Basis Of Clinical Examination Research Articles

Should routine assessment of anastomotic integrity be undertaken using radiological contrast swallow after oesophagectomy with intra-thoracic anastomosis? Best evidence topic (BET)

Thoracic anastomotic leak is associated with significant postoperative morbidity and mortality. Routine contrast oesophagograms are consequently employed by a number of centres to routinely screen for this complication yet there exists little consensus as to if and when this assessment should occur. We have demonstrated within this BestBET analysis of five level IV case series that routine contrast oesophagograms lack adequate sensitivity or positive predictive value to be effective as screening tools, with leaks often arising clinically prior to scheduled routine assessment. We additionally demonstrate the significant risk of aspiration associated with contrast swallow use. The use of contrast swallow studies as diagnostic tools in patients for whom a leak is considered likely on the basis of clinical examination is nevertheless supported by relatively greater negative predictive values and specificity reported within the literature. There is additional evidence to support the use of CT imaging with oral contrast and endoscopic assessment of the anastomosis as valuable tools to assess for anastomotic integrity.

Multiple skin ulcers from malignant syphilis

A 38-year-old man presented to our department in April, 2014, with a 1 month history of multiple painful skin ulcers (fi gure) on his face, trunk, and extremities. The eruptions had started as papular and nodular lesions and progressed to pustules and painful ulcers within 2 weeks. He had been diagnosed with pyoderma gangrenosum at his local hospital and treated with methylprednisolone. After 1 week, the lesions had worsened and he had developed fever. He reported having had sex with four women during the past year and denied ever having sex with men. Histological examination of a biopsy sample from an ulcer on his left arm indicated psoriasiform epidermal hyperplasia with central ulceration. In the dermis we noted mixed perivascular infi ltrate with neutrophils, lymphocytes, plasma cells, and histiocytes. Stains for fungi, mycobacteria, and spirochetes were negative. Full blood cell count, CD4 cell count, CD8 cell count, anti-neutrophil cytoplasm antibody test, HIV serotest, and cultures for fungi and bacteria (including Mycobacterium tuberculosis and Neisseria gonorrhoeae) were normal or negative. The erythrocyte sedimentation rate (ESR) was 50 mm/h (normal range 0–20 mm/h). Serum treponema pallidum particle agglutination assay (TPPA) was positive and rapid plasma reagin (RPR) titre was 1:128. On the basis of clinical examination, serum TPPA, RPR, and histological examination, we diagnosed malignant syphilis. We started 2·4 mg intramuscular benzathine penicillin injections, once a week for 3 weeks. 6 months later the ulcers had healed completely, although atrophic scars remained (fi gure); the RPR titer dropped to 1:1 and HIV serotest remained negative. Malignant syphilis is a rare form of destructive secondary syphilis. It usually occurs from 6 weeks to 1 year after primary infection, or earlier in people with HIV. Syphilis is a common sexually transmitted disease in China, with an incidence of 0·03% in 2014. However, malignant syphilis is rare.

Appendicular Mucocele : High Frequency Sonography Imaging A case report and short review of literature

Appendicular mucocele, a cystic mass resulting from a dilated appendiceal lumen caused by abnormal accumulation of mucus that often is not considered when problems of the right quadrant lower abdominal pain are assessed. It is rare entity; occurring in 0.25% of 43,000 appendectomy specimens in one series. A correct preoperative diagnosis is rarely made on the basis of clinical examination. Accurate diagnosis is essential in order to prevent rupture at surgery with development of pseudomyxoma peritonei and predict malignant transformation. We describe high frequency sonography findings that led to the correct preoperative diagnosis confirmed with surgery and histopathological confirmation.

Non-invasive evaluation of the haemodynamic effects of high-dose medetomidine in healthy cats for semen collection.

This study aimed to assess non-invasively the cardiovascular effects of high-dose medetomidine on healthy male cats undergoing semen collection. Haemodynamic evaluations were assessed on the basis of clinical examination, systolic arterial pressure (SAP) and transthoracic echocardiographic examination. Eight client owned, male domestic shorthair cats were sedated with a bolus of medetomidine intramuscularly (IM; 0.13 mg/kg), and semen collection was performed. A second transthoracic echocardiographic examination and SAP measurement were carried out 15 mins after sedation. At the end of the examination, the patients received a bolus of atipamezole (0.3 mg/kg) IM. The cats were deeply sedated, relaxed and laterally recumbent during the entire procedure. No rhythm abnormalities were observed during the examinations and no significant increase in SAP was recorded. Heart rate dropped from 200 ± 33 to 92 ± 13.1 beats per min after sedation. There was a significant increase in left ventricular dimensions and the left atrial area. The parameters of left ventricular systolic function were reduced, as were systemic and pulmonary cardiac outputs. Peak diastolic wave velocities were significantly reduced, while isovolumic contraction and relaxation time of the left ventricle were prolonged. Aortic valve insufficiency was recorded for all cats, while mitral valve insufficiency was noted in five cats. None of the subjects developed systolic anterior motion of the mitral valve. The protocol allowed us to collect good semen samples in healthy cats. However, high-dose medetomidine induces significant haemodynamic effects on the feline heart, mainly due to a reduced heart rate, an increased cardiac preload and impaired systolic function. The animals recovered from the anaesthesia, after antagonist administration, without showing any clinically relevant consequences.

Comparative Study of Endonasal Endoscopic Dacryocystorhinostomy and External Dacryocystorhinostomy

ABSTRACT A prospective study on 50 cases of chronic dacryocystitis was done to see outcome of management by endoscopic dacryocystorhinostomy (DCR) in Indian population and to look for its advantages or disadvantages over external-DCR. Effect of mitomycin-C was also evaluated in endoscopic DCR cases. Dacryocystitis was diagnosed on the basis of clinical examination by doing regurgitation test and lacrimal syringing. These patients were divided into two groups: group I consisted of those 25 subjects who were planned for endonasal endoscopic DCR and group II of those 25 subjects who underwent external-DCR in ophthalmology department. Of all the cases, maximum number of cases was in the age group of 21 to 35 years, 27 (54%) cases, 88% were females and 12% were males. External-DCR required a relatively longer surgical duration of an average 65 minutes as compared to 35 minutes for endonasal DCR. Average hospital stay for patient in group I was 3 days and it was 7 days in group II. There were minimal intraoperative complications in endoscopic procedure as compared to external-DCR group. Average follow-up was 6 months. Primary success rate was 96% in both the groups. Thus, it was concluded that both the procedures represent good alternatives for the treatment of primary nasolacrimal sac or duct obstruction or chronic dacryocystitis, endoscopic DCR having advantage of less complications and less traumatic. Mitomycin-C was found to be helpful in reducing fibrosis. How to cite this article Singh H, Mohindroo NK. Comparative Study of Endonasal Endoscopic Dacryocystorhinostomy and External Dacryocystorhinostomy. Clin Rhinol An Int J 2015;8(1):1-4.

Features of clinical and morphological picture and diagnostics of "atypical forms" of hematogenous osteomyelitis of long bones

In recent years one observes increased frequency of hematoge-nous osteomyelitis (HO) with atypical clinical course diagnostics of which is difficult and morphogenesis and pathogenesis is not completely clear. Objective: on the basis of clinical examination of patients with clinical, laboratory, visual and pathomorpho­logical methods to determine the features of chronic GO (CHO) with atypical clinical course particularly Brodie abscess (BA) and Garre's sclerosing osteomyelitis (GSO). Methods: The clini­cal course, pathologic features, the results visualizing methods of examination and complex treatment of patients with BA (26) and GSO (10). Results: In cases of AB intraosseous inflammatory focus with relatively sharp edges exists for many months and even years. At pathomorphological examination there were revealed destructive lesions with the capsule, consisting of internal, fibrous, and bone membranes. While GSO a significant portion of the bone involved into the inflammatory process until subtotal lesion. In the amended cortex numerous areas of osteonecrosis are noted. Either in them or in periosteal and endosteal regenerates polymorphic resorptive cavities filled as well as intertrabecular spaces with mellow fibrous or immature fibrous tissue with mononuclear inflammatory plasmocytic infiltrates are located. BA belongs to the destructive form of CHO with predominantly productive-infiltrative inflammation of high activity in the focal capsule, and GSO — to fibrozive and fibrozive with mikroabscessing. Conclu­sion: Definitions for atypical forms of HO (subacute, primary chronic, primary subacute) relate to the clinical features of its course. Morphologically foci of latent HO correspond to the basic forms of osteomyelitic foci: destructive, fibrozive, and fibrozive with mikroabscessing.

Angiopoietin-2 as a biomarker for metabolic syndrome and disease activity in rheumatoid arthritis patients

BackgroundThe incidence of metabolic syndrome (MetS) increases in rheumatoid arthritis (RA) patients which increases the risk of cardiovascular disease (CVD). Angiopoietin-2 levels increase in RA and were reported to predict CVD. Aim of the workTo assess the level of angiopoietin-2 in RA patients and study its relation to disease activity and its role in those with MetS. Patients and methodsThe study included 80 RA patients (67 females and 13 males) and 20 healthy age and sex matched controls. The patients were divided into Group 1 (n=40) with MetS and Group 2 (n=40) without. Data were collected throughout history, basic clinical examination and investigation. Disease activity score (DAS-28) was assessed in all patients. Enzyme linked immunosorbent assay was used for the estimation of angiopoietin-2. ResultsThe age and disease duration of those with MetS (40.7±7.23years and 9.63±6.73years respectively) and those without (38.6±9.2 and 8.65±5.52years respectively) were comparable (p=0.26 and p=0.48 respectively). The disease activity (DAS-28) was also similar in both groups (5.12±0.77 and 5.01±0.96 respectively; p=0.56). There was a significant increase in the angiopoietin-2 levels in RA patients with MetS (5.31±0.56ng/ml) than those without (4.93±0.44ng/ml) (p<0.001). The levels were significantly higher than those of the control (4.44±0.29ng/ml) (p<0.001). The angiopoietin-2 level significantly correlated with the DAS-28 (r=0.23, p=0.045), systolic (r=0.36, p=0.001) and diastolic blood pressure (r=0.35, p=0.001), fasting blood sugar (r=0.29, p=0.009) and triglycerides (r=0.24, p=0.03). ConclusionsAngiopoietin-2 can be used as a biomarker of MetS and disease activity in RA patients. This could point to those RA patients at risk of developing CVDs.

A clinical evaluation denture adhesives used by patients with xerostomia.

The purpose of study was to analyze the participants’ opinions concerning the effectiveness of 6 denture adhesives (DA).The study group included 60 participants. Criteria for selecting the patients were as follows: reduced retention and stabilization of maxillary complete dentures and xerostomia. These features were evaluated on basis of clinical examination and standard sialometry tests (u-SFR). Retention of maxillary dentures was scored by modified Kapur index before application of DA. All participants were divided randomly into 6 groups regarding the use of the 6 DA during a 6-month period. After this time, participants completed an HRQL questionnaire.DA noticeably improved retention and stabilization of maxillary complete dentures. DA in the glue form had the best retention effectiveness in participants with xerostomia. These materials are difficult to clean from the denture base. The data are presented in tables and figures.The results of the study collected positive influence of adhesives on retention of dentures in xerostomia patients. The cleaning dentures and denture bearing tissues was difficult.DA help in the use of prostheses, but it is also necessary for the treatment of the causes and symptoms of xerostomia.

Unilateral Benign Masseteric Hypertrophy: Surgical Intervention and Case Report

Hypertrophy is related to an enlargement caused by a growth in the size but not in the number of cells. Generalized masticatory muscle hypertrophy may affect the temporalis muscle, masseters, and medial pterygoids in a variety of combinations. Masseter hypertrophy is recognized as a rare disorder and persistent asymptomatic enlargement of one or both masseter muscles. Etiology for benign masseteric hypertrophy is unknown in most of the cases so considered as idiopathic. Although numerous factors such as facial asymmetry, trismus, protrusion, bruxism, clenching, malocclusion, or temporomandibular disorders have been reported on the basis of clinical examination and cited previous literatures but have not proven still. This article reports a case of unilateral benign masseter hypertrophy with retrognathic mandible in which surgical intervention was rendered to the patient by using a combination approach.

Preliminary study of intralesional bleomycin injection for the treatment of genital warts.

Preliminary study of intralesional bleomycin injection for the treatment of genital warts.

Congenital Cholesteatoma of Inner Ear: Still a dilemma

Congenital cholesteatoma is an intriguing entity with 71% cases being detected on the basis of clinical examination in the age group of 4 to 5 years. We present an extensive case of inner ear congenital cholesteatoma in an adult male who presented with multiple intratemporal and intracranial complications.

Endogenous endophthalmitis following prolong use of methotrexate

A 46 yr old male presented to us with a 2 day history of pain, redness and discharge in left eye. The patient was on oral Methotrexate (12.5 mg) weekly with folic acid supplement for the last 1 year for recurrent Uveitis (LE). There was a history of three previous episodes of acute anterior uveitis in left eye 2 years back for which he was prescribed oral steroids. The uveitis attack use to flare up on tapering the steroids. In the hope to reduce the recurrences and to prevent long-term complications, the patient was shifted to oral methotrexate (12.5 mg) weekly with folic acid supplementation. On the basis of clinical examination and B- scan a presumptive diagnosis of endogenous endophthalmitis was made. Vitreous tap revealed a straw colored sample and the culture subsequently grew methicillin sensitive Staphylococcus epidermidis. Intravitreal injection of (Piperacillin+Tazobactum) 225 microgram in 0.1 ml was administered. In addition, intravenous (piperacillin+tazobactum) 4.5 gram BD was given for 3 days. Post intra vitreal injection the symtoms and signs resolved remarkably. Methotrexate has not been previously implicated with endogenous endophthalmitis. Besides, Endogenous endophthalmitis is an ongoing diagnostic and therapeutic dilemma for ophthalmologists as it is relatively rare and often presents like uveitis. It requires a high index of suspicion for prompt diagnosis and treatment. The treatment of EE is still controversial due to a lack of clinical trials. Future large group studies need to be done for validation of the above therapeutic regime.

Large midline persistent parietal foramina with occipital encephalocele and abnormal venous drainage

Enlarged persistent parietal foramen is rare congenital skull defect and associated anomalies like underlying encephalomalacia, and venous malformations are known. We here report a very rare association with persistent occipital foramina and occipital encephalocele. This patient presented later in life with complaints of headache and seizure. Basic clinical examination like palpation of scalp was helpful in diagnosing this rare condition. Radiological investigations later revealed an array of associated congenital abnormalities like hypoplastic inferior sagittal sinus, which is even rare finding in a single case.

Prevalence of congenital heart diseases in Koranic schools (daara) in Dakar: a cross-sectional study based on clinical and echocardiographic screening in 2019 school children

Congenital heart diseases are one of the major cardiovascular diseases in developing countries. Most prevalence studies were based on clinical examination of children with echocardiographic confirmation of suspected cases and underestimate its prevalence. The objective of this study was to investigate the prevalence of congenital heart disease in "daara" (Koranic schools) in the city of Dakar and its suburbs on the basis of clinical examination and Doppler echocardiography in school children. This cross-sectional survey was carried out from 9(th) August to 24(th) December 2011, and included a population of 2019 school children aged 5 to 18 years in 16 selected "daaras" under the Academic Inspectorate of Dakar and its suburbs. Anamnestic, clinical and echocardiographic data were recorded in a validated questionnaire. A p < 0.05 was considered to be statistically significant in bivariate analysis. 2 019 school children were included out of which 60.1% were male (sex-ratio: 0.66). The average age was 9.7 years (± 3.3 years). 18 cases of congenital heart diseases were detected being a prevalence of 8.9 per 1 000 (95 % CI: 1.8 to 7.9). This included 6 cases of inter-atrial septal aneurysm, 5 cases of peri-membranous ventricular septal defects, 4 cases of patent ductusarteriosus and 3 cases of tetralogy of Fallot. Factors correlated with the presence of congenital heart disease were ageless than 8 (p <0.001) and residence in the suburbs of Dakar (p <0.001). We also detected 10 cases of rheumatic valvular disease, a prevalence of 4.9 per 1 000 (95% CI: 2.4 to 9.1). Our study shows a high prevalence of congenital heart diseases, which is almost identical to the WHO estimates and that ultrasound screening is more sensitive than clinical screening. Reducing the prevalence of these diseases requires implementation of appropriate policies, focusing on awareness and early detection.

English

Arthrofibrosis following total knee arthroplasty is an uncommon complication defined as less than 80 degrees of knee flexion 6-8 weeks post operatively. It is characterized by abnormal scarring of the joint in which the formation of dense fibrous tissue and tissue metaplasia prevent normal range of motion. Clinical features include limited knee Range of motion with extension deficit, pain with activities of daily living and unusual amount of pain and swelling post operatively in the absence of infection, bleeding or mechanical complications. We present case of 55 years old female who undergone for total knee replacement before 3 months and presented to our department with complain of knee pain and swelling with activities of daily living. She was diagnosed on the basis of clinical examination. Her detailed evaluation was carried out and Physiotherapy treatment was started.

Allergen Skin Prick Testing in Early Childhood: Reproducibility and Prediction of Allergic Symptoms into Early Adulthood

To assess the predictive value of skin prick testing in early childhood on subsequent allergic symptoms up to adult age. A cohort of 200 unselected healthy newborns was prospectively followed from birth to 20 years of age. Of them, 163 (82%) were reassessed at age 5 years, 150 (76%) at age 11 years, and 164 (83%) at age 20 years with a skin prick test that included 11 common allergens. On the basis of clinical examination and structured interview, the occurrence of atopic dermatitis, allergic rhinoconjunctivitis, recurrent wheezing, and symptoms of food hypersensitivity were recorded at each of the follow-up visits. The reproducibility of skin prick test positivity at age 5 years was 100% at ages 11 and 20 years, ie, none of the skin prick-positive subjects turned negative during the follow-up. Gaining of new sensitizations to aeroallergens was common. Skin prick test positivity at age 5 years predicted allergic symptoms at ages 11 (sensitivity 28%, specificity 94%) and 20 years (sensitivity 23%, specificity 91%) but not atopic dermatitis. Skin prick test positivity at age 5 years strongly predicts later skin prick test positivity and is associated with respiratory symptoms, ie, allergic rhinoconjunctivitis and recurrent wheezing, at ages 11 and 20 years. However, skin prick test negativity at age 5 years does not exclude sensitization and allergic symptoms at a later age.

Phenotyping heterozygous carriers of juvenile neuronal ceroid lipofuscinosis with CLN3 mutations.

The objective of this study was to establish an ophthalmologic phenotype of heterozygous carriers of juvenile neuronal ceroid lipofuscinosis (CLN3 disease, Batten disease). The eyes and vision of nine heterozygous carriers of juvenile neuronal ceroid lipofuscinosis with classical CLN3 mutations were examined using the following methods: clinical examination, visual acuity, ophthalmoscopy, optical coherence tomography (macular thickness and peripapillary retinal nerve fibre layer measurement [RNFL]), fundus autofluorescence measurement, infrared imaging, and full-field and multifocal electroretinogram. Optical coherence tomography and electrophysiological data were statistically compared with age- and sex-matched control groups. The basic clinical examination as well as the fundus autofluorescence and infrared images of the macular region were unremarkable. Neither the electrophysiological examinations nor optical coherence tomography yielded fundamental abnormalities. There were only two significant-albeit most likely clinically irrelevant-differences that occurred in comparison to the control group: a decrease in RNFL of the nasal quadrant in the OCT and a prolongation of the N1 implicit time of the second-ring eccentricity in the multifocal electroretinogram. The eyes and vision of heterozygous carriers of CLN3 disease showed normal features when compared to a control group, which controverts a previously suggested retinal dysfunction in these subjects.

Therapeutic interventions in oral submucous fibrosis: an experimental and clinical study.

Oral submucous fibrosis (OSF) is a chronic debilitating disease and premalignant condition of the oral cavity and is a serious public health issue in India and many parts of the world. The treatment is still elusive and empirical because of poorly understood etiopathogenesis, which is believed to be multifactorial including areca nut chewing, ingestion of chillies, genetic and immunologic processes, nutritional deficiencies, and many others. The present investigations was focused to understand the possible therapeutic interventions of anti-OSF agents in arecoline induced experimental in vitro model of OSF and clinical application of these anti-OSF agents in the restoration of various grade of the disease. The 127 subjects were selected from patients who visited the OPD of Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, K.G. Medical University, Lucknow. Further the subjects were divided in two groups on the basis of clinical examination. Group-1 subjects showed presence of fibrosis bands in the labial and/or buccal mucosa, loss of elasticity, difficulty to open the mouth and had a habit chewing areca-nut in some form. Group-2 subjects had no habit of chewing areca-nut, were apparently healthy with no mucosal disorder. The samples were collected and were immediately transported to Indian Institute of Toxicology Research, Lucknow, for isolation and cultivation of primary cultures of mucosal fibroblast cells. Then isolation and cultivation of oral mucosal fibroblast, identification of non-cytotoxic doses of arecoline, real time PCR, immunocytochemistry, cytokine determination in culture cells, western blot analyses, functional activity of collagenase, lysyl oxidase enzyme activity, collagen beads assay, cyclooxygenase (COX-2) expression analysis was done. This study, shows that the reduction of phagocytic cells was strongly related to the arecoline levels in fibroblast culture when we exposed arecoline to normal oral mucosal cells (NOMC) and cells from OSF patient. An enhancement of phagocytic cells was observed following the pre exposure of cells to 1μM dexamethasone, a glucocorticoids, In this study, histologic evidence is presented which supports the finding that COX-2 expression is upregulated in OSF specimens compared to normal oral submucosal cells. Strong immunostaining for COX-2 was detected in arecoline exposed NOMC and cells from OSF patient. Areca nut extract up-regulates prostaglandin production, cyclooxygenase-2 mRNA and protein expression of human oral keratinocytes. The number of phagocytic cells and phagocytic activity in cultured human oral fibroblasts from OSF site was lower than the fibroblasts from the normal regions of the same person.

Need for Level V Neck Dissection in T3‐T4 Oral Squamous Cell Carcinoma

Objectives: (1) Recognize the frequency of level V neck node involvement in T3-T4 oral squamous cell carcinoma. (2) Analyze the need of level V neck dissection with N0 - N1 neck in T3-T4 oral squamous cell carcinoma (SCC). Methods: Noninterventional, descriptive study from January 2011 to August 2012 at Dow University of Health Sciences &amp; Civil Hospital Karachi, Pakistan, a tertiary care teaching hospital. Sampling was nonprobability and purposive. Histopathologically proven cases of squamous cell carcinoma of oral cavity with T3-T4 lesion and N0-N1 neck on basis of clinical examination and computed tomography scan findings were included in this study. All patients underwent modified radical neck dissection type-I along with excision of the primary growth. Results: Forty-nine patients fulfilling selection criteria were assessed on the basis of histopathological reports. At level I, metastatic lymph nodes were positive in 12 patients; 4 had positive nodes at level II and 2 each at level III and IV. However, none were positive at level V. Primary lesion was involving cheek in 40 and tongue in 9 cases. Histopathology revealed moderately differentiated SCC in 33 and well-differentiated SSC in 16 patients. Conclusions: Our study suggests that level V neck dissection is not needed in oral SCC with N0-N1 neck even in T3-T4 lesions. However, as the sample size is small, further study with a larger number of cases is required to establish future guidelines for the extent of neck node clearance in oral cancer.

Prospects for management of ischemia and reperfusion

*Despite all of the advances that have been achieved by researchers into the pathophysiology of ischemia and reperfusion (I/R), there is still a great deal to be investigated. Enormous challenges remain in understanding the mechanisms of injury and, clearly, in introducing new treatments. Faced with a patient with acute ischemia of an extremity, the vascular surgeon’s greatest concern will always be to achieve successful revascularization, while bearing in mind the risks involved in this procedure in more serious situations. It is very difficult to determine the limit of cell viability, particularly on the basis of clinical examination and this fact is the reason that surgeons tend to favor revascularization in attempts to salvage