Can Isolated Discordant Atrioventricular Connections Survive Without Interatrial or Interventricular Shunt?

Clinical presentation of isolated discordant atrioventricular connections is akin to transposition of the great arteries. In the absence of a significant intracardiac shunt, profound cyanosis is expected at birth. We report one such 5-month-old infant who had only mild cyanosis. The left-sided tricuspid valve straddled the interventricular septum with a closed interventricular communication, a type of "Double Outlet Left Atrium with three atrioventricular valves," which provided the necessary "left to right" shunt while severe regurgitation through the straddling part and a patent ductus arteriosus provided the effective pulmonary blood flow.

Large aortopulmonary collateral artery exclusively supplying the lower lobe of left lung in an infant with common arterial trunk with aortic dominance with confluent pulmonary arteries.

INTRODUCTION: Common arterial trunk with aortic dominance has well-developed bilateral pulmonary arterial arborization without any essential major aortopulmonary collateral arteries (MAPCAs), whereas "solitary" arterial trunk is characterized by collateral arterial supply to all bronchopulmonary segments and absent pulmonary arteries. CASE REPORT: We report a term female neonate with common arterial trunk with aortic dominance with confluent pulmonary arteries with a large MAPCA as the sole blood supply to the lower lobe of the left lung. RESULTS: Initial diagnostic workup missed this MAPCA from the descending thoracic aorta. It was suspected during surgery due to massive left atrial return and confirmed by cardiac catheterization study in the early postoperative period and treated successfully by unifocalization. DISCUSSION: A large essential MAPCA supplying an entire lobe in the common arterial trunk with aortic dominance has not been described. It can present as heart failure and inability to wean off the ventilator in the early postoperative period following intracardiac repair. CONCLUSION: This is a case hitherto undescribed and possibly falling outside the well-entrenched classifications of the common arterial trunk and a large MAPCA could be an addition to the list of lesion modifiers. Our experience with this case underlines the importance of a thorough and open-minded approach to the initial imaging assessment of even well-described conditions.

Echo Rounds: Partial Anomalous Systemic and Pulmonary Venous Return.

Anomalous drainage of a right-sided superior vena cava to the left atrium is a rare variant of systemic venous return anomalies. During the course of investigation for a heart murmur, an asymptomatic child was found to have a superior sinus venosus atrial septal defect with partial anomalous systemic and pulmonary venous drainage. Despite the right superior vena cava overriding the upper end of the atrial septum and draining into the left atrium, the child did not exhibit hypoxemia. Saline contrast transesophageal echocardiography suggested an explanation for the absence of hypoxemia.

Childhood Obesity.

Childhood obesity is a pathologic process with multifactorial causes. The reasons range widely. Obesity leads to chronic health conditions, increasing morbidity. The management of obesity must include the patient, family, school, community, and even government for policy changes. Lifestyle changes are the mainstay of treatment, including a healthy diet and increased physical activity. Medications and bariatric surgery may have a role in certain severe cases. Community and policy changes concerning food and physical activities may facilitate practical strategies against the increasing obesity epidemic. It will help families and health care systems tackle childhood obesity effectively.

Mixed Methods Study of Patient and Primary Care Provider Perceptions of Chronic Pain Treatment.

OBJECTIVE: A mixed-method study involving patient focus groups and survey of primary care providers (PCPs) sought to compare perspectives about chronic pain (CP) and its treatment. Our goal was to identify needs and barriers for facilitating patient-centered care. METHODS: Two focus groups of CP patients from a single academic medical center explored interactions with PCPs and their understandings, experiences, and expectations of CP treatment. They were also asked their opinions about self-assessment/communication tools. We compared themes with survey data from two PCP research networks. RESULTS: CP patients understand opioid risks and fear PCP judgement and condescension, while sensing PCP fear and avoidance of opioid prescribing. PCPs are dissatisfied with their ability to provide optimal CP care, despite feeling that patients are generally satisfied with their clinic visits. Evaluation tools, especially assessment of functional activities, are favorably viewed by all, but deemed time prohibitive. CONCLUSION: Patients' understanding of opioid risks, desire for attention on functional goals and behavioral treatment may be greater than PCPs perceive. Such gaps in understanding and attitudes, if recognized, could support high-quality communication and interventional strategies. PRACTICE IMPLICATIONS: These findings guide patient-PCP communication toward alignment of treatment goals and enhanced coordination of care.

Double outlet right atrium-A "bridge" across the bridging leaflets.

INTRODUCTION: Mal-alignment between the inter-atrial septum (IAS) and the inter-ventricular septum (IVS) during cardiac embryogenesis results in abnormal atrioventricular (AV) connections ranging from doubleoulet left atrium (DOLA) to double outlet right atrium (DORA)1. CASE REPORT: We report DORA resulting from partial override of the interatrial septum (IAS) across the cleft between the bridging leaflets of the left atrioventricular (AV) valve. RESULTS: Successful surgical management with preservation of the orifice is described, leading to an unusual type of double orifice left AV valve. DISCUSSION: The mal-alignment of the interatrial septum, resulting in it bridging the bridging leaflets, leads to an additional orifice between the RA and the LV and a unique form of right to left shunt. DORA can cause cyanosis depending on the size of the shunt and the compliance of the ventricles. Our patient was acyanotic, possibly due to the small size of the orifice and low LV compliance secondary to hypertrophy of the LV. CONCLUSION: our case adds to the spectrum of atrial septal mal-alignment variant of DORA in the setting of AVSD without atrial and ventricular components, with RA to LV communication occurring via the smaller orifice of a left atrioventricular valve divided by the abnormal insertion of a partially overriding, mal-aligned atrial septum; a mechanism not described previously - the 'bridge' across the bridging leaflets!

Eosinophilic Granuloma of the Mandible.

Eosinophilic granuloma (EG) is a rare histiocytic disorder resulting from clonal proliferation of Langerhans cells. Eosinophilic granuloma, the most benign of the three entities of Langerhans cell histiocytosis, may be multiple or solitary. This lesion can affect any bones but commonly involves the mandible when the jaws are affected. It is difficult to make a correct diagnosis on it without proof of a pathological diagnosis, which correlates with the diverse clinical and radiographic presentations of EG in the jaws. This report describes a case of unifocal EG of the mandible occurring in a 6-year-old boy whose initial presentation led to confusion of any solitary bony lesion. A final diagnosis of EG was established after histopathological examination of the biopsy specimen.

Percutaneous Closure of Ventricular Septal Defects in 116 Patients: Experience with different devices.

OBJECTIVES: This study aimed to review the experience with percutaneous closure of ventricular septal defects (VSDs) at the National Heart Center (NHC) in Muscat, Oman. METHODS: This retrospective study was conducted from November 2008 to December 2017. Patients' electronic medical records were reviewed to identify their clinical, imaging and interventional data before and after the procedure and on the last follow-up. RESULTS: A total of 116 patients, the majority of which were female (58%), underwent 118 percutaneous procedures for VSD closure at a median age of 3.54 years (range: 0.25-33 years) and a median weight of 12 kg (range: 3.5-78 kg). The mean diameter of the VSDs as determined by transoesophageal echocardiogram was 5.6 ± 1.9 mm (n = 105). The commonest type of VSD was perimembranous (n = 75, 63.5%). Devices were successfully placed during 111 (94.1%) procedures in 109 (94.0%) patients, with the commonest device being a Amplatzer™ duct occluder I (St. Jude Medical, Little Canada, Minnesota, USA; n = 39, 35.1%). There was no mortality. Early major cardiac complications occurred in six patients (5.5%) with device embolisation being the commonest (n = 4, 3.7%). The median follow-up period was 19 months (range: 1-84 months) in 89 (81.7%) of the patients. One patient (0.9%) required a permanent pacemaker for a complete heart block. CONCLUSION: This study has demonstrated a good rate of VSD closure with low morbidity and no mortality using the percutaneous approach with different devices. Long-term follow-up is needed to specifically evaluate the function of adjacent structures and the long-term effects on conduction systems.

Comparative Evaluation of Hydrophobic and Hydrophilic Resin-based Sealants: A Clinical Study.

AIM: The purpose of this study is to clinically evaluate and compare the retention and evidence of caries of three fissure sealants. MATERIALS AND METHODS: A total of 150 children, between 7 and 13 years of age, with fully erupted permanent molars, had sealants placed using a full-mouth design. Sealant retention was evaluated at 1, 3, 6, 9, and 12 months later. Teeth were evaluated for retention and evidence of caries using Simonsen's criteria and results were subjected to statistical analysis using the Chi-square test. RESULTS: At 1-year examination, in teeth sealed with Clinpro: (a) 8% were completely retained, (b) 74.4% were partially lost, and (c) 8.5% were completely lost; with Embrace Wetbond: (a) none of the sealants were completely retained, (b) 13.1% were partially lost, and (c) 59.1% were completely lost; with Champ: (a) 1% were completely retained, (b) 71.4% were partially lost, and (c) 10.9% were completely lost. All the three sealants showed evidence of caries from 9 months. CONCLUSION: The retention of hydrophobic (Clinpro) sealant was superior to hydrophilic (Embrace Wetbond and Champ) sealants. The evidence of caries was less in the hydrophobic sealant group when compared with the hydrophilic sealant groups. There was no statistical difference in retention and evidence of caries between maxillary and mandibular teeth for all the three sealant groups. CLINICAL SIGNIFICANCE: Sealants prevent the occurrence of caries in the majority of children. Though hydrophobic sealants appear to be more successful, hydrophilic sealants too may provide promising results in the near future.

Correlation Between Body Mass Index and Dental Caries Among Three- to 12-Year-Old Schoolchildren in India: A Cross-Sectional Study.

INTRODUCTION:  Diet is a deeply ingrained element of a person's life. Children's dietary habits are a significant contributor to obesity and dental caries. Dental caries during childhood continues to be a significant public health concern, while childhood obesity is increasingly being cited as a major public health problem. This study aimed to assess the correlation between body mass index (BMI) and dental caries in children aged three to 12 years who attended both government and private schools in Chennai, Tamil Nadu, India. MATERIALS AND METHODS:  We conducted a cross-sectional review of 2200 children aged three to 12 years with clinically recorded dental caries. The World Health Organization diagnostic criteria for BMI percentile was used to evaluate and record dental caries clinically. The Mann-Whitney and the Kruskal-Wallis tests were used for univariate comparisons. RESULTS:  Mean values between the overweight category and underweight category revealed no significant differences. CONCLUSION:  We found no association between BMI-for-age and dental caries in children in both primary and mixed dentition. This relationship should be investigated further by longitudinal studies.

Efonidipine-Induced Exanthematic Drug Eruption and Literature Review.

We report the case of an elderly woman who developed exanthematic drug eruption after administration of efonidipine. An 84-year-old woman presented to emergency department with complaints of generalized itching and erythema since 4 days. She was on human-soluble insulin since 11 years. In view of her hypertension and left anterior descending artery stenosis, she was initiated on aspirin, clopidogrel, atorvastatin, pantoprazole, nebivolol, aldactone, and efonidipine a week ago. Her presenting complaints were initially managed with parenteral pheniramine maleate and hydrocortisone. She was admitted, and all her medications except antiplatelets and insulin were discontinued. She was prescribed topical beclomethasone and oral antihistamines for better control of her symptoms. To confirm the drug precipitating the reaction, she was rechallenged with efonidipine, 20 mg once daily on the third day of admission. She developed itching 8 hours after administering the medication, and efonidipine was stopped and nebivolol 5 mg once daily was restarted for hypertension. She did not develop any adverse event when the remaining medications were reinitiated. World Health Organization-Uppsala Monitoring Centre causality assessment criteria indicated a "certain" association. To the best of the knowledge of the authors, this is one among the first reported cases of efonidipine-induced exanthematic drug eruption.

Intraosseous lipoma of the maxillary tuberosity: A rare entity with diagnostic challenge.

Lipoma is called the "universal tumor" or the "ubiquitous tumor" as it occurs anywhere in the body where fat is found. Intraosseous lipoma is a rare lesion that constitutes not more than 0.1% of bone tumors. There are only a few reported cases of intraosseous lipoma of the maxilla in the literature. The diagnosis of intraosseous lipoma of the maxilla may be a challenge, due to its rarity and clinical similarity with many other radiolucent lesions. Therefore, histopathological examination is mandatory. The radiolucent nature and mature adipose tissue admixed with the bony trabeculae confirms the diagnosis of intraosseous lipoma. Here, we report a case of intraosseous lipoma of the left maxillary tuberosity in a 52-year-old male patient.

Volumetric analysis of hand, reciprocating and rotary instrumentation techniques in primary molars using spiral computed tomography: An in vitro comparative study.

OBJECTIVE: This present study was conducted to analyze the volumetric change in the root canal space and instrumentation time between hand files, hand files in reciprocating motion, and three rotary files in primary molars. MATERIALS AND METHODS: One hundred primary mandibular molars were randomly allotted to one of the five groups. Instrumentation was done using Group I; nickel-titanium (Ni-Ti) hand file, Group II; Ni-Ti hand files in reciprocating motion, Group III; Race rotary files, Group IV; prodesign pediatric rotary files, and Group V; ProTaper rotary files. The mean volumetric changes were assessed using pre- and post-operative spiral computed tomography scans. Instrumentation time was recorded. Statistical analysis to access intergroup comparison for mean canal volume and instrumentation time was done using Bonferroni-adjusted Mann-Whitney test and Mann-Whitney test, respectively. RESULTS: Intergroup comparison of mean canal volume showed statistically significant difference between Groups II versus IV, Groups III versus V, and Groups IV versus V. Intergroup comparison of mean instrumentation time showed statistically significant difference among all the groups except Groups IV versus V. CONCLUSION: Among the various instrumentation techniques available, rotary instrumentation is the considered to be the better instrumentation technique for canal preparation in primary teeth.