Severe Posterior Infra-occlusion on a Young Girl Posing a Diagnostic Challenge- Review and Report of a Case of Primary Failure of Eruption

Primary failure of eruption is characterized by a non-syndromic eruption failure of permanent teeth in the absence of any mechanical obstruction. Applying orthodontic traction to teeth affected by PFE will not be successful and may cause ankylosis. This correspondence reviews and demonstrates the treatment of a case of PFE.

443 Arterial hypertension in aortic valve stenosis: a critical update

Aims Aortic stenosis (AS) is a very common valve disease and is associated with high mortality once it becomes symptomatic. Arterial hypertension (HT) has a high prevalence among patients with AS leading to worst left ventricle remodelling and faster degeneration of the valve. HT also seems to interfere with the assessment of the severity of AS leading to an underestimation of the real degree of stenosis. Treatment of HT in AS has historically been associated with reluctance due to both the lack of clear guidelines and the fear of adverse effects, but the most recent evidence shows as several drugs that can be used. Methods The pathophysiology of the combination of AS and HT is the association of a first fixed mechanical obstruction of the aortic root and a second obstruction due to systemic vascular resistance. Consequently, a decrease in systemic vascular resistance through, for example, the administration of vasodilators could theoretically cause a drop in systemic pressure due to the fixed mechanical obstruction given by the stenosis which prevents an increase in cardiac output. This theory was the basis for avoiding vasodilators in patients with AS. Results There is a unanimous opinion on maintaining blood pressure values of 130–139 mmHg of systolic and 70–90 mmHg of diastolic, but there is not the same agreement on which drugs to adopt to achieve the aforementioned values. Renin-Angiotensin-Aldosterone system inhibitors are certainly the first-line treatment thanks to their cardioprotective, plaque stabilizing, and antiarrhythmic effect since they are also associated with increased survival rates and greater left ventricular mass reduction in patients after surgical or transcatheter aortic valve replacement for severe AS. If blood pressure is not yet controlled, the addition of a beta-blocker should be considered: metoprolol has the greatest literature, showing not only an improvement in haemodynamic and metabolic performance but also a reduction in mortality in patients who already presented with coronary artery disease. Mineralocorticoid receptor antagonist can be used, among them eplerenone has been studied and can be useful to relieve symptoms of patients with a flare-up of heart failure by reducing the preload, provided that a close fluid and echocardiographic monitoring is implemented. Conclusions The use of phosphodiesterase 5 inhibitors can improve the haemodynamic status of patients with aortic stenosis and reduce the level of left ventricular hypertrophy, as well as improve pulmonary circulation and exercise tolerability of patients with AS, however it should be considered that in other studies sildenafil was associated with a worse clinical outcome. Calcium channel blocker are one the most used medications in patients with HT, but their use was associated with a 7-fold relative risk of all-cause mortality independent of known confounders and was also associated with an adverse effect on treadmill exercise and higher risk of all-cause mortality in patients with AS.

The role of shuntography in diagnosis of mechanic complications after implantation of ventriculoperitoneal shunts in patients with idiopathic normal pressure hydrocephalus: a retrospective clinical evaluation

Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

Sudden circulatory collapse caused by mechanical obstruction of the left main coronary trunk with infective endocarditis vegetation: a case report

Background Acute coronary syndrome (ACS) caused by mechanical obstruction of the coronary artery with a vegetation is extremely rare but associated with high mortality. The optimal management strategy of this condition remains controversial because of its scarcity. We experienced a case of sudden circulatory collapse due to mechanical occlusion of the left main coronary trunk with a vegetation. Case presentation A 68-year-old woman with aortic and mitral valve infective endocarditis suffered sudden dyspnea followed by heart arrest while awaiting surgery. Despite treatment with adequate antibiotic therapy, she had had multiple embolic infarctions and ruptured infectious cerebral aneurysms. We conducted transcatheter arterial embolization of the aneurysm and postponed the cardiac surgery due to residual aneurysmal blood flow. She suffered sudden cardiac arrest, and extracorporeal membrane oxygenation was applied after cardiopulmonary resuscitation. An echocardiogram revealed diffuse severe hypokinesis, and emergency coronary angiography was performed under suspicion of ACS. It revealed obstruction of the left main coronary trunk by a vegetation. Emergent cardiac surgery was performed. A vegetation had occluded the left coronary orifice. Aortic and mitral valve replacement with coronary artery bypass to the left antero-descending branch was performed. Regarding her cardiac function, she still required extracorporeal membrane oxygenation after surgery. She passed away 19 days after surgery due to multiple organ failure. Conclusions ACS caused by mechanical obstruction of the coronary artery with a vegetation is rare but associated with high mortality. When circulatory collapse acutely occurs in patients with aortic valve infective endocarditis, we should suspect acute coronary artery obstruction. Urgent coronary angiography is mandatory to rescue the patient while preparing for emergency surgery.

Multiple Esophageal Leiomyoma Presenting with Clinical Dysphagia from Mechanical Obstruction and Motility Disorder

Esophageal leiomyoma is uncommon. However, this tumor is the most common subepithelial tumor affecting the esophagus, comprising approximately two-thirds of benign esophageal tumors. Leiomyomas of the esophagus rarely cause symptoms when they are single and <5 cm. The mainstay of treatment is esophagectomy for symptomatic patients. A 68-year-old male patient presented with progressive dysphagia for 4 months. The degree of dysphagia and chest discomfort was more severe on solid rather than liquid diet. The CT scan of the chest showed multiple well-defined, submucosal nodules, up to 1.9 cm in diameter located at the middle esophagus. The barium swallow study illustrated multiple, well-defined, smooth, semilunar filling defects along the mid to distal esophagus. Meanwhile, esophagogastroduodenoscopy revealed 8 smooth subepithelial masses. Moreover, the radial EUS showed multiple hypoechoic masses arising from the 4th layer, with some of the tumors connected to others as a horseshoe-like shape causing narrowed lumen. Last, high-resolution esophageal manometry revealed ineffective esophageal motility. We report a rare case of numerous esophageal leiomyomas which caused dysphagia as a result of both mechanical obstruction and hypomotility disorder. The histopathology confirmed the diagnosis of esophageal leiomyoma. Symptoms improved significantly after lifestyle modifications and adherence to dietary advice on the part of the patient.

STUDY OF THE ACTIVITY OF SOME RAT SERUM ENZYMES IN THE DYNAMICS OF EXTRAHEPATIC CHOLESTASIS

Extrahepatic cholestasis occurs with mechanical obstruction of the main extrahepatic or main intrahepatic ducts. The most common cause of extrahepatic cholestasis is common bile duct stones. This article describes hypertension in the bile ducts and acholysis developing in cholestasis, which cause serious functional and morphological changes in the liver and lead to the rapid growth of liver insufficiency. Thus, in the dynamics of extrahepatic cholestasis development there are significant shifts in blood serum of experimental animals, manifested by hyperfermentemia. These changes indicate the involvement of the liver in the pathological process, which naturally requires their correction.

Gorilla Glue Ingestion in Dogs: 22 Cases (2005–2019)

ABSTRACT Gorilla Glue contains methylene diphenyl diisocyanate that expands significantly and hardens once exposed to moisture. Case reports of methylene diphenyl diisocyanate glue ingestion in dogs document gastrointestinal foreign body formation and mechanical obstruction. Medical record queries from four veterinary hospitals identified 22 dogs with Gorilla Glue ingestion. Records were evaluated retrospectively to characterize clinical presentation, diagnostic findings, treatment, and patient outcome. Vomiting was the most common clinical sign (n = 11), with a median time from ingestion to presentation of 42 hr. Abnormal abdominal palpation (e.g., pain) was the most reported examination finding (n = 13). Radiographs were performed in 18/22 dogs, with Gorilla Glue expansion described as granular or mottled soft tissue with gas in the stomach. In 73% (11/15) of dogs requiring surgery, history, clinical findings, and survey abdominal radiographs sufficed to proceed with celiotomy. Surgical removal of the Gorilla Glue foreign body was performed via gastrotomy (n = 14) or gastrotomy and duodenotomy (n = 1). Endoscopic removal was performed in one dog. One dog with suspected mechanical obstruction was euthanized owing to financial constraints. Remaining cases were managed conservatively (n = 5). Short-term prognosis following appropriate fluid therapy and surgical or endoscopic removal was very good.

Asystole Following Concomitant Intravenous Administration of Neostigmine and Dexmedetomidine in a Patient With Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a condition characterized by acute dilation of the large bowel without evidence of mechanical obstruction that occurs in a variety of hospitalized patients with many predisposing factors. Management includes supportive care and limitation of offending medications with mainstays of treatment of neostigmine administration and colonic decompression. We report the case of a critically ill patient with ACPO who experienced bradycardia and a brief episode of asystole when receiving concomitant dexmedetomidine and neostigmine infusions but who later remained hemodynamically stable when receiving propofol and neostigmine infusions. The bradycardia and associated hemodynamic instability experienced while on dexmedetomidine and neostigmine infusions were rapidly corrected with atropine and cessation of offending agents. Because ACPO is encountered frequently and the use of dexmedetomidine as a sedative agent in the ICU is increasing, practitioners should be aware of the additive risk of bradycardia and potential for asystole with the combination of neostigmine and dexmedetomidine. Electronic drug interaction databases should be updated and drug information sources should include a drug-drug interaction between dexmedetomidine and neostigmine to reduce the likelihood of concomitant administration.

Abstract 32: Residual Perfusion Deficit is Common Post Successful EVT and is Associated With Worse Clinical Outcome

Introduction: A significant portion of patients despite achieving successful recanalization following endovascular therapy (EVT) still have some residual perfusion deficit. The objective of this study was to identify the association of residual perfusion deficit with recanalization status and clot presence post EVT. Methods: Patients were included if they were evaluated at one of two comprehensive stroke centers from January 2015 through February 2018, had LVO of the anterior circulation, had baseline MRI pre EVT, and treated with EVT. Independent image reads by two separate readers blinded to target vessel, TICI score, and clinical outcome, evaluated the pre EVT, 2 hours, and 24 hours post EVT MRI for perfusion deficit and clot presence. The MTT and TTP maps post EVT were read separately for residual perfusion deficit, compared to the pre EVT perfusion deficit. Clot presence was read as susceptibility sign on GRE consistent with the vascular territory identified on the pre EVT PWI. Successful recanalization was defined as TICI 2b\3 in the IR suite. Early neurological improvement (ENI) was defined as a reduction of the admit NIHSS by ≥4 points or a score of 0-1 at 24 hours. Results: Fifty-eight patients were included with median age of 58 years, 55% female, 47% Black\African-American, median admit NIHSS of 19, 72% with M1 LVO, 69% treated with IV tPA, 79% achieved TICI of 2b\3, and 52% with ENI at 24 hours. All patients had a perfusion deficit pre EVT with 73% having a corresponding clot on GRE. Following EVT, 76% and 52% of patients had residual perfusion deficit at 2 and 24 hours post EVT, but only 24% and 13%, respectively, still had evidence of clot. For the 46 patients with successful recanalization, 41% still had some residual perfusion deficit at 24 hours, but only 9% still had clot, suggesting inadequate perfusion without a mechanical obstruction. The frequency of ENI at 24 hours was associated with complete reperfusion, 88% versus 46% (p=0.039) at 2 hours post EVT, and 76% versus 33% (p=0.002) at 24 hours post EVT. Conclusions: Residual perfusion deficit on post EVT MRI is common, even with successful recanalization, and is associated with poor outcome. Patients with residual perfusion deficit may benefit from early adjunctive therapy following EVT to improve outcome.