Manipulation and reduction of paediatric fractures of the distal radius and forearm using intranasal diamorphine and 50% oxygen and nitrous oxide in the emergency department: a 2.5-year study.

UNLABELLED: A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation. The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED. By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method. TAKE HOME MESSAGE: Simple easily reducible fractures of the distal radius and forearm in children can be successfully and safely treated in the ED using this approach, thus avoiding theatre admission and costly hospital stay.

Pneumococcal serotypes associated with invasive disease in under five children in India & implications for vaccine policy.

BACKGROUND & OBJECTIVES: Streptococcus pneumoniae is a major cause of morbidity and mortality especially in children less than five years, particularly in India. We present data on S.pneumoniae infections in children less than five years age group, with response to its serotype distribution, antibiotic resistance profile and available vaccines expected coverage. METHODS: Children aged less than five, who were suspected for invasive pneumococcal disease were included in the study and their sterile body fluids were investigated for the presence of S. pneumoniae. Invasive S. pneumoniae isolates from sterile body fluids were identified by bile solubility and optochin susceptibility test. Pneumococcal serotyping was performed with co-agglutination technique and reconfirmed with multiplex PCR. RESULTS: The most common pneumococcal serotypes causing invasive infections in children less than five years of age were 14, 19F, 5, 6A and 6B. Of the 114 S. pneumoniae isolates studied, 110 (96.4%) were non-susceptible to co-trimoxazole and 30 per cent were non-susceptible to erythromycin, 5.2 per cent of the isolates were non-susceptible to penicillin and only 0.8 per cent was non-susceptible to cefotaxime. INTERPRETATION & CONCLUSIONS: Our results indicate that PCV-10 can protect against 64 per cent of serotypes causing invasive pneumococcal infections. Use of PCV-13 in this region can provide increase in protection upto 74.6 per cent against serotypes causing invasive pneumococcal infections. Incorporating PCV-13 in the Universal Immunization Programme may provide incremental protection against IPD serotypes in the southern region of the country.

Septic arthritis in the era of immunosuppressive treatments.

Immunosuppressants have been the mainstay of treatment for certain inflammatory joint conditions for many years. Developments in this field, namely biological treatments, have led to a change in the classical presentation of acute bone, joint and soft tissue infections. The normal findings of severe pain and tenderness on examination may be absent or simply mimic a typical exacerbation of the chronic joint condition. A minimally raised white cell count and elevated C-reactive protein in the absence of systemic signs of infection may be interpreted as further evidence for the diagnosis of an exacerbation of inflammatory arthritis. We present a unique case of recurrent polyarticular septic arthritis in a patient treated with immunosuppression for refractory rheumatoid arthritis. We hope this article will enable doctors to appreciate and recognise the changing face of septic arthritis in the modern era of immunosuppressant treatments.

Bone graft substitutes currently available in orthopaedic practice: the evidence for their use.

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Histopathology grading systems for characterisation of human knee osteoarthritis--reproducibility, variability, reliability, correlation, and validity.

OBJECTIVE: To determine the reliability, reproducibility, variability and validity of the Osteoarthritis Cartilage Histopathology (OACH) assessment system and Mankin Histological-Histochemical Grading System (HHGS) when applied to the characterisation of the osteoarthritic human knee. METHOD: Osteoarthritic knees of 10 patients undergoing unilateral knee arthroplasty were assessed, and assigned Kellgren-Lawrence and Line Drawing Atlas (LDA) radiology scores. The tibial plateaux were scored using the Modified Collins (MC) and Société Française d'Arthroscopie (SFA). Three observers twice scored both the OACH and HHGS across a single complete medial and lateral tibial plateau transect taken to include the region with the most severe osteoarthritis (OA) lesion. Intra- and inter-observer reliability, reproducibility, variability and validity were assessed, and the correlation between the two histopathology scoring systems was calculated. RESULT: Both histopathology scoring systems were determined to be reliable and reproducible exhibiting similar variability, when applied to characterise OA specimens sampled from a well defined patient group with knee OA. A strong correlation between the mean OACH and mean HHGS scores was identified (Spearman's ρ 0.980, P<0.0001). CONCLUSION: Both scoring systems implemented provide useful measures in the characterisation of knee osteoarthritis. It is of note that an additional parameter within the OACH score over the HHGS defines the extent of the disease, where the HHGS is a grade attributed to the most representative level of the biological aggression within the OA lesions. This study has confirmed the OACH system's utility in human knee OA and is supported by a significant correlation with the established HHGS.

Three dimensional reconstruction of a human breast carcinoma using routine laboratory equipment and immunohistochemistry.

AIMS: To establish a three dimensional reconstruction of an invasive breast carcinoma using basic laboratory equipment to evaluate and characterise the spatial arrangement of the parenchymal cells of the breast. METHODS: One hundred and twenty eight sequential 4 microm sections (20 microm apart) of the tumour were stained immunohistochemically with an epithelial specific marker (AE1/AE3) or tumour specific marker (c-erbB-2) to reconstruct two different three dimensional images of the normal and malignant parenchymal cells. Sections were digitally imaged using a microscope, scanner, and digital camera linked to a conventional personal computer. Accurate alignment of the digitalised images was carried out using a semiautomatic graphical method of manual interaction, using the cross correlation coefficient as a goodness of fit measure, and an automatic search algorithm using the Fibonacci search algorithm for automatic alignment. The volume was reconstructed using maximum, minimum point projection and "back to front" opacity blending. RESULTS: The quality of the reconstructed images was distinct and perfect, providing a comprehensive and explicit view of the normal and malignant parenchymal tissues of the breast that is not possible by viewing two dimensional histological sections. Specifically, this approach showed the spatial arrangement of the tumour cells and their relation to the surrounding tissues at a high resolution. CONCLUSION: This simple and reproducible approach enables the spread and infiltration of invasive carcinoma to be understood and could also be used to analyse the spatial relation between atypical hyperplastic and malignant in situ lesions of the breast.

Community prevalence of hepatitis B infection and modes of transmission in Tamil Nadu, India.

BACKGROUND AND OBJECTIVE: There have been very few community based studies on prevalence of hepatitis B virus (HBV) infection in India. We undertook this study to determine the prevalence of HBV infection in a southern State of India, Tamil Nadu and to describe the important factors related to transmission of the virus in the community. METHODS: Analysis of stored blood samples from a representative population of Tamil Nadu from an earlier community cluster survey on sexually transmitted diseases (STD) prevalence using proportionate to population size (PPS) technique was done. Serum markers of HBV viz., hapatitis B surface antigen (HBsAg), hepatitis B e antigen (HBe Ag) and antibody to surface antigen (anti-HBs) were performed. RESULTS: 1981 subjects were screened in the study. HBsAg prevalence was 5.7 per cent (CI 4.6- 6.8) with 23.5 per cent (25/106) of these having positive HBe-antigen. Community seroprevalence (HbsAg + anti-HBs) of hepatitis B infection was 27.4 per cent (CI: 25.3-29.5) with the highest prevalence of 32.7 per cent (CI: 30.2-35.2) noted in the 15-20 yr age group. Significant independent association (OR 1.4; P=0.006) was detected with family history of exposure to HBV infection by logistic modeling. Other risk factors noted to have significant association were use of disposable needles during injection (OR 0.5; P=0.02) in men, smoking (OR 3; P=0.04) and use of condom (OR 0.6; P=0.08) in women. INTERPRETATION AND CONCLUSION: This community based study shows a high prevalence of hepatitis B infection in the state of Tamil Nadu with the highest prevalence being in the younger (15-20 yr) age group. High prevalence rate in childhood with e-antigenemia seen in 23.5 per cent of HBsAg positive subjects suggest childhood transmission. Poor injection practices and high-risk sexual behavior were found to be additional risk factors for transmission of the disease in the community.

Chlamydia trachomatis genital infection in apparently healthy adult population of Tamil Nadu, India: a population-based study.

Since the epidemiology of Chlamydia trachomatis infection in apparently healthy population has not been studied in India, a population-based study was conducted in the state of Tamil Nadu, India in order to analyse the prevalence of genital chlamydial infections in the community and to implement control programmes. A representative sample was taken from three randomly selected districts by using the 'probability proportional to size' cluster survey method. Households were the basic units of clusters. Adults aged 15-45 years, pre-identified from the selected households were enrolled during the medical camps conducted for a major study on community prevalence of sexually transmitted diseases in Tamil Nadu. Blood and urine samples collected from the study subjects were tested by enzyme-linked immunosorbent assay (ELISA) for anti-chlamydial IgM antibodies and by the commercial Amplicor polymerase chain reaction (PCR) test for chlamydial DNA. The prevalence of anti-C. trachomatis antibodies determined by IgM-ELISA was 2.4% (95% CI 1.6%-3.2%). The prevalence of genital chlamydial infection determined by PCR was 1.1% (95% CI 0.5%-1.7%). Majority of the detected infections (68.8%) were asymptomatic. This is the first Indian report on the prevalence of genital chlamydial infections in the general population. It is concluded that this study provides evidence for a substantial burden of approximately 10 million asymptomatic genital chlamydial infection cases in the sexually active age groups in the general population of India.

Serodiagnosis of syphilis in a community: an evaluatory study.

PURPOSE: To analyse the prevalence of syphilis in the apparently healthy population and to provide data for implementation of the joint STD/HIV control programme, a population based study was undertaken by using 'probability proportional to size' cluster survey method in three randomly chosen districts of Tamil Nadu, India namely Dindigul, Ramnad and Tanjore. METHODS: Blood samples were collected from adults (n=1873) aged 15-45 years, from the selected households enrolled in this study. The sera were tested parallelly by rapid plasma reagin (RPR) and Treponema pallidum haemagglutination (TPHA) tests. Reactive samples by RPR and/or TPHA were later analysed by fluorescent treponemal antibody absorption (FTA-ABS) test. RESULTS: The prevalence of syphilis in the community of Tamil Nadu as per RPR positivity was 2.7% (50/1873) as against 0.7% by TPHA (13/1873). FTA-ABS positivity was observed in only 12 out of 48 (25%) RPR/TPHA reactive samples tested. By taking the positivity by two of the three tests, the community prevalence of acute ongoing syphilis in Tamil Nadu was determined as 1.1% (20/1873). CONCLUSIONS: The results confirmed that no single serological test for syphilis can act as the marker of ongoing acute infection in an apparently healthy population. The study suggests that for specific diagnosis of ongoing syphilis, the FTA-ABS test may be performed along with RPR and TPHA.

Molecular typing of Neisseria gonorrhoeae from hospital and community isolates by restriction fragment length polymorphism.

Strains of Neisseria gonorrhoeae are generally characterized by auxotyping, serotyping, plasmid profile, antibiotic sensitivity and deoxyribonucleic acid (DNA) amplification fingerprinting. The aim of this study was to analyse the generation of restriction fragment length polymorphism (RFLP) patterns by BgIII digestion of total genomic DNA of N. gonorrhoeae isolated from the community (n =30) and the hospital (n =15) and to establish an association with serogrouping and antibiogram. The RFLP patterns produced by BgIII restriction digestion showed 7 different patterns among 30 community isolates and 9 different patterns among 15 hospital isolates. 66.7% of isolates belonged to serogroup WI. Penicillin resistance was observed in 46.7% of community isolates and 66.7% hospital isolates. However, penicillinase producing N. gonorrhoeae (PPNG) were lower in the community (6.6%) than in the hospital isolates (53.3%). PPNG strains were more often seen in serogroup WI. This is the first Indian report on RFLP genotype pattern in N. gonorrhoeae. We noted differences in RFLP genotypes of the community (RFLP types 1, 2, 3, 4, 5 and 7) and hospital strains (RFLP types 6 and 8), while no differences in the serogroup were observed. Ciprofloxacin resistance was 20.0% and 26.6% in the community and hospital isolates, respectively. Ceftriaxone emerges as the current drug of choice for an effective policy of antibiotic treatment of gonorrhoea through syndromic management in developing countries.

Asymptomatic malarial parasitaemia in Tamil Nadu.

AIM: The aim of the study was to determine the community prevalence of asymptomatic malarial parasitaemia in the state of Tamil Nadu. METHODS: Free medical camps were organised in three randomly selected districts of Tamil Nadu, namely Dindigul, Ramnad and Thanjavur districts in November, 1997. Proportionate to population size cluster survey method was followed to collect peripheral blood smear by finger prick from 30 clusters in each district. Fifteen households were randomly selected from each district with the target age group of 15-45 years. Peripheral blood smears were stained by Leishman's stain and the slides were examined end to end by two independent experts to diagnose malarial parasites. RESULTS: The male:female ratio of the population studied was 1:1.6. Asymptomatic malaria was identified in 17 out of 569 individuals screened with a positive rate of 2.9% (CI 1.5-4.3). Out of the 17 malarial positive peripheral smears 15 were P. vivax and only two were P. falciparum with the predominance of gametocyte stage. CONCLUSION: This study reaffirms the prevalence of asymptomatic malaria in Tamil Nadu especially with P. vivax.

Comparison of transdermal nitroglycerin and intracavernous injection of papaverine in the treatment of erectile dysfunction in patients with spinal cord lesions.

This study was done to evaluate the effectiveness of transdermal nitroglycerin in the treatment of erectile dysfunction in males with spinal cord lesions as compared to the treatment with intracavernous injection of papaverine. The study design used was an open, randomized, cross over trial of intracavernous injection papaverine versus transdermal nitroglycerin. Twenty eight male patients with spinal cord lesions with erectile dysfunction were included in the study, and were subjected to intracavernous injection of papaverine and transdermal nitroglycerin with an interval of 2 weeks as the wash out period. Objectively, the times taken for the onset and the duration of erection were noted. The length of the penis and its circumference at its base were measured at intervals until the erection subsided. The volume of the penis at the onset and at the peak of erection was calculated. Twenty six patients (ie 93%) who received an injection of papaverine, and 17 (ie 61%) of the patients who received nitroglycerin showed a complete response. The difference was statistically significant (P = 0.004). Nine (32%) patients had complications with the injection of papaverine. The only complication noted with the application of a nitroglycerin patch was mild headache, experienced by six (21%) patients. It was concluded from the study that intracavernous injection of papaverine is more effective than transdermal nitroglycerin in the treatment of erectile dysfunction in patients with spinal cord lesions.

Cutaneous lymphatic sporotrichosis.

The first case of cutaneous lymphatic sporotrichosis from Nagaland and a case of cutaneous sporotrichosis from Kerala who had acquired infection from Assam are reported. The diagnosis in both cases were established by isolating Sporothrix schenckii from multiple cutaneous lesions. The dimorphic nature of fungus was established in vitro by demonstrating the mycelial phase at 25-30 degrees C and yeast phase at 37 degrees C and pathogenicity to white mice. Both the patients were successfully treated with oral administration of potassium iodide for 3 months.

Management of neuroleptic malignant syndrome--a series of eight cases.

Neuroleptic Malignant Syndrome (NMS) is a rare and life threatening complication of treatment with Neuroleptic medication. Phenothiazine and butyrophenones are most frequently implicated in this syndrome even though there are case reports with other drugs. In this paper we describe the classical presentation of this syndrome in eight cases who had been on either a butyrophenone, a phenothiazine or a combination of these drugs. In addition some of our patients were also on either Lithium and/or Amitrytiline for control of depressive symptoms. Fever, muscule rigidity and elevated CPK are the important criteria for diagnosis and they were noted in all our patients. In addition four of our patients fulfilled five of the six minor criteria laid down by Levenson. Both Sinemet and Bromocriptine were found to be effective in the treatment of seven of the eight cases. However treatment with Dantroline sodium was associated with severe muscle wasting in one of our cases and the drug had to be discontinued. Two of our patients developed suspected myoglobinuria with dark coloured urine and progressive renal failure. One patient died after development of renal failure, pulmonary edema and hyperkalemia as a consequence of this disorders.

Restoration of antioxidants in liver by methionine feeding in experimental rat urolithiasis.

The effect of methionine or citrate on antioxidant defense system has been studied in urolithic rat. Liver weight and its protein concentration did not change in the rats fed with calculi producing diet (CPD) when compared to normal diet fed rats. Feeding rats along with citrate (c-CPD) or methionine (m-CPD) improved their body weight gain. Liver microsomes and mitochondria fractions of CPD and c-CPD fed groups showed increased susceptibility for lipid peroxidation in presence of ascorbate and t-butyl hydroperoxide when compared to either control or m-CPD fed groups. Increased superoxide dismutase and xanthine oxidase activities, decreased catalase, glutathione peroxidase and glucose-6-phosphate dehydrogenase activities, decreased concentrations of reduced glutathione, total thiols, ascorbic acid and vitamin-E and increased formation of hydroxyl radical, hydroperoxides and diene conjugates were observed in the liver of both CPD fed group as well as c-CPD fed group. Except SOD and xanthine oxidase, all other parameters were normalized in m-CPD fed group. This suggested that feeding methionine reduced the susceptibility for lipid peroxidation by restoration of the level of free radical scavengers.

Induction of lipid peroxidation in calcium oxalate stone formation.

The function of lipid peroxidation and the anti-peroxidative enzymes of rat liver and kidney were investigated under hyperoxaluric and stone forming conditions. The experimental animals showed higher malondialdehyde content in liver and kidney than that of control. A significant increase in malondialdehyde release was observed in the experimental liver or kidney when incubated with either ferrous sulphate or hydrogen peroxide compared to that of control liver or kidney. Superoxide dismutase activity was not affected in the hyperoxaluric rats while there was a moderate increase in the stone forming rats when compared to control. Highly significant decrease in catalase activity was observed in both conditions in liver and kidney compared to control.