Overriding fifth finger: an unusual sign in lower brachial plexopathy

Hand deformities are often useful clinical signs. To our knowledge, they have not been described in association with brachial plexus lesions. A 28-year-old female presented with sudden left shoulder pain and medial forearm parasthesia. Examination showed the left fifth finger adducting and flexing over the dorsal aspect of the fourth finger. Neurophysiological studies and MRI supported a brachial plexus lesion. The physical sign was not present 5 months post onset and the patient experienced near complete clinical improvement. The unusual physical sign occurred in association with neuralgic amyotrophy. Its occurrence can be explained in terms of transient patchy involvement of nerve fascicles in the brachial plexus.

A case of nephrogenic fibrosing dermopathy

INTRODUCTION

Nephrogenic fibrosing dermopathy is a recently recognised fibrosing disorder originally identified as a scleromyxoedema-like cutaneous disease in patients with renal disease.

CLINICAL PICTURE

A 45-year-old lady with systemic lupus erythematosus presented with well-defined erythematous, non-tender, indurated plaques on both legs 4 months after haemodialysis for rapidly progressive glomerulonephritis and acute renal failure. Skin biopsy showed dermal fibrosis with increased proliferation of dermal fibroblasts and collagen bundles separated by clefts. There were increased dermal deposits of mucin and an increase in elastic fibres.

TREATMENT AND OUTCOME

Haemodialysis was instituted for 2 weeks followed by monthly intravenous cyclophosphamide. Skin lesions remained unchanged 8 months later despite normalisation of renal function.

CONCLUSION

Nephrogenic fibrosing dermopathy appears to be a definite new entity in patients with underlying renal insufficiency. Further multi-centre collaborative study is necessary to identify the prevalence, cause, treatment and prognosis of this disorder.

Discovery of binding motif pairs from protein complex structural data and protein interaction sequence data

Unravelling the underlying mechanisms of protein interactions requires knowledge about the interactions' binding sites. In this paper, we use a novel concept, binding motif pairs, to describe binding sites. A binding motif pair consists of two motifs each derived from one side of the binding protein sequences. The discovery is a directed approach that uses a combination of two data sources: 3-D structures of protein complexes and sequences of interacting proteins. We first extract maximal contact segment pairs from the protein complexes' structural data. We then use these segment pairs as templates to sub-group the interacting protein sequence dataset, and conduct an iterative refinement to derive significant binding motif pairs. This combination approach is efficient in handling large datasets of protein interactions. From a dataset of 78,390 protein interactions, we have discovered 896 significant binding motif pairs. The discovered motif pairs include many novel motif pairs as well as motifs that agree well with experimentally validated patterns in the literature.

Investigation of fixation screw pull-out strength on human spine

For the purpose of fixation and stabilizing the spine, the pull-out strength of the screw is one of the most important factors to be considered. The material properties of the bone, coupled with the principal dimensions of the screw such as major diameter, minor diameter, pitch and purchase length, may affect the pull-out strength of the fixation screw. In this study, the effects of various factors on the bone screw pull-out strength were studied using finite element method of analysis. A three-dimensional finite element model simulating the threaded connection of bone and surgical screw was constructed. The behavior of both the bone and the screw during screw pull-out were analyzed and discussed. The effect of the screw parameters on the screw pull-out strength was also investigated. The results showed that failure of the connection was due to bone shearing which occurred along a cylindrical surface determined by the outer perimeter of the screw and penetrated length. The distribution of the shear stress along the threaded length in the bone was nearly uniform. The effect of the major diameter on the screw pull-out strength was more significant than those of the minor diameter and the pitch. The minor diameter hardly affected the pull-out strength.

Secondary syphilis presenting as a lichen planus-like rash

We describe a case of secondary syphilis in a 29-year-old man who presented with a severely pruritic lichen planus-like eruption that mimicked a lichenoid drug eruption histologically. Although uncommon, syphilis should be considered in the differential diagnosis of any lichenoid eruption.

Quantitative three-dimensional anatomy of cervical, thoracic and lumbar vertebrae of Chinese Singaporeans

This paper details the quantitative three-dimensional anatomy of cervical, thoracic and lumbar vertebrae (C3-T12) of Chinese Singaporean subjects based on 220 vertebrae from 10 cadavers. The purpose of the study was to measure the linear dimensions, angulations and areas of individual vertebra, and to compare the data with similar studies performed on Caucasian specimens. Measurements were taken with the aid of a three-dimensional digitiser. The means and standard errors for linear, angular and area dimensions of the vertebral body, spinal canal, pedicle, and spinous and transverse processes were obtained for each vertebra. Compared to the Caucasian data, all the dimensions were found to be smaller. Of significance were the spinal canal area, and pedicle width and length, which were smaller by 31.7%, 25.7% and 22.1% on average, respectively. A slight divergence, instead of convergence, was found from T8 to T12. According to the findings, the use of a transpedicle screw may not be feasible. The results can also provide more accurate modelling for analysis and design of spinal implants and instrumentations, and also allow more precise clinical diagnosis and management of the spine in Chinese Singaporeans.

Cutaneous lymphomas other than mycosis fungoides in Singapore: a clinicopathological analysis using recent classification systems

BACKGROUND

Cutaneous lymphomas other than mycosis fungoides (MF) are a heterogeneous group with wide variations in clinical presentation, biological behaviour and prognosis. New classification systems have been designed or proposed in recent years, with well-defined disease entities and emphasis on the importance of site.

OBJECTIVES

This study aims to analyse a series of non-MF lymphomas in an institution-based dermatological setting in Singapore, based on the European Organization for Research and Treatment of Cancer (EORTC) classification and the World Health Organization (WHO) classification. A secondary objective is to highlight the clinical utility of both classification systems.

PATIENTS AND METHODS

Forty cases diagnosed over a 12-year period were examined by immunohistochemistry with antibodies targeting CD3, CD4, CD5, CD8, CD20, CD30, CD43, CD45RO, CD56 and CD68 in paraffin-embedded specimens. The immunohistological diagnosis was correlated with the clinical presentation and staging investigations for the final diagnosis and the course of disease recorded.

RESULTS

Non-MF T-cell lymphomas presenting in the skin comprised 31 cases (78%) and were 3(1/2) times more common than B-cell lymphomas, which comprised nine cases (22%). The common subtypes were lymphomatoid papulosis, CD30+ large cell cutaneous T-cell lymphoma and subcutaneous panniculitis-like T-cell lymphoma. The commonly ascribed B-cell pattern with infiltrates in the mid and deep dermis and perivascular spaces was seen in 60% of T-cell lymphomas. Overall, there were equal numbers of primary cutaneous T-cell lymphomas and those due to concurrent or secondary cutaneous lymphoma. Five of six cases of subcutaneous panniculitis-like T-cell lymphoma had concurrent cutaneous and systemic involvement and their median survival was 7 months.

CONCLUSIONS

The predominance of cutaneous T-cell lymphomas in this case series closely matched that reported from east Asia; cutaneous B-cell lymphomas are much less common than in Europe. The EORTC classification, which is designed only for primary cutaneous lymphomas, should be used in conjunction with the WHO classification because of the high prevalence of cutaneous lymphomas as the secondary site of disease from systemic lymphoma. In addition, subcutaneous panniculitis-like T-cell lymphoma is a primary cutaneous lymphoma where systemic involvement is common at initial presentation. We propose full immunophenotyping and complete clinical evaluation with staging investigations for all patients presenting with cutaneous lymphomas other than MF.

Clinical profile and treatment outcome of livedoid vasculitis: a case series

INTRODUCTION

Livedoid vasculitis is a painful ulcerative condition affecting the legs that is often difficult to treat. In this case series, the clinical profile of 6 patients with livedoid vasculitis and their treatment response to aspirin and pentoxifylline are reported.

MATERIALS AND METHODS

This is an open trial. Investigations to exclude secondary causes of livedoid vasculitis were done. Skin biopsies were performed for histology and direct immunofluorescence. Four patients were treated with pentoxifylline and 2 with aspirin. Response to treatment was assessed at the third and sixth weeks. Thereafter, treatment was individualised according to each patient's clinical response.

RESULTS

Only 1 out of 6 patients had a good response. This patient was treated with pentoxifylline. Most patients required treatment with drugs such as prednisolone, colchicine and azathioprine to control disease activity after the trial period.

CONCLUSION

Pentoxifylline or aspirin did not result in significant improvement for most of our patients when used alone. Combination with immunosuppressive treatment yielded better results.

Early events of SARS coronavirus infection in vero cells

An isolate from a patient in the recent severe acute respiratory syndrome (SARS) outbreak in Singapore was used to infect Vero E6 cells. This study concentrated on the first 30 min of infection. It was discovered that the SARS coronavirus attached, entered, and uncoated the nucleocapsids, all within a 30-min period. At 5 min after infection, several virus particles lined the Vero cell plasma membrane. Virus particles were at various stages of fusion at the cell surface, since entry was not a synchronised process. After entry (10 and 15 min), spherical core particles moved into the cytoplasm within large vacuoles. Quite surprising at such early stages of infection (20 min), a virus-induced change in the infected cells was evident. The induction of myelin-like membrane whorls was obvious within the same vacuoles as the core particles. The significance of this virus-induced change is unknown at this stage. By 25-30 min postinfection (p.i.), the spherical core particles appeared to be disassociating and, in their place, doughnut-shaped electron-dense structures were observed. These could be the virus genomes together with the helical nucleocapsids. They were no longer in large vacuoles but packaged into smaller vacuoles in the cytoplasm, and occasionally in small groups.

Heterodigital arterialized flaps for large finger wounds: results and indications

Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint, or neurovascular structures require flap coverage. However, the location and size of the defects often preclude the use of local flap coverage. Free-flap coverage is often not desirable either, because the recipient vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap, the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also preserves fingertip cosmesis. Twenty-nine flaps were performed in 29 patients and the outcomes in the donor finger and the reconstructed finger were reviewed. The flap survival was 100 percent. There were no cases of flap ischemia or flap congestion. Good venous drainage of the flap through the additional dorsal vein was helpful in preventing the occurrence of early postoperative venous congestion, which is common in island flaps of the fingers, which depend on only the venae comitantes for drainage. Donor-finger morbidity, measured in terms of range of motion and two-point discrimination in the pulp, was minimal. Ninety-seven percent of the donor fingers achieved excellent or good total active motion according to the criteria of Strickland and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold intolerance of the donor finger or the adjacent finger is reported in this series.

Sweet's syndrome associated with Mycobacterium chelonae and herpes simplex virus infections: a case report

INTRODUCTION

We report a case of Sweet's syndrome associated with Mycobacterium chelonae and herpes simplex virus infection.

CLINICAL PICTURE

A 56-year-old Chinese woman presented with a granulomatous subglottic mass and right lung nodules, which responded to a 9-month course of anti-tuberculous treatment. Subsequently, she developed genital herpes simplex virus infection, which was followed by a cutaneous eruption with vesicular plaques associated with fever, bilateral cervical lymph nodes and neutrophilia. Mycobacterium chelonae was isolated from lymph node cultures. The cutaneous presentation of Sweet's syndrome was confirmed on skin biopsy. There was no evidence of underlying immunosuppression, malignancy or connective tissue disease.

TREATMENT

She was treated with rifampicin, clarithromycin and oral prednisolone.

OUTCOME

There was complete resolution of her cutaneous lesions and cervical lymphadenopathy.

CONCLUSION

The association between Sweet's syndrome and Mycobacterium chelonae as well as herpes simplex virus, though rare, should be considered in all patients presenting with Sweet's syndrome.

Anterior subfascial transposition of the ulnar nerve

After anterior subfascial transposition, the ulnar nerve lies superficial to the flexor-pronator muscle group but deep to its fascia. Eight patients with cubital tunnel syndrome were treated with this method and reviewed retrospectively. The average age at the time of operation was 52 years. All patients had severe cubital tunnel syndrome based on Dellon's classification. The average follow-up period was 2 years and 9 months. Post-operative outcome assessment was based on the modified Bishop rating system. Six patients had excellent and two had good outcomes. All were back at work by the 5th post-operative week. There were no complications or recurrence of symptoms. Anterior subfascial transposition of the ulnar nerve is an effective method of surgical treatment for patients with severe cubital tunnel syndrome.

Isolation and characterization of cDNA clones encoding ADP-glucose pyrophosphorylase from sago palm (Metroxylon sagu)

Four ADP-glucose pyrophosphorylase cDNA clones were isolated from mature leaves and pith of sago palm by the polymerase chain reaction (PCR) technique. Three of them (agpp10, agpp12 and agpl19) encoded the AGP large subunit, while the fourth clone (agpl1) encoded the small subunit. agpp10 and agpp12 were isolated from pith, agpl19 was isolated from mature leaves, while agpl1 from both tissues. In addition, a full-length cDNA of agpl1 was successfully isolated from a cDNA library of mature leaves by a PCR-based screening technique. Semi-quantitative analysis suggests that agpp10 and agpp12 were detectable only in pith, agpl19 only in leaves, while agpl1 was expressed in both leaves and pith tissues.

The cloning of Ty1-copia-like retrotransposons from 10 varieties of banana (Musa Sp.)

Ty1-copia-like retrotransposons have been identified and investigated in several plant species. Here, the internal region of the reverse transcriptase (RT) gene of Ty1-copia-like retrotransposons was amplified by PCR from total genomic DNA of 10 varieties of banana. Two to four clones from each variety were sequenced. Extreme heterogeneity in the sequences of Ty1-copia-like retrotransposons from all the varieties was revealed following sequence analysis of the reverse transcriptase (RT) fragments. The size of the individual RT gene fragments varied between 213 and 309 bp. Southern blots of genomic DNA digested from Musa acuminata and other banana varieties probed with W8 clone from M. acuminata and A4 clone from Pisang Abu Nipah showed similar strong, multiple restriction fragments together with other faint hybridization band patterns with variable intensities indicating the presence of many copies of the Ty1-copia-like retrotransposons in the genomes. There was no correlation between retroelement sequence and the banana species (with A or B genomes) from which it arose, suggesting that the probes are not useful for tracking genomes through breeding populations.

Quantitative three-dimensional anatomy of lumbar vertebrae in Singaporean Asians

This paper details the quantitative three-dimensional anatomy of lumbar vertebrae L1-L5 from Asian (Singaporean) subjects based on 60 lumbar vertebrae from 12 cadavers. The purpose of the study was to measure the dimensions of the various parameters of the lumbar vertebrae and thereafter to compare the data with a study performed on Caucasian specimens. Measurements were taken with the aid of a three-dimensional digitiser. The means and standard errors for linear, angular and area dimensions of the vertebral body, spinal canal, pedicle, and spinous and transverse processes were obtained for each lumbar vertebra. From this comparison, it was found that the dimensions of the vertebral body of the Asian subjects are slightly larger, with a maximum average difference of 8% for the posterior vertebral body height. The dimensions of the spinal canal, pedicle, and spinous and transverse processes of Asian subjects are smaller. The greatest difference can be found in the spinal canal area and pedicle width, which are smaller by an average of 30% and 20%, respectively. With the exception of the spinal canal depth, spinal canal area and pedicle width, all other parameters compared show a similar trend. The findings can provide more accurate modelling for analysis and spinal implant design and also allow more precise clinical diagnosis in sub-Asian groups.

Cardiovascular comorbidity and mortality in patients starting peritoneal dialysis: an American midwestern center experience

End-stage renal disease (ESRD) patients frequently have multiple comorbidities, and cardiovascular disease remains the leading cause of death in these patients. The objectives of the present study were (1) to characterize the number and severity of cardiovascular comorbidities at the start of peritoneal dialysis (PD), and (2) to determine the impact of these comorbidities on mortality. We retrospectively studied all ESRD patients starting peritoneal dialysis at our center between 1990 and 1999. The baseline cardiovascular comorbid factors were categorized as ischemic heart disease, congestive heart failure, arrhythmia, peripheral vascular disease, and cerebrovascular disease. The severity of each factor was scored from 0 to 3. The number of comorbidities and the total cardiovascular comorbidity severity scores were determined for each patient. Cardiovascular deaths included those attributed to sudden death, cardiac disease, cerebrovascular disease, and complications of peripheral vascular disease. Of the 191 patients, 105 were men, and 105 (55%) had diabetes mellitus. The mean age was 60.8 +/- 13.3 years and the mean time on PD was 18.8 +/- 16.3 months. As the number of cardiovascular comorbidities increased, the proportion of patients who died of cardiovascular causes increased eighteen-fold. At each level of cardiovascular comorbidity, diabetic patients starting dialysis were younger, and their survival time was shorter as compared with non diabetic patients. Baseline comorbidity determination is important, as comorbidities are prognostic harbingers of eventual complications.

Transport and budding at two distinct sites of visible nucleocapsids of West Nile (Sarafend) virus

It has been difficult to detect and visualize the physical nucleocapsid particles during the replication process of the flaviviruses. The use of cryo-immunoelectron microscopy has clearly revealed the capsid proteins and nucleocapsid particles of West Nile (Sarafend) virus (a flavivirus) for the first time. Physical nucleocapsid particles accumulated in large numbers from 8 hr postinfection. Double immunolabeling of the envelope and capsid proteins showed a close association of these structural proteins for most of the replication cycle. By 10 hr postinfection, budding of nucelocapsids from the plasma membrane was very obvious. Although maturation at the plasma membrane was the dominant mode, during late infection, intracellular maturation into large vacuoles was also observed.

Hypertensive basal ganglia hemorrhage: a prospective study comparing surgical and nonsurgical management

BACKGROUND

The optimal treatment of hypertensive supratentorial intracerebral hemorrhage is still debated. Some studies have shown no improvement in survival or functional outcome after surgery when compared to conservative management while others have shown otherwise.

METHODS

This study was a prospective trial, matching patients for hematoma volume and Glasgow Coma score on admission.

RESULTS

There were a total of 34 patients. Seventeen were treated conservatively and 17 surgically. There was no significant difference between the two groups in terms of age, GCS, hematoma volume, or presence of intraventricular blood. At 3, 6, and 12-month follow-up, they were assessed using the Modified Barthel Index by a blinded observer. There was no difference between the two groups at 3, 6, or 12 months follow-up. The mortality rate was similar in the two groups.

CONCLUSIONS

Based on this study and review of the literature, we cannot recommend routine evacuation of clots to treat these hemorrhages.

Pemphigus vulgaris following varicella infection

We describe a 26-year-old Indian man who presented with chickenpox and subsequently developed pemphigus vulgaris 17 days after initial resolution of lesions. The mechanism of progression from one disease to the other is postulated to be that of epitope spreading or molecular mimicry.

Hypodermoclysis or subcutaneous infusion revisited

AIM OF STUDY

To review the use of hypodermoclysis in a local Hospice.

METHOD

A review of all hypodermoclysis carried out over a six-month period was conducted. Special attention was paid to the reason for starting and stopping the drip, duration of the drip, complications, the type and amount of solution infused.

RESULTS

Fifty-one (19%) out of 266 patients received hypodermoclysis during their stay. This constituted 5.9% of total patient-days in the study period. Vomiting and drowsiness were the main reasons for the use of drip. The commonest reason for stopping the drip was patient demise. Complications seen were drip site redness (16%), extravasation (15%) and bleeding (2.5%) There was no overt clinical sepsis in any of the patients.

CONCLUSION

Hypodermoclysis is an easy and convenient means of providing hydration. The availability of a standard protocol with clearer guidelines on its use will help to reduce procedure-related complications and promote wider adoption of the practice.

Chemical degradation of composite restoratives

The chemical environment is one aspect of the oral environment, which could have an appreciable influence on the in vivo degradation of composite restoratives. The effects of chemical media on surface hardness of four composite restoratives (Silux [SX], Z100 [ZO], Ariston [AR] and Surefil [SF]) were investigated. The relationship between hardness and the thickness of the degradation layer was also studied. Thirty six specimens (3 x 4 x 2 mm) were made for each material. Following polymerization, the specimens were stored in artificial saliva at 37 degrees C for 24 h. The specimens were then randomly divided into six groups of six, subjected to microhardness testing (load = 500 gf, dwell time = 15 s) and stored in the following chemicals for 1 week at 37 degrees C: artificial saliva (S), distilled water (W), 0.02 N citric acid (C), 0.02 N lactic acid (L), heptane (H) and 75-25% ethanol-water solution (E). After conditioning, the specimens were again subjected to hardness testing and sectioned. Change in hardness (DH) was computed and the thickness of the degradation layer (DL) was measured using a computerized image analysis system at 600x magnification. Results of statistical analysis (ANOVA/Scheffe's [P < 0.05]) of DH based on materials were as follows: SX - E > all other mediums; ZO - W > C; and AR - S, W, E > H (> indicates significantly greater hardness change). No significant difference in DH was observed between the different chemicals for SF. The effects of chemical media on DH were found to be material dependent. A significant but weak positive correlation (Pearson's correlation [P < 0.05]) exists between change in hardness and thickness of the degradation layer.

Comparative study of pemphigus vulgaris and pemphigus foliaceus in Singapore

This is a retrospective study of all patients diagnosed to have pemphigus in our centre over a 3 year period. The case records of all patients with pemphigus from January 1995 to December 1997 were analysed. Fifty patients were diagnosed to have pemphigus during the study period. The diagnoses were pemphigus vulgaris in 31 patients, pemphigus foliaceus in 16, paraneoplastic pemphigus in two and IgA pemphigus in one. The average titre of anti-intercellular antibodies in patients with pemphigus vulgaris (1:96) was higher than the titre in patients with pemphigus foliaceus (1:69). The average initial dose of prednisolone required for disease control in patients with pemphigus vulgaris (62 mg/day) was significantly higher than that required for patients with pemphigus foliaceus (44 mg/day). In our study population, pemphigus vulgaris is a more severe and chronic disease than pemphigus foliaceus, as reflected in the higher titre of anti-intercellular antibodies, higher dose of systemic corticosteroids required for control of the disease, the longer duration to achieve complete remission and longer follow-up period.