Difficulties in the diagnosis of periapical translucencies and in the classification of cemento-osseous dysplasia

Background

Cemento-osseous dysplasia is a benign fibro-osseous lesion of the tooth-bearing region of the jaws with a periodontal ligament origin. It appears predominantly in Black and Asian middle-aged females. Its importance is that it could mimic a periapical lesion in the early, translucent stage.

Case presentation

In this report a rare case of familial cemento-osseous dysplasia is presented: a 50-years old Caucasian woman with labial paraesthesia and radiological translucency around the roots of the mandibular incisors and the first molar teeth. The lesion around the first molar was diagnosed as periapical granuloma and a root canal treatment was carried out. The diagnosis of florid cemento-osseous dysplasia and the treatment plan based on two- and three-dimensional radiographic examinations were certified histologically after surgical removal of the lesion. We screened the family members - including the patient’s mother, daughter and son - and identified a periapical version of cemento-osseous dysplasia in the daughter. Our case highlights the difficulties of differential diagnosis of cemento-osseous dysplasia and other periapical pathologies. The inconsistencies in the present classification of cemento-osseous dysplasia are also discussed with a proposal for a different classification based on new aspects that would be very helpful in setting up a correct treatment plan.

Conclusion

Differentiation of endodontic and non-endodontic origin of radiolucency and distinguishing it from anatomical landmarks by appropriate clinical evaluation and using vitality testing can give an opportunity to prevent unnecessary endodontic treatment.

The current categories of cemento-osseous dysplasia classification do not cover the early stage of a hereditary florid form of cemento-osseous dysplasia.

Instead of anatomical location of the lesion, clinical and genetic features may be recommended as parameters of cemento-osseous dysplasia classification.

Mutational and radiographic analysis of pulmonary disease consistent with lymphangioleiomyomatosis and micronodular pneumocyte hyperplasia in women with tuberous sclerosis

Lymphangioleiomyomatosis (LAM) and multifocal micronodular pneumocyte hyperplasia (MMPH) produce cystic and nodular disease, respectively, in the lungs of patients with tuberous sclerosis. The objective of this study was to prospectively characterize the prevalence, clinical presentation, and genetic basis of lung disease in TSC. We performed genotyping and computerized tomographic (CT) scanning of the chest on 23 asymptomatic women with tuberous sclerosis complex (TSC). Cystic pulmonary parenchymal changes consistent with LAM were found in nine patients (39%). These patients tended to be older than cyst-negative patients (31.9 +/- 7.6 yr versus 24.8 +/- 11.6 yr, p = 0.09). There was no correlation between presence of cysts and tobacco use, age at menarche, history of pregnancy, or estrogen-containing medications. Three of the cyst-positive patients had a prior history of pneumothorax. Pulmonary function studies revealed evidence of gas trapping but normal spirometric indices in the cyst-positive group. All nine cyst-positive patients had angiomyolipomas (AML), which were larger (p < 0.05) and more frequently required intervention (p = 0.08) than cyst-negative patients (8 of 14 with AMLs, p < 0.05). Ten patients (43%) had pulmonary parenchymal nodules. Pulmonary nodules were more common in women with cysts (78% versus 21%, p < 0.05), and 52% of all patients had either cystic or nodular changes. TSC2 mutations were identified in all cyst-positive patients who were tested (n = 8), whereas both TSC1 and TSC2 mutations were found in patients with nodular disease. Correlation of the mutational and radiographic data revealed one pair of sisters who were discordant for cystic disease, two mother- daughter pairs who were discordant for nodular disease, and no clear association between cyst development and a specific mutational type. This prospective analysis demonstrates that cystic and nodular pulmonary changes consistent with LAM and MMPH are common in women with TSC.

Connective tissue growth factor mRNA expression is upregulated in bleomycin-induced lung fibrosis

Connective tissue growth factor (CTGF) is a newly described 38-kDa peptide mitogen for fibroblasts and a promoter of connective tissue deposition in the skin. The CTGF gene promotor contains a transforming growth factor-beta1 (TGF-beta1) response element. Because TGF-beta1 expression is upregulated in several models of fibroproliferative lung disease, we asked whether CTGF is also upregulated in a murine lung fibrosis model and whether CTGF could mediate some of the fibrogenic effects associated with TGF-beta1. A portion of the rat CTGF gene was cloned and used to show that primary isolates of both murine and human lung fibroblasts express CTGF mRNA in vitro. There was a greater than twofold increase in CTGF expression in both human and murine lung fibroblasts 2, 4, and 24 h after the addition of TGF-beta1 in vitro. A bleomycin-sensitive mouse strain (C57BL/6) and a bleomycin-resistant mouse strain (BALB/c) were given bleomycin, a known lung fibrogenic agent. CTGF mRNA expression was upregulated in the sensitive, but not in the resistant, mouse strain after administration of bleomycin. In vivo differences in the CTGF expression between the two mouse strains were not due to an inherent inability of BALB/c lung fibroblasts to respond to TGF-beta1 because fibroblasts from untreated BALB/c mouse lung upregulated their CTGF message when treated with TGF-beta1 in vitro. These data demonstrate that CTGF is expressed in lung fibroblasts and may play a role in the pathogenesis of lung fibrosis.

Clinical classification as a guide to treatment of sinusitis in children

Evaluation of all 153 children undergoing CT scan of the paranasal sinuses for recalcitrant sinusitis symptoms between January 1988 and July 1992 was performed. Clinical categorization into groups of patients presenting with chronic sinusitis (CS) and recurrent acute sinusitis (RAS) was based upon pattern of disease and presentation. Clinical symptoms and signs, radiological examination, treatment, and outcome were compared between these distinct clinical groups. Eighty-two (55%) children were categorized as RAS and 68 (45%) as CS. Children with CS presented more frequently with a persistent cough, purulent nasal discharge, immune deficiency, and more severe mucosal disease on CT than children with RAS. Medical therapy successfully controlled the symptoms of sinusitis in 79 (96%) with RAS versus 27 (40%) with CS. Surgery was performed in 44 children: 3 (3.6%) with RAS versus 41 (60%) with CS, p < 0.01. At a mean follow-up of 2.0 years, >80% of all the children were either asymptomatic or improved regardless of treatment modality. These data support the use of clinical classification as a guide to medical versus surgical therapy in children with sinusitis.

Ultrafast computed tomography as a diagnostic modality in the detection of coronary artery disease: a multicenter study

BACKGROUND

Ultrafast computed tomography (CT), by acquiring images of the proximal coronary arteries, detects coronary calcifications and has been demonstrated to be highly sensitive for the detection of coronary artery disease in many small studies. The aim of this study was to determine the relationship between ultrafast CT scanning and coronary angiography in a large number of symptomatic patients.

METHODS AND RESULTS

The study population consisted of 710 patients from six participating centers. A multivariate logistic regression model was used to evaluate the individual contributions of age, number of calcified vessels, and the calcium score for the probability of angiographically significant disease. Of the 710 patients enrolled, 427 patients had significant angiographic disease, and coronary calcification was detected in 404, yielding a sensitivity of 95%. Of the 23 patients without calcifications, 19 (83%) had single-vessel disease at angiography. Of the 283 patients without angiographically significant disease, 124 had negative ultrafast CT coronary studies, for a specificity of 44%. An increasing number of vessels with calcification present on ultrafast CT was found to increase specificity for the presence of obstructive coronary artery disease in at least one vessel (P < .0001). As the log of the calcium score increases, the probability of multivessel obstructive disease increases (P < .0001).

CONCLUSIONS

Ultrafast CT scanning is an noninvasive, non-exercise-dependent test with an excellent sensitivity for the detection of coronary artery disease. The presence of calcifications in multiple vessels and in younger populations correlates with higher specificities for obstructive disease, making ultrafast CT coronary scanning a very useful diagnostic test.

Litigation in residency training programs and suggested due process guidelines for "residents in trouble"

Litigation involving the dismissal of residents has increased in the past decades. A review of relevant court decisions and their implications for residency training programs is provided. To assure due process in such cases and to help programs deal fairly with situations involving problem residents that may never come to frank dismissal, a set of guidelines to assist training programs in dealing ivith residents "in trouble" is presented. The guidelines were developed collaboratively at University of California at Los Angeles (UCLA) and the University of Southern California (USC) and were reviewed and approved by the local hospital, university, and Veterans Affairs counsels to assure compliance with institutional policies and procedures regulating due process for employees and students. The guidelines were also reviewed and approved by an American Association of Directors of Psychiatric Residency Training (AADPRT) task force, but they were never published or widely distributed. Although modifications of these guidelines may be required to meet local educational or institutional variations, or to meet variations in state law or precedent, these suggestions provide a useful template with which to develop adequate and effective due process procedures.

Cystic periventricular leukomalacia and type of cerebral palsy in preterm infants

A case series design was used to identify cases of cystic periventricular leukomalacia (N = 31) identified by neurosonography at one regional tertiary intensive care nursery. Patients were preterm infants born at < or = 32 weeks of gestation who had cysts involving predominantly the middle-posterior or posterior periventricular regions. Neurodevelopmental evaluations were made for 26 (96%) of 27 survivors. All infants assessed had cerebral palsy (i.e., 54% quadriplegia, 42% diplegia, and 4% hemiplegia). Most cognitive delays and all sensory impairments occurred in children with quadriplegia. Periventricular cysts were most extensive on parasagittal, anteroposterior views. The parasagittal, anteroposterior extent of periventricular cysts was most accurate in predicting the type and severity of motor and cognitive disabilities. Quadriplegia was associated with larger and more extensive cysts.

Nerve palsy during femoral lengthening: MRI, electrical, and histologic findings in the central and peripheral nervous systems--a canine model

Six dog's femurs were lengthened until complete peroneal palsy was present. Ten-24 days later MRIs of the spinal cords were normal. EMGs located lesions at the spinal foramina in five dogs and at the lumbar plexus in one. In all dogs nerve conduction below the lesions was normal and amplitudes were diminished. Muscle histology confirmed neurogenic atrophy. Nerve histology at the sites of the lesions showed myelin and axon changes, but there was no Wallerian degeneration at or distal to those sites. Thus, the nerve lesions were either a variant of Sunderland first degree injury or were developing into second degree.

Nonoperative management of major blunt renal trauma in children: in-hospital morbidity and long-term followup

The management of 26 children with major renal injury secondary to blunt trauma was reviewed. Emergency computerized tomography (CT) was performed in all instances. Injury ranged from parenchymal laceration to vascular avulsion. Early surgical exploration was done in 5 children due to hemodynamic instability, renal pedicle injury or suspected malignancy. The remaining 21 children were observed. Of these children 5 had associated intra-abdominal organ injuries. The average length of hospitalization was 13.4 days and the average intensive care unit stay was 6.9 days. A third of the children were transfused with an average 10.8 cc/kg. of packed red cells. Ten patients (47.6%) had febrile episodes that lasted an average of 3 days. No foci of infection other than bladder urine were identified and there were no infected perirenal collections. In 2 children ureteral stents were placed cystoscopically. Exploration was performed in 1 child for delayed hemorrhage 2 months after hospital discharge. Followup CT was available in 15 patients and all kidneys functioned, including 3 with residual focal scarring, 2 with parenchymal calcifications and 1 with a cyst. Eleven patients were evaluated clinically at least 1 year after injury and all were asymptomatic, while 1 child had mild diastolic hypertension. In conclusion, nonoperative management results in an excellent long-term outcome in the majority of cases. In-hospital morbidity is minimal and early surgical exploration should be reserved for those with hemodynamic instability or renal pedicle injury. Immediate CT is an invaluable aid in categorizing and managing these patients.

Pathophysiology of congenital diaphragmatic hernia. III: Exogenous surfactant therapy for the high-risk neonate with CDH

Exogenous surfactant therapy (EST) in surfactant-deficient premature infants has been shown to improve lung compliance, decrease morbidity, and improve survival. Reports have demonstrated that newborns with congenital diaphragmatic hernia (CDH) have lung compliance, pressure-volume curves, and hyaline membrane formation resembling those changes seen in surfactant deficient premature newborns. We hypothesize that EST may also benefit infants with CDH. All high risk cases of prenatally diagnosed CDH at Children's Hospital of Buffalo from November 1988 to February 1991 were prospectively evaluated for EST. In those families who chose to participate, the surfactant preparation, Infasurf (100 mg/kg), was instilled into the newborn's lungs prior to the first breath. The remainder of the perinatal, neonatal, and surgical care was performed in a routine manner. Three high-risk prenatally diagnosed newborns with left CDH were treated with EST. All showed signs of decreased pulmonary compliance, but could still be adequately oxygenated and ventilated. Surgical correction was performed after stabilization and all required patch closures. Two of the three infants suffered no life-threatening episodes of pulmonary hypertension and all survived. These infants had many known indicators for poor outcome in CDH with an expected survival of less than 20%. We believe that EST in these neonates with CDH contributed to their survival with minimum morbidity. These results suggest that surfactant replacement for the high-risk neonate with CDH warrants further consideration and a randomized clinical trial is being planned.

Studies on the incorporation of lanthanides in dental hard tissues

Rare earth elements (lanthanides)--known from chrystal-chemistry for the rehardening effect on apatites--have been tested previously for the possibility of their incorporation in dental enamel. From the non-toxic lanthanides cerium was incorporated under in vitro conditions in human dental enamel. In the present study, the incorporation of lanthanum (La), europium (Eu), samarium (Sa), ytterbium (Yb) and neodymium (Nd) in human permanent enamel, dentine and deciduous enamel has been investigated by neutron activation analysis. The lanthanides were incorporated--following the above sequence--in an increasing ratio into enamel and dentine, by forming new, more resistant rare earth elements containing apatite structures.

Rotational remodeling of malrotated femoral fractures: a model in the rabbit

It is estimated that 20-40% of femoral fractures in children heal in malrotation, yet few patients later complain. To determine if malrotation corrects spontaneously, midshaft osteotomies were made in femurs of 16 rabbits aged 8 weeks and the distal fragments were internally rotated 45 degrees, where they were held with external fixators. The animals were killed between week 0 and week 17. Version of the femoral necks was determined by computed tomography scan (CT). The version altered rapidly toward normal from weeks 0 to 4 and then remained stable, with an average rotational remodeling of 55%.

Needle aspiration of neck abscesses in children

Needle aspiration of neck abscesses with CT-scan guidance was studied in 17 children with 18 abscesses from 1986 to 1991. Clinical and radiologic findings were analyzed according to treatment outcome. A majority of abscesses (55.6%) resolved after treatment with one to two attempts at needle aspiration and parenteral antibiotics. Unilocular abscesses were more likely than multilocular abscesses to resolve with needle aspiration. In general, abscesses in younger children who presented with smaller neck masses on physical examination and smaller abscess cavities on CT scan resolved with needle aspiration. The data support the use of needle aspiration as an effective initial treatment for pediatric neck abscesses. CT scan was found beneficial in documenting the abscesses and in guiding treatment. A treatment protocol is suggested for the use of needle aspiration in the management of neck abscesses in children.

Concomitant vascular procedures in conjunction with myocardial revascularization: all or none? A report of a case

Patients with coronary artery atherosclerosis usually have concomitant peripheral vascular lesions. The authors describe the case of a 65-year-old woman who had multiple symptomatic lesions: severe stenosis of the left main coronary artery and the carotid arteries, a large abdominal aortic aneurysm and bilateral renal artery occlusion. To manage these and to avoid myocardial infarction and cerebrovascular accident at operation, concomitant procedures were performed as follows: coronary artery bypass grafting, aneurysm resection, carotid endarterectomy and revascularization of the larger kidney. Although the patient's hospital stay was prolonged, there was no major morbidity and her recovery was good. She returned to a normal life-style, requiring only hemodialysis on an outpatient basis.

Uterine leiomyosarcoma with cardiac metastases

Leiomyosarcoma metastatic to the heart is rare and is usually fatal. The authors present the case of a 58-year-old woman who had a history of uterine leiomyosarcoma. Echocardiography and cardiac catheterization revealed a large right ventricular mass. Computed tomography confirmed the presence of the mass which extended into the pulmonary artery. The inferior vena cava was free of disease. At operation, a large tumour originating in the right ventricle and protruding through the pulmonary valve was found. Histologically, it was a leiomyosarcoma. Because there were numerous septal and intramural foci of tumour, complete resection was impossible, but palliative resection was performed successfully and the patient was alive and active 1 year after operation.

Magnetic resonance imaging of vascular lesions in children. Assessment of flow patterns

Ten children aged 1 week to 13 years with 12 vascular abnormalities were examined with magnetic resonance imaging (MRI) and other imaging modalities. MRI was the only single non-invasive modality that demonstrated all lesions and their internal structures. The vascular nature of 3 hemangiomas could not be established with MRI alone. No marked differences in MRI appearance was seen in 5 cases with vascular tumors compared with 5 cases with other vascular abnormalities. The status of the blood in the vascular lesions as flowing fast, slow, or not at all was successfully assessed in 9 of the 12 lesions.

Bone marrow alterations induced in mice with inhalation of chrysotile asbestos

The effect of chrysotile asbestos exposure on bone marrow and immune parameters was examined in mice at 2, 12, and 26 weeks following a 3-day inhalation exposure. Ultrastructural examination revealed that the fibers were deposited primarily at alveolar duct bifurcations within the centriacinar region of the lung. Histological pulmonary changes were minimal, but by 26 weeks early asbestosis characterized by clusters of macrophages and minimal fibrosis were present in the centriacinar region of the lung. Lymphoproliferative responses, antibody levels, and number of plaque forming cells were not significantly altered in exposed mice. Pulmonary macrophages, but not peritoneal macrophages, showed evidence of activation in the chrysotile-exposed mice at 26 weeks following exposure. The most striking change was the depression of the number of bone marrow pluripotent stem cells (CFU-S) and marrow granulocyte macrophage progenitors (CFU-GM) which were lower at all three postexposure examinations. It is felt that the depression of bone marrow progenitors in asbestos-exposed mice may have relevance to the leukopenia reported in workers with occupational history of asbestos exposure.