Augmenting ENT surgery outside the medical school curriculum: the role of a 1-day otolaryngology course.

BACKGROUND: ENT is highly under-represented in the saturated UK medical school curriculum, comprising less than 1 per cent of the curriculum. A 1-day course was implemented in order to raise awareness of ENT among medical students, educate them in the specialty and teach a basic skill. METHODS: The skills day comprised lectures by consultants followed by a consultant-led workshop teaching tracheostomy. Pre- and post-course questionnaires assessed perceptions of ENT, confidence performing tracheostomy and interest in ENT as a career. RESULTS: Perceptions of ENT as a specialty were improved by up to 80 per cent (p < 0.01). There was improved understanding of and confidence in performing tracheostomies. Interest in a career in ENT was increased by 77 per cent (p < 0.01). CONCLUSION: A 1-day course run by a student body can be a powerful adjunct to the medical school curriculum, in terms of educating undergraduates in ENT and inspiring the pursuit of ENT as a career.

Neurosarcoidosis presenting as trigeminal nevralgia: a case report and review of the literature.

Sarcoidosis is a granulomatous disease that can present systemically, but primarily has pulmonary manifestations. It is reported across all races, but has a higher incidence among African Americans. Neurological involvement in sarcoidosis is rare, with cranial nerve seven being the most commonly reported neurological finding. Trigeminal neuralgia, as presented in this case, is very rare. A 38-year-old African American female, with history of refractory trigeminal neuralgia, cutaneous sarcoidosis, and an extensive psychiatric history, presented to the hospital for fifth cranial nerve decompression. She had failed medical therapy and gamma knife therapy. Prior to surgery, magnetic resonance imaging (MRI) revealed a mass of 1.5 cm x 0.6 cm x 1.1 cm in the left Meckel's cave, which, when compared with prior imaging, was not present. A partial craniotomy was done to excise the mass. Frozen pathological sections showed granulomatous inflammation consistent with sarcoidosis. Stains for acid fast bacilli and fungi remained negative. Quantiferon Gold and HIV serum studies were negative. High resolution computed tomography (CT) scan the chest showed patchy infiltrates in the lungs that presented as chronic interstitial lung disease. The patient's neurological symptoms resolved after surgical resection. She was dismissed home on a tapering dose of dexamethasone and follow-up with a rheumatologist. This case illustrates that when a patient with sarcoidosis presents with neurological symptoms, neurosarcoid should be considered. Most cases are diagnosed during autopsies. Recognizing and correctly diagnosing neurosarcoid leads to proper treatment and decreased morbidity in patients.

Mycobacterium avium-intracellulare presenting as an endobronchial tumour due to immune reconstitution inflammatory syndrome.

Mycobacterium avium-intracellulare (MAI) infection in an HIV-positive patient can present shortly after starting antiretroviral therapy, as a result of immune reconstitution inflammatory syndrome (IRIS). We report a case of a 33-year-old woman where MAI presented as an endobronchial tumour due to IRIS. She responded well to standard anti-MAI treatment (rifamycins, macrolide and ethambutol).

[Comparative results of macular hole surgery with and without internal limiting membrane staining with Brilliant Blue G]. / Résultats comparatifs de la chirurgie des trous maculaires opérés avec et sans coloration de limitante interne par le Brilliant Blue G.

OBJECTIVE: To evaluate the role of Brilliant Blue G (BBG) in macular hole (MH) surgery. METHODS: Comparative retrospective study between two groups of 20 consecutive patients who underwent macular hole surgery. In the first group (G1), the inner limiting membrane (ILM) was systematically peeled without staining, while in the second group (G2), BBG was consistently utilized. Pre- and postoperative logMAR visual acuities (VA) were studied, as well as macular optical coherence tomography (OCT) scans to measure MH size, to confirm postoperative closure and to evaluate the integrity of the IS/OS junction. Time required and difficulty of peeling were compared between the two groups. Minimum follow-up was six months. RESULTS: After six months follow-up, the average improvement in acuity was 0.56±0.48 logMAR for G1, versus 0.60±0.44 logMAR for G2 (P=0.80). The rate of closure after one surgery was 85% (17/20 patients) for G1, versus 95% (19/20 patients) for G2 (P=0.29). Postoperative OCT appearance of the IS/OS junction was similar in both groups: intact in 16/20 patients (80%), disrupted in 3/20 patients (15%), and indeterminate in 1/20 patients (5%) (P=1). The mean duration of peeling in G1 was 270.9±27.4 seconds. It was deemed difficult in ten eyes and incomplete in two patients, while in the G2 group, the mean duration of ILM peeling was 140.8±37.6 seconds (P<0.01); it was deemed complete and technically easy in all cases. CONCLUSION: The use of BBG was effective in facilitating and accelerating ILM peeling during MH surgery. The anatomical and functional results were not statistically better in the group that received BBG.

Investigation of a cluster of syphilis among heterosexuals in an English town.

A cluster of five (3 primary and 2 early latent) cases of syphilis were identified in young heterosexuals in the east of England. Three were symptomatic at presentation. No further cases linked to this cluster have been diagnosed since June 2010. Effective partner notification is key to the identification and treatment of infected contacts.

The modic vertebral endplate and marrow changes: pathologic significance and relation to low back pain and segmental instability of the lumbar spine.

Two decades following their description, the significance of Modic vertebral endplate and marrow changes remains a matter of debate. These changes are closely related to the normal degenerative process affecting the lumbar spine, and their prevalence increases with age. However, the exact pathogenesis underlying these changes and their relation to segmental instability of the lumbar spine and to low back pain remain unclear. In this paper, we review the literature relevant to this topic and discuss the currently available evidence regarding the pathologic and clinical significance of Modic changes.

Acute Korsakoff-like amnestic syndrome resulting from left thalamic infarction following a right hippocampal hemorrhage.

Korsakoff-like amnestic syndromes have been rarely described following structural lesions of the central nervous system. In this report, we describe a case of acute Korsakoff-like syndrome resulting from the combination of a left anteromedian thalamic infarct and a right hippocampal hemorrhage. We also review the literature relevant to the neuropathology and pathophysiology of Korsakoff syndrome and anterograde amnesia.

Safety and efficacy of two ocular anesthetic methods for phacoemulsification: topical anesthesia and viscoanesthesia (VisThesia).

PURPOSE: VisThesia is a new ophthalmic viscosurgical device (OVD) which has 1% lidocaine combined with 1.5% sodium hyaluronate. This is a prospective evaluation of the safety and efficacy of VisThesia used in association with phacoemulsification. METHODS: A total of 114 eyes were divided into two groups. Fifty-nine eyes were treated with tetracaine + oxybuprocaine topical anesthesia and DuoVisc OVD and 55 eyes were treated with VisThesia, for use as both topical anesthetic and OVD. Endothelial cell counts were measured at 30 days postoperatively and compared to preoperative baseline values. Pain and discomfort was subjectively evaluated by patients using a visual analog pain scale (0-10). RESULTS: All surgeries were uneventful with no intraoperative or immediate postoperative complications. Patients receiving topical anesthesia had a mean pain score of 1.1+/-6.8 compared to a mean score of 1.3+/-4.6 for patients receiving VisThesia (p=0.59). Postoperatively, endothelial cell loss at 1 month was greater for patients receiving VisThesia (20.32%+/-43.75) than for those receiving the topical anesthetic (8.8%+/-59.6; p<0.0001). CONCLUSIONS: The results from the visual analog pain scale were comparable between groups, showing that VisThesia provides similar pain relief to topical anesthesia. Specular microscopy performed at 30 days postoperatively showed a significantly greater loss of endothelial cells with the use of VisThesia, suggesting that the 1% lidocaine concentration used in VisThesia may be toxic to corneal endothelial cells.

[Etiologic spectrum of intracerebral hemorrhage in young patients]. / Hématome intracérébral spontané du sujet jeune. Etiologies et rapports avec l'hypertension artérielle

INTRODUCTION: Hemorrhagic stroke is uncommon in young patients. The etiologic spectrum is very wide in the literature. The purpose of this study was to determine the range of etiology in a group of patients completely investigated and to study the relation with a history of high blood pressure. PATIENTS AND METHODS: We reviewed study database, clinical and diagnostic records of 130 patients identified in a population based study, aged 18 to 55 years presenting with hemorrhagic stroke. There were divided into two groups: 67 patients treated at Hotel-Dieu Hospital in Beirut, Lebanon, and 63 patients reviewed at Yale New Haven Hospital, Connecticut, USA. Patients presenting with selective subarachnoidal or intraventricular hemorrhage were excluded. Diagnostic evaluation was assessed for completeness (based on prospectively articulated evidence based criteria) and for identifiable etiology of hemorrhagic stroke and its relation to high blood pressure. RESULTS: There were 84 cases (64%) with complete diagnostic workup. The most common cause of incomplete investigations in remaining cases was death, poor neurological condition and incomplete follow up. Hematoma was superficially located (lobar) in 59.2%, deep seated (thalamo-capsulo-lenticular) in 26%, within the brain stem in 8.7% and cerebellar in 6.1%. An etiology was established in 70.4% of cases (pial AVM 16.7%, aneurysms 15.5%, hematological disorders 13%, cavernous malformations 10.7%, tumors 4.8%, bleeding within ischemic area 3.8%, vasculitis 2.3%, venous thrombosis 1.2% and venous angioma 1.2%. 29.6% of patients remained with undetermined etiology despite complete investigations. In a subgroup of 45 patients, a history of high blood pressure was found in 46.7%. In this cohort, an underlying etiology was established in 71% of cases. CONCLUSION: Complete investigation can establish an etiology in 70% of young patients who survived hemorrhagic stroke, independently from the presence of a history of high blood pressure.

Changes in phosphorylation of the NMDA receptor in the rat hippocampus induced by status epilepticus.

Systemic administration of pilocarpine preceded by lithium induces status epilepticus (SE) that results in neurodegeneration and may lead to the development of spontaneous recurrent seizures. We investigated the effect of Li/pilocarpine-induced SE on phosphorylation of the NMDA receptor in rat hippocampus. Phosphorylation of NR1 by PKC on Ser890 was decreased to 45% of control values immediately following 1 h of SE. During the first 3 h following the termination of SE, phosphorylation of Ser890 increased 4-fold before declining to control values by 24 h. Phosphorylation of NR1 by PKA was also depressed relative to controls immediately following SE and transiently increased above control values upon the termination of SE. SE was accompanied by a general increase in tyrosine phosphorylation of hippocampal proteins that lasted for several hours following the termination of seizures. Tyrosine phosphorylation of the NR2A and NR2B subunits of the NMDAR increased 3-4-fold over control values during SE, continued to increase during the first hour following SE and then declined to control levels by 24 h. SE resulted in the activation of Src and Pyk2 associated with the postsynaptic apparatus, suggesting a role for these enzymes in the SE-induced increase in tyrosine phosphorylation. Changes in phosphorylation of the NMDA receptor may play a role in the pathophysiological consequences of SE.

[Central neurocytoma. Four patients]. / Neurocytome central. A propos de quatre cas.

We report four cases of central neurocytoma we operated on at our institution, between 1994 and 2002. This uncommon lesion occurred in young patients, was located in the lateral ventricules and was revealed by signs of intracranial hypertension. The tumor was totally removed in three cases and subtotally in one. Immunohistochemistry provided useful information to distinguish neurocytoma from other nervous system tumors. Prognosis was excellent in two patients. One patient developed tumor recurrence seven years after surgery, without any progression on further follow up evaluation. In the last patient, the tumor showed a more aggressive progression requiring the adjunction of radiosurgery.

[Anterior cervical discectomy with or without bone graft placement in the treatment of cervical radiculopathy. Long-term results]. / Discectomie cervicale antérieure avec ou sans greffe dans les conflits radiculaires. Résultats à long terme.

BACKGROUND AND PURPOSE: Anterior approach for cervical radiculopathy is a frequently performed operation in neurosurgery. The goal of this study is to evaluate the short and long-term results of anterior cervical discectomy with and without fusion. METHODS: Between 1984 and 1999, we operated on 101 patients presenting with cervical radiculopathy by an anterior approach. The operation consisted of one-level discectomy in 74 cases, two-level discectomy in 25 cases and three-level discectomy in 2 cases. Eighty-four out of 130 levels operated on were fused. Evaluation was done following a consultation with dynamic cervical X-rays and by telephone using a detailed questionnaire. Follow-up was obtained in 91 cases with a mean of 54 months in fused patients, and a mean of 45 months in the non-fused patients. RESULTS: Post-operative results were good in 95% in the 2 groups of patients. We encountered 8 complications, all in patients operated with bone graft placement. Five patients were reoperated on at an adjacent level, 4 being fused previously. CONCLUSIONS: The 2 techniques are comparable in term of goods results at short and long-term follow-up. Anterior discectomy without fusion is associated with less complications, less post-operative pain, and less operative time cost.

Seizure activity results in increased tyrosine phosphorylation of the N-methyl-D-aspartate receptor in the hippocampus.

Systemic administration of kainic acid (KA) induces status epilepticus (SE) that causes neurodegeneration and may subsequently lead to spontaneous recurrent seizures. We investigated the effects of KA-induced SE on tyrosine phosphorylation and solubility properties of the NMDA receptor. Following 1 h of SE, total protein tyrosine phosphorylation was elevated in both the hippocampus and frontal cortex relative to controls. Tyrosine phosphorylation of the NMDA receptor subunits NR2A and NR2B was also enhanced following SE. Animals that received KA but did not develop SE, did not exhibit increased tyrosine phosphorylation. SE resulted in a decrease in the solubility of NMDA receptor subunits and of PSD-95 in 1% deoxycholate. In contrast, the detergent solubility of AMPA and kainate receptors was not affected. These findings demonstrate that SE alters tyrosine phosphorylation of the NMDA receptor, and indicate that the interaction of the NMDA receptor with other components of the NMDA receptor complex are altered as a consequence of seizure activity.

Herbicide transport to surface waters at field and watershed scales in a Mediterranean vineyard area.

The contamination of soil and runoff water by two herbicides, diuron [N'-(3,4-dichlorphenyl)-N,N-dimethylurea] and simazine (6-chloro-N,N'-diethyl-1,3,5-triazine-2,4-diamine), were monitored on two fields, one no-till and one tilled. Experiments were carried out in a 91.4-ha watershed in southern France during the 1997 growing season in order to understand the patterns of pesticide transport from field to watershed. The persistence of the herbicides in soil was prolonged due to the climatic conditions. At the field scale, annual herbicide loads were due to overland flow and amounted to 65.6 and 6.3 g ha(-1) of diuron for the no-till and tilled field, respectively, and to 29.6 and 1.83 g ha(-1) of simazine. Maximum herbicide concentrations exceeded 580 microg L(-1) during the first storm event after application and decreased thereafter but remained for 8 mo above 0.1 microg L(-1). At the watershed outlet, estimated annual loads amounted to 4.12 g ha(-1) of diuron and 0.56 g ha(-1) of simazine. Among them, 96% of the losses in diuron and 83% of those in simazine were caused by the fast transmission through the network of ditches of the overland flow exiting the fields. For diuron, which was sprayed over most of the vineyards, its in-stream concentrations during storm flow were close to those at the outlet of the fields. The herbicide loads in baseflow were smaller than 0.2 g ha(-1). The patterns of the loads at the field and watershed scales suggested that a major part of the herbicides leaving the fields reinfiltrated to the ground water by seepage through the ditches, and was there degraded or adsorbed.

[Genetic factors related to intracranial arteriovenous malformations]. / Les facteurs génétiques associés aux malformations artério-veineuses cérébrales.

Genetic studies are interesting not only in the diagnosis and screening of new cases within a family harboring a particular disease, but also in understanding the underlying genetic and molecular factors related to that disease. Such studies revealed 3 categories of cerebral arteriovenous malformations in relationship to possible genetic factors. The first one concerns cerebral arteriovenous malformations in relationship to inherited diseases where a genetic support is clearly identified. Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) represents the most classical picture. The second category corresponds to familial cases of cerebral arteriovenous malformations were several members and relatives of the same family harboring the pathology without clear demonstration of any genetic basis. The third category includes cerebral arteriovenous malformations described in association with neurocutaneous disorders issued from maldevelopment events. Sturge-Weber disease and Wyburn-Mason syndrome best illustrate this category. A review of these categories will help in a better understanding of some genetic issues related to cerebral arteriovenous malformations.

[Hemorrhage after radiosurgery of cerebral arteriovenous malformations]. / Hémorragie après radiochirurgie des malformations artério-veineuses cérébrales.

BACKGROUND AND PURPOSE: Obliteration is progressive after radiosurgery of cerebral arteriovenous malformations. Thus the hemorrhage risk still remains until obliteration. Purposes of this study are to appreciate severity of post-radiosurgery hemorrhages, actuarial risk of hemorrhage and parameters associated with it. PATIENTS: and method. Over 705 patients treated, 46 (6.5%) had one or several hemorrhages. Clinical, anatomic, dosimetric parameters and obliteration rates before hemorrhage were studied. Then, actuarial risks per patient and per hemorrhage were calculated. Correlations between parameters and risk were searched by uni and multivariate analysis by drawing hemorrhage-free survival curves (limit-product Kaplan-Meier) and Cox model. RESULTS: Except one pure ventricular hemorrhage causing death of one patient, only parenchymal hemorrhages were associated with morbidity (80% of cases with 45% of permanent deficits). Overall mortality rate by hemorrhage was 6.5%. Overall morbidity rate was 34.8% and 13.6% for permanent deficit. Mean obliteration rate before hemorrhage was 25%. Actuarial hemorrhage rate were 2.98% per patient and 3.24% per hemorrhage. Actuarial rate per patient increased from 1.46% first year to 5.95% 4(th) year after radiosurgery. Parameters correlated with hemorrhage risk were in univariate analysis size (p=0.01), Spetzler and Martin's grade (p<0.001), dose to reference isodose (p=0.03), Dmin (p=0.08), intra or paranidal aneurysms (p<0.001), and recoverage (p<0.001). After multivariate analysis, only intra or paranidal aneurysms, recovering and Dmin were significantly associated with hemorrhage-free survival after RS. CONCLUSIONS: Post-radiosurgery hemorrhages are often sum of hemorrhage risk factors of the cerebral arteriovenous malformation and factors predicting low rate of obliteration. They can be in some cases foreseen but rarely avoided.

Subcranial fronto-orbito-nasal approach for ethmoidal cancers surgical techniques and results.

BACKGROUND: The authors report their experience with the subfronto-orbito-nasal approach (SFON) for the treatment of 30 patients suffering from ethmoidal cancers over the past 3 years. The advantages and pitfalls of this technique are described and compared with other classic approaches. METHODS: Among 156 patients suffering from ethmoidal cancers and treated between January 1984 and January 1998, 30 patients were operated on using the SFON approach during the past 3 years. There were 27 males and 3 females, ranging in age from 15 to 77 years. Histologic composition of the lesions was as follows: 15 adenocarcinomas, 6 esthesioneuroblastomas, 3 melanomas, 2 epidermoid carcinomas, 1 nondifferentiated carcinoma, 1 neuroendocrine carcinoma, 1 villous carcinoma, and 1 cystic adenoid carcinoma (cylindroma). According to the authors' classification, 7% were T1, 6% T2, 22% T3, 38.5% T4a, and 26.5% T4b. All patients were operated on through a SFON approach, followed by removal of the tumor and reconstruction of the skull base with a pericranial flap. RESULTS: Since the mean follow-up was of short duration (12 months, ranging from 3 to 29 months), significant carcinologic results could not be obtained. However, a detailed analysis of the surgical procedure was performed. No patient died or had major complications related to the SFON approach. One cerebrospinal fluid (CSF) fistula and four oculomotricity dysfunctions were observed. Definitive anosmia was reported in all cases. CONCLUSION: The advantages of the procedure include a wide exposure of the anterior skull base through a limited approach, the possibility of modifying the approach according to the size and location of the lesion, total resection of tumors, simplified skull base reconstruction technique, and reduction of postoperative confusion and hospital stay.