Osteopenic consequences of botulinum toxin injections in the masticatory muscles: a pilot study.

Patients with temporomandibular muscle and joint disorder (TMJD) increasingly seek and receive treatment for their pain with botulinum toxin (BoNTA; botulinum toxin A). Used intramuscularly in therapeutic doses, it produces localised paresis. Such paresis creates risk of reduced bone mineral density, or 'disuse osteopenia'. Animal studies have frequently used BoNTA as a model of paralysis to induce bone changes within short periods. Osteopenic effects can be enduring in animals but have yet to be studied in humans. This is the first study in humans to examine bone-related consequences of BoNTA injections in the masticatory muscles, comparing oral and maxillofacial radiologists' ratings of trabecular bone patterns in the condyles of patients with TMJD exposed to multiple masticatory muscle injection sessions with BoNTA to a sample of patients with TMJD unexposed to masticatory muscle injections with BoNTA. Cone-beam computed tomography (CBCT)-derived images of bilateral condyles were evaluated in seven patients with TMJD receiving 2+ recent BoNTA treatment sessions for facial pain and nine demographically matched patients with TMJD not receiving BoNTA treatment. Two oral and maxillofacial radiologists evaluated CBCT images for evidence of trabecular changes consistent with osteopenia. Both evaluators noted decreased density in all participants exposed to BoNTA and in none of the unexposed participants (P < 0.001). No other abnormalities associated with reduced loading were detected. These findings need replication in a larger sample and over a longer time period, to ensure safety of patients with TMJD receiving multiple BoNTA injections for their pain.

Cone beam CT analysis of Haller cells: prevalence and clinical significance.

OBJECTIVES: Haller cells are anterior ethmoid air cells located in the medial orbital floor immediately lateral to the maxillary infundibulum. The purpose of this study was to demonstrate the prevalence and relationship between the existence and size of these cells with ipsilateral maxillary sinusitis and orbital floor dehiscence as visualized on cone beam CT (CBCT) images. METHODS: CBCT image volumes of 50 patients were retrieved and analysed. All CBCT images were acquired with a 9-inch field of view scan. χ(2) and Cochran-Mantel-Haenszel tests were used for statistical analysis of the obtained data, and p-values of <0.05 were considered to be statistically significant. RESULTS: There was no statistically significant association between the existence and size of Haller cells and maxillary sinusitis. There was a significant association between Haller cells and orbital floor dehiscence. CONCLUSIONS: The explanation of maxillary sinusitis on the basis of mechanical obstruction is unlikely. This study provides evidence for the usefulness of CBCT scan in delineation of the sinonasal anatomy.

Prevention principles for practitioners: a solution or an illusion?

The social work profession has sought to eliminate, or at the very least, ameliorate those social ills that were believed to contribute to severe social and personal dysfunction. Prevention programs have been a primary factor in this endeavor. Prevention programs have addressed a vast array of difficulties including adolescent suicide, youth violence, teenage pregnancy, home visiting programs for families at high-risk for neglect and abuse as well as out-of-home placement. This paper addresses the concept of prevention and incorporates the notion of resilience in eight (8) prevention practice principles. Case examples are provided as well as a discussion for future directions for prevention in the field of social work.

Cysts and cystic lesions of the mandible: clinical and radiologic-histopathologic review.

Many lesions that occur in the mandible have a cystlike radiographic appearance. These lesions are often difficult to differentiate on the basis of their radiographic features alone. Mandibular lesions may be odontogenic or nonodontogenic. Among odontogenic lesions without mineralization, ameloblastomas, odontogenic keratocysts, and dentigerous cysts can all appear as well-defined, unilocular, well-corticated, lucent lesions that are often associated with the crowns of impacted or unerupted teeth. Most radicular cysts appear as round or pear-shaped, unilocular, lucent lesions in the periapical region. Among odontogenic lesions with mineralization, complex odontomas contain multiple masses of dental tissue and compound odontomas contain multiple teeth or toothlike structures. Odontogenic myxomas are characterized by lytic osseous changes of varying size, which may be demarcated and expansile or exhibit ill-defined borders. Nonodontogenic lesions that mimic odontogenic lesions include benign fibro-osseous lesions (conventional or juvenile ossifying fibroma, focal or periapical cemento-osseous dysplasia, florid osseous dysplasia), traumatic bone cyst, lingual salivary gland inclusion defect, central giant cell granuloma, brown tumor of hyperparathyroidism, arteriovenous malformation, and mucoepidermoid carcinoma. The clinical and radiographic features of these mandibular lesions help establish a differential diagnosis, although microscopic tissue evaluation is generally necessary to accurately identify the lesion.

Wide variation in serum anion gap measurements by chemistry analyzers.

The traditional anion gap [AG = Na-Cl-(total CO2)] mean value of 12 mEq/L was established during the 1970s with analyzer methods that are no longer used widely. No studies have systematically compared mean AG values from analyzers in current use. We used data from healthy subjects obtained from 27 clinical laboratories, 5 manufacturers, and 8 publications to compute mean AG values from 1970s analyzers and 8 current analyzers. We also compared mean AG values by evaluating Na, Cl, and total CO2 data from the College of American Pathologists Chemistry Surveys (1990-1996). Data from healthy subjects showed that overall mean AG values of the 9 analyzers ranged from 5.9 to 12.4 mEq/L. The pooled (i.e., average) AG SD was 2.3 mEq/L. We then used the data of the Surveys and the mean value from 1 analyzer to compute predicted mean values for the other 7 current analyzers. Almost all mean AG values predicted from the Surveys agreed (within 1.5 mEq/L) with mean values from healthy subjects. These results show that mean values of analyzers vary widely, indicating that analytic bias strongly influences the AG. The results should be a useful guide for the AG measurements that can be expected from different analyzers.

The additional value of free prostate specific antigen to the battery of age-dependent prostate-specific antigen, prostate-specific antigen density and velocity.

This study describes the value of using the fraction of free prostate-specific antigen as a further marker in the early detection of prostate cancer. This newly introduced marker is compared to the usual battery of age-dependent total prostate-specific antigen, prostate-specific antigen density (microg/l x g tissue) and prostate-specific antigen velocity (microg/l x year). Determination of total prostate-specific antigen and free prostate-specific antigen was performed on fresh serum samples obtained from 3470 symptomatic patients aged 45-80 attending the Urology Clinics, or their General Practitioners. Among them, 310 patients had total prostate-specific antigen above the age-dependent cut-off, and/or free/total prostate-specific antigen under 11%, with different prostate-specific antigen densities and velocities. Only 147 patients complied to undergo biopsy: in 72 of those patients, benign prostatic disease was histologically confirmed, while in 75 patients primary prostate cancer was histologically confirmed. Total and free prostate-specific antigen levels were determined using the third generation DPCs prostate-specific antigen assay performed on the Immulite automated immunoassay instrument. Total prostate-specific antigen age reference values were adopted from Oesterling et al. (J Am Med Ass 1993; 270:860-4); the prostate-specific antigen density was considered suspicious of prostate cancer if it was greater than 0.15 microg/l prostate-specific antigen per gram tissue (Seaman et al. Urol Clin N Am 1993; 20:653); prostate-specific antigen velocity greater than 0.75 microg/l x year (Carter et al., J Am Med Ass 1992; 267:215) was considered suspicious for prostate cancer. Of the 147 patients, 75 had prostate cancer and 72 had benign prostatic hypertrophy. The difference between prostate cancer and benign prostatic hypertrophy was significantly reflected only by free/total prostate-specific antigen and prostate-specific antigen velocity. These parameters also provided the best sensitivity and specificity. Only these parameters proved to be significant when using a backwards logistic regression model (prostate-specific antigen velocity, p = 0.007 odds ratio 2.782; free/total prostate-specific antigen %, p = 0.016 odds ratio 2.678). Combinations of various parameters became significant when including free/total prostate-specific antigen, increasing prostate cancer detection to 88%. We conclude that free/total prostate-specific antigen is the most significant among prostate-specific antigen quantities (total age-dependent prostate-specific antigen, prostate-specific antigen density and prostate-specific antigen velocity). Adding this parameter to other prostate-specific antigen parameters improves the discrimination between prostate cancer and benign prostatic hypertrophy for the population at risk.

Imaging of the temporomandibular joint: a position paper of the American Academy of Oral and Maxillofacial Radiology.

Various imaging techniques for the temporomandibular joint are discussed with respect to uses, strengths, and limitations. An imaging protocol is outlined for evaluating patients with a wide variety of temporomandibular joint related signs and symptoms.

A 12 versus 6-week course of bacillus Calmette-Guerin prophylaxis for the treatment of high risk superficial bladder cancer.

PURPOSE: We examined the efficacy of a 12-week prophylactic course of bacillus Calmette-Guerin (BCG) on superficial bladder cancer. MATERIALS AND METHODS: From August 1992 until July 1994, 70 evaluable patients 41 to 80 years old (mean age 68.5) with high risk transitional cell carcinoma of the bladder were prospectively randomized to a 12-week prophylactic course of BCG (group 2) versus a traditional 6-week course (group 1). Mean followup was 28 months. RESULTS: A 70% tumor-free rate (21 patients) and mean interval of 12.9 months to recurrence were achieved in group 2 compared to 55% (22 patients) and 12.3 months, respectively, in group 1. Group 2 patients had an overall longer disease-free survival, although no statistical significance was achieved. A subgroup of patients with stage Ta cancer in whom at least 1 tumor was resected 12 month before treatment showed the most benefit from long-term prophylactic treatment in terms of disease-free survival. Side effects were only slightly more prominent in group 2, rendering the longer course fairly acceptable. CONCLUSIONS: Our findings suggest a difference for better overall results with the 12-week course of BCG. However, a larger number of patients are needed to demonstrate a statistically significant difference between the 2 groups.

Synchronous and metachronous contralateral adrenal metastases from primary renal cell carcinoma.

Two rare cases of contralateral adrenal metastases are reported. One with a synchronous presentation where the renal tumor was removed together with a solitary large contralateral adrenal metastasis. The second patient underwent adrenalectomy for a metastatic lesion diagnosed 4 years after nephrectomy performed for renal cell carcinoma of the contralateral kidney. Five years following the adrenalectomy the patient underwent leg amputation because of a solitary bone metastasis.

Dosimetry and cost of imaging osseointegrated implants with film-based and computed tomography.

Thermoluminescent dosimeters were used to measure radiation doses at craniofacial sites in a tissue-equivalent phantom during film-based multidirectional tomography with the Tomax Ultrascan (Incubation Industries, Ivyland, Pa.) and during computed tomography with the Elscint Excel 2400 (Elscint Corp., Tel Aviv, Israel). Mean absorbed doses for presurgical mandibular and maxillary canine and molar implant assessments were converted to equivalent doses, which were then multiplied by published weighting factors and summed to give effective doses. The computed tomography device consistently delivered higher doses than the Tomax Ultrascan to all anatomic locations; the differences were most pronounced when only one or two implant sites were evaluated. The reasons for the dose disparities are considered both anatomically and procedurally. A survey of examination cost revealed film-based multidirectional tomography to be less expensive than computed tomography.

Serum free/total prostatic-specific antigen in prostate cancer patients treated with LH-RH agonists.

OBJECTIVE: This study is based on promising results using the ratio of free/ total (F/T) prostatic-specific antigen (PSA) for discrimination between benign prostatic hypertrophy and prostate cancer. We tried to determine the value of F/T PSA in different clinical situations at a certain time point during follow-up of luteinizing-hormone-releasing hormone (LH-RH) agonist treatment and to correlate it to T-PSA. PATIENTS AND METHODS: 182 patients followed-up for different periods in the last 3 years were routinely monitored for serum T-PSA. During the last 11 months, F-PSA was also measured together with T-PSA, and the ratio of F/T PSA was calculated. In 26 patients, the ratio of F/T PSA was monitored sequentially in several samples. RESULTS: Although 5 patterns of clinical response to LH-RH agonists were identified according to previous T-PSA, the F/T ratio could significantly (p < 0.05) discriminate between patients responding to treatment in contrast to patients escaping, fluctuating or not responding to hormonal ablation. Those patients responding to hormones showed a higher F/T PSA ratio (36.5 +/- 33.1%) compared to the nonresponding group (12.0 +/- 10.1%). CONCLUSIONS: During individual follow-ups, the pattern of response to LH-RH treatment is reflected by the F/T PSA ratio: while successful treatment causes an F/T PSA increase, relapse is accompanied by a decrease in this ratio. However, the changes in the F/T PSA ratio did not precede the indicative changes in T-PSA. It seems that increased values of F/T PSA ratios are intrinsic features of 'benign' prostatic disease, and the molecular events resulting in different PSA molecules in various clinical situations have to be elucidated.

Strategies for helping young adults with severe mental disorders.

Severe mental illness is defined in terms of psychosocial development and attention is given to socio-economic forces in these patients' lives. The difficulties faced by the young, severely mentally ill persons in the United States is discussed and data regarding prevalence and treatment strategies are outlined with implications for individual and family therapy modalities. Programs with a wide range of psychosocial, vocational and housing support systems together with counseling are emphasized as integral components if young, emotionally disabled persons are to be sustained in the community. The lay and professional communities must be mobilized to provide the needed resources. Available and accessible innovative programmatic concepts together with a more hopeful attitude on the part of professionals can make a difference.

Venous aneurysm, arterial dysplasia, and near-fatal hemorrhages in neurofibromatosis type 1.

Venous aneurysms are rare and usually develop following trauma. This report describes an aneurysm of the internal jugular vein that was associated with dysplasia of the cervical arteries, in a patient with neurofibromatosis type 1 (NF1). The finding of neurofibromatous tissue in the wall of the aneurysm as well as in small veins, suggested that the venous aneurysm was caused by the neurofibromatous invasion. No features of the dysplasia encountered in arteries of NF1 lesions were observed in the aneurysm or veins. During and after surgical excision of the aneurysm, the patient developed massive hemorrhages that required two reexplorations and evacuations of cervical hematomas. During surgeries, the bleeding was difficult to control because of excessive friability of the blood vessels. We suggest that the increased vascular fragility in this patient was caused by the NF1-associated arterial dysplasia and by the neurofibromatous venous invasion. Despite the vascular invasion by tumor, there is no evidence of malignancy or malignant transformation in this NF1 patient after a 10-year follow-up.

Single-dose intramuscular ketorolac versus diclofenac for pain management in renal colic.

A double-blind controlled study was designed to compare the effective- ness of a single intramuscular dose of 60 mg ketorolac with that of 75 mg diclofenac in the treatment of renal colic and to monitor side effects. Fifty-seven patients completed the study, 27 in the ketorolac group and 30 in the diclofenac group. Effectiveness of treatment was monitored by pain relief reported on a 4-point verbal scale at different time points. At 60 minutes 77.8% and 86.6% (P = 0.4) of patients, and at 120 minutes 81.5% and 96.6% (P = .1 5) of patients, reported significant pain relief following ketorolac and diclofenac doses, respectively. Both groups had an equal 92% significant pain relief at discharge from the emergency department. Both drugs were well tolerated by the patients. Ketorolac therefore, seems as effective as diclofenac in the treatment of renal colic.

Perivesical fat closure during suprapubic prostatectomy: does it prevent urinary leakage? A prospective randomized study.

Urinary leakage from the operative wound may be a troublesome complication after suprapubic prostatectomy. In an attempt to prevent this complication, an additional closure layer with perivesical fat was performed. Eighty-nine patients who underwent suprapubic prostatectomy were prospectively randomized into two groups: 45 patients without fat closure and 44 with perivesical fat closure. Patients in both groups were comparable with respect to their preoperative risk factors (urinary tract infection, cystolithiasis, incidental malignancy of bladder or prostate) for bladder healing. Six patients from the first group (13.3%) and one patient from the second group (2.2%) had postoperative urinary leakage (p = 0.06). Perivescical fat closure seems to have a protective effect against urinary leakage from bladder after suprapubic prostatectomy.

The Asthma Impact Record (AIR) index: a rating scale to evaluate the quality of life of asthmatic patients in France.

Asthma is a chronic disease, which affects patients' daily lives. The goal of this study was the development of a disease-specific scale to evaluate quality of life in asthmatic patients in France: The Asthma Impact Record Index (AIR Index). The study was conducted with the participation of 486 asthmatic patients using the following steps: 1) selection of dichotomous items; 2) reduction of the number of items; 3) study of reproducibility of the questionnaire; 4) weighting of items; 5) study of the reliability and validity of the final version of the AIR Index. The final version of the AIR Index contains 63 unweighted items. The items were classified into subscales representing the main dimensions of quality of life: 1) physical, which was itself split into two subscales: a) physical activities; and b) symptoms; 2) psychological; and 3) social or relational. The internal consistency, measured by Cronbach's alpha coefficients, was found to be high, for the global scale and all subscales (range 0.79-0.94). The concurrent validity, evaluated by studying the relationship between the score values on the global scale and the subscales, and the parameters reflecting disease severity, was also high. We conclude that the AIR Index might represent a useful evaluative and discriminant instrument in studying quality of life in asthma in French populations.

A fibroepithelial urethral polyp protruding into the base of the bladder: sonographic diagnosis.

A case of congenital urethral polyp in a 10-month-old boy is presented. These rare congenital tumors can lead to urinary retention, hematuria, urinary tract infections, hydronephrosis and hydroureter. Traditionally the diagnosis was based either on voiding cystourethrography or cystoscopy. The sonographic features of these polyps have only been reported in a few cases in the past. This modality is not infrequently the imaging procedure of choice in the work-up of children with signs and symptoms related to the urinary system. In the case presented herein the polyp was demonstrated initially by sonography as a soft tissue mass arising at the base of the urinary bladder. The differential diagnosis of these lesions is presented.