Comparison of noninvasive cardiac output monitoring by electrical cardiometry with transthoracic echocardiography in postoperative paediatric cardiac surgical patients - A prospective observational study.

Aim: The present study was conducted to validate cardiac output (CO) and cardiac index (CI) obtained from electrical cardiometry (EC) ICON ® with transthoracic echocardiography (TTE) in postoperative pediatric cardiac surgical patients. Materials and Methods: A prospective observational study was conducted in 25 pediatric patients with age < 10 years who underwent elective cardiac surgery. Data Analysis: BlandAltman plot was constructed for interchangeability and Polar plot was constructed to know trending ability. Results: A total of 250 datasets were analyzed. Spearman's correlation coefficient for CO between ICON ® and TTE showed good positive correlation (r = 0.850, 95% confidence interval 0.81 to 0.881, P <.0001). Moderate positive correlation was observed between ICON ® and TTE for CI (r = 0.60, 95% confidence interval 0.515 to 0.674, P <.0001). Linear regression equations for CO and CI between ICON ® and TTE were: y = 0.5230 + 0.8078 X (R2 = 0.6597, P <.001) and y = 1.8350 + 0.5869 X (R2 = 0.3985, P <.001) [y- ICON ®; X - TTE], respectively. BlandAltman plot for CO between ICON ® and TTE showed a bias of 0.3012 with limits of agreement (LOA) being -0.69 to 1.3 and for CI bias was 0.6939 with LOA-2.1 to 3.5. Polar plot analysis showed an angular bias of 8.1750, with radial LOA being -13.74° to 30.08° for CO and angular bias of 6.6931, with radial LOA being -15.69° to 29.07° for CI. Conclusion: ICON ® monitor-derived parameters are not interchangeable with the values derived from TTE. However, the ICON ® monitor demonstrated a good trending ability for both CO and CI.

Comparision of cardiac output measured by transthoracic echocardiography with continuous cardiac output measured by pressure recording analytical method.

Background: Low cardiac output is a common complication following cardiac surgery and it is associated with higher mortality in the pediatric population. A gold standard method for cardiac output (CO) monitoring in the pediatric population is lacking. The present study was conducted to validate cardiac output and cardiac index measured by transthoracic echocardiography and Pressure recording analytical method, a continuous pulse contour method, MostCareUp in postoperative pediatric cardiac surgical patients. Materials and Methods: This was a prospective observational clinical study conducted at a tertiary care hospital. A total of 23 pediatric patients weighed between 2 and 20 kg who had undergone elective cardiac surgery were included in the study. Results: Spearman's correlation coefficient of CO between transthoracic echocardiography (TTE) and Pressure Recording Analytical Method (PRAM) showed of positive correlation (r = 0.69, 95% Confidence interval 0.59-0.77, P < 0.0001) Linear regression equations for CO between TTE and PRAM were y = 0.55 + 0.88x (R2 = 0.46, P < 0.0001). (y = PRAM, x = TTE), respectively. Bland- Altman plot for CO between TTE and PRAM showed a bias of -0.397 with limits of the agreement being -2.01 to 1.22. Polar plot analysis showed an angular bias of 6.55° with radial limits of the agreement being -21.46 to 34.58 for CO and angular bias of 6.22° with radial limits of the agreement being -22.4 to 34.84 for CI. Conclusion: PRAM has shown good trending ability for cardiac output. However, values measured by PRAM are not interchangeable with the values measured by transthoracic echocardiography.

Inadequate response to adenosine infusion during cardiac stress magnetic resonance imaging.

Aim: To determine the factors associated with an inadequate response to adenosine infusion during cardiac stress magnetic resonance imaging (MRI). Study Design: It is a retrospective cohort study. Introduction: Stress cardiac MRI is a highly accurate and non-invasive method to diagnose coronary artery disease (CAD). Stress MRI is performed by inducing stress with adenosine infusion. There is an increase in systemic and myocardial blood flow (MBF) with vasodilator agents. Capillaries are maximally dilated in a diseased artery and cannot sustain increased myocardial oxygen demand. It results in delayed delivery of contrast, which leads to an area of perfusion defect in the myocardium. These perfusion defects can be accurately seen by cardiovascular magnetic resonance (CMR) and help in the prognosis of patients. Methods: A retrospective study on patients subjected to cardiac stress MRI was conducted in a Tertiary Care Cardiac Center from January 2019 to January 2022. In total, 99 patients underwent adenosine stress perfusion cardiac MRI. All patients received an adenosine infusion of 140 mcg/kg/min for 2 min. Subsequently, the dosage was increased by 20 mcg/kg/min every 2 min to a maximum of 210 mcg/kg/min until an adequate stress response was achieved. Adequate stress was defined as two or more of the following criteria: 1) Increase in heart rate >/= 10 beats per minute. 2) Decrease in systolic blood pressure SBP by >/= 10 mm Hg Symptoms like chest discomfort, breathlessness, and headache. Patients who satisfied two or more of the above criteria were labeled as responders and the patients who did not satisfy the above criteria with the maximum dose of 210 mcg/kg/min of adenosine infusion were labeled as non-responders. Multivariable logistic regression analysis with forward and backward stepwise selection was used to identify predictors in non-responders. Basic demographic variables with P value

Myco-Facilitated Biosynthesis of Nano-Silver From Wasp Nest Fungus, Paecilomyces variotii, and Its Antimicrobial Activity Against MTCC Strains.

The utility of fungi as stabilizing and reducing agents in the biogenic synthesis of silver nanoparticles is striking due to the production of large quantities of biomolecules of minute toxic residuals. During the current study, sunlight- and dark-assessed silver nanoparticles were synthesized from wasp nest fungus, Paecilomyces variotii, at different pHs. Synthesized silver nanoparticles (AgNPs) at 6 pH were found to be more prominent than at 7 and 8 pHs. AgNPs were within the 20- to 90-nm range and were polygonal and elongated in shape. FTIR spectra of light-mediated AgNPs showed diverse transmittance bands than the silver nanoparticles synthesized in the dark. The synthesized AgNPs were found with diverse antimicrobial activities against pathogenic MTCC bacterial strains, i.e., Staphylococcus aureus, Vibrio parahaemolyticus, Escherichia coli, Shewanella putrefaciens, and fungus, Candida albicans. Aqueous filtrate and filtrate-mediated AgNPs combined with methanol solvent extract of yeast extract manitol broth (YEMB) had more inhibitory effects on all bacteria and Candida albicans. Furthermore, the combined effect of AgNPs and methanol solvent extract from YEMB culture filtrate was found more effective against E. coli, while AgNPs combined with methanol solvent of aqueous filtrate had inhibitory effects on E. coli and Candida albicans.

Comparision of upper thoracic epidural analgesia versus low thoracic epidural analgesia in off-pump coronary artery bypass graft for perioperative pain management and fast tracking.

Background: Upper thoracic epidural analgesia (TEA) is compared with lower thoracic epidural analgesia for the perioperative pain management and fast tracking in patients undergoing off pump coronary artery bypass grafting (OPCAB) surgery for the intraoperative hemodynamic, quality of analgesia, incentive spirometry, time to awakening & extubation and intensive care unit (ICU) duration. Materials and Methods: A prospective, randomized comparative clinical study was conducted with total of 60 patients randomized to either Group U: Upper TEA (n = 30) or Group L: Lower TEA (n = 30). Visual analog scale (VAS) was recorded in both the groups during rest and deep breathing at the various time intervals postextubation. Both the groups were also compared for intraoperative hemodynamics, incentive spirometry, time to awakening, and extubation and ICU duration. Statistical analysis was performed using the independent Student's t-test. A value of P < 0.05 was considered statistically significant. Results: Postextubation VAS score at rest and deep breathing at 0, 3, 6, 12, 24, 36, and 48 h were statistically significant in both groups (P ≤ 0.05). Incentive spirometry, time to awakening and extubation and duration of ICU stay were also statistically significant (P ≤ 0.05) between the groups. Conclusion: Lower thoracic epidural was better than upper thoracic epidural in perioperative pain management and fast tracking in OPCAB surgery.

Comparative evaluation of color stability of three composite resins in mouthrinse: An in vitro study.

AIM: The aim of this study was to compare the effect of chlorhexidine mouthrinse on the color stability between three different types of composites. MATERIALS AND METHODS: A total of 30 samples of size 10-mm length, 1-mm width, and 1-mm thickness were prepared on a customized microglass slide from each of the composite materials and immersed in 20 ml of distilled water followed by incubation at 37°C for 24 h. The samples were divided into three groups (n = 10) - Group I: A nanofilled composite, Filtek Z350XT (3M ESPE, St. Paul, USA); Group II: A microhybrid composite, Polofil Supra (Voco GmbH, Germany); and Group III: A nanoceramic composite, Ceram.x Sphere TEC (Dentsply, Konstanz, Germany). Baseline color values were recorded using a spectrophotometer (V-770 UV-Visible/NIR Spectrophotometer, Easton, Maryland, USA) according to the laboratory scale. After baseline color measurements, ten randomly selected specimens from each group were immersed in 20 ml of 0.2% chlorhexidine mouthrinse (Rexidin Plus, Aurangabad, India) for 24 h. The postimmersion color values of the samples were then recorded, respectively, using the same spectrophotometer. STATISTICAL ANALYSIS USED: The statistical analysis was done using one-way ANOVA followed by Tukey's post hoc test. RESULTS: Statistically significant difference was observed between the mean color change values in the three groups (P < 0.05) with the highest color change (delta E [ΔE]) in Group III (Nanoceramic composite). The ΔE for Group I (Nanofilled composite) was 3.16, Group II (Microhybrid composite) was 3.32, and Group III (Nanoceramic composite) was 3.51. CONCLUSION: All the three types of composites displayed color changes after immersion in mouthrinse, but the color shift depended on the material used, and the nanofilled composites (Filtek Z350XT, 3M ESPE, St. Paul, MN, USA) had higher color stability.

Dual threshold neural closed loop deep brain stimulation in Parkinson disease patients.

BACKGROUND: Closed loop deep brain stimulation (clDBS) in Parkinson's disease (PD) using subthalamic (STN) neural feedback has been shown to be efficacious only in the acute post-operative setting, using externalized leads and stimulators. OBJECTIVE: To determine feasibility of neural (N)clDBS using the clinical implanted neurostimulator (Activa™ PC + S, FDA IDE approved) and a novel beta dual threshold algorithm in tremor and bradykinesia dominant PD patients on chronic DBS. METHODS: 13 PD subjects (20 STNs), on open loop (ol)DBS for 22 ±â€¯7.8 months, consented to NclDBS driven by beta (13-30 Hz) power using a dual threshold algorithm, based on patient specific therapeutic voltage windows. Tremor was assessed continuously, and bradykinesia was evaluated after 20 min of NclDBS using a repetitive wrist flexion-extension task (rWFE). Total electrical energy delivered (TEED) on NclDBS was compared to olDBS using the same active electrode. RESULTS: NclDBS was tolerated for 21.67 [21.10-26.15] minutes; no subject stopped early. Resting beta band power was measurable and similar between tremor and bradykinesia dominant patients. NclDBS improved bradykinesia and tremor while delivering only 56.86% of the TEED of olDBS; rWFE velocity (p = 0.003) and frequency (p < 0.001) increased; tremor was below 0.15 rad/sec for 95.4% of the trial and averaged 0.26 rad/sec when present. CONCLUSION: This is the first study to demonstrate that STN NclDBS is feasible, efficacious and more efficient than olDBS in tremor and bradykinesia dominant PD patients, on long-term DBS, using an implanted clinical neurostimulator and driven by beta power with a novel dual threshold algorithm, based on customized therapeutic voltage windows.

Evaluation of risk scores in predicting perioperative blood transfusions in adult cardiac surgery.

Objective: Allogeneic blood product transfusions are associated with an increased morbidity and mortality risk in cardiac surgery. At present, a few transfusion risk scores have been proposed for cardiac surgery patients. The present study is aimed to develop a new score and to compare with preexisting scores - Transfusion Risk and Clinical Knowledge (TRACK) and Transfusion Risk Understanding Scoring Tool (TRUST) score. Methodology: A total of 1014 adult patients undergoing cardiac surgery were enrolled in the retrospective study. Independent predictors of allogeneic blood transfusions were selected from TRACK and TRUST scores. A predictive score was developed from six variables using logistic regression analysis, and new score was compared to the other existing scores - TRACK and TRUST. Results: The new score had following predictors: age >58 years, weight <63 kg for males and <49 kg for females, gender (female), complex surgery, hemoglobin <13.5 g/dl, and creatinine >1.36 mg/dl. Validation of new score demonstrated an acceptable predictive power (area under the curve [AUC] 0.749) and a good calibration at the Hosmer-Lemeshow test. New score was comparable with TRACK score with P = 0.578 (AUC of TRACK 0.756 and AUC of new score 0.749). There was a significant difference between new score and TRUST score, P = 0.01 (AUC of TRUST 0.72 and AUC of new score 0.749). Conclusion: New score is a simple risk model based on six predictors having a similar accuracy and calibration in predicting the transfusion rate in cardiac surgery as compared to TRACK score.

ANSiscope™: Can it be the crystal ball of cardiac anesthesia?

Background: : Autonomic dysfunction (AD) is infrequently evaluated preoperatively despite having profound perioperative implications. The ANSiscope™ is a monitoring device that quantifies AD. This study aims to determine the potential of the device to predict hypotension following anesthetic induction, occurrence of arrhythmias, and inotrope requirement for patients undergoing off-pump coronary artery bypass surgery (OPCAB). Study Design: : Prospective observational double-blinded study. Materials and Methodology: Seventy-five patients undergoing OPCAB had their autonomic function assessed by ANSiscope™. They were classified into four groups based on their AD and compared to perioperative adverse events. Results: Patients with diabetes had a higher ANSindex (P = 0.0263). They had a greater decrease in systolic blood pressure (P = 0.001) and mean arterial pressure (P = 0.004) postinduction, had an increased incidence of arrhythmias (P = 0.009), required higher inotropic support immediately (P = 0.010) and at 24 h after surgery (P = 0.018), and longer duration of postoperative ventilation (P < 0.001). They also had a higher incidence of emergency conversion of OPCAB to on-pump surgery (P = 0.009). Conclusions: An increased association between AD as quantified by the ANSiscope™ and perioperative adverse outcomes was observed. An increased rate of emergency conversion of OPCAB to on-pump surgery with higher dysfunction was noted. The authors opine that the threshold for conversion must be lower in patients deemed to be at a higher risk. Proper evaluation of the autonomic nervous system empowers the anesthesiologist to anticipate and adequately prepare for complications.

Early prediction of acute kidney injury using serum phosphorus as a biomarker in pediatric cardiac surgical patients.

BACKGROUND: Acute kidney injury (AKI) is a strong predictor of morbidity and mortality after cardiac surgery. Lack of valid early biomarkers for predicting AKI has hampered the ability to take therapeutic measures for preventive cause. Hyperphosphatemia that occurs in AKI due to renal excretion defect was not studied in this context and could be simple marker of AKI. Therefore, we tested role of serum phosphorus in prediction of AKI as a biomarker after cardiac surgery in children. METHODOLOGY: We prospectively evaluated 51 children aged between 3 weeks and 12 years undergoing elective cardiac surgery. Serum creatinine and phosphorus were measured preoperatively and postoperatively at 24 and 48 h. As per the Kidney Disease Improving Global Outcomes criteria, patients were grouped into AKI and non-AKI on the basis of the development of AKI within 48 h postsurgery. The postoperative diagnostic performance of phosphorus thresholds was analyzed by the area under receiver operating characteristic curves (AUC-ROC). RESULTS: From 51 children included, 10 developed AKI. In AKI group, serum phosphorus increased significantly from 4.47 ± 0.43 baseline to 6.29 ± 0.32 at 24 h postsurgery (P = 0.01) while serum creatinine increased from baseline 0.33 (0.24-0.46) to 0.49 (0.26-0.91) at 24 h which is statistically insignificant (P = 0.16). ROC analysis showed that serum phosphorus at 24 h, the AUC was 0.84 with sensitivity 0.75 and specificity 0.93 for a cutoff value of 6.4 mg/dl. Whereas serum phosphorus at 48 h, the AUC was 0.86 with sensitivity 66.67% and specificity 97.62% for a cutoff value of 5.4 mg/dl. CONCLUSION: Serum phosphorus can be an alternative biomarker as early as 24 h for early prediction of AKI in pediatric cardiac surgery.

The Effect of Inhaled Milrinone Versus Inhaled Levosimendan in Pulmonary Hypertension Patients Undergoing Mitral Valve Surgery - A Pilot Randomized Double-Blind Study.

OBJECTIVE: To compare the effects of inhaled milrinone and levosimendan on pulmonary and systemic hemodynamics in patients with pulmonary hypertension. DESIGN: Prospective, double-blind, randomized controlled study. SETTING: Tertiary care cardiac institute with 650 beds. PARTICIPANTS: The study comprised 150 adult patients with pulmonary hypertension undergoing mitral valve surgery. INTERVENTIONS: Patients were assigned randomly into 1 of the following 3 groups: milrinone (M), levosimendan (L), or control (C); n = 50 per group. In group M, inhaled milrinone (50 µg/kg); in group L, inhaled levosimendan (24 µg/kg); and in group C, normal saline was administered when the patient arrived in the recovery room. Pre-inhalation and post-inhalation hemodynamics (mean arterial pressure [MAP], pulse rate, and systemic vascular resistance [SVR]) were noted until 24 hours of inhalation of the drug. The change in pulmonary artery pressures (pulmonary artery systolic pressure [PASP] and mean pulmonary artery pressure [MPAP]) and the duration for which they remained decreased compared with the control group, were noted. MEASUREMENTS AND MAIN RESULTS: MAP, pulse rate, and SVR were comparable in the 3 groups at various time intervals. PASP and MPAP decreased comparably after inhalation of levosimendan and milrinone. However, they reached levels near the control group values after 2.5 to 3 hours in group L and after 0.5 hours in group M. CONCLUSIONS: Because inhaled levosimendan causes a decrease in PASP and MPAP without causing a decrease in SVR and MAP, the authors conclude that inhaled levosimendan is a selective pulmonary vasodilator. It is as effective as milrinone in reducing pulmonary artery pressures. In addition, it has advantage over inhaled milrinone because it is has a longer duration of action.

Interference of apex locator, pulp tester and diathermy on pacemaker function.

AIM: The purpose of this study was to evaluate the effects of three electronic apex locators (EAL), electric pulp tester (EPT) and diathermy on pacemaker function in vitro. MATERIALS AND METHODS: Three EALs: Root ZX (J. Morita Co., Tustin, CA, U.S.A.), Propex (Dentsply), Mini Apex locator (SybronEndo, Anaheim, CA, USA), EPT (Parkell pulp vitality tester Farmingdale, NY, USA) and Diathermy (Neomed 250 B) were tested for any interference with one pacemaker (A medtronic kappa KVDD901-serial number: PLE734632S). Directly connecting the pacemaker lead with the EAL/EPT/diathermy operating on a flat bench top, the telemetry wand was held directly over the pacemaker to monitor the pacing pattern for a period of 30 s. Pacemaker activity was continuously recorded on the telemetric programmer and electro gram (EGM) readings examined for pacer inhibition, noise reversion or inappropriate pacemaker pulses. RESULTS: All the three apex locators showed no pacing interference or background noise during its function or at rest. The EGM readings of EPT showed varying levels of background noise in between pacing however, this did not affect the normal pacing pattern and the pacing interval remained constant. EGM readings of diathermy showed an increase in the pacing interval (irregular pacing pattern) followed by complete inhibition of the pacing system. CONCLUSION: The tested EALs do not interfere with cardiac pacemaker function. The tested EPT showed varying levels of background noise but does not interfere with cardiac pacemaker function. Use of Diathermy interfered with the normal pacing, leading to complete inhibition of the pacing system.

Determination of Trace Metals, Moisture, pH and Assessment of Potential Toxicity of Selected Smokeless Tobacco Products.

The characterization and classification of smokeless tobacco products has been a continuously evolving process. This is based on a number of different parameters like nicotine content, moisture content, amount of heavy metals, pH, and in vitro cytotoxicity assays. Their contexts often vary between countries, research institutions, and legal requirements. The categorisation of these products is quite challenging due to the diffused sample sizes, diverse array of branded products on offer, and the absence of a centralized manufacturing facility. This study aims at a systematic classification of 10 smokeless tobacco product samples from the retail market based on their potential toxicity upon long-term use. The estimation of potential toxicity follows a well-established method that employs the concentration of toxic metals in the different samples. The potential toxicity as well as heavy metal concentrations of the smokeless tobacco products analysed was found to be much higher than acceptable limits. For instance, the levels of lead, cadmium, copper and zinc of 2.5, 1, 4 and 23 ppm, respectively, are well above their recommended limits. The results from the study indicate that chronic use of smokeless tobacco products is a significant health risk, especially in the vulnerable population. Further studies of this nature will help establish a toxicological fingerprint on the diverse class of products that floods the market now.

Efficacy of peracetic acid in rapid disinfection of Resilon and gutta-percha cones compared with sodium hypochlorite, chlorhexidine, and povidone-iodine.

BACKGROUND: The aim of this investigation was to compare the effectiveness of 3% sodium hypochlorite (NaOCl), 2% chlorhexidine, 1% peracetic acid, and 10% povidone-iodine in the rapid disinfection of Resilon (Pentron Clinical Technologies, LLC, Wallingford, CT) and gutta-percha cones contaminated with Enterococcus faecalis and Bacillus subtilis. METHODS: Two hundred fifty-six samples consisting of 128 gutta-percha cones and 128 Resilon cones were used in this study. The materials were tested for disinfection according to the type of solution (3% NaOCl, 2% chlorhexidine, 1% peracetic acid, or 10% povidone-iodine), the time of exposure to each solution (1 or 5 minutes), and the type of microorganisms (E. faecalis or B. subtilis). Subsequent to the disinfection, samples were placed in test tubes containing 10 mL Mueller-Hinton broth and incubated at 37°C for 7 days. All test tubes were observed at 24-hour intervals and visually checked for turbidity, signifying microbial growth. RESULTS: In this study, 1% peracetic acid showed the best results for both 1 minute and 5 minutes of disinfection, 2% chlorhexidine showed the second best results although it was statistically at par with peracetic acid, and 3% hypochlorite ranked third in disinfection; this was statistically significant when compared with peracetic acid and chlorhexidine. Disinfection by povidone-iodine was the least within all the groups for both contact times although disinfection for 5 minutes showed better results than disinfection for 1 minute for gutta-percha. CONCLUSIONS: The outcome of this study confirmed the efficacy of 1% peracetic acid and 2% chlorhexidine in the rapid disinfection of both Resilon and gutta-percha.

Spiral computed tomographic evaluation and endodontic management of a maxillary canine with two canals.

Aberrations in the root canal system can pose a considerable challenge to the endodontist during root canal treatment. These anatomical variations are more commonly seen in maxillary molars and mandibular teeth, but only a few cases have been reported with alteration in the internal canal anatomy of maxillary canine. The present report describes the diagnosis of bilateral occurrence of two root canals in maxillary canines with single root and the endodontic management of the right maxillary canine with the aid of spiral computed tomography (CT). The CT images revealed the presence of Vertucci's type-III canal configuration in the right maxillary canine. The same canal pattern was found in the contra-lateral canine, which was absolutely healthy; and also all the mandibular anterior teeth and first premolars showed bifid canal pattern.

Classification of Swiss cheese starter and adjunct cultures using Fourier transform infrared microspectroscopy.

The acceptability of Swiss cheese largely depends on the flavor profile, and strain variations of cheese cultures will affect the final quality. Conventional biochemical methods to identify the cultures at the strain level are time-consuming and expensive, and require skilled labor. Our objective was to develop rapid classification methods of starter cultures at the strain level by using a combination of hydrophobic grid membrane filters and Fourier transform infrared (FTIR) spectroscopy. Forty-four pulsed-field gel electrophoresis-verified strains of starter and nonstarter cultures including Streptococcus thermophilus, Propionibacterium freudenreichii, and Lactobacillus spp. were analyzed. The strains were grown on their respective agar media, transferred to broth media, and incubated. Then, cultures were centrifuged and the pellets were resuspended in saline solution (10 µL). Aliquots (2 µL) of the suspended bacterial solution were placed onto a grid of the hydrophobic grid membrane filters, having 6 grids per each strain analyzed. The dried filters were read by FTIR microspectroscopy fitted with an attenuated total reflectance probe. Collected spectra were statistically analyzed by a soft independent modeling of class analogy (SIMCA) for pattern recognition. Classification models were developed for Streptococcus thermophilus, Propionibacterium freudenreichii, and Lactobacillus spp. strains. The models showed major discrimination in the spectral region from 1,200 to 900 cm(-1) associated with signals from phosphate-containing compounds and various polysaccharides in the cell wall. The developed method allowed for rapid classification of several Swiss cheese starter and nonstarter cultures at the strain level. This information provides a detailed overview of microbiological status, which would enable corrective measures to be taken early in the cheese making process, limiting production of inferior quality cheese and minimizing defects. This method could be an effective tool to identify and monitor activity of cheese and other dairy starter cultures.

Bilateral anterosuperior dislocation of intact mandibular condyles in the temporal fossa.

Dislocation of the temporomandibular joint occurs when the mandibular condyle is displaced anteriorly beyond the articular eminence and represents 3% of all dislocated joints reported in the body. Superolateral dislocation of the condyle into the temporal fossa is well documented in the literature, but anterosuperior dislocation without an associated fracture is rarely described. This report documents the case of a middle-aged woman with bilateral anterosuperior dislocation of the intact mandibular condyle after a fall on the face. This report reviews the literature on dislocations, suggests a nomenclature, possible causative mechanism and documents the importance of early management.

Hyperprolactinaemia.

Hyperprolactinaemia is a frequent cause of reproductive problems encountered in clinical practice. A variety of pathophysiological conditions can lead to hyperprolactinaemia; therefore, pregnancy, drug effects, hypothyroidism and polycystic ovary syndrome should be excluded before investigating for prolactin-secreting pituitary tumours. Prolactinomas are mainly diagnosed in women aged 20-40 years. They present with clinical features of hyperprolactinaemia (galactorrhoea, gonadal dysfunction), and more rarely with large tumours, headache and visual field loss due to optic chiasm compression. Medical therapy with dopamine agonists is the treatment of choice for both micro- and macroprolactinomas. Tumour shrinkage and restoration of gonadal function are achieved in the majority of cases with dopamine agonists. A trial of withdrawal of medical therapy may be considered in many patients with close follow-up. Pituitary surgery and radiotherapy currently have very limited indications. Pregnancies in patients with prolactinomas need careful planning and close monitoring.

PTH circadian rhythm and PTH target-organ sensitivity is altered in patients with adult growth hormone deficiency with low BMD.

UNLABELLED: AGHD is associated with osteoporosis. We examined PTH circadian rhythmicity and PTH target-organ sensitivity in 23 patients with AGHD with low BMD and 20 patients with AGHD with normal BMD. Patients with low BMD had a blunted nocturnal rise in PTH concentration and reduced PTH target-organ sensitivity compared with patients with normal BMD; these factors may be important in the pathogenesis of AGHD-related osteoporosis. INTRODUCTION: Adult growth hormone deficiency (AGHD) is associated with decreased BMD. Reduced parathyroid gland sensitivity to changes in calcium and reduced PTH target-organ sensitivity may underlie the pathogenesis of AGHD-related osteoporosis. A blunted nocturnal PTH rise has been reported in AGHD and may contribute to the reduction in BMD. We examined the difference in PTH concentration and markers of bone metabolism in patients with AGHD with normal and low BMD. MATERIALS AND METHODS: Forty-three patients with AGHD consented to the study. Twenty-five patients were growth hormone (GH) naïve (GH-N, 13 had BMD femoral neck or lumbar spine T-score < -1.0), and 18 patients had received GH for >2 yr (GH-R, 10 had BMD T-score < -1.0). Patients were hospitalized for 24 h, where blood samples were collected every 0.5 h and urine samples were collected every 3 h for PTH, calcium, phosphate, NcAMP, 1,25-dihydroxyvitamin D [1,25(OH)(2)D], type-I collagen beta C-telopeptide (betaCTX), and procollagen type-I amino-terminal propeptide (PINP). Serum calcium was adjusted for albumin (ACa). RESULTS: Low BMD GH-N and GH-R patients exhibited a reduced nocturnal rise in PTH concentration compared with patients with normal BMD (p < 0.001). GH-N low BMD patients had significantly higher 24-h mean PTH (p < 0.001) than GH-N normal BMD patients, with significantly lower 24-h mean NcAMP, ACa, and 1,25(OH)(2)D (p < 0.01), suggesting a reduction in renal PTH sensitivity. GH-R low BMD patients had significantly lower 24-h mean PTH, NcAMP, ACa, and 1,25(OH)(2)D (p < 0.01) than GH-R normal BMD patients, suggesting reduced renal PTH action. Lower PTH concentration in the presence of lower ACa may reflect reduced sensitivity of the parathyroid calcium-sensing receptor to changes in ACa concentration in the GH-R low BMD patients. CONCLUSIONS: Low BMD in GH-N and GH-R AGHD patients may be a consequence of abnormalities in PTH circadian rhythmicity together with reduced parathyroid gland and target-organ sensitivity. Further studies are needed to determine the potential benefit of therapeutic manipulation of PTH rhythmicity and sensitivity on BMD.