Implantation of collagen punctal plugs for the reduction of post-keratoplasty ametropia

In 1995, a 46-year-old woman was referred for refractive surgery. Eleven years earlier, she had undergone an uncomplicated penetrating keratoplasty in her right eye to treat a dense corneal opacity caused by contact lens-related microbial keratitis. Due to high myopia in the graft, she was unable to achieve useful vision and declined contact lens use. After extensive counseling, she elected to undergo radial keratotomy (RK) and arcuate keratotomy (AK) in her right eye. We recommended the insertion of collagen punctal plugs into the keratotomy incisions to increase the RK effect. She also decided to have RK in her left eye. Postoperatively, her uncorrected visual acuity was 20/25 OD and 20/30 OS. We were able to contact her and her ophthalmologist eleven years later, and eight of eleven collagen plugs were still present in the incisions, with no signs of rejection or inflammation. Later, we learned that she underwent a repeat penetrating keratoplasty due to corneal graft failure after a phacoemulsification procedure. The pathologic examination of the intact plugs and graft also showed no rejection or inflammation.

Virtual bronchoscopy as a dynamic modality in the diagnosis and treatment of suspected foreign body aspiration

AIM

Rigid bronchoscopy (RB) is an invasive procedure and has its own risks. The place of virtual bronchoscopy (VB) in the treatment of patients with a clinical and radiological suspicion of foreign body aspiration was evaluated to see whether its usage can prevent rigid bronchoscopy.

PATIENTS AND METHODS

The study was performed between December 2005 and May 2007 in 60 patients (35 M and 25 F) aged between 4 months and 7 years with clinical and radiographical suspicion of foreign body aspiration. Patients with radio-opaque foreign body aspiration were excluded from the study and treated directly by RB. VB was performed using 16 detector multislice computerized tomography (MDCT). If VB or clinical follow-up supported the diagnosis of foreign body, RB was performed for diagnosis and treatment. The results of RB were compared with the results of VB.

RESULTS

All patients underwent VB. In 40 patients there was a suspicion of foreign body with VB. Two patients improved without RB: one had spontaneous discharge of the foreign body with coughing, and one experienced spontaneous clinical improvement. The remaining 38 patients underwent RB and a foreign body was found in the reported localization in 33. No foreign body was found with RB in 5 patients showing foreign body in VB. But we found bronchial vegetations in 2, obstructing mucus plug in 2 and external bronchial compression by neuroenteric cyst in one. In 20 patients there was no suspicion of foreign body with VB. Of these, 7 patients with presenting symptoms for more than one month underwent RB, but no foreign body was found. The 13 remaining patients were followed up clinically with improvement of symptoms.

CONCLUSION

MDCT devices still require further investigation when used in pediatric surgical pathologies. Reconstructed images of VB can reveal images close to the real anatomy. In patients with a suspicion of foreign body ingestion, initial VB may help to determine the presence and exact localization of the foreign body and if negative, may reduce the number of unnecessary rigid bronchoscopies. None of the patients with negative VB had foreign bodies. Positive VB may help to shorten the operative time by providing information about the localization and size of the foreign body.

The treatment of primary and metastatic renal cell carcinoma (RCC) with stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS)

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Background: RCC is often regarded as a radio-resistant tumor. However, brain metastases from RCC have been successful treated with SRS. Therefore, metastases to extra-cranial sites may be treated with similar success using stereotactic body radiation therapy (SBRT), where image-guidance allows for the delivery of precise high dose radiation in a few fractions. We report our experience with SRS/SBRT in the management of primary and metastatic RCC. Methods: The image-guided Novalis radiation therapy system was used. Thirty patients with brain metastases were treated with SRS (16–22 Gy in a single fraction). Five of these patients underwent resection of their metastatic lesions after SRS and their pathology were reviewed. Twenty patients with extra-cranial metastatic lesions (orbits, head and neck, lung, mediatinum, sternum, clavicle, scapula, humerus, rib, spine, abdomen) and 2 patients with biopsy proven primary RCC (not surgical candidates), were treated with SBRT (24–32 Gy in 3–4 fractions over 1–2 weeks). All patients were immobilized in body cast and image-guidance was used for all fractions. 4D-CT was utilized in the treatment planning to assess tumor motion. Results: Of the 30 patients who received SRS to brain metastases, 25 showed decreasing or stable lesion size. Five patients showed an increase in size and underwent resection. Their pathology revealed necrosis in >99% of the specimen, with no viable RCC. Nineteen patients who received SBRT to extra-cranial metastases achieved symptom relief. One patient had local progression, yielding a local control rate of 95%. In the 2 patients with primary RCC, tumor size remained unchanged but their pain improved, and their renal function was unchanged post SBRT. There was no significant treatment related side-effect. Conclusions: Precise high dose radiation can cause significant tumor cell death in “radio-resistant” metastases from RCC. It also offers excellent local control and symptom palliation, without significant toxicity. Therefore, SBRT may represent a novel non-invasive, nephron-sparing option for the treatment of primary RCC as well as extra-cranial metastatic RCC. A prospective clinical trial using SBRT for primary and metastatic RCC is on-going.

No significant financial relationships to disclose.

Local bleomycin injection in the treatment of lymphangioma

AIM

We report here our experience with local bleomycin injection in lymphangioma.

PATIENTS AND METHODS

Nine patients with lymphangioma were treated with locally injected bleomycin and followed prospectively. We performed an ultrasound study in all cases to delineate the size, location, nature, and number of compartments of the cyst prior to the injection. Under ultrasound guidance, the content of the cystic cavity was aspirated and 1 - 3 mg/kg bleomycin were injected. The patients were revisited monthly. No attempt at re-injection was made as long as the mass continued to decrease in size.

RESULTS

Patients consisted of 4 boys and 5 girls aged between 14 days and 6 years. The localisation of the mass was cervical in 6, cervical, sublingual, and lingual in 1, axillary in 1 and axillary and thoracic in 1. In six children, the mass disappeared totally after a single injection. In one patient a second injection was needed, and surgical excision was performed in two patients with residual solid component. No complication related to bleomycin was seen.

CONCLUSION

Local application of bleomycin in children with lymphangioma is a simple, safe, and effective method. In the majority of cases, total healing may be achieved with a single injection.

Lymphomatoid granulomatosis in a boy with long-term follow-up

Lymphomatoid granulomatosis is an angiocentric lymphoreticular proliferative disease. Some patients go on to develop frank neoplasia. The authors describe a patient who presented at the age of 12 years with pulmonary nodules and hepatosplenomegaly and was followed up for 6 years, and who subsequently developed lymphoma after cessation of therapy.

CNS melanocortin system involvement in the regulation of food intake

Accumulating evidence indicates that the central melanocortin (MC) system plays a key role in the regulation of food intake and energy balance. This evidence includes findings that either spontaneous genetic mutations or targeted gene deletions that impair melanocortin signaling cause disrupted food intake and body-weight control. In addition, expression of the mRNA that encodes the endogenous agonists and antagonists for CNS melanocortin receptors is regulated by changes in energy balance and body-adiposity signals. Finally, administration of both natural and synthetic ligands to MC receptors produces changes in food intake. The data collectively suggest a critical role for melanocortin signaling in the control of energy balance.

An unusual foreign body in the bowel lumen causing obstruction in a neonate

Most of the foreign bodies swallowed by children pass the entire gastrointestinal tract without any complication. Neonatal intestinal foreign bodies are extremely rare. A newborn with a small bowel obstruction caused by a fresh grape is reported.

A case of incomplete Currarino triad with malignant transformation

A case of an incomplete Currarino triad is reported. The baby underwent an emergency laparotomy due to a life-threatening intestinal obstruction caused by severe rectal stenosis. During the posterosagittal anorectoplasty (PSARP), a presacral teratoma was identified and resected. The tumor recurred three times; she initially responded to chemotherapy, but nonetheless died at the age of 4 years. In cases with evidence of anorectal stenosis, a presacral mass should be suspected. PSARP is the best choice of treatment for both the anorectal anomaly and excision of the presacral mass. The presacral region should be followed up closely for recurrence of the tumor.

Snapshot of a large dynamic replicon in a halophilic archaeon: megaplasmid or minichromosome?

Extremely halophilic archaea, which flourish in hypersaline environments, are known to contain a variety of large dynamic replicons. Previously, the analysis of one such replicon, pNRC100, in Halobacterium sp. strain NRC-1, showed that it undergoes high-frequency insertion sequence (IS) element-mediated insertions and deletions, as well as inversions via recombination between 39-kb-long inverted repeats (IRs). Now, the complete sequencing of pNRC100, a 191,346-bp circle, has shown the presence of 27 IS elements representing eight families. A total of 176 ORFs or likely genes of 850-bp average size were found, 39 of which were repeated within the large IRs. More than one-half of the ORFs are likely to represent novel genes that have no known homologs in the databases. Among ORFs with previously characterized homologs, three different copies of putative plasmid replication and four copies of partitioning genes were found, suggesting that pNRC100 evolved from IS element-mediated fusions of several smaller plasmids. Consistent with this idea, putative genes typically found on plasmids, including those encoding a restriction-modification system and arsenic resistance, as well as buoyant gas-filled vesicles and a two-component regulatory system, were found on pNRC100. However, additional putative genes not expected on an extrachromosomal element, such as those encoding an electron transport chain cytochrome d oxidase, DNA nucleotide synthesis enzymes thioredoxin and thioredoxin reductase, and eukaryotic-like TATA-binding protein transcription factors and a chromosomal replication initiator protein were also found. A multi-step IS element-mediated process is proposed to account for the acquisition of these chromosomal genes. The finding of essential genes on pNRC100 and its property of resistance to curing suggest that this replicon may be evolving into a new chromosome.

Division of the genitofemoral nerve and late orchiectomy: effects on the contralateral testis in ipsilateral testicular torsion

Unilateral torsion of the spermatic cord has been demonstrated to damage the contralateral testis; however, the pathogenesis has not yet been examined in detail. The purpose of this study was to evaluate the influence of unilateral torsion on the contralateral testis in rats by performing ipsilateral division of the genitofemoral nerve (GFN) and/or late orchiectomy. Male 25-day-old, prepubertal Wistar albino rats were divided into five groups: (1) sham operation; (2) unilateral testicular torsion; (3) simultaneous unilateral testicular torsion and ipsilateral GFN division; (4) unilateral testicular torsion and orchiectomy on the 4th day after torsion; and (5) simultaneous unilateral testicular torsion and GFN ipsilateral division, and orchiectomy on the 4th day after torsion. Torsions performed were 720 degrees, all on the right testes. On day 55 after torsion, which represents the early postpubertal period of the rat, the contralateral testes were removed. Tubular biopsy score (TBS) was calculated, and seminiferous tubular diameters (STD) were measured. Student's t-test was used for statistical analysis. There was no contralateral testicular damage in the control group, but in all of the study groups destructive changes were found in the left gonad after torsion of the right testicle. The mean TBS of the study groups was higher than that of the control group. STD values were lower in the study groups, but the differences were not statistically significant between groups. In prepubertal rats, unilateral torsion causes histologically measurable changes in the contralateral testis. Ipsilateral division of the GFN and late orchiectomy did not cause any significant alterations in terms of contralateral damage. Further investigations are needed to determine the role of the GFN in testicular torsion.

Complete genomic sequence and analysis of the prion protein gene region from three mammalian species

The prion protein (PrP), first identified in scrapie-infected rodents, is encoded by a single exon of a single-copy chromosomal gene. In addition to the protein-coding exon, PrP genes in mammals contain one or two 5'-noncoding exons. To learn more about the genomic organization of regions surrounding the PrP exons, we sequenced 10(5) bp of DNA from clones containing human, sheep, and mouse PrP genes isolated in cosmids or lambda phage. Our findings are as follows: (1) Although the human PrP transcript does not include the untranslated exon 2 found in its mouse and sheep counterparts, the large intron of the human PrP gene contains an exon 2-like sequence flanked by consensus splice acceptor and donor sites. (2) The mouse Prnpa but not the Prnpb allele found in 44 inbred lines contains a 6593 nucleotide retroviral genome inserted into the anticoding strand of intron 2. This intracisternal A-particle element is flanked by duplications of an AAGGCT nucleotide motif. (3) We found that the PrP gene regions contain from 40% to 57% genome-wide repetitive elements that independently increased the size of the locus in all three species by numerous mutations. The unusually long sheep PrP 3'-untranslated region contains a "fossil" 1.2-kb mariner transposable element. (4) We identified sequences in noncoding DNA that are conserved between the three species and may represent biologically functional sites.

Operative complications of hernia repair in childhood

In a training center, 1,131 inguinal hernias were repaired in 1,000 consecutive patients in 6 years. The documents of these patients were reviewed retrospectively for surgical complications. A total of 38 complications were encountered in 35 patients, including wound infection (1.9%), recurrence (0.9%), tethered testis (0.3%), bladder injury (0.3%), was deferens injury (0.2%), iatrogenic orchiectomy (0.1%), and postoperative death. Most of them occurred in the early years of the clinic, and nearly one-half were technical in nature. Careful training, stressing the importance of gentle handling of the tissues, and meticulous dissection with emphasis on learning groin anatomy should reduce the incidence of such complications.

Random mutagenesis of Thermus aquaticus DNA polymerase I: concordance of immutable sites in vivo with the crystal structure

Expression of Thermus aquaticus (Taq) DNA polymerase I (pol I) in Escherichia, coli complements the growth defect caused by a temperature-sensitive mutation in the host pol I. We replaced the nucleotide sequence encoding amino acids 659-671 of the O-helix of Taq DNA pol I, corresponding to the substrate binding site, with an oligonucleotide containing random nucleotides. Functional Taq pol I mutants were selected based on colony formation at the nonpermissive temperature. By using a library with 9% random substitutions at each of 39 positions, we identified 61 active Taq pol I mutants, each of which contained from one to four amino acid substitutions. Some amino acids, such as alanine-661 and threonine-664, were tolerant of several or even many diverse replacements. In contrast, no replacements or only conservative replacements were identified at arginine-659, lysine-663, and tyrosine-671. By using a library with totally random nucleotides at five different codons (arginine-659, arginine-660, lysine-663, phenylalanine-667, and glycine-668), we confirmed that arginine-659 and lysine-663 were immutable, and observed that only tyrosine substituted for phenylalanine-667. The two immutable residues and the two residues that tolerate only highly conservative replacements lie on the side of O-helix facing the incoming deoxynucleoside triphosphate, as determined by x-ray analysis. Thus, we offer a new approach to assess concordance of the active conformation of an enzyme, as interpreted from the crystal structure, with the active conformation inferred from in vivo function.

Rapid purification of fluorescent dye-labeled products in a 96-well format for high-throughput automated DNA sequencing

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Neuropathological and neuropsychological changes in Alzheimer's disease. Relationship of biologic markers to behavioral markers

Alzheimer's disease is the fourth most common cause of death in the United States, and is the leading cause of functional disability in the elderly. This article analyzes the pathologic validity of mental status tests and the biochemistry of Alzheimer's disease patients.

MR imaging of hyperacute intracranial hemorrhage in the cat

Hyperacute intracerebral hematomas were successfully created in five cats by injecting a prepared blood sample in which the oxygen (O2) saturation ranged from 0-80%. T1- and T2-weighted spin-echo sequences and T2-weighted gradient refocused scans were obtained 2.5-10 hr after injection on a 1.5-T imaging system. Detailed histology or electron microscopy was performed on each brain to confirm the presence of intact red blood cells in a retracted clot matrix. Areas of the hematoma were hypointense relative to brain in all five cats on the gradient refocused scans. The hematoma was isointense relative to brain on the T1- and T2-weighted spin-echo scans in all cats except one, which suffered a seizure/respiratory arrest and died during the scanning procedure. Portions of the hematoma in this animal had a hypointense T2-weighted signal and a hyperintense T1-weighted signal, which corresponded to the predicted MR properties of intracellular methemoglobin. We hypothesize that acute (less than 10 hr old) hematomas that contain virtually 100% intracellular deoxyhemoglobin may not appear hypointense relative to brain on T2-weighted scan sequences at 1.5 T unless surrounding tissue hypoxia and/or anoxia promote additional changes, one of which may be the formation of intracellular methemoglobin.

Termination criteria in psychotherapy: a comparison of private and public practice

Results obtained from a questionnaire regarding termination criteria in psychotherapy, revealed significant differences between the public and private sector. Additional differences were also found for: length of sessions, frequency of sessions, length of treatment, hospitalizations, medication usage, ethnicity, diagnosis, degree of perceived improvement, and degree of clinical improvement.

Responses of pancreatic b cells to alloxan and streptozotocin in the guinea pig

Guinea pigs injected with streptozotocin were significantly hyperglycemic on day 1 after injection but only mildly so on day 14. However, serum insulin levels were significantly depressed on day 14; at this time the animals had lost 25% of their initial body weights and were severely glycosuric. The volume fraction of immunostainable B cells in the pancreas was reduced to one third of control values by day 1 after injection and remained at this level by day 14. Animals that received alloxan were slightly hyperglycemic on day 1 but not day 14. Both serum insulin and volume fraction of B cells in the pancreas were reduced by 70% on day 1 but had returned to control levels by day 14. Body weights for this group were equivalent to controls at both time points. These data indicate that: streptozotocin treatment of guinea pigs causes a diabetes-like condition characterized by insulin deficiency, pancreatic B cell loss, glycosuria, and weight loss, which are not reversed in the first 2 weeks after injection, whereas hyperglycemia is only transitory; alloxan also produces a diabetes-like condition early after injection, but all signs of diabetes disappear within 2 weeks, by which time serum insulin levels and the volume fraction of B cells in the pancreas have returned to normal. The experimental results suggest that regeneration of islet B cells following destruction by alloxan may be the primary cause of the recovery of alloxan-injected guinea pigs from the effects of the drug, whereas the persistence of insulin deficiency is consistent with an absence of islet B cell regeneration in the streptozotocin-treated animals.

Do community mental health centers serve the chronically ill? The New York experience

Some critics of the community mental health movement have contended that fewer clients with serious mental disorders are seen by local mental health centers. This statewide study compared patients being treated at community health centers (CMHC) with those seen at state psychiatric hospitals in New York State. Minor differences in psychiatric diagnoses and requisite levels of care needed emerged between short-term state psychiatric patients and CMHC inpatients. Suggestions for future research are offered.

Cross-cultural conceptions of mental illness

Previous published papers by the author addressed the issue of the epidemiology of mental illness across different cultures. This paper departs from this basis and stresses the need for examining mental illness within the context of any given culture. Thus, the application of rigorous criteria, such as those specified by DSM III or ICD-9, to all cultures, regardless of how different behaviors are viewed within the culture is deemed to be specious. Moreover, the treatment of mental illness has been shown to be related to the perception of mental illness within any given culture and is clearly affected by social norms. Mental health professionals from over 20 countries were administered a questionnaire querying whether hypothetical cases would be diagnosed as mentally ill and if so what would be their diagnosis. Differences between professionals were discussed in light of cross-cultural variations. Suggestions for future research are offered.

A treatment outcome study of alcohol halfway house residents in the south Bronx

A sample of 31 residents in an alcohol halfway house were evaluated upon admission and after a duration of time. An assessment of alcohol use, personality, and behavioral characteristics was conducted both initially and at the time of follow-up. The subjects were also compared based on the degree of successful outcome in the program. Differences between three outcome groups were found, indicating that the poor outcome group was younger, had a multiple-drug history, included more subjects who tended to drink with others, and had a greater number of blackouts while drinking. Suggestions for future research and a discussion of methodological difficulties are offered.

Deinstitutionalization: a microcosmic perspective

Changes have taken place in caring for chronic patients due to deinstitutionalization, and these changes have affected the services rendered by the community mental health centers. Statistical data on dehospitalized patients treated in a community mental health center located in the South Central Bronx are examined to determine trends in service utilization by these patients. Demographic characteristics of this population are also examined. Issues surrounding treatment and rehabilitation of chronic mentally ill patients are critically explored and recommendations for changes in the care of the chronically mentally ill patient are offered.

Incestuous experiences within homosexual populations: a preliminary study

The incidence, frequency rates, and effects of both homosexual and heterosexual incestuous experiences within lesbian and male homosexual populations are examined. Twenty-nine female homosexuals and 54 male homosexuals from diverse demographic backgrounds were administered a 16-page anonymous questionnaire designed to capture a wide range of demographic, personality, life history, and attitudinal information. Differences in family characteristics that exist between individuals who have experienced nuclear family incest, extended family incest, and those who have never experienced incest are investigated. Differences that exist between the two populations, incest and nonincest, were also studied.

Mental health systems and services abroad

A cross-national survey of forty-two countries and provinces was undertaken to compare mental health policies, mental health services, awareness of these services, the evaluation of such services and how mental health care is financed. Notable differences were found between respondents and these differences could not always be accounted for in terms of the level of the countries economic development. Discussions of trends are detailed and suggestions for future inquiry are proffered.

Mental illness in minority women

Explored whether psychiatric diagnostic differences exist between male and female, black, white and Hispanic-American patients seen in the Department of Psychiatry/Community Mental Health Center of a major hospital in the South Bronx, New York. Admission data on almost 2,000 patients furnished demographic and diagnostic characteristics of the patients. Sex and ethnic differences were found. Suggestions are offered as to why various subpopulations are perceived differently.

Ethnicity and psychiatric diagnosis

Examined diagnostic differences between black, white, and Hispanic-American patients (N = 1968) seen in psychiatric outpatient clinics of a large hospital in the South Bronx. Distribution of diagnoses also was compared statistically in relation to the diagnostician's ethnicity. Results indicated statistical differences between the patient's ethnicity and psychiatric diagnosis, as well as interactions between the therapists' ethnicity and these variables. Implications of the findings were discussed, and suggestions were offered for future research.

A study of criminal defendants referred for multiple psychiatric examinations regarding their competency to stand trial

One of the mainstays of forensic psychiatry has been the determination of a defendant's competency to stand trial. Competency to stand trial is based on the U.S. Supreme Court ruling that a defendant must have sufficient ability to understand court proceedings. Regardless of whether or not the defendant was mentally ill at the time a crime was committed or when the charged, the court can try someone only if that person has the capacity to understand proceedings in order to defend himself. When there is any question as to the competency of the defendant, he is referred for psychiatric evaluation of competency. Very little research has been undertaken in the past to examine this clinically interesting group of subjects. A study was conducted to explore the characteristics of 137 defendants who had been charged and referred for evaluation at least twice to the Court Clinic of the Bronx-Lebanon Hospital Center Department of Psychiatry. It was expected that these would reflect the consequence of deinstitutionalization in New York State. Data were collected for each evaluation with regard to demographic characteristics, criminal history, and psychiatric history. Results are presented and discussed in light of the issue of deinstitutionalization. Note is made of the fact that only very small percentage of these patients have received outpatient psychiatric care. Suggestions for future research are offered.

Time analysis of patients seen for multiple psychiatric evaluations of competency

Changes over time for a total of 137 individuals who were referred for multiple psychiatric examinations for competency were analyzed, using data on the evaluation of competency, psychiatric diagnoses, and criminal charges. Despite the fact that most of the subjects were repeatedly diagnosed as mentally ill, most of them were found competent. The only diagnoses which seemed to repeatedly be made were schizophrenia and mental retardation. The recurrence of certain serious criminal charges against the same defendants was reported and discussed. Suggestions for future research were made.

Multiple psychiatric competency examinations in borough of the Bronx

The sample of 137 people had been referred for multiple psychiatric competency examinations over an 11-yr. period. The study examined the relationships between the decision on competency and many demographic, psychiatric, and criminal history variables. On many variables there were no significant differences between those found competent and those found incompetent but those subjects deemed incompetent were more likely to be diagnosed as schizophrenic or psychotic. Suggestions for future research are offered.