Management of isolated mandibular body fractures in adults

Objective@#The mandible is the most common fractured craniofacial bone of all craniofacial fractures in the Philippines, with the mandibular body as the most involved segment of all mandibular fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and management of mandibular body fractures in particular. General guidelines include the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic Review on interventions for the management of mandibular fractures. On the other hand, a very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and management, this clinical practice guideline focuses on the management of isolated mandibular body fractures in adults.@*Purpose@#This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as well as primary care and specialist physicians, nurses and nurse practitioners, midwives and community health workers, dentists, and emergency first-responders) who may provide care to adults aged 18 years and above that may present with an acute history and physical and/or laboratory examination findings that may lead to a diagnosis of isolated mandibular body fracture and its subsequent medical and surgical management, including health promotion and disease prevention. It is applicable in any setting (including urban and rural primary-care, community centers, treatment units, hospital emergency rooms, operating rooms) in which adults with isolated mandibular body fractures would be identified, diagnosed, or managed. Outcomes are functional resolution of isolated mandibular body fractures; achieving premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing use of ineffective interventions; avoiding co-morbid infections, conditions, complications and adverse events; minimizing cost; maximizing health-related quality of life of individuals with isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in patients and occurrence in others.@*Action Statements@#The guideline development group made strong recommendationsfor the following key action statements: (6) pain management- clinicians should routinely evaluate pain in patients with isolated mandibular body fractures using a numerical rating scale (NRS) or visual analog scale (VAS); analgesics should be routinely offered to patients with a numerical rating pain scale score or VAS of at least 4/10 (paracetamol and a mild opioid with or without an adjuvant analgesic) until the numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- prophylactic antibiotics should be given to adult patients with isolated mandibular body fractures with concomitant mucosal or skin opening with or without direct visualization of bone fragments; penicillin is the drug of choice while clindamycin may be used as an alternative; and (14) prevention- clinicians should advocate for compliance with road traffic safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor vehicle, cycling and pedestrian accidents and maxillofacial injuries.The guideline development group made recommendations for the following key action statements: (1) history, clinical presentation, and diagnosis - clinicians should consider a presumptive diagnosis of mandibular fracture in adults presenting with a history of traumatic injury to the jaw plus a positive tongue blade test, and any of the following: malocclusion, trismus, tenderness on jaw closure and broken tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray as the initial imaging tool in evaluating patients with a presumptive clinical diagnosis; (3) radiographs - where panoramic radiography is not available, clinicians may recommend plain mandibular radiography; (4) computed tomography - if available, non-contrast facial CT Scan may be obtained; (5) immobilization - fractures should be temporarily immobilized/splinted with a figure-of-eight bandage until definitive surgical management can be performed or while initiating transport during emergency situations; (8) anesthesia - nasotracheal intubation is the preferred route of anesthesia; in the presence of contraindications, submental intubation or tracheostomy may be performed; (9) observation - with a soft diet may serve as management for favorable isolated nondisplaced and nonmobile mandibular body fractures with unchanged pre - traumatic occlusion; (10) closed reduction - with immobilization by maxillomandibular fixation for 4-6 weeks may be considered for minimally displaced favorable isolated mandibular body fractures with stable dentition, good nutrition and willingness to comply with post-procedure care that may affect oral hygiene, diet modifications, appearance, oral health and functional concerns (eating, swallowing and speech); (11) open reduction with transosseous wiring - with MMF is an option for isolated displaced unfavorable and unstable mandibular body fracture patients who cannot afford or avail of titanium plates; (12) open reduction with titanium plates - ORIF using titanium plates and screws should be performed in isolated displaced unfavorable and unstable mandibular body fracture; (13) maxillomandibular fixation - intraoperative MMF may not be routinely needed prior to reduction and internal fixation; and (15) promotion - clinicians should play a positive role in the prevention of interpersonal and collective violence as well as the settings in which violence occurs in order to avoid injuries in general and mandibular fractures in particular.

Fungal pneumaturia: A case report on a large urinary bladder fungal bezoar in a young diabetic male

@#Fungal bezoars or fungus balls are extremely rare cases especially when they occur within the urinary tract. Reported here is a 26-year old diabetic male presenting with pneumaturia, passage of debris per urethra and lower urinary tract symptoms. He was initially managed as a case of enterovesical fistula. Further work-up revealed a urinary bladder fungal bezoar. The patient was managed by endoscopic morcellation and evacuation of the fungal ball from the bladder and anti-fungal therapy. Awareness of this rare clinical entity and its presentation will aid in its proper diagnosis and management.

Effect of alkaloids extract of Gnetum africanum on serum enzymes levels in albino rats.

Alkaloids extract of the leaf of Gnetum africanum pretreatment was investigated on the activities of aspartate amino transaminase (AST), alanine amino transaminase (ALT) and alkaline phosphatase (ALP) serum and tissue levels in rats. The alkaloids extract was soxhlet extracted following a modified standard procedure. Acute toxicity of the extract was carried out in male rats to determine two tolerated doses used in investigation. Thirty adult male rats were divided into three groups (n=10). Group one received normal saline (0.85%Nacl) as control; groups two and three received alkaloids extract of Gnetum africanium, 12 and 800mg/kg/d, for 3 and 31 days respectively. At the end of each treatment course, the rats were sacrificed 24h after last dose and blood samples collected through cardiac puncture into non-haperinized tubes, allowed to clot for 30 min and sera obtained by ultra iced-centrifugation. The biological activities of AST, ALT and ALP were measured by enzyme kits method. Histopathology of rat liver tissues of all treated groups were carried out. The alkaloids extract pretreatment for 3 days did not significantly alter serum and tissue enzymes levels of AST and ALT but significantly reduced the activity of ALP. However, subchronic treatments for 31 days significantly reversed the inhibitory effect of the extract on AST, ALT and ALP respectively. Histopathology of the rat liver morphology of all the treated groups showed no disorder. The observation allows conclusion that alkaloids extract of the leaf of Gnetum africanum is non hepatoxic.

Small babies on a small island: survival of very low birthweight infants in Antigua and Barbuda 1986 to 2006 / Bebés pequeños en islas pequeñas: supervivencia de infantes con muy bajo peso al nacer en Antigua y Barbuda, de 1986 a 2006

INTRODUCTION: Recent attention has been focussed on pregnancy outcomes in developing countries, with the publication of the World Health Organization Report 2005, Make Every Mother and Child Count and the Neonatal Survival Series from the Lancet in 2005. Scant outcome data from the smaller islands of the Caribbean exist for very low birthweight (VLBW) babies (birthweight < 1500 g). PATIENTS AND METHODS: a retrospective review of mortality data on vlbw babies in antigua and barbuda was performed. antigua and barbuda had a population of 71 500 with per capita income of (us) $6054 dollars in 1998. in november 1985, a neonatal special care nursery (scn) was established. the survival to discharge from scn for vlbw babies was reviewed from january 1986 to december 2006. RESULTS: there were 26 455 babies born from 1986 to 2006; 344 (1.3%) were vlbw babies. survival to scn discharge was 45% from 1986 to 1992, 46% from 1993 to 1999, and increased to 60% from 2000 to 2006 (p < 0.05 compared with the first two time-periods). babies from 1000 to 1499 g accounted for 64% of vlbw babies and survival to scn discharge was 60% from 1986 to 1992, 58% from 1993 to 1999, and increased to 83% from 2000 to 2006 (p < 0.01 compared with the first time period; p < 0.001 compared with the second). babies < 1000g accounted for 36% of VLBW babies and survival to SCN discharge was 10% from 1986 to 1992, increased to 25% from 1993 to 1999 and to 28% from 2000 to 2006 (trend of p < 0.10 compared with first time period). conservative newborn care only was available. antenatal steroids were given from 2000 to 2006. CONCLUSION: the outlook for vlbw babies using conservative newborn care techniques has significantly improved over 21-years in antigua and barbuda.

INTRODUCCIÓN: Recientemente se ha centrado la atención en los resultados del embarazo en los países en vías de desarrollo, a partir de la publicación del Informe 2005 de la Organización Mundial de la Salud, Que cada madre y cada niño cuente y la Serie de Supervivencia Neonatal de la Lancet en 2005. Son escasos los datos de resultados existentes en las islas más pequeñas del Caribe, acerca de los bebés con muy bajo peso al nacer (MBPN) (peso al nacer < 1500 g). PACIENTES Y MÉTODOS: se llevó a cabo una revisión retrospectiva de datos sobre la mortalidad de bebés mbpn en antigua y barbuda. antigua y barbuda tenían una población de 71 500 con un ingreso per cápita de $6054 usd en 1998. en noviembre de 1985, se creó una sala de cuidados especiales del Recién Nacido (SCN). La supervivencia en término de los bebés MBPN dados de alta de la SCN fue examinada de enero de 1986 a diciembre de 2006. RESULTADOS: De 1986 a 2006, hubo 26 455 bebés nacidos; de ellos 344 (1.3%) fueron bebés MBPN. La supervivencia en término de las altas de la SCN fue de 45% de 1986 a 1992, 46% de 1993 a 1999, y aumentó a 60% de 2000 a 2006 (p <0.05 en comparación con los primeros dos períodos de tiempo). Los bebés de 1000 a 1499g representaron el 64% de los bebés MBPN y la cifra de los supervivientes dados de alta del SCN fue de 60% de 1986 a 1992, 58% de 1993 a 1999, y aumentó a 83% de 2000 a 2006 (p < 0.01 en comparación con el primer periodo de tiempo; p <0.001 en comparación con el segundo). Los bebés <1000 g representaron el 36% de los bebés MBPN, y la supervivencia en términos de los dados de alta de la SCN fue 10% de 1986 a 1992, aumentó a 25% de 1993 a 1999, y a 28% de 2000 a 2006 (la tendencia de p <0.10 en comparación con el primer periodo de tiempo). Sólo hubo disponible atención neonatal conservadora Se administraron esteroides antenatales desde el año 2000 al 2006. CONCLUSIÓN: El pronóstico para MBPN usando técnicas de cuidado neonatal conservadoras ha mejorado significativamente a lo largo de 21 años en Antigua y Barbuda.

Endoscopic removal of chicken bone that caused gastric perforation and liver abscess.

A 40-yr-old gentleman presented with abdominal pain, nausea and vomiting since 3 weeks. CT scan of the abdomen showed a liver abscess but also a bone penetrating the left lobe of the liver. A 5-cm-long chicken bone was removed endoscopically. He was discharged on day 8 and was asymptomatic 12 months later. Endoscopic retrieval of an extraluminal foreign body causing liver abscess has not been reported previously.

Intravascular lymphoma of the inferior turbinate: An unusual rhinologic presentation of a rare neoplasm

Objective: To present a unique case of intravascular lymphoma of the inferior turbinate because of its rarity, unusual clinical presentation and difficulty in establishing a diagnosis. Design: Case Report Setting: A tertiary hospital Patient: A 66-year-old male admitted to the hospital due to intermittent high grade fever of six months duration. Result: The patient presented with fever of unknown origin, and exhaustive laboratory, ancillary procedures and biopsies to rule in/out infectious, autoimmune and oncologic causes were performed to arrive at a diagnosis. Nasal endoscopy revealed an enlarged, hypertrophied and violaceous right inferior turbinate with watery to mucoid discharge and septal deviation to the right confirmed by CT scans of the paranasal sinuses. Functional Endoscopic Sinus Surgery (FESS), septoplasty and turbinoplasty with biopsy revealed intravascular lymphoma. Chemotherapy was deferred due to the deteriorating medical condition and the patient expired seven months after the initial onset of symptoms. Conclusion: Patients who present with fever of unknown origin should undergo a thorough otorhinolaryngologic examination to exclude primary ENT conditions and ensure proper management. Given its rarity and multiplicity of presentation, it is extremely difficult to make a diagnosis of intravascular lymphoma. A high index of suspicion of intravascular lymphoma is necessary so that timely acquisition of tissue biopsy of any lesion involved will make a definite diagnosis. (Author)

Oto-drill (A prototype surgical drill unit)

OBJECTIVE: To design and produce a high quality, inexpensive surgical drill using locally available electronics. DESIGN: Descriptive (Instrument Design) SETTING: University based tertiary hospital MATERIALS AND METHODS: The surgical drill apparatus will use high quality electronics readily available locally which will make it cheaper than the other available units. This prototype unit was designed and tested by the author in collaboration with the Santo Tomas University Hospital Biomedical Engineers. The drill units schematics and specifications where patterned from the RAM Microtorque II drill unit which is produced in the U.S.A. RESULTS: The prototype is a cost effective alternative to the expensive drill units available in the market. It was given a 24 hour durability test which it passed with no loss of power or drilling efficiency proving that it can be used for major surgeries especially in the field of Otolaryngology and Neurosurgery. CONCLUSION: The OTODRILL is a cheap alternative and of comparable quality to expensive surgical drills available in the market which can be used in major surgeries in the field of Otolaryngology and other surgical fields. (Author)

Suture ligation technique in hemangioma of the head and neck

Intra-operative bleeding is what most surgeons want to avoid in any surgery. Excessive blood loss and compromise of vital structures are possible morbidities when this happens. This paper presents a method that will minimize intra-operative bleeding during excision of hemangiomas. "Suture ligation technique" is the application of simple interrupted overlapping sutures using silk 2.0 with an atraumatic needle around the hemangiomas prior to the skin incision. Although a number of cases have been done three were documented. It was observed that the technique provides a less bloody and clearer operative fields hence resulting in a faster and less stressful operation with lesser complications. (Author)

Did exclusive breast-feeding and early discharge lead to excessive bilirubin levels in newborns in Antigua and Barbuda?

Hyperbilirubinaemia is a common neonatal problem worldwide and is the leading cause of admission to the Special Care Nursery in Antigua and Barbuda. In 1990, the Innocenti Declaration in support of breast-feeding led to the adoption of the Baby-Friendly Hospital Initiative in many countries of the Caribbean, including Antigua and Barbuda. Comparing 1989 to the years 1992 to 1994, the Special Care Nursery at Holberton Hospital experienced a 40 increase in newborns admitted with hyperbilirubinaemia (peak total bilirubin > 12 mg/dl or 205 mumol/l). A retrospective review of Special Care Nursery and Maternity Ward records was undertaken to determine the incidence and aetiology of hyperbilirubinaemia from 1992 to 1994. There were 3721 infants born in Antigua and Barbuda in those years, 98 of Afro-Caribbean or mixed ancestry. The overall incidence of peak total bilirubin over 12 mg/dl (205 mumol/l) was 12.5 (466/3721), not inconsistent with the reported incidence of 8 to 20 in other countries. However, the incidence of higher levels of hyperbilirubinaemia in Antigua and Barbuda exceeded those reported for other countries. In Antigua and Barbuda, total bilirubin of 15 mg/dl (255 mumol/l) or higher was found in 263 of 3721 infants (7.1) compared to 5.9 in India and 2 of breast-fed infants in the United States of America (USA). Total bilirubin of 20 mg/dl (340 mumol/l) or higher was seen in 91 of 3721 infants (2.5) exceeding reported prevalence in the USA for both African-American and Caucasian infants (1) and equal to the reported prevalence in Asian infants (2). The possible aetiologies of hyperbilirubinaemia in neonates with total bilirubin 18 mg/dl (306 mumol/l) or higher in our patients were investigated. Medical records of 134 of 156 (86) infants having this level of hyperbilirubinaemia were available for review. The possible reason for hyperbilirubinaemia was ABO incompatibility in 4/134 (3), Rh incompatibility in 1/134 (1), prematurity in 12/134 (9) and sepsis neonatorum in 21/134 (16). The hyperbilirubinaemia was idiopathic in 96/134 (71) infants. Newborns in Antigua and Barbuda were discharged 3.7 days after their mothers' admission, with 50 discharged prior to 48 hours of age. Early discharge in developed countries has led to increased readmissions for hyperbilirubinaemia. Following the appointment of a dietitian to supervise breast-feeding, admissions for hyperbilirubinaemia fell by 50 by 1998. These data suggest that exclusive br

Developmental regulation of cytochrome P-450 (b+e) and glutathione transferase (Ya+Yc) gene expression in rat liver.

The expression of cytochrome P-450 (b+e) and glutathione transferase (Ya+Yc) genes has been studied as a function of development in rat liver. The levels of cytochrome P-450 (b+e) mRNAs and their transcription rates are too low for detection in the 19-day old fetal liver before or after phenobarbitone treatment. However, glutathione transferase (Ya+Yc) mRNAs can be detected in the fetal liver as well as their induction after phenobarbitone treatment can be demonstrated. These mRNAs contents as well as their inducibility with phenobarbitone are lower in maternal liver than that of adult nonpregnant female rat liver. Steroid hormone administration to immature rats blocks substantially the phenobarbitone mediated induction of the two mRNA families as well as their transcription. It is suggested that steroid hormones constitute one of the factors responsible for the repression of the cytochrome P-450 (b+e) and glutathione transferase (Ya+Yc) genes in fetal liver.

Using information about elderly subjects attending Government Medical Clinics to tailor nutrition education services to their needs

A study of the elderly was carried out in 2 Cornwall County parishes (Hanover and Westmoreland) from June to August, 1987. the health status and general situation of the elderly attending Government Medical Clinics was studied to obrain information to design nutrition education services that met their need. four Health Centres (two Type II and two Type III) were selected by stratified random sampling for the study. The results indicted that more elderly women (71%) than men (29%) used the Primary Health Care Services. Obesity was more common among women (29%) than men (0%). More men (30%) were underweight than women (9%). Food stamps appeared to be the most regular source of income for the elederly. Most of the elderly (92%) felt that they were not in good health. Although they generally had 2 to 3 meals per day, their food intake, particularly of fruits and peas, appeared to be inadequate. The results point clearly to a need to strengthen the education services offered to the elderly attending Government Medical Clinics in Cornwall County, Jamaica

Feeding practices of infants, and beliefs of mothers in Western Jamaica

An infant feeding survey was carried out in three parishes in Cornwall County, Jamaica, from March to August, 1984, in an attempt to determine the feeding practices of infants and beliefs of mothers in Western Jamica Forty-one Enumeration Districts (EDs were randomly selected from two strata. urban and rural, in proportion to the population distribution. Six hundred and fourteen households with children under 36 months of age were selected from 41 EDs. The results showed that prevalence of breastfeeding was 98.0%. Despite the high frequency of breastfeeding, infant formula was introduced very early, and only about half of the mothers introduced semi-solids and solids within one month of the recommended time. The most popular foods, identified as good foods, were also popular weaning foods. It is concluded that there is need for adequate rraining of both primary and secondary health-care staff, and reinforcemen of nutrition messages by frontline health workers. The collection of adequate baseline data in evaluating the effectiveness of nutrition education programmes is also important