Radiographic Evaluation of the Gap between Cemented Post and Remaining Gutta-Percha in Endodontically Treated Teeth Performed by Undergraduate Students: A Retrospective Cross-Sectional Study.

The coronal seal in root canal-treated teeth may be compromised depending on the accuracy of post space preparation and post cementation along with remaining gutta-percha. Root canal treatment can be compromised by endotoxins released by the coronal bacteria as a result of microleakage. The study was conducted by undergraduate students to measure the gap between the cemented post and residual gutta-percha. In total, 217 endodontically treated teeth were evaluated with intraoral peri-apical radiographs. Based on the intraoral periapical radiographic examination in the CS-R4 program, Group I had no gap, Group II had a gap of >0 to 2 mm, and Group III had a gap of more than 2 mm between the end of the cemented post and the remaining gutta-percha. In total, 40% (n = 87) of the teeth had no gap, 59% (127) had a gap of >0 to 2 mm, and 1% (n = 3) had a gap of more than 2 mm between the cemented post end and remaining gutta. Chi square test revealed a significant difference in the gap between the post and remaining gutta-percha between males and females students (p < 0.001). In terms of the gap between the cemented post end and the residual gutta-percha, the root canal treated teeth with post and core by undergraduates were clinically acceptable.

Multicomponent Pseudomonas aeruginosa Vaccines Eliciting Th17 Cells and Functional Antibody Responses Confer Enhanced Protection against Experimental Acute Pneumonia in Mice.

The Gram-negative pathogen Pseudomonas aeruginosa is a common cause of pneumonia in hospitalized patients. Its increasing antibiotic resistance and widespread occurrence present a pressing need for vaccines. We previously showed that a P. aeruginosa type III secretion system protein, PopB, elicits a strong Th17 response in mice after intranasal (IN) immunization and confers antibody-independent protection against pneumonia in mice. In the current study, we evaluated the immunogenicity and protective efficacy in mice of the combination of PopB (purified with its chaperone protein PcrH) and OprF/I, an outer membrane hybrid fusion protein, compared with immunization with the proteins individually either by the intranasal (IN) or subcutaneous (SC) routes. Our results show that after vaccination, a Th17 recall response from splenocytes was detected only in mice vaccinated with PopB/PcrH, either alone or in combination with OprF/I. Mice immunized with the combination of PopB/PcrH and OprF/I had enhanced protection in an acute lethal P. aeruginosa pneumonia model, regardless of vaccine route, compared with mice vaccinated with either alone or adjuvant control. Immunization generated IgG titers against the vaccine proteins and whole P. aeruginosa cells. Interestingly, none of these antisera had opsonophagocytic killing activity, but antisera from mice immunized with vaccines containing OprF/I, had the ability to block IFN-γ binding to OprF/I, a known virulence mechanism. Hence, vaccines combining PopB/PcrH with OprF/I that elicit functional antibodies lead to a broadly and potently protective vaccine against P. aeruginosa pulmonary infections.

Disruption of the biological activity of protease-activated receptors2/4 in adults rather than children in SARS CoV-2 virus-mediated mortality in COVID-19 infection.

One of the most remarkable results in 2019 is the reduced prevalence and death of children from coronavirus infection (COVID-19). In 2019, a worldwide pandemic impacted around 0.1 billion individuals, with over 3.5 million mortality reported in the literature. There is minimal knowledge on SARS-CoV-2 infection immunological responses in kids. Studies have been focused mostly on adults and children since the course of pediatric sickness is often short. In adults, severe COVID-19 is related to an excessive inflammatory reaction. Macrophages and monocytes are well known to contribute to this systemic response, although numerous lines are indicative of the importance of neutrophils. An increased number of neutrophils and neutrophil to lymphocyte ratios are early signs of SARS-CoV-2 and a worse prognosis. In this study that it is crucial to monitor PAR2 and PAR4 expression and function (since nursing children have elevated levels) and the inhibiting the normal physiology through the use of anticoagulants may exacerbate the problem in adults. Thus, in COVID-19 infection, we propose the use of antiplatelet (thromboxane A2 inhibitors), if required rather than anticoagulants (FXa and thrombin Inhibitors).

Role of Various Gene Expressions in Etiopathogenesis of Type 2 Diabetes Mellitus.

CONTEXT: Diabetes is a metabolic disease, with high mortality, and is characterized by increased glucose levels in the blood occurring due to poor pancreatic insulin secretion or development of insulin resistance in the body. Type 2 DM (T2DM) represents 90% of diabetic cases, and its pathogenesis involves a genetic correlation with insulin resistance, ß-cell dysfunction, lifestyle, and environmental factors. OBJECTIVE: The current study intended to examine the pathophysiology of T2DM, including factors influencing insulin resistance and beta (ß)-cell dysfunction as well as the genetic factors that indicate susceptibility to T2DM. DESIGN: The research team performed a narrative review by searching the Mendeley, Science Direct, Medline, PubMed, Google Scholar, and Springer databases. The search used the keywords Diabetes, insulin secretion and environmental factor. SETTING: This study was take place in School of Pharmacy, Suresh Gyan Vihar University, Jaipur, India. RESULTS: The paraoxonase-1 gene Q192R and the L55M, INS-VNTR, and IL-38 gene alterations can result in insulin resistance while PAM variants and miR-132 and miR-18 expression can lead to ß-cell dysfunction. Palmitate-like FFA expression of mRNA MafA, and IRS-2 can lead to impairment of insulin secretion. CONCLUSIONS: T2DM is the most common metabolic disorder of the twenty-first century, and its incidence, complications, and morbidity increase every day. The examination of T2DM's pathophysiology and the literature review have revealed that it has a strong correlation with genetic defects.

Compliance of hand written transfusion requisition form and improvement after online request - a clinical audit.

OBJECTIVE: To assess the compliance of healthcare personnel with regard to sending completely filled transfusion requisition forms. METHODS: The audit was conducted at Aga Khan University Hospital, Karachi, and comprised requisition slips received at the hospital blood bank from September 2014 to February 2015. The British Committee for Standards in Haematology guidelines was used as the standard. Percentage of each variable on the proforma was analsyed. Rating <50% for each form was defined as "needs improvement", 51-99% as "good compliance" and 100% as "excellent compliance". After implementing strategies to increase awareness and the launching of an online transfusion requisition form, a re-audit of physician compliance was done from February to April 2016 and the results were compared with the initial audit.. Data was analysed using SPSS 21. RESULTS: The audit and the re-audit both comprised 1000 transfusion requisition forms each. In the audit, The sum of total scores of all the transfusion requisition forms was 4911, indicating a compliance rate of 46.9%, while the corresponding numbers in the re-audit were 10000 and 100%. CONCLUSIONS: The implementation of online blood transfusion requisition system had a positive impact on compliance rate.

Crescent durotomy for midline posterior fossa lesions.

OBJECTIVE: The conventional midline suboccipital craniectomy, the standard approach for posterior fossa lesions, involves ligation of the occipital sinus. Postoperative sequelae that could occur from ligation of the occipital sinus include hydrocephalus, cerebrospinal fluid (CSF) leak, and pseudomeningiocoele formation. The standard of practice of venous pathway preservation, as practiced elsewhere in the cranium, should also be attempted in the posterior fossa. In the current study, we compared postsurgical complications between conventional "Y" durotomy with the proposed crescent durotomy in patients with posterior fossa lesions who underwent midline suboccipital craniectomy. MATERIALS AND METHODS: The prospective data of 104 patients who underwent a midline suboccipital craniotomy for posterior fossa tumors between January 2011 and December 2015 was performed. Comparison of study variables was done between the durotomy techniques used. RESULTS: Of the 104 patients who formed the study population, 39 (37.5%) were women. While 75 patients underwent crescent durotomy, the remaining underwent the conventional "Y" durotomy. Among the postsurgical complications, there were no differences between groups in terms of their surgical site hematoma (2.7% vs 3.4%; P = 1.000) and edema (1.3% vs 0.0%; P = 1.000). The groups were also similar in terms of the incidence of postsurgical CSF leak (1.3% vs 6.9%; P = 0.187) and cranial nerve deficits (4.0% vs 6.9%; P = 0.617). However, more number of patients who underwent the "Y" durotomy had postoperative pseudomeningiocoele (2.7% vs 17.2%; P = 0.017). CONCLUSION: The "crescent" durotomy is a novel dural opening technique which attempts to preserve the normal venous flow physiology. The crescent durotomy reduces the need for a duroplasty, facilitates a comfortable primary closure, thus reducing the risk of developing a postoperative pseudomeningiocoele.

Patient-specific predictors of failure to rescue after pancreaticoduodenectomy.

BACKGROUND: Failure to rescue (FTR) is a recently described outcome metric for quality of care. However, predictors of FTR have not been adequately investigated, particularly after pancreaticoduodenectomy. We aim to identify predictors of FTR after pancreaticoduodenectomy. METHODS: We reviewed all patients who developed serious morbidity after pancreaticoduodenectomy from 2005 to 2012 in the ACS-NSQIP database. Logistic regression was used to identify preoperative and postoperative risks for 30-day mortality within a development cohort (randomly selected 80%). A score was created using weighted beta coefficients. Predictive accuracy was assessed on the validation cohort (remaining 20%) using a receiver operator characteristic curve and calculating the area under the curve (AUC). RESULTS: The FTR rate was 7.2% after pancreaticoduodenectomy (n = 5,027). We identified 5 independent risk factors: age ≥65 and albumin ≤3.5 g/dL, preoperatively; and development of shock, renal failure, and reintubation, postoperatively. The generated score had an AUC = 0.83 (95% CI, 0.77-0.89) in the validation cohort. Using the score: 1*Albumin ≤3.5 g/dL + 2*Age ≥ 65 + 2*Shock + 5*Renal failure + 5*Reintubation, FTR rates increased with increasing score (p < 0.001). CONCLUSION: FTR rates have previously been shown to be associated with hospital factors. We show that FTR is also associated with preoperative and postoperative patient-specific factors.

Multidisciplinary strategies in bloodless medicine and surgery for patients undergoing pancreatectomy.

BACKGROUND: Bloodless pancreatic surgery (BPS) is rarely performed and/or reported. We aim to characterize perioperative and anesthetic strategies in BPS. MATERIALS AND METHODS: A literature search was performed on MEDLINE looking for case reports/case series using search terms ("Jehovah's Witness" [All Fields]) AND ("Pancreatic Surgery" [All Fields] OR "Pancreaticoduodenectomy" [All Fields] OR "Distal Pancreatectomy" [All Fields]). Data regarding categorical variables are reported as proportions and quantitative continuous variables as medians with ranges or means with standard deviation. Forty-one patients requiring BPS are reported in the literature with three additional cases from our institution (n = 44). The data analyzed included clinicopathologic factors, BPS strategies, patient complications, and in-hospital mortality. RESULTS: The most common procedure and diagnosis were pancreaticoduodenectomy (n = 34, 77.3%) and pancreatic ductal adenocarcinoma (n = 12, 27.3%), respectively. Transfusion reduction strategies in BPS fell into three categories: preoperative, intraoperative, and postoperative. Preoperative strategies included iron supplementation (n = 24, 54.5%) and erythropoietin administration (n = 14, 41.2%). Intraoperative strategies included acute normovolemic hemodilution (n = 30, 68%) and cell saver (n = 4, 9.1%). Postoperative strategies included erythropoietin (n = 16, 48.5%) and iron supplementation (n = 16, 48.5%). Complications occurred in 21 (60%) patients. There was no in-hospital mortality among the 44 patients in this cohort. CONCLUSIONS: A broad spectrum of bloodless medicine and surgery practices were used based on patient selection, multidisciplinary practice, and preference. With careful perioperative and anesthetic management, BPS can be performed with good outcomes.

Reconstruction options following pancreaticoduodenectomy after Roux-en-Y gastric bypass: a systematic review.

BACKGROUND: Obesity is a risk factor for pancreatic cancer which may be treated with Roux-en-Y gastric bypass and represents an increasing morbidity. Post-RYGB anatomy poses considerable challenges for reconstruction after pancreaticoduodenectomy (PD), a growing problem encountered by surgeons. We characterize specific strategies used for post-PD reconstruction in the RYGB patient. METHODS: PubMed search was performed using MeSH terms "Gastric Bypass" and "Pancreaticoduodenectomy" between 2000 and 2018. Articles reporting cases of pancreaticoduodenectomy in post-RYGB patients were included and systematically reviewed for this study. RESULTS: Three case reports and five case series (25 patients) addressed PD after RYGB; we report one additional case. The typical post-gastric bypass PD patient is a woman in the sixth decade of life, presenting most commonly with pain (69.2%) and/or jaundice (53.8%), median 5 years after RYGB. Five post-PD reconstructive options are reported. Among these, the gastric remnant was resected in 18 cases (69.2%), with reconstruction of biliopancreatic drainage most commonly achieved using the distal jejunal segment of the pre-existing biliopancreatic limb (73.1%). Similarly, in the eight cases where the gastric remnant was spared (30.8%), drainage was most commonly performed using the distal jejunal segment of the biliopancreatic limb (50%). Among the 17 cases reporting follow-up data, median was 27 months. CONCLUSION: Reconstruction options after PD in the post-RYGB patient focus on resection or preservation gastric remnant, as well as creation of new biliopancreatic limb. Insufficient data exists to make recommendations regarding the optimal reconstruction option, yet surgeons must prepare for the possible clinical challenge. PD reconstruction post-RYGB requires evaluation through prospective studies.

Analysis of the American Society of Anesthesiologists Physical Status Classification System and Caprini Risk Assessment Model in Predicting Venous Thromboembolic Outcomes in Plastic Surgery Patients.

BACKGROUND: Venous thromboembolism (VTE) can be a fatal outcome of plastic surgery. Risk assessment models attempt to determine a patient's risk, yet few studies have compared different models in plastic surgery patients. OBJECTIVE: The authors investigated preoperative ASA physical status and 2005 Caprini scores to determine which model was more predictive of VTE. METHODS: A retrospective chart review examined 1801 patients undergoing contouring and reconstructive procedures from January 2008 to January 2012. Patients were grouped into risk tiers for ASA scores (1-2 = low, 3+ = high) with 2 cutoffs for Caprini scores (1-4 = low, 5+ high; 1-5 = low, 6+ = high), then re-stratified into 3 tiers using Caprini score cutoffs (1-4 = low, 5-8 = high, 9+ = highest; 1-5 = low, 6-8 = high, 9+ = highest). Median scores of VTE patients were compared to those without VTE. Odds ratio and chi-squared analyses were performed. RESULTS: Of the 1598 patients included in the study, 1.50% developed VTE. Median ASA scores differed significantly between comparison groups but Caprini scores did not vary regardless of cutoff. When examining the 2-tiered Caprini scores, using low risk = 1-5 showed a significant relationship between risk tier and DVT development (P = 0.0266). CONCLUSION: The ASA system yielded the highest odds ratio of VTE development between low and high-risk patients. The Caprini model captured more patients with VTE in its high-risk category. Combining the two models for a more heuristic approach to preoperative care may identify patients at higher risk. LEVEL OF EVIDENCE: 4 Risk.

Clinico-Pathological Profile And Outcomes Of Patients With Polycythaemia Vera, Essential Thrombocythaemia And Idiopathic Myelofibrosis: A Tertiary Care Center Experience From Southern Pakistan.

BACKGROUND: The "Philadelphia Negative Classic Myeloproliferative Neoplasms" include polycythaemia vera (PV), essential thrombocythaemia (ET) and idiopathic myelofibrosis (IMF). These three disorders share several clinical and laboratory features including JAK2 V617F mutation. Our objectives were to determine the clinico-pathological profile and outcomes of Pakistani patients with polycythaemia vera (PV), essential thrombocythaemia (ET) and idiopathic myelofibrosis (IMF) in order to have an insight regarding behaviour of these conditions. METHODS: A retrospective analysis of all the cases of PV, ET and IMF diagnosed at our institute from January 1995 to December 2013 was performed. Age, gender, clinical presentation, laboratory investigations, treatment provided and duration of follow-up were included for analysis. Appropriate statistics were utilized for calculation of data. RESULTS: A total of 58 patients were diagnosed as PV, ET or IMF during the study period. Male to female ratio was 1.1:1. Forty five percent (n=27) patients came to medical attention due to abnormal laboratory results, 3 had cerebrovascular events, 3 had pruritus, and 1 patient each with gangrene and Budd-Chiari syndrome. Haemorrhage was not seen in any patient. Sixty percent (n=35) patients were treated with phlebotomy, hydroxyurea and aspirin alone or in combination. None of the patients transformed to myelofibrosis (MF) or myelodysplasia (MDS) during the mean (±SD) follow-up period of 57.2±50 months. One patient with ET transformed to acute myeloid leukaemia 9 years after the diagnosis. CONCLUSIONS: This study demonstrated a relatively more benign form of PV, ET and IMF with lesser frequency of symptoms, good response to treatment and less likelihood of transformation to MF, MDS or AML.

Pancreatic mucinous cystic neoplasm in a transgender patient.

BACKGROUND: Cystic pancreatic lesions are increasingly more frequent detected clinical entities. Mucinous cystic neoplasm (MCN) is a hormone-related pancreatic tumor (HRTP) with a strong predominance in young and middle-aged females. CASE PRESENTATION: Here, we present the case of a 31-year-old surgically transgendered female-to-male patient with a history of alcoholic pancreatitis, on chronic testosterone therapy. He was found to have a pancreatic MCN and underwent distal pancreatectomy and splenectomy. CONCLUSION: To our knowledge, this is the first reported case of a transgender patient with a history of hormone replacement therapy (HRT) and pancreatic MCN. We consider possible mechanisms for the pathogenesis to explain this patient's neoplasm.

Retroperitoneal Castleman's disease: advocating a multidisciplinary approach for a rare clinical entity.

BACKGROUND: Castleman's disease is a rare and poorly understood disease entity that may resemble more common conditions and represents a clinical challenge to the treating surgeon. CASE PRESENTATION: In this report, we describe a case of a 61-year-old Caucasian woman with a symptomatic retroperitoneal mass. The specimen obtained from her resection contained a protuberant encapsulated mass, exhibiting microscopic features consistent with localized, unicentric Castleman's disease. These characteristics included architectural features and immunohistochemical findings consistent with the hyaline vascular variant of Castleman's disease. CONCLUSION: We report a very rare case of a retroperitoneal hyaline vascular type of Castleman's disease. We discuss the diagnostic dilemma Castleman's disease may present to the surgeon, with an emphasis on multidisciplinary management of these patients. We also review current data on pathogenesis, treatment and outcomes.

Reducing the carbon footprint of cataract surgery: co-creating solutions with a departmental Delphi process.

BACKGROUND: Climate change is arguably the greatest threat to global health of the 21st century. Although cataract surgery is a major contributor to global greenhouse gas emissions, recent literature review identified a paucity of evidence-based strategies for improving the environmental impact of cataract services. Our study aimed to assess the effectiveness of a departmental Delphi process for improving cataract services' environmental sustainability. METHODS: All members of ophthalmology theatre teams in a UK teaching hospital were invited to participate in a three-stage Delphi process. Team members were surveyed for suggestions for reducing the department's environmental impact. Suggested interventions were refined during a plenary face-to-face discussion and ranked. The highest ranked interventions were combined into a mutually agreed action plan. Data on the economic and environmental cost of cataract services was collected prior to and six months after the Delphi process using the Eyefficiency mobile application. RESULTS: Twenty-three interventions were suggested by a range of staff cadres. Interventions were ranked by 24 team members. The 2nd, 4th, 5th, 8th and 11th ranked interventions were combined into an "Eco-packs" project in collaboration with suppliers (Bausch + Lomb), saving 675 kg of waste and 350 kg of CO2 equivalent annually. CONCLUSIONS: The Delphi process is an effective method for provoking departmental engagement with the sustainability agenda that we would encourage all ophthalmology departments to consider utilising. The baseline per case CO2 equivalent measured in our department was reproducible and could serve as a maximum benchmark to be improved upon.

Using Coronary Guide Catheters with the Sheath-in-sheath Technique to Retrieve a Micra™ Leadless Pacemaker.

As the prevalence of leadless pacemaker systems increases, identifying various methodologies for retrieval of these devices in certain instances becomes even more paramount. We describe a case demonstrating the utility of a coronary guide catheter as part of an improvised sheath-in-sheath technique for the challenging retrieval of a Micra™ leadless pacing system (Medtronic, Minneapolis, MN, USA).

Anti-Infective Activity of Momordica charantia Extract with Molecular Docking of Its Triterpenoid Glycosides.

Momordica charantia, commonly known as bitter melon, is a fruiting plant that has been used for several diseases including infectious diseases. In this study, we report the antibacterial, antifungal, and antiviral activity of different bitter melon fruit parts originating from India and Saudi Arabia. The in vitro experiments are supported by the molecular docking of karavilosides to verify their role in the bioactivity. The antimicrobial assays revealed activity against Candida albicans, Escherichia coli, and Staphylococcus aureus. The extracts exhibited the potent inhibition of HIV-I reverse transcriptase, with an IC50 of 0.125 mg/mL observed for the pith extract originating from Saudi Arabia and the standard drug doxorubicin. The molecular docking of karavilosides exhibited a significant affinity to reverse transcriptase comparable to Rilpivirine and higher than that of doxorubicin. These outcomes encourage the precious bioactive components of the seed and pith of the Saudi bitter melon fruits to be further studied for isolation and structure elucidation.

Severe Acute Cor Pulmonale With Impending Shock: An Insidious Incidental.

The S1Q3T3 sign associated with cor pulmonale was first described by Sylvester McGinn and Paul White in 1935. It has since become an overlooked and relatively nonspecific finding associated with pulmonary embolism. We present this case to elucidate the importance for clinicians to promptly identify this electrocardiographic triad.

Effect of Dexmedetomidine Addition in Erector Spinae Plane Block on Opioid Consumption after Lumbar Spine Surgery.

OBJECTIVE: To investigate the efficacy of adding 0.5 micrograms/kg of dexmedetomidine to 0.2% ropivacaine in erector spinae plane block in terms of 24-hour opioid consumption after lumbar spine surgeries. STUDY DESIGN: A randomised controlled trial. Place and Duration of the Study: The Security Forces Hospital, Riyadh, Saudi Arabia, from 30th November 2022 to 30th March 2023. METHODOLOGY: Patients aged between 18-70 years, ASA 1-3 who were booked to undergo lumbar spine surgeries under general anaesthesia were inducted. Patients in the intervention group received erector spinae plane block (ESPB). Exclusion criteria were patient refusal, inability to give consent, patients with contraindications to regional anaesthesia, known allergy to study medications, inability to use patient-controlled analgesia (PCA), psychiatric disorders or patients using any psychiatric medications. The primary outcome measure of the study was 24-hour opioid consumption. RESULTS: The numeric rating scale (NRS) pain scores were significantly decreased in the ESPB-D group at 30 minutes (p = 0.042), at 1 hour (p = 0.018), at 2 hours (p = 0.044), at 12 hours (p = 0.039), at 18 hours (p = 0.011), and at 24 hours (p = 0.020). Intraoperative use of remifentanil was also significantly lower in the ESPB-D group (p <0.01). ESPB using dexmedetomidine also reduced opioid consumption over a period of 24 hours (p <0.01). Median patient satisfaction score and median ease of mobility were also significantly better in the ESPB-D group. CONCLUSION: Addition of dexmedetomidine in erector spinae plane block reduced pain scores and intraoperative and postoperative opioid consumption after lumbar spine surgery. KEY WORDS: Dexmedetomidine, Erector spinae plane block, Lumbar spine surgery, Opioid consumption, Pain control.

Exploring novel insights into the molecular mechanisms underlying Bisphenol A-induced toxicity: A persistent threat to human health.

Bisphenol A (BPA) is a ubiquitous industrial chemical used in the production of polycarbonate plastics and epoxy resins, found in numerous consumer products. Despite its widespread use, its potential adverse health effects have raised significant concerns. This review explores the molecular mechanisms and evidence-based literature underlying BPA-induced toxicities and its implications for human health. BPA is an endocrine-disrupting chemical (EDC) which exhibits carcinogenic properties by influencing various receptors, such as ER, AhR, PPARs, LXRs, and RARs. It induces oxidative stress and contributes to cellular dysfunction, inflammation, and DNA damage, ultimately leading to various toxicities including but not limited to reproductive, cardiotoxicity, neurotoxicity, and endocrine toxicity. Moreover, BPA can modify DNA methylation patterns, histone modifications, and non-coding RNA expression, leading to epigenetic changes and contribute to carcinogenesis. Overall, understanding molecular mechanisms of BPA-induced toxicity is crucial for developing effective strategies and policies to mitigate its adverse effects on human health.