[Aniridia, congenital glaucoma and white corneas in a newborn baby]

CASE REPORT

We present the case of a newborn baby in whom we observed aniridia, congenital glaucoma and edematous corneas, without clearance of the cornea after glaucoma surgery, and in whom a keratoplasty was considered. The patient had no evidence of systemic diseases and no deletion of chromosome 11.

DISCUSSION

It is important to perform a thorough ophthalmological and systemic exploration in newborn patients with aniridia due to other diseases that can be associated with it. We present the unusual case in which aniridia, congenital glaucoma and white corneas coexisted in a newborn baby. To our knowledge, such cases have only been reported twice before in the literature (Arch Soc Esp Oftalmol 2009; 84: 573-576).

Mitochondrial cholesterol in health and disease

Cholesterol is a critical component of biological membranes, which not only plays an essential role in determining membrane physical properties, but also in the regulation of multiple signaling pathways. Cells satisfy their need for cholesterol either by uptake from nutrients and lipoproteins or de novo synthesis from acetyl-CoA. The latter process occurs in the endoplasmic reticulum, where transcription factors that regulate the expression of enzymes involved in the de novo cholesterol synthesis reside. Cholesterol is distributed to different membranes most prominently to plasma membrane, where it participates in the physical organization of specific membrane domains. Mitochondria, however, are considered cholesterol-poor organelles, and obtain their cholesterol load by the action of specialized proteins involved in its delivery from extramitochondrial sources and trafficking within mitochondrial membranes. Although mitochondrial cholesterol fulfills vital physiological functions, such as the synthesis of bile acids in the liver or the formation of steroid hormones in specialized tissues, recent evidence indicates that the accumulation of cholesterol in mitochondria may be a key step in disease progression, including steatohepatitis, carcinogenesis or Alzheimer disease.

Validation of two complementary oral-health related quality of life indicators (OIDP and OSS 0-10 ) in two qualitatively distinct samples of the Spanish population

BACKGROUND

Oral health-related quality of life can be assessed positively, by measuring satisfaction with mouth, or negatively, by measuring oral impact on the performance of daily activities. The study objective was to validate two complementary indicators, i.e., the OIDP (Oral Impacts on Daily Performances) and Oral Satisfaction 0-10 Scale (OSS), in two qualitatively different socio-demographic samples of the Spanish adult population, and to analyse the factors affecting both perspectives of well-being.

METHODS

A cross-sectional study was performed, recruiting a Validation Sample from randomly selected Health Centres in Granada (Spain), representing the general population (n = 253), and a Working Sample (n = 561) randomly selected from active Regional Government staff, i.e., representing the more privileged end of the socio-demographic spectrum of this reference population. All participants were examined according to WHO methodology and completed an in-person interview on their oral impacts and oral satisfaction using the OIDP and OSS 0-10 respectively. The reliability and validity of the two indicators were assessed. An alternative method of describing the causes of oral impacts is presented.

RESULTS

The reliability coefficient (Cronbach's alpha) of the OIDP was above the recommended 0.7 threshold in both Validation and Occupational samples (0.79 and 0.71 respectively). Test-retest analysis confirmed the external reliability of the OSS (Intraclass Correlation Coefficient, 0.89; p < 0.001) Some subjective factors (perceived need for dental treatment, complaints about mouth and intermediate impacts) were strongly associated with both indicators, supporting their construct and criterion validity. The main cause of oral impact was dental pain. Several socio-demographic, behavioural and clinical variables were identified as modulating factors.

CONCLUSION

OIDP and OSS are valid and reliable subjective measures of oral impacts and oral satisfaction, respectively, in an adult Spanish population. Exploring simultaneously these issues may provide useful insights into how satisfaction and impact on well-being are constructed.

Optical coherence tomography predictive factors for macular hole surgery outcome

AIM

To evaluate the use of preoperative optical coherence tomography (OCT) findings as predictive factors for macular hole (MH) surgery outcomes.

METHODS

46 eyes from 46 patients with a diagnosis of MH were included in this study. In all cases, a pars plana 25-gauge vitrectomy with peeling of the internal limiting membrane was performed. Before and after surgery, a complete clinical examination and a detailed macular analysis, which included the MH minimum and base diameter, the MH height, the Macular Hole Index (MHI), Diameter Hole Index (DHI) and Tractional Hole Index (THI), were performed. Predictive factors for visual prognosis after surgery were obtained by receiver operating characteristic curve analysis.

RESULTS

Minimum and base diameter as well as THI and MHI correlated significantly (p<0.01, p = 0.01, p = 0.04, p = 0.03, respectively) with postoperative best spectacle corrected visual acuity at 3 months, but DHI and MH height did not. Cut-off values of 311 microm and 1.41 were obtained for the minimum diameter and THI, respectively, from receiver operating characteristic curve analysis, providing an acceptable sensitivity and specificity.

CONCLUSION

An MH minimum diameter of <311 microm or a THI >1.41 are predictive factors for a good visual prognosis after MH surgery.

[Intravitreal injection of bevacizumab for pseudophakic cystoid macular edema resistant to steroids]

CLINICAL CASE

A 71-year-old man presented with pseudophakic cystoid macular edema (PCME) and a visual acuity (VA) of 0.1. He had been treated with 2 intra-vitreal injections of triamcinolone acetonide (4 mg) 16 months previously. One week after the intra-vitreal injection of bevacizumab (1.25 mg), VA improved to 0.33, and the OCT demonstrated decreased macular thickness. Two months after the injection, no ocular complications were observed, VA was 0.5 and the OCT showed a significant reduction in the retinal thickness.

CONCLUSION

Intra-vitreal injection of bevacizumab may be an additional tool for the treatment of therapy-resistant PCME.

Musk-antibody positive myasthenia gravis presenting with isolated neck extensor weakness

Dropped head sign is characterized by the gradual forward sagging of the head due to weakness of neck extensor muscles. This may be a prominent sign of several neuromuscular disorders and may be an isolated feature of myasthenia gravis (MG). We describe a patient with isolated neck extensor weakness, eletrophysiological findings suggesting myasthenia gravis and positive MuSK antibodies. This case supports that finding anti-MuSK antibodies may be extremely helpful in dropped head patients and negative acetylcholine receptor antibodies especially if needle EMG does not reveal myopathic or neurogenic patterns.

Abnormal sudomotor skin responses to temperature and pain stimuli in syringomyelia

Thermoalgesic sensory deficits in patients with syringomyelia may escape objective documentation with conventional electrophysiological techniques. We examined six patients with radiologically proven centrospinal cavities and patchy thermoalgesic sensory deficits by recording the evoked potentials and the sympathetic sudomotor skin responses (SSR) to laser stimuli. While electrical stimuli to the affected areas induced evoked potentials and SSRs of normal latency and amplitude, CO2 laser stimulation induced absent or abnormally reduced evoked potentials. Also, warmth and heat pain stimulation with a Peltier thermode induced absent or abnormal SSRs when applied over the affected areas but well defined SSRs when applied to the corresponding contralateral areas. Our results reveal the utility of recording the SSR to pain and temperature stimuli over specific body sites to demonstrate impairment of pain and temperature pathways in patients with syringomyelia. Comparison of electrical versus laser and temperature induced SSRs is an objective means to evaluate the selective thermoalgesic sensory deficit in these patients.

Electrophysiological study of ephaptic axono-axonal responses in hemifacial spasm

One of the classic features of hemifacial spasm (HFS) is spread of the blink reflex responses to muscles other than the orbicularis oculi. The pathophysiological mechanisms underlying the generation of such abnormal responses include lateral spread of activity between neighboring fibers of the facial nerve and hyperexcitability of facial motoneurons. In this report we present evidence for another mechanism that can contribute to the generation of responses in lower facial muscles resembling the R1 response of the blink reflex. In 13 HFS patients, we studied the responses induced in orbicularis oris by electrical stimuli applied at various sites between the supraorbital and zygomatic areas. We identified responses with two different components: an early and very stable component, with an onset latency ranging from 10.5 to 14.8 ms, and a more irregular longer-latency component. Displacement of the stimulation site away from the supraorbital nerve and towards the extracranial origin of the facial nerve caused a progressive shortening of response latency. These features indicate that, in our patients, the shortest latency component of the orbicularis oris response was likely generated by antidromic conduction in facial nerve motor axons followed by axono-axonal activation of the fibers innervating the lower facial muscles. Our results suggest that motor axono-axonal responses are generated by stimulation of facial nerve terminals in HFS.

Sealant and fluoride varnish in caries: a randomized trial

Little is known about the effect of discontinuation of sealant or fluoride varnish. The purpose of this study was to compare sealant with fluoride varnish in the prevention of occlusal caries in permanent first molars of children over a nine-year period: 4 yrs for program evaluation plus 5 yrs of discontinuation. A clinical trial was conducted on three groups of six- to eight-year-old schoolchildren: a control group (n = 45); a group (n = 37) in which sealant was applied and reapplied up to 36 mos; and a group (n = 38) in which fluoride varnish was applied and re-applied up to 42 mos. Percent caries reduction was studied in these initially healthy molars with complete occlusal eruption: 129 (control), 113 (sealant), and 129 (varnish) molars met inclusion criteria. Of these, 76.7%, 26.6%, and 55.8% had developed occlusal caries at 9 yrs, which implies caries reductions of 65.4% (SE = 8.5%) for sealants vs. control and 27.3% (SE = 10.2%) for varnish vs. control. Furthermore, the varnish program was not effective during the discontinuation period.

Stimulated single-fiber EMG of the frontalis and orbicularis oculi muscles in ocular myasthenia gravis

We performed single-fiber electromyography by axonal stimulation (stimulated SFEMG) of the frontalis and orbicularis oculi muscles of 20 patients with ocular myasthenia gravis (OM) and 46 controls. In controls, mean consecutive differences (MCD) ranged from 5 to 55 micros (average, 14.7 +/- 2.8 micros) in the frontalis and from 4 to 56 micros (average, 12.56 +/- 2.19 micros) in orbicularis oculi. The mean MCD of individual muscle potentials (MPs) was 14.6 +/- 6.8 micros in frontalis and 12.68 +/- 6.10 micros in orbicularis oculi. In the OM patients, the mean MCD was 43.85 +/- 25.18 micros in the frontalis and 69.85 +/- 29.55 micros in orbicularis oculi (P < 0.0001), and the number of MPs with altered MCD was 7.15 +/- 4.66 (range, 1-18) and 12.65 +/- 4.90 (range, 6-21), respectively (P < 0.0001). We conclude that stimulated SFEMG of the orbicularis oculi muscle is more sensitive for the diagnosis of OM than of the frontalis muscle.

Steroidal management and serum cytokine profile of a case of alcoholic hepatitis with leukemoid reaction

Leukemoid reactions (LRs) are rare in alcoholic hepatitis (AH), but they are a sign of poor prognosis. The treatment of AH with corticosteroids is controversial, though several reports suggest that these should be used in severe cases of AH. We report a case of AH-associated LRs that presented with an increase of the serum concentrations of the proinflammatory cytokines interleukin (IL)-18 (an initiator of inflammation) and IL-1beta (likely responsible for the neutrophilia of the LRs). These findings provided a pathogenic indication for the use of corticosteroids (that block the transcription of IL-1beta), and this approach achieved a clinical and analytical recovery in our patient. This pathogenic mechanism might also underlie other cases of LRs and other complications of AH, thus providing a rationale for the benefits of corticotherapy in these rare but severe conditions.

Diabetic polyneuropathy. Axonal or demyelinating?

Diabetic polyneuropathy is the most common subgroup of diabetic neuropathy, but its nature is controversial as it might be demyelinating and/or axonal. We have tried to determine whether diabetic polyneuropathy is electrophysiologically axonal, demyelinating, or both. We have studied the sural and peroneal nerves and the electromyographies of leg muscles in 50 healthy subjects (average age 67.2 years, range 45 to 84 years), in 50 diabetic patients (average age 66.34 years, range 44 to 82 years) showing no symptoms and/or signs of polyneuropathy (DP1), and in 50 diabetic patients (average age 67.10 years, range 49 to 87 years) showing symptoms and/or signs of polyneuropathy (DP2). The amplitude (AMP) of sural and peroneal nerves in healthy and DP1 subjects was similar. Conduction velocity (CV) of sural and peroneal nerves was slower in DP1 subjects than in healthy subjects. DP2 subjects showed AMP and CV values significantly lower than those in DP1 subjects, and signs of acute and chronic denervation/reinervation were found in the leg muscles. We believe that this result indicates that diabetic patients have two types of polyneuropathies: a demyelinating disease that could appear in diabetic patients with and without symptoms of polyneuropathy, and an axonal loss that is responsible for most of the symptoms.

Genetic study of patients with dexamethasone-suppressible aldosteronism without the chimeric CYP11B1/CYP11B2 gene

Glucocorticoid-remediable aldosteronism is an inherited disorder caused by a chimeric gene duplication between the CYP11B1 (11beta-hydroxylase) and CYP11B2 (aldosterone synthase) genes. The disorder is characterized by hyperaldosteronism and high levels of 18-hydroxycortisol and 18-oxocortisol, which are under ACTH control. The diagnosis of glucocorticoid-remediable aldosteronism had been traditionally made using the dexamethasone suppression test; however, recent studies have shown that several patients with primary aldosteronism and a positive dexamethasone suppression test do not have the chimeric CYP11B1/CYP11B2 gene. The aim of this work was to evaluate whether other genetic alterations exist in CYP11B genes (gene conversion in the coding region of CYP11B1 or in the promoter of CYP11B2) that could explain a positive dexamethasone suppression test and to determine another genetic cause of glucocorticoid-remediable aldosteronism. We also evaluated the role of 18-hydroxycortisol as a specific biochemical marker of glucocorticoid-remediable aldosteronism. We studied eight patients with idiopathic hyperaldosteronism, a positive dexamethasone suppression test, and a negative genetic test for the chimeric gene. In all patients we amplified the CYP11B1 gene by PCR and sequenced exons 3-9 of CYP11B1 and a specific region (-138 to -284) of CYP11B2 promoter. We also measured the levels of 18-hydroxycortisol, and we compared the results with those found in four subjects with the chimeric gene. None of eight cases showed abnormalities in exons 3-9 of CYP11B1, disproving a gene conversion phenomenon. In all patients a fragment of 393 bp corresponding to a specific region of the promoter of CYP11B2 gene was amplified. The sequence of the fragment did not differ from that of the wild-type promoter of the CYP11B2 gene. The 18-hydroxycortisol levels in the eight idiopathic hyperaldosteronism patients and four controls with chimeric gene were 3.9 +/- 2.3 and 21.9 +/- 3.5 nmol/liter, respectively (P < 0.01). In summary, we did not find other genetic alterations or high levels of 18-hydroxycortisol that could explain a positive dexamethasone suppression test in idiopathic hyperaldosteronism. We suggest that the dexamethasone suppression test could lead to an incorrect diagnosis of glucocorticoid-remediable aldosteronism.