'Clinical scaphoid fracture': is it time to abolish this phrase?

INTRODUCTION

Most patients with post-traumatic painful wrists and negative radiographs are treated as having a clinical scaphoid fracture. Such cases are usually followed up with repeat radiographs. If the radiographs are inconclusive further imaging is done. However, this traditional approach results in the vast majority of patients being unnecessarily immobilised for an unspecified period, leading to loss of productivity and income to the patient and the community. A number of studies have highlighted the use of early CT or MRI scans to identify these fractures. The aim of this study was to evaluate our current practice in managing patients with suspected fractures of the scaphoid.

PATIENTS AND METHODS

A retrospective audit was carried out. The period studied was from January to August 2008. Fifty consecutive patients who were investigated for occult fractures of the scaphoid were included.

RESULTS

92% of the patients studied had a repeat radiograph in the fracture clinic. 84% of the patients had their wrists immobilised in a cast while awaiting further imaging. Only 6% had confirmed fracture of the scaphoid; all of these healed uneventfully. 76% of patients with negative scans had their wrists immobilised for an average period of 30.63 days.

CONCLUSIONS

It is time we rethink this dogmatic approach to patients with clinical signs but negative radiographs. We recommend that patients with a painful wrist following an injury and negative radiographs should be referred early to an appropriate clinician and earlier recourse to advanced imaging should be advocated.

Canadian College of Medical Geneticists guidelines for the indications, analysis, and reporting of cancer specimens

The Canadian College of Medical Geneticists (ccmg) is a national organization of medical and laboratory geneticists. The mission of the ccmg is to establish and maintain high-quality professional and ethical standards for medical genetics services in Canada and to help to ensure that service of the highest quality is delivered to the Canadian public.Cancer cytogenetics is one of the sections of practice of the ccmg. The ccmg Cytogenetic Committee has, therefore, put forward guidelines to provide oncologists and ccmg cytogeneticists with a comprehensive review of the cytogenetic diagnostic tests that are recommended as a minimum standard of care for tumours of hematopoietic and lymphoid tissues and for tumours of soft tissue and bone. The guidelines were approved by the ccmg board of directors in June 2010.

Long-term follow-up and survival of antiretroviral-naive patients with cryptococcal meningitis in the pre-antiretroviral therapy era, Gauteng Province, South Africa

Cryptococcal meningitis (CM) is a major cause of death among HIV-infected persons in sub-Saharan Africa. We conducted a study to describe the long-term outcomes during the pre-antiretroviral post-ART therapy period. Enrolled cases were those detected through population-based surveillance in Gauteng Province, South Africa, and diagnosed during March-November 2002 and July-September 2003 from eight large hospitals representing academic, provincial and rural settings. Of 1089 case-patients diagnosed with CM, 721 (70%) survived to discharge. Among the 256 with follow-up information, 154 (60%) were established to have died, 44% of whom died as outpatients. Overall, the 14- and 90-day survival post-diagnosis was 68% and 41%, respectively. On Cox proportional hazards multivariable analysis, severe disease was associated with shorter survival time; having received any antifungal treatment for the cryptococcal episode was associated with increased survival time at follow-up. Although most patients in this cohort survived the initial hospitalization, only 41% were still alive three months after diagnosis, with nearly half of deaths occurring outside a hospital. These data are an important baseline from which to measure effectiveness of public health management of CM in South Africa.

Antiplatelet antibodies in cases of Glanzmann's thrombasthenia with and without a history of multiple platelet transfusion

Antiplatelet antibodies are known to be present in a wide spectrum of patients, which include chronic Idiopathic Thrombocytopenic Purpura (ITP), infections, etc., including Glanzmann's thrombasthenia (GT) patients who receive multiple platelet transfusions. The presence of natural antibodies to platelet receptors is not studied in cases of GT. We studied the antiplatelet antibodies in 23 patients with GT, 15 of which had received multiple transfusions and eight that had not received transfusions, along with 50 cases of chronic ITP. The prevalence and specificity of platelet-bound antibodies were detected by inhibition assays using O-group platelets on flow cytometry. The mean antiplatelet antibodies in 15 patients of GT who had not received transfusions and eight patients with multiple transfusions was 8427 + 2131.88 and 9038 + 2856 antibodies/platelet, respectively, while in case of the 50 ITP patients studied, it was 22166 + 5616 antibodies/platelet (Normal Range 1500–3200 antibodies/platelet). We conclude that GT patients who have not received transfusions may develop antiplatelet antibodies to the missing/abnormal receptor. Whether this is due to a molecular mimicry or due to some other mechanism needs to be explored.

Evaluation of light emitting diode-based fluorescence microscopy for the detection of mycobacteria in a tuberculosis-endemic region

OBJECTIVES

To evaluate fluorescence microscopy (FM) using light emitting diode (LED) technology for the detection of acid-fast bacilli at a tertiary referral centre in Mumbai, India, a tuberculosis-endemic country.

DESIGN

LED FM was introduced into a laboratory experienced with Ziehl-Neelsen (ZN) microscopy but unfamiliar with FM. It was evaluated in parallel with routine ZN microscopy services and compared with mycobacterial culture as a reference standard.

RESULTS

A total of 1357 pulmonary and 917 extra-pulmonary specimens were examined during the study. LED FM had 78.3% sensitivity and 92.0% specificity against mycobacterial culture when using pulmonary specimens, and 34.0% sensitivity and 88.8% specificity for extra-pulmonary specimens. The mean time per smear examination was 2.48 min for ZN vs. 1.41 min for LED FM. Several biases in study design and operation identified during analysis, which are likely to lead to underestimates of LED FM accuracy, are discussed in the context of future LED FM evaluations.

CONCLUSIONS

Although LED FM has significant benefits over both ZN microscopy and conventional FM, its implementation and validation may be prone to difficulties which could hamper evaluation of its performance. Adequate training and detailed standard operating procedures are important to maximise accuracy.

CCMG guidelines: prenatal and postnatal diagnostic testing for uniparental disomy

The aim of this statement is to provide clinicians, cytogeneticists and molecular geneticists of the Canadian College of Medical Geneticists (CCMG) a comprehensive review of the role of UPD in constitutional genetic diagnosis and to provide a guideline as to when investigation for UPD is recommended. Members of the CCMG Cytogenetics, Molecular Genetics, Clinical Practice, and Prenatal Diagnosis committees reviewed the relevant literature on uniparental disomy (UPD) in constitutional genetic diagnosis (May 2010). Guidelines were developed for UPD testing in Canada. The guidelines were circulated for comment to the CCMG members at large and following appropriate modification, approved by the CCMG Board of Directors (July 2010).

A comparative study of oral health knowledge, attitude and behaviour of non-medical, para-medical and medical students in Udaipur city, Rajasthan, India

AIM

The aim of the study was to assess and compare the Oral health knowledge, attitude and behaviour of the non-medical, para-medical and medical students.

MATERIAL AND METHODS

In a cross-sectional study, a total of 825 students (males - 577, females - 248) of six different professions belonging to non-medical, para-medical and medical categories were surveyed using a self-administered, structured questionnaire pretested through a pilot survey. The mean percentage scores, standard deviation and frequency distribution were calculated. The Student's t-test, anova test, Scheffe's test and chi-squared test were used as test of significance. The linear regression analysis was used to assess the relation of behaviour with knowledge and attitude.

RESULTS

The knowledge scores were significantly higher for the medical students compared with those of non-medical students. The attitude scores were significantly lower for the non-medical category compared with the other two categories and the scores were the highest among the para-medical students. The behaviour scores were significantly lower for the non-medical students than for the para-medical and the medical categories. All the scores were significantly higher for females than for the males. Regression analysis showed a linear relationship of behaviour with the attitude, but no significant linear relation with the knowledge.

CONCLUSION

All the students showed low level of knowledge and the preventive behaviour among the students could still be improved. The results indicate that the knowledge was not enough to influence the oral health behaviour, but behaviour showed linear relationship with attitude of the students.

Numb chin syndrome: a metastatic deposit in the mandible

Metastatic deposits in the mandible are discussed and a case of leiomyosarcoma arising from a testicular primary is presented. The patient presented with symptoms typical of those that would present to a general dental practitioner. The various stages involved in the diagnosis and management of the condition are discussed.

CLINICAL RELEVANCE

Intra-oral malignant secondary tumours may present to dentists with signs and symptoms similar to those of benign, cystic or infectious processes. Metastatic tumours in the oral cavity are uncommon, most commonly arising in the mandible. Owing to their relative infrequency, these tumours present a challenge in diagnosis and treatment.

Remnants of a 35-year-old ventriculo-atrial shunt presenting as orofacial pain

A 36-year-old man presented to his general dental practitioner with pain in the right jaw and neck. This was initially treated as a dento-alveolar abscess. Three days later, he presented to the oral and maxillofacial unit with neck swelling to the right side. An ultrasound confirmed the swelling was due to thrombosis associated with remnants of a ventriculo-atrial (VA) shunt in the right internal jugular vein. This had been placed during the patient's infancy and apparently removed at the age of 8 years. The patient was treated conservatively with warfarin and Coamoxyclav. The patient made a full recovery and was placed on long-term anticoagulant therapy. The introduction of cerebral spinal fluid shunt procedures for the treatment of hydrocephalus has resulted in a reduction in the mortality rate from 80% to 15-20%. Various thrombo-embolic complications have been described with VA shunts. A thorough medical history is absolutely essential in order to identify uncommon causes of common presentations.

Awareness of Consumer Protection Act among Doctors in Udaipur City, India

OBJECTIVE

To compare the awareness of provisions of consumer protection act among dental and medical professionals in Udaipur city, Rajasthan, India.

MATERIALS AND METHODS

In a cross sectional study, a total of 448 professionals (253 males, 195 females) belonging to dental (222) and medical (226) categories were surveyed using a self administered structured questionnaire. The questionnaire comprised of 22 questions about the awareness of consumer protection art (CPA) and whether these professionals were following the recommendations of CPA. The student's t-test, ANOVA test, and Scheffe's test were used as tests of significance.

RESULTS

The awareness scores were significantly higher for medical professionals compared with those of dental professionals. Similarly, postgraduates showed more awareness in both the professions and it was found that private practitioners significantly have more awareness than the academic sector.

CONCLUSION

Though medical professionals have more awareness of CPA compared to dental professionals, considering the present scenario, better knowledge of CPA is necessary for both professionals in order to be on the safer side.

Antiphospholipid antibodies in haemophilia patients with severe bleeding tendency: cause, consequence or a consequential cause?

The prevalence, cause and the impact of antiphospholipid antibodies (APAs) on the clinical severity in haemophilia patients is poorly studied. We studied 72 severe seronegative (negative for HIV, HBsAg, HCV) haemophilia patients for the presence of four common APAs. Twenty-six (36.1%) were positive for any one of the APAs studied of which eight were positive only for anticardiolipin antibodies, three for beta2 glycoprotein (beta2GP1), four for prothrombin (PT) and six for anti annexin antibodies. Remaining six patients showed multi-specific antibodies. Further, clinically severe haemophilia patients (n = 37) showed higher prevalence of APAs as compared with the clinically milder group (n = 35) suggesting that these antibodies do not contribute in alleviating the clinical severity in haemophilia patients as has been observed with other inherited thrombophilia markers. The study of in vitro thrombin generation showed a higher endogenous thrombin potential (ETP) i.e. almost normal, in case of beta2GP1-positive patients as compared with patients with other types of APAs. High prevalence of APAs in clinically severe haemophilia patients may be a consequence of continuing tissue damage in the clinically severe group; as in India, clotting factor concentrates cannot be used ad lib because of financial constraints. Higher thrombin-generating potential in case of patients positive for beta2GP1 did not seem to have any impact on the clinical severity of haemophilia patients.

A comparative study of oral health knowledge, attitude and behaviour of first and final year dental students of Udaipur city, Rajasthan, India

OBJECTIVE

To assess and compare differences in oral health knowledge, attitudes and behaviour among first and final year dental students in Udaipur city, Rajasthan, India.

MATERIALS AND METHODS

In a cross-sectional study, 182 first year students (59 males and 123 females) and 157 final year students (75 males and 82 females) of the two dental colleges in Udaipur city; Rajasthan, were surveyed using a self-administered structured questionnaire including 37 multiple choice questions pretested through a pilot survey. The data was analysed using the spss version 10.0. The mean percentage scores, standard deviation and frequency distribution were calculated. The Student's t-test and anova test were used as test of significance. The linear regression analysis were used to assess the relation of knowledge, attitude and behaviour.

RESULTS

The mean % score for oral health knowledge, attitude and behaviour were significantly higher in final year students compared to first year students (P < 0.001). The linear regression analysis showed a statistically significant linear relationship of attitude with the knowledge (P < 0.001) and behaviour with the attitude (P < 0.001) of the students.

CONCLUSION

Besides the positive changes revealed in the oral health knowledge, attitude and behaviour, among the students from first to final year of dental studies, preventive behaviour among the students could still be improved.

Placental histomorphology in unexplained foetal loss with thrombophilia

BACKGROUND & OBJECTIVES

Acquired and genetic thrombotic conditions, both organ and non organ specific, are associated with increased foetal wastage. This study was carried out to examine the placenta from women with abnormal pregnancies and a history of unexplained foetal loss, and to associate with maternal thrombophilia status.

METHODS

Placentas from eight women with history of unexplained foetal loss were analyzed for histopathological characteristics. All the women were simultaneously screened for the common acquired and genetic thrombophilia markers i.e., lupus anticoagulants ( LA), IgG / IgM antibodies for anticardiolipin (ACA), beta2 glycoprotein 1 (beta2GPI) and annexin V, protein C (PC), protein S (PS), antithrombin III (AT III), factor V Leiden ( FVL) mutation, prothrombin (PT) gene G20210A, methylene tetrahydrofolate reductase (MTHFR) C 677T, endothelial protein C receptor (EPCR) 23 bp insertion and plasminogen activator inhibitor ( PAI-1 4G/5G) polymorphisms

RESULTS

Six of eight women were positive for one or more thrombophilia markers. The placenta in all the cases except one, showed the characteristic features of infarct fibrin deposition and calcification. Among two women who were negative for thrombophilia, one showed clear evidence of thrombus in the placental sections while the other did not show any characteristic infarcts in the placental sections.

INTERPRETATION & CONCLUSION

Our findings showed that the histopathological examination of the placentas confirmed thrombophilia as the aetiological cause of thrombosis in 6 of the 8 women. The presence of thrombus in a negative thrombophilia woman suggests yet unidentified thrombophilia markers or probably non-haemostatic factors causing thrombosis.

Unicystic plexiform ameloblastoma: an insight for pediatric dentists

Ameloblastomas have been categorized broadly into three biologic variants: cystic (unicystic), solid, and peripheral. The term plexiform unicystic ameloblastoma refers to a pattern of epithelial proliferation that has been described in cystic lesions of the jaws. Although the histology suggests that cystic ameloblastomas follow a biologically low-grade course, recent evidence suggests that they may often behave clinically as biologically aggressive tumors. This is supported by the high incidence of cortical perforation, tooth resorption, lesion size, bony destruction, and a high rate of recurrence after simple enucleation. This article tries to provide an insight for pediatric dentists regarding this biologically distinct entity. A literature review on the topic has been added along with a case report highlighting the state-of-the-art approach and management of such ameloblastomas, in pediatric patients.

Haematological malignancies presenting with acute liver injury: a single-centre experience

INTRODUCTION

Early recognition and identification of the underlying cause of acute liver injury (ALI) is crucial in instituting medical treatment and assessing the need for liver transplantation. Haematological malignancies have been reported to present as ALI with progression to acute liver failure but experience is limited.

AIM

Review our experience of ALI secondary to haematological malignancies.

PATIENTS AND METHODS

Patients admitted to the liver unit with ALI secondary to a haematological malignancy between 1996 and 2006 were identified. A retrospective review was made of their case notes and our database.

RESULTS

Of the 752 cases of ALI, six cases of ALI secondary to haematological malignancy were identified. Common features were a prodromal illness (median duration of 5 weeks; range 2-6 weeks) and jaundice (median bilirubin 208 micromol/l; range 112-238 micromol/l). The majority of patients (5/6) had hepatomegaly. Liver biopsy was performed in two patients and confirmed the diagnosis in both cases. In other cases, the diagnosis was made following lymph node biopsy (1), bone marrow examination (2) or from post-mortem examination (1). Median time from jaundice to encephalopathy was 12 days; range 1-22 days. A single patient underwent liver transplantation but died in the immediate post-operative period. All patients died soon after admission with a median survival of 8 days (range 3-26 days).

CONCLUSION

Haematological malignancy should be considered in ALI patients presenting with a prodromal illness, jaundice and hepatomegaly. Biopsy is essential to confirm the diagnosis but the benefit of definitive therapy such as chemotherapy and/or transplantation in this setting is unclear and survival is poor.

Exenatide and acute pancreatitis

For a female, type 2 diabetic patient, with 4 years duration of diabetes, Exenatide (Byetta) was prescribed as glycaemic control was not satisfactory along with Glimepiride and Metformin. She had gastrointestinal disturbances, since the first day of the injection. From the eighth day she developed signs of acute pancreatitis which was confirmed with CT-Scan and biochemical investigations. Byetta was withdrawn, the patient was treated for acute pancreatitis and the symptoms subsided.

Effects of sex chromosome aneuploidy on male sexual behavior

Incidence of sex chromosome aneuploidy in men is as high as 1:500. The predominant conditions are an additional Y chromosome (47,XYY) or an additional X chromosome (47,XXY). Behavioral studies using animal models of these conditions are rare. To assess the role of sex chromosome aneuploidy on sexual behavior, we used mice with a spontaneous mutation on the Y chromosome in which the testis-determining gene Sry is deleted (referred to as Y(-)) and insertion of a Sry transgene on an autosome. Dams were aneuploid (XXY(-)) and the sires had an inserted Sry transgene (XYSry). Litters contained six male genotypes, XY, XYY(-), XXSry, XXY(-)Sry, XYSry and XYY(-)Sry. In order to eliminate possible differences in levels of testosterone, all of the subjects were castrated and received testosterone implants prior to tests for male sex behavior. Mice with an additional copy of the Y(-) chromosome (XYY(-)) had shorter latencies to intromit and achieve ejaculations than XY males. In a comparison of the four genotypes bearing the Sry transgene, males with two copies of the X chromosome (XXSry and XXY(-)Sry) had longer latencies to mount and thrust than males with only one copy of the X chromosome (XYSry and XYY(-)Sry) and decreased frequencies of mounts and intromissions as compared with XYSry males. The results implicate novel roles for sex chromosome genes in sexual behaviors.

Pneumocephalus as a complication of diverticulitis

We report a case of pneumocephalus, as a complication of diverticulitis, in a 48-year-old man who presented with back pain and mild disorientation. There are no previous reports of diverticulitis causing this phenomenon.

Recurrent ameloblastoma of the infratemporal fossa: diagnostic implications and a review of the literature

It is unusual for odontogenic tumours such as ameloblastoma to occur in the infratemporal fossa. Although these odontogenic tumours usually arise in jaws, they can infiltrate into the infratemporal region, pterygomaxillary space or fissure, invading soft tissues by way of extension. A case of recurrent ameloblastoma in the infratemporal fossa region arising from an extension of the lesion from the site of previous occurrence in the right mandibular body is reported.

Orofacial pain – a presenting symptom of bisphosphonate associated osteonecrosis of the jaws

Osteonecrosis of the jaws (ONJ) associated with bisphosphonate therapy is being reported with increasing frequency all over the world. Pain may be the presenting symptom commonly associated with intra-oral bone exposure. The aetiology of this therapeutic complication is still not well understood. Three cases are presented and the management of the condition is discussed.

Primary spinal paragangliomas: a clinicopathological and immunohistochemical study of six cases

Spinal paragangliomas are uncommon neoplasms and subject of much debate regarding the factors governing their biological behaviour. We describe the clinicopathological and immunohistochemical (IHC) features of six cases of spinal paraganglioma. The mean age of patients was 40 years (range 20-60 years) with a male to female ratio of (2:1). Majority presented with low backache, sphincter disturbances and sensory symptoms. All tumors were intradural in the cauda region one of them extending to the filum. Only one showed focal extradural extension on microscopy. Gross total resection of tumors was possible in all cases. Histologically four showed classical 'zell-ballen' pattern and two revealed an ependymal morphology. On immunohistochemistry, in all the six cases the chief cells were intensely labeled by antibody to chromogranin but not for GFAP while staining for synaptophysin was less intense and variable in five. Sustentacular cells in all cases showed strong expression for S-100 protein and chief cells were stained light in three cases. Low MIB-1 labeling index of 0.01-2% was noted in five cases and in the sixth it was 5%. None of the tumours recurred. Immunohistochemistry assisted in differentiating these relatively benign neural crest tumours from the more aggressive spinal ependymomas.