Orbital hydatid cyst manifested as expanding exophthalmos following blunt orbital trauma

A 14-year-old boy suffered right blunt orbital trauma. X-ray revealed a compressed fracture of the right ethmoidal sinuses. Three months after the trauma, progressive, painless right proptosis developed. Ocular examination revealed a severe proptosis and pronounced down displacement of the right globe without signs of orbital inflammation. A well-demarcated, extraconal right orbital cystic mass was seen on computerized tomography scan. The cyst contents were aspirated and found to contain echinococcal scolices and "hydatid sand." Hypertonic saline was injected and the cyst was excised. Progressive proptosis after blunt orbital trauma in patients from endemic areas should be suspected of being an orbital hydatid cyst.     

Augmentation with amisulpride for schizophrenic patients nonresponsive to antipsychotic monotherapy

Despite the effectiveness of antipsychotic medications in treatment of schizophrenia, about 30% of patients who receive an adequate treatment have significant persisting symptoms. The problem of treatment-resistant psychosis is an important and difficult one. The aim of this study was to retrospectively evaluate the efficacy and safety of amisulpride augmentation in treatment-resistant schizophrenic patients. To the best of our knowledge, this is the first report about resistant schizophrenic and schizoaffective patients treated with the combinations of risperidone and amisulpride and ziprasidone and amisulpride. Data were collected from patient records. A total of 15 resistant schizophrenic patients (7 men, 8 women, 54.0 +/- 16.9 years old) were included in the study. Before addition of amisulpride, the patients were treated with monotherapy by atypical neuroleptics (clozapine, olanzapine, risperidone, or ziprasidone). The mean amisulpride dose was 693.3 +/- 279.6 mg/d. The mental state of 12 (80%) patients treated with combination was improved. Three (20%) patients showed no change in their mental state. Only 2 patients treated with a combination of risperidone and amisulpride had mild side effects. The results are preliminary and require confirmation in a randomized controlled trial. The authors suggest that amisulpride may be a promising option as an augmentation strategy in treatment-resistant schizophrenic patients.     

Detailed exploration of face-related processing in congenital prosopagnosia: 2. Functional neuroimaging findings

Specific regions of the human occipito-temporal cortex are consistently activated in functional imaging studies of face processing. To understand the contribution of these regions to face processing, we examined the pattern of fMRI activation in four congenital prosopagnosic (CP) individuals who are markedly impaired at face processing despite normal vision and intelligence, and with no evidence of brain damage. These individuals evinced a normal pattern of fMRI activation in the fusiform gyrus (FFA) and in other ventral occipito-temporal areas, in response to faces, buildings, and other objects, shown both as line drawings in detection and discrimination tasks and under more naturalistic testing conditions when no task was required. CP individuals also showed normal adaptation levels in a block-design adaptation experiment and, like control subjects, exhibited evidence of global face representation in the FFA. The absence of a BOLD-behavioral correlation (profound behavioral deficit, normal face-related activation in the ventral occipito-temporal cortex) challenges existing accounts of face representation, and suggests that activation in these cortical regions per se is not sufficient to ensure intact face processing.     

Arterial embolisation for persistent primary postpartum haemorrhage: before or after hysterectomy?

Arterial embolisation is a recognised treatment for postpartum haemorrhage (PPH). In this retrospective study, we evaluate its use in the management of persistent PPH. Records of all births during a 54 month period at a university hospital were analysed. Two sub-groups were identified. Group I (n= 5), underwent embolisation after hysterectomy and Group II (n= 4), had embolisation as a first-line theraphy without hysterectomy. Of 20,215 births, there were 636 cases of PPH (3.1%). Nine required embolisation to control bleeding (1.4%). Group I needed multiple surgical procedures, had a larger pre- and post-operative blood requirement (12-100, median 22 units, vs. 6-12, median 8.5 units), longer embolisation (33-93, median 54 minutes, vs 20-66, 47 minutes) with a larger radiation exposure (5194-9067, median 6301 dGy, vs. 269-3862, median 950 dGy), a longer intensive care stay (3-7, median four days vs. 0-1.5, median one day), and more complications, when compared with Group II. Three of four women from Group II resumed menstrual function. Embolisation prior to hysterectomy may be preferable to embolisation after hysterectomy for the control of PPH.     

Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations

Arthrotomy of the hip joint followed by a variable period of drainage or continuous irrigation and drainage is considered the accepted treatment of septic arthritis of the hip joint (SAHJ). The authors reviewed the results of a cohort of children with SAHJ with repeated aspirations of the hip joint. Thirty-four children diagnosed with SAHJ were treated with repeated aspirations of the hip joint. The aspirations were performed under ultrasound guidance and topical anesthesia or under sedation. After the aspiration the joint was irrigated using the same needle, and the procedure was repeated daily. Six of the patients were operated on and then treated with aspirations because of drain dislodgement or clogging. Twenty-eight of the patients were treated primarily with repeated aspirations. Four of those patients did not improve and underwent arthrotomies, and 24 were treated only by repeated aspirations and healed completely. The mean number of aspirations was 3.6 (range 3-5), and 75% of the patients resumed walking after 24 hours. The mean follow-up time was 7.4 years (range 3-18). No complications were seen. Repeated aspiration is a safe and efficacious method of treatment for SAHJ. This method of treatment is not associated with surgery and its complications and prevents scarring of the skin and the need for general anesthesia. Faster return to normal activity was noted in this series.     

Immune response, accommodation, and tolerance to transplantation carbohydrate antigens

The carbohydrate antigens, blood groups A and B, and the alpha-gal epitope (Galalpha1-3Gal) are major risk factors in transplantation. Transplantation across ABO barriers may result in rejection by elicited anti-blood group antibodies, accommodation where elicited anti-blood group antibodies do not reject the graft, or tolerance where no anti-blood group antibodies are produced and the graft is not rejected. alpha1,3Galactosyltransferase knockout mice that lack alpha-gal epitopes but produce the anti-Gal antibody serve as a model for studying these immune responses. Knockout mice underwent transplantation heterotopically with wild-type mouse heart expressing alpha-gal epitopes and subsequently received lymphocytes including naive and memory anti-Gal B cells. The type of elicited immune response was found to be associated with the period that anti-Gal B cells were exposed to alpha-gal epitopes of the graft in the absence of T-cell help. Immediate T-cell help induced production of cytolytic anti-Gal antibodies that reject the graft, whereas delayed T-cell help induced production of accommodating anti-Gal antibodies. In the absence of T-cell help for prolonged periods, anti-Gal B cells exposed to alpha-gal epitopes were deleted, resulting in tolerance. Similar variations in the extent of T-cell help may determine the B-cell response to incompatible A or B antigens. The experimental model further suggests that active tolerance induction before transplantation may be achieved by gene therapy with autologous bone marrow cells or autologous lymphocytes manipulated to express the incompatible transplantation carbohydrate antigen by introduction of the corresponding glycosyltransferase gene into these cells.     

Impact of Carotid Artery Angioplasty and Stenting on Management of Recurrent Carotid Artery Stenosis

Citing the higher perioperative risk of redo carotid surgery, balloon angioplasty and stenting of the carotid artery (CAS) has been advocated for recurrent carotid stenosis (RCS). To examine the impact of CAS on the management and outcome of recurrent stenosis, a retrospective review of a prospectively compiled database was performed. From a registry of patients treated for carotid disease, 105 procedures were performed from 1992 to 2002 for RCS. For comparison, two study groups were examined. Time I consisted of 77 reoperations performed through 1998, before CAS was introduced at our institution. Time II included 12 reoperations and 16 CAS procedures performed for RCS from 1999 through 2002. Using perioperative stroke as a measure of outcome, the results for time II were poorer than for time I (7.2% vs. 5.2%, p = NS). Overall, the risk of perioperative stroke was the same for reoperation (5/89) and CAS (1/16) (5.6% vs. 6.3%, p = NS). Although not statistically significant, there was a trend toward a higher risk of perioperative stroke for patients treated with reoperation during the latter time period (8.3% vs. 5.2%, p = NS). This probably relates to the finding that during time II, CAS was most likely to be used in asymptomatic patients (68.6% vs. 41.7%, p = NS) with early (<3 years) RCS (87.5% vs. 41.7%, p = 0.01). No patient with asymptomatic, early RCS had a perioperative stroke with either surgery or CAS (0/35 cases, 0%). The presence of preoperative neurologic symptoms was significantly predictive of a perioperative stroke among all procedures performed for RCS (13.6% vs. 0%, p = 0.004). Contrary to suggestions that CAS might improve the management of RCS, a review of our data shows the overall risk of periprocedural stroke to be no better since CAS has become available. The bias for using CAS for asymptomatic myointimal hyperplastic lesions, and reoperation for frequently symptomatic late recurrent atherosclerotic disease, makes direct comparisons of the two techniques for treating RCS difficult. It is expected that the overall risk for redo carotid surgery will increase, as fewer low-risk patients will be receiving open procedures. However, the increased risk among symptomatic patients undergoing reoperation suggests that endovascular techniques should be investigated among this group of cases as well.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.     

Diode laser thermal keratoplasty to correct hyperopia

PURPOSE: We investigated long-term efficacy, predictability, stability, and safety of diode laser thermal keratoplasty (DTK) to correct hyperopia. METHODS: DTK was performed on 24 eyes (18 patients). Eight eyes with high hyperopia (mean +4.75 +/- 0.63 D; range +3.50 to +5.50 D) received 12 pairs of coagulation spots at 6-mm and 7-mm treatment zone diameters; eight eyes with low hyperopia (mean +2.25 +/- 0.40 D; range +1.50 to +2.75 D) received eight coagulation spots at 8 mm, and eight eyes with low hyperopia (mean +1.50 +/- 0.46 D; range +1.25 to +2.25 D) were treated to induce mild myopia (-1.50 D) in the non-dominant eye for monovision using eight pairs of spots at 7 and 8-mm diameters. Minimum follow-up was 18 months. RESULTS: Mean decrease in cycloplegic refraction at 18 months was 5.00 +/- 0.38 D in the high hyperopia group, 1.75 +/- 0.19 D in the low hyperopia group, and 3.25 +/- 0.27 D in the presbyopia group. Mean increase in uncorrected visual acuity (UCVA) at 18 months was 8.125 +/- 2.1 Snellen lines in the high hyperopia group, 6.625 +/- 0.744 lines for low hyperopia; decrease of 1.00 +/- 1.85 line occurred in the presbyopia group. Near UCVA in the presbyopia group improved by 3.875 +/- 0.83 Jaeger lines. Best spectacle-corrected visual acuity (BSCVA) was restored by 3 months in all eyes. CONCLUSION: DTK was an effective and fairly safe procedure, with reasonable predictability and stability. Nomograms for laser energy level, treatment zone diameter, and number of spots need improvement.