Bone grafts are necessary to provide support, fill voids, and enhance biologic repair of skeletal defects. They are used by orthopaedic surgeons, neurosurgeons, craniofacial surgeons, and periodontists. Bone harvested from donor sites is the gold standard for this procedure. It is well documented that there are limitations and complications from the use of autograft, including the limited quantity and associated chronic donor site pain. Despite the increase in the number of procedures that require bone grafts, there has not been a single ideal bone graft substitute Scientists, surgeons, and medical companies, thus, have a tremendous responsibility to develop biologic alternatives that will enhance the functional capabilities of the bone graft substitute, and potentially reduce or eliminate the need for autograft. This article is an attempt to review the past and existing bone graft substitutes, and future directions of research. The historical data was extracted after thorough review of the literature. The data for the current concepts and future directions was compiled from the Internet, and from direct correspondence with medical companies. Since many products are undergoing clinical trials, and are yet not commercially available, their data cannot be found in literature. The main purpose of this article is to give the reader an idea about the existing market products and products likely to be available in near future.

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During the last two decades many advances have been made in the field of sarcoidosis. The disease is now recognised as a multisystem disorder occurring in patients with a genetic predisposition and an exposure to yet unknown transmissible environmental agent/s. The diagnosis is based on a compatible clinical and/or radiological picture, histological evidence of non-caseating granuloma and exclusion of other diseases capable of producing a similar clinical or histological picture. Treatment primarily consists of administration of corticosteroids, although there are valuable alternative drugs. Treatment should be considered in symptomatic patients with evidence of radiologic or lung function deterioration. The patients with extra-pulmonary involvement particularly with ocular, myocardial, and neuro-sarcoidosis almost always need treatment. For asymptomatic pulmonary sarcoidosis patients no therapy is needed.

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Gallstone disease is a complex disorder where both environmental and genetic factors contribute towards susceptibility to the disease. Epidemiological and family studies suggest a strong genetic component in the causation of this disease. Several genetically derived phenotypes in the population are responsible for variations in lipoprotein types, which in turn affect the amount of cholesterol available in the gall bladder. The genetic polymorphisms in various genes for apo E, apo B, apo A1, LDL receptor, cholesteryl ester transfer and LDL receptor-associated protein have been implicated in gallstone formation. However, presently available information on genetic differences is not able to account for a large number of gallstone patients. The molecular studies in the animal models have not only confirmed the present paradigm of gallstone formation but also helped in identification of novel genes in humans, which might play an important role in pathogenesis of the disease. Precise understanding of such genes and their molecular mechanisms may provide the basis of new targets for rational drug designs and dietary interventions.

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CONTEXT: Risk factors for failure of trabeculectomy may have a cumulative effect on the outcome. AIMS: To study the effect of preoperative ocular risk factors on the surgical outcome of trabeculectomy augmented with 2 commonly used doses of Mitomycin C. SETTINGS AND DESIGN: In a prospective cohort study, cases were recruited over an 18 month period. 92 eyes of 83 patients with one to three known risk factors for failure of trabeculectomy underwent Mitomycin-C (MMC) augmented trabeculectomy. METHODS AND MATERIAL: Trabeculectomy was done with a randomly chosen MMC dose of 0.2 mg/ml or 0.4 mg/ml. All cases were followed up for a period of at least 3 months. Surgical success was defined as the lowering of intraocular pressure (IOP) below 21 mmHg during the follow up period. STATISTICAL ANALYSIS USED: Chi square test, paired t test, odds ratio, effect size. RESULTS: Eyes with two or three risk factors (out of aphakic glaucoma, failed trabeculectomy, neovascular glaucoma, post uveitic glaucoma, traumatic glaucoma, adherent leucoma, juvenile glaucoma, prolonged medical therapy, steroid induced glaucoma, post penetrating keratoplasty glaucoma and developmental glaucoma) had a significantly poorer surgical success rate (88% and 78%) than eyes with one risk factor (100%). 0.4 mg/ml MMC used sub-sclerally had a statistically similar effect on lowering the IOP as 0.2 mg/ml in all groups. The rate of complications was significantly higher in the 0.4 mg/ml subgroup. CONCLUSIONS: The presence of more than one preoperative ocular risk factor, affects the surgical success of MMC augmented trabeculectomy in high-risk cases. Because of the significantly higher rate of complications with the higher dose of MMC, this should be used sparingly, only in cases with more than two risk factors.

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BACKGROUND AND AIM: Bacteriological studies are necessary to confirm the diagnosis of tuberculous lymphadenitis, as cytological appearances mimic other granulomatous lesions. The objective was to assess the diagnostic role of culture of fine needle aspiration done on clinically suspected cases of tuberculous lymphadenitis and to determine the prevalence of drug resistance in M. tuberculosis isolates. SETTING AND DESIGN: A prospective, double-blind study over a period of one year in a tertiary care hospital. MATERIAL AND METHODS: Fine needle aspiration cytology and culture were done on 250 patients with clinical suspicion of tuberculous lymphadenitis. STATISTICAL ANALYSIS: Data was statistically analysed using chi square test. Sensitivity, specificity, positive predictive and negative predictive values and likelihood ratio were also calculated. RESULT: Of the 161 cytologically or microbiologically proven cases of tuberculous lymphadenitis, cytological changes consistent with tuberculosis were observed in 133 patients, out of which mycobacteria were isolated in 102 aspirates. Mycobacteria were also isolated from 28 aspirates cytologically missed as tuberculous lymphadenitis. Of the 130-mycobacterial isolates, 5 were non-tuberculous mycobacteria. Culture positivity was significantly higher (P<0.001) than smear positivity. Drug susceptibility studies showed resistance to one or more drugs in 61% of isolated strains with maximum resistance to isoniazid (16% primary and 48% secondary) and minimum to ethambutol (4% primary and 12% secondary). CONCLUSION: Culture for mycobacteria should be carried out on all aspirates from patients suspected with tuberculous lymphadenitis.

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CONTEXT: Nocturnal Oxygen Desaturation (NOD) in patients with chronic obstructive pulmonary disease (COPD) is associated with a poor prognosis. AIMS: To document the occurrence of NOD in COPD and to identify factors which might predict NOD in COPD patients with daytime arterial oxygen tension (PaO2) > or =60 mm Hg. SETTINGS AND DESIGN: This prospective study was conducted in patients attending the special respiratory clinics or admitted in JIPMER, Pondicherry. METHODS AND MATERIAL: Thirty consecutive patients with COPD were divided into two groups, desaturators and non-desaturators on the basis of nocturnal oxygen saturation. Statistical analysis used: Unpaired 't' test, Karl Pearson's correlation equation and stepwise multiple regression analysis was done. RESULTS: Fourteen patients (46.6%) experienced NOD. Desaturators had lower awake oxygen saturation, PaO2, forced vital capacity, forced expiratory volume in one second and peak expiratory flow rate. There was positive correlation between nocturnal O2 saturation and PaO2 (r=0.638 and P value =0.014) and awake SPO2 (r=0.901 and P value <0.001). CONCLUSIONS: The rate of occurrence of NOD in COPD was 46.6%. Awake SPO2 is the only single predictor of nocturnal oxygen desaturation in these patients.

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We describe a 63-year-old Afro-Caribbean female who presented with complete ophthalmoplegia of the right eye. Magnetic resonance imaging revealed a mass in the cavernous sinus, which was pathologically confirmed as due to sarcoidosis. No clinical or laboratory evidence of sarcoidosis was found in any other organs. We believe this is the first reported case of an isolated cavernous sinus syndrome due to sarcoidosis and suggest that sarcoidosis should be considered in the differential diagnosis of cavernous sinus syndromes even in the absence of systemic involvement of sarcoidosis.

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BACKGROUND AND AIMS: St. John's Wort (SJW) is known to induce expression and activity of cytochrome P4503A4 (CYP3A4). However, its effects on other cytochrome P450 (CYP) are not well understood. Our objective was to characterise the effect of SJW on the expression of CYP1A2 in the LS180 intestinal cell model. STUDY DESIGN AND METHODS: LS180 cells were cultured in the presence and absence of SJW extract for 48 hours. CYP1A2 protein content was measured by Western blot analysis using monoclonal antibody. Time-dependent expression of CYP1A2 was assessed during exposure to SJW extract for 24 hours and following its removal for another 24 hours. RESULTS: SJW increased the expression of CYP1A2 in the LS180 cells in a concentration dependent manner. The induction was time-dependent, as enzyme levels returned to baseline within 4-8 hours after removal of SJW. CONCLUSIONS: SJW reversibly induces expression of CYP1A2 in LS180 cells. This induction may be responsible for reduced plasma theophylline concentrations upon co-administration of SJW, as reported earlier.

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Calculi in the seminal vesicles (SV) are extremely rare. A patient having large bilateral star-shaped calculi in the SV is reported. They were seen on plain x-ray and confirmed by computed tomography. On the reconstructed CT scans the large stone on the right side measured about 35 X 35 X 50 mm and the one on the left, 30 X 20 X 45 mm. They were not felt on rectal examination, as they were situated laterally.

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AIM: To determine whether intravenous ketoprofen is effective as pre-emptive analgesia for breast surgery. DESIGN: Randomised, controlled, double blind study. PATIENTS AND METHODS: 50 patients undergoing breast surgery under general anaesthesia randomised to receive either 100 mg intravenous ketoprofen 30 minutes before (Group I), or immediately after surgical incision (Group II). Postoperatively, pain scores (Visual Analogue Scale, VAS) and time to rescue analgesic were recorded by an independent, blinded observer. The study was terminated when rescue analgesic was required (VAS > or =4 or demand for analgesic). STATISTICAL ANALYSIS: Continuous variables were analysed by the unpaired 't' test, discrete variables with the chi square test, and survival curves by the log-rank test. RESULTS: Pain scores were significantly lower in Group I till 10 hours after surgery. The number of patients requiring analgesia at 4, 6, 8 and 10 hours was significantly lower in group I (0% vs. 47% [P <0.0001], 0% vs. 44% [P <0.003], 0% vs. 80% [P <0.0001], 0% vs. 100% [P <0.0001] respectively). The mean time for rescue analgesic was 15.47 -/+ 2.87 hours in group I versus 4.22 -/+ 2.55 hours in group II (P <0.0001). CONCLUSION: Pre-emptive analgesia with Intravenous ketoprofen (100mg) produces better postoperative pain-relief in patients undergoing breast surgery.

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BACKGROUND: South Gujarat has been witnessing increasing incidence of leptospirosis for the last few years. AIM: To study the clinical profile of leptospirosis in South Gujarat. SETTINGS AND DESIGN: Prospective study during July-September 2000 at the New Civil Hospital, Surat, Gujarat. PATIENTS AND METHODS: All the consecutive cases with clinical suspicion of leptospirosis were screened for lgM antileptospira antibody on the first and the fourteenth day. A four fold or greater increase in agglutinin antibody titre on paired samples was considered diagnostic. If the patient died before the fourteenth day then initial titre greater than 1:15 was considered diagnostic. RESULTS: Total number of patients referred to the hospital were fifty, of which thirty-eight [33 males, with age 14-50 (30 +/- 10.51)] were diagnosed as having leptospirosis. Most common organs involved were liver (27, 71.05%) and kidney (24, 63.15%). Cardio-vascular (12, 31.5%), pulmonary (10, 26.35%), neurological (2, 5.26%) and haematological (8, 21%) involvements were less common. Six patients died because of pulmonary involvement in the form of alveolar haemorrhage, while one died because of cardiac involvement. CONCLUSION: Liver and kidney were the most commonly involved organs in severe leptospirosis. Pulmonary involvement, though uncommon, led to high mortality.

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The coexistence of two different types of benign cartilaginous tumours of bone in the same patient has not been reported in literature. We report a case in which a sixteen-year-old male had a benign chondroblastoma of the proximal left humerus and an osteochondroma of the distal left femur. Both originated at the same time and had a progressive increase in size with growth.

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Melioidosis is an infection caused by Burkholderia pseudomallei. It is an important human pathogen in tropical area. The clinical manifestations are protean and multisystem involvement. We report an unusual case of melioidosis with abscess at root of mesentery in an elderly, non-insulin dependent diabetic Thai women. She presented with prolonged fever and chronic abdominal pain. The early clinical diagnosis was carcinomatous mass with peritonitis. Diagnosis of melioidosis arose from the surgical finding and pus culture. Treatment with surgical drainage and ceftazidime followed by co-trimoxazole plus doxycycline had a good clinical outcome.

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CONTEXT: Sexual communication and appropriate treatment of sexual partners is critical to the success of STD and HIV/AIDS prevention and control. AIMS: To understand factors influencing intention of STD patients to inform their regular sexual partners and identify predictors influencing actual return of the partners. SETTINGS AND DESIGN: A non-randomised survey of patients attending STD clinic in a district hospital between May and November 2000. METHODS AND MATERIAL: 182 patients were administered structured questionnaires to understand their intention to notify their regular sexual partners and encouraged to refer their regular sexual partners to the clinic for management. Factors related to intent to notify partners and actual partner referral were analysed. Statistical analysis used: Chi square test and forward stepwise logistic regression. RESULTS: Of the 182 STD patients 77.47% expressed their positive intention to notify their regular sexual partners. However, overall partner return rate was 40.65%. Patients from a better economic class (p=0.014), those who had sex since having the disease (p=0.001), those who felt it was easy to tell their partners (p=0.047) and perceived the necessity of investigating their partners (p<0.001) were more likely to have an intention to notify their partners. Independent predictors of actual return of sexual partners were patients' perception of partners' susceptibility (p=0.044), positive intention to notify partners (p=0.001), partners already informed before clinic visit (p=0.030) and presence of genital ulcerative diseases (p=0.033). CONCLUSIONS: STD clinic counselling and education should focus on risk reduction, partner susceptibility, role of STDs in HIV transmission and improving spousal communication.

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