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Fusion of a maxillary third molar with a supernumerary fourth molar: a case reportCase ImageA 20-year-old Caucasian male consulted the Department of Dentoalveolar Surgery, School of Dentistry in February 2023 due to intermittent pain in the left side of maxilla and face. Intraoral examination revealed probing pocket depth distally to left maxillary second molar 7mm and bleeding on probing. No health problem arises from medical history. Panoramic radiograph revealed impacted mandibular third molar, mesially angulated, with medium impaction depth, abnormal shape and size in close proximity with maxillary sinus floor (Figure 1).Preoperatively 2gr of Amoxicillin were prescribed. Surgical extraction took place under local anesthesia. Infiltration anesthesia with Lidocaine 2% with 1:80000 epinephrine. A full thickness mucoperiosteal flap was prepared and raised, and then ostectomy was performed using surgical handpiece and sterile saline irrigation. Tooth extraction was performed using straight and Warwick-James elevators. Valsalva maneuver was negative. Extraction socket was flushed with saline and flap was repositioned and sutured. Niflumic acid 250mg was prescribed for 3-5 days. Ex vivo examination of the tooth confirmed “double” tooth diagnosis. In order to obtain as much information as possible regarding dental anatomy, photos of all aspects of the tooth were taken and ex vivo CBCT of the tooth was carried out (Figure 2, Figure 3). Additionally, tooth was submerged in epoxy resin. After setting, three sections of the tooth were cut with a low-speed precision sectioning machine (Isomet 11-1180 Buehler, Lake Bluff, IL, USA) with water cooling. The cut surface of each tooth specimen was ground on a polishing machine (Jean Wirtz TG 250, Dusseldorf, Germany) with 200 rpm under water cooling (50 mL/min) using gradually 600-, 800-, and 1000-grit silicon carbide abrasive papers (Apex S system, Buehler, Lake Bluff, IL, USA) for 20s each. Final tooth sections were <1mm. Tooth specimen was placed between two liner polarization filters. Afterwards flash (Speedlight SB-700, Nikon, Japan) with softbox (Godox, China) was held from one side and DSLR camera (D7200, Nikon, Japan) with macro lens (Micro Nikkor 105mm, Nikon, Japan) from the other side. Filters were crossed in different directions until intended result was obtained (Figure 4, 5, 6). Sutures were removed after one week, healing was unproblematic. Oral examination after six months revealed complete healing of soft tissues.Differential diagnosis between different subcategories of “double” tooth is difficult. The supposition that gemination displays a single root canal and fusion displays several root canals is controversial. Fusion of a normal tooth with supernumeraries will still result in a normal tooth count. Given the presence of features suggestive of both diagnoses, this case, actually, presented a diagnostic dilemma.Fusion of two impacted teeth apparently results in a larger dental structure that makes extraction more invasive and inevitably raises the possibility of complications. Close proximity of maxillary third molar with maxillary sinus floor has to be appreciated. Fracture of maxillary tuberosity may occur in cases with extensive ostectomy.Alterations in tooth size and shape during initial radiographic examination may be a primary sign of dental abnormalities. Utilizing contemporary imaging techniques, including CBCT and dental photography, may showcase such special dental anatomies and complement dentists’ education in this field. Dentists’ awareness will result in a meticulous treatment planning and ensure a successful outcome.Figure legendsFigure 1: Initial panoramic radiograph. White arrow shows impacted third molar with small changes in size and shapeFigure 2: Images of the extracted “double” tooth from different aspectsFigure 3: Images exported from ex vivo CBCT of extracted “double tooth”. Shared pulp canal system is noticed.Figure 4: Image of the first tooth section, using polarization filters, DSLR, macro lens and flashFigure 5: Image of the second tooth section, using polarization filters, DSLR, macro lens and flashFigure 6: Image of the third tooth section, using polarization filters, DSLR, macro lens and flash

Type V Gastric Ulcer: An Unusual Etiology of Gastrosplenic Fistula Associated with Upper Gastrointestinal BleedingMuhammad Nadeem Yousaf MD1, Riyasha Dahal MBBS2, Subeena Phull MD3, Vinayak Aryal MD4, Karun Neupane MD5, Hamza Ertugrul MD6, Ebubekir Daglilar MD71Department of Medicine, Division of Gastroenterology and HepatologyUniversity of Missouri, Columbia, MO, United States2Department of Medicine, Universal College of Medical Sciences, Bhairahawa, Nepal3Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States4Department of Pathology and Laboratory Medicine, MetroHealth System, Case Western Reserve University, Cleveland, OH, United States5Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States6Department of Medicine, Saint Mary’s Hospital, Waterbury, CT, United States7Department of Medicine, Division of Gastroenterology and HepatologyCharleston Area Medical Center, Charleston, WV, United StatesKeywords: Gastric Ulcers, Gastrosplenic fistula, Gastrointestinal bleeding, NSAIDs, Embolization, Endoscopy.Consent statement: Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.

Prakriti Adhikari1, Anil Nepali1,2, Amit Shah2, Shailes Paudel2, Prakriti Bhandari2, and Prakash Nepali31 MBBS doctor, Kathmandu University School of Medical Sciences2 MBBS doctor, Patan Academy of Health Sciences3 MBBS doctor, Chitwan Medical CollegeCorresponding AuthorDr. Anil Nepali, Patan Academy of Health [email protected]

Abstract :Background: A noval radiologic sign in patients with renal failure and UE with metabolic acidosis has recently been identified as the lentiform fork sign. On magnetic resonance imaging (MRI), the ”lentiform fork sign” has been described as bilateral symmetrical hyperintensities in the basal ganglia encircled by a hyperintese rim delineating the lentiform nucleus. Changes in uremic solute retention, aberrant blood-brain barrier transport, disorderd vascular reactivity, altered electrolyte and acid-base balance, and altered hormone metabolism are the most likely causes of the condition.Case presentation : 56-year-old man with end-stage renal disease was brought to the emergency room for a progressive change in mental status and involuntary arm movements over the previous five days, which were also accompanied by mild dyspnea.A brain MRI was performed, and it revealed hyperintensity on T2/FLAIR in the white matter surrounding the basal ganglia. The haloperidol was stopped, and there more dialysis sessions were carried out.Conclusion : intensified hemodialysis and glycemic control are the cornerstones of treating DUS with likely reversible clinical symptoms and remission of imaging abnormalities.

Introduction Survival is dismal for the 40-60% of children with MDS who relapse post allogeneic HCT1,2,3. Strategies to decrease relapse risk include use of cytoreduction prior to HCT or maintenance treatment after HCT, data on the utility of these approaches remains limited4-12. Rapid withdrawal of immune suppression or use of donor lymphocyte infusion (DLI) can enhance the graft versus leukemia effect and achieve disease control in some cases13,14. Addition of hypomethylating agents to DLI may provide additional benefit15 and second HCT should be considered16-21. While several novel therapies may alter the future landscape of MDS therapy22-28 (Table 1), the optimal approach to relapsed pediatric MDS remains unclear. We report the management of a child who relapsed less than 70 days after initial HCT. Our approach demonstrates that multimodal therapy may permit prolonged survival with excellent quality of life (QOL) despite lack of long-term cure.

Optic neuritis after mRNA COVID-19 vaccination; A case reportRaghad Tarcha, Afraa Ghazal, Lama Al-Darwish, Hoda Abdoh, Maysoun Kudsi.

Hashimoto Thyroiditis in a lingual thyroid: an interesting case

TITLE PAGEArticle TypeClinical pictureTitlePenile Injury Caused by Neodymium MagnetsAuthorsYuki Akiyama1, Ryo Ichibayashi2Affiliations1. Department of Orthopaedic Surgery, Toho University Medical Center, Sakura Hospital, Chiba, Japan2. Division of Emergency Medicine Department of Internal Medicine, Toho University Medical Center, Sakura Hospital, Chiba, JapanCorresponding AuthorRyo Ichibayashi, MD, PhDORCID iD https://orcid.org/0000-0002-1273-4875Division of Emergency Medicine Department of Internal MedicineToho University Medical Center, Sakura Hospital564-1 ShimosizuSakura-shi, Chiba 285-8741, JapanPhone: +81-43-462-8811Fax: +81-43-462-8835e-mail: [email protected] titleDamage caused by neodymium magnetsKeywordsNeodymium magnet, Penile foreign body, Emergency, TreatmentConflict of interestThe authors have no conflict of interest to disclose.Financial supportThe author(s) received no financial support for this article’s research, authorship, and publication.Patient consentWritten informed consent was obtained from the patient to publish this report by the journal’s patient consent policy.Author contributionYA wrote and drafted the manuscript. RI helped draft the manuscript. All authors read and approved the final manuscript.Data availability statementThe data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical considerations.AcknowledgmentsNone.Key clinical messageMultiple neodymium magnets can pinch tissue and cause barotrauma. Be careful if the tissue of the penis or foreskin is pinched, as this may cause foreskin necrosis or damage to the urethra.Clinical picture11-year-old boy. He has no history of developmental disabilities or mental illness. The boy played with a neodymium magnet attached to his penis in the bathroom out of curiosity. However, the neodymium magnet remained attached to his penis and could not be removed, and he was transported to our hospital by ambulance with the chief complaint of penile pain. Emergency crews tried to remove it, but it was impossible because it was painful, and there were concerns that it might damage the foreskin. Two hours had passed since he was transferred to our hospital because he was refused admission by multiple medical institutions. At the time of his visit, his penis had two circular neodymium magnets, each approximately 1 cm in diameter, placed against the foreskin of his penis (Figure 1A). Although it was difficult to remove it by pulling it in the opposite direction, it was possible to remove it by shifting the ground surface. After the foreskin was released, there was a crushed wound, so ointment was applied（Figure 1B）. After confirming that there was no problem with the color tone of his glasses, he returned home. The next day, he returned to the outpatient clinic and confirmed that the color of his glans was standard and that he could urinate. Neodymium magnets were developed in Japan in 1982 and have become famous worldwide due to their effectiveness. It is said to be the strongest magnet currently in use. Neodymium magnets are used in various fields and children’s toys [1]. For this reason, accidents such as accidental ingestion by children and insertion into the urinary tract or anus due to sexual preference are problems in the medical field. Accidents caused by multiple neodymium magnets, especially when accidentally swallowed or inserted with a foreign object, are dangerous because they adhere to each other and pinch tissue, resulting in pressure necrosis [2]. This case also had a crush injury to the foreskin. A month later, the scar remained on my foreskin. Barotrauma caused by neodymium magnets often involves damage to thin tissues, including the intestinal tract and mucous membranes. The structures of the corpus cavernosum and the corpus cavernosum of the urethra, which form the penis, are spongy and soft tissues. This tissue becomes rigid as it fills with blood. For this reason, if not only the foreskin but also the corpus cavernosum of the penis is pinched, there is a possibility that blood flow to the corpus cavernosum and damage to the urethra may occur. After removing the neodymium magnet, it is necessary to observe the color of the glans and foreskin and the state of urination.References1. Taylor MA, Spanos SP, Fenton SJ, Russell KW. Ball Magnets Clicked Together on the Epiglottis. Cureus . 2020. 12(5): e8181. doi: 10.7759/cureus.81812. Yuksel C, Ankarali S, Aslan Yuksel N. The use of neodymium magnets in healthcare and their effects on health. North Clin Istanb . 2018; 5(3): 268-273. doi:10.14744/nci.2017.00483Figure 1A　Neodymium magnet that pinches the foreskin of the penisB　 Foreskin with a crush injury

Title : Synovial Sarcoma of the Maxilla: A Challenging Diagnostic Case Report and Literature ReviewAbstract : Synovial sarcoma, a malignant mesenchymal tumor, is primarily associated with the extremities. Nevertheless, its appearance within the head and neck region, particularly in the maxillary area, is remarkably rare. This rarity underscores the significance of each case in unraveling the complexities of its behavior and management strategies. The core focus of this research is a detailed case report involving a 6-year-old female patient who presented with a conspicuous swelling in the left posterior maxilla. Subsequent incisional biopsy led to microscopic identification of malignant spindle cell proliferation, marked by dysplastic changes and abundant mitoses. Immunohistochemical analysis demonstrated negative reactivity for neural and muscular markers, while positive expression of Vimentin, Bcl-2, and TLE1. These morphological and immunohistochemical findings coalesced to definitively diagnose synovial sarcoma, substantiated by a notable 40% Ki67 proliferative index. The chosen treatment strategy encompassed surgery and radiotherapy, which yielded successful outcomes, with no recurrence observed during the one-year follow-up period. Beyond the specific case, this article undertakes a review of existing literature, meticulously analyzing nine similar cases reported in scholarly sources.Keywords : Case report, Head and neck, Maxilla, Synovial sarcoma

INTRODUCTIONThe concept of cantilevered fixed partial denture (CFPD) was described as early as 1960.1 Subsequently, the innovations in dental materials and adhesive dentistry allowed for the description of full ceramic CFPDs as a sound solution for the replacement of missing anterior teeth in 1997.2 Since this initial description, this therapeutic solution has provided patients with a minimally invasive alternative to three-unit fixed partial dentures (FPD). The indication of CFPD is often disputed in comparison with an implant-based treatment, which in some cases, can present challenges, or even be contraindicated. In this regard, CFPDs benefits from more reproducible esthetics, quicker execution and lower costs.2The question remains, however, whether this method would also be suitable for the replacement of missing teeth in the posterior sector, the main problem being the significant increase in occlusal loads on the premolars and molars.3 Different teams have begun to develop posterior CFPDs and some already have the necessary follow-up to validate this practice.4-8 The material used in these early clinical trials has been zirconia doped with 3%mol yttrium oxide (3Y-TZP), which gives the best mechanical properties at the expense of low aesthetic translucency. Yazigii and Kern recommend a thickness of 0.7mm zirconia of the overlay part and a connector of at least 3mm in vertical section and 3mm in horizontal section to ensure the mechanical resistance of the CFPD’s pontic in the posterior sector.6 This case report describes the realization of a reinforced glass-ceramic CFPD replacing à first premolar, this material opens the possibility of single appointment chairside production, and has superior adhesive and esthetic characteristics compared to zirconia.9-11 Its lower mechanical resistance is however to be taken into consideration,12 but still might be suitable if some prerequisites are met.

Spontaneous Spinal Cord Herniation with Post-operative paraplegia- A case report with 10-year follow-upAbstract:Background: Spinal cord herniation is an uncommon diagnosis in the field of spine surgery. The usual presentation of spontaneous spinal cord herniation is in the form of progressive Brown-Sequard syndrome. We describe a case of a 37-year-old male with progressive back pain and sensory deficits due to spinal cord herniation and a post-operative complication associated with reduction of the hernia.Case description: A 37-year-old male presented with insidious onset upper back pain and altered sensations of pain and temperature over the right half of the body below the nipple 2 months before the examination. The patient did not have motor weakness of lower limbs, abnormal/ involuntary movements, or loss of control over the bowel and bladder. MRI of the thoracic spine showed an anterolateral defect(left) at the level of the T2-T3 vertebra. A posterior approach was chosen and the cord with roots was reduced into the dura. The defect was covered by a dural graft (Lyodura) and the wound was closed with a drain insitu. On the 3rd post-operative day, patient developed paraplegia. Patient was treated by exploration and decompression of the hematoma that compressed spinal cord. The deficits were completely recovered at one-month follow-up.Conclusion: Patients with spinal cord herniation and neurologic deficits when treated timely with reduction of the hernia, have good outcomes. The drain should be removed only when the treating team is satisfied regarding the lack of ongoing hemorrhage. The recovery was maintained till the last follow-up at 10 years.Key words: spontaneous spinal cord herniation, spinal cord defect, paraplegia, Brown-Sequard syndrome

INTRODUCTIONAn unpleasant experience for both the patient and the anesthetist, post-dural puncture headache (PDPH) is a complication of spinal anesthesia or lumbar puncture. It is believed to be caused by cerebral vasodilation, which is an indirect consequence of low cerebrospinal fluid (CSF) pressure, or meningeal traction linked to low CSF pressure.1 PDPH incidence varies, although it is generally thought to be 36% or more after lumbar puncture, 0%-10% after spinal anesthesia, and 81% after an unintentional dural puncture during epidural insertion.2, 3 Although PDPH typically resolves on its own, it can make it difficult for mothers to care for their infants and lengthen hospital stays. Serious side effects such as subdural hematoma, convulsions, sagittal sinus thrombosis, and cranial nerve palsies are more infrequently linked to PDPH.

Alemtuzumab‐induced petechiae and epistaxis in a patient with relapsing remitting multiple sclerosis; A case report Farhad Mahmoudi1*, Sayed Ali Emami1, Farid Masaeli1, Najmeh Rayatpisheh21 School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran2School of Medicine, Shahrekord University of Medical Sciences, Shahrekord, IranCorresponding author*Farhad MahmoudiSchool of Medicine,Isfahan University of Medical Sciences,Isfahan, IranEmail: [email protected]: This case report presents a 58-year-old woman with Multiple Sclerosis (MS) who developed petechiae and epistaxis, rare side effects following Alemtuzumab treatment. While these reactions are infrequent, heightened awareness among healthcare providers is essential as Alemtuzumab gains popularity in MS treatment. Recognizing and managing such hypersensitivity reactions promptly is crucial for improved patient care. 1.Introduction Multiple Sclerosis (MS) is an autoimmune disease that affects the central nervous system. The course of the disease varies among individuals, leading to a wide range of symptoms and patterns of presentation. Additionally, there are other conditions, such as radiologically isolated syndrome, which can progress to MS(1). While there is no curative therapy for this condition, certain drugs can modify the course of the disease and improve the prognosis and quality of life for patients.Disease-modifying treatments (DMTs) are the preferred treatment option for patients with MS. Alemtuzumab is an intravenously administered DMT drug that has been available since 2014 for the treatment of patients with multiple sclerosis who have not responded adequately to two or more DMTs. It is a recombinant DNA-derived humanized monoclonal antibody that selectively binds to the CD52 antigen on B and T lymphocytes, depleting them from the bloodstream. This drug has been described as a safe and effective treatment with minimal side effects for patients with relapsing-remitting multiple sclerosis.(2)While there are few studies on the cutaneous adverse effects of Alemtuzumab, in this study, we report the first case of an MS patient treated with Alemtuzumab who developed drug-induced petechiae and epistaxis.2. Case presentationA 58-year-old Caucasian woman with relapsing-remitting multiple sclerosis, who had no previous medical conditions, presented to the emergency department due to muscle spasms and stiffness in her right foot. Neurological examination revealed weakness in her right lower limb with 3/5 muscle strength. She was diagnosed with MS at the age of 26 through an MRI and had previously been on weekly Interferon-beta (IFNb) treatment. During acute MS attacks, she received intravenous corticosteroids. Despite being on disease-modifying therapies (DMTs), she experienced more relapses in the last year, and her Expanded Disability Status Scale (EDSS) was 3. During the current hospitalization, the patient underwent brain and cervical spinal MRI, which revealed the appearance of new periventricular white active plaques in addition to previous black old lesions.Considering the progression of her disease condition, she was started on treatment with Alemtuzumab at a dose of 12mg/day IV. There were no drug reactions, and after completing the treatment, her muscle spasms and stiffness resolved, and the patient was discharged from the hospital.The day after, the patient came to the hospital to receive the second dose of the drug. While receiving the treatment, her condition remained stable, and she did not experience any notable symptoms. However, one day after finishing the first dose, the patient started to experience a gradual appearance of petechiae on her upper and lower limbs, chest, shoulders, and back. Moreover, a few minutes later, she developed epistaxis. Her blood pressure and heart rate were 127/73 and 87, respectively. The patient denied any previous history of eczema, skin issues, or respiratory allergies.Dermatology was consulted to investigate the possible causes of petechiae, and ENT was consulted to manage and evaluate the epistaxis. Despite applying pressure to the nostrils and placing ice on the forehead, the epistaxis did not cease. Consequently, the patient underwent posterior nasal packing, which successfully halted the bleeding.

Diagnosis of hypertrophic cardiomyopathy accompanied with secondary hypertension - case report

MEASLES - AN ENT DIAGNOSIS?

A premature newborn born to an adolescent girl with acute Ebola virus disease and malaria survives in a resource-limited setting in an Ebola Treatment Unit in DR Congo. “ A Case Report”.