Oncocytic Adenocarcinoma of the Orbit.

Oncocytic adenocarcinoma of the orbit is a rare tumor, with 1 case of nonlacrimal sac, nonlacrimal gland origin, and a poor outcome previously reported. An 85-year-old man with a 2-month history of left-sided epiphora, enlarging eyelid nodules, and diplopia in left gaze was found on imaging to have a poorly circumscribed, nodular mass of uniform radiodensity in the inferomedial orbit. Incisional biopsy revealed morphologic and immunohistochemical features of oncocytic adenocarcinoma with origin in the caruncle suspected, and CT of the neck, chest, abdomen, and pelvis showed no metastases or remote primary tumor source. Based on multidisciplinary consensus, orbital exenteration with adjuvant radiation therapy was performed, and there was no evidence of residual or recurrent tumor 2 years after treatment.

Traumatic orbital encephalocele: Presentation and imaging.

OBJECTIVE: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children. METHODS: Retrospective case series from the University of Wisconsin - Madison and Medical College of Wisconsin. RESULTS: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele. CONCLUSION: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.

Treatment of refractory substance-induced psychosis in adolescent males with a genetic predisposition to mental illness.

This article presents two cases of adolescent males who were admitted to our inpatient psychiatric unit with a psychotic, disorganized presentation. Both males had a genetic vulnerability to mental illness and reported significant substance use. Their symptoms were refractory to treatment and required the use of clozapine. Both patients experienced significant side effects, which limited the maximum daily dose of clozapine. However, they responded to a dose that was much lower than that typically used in adults. There is significant evidence in the literature about cannabis use triggering psychotic breaks in vulnerable individuals. We speculate that substance use (including synthetic cannabinoids) triggers treatment-resistant psychosis that requires the use of clozapine. Further, lower doses of clozapine may be sufficient to treat the substance-induced psychotic symptoms than those typically used in adult schizophrenia.

Polymer leachates emulate naturally derived fluorescent dissolved organic matter: Understanding and managing sample container interferences.

Fluorescence spectroscopy has become a fundamental tool for the qualitative and quantitative fingerprinting of dissolved organic matter. Due to the inherent sensitivity of the technique, a strict sampling protocol should be followed to ensure sample integrity. A literature survey conducted as part of this research determined that 27% of fluorescence sampling has been conducted in polymeric containers, while 52% did not report. Given the potential for fluorescence leachates to arise from plastics commonly used in sampling bottles, a systematic laboratory investigation was undertaken to assess the likelihood of leachate contamination and consequent interferences. It was observed that characteristic fluorescent dissolved organic matter (FDOM) leachates from standard polypropylene sampling containers were produced at environmentally relevant peaks, Peak T (λEx/λEm: 250/349 nm) and B (λEx/λEm: 250/306 nm), commonly attributed to tryptophan-like and tyrosine-like molecular origins. Leachate fluorescence and concentration generally increased with elevated storage temperatures (>4 °C), sample acidification, container steam sterilisation and in new containers, with variability across different manufactured batches. For example, at ambient storage temperatures, the highest observed leachate intensity could contribute an error equivalent to as much as 98% (Peak T) and 2062% (Peak B) for highly treated water or 28% (Peak T) and 398% (Peak B) for surface water. For leachates formed under typical conditions, i.e., 3-day fridge storage, this reduced to 9% (Peak T) and 15% (Peak B) or 3% (Peak T/B) for the same water samples. In addition, PP was found to be typically unsuitable for DOC measurements, except under strict conditions (well-aged containers in short term cold storage). Consequently, we demonstrate the need for container material reporting, refrigerated storage, steam sterilisation avoidance, and the importance of glass usage for low FDOM samples. Future research should investigate the potential for polymer-based pollution as a potential origin of environmentally sampled FDOM.

A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.

OBJECT: The objective of this study was to measure the incidence of concussion (scaled relative to number of athlete exposures) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players (16-21 years old) during 1 regular season. METHODS: A prospective cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season (2009-2010) involving 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16-21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing. If the protocol was not followed, the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels. Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer. Players who suffered a suspected concussion were evaluated at the game. If a concussion diagnosis was made, the player was subsequently examined in the physician's office for a full clinical evaluation and the SCAT2 and ImPACT were repeated. Based on these evaluations, players were counseled on the decision of when to return to play. Athlete exposure was defined as 1 game played by 1 athlete. RESULTS: Twenty-one concussions occurred during the 52 physician-observed games (incidence 21.5 concussions per 1000 athlete exposures). Five players experienced repeat concussions. No concussions were reported during practice sessions. A concussion was diagnosed by the physician in 19 (36.5%) of the 52 observed games. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 total concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated. CONCLUSIONS: The incidence of game-related concussions (per 100 [corrected] athlete exposures) in these fourth-tier junior [corrected] ice hockey players was 7 [corrected] times higher than [corrected] previously reported in the literature. This difference may be the result of the use of standardized direct physician observation, diagnosis, and subsequent treatment. The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings. These follow-up studies should involve other contact sports (for example football and rugby) and also include the full spectrum of gender, age, and skill levels.

A prospective study of concussion education in 2 junior ice hockey teams: implications for sports concussion education.

OBJECT: The aim of this study was to evaluate the effectiveness of an educational intervention on concussion knowledge within a sample of junior fourth-tier ice hockey players. METHODS: A prospective cohort study, called the Hockey Concussion Education Project, was conducted during 1 junior ice hockey regular season (2009-2010) with 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16-21 years) from 2 teams. All participating players were randomized into 3 concussion education intervention groups (DVD group, interactive computer module [ICM] group, or control group) before the beginning of the season. Each individual received a preintervention knowledge test prior to the intervention. The DVD and ICM groups received a posttest after the completion of their intervention. All participants were offered the same knowledge test at 15 games (50 days) and 30 games (91 days) later. RESULTS: In the concussion education intervention component no significant group differences were observed at baseline between individuals in the control group and between individuals within the interventional group. At the 15-game follow-up, however, the difference between groups approached significance (F [1, 30] = 3.91, p = 0.057). This group difference remained consistent at the 30-game follow-up. CONCLUSIONS: This study demonstrates a positive trend concerning concussion education intervention and knowledge acquisition with either the ICMs or the educational DVD. Both forms of intervention produced a positive and sustainable improvement that approached statistical significance when compared with the control group. The control group demonstrated a negative longitudinal trend concerning concussion knowledge.

Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion.

OBJECT: The authors investigated return-to-play duration for initial and recurrent concussion in the same season in 2 teams of junior (16-21-year-old) ice hockey players during a regular season. METHODS: The authors conducted a prospective cohort study during 1 junior regular season (2009-2010) of 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years [SD], range 16-21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments that were determined using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete a baseline SCAT2 and ImPACT. If the protocol was not followed, the postinjury test results of a player without true baseline test results were compared with previously established age- and sex-matched group normative levels. Each game was directly observed by a physician and at least 1 neutral nonphysician observer. Players suspected of suffering a concussion were evaluated by the physician during the game. If a concussion was diagnosed, the player underwent clinical evaluation at the physician's office within 24 hours. The return-to-play decision was based on clinical evaluation guided by the Zurich return-to-play protocol (contained in the consensus statement of international expert opinion at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008). This clinical evaluation and return-to-play protocol was augmented by the 2 tests (SCAT2 and ImPACT) also recommended by the Zurich consensus statement, for which baseline values had been obtained. RESULTS: Seventeen players sustained a physician-observed or self-reported, physician-diagnosed concussion during a physician-observed ice hockey game. The mean clinical return-to-play duration (in 15 cases) was 12.8 ± 7.02 days (median 10 days, range 7-29 days); the mean number of physician office visits by players who suffered a concussion (15 cases) was 2.1 ± 1.29 (median 1.5 visits). Five of the 17 players who sustained a concussion also suffered a recurrent or second concussion. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated. The mean interval between the first and second concussions in these 5 players was 78.6 ± 39.8 days (median 82 days), and the mean time between the return-to-play date of the first and second concussions was 61.8 ± 39.7 days (median 60 days). CONCLUSIONS: The mean rates of return to play for single and recurrent concussions were higher than rates cited in recent studies involving sport concussions. The time interval between the first and second concussions was also greater than previously cited. This difference may be the result of the methodology of direct independent physician observation, diagnosis, and adherence to the Zurich return-to-play protocol.

Glossopharyngeal Dystonia Secondary to a Lurasidone-Fluoxetine CYP-3A4 Interaction.

Acute dystonic reactions are becoming much less prevalent in clinical practice due to the use of newer antipsychotics. Drug-drug interactions, patient characteristics, and environmental and genetic factors all contribute to the rate of occurrence of acute dystonia with second generation agents. In this case, we report a glossopharyngeal dystonia secondary to a lurasidone-fluoxetine CYP-3A4 interaction to highlight the importance of maintaining an index of suspicion for laryngeal dystonia, a potentially fatal dystonia.

Efficacy of electroconvulsive therapy for comorbid frontotemporal dementia with bipolar disorder.

Challenges encountered in the diagnosis and treatment of frontotemporal dementia (FTD) are further confounded when presented with comorbid psychiatric disorder. Here we report a case of progressive FTD in a patient with a long history of bipolar affective disorder (BAD) 1, depressed type. We also report beneficial effects of electroconvulsive therapy and its potential application in similar comorbid disorders.

Interface haze associated with topical nonsteroidal anti-inflammatory drug use after descemet stripping automated endothelial keratoplasty.

PURPOSE: To determine if topical nonsteroidal anti-inflammatory drug (NSAID) use after Descemet stripping automated endothelial keratoplasty (DSAEK) is associated with the development of interface haze. METHODS: A retrospective case-control study of patients undergoing DSAEK surgery. RESULTS: Of the 61 patients receiving topical NSAIDs, 51% were noted to develop interface haze, and 9% of the control group (N=100, no NSAID) developed haze. There was no significant difference in best corrected visual acuity between the 2 groups. CONCLUSIONS: Topical NSAID use is associated with the development of interface haze, although it may not be visually significant and could be related to confounding factors.

Periocular necrotizing fasciitis causing blindness.

IMPORTANCE: Periocular necrotizing fasciitis is a rare but potentially devastating disease, accompanied by high rates of morbidity and mortality. OBSERVATIONS: We report 5 cases of periocular necrotizing fasciitis resulting in severe vision loss, 3 of which required exenteration to contain the disease and only 1 of which recovered vision. Three cases were caused by group A streptococcus; 1, by methicillin-resistant Staphylococcus aureus; and 1, by Streptococcus anginosus constellatus. CONCLUSIONS AND RELEVANCE: Providers should maintain a high clinical suspicion for necrotizing fasciitis and distinguish it from more common forms of cellulitis. As seen in these 5 cases, periocular necrotizing fasciitis may cause severe visual loss more often than previously recognized. To our knowledge, this is also the first report of Streptococcus anginosus constellatus causing necrotizing fasciitis.

Intralesional bevacizumab use for invasive ocular surface squamous neoplasia.

PURPOSE: Report the use of bevacizumab intralesional injection as an adjunctive therapy in a patient with ocular surface squamous neoplasia (OSSN) after an incomplete response to topical and intralesional chemotherapy. METHODS: This is a case report of a 79-year-old man who was treated with topical and intralesional chemotherapy (interferon-alpha-2b, mitomycin-C, and 5-fluorouracil) over 22 months with incomplete resolution of severe OSSN. Intralesional bevacizumab was tried as an adjuvant treatment to resolve the residual tumor. RESULTS: Grossly and histologically there was no significant change in the residual tumor after treatment with intralesional bevacizumab. CONCLUSIONS: While intralesional bevacizumab has been utilized as a treatment modality in the use of other squamous tumors, further studies on the use of bevacizumab in squamous neoplasia would be needed to recommend this treatment for the ocular surface. In the absence of further studies, the current topical and intralesional chemotherapeutic agents should continue to be the mainstay of medical treatment for squamous neoplasia; surgical management is still the definitive treatment.

Cardiothoracic surgery resident education: update on resident recruitment and job placement.

BACKGROUND: Applications to cardiothoracic surgery training programs have steadily declined. The application cycle for 2004 marked the first time the number of applicants was lower than the positions offered. This survey reflects on this trend in applications and the perspectives of current and graduating residents. METHODS: In June 2004, the Thoracic Surgery Residents Association, in conjunction with CTSNet, surveyed residents completing accredited cardiothoracic training or additional subspecialization. Participation was anonymous and voluntary. RESULTS: Of the 140 graduates, 88 responded. Most were male (92%) and married (72%). Their average age was 35.7 years, and 56% had children. The mean educational debt was less than $50,000. Of the 88 respondents, 69 (78%) had plans to seek jobs whereas 15 (17%) sought additional training. Among job-seeking residents, 12% received no offers. Also, 59% of graduates initially sought a position in academics and 41% in private practice. Nearly one quarter (23%) reported that they would not choose a career in cardiothoracic surgery again, and more than half (52%) would not strongly recommend cardiothoracic surgery to potential trainees. Almost all (90%) of the graduates believed that the number of cardiothoracic training spots should be decreased, and 92% believed that a reduction in training positions should be achieved by closing marginal training programs. Additionally, 91% believed reimbursement for cardiothoracic surgery was inadequate, and 88% thought low reimbursement resulted in restricted patient access and decreased quality of care. CONCLUSIONS: Cardiothoracic training programs are having difficulty in both applicant recruitment and in suitable job placement. This frustration in the job search coupled with reimbursement and lifestyle issues most likely contributes to the general dissatisfaction conveyed by the graduates. If these trends continue, the field will be faced with a crisis of unfilled residency programs and unemployed graduates.