The assessment of insight in psychosis

An assessment schedule was used to determine the nature of insight in 91 mixed psychotic patients, and to examine its distribution and associations. While all the components of the schedule intercorrelated significantly, scores for compliance were only weakly related to those for ability to label psychotic phenomena as abnormal. Compliance and illness recognition were related to IQ. Total insight score was inversely correlated, moderately, with a global measure of psychopathology derived from the PSE, and was less in patients involuntarily committed. Age, sex, diagnosis, and the number of previous hospital admissions had little effect. The results support the notion that insight is not a unitary concept.

Phenomenology, demography and diagnosis in late paraphrenia

One hundred and one patients with late paraphrenia were examined using the Present State Examination. The established high prevalence rates of female gender, the unmarried state and sensory impairment were confirmed. All of the symptoms of schizophrenia, with the exception of formal thought disorder, were found in the subjects with approximately the same prevalence as reported in schizophrenics with a symptom onset in younger life. The presence of visual hallucinosis was significantly associated with visual impairment, but the same association was not found between auditory hallucinations and deafness. Mean age at onset of symptoms was high at 74.1 years. Using ICD-10 diagnostic criteria the patients were categorized as schizophrenia (61.4%), delusional disorder (30.7%) and schizoaffective disorder (7.9%). Patients in these diagnostic categories differed in their pre-morbid IQ estimations, current cognitive state measured by the Mini-Mental State Examination and in the number of scored positive psychotic PSE symptoms and their systematization of and preoccupation with delusions and hallucinations. There were no significant differences between the patients in the ICD-10 schizophrenia and delusional disorder groups in terms of age at symptom onset, sex ratio, response to treatment, being unmarried, the presence of insight or sensory impairment. The high degree of clinical similarity between patients with late paraphrenia combined with the inability of ICD-10 to define diagnostic subgroups that correspond to patient clusters derived from clinical symptoms or which are meaningfully different from each other in terms of demographic and prognostic factors provide a strong argument for the retention of late paraphrenia as the most appropriate diagnosis for such patients.

Quantitative magnetic resonance imaging volumetry distinguishes delusional disorder from late-onset schizophrenia

BACKGROUND

Late paraphrenia is recognised as a heterogeneous disorder. This is reflected by the division of such patients into schizophrenia and delusional disorder in ICD-10. Earlier imaging studies have suggested that major structural abnormalities may be associated with the onset of psychosis in later life.

METHOD

Fifty late paraphrenics and 35 age-matched healthy controls underwent structural magnetic resonance imaging of the whole brain in the coronal plane. Measurements were made of intracranial and brain volumes and the volumes of the intracerebral and extracerebral cerebrospinal fluid spaces.

RESULTS

No differences in intracranial, brain or extracerebral cerebrospinal fluid volumes between patients and controls were found. Late paraphrenic patients had greater lateral and third ventricle volumes than controls and the left lateral ventricle was larger than the right. When the patients were divided into appropriate ICD-10 diagnoses: paranoid schizophrenia (n = 31) and delusional disorder (n = 16), lateral ventricle volumes in the delusional disorder patients were much greater than those of the schizophrenics and almost twice those of controls.

CONCLUSIONS

Structural brain differences underly diagnostic heterogeneity within late paraphrenia. The brains of late onset schizophrenics are only subtly different from those of healthy elderly individuals.

Magnetic resonance imaging volumetric measurements of the superior temporal gyrus, hippocampus, parahippocampal gyrus, frontal and temporal lobes in late paraphrenia

Quantified magnetic resonance measurements were made of superior temporal gyrus, parahippocampal gyrus, hippocampal, frontal and temporal lobe volumes and of the planar area of the thalamus and basal ganglia structures in 47 late paraphrenic patients and 33 healthy elderly controls. The late paraphrenics were divided into 31 schizophrenics and 16 patients with delusional disorder according to ICD-10 guidelines. Patients with delusional disorder tended to have smaller left temporal volumes compared with control subjects and patients with schizophrenia, but this difference failed to reach accepted levels of statistical significance after correction for the effects of multiple statistical comparisons, age and total brain size. Physiological right-left asymmetry, reported for temporal and frontal lobe volumes, was present in control, schizophrenic and delusional disorder subjects but delusional disorder patients had a significantly greater degree of temporal lobe asymmetry. The results add to the evidence for heterogeneity among late-onset psychoses and emphasize the subtle nature of any structural brain abnormalities in these patients.

White matter signal hyperintensities in the brains of patients with late paraphrenia and the normal, community-living elderly

We determined the prevalence and anatomical location of areas of white matter hyperintensity visualized by magnetic resonance imaging in the brains of 38 late paraphrenic patients with an onset of psychotic illness after the age of 60 and 31 healthy aged community volunteers. All degrees of white matter signal hyperintensity were very common in both groups, and there was no excess of such changes in the brain of patients. Periventricular white matter and subcortical grey matter hyperintensities were significantly associated with both measured diastolic and systolic blood pressure in patients and control subjects. Periventricular and deep white matter, together with subcortical grey matter hyperintensities, were significantly associated with increased age. The excess of such presumed brain-imaging abnormalities previously reported in patients with an onset of psychosis late in life may be a consequence of earlier authors' failure to include examination of appropriate community control populations and to carefully exclude patients with evidence of stroke.

Brain and ocular metastases from a transmissible venereal tumour in a dog

A five-year-old crossbred dog was referred with rapidly growing masses over its penis and right popliteal lymph node. The dog had severe blepharospasm, congestion of episcleral vessels and rubeosis iridis of the left eye. A presumptive diagnosis of transmissible venereal tumour (TVT) and iridocyclitis was made based on the results of fine needle aspiration. Chemotherapy with vincristine and prednisolone was initiated and after four months the dog made a complete recovery. However, the dog subsequently relapsed, showing miosis, blepharospasm and a well defined mass within the anterior chamber of the left eye. In addition, the dog exhibited generalised 'grand mal' type seizures. Computed tomographic (CT) examination of the brain revealed two distinct masses in the left frontal lobe. Because of the poor prognosis, the owners elected to have the dog euthanased. On histopathology, metastases of TVT in the left eye and left cerebral hemisphere were found, showing no specific staining for CD3, immunoglobulin (Ig) G, IgM and lambda light chains. It was therefore concluded that the tumour growth was progressive, and that there was an absence of local humoral immune response against TVT in this case.

Transition from glass to digital slide microscopy in the teaching of oral pathology in a Brazilian dental school

Objectives: Several medical and dental schools have described their experience in the transition from conventional to digital microscopy in the teaching of general pathology and histology disciplines; however, this transitional process has scarcely been reported in the teaching of oral pathology. Therefore, the objective of the current study is to report the transition from conventional glass slide to virtual microscopy in oral pathology teaching, a unique experience in Latin America. Study Design: An Aperio ScanScope® scanner was used to digitalize histological slides used in practical lectures of oral pathology. The challenges and benefits observed by the group of Professors from the Piracicaba Dental School (Brazil) are described and a questionnaire to evaluate the students’ compliance to this new methodology was applied. Results: An improvement in the classes was described by the Professors who mainly dealt with questions related to pathological changes instead of technical problems; also, a higher interaction with the students was described. The simplicity of the software used and the high quality of the virtual slides, requiring a smaller time to identify microscopic structures, were considered important for a better teaching process. Conclusions: Virtual microscopy used to teach oral pathology represents a useful educational methodology, with an excellent compliance of the dental students.

Key words:Digital microscopy, virtual microscopy, dental education, virtual slides, oral pathology.

Peripheral developing odontoma in newborn. Report of two cases and literature review

Extra-osseous odontogenic tumors are rarely observed. However, it is widely accepted that the remains of odontogenic epithelium entrapped in the oral soft tissues may be a possible source for peripheral odontogenic tumors differentiation. Peripheral developing odontoma is considered exceptionally rare, since few similar cases are described in the English-related literature under diverse nomenclature, such as irregular eruption, ectopic tooth, ectopic soft-tissue mesiodens, ectopic odontoma and extra-osseous tooth germ. Previously reported cases invariably affected children and surgical exploration revealed tooth germs exclusively embedded in the soft tissue without bone involvement. Microscopically, all these cases exhibited developing tooth germs composed of ameloblasts, enamel matrix, odontoblastic layer, dentin and dental papilla and the morphological findings seem to depend on the developmental stage of each tooth germ at discovery. Thus, we believe that it is relevant to report two additional cases that were recently diagnosed in Brazil and Guatemala, focusing on their nomenclature, correct diagnosis and further treatment.

Tissue microarray construction for salivary gland tumors study

OBJECTIVE

To describe and discuss the design, building and usefulness of tissue microarray (TMA) blocks for the study of salivary gland tumors (SGTs).

STUDY DESIGN

Two hundred thirty-eight formalin-fixed, paraffin-embedded SGTs were arranged in blocks of TMA using a manual tissue arrayer. Three representative cores of 1.0, 2.0 or 3.0mm were taken from each original block and their characteristics were analyzed and described.

RESULTS

It was created 12 TMA blocks that presented highly representative neoplastic cylinders. However, those neoplasias rich in cystic spaces such as mucoepidermoid carcinoma and Warthin tumor presented more difficulties to be sampled, as the neoplastic tissue available was scarce. Tissue damage and loss during TMA construction was estimated as 3.7%.

CONCLUSION

Representative areas of SGTs, with relatively small loss of tissue, can be obtained with the construction of TMA blocks for molecular studies. However, tumors rich in cystic spaces present more difficulties to be adequately sampled.

Intermittent fetal bradycardia induced by midpregnancy fetal ultrasonographic study

Fetal bradycardias were observed during fetal ultrasonographic and echocardiographic studies performed in the second trimester of pregnancy. The episodes of bradycardia were brief and recovery was usually rapid. Ultrasound transducer pressure applied to the maternal abdomen during the study provoked the phenomenon. Vagal discharge resulting from an increase in intrauterine pressure appeared to be the causative mechanism.

Burkitt's lymphoma of the jaws in the Amazon region of Brazil

Objectives: To describe the clinicopathologic and immunohistochemical features of Burkitt’s lymphoma of the jaws in 7 patients of Northern Brazil. Study Design: Clinical data concerning gender, age, affected site, clinical presentation, symptomatology and follow-up were collected from the clinical files. Histopathology was complemented with a broad immunohistochemical panel and in situ hybridization for Epstein-Barr virus (EBV). Results: Most of the patients were infants and 5 out of 7 were males. The mandible was affected in 5 cases and all patients also presented abdominal involvement. All cases were positive for CD45, CD20, CD79a, CD10, Bcl-6 and EBV. Ki-67 proliferative index was approximately 100%. Six patients were treated with R-CHOP (Rituximab + Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone) chemotherapy, and 2 of these died of the disease. One young adult patient refused treatment and died 3 months after initial diagnosis. Conclusions: Burkitt’s lymphoma of the jaws diagnosed in the Amazon region of Brazil present similar clinicopathologic features to those described in endemic areas of Africa, including EBV positivity.

Key words:Burkitt’s lymphoma, EBV, Brazil, Amazon region.

Clear cell variant of calcifying epithelial odontogenic tumor: Case report with immunohistochemical findings

Calcifying epithelial odontogenic tumor (CEOT) is a rare benign odontogenic neoplasm, locally aggressive, characterized by sheets and nests of polyhedral epithelial cells exhibiting eosinophilic cytoplasm or less often clear cytoplasm. Additional features include nuclear pleomorphism without mitotic activity, concentric calcifications, and deposits of amyloid. Herein, we present an additional example of clear cell variant of CEOT occurring in a 25-year-old female. Microscopically, the tumor consisted on proliferation of epithelial cells with eosinophilic, clear vacuolated cytoplasm interspersed with focal areas of amyloid deposition. Tumor cells were immunopositive for AE1/AE3, CK14, CK19, β-catenin, CD138, and p63.

Key words:Calcifying epithelial odontogenic tumor, clear cell, histopathology, immunohistochemistry.

Schizophrenic symptoms in late paraphrenia

The prevalence of most individual schizophrenic symptoms in late paraphrenia is unknown. Previous attempts to characterize the symptoms of late paraphrenia have been retrospective case-note studies, have not used standardized assessment instruments or have only examined small populations of patients. We examined 83 late paraphrenic patients using the Present State Examination. Persecutory delusions occurred in 86.7% of patients and were the most common symptom elicited. Nonverbal (63.8%) and verbal third person (50.6%) auditory hallucinations were common, as were visual hallucinations (30.1%). Earlier authors have claimed that thought insertion and thought withdrawal do not occur in late paraphrenia; we found them in 15.7 and 6.0%, respectively, of our patients.

Extraskeletal myxoid chondrosarcoma of the masticator space in a pediatric patient

Extraskeletal myxoid chondrosarcoma (EMC) is a malignant soft-tissue neoplasm rarely described in the head and neck region of children and adolescents. We describe a case of EMC affecting the masticator space and a literature review. A 13-year-old boy who presented a large painless, diffuse mass causing progressive midfacial asymmetry of 6 months duration. Histopathological evaluation revealed a multinodular lesion, containing scattered round vacuolated tumor cells dispersed in an abundant myxoid stroma, separated by fibrous septae. Immunohistochemical analysis revealed positivity for vimentin, neuron-specific enolase, and chromogranin. The Ki-67 labelling index was 42%. The patient was treated surgically with tumor resection followed by adjuvant local radiotherapy. The patient died 1 year after initial diagnosis due to locoregional tumor dissemination. EMC should be considered in the differential diagnosis of myxoid neoplasms in the head and neck region.

Key words:Extraskeletal myxoid chondrosarcoma, masticator space, parapharyngeal space, immunohistochemistry, children.

Pigmented odontogenic keratocyst: Report of a rare case and review of the literature

Pigmented odontogenic keratocyst (OKC) is very rare and its etiology remains uncertain. To the best of our knowledge, only 9 cases of pigmented OKC have been published in English-language literature. This report describes a pigmented OKC in a 14-year-old black male patient. Radiographically, the lesion appeared as a well-circumscribed, unilocular, and radiolucent image. A surgical excision was performed. Histopathological examination revealed an OKC. Additionally, a brownish, sparsed, intracytoplasmic pigmentation was observed in the basal cell layer, which was positive for Fontana-Masson staining. Immunohistochemistry reactions revealed positive dendritic cells for S-100 protein, HMB45 and Melan A. No clinical and imaging signs of recurrence were observed after 24 months. In conclusion, melanin apparently does not represent a factor for distinct biological behavior in OKC.

Key words:Melanin, melanocytes, odontogenic cyst, odontogenic keratocyst, pigmented.

Coronectomy - An alternative approach to remove impacted teeth in oncological patients

Background

Coronectomy involves the section of the tooth crown leaving the roots in the socket. Possibility of inferior alveolar nerve injury and mandibular fracture are the main indications for this approach. Herein, we describe a case series of coronectomy to highlight its indication in normal and oncological patients.

Material and Methods

A total of 9 patients were submitted to coronectomy, 6 of them were oncological. Three patients were evaluated before head and neck radiotherapy (HNRT), 2 after HNRT and 1 before bone marrow transplantation.

Results

Mean age of the patients was 49 years, most of them male (n=7). Lower third molars were the main teeth that received this procedure, and all cases presented intimate anatomic relationship between the roots and the mandibular canal. Moreover, three cases also presented evident mandibular fracture risk in removing the tooth. During the follow-up period, none complications were observed related to coronectomy and oncological treatment.

Conclusions

Coronectomy is a safe approach including for cancer patients and it should be considered in high-risk impacted teeth extractions.

Key words:Coronectomy, impacted teeth, oncological patients, postoperative complications.

Oral encapsulated vascular malformation: An undescribed presentation in the mouth

Vascular lesions have been classified in two broad categories, hemangiomas and malformations. Encapsulated vascular lesions have not been reported in the oral cavity, but they were described in other sites, mainly in the orbit. Herein, we present a case of an oral encapsulated vascular lesion located in the right buccal mucosa of a 69-year-old male, including histological and immunohistochemical description and a literature review.

Key words:Buccal mucosa, hemangioma, vascular malformation, oral cavity.

Craniofacial fibrous dysplasia with cystic degeneration - A diagnostic challenge

Benign fibro-osseous lesions with cystic degenerations have been scarcely reported in craniofacial bones and its unusual characteristics pose a diagnostic challenge. Here, we report a case of craniofacial fibrous dysplasia presenting a large cystic degeneration. A 55-year-old woman had a history of pain, slight asymmetry on the zygomatic region and ocular pressure. Computed tomography revealed on the right side, multiple craniofacial bones showing a ground glass aspect, associated with an extensive hypodense, unilocular, well circumscribed lesion in the maxilla, and smaller lesions in the sphenoid bone. After a surgical procedure performed in another service, there was a complete improvement in symptoms, and after 1 year, the patient remains stable, with no changes. In the literature review, thirty-three reported cases of the same association in the craniofacial region were found. The main symptoms were sudden increase in the lesion and pain, and the indication of intervention in cystic lesions was only indicated in symptomatic cases or functional deficit. The knowledge of the possibility of the association of benign fibro-osseous lesions and cystic degenerations in craniofacial bones is essential to perform a correct diagnosis and treatment for these patients, consequently avoiding unnecessary procedures. Key words:Craniofacial fibrous dysplasia, Fibrous dysplasia, Benign fibro-osseous lesions, Cystic degeneration.

[Paraphrenia in the elderly. Psychopathologic and computer tomography indications of two subtypes]

Psychopathological and cranial computed tomography findings in 48 patients with late paraphrenia were compared with the findings in 40 normal controls. 19 patients with late paraphrenia and first rank symptoms showed significantly less cortical atrophy than 29 patients without first rank symptoms (p less than 0.01). There were no significant differences of ventricular enlargement, cerebellar atrophy, the presence of leukoaraiosis or basal ganglia mineralisation between the late paraphrenic and control groups. In contrast to the controls, cortical atrophy, ventricular enlargement and the presence of leukoaraiosis were not age-related. These results may indicate different origins of late paraphrenia with or without first rank symptoms.

Proliferative verrucous leukoplakia, squamous cell carcinoma and axillary metastasis

Proliferative verrucous leukoplakia (PVL) is an aggressive form of oral leukoplakia with multifocal presentation, high rates of recurrence and malignant transformation. Although development of regional lymph node metastasis is relatively frequent in patients with oral squamous cell carcinoma, axillary metastasis is quite uncommon. This paper presents a case of a 64-year-old female patient who was diagnosed with PVL and developed five oral squamous cell carcinomas and later an axillary lymph node metastasis.