Syndromic micrognathia and peri-natal management with the ex-utero intra-partum treatment (EXIT) procedure

Many advances in healthcare are built on advances in technology. In the case of fetal medicine, technology has availed an entirely new patient population. The authors report a case of severe micrognathia and Pierre Robin Sequence that was diagnosed prenatally. Antenatal planning and treatment were instituted via the Fetal Diagnosis/Treatment Team to avoid loss of the neonate's airway. An EXIT procedure was utilized to ensure a secure airway. The benefits of team care for these types of deformities are highlighted including the importance of craniomaxillofacial specialists.     

Treatment disparities in Parkinson's disease

We sought to identify racial disparities in the treatment of Parkinson's disease (PD). We identified 307 incident PD cases using Pennsylvania State Medicaid claims, and extracted claims for medications, physical therapy, and healthcare visits for the 6 months after diagnosis. After controlling for age, sex, and geography, African‐Americans were four times less likely than whites to receive any PD treatment (odds ratio, 0.24; 95% confidence interval, 0.09–0.64), especially indicated medications. In a group with the same healthcare insurance, disparities in PD treatment exist. Physician and community awareness of these racial differences in PD treatment is the first step in addressing healthcare disparities. Ann Neurol 2009;66:142–145     

Measurement of post-lens tear thickness.

PURPOSE: A method to measure the tear film beneath a soft contact lens, referred to as post-lens tear thickness (PLTT), would have many applications to contact lens research. In this study a noninvasive technique for measuring the PLTT is presented. METHODS: The feasibility of measuring the tear layer by optical pachometry was first assessed using a model eye. The baseline corneal thickness (B) of both eyes of 21 subjects was measured, etafilcon-A ionic disposable soft contact lenses (58% water) were inserted, and the total thickness (T) of the cornea, contact lens, and PLTT were measured. After the pachometry readings the lenses were removed and their center thickness (C) determined. The PLTT was calculated using the equation: PLTT = T-(B+C). Two sets of measurements of T were performed at 15 and 25 minutes after lens insertion. The entire procedure was repeated at a second visit. RESULTS: The pachometry measurements of the small aqueous reservoir between the model eye and the lens closely matched those obtained by direct microscopic measurement. For human PLTT, the mean values (and 95% confidence intervals) for right eyes on visits 1 and 2 were 11 (8, 13) and 12 (10, 15) microm, respectively, and for left eyes were 12 (10, 15) and 11 microm (8, 14) microm, respectively. CONCLUSIONS: It is possible to measure the post-lens tear thickness using optical pachometry. The variability between repeated measurements suggests that with careful sample size planning, the technique is sufficiently precise to be useful in group assessments of PLTT.     

Histologic evaluation of platinum coil embolization in an aneurysm model in rabbits.

PURPOSE: To characterize the histologic response to platinum coil embolization by using a rabbit aneurysm model. MATERIALS AND METHODS: Saccular aneurysms were created in New Zealand White rabbits by using vessel ligation with intraluminal elastase incubation. Aneurysms were subsequently embolized by using platinum coils. Subjects were sacrificed at various intervals up to 12 weeks following coil embolization. The aneurysm cavities and adjacent vessels were embedded in methylmethacrylate, were sectioned, and were stained for histologic examination. RESULTS: Two weeks following coil implantation, aneurysms were filled predominantly with unorganized thrombus. Six weeks following coil implantation, histologic features included complete filling of the aneurysm lumen with either prominent laminated but unorganized thrombus or areas of unorganized thrombus interspersed among areas of cellular infiltration. At 12 weeks following coil implantation, aneurysms were filled with the loosely packed, disordered cells contained within the extracellular matrix. Fibrosis or smooth muscle cell infiltration was not present in any of the 6- or 12-week samples. CONCLUSION: Platinum coils placed into experimental saccular aneurysms in New Zealand White rabbits failed to elicit a fibrotic response. This model can be used for the testing of biologic modifications of platinum coils aimed at increasing intra-aneurysmal fibrosis.     

Triage Nurse Application of the Ottawa Knee Rule

OBJECTIVE: To determine interobserver agreement between triage registered nurses (RNs) and emergency physicians (EPs) regarding indication for knee radiographs by applying the Ottawa knee rule (OKR) and individual components of the rule. METHODS: This was a prospective, observational study in a suburban, teaching emergency department. The study enrolled a convenience sample of patients aged >17 years with traumatic knee injuries less than one week old. Patients with prior knee surgery or distracting conditions were excluded. Before study initiation, the RNs and EPs were in-serviced in the OKR. Nurses and EPs independently examined each patient for OKR criteria, blinded to the other's assessment. Knee radiographs were ordered at the discretion of the EP and were interpreted by board-certified radiologists. All patients received follow-up with a structured telephone interview to identify any undetected fractures. Kappa was calculated for each component and the overall application of the OKR to assess interobserver agreement. RESULTS: Ninety-six patients were enrolled. The mean age was 39.6 +/- 18.7 years; 50% were male. Eight patients (8%) had knee fractures. Interobserver agreements between the RNs and EPs for individual components of the OKR were: age > or =55 years (kappa = 0.97); inability to weight bear (kappa = 0.51); inability to bend knee to 90 degrees (kappa = 0.52); fibular head tenderness (kappa = 0.45); and isolated patellar tenderness (kappa = 0.40). The EPs and RNs agreed with OKR criteria for x-ray 71% of the time (kappa = 0.41). CONCLUSIONS: The only criterion that resulted in almost perfect agreement between the RNs and EPs was patient age; agreement for the other four criteria and the overall decision to order x-rays was moderate.     

Primary nasal-paranasal oropharyngeal lymphoma in the pediatric age group

Nasal-paranasal oropharyngeal (NPOP) non-Hodgkin's lymphoma (NHL) is a disease of the very young (median age, 5 years) and of the aging adult (median age, 50-60 years). Of a total of 208 pediatric patients with NHL studied, 20 (9.6%) had primary NPOP. Sixty percent of the patients had Stage I and II disease. Primary sites were maxillary sinus in eight patients; tonsils in eight; posterior pharynx in two; mandible in one; and orbit in one patient. Histologically, the disease is different than that of the adults since most patients had B-cell lymphomas of the diffuse undifferentiated type (Rappaport) or small cell non-cleaved types (Lukes-Collins, Kiel, and Working Formulation). None of these patients had gastrointestinal involvement. All patients were treated with the LSA2-L2 regimen and radiation therapy was given to primary unresectable tumors and regional metastases. The lymphoma event-free survival was 75%, with a median observation period of 99+ months. In staging systems that refer mostly to amount of disease outside of the primary (such as ours, Murphy's, and the Ann Arbor staging systems) stage did not correlate well with disease-free survival. In the TNM staging of 1977, a staging system that refers to size of primary tumor as well as regional and systemic disease, stage correlated better with prognosis and survival. In our staging system, eight of 12 patients (66.7%) with Stage I and II disease; four of four with Stage III; two of two with Stage IVA; and zero of two with Stage IVB survived. In the TNM staging system, three of three patients with Stage II and III disease and 12 of 18 patients (67%) with Stage IV disease survived. All recurrences occurred early suggesting that early intensification of chemotherapy may produce better results.     

A prospective randomized trial of ceftazidime versus cefazolin/tobramycin in the treatment of hospitalized patients with pneumonia

Ceftazidime and cefazolin/tobramycin were compared in the treatment of hospitalized patients with pneumonia. Iv doses 8-hourly were: ceftazidime--2 g, cefazolin--1.5 g, tobramycin--1.7 mg/kg. For patients with pseudomonas infection randomized to cefazolin/tobramycin, ticarcillin (3 g iv 4-hourly) was used instead of cefazolin. One hundred and ten of 129 patients were evaluable (ceftazidime = 52, cefazolin/tobramycin = 58). Seventy five cases (68%) had documented pathogens of which 81% were aerobic Gram-negative bacilli. Analysis of clinical response showed no difference in overall results (P = 0.77), or separate outcomes: cured (P = 0.85), improved (P = 0.62), failed (P = 0.53), or relapsed (P = 0.50). No differences in bacteriological response were noted either: eradication (P greater than 0.10), elimination with recurrence (P greater than 0.10), persistence (P greater than 0.10). The incidence of enterococcal and fungal colonization and superinfection was the same for both regimens. There was a greater incidence of Coombs' test positivity with ceftazidime (P less than 0.01) but greater nephrotoxicity with cefazolin/tobramycin (P less than 0.02). Ceftazidime appears to be as efficacious as cefazolin/tobramycin in the treatment of hospitalized patients with pneumonia, and is less nephrotoxic.     

Arousal and stability: the effects of five new sympathomimetic drugs suggest a new principle for the prevention of space motion sickness

Sympathomimetic agents are frequent components in antimotion-sickness drug combinations because of their usefulness in counteracting the sedation caused by stressful motion or resulting from the administration of other antimotion-sickness drugs. The noradrenergic neurochemistry of the brain's arousal-attentional systems prompted us to evaluate the efficacy of five new sympathomimetic drugs and to further define the role of arousal in susceptibility to motion. Subjects were orally administered methamphetamine (20 mg), phenmetrazine (25 mg), phentermine (37.5 mg), methylphenidate (20 mg), or pemoline (75 mg) 2 h prior to taking a Staircase Profile Test. All of the drugs increased resistance to stressful coriolis stimulation by 80-120%. Methylphenidate and pemoline showed fewer side effects. These findings, interpreted in conjunction with the documented inefficacy of most anticholinergic and antihistaminergic drugs tested to date, suggest that sympathomimetic drugs or a generalized state of arousal can inhibit the development of motion sickness.     

Spinal cord schistosomiasis: a pediatric case mimicking intrinsic cord neoplasm

We present the clinical, myelographic, MRI, and histologic data on a 7-year-old girl with confirmed Schistosoma mansoni infection of the spinal cord. MRI of the granulomatous spinal lesion revealed extensive enlargement of the cord in the T11-12 area, with some intramedullary swelling extending to T-5 through T-7. The clinical manifestations of spinal schistosomiasis can be diverse, and there should be a high index of suspicion for all patients from endemic areas.