clinical

Peripartum cardiomyopathy (PPCM) is a relatively rare cardiac disease that manifests in the final stage of pregnancy and in the first months after delivery in women with no preexisting heart disease. Many etiological processes have been suggested: viral myocarditis, abnormal immune response to pregnancy, excessive prolactin excretion, prolonged tocolysis and a familiar predisposition to PPCM. Its diagnosis is often delayed because its symptoms, which include fatigue, dyspnea and palpitations are nonspecific. For this reason the diagnosis of PPCM is still made by exclusion of other etiologies. The long-term prognosis, once the acute phase is over, is a function of myocardial damage, this varies from complete functional recovery to chronic HF. The outcome of PPCM is highly variable with an alevated risk of fetomaternal morbidity and mortality. We report a serious case of a 40 years old female with biamniotic bicorionic twin pregnancy (PMA) who delivered by caesarean section and developed acute PPCM on post-operative. Symptoms occurred two hours after an intramuscular injection of two vials of methylergonovine the same day of cesarean delivery. These manifested in sudden tachypnoe, tachycardia and the appearance itchy maculopapular rash on her chest. On further evaluation, ECHO revealed cardiomegaly with reduced ejection fraction (< 15%). The case was successfully managed by a multidisciplinary team, using drugs like levosimendan and cabergoline, which rapresent emerging strategy in this clinical context.

We describe here the case of a 23-year old woman with small cell carcinoma of the ovary of the hypercalcemic type (SCCOHT) with SMARC-A4 mutation who benefited from surgery in two steps leading to a total hysterectomy with bilateral salpingo-oophorectomy, omentectomy, pelvic and lombo-aortic lymph nodes dissection. She also received 6 courses of poly-chemotherapy after the surgery. A close follow-up was then performed by clinical examination every three months with determination of serum calcium and CA125 level as well as imaging with thoraco-abdominal CT scan. To date, the patient has a disease-free survival of more than 9 years. We also reviewed the literature on this topic and discuted the new diagnostic and prognostic genetic tool SMARC-A4 mutation.

Purpose:Accurate patient positioning is crucial in radiation therapy. To fully benefit from the preciseness of proton therapy, image guided patient positioning and verification system is typically utilized in proton therapy. The purpose of this study is to evaluate the inter-observer variability of image alignment using a commercially available patient positioning and verification system in proton therapy. Methods:The VeriSuite patient positioning and verification system (MedCom GmbH, Darmstadt, Germany) provides a six degrees of freedom correction vector by registering two orthogonal x-ray images to digitally reconstructed radiograph (DRR) images that are rendered in real time from the planning computed tomography (CT) images. Six cases of various disease sites, including brain, head & neck, lung, prostate, pelvis, and bladder, were used in this study. For each case, the planning CT images and a daily orthogonal x-ray portal image pair were loaded into the VeriSuite system. The same set of x-ray images and CT images for each case were reviewed and aligned separately by each of the 10 radiation therapist, following the clinical procedure for the corresponding disease site. The resulting correction vectors were then recorded and analyzed. Results:Our study shows that the inter-observer variation (One standard deviation) in image alignment using the VeriSuite system ranged from 1.2 to 2.0 mm for translational correction and from 0.6 to 1.3 degrees for rotational correction for the six cases. The use of fiducial markers for prostate patient alignment achieved the least inter-observer variation while the bladder case produced the largest. Conclusions:Inter-observer variation in image alignment could be relatively large, depending on the complexity of patient anatomy, image alignment approach, and user experience and software limitations. Automatic registration and fiducial markers could potentially be used to align patient more accurately and consistently. To ensure adequate tumor coverage in proton therapy, inter-observer variability in patient alignment should be carefully evaluated and accounted for in patient setup uncertainty analysis and treatment planning margin determination.

Background:Topical therapy with antimicrobial agents is used in otitis treatment. Due to increase of antibiotic resistance, new strategies are needed. Antiseptics are used but they may induce contact dermatitis. Natural antimicrobial peptides may represent future effective drugs. Objectives:The objectives were to test the efficacy of an 11% lactoferricin otological solution (LCF) in bacterial and yeasts otic overgrowth and compare LCF with a commercial one containing chlorhexidine (CLX) 0.05%. Materials and methods:Forty-one dogs diagnosed with bacterial or yeasts otitis overgrowths were included according to general good practice. They were randomly assigned to lactoferricin or chlorhexidine group for treatment. Otological solution were applied twice a day for a week and then daily for another week. Clinical and cytological score was assessed at day 1 and day 14. At the end of the study, the owners had to express an opinion on the overall efficacy of the products. Statistical analyses were performed using Wilkoxon’s test and T test for paired samples. Results in lesional and cytological score were significative with a p<0.05. Results:Forty dogs completed the study. All cases, receiving lactoferricin or chlorhexidine, were successfully treated with clinical signs remission and regression of infection (p<0.05). The owners’ judgment was good in 87%, mild in 13% for LCF group. For CLX they scored good in 41%, mild in 24% and unuseful in 35% of cases. Conclusions:Lactoferricin, an antimicrobial natural peptide, showed the same efficacy of chlorhexidine in the treatment of otitis characterized by bacterial or/and yeast overgrowth.

Septic arthritis of the shoulder joint is rare and might affect around 3% of the general population [1]. A delay in diagnosis may increase morbidity and lead to bone and cartilage destruction [2]. Septic arthritis is an unusual complication of pregnancy and can progress to permanent arthropathy and disability [3]. Septic arthropathy in pregnancy requires multidisciplinary team involvement for prompt recognition and treatment to improve both maternal and fetal outcomes. High index of suspicion is vital when clinical and laboratory findings suggest septic arthritis. There are multiple predisposing factors reported previously for septic arthritis of the shoulder in pregnancy such as medical conditions, pyelonephritis and trauma. We report a 37 year old lady who presented at 26 weeks gestation with acute left shoulder pain and high temperature following minor left palm trauma. She also had left mastectomy with axillary clearance ten years earlier. She underwent arthroscopic wash out of her left shoulder joint and was covered with antibiotics with rapid improvement and recovery. We reinforce the importance of early multidisciplinary involvement when septic arthritis of the shoulder in pregnancy is suspected especially in women who have had previous mastectomy and axillary clearance which could be a predisposing factor for such a rare and serious joint condition in pregnancy.

Introduction: Radioiodine therapy is a standard procedure in thyroid autonomy treatment. Discrepancies in the visual comparisons of the scintigraphies prepared for this purpose using Tc-99m-O4- and I-131 have been known for years. In this study a new method is used to calculate and perform a quantitative comparison of both uptakes using subtraction analysis and 3D imaging. The results and their causes are discussed together with practice-relevant conclusions for better clinical results. Material and Methods: The new method was used in 38 patients with thyroid autonomies for the subtraction analysis of standardized pretherapeutic and intratherapeutic scintigraphies. The parametric distribution of activity was calculated absolutely and as a percentage and displayed three-dimensionally. These results were compared with the visual assessment of the different scintigraphies by the experts. Inclusion criteria were pretherapeutic and intratherapeutic hyperthyroidism without medication affecting the thyroid. The time difference between acquiring the scintigraphies was 28 days maximum. Results: Activity distribution was visually discrepant in 39.5% of cases. 60.5% displayed comparable uptake. The calculated values showed reversed results after applying the new method. The results using our method show a higher rate of calculated discrepancies compared with visual analysis. Conclusion: Accurate functional imaging of the thyroid is next to further aspects very important in establishing the diagnosis and deciding about the therapy activity for thyroid treatment. In combination with clinical symptoms and laboratory values, Tc-99m-O4 - scintigram can be used for an orientated, preliminary assessment of functional disorders of the thyroid. But because of the higher rate of found discrepancies, the solely use of Tc-99m-O4 - scintigram is not always capable for exact and reliable diagnosis. The known reason for this is most probably due to the different biokinetics of both radiopharmaceuticals, which can be imaged more sensitively with this method. Consequently, a scintigram should be performed in the pretherapeutic radioiodine uptake test. Despite higher costs and radiation exposure, alternatively, pretherapeutic use of other diagnostic iodine isotopes like I-123 or -124 should be discussed, because they could overcome the limitation of the different biokinetics. Following this approach the preliminary assessment using Tc-99m-O4 - scintigraphy can be precised and double checked to improve diagnostic confi dence and treatment results for a better outcome of the patients.  

Canine Distemper have become a major concern within the veterinary clinical work. Thus, the appearance of many cases of canine distemper in adult animals with their vaccination plan up to date has alarmed veterinarians. Many cases of canine distemper have become a major concern within the clinical veterinary task. The purpose of this work was to detect the gene of hemagglutinin of the virus canine distemper, by using the Polymerase Chain Reaction associated with Reverse transcription (RT-PCR), as confirmation of the clinical diagnosis of disease. For this, peripheral blood samples of animals were used clinically patients and were grouped according to their date of extraction and using vaccines commercial as control. The results allow to demonstrate a high sensitivity of the technique, besides allowing the use of samples up to seven days of storage at 4°C, despite the fragility of RNA viral. Detection of canine distemper virus haemagglutinin gene in field samples and its high sensitivity, suggests studying its use as a diagnostic tool complementary to the clinical diagnosis of canine distemper in our country.

Worldwide, Canine Distemper Virus (CDV) infection is a highly prevalent disease with high morbidity and mortality. CDV causes a multisystemic disease in a wide range of hosts including 9 families of mammals among them some primates, cetaceans and numerous carnivores. It presents a high tropism for lymphoid, neurological and epithelial tissue, leading to an infection of almost all systems, so the clinical signs observed are very varied. The diagnosis is made based on the clinical presentation of the disease, which considers a variety of signs and must be confirmed by a laboratory diagnostic method. The molecular technique called Reverse Transcription Polymerase Chain Reaction (RT-PCR) has been used to characterize viral strains based on the basis of genetic differences on the hemagglutinin (H) gene of CDV has allowed the identification of 14 circulating lineages in the world. Two lineages, namely the America-1 and the Europe-1/South America-1 have been described in Chile. The goal of this work was to implement a multiplex RT-PCR protocol, which was built on the in silico design of primers based on the H gene nucleotide sequences stored in the Genbank® database. This method was capable of detecting the previously described two circulating genetic lineages of CDV in a differential way providing a supporting diagnostic tool for epidemiological studies in the country. These results suggest that the primers described here are extremely selective for the above-mentioned lineages. In addition, our initial screening indicated that most analyzed clinical samples corresponded to the America-1 lineage, stressing the need for a continuous surveillance in order to properly address the prevalence of both lineages in Chile.

Respiratory tract infections in dogs pose a significant problem and often require prolonged treatment. The effectiveness of pharmacological therapy can be improved through the administration of nebulized compounds to liquidize mucus and promote its evacuation from the respiratory tract. The aim of this study was to evaluate the effectiveness of nebulized 0.9% NaCl in dogs with respiratory tract infections. Respiratory functions were assessed based on the results of arterial blood gas analyses, and the patients’ clinical status was determined by evaluating the severity of symptoms on a point grading scale. Inhalation of nebulized 0.9% NaCl significantly accelerated improvement in the patents’ clinical status (normalization of body temperature, decreased cough frequency, decrease/elimination of nasal and ocular discharge, improved appetite) and improved pulmonary gas exchange by reducing partial pressure and total content of carbon dioxide and increasing partial pressure and total content of oxygen in blood.

The problems of reproduction in the camel are not extensively investigated as in the bovine, caprine and ovine species. There is need to elucidate the problem in detailed in order to overcome the problem of production and genetic multiplication. The information collected on these problems is derived mainly from questioning the camel owners, slaughterhouse material and very limited clinical and farm observations.

The main method for evaluation of healing processes of the jaws in oral and maxillofacial surgery are radiological diagnostics. Quantitative description is possible by measuring the relative bone density, which puts the mean grey value of a certain area in relation to the surrounding bone tissue. In this research the intra- and interindividual variability is determined for this method and a standard operation procedure is elaborated. Therefore ten panoramic radiographs of typical surgical indications in oral a maxillofacial surgery were analyzed by three different members of the workgroup, five times each. The measurements were analyzed with descriptive and comparative statistical methods. The mean coefficient of variation was 2.972% ± 2.361%. The measurements of defect regions were more consistent (2.252% ± 1.928%) than the measurements of surrounding bone (3.691% ± 2.626%). The analysis of variance did not show a statistically significant influence of the different raters to the measurements (ANOVA, Pr>F = 0.9462). Following the standard operation procedure this method seems to be an easy, cheap and close to practice way to visualize healing process of the jaws. Especially in the mandibula, but also in the maxilla with special reconsideration of the sinus-region, it seems to be suitable.

Introduction: Several treatment options are available for the optimal treatment for orbital fractures, depending on aesthetic and functional results after orbital wall reconstruction. The objective of this study is to compare the effect and safety of large orbital floor fractures with titanium mesh combined with poly-L-lactic acid/polyglycolic acid copolymer implants (Lactosorb®) vs. autologous costochondral graft. A wide range of permanent and biodegradable materials have been used successfully for orbital floor reconstruction, however they present with disadvantages for reconstruction of large defects, even if combined. Patients and Methods: A retrospective cohort study of patients from Estado de México, México, with access to ISSEMYM health care service, presenting with orbital floor fracture treated at Department of Plastic & Reconstructive Surgery/Maxillofacial Surgery at ISSEMYM Medical Center Toluca between January 2007 and July 2010. Age, sex, etiology, clinical findings, fracture pattern, and treatment modality (Titanium mesh with absorbable implant vs. costochondral graft) were considered. Predictor and outcome variables as complications, inpatient, trauma- surgery interval, surgical time and donor site pain are considered. Results: Follow up of 21 patients (12 weeks) 17 male, 4 female, ages 22-63 was made. Enophthalmos, main objective of this study, was identified with statistical significance presenting 0% (n=0) post-op Group B patients and 30% (n=3) for Group A (p=0.049). Statistical significance was found referring to inpatient days between two groups being less for costochondral reconstruction patients (p=0.02). No pain in patients undergoing alloplastic surgery. An interesting result was that donor area analogue pain scale for costochondral graft was 2.9/10. Conclusion: Surgical outcome and complications where evaluated comparing different materials for orbital floor reconstruction. Costochondral graft is a suitable choice when orbital reconstruction is indicated.

The recent introduction of the miniscrew in orthodontics revolutionized the clinical and biomechanical approach of anchoring. Used as direct or indirect anchoring, the orthodontic micro screws indications field is expanding due to their easy insertion, and their immediate loading ensuring an absolute anchoring. Our objective through this clinical case is to show the effectiveness of these miniscrews in the correction of the uncontrolled loss of anchoring.

The indications for impacted third molar extraction include the prevention of dental reabsorption on the adjacent tooth. Resorption can be classified as physiological (when deciduous teeth are exfoliated) or pathological (when caused by injury or irritation to the periodontal ligament). Many causes can trigger external root resorption (ERR), the most common cause of which is orthodontic forces. The most common cases of ERR involve impacted third molars which, due to the lack of space for their eruption, generate a greater chance of ERR on the distal portion of the second molar. This pathology is becoming progressively more frequent in clinical dental care. Periapical and panoramic radiographs are used to aid in diagnosis, as is cone beam computed tomography. In cone beam computed tomography scans, radiolucent areas with irregular gaps are detected; these gaps represent a significant loss of dental material. The objectives of this article were to report a case of second molar resorption triggered by an impacted third molar and to perform a review of the literature on the causes of external root resorption. Ideally, this information will aid dental clinicians (and orthodontists in particular) in understanding the features of this pathology so that they may recommend preventive third molar extraction when necessary.

Introduction: One of the essential requirements for efficient oral and maxillofacial surgeon is comprehensive knowledge in anatomy of head and neck regions. Authors believe that asking students to draw anatomical sketches will assist them to improve their imaginary memory for human anatomy. However, drawing, as learning aid in anatomy, has not been given enough attention as a learning aid for human anatomy. Aim of the study: To determine dental students’ level of appreciation to drawings as practical learning aid in human anatomy. Materials and methods: Seventy nine first year dental students in Ibn Sina University for Medical and Pharmaceutical Sciences College of Dentistry for the academic year 2016-2017, were requested to complete a questionnaire. The questions were mostly related to the importance of drawing in anatomy and its relation to Anatomy education. The participation in the questionnaire was optional. Results: This study showed highly significant relationship between the ability to understand anatomy subject and the importance of drawing (P=0.006). It also showed highly significant relationship between the importance of drawings and giving clinical examples during lectures or anatomical labs (P=0.006). Furthermore, the results showed no significant relationship between the importance of drawings and the load of anatomical material, introduced in anatomical lectures and labs (P=0.639). Conclusion: Anatomical drawings, from first year dental students’ perspective, are a useful learning tool and can relate to different aspects of proper education of human anatomy. Drawings can be implemented as practical tool in human anatomy curriculum for undergraduate dental education.

Necrotizing fasciitis is a quickly progressing soft tissue infection that can be described with diffuse necrosis of subcutaneous tissue and superficial fascia. The cause of this can be infectious process of odontogenic origin, most commonly caused by mixed gram+ and gram- , aerobic and anaerobic microorganisms that are found in patients that are predisposed to infections. In a case of undiagnosed illness, there is a possibility of life threatening complications. This case analysis introduces the diagnostic criteria of the disease and treatment plan, encouraging doctors to devote more attention to prevention of infections. 

Objective: To describe pathological fi ndings on pre-treatment dental panoramic tomograms of edentulous jaws taken before complete denture treatment. Design: Descriptive cross-sectional study. Setting: Prosthetic division, Department of Conservative and Prosthetic Dentistry. School of Dental Sciences, University of Nairobi. Results: Data was obtained from clinical records and OPGs of 163 edentulous patients seen at the prosthetic clinic between 2010 and 2016 for complete denture therapy. From history and examination alone, clinicians reported significant findings on 50.3% of records, while 43.6% had no such findings. Ten (10) (6.1%) records were unclear. Examination of OPGs revealed 79.1% of the films had no pathological findings while in 20.9% had. Most of the findings (70.0%) were retained roots, 6% were radio-lucencies, 12% were other radio-opacities, 9% were impacted teeth while 3% had both retained root and radio-opacity. Most pathologies (64%) were located in the posterior region of jaws while the other findings were evenly distributed in the anterior and posterior regions of the jaws. There was no predilection of pathological findings to any other factor other than gender. In 83.4% records, queries on clinical notes coincided with significant findings on OPGs; while 16.6% were either unclear or did not coincide. Most (71%) OPG findings led to modification of treatment plan. Conclusion: Pathological findings are common on pre-treatment OPGs. It may be good practice to take an OPG for edentulous patients prior to complete denture therapy where such services are available, to prevent complications from intra-bony pathologies. However, Most of the findings are either detectable by clinical exam or may not be of major consequence to the health of patients. Complete denture may be done without OPGs for new and old denture wearers where the service is not available.

Several articles have discussed mandibular condyle position after bilateral sagittal split osteotomies (BSSO). However, previous studies have sought to establish a relationship between orthognathic surgery and the improvement of temporomandibular joint (TMJ) signs and symptoms. Also, they have been limited to two-dimensional evaluation of condylar position considering only the condylar “sag” or improper inferior seating of the condyle. The purpose of this study was to investigate a relationship between changes in condylar position using three-dimensional computed tomography and the negative clinical impact of BSSO on the temporomandibular joint. 

Introduction: Temporomandibular joint (TMJ) ankylosis is one of the most disruptive anomaly that affects the masticatory system and is referred as permanent movement disfunction of the mandible caused by bilateral or unilateral fibrous or bony adhesions and create problems. The etiology is congenital or idiopathic and include trauma, arthritis, infection, previous TMJ surgery etc. Management requires extensive resection of the ankylotic mass and reconstruction of the ramus-condyle unit with autogenous or alloplastic grafts. Most of the time, combination of surgical treatment with physiotherapy is needed in order to achieve maximum rehabilitation and functionality of the mandible. Purpose: The aim of this study is to present the surgical management of an unusual case of unilateral TMJ ankylosis and recent of literature review. Case report: A thirty-seven-year old patient reported unable moving his lower jaw. Clinical examination revealed unilateral TMJ ankylosis of congenital cause and the lateral movement of the mandible was impossible. The patient surgical treatment included resection of the newly formed bone mass, replacement of the condyle with costo-chondral graft and replaced of articular disc with the temporal fascia. Since and for ten years after surgery the patient shows no signs of relapse. Conclusion: The development of TMJ ankylosis may be congenital or acquired etiology. In order to manage it required a comprehensive clinical and radiographic examination. Surgical resection of the bone and coronoid process on the entire side is necessary and a graft that mimics the articular disc is placed, while it is necessary the immediate postoperative kinesiotherapy.

Introduction: In this retrospective study, we comment on the cause and diagnostic potential of the elevated serum total cholesterol and some non-cholesterol sterols in a population of healthy pregnant women from Prague, Czech Republic. Methods: Based on a total of 21,000 clinical biochemistry tests of healthy pregnant women with hypercholesterolemia observed during pregnancy, a testing group of 84 women with a total cholesterol (TC) above 7.0 mmol/l was established to analyze their non-cholesterol sterols (NCS) by Gas Chromatography–Mass Spectrometry. Lathosterol (Lat) and desmosterol (Des) were evaluated as markers of endogenous cholesterol synthesis, whereas campesterol (Cam) and sitosterol (Sit) were analysed as markers of intestinal absorption. Results: In the basic population, the frequency of gestational hypercholesterolemia with the serum TC levels > 7.0mmol/l was 1 to 136.The mean values were: TC 6.8 mmol/l, LDL-C 4.6 mmol/l, and HDL-C 2.2 mmol/l. In the selected testing group of 84, the mean values were: Lat 7.8+/-1.7 μmol/l, Des 4.7+/-0.9 μmol/l, Cam 9.8+/-2.6 μmol/l, and Sit 9.6+/-3.8 μmol/l. Lat correlated with TC (r = 0.53), LDL-C (r = 0.36), and non-HDL-C (r = 0.35). No such correlations were observed for Cam or Sit. Conclusion: Our findings prove that gestational hypercholesterolemia is caused by increased endogenous cholesterol synthesis via lathosterol. Subsequently, we demonstrate how a single cholesterol test taken in the fifth to sixth month gestation can efficiently help detect familial hypercholesterolemia, and prevent related late pregnancy circulatory complications.