138 Sexual History, Is it Important?

Oral candidiasis (OC) is the most common opportunistic infection seen in patients infected with Human Immunodeficiency Virus (HIV) and remains the second AIDS-defining illness in Europe, as it has previously been reported in 11-51% of cases. We present a case of a 70-year-old male who attended the Oral and maxillofacial surgery department with refractory OC and was later diagnosed with HIV after multiple visits to various departments in hospital. Sadly, the patient declined medically and died of multi-organ failure one month following this diagnosis. On reflection, it was found that the patient suffered from the medical conditions and opportunistic infections which can be associated with HIV, but as no sexual history was ascertained this diagnosis was missed. It is prudent that we, as clinicians, take a step back and look at each patient as a whole, in order to ensure complete and holistic care. We argue that sexual history is sometimes vital in achieving a complete history of a patients’ condition, especially in cases of refractory OC where it can be a key piece in the diagnostic puzzle.

Evaluation of Mineral Trioxide Aggregate and Biodentine as pulpotomy agents in immature first permanent molars with carious pulp exposure: A randomised clinical trial

AIM

There is insufficient evidence on the outcome of pulpotomies in carious exposed young permanent molars with newer biomaterials. This study aimed to compare Mineral Trioxide Aggregate (MTA) and Biodentine as pulpotomy materials in carious exposed vital immature mandibular first permanent molars.

MATERIALS AND METHODS

Study design: Sixty immature first mandibular permanent molars, with carious exposure were randomly assigned to an MTA or Biodentine group in a split-mouth design. After the amputation of the coronal pulp, the pulp stumps were covered with one of the study materials and coronal restorations placed. Blinded clinical and radiographic evaluations were performed at baseline. Following this there were evaluations at 6, 12 and 18 months where comparisons between and within the two groups were made.

RESULTS

A high success was observed in both groups for all outcome measures for clinical success, with no significant difference between them. The mean survival time for the Biodentine and MTA groups was (17.8 and 18 months) with 95% confidence interval (17.4-18.2) and (18 .0-18.0) months respectively. Similarly, there were no significant differences between the Biodentine and MTA groups for radiographic success (P<0.001) with an increase in root length and increasing apical closure observed in both groups.

CONCLUSIONS

Both materials were equally effective in the treatment of cariously exposed vital immature mandibular first permanent molars.

Safe transportation of biomedical waste in a health care institution

INTRODUCTION

The chances of health care waste (Biomedical waste) coming in contact with the health care workers, patients, visitors, sanitary workers, waste handlers, public, rag pickers and animals during transportation are high.

MATERIALS AND METHODS

The study was conducted over a period of seven months (April 2013-October 2013) in a 500-bedded hospital where the average quantum of biomedical waste is 0.8 kg/bed/day. The issues related to transportation of health care waste from 39 generation sites to the health care waste storage site inside the hospital (intramural transfer) were addressed and analysed in a predesigned proforma.

RESULTS

The biomedical waste management team inspected the generation sites in the hospital on a daily basis and conformance to the procedures was checked. It was found that waste was collected at scheduled timings in 99.6% occasions; however, compliance to wearing personal protective equipment (PPE) was poor and ranged from 1.22-1.84%.

CONCLUSION

Transportation of health care waste is a crucial step in its management. Regular training program for all the sections of health care workers with special emphasis on waste handlers is needed.

Cupriavidus pauculus (Ralstonia paucula) concomitant meningitis and septicemia in a neonate: first case report from India

Ralstonia paucula (formerly classified as CDC (Centre for Disease Control) group IVc-2, Wautersia paucula; recently renamed as Cupriavidus pauculus) is an environmental Gram-negative bacillus isolated from water sources and can cause serious human infections. Patients recover bacteriologically indicating low virulence. A total of 32 cases have been reported world-wide, but no isolation has ever been reported from cerebrospinal fluid or in India. The first case of R. paucula meningitis and septicemia is being reported here along with the brief summary of cases reported world-wide.

Case of sparganosis: a diagnostic dilemma

Sparganosis, also known as larval diphyllobothriasis, is a rare disease of humans as man is not a natural host in the life cycle of Spirometra spp. Diagnosis of the latter is difficult as it mimics other conditions that commonly cause subcutaneous or visceral fluid collection. Clinical diagnosis of this particular case was also erroneously labelled as tuberculosis but later labelled as a case of sparganosis. To the best of our knowledge, this is the first case from India where a sparganum-like parasite was isolated in drain fluid from the perinephric area.

Female genital TB and HIV co-infection

HIV-induced immunosuppression paves the way for several infections, tuberculosis being very common in our country. Female genital tuberculosis (FGTB), presenting as menstrual irregularities, is a diagnostic challenge in an adolescent female when these may be considered normal. The present case is of a young female who presented with menstrual irregularities, diagnosed subsequently as a case of genital tuberculosis. Microbiological relapse after anti-tubercular treatment of six months caused suspicion of a co-existing immunodeficiency and investigations revealed HIV co-infection; thus emphasizing the need of HIV testing in all patients of tuberculosis for timely diagnosis and treatment support thereafter.

Recent outbreak of meningococcal meningitis--a microbiological study with brief review of literature

Meningococcal disease presents in various clinical forms, most common being meningitis and meningococcemia. A spurt of meningococcal cases was seen in medicine and pediatric wards of Dr. Ram Manohar Lohia Hospital during the recent outbreak from Dec 2005 - June 2006. These had presented either with the classical features of acute purulent meningitis or as fever with rash. The patients were investigated microbiologically for the causative organism which was identified as Neisseria meningitidis in 257 out of 531 cases (48.39%). The classic finding of gram negative diplococci on gram stain remained the mainstay of diagnosis. N. meningitidis isolates from culture were sensitive to all commonly used antibiotics.

Preimplantation B-type natriuretic peptide concentration is an independent predictor of future appropriate implantable defibrillator therapies

OBJECTIVE

To assess prospectively whether preimplantation B-type natriuretic peptide (BNP) and C reactive protein (CRP) concentrations predict future appropriate therapies from an implantable cardioverter-defibrillator (ICD).

DESIGN AND SETTING

Prospective cohort study conducted in a tertiary cardiac care centre.

METHODS

345 consecutive patients undergoing first time ICD implantation were prospectively studied. Serum BNP and CRP concentrations were obtained the day before ICD implantation. Patients were followed up with device interrogation to assess for appropriate shocks or antitachycardia pacing. Inappropriate therapies were excluded. Mean (SD) follow up was 13 (5) months.

RESULTS

Patients had ischaemic (71%), primary dilated (17%), and valvar or other cardiomyopathies (12%). About half (52%) had ICDs implanted for primary prevention. Sixty three (18%) received appropriate ICD therapies. Serum creatinine, beta blocker, statin, and angiotensin converting enzyme inhibitor usage did not differ between therapy and no therapy groups. By univariate comparison, ejection fraction (p = 0.048), not taking amiodarone (p = 0.033), and BNP concentration (p = 0.0003) were risk factors for ICD therapy. However, by Cox regression multivariate analysis, only BNP above the 50th centile was a significant predictor (hazard ratio 2.19, 95% confidence interval 1.07 to 4.71, p = 0.040). Median BNP was 573 ng/l versus 243 ng/l in therapy and no therapy patients, respectively (p = 0.0003). More patients with BNP above the 50th centile (27% v 10%, p = 0.006) received ICD therapies.

CONCLUSIONS

A single preimplantation BNP concentration determination is independently predictive of ICD therapies in patients with cardiomyopathies undergoing first time ICD implantation. CRP was not independently predictive of ICD therapies when compared with BNP.

Prenatal ethanol exposure has differential effects on fetal growth and skeletal ossification

There is increasing evidence suggesting that the intrauterine environment may influence long-term bone health and the risk of developing osteoporosis in later life. Alcohol (ethanol) is one factor whose presence in the prenatal environment has long-term consequences for the offspring, including permanent growth retardation. Moreover, prenatal ethanol exposure retards both fetal and postnatal bone development. It is unknown if ethanol's effects on skeletal development result from generalized growth retardation or effects specific to skeletal development. Furthermore, the level of ethanol exposure required to produce skeletal effects is unknown. The objectives of this study were to determine (1) if ethanol exerts specific effects on fetal skeletal development that are independent from its effects on general growth, and (2) the level of prenatal ethanol exposure required to affect fetal growth and skeletal ossification. Rats were fed isocaloric diets with ethanol (15%, 25%, or 36% ethanol-derived calories (EDC), approximating low, moderate, and high exposure levels), or without ethanol (pair-fed, PF, or control, C groups), prior to and throughout 21 days of gestation. The degree of E-induced delay in development was determined by comparison of E fetuses on d21 gestation to C fetuses on d17-d21 gestation. Prenatal ethanol exposure at 36% EDC decreased fetal body weight, length, and skeletal ossification compared with PF and C fetuses on d21 gestation. Importantly, effects on ossification, but not body weight or length, were also seen at the more moderate dose of 25% EDC, and the number of bones affected and the severity of effects on ossification tended to increase with dose of ethanol. Comparison of E fetuses on d21 gestation with C fetuses from d17 to 21 gestation indicated that the ethanol-induced delay in development differed for weight and skeletal ossification, and was not uniform among skeletal sites. Taken together, these data suggest that prenatal ethanol exposure has effects on fetal skeletal development that are independent of those on overall fetal growth, and that these effects occur even at moderate levels of maternal drinking. Effects of prenatal ethanol exposure on fetal skeletal development could potentially increase the offspring's risk of osteoporosis later in life.

Depressive symptomatology in childhood and adolescence

Antecedents of depressive symptomatology in childhood and adolescence were examined in a prospective longitudinal study of at-risk youth (n = 168) from families of lower socioeconomic status. Relations between family context factors, maternal depressive symptoms, and depressive symptoms in childhood and adolescence were examined, with a focus on early family relationship factors rarely available for analysis in longitudinal data sets. Results suggest the possibility of etiological differences between depressive symptoms in childhood and in adolescence. Depressive symptomatology in childhood was predicted by the overall family context. Cumulative effects of maternal depressive symptomatology, early care lacking in emotional supportiveness, abuse, and family stressors were observed. Depressive symptomatology in adolescence, on the other hand, was specifically associated with maternal depression and early care lacking in emotional supportiveness. Moreover, an intriguing sex difference emerged: maternal depressive symptomatology was strongly associated with depressive symptomatology in adolescence for females, but for males supportive early care appeared more relevant.

Assessment of life stress in adolescents: self-report versus interview methods

OBJECTIVE

To compare the investigator-based Life Events and Difficulties Schedule (LEDS) with a self-report measure (Life Events Checklist [LEC]) for the purpose of measuring life stress in adolescents with and without a diagnosis of major depressive disorder (MDD).

METHOD

Adolescents (aged 13-18 years) with a recent episode of MDD based on DSM-III-R (n = 35) and normal controls free of any Axis I lifetime psychiatric disorder (n = 35) were assessed using both the LEC and the LEDS.

RESULTS

Both measures predicted membership in the depressed and nondepressed groups of adolescents. Adolescents in the depressed group were more likely to report a severe event on the LEDS (97%) than adolescents in the nondepressed group (66%) (p = .001). Similarly, subjects in the depressed group endorsed a greater number of negative events (mean = 8.1) on the LEC than subjects in the nondepressed group (mean = 3.0) (p = .0001). An examination of potential provoking agents for episodes of major depression revealed that the LEC captured only 32% of preonset severe events and 36% of preonset major difficulties identified by the LEDS.

CONCLUSIONS

Interpreted in light of relative advantages and disadvantages, the results suggest that checklist and interview measures each have distinct advantages depending on the purpose for which they are being used.

Recovered memory of childhood sexual trauma: a documented case from a longitudinal study

A case of recovered memory of childhood trauma is reported with documented sexual trauma in early childhood, chronicled evidence of the absence of memory for traumatic experience over a period of time, and substantial evidence of 'spontaneous' recovery of memory. This account contains the first available prospective report of memory loss in a case in which there is both documented evidence of trauma and evidence of recovery of memory. The case emerged as part of a broadband, large-scale study of children followed closely from birth to adulthood which was not focused on memory for trauma. Prospective data gathered in a neutral research context, corroborated and supplemented by retrospective information, circumvent many limitations of previous retrospective accounts of recovered memories.

Vegetarianism and growth in Urdu, Gujarati, and Punjabi children in Britain

As part of a nutritional surveillance system of primary school children the relation between growth and vegetarianism in the Urdu, Gujarati, and Punjabi groups was explored. The aim of the analysis was to ascertain if vegetarian children from ethnic minorities are at a disadvantage in terms of nutritional status within their group of origin. Data for 80.7% of 473 Urdu children, 86.6% of 551 Gujarati children, and 84.4% of 1265 Punjabi children were available for the analysis. No significant differences in weight-for-height and triceps skinfold were found between vegetarians and non-vegetarians even after adjustment for potential confounding variables. Vegetarian girls tended to be shorter than non-vegetarian girls in all Asian groups, although this difference reached a statistically significant level (p less than 0.01) only in the Urdu group. Although our findings should be interpreted with caution they indicate that health visitors and other health staff should be aware of the possible contribution of vegetarianism to the nutritional status of Asian girls.

Sequelae of the initial attack of acute rheumatic fever in children from north India. A prospective 5-year follow-up study

We determined the outcome of acute rheumatic fever in 85 children from North India who had received regular antistreptococcal prophylaxis after their first attack. By the end of the 5-year follow-up, 33 patients had rheumatic heart disease. Mitral insufficiency, the most common valvular lesion, appeared in 91% of the patients, whereas mitral stenosis developed in only 18%. Initial carditis, congestive heart failure, cardiomegaly or moderate-to-severe mitral insufficiency significantly increased the risk of rheumatic heart disease (p less than 0.001). The recurrence rate of acute rheumatic fever in children who received continuous prophylaxis was 0.006 per patient-year. Most recurrence (92%) mimicked the first attack and produced further cardiac damage in five patients with carditis and in one patient with chorea. Cardiac status during the first attack of rheumatic fever and the continuity of prophylaxis were the major determinants of outcome. Statistical comparisons disclosed that with continuous prophylaxis, the prevalence rate, evolution and clinical spectrum of the sequelae of acute rheumatic fever in children from India do not differ significantly from those in the West.