Non-syndromic multiple talon cusps in siblings

Talon′s cusp is an anomalous structure that projects palatally from the cingulum areas of maxillary or mandibular anterior teeth. This dental anomaly may pose several pathological, functional and esthetic problems. Talon cusps usually affect a single tooth, but may rarely affect an entire sextant. Such multiple talon cusps may not always occur in association with a syndrome. Furthermore, they may exhibit a genetic pattern of inheritance. This article emphasizes rare occurrence of such nonsyndromic multiple talon cusps in two siblings

170 Post ERCP de novo fever and de novo bacteremia: Insights from the national inpatient database

Background: The aim of the study was to assess the incidence of post ERCP fever and bacteremia in the national cohort. The secondary aims were to evaluate the in-hospital mortality, length of stay and total hospitalization charges. Methods: This was a retrospective cohort study using the 2016 Nationwide Inpatient Sample (NIS). Patients with ICD-10 CM procedure codes for ERCP were included. Patients were excluded from the study if they had an ICD-10 CM code for a principal diagnosis of acute cholangitis and principal diagnosis of sepsis. Post-ERCP bacteremia was defined as an ICD-10 CM code for a secondary diagnosis of infection or septic shock or fever in patients who received an ERCP. Primary outcome was incidence of post-ERCP bacteremia. Secondary outcomes included in-hospital mortality, length of stay (LOS)and total hospitalization charges. Proportions were compared using fisher’s exact test and continuous variables using student t-test. Multivariable and Poisson regression was performed. Results: We included a total of 152,924 ERCP procedures which were performed in hospitals in the year 2016 across the US. Fever with no signs of bacteremia or sepsis after ERCP was noticed in 0.2% of the population. Post ERCP bacteremia was noticed in 0.5% of all the procedures. 9% of patients with sepsis after ERCP progressed to septic shock. Hispanics were less likely to develop signs of sepsis versus fever alone after ERCP (15% vs 21%, p\u3c0.001)which persisted after adjustment of confounders. ERCP with placement of biliary stent and pancreatic stent was associated with increased odds of developing de novo sepsis by 3 times and 5 times respectively. There was no significant difference in terms of post ERCP percutaneous cholecystectomy or bile duct exploration in the two cohorts. Fever alone did not increase the odds of mortality. However, mortality risk is increased by almost 3 times after the development of sepsis (OR 2.96 (1.36-6.46), p = 0.006). The mean length of stay was significantly higher in patients with post ERCP bacteremia as compared to fever with no sepsis (8 days vs 16 days, p\u3c0.001)which was significant even after adjustment of confounders for Poisson regression. Post ERCP bacteremia is associated with higher total hospitalization charges (114,381 $vs 188,835$, p\u3c0.001). Discussion/conclusion: The study shows that occurrence of fever and post ERCP sepsis from national database is 0.7%. Febrile episode after ERCP leads to prolonged stay which might indicate physicians being cautious. Further studies are warranted to determine any racial and genetic differences, given that hispanics had lower incidence of progression to sepsis. Placement of biliary stent and pancreatic stent were associated with increased progression and therefore further studies might be needed to elucidate which patients might benefit from prophylactic antibiotics. [Figure presented][Figure presented

Thirty-day incidence of post-ERCP complications: Incidence, risk factors and outcomes

Introduction: Endoscopic Retrograde Cholangiopancreatography often leads to mortality and morbidity with complications such as post procedure bleeding, post procedure laceration and post procedure hematoma. Currently, there are no national studies to determine the incidence of these complications and impact on health care utilization in terms of readmissions. Therefore, we aim to assess the national incidence of post ERCP hemorrhage, laceration and hematoma. The secondary aims of the study were to identify the readmissions associated with such complications and evaluate differences in the index admissions in terms of demographics, procedural differences. Methods: This was a retrospective cohort study using the National Readmission Database for the year 2016. Discharges with International Classification of Diseases,10th Revision, Clinical Modification (ICD-10-CM) procedures codes for ERCP were included. Post ERCP complications such as post procedure laceration, hematoma and hemorrhage were defined as an ICD-10-CM code for the same. Subsequently, 30-day readmissions were then calculated for readmissions focusing on post ERCP fever and post ERCP bacteremia. Primary aims were to evaluate the incidence of complications during index admission and readmission. We also aimed to analyze demographic and procedure differences leading to complications. All statistical analysis was performed using STATA software. Results: We analyzed a total of 135,905 discharges undergoing ERCPs for diagnostic and therapeutic purposes. Out of these, 8 cases of post procedure hematoma per 1,000 ERCP were noticed during index admission. Similarly, incidence of post procedure laceration was 3.5/1,000 ERCP cases and post procedure bleeding was 6 per 1,000 ERCPs during the index admission. Approximately, 11.35% of these discharges were readmitted within 30 days of discharge indicating early readmission. However, complications of ERCP leading to readmissions were infrequent. Out of the discharges, post procedure hematoma was reported in 1.4 per 1,000 ERCPs, post procedure laceration in 1.07 per 1,000 ERCPs and post procedure hematoma in 1.07 per 1,000 ERCPs. The occurrence of post procedure complications had higher frequency of PTC or bile duct exploration. As expected, the length of stay and total hospitalization charges were also higher. Discussion: In a retrospective study, the occurrence of post ERCP complications such as post procedure hematoma, post procedure laceration and post procedure hemorrhage were less than 1%. Majority of the complications were noticed during the index admission. Early readmissions after index admission with ERCP for the complications are also infrequent. These suggest that the adverse effects with ERCP are relatively low with low effect on health care utilization. Further studies are warranted to determine the specific risk factors for the complications

Interstitial pneumonia and pulmonary hypertension associated with suspected ehrlichiosis in a dog

BACKGROUND: In dogs with canine monocytic ehrlichiosis (CME), respiratory signs are uncommon and clinical and radiographic signs of interstitial pneumonia are poorly described. However, in human monocytic ehrlichiosis, respiratory signs are common and signs of interstitial pneumonia are well known. Pulmonary hypertension (PH) is classified based on the underlying disease and its treatment is aimed at reducing the clinical signs and, if possible, addressing the primary disease process. PH is often irreversible, but can be reversible if it is secondary to a treatable underlying etiology. CME is currently not generally recognized as one of the possible diseases leading to interstitial pneumonia and secondary PH in dogs. Only one case of PH associated with CME has been reported worldwide. CASE PRESENTATION: A seven-year-old, male intact, mixed breed dog was presented with 2 weeks history of lethargy and dyspnea. The dog previously lived in the Cape Verdean islands. Physical examination showed signs of right-sided congestive heart failure and poor peripheral perfusion. Thoracic radiography showed moderate right-sided cardiomegaly with dilation of the main pulmonary artery and a mild diffuse interstitial lung pattern with peribronchial cuffing. Echocardiography showed severe pulmonary hypertension with an estimated pressure gradient of 136 mm Hg. On arterial blood gas analysis, severe hypoxemia was found and complete blood count revealed moderate regenerative anemia and severe thrombocytopenia. A severe gamma hyperglobulinemia was also documented. Serology for Ehrlichia canis was highly positive. Treatment with oxygen supplementation, a typed packed red blood cell transfusion and medical therapy with doxycycline, pimobendan and sildenafil was initiated and the dog improved clinically. Approximately 2 weeks later, there was complete resolution of all clinical signs and marked improvement of the PH. CONCLUSION: This report illustrates that CME might be associated with significant pulmonary disease and should be considered as a possible differential diagnosis in dogs presenting with dyspnea and secondary pulmonary hypertension, especially in dogs that have been in endemic areas. This is important because CME is a treatable disease and its secondary lung and cardiac manifestations may be completely reversible