenting through rigid bronchoscopy has been suggested as a valuable therapeutic option. We report on a patient with a large TEF successfully sealed by deployment of a self-expandable stent through flexible bronchoscopy (FB) without fluoroscopy. Dramatically improved health status permitted him to undergo radiation, attaining further clinical improvement. Four months after stent placement no sequelae were observed. During the fifth month a new fistula developed distally to the stent finally leading to death from septic complication. Palliative management of inoperable malignant TEF by tracheal stent placement through FB without fluoroscopy, is feasible, safe and rewarding leading to important clinical improvement.

Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis: Long term outcomes

Knee osteoarthritis (OA) is a common, debilitating chronic disease. Prolotherapy is an injection therapy for chronic musculoskeletal pain. Recent 52-week randomized controlled and open label studies have reported improvement of knee OA-specific outcomes compared to baseline status, and blinded saline control injections and at-home exercise therapy (p<0.05). However, long term effects of prolotherapy for knee OA are unknown. We therefore assessed long-term effects of prolotherapy on knee pain, function and stiffness among adults with knee OA. Post clinical-trial, open-label follow-up study. Outpatient; adults with mild-to-severe knee OA completing a 52-week prolotherapy study were enrolled. Participants received 3-5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index, (WOMAC, 0-100 points), at baseline, 12, 26, 52 weeks, and 2.5 years. 65 participants (58±7.4 years old, 38 female) received 4.6±0.69 injection sessions in the initial 17-week treatment period. They reported progressive improvement in WOMAC scores at all time points in excess of minimal clinical important improvement benchmarks during the initial 52-week study period, from 13.8±17.4 points (23.6%) at 12 weeks, to 20.9±2.8 points, (p<0.05; 35.8% improvement) at 2.5±0.6 years (range 1.6-3.5 years) in the current follow-up analysis. Among assessed covariates, none were predictive of improvement in the WOMAC score. Prolotherapy resulted in safe, significant, progressive improvement of knee pain, function and stiffness scores among most participants through a mean follow-up of 2.5 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care.

SAT0333 The Influence of Golimumab Levels on Clinical Response in Spondyloarthritis Patients at 52 Weeks of Follow-Up

BackgroundPreviously an association has been demonstrated between drug levels and clinical activity in Spondyloarthritis (SpA) patients treated with Infliximab, Adalimumab or Etanercept. Until now, there is not enough evidence about...

FRI0248 Prediction of Therapy Response by Baseline Scintigraphic Detection of Tnfα with A Radiolabeled Anti-TNF-α in Patients with Active Peripheral Spondyloarthritis and Rheumatoid Arthritis

BackgroundA major challenge in the biologic era is to predict clinical response. A large variability in the level of TNFα expression has been recognized which may influence the outcome of...

PReS-FINAL-2178: Clinical and microarray follow-up of SJIA patients treated with anakinra over the past 10 years in a single institution

Results 51 SOJIA patients (30 F/21 M) with median disease duration of 1.0 years (range 0 days post dx-11.6 years) and median of 4 active joints (range 0-40) at initiation of anakinra were treated with a mean dose of 2.67 mg/kg (range 1-10) with an average follow-up of almost 5 years (range 0.49-9.75) on anakinra. All children had a sJIA signature as previously described (1) by microarray analysis. After 1L-1 blockade, significant improvements were seen in rash (p = 0.0008), fever (p < 0.0001), number of active joints (p = 0.0002), WBC (p < 0.0001), hemoglobin (p < 0.0001), platelets (p < 0.00001), and ESR (p < 0.0001). Twenty-two patients (17 new, 5 with flares) were treated without any steroids on anakinra alone (18), or concomitantly with methotrexate (4). 37/51 (72%) patients met Wallace criteria for inactive disease, 30/51 (59%) for clinical remission on medications, and 13/51 (25%) met criteria for clinical remission. Eight children (16%) had a partial response with important clinical improvements and were able to stop or greatly wean steroids. Five children (10%) had no sustained response. Most side effects were minor although 1 patient had sepsis immediately after IVMP. One patient had a drug induced hepatitis necessitating discontinuation of anakinra. One patient continued anakinra throughout pregnancy and delivered a normal term baby. Four patients with clinical MAS have resolved on anakinra. Gene expression profiling showed a remarkably homogeneous pattern of IL-1 related gene dysregulation (1), which normalized in most patients after anakinra. In some patients there was a time lapse between clinical response and correction of gene expression, suggesting that immune alterations are not completely resolved at time of first clinical response. Most upregulated transcripts encoded innate immunity related proteins. Down regulated transcripts encoded proteins involve in cytoxic/NK cell function and protein synthesis. In a small number of patients, interferon inducible genes were upregulated, especially in patient who had never received steroids and 5/7 of these showed normalization post anakinra.

FLAIR fornix hyperintensity in VGKC-related autoimmune encephalitis

A 52-year-old man presented with progressive fatigue, drowsiness, weight loss, and memory impairment associated with left-sided temporal lobe seizures. Brain MRI revealed increased bilateral FLAIR signal in the hippocampus, amygdala, mammillary bodies, hypothalamus and fornix (Figs. 1, 2). Blood analysis showed normal CRP, TSH, vitamin B1 and B12 levels. Routine immunological screening, and HIV and syphilis serology were negative. Anti-voltage-gated potassium channel (VGKC) antibodies were positive (463 pmol/l; normal range 0–100 pmol/l), in the absence of antiganglioside antibodies, NMDA/TPO/ GAD antibodies and other paraneoplastic antibodies. CSF analysis showed oligoclonal bands in the absence of other abnormalities. Brain FDG-PET revealed bilateral frontal, parietal and temporal hypometabolism (all equally involved). Whole-body FDG-PET, thoraco-abdominal– pelvic CT and testicular echography were normal. Oral antiepileptic treatment (valproic acid 500 mg bid) led to seizure freedom. Important clinical improvement after corticosteroid treatment (60 mg od for 1 month, followed by tapering during 3 months) was seen, in the presence of persistent MRI abnormalities (although increased signal became less severe) 4 months later. After 1 year of followup, no clinical relapse occurred, and thoraco-abdominal– pelvic CT and whole-body FDG-PET remained normal. A diagnosis of VGKC-related autoimmune, probably nonparaneoplastic, encephalitis was made. Autoimmune-mediated encephalitis can involve several brain areas with notably frequent involvement of limbic system structures (referred to as limbic encephalitis) including the hippocampus, amygdala and the mammillary bodies [1, 2]. MRI (together with FDG-PET) is probably the most adequate imaging technique to reveal abnormalities in these structures. MRI abnormalities due to autoimmune-mediated encephalitis are best seen on FLAIR sequences as an increased signal. To the best of our knowledge, despite radiological involvement of other limbic substructures and associated brain areas (e.g., the hypothalamus), fornix signal changes have never been reported in autoimmune encephalitis. The fornix is an important fiber bundle or projection bundle within the limbic system explaining probably its involvement in our patient. The limbic system includes territories of the diencephalon (the epithalamus, hypothalamus, subthalamic zona incerta), telencephalon (the septal and preoptic regions, hippocampus and some adjacent cortical areas, amygdala, the bed nucleus of the stria terminalis), and mesencephalon. Fornix involvement has been described in multitude other diseases [3]. The fornix is a compact fiber bundle connecting the hippocampus with the hypothalamus and various other structures. Its anterior–posterior orientation makes coronal MRI views particularly interesting. Because of the close proximity of the fornix to structures containing CSF, FLAIR imaging is of special interest to visualize fornix signal abnormalities. Neuropathological findings in autoimmune limbic encephalitis are non-specific, including gliosis, perivascular lymphocyte infiltration and microglial activation. In our patient, it is unclear if signal changes of the fornix were secondary (e.g., due to edema or Wallerian degeneration) D. Renard (&) D. Ratiu Department of Neurology, CHU Nimes, Hopital Caremeau, Place du Pr Debre, 30029 Nimes Cedex 4, France e-mail: dimitrirenard@hotmail.com

AB0852 Early improvement in enthesis by us predict later favorable response in TNF inhibotors with SPA

BackgroundLower limbs enthesis by ultrasound (US) detects inflammatory activity in patients with spondyloarthritis (SpA) and is a diagnostic tool of early SpA.ObjectivesThe present objective was to follow SpA patients starting...

SAT0341 Strontium Ranelate Improves Osteoarthritis Symptoms Compared to Placebo in Patients with Knee OA - The Sekoia Study

ObjectivesIn SEKOIA, strontium ranelate 2g/day (SrRan) has shown a structure-modifying activity with significant symptomatic improvement compared to placebo in patients with knee OA. This analysis aimed to determine proportion of...

Can Coenzyme Q10 Improve Clinical and Molecular Parameters in Fibromyalgia?

Fibromyalgia (FM) is a complex disorder that affects up to 5% of the general population worldwide. Its pathophysiological mechanisms are difficult to identify and current drug therapies demonstrate limited effectiveness. Both mitochondrial dysfunction and coenzyme Q10 (CoQ10) deficiency have been implicated in FM pathophysiology. We have investigated the effect of CoQ10 supplementation. We carried out a randomized, double-blind, placebo-controlled trial to evaluate clinical and gene expression effects of forty days of CoQ10 supplementation (300 mg/day) on 20 FM patients. This study was registered with controlled-trials.com (ISRCTN 21164124). An important clinical improvement was evident after CoQ10 versus placebo treatment showing a reduction of FIQ (p<0.001), and a most prominent reduction in pain (p<0.001), fatigue, and morning tiredness (p<0.01) subscales from FIQ. Furthermore, we observed an important reduction in the pain visual scale (p<0.01) and a reduction in tender points (p<0.01), including recovery of inflammation, antioxidant enzymes, mitochondrial biogenesis, and AMPK gene expression levels, associated with phosphorylation of the AMPK activity. These results lead to the hypothesis that CoQ10 have a potential therapeutic effect in FM, and indicate new potential molecular targets for the therapy of this disease. AMPK could be implicated in the pathophysiology of FM.

Vitamin B12 extensive thoracic myelopathy: clinical, radiological and prognostic aspects. Two cases report and literature review

The myelopathy caused by vitamin B12 deficiency is known as subacute combined degeneration. It is rare, but a well known cause of demyelination of the dorsal columns of the spinal cord. The magnetic resonance imaging is characterized by an increased signal on T2-weighted images involving the posterior columns of cervical and thoracic cord. There have been few cases in literature with extensive lesions (more than seven levels) of the thoracic spinal cord. The clinical and radiological improvements are possible if the replacement of vitamin B12 is initiated precocious. We present two rare cases of extensive thoracic myelopathy due to vitamin B12 deficiency. The first is a young woman with complete clinical recovery and important radiologic improvement after early treatment. In addition, the second case is an older man with partial response to the treatment. Those cases illustrate the importance of considering vitamin B12 deficiency in any patient, who presents with myelopathy.

The Neurorehabilitation Pathways Team (NRPT): a model of good practice?

Background: It is suggested that community based neurorehabilitation can provide benefits to both patients and health care providers in the shape of improved clinical outcomes and lower costs relative to inpatient care in tertiary centres. National guidelines within the UK have also called for care to be delivered ‘closer to home’. However, there is very little research on community based models of care for complex neurological patients and little evidence of how these models can deliver improved outcomes. Content: This article describes the model of care employed by Central Surrey Health and presents data from an audit of clinical records to support its effectiveness. Conclusions: This article has shown that the Neurorehabilitation Pathways Team (NRPT) achieve important clinical improvements for our patients whether treated as inpatients or in the community. As a group of experienced senior clinicians the NRPT accurately predict the likely clinical outcomes for each patient (90–97%) and give health care purchasers accurate predictions of the care pathway each patient will follow (84%). This provides a model of care which meets national guidelines and is potentially delivering both good clinical outcomes and cost savings for the health service compared to the former and more common model of care used in the UK.

Bromperidol decanoate (depot) for schizophrenia.

Antipsychotic drugs are the mainstay treatment for schizophrenia. Long-acting depot injections of drugs such as bromperidol decanoate are extensively used as a means of long-term maintenance treatment. To assess the effects of depot bromperidol versus placebo, oral antipsychotics and other depot antipsychotic preparations for people with schizophrenia in terms of clinical, social and economic outcomes. For this 2012 update we searched the Cochrane Schizophrenia Group's Register (February 2012). We sought all randomised trials focusing on people with schizophrenia where depot bromperidol, oral antipsychotics or other depot preparations. Primary outcomes were clinically significant change in global function, service utilisation outcomes (hospital admission, days in hospital), relapse. For the 2011 update MP independently extracted data, CEA carried out the reliability check. We calculated fixed-effect risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data, and calculated weighted or standardised means for continuous data. Where possible, we calculated the number needed to treat statistic (NNT). Analysis was by intention-to-treat.For the 2012 update, data collection and analysis was not carried out as no new studies were found. The 2012 search found no new studies, we have therefore included no new trials in this 2012 update. The number of included trials remain 4 RCTs, total n = 117. A single, small study of six months' duration compared bromperidol decanoate with placebo injection. Similar numbers left the study before completion (n = 20, 1 RCT, RR 0.4 CI 0.1 to 1.6) and there were no clear differences between bromperidol decanoate and placebo for a list of adverse effects (n = 20, 1 RCT, RR akathisia 2.0 CI 0.21 to 18.69, RR increased weight 3.0 CI 0.14 to 65.9, RR tremor 0.33 CI 0.04 to 2.69). When bromperidol decanoate was compared with fluphenazine depot, we found no important change on global outcome (n = 30, RR no clinical important improvement 1.50 CI 0.29 to 7.73). People allocated to fluphenazine decanoate and haloperidol decanoate had fewer relapses than those given bromperidol decanoate (n = 77, RR 3.92 Cl 1.05 to 14.60, NNH 6 CI 2 to 341). People allocated bromperidol decanoate required additional antipsychotic medication somewhat more frequently than those taking fluphenazine decanoate and haloperidol decanoate, but the results did not reach conventional levels of statistical significance (n = 77, 2 RCTs, RR 1.72 CI 0.7 to 4.2). The use of benzodiazepine drugs was very similar in both groups (n = 77, 2 RCTs, RR 1.08 CI 0.68 to 1.70). People left the bromperidol decanoate group more frequent than those taking other depot preparation due to any cause (n = 97, 3 RCTs, RR 2.17 CI 1.00 to 4.73). Anticholinergic adverse effects were equally common between bromperidol and other depots (n = 47, RR 3.13 CI 0.7 to 14.0) and additional anticholinergic medication was needed with equal frequency in both depot groups, although results did tend to favour the bromperidol decanoate group (n = 97, 3 RCTs, RR 0.80 CI 0.64 to 1.01). The incidence of movement disorders was similar in both depot groups (n = 77, 2 RCTs, RR 0.74 CI 0.47 to 1.17). Minimal poorly reported trial data suggests that bromperidol decanoate may be better than placebo injection but less valuable than fluphenazine or haloperidol decanoate. If bromperidol decanoate is available it may be a viable choice, especially when there are reasons not to use fluphenazine or haloperidol decanoate. Well-conducted and reported randomised trials are needed to inform practice.

The influence of surgery on quality of life in patients with intracranial meningiomas: a prospective study

Meningiomas may influence both survival and neurological functions. Studies assessing the impact of surgery on health-related quality of life (HRQL) remain absent. In this prospective study we aimed to describe HRQL dynamics before and after surgery in patients with meningiomas. HRQL assessments were performed using EuroQol-5D (EQ-5D), a generic HRQL instrument. All adult patients with suspected intracranial meningioma from 2007 through 2011 were eligible for inclusion, and 54 patients were included after informed consent. All patients received a histopathological diagnosis of meningioma. The average preoperative EQ-5D index value (±SD) was 0.69 ± 0.26. The mean improvement 6 weeks after surgery was 0.06 (95 % CI, -0.03 to 0.16; p = 0.161) and the mean long term improvement was 0.09 (95 % CI, 0.00-0.17; p = 0.040). Surgery reduced pain/discomfort and anxiety/depression and improved the capability of performing usual activities. Clinically significant improvement at long-term assessment was noted in 25 patients (49 %) while a significant deterioration was reported in 10 patients (20 %). Patients who reported postoperative worsening of HRQL were also reporting better preoperative scores, suggesting a possible ceiling effect of EQ-5D in some of these patients. In our patients a modest average improvement in HRQL was seen after surgery for meningioma. About half of the patients reported a clinical important improvement at the late follow-up assessment. This improvement was mainly observed in the domains usual activities, pain/discomfort and anxiety/depression. However, one in five patients fared worse on late follow-up assessment, a figure of particular importance when treating asymptomatic meningiomas.

Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex: 5-year results of an ongoing randomized clinical trial

Aim of this randomized, long-term clinical trial was to compare clinical- and patient-based outcomes following periodontal regeneration or extraction and replacement of hopeless teeth with chronic perio-endo lesions and/or attachment loss to or beyond the apex. Fifty patients presenting with generalized severe periodontitis and at least one hopeless tooth to be extracted for periodontal reasons were entered in this study. The test treatment consisted in the application of a regenerative strategy to 25 hopeless teeth. The control treatment consisted in the extraction of the 25 hopeless teeth and their replacement with conventional or implant-supported fixed partial dentures. In the control group, 14 teeth were replaced with implant-supported restorations, eight with tooth-supported bridges, two with Maryland bridges, while one was not replaced. All fixed partial dentures survived the 5-year follow-up period and 83% were free from biological complications. In the test group, 23 of the 25 regenerated teeth showed important clinical improvements: the two teeth with unsatisfactory outcomes were extracted at 1 year. The 23 successfully regenerated teeth (92%) were in good health and function at 5-year examination visit and 84% did not develop biological complications during the recall period. All patients consistently reported comfort in function at the experimental test and control units. In the test group, average clinical attachment level gains were 7.7±2.8 mm, radiographic bone gain 8.5±3.1 mm, probing pocket depth (PPD) reduction 8.8±3 mm. Residual PPDs were 4±1.7 mm. Most of the regenerated teeth showed a decrease in tooth mobility. Regenerative therapy can be applied at hopeless teeth and has the potential to change their prognosis; it is a suitable alternative to extraction of severely compromised teeth with intra-bony defects to or beyond the root apex.