'Thunder bolts and lightning': survival and neurorehabilitation following out of hospital cardiac arrest secondary to lightning strike.

BACKGROUND: There is a limited evidence base to inform patient management following lightning-induced injuries. CASE REPORT: A 36-year-old right-handed Caucasian male struck by lightning while outdoors suffered an out-of-hospital cardiac arrest with a recorded 50-min interval before the restoration of spontaneous circulation. Multiple life threatening injuries were sustained and a profound peripheral neuropathy developed. Cognitively, he was remarkably intact. We document his acute admission and his recovery during an inpatient stay in a UK-based Neurorehabilitation Unit. CONCLUSION: Intensive neurorehabilitation in this case improved functional independence and facilitated neuropsychological recovery, to the point that our patient was discharged to independent living. This case offers some support to the hypothesis that the electrical activity of a lightning strike can be both cardioprotective and neuroprotective, and that prolonged cardiopulmonary resuscitation is warranted in such cases.

Orbital Volume Augmentation for Enophthalmos Following Ventriculoperitoneal Shunting: A Case Study in "Silent Brain Syndrome".

A 21-year-old female with a history of infantile hydrocephalus and ventriculoperitoneal shunting presented with bilateral persistent tearing. Examination revealed marked bilateral enophthalmos, poor lower eyelid apposition to the ocular surface, and patent nasolacrimal systems. Radiographic imaging demonstrated expanded orbital volumes with high arching orbital roofs, sequestered air under the eyelids, short, straight optic nerves, and expanded paranasal sinuses. Surgical intervention included insertion of mesh and block implants within the subperiosteal space of the orbital roof, resulting in correction of enophthalmos, improved lower eyelid apposition and resolution of tearing. However, new onset myopic astigmatism and bilateral ptosis were noted postoperatively and treated successfully with corrective spectacles and ptosis repair. Current literature has demonstrated the benefit of orbital roof implants through a upper eyelid crease incision. The authors present a case that supports the utility of this approach and addresses its potential complications, including postoperative-induced astigmatism/myopia and ptosis.

A combination of mild hypothermia and sevoflurane affords long-term protection in a modified neonatal mouse model of cerebral hypoxia-ischemia.

BACKGROUND: Infant brain injury from hypoxia-ischemia (HI) can lead to life-long impairment, but protective strategies are lacking. Short-term but not long-term protection has been demonstrated in the Rice-Vannucci neonatal brain ischemia model (RVM) by volatile anesthetic administration before HI, while exposure during HI has not been tested. In the current study, we evaluated a combination of sevoflurane and mild hypothermia as a protective approach during HI, both short- and long-term, by introducing intubation and mechanical ventilation to the RVM. METHODS: The right common carotid artery was ligated in 10-day-old mice during brief sevoflurane anesthesia, followed by a 2-hour recovery with the dam. Littermates were then randomized to either: HI spontaneously breathing 10% oxygen for 60 minutes (the classical RVM); HI-Protect mild hypothermia and orotracheal intubation and mechanical ventilation with 3.5% sevoflurane in 10% oxygen for 60 minutes; or Room Air spontaneously breathing room air for 60 minutes. In a nonsurviving cohort, cerebral oxygenation was monitored in the area at risk and the contralateral hemisphere during HI or HI-Protect using visible-light spectroscopy (Spectros Corp). Mean arterial blood pressure and heart rate were measured. Arterial blood gases were obtained. Right/left brain hemispheric weight ratios and brain damage scores were determined 1 week after HI. In another group, learning and behavior were assessed in young adulthood (9 weeks) using spontaneous locomotion, Morris water maze, and apomorphine injection. RESULTS: During HI, ipsilateral and contralateral brain oxygenation, arterial blood pressures, blood gases, and glucose levels were similar in both ischemic groups, while heart rate was slower in the HI-Protect group. One week after ischemia, brain hemispheric weight ratios and injury scores in several brain regions were significantly worse after HI, compared with HI-Protect. Nine weeks after HI, Morris water maze hidden platform and reversal platform escape latencies, measures of spatial memory function, were superior after HI-Protect, compared with HI (P < 0.0001). HI-Protect animals demonstrated significantly less circling behavior after an apomorphine challenge (P < 0.0001), a measure of striatal integrity. CONCLUSIONS: To test the neuroprotective effects of volatile anesthetics during neonatal brain ischemia, we developed a modification of the RVM. By using mechanical ventilation and endotracheal intubation, sevoflurane administration during HI was survivable. The combination of sevoflurane administration and mild hypothermia during HI conferred not only short-term structural, but also long-term functional protection, compared with littermates treated according to the RVM. These findings warrant further studies to improve neurological outcome in critically ill infants.

Use of hyaluronic acid gel in the treatment of lagophthalmos in sunken superior sulcus syndrome.

PURPOSE: To evaluate the use of hyaluronic acid gel in the management of lagophthalmos in sunken superior sulcus syndrome. INTRODUCTION: Lagophthalmos associated with orbital fat atrophy and deep superior sulcus is a known entity described previously. Orbital fat atrophy results in deep superior sulcus where skin, orbicularis muscle, and orbital septum retract posteriorly in the deep superior sulcus, leading to lagophthalmos from suboptimal orbicularis function and effective skin shortening. The authors define this condition as sunken superior sulcus syndrome (SSSS) when the deep superior sulcus leads to exposure keratopathy. Thus, the syndrome consists of deep superior sulcus, lagophthalmos, and exposure keratopathy. Although the use of hyaluronic acid gel has been proposed as a management option for paralytic lagophthalmos, its application in the treatment of lagophthalmos in SSSS has not been reported. METHODS: In this study, 5 patients (10 eyelids) with SSSS were injected with hyaluronic acid gel in the superior sulcus of the upper eyelid. Injected amount was titrated until the desired point was reached: complete or nearly complete eyelid closure. RESULTS: After an average follow up of 9.5 months, lagoph thalmos improved by 2 mm or 69% (p = 0.02) on the right side and by 1 mm or 71% (p = 0.01) on the left side. Most patients also reported significantly improved ocular comfort and appearance of the superior sulcus. The only complications noted were bruising and temporary uneven contour of the upper eyelid sulcus. CONCLUSIONS: Management of lagophthalmos in SSSS with hyaluronic acid gel is an effective and safe alternative to surgery.

Characterization and quantification of isoflurane-induced developmental apoptotic cell death in mouse cerebral cortex.

BACKGROUND: Accumulating evidence indicates that isoflurane and other, similarly acting anesthetics exert neurotoxic effects in neonatal animals. However, neither the identity of dying cortical cells nor the extent of cortical cell loss has been sufficiently characterized. We conducted the present study to immunohistochemically identify the dying cells and to quantify the fraction of cells undergoing apoptotic death in neonatal mouse cortex, a substantially affected brain region. METHODS: Seven-day-old littermates (n = 36) were randomly assigned to a 6-hour exposure to either 1.5% isoflurane or fasting in room air. Animals were euthanized immediately after exposure and brain sections were double-stained for activated caspase 3 and one of the following cellular markers: Neuronal Nuclei (NeuN) for neurons, glutamic acid decarboxylase (GAD)65 and GAD67 for GABAergic cells, as well as GFAP (glial fibrillary acidic protein) and S100ß for astrocytes. RESULTS: In 7-day-old mice, isoflurane exposure led to widespread increases in apoptotic cell death relative to controls, as measured by activated caspase 3 immunolabeling. Confocal analyses of caspase 3-labeled cells in cortical layers II and III revealed that the overwhelming majority of cells were postmitotic neurons, but some were astrocytes. We then quantified isoflurane-induced neuronal apoptosis in visual cortex, an area of substantial injury. In unanesthetized control animals, 0.08% ± 0.001% of NeuN-positive layer II/III cortical neurons were immunoreactive for caspase 3. By contrast, the rate of apoptotic NeuN-positive neurons increased at least 11-fold (lower end of the 95% confidence interval [CI]) to 2.0% ± 0.004% of neurons immediately after isoflurane exposure (P = 0.0017 isoflurane versus control). In isoflurane-treated animals, 2.9% ± 0.02% of all caspase 3-positive neurons in superficial cortex also coexpressed GAD67, indicating that inhibitory neurons may also be affected. Analysis of GABAergic neurons, however, proved unexpectedly complex. In addition to inducing apoptosis among some GAD67-immunoreactive neurons, anesthesia also coincided with a dramatic decrease in both GAD67 (0.98 vs 1.84 ng/mg protein, P < 0.00001, anesthesia versus control) and GAD65 (2.25 ± 0.74 vs 23.03 ± 8.47 ng/mg protein, P = 0.0008, anesthesia versus control) protein levels. CONCLUSIONS: Prolonged exposure to isoflurane increased neuronal apoptotic cell death in 7-day-old mice, eliminating approximately 2% of cortical neurons, of which some were identified as GABAergic interneurons. Moreover, isoflurane exposure interfered with the inhibitory nervous system by downregulating the central enzymes GAD65 and GAD67. Conversely, at this age, only a minority of degenerating cells were identified as astrocytes. The clinical relevance of these findings in animals remains to be determined.

Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders.

BACKGROUND: Management of the neurogenic bladder has the primary objectives of maintaining continence, ensuring low bladder pressure (to avoid renal damage) and avoiding or minimising infection. Options include intermittent urethral catheterisation, indwelling urethral or suprapubic catheterisation, timed voiding, use of external catheter (for men), drug treatment, augmentation cystoplasty and urinary diversion. OBJECTIVES: The primary objective was to determine the effects of different methods of managing long-term voiding problems (persisting after three months) with catheters in patients with neurogenic bladder.Specific hypotheses to be addressed included:1. that intermittent catheterisation is better than indwelling catheterisation;2. that indwelling urethral catheterisation is better than suprapubic catheterisation;3. that external (sheath) catheters are better than indwelling or intermittent urethral catheters;4. that external (sheath) catheters are better than suprapubic catheters;5. that intermittent catheterisation is better than timed voiding. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register (searched 3 July 2013), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process, and handsearched journals and conference proceedings. We sought additional trials from other sources such as the reference lists of relevant articles and by contacting consultants in Spinal Cord Injury Centres throughout the United Kingdom. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing methods of using catheters to manage urinary voiding in people with neurogenic bladder. DATA COLLECTION AND ANALYSIS: Abstracts were independently inspected by the reviewers and full papers were obtained where necessary. MAIN RESULTS: Approximately 400 studies were scrutinised. No trials were found that met the inclusion criteria, and five studies were excluded from the review. AUTHORS' CONCLUSIONS: Despite a comprehensive search no evidence from randomised or quasi-randomised controlled trials was found. It was not possible to draw any conclusions regarding the use of different types of catheter in managing the neurogenic bladder.

Lower eyelid and midface rejuvenation.

Lower eyelid blepharoplasty is one of the most common procedures in aesthetic plastic surgery. Although patients desiring lower eyelid blepharoplasty typically describe their problem as "bags in the lower eyelids," there are many anatomical imperfections that should be assessed. With aging, the youthful single convexity of the lower lid separates into a double convexity with a valley at the intersection of the lower lid and midface. Midface descent further drags this intersection inferiorly, leading to a vertically lengthened lower eyelid. This article discusses how to clinically evaluate lower lid deformities, how to formulate a surgical plan, the preoperative assessment, and surgical markings. The rationale and anesthetic technique for outpatient versus in-office surgery is reviewed, and a detailed step-by-step approach with accompanying figures for lower lid blepharoplasty via a transconjunctival or transcutaneous incision is given. An approach to vertically supporting the lower eyelid is presented.

Anterior filler displacement following injection of calcium hydroxylapatite gel (Radiesse) for anophthalmic orbital volume augmentation.

OBJECTIVE: To describe the complication of anterior filler displacement following injection of calcium hydroxylapatite gel (Radiesse) for anophthalmic enophthalmos correction. METHODS: Retrospective case series of patients who experienced anterior filler displacement following orbital injection of calcium hydroxylapatite. Data includes patient demographics, indication for injection, route and volume of injection, description of postinjection complications, and final outcome. RESULTS: Four cases of anterior filler displacement and expansion following injection of calcium hydroxylapatite were identified. The patients' ages ranged from 33 to 64 years old. All 4 patients underwent multiple prior orbital surgeries and suffered from anophthalmic enophthalmos. Injectable calcium hydroxylapatite was delivered transcutaneously, to the deep extraconal orbital space, via 27-gauge, 1.25-inch retrobulbar needles. Each patient received an initial 1.3 ml of filler, with 1 patient receiving an additional 0.8 ml. Within 1 week, all patients experienced prominent, edematous lower eyelids. A CT scan of 1 patient radiographically documented anterior migration of the filler material. Two patients required transconjunctival excision of the filler and infiltrated orbital fat. Histopathologic examination of 1 specimen revealed chronic foreign body granulomatous inflammation. Two patients were treated medically, with resolution of clinical findings over 6 to 9 months. CONCLUSIONS: Anterior filler displacement is a potential complication of orbital volume augmentation with injectable calcium hydroxylapatite. Patients should be counseled regarding this possibility when considering options for the treatment of anophthalmic enophthalmos. A history of multiple prior orbital surgeries, with associated tissue disruption and scarring, may be a risk factor for filler displacement.

Edges and gradients in lightness illusions: Role of optical veiling glare.

Lightness Illusions (Contrast, Assimilation, and Natural Scenes with Edges and Gradients) show that appearances do not correlate with the light sent from the scene to the eye. Lightness Illusions begin with a control experiment that includes two identical Gray Regions-Of-Interest(GrayROI) that have equal appearances in uniform surrounds. The Illusion experiment modifies "the-rest-of-the-scene" to make these GrayROIs appear different from each other. Our visual system performs complex-spatial transformations of scene-luminance patterns using two independent spatial mechanisms: optical and neural. First, optical veiling glare transforms scene luminances into a different light pattern on receptors, called retinal contrasts. This article provides a new Python program that calculates retinal contrast. Equal scene luminances become unequal retinal contrasts. Uniform scene segments become nonuniform retinal gradients; darker regions acquire substantial scattered light; and the retinal range-of-light changes. The glare on each receptor is the sum of the individual contributions from every other scene segment. Glare responds to the content of the entire scene. Glare is a scene-dependent optical transformation. Lightness Illusions are intended to demonstrate how our "brain sees" using simple-uniform patterns. However, the after-glare pattern of light on receptors is a morass of high-and low-slope gradients. Quantitative measurements, and pseudocolor renderings are needed to appreciate the magnitude, and spatial patterns of glare. Glare's gradients are invisible when you inspect them. Illusions are generated by neural responses from "the-rest-of-the-scene." The neural network input is the simultaneous array of all receptors' responses. Neural processing performs vision's second scene-dependent spatial transformation. Neural processing generates appearances in Illusions and Natural Scenes. "Glare's Paradox" is that glare adds more re-distributed light to GrayROIs that appear darker, and less light to those that appear lighter. This article describes nine experiments in which neural-spatial-image processing overcompensates the effects of glare. This article studies the first-step in imaging: scene-dependent glare. Despite near invisibility, glare modifies all quantitative measurements of images. This article reveals glare's modification of input data used in quantitative image analysis and models of vision, as well as visual image-quality metrics. Glare redefines the challenges in modeling Lightness Illusions. Neural spatial processing is more powerful than we realized.

The Biomedical Research Hub: a federated platform for patient research data.

OBJECTIVE: The objective was to develop and operate a cloud-based federated system for managing, analyzing, and sharing patient data for research purposes, while allowing each resource sharing patient data to operate their component based upon their own governance rules. The federated system is called the Biomedical Research Hub (BRH). MATERIALS AND METHODS: The BRH is a cloud-based federated system built over a core set of software services called framework services. BRH framework services include authentication and authorization, services for generating and assessing findable, accessible, interoperable, and reusable (FAIR) data, and services for importing and exporting bulk clinical data. The BRH includes data resources providing data operated by different entities and workspaces that can access and analyze data from one or more of the data resources in the BRH. RESULTS: The BRH contains multiple data commons that in aggregate provide access to over 6 PB of research data from over 400 000 research participants. DISCUSSION AND CONCLUSION: With the growing acceptance of using public cloud computing platforms for biomedical research, and the growing use of opaque persistent digital identifiers for datasets, data objects, and other entities, there is now a foundation for systems that federate data from multiple independently operated data resources that expose FAIR application programming interfaces, each using a separate data model. Applications can be built that access data from one or more of the data resources.

Comparison of the neuroapoptotic properties of equipotent anesthetic concentrations of desflurane, isoflurane, or sevoflurane in neonatal mice.

BACKGROUND: Volatile anesthetics facilitate surgical procedures and imaging studies in millions of children every year. Neuronal cell death after prolonged exposure to isoflurane in developing animals has raised serious concerns regarding its safe use in children. Although sevoflurane and desflurane are becoming more popular for pediatric anesthesia, their cytotoxic effects have not been compared with those of isoflurane. Accordingly, using newborn mice, the current study established the respective potencies of desflurane, isoflurane, and sevoflurane and then compared equipotent doses of these anesthetics regarding their effects on cortical neuroapoptosis. METHODS: Minimum alveolar concentrations were determined in littermates (aged 7-8 days, n = 42) using tail-clamp stimulation in a bracketing study design. By using equipotent doses of approximately 0.6 minimum alveolar concentration, another group of littermates was randomly assigned to receive desflurane, isoflurane, or sevoflurane or to fast in room air for 6 h. After exposure, animals (n = 47) were euthanized, neocortical apoptotic neuronal cell death was quantified, and caspase 3 activity was compared between the four groups. RESULTS: The minimum alveolar concentration was determined to be 12.2% for desflurane, 2.7% for isoflurane, and 5.4% for sevoflurane. After a 6-h exposure to approximately 0.6 minimum alveolar concentration of desflurane, isoflurane, or sevoflurane, neuronal cell death and apoptotic activity were significantly increased, irrespective of the specific anesthetic used. CONCLUSIONS: In neonatal mice, equipotent doses of the three commonly used inhaled anesthetics demonstrated similar neurotoxic profiles, suggesting that developmental neurotoxicity is a common feature of all three drugs and cannot be avoided by switching to newer agents.

Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders.

BACKGROUND: Management of the neurogenic bladder has the primary objectives of maintaining continence, ensuring low bladder pressure (to avoid renal damage) and avoiding or minimising infection. Options include intermittent urethral catheterisation, indwelling urethral or suprapubic catheterisation, timed voiding, use of external catheter (for men), drug treatment, augmentation cystoplasty and urinary diversion. OBJECTIVES: To assess the effects of using different types of urinary catheters and external (sheath) catheters in managing the neurogenic bladder, compared to alternative management strategies or interventions. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register (searched 1 November 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings. We sought additional trials from other sources such as reference lists of relevant articles and contacting consultants in Spinal Cord Injury Centres throughout the United Kingdom. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing methods of using catheters to manage urinary voiding in people with neurogenic bladder. DATA COLLECTION AND ANALYSIS: Abstracts were independently inspected by the reviewers and full papers were obtained where necessary. MAIN RESULTS: Approximately 400 studies were scrutinised. No trials were found that met the inclusion criteria, and five studies were excluded from the review. AUTHORS' CONCLUSIONS: Despite a comprehensive search no evidence from randomised or quasi-randomised controlled trials was found. It was not possible to draw any conclusions regarding the use of different types of catheter in managing the neurogenic bladder.

Lateral canthal resuspension sine canthotomy.

PURPOSE: The purpose of this study is to describe a novel canthopexy technique-the lateral canthal resuspension sine canthotomy (LCR-SC)-performed via an upper-eyelid incision and to compare it with the lateral tarsal strip procedure (LTS). METHODS: This is a retrospective study in which the pre- and postoperative photographs of 20 patients per group who had LCR-SC, LCR-SC + midface lift (LCR-SC+ML), or LTS were analyzed by using the Image-J 1.40 software. Parameters measured were as follows: the horizontal palpebral aperture margin-reflex distance 2 (MRD-2) and the height of lateral canthus. LCR-SC was performed through an upper-eyelid incision, by using a 4.0 Prolene suture. For the LCR-SC+ML, a large myocutaneous flap was created first and anchored to the orbital-rim periosteum. The surgical technique is described. Two-way ANOVA was used for analysis. RESULTS: The horizontal palpebral aperture was significantly increased by LCR-SC and LCR-SC+ML when compared with LTS (1.61 ± 0.22 mm and 1.56 ± 0.14 vs. 0.04 ± 0.12 mm; p < 0.01). LCR-SC and LCR-SC+ML decreased the MRD-2 more than the LTS (1.06 ± 0.26 and 1.50 ± 0.23 mm vs. 0.86 ± 0.1 mm; p < 0.01). All 3 procedures increased the lateral canthal height by less than 0.5 mm. CONCLUSIONS: LCR-SC is a safe and effective procedure for tightening the lower eyelids. It tightens both the upper and the lower cruri of the lateral canthal tendon, avoiding imbrication of the eyelids. LCR-SC obviates the need for a lateral canthal incision and widens the horizontal palpebral aperture. LCR-SC is more effective than LTS at decreasing the MRD-2. Concomitant midface elevation (LCR-SC+ML) further decreases MRD-2.

Orbital augmentation with injectable calcium hydroxylapatite for correction of postenucleation/evisceration socket syndrome.

PURPOSE: To demonstrate the utility of injectable calcium hydroxylapatite (Radiesse) for orbital volume augmentation to correct postenucleation/evisceration socket syndrome (PESS). METHODS: A retrospective chart review of all consecutive patients in our practice who received injectable calcium hydroxylapatite placed in the extraconal space to augment orbital volume was conducted. Patients with at least 6 months follow-up were included in the study. RESULTS: Among 26 patients with PESS who received injectable calcium hydroxylapatite for orbital volume augmentation, 15 individuals were identified with adequate follow-up. The mean amount of preoperative relative enophthalmos measured by Hertel exophthalmometry was 4 mm (range 0.5-7 mm). An average reduction of 2.4 mm of enophthalmos per syringe of filler was achieved. The mean follow-up obtained was 46 weeks (range 24-78 weeks). Most patients demonstrated clinical and aesthetic improvement that was observed to continue up to 1.5 years. Complications observed included anterior migration of filler, a peribulbar hemorrhage, and orbital discomfort. Two patients demonstrated little response to filler. CONCLUSIONS: Injectable calcium hydroxylapatite provides a novel, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit with little volume loss. Volume replacement can be titrated to the socket requirements. Correction of PESS using this technique may be limited in orbits that demonstrate significant fibrosis as a result of multiple surgeries, severe trauma, or radiation treatment.

Vitamin D status and markers of bone turnover in Caucasian and South Asian postmenopausal women living in the UK.

Suboptimal vitamin D status among the South Asian UK population is widely reported; however, its impact on bone health is unclear. The aim of the present study was to conduct a comparative investigation of vitamin D status in postmenopausal South Asian (SA) and Caucasian (C) women and its relationship to parathyroid hormone (PTH) concentration, biochemical markers of bone turnover and bone quality. A cross-sectional study of community-dwelling women aged 50-66 years was carried out. A total of sixty-six SA women of Pakistani origin and forty-two C women living in the same community were recruited. Fasting blood was taken for the measurement of vitamin D, PTH and biochemical markers of bone turnover, including type-1 collagen beta C-telopeptide (betaCTX), procollagen type-1 amino-terminal propeptide (P1NP), and bone-specific alkaline phosphatase (BAP) activity. Bone quality was assessed using broadband ultrasound attenuation (BUA). Total serum 25-hydroxyvitamin D (25(OH)D) was significantly lower in the SA women than the C women (medians: SA 10.5 v. C 47.1 nmol/l; P < 0.001) This was associated with a significantly elevated serum PTH concentration in the SA group (medians: SA 7.3 v. C 4.5 pmol/l; P < 0.01). BAP activity was also significantly higher in the SA group, indicating elevated osteoblast activity and bone turnover (medians: SA 23.0 v. C 20.0 U/l; P < 0.05). No significant differences were observed between the two groups for P1NP, betaCTX or BUA. Although the SA women had significantly higher serum PTH and lower 25(OH)D concentrations than C women, this was not associated with significantly higher markers of bone resorption, or reduced bone quality in the SA women.

Evisceration with equatorial sclerotomy for phthisis bulbi and microphthalmos.

PURPOSE: To describe a new technique for ocular volume augmentation at the time of evisceration in patients with phthisis bulbi and microphthalmos. METHODS: A retrospective, interventional, noncomparative case series of all patients with phthisis bulbi and microphthalmos who underwent successful evisceration with equatorial sclerotomy. The medical records were reviewed for patient history, surgical method, and postoperative course. RESULTS: Eighteen patients (16 with phthisis bulbi and 2 with microphthalmos) underwent evisceration with equatorial sclerotomy and placement of an orbital implant of 20 mm in 11 patients (61%), 18 mm in 6 patients (33%) and 16 mm in 1 patient. Complications encountered were implant exposure in one patient, fornix shortening and symblepharon in one patient, and enophthalmos in another. CONCLUSION: Equatorial sclerotomy could be a useful adjuvant technique for placement of a larger orbital implant at the time of evisceration in patients with phthisis bulbi and microphthalmos.

Brow ptosis correction: a comparison of five techniques.

This study evaluates the effectiveness of five surgical techniques for brow ptosis repair including internal brow release (IBR), internal brow release with brow pexy (IBR + BP), internal brow release with corrugator and depressor supercilii removal (IBR + CDR), direct brow-lift (DB), and endoscopic brow-lift (EB). This is a retrospective study of 120 patients in which the preoperative and postoperative position of the medial, central, and lateral brow on both sides was measured. The brow was elevated 1.16 +/- 0.05 mm by IBR, 1.74 +/- 0.05 mm by IBR + BP, and 2.52 +/- 0.06 mm by IBR + CDR. IBR + BP was more effective than IBR in elevating the lateral brow ( P < 0.05). Removal of the medial brow depressors resulted in greater elevation of the medial and central brow than could be achieved with IBR or IBR + BP alone ( P < 0.01). EB resulted in the greatest amplitude of brow elevation (3.44 +/- 0.06 mm). Eyebrow-lifting surgery performed via the upper eyelid blepharoplasty incision prevents the lowering of brow position caused by blepharoplasty surgery alone. Brow pexy sutures are useful in enhancing elevation of the lateral brow, and removal of the medial brow depressors is useful in raising the medial and central brow.

Neurocognitive outcomes in adults following cerebral hypoxia: A systematic literature review.

BACKGROUND: Hypoxic ischemic brain injury (HIBI) occurs as a result of complete or partial disruption of cerebral oxygen supply. The physical and cognitive sequelae of adults following hypoxia varies widely. OBJECTIVE: To systematically review studies exploring the neuropsychological outcomes following hypoxic brain insult in adults. METHODS: Data was sourced using six databases (CINAHL, Cochrane, Embase, Medline, PsycInfo and Web of Science). Initial MESH terms identified 2,962 articles. After a three-stage independent review process, 18 articles, 9 case studies and 9 group studies were available for data synthesis from 1990-2012. Case study data was converted to standardised scores and compared to available test norms. Cohen's d was calculated to permit group data interpretation. RESULTS: Intellectual decrement was observed in some studies although difficult to delineate given the lack of use of measures of premorbid ability. Cognitive sequelae varied albeit with predominant disturbance in verbal memory, learning ability and executive function observed across studies. Wechsler Memory Scale Revised (WMS-R) visual memory was comparable to normative data. Impaired Rey Osterrieth Complex Figure (ROCFT) performance was found among group studies. Across visuo-constructional and attention domains, performance varied, although no significant difference relative to reported means was observed. CONCLUSIONS: Future studies should consider the use of standardised assessment protocols, which include measures of premorbid functioning and performance validity.