Splenogonadal fusion: aiding detection and avoiding radical orchidectomy.

Splenogonadal fusion is a rare benign congenital anomaly in which there is an abnormal connection between the gonad and the spleen. It was first described over 100 years ago with limited reports in the literature since then. Its similarity in presentation to testicular neoplasia poses a significant challenge in diagnosis and management, often resulting in radical orchidectomy. We present the case of a 31-year-old man who presented with a rapidly growing left-sided testicular mass and suspicious ultrasound findings; histology from the subsequent radical inguinal orchidectomy showed findings consistent with splenogonadal fusion. We describe points for consideration in the clinical history, examination and imaging that could suggest splenogonadal fusion, including preoperative technetium-99m-sulfur colloid imaging and intraoperative frozen section evaluation, which may confirm the diagnosis and prevent unnecessary orchidectomy.

Splenogonadal fusion: aiding detection and avoiding radical orchidectomy.

Splenogonadal fusion is a rare benign congenital anomaly in which there is an abnormal connection between the gonad and the spleen. It was first described over 100 years ago with limited reports in the literature since then. Its similarity in presentation to testicular neoplasia poses a significant challenge in diagnosis and management, often resulting in radical orchidectomy. We present the case of a 31-year-old man who presented with a rapidly growing left-sided testicular mass and suspicious ultrasound findings; histology from the subsequent radical inguinal orchidectomy showed findings consistent with splenogonadal fusion. We describe points for consideration in the clinical history, examination and imaging that could suggest splenogonadal fusion, including preoperative technetium-99m-sulfur colloid imaging and intraoperative frozen section evaluation, which may confirm the diagnosis and prevent unnecessary orchidectomy.

Seasonal prevalence of Cryptococcus neoformans var. grubii and Cryptococcus gattii inhabiting Eucalyptus terreticornis and Eucalyptus camaldulensis trees in Jabalpur City of Madhya Pradesh, Central India.

This study presents a two-year retrospective analysis of the work done during 2003-2005 on the distribution population density and isolation frequency of Cryptococcus neoformans var. grubii and Cryptococcus gattii recovered from different parts of Eucalyptus tree spp., at Jabalpur Madhya Pradesh, Central India. Of the 1000 samples collected from bark, flowers, fruits, buds and leaves of Eucalyptus trees E. terreticornis and E. camaldulensis, 32 (3.2%) were found to be positive for C.n var. grubii and 28 (2.8%) for C. gattii respectively. While both the pathogens were isolated through all the seasons, no significant difference was found in prevalence of the two species (P>0.05) from different Eucalyptus tree samples. For C. neoformans var. grubii the highest isolation frequency of the pathogen was in spring followed by autumn, summer, winter and rainy season. For C. gattii, highest isolation frequency of the pathogen was in summer, followed by autumn, spring, winter and rainy season. Significant difference was seen in the isolation frequency of C. neoformans var. grubii and C. gattii during autumn and rainy season (P<0.01), spring and rainy season (P<0.001) and summer and rainy season (P<0.001). Population density and isolation frequency of the both pathogens were significantly lower in rainy season. Bark of the Eucalyptus tree yielded the highest frequency of C. neoformans var. grubii followed by flower, fruits, buds and debris. Trees located in the densely populated area of the city yielded highest frequency of the pathogens followed by trees located in sparsely populated area on the outskirt of the city and areas near the river Narmada. Further comprehensive study is suggested to assess the overall impact of seasonal prevalence in the isolation frequency and population density of both the pathogens and their clinical significance across climatically divergent region of India.

Thrombotic thrombocytopenic purpura: a true haematological emergency.

There are so few true haematological emergencies that they are often way down the list as a differential diagnosis. Those that do exist, however, can prove devastatingly fatal if left untreated and a case is presented of one such possible diagnosis, thrombotic thrombocytopenic purpura, which falls into the remit of many possible presenting conditions. Particularly prevalent in young adults, this condition must always be thought of in any patient presenting with confusion, renal impairment, fever or other neurological abnormalities.

A critical appraisal of cesarean section rates at teaching hospitals in India.

OBJECTIVES: To obtain an estimate of cesarean section rates and examine the indications and consequences at teaching hospitals in India. METHODS: Information was obtained on total number of normal and cesarean deliveries during 1993-1994 and 1998-1999 from 30 medical colleges/teaching hospitals. In addition, prospective data were recorded for a period of 2 months on 7017 consecutive cesarean sections on indications for cesarean delivery, associated complications and mortality. RESULTS: The overall rate of cesarean section increased from 21.8% in 1993-1994 to 25.4% in 1998-1999. Among the 7,017 cesarean section cases, 42.4% were primigravidas, 31% had come from rural areas, 20.8% were referred including 8% with history of interference, 66% were booked cases, period of gestation was less than 37 weeks in 21.7% and in 18% the surgery was elective. Major indications for cesarean section included dystocia (37.5%), fetal distress with or without meconium aspiration (33.4%), repeat section (29.0%), malpresentation (14.5%) and PIH (12.5%). Maternal and perinatal mortality was 299/100,000 and 493/1,000 deliveries, respectively, and is high in spite of the increase in the cesarean section rates. CONCLUSIONS: There is need for standardized collection of information on all aspects of childbirth to ascertain the incidence and indications of cesarean section nationally so that comparison and improvements of care can take place.

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms.

OBJECTIVES: To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference. DESIGN: Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes. SETTING: 31 general practices in Trent region. PARTICIPANTS: Patients aged 18-70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms. MAIN OUTCOME MEASURES: Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria. RESULTS: At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval -2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist's overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse. CONCLUSIONS: Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment.

Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial.

BACKGROUND: There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor. AIMS: To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response. METHOD: A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms. RESULTS: There were 103 randomised and 220 preference patients in the trial. We found: no differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome. CONCLUSIONS: These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting.

Cotinine replacement levels for a 21 mg/day transdermal nicotine patch in an outpatient treatment setting.

This study examined plasma cotinine replacement levels of 56 outpatient smokers administered a 21 mg/day transdermal nicotine patch (Nicoderm CQ ). The percentage of cotinine replacement ranged from 35 to 232% (mean 107%; median 90.5%). Four subject variables were found to be significantly correlated with percentage of cotinine replacement-baseline cotinine level, prior quit attempts, gender, and the Fagerström Tolerance Questionnaire score. A two-variable model consisting of baseline cotinine level and gender provided the most powerful predictor combination. The percentage of cotinine replacement was not predictive of post-treatment smoking. The relatively high levels of cotinine replacement obtained using the Nicoderm CQ 21 mg/day patch suggest cautious use of higher dose treatment with this particular patch.

Abuse liability of buprenorphine--a study among experienced drug users.

Six male post-detoxified opiate dependent subjects were evaluated for abuse liability of buprenorphine (0.6 mg), morphine (16 mg), pentazocine (30 mg) and distilled water (placebo) intramuscular injection in a single blind cross-over random order. Subjective states, drug discrimination, drug linking, sedation and euphoria were assessed at pre-injection, 30 min and 4 hrs post-injection. Buprenorphine caused significant euphoria and was identified as heroin. On all parameters, buprenorphine resembled morphine rather than pentazocine and placebo. The data suggest that abuse liability of buprenorphine is similar to morphine i.e. moderate rather than low.