Utility of bronchoalveolar lavage for COVID-19: a perspective from the Dragon consortium

Diagnosing COVID-19 and treating its complications remains a challenge. This review reflects the perspective of some of the Dragon (IMI 2-call 21, #101005122) research consortium collaborators on the utility of bronchoalveolar lavage (BAL) in COVID-19. BAL has been proposed as a potentially useful diagnostic tool to increase COVID-19 diagnosis sensitivity. In both critically ill and non-critically ill COVID-19 patients, BAL has a relevant role in detecting other infections or supporting alternative diagnoses and can change management decisions in up to two-thirds of patients. BAL is used to guide steroid and immunosuppressive treatment and to narrow or discontinue antibiotic treatment, reducing the use of unnecessary broad antibiotics. Moreover, cellular analysis and novel multi-omics techniques on BAL are of critical importance for understanding the microenvironment and interaction between epithelial cells and immunity, revealing novel potential prognostic and therapeutic targets. The BAL technique has been described as safe for both patients and healthcare workers in more than a thousand procedures reported to date in the literature. Based on these preliminary studies, we recognize that BAL is a feasible procedure in COVID-19 known or suspected cases, useful to properly guide patient management, and has great potential for research.

Doubts and concerns about COVID-19 uncertainties on imaging data, clinical score, and outcomes

BACKGROUND

COVID-19 is a pandemic disease affecting predominantly the respiratory apparatus with clinical manifestations ranging from asymptomatic to respiratory failure. Chest CT is a crucial tool in diagnosing and evaluating the severity of pulmonary involvement through dedicated scoring systems. Nonetheless, many questions regarding the relationship of radiologic and clinical features of the disease have emerged in multidisciplinary meetings. The aim of this retrospective study was to explore such relationship throughout an innovative and alternative approach.

MATERIALS AND METHODS

This study included 550 patients (range 25-98 years; 354 males, mean age 66.1; 196 females, mean age 70.9) hospitalized for COVID-19 with available radiological and clinical data between 1 March 2021 and 30 April 2022. Radiological data included CO-RADS, chest CT score, dominant pattern, and typical/atypical findings detected on CT examinations. Clinical data included clinical score and outcome. The relationship between such features was investigated through the development of the main four frequently asked questions summarizing the many issues arisen in multidisciplinary meetings, as follows 1) CO-RADS, chest CT score, clinical score, and outcomes; 2) the involvement of a specific lung lobe and outcomes; 3) dominant pattern/distribution and severity score for the same chest CT score; 4) additional factors and outcomes.

RESULTS

1) If CT was suggestive for COVID, a strong correlation between CT/clinical score and prognosis was found; 2) Middle lobe CT involvement was an unfavorable prognostic criterion; 3) If CT score < 50%, the pattern was not influential, whereas if CT score > 50%, crazy paving as dominant pattern leaded to a 15% increased death rate, stacked up against other patterns, thus almost doubling it; 4) Additional factors usually did not matter, but lymph-nodes and pleural effusion worsened prognosis.

CONCLUSIONS

This study outlined those radiological features of COVID-19 most relevant towards disease severity and outcome with an innovative approach.

Historical eye on IPF: a cohort study redefining the mortality scenario

Rationale

Therapies that slow idiopathic pulmonary fibrosis (IPF) progression are now available and recent studies suggest that the use of antifibrotic therapy may reduce IPF mortality.

Objectives

The aim of the study was to evaluate whether, to what extent, and for which factors the survival of IPF in a real-life setting has changed in the last 15 years.

Methods

Historical eye is an observational study of a large cohort of consecutive IPF patients diagnosed and treated in a referral center for ILDs with prospective intention. We recruited all consecutive IPF patients seen at GB Morgagni Hospital, Forlì, Italy between January 2002 and December 2016 (15 years). We used survival analysis methods to describe and model the time to death or lung transplant and Cox regression to model prevalent and incident patient characteristics (time-dependent Cox models were fitted).

Measurements and main results

The study comprised 634 patients. The year 2012 identifies the time point of mortality shift (HR 0.58, CI 0.46-0.63, p < 0.001). In the more recent cohort, more patients had better preserved lung function, underwent cryobiopsy instead of surgery, and were treated with antifibrotics. Highly significant negative prognostic factors were lung cancer (HR 4.46, 95% CI 3.3-6, p < 0.001), hospitalizations (HR 8.37, 95% CI 6.5-10.7, p < 0.001), and acute exacerbations (HR 8.37, 95% CI 6.52-10.7, p < 0.001). The average antifibrotic treatment effect estimated using propensity score matching showed a significant effect in the reduction of all-cause mortality (ATE coeff -0.23, SE 0.04, p < 0.001), acute exacerbations (ATE coeff -0.15, SE 0.04, p < 0.001), and hospitalizations (ATE coeff -0.15, SE 0.04, p < 0.001) but no effect on lung cancer risk (ATE coeff -0.03, SE 0.03, p = 0.4).

Conclusion

Antifibrotic drugs significantly impact hospitalizations, acute exacerbations, and IPF survival. After the introduction of cryobiopsy and antifibrotic drugs, the prognosis of IPF patients has significantly improved together with our ability to detect IPF at an earlier stage.

Idiopathic Pulmonary Fibrosis Is Associated with Common Genetic Variants and Limited Rare Variants

Rationale: Idiopathic pulmonary fibrosis (IPF) is a rare, irreversible, and progressive disease of the lungs. Common genetic variants, in addition to nongenetic factors, have been consistently associated with IPF. Rare variants identified by candidate gene, family-based, and exome studies have also been reported to associate with IPF. However, the extent to which rare variants, genome-wide, may contribute to the risk of IPF remains unknown. Objectives: We used whole-genome sequencing to investigate the role of rare variants, genome-wide, on IPF risk. Methods: As part of the Trans-Omics for Precision Medicine Program, we sequenced 2,180 cases of IPF. Association testing focused on the aggregated effect of rare variants (minor allele frequency ⩽0.01) within genes or regions. We also identified individual rare variants that are influential within genes and estimated the heritability of IPF on the basis of rare and common variants. Measurements and Main Results: Rare variants in both TERT and RTEL1 were significantly associated with IPF. A single rare variant in each of the TERT and RTEL1 genes was found to consistently influence the aggregated test statistics. There was no significant evidence of association with other previously reported rare variants. The SNP heritability of IPF was estimated to be 32% (SE = 3%). Conclusions: Rare variants within the TERT and RTEL1 genes and well-established common variants have the largest contribution to IPF risk overall. Efforts in risk profiling or the development of therapies for IPF that focus on TERT, RTEL1, common variants, and environmental risk factors are likely to have the largest impact on this complex disease.

Primary Lymphoproliferative Lung Diseases: Imaging and Multidisciplinary Approach

Lymphoproliferative lung diseases are a heterogeneous group of disorders characterized by primary or secondary involvement of the lung. Primary pulmonary lymphomas are the most common type, representing 0.5–1% of all primary malignancies of the lung. The radiological presentation is often heterogeneous and non-specific: consolidations, masses, and nodules are the most common findings, followed by ground-glass opacities and interstitial involvement, more common in secondary lung lymphomas. These findings usually show a prevalent perilymphatic spread along bronchovascular bundles, without a prevalence in the upper or lower lung lobes. An ancillary sign, such as a “halo sign”, “reverse halo sign”, air bronchogram, or CT angiogram sign, may be present and can help rule out a differential diagnosis. Since a wide spectrum of pulmonary parenchymal diseases may mimic lymphoma, a correct clinical evaluation and a multidisciplinary approach are mandatory. In this sense, despite High-Resolution Computer Tomography (HRCT) representing the gold standard, a tissue sample is needed for a certain and definitive diagnosis. Cryobiopsy is a relatively new technique that permits the obtaining of a larger amount of tissue without significant artifacts, and is less invasive and more precise than surgical biopsy.

Update of penetrance estimates in Birt-Hogg-Dubé syndrome

BACKGROUND

Birt-Hogg-Dubé (BHD) syndrome is a rare genetic syndrome caused by pathogenic or likely pathogenic germline variants in the FLCN gene. Patients with BHD syndrome have an increased risk of fibrofolliculomas, pulmonary cysts, pneumothorax and renal cell carcinoma. There is debate regarding whether colonic polyps should be added to the criteria. Previous risk estimates have mostly been based on small clinical case series.

METHODS

A comprehensive review was conducted to identify studies that had recruited families carrying pathogenic or likely pathogenic variants in FLCN. Pedigree data were requested from these studies and pooled. Segregation analysis was used to estimate the cumulative risk of each manifestation for carriers of FLCN pathogenic variants.

RESULTS

Our final dataset contained 204 families that were informative for at least one manifestation of BHD (67 families informative for skin manifestations, 63 for lung, 88 for renal carcinoma and 29 for polyps). By age 70 years, male carriers of the FLCN variant have an estimated 19% (95% CI 12% to 31%) risk of renal tumours, 87% (95% CI 80% to 92%) of lung involvement and 87% (95% CI 78% to 93%) of skin lesions, while female carriers had an estimated 21% (95% CI 13% to 32%) risk of renal tumours, 82% (95% CI 73% to 88%) of lung involvement and 78% (95% CI 67% to 85%) of skin lesions. The cumulative risk of colonic polyps by age 70 years old was 21% (95% CI 8% to 45%) for male carriers and 32% (95% CI 16% to 53%) for female carriers.

CONCLUSIONS

These updated penetrance estimates, based on a large number of families, are important for the genetic counselling and clinical management of BHD syndrome.

A pilot study on the use of the super dimension navigation system for optimal cryobiopsy location in interstitial lung disease diagnostics

BACKGROUND

Transbronchial cryobiopsies has become increasingly important in the diagnostic workup for interstitial lung diseases. The rate of complications and mortality are low compared to surgical lung biopsies, but the diagnostic yield is not as high. The reason for the lower diagnostic yield could in some cases be explained by biopsies taken too centrally or in less affected areas. In this pilot study we examined the feasibility of using the electromagnetic navigation system, superDimension (SD), when performing cryobiopsies to increase the diagnostic yield.

METHODS

Electromagnetic navigation bronchoscopy and cryobiopsies were performed using SD. An electromagnetic board placed on the back of the patient and a position sensor at the tip of the navigational probe created a real-time 3D reconstruction of previously acquired computer tomography images. The procedure was performed with the patients in general anesthesia using a rigid bronchoscope when performed in Florence and with a flexible bronchoscope through an orotracheal tube when performed in Aarhus.

RESULTS

In total, 18 patients were included. Five patients were excluded, partly due to technical difficulties. Disposable 1.7 mm cryoprobes were used in Aarhus, and reusable 1.9 mm probes in Florence. Pneumothorax was detected in three (23%), mild hemorrhage was seen in one (8%) and moderate hemorrhage in six (46%). The biopsies contributed to the diagnosis in 11 of the patients (85%).

CONCLUSION

Using superDimension electromagnetic navigation system when performing cryobiopsies is feasible. A larger prospective trial is necessary to homogenize the technique between centres and to evaluate diagnostic advantage and complications.

Clinical implications of interstitial pneumonia with autoimmune features diagnostic criteria in idiopathic pulmonary fibrosis: A case control study

Background

A subgroup of IPF patients can meet IPAF criteria (features suggesting an underlying autoimmune process without fulfilling established criteria for a CTD). This study was aimed to evaluate whether IPAF/IPF patients compared to IPF patients differ in clinical profile, prognosis and disease course.

Methods

This is a retrospective, single center, case-control study. We evaluated 360 consecutive IPF patients (Forlì Hospital, between 1/1/2002 and 28/12/2016) and compared characteristics and outcome of IPAF/IPF to IPF.

Results

Twenty-two (6%) patients met IPAF criteria. IPAF/IPF patients compared to IPF were more frequently females (N = 9/22, 40.9% vs. N = 68/338, 20.1%, p = 0.02), suffered more frequently from gastroesophageal reflux (54.5% vs. 28.4%, p = 0.01), and showed a higher prevalence of arthralgias (86.4% vs. 4.8%, p < 0.0001), myalgias (14.3% vs. 0.3%, p = 0.001) and fever (18.2% vs. 1.9%, p = 0.002). The serologic domain was detected in all cases (the most frequent were ANA in 17 and RF in nine cases) and morphologic domain (histology features) was positive in 6 out of 10 lung biopsies (lymphoid aggregates). Only patients with IPAF/IPF evolved to CTD at follow-up (10/22, 45.5%; six rheumatoid arthritis, one Sjögren's and three scleroderma). The presence of IPAF was a positive prognostic determinant (HR 0.22, 95% CI 0.08-0.61, p = 0.003), whereas the isolated presence of circulating autoantibody did not impact prognosis (HR 1.00, 95% CI 0.67-1.49, p = 0.99).

Conclusion

The presence of IPAF criteria in IPF has a major clinical impact correlating with the risk of evolution to full blown-CTD during follow-up and identifying a subgroup of patients with a better prognosis.

Incidental discovery of interstitial lung disease: diagnostic approach, surveillance and perspectives

The incidental discovery of pre-clinical interstitial lung disease (ILD) has led to the designation of interstitial lung abnormalities (ILA), a radiological entity defined as the incidental finding of computed tomography (CT) abnormalities affecting more than 5% of any lung zone. Two recent documents have redefined the borders of this entity and made the recommendation to monitor patients with ILA at risk of progression. In this narrative review, we will focus on some of the limits of the current approach, underlying the potential for progression to full-blown ILD of some patients with ILA and the numerous links between subpleural fibrotic ILA and idiopathic pulmonary fibrosis (IPF). Considering the large prevalence of ILA in the general population (7%), restricting monitoring only to cases considered at risk of progression appears a reasonable approach. However, this suggestion should not prevent pulmonary physicians from pursuing an early diagnosis of ILD and timely treatment where appropriate. In cases of suspected ILD, whether found incidentally or not, the pulmonary physician is still required to make a correct ILD diagnosis according to current guidelines, and eventually treat the patient accordingly.

In patients with interstitial lung abnormalities (ILA), monitoring of those at risk of progression is currently recommended, and pulmonary physicians should pursue an early diagnosis when ILA become clinically significant to facilitate timely treatment https://bit.ly/3HKOQc8

Obstructive sleep apnea syndrome in the pediatric age: the role of the dentist

OBJECTIVE

Sleep disordered breathing in children designates a wide spectrum of respiratory disorders characterized by partial or complete obstruction of the upper airways. It ranges from primary snoring, its mildest clinical manifestation, to obstructive sleep apnea syndrome (OSAS): complete obstruction of the upper airways with cessation of airflow. The aim of this paper is to highlight the roles of the pediatric dentist and the orthodontist in the therapeutic approach to pediatric OSAS as a "sentinel" who can detect early signs of the disease for immediate referral to the otolaryngologist and as an active participant in therapy.

MATERIALS AND METHODS

A literature review has been performed on the following topics: pediatric OSAS, orthodontic clinical aspects of pediatric OSAS, orthodontic therapy of pediatric OSAS, mandibular advancement devices and functional orthodontic devices in OSAS treatment.

RESULTS

The role of the dentist in pediatric OSAS is essential to correct orthodontic alterations that may favor the development of the condition. Orthodontic treatment aims at reducing the severity of OSAS by increasing the airspace and improving airflow through orthopedic expansion of the upper jaw and mandibular advancement. Rapid palatal expanders and mandibular advancement devices are successfully used in the treatment of OSAS.

CONCLUSIONS

Scientific evidence of a strong association between craniofacial growth and OSAS; the pediatric dentist and the orthodontist participate as sentinels, observing and identifying conditions requiring referral to the otolaryngologist and playing a pivotal role in the orthodontic treatment phase.

Bisphosphonate-related osteonecrosis of the jaws and dental surgery procedures in children and young people with osteogenesis imperfecta: A systematic review

BACKGROUND

Bisphosphonates (BPs) contrast the bone fragility and improve bone density in some metastatic cancers and bone diseases, such as Osteogenesis Imperfecta (OI). BPs use has been associated with osteonecrosis of the jaws (BRONJs) in adults needing for invasive dental procedures.

AIM

To conduct a systematic review on BRONJ occurrence after dental surgery in paediatric population under BPs therapy for OI, so as to identify the pre-surgical protocols adopted.

DESIGN

According to PRISMA guidelines, Pubmed, Web of Science (WoS) and Cochrane were investigated on September 2018, and re-checked on July 2019. Inclusion criteria were English-language papers on children/young adults (until 24 years old) reporting dental/oral surgery procedures.

RESULTS

Totally, 60 articles were found. After title/abstract reviews and duplicates exclusion, 22 eligible titles underwent full-text evaluation. Finally, 10 studies were included.

CONCLUSIONS

The lack of BRONJ occurrence in paediatric population suffering OI and treated with BPs, was confirmed, but the reasons are still debated, being the BPs therapies and the surgical strategies various and not standardized. Longitudinal studies should evaluate what happens to those former children once adult, to evaluate the delayed BRONJs onset associated with the occurrence of comorbidities during the adulthood.

Quantitative Evaluation of Lobar Pulmonary Function of Emphysema Patients with Endobronchial Coils

BACKGROUND

Recent advances in bronchoscopic lung volume reduction offer new therapies for patients with emphysema and hyperinflation. Pulmonary lobe segmentation with quantification of lobar volumes and emphysema severity plays a pivotal role in treatment planning and post-interventional assessment. Computed tomography (CT)-derived lobar volumes could reflect more accurate regional changes in pulmonary function.

OBJECTIVES

The aim of our study is to validate the reliability of an in-house CT Lung Segmentation software (LungSeg; the Hamlyn Centre, Imperial College London, UK) for lung lobar volume and emphysema quantification for chronic obstructive pulmonary disease (COPD) patients.

METHODS

A total of 108 CT scans from subjects who participated in an endobronchial coil treatment trial were included. Lobar volume and emphysema quantification were performed using the LungSeg and Syngo CT Pulmo 3D package (Siemens Healthcare GmbH, Germany). The inter-user reliability of the LungSeg program was investigated. Correlation coefficients and Bland-Altman analyses were used to quantify the inter-software variability. The agreement between CT volume analysis and plethysmography analysis was also examined.

RESULTS

The high intraclass correlation coefficients (mean ICC = 0.98) of the lobar volumes and emphysema indices measured by LungSeg suggest its excellent reproducibility. The LungSeg and Syngo program have good correlation (rho ≥0.94) and agreement for both lobar volume (median difference = 94 mL and LOAnp = 214.6 mL) and emphysema index (median difference ≤1.5% and LOAnp ≤2.03%) calculations. CT analysis provides a higher estimation of total lung capacity (TLCCT) than body plethysmography (TLCpleth), while there is a fair agreement on residual volume (RVCT) by LungSeg as compared with body plethysmography (RVpleth).

CONCLUSIONS

CT-derived lobar volume and emphysema quantification using the LungSeg program is efficient and reliable in allowing lobar volume assessment. LungSeg has low inter-user variability and agrees better with plethysmography for COPD assessment in our study.

Using of modified rapid palate expander with miniscrews in a patient affected by ectodermic dysplasia

OBJECTIVES

To show the orthodontic treatment in a 8-year-old patient affected by Ectodermal Dysplasia (hypohidrotic type) and presenting multiple agenesiae, contraction of the maxilla and skeletal Class III malocclusion.

STUDY DESIGN

Because of both oligodontia of primary and secondary dentition and no good retention and anchoring, a hybrid modified rapid palatal expander (RPE) was used. It presented dental anchoring with two bands on first upper molars and skeletal anchoring with two miniscrews in the anterior palate. The project included the use of a CBTC for the bone examination and precise silicon dental impression for the insertion of miniscrews.

RESULTS

The procedure was successful and the patient solved the expansion in few days, so RPE has been embedded throughout 6 months in order to develop the bone at the median suture.

CONCLUSIONS

This case report can be considered as a valid example for approaching patients affected by Ectodermal Dysplasia with multiple agenesiae and palatal contraction because of the difficult retention.

Competence in bronchoscopic treatments in emphysema

Bronchoscopic lung volume reduction (BLVR) has been proven to be effective in patients with severe emphysema. These techniques are divided into two groups: non-blocking devices that are independent of collateral ventilation and blocking devices that are dependent on collateral ventilation so the choice of the target lobe with inadequate scissors is crucial for the success of the treatment. Current evidences suggest that not all classes and phenotypes of emphysema will benefit from BLVR, and that each technique appears to provide a greater benefit to specific sub-groups of patients. Careful patient selection is imperative to prevent insertion in patients unlikely to gain clinical benefits as well as wasteful expenditure. The Chartis system represents the gold standard for measuring fissure integrity and is a direct measurement method. Indirect method is instead the TC study which, thanks to the development of software for quantitative analysis, allows us to obtain reliable measurements of regional density of parenchyma, airway thickness and scissor integrity. BLVR is a highly complex procedure: a first-level competence is a pre-requisite for admission to training. The practical training must be based on discussion of clinical cases and the insertion techniques of the different devices on plastic or animal models, or on cadavers. A specific course, offering final certification, has been developed on the use of Zephyr valves.

Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: results of a multicenter study

Background

Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes.

Methods

It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV₁); of -8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant.

Results

One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those <350 mL (n=43) had a statistically significant higher improvement in FEV₁ (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (-10.0%±4.8% vs. -4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (-15.0±2.9 vs. -8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV₁ (19.0%±3.9%), RV (-10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (-15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described.

Conclusions

Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach.

Craniofacial morphology and airflow in children with primary snoring

OBJECTIVE

Sleep-disordered breathing (SDB) is among the most common diseases and includes a group of pathological conditions that form a severity continuum from primary snoring (PS) to obstructive sleep apnea (OSA). SDB presents a multifactorial etiology and in children, it is often linked to adenotonsillar hypertrophy, which may lead to an alteration of the breathing pattern. Therefore, several studies hinted at the existence of a correlation between SDB and the alteration of craniofacial growth. However, these studies concentrated on the most severe forms of SDB and little evidence still exists for the mildest form of SDB, namely PS. This preliminary study investigates the association between nasal airflow, measured through rhinomanometry, and cephalometric parameters in a sample of young children with PS.

PATIENTS AND METHODS

A sample of 30 children with habitual snoring aged between 5 and 8 years was selected by a SDB validated questionnaire at the Pediatric Allergology and Immunology Center of "Sapienza" University of Rome, Italy. To assess the degree of nasal obstruction, all children underwent anterior active rhinomanometry while nocturnal pulse oximetry and polysomnography were used to characterize the SDB. Cephalometric analysis was used to evaluate relevant orthodontic parameters associated to the sagittal and vertical craniofacial development and to the position of the hyoid bone.

RESULTS

We found a statistically significant association between the Frankfurt mandibular angle (FMA), which measures the total facial vertical divergence, and the severity of the airflow's obstruction (p = 0.014).

CONCLUSIONS

The present study supports the association between the level of nasal obstruction in children with PS and the alteration of cephalometric parameters associated with the vertical craniofacial growth, thus placing the evaluation of craniofacial parameters in the growth period in a privileged position to determine an early diagnosis of a possible insurgence of sleep disorders.

Collaboration spotting for dental science

AIM

The goal of the Collaboration Spotting project is to create an automatic system to collect information about publications and patents related to a given technology, to identify the key players involved, and to highlight collaborations and related technologies. The collected information can be visualized in a web browser as interactive graphical maps showing in an intuitive way the players and their collaborations (Sociogram) and the relations among the technologies (Technogram). We propose to use the system to study technologies related to Dental Science.

METHODS

In order to create a Sociogram, we create a logical filter based on a set of keywords related to the technology under study. This filter is used to extract a list of publications from the Web of Science™ database. The list is validated by an expert in the technology and sent to CERN where it is inserted in the Collaboration Spotting database. Here, an automatic software system uses the data to generate the final maps.

RESULTS

We studied a set of recent technologies related to bone regeneration procedures of oro--maxillo--facial critical size defects, namely the use of Porous HydroxyApatite (HA) as a bone substitute alone (bone graft) or as a tridimensional support (scaffold) for insemination and differentiation ex--vivo of Mesenchymal Stem Cells. We produced the Sociograms for these technologies and the resulting maps are now accessible on--line.

CONCLUSION

The Collaboration Spotting system allows the automatic creation of interactive maps to show the current and historical state of research on a specific technology. These maps are an ideal tool both for researchers who want to assess the state--of--the--art in a given technology, and for research organizations who want to evaluate their contribution to the technological development in a given field. We demonstrated that the system can be used for Dental Science and produced the maps for an initial set of technologies in this field. We now plan to enlarge the set of mapped technologies in order to make the Collaboration Spotting system a useful reference tool for Dental Science research.

Collaboration Spotting for oral medicine

AIM

The goal of the Collaboration Spotting project is to create an automatic system to collect information about publications and patents related to a given technology, to identify the key players involved, and to highlight collaborations and related technologies. The collected information can be visualized in a web browser as interactive graphical maps showing in an intuitive way the players and their collaborations (Sociogram) and the relations among the technologies (Technogram). We propose to use the system to study technologies related to oral medicine.

METHODS

In order to create a sociogram, we create a logical filter based on a set of keywords related to the technology under study. This filter is used to extract a list of publications from the Web of Science™ database. The list is validated by an expert in the technology and sent to CERN where it is inserted in the Collaboration Spotting database. Here, an automatic software system uses the data to generate the final maps.

RESULTS

We studied a set of recent technologies related to bone regeneration procedures of oro-maxillo-facial critical size defects, namely the use of porous hydroxyapatite (HA) as a bone substitute alone (bone graft) or as a tridimensional support (scaffold) for insemination and differentiation ex vivo of mesenchymal stem cells. We produced the sociograms for these technologies and the resulting maps are now accessible on-line.

CONCLUSION

The Collaboration Spotting system allows the automatic creation of interactive maps to show the current and historical state of research on a specific technology. These maps are an ideal tool both for researchers who want to assess the state-of-the-art in a given technology, and for research organizations who want to evaluate their contribution to the technological development in a given field. We demonstrated that the system can be used in oral medicine as is produced the maps for an initial set of technologies in this field. We now plan to enlarge the set of mapped technologies in order to make the Collaboration Spotting system a useful reference tool for oral medicine research.

Occlusal trauma in mixed dentition: literature review

Controversy over the relationship between occlusion and the progression of periodontal destruction has been ongoing since the beginning of scientific studies of dental diseases. This paper reviews the literature and explores the relationship between trauma from occlusion with periodontal disease in children, presenting recommendations for clinical practice based on the available evidence.

Effects of interceptive orthodontics on orbicular muscle activity: a surface electromyographic study in children

The purpose of this study was to assess by surface electromyography (sEMG) the changes in upper and lower orbicular oris (OO) muscles produced by a preformed functional device in subjects with Class II, division 1 malocclusion, deep bite, and labial incompetence. Twenty-eight subjects were selected: 13 subjects (mean age 9 ± 1.5 years) with Class II malocclusion, deep bite, and labial incompetence were treated with a preformed functional device, while 15 subjects (mean age 9.5 ± 0.8 years) with normal occlusion were used as control. Inclusion criteria for both groups were: presence of mixed dentition, no previous orthodontic treatment, and absence of speech disturbance. sEMG recordings were taken at the time of the first visit (T0), and after 3 (T1) and 6 months (T2) for the treated group, and at T0 and T2 for the control group. The sEMG recording was performed at rest, and while kissing, swallowing, opening the mouth, clenching the teeth, and during protrusion of the mandible, by placing electrodes at the area of muscle contraction. At T0, except during swallowing, the treated group always showed a lower sEMG activity of the lower OO muscle with respect to the control group, with significant differences at rest and during mandibular protrusion (p<0.05). In the treated group, a significant increase in muscle tone was observed for the lower OO muscle from T0 to T1, but only at rest. The upper OO muscle showed a significant increase during the protrusion of the mandible from T1 to T2. No significant change was observed in the control group during the follow-up. Muscular contractility of treated patients at T2 reached the same values as that of the control group at T2. Interceptive orthodontics seems to improve the form and function of the orofacial muscle structure. Improvement in muscle contraction after treatment was demonstrated by sEMG.

Noonan syndrome: A case report

AIM

Noonan syndrome is a rare genetic alteration; the responsible gene is located on the long arm of chromosome 12.

CASE REPORT

The authors examined a caucasic girl of eight years with Noonan syndrome. The patient had systemic problems, such as: otitis, heart trouble, language disturbances and asymmetry of the lower limbs. Light mental delay was also found. She had the bad habit of sucking the lower lip. The treatment plan was extraction of some teeth, sealing of first molars and orthodontic treatment with functional appliance.

[Clinical and radiographic association between tooth agenesis and systemic pathology on a group of children from U.O.C. of paediatric dentistry of Sapienza University, Rome]

The aim of this work is to identify the association between tooth agenesis and systemic pathologies in paediatric patients. The Authors used clinical case-history and orthopanoramic rx of paediatric patients between 5 and 12 years old, gone to U.O.C. of Paediatric Dentistry, from genuary 2006 to genuary 2009. It resulted that 9.1% of 1190 children presented tooth agenesis and in this group the Authors put in evidence a percentage of 41.5% with syndromes or orofacial diseases.

Evaluation of customer satisfaction at the Department of Paediatric Dentistry of "Sapienza" University of Rome

AIM

Healthcare facility management requires the optimisation of the quality of services offered.

METHODS

The Authors adopted a questionnaire as a means to assess customer satisfaction and needs. The Questionnaire has been designed to address adults, i.e., parents or guardians of children attending the Paediatric unit as patients. To estimate their degree of satisfaction, either regarding the environment where children are treated or about the direct interactions between the parents and the structure (waiting room, waiting time, treatment time and time needed to make the payments, costs, etc.), the questionnaire was submitted to a sample of approximately 600 customers, between March and June of 2005.

RESULTS

On one hand results provide a pleasant confirmation on customers' perception of the service, especially regarding the direct relationship between the parties; on the other, they highlight aspects that could be improved (waiting room, optimisation of waiting time), distinguishing between factors that need extra funding to be implemented, and those that, instead, could be simply improved through a better and more efficient organisation of labour and time.

CONCLUSION

The present analysis and previous experiences confirm that appraisal of the degree of customers' satisfaction by means of questionnaires is a valid and necessary instrument for the quality improvement of a healthcare service. Doing so, economic and human resources can be more efficiently allocated.

Malignant infantile osteopetrosis: dental effects in paediatric patients. Case reports

AIM

Malignant Infantile Osteopetrosis is a hereditary pathology caused due to osteoclastic cells which are incapable of carrying out their functions and hence do not resorb osseous tissue where required. Thus the consequence is that during growth phase, the medullary cavities and nervous tissue cavities do not undergo sufficient growth and the corresponding organs do not develop adequately. The aim of this study is to outline the role of the pediatric dentist who has to carry out protocols of primary, secondary, tertiary prevention intervening at many levels. Clinical features and dental effects are described. Two case reports are presented in this study.

CONCLUSION

Oral problems of osteopetrosis are delayed tooth eruption, absence of some teeth, malformed teeth, enamel hypoplasia, disturbed dentinogenesis, hypomineralisation of enamel and dentin, propensity for tooth decay, defects of the periodontal membrane, thickened lamina dura, mandibular protrusion, and the presence of odontomas. Tooth removal should be limited as it may induce bone fractures and osteomyelitis. The role of the pediatric dentist is defined.

Rare compound odontoma of the mandible in a 7-year-old child: case report

BACKGROUND

A compound odontoma is a mixed tumor of odontogenic origin, in which both ectodermal and mesenchymal cells exhibit complete differentiation, resulting in the formation of tooth structures. It occurs with equal frequency in both sexes, and is often initially asymptomatic.

CASE REPORT

A 7-year-old boy was recently examined in our Department for management of a compound odontoma. Surgical treatment was invasive because of the size of the lesion, but it was possible to use interceptive orthodontic treatment to restore the dental arch.

Case report: clinical management of hypoplastic amelogenesis imperfecta

BACKGROUND

The fundamental therapeutic problems related to amelogenesis imperfecta treatment are governed by the need to effect primary prevention interventions, reducing the risk of calculus accumulation and caries. There are also aesthetic and functional rehabilitative needs. Clinical management rehabilitation techniques vary depending on the AI type, but usually require restoration of affected teeth. Where orthodontic problems also exist, these should be corrected prior to the final restorative treatment.

CASE REPORT

The use of composite resins in aesthetic restoration of permanent anterior and posterior teeth as affected by hypoplastic AI type is described. This case illustrates a patient who suffered from less attrition than those of the hypomineralized varieties. The therapeutic choice has allowed the correction of vertical dimension without the use of preformed crowns.

Expression profiling of ductal carcinoma in situ by laser capture microdissection and high-density oligonucleotide arrays

Gene expression profiling through the use of nucleic acid arrays is a powerful method for the molecular classification of human neoplasms. Laser capture microdissection is an equally useful technique to selectively isolate defined cell populations from heterogeneous histological tissue sections. In this report, we demonstrate how a modest use of laser capture microdissection is sufficient to isolate nanogram quantities of high-quality RNA. Together with the use of several internal standards and microcapillary electrophoresis of input RNA, two rounds of linear molecular amplification have been used to generate sufficient quantities of labeled target for hybridization to high-density oligonucleotide expression arrays. Results demonstrate that the technique is reproducible, generates only modest biasing of the original transcript population, and is comparable to the sensitivity achieved with standard methodology. Using this approach, we have compared the expression profiles of nonmalignant human breast epithelium and adjacent ductal carcinoma in situ lesions from breast cancer patients. Several genes, previously implicated in human breast cancer progression, demonstrate differential expression among the microdissected cell populations.

Sperm factor induces intracellular free calcium oscillations by stimulating the phosphoinositide pathway

Injection of a porcine cytosolic sperm factor (SF) or of a porcine testicular extract into mammalian eggs triggers oscillations of intracellular free calcium ([Ca(2+)](i)) similar to those initiated by fertilization. To elucidate whether SF activates the phosphoinositide (PI) pathway, mouse eggs or SF were incubated with U73122, an inhibitor of events leading to phospholipase C (PLC) activation and/or of PLC itself. In both cases, U73122 blocked the ability of SF to induce [Ca(2+)](i) oscillations, although it did not inhibit Ca(2+) release caused by injection of inositol 1,4,5-triphosphate (IP(3)). The inactive analogue, U73343, had no effect on SF-induced Ca(2+) responses. To determine at the single cell level whether SF triggers IP(3) production concomitantly with a [Ca(2+)](i) rise, SF was injected into Xenopus oocytes and IP(3) concentration was determined using a biological detector cell combined with capillary electrophoresis. Injection of SF induced a significant increase in [Ca(2+)](i) and IP(3) production in these oocytes. Using ammonium sulfate precipitation, chromatographic fractionation, and Western blotting, we determined whether PLCgamma1, PLCgamma2, or PLCdelta4 and/or its splice variants, which are present in sperm and testis, are responsible for the Ca(2+) activity in the extracts. Our results revealed that active fractions do not contain PLCgamma1, PLCgamma2, or PLCdelta4 and/or its splice variants, which were present in inactive fractions. We also tested whether IP(3) could be the sensitizing stimulus of the Ca(2+)-induced Ca(2+) release mechanism, which is an important feature of fertilized and SF-injected eggs. Eggs injected with adenophostin A, an IP(3) receptor agonist, showed enhanced Ca(2+) responses to CaCl(2) injections. Thus, SF, and probably sperm, induces [Ca(2+)](i) rises by persistently stimulating IP(3) production, which in turn results in long-lasting sensitization of Ca(2+)-induced Ca(2+) release. Whether SF is itself a PLC or whether it acts upstream of the egg's PLCs remains to be elucidated.

Characterization of a biological detector cell for quantitation of inositol 1,4,5-trisphosphate

Prior strategies to measure inositol 1,4,5-trisphosphate (IP(3)) in single cells either have been qualitative or have had a limited spatial resolution. Capillary electrophoresis combined with a biological detector cell has been used to quantitate IP(3) in small regions of a Xenopus oocyte. To improve the detection limits of this method, we elucidated the experimental parameters which influenced the sensitivity and reliability of the IP(3)-detector cell coupled to capillary electrophoresis. The variables which influenced the detector cell were the magnitude of the voltage drop across the detector cell, the duration of this voltage drop, the direction of fluid flow in the capillary, the concentration of free Ca(2+) around the detector cell, and the presence of protease inhibitors during permeabilization of the detector cell. For the sample volumes imposed by the capillary diameter, the detector cell acted primarily as an IP(3) mass detector rather than a concentration detector. Characterization of the experimental variables influencing the sensitivity and reliability of this detector cell has the potential to enhance other analyte measurements performed by mating capillary electrophoresis with a biological detector cell.

The physiologic concentration of inositol 1,4,5-trisphosphate in the oocytes of Xenopus laevis

To measure the concentration of inositol 1,4,5-trisphosphate ([IP3]) in small regions of single Xenopus oocytes, a biological detector cell was combined with capillary electrophoresis. This method is 10, 000 times more sensitive than all existing assays enabling subcellular measurement of [IP3] in Xenopus oocytes. Upon addition of lysophosphatidic acid to an oocyte, [IP3] increased from 40 to 650 nM within 2 min. IP3 concentrations as high as 1.8 microM were measured after activation with lysophosphatidic acid, suggesting that the physiologic concentration of IP3 ranges from the tens of nanomolar to a few micromolar in Xenopus oocytes. Since the IP3 receptor in Xenopus oocytes is nearly identical to the type I receptor of mammalian cells, the range of [IP3] in most mammalian cells is likely to be similar to that in the oocyte. By selecting or engineering the appropriate detector cell, this strategy should be applicable to cyclic adenosine diphosphate ribose and nicotinic acid adenine dinucleotide phosphate, and to the discovery of new Ca2+-releasing second messengers.

Localized sampling of cytoplasm from Xenopus oocytes for capillary electrophoresis

Continued progress in cellular physiology requires new measurement strategies which can be applied to solitary cells. Since many cellular signaling pathways act on time scales of a few seconds, there is a critical need for single-cell techniques with subsecond time resolution. Capillary electrophoresis shows great promise as a tool for the analysis of individual cells. In the present work, we describe a technique to load a capillary with picoliter to nanoliter volumes of cytoplasm and initiate electrophoresis in less than 500 ms. When cytoplasm was sampled from a Xenopus laevis oocyte previously loaded with fluorescein, calcium green, or a mixture of the two fluorophores, their fluorescent peaks were readily identifiable on the electropherogram. Since the volume of cytoplasm (< or = 30 nL) loaded into the capillary was much smaller than the 1 microL oocyte volume, spatially localized biochemical measurements were also possible. To demonstrate the utility of this new technique, the activity of the enzyme beta-galactosidase was measured in small regions of the Xenopus oocyte. Subcellular, subsecond sampling of oocyte cytoplasm will enable biochemical measurements with the resolution required to understand many cellular signal transduction pathways.

[An echocardiographic study of patients with left bundle branch block]

24 patients (19 females and 5 males) between 45 and 81 years of age (average age 61.6) with chronic left bundle branch block and with no signs of reduced left ventricular function have been studied by M-Mode echocardiography. These patients have been split into three groups: A) pts. with normal indexes of left ventricular function and normal thickness of the left ventricular walls; B) pts. with normal indexes of left ventricular function and thickness of the interventricular septum at upper limits or increased; C) pts. with different cardiac pathologies but with no signs of reduced ventricular function. The contractility indexes and the motion of the interventricular septum in both the basal and the medial portion have been studied. The results did not show any important variation concerning the ventricular function compared to the normal values. The study of the septal motion pointed out, as a main feature of the left bundle branch block, a preejective posterior motion followed by: a) a normal posterior systolic motion of the interventricular septum, or b) a posterior systolic motion followed by a further posterior protodiastolic motion (delayed motion), or c) an anterior systolic and posterior diastolic motion (paradoxical motion). The alterations of the septal movement ranked in different degrees. The clearest alterations were peculiarly found in the patients of the first group. The patiens of the third group, besides, have shown the lightest alterations. The results allowed to deduce that patients with left bundle branch block can have both normal motion or alterations of the interventricular septum motion of different degree.(ABSTRACT TRUNCATED AT 250 WORDS)