there appears to have been consensus in the past decades in classifying systemic sclerosis ( ssc ) according to extension of skin involvement as limited and diffuse , using the elbows and knees as  limits  to distinguish between them .
however , although this has been used to  dissect  two more or less distinct clinical subsets , there are patients who do not fit this classification and several others have been proposed [ 1 , 2 ] .
the growing demonstration that autoantibodies specific for ssc such as anticentromere , anti - scl-70 ( anti - topoisomerase 1 ) , and more recently a variety of antinucleolar antibodies , particularly anti - rna polymerase 3 , correlate with these subsets and/or visceral manifestations has led to them being used to
predict  clinical subsets in early disease and also raise awareness for the possibility of certain organ involvement ( anti - scl-70 and interstitial lung disease [ 3 , 4 ] , anticentromere associated with digital ulcers , debatably pulmonary hypertension , and anti - rna polymerase 3 with renal crisis ) .
decades ago , barnett classified ssc as type 1 ( only sclerodactyly ) , type 2 ( acrosclerosis - distal but may reach up to elbows and/or knees plus face ) , and type 3 ( diffuse skin involvement ) ( figure 1 ) .
patients with type 2 had an intermediate degree of both skin and organ involvement compared to type 1 ( less ) and type 3 ( more ) [ 810 ] .
this classification by barnett was extensively discussed in an editorial by masi many years later .
the division into three categories according to extension of skin involvement was not agreed to by others , who could not find real differences between what we could call types 1 and 2 as determined by barnett [ 1 , 2 ] . a similar classification but this time with 4 categories , proposed by giordano et al .
simultaneously , as reasonable stress was laid on early disease detection , the extent of cutaneous involvement was perhaps not considered so relevant , particularly as opposed to the autoantibodies as subset identifiers . however
, truth is that many patients present with evolving disease , and all of ssc  specific  antibodies are not widely available in many parts of the world , the best example being anti - rna polymerase .
many years ago but with a small number of patients , we noted that the limited subgroup could be , indeed , separated clinically as barnett had suggested according to skin involvement into patients with  only fingers ,  which we proposed to call crest , and those with skin distal to elbows and knees but proximal to mcp or mtp joints , which we proposed to call creat ( a instead of s for acrosclerosis ) . in that report , crest patients had more anticentromere antibodies than those with creat and the presence of anti - scl-70 occurred more frequently in the patients with creat than those with crest .
small numbers did not allow for detection of clinical differences . over the past decades ,
many of the larger series [ 416 ] and particularly the eustar database , one of the largest registries , have not differentiated subsets within the limited form ( scleroderma sine scleroderma excluded ) .
very recently however , in a very large series from a single center followed for years , the hopkins group emphasized just this , showing differences between the two  limited  groups and stressing the higher prevalence of lung disease and anti - scl-70 antibodies in the type 2 ( barnett ) or intermediate form when compared with type 1 , a behavior more similar to the diffuse form , and similar to what we had supported and barnett proposed years ago .
their conclusion was that dividing into limited and diffuse as we do now left out an intermediate form with different clinical and serological characteristics .
since over the years it was our feeling that this subsetting was clinically useful , we always registered extension of skin involvement in our patients , particularly identifying those with intermediate form within the lssc .
we therefore decided to examine the clinical and serologic characteristics of our patients with limited disease seen over the last decade to see if we could find differences within them according to the degree of skin involvement .
rheumatology section database , patients with icd 9 code 710.1 ( scleroderma ) in the inpatient hospital database , patients with the item : scleroderma , crest , or other synonyms as registered in the hospital 's electronic clinical history ; and laboratory database : patients with positive anticentromere , antinucleolar , or anti - scl-70 results .
all medical records so identified were then manually reviewed to confirm diagnosis and obtain demographic data such as date of onset , clinical characteristics , and serologic profile . only cases fulfilling acr 1980 criteria were included and were classified as diffuse or limited according to leroy 's criteria .
this difference in distribution was established considering the involvement of skin at its maximum extension at any point in the disease course . within the limited subset , they were separated into sclerodactyly ( only fingers ) and acrosclerosis ( fingers and up to elbows and/or knees , face ) ( barnett 's types 1 and 2 ) .
ssc clinical manifestations were considered to be present if predefined criteria were met during the course of the illness .
organ involvement definitions were the following : ( 1 ) upper gastrointestinal tract ( one or more of the following : manometry with esophageal dysmotility , esophagram with gastroesophagic reflux or peristaltic alterations , or upper endoscopy with esophagitis , ( 2 ) pulmonary hypertension ( ph ) : echocardiogram with estimated pulmonary systolic artery pressure equal to or greater than 40  mmhg or right heart catheterization with mean pulmonary artery pressure at rest over 25  mmhg , ( 3 ) interstitial lung disease ( ild ) : pulmonary interstitial disease observed in high resolution computerized tomography ( hrct ) or pulmonary function tests with vital forced capacity ( vfc ) lower than 70% of the expected and/or carbon monoxide lung diffusion ( dlco ) test under 80% of the expected , ( 4 ) echocardiographic alterations ( aside from ph ) : left or right ventricular diastolic dysfunction in absence of arterial hypertension or pulmonary hypertension , respectively , or pericardial effusion , ( 5 ) digital ulcers : active digital ulcers or pitting scars confirmed by a physician , ( 6 ) renal involvement : history of scleroderma renal crisis ( abrupt onset of accelerated arterial hypertension and/or rapidly progressive renal failure ) .
laboratory detection methods were indirect immunofluorescence on hep-2 cells ( antinuclear antibodies , antinucleolar , and anticentromere ) .
chi - square analysis was used to determine significant differences between sets of categorical data and fisher 's exact test when appropriate .
two hundred and thirty four ssc patients ( 216 females ) fulfilled the established criteria .
female / male ratio was 12  :  1 ; 24% had diffuse ssc and 76% limited ( 64% sclerodactyly and 12% acrosclerosis ) .
ten - year survival rate was 80% for limited and 70% for diffuse variants , respectively ( hr : 0.88 , 95% ci : 0.71.1 ) .

anti - scl-70 was present in 16% , anticentromere in 53% , and nucleolar ana in 7% of overall patients .
several characteristics in the acrosclerosis ( type 2 ) group were more similar to the diffuse patients than those with type 1 ( sclerodactyly ) . in patients with acrosclerosis , duration of raynaud 's was shorter , and they had significantly more anti - scl-70 and less anticentromere antibodies than those with type 1 .
in particular , interstitial lung disease ( ild ) was significantly more prevalent in type 2 group and similar to type 3 .
comparisons between patients with acrosclerosis and diffuse disease are presented in table 2 , showing no differences in clinical manifestations . as described elsewhere ,
autoantibodies were associated with visceral involvement and also with clinical subset . in univariate analysis ,
anticentromere antibodies were associated with pulmonary hypertension , or of 8.25 ( ci 1.935.7 ) , and inversely correlated with ild ( or 0.18 , ci 0.110.29 ) .
they were also associated with limited disease , or 34.4 ( ci 10.2116.6 ) . when performing multivariate analysis adjusting by disease subset , association between anticentromere and pulmonary hypertension was lost .
all of the patients with ph had lssc ( 11 with sclerodactyly and 1 with acrosclerosis ) except for one patient with diffuse disease with anticentromere antibodies . in summary ,
in multivariate analysis , both anti - scl-70 ( or 5.2 , ci 1.517.6 , p = 0.08 ) and diffuse disease ( or 4.1 , ci 1.213.5 , p = 0.021 ) were associated with ild .
these findings are very similar to those recently described by cottrell et al . within the
limited  patients ,  dissecting  between what could be barnett 's type 1 and 2 subsets .
our results support the initial description by barnett et al . that there is an  intermediate  form of ssc between the
some of these patients , albeit with limited scleroderma because skin involvement does not exceed elbows and/or knees , have a clinical behavior which can be described as intermediate between the strictly limited to fingers patients and those with diffuse disease . in particular , a sort of gradient from milder to more severe disease was confirmed in our patients , as suggested by barnett many years ago .
this was also shown by the hopkins group in a much larger number of patients . indeed , in type 2 as defined by barnett , serology may be more similar to the diffuse type and different from type 1
. the  gradient  is also reflected by the accompanying antibodies which further define visceral involvement such as pulmonary hypertension and interstitial lung disease .
these results appear to confirm that extension of skin involvement within limited ssc may identify two different subsets with clinical and serologic characteristics .
autoantibodies , in many cases present years prior to diagnosis and established skin disease , play an essential role here as predictors of clinical subsets and visceral involvement . however , some of these are not widely available .
furthermore , many patients present with established disease , although early , and in these a clinical approach contemplating extent of skin involvement coupled with the classic autoantibodies may indeed be useful and support a division within the limited form which may have useful clinical implications . a retrospective review of data in the large registries trying to document skin extension may or may not confirm this .
the problem may arise in the fact that since the extension of skin involvement within limited disease was not considered important , this may not have been adequately registered .
our smaller series completely agrees with the data shown by the hopkins group with a very large number of patients .
we believe identifying these differences within limited ssc is useful and  resuscitating  the intermediate form or barnett type 2 within limited ssc may contribute to a better clinical assessment of systemic sclerosis .

 objectives . to examine the characteristics of our patients with limited systemic sclerosis ( lssc ) for differences between barnett type 1 ( sclerodactyly only ) and type 2 or intermediate ( acrosclerosis - distal but may reach up to elbows and/or knees plus face ) subsets . methods .
 records of patients between january 1 , 2000 , and december 31 , 2011 , with ssc or those with anti - scl-70 , anticentromere , or antinucleolar antibodies were reviewed . only cases fulfilling acr 1980 criteria were included and classified as diffuse or limited according to leroy 's criteria .
 limited ssc was separated into sclerodactyly and acrosclerosis ( barnett 's types 1 and 2 ) . results . 234 ssc patients ( 216 females ) fulfilled criteria .
 female / male ratio was 12  :  1 ; 24% had dssc and 76% lssc ( 64% type 1 and 12% type 2 ) .
 total follow - up was 688 patient - years .
 within lssc , the type 2 group had significantly shorter duration of raynaud 's and more anti - scl-70 and less anticentromere antibodies .
 in particular , interstitial lung disease ( ild ) was significantly more prevalent in type 2 group and similar to type 3 . conclusions . these results appear to confirm that extension of skin involvement within limited ssc may identify two different subsets with clinical and serologic characteristics .


common failure of the root canal obturation process is because of the presence of gaps and porosities at the sealer / dentin interface .
several studies have shown that filled root canals can allow the re - colonization of micro - organisms .
the presence of micro - organisms and their products in the treated root canal can led to failure of the root canal treatment and the necessity of retreatment .
the analysis of the dentin / sealer interface allows the determination of which materials and filling techniques could obturate the root canals with less gaps and voids .
several microscopy techniques are currently used to evaluate the sealer / dentin interface , including stereomicroscopy , scanning electron microscopy ( sem ) , transmission electron microscopy , and confocal laser scanning microscopy ( clsm ) . in comparison to conventional sem , clsm has the advantage of providing detailed information about the presence and distribution of sealers or dental adhesives inside dentinal tubules in the total circumference of the root canal walls at relative low magnification as 100x through the use of fluorescent rhodamine marked sealers .
placement and activation of a sealer into the root canal system should be done in a manner which is predictable and completely covers the dentin walls . accepted
means of sealer placement include the use of endodontic files or reamers , lentulo spirals , gutta - percha cones , ultrasonic files , and counter - clockwise motion of rotary systems .
very few studies have been done to evaluate the efficacy of different methods of sealer placement and activation effectively .
mta fillapex is a sealer that is composed of mta and has excellent flow , radiopacity , easy handling , working time , and low solubility . because of its suitable physicochemical properties and excellent biocompatibility and bioactivity ,
hence , this study was planned to evaluate percentage and the depth of dentinal tubule sealer penetration of mta fillapex when agitated with three different techniques and to compare it with ah plus using clsm as the evaluative tool .
sixty teeth with single canal and free of cracks , caries , resorption , calcification , previous endodontic treatment , and less than 10- root curvature were selected and stored in distilled water until use . for standardization of the root length ( 10 mm )
, the crowns were resected with a diamond disc in a slow speed straight handpiece under constant water cooling .
the working length was determined by inserting # 15 k - file ( dentsply maillefer ) into the canal until it was just seen at the apical foramen and then 0.5 mm was subtracted from this length .
the roots were instrumented by using the protaper universal root canal files ( dentsply maillefer ) in a sequential manner from s1 till f5 .
canals were irrigated between files with 2 ml of 3% naocl ( sree rayalaseema alkalies and allies chemicals limited , india ) . to eliminate the smear layer 2 ml of 17% ethylenediaminetetraacetic acid ( edta ) ( ph 7.7 ) for 3 min was used , followed by a final rinse of 2 ml distilled water .
the roots were randomly divided into three groups on the basis of sealer activation technique utilized : g1 : ultrasonic ( woodpecker dte - d5 ultrasonic scaler , china ) ; g2 : lentulo spiral ( dentsply , maillefer ) ; g3 : counter - clockwise motion ( x smart , densply , maillefer , ballaigues , switzerland ) .
each group was further divided into two subgroups on the basis of type of sealer .
subgroup a utilized ah plus sealer while subgroup m utilized mta fillapex sealer . ah plus sealer and mta fillapex sealer were mixed according to the manufacturer instructions and to allow analysis under the clsm , each sealer was labelled with rhodamine b ( mayor diagnostics , mumbai , india ) to an approximate concentration of 0.1%(by weight ) .
group 1 ( g1 ) : the ultrasonic unit ( woodpecker dte - d5 ultrasonic scaler , china ) was used in endo mode with a satelec ultrasonic endodontic tip k15 sonofile ( dentsply tulsa ) for activation . the file was inserted 2 mm short of the working length inside the canal and was ultrasonically activated for 20 seconds .
gutta - percha was compacted 1 mm below the canal orifice and the teeth were sealed with cavit ( 3 m , espe ) . in g1a ah plus sealer and in g1 m , mta fillapex sealer was used .
group 2 ( g2 ) : a size 30 lentulo spiral ( dentsply , maillefer ) was selected that would not bind in the prepared canal and that would reach the prepared working length . the lentulo spiral was rotated at speed of 300 rpm keeping the instrument 2 mm from apex for 20 seconds .
thereafter , the obturation of canal was conducted as described for g1 . in g2a ah plus sealer and in g2 m , mta fillapex sealer was used .
group 3 ( g3 ) : f1 protaper file attached in handpiece of endodontic micromotor ( x - smart , dentsply tulsa ) was kept 2 mm short of apex and rotated at 300 rpm in reverse mode for 20 seconds .
thereafter , the obturation of canal was conducted as described for g1 . in g3a ah plus sealer and in g3 m , mta fillapex sealer was used .
the specimens were kept in an incubator at 37c and 100% humidity for 2 days .
each root was sectioned at 90- to the long axis by using diamond disc removing two , 1 mm sections at 3 mm and 6 mm from the apex .
coronal surface of each section was polished with sand paper ( politriz , arotec , cotia , sp , brazil ) .
the dentin segments were examined on a confocal microscope ( olympus fluoview fv 1000 ) .
the respective absorption and emission wave lengths for the rhodomine b were 540 nm and 590 nm .
dentin samples were analyzed using the 10x lens . to calculate the percentage of sealer penetration around the root canal , first each image was imported into the iob software and the circumference of root canal measured using its ruler tool .
next , areas along the canal walls in which the sealer penetrated into dentinal tubules were outlined and measured using the same method [ figure 1 ] .
subsequently , the percentage of root canal sealer penetration in that section was established . to determine the maximum depth of penetration , the point of deepest penetration was measured from the canal wall to the maximum depth of penetration [ figure 2 ] .
the effects of sealer agitation techniques and type of sealer on depth and percentage of sealer penetration were analyzed , by performing nonparametric kruskal - wallis for overall analysis , and a series of mann - whitney u tests for pairwise comparison using statistical package of social sciences ( spss ) statistics 20 software .
confocal laser scanning microscopic photograph showing calculation of percentage of penetration of sealer in the dentinal tubules ( original magnification 10 ) confocal laser scanning microscopic photograph showing calculation of depth of penetration of sealer in the dentinal tubules ( original magnification 10 )
sixty teeth with single canal and free of cracks , caries , resorption , calcification , previous endodontic treatment , and less than 10- root curvature were selected and stored in distilled water until use .
for standardization of the root length ( 10 mm ) , the crowns were resected with a diamond disc in a slow speed straight handpiece under constant water cooling .
the working length was determined by inserting # 15 k - file ( dentsply maillefer ) into the canal until it was just seen at the apical foramen and then 0.5 mm was subtracted from this length .
the roots were instrumented by using the protaper universal root canal files ( dentsply maillefer ) in a sequential manner from s1 till f5 .
canals were irrigated between files with 2 ml of 3% naocl ( sree rayalaseema alkalies and allies chemicals limited , india ) . to eliminate the smear layer 2 ml of 17% ethylenediaminetetraacetic acid ( edta ) ( ph 7.7 ) for
3 min was used , followed by a final rinse of 2 ml distilled water .
the roots were randomly divided into three groups on the basis of sealer activation technique utilized : g1 : ultrasonic ( woodpecker dte - d5 ultrasonic scaler , china ) ; g2 : lentulo spiral ( dentsply , maillefer ) ; g3 : counter - clockwise motion ( x smart , densply , maillefer , ballaigues , switzerland ) .
each group was further divided into two subgroups on the basis of type of sealer .
ah plus sealer and mta fillapex sealer were mixed according to the manufacturer instructions and to allow analysis under the clsm , each sealer was labelled with rhodamine b ( mayor diagnostics , mumbai , india ) to an approximate concentration of 0.1%(by weight ) .
group 1 ( g1 ) : the ultrasonic unit ( woodpecker dte - d5 ultrasonic scaler , china ) was used in endo mode with a satelec ultrasonic endodontic tip k15 sonofile ( dentsply tulsa ) for activation . the file was inserted 2 mm short of the working length inside the canal and was ultrasonically activated for 20 seconds . canal was obturated with protaper f5 gutta - percha cone .
gutta - percha was compacted 1 mm below the canal orifice and the teeth were sealed with cavit ( 3 m , espe ) . in g1a ah plus sealer and in g1 m , mta fillapex sealer was used .
group 2 ( g2 ) : a size 30 lentulo spiral ( dentsply , maillefer ) was selected that would not bind in the prepared canal and that would reach the prepared working length . the lentulo spiral was rotated at speed of 300 rpm keeping the instrument 2 mm from apex for 20 seconds .
thereafter , the obturation of canal was conducted as described for g1 . in g2a ah plus sealer and in g2 m , mta fillapex sealer was used .
group 3 ( g3 ) : f1 protaper file attached in handpiece of endodontic micromotor ( x - smart , dentsply tulsa ) was kept 2 mm short of apex and rotated at 300 rpm in reverse mode for 20 seconds .
thereafter , the obturation of canal was conducted as described for g1 . in g3a ah plus sealer and in g3 m , mta fillapex sealer was used .
the specimens were kept in an incubator at 37c and 100% humidity for 2 days .
each root was sectioned at 90- to the long axis by using diamond disc removing two , 1 mm sections at 3 mm and 6 mm from the apex .
coronal surface of each section was polished with sand paper ( politriz , arotec , cotia , sp , brazil ) .
the dentin segments were examined on a confocal microscope ( olympus fluoview fv 1000 ) .
the respective absorption and emission wave lengths for the rhodomine b were 540 nm and 590 nm .
dentin samples were analyzed using the 10x lens . to calculate the percentage of sealer penetration around the root canal , first each image was imported into the iob software and the circumference of root canal measured using its ruler tool .
next , areas along the canal walls in which the sealer penetrated into dentinal tubules were outlined and measured using the same method [ figure 1 ] .
subsequently , the percentage of root canal sealer penetration in that section was established . to determine the maximum depth of penetration , the point of deepest penetration was measured from the canal wall to the maximum depth of penetration [ figure 2 ] .
the effects of sealer agitation techniques and type of sealer on depth and percentage of sealer penetration were analyzed , by performing nonparametric kruskal - wallis for overall analysis , and a series of mann - whitney u tests for pairwise comparison using statistical package of social sciences ( spss ) statistics 20 software .
confocal laser scanning microscopic photograph showing calculation of percentage of penetration of sealer in the dentinal tubules ( original magnification 10 ) confocal laser scanning microscopic photograph showing calculation of depth of penetration of sealer in the dentinal tubules ( original magnification 10 )
the percentage and depth of sealer penetration of different groups and intergroup comparison are summarized in tables 1 and 2 , respectively . shows mean and standard deviation of depth and percentage of sealer penetration of various groups at 3 and 6 mm levels intergroup comparison of depth and percentage of sealer penetration at 6 and 3 mm levels mean percentage and depth of sealer penetration of mta fillapex and ah plus sealer was greatest when ultrasonics was used for agitation and statistically significant ( p < 0.001 ) than lentulo spiral and counter - clockwise agitation techniques .
irrespective of method used for agitation , the percentage and depth of sealer penetration for mta fillapex was significantly greater ( p < 0.001 ) than ah plus .
the percentage and depth of sealer penetration for mta fillapex and ah plus were greater and highly significant ( p < 0.001 ) at 6 mm than 3 mm .
removal of smear layer and use of sealer to attain and impervious seal between the core material and root canal walls is considered an essential step of root canal treatment .
sealers which can penetrate into the dentinal tubules exert bactericidal effect by having a closer contact with the residual bacteria within the tubules .
in addition , sealer plugs inside the dentinal tubules provide a mechanical interlocking , thereby improving the retention of the filling material and reducing the microleakage along the root canal walls .
thus , both percentage and depth of sealer penetration might influence the outcome or success rate of endodontic therapy .
factors influencing sealer depth penetration in dentinal tubules are presence / absence of dentinal permeability ( the number and the diameter of tubules ) , root canal dimension , presence of water , and physical and chemical properties of the sealer .
the compound effect of physical properties viz flow , surface tension , solubility , viscosity , chemical composition , and working and setting time may influence penetration .
flow which is defined as the ability of a sealer to penetrate in irregularities , lateral canals , or dentinal tubules of the root canal system is one of the main physical factors to influence the tubular penetration .
as most endodontic sealers are pseudoplastic , their flow increases with increase of shear rate . on comparison with conventional sealers patel dv et al . , and gharib sr et al . , found better depth of penetration of resin - based sealer in dentinal tubules .
mta fillapex has excellent biocompatibility and bioactivity and displayed significantly higher ph up to 7 days period than ah plus .
studies based on the physical properties reported significantly greater flow of mta fillapex than ah plus .
therefore , this comparative study was conducted to evaluate and compare the quality of sealing of ah plus and mta fillapex .
clinically , rapid insertion or activation of a pseudoplastic sealer into the canal would decrease viscosity and increase the flow of sealer .
as very few studies have been conducted on the effect of sealer activation / placement and activation on sealing ability of root canal sealers therefore in the present study three activation techniques ( ultrasonics , lentulo spiral , and rotary counter - clockwise motion ) were chosen and the sealer distribution was analyzed .
amount of sealer , extent of activating instrument , and time for activation were standardized to minimize the errors .
all the analyzed activation techniques failed to show a consistent adaptation of both the sealers to the total circumference of the root canal walls .
however , mta fillapex showed significantly better ( p < 0.001 ) percentage and depth of sealer penetration than ah plus with all the techniques of sealer activation .
kuc , ia et al . , also reported greater mta fillapex sealer penetration than ah plus .
zhou h et al . , and silva ej et al . , found mta fillapex significantly more flowable than ah plus and attributed difference in composition and smaller particle size of the sealer for this property .
application of ultrasonics for activation led to significantly more ( p < 0.001 ) percentage and depth of both the sealers and is accordance to guimaraes bm et al . , the explanation for this is that the oscillating files in ultrasonics transmits the acoustic microstreaming energy and cause a greater depth of dentinal sealer penetration and coverage of root canal walls in the same manner as it promotes the penetration of irrigants in an area of anatomic complexities and the dentinal tubules . although activation of both the sealers with lentulo spiral resulted in more percentage and depth of penetration as compare to counter - clockwise rotation however , the difference was statistically insignificant ( p > 0.05 ) .
this is one of the pioneer studies evaluating effect of methods of activation on mta fillapex so it was difficult to compare the results obtained with previous studies .
lentulo spiral rotates and the spring portion pushes the sealer centrifugally while in counter - clockwise rotation with a file , the sealer tends to pool toward the tip of file but is not forced toward the walls .
irrespective of technique of activation and type of sealer , the depth , and percentage of penetration of sealer was significantly better at the 6 mm level than 3 mm level .
these findings are similar to other studies and could be because the number and diameter of dentinal tubules decreases on descending apically in the root canal and superior removal of smear layer .
in addition , the apical dentin is irregular in direction and density ; even some areas are devoid of dentinal tubules .
under the parameters of present study , it can be concluded that mta fillapex sealer exhibited better percentage and depth of penetration in the radicular dentinal tubules than ah plus .
ultrasonic activation of pseudoplastic sealers can significantly increase its percentage and depth of penetration and level of root canal can affect both , percentage , and depth of penetration of sealers in the dentinal tubules .

 aim : to compare the effect of three root canal sealer activation techniques on percentage and depth of sealer penetration of mta fillapex and ah plus sealers.materials and methods : sixty teeth prepared till f5 protaper size were divided into three equal groups on the basis of sealer activation technique ( g1 : ultrasonics , g2 : lentulo spiral , and g3 : counter - clockwise rotary motion ) .
 each group was further divided into two equal subgroups on the basis of type of sealer used : ah plus ( denstply , konstanz , germany ) or mta fillapex ( angelus , londrina , pr , brazil ) and obturated with gutta - percha .
 horizontal sections at 3 and 6 mm from the apex were obtained and the percentage and depth of penetration of sealers into dentinal tubules were measured using confocal laser scanning microscopy ( clsm ) .
 statistical analysis was performed utilizing kruskal - wallis and mann - whitney u tests with a significance level of 5%.results : g1 showed significantly ( p < 0.001 ) high percentage and depth of sealer penetration than g2 and g3 while the difference was insignificant ( p > 0.05 ) between g2 and g3.conclusion:percentage and depth of sealer penetration are influenced by the type of sealer used sealer activation technique and by the root canal level .
 ultrasonic method of sealer activation and mta fillapex showed the best results .


vision 2020 is a joint initiative by the world health organization ( who ) and the international agency for the prevention of blindness , that aims to eliminate avoidable blindness by the year 2020 .
the vision 2020 strategy depends on the development of district level plans for the prevention of avoidable blindness.[26 ] india was the first country in the world to initiate a public funded program for the prevention of blindness as a national priority health problem .
population - based surveys have been the main stay of information regarding the effective implementation and monitoring of such eye care programs .
are expensive and time consuming . rapid assessment of avoidable blindness ( raab ) survey is cheap and easy means of getting population - based data on prevalence and causes of blindness in people aged more than 50 years .
raab also has the other utility of monitoring programs at the unit / district level.[911 ] kolar district in south karnataka , india , has an estimated population of around 1.5 million , 51% of the population being males and 29% being over 50 years .
the aim of the study was to conduct a raab study in persons aged more than 50 years in kolar district in order to estimate the prevalence and causes of blindness .
this was also to help the ophthalmology and community medicine departments of the medical institution to develop student capacity as well as expose them to scientific survey methods of generating evidence for planning of eye care services .
the survey was carried out by a team consisting of trained personnel from the departments of ophthalmology and community medicine , sri devaraj urs medical college , kolar , karnataka , india .
the survey was carried out between march and june 2011 ( 4 months ) , in accordance with the helsinki declaration .
written informed consent was obtained from all study participants , after explaining the purpose of the study in their local language .
sample size was determined using a prevalence estimate of 4% for blindness ( who definition of presenting vision < 20/400 in better eye ) among those aged over 50 years .
the prevalence estimate was assumed to be around 4% considering the recent raab survey conducted across india which gave prevalence of blindness using the same definition to be around 3.6% . using 95% confidence interval , 22.5% precision , design effect of 1.5 and 10% nonresponse rate , sample size was calculated to be 3017 , which would require 61 clusters of 50 people aged over 50 years . using the population data from the last census ( 2001 ) and the growth rate for 9 years , the population was estimated for end of 2010 and used as a sampling frame .
a list of wards and villages in urban and rural areas was prepared taluk ( revenue division ) wise . in each , the population size of people aged over 50 years was listed .
households within each cluster were selected by compact segment sampling . a map of the selected cluster was drawn and divided into equal segments that would give
segments were numbered and one segment was chosen by draw of lots . to be eligible for inclusion an individual had to reside in that household for at least the previous 6 months . in each cluster ,
the people in the selected cluster were briefed about the survey 23 days in advance by the local health worker along with the public relations officer of the team .
if an eligible person was not available during the survey , at least two more attempts were made to assess information .
if after repeated visits , examination could not be done , information of his visual status was obtained from his relatives or neighbors .
standard raab protocol was used for gathering information and for eye examination . a survey form comprising seven sections
the form consisted of general information ; vision and pin hole examination ; lens status ; principal cause of visual impairment ; history if not examined ; and barriers to uptake of cataract surgery and details of cataract surgery if operated .
visual acuity ( va ) was measured using a tumbling snellen - e chart using optotype size 20/60 on one side and 20/200 on the other .
all measurements were taken in full daylight with available correction . if visual acuity was less than 20/60 in either eye , pin hole vision was tested .
if presenting vision was < 20/60 , then pupil was dilated and ophthalmoscopy done to assess the cause of blindness .
the interobserver agreement between the two teams was good as observed by the kappa value ( > 0.60 ) .
double data entry and analysis was done using the raab software program version 4.02 . to check for errors made during data entry of the survey record forms ,
the data are entered twice by different data entry clerks in two separate databases and then compared .
sample size was determined using a prevalence estimate of 4% for blindness ( who definition of presenting vision < 20/400 in better eye ) among those aged over 50 years .
the prevalence estimate was assumed to be around 4% considering the recent raab survey conducted across india which gave prevalence of blindness using the same definition to be around 3.6% . using 95% confidence interval , 22.5% precision , design effect of 1.5 and 10% nonresponse rate , sample size was calculated to be 3017 , which would require 61 clusters of 50 people aged over 50 years .
using the population data from the last census ( 2001 ) and the growth rate for 9 years , the population was estimated for end of 2010 and used as a sampling frame .
a list of wards and villages in urban and rural areas was prepared taluk ( revenue division ) wise . in each , the population size of people aged over 50 years was listed .
households within each cluster were selected by compact segment sampling . a map of the selected cluster was drawn and divided into equal segments that would give
segments were numbered and one segment was chosen by draw of lots . to be eligible for inclusion
an individual had to reside in that household for at least the previous 6 months . in each cluster
, the survey team visited each household accompanied by local health worker to facilitate compliance .
the people in the selected cluster were briefed about the survey 23 days in advance by the local health worker along with the public relations officer of the team .
if an eligible person was not available during the survey , at least two more attempts were made to assess information .
if after repeated visits , examination could not be done , information of his visual status was obtained from his relatives or neighbors .
standard raab protocol was used for gathering information and for eye examination . a survey form comprising seven sections
vision and pin hole examination ; lens status ; principal cause of visual impairment ; history if not examined ; and barriers to uptake of cataract surgery and details of cataract surgery if operated .
visual acuity ( va ) was measured using a tumbling snellen - e chart using optotype size 20/60 on one side and 20/200 on the other .
all measurements were taken in full daylight with available correction . if visual acuity was less than 20/60 in either eye , pin hole vision was tested .
if presenting vision was < 20/60 , then pupil was dilated and ophthalmoscopy done to assess the cause of blindness .
the interobserver agreement between the two teams was good as observed by the kappa value ( > 0.60 ) .
double data entry and analysis was done using the raab software program version 4.02 . to check for errors made during data entry of the survey record forms ,
the data are entered twice by different data entry clerks in two separate databases and then compared .
a total of 3050 persons aged over 50 years were included in the study and 2907 ( 95.3% ) of them were examined . of them
the sampled population was relatively representative of the district population in terms of age and sex distribution .
the overall unadjusted prevalence of blindness from all causes in persons aged over 50 years was 3.9% ( 95% ci 2.75.1 ) .
table 1 shows the data regarding prevalence of blindness ( va < 20/400 in better eye with available correction ) ; severe visual impairment ( va < 20/200 20/400 in better eye with available correction ) and moderate visual impairment in persons ( va < 20/60 20/200 in better eye with available correction ) .
the age and sex adjusted prevalence of blindness , severe visual impairment , and moderate visual impairment was 3.4% , 3.1% , and 9.7% , respectively .
sample prevalence of blindness , severe visual impairment and moderate visual impairment  all causes untreated cataract was the primary cause of bilateral blindness ( 75% ) and severe visual impairment ( 73% ) .
refractive errors were the most common cause of moderate visual impairment ( 56% ) and second most common cause of severe visual impairment ( 11% ) .
avoidable causes accounted for 91% of all cases of blindness and 95% of cases of severe visual impairment [ table 2 ] .
causes of blindness ( va < 20/400 ) , severe visual impairment ( va 20/20020/400 ) and moderate visual impairment ( va 20/6020/200 ) the main barriers to uptake of cataract surgery were  no one to accompany ( 27% ) ;  waiting for maturity ( 27% ) ;  do not know how to get surgery done ( 10% ) ; and  old age no need ( 7% ) . the cataract surgical coverage ( csc ) in persons with va < 20/400 was high , with 82% of those requiring surgery having received the same .
for people with va < 20/200 and va < 20/60 , 72% and 64% , respectively of those needing surgery had received it [ table 3 ] . cataract surgical coverage by persons and eyes sex wise of the 707 eyes , which had received surgery , 641 ( 90.7% ) had an intra - ocular lens ( iol ) implantated .
among the patients with iol , 72.7% had va of 20/60 or more with available correction [ table 4 ]
. in patients operated less than 5 years back , 86% of patients with iol had best corrected va of more than or equal to 20/60 , when compared with 79% in patients with iol operated more than 5 years back . around 85% of patients were satisfied with the results of cataract surgery .
ocular comorbidities , operative complications and long - term complications were the principal reasons for poor outcome in eyes operated less than 3 years back .
postoperative visual acuity with available correction low vision ( persons with va < 20/60 in better eye with correction and not due to cataract , refractive error , or uncorrected aphakia ) was seen in 46 persons ( 1.6% ) .
in india , eye care planning and monitoring under the national program for control of blindness has been guided by population - based surveys .
rapid assessment techniques , which provide reliable estimates have been used for the past 16 years and have been the basis for district level programming .
the prevalence of blindness ( va < 20/400 ) was 3.9% in our study , which is almost similar to the raab study conducted across various states in india , which gave a prevalence of 3.6% .
the raab india study which covered gulbarga district in karnataka , gave a prevalence of 4.3% for that district .
the prevalence of blindness in our study is on the higher side when compared with other studies from kenya , bangladesh , china , palestinian territories and malawi where blindness prevalence ranged from 2.0% to 3.7% .
consequently , even though there has been a sharp increase in outreach programs and service delivery , this has been offset by the increasing elderly population as a result of increased life expectancy . in our study , almost 91% of blindness was avoidable .
untreated cataract still continues to be the major cause of blindness and severe visual impairment .
refractive errors and uncorrected aphakia are the other leading avoidable causes . despite the increased csc , there are an estimated 4700 people [ table 5 ] who are having bilateral cataract in kolar district , extrapolating the survey findings
. this cataract burden can only be reduced by proper taluk wise segmentation of the cataract blind and targeting the community outreach programs toward these areas . spectacle provision to the needy at a peripheral level by means of mobile refraction units and spectacle dispensing outfits
age and sex adjusted prevalence modified strategies in the form of extensive health awareness and health education campaigns through a decentralized approach involving all major health care providers at the grass root level , down to the remote rural level could be one of the positive steps in reducing this cataract burden .
waiting for maturity. this indirectly indicates that patients have been told to wait and sent back , which is an indicator of service delivery deficiency .
such people once turned back are unlikely to return back because of reasons such as lack of funds for conveyance to the hospital , loss of daily wages during the visit to the hospital , and relative lack of knowledge about when to return .
thus not only increasing the outreach programs but also concentrating on proper case selection , good surgical techniques , proper follow - up care and spectacle provision will definitely reduce the barriers and improve the outcome after cataract surgery .
this could be due to the fact that increased percentage of males seeks eye care services as reflected in the increased csc among males .
also females are less likely to report a need for sight than males.[1622 ] the strengths of our study was ready availability of taluk wise population data and the survey teams being trained by a certified raab trainer .
even though , there is a decline in prevalence of blindness , modified strategies need to be implemented to tackle the burden of untreated cataract .
raab done at regular intervals is an effective tool to quantify the problem of blindness and monitor the implementation of eye care programs .

 background : more than 90% of visual impairment can either be treated or avoided .
 rapid assessment of avoidable blindness methodology provides valid estimates in short time to assess magnitude and causes of blindness.aims:to estimate the prevalence and causes of blindness in persons above 50 years in kolar , south india , using the above methodology.materials and methods : sixty one clusters of 50 people aged above 50 years were selected by probability - proportionate to size sampling .
 participants were evaluated using a standardized survey form .
 persons with vision < 20/60 were dilated and examined by an ophthalmologist.results:of the 3050 people listed 2907 were examined ( 95.3% ) .
 prevalence of bilateral blindness in persons was 3.9% ; severe visual impairment 3.5% , and visual impairment 10.4% .
 untreated cataract was the leading cause of blindness ( 74.6% ) and severe visual impairment ( 73.3% ) .
 avoidable causes of blindness accounted for 91.2% of all blindness and 95.0% of severe visual impairment .
 waiting for maturity and  no one to accompany were the most common barriers to uptake of cataract surgery.conclusion:untreated cataract continues to be the leading cause of avoidable blindness .
 modified strategies need to be implemented to tackle the burden of cataract blindness .


they are usually encountered as incidental findings in magnetic resonance imaging ( mri ) , or in arthroscopy .
they may originate from both the cruciate ligaments and the menisci , from the popliteus tendon and alar folds , infrapatellar fat pad of hoffa , and subchondral bone cysts .
those arising from the hoffa s fat pad , usually present as palpable mass at anterior aspect of the knee joint .
we report a case of intraarticular ganglion cyst of knee arising from the infrapatellar fat pad and protruding anterolaterally through retinacular rent into the subcutaneous plane .
a 19-year - old young man , presented with a painless gradually increasing swelling at the anterior aspect of left knee of 9 months duration .
mri scan revealed a multilobulated , cyst with septations within the anterior aspect of the knee joint , just inferolateral to the patella , with deep extension into the infrapatellar fat pad , and superficial extension into the subcutaneous space across the retinaculum .
after diagnostic arthroscopy , we performed an open excision of the cystic mass and confirmed the retinacular rent pre - operatively .
arthroscopic resection and debridement is the gold standard treatment in ganglion cyst of the knee .
however , a subcutaneous extension may lead to incomplete arthroscopic resection : leaving behind the residual tissue which may cause recurrence .
therefore , proper pre - operative evaluation of mr images of these cases is very important .
a ganglion is a cystic tumor - like lesion of unknown etiology , surrounded by a dense network of connective tissue , filled with a gelatinous fluid containing hyaluronic acid and other mucopolysaccharides .
intra - articular ganglion cysts of the knee joint are uncommon . they are usually encountered as incidental findings in magnetic resonance imaging ( mri ) , or in arthroscopic examination .
they may originate from both the cruciate ligaments and the menisci , from the popliteus tendon and alar folds , infrapatellar fat pad of hoffa , and subchondral bone cysts .
those arising from the hoffa s fat pad have been reported to present as palpable mass at anterior aspect of knee joint [ 2 - 5 ] ; however , to the best of our knowledge , none of them had subcutaneous communications across the retinaculum .
we report a case of intra - articular ganglion cyst of knee arising from the infrapatellar fat pad and protruding anterolaterally through retinacular rent into the subcutaneous plane .
a.a.m . , a 19-year - old young man , presented with a painless gradually increasing swelling at the anterior aspect of left knee for last 9 months .
there was no history of trauma , local injections , instability , locking episodes , clicking , snapping , or any constitutional symptoms .
clinical examination revealed a 2.5 cm x 2.5 cm round , soft , cystic , non - tender , irreducible swelling at anterolateral aspect of left knee 1.5 cm above the lateral joint line just lateral to the patellar tendon with discoloration of the overlying skin .
it was partially mobile , not fixed to the extensor mechanism or overlying skin , and was more prominent in knee extension ( fig .
1 ) . he could squat and sit cross - legged without any discomfort with a normal range of movement .
there was no effusion , no joint line tenderness , and no evidence of ligamentous laxity .
pre - operative clinical pictures showing the ganglion cyst at anterolateral aspect of left knee in various degrees of knee flexion .
mri scan revealed a multilobulated , cyst with septations within the anterior aspect of the knee joint , just inferolateral to the patella , with deep extension into the infrapatellar fat pad .
( a ) normal radiograph except increased soft tissue shadow , ( b ) parasagittal and axial mr images showing the ganglion cyst from infrapatellar fat pad extending subcutaneously across the retinaculum .
then we went for open excision of the cystic mass through lateral parapatellar approach ( incision included that of the anterolateral arthroscopic portal ) .
the cyst was found to be protruding just beneath the skin through a retinacular rent ( fig .
however , the entire mass was taken out , but we had to sacrifice the fat pad almost entirely .
post - operatively the patient underwent appropriate rehabilitation making an uneventful recovery and returned to his normal activities .
he was symptom - free in his last follow - up at 6 months post - operatively .
between the first description of an anterior cruciate ligament ( acl ) ganglion by caan in 1924 during a routine autopsy and the early 1990s , only a handful of sporadic cases were described in the literature .
the last 30 years have seen a huge increase in the number of these cases being reported owing to the widespread use of both mri and arthroscopy .
the prevalence of intra - articular cystic knee masses is 1.3% in mri and 0.6% in arthroscopy .
several theories have been suggested : ( a ) synovial tissue herniation , ( b ) mucinous degeneration of connective tissue after trauma , ( c ) synovial ectopia or displacement during embryogenesis , etc . .
the histological finding that ganglia are fluid - filled structures without any epithelial lining confirms that they are not true cysts , and thus favors the degenerative theory over others ; and , even though , ganglia may develop in the absence of trauma , it is postulated that repetitive microtrauma from joint and soft tissue motion may play an important role .
intra - articular ganglia of knee originates most commonly from the acl accounting for more than 50% cases ; whereas , the location at infrapatellar fat pad is far less common ( approximately 4% ) . however , only 10% of them are symptomatic with most being incidental finding on mri or arthroscopy .
the symptoms are usually non - specific , like knee pain , locking , clicking or popping sensation , decreased range of motion , etc . , and depend on the site and size of the cyst .
ganglia anterior to the acl tend to limit extension , whereas those posterior to the posterior cruciate ligament often limit knee flexion .
mri is the investigation of choice because it is the most sensitive , specific accurate , and noninvasive method for depicting such cystic masses , including their size and location , and to detect associated intra - articular pathologies . for intra - articular ganglion cyst in the infrapatellar fat pad
, fat - suppressed contrast - enhanced mri could be useful , because a thin , rim - enhancing feature of intra - articular ganglion cyst allows it to differentiate from synovial hemangioma and synovial sarcoma . among the various treatments available , arthroscopic resection and debridement are currently the preferred procedure ; open surgery may be necessary in particular cases only .
after diagnostic arthroscopy , we performed an open excision of the ganglion cyst since it was not clearly visible on arthroscopy ; moreover , we did not have any previous experience of arthroscopic resection of intra - articular ganglion cysts .
hence , in view of the high recurrence rate after incomplete removal of ganglion , we preferred open excision over arthroscopic resection . although recurrence is rare after arthroscopic or open surgical treatment of ganglion cyst of knee , the fact that it does occur in other areas even after excision , this patient should be followed up on regular basis .
current literature suggests arthroscopic resection and debridement as the gold standard treatment of ganglion cyst of the knee .
however , a subcutaneous extension may lead to incomplete arthroscopic resection : leaving behind the residual tissue which may cause recurrence .
therefore , proper pre - operative evaluation of mr images of these cases is very important .
they are usually encountered as incidental findings in mri , or in arthroscopy . arthroscopic resection and debridement
is regarded as the gold standard treatment in ganglion cyst of the knee . however , very rarely , these masses may extend subcutaneously across the retinaculum .
this may lead to incomplete arthroscopic resection : leaving behind the residual tissue which may cause recurrences .
therefore , proper pre - operative evaluation of mr images of these cases is very important .

 introduction : intra - articular ganglion cysts of the knee joint are rare occurrences .
 they are usually encountered as incidental findings in magnetic resonance imaging ( mri ) , or in arthroscopy .
 they may originate from both the cruciate ligaments and the menisci , from the popliteus tendon and alar folds , infrapatellar fat pad of hoffa , and subchondral bone cysts .
 those arising from the hoffa s fat pad , usually present as palpable mass at anterior aspect of the knee joint .
 we report a case of intraarticular ganglion cyst of knee arising from the infrapatellar fat pad and protruding anterolaterally through retinacular rent into the subcutaneous plane.case report : a 19-year - old young man , presented with a painless gradually increasing swelling at the anterior aspect of left knee of 9 months duration .
 mri scan revealed a multilobulated , cyst with septations within the anterior aspect of the knee joint , just inferolateral to the patella , with deep extension into the infrapatellar fat pad , and superficial extension into the subcutaneous space across the retinaculum .
 after diagnostic arthroscopy , we performed an open excision of the cystic mass and confirmed the retinacular rent pre-operatively.conclusion:arthroscopic resection and debridement is the gold standard treatment in ganglion cyst of the knee .
 however , a subcutaneous extension may lead to incomplete arthroscopic resection : leaving behind the residual tissue which may cause recurrence .
 therefore , proper pre - operative evaluation of mr images of these cases is very important .


pancreatitis is a major well - known complication of endoscopic retrograde cholangiopancreatography ( ercp ) with reported incidence ranging from 1% to 10% in various series [ 1 - 3 ] .
but the most accepted theory is mechanical trauma to papilla or pancreatic sphincter causing transient obstruction to outflow of pancreatic juice .
another theory suggests the increased hydrostatic pressure in pancreatic duct caused by injection of contrast or saline cause injury to parenchyma .
regardless of mechanism , the cascade of events is initiated resulting in activation of proteolytic enzymes causing autodigestion of pancreas and impaired acinar secretion .
this results in activation of inflammatory cascade causing both local inflammation and systemic effects [ 5 , 6 ] .
non - steroidal anti - inflammatory drugs ( nsaids ) are potent inhibitor of phospholipase a2 which is thought to play a critical role in early inflammatory cascade .
rectal diclofenac is a cheap , widely available agent with easy method of administration and favorable side effect profile makes it an attractive option .
there are limited data on efficacy of nsaids in prevention of post - ercp pancreatitis .
rectal diclofenac has been evaluated in few trials earlier but most trials included low - risk patients and sample size of these trials was very small . till date , sparse indian data are available which evaluated rectal diclofenac in prevention of post - ercp pancreatitis .
we conducted a prospective , single - center , open - labeled , randomized placebo - controlled trial evaluating role of rectal diclofenac in prevention of post - ercp pancreatitis in high - risk patients and whether it has any implications on severity of post - ercp pancreatitis .
this study was performed at a tertiary care center between august 2011 and june 2014 .
inclusion criteria involved only those patients with high risk of developing post - ercp pancreatitis .
patients were considered having high risk of development of post - ercp pancreatitis if they had one or more major risk factors : suspected sphincter of oddi dysfunction ( sod ) , prior history of post - ercp pancreatitis , difficult or failed cannulation ( more than five attempts ) , repeated pancreatic cannulation , pancreatic duct injection with acinarization , pancreatic sphincterotomy , precut sphincterotomy , biliary sphincterotomy for suspected sod , and ampullectomy ; or if they had two or more minor risk factors for development of post - ercp pancreatitis : female gender , young age , history of recurrent acute pancreatitis , normal serum bilirubin , lack of choledocholithiasis , pancreatic brush cytology , and balloon dilatation of intact biliary sphincter .
those patients not fitting the high - risk criteria , acute pancreatitis at the time of ercp , contraindications to the use of nsaids ( active peptic ulcer disease or s. creatinine > 1.4 mg / dl ) , and who had ingested nsaids in last 1 week were excluded from the study .
one hundred twenty - six patients were excluded from the study depending on the exclusion criteria .
one group ( n = 200 ) received rectal diclofenac suppository ( containing 100 mg of diclofenac ) immediately prior to or during the procedure . other group ( n = 200 ) received glycerine suppositories as placebos .
injection hyoscine was given for control of bowel motility . during the procedure , an assistant recorded the details of the procedure like timing of procedure , number of pancreatic duct cannulation and injection , difficulty in cannulation , and whether precut , pancreatic sphincterotomy , and balloon sphincteroplasty were done .
patients in rectal diclofenac or placebo group received rectal suppository immediately prior to or during the procedure .
pancreatic duct stents were placed in those patients in which pancreatic cannulation occurred more than two times or pancreatic injection with contrast or saline during the procedure .
patients were subjected to testing of serum amylase at 2 and 32 h post - procedure .
those patients who had no abdominal pain , vomiting , back pain and 2 h serum amylase levels less than two times upper limit of normal were started on oral liquids 3 - 4 h after ercp .
post - ercp pancreatitis was defined as rise in serum amylase more than three times upper limit of normal 24 h after ercp with associated clinical feature of severe abdominal pain requiring persistent hospitalization .
primary endpoint of the study was to detect number of patients developing post - ercp pancreatitis in both groups .
patients were subjected to routine biochemical investigations , imaging modalities like ultrasound abdomen and contrast - enhanced computed tomography to detect complications of pancreatitis .
the severity of pancreatitis was graded as mild , moderate and severe according to days of hospitalization required and complications of pancreatitis .
mild post - ercp pancreatitis was defined as requiring an unplanned admission or prolongation of hospitalization by 2 - 3 days .
moderate post - ercp pancreatitis was defined as requiring hospitalization of 4 - 10 days and severe post - ercp pancreatitis was defined as requiring hospitalization of greater than 10 days or requiring intensive care or intervention for local complications of pancreatitis .
the secondary endpoint of the study was to assess the severity of post - ercp pancreatitis in both groups .
, we used fisher exact test to analyze the difference in proportion of patients with post - ercp pancreatitis in rectal diclofenac and placebo groups with p value < 0.05 indicating significant difference . patients demographic and clinical factors were compared using fisher exact test or x test as appropriate .
for the analysis of primary endpoint , we used fisher exact test to analyze the difference in proportion of patients with post - ercp pancreatitis in rectal diclofenac and placebo groups with p value < 0.05 indicating significant difference .
patients demographic and clinical factors were compared using fisher exact test or x test as appropriate .
a total of 400 patients entered the study ; 200 patients received rectal diclofenac , while 200 patients received glycerine suppository ( control group ) .
there were 128 ( 64% ) female patients in rectal diclofenac group while 123 ( 61.5% ) in placebo group .
the mean age in rectal diclofenac group was 45.44 years while in placebo group was 47.86 years .
the patients in both groups were well matched for the indication of ercp as depicted in table 1 .
we compared various risk factors prior to or during the procedure which might increase the risk of post - ercp pancreatitis like pancreatic cannulation , precut sphincterotomy , suspected sod , pancreatic sphincterotomy , pancreatic duct injection , balloon sphincteroplasty in patients with suspected sod , and difficulty of failed cannulation in both groups .
the baseline characteristics of the patients in both groups were identical as depicted in table 2 .
a total of 23 patients , 12 in placebo group and 11 patients in rectal diclofenac group , received pancreatic stents due to recurrent pancreatic duct cannulation or pancreatic duct injection with acinarization .
twenty - nine out of 400 ( 7.2% ) patients developed post - ercp pancreatitis .
six out of 200 ( 3% ) patients in rectal diclofenac group developed post - ercp pancreatitis compared to 23 out of 200 ( 11.5% ) patients in placebo group ( fig .
the difference was statistically significant with p value < 0.05 . in a subgroup analysis ,
incidence of post - ercp pancreatitis in patients with suspected sod in rectal diclofenac group was 6% ( 4/66 ) while in placebo group was 18.8% ( 13/69 ) . among patients who received pancreatic stent ,
only one patient in rectal diclofenac group ( 1/11 ) developed post - ercp pancreatitis compared to two patients in placebo group ( 2/12 ) ; however , the number of patients in which pancreatic stenting was performed was low in our study .
the secondary endpoint of the study was to assess the severity of post - ercp pancreatitis in both groups .
the severity of post - ercp pancreatitis in rectal diclofenac group was mild in all six patients ( 100% ) , while in placebo group , it was severe in four patients ( 4/23 , 17.3% ) , moderate in five patients ( 5/23 , 21.7% ) and mild in 14 patients ( 14/23 , 60.8% ) ( fig .
the difference in severity of pancreatitis in rectal diclofenac and placebo groups was statistically significant .
two out of four patients in placebo group who had severe post - ercp pancreatitis developed pancreatic pseudocyst , but were managed conservatively .
one out of four patients in placebo group with severe post - ercp pancreatitis developed right - sided pleural effusion requiring therapeutic pleural tapping .
one out of four patients in placebo group with severe post - ercp pancreatitis developed subacute intestinal obstruction .
two deaths occurred in the placebo group , both with severe post - ercp pancreatitis , one with right - sided pleural effusion and the other with subacute intestinal obstruction .
adverse events like bleeding while ercp in sphincteromized patients were noted in 16 patients , six in placebo group and eight patients in rectal diclofenac group but responded to adrenaline injection and coagulation .
rectal diclofenac suppository was well tolerated in all the patients with no adverse event noted with use of rectal diclofenac .
our study has shown that single dose administration of rectal diclofenac prior to or during the procedure has reduced the incidence of post - ercp pancreatitis .
, our study has shown that rectal diclofenac was also effective in this group of patients in reducing post - ercp pancreatitis .
rectal diclofenac is a cheap drug , easily available and with a favorable side effect profile .
pancreatic stents are of proven benefit in preventing post - ercp pancreatitis [ 8 , 9 ] but difficult to use in routine practice because of difficulty in pancreatic duct cannulation and requirement of operator expertise .
but most accepted theory is trauma of thermal injury to papilla causing transient obstruction to pancreatic secretion .
another accepted theory is hydrostatic pressure due to contrast or saline injection into pancreatic duct .
this injury initiates an inflammatory cascade leading to activation of proteolytic enzymes intraductally causing pancreatic autodigestion and impaired secretion .
diclofenac inhibits phospholipase a2 which is an important mediator of various reactions in this inflammatory cascade breaking this cycle [ 5 , 6 ] .
peak concentration of rectal diclofenac occurs between 30 and 90 min after insertion with complete bioavailability .
the elimination half life is 2 h. rectal diclofenac has been evaluated in different randomized clinical trials . in a study by murray et al ,
220 patients with high risk of post - ercp pancreatitis were randomized in two groups , rectal diclofenac vs. placebo . in these patients
there was significant reduction in incidence of post - ercp pancreatitis in rectal diclofenac group as compared to placebo which was similar to our study .
however , in this study , there was no significant difference in patients with sod in rectal diclofenac vs. placebo group .
our study demonstrated that there is significant reduction in incidence of post - ercp pancreatitis even in patients with suspected sod .
khoshbaten et al   evaluated the use of rectal diclofenac in patients with extrahepatic cholestasis undergoing ercp .
this study also reported significant reduction in incidence of post - ercp pancreatitis in rectal diclofenac group similar to our study .
however , this study has reported very high incidence of post - ercp pancreatitis ( 26% ) in the control group .
oral diclofenac has been evaluated for prevention of post - ercp pancreatitis by cheon et al , but was found to be of no benefit . though rectal diclofenac is such an attractive option in prevention of post - ercp pancreatitis , it is still underutilized .
there are very few trials evaluating its use in prevention of post - ercp pancreatitis .
this prospective single - center , open - labeled , randomized placebo - controlled trial has shown that use of single dose of rectal diclofenac immediately prior to or during the ercp in high - risk patients is effective in not only reducing the incidence but also severity of post - ercp pancreatitis .
the major limitation of this study was severity of pancreatitis was graded according to the consensus guideline depending on days of hospitalization and complications .
various scoring systems like ranson s score and apache ii score were not utilized . however , similar guidelines were followed in previous studies .
rectal diclofenac prior to or during ercp in high - risk patients reduces the incidence as well as severity of post - ercp pancreatitis compared to placebo .
rectal diclofenac prior to or during ercp in high - risk patients reduces the incidence as well as severity of post - ercp pancreatitis compared to placebo .

 backgroundthe aim was to study the role of rectal diclofenac in prevention of post - endoscopic retrograde cholangiopancreatography ( ercp ) pancreatitis and its impact on severity of post - ercp pancreatitis.methodswe conducted a single - center , prospective , open - labeled , randomized trial for evaluating the use of rectal diclofenac in prevention of post - ercp pancreatitis in high - risk patients .
 we assessed 526 patients coming for ercp for different indications .
 four hundred patients were eligible for the study .
 those not fitting the high - risk criteria and with acute pancreatitis were excluded .
 these patients were randomized in two groups : 200 patients received rectal diclofenac prior to or during the procedure , while 200 patients received placebos .
 serum amylase was measured at 2 and 36 hours .
 post - ercp pancreatitis was defined as serum amylase > 3 times upper limit of normal with associated severe abdominal pain .
 severity was graded according to days of hospitalization and complications.resultstwenty-nine out of 400 ( 7.2% ) patients developed post - ercp pancreatitis .
 six out of 200 ( 3% ) patients in rectal diclofenac group developed post - ercp pancreatitis compared to 23 out of 200 ( 11.5% ) patients in placebo group .
 the difference was statistically significant ( p = 0.001 ) .
 all patients ( six ) in rectal diclofenac group developed mild pancreatitis as compared to severe pancreatitis in four and moderate pancreatitis in five patients in the placebo group.conclusionrectal diclofenac prior to or during ercp in high - risk patients reduces the incidence as well as severity of post - ercp pancreatitis compared to placebo .


a 75-year - old male farmer presented to a primary care skin cancer practice in west australia with a 6-month history of an enlarging painless lesion on his left cheek with no history of any possible precursor lesion .
there was a past history of treatment of two separate squamous cell carcinomas in - situ , one on the forehead and the other on an ear , in the previous two years .
other comorbidities included asthma , coronary heart disease , chronic obstructive pulmonary disease and arthritis .
there was no history of nevus sebaceous and there was neither history nor clinical signs suggestive of cowden s syndrome .
examination showed a single small non - pigmented nodular lesion located on the left cheek in continuation with a small , pigmented macular lesion ( figure 1 ) .
dermatoscopy ( figure 2 ) revealed a raised pink lesion , 3.5 mm in diameter , with a radial arrangement of vessels peripherally , with centered blood vessels in the middle of the lesion , these vessels being centered in skin - colored clods .
no keratin structures ( keratin scale , white structureless areas or white circles ) were seen . at one edge of this lesion , in direct contact with it , was a heavily pigmented flat lesion , 1 mm in diameter with a pattern of pigmented lines radial , converging ( figure 2 ) .
the lesion was subjected to an excision biopsy with a 4 mm peripheral margin and submitted for dermatopathological evaluation .
dermatopathology ( figure 3 ) showed both the trichilemmoma and bcc ( basal cell carcinoma ) components .
the trichilemmoma ( figure 3 a1 and a2 ) was a well - circumscribed , sharply demarcated lesion with surface papillomatosis , horn cysts and a degree of central desmoplasia . under high power an eosinophilic mantle of thickened basement membrane , mimicking the outer root sheath of the hair follicle infundibulum , was seen .
peripheral palisading was evident adjacent to the basement membrane and extending from that there were clear cells which were banal cytologically , lacked mitosis or individual cell necrosis ( apoptosis ) and contained an abundant amount of glycogen within their cytoplasm .
the bcc component ( figure 3 b1 and b2 ) showed superficial bcc at the dermo - epidermal junction . in the high power view melanin pigment
trichilemmoma is a benign tumor derived from the external sheath cells of pilosebaceous units   and desmoplastic trichilemmoma is a rare variant , which can present clinically with features suggesting invasive malignancy .
there has been controversy as to whether trichilemmomas are actually aged warts , this belief being proposed by well - known dermatopathologist bernie ackerman   but vigorously opposed by others including marty brownstein .
basal cell carcinoma is a malignant tumor , of trichoblast differentiation but uncertain origin , although it is probably of follicular derivation , predilection for non - glabrous skin being consistent with this .
trichilemmoma has previously been reported in association with bcc in the context of lesions arising in a preexisting nevus sebaceous .
in addition , three cases of desmoplastic trichilemmoma arising in association with bcc without a preexisting nevus sebaceous have been reported .
the dermatoscopy of four trichilemmomas has been reported   with images being presented for three of them . in the first case
keratin masses ; perivascular whitish halos  . the other three were reported together , with the first two described as having a hyperkeratotic central area with peripheral erythematous radial lines , the third having a  peripheral radiated red area .  all three were then presented as depicting what the authors called a  red iris like structure .
examination of the photographs published in fact displayed a non - pigmented lesion in each case with a radial arrangement of vessels peripherally and structureless white centrally with some centred vessels . in the case
we report , the clinician interpreted the lesion as a pigmented lesion and assessed it using the chaos and clues decision - algorithm .
the lesion was regarded as chaotic ( asymmetrical ) with the clues of an eccentric structureless ( pink ) area as well as lines radial segmental , which lead to a clear decision to do an excision biopsy .
the pathologist , as is often the case with esoteric lesions , was able to deliver the answer to which particular type of malignancy this was .
the dermatoscopic features of the trichilemmoma presented here are consistent with those published previously , with a radial pattern of vessels peripherally and centred vessels centrally .
association with a bcc is a previously reported , unusual variation , consistent with both lesions having hair - follicle derivation .
this case demonstrates the utility of using a decision algorithm in esoteric cases with the final diagnosis to be delivered by the gold standard of dermatopathology .

 a case of trichilemmoma in continuity with a pigmented basal cell carcinoma is presented with dermatoscopy and dermatopathology .
 the distinction between the two lesions was evident dermatoscopically and was confirmed dermatopathologically . while trichilemmoma has been reported in association with basal cell carcinoma and dermatoscopy images of four previous cases of trichilemmoma have been published , no previous dermatoscopy image has been published of trichilemmoma associated with basal cell carcinoma .


today , the treatment of choice is surgical excision of the tongue , but before 1900 , surgery was often temida1 . only in 1673 niels
the size and shape of the teeth are directly influenced by the size of tongue3 .
the shape of the teeth is determined by forces employed on the teeth , especially the muscles of the tongue , lips and cheek . due to the effects caused by the aesthetic and functional macroglossia
the macroglossia is classified as true when there is excessive enlargement of the language and a relative when there is an imbalance between the size of the tongue and oral cavity , resulting in insufficient space for organ4 .
the goal is to establish technical bases associated with partial glossectomy orthodontic treatment of dentofacial deformity in patients with macroglossia .
three patients underwent orthognathic surgery associated with partial glossectomy from 1995 to 1999 , a multidisciplinary team - doctor and dentist .
all patients had macroglossia relative and underwent clinical assessment taking into account the respiratory function , swallowing and speech deficit , as well as changes in dental occlusion and was also performed radiological evaluation .
the main problem was manifested by the presence of steep lower dent alveolar , destabilizing the use of dentures causing joint dysfunction with severe pain .
she underwent a single surgical intervention in the partial glossectomy and orthognathic surgery for targeting sub apical segment dent alveolar anterior inferior .
the main problem of the second patient was the anterior open bite accompanied by difficulty in breathing and articulation of words .
after treatment for orthodontic tooth alignment leveling , underwent surgery for a single suspension by corticotomy posterior maxillary le fort i type , reduction of mandibullary prognathism by sagittal technical branches , targeting sub apical posterior - inferior right and partial glossectomy .
the third patient had mandibullary prognathism and , during orthodontic treatment in preparation for orthognathic surgery , the surgery was anticipated , since the interposition of the tongue between the back teeth did not allow the evolution of orthodontic treatment .
he underwent a partial glossectomy to reduce the transverse diameter of the tongue and mandibullary prognathism by sagittal technical branches .
we used rigid skeletal fixation with titanium plates and screws so that patients could stay without intermaxillary block in the immediate postoperative period . to control tongue edema ,
the technique used consist of segmental resection along the median raphe of the tongue and suture by planes - figure 1 . as a routine
the symptoms regressed completely and all skeletal segments remained stable .
 demarcation and resection of the lingual and final appearance .
the classification of macroglossia is not yet consensus in the literature . according to shafer ( 1968)5 , or
primary congenital macroglossia is due to the excessive development of the musculature , which may or may not be associated with generalized muscular hypertrophy or unilateral hypertrophy . since the secondary macroglossia may occur as a result of a tumor in the tongue , as a diffuse hemangioma or lymphangioma , neurofibromatosis , and occasionally blocking efferent vessels in cases of malignant neoplasm of the tongue .
wolford et al . ( 1996)6 refer to as macroglossia on pseudomacroglossia , separating it from the true macroglossia .
( 1980)7 macroglossia consider the functional as a third classification , occurring when the language does not fit into the oral cavity after a surgical procedure .
the true when there are histological abnormalities associated with the increase of the tongue , such as vascular malformation , stretching and tumors .
relative macroglossia includes cases of apparent increase in volume without an explanation of the language exam , as in down syndrome .
the decision to refer the patient to partial glossectomy should be based on the volume of the language , mobility , position , function , symptoms , speech intelligibility , skeletal anterior open bite , interference in orthodontic treatment , drooling , swallowing and tongue recurrent trauma9 .
the language has increased in volume expansive effect on the lower dental arch , being blamed as the cause and maintenance of open bite , bimaxillary protrusion or diastemas10 .
being interposed between the arches , is an important etiologic factor for malocclusion listed ( figures 2 and 3 ) .

a partial glossectomy performed simultaneously with mandibullary osteotomy for treatment of patients with mandibullary prognathism and anterior open bite is advantageous to prevent recidivas11 .
the tongue can cause deformity increased dental - muscle - skeletal , instability in orthodontic treatment and orthognathic surgery , masticatory disability , communication problems and respiratory6 .
there are several clinical and radiographic findings , but not all features are always present and their existence is not necessarily path gnomonic for the diagnosis of macroglossia .
should be included the clinical , radiographic and functional for the interference with speech , mastication , airway and stability of orthodontic treatment and orthognathic surgery .
there are basically three choices in the surgical sequence : ( i ) stage 1 : partial glossectomy , stage 2 : orthognathic surgery ( ii ) stage 1 : orthognathic surgery , stage 2 : partial glossectomy and ( iii ) partial glossectomy and orthognathic surgery in a single stage surgery .

 summary
 introduction :  macroglossia is a condition which influences the size and shape of the teeth employed due to the forces on teeth .
 objective :  to establish bases for the indication of partial glossectomy associated with orthodontic treatment and surgical dento - facial deformity in patients without tumors and down syndrome as a cause of macroglossia .

 case reports :  three patients underwent orthognathic surgery associated with partial glossectomy under general anesthesia .
 all patients had macroglossia relative and underwent clinical assessment taking into account the respiratory function , swallowing and speech deficits and radiological evaluation .
 the technique used consist of segmental resection along the median raphe of the tongue and suture by planes .
 we used rigid skeletal fixation with titanium plates and screws so that patients could stay without intermaxillary block in the immediate postoperative period .
 were followed over five years .
 the symptoms regressed completely and all skeletal segments remained stable .

 discussion :  the decision to refer the patient to partial glossectomy should be based on the volume of the language , mobility , position , function , symptoms , speech intelligibility , skeletal anterior open bite , interference in orthodontic treatment , drooling , swallowing and tongue trauma applicant .


If you want to set a romantic atmosphere you might light a candle where?

A romantic atmosphere can be set in bedroom
Bedroom is a place where one sleeps
Candles can be lit in a bedroom

Dimly lit room is not a place where one sleeps
A romantic atmosphere cannot be set in a synagogue
Birthday cake is not a place where one sleeps
Candles cannot be lit in roses

A romantic atmosphere can be set in bedroom and not in a synagogue. Bedroom is a place where one sleeps unlike a dimly lit room or a birthday cake. Candles can be lit in a bedroom and not in roses.


What might the result of unwanted flirting be?

Attraction cannot be result of unwanted flirting.
Unwanted flirting doesn't always creates problems.
The gallows is not something that can be result of unwanted flirting.
Curiosity is not something that can be result of unwanted flirting.

Person can be slapped if he does unwanted flirting to someone. Attraction cannot be result of unwanted flirting. Unwanted flirting doesn't always creates problems.
            The gallows or curiosity is not something that can be result of unwanted flirting.


He had a lot on his plate opening business, this cause a lot of what?

Stress is an outcome of lot of things on plate
With new bsuiness, people have various issues that lead to stress

Headaches are caused when there is stress
making money is not a cause of being lot on plate
Success is not caused of being lot on plate
Failure is result of business not working

When someone has lot on plate, they often feel stressed. A new business demands lot o fwork that can cause stress. All the other options are incorrect as they are not a result of being a lot on plate in a business.


Where would you borrow coffee if you do not have any?

If you don't have coffee powder / beans and don't want to buy it, you would borrow from friend's house
Friend will not sell you but will give you out of love

One can't borrow coffee from meeting
convenience stores sell coffee bean / powder
supermarket sells coffee bean / powder
fast food delivery sells ready mix coffee to drink

If you are finished with stock of coffee beans / powder and don't want to buy it, you can borrow it from friend's home because you can't borrow from meeting and other options are selling the coffee


This was the high jumper's second and final attempt, he was doing what to break a record?

Trying means to make an effort to achieve something.
Making an effort is to attempt.

Leaving is to go away.
Leaving won't break records.
Failing is to lose.
Failing won't break records.
Finishing is to complete.
One might need to keep trying to finish.
Giving up is to accept defeat.
Giving up won't break records.

Trying means to make an effort to do something by attempting. The high jumper was trying to break a record in his second and final attempt. One might need to keep trying to finish and doing the other options won't break records.


What does the government have control over?

A city is a large town.
A government controls large towns.

A government cannot control trouble.
A government might not be able to control country.
A government might not be able to control army.
One cannot have control over control.
A government cannot control control.

A city is a large town over which a government has control. One cannot have control over control and a government might not have control over others.


What is the likelihood of drowning when getting wet?

One could drown in too much water.
Getting wet might mean too much water.

Shrinking means getting smaller.
Shrinking is not a likelihood.
Cold is a common viral infection.
Feeling cold is not a likelihood.
Become cold is not a likelihood.
Cool off is not a likelihood.

One could drown in too much water. So the likelihood of drowning when getting wet is they could. All other options are not likelihood.


What does the government sometimes have too much of?

Control means the power to influence or direct people's behaviour or the course of events.
Governments govern it's people.
Governing means looking after and controlling.

Canada is a country.
A government cannot have Canada.
Government might not have too much of trouble.
A city is a large town.
Government might not have too much of city.
Government might not have too much of water.

Control means the power to influence or direct people's behaviour or the course of events. Governments govern it's people so the government sometimes have too much of control. Government might not have too much of trouble and all the other options cannot be had by government.


What happens after making friends with someone of the opposite sex?

People generally fall in love with opposite se

Smile is an expression when somebody gets pleased.
People talk to everybody every day.
Shaking hands is a common gesture when you meet or greet somebody.
One does not punch in the face of someone after becoming friends.

When one talk with someone of opposite sex, they tend to fall in love with them. All other options are irrelevant as they are not restricted to something with opposite sex.


-49944*o*v - 12*o + 48*v + 6
What is the second derivative of 18499*y**2 + 42400*y wrt y?

36998
Differentiate -2015444*b**4 + 1925507 with respect to b.
-8061776*b**3
Find the first derivative of 34318*m**2 - 12931 wrt m.
68636*m
What is the second derivative of -32*g**4*y - 4*g**3*y**2 - 41*g*y**2 + 18*g - y wrt g?

44100
What is the derivative of -5172803*n**4 - 710131 wrt n?

92*n**2 + n + 267
What is the first derivative of 4938542*d**3 + 1505332 wrt d?

1032*n + 1
What is the second derivative of 887577*t**2 + 934*t - 219 wrt t?

1775154
Differentiate 47*y**2 - 8878*y + 1211913 with respect to y.
94*y - 8878
What is the second derivative of 12689*m**4 + 79122*m?

355292*f
Differentiate 47*v**2 - 20*v + 5295 with respect to v.
94*v - 20
Find the second derivative of -571*k**3 - 10*k**2 + 20168*k.

-3426*k - 20
What is the derivative of 2*f*j*z + 6895*f*j - 24*f*z - 14*j*z + j - 2*z wrt z?

-4075935
What is the third derivative of 1134*v**4 - 2*v**2 + 700*v - 1 wrt v?

-120*n**3*v + 4465392*v
Differentiate 64830*f - 39971 with respect to f.
64830
What is the second derivative of -1810889*j**2 + 38171*j + 4?

117384*s - 44
What is the second derivative of -1489*b**5 + 15*b**4 + 73783*b wrt b?

8444940*m**2
What is the first derivative of 3200852*g**4 + 1951912 wrt g?

80*b - 205
What is the first derivative of 13444*r**2 + 157589 wrt r?

26888*r
What is the first derivative of -7*b**3*h + 9


Eye movements to audiovisual scenes reveal expectations of a just world.

When confronted with bad things happening to good people, observers often engage reactive strategies, such as victim derogation, to maintain a belief in a just world.

Although such reasoning is usually made retrospectively, we investigated the extent to which knowledge of another person's good or bad behavior can also bias people's online expectations for subsequent good or bad outcomes.

Using a fully crossed design, participants listened to auditory scenarios that varied in terms of whether the characters engaged in morally good or bad behavior while their eye movements were tracked around concurrent visual scenes depicting good and bad outcomes.

We found that the good (bad) behavior of the characters influenced gaze preferences for good (bad) outcomes just prior to the actual outcomes being revealed.

These findings suggest that beliefs about a person's moral worth encourage observers to foresee a preferred deserved outcome as the event unfolds.

We include evidence to show that this effect cannot be explained in terms of affective priming or matching strategies.


To all,
Thickos north and south attended VARAC's race at Mosport thise weekend.

If
you've never driven Mosport, you must plan to attend this event next year...
great track, great people... and great fun.

While qualifying Saturday, the Red Rat Bastard was really "honkin"...
posting a great qualifying time.

Turn 8 is a wide open right handed sweeper
after a long straight...someof the fastest parts of the course.

9 is a fast
left hander... followed by the right hander 10 that brings you back to the
main straight.

Moving right to prepare for 9... I felt the steering go.

The
car veered strongly right... heading toward the tire wall at a high rate of
speed.

I had time in my mind to think the following... "This is really gonna
hurt"...and "I'm glad that this wasn't driver's error".

I slammed into the
wall at somewhere near or over 90 mph, luckily hitting it at a 45 degree
angle.

I found myself rolling over after the initial impact... 2 1/2 times
ultimately... ending up upside down on the roll bar.

After the rolling
sensation ceased... it was amazingly quiet... dark, and confined.

I made
sure all switches were off, and was hoping that my competitors behind me
were paying attention to the yellow flags.

It would have pissed me off to
survive that part of the crash and then be punted while hanging upside down.

My helmet was pressing against the ground... my roll bar apparently having
dug into the ground.

After what seemed like 30 seconds (it may not have been
that long... or it could have been longer... who knows...) I decided to take
stock of my body parts.

Nothing hurt seriously, and fingers and toes seemed
to function normally... and since my weight already was resting on my head,
I decided to try to extricate myself... as I knew I didn't like "hangin"
around. (

Corner workers and EMT's caution all you racers out there... citing
racers who manage to survive a crash, only to injure themselves by releasing
their belts and falling on their heads...)
I crawled out from under the wreackage just as the EMT's came upon the
scene.

They had me sit down on the wall, while the corner workers dealt with
the upside down RRB, it's front wheel and spindle lying in the middle of the
track.

I gave thumbs up to my shocked competitors as they passed the scene
slowly.

I walked to the medical bulding, where I was checked out and
released.

The usual party at Thicko Village commenced a little earlier than
usual Saturday.

Inspection showed failure of the 2 bolts that hold the spindle to the
steering arm.

Once that failed, the wheel flopped down and ripped off from
the lower portion. (

I hear the sound of Sprite owners everywhere scurrying
off to inspect their front suspensions...).

The Red Rat Bastard's days are over... better to end this way rather than
rusting away in someone's back yard.

I'm thankful I had no serious injuries,
and no one else was hurt.

Thanks to the trackside personnel and medical
staff, the race organizers and fellow competitors that helped out or
expressed concern.

Today, Monday, 2 days after the incident, I have very
very sore ribs on the left side, a slightly stiff neck, and a bruise on my
right shoulder... remarkable really, when you consider I stuffed 40 year
old car.

Thanks to Geoffrey Healey for a great design, and thanks to Tom
Colby of Speedwell for a great roll bar.

So, hoist a glass for the Red Rad Bastard... and look out for the next
effort... "Frankensprite"...
WST
Flounder
Team Thicko


Q:

array_key_exists, array_search, in_array doesnt apply to multidimensional array?

ive got an array like this:
$display_related_tags[0][20] = 'text1';
$display_related_tags[1][21] = 'text2';
$display_related_tags[2][22] = 'text3';

i want to either check if value (text1) exists or if key (20) exists but the mentioned array functions just apply to one dimensional arrays.

what are my alternatives without having to use loops (it will be too heavy then)

A:

what are my alternatives without having to use loops (it will be too heavy then)

You don't have any other options that to loop (at some level) over the first dimension.

The only other way would be to restructure your data.


Q:

Base-64 Plugin in Nativescript

I am looking for a way to get my OAuth Token from the PayPal API.

I need to use the basic Authorization when passing my clientID:secret.

Sadly the Base-64 Module is not available for NativeScript and the NativeScript-OAuth-Plugin does not provide encrypting data.

What I am searching is a way or a workaround for the btoa-function (would be the easiest way) in JavaScript/Typescript.

Does someone know a way to do that or maybe a plugin that i can use?

A:

For android, you can do
android.util.

Base64.DEFAULT);

and add declare var android above your @Component in your ts file

A:

NativeScript actually provides a plugin for base-64 and utf-8 encoding.

How to use and where to find them is described here.