Delayed ulnar artery pseudoaneurysm presentation after percutaneous cardiac intervention: A case report and review of the literature.

PURPOSE: Here we present a case of a 62-year-old female with a delayed ulnar artery pseudoaneurysm presentation after cardiac catheterization. CASE REPORT: A 62-year-old woman with multiple medical comorbidities including end-stage renal disease (ESRD) on hemodialysis (HD) and atrial fibrillation on tablet apixaban who presented 8 weeks after cardiac catheterization through right ulnar artery access with a pulsatile mass, pain, and tingling of her right-hand fingers. Ultrasound exam confirmed presence of ulnar artery pseudoaneurysm with >2 cm active chamber. This pseudoaneurysm was repaired via forearm exploration, evacuation of hematoma, and primary repair with non-absorbable sutures. CONCLUSION: We report a case of delayed ulnar artery pseudoaneurysm presentation following cardiac catheterization through the right ulnar artery. Open surgical repair offers a definitive addressal of ulnar artery pseudoaneurysm and removes ulnar nerve compressive neuropathy with less risk of distal embolization in patients with delayed pseudoaneurysm presentation whenever ultrasound-guided thrombin injection (UGTI) is contraindicated.

Role of intravascular ultrasound in endovascular management of nutcracker syndrome: A case report.

PURPOSE: Here, we describe nutcracker syndrome management using intravascular ultrasound (IVUS) during endovascular stent placement of the renal vein. CASE REPORT: A 60-year-old woman with a known Factor V Leiden mutation, long-standing smoking history, and family history of pancreatic cancer presented with 2 years of intermittent left upper quadrant pain (LUQ) and a 15 lb unintentional weight loss. Work-up included abdominal ultrasound (US) and abdominal computerized tomography (CT) scan. Abdominal US and Chest CT scan were negative while the abdominal CT scan revealed severe compression of the left renal vein by the superior mesenteric artery, consistent with nutcracker syndrome. Renal venogram and endovascular stent placement performed under IVUS guidance. IVUS was used to determine stent size and measure flow and assess patency after stent placement. CONCLUSIONS: Post-renal vein stent placement, the patient had resolution of her symptoms with follow-up duplex renal ultrasound exam demonstrating restored blood flow in the left renal vein with improved patency.

Development of hypoimmunogenic muffins: batter rheology, quality characteristics, microstructure and immunochemical validation.

A high demand exists for gluten free and hypoimmunogenic products from gluten sensitive population. The present study focuses on the development of hypoimmunogenic muffins using a combination of the blend (CB) consisting of modified (protease treated) Whole Wheat Flour (WWF) and Pearl Millet Flour (PMF). The batter density of CB was 0.97, and it varied between 0.91-0.93 and 0.97-0.99 g/cc with the use of emulsifiers and hydrocolloids respectively. The volume of the muffin made using CB was 70 mL, and it increased to 120 mL with the combination of additives (CAD) comprising of Carboxy Methyl Cellulose (CMC) and Polysorbate-60 (PS-60). The muffins made of CB + CAD had the lowest hardness (19.8 N) and gumminess (6.6 N) values and highest springiness value (13.3 mm) indicating that the texture was soft. Sensory characteristics of the muffin made with CB + CAD were good and had an overall quality score of 90.5 out of 100. Rheometer studies showed that the incorporation of additives improved the visco-elastic properties of muffin batters. Microstructure studies showed a change in gluten matrix of muffins followed by treatments. Immunochemical validation of muffins made using CB + CAD showed that the immunogenicity reduced by 70.8 % which may be suitable for patients with gluten sensitivity.

Comparative evaluation of sealing ability of four different restorative materials used as coronal sealants: an in vitro study.

BACKGROUND: The purpose of the present study was to evaluate and compare the sealing ability of glass ionomer cement (GIC), composite resin, gray mineral trioxide aggregate (GMTA) and white mineral trioxide aggregate (WMTA) when placed coronally as double - sealing material over gutta-percha in root canal treated teeth. MATERIALS AND METHODS: A sample of 70 freshly extracted human single rooted teeth were cleaned, shaped and obturated with gutta-percha and AH Plus. The gutta-percha was reduced to a depth of 4 mm from the cemento enamel junction using hot plugger and standardized access cavities with 4 mm depth were prepared at the coronal ends of the roots. The specimens were randomly divided into four groups containing 15 teeth each depending on the restorations they received in the coronal cavity. A positive control group of five teeth received no restorative barrier over gutta-percha. All root surfaces were covered with two coats of nail varnish, leaving only the access openings uncovered except teeth in the negative control group, which were completely covered with nail varnish. All teeth were immersed in India ink, cleared and observed under stereomicroscope for the depth of dye penetration. RESULTS: The results were tabulated and analyzed using Kruskal-Wallis test and multiple comparison between each group was carried out using Mann-Whitney test. The groups sealed with GMTA and WMTA showed least dye penetration than other groups and the difference was statistically significant. Highest dye penetration was seen with groups sealed with GIC and was statistically significant compared with other three groups. CONCLUSION: The results showed that the GMTA and WMTA provided significantly better coronal seal when compared to other two restorations. The composite resin also showed significantly better seal than the unsealed group and the group sealed GIC, which showed highest leakage that was equivalent to that of unsealed group.

The impact of perioperative blood glucose levels on pancreatic cancer prognosis and surgical outcomes: an evidence-based review.

Although diabetes mellitus (DM) and pancreatic cancer (PC) are intricately linked, a comprehensive review addressing the impact of DM on PC prognosis and surgical outcomes is lacking. PubMed search was performed (1980-2012) using keywords "pancreatic cancer", "diabetes mellitus", "glucose intolerance", "pancreatic resection", "prognosis", and "post-operative outcomes". The search results were analyzed to determine the strength of association between DM and PC and to assess the impact of DM on PC prognosis and postoperative outcomes. Thirty-one studies involving 38,777 patients were identified. Patients with non-insulin-dependent DM have 1.5-2 fold increased relative risk of developing PC. Non-insulin-dependent DM is identified in 25.7% of patients with PC compared to 10.4% age-matched controls (95% confidence interval, 1.5-4.7; P < 0.0001). Patients with PC are more likely to have a diagnosis of new-onset DM than age-matched controls (14.7% vs 2.7%; P < 0.0001). Patients with PC with DM have a significantly lower overall survival than those without DM (14.4 vs 21.7 months; P < 0.001). The presence of DM significantly increases overall postoperative complication rates (45.6% vs 35.6%; P < 0.008). Patients with new-onset non-insulin-dependent DM are at a higher risk of developing PC and have a worse long-term survival and a higher rate of postoperative complications.

Laparoscopic resection of antenataly identified duodenal duplication cyst.

We report the first case of complete laparoscopic resection of a duodenal duplication cyst (DDC) in an 8-mo-old patient. The cyst was diagnosed by routine antenatal ultrasound performed at 3 mo of gestational age. Although the baby was born asymptomatic without any congenital abnormalities, the cyst had continued to increase on serial sonographic examinations. Previous reports have described treatment of DDC by surgical resection (laparotomy) or endoscopic marsupialization; we describe here, the first report of laparoscopic approach to resect DDC in a pediatric patient with a favorable outcome.

Subdiaphragmatic bronchogenic cyst at the gastroesophageal junction presenting with Dysphagia: a case report.

BACKGROUND: Bronchogenic cysts are benign lesions derived from the primitive foregut. They frequently occur in the mediastinum, most commonly at the subcarinal level. Subdiaphragmatic location for bronchogenic cysts is extremely rare. METHODS: A 40-year-old woman presented with worsening dysphagia and was diagnosed as a bronchogenic cyst arising from infradiaphragmatic esophagus by computed tomographic scan and endoscopic ultrasound-guided aspiration. Total laparoscopic enucleation of the cystic mass was performed. RESULTS: The postoperative esophagogram revealed no leak or reflux and the patient was discharged on day 2. The histopathologic examination revealed a bronchogenic cyst. No recurrence of the cyst or symptoms was noted at 6 months. CONCLUSIONS: Infradiaphragmatic bronchogenic cysts are uncommon and may become symptomatic secondary to compression of surrounding structures. A complete resection by laparoscopy is feasible and represents a safe and minimally invasive alternative to traditional resection through laparotomy or thoracotomy.

Biomarkers for pancreatic cancer: promising new markers and options beyond CA 19-9.

Pancreatic adenocarcinoma accounts for nearly 90-95% of exocrine malignant tumors of the pancreas. Traditionally, overexpressed proteins/epitopes such as CA 19-9, CA-50, CEA, and many others were being used as pancreatic cancer tumor markers. The main utility of these biomarkers was in the diagnosis of pancreatic cancer as well as to assess response to chemotherapy and to determine prognosis and to predict tumor recurrence. However, these markers had significant limitations such as lack of sensitivity, false-negative results in certain blood groups, as well as false-positive elevation in the presence of obstructive jaundice. To circumvent these limitations, an extraordinary amount of research is being performed to identify an accurate tumor marker or a panel of markers that could aid in the management of the pancreatic cancer. Although this research has identified a large number and different variety of biomarkers, few hold future promise as a preferred marker for pancreatic cancer. This review provides an insight into exciting new areas of pancreatic biomarker research such as salivary, pancreatic juice, and stool markers that can be used as a noninvasive test to identify pancreatic cancer. This manuscript also provides a discussion on newer biomarkers, the role of microRNAs, and pancreatic cancer proteomics, which have the potential to identify a preferred tumor marker for pancreatic adenocarcinoma. This review further elaborates on important genetic changes associated with the development and progression of pancreatic cancer that holds the key for the identification of a sensitive biomarker and which could also serve as a therapeutic target.

Utility of intraoperative frozen section examination of sentinel lymph nodes in ductal carcinoma in situ of the breast.

BACKGROUND: Intraoperative frozen section (IFS) examination of sentinel lymph nodes (SLN) is useful in selecting patients with invasive breast cancer for immediate axillary lymph node dissection. However, whether IFS evaluation of the SLNs in ductal carcinoma in situ (DCIS) of the breast has any value has not been previously assessed. METHODS: Clinicopathologic data from patients with DCIS who underwent resection with SLN biopsy (2004-2010) were collected to assess the sensitivity, specificity, and accuracy of IFS, and its impact on axillary management. RESULTS: A total of 267 patients with DCIS underwent resection with SLN biopsy and IFS evaluation. Preoperative pathology was DCIS (n = 231), DCIS with microinvasion (n = 24), and DCIS with other lesions (n = 12). Fifty-two (19.5%) patients had invasive breast cancer on final pathology. SLN metastases were identified in 13 (4.8%) patients; however, only 4 (1.5%) were IFS positive. IFS examination was negative in 263 (98.5%) patients. Among patients with SLN metastases, the most common pattern of metastases was either micrometastasis (n = 6) or immunohistochemistry-positive individual tumor cells (n = 4), whereas 3 patients had a macrometastasis. IFS examination was falsely negative in 9 of these 13 patients for a false-negative rate of 69.3%, and a sensitivity and specificity of 31% and 100% respectively. Nine of the 13 patients underwent axillary lymph node dissection and only 1 patient had further axillary metastasis. CONCLUSIONS: SLN metastases in DCIS is rare and most commonly involves SLN micrometastasis or immunohistochemistry-positive individual tumor cells. SLN IFS evaluation in DCIS has a low yield and sensitivity, and can be safely omitted to reduce operative duration and cost.

Carcinoma of dual ectopic thyroid gland in a patient with cyanotic congenital heart disease--a case report and review of literature.

Carcinoma arising from an ectopic thyroid gland in the absence of a normal thyroid gland is uncommon. There is a clinically relevant and unique association of ectopic thyroid with congenital heart disease which in turn is related to thyroid embryogenesis. The median thyroid anlage develops adjacent to the newly differentiated myocardium during the 3rd week of intrauterine life. The downward pull exerted by continued descent of heart is postulated to assist in the descent of the thyroid to its final location in the lower cervical position. Ectopic thyroid tissue can result from abnormal heart development or abnormal interaction between thyroid primordium and heart. We present a rare association of cancer of the ectopic thyroid gland in a patient with congenital heart disease.

The clinical utility of serum CA 19-9 in the diagnosis, prognosis and management of pancreatic adenocarcinoma: An evidence based appraisal.

BACKGROUND: Serum carbohydrate antigen (CA 19-9) is the most common tumor marker assessed in pancreatic cancer patients; nevertheless few articles have comprehensively evaluated the evidence for its utility in pancreatic cancer management. METHODS: Literature search was performed using Medline with keywords "pancreatic cancer", "tumor markers", "CA 19-9", "diagnosis", "screening", "prognosis", "resectability" and "recurrence". All English language articles pertaining to the role of CA 19-9 in pancreatic cancer were critically analyzed to determine its utility as a biomarker for pancreatic cancer. RESULTS: Serum CA 19-9 is the most extensively validated pancreatic cancer biomarker with multiple clinical applications. CA 19-9 serum levels have a sensitivity and specificity of 79-81% and 82-90% respectively for the diagnosis of pancreatic cancer in symptomatic patients; but are not useful as a screening marker because of low positive predictive value (0.5-0.9%). Pre-operative CA 19-9 serum levels provide useful prognostic information as patients with normal levels (<37 U/mL) have a prolonged median survival (32-36 months) compared to patients with elevated levels (>37 U/mL) (12-15 months). A CA 19-9 serum level of <100 U/mL implies likely resectable disease whereas levels >100 U/mL suggest unresectablity or metastatic disease. Normalization or a decrease in post-operative CA 19-9 serum levels by ≥20-50% from baseline following surgical resection or chemotherapy is associated with prolonged survival compared to failure of CA 19-9 serum levels to normalize or an increase. Important limitations to CA 19-9 serum level evaluation in pancreatic cancer include poor sensitivity, false negative results in Lewis negative phenotype (5-10%) and increased false positivity in the presence of obstructive jaundice (10-60%). CONCLUSIONS: CA 19-9 is the most extensively studied and validated serum biomarker for the diagnosis of pancreatic cancer in symptomatic patients. CA 19-9 serum levels can provide important information with regards to prognosis, overall survival, and response to chemotherapy as well as predict post-operative recurrence. However, non-specific expression in several benign and malignant diseases, false negative results in Lewis negative genotype and an increased false positive results in the presence of obstructive jaundice severely limit the universal applicability of serum CA 19-9 levels in pancreatic cancer management.

Traction esophageal diverticulum: a rare cause of gastro-intestinal bleeding.

Esophageal diverticula are uncommon lesions that are usually classified according to their location (cervical, thoracic, or epiphrenic), or underlying pathogenesis (pulsion or traction), and their morphology (true or false).The majority of esophageal diverticula are acquired lesions that occur predominantly in elderly adults. Pulsion, or false, diverticula are the most commonly encountered type of esophageal diverticula noticed at the level of cricopharyngeus muscle, occur as a localized outpouchings that lacks a muscular coat, and as such their wall is formed entirely by mucosa and submucosa. True, or traction, esophageal diverticulum (TED) is seen in the middle one third of the thoracic esophagus in a peribronchial location, occurs secondary to mediastinal inflammatory lesions such as tuberculosis or histoplasmosis. The resultant desmoplastic reaction in the paraesophageal tissue causes full thickness pinching on the esophageal wall, producing a conical, broad-mouthed true diverticulum. They often project to the right side because subcarinal lymph nodes in this area are closely associated with the right anterior wall of the esophagus. TED usually presents with symptoms such as dysphagia, postural regurgitation, belching, retrosternal pain, heartburn, and epigastric pain. As in patients with pharyngoesophageal (Zenker's) diverticula, pulmonary symptoms are often present but underestimated in TED patients. These symptoms range from mild nocturnal cough to life-threatening massive aspiration. In this particular report we describe a rare case of TED presenting as a symptomatic upper gastrointestinal bleeding. Diagnostic evaluation of TED includes chest X-ray, barium esophagogram and manometry. A significant proportion of lower esophageal diverticula are associated with motility disorders. Management of TED include treating the underlying cause sometimes a surgical resection of diverticulum along with esophageal myotomy is necessitated in symptomatic patients.

Evaluation of canine retraction through distraction of the periodontal ligament: a clinical study.

AIM: The aim of this study is to evaluate the efficiency of canine distraction and also to evaluate the position of canine in the arch after distraction. MATERIALS AND METHODS: The study sample consisted of five patients, (4 males and 1 female), in the age group of 14 to 25 years who needed canine retraction (ten maxillary canines including both left and right) and first premolar extraction as their treatment protocol were included in the study. This study used a in-house manufactured periodontal ligament distractor. RESULTS: The maxillary canines were distracted distally by 6.42 mm in three and half weeks with a distal tipping of around 15.1° and the maxillary first molars tipped mesially by an average of 6.1°. The maxillary canines rotated mesiobucally by an average of 7.8° bilaterally. CONCLUSION: Canines can be distracted rapidly with minimal effects on the vitality and the periodontal condition and almost all of extraction space can be used for anterior dental alignment or retraction. Maxillary canines can be rapidly retracted into the first premolar extraction space at the rate of about 2.43 mm per week. CLINICAL SIGNIFICANCE: The overall treatment time is reduced as the time taken for retraction of canine is decreased considerably from 6 and 8 months to 3 weeks. Also there is no significant anchorage loss during this period and is well suitable for cases with group a anchorage where the whole extraction space is needed for retraction of anterior teeth.

Knowledge, Attitude and Practices of Parents Regarding Primary Teeth Care of their Children in Davangere city, India

Objetivo: Avaliar o conhecimento, atitudes e práticas de pais da cidade de Davangere, Índia, a respeito do cuidado com osdentes decíduos de seus filhos. Método: Mil questionários contendo aproximadamente 10 perguntas em dois idiomas Inglês e em dialeto local) foram distribuídos aos pais da cidade de Davangere, Índia. As respostas foram tabuladas e os resultados expressos por meioda distribuição de freqüência (absoluta e percentual). Resultados: A maioria dos pais não tinham consciência da importância dos dentes decíduos. Apenas 4% dos entrevistados tinham conhecimento sobre os dentes decíduos. Quando perguntados sobre a importância dos dentes decíduos, 82%dos pais disseram que esses elementos dentários não são importantes. Quanto à freqüência de escovação, a maioria(91,1%) dos pais relatou que eles solicitavam que os seus filhos escovassem os dentes uma única vez ao dia. Noventa vírgula seis por cento dos pais afirmaram que escolheriam os pediatras dos seus filhos. Apesar de trazerem os filhos ao cirurgião-dentista regularmente para consultas de rotina, muitos preferem não restaurá-los, mas deixá-los como estão (32%) e até mesmo extraí-los (61%).Conclusão: Verifica-se uma falta de conhecimento entre amaioria dos pais de Davangere, relativas aos cuidados com a dentição decídua de seus filhos. Deste modo, um alto nível deconsciência era obviamente desejável entre esses pais.

Objective: To assess the knowledge, attitude and practices of parents of Davangere city regarding the care of primary teeth. Methods: 1000 questionnaires containing about 10 questions written both in English and local language (Kannada) were prepared for data collection and were personally distributed to 1000 parents of Davangere city. Reponses obtained were tabulated and the results of the questionnaire were expressed as frequency distribution and computed in percentages. Results: Most of the parents were unaware of the importance of the primary teeth. Only 4% of parents had knowledge about primary teeth. When questioned about the importance of primary teeth, 82% of parents told that primary teeth are not important. For frequency of brushing, majority (91.1%) of parents reported that only once they ask their children to brush in a day. 90.6% parents stated that they would choose their child's paediatricians. Despite bringing their children to the dentist on a regular basis for check-ups, many would prefer not to have these teeth filled but would rather that they were left (32%) or even extracted (61%). Conclusion: There is a lack of knowledge in majority of parents of Davangere, pertaining to primary teeth care of their children. Thus, a high level of awareness was obviously desirable among these parents.

Serum CA 19-9 as a Biomarker for Pancreatic Cancer-A Comprehensive Review.

Pancreatic cancer is an aggressive tumor with a dismal prognosis, biomarkers that can detect tumor in its early stages when it may be amenable to curative resection may improve prognosis. At present, serum CA 19-9 is the only validated tumor marker in widespread clinical use, but precise knowledge of its role in pancreatic cancer diagnosis, staging, determining resectability, response to chemotherapy and prognosis remains limited. A comprehensive search was performed using PubMed with keywords "pancreatic cancer" "tumor markers" "CA 19-9" "diagnosis" "screening" "prognosis" "resectability" and "recurrence". All English language articles pertaining to the role of CA 19-9 in pancreatic cancer were critically analyzed to determine its utility as a biomarker for pancreatic cancer. Serum CA 19-9 is the most extensively studied and clinically useful biomarker for pancreatic cancer. Unfortunately, CA 19-9 serum level evaluation in pancreatic cancer patients is limited by poor sensitivity, false negative results in Lewis negative phenotype (5-10%) and increased false positivity in the presence of obstructive jaundice (10-60%). Serum CA 19-9 level has no role in screening asymptomatic populations, and has a sensitivity and specificity of 79-81% and 82-90% respectively for the diagnosis of pancreatic cancer in symptomatic patients. Pre-operative CA 19-9 serum level provide useful prognostic information as patients with normal CA 19-9 serum levels (<37 U/ml) have a prolonged median survival (32-36 months) compared to patients with elevated CA 19-9 serum levels (>37 U/ml) (12-15 months). A CA 19-9 serum level of <100 U/ml implies likely resectable disease whereas levels >100 U/ml may suggest unresectablity or metastatic disease. Normalization or a decrease in post-operative CA 19-9 serum levels by ≥20-50% from baseline following surgical resection or chemotherapy is associated with prolonged survival compared to failure of CA 19-9 serum levels to normalize or an increase. Carbohydrate antigen (CA 19-9) is the most extensively studied and validated serum biomarker for the diagnosis of pancreatic cancer in symptomatic patients. The CA 19-9 serum level can provide important information with regards to prognosis, overall survival, and response to chemotherapy as well as predict post-operative recurrence. Non-specific expression in several benign and malignant diseases, false negative results in Lewis negative genotype and an increased false positive results in the presence of obstructive jaundice severely limit the universal applicability of serum CA 19-9 levels in pancreatic cancer management.

Efficacy of platelet-rich-plasma (PRP) in bone regeneration after cyst enucleation in pediatric patients--a clinical study.

BACKGROUND: Platelet-rich-plasma (PRP) is a type of natural source of autologous growth factors, and has been used successfully in various fields. However the use ofPRP in children is not well documented. OBJECTIVE: To evaluate the efficacy of adding PRP to a bone graft in the bone regeneration of cystic bony defects following cystectomy. STUDY DESIGN: Study sample included 20 children who were randomly divided into two groups with 10 patients in each group; all underwent cystectomy In the first group (test group), after cystectomy the cystic defect was filled with PRP and bone graft. In the second group (control group) bone graft alone (without PRP) was used. Radiographs were recorded at 1 month, 2 months, 4 months and 6 months intervals after surgery to evaluate the defect bone fill in both groups. RESULTS: The post-operative successive radiographs in the test group showed a significantly greater regeneration of bone in the height of bony defects with application of PRP to bone graft as compared to the control group. In the test group, by the first post operative month, about 58% of the defect was filled, which gradually increased in each month and showed about 94% of defect-fill by 6 months. In the control group, similar observation revealed only 31% of defect-fill by the first post-operative month and a 47% defect-fill at 6 months. CONCLUSION: The addition of PRP to bone graft appeared to enhance bone regeneration considerably. The combination of PRP and bone graft might have a potential for routine clinical use for regeneration of cystic bony defects in children.

Minimal access is not maximal safety: pelviureteric necrosis following percutaneous chemical lumbar sympathectomy.

Lumbar sympathectomy remains popular in the treatment of a variety of painful and circulatory conditions of the lower extremities. Although percutaneous chemical lumbar sympathectomy (PCLS) under radiographic guidance is minimally invasive and has decreased the need for open surgical sympathectomy, inadvertent damage to neighbouring structures is a matter for concern. We report the case of a 38-year-old man with thromboangiitis obliterans who had PCLS under radiographic guidance for relief of ischaemic rest pain that was complicated by necrotic disruption of the left pelviureteric region. The kidney was salvaged with an ureterocalycostomy and he remains well 4 years later. Such complications point to imprecise and unpredictable spread of the injected chemical too far beyond the needle tip. It is possible that such complications are often under reported and, therefore, not taken into consideration during informed consent. Precise neurolysis with laser and radiofrequency may be a safer alternative.