Splenic Syndrome due to Sickle Cell Trait amongst Indian Soldiers Serving in Kashmir

Background

Heterozygous transmission of gene for Haemoglobin S leads to sickle cell trait. Mostly the trait remains silent with no additional morbidity or mortality. When these persons migrate to higher altitudes, in times of high oxygen demand, some of them develop splenic infarction. This is a rare phenomenon and only 47 such cases had been reported till 2005.

Methods

This study was conducted at an Indian military hospital serving the troops deployed in Kashmir valley at altitudes ranging from 5500 ft to 13000 ft. When two consecutive splenectomies for splenic abscesses, turned out to be sickling induced infarction histopathologically, we reviewed splenectomy specimens received in last six years for evidence of sickling.

Result

Out of 33 splenectomies performed during the period of study, 22 were due to trauma (gun shot injury 11; splinter injury one and blunt injury 10). Of the rest eleven, who presented without any history of trauma, seven had evidence of vascular occlusion with aggregates of sickled red blood cells. In none, Gram stain or Periodic Acid Schiff stain revealed any bacterial or fungal colonies. One patient of splenic syndrome was found to have unrecognised sickle cell trait and he was managed conservatively.

Conclusion

Sickle cell trait should be excluded before considering splenectomy in ethnically vulnerable patients presenting with splenic syndrome. An uncomplicated splenic infarction can be managed conservatively.Key Words: Sickle cell trait, Splenic infarction, Splenic syndrome     

A comparative study of whole body DWIBS MRI versus bone scan for evaluating skeletal metastases

Background

Skeletal metastases in oncology patients are identified by Bone scan and/Positron Emission Tomography (PET) scan. But developing countries in the world still lack adequate numbers of these imaging facilities.

Aims

Since Magnetic Resonance Imaging (MRI) is widely available as compared to bone scan or PET scan; a double blind study was undertaken to see if whole body imaging with MRI can give an idea of skeletal metastases.

Method

Diffusion weighted whole body Magnetic Resonance Imaging with background body signal suppression (DWIBS) was performed using 1.5 Tesla (T) MRI on histopathologically proven cases of carcinoma of breast within two months of mastectomy and followed up after a year of surgery. Similarly bone scan was also performed in these patients.

Results

DWIBS MRI demonstrated the presence and extent of bone metastases in 10 out of a total 18 patients included in study while bone scan could demonstrate them in only three cases. A highly significant difference between proportions of the skeletal metastases detected by whole body DWIBS-MRI than that by bone scan at one year follow-up. (i.e. p<0.01, z=2.66) was seen.

Conclusion

DWIBS MRI scores high in demonstrating skeletal metastases. Further comparative studies are necessary to evaluate if DWIBS can replace bone scan or PET scan.     

Comparison of topical iodine and silver sulfadiazine as therapies against sulfur mustard burns in a pig model

Sulfur mustard (SM) is a powerful vesicant used as an agent of chemical warfare. The severity of lesions incurred after exposure to SM reiterated the need for an efficient and rapid neutralizing agent against SM. Previous studies have shown that postexposure treatment with iodine is effective against SM lesions in rodents. In the current study we used the pig model to emulate SM-induced burn lesions, and observed the immediate effect of a single dose of iodine formulation treatment on these burns. SSD, a common agent recommended for use in both chemical and thermal burns was used as control. Results indicated that 1.27 mg of SM caused deep lesions and histopathological changes in the pig skin as scored in the biopsies obtained. A single application of an iodine formulation 20 minutes from exposure to SM exhibited no protective action on the skin as evident in the biopsies obtained 1, 3, 5, 10, and 21 days after treatment. SSD treatment induced the least protective action. The SSD-treated wounds also took the longest to heal. Attempts to neutralize the SM action with iodine compounds were not successful in the pig model. Currently, other compounds are being investigated. Attention must be drawn to the adverse effect of SSD on SM-induced wounds. Further studies must be initiated to elucidate this phenomenon.     

De novo minimal change disease

Beyond the acute posttransplantation period, glomerular causes of proteinuria in the renal allograft include recurrent glomerulopathy, transplant-associated entities, and de novo disease. We present a case of de novo minimal change disease with reversible acute renal failure occurring 2.5 years posttransplantation in a 56-year-old man. The cause of end-stage renal disease in the native kidney was membranous glomerulopathy. De novo minimal change disease in the renal allograft is an extremely rare entity requiring stringent clinical-pathological criteria for diagnosis. Many of the cases previously reported as de novo minimal change disease fail to meet these criteria. We review the eight reported cases that appear to fulfill a strict definition of minimal change disease in the context of the current report.     

Holmium:YAG laser arthroscopy of the temporomandibular joint.

A new pulsed midinfrared laser has become available for use in arthroscopic surgery of the temporomandibular joint (TMJ). This article reviews holmium:YAG (yttrium-aluminum-garnet) laser physics, its tissue effects, and reports initial experience with its use in TMJ arthroscopy. Because the Ho:YAG laser can precisely and rapidly resect cartilaginous tissues with only moderate necrosis, can function in a saline environment, and can be transmitted through conventional optical fibers, it has the potential of becoming a useful and adaptable system for TMJ arthroscopic surgery.     

Acute Bone Marker Responses to Whole-Body Vibration and Resistance Exercise in Young Women

Whole-body vibration (WBV) augments the musculoskeletal effects of resistance exercise (RE). However, its acute effects on bone turnover markers (BTM) have not been determined. This study examined BTM responses to acute high-intensity RE and high-intensity RE with WBV (WBV + RE) in young women (n = 10) taking oral contraceptives in a randomized, crossover repeated measures design. WBV + RE exposed subjects to 5 one-minute bouts of vibration (20 Hz, 3.38 peak-peak displacement, separated by 1 min of rest) before RE. Fasting blood samples were obtained before (Pre), immediately after WBV (PostVib), immediately after RE (IP), and 30-min after RE (P30). Bone alkaline phosphatase did not change at any time point. Tartrate-resistant acid phosphatase 5b significantly increased (p < 0.05) from the Pre to PostVib, then decreased from IP to P30 for both conditions. C-terminal telopeptide of type I collagen (CTX) significantly decreased (p < 0.05) from Pre to PostVib and from Pre to P30 only for WBV + RE. WBV + RE showed a greater decrease in CTX than RE (?12.6% ± 4.7% vs ?1.13% ± 3.5%). In conclusion, WBV was associated with acute decreases in CTX levels not elicited with RE alone in young women.     

Biomechanical evaluation of the extensor musculature of the cervical spine

Dissection of the musculature in the cervical spines of four cadavers indicated that the semispinalis cervicis and capitis muscles appeared to be the muscles primarily responsible for extension of the cervical spine and head. The minimum force needed to balance a biomechanical model of the cervical spine in the neutral prone position against gravity measured 14.38 kg. The values obtained with this model, with roentgenograms of the cervical spine, and vector analysis were close enough to establish that the model is apparently valid for studying the extensor musculature of the cervical spine. Because the extensors appear to generate considerable force and may act as significant dynamic stabilizers of the cervical spine, the authors have altered their posterior surgical approach to minimize disruption of the extensor musculature.     

Relationships Between Body Composition, Muscular Strength, and Bone Mineral Density in Estrogen-Deficient Postmenopausal Women

The purpose of this study was to examine relationships between muscular strength, body composition, and bone mineral density (BMD) in untrained postmenopausal women who are not on hormone replacement therapy (HRT). Fifty-five women (age: 63.3 ± 0.6 yr) completed menstrual history, physical activity, and calcium intake questionnaires. Total and regional body composition and total body, anteroposterior lumbar spine, nondominant forearm, and right proximal femur BMD were measured using dual-energy X-ray absorptiometry (DXA) (GE Lunar Prodigy, Prodigy enCORE software version 10.50.086, Madison, WI). Participants performed strength tests for 3 upper body and 5 lower body resistance exercises. Women with a relative skeletal muscle mass index (RSMI) value less than 5.45 kg/m² were defined as a sarcopenia group (SAR). SAR had significantly (p < 0.05) lower total body and forearm BMD compared with those who were not sarcopenic. BMD sites were significantly correlated with upper body strength (UBS) and lower body strength (LBS) (r = 0.28–0.50, p < 0.01), with the strength of relationship being site specific. Strength and fat mass (FM) significantly predicted total body BMD (R² = 0.232–0.241, p < 0.05), FM variables predicted spine BMD (R² = 0.109–0.140, p < 0.05), and LBS and RSMI predicted hip BMD sites (R² = 0.073–0.237, p < 0.05). Body composition variables failed to significantly predict LBS. In conclusion, the contribution of body composition and strength variables to BMD varied by site as FM was more important for total body, forearm and spine BMD, and LBS exerted greater influence on the hip sites.     

Non‐medically supervised treatment interruptions among participants in a universally accessible antiretroviral therapy programme

Background

We examined clinical outcomes, patient characteristics and trends over time of non‐medically supervised treatment interruptions (TIs) from a free‐of‐charge antiretroviral therapy (ART) programme in British Columbia (BC), Canada.

Methods

Data from ART‐naïve individuals ≥18 years old who initiated triple combination highly active antiretroviral therapy (HAART) between January 2000 and June 2006 were analysed. Participants having ≥3 month gap in HAART coverage were defined as having a TI. Cox proportional hazards modelling was used to examine factors associated with TIs and to examine factors associated with resumption of treatment.

Results

A total of 1707 participants were study eligible and 643 (37.7%) experienced TIs. TIs within 1 year of ART initiation decreased from 29% of individuals in 2000 to 19% in 2006 (P<0.001). TIs were independently associated with a history of injection drug use (IDU) (P=0.02), higher baseline CD4 cell counts (P<0.001), hepatitis C co‐infection (P<0.001) and the use of nelfinavir (NFV) (P=0.04) or zidovudine (ZDV)/lamivudine (3TC) (P=0.009) in the primary HAART regimen. Male gender (P<0.001), older age (P<0.001), AIDS at baseline (P=0.008) and having a physician who had prescribed HAART to fewer patients (P=0.03) were protective against TIs. Four hundred and eighty‐eight (71.9%) participants eventually restarted ART with male patients and those who developed an AIDS‐defining illness prior to their TI more likely to restart therapy. Higher CD4 cell counts at the time of TI and unknown hepatitis C status were associated with a reduced likelihood of restarting ART.

Conclusion

Treatment interruptions were associated with younger, less ill, female and IDU participants. Most participants with interruptions eventually restarted therapy. Interruptions occurred less frequently in recent years.