Complication rate, outcome, and risk factors associated with surgical repair of fractures of the lateral aspect of the humeral condyle in dogs.

OBJECTIVE: To determine outcome, report complications, and risk factors for complications associated with the surgical treatment of fractures of the lateral aspect of the humeral condyle (FLHC) in dogs. STUDY DESIGN: Fifty dogs with FLHC that had been repaired surgically were included in this retrospective case series. METHODS: The medical records and radiographs from 50 dogs with FLHC from 1990--2006 were analyzed. RESULTS: The complication rate was 30%. For every 30-minute increase in surgical time the odds of a complication increased by 2.00 (95% CI: 1.06, 3.77). For every 10 degrees increase in the angle between the transcondylar screw and a line between the epicondyles viewed on a craniocaudal radiograph there was a 4.82 (95% CI: 1.23, 18.86) greater odds of an intracondylar fracture gap appearing on postoperative radiographs. When an intracondylar fracture gap was present after surgery there was a 25% long-term radiographic outcome failure rate, whereas there was a 0% radiographic failure rate in the dogs in which an intracondylar fracture gap was not present. In conclusion, transcondylar screw placement parallel to the epicondylar line should be attempted for the repair of FLHC. An increase in surgical time leads to an increase in postoperative complication rate. The presence of an intracondylar fracture gap may be associated with fracture failure. CLINICAL SIGNIFICANCE: Screw angulation predisposed to postoperative intracondylar fracture gap which in turn may be associated with higher fracture fixation failure rate. The dogs that had prolonged surgical times had an increased complication rate.

A critical role for Dnmt1 and DNA methylation in T cell development, function, and survival.

The role of DNA methylation and of the maintenance DNA methyltransferase Dnmt1 in the epigenetic regulation of developmental stage- and cell lineage-specific gene expression in vivo is uncertain. This is addressed here through the generation of mice in which Dnmt1 was inactivated by Cre/loxP-mediated deletion at sequential stages of T cell development. Deletion of Dnmt1 in early double-negative thymocytes led to impaired survival of TCRalphabeta(+) cells and the generation of atypical CD8(+)TCRgammadelta(+) cells. Deletion of Dnmt1 in double-positive thymocytes impaired activation-induced proliferation but differentially enhanced cytokine mRNA expression by naive peripheral T cells. We conclude that Dnmt1 and DNA methylation are required for the proper expression of certain genes that define fate and determine function in T cells.

Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population.

OBJECTIVE: Our goal was to compare the prevalence of mental illness and its impact on functional status in an indigent uninsured primary care population with a general primary care sample. We also hoped to assess patient preferences about mental health and medical service integration. STUDY DESIGN: We compared a survey of consecutive primary care adults in April and May 1999 with a 1997-98 survey of 3000 general population primary care patients. Both studies used the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and the 20-question Medical Outcomes Study Short Form. POPULATION: The patients were from a private nonprofit primary care clinic in Grand Junction, Colorado, that served only low-income uninsured people. We approached a total of 589 consecutive patients and enrolled 500 of them. MAIN OUTCOME MEASURE: The main outcomes were the prevalence of psychiatric illnesses and the relationship with functional impairment. We compared our findings with a more generalizable primary care population. RESULTS: This low-income uninsured population had a higher prevalence of 1 or more psychiatric disorders (51% vs 28%): mood disorders (33% vs 16%), anxiety disorders (36% vs 11%), probable alcohol abuse (17% vs 7%), and eating disorders (10% vs 7%). Having psychiatric disorders was associated with lower functional status and more disability days compared with not having mental illness. Patients indicated a preference for mental health providers and medical providers to communicate about their care. CONCLUSIONS: This low-income uninsured primary care population has an extremely high prevalence of mental disorders with impaired function. It may be important in low-income primary care settings to include collaborative care designs to effectively treat common mental disorders, improve functional status, and enhance patient self-care.

Stabilization of eyelid height after aponeurotic ptosis repair.

OBJECTIVE: To develop guidelines for revision of ptosis surgery in the early postoperative period by establishing what percentage of eyelids after anterior levator advancement have reached their final height by the first postoperative week. DESIGN: Prospective noncomparative case series. PARTICIPANTS: An analysis was performed on 164 eyelids in 97 patients with involutional aponeurotic ptosis. INTERVENTION: Anterior levator advancement was performed on each of these 164 eyelids. Exclusion criterion consisted of a history or evidence of neurologic or muscular disease, preceding trauma, an anophthalmic socket, or prior eyelid surgery. MAIN OUTCOME MEASURES: The marginal reflex distance, eyelid excursion, and degree of swelling were recorded perioperatively; additionally, photographs were obtained before surgery and at 1 and 6 weeks after surgery. RESULTS: At 1 week after surgery, only 40% of eyelids had reached their final height; 52% continued to rise a mean of 1.1 mm. The percentage of eyelids continuing to rise after the first postoperative week varied with the amount of swelling present at 1 week, although a direct correlation did not exist (Pearson correlation, 0.22; P < 0.26). Although this increase ranged from 0.5 to 3.0 mm for 71% of eyelids, the subsequent increase was 1 mm or less. Maximal eyelid height was achieved almost universally by 6 weeks, after which 18% of eyelids subsequently dropped a mean of 0.8 mm. CONCLUSIONS: Based on this study, the authors suggest revision at 1 week after anterior levator advancements in which minimal-to-moderate eyelid swelling exists for contour abnormalities, if the eyelid height is 0.5 mm or more above or more than 1.0 mm below the target height, or if asymmetry between the eyelids is 1.0 mm or more. The authors do not advise early revision for patients with excessive swelling still present 1 week after surgery.

Vascular anatomy of the lacrimal gland.

This study was undertaken to establish the detailed vascular architecture of the lacrimal gland. The common carotid arteries of seven fresh human cadaver heads were injected with a compound consisting of a partially polymerized monomer, to which a catalyst and promoter were added to cause hardening. The soft tissue was then digested, using 40% potassium hydroxide, to obtain detailed casts of the lacrimal artery. The authors describe the anatomy of 14 cadaver lacrimal arteries from their entrance into the lacrimal gland to their terminal conjunctival branches. Consistent vascular patterns within the lacrimal gland were observed. A better understanding of the vascular anatomy of the lacrimal gland should allow modification of surgical techniques to reduce bleeding during biopsy or excision of the lacrimal gland.

The anatomy of the common canaliculus.

BACKGROUND: The functional valve between the common canaliculus and the lacrimal sac has traditionally been attributed to the valve of Rosenmüller, although this anatomical structure has never been rigorously documented. OBJECTIVE: To define the anatomy of the canaliculus-sac junction. METHODS: Twelve rigid plastic casts of the lacrimal outflow systems were obtained in human cadaver specimens using a well-known biologic casting material (partially polkymerized monomer to which a catalyst and promoter were added). RESULTS: A consistent pattern of angulation within the canalicular system was documented. The canaliculi bend posteriorly behind the medial canthal tendon, then anteriorly to enter the sac at an acute mean angle of 58 degrees to the lateral wall of the sac. CONCLUSIONS: This consistent configuration at the canaliculus-sac junction has not been previously described and may contribute to the 1-way valve phenomenon seen in some lacrimal disorders.

Measurement of the resistance to fluid flow within the lacrimal outflow system.

BACKGROUND: Although the presence of complete obstruction within the human lacrimal drainage system can be easily determined with diagnostic techniques currently available, it is not possible to quantitate degrees of partial obstruction. The authors have developed a new instrument that directly measures pressures associated with fluid flow, allowing the calculation (pressure : flow) of resistance within the tear drainage system. The authors believe that the ability to measure the degree of partial lacrimal stenosis quantitatively will be clinically useful, allowing the diagnosis of lacrimal disease before complete obstruction. Of course, it is first necessary to establish normal values, which was the goal of the study. METHODS: A constant flow rate of distilled water was irrigated into the lacrimal system through the lower canaliculus, and pressure was measured continuously. Resistance then was calculated as the differential of pressure to flow rate (pressure : flow). In the first stage of a two-part study the authors determined the resistance to fluid flow in 43 tear ducts of 24 healthy patients. In this group, the resistance within the entire lacrimal system was obtained. In the second stage of this study, the authors measured the resistance in 28 tear ducts of 26 patients after successful lacrimal bypass surgery (dacryocystorhinostomy). Because dacryocystorhinostomy byasses the lower drainage system (sac and nasolacrimal duct), the resistance measured in this group of patients was determined only by the upper (canalicular) system. RESULTS: The mean resistance within the normal lacrimal system is 49.5 +/- 17.0 mmHg.seconds/ml. Just more than half of the resistance, 26.8 +/- 13.1 mmHg.seconds/ ml (54%), comes from the canaliculi, leaving 22.7 mmHg.seconds/ml (46%) attributable to the lower system. The authors comment on comparisons between these values and theoretical values calculated using information on average dimensions obtained from casts of the lacrimal drainage system. CONCLUSION: The authors have developed a new instrument to measure the resistance to fluid flow within the human lacrimal outflow system, and resistance values in control subjects have been documented.

Repair of upper eyelid retraction: a comparison between adjustable and non-adjustable sutures.

BACKGROUND: The challenge with the surgical repair of upper eyelid retraction is to obtain a more predictable and satisfactory postoperative eyelid contour and height, and to minimise the need for further surgery. METHODS: A retrospective analysis was performed on all patients treated surgically for eyelid retraction at Moorfields Eye Hospital over a 13 year period. RESULTS: In this study good postoperative results were obtained in 10 of 13 (77%) eyelids using adjustable sutures, compared with 56 of 148 (38%) eyelids using non-adjustable sutures (p < 0.01). With non-adjustable sutures, good results were achieved more often for non-thyroid compared with thyroid related eyelid retraction (26/55 versus 31/93 eyelids respectively, p < 0.05). Previous eyelid surgery did not affect outcome. CONCLUSION: We recommend the use of adjustable sutures for the repair of upper eyelid retraction, particularly in patients with thyroid disease.

Orbital expansion of the congenitally anophthalmic socket.

BACKGROUND: Congenital anophthalmos is a rare condition in which intervention at an early age can stimulate orbital expansion and maximise facial symmetry. Much is still unknown, however, regarding the degree of soft tissue and bony orbital growth achieved using the orbital expanders presently available. METHODS: A retrospective review of 59 congenitally anophthalmic orbits in 42 patients was carried out. RESULTS: The soft tissue and bony orbital expansion achieved using serial solid shapes is reported, and experience with hydrophilic expanders and inflatable silicone expanders is reviewed. CONCLUSION: Although serially fitted solid shapes in the orbit lead to increased expansion of orbital soft tissue and bone compared with no orbital implant, further orbital tissue enlargement is required. The inflatable silicone expander may allow more rapid and extensive orbital tissue expansion, but design changes are needed to achieve this.

The consumer's role in quality: partnering for quality outcomes.

Partnering with the patient in the planning and delivery of care to achieve high-quality outcomes is a goal shared by health care providers. The achievement of a full partnership with the patient often varies based on the communication skills of individual nurses. To provide more consistency, Patient Standards of Care (SOCs) were created that are written from the patients' viewpoint in lay terms and are condition-specific. The content includes commitments of the health care team, patient care issues and concerns, what the team will do, what the patient can do, and outcome expectations. The end result is to promote the patients' engagement in their own care through the sharing of accountabilities for desired outcomes.

Vascular anatomy of the eyelids.

PURPOSE: The eyelids have a rich vascular supply, and bleeding may compromise both surgical technique and postoperative results. Generally, it is known that the eyelids contain a marginal and peripheral arcade, but detailed anatomic information is not available. This study therefore was undertaken to determine the detailed anatomy of eyelid vascularity. METHOD: The common carotid arteries of six fresh cadaver heads were injected with a compound consisting of a partially polymerized monomer, to which a catalyst and promoter were added to cause hardening. The soft tissue was then digested, using 40% potassium hydroxide, to obtain detailed casts of the eyelid arteries, arterioles, and capillaries. RESULTS: The authors describe the eyelid vascularity and anastomotic network with average distance measurements from clinically relevant soft tissue landmarks in the 12 cadaver eyelids. CONCLUSIONS: Consistent patterns of eyelid vascularity were observed. A better understanding of the eyelid vascularity should allow modification of surgical techniques and reduce postoperative complications after eyelid surgery.

Relapsing polychondritis, another cause for a "salmon patch".

We present the case of a patient with long-standing relapsing polychondritis and, first, an orbital mass and, then, a "salmon patch" conjunctival mass. The histologic pathologic findings were similar on both occasions, showing an inflammatory process with reactive lymphoid hyperplasia. In both situations, the masses responded to a short course of systemic corticosteroids. Although ocular inflammatory changes from relapsing polychondritis have been well described, to our knowledge, there have been no previous reports of conjunctival changes in the form of a salmon patch lesion, as described here. Relapsing polychondritis may be added to the differential diagnosis of a conjunctival salmon patch lesion.

Scleral melt after cryotherapy for conjunctival melanoma.

BACKGROUND: The authors report a patient with a cryotherapy-induced scleral melt after combined excision and cryotherapy of a conjunctival melanoma arising within primary acquired melanosis with atypia. FINDINGS: In a 65-year-old white man, a severe scleral melt developed within 1 month of complete excision of a superficial conjunctival melanoma combined with double-freeze-thaw nitrous oxide cryotherapy to the scleral bed and surrounding conjunctival margins. Ultrasound biomicroscopy showed the degree of scleral thinning. CONCLUSIONS: Although many complications associated with cryotherapy have been described in the literature, there are no reports of a scleral melt. Scleral melt is a potential complication of cryotherapy that can occur despite taking precautions and should be monitored in the first few weeks after cryotherapy to the scleral bed of excised conjunctival tumors.

Corneal diameter, axial length, and intraocular pressure in premature infants.

PURPOSE: Seventy premature infants 25 to 37 weeks' postconceptional age were examined during their first week of life to determine the correlation of corneal diameter, axial length, and intraocular pressure with gestational age and birth weight. METHODS: Corneal diameter measurement was determined with corneal templates, total axial length with standardized A-scan ultrasound, and intraocular pressure with a Tonopen II tonometer. RESULTS: Corneal diameter and total axial length showed parallel linear increases from 6.2 mm to 9.0 mm and 12.6 mm to 16.2 mm, respectively; however, no significant correlation was found between intraocular pressure and gestational age or birth weight. The mean intraocular pressure was 10.3 mmHg (standard deviation, 3.5). CONCLUSION: Normative values are established for corneal diameter and total axial length as they relate to birth weight and gestational age, and a mean and standard deviation for intraocular pressure in the premature newborn. These values will aid the ophthalmologist in assessing ocular dimensions in premature infants.

Screening of hearing impairment in the newborn using the auditory response cradle.

The Auditory Response Cradle (ARC) is a fully automated microprocessor controlled machine that was designed for the hearing screening of full term neonates. In order to evaluate the ARC, 6000 babies were screened at a district maternity hospital over a period of three years. Every infant subsequently entered a three year follow up programme. One hundred and two babies (1.7%) failed the ARC screen (that is, they failed two ARC tests) and 20 of these were found to have some hearing impairment: in 10 it was severe (80-90 dBHL), in seven moderate (45-60 dBHL), and in three it was mild to moderate (less than 45 dBHL). In addition, of the 20 babies who failed a first test and were discharged before a second could be performed, two were confirmed to have a severe hearing loss; 79 infants failing the screen were cleared on further testing, giving the ARC a false positive rate of 1.3%. On following up all 6000 infants for three years, seven children who passed the neonatal screen were subsequently found to have a hearing loss. For two babies the aetiology was unknown but for five the hearing impairment was either due to a hereditary progressive loss or definite postnatal factors. Progressive and acquired hearing losses cannot be detected at a neonatal screen and this emphasises the need for follow up screens at other stages in the child's life. In this long term study the ARC has been found to have a high detection rate for severe hearing loss and confirms the practical possibility of using a behavioural technique for the universal screening of hearing in neonates.