Duane—minus (Duane sine retraction and Duane sine limitation): possible incomplete forms of Duane retraction syndrome

PurposeTo report ocular motility patterns that mimic, but do not fulfil the full clinical picture of Duane retraction syndrome (DRS) and to describe their clinical features and surgical management.MethodsThis is a retrospective case series study conducted on patients with DRS, mimicking non-comitant exotropia or esotropia and a face turn. Patients were included only if they lacked either globe retraction on adduction (sine retraction) or limitation of adduction or abduction on ductions (sine limitation not >0.5). Any overshoots or pattern strabismus was recorded. The ocular motility and alignment, details of surgery and their surgical outcomes were analysed.ResultsTwenty-one patients were identified; 13 in the sine retraction and 8 in the sine limitation group. All patients presented with a compensatory face turn. Overshoots were present in 10 (77%) and 7 patients (88%) in the sine retraction and sine limitation groups, respectively. Forced duction test showed tightness of the ipsilateral medial and the ipsilateral lateral rectus muscle in esotropic (n = 3) and exotropic patients (n = 18), respectively. Orthotropia was achieved in 82% of patients following ipsilateral medial or lateral rectus muscle recession.ConclusionsThere is a subset of patients who present with motility pattern similar to DRS but lack its complete diagnostic criteria. The presence of a face turn, overshoots on adduction or an ipsilateral tightness of the affected muscle should make one consider DRS sine retraction/sine limitation. The patients in our study responded well to lines of management similar to those of DRS.Subject terms: Ocular motility disorders, Eye abnormalities     

Bradycardia in minor trauma: don't be slow on the uptake!

We report the case of a 13-year-old boy presenting with profound bradycardia following minor trauma. Our patient had gastroschisis at birth and has moderate learning difficulties but is otherwise fit and well. Whilst playing at home he fell sustaining a minor cervical hyperextension injury. He immediately complained of tetraplegia and hyposensibility. The ambulance crew noted profound bradycardia with normotension and he was transported to hospital with full spinal immobilisation precautions. Over the subsequent 2 hours he made a full neurological recovery. Bradycardia persisted with a beat-to-beat variation of 30-60 bpm. ECG showed sinus bradycardia with atrial ectopics and he remained haemodynamically normal. Neuroimaging studies revealed hypoplasia of the odontoid peg with a relative narrowing of the spinal canal at this level. There was no evidence of spinal cord contusion or compression. His bradycardia resolved over 36 hours without further intervention. On discharge the patient was advised to wear a cervical hard collar when mobilising. This association of a craniocervical abnormality with learning difficulties, and gastroschisis has not been previously described. We discuss several other causes of odontoid peg instability, which may lead to severe autonomic effects with relatively insignificant trauma.     

Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial

Pratik P. Pandharipande, MD, MSCI; Brenda T. Pun, RN, MSN, ACNP; Daniel L. Herr, MD; Mervyn Maze, MB, ChB; Timothy D. Girard, MD, MSCI; Russell R. Miller, MD, MPH; Ayumi K. Shintani, MPH, PhD; Jennifer L. Thompson, MPH; James C. Jackson, PsyD; Stephen A. Deppen, MA, MS; Renee A. Stiles, PhD; Robert S. Dittus, MD, MPH; Gordon R. Bernard, MD; E. Wesley Ely, MD, MPH

JAMA. 2007;298(22):2644-2653.

Context  Lorazepam is currently recommended for sustained sedation of mechanically ventilated intensive care unit (ICU) patients, but this and other benzodiazepine drugs may contribute to acute brain dysfunction, ie, delirium and coma, associated with prolonged hospital stays, costs, and increased mortality. Dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction.

Objective  To determine whether dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU patients while providing adequate sedation as compared with lorazepam.

Design, Setting, Patients, and Intervention  Double-blind, randomized controlled trial of 106 adult mechanically ventilated medical and surgical ICU patients at 2 tertiary care centers between August 2004 and April 2006. Patients were sedated with dexmedetomidine or lorazepam for as many as 120 hours. Study drugs were titrated to achieve the desired level of sedation, measured using the Richmond Agitation-Sedation Scale (RASS). Patients were monitored twice daily for delirium using the Confusion Assessment Method for the ICU (CAM-ICU).

Main Outcome Measures  Days alive without delirium or coma and percentage of days spent within 1 RASS point of the sedation goal.

Results  Sedation with dexmedetomidine resulted in more days alive without delirium or coma (median days, 7.0 vs 3.0; P = .01) and a lower prevalence of coma (63% vs 92%; P < .001) than sedation with lorazepam. Patients sedated with dexmedetomidine spent more time within 1 RASS point of their sedation goal compared with patients sedated with lorazepam (median percentage of days, 80% vs 67%; P = .04). The 28-day mortality in the dexmedetomidine group was 17% vs 27% in the lorazepam group (P = .18) and cost of care was similar between groups. More patients in the dexmedetomidine group (42% vs 31%; P = .61) were able to complete post-ICU neuropsychological testing, with similar scores in the tests evaluating global cognitive, motor speed, and attention functions. The 12-month time to death was 363 days in the dexmedetomidine group vs 188 days in the lorazepam group (P = .48).

Conclusion  In mechanically ventilated ICU patients managed with individualized targeted sedation, use of a dexmedetomidine infusion resulted in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion.

Trial Registration  clinicaltrials.gov Identifier: NCT00095251

     

The tuberculin specificity in humans of Mycobacterium tuberculosis antigen 5

Mycobacterium tuberculosis antigen 5 is a protein antigen limited in distribution to M. tuberculosis and M. bovis and capable of eliciting typical delayed tuberculin skin test reactions in humans. A single large batch of this antigen was purified by immunoabsorbent affinity chromatography and used to skin test patients with tuberculosis and other mycobacterial infections and healthy persons in general populations in geographic areas where nonspecific tuberculin reactivity is frequently encountered. Antigen 5 was found to be no more specific as a tuberculin antigen than PPD. If the available data are accepted, then either a disparity in antigen recognition by antibody and T lymphocytes may exist or the widely accepted hypothesis attributing nonspecific tuberculin reactivity to antigenic cross reactivity with other mycobacteria may be incorrect.     

Clinical validation and assessment of a modular fluorescent imaging system and algorithm for rapid detection and quantification of dental plaque

Background

Significant numbers of adults and children have untreated plaque due to poor oral hygiene and consequently suffer from associate dental and systemic diseases.

Methods

A handheld device equipped with 405 nm light-emitting diodes was constructed to examine the prevalence of red fluorescence signatures associated with dental plaque. This device was used for in vivo imaging of all four incisors and all four canines of twenty-eight consenting human subjects. The same areas were further imaged under white light illumination with a commercial image-processing based plaque-imaging device, and evaluated by a hygienist and dentist. A custom computer vision algorithm using pixel information was developed to calculate plaque coverage ratios ranging from 0 (no plaque) to 1 (complete plaque coverage) for images captured by both devices.

Results

The algorithm calculated red fluorescence-based plaque coverage ratios ranging from 0.011 to 0.211 for the subjects imaged. Clinical assessment and statistical analyses of associated plaque ratios of the 405 nm device images indicated high sensitivity and specificity in detecting dental plaque by the experimental device compared to the commercial reference device.

Conclusions

The low-cost and open source 405 nm device and the associated computer vision algorithm successfully captured red fluorescence signatures associated with dental plaque and demonstrated comparable performance to a commercially available device. Therefore, a proof of concept validation was provided for the construction and application of a sensitive cost-effective plaque-detecting device. A miniaturized mobile adaptable version of the device was also provided, together with and a step-by-step guide for device assembly and webhost the associated software, to facilitate open-source access to a cost-effective at-home, in-clinic oral care technology.

Trial registration

ClinicalTrials.gov NCT03379337, December 19 2017. Retrospectively registered.

     

Primary Chondrosarcoma of Male Breast: A Rare Case

Sarcomas of the breast are relatively rare and account for 1% of all primary malignant tumors of the breast. Pure and primary chondrosarcoma of the male breast is an extremely rare tumor. It may arise either from the breast stroma itself or from underlying bone or cartilage. Differential diagnoses include cystosarcoma phyllodes and breast metaplastic carcinoma with chondroid differentiation.     

Laparoscopic Drainage of a Large Pancreatic Pseudocyst

Laparoscopic cystogastrostomy is an established procedure for the drainage of pancreatic pseudocysts. Cysts are mainly present in the lesser sac (retro-gastric), which is completely amenable to cystogastrostomy. We discuss the problems faced and simple solutions to the problems in managing a huge pancreatic pseudocyst of 22 cm×18 cm in a young boy 18 y of age.