CT-guided mapping in the removal of an impalpable, radiopaque foreign body in subcutaneous tissue: a case report.

Small fragments sometimes penetrate the soft tissue, and their depth and location can be difficult to determine accurately. This case study describes localisation of a thin, short wire that had penetrated the soft tissue of a 24-year-old man's back, using computed tomography (CT) with a reference grid made with an angiographic catheter. The axial non-contrast-enhanced CT scan with the grid placed over the affected body part surveyed by the CT scout view showed that the foreign body was buried in fascia 7cm from a puncture wound. Surgical removal of the foreign body was then performed without any sequelae. CT with the use of external references that do not cause metal artefacts is a simple and helpful procedure in localising radiopaque foreign bodies.

Dislocation of temporomandibular joint: complication of sagittal split ramus osteotomy.

Sagittal split ramus osteotomy (SSRO) has wide-ranging indications and results in simultaneous improvements in occlusion and facial appearance. Thus, it is the most frequently used osteotomy for jaw deformities. Its main intraoperative and postoperative complications are massive bleeding, atypical fractures, inferior alveolar nerve paralysis, and relapse. This report describes a case of temporomandibular joint dislocation, a rare complication of SSRO. The patient was a 23-year-old man with mandibular prognathism which was treated by bilateral SSRO. Postoperative x-ray showed that the left temporomandibular joint was dislocated anteriorly. Thus, the patient underwent reoperation, including reduction and re-fixation. Subsequently, it was discovered that the patient had a previous history of recurrent dislocation of the temporomandibular joint. This case illustrates the need for practitioners to be mindful of temporomandibular joint dislocation as a rare complication of SSRO.

Poor performance status is a strong predictor for death in patients with smear-positive pulmonary TB admitted to two Japanese hospitals.

BACKGROUND: Estimation of performance status (PS) has been assessed as a tool to determine which patients with newly diagnosed pulmonary TB (PTB) are most at risk of dying. This simple prediction rule has not been validated in patients with PTB with different background characteristics and from different geographic areas. METHODS: A retrospective cohort study was conducted in two Japanese hospitals in different regions and included 432 inpatients with newly diagnosed smear-positive non-multidrug-resistant lung TB without HIV infection. The patients had a mean ± SD age of 64.9 ± 19.7 years and 135 were female (31.3%). Detailed nursing charts were reviewed to estimate PS, which was graded 0 (best condition), 1, 2, 3 or 4 (worst condition), for each patient. RESULTS: Single variable and multivariable Cox regression analyses models revealed that a one-point increase in PS was associated with a 2.8-fold (95% CI 2.2-3.6) and 2.3-fold (95% CI 1.8-3.0), adjusted for age, gender, comorbidities and treatment regimen, increase in the HR for death (p < 0.001 for both models). Kaplan-Meier curves also showed a significant difference in mortality among different PS groups (p < 0.001). CONCLUSION: PS was strongly associated with mortality from PTB in the study cohort. Estimation of PS at the start of treatment for newly diagnosed PTB patients could be a useful tool in case management in resource-limited countries.

Comparison of lymphoscintigraphy and indocyanine green lymphography for the diagnosis of extremity lymphoedema.

BACKGROUND: Lymphoscintigraphy is the gold-standard examination for extremity lymphoedema. Indocyanine green lymphography may be useful for diagnosis as well. We compared the utility of these two examination methods for patients with suspected extremity lymphoedema and for those in whom surgical treatment of lymphoedema was under consideration. METHODS: A total of 169 extremities with lymphoedema secondary to lymph node dissection and 65 extremities with idiopathic oedema (suspected primary lymphoedema) were evaluated; the utility of indocyanine green lymphography for diagnosis was compared with lymphoscintigraphy. Regression analysis between lymphoscintigraphy type and indocyanine green lymphography stage was conducted in the secondary lymphoedema group. RESULTS: In secondary oedema, the sensitivity of indocyanine green lymphography, compared with lymphoscintigraphy, was 0.972, the specificity was 0.548 and the accuracy was 0.816. When patients with lymphoscintigraphy type I and indocyanine green lymphography stage I were regarded as negative, the sensitivity of the indocyanine green lymphography was 0.978, the specificity was 0.925 and the accuracy was 0.953. There was a significant positive correlation between the lymphoscintigraphy type and the indocyanine green lymphography stage. In idiopathic oedema, the sensitivity of indocyanine green lymphography was 0.974, the specificity was 0.778 and the accuracy was 0.892. CONCLUSION: In secondary lymphoedema, earlier and less severe dysfunction could be detected by indocyanine green lymphography. Indocyanine green lymphography is recommended to determine patients' suitability for lymphaticovenular anastomosis, because the diagnostic ability of the test and its evaluation capability for disease severity is similar to lymphoscintigraphy but with less invasiveness and a lower cost. To detect primary lymphoedema, indocyanine green lymphography should be used first as a screening examination; when the results are positive, lymphoscintigraphy is useful to obtain further information.

Early diagnosis and risk factors for lymphedema following lymph node dissection for gynecologic cancer.

BACKGROUND: Although early diagnosis is important for selecting an effective surgical treatment for secondary lymphedema, an efficient screening test for detecting early-stage lymphedema has not yet been established. Serial changes of lymphatic function before and after lymph node dissection and risk factors for secondary lymphedema are important indicators. METHODS: A prospective cohort observational study was conducted with 100 consecutive gynecologic cancer patients who underwent pelvic lymph node dissection. Lymphatic function was assessed by noninvasive lymphography using indocyanine green fluorescence imaging on a routine schedule. Earliest findings after lymphadenectomy and risk factors for lower leg lymphedema were investigated. RESULTS: Atypical transient dermal backflow patterns were observed in an early postoperative period in 50 cases, all of which disappeared within 3 months. Of these patterns, the splash pattern was observed in 31 patients, of which five improved to normal following a natural course. In contrast, the stardust pattern was observed in 27 patients, and none had improved with conservative therapy. Postoperative radiotherapy was a significant risk factor for the stardust pattern. CONCLUSIONS: All patients who undergo lymphadenectomy for gynecologic malignancies should be examined for secondary lower extremity lymphedema by qualitative evaluation methods on a routine schedule to determine the earliest possible diagnosis. Because the splash pattern on indocyanine green lymphography is a reversible lymphatic disorder following a natural course, surgical treatments are not recommended. The decision regarding surgical treatment can be made after observing the stardust pattern. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Gas-producing cellulitis from injection of spot remover fluid (n-Hexane).

BACKGROUND: Subcutaneous administration of hydrocarbons, categorized according to their toxicological profiles, is rare compared to oral, inhalational, and cutaneous routes of exposure. Furthermore, injection of n-hexane in humans has not been described. OBJECTIVES: This report demonstrates a singular case of subcutaneous administration of n-hexane. CASE REPORT: A 21-year-old man presented to the Emergency Department (ED) 7 h after injecting his left antecubital fossa with approximately 5 cc of spot remover fluid, which contained more than 95% n-hexane, in a suicide attempt. There was redness in the left forearm, but no apparent swelling was observed. He was administered tetanus prophylaxis and discharged with follow-up. However, the patient returned to the ED 14 h later, complaining of progression of the swelling around the injection site extending to the axilla. Significant volume of air in the soft tissue of the affected extremity was noted on both the radiograph and computed tomography scan; therefore, an immediate extensive incision and debridement of the diseased limb was performed. The postoperative course was uneventful, and a complete resolution of emphysema without any functional deficits was obtained for 5 months of follow-up. CONCLUSION: In patients suffering from n-hexane injection, initial physical examination findings may not be apparent. Thus, the patient must be monitored closely for evidence of a spread of subcutaneous gas with elevation and immobilization. If increase in tissue pressure or spread of gas is not prevented, as in our case, immediate incision and removal of the toxic substances should be planned.

The presence of pretreatment cavitations and the bacterial load on smears predict tuberculosis infectivity negative conversion judged on sputum smear or culture.

OBJECTIVE: There are no rules to predict the time to infectivity negative conversion based on sputum smear conversion or culture conversion during chemotherapy in smear-positive tuberculosis patients. We aimed to develop and validate rules of sputum smear grades and cavitations in the lungs due to tuberculosis. METHODS: This study was a retrospective cohort study that consisted of development (n=158, 64 ± 19 years of age) and validation (n=214, 63 ± 20 years of age) steps in different cohorts. We developed a rule with pretreatment smear grades and the existence of cavitations in the lungs due to tuberculosis as independent variables and the duration to infectivity negative conversion as the dependent variable in a Cox hazard model. The smear grade indicating the pretreatment bacterial load was classified into four grades according to the Japanese guidelines. The presence of cavitations was assessed on X-ray. Infectivity conversion was defined according to the criteria of the Japanese Ministry of Health, Labour and Welfare: a patient is currently receiving proper treatment and shows clinical improvement and sputum smears and cultures in any combination are consecutively negative three times. RESULTS: We developed an "Infectivity Conversion Score" classifying each patient with a smear grade of I though IV and assessing the existence of cavitations in the lungs due to tuberculosis. The median time to infectivity conversion in the validation cohort was 13, 22, 35 and 50 days for Infectivity Conversion Scores I through IV, respectively (p<0.001). CONCLUSION: We developed and validated Infectivity Conversion Scores.

Reconstruction of a contracted eye socket using an anterofrontal superficial temporal artery island flap and scapha composite grafting in an elderly patient.

There are numerous methods for reconstruction of the eye socket. However, the use of an island flap on the forehead based on the anterofrontal branch of the superficial temporal artery has not been reported upon. This article describes an experience of eye-socket reconstruction in a 90-year-old woman with an anterofrontal superficial temporal artery island flap, a temporoparietal fascia flap and scapha composite grafting in a one-step procedure. Deep fornices were obtained and the convex eye socket was stably and easily fitted with the ocular prosthesis, which the patient started to wear 4 weeks after the operation. The socket and eyelids are without any deficits and in good condition with a 1-year follow-up.

Cryoprotective activity of mannoprotein from the cell membrane of Pichia anomala.

Some organisms like bacteria and plants have a cryoprotective protein to cryopreserve the freeze-labile enzyme under stable conditions having high activity. By screening of the cryoprotective activities of various food-industrial yeasts, we found that the cell membrane component that was a glucanase extractable component in Pichia anomala NBRC 141 had a high level of cryoprotective activity against freeze-labile lactate dehydrogenase (LDH). The absorption of the active compound in the crude extract by ConA-Sepharose chromatography suggested that this active compound might be a glycoprotein (COGP). Strain NBRC had the COGP constantly without the treatment of cold acclimation. The active compound, that is, a COGP, could be homogeneously purified using DEAE-TOYOPEARL and Sephacryl S-400 chromatography. The purified COGP had a cryoprotective activity of 50.9% at a sugar concentration of 17.9 microg/ml. The molecular weight of purified COGP was 83,000, which was composed of one protein with a molecular weight of 22,000 and polysaccharide. Furthermore, the constituent sugar of COGP was only D-mannose based on HPLC analysis of its acid hydrolysate. Also, we confirmed that the cryoprotective activity of COGP was higher than those of the commercial cell membrane components. The CP50 of COGP was 0.28 microM, which was half to the CP50 of BSA. This is the first report, to our knowledge, that the cell membrane component of Pichia anomala had a high level of cryoprotective activity against a freeze-labile enzyme.

Polychlorinated biphenyls alter the expression of endothelial nitric oxide synthase mRNA in human umbilical vein endothelial cells.

Polychlorinated biphenyls (PCBs) are a group of persistent pollutants that are detected in maternal serum and umbilical cord, suggesting that fetal exposure also needs to be considered. The effects of dioxin-like PCB congeners 3,3',4,4'-tetrachlorobiphenyl (PCB77) and 3,3',4,4',5-pentachlorobiphenyl (PCB126) and a non-dioxin-like compound 2,2',4,4',5,5'-hexachlorobiphenyl (PCB153) on the expression of endothelial nitric oxide synthase (eNOS), known to maintain blood flow to the fetus, in human umbilical vein endothelial cells (HUVECs) were investigated. The mRNA levels of eNOS, aryl hydrocarbon receptor (AhR) and cytochrome P450 (CYP) 1A1 in cells treated with 5 microM PCBs for 24 hours were analysed by real-time RT-PCR. Cells were also treated with alpha-naphthoflavone (alpha NF), an AhR antagonist or ICI 182780, an estrogen receptor (ER) antagonist, one hour prior to PCB exposure, to observe the effects of these receptors on eNOS modulation. Each PCB increased the eNOS mRNA level by 4.5-fold that was markedly inhibited by alphaNF. ERs were also suspected of altering eNOS levels because ICI 182780 treatment resulted in a decrease in the eNOS level. These results suggest that the eNOS mRNA expression increases due to the action of PCBs related to both AhR and ERs in HUVECs, and that maternal PCB exposure could influence fetal circulation.