Does vertical incomitance predict the diplopia outcome in orbital fracture patients? A prospective study of 188 patients.

OBJECTIVE: To determine the predictive value of vertical incomitance for diplopia outcome in orbital fracture patients. PATIENTS AND METHODS: A prospective cohort study composed of patients with orbital fractures was designed. The predictor variable was vertical incomitance, and the primary outcome variable was diplopia. Incomitance was calculated in prism diopters (Δ) as the difference of the maximum absolute deviation between the upper and lower three gaze directions. Standard statistics for patient characteristics, the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables were computed. RESULTS: The sample was composed of 188 patients grouped as follows: non-operated (n = 124) and operated (n = 64). Fifty-one patients showed vertical incomitance of whom 10 (19.6%) had persistent diplopia at the 1-year follow-up. The mean incomitance was 9.6Δ in the diplopia group versus 2Δ in the non diplopia group (OR = 1.13; p < 0.001). There was a statistically significant association between vertical incomitance of >2Δ and persistent diplopia at 1 year after adjusting for the surgery variable (OR = 1.07; p < 0.04). CONCLUSION: The present study has demonstrated that in orbital fracture patients, vertical incomitance was associated with (1) persistence of long-term diplopia, (2) the decision to perform surgery, and (3) the severity of the fracture.

Early-onset or rapidly progressive scoliosis in children: check the eyes!

Horizontal gaze palsy with progressive scoliosis (HGPPS) is a rare autosomal recessive disorder characterized by the absence of conjugate horizontal eye movements, and progressive scoliosis developing in childhood and adolescence, caused by mutations in the ROBO3 gene which has an important role in axonal guidance and neuronal migration. We describe two female children aged 12 years and 18 months, with progressive scoliosis, in whom the neurological examination showed absent conjugate horizontal eye movements, but preserved vertical gaze and convergence. Cerebral Magnetic resonance imaging findings included pontine hypoplasia, absent facial colliculi, butterfly configuration of the medulla and a deep midline pontine cleft, while Diffusion tensor imaging (DTI) maps showed the absence of decussating ponto-cerebellar fibers and superior cerebellar peduncles. Somatosensory and motor evoked potential studies demonstrated ipsilateral sensory and motor responses. The diagnosis was confirmed by the identification of bi-allelic mutations in the ROBO3 gene.

Visual vertigo: an observational case series of eleven patients.

BACKGROUND: Dizziness is a common symptom which is frequently due to either peripheral or central vestibular dysfunction. However, some patients may lack typical signs suggesting a vestibular or cerebellar lesion and they mostly complain of vertigo or posture imbalance induced by visual stimulation. The symptoms immediately improve either on cessation of the visual input or upon closure of the eyes. Such a presentation is typical of visual vertigo. PATIENTS AND METHODS: From 1993 to 2003, 242 patients were examined for either "vertigo" or "dizziness". The diagnosis of visual vertigo was based on both history and clinical examination and was present in 11 patients. RESULTS: Visual vertigo was diagnosed in 11/242 patients (4.5 %). Age range was 31 - 77 years (mean 47 years) with a sex ratio of 8 females for 3 males. Neuro-ophthalmological examination was normal in all cases. CONCLUSIONS: Visual vertigo is not a rare condition but the disease is underdiagnosed. The symptoms result from a mismatch between vestibular, proprioceptive and visual inputs. Neuro-ophthalmological, neurological and neuro-otological examination are often normal or not relevant and the diagnosis is largely based on history. It is important to recognize this entity because the symptoms might improve if the patients are treated with psycho-motor rehabilitation.

First-line tuberculosis therapy and drug-resistant Mycobacterium tuberculosis in prisons.

BACKGROUND: We assessed a programme of tuberculosis control in a prison setting in Baku, Azerbaijan. The programme used first-line therapy and DOTS (directly observed treatment, short course). METHODS: 467 patients had sputum-positive tuberculosis. Their treatment regimens followed WHO guidelines, and they had regular clinical examinations and dietary supplements. Isolates were tested by standard methods for resistance to isoniazid, rifampicin, ethambutol, and streptomycin in three laboratories. Treatment success was defined as three consecutive negative sputum smears at end of treatment. Factors independently associated with treatment failure were estimated by logistic regression. FINDINGS: Drug-resistance data on admission were available for 131 patients. 55% of patients had strains of Mycobacterium tuberculosis resistant to two or more antibiotics. Mortality during treatment was 11%, and 13% of patients defaulted. Overall, treatment was successful in 54% of patients, and in 71% of those completing treatment. 104 patients completed a full treatment regimen and remained sputum-positive. Resistance to two or more antibiotics, a positive sputum result at the end of initial treatment, cavitary disease, and poor compliance were independently associated with treatment failure. INTERPRETATION: The effectiveness of a DOTS programme with first-line therapy fell short of the 85% target set by WHO. First-line therapy may not be sufficient in settings with a high degree of resistance to antibiotics.

Drug resistant tuberculosis in prisons in Azerbaijan: case study.

OBJECTIVES: To document the existence of drug resistance in a tuberculosis treatment programme that adheres strictly to the DOTS principles (directly observed treatment, short course) and to determine the extent of drug resistance in a prison setting in one of the republics of the former Soviet Union. DESIGN: Case study. SETTING: Central Penitentiary Hospital in Baku, the referral centre for tuberculosis patients from all prisons in Azerbaijan. SUBJECTS: Prisoners with tuberculosis: 28 selected patients not responding clinically or bacteriologically to the standard treatment (group 1) and 38 consecutive patients at admission to the programme (group 2). MAIN OUTCOME MEASURES: Drug resistance of Mycobacterium tuberculosis strains grown from sputum. RESULTS: All the non-responding patients (group 1) had strains resistant to at least one drug. 25 (89%) of the non-responding patients and nine (24%) of the consecutive patients had M tuberculosis strains resistant to both rifampicin and isoniazid. A further 17 patients in group 2 had strains resistant to one or more first line drugs. CONCLUSIONS: Drug resistant M tuberculosis strains are common in prisons in Azerbaijan. Tuberculosis problems tend to be worse in prisons, but prisoners and former prisoners may have an important role in the transmission of tuberculosis, particularly of drug resistant forms, in the community. National programmes to control tuberculosis will have to take into account and address the problems in prisons to ensure their success.

PIP: Tuberculosis is a significant health problem in Azerbaijan. In prisons, this problem is compounded by overcrowding, poor general health, a high representation of risk groups, late case finding, and incomplete treatments. The present study investigated the extent of drug resistance at the Central Penitentiary Hospital in Baku--the country's only treatment center for prisoners with tuberculosis. This International Committee of the Red Cross program, established in 1995, uses the directly observed treatment, short course (DOTS) strategy. Sputum samples were collected from two groups of prisoners: 1) 28 patients who failed to respond, clinically or bacteriologically, after a minimum of 8 weeks to the treatment regimen recommended by the World Health Organization and 2) 38 patients consecutively enrolled over a 4-week period from whom sputum was taken before the start of treatment. Mycobacterium tuberculosis was isolated from all 66 sputum specimens. In the first group, 25 strains (98%) were multidrug resistant (to rifampicin and isoniazid). Such resistance occurred in all new cases and 14 (82%) of the 17 failure or relapse cases. In the second group, 9 strains (24%) were multidrug resistant and only 12 (32%) were fully susceptible. This resistance was found in 3 strains (15%) among the 20 new cases and in 6 strains (33%) among the 18 cases of treatment failure or relapse. These findings suggest that prisoners may have an important future role in the transmission of tuberculosis, especially multidrug resistant forms, in the former Soviet Union.

[Efficacy of smoking prevention campaign in adolescents: critical review of the literature]. / Efficacité de la prévention du tabagisme chez les jeunes: revue critique de la littérature.

This review is intended to assist those interested in smoking prevention in young people in choosing the most efficient and cost-effective methods. The importance of a critical analysis of the abundant literature available on the topic before implementing a new programme is stressed. In view of the present knowledge, preventive methods should start at age 12 and extend up to age 18 through actualizing sessions. The most promising programme should include learning to resist to social pressures and a cognitive and developmental approach which anchor smoking prevention in the psychological evolution of the adolescent. Training of peers being disproportionate in regard to what can be expected from their intervention, one key element is the teacher's training in the technique of changing behaviour. Evaluation of methodology and of long term results should belong to any programme.

Domiciliary oxygen--by liquid or concentrator? Working Group on Oxygen Therapy of IUATLD.

A few hypoxaemic and even less non-hypoxaemic patients with chronic obstructive pulmonary disease (COPD) benefit from portable oxygen. For these few, selected by double-blind tests against compressed air, liquid oxygen would seem more convenient and efficient. The extra cost of treating all hypoxaemic COPD patients with liquid oxygen by displacing the oxygen concentrator is not justified on the basis of current knowledge. The application of differing oxygen delivery systems to COPD patients requires more evaluation. The selection of patients for long-term oxygen therapy (LTOT) still presents major difficulties, which reflects on the numbers of patients likely to benefit from portable oxygen. No studies have yet shown the benefit of LTOT to chronic respiratory failure in other disorders such as lung fibrosis. As the pathophysiology is quite different, extension of the use of LTOT and portable oxygen to non-COPD patients must be treated with great caution.

[Cheese-washer's disease. A current stable form of extrinsic allergic alveolitis in a rural setting]. / Maladie des laveurs de fromages. Une forme toujours actuelle d'alvéolite allergique extrinsèque en milieu rural.

Inhalation of organic particles (bacteria, fungi or animal proteins) by sensitized subjects is known to induce extrinsic allergic alveolitis (EAA). The most frequent type of EAA and the best known in rural environment is farmer's lung disease. Nevertheless a rarer form is also to be considered in rural environment: cheesewasher's disease. Here we report 4 cases of cheesewasher's disease, who all presented with relevant aspects of the disease: diversity of antigens involved, prophylaxis problems, severity of the disease, rapidity of onset, reversibility and importance of history in the diagnosis. Penicillium casei usually is the responsible antigen, and precipitating antibodies against these moulds, but against other moulds such as Aspergillus, Circinomucor circilloïdes, Fusarium as well, can be detected in the patient's serum. Thus, in a rural environment, a respiratory symptomatology suggestive of EAA should lead to thorough search for antigens and cheesewasher's disease should be considered. Among the many other diagnostic tests, precipitin determinations are cheap and non invasive and can be very useful in the diagnostic approach.

[Mechanical home ventilation: its organization in Switzerland and perspectives]. / Heimventilation: Organisation in der Schweiz und Aussichten.

Aware of the improvement of quality of life which home ventilation can bring to some patients with respiratory insufficiency, the Swiss Association against Tuberculosis and Lung Diseases (SATL) has organized this treatment for the country. Purchase and management of the apparatus are taken over by the Swiss Federation for Common Tasks of the Sickness Insurance, and the cantonal Leagues of the SATL will provide the home supervision. In order to limit this expensive treatment which may be heavy for patients and families, guidelines have been issued. They specify the indications, the prerequisites, the conditions for providing the apparatus, the home surveillance and the prospective evaluation. Presently home ventilation is estimated to be indicated in about 200 patients in Switzerland.

Spinal tuberculosis in a developed country. A review of 26 cases with special emphasis on abscesses and neurologic complications.

A retrospective study of 26 cases was analyzed to review the sometimes unfamiliar clinical appearance and outcome of Pott's disease. Swiss nationals (46%) were older than patients from Mediterranean or developing countries (mean age, 69 versus 29 years). The number of vertebrae initially involved was 2.2. Localization was lumbar in ten cases, thoracic and lumbar in two, and thoracic or cervical in 14. Abscesses were present in 15 (57%) subjects and appeared during treatment in 20% of these cases. They were twice as frequent in non-Swiss patients. Three patients had surgery because of progression of the abscess under treatment. Ten cases needed single or multiple aspirations. Three of six lumbar abscesses were initially visualized only by computed tomography. Neurologic complications occurred in 12 (46%) patients, 11 of whom had cervical or thoracic vertebrae involved. In four cases (33%), the neurologic deficit developed during the first two months of treatment. Three patients had laminectomies, two without any benefit. Outcome was favorable for 11 of 12 patients without any difference between conservative treatment and surgery. Neurologic symptoms are in most cases related to radicular and medullary inflammation, with arachnoiditis and without compression. The possible benefit of steroids seems promising enough to warrant further investigation.

[Intermittent mechanical ventilation as home care]. / Die intermittierende mechanische Ventilation als Heimbehandlung.

Nocturnal mechanical ventilation (NMV) is a promising technique increasing survival and improving the quality of life of myopathic and kyphoscoliotic patients. The indications for NMV must be careful and the patients strictly selected. NMV is rarely useful in patients with pulmonary diseases, like COPD or restrictive disorders. When a professional medical and paramedical support is locally available, NMV can be undertaken at home. Negative and positive pressure ventilation can be used for NMV. Actually, tracheostomy can be replaced very often by a new type of positive pressure ventilation via a nasal face mask. We present here our series of 11 patients submitted to NMV and describe carefully the problems and the results of a 5-years experience with NMV in Geneva.

[Use of precipitins in the diagnosis of bird fancier's lung: apropos of 2 cases]. / Utilité des précipitines dans le diagnostic de la maladie des oiseleurs: à propos de deux cas.

Bird breeder's disease is a frequent diagnosis among the forms of extrinsic allergic alveolitis seen in the urban environment. We report two illustrative cases and discuss the respective roles of broncho-alveolar lavage cells and precipitating antibodies against avian antigens in the diagnostic work-up and the pathogenesis of the disease. In 1988 we evaluated over 100 sera from all over Switzerland with clinical suspicion of bird breeder's disease. In this cohort preliminary results show sensitivity of 85% and specificity of 92% for the presence of precipitins against avian antigens in the diagnosis of bird breeder's disease. The results suggest that this non-invasive test deserves revaluation as a diagnostic tool in bird breeder's disease.

Insufficient oxygen concentration obtained at domiciliary controls of eighteen concentrators.

The oxygen concentration (O2%) produced by 12 type A concentrators, with a working time of 28-18,099 h, and 6 type B concentrators, with a working time of 0-3,033 h, was measured over a 12 month period in the user's home, at a flow rate of 2 l.min-1. One hundred and two measurements of O2% (mean 82.9), made at least once monthly by a visiting nurse, showed that type A concentrators were usually delivering less than 92% expected O2. Four concentrators were delivering less than 40% O2 after a working time of only 4,000 h. Sixty two measurements made by the manufacturer confirmed these findings (mean 86.8). The 18 measurements performed by the nurse on the type B concentrators showed expected O2% values (mean 93.1). Our study demonstrates the necessity of regular clinical and technical surveillance, at the user's home, during long-term domiciliary oxygen therapy and the need for the manufacturer to incorporate an alarm system monitoring the O2% into oxygen concentrators.

[Long-term oxygen therapy in Switzerland]. / Oxygénothérapie au long cours en Suisse.

In Switzerland long-term oxygen treatment is chiefly performed with oxygen concentrators provided by the Swiss Association against Tuberculosis and Pulmonary Diseases through its cantonal leagues. Prescription and supervision are carried out according to the Association's guidelines. To assess compliance with these guidelines, the prescription forms of 447 patients (1981-1985) were analyzed concerning diagnosis, lung function and blood gases. Of the 398 diagnoses mentioned, 73% were COPD, 16% restrictive syndromes and 11% cardiovascular diseases (including cor pulmonale). Lung function results were given in 81% of the total but in only 73% and 67% of two non-COPD groups. Blood gases at ambiant air were given in 92% and under oxygen at the flow chosen for treatment in 72%. At ambiant air the PaO2 was greater than 7.33 kPa in 21% (8.18 +/- 0.85 kPa) and less than 5.33 kPa in 19% (4.86 +/- 0.33 kPa). - These results show that prescription criteria are not always correctly met, especially in non-COPD patients. They also suggest that long-term oxygen treatment is often prescribed mainly on the basis of clinical criteria, despite a PaO2 which would not require it, and also in unstable state, as indicated by the high proportion of cases with very low PaO2. The rationale behind the guidelines should be explained more clearly to prescribing doctors, in order to confine this difficult and costly treatment to patients who really need it.

[Humidifier disease. Role of endotoxins and precipitating antibodies]. / Maladie des humidificateurs. Rôle des endotoxines et des anticorps précipitants.

A case of an acute form of humidifier disease secondary to the inhalation of endotoxins (humidifier fever) is reported. The respective roles of endotoxins and precipitating antibodies in the diagnosis of the two forms of humidifier disease are discussed. This appears to be an important epidemiological problem in Switzerland, since the authors see approximately one case a month. With respect to treatment, preventive measures are necessary and usually sufficient.

[Pleuropulmonary infection caused by Mycobacterium smegmatis. Case description and literature review]. / Infection pleuro-pulmonaire à Mycobacterium smegmatis. Description d'un cas et revue de la littérature.

The case is described of a patient with a tracheostomy subsequent to laryngectomy for carcinoma, who developed a pleuro-pulmonary infection due to Mycobacterium smegmatis complicating lipoid pneumonia after prolonged instillation of gomenol oil into the tracheostoma. The adjuvant property of lipids for the development of respiratory infections due to M. smegmatis and other rapid-growing mycobacteria is discussed in the light of the cases described in the literature.