A rare case of bilateral pseudoaneurysm secondary to mandibular condyle fracture-a case report with review of literature.

This paper aims to present a rare case report of bilateral pseudoaneurysm secondary to condylar fracture and its management with a brief review of literature. A patient of age 19 years with alleged history of road traffic accident presented 6 weeks lately to our department with slow growing swelling in right preauricular area. History revealed bilateral condylar fracture with right parasymphysis fracture of mandible for which patient underwent maxillomandibular fixation for 4 weeks. The diffuse swelling in preauricular region showed positive signs of pulsation and audible bruit. Ultrasonography and contrast-enhanced computed tomography suggested the bilateral presence of vascular anamoly from the terminal branches of external carotid artery. Diagnostic angiography confirmed presence of pseudoaneurysm at the bifurcation of the internal maxillary artery and superficial temporal artery (STA) on right side whereas on the left side it was at proximal STA. Bilateral endovascular coil and gel foam embolization was done and thrombosis was confirmed with high frequency ultrasound on fourth postintervention day. The swelling completely resolved in a period of 1 month with no evidence of recurrence in the following 2-year follow-up period. Routine investigation revealed presence of pseudoaneurysm on left side which was completely without any clinical signs as repoterd by many cases of condylar fracture in the literature review. Pseudoaneurysm may remain silent and are exposed intraoperatively with massive bleeding which causes significant morbidity. Hence, prompt diagnosis and management is essential to avoid unexpected complication perioperatively.

Quantifying the impact of regional variations in COVID-19 infections and hospitalizations across Ireland.

BACKGROUND: As most COVID-19 transmission occurs locally, targeted measures where the likelihood of infection and hospitalization is highest may be a prudent risk management strategy. To date, in the Republic of Ireland, a regional comparison of COVID-19 cases and hospitalizations has not been completed. Here, we investigate (i) the variation in rates of confirmed infection and hospital admissions within geographical units of the Republic of Ireland and (ii) frequency of deviations in risk of infection or risk of hospitalization. METHODS: We analyzed routinely collected, publicly available data available from the National Health Protection and Surveillance Centre and Health Service Executive from nine geographical units, known as Community Health Organization areas. The observational period included 206 14-day periods (1 September 2020-15 April 2021). RESULTS: A total of 206 844 laboratory-confirmed cases and 7721 hospitalizations were reported. The national incidence of confirmed infections was 4508 [95% confidence interval (CI) 4489-4528] per 100 000 people. The risk of hospital admission among confirmed cases was 3.7% (95% CI 3.5-3.9). Across geographical units, the likelihood that rolling 14-day risk of infection or hospitalization exceeded national levels was 9-86% and 0-88%, respectively. In the most affected regions, we estimate this resulted in an excess of 15 180 infections and 1920 hospitalizations. CONCLUSIONS: Responses to future COVID-19 outbreaks should consider the risk and harm of infection posed to people living in specific regions. Given the recent surges of COVID-19 cases in Europe, every effort should be made to strengthen local surveillance and to tailor community-centred measures to control transmission.

Role of Carnoy's solution as treatment adjunct in jaw lesions other than odontogenic keratocyst: a systematic review.

Carnoy's solution (CS) is routinely used as adjuvant therapy in the management of odontogenic keratocyst (OKC) and a few other benign lesions. The purpose of this study was to explore the evidence of its application and efficacy in benign lesions other than OKC. We have systematically reviewed published articles to identify the evidence of CS in benign jaw lesions other than OKC following the PRISMA guidelines. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane Library database, to find relevant articles from 1980 to March 2020. Finally, 39 studies were analysed in this review. It included studies where CS was used as an adjunct for the benign lesion of the jaw and followed for a minimum of 6 months. Thirty-nine studies with 11 different types of lesion were reported where CS was used as an adjuvant and application time was restricted to 3-5minutes. Recurrence were reported only in ameloblastoma cases [unicystic=10.98% (10/91), mixed=18.18% (26/143)]. Meta-analysis was not possible as all studies were non-controlled in nature. Based on the available data, there was no strong evidence for the use of CS as an adjuvant in the benign lesion of the jaw. Prospective and randomised control studies are recommended for the best stratification for the use of CS.

Molecular detection of Candidatus Rickettsia asembonensis in fleas collected from pets and domestic animals in Puducherry, India.

Rickettsia are obligate intracellular pathogens transmitted by arthropod vectors. The re-emergence of several rickettsioses imposes severe global health burden. In addition to the well-established rickettsial pathogens, newer rickettsial species and their pathogenic potentials are being uncovered. There are many reports of spotted and typhus fever caused by rickettsiae in India. Hence, in this study we screened the ectoparasites of pet and domestic animals for the presence of rickettsia using polymerase chain reaction. Nine cat flea samples (Ctenocephalides felis felis), that tested positive for the presence of rickettsia were subjected to Multi Locus Sequence Typing. Nucleotide sequencing and Phylogenetic analysis of gltA, ompB and 16rrs genes revealed that the rickettsiae detected in cat fleas was Rickettsia asembonensis. Further studies are required to assess Rickettsia asembonensis pathogenic potential to human and its enzootic maintenance of in various hosts and vectors.

Knowledge and attitudes towards HIV/AIDS amongst Kuwait University dental students.

The HIV and AIDS have emerged as complex health threats to the world population. As future dentists, it is pertinent that the dental students have sufficient knowledge and a positive approach towards the disease. Accordingly, the aim of this study was to assess the HIV/AIDS related knowledge and attitudes amongst clinical dental students at Kuwait University. A cross-sectional survey was conducted amongst the clinical dental students using a structured questionnaire with 60 questions to examine their knowledge under various categories and 13 questions to examine their attitudes towards the disease. The survey revealed that almost 58% of the respondents demonstrated a high level of knowledge (mean score: 45.23 ± 4.35 SD). Majority of the students (63.6%) expressed negative attitude (mean score: 5.36 ± 2.56 SD). The mean knowledge score of the fifth year dental students was significantly higher (P = 0.022) than that of the final year dental students regarding the knowledge of virus and disease process. However, no significant difference was observed with respect to other knowledge categories. Despite their high level of knowledge, the majority displayed a negative attitude towards HIV/AIDS. Hence, the findings imply that there is a need to address, more clearly, the students' misconceptions and attitudes towards the disease.

Prevalence of hepatitis C antibodies among hemodialysis patients in Al-hasa region of saudi arabia.

The prevalence of anti-HCV antibodies among hemodialysis (HD) patients was studied at King Fahad Hospital, Hofuf, Saudi Arabia. The records of 189 patients undergoing HD were reviewed. The overall prevalence of anti-HCV antibodies was 43.9%. Anti-HCV antibody prevalence was more common among female patients. There was no correlation between repeated blood transfusions and anti-HCV positivity as 4.8% of the patients who did not receive any blood transfusion during HD were positive for anti-HCV antibodies. A positive correlation was observed between the duration on dialysis and anti-HCV antibodies. An annual serocoversion rate of 6.8% was observed in this study.

Vascular access related septicemia in hemodialysis: a focus on bacterial flora and antibiotic access salvage.

A good vascular access is the lifeline of patients on long-term hemodialysis (HD) and anteriovenous fistula is considered the ideal access. Vascular access related septicemia (VARS) is the second most common cause of mortality among HD patients. Such infections could also lead to loss of vascular access unless specific measures are taken to preserve the accesses. The present study was designed to determine the incidence of septicemia, common bacterial flora involved, and impact of early, empirical antibiotic therapy on vascular access salvage among HD patients. This prospective study, involved 209 patients, undergoing long-term HD, from June 1996 to June 2000. A total of 85 (40.6%) developed VARS with predominance in females (63.7%), patients above 50 years of age (37.0%) and those having diabetes mellitus (25.1%). A total of 124 episodes of septicemia were recorded with an average of 1.23 episodes per 100 patient-months during the four year (10032 patient-months) study period. Peripheral blood samples for culture and sensitivity were collected and the patients were started empirically on amikacin-vancomycin combination which was modified after obtaining culture and sensitivity results. A cure was defined as 45 days symptom-free interval after antibiotic therapy was completed. Staphylococcus aureus was the commonest (29.0%) organism associated with VARS, followed by Pseudomonas aeruginosa (15.3%). The temporary vascular access group recorded maximum number of VARS episodes; [femoral catheter (FC) group, (43.5%), followed by subclavian (SC) group, (28.2%)] and the lowest (8.8%) was seen in the AVF group. Vascular access salvage rate of 48/85 (56.4%) and mortality of 22/85 (25.9%) was observed in the present study. Antibiotic access salvage with Amikacin-Vancomycin combination has an advantage of preserving vascular access sites in at least, 50% of cases.

The role the type of vascular access plays in the transmission of hepatitis C virus in a high prevalence hemodialysis unit.

BACKGROUND: The necessity of having a vascular access site as well as extracorporeal blood circulation, may add to the risk for patients being dialyzed in units with high HCV prevalence of acquiring hepatitis C virus (HCV) infection. This study endeavors to determine the role the type of vascular access plays in the transmission of HCV infection in the hemodialysis (HD) unit of a Middle Eastern country. METHODS: The records of 198 patients with end-stage renal disease (ESRD) enrolled on maintenance HD from November 1995 to November 2000 at this tertiary care center, were retrospectively reviewed to match the HCV prevalence and seroconversion rates among patients groups being dialyzed through various types of vascular accesses. Factors such as, number of units of blood transfused and dialytic age (time-span since the initiation of the HD treatment), implicated in transmission of HCV infection in HD units, were also recorded, and compared among these cohorts. RESULTS: The overall, high HCV seroprevalence of 43.4% (86/198) and annual seroconversion rate of 8.6% per year were recorded. Patients with arteriovenous fistula (AVF) documented peak anti-HCV prevalence [61.7% (63/102)] and annual seroconversion rates (12.3%) as compared to lowest prevalence of 12.9% (4/34) and seroconversion rate of 2.5%, observed among patients with permanent Catheters (PC). Patients dialyzed through polytetrafluoroethylene (PTFE) grafts recorded the next highest HCV prevalence of 47.8% (11/23) with seroconversion rate of 9.5% but temporary catheter (TC) group had HCV prevalence of 19% (8/42) and seroconversion rate of 3.8% [Odd Ratio (OR)-1.58, 95% Confidence Interval (CI) (0.37-7.12), p-NS]. CONCLUSIONS: Considerably higher annual seroconversion rates in AVF [OR-10.90, 95% CI (3.2-40.0), p<0.0001] and PTFE [OR-5.71, 95% CI (1.31-26.79), p<0.016)] groups, appear to suggest that the patients being dialyzed through AVF and PTFE, carried significantly higher risk of acquisition of HCV infection compared to those dialyzed through TC and PC (reference group). This could possibly be attributed to likely accessibility of HCV to blood circulation due to possible breakdown of standard infection control precautions during repeated punctures and cannulations of AVF and PTFE to perform a HD, in a unit with high baseline HCV prevalence.

Tunneled catheters' outcome optimization among diabetics on dialysis through antibiotic-lock placement.

Efficacy and safety of antibiotic 'locks', in prevention of thrombotic and infectious complication-related morbidity and mortality, among diabetics dialyzed through tunneled-cuffed catheters (TCCs) has not been effectively investigated. This trial was designed to investigate the outcome of TCCs (n = 109), inserted among 96 diabetic end-stage renal disease patients (March 2002-February 2003), by comparing the catheter thrombosis, catheter-related bloodstream infections (CRBSI), catheter survival, and mortality rates, between the cohorts of 49 patients who had TCCs (n = 51) 'locked' with cefotaxime/heparin (group I) and 47 patients with TCCs (n = 58) filled with standard heparin (group II). Thrombosis was defined as the inability to use catheter at a blood flow of 200 ml/min despite intraluminal thrombolysis. Primary end points were catheter thrombosis and CRBSI; elective catheter removal and CRBSI-related death led to sensor of TCCs follow-up. Patients with intraluminal cefotaxime/heparin lock, on cumulative survival analysis, showed a superior thrombosis-free (86.3 vs 63.8%, P = 0.023, log rank), infection-free (72.9 vs 27.1%, P = 0.004, log rank), and thrombosis- and infection-free TCC survival (78.4 vs 37.9%, P = 0.001, log rank) at 365 days, besides having significantly lower incidence of CRBSI (1.56 vs 3.68 episodes/1000 catheter days, P < 0.0001) and CRBSI-related mortality (9.8 vs 23.4%, P = 0.015), compared with the heparin-alone group. Deployment of cefotaxime-heparin 'lock' enhances catheter survival; reduces thrombotic and infectious complications and ensuing mortality, among diabetics on dialysis. However, further studies are needed to define the long-term implications of antibiotic locks in terms of the risk of emergence of antimicrobial resistance.

Impact of dedicated space, dialysis equipment, and nursing staff on the transmission of hepatitis C virus in a hemodialysis unit of the middle east.

BACKGROUND: Infection with the hepatitis C virus (HCV) is endemic in hemodialysis (HD) units, especially in Middle Eastern countries. The meticulous isolation policy recommended for patients with the hepatitis B virus (HBV) in an HD unit resulted in a significant drop in HBV incidence globally. This study was developed to prospectively investigate the impact of an identical isolation policy on incidence of nosocomial HCV infection in this HD unit of the Middle East. METHODS: In phase I of the study, we retrospectively reviewed the records of 189 patients with a mean age of 47.5 +/- 11.4 years (range, 15-85 years) who were receiving maintenance HD from December 7, 1995, to December 6, 2000, for the mean duration of 73 +/- 6.3 months (range, 3-144 months) to record the prevalence of HCV. Factors such as blood transfusions and dialytic age (time span that patient has received dialysis since its initiation) implicated in transmission of HCV in the HD unit also were recorded. Phase II involved stringent isolation of anti-HCV positive patients detected during phase I through provision of dedicated space, dialysis equipment, and nursing staff from December 7, 2000, to December 6, 2001. Liver function and anti-HCV tests were repeated for all the 198 patients every 6 months to identify new HCV seroconversions. RESULTS: An HCV prevalence rate of 43.9% (83/189) and an annual HCV seroconversion rate of 6.8% were identified in this cohort. No significant association with blood tranfusion was observed. Eighty-three anti-HCV positive (43.9%) patients had a mean dialytic age of 48.5 +/- 14.2 months compared with 25.0 +/- 8.6 months among 106 (56.1%) anti-HCV negative patients (relative risk [RR], 1.89; 95% confidence interval [CI], 1.39-5.86; P <.001). Only 2 new HCV seroconversions (1.01% [2/198]) were identified. CONCLUSIONS: Evidently, the sharing of facilities in a high-risk HD environment for a prolonged dialytic age facilitates the nosocomial transmission of HCV infection. A significant decline of annual seroconversion rate from 6.8% to 1.01% (odds ratio [OR], 7.535; 95% CI, 1.598-48.89; P <.005) suggests that a comprehensive, strictly enforced isolation policy for HCV-positive patients may play a significant role in limiting HCV transmission in HD units, just as it has in drastically reducing HBV transmission in these settings.

The impact of nasal carriage of methicillin-resistant and methicillin-susceptible Staphylococcus a ureus (MRSA & MSSA) on vascular access-related septicemia among patients with type-II diabetes on dialysis.

BACKGROUND: Fairly higher nasal carriage rates among type-II diabetics place them at a greater risk of endogenous Staphylococcus aureus linked vascular access-related septicemia (VRS) that is also dependent on the type of vascular access used for hemodialysis (HD). The prevalence of nasal carriage of methicillin susceptible and methicillin-resistant S. aureus (MSSA and MRSA) and its impact on VRS was determined in order to identify most vulnerable group and plan potential prophylactic strategies, accordingly. METHODS: Five standardized nasal swab cultures were performed in 208 patients enrolled for long-term HD through July 1996 to July 1999. Persistent nasal carriage was defined by two or more positive cultures for MSSA or MRSA. Peripheral blood cultures were collected on clinical suspicion of septicemia. RESULTS: The prevalence of type-II diabetes of 28.0% with 72.4% of nasal carriage rate and three folds higher S. aureus related VRS (RR-3.19, p<0.0001) than diabetic non-carriers on HD, was observed. Type-II diabetics also had higher MSSA and MRSA nasal carriage rates (53.4% and 19.0%) than non-diabetic nasal carriers (18.6 and 6.0%) yet, carried a comparable (RR-4.0 vs. 4.5) risk of VRS between MSSA and MRSA nasal carriers. Among diabetic type-II S. aureus nasal carriers, central venous catheters (CVCs) carried 35 and 38 times higher collective risk of developing MSSA and MRSA nasal carriage-related VRS respectively than Arterio-venous fistula (AVF). The AVF recorded the lowest risk of developing MSSA and MRSA nasal carriage-related VRS (0.013 and 0.010 episodes/patient-year) in both diabetic type-II MSSA and MRSA nasal carrier groups. CONCLUSIONS: Diabetic type-II S. aureus nasal carriers on HD through CVCs make an extremely high-risk group for MSSA and MRSA nasal carriage-related VRS. The incidence of S. aureus nasal carriage-related VRS could reasonably be reduced through a challenging obligation of optimizing AVF prevalence in this high-risk group, while limiting the use of CVCs, at the same time.

Outcome of dialysis access-related septicemia among diabetics following optimized AV-fistula placement.

BACKGROUND: AV fistula (AVF) is the safest of vascular accesses with lowest infection rates; yet only 23% patients used AVF during 1997 in USA. The lower prevalence of AVF among diabetics on hemodialysis (HD) places them at a higher risk of vascular-access-related septicemia (VRS) and ensuing mortality. In this study we assessed the outcome of VRS after maximizing the frequency of native AVF in this largest growing population on HD. METHODS: Study included 218 patients, 63 diabetics and 155 nondiabetics on HD, through July 1996 to July 2000 when National Kidney Foundation-Dialysis Outcome and Quality Initiative (NKF-DOQI) set goal was accomplished with overall 72% of functioning AVF (57.2% diabetics and 78.1% nondiabetics) through joint efforts of nephrologists and vascular surgeons. RESULTS: Overall, 10.6% patients per year developed VRS through 125 episodes, over 10,464 patient-months, recording 1.19 episodes per 100 patient-months. In the diabetic group, 13.87% patients per year had VRS during 44 episodes with 1.45 episodes per 100 patient-months while 1.08 episodes per 100 patient-months were recorded in nondiabetics with 9.35% per year having VRS during 81 episodes. Collectively, catheters recorded 1.5 folds higher VRS episodes in diabetic than in nondiabetic group. Mortality of 9.28% per year in diabetic group as compared to that of 6.45% per year in nondiabetic group [RR-1.436, 95% CI (0.778-2.651)] was observed, while overall mortality of 7.5% per year recorded is a good deal lower than 12-22% reported. CONCLUSION: The NKF-DOQI set aim of dialyzing over 50% patients through AVF is attainable in diabetics as well. Optimizing AVF is a viable approach to lessen VRS related mortality in diabetics on HD. Our continued dependence on vascular catheters is largely responsible for higher mortality in diabetics than nondiabetics on HD due to lack of cagily established pre-ESRD program for diabetics.