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Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
Malonyl-CoA, a product of acetyl-CoA carboxylase is a metabolic intermediate in lipogenic tissues that include liver and adipose tissue, where it is involved in the de novo fatty acid synthesis and elongation. Malonyl-CoA decarboxylase (MLYCD, E.C.18.104.22.168), a 55-kDa enzyme catalyses the conversion of malonyl-CoA to acetyl-CoA and carbon dioxide, thus providing a route for disposal of malonyl-CoA from mitochondria and peroxisomes, whereas in the cytosol, the malonyl-CoA pool is regulated by the balance of MLYCD and acetyl-CoA carboxylase activities. So far, 34 cases with different MLYCD gene defects comprising point mutations, stop codons, and frameshift mutations have been reported in the literature. Here, we describe the follow-up of a patient affected by malonic aciduria upon neonatal onset. Molecular analysis showed novel homozygous mutations in the MLYCD gene. Our findings expand the number of reported cases and add a novel variant to the repertoire of MLYCD mutations.
OBJECTIVES/GOALS: The current proposal seeks to investigate the effect of early life antibiotic use in the development of functional gastrointestinal (GI) disorders. We propose that infants exposed to antibiotics will present with gut microbial dysbiosis, changes in fecal bile acid concentrations and develop more GI symptoms compared to unexposed children. METHODS/STUDY POPULATION: We analyzed fecal samples from 174 subjects at 12 months of age, of whom 52 were exposed to antibiotics in their first year of life. Of these, 33 subjects were sampled again at 24 months of age. DNA from 200mg of frozen stool (−80C) was isolated with the Qiagen DNeasy PowerSoil kit. Shotgun libraries were generated using the NexteraXT kit and sequenced on the Illumina HiSeq 2500 using 2x125 bp chemistry. Sequence data were analyzed using the Sunbeam metagenomics pipeline. The abundance of bacteria was estimated using Kraken version 2.0.8. Fecal bile acids will be quantified by liquid chromatography–mass spectrometry (LC-MS). RESULTS/ANTICIPATED RESULTS: Overall bacterial community composition at 12 or 24 months was not associated with antibiotic exposure (PERMANOVA test, Bray-Curtis distance). An increase in Enterobacteriaceae, in particular Escherichia coli, is a signature of antibiotic-induced dysbiosis, but also of early infant gut. Children with antibiotic exposure had slightly higher abundance of Escherichia coli compared to those with no exposure (p = 0.03). At 24 months, the abundance of Bacteroides caccae, a commensal gut species, was decreased for children exposed to antibiotics in the first year of life (fdr = 0.02). We will perform further analysis of bile acid modifying bacteria, fecal bile acid concentrations and correlate to GI symptoms. DISCUSSION/SIGNIFICANCE OF IMPACT: Our findings suggest a significant but nuanced impact of early life antibiotic use on the composition of the gut microbiota. The association of antibiotic exposure with B. caccae and E. coli warrant further attention in the context of the rapidly developing early-life microbiome. CONFLICT OF INTEREST DESCRIPTION: The authors declare no conflicts of interest relevant to this work.
Kartagener's Syndrome is a rare congenital malformation and characterized by the triad of bronchiectasis, sinusitis, and situs inversus. We presented a case diagnosed as Kartagener's syndrome and psychotic disorder not elsewhere specified.
Method and results
The case was a male patient, 32 years old, high school educated, married, with two children. He had a history with increasing psychotic symptoms and two times of suicide attempts for the last two months needed hospitalisation. In the psychiatric examination affect was blunted, there were anxiety, fear due to auditive hallusinations and referance delusions, anhedonia, suicidal thoughts and attempts, secondary depression. Psychiatric disorder predominently with auditive hallusinations and social withdrawal had a duration of three years. He was diagnosed as Kartagener's Syndrome when he was nine years old. The patient was treated with haloperidol 20 mg/day, biperiden 5 mg/day, klorpromazin 100 mg/day during hospitalisation. The psychotic symptoms were reduced within third day. On radiography his heart was seen at the right side of his body, there was bronchial dilatation in the medial and inferior lobes of left lung, thickness of walls of bronches and increased peribronchial density.
We assume that the biochemical disorder that is the cause of the development of Kartegener Syndrome is related with the genetic location which facilitates the development of psychosis or risk of psychosis.
This case is a presentation of three siblings diagnosed as affective disorder with polycythaemia vera during the episodes. Polycythaemia dissappearing with the remission of affective disorder is focus of attention of these cases.
Method and results
First sister is 28 years old, single, treated for manic and subclinic depressive episodes for almost ten years. Polycythaemia vera has been developed with beginning of every manic episode and disappeared with the remission of episode. The patient made venopunction of 500cc weekly during the manic episode. Second brother is 26 years old, single, polycythaemia and psychotic depression were developed rapidly after a stressful life event. Venopunction was made for four times during one month medication. Polycythaemia and depression remitted at the same time. Third brother is 24 years old, single, polycythaemia and nonpsychotic depression were developed after his brother's depression. Venopunction was made for three times during three weeks of treatment. Again polycythaemia and depression remitted at the same time.
The siblings had no internal disease. Only first sister was on lithium treatment, 600mg/day for chronic affective disorder but her first polycythaemia attack was prior to lithium treatment. We found only one report upon the relationship between affective disorder and polycythaemia vera in which mania, delirium and polycythaemia rubra vera were documented. #Freeman MP, Wiegand C, Gelenberg AJLithium. İn Textbook of Psychopharmacology. Third Edition. Schatzberg AF, Nemenoff CB (editors) American Psychiatric Publishing, Washington DC. 2004, 547-565.
Forty four years old, single, unemployed male patient with paranoid schizophrenia and congenital myotonia has been presented in this case report. He was hospitalized because of collecting garbages, hostility toward his brothers, fattening many animals, living in very dirty surroundings. His mother was treated as bipolar disorder.
Method and results
He had muscular disease since childhood, weakness began initially in arms then in legs. There is muscular weakness in both of the proximal and distal extremities. He presented with dirty, old attire. He was indifferent and had flattened affect. His behaviors were bizarre. He made poor eye contact. He had no insight. He was in defensive attitude. There was no hallusinations. He had severe persecutive delusions toward his brothers. Generalized muscular disease with myotonic decharges was diagnoses in EMG. Olanzapine,20mg/day was applied. The patient responded to the medication and the psycotic symptoms were totally disappeared.
It is known that central serebral system may be effected and hypodense areas are seen in the brains of Thomsen type congenital muscular dystrophy which is comorbid with mental retardation (Kamoshıta et al 1963). We assume that an unspecified disorder in the central serebral system might be presented as paranoid schizophrenia in this patient with congenital myotonia and there may be some common aspects among both of these illnesses.
Behcet's Syndrome is a chronic inflammatory disorder of unknown etiology, characterized by aphthous lesions and recurrent ulceration of the mouth, genitals and uveitis.
The central nervous system is involved in about 20% of cases.
Only few reports deal with affective symptoms associated with Behcet's syndrome.
We report a case of a 43 year old male with Neuro-Behcet's Syndrome that presents with a psychotic manic attack. He developed Behcet's Syndrome at the age of 23, with recurrent uveitis and aphthous lesions in the mouth, painful ulcers in the genitalia and erythema nodosum. HLA-B 5 was positive.
He was treated with azothioprine 150 mg/day for 13 years and prednole 100 mg/day during uveitis attacts for a week. At the age of 37 a sudden occurrence of right hemiparesia due to cerebrovascular accidence salicylic acid 100mg/day, siclosporine 150 mg/day, piracetame 1600mg/day were administered. He presented to psychiatry clinic in manic episode with euphoric mood, psychomotor agitation, talkativeness, decreased need for sleep, excessive buying and he had an unrealistical thought that he was a player of a famous soccer team. He was diagnosed as bipolar I disorder, according to DSM-IV. This was the patient's first admission and the symptoms which were continuing for 6 years exaggerated during uveitis attacks.Psychiatric examination releaved that increaced psychomotor activity, hypomaniac affect, amount and affect speed of speech affect, increased associations, grandiose delusions.
There are a few reports dealing with bipolar disorder as an entity related to Behcet's syndrome.
To report the long-term remission results from the relapse prevention trial (ConstaTRE) in stable patients treated either with risperidone long-acting injectable (RLAI) or the oral atypical antipsychotic quetiapine.
Clinically stable adults with schizophrenia or schizoaffective disorder treated with oral risperidone, olanzapine, or oral conventional antipsychotics were randomized to treatment with RLAI or oral quetiapine. Dosing was according to package-insert recommendation. Efficacy and tolerability were recorded for up to 24 months of treatment. Remission was defined as achieving and maintaining mild or less symptoms of schizophrenia over a 6-month period as defined by Andreasen et al, (2005).
710 patients were randomized (n=355 per group) to either RLAI or quetiapine. Demographics were similar between treatment groups. Relapse occurred in 54 RLAI (16.5%) and 102 quetiapine (31.3%) patients (p< 0.001). Full remission was achieved by 51% RLAI and 39% of quetiapine-treated patients (p=0.003) and was maintained until the end of the trial by 44% of RLAI and 31% of quetiapine patients. Mean duration of full remission was 540.8±181.4 and 508.1±188.0 days for RLAI and quetiapine groups, respectively (p=0.1325). Tolerability was similar between treatment groups. Most adverse events (AEs) were transient. Six RLAI and 10 quetiapine patients discontinued study treatment due to AEs.
Among stable patients with schizophrenia or schizoaffective disorder, remission was more likely to occur in patients switching to RLAI when compared with quetiapine. both RLAI and quetiapine treatments were well tolerated.
Selective Serotonin Reuptake Inhibitors (SSRIs) have been accused of causing bleeding problems as a side effect. Theories about the mechanism are still being discussed. We report a case, presenting bleeding problems, during sertraline treatment. The SSRIs are widely used to treat depression and many other psychiatric disorders. Their lower severity of side effects and being markedly safer in overdose are some of the reasons of their preference as primary choice in most of the cases. Besides their common side effects like, agitation, headache, insomnia, weight gain or loss, and sexual dysfunction, SSRIs also have been suspected of increasing the risk of bleeding. A population-based cohort study supported the hypothesis of an increased risk of upper gastrointestinal bleeding during the use of SSRIs, and they also indicated that this effect is potentiated with concurrent use of NSAIDs or low-dose aspirin. We would like to report our recent experience with one patient who was on sertraline, 50mg/day.
Eating disorders are associated with two or four comorbid diagnoses especially mood, anxiety, obsessive compulsive, substance abuse and personality disorders.
Psychotic disorders are seen rarely with eating disorders which have been reported as case reports.
40 years old male patient suffering for vomiting after eating and drinking large amounts of water and then purge. Recently vomiting has became habituation; he felt dysphoria after eating and forced himself to vomit. He didn’t want to be thin and wanted to gain weight. He didn’t think that condition could be a disease.
In his childhood he had bizarre behaviours. For instance he pulled up the paints of walls and then ate the pieces of paints. He teared off the skin nearby his nails. Since adolescence he was social isolated, introverted, affective flattened. His self appearance was poor. He couldn’t perform his grooming and cleaning by himself. He didn’t want to take a bath. Eight years ago with his mother's death he developed binge eating and vomiting problems.
He was hospitalized in internal clinics for two times due to losing weight. Then he was admitted to psychiatry clinic. The level of plasma potassium was 2.4 mEq/lt during hospitalization. The patient was treated both for weight restoration, electrolite regulation and psychiatric condition. Olanzapine 20 mg/day, ketiapine 600 mg/day was administered. Within 1 month his medical condition was remitted but he couldn’t gain weight, his negative symptoms.
This case is a male diagnosed as schizophrenia comorbid with atypic eating.
It is important to differentiate between adult autism and schizophrenia. In this presentation, the distinction between autism and schizophrenia will be discussed in the light of two cases.
At the time that they applied to our clinic, we investigated autistic and psychotic symptoms and firstly diagnosed them as schizophrenia.With the more detailed history of illness and investigation the diagnose change as adult autism. In the conclusion the cases will be discussed generally.
The most important clinical differences between adult autism and schizophrenia are stereotypic behaviour and speech. Schizophrenic stereotype has anxiolytic character and autistic one has hedonistic structure. Autistic patients are always aware of their environment and they seem to be mute because of their inner speech, but schizophrenic patients are not. On the other hand, schizophrenic stereotype is aimless and spontaneous, while the autistic stereotype has an aim such as an assurance of being same, and is relatively voluntary. All stereotypic behaviours and speech of the autistic patients are target-locked and cannot be blocked or broken. It seems that, as if autistic patients are addicted to stereotypical behaviours. In such cases, the patient's sentences can be lack of certain grammatical elements or can be incomprehensible. The prosody of this speech can follow certain rules. When he is joined in a conversation, it is rather like a monologue. Patients of schizophrenia generally respond positively to a neuroleptic drug, while autistic patients need a combined therapy of neuroleptic and anti-depressive drugs.
Although the cause of autism is not yet known, it is thought that this disorder is related to genetic and environmental factors. Cytogenetic anomalies and single gene disorders are responsible for less than 10% of all autistic cases. We herein present a case of autism, the etiology of which is metabolic cytopathy.
BA is a 25 years-old male and is the only child in the family. He was diagnosed by many doctors as having ‘Attention Deficit Hyperactivity Disorder’ (ADHD) until he was thirteen. The patient has been under our follow-up for the last 12 years since he was 13 and the diagnosis was corrected to Autistic Disorder at his first visit. During all this period, the patient gained 25 kg and he showed no neurological symptoms. On the cranial magnetic resonance imaging, bilateral lesions in the putamen, thalamus, partial lesions in the caudate heads, cerebellar white matter and the dentate nucleus were detected, which were hypointense at T1, hyperintense at T2 and iso-hypointense at FLAIR. The patient underwent evaluation by neurologists, biochemists and radiologists, but no etiologic factors could be detected. The present condition was considered to bean unconfirmed ‘metabolic cytopathy’.
Should autistic cases be stratified into subgroups according to the underlying genetic risks, it may even be possible to define a special subgroup which would cover the metabolic cytopathy present in our case. In conclusion, it is possible that autism due to metabolic causes is of genetic origin; however, this tendency should be detected by a molecular approach.
Brain-derived neurotrophic factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF) have essential roles in synaptic plasticity which is involved in pathogenesis and treatment of psychiatric disorders. However, it is not clear whether they act simultaneously during illness states in major psychiatric disorders.
BDNF and GDNF serum levels were measured concomitantly by enzyme-linked immunosorbent assay (ELISA) method in 171 patients diagnosed with schizophrenia (n = 33), bipolar disorder-manic episode (n = 39), bipolar/unipolar depression (n = 64, 24/40) and obsessive-compulsive disorder (n = 35) according to DSM-IV, and 78 healthy volunteers. SCID-I and SCID non-patient version were used for clinical evaluation of the patients and healthy volunteers, respectively. Correlations between the two trophic factor levels, and illness severity scores, duration of illness and medication dosages were studied across different illnesses.
While patients had equally lower BDNF levels in all diagnoses, GDNF levels were significantly higher in mania and lower in schizophrenia compared to healthy controls. BDNF levels were negatively correlated to illness severity scores in affective episodes (mania and depression). Longer duration of illness (> 5 years) had an impact on lower GDNF levels in schizophrenia. BDNF levels and antipsychotic drug dosages in schizophrenia, and GDNF levels and antidepressant drug dosages in obsessive-compulsive disorder were positively correlated.
Our data confirmed the evidence of equally deficient neuronal support by BDNF in all major psychiatric illnesses, but suggested a diverse glial functioning between schizophrenia and mania.
Previous studies reported high burnout rates and indicated significant factors associated with burnout syndrome among psychiatric trainees, such as hard working conditions, lack of supervision and not opting for psychiatry as a first career choice.
A substantial amount of variance was reported in psychiatry training across countries. However, there is not sufficient national data regarding the rates and risk factors of burnout syndrome among psychiatric trainees in Turkey.
To determine the burnout syndrome rates and the risk factors associated with burnout syndrome among psychiatric trainees.
A questionnaire of occupational, educational and personal factors and Maslach burnout inventory (MBI) were answered by 180 of 450 psychiatric trainees in Turkey. The data was collected from 167 (56% females) trainees who completed the survey material. Converting the scores of three subscales by using MBI manual, a dichotomous variable (severe/non-severe burnout) was obtained for each participant and the data was analyzed using descriptive statistics and regression models.
Mean age was 28.85 ± 2.99-year-old and mean duration of residency was 2.61 ± 1.31 years. Severe burnout was found in 38.3% of the trainees. Logistic regression confirmed that older age (P = 0.02) and pressure from superiors (P = 0.04) are predictive factors associated with severe burnout. The high number of patient visits (P = 0.001), violation of employee personal rights (P = 0.04) and pressure from superiors (P = 0.01) were significantly associated with the “wish working in another institution”.
Pressure from superiors and older age can be described as risk factors associated with burnout syndrome among psychiatric trainees in Turkey.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Sjogren's syndrome (SS) is a common autoimmune disorder that is characterized by chronic inflammation of lachrymal and salivary glands. The well-known clinical manifestations of SS are dry eyes and dry mouth. However, the disease may first present itself with psychiatric symptoms, such as depressed mood, agitation or irritability.
Our objective is to highlight the importance of systemic examination, including detailed biochemical workup in psychiatric patients with somatic complaints like fatigue and those patients with partial response to treatment.
We present a 35-years-old woman who had depressed mood, obsessions and compulsions, chronic fatigue, generalized muscle and joint pain, balance problems, weight loss, dry mouth and dry eyes for the past few years. Her symptoms would worsen during spring. She was diagnosed with seasonal affective depressive disorder and chronic fatigue and was started on mirtazapine 30 mg/day and venlafaxine 75 mg/day. She was partially responsive to this treatment. The detailed biochemical workup came 1/320 positive for anti-nuclear antibodies (ANA). The oral biopsy showed Sjogren's disease. Gluten sensitivity was found as well.
The patient was started on hydroxychloroquine sulfate 400 mg/day in addition to her anti-depressant medication. She was put on a gluten-free diet. She was in full remission in a month and had no depressive attack in spring. Her ANA decreased to 1/80.
Psychiatric syndromes may arise from different pathologies of the central nervous system. In patients with recurrent psychiatric syndromes or patients who are partially responsive to conventional treatment approaches further systemic evaluation of the patient is needed.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
BETWEEN 1894 AND 1896, THE Hamidian Massacres caused the deaths of thousands of Armenians throughout the Ottoman Empire. Partially elicited by the rise of Armenian nationalist movements in the preceding decades, the political dynamic between the Ottoman Sultanate and the indigenous Christian minority was of great importance to the British Empire. Britain hoped to prevent the fall of the Ottoman Empire because such a collapse would mean ceding control of its territories to Russia. For this reason, during the 1890s the Armenian Question and the Hamidian Massacres themselves featured heavily in the British press. One individual who had first-hand experience of these events was Lady Mary Montgomerie Currie, wife of the British ambassador to the Ottoman Empire between 1894 and 1898. Lady Currie was better known by her literary pseudonym, Violet Fane. Having published both poetry and prose throughout her earlier life in a range of periodical titles, Fane was a well-known, if not commercially successful, writer. Crucially, Fane also wrote several poems on the theme of civil unrest in the Ottoman sphere during her time in Constantinople. These pieces are remarkable examples of poetic reportage because they focus on a series of genocidal acts that Fane herself witnessed in situ. This essay explores how Fane used her poetry from this period to engage with the Armenian massacres within the British press during the 1890s. Her politically charged contributions to the Lady's Realm, ‘On the Marmora’ (1896) and
‘A Deserted Village’ (1897), did not attract political attention during the period in which the Armenian Question was the subject of heated national discussion. Using these poems as case studies, I argue that Fane used the Lady's Realm as an accessible platform for communicating her ideas about controversial political issues – ideas that would have created controversy if they had appeared in a different publishing venue such as the British Review, where her poetry also appeared during this time period. As a review magazine that was interested in the Eastern Question and devoted significant attention to the Armenian atrocities, the British Review would at first seem to be a more appropriate place for poems such as ‘On the Marmora’ or ‘A Deserted Village.’ She clearly preferred publishing her more controversial work in a woman's magazine, perhaps because they would be less likely to attract negative publicity in that context.
In this paper, we propose an approach for modeling claim dependence, with the assumption that the claim numbers and the aggregate claim amounts are mutually and serially dependent through an underlying hidden state and can be characterized by a hidden finite state Markov chain using bivariate Hidden Markov Model (BHMM). We construct three different BHMMs, namely Poisson–Normal HMM, Poisson–Gamma HMM, and Negative Binomial–Gamma HMM, stemming from the most commonly used distributions in insurance studies. Expectation Maximization algorithm is implemented and for the maximization of the state-dependent part of log-likelihood of BHMMs, the estimates are derived analytically. To illustrate the proposed model, motor third-party liability claims in Istanbul, Turkey, are employed in the frame of Poisson–Normal HMM under a different number of states. In addition, we derive the forecast distribution, calculate state predictions, and determine the most likely sequence of states. The results indicate that the dependence under indirect factors can be captured in terms of different states, namely low, medium, and high states.
Several lines of evidence suggest that bipolar disorder (BD) is associated with white matter (WM) pathology. Investigation of unaffected first-degree relatives of BD patients may help to distinguish structural biomarkers of genetic risk without the confounding effects of burden of illness, medication or clinical state. In the present study, we applied tract-based spatial statistics to study WM changes in patients with BD, unaffected siblings and controls.
A total of 27 euthymic patients with BD type I, 20 unaffected siblings of bipolar patients and 29 healthy controls who did not have any current or past diagnosis of Axis I psychiatric disorders were enrolled in the study.
Fractional anisotropy (FA) was significantly lower in BD patients than in the control group in the corpus callosum, fornix, bilateral superior longitudinal fasciculus, inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, anterior thalamic radiation, posterior thalamic radiation, cingulum, uncinate fasciculus, superior corona radiata, anterior corona radiata and left external capsule. In region-of-interest (ROI) analyses, we found that both unaffected siblings and bipolar patients had significantly reduced FA in the left posterior thalamic radiation, the left sagittal stratum, and the fornix compared with healthy controls. Average FA for unaffected siblings was intermediate between the healthy controls and bipolar patients within these ROIs.
Decreased FA in the fornix, left posterior thalamic radiation and left sagittal stratum in both bipolar patients and unaffected siblings may represent a potential structural endophenotype or a trait-based marker for BD.
Despite extensive soft tissue reduction, the most common complications associated with bone-anchored hearing aid systems, also known as bone-anchored hearing implants, are related to adverse skin reactions around the abutment. The necessary soft tissue reduction also adds complexity to the surgical procedure. This study aimed to evaluate the surgical and audiological outcomes of a new connective interface of the Cochlear™ Baha® BA400 device implanted using the one-stage surgical technique.
A multicentre, retrospective case series is presented, including data collected from three tertiary care institutions.
In total, 16 patients who had undergone bone-anchored hearing aid surgery over a 10- to 12-month period were assessed for hearing performance, implant stability and surgical complications.
This case series indicates that new abutments with a hydroxyapatite coating can be implanted percutaneously without soft tissue reduction. Furthermore, device implantation using this surgical technique may have some advantages compared with a conventional device and procedure combination over 12- to 16-months of follow up.