Cranial nerve palsies in typhoid fever: report of three cases

Neurological manifestations of enteric fever are well known. However, isolated cranial nerve palsies are rare. A 4-year-old boy and two girls aged 5 and 11 years with culture-proven typhoid fever are described, two of whom developed palatal palsy and the other sixth cranial nerve palsy. Following treatment, there was complete resolution of the cranial nerve palsies within 5-7 weeks. While palatal palsy is reported rarely, isolated sixth cranial nerve palsy associated with typhoid has not been reported previously.

Proficiency panel testing--a reliable tool in external quality assessment of sputum smear microscopy services in Gujarat, India

OBJECTIVE

To assess the proficiency of Senior TB Laboratory Supervisors (STLSs) and district level Laboratory Technicians (LTs) in sputum smear microscopy.

METHOD

Intermediate Reference Laboratory (IRL), Ahmedabad had manufactured and validated Proficiency Panel Testing slides from sputum samples, made On Site Evaluation (OSE) visits of District TB Centres (DTCs) in two rounds, and conducted Proficiency Panel Testing of STLSs & DTC-LTs from January 2005 to June 2009.

RESULTS

High level of concordance in Z-N smear grading was found between Microbiologist and district laboratory staff. DTC readers reported overall consistency level of more than 98% in Z-N grade agreement during both the IRL, EQA, OSE visits. The tendency to over-grade the panel slides was much higher (more than 22%) as compared to under-grade (less than 2%) them in "correct slides". High False Positive (HFP) error was not observed in the present study.

CONCLUSION

Laboratory supervisor's proficiency can be quickly assessed by Proficiency Panel Testing, under multi-level quality assurance network system of sputum smear microscopy in public health programmes like the RNTCP. Proficiency Panel Testing is highly replicable and reproducible tool for quick and reliable assessment of proficiency of the staff and it can be made more effective by raising the proportion of lower grade positive slides in panel set of each reader. DTC readers' overall agreement level of more than 98% in Z-N grade suggests high level of precision and excellent consistency during both the IRL, EQA, OSE rounds. It is concluded that even for a large network of sputum smear microscopy centres under public health programmes like the RNTCP in order to take corrective action, Proficiency Panel Testing can be effectively used for quick identification of suboptimal- technical performance of the supervisory staff.

Reasons underlying the extraction of permanent teeth in patients attending Peoples Dental College and Hospital

Extraction of permanent teeth is common in Nepal. The study was undertaken to determine the causes and pattern of missing permanent teeth among patients attending Peoples Dental College and Hospital (PDCH) and to see if there is any association between variables like socio economic status, patient education level, dental visit and extraction of permanent teeth. A prospective cross sectional survey was carried out in patients attending the Department of Oral Surgery in PDCH between August 2006 and October 2006. The data was collected by trained clinician through clinical examination and using semi- structured questionnaires. Computer software SPSS 15 was used for statistical analysis. In age groups < or = 30 years, 90.0% it was reported that Dental caries was the most common reason for extraction of teeth. In age groups > 30 years, 55.6% periodontal disease was the most common reason for extraction of teeth. Distribution by type of teeth and dental disease was highly significant where. Dental caries was the reason for extraction of first permanent molar. Distribution by education level and visit to dentist was highly significant. About 93.1% of the people who were illiterate visited the dental surgeon while in pain and 76.0% of the university level graduates visited the dentist while in pain. Caries and its sequel remain the most important cause of tooth loss throughout adult life along with periodontal diseases at later stages.

Immediate reattachment of fractured tooth segment using dual cure resin

Crown fracture of maxillary anterior teeth is frequent dental injuries for which patients seek immediate dental treatment. Immediate reattachment of the intact fractured tooth segment is a therapeutic choice in such cases. This case report presents one of the best methods used for reattachment, which is an ultraconservative technique. It allows the restoration of original tooth contour, colour and aesthetics.

Deflazacort

Conventional oral steroids like prednisolone have various adverse effects both during short-term and long-term use. Hence a search for an alternative oral steroid with fewer side-effects is underway throughout the world. Deflazacort, an oxazoline derivative, is a step in this direction. The number of large randomized trials using deflazacort for steroid-responsive disorders in children is limited. Use of deflazacort has been explored largely in patients with Duchenne's muscular dystrophy. Preliminary data suggest reduced osteoporosis, lesser growth retardation and weight gain with use of deflazacort, as compared to other steriods. In view of the limited data demonstrating superiority of deflazacort over the available oral steroids and its prohibitive cost, it is early to advocate widespread use of this drug in children.

Three rooted, four canalled mandibular first molar (Radix Entomolaris)

A mandibular first molar with two distal roots is an interesting example of anatomic variation. This paper describes case reports of mandibular first molar with three roots (one mesial and two distal) and four canals (two in mesial and one in each distobuccal and distolingual root). The canals were shaped with protaper rotary files and irrigated with 5.25% sodium hyochlorite, 0.2 %w/v of chlorhexidine gluconate and normal saline as the fi nal irrigant. The canals were then obturated with gutta- percha and AH plus sealer. These case reports show an anatomic variation of internal morphology of the tooth and points out the importance of searching for additional canals.

Maturation of the neuromuscular junction in masseters of human fetus

OBJECTIVES

The aim of the present investigation is to examine if the histological maturation of the neuromuscular junction in the masseters of human fetuses has already begun by the 12-th week of gestation or not.

MATERIAL AND METHODS

Twenty-four masseter muscles from 14 human fetuses at gestational age 12 weeks were divided into two groups. In the first group, muscle sections were stained with Bielschowsky and Holzer stains for examination of neurofibrils and glial cells respectively. In the second group, rhodamine and fluorescein conjugated alpha-bungarotoxin were used to detect nicotinic receptors and anti-GAD for neuronal terminals.

RESULTS

It was observed the presence of one axon for each end-plate and glial cells spread over a branched axon. The nicotinic receptors clustered in the neuromuscular junction, neuronal terminals and large oval nucleus were detected.

CONCLUSIONS

These observations suggest that the maturation of the neuromuscular junctions of the masseter muscles in the human fetuses has already begun at the 12-th week of gestation.

A conservative method to reproduce lost gingival tissue--an innovative approach

One of the greatest assets a person can have is a smile that shows beautiful, natural teeth. The restoration of a smile is one of the most appreciated and gratifying services a dentist can render. The positive psychologic effects of improving a patient's smile often contribute to an improved self image and enhanced self esteem. Periodontal attachment loss in the maxillary anterior region can often lead to esthetic and functional clinical problems. Lifelong motivation is essential to the supportive therapy for these patients, and the maintenance of good esthetics, combined with conducive to maintaining long term dental and professional health. This paper aims to demonstrate an innovative treatment option for dealing with aesthetic challenges posed by a patient.

Clinical spectrum of fever of unknown origin among Indian children

BACKGROUND

Fever of unknown origin (FUO) is an important cause of morbidity and mortality in children, especially in tropical and developing countries.

AIM

To determine the aetiology and outcome of FUO in Indian children.

METHODS

A hospital-based, prospective, observational study was conducted over a 1-year period (2006-2007). Children aged > or =3 months to 12 years who qualified for the definition of FUO were recruited. Initial evaluation included complete blood count, peripheral smear for malarial parasites, erythrocyte sedimentation rate (ESR), urine analysis and culture, blood culture, tuberculin test and chest X-ray.

RESULTS

Of 49 patients evaluated, a diagnosis was reached in 43 (88%). Infections were the predominant cause of FUO in 34 patients (69%). Enteric fever was the most common infection (14), followed by visceral leishmaniasis (10) and tuberculosis (5). The next most common cause was malignancy (6, 12%). Among the six undiagnosed patients, spontaneous resolution occurred in five whereas one child continued to be febrile without an established cause at the end of the study.

CONCLUSION

Repeated, thorough clinical examination and carefully selected laboratory examinations proved useful in the diagnosis of FUO. Serology (e.g. enteric fever) and bone marrow examination (e.g. leishmaniasis, malignancy) were the most useful diagnostic tests.

Use of the orbicularis retaining ligament in lower eyelid reconstruction

INTRODUCTION

The orbicularis retaining ligament (ORL) is a distinct anatomical structure that has only been recently characterised. A variety of techniques, based on Hamra's concepts, now divide this ligament during lower lid blepharoplasty. This often produces a substantial skin excess which is discarded. We set out to investigate the validity of this surgical manoeuvre as a means of recruiting anterior lamella for the purposes of lower lid reconstruction.

MATERIALS AND METHODS

Between September 2002 and August 2004, 23 patients underwent reconstruction of the anterior lamella of their lower eyelid using this technique. The mean age of the patients was 56 years (range 26-86 years). The mean follow-up time was 20 months (range 12-36 months). Clinical evaluation was carried out preoperatively and postoperatively to assess the presence of palpebral non occlusion, epiphora, the sensation of a dry eye, ectropion, conjunctivitis and keratitis. Assessment of the tissue deficit was made clinically and with standardised digital photographs.

RESULTS

Satisfactory reconstruction of the anterior lamella of the lower eyelid was achieved in 19/23 patients. Preoperative symptoms of epiphora and lower lid position were improved. The visual analogue scale of appearance was improved postoperatively. In some cases, particularly in the atrophic lower lid, the results were short lived and further surgery was required to achieve optimal results.

CONCLUSION

In cases of isolated cutaneous deficit where the lid support mechanisms are intact, the procedure is both successful and aesthetically favourable for resurfacing this challenging area.

Vitamin B12 and folate concentrations during pregnancy and insulin resistance in the offspring: the Pune Maternal Nutrition Study

AIMS/HYPOTHESIS

Raised maternal plasma total homocysteine (tHcy) concentrations predict small size at birth, which is a risk factor for type 2 diabetes mellitus. We studied the association between maternal vitamin B12, folate and tHcy status during pregnancy, and offspring adiposity and insulin resistance at 6 years.

METHODS

In the Pune Maternal Nutrition Study we studied 700 consecutive eligible pregnant women in six villages. We measured maternal nutritional intake and circulating concentrations of folate, vitamin B12, tHcy and methylmalonic acid (MMA) at 18 and 28 weeks of gestation. These were correlated with offspring anthropometry, body composition (dual-energy X-ray absorptiometry scan) and insulin resistance (homeostatic model assessment of insulin resistance [HOMA-R]) at 6 years.

RESULTS

Two-thirds of mothers had low vitamin B12 (<150 pmol/l), 90% had high MMA (>0.26 micromol/l) and 30% had raised tHcy concentrations (>10 micromol/l); only one had a low erythrocyte folate concentration. Although short and thin (BMI), the 6-year-old children were relatively adipose compared with the UK standards (skinfold thicknesses). Higher maternal erythrocyte folate concentrations at 28 weeks predicted higher offspring adiposity and higher HOMA-R (both p < 0.01). Low maternal vitamin B12 (18 weeks; p = 0.03) predicted higher HOMA-R in the children. The offspring of mothers with a combination of high folate and low vitamin B12 concentrations were the most insulin resistant.

CONCLUSIONS/INTERPRETATION

Low maternal vitamin B12 and high folate status may contribute to the epidemic of adiposity and type 2 diabetes in India.