Atypical presentation of isolated orbital Langerhans cell histiocytosis

Background

A 9-year old female presented with one month of waxing and waning upper eyelid swelling. An excisional biopsy via anterior orbitotomy was performed.

Objective

To describe a patient presenting atypically with symptoms concerning for orbital cellulitis who was diagnosed with Langerhans cell histiocytosis (LCH).

Methods

Description of case report.

Results

We report a case of a 9-year old female with one month of periorbital edema and erythema suspected to be orbital cellulitis. A complete ophthalmological exam, subsequent imaging, and an excisional biopsy revealed the diagnosis of LCH. With a confirmed diagnosis, the patient started chemotherapy indicated by the Histiocyte Society Evaluation and Treatment Guidelines.

Conclusion

Langerhans cell histiocytosis (LCH) embodies a spectrum of diseases with the primary pathologic process being the abnormal proliferation of polyclonal Langerhans cells. In children with isolated bony involvement, the most common presenting symptom is pain. Rarely is orbital involvement with associated periorbital edema and erythema the primary presentation.

Reoperation following strabismus surgery among Medicare beneficiaries: Associations with geographic region, academic affiliation, surgeon volume, and adjustable suture technique

Purpose:

The objective of this study was to determine the associations of strabismus surgery reoperation rates in a large national database of provider payments with geographic region, practice type and volume, and the availability of adjustable suture technique.

Methods:

Fee-for-service payments to providers for medicare beneficiaries having strabismus surgery between 2012 and 2015 were retrospectively analyzed to identify reoperations in the same calendar year. The adjustable-suture technique was considered to be available to the patient if the patient's surgeon billed for adjustable sutures. Predictors of reoperation in the same calendar year were determined by multivariable logistic regression.

Results:

Availability of the adjustable suture technique was not associated with reoperation rate in multivariable analysis among 5971 patients having horizontal muscle surgery (odds ratio, [OR] 0.86, P = 0.29), 2840 patients having vertical muscle surgery (OR 0.98, P = 0.93), or 1199 patients having surgery with scarring or restriction (OR 0.86, P = 0.61). For horizontal surgery, the reoperation rate was higher in academic practices (OR 1.67), as compared with community practices, and in the South (OR 2.85) and West (OR 1.92, all P < 0.001). The reoperation rate was unchanged with surgeons in the lowest-quartile of surgical volume. Among surgeons paid for horizontal surgery, 45% of surgeons in the Northeast, the West, or Florida coded for adjustable sutures, compared with 8% of surgeons elsewhere (P < 0.001).

Conclusion:

The availability of the adjustable-suture technique was not associated with reoperation rate after strabismus surgery in this large national database. Having surgery by a lower-volume surgeon was not associated with a higher reoperation rate. The reoperation rate was higher when surgery was conducted in an academic practice, or in certain regions of the country. Adjustable sutures are largely a bicoastal practice.

Aspiration of cataract in 1815 in Philadelphia, Pennsylvania

We present and discuss the previously unrecognized evidence for the possible introduction of cataract extraction by aspiration into modern Western medicine on March 26, 1815, in Philadelphia, Pennsylvania, by surgeon Philip Syng Physick. On this date, he successfully extracted a cataract by suction through a tube, according to newspaper reports written by the patient, an attorney who sought a patent on the suction device. Aspects of the patient's account are confirmed by supporting evidence from the medical community and by a cataract instrument set attributed to Physick, which includes a cannula attached to a syringe. The evidence suggests that Physick was the first to reintroduce cataract aspiration to Western medicine.

Artificial tears potpourri: a literature review

Numerous brands and types of artificial tears are available on the market for the treatment of dysfunctional tear syndrome. Past literature has focused on comparing the components of these products on patient’s clinical improvement. The wide array of products on the market presents challenges to both clinicians and patients when trying to choose between available tear replacement therapies. Different formulations affect patients based on etiology and severity of disease. In order to provide an unbiased comparison between available tear replacement therapies, we conducted a literature review of existing studies and National Institutes of Health clinical trials on commercially available, brand name artificial tears. Outcomes evaluated in each study, as well as the percent of patients showing clinical and symptomatic improvement, were analyzed. Fifty-one studies evaluating different brands of artificial tears, and their efficacy were identified. Out of the 51 studies, 18 were comparison studies testing brand name artificial tears directly against each other. Nearly all formulations of artificial tears provided significant benefit to patients with dysfunctional tear syndrome, but some proved superior to others. From the study data, a recommended treatment flowchart was derived.

Environmental assessment of a road site built with MSWI residue

A 23-year-old road built with MSWI residue (mix of fly and bottom ashes) was investigated through the environmental assessment of the residue, soils (adjacent to and underlying the road) and seepage waters. The pH and ANC(4.3) of the material indicate a low carbonation and a high alkaline stock. The material leaches few trace elements. The underlying road soil shows significant effects with respect to K and Na, attributable to the MSWI residue. Effects regarding Cd, Cr, Cu and Ni are observed, yet pollution thresholds are not exceeded. Compared to groundwater thresholds, the MSWI residue percolate is of poor to very poor quality (French reference system - FWQAS) in terms of pH, K, Na, Cl(-), F(-), As and Cu. It lies above the intervention values of the Dutch Soil Protection Act (DSPA) for Cu, Ni and Pb. Downstream, water from the road shoulder (W(Sdr)) is of very poor quality with respect to Na and Cl(-), and fair to poor quality regarding K. All other parameters comply with the best quality thresholds (FWQAS and DSPA). The high Cl(-) concentration of W(Sdr) would not fit for direct discharge in any watercourse. Toward a weakly-mineralised water, Cd and Cu would also be penalizing. The geometry of the road site creates penalizing conditions increasing the washing of the MSWI residue. The road structure does not cause downstream effect as regards trace elements, but effects exist for Cl(-), Na and K. Opposite downstream effects are observed (Ca, Mg, Mn and SO(4)(2-)) due to farming treatments and the nature of the local soil.

A seasonal study of arsenic in groundwater, Snohomish County, Washington, USA

A series of arsenic poisonings near Granite Falls in Snohomish County, Washington, were identified during 1985-87. An initial investigation revealed the source of arsenic exposure to be high levels of arsenic in well water. A large number of wells in eastern Snohomish County were tested, residents were interviewed and sources of contamination, both natural and man-made, were investigated. More than 70 private drinking-water wells were found to contain elevated levels of arsenic . One well contained 33 mg As L(-1). The finding of elevated arsenic levels in a previously approved drinking-water well for a restaurant, plus suggestions of symptoms consistent with arsenic poisoning among people with wells with no detectable arsenic, raised concern over possible temporal variation in arsenic levels. To evaluate this temporal variation, a 12-month study of arsenic in groundwater was conducted in selected wells near Granite Falls. The 12-month study of 26 wells, conducted between February 1988 and January 1989, found arsenic levels for individual wells to vary from one to 19 fold over time. Because of this variability, four out of the eight wells with arsenic levels close to the Maximum Contamination Level (MCL) of 0.050 mg As L(-1) would have been considered safe on the basis of a single sample, but would have exceeded the MCL at another time of the year.In areas with a high occurrence of arsenic contaminated drinking water, approval of well water prior to the sale of a house or issuance of a building permit which is based on a single arsenic test may result in later findings of unacceptable drinking water. When the arsenic is near the MCL, it may be prudent to follow well-water arsenic concentrations over time to assure that the arsenic level remains within acceptable bounds. If lower arsenic standards are adopted for drinking water, the issue of temporal variation around the standard will become a matter of more widespread concern.

The inability of in vitro transforming SV40 subgenomes to cause tumors in vivo

Linear or subgenomic SV40 DNAs were transfected into cells from a variety of species (including rodent, dog, muntjak, and monkey) and injected subcutaneously into neonate Syrian hamsters for tumorigenicity testing. The 'early-region' subgenomes were capable of transforming cells in vitro. Complete genomes or complementary subgenomes could transform nonpermissive and semipermissive cells, were infectious for permissive cells, and induced tumors from which infectious virus could be rescued. Tumors were not formed in neonate hamsters upon injection with subgenomic SV40 DNAs, even those capable of transforming cells in vitro. These results suggested that SV40 tumor formation in vivo may require a complete genome.