Odontogenic Myxoma Of The Maxilla: A Clinical Case Report And Review Of Literature

Odontogenic myxomas are rare benign mesenchymal  tumours of head and neck with a potential for  local infiltration and recurrence. They appear to originate from the dental papilla, follicle or periodontal ligament in mandible and less commonly the maxilla.These usually present in second or third decade of life as slowly progressive space occupying lesion in the jaw giving a  mixed radiopaque-radiolucent appearance.The treatment is considered to be wide local excision in view of high recurrence with curettage alone. Here, we present a case of odontogenic myxoma of maxilla, in a 40 year old lady, with a brief review of  literature, clinical, radiological, histopathological characteristics and therapeutic modality employed.

Determination of frequency of specified structural congenital anomalies and the pattern of determinants affecting congenital malformations in prenatally diagnosed fetal anomaly cases before 20 weeks

Background: Congenital anomalies accounts for 8-15% of perinatal deaths and 13-16% of neonatal deaths in India. The aim of this study was to determine frequency of specified structural congenital anomalies and the pattern of determinants affecting congenital malformations in prenatally diagnosed fetal anomaly cases before 20 weeksMethods: The present study was conducted at Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla. During the study period, all pregnant women with prenatally diagnosed fetal anomaly before 20 weeks, reporting to the Department of OBG, were enrolled for this non-interventional prospective observational study. The observations were analysed on a statistical basis in structured data collection form.Results: Congenital malformations were significantly more common in the age groups of 20-30 years, of low socioeconomic status, vegetarians and who were non-compliant regarding folic acid intake. The majority of women bearing malformed foetuses came from areas at altitude of 500-2000 meters. 33.33% of foetuses had amniotic fluid abnormalities. 83.33% of the foetuses had a single malformation. Central nervous system was the most common system involved (61.90%) out of which neural tube defects (76.91%) were commonest. 11.9% malformations were of the gastrointestinal tract out of which majority (60%) were omphalocele. 4.76% of the total malformations were of the musculoskeletal system. 4.76% malformations involved the genito-urinary tract and 2.38% of the total malformations were of the cardiovascular system and craniofascial anomalies.Conclusions: Early detection of major malformation during pregnancy helps in reducing the high morbidity and mortality of neonates due to congenital malformations because of termination of pregnancy. The commonest system found to be affected was central nervous system followed by gastro-intestinal system. Food fortification with folates and vitamin B12 is the need of the hour

Outcome of pregnancy in women with previous one cesarean section

Background: Worldwide rise in cesarean section (CS) rate during the last three decades has been the cause of alarm and needs an in-depth study. The purpose of this study was to determine the outcome of pregnancy in women with previous one cesarean section and maternal and perinatal complications. It also aimed at identifying the factors, which can influence the outcome of trial of labour (TOL).Methods: The prospective study was conducted in the department of Obstetrics and Gynaecology, Kamla Nehru hospital for mother and child, Indira Gandhi Medical College, Shimla, from June 2013 to May 2014 which included all women undergoing trial for vaginal birth after a previous cesarean who were more than 34 weeks, singleton viable fetus of appropriate size with cephalic presentation with inter delivery interval more than 18 months. Collected data was analysed by Student T-test and Chi-square test was used where required, for statistical analysis using Epi info 7 software. P value <0.05 was considered significant.Results: Out of 152 subjects given trial of labour, 107 (70.39%) subjects had successful VBAC and 45 (29.61%) had repeat emergency cesarean section. The maternal morbidity in emergency cesarean section group and vaginal delivered group was seen in 14 (31%), 8 (7.47%) subjects respectively. No significant perinatal morbidity was observed. VBAC rate was significantly more in women who had prior vaginal deliveries, especially in those with previous VBAC.Conclusions: In carefully selected cases, trial of labour (TOL) after a prior cesarean is safe and often successful. A prior vaginal delivery, particularly, a prior VBAC are associated with a higher rate of successful TOL

The association of atrial fibrillation and ischaemic stroke in patients on haemodialysis: a competing risk analysis

Background: Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective: The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design: A national record linkage cohort study. Setting: All renal and stroke units in Scotland, UK. Patients: All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements: Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods: Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results: Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations: Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions: The incidence of stroke in HD patients is high. The competing risk of “prestroke” mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes

An Assessment of Dialysis Provider's Attitudes towards Timing of Dialysis Initiation in Canada

Background: Physicians' perceptions and opinions may influence when to initiate dialysis. Objective: To examine providers' perspectives and opinions regarding the timing of dialysis initiation. Design: Online survey. Setting: Community and academic dialysis practices in Canada. Participants: A nationally-representative sample of dialysis providers. Measurements and Methods: Dialysis providers opinions assessing reasons to initiate dialysis at low or high eGFR. Responses were obtained using a 9-point Likert scale. Early dialysis was defined as initiation of dialysis in an individual with an eGFR greater than or equal to 10.5 ml/min/m 2 . A detailed survey was emailed to all members of the Canadian Society of Nephrology (CSN) in February 2013. The survey was designed and pre-tested to evaluate duration and ease of administration. Results: One hundred and forty one (25% response rate) physicians participated in the survey. The majority were from urban, academic centres and practiced in regionally administered renal programs. Very few respondents had a formal policy regarding the timing of dialysis initiation or formally reviewed new dialysis starts (N = 4, 3.1%). The majority of respondents were either neutral or disagreed that late compared to early dialysis initiation improved outcomes (85–88%), had a negative impact on quality of life (89%), worsened AVF or PD use (84–90%), led to sicker patients (83%) or was cost effective (61%). Fifty-seven percent of respondents felt uremic symptoms occurred earlier in patients with advancing age or co-morbid illness. Half (51.8%) of the respondents felt there was an absolute eGFR at which they would initiate dialysis in an asymptomatic patient. The majority of respondents would initiate dialysis for classic indications for dialysis, such as volume overload (90.1%) and cachexia (83.7%) however a significant number chose other factors that may lead them to early dialysis initiation including avoiding an emergency (28.4%), patient preference (21.3%) and non-compliance (8.5%). Limitations: 25% response rate. Conclusions: Although the majority of nephrologists in Canada who responded followed evidence-based practice regarding the timing of dialysis initiation, knowledge gaps and areas of clinical uncertainty exist. The implementation and evaluation of formal policies and knowledge translation activities may limit potentially unnecessary early dialysis initiation

Geographic and facility variation in initial use of non-tunneled catheters for incident maintenance hemodialysis patients

Abstract Background Non-tunneled (temporary) hemodialysis catheters (NTHCs) are the least-optimal initial vascular access for incident maintenance hemodialysis patients yet little is known about factors associated with NTHC use in this context. We sought to determine factors associated with NTHC use and examine regional and facility-level variation in NTHC use for incident maintenance hemodialysis patients. Methods We analyzed registry data collected between January 2001 and December 2010 from 61 dialysis facilities within 12 geographic regions in Canada. Multi-level models and intra-class correlation coefficients were used to evaluate variation in NTHC use as initial hemodialysis access across facilities and geographic regions. Facility and patient characteristics associated with the lowest and highest quartiles of NTHC use were compared. Results During the study period, 21,052 patients initiated maintenance hemodialysis using a central venous catheter (CVC). This included 10,183 patients (48.3 %) in whom the initial CVC was a NTHC, as opposed to a tunneled CVC. Crude variation in NTHC use across facilities ranged from 3.7 to 99.4 % and across geographic regions from 32.4 to 85.1 %. In an adjusted multi-level logistic regression model, the proportion of total variation in NTHC use explained by facility-level and regional variation was 40.0 % and 34.1 %, respectively. Similar results were observed for the subgroup of patients who received greater than 12 months of pre-dialysis nephrology care. Patient-level factors associated with increased NTHC use were male gender, history of angina, pulmonary edema, COPD, hypertension, increasing distance from dialysis facility, higher serum phosphate, lower serum albumin and later calendar year. Conclusions There is wide variation in NTHC use as initial vascular access for incident maintenance hemodialysis patients across facilities and geographic regions in Canada. Identifying modifiable factors that explain this variation could facilitate a reduction of NTHC use in favor of more optimal initial vascular access

The risk of stroke and stroke type in patients with atrial fibrillation and chronic kidney disease

Background: Atrial fibrillation (AF) and chronic kidney disease (CKD) are known to increase the risk of stroke. Objectives: We set out to examine the risk of stroke by kidney function and albuminuria in patients with and without AF. Design: Retrospective cohort study. Settings: Ontario, Canada. Participants: A total of 736 666 individuals (>40 years) from 2002 to 2015. Measurements: New-onset AF, albumin-to-creatinine ratio (ACR), and an estimated glomerular filtration rate (eGFR). Methods: A total of 39 120 matched patients were examined for the risk of ischemic, hemorrhagic, or any stroke event, accounting for the competing risk of all-cause mortality. Interaction terms for combinations of ACR/eGFR and the outcome of stroke with and without AF were examined. Results: In a total of 4086 (5.2%) strokes (86% ischemic), the presence of AF was associated with a 2-fold higher risk for any stroke event and its subtypes of ischemic and hemorrhagic stroke. Across eGFR levels, the risk of stroke was 2-fold higher with the presence of AF except for low levels of eGFR (eGFR < 30 mL/min/1.73 m2, hazard ratio [HR]: 1.38, 95% confidence interval [CI]: 0.99-1.92). Similarly across ACR levels, the risk of stroke was 2-fold higher except for high levels of albuminuria (ACR > 30 mg/g, HR: 1.61, 95% CI: 1.31-1.99). The adjusted risk of stroke with AF differed by combinations of ACR and eGFR categories (interaction P value = .04) compared with those without AF. Both stroke types were more common in patients with AF, and ischemic stroke rates differed significantly by eGFR and ACR categories. Limitations: Medication information was not included. Conclusions: Patients with CKD and AF are at a high risk of total, ischemic, and hemorrhagic strokes; the risk is highest with lower eGFR and higher ACR and differs based on eGFR and the degree of ACR