Neuropsychiatric manifestations in an adolescent male with Rowell syndrome.

A 15-year-old boy presented with fever, skin, and oral lesions for 4 weeks. The cutaneous lesions were suggestive of subacute cutaneous lupus erythematosus and erythema multiforme. His clinical, histopathological, and immunological features were indicative of Rowell syndrome and he satisfied the diagnostic criteria of Rowell syndrome proposed by Zeitouni et al. He subsequently developed neurological manifestations and was diagnosed to have neuropsychiatric systemic lupus erythematosus. We report this case for the unusual occurrence of a rare entity like Rowell syndrome in an adolescent male with co-existence of neuropsychiatric systemic lupus erythematosus.

Ovarian development in Wistar rat treated prenatally with single dose diisobutyl phthalate.

Phthalates are a class of industrial compounds with an array of toxicological properties used in day to day life. Diisobutyl phthalate on (DIBP) is used as an additive to keep the plastics soft or flexible (plasticizer) in nitrocellulose plastic, nail polish, explosives, lacquer manufacturing etc. Although DIBP exposure in humans is generally low, people in adhesive industries and pharmaceutical industries are exposed to higher levels. The aim of this study was to determine the effect of single dose of DIBP on developing ovary of Wistar rat. One hundred and eight adult pregnant Wistar rats were divided into control and experimental groups. Rats in experimental group were given DIBP on day 10, 12 and 14 of gestation at 0.375, 0.75 and 1.25 ml/kg body weight dose intraperitoneally in a single dose. Sections of ovaries collected on day 21 of gestation were stained with hematoxylin and eosin and examined and Masson's trichrome histologically. Sections belonging to the control group showed the presence of oocytes in clusters separated by thin fibrous septa. Degeneration oocytes, empty follicles surrounded by follicular cells without gonocytes in the center were observed in ovarian stroma. Blood vessels in the ovarian stroma were prominent and congested. Around a bunch of follicles total architectural disarray was observed although on special staining fibrosis was not evident. As pregnant women are constantly exposed, effect of DIBP on ovary of a developing fetus would denote the long term consequence in future generations (Fig. 5, Ref. 39).

Discovery of a case of Waugh's syndrome during a mission to Haiti.

INTRODUCTION: A rarely reported entity, Waugh's syndrome is the association between intestinal malrotation and intussusception. We present a case of Waugh's syndrome encountered during a medical mission to a resource poor country. PRESENTATION OF CASE: A 3-month-old female presented with septic shock and acute bowel obstruction secondary to intussusception and malrotation. She required aggressive resuscitation and emergent laparotomy, bowel resection, Ladd procedure and temporary ileostomy. DISCUSSION: First described in 1911, Waugh's syndrome has been rarely reported in the literature. We summarize a total of 54 cases of Waugh's syndrome that are reported in the literature to date. The complicated but successful care of this patient reflects the severe outcome of any inadequate treatment of Waugh's syndrome and illustrates the importance of medical volunteers in developing countries. CONCLUSION: As the relationship between malrotation and intussusception may be more frequent than recorded, surgeons must be aware that non-operative management of intussusception may be inadequate therapy.

Maxillary tuberosity fracture: a life-threatening haemorrhage following simple exodontia.

Maxillary tuberosity fracture is a potential complication of routine exodontia of posterior maxillary teeth. On rare occasions, such a complication can result in torrential haemorrhage due to the close proximity of significant vessels to the area. We present a case of life-threatening haemorrhage complicating a tuberosity fracture during simple extraction of a maxillary posterior tooth. The local anatomy of the region is discussed and we provide guidelines for general dental practitioners for the management of the complication of a tuberosity fracture during routine exodontia.

Vibrational spectroscopy studies of formalin-fixed cervix tissues.

Optical histopathology is fast emerging as a potential tool in cancer diagnosis. Fresh tissues in saline are ideal samples for optical histopathology. However, evaluation of suitability of ex vivo handled tissues is necessitated because of severe constraints in sample procurement, handling, and other associated problems with fresh tissues. Among these methods, formalin-fixed samples are shown to be suitable for optical histopathology. However, it is necessary to further evaluate this method from the point of view discriminating tissues with minute biochemical variations. A pilot Raman and Fourier transform infrared (FTIR) microspectroscopic studies of formalin-fixed tissues normal, malignant, and after-2-fractions of radiotherapy from the same malignant cervix subjects were carried out, with an aim to explore the feasibility of discriminating these tissues, especially the tissues after-2-fractions of radiotherapy from other two groups. Raman and FTIR spectra exhibit large differences for normal and malignant tissues and subtle differences are seen between malignant and after-2-fractions of radiotherapy tissues. Spectral data were analyzed by principal component analysis (PCA) and it provided good discrimination of normal and malignant tissues. PCA of data of three tissues, normal, malignant, and 2-fractions after radiotherapy, gave two clusters corresponding to normal and malignant + after-2-fractions of radiotherapy tissues. A second step of PCA was required to achieve discrimination between malignant and after-2-fractions of radiotherapy tissues. Hence, this study not only further supports the use of formalin-fixed tissues in optical histopathology, especially from Raman spectroscopy point of view, it also indicates feasibility of discriminating tissues with minute biochemical differences such as malignant and after-2-fractions of radiotherapy.

Cutting seton for pilonidal disease: a new approach.

I present a technique for dealing with chronic pilonidal disease that avoids use of general anesthesia, long hospital stay, complex wound care and prolonged disability that has so often been associated with more traditional surgical treatment in the past. Satisfactory resection was achieved by means of a single cutting seton (garrotte) in 8 patients, 5 males and 3 females ranging in age from 18 years to 31 years, all of whom had had prior unsuccessful incision and drainage for long-standing disease with local abscesses and suppuration. The seton was applied in an ambulatory care setting under local anesthesia. It was tied and progressively tightened over a period of two weeks. Complete excision of the diseased area was achieved and revascularization of the wounds site occurred with optimum healing by secondary intention, leaving an acceptable scar. It required minimal wound care. There were no recurrences over an average follow-up period of 22.5 months. All patients were uniformly satisfied. The encouraging preliminary results for this novel technique suggest that it is simple, safe and effective. It requires evaluation in a larger series with longer follow-up.

Impact of European Society of Cardiology/American College of Cardiology guidelines on diagnostic classification of patients with suspected acute coronary syndromes.

BACKGROUND: Assessment of the relative diagnostic accuracy of investigation strategies for patients with suspected acute coronary syndromes (ACS). METHODS: A prospective observational study followed two groups of patients over a 3-month period in a UK district general hospital. Group one: all admissions with suspected ACS (n = 576); group two: non-cardiac in-patients who were suspected of developing ACS (n = 87). Both were investigated by full clinical history, examination and serial electrocardiographs (ECGs). Conventional World Health Organization (WHO) criteria for myocardial damage were compared with diagnosis based on cardiac troponin T (cTnT). Clinical discharge diagnosis based on conventional WHO criteria was compared with the review diagnosis based on measurement of cTnT. RESULTS: Diagnosis based on WHO criteria missed 58 patients (8.7%) admitted with suspected ACS who had high risk unstable angina. Thirty-three patients (5% of all admissions) who were diagnosed as non-Q wave acute myocardial infarction (AMI) were found to have normal troponin values and to have been incorrectly classified as AMI. CONCLUSIONS: Diagnostic strategies based on WHO criteria are inaccurate. The measurement of cTnT in all patients with suspected ACS would have increased the number of those with a diagnosis of AMI by 58 (8.7%), while avoiding inaccurate diagnosis in 33 (5%), therefore producing an absolute increase of 25/663 (3.8%) but a relative increase of 58/138 (42%). In patients with a primary diagnosis of suspected ACS, the overall increase in patients with a diagnosis of AMI will be 55 (9.5%), a relative increase of 55/118 (46.6%) but an absolute increase of 36/576 (6.3%).

Troponin T measurement after myocardial infarction can identify left ventricular ejection of less than 40%.

AIM: To determine whether measurement of serum troponin T concentration after first acute myocardial infarction can be used to identify patients with a left ventricular ejection fraction of < 40%, who have an adverse prognosis. METHODS: Troponin T concentration was measured, and coronary and left ventriculography performed in 50 consecutive patients with acute myocardial infarction. Angiographic left ventricular ejection fraction was compared with serum troponin T concentration. Patients with previous myocardial infarction were excluded. RESULTS: There was a strong negative correlation between left ventricular ejection fraction and troponin T concentration. Spearman's rank correlation coefficient (corrected for ties) was -0.72 (95% confidence intervals (CI) -0.55 to -0.83; p < 0.0001). Analysis by receiver operator characteristic curve produced an area under the curve of 0.9773 (95% CI 0.9409 to 1.0136). A troponin T concentration of > 2.8 micrograms/l predicted a left ventricular ejection fraction of < 40% with a sensitivity of 100% (CI 84.6 to 100.0) and specificity of 92.9% (CI 76.5 to 99.1). Exclusion of patients who did not receive thrombolytic treatment did not significantly affect the results. CONCLUSION: Serum troponin T concentration measured 12-48 hours after admission for first myocardial infarction is a reliable, simple, quick, inexpensive, non-invasive method for identifying patients with a left ventricular ejection fraction of < 40% for whom there is a poor prognosis.

Direct current cardioversion does not cause cardiac damage: evidence from cardiac troponin T estimation.

AIM: To determine whether elective direct current (dc) cardioversion of atrial fibrillation/flutter causes myocardial damage. METHODS AND RESULTS: Cardiac troponin T and creatine kinase were estimated 20-28 hours after dc cardioversion in 51 patients who received dc shocks for elective cardioversion of chronic atrial fibrillation/flutter. Although creatine kinase was raised in 44 patients, cardiac troponin T was undetectable in all patients. CONCLUSION: Cardiac damage does not occur as a result of cardioversion.

Prophylactic nasogastric tube decompression: is its use justified?

To evaluate the need for routine prophylactic nasogastric tube decompression following gastrointestinal surgery, we retrospectively reviewed the cases of 177 patients. The patients were classified as those not receiving nasogastric tubes, those whose tubes were removed within 48 hours postoperatively, and those whose tubes remained for more than 48 hours. No significant differences were noted in duration of hospital stay, time for return of adequate bowel function, or time before beginning an oral diet. Further, there were no differences in the frequency of wound complications, anastomotic leakage, or mortality. Patients without tubes had no greater incidence of vomiting, and despite a more frequent occurrence of abdominal distention and nausea, only 8% required insertion of a tube for persistent symptoms. Intubated patients had a greater frequency of respiratory complications. The results indicate that routine prophylactic use of nasogastric decompression is unnecessary and may be safely eliminated in patients having gastrointestinal surgery.

Clinical experience with a new lead combining active fixation with steroid elution.

The Medtronic lead engineering model number 10335A represents a new concept in lead design combining active fixation with steroid elution. It aims for immediate stability and low chronic thresholds. Twenty-one leads, 9 atrial and 12 ventricular, were implanted in 13 patients (10 males, mean age 68; range 22-91 years). The atrial leads showed no rise in pulse width threshold at a voltage of 1.6 volts (mean thresholds at implant, 1, and 26 weeks; 0.1 +/- 0.09 msec, 0.15 +/- 0.04 msec, and 0.1 +/- 0.03 msec, respectively). The ventricular leads had a small but significant rise between implant and 1 week at an output of 1.6 volts (0.07 +/- 0.03 msec increasing to 0.11 +/- 0.04 msec; P < 0.02) but no significant later rise (0.1 +/- 0.04 msec at 2 weeks and 0.1 +/- 0.05 msec at 6 months). These low chronic thresholds would allow early reprogramming of the unit to low voltages resulting in a battery saving with prolongation of the unit's life. There were no significant changes in the P and R wave amplitudes, but there was a fall in lead impedance in the ventricular leads between implantation and 1 week (P < 0.02) but none subsequently, and there was no significant change in atrial impedance. There were no sensing failures and no lead displacements. Despite impressive pacing characteristics, the study was suspended because of a high level of mechanical complications. Of the 96 patients implanted worldwide with 136 leads there were eight helix deformations, which will require redesign.(ABSTRACT TRUNCATED AT 250 WORDS)

Apolipoprotein profile in type II diabetic patients with and without coronary heart disease.

Diabetes mellitus is frequently associated with lipid metabolism abnormalities. In the present study the lipid and apolipoprotein profiles have been compared in type II diabetic subjects with (n = 30) and without (n = 30) coronary heart disease (CHD). All subjects were studied after good metabolic control had been achieved. Significant differences in plasma lipids and apolipoproteins were seen in diabetic patients with CHD in comparison with diabetics without CHD. Patients with CHD presented higher total cholesterol, triglyceride, LDL-cholesterol, apo B, apo CII and apo CIII levels and total cholesterol/HDL-cholesterol and LDL-cholesterol HDL-cholesterol ratios and lower HDL-cholesterol values and apo A1/apo B ratio than the patients without CHD. The same findings were found in females; while male subjects with CHD had significantly increased total cholesterol, LDL-cholesterol and apo B levels and total cholesterol/HDL-cholesterol and LDL-cholesterol/HDL-cholesterol ratios and significantly decreased apo A1/apo B ratio compared with males without CHD. These findings support the concept that the apolipoprotein profile plays a remarkable role as risk factor for CHD in type II diabetes mellitus.

Myxoedema presenting with psychosis.

Presented here is the case report of a lady who was referred for evaluation and management of frank psychotic manifestations. A carefully taken history and physical findings pointed to the presence of hypothyroidism. This was later confirmed by laboratory evaluation. The patient improved after thyroxine supplementation.