Prosthetic joint infections of the shoulder: A review of the recent literature.

Introduction: Shoulder arthroplasty is a common treatment for shoulder arthritis. Prosthetic joint infection of the shoulder (PJIS) is a debilitating complication to the patient and the healthcare system. Incidence of infection is 0.98-5% for primary arthroplasty. The mean hospital cost for two-stage revision was approximately $35,824. The aim of this paper is to review the recent literature and collate the latest evidence to aid diagnosis and treatment of this serious complication. Methods: A literature review was performed using PubMed and Google Scholar databases. A search strategy was adopted using the keywords: 'infection' AND 'shoulder arthroplasty' OR 'total shoulder arthroplasty'OR 'TSA' OR 'reverse shoulder arthroplasty' OR 'RSA' OR 'rTSA'. This initial search resulted in 349 articles. A PRISMA flowchart process was followed. Duplicates were removed, screening was performed and the resulting full texts were analysed and further excluded, leaving 46 articles suitable for inclusion. A PICO search strategy was also used. Results and interpretation: Risk factors for PJIS include procedure type, trauma indications and patient factors.The organism commonly isolated is Cutebacterium acnes, which makes diagnosis challenging due to its indolent nature. Investigations include biochemical tests, synovial aspirate, tissue cultures and radiological examinations.Treatment depends on the depth of the infection and the patient requirements. Medical treatment with antibiotics to local debridement, cement spacer and revision arthroplasty have all been described in the literature. A multidisciplinary decision is made on the microbiological evidence and patient factors. Conclusion: PJIS is a rare but potentially devastating complication of shoulder arthroplasty and diagnosis is often challenging. There has been much research performed recently, providing more evidence on how to optimise management.

Proximal ulna fractures in adults: A review of diagnosis and management.

Proximal ulna fractures are relatively common upper limb injuries, which may represent fragility fractures or result from high-energy trauma. These include fractures of the olecranon, coronoid and associated radial head dislocations. A wide variety of treatment options are available for the management of these injuries that makes the selection of most appropriate treatment difficult. We aim to provide a brief overview of the treatment options for such injuries.

Results of a Standard versus an Accelerated Ponseti Protocol for Clubfoot: A Prospective Randomized Study.

BACKGROUND: The aim of this study was to compare the results of the standard once-weekly Ponseti casting technique to an accelerated twice-weekly regimen in our population cohort. METHODS: A prospective randomized controlled study was conducted with a total of 100 consecutive patients (158 feet) being enrolled for the study. Fifty patients were randomized to each group and followed up for at least one year. RESULTS: Initial mean Pirani score was 4.67 ± 0.73 in the standard group and 4.35 ± 0.76 in the accelerated group, and the score decreased to 0.34 ± 0.38 and 0.35 ± 0.31, respectively. Initial mean Dimeglio score was 11.75 ± 2.75 in the standard group and 10.51 ± 2.57 in the accelerated group, and the score decreased to 0.79 ± 0.77 and 0.79 ± 0.71, respectively, immediately after casting. The average number of casts required to correct all the deformities was 6.3 ± 1.2 in the standard group and 6.1 ± 1.4 in the accelerated group (p = 0.45). Average time spent in cast was 58.2 ± 8.3 days in the standard group and 39.5 ± 5.2 days in the accelerated group (p < 0.001). Percutaneous Achilles tendon tenotomy was done in 86.42% in the standard group and in 84.41% in the accelerated group (p = 0.72). Final results were assessed by using a modified functional rating scoring system: 55.55% clubfeet had excellent results and 44.45% had good results in the standard group, whereas 66.23% clubfeet had excellent results and 33.77% had good results in the accelerated group. None amongst the two groups had fair or poor results. CONCLUSIONS: These results suggest that the accelerated Ponseti technique significantly reduces the correction time without affecting the final results and that it is as safe and effective as the traditional Ponseti technique.

Pattern of sexually transmitted infections in a Muslim majority region of North India.

BACKGROUND: Changing trends of sexually transmitted infections (STI) and HIV/AIDS has been noted in the literature over years, depending to some extent on the geographical and cultural factors of the region. In Kashmir Valley also, the pattern of STI may be different from the rest of the country. AIMS OF THE STUDY: The aim was to present the experience with patterns of STI in Kashmir. MATERIALS AND METHODS: Retrospective hospital-based study carried out by detailed analysis of case records of 5-year period. RESULTS: A total of 184 patients, 100 males and 84 females, had specific STI. Genital ulcer disease was the presentation in 54 patients (29.35%), out of which herpes genitalis was found in 27 patients (50%), followed by chancroid in 13 (24.07%) and syphilis in 10 (18.52%) patients. 42 female patients (22.83%) presented with vaginal discharge, out of which, 24 (57.14%) had vaginal candidiasis. 24 males (13.04%) presented with urethral discharge, out of which, 15 (62.5%) had nongonococcal and 9 (37.5%) gonococcal urethritis. Genital molluscum contagiosum (MC) was found in 19 patients (10.33%), and warts in 15 (8.15%). HIV positive serology was detected in 3 patients (1.63%). CONCLUSION: The most common STI encountered in our study was genital ulcer, followed by vaginal discharge, urethritis, genital MC, and genital warts. Herpes genitalis was the commonest genital ulcer; candidiasis was the most common cause of vaginal discharge and nongonococcal urethritis the most common cause of urethritis. These findings are by and large similar to those noted in other parts of our country.

Assessment of esophageal involvement in systemic sclerosis and morphea (localized scleroderma) by clinical, endoscopic, manometric and pH metric features: a prospective comparative hospital based study.

BACKGROUND: Systemic sclerosis (SSc) is a generalized disorder of unknown etiology affecting the connective tissue of the body. It affects the skin and various internal organs. Gastrointestinal tract involvement is seen in almost 90% of the patients. Esophagus is the most frequently affected part of the gastrointestinal tract. Esophageal motility disturbance classically manifests as a reduced lower esophageal sphincter pressure (LESP) and loss of distal esophageal body peristalsis. Consequently, SSc patients may be complicated by erosive esophagitis and eventually by Barrett's esophagus and esophageal adenocarcinoma. Morphea, also known as localized scleroderma, is characterized by predominant skin involvement, with occasional involvement of subjacent muscles and usually sparing the internal organs. The involvement of esophagus in morphea has been studied very scarcely. The proposed study will investigate the esophageal involvement in the two forms of scleroderma (systemic and localized), compare the same and address any need of upper gastrointestinal evaluation in morphea (localized scleroderma) patients. METHODS: 56 and 31 newly and already diagnosed cases of SSc and morphea respectively were taken up for the study. All the patients were inquired about the dyspeptic symptoms (heartburn and/or acid regurgitation and/or dysphagia). Upper gastrointestinal endoscopy, esophageal manometry and 24-hour pH monitoring were done in 52, 47 and 41 patients of SSc; and 28, 25 and 20 patients of morphea respectively. RESULTS: Esophageal symptoms were present in 39 cases (69.6%) of SSc which were mild in 22 (39.3%), moderate in 14 (25%), severe in three (5.3%); while only four cases (7.1%) of morphea had esophageal symptoms all of which were mild in severity. Reflux esophagitis was seen in 17 cases (32.7%) of SSc and only two cases (7.14%) of morphea. Manometric abnormalities were seen in 32 cases (68.1%) of SSc and none in morphea. Ambulatory 24-hour esophageal pH monitoring documented abnormal reflux in 33 cases (80.5%) of SSc and no such abnormality in morphea. CONCLUSION: While the esophageal involvement is frequent in SSc, no such motility disorder is seen in morphea. Meticulous upper gastrointestinal tract evaluation is justified only in SSc and not in morphea.

Comparison of levels of serum copper, zinc, albumin, globulin and alkaline phosphatase in psoriatic patients and controls: A hospital based casecontrol study.

BACKGROUND: Psoriasis is a chronic, immune-mediated skin disease with unknown etiology, with an epidermal turnover time of <10 days compared to a normal turnover time of 4-8 weeks. This epidermal hyperproliferation accounts for many of the metabolic abnormalities including alteration in the serum levels of proteins and some trace elements. AIM: The aim was to detect any statistically significant difference in the serum levels of zinc, copper, albumin, globulin and alkaline phosphatase between psoriasis patients and healthy controls. MATERIALS AND METHODS: Hundred cases of psoriasis and 100 age and sex matched controls were enrolled in a hospital based case-control study. The serum levels of zinc, copper, albumin, globulin and alkaline phosphatase were calculated and compared among the cases and controls and evaluated statistically. RESULTS: Serum zinc levels were significantly low in the psoriasis group as compared with controls (mean 80.028 µg/dl vs. 109.179 µg/dl, P < 0.0001). Serum copper levels were significantly raised among cases as compared with controls (mean 167.317 µg/dl vs. 133.884 µg/dl P < 0.0001). Serum albumin levels were significantly decreased (3.762 g/dl vs. 4.103 g/dl, P < 0.001), whereas serum globulin levels were raised (3.296 g/dl vs. 2.596 g/dl, P = 0.0014) among cases as compared with controls, respectively. Serum alkaline phosphatase levels were comparable between the two groups. CONCLUSION: The results of this study show significant alterations in the serum levels of copper, zinc, albumin, and globulin in psoriatic patients. This paper aims at highlighting the possible role of trace metals copper and zinc in the aetiopathogenesis of psoriasis and also provides a proposed interplay of factors involved in the pathogenesis of psoriasis.

Non Comparative Study on Various Pulse Regimens (DCP, DAP and DMP) in Pemphigus: Our Experience.

BACKGROUND: Pemphigus has been treated with Dexamethasone Cyclophosphamide Pulse (DCP) Therapy since 1981. Various modifications have been suggested in the original regimen. These include Dexamethasone Azathioprine Pulse (DAP) and Dexamethasone Methotrexate Pulse (DMP) therapies. AIMS: To report our experience on the noncomparative study of various Pulse regimens DCP, DAP AND DMP therapies in patients with Pemphigus. MATERIALS AND METHODS: The patients were put on three regimens depending upon the situation-Conventional DCP, DAP in the reproductive age group, DMP in patients who showed prolonged Phase I more than 12 months while on DCP. RESULTS: 30 patients were put on DCP therapy. The duration of phase I was on an average six months. Relapse was seen in 3 patients in phase IV. 12 patients on DAP therapy were considered. In Phase III 5 patients relapsed in phase IV four patients relapsed. Five patients were put on the DMP. Disease activity was poorly controlled and in three DMP was discontinued. CONCLUSION: DCP remains the most effective regimen with quickest onset of remission and continuance of remission. In DAP therapy fixation of dose of azathioprine at 50 mgs daily may be counterproductive. DMP does not fulfil the promise of a viable treatment option in recalcitrant pemphigus and this lacunae needs to be plugged.

Epidermolysis bullosa: a series of 12 patients in kashmir valley.

BACKGROUND: Epidermolysis Bullosa (EB) is a genetically determined mechano-bullous disorder of the skin encompassing a group of conditions that share skin fragility as a common feature. MATERIALS AND METHODS: Twele patients with Epidermolysis Bullosa from Kashmir valley are reported. RESULTS: Our series included 12 patients, 5 males and 7 females. Features were consistent with EB simplex in 8 patients, EB pruriginosa in 2 patients, generalized atrophic benign EB in one patient and EB acquista in one patient. CONCLUSION: EB is a rare, genetically determined, blistering disorder affecting both males and females with predominant involvement of hands and feet. In the absence of specific therapy, treatment mainly involves avoidance of provoking factors, prevention and treatment of complications.

Childhood vitiligo: response to methylprednisolone oral minipulse therapy and topical fluticasone combination.

BACKGROUND: Childhood vitiligo is always a challenge to treat, especially when the disease is progressing rapidly in such a patient. Oral minipulse with betamethasone has been tried in childhood vitiligo and also in some other immune mediated skin disorders with good results. AIMS: The aim of the present study was to see the overall efficacy of methylprednisolone oral minipulse therapy in combination with topical fluticasone in progressive childhood vitiligo. The combination was tried to achieve a significant amount of repigmentation of vitiligo lesions already present at the initial visit. MATERIALS AND METHODS: Four hundred children with progressive vitiligo were enrolled for this study and were prescribed oral methylprednisolone on two consecutive days every week in a minipulse form for a period of six months. In addition, the patients were instructed to apply fluticasone ointment topically once a day on their vitiligo lesions. The patients were assessed for the remission achieved as well as the extent of repigmentation of their already existent lesions. RESULTS: More than 90% of patients went into complete remission after the start of the therapy. Moreover, about 65% (two-thirds) of patients achieved good to excellent repigmentation of lesions at the end of six months of therapy. The therapy was also well tolerated and the side effects seen were almost negligible. CONCLUSIONS: Oral minipulse treatment with methylprednisolone is an effective treatment option for controlling the disease spread in childhood vitiligo and with the addition of topical fluticasone the extent of repigmentation achieved is also quite significant.

Papillon-lefevre syndrome.

BACKGROUND: Papillon-Lefevre syndrome is a rare autosomal recessive disorder caused by cathepsin C gene mutation leading to the deficiency of cathepsin C enzymatic activity. The disease is characterized by palmoplantar hyperkeratosis, loss of deciduous and permanent teeth and increased susceptibility to infections. Onset of palmoplantar hyperkeratosis and periodontopathy is most commonly before the age of 4 years. MAIN OBSERVATIONS: A 15 year old boy with a history of frequent infections presented with hyperkeratosis of palms and soles, which worsened during winter season. Examination of the oral cavity revealed missing mandibular central incisors and left lateral incisors. Most remaining permanent teeth were mobile. Fibrosis and scarring of gingival and labial mucosa restricted opening of the mouth. CONCLUSION: Early diagnosis of Papillon-Lefevre syndrome may help preserve the teeth. We present a case of a late diagnosis of this syndrome.

Plica Neuropathica.

A case of Plica neuropathica is reported. This condition is uncommon and.