Anesthetic and surgical management of tracheotomy in a patient with Kennedy's Disease.

Introduction: Kennedy's disease (KD) is a rare X-linked recessive motor-neuron neuropathy also known as Spinal and Bulbar Muscular Atrophy (SBMA). Case report: We report a case of Kennedy's disease (KD) with acute laryngeal stridor and dysphagia whose anesthesiologic management required a tracheotomy. The surgical procedure was conducted under local anesthesia performed by ultrasound-guided superior laryngeal nerve block and superficial cervical plexus block using 2% lidocaine. The surgical procedure was well tolerated without any discomfort reported from the patient. Conclusions: In KD local anesthesia should be preferred to general anesthesia as general anesthesia is associated with increased potential for laryngospasm, pulmonary aspiration, and respiratory insufficiency related to the use of neuromuscular blocking agents and opioids. At the best of our knowledge, this is the first case of tracheostomy in KD patient under locoregional anesthesia performed thorough superior laryngeal nerve and superficial cervical plexus block.

Awake fiberoptic intubation in patients with stenosis of the upper airways: Utility of the laryngeal nerve block.

Awake fiberoptic intubation (AFOI) is mandatory to manage difficult airways. Superior laryngeal nerve block (SLNB) could reduce risks and improve patient comfort. The aim of this study is to assess the procedural comfort of SLNB during AFOI in a population of patients undergoing upper airway oncological surgery. Forty patients were randomized into two groups and were treated with continuous infusion of remifentanil, topic anesthesia and intercricoid block. In the study group (=20), SLNB was performed with lidocaine (L-SLNB); in the control group (n=20) SLNB was performed using saline (S-SLNB). AFOI was more comfortable in the L-SLNB group compared to S-SLNB patients [FOICS ≤ 1 in 18 patients (90%) L-SLNB; 2 (10%) S-SLNB (P <0.001)]. Intubation was faster in L-SLNB (47.45 ±15.38 sec) than S-SLNB (80.15 ±37.91 sec) (p <0.001). The SLNB procedure during AFOI is a safe and comfortable procedure in a population of patients undergoing upper airways surgery. Time to intubation was shorter in L-SLNB than in S-SLNB.

Obstructive sleep apnea syndrome in the pediatric age: the role of the anesthesiologist.

OBJECTIVE: Childhood obstructive sleep disordered breathing (SDB) is a sleep-related upper airway obstruction that degrades sleep quality, ventilation and/or oxygenation; obstructive sleep apnea syndrome (OSAS) is one of the most common causes of SDB in children. The aim of this review is to evaluate the role of the anesthesiologist in pediatric OSAS. MATERIALS AND METHODS: A literature review has been performed on the following topics: clinical aspects of pediatric OSAS, preoperative investigations including questionnaires, clinical parameters, laboratory polysomnography and home sleep apnea testing, anesthesiologic preoperative management, anesthesiologic perioperative management, anesthesiologic postoperative management including postoperative analgesia, postoperative nausea and vomiting (PONV), and post-tonsillectomy bleeding. RESULTS: OSAS in children is a distinct disorder from the condition that occurs in adults; adenoidectomy and tonsillectomy are the first line of therapy in these patients. Even if these surgical procedures are frequently performed, they represent a great challenge for surgeons and anesthesiologists and are associated with a substantially increased risk of morbidity and mortality. CONCLUSIONS: The role of the anesthesiologist is pediatric OSAS is crucial before, during and after surgery, as pediatric patients are at higher risk of preoperative, perioperative and postoperative adverse events including airway obstruction, PONV, and bleeding.

Corneal transplantation activity over 7 years: changing trends for indications, patient demographics and surgical techniques from the Corneal Transplant Epidemiological Study (CORTES).

This study aims to examine evolving indications and changing trends for corneal transplantation in Italy. Corneal transplantations performed with donor tissues distributed by the Veneto Eye Bank Foundation between 2002 and 2008 were prospectively evaluated. Of the 13,173 keratoplasties performed on 11,337 patients, 10,742 (81.5%) were penetrating (PK), 1644 (12.5%) were anterior lamellar (ALK), and 787 (6.0%) were endothelial (EK). Keratoconus (42.5%), regraft (18.9%), and pseudophakic bullous keratopathy (PBK, 11.9%) were the leading indications for PK, with keratoconus (69.6%) and regraft (6.5%) showing higher indications for ALK, whereas pseudophakic bullous keratopathy (50.1%) and regraft (18.7%) were the major indications for EK. There was an overall decrease observed in corneal grafting for keratoconus (P = .0048) and an increase for PBK (P = .0653) and regrafting (P = .0137). These indications differed by age and gender. The number of keratoplasties over 7 years was stable (P = .2394), although the annual number of PKs declined by 34.0% (P = .0250), ALKs began to rise from 2005 (P = .0600), whereas EKs showed a huge growth, with their number tripling in 2007 and further doubling in 2008 (P = .0004). Leading indications for keratoplasty showed similar data that have been reported elsewhere for Western countries over the past few decades, albeit with a higher percentage of keratoconus. However, the overall number of keratoplasties for keratoconus was in decline, whereas regraft keratopathy and PKs increased due to the application of the newer surgical techniques for corneal grafting. This highlights an important shift in managing corneal diseases toward the application of selective and more conservative surgeries and changes in indications in corneal transplantation.

Monitoring of CD34+ cells during leukapheresis allows a single, successful collection of hemopoietic progenitors in patients with low numbers of circulating stem cells.

We have studied a total of 188 patients with hematological malignancies, submitted to mobilization therapy with G-CSF associated or not with chemotherapy in order to: (1) establish the lower limit of circulating progenitor cells that allows the collection of 2 x 10(6) CD34+ cells/kg by a single leukapheresis, utilizing the instrument set on standard parameters; (2) evaluate whether the number and quality of CD34+ cells collected remain stable during leukapheresis; and (3) collect a sufficient number of circulating CD34+ cells by a single procedure in patients in whom such an approach would have been insufficient to reach the target with the instrument set on standard parameters. The retrospective analysis conducted in 85 patients showed that 19 circulating CD34+ cells/microl represented the cut-off number capable of discriminating between patients who will require one or more apheresis to collect 2 x 10(6) CD34+ cells/kg. The validity of this value was prospectively confirmed in 70 subsequent patients. Based on in vitro results that showed the stability in the number of CD34+ cells, the proportion of different CD34+ cell subpopulations and the clonogenic capacity of the stem cell compartment during leukapheresis both in the blood of the patients and in samples taken directly from the instrument, we have adapted the blood volume to be processed in 33 patients with <19 PB CD34+ cells/microl. Stem cell collection was monitored during the leukapheresis and the procedure was prolonged for a time period estimated to be sufficient to reach the target number of CD34+ cells with a single procedure. The median increment of the total blood volume processed, calculated from the volume set automatically by the instrument was 25.2%, with a median of 3.3-fold total blood volume processed. In all cases, a sufficient CD34+ cell collection was completed in a single procedure. After autograft, the pattern of blood reconstitution was similar to that of all the other patients.

Modulation of VLA-4 and L-selectin expression on normal CD34+ cells during mobilization with G-CSF.

We have evaluated the immunophenotype, functional activity and clonogenic potential of CD34+ cells from peripheral blood (PB) of normal donors before and after 4 and 6 days of G-CSF administration. The percentage and absolute number of CD34+ cells significantly increased at days 4 and 6 of G-CSF administration, compared to the steady-state level (P < 0.0001). Two-colour fluorescence analysis showed, at days 4 and 6, a lower proportion of CD34+/c-kit+ compared to the steady-state level (P < 0.0001), but a similar expression of CD13, CD33, CD38, HLA-DR and Thy-1 antigens on CD34+ cells. The expression of adhesion molecules on CD34+ cells revealed a significant reduction of CD11a (P = 0.009), CD18, CD49d and CD62L (P < 0.0001) at days 4 and 6, compared to the baseline level. Three-colour staining showed a reduction of the more immature compartment (34+/DR-/13-) and an increase of the more differentiated compartment (34+/DR+/13+). Downregulation of VLA-4 during mobilisation was seen almost exclusively on more committed cells (34+/13+); downregulation of CD62L, on the contrary, was observed on both early progenitors (34+/13-) and more committed cells (34+/13+). The expression of 34+/VLA-4+ decreased on both c-kit+ and c-kit- cells, while the expression of 34+/62L+ decreased on the c-kit+ cells only. In vivo administration of G-CSF reduced the adherence capacity of CD34+ cells to normal BM stroma; in vitro incubation with SCF or IL-3 enhanced the expression of CD49d on CD34+ cells, while GM-CSF reduced the expression of CD62L. SCF was the only cytokine able to induce a significant increase of CD34+ cell adherence to preformed stroma. Pre-incubation with the blocking beta2 integrin monoclonal antibody caused a reduction of CD34+ cell adherence. In conclusion, the decrease of CD49d expression on mobilized CD34+ cells correlates with a poor adhesion to BM stroma; CD34+ cells incubated in vitro with SCF showed, conversely, a higher expression of CD49d and a greater adherence capacity on normal preformed stroma.

Interferon-alpha and bcr-abl antisense oligodeoxynucleotides in combination enhance the antileukemic effect and the adherence of CML progenitors to preformed stroma.

We have studied the in vitro effect of IFN-alpha and bcr-abl antisense oligodeoxynucleotides (As ODN) alone and in combination with the aim of enhancing the antileukemic activity of the two single agents and evaluating whether the two agents in combination might restore the adherence capacity of chronic myeloid leukemia (CML) progenitors to preformed stroma. We have also correlated the increased adhesion found after in vitro treatment with the expression of adhesion molecules on leukemic progenitors. Incubation of the BV173 cell line with escalating doses of IFN-alpha (100-10000 U/ml) showed a colony growth inhibition between 10 and 30%. IFN-alpha and junction-specific As ODN in combination showed a greater antiproliferative effect compared to that observed with the two agents used alone. In particular, As ODN at a concentration of 40 microg/ml in combination with IFN-alpha at 100 and 1000 U/ml showed a greater inhibitory effect compared to that obtained with IFN-alpha only. Addition of As ODN to IFN-alpha at 10000 U/ml did not result in a greater BV173 inhibition. In a further set of experiments, primary cells from 16 CML patients at diagnosis were incubated with 40 microg/ml of J-spec As ODN, several control ODNs and IFN-alpha at 1000 U/ml alone and in combination. A significantly greater elimination of CML progenitors was found after treatment with the combination of IFN-alpha and J-spec As ODN, compared to any other treatment group, confirmed also by a more marked effect on p210 expression. The deficient adhesion of CML progenitors on human preformed stroma was restored at levels similar to that of normal bone marrow cells after treatment with IFN-alpha and/or J-spec As ODN, while the phenotypic analysis showed that the combined treatment increased significantly the expression of CD49b and CD62L on CML CD34+ cells. However, when the expression of adhesion molecules was blocked with specific monoclonal antibodies, only CD49d (expressed on more than 90% of CML CD34+ cells) appeared to influence the functional activity of adhesion molecules. In conclusion, IFN-alpha and bcr-abl As ODN in combination exert a marked in vitro antileukemic activity and could be a useful approach for in vitro purging of CML cells prior to autologous transplantation.

Pseudoaccommodation with the 3M diffractive multifocal intraocular lens: a refraction study of 52 subjects.

A refraction study was performed of 52 pseudophakic subjects implanted with a 3M diffractive intraocular lens (IOL). Twenty patients implanted with conventional monofocal IOLs from 3M were used as controls. The refraction for distance and near was determined, corresponding to the refractive (distance vision) and diffractive (near vision) foci. Pseudoaccommodation amplitude was measured relative to the variation of visual acuity as a function of "fogging" obtained with plus and minus lenses over any required spherical cylindrical power. Results showed that the 3M diffractive IOL acted as a bifocal lens in all subjects except those whose IOLs had decentered markedly. The dioptric range allowing good vision for distance and near is much wider with the diffractive IOL than it is with a monofocal IOL. Almost perfect vision, and the satisfaction of the patients, was achieved when the distance refraction was near to emmetropia and astigmatism was minimal. However, hyperopic biometric inaccuracies were less disturbing than myopic inaccuracies.

Cataract surgery in eyes with early cataracts.

This prospective study assessed visual results and subjective rehabilitation after cataract surgery in eyes with a preoperative acuity of 0.4 (20/40) or better. Fifty eyes (50 patients) were entered in the study. Corrected and uncorrected visual acuity, lens opacity, glare disability, and contrast sensitivity were measured before surgery and four months after surgery. Patient satisfaction was also measured. Best corrected visual acuity was 0.54 +/- 0.12 before surgery and 0.95 +/- 0.15 four months after surgery. Uncorrected visual acuity was 0.24 +/- 0.18 before and 0.58 +/- 0.27 after surgery. Impairment of corrected visual acuity from glare decreased from 0.12 +/- 0.09 before surgery to 0.04 +/- 0.08 four months after surgery. Contrast sensitivity at 6 cycles/degree increased from 2.71 +/- 0.94 units to 4.73 +/- 1.09 units. After surgery, 62% of patients judged their vision to be greatly improved, 32% judged it improved, 6% judged it unchanged. The patient's satisfaction was partially related to the improvement in uncorrected visual acuity. We conclude that cataract surgery can benefit eyes with limited visual impairment if the surgery is uncomplicated and IOL power is calculated correctly.

Corneal topography and astigmatism after superior sutured 8 mm scleral tunnel incisions.

OBJECTIVES: To verify corneal topography and astigmatism after cataract surgery with 8 mm scleral tunnel incisions closed with a continuous 10-0 nylon suture. SETTING: Institute of Ophthalmology, University of Verona, Italy. METHOD: Twenty eyes were studied for 12 months after cataract extraction with 8 mm, sutured, scleral tunnel incisions. Corneal topography (EyeSys 2.1) was evaluated for the first 5 months. Astigmatism (absolute and induced) was measured by Javal ophthalmometry preoperatively and 1, 7, 30, 60, 90, 150, and 360 days after surgery. RESULTS: In the week following surgery, corneal shape was minimally affected and uncorrected visual acuity was not compromised. Mean with-the-rule induced cylinder was less than 1.00 diopter (D). After 5 and after 12 months, the mean induced cylinder was still less than 1.50 D but with an against-the-rule shift in almost all eyes. CONCLUSIONS: Sutured 8 mm tunnel incisions showed good results in terms of absolute cylinders but late against-the-rule shift could not be avoided.

Secondary implantation of angle-supported anterior chamber and scleral-fixated posterior chamber intraocular lenses.

PURPOSE: To compare the results of secondary implantation of angle-supported anterior chamber intraocular lenses (IOLs) and scleral-fixated posterior chamber lenses. SETTING: Eye Clinic, University of Verona, Italy. METHODS: This study of 68 eyes of 60 patients comprised two groups. In Group A (n = 35), an angle-supported anterior chamber IOL was implanted and in Group B (n = 33), a scleral-fixated posterior chamber IOL. Follow-up was from 12 to 45 months. RESULTS: In Group A, one eye developed a retinal detachment and another, pseudophakic bullous keratopathy. In Group B, one eye had a major intraoperative choroidal hemorrhage and two developed a retinal detachment postoperatively. All other complications were minor. CONCLUSIONS: Although the rate of sight-threatening complications was about 6% for both groups, scleral-fixated posterior chamber IOLs were associated with more intraoperative and postoperative complications than angle-fixated anterior chamber IOLs, and surgery took longer. Thus, anterior chamber IOL implantation should be considered for older patients with relatively good endothelial cell counts.

Intraocular penetration of topical lidocaine 4%.

PURPOSE: To evaluate the intraocular penetration of lidocaine 4% topically applied before phacoemulsification. SETTINGS: Institute of Ophthalmology, University of Verona, and Department of Medical Pharmacology, University of Padua, Italy. METHODS: Thirty eyes having phacoemulsification for senile cataract were anesthetized by topical application of lidocaine 4%. The drug was applied 3 times in 30 minutes in 15 eyes and 6 times in 60 minutes in 15 eyes. At the beginning of surgery, aqueous humor samples were obtained to measure the lidocaine levels. Blood samples were obtained in 6 patients 30 and 60 minutes after aqueous humor collection. The aqueous humor levels were compared with the amount of pain perceived by patients during surgery. RESULTS: Mean aqueous humor lidocaine concentration was 8.68 micrograms/mL +/- 2.43 (SD) after 3 instillations and 23.21 +/- 8.87 micrograms/mL after 6 instillations. Blood levels of lidocaine were negligible. Patients whose intraocular level was below 12 micrograms/mL perceived more pain during surgery. Only 2 eyes had these low levels after 6 instillations. CONCLUSIONS: Topically applied lidocaine 4% effectively penetrates the eye, providing analgesia for phacoemulsification. We suggest at least 6 instillations in the hour preceding surgery. In this study, pain during surgery was primarily related to poor intraocular levels of the anesthetic agent.

Efficacy and safety of combined diclofenac 0.1% and gentamicin 0.3% eyedrops after phacoemulsification.

PURPOSE: To study the efficacy of combined diclofenac 0.1% and gentamicin 0.3% (Digen) eyedrops to treat postoperative inflammation and prevent ocular infection in eyes having phacoemulsification. SETTING: Department of Ophthalmology, University of Milan, San Paolo Hospital, Milan; Eye Clinic, University of Verona; and Department of Ophthalmology, University of Palermo, Italy. METHODS: This double-masked, randomized, clinical trial comprised 90 patients; 45 received Digen and 45, gentamicin 0.3% eyedrops. The main outcome measure of the study was the reduction in signs and symptoms of inflammation, graded on a four-point scale. Also assessed were the presence of bacteria in the conjunctival swab and the proportion of patients requiring additional medication. RESULTS: Digen was more effective in reducing postoperative inflammation than gentamicin alone (P < .01). No statistically significant between-group difference was found regarding antibacterial activity. Both treatments were well tolerated throughout the study. CONCLUSION: Digen seemed to maintain the properties and activities of each individual drug, making it a promising treatment for reducing inflammation after phacoemulsification.

Clear lens phacoemulsification for correction of high myopia.

PURPOSE: To assess phacoemulsification and posterior chamber intraocular lens (IOL) implantation as an effective, safe, and predictable technique for the correction of high myopia. SETTING: University Eye Clinic of Verona, Verona, Italy. METHODS: A series of 25 eyes with myopia higher than -12.0 diopters (D) had clear lens extraction by phacoemulsification and IOL implantation in the capsular bag. The mean postoperative follow-up was 42.92 months +/- 3.76 (SD). RESULTS: No serious intraoperative complications occurred. Uncorrected visual acuity improved in all cases. The mean postoperative best corrected visual acuity improved by an average of 1 line. One case (4.0%) of postoperative retinal detachment (RD) occurred at 12 months. One case (4.0%) of biometric error (3.0 D) occurred. CONCLUSION: Clear lens extraction by phacoemulsification and IOL implantation in a series of highly myopic eyes was effective and had an acceptable predictability and a low rate of complications. Careful evaluation of the retinal periphery by indirect ophthalmoscopy is recommended to avoid postoperative RD.

Otosclerosis surgery in a resident training program.

Controversy exists regarding the appropriateness of offering all residents training in stapes surgery due to dwindling case loads in residency programs nationally. A recent study indicated poorer results for stapes surgery performed by residents than results obtained by practicing otologists. One hundred consecutive stapedectomies performed by residents over a three-year period at our institution were reviewed retrospectively, with the objective of determining whether these results should be generalized.

Cochlear hearing loss in tympanoplasty.

In tympanoplasty, trauma to the cochlea is usually caused by the transmission of vibration induced during the removal of cholesteatoma, granulation tissue, and tympanosclerosis surrounding the ossicular chain. In 100 sequential cases 20 showed evidence of cochlear trauma. Hearing was recovered in 10 of these cases during the immediate postoperative period. In nine the hearing was partially recovered but remained below the preoperative bone-conduction level, and in one there was a total cochlear hearing loss. When the stapes footplate was fractured or dislocated and a perilymphatic fistula developed, profound cochlear hearing loss occurred. This complication usually can be avoided by inspection of the round and oval windows under high magnification and by tissue grafts over the fistula. An unanticipated pathologic fistula of the semicircular canals is another common source of major cochlear damage. Despite all precautions and sometimes without apparent cause, a total cochlear hearing loss may result after a tympanoplasty. Although this is rare, as evidenced by the fact that there were only 15 cases in some 1000 tympanoplasties, before surgery the surgeon must inform the patient of the risks involved.

Trends and profiles in stapes surgery.

Stapedectomy has become recognized as the procedure of choice in the surgical treatment of clinical otosclerosis. Based on results obtained in stapes surgery performed in 1977, profiles were established for hearing improvement, vertigo, tinnitus, chorda tympani injury and temporary threshold shift of high tones. Tympanometric and stapedial muscle reflex tests in cases of proved clinical otosclerosis also are discussed. The profiles indicate that stapedectomy performed on a regular basis and under ideal conditions is highly successful for the improvement of hearing. The incidence and probable causes of complications are presented and discussed. This study reveals, however, that the number of new patients with otosclerosis has decreased steadily since its peak in 1964. Should the number of surgical cases continue to diminish, it may be impossible for the practicing otologist to maintain sufficient expertise for the performance of an occasional stapedectomy. Also, it may become impossible to provide sufficient experience in otosclerosis surgery for all trainees in otolaryngology.

Apraclonidine protection of the blood-aqueous barrier from traumatic break-down.

This study investigated the effects of apraclonidine hydrochloride 1% eye drops on blood-aqueous barrier in 108 pigmented rabbits. The effects of pretreatment with dapiprazole and yohimbine, and a comparison with clonidine 0.125% eye drops are also reported. The disruption of blood-aqueous barrier was obtained by argon laser burning of the iris. The degree of permeability of the barrier was deduced by the amount of proteins in aqueous humor 60 min after laser application. Intraocular pressure and pupil diameter were also studied. Protein content in aqueous humor was 0.72 +/- 0.26 g/l in control rabbits that did not receive any treatment; 5.98 +/- 4.23 g/l in rabbits instilled with placebo eye drops and treated by laser burning of iris; 0.43 +/- 0.25 g/l in rabbits that received apraclonidine eye drops prior to laser burning; 2.19 +/- 1.3 g/l in rabbits that received apraclonidine eye drops immediately after laser application; 0.35 +/- 0.08 g/l in rabbits that received apraclonidine 1% eye drops both before and after laser application. Rabbits treated with clonidine 0.125% had a protein content in aqueous humor of 5.45 +/- 2.08 g/l after laser application. Dapiprazole 0.5% eye drops prior to apraclonidine led to a protein content in aqueous humor of 1.93 +/- 2.13 g/l; yohimbine 0.3% eye drops prior to apraclonidine led to a protein content of 0.70 +/- 0.40 g/l. Protein content in aqueous humor was 0.93 +/- 0.36 g/l, 0.82 +/- 0.899 g/l and 1.68 +/- 1.39 g/l in rabbits treated with yohimbine 0.3, 0.6 and 1.2 mg/kg i.v. and then with apraclonidine 1% eye drops. In one group of rabbits, the penetration into the aqueous humor of Evans blue injected intravenously was also studied. Evans blue content in aqueous humor was 0.03 +/- 0.08 mg/100 ml in control rabbits; 0.92 +/- 0.53 mg/100 ml in placebo rabbits treated by laser; and 0.28 +/- 0.19 mg/100 ml in apraclonidine rabbits treated by laser. Apraclonidine eye drops led to a decrease in IOP and prevented IOP rise following argon laser application. Placebo treated rabbits had a 20% increase in IOP following laser application. Apraclonidine-treated eyes showed mydriasis and blanching of the conjunctiva. These effects were not affected by pretreatment with dapiprazole or yohimbine. In these experiments, the treatment with apraclonidine 1% eye drops completely protected the blood aqueous barrier from the disruption caused by laser burning of the iris. The protection was less effective when apraclonidine was applied after laser burnings.

Selection of cases and classification of tympanoplasty.

Meticulous mastoid surgery does not always result in a dry, stable ear. Eustachian tube malfunction has been accepted as an important factor in chronic and recurrent middle ear infection. There are many parameters of eustachian tube malfunction, which form a complicated problem for investigation and analysis. Of most importance appears to be varying degrees of malformation of the nasopharynx and palate. A gradient from mild to overt deformity appears to be related to the degree of eustachian tube function. Other factors, such as nasal infection and allergy, nasopharyngeal scar tissue and tumors, and general resistance to infection, are of less importance but must be considered in the etiology of chronic ear disease. Tympanoplasty is relatively unsuccessful in a chronic discharging ear, as the infection ultimately destroys a surgical repair. Persistent otorrhea can be caused by either eustachian tube malfunction or a reservoir of chronic infection in the mastoid cavity. A mastoidectomy often controls the infection in the mastoid cells and a tympanoplasty may be done as a secondary procedure when the cavity is stable. A careful preoperative evaluation should be made in every case to determine the responsible factors for persistent ear infection. If possible, attempts should be made to eliminate the causative factors prior to the tympanoplasty. Classification of cases into four groups helps to separate those cases with a good prognosis from those that will continue to suppurate and will have a poor functional result. A dual classification of tympanoplasty has been established in which the type of reconstruction is documented and the stability of the ear against infection is estimated. Classified clinical material forms the basis for a clearer representation of the cases under investigation and the results of tympanoplastic surgery become statistically comparable. Classification of cases also aids in the selection of cases for surgery by identifying preoperatively those cases that will be successful from those that may not have a good result. With this information at hand it is possible to more accurately inform the patient preoperatively regarding hearing improvement and control of infection following a tympanoplasty.

Long-term progression of a case of trans-epiphyseal fracture-dislocation of the proximal epiphysis of the femur.

Epiphyseal detachment-dislocation of the proximal femur constitutes a traumatic lesion, the immediate resolution of which always requires surgical treatment. How early treatment is carried out is important in improving the prognosis of the lesions which, however, in most cases is poor. In our case, clinical examination made 6 years post-surgery shows satisfactory preservation of range of movement with no important subjective disorders and with a minimal amount of hypometria (1 cm) even if structural epiphyseal changes visualized on radiographic examination and CT scan predict progression towards early arthritic degeneration.