Is Dental Panoramic Radiography Reliable to Assess Position of Bicortical Fixation Screws in Mandibular Fractures? Case Report

Background: Panoramic radiography is widely used as a diagnostic tool before oral surgeries and can be considered the foremost follow-up image after. It provides a broad observation of the maxillomandibular complex at a lower cost and radiation dose. But cone-beam computed tomography (CBCT) examination, after panoramic radiograph evaluation, can produce a change in the diagnostic thinking of maxillofacial surgeons leading to alterations in treatment plans. Objective: We aim to report a case with incidentally discovered radiographic findings where diagnostic changes were caused by switching from panoramic to CBCT imaging. Conclusion: Radiographic assessment of the position and angulation of screws by panoramic x-ray should be approached with extreme caution. The image of choice is CBCT if nerve injury is suspected.

Critical issue on the extinction and inattention subtest of NIHSS scale: an analysis on post-acute stroke patients attending inpatient rehabilitation

Objectives This study aims to evaluate the diagnostic performance of NIHSS extinction and inattention item, compared to the results of the Oxford Cognitive Screen (OCS) heart subtest. Additionally, the possible role of the NIHSS visual field subtest on the NIHSS extinction and inattention subtest performance is explored and discussed. Methods We analysed scores on NIHSS extinction and inattention subtest, NIHSS visual field subtest, and OCS heart subtest on a sample of 118 post-stroke patients. Results Compared to OCS heart subtest, the results on NIHSS extinction and inattention subtest showed an accuracy of 72.9% and a moderate agreement level (Cohen’s kappa = 0.404). Furthermore, a decrease in NIHSS accuracy detecting neglect (61.1%) was observed in patients with pathological scores in NIHSS visual field item. Conclusions Extreme caution is recommended for the diagnostic performance of extinction and inattention item of NIHSS. Signs of neglect may not be detected by NIHSS, and may be confused with visual field impairment. Trial registration This study refers to an observational study protocol submitted to ClinicalTrials.gov with identifier: NCT03968627. The name of the registry is “Development of a National Protocol for Stroke Rehabilitation in a Multicenter Italian Institution” and the date of the registration is the 30th May 2019.

Rescue liver re-transplantation after graft loss due to severe rejection in the setting of pre-transplant nivolumab therapy

Immune checkpoint inhibitors (ICI) have been used to treat hepatocellular carcinoma (HCC) since 2017. The safety of ICIs in the setting of solid organ transplantation remains controversial. When used in the post-transplant setting, ICIs have been associated with high allograft rejection rates, but there are few published reports on the use of ICIs prior to transplant. We present the first reported case of rescue liver re-transplantation after loss of the first allograft due to severe acute rejection with extensive hepatic necrosis in the setting of pre-transplant ICI therapy with the PD-1 inhibitor nivolumab. It is likely that the durable immune response triggered by nivolumab contributes to graft rejection, therefore extreme caution should be taken when using ICIs before transplant until further investigation has been conducted on their safety in the pre-transplant setting.

EP.TU.734Rectal mesh erosion post pelvic gynaecological surgery: A literature review

Introduction Surgical mesh has long been used for the repair of pelvic organ prolapse. In recent years high rates of serious complications have been reported and the US has withdrawn it from use, while the UK advises extreme caution. Here, we present a review of the literature with a focus on causative factors. Methods Twenty-three articles were included in the review: 21 cases of rectal mesh erosion and three cases of sigmoid mesh erosion. Causative factors were subdivided into patient-related, mesh-related and procedure-related. Results Main patient related risk factors included pre-existing intestinal diseases (reported in 4 cases) and an older age (median 65.5). Risk factors that were mesh related included increased porosity. 11 cases were reported with a macroporous (>75µm) mesh, whereas only 1 case had used a microporous (<10µM) mesh. 9 cases with partial/ no details of the mesh. The main risk factor that was procedure related was concomitant hysterectomy with 7 cases of mesh erosion had concomitant hysterectomy, 11 cases without concomitant hysterectomy, with a further 5 being unclear. Conclusion Pre-existing bowel disease, mesh type and mechanical factors associated with surgical technique all influenced the risk of mesh erosion into the bowels. A lack of reported information regarding the original surgical mesh and operation hindered the ability to draw conclusions. A step into rectifying this in the future would be the provision of medical device cards directly to the patient detailing the mesh.

Policy Practice Dilemma in the Interests of the Environmental Case

The purpose of the study to ensuring legal certainty and order in the operation of buildings, each building must comply with the administrative and technical requirements of the building, and all work must be completed in a timely manner. There is always an apparent struggle over whether to take a position in favor of the environment or not. It is essential to exercise extreme caution in order to avert the potential of even higher losses to humanity. This study considered scenarios that may be faced by a variety of different administrations

Structure of the Pacific Walker Circulation Depicted by the Reanalysis and CMIP6

The Pacific Walker circulation (PWC) is one of the most important components of large-scale tropical atmospheric circulations. The PWC and its influences have been studied extensively by numerical models and reanalysis. The newly released ERA5 and NCEP2 are the most widely used reanalysis datasets and serve as benchmarks for evaluation of model simulations. If the results of these datasets differ significantly, this could lead to a bias in projected long-term climate knowledge. For better understanding of future climate change, it is necessary to evaluate PWC reanalysis productions. As a result, we compared the PWC structures between the ERA5 and NCEP2 datasets from month to seasonal time scales. We used the zonal mass streamfunction (ZMS) over the equatorial Pacific to indicate the strength of the PWC. The PWC’s average monthly or seasonal cycle peaks around July. From February to June, the NCEP2 shows a higher PWC intensity, whereas the ERA5 shows greater intensity from July to December. The circulation center in the NCEP2 is generally stronger and wider than in the ERA5. The ERA5, however, revealed that the PWC’s west edge (zero line of ZMS over the western Pacific) had moved 10 degrees westward in comparison to the NCEP2. In addition, we compared the PWC mean state in the reanalysis and CMIP6 models; the mean state vertical structures of the tropical PWC in the CMIP6 multi-model ensemble (MME) are similar to those of the reanalyses in structure but weaker and wider than in the two reanalysis datasets. The PWC is broader in CMIP6, and the western boundary is 7 and 17 degrees farther west than in the ERA5 and NCEP2, respectively. This study suggests that, when using reanalysis datasets to evaluate PWC structural changes in intensity and western edge, extreme caution should be exercised.

A Low Noise High Input Impedance Chopper-Stabilized Biopotential Amplifier with Ripple Reduction Technique

Biopotential signals are created as a result of the electrochemical activity of the many cells that comprise the nervous system, and they represent both normal and pathological organ function. These signals must be identified with extreme caution because they are surrounded by a great deal of noise when detected by sensors. This article explores a novel biopotential amplifier that incorporates the chopper stabilization technique to increase noise performance and minimize offset. However, by introducing the chopper modulator into the proposed design, the amplifier's overall input impedance was lowered, which was then increased to greater than 200 MΩ by adding the forward auxiliary path to the input branch. Additionally, the output ripple, produced due to switching activity and up-sampling, was reduced by inclusion of the R-C ripple removing block at the output of the operational transconductance amplifier (OTA). The designed architecture had a mid-band gain of 40dB with a power consumption of 9 µW and an offset of 10µV and a CMRR of 82 dB. It generated a noise of 42nV/√Hz. Also, the obtained results were compared with a conventional amplifier. The proposed design was verified by carrying out simulations using 180nm technology parameters. Cadence Virtuoso (Schematic editor), Spectre (Simulator), Symica and Magic (Layout) tools were used to complete the implementation and simulation of the proposed design. HIGHLIGHTS Biopotential signals are created as a result of the electrochemical activity of the many cells which must be identified with extreme caution because they are surrounded by a great deal of noise when detected by sensors It explores a novel biopotential amplifier that incorporates the chopper stabilization technique to increase noise performance and minimize offset By introducing the chopper modulator into the proposed design, the amplifier's overall input impedance was lowered, which was then increased to greater than 200 MΩ by adding the forward auxiliary path to the input branch The output ripple, produced due to switching activity and up-sampling, was reduced by inclusion of the R-C ripple removing block at the output of the operational transconductance amplifier (OTA) The designed architecture had a mid-band gain of 40dB with a power consumption of 9 µW and an offset of 10 µV and a CMRR of 82 dB. It generated a noise of 42 nV/√Hz GRAPHICAL ABSTRACT

Spastic Motility Disorders: Diagnosis and Management in the Era of the Chicago Classification

Spastic esophageal motility disorders are represented, as per the Chicago classification 4.0, by diffuse esophageal spasm and hypercontractile esophagus. They are very rare and therefore poorly understood. The diagnosis is usually made by manometry in presence of dysphagia or chest pain, but often it is often an unexpected finding. In this paper, the authors review the current knowledge and possible treatments of these disorders, when needed. They underline that invasive treatments, as surgical myotomy or POEM, are rarely necessary and that the indications for them are based on low quality studies. Therefore, they should be used with extreme caution in treating spastic motility disorders other than achalasia.

Modular neck stems in total hip arthroplasty: current concepts

Modular neck (MN) implants can restore the anatomy, especially in deformed hips such as sequelae of development dysplasia. Early designs for MN implants had problems with neck fractures and adverse local tissue, so their use was restricted to limited indications. Results of the latest generation of MN prostheses seem to demonstrate that these problems have been at least mitigated. Given the results of the studies presented in this review, surgeons might consider MN total hip arthroplasty (THA) for a narrower patient selection when a complex reconstruction is required. Long MN THA should be avoided in case of body mass index > 30, and should be used with extreme caution in association with high offset femoral necks with long or extra-long heads. Cr-Co necks should be abandoned, in favour of a titanium alloy connection. Restoring the correct anatomic femoral offset remains a challenge in THA surgeries. MN implants have been introduced to try to solve this problem. The MN design allows surgeons to choose the appropriate degree and length of the neck for desired stability and range of motion. Cite this article: EFORT Open Rev 2021;6:751-758. DOI: 10.1302/2058-5241.6.200064

The (mis)conception of average Quaternary conditions

The concept of Quaternary average conditions has gained popularity over the past few decades, especially with studies of long-term landscape evolution. In this paper, we critically assess this concept by analyzing the marine isotope record (LR04 δ18O stack) relative to the Quaternary. This shows that the frequency and amplitude of climate glacial-interglacial cycles are not constant throughout the Quaternary, with a clear change during the Middle Pleistocene Transition (MPT), and that many minor oscillations exist within each cycle. For this reason, the identification of pre- and post-MPT most-frequent and, cumulatively, longest-lasting (rather than average) conditions is recommended. The most-frequent pre-MPT δ18O value of 3.725 ± 0.025‰ last occurred during 11.31–11.47 ka, while the most-frequent post-MPT δ18O value of 4.475 ± 0.025‰ last occurred during 14.81–15.04 ka. However, many other δ18O values were almost as frequent throughout the Quaternary and we present geomorphological reasons as to why it is unlikely that the present-day landscape reflects Quaternary average or, indeed, most-frequent conditions. Collectively, our results indicate that extreme caution should be taken when attempting to infer long-term landscape evolution processes (including the buzzsaw hypothesis) based on average Quaternary conditions.