Heterotopic ossification around the hip in spinal cord-injured patients. A long-term follow-up study.

Twenty patients with spinal cord injury complicated by ossification around the hip were followed for eighteen months or more. The bone scan, roentgenogram, level of alkaline phosphatase, and range of hip motion of each patient were analyzed. The average follow-up was forty months. The heterotopic ossification usually did not mature until after one and one-half years. The roentgenograms were of no value in judging its maturity. The bone scan correlated well with the results of the alkaline phosphatase testing in judging maturity of the ossification. We concluded that before operative resection, a patient should have a normal level of alkaline phosphatase, decreasing activity on the bone scans, and a restriction of motion to less than 50 degrees of hip flexion.     

Alopecia syphilitica, a simulator of alopecia areata: histopathology and differential diagnosis

Alopecia syphilitica (AS) may be "moth-eaten" or diffuse, clinically, and be confused with alopecia areata (AA) or other alopecias. The English language literature contains scant information regarding the histopathology of AS, and the resemblance between AS and AA has not been given adequate recognition. We report the histopathological findings of AS from nine patients with secondary syphilis and acute hair loss. The alopecia was moth-eaten in four patients and diffuse, but slightly moth-eaten, in five. Microscopically, the dermoepidermal interface was not involved. The numbers of hair follicles were diminished, with increased numbers of catagens and telogens. Lymphocytic infiltration was present around the hair bulbs and fibrous tracts in eight cases. Plasma cells were present in four biopsies. Other less common findings included lymphocytes in the isthmus, parabulbal lymphoid aggregates, and granulomatous infiltrate in the upper dermis. The findings, save for the follicular changes, resembled those of macular/maculopapular syphilides outside the scalp. With the follicular changes, the overall patterns resembled AA closely. The modified Steiner stain did not reveal spirochetes in any of our cases and failed to differentiate between AS and AA. Comparing the AS cases to 13 cases of AA, we found only a few differentiating features. The presence of peribulbal eosinophils strongly suggests AA. Without peribulbal eosinophils, the presence of plasma cells, abundant lymphocytes in the isthmus, or parabulbal lymphoid aggregates suggests AS.     

Diffuse leiomyomatosis of the esophagus

BACKGROUND: Leiomyomas are rare esophagus neoplasms. They are usually solitary, and the diffuse lesion is extremely rare. CASE REPORT: A 19-year-old male presented with a 3-year history of occasional dysphagia and postprandial regurgitation. The chest radiographs showed a huge mass in the posterior mediastinum. Barium esophagograms showed narrowing of the middle third esophagus with proximal dilatation. The fibroesophagoscopy demonstrated multiple submucosal nodules below a level 22 cm from the incisor and covered with intact mucosa. CT scans of the chest showed a long segment of circumferential soft tissue in the posterior mediastinum which encircled and involved the upper two thirds of the esophagus. An intrathoracic esophagectomy with cervical esophagogastrostomy via the substernal route was performed. Grossly, multiple confluent myomatous nodules circumferentially involved the upper and middle third of the esophagus. Histologic findings showed diffuse leiomyomatosis of the esophagus. CONCLUSION: Esophageal leiomyomatosis should be considered in a young patient with long-standing dysphagia in whom smooth, tapered esophageal narrowing on barium study and circumferential esophageal wall thickening on CT scan are seen. An esophagectomy combined with a reconstruction procedure is indicated.     

Quantitative computer‐assisted digital‐imaging upper airway analysis for obstructive sleep apnoea*

This was a prospective study of a new objective method which quantitatively analyses the upper airways in patients with obstructive sleep apnoea (OSA). Video‐nasopharyngoscopic examinations of the upper airways of 45 patients were carried out with an endoscopic calibrator. Images of the upper airway during quiet respiration and Mueller's manoeuvre in erect and supine positions were digitized by computer to generate the actual dimensions of obstructive sites. Measurements by the new method were validated by comparing 90 pairs of videoendoscopic images with upper airway magnetic resonance imaging (MRI) measurements at two identical levels. Quantitative precision is 100% for the retropalatal level and 95.6% for the retrolingual level with a tolerance of 0.5 cm² between the two methods. The absolute mean of the difference between the two methods of measurement is 0.08 cm² at the retropalatal level and 0.18 cm² at the retrolingual level. The agreement between the digital‐imaging videoendoscopic and MRI measurements was 93.3% for the retropalatal level and 95.6% for the retrolingual level. Quantitative computer‐assisted digital imaging is a reliable, cost‐effective clinical method of upper airway evaluation in OSA patients. This method allows us to examine the dynamic and static morphology objectively, measure surgical outcomes of upper airway, opening up new avenues for OSA management.     

Blunt hepatic injury: minimal intervention is the policy of treatment

BACKGROUND: Many publications recommend nonoperative treatment for stable blunt hepatic injury patients. Unstable hemodynamic status is the only indication for surgery. When operation is indicated, controversies exist regarding which operative procedure will be more beneficial to the patients. The purposes of this study are to compare the results of operative and nonoperative management of patients with blunt hepatic injuries and to identify the optimal surgical approach when surgery is indicated. METHODS: Different prospective protocols of treating adult blunt hepatic injuries were conducted. From 1992 to 1993 (group I), urgent surgery would be performed in the presence of hemoperitoneum. The policy shifted to aggressive nonoperative approach between 1996 and 1997 (group II). The patients from each period were divided into three subgroups. Group A included the patients who received nonoperative treatment in either period. Group B consisted of the patients who received surgery in the first period and nonoperative management in the second period. Group C included the patients who were operated on in either group. Comparisons were made between matched groups. RESULTS: Groups IA and IIA patients had minor injuries and could be successfully treated nonoperatively. The results of groups IB and IIB were similar concerning hospital stay, morbidity, and mortality. Transfusion requirements of group IIB patients were significantly higher (2.2 vs. 1.1 units,p = 0.01) than those of group IB. However, 25 (58%) celiotomies of group IB patients were nontherapeutic. When surgery was indicated, group IC patients had significantly higher liver-related mortality (14 of 49 vs. 3 of 55, p = 0.002). Anatomic resection was performed more frequently in that period. CONCLUSION: Nonoperative treatment significantly decreased the rate of nontherapeutic laparotomy but carried the risks of higher transfusion requirements and delaying operation. When surgery was indicated, the policy of minimal intervention positively affected the patients' outcomes. The goal of surgery should be hemorrhage control rather than resection of the injured liver tissues.     

Characteristics and trends in incidence of inflammatory bowel disease in Taiwanese children.

BACKGROUND AND PURPOSE: Although chronic inflammatory bowel disease (IBD) is rare in Asian children, increasing numbers of pediatric patients with chronic IBD worldwide have been noted in recent years. This study was conducted to delineate the trend in incidence and clinical patterns of childhood IBD in Taiwan. METHODS: All children admitted to National Taiwan University Hospital (NTUH) between 1979 and 2000 who met the criteria for IBD, Crohn's disease (CD), ulcerative colitis (UC), probable CD (PCD), or indeterminate colitis were included. The clinical features and outcomes were analyzed retrospectively. Incidence was calculated using cases of chronic diarrhea during the same period of time as the risk population. RESULTS: IBD was diagnosed in 17 children (9 females and 8 males, aged 2 months to 18 years) during the study period. Six (35%) of these children had UC, 9 (53%) had CD, and 2 (12%) had PCD. The cumulative incidence of CD during 1979-1995 was 0.85%, and increased to 2.6% during 1996-2000 (p < 0.001), while the incidence of UC did not change significantly between these periods (from 0.85% to 0.99%, p = 0.16). The median interval from onset to diagnosis was 7.7 months. Eighty percent of patients had moderate to severe disease activity at diagnosis. The follow-up duration ranged from less than 1 year to 20 years, with a mean of 4.3 years. Two patients were lost to follow-up. Eighty six percent of patients responded to treatment, and 80% of patients had inactive to mild disease activity when re-evaluated at the end of 2000. CONCLUSION: There has been a marked recent increase in the incidence of childhood CD in Taiwan but the rate of childhood UC has remained unchanged. Eighty percent of cases of childhood IBD responded well to treatment.