Early/Subtle Electrocardiography Features of Acute Coronary Syndrome and ST-Segment Elevation Myocardial Infarction.

Chest pain is one of the most common presenting complaints in the emergency department. Interpreting a 12-lead electrocardiography (ECG) for evidence of ischemia is always challenging. Frank ECG changes such as ST-segment elevation and ST-segment depression can be easily identified by emergency physicians. However, identifying subtle or early features of ACS in the 12-lead ECG is essential in preventing significant mortality and morbidity from ACS. In the following case series, we describe five of the subtle/early ECG changes of ACS, namely (1) T-wave inversion in lead aVL; (2) terminal QRS distortion; (3) hyperacute T-waves; (4) negative U-waves in precordial leads; and (5) loss of precordial T-wave balance. In all these cases, the initial 12-lead ECG showed only subtle/early ECG changes which were followed up with serial ECGs which progressed to STEMI.

An Unusual Cause of Bulbar Palsy in the Emergency Department.

BACKGROUND: Osmotic demyelination syndrome commonly occurs after rapid correction of hyponatremia. But it has also been reported after graded correction of hyponatremia in the presence of other risk factors like chronic alcoholism, malnutrition, liver disease, and hypokalemia. CASE REPORT: We report a case of a 67-year-old man who presented with dysphagia and nasal regurgitation and had features suggestive of bulbar palsy on neurological examination. He had spontaneous rapid correction of hyponatremia from a serum sodium level of 122 mEq/L to 132 mEq/L after discharge from our hospital. Neuroimaging was suggestive of extrapontine myelinolysis involving the basal ganglia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician should be aware of this because osmotic demyelination syndrome should also be considered in the differential diagnosis of patients presenting with bulbar palsy to the emergency department.

The Alpha-bent and Tunneling: A Novel Technique for Fixing the Transvenous Pacer Lead during Temporary Transvenous Pacing in the Emergency Department.

The last step in the management of symptomatic bradycardia according to the advanced cardiac life support algorithm is temporary transvenous pacemaker insertion (TPI). TPI done by an emergency physician in the emergency department (ED) is on the rise particularly in South India owing to the increased incidence of yellow oleander poisoning. As in ED, we use passive fixation leads, fixation of a transvenous pacer lead is very important. In the following case series, we describe two novel techniques namely, "the alpha-bent" and "tunneling" for fixing the transvenous pacer lead. This technique of fixing the lead reduces lead displacement thus minimizing the potential complications.

Brugada phenocopy induced by consumption of yellow oleander seeds - A case report.

Brugada phenocopy is a brugada-like pattern in ECG seen in some diseases without an inherited channelopathy. The causes of brugada phenocopy are usually reversible. Once the reversible condition resolves, the ECG pattern disappears. There are many conditions that cause brugada phenocopy like myocardial infarction, hyperkalemia etc. Here we report a case of brugada phenocopy induced by consumption of yellow oleander seeds (T. Peruviana).

Memory T-Waves, a Rare Cause of T-Wave Inversion in the Emergency Department.

One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.

Bulk size crystal growth, spectroscopic, dielectric and surface studies of 4-N,N-dimethylamino-4-N'-methylstilbazolium m-nitrobenzenesulfonate (DSMNS): A potential THz crystal of stilbazolium family.

The synthesis and growth of a potentially useful and efficient nonlinear optical organic single crystal of 4-N,N-dimethylamino-4-N'-methylstilbazolium m-nitrobenzenesulfonate (DSMNS) is reported. The growth experiment involved the slope nucleation method coupled with slow cooling as well as slow solvent evaporation techniques. Single crystal X-ray diffraction (XRD), Fourier transform infrared (FT-IR), FT-Raman and nuclear magnetic resonance (NMR) techniques have been employed to ascertain the structure and composition of the crystal. Second harmonic generation (SHG) efficiency of the sample has been examined by Kurtz and Perry powder test. Thermogravimetry (TG), differential thermal analysis (DTA) and differential scanning calorimetry (DSC) techniques are employed to investigate the thermal behavior of the grown crystal. The frequency/temperature dependent dielectric properties of the organic crystal of DSMNS are studied. The surface features of the grown crystal are investigated by chemical etching study and atomic force microscopy (AFM).

Neuroradiological findings in maple syrup urine disease.

Maple syrup urine disease is a rare inborn error of amino acid metabolism involving catabolic pathway of the branched-chain amino acids. This disease, if left untreated, may cause damage to the brain and may even cause death. These patients typically present with distinctive maple syrup odour of sweat and urine. Patients typically present with skin and urine smelling like maple syrup. Here we describe a case with relevant magnetic resonance imaging findings and confirmatory biochemical findings.

Maxillary movement in cleft patients treated with internal tooth borne distractor.

Cleft lip and palate is associated with maxillary hypoplasia and retrognathism. Surgery and distraction have been the most common treatment approaches used. The aim of this study was to objectively assess the quantum and direction of movement of the anterior maxilla in cleft patients treated with an internal tooth borne distractor. A prospective clinical study design was followed in which 8 consecutive patients with cleft maxillary hypoplasia were included in the age range of 15-25 years. All patients had undergone secondary alveolar bone grafting earlier. Anterior maxillary distraction was performed using a tooth borne appliance in all 8 patients after necessary osteotomy. Lateral cephalograms were obtained preoperatively, predistraction and postdistraction. The angular and linear change at the maxillary anterior segment, rotation of the palatal plane, mandibular plane, increase in lower facial height and vertical changes of the anterior and posterior dentoalveolar segments were measured. The movement of the anterior maxillary segment was demonstrated anteriorly and superiorly in all the patients. The anterior and posterior dentoalveolar heights were increased post-distraction. There was also an increase in lower anterior facial height and the mandibular plane angle. Predictable superior and anterior movement of the anterior maxilla along with significant increase in palatal length could be achieved with the internal tooth borne distractor leading to remarkable improvement in esthetics and better function.

Oral lesions associated with nevirapine-related Stevens Johnson syndrome: A report of four cases.

Nevirapine is a non-nucleoside reverse transcriptase inhibitor, widely used in combination with other antiretroviral agents for treatment of HIV infection. Steven Johnson syndrome (SJS) is the major toxicity of nevirapine. We describe here four cases of SJS in HIV seropositive patients following nevirapine therapy. In all four cases cutaneous hypersensitivity reaction was seen with extreme oral lesions, three patients presented clinically with elevated liver enzymes and hepatitis, and two patients had ocular involvement.

Microscope-aided endodontic treatment of maxillary first premolars with three roots: a case series.

Maxillary premolars have a highly variable root canal morphology. However, the presence of three roots is a rare occurrence. This clinical article describes the unusual anatomy detected in maxillary premolars during routine endodontic treatment using microscope. The diagnosis and clinical management of maxillary first premolars with three roots and canals using radiographic interpretation, access cavity modification and visual enhancement with operative microscopes is discussed in the article.

Simultaneous genial distraction and interposition arthroplasty for management of sleep apnoea associated with temporomandibular joint ankylosis.

Temporomandibular joint (TMJ) ankylosis affects the growth of the mandible and results in gross facial deformities. A critical clinical feature of long-standing TMJ ankylosis is retrogenia, which when combined with an inability to open the mouth leads to severe compromise of the airway. A case is presented of obstructive sleep apnoea syndrome secondary to TMJ ankylosis that was corrected by a new technique employing simultaneous genial distraction along with interposition arthroplasty.

Areca nut use among rural residents of Sriperambudur Taluk: a qualitative study.

OBJECTIVE: The main objective of the study was to understand the perceptions of the residents of rural part of Sriperambudur Taluk, regarding areca nut use. This article discusses the findings of in-depth interviews and focus group discussions at rural part of Sriperambudur Taluk. MATERIALS AND METHODS: A community-based survey was conducted using qualitative methods. Out of 168 villages, 11 were randomly chosen. Fifteen in-depth interviews and five focus group discussions were conducted. Only those above 10 years of age and who used areca nut either in processed or un-processed form were included in the study. RESULTS: Among different forms of areca nut products, the use of Hans, which is a commercial flavored product containing areca nut, tobacco and other ingredients is believed to be the most prevalent habit in all the age groups. Chewing areca nut is the initiating habit, leading to other habits such as smoking and consuming alcoholic beverages. Residents less than 30 years of age chew areca nut products for fun or because of peer pressure whereas the 30 to 50 year olds get habituated due to reasons such as boredom and family problems. Although there is awareness regarding the ill-effects of tobacco use, there is not much awareness regarding areca nut. According to the residents, the community has not given enough thought regarding areca nut products and therefore no action has been taken to mitigate this high-risk behavior. CONCLUSION: It is the perception of the community that there is an increasing trend in the use of areca nut especially the commercial forms such as Hans , in rural Tamilnadu. Habit gets initiated at a very young age; therefore age specific intervention programs should be implemented. Periodic research should be conducted to better understand the changing trends of chewing areca nut products.

Prevalence of oral lesions in relation to habits: Cross-sectional study in South India.

BACKGROUND: Smoking, drinking and chewing tobacco product, common habits in India have been positively associated with oral lesions. No study has been conducted in this part of Tamilnadu regarding the prevalence of oral lesions in relation to habits. METHODS: A hospital based cross-sectional study was carried out at Ragas Dental College, Chennai. Already existing data of two thousand and seventeen consecutive patients from sub-urban areas of Chennai, who attended the outpatient department, at Ragas Dental College, for dental complaints during a period of three months in 2004, who underwent oral examination and interviewer based questionnaire was used. RESULTS: Oral soft tissue lesions were found in 4.1% of the study subjects. The prevalence of leukoplakia, OSF and oral lichen planus was 0.59%, 0.55%, and 0.15% respectively. The prevalence of smoking, drinking alcoholic beverages and chewing was 15.02%, 8.78% and 6.99% respectively. Smoking and chewing were significant predictors of leukoplakia in this population. DISCUSSION: The prevalence of leukoplakia, OSF and oral lichen planus in our study population is similar to those found in other populations. The prevalence of consumption of alcoholic beverages in our study population was higher when compared to the Indian National Sample Survey study. However the prevalence of smoking and chewing was found to be lower. Smokers were more likely to develop smoker's melanosis compared to other lesions. Among those who consumed alcoholic beverages alone, the prevalence of leukoplakia was higher compared to other lesions. OSF was the most prevalent lesion among those who chewed panmasala or gutkha or betel quid with or without tobacco.

Overview of the SwissPlus Implant System.

Although many improvements have been made to implant dentistry during the last quarter of a century, clinical challenges still remain. For the surgeon, achieving implant stability in low-density bone can be difficult. For the restorative dentist, incompatibility between implant systems and the increasing complexity of esthetic restorative options frequently require special training in the selection and use of prosthetic components. This article presents an overview of a 1-stage implant system with a textured surface and osteocompressive surgical protocol designed to achieve stability in soft bone. Self-tapping, double lead threads and a separate surgical protocol also enable the implant to be placed in high-density bone. The implant is packaged on a fixture mount that also functions as a transfer and transitional or definitive abutment for cemented restorations. This implant is designed to help simplify restorative procedures by eliminating many ancillary restorative components. For multiple-unit, screw-retained restorations, the prosthesis can be splinted directly to the top of the implant without an intermediate abutment. Overdenture attachments and straight, angled, screw-receiving, and custom-cast abutments complete the restorative system.

Fabrication of a cement- and screw-retained implant prosthesis.

The advantages of cement-retained implant-supported restorations over screw-retained implant restorations are well documented. Difficulty with prosthesis retrieval and excess cement removal may be experienced with cemented restorations. The technique described allows for the fabrication of a retrievable cemented prosthesis that is simple, practical, and effective.

Condylar reconstruction in extensive ankylosis of temporomandibular joint in adults using resected segment as autograft. A new technique.

A new method of condylar reconstruction after gap-arthroplasty in extensive ankylosis of the temporomandibular joint in adults is presented. An autogenous graft, consisting of the excised ankylotic mass, was contoured, reimplanted and used for condylar reconstruction. This technique has given good results and is a simple alternative to other methods of reconstruction in adults. Successful results in three cases with more than 12 months' follow up, has prompted us to use this technique routinely in adult patients.