SARS-CoV-2 transmission risk for common group activities and settings: a living scoping review

BACKGROUND

While the modes of transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are well studied, the risk of transmission in various group settings or activities is less clear. This living scoping review aims to summarize the risk factors of coronavirus disease 2019 (COVID-19) spread in common group activities (e.g. social gatherings) or settings (e.g. schools, hospitals, shared workplaces) to understand the drivers of transmission and to inform a risk assessment profile tool for use of rapid antigen detection tests.

METHODS

We systematically searched electronic databases, MEDLINE and Embase, from January 2019 until February 2022. We included studies that evaluated the risk of SARS-CoV-2 transmission in activities and settings, deemed strategically important to government departments in Ireland, provided by the Department of Health (Ireland) Expert Advisory Group on Rapid Testing.

RESULTS

After screening 14 052 records, data from 139 studies were narratively synthesized. The risk was consistently reported as 'high' for large social events (e.g. weddings) and indoor sports, working in healthcare settings and shared workplaces, working/living in residential settings and travelling via public transportation. Most studies were from healthcare settings, with common risk factors including close contact with COVID-19 cases, working in high-risk departments and inappropriate use of personal protective equipment. For other settings and activities, lack of infection prevention and control practices reportedly contributed to infection transmission.

CONCLUSION

The heterogeneity across studies and lack of direct information on dominant variants, preventive measures, vaccination coverage necessitates further research on transmission risk within group activities to inform infection prevention and control measures.

Performance of different rapid antigen testing strategies for SARS-CoV-2: A living rapid review

BACKGROUND

Rapid antigen detection tests (RADTs) for SARS-CoV-2 testing offer several advantages over molecular tests, but there is little evidence supporting an ideal testing algorithm. We aimed to examine the diagnostic test accuracy (DTA) and the effectiveness of different RADT SARS-CoV-2 testing strategies.

METHODS

Following PRISMA DTA guidance, we carried out a living rapid review and meta-analysis. Searches were conducted in Ovid MEDLINE® ALL, Embase and Cochrane CENTRAL electronic databases until February 2022. Results were visualized using forest plots and included in random-effects univariate meta-analyses, where eligible.

RESULTS

After screening 8010 records, 18 studies were included. Only one study provided data on incidence outcomes. Seventeen studies were DTA reports with direct comparisons of RADT strategies, using RT-PCR as the reference standard. Testing settings varied, corresponding to original SARS-CoV-2 or early variants. Strategies included differences in serial testing, the individual collecting swabs and swab sample locations. Overall, specificity remained high (>98%) across strategies. Although results were heterogeneous, the sensitivity for healthcare worker-collected samples was greater than for self-collected samples. Nasal samples had comparable sensitivity when compared to paired RADTs with nasopharyngeal samples, but sensitivity was much lower for saliva samples. The limited evidence for serial testing suggested higher sensitivity if RADTs were administered every 3 days compared to less frequent testing.

CONCLUSIONS

Additional high-quality research is needed to confirm our findings; all studies were judged to be at risk of bias, with significant heterogeneity in sensitivity estimates. Evaluations of testing algorithms in real-world settings are recommended, especially for transmission and incidence outcomes.

CARDIAC REHABILITATION: IMPROVING OUTCOMES FOR PATIENTS WITH HEART DISEASE

To evaluate the extent to that blood pressure management objectives are fulfilled in patients with Diabetes Mellitus (DM) and hypertension (HT), as well as the impact of the Cardiac Rehabilitation plan on the patient's useful ability, mental health, and pathological risk factors. The Cardiac Rehabilitation (CR) participants' anthropometric measurements, medications, lipid profiles, and medical and social backgrounds were all the subjects of the 19-month data collection. The parameters of the topics' minute walk test and Patient Health Questionnaire(PHQ) were further investigated. The Calvary Public Hospital in Canberra's CR program sessions required participants to show up for at least 10 of the sessions to be qualified. Seventy-nine people took part in the research. Significant reductions in low-density lipoprotein (LDL) cholesterol levels in the blood of participants, as well as gains in a patient health questionnaire and 6 min walk test (6MWT) scores, were seen. Additionally, people increased drug management. Results showed considerable improvements in diastolic blood pressure, physical capacity, depression, and anxiety in DM patients. A cardiac rehabilitation program may lower cardiovascular disease risk factors while enhancing participants' physical and emotional well-being. Results shown the cardiac rehabilitation program lowers the risk factors linked with DM patients' cardiovascular and renal disease via increased physical fitness and decreased levels of anxiety and despair.

Antibiotic prescribing and antimicrobial stewardship in long-term care facilities: Past interventions and implementation challenges

Background

The threat of antimicrobial resistance (AMR) is rising, leading to increased illness, death and healthcare costs. In long-term care facilities (LTCFs), high rates of infection coupled with high antibiotic use create a selective pressure for antimicrobial-resistant organisms that pose a risk to residents and staff as well as surrounding hospitals and communities. Antimicrobial stewardship (AMS) is paramount in the fight against AMR, but its adoption in LTCFs has been limited.

Methods

This article summarizes factors influencing antibiotic prescribing decisions in LTCFs and the effectiveness of past AMS interventions that have been put in place in an attempt to support those decisions. The emphasis of this literature review is the Canadian LTCF landscape; however, due to the limited literature in this area, the scope was broadened to include international studies.

Results

Prescribing decisions are influenced by the context of the individual patient, their caregivers, the clinical environment, the healthcare system and surrounding culture. Antimicrobial stewardship interventions were found to be successful in LTCFs, though there was considerable heterogeneity in the literature.

Conclusion

This article highlights the need for more well-designed studies that explore innovative and multifaceted solutions to AMS in LTCFs.

P-270 Assisted gamete treatment to pinpoint acquired meiotic maturity and overcome oocyte activation deficiency contributed by both gametes

Study question

How can we treat couples with complete and persistent fertilization failure with ICSI linked to a combination of oocyte- and sperm-related oocyte activation deficiency (OAD)?

Summary answer

By targeting spindle presence, we optimized oocyte response to chemical activation and enhanced fertilization. Genomic assessment confirmed gamete contribution.

What is known already

Total fertilization failure occurs in 1-3% of all intracytoplasmic sperm injection (ICSI) cases. In sperm-factor OAD, the lack of phospholipase C zeta (PLCζ) prevents the spermatozoon from initiating downstream calcium oscillation in the oocyte. In these cases, assisted gamete treatment (AGT), which exposes gametes to calcium ionophore, has been adopted to artificially trigger the influx of calcium ions and has been shown to effectively improve fertilization. However, AGT is limited to triggering an intracytoplasmic calcium influx and still requires optimal ooplasmic maturity.

Study design, size, duration

Over the past 17 months, we identified couples with compromised PLCζ and reported persistent fertilization failure with ICSI despite AGT treatment. We then devised a treatment plan comprising an extended in vitro culture (IVC) to pinpoint meiotic oocyte maturity confirmed by the presence of a meiotic II spindle and followed by AGT post-ICSI. Genomic assessment was also carried out.

Participants/materials, setting, methods

Two couples with recurrent and total fertilization failure even after AGT were included. PLCζ expression was assessed using immunofluorescence on ≥ 200 cells/specimen with a 30% threshold. In the follow-up cycles, IVC was extended for at least 8 hours between retrieval and ICSI. Metaphase II spindles were visualized by Oosight®. AGT was performed by exposing both spermatozoa and oocytes to calcium ionophore. NGS was performed on spermatozoa to identify gene mutations involved in fertilization.

Main results and the role of chance

We identified 2 couples (couple A: 37-year-old female, 39-year-old male; couple B: 32-year-old female, 33-year-old male) with the following semen parameters: average volume of 2.6 ml, concentration of 82.0x106/ml, 44% motility, and normal morphology of 3%. The oocyte maturation rate was 76.3% (45/59) but resulted in zero fertilized out of a total of 45 MII oocytes injected. In-house PLCζ assessment revealed a deficiency of oocyte activation factor at 12.9%. AGT treatment alone failed to enhance fertilization on a subsequent cycle, resulting in 0% (0/8) and 5.6% (1/18) fertilization rates for couples A and B, respectively. Couple A then underwent 3 ICSI cycles with extended IVC and AGT; upon examination of nuclear maturity, 91.4% (32/35) of oocytes displayed normal metaphase II spindle and achieved an overall fertilization rate of 43.8% (14/32). To date, 12 blastocysts were cryopreserved. In couple B, 27 oocytes out of 34 retrieved presented normal metaphase II spindles after extended IVC; ICSI with AGT yielded a fertilization rate of 63.0% (17/27). All 17 zygotes were cryopreserved. Overall, our treatment improved fertilization to an overall rate of 52.5% (31/59, P  <0.00001). Genomic assessment of spermatozoa identified gene mutations involved in fertilization (ADAM15, ADAM30) and calcium channel activity (CATSPER1).

Limitations, reasons for caution

Assisted gamete treatment can enhance fertilization in cases of deficiency in PLCζ. However, chemical activation requires a responsive ooplasm that has reached meiotic maturity. These rare cases require precise diagnoses and tailored treatment techniques to address each aspect of sperm- and/or oocyte-factor OAD.

Wider implications of the findings

Our study has demonstrated the usefulness of extended IVC by targeting spindle presence to enhance chemical responses to AGT. Our findings show that although calcium ionophore can trigger the release of intracellular calcium and allow fertilization, a fully mature ooplasm is required.

Trial registration number

N/A

Retinal Vein Occlusion with COVID-19: A Case Report and Review of Literature

OBJECTIVES

To provide a case report of Retinal Vein Occlusion (RVO) with COVID-19 infection.

CASE

A 15-year-old healthy male presented with blurring of vision, 2+ vitreous cells, retinal haemorrhages and dilated and tortuous retinal vessels in the left eye within 28 days of a positive COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) assay. He was diagnosed with left non-ischaemic CRVO, with a suspected aetiology of COVID-19.

DISCUSSION

A literature review found 12 reported cases of RVO associated with COVID-19. All but one patient was younger than 60, with a mean age of 42 years. Management varied, but in the majority (8/12), visual acuity (VA) improved with follow-up, and five (42%) had a final VA of 20/20.

CONCLUSION

In the absence of other known aetiological factors, ophthalmologists should consider COVID-19 as a cause of RVO. The outcome can vary, but the majority can expect improvement in VA with time.

Improved biofilm removal using cavitation from a dental ultrasonic scaler vibrating in carbonated water

The use of cavitation for improving biofilm cleaning is of great interest. There is no system at present that removes the biofilm from medical implants effectively and specifically from dental implants. Cavitation generated by a vibrating dental ultrasonic scaler tip can clean biomaterials such as dental implants. However, the cleaning process must be significantly accelerated for clinical applications. In this study we investigated whether the cavitation could be increased, by operating the scaler in carbonated water with different CO₂ concentrations. The cavitation around an ultrasonic scaler tip was recorded with high speed imaging. Image analysis was used to calculate the area of cavitation. Bacterial biofilm was grown on surfaces and its removal was imaged with a high speed camera using the ultrasonic scaler in still and carbonated water. Cavitation increases significantly with increasing carbonation. Cavitation also started earlier around the tips when they were in carbonated water compared to non-carbonated water. Significantly more biofilm was removed when the scaler was operated in carbonated water. Our results suggest that using carbonated water could significantly increase and accelerate cavitation around ultrasonic scalers in a clinical situation and thus improve biofilm removal from dental implants and other biomaterials.

How does ultrasonic cavitation remove dental bacterial biofilm?

Bacterial biofilm accumulation is problematic in many areas, leading to biofouling in the marine environment and the food industry, and infections in healthcare. Physical disruption of biofilms has become an important area of research. In dentistry, biofilm removal is essential to maintain health. The aim of this study is to observe biofilm disruption due to cavitation generated by a dental ultrasonic scaler (P5XS, Acteon) using a high speed camera and determine how this is achieved. Streptococcus sanguinis biofilm was grown on Thermanox™ coverslips (Nunc, USA) for 4 days. After fixing and staining with crystal violet, biofilm removal was imaged using a high speed camera (AX200, Photron). An ultrasonic scaler tip (tip 10P) was held 2 mm away from the biofilm and operated for 2 s. Bubble oscillations were observed from high speed image sequences and image analysis was used to track bubble motion and calculate changes in bubble radius and velocity on the surface. The results demonstrate that most of the biofilm disruption occurs through cavitation bubbles contacting the surface within 2 s, whether individually or in cavitation clouds. Cleaning occurs through shape oscillating microbubbles on the surface as well as through fluid flow.

The effect of standoff distance and surface roughness on biofilm disruption using cavitation

Effective biofilm removal from surfaces in the mouth is a clinical challenge. Cavitation bubbles generated around a dental ultrasonic scaler are being investigated as a method to remove biofilms effectively. It is not known how parameters such as surface roughness and instrument distance from biofilm affect the removal. We grew Strepotococcus sanguinis biofilms on coverslips and titanium discs with varying surface roughness (between 0.02-3.15 μm). Experimental studies were carried out for the biofilm removal using high speed imaging and image analysis to calculate the area of biofilm removed at varying ultrasonic scaler standoff distances from the biofilm. We found that surface roughness up to 2 μm does not adversely affect biofilm removal but a surface roughness of 3 μm caused less biofilm removal. The standoff distance also has different effects depending on the surface roughness but overall a distance of 1 mm is just as effective as a distance of 0.5 mm. The results show significant biofilm removal due to an ultrasonic scaler tip operating for only 2s versus 15-60s in previous studies. The technique developed for high speed imaging and image analysis of biofilm removal can be used to investigate physical biofilm disruption from biomaterial surfaces in other fields.

Numerical investigation of cavitation generated by an ultrasonic dental scaler tip vibrating in a compressible liquid

Bacterial biofilm accumulation around dental implants is a significant problem leading to peri-implant diseases and implant failure. Cavitation occurring in the cooling water around ultrasonic scaler tips can be used as a novel solution to remove debris without any surface damage. However, current clinically available instruments provide insufficient cavitation around the activated tip surface. To solve this problem a critical understanding of the vibro-acoustic behaviour of the scaler tip and the associated cavitation dynamics is necessary. In this research, we carried out a numerical study for an ultrasound dental scaler with a curved shape tip vibrating in water, using ABAQUS based on the finite element method. We simulated the three-dimensional, nonlinear and transient interaction between the vibration and deformation of the scaler tip, the water flow around the scaler and the cavitation formation and dynamics. The numerical model was well validated with the experiments and there was excellent agreement for displacement at the free end of the scaler. A systematic parametric study has been carried out for the cavitation volume around the scaler tip in terms of the frequency, amplitude and power of the tip vibration. The numerical results indicate that the amount of cavitation around the scaler tip increases with the frequency and amplitude of the vibration. However, if the frequency is far from the natural frequency, the cavitation volume around the free end decreases due to reduced free end vibration amplitude.

Imaging and analysis of individual cavitation microbubbles around dental ultrasonic scalers

Cavitation is a potentially effective and less damaging method of removing biofilm from biomaterial surfaces. The aim of this study is to characterise individual microbubbles around ultrasonic scaler tips using high speed imaging and image processing. This information will provide improved understanding on the disruption of dental biofilm and give insights into how the instruments can be optimised for ultrasonic cleaning. Individual cavitation microbubbles around ultrasonic scalers were analysed using high speed recordings up to a million frames per second with image processing of the bubble movement. The radius and rate of bubble growth together with the collapse was calculated by tracking multiple points on bubbles over time. The tracking method to determine bubble speed demonstrated good inter-rater reliability (intra class correlation coefficient: 0.993) and can therefore be a useful method to apply in future studies. The bubble speed increased over its oscillation cycle and a maximum of 27ms^-1 was recorded during the collapse phase. The maximum bubble radii ranged from 40 to 80μm. Bubble growth was observed when the ultrasonic scaler tip receded from an area and similarly bubble collapse was observed when the tip moved towards an area, corresponding to locations of low pressure around the scaler tip. Previous work shows that this cavitation is involved in biofilm removal. Future experimental work can be based on these findings by using the protocols developed to experimentally analyse cavitation around various clinical instruments and comparing with theoretical calculations. This will help to determine the main cleaning mechanisms of cavitation and how clinical instruments such as ultrasonic scalers can be optimised.

Penetration of sub-micron particles into dentinal tubules using ultrasonic cavitation

OBJECTIVES

Functionalised silica sub-micron particles are being investigated as a method of delivering antimicrobials and remineralisation agents into dentinal tubules. However, their methods of application are not optimised, resulting in shallow penetration and aggregation. The aim of this study is to investigate the impact of cavitation occurring around ultrasonic scalers for enhancing particle penetration into dentinal tubules.

METHODS

Dentine slices were prepared from premolar teeth. Silica sub-micron particles were prepared in water or acetone. Cavitation from an ultrasonic scaler (Satelec P5 Newtron, Acteon, France) was applied to dentine slices immersed inside the sub-micron particle solutions. Samples were imaged with scanning electron microscopy (SEM) to assess tubule occlusion and particle penetration.

RESULTS

Qualitative observations of SEM images showed some tubule occlusion. The particles could penetrate inside the tubules up to 60μm when there was no cavitation and up to ∼180μm when there was cavitation.

CONCLUSIONS

The cavitation bubbles produced from an ultrasonic scaler may be used to deliver sub-micron particles into dentine. This method has the potential to deliver such particles deeper into the dentinal tubules.

CLINICAL SIGNIFICANCE

Cavitation from a clinical ultrasonic scaler may enhance penetration of sub-micron particles into dentinal tubules. This can aid in the development of novel methods for delivering therapeutic clinical materials for hypersensitivity relief and treatment of dentinal caries.

A quantitative method to measure biofilm removal efficiency from complex biomaterial surfaces using SEM and image analysis

Biofilm accumulation on biomaterial surfaces is a major health concern and significant research efforts are directed towards producing biofilm resistant surfaces and developing biofilm removal techniques. To accurately evaluate biofilm growth and disruption on surfaces, accurate methods which give quantitative information on biofilm area are needed, as current methods are indirect and inaccurate. We demonstrate the use of machine learning algorithms to segment biofilm from scanning electron microscopy images. A case study showing disruption of biofilm from rough dental implant surfaces using cavitation bubbles from an ultrasonic scaler is used to validate the imaging and analysis protocol developed. Streptococcus mutans biofilm was disrupted from sandblasted, acid etched (SLA) Ti discs and polished Ti discs. Significant biofilm removal occurred due to cavitation from ultrasonic scaling (p < 0.001). The mean sensitivity and specificity values for segmentation of the SLA surface images were 0.80 ± 0.18 and 0.62 ± 0.20 respectively and 0.74 ± 0.13 and 0.86 ± 0.09 respectively for polished surfaces. Cavitation has potential to be used as a novel way to clean dental implants. This imaging and analysis method will be of value to other researchers and manufacturers wishing to study biofilm growth and removal.

ID: 28: ACQUIRED IMMUNODEFICIENCY SYNDROME RELATED KAPOSI SARCOMA A RARE INTRUDER AFFECTING THE STOMACH

Introduction

Kaposi sarcoma (KS) is a vascular tumor that is commonly associated with human herpesvirus 8 (HHV-8). The epidemic type of KS is associated with the most common tumor arising in HIV infected people, which is considered by CDC guidelines an AIDS defining illness. Lesions on the skin are the most common initial presentation in patients unlike the involvement of visceral sites. We present a unique case of KS affecting the stomach, initially presenting as abdominal pain and diarrhea.

Case

Patient is a 34 year old female with past medical history of AIDS/HIV with a CD4 count of 143 cells/μL, VL 46 copies/mL on HAART therapy diagnosed with visceral and cutaneous manifestations presents to the ED with nausea, vomiting, diarrhea and diffuse abdominal pain for three days. The symptoms have progressively gotten worse. Patient denies any history of fevers, recent travel, sick contacts or recent antibiotic use. On examination, the patient had stable vitals and evidence of dark brown, papular skin lesions of various sizes over face, torso and upper extremity. Abdominal examination revealed tenderness in the epigastric area. Laboratory studies and initial abdominal cat-scan with contrast were unremarkable. All infectious workup was negative. However, EGD revealed esophageal nodule in the mid-distal esophagus (figure 1A), non-obstructive lower esophageal (LE) stricture (figure 1B), and a gastric ulcer raised with heaped margins (figure C). Biopsy of the gastric ulcer reveals KS with necrosis. Throughout hospital course, patient received 12 rounds of Doxirubicin for treatment, continued with HAART therapy. Patient is tolerating chemotherapy well, cutaneous lesions are improving and signs and symptoms of diarrhea and abdominal pain have alleviated.

Discussion

Cutaneous manifestation is usually the initial presentation of KS and visceral involvement is typically a later manifestation of disease. What is interesting in this case is the involvement of both cutaneous and visceral sites. It can be observed in the gastrointestinal (GI) tract, but rarely seen in the stomach. GI lesions may be asymptomatic or may cause weight loss, abdominal pain, nausea, vomiting and obstruction, which is seen in our case. EGD revealed distal LE stricture and gastric ulcer biopsy showing KS with necrosis. For AIDS patients who have KS, HAART therapy should be initiated to induce regression. For systemic treatment chemotherapy with Doxirubicin should be considered when there is symptomatic visceral or mucosal involvement and extensive cutaneous KS. We suggest the KS be included in the differential in AIDS patients with diarrhea and non-specific GI symptoms. Moreover, EGD should be considered for symptomatic patients because untreated GI KS includes hemorrhage and perforation.

Abstract ID: 28 Figure 1

ID: 17: GRAVES DISEASE INDUCED DILATED CARDIOMYOPATHY

Introduction

Graves' thyrotoxicosis has many cardiovascular complications; however, the most cardiac complication is atrial fibrillation but rarely causes heart failure. Less than 1% develops dilated cardiomyopathy with impaired left ventricular systolic function. In this case report we describe a case of Graves' hyperthyroidism-induced reversible cardiomyopathy.

Case presentation

45 year old female with a history of previously treated Graves' disease who presented to hospital for altered mental status and severe hypoglycemia. The hospital course complicated by Atrial fibrillation with RVR. Patient states that recently started feeling fatigue, orthopnea, decrease exercise intolerance, lower extremities edema and distended abdomen. In emergency department, patient found to have hypotension and tachycardic. She was given IV fluids but her blood pressure didn't respond. Patient was started on Levophed for hypotension. Physical examination demonstrated impressive proptosis, positive jugular venous distension, irregular irregularity of her plus and +2 lower extremities edema .

Patient found to have Graves storm (TSH: 0.07 uIU/ml, Free T4: 1.89 ng/dL, T3: 36.6 ng/dL, cortisol level: 59.36 Ug/dL). She was started on methimazole, steroids and lugols iodine drops. Hypoglycemia that she had most likely was related to lack of glycogen stores and increased metabolic demand with graces. After the patient stabilized, echocardiogram obtained which showed severe left ventricular dysfunction (LVEF 30%), bi-atrial dilatation, LV dilated, moderate MR and TR. So, patient was transferred to CCU for acute dilated cardiomyopathy secondary to graves storm. She was started on Lasix 40 mg IV then switched to 20 mg PO twice a day, Metoprolol 25 mg twice a day and Digoxin 0.125 mg daily and Apixaban 5 mg twice daily. Ophthalmology consulted for proptosis who recommended artificial tears, ocular lubricant and decompression.

Abstract ID: 17 Figure 1

ID: 74: A RETROSPECTIVE STUDY OF CORONARY ARTERY DISEASE IN PATIENTS WITH BODY MASS INDEX ≥30

Introduction

Coronary Artery Disease (CAD) is a major cause of morbidity and mortality worldwide, and although mortality is decreasing, prevalence of CAD is increasing. A number of modifiable risk factors (smoking) and non-modifiable risk factors (gender, age) have well established association with CAD, whereas other potential risk factors (such as obesity) are less well established. In this study, we evaluated the obesity as a single risk factor for CAD and evaluated the synergistic effect of obesity with the other risk factors.

Method

A retrospective study of 7,567 patients admitted to hospital for chest pain from 2005–2014 and underwent cardiac catheterization. Patients were divided into two groups: obese and normal with body mass index (BMI) calculated as ≥30 kg/m2 and ≤25, respectively. Patients with BMIs between 26 and 29 were excluded. We assessed the modifiable and non-modifiable risk factors in obese patients and the degree of CAD with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries.

Results

Of the 7,567 patients who underwent cardiac catheterization, 414 (5.5%) had a BMI ≥30. Of 414 obese patients, 332 (80%) had evidence of CAD. Obese patients displayed evidence of CAD at the age of 57 versus 63.3 in non-obese patients (p<0.001).

Of the 332 patients with CAD and obesity, 55.4% had obstructive CAD versus 44.6% with non-obstructive CAD. In obese patients with CAD, Male gender and history of smoking were major risk factors for development of obstructive CAD (p=0.001 and 0.01, respectively) while dyslipidemia was a major risk factor for non-obstructive CAD (p 0.01). Additionally, obese patients with more than one risk factor; developed obstructive CAD compared to non-obstructive CAD (p=0.003). Approximately 40% presented with STEMI, 30% with NSTEMI and 30% had stable angina as a primary diagnosis.

Of the 332 obese patients with CAD, 24% received medical treatment, 58% underwent percutaneous coronary intervention (PCI) and 18% obtained coronary artery bypass grafting (CABG).

In a gender comparison, average age of CAD in obese males were 55 years of age compared to 59 in females (p <0.001). Approximately 67% of males underwent PCI (OR: 2.4, 95% CI: 1.5–3.6, p<0.001) and 24% obtained CABG (OR: 3, 95% CI: 1.6–5.6, p<0.001), whereas in obese females 43% received medical therapy (OR: 9, 95% CI: 5–17, p<0.001).

Conclusion

Having a BMI ≥30 appears to correlate as a risk factor for early development of CAD. Severity of CAD in obese patients is depicted on non-modifiable and modifiable risk factors such as the male gender and smoking or greater than one risk factor, respectively. Early lifestyle modification and education may provide benefit in striving to aid decreasing incidents of CAD and possibly lowering cardiovascular events.

ID: 37: SILENT BUT DEADLY CYTOMEGALOVIRUS TRIGGERING AUTOIMMUNE HEPATITIS

Introduction

To consider that viruses, more specifically cytomegalovirus (CMV), can trigger autoimmune hepatitis.

Case Report

54 year-old female presents with new onset jaundice, which was associated with abdominal distension, lower extremity edema and 10 pound weight gain. She has no history of intravenous drug use, blood transfusions, any new sexual partners in over 8 years or a family history of liver disease. The physical examination was remarkable for spider angiomata, icteric sclera, ascites, and edema.

The results of the biochemical analysis of the blood were the following: Liver enzymes were all elevated ALP 162 U/L, GGT 65 U/L, AST 154 U/L, ALT 72 U/L. Furthermore, her autoimmune workup was significant for an elevated ANA titer of 1:640, anti-smooth muscle ab titer 1:40 and a significant increase in immunoglobulins specifically IgG which was 4100 mg/dL. Interestingly, CMV Ab IgM was positive at 36.6 u/mL as well as CMV Ab IgG, which was positive at >10.00 u/mL. The rest of the work up was unremarkable in regards to hepatitis A, B, C, HIV, HSV, Epstein Barr virus (EBV), alpha1 antitrypsin, ceruloplasmin, iron level, ferritin and antimitochondrial ab. A liver biopsy was performed which showed heavy infiltration with lymphoplasmacytic inflammatory cells, interface hepatitis, bridging necrosis, and fibrosis. These pathologic and laboratory findings led us to a definitive diagnosis of autoimmune hepatitis (AIH) Type 1. In the setting of positive CMV IgG and IgM ab titers, we suggest that the trigger for AIH in this case was a preceding CMV infection. Her evolution was satisfactory under corticosteroid and azathioprine therapy.

Discussion

Autoimmune hepatitis is a chronic hepatocellular inflammation and necrosis of unknown cause. The most supported pathogenesis of AIH postulates that a combination of environmental triggers, failure of immune system tolerance and a genetic predisposition that may induce a T cell–mediated immune attack against the liver. Case studies in the literature report AIH being triggered by virus and drugs. There is evidence of cross-reactivity between anti-LKM1 and antibodies against homologous regions of cytomegalovirus (exon CMV130-135). This case could explain an association between cytomegalovirus infection and autoimmune hepatitis.

As clinicians, it is difficult to diagnose autoimmune hepatitis because its presentation can be acute, severe, asymptomatic or chronic. Diagnosis requires multiple findings and exclusions of similar diseases. When excluding, make sure viral etiologies are part of the differential, which in this case is CMV. If indeed a trigger is required to set off a sequence of events leading to autoimmune hepatitis in these predisposed individuals, viruses are among the most likely candidates.

Abstract ID: 37 Figure 1

ID: 34: ASSOCIATION BETWEEN VITAMIN D AND GASTRIC CANCER

Background and Objectives

Vitamin D deficiency is linked to several gastrointestinal malignancies including gastric cancer and affects a multitude of cellular processes involved in tumorigenesis. Vitamin D is presumed to have anticancer actions by inducing differentiation and cell cycle arrest in malignant cells. Furthermore, it significantly promotes apoptosis in the undifferentiated gastric cancer cell line HGC-27. The aim of this study was to determine whether there is an increased risk of gastric adenocarcinoma (GA) associated with vitamin d deficiency.

Methodology

A retrospective case-control study was conducted at Elmhurst Hospital Center from 2005–2015. Three hundred and four patients who were diagnosed with GA were selected as cases. Of 304 individuals with GA, 255 were excluded, because they did not have vitamin D levels, 49 patients were included in our study. The data was compared to a matched control group of 49 patients with no known malignancies who had vitamin D levels. Prevalence of vitamin D deficiency was compared between cases and controls using odds ratios (ORs) and 95% confidence intervals.

Results

The mean age of the case sample was 63.96 vs 60.43% in the control group. The gender distribution was the same, 49% male and 51% female. Hispanic patients were predominant in both samples accounting for 61.2% of the groups (table 1). Of 49 patients with GA included in our study, 20.48% were stage I; 36.7% were stage II; 24.9% were stage III, and 18.4% were stage IV. The prevalence of vitamin D deficiency in the case group (GA) was significantly higher than in the control group 19[38.8%] vs 7[14.3%] respectively (OR: 3.8, 95% CI 1.42–10.18, P value 0.0079) figure 1.

Conclusion

The results of our study suggest that there is a positive correlation between vitamin D deficiency and gastric adenocarcinoma. More specifically patients with vitamin D deficiency have an increased association with GA. Additional multicenter randomized double blind clinical trials are required to further assess this association and the potential benefit of vitamin D supplementation in preventing gastric adenocarcinoma.

Abstract ID: 34 Figure 1

ID: 33: ACUTE PANCREATITIS WITH NORMAL LIPASE AND AMYLASE ENZYMES

Case Report

A 44 year-old Male with no significant past medical history presented to the Emergency Department complaining of nausea, vomiting, diarrhea, upper abdominal pain and fever. For the past one week prior to presentation, patient developed pressure-like epigastric pain, radiating to the back, worsened with lying down, and associated with non-bloody, non-bilious vomiting, followed by anorexia, nausea and fever to 102F. Patient had not eaten several days prior to arrival to the hospital; hence he was brought in by his family for evaluation. Notably, two months prior to presentation, patient was evaluated in an outside hospital for abdominal pain similar in quality, but not in intensity, and reportedly had normal blood tests and imaging.

Physical examination: vital signs significant for hypertension of 150/90, tachycardia to 108 and fever of 101.5; abdomen notable for tenderness to palpation over epigastrium, with mild guarding, but no rebound or Murphy's sign; the rest of the exam, including cardiovascular, pulmonary, integumentary and neurological exam, unremarkable. Initial laboratory findings are: WBC of 10.1, with 81% neutrophils, amylase of 47 (N 28–100 U/L), lipase level of 14 (N 11–82 U/L), and unremarkable basic metabolic panel. Liver function tests notable for normal AST and ALT, elevated GGT to 277 (N <50 U/L), LDH: 681 (N 90–225 U/L), Total bilirubin: 0.9(N 0–1.5 mg/dl). Lipid panel: Total Cholesterol 201 (N<200 mg/dL), Triglycerides 80 (N<150 mg/dL), LDL 68 (<100 mg/dL). Chest X-ray showed a small left-sided pleural effusion.

Patient was admitted to medicine service for treatment of gastroenteritis, and was started on intravenous fluids and symptomatic management. On day three of hospitalization, patient developed worsening abdominal pain, associated with inability to tolerate per oral intake secondary to vomiting of food contents, and due to worsening abdominal pain, underwent further workup. CBC revealed leukocytosis with a left shift, WBC count of 15.3, with 81.5% neutrophils. Basic metabolic panel notable for sodium of 124, potassium of 3.2, calcium of 7.4, magnesium of 1.7, phosphate of 1.9. Repeat lipase was 67(N 11–82 U/L). An abdominal CT scan (figure 1) with IV and oral contrast was performed, and showed extensive pancreatic edema, especially involving the pancreatic head and uncinate process, and peripancreatic stranding; these changes deemed consistent with acute pancreatitis; no calcifications or pseudocysts were observed on the CT. Abdominal ultrasound showed multiple gallbladder stones, however, common bile duct was of normal diameter (2.5 mm), and no intrabiliary duct dilatation was noted.

Based on clinical presentation and radiological findings, the diagnosis of acute pancreatitis was made. The patient started on aggressive intravenous fluid hydration, pain management and bowel rest, with good improvement in symptoms. On day 5, patient was able to tolerate a regular diet, and noted an almost complete resolution of pain, and therefore was discharged home.

Abstract ID: 33 Figure 1

ID: 8: 30-DAY READMISSION RATE OF PATIENTS UNDERGOING CORONARY CARDIAC CATHETERIZATION IN THE AMBULATORY VERSUS IN-HOSPITAL SETTING

Background

Cardiac Catheterizationis increasingly performed in an outpatient setting. No study has been large enough to detect differences in the major complication rate which occur infrequently in whichever setting, and there is considerable variation between studies in the incidence of minor complications after outpatient procedures.

Objective

To investigate the 30-days readmission rate of ambulatory and in-hospital coronary cardiac Catheterization.

Method

A retrospective study of 9053 patients who had coronary cardiac angiography between 2005 and 2014. We divided the patients in to two groups, patients who had cardiac Catheterizationin ambulatory setting versus in-hospital setting.

Results

Of 9053 patients, 5998 (66%) patients had in-hospital cardiac Catheterizationand 3,055 (34%) had ambulatory cardiac catheterization. Patients who had ambulatory coronary cardiac Catheterizationhad a higher 30-days readmission rate comparing to in-hospital setting (Odd ratio: 3.2, 95% CI: 2.8–3.7, p<0.0001).

Gender analysis, 27% of males who had ambulatory coronary cardiac Catheterizationreadmitted within 30-days of discharge versus 12% of females (OR: 2.4, 95% CI: 2–2.9, p<0.0001). Among in-hospital setting, no statistically significant between males and females (p=0.6).

Conclusion

Our study showed that ambulatory coronary cardiac Catheterization associated with a higher 30-days readmission rate comparing to in-hospital setting. Furthermore, males who had ambulatory cardiac Catheterization seem to have more 30-days readmission rate.

ID: 35: ASSOCIATION BETWEEN HELICOBACTER PYLORI INFECTION WITH CORONARY ARTERY DISEASE AND ACUTE MYOCARDIAL INFARCTION: A RETROSPECTIVE CHART ANALYSIS

Introduction

Helicobacter pylori (HP) infection is known to target the gastrointestinal system and is associated with extra gastrointestinal manifestations, but there is limited literature on cardiac associations. The most supported pathogenesis uses chronic inflammation as a risk factor causing atherosclerosis resulting in cardiovascular disease. Our aim is to evaluate whether there is an association between HP infection and acute myocardial infarction (AMI) and coronary artery disease (CAD).

Method

We performed a retrospective single center study at our medical center from 2005 to 2014 consisting of 1,671 patients who underwent Coronary Angiography (CA). We divided these patients into two groups based on CA reports. Patients with CAD defined as left main stenosis of ≥50% or any stenosis of ≥70% versus normal coronaries. We reviewed each patient chart to determine the prevalence of positive serum HP IgG antibody. Smoking, hypertension, dyslipidemia and obesity were also considered in each group.

Results

Of 1,671 patients, 1,237 had evidence of CAD vs 434 with normal coronary arteries. Twelve percent of CAD patients were found to have seropositive HP (SPHP) versus 1% in the control group (OR: 7.3, 95% CI: 3.5–15, p<0.0001) as depicted in figure 1. When we looked at the CAD group and compared SPHP patients to seronegative HP (SNHP) patients we found a greater amount of multiple coronary vessels disease in the SPHP group (OR: 1.4, 95% CI: 1.1–2, P=0.04). With regards to AMI, 30% of the SPHP group presented with AMI versus 10% seen in the SNHP group (OR: 4.3, 95% CI: 3–6.5, p<0.0001). In the CAD group with SPHP there was more hyperlipidemia and a higher BMI than in the CAD SNHP group (p<0.0001 and <0.0001, respectively), but there was no statistical difference between the two groups for the risk factors of smoking, hypertension and diabetes.

Conclusion

According to this study, the results showed a correlation with SPHP patients and CAD. Patients with HP seropositivity also tend to have multiple coronary artery vessel disease. In addition, our results also confirmed that there is an association between with HP infection and AMI. We hypothesize that the associated maybe secondary to inflammatory reaction associated with HP. Additional studies with larger sample groups are needed to investigate the possible role of this pathogen as a risk factor for heart disease.

Abstract ID: 35 Figure 1

Twelve percent of CAD patients were found to have seropositive HP (SPHP) versus 1% in the control group (OR: 7.3, 95% CI: 3.5–15, p<0.0001).

ID: 76: AVOIDING TRANSTHORACIC ECHOCARDIOGRAPHY (TTE) AND TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) FOR PATIENTS WITH VARIABLE BODY MASS INDEXES (BMI) IN INFECTIVE ENDOCARDITIS

Background

Echocardiography has been a popular modality used to aid in the diagnosis of infective endocarditis (IE) with the modified Dukes' criteria. We evaluated the necessity between the uses of either a transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) in patients with a body mass index (BMI) greater than or equal to 25 kg/m2 and less than 25.

Methods

A single-centered, retrospective study of 198 patients between the years of 2005 and 2012 diagnosed with IE based on modified Dukes' criteria. Patients were required to be above the age of 18, undergone an echocardiogram study and had blood cultures to be included in the study.

This study was conducted at a major hospital in one of the most diverse communities in the United States, providing a cultural and epidemiologically significant advantage. An approved chart analysis using QuadraMed Computerized Patient Record (QCPR) was retrospectively accessed with data-input and calculations formulated in computerized software.

Results

Among 198 patients, two echocardiographic groups were evaluated as 158 patients obtained a TTE, 143 obtained a TEE, and 103 overlapped with TEE and TTE. 167 patients were included in the study as 109 (65%) were discovered to have native valve vegetations on TEE and 58 (35%) with TTE. TTE findings were compared to TEE results for true negative and positives to isolate valvular vegetations Overall sensitivity of TTE was calculated to be 67% with a specificity of 93%. Patients were further divided into two groups with the first group having a BMI less than or equal to 25 kg/m2 and the subsequent group with a BMI<25. Patients with a BMI less than or equal to 25 that underwent a TTE study had a sensitivity and specificity of 54% and 92, respectively. On the contrary, patients with a BMI<25 had a TTE sensitivity and specificity of 78% and 95, respectively. Furthermore, we obtained the sensitivities of specific valves diseased from vegetations, visualized by TTE (figure 1). Lastly, we were able to demonstrate a correlation between the different modalities of echocardiography used to the specific organism identified on blood cultures (figure 2).

Conclusion

Calculating a BMI in patients with suspicion for IE may provide benefit in reducing further diagnostic imaging. Our study demonstrated that patients having a BMI <25 kg/m2 with a negative TTE should refrain from further diagnostic studies with TEE, given the findings of increased sensitivities (figure 3). Patients with a BMI less than or equal to 25 may proceed directly to a TEE, possibly avoiding an additional study with a TTE given the low sensitivities identified in this population. Clinicians should be aware that this study has several limitations, one of which a small sample size that may be increased with a multi-centered study. Further investigations with a larger population may improve and possibly provide similar findings, reinforcing the study.

ID: 99: PREVELNACE, MORBIDTY AND MORTALITY OF INFECTIVE ENDOCARDITIS IN THE MOST DIVESE AREA OF USA IN NEW YORK CITY

Background

Infective endocarditis (IE) is a serious illness associated with significant morbidity and mortality. The primary purpose of this study was to evaluate the mortality and morbidity of IE in a community public hospital of the most diverse area in New York.

Methods

An analysis of 209 patients that were admitted to hospital from 2000 to 2012, found to have IE based on Duke's criteria.

Results

The incidence rate of IE is trending down since 2000 (figure 1A).

Among our study population, the overall mortality rate of IE was 20.1% (95% CI: 9.84–19.56%), readmission rate within 30 days after discharge was 21.5% (95% CI: 16.22–27.58%) with an average age of 59 years (95% CI: 57.63–60.37%). The most common causative organisms were staphylococcus aureus (43.7%), followed by streptococcus viridians (17%) and Group D enterococcus (14.7%). We divided the patients into two groups; male (n=107) versus female (n=102). And the same aspects were identified and studied in each gender group.

The incidence of IE has a slight female predominance, except two age groups with male significant predominance; 40–49 and 50–59 years. (figure 1-B).

The mortality rate in males was 17% vs 23% in females (p=0.09) and Readmission rate within 30 days after discharge from the hospital was 20% in males vs 22% in females (p=0.1).

Of the 209 patients, 188 patients were with native hearts and 21 patients had non-native heart valves. Of the 188 native heart valves, 114 had risk factors such as: CABG surgeries, were active drugs users, had pacemakers, valves disease or CHF. Mortality rate in non-native hearts and/or patients with risk factors were 27.7% compared to patients with native heart without risk factors of 8.11%(OR:3, P<0.0001).

The causative organism of IE was evaluated in our study and we found that S. aureus is the most common cause in males and females among all age groups. The only exception to that is a slightly higher prevalence of S. viridians in males between the ages of 30–39 (figure1-C). Similarly, the prevalence of group D enterococcus appeared higher in females aged 70–79 years. (figure 1-D).

Approximately 71% of males' patient with S. aureus IE between ages 50–49 had DM. Also, 80% of female patients with IE between ages 60–69 had DM which could explain the high prevalence of IE with S. aureus in this age groups as DM may complicated with skin infections which is mostly Staphylococcus infection that led to IE.

The highest incidences of IE in our study were in Hispanic ethnicity group (38%) follow by white (29%). However, the lowest incidences were observed in South Asia population (5%).

Conclusion

Despite appropriate prophylaxis and treatment of IE patients, high rates of incidences, morbidity and mortality remained especially in population >50 years. Risk factors for developing IE such as Diabetes Mellitus which might complicated with skin infection and lead to IE, raising the importance of controlling and monitoring risk factors for IE in patients older than 50 years of age.

Abstract ID: 99 Figure 1

ID: 68: CORONARY ARTERY DISEASE AND ACUTE CORONARY SYNDROME IN PATIENTS ≤40 YEAR OLD

Background

Coronary artery disease (CAD) in the younger adult population has been commonly under-represented in clinical practice and research studies given its early latent asymptomatic course, in addition to the underestimation of this population's CHD lifetime risk by commonly used CHD risk predictors such as Framingham's score.

Objective

To assess the risk factor profile for premature coronary artery disease CAD and ACS presentation in younger adults.

Methods

Retrospective chart analysis of 393 patient's ≤40 years old admitted from 2005 to 2014 for chest pain and underwent coronary angiography. The implication of modifiable risk factors and non-modifiable risk factors were evaluated in those with obstructive CAD (LM stenosis of ≥50% or stenosis of ≥70% in a major epicardial vessel), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Additionally we evaluated the impact of the same risk factors on ACS presentation (NSTEMI vs STEMI) and the extent of CAD (single-vessel/multi vessel).

Results

Of 9012 patients who underwent cardiac catheterization, 393 (4.3%) patients were ≤40 years old.

Out of 393, 212 (54%) had CAD (153 obstructive versus 59 non-obstructive) while 185 (46%) had normal coronaries.

Fifty two (25%) patients presented with STEMI while 140 (66%) patients presented with NSTEMI.

Of 153 patients with obstructive CAD, 87 (57%) patients had single vessel disease vs 66 (43%) multiple vessel disease.

When compared to patients with normal coronaries patients with CAD were more likely to be smokers (p<0.0001), dyslipidemia (p<0.0001), Diabetic (p<0.0001) cocaine users (p 0.4) have a family history of premature CHD (<0.0001) and be males (p<0.0001) (figure=1).

Smokers were more likely to present with acute coronary syndrome; 5 times more likely to present with STEMI (p<0.0001) and 1.7 with NSTEMI (p 0.0003) compared to the control group.

When compared head to head, smokers were 2.2 times more likely to present with STEMI compared to NSTEMI (p<0.001).

Smoking also, alone and with another risk factor increased the risk of obstructive versus no obstructive CAD (p=0.04 and 0.015, respectively).

No significant difference was noted in the single vessel vs multi vessel CAD subgroups.

Coronary artery disease was highest in South Asian population (38.4%), followed by Hispanic (13.7%), African-American (10%) and Caucasian (9%). The main in risk factors in African–American was Hyperlipidemia +/− Diabetes (47.8%) while the main risk factors in Hispanic and white were smoking alone (24.14% and 47.4% respectively). In East Asia population, Smoking with hyperlipidemia was the main risk factors (44%).

Conclusion

In our population of young adults, smoking as a single risk factor was the most prevalent for earlier CAD. It was also associated with more STEMIs and obstructive CAD. Healthcare intervention in the general population through screening, counseling and education regarding smoking cessation is warranted to reduce premature coronary artery disease.

Abstract ID: 68 Figure 1

ID: 38: PRIMARY SQUAMOS CELL CARCINOMA OF THE RECTUM

Introduction

Squamous cell carcinoma (SCC) of the gastrointestinal (GI) tract is an uncommon occurrence, as it usually involves the esophagus or anal canal. Approximately 90% of cases of rectal malignancy are adenocarcinoma and other rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%). We are presenting a rare and unique case of patient with SCC of the rectum presenting with lower abdominal pain and significant weight loss.

Case

A 52 year old female was admitted with a two month history of diffuse lower abdominal pain and hematochezia. The pain was constant and pressure like. The patient was a nonsmoker and nondrinker. Review of systems was pertinent for an unintentional weight loss of 10lbs. Physical examination revealed diffuse lower abdominal tenderness and a firm, irregular anterior rectal mass. She had no lymphadenopathy and her skin exam was normal. Laboratory results a normocytic anemia with a hemoglobin of 8.8 g/dl and a CEA of 1.35 ng/ml. Abdominal CT scan revealed a 7 cm irregular rectal mass with extra luminal compression to the rectosigmoid area, (figure 1). The mass did not extend from uterus and confirmed with transvaginal ultrasound. Patient underwent a flex sigmoidoscopy which revealed a lesion 5 cm from anal verge extending distally. There is a semi-circumferential narrowing occupying 7% of lumen and a dense layer of mass tissue with superficial friability of mucosa. Biopsy was taken from the mass, histology shows invasive moderately differentiated squamous cell carcinoma (figure 1).

Discussion

SCC of the rectum has a very similar presentation to colon adenocarcinoma. Diagnoses can be established by proctoscopy/colonoscopy and more specifically, a biopsy to get a definitive histological analysis. The latter is a used to differentiate from SCC of the anus, which presents similarly. Immunohistochemistry has proved useful in characterizing lesions, especially when using cytokeratin stains. Pathogenesis is unclear due to its rarity; however one of the proposed mechanisms suggests that inflammation or infection results in squamous metaplasia from which carcinoma develops. Thus there is an association with HPV and various squamous cancers. In conclusion, SCC of rectum is a distinct entity and it is important to shed some light on this rare condition because it has different epidemiology, etiology, pathogenies and requires a different treatment approach than other colorectal carcinomas. Surgery is the primary treatment which consists of local excision versus radical resection and the need for adjuvant therapy.

Abstract ID: 38 Figure 1

ID: 50: PERFORATED DIVERTICULOSIS COMPLICATED WITH ACTINOMYCOSIS INFECTION AND PRESENTED AS PELVIC MALIGNANCY

Case Presentation

A 48-year-old female with no significant past medical history who presented with fatigue, and lower abdominal pain, unintentionally weight lost and yellowish vaginal discharge. Physical examination was remarkable for a palpable mass extending from supra-pubic to supra-umbilical area and vaginal examination remarkable for foul-smelling vaginal discharge. Initial laboratory studies indicated Hemoglobin 5.8 mg/dl and white blood counts 15,000/µL. Computerized tomography of Abdomen/Pelvis CT with contrast which demonstrating an infiltrative process or mass like structure involving the pelvis measuring 10×12×6 cm. The initial impression was Gynecological cancer which could be uterine/cervix/ovarian cancer. However, Pap-smear was negative. Biopsy was obtained which showed acute inflammatory exudates fragments of benign appearing smooth muscle proliferation and fibro-adipose tissue infiltrated with histiocytes. The decision for exploratory laparotomy was made which revealed a large pelvic abscess. The surgery resulted in modified radical hysterectomy, resection of left and right tubo-ovarian abscess complexes, recto-sigmoid resection with end-sigmoid colostomy and Hartmann's pouch, and ileo-colic resection with a primary anastomosis. Pathology examination revealed a segment of colon with perforated diverticulosis and a tubo-ovarian complex with acute and chronic inflammations, granulation tissue formation and bacterial colonies morphologically suggestive of Actinomyces. Patient started on Intra-venous Penicillin-G. After 4 weeks, CT abdomen/Pelvic repeated which showed post-surgical changes and decreased in size of abscess/fluid collections.

Discussion

Actinomycosis is a rare and insidious disease. The most common etiologic organism is the anaerobic, Gram-positive bacterium, Actinomyces israelii. Actinomycetes are prominent among the normal flora of the oral cavity but less prominent in the lower gastrointestinal and female genital tract. Because these microorganisms are not virulent, they require a break in the integrity of the mucous membranes and the presence of devitalized tissue to invade deeper body structures and to cause human illness.

Cervicofacial actinomycosis is the most common type of the infections followed by Thoracic actinomycosis and less common in abdomen and pelvis. The most common cause of abdominal/pelvic actinomycosis is acute perforated appendicitis. Also, most of Abdomen/Pelvis cases have a history of recent or remote bowel surgery (e.g.perforated appendicitis, perforate colonic diverticulitis). Pelvic actinomycosis has become more common in females who use an Intra-Uterine Devices, which may increase the risk of infection through injury to the normal uterine mucosa. Diagnosis of Abdomen/Pelvic actinomycosis is usually established postoperatively, following exploratory laparotomy for a suspected malignancy. Involvement of any abdominal organ, including the abdominal wall, can occur by direct spread, with eventual formation of draining sinuses.

Abstract ID: 50 Figure 1

ID: 36: PEGASPARGASE INDUCED SEVERE PANCREATITIS. FRIEND OR FOE?

Introduction

Pegaspargase (Oncaspar) is a modified version of L-asparaginase conjugated with polyethylene glycol. In leukemic cells, asparaginase hydrolyzes L- asparagine to ammonia and L-aspartic acid leading to depletion of asparagine. Despite its potential benefits there are a wide range of side effects. One rare but potentially deadly complication is severe pancreatitis.

Case

The patient was a 24 year old Mexican male with a history of Acute T-Cell Lymphoblastic Leukemia (ALL) on recent chemotherapy including pegaspargase, admitted for abdominal pain, found to have acute pancreatitis secondary to hypertriglyceridemia. Heart rate was 127 bpm, chest revealed decreased air entry in right lung bases, and a distended severely tender abdomen. Laboratory tests were remarkable for elevated liver enzymes ALP 360 U/L, AST 310 U/L, GGT 216 U/L, ALT 44 U/L, LDH 829 U/L, elevated lipase 228 U/L, and hypertriglyceridemia >3,000 mg/dL. Abdominal CT showed pancreatitis with necrosis; peripancreatic, intraperitoneal and extensive retroperitoneal fluid. Subsequently his severe pancreatitis was associated with acute kidney injury and respiratory failure which is illustrated by his (BUN 22 Creatinine 2.16, and persistent hypoxia.) According to the Atlanta Classification, patient is classified under severe acute pancreatitis.

Discussion

Pegaspargase is used for treatment of ALL and is gaining in popularity over Asparaginase therapy due to it having fewer incidences of hypersensitivity reactions and because of its long half life (367 hrs) allowing dosing every 14 days as opposed to Asparaginase which is dosed daily. Pegaspargase definitely has its benefits but we can't lose sight of one of its rare, but potentially deadly complications, pancreatitis. In one study nine of the 50 patients (18%) with ALL treated with pegaspargase were diagnosed to have pancreatitis. In contrast, only one out of 52 (1.9%) ALL patients who received native E. coli L-asparaginase during the same time period developed pancreatitis. One proposed mechanism of this drug-induced pancreatitis is hypertriglyceridemia, which is seen in our case. It is suggested that apolipoprotein E polymorphism may influence the development of hyperlipidemia in ALL patients receiving pegaspargase therapy.

We report a case to increase the awareness of higher incidence of pegaspargase-induced pancreatitis, which is a rare but potentially deadly complication. Clinicians should monitor triglycerides while on treatment and suspect pancreatitis if patient develops abdominal pain. If pancreatitis occurs, therapy should be stopped and not reinstituted. For patients with hypertriglyceridemia without pancreatitis discontinuation of therapy should be considered.

Abstract ID: 36 Figure 1

Impression: Severe acute pancreatitis. Significant interval worsening.

ID: 2: VITAMIN D AND ITS ASSOCIATION IN OBSTRUCTIVE, NON-OBSTRUCTIVE CORONARY ARTERY DISEASE, AND NORMAL CORONARIES ASSESSED ON CORONARY ANGIOGRAPHY

Background

Pro-atherosclerotic nature of vitamin D deficiency has been shown to increase cardiovascular events. To further demonstrate this phenomenon, we evaluated the degree of coronary artery disease (CAD) with varying levels of vitamin D.

Method

A retrospective, single-center study of 9,399 patients admitted between 2005 and 2014 for chest pain who underwent coronary angiography. Patients without a vitamin D level, measured as 25-dihydroxyvitamin D (25[OH]D) were excluded from our study. 25(OH)D deficiency and insufficiency were defined by having serum concentration levels of less than 20 ng/ml and 20 to 29.9 ng/ml, respectively, while normal levels were defined as greater than or equal to 30 ng/ml. We assessed the degree of 25(OH)D and the extent of coronary disease with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%).

Results

Among 9,399 patients, 1,311 qualified, of which 308 patients (23%) had normal 25(OH)D levels, 552 patients (42%) had 25(OH)D deficiency and 451 patients (35%) had 25(OH)D insufficiency. In an analysis for the extent of coronary disease we identified 259 patients (20%) having normal coronaries, 720 patients (55%) with obstructive CAD and 291 patients (25%) with non-obstructive CAD.

Baseline clinical risk factors, and co-morbidities did not differ in either groups. Patients with 25(OH)D deficiency and insufficiency (n=1003) developed symptomatic CAD at a mean age of 63-years-old versus 67 with normal 25(OH)D (n=308, p<0.0001).

Patients with normal 25(OH)D levels were found to have normal coronaries compared to patients with 25(OH)D deficiency or insufficiency (OR: 7, 95% CI: 5.2–9.5, p<0.0001). Comparing patients with normal 25(OH)D levels, in patients with 25(OH)D deficiency or insufficiency (<29 ng/ml), 65% were found to have obstructive CAD (n=612, OR: 2.9, 95% CI: 2.3–3.7, p<0.0001) and 24% had non-obstructive CAD (n=237, OR: 1.5, 95% CI: 1.1–2, p=0.02).

In a head-to-head, sub-grouped comparison, patients with 25(OH)D deficiency and insufficiency were found to have obstructive CAD (n=394, OR: 2.7, 95% CI: 2–3.4, p<0.0001) and non-obstructive CAD (n=169, OR: 2.6, 95% CI: 2–3.4, p<0.0001), respectively.

Conclusion

Vitamin D deficiency and insufficiency correlate with obstructive and non-obstructive CAD, respectively. Normal coronaries were shown to be related with normal levels of vitamin D. Vitamin D levels may provide benefit in improving risk stratification for patients with CAD as a possible modifiable risk factor. Further studies may be needed to enhance our findings.

ID: 4: OUTCOMES IN CONGESTIVE HEART FAILURE PATIENTS UNDERGOING TRANSFEMORAL VERSUS TRANSRADIAL CARDIAC CATHETRIZATION: RESTROSPECTIVE CHART ANALYSIS

Background

Several studies addressed outcomes in terms of NACE and MACE in patients undergoing transradial vs tranfemoral cardiac catheterization. However, data on core quality measures such as length of stay and rehospitalization rates is lacking in the congestive heart failure population.

Method

A retrospective chart analysis of 9,320 patients who were admitted to the hospital for chest pain and underwent cardiac catheterization. Based on ICD-9 codes, we included only patients with Congestive Heart Failure (CHF) with an Ejection Fracture ≤40 (HFrEF). We compared readmission rate and Length of stay in patients who underwent Transradial cardiac catheterization vs Transfemoral cardiac catheterization.

Results

Of a total 9,320 patients undergoing diagnostic coronary angiography, 800 patients had HFrEF. Four hundred patients underwent Transradial cardiac catheterization and 400 patients underwent Transfemoral cardiac catheterization. In the transfemoral cardiac catheterization group, 37 (9%) were readmitted within 30 days of discharge while 17 (4%) patients of 400 patients who underwent transradial cardiac catheterization were readmitted within 30 days of discharged (Odds ratio: 2.3, 95% CI: 1.8–3, p value 0.005).

Length of stay was ∼5.2 days in transradial catheterization vs. ∼6 days in Transfemoral catheterization group (p 0.4).

Conclusion

In our study population, transradial cardiac catheterization in HFrEF patients seemed to have a better outcome when compared to transfemoral cardiac catheterization in terms of 30-days readmission rate. Length of hospital stay was higher in the transfemoral group but did not achieve statistical significance, however. Larger studies that may also include patients with heart failure with preserved ejection fraction (HFpEF) are needed to investigate factors that may contribute to such outcomes.

Pleomorphic Adenoma of the Parotid Gland: Report of a Case With Review of Literature

Background

Pleomorphic adenomas are benign salivary gland tumors, which predominantly affect the superficial lobe of the parotid gland. The “pleomorphic” nature of the tumor can be explained on the basis of its epithelial and connective tissue origin. The tumor has a female predilection between 30–50 years of age. Slowly progressing asymptomatic swelling is the usual presentation of the tumor. Surgical excision of the tumor mass forms the mainstay of treatment, with utmost care taken to preserve the facial nerve.

Case Details

This case report aims to throw light on an interesting case of pleomorphic adenoma of the parotid gland in a 50 years old female patient. The patient presented with a slowly progressing asymptomatic swelling on the left side of the face. There is also a special emphasis to a detailed review of literature.

Conclusion

Salivary gland neoplasms can occur at any site where salivary tissue is present. Pleomorphic adenoma is the commonest salivary gland tumor characterized by diverse histomorphological features. Early diagnosis and treatment plan entails thorough history taking, clinical examination, coupled with radiographic and histopathological findings.

Effect of Single Dose Intramuscular Methylprednisolone Injection into the Masseter Muscle on the Surgical Extraction of Impacted Lower Third Molars: a Randomized Controlled Trial

Background Lower impacted third molar surgical extraction usually causes post-surgical sequelae like pain, trismus and swelling as a result of postoperative inflammatory response.Objective The aim of this study was to evaluate and compare the efficacy of single dose 40-mg (1cc) of methylprednisolone acetate, injected into the masseter muscle, preoperatively one hour before the surgery or post-operatively, immediately following the surgical removal of impacted lower third molars, in controlling most common postoperative sequelae, i.e. trismus, pain and swelling of facial soft tissue.Methods A randomized control study was done of 60 patients. Each patient was categorized in two groups, group I and group II, according to the time of receiving methylprednisolone acetate. Group I was injected 40mg of methylprednisolone acetate into the masseter muscle via the intrabuccal approach, one hour before the surgery. Group II was injected 40mg of methylprednisolone acetate into the masseter muscle via the intrabuccal approach, immediately after suturing of the surgical wound. The washout period was one month after the first operation. Evaluation were made of postoperative pain, trismus and swelling. The numeric pain scale (NPS) was used for pain assessment.Results When the patients were administered methylprednisolone acetate preoperatively, showed superior results in terms of oral aperture, pain and all the facial swelling parameters, with statistically significant differences versus the postoperatively administered methylprednisolone acetate (p < 0.05).Conclusions A single dose of 40 mg (1cc) methylprednisolone acetate injected into the masseter muscle preoperatively is more effective in reducing pain, trismus and swelling, when compared to that administered postoperatively.Kathmandu University Medical Journal Vol.12(1) 2014: 4-8

Antimicrobial susceptibility pattern in diabetic foot ulcer: a pilot study

BACKGROUND

Diabetic foot infections (DFIs) are major public health problems and knowledge of microbes that cause infections are helpful to determine proper antibiotic therapy.

AIMS

The aim was to investigate the antimicrobial susceptibility pattern of microbes in DFIs.

SUBJECTS AND METHODS

A cross-sectional study was conducted for a period of 6 months at the Department of General Surgery, KMC hospital, Manipal University, Manipal, India. During this period, 108 patients having DFIs admitted in the general surgery wards were tracked from the hospital data management system. These patients' pus samples were examined as Gram-stained smear and cultured aerobically on blood agar and MacConkey agar plates. Antimicrobial susceptibility test was performed by disc diffusion techniques according to Clinical and Laboratory Standards Institute guidelines.

RESULTS

Of the 108 specimens of the diabetic foot lesions, culture showed polymicrobial growth in 44.4% (48/108). Prevalence of Gram-negative organisms (56%, 84/150) was found to be more than Gram-positive organisms (44%, 66/150). However, Staphylococcus aureus was the most frequent pathogen (28%, 42/150). All Gram-positive aerobes were sensitive to doxycycline. All Gram-negative isolates, including extended spectrum beta lactamase producing strains of Proteus mirabilis and Klebsiella oxytoca except Acinetobacter were highly sensitive to amikacin, cefoperazone/sulbactam, and meropenem. Acinetobacter was completely resistant to all the common antibiotics tested.

CONCLUSION

Prevalence showed Gram-negative bacteria was slightly more than Gram-positive bacteria in diabetic foot ulcers. This study recommends doxycycline should be empirical treatment of choice for Gram-positive isolates and amikacin, cefoperazone/sulbactam, and meropenem should be considered for most of the Gram-negatives aerobes.

Evaluation of a closed-system cytotoxic transfer device in a pharmaceutical isolator

PURPOSE

The occupational risk associated with handling of cytotoxic anticancer drugs is well documented and, in many countries, pharmaceutical isolators are used to contain cytotoxic residues during preparation of cytotoxic infusions. Isolators are difficult to clean leading to concerns that cytotoxic contamination from the work area could be transferred to surfaces of products leaving the isolator. This study investigated the surface contamination arising from the preparation of five anticancer drug infusions (Epirubicin, Fluorouracil, Cisplatin, Oxaliplatin and Carboplatin) in a pharmaceutical isolator and compared use of a conventional syringe and needle technique with a closed-system drug transfer device (CSDTD).

METHODS

Wipe samples were taken over 1 week from pre-defined areas in the isolator, gloves, preparation mats, and also from the surfaces of prepared cytotoxic infusion bags and pre-filled syringes to obtain baseline surface contamination data. Following operator familiarisation, the CSDTD was then introduced and sampling repeated for a further week (intervention period). The samples obtained were analysed using validated HPLC-UV, HPLC-FL and ICP-MS techniques, as appropriate.

RESULTS

All surfaces sampled during baseline, including external surfaces of infusions and syringes, were contaminated with each marker drug. During the intervention phase, isolator surfaces were free from detectable contamination and the contamination measured on gloves, preparation mats and surface of infusions was markedly reduced. The frequency of contamination on syringe and infusion surfaces was also lower.

CONCLUSION

Surface contamination from cytotoxic infusion preparation in a pharmaceutical isolator was significant and could transmit cytotoxic residues to patient and public areas via infusion surfaces. The frequency and amount of contamination were reduced by the CSDTD.

A decade's experience with vesicovaginal fistula in India

A retrospective analysis of 252 cases of vesicovaginal fistulae was done to analyse its etio-pathology and management in an Indian population. After a thorough evaluation, different techniques of fistula closure were used for repair and the results were listed. The main outcome measures were the etiology of the fistula, need for tissue interposition and cure rate per repair as well as the overall cure rate. We compared our results with literature and concluded that simple and small fistulae should be repaired with layered closure. All complicated fistulae should be repaired with tissue interposition or tissue graft. This is the first study from India compiling 10 years of experience on vesicovaginal fistula.

POST CAESAREAN VESICOUTERINE FISTULAE - YOUSSEF SYNDROME: OUR EXPERIENCE AND REVIEW OF PUBLISHED WORK

OBJECTIVE

To analyse the incidence, symptomatology, diagnosis and therapeutic aspects of Youssef syndrome (post caesarean vesicouterine fistula), and to review relevant published work.

METHODS

A retrospective study from the urosurgical unit of a tertiary care referral hospital was carried out. In a retrospective analysis of urogenital fistulae over 10 years, we identified 14 patients with uterovesical fistulae, resulting from caesarean section. All the patients were evaluated by history, physical examination, radiological tests and cystoscopy. All patients underwent transperitoneal repair of these fistulae with omental interposition. Results of surgery were evaluated by absence of cyclic haematuria, stoppage of urinary incontinence, and achievement of fertility.

RESULTS

A total of 12 patients who had minimum follow up was included in the present study. The results showed that 50% of the fistulae resulted from emergency caesarean operation with 58% of patients presenting after their second caesarean section. The mean age of the patients was 19 years (range 15-29) and mean duration of symptoms was 7 months (range 3-16). Menouria and amenorrhoea were predominant presenting symptoms. The results of surgical treatment were excellent with good continence and resolution of the cyclic haematuria. Three pregnancies (37.5%) which resulted in elective caesarean section were recorded.

CONCLUSION

Vesicouterine fistulae, despite being infrequent, are no longer a rare diagnosis and are most commonly secondary to lower segment caesarean section. With patient history and selected investigations diagnosis is relatively easy. The surgical repair of these fistulae is standard treatment, especially with delayed fistulae with achievement of total continence, and complete resolution of cyclic haematuria. Meticulous practice of obstetric and surgical principles during caesarean section can prevent the formation of these fistulae.

Povidone iodine and dextrose solution combination sclerotherapy in chyluria

OBJECTIVES

To evaluate the effectiveness of combination (povidone iodine and 50% dextrose) renal pelvic instillation sclerotherapy (RPIS) as a minimally invasive therapy for chyluria resistant to conservative treatment.

METHODS

A total of 50 patients with chyluria and hematochyluria (28 men and 22 women) were included in the study. Initially, all were offered conservative antifilarial drug therapy and dietary fat restriction. Intravenous urography was done in all cases to document normal renal functional status. In the patients in whom chyluria persisted after 3 weeks of conservative therapy, cystoscopic lateralization was done and a 5F open-ended ureteral catheter was positioned under local anesthesia. The same was left attached to a 16F Foley catheter for 3 days of RPIS. A solution of 5 mL of 5% povidone iodine and 5 mL of 50% dextrose was instilled twice a day with the patient in the Trendelenburg position for 3 days. In cases of bilateral efflux, the dominant side was treated first. The opposite side was subjected to a similar instillation sclerotherapy schedule after 6 weeks if chyluria persisted.

RESULTS

Of the 50 patients, only 4 responded to conservative therapy. The remaining 46 patients underwent combination RPIS. The mean follow-up was 24 months. Complete remission of chyluria or hematochyluria occurred in 40 (87%) and persisted in 6 patients (13%). Of the 6 patients in whom symptoms persisted, 2 developed chyluria on the side opposite the one treated with RPIS. Another 2 patients developed recurrence on the same side after remaining asymptomatic for 6 months after RPIS. All four of these patients subsequently underwent chylolymphatic disconnection and nephropexy (two open and two laparoscopic) with a successful outcome. The final 2 patients with persistent symptoms were lost to follow-up.

CONCLUSIONS

Combination sclerotherapy using a 5% povidone iodine and 50% dextrose solution is a safe and cost-effective minimally invasive therapy for chyluria refractory to conservative treatment.

Longitudinal changes in corneal asphericity in myopia

PURPOSE

To report the change in shape of the peripheral cornea (asphericity, Q) as it relates to myopia progression in adolescence.

METHODS

Forty-eight subjects with initial ages between 11 and 13 years of age were observed for 5 years. Each subject had participated in a variety of soft contact lens studies and all had worn daily wear soft contact lenses successfully for the 2 years before collection of the second data set.

RESULTS

Myopia increased by an average of 1.46 D and was strongly correlated with a 0.56-mm increase in axial length. There was no contribution to the change in myopia from the change in central radius of the cornea. A significant (p < 0.01, one tail) correlation was found between Q and the progression of myopia. Principal axis analysis yielded a slope of -0.04 in Q per diopter of increase in myopia.

CONCLUSION

These data show a shift to a more positive Q (in the oblate direction) with increased myopia.

Enhanced Gi-protein-mediated mitogenesis following chronic ethanol exposure in a rat model of experimental hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is associated with increased expression and function of inhibitory guanine nucleotide regulatory proteins (Gi-proteins). This study addresses the effects of chronic ethanol exposure on the expression and function of adenylyl cyclase (AC)-linked G-proteins (Gs and Gi) and growth in experimental HCC. G-protein expression and function was determined by immunoblot in the hepatic tumorigenic H4IIE cell line and isolated cultured hepatocytes in the absence or presence of ethanol (5-100 mmol/L). Chronic exposure (24 hours) to ethanol dose-dependently increased Gialpha1/2 expression in the H4IIE cell line, but not in cultured hepatocytes. Gsalpha-protein expression remained unchanged in both H4IIE cells and cultured hepatocytes following ethanol treatment. In addition, ethanol directly activated a Gi-protein, because pertussis toxin (PTx)-catalyzed, adenosine diphosphate (ADP)-dependent ribosylation of Gialpha substrates decreased following ethanol treatment. The increased functional activity of Gialpha1/2-protein expression was confirmed by demonstrating that ethanol dose-dependently inhibited basal and stimulated AC activity in H4IIE cells, while not significantly altering basal AC activity in isolated cultured hepatocytes. Furthermore, while ethanol had no significant effect on basal mitogenesis in H4IIE cells or hepatocytes, increased mitogenesis caused by direct Gialpha-protein stimulation (mastoparan M7; 10-5,000 nmol/L) was further enhanced in the presence of ethanol, an effect that was completely blocked following Gi-protein inhibition (PTx; 100 ng/mL). In contrast, activation of Gi-proteins using M7 failed to alter cellular mitogenesis in isolated cultured hepatocytes, whether in the absence or presence of ethanol. Finally, analysis of mitogen-activated protein kinase (MAPK) activity demonstrated that chronic ethanol treatment further enhanced Gi-protein-stimulated MAPK activity in hepatic tumorigenic cells. In conclusion, these data demonstrate that ethanol enhances cellular mitogenesis in experimental HCC as a result of, at least in part, a Gi-MAPK-dependent pathway. Furthermore, this effect may be caused by ethanol's direct up-regulation of the expression and activity of Gi-proteins in HCC.

Longitudinal fluctuations in cytomegalovirus load in bone marrow transplant patients: relationship between peak virus load, donor/recipient serostatus, acute GVHD and CMV disease

Quantitative competitive PCR was used to monitor the quantity of cytomegalovirus (HCMV) in 1647 blood samples from 110 BMT recipients. DNAemia was detected in 49/110 (45%) of the patients, of whom 15/49 experienced HCMV disease. Peak virus load during surveillance was elevated in symptomatic (median 4.5 log10 genomes/ml) vs asymptomatic patients (median 3.6 log10 genomes/ml, P=0.002) and was also significantly elevated in HCMV seropositive recipients of seronegative marrow, (R+D-, median 5.0 log10), compared to those in the R-D- and R+D+ groups (P < 0.01 and <0.005). Odds ratios for disease per 0.25 log10 increase in viral load, recipient seropositivity and aGVHD were 1.43 (P=0.004), 6.60 (P=0.05) and 3.17 (P=0.08), respectively. In multivariate logistic regression analysis only elevated viral load remained a significant risk factor for HCMV disease. The computed disease probability viral load curve showed a rapid increase in disease risk at viral loads between 3.8 and 5.5 log10 genomes/ml in blood, and odds ratios for disease were determined for different threshold viral loads. These data demonstrate the central role of viral load in the pathogenesis of HCMV in BMT recipients and provide an additional marker for targeting and monitoring therapy.

Anti-HBs detection: a modified passive haemagglutination assay

Modification of a commercial haemagglutination assay for the detection of anti-HBs has reduced the test time from over one hour to approximately 25 min. increased sensitivity ten-fold without any prozoning, maintained specificity and reduced costs by 90%. The modification consists of diluting the reagent cells ten-fold; these are then added to dilutions of test serum in a V-well microplate. After incubation, plates are centrifuged and then inclined at 70 degrees. Positive and negative reactions can be clearly distinguished within approximately 10 minutes.

How to become involved in EDS

This article presents ways in which dental students may become involved in EDS. It is important that EDS has the support of dental students as it is a Committee which works in their interest.