Vitamin D deficiency in long-term hospitalization psychiatric wards in an equatorial nation.

INTRODUCTION: Vitamin D deficiency and insufficiency have been shown to be prevalent in several populations, including in people who have a mental illness. Deficiency has been linked to specific mental health sequelae. Furthermore, deficiency may be perpetuated by medications routinely prescribed to people with severe mental illness. Therefore, symptoms of mental illness may be exacerbated by deficient levels of vitamin D, and treatments for mental illness may exacerbate deficiency. This study sought to determine the vitamin D levels of people hospitalized for a period longer than a year in an equatorial nation, Singapore. The inpatient population was then categorized according to levels to determine the need for supplementation. METHODS: Total 25-hydroxy vitamin D in serum and plasma levels were tested in 403 individuals in long-term psychiatric wards. Blood serum and plasma levels were classified into three groups. Regression models were constructed to test the associations between levels and clinical covariates. RESULTS: Forty (9.9%) people had vitamin D levels that were sufficient. A link was found between vitamin D levels and medications given for gastrointestinal illnesses (ß -2.48, p = .014, 95%CI -4.46 to-0.51) and between vitamin D levels and length of stay (ß -0.13, p = .027, 95%CI -0.24 to-0.01). No other relationships were statistically significant. DISCUSSION: Despite its geographic location and opportunities for regular outdoor activity, vitamin D deficiency, and insufficiency are prevalent among people hospitalized for long periods of time in an equatorial nation. The level of deficiency is comparable to those observed in other settings.

Electric Shock-Induced Vertebral Fracture: A Case Report and Literature Review with Special Emphasis on Fracture Morphology.

CASE: A 35-year-old man suffered electric injury with 220 V alternating current when he was connecting electric wires at approximately 5 feet height and accidentally touched a live wire. He was diagnosed to have fracture involving superior and inferior endplates of L2 vertebral body without involvement of posterior elements. He, subsequently, underwent spinal stabilization with percutaneous pedicle screws fixation. CONCLUSION: Electric shock can cause vertebral fractures even at a low voltage. These fractures tend to have coronal plane involvement and involve both superior and inferior end plates.

Plexiform Schwannoma of Lumbar Region.

Plexiform schwannoma is an unusual peripheral nerve sheath tumor. It can mimic plexiform neurofibroma. A five-year-old girl presented with painful swelling in left lumbar region. Radiologic investigations showed a multinodular tumor in the subcutaneous plane of lumbosacral region. A complete excision and histopathologic examination revealed a plexiform tumor composed of hypocellular and hypercellular areas with verocay bodies. The tumor cells showed strong positivity for S-100 protein, rendering a final diagnosis of plexiform schwannoma. The child has been free of recurrence in 12-month follow-up.

Tuberculosis of the calcaneus in children.

PURPOSE: To review 10 children with calcaneal tuberculosis in terms of presentation, healing, and functional outcome. METHODS: Medical records of 7 boys and 3 girls aged 7 to 12 (mean, 9.8) years who presented with calcaneal tuberculosis were reviewed. The erythrocyte sedimentation rate of all patients was elevated. All patients presented with pain and swelling around the lateral malleolus and a 'heal-up' sign; 7 of them presented with an additional discharging sinus. Three patients had palpable lymph nodes in the right inguinal or left popliteal region. Symptoms had lasted for one month to 1.5 years. Two patients had healed tuberculosis in the lungs; 8 patients had no pulmonary involvement. Seven patients had a single lytic lesion in the calcaneal body (n=1), tuberosity (n=3), and extension to anterior process (n=3). Three patients had multiple lytic lesions in the calcaneum; one of them had bilateral involvement who had lesions in the phalanges, lumbar spine, and ulna. Two patients had subtalar joint involvement. RESULTS: The mean follow-up period was 17 (range, 8-60) months. The erythrocyte sedimentation rate returned to normal after 3 months in 7 patients and after >6 months in 3 patients. The subtalar range of movement was normal in all except for 2 patients. One patient developed subtalar ankylosis. Sinuses healed in a mean of 10 (range, 2-16) weeks. No patient had pain on level walking after treatment. At 3 months, remineralisation of bone was evident in all patients. Sclerosis of cavity margins and sequestra resorption was noted from 6 to 9 months. No patient experienced recurrence. CONCLUSION: The 'heel up' sign was common in children with calcaneal tuberculosis in this endemic region. The central granuloma-type presentation was the most common. Pathological fractures and involvement of the subtalar joint were not common. Subtalar joint involvement was a poor prognostic factor.

Tuberculosis of the hip in children: A retrospective analysis of 27 patients.

BACKGROUND: We retrospectively evaluated the pretreatment radiological presentation and the clinicoradiological outcome at the completion of 1 year chemotherapy in osteoarticular tuberculosis of hip in children to prognosticate correlation between them. MATERIALS AND METHODS: We retrospectively analyzed the clinical and plain radiographic findings in 27 patients with an age of 12 years or younger in whom hip tuberculosis was diagnosed and treated between 2006 and 2010. The diagnosis was based on histopathology in 14 and clinicoradiological basis in 13 patients. The pre and post treatment plain radiographs were evaluated according to Shanmugasundaram radiological classification and our observations regarding unclassified cases which were not fit in this classification were suggested. The functional outcome at the completion of chemotherapy was assessed using modified Moon's criteria. RESULTS: The male female ratio was 11:16. The left hip was involved more frequently than the right (17:10). The average age was 7.37 years (range, 2-12 years). In the pretreatment radiographs, 9 hips were normal, 6 traveling, 4 dislocating, 1 protrusio acetabuli, 3 atrophic and 4 unclassified types (3 triradiate; 1 pseudarthrosis coxae). There were no Perthes and mortar pestle at the initial presentation. Posttreatment, the types changed to 9 normal, 3 Perthes, 1 protrusio acetabuli, 1 atrophic, 4 mortar pestle and 9 unclassified types (3 triradiate, 3 pseudarthrosis coxae and 3 ankylosed). There were 37% excellent, 18.5% good, 26% fair and 18.5% poor results. The prognosis was best with initial "triradiate" and normal types and worst with posttreatment atrophic and "ankylosed" types. CONCLUSIONS: The Shanmugasundaram radiological types accurately predict prognosis only in normal types and "triradiate" pattern. The functional outcome is independent of radiological morphology of the hip in smaller children.

Lytic lesions of distal radius in children: a rare tubercular presentation.

INTRODUCTION: We report the presentation, management, and outcome in five children with osteoarticular tuberculosis of distal radius. PATIENTS: PATIENTS were recruited in a prospective study. All patients underwent an open biopsy, curettage and diagnosis confirmed by histopathological/microbiological examination. In cavitary lytic lesions, bone grafting was also undertaken. The multidrug anti-tubercular chemotherapy was given for one year. OBSERVATIONS: Five patients were included in the study. The average follow-up post-completion chemotherapy was 34.8 months. Bony lesions presented as a poorly defined radiolucent lytic area in metaphysis, cavitary lytic lesions with or without sequestrum or spanned the physeal plate. At final follow-up, except for one case, a full pain free range of movements was achieved in all cases. Fibular graft was used in two cases with cavitary lesions and incorporated well in both cases. CONCLUSIONS: Tuberculosis can involve the adjacent physis and can be multifocal. The presentation is usually lytic with minimal sclerosis. For smaller ill defined lesions, curettage and multidrug anti-tubercular chemotherapy results in excellent outcome. Cavitary lytic lesions should be bone grafted as there is a risk of pathological fractures.

Trench foot: a relatively rare condition in tropical countries - a case report.

Trench foot is a relatively rare condition in tropical countries. We present here a case report of trench foot in a child who was put on hip spica for her hip ailment. Although rare, awareness on the part of the clinician can prevent this potentially serious condition and early diagnosis and treatment can prevent further consequences.

Tuberculosis of knee region in children: a series of eight cases.

Our study retrospectively reviewed the presentation, healing response, and functional results of eight cases of unilateral knee tuberculosis in children. The patients were evaluated for pain, instability, deformity, range of motion, and limb length discrepancy. Seven cases presented radiologically with Kerri and Martini's stage 1 or 2 and one in stage 4. Epiphyseal involvement was present in five cases. At final follow-up, all the knees were painless and stable. A full range of motion was recovered in the early stages. Limb length discrepancy was seen in six cases. Radiologically, despite clinical healing, the lytic lesions persisted for longer. Joint space was not reduced in seven cases at the initial presentation which was maintained following treatment. In the early stages, multidrug chemotherapy alone is sufficient and joints should be mobilized early in order to prevent stiffness. The lytic epiphyseal and metaphyseal cavities may persist for several months even after successful treatment. Limb length discrepancy is a common complication of knee tuberculosis in children.

Obstetric and gynecological outcome in a patient with traumatic pelvic fracture and perineal injuries.

A 19-year-old woman presented with pelvic trauma following a road accident. She was hemodynamically stable. Examination revealed perineal injuries and type C pelvic fracture, which was stabilized with an external fixator. The broken ends of the pubic bone were brought together by an orthopedic wire. The detached vaginal wall and torn anal sphincter were surgically repaired after making a diverting colostomy. The postoperative period was uneventful. Colostomy was reversed after 3 months. Postoperatively the patient developed a cystocele, dyspareunia and vaginal pain. She conceived spontaneously and was planned for an elective cesarean at 37 weeks gestation; however, she presented in labor at 36 weeks and had a normal vaginal delivery. Pelvic fractures may be associated with genitourinary and anal sphincter injuries, which require management by a multidisciplinary team. On recovery the patient may develop prolapse, dyspareunia and persistent local pain. Spontaneous conception and normal vaginal delivery are nevertheless possible.

Pseudoaneurysm of the anterior tibial artery: A rare complication of proximal tibial steinman pin insertion.

An anterior tibial artery pseudoaneurysm is a rare and unexpected complication of Steinmann pin insertion. We describe the case of an 18-year-old boy, who sustained such an injury to the anterior tibial artery during this procedure. Diagnosis was confirmed on a magnetic resonance (MR) angiogram. Aneurysmal sac excision with lateral repair of the vessel wall was performed. Postoperatively, a good flow was documented on a follow-up MR angiogram. This case highlights a major and unexpected complication of a so-called minor procedure. Too posterior a pin placement in the proximal tibia should be avoided to prevent such injuries.

Evaluation of adequacy of short-course chemotherapy for extraspinal osteoarticular tuberculosis using 99mTc ciprofloxacin scan.

In the evidence-based medicine era, objective treatment guidelines have been laid down for pulmonary tuberculosis, but the same is not true for osteoarticular tuberculosis. This has led to demands for standardising the treatment protocol and to a lack of consensus between doctors regarding the composition and duration of treatment. Twenty-five patients with extraspinal osteoarticular tuberculosis were evaluated prospectively. Following the diagnosis, patients were given standard directly observed treatment short course (DOTS) regimen and were monitored for disease activity at zero, three and six months with the help of technetium-99m-labelled ciprofloxacin ((99m)Tc) scan. Tracer activity at the site was recorded and compared on sequential scans. Clinical and radiological profile of all the patients were also recorded at regular intervals and compared. All 25 cases had a positive (99m)Tc bone scan initially. Four patients (16%) converted to negative scans at three months, whereas the remaining 21 patients (84%) showed negative scans at six months. The end of six months therapy also coincided with resolution of clinical and radiological parameters in all cases. In conclusion, (99m)Tc scan is a promising tool for monitoring drug response in osteoarticular tuberculosis; however, due to the small sample size, studies with a large number of patients might be of help.

Trans-scaphoid transcapitate transhamate fracture of the wrist: case report.

We describe a new pattern of upper limb injury: a combination of fractures of both radius and ulna, with a rare type of trans-scaphoid transcapitate transhamate greater arc injury of the wrist and fractures of metacarpals, managed successfully.