Retrieval of lost medial rectus muscles with a combined ophthalmologic and otolaryngologic surgical approach

PURPOSE: To report retrieval of a medial rectus muscle completely detached from the globe and lost in the orbital tissue in four eyes. METHOD: A lost medial rectus muscle was retrieved in four eyes of four patients with either a transcutaneous medial orbitotomy approach or a transnasal endoscopic ethmoid sinus approach. RESULTS: The lost medial rectus muscle was successfully retrieved in all four patients. One patient lost the medial rectus muscle secondary to trauma, and the other three cases resulted from complications of strabismus surgery. The mean preoperative angle of exotropia was 44 prism diopters. The endoscopic approach was attempted in three patients, and the medial rectus muscle was successfully found in two of these patients. In one case in which the endoscopic approach was used, an image guidance system was used to aid in finding the lost medial rectus muscle. The endoscopic approach was abandoned in one case in which the medial rectus muscle could not be identified after extensive searching, but the muscle was subsequently found by means of the transcutaneous medial orbitotomy approach. A transcutaneous medial orbitotomy alone was used to find the lost medial rectus muscle in one of the cases. The postoperative ocular deviation for primary position at distance fixation was a mean of 24 prism diopters of exotropia. With one additional operation in two patients, the mean ocular deviation was less than 12 prism diopters. CONCLUSION: We successfully retrieved a lost medial rectus muscle in four patients with the use of nontraditional strabismus surgical techniques. We effectively combined techniques taken from both ophthalmology and otorhinolaryngology to help solve this difficult problem.     

Venlafaxine in children, adolescents, and young adults with autism spectrum disorders: an open retrospective clinical report

Autism is characterized by social deficits, communication and language impairments, narrow restricted interests, repetitive behaviors, inattention, and hyperactivity. While selective serotonin reuptake inhibitors have demonstrated efficacy in treating core symptoms of autism, norepinephrine reuptake inhibitors have demonstrated efficacy in symptoms of attention-deficit hyperactivity disorder (ADHD). An open, retrospective clinical study with venlafaxine evaluated its effect on core symptoms of autism as well as associated features of ADHD. Ten consecutive subjects meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria for an autism spectrum disorder were treated with venlafaxine, initiated at 12.5 mg per day and adjusted on a flexible basis. Six of 10 completers were judged to be sustained treatment responders, by scoring 1 (very much improved) or 2 (much improved) on the Clinical Global Impressions improvement scale. Venlafaxine was effective in low dosages (mean, 24.37 mg/day; range, 6.25 to 50 mg/day) and was well tolerated. Improvement was noted in repetitive behaviors and restricted interests, social deficits, communication and language function, inattention, and hyperactivity. Controlled treatment trials with venlafaxine are warranted in autism spectrum disorders.     

Psychosocial factors and the timing of prenatal care among women in New Jersey's HealthStart program

CONTEXT: Helping high-risk pregnant women obtain prenatal care early is the main policy goal of most U.S. publicly funded programs aimed at reducing the incidence of low birth weight and infant mortality It is therefore crucial to understand the factors that influence when women initiate prenatal care. METHODS: The effects of psychosocial and demographic risk factors on the timing of entry into prenatal care were estimated using data on roughly 90,000 Medicaid recipients who participated in New Jersey's HealthStart prenatal care program. RESULTS: Overall, 37% of women began prenatal care in the first trimester. Multivariate logistic regression indicated that women who lived in poor housing conditions and those who smoked, drank or used hard drugs had a reduced likelihood of entering care early (odds ratios, 0.8-0.9), while those who had clinical depression or who experienced domestic violence or abuse had elevated odds of early entry (1.1-1.2). The risk factor with the greatest impact on the timing of prenatal care was the wantedness of the pregnancy; women whose pregnancy was unwanted had dramatically reduced odds of entering care early (0.4). Separate analyses of women of varying racial and ethnic backgrounds demonstrated the differential effects of risk factors, the importance of including ethnicity with race and the universal impact of wantedness across racial and ethnic groups. CONCLUSIONS: Entry into prenatal care for at-risk women is affected by factors from multiple domains. It is important for prenatal programs to recognize the complexity of the issue as well as the barriers that different subgroups of women face.     

External Cephalic Version at Term

Summary: The case notes of women with singleton term (37 weeks' gestation and beyond) breech presentation and delivery were retrospectively reviewed. Thirty-two of the 72 women in the study group had attempted external cephalic version at term, with a success rate of 53% (17 women). The Caesarean section rate was significantly lower in the group which had attempted ECV compared to the group which did not.     

Prevalence of hypothyroidism and diabetes mellitus in elderly kibbutz members

The aim of this study was to determine the prevalence of hypothyroidism and diabetes mellitus (DM) in elderly (aged 65–92 years) kibbutz members in Northern Israel. Method: The medical records of 1096 elderly (642 females and 454 males) residing in 11 kibbutzim were reviewed for data regarding thyroid function tests (TSH and FT4) and fasting blood glucose. Fasting blood glucose levels above 7.8 mmol/l was considered diagnostic for diabetes mellitus. Results: The prevalence of hypothyroidism was 14% (9.7% in males and 18.2% in females) and that of DM was 11.5% (12.1% in males and 11.1% in females). In 74% of the diabetics the diagnosis was made after the age of 60 years. Distribution of treatment modalities in diabetics was as follows: diet only 42%, oral hypoglycemic agents 52% and Insulin 6%. Subclinical hypothyroidism (serum TSH levels above 4.5 mU/L with normal FT4 levels) was detected in 38% of all the hypothyroid subjects. Conclusion: The data suggest that diabetes mellitus and primary hypothyroidism are common disorders in elderly subjects. DM in the elderly can usually be handled with diet and oral hypoglycemic drugs. Since the clinical features of hypothyroidism in the elderly are often atypical, we suggest that elderly subjects should be screened for hypothyroidism.     

Unexplained fever in neonates may be associated with hepatitis B vaccine.

AIM: To investigate whether hepatitis B vaccination has increased the number of cases of unexplained neonatal fever. METHOD: The files of all infants born from 1 January 1991 to 31 December 1992, in whom a diagnosis of "injected antibiotic" or "disease of temperature regulation" was recorded, were reviewed. Those who had unexplained fever of 38 degrees C or higher during the first three days of life were divided into two groups: infants who did not receive the hepatitis B vaccine (1991) and infants who did (1992). RESULTS: In 1992 the incidence of unexplained fever in hepatitis B vaccinated neonates was significantly higher than in the 1991 group of pre-vaccination neonates (35 out of 5819 (0.6%) vs 14 out of 5010 neonates (0.28%) respectively, p=0.013). CONCLUSIONS: The increase in the number of cases of unexplained neonatal fever seems to be associated with the introduction of routine hepatitis B vaccination on the first day of life. The possibility that an excess number of neonates will undergo unnecessary procedures and treatment to diagnose unexplained fever justifies planning a controlled study to determine whether these preliminary findings point to a significant problem.     

The effect of thyroxine and corticosteroids upon amniotic fluid fluorescence polarization: a randomized controlled study.

The efficacy of glucocorticoid and intra amniotic thyroxine therapy on fetal lung maturity were compared in a randomized prospective clinical trial. Eighty two patients received either intra amniotic thyroxine (n = 36), or intra muscular Dexamethasone (n = 46). The Fluorescence Polarization (FP) of amniotic fluid measured prior to and one week following treatment were similar in the two groups. The rate of decrease in FP value per unit of time (dFP/dt) was identical in the T4 and corticosteroid treated patients and the proportion of immature FP values obtained was similar in the two groups. The effect of thyroxine therapy was more pronounced in pregnancies above 33 weeks gestation. Intra amniotic thyroxine therapy appeared to be as effective as glucocorticoids for the enhancement of fetal lung maturity. This therapeutic modality may be of particular use on pregnant subjects in whom a relative contra indication for the administration of steroids exists.