Rituximab-induced interstitial lung disease in a patient with immune thrombocytopenia purpura.

We report the case of an 84-year-old man with refractory immune thrombocytopenia purpura (ITP) who was treated with rituximab and subsequently developed severe interstitial lung disease. There has been increasing use of rituximab in the treatment of ITP with success rates of up to 62% in adult patients with recurrent ITP. Interstitial lung disease is a rare but recognised complication of rituximab but has been rarely reported in the setting of ITP.

Diagnostic yield of bronchoscopic sampling in febrile neutropenic patients with pulmonary infiltrate and haematological disorders.

BACKGROUND: The development of pulmonary infiltrate in neutropenic patients is potentially life-threatening, and requires early diagnosis and treatment. Bronchoscopic sampling is an established form of investigation in such patients. AIM: The aim of the study is to determine the diagnostic yield and complication rate of bronchoscopic sampling in patients with a haematological disorder presenting with febrile neutropenia and pulmonary infiltrate. METHODS: Medical records and laboratory investigations were retrospectively reviewed for all patients with a haematological disorder who underwent flexible bronchoscopy and bronchoalveolar lavage (BAL) or bronchial washing (BW) at Auckland City Hospital, New Zealand, after presenting with febrile neutropenia and pulmonary infiltrate between January 2008 and December 2009. Demographic, clinical, radiological and microbiological data, procedure-related complications and treatment were recorded. Modifications to treatment regimens as a result of bronchoscopy and 30-day mortality were recorded. RESULTS: Out of 678 bronchoscopies performed during this period, 26 were in patients with a haematological disorder presenting with febrile neutropenia and pulmonary infiltrate. Most patients had a haematological malignancy (19/26). Two (7.7%) patients reported minor haemoptysis. No biopsies were performed. Positive microbiological samples were obtained with BAL/BW in 23% of patients. The most common organisms identified were Aspergillus species (15.4%); other organisms were Candida (11.6%) and Streptococcus pneumoniae (3.9%). The bronchoscopic results altered the clinical management of 10 (38.4%) patients. The 30-day mortality rate was 19.2%, but no deaths were related to the procedure. CONCLUSIONS: In haematology patients presenting with febrile neutropenia and pulmonary infiltrate, bronchoscopy is a safe procedure that plays a significant role in management.

Befriending patients with medication-resistant schizophrenia: can psychotic symptoms predict treatment response?

OBJECTIVES: Supportive interventions are used in schizophrenia, but little research has been conducted into whether any baseline variable predicts treatment response. The aim of this study was to establish if baseline delusions or hallucinations are associated with changes in overall symptoms in patients who received a befriending intervention. DESIGN: The sample consisted of 44 patients with schizophrenia. These patients comprised the befriending arm of a multicentre randomized controlled trial which compared the efficacy of using CBT against befriending as an adjunct to routine care for patients with medication-resistant schizophrenia. METHODS: Scores for auditory hallucinations and delusions relating to persecution or control were entered into two regression models. The dependent variables were change in overall symptoms (1) between baseline and end of the intervention, and (2) between baseline and 9 months post-intervention. RESULTS: Baseline delusions predicted a good response and auditory hallucinations predicted a poor response at 9 months. CONCLUSIONS: Baseline psychotic symptoms strongly predicted outcome in this sample. The finding that hallucinations predicted a poor outcome is consistent with previous research. These results may help to determine which patients would benefit from supportive interventions.

A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication.

BACKGROUND: Research evidence supports the efficacy of cognitive-behavioral therapy in the treatment of drug-refractory positive symptoms of schizophrenia. Although the cumulative evidence is strong, early controlled trials showed methodological limitations. METHODS: A randomized controlled design was used to compare the efficacy of manualized cognitive-behavioral therapy developed particularly for schizophrenia with that of a nonspecific befriending control intervention. Both interventions were delivered by 2 experienced nurses who received regular supervision. Patients were assessed by blind raters at baseline, after treatment (lasting up to 9 months), and at a 9-month follow-up evaluation. Patients continued to receive routine care throughout the study. An assessor blind to the patients' treatment groups rated the technical quality of audiotaped sessions chosen at random. Analysis was by intention to treat. RESULTS: Ninety patients received a mean of 19 individual treatment sessions over 9 months, with no significant between-group differences in treatment duration. Both interventions resulted in significant reductions in positive and negative symptoms and depression. At the 9-month follow-up evaluation, patients who had received cognitive therapy continued to improve, while those in the befriending group did not. These results were not attributable to changes in prescribed medication. CONCLUSION: Cognitive-behavioral therapy is effective in treating negative as well as positive symptoms in schizophrenia resistant to standard antipsychotic drugs, with its efficacy sustained over 9 months of follow-up.

Attributes and practices of oral and maxillofacial radiology departments in US and Canadian dental schools.

OBJECTIVE: To assess the actual state of oral and maxillofacial radiology departments in US and Canadian dental schools against the ideal characteristics defined by the American Academy of Oral and Maxillofacial Radiology (AAOMR) 1997 position paper. STUDY DESIGN: Cross-sectional survey of all 65 US and Canadian dental schools. RESULTS: Sixty-four surveys were returned (98%). At most schools, oral and maxillofacial radiology (OMR) was an identifiable division of a department, established policies, and had operational authority for radiographic practices in the primary radiology clinic. The majority of full-time faculty (72%) had formal training in OMR; the majority of part-time faculty (86%) did not. Full-time faculty spent approximately 60% of their time teaching, with the remainder of their time divided among research and scholarship, faculty practice, and service. Routine x-ray equipment was universally available; advanced imaging technologies were not. OMR faculty involvement in the interpretation of radiographs varied across diseases and conditions. Most published scholarship (85%+) was produced by full-time faculty. Average output was 1 paper per person per year, but a relatively small cadre of OMR faculty generated most papers. CONCLUSIONS: In some attributes, the status of OMR closely approximated the ideal characteristics established in the AAOMR report. Among the remaining attributes, bridging the difference between the actual and the ideal will be the challenge for the next 5 years.

Education and training in psychosocial interventions: a survey of Thorn Initiative course leaders.

The Thorn Initiative is a prominent education and training programme for psychosocial interventions. The course originated in two centres in the UK in 1992, 10 years on the programme had expanded to 13 centres across England and Wales. A survey of course content and structure was sent out to all 13 sites by email of which eight responded by post. The survey results showed that since 1999 there has been a rapid growth in the number of Thorn sites. There remains a high degree of fidelity to the original courses in mode of delivery, service user and carer participation, and core content. All of the sites were progressing towards providing degree courses, usually in a modular format and with an expanded curriculum. In conclusion, the Thorn Steering Group has been successful in Thorn site expansion and curriculum development. Such success has taken activity away from audit and research in psychosocial interventions, education, training, implementation and fidelity to taught skills. Implementation remains a cause for concern and it is recommended that a focus for Thorn sites should be on creating and evaluating novel solutions to this pervasive problem.

Growth of an ameloblastoma during pregnancy: opportunity lost?

A 19-year-old pregnant woman presented with an enlarging lesion in the right mandible. She was examined by a general dental practice resident in the hospital outpatient clinic and subsequently managed by the resident as an inpatient. Both moral and ethical questions arose because of the discovery of the lesion early in the patient's pregnancy. Delay on the part of the patient while she contemplated termination of the pregnancy, compounded by loss of contact with her, eliminated the possibility of removal of the lesion during the second trimester. The patient elected to continue the pregnancy, and an en bloc procedure was used to remove the ameloblastoma.

Type I dentin dysplasia: report of two cases.

Dentin dysplasia is a rare developmental disturbance of dentin affecting approximately 1:100,000 people. It has been classified as an autosomal dominant disease. Two distinct forms of dentin dysplasia have been described. As more cases of dentin dysplasia were reported these categories seemed inadequate; subclassification of type I dentin dysplasia were proposed based on root length and the presence or not of a pulpal remnant. This paper presents two cases demonstrating the classic features of type I dentin dysplasia in the mixed and permanent dentitions and discusses the suggested subclassifications. The authors suggest that while differences in root length may be useful in determining treatment options, thinking of these variables as separate types of dentin dysplasia is not warranted at this time. Justification of a subcategory of type I dentin dysplasia should be based on a different disease process, different histology, significantly different symptoms, or different etiologies, and until researchers can clearly prove from a genetic or chromosomal standpoint that the subcategories are separate entities, we should accept, as we do for many other genetic disorders, that some patients are more severely affected than others.

Sexual and reproductive health in men with cystic fibrosis: consistent preferences, inconsistent practices.

BACKGROUND: Sexual and reproductive health (SRH) is increasingly relevant for men with CF. However, the extent of similarities or differences in SRH clinical practices across different centres or states is unknown as single clinic studies are not informative about variations in male preferences or clinical practices. We wished to determine the variability of male SRH knowledge and preferences, and clinical practices across different CF clinics. METHODS: Men attending 5 adult CF clinics in Australasia completed a survey of SRH knowledge, attitudes and behaviours. RESULTS: 264 (64%) men participated, with a median age of 30 years (17-56). 65% knew of near universal infertility due to a transport problem. 43% heard about infertility from their preferred source, but significantly later than desired. Less than half had undergone semen analysis (SA), which, while varying by site, was consistently later than preferred. 57 men were fathers, of whom 29 had utilised ART. CONCLUSION: Men's preferences around SRH were more consistent than clinical practices. Clinical practice guidelines and training for health professionals would help reduce the gap between men's SRH preferences and clinical practice.

Primary disorders of bone with 'spinal block'.

Two hundred and thirty-two cases of compression of the spinal cord or cauda equina included 11 cases where compression was entirely due to a primary bony disorder and 20 further cases where developmental spinal stenosis was the main cause of compression. The former group consisted of two cases of Paget's disease and one each of polyostotic fibrous dysplasia, chondrosarcoma, achondroplasia, spondylo-epiphyseal dysplasia, Klippel--Feil syndrome, haemangioma of bone, primary bone reticulosarcoma, osteoporotic fracture and vertebral osteomyelitis. Three patients, with fibrous dysplasia, chondrosarcoma and Paget's disease with recurrent compression respectively, are described and the relevant literature is reviewed. The large number of primary disorders of bone which can cause cord compression are tabulated. Cord compression is a rare complication in most of these disorders but collectively they caused 13% of the cases of spinal block in this series.

Excitations for lattice ferromagnetic classical spin systems at high temperature: noneven single-spin distributions

We consider general d-dimensional lattice ferromagnetic spin systems with nearest neighbor interactions in the high temperature region (beta<<1). Each model is characterized by a single-site a priori spin probability distribution taken to be noneven. We state our results in terms of the parameter alpha=(<&smacr; (4)>-3<&smacr; (2)>(2)-<&smacr; (3)>(2)<&smacr; (2)>(-1))/(<&smacr; (4)>-<&smacr; (2)>(2)-<&smacr; (3)>(2)<&smacr; (2)>(-1)), where &smacr;=s-, and denotes the kth moment of the single-site distribution. Associated with the model is a lattice quantum field theory which is known to contain a particle of mass m approximately ln beta. Assuming <&smacr;(3)> not equal0 we show that for alpha>0, beta small, there exists a bound state with mass below the two-particle threshold 2m. For alpha<0 bound states do not exist. These results are obtained using a Bethe-Salpeter (BS) equation in the ladder approximation in conjunction with a representation for the inverse of the two-point function designed to analyze the spectrum below but close to 2m.

Bound states in the transfer matrix spectrum for general lattice ferromagnetic spin systems at high temperature

We obtain different properties of general d dimensional lattice ferromagnetic spin systems with nearest neighbor interactions in the high temperature region (beta<<1). Each model is characterized by a single site a priori spin distribution, taken to be even. We state our results in terms of the parameter alpha=-3(2) where denotes the kth moment of the a priori distribution. Associated with the model is a lattice quantum field theory that is known to contain particles. We show that for alpha>0, beta small, there exists a bound state with mass below the two-particle threshold. For alpha<0, bound states do not exist. The existence of the bound state has implications on the decay of correlations, i.e., the four-point function decays at a slower rate than twice that of the two-point function. These results are obtained using a lattice version of the Bethe-Salpeter equation in the ladder approximation. The existence and nonexistence results generalize to N-component models with rotationally invariant a priori spin distributions.

Calcification in the stylohyoid ligament.

This article describes the incidence of calcification in the stylohyoid ligament in a sample of the patient population of the University of Mississippi School of Dentistry. The records of 479 patients were reviewed, with particular attention given to the panoramic radiograph. The patients ranged in age from 4 to 78 years, with a mean age of 29. There was a sharp increase in incidence of calcification during the first three decades of age from 45.3% in the first decade to 86.2% in the third, with a gradual increase from the fourth to the seventh decade (87.3% to 92%). The eighth decade, represented by nine patients, showed an incidence of 100%. There appears to be no race predilection for calcification, a slight sex predilection for females, and an age incidence that seems to support both the developmental and degenerative theories of etiology of calcification in the stylohyoid ligament.

Burkholderia pseudomallei: another emerging pathogen in cystic fibrosis.

BACKGROUND: Burkholderia pseudomallei is an important cause of acute fulminant pneumonia and septicaemia in tropical regions of northern Australia and south east Asia. Subacute and chronic forms of the disease also occur. There have been three recent reports of adults with cystic fibrosis (CF) who presumably acquired B pseudomallei infection during extended vacations or residence in either Thailand or northern Australia. METHODS: The clinical course, molecular characteristics, serology and response to treatment are described in four adult CF patients infected with B pseudomallei. Polymerase chain reaction (PCR) based methods were used to confirm B pseudomallei and exclude B cepacia complex. Genotyping was performed using randomly amplified polymorphic DNA (RAPD) PCR and pulsed field gel electrophoresis (PFGE). RESULTS: Four patients are described with a mean duration of infection of 32 months. All but one patient lived in tropical Queensland. Two patients (with the longest duration of infection) deteriorated clinically and one subsequently died of respiratory failure. Both responded to intravenous treatment specifically targeting B pseudomallei. Another patient suffered two severe episodes of acute bronchopneumonia following acquisition of B pseudomallei. Eradication of the organism was not possible in any of the cases. PFGE of a sample isolate from each patient revealed the strains to be unique and RAPD analysis showed retention of the same strain within an individual over time. CONCLUSIONS: These findings support a potential pathogenic role for B pseudomallei in CF lung disease, producing both chronic infection and possibly acute bronchopneumonia. Identical isolates are retained over time and are unique, consistent with likely environmental acquisition and not person to person spread. B pseudomallei is emerging as a significant pathogen for patients with CF residing and holidaying in the tropics.

Unusual combination of presenting features in multiple myeloma.

Initial oral signs of multiple myeloma may involve pain, paraesthesia, swelling, tooth mobility and radiolucency. A 62-year-old female patient presented with the chief complaint of numbness in the right lower jaw. Intraoral examination revealed no abnormalities and her history was non-contributory. A panoramic radiograph revealed an irregular, small radiopacity in the premolar region and small, multiple and diffuse osteolytic alterations in the mandible. Computed tomography revealed maxillary and mandibular cortical destruction. An incisional biopsy was performed. The histopathological diagnosis was plasma cell myeloma and further investigations lead to the diagnosis of multiple myeloma. Dysfunction of a nerve coursing through diseased bone is an ominous sign and may be an indication that a malignant process is present.