Epigastric pain associated with herpes esophagitis: case report.

BACKGROUND: Herpes esophagitis is uncommon disease caused by Herpes simplex virus (HSV). While the disease most often occurs in immunocompromised patients, including post-chemotherapy, immunosuppression with organ transplants, and in AIDS, Herpes esophagitis can also occur in immunocompetent individuals. CASE PRESENTATION: We report a case of herpes esophagitis in a 72 year- old woman who was presumed to be immunocompromised following prolonged radiotherapy and chemotherapy for lymphoma. Her main symptom was epigastric pain. Upper endoscopy showed multiple rounded ulcers in lower esophagus. The diagnosis was confirmed histologically by multiple biopsies. The patient received Valacyclovir for 2 weeks and started to get better within 3 days of treatment. CONCLUSION: Although there are few published cases of Herpes esophagitis disease in the medical literature, we recommend that this disease should be considered as one of the differential diagnoses when assessing immuno-compromised patients presenting with non-specific abdominal symptoms.

A Predominant Variable-Number Tandem-Repeat Cluster of Mycobacterium tuberculosis Isolates among Asylum Seekers in the Netherlands and Denmark, Deciphered by Whole-Genome Sequencing.

In many countries, Mycobacterium tuberculosis isolates are routinely subjected to variable-number tandem-repeat (VNTR) typing to investigate M. tuberculosis transmission. Unexpectedly, cross-border clusters were identified among African refugees in the Netherlands and Denmark, although transmission in those countries was unlikely. Whole-genome sequencing (WGS) was applied to analyze transmission in depth and to assess the precision of VNTR typing. WGS was applied to 40 M. tuberculosis isolates from refugees in the Netherlands and Denmark (most of whom were from the Horn of Africa) that shared the exact same VNTR profile. Cluster investigations were undertaken to identify in-country epidemiological links. Combining WGS results for the isolates (all members of the central Asian strain [CAS]/Delhi genotype), from both European countries, an average genetic distance of 80 single-nucleotide polymorphisms (SNPs) (maximum, 153 SNPs) was observed. The few pairs of isolates with confirmed epidemiological links, except for one pair, had a maximum distance of 12 SNPs. WGS divided this refugee cluster into several subclusters of patients from the same country of origin. Although the M. tuberculosis cases, mainly originating from African countries, shared the exact same VNTR profile, most were clearly distinguished by WGS. The average genetic distance in this specific VNTR cluster was 2 times greater than that in other VNTR clusters. Thus, identical VNTR profiles did not represent recent direct M. tuberculosis transmission for this group of patients. It appears that either these strains from Africa are extremely conserved genetically or there is ongoing transmission of this genotype among refugees on their long migration routes from Africa to Europe.

LONG-TERM OUTCOMES AND INCIDENCE OF RECURRENCE OF NEOVASCULARIZATION IN TREATED EXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To assess the long-term visual outcome and incidence of recurrence of neovascular age-related macular degeneration (NAMD) treated with intravitreal anti-VEGF injections (IVAI). METHODS: One hundred and thirty-two consecutive eyes treated with IVAI for NAMD based on an as-needed regimen with a follow-up ≥5 years (mean 7.55, range 5-9.67) were retrospectively reviewed. Main outcome measures included visual acuity, yearly number of IVAI, and occurrence of a long-term remission, defined as no recurrence of NAMD for ≥12 consecutive months. RESULTS: Mean baseline visual acuity was 20/100. Mean final visual acuity change was -3.41 letters. Mean overall IVAI number was 22.8 ± 17.4 (range 2-71), decreasing from 4.6 during Year 1 to 2.21 during Year 8. A significant positive correlation was found between the number of IVAI during the first year of treatment and the overall number of IVAI during 5 years, 6 years, 7 years, or 8 years follow-up (r = 0.67-0.70, P <0.0001). Long-term remission occurred at least once in 83/132 eyes (63%) and was associated with a better visual outcome (-1.04 vs. -7.43 letters, P = 0.034). Incidence of yearly remission of NAMD increased from 28% during Year 2 to 59% during Year 8, fitting along a single straight line (+5.231%/year, R = 0.9511). CONCLUSION: The incidence of recurrence of treated NAMD decreases slowly but steadily during follow-up. The number of years of follow-up is the main factor to assess the proportion of treated eyes at remission at a given moment. Incidence of recurrence of neovascularization during year 1 and length of follow-up are significant factors when tailoring an optimal long-term follow-up regimen.

Sporadic and rapidly progressive arrhythmogenic right ventricular cardiomyopathy in a 12-year-old boy who was diagnosed with epilepsy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is one of the leading causes of sudden cardiac death amongst young people and athletes. In this genetic disease, arrhythmia and fibro-fatty changes in the right ventricular myocardium are the main characteristics of the disease. Here, we report a case of ARVC in a 12-year-old boy who was previously diagnosed with epilepsy, the patient's condition manifested sporadically and was complicated by rapid progression, and unfortunate fatal deterioration after admission into the pediatric emergency room due to fatigue, dizziness and palpitation. A diagnosis of ARVC was established, even though a family history was absent. Due to possible rapid deterioration, as described in this case, we recommend immediate primary and secondary prevention of arrhythmias in these patients, and to take in consideration of the potential risks of using sodium valproate in these patients.

Improvement in glycemic control in morbidly obese type 2 diabetic subjects by gastric stimulation.

BACKGROUND: Gastric electrical stimulation synchronized to the refractory period of gastric electrical activity and applied during meals was evaluated for safety and for improvement of body weight and glycemic control in obese type 2 diabetes. METHODS: The study involved obese diabetic type 2 (ODM) patients in a multicenter open-label European feasibility trial. A total of 24 ODM (nine males, 15 females) treated with insulin and/or oral hyperglycemic agents and body mass index between 33.3 to 49.7 kg/m(2) were implanted laparoscopically with a TANTALUS system. RESULTS: There were 18 adverse events related to the implant procedure or the device reported in 12 subjects. All were short lived and resolved with no sequelae. In the 21 subjects that reached the 1-year visit weight was reduced by 4.5 +/- 2.7 kg (p < 0.05) and HbA1c by 0.5 +/- 0.3% (p < 0.05). In a subgroup (n = 11) on stable or reduced oral medication, weight was reduced by 6.3 +/- 3.4 kg (p < 0.05) and HbA1c by 0.9 +/- 0.4% (p < 0.05). The group on insulin (n = 6) had no significant changes in weight and HbA1c. CONCLUSIONS: The TANTALUS system is well tolerated in obese type 2 diabetic subjects. Gastric electrical stimulation can potentially improve glucose metabolism and induce weight loss in obese diabetic patients, who are not well controlled on oral antidiabetic therapy. Further evaluation is required to determine whether this effect is due to induced weight loss and/or to direct signal dependent mechanisms.

Treatment of type 2 diabetes using meal-triggered gastric electrical stimulation.

BACKGROUND: The TANTALUS System (MetaCure Limited) is a minimally invasive implantable device for the treatment of type 2 diabetes. The system detects food intake by sensing gastric electrical variations and applies electrical stimulation to the gut synchronized to natural gastric activity. The system is commercially available in Europe and Israel and is in clinical trials in the United States. It has been tested in 132 patients worldwide to date. OBJECTIVES: To re-analyze previously reported datafrom different studies. This retrospective analysis of the type 2 diabetes subpopulation analyzed the expected benefit and characterized the significance of baseline A1c in the determination of the expected clinical outcome. METHODS: From the total cohort of 132 patients implanted with the TANTALUS device in 10 different centers in Europe and the U.S., we identified 50 subjects (27 females, 23 males) who were obese with uncontrolled T2DM on a stable regime of oral medication for 3 months prior to implant. This population had similar inclusion/exclusion criteria as well as treatment protocols and were all treated for at least 24 weeks. The analysis was based on the A1c change compared to baseline. RESULTS: Data after 24 weeks demonstrated a reduction in A1c in 80% of the patients with average drop in A1c of 1.1 +/- 0.1%. The average weight loss was 5.5 +/- 0.7 kg. CONCLUSIONS: The results suggest that the TANTALUS stimulation regime can improve glucose levels and induce moderate weight loss in obese T2DM patients.

The TANTALUS system for obesity: effect on gastric emptying of solids and ghrelin plasma levels.

BACKGROUND: Gastric electrical stimulation (GES), using the implantable TANTALUS System, is being explored as a treatment for obesity. The system delivers nonstimulatory electrical signals synchronized with gastric slow waves, resulting in stronger contractions. We hypothesized that this GES may enhance gastric emptying and as a result affect plasma ghrelin and insulin homeostasis. The aim was to test the effect of GES on gastric emptying of solids and on ghrelin and insulin blood levels in obese subjects. METHODS: The system consists of 3 pairs of gastric electrodes connected to an implantable pulse generator. Gastric emptying test (GE) of solids was performed twice, on separate days, a few weeks after implantation, before and after initiation of stimulation. Blood samples for ghrelin and insulin were taken at baseline and at 15, 30, 60 and 120 min after the test meal. RESULTS: There were 11 females, 1 male, mean age 39.1 +/- 8.9 years, mean BMI 41.6 +/- 3.4. Data is available from 11 subjects; GE was normal in 9 subjects and accelerated in 2 subjects. GES significantly accelerated GE compared to control: percent retention at 2 hours 18.7 +/- 12.2 vs 31.9 +/- 16.4, respectively (P < 0.01). Overall, there was no significant change in ghrelin or insulin profile after food intake. Ghrelin levels fell significantly at 60 min compared to baseline during stimulation (P = 0.014) and control (P = 0.046). CONCLUSION: GES results in a significant acceleration of gastric emptying of solids in obese subjects. GES did not have a significant effect on postprandial ghrelin levels when compared to control.

Photodynamic therapy vs limited macular translocation in the management of subfoveal choroidal neovascularization in pathologic myopia: a two-year study.

PURPOSE: To compare the results of limited macular translocation and photodynamic therapy (PDT) in subfoveal choroidal neovascularization (CNV) attributable to pathologic myopia with a 24-month follow-up. DESIGN: Retrospective analysis of nonrandomized interventional clinical study. METHODS: Retrospective review of 66 consecutive patients: 34 myopic eyes with subfoveal neovascularization treated by PDT and 32 operated on with the translocation technique. Translocation was considered principally when the lesion size was adequate (nasal inferior margin of the membrane less than half a disk diameter away from the center of the fovea) with duration of symptoms of less than four months. Main outcome measure was the postoperative change in visual acuity. RESULTS: In the translocation group, mean gain in visual acuity was greater than in the PDT group (+2.8 lines and -1.8 line, respectively, P = .001). In the translocation group, 55% of eyes gained 3 lines or more at two years compared with 10% in the PDT group. Sixty percent of eyes in the translocation group vs 40% in the PDT group had an improvement of at least five letters. Mean foveal displacement after translocation was 906 mum; postoperative complications included retinal detachment (three eyes), macular fold (one eye), and transient diplopia (four eyes). In young patients, the postoperative gain was better in both groups. In the translocation group, mean survival time for choroidal neovascularization recurrence was 40 months for patients younger than 40 years and 20 months for older patients. CONCLUSIONS: Translocation showed better results than PDT at two years. Further studies are required to confirm these findings.

LASIK for high myopic astigmatism resulting from perforating ocular injury.

PURPOSE: To present a case of successful treatment of high myopic astigmatism after a perforating injury with significant corneal laceration and pupil ectopia using excimer LASIK. METHODS: A 30-year-old man presented for treatment of high myopic astigmatism in his right eye resulting from perforating ocular trauma, which occurred 8 years prior to presentation. The corneoscleral wound repair was performed with posterior chamber intraocular lens implantation. Uncorrected visual acuity (UCVA) in the right eye was counting fingers at 1 m, best corrected to 20/30 with -7.00 + 5.00 x 110. Visual acuity in the left eye was 20/20 with -1.5 D. The patient was unable to tolerate spectacles and contact lenses because of asthenopia and high astigmatism, respectively. As an alternative, LASIK with the Allegretto Wave excimer laser was performed. RESULTS: Three months postoperatively, UCVA was 20/25 in the right eye and 20/15 in the left eye. CONCLUSIONS: This case indicates that LASIK can be a useful surgical method for correcting high myopic astigmatism resulting from ocular trauma with significant corneoscleral laceration.

Cardiac contractility modulation by electric currents applied during the refractory period in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

We assessed the feasibility of cardiac contractility modulation (CCM) by electric currents applied during the refractory period in patients with heart failure (HF). Extracellular electric currents modulating action potential and calcium transients have been shown to potentiate myocardial contractility in vitro and in animal models of chronic HF. CCM signals were biphasic square-wave pulses with adjustable amplitude, duration, and time delay from sensing of local electric activity. Signals were applied to the left ventricle through an epicardial vein (in 12 patients) or to the right ventricular (RV) aspect of the septum endocardially (in 6 patients). Simultaneous left ventricular (LV) and aortic pressure measurements were performed using a Millar catheter (Millar Instruments, Houston, Texas). Hemodynamics during RV temporary dual-chamber pacing was regarded as the control condition. Both LV and RV CCM stimulation increased dP/dt(max) to a similar degree (9.1 +/- 4.5% and 7.1 +/- 0.8%, respectively; p <0.01 vs controls), with associated aortic pulse pressure changes of 10.3 +/- 7.2% and 10.8 +/- 1.1% (p <0.01 vs controls). Regional systolic wall motion assessed quantitatively by color kinesis echocardiography was markedly enhanced near the CCM electrode, and the area of increased contractility involved 4.6 +/- 1.2 segments per patient. In 6 patients with HF with left bundle branch block, CCM signals delivered during biventricular pacing (BVP) produced an additional 16.1 +/- 3.7% increase in dP/dt(max) and a 17.0 +/- 7.5% increase in pulse pressure compared with BVP alone (p <0.01). CCM stimulation in patients with HF enhanced regional and global measures of LV systolic function, regardless of the varied delivery chamber or whether modulation was performed during RV pacing or BVP.

Long-term effects of non-excitatory cardiac contractility modulation electric signals on the progression of heart failure in dogs.

OBJECTIVE: We previously showed that acute delivery of non-excitatory cardiac contractility modulation (CCM) electric signal during the absolute refractory period improved LV function in dogs with chronic heart failure (HF). In the present study we examined the long-term effects of CCM signal delivery on the progression of LV dysfunction and remodeling in dogs with chronic HF. METHODS: Chronic HF was produced in 12 dogs by multiple sequential intracoronary microembolizations. The CCM signal was delivered using a lead implanted in the distal anterior coronary vein. A right ventricular and a right atrial lead were implanted and used for timing of CCM signal delivery. In six dogs, CCM signals were delivered continuously for 6 h daily with an average amplitude of 3.3 V for 3 months. Six HF dogs did not have leads implanted and served as controls. RESULTS: In control dogs, LV end-diastolic volume (EDV) and LV end-systolic volume (ESV) increased (64+/-5 ml vs. 75+/-6 ml, P=0.003; 46+/-4 ml vs. 57+/-4 ml, P=0.003; respectively), and ejection fraction (EF) decreased (28+/-1% vs. 23+/-1%, P=0.001) over the course of 3 months of follow-up. In contrast, CCM-treated dogs showed a smaller increase in EDV (66+/-4 vs. 73+/-5 ml, P=0.01), no change in ESV, and an increase in EF from 31+/-1 to 34+/-2% (P=0.04) after 3 months of therapy. CONCLUSIONS: In dogs with HF, long-term CCM therapy prevents progressive LV dysfunction and attenuates global LV remodeling. These findings provide compelling rationale for exploring the use of CCM for the treatment of patients with chronic HF.

Retinal detachment after phacoemulsification: a study of 114 cases.

PURPOSE: To analyze the features of retinal detachment (RD) occurring after cataract surgery performed by Kelman phacoemulsification (KPE) and to identify any potential correlations between KPE intraoperative complications and the features of RD (incidence apart) as well as the final visual outcome. DESIGN: Interventional consecutive case series. METHODS: Retrospective review of 114 eyes of 114 consecutive patients with RD occurring after KPE and followed for 6 months or more after surgery. RESULTS: Removal of posteriorly dislocated lens fragments during KPE by pars plana vitrectomy (PPV) was associated with a significantly shorter time interval between KPE and RD (3.89 vs. 15.7 months, P =.0044). Once RD occurred, no other statistically significant correlation between its features or the final visual outcome and KPE intraoperative complications (posterior capsular rupture, vitreous loss, posteriorly dislocated lens fragments) was detected. The overall anatomic reattachment rate was 94%. Only redetachment associated with the development of proliferative vitreoretinopathy (PVR) was significantly correlated with ultimate anatomic failure (P =.0036). A best-corrected visual acuity of 20/60 or better was achieved in 58 out of 114 eyes (51%). Three variables were independently correlated with visual results: more extensive RD (P =.0001), redetachment associated with the development of PVR (P =.0029), and failure to identify retinal breaks (P =.0114). CONCLUSIONS: Posterior capsular rupture and vitreous loss during KPE do not seem to affect the features (incidence apart) or the final visual outcome of RD occurring afterwards, except for a shorter time interval between KPE and RD in eyes that underwent PPV to remove posteriorly dislocated lens fragments.

Intermittent exotropia with high AC/A ratio: is it a bane to surgical cure? Some facts and fictions of the two clinical tests: occlusion of one eye and the use of +3.00 spherical lenses.

BACKGROUND AND PURPOSE: To review the multiple factors in intermittent exotropia (X(T)) responsible for the discrepancy between the distance and near deviations; to challenge the classification of X(T) into types according to the two standard clinical tests of occlusion of one eye and the use of +3.00 D spherical lenses at near by demonstrating the pitfalls of these two tests, as in X(T), masquerading as high AC/A ratio at times or as strong proximal fusional convergence at other times. METHODS OF STUDY: Fifteen patients demonstrating findings characteristic of X(T) with so-called high AC/A ratio are reported. Fourteen patients had an exodeviation initially. The fifteenth had become exotropic following medial rectus recessions for infantile esotropia. Fourteen patients had bilateral lateral rectus recession and one had unilateral lateral rectus recession. RESULTS: The only patient who did develop a long term postoperative overcorrected high AC/A ratio esotropia was the patient who had initially an infantile esotropia. Of the other 14 patients initially X(T) none developed a long term postoperative overcorrected high AC/A ratio esotropia. Fifty % of these were "cured" (OT +/- 8 delta) and 50% had a "significant (> or = 8 delta) recurrence" of their exodeviation. CONCLUSION: Patients with intermittent exotropia and significantly more exodeviation at distance than at near, and classified to have high AC/A ratio by occlusion of one eye and the use of +3.00 spheres at near, do not necessarily have a high accommodation-convergence relationship but rather, other factors mimicking this high AC/A relationship. They do not necessarily develop a postoperative overcorrected high AC/A ratio esotropia.

[Age-related macular degeneration]. / Dégénérescence maculaire liée à l'âge.

UNLABELLED: EPIDEMIOLOGICAL AND PATHOGENIC DATA: Age-related macular degeneration (ARMD) is the first cause of blindness in industrialized countries in patients over the age of 55. Its prevalence increases with age, affecting up to 25% of the population aged over 75. The pathogenesis of this disease is not well known. Not only aging, but also other varying degrees of genetic and environmental factors are implied. CLINICAL ASPECTS: Precursors (first clinical signs of ARMD) can be observed on examination of the fundus: drusen (localized deposits of lipids and lipoproteins) and alterations in retinal pigment epithelium (RPE) (hypo- or hyperpigmentation). Two forms of complications are observed: atrophic (or "dry") and exudative (or "wet"). The atrophic form is defined by the presence of degeneration in the central RPE, choriocapillaris and photoreceptors, resulting from the enlargement and/or coalescence of small areas of peri-foveolar atrophy (or "geographic" atrophy). The exudative form, responsible for the majority of cases of blindness due to ARMD, is characterized by the appearance of choroidal new vessels, identifiable on fluorescein angiography and responsible for serous retinal detachment, edema and hemorrhage, leading to the destruction of the macular photoreceptors. FROM A THERAPEUTIC POINT OF VIEW: Treatment of the atrophic form is currently only palliative (visual aids and re-habilitation of low vision). Treatments of the exudative form having demonstrated their efficacy are laser photocoagulation and dynamic phototherapy with verteporfine, providing relative stabilization of visual acuity in around 2/3 of the eyes. Other treatments are under evaluation: anti-angiogenic treatments, surgical techniques (ablation of the new vessels, foveal translocation), new laser treatments (transpupillary thermotherapy, selective photocoagulation of the feeder vessels). Photoreceptor and pigment epithelium transplantations or implantation of microphotodiodes represent other long-term alternatives.

Intertrochanteric fracture under an arthrodesed hip.

PATIENT: Female, 30. PRIMARY DIAGNOSIS: Intertrochanteric fracture under an arthrodesed hip. CO-EXISTING DISEASES: Developmental dysplasia of the hip. MEDICATION: Pain • inability to walk. CLINICAL PROCEDURE: Open reduction and internal fixation. SPECIALTY: Orthopedics and traumatology. OBJECTIVE: Rare disease, Unusual setting of medical care. BACKGROUND: An intertrochanteric fracture among elderly people is common, but it is rare to see such a fracture under a longstanding hip arthrodesis. Its surgical management represents a real challenge to orthopedic surgeons. CASE REPORT: A 30-year-old female teacher with long-standing hip arthrodesis was involved in a traffic accident. Clinical and radiological examination revealed the presence of a displaced intertrochanteric fracture under an arthrodesed hip and high neck shaft angle. Before embarking on surgery, we have to consider many factors such as patient personality (a young active and ambitious woman) and the mature of the fracture (a displaced fracture, coxa valga, and atrophied muscles). After a deep discussion and evaluation of the available devices, we selected a heavy duty locked plate and cannulated screws to fix the fracture. CONCLUSIONS: Because of the rarity of intertrochanteric fracture under an arthrodesis hip, the proper surgical treatment is controversial. Nevertheless, we were fortunate in successfully treating this unusual fracture using a locked plate and cannulated screws, which are implants that can be useful in treatment of such fractures.

Comparison of 2 types of intrastromal corneal ring segments for keratoconus.

PURPOSE: To assess the effectiveness and safety of 2 types of 6.0 mm intrastromal corneal ring segments (ICRS) in patients with mild to severe keratoconus. SETTING: Lebanese American University, Beirut, Lebanon. DESIGN: Retrospective comparative case series. METHODS: Eyes had implantation of Intacs SK ICRS (Group 1) or Keraring SI6 ICRS (Group 2). Visual acuity (logMAR), refraction, keratometry, and higher-order aberrations were compared 6 months and 1 year postoperatively. RESULTS: Group 1 comprised 66 eyes and Group 2, 107 eyes. The groups were comparable preoperatively. One-year postoperatively, the mean uncorrected distance visual acuity improved by 0.62 logMAR ± 0.19 (SD) in Group 1 and by 0.67 ± 0.17 logMAR in Group 2 (P=.211). The mean corrected distance visual acuity improved by 0.12 ± 0.11 logMAR and by 0.08 ± 0.13, respectively (P=.301). The spherical equivalent decreased by a mean of 2.80 ± 2.87 D and 2.65 ± 3.00 D, respectively (P=.572). Keratometry (K) flat and K steep decreased by a mean of 1.51 ± 1.57 D and 2.24 ± 1.61 D, respectively, in Group 1 and by 1.10 ± 2.00 D and 1.44 ± 1.64 D, respectively, in Group 2 (P=.667 and P=.184, respectively). Primary coma root mean square decreased by a mean of 1.09 ± 0.66 µm in Group 1 and 0.99 ± 0.72 µm in Group 2 (P=.716). CONCLUSION: Both ICRS models significantly improved visual function in patients with keratoconus, with comparable postoperative profiles and no major complications. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Surgical management of low grade isthmic spondylolisthesis; a randomized controlled study of the surgical fixation with and without reduction.

BACKGROUND: spondylolisthesis is a condition in which a vertebra slips out of the proper position onto the bone below it as a result of pars interarticularis defect. The slipped segment produces abnormal positioning of the vertebrae in relation to each other along the spinal column and causes mechanical back pain and neural breach. MATERIALS AND METHODS: A randomized and double blinded study consisted of 41 patients aged 36-69 years (18 females and 28 males) treated for symptomatic spondylolisthesis between December,2006 and December, 2009. All patients were randomly distributed into two groups I and II. Twenty patients were in Group I; they underwent reduction of the slipped vertebrae by using Reduction-Screw Technique and posterior lumbar interbody fixation (PLIF). Group II consisted of twenty one patients who underwent only surgical fixation (PLIF) without reduction. All patients in this study had same pre and post operative management. RESULTS: only one case had broken rod in group I that required revision. Superficial wound infection was experienced in two patients and one patient, from group II, developed wound hematoma. The outcome in both groups was variable on the short term but was almost the same on the long term follow up. CONCLUSION: surgical management of symptomatic low grade spondylolisthesis should include neural decompression and surgical fixation. Reduction of slipped vertebral bodies is unnecessary as the ultimate outcome will be likely similar.

Efficacy of laser in situ keratomileusis in correcting anterior and non-anterior corneal astigmatism: comparative study.

PURPOSE: To compare the efficacy of conventional laser in situ keratomileusis (LASIK) in treating corneal astigmatism and in treating noncorneal ocular residual astigmatism. SETTING: Private practice, Nashville, Tennessee, USA. DESIGN: Retrospective case series. METHODS: The records of dominant eyes of consecutive patients who had LASIK were retrospectively analyzed to compare the efficacy of LASIK in eyes with predominantly anterior corneal astigmatism with the efficacy in eyes with predominantly ocular residual astigmatism (ORA). The ORA was determined by vector analysis using refractive cylinder and topographic astigmatism. Preoperatively, the ratio of ORA to preoperative refractive cylinder (R) was used to divide the patients into 2 groups; that is, eyes with predominantly anterior corneal astigmatism (ORA/R ratio <1.0) and eyes with predominantly ORA (ORA/R ratio ≥1.0). Efficacy was determined by examining the magnitude of the remaining uncorrected astigmatism and comparing the index of success (proportion of preoperative refractive astigmatism that remained uncorrected by LASIK) between the 2 groups. RESULTS: The study evaluated 61 eyes of 61 patients. Conventional LASIK was twice as efficacious in the low-ORA group as in the high-ORA group. The index of success was 0.24 and 0.50, respectively, and the difference between groups was statistically significant (P = .036). CONCLUSION: The efficacy of astigmatic correction by LASIK was significantly higher in eyes in which the preoperative refractive astigmatism was located mainly on the anterior corneal surface than in eyes in which it was mainly located posterior to the anterior corneal surface.

Unusual case of difficult double-lumen endotracheal tube removal.

A reusable Robertshaw red rubber double-lumen endotracheal tube (DLT) was placed to facilitate lung isolation for thoracoscopy in a 49-year-old atopic patient. In spite of its smooth insertion, it was then not possible to remove the DLT. Direct laryngoscopy showed severe laryngeal edema. After 48 hours of medical treatment with steroids, the trachea was extubated. The laryngeal edema could have been the result of physical and chemical irritation by the reusable rubber DLT itself, or from the substances formed during repeated cleaning and sterilization of the DLT. Atopic patients who are prone to developing latex allergy are also more liable to develop severe reactions to chemical, mechanical, and physical irritation from reusable red rubber DLTs or from the chemical solution used for its cleaning and sterilization.