Cervicofacial subcutaneous emphysema and pneumomediastinum secondary to dental treatment in a young man.

The occurrence of cervicofacial subcutaneous emphysema and pneumomediastinum is very rare but can be potentially life-threatening. These complications can happen during or after bronchoscopic or dental procedures, esophageal rupture or perforation, infections involving the head and neck and alveolar rupture in the setting of an inciting event such as asthma. The symptoms can appear promptly after the inciting event, but can also be delayed or do not reach maximal intensity for hours. Cervicofacial subcutaneous emphysema usually occurs during or within minutes to hours after dental treatment and can be easily misdiagnosed as post-procedure swelling or an allergic reaction. We report a 36-year-old male who underwent dental treatment for a fractured left lower molar tooth and subsequently developed extensive subcutaneous emphysema and pneumomediastinum. The purpose of this report is to bring attention to the fact that obtaining an accurate diagnosis for this condition is very important and management in a timely manner can prevent serious complications.

Association of osteoprotegerin with peripheral artery disease in patients with type 2 diabetes.

BACKGROUND: Osteoprotegerin plays a critical role in the pathogenesis of atherosclerosis. Elevated osteoprotegerin concentrations have been reported in microvascular complications of diabetes. Patients with diabetes are at increased risk of macrovascular complications, particularly peripheral artery disease (PAD). AIM: To investigate the association between osteoprotegerin concentration and PAD in diabetes. METHODS: In a cross-sectional setting, patients with type 2 diabetes for>5 years and no apparent diabetic foot ulcer were recruited. Patients underwent colour Doppler ultrasonography of lower limbs and were designated PAD+ if arterial narrowing was detected. Ankle-brachial index (ABI) was measured. Serum osteoprotegerin concentrations were determined. RESULTS: Ninety-eight patients (47 PAD+, 51 PAD-) were recruited. Osteoprotegerin concentrations (median [interquartile range]) were significantly higher in PAD+ versus PAD- patients (0.80 [0.50-1.95] ng/mL vs 0.30 [0.25-0.40] ng/mL; P<0.001). In logistic regression, log-osteoprotegerin was a predictor of PAD in univariate and multivariable analyses. In the final multivariable model, adjusting for age, sex, body mass index, smoking, hypertension, glycaemic control, lipid profile, renal function and C-reactive protein, one standard deviation increase in log-osteoprotegerin was associated with a more than twofold increase in the risk of having PAD (odds ratio 2.26, 95% confidence interval 1.50-3.40). In PAD+ patients, osteoprotegerin was a significant predictor of disease severity, determined by ABI and percentage of vessel occlusion in univariate and multivariable models. CONCLUSIONS: Osteoprotegerin concentrations are increased in patients with diabetes and PAD. Osteoprotegerin is an independent predictor of the presence and severity of PAD in diabetic patients.

ASSOCIATION OF PERIPHERAL 5-HYDROXYINDOLE-3-ACETIC ACID, A SEROTONIN DERIVATIVE, WITH METABOLIC SYNDROME AND LOW-GRADE INFLAMMATION.

OBJECTIVE: The constellation of metabolic abnormalities seen in metabolic syndrome (MetS) has been linked to atherosclerosis and adverse cardiovascular outcomes due to heightened inflammation. Accumulating evidence suggests that peripheral 5-hydroxyindole-3-acetic acid (5-HIAA), the derivative end-product of serotonin (5-HT), might be involved in the pathogenesis of obesity, and abnormal lipid and glucose metabolism. We examined the association between serum 5-HIAA concentrations and MetS and also highly sensitive C-reactive protein (hsCRP). METHODS: We assessed 180 healthy adults (110 males and 70 females) in a cross-sectional setting. Anthropometric indices and blood pressure were measured, as were laboratory parameters including fasting 5-HIAA concentrations. The associations between 5-HIAA and individual components of MetS, as well as MetS as a single entity, were investigated with bivariate correlation and logistic regression analyses. RESULTS: Eighty-nine individuals (49.4%) were diagnosed with MetS. Significant correlations were found between 5-HIAA concentrations and age (r = 0.184), waist circumference (r = 0.415), high-density lipoprotein (HDL) cholesterol (r = -0.148), systolic blood pressure (r = 0.374), diastolic blood pressure (r = 0.355), homeostasis model assessment of insulin resistance (r = 0.201), and hsCRP (r = 0.453) were found (P<.05 in all tests). In logistic regression, 5-HIAA was significantly associated with 4 MetS components including central obesity, raised triglycerides, raised blood pressure, and raised fasting plasma glucose (FPG) (P<.05). Moreover, 5-HIAA was a predictor of MetS as a single entity, and the relationship persisted after adjusting for hsCRP (odds ratio [OR] = 4.41, 95% confidence interval [CI]: 2.58-7.67, P<.001). CONCLUSION: Elevated concentrations of 5-HIAA are seen in individuals with MetS. Increased 5-HIAA is also associated with hsCRP, a marker of chronic low-grade inflammation underlying MetS.

Intermittent voiding per urethra as an indicator of cutaneous vesicostomy malfunction.

PURPOSE: To present a new approach for management of cutaneous vesicostomy (CV) prolapse, with special emphasis on normal appearing vesicostomy may be malfunctioning. To introduce the application of temporary stoma-free drainage as a diagnostic and therapeutic tool. MATERIALS AND METHODS: From December 2000 to September 2006, 66 children (61 males and 5 females) with CV were studied. The mean age at vesicostomy was 7 months (range 1-30), and the main underlying disease was posterior urethral valves (in 45 children, 68%). Indications for CV included significant hydroureteronephrosis (HUN) and recurrent urinary tract infection. Patients were followed up for complications and were treated based on our institutional approach. All patients with persistent upper tract dilatation and micturition per urethra underwent temporary bladder (via stoma) free drainage. Patients with stomal stenosis were managed either by a revision surgery or by simple dilatation and intermittent catheterization. Purse string suturing was applied in mucosal prolapses as the first choice. RESULTS: The complications were observed in 21 patients (31%), including twelve stomal stenosis, nine severe mucosal prolapses, and two recurrent urinary infections. HUN and significant voiding per urethra persisted following initial CV in 19 out of 66 patients (29%), eleven of which having normal appearing CVs. Seventeen of these patients were managed by temporary stoma-free drainage (accompanied by purse string suturing in mucosal prolapse), and two patients with severe stenosis underwent surgical revision. Temporary stoma-free drainage improved HUN in 94% of patients (16 of 17). CONCLUSIONS: Voiding per urethra is an indicator of CV malfunction, and temporary stoma-free drainage can be a diagnostic and therapeutic option in such children. A seemingly open CV may still be malfunctioning, and ureterovesical or intravesical obstructions should be considered if HUN does not improve following temporary stoma-free drainage.

Multiple hypoplastic duplicated urethral hydrodistension and simple end-to-end anastomosis to penoscrotal hypospadias: a novel technique.

Complete urethral duplication is a rare congenital genitourinary anomaly with various symptoms. Since anatomical place of urethra greatly varies between cases, surgical management of the patients is personalized according to the type of the duplication and requires a careful workup before planning for any intervention. In this case report, a 4-year-old boy with finding of complete proximal hypospadiac urethral duplication is presented with double-stream voiding. He was passing a normal stream of urine through the hypospadiac tract, while a thin stream came out from the normal meatal site. Examination revealed a hypoplastic orthotopic urethra with an accessory penoscrotal hypospadiac urethra. The patient was successfully managed with hydrodistension technique which was used to resolve the stricture of hypoplastic dorsal urethra followed by end-to-end anastomosis to penoscrotal hypospadias. This approach gives an insight that the technique could be possibly considered as a simple alternative to avoid proximal hypospadias repair which is comparatively a challenging surgical task.

Use of biodegradable plates and screws for approximation of symphysis pubis in bladder exstrophy: applications and outcomes.

OBJECTIVES: To investigate the feasibility of biodegradable plate and screws for the tension-free internal fixation of the symphysis pubis in patients with bladder exstrophy, with a particular emphasis on pelvic bone changes as seen on 3-dimensional computed tomography. METHODS: A total of 11 children with bladder exstrophy underwent surgical repair with biodegradable plate and screw fixation (mean age 4.13 years). Of the 11 patients, 6 had a history of failed bladder closures and pelvic osteotomies, 1 had failed bladder closure, and 4 had no such history. All 11 children underwent single-stage classic bladder closure. Subsequently, the symphysis pubis was fixed by placing a biodegradable miniplate and screws. The patients remained in leg bandages for 2 weeks. The follow-up period was 6-50 months (average 30.1). Three-dimensional pelvic bone computed tomography was performed initially and at 6 months postoperatively. RESULTS: All 11 children had an uneventful postoperative period, except for a superficial infection at the site of the suprapubic tube in 1 patient. The mean hospital stay was 13.4 days. The plate remained in situ, and no further surgery was needed to remove it. Pelvic 3-dimensional computed tomography revealed a 35.48 ± 1.50 mm, 20.06 ± 1.97 mm, and 10.73° ± 0.84° decrease in pubic diastasis, intertriradiate distance, and iliac wing angle at 6 months postoperatively, respectively. Significant improvement was seen in the patients' urinary continence and gait compared with the preoperative values. At the final follow-up visit, 6 patients were socially dry. CONCLUSIONS: Internal fixation of the pubic arch using biodegradable plates as a biocompatible alternative to current metal fixation system offers intriguing potential for early exstrophy management. This adds a layer of security to the pubic closure, in addition to the current surgical armamentarium for bladder exstrophy.