Injection sclerotherapy for the treatment of haemorrhoids in anticoagulated patients

BACKGROUND

Symptomatic haemorrhoids (SH) are a common condition; however, conventional outpatient treatment, including rubber band ligation, is contraindicated in patients receiving concurrent anticoagulation. Injection sclerotherapy (IST) has been proposed as a treatment option for these patients.

METHODS

A retrospective review of case notes was performed in a colorectal surgery department that sits alongside a tertiary cardiothoracic surgical unit. Patients treated with an IST for SH between 1 April 2014 and 30 November 2021 were identified. Anticoagulation was not stopped in these patients as they were at high risk of developing thromboembolism, except in two patients who required alternative procedures. The primary outcome was symptom resolution, defined as no patient reporting bleeding for at least six months. The secondary outcomes were patient-reported complications, number of IST procedures and number of other procedures performed to achieve symptom resolution.

RESULTS

A total of 20 patients with a median age of 64 years (range 35-86, 14 male) who underwent 32 IST treatments were identified. Symptom resolution was achieved in 18 (90%) patients using IST while continuing anticoagulation treatment, with two (10%) patients requiring alternative interventions. Ten patients (50%) required only one IST procedure, and three patients (15%) required two procedures. The remaining five (25%) patients required three or four interventions. The median time between IST treatments was 32 weeks (range 8-133). No complications were reported.

CONCLUSION

Our study demonstrates that IST can be considered as a potential treatment option for patients with SH who are at a high risk of thromboembolic disease requiring anticoagulation.

Serum Vitamin D status in full term neonates with severe perinatal depression

BACKGROUND

Severe perinatal depression is a significant cause of mortality and morbidity in neonates. Vitamin D levels were observed to be low in mothers and their neonates with hypoxic ischemic encephalopathy in some studies, owing to its neuroprotective properties.

OBJECTIVE

Primary objective was to compare vitamin D deficiency state in full term neonates with severe perinatal depression and healthy term controls. Secondary objectives were to determine sensitivity and specificity of serum 25(OH)D<12 ng/mL in predicting mortality, development of hypoxic ischemic encephalopathy, abnormal neurological examination at discharge, and developmental outcome at 12 weeks of age.

MATERIAL AND METHODS

Serum 25(OH)D levels in full term neonates with severe perinatal depression and healthy controls were compared.

RESULTS

Serum 25(OH)D levels in severe perinatal depression and controls (n = 55 each group) were significantly different (7.50 ± 3.53 ng/mL vs 20.23 ± 12.70 ng/mL). At cut-off of <  12 ng/mL, serum 25(OH)D could predict mortality with 100% sensitivity and 17% specificity and poor developmental outcomes with sensitivity of 100% and specificity of 50% .

CONCLUSION

Vitamin D deficiency status at birth can serve as an effective screening tool and poor prognostic markers in term neonates with severe perinatal depression.

Neonatal outcomes following phenylephrine or norepinephrine for treatment of spinal anaesthesia-induced hypotension at emergency caesarean section in women with fetal compromise - a randomised controlled study

BACKGROUND

Norepinephrine is as effective as phenylephrine for management of spinal anaesthesia-induced hypotension. Most of the studies comparing these vasopressors have been conducted in healthy pregnant women undergoing elective caesarean section. In the current study, we tested the null hypothesis that there is no difference in neonatal outcome when phenylephrine or norepinephrine is used to treat spinal anaesthesia-induced hypotension in women undergoing emergency caesarean section for fetal compromise.

METHODS

Patients undergoing caesarean section for fetal compromise who developed spinal anaesthesia-induced hypotension were randomised to receive phenylephrine 100 μg or norepinephrine 8 μg for treatment of each hypotensive episode, defined as systolic blood pressure <100 mmHg. Umbilical cord arterial and venous blood samples were obtained for blood gas analysis. The primary outcome measure was umbilical artery pH.

RESULTS

One hundred patients (50 in each group) were studied. There was no significant difference in umbilical artery pH between the two groups (mean difference 0.001; 95% CI -0.032 to 0.034). The number of hypotensive episodes, vasopressor boluses required, the incidence of bradycardia, heart rate and blood pressure trends following vasopressor administration, and the incidence of nausea/vomiting were not significantly different between groups.

CONCLUSION

Phenylephrine 100 μg and norepinephrine 8 μg were not significantly different in terms of neonatal outcome when administered as intravenous boluses for treatment of spinal anaesthesia-induced hypotension in parturients undergoing emergency caesarean sections for fetal compromise.

Prevalence and predictors of adverse outcomes in neonatal seizures

OBJECTIVES

Neonatal seizures are significant cause of neonatal mortality and morbidity. Current study was planned to study prevalence of adverse outcomes in neonatal seizures and identify its predictors.

METHODS

This observational descriptive study was carried out on 220 neonates with seizures. Neonates who succumbed to illness/ death before investigations, or whose maternal records were incomplete were excluded. Blood sugar, serum calcium, serum electrolytes, and USG skull were done in all patients. CT scan, MRI and inborn errors of metabolism profile were done as and when indicated. Adverse outcomes were defined as death, phenobarbitone non responders, or abnormal examination at discharge. Antenatal, perinatal and neonatal predictors of adverse outcomes in neonatal seizures were evaluated.

RESULTS

Out of 220 neonates with seizures 76(34.5%) had adverse outcomes. Very low birth weight babies (≤1500 gm) [OR 1.27(CI 0.57-2.84)], microcephaly [OR 5.93 (CI 0.55-64.41)], Apgar score≤3 at 5 minutes [OR 11.28(CI 14.18-30.45)], seizure onset within 24 hours [OR 5.99(CI 12.43-14.78)], meningitis [OR 2.63(CI 0.08-6.39)], septicemia [OR1.22(CI 0.45-3.31)] and abnormal cranial USG [OR 7.95(CI 12.61-24.22)] were significant predictors of adverse outcomes in neonates with seizures.

CONCLUSION

Prematurity, very low birth weight, birth asphyxia, meningitis, septicemia and abnormal USG could predict adverse outcomes in neonatal seizures. Improved antenatal and neonatal clinical practices may help reduce adverse outcomes in these patients.

Biomarkers as point of care tests (POCT) in neonatal sepsis: A state of science review

Lack of a standard definition of neonatal sepsis and a swift diagnostic method has proven detrimental in the management of this serious condition. Biomarkers have emerged as a beacon that might help us detect neonatal sepsis more effectively. The use of point-of-care biomarkers can aid in early diagnosis and timely initiation of treatment. Procalcitonin, presepsin, interleukin-6, highly specific C-reactive protein, and neutrophil gelatinase-associated lipocalin have been proven to aid in early diagnosis and timely initiation of treatment, thereby reducing sepsis-induced morbidity and mortality. These biomarkers have been found to be useful in reducing the duration of hospital stay and monitoring the response to therapy. When used in combination with each other, or with clinical scores, they have been proven to be advantageous over the gold standard by eliminating the waiting time for blood culture results. The use of biomarkers as a point of care investigation holds a future over the traditional method. We present a state of science review of literature summarizing the current status of these biomarkers in neonatal sepsis.

Genotype concordance and polygenic risk score estimation across consumer genetic testing data

The consumer genomics industry is steadily growing and delivering genetic information to over 10 million individuals. Yet, the implications of using data from different services remain unclear. We investigated the genotyped sites, concordance, and genetic risk estimation using data from three consumer services-two single nucleotide polymorphism (SNP)-array based and one sequencing based. In an N-of-one setting, we found the three services genotyped predominantly distinct sets of sites. While there was a high concordance between overlapping sites of the two SNP-array services (99.6%), there was a lower concordance between these services and a low-pass whole-genome service (73.0%). The discrepancy between the three sets of data resulted in different APOE genotypes and genetic risk scores of Alzheimer's disease. Our results demonstrate genotype results across consumer genomics platforms may lead to different genetic risk estimates, highlighting the need for careful quality control and interpretation.

Hair Loss in Lichen Planopilaris and Frontal Fibrosing Alopecia: Not Always Irreversible

Introduction

We present 2 cases in which typically irreversible lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) showed signs of reversal.

Case Presentation

A 27-year-old Caucasian man presented with hair loss and intense pruritus on the vertex scalp for 4 years with biopsy-proven LPP and having failed multiple pharmacologic modalities. Six months after adding oral tofacitinib and later dapsone, he demonstrated reduced scalp visibility, evidence of crown and vertex hair regrowth, and elimination of itch. A 45-year-old premenopausal Hispanic woman presented with eyebrow loss for 3.75 years and hair loss for 9 months with biopsy-proven FFA. After beginning oral finasteride and hydroxychloroquine, triamcinolone injections, and topical minoxidil, she initially worsened over 11 months but subsequently improved over 6 months, demonstrating hair and eyebrow regrowth, reduction in glabella-hairline distance, and new absence of frontal hair line hyperkeratosis and inflammation.

Discussion/Conclusion

Cicatricial alopecia involves inflammation with JAK-STAT upregulation. We report a positive clinical response in LPP to tofacitinib, a JAK1/3 inhibitor, and dapsone, an anti-neutrophilic agent. FFA is believed to involve autoimmune and/or hormonal processes. Here we report a positive clinical response to androgenic and immune modulators.

Hyperpigmentation as a cutaneous manifestation of fungal sepsis in neonates: Case series report

With improved and prolonged survival of very and extremely low birth weight infants, invasive fungal infection has emerged as an important concern in the neonatal intensive care units. Candidiasis is the third leading cause of late onset sepsis in these neonates and is associated with 20-30% mortality. Extreme prematurity, central venous catheters, prolonged antibiotic exposure, parenteral nutrition are important risk factors. Various forms of cutaneous manifestations of candidiasis have been described ranging from local diaper dermatitis and oral thrush to widespread erosive and ulcerative lesions with extensive crusting in invasive fungal dermatitis. We report a series of four cases with cutaneous hyperpigmentation as manifestation of systemic candidiasis.

Quantitative lung morphology: semi-automated measurement of mean linear intercept

BACKGROUND

Quantifying morphologic changes is critical to our understanding of the pathophysiology of the lung. Mean linear intercept (MLI) measures are important in the assessment of clinically relevant pathology, such as emphysema. However, qualitative measures are prone to error and bias, while quantitative methods such as mean linear intercept (MLI) are manually time consuming. Furthermore, a fully automated, reliable method of assessment is nontrivial and resource-intensive.

METHODS

We propose a semi-automated method to quantify MLI that does not require specialized computer knowledge and uses a free, open-source image-processor (Fiji). We tested the method with a computer-generated, idealized dataset, derived an MLI usage guide, and successfully applied this method to a murine model of particulate matter (PM) exposure. Fields of randomly placed, uniform-radius circles were analyzed. Optimal numbers of chords to assess based on MLI were found via receiver-operator-characteristic (ROC)-area under the curve (AUC) analysis. Intraclass correlation coefficient (ICC) measured reliability.

RESULTS

We demonstrate high accuracy (AUCROC > 0.8 for MLIactual > 63.83 pixels) and excellent reliability (ICC = 0.9998, p < 0.0001). We provide a guide to optimize the number of chords to sample based on MLI. Processing time was 0.03 s/image. We showed elevated MLI in PM-exposed mice compared to PBS-exposed controls. We have also provided the macros that were used and have made an ImageJ plugin available free for academic research use at https://med.nyu.edu/nolanlab.

CONCLUSIONS

Our semi-automated method is reliable, equally fast as fully automated methods, and uses free, open-source software. Additionally, we quantified the optimal number of chords that should be measured per lung field.

Database of evidence for precision oncology portal

Summary

A database of curated genomic variants with clinically supported drug therapies and other oncological annotations is described. The accompanying web portal provides a search engine with two modes: one that allows users to query gene, cancer type, variant type or position for druggable mutations, and another to search for and to visualize, on three-dimensional protein structures, putative druggable sites that cluster with known druggable mutations.

Availability and implementation

http://dinglab.wustl.edu/depo.

Genomic Stability in Syndromic Basal Cell Carcinoma

Basal cell cancers (BCCs) are characterized by upregulation of Hedgehog pathway through loss of PTCH1 or activation of SMO, and SMO inhibitors, such as vismodegib, are effective therapies for advanced BCCs. Although most BCCs are sporadic, rare individuals with basal cell nevus syndrome (BCNS) harbor germline defects in PTCH1 and develop up to hundreds of tumors that are histopathologically indistinguishable from sporadic BCCs. Interestingly, BCNS-BCCs are more responsive to SMO inhibitors than sporadic BCCs, with minimal development of resistance. Given differences in clinical course and therapy response, we sought to characterize BCCs in the setting of BCNS. We found that BCNS individuals with low tumor burden demonstrated significantly fewer UV signature somatic mutations and lower overall somatic mutational load compared to BCNS individuals with high burden, supporting a role of UV exposure in driving BCC development in BCNS individuals. However, compared with sporadic BCCs, BCNS-BCCs have a significantly lower mutational load, lower proportion of UV mutagenesis, increased genomic stability, and harbor fewer functionally resistant SMO mutations at baseline, explaining why BCNS-BCCs lack intrinsic resistance to SMO inhibitors. BCNS-BCCs appear to have reduced mutator phenotype compared with sporadic BCCs, which may contribute to their relatively more indolent clinical course and responsiveness to therapy.

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus seroprevalence in critically ill emergency department patients at a Trauma Care Centre, India

INTRODUCTION

Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are the most common occupationally acquired infections amongst the healthcare workers (HCWs) with critically ill patients attending the emergency department being the most common source of occupationally acquired infections. Therefore, the present study was conducted at a 165 bedded level-1 trauma centre of India to ascertain the seroprevalence rate of HIV, HBV and HCV; and thus the risk associated with the occupational exposure in a busy emergency setting of the developing world.

METHODOLOGY

A retrospective, 7 years study (2007-2013) was carried out at the JPNA Trauma Centre of the 2,500 bedded All India Institute of Medical Sciences, New Delhi. Records of all patients whose serum samples were sent to the laboratory for viral markers testing were obtained and those falling in the red area were included.

RESULTS

A total of 11,630 patients were received in the red area; and samples from 7,650 patients were sent for testing. Seropositivity of HIV, HBV and HCV in these samples was 0.28%, 3.4% and 0.9% respectively. The number of samples received was lesser than the total number of patients received in the red area.

CONCLUSION

Adopting Standard Precautions (SP) can be used as an easy method to decrease the risk of occupationally acquired infections.

A Cross-Cultural Study of Young Children's Understanding of Spatial Prepositions

Bengali-, English and Hindi-speaking children aged 5 to 9 years were asked to place an object 'in front of or 'behind' a frontedor nonfronted-object. All children responded on the basis of an inherent object cue when the fronted-object was used. When a nonfronted-object was used all children treated it as if it was a fronted-object facing towards themselves. These results were compared with those of Hausa-speakers who also use the inherent object cue for fronted-objects but treat nonfronted-objects as if they are facing away from themselves.

Resting state functional connectivity magnetic resonance imaging integrated with intraoperative neuronavigation for functional mapping after aborted awake craniotomy

BACKGROUND

Awake craniotomy is currently the gold standard for aggressive tumor resections in eloquent cortex. However, a significant subset of patients is unable to tolerate this procedure, particularly the very young or old or those with psychiatric comorbidities, cardiopulmonary comorbidities, or obesity, among other conditions. In these cases, typical alternative procedures include biopsy alone or subtotal resection, both of which are associated with diminished surgical outcomes.

CASE DESCRIPTION

Here, we report the successful use of a preoperatively obtained resting state functional connectivity magnetic resonance imaging (MRI) integrated with intraoperative neuronavigation software in order to perform functional cortical mapping in the setting of an aborted awake craniotomy due to loss of airway.

CONCLUSION

Resting state functional connectivity MRI integrated with intraoperative neuronavigation software can provide an alternative option for functional cortical mapping in the setting of an aborted awake craniotomy.

Sequence to Medical Phenotypes: A Framework for Interpretation of Human Whole Genome DNA Sequence Data

High throughput sequencing has facilitated a precipitous drop in the cost of genomic sequencing, prompting predictions of a revolution in medicine via genetic personalization of diagnostic and therapeutic strategies. There are significant barriers to realizing this goal that are related to the difficult task of interpreting personal genetic variation. A comprehensive, widely accessible application for interpretation of whole genome sequence data is needed. Here, we present a series of methods for identification of genetic variants and genotypes with clinical associations, phasing genetic data and using Mendelian inheritance for quality control, and providing predictive genetic information about risk for rare disease phenotypes and response to pharmacological therapy in single individuals and father-mother-child trios. We demonstrate application of these methods for disease and drug response prognostication in whole genome sequence data from twelve unrelated adults, and for disease gene discovery in one father-mother-child trio with apparently simplex congenital ventricular arrhythmia. In doing so we identify clinically actionable inherited disease risk and drug response genotypes in pre-symptomatic individuals. We also nominate a new candidate gene in congenital arrhythmia, ATP2B4, and provide experimental evidence of a regulatory role for variants discovered using this framework.

Technological advances have dramatically reduced the cost of sequencing the human genome. Tools for analyzing such data across families including annotation of clinically important variants and aggregation of variants for personalizing drug prescriptions have been developed but few are publically available. Here we describe such tools then demonstrate their application in several distinct data sets. In particular, we use the tools to define the genetic basis of a new congenital arrhythmia syndrome.

Genital injuries in neonates following breech presentation

Breech presentation is seen in 3-4% of babies born. Delivering a breech baby through vaginal route is difficult and carries a much higher complication rate than cesarean sections. Breech born babies carry an overall increased risk of maternal morbidity, neonatal mortality, birth asphyxia and birth injuries. Various types of birth injuries to the babies have been reported following breech delivery, but genital injuries are less commonly reported and thus, less anticipated. We report series of five babies with spectrum of genital injuries following breech delivery. These injuries led to significant short and long term morbidity in these babies. Keeping high index of suspicion, an early cesarean section can be an aide in preventing these complications. Once the baby is born, careful examination and early intervention should be done to prevent long term complications.

Pilot randomized trial demonstrating reversal of obesity-related abnormalities in reward system responsivity to food cues with a behavioral intervention

OBJECTIVES

Obesity is associated with hyperactivation of the reward system for high-calorie (HC) versus low-calorie (LC) food cues, which encourages unhealthy food selection and overeating. However, the extent to which this hyperactivation can be reversed is uncertain, and to date there has been no demonstration of changes by behavioral intervention.

SUBJECTS AND METHODS

We used functional magnetic resonance imaging to measure changes in activation of the striatum for food images at baseline and 6 months in a pilot study of 13 overweight or obese adults randomized to a control group or a novel weight-loss intervention.

RESULTS

Compared to controls, intervention participants achieved significant weight loss (-6.3±1.0 kg versus +2.1±1.1 kg, P<0.001) and had increased activation for LC food images with a composition consistent with that recommended in the behavioral intervention at 6 months versus baseline in the right ventral putamen (P=0.04), decreased activation for HC images of typically consumed foods in the left dorsal putamen (P=0.01). There was also a large significant shift in relative activation favoring LC versus HC foods in both regions (P<0.04).

CONCLUSIONS

This study provides the first demonstration of a positive shift in activation of the reward system toward healthy versus unhealthy food cues in a behavioral intervention, suggesting new avenues to enhance behavioral treatments of obesity.

Anxiety, locus of control, and coping strategies among end-stage renal disease patients undergoing maintenance hemodialysis

End-stage kidney disease (ESKD) patients on maintenance hemodialysis (MHD) have a lot of anxiety. Anxiety and coping are associated with the locus of control; the present investigation aimed to study the state and trait anxiety, locus of control, and active and passive coping among patients on MHD. Thirty MHD patients and 30 controls were administered State-Trait Anxiety Inventory, Rotter's Locus of Control Scale, and Coping Responses Inventory. There were significantly higher scores on state and trait anxiety, respectively (67.53 ± 10.89 vs. 59.40 ± 6.97, P < 0.01, and 62.97 ± 8.45 vs. 58.07 ± 7.06, P < 0.05), and locus of control (11.27 ± 3.55 vs. 9.04 ± 1.86, P < 0.01) in patients as compared to controls. On coping responses, patients and controls differed on positive reappraisal (54.33 ± 4.67 vs. 51.17 ± 3.12, P < 0.01), seeking guidance and support (58.07 ± 5.51 vs. 53.27 ± 4.22, P < 0.01), problem solving (51.03 ± 4.70 vs. 47.57 ± 4.73, P < 0.01), cognitive avoidance (60.27 ± 6.76 vs. 56.80 ± 4.08, P < 0.05), acceptance or resignation (61.67 ± 6.30 vs. 58.83 ± 4.23, P < 0.01), emotional discharge (68.07 ± 6.78 vs. 64.30 ± 4.50, P < 0.05), approach coping (205.57 ± 10.55 vs. 189.70 ± 11.37, P < 0.01), and avoidance coping (255.30 ± 16.45 vs. 241.10 ± 10.50, P < 0.01). A higher prevalence of anxiety trait could be the cause of anxiety in MHD patients besides the medical problems. The locus of control among patients though a mixed one was significantly more toward externalism. Thus, there is a need to identify this group well in advance and prepared not only medically but also psychologically for MHD.

Pleuropulmonary blastoma: transition from type I (cystic) to type III (solid)

Pleuropulmonary blastoma is a unique dysontogenetic neoplasm of childhood that appears as a pulmonary and/or pleural-based mass, and is characterised histologically by a primitive, variably mixed blastematic and sarcomatous appearance. We report a 12-month-old female child who was operated for a lung cyst at the age of six months and postoperative histopathology was suggestive of type I pleuropulmonary blastoma (PPB). She presented to us at the age of twelve months with a huge mass over the left chest wall and axilla, histopathological examination of which was type III PPB. Partial removal of the lung cyst led to transition from type I to type III PPB in a short span of a few months. Complete surgical removal followed by adjuvant chemotherapy is needed for a better outcome in type I PPB.

Post-varicella myasthenia gravis

Myasthenia gravis is an autoimmune disease of neuromuscular junctions. We report a three-year-old boy with post-varicella myasthenia gravis. This patient, to the best of our knowledge, is the youngest in age and second reported case of the condition. The patient presented with drooping of both eyelids which increased as the day progressed, two weeks after varicella infection. Repetitive nerve stimulation tests showed decremental response in action potential, and the child responded dramatically to test doses of neostigmine. A diagnosis of post-varicella myasthenia gravis was made and the patient was started on oral pyridostigmine. He is doing well at follow-up and there is no recurrence of symptoms to date.

Distraction in a case of otopalatodigital syndrome type II

INTRODUCTION

Otopalatodigital syndrome type II is a rare X-linked recessive disorder with generalized skeletal dysplasia and hearing anomalies. Its features include conductive hearing loss, unusual facies, cleft palate, micrognathia, and overlapping flexed fingers and toes. It is a more lethal variant of otopalatodigital syndrome type I. There are many consistently reported craniofacial and dental findings; however, no case has been published in dental literature.

CASE REPORT

We report a case of otopalatodigital syndrome type II with micrognathia, cleft of the soft palate, and partial anodontia, and discuss the combined orthodontic and surgical management.

CONCLUSION

We also discuss the differential diagnosis and consider more recent theories on possible aetiology as well as clinical management strategies for such cases.

Alkaline phosphatase activity in gingival crevicular fluid during canine retraction

OBJECTIVES

The aim of the study was to investigate alkaline phosphatase activity in the gingival crevicular fluid (GCF) during orthodontic tooth movement in humans.

SETTING AND SAMPLE POPULATION

Postgraduate orthodontic clinic. Ten female patients requiring all first premolar extractions were selected and treated with standard edgewise mechanotherapy.

EXPERIMENTAL VARIABLE

Canine retraction was done using 100 g sentalloy springs. Maxillary canine on one side acted as experimental site while the contralateral canine acted as control.

OUTCOME MEASURE

Gingival crevicular fluid was collected from mesial and distal of canines before initiation of canine retraction (baseline), immediately after initiation of retraction, and on 1st, 7th, 14th and 21st day and the alkaline phosphatase activity was estimated.

RESULTS

The results show significant (p < 0.05) changes in alkaline phosphatase activity on the 7th, 14th and 21st day on both mesial and distal aspects of the compared experimental and control sides. The peak in enzyme activity occurred on the 14th day of initiation of retraction followed by a significant fall in activity especially on the mesial aspect.

CONCLUSIONS

The study showed that alkaline phosphatase activity could be successfully estimated in the GCF using calorimetric estimation assay kits. The enzyme activity showed variation according to the amount of tooth movement.

Non-syndromic multiple supernumerary teeth transmitted as an autosomal dominant trait

Supernumerary teeth are common in the general population and occur more frequently in-patients with family history of such teeth. Multiple supernumerary teeth are associated with cleidocranial dyplasia and Gardner syndrome. However it is rare to find multiple supernumeraries in individuals with no other associated disease or syndrome. We describe the occurrence of multiple supernumerary teeth in a family occurring as a non-syndromal trait. The autosomal dominant transmission of non-syndromal multiple supernumerary teeth is new.

In vitro microtuberization in potato (Solanum tuberosum L.) cultivars

Mechanism of microtuberization in three elite cultivars kufri badhsha (KB), kufri chandramukhi (KCM) and kufri jawahar (KJ) of potato was studied. Sprouts of all the three cultivars were used to obtain in vitro shoot cultures. MS medium supplemented with chlorocholine chloride was found to be most suitable for all the cultivars. Maximum tuberization was obtained under incubation conditions of continuous darkness at 20 degrees +/- 1 degrees C. The highest number of micro-tubers per plant basis was produced under continuous darkness and KCM recorded the highest yield of micro-tubers and was found significantly superior to KJ and KB.

Recalcitrant osteomyelitis following tooth extraction in a case of malignant osteopetrosis

Malignant osteopetrosis generally begins in utero and often results in stillbirth. Besides, failure to thrive, increased bone fragility resulting in frequent fractures and recurrent bone infections are the other characteristic features. Infections after tooth extraction and fracture of the sclerotic bone following mild trauma are serious complications, as these ordinarily common problems are very difficult to treat in such patients. Poor bone vascularisation and reduced local defences prolong the defensive response. A rare case of malignant osteopetrosis in a 19-year-old girl, who presented with the complication of osteomyelitis of the mandible following tooth extraction, is presented. The case is of interest for two reasons: it is very rare for a case of malignant osteopetrosis to survive until adulthood and to be aware of the potential dental and oral complications of the disorder.

Langerhans' cell histiocytosis - A Case Report

Langerhan's histiocytosis was formerly known as histiocytosis X and refers to a group of conditions characterized by the uncontrolled stimulation and proliferation of a normal antigen-processing cell, the Langerhan's cell. Mandibular involvement associated with LCH is uncommon in a young child. Most reports describing bone involvements in LCH have mainly referred to male subjects over 20 years of age. The purpose of this report is to describe a case of multifocal bony LCH with mandibular involvement in a 8 year old girl and to discuss the appropriate management of such a case.

"Craniofacial and dental manifestations of a case of Proteus syndrome"

Proteus syndrome, which is a reference to the ancient Greek god Proteus, the Polymorphous, was called to the attention of pediatricians. Recognition of this syndrome has been difficult because of the variability of the syndrome's manifestations and because of its rarity. We describe a rare case of Proteus syndrome and we discuss its differential diagnosis. Our case presents with hemi facial hypertrophy, scrotal tongue, enamel hyperplasia as well as differential in the size of the dentition on both sides of the arch.

Secondary bone grafting in cleft lip and palate with eruption of tooth into the graft: a case report

Secondary bone grafting in cleft lip and palate patients is performed preferably before the eruption of permanent canine in order to provide adequate periodontal support for eruption and preservation of the teeth adjacent to the cleft. Presented here with is a case of unilateral cleft lip and palate, which was followed up from birth to 15 years of age. The role of an orthodontist in the team approach for management of such anomalies is described. Also discussed in detail is the entire range of treatment procedures the child underwent, especially the role of secondary bone grafting.

Canine ectopia: report of two cases

Transmigration of mandibular canine is a rare elusive phenomenon described in dental literature. The eruption of such transmigrated canines is even rarer. Two rare cases one of midline mandibular canine and the other of transmigrated mandibular canine across the midline and erupted distal to the opposite lateral incisor are presented. The transmigrated canine maintained its nerve supply from the original site. It is suggested that on routine evaluation of orthopantomograms when the dentist finds an excessive mesial inclination of the unerupted mandibular canine at 8-9 years associated with proclination of lower anteriors. increased axial inclination of the unerupted canine and an enlarged symphyseal cross section area of the chin, it is best to keep such a patient under routine evaluation.

Midline lethal granuloma--a clinical enigma

Midline Lethal granuloma is characterized by progressive destruction of nose, paranasal sinuses and palate. Till date, the diagnosis of this mutilating process remains as enigma due to the non specific histological and systemic findings. However, over the years the clinicians have been able to divide the "Lethal midline granuoloma syndrome" into clinical entities: Idiopathic midline destructive disease, Wegener's granulomatosis, polymorphic retiaculosis and Non-Hodgkins lymphoma. This article attempts to distinguish between these disease entities in the light of 2 case reports of Idiopathic midline destructive disease.

EEC syndrome--a case report

EEC syndrome is a multiple congenital anomaly syndrome characterized by ectodermal dysplasia, distal limb anomaly, cleft lip and palate and ocular adnexia anomalies. A case report of a 10 year old female patient with EEC is presented and it is emphasised that management of these cases requires a multidisciplinary approach. Early diagnosis will allow parents to get accurate counseling and in particular obtain reassurance regarding the low risk of mental handicap.

Cerebrospinal fluid lysozyme level for the diagnosis of tuberculous meningitis in children

Lysozyme activity was assayed in the cerebrospinal fluid (CSF) of 32 tuberculous meningitis (TBM), 17 bacterial meningitis, 10 partially treated bacterial meningitis, 18 encephalitis and 18 control subjects. The mean CSF lysozyme activity was significantly raised (p < 0.001) in TBM patients compared with other study groups. A cut-off CSF lysozyme level of > or = 26 U/l had a sensitivity and specificity of 93.7 and 84.1 per cent, respectively for the diagnosis of TBM. Overall, it was found to be a better test than any other single test and thus can be used for rapid and early diagnosis of TBM in children.

Dentofacial characteristics in Apert syndrome: a case report

Apert's syndrome is a developmental malformation characterized by craniosynostosis, a cone shaped calvarium, midface hypoplasia, pharyngeal attenuation, ocular manifestations and syndactyly of the hands and feet. The prodromal characteristic for the typical craniofacial appearance is early craniosynostosis of the coronal suture, cranial base and an agenesis of the sagittal suture. These craniofacial characteristics predispose the patient to maxillary transverse and sagittal hypoplasia with concomitant dental crowding, a pseudo cleft palate and a skeletal and dental anterior open bite. A case of Apert syndrome is presented with special emphasis on craniofacial characteristics and multidisciplinary approach to treatment. The differences between Apert and Crouzon's syndrome are highlighted.

Pitfalls in the diagnosis of thoracic aortic dissection at CT angiography

Two hundred seventy-five computed tomographic (CT) angiograms of the thoracic aorta were obtained over a period of approximately 4 years in patients with suspected or known aortic dissection. In all cases, unenhanced images were initially obtained, followed by contrast material-enhanced images. A variety of pitfalls were encountered that mimicked aortic dissection. These pitfalls were attributable to technical factors (eg, improper timing of contrast material administration relative to image acquisition); streak artifacts generated by high-attenuation material, high-contrast interfaces, or cardiac motion; periaortic structures (eg, aortic arch branches, mediastinal veins, pericardial recess, thymus, atelectasis, pleural thickening or effusion adjacent to the aorta); aortic wall motion and normal aortic sinuses; aortic variations such as congenital ductus diverticulum and acquired aortic aneurysm with thrombus; and penetrating atherosclerotic ulcer. Although several of these pitfalls are easy to recognize and therefore unlikely to present a diagnostic problem, others are potentially confusing. Familiarity with these common pitfalls, coupled with a knowledge of normal intrathoracic anatomy, will facilitate recognition of true aortic dissection and help avoid misdiagnosis at thoracic aortic CT angiography.

Modeling and efficient optimization for object-based scalability and some related problems

MPEG-4 is the first visual coding standard that allows coding of scenes as a collection of individual audio-visual objects. We present mathematical formulations for modeling object-based scalability and some functionalities that it brings with it. Our goal is to study algorithms that aid in semi-automating the authoring and subsequent selective addition/dropping of objects from a scene to provide content scalability. We start with a simplistic model for object-based scalability using the "knapsack problem"--a problem for which the optimal object set can be found using known schemes such as dynamic programming, the branch and bound method and approximation algorithms. The above formulation is then generalized to model authoring or multiplexing of scalable objects (e.g., objects encoded at various target bit-rates) using the "multiple choice knapsack problem." We relate this model to several problems that arise in video coding, the most prominent of these being the bit allocation problem. Unlike previous approaches to solve the operational bit allocation problem using Lagrangean relaxation, we discuss an algorithm that solves linear programming (LP) relaxation of this problem. We show that for this problem the duality gap for Lagrange and LP relaxations is exactly the same. The LP relaxation is solved using strong duality with dual descent--a procedure that can be completed in "linear" time. We show that there can be at most two fractional variables in the optimal primal solution and therefore this relaxation can be justified for many practical applications. This work reduces problem complexity, guarantees similar performance, is slightly more generic, and provides an alternate LP-duality based proof for earlier work by Shoham and Gersho (1988). In addition, we show how additional constraints may be added to impose inter-dependencies among objects in a presentation and discuss how object aggregation can be exploited in reducing problem complexity. The marginal analysis approach of Fox (1966) is suggested as a method of re-allocation with incremental inputs. It helps in efficiently re-optimizing the allocation when a system has user interactivity, appearing or disappearing objects, time driven events, etc. Finally, we suggest that approximation algorithms for the multiple choice knapsack problem, which can be used to quantify complexity vs. quality tradeoff at the encoder in a tunable and universal way.

Computed radiography dual energy subtraction: performance evaluation when detecting low-contrast lung nodules in an anthropomorphic phantom

A dedicated chest computed radiography (CR) system has an option of energy subtraction (ES) acquisition. Two imaging plates, rather than one, are separated by a copper filter to give a high-energy and low-energy image. This study compares the diagnostic accuracy of conventional computed radiography to that of ES obtained with two radiographic techniques. One soft tissue only image was obtained at the conventional CR technique (s = 254) and the second was obtained at twice the radiation exposure (s = 131) to reduce noise. An anthropomorphic phantom with superimposed low-contrast lung nodules was imaged 53 times for each radiographic technique. Fifteen images had no nodules; 38 images had a total of 90 nodules placed on the phantom. Three chest radiologists read the three sets of images in a receiver operating characteristic (ROC) study. Significant differences in Az were only found between (1) the higher exposure energy subtracted images and the conventional dose energy subtracted images (P = .095, 90% confidence), and (2) the conventional CR and the energy subtracted image obtained at the same technique (P = .024, 98% confidence). As a result of this study, energy subtracted images cannot be substituted for conventional CR images when detecting low-contrast nodules, even when twice the exposure is used to obtain them.

Chest teleradiology in a teaching hospital emergency practice

OBJECTIVE

New standards for hospital accreditation and health care reimbursement may require that faculty subspecialists be more available after regular working hours to supervise residents in academic radiology departments. We designed a receiver operating characteristic study to determine whether a thoracic radiologist who evaluated computed radiography (CR) images of the chest at a home-based teleradiology workstation could add significant value to a junior resident's interpretations of films within the hospital for acutely ill patients.

SUBJECTS AND METHODS

Using a hybrid cassette, we obtained analog chest films and CR images simultaneously for each of 252 acutely ill patients in the emergency department and in an intensive care unit. Interpretations of the analog films by three first-year residents were analyzed for 11 parameters deemed critical for patient management. Likewise, CR images of the same chest studies were viewed on a home teleradiology workstation by a faculty thoracic radiologist who analyzed the images for these 11 interpretive parameters. All interpretations by radiology residents and by the home-based thoracic radiologist were then compared with the interpretations of a consensus panel consisting of another thoracic radiologist and a full-time emergency department radiologist.

RESULTS

Analysis of the pooled results from the three junior residents as a group failed to show significant differences between their interpretations of chest films and the interpretations of CR images by a thoracic radiologist at a home workstation. However, we observed significant differences for several image interpretation parameters between individual residents and the home-based radiology subspecialist.

CONCLUSION

The data confirm that significant value can be added to the interpretations of chest films by individual junior residents when a home-based thoracic radiologist uses teleradiology to provide expert interpretations. Accordingly, it is reasonable to infer that on-line supervision by faculty subspecialists via teleradiology could be used to complement the scheduled visits that are being made now by individual faculty members of our institution to interpret films periodically with a radiology resident during overnight and weekend periods.