Symptoms of temporomandibular joint osteoarthrosis and internal derangement 30 years after non-surgical treatment

To evaluate the long-term condition of temporomandibular joints (TMJs) affected by osteoarthrosis and internal derangement, 99 patients treated non-surgically between 1958 and 1962 were recalled for follow-up. The patients, 16 men and 83 women (mean age 58.2 years) with either reducing or permanent disk displacement, were submitted to a structured interview concerning previous treatment, masticatory function, and the presence of symptoms of osteoarthrosis and internal derangement of the masticatory system, and of complaints of the musculoskeletal system in general. A control group, consisting of eight men and 27 women (mean age 58.9 years) without complaints of the masticatory system, matching the patient group for sex, age and state of dentition, was included in the study to avoid simply documenting age-related joint conditions. Satisfaction with the treatment outcome was high. Chewing ability of the the patients did not differ from that of the controls, although patients more often expected pain and difficulty with opening the mouth wide. The main TMJ symptoms of the patients had decreased significantly; patients reported joint noises more often than controls. It is concluded that, despite some persisting symptoms, the non-surgical treatment approach of TMJ osteoarthrosis and internal derangement provides long-lasting satisfactory subjective results and is well-accepted by the patients.     

Outpatient management of patients with large multinodular goitres treated with fractionated radioiodine

The efficacy of fractionated out-patient radioiodine therapy in 38 patients with compressive symptoms due to long-standing large multinodular goitres was assessed. The diagnosis was established by clinical assessment in addition to technetium-99m pertechnetate thyroid scan or computed tomography scan of the thyroid and mediastinum. Oral iodine-131 therapy was administered as a 2.22 GBq (60 mCi) cumulative dose over 4 months (555 MBq per month). All patients were monitored with serum thyroid-stimulating hormone and free thyroxine (+/- free tri-iodothyronine) assays before the treatment and after each dose fraction. Clinical and biochemical follow-up was performed on all patients and ranged from 6 to 45 months after therapy. The patients consisted of 35 female and three male patients with a median age of 59 years (range 37-87 years). Prior to treatment 20 patients were biochemically hyperthyroid and 18 were euthyroid. Overall, 71% of patients reported a subjective improvement in compressive symptoms and 29% reported no change. Clinically assessed reduction in goitre size occurred in 92% of patients while there was no change in 8%. At 3 months of follow-up, 31% of patients had become hypothyroid and at 18 months 66% were hypothyroid. Seven hyperthyroid patients (35%) became euthyroid and 13 hyperthyroid patients (65%) became hypothyroid. Three patients who became hypothyroid experienced neck soreness (transient in one patient, persistent in two patients). There were no differences in outcome between patients who were hyperthyroid and those who were euthyroid prior to treatment. Fractionated out-patient radioiodine therapy showed excellent short- and medium-term safety, was very well tolerated and offered a satisfactory alternative treatment to surgery.     

Quality of life following bone marrow transplantation: a comparison of patient reports with population norms

All surviving patients who had received an allogeneic bone marrow transplant at the Princess Margaret Hospital were asked to participate in a health-related quality of life (HQL) study using the Medical Outcomes Survey-Short Form 36 (MOS SF-36), the Satisfaction with Life Domains Scale-Bone Marrow Transplantation (SLDS-BMT) and a current symptoms checklist. The main objective was to compare the health status of BMT survivors with age-adjusted population norms. Of the 251 patients contacted, 93% returned questionnaires. The median follow-up after BMT was 40 months, ranging from 1-253 months. On average, survivors had some diminished HQL relative to the health status of the population in general. Time since transplant had a significant influence on HQL; those less than 3 years from transplant experienced considerable impairment while those who had survived beyond this point were indistinguishable from the normal population in most domains and significantly better in certain psychosocial aspects of health. Many patients still reported symptoms months after BMT; some were mildly affected while others experienced more troublesome symptoms. However, 81% of patients were satisfied with the HQL outcome that they had achieved and 94% would recommend a transplant for someone in similar circumstances.     

Persistent disability associated with ankle sprains: a prospective examination of an athletic population

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17-24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.     

Urinary apolipoprotein (a) excretion in patients with proteinuria

BACKGROUND: Neurogenic sphincter dysfunction may result from acute transverse myelopathy. The aim of this paper is to study the course of such a dysfunction and to propose management techniques. PATIENTS AND METHODS: The files of 21 children admitted at the mean age of 8 years 5 months (2 to 14 years, 8 months) for acute transverse myelopathy were retrospectively studied. RESULTS: Bladder sphincter dysfunction occurred in the first days of disease in 85% of these patients. Abnormal perception of micturition was one of the most constant and specific symptoms. Anorectal function was also impaired. Complete regressive course was noted in 38% of patients, minor sequellae in 39% and major sequellae beyond 6 months of course in 23%. None upper tract deterioration was noted after 3 years of course. Factors of favorable prognosis were early motor function recovery (especially recommencement of walking before 20 days) and early management of bladder dysfunction (inability to void had better prognosis than urinary incontinence). CONCLUSION: Early systematic bladder drainage in case of inability to void might be essential for improved prognosis.     

Clinical experience in temporomandibular joint arthroscopy

Clinical experience of arthroscopy in 12 temporomandibular joints with a clinical diagnosis of closed lock was described. There were 10 patients and all were females with a mean age of 31.2 years (range 20 to 59 years). The antero-lateral approach was used for entry into 11 joints. The clinical findings were adhesions (64%), fibrillation (64%), anterior displacement of disc (36%) and scuffing of the articular surface of the glenoid fossa (9%). Two of the joints that had arthrocentesis prior to arthroscopy did not show any different findings from the rest. Of the 8 patients who had pre-arthroscopy pain, 7 patients (88%) had reduction of the symptom. Three patients (38%) had complete resolution of pain. The range of mouth opening (measured as maximal incisor opening) increased in all patients two weeks following arthroscopy. The average change in maximal incisor opening was 40.3% with a range of 22% to 85%. The mean follow-up was 34 months (range 4 to 68 months).     

Role of infrainguinal bypass in Buerger''s disease: an eighteen-year experience

We studied the mouth opening response to appendicular compression in two groups of children. This study was performed with the intention of testing the semiologic role of the act of mouth opening following stimulation of various regions, based on the hand mouth reflex of Babkin. Group I was formed by 33 normal children who underwent monthly follow up assessments since birth; and group II consisted of 50 children older than 6 months of age, known to have a neurologic deficit and a neuro-psychomotor development equivalent to that of a child in the first trimester of life. We observed that the normal mouth opening response in group I was more pronounced following compression of the hand and forearm when compared to compression of the arm (p < 0.001). This response could persist for as long as the first 6 months of life. We were not able to elicit a mouth opening response following compression of the lower limb in this group. Among children from group II, we observed mouth opening responses to stimulation of all limb segments. Within the upper limb, the response was more pronounced following compression of the hand in comparison to the forearm (p < 0.01), and forearm in comparison to the proximal arm (p < 0.01). Stimulation of the foot was more effective in eliciting a mouth opening response when compared to equivalent stimulation of the lower leg (p < 0.05). However, there was no statistical difference when responses to stimulation of the lower leg and thigh were compared. The presence of the previously unreported foot-mouth response may serve as an indicator of central nervous system compromise and could be associated with a poorer prognosis. We believe that our observations of the specific foot-mouth response patterns may serve as a marker of early neuro-psychomotor development dysfunction during childhood.     

Surgical management of temporomandibular joint ankylosis type III by retaining the displaced condyle and disc

PURPOSE: This article proposes a hypothesis regarding the value of saving the fractured condyle and disc in their displaced position in ankylosis type III for optimal temporomandibular joint (TMJ) function and growth, and describes four cases treated in this manner. PATIENTS AND METHODS: Four patients (three females and one male, 9 to 48 years old) with TMJ ankylosis type III of 3 to 8 years' duration, a maximal mouth opening of 15 to 19 mm, and severely limited lateral and protrusive movements were treated. The ankylosed sites were resected, leaving the displaced condyle and disc in their medial position. RESULTS: Fifteen to 60 months after surgery, the patients had a maximal mouth opening of 44 to 50 mm, as well as better contralateral and protrusive movements. In addition, two young patients (9 and 11 years old) showed an improved facial symmetry. CONCLUSIONS: Treatment of patients with type III TMJ ankylosis should involve retention rather than removal of the displaced condyle and disc. The condyle and disc are left untouched in their precarious medial position so as to provide normal function and growth.     

Phototherapy for patients with Alzheimer disease with disturbed sleep patterns: results of a community-based pilot study

Twenty of 67 children registered on the International Registry of Childhood Adrenocortical Tumors between May 1988 and December 1994 had small adrenocortical tumors (defined for this study as measuring < or = 200 cm3 and/or weighing < or = 100 g). We reviewed the records of these 20 patients to characterize the clinical and pathologic findings and outcomes of children with small adrenocortical tumors. Median patient age was 2 years (range, 4 months to 5 years). There was only one boy. All had clinical signs of virilization, and seven had signs or symptoms of Cushing syndrome. A median 5.5 months (range, 1-40 months) had elapsed between the first signs of endocrine dysfunction and diagnosis. All tumors were surgically resected. Tumor volume was 3.3-195 cm3 (median, -8.7 cm3), and weight was 3.7-100 g (median, 36 gm Tumor samples were histologically reviewed in 18 cases. Eight were adenomas, and 10 were carcinomas (6 low grade and 4 high grade). Pathology records described tumor with diagnostic features of adrenocortical carcinoma in two patients. One patient received mitotane for 8 months after surgery. Only one patient had recurrent disease, which was detected 6 months after diagnosis and proved rapidly fatal. Another has been lost to follow-up. The remaining 18 patients are alive with no evidence of disease at a median 2.3 years (range, 6 months to 6.1 years) after diagnosis. Our data suggest that children with small adrenocortical tumors have an excellent prognosis with surgery as the sole therapy, regardless of tumor histiotype.     

Diabetic papillopathy: two case reports in individuals with adult onset diabetes mellitus

BACKGROUND: Diabetic papillopathy is a benign unilateral or bilateral optic neuropathy with transient optic disk edema and minimal reduction in visual function. The optic disk edema typically resolves in a few months with no resulting optic atrophy and minimal or no decrease in acuity. The exact etiology of the disk edema is unknown, but theories include retinal vascular leakage into and surrounding the optic nerve and disruption of axoplasmic flow resulting from microvascular disease of the optic nerve head vasculature. CASE REPORTS: Two adult patients receiving insulin for type II diabetes mellitus manifested bilateral disk edema and minimal visual dysfunction. Both patients showed funduscopic evidence of mild-to-moderate nonproliferative diabetic retinopathy O.D. and O.S., and one patient had clinically significant macular edema in both eyes. The diagnosis in both cases was diabetic papillopathy. Both patients had significant resolution of their disk edema in 3 to 6 months, with stable acuities and no signs of optic atrophy. CONCLUSIONS: Although diabetic papillopathy is a well-known clinical entity in patients with type I diabetes, the clinical profile can be expanded to include individuals with type II diabetes.     

Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction

PURPOSE: This study was designed to evaluate the efficacy of arthroscopic lysis and lavage for patients with limited mouth opening. The relationship between preoperative mouth opening and the surgical outcome was determined. METHOD: Fourteen patients with 16 internally deranged joints were treated by arthroscopic lysis and lavage. All had received 10.4 (7 to 19) months of nonsurgical treatment before arthroscopy. The preoperative magnetic resonance images showed anterior disc displacement without reduction in all treated joints. RESULTS: Twelve of the 14 patients (86%) showed good reduction in pain and improved range of jaw movement on average follow-up of 28.5 (13 to 66) months. Two patients showed no improvement after arthroscopy and required open surgical procedures. The preoperative mouth opening of the successful group averaged 29.4 (22 to 35) mm, whereas the two failed cases had 10- and 19-mm openings, respectively (P < .05). CONCLUSION: Persistent limitation of mouth opening of more than 22 mm after nonsurgical treatment has a good prognosis when treated by arthroscopic lysis and lavage. However, those with greater limitation should probably have earlier surgical intervention.     

Depressive symptoms in individuals with idiopathic subjective dry mouth

It has been known for many centuries that there is a relationship between saliva flow rate and emotional status. The significance of psychological processes in the subjective sensation of a dry mouth has been discussed earlier, and this study deals with the presence of depressive symptoms in individuals with idiopathic subjective sensation of a dry mouth. Depressive symptoms in 94 healthy subjects with normal flow rates for unstimulated and stimulated whole saliva but with a subjective sensation of a dry mouth were assessed by the Beck Depression Inventory (BDI) and compared with healthy age- and gender-matched controls. The subjects with a subjective dry mouth condition were significantly more depressive and also had a significantly higher frequency of depressive symptoms. Depression was found in 21.3% of the individuals with a subjective dry mouth sensation and in 3.2% of the controls. The results of this study indicate that, in some cases, subjective dry mouth may be of psychological origin.     

Difficulty in eye opening following left hemispheric infarction-- causative lesion and pathophysiology of abnormalities of the eye and eyelids movements]

Creutzfeldt-Jakob disease (CJD) is a transmissible disease of the nervous system causatively related to the presence of an abnormal prion protein, with dementia, myoclonic jerks, and periodic EEG activity. Fourteen patients (7 females and 7 males) ranging from 26 to 76 years of age (median 59 years) were evaluated between 1974 and 1995 at the Neurologic Clinic of S?o Paulo University School of Medicine. The average duration of the disease was 12 months (3.5-34 months). Early clinical findings were: behaviour changes in 7 patients, dementia in 4, visual disturbances in 4, vertigo in 2, tremor in 9, and dystonia in one. Advanced symptoms were dementia and myoclonus in all patients. Pyramidal tract dysfunction was found in 6, cerebellar ataxia in 2, seizures in 3, nystagmus and vertigo in 4, and peripheral nervous system involvement in 2. Atypical clinical forms were found in 5 patients. Periodic EEG activity was found in 10 patients. Cerebrospinal fluid evaluation showed pleocytosis in 1 patient, higher protein content in 2, and higher gamma globulin level in 2. In 10 patients anatomopathological evidence in the central nervous system confirmed the clinical diagnosis by presenting with status spongiosus. All except one patient presented with the sporadic form of the disease.     

In vitro susceptibility of Mycobacterium ulcerans to clarithromycin

BACKGROUND: Long-term visual outcome following renal transplantation is poorly documented in medical literature. The purpose of this study was to determine the ocular morbidity in a group of renal transplant patients receiving immunosuppressive therapy. METHODS: Patients who had undergone renal transplantation were identified from the renal outpatient register, and patients who were at least 8 years posttransplantation were included in the study. Ocular examination was on average 14.6 years post-surgery. There were 43 males and 28 females, with ages ranging from 29 to 74 years. The patients had undergone renal transplantation between March 1968 and September 1986. The ophthalmic examinations were carried out over a 15-month period in a research clinic. RESULTS: Visual acuity was greater than or equal to 6/9 in 75% of the eyes. 10% of eyes had visual acuities of less than 6/24. Four eyes had central/branch retinal-vein occlusions; four eyes had posterior subcapsular lens opacities; three eyes had optic atrophy; one eye had complications of proliferative diabetic retinopathy; one eye had diabetic maculopathy and one eye had a central retinal artery occlusion. Only five eyes had irreversible visual loss resulting in visual acuities of less than 6/60. CONCLUSION: The incidence of sight-threatening complications in long-term survivors of renal transplantation was low. The results indicate that long-term prognosis for normal vision in patients who have undergone renal transplantation is good. Regular ophthalmic examinations are recommended for early detection of sight-threatening complications.     

The postconcussional syndrome reappraised

Despite the apparently benign nature of mild head injury, reflected by the short post-traumatic amnesia duration, relative absence of CNS signs and brief hospital stay, a significant number of patients report persistent symptomatology over the weeks or months afterwards. Largely subjective in nature, such symptom clusters are termed the postconcussion syndrome. The discrepancy between the predominantly subjective complaints and negative examination findings has generated uncertainty and debate about the respective causation roles of organic and psychogenic factors. Over the past 30 years evidence for organic brain changes has accumulated through studies of cerebral circulation, neuropsychological deficits, evoked potential recordings and neuroimaging. This paper reviews data from two UK prospective studies of the evolution and course of postconcussional symptomatology using parallel psychosocial, neuropsychiatric, quantitative EEG and brainstem auditory evoked potential recordings. Changes in theta power occurred early with resolution within 10 days. Prolonged brainstem evoked response I-V intervals were seen in between 27% and 46% of patients. Symptom chronicity noted in a minority of people (13%) was associated with a high prevalence of brainstem dysfunction, while the degree of QEEG recovery appeared to relate to the intensity of early symptom reaction to the trauma. Levels of perceived stress at the time of the injury or afterwards were not related to symptom formation, but chronic social difficulties were a feature of the 21% of patients who initially improved but had a late exacerbation of symptoms between 6 weeks and 6 months after the trauma.     

Glial tumourettes (glial microtumours): their clinical and histopathological manifestations

This study represents our experience with eight cases (males: 4; females: 4; 13-47 years old, average age 28.5 years) of a "glial tumourette" (minute glioma), which measured less than 15 mm in diameter on an MRI. Four tumours were located in the frontal lobe, one in the rostrum of the corpus callosum, two in the midbrain, and one in the thalamus. The symptoms and signs lasted from two days to 15 months prior to diagnosis, and they consisted of epileptic seizures in five patients and increased intracranial pressure due to hydrocephalus resulting from aqueductal stenosis in three. All patients had a CT scan and an MRI as a part of their initial neuroimaging evaluations. While the CT findings failed to show the lesion in four patients, MRI demonstrated it in all cases. Five tumours were either totally or subtotally removed while the remaining three were biopsied. Histological examinations revealed six tumours to be low-grade gliomas (fibrillary astrocytoma: 4; oligoastrocytoma: 2) and two to be high-grade gliomas (anaplastic astrocytoma: 1; anaplastic oligodendroglioma: 1). Regarding adjuvant therapy, three patients received radiation and/or chemotherapy. One of the patients with midbrain fibrillary astrocytoma died of the disease 38 months after the operation, however, no evidence of progression in the remaining seven has been observed in the follow-up period ranging from five to 65 months after the operation (average: 25.4 months). The histogenesis of benign and malignant gliomas and the importance of surgical exploration in the management of such patients with minute intracerebral tumours are also discussed.     

Chronic graft-versus-host disease treated with UVB phototherapy

Chronic graft-versus-host disease (cGVHD) is a major complication of allogeneic bone marrow transplantation. Immunosuppressive treatment regimens carry the potential of causing severe morbidity and mortality, so that additional modes of therapy with fewer side-effects are clearly needed. Five cGVHD patients (sclerodermoid cGVHD in two patients, lichenoid cGVHD in one patient and intraoral cGVHD in two patients), who had not responded to standard immunosuppressive drugs, were treated with adjuvant UVB phototherapy. The patient with lichenoid cGVHD experienced complete clearing of cutaneous lesions, whereas both patients with sclerodermoid cGVHD experienced significant relief of pruritus, but showed no change of the sclerodermoid skin lesions. Intraoral lesions cleared in one patient. The effects of UVB phototherapy were furthermore documented by measurement of skin viscoelasticity and mouth opening. No side-effects were encountered. This preliminary study suggests that UVB phototherapy is useful as an adjuvant therapeutic modality in intraoral and cutaneous lichenoid cGVHD.     

Occipitocervical fixation using hooks and screws for upper cervical instability

OBJECTIVES: Occipitocervical fixation is used for the treatment of nontraumatic upper cervical instabilities. To date, plates have been fixed with screws or wires. However, these devices are not indicated in the treatment of patients with severe osteoporosis or in instances of significant thinning of the occipital bone. We performed a clinical trial of a new type of fixation that uses cervical interlaminar hooks and occipital claws with hooks or with screws (CCD type; Sofamor-Danek, Roissy, France) for the treatment of nontraumatic upper cervical instabilities. METHODS: Five women and one man ranging in age from 28 to 72 years (average age, 54 yr) were thus treated. The CCD type material had two rod plates and hooks allowing the proper placement of interlaminar and occipital claws. The occipital plate can also be directly screwed to the bone. Occipital hooks were used in four patients. The other two patients, who had occipitocervical congenital abnormalities that required an occipitocervical opening and an additional dural enlargement, underwent occipital screw fixation because of the previous opening of the foramen magnum. A cancellous iliac autograft allowed the usual fusion. RESULTS: No postoperative complications were observed, and all patients experienced significant improvement of their neck pain. Four patients had neurological symptoms. The condition of two patients improved, and the condition of the other two stabilized. CONCLUSION: This report confirms the interest of the CCD method to correct all types of upper cervical instabilities, even in cases of unusual thinning of the occipital bone or in osteoporotic states.     

Improved one-step solid-phase extraction method for morphine, morphine-3-glucuronide, and morphine-6-glucuronide from plasma and quantitation using high-performance liquid chromatography with electrochemical detection

OBJECTIVE: The purpose of this survey was to study the sensation of oral dryness and its underlying factors in the 55-year-old population of Oulu (a medium-sized Finnish town), 780 of whom (77%) participated. METHOD: In addition to the examination of oral health status and salivary flow rate measurements, depressive symptoms were determined on the basis of the Zung Self-Rating Depression Scale (ZSDS). The participants were also interviewed about their health, medication, physical health, physical activity, smoking habits, alcohol consumption, and factors related to their work. RESULTS: The prevalence of subjective sensations of dry mouth was 25.8% among men and 33.3% among women (p = 0.025). A statistically significant association was found between a subjective sensation of dry mouth and a low unstimulated flow rate, regular smoking, xerogenic medication, and the presence of at least one illness connected with dry mouth. Those who had a sensation of dry mouth also thought their physical condition and their health to be poorer and more often had a high rate of depressive symptoms. After the confounding factors had been added stepwise into the logistic regression model, depressive symptoms were still significantly associated with the sensation of oral dryness. CONCLUSIONS: When evaluating the causes of the sensation of dry mouth, the possibility of depression as an underlying factor should be considered.     

Choledochoduodenostomy using suturing device SPP-20

The article discusses the results of choledochoduodenostomy formed with the C[symbol; see text]-20 suturing instrument in 51 patients by a method developed by the authors. The late-term results were studied in 46 patients in follow-up periods of 3 months to 2 years. In the group of 46 patients who were examined 45 had no complaints, they returned to their previous occupation, and stopped adhering to the diet 3-6 months after the operation. One patient noted significant improvement of his condition but nonetheless complained of aching pain experienced from time to time in the epigastrium, a bitter taste in the mouth, and sometimes nausea, which was associated with chronic pancreatitis. Immediate and late-term complications directly connected with formation of the anastomosis with a mechanical suture (C[symbol; see text]-20 instrument) as well as fatal outcomes were not encountered.