The J-Curve for Navigating the Nasolacrimal Outflow Tract.

PURPOSE: To describe the technique of J-shaped manipulation of the metallic stent for instrument-free intubation of the nasolacrimal outflow tract after dacryocystorhinostomy. METHODS: The internal diameter of the J-shaped curve placed in the intubation stents was measured and the technique of intubation of the nasolacrimal outflow tract and out the external naris is described. In addition, the anatomic relationships of the nasolacrimal system are illustrated and videographed in relation to the described procedure. RESULTS: This technique has been used successfully on 75 consecutive endoscopic dacryocystorhinostomy cases. After completion of bony osteotomy and opening of the nasolacrimal sac, the metallic portion of the stent is bent into a J-shaped curved with an average internal diameter of 4 cm. The punctum is then canulated with the metallic stent and directed 2 mm vertically then 8 mm to 10 mm medially along the path of the canalicular system. On entering the osteotomy, the stent is directed inferior and slightly lateral in the direction of the external naris. Gentle advancement with small angle redirection of the stent as needed allows exit through the external naris without using additional instrumentation in the nose. CONCLUSION: The authors present a technique of J-shaped manipulation of the intubation stent allowing navigation of the nasolacrimal outflow tract and exit through the external naris without additional instrumentation. This technique offers advantages over instrument-assisted retrieval of the intubation tube. First, the J-Curve technique is faster than multi-instrument retrieval. Second, less damage is incurred to the mucosa of the lateral nasal wall and/or septum secondary to blind placement of a Crawford hook, hemostat, or grooved director.

Relapsing acute lymphoblastic leukemia presenting with a rapidly enlarging and vision-threatening orbital mass.

This case report describes a patient with known acute lymphoblastic leukemia (ALL) presenting with a rapidly enlarging and vision-threatening orbital mass. Orbital disease is rare in patients with ALL, and to our knowledge only six cases have been previously described, five of which are in children. We describe a 36-year-old Caucasian female with known acute lymphoblastic leukemia who developed markedly decreased visual acuity, proptosis, and elevated intraocular pressure over the course of 12 h. She was treated with emergent surgical intervention followed by intrathecal chemotherapy and intravenous steroids. Following medical and surgical intervention, the patient demonstrated rapid resolution of symptoms and a return to baseline visual acuity. The initial presentation of acute onset proptosis with optic nerve compromise can be suggestive of infectious etiologies, however, this case suggests caution in evaluation of patients with known systemic malignancy, particularly ALL, as early intervention with systemic steroids and surgery may result in return of visual function.

Vision loss after maxillary artery embolization secondary to compressive optic neuropathy.

The authors report a case of no light perception (NLP) vision in a patient with sinonasal melanoma after maxillary artery embolization secondary to presumptive compressive optic neuropathy. Two reports of NLP vision occurring after maxillary artery embolization are reported in the literature,, both occurring secondary to collateral blood flow to the ophthalmic artery resulting in central retinal artery occlusion. In the current case report, the presumed mechanism of vision loss is secondary to compressive optic neuropathy from local edema occurring after maxillary artery embolization.

Instillation of coarse ash particulate matter and lipopolysaccharide produces a systemic inflammatory response in mice.

Coronary ischemic events increase significantly following a "bad air" day. Ambient particulate matter (PM10) is the pollutant most strongly associated with these events. PM10 produces inflammatory injury to the lower airways. It is not clear, however, whether pulmonary inflammation translates to a systemic response. Lipopolysaccharide (LPS) is a proinflammatory molecule often associated with the coarse fraction of PM. It was hypothesized that PM>2.5 from coal plus LPS induce pulmonary inflammation leading to a systemic inflammatory response. Mice were intratracheally instilled with saline, PM (200 microg), PM + LPS10 (PM + 10 microg LPS), or PM + LPS100 (PM + 100 microg LPS). Eighteen hours later, histologic analysis was performed on lungs from each group. Pulmonary and systemic inflammation were assessed by measuring the proinflammatory cytokines tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 in the pulmonary supernatant and plasma. In a follow-up study, the effects of LPS alone were assessed. Histologic analysis revealed a dose-dependent elevation in pulmonary inflammation with all treatments. Pulmonary TNF-alpha and IL-6 both increased significantly with PM + LPS100 treatment. Regarding plasma, TNF-alpha significantly increased in both PM + LPS10 and PM + LPS100 treatments. For plasma IL-6, all groups tended to rise with a significant increase in the PM + LPS100 group. The results of the follow-up study indicate that the responses to PM + LPS were not due to LPS alone. These results suggest that coarse coal fly ash PM>2.5 combined with LPS produced pulmonary and systemic inflammatory responses. The resulting low-level systemic inflammation may contribute to the increased severity of ischemic heart disease observed immediately following a bad air day.

A prospective, controlled trial of a pharmacy-driven alert system to increase thromboprophylaxis rates in medical inpatients.

Although venous thromboembolism is an important cause of morbidity and mortality within the hospital, a significant proportion of at-risk inpatients do not receive measures known to reduce the risk of deep vein thrombosis and pulmonary embolism. The objective of the present study was to determine whether a pharmacy-driven alert system would, compared to usual care, be associated with a higher rate of adequate venous thromboembolism prevention measures among at-risk inpatients on a general internal medicine service. The study was a prospective, controlled trial set at a university-based teaching hospital. The participants were adults who were admitted (Monday through Friday) to the general internal medicine inpatient service from 19 June to 21 September 2006. Their treatment included a pharmacist assessment of venous thromboembolism risk and a pharmacist-driven alert to the treating physician. The Proportion of at-risk patients receiving adequate thromboprophylaxis within 36 h of admission was recorded. Overall, 140 patients were at sufficient risk for venous thromboembolism to be included. In the usual care group, prophylactic measures were ordered for 49 (61%) of the 80 patients at moderate to high risk. In the pharmacist-alert group, 44 (73%) of the 60 moderate to high venous thromboembolism-risk patients received adequate thromboprophylaxis (P = 0.15). Although we did not observe a statistically significant difference between the groups, our results are consistent with previous reports suggesting that alert systems can increase the proportion of hospitalized patients who receive adequate measures to prevent venous thromboembolism.