Primary malignant melanoma of oral cavity: A report of three rare cases

Oral malignant melanoma (OMM) is a rare tumor of melanocytic origin, accounting for 20–30% of malignant melanomas at the mucosal surface and 16% intra-orally. Hard palate and maxillary gingiva are the most common involved sites. In this case series, we present varying patterns of presentation of three cases of OMM with one case of distant metastasis. All cases in the current series presented at an advanced stage and died within a year of diagnosis. In conclusion, due to the aggressive clinical course and poor prognosis of this deadly lesion, it is of paramount importance to maintain a high index of suspicion for early detection and diagnosis for any pigmented lesion in the oral cavity.

Interferon Gamma ELISPOT Testing as a Risk-Stratifying Biomarker for Kidney Transplant Injury: Results From the CTOT-01 Multicenter Study

Previous studies suggest that quantifying donor-reactive memory T cells prior to kidney transplantation by interferon gamma enzyme-linked immunosorbent spot assay (IFNγELISPOT) can assist in assessing risk of posttransplant allograft injury. Herein, we report an analysis of IFNγELISPOT results from the multicenter, Clinical Trials in Organ Transplantation-01 observational study of primary kidney transplant recipients treated with heterogeneous immunosuppression. Within the subset of 176 subjects with available IFNγELISPOT results, pretransplant IFNγELISPOT positivity surprisingly did not correlate with either the incidence of acute rejection (AR) or estimated glomerular filtration rate (eGFR) at 6- or 12-month. These unanticipated results prompted us to examine potential effect modifiers, including the use of T cell-depleting, rabbit anti-thymocyte globulin (ATG). Within the no-ATG subset, IFNγELISPOT(neg) subjects had higher 6- and 12-month eGFRs than IFNγELISPOT(pos) subjects, independent of biopsy-proven AR, peak PRA, human leukocyte antigen mismatches, African-American race, donor source, and recipient age or gender. In contrast, IFNγELISPOT status did not correlate with posttransplant eGFR in subjects given ATG. Our data confirm an association between pretransplant IFNγELISPOT positivity and lower posttransplant eGFR, but only in patients who do not receive ATG induction. Controlled studies are needed to test the hypothesis that ATG induction is preferentially beneficial to transplant candidates with high frequencies of donor-reactive memory T cells.

Characterization of muscle alteration in oral submucous fibrosis-seeking new evidence

Background

The aim of the study was to assess the progression of Oral Submucous Fibrosis (OSF) by investigating the correlation between clinical mouth opening and muscle-epithelial distance in tissue sections. Characterization of changes involving muscle was ascertained.

Material and Methods

50 cases and 10 controls were included in this case-control study. Inter-incisal mouth opening was measured and classified according to Lai et al. as Group A (more than 35mm), Group B (30 to 35mm), Group C (20 to 30mm), Group D (less than 20mm). Histopathological sections were graded as very early, early, moderately advanced, advanced OSF. Muscle-epithelial distance was calculated using image analysis software. The four most common degenerative changes observed in muscles, namely fragmentation, highly eosinophilic areas with loss of striations, nucleus internalization and multiple pyknotic nuclei were also assessed.

Results

Comparisons of muscle-epithelial distance were made between the clinical and histopathological groups to those of controls. The mean muscle-epithelial distance was: Group A-626.8±309.36 µm, B-827.5±549.72 µm, C-673.2±321.93 µm, D-439.9±173.84µm, Controls-1222.19 ±441.7µm. Post-hoc Bonferroni Test revealed a statistically significant reduction in the muscle-epithelial distance in Group C (p-value = 0.001) and D (p-value = 0.001) as compared to controls. The mean muscle-epithelial distance in very early, early, moderately advanced and advanced OSF was 732.73±232.81µm, 726.54±361.63 µm, 548.36±273.13 and 172.40±58.41 µm respectively. Highly significant difference in muscle-epithelial distance was seen between controls as compared to early (p-value =0.002), moderately advanced (p-value = 0.001) and advanced OSF (p-value = 0.001. Fragmentation and highly eosinophilic areas were invariably noticed in advanced OSF. Multiple pyknotic nuclei were variable with no specificity.

Conclusions

Reduction in muscle-epithelial distance may prove to be a significant predictor of OSF progression. Degenerative changes must be noted while observing OSF cases, irrespective of the histopathological grade.

Key words:Oral submucous fibrosis, muscle changes, muscle-epithelial distance.

Calcifying ghost cell odontogenic tumor (CGCOT) with predominance of clear cells: a case report with important diagnostic considerations

An 18-year-old female reported painful swelling in the left maxillary region 4 months after the extraction of tooth #15. Because incisional biopsy suggested ameloblastoma with clear-cell changes, segmental resection was performed. The microscopic examination of the excised tissue revealed histomorphologic diversity, with features of typical calcifying ghost cell odontogenic tumor (CGCOT) and a significant clear-cell component constituting more than 50% of the tumor mass without any features of malignancy. Clear cells were periodic acid-Schiff (PAS) positive and mucicarmine negative. CK19 was strongly positive in the solid tumor islands and variably positive in clear cells. A definitive diagnosis of CGCOT with predominance of clear cells was confirmed. Because both squamous metaplasia and clear-cell components were present in the ameloblastic follicles independent of each other, the presence of abundant calcifications favored the diagnosis of CGCOT with a clear-cell component over that of an ameloblastoma with clear-cell changes. The importance of identifying the histomorphologic features of the 2 entities, ameloblastoma and CGCOT, is highlighted. This appears to be the second case reported in the literature, to the best of our knowledge.

Pediatric solitary intraosseous infantile myofibroma of the mandible

Myofibroma is a rare benign tumor of myofibroblastic origin that presents as solitary or multiple, and as an intraosseous and/or soft tissue lesion. It most commonly occurs in infants and children, although adult myofibromas have also been reported. Solitary central infantile myofibroma of the jaws is very rare and should be considered in the differential diagnosis of central jaw lesions involving the mandible in children. Its etiology is unknown. The purpose of this manuscript is to report a case of solitary intraosseous infantile myofibroma of the mandible wherein trauma may have been a contributory factor to the development of the tumor. The importance of immunohistochemistry in diagnosing this entity has also been emphasized. Resection should be preferred over enucleation when the lesion infiltrates the surrounding bone.

Aneurysmal Bone Cyst of the Jaws: Clinicopathological Study

AIM

The aim of the present study was to analyze clinical, radiological and histopathological features of aneurysmal bone cysts (ABCs) of jaws.

MATERIALS AND METHODS

Archival data from 2009 to 2012 present in the Oral Pathology Department was retrieved and clinicopathological features of all the cases which had been previously diagnosed as ABC were analyzed in detail.

RESULTS

Seven cases ranging in age from 10 to 50 years were included, in which maximum (5/7) cases were below 20 years. Ratio of presentation of lesion in male to female and in maxilla to mandible was 3:6 and 1:6 respectively. Swelling and pain were the most common presenting features. Variable presentation of the lesion was observed radiographically; although multilocular, well defined, bone expansion and perforation were the most common observations. Histopathological analysis revealed association of one case with ossifying fibroma and two cases with trabecular variety of juvenile ossifying fibroma. Predominance of solid variety was noted and other features like stroma, giant cells, nature of blood vessels, bone destruction and perforation and presence of any osteoid or calcified material was also accounted for. The current study showed association of two cases with trabecular variety of juvenile ossifying fibroma, which is a rare finding.

CONCLUSION

ABCs of jaws, thus have varying patterns of presentation which are diagnostically challenging. A thorough examination of the incisional/excisional tissue is thus required to confirm the association with any other lesion which will affect the treatment plan for the patient.

Clinical profile and outcome of chronic pancreatitis in children

OBJECTIVE

To evaluate the etiology, presentation, complications and management of chronic pancreatitis in children.

DESIGN

Retrospective chart review.

SETTING

Gastroenterology department at Christian Medical College and Hospital, Vellore, India between January 2005 and December 2010.

PARTICIPANTS

99 Children (>18 yrs) diagnosed with chronic pancreatitis based on clinical and imaging features.

MAIN OUTCOME MEASURES

Etiology, clinical presentation, complications and management of chronic pancreatitis in children.

RESULTS

Of 3887 children who attended the Gastroenterology department, 99(2.5%) had chronic pancreatitis, of which 60 (60.6%) were males. In 95(95.9%) patients no definite cause was detected and they were labeled as Idiopathic chronic pancreatitis. All patients had abdominal pain, while 9(9.1%) had diabetes mellitus. Of the 22 children tested for stool fat, 10(45.5%) had steatorrhea. Pancreatic calcification was seen in 69 (69.7%). 68 (71.6%) patients with idiopathic chronic pancreatitis had calcification. Calcific idiopathic chronic pancreatitis was more frequent in males (67.6% vs. 48.1%, P=0.07), and was more commonly associated with diabetes mellitus (13.2% vs. none, P=0.047) and steatorrhea (61.5% vs. 16.7%, P=0.069). Pseudocyst (17.1%) and ascites (9.1%) were the most common complications. All children were treated with pancreatic enzyme supplements for pain relief. 57 patients were followed up. With enzyme supplementation, pain relief was present in 32 (56.1%) patients. Of those who did not improve, 10 underwent endotherapy and 15 underwent surgery. Follow up of 8 patients who underwent endotherapy, showed that 5 (62.5%) had relief. Follow up of 11 patients who underwent surgery showed that only 3 (27%) had pain relief. There was no death.

CONCLUSIONS

Idiopathic chronic pancreatitis is the predominant form of chronic pancreatitis in children and adolescents. It can present with or without calcification. The calcific variety is an aggressive disease characterized by early morphological and functional damage to the pancreas.

Infiltrating lipomatosis of the face: A case series

Infiltrating lipomatosis of the face is a very rare entity which is characterized by the collection of non-encapsulated mature adipocytes infiltrating local tissues, resulting in craniofacial deformities. Psychomotor development of the patients is normal, esthetics often being the primary concern to seek treatment. The presentation is always unilateral with hypertrophy of hard and soft structures on the affected side of the face. The pathogenesis of the condition is unclear. This condition shows a wide phenotypic range, uncertain prognosis with high rates of recurrence after surgery, and variable post-op cosmetic improvement. The condition shows no gender predilection, with most of the cases presenting in and beyond the second decade of life. Here, we present a series of four cases presenting in varying age groups with history of recurrence in three cases.

Rare pediatric presentation of aneurysmal bone cyst with trabecular juvenile ossifying fibroma and ossifying fibroma

Aneurysmal bone cyst (ABC) is a benign intraosseous lesion characterized by blood filled spaces of varying sizes associated with a fibroblastic stroma containing multinucleated giant cells, osteoid and woven bone. ABC can present either singly or in association with osseous neoplasms such as ossifying fibroma (OF), giant cell granuloma etc. Juvenile ossifying fibroma has two variants: psammomatoid JOF (PJOF) and trabecular JOF (TJOF). ABC formation in TJOF is very rare in pediatric patients with only three cases reported in literature till date to the best of our knowledge. We hereby report three pediatric cases of ABC, two of which were associated with TJOF and one associated with OF.

Unicystic ameloblastoma in 3 year old paediatric patient - A rare entity

Unicystic ameloblastoma (UA) is a benign epithelial odontogenic tumor of the jaws that commonly occurs in 2nd and 3rd decade of life. In fact, this entity is rare in children under 12 years of age. It is characterised as a distinct variant of ameloblastoma, exhibiting a less aggressive behaviour and a lower rate of recurrence than solid conventional ameloblastoma. There are very few reported cases of UA occurring in children below five years of age. The purpose of this case report is to describe a case of UA involving the crown of an unerupted maxillary second premolar in a 3 year old girl. The pathogenesis, clinical appearance, radiographic presentation, histological findings and management of the tumour have also been discussed.

Cheiloscopy as an adjunct to forensic identification: a study of 600 individuals

Cheiloscopy deals with examination of system of furrows on the red part of human lips. The present study was undertaken to classify lip prints, study their variations, determine the most common pattern in the study population, evaluate differences in lip prints between males and females and between different age groups, ascertain whether there is any hereditary pattern and thereby investigate their potential role in personal identification. Lip prints of 600 individuals, including 52 families, of ages ranging from 3 to 83 years were obtained using lipstick and two kinds of adhesive tape. The lip prints were analyzed using Adobe® Photoshop® software and classified according to Tsuchihashi classification. Patterns of lip prints occurred in diverse combinations. The patterns were similar between males and females and varied among different age groups. Some hereditary resemblance was observed between parents and offspring. Lip prints have a good potential for use in criminal investigations. They have been used only occasionally despite their frequent occurrence at crime scenes. A place for cheiloscopy is recommended within the scope of forensic odontostomatology, along with other means of forensic identification.

Studies on digoxin--14C-acetate incorporation in to digoxin and degenerative changes in the brain in rats administered digoxin

The human hypothalamus produces an endogenous membrane Na+-K+ ATPase inhibitor digoxin. Digoxin is a steroidal glycoside and could be synthesised by the isoprenoid pathway. The other metabolites of the isoprenoid pathway are cholesterol, dolichol and ubiquinone. We have tried to find out the extent of incorporation of 14C acetate into digoxin in rat brain. The effects of digoxin administration on the rat brain was also studied. The results show that the percentage incorporation of 14C acetate into digoxin is low but detectable. The maximum incorporation was observed for cholesterol, followed by dolichol and finally ubiquinone. The histopathological changes observed after digoxin administration were focal degeneration of the ganglion cells in the cerebrum and cerebellum. The carbohydrate components of the glycoproteins were reduced and the concentration of serotonin, dopamine, and epinephrine showed a significant increase. The role of digoxin in mediating neuronal cell death is discussed.

Evaluation of missed diagnoses for patients admitted from the emergency department

OBJECTIVE

To define a quality assurance instrument to evaluate errors in diagnostic processes made by physicians in the emergency department (ED).

METHODS

This was a retrospective clinical investigation of inpatient ED records. Over a six-year period, 5,000 medical records of admitted patients were randomly selected for evaluation. Each record was initially examined by one of five physician evaluators. If the primary ED diagnosis differed from the primary discharge diagnosis, the ED record was inspected to determine reasons for the misdiagnosis. The authors considered several aspects of the diagnostic process, including patient history, tests ordered, interpretation of clinical data, choice and performance of procedures, injury pattern recognition, reasoning, and evaluation. Records that demonstrated errors in the diagnostic process were reevaluated for the same diagnostic process errors by a sixth physician. Disagreements regarding suspected errors in the diagnostic process were settled by discussion. Finally, to determine potential medical consequences of the misdiagnosis, one individual reviewed the complete medical records of patients whose ED medical records were scored with errors by both evaluators. Interevaluator reliability was assessed using Cochran's Q-test with a selected series of medical records.

RESULTS

Twenty-eight records (0.6%) were found to contain one or more errors in the diagnostic process that contributed to misdiagnosis. For these patients appropriate diagnosis was not made until one to 16 days after admission. Three patients of 18 whose records were available for detailed review may have suffered complications that resulted, in part, from the delay in diagnosis and subsequent treatment. Significant interevaluator reliability for identification of errors in the diagnostic process was obtained (p > 0.1).

CONCLUSIONS

A two-tiered evaluation of ED records selected by inconsistent initial and final diagnoses can be used reliably to screen for errors in the diagnostic process made by emergency physicians (EPs). The rate of physician error contributing to a misdiagnosis is very low, suggesting that EPs are delivering quality patient care.

Bed mobility task performance in older adults

Difficulty in transferring, the ability to rise in and out of a bed and chair, is a common problem in older adults, particularly those residing in skilled nursing facilities. Focusing on one aspect of transferring, rising from supine to sitting position, we devised a set of bed mobility tasks to test key arm, leg, and trunk movements that likely contribute to successful rising from bed. Healthy young controls (YC, n=22, mean age 23), and older adults (aged 60 and over) either residing independently in congregate housing (CH, n=29, mean age 84) or undergoing rehabilitation in a skilled nursing facility (SNF, mean age 77) were assessed in the time to rise from supine to sitting and in the ability or inability to perform 16 other bed mobility tasks. Trunk function-related tasks, specifically those requiring trunk elevation and trunk balance, were most difficult for the SNF, followed by CH, and then YC. Tasks focusing on trunk flexion strength (sit up arms crossed, bilateral heel raise) and lateral trunk strength/balance were the most difficult for both SNF and CH, although there was minimal difference in the percent unable to complete each task. The major CH-SNF differences occurred in trunk elevation tasks where the upper limb was important in facilitating trunk elevation (sit up with head of bed elevation with use of arms, sit up with the use of a trapeze, or sit up with use of arms from a flat bed position). These findings suggest that to improve frail older adult performance on bed mobility tasks, and specifically in rising from supine to sitting, training should move beyond improving trunk function (i.e., trunk strength). There should be an additional focus, either through therapy or bed design modifications, on how upper limb movements and positioning can be used to assist in trunk elevation.

Isoprenoid pathway and free radical generation and damage in neuropsychiatric disorders

Two substances which are products of the isoprenoid pathway, can participate in lipid peroxidation. One is digoxin, which by inhibiting membrane Na(+)-K+ ATPase, causes increase in intracellular Ca2+ and depletion of intracellular Mg2+, both effects contributing to increase in lipid peroxidation. Ubiquinone, another products of the pathway is a powerful membrane antioxidant and its deficiency can also result in defective electron transport and generation of reactive oxygen species. In view of this and also in the light of some preliminary reports on alteration in lipid peroxidation in neuropsychiatric disorders, a study was undertaken on the following aspects in some of these disorders (primary generalised epilepsy, schizophrenia, multiple sclerosis, Parkinson's disease and CNS glioma)--1) concentration of digoxin, ubiquinone, activity of HMG CoA reductase and RBC membrane Na(+)-K+ ATPase 2) activity of enzymes involved in free radical scavenging 3) parameters of lipid peroxidation and 4) antioxidant status. The result obtained indicates an increase in the concentration of digoxin and activity of HMG CoA reductase, decrease in ubiquinone levels and in the activity of membrane Na(+)-K+ ATPase. There is increased lipid peroxidation as evidenced from the increase in the concentration of MDA, conjugated dienes, hydroperoxides and NO with decreased antioxidant protection as indicated by decrease in ubiquinone, vit E and reduced glutathione in schizophrenia, Parkinson's disease and CNS glioma. The activity of enzymes involved in free radical scavenging like SOD, catalase, glutathione peroxidase and glutathione reductase is decreased in the above diseases. However, there is no evidence of any increase in lipid peroxidation in epilepsy or MS. The role of increased operation of the isoprenoid pathway as evidenced by alteration in the concentration of digoxin and ubiquinone in the generation of free radicals and protection against them in these disorders is discussed.

A hemodynamic approach to resistant hypertension

Resistant hypertension affects a minority of treated hypertensive patients, yet the resulting target organ damage causes disproportionate morbidity and increased risk of cardiovascular events. The clinical features and efforts to adjust drug treatment in a resistant hypertensive patient are described. As demonstrated, serial hemodynamic measurements using thoracic bioimpedance may provide a rationale for selection of effective combination antihypertensive therapy. (c)2000 by CHF, Inc.