Background: Tuberculous epididymitis is one of the causes of chronic epididymal lesions. It is difficult to diagnose in the absence of renal involvement. Aim : To profile isolated tuberculous epididymitis and to assess our approach in the evaluation of this group of patients. Setting and Design : Retrospective study done at Christian Medical College, Vellore, South India. Methods and Materials : Between 1992 and 2002, 156 fine needle aspiration cytology specimens and 108 epididymal biopsies were carried out in 187 men for evaluation of chronic epididymal nodules. Isolated epididymal tuberculosis was defined as "tuberculous infection affecting the epididymis without evidence of renal involvement as documented by the absence of acid fast bacilli in the urine sample and on imaging". The age, laterality, mode of presentation and method of histological diagnosis were studied with the objective of profiling isolated tuberculous epididymitis. Results : Fifty-four of the 187 men (median age 32 years; interquartile range: 21-37 years) had tuberculous epididymitis. Fourteen were excluded from the analysis (10 had associated urinary tract tuberculosis and 4 were lost to follow-up). None of the 40 men with isolated tuberculous epididymitis had urinary symptoms. Bilateral involvement was seen in five (12.5%) cases. The salient presenting features included painful swelling (16 subjects, 40%), scrotal sinus (4, 20%) and acute epididymitis (2, 10%). Past history or concomitant presence of tuberculosis was noted in three subjects each. Anti TB treatment resulted in a complete response in 10 and partial response in 18. Five subjects underwent epididymectomy. Tuberculous epididymitis was found incidentally in 5 (10%) cases on high orchiectomy specimen done for suspected testicular tumour. Conclusions : Tuberculous epididymitis can be the sole presentation of genitourinary tuberculosis.

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Infectious diseases account for a third of all the deaths in the developing world. Achievements in understanding the basic microbiology, pathogenesis, host defenses and expanded epidemiology of infectious diseases have resulted in better management and reduced mortality. However, an emerging infectious disease, melioidosis, is becoming endemic in the tropical regions of the world and is spreading to non-endemic areas. This article highlights the current understanding of melioidosis including advances in diagnosis, treatment and prevention. Better understanding of melioidosis is essential, as it is life-threatening and if untreated, patients can succumb to it. Our sources include a literature review, information from international consensus meetings on melioidosis and ongoing discussions within the medical and scientific community.

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In general, the risk of transfusion-transmitted infections has been greatly reduced today. However, blood-borne bacterial and parasitic infections and emerging infections transmitted through transfusion are an area of increasing concern. Implementation of stringent donor eligibility criteria, improved donor screening and more sophisticated as well as sensitive methods of antibody, antigen and viral genome detection, have virtually eliminated transfusion transmitted infection in developed countries. In developing countries like India, the risk of transfusion-transmitted infections is still considerable. A comprehensive MEDLINE search and review of relevant transfusion medicine literature were carried out and the data extracted and studied with particular reference to emerging pathogens transmitted through blood transfusion and posing a huge threat.

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A rare case of synovial chondromatosis with extension to the middle cranial fossa is reported. Synovial chondromatosis, a benign disorder characterized by multiple cartilaginous, free-floating nodules that originate from the synovial membrane is not exclusive to the temporomandibular joint (TMJ). This condition is commonly seen in the axial skeleton and can involve multiple joints. In this case, synovial chondromatosis of the TMJ led to complete bony erosion of the glenoid fossa extending into the middle cranial fossa. Although plain radiographs showed the involvement of the joint, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) provided more detailed information about the lesion in all three dimensions. This case demonstrates the value of CT and MRI in both the diagnosis and treatment planning. A review of previously reported cases of synovial chondromatosis with cranial extensions is included.

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Background: There is abundant literature documenting that the Internet is fast changing the way patients access health-related information, learn about their illnesses, and make healthcare- related decisions. However, there is hardly any data regarding Indian patients accessing health-related information available on the Internet. Aims: To determine patients' use of the Internet as a medical information resource and to determine their experience, their perceptions of the quality and reliability of the information available. Setting: The study was carried out in the outpatient clinic of an urban, tertiary care private sector hospital in November 2004. Material and Methods : Our survey instrument consisted of an anonymous single-page questionnaire. Eight hundred and eighty consecutive adults aged 18-70 years, attending the general outpatient clinic of a tertiary care private hospital completed the questionnaire. Results: Two hundred and eighty-one (32%) patients acknowledged surfing the Internet, while 75% (212/281) of them acknowledged that they accessed health-related information. Amongst those who accessed the Internet, 130 (61%) found the information on the net to be of average quality. Almost all patients (211/212) felt that the information served the purpose and 95% (201/212) also found also found it to be reliable. Only 7% (21/281) patients were aware of the presence of any quality standards pertaining to health information sites and none could name any accreditation standard. Conclusions: One in four patients attending the private set-up is using the Internet for health information. A majority of patients find the information on the net reliable and of good quality. Awareness about health information quality standards is a rarity.

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Metastatic deposits within the breast may be difficult to distinguish from primary breast carcinoma. Radiological features and immunohistochemistry especially for steroid hormone receptors and expression of gross cystic disease fluid protein may be helpful in differentiating these two conditions. In this report, we present a case of signet ring cell stomach cancer with metastasis to the breast and discuss the differential diagnostic options.

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Background: The importance of communication skills in postgraduate medical training is likely to be highlighted given the convergence of research and educational forces. Assessment of these skills in residency training is vital since it can provide basis for policy undertaking among Pakistani medical academia for improving postgraduate training programs. Aim: To assess the perceived status of communication skills of residents in different specialties. Materials and Methods: A cross sectional survey was conducted in four teaching hospitals of Karachi between July 1999 and January 2001. A total of 455 residents in different residency programs were contacted. Residents registered both with College of Physicians and Surgeons of Pakistan and Postgraduate Medical Education office of selected hospitals were included in this study. Responses of residents were obtained on 5-point Likert scale. Indices were formed for three components of communication skills: informative, affective and professional communication. Statistical Analysis: Differences between residents' groups were assessed through analysis of variance. Results: Total informative communication index was lowest for multi-disciplinary (12.05, SD = 4.87) and highest for surgical (15.27, SD = 2.51) residents. Total affective index was lowest for multi-disciplinary (12.58, SD = 5.68) and highest for medical (15.74, SD = 3.59) residents. The group differences for four groups of residency programs were not statistically significant for either professional attributes separately or for the total professional index. Conclusions: The residency programs must establish goals, process and outcomes to incorporate communication skills in postgraduate medical training since this can enhance residents' performance as effective health care providers. Accomplishment of better communication skills can be achieved if the importance of its teaching and training is valued by residency program coordinators.

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Background and Aims: Chest radiographs (CXRs) are performed routinely after permanent pacemaker implantation to identify pacemaker lead position and exclude pneumothorax. We assessed the clinical value and need for this procedure. Design: Retrospective analysis of pacemaker data and CXRs following permanent pacemaker insertion between December 2002 and February 2004. Materials and Methods: Post-procedural CXRs were available in 125/126 consecutive patients after either first endocardial pacemaker implantation or insertion of at least one new lead. Subclavian vein puncture was used for venous access in all cases. CXRs were examined to establish the incidence of pneumothorax and assess pacing lead positions. The clinical records were examined in all patients who had subsequent CXRs or a further pacemaker procedure to identify the indication for these and to establish whether CXR had influenced patient management. Results: In total, 192 post-procedural CXRs were performed, either postero-anterior (PA) and/or lateral views. Ventricular and/or atrial pacing lead contour and electrode position was considered radiographically appropriate in 86% CXRs. Fourteen per cent of post-procedural radiographs were considered to have radiologically sub-optimal pacemaker lead positioning. None of the patients with these "abnormal" radiographs experienced subsequent pacemaker complications or had further radiographs recorded at a later date. Later repeat CXRs were performed in 16 patients (13%) but only 3 patients (2%) had pacing abnormalities as the primary indication. All three had satisfactory pacing lead position on initial post-implantation and later radiographs, but required further procedures for lead re-positioning. Iatrogenic pneumothorax occurred in one patient (incidence 0.8%) in our series. CXR confirmed the clinical diagnosis and allowed an assessment of size to guide treatment. Conclusion: Routine CXR after permanent pacemaker insertion is not necessary in uncomplicated cases with adequate pacing characteristics.

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Background: Mixed connective tissue disease (MCTD) has features common to lupus, scleroderma and myositis with high levels of antibodies to U1 ribonucleoprotein (U1 RNP). Identification of a high incidence of pulmonary artery hypertension (PAH) has changed its prospect. We report the largest series from India. Settings and Design: Rheumatology unit of a tertiary care centre in India; prospective. Materials and Methods: Patients seen between January 2002 and June 2004, satisfying the Kasukawa criteria were enrolled. All patients had a complete laboratory work-up including pulmonary function test, 2-D echocardiography, and Schirmer's test, antinuclear antibodies (ANA) and antibodies to extractable nuclear antigens. HRCT of chest was done where indicated. All patients were given standard treatment and followed up regularly. Results: Out of 1500 patients, thirteen (one male) were diagnosed to have MCTD. The median follow-up period was 18 months [Interquartile range (IQR) 12-22]. The median age of onset of symptoms was 36 years (IQR 22-39) and the median duration of disease was three years (IQR 1.75-4). The most common manifestation was polyarthritis followed by puffy fingers. Sjogren's syndrome, dysphagia and interstitial lung disease, was present in four, three and two patients respectively. Two patients each had myositis and migraine. None had PAH, serositis or renal involvement. Arthritis, puffy fingers and RaynaudÆs phenomenon were the most common manifestations at onset. All patients were positive for ANA and anti U1 RNP. Two patients each had antibodies to Sm and SSA. Response to treatment also was noted. Conclusion: Pulmonary artery hypertension is not common in early MCTD.

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Squamous cell carcinoma (SCC) of the skin usually occurs in older patients and commonly develops from actinic keratosis. Patients with xeroderma pigmentosum (XP) are highly sensitive to ultraviolet radiation and prone to develop multiple skin malignancies and can acquire SCC at an early age. We report an 18-month-old girl with XP who presented clinically because of a bilateral facial skin mass that was biopsied and found to be SCC. To our knowledge, the case we describe represents the youngest XP patient to have developed facial SCC.

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Aim: To develop a customised, portable, cost-effective (logarithmic minimal angle resolution) LogMAR chart with adjustable illumination for use as a mass vision-screening device in the rural population. Materials and Methods : Visual acuity of 100 individuals was evaluated with a customised chart and compared with the standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart and Snellen's Chart. Bland and Altman analytical techniques were used for analysis. Results: Test-retest variability of the customised chart was just a one-line difference (95% CI for agreement), and so were the results with the standard ETDRS charts; a variability of 3-line was noted with Snellen's chart. Two-line differences were observed when comparison was made with Standard ETDRS chart and 2 to 3-line differences with Snellen's chart. Conclusion: The customised portable LogMAR chart with adjustable illumination shows less test-retest variability and better agreement with standard ETDRS chart; therefore, it can be used as a mass vision-screening device in rural settings.

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We describe a case of a 58-year-old male with longstanding hypertension and Type 2 diabetes mellitus who developed sudden onset renal impairment. The first clue to the possible presence of amyloidosis in this case was provided by the radionuclide renal cortical scan performed with trivalent dimercapto succinic acid (Tc99m-DMSA-3), which revealed intense tracer uptake in the spleen suggesting amyloid deposit. Further workup to ascertain the cause of amyloidosis led to the diagnosis of multiple myeloma. We conclude that in cases of extra-renal or splenic accumulation of Tc99m-DMSA-3, a diagnosis of amyloidosis should be considered, in an appropriate clinical setting.

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Background: Incinerator workers are not considered to have arsenic overexposure although they have the risk of overexposure to other heavy metals. Aim: To examine the relationship between arsenic burden and risk of occupational exposure in employees working at a municipal refuse incinerator by determining the concentrations of arsenic in the blood and urine. Settings and Design: The workers were divided into three groups based on their probability of contact with combustion-generated residues, namely Group 1: indirect contact, Group 2: direct contact and Group 3: no contact. Healthy age- and sex-matched residents living in the vicinity were enrolled as the control group. Materials and Methods: Heavy metal concentrations were measured by atomic absorption spectrophotometer. Downstream rivers and drinking water of the residents were examined for environmental arsenic pollution. A questionnaire survey concerning the contact history of arsenic was simultaneously conducted. Statistical analysis: Non-parametric tests, cross-tabulation and multinomial logistic regression. Results: This study recruited 122 incinerator workers. The urine and blood arsenic concentrations as well as incidences of overexposure were significantly higher in the workers than in control subjects. The workers who had indirect or no contact with combustion-generated residues had significantly higher blood arsenic level. Arsenic contact history could not explain the difference. Airborne and waterborne arsenic pollution were not detected. Conclusion: Incinerator workers run the risk of being exposed to arsenic pollution, especially those who have incomplete protection in the workplace even though they only have indirect or no contact with combustion-generated pollutants.

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