[Functionnal revalidation of patients with Age-related Macular Degeneration]. / Prise en charge en revalidation fonctionnelle de la dégénérescence maculaire liée à l'âge.

Age-related Macular Degeneration (AMD) is the leading cause of blindness and visual impairment in developed countries for people older than 50 years. This disease can lead to loss of autonomy, which can be managed in Functional Revalidation Center.

La Dégénérescence Maculaire liée à l'Age (DMLA) est la principale cause de malvoyance et de cécité chez les patients de plus de 50 ans dans les pays industrialisés. Cette maladie est à l'origine d'une perte d'autonomie dans les tâches de la vie quotidienne qui peut faire l'objet d'une prise en charge en Centre de Revalidation Fonctionnelle.

Lacrimal gland swelling in a young African woman.

We describe an African patient with sarcoidosis involving the lacrimal glands. Gallium scintigraphy showed the so-called "panda sign".

[Clinical case of the month. Sudden orbital cellulitis in the emergency unit]. / Le cas clinique du mois. Exophtalmie aiguë au service des urgences.

We report a case of infectious orbital cellulitis complicating a frontal sinusitis in a seventy-three-year-old patient. The onset of this orbital complication was sudden. A clinical examination and an orbital CT-scan allowed an early diagnosis. Despite an appropriate surgical and medical treatment, the patient retains an altered visual function. We consider the clinical causes and consequences of orbital cellulitis as well as their surgical indications.

[Clinical case of the month. Bilateral optic neuropathy secondary to biphosphonate therapy]. / Neuropathie optique bilatérale secondaire à la prise de biphosphonates.

Ocular side effects associated with biphosphonates have been described. Conjunctivitis, uveitis and scleritis are the most common adverse events. We report a case of bilateral toxic optic neuropathy with optic dies edema occurring soon after a pamidronate intravenous infusion in a patient who previously presented both a conjunctivitis and an uveitis of moderate intensity associated with alendronate therapy.

AV nodal re-entry tachycardia in elderly patients: clinical presentation and results of radiofrequency catheter ablation therapy.

BACKGROUND: Modification of AV nodal conduction by means of radiofrequency catheter ablation has become the accepted mode of therapy for patients with symptomatic AV nodal re-entry tachycardias (AVN-RT). The published results demonstrate high success rates and a low incidence of severe complications. However, published series have primarily dealt with relatively young patient populations. Little is known about the efficacy and risks of radiofrequency catheter ablation of AVN-RT in the elderly. METHODS: We retrospectively analysed our data of 404 patients who underwent a catheter ablation therapy for AVN-RT between 1992 and June 1997. Nine patients were excluded from further analysis because of presence of more than one tachycardia mechanism. The ablation procedure was performed at the time of the diagnostic electrophysiologic study. RESULTS: The mean age of 395 patients undergoing catheter ablation for AVN-RT was 52.3 years (19-90 years); 85 patients were 65 years old or older. Compared with the younger subgroup, these elderly patients (mean age 70.4 years) more often had organic heart disease (coronary heart disease with or without myocardial infarction 19.3% versus 2.6%; P < 0.02), more often had syncopes or presyncopes with AVN-RT (43.2% versus 29.8%; P < 0.05), had more hospitalisations and emergency treatments because of their symptoms (56.8% versus 39.5%; P < 0.05) although the cycle length of the induced AVN-RT was significantly shorter in the younger patient group (325 ms versus 368 ms; P < 0.001). Slow pathway ablation was performed in 94% of the young and 82% of the elderly (P < 0.001). In 17.5% of the elderly patients versus 6.5% of the young (P < 0.05) the fast pathway approach was chosen as the first therapy or tried after an unsuccessful approach to the slow pathway. The overall success rate (96.8% in the young and 95.3% in the elderly) and the recurrence rate (5.8% in the elderly versus 4.9% in the young) were similar in both patient groups. There were no differences regarding the total procedure of fluoroscopy time, radiation exposure or the incidence of high-degree AV-block necessitating pacemaker implantation (2.3% in the elderly versus 1.6% in the young). CONCLUSIONS: In patients older than 65 years, AVN-RT may lead to severe, sometimes life-threatening symptoms, despite the fact that the tachycardia is not as fast as in younger patients. Radiofrequency catheter ablation can be performed effectively and safely and should be offered to these patients as first-choice therapy.

Exercise tolerance and working capacity after valve replacement.

Between 1978 and 1987, 1270 patients who survived single aortic or mitral valve replacement at the Rehabilitation Center in Bad Krozingen, Germany, underwent a comprehensive rehabilitation program. The preoperative diagnosis was isolated aortic stenosis in 425, isolated aortic regurgitation in 159, mixed aortic lesion in 211, isolated mitral stenosis in 208, isolated mitral insufficiency in 137 and mixed mitral lesion in 130 cases. Follow up examinations were carried out one and six months after surgery, and at yearly intervals thereafter. Exercise testing was performed with an electrically braked bicycle ergometer in the supine position, and the load was increased by 25 or 50 watts every two minutes until fatigue, severe angina, more than 0.3 mV ST-segment depression, or 80% of the age predicted maximum heart rate was achieved. Patients after aortic valve replacement had a better exercise performance one month after operation than did those after mitral valve replacement. Those with mitral stenosis showed more severe impairment of exercise tolerance than did the mitral insufficiency group. There was a steady increase in exercise tolerance between one and six months postoperatively, both in patients with aortic and those with mitral valve replacement, but the difference in performance between the two groups was still present (72% versus 57% of normal). The results of univariate and multivariate analyses showed that the preoperative employment status was the most important factor for postoperative return to work, followed by gender (male > female), exercise tolerance and valualar lesion (aortic > mitral).(ABSTRACT TRUNCATED AT 250 WORDS)

Unusual suicides with electric saws.

Four suicides by band or circular saws are reported, some with very unusual features. In one case, a two-fold amputation of the left forearm was observed in a female schizophrenic whereas another female suffering chronic depression committed suicide with a band saw by amputation of the upper skull including almost the total brain. It seems noteworthy that three of the four deceased were females with severe psychiatric disorders.

Suicide by a power drill.

This is the report of a 62-year-old man who committed suicide by drilling through his anterior chest wall with an electric power drill. Death was caused by pericardial tamponade combined with bleeding into the pleural cavity. The skin lesion at the left hemithorax was similar to a bullet entrance wound.

Thermally induced entrance wound-like defect of the skull.

A case of death due to car fire is described where the carbonised skull of the cremated corpse showed an ovoid defect of the cranial bone. The question arose whether this formed fracture was caused by a gunshot. But the reconstruction of the cranial remains with detached parts of the tabula externa provided evidence that the suspicious defect was to be classified as an uncommon heat-induced post-mortem artefact.

Injection of toxic agents: an unusual cause of death.

Self-injection of toxic substances is a rare method of suicide. Since only case reports exist in the forensic literature, an evaluation of the autopsy reports of the Munich Department of Legal Medicine in the period 1976-1994 was performed including 36 suicides and seven homicides due to injection of toxic agents. The majority of the decreased were physicians nurses or, in cases of homicidal intoxication relatives. The commonly used substances were anaesthetic drugs.

A contribution to a possible differentiation between SIDS and asphyxiation.

The singular and combined appearance of conjunctival petechiae, of acute pulmonary emphysema and of signs of aspiration was evaluated in resuscitated and non-resuscitated children dying of SIDS (n = 115), of other causes of natural death (n = 17), of severe head injury (n = 10) and of asphyxiation/strangulation (n = 7). Conjunctival petechiae occurred in all of the asphyxiated victims and in five out of 10 children dying of severe head injury, but were exclusively found in four resuscitated babies and one baby with questionable resuscitation trials of the SIDS-group (4%), furthermore in one resuscitated child dying of a congenital heart defect. Acute pulmonary emphysema was detected in six out of the seven children of the asphyxiation/strangulation group, in two resuscitated children with head injury and in five resuscitated babies dying of SIDS. Both parameters were observed exclusively in the asphyxiation/strangulation group (71% of the cases) but not in the control cases. Therefore, it can be concluded that the simultaneous appearance of conjunctival petechiae and of acute pulmonary emphysema strongly indicates death by asphyxiation.

The detection of petechial haemorrhages of the conjunctivae in dependency on the postmortem interval.

Petechial haemorrhages of the conjunctivae are not specific for lethal throttling or strangulation, but they belong to the important indicators for such mechanisms. In experimental models it is shown that petechial bleedings of the conjunctivae disappear with the occurrence of advanced signs of putrefaction or in cases of fresh-water logging. Therefore, it must be emphasized that the lack of petechial haemorrhages in putrefied or fresh-water-logged corpses is of very restricted meaning for the examination, whether throttling or strangulation has taken place or not, and the autopsy should always be performed in these cases with special regard to the neck.

Fatalities due to intestinal obstruction following the ingestion of foreign bodies.

Two fatalities due to an occlusive ileus following the ingestion of foreign bodies in patients with psychiatric disorders are described. A severely mentally handicapped young man developed a temperature and died 1 h after admission to a surgical ward. At autopsy, approximately 2000 cm3 of foreign material, including broken glass and porcelain, branches, buttons, parts of clothing and other material were found in the gastrointestinal tract, leading to a complete obstruction of the distal intestine and colon with resulting faecal vomiting. The other case was even more unusual as hair fetishist had swallowed a thick strand of his own hair, 50 cm long, also resulting in mechanical obstruction of the distal intestine.

Alveolar macrophages and the diagnosis of drowning.

In the present study, we examined the number of alveolar macrophages in lung tissue from 17 cases of fresh water drowning, 22 cases of acute death and 6 cases of lung emphysema. When counting only the number of alveolar macrophages per alveolus without consideration of the alveolar size we found no relevant differences between the groups investigated. To exclude any influence of the alveolar size on the results the surface density of the alveolar macrophages and interstitial tissue was estimated and compared in the different groups. In cases of drowning, the lungs showed significantly lower values in both categories. The ratio of 'alveolar macrophages/interstitial tissue' was also reduced in cases of drowning in comparison to the other groups, however, without significant differences. These morphometrical results characterizing the 'emphysema aquosum' with almost 'empty' and dilated alveoli could be explained by a wash-out effect of the drowning fluid leading to a partial removal of the macrophages from the alveoli. This hypothesis was confirmed by the detection of alveolar macrophages in the drowning froth by immunohistochemical analysis. Even though alveolar macrophages were unambiguously identified in advanced putrefied lungs in HE-stained sections as well as by immunohistochemical staining, an estimation of the number of these cells cannot provide further information for the diagnosis of drowning in putrefied corpses due to the autolytic destruction of the lung architecture providing no reliable values.

Fractures at the base of the skull in gunshots to the head.

The distribution of fractures at the base of the skull was investigated in 147 victims with lethal head shot wounds caused by handguns or small calibre low-velocity rifles. In individuals without an impact of the projectile at the base of the skull, bullets lodged in the head were found up to a calibre of 7.65 mm (pistol) or .38 special (revolver), respectively. In cases with a trajectory through the cranial fossae positive results were obtained up to 9 mm (pistol) or even .45 (revolver). Fractures in anterior parts of the base of the skull were a rather frequent finding (82% of the cases) and could also be observed in victims shot by low energy guns. Fracture lines in particular in all cranial fossae, however, indicate a comparatively high energy missile and were found in victims without a direct impact of the bullet at the base of the skull after the use of guns with a calibre of at least 7.65 mm. Severe fractures leading to a hinge-like mobility of the base of the skull point also to projectiles of rather high energy. On the other hand, such fractures were also found in a victim with a contact shot by a .22 rifle. Therefore, it must be emphasized that individual factors such as the constitution of the base of the skull, the path of the bullet, technical parameters of the gun and ammunition used are of great importance if conclusions are to be drawn on an unknown gun by evaluation of fractures at the base of the skull.

Frequency of blood spatters on the shooting hand and of conjunctival petechiae following suicidal gunshots wounds to the head.

A total of 103 suicidal and 29 homicidal gunshot fatalities were evaluated. In 42% of the suicides, characteristic findings like blood spatters and/or powder soilings, could be found on the shooting hand by naked-eye inspection indicating the importance of an accurate examination of the deceased's hands at autopsy for a preliminary diagnosis. Petechial hemorrhages of the conjunctivae due to the gas pressure after discharge of the weapon were observed in 22% of those cases with contact shot wounds to the head/neck, but not in cases of distant shot injuries following the use of non-high velocity ammunition. Therefore, conjunctival petechiae can be regarded as an additional but optional sign of contact head shots in cases without alterations possibly influencing the development of conjunctival pin-point bleedings. The evidence of such findings can be of practical importance if the entrance shot wound cannot be examined for whatever reason.

On-site testing of illicit drugs: the use of the drug-testing device "Toxiquick".

Since 1998, driving under the influence of drugs such as amphetamine, MDMA, MDE, cannabis, cocaine, heroine and morphine is sanctioned due to Section 24a of the Road Traffic Regulations of Germany. Therefore, from December 2000 to June 2002 altogether 751 roadside tests with the immunochemical test device Toxiquick were conducted on 302 drivers (273 male and 29 female) on oral fluid samples obtained during control actions in Franconia. The results of the tests are compared to the results obtained through quantification of corresponding blood samples by GC/MS. In general, in 75% the roadside test produced correct results and therefore gave helpful assistance to the police officers into the right direction regarding drug abuse. Except for cannabinoids, the number of false negative results was relatively small, whereas false positive results ranged between 32.2% for opiates and 10.7% for benzoylecgonine.

Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome.

A morphometrical analysis of retinal hemorrhages was performed in cases of physical child abuse including the shaken baby syndrome and in controls (severe head injury, intravital brain death, non-traumatic intracranial hemorrhage, SIDS including cardiopulmonary resuscitation). The extent of the retinal hemorrhages was significantly different between both groups. In all cases of physical child abuse, massive retinal hemorrhages in at least one eye could be found ranging between a maximum value of 19.2 and 73.2% of the entire retinal area. In contrast, only two cases of the control group (severe head injury with skull fractures and intracranial bleeding following traffic accident or fall) showed slight hemorrhages of 3.33 or 1.18% of the retinal area but only in one eye. Therefore, the results provide evidence that massive intraretinal hemorrhages indicate violent shaking -- in particular in association with other signs of physical child abuse.