Significance of the tethered maxillary frenulum: a questionnaire-based observational cohort study

BACKGROUND

The clinical significance of lip-tie, or a tethered maxillary frenulum, remains under debate. Clinicians and parents are often perplexed when deciding whether procedures available to relieve a seemingly tight or severe maxillary frenulum are needed.

PURPOSE

No previous studies have assessed the consequences of not subjecting a tethered maxillary frenulum in newborns to surgical intervention. This study aimed to contribute the first prospective trial on this topic with a relatively extended followup of these newborn infants.

METHODS

This prospective observational questionnaire-based cohort trial was performed in a community setting and aimed to determine whether lip-tie is associated with an increased likelihood of eventual feeding or oral disorders.

RESULTS

The convenience sample comprised of 61 consecutively arriving infants with concomitant tethered frenula who were treated at the clinic for various reasons. This cohort was compared with a random sample of 66 age-matched children for a mean follow-up period of 6.42 years. Infants undergoing oropharyngeal procedures were excluded. Awareness of a deviation in oral structures was reported by 18% of the study group versus 0% of the controls. Mothers participating in the study group (24.6%) less frequently recalled painful nipples or discomfort during breastfeeding than those in the control group (47.0%) (P<0.01). There were no intergroup differences in other types of feeding difficulty, dental hygiene, pronunciation, or speech development.

CONCLUSION

Our findings suggest that a tethered labial frenulum is not associated with an increase in breastfeeding disturbances or oral disorders. These data encourage clinicians to question the need to intervene in cases of tethered maxillary frenula.

Post Circumcision Corona Obliteration

OBJECTIVE

Abnormal healing after neonatal ritual circumcision is a source of significant concern to patients' parents and their caregivers. This report presents a series of male infants who underwent ritual circumcision and subsequently developed obliteration of the normally distinct structure of the corona.

METHODS

We report a case series of infants recruited from the community and a medical center. The compulsory inclusion criterion was absence of the normal landmarks of the glans penis with confirmed integrity of normal male genitalia. Illustrative cases are presented. The possible pathogenetic mechanisms leading to this condition are discussed. A literature search was conducted to discern whether this phenomenon has ever been previously reported.

RESULTS

The eight cases we diagnosed were all otherwise normal. In one case, where we discovered use of an active substance on the circumcision wound, the condition persisted for an extended period but it resolved completely by 15 months of age. In all but one of the subjects the condition was transient and resolved over time. We could not reveal any previous publication on this topic.

DISCUSSION

This noteworthy complication of circumcision raises debate whether it was previously existent, though unreported or a novel phenomenon. We postulate that contributing factors leading to tissue injury may possibly be injured tissue exposure to irritating substances, vascular compromise, the technique chosen to control bleeding or an idiosyncratic response to tissue trauma. More attention to the occurrence of this phenomenon is compulsory to collect more data and learn of its incidence and eventual impact.

CONCLUSIONS

Obliteration of the corona, constitutes an unreported, rare albeit significant complication following circumcision. We recommend refraining from potentially inciting factors leading to this undesirable condition. More extensive experience with this disorder may enable us to employ preventive measures to eliminate it or at least provide reassurance wherever possible.

The new kid on the block in physical diagnosis? Introducing digital microscopy

Emerging microprocessor technology has revolutionized all aspects of life in the modern era. Feats previously achieved through sophisticated, cumbersome and expensive devices are currently both commonplace and feasible with convenient instruments available at low-cost. Body surface inspection can prove very challenging when seeking minute alterations of anatomy and miniature inflicting culprits. USB (universal serial bus) dermatoscopy (UD) is the most economical and widespread technique widely utilized in industry and even lay use but inadeqautely addressed in the field of medicine. This manuscript provides a preliminary exposure of UD to those unfamiliar with this technique and demonstrates its merits improving patient care. UD constitutes an ideal method to magnify, up to over 100 fold, minute detail and project images on a screen of choice, be it a laptop, tablet or standard smartphone. Clinical practice, especially in rural areas, has much to gain from a device that can expose illusive clinical detail that is imperceptible by the naked eye. The basis of the technique is described and genuine cases where it was utilized are shared. Personal experience with this technique demonstrates that employing ample magnification and thorough illumination facilitates reaching the correct diagnosis whenever physical examination of the superficial body surface is necessary. Body regions amenable for improved visualization with this method extend from scalp hair, skin and ocular structures, all the way to the anal sphincter. The objective of this paper is to familiarize physicians with the advantages of digital microscopy through numerous clinical illustrations, as: characterization and surveillance of lesions, sores, cutaneous and corneal foreign bodies, painful conditions of the nipple, hematomas retained sutures, secretions and purulent lesions. This introduction is hoped to arouse enthusiasm towards digital microscopy and encourage its adoption into routine practice.

Revisiting the Jewish Ethical Approach Toward Perimortem Cesarean Section in Light of Emerging Medical Evidence

BACKGROUND

Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus.

OBJECTIVES

To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized.

METHODS

Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother's vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother.

RESULTS

We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered.

CONCLUSIONS

The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible.

"Seeing Is Believing": Dermatoscope Facilitated Breast Examination of the Breastfeeding Woman with Nipple Pain

BACKGROUND

It is well recognized that breastmilk provides optimal nutrition and immunological protection for infants. Many women, however, experience nipple pain while breastfeeding, leading to premature cessation of nursing. To overcome these difficulties, timely diagnosis is crucial to effectively treat the underlying pathology and permit resumption of breastfeeding. Examination of the superficial breast plays a key role in accurate diagnosis. Traditional direct inspection is clearly inadequate for this task.

MATERIALS AND METHODS

The dermatoscope is a useful tool, enlarging and illuminating an area of epidermis to obtain an optimal image. Improvements in dermoscopy involving polarization obviate the need for full contact with the examined surface, thereby providing anatomical detail in three dimensions.

RESULTS

A novel practice presented in this article features clinical cases introducing this technique as it is applied to the lactating breast, conclusively distinguishing normal from abnormal and illustrating the efficacy and added diagnostic value of this approach. The dermoscope is shown to facilitate identification of the causes of nipple pain ranging from asymptomatic candidal infection to exquisitely painful, minute traumatic erosions, aiding, thereby, in diagnosis of the underlying causes of nursing difficulties. Improved wound surveillance and standardization for purposes of research documentation are additional benefits anticipated with the use of breast dermoscopy.

CONCLUSIONS

We conclude that real-time, high-quality, magnified imaging of the lactating breast represents a recognizable advance in pursuit of a rapid and accurate technique that aids in the identification of the factors responsible for lesions affecting nursing women. Moreover, it features an already existing technology requiring little training at a reasonable cost.

[THE HUMAN CHAMELEON--BOMBARDED]

A new attitude recently raised in the literature emphasizing the role of the family in the care of the patient introduces a novel paradigm of family presence during resuscitation, which continues to be a debatable issue without widespread implementation. Can the same recommendations rooted at medical centers be extrapolated to the traumatic scene where a physician is called to treat his own community members? In this paper the scenario presented depicts a family physician called to treat terrorist victims of his own community overwhelmed by dilemmas including ethical considerations. He is subjected to stress and strain that seem beyond his capacity. The physician in rural settings may be placed in situations that confront challenges demanding metamorphosis in order to answer unexpected needs towards which he has not been fully trained. Despite the hardships involved, withstanding such situations can lead to profound satisfaction.

Retrospective study of the incidence of unstable and shock patients presenting to the emergency room

BACKGROUND

Over a period of three decades, medical personnel working in our emergency room observed that fewer severe cases presented to the emergency department. The objective of this study is to assess whether a genuine change in the presentation rates of clinically unstable non-trauma patients to the emergency room indeed exists.

METHODS

We conducted a retrospective review of patients treated in the shock room. Patients' demographic data, diagnoses and outcomes were accessed. Populations of patients presenting to the shock room over a span of four seasons, in two separate periods eight years apart were compared. This rate was compared with the complementary bulk rate of patients presenting to the emergency room at the center.

RESULTS

While absolute rates of emergency room utilization rose, the rate of unstable patients demanding urgent intensive care showed a clear decline. An absolute reduction of close to 50% across the different seasons of the examined years was found. Per patient, the proportion of those requiring artificial respiration and urgent hemodialysis remained uniform in both periods. All parameters of patient outcomes were similar in both periods of the study.

CONCLUSION

This unexplored aspect of emergency care demonstrates a dramatic decline in the incidence of unstable patients. While we should continue to reinforce delivery of superior care, our medical educational system should adapt itself to compensate for the diminished exposure of our trainees to emergencies. Further research in this field should explore whether the trend we observed exists in other geographical locations and whether this parameter can be utilized as a quality measure of medical systems.

Diagnosis of ophthalmomyiasis externa by dermatoscopy

Ophthalmomyiasis in humans caused by the larvae of the sheep nasal botfly (Oestrus ovis) and is a rare phenomenon in Israel. We describe the utilization of the dermatoscope as a diagnostic tool for the facilitation of early diagnosis of conjunctivitis due to the infestation of the eyes by the sheep nasal botfly in two patients. After the physical removal of the larvae with the help of a cotton swab applicator under a slit lamp examination and the topical use of antibiotics, the clinical symptoms improved within 1-2 days. Undoubtedly the dermatoscope played a crucial role leading to the definitive diagnosis and immediate therapeutic intervention.

Delivering bad news: an approach according to jewish scriptures

Despite a preoccupation in the medical literature with developing an effective approach for breaking bad news, the sources are based on personal opinion alone and only in some instances on qualitative research. Recognizing the gravity of this topic coupled with respect for the wisdom of the written and oral Jewish scriptures, this work is an attempt to delve into the diverse ancient writings to draw conclusions regarding a recommended methodology to guide and inform this task. It is interesting to learn that most elements related to this topic have previously been raised in various forms in the scriptures. The issues range from where, when, and how the bearer of bad news should undertake this duty, to details such as the environment, the format, the speed, and depth of the details to be disclosed. The essence of this paper is to enrich the reader using both positive and negative examples found in the Jewish heritage. Adopting these principles will hopefully provide an effective method for performing this unpleasant obligation, with the goal of limiting harmful consequences as much as possible.

Enhancement of pediatric ophthalmologic diagnosis with a handheld polarized dermatoscope

OBJECTIVE

In pediatric primary care, an adjunct for ophthalmology diagnosis and monitoring of treatment could be of great advantage. The portable polarized dermatoscope can readily fit the purpose as an alternative to the classic slit lamp device.

METHODS

We describe and demonstrate our clinical experience using the dermatoscope for diverse ocular conditions.

MAIN MESSAGE

Beyond its effective primary role as an examination tool for detecting dermatopathology, the dermatoscope proves its worth in a variety of separate ophthalmologic clinical states where intricate details need recognition. From corneal or subtarsal foreign body identification, to tear gutter assessment, this instrument can facilitate our work whenever magnification and illumination is beneficial.

CONCLUSION

The technique described raises the option of using a substitute for usually lacking, cumbersome equipment for many therapeutic situations, rural clinics and home visits, easily available for the busy pediatrician, demanding little training, and at a reasonable cost.

[Safe quadruplet gestation following peripartum discectomy for massive disc prolapse]

INTRODUCTION

We would Like to present a rare case of multiple gestation following a severe event of spinal cord morbidity during a previous singleton gestation. The medical literature carries a paucity of evidence regarding the future fate of pregnancies following gestational induced intervertebral disc prolapse.

CASE HISTORY

A 21 year old mother delivered a healthy boy after unbearable back pain. She subsequently developed urinary retention with laxity of the anal sphincter and underwent urgent L5-S1 discectomy. Following in vitro fertilization for infertility she conceived and was warned of the dangers of a gestation with quadruplets. The parents decided to continue the gestation regularly without intervention despite possible complications. At 31 weeks of gestation the mother delivered four normal male babies, each weighing over 1200 grams after a normal (supervised) pregnancy devoid of any back symptoms. This case demonstrates a novel clinical scenario of hitherto unreported major challenges to an established vulnerable vertebral column.

DISCUSSION

To the best of our knowledge this is the first report of a multiple gestation following severe spinal column pathology demanding surgical intervention in order to prevent long term handicap. We could not even locate a series of singleton gestations following such a clinical scenario. The favorable outcome observed in this case is very encouraging and can serve to reassure potential mothers who have experienced a similar previous episode as demonstrated here.

CONCLUSION

Special caution must be taken when consulting pregnant patients. From this case history we may learn that precautions such as indefinite contraception after a previous incident of massive disc prolapse may be widely unnecessary.

Abdominal wall ischemic fasciitis associated with a torso brace in a young girl

We describe a rare case of ischemic fasciitis of the abdominal wall in a child with scoliosis. The fasciitis was apparently caused by the constant pressure exerted by her torso brace. Clinicians should be alert to the possibility of mechanical factors in the etiology of ischemic fasciitis.

Office management of penile skin bridges with electrocautery

BACKGROUND

Penile skin bridges are an uncommon complication of circumcision that are often found in general practice. This condition can be treated successfully in the office, avoiding referral for a surgical procedure.

METHODS

Four case reports of the technique of treating penile skin bridges are described, and the literature on the cause and treatment of skin bridges is reviewed.

RESULTS AND CONCLUSIONS

Using local anesthesia and bipolar diathermy, penile skin bridges were successfully treated in the office on 4 patients of different ages. There was no bleeding and the wounds healed without complication. This brief and simple technique, described in detail, is appropriate for an office procedure in family practice.

Household papular urticaria

BACKGROUND

Papular urticaria often occurs after bites of insects such as mosquitoes, sandflies, bed bugs and fleas. Multiple bites and local pruritus are characteristic symptoms. Treatment is usually symptomatic and includes antihistamines and corticosteroids. The reappearance of the symptoms can be prevented by successful control of the parasite.

OBJECTIVES

To find the causative agent of papular urticaria in afflicted households with involvement of numerous family members, all in a narrow geographic area.

PATIENTS

We describe the cases of 20 patients belonging to seven families, who presented to the local primary clinic, suffering from papular urticaria.

RESULTS

The cat flea, Ctenocephalides felis, was the hematophagous insect responsible for all infestations. The pruritus and the papular urticaria were treated symptomatically with calamine lotion, topical corticosteroids or oral antihistamines. All clinical symptoms disappeared within a few weeks after effective control of the parasites by spraying and fumigating the infested locations.

CONCLUSIONS

Thorough investigation--including, at times, environmental inspection--is necessary to reach the rewarding discovery of the etiology of household papular urticaria. This condition may arise in other environments of similar character.

Pyogenic granuloma of the penile shaft following circumcision

Pyogenic granuloma is a benign vascular, inflammatory proliferation that appears following minor trauma in children. The exact pathogenesis of pyogenic granuloma is unknown, but its formation is closely related to minor trauma, chronic irritation, and hormonal influences. We present a unique case of a pyogenic granuloma that appeared in an infant following circumcision.

Elastic adhesive dressing treatment of bleeding wounds in trauma victims

Conventional methods for hemorrhage control in the trauma patient fall short of providing a full solution for the life-threatening bleeding injury. The tourniquet is limited specifically to injuries of the distal limbs. Local pressure or tight bandaging with military bandages is cumbersome and often insufficient. Therefore, we sought a superior method to stop bleeding in emergency situations. Our objective is report and description of our experience with this method. Since 1992 our trauma team repeatedly encountered multiple trauma victims presenting with bleeding wounds. We achieved hemorrhage control by means of an adhesive elastic bandage applied directly over a collection of 4 x 4 gauze pads placed on the wound surface. The roll is then wrapped around the body surface, over the bleeding site, until sufficient pressure is reached to terminate ongoing hemorrhage. Three typical cases are described in detail. Adhesive elastic dressing compression was successful in fully controlling bleeding without compromise of distal blood flow. Our method corresponded to the demand for an immediate, effective and lasting form of hemorrhage control without complications. Furthermore, this technique proved successful even over body surfaces normally recognized as difficult to compress. We experienced equal favorable success while working during transit by either ambulance or helicopter transportation. We find our preliminary experience using elastic adhesive dressing for bleeding control encouraging and suggest that this may substitute existing practices as the selected treatment when indicated. This method is presently underrecognized for this purpose. Development of a single unit bandage may further enhance success in the future.

Plantar hidradenitis in children induced by exposure to wet footwear

Painful erythematous papules and nodules involving either the palms of the hands, or, more commonly, the soles of the feet, characterize palmoplantar eccrine hidradenitis or palmoplantar hidradenitis (PH). The younger pediatric population is predominately affected. Histologically, the eccrine gland apparatus is the target of inflammatory neutrophilic infiltrates. This entity has been reported under a variety of names, including traumatic plantar urticaria, neutrophilic eccrine hidradenitis, plantar erythema nodosum, and idiopathic recurrent palmoplantar hidradenitis. All are essentially the same process, described in different forms. Despite the growing number of reported cases, the pathogenesis remains obscure. We present four children with PH of the soles of the feet, who shared a common recent history of exposure to cold, damp, footwear. The temporal relationship between exposure to dampness and cold and the appearance of the skin lesions suggest a possible pathogenetic mechanism.

Davener's dermatosis: a variant of friction hypermelanosis

BACKGROUND

As part of our clinical experience we encountered a group of patients from a specific population with a similar peculiar pigmentation over the lower dorsal spine.

OBJECTIVE

We investigated these patients to see whether we could determine a common origin.

METHODS

Patients meeting the inclusion criteria underwent detailed history and complete physical examination; biopsy specimens from 3 patients were studied.

RESULTS

All 13 patients were full-time male students at Orthodox Jewish Talmudic seminaries (Yeshivas). The lesion consisted of an elongated, vertical, midline, hyperpigmented patch with indistinct borders, which was distributed along the skin overlying the bony protuberances of the inferior thoracic and lumbar vertebrae. It was often unrecognized by the patients. Mean body mass index was lower than that for the general population. Histologic study showed a marked diffuse hyperkeratosis and hyperplastic epidermis with diffuse hyperpigmentation. We attributed the phenomenon to friction from the rigid backrests against the cutaneous surface of the lower back generated by the characteristic swaying activity that traditionally accompanies Torah study or "davening" (praying) and termed it Davener's dermatosis.

CONCLUSION

We believe this phenomenon represents a new form of benign friction hypermelanosis. This report highlights the importance of a thorough history in patients presenting with pigmented lesions.