1
|
Kabir KF, Hanna JP, Haghbin H. No Stone Left Unturned: Bouveret Syndrome Treated With Electrohydraulic Lithotripsy and Open Extraction With Pyloric Exclusion and Gastrojejunostomy. Cureus 2023; 15:e39661. [PMID: 37398755 PMCID: PMC10309015 DOI: 10.7759/cureus.39661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
Bouveret syndrome is ectopic gallstone impaction and obstruction of the duodenum or pylorus affecting a small minority of gallstone ileus cases. There have been advances in its endoscopic management, but this remains a challenging condition to treat successfully. We present a patient with Bouveret syndrome who required open surgical extraction and gastrojejunostomy after attempts of endoscopic retrieval and electrohydraulic lithotripsy (EHL). A 79-year-old man with a medical history of gastroesophageal reflux disease, chronic obstructive pulmonary disease on 5 liters of oxygen at baseline, and coronary artery disease with recent stenting presented to the hospital with three days of abdominal pain and vomiting. CT of the abdomen/pelvis demonstrated gastric outlet obstruction, a 4.5 cm gallstone in the proximal duodenum, cholecystoduodenal fistula, gallbladder wall thickening, and pneumobilia. Esophagogastroduodenoscopy (EGD) demonstrated a black pigmented stone impacted in the duodenal bulb with ulceration of the inferior wall. Repeated Roth net retrieval attempts of the stone were unsuccessful even after biopsy forceps were used to trim the stone's margins. The next day, EGD with EHL used 20 shocks of 200 watts, allowing for partial stone removal and fragmentation, but the majority of the stone remained stuck to the wall. Laparoscopic cholecystectomy was attempted but was converted to an open extraction of the gallstone from the duodenum, pyloric exclusion, and gastrojejunostomy. The gallbladder remained in place, and the cholecystoduodenal fistula was not surgically repaired. The patient experienced significant postoperative pulmonary insufficiency and remained on the ventilator with failure of multiple spontaneous breathing trials. Postoperative imaging showed resolution of pneumobilia but a small amount of contrast leaked from the duodenum revealing the fistula's persistence. After 14 days of unsuccessful ventilator weaning, the family opted for palliative extubation. Advanced endoscopic techniques have been regarded as the first-line intervention for Bouveret syndrome as there is low morbidity and mortality associated with them. However, there is a reduced success rate compared to surgical intervention. Open surgical management has high morbidity and mortality in the elderly and comorbid patients commonly affected by this condition. Thus, the risks and benefits must be weighed and individualized for each patient with Bouveret syndrome before therapeutic intervention.
Collapse
Affiliation(s)
- Kaiser F Kabir
- Internal Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, USA
- Internal Medicine, Ascension Macomb-Oakland Hospital, Warren, USA
| | - John P Hanna
- Internal Medicine, Ascension Macomb-Oakland Hospital, Warren, USA
| | - Hossein Haghbin
- Gastroenterology, Ascension Providence Hospital, Southfield, USA
| |
Collapse
|
2
|
Rizk VT, Naghavi AO, Brohl AS, Joyce DM, Binitie O, Kim Y, Hanna JP, Swank J, Gonzalez RJ, Reed DR, Druta M. Chemotherapy improves distant control in localized high-grade soft tissue sarcoma of the extremity/trunk. Clin Sarcoma Res 2020; 10:11. [PMID: 32670544 PMCID: PMC7350709 DOI: 10.1186/s13569-020-00132-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 06/29/2020] [Indexed: 02/01/2023] Open
Abstract
Background Soft tissue sarcomas (STS) are rare and heterogeneous tumors making chemotherapy use controversial. Our goal was to identify a subset of patients with primary STS that benefit with the addition of chemotherapy. Methods A retrospective chart review included intermediate to high-grade localized primary STS of the extremity/trunk, and tumor size > 5 cm. The effect of chemotherapy was evaluated for local control (LC), distant control (DC), progression free survival (PFS), and overall survival (OS). Results In this cohort (n = 273), patients were treated with surgery (98%), radiation (81%), and chemotherapy (24.5%). With a median follow-up of 51 months, the entire cohort’s 5-year LC, DC, PFS, and OS are 79.1%, 59.9%, 43.8%, and 68.7%, respectively. The addition of chemotherapy did not provide a DC benefit (p = 0.238) for the entire cohort. High-grade disease (n = 210) experienced a 5-year benefit in DC (68% vs. 54.4%, p = 0.04), which was more pronounced with MAI (Mesna, Adriamycin, Ifosfamide) based regimens (74.2%, p = 0.016), and a 5-year PFS (50.8% vs 45%, p = 0.025) and OS benefit (76.2% vs 70%, p = 0.067) vs. no chemotherapy. On multivariate analysis of the high-grade subset, chemotherapy independently predicted for a DC benefit (HR 0.48 95% CI 0.26–89, p = 0.019). The benefit of chemotherapy was more pronounced with MAI, showing a significant benefit in DC (HR 0.333 95% CI 0.145–0.767, p = 0.01) and PFS (HR 0.52 95% CI 0.28–0.99, p = 0.047). Conclusion In patients with localized STS > 5 cm, the high-grade subset had a distant control benefit with the addition of chemotherapy, leading to improved progression free survival. This is more pronounced with the use of MAI and should be considered in patients eligible for this regimen.
Collapse
Affiliation(s)
- Victoria T Rizk
- Department of Hematology and Oncology, Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612 USA
| | - Arash O Naghavi
- Department of Radiation Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - Andrew S Brohl
- Department of Sarcoma, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - David M Joyce
- Department of Sarcoma, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - Odion Binitie
- Department of Sarcoma, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - John P Hanna
- Department of Surgery, University of South Florida, Tampa, FL USA
| | - Jennifer Swank
- Department of Pharmacy, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - Ricardo J Gonzalez
- Department of Sarcoma, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - Damon R Reed
- Department of Sarcoma, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - Mihaela Druta
- Department of Sarcoma, Moffitt Cancer Center and Research Institute, Tampa, FL USA
| |
Collapse
|
3
|
Smith KE, Saad AR, Hanna JP, Tran T, Jacobs J, Richter JE, Velanovich V. Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy. J Gastrointest Surg 2020; 24:991-999. [PMID: 31147973 DOI: 10.1007/s11605-019-04264-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrent/persistent symptoms of achalasia occur in 10-20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. METHODS All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. DATA COLLECTED demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. RESULTS A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. CONCLUSION There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.
Collapse
Affiliation(s)
- Kaylee E Smith
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA
| | - John P Hanna
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Thanh Tran
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - John Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Joel E Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.
| |
Collapse
|
4
|
Gonzalez C, Hanna JP, Tran T, Montera B, Chharath K, Saad A, Velanovich V. Case-Control Comparison of Separation of Components Retrorectus Urinary Bladder Extracellular Surgical Device with Bovine Fetal/Calf Decellularized Dermis Underlay/Prosthetic Mesh Overlay Incisional Hernia Repair. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
5
|
Hanna JP, Frank JI, Furlan AJ, Sila CA, Secic M. Prediction of worsening consciousness from edema after hemispheric infarction. J Stroke Cerebrovasc Dis 2009; 6:25-9. [PMID: 17894961 DOI: 10.1016/s1052-3057(96)80022-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/1995] [Accepted: 01/16/1996] [Indexed: 11/25/2022] Open
Abstract
We sought to develop a risk profile that would predict worsening consciousness from edema after hemispheric infarction. Charts were reviewed correlating initial computed tomography scan, neurologic examination, demographic features, and ischemic mechanism with worsening consciousness from massive edema after hemispheric infarction. An edema risk profile composed of two of three clinical factors (gaze preference, hemiplegia, or hemineglect) and evidence of acute cortical infarction on initial computed tomography scan highly correlated with the later development of worsening consciousness from edema. The edema risk profile correlated with worsening consciousness from edema after hemispheric infarction. The profile requires prospective verification before use for family counseling, for anticipatory care, and for randomizing patients in acute stroke trials aimed at controlling the formation and sequelae of edema after ischemic stroke.
Collapse
Affiliation(s)
- J P Hanna
- Department of Neurology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | | | | |
Collapse
|
6
|
Bekavac I, Hanna JP, Sila CA, Furland AJ. Warfarin and low-dose aspirin for stroke prevention from severe intracranial stenosis. J Stroke Cerebrovasc Dis 2007; 8:33-7. [PMID: 17895135 DOI: 10.1016/s1052-3057(99)80037-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/1998] [Accepted: 09/16/1998] [Indexed: 11/16/2022] Open
Abstract
Management of symptomatic, intracranial, large-arterial atherosclerosis is controversial. We assessed the safety and efficacy of combining warfarin and low-dose aspirin to prevent stroke from intracranial atherosclerotic stenosis failing prior treatment with either aspirin or warfarin. Patients with severe intracranial stenosis were prescribed combination therapy, warfarin (international normalized ratio [INR] 2 to 3) and aspirin 81 mg daily. Ten men and six women treated with combination therapy had one recurrent ischemic event during 382 months of therapy. No patient suffered a myocardial infarction or sudden vascular death. No serious hemorrhagic complication occurred. The combination of warfarin and low-dose aspirin seems safe and effective in preventing recurrent stroke from symptomatic, intracranial, large-arterial occlusive disease after failure with either aspirin or warfarin monotherapy.
Collapse
Affiliation(s)
- I Bekavac
- Department of Neurology, MetroHealth Medical Center, Cleveland, OH, USA; Department of Neurology, The Cleveland Clinic Foundation, Cleveland, OH. USA
| | | | | | | |
Collapse
|
7
|
Hanna JP. A new direction in health insurance. 1955. Conn Med 2005; 69:425-8. [PMID: 16350488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
|
8
|
Abstract
As well as describing our pediatric BB and pellet gun injuries and the circumstances surrounding these injuries, we also evaluated parental perceptions of the dangers of BB and pellet guns. A convenience sample of three groups of parents and their children presenting to a Midwest, urban, children's hospital emergency department was prospectively enrolled. The three groups of parents included the injured group, which consisted of the parents whose children had been injured by BB or pellet guns; the gun group, which consisted of the parents who allowed their children to possess BB or pellet guns but had not sustained injury from these guns; and the no gun group, which consisted of the parents who did not allow their children to have these guns. All parents completed a survey concerning their attitudes toward BB and pellet guns. Twenty-eight parents completed questionnaires in each of the three groups. Most BB and pellet gun injuries occurred in adolescent males at home without adult supervision and were inflicted by a friend or by themselves. The injured group and the no gun group viewed BB and pellet guns as significantly more dangerous than the gun group. Parents who allow their children to have BB or pellet guns appear to misperceive their potential for injury by allowing their children to use these guns in an unsafe manner. Clinicians must educate parents about the significant potential for injury of nonpowdered guns.
Collapse
Affiliation(s)
- D T Damore
- Children's Hospital Medical Center of Akron, Ohio, USA
| | | | | | | |
Collapse
|
9
|
Hanna JP, Grasso FW, Atema J. Temporal Correlation Between Sensor Pairs in Different Plume Positions: A Study of Concentration Information Available to the American Lobster, Homarus americanus, During Chemotaxis. Biol Bull 1999; 197:250-251. [PMID: 28281801 DOI: 10.2307/1542632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
|
10
|
Duldner JE, Mikesell KA, Kiomento DJ, Barile AM, Emerman CL, Kovach B, Hanna JP, Fallon WJ. Acute stroke treatment in the rural emergency department: Effect of helicopter transport coordinated care track. Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80489-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
11
|
Abstract
Propofol, a new anesthetic, is now used more commonly to sedate patients in the intensive care unit. Propofol's rapid elimination has popularized its use to induce and maintain hypnosis in patients with refractory status epilepticus. It is also associated with occasional severe metabolic acidosis and hypoxia of indeterminate cause in children. We report a child and an adolescent who developed severe metabolic acidosis, progressive hypoxia, and rhabdomyolysis during maintenance infusion of propofol for the treatment of refractory status epilepticus. We suggest that propofol should not be used for prolonged sedation in children until its safety can be ensured.
Collapse
Affiliation(s)
- J P Hanna
- Department of Neurology, MetroHealth Medical Center, Cleveland, OH 44109, USA
| | | |
Collapse
|
12
|
Bekavac I, Hanna JP, Wallace RC, Powers J, Ratliff NB, Furlan AJ. Intra-arterial thrombolysis of embolic proximal middle cerebral artery occlusion from presumed atrial myxoma. Neurology 1997; 49:618-20. [PMID: 9270611 DOI: 10.1212/wnl.49.2.618] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The role of thrombolysis in brain ischemia in patients with atrial myxoma is unknown. A patient with acute brain ischemia and previously undiagnosed atrial myxoma recanalized an occluded middle cerebral artery with intra-arterial thrombolysis. Arterial occlusion from presumed myxoma may be amenable to fibrinolysis. Angiography before treatment in patients with atrial myxoma excludes a myxomatous pseudoaneurysm and permits site-specific thrombolytic instillment.
Collapse
Affiliation(s)
- I Bekavac
- Department of Neurology, Cleveland Clinic Foundation, OH 44195, USA
| | | | | | | | | | | |
Collapse
|
13
|
Abstract
Both spontaneous and reflexive movements may occur during the final stages of herniation and following brain death. We describe spontaneous, rhythmic (0.2 to 0.5 Hz), alternating flexion of the hip, knee, and ankle in two patients during the pontomedullary phase of central herniation following a massive hemispheric infarct. Automatic stepping is likely a spinal automatism generated within the spinal locomotion center and regulated by both ascending and descending brainstem tracts. Clinicians and family members of neurologically devastated patients should be aware that this and other movements can occur during the late stages of central herniation preceding and following brain death.
Collapse
Affiliation(s)
- J P Hanna
- Department of Neurology, Cleveland Clinic Foundation, OH 44195, USA
| | | |
Collapse
|
14
|
Hanna JP, Sun JP, Furlan AJ, Stewart WJ, Sila CA, Tan M. Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke 1994; 25:782-6. [PMID: 8160221 DOI: 10.1161/01.str.25.4.782] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Paradoxical embolism through a patent foramen ovale is a recognized cause of stroke, but clinical predictors, recurrence rate, and prevention of brain infarcts in patients with patent foramen ovale have not been determined. We reviewed transesophageal echocardiographic records to ascertain echocardiographic predictors and optimal prophylaxis for patent foramen ovale-related infarcts. METHODS A patent foramen ovale was identified in 74 patients during 615 transesophageal echocardiograms by color Doppler or saline contrast during a 60-month period. On the basis of final clinical situation, the patients were divided into the following groups: group 1, infarct with patent foramen ovale a likely cause (n = 16); group 2, infarct with patent foramen ovale an unlikely cause (n = 23); and group 3, no infarct (n = 35). Transesophageal echocardiograms were reviewed to assess patent foramen ovale characteristics and associated cardio-embolic sources without knowledge of clinical details or group assignment. Follow-up after a patent foramen ovale-related infarct was obtained by telephone or written correspondence in 15 of 16 group 1 patients. RESULTS Atrial septal aneurysms were more common in group 1 (38%) compared with group 2 (10%) and group 3 (8%) (P = .02). Contrast right-to-left shunting occurred in 88% of group 1 (P = .06) and 86% of group 2 (P = .07) compared with 60% of group 3. Prevention of recurrence in subjects with presumed patent foramen ovale-related brain infarcts varied. Aspirin was usually chosen after initial brain ischemia. Warfarin and patent foramen ovale closure were usually reserved for subjects with symptoms of brain ischemia while taking aspirin or those who required warfarin or cardiac surgery for other indications. No recurrent infarcts occurred in 15 patients during a mean follow-up period of 28 months. CONCLUSIONS Atrial septal aneurysm and right-to-left shunt may be predictive of a patent foramen ovale that predisposes a patient to stroke. Aspirin may provide sufficient infarct prophylaxis after initial ischemia. Warfarin and surgical correction should likely be reserved for those in whom aspirin is not effective or those who require warfarin or cardiac surgery for other reasons until prospective studies are available.
Collapse
Affiliation(s)
- J P Hanna
- Department of Neurology, Cleveland Clinic Foundation, Ohio 44195
| | | | | | | | | | | |
Collapse
|
15
|
Abstract
We compared the reliability of asymmetry of forearm rolling (rotation of one forearm around the other in front of the torso) as a sign of unilateral cerebral dysfunction with that of other standard clinical tests. We studied 62 patients with radiologically confirmed unilateral cerebral lesions and 20 control subjects with normal imaging. Asymmetric forearm rolling was the most sensitive indicator of unilateral hemispheric disease (85%). This simple test is a useful addition to the neurologic examination.
Collapse
Affiliation(s)
- R N Sawyer
- Department of Neurology, Department of Veterans Affairs Medical Center, Cleveland, OH
| | | | | | | |
Collapse
|
16
|
Grant MP, Leigh RJ, Seidman SH, Riley DE, Hanna JP. Comparison of predictable smooth ocular and combined eye-head tracking behaviour in patients with lesions affecting the brainstem and cerebellum. Brain 1992; 115 ( Pt 5):1323-42. [PMID: 1422791 DOI: 10.1093/brain/115.5.1323] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We compared the ability of eight normal subjects and 15 patients with brainstem or cerebellar disease to follow a moving visual stimulus smoothly with either the eyes alone or with combined eye-head tracking. The visual stimulus was either a laser spot (horizontal and vertical planes) or a large rotating disc (torsional plane), which moved at one sinusoidal frequency for each subject. The visually enhanced vestibulo-ocular reflex (VOR) was also measured in each plane. In the horizontal and vertical planes, we found that if tracking gain (gaze velocity/target velocity) for smooth pursuit was close to 1, the gain of combined eye-hand tracking was similar. If the tracking gain during smooth pursuit was less than about 0.7, combined eye-head tracking was usually superior. Most patients, irrespective of diagnosis, showed combined eye-head tracking that was superior to smooth pursuit; only two patients showed the converse. In the torsional plane, in which optokinetic responses were weak, combined eye-head tracking was much superior, and this was the case in both subjects and patients. We found that a linear model, in which an internal ocular tracking signal cancelled the VOR, could account for our findings in most normal subjects in the horizontal and vertical planes, but not in the torsional plane. The model failed to account for tracking behaviour in most patients in any plane, and suggested that the brain may use additional mechanisms to reduce the internal gain of the VOR during combined eye-head tracking. Our results confirm that certain patients who show impairment of smooth-pursuit eye movements preserve their ability to smoothly track a moving target with combined eye-head tracking.
Collapse
Affiliation(s)
- M P Grant
- Department of Neuroscience, Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | | | | | | | | |
Collapse
|
17
|
Abstract
Poisoning with tropine alkaloids from cultivated plants and pharmaceuticals is an uncommon cause of delirium and coma. We report a patient with a toxic delirium following ingestion of the tropine alkaloid-containing root of Datura innoxia. Thin-layer chromatography and gas chromatography/mass spectrometry confirmed the presence of atropine and scopolamine in samples of the ingested root. Routine clinical toxin screens may not include an assay for tropine alkaloids. A specific tropine alkaloid assay may provide supporting evidence. The clinical, electroencephalographic, and therapeutic aspects of anticholinergic poisoning are discussed.
Collapse
Affiliation(s)
- J P Hanna
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | |
Collapse
|