Effect of Molar Distalization on Condyle-Glenoid Fossa Relationship

Objective

It is essential to be aware of the potential effects of orthodontic treatment on tissues and anatomical structures associated with the masticatory system, especially the temporomandibular joint (TMJ). Little information is available about the consequences of molar distalization on the TMJ. Therefore, this study is aimed at investigating the changes of the condyle-fossa relationship after molar distalization using the distal jet appliance.

Materials and Methods

The sample consisted of twenty-five patients (mean age 20.4 ± 2.6) who underwent molar distalization by the distal jet appliance. CBCT scans were taken before (T0) and after (T1) the completion of the molar distalization. Joint spaces (anterior, superior, and posterior) and cephalometric vertical angles (SN.GOME and Björk sum) were measured and compared at T0 and T1.

Results

Superior and posterior joint spaces increased significantly after molar distalization (PS 0.29 mm, P < 0.001, SS 0.06 mm, P < 0.5). Vertical cephalometric angles also increased after molar distalization by the distal jet appliance (SN.GOME 0.92°, Björk 1.11°).

Conclusion

There was a statistically significant increase in the superior and posterior joint spaces after molar distalization. However, this increase may not be of clinical importance. The vertical dimension has also increased.

Relationship between heart rate variability, low grade inflammation and glycated hemoglobin. A sugary sweet story

Background

Low grade inflammation (LGI) is significantly associated with microvascular complications in diabetes mellitus (DM). Reduced and impaired Heart rate variability (HRV) is a strong marker of autonomic dysfunction and neuropathy and strongly associated with microvascular disease in DM. New studies and observations indicate that the diabetic neuropathic process starts early during pre-diabetes. On the other hand, HRV and LGI are closely interrelated. Our aim was to evaluate whether LGI or hyperglycemia (i.e. high HbA1c) is associated with the autonomic dysfunction or reduced HRV among people with diabetes and pre-diabetes.

Methods and materials

This study is based on The Copenhagen Holter Study, in which 678 community dwelling subjects aged 55 – 75 years who were free of previous cardiovascular disease, except from well controlled hypertension, and who underwent a 48-hours Holter recording. Analysis of HRV including night-time HRV were available for 653 participants and this population included 133 people with well-controlled and newly recognized T2DM (mean HbA1c 55 mmol/mol (7.2%)) and 386 people with pre-diabetes defined as HbA1c between 39 mmol/mol (5.7%) and 47 mmol/mol (6.4%). We selected high-sensitive CRP, as markers of LGI. As measures of HRV we used the standard deviation of normal-to-normal (N-N) beats (SDNN), the root mean square of N-N beats (RMSSD) which has been acknowledged to be best linked to vagal parasympathetic tone, and the mean time between N-N complexes (meanNN) which represents the average 24-hour heart rate (60.000/meanNN = average 24-hour HR in beats/min)

Results

Measures of HRV were associated with HgbA1c among both people with T2DM and pre-diabetes. Among people with pre-diabetes HbA1c was inversely associated with 24-hour RMSSD (r=−0.11, p=0.03) and night-time SDNN (r=−0,13, p&gt;0.01), while among T2DM HgbA1c was only associated with 24-hour RMSSD (r=−0.21, p=0.02). These association stayed significant when adjusted for sex, age, BMI, smoking, HOMA-ir, hs-CRP and systolic blood pressure in multiple linear regression (Table 1). LGI was only associated with HRV in diabetes. HbA1c was not associated with any measures of HRV or LGI among people with normal glucose metabolism.

Conclusion

HRV is closely and inversely associated with HbA1c in both diabetes and prediabetes, but only in diabetes LGI is associated with HRV. This indicates that the process of autonomic dysfunction/neuropathy starts at an early phase during pre-diabetes and probably provoked by postprandial hyperglycemia, while in diabetes both HbA1c and LGI are associated with HRV showing that LGI is activated later in the disease process probably provoked by long-term postprandial hyperglycemia, indicating treatment of hyperglycemia and postprandial hyperglycemia in the prediabetes state may be helpful.

Funding Acknowledgement

Type of funding sources: None.

Night heart rate variability identifies cardiovascular risk in community dwelling people with uncomplicated type 2 diabetes mellitus

Introduction

Low Heart rate variability (HRV) reflects cardiac autonomic neuropathy, associated with increased cardiovascular mortality in type 2 diabetes (T2DM) patients. Measuring HRV is challenged by environmental noise, mental stress and physical activity during the day-time. Thus, measuring night-time HRV during sleep may be a better tool to predict cardiovascular (CV) events in low risk T2DM patients without previous cardiovascular disease.

Methods

Copenhagen Holter Study included 678 community dwelling subjects aged 55–75 years free of previous cardiovascular disease. Day- and night-time HRV were available for 653. The population included 133 well-controlled T2DM patients (mean HbA1c 7.2%). Median follow- up was 14.4 years. HRV is defined as standard deviation for the mean value of normal-to-normal complexes (SDNN). Night-time HRV measurements were pre-defined from 2:00 to 2:15 AM. CV events were defined as CV death, myocardial infarction, stroke, or coronary revascularization.

Results

The rate of CV events was 17 and 31 per 1000 patient-year in patients without and with T2DM, respectively (p=0.015). Night-time SDNN was inversely associated with CV events in T2DM patients with a HR of 0.74 (0.61–0.89), P=0.001, for each 10 ms increment in SDNN, after adjustment for sex, age, LDL, smoking, systolic BP, glucose, CRP and NT pro-BNP (table 1). Twenty-four-hours HRV was not associated with cardiovascular events (table 1). Conventional risk factors had an AUC of 0.704 (95% CI 0.602–0.806) to predict CV events in T2DM. Prediction was improved by the addition of night-time SDNN; AUC 0.765 (95% CI 0.669–0.862), P=0.037, but not by CRP or NT-proBNP (Figure 1). In subjects with well-controlled T2DM and night-time SDNN ≤30 ms, the 10-year risk of CV death and CV even-rate were 12% and 45%, respectively. This allocates these T2DM patients in a “very high-risk” group, and more aggressive targets for blood-pressure and lipids according to the current guidelines.

Conclusion

Reduced night-time HRV associates with increased risk of CV events in persons with well-controlled T2DM. We observed improved risk prediction of cardiovascular events in T2DM by night-time HRV, which may have therapeutic consequences.

Figure 1. ROC Curve

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Danish Heart Foundation

Fabry Disease in Young Ischemic Stroke Patients in Northern Israel

INTRODUCTION

The prevalence of Fabry Disease (FD) with cerebrovascular complications varies in different populations. The aim of this study was to estimate the presence of FD among young stroke patients in northern Israel.

PATIENTS AND METHODS

We performed a retro-/prospective search for FD in young patients (aged ≤50 years old) admitted to the Department of Neurology due to acute ischemic stroke of any etiology.

RESULTS

Overall, 114 patients were examined for FD. Mean age of patients was 40±7.44 years. There were 75 (65.78%) males. FD was found in 4 (3.5%) patients. None of the FD patients had a cryptogenic stroke.

CONCLUSION

The results of our study call for a search of FD in young stroke patients of any etiology, and not only among cryptogenic ones.

Effectiveness of different adjunctive interventions in the management of orthodontically induced white spot lesions: A systematic review of systematic reviews and meta-analyses

The purposes of this review were to appraise the current evidence on the management of orthodontically induced white spot lesions (OIWSLs) and to choose the best evidence from among conflicting systematic reviews. The published literature was searched from inception through November 2019 in 5 databases. Only systematic reviews and/or meta-analyses were eligible for inclusion. Methodological quality was assessed using A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2). The Jadad decision algorithm was applied to choose the best available evidence from among discordant reviews. Thirteen publications were included. The interventions reported in the management of OIWSLs were topical fluorides, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)-containing products, fluoridecontaining bonding materials, laser therapy, resin infiltration, and micro-abrasion. The methodological quality of the reviews ranged between moderate and critically low according to the AMSTAR-2 tool. Based on the Jadad decision algorithm criteria, topical fluorides yielded a 25-30% prevention of OIWSLs; however, their effect on reversing OIWSLs was unclear. The CPP-ACP products were effective in both preventing and reversing OIWSLs. No differences were noted between fluoride-releasing adhesives and conventional adhesives. Laser irradiation was effective in preventing OIWSLs, with some concerns about the argon laser at a certain setting. Finally, there is a lack of reliable evidence supporting the efficacy of resin infiltration or micro-abrasion due to the limited number of available studies. Based on the currently available information, topical fluorides and laser irradiation are effective in preventing OIWSLs. The CPP-ACP products are effective in preventing and reversing OIWSLs. Fluoride-releasing adhesives have no effect on OIWSL prevention.

Effectiveness of supplemental vibrational force in reducing pain associated with orthodontic treatment: a systematic review

OBJECTIVE

The aim of this review was to systematically appraise the current evidence of utilizing vibration to reduce orthodontic pain.

METHOD AND MATERIALS

A comprehensive search was performed in ten databases. Only randomized controlled trials (RCTs) with patients receiving orthodontic treatment accompanied by vibrational force application were included. Risk of bias was assessed using the Cochrane tool. The lack of reasonable homogeneity across studies prevented the quantitative synthesis of the data.

RESULTS

Fifteen RCTs were included. Three out of four RCTs revealed lower pain levels in at least one time-point when aligners were enhanced by vibration. Three out of 11 RCTs found that vibration accompanying fixed appliances was effective in reducing orthodontic pain. All studies had different methodologic shortcomings including: performance bias due to lack of participants' blinding; inappropriate sample size calculation; nonuniform demographic characteristics of participants; high potential of retrospective documentation of pain perception; and attrition bias.

CONCLUSION

It is difficult to answer the question of whether vibration alleviates orthodontic pain or not, especially with the multiple existing shortcomings. More precise research is needed. It is recommended to focus on comparing different vibrational variables in an attempt to find the optimal values that might contribute to pain reduction, including: vibrational frequency; magnitude; and number and duration of sessions per day. Based on the concept of stimulation-induced analgesia, it is suggested that future research highlights the number of vibration sessions/day.

Effectiveness of low-level laser therapy in accelerating the orthodontic tooth movement: A systematic review and meta-analysis

OBJECTIVES

The aim of the paper was to appraise the current evidence of the effectiveness of low-level laser therapy (LLLT) in accelerating the tooth movement.

METHODS

A comprehensive search was performed in 9 databases up to June 2019. Only randomized controlled trials (RCTs) were included. The risk of bias was assessed using the Cochrane Collaboration tool. The quantitative data synthesis was attainable only for the studies evaluating the effect of laser on canine retraction; the qualitative description was used for the rest of the studies. The overall quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

A total of 25 RCTs were included in this review. The radiated upper canines showed a greater retraction – 0.50 mm and 0.49 mm at months 2 and 3, respectively. The radiated lower canines showed a greater retraction – 0.28 mm and 0.52 mm at months 2 and 3, respectively. No statistically significant differences were observed among the upper and lower canines after the 1st month of retraction. When the GRADE approach was utilized, the overall quality of evidence limited confidence in the estimates. The qualitative description revealed enhanced tooth movement when LLLT was applied. The attrition bias was the main risk factor affecting the methodology of the studies.

CONCLUSION

Low-level laser therapy can speed up the rate of the tooth movement. However, the overall quality of evidence ranged from low to very low and the clinical significance of the obtained statistically significant differences is questionable. Hence, more precise studies are needed. As discussed in this review, it is highly recommended to express and compare the laser dosage with the total number of joules applied per month rather than the previously used J/cm2. Moreover, the previous recommendation indicating that lower energy densities (2.5, 5 and 8 J/cm2) are more effective than 20 and 25 J/cm2 is misleading.

Volumetric upper airway changes following a new technique for Surgically-Assisted Maxillary Expansion (SAME)

BACKGROUND

Skeletal maxillary constriction (SMC) is one of the common skeletal discrepancies which are associated with alterations in the respiratory function. Today, many surgical techniques are used to expand the maxilla in adult patients with no consensus about the optimal technique.

OBJECTIVES

The present study aimed to investigate the changes of the upper airway volume resulting from the use of a new, minimally invasive surgically-assisted maxillary expansion (SAME) technique, and compare the results with the conventional SAME technique.

MATERIAL AND METHODS

A prospective study was conducted between September 2015 and July 2018. A total of 28 adult patients (11 males, 17 females; mean age: 19.1 ±2.7 years) with SMC underwent SAME. The sample was divided according to the applied surgical technique into 2 groups: the conventional osteotomy SAME (CO‑SAME) group consisted of 13 patients (18.7 ±2.2 years) and the selective osteotomy SAME (SO-SAME) group consisted of 15 patients (19.4 ±3.2 years). Cone beam computed tomography (CBCT) scans were initially obtained preoperatively (T1) and 3 months post expansion (T2). The upper airway was divided into 2 segments: retropalatal and retroglossal. The volume of each segment and the total airway volume (TAV) were assessed using the OnDemand3D® software.

RESULTS

The total upper airway volume showed a significant increase after both CO‑SAME and SO-SAME (1.29 ±0.26 cc and 1.21 ±0.19 cc, respectively), with significant increases in retropalatal and retroglossal airway volumes (RPAV and RGAV) after both CO‑SAME and SO-SAME (RPAV - 0.73 ±0.10 cc and 0.83 ±0.10 cc, and RGAV - 0.56 ±0.23 cc and 0.38 ±0.23 cc, respectively). No significant differences were observed in the maxillary width (MW), TAV or RGAV between the 2 SAME techniques, whereas the increase in RPAV in the SO-SAME group was significantly greater than that of the CO‑SAME group.

CONCLUSIONS

The new, minimally invasive SAME technique was an effective procedure to increase MW and the upper airway volume.

Skeletal Age-related Changes of Midpalatal Suture Densities in Skeletal Maxillary Constriction Patients: CBCT Study

AIM

To determine if density measurements of the midpalatal suture and cervical vertebral maturation index (CVMI) are related, and to investigate if CVMI could help in predicting of the developmental status of the midpalatal suture.

MATERIALS AND METHODS

Cone-beam computed tomography (CBCT) images of 95 skeletal maxillary constriction patients (aged 8 to 18 years) were examined. The maturational stages of the cervical vertebrae were visually defined, and midpalatal suture density in the anterior region, the middle region, and the posterior region were measured. One-way ANOVA and Fisher's least significant difference (LSD) post-hoc test were used for statistical assessment.

RESULTS

Significant differences were found in MPDS: in anterior region between (c1,c2,c3,c4) and (c5,c6) stages, in middle region between (c1,c2,c3) and (c5,c6) stages, and in posterior region between (c1,c2,c3) and (c4,c5,c6) stages.

CONCLUSION

Midpalatal suture densities in all regions increase with skeletal maturation advancement.The significant increase after puberty may have the key role in decreasing the skeletal effects of RME after that age. Clinical significances: It is important to assess the midpalatal suture density to choose between rapid maxillary expansion (RME) and surgically assisted rapid maxillary expansion (SARME). This study revealed a significant increase in the midpalatal suture density after puberty. Thus, it may better to perform RME before puberty.

Midpalatal suture: evaluation of the morphological maturation stages via bone density

Background

To investigate the relationship between the morphological maturation stages of the midpalatal suture and its bone densities.

Methods

The sample consisted of 91 subjects aged 8–18 years who underwent cone beam computed tomography. All images were examined to classify morphological maturation of the midpalatal suture to five groups according to Angelieri et al. Bone density of the midpalatal suture was measured at the maxillary and palatal regions. Kruskal-Wallis and Mann-Whitney U tests were used to analyze the difference between groups.

Results

Bone density of the midpalatal suture was significantly higher in the palatal region in E stage and in the maxillary region in D and E stages.

Conclusions

It is concluded that the change in bone density of the midpalatal suture between the morphological maturation stages supports their reliability in clinical application.

Correlation between Cervical Vertebrae Volume Parameter and the Skeletal Maturation Status

AIM

Assessing skeletal maturity is a critical factor in orthopedic treatment and orthognathic surgery. Quantitative methods have been suggested to decide the skeletal age. This study aims to assess the correlation between the middle phalanx of the third finger (MP3) method and cervical vertebral volume parameters (CVVP) in skeletal age determination.

MATERIALS AND METHODS

This cross-sectional study was conducted on 21 boys and 29 girls between the ages of 8 and 16 years, who were divided into five groups of skeletal maturation: 100 MP3 radiographs and cone beam computed tomography (CBCT) were obtained and analyzed. Middle phalanx of the third finger maturation stages were evaluated according to Perinetti method (stages F-FG-G-H-I). The CVVP was determined on CBCT using Mimics Medical software. Analysis of variance (ANOVA) and Bonferroni tests were utilized to investigate the differences in volumetric parameters between MP3 stages. Spearman correlation coefficient was employed to obtain the correlation between MP3 stages and the CVVP.

RESULTS

The differences in CVVP concentrated between MP3-I stage and the previous stages, with the highest values those for the 4th vertebra. Spearman test revealed a significant highest correlation between MP3 stages and the CVVP in the 4th vertebra; the lowest was in the 2nd, which was higher in the girls group.

CONCLUSION

Strong level of agreement between the two methods was significant in the 4th vertebra.

CLINICAL SIGNIFICANCE

Measurement of volumes of the 4th CVVP could be used as simple quantitative analysis in clinical practice to evaluate the maturity in orthodontic patients.

Abstract P3-06-03: Oral bisphosphonates and survival of breast and colon malignancies

Bisphosphonates are traditionally used for treatment of osteoporosis and more recently for treatment and prevention of bone metastases in various malignancies. The use of 2nd-generation oral bisphosphonates has been reported to reduce the risk of developing breast and colon cancer but their influence on cancer survival has not been studied.

Methods Two large cohorts of consecutively diagnosed cases with breast or colorectal cancer were studied for the association between use of 2nd-generation oral bisphosphonates and cancer survival. Using computerized prescription records, sustained use of alendronate/risedronate was assessed in postmenopausal women with newly diagnosed breast (n = 2,843) or colorectal cancer (n = 1,706). Overall survival and cancer-specific survival were evaluated using time dependent analysis.

Results Postmenopausal women with breast cancer previously unexposed to bisphosphonates who used 2nd-generation bisphosphonates after diagnosis for at least one year had a significantly better survival than non-users, adjusted for age, tumor stage and grade (Overall survival: HR = 0.53, 0.33-0.86, breast cancer-specific survival: HR = 0.26, 0.10-0.71, p = 0.009). A similar advantageous hazard ratio was found in users with ER positive, ER negative and HER2neu positive tumors. A similar significantly better survival was noted for colorectal cancer after adjustment for age, tumor stage and grade (Overall survival: HR = 0.53, 0.33-0.85, colorectal cancer-specific survival: HR = 0.44, 0.21-0.88, p = 0.02). Women who used bisphosphonates before diagnosis did not exhibit a significant survival benefit. Pharmacogenetic studies of F(D)PPS (Farnesyl Pyrophosphate Synthase), a gene coding a key step in the mevalonate pathway revealed direct correlation between a minor homozygous status and survival in bisphosphonate users.

Conclusions The use of 2nd-generation bisphosphonates initiated after diagnosis was associated with a significant improvement in overall and in cancer-specific survival of postmenopausal women with breast or colon cancers.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-06-03.

Prevalence trends in Sweden for the new variant of Chlamydia trachomatis

In 2006, a new variant of Chlamydia trachomatis (nvCT) was discovered in Sweden that was not detectable with Abbott m2000 (Abbott) and Amplicor/COBAS Amplicor/TaqMan48 (Roche). The proportion of nvCT was 20-64% of the detected Chlamydia cases in counties using Abbott/Roche test systems. Although the ProbeTec system from Becton Dickinson (BD) could detect nvCT, the proportion of nvCT in counties using BD was 7-19%. The objective of the current study was to follow the nvCT proportions from 2007 to 2009 in two counties that used Roche and had introduced test systems able to detect nvCT in late 2006. The nvCT was also followed in two counties that used BD, and in all four counties the effect of nvCT on the serotype distribution of C. trachomatis wild-type strains was analysed. A total of 2576 specimens positive for C. trachomatis were collected in the four counties at three time points, and analysed for nvCT and serotype E. The proportion of nvCT declined significantly in the two counties using Roche, from 65% and 48% in 2007 to 24% for both counties in 2009 (p <0.001). The nvCT proportion increased in Norrbotten county, which used BD, from 9% in 2007 to 19% in 2009 (p 0.03). In Uppsala county, which also used BD but was surrounded by counties using detection systems from Roche, the proportion of nvCT declined from 24% in 2007 to 18% in 2009 (p <0.03). No major difference in the level of serotype E was seen. The proportion of nvCT seems to rapidly converge in the Swedish counties after the selective diagnostic advantage for nvCT has been lost in the Abbott/Roche counties.

Evaluation of the new COBAS TaqMan CT test v2.0 and impact on the proportion of new variant Chlamydia trachomatis by the introduction of diagnostics detecting new variant C trachomatis in Orebro county, Sweden

BACKGROUND

The new variant of Chlamydia trachomatis (nvCT), discovered in Sweden in 2006, contains a 377-bp cryptic plasmid deletion, which includes the targets for the COBAS Amplicor/TaqMan C trachomatis/Neisseria gonorrhoea and Abbott m2000rt C trachomatis/N gonorrhoea tests.

OBJECTIVES

To evaluate the new real-time COBAS TaqMan CT test v2.0 (CTM CT v2.0) for C trachomatis diagnostics and to investigate whether the proportion of nvCT was affected by the introduction of genetic diagnostics detecting nvCT (LightMix 480HT) in Orebro county, Sweden.

METHODS

CTM CT v2.0 compared with LightMix 480 HT PCR for the diagnosis of C trachomatis was evaluated. Discrepant samples were analysed using BD ProbeTec ET and Abbott m2000rt RealTime CT II. All previously LightMix and cell culture-positive samples were analysed using an nvCT-specific PCR.

RESULTS

The sensitivity, specificity, negative predictive value and positive predictive value of CTM CT v2.0 for examined samples (n = 1058) was 100%, 99.8%, 100% and 98.2%, respectively. Of 11,577 consecutive PCR samples, 9.4% (n = 1084) were positive and 34.3% (n = 372) of these were nvCT. Of 2306 consecutive culture samples, 5.0% (n = 116) were C trachomatis positive and 38.8% (n = 45) of these were nvCT.

CONCLUSIONS

CTM CT v2.0 is a sensitive and specific method for C trachomatis detection. Studies including larger numbers of symptomatic and asymptomatic patients as well as genital and extragenital samples, and in comparison with other internationally validated and, ideally, US Food and Drug Administration-approved C trachomatis nucleic acid amplification tests are imperative. The proportion of nvCT remains high in Orebro county, Sweden, despite the introduction of genetic diagnostics to detect the mutant.

Micro-tensile bond strength to surface and subsurface enamel

Testing of bond strength to enamel has been undertaken on both surface and subsurface enamel on the assumption that it is the same substrate. Over recent years, the micro-tensile method has become widely used for the evaluation of dental adhesives. However, there have been no micro-tensile bond strength studies comparing surface and subsurface enamel using orthodontic adhesives. It has been proposed that the bond strength to subsurface enamel is greater than that to surface enamel.

OBJECTIVE

The micro-tensile bond strength (MTBS) of Transbond (light activated paste, 3 M Unitek, USA) to surface and subsurface enamel was investigated.

METHODS

Ten sound freshly extracted lower human first molars were divided into two groups of five each. Surface enamel of the first group was removed with 500-grit silicone carbide paper, whilst in the second group it was left intact. Gelatin capsules filled with Transbond composite paste were bonded perpendicular to the enamel using light cure adhesive Primer (Transbond XT, 3 M Unitek, USA) in both groups, and stored in distilled water at 37 degrees C for 24 h. Crowns of all specimens were sectioned bucco-lingually into vertical slabs of approximately 0.6 mm thickness. Slabs in each group were prepared into an hourglass shape of 1mm width and 0.6 mm thickness. Micro-tensile bond strength was determined using a mini tensile testing machine (COMPACT Gauge, DILLON).

RESULTS

Mean values of MTBS were: 31.2 MPa (SD14.5) for surface enamel and 47.9 (SD15.0) for subsurface enamel.

SIGNIFICANCE

There was a significant difference between the two groups P = 0.001. It was concluded that subsurface enamel has significantly higher bond strength than surface enamel. This has implications for bonding in restorative dentistry and orthodontics.

Return visits to the emergency room after minor trauma from motor vehicle accidents

Most patients with minor trauma following motor vehicle accidents (MVAs) are discharged from the emergency room (ER) of a trauma centre after evaluation and observation. Some return with similar or additional symptoms. This study aimed to determine which patients returned, if any injuries had been missed, and what should be the policy of medical management. We reviewed the records of 8836 patients with minor trauma following MVAs who were examined in an inner city trauma centre during 1997. When the group of patients who returned to the emergency room (n = 160) was compared with the whole post-MVA minor trauma group, the former was found to have more males (75.6% vs. 55.9%), younger age (36.31 years vs. 39.72 years), more motorcyclists than drivers, passengers and pedestrians ( p < 0.002, for the three variables), and had more multi-site injures. During the return visits the patients stayed longer in the emergency room, were examined by more consultants and had repeated radiological evaluations and tests, compared with the initial visit. However, in none of the patients was the initial diagnosis revised nor were additional injuries found and consequently the initial management was not changed in any of them. It is concluded that the initial thorough evaluation by the primary traumatologist is adequate for MVA patients with minor trauma. These patients do not require any follow up in specialized clinics, and are best managed in the community by their general practitioners.

Survival of colorectal carcinoma in the elderly. A prospective study of colorectal carcinoma and a five-year follow-up

PURPOSE

Colorectal carcinoma in elderly patients has become a more common problem in the last decade. There are some physicians who tend to offer a less definitive treatment for these patients because of their chronologic age. The purpose of this study was to evaluate the long-term survival of elderly patients (> 70) who underwent surgery for colorectal carcinoma in comparison with a younger group of patients with the same disease.

METHODS

Long-term survival of patients with colorectal carcinoma who underwent surgery was prospectively evaluated. Long-term survival was compared between an elderly group of patients (age, > 70) and a younger group of patients.

RESULTS

There was no significant difference in the five-year survival between the two age groups. Patients' survival was influenced by stage of the disease and type of operation (emergency vs. elective).

CONCLUSIONS

Treatment decisions in elderly patients with colorectal carcinoma should not be influenced by the chronologic age of the patient.

[Whipple operation in trauma]

Pancreato-duodenectomy is a formidable operation for the critically injured patient. We describe a patient who sustained a stab wound to the stomach and duodenum. At operation this injury could not be reconstructed. A Whipple operation was performed in which the pancreatic stump was stapled and recovery was uneventful, although there was a low output fistula from the pancreatic stump. Limited indications for the Whipple procedure in trauma patients are suggested.