Brain injury patterns in hypoglycemia in neonatal encephalopathy.

BACKGROUND AND PURPOSE: Low glucose values are often seen in term infants with NE, including HIE, yet the contribution of hypoglycemia to the pattern of neurologic injury remains unclear. We hypothesized that MR features of neonatal hypoglycemia could be detected, superimposed on the predominant HIE injury pattern. MATERIALS AND METHODS: Term neonates (n = 179) with NE were prospectively imaged with day-3 MR studies and had glucose data available for review. The predominant imaging pattern of HIE was recorded as watershed, basal ganglia, total, focal-multifocal, or no injury. Radiologic hypoglycemia was diagnosed on the basis of selective edema in the posterior white matter, pulvinar, and anterior medial thalamic nuclei. Clinical charts were reviewed for evidence of NE, HIE, and hypoglycemia (<46 mg/dL). RESULTS: The predominant pattern of HIE injury imaged included 17 watershed, 25 basal ganglia, 10 total, 42 focal-multifocal, and 85 cases of no injury. A radiologic diagnosis of hypoglycemia was made in 34 cases. Compared with laboratory-confirmed hypoglycemia, MR findings had a positive predictive value of 82% and negative predictive value of 78%. Sixty (34%) neonates had clinical hypoglycemia before MR imaging. Adjusting for 5-minute Apgar scores and umbilical artery pH with logistic regression, clinical hypoglycemia was associated with a 17.6-fold higher odds of MR imaging identification (P < .001). Selective posterior white matter and pulvinar edema were most predictive of clinical hypoglycemia, and no injury (36%) or a watershed (32%) pattern of injury was seen more often in severe hypoglycemia. CONCLUSIONS: In term infants with NE and hypoglycemia, specific imaging features for both hypoglycemia and hypoxia-ischemia can be identified.

Global flash multifocal electroretinogram: early detection of local functional changes and its correlations with optical coherence tomography and visual field tests in diabetic eyes.

PURPOSE: To investigate the correlations of the global flash multifocal electroretinogram (MOFO mfERG) with common clinical visual assessments--Humphrey perimetry and Stratus circumpapillary retinal nerve fiber layer (RNFL) thickness measurement in type II diabetic patients. METHODS: Forty-two diabetic patients participated in the study: Ten were free from diabetic retinopathy (DR), while the remainder suffered from mild to moderate nonproliferative diabetic retinopathy. Fourteen age-matched controls were recruited for comparison. MOFO mfERG measurements were made under high- and low-contrast conditions. Humphrey central 30-2 perimetry and Stratus OCT circumpapillary RNFL thickness measurements were also performed. Correlations between local values of implicit time and amplitude of the mfERG components [direct component (DC) and induced component (IC)], and perimetric sensitivity and RNFL thickness were evaluated by mapping the localized responses for the three subject groups. RESULTS: MOFO mfERG was superior to perimetry and RNFL assessments in showing differences between the diabetic groups (with and without DR) and the controls. All the MOFO mfERG amplitudes (except IC amplitude at high contrast) correlated better with perimetry findings (Pearson's r ranged from 0.23 to 0.36, p < 0.01) than did the mfERG implicit time at both high and low contrasts across all subject groups. No consistent correlation was found between the mfERG and RNFL assessments for any group or contrast conditions. The responses of the local MOFO mfERG correlated with local perimetric sensitivity but not with RNFL thickness. CONCLUSION: Early functional changes in the diabetic retina seem to occur before morphological changes in the RNFL.

Photodynamic therapy using aminolaevulinic acid for patients with nonhyperkeratotic actinic keratoses of the face and scalp: phase IV multicentre clinical trial with 12-month follow up.

BACKGROUND: Actinic keratoses (AKs) are the most common epithelial precancerous lesions, especially among individuals with light complexions. AKs are believed to progress to in situ squamous cell carcinoma (SCC) and potentially, to invasive SCC. AKs and invasive SCCs share certain histopathological features and both share genetic tumour markers and p53 mutations. Given these facts, the treatment and management of AKs are integral components to quality dermatological health care. OBJECTIVES: Topical aminolaevulinic acid-based photodynamic therapy (ALA-PDT) has been extensively studied over the last several years. This study seeks to characterize further the efficacy and safety of ALA-PDT by extending previous work to: (i) assess the long-term recurrence rate of AKs that have resolved after ALA-PDT; (ii) to characterize the histopathology of treated AK lesions that do not completely respond to ALA-PDT or recur in long-term follow up; (iii) to characterize the histopathology of untreated clinically diagnosed AK lesions in the study population at baseline; and (iv) to evaluate ALA-PDT in darker skin types than previously studied. METHODS: Patients enrolled in this study had six to 12 discrete AK lesions, either on the face or the scalp. Individual AK lesions designated for treatment were graded as either grade 1 (lesions slightly palpable and more easily felt than seen) or grade 2 (moderately thick AKs, easily seen and felt). Patients with grade 3 (very thick and/or hyperkeratotic) lesions were excluded. For each subject, two lesions at baseline were randomized to biopsy, and were not followed as part of the study while the remaining lesions (target lesions) were treated with ALA-PDT (baseline and month 2, if required) and followed for 12 months. RESULTS: Of the 110 patients enrolled, 101 completed the study. The target AK lesions in the per-protocol population clearing completely in the first and second months following a single ALA-PDT treatment (baseline) were 76% and 72%, respectively. Sixty per cent of the patients received a second ALA-PDT treatment, limited to the target AKs still present at month 2. The percentage of treated target lesions that cleared completely peaked at 86% at month 4 then decreased gradually over time to 78% at month 12. The overall recurrence rate for all lesions that were noted to be cleared at some visit during the 12-month period was 24% (162/688). Of the 162 recurrent lesions 16 were lost to follow up, seven spontaneously cleared and 139 were biopsied. With respect to the lesions biopsied, 91% (127/139) were diagnosed histopathologically as AK, with the balance of lesions being SCC (nine of 139: 7%), basal cell carcinoma (one of 139: 0.7%) and other non-AK diagnoses (two of 139: 1%). The recurrence rate for histologically confirmed AKs was 19%. The clinical diagnosis of AK by investigators appeared to be accurate, with 91% (200/220) of the untreated clinically diagnosed AK lesions being histopathologically confirmed to be AK (AK, 142/220: 65%; advanced AK, 29/220: 13%; macular AK, 29/220: 13%). Despite concentrated efforts to recruit patients with Fitzpatrick skin types IV-VI, the distribution was as follows: I, 11%; II, 36%; III, 41%; IV, 11%; V, 2%. The demographics of this study population are typical of a patient population with AK. CONCLUSIONS: ALA-PDT was shown to be an effective and safe therapy for the treatment of AKs of the face and scalp in skin types I-V, with an acceptable rate of recurrence over 12 months of histologically confirmed AKs of 19%. Phototoxicity reactions were all expected, nonserious and had essentially resolved after 1 month post-treatment independent of skin type.

An optical supernova associated with the X-ray flash XRF 060218.

Long-duration gamma-ray bursts (GRBs) are associated with type Ic supernovae that are more luminous than average and that eject material at very high velocities. Less-luminous supernovae were not hitherto known to be associated with GRBs, and therefore GRB-supernovae were thought to be rare events. Whether X-ray flashes--analogues of GRBs, but with lower luminosities and fewer gamma-rays--can also be associated with supernovae, and whether they are intrinsically 'weak' events or typical GRBs viewed off the axis of the burst, is unclear. Here we report the optical discovery and follow-up observations of the type Ic supernova SN 2006aj associated with X-ray flash XRF 060218. Supernova 2006aj is intrinsically less luminous than the GRB-supernovae, but more luminous than many supernovae not accompanied by a GRB. The ejecta velocities derived from our spectra are intermediate between these two groups, which is consistent with the weakness of both the GRB output and the supernova radio flux. Our data, combined with radio and X-ray observations, suggest that XRF 060218 is an intrinsically weak and soft event, rather than a classical GRB observed off-axis. This extends the GRB-supernova connection to X-ray flashes and fainter supernovae, implying a common origin. Events such as XRF 060218 are probably more numerous than GRB-supernovae.

A retrospective study on the efficacy and complications of Q-switched alexandrite laser in the treatment of acquired bilateral nevus of Ota-like macules.

BACKGROUND: Acquired bilateral nevus of Ota-like macules (ABNOM), or Hori's macules, is a common Asian condition that is characterized by bluish hyperpigmentation in the bilateral malar regions. Unlike nevus of Ota, ABNOM is an acquired condition that often develops after 20 years of age and involves both sides of the face, but there is no mucosal involvement. Recently Q-switched (QS) 1064 nm Nd:YAG lasers have been effective in clearing this condition. The effectiveness of QS alexandrite lasers has not yet been studied. OBJECTIVE: To retrospectively assess the efficacy and complications of QS alexandrite lasers in the treatment of ABNOM. METHODS: Thirty-two Chinese women with ABNOM ranging in age from 28 to 66 years were involved in the study. All underwent QS alexandrite laser treatment (755 nm, spot size 3 mm, 8 J/cm(2)). Topical hydroquinone and tretinoin cream were given to those with hyperpigmentation after the laser surgery. Clinical photographs were taken before and after laser surgery and assessed by two independent observers. The degree of clearing was scored and complications, including hypopigmentation, hyperpigmentation, scarring, and erythema, were assessed. RESULTS: The mean number of treatment sessions was 7 (range 2-11) and the mean treatment interval was 33 days. Both observers identified more than 80% of the patients as having more than a 50% degree of clearing, and complete clearance was seen in more than 28% of patients. Although most patients had postlaser hyperpigmentation and were on depigmentary regimes, the hyperpigmentation was seen in only 12.5% of the patients during photographic evaluation. Hypopigmentation was seen in 50% of patients and erythema in 41%. CONCLUSION: QS alexandrite appears to be effective in the treatment of ABNOM. Postoperative pigmentary changes were frequent and the use of topical depigmentary agents was necessary to achieve a satisfactory result. Transient hypopigmentation risk was high, affecting up to 50% of the patients. Further study is warranted to compare the efficacy and complications of different laser systems in the treatment of this condition.

An in vivo study comparing the efficacy and complications of diode laser and long-pulsed Nd:YAG laser in hair removal in Chinese patients.

BACKGROUND: Lasers with long wavelengths are less well absorbed by melanin and are considered to be particularly suitable for hair removal in dark-skinned patients. OBJECTIVE: To compare the efficacy and complications of 800 nm diode and long-pulsed 1064 nm Nd:YAG lasers in laser-assisted hair removal in Chinese patients. METHODS: Fifteen women had hair removal treatments (13 axillae and 2 legs) with diode laser on one side and Nd:YAG laser on the other. They were followed up for 36 weeks. Subjective assessments included the degree of immediate pain and the degree of hair regrowth. Clinical photographs were taken for evaluation by two independent observers to assess complications and the degree of hair regrowth. RESULTS: Long-pulsed Nd:YAG laser was found to be significantly associated with a greater degree of immediate pain after laser surgery (P =.0001, independent sample t-test) and also had a longer laser time (P =.0001, independent sample t-test). Besides transit adverse effects such as erythema and perifollicular edema, only one patient developed hypopigmentation at week 6 which resolved by week 36. Although regrowth rates were low at week 6 (subjective rates were 23% and 19% for Nd:YAG and diode laser, respectively), most patients had significant regrowth at week 36 (subjective regrowth rate 91% for both long-pulsed Nd:YAG and diode lasers). CONCLUSION: Diode 800 nm and Nd:YAG 1064 nm lasers are safe in laser-assisted hair removal in Chinese patients, and besides immediate pain, there was no other significant adverse effect. Most patients experienced regrowth 36 weeks after a single treatment. Further study is necessary to determine the long-term clinical efficacy and complications of laser-assisted hair removal with these systems in dark-skinned patients.

Signs and symptoms of malignant parotid tumours: an objective assessment.

BACKGROUND: The clinical features that may be associated with malignancy in parotid tumours are well known. Classical teaching dictates caution in their presence but this raises a false alarm in many cases. Formal studies looking at these features are few. The aim of this article was to study quantitatively those features that provide a better prediction of malignancy. METHODS: Clinical records of 186 consecutive patients treated for parotid tumours over a 12-year period were reviewed. Presence of suspicious clinical features and the final histology in each patient were noted. RESULTS: The overall pick-up rate for malignancy, based on clinical features alone, was around 30%. Palpable cervical lymph nodes, facial nerve palsy, deep fixation and rapid enlargement of the tumour were significant parameters indicative of malignancy (p = 0.000 for all 4 parameters, chi-squared test). The risk of malignancy increased when multiple parameters were present together at the same time. CONCLUSION: Clinical features remained the most important single modality identifying malignancy in patients with parotid tumours. The logistic regression model allowed for simple clinical prediction of malignancy with improved sensitivity and much better specificity.

Nevus of Ota: a new classification based on the response to laser treatment.

BACKGROUND AND OBJECTIVE: For 60 years, Tanino's classification has been used to classify the extent of nevus of Ota. However, such classification not only fails to address variants such as phacomatosis pigmentovascularis but also cannot be used to predict the therapeutic outcome. Our objective is to retrospectively study our series of laser-treated patients with the aim of re-classifying nevus of Ota, so that such important issues can be taken into account. STUDY DESIGN/MATERIALS AND METHODS: One hundred nineteen patients that had received Q-switched laser treatment were recruited into the study. They were recalled for interview and examination for evidence of coexisting birthmarks and extracutaneous involvement. Two observers assessed the pre- and posttreatment clinical photographs for evidence of periorbital under-response (panda's sign), defined as the degree of periorbital laser clearing significantly less than clearing in the other area. RESULTS: A total of 47.8% of the patients with periorbital pigmentation were considered by the observers to have significant periorbital under-response (panda's sign). Additionally, 10.1% had other birthmarks, and extracutaneous involvement was seen in 31.4% of the patients. CONCLUSION: Periorbital under-response is commonly seen in patients with periorbital pigmentation. Taking this and other factors into consideration, we have proposed a new classification for nevus of Ota that allows for the prediction of the clinical outcome of laser treatment.

Surface landmarks of the facial nerve trunk: a prospective measurement study.

BACKGROUND: Facial nerve identification and preservation is the key to safe parotidectomy in most clinical situations. Traditional approaches to the main trunk have depended solely on internal landmarks but localization may further be enhanced if data are available on its position with reference to neighbouring external features. METHODS: Prospective measurements were taken on a series of parotidectomy patients intraoperatively. Using that spot on the main trunk 10 mm proximal to its bifurcation as the reference point, the depth from the skin and its cranio-caudal distance from the summit of the tragus were measured. RESULTS: Thirty-three patients were included, whose body mass index showed that they had average body build. The reference point nerve was 23.6 mm (SD = 5.1 mm) from the skin surface, and 18.8 mm (SD = 6.0 mm) caudal to the tragus. CONCLUSION: Measurements relating to the siting of the facial nerve trunk were obtained live at operation. This information should be helpful in the initial mobilization of the parotid gland from its posterior relations and in facilitating the classical internal landmarks in the 3-D localization of the main trunk, thereby allowing quicker and safer parotidectomy.

The omohyoid sling syndrome.

BACKGROUND: Patients with the omohyoid syndrome present with a transient lower neck swelling during swallowing. The mechanism of functional derangement has been hypothesized previously but never proven. Our aim is to show how this can be demonstrated real-time. METHOD AND PATIENTS: Five patients were studied. Serial photography, clinical videography, real-time ultrasonography, and simulated cine mode computed tomography were used. Findings were compared with the normal side. The literature was reviewed. RESULTS: Very little literature experience is available. The swelling appears when the throat ascends and subsides with its descent in unison with omohyoid prominence. The sternomastoid is passively tented up by an abnormal underlying omohyoid. This latter appears to have lost its restriction to bowstring by the retaining deep cervical fascia. CONCLUSION: The described approach allowed for definite proof of the pathogenetic mechanism, provided a means of diagnosis, and suggested further insight into the management of these patients.

The role of fine-needle aspiration cytology in the management of parotid tumors: a critical clinical appraisal.

BACKGROUND: Fine-needle aspiration cytology (FNA) is a well-established tool for investigating many head and neck conditions. It application in parotid tumors is, however, very controversial. This article is aimed at defining the exact role of FNA in the diagnostic workup of patients. METHODS: A retrospective review of a 12-years' experience in a university surgical unit of 186 consecutive patients. Clinical opinion, FNA results, and final pathologic findings were examined. RESULTS: FNA obtained the correct final pathologic condition in 54.3% of cases. It increased the identification of malignancy to 64.5% compared with 26% based solely on clinical signs. Malignant FNA diagnoses (85.7%) and repeatedly inconclusive reports (25.7%) were associated with a higher incidence of malignancy. CONCLUSIONS: Methodological interpretation of FNA results provides useful preoperative information and enables more reliable patient counseling and reduces pathologic surprises. Its enhancement of the preoperative recognition of malignant parotid tumors may alert more stringent attention to the operative margin and hence better tumor clearance.

Embolic vascular seeding of endometrial adenocarcinoma, a complication of hysteroscopic endometrial biopsy.

OBJECTIVE: A case of embolic vascular seeding of endometrial adenocarcinoma following hysteroscopy is reported. METHODS: This phenomenon was recognized in the uterus specimen from a hysterectomy performed 1 week after hysteroscopic endometrial biopsy. Tissue processing artifact was excluded. RESULTS: Since the patient was otherwise low risk, treatment was limited to hysterectomy. The patient was not given adjuvant therapy. Two years later she remains alive and well with no evidence of disease. The surgical, morphologic, and clinical features of this case are presented and illustrated. CONCLUSION: Previous reports of peritoneal tumor seeding associated with hysteroscopy are reviewed. Tumor embolization during hysteroscopic endometrial biopsy was not followed by tumor recurrence in this case.

A new method of maintaining airway during nasotracheal intubation--the hand mask technique.

The efficacy of a new method (The hand mask technique) for airway maintenance during nasotracheal intubation was evaluated in our randomized crossover study. Sixty, age less than 50, ASA physical status class I-II patients undergoing surgery for the extremities with informed consent were randomly chosen for the study. Pulse oximeter, capnometer, EKG, blood pressure monitor and a peripheral nerve stimulator were attached to the patients before induction for continuous monitoring. An arterial cannula was inserted for intermittent blood gas sampling. After baseline room air blood gas data had been obtained from the spontaneously breathing patients, a flow rate of 6L/min pure oxygen was applied through a loosely fitted face mask and a semi-closed anesthesia breathing circuit for a period of 5 minutes. An arterial blood sample was drawn and the patients were put under general anesthesia with full muscle relaxation thereafter. Patients were then randomly assigned into two groups according to the ventilation technique used. Group A patients (n = 30) were manually ventilated first through a face mask for ten minutes and then the hand mask technique for another ten minutes. Blood gas data was sampled and heart rate, blood pressure, peak inspiratory airway pressure and end tidal CO2 were recorded immediately after each ventilation technique. For patients in Group B (n = 30), the sequence of the two ventilation technique were reversed. The results showed significant increases in PaO2 after artificial ventilation in both groups (No significant difference in results between the two groups) and less incidence of nasal bleeding in Group A.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary cutaneous aspergillosis near central venous catheters in patients with the acquired immunodeficiency syndrome.

BACKGROUND: Aspergillosis in patients with the acquired immunodeficiency syndrome is unusual, and the clinicopathologic features of primary cutaneous aspergillosis in this setting are undefined. Our findings show that the manifestations can differ from those of primary cutaneous aspergillosis in other immunocompromised patients. OBSERVATIONS: Two men with the acquired immunodeficiency syndrome developed foci of primary cutaneous aspergillosis beneath adhesive tape near central venous catheter sites. Typical lesions were flesh-colored to pink, umbilicated papules that clinically resembled molluscum contagiosum. Biopsy specimens showed variably ruptured follicles that contained collections of fungal hyphae typical of Aspergillus species. Cultures in one case identified Aspergillus fumigatus. The use of nonocclusive dressings and local wound care resulted in involution of several lesions. CONCLUSIONS: Primary cutaneous aspergillosis begins as saprophytic involvement of hair follicles secondary to the altered microenvironment beneath adhesive tape. Systemic antifungal therapy is prudent, but in the absence of neutropenia or other traditional risk factors for dissemination, it appears that Aspergillus in patients with the acquired immunodeficiency syndrome can produce relatively indolent cutaneous lesions with a tendency to resolve once precipitating factors are removed.

The laryngeal mask airway--clinical experience.

The laryngeal mask airway (LMA), a new type of airway, when it is inserted blindly into the hypopharynx forms a seal around the larynx and allows easy and convenient spontaneous or controlled positive pressure ventilation. A clinical application of the LMA to 70 surgical patients in our hospital have been evaluated. LMA was successfully applied to 68 (97%) patients who all received general anesthesia with unobstructed controlled ventilation. The patency of the airway did not change throughout the course of anesthesia. There were 2 patients whose airway was obstructed at the first attempt due to downfolding of epiglottis; in one of them the obstruction was confirmed by flexible fibreoptic laryngoscopy. Subsequent placement was successful in these 2 patients. Insertion failure was seen in 2 patients respectively due to small mouth and excessive salivation. The placement of LMA does not require laryngoscopy and there is no fear of misplacement in the esophagus. It becomes obvious that the LMA would substantially gain a place in the armamentarium in anesthesia and we think that its use would be of interest to anesthesiologists.

Aggressive-growth basal cell carcinoma in young adults.

Aggressive-growth basal cell carcinoma (AG-BCC) defines a group of basal cell cancers that are histologically and clinically aggressive. This group includes morpheaform, infiltrating, and recurrent BCCs. Because of the clinical observation that the incidence of AG-BCC may be increased in patients under 35 years of age, compared with those older, we performed a retrospective study. We reviewed the pathologic findings of 3381 patients diagnosed with BCC, including 102 patients with BCC referred for Mohs surgery to determine whether AG-BCC occurs with increased frequency in patients younger than than 35 years of age. Among patients under 35 years of age, 38% of women had AG-BCC compared with 9% of women in the older age group. Similarly, 25% of men under 35 years of age had AG-BCC compared with 11% among men in the older age group. Aggressive-growth BCC is more frequently noted in patients under 35 years of age than in those older. Failure to diagnose this type of BCC, which may be clinically subtle, may lead to incomplete or inadequate treatment. Because of the tendency of these tumors to recur, greater long-term morbidity may result.