Periodontal therapy for hopeless mandibular anterior teeth: a retrospective case report with a multidisciplinary approach and a 20-year follow-up

Introduction: This case report presents the intentional periodontal maintenance of two periodontal hopeless lower central incisors with a multidisciplinary approach and 20-year follow-up. Case presentation: A 36-year-old male, in 2001, was diagnosed with aggressive periodontitis, gingival swelling, bleeding, and mandibular central incisors with mobility and poor prognosis. Following periodontal therapy (phase I), root canal treatment, and occlusal adjustment, #31 and #41 were gently extracted to remove the granulation tissues, calculus, and infected cementum from the root surface. Then, tetracycline-HCl was applied for 5 minutes on the root surfaces. The teeth were repositioned into the sockets and splinted with a lingual bar. At 3 months, the bar was removed, and a free gingival autogenous graft was done to improve the local keratinized tissue width. Mobility scores, pocket depths, and clinical attachment levels were recorded, and radiographs were taken at 1, 5, and 20 years. The 5-year follow-up showed that the teeth were clinically and radiographically in function. There was a reduction in probing depth and a gain in clinical attachment and radiographic alveolar bone levels. After 20 years, #41 was stable, but #31 had external root resorption, leading to a new treatment plan (dental implants) and extraction. Conclusion: The clinical result of this case was satisfactory for 20 years. Intentional periodontal maintenance of the teeth may be an alternative treatment, even considering the high level of complexity.

Concomitant ablation for non-paroxysmal atrial fibrillation: combined energy versus cryoablation alone.

Background: Surgical ablation of atrial fibrillation has been the most efficient treatment for atrial fibrillation (AF). Combined energy (CE) ablation and cryoablation alone (CA) are the most common energy modes used for ablation, however, comparative data is lacking. Objectives: To compare the efficacy of CE ablation with CA in the setting of concomitant biatrial ablation for non-paroxysmal AF. Methods: A retrospective analysis of 453 patients with non-paroxysmal AF undergone concomitant biatrial ablation from November 2007 to December 2022 during elective cardiac surgery using either combined bipolar radiofrequency with cryoenergy or cryoenergy alone was performed. Propensity score matching was conducted to balance the covariates in the groups. Results: There were 157 patients per group after matching. CE ablation was associated with lower odds of atrial tachyarrhythmia recurrence (OR = 0.13, 95% CI 0.02-0.91, p = 0.040), a significantly lower rate of hospital readmissions due to rhythm disruption (HR = 0.34, 95% CI 0.18-0.65, p < 0.001), and lower cumulative incidence of stroke (SHR = 0.38, 95% CI 0.15-0.97, p = 0.043). No significant difference in permanent pacemaker implantation was observed between the two groups. Conclusions: In the setting of concomitant biatrial ablation for non-paroxysmal AF, combined bipolar radiofrequency and cryoablation appear to be a superior treatment modality compared to cryoablation alone in achieving long-term freedom from atrial arrhythmias, in reducing arrhythmia-related hospital readmissions and ischemic strokes.

Are We Resecting Too Much Colon in Perforated Diverticulitis?

Initially, the Hartmann's procedure was done to reduce mortality in surgery cases of malignant rectal lesions, and not benign disease. However, the procedure was popularized in the management of perforated diverticular disease (PDD) in the 1970s. Herein, we present a case of a patient who had laparotomy and colostomy for PDD. During the post-operative planning for reversal of the diverting colostomy, a contrast study was done that revealed that most of the sigmoid colon was in fact healthy. In this patient, the colon was severed at the point of the perforation and exteriorized, which allowed time for the resolution of the gut inflammatory changes. Thus, Hartmann's operation would have led to the unnecessary resection of the healthy sigmoid colon and possibly condemned the patient to an irreversible stoma. In severe PDD, where a Hartmann's procedure is considered, one could sever the colon at the site of perforation and bring out a colostomy while tacking the closed, unresected distal end near the ostomy. Further contrast studies of the colon could assist in planning resection and anastomosis.

Clinical application of an optimized reference measurement procedure for serum digoxin using bracketing calibration method by ID-LC-MS/MS.

Digoxin, a cardiac glycoside, is widely used in the treatment of cardiovascular diseases. Due to its narrow therapeutic range, precise monitoring of its blood concentration is essential. A reference measurement procedure (RMP) is pivotal for ensuring result accuracy and comparability. The RMP for serum digoxin by ID-LC-MS/MS was optimized with sample pre-treatment and detection processes, and the bracketing calibration method was used, which facilitates more accurate measurement, especially for extreme concentrations. The performance of this optimized RMP was thoroughly evaluated. The limit of detection (LoD) was 0.05 ng/mL (0.06 nmol/L) and the lowest limit of quantification (LLoQ) was 0.10 ng/mL (0.13 nmol/L). The intra- and inter-assay imprecisions were 2.24%, 2.51%, 1.40% and 1.72%, 1.65%, 0.97% at 0.5, 2.0, 5.0 ng/mL, respectively. Recoveries were 99.63 to 101.42% and the linear response ranged from 0.1 to 10.0 ng/mL. The relative bias was 0.41% and 2.00% of our results compared with the median of all participating reference laboratories for IFCC-RELA (External Quality Assessment Scheme for Reference Laboratories in Laboratory Medicine) 2023A and 2023B. The uncertainty, calibration and measurement capability (CMC) of this method were also evaluated. The optimized RMP was applied in the Trueness Verification Plan of Southern China, which indicates significant differences among clinical systems, highlighting the need for standardization efforts. In addition, two commonly used clinical systems which employed immunoassay methods were compared with this optimized RMP, and 26 individual serum samples were analyzed. The good correlations indicate the feasibility of standardization for serum digoxin. The optimized RMP serves as an accurate reference baseline for routine methods, aiming to enhance the accuracy and precision of measurements in clinical laboratories.

Variation in the Branches of Arch of Aorta in Patients Undergoing Contrast Enhanced Multidetector Computed Tomography in a Tertiary Centre, Nepal.

INTRODUCTION: Variations in the branching pattern of the Arch of Aorta (AoA) are common in patients undergoing contrast-enhanced Multidetector Computed Tomography, the identification of which is crucial in managing patients undergoing cardiovascular/neck surgeries and interventions. METHODS: This prospective cross-sectional study involved 513 patients who were sent to the Department of Radiology for evaluation of various pathologies of chest and neck between August 2018 and July 2019. After approval from the Institutional Review Committee {Reference No: 11(6-11) E2/075/076}, contrast-enhanced computed tomography images were evaluated with variations in branches of the left-sided arch of the aorta and symptoms associated. RESULTS: Variations in branches of the arch of aorta were seen in 69 (13.45%; 95% CI: 10.60%-16.71%) of cases, left common carotid artery and brachiocephalic trunk having common origin or common trunk was 51(9.94%). The mean age was 52.4±20 years (Range 3 months to 92 years) with male to female ratio of 1.3:1. CONCLUSIONS: Contrast-enhanced computed tomography is the modality of choice for the detection of the variations in branches of AoA, recognition of which is crucial in vascular intervention and surgical procedures to reduce the postoperative morbidity and mortality of the patients.

A clinical comparative study of an outpatient treatment group and an endoscopic sinus surgery group for maxillary sinus fungus ball.

PURPOSE: This study aimed to clarify the differences in the pathophysiology of maxillary sinus fungus balls (FB) among different case groups and to identify which patients with maxillary sinus FB would be suitable for outpatient procedures. METHODS: Thirty-four patients diagnosed with maxillary sinus FB between January 2017 and December 2021 were divided into two groups (O and S). We retrospectively compared the clinical and imaging characteristics, and the treatment outcomes between the groups. Group O comprised 12 patients (13 sides) treated in an outpatient clinic and Group S comprised 15 patients (16 sides) treated with endoscopic sinus surgery (ESS). RESULTS: Compared to Group S, Group O had more patients with an enlarged maxillary sinus membranous portion, and shadows indicative of fungal masses (P < 0.01 and P < 0.05, respectively). In particular, the anteroposterior ratio of the open maxillary sinus membranous area was 0.68 ± 0.16 in Group O and 0.5 ± 0.12 in Group S. After surgery, Group O exhibited greater anteroposterior expansion of the maxillary sinus membranous portion compared to Group S (P < 0.01). Additionally, Group O had more patients with shadows in sinuses other than the maxillary sinus (P < 0.01) and medial displacement of the uncinate process (P < 0.01) than Group S. In addition, Group O required fewer procedures and hospital visits than Group S (P < 0.001 and P < 0.01, respectively). CONCLUSIONS: Determining the indications for outpatient procedures while considering the pathophysiology of maxillary sinus FB can significantly benefit patients and medical professionals in terms of safety and medical costs.

Recurrent Anterior Shoulder Dislocation with Coracoid Fracture in an Old Age Male: A Rare Case Report.

Introduction: Anterior shoulder dislocation is a common pathology in young males with less prevalence in other age groups. Anterior shoulder dislocation being the most common variety of dislocation among the shoulder dislocation can be managed both conservatively and surgically. Recurrent anterior dislocation in middle-aged males with a coracoid fracture is a rare entity and should be managed with proper pre-operative planning including computed tomography (CT) scan, magnetic resonance imaging (MRI), and surgery. Case Report: A 65-year-old male is a known case of recurrent anterior dislocation presented with anterior shoulder dislocation 1½ years back. Closed reduction was done. Radiological evaluations such as CT scan and MRI were done which were suggestive of bony Bankart and coracoid fracture which was managed with open Latarjet procedure. Conclusion: Recurrent anterior shoulder dislocation with a concomitant coracoid fracture is a rare entity in old age, which can be managed with a Latarjet procedure and has a good post-operative outcome.

Congenital Pseudoarthrosis of the Femur Managed with Masquelet Technique.

Introduction: Congenital pseudoarthrosis is a rare disorder, and mostly occurs in the radius, ulna, tibia, and fibula, but is not reported in the femur. Congenital cases that were reported in the literature, most were associated with neurofibromatosis, cleidocranial dysostosis, congenital constriction band syndrome and fibrous dysplasia and the acquired cases followed fractures of bones or tuberculosis. Since the life span of the patient is affected rarely, clinical examination of these patients and serial radiographs can give us plenty of information about the limb abnormality, its clinical course, and the nature of the underlying disturbance of growth. Case Report: A 3 year female child presents to the outpatient department of a tertiary care hospital with complaints of pain, swelling and deformity thigh region right side for 5 months. On examination, Swelling was present [2x2 cm] at the junction of the mid and distal thigh, smooth surface, ill defined edges, soft and non tender. There was abnormal mobility which was noted at the right thigh at the junction of the middle and distal 1/3 right femurMRI reported circumferential periosteal reaction with cortical surface irregularity of the right femoral shaft was also noted. The findings were reported to be concerning for chronic osteomyelitis with non-united fracture & cortical resorption/chronic bone loss. Histopathological sections showed multiple bits of viable bony trabeculae with surrounding fibro-collagenous tissue displaying significant proliferation of fibroblasts, slit-like blood vessels, arterioles and moderate mixed inflammatory infiltrate of plasma cells, few neutrophils, lymphocytes, histiocytes and few multinucleated histiocytes.She was managed with resection of pseudoarthrosis and masquelet procedure stage 1 and later masquelet stage 2 (cement spacer removal, ipsilateral ileac crest bone grafting with fixation with 7-hole distal fibular anatomical plate and bone graft substitute placement [ChronOs]). Conclusion: Idiopathic or primary congenital pseudoarthrosis can involve the femur as well as other long bones. It may or may not be associated with hip dysplasia and the outcome may not be as bad as previously reported in the pseudoarthrosis of other long bones.

A Case Report of Duodenal Malignancy and Its Management With Pancreaticoduodenectomy.

Gastrointestinal malignancies, most specifically duodenal malignancy, are uncommon in the population; however, they are tricky to manage because the lesions are diagnosed at a late stage and located in a complex area. This case report focuses on a patient who was diagnosed with a second (descending) part of the duodenum (D2) malignancy; the tumour was localised at the second part of the duodenum, and the management of this patient was through the Whipple procedure or pancreaticoduodenectomy. The patient complained of stinging abdomen pain. Diagnostic examination comprised of CT and biopsy proved the presence of a malignant tumour originating from the D2 area. The tumour's characteristics and the patient's general health status are determined by using Whipple's procedure. Post-operative management entails the use of IV antibiotics, analgesics, multivitamins and nasojejunal (NJ) tube feeding. The case also expounds on the consequences of a multimodal treatment strategy, meticulous planning of the surgical procedure, and adequate post-operative management of D2 malignancies. These data may shed some light on the peculiarities of duodenal cancer management with the Whipple procedure; nonetheless, early diagnosis and proper management should remain the primary goals.

Treatment of degenerated mitral bioprosthesis using Inovare alpha rapid deployment balloon-expandable prosthesis-a minimally invasive approach.

This case report describes an 82-year-old woman with severe mitral bioprosthesis stenosis and NYHA II-III heart failure, EuroScore II of 22.54% and STS Score of 13.7%. She received innovative treatment with transatrial mitral valve-in-valve implantation of a rapid deployment balloon-expandable prosthesis (BEP) via video-assisted right lateral mini-thoracotomy, with myocardial protection through ventricular fibrillation. The patient was discharged and, under cardiology follow-up, achieved NYHA I class with no angina.

Adopting Interventional Glaucoma Via Sustained-Release Therapies: The Wide-Ranging Impact of Procedural Pharmaceuticals in Ophthalmology.

Topical medical therapy is the most common approach to the treatment of many ocular conditions. While effective, topical therapy has numerous important limitations. Eye drops can have unpleasant or even dangerous side effects, are often difficult to self-administer, and the application of multiple drops per day, possibly from multiple different bottles, can be burdensome. Perhaps the most important limitation of topical medical therapy is non-adherence, a complex multifactorial behavior that increases the risk of poor outcomes associated with undertreatment. There is growing interest in a class of therapeutics termed "procedural pharmaceuticals" (PPs), which remove the responsibility of self-dosing from patients. An array of PPs are available for the treatment of a variety of ocular conditions, such as those for glaucoma, retina, and cataract surgery; and many more will emerge in coming years. A paradigm shift away from patient-administered therapy toward provider-administered therapy will have important implications for both providers and patients. This paper explores the impact that PPs have had, and will have, on the clinical practice of ophthalmology.

Endoscopic clipping of gastrojejunostomy leakage following Whipple procedure: A case report.

BACKGROUND: Currently, perioperative complications of classic Whipple surgery occur at a rate of approximately 40%. Common complications include delayed gastric emptying, pancreatic fistula, and bile leakage, whereas gastrojejunostomy (GJ) leakage is rare. CASE SUMMARY: This case report will assess the management of a GJ leak in a 71-year-old male patient following the Whipple procedure. After surgery, the patient was transferred to the clinic after four days of intensive care, where vacuum therapy was used to handle a developing subcutaneous collection. The patient, who had bile in the drains and incision during follow-up, underwent endoscopic examination on the 21st day after the operation. An opening of approximately 4 mm was observed in the GJ anastomosis during endoscopy. Five titanium clips were used to close the openings. The drainage of bile decreased to less than 50 mL on the first day after the procedure, and the patient's oral intake was opened. CONCLUSION: Current literature reports a GJ leakage rate of 0. 54% following Whipple surgery, with clinical findings lasting on average between 4-34 days. Surgery was the main form of therapy for this case, with a success rate of 84%, and percutaneous drainage was also utilized as a treatment option. This case report is the first to document endoscopic treatment of GJ leaks following the classic Whipple procedure.

Evaluation of the review models and approval timelines of authorities participating in the East African Medicine Regulatory Harmonisation initiative: alignment and strategies for moving forward.

Introduction: Medicines regulatory harmonisation has been embraced by many national regulatory authorities (NRAs) to improve public health through faster availability of safe, high-quality, and effective medical products to patients and enhanced standardisation of technical guidelines and work sharing, leading to reduced cost to pharmaceutical companies. After ten years of implementing regulatory harmonisation by the East African Community Medicines Registration Harmonization (EAC-MRH) initiative, it is now imperative for participating NRAs to rely on each other to minimise duplication of use of limited resources. Major challenges in implementing reliance are the lack of clear registration processes and delays in the approval. The aim of this study was to compare review models, target timelines and data requirements used in assessing applications by EAC-MRH NRAs so as to align and propose strategies for improvement. Methods: A validated questionnaire that standardises and captures review processes was completed by the head of the medicine's registration division in each of the seven EAC-MRH NRAs. A country report based on the completed questionnaire was developed for each NRA and validated by the heads of the respective authorities. Results: Most applications received by all countries were for generics except Kenya, which received a significant number of new active substance applications (55 and 53 in 2020 and 2021). Mean approval times for generics using full review varied, with Tanzania's time declining for the three years. Target timelines for full review for the five countries ranged between 180 calendar days (Tanzania) to the highest 330 days (Zanzibar). The three countries (Kenya, Rwanda and Uganda) utilising the verification review model had a target timeline of 90 days. All six authorities conducted abridged reviews and fast-track assessments through a priority review track. The common technical document format was mandatory for applications in all authorities. The target timeline for key milestones in the review process varied for each country with a few similarities. Discussion: The study has provided a baseline for review models, target timelines and data requirements utilised in assessing applications for registration by EAC-MRH NRAs. Implementing the recommendations from this study will enable the NRAs to align and improve their registration processes.

Unstable Spinal Fracture With Arteria Lusoria: Management to Mitigate Aortic Risks.

Aortic injuries associated with unstable spinal fractures are a rare but serious condition, with high mortality. Rapid and multidisciplinary management is crucial to prevent fatal complications. We report the case of a female patient who, following a road traffic accident, presented with a displaced fracture of the fourth dorsal vertebrae (D4), with a detached anterior fragment adjacent to the posterior aspect of the aortic arch and the origin of the arteria lusoria. The multidisciplinary discussion concluded that surgery without an aortic prosthesis is associated with a major hemorrhagic risk due to aortic injury during spinal fixation manipulations, and surgery with a prosthesis is associated with immediate risks of ischemic cerebrovascular accident, gas embolism, and upper limb ischemia. We opted to prepare the patient for spinal stabilization surgery after placing the aortic prosthesis type: Zenith Alpha ZTA-PT-30-26-108 thoracic prosthesis (Cook Medical, Bloomington, Indiana, US). Our team's therapeutic approach is being discussed given the rarity of cases in the literature and the patient's anatomical characteristics. Surgical management in these situations must repair the unstable fracture while avoiding the aggravation of an existing or potential aortic injury. The aortic lesion can be treated first, before spinal fixation, either with open surgery, which carries a high risk of severe complications, or thoracic endovascular repair (TEVAR), which allows the prevention of the potential aortic injury or repair of the existing aortic injury while minimizing the side effects of open surgery. However, endovascular surgery may have limitations due to individual vascular anatomy, as in our patient's case, which can prevent optimal endograft positioning and lead to risks such as endoleak, ischemia, infection, or thrombosis, necessitating periodic radiological follow-up. Endovascular repair is a new paradigm that has improved clinical outcomes for these patients by securing the vascular injury first before spinal surgery. Teamwork and multidisciplinary discussion ensure optimal safety, minimizing the side effects of these lesions, which can be fatal at any time during management.

Peri anal region is an overlooked location for pilonidal recurrence after surgical excision and closure - A case series.

INTRODUCTION AND IMPORTANCE: Patients with pilonidal disease (PD) often undergo wide excision of pilonidal sinuses and flap-based closures. Patients who failed these procedures can have recurrent perianal wounds obscured by hair and unrecognized even by the treating physicians. In this report, we describe a series of pilonidal patients with recurrent disease and perianal wounds. CASE PRESENTATION: Five pilonidal patients with recurrent disease after surgical excision and flap closure were referred to our Pilonidal Care Clinic. All five were found to have perianal wounds. Each patient was treated with regular manual and laser epilation and only one patient required a Gips procedure. All wounds were successfully healed. CLINICAL DISCUSSION: After removal of hair at the perianal region, patients with recurrent pilonidal disease can expose a pilonidal sinus that was previously unrecognized. Peri-anal wounds can have poor wound healing due to the close proximity of the wound to the anal verge, risk of contamination, difficulty of consistent observation of the wound, and moist environment of the anus that retains bacteria. Careful consideration of proper wound care post-excision of perianal pilonidal sinuses should be prioritized. CONCLUSIONS: Pilonidal perianal wounds after previous surgical excision and flap closure can be obscured by hair, resulting in recurrent pain and drainage. The perianal wounds can be successfully healed with regular manual and laser epilation and selectively excised using Gips procedure.

Expedient measurement of total protein in human serum and plasma via the biuret method using fiber optic probe for patient samples and certified reference materials.

The biuret method is currently recognized as a reference measurement procedure for serum/plasma total protein by the Joint Committee for Traceability in Laboratory Medicine (JCTLM). However, as the reaction involved in this method is highly time-dependent, to ensure identical measurement conditions for calibrator and samples for high accuracy, a fast and simple measurement procedure is critical to ensure the precision and trueness of this method. We measured serum/plasma total protein using a Cary 60 spectrophotometer coupled with a fiber optic probe, which was faster and simpler than the conventional cuvette method. The biuret method utilizing alkaline solutions of copper sulfate and potassium sodium tartrate was added to the sample and calibrator (NIST SRM 927e) incubated for 1 h before measurement. A panel of samples consisting of pooled human serum, single donor serum, and certified reference materials (CRMs) from three sources were measured for method validation. Sixteen native patient samples were measured using the newly developed biuret method and compared against clinical analyzers. Additionally, the results of three cycles of a local External Quality Assessment (EQA) Programme submitted by participating clinical laboratories were compared against the biuret method. Our biuret method using fiber optic probe demonstrated good precision with within-day relative standard deviation (RSD) of 0.04 to 0.23% and between-day RSD of 0.58%. The deviations between the obtained values and the certified values for all three CRMs ranged from -0.38 to 1.60%, indicating good method trueness. The routine methods using clinical analyzers were also found to agree well with the developed biuret method using fiber optic probe for EQA samples and native patient samples. The biuret method using a fiber optic probe represented a convenient and reliable way of measuring serum total protein. It also demonstrated excellent precision and trueness using CRMs and patient samples, which made the method a simpler candidate reference method for serum protein measurement.

Assessment and prediction of Water Quality Index (WQI) by seasonal key water parameters in a coastal city: application of machine learning models.

The Water Quality Index (WQI) provides comprehensive assessments in river systems; however, its calculation involves numerous water quality parameters, costly in sample collection and laboratory analysis. The study aimed to determine key water parameters and the most reliable models, considering seasonal variations in the water environment, to maximize the precision of WQI prediction by a minimal set of water parameters. Ten statistical or machine learning models were developed to predict the WQI over four seasons using water quality dataset collected in a coastal city adjacent to the Yellow Sea in China, based on which the key water parameters were identified and the variations were assessed by the Seasonal-Trend decomposition procedure based on Loess (STL). Results indicated that model performance generally improved with adding more input variables except Self-Organizing Map (SOM). Tree-based ensemble methods like Extreme Gradient Boosting (XGB) and Random Forest (RF) demonstrated the highest accuracy, particularly in winter. Nutrients (Ammonia Nitrogen (AN) and Total Phosphorus (TP)), Dissolved Oxygen (DO), and turbidity were determined as key water parameters, based on which, the prediction accuracy for Medium and Low grades was perfect while it was over 80% for the Good grade in spring and winter and dropped to around 70% in summer and autumn. Nutrient concentrations were higher at inland stations; however, it worsened at coastal stations, especially in summer. The study underscores the importance of reliable WQI prediction models in water quality assessment, especially when data is limited, which are crucial for managing water resources effectively.