Nitrite and nitrate are formed by endogenous synthesis in the human intestine.

Studies of nitrate balance in humans and analyses of fecal and ileostomy samples indicate that nitrite and nitrate are formed de novo in the intestine, possibly by heterotrophic nitrification. These findings significantly alter our previous conceptions of human exposure to nitrite and suggest an even wider role for nitrite in the etiology of human cancer.

Sweet's syndrome: systemic signs and symptoms and associated disorders.

OBJECTIVE: To characterize the findings associated with acute febrile neutrophilic dermatosis (Sweet's syndrome [SS]) and the response of SS to treatment. DESIGN: We retrospectively reviewed 48 cases of SS encountered at the Mayo Clinic between 1980 and 1992. MATERIAL AND METHODS: Histopathologic specimens and medical records were studied to determine initial manifestations, patterns of involvement, systemic signs and symptoms (including mucosal, musculoskeletal, hematologic, pulmonary, hepatic, and renal findings), and conditions associated with SS. RESULTS: In patients with SS, the typical manifestations are the acute onset of tender, erythematous or violaceous nodules or plaques in association with fever, leukocytosis, and dermal neutrophilia. In our study group, the cutaneous lesions most frequently involved the arms and legs. Of our 48 patients, 26 (54%) had a hematopoietic, plasma cell, or malignant disorder, and many of these patients had associated anemia, especially the male patients. No single laboratory finding specifically indicated an association with serious systemic disease. Most patients were treated with a tapering dose of prednisone, which yielded a good response. CONCLUSION: Clinical acumen and appropriate laboratory tests are the main requirements for detection of hematologic disorders, internal malignant diseases, or other systemic conditions associated with SS.

Primary localized amyloidosis presenting as an eyelid margin tumor.

A 40-year-old man had slow-growing, nodular, amyloid tumors of the eyelid margin associated with recurrent intradermal hemorrhages for 18 years. Medical evaluation revealed no evidence of primary systemic amyloidosis. We suggest that amyloidosis be included in the differential diagnosis of painless, slow-growing, nodular tumors of the eyelid margin.

Levator injury during blepharoplasty.

Upper eyelid blepharoplasty has been increasing in popularity and complexity. New techniques involve deep dissection into the upper eyelid, with increased surgical risk to the levator complex. The resulting forms of trauma and subsequent ptosis commonly include direct injury, edema, hematoma, supratarsal fixation, and septal adhesion. Ptosis after blepharoplasty is common and, while spontaneous resolution occurs in some cases, other may require one of the suggested methods for treatment.

Moxalactam retinal toxicity.

Moxalactam disodium is a new third-generation semisynthetic, broad-spectrum, cephalosporin-like antibiotic for parenteral administration. Topical, subconjunctival, and intravenous administration provide poor concentration in the vitreous. To determine its toxicity in intravitreal administration, we injected comparative doses directly into the vitreous cavity of 21 rabbits. With doses of 1.25 mg or less there was no toxic damage to the retina. With a dose of 2.5 mg, early degeneration of photoreceptors was seen after three months. With higher doses (5 and 10 mg) there were major histopathologic and electroretinographic changes. These results suggest the feasibility of employing moxalactam in the treatment of acute, severe, fulminant bacterial endophthalmitis.

Flow cytometric testing of susceptibilities of Mycobacterium avium to amikacin, ciprofloxacin, clarithromycin and rifabutin in 24 hours.

OBJECTIVE: To develop a biologically safe flow cytometric susceptibility test that depends on detection and enumeration of actively growing Mycobacterium avium organisms in drug-free and antimycobacterial agent-containing medium. METHODS: Prior to analysis by flow cytometry, all M. avium susceptibility test samples were inactivated by exposure to paraformaldehyde. The susceptibilities of 20 clinical isolates of M. avium to amikacin, ciprofloxacin, clarithromycin, and rifabutin were tested by the flow cytometric and BACTEC methods. RESULTS: Agreement was 97% between the results of the two methods. The results of flow cytometric susceptibility tests were available 24 h after inoculation of drug-containing medium, while the BACTEC method required 4-8 days to complete. CONCLUSIONS: The flow cytometric assay is safe, simple and reproducible.

The coronal brow lift.

We use a coronal brow lift to correct brow ptosis and associated forehead wrinkling. This technique eliminates the disadvantages of the traditional direct brow elevation, including scarring above the brow and failure to correct forehead and glabellar ptosis and wrinkling. The entire upper face is elevated as a unit, preserving the natural anatomy as much as possible. The scars are covered by hair. Eyebrow elevation and the final cosmetic results were satisfactory in all 22 cases in which we used this technique. There were no serious complications.

An unusual case of severe griseofulvin-alcohol interaction.

Drug-alcohol interactions in patients who present to emergency departments with a severe "disulfiram-like" illness (including vomiting, diarrhea, flushing, tachycardia, and hypotension) must be recognized and treated appropriately. We report a case of such an interaction caused by oral griseofulvin and alcohol. Emergency physicians should be aware of this potential interaction.

Müller's muscle in the treatment of upper eyelid ptosis: a ten-year study.

Müller's muscle is a sympathetically innervated muscle that can be resected to treat upper eyelid ptosis. Candidates for the ptosis procedure are those whose upper lids elevate to a normal level following instillation of phenylephrine hydrochloride drops into their upper ocular fornix. A specially designed clamp is applied to 6.5 to 9.5 mm of conjunctiva and Müller's muscle above the superior tarsal border. A suture is run distal to the clamp, connecting conjunctiva and Müller's muscle to the superior tarsal border; then, the tissues held in the clamp are resected. In a ten-year study of this procedure, 90% of the lids with acquired ptosis and 100% of those with congenital ptosis were within 1.5 mm of the level of the opposite lid postoperatively. Only two of 232 treated lids required additional surgery.

Müller's muscle in the treatment of upper eyelid retraction: a 12-year study.

Müller's muscle is a sympathetically innervated muscle that can be excised to relieve upper eyelid retraction. A graded, controlled excision of Müller's muscle, with or without recession of the levator aponeurosis, using sensory without motor anesthesia is an excellent technique for releasing thyroid-related upper eyelid retraction. The procedure is simple, based on anatomic and physiologic principles, tailored to the individual patient intraoperatively, and yields consistently good results. In a 12-year study of this procedure, 96% of the treated lids attained lid levels within 1.5 mm of the opposite side. Only seven of 156 treated eyelids required additional surgery.

Conjunctiva-Müller's muscle excision to correct anophthalmic ptosis.

We treated 35 eyelids with ptosis and anophthalmos by resecting conjunctiva and Müller's muscle. Before surgical intervention all patients were evaluated by an experienced ocularist who, if necessary, modified or refit the prosthesis. All eyelids had a positive response to 10% phenylephrine hydrochloride. Preoperatively, the margin reflex distance-one (MRD-1) of the ptotic eyelids ranged from -2.0 to +3.5 mm. The amount of conjunctiva-Müller's muscle excision ranged from 7.25 to 9.25 mm. Following surgery, the average change in MRD-1 was 3.33 mm. Thirty-one eyelids (88.6%) achieved a post-operative level within 1 mm of the opposite eyelid. There were two overcorrections and two undercorrections. Postoperatively, no patients had any compromise of the superior fornix, socket dryness, or inability to retain their prosthesis. Resection of conjunctiva and Müller's muscle is a simple and effective method to treat ptosis associated with anophthalmos.

Low-dose atrial natriuretic factor and furosemide in experimental acute congestive heart failure.

This study was designed to address three objectives in an experimental model of acute congestive heart failure (CHF) in the dog produced by rapid ventricular pacing. The first objective was to characterize cardiorenal and humoral responses before and during 2 h of acute CHF. The second objective was to determine the modulating action of iv furosemide upon these biologic responses to acute CHF, testing the hypothesis that furosemide-mediated natriuresis is associated with activation of the renin-angiotensin-aldosterone system (RAAS) compared with the control group. The third objective was to determine the modulating action of continuous low-dose atrial natriuretic factor (ANF) administration during acute CHF upon these biologic responses, testing the hypothesis that exogenous low-dose ANF would prevent activation of the RAAS and enhance the natriuretic action of furosemide. In the control group (Group 1; N = 6), plasma ANF increased after the onset of CHF; GFR and sodium excretion were maintained without activation of this RAAS despite arterial hypotension. In Group 2 (N = 6), furosemide in acute CHF increased sodium excretion but in association with a decrease in GFR and activation of the RAAS. Low-dose exogenous ANF and furosemide (Group 3; N = 6) in acute CHF were associated with a maintenance of GFR, no activation of the RAAS, and potentiation of furosemide-induced natriuresis. In summary, these studies demonstrate that furosemide potently increases sodium excretion in acute CHF, but with a decrease in GFR and activation of the RAAS. Low-dose ANF in acute CHF with furosemide maintains GFR, attenuates activation of the RAAS, and potentiates natriuresis.

Infantile leukocoria caused by posterior lenticonus.

Posterior lenticonus--a bulging of the posterior capsule and cortex--is an acquired lens abnormality, which becomes increasingly opaque. We report an unusual case of bilateral posterior lenticonus in an infant, who initially presented with leukocoria and was referred with a diagnosis of retinoblastoma. Careful physical examination and ultrasound analysis were important in the diagnosis. Ultrasound also aids the surgeon in planning therapy. Posterior lenticonus should be considered in the differential diagnosis of retinoblastoma.

Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis.

The Mueller's muscle-conjunctival resection procedure has been effective in treating ptosis in eyelids that elevate upon instillation of topical 10% phenylephrine (Neo-Synephrine). The small risk of an adverse systemic reaction to phenylephrine could be even further decreased by using 2.5% phenylephrine instead of 10% phenylephrine. In order to assess the feasibility of using 2.5% phenylephrine instead of 10% phenylephrine in ptosis evaluation, we compared the amount of upper eyelid elevation produced by the two solutions. Thirty ptotic upper eyelids in 20 patients exposed to 10% phenylephrine rose an average of 0.2 mm higher than the same lids exposed to 2.5% phenylephrine. Although this difference was statistically significant, we suspect that the small magnitude of this difference would have little effect on the decision to perform a Mueller's muscle-conjunctival resection procedure or on the calculation of the amount of tissue to resect.

Muller's muscle-conjunctival resection procedure in the treatment of ptosis in Horner's syndrome.

The predictability of the phenylephrine test and the efficacy of the Muller's muscle-conjunctival resection procedure in the management of blepharoptosis in six cases of Horner's syndrome were assessed. Before phenylephrine testing or surgery, an average of 2.3 mm of ptosis was present. Topical phenylephrine elevated upper lids an average of 2.2 mm. The amount of elevation produced by the phenylephrine guided the amount of Muller's muscle and conjunctiva resected. Postoperative upper lid levels were exactly symmetrical in five of six patients. In one patient the previously ptotic lid was 0.5 mm higher than the contralateral lid. Even though Muller's muscle is rendered nonfunctional in Horner's syndrome by denervation, the Muller's muscle-conjunctival resection procedure proved to be a very effective method of treating ptosis in this setting. Our findings imply that the mechanism by which this procedure alleviates ptosis is independent of active contraction of Muller's muscle.

Bleeding in cosmetic blepharoplasty: an anatomical approach.

The complication of bleeding associated with cosmetic blepharoplasty was investigated by dissection of two fresh-frozen cadaver heads. The arteries were injected with Neoprene latex and dissection of the tissues encountered in blepharoplasty surgery was performed. From the study, three major components of the orbital and eyelid vascular system were felt to be important. These consisted of the individual tissue vascularity, the major arterial trunks in the region, and the connective tissue support of the arteries. Conclusions are reached regarding the prevention of bleeding associated with cosmetic blepharoplasty.

Evaluation of lubricants for the prosthetic eye wearer.

We evaluated the need for additional lubrication in 200 consecutive patients using an ocular prosthesis. Of these patients, 154 (77%) required no additional lubrication, while 46 patients (23%) required supplemental lubrication. Enuclene, the only product manufactured specifically for the patient with an ocular prosthesis, has been reported by the majority of our patients to be inadequate for comfort and wearability. Other solutions for contact lens use were compared with Enuclene and found to be far superior by patients using an ocular prosthesis.

Sweet syndrome: acute febrile neutrophilic dermatosis.

Sweet, in 1964, described a skin condition characterized by fever, leukocytosis, tender erythematous plaques, and, histopathologically, a predominantly neutrophilic dermal inflammation. However, other dermatologic conditions can present with similar clinical and histological features. Therefore, diagnostic criteria are important for the correct diagnosis. Use of systemic steroids is the treatment of choice for Sweet syndrome. A number of other medications can be useful at times, such as potassium iodide, dapsone, indomethacin, and colchicine.

Autogenous auricular cartilage grafting for lower eyelid retraction.

The authors discuss the surgical correction of lower eyelid retraction in dysthyroid, socket, and blepharoplasty patients. Sixty-three patients underwent a lateral canthal tightening combined with a vertical lengthening of the posterior lamella using autogenous posterior auricular cartilage. The average follow-up was for 2 years. We propose this combined procedure as the surgery of choice in the treatment of lower eyelid retraction seen in these three groups of patients.