Appendiceal diverticulitis presenting as acute appendicitis diagnosed postoperatively.

Appendiceal diverticular disease is a rare entity. We report a case of appendiceal diverticulitis mimicking acute appendicitis and diagnosed postoperatively on histopathology. A 28-year-old female presented with a 2-day history of shifting periumbilical pain associated with nausea and anorexia. A computed tomography scan of the abdomen demonstrated acute appendicitis. She was taken to laparoscopic appendectomy. Histopathology showed appendiceal diverticulitis, and perforation of an inflamed diverticulum with periappendicitis. Diverticulosis of the appendix is classified as congenital and acquired. Diagnosis can be made preoperatively by imaging. In this case, diverticulosis was not radiologically evident, and was interpreted as acute appendicitis. Gross appearance of the resected appendix was not suggestive of diverticulitis. Other cases reported that the gross specimen had evidence of diverticular disease. Surgeons should be aware that inflamed appendixes may harbor different pathologies warranting further management.

Role of Apoptosis in the Pathogenesis of Common Variable Immunodeficiency (CVID).

BACKGROUND: Common variable immunodeficiency (CVID) is a heterogeneous immune deficiency characterized by hypogammaglobulinemia. Since B cell maturation and differentiation is defective in this disorder, we evaluated apoptosis in B cells of patients with CVID compared with healthy donors (HD). METHODS: Determination of peripheral blood B-cell subsets in CVID and HDs, was performed using flow cytometry. We compared total apoptosis, early apoptosis and late apoptosis/necrosis in unstimulated and stimulated B-cells of patients with CVID and HDs. We also assessed the expression of the anti-apoptotic molecule BCL2 mRNA levels in B-cells by real-time PCR in CVID patients compared with HDs. RESULTS: Total B-cell apoptosis was increased in both unstimulated and stimulated B-cells from CVID patients compared with HDs (p=0.02 and p=0.004). Early apoptosis in stimulated B-cells (p=0.04) and late apoptosis/necrosis of B-cells in both unstimulated and stimulated B-cells (p=0.04 and p=0.03, respectively) were significantly higher in CVID patients compared with HDs. There was a significant inverse correlation between the percentages of post germinal center B-cells in the peripheral blood of CVID patients compared with percentage of apoptotic B-cells. However, anti-apoptotic BCL2 expression was not significantly reduced in B-cells from CVID patients compared with HDs (p=0.16). CONCLUSION: Increased apoptosis of B-cells may be a factor in abnormality of differentiated B-cell subsets and the impaired endogenous immunoglobulin production in CVID patients. Further studies of the expression of pro/anti-apoptotic mediators in B-cells of CVID patients may shed light on the mechanism behind this increased B-cell apoptosis, and present potential therapeutic interventions in the future.

Percutaneous Closure of the Aorto-Ostial Origin of a Coronary Artery Saphenous Bypass Graft with a Large Pseudoaneurysm Using the AMPLATZER Muscular Ventricular Septal Defect Occluder.

We report the case of a 76-year-old male patient with a history of coronary artery bypass graft surgery presented with a large pseudoaneurysm emerging from a previously occluded saphenous bypass graft (SVG). A largely contained hematoma is seen in the mediastinum on computed tomography angiography (CTA) of the chest. Flow was seen from the ascending aorta into the pseudoaneurysm through the aorto-ostial opening of the bypass graft. Closure of the aorto-ostial origin of the graft was performed using the AMPLATZER muscular ventricular septal defect (VSD) occluder (St Jude's Medical, St. Paul, MN) with immediate interruption of flow into the graft and the pseudoaneurysm. A repeat CTA of the ascending aorta at 6 months postprocedure continued to confirm an optimal positioning of the occluder with no flow into the pseudoaneurysm. This case offers an endovascular alternative to close the aorto-ostial opening of a saphenous bypass graft in the setting of a rare but potentially life-threatening SVG pseudoaneurysm.

Predictors of common femoral artery access site complications in patients on oral anticoagulants and undergoing a coronary procedure.

BACKGROUND: It is unclear whether patients on oral anticoagulants (OAC) undergoing a procedure using common femoral artery access have higher adverse events when compared to patients who are not anticoagulated at the time of the procedure. METHODS: We retrospectively reviewed data from consecutive patients who underwent a cardiac procedure at a tertiary medical center. Patients were considered (group A) fully or partially anticoagulated if they had an international normalized ratio (INR) ≥1.6 on the day of the procedure or were on warfarin or new OAC within 48 h and 24 h of the procedure, respectively. The nonanticoagulated group (group B) had an INR <1.6 or had stopped their warfarin and new OAC >48 h and >24 h preprocedure, respectively. The index primary end point of the study was defined as the composite end point of major bleeding, vascular complications, or cardiovascular-related death during index hospitalization. The 30-day primary end point was defined as the occurrence of the index primary end point and up to 30 days postprocedure. RESULTS: A total of 779 patients were included in this study. Of these patients, 27 (3.5%) patients were in group A. The index primary end point was met in 11/779 (1.4%) patients. The 30-day primary composite end point was met in 18/779 (2.3%) patients. There was no difference in the primary end point at index between group A (1/27 [3.7%]) and group B (10/752 [1.3%]; P=0.3155) and no difference in the 30-day primary composite end point between group A (2/27 [7.4%]) and group B (16/752 [2.1%]; P=0.1313). Multivariable analysis showed that a low creatinine clearance (odds ratio [OR] =0.56; P=0.0200) and underweight patients (<60 kg; OR =3.94; P=0.0300) were independent predictors of the 30-day primary composite end point but not oral anticoagulation (P=0.1500). CONCLUSION: Patients on OAC did not have higher 30-day major adverse events than those who were not anticoagulated at index procedure.

Spontaneous Renal Artery Dissection in a Patient with Neurofibromatosis Type I.

We present a case of spontaneous renal artery dissection (SRAD) in a 28-year-old female with history of neurofibromatosis type I (NF-1) treated successfully with endovascular stenting. The clinical presentation, diagnostic testing, and treatment options are discussed. An endovascular approach with stenting was successfully performed after failure of medical treatment with subcutaneous low molecular weight heparin. Patient's blood pressure and symptoms improved significantly. This may be the first reported case of SRAD in a patient with NF-1 successfully treated with endovascular stenting.

Study of a quadrupole ion trap with damping force by the two-point one block method.

RATIONALE: The capabilities and performances of a quadrupole ion trap under damping force based on collisional cooling is of particular importance in high-resolution mass spectrometry and should be analyzed by Mathieu's differential solutions. These solutions describe the stability and instability of the ion's trajectories confined in quadrupole devices. One of the methods for solving Mathieu's differential equation is a two-point one block method. In this case, Mathieu's stability diagram, trapping parameters a(z) and q(z) and the secular frequency of the ion motion w(z), can be derived in a precise manner. The two-point one block method (TPOBM) of Adams Moulton type is presented to study these parameters with and without the effect of damping force and compared to the 5th-order Runge-Kutta method (RKM5). The simulated results show that the TPOBM is more accurate and 10 times faster than the RKM5. The physical properties of the confined ions in the r and z axes are illustrated and the fractional mass resolutions m/Δm of the confined ions in the first stability region were analyzed by the RKM5 and the TPOBM. METHODS: The Lagrange interpolation polynomial was applied in the derivation of the proposed method. The proposed method will be utilized to obtain a series solution directly without reducing it to first order equations. RESULTS: The problem was tested with the ion trajectories in real time with and without the effect of damping force using constant step size. Numerical results from the two-point one block method have been compared with the fifth order Runge-Kutta method. CONCLUSIONS: The proposed two-point one block method has a potential application to solve complicated linear and nonlinear equations of the charged particle confinement in a quadrupole field especially in fine tuning accelerators, and, generally speaking, in physics of high energy.

Tryptophan metabolism in breast cancers: molecular imaging and immunohistochemistry studies.

INTRODUCTION: Tryptophan oxidation via the kynurenine pathway is an important mechanism of tumoral immunoresistance. Increased tryptophan metabolism via the serotonin pathway has been linked to malignant progression in breast cancer. In this study, we combined quantitative positron emission tomography (PET) with tumor immunohistochemistry to analyze tryptophan transport and metabolism in breast cancer. METHODS: Dynamic α-[(11)C]methyl-l-tryptophan (AMT) PET was performed in nine women with stage II-IV breast cancer. PET tracer kinetic modeling was performed in all tumors. Expression of L-type amino acid transporter 1 (LAT1), indoleamine 2,3-dioxygenase (IDO; the initial and rate-limiting enzyme of the kynurenine pathway) and tryptophan hydroxylase 1 (TPH1; the initial enzyme of the serotonin pathway) was assessed by immunostaining of resected tumor specimens. RESULTS: Tumor AMT uptake peaked at 5-20 min postinjection in seven tumors; the other two cases showed protracted tracer accumulation. Tumor standardized uptake values (SUVs) varied widely (2.6-9.8) and showed a strong positive correlation with volume of distribution values derived from kinetic analysis (P<.01). Invasive ductal carcinomas (n=6) showed particularly high AMT SUVs (range, 4.7-9.8). Moderate to strong immunostaining for LAT1, IDO and TPH1 was detected in most tumor cells. CONCLUSIONS: Breast cancers show differential tryptophan kinetics on dynamic PET. SUVs measured 5-20 min postinjection reflect reasonably the tracer's volume of distribution. Further studies are warranted to determine if in vivo AMT accumulation in these tumors is related to tryptophan metabolism via the kynurenine and serotonin pathways.

Optimizing the coagulation process in a drinking water treatment plant -- comparison between traditional and statistical experimental design jar tests.

In this study of coagulation operation, a comparison was made between the optimum jar test values for pH, coagulant and coagulant aid obtained from traditional methods (an adjusted one-factor-at-a-time (OFAT) method) and with central composite design (the standard design of response surface methodology (RSM)). Alum (coagulant) and polymer (coagulant aid) were used to treat a water source with very low pH and high aluminium concentration at Sri-Gading water treatment plant (WTP) Malaysia. The optimum conditions for these factors were chosen when the final turbidity, pH after coagulation and residual aluminium were within 0-5 NTU, 6.5-7.5 and 0-0.20 mg/l respectively. Traditional and RSM jar tests were conducted to find their respective optimum coagulation conditions. It was observed that the optimum dose for alum obtained through the traditional method was 12 mg/l, while the value for polymer was set constant at 0.020 mg/l. Through RSM optimization, the optimum dose for alum was 7 mg/l and for polymer was 0.004 mg/l. Optimum pH for the coagulation operation obtained through traditional methods and RSM was 7.6. The final turbidity, pH after coagulation and residual aluminium recorded were all within acceptable limits. The RSM method was demonstrated to be an appropriate approach for the optimization and was validated by a further test.

Dental amalgam: effects of alloy/mercury mixing ratio, uses and waste management.

BACKGROUND: Silver dental amalgam is one of the oldest filling materials used in dentistry. The American Dental Association (ADA) has estimated that billions of amalgam restorations have been placed in patients in the last 150 years. Due to the presence of mercury and mishandling during the filling make it more controversial. The objective of this study was to conduct a survey of the use of different brands and to assess any deviations in practice from the hand mixing manual method of elemental mercury and alloy in a pestle/mortar and encapsulated form. METHODS: A questionnaire was sent to 250 of randomly selected dental practitioner in various localities of Karachi. Data was analysed to record the specified brands used along with their powder/liquid (P/L) ratio and the different methods for disposing off mercury in this study. RESULTS: The most commonly used form of dispensing method was hand mixing (57%) and only 30% of the dentists followed the manufacturer instruction for hand mixing ratio.Eighty-seven percent of dental amalgam restoration was performed and 13% removed by the dentist per month and the method of disposing the amalgam wastage that 55%, 25%, and 20% dentists were used the sink, bin and other methods respectively in their dental clinics. CONCLUSION: Amalgam restoration is still popular filling material in the posterior region of the mouth but we need to create awareness among the dentists who do not follow the ADA specifications.

A national epidemiological survey of oral mucosal lesions in Malaysia.

The prevalence of oral mucosal lesions in Malaysia was determined by examining a representative sample of 11,707 subjects aged 25 years and above throughout the 14 states over a period of 5 months during 1993/1994. A two-stage stratified random sampling was undertaken. A predetermined number of enumeration blocks, the smallest population unit in the census publication, was selected from each state. With the selected enumeration block, a systematic sample of living quarters was chosen with a random start. The survey instrument included a questionnaire on sociodemographic characteristics and a clinical examination. The clinical examination was carried out by 16 specially trained dental public health officers and the diagnosis calibrated with a final concordance rate of 92%. The age in the sample ranged from 25 to 115 years with a mean of 44.5+/-14.0. The sample comprised 40.2% males and 59.8% females; 55.8% were Malays, 29.4% Chinese, 10.0% Indians and 1.2% other ethnic groups. Oral mucosal lesions were detected in 1131 (9.7%) subjects, 5 (0.04%) had oral cancer, 165 (1.4%) had lesions or conditions that may be precancerous (leukoplakia, erythroplakia, submucous fibrosis and lichen planus) and 187 (1.6%) had betel chewer's mucosa. The prevalence of oral precancer was highest amongst Indians (4.0%) and other Bumiputras (the indigenous people of Sabah and Sarawak) (2.5%) while the lowest prevalence was amongst the Chinese (0.5%).

Dental anomalies in the primary dentition: distribution and correlation with the permanent dentition.

The study consisted of analysis of all cases of anomalies in the primary dentition that were seen or treated by the authors in the Department of Children's Dentistry and Orthodontics. A total of 79 occurrences of anomalies was seen in 65 children. The anomalies detected were double teeth, hypodontia and supernumerary teeth. Radiographic examinations of the affected children showed that over 60% of the cases with anomalies in the primary dentition are associated with anomalies of the succadeneous permanent dentition. All subjects with hypodontia of the primary dentition presented with hypodontia of the permanent dentition. However, anomalies of the permanent dentition were seen in 59% of subjects with primary double tooth and 50% of subjects with primary supernumerary tooth.

The prevalence of caries and enamel defects in 229 Malaysian children 16 years after water fluoridation (a pilot study).

Two hundred and twenty-nine children aged 12-15 years who were continuous residents of Penang island, in the north of Peninsular Malaysia were examined for caries and enamel defects. Caries prevalence was 82.2% with a DMFT score of 3.4 and DMFS score of 4.9; there were very few missing teeth and very little untreated caries in the population examined. Majority of DF (decayed/filled) lesions were pits and fissures with approximal and smooth surfaces relatively caries free. The prevalence of enamel defects was 76.4% with 19.1% of all teeth examined being affected. More posterior than anterior teeth were affected by enamel defects just as there were more maxillary than mandibular teeth affected by enamel defects. Diffuse patchy opacities were the most common defect diagnosed and this was found in 60.2% of the population examined. A bilateral distribution of diffuse patchy opacities was seen in 41.5% of the population examined. Tooth surfaces with enamel defects were no more susceptible to caries than defect-free surfaces.

Erupted compound odontoma.

A case is described in which a compound odontoma erupted into the oral cavity in an 8 1/2-year-old girl. The odontoma was initially discovered as a chance radiographic finding 2 years 8 months previously.

Crouzon syndrome. A review of literature and case report.

A sporadic case of Crouzon Syndrome without mental retardation is described. The patient, an 11 year old boy with grossly carious teeth and in severe pain was referred for dental treatment. A review of literature on Crouzon Syndrome is presented.

The cracked tooth syndrome--crown root vertical fracture.

A case of an incomplete tooth fracture followed by a complete fracture was presented. The difficulty of diagnosing this condition was discussed as well as the possible histological explanation of the symptoms experienced by the patient. It once again points out to practising dentists, that whilst deep pockets can give rise to severe periodontal pain, intense and excruciating pain should be investigated with the cracked tooth in mind.

The dental health of factory workers in Pasir Gudang, Johor (Malaysia).

A study on the oral health status of 198 factory workers (in Antara Steel, Pasir Gudang, Johor) was carried out in November 1986. The subjects were predominantly male (94%) and Malay (91%) with an average age of 27.4 years. The prevalence of caries was 87.4% with a mean DMFT of 7.1 + 5.4. There were 3 subjects with full upper, lower dentures and 16 subjects with partial dentures. Two subjects examined needed dentures but were not wearing them. Thirty five (17.7%) of those examined needed urgent extractions, and 8 needed emergency treatment for fillings. Enamel opacities were found in 141 subjects (75.6%) but only 9 were aware of these defects. Dental health was very poor with 72% examined needing scaling. Seventeen (9%) had gross supra and subgingival calculus. There was a total of 107 (54%) smokers and heavy nicotine stains were found in 41 (20.7%), of the population examined. Examination of soft tissues showed 111 (56%) subjects with recurrent aphthous ulcers whilst 15 (7.6%) suffered from herpes labialis. Five subjects (2.5%) suffered from denture stomatitis whilst the prevalence of other soft tissue lesions was very low.