What predicts outcome after recanalization of chronic venous obstruction: hemodynamic factors, stent geometry, patient selection, anticoagulation or other factors?

In this review we evaluated the effect of different suggested factors associate with the outcome after recanalization of chronic venous obstruction (CVO).

Hemodynamic factors:

Based upon literature no clear suggestions can be made to identify the risk of stent occlusion in association with the hemodynamic effects. However it is evident that ensuring optimal in- and outflow of the stented tract is key in maintaining the patency.

Patient selection:

Noninvasive imaging modalities are used to divide patients in three subgroups based on the place and extension of post-thrombotic changes. Moreover it should be noted that AV fistula in selected patients can reduce the risk of thrombosis or re-occlusion.

Geometry:

Excessive oversizing of the stent and stent compression from outside are considered to be associated with stent occlusion. Additionally, overlapping rigid stents, unnatural angel between stents and in-stent kinking are other geometrical factors related to worse outcome after venous recanalization.

Anticoagulation:

Adequate peri-and postoperative anticoagulation has a crutial role in stent patency. There is no data regarding the duration of anticoagulation therapy and recommendations vary between 6 weeks to 6 months.

Result:

impaired inflow or outflow, presence of a hypercoagulability, total number of treated segments and use of stents designed for implantation in arterial system are associated with decreased stent patency.

Strategies to increase adherence with tuberculosis test reading in a high-risk population

OBJECTIVE

To determine the most effective strategy to encourage adherence with tuberculosis test reading in a high-risk population. Design. Prospective randomized controlled trial.

SETTING/PARTICIPANTS

Consecutive sample of 627 children ages 1 to 12 years due for a tuberculosis (TB) test in an urban children's hospital outpatient department. One child per family was enrolled.

INTERVENTION

All families received education regarding the importance of skin testing for TB and the need for follow-up, and written and verbal instructions regarding test reading. Families were randomly assigned to one of five strategies for follow-up TB test reading at 48 to 72 hours: 1) routine verbal and written instructions, 2) reminder phone call, 3) transportation tokens and toy on return, 4) withholding of school forms until time of reading and need to repeat TB test if not timely read, 5) parents taught to read induration with nurse home visit. Those who did not have tests read at 48 to 72 hours by a trained professional were phoned 1 week later.

RESULTS

The five groups did not differ with regard to TB risk factor score, maternal education, transportation source, or perceived importance of TB testing. Before the study the follow-up rate of TB test reading by a trained professional was 45%. Reading rates in this study were 58%, 70%, 67%, 70%, and 72% for groups 1 to 5, respectively. In group 4, only 39% had school forms to be completed and their adherence rate was 84% (53/63). Compared to group 1, the only statistically significant improvement was in group 4, especially for those who needed school forms completed, and in group 5. Those not adhering in groups 1 to 4 did not differ from returnees with regard to TB risk factors, maternal education, transportation, or perceived importance of testing. The most common reasons for failing to return included forgetfulness, transportation, and time constraints. Group 5 was stopped early because of difficulty with nurse visits (N = 98). When told of the nurse visit, 9% (9/98) families could not find a time for the visit. Seventeen percent (17/98) were visited but the child was not home, and 7% (7/98) were not visited because of a nurse scheduling problem.

CONCLUSIONS

In a high-risk population, adherence with TB test reading is poor. However, education and return of school forms at reading time can significantly improve adherence. Although requiring larger investment in resources, visiting nurses may also aid in test reading.

Golf-related ocular injuries

OBJECTIVE

To review golf-related ocular injuries, which account for 1.5% to 5.6% of all sports injuries.

METHODS

During 8 years (1986 to 1994), a retrospective review of sports-related trauma was performed at the Medical College of Wisconsin, Milwaukee. Eight blunt ocular injuries (four ruptured globes and four globes without rupture) caused by golf-related activities were identified. The four ruptured globes caused by golf-related trauma accounted for 1.2% of all penetrating injuries and/or ruptured globes and 11.7% of sports-related injuries.

RESULTS

A golf ball projectile was the mechanism of injury in six patients, while two patients were struck with a gold club. The four patients with ruptured globes had an initial visual acuity of light perception or worse, and three globes were subsequently enucleated, while one was prephthisic. In the four trauma cases without rupture, surgical intervention was required to achieve anatomic stability, with final visual acuities ranging from 20/25 to 20/40.

CONCLUSIONS

The incidence of ocular injuries caused by golf-related trauma is low compared with that for other sports-related injuries. Although the prognosis for ruptured globes occurring in this setting remains extremely guarded, blunt trauma without rupture caused by a golf-related injury is associated with a more favorable visual and anatomic outcome.

Phialophora verrucosa infection in an AIDS patient

Phialophora verrucosa is one of several pathogenic dematiaceous fungi associated with chromomycosis and occasionally phaeohyphomycosis. Infection appears to be increasing in frequency in both immunocompromised and presumably healthy patients. Medical therapy is often difficult, and a wide variety of antifungal agents have been tried with varying degrees of success. We report a patient with acquired immunodeficiency syndrome (AIDS) and extensive cutaneous fungal infection due to Phialophora verrucosa. The disease failed to respond to ketoconazole, but regression of the lesions was obtained with itraconazole.

High-resolution magnetic resonance imaging evaluation of blood-retinal barrier integrity following transscleral diode laser treatment

OBJECTIVE

To compare the effects of contact transscleral diode laser treatment and retinal cryotherapy on blood-retinal barrier integrity with the use of high-resolution magnetic resonance imaging techniques with constant infusion of gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA).

METHODS

Transscleral diode laser photocoagulation and retinal cryotherapy were used to treat equivalent areas of the inferior retinal periphery of pigmented rabbits. Magnetic resonance imaging time-course studies with measurement of signal enhancements due to Gd-DTPA leakage were conducted 2 and 15 days following treatment.

RESULTS

Two days following treatment, cryotherapy-treated eyes exhibited a mean (+/- SD) effective Gd-DTPA permeability coefficient of 4.6 +/- 0.8 x 10(-6) cm/s; in comparison, diode laser-treated eyes exhibited 1.6 x 1.4 x 10(-6) cm/s effective permeability. Significant decreases in the effective permeability were also noted 15 days after treatment in both groups.

CONCLUSIONS

Transscleral contact probe diode laser photocoagulation induces less disruption of the blood-retinal barrier than does conventional cryotherapy. In addition, the continuous infusion method of Gd-DTPA delivery is a reliable and easily interpretable alternative to the commonly used bolus injection approach.

Surgical removal of an extrafoveal fibrotic choroidal neovascular membrane with foveal serous detachment in age-related macular degeneration

BACKGROUND

Visual recovery after submacular surgery for age-related macular degeneration (AMD) has been very limited.

METHODS

A patient with an extrafoveal fibrotic choroidal neovascular membrane from AMD had an overlying serous foveal detachment with the fibrotic tissue elevating the foveal retina. Photocoagulation of the neovascular membrane was not recommended because of its nonpigmented, fibrotic nature. The membrane was surgically excised.

RESULTS

Preoperative and postoperative visual acuity and central 30 degrees visual fields were followed. Visual acuity improved from 20/200 to 20/25, and a preoperative central scotoma resolved completely 18 months after surgical excision of the extrafoveal fibrotic neovascular membrane. There were no intraoperative or postoperative complications.

CONCLUSION

This type of patient may represent a distinct subset of patients with AMD amenable to subretinal surgery who could potentially have good recovery of vision.

Posterior segment changes in membranoproliferative glomerulonephritis

Membranoproliferative glomerulonephritis is a renal disorder characterized by proliferation of cells and changes in the basement membrane of the glomerulus. The disease is divided into three subtypes: type I, characterized by the presence of subendothelial electrondense deposits; type II, characterized by deposition of electrondense material of unknown origin in the lamina densa of the glomerular basement membrane; and type III, characterized by lesions having both type I and type II qualities. Specific posterior segment changes have been reported with membranoproliferative glomerulonephritis type II. We examined three patients with membranoproliferative glomerulonephritis type II and two patients with type III disease. All three patients with type II disease had Bruch's membrane and retinal pigment epithelial changes, whereas both patients with type III disease had normal posterior segments.

Cranial nerve involvement with Lyme borreliosis demonstrated by magnetic resonance imaging

We report a patient with cranial nerve and meningeal symptoms secondary to Lyme borreliosis. MRI using gadolinium contrast material demonstrated this inflammatory process. The patient did not have the parenchymal lesions described in previous reports of patients with CNS Lyme borreliosis.

Long-term visual function in acute posterior multifocal placoid pigment epitheliopathy

Acute posterior multifocal placoid pigment epithellopathy is a chorioretinal inflammatory disease occurring in young, healthy adults. The long-term visual prognosis and recurrence rate is uncertain. We reexamined 28 patients (53 affected eyes) with acute posterior multifocal placoid pigment epitheliopathy (mean follow-up, 8 years) to obtain details on the long-term functional visual outcome. The final visual acuities were 20/25 or better in 48 eyes (90.6%), 20/30 to 20/100 in four eyes (7.5%), and 20/200 in one eye (1.9%). Although the final visual acuity was good, 33 eyes (62.3%) were symptomatic with blurred vision, metamorphopsia, or scotomas. Thirty-six eyes (67.9%) had significant central visual field defects on follow-up examination. There were no recurrences after the initial month of symptoms. The chorioretinal scars did not enlarge with time. Acute posterior multifocal placoid pigment epitheliopathy has a good longterm prognosis for visual acuity, although most patients have residual symptoms and paracentral scotomas.

HLA-B7 and HLA-DR2 antigens and acute posterior multifocal placoid pigment epitheliopathy

Acute posterior multifocal placoid pigment epitheliopathy is a chorioretinal inflammatory disease occurring in young, healthy adults. Its cause is unknown, although it frequently follows a flulike illness. We reexamined 30 patients with documented acute posterior multifocal placoid pigment epitheliopathy to determine their HLA class I antigen (A and B) and class II antigen (DR and DQ) distribution. The HLA class I antigen B7 was found in 12 patients (40.0%) compared with 63 controls (16.6%) (relative risk, 3.38). The class II antigen DR2 was present in 17 patients (56.7%) compared with 107 controls (28.2%) (relative risk, 3.34). The specific role of HLA antigens in uveitis is unknown, but the finding of an increased prevalence of HLA-B7 and HLA-DR2 antigens in patients with acute posterior multifocal placoid pigment epitheliopathy suggests an immunogenetic predisposition to acquiring this disease.

Prognostic factors in the uveitis of juvenile rheumatoid arthritis

Risk factors for significant visual loss were investigated in 51 patients with iridocyclitis associated with juvenile rheumatoid arthritis (JRA). Average follow-up was 12.7 years. Of 89 eyes with uveitis, 22% had visual loss to 20/200 or worse, 46% had cataracts, 30% had band keratopathy, and 27% had glaucoma. Severity of visual loss and complications correlated with the degree of inflammation found on initial ocular examination. Of 58 eyes that were initially normal or had signs of mild inflammation (cells, flare, keratitic precipitates), 3% had final vision of 20/200 or worse, 28% had cataracts, 5% had band keratopathy, and 17% had glaucoma. Of 31 eyes with posterior synechiae on initial examination, 58% had final vision of 20/200 or worse, 81% had cataracts, 77% had band keratopathy, and 45% had glaucoma. When arthritis clearly preceded uveitis, 6% of patients had a poor visual outcome compared to 67% of patients whose initial manifestation of JRA was uveitis. Systemic corticosteroid administration used primarily for arthritis correlated with cataract formation.

Multicentric giant cell reparative granuloma of the small bones of the hand. A case report and review of the literature

Giant cell reparative granuloma (GCRG) usually occurs in the jaw, but a histologically identical lesion is occasionally seen in the small bones of the hands and feet. A 24-year-old man had GCRG involving the second metacarpal and the capitate. The involvement of a carpal bone and the presence of multiple lesions are unusual for this entity.

Effects of chlorpromazine on escape and avoidance responses: a closer look

While a wealth of evidence has implicated the nigrostriatal dopamine system in the initiation of movement, most or all of these movements have been in a conditioned avoidance framework, and on the order of 3-14 seconds in latency. It is proposed here that an elucidation of dopaminergic involvement in movement initiation requires a behavioral paradigm wherein experimental animals must rapidly and voluntarily respond to a stimulus to move (i.e., in less than 300 msec, paralleling human reaction time). Such a paradigm was developed and implemented in a re-analysis of earlier reports of chlorpromazine (CPZ) effects on escape from an avoidance of electric shock. Catecholaminergic or dopaminergic receptor blocking by CPZ resulted in clear impairment of the ability to initiate rapid avoidance movements, but in contrast to earlier work, some impairment of escape responses was also seen. Results are seen as further support for dopaminergic involvement in the initiation of voluntary movement.

Strain differences in dopamine receptor function and the initiation of movement

The relationship between voluntary movement initiation (VMI) and caudate nucleus dopamine receptor dynamics was analyzed in two rat strains. Charles River CD/F F-344 (CR-CD/F) and Zivic-Miller CD (ZM-CD) rats (male, 125-150 g) were trained to rapidly release and reset a response lever to avoid electric shock. Whereas 86% of all CR-CD/Fs completed training, only 43% of the ZM-CDs were able to do so. Of those rats completing training, the CR-CD/Fs showed marginally higher avoidance percentage and significantly faster VMI latencies. Physiologically, the more behaviorally-successful CR-CD/Fs showed significantly higher affinity for binding than the trained ZM-CDs and the large group of ZM-CDs which could not be successfully trained. In contrast, the trained ZM-CDs showed significantly higher density of dopamine receptors Bmax than the ZM-CDs which failed to train and the trained CR-CD/Fs. The behavior-physiology continuum is summarized as follows: CR-CD/F Rats = highest affinity and lowest Bmax--rapid, highest percentage avoidance; Trained ZM-CD Rats = lowest affinity and highest Bmax--slower, high percentage avoidance; ZM-CD rats that failed training = intermediate affinity and Bmax--avoidance failure.