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1/135. Use of computed tomography and plantar pressure measurement for management of neuropathic ulcers in patients with diabetes.

    BACKGROUND AND PURPOSE: Total contact casting is effective at healing neuropathic ulcers, but patients have a high rate (30%-57%) of ulcer recurrence when they resume walking without the cast. The purposes of this case report are to describe how data from plantar pressure measurement and spiral x-ray computed tomography (SXCT) were used to help manage a patient with recurrent plantar ulcers and to discuss potential future benefits of this technology. CASE DESCRIPTION: The patient was a 62-year-old man with type 1 diabetes mellitus (DM) of 34 years' duration, peripheral neuropathy, and a recurrent plantar ulcer. Although total contact casting or relieving weight bearing with crutches apparently allowed the ulcer to heal, the ulcer recurred 3 times in an 18-month period. Spiral x-ray computed tomography and simultaneous pressure measurement were conducted to better understand the mechanism of his ulceration. OUTCOMES: The patient had a severe bony deformity that coincided with the location of highest plantar pressures (886 kPa). The results of the SXCT and pressure measurement convinced the patient to wear his prescribed footwear always, even when getting up in the middle of the night. The ulcer healed in 6 weeks, and the patient resumed his work, which required standing and walking for 8 to 10 hours a day. DISCUSSION: Following intervention, the patient's recurrent ulcer healed and remained healed for several months. Future benefits of these methods may include the ability to define how structural changes of the foot relate to increased plantar pressures and to help design and fabricate optimal orthoses.
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2/135. pneumothorax due to electrical burn.

    A 25-year-old male developed early as well as delayed (15 days post burn) pneumothorax of right side following high voltage, 1100 KV, electrical burn of the right side of the chest wall. diagnosis was established by clinical examination and chest x-ray. Intercostal tube drainage with underwater seal relieved the patient of pneumothorax.
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3/135. Pulmonary hydatid cyst as a cause of recurrent haemoptysis and responding to treatment with albendazole.

    A 28 year old Ethiopian male who presented with recurrent haemoptysis, fever, and multiple well defined masses on a chest x-ray and subsequently responded to treatment with albendazole is reported. Complete remission of the symptoms and improvement of chest x-ray findings was attained within 2 months of initiation of treatment. The unusual presentation of pulmonary hydatid cyst and the response to pharmacotherapy is briefly reviewed.
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4/135. Chronic eosinophilic pneumonia.

    Chronic eosinophilic pneumonia (CEP) belongs to a group of syndromes manifested by pulmonary infiltrates with peripheral eosinophilia (PIE syndromes). The role of the eosinophil as a destructive agent in CEP is discussed. The degree of manifested eosinophilia at the time of diagnosis, the frequency of relapses of pneumonia, the response to steroid therapy, the status of current physical and x-ray findings, and especially the trend in pulmonary function data, all appear to be critical factors in determining the potential mortality risk of CEP cases.
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5/135. Acute relapsing encephalopathy mimicking acute necrotizing encephalopathy in a 4-year-old boy.

    A 4-year-old boy showed two episodes of encephalitis/encephalopathy involving disturbed consciousness, convulsion, and paresis associated with the elevated levels of protein and myelin basic protein of the cerebrospinal fluid. MRI studies of the brain revealed symmetrical lesions in the brain stem and thalami at the first episode, and additional lesions were found in the cerebellum involving both the gray and white matter in the second episode. The intensities of MRI lesions were low in T I and high in T2. These episodes were followed by an elevation of the anti-viral antibody titers, for influenza a virus during the first episode and for adenovirus during the second. In the second episode, intravenous methylprednisolone therapy resulted in rapid improvement of his neurological signs.
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6/135. An unusual cause of recurrent abdominal pain.

    abdominal pain is a common complaint with diverse etiologies. We describe an unusual case of recurrent abdominal pain in an adult due to lead poisoning, a condition usually associated with childhood. A previously healthy 42-yr-old man presented with 2 days of severe crampy abdominal pain and a 1-month history of constipation. physical examination was remarkable for diffuse abdominal pain but peritoneal signs were not present. blood tests were remarkable for hematocrit of 33 and mean cell volume of 78, with ovalocytes and basophilic stippling on blood smear. Abdominal x-ray showed stool throughout the colon and a nonspecific bowel gas pattern. The patient was treated with intravenous fluids and enemas, and his symptoms resolved within 2 days. Repeat history taking revealed he had been stripping paint from an old Victorian house in the preceding few months. He was discharged after a blood lead level was obtained. Before his clinic appointment he was readmitted 2 days later with recurrent abdominal pain. His blood lead level was elevated at 110 microg/dl (toxic range). After consultation with the occupational health and safety Administration and local poison control service, he was treated with intravenous calcium edetate disodium and intramuscular dimercaprol. He was asymptomatic at discharge, with a level of 56 microg/dl. Two weeks later, a repeat level was elevated at 72 microg/dl, for which he received a 3-wk course of oral dimercaptosuccimer. Subsequent levels were unremarkable, and the patient remains asymptomatic. abdominal pain secondary to lead poisoning in adults is uncommon. This case highlights the importance of taking a detailed occupational history and appropriately using "routine" blood tests to diagnose a rare condition that presented with a common complaint.
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7/135. Clinical treatment with the Begg appliance.

    In a series of three articles, clinical treatment with the Begg appliance has been discussed. In the March, 1973 article, the standard procedures in the three stages commonly used in the Begg method were illustrated in a series of eight cases showing the wide range of orthodontic treatment possibilities of this method. The February, 1974 article contained a case report that illustrated some of the problems connected with orthodontic observation, diagnosis, Begg treatment, and retention. In this third article, due attention has been given to common problems of the chairside worker as encountered in daily practice. Certain comments have been offered, particularly with regard to child dental care and orthodontic guidance procedures of the growing child. A treatment approach, based on an individual optimum for each patient is discussed, following the course of treatment of three cases (Figs. 1, 2, and 4) with unfavorable jaw patterns and dental problems. These are compared with others having better anatomic proportions (Figs. 3 and 5). In the last case (Fig. 5) diagnosis and treatment planning are once again reviewed. The essential decision to be made for each orthodontic treatment, namely, whether and which teeth must be removed, is discussed and illustrated. In all cases, attention has been given to the portrayal of methods and technical details through the three stages of Begg treatment.
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8/135. Management of cutaneous verruciform xanthoma.

    Verruciform xanthoma is an uncommon mucocutaneous condition of uncertain cause that only occasionally affects the skin. The histopathology is distinctive for the presence of foamy histiocytes present within elongated dermal papillae. Although simple excision of intraoral lesions is reportedly curative, treatment of cutaneous lesions has not been previously reported. We describe a 62-year-old man with a large lesion of verruciform xanthoma affecting both inguinal folds. Immunohistochemical staining, reverse transcriptase polymerase chain reaction for human papilloma virus, and ultrastructural analysis were performed to investigate the pathogenesis of this lesion. The results of these studies support the theory that the source of lipid in dermal histiocytes is degenerating keratinocytes. Initial treatment with wire loop electrosection, pulsed dye (585 nm) laser, and x-ray therapy of this patient proved unsuccessful. Preliminary success has been achieved using wide surgical excision with primary closure.
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9/135. "It isn't fair": postoperative depression and other manifestations of survivor guilt.

    The objective of this paper is to demonstrate and explain an array of phenomena, clinical and social, that share a common dynamic although they seem to be quite disparate. These experiences range from combat neuroses to postoperative depressions. Situations and case histories demonstrating this dynamic are presented, namely, the guilt of getting more than one's share of life, material possessions, or physical gifts than the people one loves. The relationship of this getting more and the concept of the "zero-sum game" is discussed. Suggestions are presented for the treatment of depressions resulting from this conflict. Survivor guilt is a common theme, running through our society in both dramatic and subtle ways. An awareness of this can help us explain certain phenomena and deal with some types of depression in our psychiatric work.
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10/135. Occult fractures of tibial plateau detected employing magnetic resonance imaging.

    We describe two cases of spontaneous fracture at the tibial metaphysis not diagnosed by standard X-ray. In both cases, only magnetic resonance imaging supplied a precise diagnosis and allowed us to follow the evolution of the pathology. Scintigraphy is equally sensitive but unspecific. osteoporosis was noted in all cases. Hypothetically, similar pathological situations could be present without being diagnosed since they are not always detected by standard x-rays.
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