The Art of the Clinician

Background: The promotion of clinical abilities could represent a significant factor leading the clinicians to in making the correct diagnosis in a timely matter. Case: Our patient is a 42-year-old African male with a history of Hypertension, ESRD on hemodialysis via right-sided Permcath (PC), Mastoidectomy & Right ear surgery due to trauma in childhood, AV Fistula (Needed intervention 4 times) in left upper extremity, admitted due to witnessed seizures in the setting of hypertensive emergency. The patient denied family history and toxic habits. While the patient was at the emergency room, CT head revealed stable curvilinear hyper-attenuation thought to be a thrombosed developmental vein more likely than small subarachnoid hemorrhage. He was loaded with levetiracetam, received Ativan 1mg IV and HD done as per Nephrology. The patient was transferred to the floor he was not in acute distress and was asymptomatic, the cardiovascular (CV) examination showed regular pulse, normal S1, S2, S4+ appreciated with 2/4 diastolic murmur at second right intercostal space (ICS); 2/6 pansystolic murmur at third right intercostal space left parasternal border (LPSB) radiated to the right parasternal border (RPSB) and right mid-clavicular line (MCL); 3/6 systolic murmur at 5LICS MCL radiated to the posterior axillar line (PAL). Point of maximal impulse (PMI) displaced to mid axillar line (MAL). Parasternal heave present; the neurological exam was preserved. Endocarditis was suspected and echocardiogram was expedited, it showed severe aortic regurgitation, 1.60cm x 1.68cm mass in the tip of the catheter in the right atrium, possible vegetation in the tricuspid valve with mild regurgitation, moderate mitral valve regurgitation. Later, staphylococcus epidermidis was identified in blood cultures twice, as well as the culture from the PC. The transesophageal echocardiogram found 2.41 X 0.62 cm mass appears to be a fibrin sheath, possibly remnant of a prior catheter, small perforation in the non-coronary cusp likely in the setting of healed endocarditis. Infectious disease onboard for antibiotic management. Conclusion: The art of the clinician goes beyond the available technology; it could prevent the loss of critical time as well as unnecessary studies, guiding a better assessment and treatment of our patients and potentially improving their outcomes.

A Complex Case of Emphysematous Cystitis in a Peritoneal Dialysis Patient

Emphysematous cystitis (EC) is a relatively rare condition characterized by gas formation in the bladder wall and/or lumen. We report a case of emphysematous cystitis with a bladder perforation in an 84-year-old male on peritoneal dialysis who presented with fever, dysuria, hematuria, and hypotension. Gas in the bladder wall, as well as a small perforation in the roof of the urinary bladder, was seen on the abdominal CT scan. The causative organism identified was Escherichia coli. The patient recovered with broad-spectrum antibiotics along with bladder irrigation and drainage. After initial bladder washouts, peritoneal dialysis was continued with close monitoring. Early antibiotic therapy and a conservative approach to the management of small intraperitoneal bladder perforations were effective in this patient. Peritoneal dialysis was uninterrupted for the duration of the admission and after discharge.

The Effect of Perforation Spacing on the Variation of Stress Shadow

When the shale gas reservoir is fractured, stress shadows can cause reorientation of hydraulic fractures and affect the complexity. To reveal the variation of stress shadow with perforation spacing, the numerical model between different perforation spacing was simulated by the extended finite element method (XFEM). The variation of stress shadows was analyzed from the stress of two perforation centers, the fracture path, and the ratio of fracture length to spacing. The simulations showed that the reservoir rock at the two perforation centers is always in a state of compressive stress, and the smaller the perforation spacing, the higher the maximum compressive stress. Moreover, the compressive stress value can directly reflect the size of the stress shadow effect, which changes with the fracture propagation. When the fracture length extends to 2.5 times the perforation spacing, the stress shadow effect is the strongest. In addition, small perforation spacing leads to backward-spreading of hydraulic fractures, and the smaller the perforation spacing, the greater the deflection degree of hydraulic fractures. Additionally, the deflection angle of the fracture decreases with the expansion of the fracture. Furthermore, the perforation spacing has an important influence on the initiation pressure, and the smaller the perforation spacing, the greater the initiation pressure. At the same time, there is also a perforation spacing which minimizes the initiation pressure. However, when the perforation spacing increases to a certain value (the result of this work is about 14 m), the initiation pressure will not change. This study will be useful in guiding the design of programs in simultaneous fracturing.

Endoscopic Tympanoplasty: Inlay Cartilage Versus Underlay Cartilage Graft

INTRODUCTION: Several graft placement methods have been described in tympanoplasty. The aim of this study is to assess the surgical effects of the endoscopic tympanoplasty utilizing inlay cartilage or underlay cartilage graft. METHODS: We reviewed medical records of 123 patients who experienced endoscopic tympanoplasty for chronic otitis media with a minimum twelve-month follow-up period. Perforations were divided into central, posterior, and anterior ones based on the place of the perforation to malleus handle. Graft success rate, air conduction pure tone audiometry (PTA) before surgery and after surgery, hearing gain and air bone gap (ABG) reduction were calculated following surgery. RESULTS: No significant difference was found between the groups in terms of the distribution of the follow-up period, age, perforation location, and gender (p>0.05). The average air conductions (AC) before surgery and after surgery for the inlay group were 36.3 ± 13.7 dB and 25.4 ± 12.3 dB 6 months after surgery and 22.5 ± 10.5 dB 12 months after surgery. They were 35.6 ± 13.3 dB and 24.8 ± 12.4 dB 6 months after surgery and 22.7 ± 9.7 12 months after surgery for the underlay group. A significant difference was found between the two groups in terms of ABG (P=0.037). There was no significant difference in the mean ABG in each group (small perforation P =0.473, medium perforation P=0.876 and large perforation P=0.341). DISCUSSION AND CONCLUSION: The inlay method can be used with high graft success rate, low risk of complications among the appropriate patients, and shorter operation time as a reliable surgical option for treatment.

Closure of small perforation in tympanic membrane by use of fat plug

<p class="abstract"><strong>Background: </strong>Chronic suppurative otitis media presents mostly with ear discharge and associated decreased hearing. Tympanoplasty is the established surgery for tympanic membrane perforation. Most commonly used graft material for tympanoplasty is temporalis fascia. Others are fascia lata, tragal perichondrium, tragal cartilage, fat. The objective of the study was to compare the graft taken up and hearing improvement following myringoplasty with use of fat.</p><p class="abstract"><strong>Methods:</strong> Patients of CSOM aged 10 to 65 years old with small central perforation which is dry for at least 3 weeks with normal middle ear mucosa and intact ossicular chain with mild conductive hearing loss. The present study was carried out in Ear, neck and throat (ENT) Department of SCL hospital, Ahmedabad from July 2016 till September 2018 and 25 patients were randomly selected fulfilling the above criteria.</p><p class="abstract"><strong>Result: </strong>The choice of graft affects not only the outcome of surgery, but also determines the complexity of the procedure and the time taken for the same. Study proves that fat is also a one of the good grafting material which is easily available and keep to prevent from major surgery. The results have been quite encouraging.</p><p class="abstract"><strong>Conclusion: </strong>Study proves that fat is also a one of the good grafting material which is easily available and keep to prevent from major surgery. An added advantage of this technique was the excellent post-operative quality of life of the operated patients, assessed in terms of the chronic ear survey and evident by the absence of the usual post-operative complaints following a conventional myringoplasty.</p>

Transcanal endoscopic myringoplasty: a retrospective study

<p class="abstract"><strong>Background:</strong> Transcanal myringoplasty has the advantages of demanding lower operative time and minimal external incisions. It can be performed using the microscopic or endoscopic approach.</p><p class="abstract"><strong>Methods:</strong> This retrospective study was conducted in the Department of ENT and Head and Neck Surgery, SMGS Hospital, Jammu from January 2018 to January 2020. Patients attending ENT OPD with central dry perforation of tympanic membrane were selected for endoscopic transcanal myringoplasty. Written and Informed consent were taken. During surgery, various parameters were noted including duration of surgery and hospitalization. These patients were followed through a period of 6 months and assessed using pure tone audiometry and graft uptake was seen. </p><p class="abstract"><strong>Results:</strong> Out of 40 patients, male: female ratio was 1.2:1. Time taken for surgery was less than 60 minutes in 16 (40%) patients whereas in 24 (60%) patients it was between 60-120 minutes. In our study the patients with small perforation had excellent graft uptake rates (18/19 patients, 94.73%), whereas patients with medium sized perforation showed graft uptake rate of 76.47% (13/17 patients). Objective analysis of cosmetic result was done at the end of six month and revealed that none of the patient had visible scar. Mean pre-operative air bone gap was 24.38 dB whereas mean postoperative air bone gap was 8.34 dB. Mean improvement comes out to be 16.04 dB.</p><p class="abstract"><strong>Conclusions:</strong> Endoscopic myringoplasty was found to be equally effective, less morbid and very cost effective in small central perforations.</p>

Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting gastrointestinal neoplasia of the colon, expanded experience and follow-up

Background and study aims Colonic lesions may not be amenable to conventional endoscopic mucosal resection (EMR) due to previous manipulation, submucosal invasion, or lesion flatness. In 2018, we described Dissection-enabled Scaffold Assisted Resection (DeSCAR) to be safe for the endoscopic resection of non-lifting or residual colonic lesions 1 In this study, we expand our original cohort to describe our expanded experience with patients undergoing DeSCAR and assess the efficacy, safety, and feasibility of DeSCAR for endoscopic resection of non-lifting or residual colonic lesions. Patients and methods We retrospectively reviewed 57 patients from 2015–2019 who underwent DeSCAR for colonic lesions with incomplete lifting and/or previous manipulation. Cases were reviewed for location, prior manipulation, rates of successful resection, adverse events, and endoscopic follow up to assess for residual lesions. Results Fifty-seven lesions underwent DeSCAR. Of the patients, 51 % were female, and average patient age was 69 years. Lesions were located in the cecum (n = 16), right colon (n = 27), left colon (n = 10), and rectum (n = 4). Average lesion size was 27.7 mm. Previous manipulation occurred in 54 cases (72 % biopsy, 44 % resection attempt, 18 % intralesional tattoo). The technical success rate for resection of non-lifting lesions was 98 %. There were two delayed bleeding episodes (one required endoscopic intervention) and one small perforation (managed by endoscopic hemoclip closure). Endoscopic follow up was available in 31 patients (54 %) with no residual adenoma in 28 patients (90 % of those surveilled). Conclusions Our expanded experience with DeSCAR demonstrates high safety, feasibility, and effectiveness for the endoscopic management of non-lifting or residual colonic lesions.

Analysis of hearing improvement following fat graft myringoplasty

<p class="abstract"><strong>Background:</strong> Fat graft myringoplasty (FGM) is a procedure with a short learning curve, cost effective, with minimal morbidity in properly selected patients. It is useful to relieve the patient of annoyance caused by a small perforation in terms of ear discharge and hearing loss. The aim was to assess postoperative hearing improvement and investigate influence of factors like age, gender and location of perforation on audiological outcomes.</p><p class="abstract"><strong>Methods:</strong> This study was a prospective study done on 25 patients at a tertiary care hospital who underwent FGM. All patients had small dry central perforation. Air and Bone conduction (AC/BC) thresholds and air-bone gap (ABG) were evaluated both preoperatively and postoperatively. </p><p class="abstract"><strong>Results:</strong> Mean hearing improvement was 14.4762 dB in &lt;40 yrs age group whereas it was 11.2500 dB in &gt;40 yrs age group. Mean hearing improvement in females was 13.75 dB whereas it was 14.154 dB in males. Mean hearing improvement was 15 dB in posterior, 14.7 dB in inferior and 14.46 dB in anteriorly located perforation.</p><p class="abstract"><strong>Conclusions:</strong> FGM is effective in improving postoperative hearing thresholds hence it can be used in small dry central perforations of tympanic membrane in patients irrespective of patient variables such as age, gender, and location of perforation. As no significant statistical difference was observed in terms of gender, location or aetiology of perforation, we consider it a procedure to be recommended across all spectrums of patients.</p>

Root Canal Perforation: A Quick Review

Root canal perforation is a communication between the root canal system and supporting tissues of the teeth (periodontium). Causes of root canal perforation can be duo to multiple factor i.e., Caries, Resorption, Iatrogenic, Perforation prognosis depend on multiple factor these are; time size and location, based on the prognostic factors perforation can be classified into, Fresh Perforation, Old Perforation, Small Perforation, Large Perforation, Coronal Perforation, Crestal Perforation, Apical Perforation. A wide variety of materials to seal the perforations have been suggested in literature. Root perforation complicates the treatment and deprives the prognosis if not properly managed. Root canal perforation can be avoided in most of the cases if the clinician follows the basic principle of the root canal treatment protocol.

The efficacy of fat myringoplasty in small central perforation of pars tensa

<p class="abstract"><strong>Background:</strong> In the present study, an attempt was made to study the effectiveness of fat graft material and the improvement in hearing following fat myringoplasty in small central perforations of pars tensa.</p><p class="abstract"><strong>Methods:</strong> This prospective study was carried out in our tertiary centre between October 2014 to October 2015 in 38 patients selected randomly who attended our ENT OPD. Patients with tubotympanic type of chronic suppurative otitis media CSOM (TT), with dry small central perforation involving less than 25% of tympanic membrane (TM) were included. Patients with ossicular fixation or disruption with air bone gap (ABG) &gt;40dB were excluded. All procedures were performed under local anesthesia (LA). Fat graft was harvested from ear lobule and was placed through endomeatal microscopic approach after freshening perforation margin. All patients were followed up to 5months postoperative period and graft status and audiological assessment was made. </p><p class="abstract"><strong>Results:</strong> In 86.8% cases (33 patients) graft was taken up while in 13.2% cases (5 patients) graft was not taken up. Mean pre-operative air conduction in right/left ear was 28.5±7.6/27.1±8.5 and post-operative was 24.9±5.3/23.4±6.9 dB respectively. Similarly, it was seen that mean pre-operative air bone gap in right/left ear was 17.6±7.2/17.0±7.4 and post-operative was 14.0±5.3/13.2±6 dB respectively.</p><strong>Conclusions:</strong> It is a very safe, simpler procedure and in this we don’t disturb the annulus so the chance of lateralization or medialization of graft is nil. During fat myringoplasty the angle of tympanic membrane and anterior recess is maintained in natural position and we don’t disturb acoustics, so fat myringoplasty is an excellent option especially for small perforation.