Hyperphagic short stature: A case report and review of literature

A 5?-year-old adopted girl was referred to us in view of short stature. After ruling out systemic illness, she was evaluated for growth hormone deficiency (GHD) by stimulation tests. The peak value was 3.47 ng/ml. She was then started on growth hormone (GH). At the end of 6 months of GH therapy, her height velocity was only 3 cm/year. There was a lack of attachment between the mother and the child. She had history of hyperphagia, stealing, and hoarding food. Psychiatry consultation confirmed that the child had appetite disorder, and hence was diagnosed as hyperphagic short stature (HSS). The girl and her parents are undergoing psychiatric therapy for the same. Psychosocial dwarfism seems to originate from serious disturbances in the mother-child relationship. These children mimic patients with GHD, but have poor response to GH therapy. This case underscores the importance of social environment in the growth of the individual.     

Meta-analyses of mortality and morbidity effects of an angiotensin receptor blocker in patients with chronic heart failure already receiving an ACE inhibitor (alone or with a beta-blocker)

BACKGROUND: While treatment with either angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) is clearly superior to placebo in the treatment of heart failure patients, controversy still surrounds the effects of ARBs in patients already receiving an ACEi. Even more controversial is the wisdom of administering ARBs in patients already on an ACEi and beta-blocker. METHODS: We present meta-analyses of the available randomised controlled trials to date (October 2003) of angiotensin II receptor antagonists versus placebo in patients with symptomatic chronic heart failure in which both groups received ACEi. The two largest eligible trials were CHARM-Added and Val-HeFT. We examined two endpoints: mortality and a combined endpoint of mortality and morbidity. RESULTS: In the first meta-analysis, covering all patients regardless of beta-blocker use, we found a significant reduction in the combined endpoint (odds ratio [OR]=0.89; 95% confidence interval [CI] 0.81-0.98), but no significant reduction in mortality itself (OR=0.97; CI: 0.87-1.08). In the second meta-analysis, covering patients concomitantly on beta-blockers, we found no significant effect on mortality (OR=1.08; CI: 0.90-1.29) or on the combined endpoint (OR=0.94; CI: 0.82-1.10). In the third meta-analysis, covering patients not on concomitant beta-blockers, there is clear evidence of a reduction in the combined endpoint (OR=0.83; CI: 0.73-0.94), but not on mortality (OR=0.93; CI: 0.81-1.06). CONCLUSION: There is now good evidence for the use of ARBs to prevent events in patients with heart failure on ACEi who are not suitable for beta-blockers.     

Benign Fibrous Histiocytoma: A Rare Case Report and Literature Review

Fibrous histiocytoma is a benign soft tissue tumour that may present as a fibrous mass anywhere in the human body. The involvement of the oral cavity is extremely rare and very few cases have been reported in literature till date. We here report a case of benign fibrous histiocytoma localized in the oral cavity. The clinical and histological features of the lesion are discussed precisely in the light of a literature review of this pathology in oral cavity.     

Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients

Background  

The antifibrinolytic tranexamic acid reduces surgical blood loss, but studies have not identified an optimal regimen.     

Postoperative Flexion Analysis of 3 Rotating-platform Knee Designs

Rotating-platform knee implants have successively undergone modifications to improve postoperative flexion. The cruciate-sacrificing Low Contact Stress (LCS) implant (DePuy Orthopaedics, Inc, Warsaw, Indiana) was modified into the cruciate-substituting PFC Sigma RP (ΣRP) implant and further into the PFC Sigma RPF (ΣRPF) implant (DePuy Orthopaedics, Inc). The goal of this study was to determine whether these modifications improved postoperative flexion. Postoperative flexion at 2 years was compared against preoperative flexion with regard to the general demographics of each group.Statistical analysis showed that the pre- to postoperative flexion changes achieved by the ΣRP (14.6°) and the ΣRPF (2.9°) were better (P<.001) than that achieved by the LCS (-10.3°); however, between the ΣRP (14.6°) and the ΣRPF (2.9°), the change was statistically insignificant (P=.045). In subgroups with preoperative flexion less than 125°, postoperative flexion achieved was 100.1° with the LCS, 119.8° with the ΣRP, and 121.3° with the ΣRPF. The difference between the ΣRP and ΣRPF and the LCS was statistically significant (P<.001), but between the ΣRP and the ΣRPF was statistically insignificant (P=.621). In subgroups with preoperative flexion 125° or more, postoperative flexion was 125° with the LCS, 132° with the ΣRP, and 130° with the ΣRPF, with no significant difference between groups (P=.416). Both cruciate-substituting designs produced better postoperative flexion than the cruciate-sacrificing design. The ΣRP, despite less preoperative flexion (P=.004), achieved statistically better postoperative flexion than the LCS (P<.001). In subgroups with comparable preoperative flexion, no statistical difference in postoperative flexion was achieved by the ΣRP and the ΣRPF.     

Diagnosis of arteriovenous fistula dysfunction

Arteriovenous fistula (AVF) dysfunction remains a major contributor to the morbidity and mortality of hemodialysis patients. The failure of a newly created AVF to mature and development of stenosis in an established AVF are two common clinical predicaments. The goal is to identify a dysfunctional AVF early enough to intervene in a timely manner to either assist with the maturation process or to prevent thrombosis. The currently available tools in our armamentarium include clinical evaluation, physical examination of the AVF, and surveillance tests. Physical examination has been recognized as a simple and cost-effective tool, but is often not implemented either because of lack of training or time constraints. Surveillance tests include measurement of access flow or pressure as a surrogate marker of AVF dysfunction. Surveillance tests often require expensive equipment, additional personnel, and are controversial. Currently, there are guidelines and recommendations to include all of these measures while evaluating an AVF. Implementing judicious use of these tools in clinical practice can facilitate early diagnosis for timely intervention in the appropriate population. Furthermore, this strategy may avoid unnecessary interventions and assist with healthcare cost containment.     

Relationship between type-2 diabetes and use of metformin with risk of colorectal adenoma in an American population receiving colonoscopy

The aim of this study is to explore the relationship between type-2 diabetes, its treatments (Use of metformin) and the development of colorectal adenoma. Colonoscopy reports from a total of 66 endoscopists in one big hospital in midwest during 2008–2009 were reviewed. Colonoscopy findings including quality of preparation, polyp size, location, morphology, pathology and history of diabetes and metformin treatment were retrieved. Of the 7382 colonoscopy reports were reviewed, 3465 average risk patients were included in our final analysis. The pathologically proven Adenoma detection rate (ADR) in total population was 24.6 % (30.2% in Men and 19.2% in Women). Old age and male sex were significantly associated with increasing risk of colorectal adenoma. Type-2 diabetes was associated increased risk of colorectal adenoma (OD 1.35, 95% confidence interval 1.08–1.70, p = 0.009). A total of 426 subjects (12.29%) had diabetes and 405 of these subjects (11.7%) had type-2 diabetes. Within diabetic patient group, people who were taking metformin have significantly lower risk of colorectal adenoma (OD 0.55, 95% confidence interval 0.34–0.87, p = 0.011). Diabetic subjects have increased risk of developing colorectal adenoma. Our study also supports the beneficial effect of metformin in development of colorectal adenoma.     

Percutaneous direct endoscopic pancreatic necrosectomy

Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.