Dental management of a patient fitted with subcutaneous Implantable Cardioverter Defibrillator device and concomitant warfarin treatment

Automated Implantable Cardioverter Defibrillators (AICD), simply known as an Implantable Cardioverter Defibrillator (ICD), has been used in patients for more than 30 years. An Implantable Cardioverter Defibrillator (ICD) is a small battery-powered electrical impulse generator that is implanted in patients who are at a risk of sudden cardiac death due to ventricular fibrillation, ventricular tachycardia or any such related event. Typically, patients with these types of occurrences are on anticoagulant therapy. The desired International Normalized Ratio (INR) for these patients is in the range of 2–3 to prevent any subsequent cardiac event. These patients possess a challenge to the dentist in many ways, especially during oral surgical procedures, and these challenges include risk of sudden death, control of post-operative bleeding and pain.This article presents the dental management of a 60 year-old person with an ICD and concomitant anticoagulant therapy. The patient was on multiple medications and was treated for a grossly neglected mouth with multiple carious root stumps. This case report outlines the important issues in managing patients fitted with an ICD device and at a risk of sudden cardiac death.     

Diminished degradation of myelin basic protein by anti-sulfatide antibody and interferon-gamma in myelin from glia maturation factor-deficient mice

In this study we show the effect of anti-sulfatide (RmAb) antibodies and inflammatory cytokines, TNF-alpha and IFN-gamma in inducing myelin basic protein (MBP) degradation in myelin isolated from control wild type (WT) and glia maturation factor (GMF)-deficient (GMF-KO) mice. GMF was not detected in isolated myelin from WT and GMF-KO mice although it is present in brains of WT mice. Our results show that calcium-dependent neutral protease activity caused significantly elevated degradation of 18.5 and/or 17.5kDa isoforms of MBP in WT myelin treated with RmAb or IFN-gamma. In contrast, MBP degradation in isolated myelin from GMF-KO mice remained unaffected following treatment with RmAb, IFN-gamma, or GM-CSF. Neither the 14kDa isoform of MBP nor proteolipid protein (PLP) showed an elevated degradation compared to controls. A virtual absence of GM-CSF, TNF-alpha and IFN-gamma in GMF-KO brain compared to WT was also evident when the animals were challenged with MOG 35-55. Additionally, the myelin from GMF-KO mice showed difference in distribution of myelin oligodendrocyte glycoprotein (MOG) and beta-tubulin in a sucrose density gradient myelin-axolemmal fractions compared to WT. Taken together, our data suggests a role for GMF in the biochemical organization of myelin and thereby its effect on MBP degradation induced by RmAb and IFN-gamma.     

Trends in Demographics and Management of Obstructing Colorectal Cancer

Introduction

Obstructing colorectal cancer (CRC) has an aggressive clinical course and poorer prognosis. With the increasing incidence and differing clinical and pathologic spectrum of CRC among Black patients, as well as a paucity of African studies, regional analysis is required. Our aim was to describe the demographics and management of obstructing CRC among the different racial groups in South Africa and to compare these parameters with international standards.

Patients and methods

Patients referred to Inkosi Albert Luthuli Central Hospital, Durban, South Africa, with CRC between 2000 and 2012 were followed prospectively. Demographic information, site of obstruction, and management of patients who underwent emergency surgery for malignant large bowel obstruction were analyzed separately.

Results

CRC was diagnosed in 1,425 patients. A total of 203 three patients (14.3 %) required emergent treatment for acute large bowel obstruction. The mean age at presentation with obstructing CRC was 59 years. Black patients presented significantly younger (50 years) than White (64), Indian (60), or Colored (61) patients (p < 0.001). The most common sites of obstruction were the sigmoid colon and rectum. A total of 58 patients (29 %) had concomitant metastatic disease. No difference was found between race, sex, and sex per race in patients with concurrent metastatic disease (p = 0.227, p = 0.415, p = 0.798, respectively). Of the 203 patients, 128 (63 %) were managed by resection, 37 (18 %) by colonic stenting, 35 (17 %) by colostomy, and 3 (2 %) by colonic bypass. Stenting was unsuccessful in six patients.

Conclusion

Tumor location of patients presenting with obstruction is comparable to that cited in international literature; however, the age of presentation among Black patients is more than a decade earlier than in other ethnic groups. Surgical management should be individualized. Stenting remains a reliable alternative in select cases.     

Indications and outcomes of enucleation versus formal pancreatectomy for pancreatic neuroendocrine tumors

BackgroundPancreatoduodenectomy (PD) or distal pancreatectomy (DP) are common procedures for patients with a pancreatic neuroendocrine tumor (pNET). Nevertheless, certain patients may benefit from a pancreas-preserving resection such as enucleation (EN). The aim of this study was to define the indications and differences in long-term outcomes among patients undergoing EN and PD/DP.MethodsPatients undergoing resection of a pNET between 1992 and 2016 were identified. Indications and outcomes were evaluated, and propensity score matching (PSM) analysis was performed to compare long-term outcomes between patients who underwent EN versus PD/DP.ResultsAmong 1034 patients, 143 (13.8%) underwent EN, 304 (29.4%) PD, and 587 (56.8%) DP. Indications for EN were small size (1.5 cm, IQR:1.0–1.9), functional tumors (58.0%) that were mainly insulinomas (51.7%). After PSM (n = 109 per group), incidence of postoperative pancreatic fistula (POPF) grade B/C was higher after EN (24.5%) compared with PD/DP (14.0%) (p = 0.049). Median recurrence-free survival (RFS) was comparable among patients who underwent EN (47 months, 95% CI:23–71) versus PD/DP (37 months, 95% CI: 33–47, p = 0.480).ConclusionComparable long-term outcomes were noted among patients who underwent EN versus PD/DP for pNET. The incidence of clinically significant POPF was higher after EN.     

Congenital mitral regurgitation due to papillary muscle infarction: a case report and approach to evaluation

Congenital mitral regurgitation is relatively rare. It can be due to congenital malformation of the valve apparatus, associated structural heart defects, or results from myocardial dysfunction leading to deformation of the valve annulus. Hence, careful delineation of the pathologic processes involved in the mechanism is critical when evaluating patients presenting with congenital mitral valve regurgitation. Congenital anomalies of the coronary system are one of the serious associations, which needs prompt recognition and treatment to prevent fatal complications. We report a case of congenital atresia of left main coronary artery in an asymptomatic 8-month-old presenting with an incidental finding of mitral valvar regurgitation. Appropriate investigations and management lead to restoration of normal coronary blood flow and valve function. This particular case illustrates that congenital coronary anomalies may present in an otherwise asymptomatic child. It should be considered as one of the possible differential diagnosis in unexplained mitral regurgitation. Early recognition and prompt surgical treatment can radically modify the prognosis.     

Research on energy expenditure in individuals with eating disorders: a review

OBJECTIVE: This study reviews the published research on energy expenditure in individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). METHOD: Individual studies are reviewed and their results summarized. RESULTS: The most consistent finding is a reduction in resting energy expenditure (REE) in patients with AN, which increases with increased energy intake and body weight. Data regarding BN are inconsistent. Three available studies in subjects with BED have not found evidence of changes in energy expenditure corrected for lean body mass compared with obese non-binge eaters. DISCUSSION: The ability to measure REE reliably and cost-effectively may aid in the refeeding of patients with AN in whom REE is reduced. Changes in individuals with BN and BED have yet to be consistently identified.     

Postinfarction Left Ventricular Remodeling: A Pathophysiological and Therapeutic Review

Over the last 50 years, studies investigating the pathogenesis of left ventricular dysfunction have resulted in many potential therapeutic targets being identified and novel classes of drugs designed to treat this condition. Despite this, the long-term prognosis of patients with clinical heart failure remains poor with mortality rates equivalent to many terminal malignancies. This article reviews our present understanding of the pathophysiology of post-infarction left ventricular dysfunction and provides a rationale for current drug usage, drugs undergoing clinical trials and compounds still under pre-clinical development. In addition, the complexities involved in deciphering intra-cellular signalling pathways mediating ventricular hypertrophy which may form the basis of future treatments are also discussed.