Biomechanically designed Curve Specific Corrective Exercise for Adolescent Idiopathic Scoliosis gives significant outcomes in an Adult: A case report

Background

This study presents findings on improvements to the Frontal and Sagittal Cobb angle, Global Spinal balance, and lung function parameters (FEV1, PEF) in an adult male with idiopathic scoliosis suffering from pain during ADL and sports activities who was treated with a biomechanically designed exercise protocol.

Case Presentation

The 26-year-old male reported upper and middle back pain which worsened when playing cricket. Whole spine standing x-Ray AP view revealed a right thoracic Scoliosis (Lenke 1 curve) of Cobb angle 48.6° with left lumbar compensatory curve of 24.7°, Thoracic hypo kyphosis of 9.9°, and VAS rating for pain of 8. The patient was treated with myofascial release, stretching, aerobics, strengthening exercises, “Breathing with core” for stabilization, and biomechanically designed curve specific corrective exercises.

Results

Re-assessment 32 weeks post intervention demonstrated significant reduction in the major Cobb angle by 13.8°, minor Cobb angle by 9.5°, Thoracic hypokyphosis normalized to 37.8°, Coronal balance improved by 17.4 mm, Sagittal balance regained by 4.2 mm, Spine ROM improved by a total of 6.5 cm, Enhancement of pulmonary function of FEV1 by 7% and PEF by 18 litres/min, and dramatic improvement in aesthetics and pain perception.

Conclusion

The biomechanically designed exercise protocol helped straighten the curve through curve specific corrective exercises and stabilized the curve by “Breathing with core”. It also treated the associated signs and symptoms of spinal pain syndrome by myofascial release and proper ergonomics, pulmonary dysfunction by aerobics, and muscle tightness and weakness (due to altered length-tension) by stretching and strengthening.

Anti-Histone H3.3 G34W antibody is a sensitive and highly specific immunohistochemistry marker for the diagnosis of Giant cell tumor of bone. A validation based on analysis of 198 cases from a single centre in India

CONTEXT

The diagnosis of giant cell tumor of bone (GCTB) is difficult in small biopsies with unusual age of presentation, location, and extensive secondary changes. Most of the GCTBs harbor H3F3A G34W mutations with a subset of cases showing alternate G34V, G34R, and G34L mutations.

OBJECTIVES

To analyze the expression of anti-histone H3.3G34W antibody in different cellular components of GCTB across different locations and presentations (including the unusual ones) and validate the utility of this antibody in the diagnosis of GCTB and differentiate it from the other osteoclast-like giant-cell-rich lesions.

DESIGN

Immunohistochemistry was performed using anti-histone H3.3G34W antibody in the diagnosed cases of GCTB (136 cases of GCTB from 133 patients, including two malignant GCTBs) and other giant cell-containing lesions (62 cases). The presence of unequivocal crisp nuclear staining was considered positive.

RESULTS

Immunohistochemistry revealed unequivocal nuclear positivity in the mononuclear cells in 87.3% of the cases of GCTB. Of these, most showed diffuse expression with moderate to strong intensity staining. The positive staining was restricted to the nuclei of mononuclear cells with the nuclei of osteoclastic giant cells being distinctly negative. In addition to conventional GCTBs, two cases each of multicentric and malignant GCTB showed positive staining. The other giant-cell containing lesions were distinctly negative. The present study showed a sensitivity of 87.3% with specificity and positive predictive value of 100%.

CONCLUSION

The anti-histone G34W antibody is a highly sensitive and specific marker for the diagnosis of GCTB and differentiating it from its mimics. The positive staining is restricted to the mononuclear cell component of GCTB with sparing the osteoclastic giant cells further reiterating the fact that the mononuclear stromal cells are the true neoplastic component of GCTB.

Prognostic Significance of Clinical and Post-Neoadjuvant Chemotherapy Associated Histomorphological Parameters in Osteosarcoma: A Retrospective Study from a Tertiary Care Center

Introduction Osteosarcoma is the most prevalent bone cancer in adolescents. Neoadjuvant chemotherapy (NACT) followed by resection is the current modality of treatment for osteosarcoma. Histological evaluation of extent of tumor necrosis on resection is a well-established prognostic indicator in osteosarcoma correlating with survival in most cases.

Objectives The main objective of this study was to establish prognostic significance of various clinical and histological parameters post-NACT in osteosarcoma and to compare the integrated prognostic index proposed by Chui et al, with grading of response to NACT by Huvos and Rosen for osteosarcoma.

Materials and Methods This is a retrospective study done over a period of four years and includes 47 cases of osteosarcoma treated with NACT. All slides were reviewed and association of various clinical and histological parameters with overall survival was assessed with chi-squared test and Cox-regression analysis.

Results Statistical analysis revealed the prognostic significance of age at presentation, anatomic site, primary tumor size, metastatic status, and clinical stage. Histological parameters such as mitosis ≥10/10hpfs, ≥10% residual tumor were significantly associated with poor survival. Tumor necrosis ≥ 90% (excluding areas of hemorrhage, fibrosis and acellular osteoid) was significantly associated with increased survival. An integrated prognostic index formed by combining above parameters gives a better estimate of overall survival compared with residual disease or necrosis alone.

Conclusion Integrated prognostic index improves prognostication in patients treated for osteosarcoma.

Post-Denosumab-Treated Giant Cell Tumor of Bone: A Retrospective Histomorphological and Immunohistochemical Study

Introduction Giant cell tumors of bone (GCTBs) are treated with surgery with or without local adjuvants. Denosumab is a human monoclonal antibody that has recently emerged to be effective in treating unresectable and recurrent GCTBs.

Objective In this study, we analyzed the histomorphological changes in GCTB following treatment with denosumab. The expression of histone mutation H3.3G34W by immunohistochemistry (IHC) using mutant specific antibody was also determined.

Materials and Methods Of the total 109 GCTBs encountered during the study period, 14 cases with neoadjuvant denosumab therapy were analyzed retrospectively. The post-treatment changes on histopathology were examined on routine hematoxylin and eosin-stained sections. IHC was done using antihistone H3.3G34 antibodies. Statistical analysis was limited to descriptive statistics. No hypothesis testing was performed.

Results All these cases except three showed fibrosis with areas of hyalinization, prominent newly formed woven bone along with spindle cells in short fascicles and storiform pattern. There was complete absence and marked reduction in osteoclast-like giant cells in six and five patients, respectively. Only three patients showed a substantial amount of residual osteoclast-like giant cells. IHC with antihistone H3.3G34W antibody showed unequivocal nuclear positivity in the mononuclear cells in nine cases. The mononuclear cells rimming and entrapped within the woven bone were also positive on IHC. The spindle cells in the benign fibrous histiocytoma-like areas and septa of aneurysmal bone cyst-like areas also retained nuclear staining.

Conclusion Awareness of post-denosumab-related histopathological changes are necessary to avoid misdiagnosis as fibroosseous lesion and low-grade central osteosarcoma. Expression of mutant-specific H3.3 G34W antibody suggests that the neoplastic stromal cells are largely retained after denosumab therapy. The positive staining of cells both within and those rimming the newly formed woven bone point toward osteoblastic phenotype of the neoplastic stromal cells.

Bone metastases: A compilation of 365 histologically verified cases spanning over two decades from a single center

Objective

To analyze the clinicopathological features of metastatic bone tumors over a period of two decades and identify the primary site of malignancy in metastasis of unknown origin.

Materials and Methods

A total number of 365 cases were included in the study. The clinical features and location of the tumors were noted. The histopathological features of all the cases were studied. Immunohistochemistry (IHC) was done either to categorize or confirm the primary diagnosis using organ specific/organ restricted markers.

Results

A total 712 bony sites were involved by metastasis in 365 patients, of which spine was the most commonly affected. Metastasis was the initial presentation in 69.5% patients. The primary site was known in 220 patients and almost half of them were detected after the diagnosis of metastasis. IHC was used as adjunct to suggest the possible origin in cases with unknown primary in 27.4%. Among the metastatic carcinoma, adenocarcinoma was the most common histological subtype with thyroid being the most frequent primary site of origin followed by lung and breast.

Conclusion

More than two-third of cases in surgical pathology practice present as initial manifestations. Detection rate of primary depends on extent of metastatic work-up and IHC with organ specific/organ restricted markers to facilitate treatment with bone targeting agents.

Utility of P63 in Differentiating Giant Cell Tumor from Other Giant Cell-Containing Lesions

OBJECTIVE

To assess P63 expression in giant cell-containing lesions of the bone (GCLB) and to determine its utility in differentiating giant cell tumor of the bone (GCTB) from other GCLBs.

MATERIAL AND METHOD

Cases diagnosed as GCLB on histopathology were included in the study. P63 immunohistochemistry was performed in all the cases. The percentage of cells showing nuclear positivity was assessed in the non-giant cell component. Statistical analysis was performed using the Mann-Whitney U test.

RESULTS

Of the total 53 cases studied, the majority were GCTBs (23), followed by 12 cases of chondroblastomas (CBL) and 18 other giant cell lesions (GCLs). All giant cell-containing lesions except one case of CBL and brown tumor of hyperparathyroidism (BTH) showed P63 staining in the non-giant cell component. However, the mean P63 labeling of GCT (52.6%) was higher compared to CBL (28.3%), aneurysmal bone cyst (ABC) (15.2%), non-ossifying fibroma (NOF) (24.5%), giant cell lesion of small bones (GCLSB) (11%), BTH (6.8%) and chondromyxoid fibroma (CMF) (12.3%), with a p-value of < 0.001.

CONCLUSION

Although p63 was present in majority of the GCLBs, its percentage positivity was significantly higher in GCTB compared to the other GCLBs. The diagnosis of GCTB is likely if cut-off value of > 50% is applied.

Left Ventricular Thrombus: An Interesting Presentation of Primary Antiphospholipid Antibody Syndrome with a Mini-review of the Literature

Antiphospholipid syndrome (APLS) is characterized by recurrent thrombosis. We report the case of a 36-year-old male who had acute right-sided ischemic stroke and right leg ischemia secondary to left ventricular (LV) thrombus caused by primary APLS. The literature review suggested that the LV thrombus presented most commonly with systemic embolism and was associated with a mortality rate of 22.2% with treatment. Thrombophilic workup in young patients with a systemic thromboembolic episode (s) is advised.

Clinical and echocardiographic predictors of outcomes in patients with peripartum cardiomyopathy: A single centre, six month follow-up study

INTRODUCTION

Peripartum cardiomyopathy (PPCM) is an important cause of maternal mortality and morbidity. But, there is a paucity of prospective data on outcomes and prognostic markers in patients receiving contemporary evidence-based therapy, particularly in developing countries.

METHODS

This was a single centre, prospective, cohort study on 43 PPCM patients who were followed for 6 months. The primary endpoint was a composite incidence of decompensation related re-hospitalization, all-cause death, and poor recovery (defined as left ventricular ejection fraction, LVEF: <45% at 6 months). Multivariate logistic regression analysis was performed to identify the independent predictors and Kaplan-Meier plots for event (re-hospitalization or death) free survival were computed at their optimal cut-offs.

RESULTS

Mean LVEF at presentation was 34.7%. Two patients died during index hospitalization but there were no deaths during follow-up and 63.4% of patients had full LV recovery after discharge. 32.5% of the study population experienced the composite endpoint with high left atrial volume index (LAVi), and low right ventricular fractional area change (RVFAC) at presentation as independent predictors. Use of Inotropic therapy during index hospitalization (with dobutamine or levosimendan) and bromocriptine therapy were not associated with better outcome.

CONCLUSIONS

At the end of 6 months after PPCM diagnosis, about 61% of patients had full LV functional recovery with a mortality rate of 4.7%. RVFAC (<31.4% with 86% accuracy) and LAVi (>29.6 ml/m² with 72% accuracy) at presentation but not LVEF, predicts poor outcomes. Presence of both these risk factors at index hospitalization was associated with a significantly lower event free survival compared to patients without these predictors.

Association between 2D echocardiographic right atrial volume to left atrial volume (RAV/LAV) ratio and in-hospital prognosis in thrombolysed acute pulmonary thromboembolism patients

Right atrial volume/Left atrial volume (RAV/LAV) ratio is a good hemodynamic parameter in acute pulmonary thromboembolism (PTE), whose prognostic ability by 2D echocardiography is not studied to date. We conducted a 27 month, prospective observational study on 55 eligible acute PTE thrombolysed (29: Tenecteplase; 26: Streptokinase) patients. The primary endpoint was a composite of in-hospital death and poor right ventricular reverse remodelling at the time of discharge. The incidence of primary end-point and death were 40% and 7.2% respectively. On regression analysis, RAV/LAV ratio was the only predictor of the primary endpoint, with an optimal cut-off of 3.8 (accuracy 75%).

Isolation, identification, and carriage of candidal species in PHLAs and their correlation with immunological status in cases with and without HAART

AIMS AND OBJECTIVES

To know the prevalence of Candidal colonization, and to isolate and know the Candidal species prevalent in the oral cavity from the oral rinse samples collected from the individuals attending to the Voluntary Counseling and Confidential Testing Center (VCCTC) and the antiretro-viral therapy (ART) Center at Government General Hospital, Guntur, Andhra Pradesh, South India.

MATERIALS AND METHODS

The study group consisted of 50 HIV negative asymptomatic individuals (Group I); 50 HIV positive individuals (people living with HIV AIDS [PLWHA's]), who are naïve to antiretro-viral therapy (direct walk-in clients of VCCTC) (Group II); and 50 HIV positive individuals with CD4+ count less than 250 and who are started on highly active anti retroviral therapy (HAART) (Group III). Routine mycological tests for the isolation of pure cultures of Candida and also the speciation procedures were done.

RESULTS

In the study group, 53 (Group I=11; Group II=23; Group III=19) were culture positive. The prevalence of Candida was comparatively high in the age range between 41-50 years in Group II; 51-60 years, in Group III. A male predominance was observed in the Group I (M:F=16:6) and Group III (M:F=20:18), with a slight female predominance in the Group II (F:M=24:22). The overall culture positivity was 35.3%. Candida albicans was the highest prevalent species (47.17% of the isolates). A comparison of the culture positivity with the CD(4) counts of the study subjects was statistically highly significant. A pair wise comparison of the culture positivity with that of the colony forming units/mL from the subjects showed a high significance between Group I and Group II, and between Group I and Group III.

CONCLUSION

Candidal infections in immuno compromised patients are often severe, rapidly progressive, and difficult to treat and such patients have a definitive risk of developing oral candidiasis wherein, even the members of the normal oral flora may become pathogenic. Candida albicans is the common isolate. Nonalbicans species are also emerging as opportunistic pathogens. In view of this changing pattern, it is strongly recommended that species identification can help in much better treatment strategies, and thus, gain a good control over the disease. The findings of this study would be helpful in any further studies which, if done prospectively on a larger cohort, can be confirmatory.

Leiomyoma of the mandible in a child

Leiomyomas are the benign tumors of the smooth muscle that usually arise in the gastrointestinal system and in the uterus. Oral leiomyomas are uncommon due to the paucity of the smooth muscles in the mouth (except in blood vessels) and those of the mandible are extremely rare. Leiomyomas have been classified as solid, angiomyoma (vascular leiomyoma), and epithelioid variants. Here, we report a rare case of leiomyoma of the mandible in a 9-year-old child, together with conventional histopathologic and immunohistochemical findings.

Malignant melanoma of the mandibular gingiva: a rare occurrence

Primary mucosal malignant melanoma of the oral cavity is a rare tumor. It accounts for only 0.2-8% of all malignant melanomas. This malignancy commonly affects male subjects and is more frequently seen on the hard palate and maxillary gingiva. The peak age for diagnosis of oral melanoma is between 55 and 65 years. A biopsy is required to establish a diagnosis. Ablative surgery with tumor-free margins remains the treatment of choice. It has a much poorer prognosis than its counterpart on the skin. Here, we present a case of malignant melanoma of the mandibular lingual gingiva in a 55-year-old male patient. Immunohistochemistry and special stains were conducted for confirmatory diagnosis.

Problems in defining a "case" of pulmonary tuberculosis in prevalence surveys

An analysis of data from two successive tuberculosis prevalence surveys (conducted at an interval of 18 months) in a random sample of villages in Bangalore District, South India, has shown that the term "a case of pulmonary tuberculosis" does not represent a single uniform entity, but rather embraces cases of several types, differing considerably in their mortality experience, tuberculin sensitivity, results of X-ray and sputum examinations, and in the reliability of their diagnosis.The status at the first survey of the cases found at the resurvey and that at resurvey of those found at the initial survey give an indication of changes with time. Such changes show considerable differences for the various types of cases and provide another dimension to study the differences among them. The authors consider that, in spite of the great need and importance of a single straightforward definition of a case, no such definition is suitable for all situations; there is no other option but to continue to use more than one definition.Although, theoretically, finding a single bacillus in the sputum should be adequate proof of pulmonary tuberculosis, it is shown that finding of a few bacilli, 3 or less, is probably far too often due to artefacts and should not be the basis for a diagnosis.The findings also well bear out the notion that positive radiological findings, in the absence of bacteriological confirmation, indicate, not pulmonary tuberculosis, but only a high risk of the disease. Direct microscopy appears to be a consistent index of disease but, in community surveys, has the limitations of missing a substantial proportion of cases and of adding some false cases. The extent of these limitations, so far as symptomatic patients in a community tuberculosis control programme are concerned, remains to be investigated.

Resistant and sensitive strains of Mycobacterium tuberculosis found in repeated surveys among a South Indian rural population

The findings in a highly selected group of patients, such as those attending clinics or sanatoria, cannot be used as the basis for assessing the true prevalence of strains of Mycobacterium tuberculosis with acquired or primary resistance or of sensitive strains in a community. The present report describes the prevalence of such strains as found in 3 successive surveys in a sizeable random sample of villages in a South Indian district. Changes in the status of cases with such strains from an earlier survey to a later one and the status at an earlier round of cases found at a later one are also described.The prevalence of tuberculous infection among household contacts of cases with acquired resistance to isoniazid was significantly higher than that among contacts of cases with primary resistance or of those with sensitive cultures. This is probably due to the longer duration of sputum positivity of the former at the time of diagnosis. But infectivity, as judged by the incidence of new infections among household contacts, was generally less for cases with acquired or primary resistance than for cases with sensitive cultures, though the difference was not statistically significant.A large number of culture-positive cases, especially those with primary resistance, had no radiological evidence of active pulmonary tuberculosis. The prevalence of primary resistance was very high among certain categories of cases, and the differences between cases with primary resistance and those with acquired resistance were many and large. It is suggested that this could be due to some of the primary resistant cultures being those of atypical mycobacteria, despite positivity in the niacin test.There was a significant increase in the number of cases with acquired resistance to isoniazid at the third survey round owing to irregular treatment with that drug after the second round. The prevalence of primary resistance at the 3 rounds was almost the same.

Distribution of tuberculous infection and disease among households in a rural community

Clinical experience has led to a strong belief that tuberculosis is a family disease and contact examination is a sine qua non for case-finding programmes. Considerable doubts are cast on the usefulness of contact examination in tuberculosis control by the present study, which is based on a sample of an entire population rather than on family contacts of known cases only. Cases of tuberculosis occurred mostly singly in households, and contact examination could have revealed only a very small percentage of the cases in this community.Another common belief is that the prevalence of infection among children under five years of age is a good index of disease in households. In this study, however, a large proportion of households with cases of tuberculosis had no children of this age, and even in homes with a bacteriologically confirmed case, about 88% of the children did not show evidence of infection.The tuberculin reactions of infected contacts were, on the average, slightly larger than those among non-contacts. Further, the proportion of large tuberculin reactions among infected persons was found to be greater in the younger age-groups than in the older age-groups. This finding has been taken to indicate that new infection gives rise to large reactions that subsequently wane to some extent in persons not constantly exposed to infection, such as, for example, the members of households without cases.

Enhancing of tuberculin allergy by previous tuberculin testing

A controlled study on the enhancing of tuberculin allergy by one or more earlier tuberculin tests was carried out in a previously untested and unvaccinated population, in an area where the prevalence of non-specific allergy was known to be high. The results have shown that a test with 1 TU of PPD RT 23 in Tween 80 diluent causes subsequent tests to elicit significantly larger reactions. This enhancing effect is more marked among those with initial reactions of 8-13 mm to 1 TU or 10 mm and more to 20 TU. There is practically no enhancement among those whose reactions to 20 TU measure 0-4 mm or even 0-9 mm. Even in the group with reactions of 10 mm and more to 20 TU only some individuals show evidence of enhancement. The enhancing of allergy increases with age.The addition of a 20 TU test increases the enhancement of allergy but mostly among those with reactions of 8-13 mm to 1 TU.The findings suggest that enhancement may be more marked in communities with a high prevalence of non-specific allergy.

Problems connected with estimating the incidence of tuberculosis infection

Many problems have to be faced in the estimation of an apparently simple but valuable index-namely, the incidence of tuberculosis infection. Very little attention seems to have been paid to these problems so far.Records from 50 villages in a district of South India, whose populations were tested with 1 TU of PPD RT 23 in Tween 80 diluent and retested after 18 months, have been examined for a reappraisal of existing methods. As a result, it has been found that some of these methods are subject to gross errors and that available figures are unreliable.For estimating the newly infected, a new approach based on the drawing of a curve for the distribution of differences in reaction size from one round of tuberculin testing to another is presented. Further, it is shown that the newly infected probably constitute a homogeneous group with an increase in mean reaction size of about 24 mm and standard deviation of 4 mm. Accordingly, 98% of the newly infected show an increase in reaction size of 16 mm or more. There are others who show similarly large increases in allergy on a retest, even in the absence of infection. The number of persons in the latter category rises with age and is likely to be greater in areas with a high prevalence of non-specific allergy.