Dupuytren's disease may extend beyond the wrist crease in continuity

Debate continues about the origin of Dupuytren's disease, which is usually in the palm but is seen elsewhere as ectopic lesions. We describe a young patient with Dupuytren's disease extending proximal to the wrist crease in continuity with the palmar lesion. Our findings support the view that the condition starts within the palmar connective tissue, but there is no palmar aponeurosis in the forearm and the proximal extension probably started in the deep layer of the superficial fascia.

DUPUYTREN’S DISEASE MAY EXTEND BEYOND THE WRIST CREASE IN CONTINUITY

Debate continues about the origin of Dupuytren’s disease, which is usually in the palm but is seen elsewhere as ectopic lesions. We describe a young patient with Dupuytren’s disease extending proximal to the wrist crease in continuity with the palmar lesion.

Our findings support the view that the condition starts within the palmar connective tissue, but there is no palmar aponeurosis in the forearm and the proximal extension probably started in the deep layer of the superficial fascia.

Benign necrotizing osteitis of the external auditory meatus

Benign necrotizing osteitis of the external auditory meatus is a rare condition which occurs in non-diabetic healthy people. The aetiology of the necrotic process with the formation of sequestrum in the bony external meatus is unknown. It is important to differentiate this benign process from malignant otitis externa and radionecrosis of the temporal bone as the management of these conditions differs. We present two cases, one managed surgically and the other medically, and review the literature. Immediate surgical excision of the sequestrum is advocated instead of long-term medical therapy and waiting for it to separate spontaneously.

Isoflurane hepatotoxicity: a case report and review of the literature

Isoflurane, hailed as the anesthetic of the 1980s, is less hepatotoxic than its predecessors, halothane and enflurane. Since its release by the Food and Drug Administration in 1979, controversy has existed about the extent to which isoflurane is capable of producing hepatotoxic effects. In this report, we provide direct evidence that isoflurane can induce liver injury and should therefore be considered as a potential cause of serum transaminase elevations in any patient who is exposed to this anesthetic.

An unusual foreign body migrating from pharynx to mediastinum

A case of a swallowed foreign body migrating from the pharynx into the soft tissues of the neck is presented, whose management was complicated by its undetected migration to the superior mediastinum occurring between radiological localization in the neck three days prior to exploration and its attempted removal. A median sternotomy was then required to retrieve the object. Radiological guidance with regard to the localization of a foreign body in the neck can only be relied on when performed immediately prior to surgical removal.

Field trial of billings ovulation method of natural family planning

There are couples with unmet family planning needs and couples who do not use any modern method, yet they desire to space or avoid pregnancies. Many of them look for safe and effective options like the natural family planning methods. The Billings Ovulation Method based on single index cervical mucus parameter is one such option. The present multicentre trial conducted in India has shown an encouraging use-effectiveness of the method, indicating method failure as low as 1.5 +/- 0.3 and use-failure 15.9 +/- 0.8 per 100 users at 21 months. The method continuation rates have also been as high as 88.3/100 users at 6 months and 52.0/100 users at 21 months.

Zinc supplementation reduces the incidence of persistent diarrhea and dysentery among low socioeconomic children in India

Persistent diarrhea (PD) and dysentery (DD) account for most diarrhea-associated deaths among children in developing countries. Zinc deficiency can cause stunting and impaired immune function, both of which are risk factors for these diarrheal illnesses. We investigated the effect of zinc supplementation on the incidence of PD and DD in a community-based, double-blind randomized trial in children 6-35 mo of age. Increase over baseline in plasma zinc concentrations in the supplemented group compared with a control group (3.61 vs. 0.009 mumol.L-1), indicated successful supplementation. The overall reductions in the zinc supplemented group of 21% in the incidence of PD (95% CI -6 to 42%) and 14% in the incidence of dysentery (95% CI -15 to 36%) were not significant. There was a significant interaction of treatment effect with baseline plasma zinc concentration and age for PD and with gender for DD. In the zinc-supplemented group compared with the control group, the incidence of PD was reduced by 73% (P < 0.05; 95% CI 34 to 91%) in children with a baseline zinc < 7.65 mumol.L-1 and by 49% (P < 0.05; 95%CI 24 to 66%) in children > 11 mo of age. Zinc supplementation resulted in a 38% (P < 0.05 95%CI 8 to 59%) reduction in the incidence of DD in boys. There was no effect on PD among children 6-11 mo old or on DD in girls. In conclusion, zinc supplementation had a significant impact on the incidence of persistent diarrhea in children > 1 y old and in children with low plasma zinc, as well as on dysentery in boys. These findings may have important implications for reducing diarrhea-related morbidity and mortality.

Effects of insulin on body composition in patients with insulin-dependent and non-insulin-dependent diabetes

Insulin is used to control blood glucose but may have an adverse effect on the amount and distribution of fat mass and other cardiovascular risk factors. To test this hypothesis the effect of insulin therapy on blood glucose, body composition, and lipid levels was measured during 6 months in 9 patients with newly diagnosed insulin-dependent (Type 1) diabetes mellitus (IDDM) and 15 patients with non-insulin dependent (Type 2) diabetes (NIDDM) and secondary failure of therapy with oral hypoglycaemic agents. Both groups received similar daily doses of insulin (approximately 0.6 units kg-1 day-1). Glycaemic control improved during 6 months treatment in both groups, although the reduction in HbA1c was greater in IDDM (5.2 +/- 0.7%) than in NIDDM (2.0 +/- 0.4%, p < 0.001). All parameters of the lipid profile improved in IDDM but not in NIDDM. Body weight, lean mass, and fat mass, measured by dual energy x-ray absorptiometry, increased at 1 month in IDDM but not in NIDDM. By 6 months, body weight had increased more in IDDM than NIDDM (9.1 +/- 1.2 vs 3.77 +/- 0.5 kg, p < 0.01). The increase in weight was predominantly lean mass in IDDM (60.4 +/- 9.3%) and fat mass in NIDDM (59.9 +/- 8.4%). The increase in lean mass was greater in IDDM than NIDDM (5.6 +/- 1.1 vs 1.4 +/- 0.3 kg, p < 0.001). Fat mass increased by similar increments in IDDM and NIDDM (3.4 +/- 0.8 vs 2.4 +/- 0.5 kg, p = ns) and was predominantly an increase in trunk fat (IDDM: 2.3 +/- 0.6 kg, NIDDM: 2.0 +/- 0.4 kg, p = ns). The central/peripheral fat mass ratio prior to treatment was lower in IDDM than NIDDM (0.64 +/- 0.05 vs 1.09 +/- 0.09, p < 0.01) and then increased in IDDM by 0.32 +/- 0.15 (p = 0.07) and in NIDDM by 0.22 +/- 0.06 (p < 0.001). In conclusion, insulin therapy is associated with weight gain in both IDDM and NIDDM. In the former, weight gain reflects increases in lean mass whereas in NIDDM it reflects an increase in trunk fat mass. It remains to be determined whether this trend to central obesity partly offsets other benefits of insulin therapy in NIDDM.

Neural-network-based classification of Space Acceleration Measurement Systems (SAMS) data via supervised learning

This paper illustrates the applicability of neural networks in classifying events using Space Acceleration Measurement System (SAMS) data. Computer programs have been written in the MATLAB environment for the following purposes: automatic retrieval of SAMS data from NASA CDROM disks, computation of power spectral densities for SAMS data and construction of input patterns for the training of a multi-layer neural network (MNN). The MNN has been trained using the backpropagation learning algorithm and the SAMS data collected on the STS-50 Space Shuttle mission for three crew exercise events. It is found that the trained MNN is highly successful in classifying events. In addition, the performance of MNN is found to be better than that of the nearest neighbor classifier.

Zinc supplementation in young children with acute diarrhea in India

BACKGROUND

In developing countries the duration and severity of diarrheal illnesses are greatest among infants and young children with malnutrition and impaired immune status, both factors that may be associated with zinc deficiency. In children with severe zinc deficiency, diarrhea is common and responds quickly to zinc supplementation.

METHODS

To evaluate the effects of daily supplementation with 20 mg of elemental zinc on the duration and severity of acute diarrhea, we conducted a double-blind, randomized, controlled trial involving 937 children, 6 to 35 months of age, in New Delhi, India. All the children also received oral rehydration therapy and vitamin supplements.

RESULTS

Among the children who received zinc supplementation, there was a 23 percent reduction (95 percent confidence interval, 12 percent to 32 percent) in the risk of continued diarrhea. Estimates of the likelihood of recovery according to the day of zinc supplementation revealed a reduction of 7 percent (95 percent confidence interval, -9 percent to +22 percent) in the risk of continued diarrhea during days 1 through 3 and a reduction of 38 percent (95 percent confidence interval, 27 percent to 48 percent) after day 3. When zinc supplementation was initiated within three days of the onset of diarrhea, there was a 39 percent reduction (95 percent confidence interval, 7 percent to 61 percent) in the proportion of episodes lasting more than seven days. In the zinc-supplementation group there was a decrease of 39 percent (95 percent confidence interval, 6 percent to 70 percent) in the mean number of watery stools per day (P = 0.02) and a decrease of 21 percent (95 percent confidence interval, 10 percent to 31 percent) in the number of days with watery diarrhea. The reductions in the duration and severity of diarrhea were greater in children with stunted growth than in those with normal growth.

CONCLUSION

For infants and young children with acute diarrhea, zinc supplementation results in clinically important reductions in the duration and severity of diarrhea.

A study on estimation of age from pubic symphysis

The present study has been carried on 82 pairs of pubic symphysis collected from fresh male cadavers. Various features were noted on the symphyseal surface--ridges and furrows, dorsal margin, ventral bevelling, lower extremity, ossific nodule, upper extremity, ventral rampart, dorsal plateau and symphyseal rim. Varying combination of these features were used as criteria for age estimation of the subjects.

Dopamine D3-preferring ligands act at synthesis modulating autoreceptors

Several compounds exist that demonstrate a binding preference for cloned dopamine D3 receptors vs. D2 receptors, including (+/-)7-OH DPAT, (+)-UH232 and (+)-AJ76. Inasmuch as recent evidence suggests that the dopamine D3 receptor may function as a dopamine autoreceptor, we have investigated the ability of these D3-preferring ligands to act at synthesis modulating dopamine autoreceptors using the gamma-butyro-lactone model in vivo to isolate the presynaptic effects of (+/-)7-OH DPAT, (+)-UH232 and (+)-AJ76. Further, given the discrete anatomical distribution of the D3 receptor, the striatum, n. Accumbens, and olfactory tubercles were examined for comparative analyses. (+/-)7-OH DPAT displayed agonist characteristics at synthesis modulating dopamine autoreceptors with a greater potency in the olfactory tubercle vs. either the striatum or the nucleus accumbens (ED-50 values were 31.8, 38.1 and 10.2 micrograms/kg for the striatum, nucleus accumbens and olfactory tubercles, respectively). Further, (+)-UH232 and (+)-AJ76 attenuated the effects of (+/-)7-OH DPAT (60 micrograms/kg s.c.) in all three regions examined. However, the effects of (+/-)7-OH DPAT were antagonized to a lesser extent in the olfactory tubercles than in either the striatum or the nucleus accumbens. Given the relative abundance of D3 receptors in the olfactory tubercles, the data are consistent with the notion that (+/-)7-OH DPAT may exert its autoreceptor effects preferentially through dopamine D3 receptors.

Purification, characterization and antitumor activity of L-asparaginase isolated from Pseudomonas stutzeri MB-405

An L-asparaginase produced by Pseudomonas stutzeri MB-405 was isolated and characterized. After initial ammonium sulfate fractionation, the enzyme was purified by consecutive column chromatography on Sephadex G-100, Ca-hydroxylapatite, and DEAE-Sephadex A-50. The 665.5-fold purified enzyme thus obtained has the specific activity of 732.3 units mg protein-1 with an overall recovery of 27.2%. The apparent M(r) of the enzyme under nondenaturing and denaturing conditions was 34 kDa and 33 kDa respectively, and the isoelectric point was 6.38 +/- 0.02. It displayed optimum activity at pH 9.0 and 37 degrees C. The enzyme was very specific for L-asparagine and did not hydrolyze L-glutaminate. The Km of the L-asparaginase was found to be 1.45 x 10(-4) M towards L-asparagine and was competitively inhibited by 5-diazo-4-oxo-L- norvaline (DONV) with a Ki of 0.03 mM. Metal ions such as Mn2+, Zn2+, Hg2+, Fe3+, Ni2+, and Cd2+ potentially inhibited the enzyme activity. The activity was enhanced in the presence of thiol-protecting reagents such as DTT, 2-ME, and glutathione (reduced), but inhibited by PCMB and iodoacetamide. The tumor inhibition study with Dalton's lymphoma tumor cells in vivo indicated that this enzyme possesses antitumor properties.

Death Acceptance: A two-Component Formulation and Scale

A formulation of death acceptance involving two components, confrontation and integration, is presented and discussed in the light of the literature on death attitudes. A proposed scale (Klug Death Acceptance Scale) to measure the two-component concept is also provided, including data on the scale's reliability and validity, along with some suggested norms. The contribution of this research is the clarification of the theoretical rationale for a multi-dimensional approach to death acceptance, an operationalization of the theory, and a proposed scale to measure it. Additional research on diverse populations, and a variety of measurement approaches, is needed to further establish the reliability and validity of the instrument.

Complementary effects of pravastatin and nicotinic acid in the treatment of combined hyperlipidaemia in diabetic and non-diabetic patients

BACKGROUND

Given that treatment with a single drug is frequently unsuccessful in patients with combined hyperlipidaemia, there is a rationale for the study of regimens using drugs that have complementary therapeutic profiles. We therefore set out to compare the efficacy of a combined pravastatin and nicotinic acid regimen with higher dose monotherapy using either drug in patients with non-insulin-dependent diabetes and in non-diabetic patients with combined hyperlipidaemia.

METHODS

Forty-four patients with total-cholesterol levels of 6.5 mmol/l or higher and triglyceride levels of 2.5 mmol/l or above were randomly assigned to receive either pravastatin alone (40mg/day) or nicotinic acid alone (1500mg/day) for 12 weeks. At the end of this period, the participants received a combination of pravastatin (20mg/day) and nicotinic acid (1000mg/day) for a further 12 weeks. The lipid parameters measured included levels of total cholesterol, triglycerides, low-density-lipoprotein (LDL) cholesterol and high-density-lipoprotein (HDL) cholesterol.

RESULTS

Thirty-three patients (22 without and 11 with diabetes) completed the protocol. Monotherapy with pravastatin was more effective than that with nicotinic acid in reducing levels of total cholesterol (-24.9 versus -9.8%, P<0.001) and LDL cholesterol (-32.1 versus -16.9%, P < 0.01), similar in reducing levels of triglyceride (-28.0 versus -31.8%, NS) and tended to be less effective in elevating levels of HDL cholesterol (+16.4 versus +30.8%, P = 0.06). Combination therapy was more effective than pravastatin monotherapy in reducing levels of triglyceride (-39.3 versus -28.0%, P < 0.05) and elevating those of HDL cholesterol (+35.6 versus +16.4%, P < 0.001) and was equally effective in reducing total-cholesterol (-22.3 versus -24.9%, NS) and LDL-cholesterol (-27.1 versus -32.1%, NS) levels. Combination therapy was more effective than nicotinic acid monotherapy in reducing levels of total cholesterol (-23.8 versus -9.8%, P < 0.001), triglyceride (-39.4 versus -31.8%, P < 0.05) and LDL cholesterol (-35.7 versus -16.9%, P < 0.05) and equally effective in elevating HDL-cholesterol levels (+33.6 versus +30.8%, NS). Diabetic and non-diabetic participants responded similarly to combination therapy. Eleven patients (25%) were withdrawn from the study: nine as a result of nicotinic acid intolerance (flushing and nausea) and one through pravastatin intolerance (nausea); one patient died of a myocardial infarction. Combination therapy elevated glycosylated haemoglobin A1c levels in non-diabetic patients (5.5 to 5.8%, P < 0.001); in diabetic patients, however, the observed rise (7.4 to 7.9%) was not statistically significant. Fasting plasma glucose levels, liver function tests and levels of creatine kinase or uric acid were unaffected by either monotherapy or by combination therapy, with the exception of an elevation of the glucose level in diabetic patients receiving nicotinic acid monotherapy.

CONCLUSION

Pravastatin and nicotinic acid in lower-dose combination are more effective than pravastatin alone in reducing levels of triglyceride and elevating those of HDL cholesterol and are more effective than nicotinic acid alone in reducing total-cholesterol triglyceride and LDL-cholesterol levels. Combination therapy is equally effective in type-II diabetic and non-diabetic people. The complementary effects of the combination therapy on lipid levels suggest that this regimen should be considered as a therapeutic option in patients with combined hyperlipidaemia who tolerate the side effects of nicotinic acid.

Significance of spina bifida occulta in children with diurnal enuresis

We reviewed retrospectively 456 patients with diurnal enuresis to determine the relationship between spina bifida occulta and attainment of continence. Of these patients 127 had undergone x-rays of the spine and 48 children (48%) had spina bifida occulta. The clinical course of these patients was compared to 79 enuretic children with normal spine films. All patients were initially treated with a timed voiding program and 28 with persistent enuresis were given anticholinergic medication. Findings on urodynamic studies were similar for both groups. Uninhibited bladder contractions were found in the majority of patients and 2 children in each group had hypertonic filling curves. Of 10 children with spina bifida occulta magnetic resonance imaging or ultrasound of the spine revealed lipoma and tethering of the cord in 1. Mean followup for both groups was 3 years. The outcome for enuretic children with spina bifida occulta was comparable to those with normal spine x-rays. The majority of patients had resolution of the enuresis with conservative management. Spinal ultrasound or magnetic resonance imaging may be warranted in those children with abnormal neurological findings on examination or hypertonic filling curves, or those who fail to respond to medical treatment. However, neurosurgical intervention to achieve continence appears necessary in only a small percentage of enuretic children with spina bifida occulta.

Osteomyelitis

Osteomyelitis can be difficult to treat. Current trends emphasize early diagnosis and aggressive treatment. Imaging has improved with nuclear scans and magnetic resonance imaging, and recent modifications in technique have enhanced the specificity. Treatment depends on debridement of necrotic bone and tissue, obtaining accurate cultures, and administration of culture- and sensitivity-directed antibiotics. Antibiotic delivery has expanded to include effective oral agents and local agents mixed with polymethylmethacrylate or a biodegradable substance. Success rates in treating this disease have improved with a systematic approach, making outcome more predictable.

Cryptococcal meningitis (C. neoformans var. gattii) leading to blindness in previously healthy Melanesian adults in Papua New Guinea

Cryptococcal meningitis is a common cause of chronic meningitis in Papua New Guinea, affecting apparently immunocompetent people. The majority of infections are believed to be due to Cryptococcus neoformans var. gattii. We have reviewed the records of 49 Melanesian adults who presented with proven cryptococcal meningitis to the University teaching hospital in Port Moresby, and compare our findings with other published studies of cryptococcal meningitis in the tropics and sub-tropics. None of the patients had an obvious cause of immunosuppression. Visual disturbances and fundoscopic changes of papilloedema or papillitis were particularly common. The in-hospital case fatality rate for patients treated with amphotericin B and flucytosine was 22.4%. Of the fully treated patients, 31% became completely blind before being discharged from hospital. Therapy directly aimed at reducing intracranial pressure may improve outcome.

Progressive decline in renal function in diabetic patients with and without albuminuria

This study describes patterns of progression of albuminuria and renal function in a subgroup of 40 patients from a total cohort of 211 diabetic patients (118 type I, 93 type II) followed over a period of 8-14 years. Forty patients (18 with type I diabetes, 22 with type II diabetes) showed progressive increases in albumin excretion rate (AER) and/or decreases in creatinine clearance (CC) during the study period. Of these, AER alone increased in 15 patients, AER increased and CC decreased in 13 patients, and CC alone decreased in 12 patients, with a similar distribution of type I and type II diabetic patients in each group. Of the 28 patients who showed an increase in albuminuria, AER increased at an annual rate of 30-40%, resulting in a 4- to 8-fold increase in AER to > 20 micrograms/min during the study. Of the 25 patients who showed a decrease in renal function, CC decreased at an annual rate of 4-5 ml/min, resulting in an approximate halving of CC to < 90 ml/min during the study. The rate of fall in CC was not related to the presence or absence of concomitant increases in albuminuria. However, a significant preponderance of women in the group showed a decline in CC alone. The decline in CC was associated with an increase in plasma creatinine as well as a progressive decrease in urinary creatinine excretion, but the underlying mechanisms remain unexplained. These data support the concept that a subgroup of diabetic patients may show a decline in renal function in the absence of significant increases in AER.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital fistula of the penile urethra

Congenital fistula of the penile urethra is rare. We report a case associated with glandular hypospadias without chordee, and discuss the possible etiology and management of this unusual anomaly.