Tarsal resection operation in correction of severe unilateral blepharoptosis with poor levator function

There are many options for surgical repair of congenital unilateral ptosis with poor levator function. We performed resection of tarsus, Müller muscle, and conjunctiva in conjunction with an intraoperative adjustable levator resection. Resection of tarsus, Müller muscle, and conjunctiva in conjunction with levator resection was performed in a prospective series of 17 consecutive patients with unilateral ptosis with poor levator function over a 2-year period. Pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Müller muscle resection, postoperative eyelid symmetry, and postoperative complications were evaluated. Mean preoperative upper eyelid margin to reflex distance was 0.11 mm. Mean postoperative upper eyelid margin to reflex distance was 3.20 mm. Improved postoperative eyelid symmetry within 1.0 and 1.5 mm was demonstrated in most of our cases (58% and 76%, respectively). The major complication has been exposure keratitis. Resection of tarsus, Müller muscle, and conjunctiva combined with adjustable levator resection can correct severe unilateral ptosis with poor levator function.     

Hepatitis B virus surface protein mutations clustered mainly in CTL immune epitopes in chronic carriers: results of an Iranian nationwide study

Mutations within the coding region of hepatitis B surface antigen (HBsAg) have been found naturally in chronic carriers. To characterize the mutations of HBsAg from Iranian chronic carriers who were vaccine and/or medication naive. The surface genes from 360 patients were amplified and directly sequenced. The distribution of amino acid substitutions was classified according to different immune epitopes of the surface protein. All isolates belonged to genotype D . 222 (61.6%) of 360 patients contained at least one amino acid substitution. 404 (74.5%) of 542 amino acid changes occurred in different immune epitopes of HBsAg, of which 112 (27.7%) in 32 residues of B‐cell epitopes (62 in the ‘a’ determinant); 111 (27.4%) in 32 residues of T helper; and 197 (48.7%) in 32 residues inside cytotoxic T lymphocyte (CTL) epitopes. One Th (186–197) and two CTL (28–51 and 206–215) epitopes were found to be hotspot motifs for the occurrence of 213 (52.7%) substitutions. 20 stop codons were identified in different epitopes. There was a significant association between amino acid substitutions and anti‐HBe seropositivity; however, the correlation between such changes with viral load and ALT levels was not significant. In chronic hepatitis B virus(HBV) carriers, positive selection in particular outside the ‘a’ determinant appeared to exert influence on the surface proteins. These changes could be immune escape mutations naturally occurring due to the host immune surveillance especially at the T‐cell level.     

Prevalence of Hepatitis Delta Virus (HDV) Infection in Chronic Hepatitis B Patients with Unusual Clinical Pictures

Background

Probably 5% of the HBV carriers have HDV super infection. The risk of fulminant hepatitis, cirrhosis and hepatocellular carcinoma is higher in superinfection than the settings when HBV is alone.

Objectives

The aim of this study was to evaluate the prevalence of HDV in Iranian HBV isolates and to compare their clinical and virological pictures as well as their HDV genetic variations with other worldwide isolates.

Patients and Methods

81 carriers with positive results for HBsAg with upper limit ranges of ALT and low or undetectable levels of HBV viral load who did not respond to HBV therapy were selected. After RT amplification of HDV Delta antigen, direct sequencing and phylogenetic study were performed to explore the genotype(s) and nucleotide/amino acid variations.

Results

12 (14.8%) patients had positive results for both HDV RNA and anti-HDV. The mean ALT level was higher in HDV positive patients (75.9 U/ML) than HBV-mono-infected individuals; however, the mean HBV viral load was lower in coinfected patients than HBV-mono-infected patients. Phylogenetically, genotype I was the only detected genotype, and the most closely related isolates were of Turkish, Italian and Mongolian origin. Within the delta Ag, there were 326 nucleotide mutations, of which 111 and 215 were silent and missense, respectively. The total number of amino acid substitution was 148; most were located in known functional/epitopic domains. There was no correlation between the numbers of amino acid mutations, with clinical, virological status of the patients.

Conclusions

HDV should be suspected in HBV carriers with unusual clinical and virological pictures. Relatedness of Iranian HDV isolates to Italian and Turkish sequences proposed a common Caucasian origin for the distribution of HDV genotype I in this ethnic group.     

The prevalence of hepatitis B virus surface antigen (HBsAg) variations and correlation with the clinical and serologic pictures in chronic carriers from Khorasan Province, North-East of Iran

This study was designed to determine the correlation of hepatitis B virus surface Ag (HBsAg) variations with the clinical/serological pictures among chronic HBsAg positive patients. The surface gene (S-gene) was amplified and directly sequenced in twenty-five patients. Eight samples (group I) contained at least one mutation at the amino acid level. Five showed alanine aminotransferase (ALT) levels above the normal range of which only one sample was anti-HBe positive. Group II (17 samples) did not contain any mutation, 4 were anti-HBe positive and 9 had increased ALT levels. In both groups, from a total of 18 mutations, 5 (27.5%) and 13 (72.5%) occurred in anti-HBe and HBeAg positive groups respectively. The small number of amino acid mutations might belong to either the initial phase of chronicity in our patients; or that even in anti-HBe positive phase in Iranian genotype D-infected patients, a somehow tolerant pattern due to the host genetic factors may be responsible.     

Management of infected femoral pseudoaneurysms in intravenous drug abusers: a review of 57 cases

BACKGROUND: The present study was carried out to evaluate the clinical characteristics and surgical methods used for the management of infected femoral pseudoaneurysms secondary to illegal drug injections. METHODS: Fifty seven consecutive patients who presented with infected pseudoaneurysm of the lower limb and were admitted to the emergency department of Sina Hospital during a 5-year period were enrolled in this study. Surgical methods performed consisted of vein angioplasty, simple ligation of femoral artery, and emergent or delayed revascularization. RESULTS: All participating patients were males with a mean age of 36.7 years. Three (5.3%) and two (3.5%) patients underwent primary repair and emergent vascular bypass, respectively; whereas delayed revascularization was performed in only eight (14%) cases. Forty four (77.2%) patients achieved a normal lifestyle without any vascular bypass. Early critical ischemia and late claudication was reported in two (3.5%) and eight (14%) patients, respectively. Other complications such as amputation and mortality were rarely reported. CONCLUSIONS: In our study, simple ligation of the external iliac or femoral artery was the most frequent management method for treating infected femoral pseudoaneurysms. Simple ligation of the external iliac or femoral artery seems to be a safe procedure in drug abusers presenting with infected femoral pseudoaneurysms.     

Acquired Brown syndrome: Report of two cases

We report 2 cases of acquired Brown syndrome, each associated with a mass in the supranasal area of the involved eye. Meticulous endoscopic surgery of an ethmoidal mucocele in the first case resulted in the recovery of superior oblique muscle function. Imaging studies suggested the presence of an orbital venous malformation in the second case, the clinical course of which was stable, with minimal intermittent diplopia over time.     

Propofol–fentanyl versus propofol–ketamine for procedural sedation and analgesia in patients with trauma

Objective

Many procedures performed in emergency department are stressful and painful, and creating proper and timely analgesia and early and effective assessment are the challenges in this department. This study has been conducted in order to compare the efficacy of propofol and fentanyl combination with propofol and ketamine combination for procedural sedation and analgesia (PSA) in trauma patients in the emergency department.