Anesthesia for sickle cell disease and congenital myopathy in combination

We report on the perioperative management of anesthesia and analgesia in a child with sickle cell disease and a congenital myopathy, presenting for corrective orthopedic surgery. The case illustrates two valuable points of interest: the many benefits of regional anesthesia in complex medical cases and the successful use of tourniquets in children with sickle cell disease.

Congenital erosive and vesicular dermatosis

An 8-year-old boy born prematurely at 26 weeks' gestation presented with a reticulate scar on the left cheek. This started as an eroded area on day 3 postpartum, followed by crusting and scarring. There were also linear scars on the left forearm, left lower back and abdomen. The clinical picture fits the entity of congenital erosive and vesicular dermatosis. This retrospective case report delineates the outcome with diagnosis only evident after an 8-year time period.

Diabetes acceleration or prevention by a coxsackievirus B4 infection: critical requirements for both interleukin-4 and gamma interferon

Type 1 diabetes acceleration in nonobese diabetic (NOD) mice through coxsackievirus B4 (CVB4) infection requires a preexisting critical mass of autoreactive T cells in pancreatic islets, and in the absence of this insulitic threshold, CVB4 infection leads to long-term disease protection. To understand this acceleration and protection process, we challenged 8- and 12-week-old NOD mice containing a disruption in interleukin-4 (IL-4) or gamma interferon (IFN-gamma) genes (NOD IL-4-/- and NOD IFN-gamma-/-, respectively) with a diabetogenic, pancreatropic Edwards strain of CVB4. The elimination of IL-4 did not alter the rate of insulitis or diabetes development in NOD mice, while the elimination of IFN-gamma delayed these events several weeks. CVB4 infection in 8-week-old mice only significantly accelerated the onset of diabetes in a subset of standard, but not IL-4- or IFN-gamma-deficient, NOD mice. Long-term diabetes protection was established in standard NOD mice as well as in the NOD IFN-gamma-/- mice that did not rapidly develop disease following CVB4 infection at 8 weeks of age. When mice were infected at 12 weeks of age, the onset of diabetes was accelerated in NOD IL-4-/- mice, while neither acceleration nor long-term protection was elicited in NOD IFN-gamma-/- mice. No differences were observed in the kinetics of CVB4 clearance in pancreases from NOD, NOD IL-4-/-, and NOD IFN-gamma-/- mice. Collectively, these results suggest that at the insulitis threshold at which CVB4 infection can first accelerate the onset of diabetes in NOD mice, IL-4 as well as IFN-gamma contributes to this pathogenic process. The protective mechanism against diabetes elicited in NOD mice infected with CVB4 prior to the development of a critical threshold level of insulitis requires neither IL-4 nor IFN-gamma.

Localization of hepatitis B surface antigen epitopes present on variants and specifically recognised by anti-hepatitis B surface antigen monoclonal antibodies

Small hepatitis B surface antigen (HBsAg) is considered to be the best marker for the diagnosis of Hepatitis B virus infection. However, HBsAg variants with mutations within the "a" determinant may be poorly or not detected by diagnostic assays. Three anti-HBsAg monoclonal antibodies (6H6B6, 27E7F10, and 2G2G10), directed against conformational epitopes, were tested for their ability to detect the wild-type HBsAg as well as variant forms and their respective epitopes were localised on the HBsAg sequence by using the phage-displayed peptide library technology. Whereas 6H6B6 did not detect mutations T123N, S143L, D144A and G145R, 27E7F10 binding was affected by mutations P120T and G145R. In contrast, 2G2G10 reacted strongly with all tested variants including variant with the G145R mutation. Part of the 6H6B6 epitope was located in the major hydrophilic region (MHR) at residues 101-105, the 27E7F10 epitope (residues 214-219) was located near the C-terminal end of the antigen and the 2G2G10 epitope at residues 199-208, within the theoretical fourth transmembrane helix. The 2G2G10 epitope localisation brings information about the HBsAg structure and the validity of established topological models. Finally, 2G2G10 is a valuable tool for HBsAg variant detection that is used as capture phase in a new bioMérieux diagnostic assay, which is currently in development.

A prospective randomized study comparing division of the pedicle of modified hughes flaps at two or four weeks

PURPOSE

To compare the incidence of upper and lower eyelid malposition or other complications when the pedicle in modified Hughes flap repair of the lower eyelid is divided at 2 versus 4 weeks.

METHODS

A prospective randomized study. Data were collected on patient age and sex, horizontal tumor dimension, upper and lower eyelid position before surgery and 3 months after division of the pedicle, and any complications.

RESULTS

Complete data from 60 patients were collected, with 32 patients in the 2-week group and 28 patients in the 4-week group. The two groups were not significantly different in terms of sex, age, or tumor dimensions. In the 2-week group, the upper eyelid was within 1 mm of its preoperative position at 3 months in 25 of 32 patients (78.1%) and in 26 of 28 (92.8%) in the 4-week group. The lower eyelid was within 1 mm of its normal position in 27 of 32 patients in the 2-week group (84.4%) versus 25 of 28 (89.3%) in the 4-week group. Statistical analysis showed no significant difference between the 2- and 4-week groups for upper and lower eyelid position at 3 months. Other complications were uncommon and evenly spread between the two groups.

CONCLUSIONS

A modified Hughes flap pedicle may be divided at 2 weeks with no increased incidence in upper or lower eyelid malposition or other complication.

Diabetes management quality improvement in a family practice residency program

BACKGROUND

Diabetes is a devastating chronic disease. Although optimal diabetes control reduces chronic complications, actual provision of diabetes care frequently falls short of accepted guidelines. We wanted to determine whether locally developed diabetes care initiatives can result in improvements in the provision of diabetes care.

METHODS

This study was a retrospective cohort analysis using Medicare claims and chart abstraction data to ascertain diabetes care indicator utilization rates at the Northeast Iowa Family Practice Clinic (NEIFPC), which serves as the training site for the Northeast Iowa Family Practice Residency Program. Diabetic patients receiving care at the NEIFPC during 1996, 1997, and 1998 were included. Diabetes care rates are compared with those of other Iowa practices. Diabetes initiatives included chart audits, glycosylated hemoglobin (HbA1c) measurement reminder cards, educational symposia, an endocrinology outreach clinic, resident elective rotations, diabetes flow sheet utilization, pharmacist interface, and nursing foot-examination preparations. The primary outcome was the utilization rate of accepted diabetes care indicators.

RESULTS

Diabetic patients at NEIFPC had greater utilization of diabetes care indicators than did patients of Iowa collaborators in 1997 and 1998. NEIFPC patients had HbA1c levels measured more frequently in 1997 and 1998 (84% and 88%, respectively) than did patients of Iowa collaborators (49% and 41%, respectively) (P < .001). The mean 1997 and 1998 HbA1c levels of 7.32% and 7.25%, respectively, are impressive compared with that of Iowa collaborators (8.83% and 8.36%) (P < .001) and other published data (8.5%-10%). The percentage of NEIFPC patients with good glycemic control (HbA1c < 8%) was 75%, compared with the reported 50% of all US patients.

CONCLUSIONS

Our findings suggest that multimodal diabetes care quality improvement initiatives, applied longitudinally, can result in significant improvements in the provision and documentation of diabetes care.

Dacryocystorhinostomy for epiphora in the presence of a patent lacrimal system

PURPOSE

To evaluate the success rate of dacryocystorhinostomy (DCR) for epiphora in patients with a clinically patent lacrmal drainage system.

METHODS

A series of 51 patients, 12 men and 39 women, who underwent DCR surgery for epiphora with a clinically patent lacrimal drainage system in the background of normal eyelid examination, were evaluated. All patients underwent fluorescein dye disappearance testing and Jones 1 and 2 testing with dacryocystograms in borderline cases. A standard DCR was performed with bicanalicular silicone tubing inserted in all cases. The average time for the removal of the silicone tubes was 9.6 weeks.

RESULTS

In 48 cases (94%) there was improvement in symptoms with minimal or no significant epiphora postoperatively.

CONCLUSIONS

Epiphora with a patent lacrimal drainage system obstruction can be successfully treated by DCR based on fluorescein dye disappearance tests and Jones 1 and 2 tests, with dacryocystography in borderline cases.

Reactivity of 13 in vitro expressed hepatitis B surface antigen variants in 7 commercial diagnostic assays

The primary marker of current hepatitis B infection is the surface antigen (HBsAg), however HBsAg negativity does not exclude hepatitis B viremia. HBsAg variants can be responsible for such diagnostic failures. Here 13 different HBsAg variants were cloned, variant protein produced in a mammalian expression system, and tested using 7 commercial HBsAg diagnostic assays. Of 12 variants analyzed, 6 samples displayed similar reactivity to the positive control (containing standard HBsAg sequence) in most of the assays, but 6 samples, containing various mutations throughout the entire major hydrophilic region (MHR), showed reduced reactivity. It was found that the loss of cysteine at amino acid (aa) 124 in 1 sample affected the secretion as well as the reactivity of HBsAg in the expression system. Thus, not all assays are equally able to detect HBsAg variants, implying that, to attain an acceptable level of sensitivity, the antibody repertoire of the current assays should be extended.

The effect of family status and schizotypy on electrophysiologic measures of attention and semantic processing

BACKGROUND

Disturbances in both attention and language are central to the phenomenology of the schizophrenia spectrum disorders. The purpose of this study was to investigate the relative contributions of two factors, family status and schizotypy, on electrophysiologic measures of attention and semantic processing in family members of individuals with schizophrenia.

METHODS

Fifteen first-degree relatives of individuals with schizophrenia and 15 comparison subject controls participated in diagnostic evaluations, an assessment of schizotypy, and two event-related potential (ERP) paradigms. The first paradigm was an auditory P300 "oddball" task designed to assess attentional functioning. The second was an N400 sentence paradigm particularly sensitive to language processing.

RESULTS

Both relatives and individuals higher in schizotypy, but not their respective comparison groups, showed reductions in P300 amplitude. In the N400 paradigm, individuals higher in schizotypy, but not relatives, showed a reduced N400 effect. There were no differences in latency for either group on either component.

CONCLUSIONS

The results suggest that both family status and schizotypal presentation independently contribute to disturbances in electrophysiologic measures sensitive to attention and language. Whereas higher levels of schizotypy appear to be associated with disturbances in both attention and language processing, family membership appears to place individuals at risk for attentional deficits alone.

Abnormal angular gyrus asymmetry in schizophrenia

OBJECTIVE

Few studies have evaluated the parietal lobe in schizophrenia despite the fact that it has an important role in attention, memory, and language-all functions that have been reported to be abnormal in schizophrenia. The inferior parietal lobule, in particular, is of interest because it is not only part of the heteromodal association cortex but also is part of the semantic-lexical network, which also includes the planum temporale. Both the inferior parietal lobule, particularly the angular gyrus of the inferior parietal lobule, and the planum temporale are brain regions that play a critical role as biological substrates of language and thought. The authors compared volume and asymmetry measures of the individual gyri of the parietal lobe by means of magnetic resonance imaging (MRI) scans.

METHOD

MRI scans with a 1. 5-Tesla magnet were obtained from 15 male chronic schizophrenic and 15 comparison subjects matched for age, gender, and parental socioeconomic status.

RESULTS

Inferior parietal lobule volumes showed a leftward asymmetry (left 7.0% larger than right) in comparison subjects and a reversed asymmetry (left 6.3% smaller than right) in schizophrenic subjects. The angular gyrus accounted for this difference in asymmetry, with the left angular gyrus being significantly larger (18.7%) than the right in comparison subjects, a finding that was not observed in schizophrenic patients. A further test of angular gyrus asymmetry showed a reversal of the normal left-greater-than-right asymmetry in the schizophrenic patients.

CONCLUSIONS

Patients with schizophrenia showed a reversed asymmetry in the inferior parietal lobule that was localized to the angular gyrus, a structure belonging to the heteromodal association cortex as well as being part of the semantic-lexical network. This finding contributes to a more comprehensive understanding of the neural substrates of language and thought disorder in schizophrenia.

A clinicopathological correlation of 134 stage 1 and 79 non-invasive cutaneous melanomas presenting over a decade (1984-1993) at the Mater Misericordiae Hospital, Dublin

In a study of malignant melanoma during the period 1984-1993, 134 (63 per cent) had invasive melanoma and in 79 (37 per cent) melanoma was confined to the epidermis (in situ). There was female predominance, F: M = 2.4 : 1, a family history of melanoma in 1.5 per cent, a mean age at diagnosis of 50 yr. Females presented a decade earlier than males on average. Over half of invasive melanomas in females occurred on lower limbs; 40 per cent of lesions in males occurred on the trunk. Almost one third of lesions in males and over two thirds in females occurred in sun exposed area. Sixty per cent of invasive lesions were of the superficial spreading type and half of all lesions were histologically thin [less than 1.5 mm vertical depth]. Surprisingly, median lesion thickness was lower in males, probably reflecting the greater frequency of nodular lesions in females compared to males (36 per cent -v- 24 per cent). The marked increase in the number of invasive melanoma patients presenting in the second half of the decade studied (treble that of the first half) probably reflects an increase in melanoma incidence. Over the decade no change in invasive melanoma type, anatomical site or histological thickness was noted, the latter suggesting a failure to diagnose melanoma at an increasingly earlier stage. An official melanoma public education programme is required, particularly as half of the patients delayed 1 yr or more before seeking medical advice. However it is encouraging that, of the invasive melanomas, 30 per cent were small (< 10 mm), 50 per cent were histologically thin and that 37 per cent of all melanomas were in situ. The melanoma-in-situ group had a similar gender ratio and mean age at diagnosis to the invasive melanoma patients but lesions were smaller, were predominantly on the head, neck and limbs with lentigo melanoma as the commonest type.

Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients

Vaccination of health care workers (HCWs) is recommended as a strategy for preventing influenza in elderly patients in long-term care. However, there have been no controlled studies to show whether this approach is effective. During the winter of 1994-1995, 1059 patients in 12 geriatric medical long-term-care sites, randomized for vaccination of HCWs, were studied. In hospitals where HCWs were offered vaccination, 653 (61%) of 1078 were vaccinated. Vaccination of HCWs was associated with reductions in total patient mortality from 17% to 10% (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.40-0.80) and in influenza-like illness (OR, 0.57; 95% CI, 0.34-0.94). Vaccination of patients was not associated with significant effects on mortality (OR, 1.15; 95% CI, 0.81-1.64). Results of this study support recommendations for vaccination against influenza of HCWs in long-term geriatric care. Vaccination of frail elderly long-term-care patients may not give clinically worthwhile benefits.

Amyloidosis of the conjunctiva

BACKGROUND

Amyloid of the eyelid conjunctiva is an extremely rare condition which may result in chronic discomfort and multiple surgeries.

METHODS

A retrospective study of four patients from Moorfields Eye Hospital is presented to assess the clinical features and results of surgical treatment.

RESULTS

Three patients had persistent ocular irritation and required multiple surgical procedures for recurrent amyloid. However, one patient has been followed for nearly 30 years with relatively few symptoms, and has required only infrequent surgical intervention. All patients underwent debulking and ptosis surgery at least once. The more severe clinical course was not related to the type of amyloid protein present. Shave excision of recurrent tarsal conjunctival amyloid with split-thickness mucous membrane grafting was successfully tried in one patient in order to minimise postoperative cicatrisation of the posterior lamella.

CONCLUSION

The clinical course of patients with eyelid amyloid may vary greatly. Management should be conservative when possible, but surgery is an integral part of management since debulking of amyloid deposits and ptosis surgery was required in all patients in this series.

Urticarial vasculitis

Urticarial vasculitis describes a distinct entity in which the gross cutaneous lesions resemble urticaria and histologically show features of a vasculitis. The incidence of vasculitis in patients with apparent urticaria is between 2% and 20%. The diagnosis is suggested clinically by more persistent (lasting > 24 hours) and more symptomatic weals than in ordinary urticaria and by the presence of residual bruising. In addition to the skin the musculoskeletal, respiratory, renal and gastrointestinal systems may be involved in the disease, which is probably an immune complex mediated process. Urticarial vasculitis is most commonly an acquired idiopathic phenomenon but may occur in association with other disorders most often systemic lupus erythematosus, Sjögren's syndrome and serum sickness. In this article we review the background, histopathology, clinical features, extracutaneous manifestations, pathogenesis, aetiology, associated diseases, investigation, treatment, course and prognosis of urticarial vasculitis.

Age-related medial ectropion of the lower eyelid

BACKGROUND

A simplified procedure is proposed for the repair of medial lower eyelid age-related ectropion.

METHODS

A posterior horizontal incision is made in the medial half of the lower eyelid at the inferior border of tarsus. The lower eyelid retractors are exposed and then plicated to the tarsus without excision of posterior lamellae or the use of everting sutures. The lid is then shortened horizontally with excision of a pentagonal section or lateral tarsal strip procedure.

RESULTS

The procedure was performed in six patients successfully without complication.

CONCLUSIONS

This is an effective method for repair of lower lid medial age-related ectropion.