Diagnosis of post-traumatic complex regional pain syndrome of the hand: current role of sympathetic skin response and three-phase bone scintigraphy

PURPOSE

To evaluate the role of sympathetic skin response (SSR) and three-phase bone scintigraphy (TPBS) in the diagnosis of complex regional pain syndrome (CRPS).

METHODS

60 patients with CRPS of the hand were recruited. TPBS was performed using a bolus injection of 20 mCi of Tc-99m methylene diphosphonate in an antecubital vein and blood flow (first phase) image, blood pool (second phase) image, and delayed (third phase) image obtained. Patients were considered to have CRPS when the blood pool and blood flow images showed diffuse asymmetric uptake, or when the delayed image indicated increased asymmetric periarticular uptake. SSR was measured simultaneously in the affected and unaffected hands. Standard surface electromyogram disc electrodes were applied to the palm and dorsum of both hands. Electrical stimuli were applied to the skin at the base of little and ring fingers of the unaffected hand. Patients were considered abnormal when response was absent or the peak-to-peak amplitude was <50% of the contralateral hand in at least 2 readings.

RESULTS

The delayed phase of TPBS tested positive in all; the first and second phases tested positive in 54 (90%) and 56 (93%) of the patients, respectively. Four of the 6 patients with a negative first phase had had symptoms persisting for more than 6 months, and the other 2 for about 3 to 6 months. No patient presenting within 3 months had a negative scan. SSR was absent in 16 (27%) patients and normal in 44 (73%). 11 (79%) of 14 patients who presented more than 6 months after symptom onset displayed an abnormal SSR, while only 10% of those presenting within 3 to 6 months and 11% of those presenting within 3 months had an abnormal SSR. 12 (75%) of the 16 patients with abnormal SSR had associated decreased sweating, compared with 2 (4.5%) of the 44 patients with a normal SSR.

CONCLUSION

TPBS is a very sensitive corroborative test to confirm the clinical suspicion of CRPS during the initial stages, but not in late cases. SSR can be used to document the sympathetic dysfunction in cases having an associated sweating abnormality and may have some diagnostic value in late cases of CRPS, when TPBS is less reliable.

Evaluating the effectiveness of school-based dental health education program among children of different socioeconomic groups

The aim of the present study was to evaluate the effectiveness of Dental Health Education programs among school children of different socioeconomic groups. The investigators made a visit to three different schools and studied 500 children. A ten items, open-ended, self-administered questionnaire was pretested on the primary and higher primary school children before and after an educational intervention. A second visit was made to one of the schools 1 year later and the same questionnaire was re-administered to those subjects who had participated in the original study. Results showed that although educational intervention was successful in improving the Dental health awareness of most children, the socioeconomic background is an important determinant for the same. Also, single-lecture technique seems to be inadequate in improving the knowledge of children in the long term.

Effect of pH on production of virulence factors by biofilm cells ofPseudomonas aeruginosa

Effect of pH on production of extracellular virulence factors of Pseudomonas aeruginosa grown on catheter in biofilm was determined. Alginate and proteinase production was higher at pH 8; in contrast, siderophores (pyochelin and pyoverdin) were synthesized more intensively at pH 5.

Use of bio-resorbable implants for stabilisation of distal radius fractures: the United Kingdom patients' perspective

Bio-resorbable implants have been, recently, introduced in the United Kingdom. To our knowledge there have been no randomised studies to assess perception of today's well-informed patients about this new method of fracture stabilisation. In order to assess the patients' perception a prospective study was performed on 100 consecutive adult patients with distal radius fractures. Following detailed verbal and written information about both resorbable and metal implants, the patients were asked to complete a specifically designed questionnaire. Ninety-five percent of the patients appreciated the 'resorbable' feature and responded that they would prefer to have their fracture stabilised with a resorbable implant. Conversely, 91% of the participants considered removal as the most negative aspect of the metal implant (p<0.0001). While 56% of the patients felt that it was relatively a new and evolving technology, 29% of them had apprehension about the relative strength of the resorbable implant. Eighty percent of the patients stated that they would be happy to participate in clinical trials to compare the use of bio-resorbable implants versus metal ones (p=0.0001). This study sets the foundation for the implementation of prospective randomised trials to assess the efficacy of the new generation of bio-resorbable implants.

"Failure" of forearm intramedullary elastic nails

Elastic nails are an established modality for treating forearm fractures in children. These nails are usually removed 6-9 months after surgery as refracture may occur in 10% of cases if the nails removed earlier. We report a case of refracture of the forearm bones with elastic nails in situ, 5 months after the original fractures. The fracture was angulated approximately 80 degrees with the apex pointing anteriorly. Closed reduction was difficult and resulted in breakage of the ulnar nail. The authors describe the details and outline the management of this unreported complication.

Chilblain lupus erythematosus mimicking acrofacial vitiligo

Chilblain lupus erythematosus with depigmentation is a rare presentation of lupus erythematosus that may simulate vitiligo. A 52-year-old lady with such a manifestation is being reported.

Incidence of low back pain in workage adults in rural North India

Out of 11234 patients reporting to our outdoor during June 2001 to June 2002, 2594 patients (23.09%) had low back pain. 4358 roentgenograms were done in these patients, a mean of 1.68 per patient. These patients were interviewed and their psychosocial and demographic details were compared with 1000 controls who did not have back pain but attended outdoor for other reasons. In the low back pain group, 67% had psychosocial issues, 57% were in blue-collar jobs, 26% had to change/leave their profession, and 38% did not enjoy their present job. All patients had used NSAIDS at some stage of illness and 64% were advised exercises for the back. The comparative figures in control group were 19% with psychosocial issues, 34% in blue-collar jobs (heavy manual workers), 7% had to switch over to new job, 6% did not relish their present job. Hence, it is concluded that along with exercises and NSAIDS, sufficient consideration should be given to short centre-based intensive rehabilitation program followed by a home-based program for chronic low back pain patients.

NMR identification of local structural preferences in HIV-1 protease tethered heterodimer in 6 M guanidine hydrochloride

Understanding protein folding requires complete characterization of all the states of the protein present along the folding pathways. For this purpose nuclear magnetic resonance (NMR) has proved to be a very powerful technique because of the great detail it can unravel regarding the structure and dynamics of protein molecules. We report here NMR identification of local structural preferences in human immunodeficiency virus-1 protease in the 'unfolded state'. Analyses of the chemical shifts revealed the presence of local structural preferences many of which are native-like, and there are also some non-native structural elements. Three-bond H(N)-H(alpha) coupling constants that could be measured for some of the N-terminal and C-terminal residues are consistent with the native-like beta-structure. Unusually shifted 15N and amide proton chemical shifts of residues adjacent to some prolines and tryptophans also indicate the presence of some structural elements. These conclusions are supported by amide proton temperature coefficients and nuclear Overhauser enhancement data. The locations of the residues exhibiting preferred structural propensities on the crystal structure of the protein, give useful insights into the folding mechanism of this protein.

Testicular tissue extraction in a young male with 47,XXY Klinefelter's syndrome: potential strategy for preservation of fertility

OBJECTIVE

To describe a case involving the cryopreservation of testis tissue retrieved from a 15-year-old male teenager with Klinefelter's syndrome.

DESIGN

Case report.

SETTING

An academic medical center.

PATIENT(S)

A 15-year-old boy with Klinefelter's syndrome.

INTERVENTION(S)

Microsurgical testis sperm extraction with cryopreservation of harvested tissue.

MAIN OUTCOME MEASURE(S)

Spermatozoa within testis tissue.

RESULT(S)

Successful extraction and cryopreservation of three vials of sperm-containing testis tissue. No effect on subsequent testosterone levels.

CONCLUSION(S)

Testis tissue extraction in the adequately virilized but azoospermic young male with 47, XXY Klinefelter's syndrome may be a strategy to preserve future biological paternity.

Application of large-eddy simulation to the study of pulsatile flow in a modeled arterial stenosis

The technique of large-eddy simulation (LES) has been applied to the study of pulsatile flow through a modeled arterial stenosis. A simple stenosis model has been used that consists of a one-sided 50 percent semicircular constriction in a planar channel. The inlet volume flux is varied sinusoidally in time in a manner similar to the laminar flow simulations of Tutty (1992). LES is used to compute flow at a peak Reynolds number of 2000 and a Strouhal number of 0.024. At this Reynolds number, the flow downstream of the stenosis transitions to turbulence and exhibits all the classic features of post-stenotic flow as described by Khalifa and Giddens (1981) and Lieber and Giddens (1990). These include the periodic shedding of shear layer vortices and transition to turbulence downstream of the stenosis. Computed frequency spectra indicate that the vortex shedding occurs at a distinct high frequency, and the potential implication of this for noninvasive diagnosis of arterial stenoses is discussed. A variety of statistics have been also extracted and a number of other physical features of the flow are described in order to demonstrate the usefulness of LES for the study of post-stenotic flows.

Trachyonychia treated with oral mini pulse therapy

A 12-year-old girl presented with dull, opalescent, nails with a roughened surface. She was successfully treated with oral mini-pulse therapy, which consisted of 4 mg betamethasone as a single oral dose with breakfast on two consecutive clays every week.