Unusual Presentation of ‘U-Shaped’ Impacted Maxillary Central Incisor with Intranasal Root: Successful Surgical Management

Background

Dilacerations is a tooth deformity characterized by an angulation between crown and root causing non-eruption of the tooth. It generally occurs following trauma to the deciduous dentition apices of which lie close to the permanent tooth buds. According to Neville, maxillary and mandibular incisors contribute only approximately to 1% of the incidence of dilacerated teeth.

Case Details

A 15 year old male patient reported with chief complaint of missing anterior teeth in the left side of maxillary arch. Radiographic evaluation showed impacted maxillary left central incisor. The radiograph depicted very unusual extreme curve in the root of the same tooth giving it characteristic U-morphology. The root of this tooth was curving into the nasal cavity. Due to extreme curve, surgical removal was suggested by orthodontist. Surgically removing this highly placed tooth with apex into nasal cavity was a surgical challenge. This was done effectively by removing the tooth under local anesthesia itself.

Conclusion

U-shaped morphology in single rooted tooth is observed very rarely. This root curvature predisposes to fracture of root during surgical removal. Proper surgical protocol is to be followed during surgical removal of a tooth with such extreme root curvature to prevent fracture of the root and accidental displacement of the tooth into nasal cavity.     

Unusual Behavior in Children- Foreign Object in Tooth: A Report of Two Cases

Background

The chance of discovering foreign object in a root canal is more commonly seen in children. Foreign objects may act as a potential source of infection, which may hinder the complete debridement of root canal. Although the main etiology being an accidental insertion, there are other possibilities such as self-injurious habits which should be ruled out.

Case Details

The present article describes two case of foreign object in root canal, their possible etiology and management modalities. The first case reports a usual case of staple pin in root canal of primary teeth. The second case was a broken pin inside anterior permanent teeth. The cases reported highlight the need for proper diagnosis and early management.

Conclusion

This case report highlights the need for proper understanding of the etiology in management of foreign body in root canal system.     

Plasma Cell Gingivitis Associated with Inflammatory Chelitis: A Report on a Rare Case

Background

Plasma cell gingivitis (PGC) is a rare disease of gingival tissues which is difficult to treat. It has a higher rate of reoccurrence and needs a detailed and careful analysis of etiology. Further, its association with chelitis is rare, only few cases have been reported and the condition with this presentation poses a diagnostic dilemma.

Case Report

This paper reports a 16 year old male with a complaint of bleeding and swelling of gingiva since 3 years. The gingival enlargement occurred on facial aspect of upper and lower anterior teeth involving attached gingival. He also presented with swelling of both lips which was recurrent and for the same duration of 3 years.

Discussion

Based on clinical features and histopathological findings, a diagnosis of plasma cell gingivitis with inflammatory chelitis was made. A detailed history of possible allergen exposure was taken and patch test was conducted to identify any such allergens. Other conditions were ruled out by blood investigation, detailed medical and drug history.

Conclusion

A close collaboration between Periodontist and Dermatologist is essential to manage such a case.     

Congenital Epulis in a Newborn: A Case Report,Immunoprofiling and Review of Literature

Background

Congenital epulis is a rare lesion of the newborn, presenting as mass in the oral cavity which can interfere with respiration and feeding. It should be distinguished from other lesions which can occur in newborns, both clinically and histopathologically.

Case Details

Here, we report a case of congenital epulis in a newborn female on the right alveolar ridge, along with an extensive review of literature and discuss the immunoprofiling.

Conclusion

Early diagnosis of CE in a newborn is of paramount importance in the successful management of these rare cases.     

Plutonium from Above-Ground Nuclear Tests in Milk Teeth: Investigation of Placental Transfer in Children Born between 1951 and 1995 in Switzerland

Background

Occupational risks, the present nuclear threat, and the potential danger associated with nuclear power have raised concerns regarding the metabolism of plutonium in pregnant women.

Objective

We measured plutonium levels in the milk teeth of children born between 1951 and 1995 to assess the potential risk that plutonium incorporated by pregnant women might pose to the radiosensitive tissues of the fetus through placenta transfer.

Methods

We used milk teeth, whose enamel is formed during pregnancy, to investigate the transfer of plutonium from the mother’s blood plasma to the fetus. We measured plutonium using sensitive sector field inductively coupled plasma mass spectrometry techniques. We compared our results with those of a previous study on strontium-90 (⁹⁰Sr) released into the atmosphere after nuclear bomb tests.

Results

Results show that plutonium activity peaks in the milk teeth of children born about 10 years before the highest recorded levels of plutonium fallout. By contrast, ⁹⁰Sr, which is known to cross the placenta barrier, manifests differently in milk teeth, in accordance with ⁹⁰Sr fallout deposition as a function of time.

Conclusions

These findings demonstrate that plutonium found in milk teeth is caused by fallout that was inhaled around the time the milk teeth were shed and not from any accumulation during pregnancy through placenta transfer. Thus, plutonium may not represent a radiologic risk for the radiosensitive tissues of the fetus.     

Cerebral Vein Thrombosis Post Cabg Precipitated by Malposition of Subclavian Central Catheter in Protein C & S Deficiency Patient

Background

Cerebral venous thrombosis is an uncommon disorder in the general population. However, it has a higher frequency among patients younger than 40 years , patients with thrombophilia and patients that have foreign body such as catheter in their veins or arterial system.

Case Details

In this case report, we described the clinical and radiological findings of a patient who developed cerebral vein thrombosis post coronary artery bypass grafting secondary undiagnosed protein C and S deficiency which was precipitated by malposition of subclavian central catheter into internal jugular vein.

Conclusion

We emphasis the importance of radiological veiw of central vein catheter position just after or at the time of cannulation of central vein, not at some hours later as in our case.     

Platelet Rich Fibrin (Prf) and B-Tricalcium Phosphate With Coronally Advanced Flap for the Management of Grade-II Furcation Defect

Background

Multirooted teeth offer unique and challenging problems due to the furcation area, creates situations in which routine periodontal procedures are somewhat limited and special procedures are generally required.

Case Detail

The present case was showing the management of grade II furcation defect by platelet rich fibrin (PRF) and β-Tricalcium phosphate with coronally advanced flap.

Conclusion

Platelet rich fibrin and β-Tricalcium phosphate with coronally advanced flap have been shown to be a promising and successful approach for the treatment of furcation defect. Its gaining clinical attachment significantly manages both the gingival recession and furcation involvement simultaneously.     

HIV Patient with Mucous Membrane Pemphigoid: A Case Report

Background

Mucous Membrane Pemphigoid, a new denomination of cicatricial pemphigoid, encompasses a group of chronic subepithelial autoimmune blistering diseases that predominantly affect the oral cavity and the eyes (conjunctivitis and symblepharon).

Case Details

A rare case of Mucous Membrane Pemphigoid (MMP) in a human immunodeficiency virus (HIV) positive patient is discussed with clinicohistopathological presentation.

Conclusion

Since our patient was HIV-positive and had lesions restricted to the oral mucosa with ocular involvement, only topical and intralesional steroids were preferred as the first line of treatment. Systemic corticosteroid therapy raises a concern regarding immunosuppression.     

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis

Objective

To determine if applying change analysis to the narrative reports made by reviewers of hospital deaths increases the utility of this information in the systematic analysis of patient harm.

Design

Qualitative analysis of causes and contributory factors underlying patient harm in 52 case narratives linked to preventable deaths derived from a retrospective case record review of 1000 deaths in acute National Health Service Trusts in 2009.

Participants

52 preventable hospital deaths.

Setting

England.

Main outcome measures

The nature of problems in care and contributory factors underlying avoidable deaths in hospital.

Results

The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. It demonstrated links between problems and underlying contributory factors and highlighted other threats to quality of care such as standards of end of life management. The method was straightforward to apply to multiple records and achieved good inter-rater reliability.

Conclusion

Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach, unpacking the nature of the problems, particularly by delineating omissions from acts of commission, thus facilitating more tailored responses to patient harm.     

Regionalization and Local Hospital Closure in Norwegian Maternity Care—The Effect on Neonatal and Infant Mortality

Objective

To study whether neonatal and infant mortality, after adjustments for differences in case mix, were independent of the type of hospital in which the delivery was carried out.

Data

The Medical Birth Registry of Norway provided detailed medical information for all births in Norway.

Study Design

Hospitals were classified into two groups: local hospitals/maternity clinics versus central/regional hospitals. Outcomes were neonatal and infant mortality. The data were analyzed using propensity score weighting to make adjustments for differences in case mix between the two groups of hospitals. This analysis was supplemented with analyses of 13 local hospitals that were closed. Using a difference-in-difference approach, the effects that these closures had on neonatal and infant mortality were estimated.

Principal Finding

Neonatal and infant mortality were not affected by the type of hospital where the delivery took place.

Conclusion

A regionalized maternity service does not lead to increased neonatal and infant mortality. This is mainly because high-risk deliveries were identified well in advance of the birth, and referred to a larger hospital with sufficient perinatal resources to deal with these deliveries.     

Intussusception as a Cause of Bowel Obstruction in Adults from a Resource Limited Area,Cameroon

Background

Intussusception refers to the telescoping of a proximal segment of bowel into a distal segment. It is a rare cause of intestinal obstruction in adulthood.

Case Details

We report two cases of adult intussusception in a post-operative period following Caesarean Section (with no lead point) and Appendicectomy (due to colonic adenocarcinoma) respectively.

Conclusion

Though rare in adulthood, intussusception should be considered as a differential diagnosis to bowel obstruction in adults even in the post-operative period.     

Hospital Use of Agency‐Employed Supplemental Nurses and Patient Mortality and Failure to Rescue

Objective

To determine the association between the use of agency-employed supplemental registered nurses (SRNs) to staff hospitals and patient mortality and failure to rescue (FTR).

Data Sources

Primary survey data from 40,356 registered nurses in 665 hospitals in four states in 2006 were linked with American Hospital Association and inpatient mortality data from state agencies for approximately 1.3 million patients.

Study Design

Logistic regression models were used to examine the association between SRN use and 30-day in-hospital mortality and FTR, controlling for patient and hospital characteristics, nurse staffing, the proportion of nurses with bachelor''s degrees, and quality of the work environment.

Principal Findings

Before controlling for multiple nurse characteristics of hospitals, higher proportions of agency-employed SRNs in hospitals appeared to be associated with higher mortality (OR = 1.06) and FTR (OR = 1.05). Hospitals with higher proportions of SRNs have poorer work environments, however, and the significant relationships between SRNs and mortality outcomes were rendered insignificant when work environments were taken into account.

Conclusions

Higher use of SRNs does not appear to have deleterious consequences for patient mortality and may alleviate nurse staffing problems that could produce higher mortality.     

Costs and process of in-patient tuberculosis management at a central academic hospital,Cape Town,South Africa

Setting:

South Africa reports more cases of tuberculosis (TB) than any other country, but an up-to-date, precise estimate of the costs associated with diagnosing, treating and preventing TB at the in-patient level is not available.

Objective:

To determine the costs associated with TB management among in-patients and to study the use of personal protective equipment (PPE) at a central academic hospital in Cape Town.

Design:

Retrospective and partly prospective cost analysis of TB cases diagnosed between May 2008 and October 2009.

Results:

The average daily in-patient costs were US$238; the average length of stay was 9.7 days. Mean laboratory and medication costs per stay were respectively US$26.82 and US$8.68. PPE use per day cost US$0.99. The average total TB management costs were US$2373 per patient. PPE was not always properly used.

Discussion:

The costs of in-patient TB management are high compared to community-based treatment; the main reason for the high costs is the high number of in-patient days. An efficiency assessment is needed to reduce costs. Cost reduction per TB case prevented was approximately US$2373 per case. PPE use accounted for the lowest costs. Training is needed to improve PPE use.     

A Nonparametric Statistical Method That Improves Physician Cost of Care Analysis

Objective

To develop a compositing method that demonstrates improved performance compared with commonly used tests for statistical analysis of physician cost of care data.

Data Source

Commercial preferred provider organization (PPO) claims data for internists from a large metropolitan area.

Study Design

We created a nonparametric composite performance metric that maintains risk adjustment using the Wilcoxon rank-sum (WRS) test. We compared the resulting algorithm to the parametric observed-to-expected ratio, with and without a statistical test, for stability of physician cost ratings among different outlier trimming methods and across two partially overlapping time periods.

Principal Findings

The WRS algorithm showed significantly greater within-physician stability among several typical outlier trimming and capping methods. The algorithm also showed significantly greater within-physician stability when the same physicians were analyzed across time periods.

Conclusions

The nonparametric algorithm described is a more robust and more stable methodology for evaluating physician cost of care than commonly used observed-to-expected ratio techniques. Use of such an algorithm can improve physician cost assessment for important current applications such as public reporting, pay for performance, and tiered benefit design.     

Cumulative Lead Exposure and Tooth Loss in Men: The Normative Aging Study

Background

Individuals previously exposed to lead remain at risk because of endogenous release of lead stored in their skeletal compartments. However, it is not known if long-term cumulative lead exposure is a risk factor for tooth loss.

Objectives

We examined the association of bone lead concentrations with loss of natural teeth.

Methods

We examined 333 men enrolled in the Veterans Affairs Normative Aging Study. We used a validated K-shell X-ray fluorescence (KXRF) method to measure lead concentrations in the tibial midshaft and patella. A dentist recorded the number of teeth remaining, and tooth loss was categorized as 0, 1–8 or ≥ 9 missing teeth. We used proportional odds models to estimate the association of bone lead biomarkers with tooth loss, adjusting for age, smoking, diabetes, and other putative confounders.

Results

Participants with ≥ 9 missing teeth had significantly higher bone lead concentrations than those who had not experienced tooth loss. In multivariable-adjusted analyses, men in the highest tertile of tibia lead (> 23 μg/g) and patella lead (> 36 μg/g) had approximately three times the odds of having experienced an elevated degree of tooth loss (≥ 9 vs. 0–8 missing teeth or ≥ 1 vs. 0 missing teeth) as those in the lowest tertile [prevalence odds ratio (OR) = 3.03; 95% confidence interval (CI), 1.60–5.76 and OR = 2.41; 95% CI, 1.30–4.49, respectively]. Associations between bone lead biomarkers and tooth loss were similar in magnitude to the increased odds observed in participants who were current smokers.

Conclusion

Long-term cumulative lead exposure is associated with increased odds of tooth loss.     

Proposed MHRA changes to UK children's paracetamol dosing recommendations: modelling study

Objectives

Paracetamol is the most commonly administered medicine to children. A recent study highlighted the risk of overdose of paracetamol using British National Formulary for Children (BNFC) age-based dosing guidelines. This current study assesses the safety of changes to the UK paracetamol product dosing system proposed by the Medicines and Healthcare products Regulatory Authority (MHRA) which include a larger number of narrower age bands and a single dose per age band.

Design

Theoretical comparison of the proposed MHRA dosing system with the product dosing instructions of a commonly prescribed form of paracetamol in the UK.

Setting

United Kingdom

Participants

Proposed MHRA dosing recommendations and current product dosing instructions were compared using a previously validated model.

Main outcome measures

For both dosing recommendations, single and cumulative daily doses of paracetamol for boys and girls at the 9th, 50th and 91st centiles for weight were calculated for 3 month, 1 year, 6 year and 12 year age groups.

Results

With the current product dosing instructions, underweight children are at risk of receiving approximately two times the recommended single and cumulative daily dose of paracetamol, particularly at age 1 year and 6 years. This risk is negligible when the same model is applied to the proposed MHRA dosing system, whereby underweight, average weight and overweight children at all ages receive doses marginally above or within the recommended dose range or limit.

Conclusion

The proposed MHRA dosing recommendations for paracetamol use in children are effective at reducing the risk of paracetamol overdose in children of all ages, when compared with current product dosing instructions.     

Hydrometrocolpos Presenting as a Huge Abdominal Swelling and Obstructive Uropathy in a 4 Day Old Newborn: A Diagnostic Challenge

Background

Abdominal swelling is an uncommon presentation in newborn babies. A combination of huge abdominal swelling, obstructive uropathy and imperforate hymen in newborns has not been reported in the medical literature.

Case Details

We report a 4 days old newborn with a rare presentation of hydrometrocolpos which posed a diagnostic challenge and consequently resulted in delays in diagnosis and treatment.

Conclusion

Hydrometrocolpos should be considered as a differential diagnosis in neonates who present with huge abdominal swelling.     

Development of peer-group-classification criteria for the comparison of cost efficiency among general hospitals under the Korean NHI program

Objectives

To classify general hospitals into homogeneous systematic-risk groups in order to compare cost efficiency and propose peer-group-classification criteria.

Data Sources

Health care institution registration data and inpatient-episode-based claims data submitted by the Korea National Health Insurance system to the Health Insurance Review and Assessment Service from July 2007 to December 2009.

Study Design

Cluster analysis was performed to classify general hospitals into peer groups based on similarities in hospital characteristics, case mix complexity, and service-distribution characteristics. Classification criteria reflecting clustering were developed. To test whether the new peer groups better adjusted for differences in systematic risks among peer groups, we compared the R² statistics of the current and proposed peer groups according to total variations in medical costs per episode and case mix indices influencing the cost efficiency.

Data Collection

A total of 1,236,471 inpatient episodes were constructed for 222 general hospitals in 2008.

Principal Findings

New criteria were developed to classify general hospitals into three peer groups (large general hospitals, small and medium general hospitals treating severe cases, and small and medium general hospitals) according to size and case mix index.

Conclusions

This study provides information about using peer grouping to enhance fairness in the performance assessment of health care providers.