Odontogenic keratocyst located in the retromolar trigone.

Odontogenic keratocysts (OKCs) are a commonly occurring, benign cystic intraosseous lesion thought to arise from the cell rests of the dental lamina. Most instances of OKC are commonly found in the posterior aspect of the mandible. In rare instances, there have been reported cases of OKCs arising in the peripheral gingiva, but these cases are few and far between. Rarer still are the few documented cases of OKCs arising in other soft tissues of the mouth. There are many divided opinions on the diagnosis of these lesions and whether they are truly odontogenic in origin, given their location when they are enucleated from a soft tissue area. To the best of our knowledge, we present the first reported case of a patient with a peripheral OKC located in the retromolar trigone. We discuss this unique case and review the current literature on peripheral OKCs.

Repurposing a fracture risk calculator (FRAX) as a screening tool for women at risk for sarcopenia.

Osteoporosis and sarcopenia share risk profiles, so we tested a fracture risk assessment tool (FRAX) as a screening tool for sarcopenia. FRAX probabilities without bone mineral density predicted sarcopenia with high sensitivity and reasonable specificity. There is potential to use this FRAX as a screening tool for sarcopenia. PURPOSE: There is a need for simple screening tools for sarcopenia. As osteoporosis and sarcopenia share risk profiles, we tested the performance of a fracture risk assessment tool for discriminating individuals at risk for sarcopenia. METHODS: In this longitudinal study, FRAX (Australia) probabilities were calculated for 354 women (ages 40-90 years) in the Geelong Osteoporosis Study. Sarcopenia was assessed a decade later using DXA-derived low appendicular lean mass (Lunar; ALM/height2 < 5.5 kg/m2) and low handgrip strength (Jamar; HGS < 16 kg), according to EWGSOP2. We determined FRAX probabilities (%) for hip fracture (HF-FRAX) and major osteoporotic fracture (MOF-FRAX), with and without BMD. Area under the receiver operator characteristic (AUROC) curves quantified the performance of FRAX for predicting sarcopenia. RESULTS: Baseline median (IQR) values for HF-FRAX without BMD were 0.4 (0.1-1.3) and for MOF-FRAX without BMD, 2.4 (1.2-5.2); comparable figures for HF-FRAX with BMD were 0.2 (0.0-0.7) and for MOF-FRAX with BMD, 2.1 (1.1-4.4). At follow-up, sarcopenia was identified for 11 (3.1%) women. When FRAX was calculated without BMD, the AUROC was 0.90 for HF-FRAX and 0.88 for MOF-FRAX. Optimal thresholds were 0.9 for HF-FRAX (sensitivity 90.9%, specificity 62.4%) and 5.3 for MOF-FRAX (sensitivity 81.8%, specificity 71.7%). Calculating FRAX with BMD did not improve the predictive performance of FRAX for sarcopenia. CONCLUSION: Here we provide preliminary evidence to suggest that FRAX probabilities without BMD might predict sarcopenia with high sensitivity and reasonable specificity. Given that FRAX clinical risk factors are identified without equipment, there is potential to use this or a modified version of the FRAX tool to screen for individuals at risk of sarcopenia.

How well do the FRAX (Australia) and Garvan calculators predict incident fractures? Data from the Geelong Osteoporosis Study.

This study reports that both FRAX and Garvan calculators underestimated fractures in Australian men and women, particularly in those with osteopenia or osteoporosis. Major osteoporotic fractures were poorly predicted, while both calculators performed acceptably well for hip fractures. INTRODUCTION: This study assessed the ability of the FRAX (Australia) and Garvan calculators to predict fractures in Australian women and men. METHODS: Women (n = 809) and men (n = 821) aged 50-90 years, enrolled in the Geelong Osteoporosis Study, were included. Fracture risk was estimated using FRAX and Garvan calculators with and without femoral neck bone mineral density (BMD) (FRAXBMD, FRAXnoBMD, GarvanBMD, GarvannoBMD). Incident major osteoporotic (MOF), fragility, and hip fractures over the following 10 years were verified radiologically. Differences between observed and predicted numbers of fractures were assessed using a chi-squared test. Diagnostics indexes were calculated. RESULTS: In women, 115 MOF, 184 fragility, and 42 hip fractures occurred. For men, there were 73, 109, and 17 fractures, respectively. FRAX underestimated MOFs, regardless of sex or inclusion of BMD. FRAX accurately predicted hip fractures, except in women with BMD (20 predicted, p = 0.004). Garvan underestimated fragility fractures except in men using BMD (88 predicted, p = 0.109). Garvan accurately predicted hip fractures except for women without BMD (12 predicted, p < 0.001). Fractures were underestimated primarily in the osteopenia and osteoporosis groups; MOFs in the normal BMD group were only underestimated by FRAXBMD and fragility fractures by GarvannoBMD, both in men. AUROCs were not different between scores with and without BMD, except for fragility fractures predicted by Garvan in women (0.696, 95% CI 0.652-0.739 and 0.668, 0.623-0.712, respectively, p = 0.008) and men, which almost reached significance (0.683, 0.631-0.734, and 0.667, 0.615-0.719, respectively, p = 0.051). Analyses of sensitivity and specificity showed overall that MOFs and fragility fractures were poorly predicted by both FRAX and Garvan, while hip fractures were acceptably predicted. CONCLUSIONS: Overall, the FRAX and Garvan calculators underestimated MOF and fragility fractures, particularly in individuals with osteopenia or osteoporosis. Hip fractures were predicted better by both calculators. AUROC analyses suggest that GarvanBMD performed better than GarvannoBMD for prediction of fragility fractures.

Vitamin D during pregnancy and offspring body composition: a prospective cohort study.

BACKGROUND: Evidence regarding the association between gestational vitamin D status and offspring body composition during childhood is inconsistent. Therefore, we aimed to determine the association between maternal vitamin D and offspring lean and fat mass in the Vitamin D in Pregnancy birth cohort. METHODS: Subjects were mother-child pairs recruited from the Australian-based Vitamin D in Pregnancy cohort study. Mothers were recruited before 16 weeks' gestation and provided a blood sample at both recruitment and at 28-32 weeks' gestation. Serum vitamin D [25(OH)D] was measured by radioimmunoassay (Tyne and Wear, UK). Offspring lean and fat mass were quantified by using dual-energy X-ray absorptiometry (GE Lunar Prodigy, Madison, WI, USA) at 11 years of age. RESULTS: Median maternal 25(OH)D levels were 55.9 (42.2-73.3) and 56.1 (43.6-73.9) at recruitment and 28-32 weeks' gestation, respectively. Maternal smoking was identified as an effect modifier in the association between maternal vitamin D status at recruitment and offspring body composition. In smokers, but not non-smokers, serum 25(OH)D status at recruitment was negatively associated with offspring fat mass percentage and positively associated with lean mass (both p < 0.05). There was no association with 25(OH)D status at 28-32 weeks' gestation. CONCLUSIONS: Maternal vitamin D status in early pregnancy, in smokers, is associated with offspring body composition. These important findings warrant confirmation in larger studies and trials.

Prediction of major osteoporotic and hip fractures in Australian men using FRAX scores adjusted with trabecular bone score.

There was no significant difference between the areas under receiver operating characteristics (AUROCs) and diagnostic indexes (sensitivity, specificity, positive predictive value, negative predictive value) for either major osteoporotic or hip fracture FRAX scores when comparing the unadjusted and trabecular bone score (TBS)-adjusted scores. INTRODUCTION: FRAX 10-year probability of fracture can be calculated with adjustment for the TBS. Studies have shown that TBS can improve FRAX assessments in some populations. This study aimed to determine if TBS-adjusted FRAX score is better than the unadjusted score for predicting major osteoporotic fracture (MOF) and hip fracture in Australian men. METHODS: This study involved 591 men aged 40-90 years, enrolled in the Geelong Osteoporosis Study. Incident MOF (n = 50) and hip fractures (n = 14) were ascertained using radiological reports. Median follow-up time was 9.5 years (IQR7.5-11.4). Diagnostic indexes were calculated using cut points of ≥20% for MOF and ≥3% for the hip. AUROC curves were also determined for adjusted and unadjusted scores as continuous variables. RESULTS: Sensitivity was higher in the TBS-adjusted scores (MOF 4%, hip 78.6%) than the unadjusted scores (MOF 2%, hip 57.1%), with a decrease in specificity (MOF 98.9 vs 99.3%; hip 79.9 vs 83.9%). When considering TBS-adjusted and unadjusted FRAX as continuous scores, AUROCs were 0.738 and 0.740, respectively, for MOF and 0.849 and 0.848 for the hip. CONCLUSIONS: Prediction of fractures by MOF or hip FRAX was not substantially improved by TBS adjustment. There was no difference in AUROCs or diagnostic indexes for cut-off points of ≥20 for MOF and ≥3% for hip FRAX.

Maternal vitamin D and offspring trabecular bone score.

No studies have explored the relationship with maternal vitamin D (25(OH)D) in pregnancy and offspring trabecular bone score (TBS). Our data suggest that maternal 25(OH)D in early pregnancy, but not late, may be associated with offspring TBS in boys. These data act as hypothesis-generating findings for confirmation in larger, longer-term studies. INTRODUCTION: Trabecular bone score (TBS), a novel tool derived from dual-energy X-ray absorptiometry (DXA), reflects the microarchitecture of the vertebrae. It has been shown to predict fracture independent of standard DXA parameters in adult populations. Previously, we demonstrated that maternal serum 25-hydroxyvitamin D (25(OH)D) during pregnancy is associated with offspring bone mineral content at age 11 years. However, associations with TBS have not been explored, thus we aimed to determine associations between maternal 25(OH)D and offspring TBS. METHODS: Data were collected from the Vitamin D in Pregnancy (VIP) study. Venous blood samples were taken at recruitment and at 28-32 weeks' gestation. Maternal 25(OH)D was measured by radioimmunoassay. Offspring (n = 195, n = 181 with complete measures) underwent spine DXA (GE Lunar), at age 11 years (median = 10.9 (IQR 10.9-11.4)). TBS was calculated using TBS iNsight software. RESULTS: Offspring of mothers with sufficient 25(OH)D levels (≥50 nmol/L) at recruitment had a higher TBS (1.363 vs. 1.340, p = 0.04). In multivariable linear regression models, after adjustment for child relative lean mass, sex and pubertal stage, a 10 nmol/L increase in maternal 25(OH)D was associated with a 0.005 (95% CI 0.000, 0.010, p = 0.04) increase in TBS. However when stratified by sex (p for interaction = 0.16), the association was significant in boys, but not girls. There were no associations with TBS and maternal 25(OH)D at 28-32 weeks. CONCLUSIONS: We speculate that maternal 25(OH)D in early pregnancy may be associated with TBS in offspring at age 11 in boys. These hypothesis-generating findings warrant confirmation with larger interventional and long-term follow-up studies.

Impact of p16 status on pro- and anti-angiogenesis factors in head and neck cancers.

BACKGROUND: Head and neck cancers (HNC) are aggressive tumours. Overexpression of p16 in HNC correlates with human papilloma virus (HPV)-associated HNC that carry a better prognosis than HPV-negative tumours. Angiogenesis is an important factor in tumour progression. Our aim was to dissect the impact of p16 expression on angiogenesis factors in HNC. METHODS: Eighteen newly diagnosed HNC patients and controls were analysed. Eleven pro- and anti-angiogenesis factors were quantified using multiplex ELISA in HNC patients and controls. Angiogenesis factors were analysed in tumour tissue using immunohistochemistry. RESULTS: Circulating levels of endostatin (anti-angiogenesis factor) were higher in the HNC group compared with healthy donors. Interestingly, the pro-angiogenesis factors angiopoietin-1 and vascular endothelial growth factor (VEGF) were significantly higher in patients with p16-negative compared with p16-positive HNC. Moreover, the major source of VEGF in p16-positive HNC tissue was tumour stromal cells. In contrast, both tumour cells and stromal cells expressed VEGF in p16-negative tissue. CONCLUSIONS: We show that p16-negative tumours associate with increased circulating levels of pro-angiogenic VEGF and angiopoietin-1. Tissue expression of VEGF differs between p16-positive and p16-negative tumours. These findings may explain differences in the biological behaviour of p16-positive and p16-negative HNC. Better understanding of mechanisms by which the p16 status influences tumour angiogenesis may guide the development of targeted therapies.

Not just another paediatric neck lump: metastatic cribriform adenocarcinoma of the palate in an adolescent.

OBJECTIVE: This paper reports the case of a 13-year-old girl with a 2-year history of left cervical lymph node swelling that was diagnosed as metastatic cribriform adenocarcinoma of the tongue and minor salivary gland. CASE REPORT: A 13-year-old girl with a left, level II cervical lymph node underwent excisional biopsy after an ultrasound suggested suspicious features. The histology indicated polymorphous low-grade adenocarcinoma, and a primary lesion in the left palate was identified. The patient underwent left maxillectomy, neck dissection and reconstruction. Histological analysis of resection specimens led to a revised diagnosis of cribriform adenocarcinoma of the tongue and minor salivary gland. CONCLUSION: Cribriform adenocarcinoma of the tongue and minor salivary gland has recently been described as a separate entity to polymorphous low-grade adenocarcinoma in light of histological and behavioural differences, including higher rates of metastasis at presentation. This is the first report in the world literature of an adolescent with this entity. It is possible that some previous reports of polymorphous low-grade adenocarcinoma in childhood would have been more accurately described as cribriform adenocarcinoma of the tongue and minor salivary gland.

Superficial granulomatous pyoderma treated preoperatively with infliximab.

We report a case of superficial granulomatous pyoderma (SGP) treated successfully with infliximab. A 71-year-old woman developed erythema, erosions and cribriform scarring in the right periorbital area following enucleation of the right eye. Histology showed three-layered granulomas typical of SGP. The patient's disease was unusual in that it failed to respond to a wide variety of immunosuppressants and this condition is rarely reported to affect the face. Eventually she was treated successfully with infliximab, enabling her to undergo extensive surgery despite the fact that her disease was pathergic in onset.

A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography.

OBJECTIVES: Pre-operative staging of the clinically N(0) neck in patients with oral squamous cell carcinoma is hindered by the relatively high false negative/positive rates of conventional imaging techniques. The aim of this study is to evaluate the utility of (18)F-fluoro-deoxy-glucose (FDG) positron emission tomography (PET) and sentinel lymph node (SLN) imaging and biopsy to determine the true disease status of the loco-regional lymphatics. METHODS: Nineteen patients with biopsy proven disease without palpable or radiological evidence of neck metastases underwent pre-operative (18)F-FDG PET and SLN imaging. All patients underwent whole-body FDG PET and a single view of the head and neck. SLN technique was performed using four peri-tumoural injections of (99m)Tc labeled albumin colloid each of 10 MBq. Dynamic and static imaging followed in the antero-posterior and lateral projections. At operation 1 ml of 2.5% Patent Blue Dye and a hand held gamma probe (Neoprobe 1500) were used in combination to identify and remove the SLN. Surgery then continued along conventional lines including a neck dissection. Histology of the resultant specimen was correlated with that of the SLN and pre-operative imaging. RESULTS: In all patients SLN harvesting was feasible. In 15/19 patients the SLN(s) and the residual neck dissection were -ve for tumour. In 3/19 patients the SLN(s) were +ve for tumour as were other neck nodes. In 1/19 patients the SLN was -ve but another single tumour +ve node was identified in the neck. This patient occurred early in our series with a SLN close to the primary tumour. (18)F-FDG PET failed to identify nodal disease in all four patients with histologically proven lymph node metastases. The size of these nodes ranged from 12 mm x 10 mm x 3 mm to 25 mm x 15 mm x 10 mm. CONCLUSION: SLN imaging and biopsy with probe and Patent Blue Dye guided harvest is feasible in patients with oral squamous cell carcinoma and can predict cervical nodal status. (18)F-FDG PET may be less useful.

The role of open reduction and internal fixation in unilateral fractures of the mandibular condyle: a prospective study.

The purpose of this report is to present our experience in the management of unilateral condylar fractures between 1995 and 1998. This prospective study was carried out at a Regional Maxillofacial Unit and Teaching Hospital in the UK, and included 54 patients, of whom 32 attended for review. In all, 42 men and 12 women (age range 17-40 years) entered the study: 28 patients had unilateral fractures of the mandibular condyle alone; the remainder also had another mandibular fracture, invariably at the parasymphysis. Thirty-five of the patients (65%) had allegedly been assaulted. This is at variance with a recent study published by the British Association of Oral and Maxillofacial Surgeons, which showed that only 24% of facial injuries were the result of inter-personal violence. Open reduction and internal fixation of the mandibular condyle seems to carry low morbidity and may be of considerable functional benefit to the patient.

Hearing loss associated with maxillectomy.

Little has been reported about the effect on auditory tube function of ablative surgery for maxillary neoplasms. Operations on the muscles of the soft palate may cause conductive hearing loss by impairing the opening of the auditory tube, which results in a middle ear effusion. Sensorineural hearing loss may also follow adjuvant radiotherapy. In this retrospective study we aimed to assess hearing status in patients who had undergone maxillary surgery for neoplastic disease between 1987 and 1997. Data recorded included personal details, site and size of lesion, treatment, and histology. Thirty-eight patients were identified, of whom 26 had survived and were contacted. Seventeen of the 26 had had part of the soft palate excised. All patients underwent tympanometry and had a pure tone audiogram. Audiograms showed an air-bone gap of > 10 dB in the ear on the side of the operation in 11 of those 17 patients. All 17 patients who had had soft palate resections had evidence of auditory tube insufficiency on tympanometry. Seven of the nine patients who had had radiotherapy had substantial sensorineural hearing loss. We conclude that conductive hearing loss is dependent on the site of resection; tympanometry is a sensitive test of middle ear function; sensorineural hearing loss may often follow radiotherapy; and audiological assessment is essential both before and after operation in patients having maxillary resections.

Determination of underivatised efaroxan and idazoxan in blood plasma by capillary gas chromatography with mass-selective detection.

Sensitive and specific methods for the determination of efaroxan and idazoxan in blood plasma have been developed based on solvent extraction, chromatographic separation and quantification by selected-ion monitoring using a quadruple mass-selective detector. The use of a short non-polar bonded-phase capillary gas chromatography (GC) column facilitated rapid separation of the compounds of interest from internal standards, metabolites and endogenous material. Of equal significance was the ability to chromatograph these basic compounds without prior derivatisation. The application of bonded-phase capillary GC coupled to selected-ion monitoring resulted in robust analytical procedures with sub-ng ml(-1) sensitivity and high selectivity.

Nonpharmacy outlets providing prescription medications to ambulatory patients.

Nonpharmacy outlets providing prescription medication to ambulatory patients in Alachua County, Florida, were investigated. The sample included 16 ambulatory clinics and 44 dispensing physicians. The types of medications dispensed and dispensing procedures used by these outlets are described. The magnitude of prescription drug dispensing in ambulatory clinics and physicians' offices was far greater than was initially expected. Numerous drug-related problems were identified within these outlets, including a failure to comply with state and federal laws, inadequate drug control and storage, and inadequate patient medication records. Practicing pharmacists should consider the possibility of their patients receiving medication from similar outlets in evaluating therapies for appropriateness and interactions. In addition, such centers have apparent need for pharmacy consultation services to ensure adherence to the principles of responsible pharmaceutical services.