Biopsy of the Parietal Branch of the Superficial Temporal Artery for the Diagnosis of Giant Cell Arteritis

BACKGROUND

Biopsy of the superficial temporal artery (STA) is central to the diagnosis of giant cell arteritis (GCA), but determining the ideal biopsy site along the course of the STA continues to be a challenge. Traditionally, the frontal branch or preauricular region of the STA is biopsied because of their accessibility, but biopsy at these locations can produce visible cosmetic defects and social disruption that can be distressing to patients, as well as increase the likelihood of adverse events such as injury to the facial nerve. The authors describe a surgical technique of biopsy of the parietal branch of the STA to improve the patient's perioperative and postoperative experience.

METHODS

In this retrospective review, 24 patients with clinical suspicion of GCA who underwent biopsy of the parietal branch of the STA were identified. Patients underwent mapping of the branches of the STA with Doppler ultrasound before the procedure. Biopsy of the parietal branch of the STA was conducted using a CO 2 laser.

RESULTS

Twenty-four patients underwent biopsy of the parietal branch of the STA. Two patients were diagnosed on histopathology with GCA. All patients tolerated the procedure well and without complications.

CONCLUSION

Application of preoperative Doppler ultrasound mapping, use of a CO 2 laser for incisions and hemostasis, and selection of the parietal branch allowed for improved cosmetic outcomes, no associated adverse events, and improved overall patient experience. The authors advocate biopsy of the parietal branch of the superficial temporal artery for the diagnosis of GCA in the absence of contraindications.

The Lowly Chalazion

Chalazia are localized cysts of chronic lipogranulomatous inflammation arising from the obstruction of sebaceous glands of the eyelid tarsal plate, including the Meibomian gland (deep chalazion) or Zeis gland (superficial chalazion). This disease entity is differentiated from the hordeolum (stye), an acute purulent localized swelling of the eyelid often associated with an eyelash follicle, Zeis gland, or Moll gland obstruction and infection. Ambiguously, the chalazion, hordeolum, and blepharitis are commonly categorized and described on a continuum in the literature. While it is one of the most common eyelid disorders across all age demographics, the chalazion remains largely understudied and pathophysiological, epidemiological, and therapeutic findings exist fragmented in the literature. We discuss current understandings of the chalazion and provide current best practice guidelines supported by clinical anecdotal evidence.

Preservation of Infraorbital Nerve in Orbital Floor and Maxillary Defect Reconstruction With Patient-Specific Three-Dimensional Implant: A Case Report

Reconstruction of orbitomaxillary defects poses many operative challenges because it requires consideration of cosmetic as well as functional elements: reestablishing facial symmetry while constituting the orbital volume and preserving involved neurovascular structures. The development of patient-specific polyetheretherketone implants have revolutionized complex craniofacial reconstruction due to its adaptability to anatomic constraints and accommodation of vital structures. Herein, we described 2 cases of orbitomaxillary reconstruction using PEEK implant with novel modifications to preserve the infraorbital nerve with optimal cosmetic outcomes and minimal postoperative morbidity.

Sutureless Transconjunctival Insertion of Eyelid Weights: A Novel Technique

PURPOSE

To describe a novel surgical technique for implanting eyelid weights via a sutureless transconjunctival approach. In comparison to the traditional supratarsal crease approach, this technique does not involve any external incisions or suture placement. The procedure can reduce surgical time and complications associated with the traditional external approach.

METHODS

This case series includes 13 patients who underwent eyelid weight placement via the transconjunctival approach for paralytic lagophthalmos secondary to facial nerve paralysis (12 patients had unilateral paralysis and 1 patient had bilateral) with a total of 14 eyelid weights placed. The procedures were performed at an outpatient office-based surgical center. All procedures were performed or supervised by the same surgeon. Patients were followed for an average 6-month postoperative period for postoperative complications.

RESULTS

The sutureless transconjunctival approach to eyelid weight insertion was successful in achieving the desired functional and aesthetic outcomes. Patients undergoing this technique avoided the discomfort of postoperative suture removal. All patients achieved comparable outcomes postoperatively. There were no complications reported across the 13 patients throughout the 6-month postoperative period.

CONCLUSIONS

This case series demonstrates that the transconjunctival approach for metal eyelid weight insertion is practical, relatively easy to perform, and associated with functional outcomes that are comparable to those achieved with the traditional approach, however, without external incision or placement of sutures.

Congenital tooth-bearing tumor of the eyelid leading to lacrimal system obstruction

PURPOSE

We present an unusual case of a congenital lesion presenting with concomitant chronic dacryocystitis. The clinical presentation, examination, management, and histopathology are reviewed.

OBSERVATIONS

A healthy male infant born at 37 weeks gestation presented with an isolated painless 5mm congenital mass of the left medial lower eyelid. Parents also reported episodic epiphora and discharge from the left eye. A surgical excision of the mass revealed an underlying dacryocystitis and the presence of a formed tooth. A dacryocystorhinostomy was performed together with a repair of the soft tissue defect. Histopathology revealed components of disorganized epithelial and mesenchymal tissues including a tooth, skeletal muscle, fat, fibrous tissue, nonkeratinized epithelium, and myelinated nerves. A diagnosis of an odontogenic choristoma of the eyelid was made. Furthermore, a lacrimal sac culture was positive for oxacillin-susceptible Staphylococcus aureus with pathological evidence of chronic dacryocystitis.

CONCLUSIONS AND IMPORTANCE

Odontogenic choristoma is a very rare finding in the periocular region with only a few cases reported in the literature. Awareness of clinical findings from this case may allow for a more accurate clinical diagnosis and understanding of the embryologic mechanisms underpinning eyelid and nasolacrimal development. Timely management of this condition is critical to ensure normal oculofacial development and prevent future complications.

Surgical and Teaching Mission to Mongolia: Experience and Lessons

BACKGROUND

For decades, the disparity in medical care across the world along with the fundamental essence of medicine as service has laid the foundation for the global medical mission. Mongolia, a country often overlooked as an area in need of medical aid, harbors a fertile environment for long-term change. In the last 15-20 years, after the fall of the Union of Soviet Socialist Republics, Mongolia has turned to a free-market healthcare model and has been struggling with the transition from the formally state-run system. These changes have slowed the original progress noted among surgical specialties, namely neurosurgery, in Mongolia. A lack of resources, a desire for international interaction, and a need for technical mentorship remain a real struggle for local neurosurgeons.

METHODS

Under the auspices of the Virtue Foundation (www.virtuefoundation.org), we report on our 3-year experiences during our surgical and teaching mission to Mongolia and look towards long-term improvements in Mongolian neurosurgery.

RESULTS

A total of 15 operations were performed and more than 50 patients seen in clinic during the 3-year experience. Patients ranged from 1 to 77 years of age. No patients encountered any significant peri- or postoperative complications.

CONCLUSIONS

In our experience with the surgical and teaching mission to Mongolia, when directed appropriately, medical missions can serve as the perfect medium in fostering that environment, providing local healthcare professionals with the knowledge, skills, and motivation to create self-sustaining improvement in their own country, hence promoting intellectual and technological advancement and raising the standard of care.

R632W mutation in PLA2G6 segregates with dystonia-parkinsonism in a consanguineous Iranian family

BACKGROUND

PLA2G6 mutations are known to be responsible for infantile neuroaxonal dystrophy (INAD) and neurodegeneration with brain iron accumulation (NBIA). In addition, novel mutations in PLA2G6 have recently been associated with dystonia-parkinsonism in two unrelated consanguineous families.

METHODS

Direct sequencing analysis of the PLA2G6 gene.

RESULTS

Here, we report the segregation of R632W with disease in an Iranian consanguineous dystonia-parkinsonism pedigree. The identical mutation was previously observed in a patient affected with NBIA.

CONCLUSION

We conclude that different and even identical PLA2G6 mutations may cause neurodegenerative diseases with heterogeneous clinical manifestations, including INAD, NBIA and dystonia-parkinsonism.

New academic partnerships in global health: innovations at Mount Sinai School of Medicine

Global health has become an increasingly important focus of education, research, and clinical service in North American universities and academic health centers. Today there are at least 49 academically based global health programs in the United States and Canada, as compared with only one in 1999. A new academic society, the Consortium of Universities for Global Health, was established in 2008 and has grown significantly. This sharp expansion reflects convergence of 3 factors: (1) rapidly growing student and faculty interest in global health; (2) growing realization-powerfully catalyzed by the acquired immune deficiency syndrome epidemic, the emergence of other new infections, climate change, and globalization-that health problems are interconnected, cross national borders, and are global in nature; and (3) rapid expansion in resources for global health. This article examines the evolution of the concept of global health and describes the driving forces that have accelerated interest in the field. It traces the development of global health programs in academic health centers in the United States. It presents a blueprint for a new school-wide global health program at Mount Sinai School of Medicine. The mission of that program, Mount Sinai Global Health, is to enhance global health as an academic field of study within the Mount Sinai community and to improve the health of people around the world. Mount Sinai Global Health is uniting and building synergies among strong, existing global health programs within Mount Sinai; it is training the next generation of physicians and health scientists to be leaders in global health; it is making novel discoveries that translate into blueprints for improving health worldwide; and it builds on Mount Sinai's long and proud tradition of providing medical and surgical care in places where need is great and resources few.

Bioemulsifier production by a halothermophilic Bacillus strain with potential applications in microbially enhanced oil recovery

A halothermotolerant Gram-positive spore-forming bacterium was isolated from petroleum reservoirs in Iran and identified as Bacillus licheniformis sp. strain ACO1 by phenotypic characterization and 16S rRNA analysis. It showed a high capacity for bioemulsifier production and grew up to 60 degrees C with NaCl at 180 g l(-1). The optimum NaCl concentration, pH and temperature for bioemulsifier production were 4% (w/v), 8.0, and 45 degrees C, respectively. Although ACO1 did not utilize hydrocarbons, it had a high emulsifying activity (E (24) = 65 +/- 5%) on different hydrophobic substrates. Emulsification was optimal while growing on yeast extract as the sole carbon source and NaNO(3) as the nitrogen source. The efficiency of the residual oil recovery increased by 22% after in situ growth of B. licheniformis ACO1 in a sand-pack model saturated with liquid paraffin.

A simplified technique of ptosis repair using a single adjustable suture

PURPOSE

To describe a simplified technique for ptosis repair using a single adjustable suture.

DESIGN

Retrospective noncomparative series.

PARTICIPANTS

Fifty-one cases of ptosis repair performed or supervised by the same surgeon between 1993 and 1995.

INTERVENTION

The surgical approach consisted of using a single adjustable "hang-back" 5-0 silk suture for plication of the superior portion of the levator aponeurosis. Lid height was then reassessed within the first 4 postoperative days and permanently readjusted by fixating the adjustable suture. Excluded were patients with history of unstable ptosis as a result of systemic disease or congenital, mechanical, and traumatic ptosis resulting from a mass or trauma. The follow-up period ranged from 3 to 31 months.

MAIN OUTCOME MEASURE

Lid position.

RESULTS

All eyelids included in this study were corrected to 1 mm of the desired result. There were no incidents of peaking or recurrence on long-term follow-up. Complications included one case of hematoma and a case of slight tenting of the eyelid margin.

CONCLUSIONS

This procedure combines the physiologic approach of levator aponeurosis surgery with the simplicity and flexibility of a single adjustable "hang-back" type suture. It may readily be combined with other procedures such as blepharoplasty. It is also useful when the "ideal" lid level may not be determined until the postoperative period, such as eyes subject to ptosis by Hering's law, levator dehiscence, or those at increased potential risk for corneal exposure.

Lower eyelid hernia repair for palpebral bags: a comparative study

The standard treatment for herniated "bags" of the lower eyelid is surgical removal of excess fat. Sachs and Bosniak in 1986 and de la Plaza and Arroyo in 1988 described a new technique for treatment of palpebral bags that consisted of returning the herniated fat to the orbital cavity and retaining it by continuous sutures of the capsulopalpebral fascia either to the dehiscent portion of the orbital septum or to the periosteum of the lower orbital rim. This article reports a prospective study of 26 patients who underwent standard blepharoplasty in one lower eyelid and capsulopalpebral fascia hernia repair in the other lower eyelid. All were evaluated at 6 weeks and at 6 months after surgery, and the outcomes were compared. The results of the two different techniques in the same patient have shown comparable aesthetic outcomes in the treatment of palpebral bags. However, results indicate that the capsulopalpebral fascia hernia repair technique carries less discomfort and pain during the operation and may be less prone to postoperative bleeding and hematoma formation. In addition, in contrast to standard lower blepharoplasty with fat resection, hollowing of the lower lid or potential sunken appearance of the globe may remain absent with capsulopalpebral fascia hernia repair beyond the 6-month period of this study.

"Pneumofornix" (air under the eyelid): a normal finding

Normal pockets of air under the eyelids have not been previously described in the literature. To assess the incidence and patterns of normal air bubbles in the region of the eyelid, computed tomography (CT) scans of 126 normal orbits and 36 orbits of patients with thyroid orbitopathy were assessed. Twenty-eight (22%) of the normal orbits and 14 (39%) of the thyroid orbits had a well-defined medial or lateral air bubble (or both) on axial views (.1 > P > .05). Oval central or paracentral air bubbles in sections through the superior or inferior fornix were seen in 19 (15%) of the normal orbits and 10 (28%) of the thyroid orbits (.1 > P > .05). It is important to be aware of the incidence and patterns of these normal air bubbles to ensure their accurate differentiation from pathologic air bubbles.

Derivatization with monomethoxypolyethylene glycol of Igs expressing viral epitopes obviates adjuvant requirements

Ig molecules expressing within the CDR3 loop viral B or T cell epitopes were derivatized with mPEG 5,000. Pegylated Ig were used to investigate the in vitro and in vivo effect of pegylation on the immunogenicity of viral epitopes expressed in chimeric Ig. Two chimeras were used in this study: Ig-HA carrying a CD4 epitope corresponding to amino acid residues 110-120 of the hemagglutinin (HA) of PR8 influenza A virus and Ig-V3C, a murine-human chimera carrying a consensus B cell epitope from the V3 loop of HIV-1 gp120 protein. Pegylated Ig-HA (Ig-HA-mPEG) with 6 to 8% substituted lysine residues showed in vivo resistance to enzymatic degradation and persisted significantly in blood circulation and lymphoid organs. Moreover, Ig-HA-mPEG was able to activate in vitro HA110-120-specific hybridoma T cells and to prime T cell proliferative response in vivo without requirement for adjuvant. Also, mildly pegylated Ig-V3C (Ig-V3C-mPEG) administered into BALB/c mice in the absence of adjuvant induced specific Ab response to V3C peptide with insignificant response to xenogeneic human Ig determinants.

Derivatization with monomethoxypolyethylene glycol of Igs expressing viral epitopes obviates adjuvant requirements

Ig molecules expressing within the CDR3 loop viral B or T cell epitopes were derivatized with mPEG 5,000. Pegylated Ig were used to investigate the in vitro and in vivo effect of pegylation on the immunogenicity of viral epitopes expressed in chimeric Ig. Two chimeras were used in this study: Ig-HA carrying a CD4 epitope corresponding to amino acid residues 110-120 of the hemagglutinin (HA) of PR8 influenza A virus and Ig-V3C, a murine-human chimera carrying a consensus B cell epitope from the V3 loop of HIV-1 gp120 protein. Pegylated Ig-HA (Ig-HA-mPEG) with 6 to 8% substituted lysine residues showed in vivo resistance to enzymatic degradation and persisted significantly in blood circulation and lymphoid organs. Moreover, Ig-HA-mPEG was able to activate in vitro HA110-120-specific hybridoma T cells and to prime T cell proliferative response in vivo without requirement for adjuvant. Also, mildly pegylated Ig-V3C (Ig-V3C-mPEG) administered into BALB/c mice in the absence of adjuvant induced specific Ab response to V3C peptide with insignificant response to xenogeneic human Ig determinants.

Antibody response elicited by T-dependent and T-independent antigens in gene targeted kappa-deficient mice

Animal models substantially contribute to the understanding of the pathogenesis of various human diseases, including those associated with genetic defects. Our study investigated the characteristics of antibody responses elicited by T-dependent and T-independent antigens in mice rendered kappa-deficient by targeted deletion of the J kappa C kappa gene segments. It is known that in normal murine species the kappa repertoire dominates the antibody repertoire (kappa/lambda ratio = 95:5). Our results indicate that the kappa gene deletion causes the alternative usage of lambda 1 (93%) and lambda 2 (7%) light chains, confirming previous studies demonstrating that in kappa-deficient mice all B cells express Ig lambda receptors. The anti-trinitrophenylbenzene (TNP) response in K-/- mice was compensated for by lambda 1 and lambda 2 bearing Igs. However, isoelectric focusing analysis of anti-TNP antibodies showed a considerably more restricted pattern of lambda anti-TNP antibodies in K-/- as compared with kappa antibodies in normal mice. No major differences were observed in the affinity for the hapten of kappa or lambda 1 or lambda 2 mAbs obtained from 129/Sv and K-/- mice. Furthermore, lambda 1 and lambda 2 chains can reconstitute the expression of an idiotype (460Id) borne on kappa anti-TNP antibodies. The 460Id was detected both in polyclonal and monoclonal anti-TNP antibodies obtained from K-/- mice. Our results clearly showed that the kappa anti-TNP repertoire is compensated by the lambda repertoire even though the latter is clonally restricted in K-/- mice.

Effects of ribosomal wash factors and spermidine on endogenous and exogenous mRNA stimulated protein synthesis in the wheat germ cell-free system

Differential effects of Mg2+, spermidine, and reticulocyte ribosomal wash factors on the translation of endogenous, myeloma, and globin mRNA's have been observed in studies with the wheat germ cell-free protein synthesizing system. Spermidine stimulated globin mRNA translation but not the translation of endogenous wheat germ messages, and the polyamine actually inhibited the translation of myeloma mRNA. Ribosomal wash factors, on the other hand, stimulated endogenous and myeloma mRNA dependent protein synthesis in an Mg2+-dependent fashion but inhibited globin mRNA translation. The combination of ribosomal wash factors and spermidine was either stimulatory or inhibitory depending on the Mg2+ concentration and the message. It was further observed that translation of exogenous myeloma mRNA proceeded for only 60 min at 25 degrees C under all conditions tested in this study, while translation of endogenous wheat germ messages continued for longer periods of time. No differential effects of spermidine on the synthesis of high molecular weight myeloma proteins were observed.

The postnatal methylation of transfer ribonucleic acid in brain. Evidence for the methylation of precursor transfer ribonucleic acid

Incubation of 3-day-old rat brain with L-[methyl-3H]methionine resulted in the rapid labeling of low-molecular-weight cytoplasmic RNA. Electrophoresis in 15% polyacrylamide gels provided evidence for the methylation of precursor tRNA molecules, and high-performance liquid chromatography demonstrated N2-methylguanine to be the predominant methylated base formed during the first 2 min of labelling.