Pseudonystagmus in trochlear nerve palsy.

We present the case report of a patient who presented with intermittent diplopia and left hypertropia associated with an apparent left superior oblique palsy. After dissociation with cover testing, he showed conjugate rhythmic vertical eye movements present in all gazes, thought to represent rapid rhythmically alternating fixation. The vertical rhythmic movement resolved after strabismus surgery.

Near-infrared transmitting occlusive intraocular lens implantation for intractable diplopia: Report of two cases.

OBJECTIVE: The objective of this article is to report two cases of black occlusive intraocular lens and implantation for treating intractable diplopia. CASE DESCRIPTIONS: Two patients with intractable diplopia after orbitofacial, trauma, and surgical removal of pituitary adenoma failed to conservative management. After uneventful cataract, phacoemulsification, a black intraocular lens was implanted in every case. In both cases, a complete degree of satisfaction was achieved, with no symptoms of diplopia, and no complications have been observed in their follow-up. The use of optical coherence tomography has been possible in both cases to assess the macula and optic nerve, since a fundoscopy is not possible in such cases. CONCLUSION: Implantation of a near-infrared transmitting occlusive intraocular lens for treating intractable diplopia provided a complete resolution of symptoms without eliminating the possibility of examining macula and optic nerve using optical coherence tomography.

Frontalis Muscle Flap Versus Maximal Anterior Levator Resection as First Option for Patients With Severe Congenital Ptosis.

PURPOSE: To compare 2 surgical techniques (frontalis flap versus maximal anterior levator resection) as first surgical options for the treatment of congenital ptosis with poor levator function in patients younger than 2 years of age with a follow up of 10 years. METHODS: A retrospective study of 58 patients (71 eyelids) with severe ptosis and poor levator function who underwent frontalis muscle flap (FMF = 47) or maximal anterior levator resection (ALR = 24) for correction of their ptosis. Eyelid measurements were taken at baseline, 1, 5, and 10 years after surgery. The presence of complications, need for reoperations, and palpebral contour were evaluated. RESULTS: Most patients in both groups required only one surgical procedure with a stable average margin-reflex distance 1 over the 10-year follow-up period in both groups, with no statistically significant difference between the 2 techniques in achieving an adequate palpebral height after one single procedure. Eleven eyelids treated with FMF (23%) and 12 treated with ALR (50%) needed a reoperation, with a statistically significant difference between the 2 techniques. Five ALR patients (21%) and 6 FMF patients (13%) had alterations of eyelid contour. Pop-eyelid and eyelash ptosis were observed in 8% of patients operated with FMF. CONCLUSION: Good functional and aesthetic results were obtained with both surgical techniques. FMF required fewer reoperations compared with maximal ALR, offering a better long-term result without residual ptosis.

Visual field defects due to optic disk drusen in children.

BACKGROUND: Optic nerve head drusen (ONHD) are deposits due to abnormalities in axonal metabolism and degeneration. Studies so far have focused on adults. Our aim was to study the effect of ONHD on visual function as well as optic nerve head structure using optical coherence tomography (OCT) in children. METHODS: Subjects younger than 18 years of age with ONHD and who had a reliable visual field defect in at least one eye due to ONHD were considered for inclusion. All subjects underwent an extensive ophthalmic examination including best-corrected visual acuity (BCVA), funduscopy, and SITA 24-2 standard automated perimetry. OCT scanning was performed using Cirrus-HD Model 4000. Retinal nerve fiber layer (RNFL) thickness data were compared with a group of age-matched healthy children. RESULTS: Fifteen children were included, with a mean age of 13 years (range 7 to 17 years). BCVA was 1.0 in all eyes, except in a child with concomitant esotropia. ONHD were bilateral in 13 children. Among the 28 eyes with ONHD, 12 (43%) were classified as type 1 (buried), eight (29%) as type 2 (ringed) and eight (29%) as type 3 (superficial). All children had a visual field defect in at least one eye, according to the inclusion criteria; however, two eyes (7%) had no defect in spite of the presence of ONHD. Five eyes showed an isolated enlarged blind spot (18%), 15 cases showed a nasal defect (54%), and six eyes showed a constricted visual field (21%). RNFL thickness was higher in type 1 and 2 ONHD than in the control group, although these differences were only significant for the average, superior, and inferior quadrant thicknesses in type 1 and the inferior quadrant in type 2. RNFL thickness was lower in type 3 ONHD than in the control group, although these differences were only significant for the average, superior, and nasal quadrant thicknesses. CONCLUSIONS: ONHD may lead to the development of visual field defects, even in children. In initial stages, ONHD produce an increase in RNFL thickness as measured with OCT. As drusen develop and become superficial, the RNFL thickness decreases. The temporal quadrant is often undamaged, probably reflecting the preservation of central visual acuity.

Mil trasplantes hepáticos en el Hospital Clínic i Provincial de Barcelona / One thousand liver transplants in Hospital Clinic i Provincial de Barcelona (Spain)

Objetivo. El objetivo de este trabajo fue estudiar una serie de 1.000 trasplantes hepáticos (TH) y evaluar los cambios experimentados en el tiempo de los donantes y receptores utilizados, así como los resultados obtenidos. Material y método. Con el fin de evaluar las diferencias entre el inicio y la actualidad, se compararon los primeros 100 trasplantes (entre junio 1988 y junio de 1990) con los últimos 200 trasplantes (entre enero de 2001 y junio de 2003). Resultados. Destaca el aumento en la edad de los donantes (23 ± 10 frente a 45 ± 19), el cambio en la etiología de la muerte cerebral (traumatismo craneoencefálico: el 78 frente al 23,5%; accidente cerebrovascular: el 17 frente al 52,5%) y el mayor porcentaje de donantes procedentes de programas alternativos a la donación estándar de cadáver en el segundo período (donante vivo: 12,5%). Asimismo, el inicio de la técnica de Piggy-back y la realización de la anastomosis biliar sin tutorización. La supervivencia actuarial del paciente al año fue superior en el segundo período con respecto al primero (el 84 frente al 91,3%).El porcentaje de retrasplante total de toda la serie fue del 9,5%. La supervivencia actuarial del retrasplante fue a 1, 5 y 10 años del 67,7, 51,3 y 39,4%, respectivamente. Conclusión. La falta de donantes y el aumento de la lista de espera han hecho que aceptemos donantes de peor calidad, receptores en situaciones más críticas y que iniciemos programas alternativos e innovadores. Pese a ello, no se han alterado los buenos resultados alcanzados, debido a una mejoría del manejo del paciente antes, durante y después del trasplante (AU)

The aim of this study was to evaluate a consecutive series of 1000 liver transplants performed in our institution and to evaluate changes over time in donors and recipients, as well as results. Material and method. To clearly evaluate the differences between the initial transplantation period and the present period, the first 100 consecutive liver transplantations performed (June 1988-June 1990) and the last 200 consecutive liver transplantations performed (January 2001-June 2003) were compared. Results. Donor age increased (23±10 vs. 45±19), the etiology of brain death changed (severe head injury: 78% vs. 23.5%; stroke: 17% vs. 52.5%) and the percentage of donors from alternative methods to cadaveric donors increased (living donors: 12.5%) in the second period. Regarding recipients, the piggy-back technique and biliary anastomosis without T-tube were introduced in the second period. Actuarial 1-year survival was higher in the second period than in the first (84% vs. 91.3%). The need for retrasplantation in the entire series was 9.5%, with actuarial survival at 1, 5 and 10 years of 67.7%, 51.3% and 39.4%, respectively. Conclusion. Because of the lack of donors and the greater number of patients on the waiting list, poorer quality donors and more critical recipients have been accepted and alternative and innovative programs have been started. Nevertheless, due to improvement in patient management before, during and after transplantation, the previous good results have been maintained (AU)

[One thousand liver transplants. Hospital Clinic i Provincial de Barcelona (Spain)]. / Mil trasplantes hepáticos en el Hospital Clínic i Provincial de Barcelona.

UNLABELLED: The aim of this study was to evaluate a consecutive series of 1000 liver transplants performed in our institution and to evaluate changes over time in donors and recipients, as well as results. MATERIAL AND METHOD: To clearly evaluate the differences between the initial transplantation period and the present period, the first 100 consecutive liver transplantations performed (June 1988-June 1990) and the last 200 consecutive liver transplantations performed (January 2001-June 2003) were compared. RESULTS: Donor age increased (23+/-10 vs. 45+/-19), the etiology of brain death changed (severe head injury: 78% vs. 23.5%; stroke: 17% vs. 52.5%) and the percentage of donors from alternative methods to cadaveric donors increased (living donors: 12.5%) in the second period. Regarding recipients, the piggy-back technique and biliary anastomosis without T-tube were introduced in the second period. Actuarial 1-year survival was higher in the second period than in the first (84% vs. 91.3%). The need for retrasplantation in the entire series was 9.5%, with actuarial survival at 1, 5 and 10 years of 67.7%, 51.3% and 39.4%, respectively. CONCLUSION: Because of the lack of donors and the greater number of patients on the waiting list, poorer quality donors and more critical recipients have been accepted and alternative and innovative programs have been started. Nevertheless, due to improvement in patient management before, during and after transplantation, the previous good results have been maintained.

Small cell melanoma and ulceration as predictors of positive sentinel lymph node in malignant melanoma patients.

Malignant melanoma (MM) early lymph node (LN) metastasis usually appears first in the sentinel LN (SLN). Breslow thickness is the main factor considered in the selection of patients to be submitted to SLN biopsy. The present study aimed to describe other independent prognostic factors useful in SLN candidate selection. During one year, 94 MM patients (90 primary cutaneous MM with Breslow thickness > or = 0.76 mm, and four cutaneous relapses), were submitted to SLN biopsy in the Melanoma Unit at the Hospital Clinic, Barcelona, Spain. The prognostic factors studied were: Breslow thickness, Clark's level of invasion, mitotic rate, cellular type (small, epithelioid, fusocellular, sarcomatoid), vertical growth phase, regression > 50%, severe vascularization, infiltrate (lymphocytic, plasmocytic), ulceration, neurotropism, intravascular/intraneural invasion, protein p16 expression and recurrence. Nineteen SLN (20.2%) were positive and 75 (79.8%) negative. No positive SLN occurred in MM with Breslow thickness < or = 1.0 mm. Breslow thickness > or = 2 mm (P = 0.005), severe vascularization (P = 0.005), small cell (P = 0.000) and ulceration (P = 0.005) were significant prognostic factors by univariate analysis. Small cell (P = 0.008) and ulceration (P = 0.05) were also significant prognostic factors in a multivariate analysis. The probability of finding a positive SLN for small cell was 56.9% [95% confidence interval (CI), 26.8-82.6%]. The probability of positive SLN for ulceration was 35.5% (95% CI, 14.2-64.7%). For small cell and ulceration together the probability increased to 86.3% (95% CI, 54.3-97.1%). The results of this study corroborated ulceration as a prognostic factor for SLN candidate selection and for the first time we have described small cell melanoma morphology as a significant factor associated with positive SLN.

Abdominal drainage after liver resection for hepatocellular carcinoma in cirrhotic patients: a randomized controlled study.

BACKGROUND/AIMS: The use of drainage after liver resection remains controversial. Data of the usefulness of drains in cirrhotic patients undergoing surgical resection are scarce. The objective of our study is to assess the usefulness of intra-abdominal drainage after liver resection for hepatocellular carcinoma in cirrhotic patients. METHODOLOGY: We performed a randomized controlled trial to assess the benefits of abdominal drainage after resection of hepatocellular carcinoma in cirrhotic patients. The main end point was to compare postoperative complications and hospital stay in both groups. RESULTS: Abdominal drainage decreased ascites leakage and significantly reduced hospital stay in comparison to the non-drainage group. In addition, local complications were less frequent in the drainage group. Postoperative ascites leakage significantly complicated patients with clinically relevant portal hypertension. CONCLUSIONS: Intra-abdominal closed drainage is advisable in cirrhotic patients undergoing liver resection for hepatocellular carcinoma, mainly if presenting preoperative portal hypertension.

Psychosocial adjustment to orthotopic liver transplantation in 266 recipients.

Although the survival rate of patients undergoing orthotopic liver transplantation (OLT) is highly satisfactory, one of the most important objectives for liver transplantation teams at the present time is to achieve the best possible quality of life and psychosocial functioning for these patients after transplantation. We present the preliminary results of a study designed to determine which domains of psychosocial functioning are most affected in liver transplant recipients, and to examine the factors associated with poorer adjustment after OLT, using a utility-based standardized measure. Patients who had undergone liver transplant more than 12 months previously were eligible. They were administered the Psychosocial Adjustment to Illness Scale (PAIS), and they provided the answers themselves. Multivariate regression models showed that attitudes toward health care were poorer in women (beta = 0.916, P <.001), in patients who were employed at the moment of transplantation (beta = 0.530, P =.032), and in patients of lower social class (beta = 0.722, P =.026) than in men, unemployed patients, and patients of higher social class. Sexual functioning was worse in women (beta = 0.907, P =.001) and older patients (beta = 0.999, P <.001) than in men or younger patients. Psychological distress was higher in women (beta = 0.981, P =.001) than in men, and lower in currently employed patients (beta = -0.937, P =.001) than in the unemployed. Only gender remained significantly associated with the total PAIS score (beta = 0.969, P <.001), with women showing a poorer overall psychosocial adjustment to OLT. In conclusion, there seems to be no doubt that liver transplantation improves quality of life, but special attention should be paid to female recipients, who seem to have more difficulty than their male counterparts in adjusting to the psychosocial consequences of the procedure.

Applicability of liver transplantation in Catalonia at the end of the millennium. A prospective study of adult patient selection for liver transplantation.

We prospectively studied the global applicability of liver transplantation in Catalonia, a region with a high rate of organ donation. We followed 232 adult patients assessed as possible candidates for liver transplantation over 12 months in the three hospitals that perform the procedure in this region. The liver disease leading to patient assessment was cirrhosis in most cases, alone (159 patients) or associated with hepatocellular carcinoma (57 patients). After being assessed, 150 patients (65%) were accepted for transplantation and included on the waiting list, and 82 (32%) were excluded. Death during the period of assessment, advanced tumoral disease, early stage of liver disease, and extrahepatic co-morbidities were the most important reasons for exclusion. The median time of assessment of patients accepted for transplantation was 40 days. Of the 150 patients included on the waiting list, 131 (87%) received transplants, 17 (11%) were removed from the list, and two were still waiting for transplantation at the end of the follow-up period. Death and tumor progression were the most important reasons for patients' removal from the waiting list. The median time on the waiting list was 59 days. In conclusion, among liver-transplant candidates the overall applicability of this therapy in Catalonia was relatively low (131 out of 232 transplant candidates finally underwent transplantation, 56%), and inadequate liver-transplant indications and death or tumor progression during the period of assessment or while the patient was on the waiting list were the most frequent reasons why liver transplantations did not proceed.

Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial.

BACKGROUND: Although early reports on laparoscopy-assisted colectomy (LAC) in patients with colon cancer suggested that it reduces perioperative morbidity, its influence on long-term results is unknown. Our study aimed to compare efficacy of LAC and open colectomy (OC) for treatment of non-metastatic colon cancer in terms of tumour recurrence and survival. METHODS: From November, 1993, to July, 1998, all patients with adenocarcinoma of the colon were assessed for entry in this randomised trial. Adjuvant therapy and postoperative follow-up were the same in both groups. The main endpoint was cancer-related survival. Data were analysed according to the intention-to-treat principle. FINDINGS: 219 patients took part in the study (111 LAC group, 108 OC group). Patients in the LAC group recovered faster than those in the OC group, with shorter peristalsis-detection (p=0.001) and oral-intake times (p=0.001), and shorter hospital stays (p=0.005). Morbidity was lower in the LAC group (p=0.001), although LAC did not influence perioperative mortality. Probability of cancer-related survival was higher in the LAC group (p=0.02). The Cox model showed that LAC was independently associated with reduced risk of tumour relapse (hazard ratio 0.39, 95% CI 0.19-0.82), death from any cause (0.48, 0.23-1.01), and death from a cancer-related cause (0.38, 0.16-0.91) compared with OC. This superiority of LAC was due to differences in patients with stage III tumours (p=0.04, p=0.02, and p=0.006, respectively). INTERPRETATION: LAC is more effective than OC for treatment of colon cancer in terms of morbidity, hospital stay, tumour recurrence, and cancer-related survival.