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Abutments are used in dentistry to attach dental crowns to dental implant. Currently, zirconia custom abutment is the one which is mostly used in restorations, since it offers several advantages, especially better esthetics and prevention from infection. Several innovations are done in the implant designs and procedures to achieve better esthetics. Computer-aided design & computer-aided manufacturing (CAD/CAM) system is widely used innovative technology in dentistry. This technology offers custom implants that help to achieve better esthetics and good internal fit. This procedure used a novel technique of anatomical modification of the final abutment incisal edge from straight anatomical edge to irregular one with a mamelon-incisal effect to enhance esthetic, shade matching, and anatomical replication of incisal structure that resembles the natural incisor. Usually, dental technicians will perform facial and incisal cut-back and apply porcelain layers to the crown in order to reproduce the translucency and the other optical effects that most closely match that of natural dentin and enamel, especially at the incisal edge. These optical effects will make the prosthetic crown look more natural and esthetically pleasant. By this presented technique will help the dental technician to achieve highly esthetic crown with completely digital workflow without the need for porcelain layering. The procedure was also followed up to 3, 6, and 12 months after the surgery and found no complications or complaints from the patient and esthetically satisfied.

Introduction Demand for urgent care is increasing, and the pressure on emergency departments (EDs) is of significant concern. Demand growth is to some extent due to the over-utilization of EDs by patients who seek care for non-urgent problems. It has been estimated that up to one-third of all ED visits are non-emergent. In EDs, patients with non-urgent problems are blamed for increased demand, even though most of the patients’ reasons for attending EDs are not well studied. The aim of this study is primarily to determine the factors that influence the decision of patients to visit EDs instead of their primary care physician for non-urgent problems. Secondary aim of this study is to assess the level of ED knowledge among the participants. Methods This is a descriptive, cross-sectional study following a convenient sampling technique conducted through an online questionnaire distributed to the population in Saudi Arabia (SA). The data, which includes sociodemographic data, ER knowledge, the correct definition of ED, cases that ED deals with, and reasons for visiting an ED over a primary health care center (PHC), were collected during August and September 2021. Results Of the 915 respondents, the most common age group was 25 years old or less (34.4%) and the majority were females (68.3%). It was observed that slightly more respondents preferred to visit a PHC (50.4%) while 49.6% preferred to visit EDs when having a medical condition. The proportion of respondents who would visit a PHC was 90.9%, and 36.6% indicated having good experiences there. The overall mean knowledge score was 4.63 (standard deviation [SD] 1.51) out of 6 points, with low, moderate, and high knowledge classified among 12.9%, 22.4%, and 64.7% of respondents, respectively. The five most reported reasons for choosing the ER as the preferred clinic over a PHC were: (1) ED provided quick medical care, (2) easy access to emergency care, (3) unavailability of appointments at a PHC center on the same day, (4) lack of full investigation at the PHC center, (5) lack of primary care providers at the PHC. The least reported reason was advice from another person to visit the emergency department. It was found that a significantly low knowledge was demonstrated by the over 45-years age group (p

Aim of Study: To identify difficulties and barriers facing primary health care physicians in rural areas of Aseer Region, Saudi Arabia. Methods: This cross-sectional study was conducted at primary healthcare centers (PHCCs) belonging to the Saudi Ministry of Health, in rural areas of Aseer Region. A total of 134 physicians participated in the study. A validated study questionnaire was adapted and used for data collection. Results: Female physicians constituted 43.3% of respondents, age of 58.2% was 30-35 years, (Mean±SD: 32.8 ± 7.0 years), 54.5% were married, the salary of 76.1% was

Background In patients with transposition of the great arteries (TGA), commissural malalignment (CM) between semilunar valves may be associated with abnormal coronary (CA) pattern. We intend to assess the degree of CM with incidence of unusual CA anatomy. Methods We proposed a ratio to measure the distance of both ends of the anterior facing sinuses of the pulmonary valve from the facing commissure of the aortic valve. We labeled it as D1 and D2 distance. A ratio (C ratio) of the smaller distance (either D1 or D2 whichever is shorter) over the sum of both D1 and D2 was taken (D1 or D2 whichever is shorter/D1+D2). We related this ratio with the incidence of the unusual CA anatomy in D-TGA patients Results We had a total of 158 patients. We defined the point beyond which the C-Ratio becomes significantly associated with abnormal coronary artery pattern, this represents the median effective level (EL50). The EL50 of the C-Ratio was found to be equal to 31% (0.31). The prediction revealed that the CA pattern would most probably be usual when there is a minor commissural malalignment (C-Ratio less than the EL50) and most probably be unusual when there is a major malalignment (C-Ratio is greater than the EL50). The sensitivity was 71% and the specificity 88% (p-value Conclusions The C-Ratio helps to categorize the degree of CM as minor (less than 0.31) or major (more than 0.31). A higher C-Ratio predicts a higher incidence of unusual CA pattern

Fungal endocarditis (FE) accounts for ~50% of the mortality rate associated with predisposing host conditions. Despite optimal therapeutic strategies, the survival rate remains low. FE is mostly caused by Candida albicans and Aspergillus fumigatus. Previous valvular surgery is the most essential risk factor for Aspergillus endocarditis, which observed in 40–50% of cases. However, native valve FE caused by Aspergillus is uncommon, with only a few reported cases. We hereby report a case of native valve FE caused by A. fumigatus with complications following Wegener’s disease and prostate cancer. The patient survived after successful management with the combination of surgical and medical therapy. Aspergillus endocarditis is a rare and fatal fungal infection. Despite difficulties in diagnosis and treatment, medical intervention with antifungal therapy and immediate surgical intervention are essential to achieve desirable outcomes.

Aim To determine if a transthoracic echocardiography (TTE) can be used as the sole diagnostic imaging modality to evaluate children with congenital heart disease (CHD) undergoing cardiac surgery. Methods A retrospective study was carried out at the King Abdulaziz Cardiac Center. We reviewed all pediatric patients who underwent cardiac surgery during the period January 2011 to December 2011. Results Three hundred ninety-one pediatric patients with CHD fulfilled the inclusion criteria. Of these patients, 287 (73%) underwent surgical interventions based on a TTE alone, while 105 (27%) required additional diagnostic imaging modalities, including a cardiac catheterization (68/105; 65%), cardiac computed tomography angiography (36/105; 35%), or cardiac magnetic resonance imaging (1/105; 1%). A TTE was not enough for all the patients who underwent a cardiac catheterization to find out additional anatomical information (22%), either to directly measure pulmonary artery pressures (62%) or to study vascular reactivity in patients with pulmonary hypertension (16%). Of 36 patients who underwent a cardiac computed tomography angiography, five (14%) had additional information to be added to TTE findings. Of all the patients, 81% had enough information using only the TTE compared to 19% in whom the TTE was not enough to provide all needed information. Only seven of 392 (0.02%) patients had additional minor intraoperative findings that did not affect the surgical decision. Conclusion Despite the emergence of other imaging modalities, a TTE can be used as the sole diagnostic imaging modality for a preoperative assessment in the majority of children with CHD. Other imaging modalities can be employed with limited indications.

Anomalies of systemic venous return are extremely heterogeneous congenital malformations with variable ranges from completely normal physiology to severe forms of right to left shunting requiring surgical treatment. Anomalous drainage of a right-sided superior vena cava (SVC) to the left atrium (LA) is one of the rarest variants of systemic venous return anomalies, characterized by right-to-left shunt physiology and cyanosis. Here we report a 2years old girl presented with cyanosis which was observed shortly after birth by her parents but not further investigated. She is otherwise active girl and with normal growth and development. Her clinical examination was unremarkable apart from mild clubbing of the fingers and low oxygen saturation of 88–90% in room air. Her ECG and chest X-ray were unremarkable. Echocardiography showed bilateral SVC connected by a small innominate vein. The right SVC drains directly into the LA while the left SVC drains into the right atrium (RA) via a dilated coronary sinus. There is a small superior sinus venosus type atrial septum defect (ASD) with left to right shunt. Also, there is partial anomalous pulmonary venous return with right upper and right middle pulmonary veins draining directly into the right SVC, which is connected to LA. The right lower pulmonary vein and left pulmonary veins drain directly to LA. The rest of her echocardiography demonstrated normal heart structures and function. This patient was referred for surgical correction, including baffling of the right SVC to the RA and closure of the ASD. We describe this case to highlight the importance of recognizing this rare anomalous systemic venous connection as one of the very rare causes of cyanosis in the pediatric age group as well as at older age.

Background Truncus arteriosus (TA) is characterised by failure of septation of the outflow tract into aortic and pulmonary trunks and is associated with high morbidity and mortality. Although ranked among the least common congenital heart defects, TA provides an excellent model for the role of individual genes in cardiac morphogenesis as exemplified by TBX1 deficiency caused by point mutations or, more commonly, hemizygosity as part of the 22q11.2 deletion syndrome. The latter genetic lesion, however, is only observed in a proportion of patients with TA, which suggests the presence of additional disease genes. Objective To identify novel genes that cause Mendelian forms of TA. Methods and results We exploited the occurrence of monogenic forms of TA in the Saudi population, which is characterised by high consanguinity, a feature conducive to the occurrence of Mendelian phenocopies of complex phenotypes as we and others have shown. Indeed, we demonstrate in two multiplex consanguineous families that we are able to map TA to regions of autozygosity in which whole-exome sequencing revealed homozygous truncating mutations in PRKD1 (encoding a kinase derepressor of MAF2) and NRP1 (encoding a coreceptor of vascular endothelial growth factor (VEGFA)). Previous work has demonstrated that Prkd1 −/− is embryonic lethal and that its tissue-specific deletion results in abnormal heart remodelling, whereas Nrp1 −/− develops TA. Surprisingly, molecular karyotyping to exclude 22q11.2 deletion syndrome in the replication cohort of 17 simplex TA cases revealed a de novo hemizygous deletion that encompasses PRDM1 , deficiency of which also results in TA phenotype in mouse. Conclusions Our results expand the repertoire of molecular lesions in chromatin remodelling and transcription factors that are implicated in the pathogenesis of congenital heart disease in humans and attest to the power of monogenic forms of congenital heart diseases as a complementary approach to dissect the genetics of these complex phenotypes.

Background Patients with Marfan (MFS) and Loeys-Dietz (LDS) syndromes have been shown to have abnormal aortic biophysical properties. The purpose of this study was to compare the effects of 12-months of therapy with atenolol or losartan on vascular function in young patients with MFS and LDS. Methods Seventeen patients with MFS or LDS were recruited and randomized to treatment with atenolol, 25-50mg, or losartan, 25mg daily. Prior to treatment and following therapy, echocardiography for left ventricular size, function and aortic root size was performed. Pulse wave velocity (PWV), input (Zi, ZiF) and characteristic (Zc, ZcF) impedances, arterial stiffness (Ep and β-index), total arterial compliance (TAC), mean (Wm) and total (Wt) hydraulic power, efficiency, power cost per unit of forward flow (Wt/CI) and brachial artery flow-mediated dilation (FMD) were measured. Results The atenolol group consisted of 9 females (17.6years) and the losartan group 7 males and 1 female (17.0years). Their height, weight, BSA, BMI, systolic and diastolic blood pressures were similar. Baseline to 12-month changes for atenolol and losartan were PWV (20% vs -14%), Zi (-2% vs -27%), Zc (-20% vs -27%), Ep (1%, vs -13%), β-index (10% vs 14%), FMD (11% vs 20%), TAC (3% vs 42%), Wm (-24% vs 15%), Wt (-24% vs 17%), and Wt/CI (3% vs 21%). There was a trend for losartan to decrease PWV and stiffness indexes while atenolol decreased power and power/unit flow. Conclusion This pilot study suggests that atenolol and losartan may have different mechanisms of action on vascular function. A larger clinical trial is needed to confirm these effects.Clinical trials registration NCT00593710 (ClinicalTrials.gov).

Cor-triatriatum dexter is an extremely rare congenital heart defect in which there is complete persistence of the right valve of embryonic sinus venosus that results in partitioning of the right atrium into a smooth and trabeculated portion. The smooth portion receives venous blood from inferior vena cava, superior vena cava, and coronary sinus while the trabeculated portion contains the right atrial appendage and the opening of tricuspid valve. We report a 1-week-old child who presented with intermittent episodes of central cyanosis. Echocardiography, established, and bubble contrast study confirmed the diagnosis of an isolated cor-triatriatum dexter. The baby initially underwent an intervention by cardiac catheterization, which was unsuccessful in disrupting the membrane and re-direct the systemic venous flow to the right heart chambers. She subsequently had the cor-triatriatum dexter membrane resected via an uncomplicated open-heart surgery.

Background Familial dilated cardiomyopathy (DCM) is genetically heterogeneous. Mutations in more than 40 genes have been identified in familial cases, mostly inherited in an autosomal dominant pattern. DCM due to recessive mutations is rarely observed. In consanguineous families, homozygosity mapping and whole exome sequencing (WES) can be utilized to identify the genetic defects in recessively inherited DCM. Methods In a consanguineous family with four affected siblings with severe DCM, we combined homozygosity mapping, linkage analysis and WES, to uncover the genetic defect. Results A region of homozygosity (ROH) on chromosome 8q24.13–24.23 was found to be shared by all of the four affected siblings. WES detected ~47,000 variants that were filtered to a homozygous mutation (p.Gly243Arg) in the FBXO32 gene, located within the identified ROH. The mutation segregated with the phenotype, replaced a highly-conserved amino acid, and was not detected in 1986 ethnically-matched chromosomes. FBXO32, which encodes a muscle-specific ubiquitin ligase, has been implicated in the pathogenesis of cardiomyopathy through the ubiquitin proteasome system (UPS). In addition, FBXO32-knockout mice manifest with cardiomyopathy. Screening the index patient for all of the WES variants in 48 genes known to be implicated in hypertrophic and dilated cardiomyopathy was negative. Conclusions Our data suggest that FBXO32 is a candidate gene for recessive DCM. Acting as a cardiac ubiquitin ligase, mutated FBXO32 could perturb the degradation of target proteins in the UPS, the impairment of which has been observed in cardiomyopathy. Our work proposes that genes encoding other ubiquitin ligases could also be implicated in familial cardiomyopathy. Electronic supplementary material The online version of this article (doi:10.1186/s12881-016-0267-5) contains supplementary material, which is available to authorized users.

A Stanford Type A aortic dissection is a life-threatening surgical emergency that requires emergent surgery. The mortality after repair is high especially if the aortic dissection is complicated by visceral or peripheral malperfusion. We describe a case of a male patient who presented with an aortic dissection involving the ascending aorta, aortic arch, descending thoracic and the abdominal aorta up to the iliac bifurcation. The dissection also involved the visceral and renal arteries with evidence of superior mesenteric artery (SMA) occlusion. Successful outcome was achieved by endovascular stenting of his SMA, followed by Bental procedure. To the best of our knowledge this is the first case report in English literature of SMA stenting followed by Bental procedure to treat acute type A aortic dissection complicated by SMA occlusion.