Blindness associated with platelet-rich plasma temporomandibular joint injections.

This case report highlights an ocular complication associated with platelet-rich plasma temporomandibular joint injections. This pioneering treatment can risk irreversible visual loss. This case highlights the importance of an experienced technique, in depth understanding of facial anatomy, and promptly recognising and referring the patient to a specialist to manage the complication should it arise.

Increased Notching of the Corpus Callosum in Fetal Alcohol Spectrum Disorder: A Callosal Misunderstanding?

BACKGROUND AND PURPOSE: In the medicolegal literature, notching of the corpus callosum has been reported to be associated with fetal alcohol spectrum disorders. Our purpose was to analyze the prevalence of notching of the corpus callosum in a fetal alcohol spectrum disorders group and a healthy population to determine whether notching occurs with increased frequency in the fetal alcohol spectrum disorders population. MATERIALS AND METHODS: We performed a multicenter search for cases of fetal alcohol spectrum disorders and included all patients who had a sagittal T1-weighted brain MR imaging. Patients with concomitant intracranial pathology were excluded. The corpus callosum was examined for notches using previously published methods. A χ2 test was used to compare the fetal alcohol spectrum disorders and healthy groups. RESULTS: Thirty-three of 59 patients with fetal alcohol spectrum disorders (0-44 years of age) identified across all centers had corpus callosum notching. Of these, 8 had an anterior corpus callosum notch (prevalence, 13.6%), 23 had a posterior corpus callosum notch (prevalence, 39%), and 2 patients demonstrated undulated morphology (prevalence, 3.4%). In the healthy population, the anterior notch prevalence was 139/875 (15.8%), posterior notch prevalence was 378/875 (43.2%), and undulating prevalence was 37/875 (4.2%). There was no significant difference among the anterior (P = .635), posterior (P = .526), and undulating (P = .755) notch prevalence in the fetal alcohol spectrum disorders and healthy groups. CONCLUSIONS: There was no significant difference in notching of the corpus callosum between patients with fetal alcohol spectrum disorders and the healthy population. Although reported to be a marker of fetal alcohol spectrum disorders, notching of the corpus callosum should not be viewed as a specific finding associated with fetal alcohol spectrum disorders.

Early detection of multi-drug resistance and common mutations in Mycobacterium tuberculosis isolates from Delhi using GenoType MTBDRplus assay.

PURPOSE: There is scarcity of prevalence data of multi-drug-resistant tuberculosis (MDR-TB) data and common mutations responsible in North India. This study aimed to detect MDR-TB among MDR-TB suspects from Delhi and mutation patterns using GenoType MTBDRplus assay. MATERIALS AND METHODS: All MDR suspects in five districts of New Delhi were referred to the laboratory from 1 st October 2011 to 31 st December 2012 as per criterion defined by Programmatic Management of Drug Resistant Tuberculosis (PMDT). GenoType MTBDRplus assay was performed on 2182 samples or cultures and mutations in the rpoB gene for rifampicin (RIF) and katG and inhA genes for isoniazid (INH) were analyzed. RESULTS: A total of 366 (16.8%) MDR-TB cases were diagnosed. MDR rate was found to be 32%, 16.6% and 10.2% during criterion A, B and C respectively. The most common mutation detected for RIF was S531L (59.0%) and for INH was S315T1 (88.3%). Mutations S531L and S315T1 occurred significantly higher in MDR strains as compared to RIF mono-resistant and INH mono-resistant strains, respectively. Average laboratory turn-around time (TAT) for dispatch of result to districts for test conducted on samples was 4.4 days. CONCLUSION: GenoType MTBDRplus is a useful assay for rapid detection of MDR-TB. The common mutations for RIF and INH were similar to those seen in other regions. However, mutations determining MDR strains and mono-resistant strains differed significantly for both RIF and INH.

Needle localization of peripheral lung nodules for video-assisted thoracoscopic surgery.

Video-assisted thoracoscopic surgery provides an alternative to conventional thoracotomy for resection of peripheral lung nodules. To localize small peripheral lung nodules that may not be visible or palpable by the surgeon, we have placed a Kopans hook wire percutaneously into the lung as a guide. The indications for localization included previous nondiagnostic percutaneous needle aspiration biopsy (PNAB) (n = 4), nodules too small for PNAB (n = 2), nodules inaccessible to PNAB (n = 3), and planned resection of a known peripheral tumor less than 1 cm (n = 1). The localization procedure was performed with computed tomographic guidance in all patients. The nodules ranged in size from 2 to 15 mm and were located immediately subpleural to 2-cm deep the pleura. A 20-gauge Greene biopsy needle was used as an introducer for a 35-cm-long Kopans hook wire. Patients were sent directly to the operating room in a dependent position. All ten nodules were successfully resected, including hamartoma (n = 1), carcinoid tumors (n = 2), granulomas (n = 3), adenocarcinoma (n = 1), fibrosis (n = 1), benign metastasizing leiomyoma (n = 1), and lymphoma (n = 1). In two patients, the wire slipped out of the lung. Small focal pneumothoraces developed in five patients. There were no major complications. This procedure can safely and effectively localize nonvisible or nonpalpable pulmonary nodules for thoracoscopic surgery for diagnostic purposes or for resection of small peripheral tumors in patients who cannot tolerate a lobectomy or pneumonectomy.

Misdiagnosis of toxoplasma infection by PCR: fears unfounded.

A nested PCR based diagnostic assay for the detection of toxoplasmosis was devised in 1990 and was used successfully among a battery of tests for the clinical diagnosis of Toxoplasma gondii infection since 1991. However, it was reported that the assay produced false positive diagnoses with Nocardia asteroides infection. Investigation of this phenomenon showed that although cross reactivity with some unrelated organisms may be observed when altered conditions are employed, the assay does not lead to misdiagnosis if performed under the appropriate, stringent conditions.

Noncardiac thoracic surgical procedures. Definitions, indications, and postoperative radiology.

The radiologist should be familiar with the various operative procedures of the chest to accurately interpret routine postoperative radiologic studies. This also will assist them in the detection of common iatrogenic problems and postoperative complications such as bleeding, air leak, and infection. Furthermore, knowledge of serious and specific complications such as cardiac herniation and post-pneumonectomy syndrome can help the radiologist play an active role in the postoperative care of such patients.

Visual-motor recalibration in geographical slant perception.

In 4 experiments, it was shown that hills appear steeper to people who are encumbered by wearing a heavy backpack (Experiment 1), are fatigued (Experiment 2), are of low physical fitness (Experiment 3), or are elderly and/or in declining health (Experiment 4). Visually guided actions are unaffected by these manipulations of physiological potential. Although dissociable, the awareness and action systems were also shown to be interconnected. Recalibration of the transformation relating awareness and actions was found to occur over long-term changes in physiological potential (fitness level, age, and health) but not with transitory changes (fatigue and load). Findings are discussed in terms of a time-dependent coordination between the separate systems that control explicit visual awareness and visually guided action.

A phase I study of a combination of allopurinol, 5-fluorouracil and leucovorin followed by hydroxyurea in patients with advanced gastrointestinal and breast cancer.

Twenty patients with advanced carcinomas of the colorectum, pancreas, stomach, and breast were enrolled in a Phase I study of a sequential administration of 5-fluorouracil-leucovorin (FU-LV) combination followed by hydroxyurea (HU) with allopurinol protection (HALF regimen). As a weekly regimen for 6 weeks, followed by a rest period of 2 weeks, FU was administered intravenously (i.v.) during infusion of a 2-hour i.v. infusion of LV at a dose of 500 mg/m2. Six hours following the FU-LV combination, HU (1 gm/m2) was administered orally. Allopurinol (300 mg every 8 hours, orally) was given the day before and on the day of the administration of the FU-LV combination. The starting dose of FU was 300 mg/m2, with escalations to 900 mg/m2. Mucositis, diarrhea, and hematologic toxicities were mild and sporadic with FU doses up to 750 mg/m2 and occurred in patients who had received prior treatment with FU and/or radiotherapy. Dose-limiting neurocerebellar toxicity was observed in 2 out of 6 patients who received a FU dose of 900 mg/m2. Three additional patients experienced moderate neuromotor toxicity at this dose level. Among 17 patients evaluable for response, partial responses were seen in 3 of the 9 patients with colorectal cancer, 1 of the 3 patients each with carcinoma of breast and pancreas. Three of the 5 responses occurred in patients who had received prior treatment with FU and/or radiation therapy. An FU dose of 750 mg/m2 is recommended for a Phase II trial of the HALF regimen.

Perceiving geographical slant.

People judged the inclination of hills viewed either out-of-doors or in a computer-simulated virtual environment. Angle judgments were obtained by having people (1) provide verbal estimates, (2) adjust a representation of the hill's cross-section, and (3) adjust a tilt board with their unseen hand. Geographical slant was greatly overestimated according to the first two measures, but not the third. Apparent slant judgments conformed to ratio scales, thereby enhancing sensitivity to the small inclines that must actually be traversed in everyday experience. It is proposed that the perceived exaggeration of geographical slant preserves the relationship between distal inclination and people's behavioral potential. Hills are harder to traverse as people become tired; hence, apparent slant increased with fatigue. Visually guided actions must be accommodated to the actual distal properties of the environment; consequently, the tilt board adjustments did not reflect apparent slant overestimations, nor were they influenced by fatigue. Consistent with the fact that steep hills are more difficult to descend than to ascend, these hills appeared steeper when viewed from the top.

Radiographic features useful for establishing patient identity from improperly labeled portable chest radiographs.

Radiologists in hospital practice often encounter radiographs that either bear no patient identification or are incorrectly labeled as those of a different patient. To avoid repeating these improperly labeled radiographs, and to establish correct patient identity, most radiologists compare these radiographs with previous radiographs of several patients. This happens most often with portable chest radiographs. To study the reliability of various surgical, pathologic, and anatomic features and to help establish a fast and accurate method of establishing the correct patient identity, we performed a retrospective study of 50 patients in the intensive care unit. The characteristic location and configuration of surgical material, fractures, and dense parenchymal/pleural scars with or without calcifications are extremely helpful in establishing patient identity. In the vast majority of patients who lack such characteristic surgical and pathologic features, the anatomic structures that are most reliable for identification purposes are, in order of decreasing reliability, the transverse processes of the first thoracic vertebrae and the adjoining tubercles of the first ribs, the spinous processes, and the scapular wings. We believe that this information will help radiologists to identify the right patient when radiographs are incorrectly labeled.

Volumetric (helical/spiral) CT (VCT) of the airways.

Volumetric computed tomography (VCT) represents an important improvement over conventional CT for assessing most airway abnormalities. Elimination of misregistration due to variations in respiration coupled with decreased motion artifact and the ability to obtain routine overlapping sections allow a more confident estimation of the presence and extent of disease. Recently, attention has focused on newer reconstruction techniques including: multiplanar reconstructions (MPRs), including curved multiplanar reformations; multiplanar volume reconstructions (MPVRs) using ray projection techniques, such as maximum and minimum projection imaging; external rendering, or 3D-shaded surface displays; and, most recently, internal rendering or so-called "virtual bronchoscopy". Given the often redundant nature of many of these methodologies determining indications for their use remains to be established, especially by comparison to axial imaging. The purpose of this article is to review these various reconstruction techniques and, based on current knowledge, place them in an appropriate clinical context.

Relation of birth spacing with birth weight, morbidity and mortality of the newborn.

PIP: A total of 410 women delivering in the U.I.S.E. Maternity Hospital in Kanpur, India, were included in a study to determine the relation of birth interval with birth weight and infant morbidity and mortality. 66.7% of the sample group had a birth spacing of less than 2 1/2 years, 25.1% between 2 1/2 and 3 1/2 years, and 8.2% above 3 1/2 years. As birth interval increased, so did mean birth weight; mean birth weight was lowest (2150 gm) when spacing was less than 1 year and exhibited an upward trend up to 3 1/2 years. 60.8% of the infants delivered at a birth interval of less than 1 year weighed less than 2000 gm compared with 11.3% of the infants born at birth interval of 3-3 1/2 years. The highest percentages of infant morbidity (52.1%) and mortality (13.1%) were found when birth spacing was less than 1 year; both rates were considerably reduced (20.5% and 2.2%, respectively) when birth spacing was 2 1/2-3 1/2 years. Birth spacing is closely related to effective family planning, and its practice may yield substantial child health benefits.^ieng

Effect of intrauterine growth and gestational maturity of the morbidity and mortality pattern of babies requiring special care.

PIP: In an attempt to reduce infant morbidity and mortality a prospective study looking at intrauterine growth and various infant morbidity and mortality patterns was undertaken in Kanpur. Infants were grouped into preterm small for delivery (SFD) and average for delivery (AFD) and term SFD. Term AFD babies who required special attention were included also. Of 102 preterm SFD 74.5% died while 48.3% of the AFD died. Mortality rates for term AFD and SFD babies were 35.5% and 29% respectively. Hypoxia and infections accounted for 31.4% of preterm SFD mortality and 27.4% of morbidities. Among preterm AFD babies, injections, birth hypoxia and intreranial hemorrhage were the leading cause of morbidity. Hypoglycemia was diagnosed only in SFD newborns. Different mortality patterns were found to be significantly different between preterm AFD and SFD and term AFD and SFD babies. The study indicates that preterm AFD and SFD babies require maximum specialized services.^ieng

Lactation failure.

Seventy five mothers with lactation failure were studied, whose less than 4-month-old babies were admitted to the hospital. Partial lactational failure (94.7%) was noted more often than complete lactational failure (5.3%). Initiation of breastfeeding was delayed for 2 to 5 days usually for traditional reasons (77.3%) and because the mothers felt that the milk output was inadequate (92%). The various causes of lactation failure were determined and the relationship to various factors was analyzed. The commonest cause of lactation failure was insufficient milk or no milk (80%). The age, parity, education, socio-economic status, religion, family structure and urban vs rural status of mother--all had a bearing on the occurrence of lactation failure. An attempt was made to relactate all these mothers. The outcome was successful in 69.3 cases and failed in only 4% cases. In 26.7% cases, we cannot predict the outcome as the mothers hospital stay was very brief with no follow up.

PIP: A total of 75 mothers whose babies under 4 months old were hospitalized with lactation failure were studied. The age of the mothers varied from 16 years to 40 years with a mean of 23.7 years. 50 (66.7%) of the mothers were from the urban areas. 43 (57.3%) of them were primipara and 61 (81.3%) were Hindus. All the mothers given prelacteal feeds comprising water, water with sugar or glucose, milk (goat, cow, or milk powder) to their babies. The commonest cause of lactation failure with insufficient milk or no milk (80%). The age, parity, education, socioeconomic status, religion, family structure, and urban vs. rural residence of mother had a bearing on the occurrence of lactation failure. The initiation of breast feeding was delayed for 2-5 days usually for traditional reasons (77.3%) and because the mothers felt that the milk output was inadequate (92%). Only 4 (5.3%) mothers had complete lactation failure and practiced exclusive top feeding. Of the 71 (94.7%) mothers with partial lactation failure, 41 (54.7%) were giving frequent breast feeds while 30 (40%) were breast feeding occasionally. Relactation was attempted in all cases. Mothers have been motivated to breast feed and were provided adequate rest, nutrition, and psychological support. If lactation was still not established, then metoclopramide was given orally in the 8-hourly dosage of 10 mg for 10 days. If this also failed, nursing supplementer was tried. The relactation attempt was successful in 49 (69.3%) partial and 3 (7.5%) complete lactation failure cases. Relactation failed in 22 (30.7%) mothers with partial lactation failure and 1 (2.5%) mother with complete lactation failure. (26.7%) mothers with partial lactation failure were lost to follow up. Out of 4 cases of complete lactation failure, 1 had severe anemia with hypoproteinemia, the 2nd developed intense dislike of her baby at birth, the 3rd had tuberculosis and was advised not to breast feed, and in the 4th case the mother stopped breast feeding completely because she felt that her milk was unsuitable.

Modified Levinson's test in rapid diagnosis of tuberculous meningitis.

Modified Levinson's precipitation test was done in 64 cases of TBM, 54 cases of TBM with inconsistent CSF finding, and 32 cases of pyogenic meningitis. The test was positive in 93.7% cases of TBM (sensitivity, 93.7%), 85.5% cases of TBM with doubtful diagnosis and in 9.4% cases of pyogenic meningitis (specificity 90.6%) compared to 79.7%, 72.2% and 18.8% in original Levinson's test, respectively. With CSF examination only 66% cases of TBM could be diagnosed while with modified Levinson's test and CSF analysis 89% cases could be diagnosed (p < 0.001). So modified Levinson's test for diagnosis of TBM is better than Levinson's test (p < 0.05) with an added advantage of time saving.