“Artifactual fracture-subluxation” of cervical spine in computed tomography screening sans plain radiographs

Background contextComputed tomography (CT) has become the sole modality of screening for cervical injury in polytrauma because of the high sensitivity, speed, and convenience, thereby eliminating the need for plain radiographs.PurposeWe report two cases of misleading artifactual fracture-subluxation of cervical spine in CT, which could have resulted in needless treatment, and describe its characteristics.Study designCase report and review.MethodsTwo patients who were initially diagnosed with fracture-subluxation on screening CT cervical spine were later noted to have motion artifacts and were reviewed.ResultsThe artifactual nature of the supposed fracture-subluxation was unmasked by the soft-tissue findings of obscuration in sagittal reconstruction and duplication in axial images, along with the presence of double bony margins.ConclusionsMotion artifact in cervical CT screening can lead to a misdiagnosis of fracture subluxation. Duplication of soft tissue is highly suggestive of this motion artifact, and an additional single lateral plain radiograph may avert this pitfall.     

Ectopic mandibular third molar leading to osteomyelitis of condyle: a case report with literature review

Background

A tooth is said to be ectopic if it is malpositioned either due to congenital factors or displaced due to pathological lesions. The incidence of osteomyelitis of condyle has a rare occurrence, very few cases have been reported, either their etiology is unknown or is due to hematogenous spread or a tuberculous focus. This particular case may be a rare of its kind, as recent literature did not reveal any case where an ectopic mandibular third molar led to osteomyelitis of the condyle.

Case report

This report presents a unique case where an ectopically placed mandibular third molar led to extraoral sinus and scar formation below the ear lobule with osteomyelitis of the mandibular condyle and proposes various indications for its removal along with literature review.

Discussion

Ectopic eruption of a tooth into the dental environment is common, whereas ectopic eruption of tooth in other sites is rare. The exact etiology of ectopic eruption of mandibular third molar in condyle is a rare occurrence and to the best of our knowledge, only 14 cases have been reported in the literature. Management of such cases should be meticulously planned after ruling out various local as well as systemic factors as an underlying cause for osteomyelitis and on the basis of the position and type of ectopic tooth and related potential trauma which could be caused by surgical intervention with less morbidity.

Conclusion

This particular case may be the unique of its kind, as recent literature did not reveal any case where an ectopic mandibular third molar led to osteomyelitis of the condyle. Diagnosis and management in such cases deserve very special attention to rule out various local and systemic causes which can cause osteomyelitis to affect very unusual site like mandibular condyle. The aim of surgical intervention should be to cause minimum morbidity without affecting the functional efficiency of the mandibular condyle. In this report, we also have proposed the indications for surgical intervention to remove ectopically erupted teeth.     

Tumor necrosis factor-alpha (TNF-α)-induced optic neuropathy in rabbits

Abstract

Both in vitro and in vivo studies have implicated a role for tumor necrosis factor-alpha (TNFoc) in various demyelinating diseases/ including HIV-related encephalopathy. To investigate whether intravitreal TNFoc can induce optic nerve axonal damage in a rabbit eye model, fifteen rabbit eyes were initially injected with TNFoc (final concentrations: 2U, 20U, and 200U respectively) and studied at varying time intervals for up to 24 weeks post-injection, using light and electron microscopy. Control optic nerves (no injection or diluent injection only) had normal myelinated axons and glia; the myelinated regions, neural retina, retinal glia and vasculature of control retinas were normal. In TNFa-exposed optic nerves, intact, degenerating and demyelinated axons were interspersed. Astrogliosis was present, particularly from 8 weeks p.i. and was noted up to 24 weeks. Oligodendrocytes were not severely affected in TNFoc-exposed optic nerves> and activated macrophages or microglia were not obvious. Axonal degeneration was visible among the more superficial myelinated fibers in TNFoc-exposed retinas however the neural retina glia were unaffected. These observations suggest that the axonal degeneration induced in TNFoc- exposed rabbit optic nerves over a 24 week period was most likely related to direct effects of TNFoc on optic nerve axons, and not primarily due to anterograde degeneration from retinal lesions. In-so-far as neurological pathology in generaland optic nerve degeneration in particular; has been described in AIDS, and TNFoc levels may be elevated in this disease, it is of great clinical significance that TNFoc has the capacity to mediate neuronal or axonal injury. If so, strategies to block or inhibit TNFoc can be pursued for treatment for the neurological symptoms of AIDS. [Neurol Res 1996; 18: 176–184]     

Outcomes of incisional negative pressure wound therapy following brachiobasilic transposition arteriovenous fistula creation: A 1:2 propensity score matched study

Incisional negative wound pressure therapy (iNPWT) use on closed incisions has been shown to improve wound outcomes, but no studies have evaluated the use of iNPWT following brachiobasilic transposition arteriovenous fistula (BBT‐AVF). We aim to investigate the efficacy of iNPWT vs conventional wound therapy in reducing surgical site infections (SSIs) for BBT‐AVF incisions. This is a retrospective cohort study of patients who underwent BBT‐AVF creation between January 2010 and December 2017. A 1:2 propensity score matching (PSM) was performed to reduce selection bias and address for confounding factors. Study outcomes included SSI and haematoma incidence, 30‐day readmission, and 30‐day mortality. A total of 154 patients were reviewed in this study: 47 (30.5%) had iNPWT and 107 (69.5%) had conventional wound therapy. The overall median age was 60.5 (interquartile range 54–69). PSM with a 1:2 ratio resulted in a total of 117 patients (39 iNPWT and 78 conventional wound therapy). In the unmatched cohort, SSI incidence was lower in the iNPWT group (n = 1/47 [2.1%] vs n = 14/107 [13.1%], P = .035). However, incidence of SSI was comparable between iNPWT and conventional wound therapy after matching (n = 1/39 [2.6%] vs n = 9/78 [11.5%], P = .102). There was no significant difference in 30‐day readmission and 30‐day mortality. Within our study population of patients with BBT‐AVF incisions, there is a non‐statistically significant reduction in SSI incidence for patients who received iNPWT as compared with conventional wound therapy. Further prospective randomised controlled studies should be conducted to validate these findings.     

Ethnic Disparities in Trauma Mortality Outcomes

Background

Ethnic disparities in trauma mortality outcomes have been demonstrated in the United States according to the US National Trauma Data Bank. The aim of this study was to determine the effect of race/ethnicity on trauma mortality in Singapore.

Methods

This was a retrospective review of patients aged 18–64 years with an injury severity score (ISS) ≥9 in the Trauma Registry of Tan Tock Seng Hospital, a 1,300-bed trauma center in Singapore, from 2006 to 2010. Chinese, Malay, and Indian patients were compared with patients of other ethnic groups. Multiple logistic regression analyses determined differences in survival rates after adjusting for demographics, anatomic and physiologic ISS and revised trauma score, mechanism or type of injury.

Results

A total of 4,186 patients (66.4 % of the database) met the inclusion criteria. Most patients were male (76.3 %) and young (mean age 40 years). Using Chinese as the reference group, we found no statistically significant differences in unadjusted or adjusted mortality rates among the ethnic groups. Independent predictors of mortality included age [odds ratio (OR) 1.05, 95 % confidence interval (CI) 1.03–1.06, p < 0.0001], presence of severe head injury (OR 1.75, 95 % CI 1.13–2.69, p = 0.012), and increasing ISS (p < 0.0001).

Conclusions

Ethnicity is not an independent predictor of trauma mortality outcomes in the Singapore population. Our findings contrast with those from the United States, where race/ethnicity (Black and Hispanic) remains a strong independent risk factor for trauma mortality. This study attests to the success of the Singapore health care/trauma system in delivering the same quality of care regardless of ethnicity.     

Novel use of fused cardiac computed tomography and transesophageal echocardiography for left atrial appendage closure

The use of the Watchman left atrial appendage occlusion device (Boston Scientific Inc.) is becoming increasingly frequent in patients with atrial fibrillation. Cardiac computed tomography (CT) for device sizing pre-procedure can help facilitate more accurate device selection compared with transesophageal echo (TEE) alone. CT can also help identify minor lobes and trabeculations that may not be apparent on TEE. We report a series of three cases to highlight the utility of a novel application of CT-TEE fusion imaging to provide procedural guidance during Watchman implant and to assess for peri-device leak post-implant.