Bilateral complete avulsion of ocular globes in a Le Fort III maxillofacial fracture: a case report and review of the literature

PURPOSE

The purpose of this paper is to demonstrate a case of bilateral complete avulsion of the globes following maxillofacial trauma.

METHODS

A 23-year-old man with bilateral complete globe avulsion following a maxillofacial trauma. Both globes were luxated out of the orbit and suspended on the skin of the upper lid below the brows. No direct or indirect light reflexes or any eye movements could be noted. Computerized tomography showed complete lacerations of both optic nerves at a level just anterior to the optic canal. There were also multiple fractures corresponding to Le Fort III fracture with Le Fort II components. The brain parenchyma was normal with an exception of brain edema. As the globes were unsuitable for repositioning, both were enucleated. The maxillofacial fractures were immobilized with plates and screws. Although the patient gained consciousness with normal vital signs in the early postoperative period, he died on the ninth day due to Pseudomonas aeruginosa infection, despite invasive antibiotic treatment.

DISCUSSION

The optic nerve and the globes are very resistant to mild and moderate trauma. The avulsion of the nerve at the canalicular or more posterior level may demonstrate central nervous system complications resulting in life-threatening conditions. The most critical issue in complete globe avulsions with a transected optic nerve is to rescue the vision. In total transected optic nerves the final eyes could only have had cosmetic benefits. In spite of promising experimental research on optic nerve regeneration, there are unknowns, such as the methods to eliminate the risk of anterior segment ischemia and phthisis bulbi.

CONCLUSIONS

Globe avulsions with a complete optic nerve cut remain a challenging problem. More research is required to better understand the pathophysiology of optic nerve repair.

Clinical and laboratory features of spontaneous bacterial peritonitis

BACKGROUND

Spontaneous Bacterial Peritonitis (SBP) is a complication of cirrhosis. The mortality rate is approximately 30-50%. SBP is defined as an ascitic fluid infection in the absence of any obvious intraabdominal infectious foci. While earlier reports of SBP emphasized high mortality rates, recently lower mortality rates have been reported.

OBJECTIVE

To evaluate the clinical and laboratory features and prognostic indicators of SBP.

DESIGN

Retrospective study.

SETTING

Hacettepe University Hospitals.

SUBJECTS

A total of 281 SBP episodes of 214 patients between 3rd march 1981 and 3rd August 1999, in Hacettepe University Hospital were evaluated. Statistical analysis was performed in the group of patients having chronic liver diseases.

RESULTS

One hundred and forty nine of the patients 214 (69.6%) were males and 65(30.4%) were females. The mean age of all patients were 49.91+/-15.01 years (17 to 90 years). All spontaneous ascites infection episodes were symptomatic. In all of the episodes, most common clinical features were as follows: icterus (54.5%), abdominal tenderness (54.5%), hepatic encephalopathy (50.7%), fatigue (46.7%), abdominal pain (44.4%) and fever (38.8%). The culture of the ascitic fluid resulted in isolation of a bacteria in 25.4% of all episodes. The most frequently isolated microorganisms turned out to be gram negative enteric bacterias (76.2%). Sixty seven patients in 179 cases with liver disease passed away (37.4%). The use of cefotaxime and newer cephalosporins seemed to have less mortality (31.7%) as compared with that (42.2%) observed in patients treated with other antibiotic regimens.

CONCLUSIONS

Of all the factors analysed in patients with chronic liver diseases, being Child-Pugh class C, having fatigue, hepatic encephalopathy, hypotension, higher peripheral blood leukocyte count (> or =12000/mm3), renal dysfunction (serum creatinine level > or = 2mg/dl), longer prothrombin time (INR > or = 2.5), lower ascites protein level (<Igr/ dl) and, liver disease for longer time, developing superinfection (an infection other than SBP starting during SBP treatment) were statistically correlated with a higher death rate (p<0.05).

Influence of high-dose leucovorin and 5-fluorouracil chemotherapy regimen on P wave duration and dispersion

BACKGROUND

Although 5-fluorouracil (5-FU)-related cardiotoxicity is well known, atrial arrhythmia, as a potentially serious complication has not been studied in detail. The aim of this study was to determine the P max and Pd in the electrocardiograms (ECG) of patients receiving 5-FU treatment.

METHODS

Twenty-five patients (mean age: 62 years) receiving a 5-FU bolus plus continuous infusion with calcium leucovorin over 48 h and with normal pre-treatment cardiac physical examinations, ECG and echocardiography were enrolled. P maximum (P max), P minimum (P min) and P dispersion (Pd) (maximum minus minimum P wave duration) were measured from the 12-lead ECG at the 0th and 48th hour of the first chemotherapy cycle. Echocardiography was also obtained in all patients at the same times.

RESULTS

Clinical cardiotoxicity was observed in two patients. P max and Pd were both significantly longer after 5-FU treatment at the 48th hour (P < 0.001). P min did not change (P > 0.05).

CONCLUSION

Treatment with 5-FU based regimens may increase Pd and prolong the P max in cancer patients. These alterations may be predictive of patients at risk of atrial arrhythmias during 5-FU treatment.

Different routes of donor-derived hematopoietic stem cell transplantation for donor-specific chimerism induction across MHC barrier

Transplantation of donor-derived stem cells can improve organ allograft survival in animal models. This study was designed to investigate the effect of different routes of bone marrow cell (BMC) transplantation on donor-specific tolerance induction across MHC barrier under short-term CsA monotherapy and alphabetaTCR/CsA treatment protocols. Forty-eight BMC transplantations were performed between BN(RT1(n)) donors and LEW(RT1(1)) recipients. Intraosseous and intravenous BMC transplantation was studied in six groups of eight animals each receiving 35 x 10(6) (n = 4) and 70 x 10(6) (n = 4) bone marrow cells. Groups I and II (controls) received BMC transplantation but no treatment, groups III and IV CsA monotherapy, and groups V, VI alphabetaTCR/CsA protocol for 7 days. Flow cytometry monitored immunodepletion and donor-specific chimerism for MHC class I RT1(n)/CD4, RT1(n)/CD8 and RT1(n)/CD45RA antigens. All animals survived without graft-versus-host disease. At day 63 under CsA monotherapy a low level of chimerism for RT1(n)/CD4 was induced after intraosseous (1.9%) and intravenous (0.8%) transplantation of (70 x 10(6)) BMC. Under alphabetaTCR/CsA protocol chimerism for RT1(n)/CD4 revealed 6.5% and 0.9% in intraosseous and intravenous (70 x 10(6)) BMC transplantation, respectively. The total number of chimerism in intraosseous and intravenous (70 x 10(6)) BMC transplantation groups was 9.9% and 3.4%, respectively. Following intraosseous BMC transplantation under alphabetaTCR/CsA protocol chimerism was 50% higher in a group receiving 70 x 10(6) (9.9%) vs 35 x 10(6) (4.9%) BMC. Intraosseous transplantation of donor BMC under alphabetaTCR/CsA protocol was 75% more efficient in induction of donor-specific chimerism compared to intravenous transplantation.

The training curriculum in hospital infection control

Standardised training curricula for infection control nurses (ICNs) and recognition of the specialty exist in many European countries, but infection control physician (ICP) is not a specialty recognised by the UEMS. To gather information on curricula for ICPs, members of the ESCMID Study Group on Nosocomial Infections received a questionnaire. There is discussion about which 'professions' should be included in an infection control team. Within the 12 countries included, the average full-time equivalents (FTEs) for ICPs and ICNs per 1000 beds were 1.2 and 3.4, respectively. In addition to ICNs and ICPs, an infection control team should also include a data manager, an epidemiologist, secretarial/administrative support, and possibly, surveillance technicians. Overall, the composition of an ideal infection control team was estimated to be 9.3 FTE per 1000 beds. The background of ICPs can be clinical microbiology or infectious diseases. Among the participants, it was predominantly clinical microbiology. The ideal training curriculum for the ICP should include 6 years of postgraduate training. Of these, at least 2 years should be 'clinical training' (e.g., internal medicine) to acquire experience in the management of high-risk patients. Furthermore, training with regard to infection control and hospital epidemiology should be offered as a 'common trunk' for those being trained in clinical microbiology or infectious diseases. Important issues that remain are: implementation/standardisation of training curricula for doctors, recognition of ICP as a separate specialty or sub-specialty of clinical microbiology and/or infectious diseases, validation of on-the-job training facilities in terms of the number of doctors and nurses who can give training and the category of patients/problems present, and mandatory postgraduate education/continuing medical education specific for infection control for doctors and nurses in the field.

Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia

The aim of this study was to compare the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia (VAP). A prospective, randomized, controlled trial was performed in a medical intensive care unit (MICU) of a university hospital in patients who received mechanical ventilation for more than 48 h. Patients were randomized to receive endotracheal suction with either closed catheters (closed suction group; N-41) or single-use catheters (open suction group; N=37). Cultures were taken from the ventilator tubing of 42 patients to determine the rate of colonization. There was no difference between the groups in terms of the frequency of development of VAP, mortality in the MICU, length of MICU stay and duration of mechanical ventilation. Thirteen patients in the open suction group and 16 patients in the closed suction group became colonized (P=0.14). The colonization rates by Acinetobacter spp. and Pseudomonas aeruginosa were more frequent in the closed suction group than in the open suction group (P<0.01 and P=0.04, respectively). In conclusion, closed endotracheal suction resulted in increased colonization rates of ventilator tubing with multi drug-resistant micro-organisms but did not increase the development of VAP and MICU outcome compared with open endotracheal suction.

Results of two worldwide surveys into physician awareness and perceptions of extended-spectrum β-lactamases

An omnibus survey of microbiologists (n = 400) and a survey of participants (n = 49) in the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) programme were conducted to determine the awareness and prevalence of extended-spectrum beta-lactamases (ESBLs), and the regularity and method of screening. Of the omnibus survey participants, 69% screened regularly for ESBLs, compared with 83% of MYSTIC participants. In both surveys, ESBLs were more common in Klebsiella pneumoniae (73% and 79%, respectively) and Escherichia coli (63% and 81%, respectively) than in other bacteria. The surveys demonstrated that awareness of, and testing for, ESBLs is inconsistent.

Congenital early onset isolated adrenocorticotropin deficiency associated with a TPIT gene mutation

TPIT is a highly cell-restricted transcription factor that is required for the expression of the propiomelanocortin (POMC) gene and for terminal differentiation of the pituitary corticotroph lineage. Its exclusive expression in pituitary POMC-expressing cells has suggested that its mutation may cause isolated deficiency of pituitary ACTH. We present a neonate with the diagnosis of congenital early onset isolated ACTH deficiency (IAD) associated with a loss of POMC function as a result of a missense mutation in the TPIT gene. A 5 day-old male infant was admitted for hypoglycemia, limpness and conjugated hyperbilirubinemia. Laboratory investigations indicated low plasma cortisol concentration (0.1 microg/dl) accompanying a very low ACTH (<5 pg/ml) concentration. An increase in plasma cortisol concentration following stimulation with low dose exogenous ACTH was observed. On replacement therapy with hydrocortisone (15 mg/m2/day orally), cholestatic jaundice and hypoglycemia resolved and subsequent normal growth (weight, height and head circumference, 25th, 10th and 50th percentile, respectively) and development was achieved without recurrence of hypoglycemic episodes.

Umbilical cord ghrelin concentrations in small- and appropriate-for-gestational age newborn infants: relationship to anthropometric markers

Ghrelin is a newly discovered orexigenic peptide originating from the stomach. Circulating ghrelin levels reflect acute and chronic energy balance in humans. However, it is not known whether ghrelin also plays a role in energy homeostasis during fetal life. Forty-one small-for-gestational age (SGA) and 34 appropriate-for-gestational age (AGA) infants were studied in order to determine whether cord blood ghrelin concentrations were different in SGA infants compared with AGA infants and the relationship to anthropometric measurements at delivery. The cord blood ghrelin concentrations of SGA infants (means+/-S.E.M.; 15.20+/-3.08 ng/ml) were significantly greater than of AGA infants (2.19+/-0.24 ng/ml) (P<0.0001). They were negatively correlated with the infants' birth weights (r=-0.481, P<0.0001) and with body mass index values (r=-0.363, P<0.001). The higher ghrelin concentrations were found in female infants (20.42+/-4.55 ng/ml) than in males (7.05+/-2.27 ng/ml) in the SGA group (P=0.042). These data provide the first evidence that cord ghrelin levels of SGA infants are greater than those of AGA infants and it is suggested that ghrelin is also affected by nutritional status in the intrauterine period.

Management of central diabetes insipidus with oral desmopressin in a premature neonate

The effect of oral administration of desmopressin (DDAVP) solution was investigated in a very low birth weight premature infant with central diabetes insipidus that was associated with grade four germinal matrix hemorrhage. As an alternative to the nasal route, long-term successful management resulting in favorable growth and development during infancy was achieved using the oral route.

Effect of PGD on implantation and ongoing pregnancy rates in cases with predominantly macrocephalic spermatozoa

Although its occurrence is rare, the presence of large headed or macrocephalic spermatozoa and increased chromosomal abnormality has recently been reported by several groups. Moreover, when intracytoplasmic sperm injection (ICSI) was performed with samples containing macrocephalic spermatozoa, lower fertilization and implantation rates result in poor clinical outcome. In order to evaluate the impact of preimplantation genetic diagnosis (PGD) on implantation and ongoing pregnancy rates in these couples, the results of 23 PGD cycles were compared with non-PGD cycles (n = 60) as well as cycles with absolute teratozoospermia (having zero normal morphology) with (n = 14) or without PGD (n = 66). Out of 82 embryos biopsied in the macrocephalic sperm group, abnormalities were detected in 46.4% of the embryos analysed. Most of the abnormalities were trisomies (37.0%) and complex aneuploidies (51.9%). A 33.3% pregnancy rate was achieved by selectively transferring euploid embryos after PGD with the statistically higher implantation rate of 25.0% compared with non-PGD cycles (IR: 12.3%, P < 0.01). Moreover, only one missed abortion (14.3%) was observed in the PGD group, whereas seven of the 15 pregnancies resulted in abortion in the non-PGD group (46.7%). Preliminary results indicate that patients should be counselled for increased chromosomal abnormality and a possible beneficial effect of eliminating chromosomally abnormal embryos with PGD on a bortion rates.

Stressful life events, anxiety, depression and coping mechanisms in patients with Behçet's disease

BACKGROUND

Behçet's disease is a systemic immunoinflammatory disease of young adults characterized by systemic vasculitis of arteries and veins. Although many studies have been published since its discovery in 1937, the etiopathogenesis of this unique disorder is still unclear.

OBJECTIVE

To assess the relationship between stress factors, psychological and somatic symptoms, and coping mechanisms in patients with Behcet's disease.

METHOD

Thirty-four patients with Behcet's disease and 43 control subjects were compared by using sociodemographic data collection forms, a psychosocial and environmental problems list, the Beck Anxiety Inventory (BAI), Hamilton Depression Rating Scale (HAM-D) and Toronto Alexithymia Scale (TAS).

RESULTS

Twenty-four patients (70.6%) defined stress factors in the first stage of the disease. Twenty-seven (79.4%) out of 34 patients stated that the recurrence period of the disease was related to the stress factors. Fear was expressed by 10 (29.4%) patients, sadness by 11 (32.3%), and fear plus sadness by 13 (38.2%) when they first learnt the diagnosis. While coping with these emotions 14 (41.2%) revealed active-reliance strategy. A statistically significant difference was present between the Behcet's patients and control subjects regarding TAS (P < 0.05), HAM-D (P < 0.001) and BAI (P < 0.001) scores.

CONCLUSION

It seems that stressful life events have important implications in both relapsing and remission periods of Behçet's disease via secondary problems.

Technetium-99m-tetrofosmin imaging with incremental nitroglycerin infusion to detect severely ischaemic but viable myocardium: a comparative study with thallium-201

The aim of this study was to assess the influence of incremental nitroglycerin infusion (NTG+Inf) on the myocardial uptake of 99mTc-tetrofosmin (TF) in order to determine whether nitrates enhance the detection of viable myocardium with TF in patients with coronary artery disease (CAD) and left ventricular dysfunction. Fifty patients (39 males, 11 females; 54 +/- 11 years) with previous myocardial infarction and left ventricular dysfunction, who had been referred for coronary revascularization procedures, were studied. Myocardial single-photon emission tomography (SPET) images were obtained 1 h after injection of 750 MBq TF at baseline and after NTG+Inf, using a 2 day protocol. NTG+Inf was performed starting at 0.4 microg x kg(-1) x min(-1), with equal increments every 5 min up to 2 microg x kg(-1) x min(-1). Within 1 week of the TF study, rest-redistribution (R-RD) 201Tl SPET was performed after the injection of 111 MBq 201Tl. For each study, quantitative analysis was performed in 17 segments. Viability was defined as the presence of tracer uptake of > 50% of the peak activity on baseline studies or reversibility. There was significant correlation between quantitative regional RD 201Tl activity and TF activity after NTG+Inf (r = 0.90, P < 0.001). Of the 131 segments with severely reduced tracer uptake on resting TF images, 34 (26%) were reversible, showing increased tracer uptake after NTG+Inf (from 41%+/-7% to 57%+/-12% of peak activity; P < 0.001). All reversible segments after NTG+Inf had viability criteria on 201Tl studies. There was 95% concordance between TF with NTG+Inf and RD 201Tl imaging with regard to the presence of myocardial viability. We conclude that TF imaging with incremental NTG+Inf improves the detection of ischaemic but viable myocardium, correlating with the viability criteria observed on 201Tl studies. When the advantages of TF imaging are considered, rest TF imaging with NTG+Inf may be a practical diagnostic protocol in patients with CAD and left ventricular dysfunction who are being considered for revascularization.