The Root Complex in Posterior Teeth: A Direct Digital Analysis.

The aim of this morphometric study was to precisely determine the 3D characteristics of the root complex of the posterior dentition. Extracted and well-preserved permanent posterior teeth were included in this analysis and grouped based on tooth type and arch location. All teeth were digitally scanned. Morphologic and dimensional features of the root complex were assessed, including length and surface area of the root trunk and individual roots, width of root concavities (RC), and furcation entrance, when present. A total of 240 posterior teeth comprised the study sample. The root complex of multirooted maxillary first premolars presented with a long root trunk (10.49 mm), representing 65.52% of the surface area, and two short roots comprising the remaining 34.8% of the surface area. Root trunks of mandibular molars were an average of 0.8 mm shorter than their maxillary counterparts. Class III furcation involvement is expected in all maxillary and mandibular molars, as well as multirooted maxillary first premolars, after 4.80 mm and 10.49 mm of clinical attachment loss, respectively. RCs were a common finding among the evaluated dentitions. The root complex morphology varies among the maxillary and mandibular posterior dentition. RCs are highly prevalent in both maxillary and mandibular dentition. The findings derived from this study can be utilized in daily clinical practice for the adequate management of posterior dentition and serve as a reference for future investigations in dental anatomy and digital technology. Also, these findings can guide the industry into creating and redefining tools that adequately adapt to the anatomical characteristics and variations of the specific tooth type.

Subacute Stent Thrombosis in a Patient With COVID-19 Despite Adherence to Antiplatelets.

The coronavirus disease 2019 (COVID-19) creates a significant burden on the cardiovascular system. Moreover, diagnosing coronary artery disease in patients with COVID-19 may be clinically challenging. Herein, we present a case of in-hospital stent thrombosis and thrombotic occlusion of the right coronary artery after initial revascularization and adherence to antiplatelet therapy.

Regadenoson Stress Testing: A Comprehensive Review With a Focused Update.

Regadenoson is a pharmacological stress agent that has been widely used since its approval by the Food and Drug Administration (FDA) in 2008. For many years, dipyridamole and adenosine, which are non-selective adenosine receptor agonists, were more popular. However, these agents are less preferred now due to their undesirable adverse effects as compared to regadenoson. In the ADVANCE (ADenoscan Versus regAdenosoN Comparative Evaluation) phase 3 clinical trial, regadenoson demonstrated non-inferiority to adenosine for detecting reversible myocardial ischemia. This review summarizes the clinical utilities of regadenoson as the most widely used pharmacological stress agent. Moreover, the use of regadenoson has been documented in specific patient populations. Although regadenoson has established safety and efficacy in most patients with chronic diseases, there are equivocal results in the literature for other chronic diseases. It is warranted to highlight that the use of regadenoson has not been studied in patients of low socioeconomic class; it is a condition that carries a significant burden on the cardiovascular system.

Wellens' Syndrome in the Setting of the 2019 Novel Coronavirus (COVID-19).

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-Cov2), is the causative pathogen of coronavirus disease 2019 (COVID-19), which is primarily described as a respiratory illness. However, a wide array of cardiovascular complications has also been described in the setting of COVID-19. Wellens' syndrome, also regarded as a left anterior descending coronary T-wave syndrome, is an electrocardiography (EKG) pattern that indicates critical proximal left anterior descending (LAD) artery stenosis. It is characterized by deeply inverted T-waves or biphasic T-waves in the anterior precordial chest leads in a patient with unstable angina. Patients typically present with symptoms consistent with acute coronary syndrome. To our knowledge, we present the first case of Wellens' syndrome in a patient with a COVID-19 infection. Furthermore, this case describes stenosis of the left circumflex artery, a variant of the unusual angiographic findings associated with Wellens', as it is usually associated with occlusion of the proximal LAD. The pathophysiology of cardiovascular complications associated with COVID-19 is not well-understood; nevertheless, it was reported that mortality from coronary artery disease (CAD) complications is significantly higher in these patient populations. Healthcare providers should also be aware of identifying Wellens' syndrome, as urgent coronary angiography is superior to stress testing.

THE PREFERENCE OF USING GLOBAL LONGITUDINAL STRAIN SPECKLE TRACKING ECHO STUDY OVER MEASUREMENT OF LEFT VENTRICLE EJECTION FRACTION (LVEF) IN THE EARLY DETECTION OF SUBCLINICAL SYSTOLIC DYSFUNCTION IN DIABETIC PATIENTS.

OBJECTIVE: The aim: Prove that the use of GLS by speckle tracking ECHO study is more sensitive to detect early systolic dysfunction. PATIENTS AND METHODS: Materials and methods: In this case control study 40 diabetic patients 22 males (55%) & 18 females (45%) who have no symptom or clinical finding of a cardiac problem with normal LVEF and a 30 healthy control subjects. The ECHO study includes measuring their LVEF &comparing it with the result global longitudinal strain by speckle tracking for assessment of systolic function. RESULTS: Results: A 62.5% of diabetic patients who are have no CVS complaint neither they have systolic dysfunction with normal LVEF they have early systolic dysfunction revealed by speckle tacking technique in compares to a healthy control group where only 10% have systolic dysfunction with mean GLS of the patients was -17.43±3.016, while that for the control group -20.58 ± 1.729 A P value of 0. 012. Also there is a significant correlation between the duration of DM & the systolic dysfunction as detected by GLS. CONCLUSION: Conclusions: Diabetic patients got early systolic dysfunction before they show any symptoms, even their LVEF is normal, which can be detected by speckle tracking ECHO study.

Vitamin D receptor gene polymorphism in patients with osteomalacic myopathy in Egypt.

INTRODUCTION: Vitamin D works by binding to vitamin D receptor (VDR). The muscle involvement in hypovitaminosis D was broadly named osteomalacic myopathy. METHODS: A case control study involved 20 female patients diagnosed with osteomalacic myopathy compared with 15 age-matched healthy female controls. We assessed both for VDR genotype single-nucleotide polymorphisms (SNP) at 3 sites (ApaI, BsmI, and FokI). RESULTS: ApaI and BsmI genotypes distribution in both groups showed non-significant difference unlike FokI genotypes in which we found significantly higher percentages of single allele mutation in patients vs. controls. CONCLUSION: The relation of VDR gene SNPs to muscle function was studied before but in healthy subjects. We tried to correlate if presence/absence of a certain mutation is responsible for the appearance of osteomalacic myopathy.

Ivermectin: A Closer Look at a Potential Remedy.

Amid the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the search for effective treatment and vaccines has been exponentially on the rise. Finding effective treatment has been the core of attention of many scientific reports and antivirals are in the center of those treatments. Numerous antivirals are being studied for the management of the coronavirus disease 2019 (COVID-19) pneumonia caused by the SARS-CoV-2. Remdesivir was the first drug to gain emergency FDA approval to be used in COVID-19. Similarly, favipiravir, an anti-influenza drug, is being studied as a potential agent against COVID-19. Contrastingly, hydroxychloroquine has been a controversial drug in the management of COVID-19. Nevertheless, the National Institute of Health (NIH), along with the World Health Organization (WHO), have discontinued clinical trials for hydroxychloroquine as the drug showed little or no survival benefit. Ivermectin, an antihelminthic drug, has shown antiviral properties previously. Additionally, it was described to be effective in vivo against the SARS-CoV-2. However, its survival benefit in patients with COVID-19 has not been documented. We herein propose the theory of inhaled ivermectin which can attain the desired lung concentration that will render it effective against SARS-CoV-2.

A Case of Seronegative ANA Hydralazine-Induced Lupus Presenting With Pericardial Effusion and Pleural Effusion.

Hydralazine induced lupus syndrome (HILS), a form of Drug-Induced Lupus (DIL), was first reported in 1953. Since then, studies have shown an increasing incidence of HILS. It presents with lupus-like symptoms such as arthralgia, fever, chest pain, anorexia, fatigue, petechiae, and rash. Though rare, HILS may initially present with pericardial effusion. Lab findings of HILS usually show positive anti-nuclear antibody (ANA) in >95% of cases, antihistone abs in >95% of cases, rheumatoid factor ab in 20%, and anti-double-strand DNA in <5%. Herein we present a case of HILS which initially presented with a seronegative ANA and pericardial effusion. An 82-year-old woman who presented with shortness of breath was found to have bilateral pleural effusion and pericardial effusion. Common etiologies of pericardial effusion have been ruled out, after careful review of her home medications, hydralazine was suspected to be the culprit of her pericardial effusion. Initial ANA testing was negative, however given high clinical suspicion autoimmune disease screening was done revealing positive anti-histone antibodies. Hydralazine was deemed to be the etiology of her pericardial effusion which led to the discontinuation of the drug. Serial echocardiography revealed no recurrence of the effusion.

Acute Kidney Injury Caused by Levetiracetam in a Patient With Status Epilepticus.

Levetiracetam is a widely used, effective and usually well-tolerated anti-epileptic medicine. It is mostly excreted by kidneys and requires dose adjustment according to the glomerular filtration rate. Very few case reports have been published in the literature about levetiracetam causing acute kidney injury (AKI). We present a case of a 26-year-old male with a seizure disorder on levetiracetam, presented with status epilepticus requiring intubation for airway protection. He received 4 g of intravenous levetiracetam as a loading dose and continued with a maintenance dose of 750 mg intravenous every 12 hours. He had signs of AKI on day two and creatinine eventually reached a maximum level of 12.2 mg/dL. His kidney function improved to his new baseline in a period of 30 days without requiring renal replacement therapy. He did not have significant rhabdomyolysis and his kidney function started improving right after his anti-epileptic therapy was switched to valproic acid pointing towards levetiracetam as the primary cause of kidney injury. Clinicians should be aware that levetiracetam can cause AKI on patients with a seizure disorder, especially when administered in high doses. Kidney function should be monitored closely and patients should be treated aggressively with intravenous fluids when they have any signs of rhabdomyolysis to prevent further kidney damage.

A Case of Pneumomediastinum and Pneumoperitoneum with Concurrent Massive Subcutaneous Emphysema due to Repositioning of a Tracheostomy Tube.

Tracheostomy is a common procedure seen in critically ill patients that require long term ventilatory support. As with all airway access procedures, tracheotomy with prolonged tracheal tube placement comes with possible risks such as tracheal scarring, tracheal rupture, pneumothorax, tracheoesophageal fistula among others. Another possible complication, though rare, is escape of free air into the surrounding tissue, as well as pneumomediastinum (PM). This may occur due to various reasons, some of them being tracheal rupture, barotrauma or tracheal tube mispositioning. Pneumomediastinum may present with concurrent free air in other body cavities such as the peritoneum, thorax or subcutaneous tissue. Though often not life-threatening it may require treatment including high flow oxygen, ventilator management or occasionally, surgical intervention. Herein we describe a rare case of PM with communicating pneumoperitoneum and massive subcutaneous emphysema due to tracheal tube mispositioning along with a review of the literature.

Wrong site surgery! How can we stop it?

INTRODUCTION: "Primum non nocere" (first do no harm): Hippocrates (c. 460 BC-377 BC). Wrong site surgery is the fourth commonest sentinel event after patient suicide, operative and post-operative complications, and medication errors. Misinterpretation of the clinic letters or radiology reports is the commonest reason for the wrong site being marked before surgery. MATERIALS AND METHODS: We analyzed 50 cases each of operations carried out on the kidney, ureter, and the testis. The side mentioned on clinic letters, the consent form, and radiology reports lists were also studied. The results were analyzed in detail to determine where the potential pitfalls were likely to arise. RESULTS: A total of 803 clinic letters from 150 cases were reviewed. The side of disease was not documented in 8.71% and five patients had the wrong side mentioned in one of their clinic letters. In the radiology reports, the side was not mentioned in three cases and it was reported wrongly in two patients. No wrong side was ever consented for and no wrong side surgery was performed. CONCLUSION: The side of surgery was not always indicated in clinic letter, theatre list, or the consent form despite the procedure being carried on a bilateral organ. As misinterpretation is a major cause of wrong side surgery, it is prudent that the side is mentioned every time in every clinic letter, consent form, and on the theatre list. The WHO surgical safety checklist has already been very effective in minimizing the wrong site surgery in the National Health Service.

Performance of ANFIS versus MLP-NN dissolved oxygen prediction models in water quality monitoring.

We discuss the accuracy and performance of the adaptive neuro-fuzzy inference system (ANFIS) in training and prediction of dissolved oxygen (DO) concentrations. The model was used to analyze historical data generated through continuous monitoring of water quality parameters at several stations on the Johor River to predict DO concentrations. Four water quality parameters were selected for ANFIS modeling, including temperature, pH, nitrate (NO3) concentration, and ammoniacal nitrogen concentration (NH3-NL). Sensitivity analysis was performed to evaluate the effects of the input parameters. The inputs with the greatest effect were those related to oxygen content (NO3) or oxygen demand (NH3-NL). Temperature was the parameter with the least effect, whereas pH provided the lowest contribution to the proposed model. To evaluate the performance of the model, three statistical indices were used: the coefficient of determination (R (2)), the mean absolute prediction error, and the correlation coefficient. The performance of the ANFIS model was compared with an artificial neural network model. The ANFIS model was capable of providing greater accuracy, particularly in the case of extreme events.

Lost needle: a dilemma in robotic-assisted laparoscopic surgery.

A case is presented where a needle was lost in the assistant's port during a robotic-assisted radical prostatectomy. This complication generated a unique dilemma: whether or not to disengage the robot and search for the needle or to continue with the operation and look for the needle at the end of the operation.

Extra-anatomical complications of antegrade double-J insertion.

INTRODUCTION: Insertion of a double-J (JJ) stent is a common procedure often carried out in the retrograde route by the urologists and the antegrade route by the radiologists. Reported complications include stent migration, encrustation, and fracture. Extra-anatomic placement of an antegrade JJ stent is a rare but infrequently recognized complication. MATERIALS AND METHODS: We performed a retrospective audit of 165 antegrade JJ stent insertions performed over three consecutive years by a single interventional radiologist. All renal units were hydronephrotic at the time of nephrostomy. All procedures were performed under local anaesthetic with antibiotic prophylaxis. RESULTS: Antegrade stent insertion was carried out simultaneously at the time of nephrostomy in 55 of the 165 cases (33%). The remainder were inserted at a mean of 2 weeks following decompression. In five (3%) patients, who had delayed antegrade stenting following nephrostomy, the procedure was complicated by silent ureteric perforation and an extra-anatomic placement of the stent. These complications had delayed manifestations, which included two retroperitoneal abscesses, a pelvic urinoma, a case each of ureterorectal fistula, and ureterovaginal fistula. Risk factors for ureteric perforation include previous pelvic malignancy, pelvic surgery, pelvic radiation, and a history of ureteric manipulation. CONCLUSION: Antegrade ureteric JJ stenting is a procedure not without complications. Extra-anatomic placement of the antegrade stent is a hitherto the infrequently reported complication but needs a high index of suspicion to be diagnosed. Risk factors for ureteric perforation at the time of stent insertion have to be considered to prevent this potential complication.

Association between nonspecific skeletal pain and vitamin D deficiency.

BACKGROUND: Deficiency of vitamin D has been reported in patients with many types of musculoskeletal pain. The present study was designed to determine the association between serum 25-hydroxyvitamin D [25-(OH)D] deficiency and nonspecific skeletal pain. METHODS: A total of 276 patients with nonspecific skeletal pain at different regions of the skeletal system diagnosed as leg pain, widespread pain, arthralgia, rib pain, back pain and fibromyalgia were compared with 202 matched controls with regard to mean serum 25-(OH)D level and 25-(OH)D deficiency. Serum 25-(OH)D was measured by enzyme-linked immunosorbent assay method and levels < 20 ng/mL were considered as deficient. Nonparametric one-way analysis of variance, Kruskal Wallis and Wilcoxon tests were used for group comparisons. Multiple logistic regression analysis with calculation of adjusted odds ratio (OR) and 95% confidence interval (95% CI) were performed to determine associations. RESULTS: In patients with nonspecific skeletal pain the mean 25-(OH)D was significantly lower (P = 0.0001) and the proportion of 25-(OH)D deficiency was significantly higher (63.4%vs. 36.1%, P = 0.0001) compared with controls. There was a significantly positive association between 25-(OH)D deficiency and skeletal pain (OR = 2.94, 95% CI = 1.01-4.3, P = 0.0001). The strength of association varied across the groups with strongest association observed with leg pain (OR = 7.4; 95% CI = 3.9-13.9, P = 0.0001) followed by arthralgia (OR = 3.9, 95% CI = 2.1-7.1, P = 0.0001) and widespread pain (OR = 2.8, 95% CI = 1.1-6.6, P = 0.020) but no association with back pain and fibromyalgia. There was a greater positive associations in women compared with men (OR = 2.1, 95% CI = 1.1-4.3, P = 0.001). CONCLUSION: The results of this study indicate a positive association of vitamin D deficiency with a variety of nonspecific bone pain, particularly in women. More studies with larger samples are required to confirm these findings. Increasing serum vitamin D to sufficient levels and longitudinal follow-up of patients may provide further evidence in relation to vitamin D deficiency and skeletal pain.

Point-of-care PSA testing: an evaluation of PSAwatch.

We present a new quantitative prostate-specific antigen (PSA) assay using a portable, point-of-care test (PSAwatch) and reader system (BioScan) for measuring PSA concentrations in the range from 0.5 to < or =25 microg/l. Blood samples from patients (n=199) were submitted for laboratory PSA and also evaluated using PSAwatch and the BioScan system. PSA concentrations in 188 men were < or =25 microg/l and studied. Correlation between the two methods was good (R(2)=0.88) with a standard error of 1.588. The regression line had a bias of -0.02 at the concentration of 4.00 microg/l. This is the first report of a quantitative, portable, point-of-care PSA test and reader system. PSAwatch may reduce the number of hospital visits for patients with prostate disease.

Spectroscopic view of life and work of the Nobel Laureate Sir C.V. Raman.

Raman spectroscopic and microscopic techniques have been used for nondestructive characterization of tissues and to differentiate benign and malignant tissues. The discovery of the principles of spectroscopy is credited to Sir C.V. Raman of India, who in 1930 brought the Nobel Prize in Physics to the East side of Suez. We present the life and work of Sir C.V. Raman with brief review of the uses of Raman spectroscopy in urology.