Endometriosis and dyspareunia: Solving the enigma

Introduction

Endometriosis is a chronic oestrogen-dependent disease that affects 1 in 10 women of childbearing age. Half of these women have deep dyspareunia. The presence of this symptom has been shown to negatively affect your quality of life. There are few studies in the literature that address this issue and its pathophysiology remains poorly understood.

Materials and methods

A case-control study has been carried out in order to assess the multi-causality of dyspareunia in patients with endometriosis. All the patients were assessed in a unit specialising in endometriosis and pelvic pain and their disease was staged using high-resolution ultrasound following the criteria of the IDEA group. The patients were divided into two groups, patients with dyspareunia n = 45 (cases) and those without it n = 55 (controls).

Results

The only element that was statistically significant in explaining the dyspareunia was the presence of nodules in the retrocervical region with p = 0.000. The odds ratio of dyspareunia in the cases group was 5.3 (95 % CI 2.2-12.5).

Conclusions

Dyspareunia in patients with endometriosis is strongly dependent on the presence of nodules in the retrocervical region, although there are other factors involved that remain unknown, so more studies are still needed to understand and optimally address this symptom.

Management of "torus" or "buckle" fractures of the distal radius: a systematic review

BACKGROUND

Torus fractures, also known as buckle fractures, of the distal radius are a very common reason for presentation to emergency departments. Traditional approaches to their management involved immobilisation in a circumferential cast but the evidence now supports the use of removable splints with or without radiological and clinical follow-up. Unfortunately current practice conflicts with the evidence base and there is no guideline which highlights all the evidence as one clear, concise management protocol.

METHODS

An online review of Pubmed, EMBASE, Biomed, and the Cochrane library using keyword searches combining "radius", "torus", "buckle" and "fracture" was performed. All prospective, retrospective or randomised trials involving the management of distal radius torus fractures in patients aged 0-18 years were included. Our outcomes focused on 5 aspects of patient care: immobilisation method and duration, clinical follow-up, radiological follow-up and the use of diagnostic ultrasound.

RESULTS

The initial search identified 143 papers which following application of the inclusion and exclusion criteria 21 articles were deemed eligible. A Cochrane review and 8 systematic reviews were also identified and manually searched for missed articles and this yielded a further 3 articles.

CONCLUSIONS

Current research indicates that torus fractures should be managed with a removable splint supplied in A&E and worn for 3 weeks. There is no need for fracture clinic follow-up or repeat radiological imaging once patients are given adequate information at the time of diagnosis. This would represent both an economical and resource saving for patients, parents and the health service.

Early recurrence of mandibular torus following surgical resection: A case report

INTRODUCTION AND IMPORTANCE

Tori are benign bony outgrowths that occur in different locations along the mandible and maxilla. Their origin is still uncertain; however, various hypotheses have been put forward, including male gender or mechanical overload. Recurrence of a torus after surgical resection is rarely described, and even less rapidly after a procedure.

CASE PRESENTATION

We present here the case of a 52-year-old patient who presented voluminous mandibular tori on the lingual side. The tori recurred very rapidly after the first resection surgery and with the same initial volume. Pathological examinations confirmed the histological type. The identified risk factors were excessive fish consumption, occlusal overload factors, and male gender. The patient then underwent a second surgery associated with a mouth guard in order to treat bruxism. There was no recurrence after one year of follow-up.

CLINICAL DISCUSSION

This case report highlights the fact that there is still a lack of understanding of the risk factors associated with torus. However, several studies have been able to understand certain genetic or dietary mechanisms in the genesis of these exostoses.

CONCLUSION

This case emphasizes the importance of mechanical overload in the recurrence of exostoses, which, coupled with dietary, gender, and ethnic factors, may be responsible for recurrence in this patient. The detection of factors associated with the risk of recurrence is a major challenge.

Pain scores in torus fractures: Using text messages as an outcome collection tool

Aims

This study sought to estimate the clinical outcomes and describe the nationwide variation in practice, as part of the feasibility workup for a National Institute for Health and Care Excellence (NICE) recommended randomized clinical trial to determine the optimal treatment of torus fractures of the distal radius in children.

Methods

Prospective data collection on torus fractures presenting to our emergency department. Patient consent and study information, including a copy of the Wong-Baker Faces pain score, was issued at the first patient contact. An automated text message service recorded pain scores at days 0, 3, 7, 21, and 42 postinjury. A cross-sectional survey of current accident and emergency practice in the UK was also undertaken to gauge current practice following the publication of NICE guidance.

Results

In all, 30 patients with a mean age of 8.9 years were enrolled over a six-week period. Of the 150 potential data points, data was captured in 146, making the data 97.3% complete. Pain scores were recorded at day 0 (mean 6.5 (95% confidence interval (CI) 5.7 to 7.3)), day 3 (4.4 (95% CI 3.5 to 5.2)), day 7 (3.0 (95% CI 2.3 to 3.6)), day 21 (1.2 (95% CI 0.7 to 1.7)) and day 42 (0.4 (95% CI 0.1 to 0.7)). Of the 100 units who participated in the nationwide survey, 38% were unaware of any local or national protocols regarding torus fractures, 41% treated torus fractures with cast immobilization, and over 60% of patients had follow-up arranged, both contradictory to national guidelines.

Conclusion

We have demonstrated the severity, recovery trajectory, and variation in pain scores among children with torus fractures. We demonstrate excellent follow-up of patient outcomes using text messages. Despite national guidelines, there is significant variation in practice. This data directly informed the development of an ongoing nationwide randomized clinical trial - the FORearm Fracture Recovery in Children Evaluation (FORCE) study.

Torus obstacle method as a wrapping approach of the deltoid muscle group for humeral abduction in musculoskeletal simulation

Musculoskeletal models of the shoulder complex are valuable research aids to investigate tears of the supraspinatus and the resulting mechanical impact during abduction of the humerus. One of the major contributors to this motion is the deltoid muscle group and for this, an accurate modeling of the lines of action is indispensable. The aim of this work was to utilize a torus obstacle wrapping approach for the deltoids of an existing shoulder model and assess the feasibility of the approach during humeral abduction. The shoulder model from the AnyBody™ modeling system was used as a platform. The size of the tori is based on a magnetic resonance imaging (MRI) approach and several kinematic couplings are implemented to determine the trajectories of the tori during abduction. To assess the model behavior, the moment arms of the virtual muscle elements and the resultant glenohumeral joint reaction force (GHJF) were compared with reference data from the literature during abduction of the humerus in the range 20°-120°. The root mean square error for the anterior, lateral and posterior part between the simulated muscle elements and reference data from the literature was 3.9, 1.7 and 5.8 mm, respectively. The largest deviation occurred on the outer elements of the muscle groups, with 12.6, 10.4 and 20.5 mm, respectively. During abduction, there is no overlapping of the muscle elements and these are in continuous contact with the torus obstacles, thus enabling a continuous force transmission. This results in a rising trend of the resultant GHJF. The torus obstacle approach as a wrapping method for the deltoid muscles provides a guided muscle pathing by simultaneously approximating the curvature of the deltoid muscle. The results from the comparison of the simulated moment arms and the resultant GHJF are in accordance with those in the literature in the range 20°-120° of abduction. Although this study shows the strength of the torus obstacle as a wrapping approach, the method of fitting the tori according to MRI data was not suitable. A cadaver study is recommended to better validate and mathematically describe the torus approach.

Images in medicine: torus palatinus

A 56 year old African-American female with history of well-controlled hypertension and hyperlipidemia presented to the office for an annual physical examination. She did not have any complaints. She reported being compliant with her medications, exercised daily at her local gym, and maintained a low salt diet. She visits her dentist every 6 months and has had a few fillings in her premolars in the past. On physical examination, her vital signs were normal and the entirety of her physical examination was normal with the exception of her oropharynx. Throat examination revealed a 2 × 1 cm midline hard palate swelling that was bony hard in consistency and covered by normally appearing oral mucosa. It was diagnosed as a torus palatinus. The patient was unaware of its presence and denied being informed about it by her dentist on any visit. She was also educated about the diagnosis and safety-netted by being informed about red-flags that would prompt investigation such as change in size or shape.

Asymmetric bone remodeling in mandibular and maxillary tori

OBJECTIVES

Tori are frequent paucisymptomatic bony outgrowths of the oral cavity in three locations: torus palatinus (TP), mandibularis (TM), and maxillaris (TMax). Their usually described histological characteristics are unspecific: normal cortical bone with more or less trabecular bone. The aim of this study was to describe tori's specific morphological and histomorphometric characteristics.

MATERIALS AND METHODS

Histological characteristics in a series of 18 tori collected after surgical removal were analyzed. Microcomputed tomography provided a 3D analysis. Mineral apposition rate (MAR) was measured after double tetracycline labeling. Osteoid tissue was identified by Goldner's trichrome and osteoclasts by the tartrate resistant acid phosphatase identification in undecalcified sections. Iron and aluminum were detected by histochemical staining methods. Osteoid thickness and MAR were determined at the outer surface of the torus and in the Haversian canals.

RESULTS

Tori appeared made of lamellar Haversian bone in 16/18 cases. Osteoid thickness did not differ between the outer surface and within the canals. An asymmetric bone remodeling was observed in the Haversian canals of 15 tori: osteoid seams were deposited on the side close to the free torus surface, and Howship's lacunae with numerous osteoclasts were observed on the opposite side. A high MAR was found at the surface of the tori and within the canals. There was no iron or aluminum deposit.

CONCLUSIONS

Tori may be characterized by a specific asymmetric bone remodeling which seems to determine their shape.

CLINICAL RELEVANCE

This finding could constitute a specific histological feature allowing to differentiate tori from exostoses. Graphical abstract.

Preprosthetic Surgery

Preprosthetic oral and maxillofacial surgery has changed dramatically over the last 3 decades. Surgical preparation for dentures has been displaced by site development for implants. Nonetheless, there is still a role to play for several preprosthetic procedures. In this article, historical context is provided, enduring concepts are reviewed, and procedures that remain relevant are described and discussed.

Mandibular tori as an incidental finding in MRI

Tori (singular: torus) are among the most common benign jaw lesions. The magnetic resonance imaging (MRI) characteristics have not been reported yet. We present a 72-year-old patient with mandibular tori, which were detected as an incidental finding on MRI and provide an overview of the imaging features of tori.

Diagnosis and treatment of greenstick and torus fractures of the distal radius in children: a prospective randomised single blind study

OBJECTIVE

The management and the diagnostic modalities used in cases of undisplaced greenstick and torus fractures of the distal radius in children vary between different treatment centres. The aim of this study was twofold: firstly, to analyse the sensitivity of X-rays versus ultrasound to diagnose these fractures; secondly, to compare three available treatment options (plaster cast, Futuro splints, and double Tubigrip) in terms of pain, analgesia requirements, grip strength, deformity, stiffness and interference with a child's activities of daily living.

METHODS

We prospectively included 79 patients suffering from undisplaced greenstick and torus fractures of the distal radius. Patients were randomized (single blindly) to the studied treatment groups.

RESULTS

In terms of diagnosis, the ultrasound was found to be more sensitive than X-rays for diagnosing these fractures. Our results also showed that Tubigrip was superior in terms of interference with a child's ADLs, stiffness and grip strength. However, there was no difference in the levels of pain, analgesia required, and deformity.

CONCLUSION

These results support the idea that ultrasound is an effective and sensitive tool for detecting undisplaced greenstick and torus fractures of the distal radius in children. Treating these fractures with functional nonrigid devices (Tubigrip) results in improved function without increased discomfort or deformity.