Invasive fungal sinusitis caused by Pseudallescheria boydii: case report and literature review.

Fungal sinusitis secondary to Pseudallescheria boydii is rare, as only 25 cases have been previously reported in the literature. Although Pboydii resembles Aspergillus on pathologic examination, it is typically resistant to amphotericin B. Therefore, culture is necessary to differentiate the two. Patients with P boydii sinusitis should generally be treated with a combination of surgery and antifungal therapy. Combination treatment is particularly important for immunocompromised patients with fungal invasion because mortality among these patients is high. The prognosis is better for immunocompetent patients, even those with fungal invasion. We describe a new case of invasive fungal sinusitis secondary to P. boydii infection, and we review the literature on this emerging pathogen.

Investigation of Postoperative Oral Fluid Intake as a Predictor of Postoperative Emergency Department Visits After Pediatric Tonsillectomy.

IMPORTANCE: This study contributes novel data on the association between oral fluid intake before discharge and adverse outcomes following tonsillectomy in pediatric patients. These data contribute to evidence-based, safe, and cost-effective decision making regarding discharge. OBJECTIVE: To determine whether the quantity of oral fluid intake before discharge is associated with adverse outcomes following tonsillectomy in pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis was conducted using the electronic medical records of 1183 pediatric patients undergoing tonsillectomy between September 24, 2012, and June 5, 2015, at a tertiary care academic medical center. Exclusion criteria included age 18 years or older, overnight admission, and missing data on fluid intake. The final cohort comprised 473 patients. Data analysis was conducted from July 8 to August 23, 2015. EXPOSURES: All patients underwent tonsillectomy by 1 of 7 attending surgeons at our institution. All patients were given intravenous fluids and analgesia in the postanesthesia care unit before being admitted to the pediatric inpatient floor for monitoring before discharge. MAIN OUTCOMES AND MEASURES: The primary outcome measured was presentation to the emergency department within 2 weeks after tonsillectomy with a related complication. We also recorded hospital readmissions and returns to the operating room for related complications. The primary diagnosis was noted for each complication. RESULTS: Among 473 patients (235 male; mean [SD] age, 7.2 [3.5] years), oral fluid intake after tonsillectomy ranged from 0.7 to 66.7 mL/kg, with a mean (SD) intake of 18.2 (10.8) mL/kg. Mean (SD) time to discharge was 6.96 (1.91) hours (range, 1.68-14.25 hours). Overall, 31 patients (6.6%) presented to the emergency department for a related complication after tonsillectomy. No correlation was found between oral fluid intake after tonsillectomy and presentation to the emergency department (odds ratio, 1.03; 95% CI, 0.98-1.08; P = .29). CONCLUSIONS AND RELEVANCE: This study suggests that oral fluid intake before discharge is not predictive of presentation to the emergency department after tonsillectomy within the ranges studied and at this institution. Therefore, discharge criteria based strictly on thresholds for oral fluid intake may be unnecessary. Further study at multiple institutions using a wider range of fluid intake volumes or a large-scale randomized clinical trial is needed before conclusions can be generalized.

Bilateral anterior transposition of the inferior obliques.

Sixty-one children with bilateral overaction of the inferior oblique muscle with concurrent or previous infantile esotropia received bilateral inferior oblique recessions with anteriorization to a point 2 to 4 mm anterior to the lateral end of the inferior rectus insertion. Subsequent reoperation for recurrent overaction of the inferior obliques was needed in only one case. Also, substantial reduction in dissociated vertical deviation (DVD), when present, and almost complete absence of subsequent need for surgery for DVD among the 61 children of this series were new findings. Only one of the 61 required subsequent surgery for manifest DVD. In another series of 60 infantile esotropes of similar ages drawn from the same practice who had previously had no inferior oblique surgery, nine needed surgery for DVD. This difference (one of 61 vs nine of 60) was significant.

Variability of strabismus surgery for acquired esotropia.

We developed a mathematical model to predict the probable success rate of the first surgery to correct acquired esotropia with normal accommodative convergence-accommodation ratio in children. A computer-averaged dose-response curve of the effect of 68 bilateral medial rectus recessions was combined with various assumptions regarding likely errors in surgical performance and likely errors in measurement of the preoperative deviation. Fifteen different sets of reasonable assumptions were tested, giving a range of theoretical success rates from 72% to 96%. The results of this study clearly indicate that a certain proportion of failures is to be expected when this or other forms of strabismus are treated surgically by a fully competent ophthalmic surgeon performing as accurately as is practically possible.

Preservation of olfaction in anterior skull base surgery.

OBJECTIVES/HYPOTHESIS: In selected unilateral tumors and defects of the anterior skull base, the preservation of contralateral olfaction is achievable through a localized subcranial approach without compromising surgical objectives of resection or repair. STUDY DESIGN: Description of a functional adaptation of anterior skull base surgical techniques through a retrospective patient series. METHODS: Nine patients underwent anterior skull base surgery for unilateral cribriform plate disease including four malignant and two benign tumors, two encephaloceles, and one iatrogenic cribriform injury with cerebrospinal rhinorrhea. All nine patients consented to a localized subcranial approach to the anterior skull base to preserve the contralateral olfactory nerves. In four patients with benign disease a portion of the ipsilateral nerves was additionally conserved. Postoperative olfaction was assessed objectively with a commercially available smell test. Indications, technique, results, and complications are reported and discussed. RESULTS: All patients had eradication of disease with preservation of functional olfaction CONCLUSIONS: Conservation of olfaction is possible in selected cases of anterior skull base surgery when the lesion is unilaterally confined.

Immunohistochemical localization of nitric oxide synthase activity in upper respiratory epithelium.

Nitric oxide (NO) production in the respiratory epithelium of the upper airways has recently been described. To better delineate the role of epithelial NO, the authors of this study attempted to identify the cell type responsible for the production of NO in rat tracheal epithelium and human nasal epithelium. They localized the activity of NO through immunohistochemical analysis with an antibody to L-citrulline, a marker for activity of the L-arginine-dependent nitric oxide synthase (NOS) pathway. Using anti-inducible NOS (iNOS) and anti-constitutive NOS (cNOS) antibodies, they also attempted to identify the specific NO isotypes that were present. The tracheal and nasal epithelium demonstrated strong immunoreactivity to citrulline in ciliated cells. The ciliated cells of the nasal turbinates demonstrated strong iNOS positivity, but no significant cNOS immunoreactivity. The study findings that iNOS activity is present in ciliated epithelial cells of rat and human upper respiratory epithelium suggest that NO may play a role in epithelial homeostasis and could potentially play a role in the pathogenesis of mucociliary dysfunction.

Self-esteem, behavior, and concerns surrounding epilepsy in siblings of children with epilepsy.

Researchers document the emotional impact of epilepsy on the child with seizures. Minimal data are available examining the effects of epilepsy on the siblings of children with seizures. Twenty children whose siblings had either frequent seizures or infrequent seizures were matched by age, gender, and birth order to control subjects with no chronic illness. These three groups were compared. Self-esteem, behavioral and social functioning, and family stress were measured by the Piers-Harris Self-Concept Scale, Child Behavior Checklist, and Family Inventory of Life Events. The siblings of children with epilepsy completed the Sibling Concern About Seizure Scale to define and measure their concerns surrounding epilepsy. There is no statistical difference in self-esteem or social functioning among the three groups. There is a trend toward increased incidence of externalizing behavior in siblings of children with frequent seizures. Data indicate a trend toward siblings of children with frequent seizures having more concerns about epilepsy than siblings of children with infrequent seizures. There is significantly more stress in families of children with frequent seizures compared to families of children with infrequent seizures and families of children with no chronic illness. Although there were no significant differences in the self-esteem, behavior, socialization, and concerns between the siblings in the family when compared to the control group or to each other, there were trends in the results that may be of clinical significance. These issues, along with the level of family stress, should be considered when coordinating and providing care to families of children with intractable epilepsy.

Antielevation syndrome after bilateral anterior transposition of the inferior oblique muscles: incidence and prevention.

BACKGROUND: Unilateral and bilateral anterior transpositions of the inferior oblique muscle (ATIOs) for primary inferior oblique (IO) muscle overaction may produce apparent new or recurrent overaction of the contralateral IO muscle. This effect has been termed "antielevating" and can produce overaction of the contralateral elevators in adduction that mimics recurrent or new overaction of the IO muscle of the other eye. This phenomenon may be termed the antielevation syndrome (AES). Kushner has hypothesized that this complication of the ATIO is produced primarily by the posterior fibers of the IO muscle. The purpose of this study is to correlate the frequency of this syndrome in a large series of patients with the mm of lateral displacement (spreading) of the IO muscle reattachment site. METHODS: There was a combination of 123 patients who received ATIO from Mims and 77 patients who received ATIO from Kushner. ATIO was performed according to a previously published technique. RESULTS: All 16 patients (14 from Mims and 2 from Kushner) with AES had received bilateral anterior transposition of the posterior fibers of the IO muscle to at least 2 mm anterior to the lateral end of the inferior rectus (IR) muscle with spreading laterally 3 to 5 mm. Among children who had the posterior fibers of their IO muscles placed 2 to 4 mm anterior to a line drawn laterally from the insertion of the IR muscle, the incidence of AES was significantly larger with more spreading out of the new IO muscle insertion. CONCLUSIONS: AES may be prevented by attaching the posterior fibers of the IO muscle no more than 2 mm lateral to the IR muscle insertion site. This complication responds to bilateral nasal IO muscle myectomy in many cases.

The maximum motor fusion test: a parameter for surgery for acquired esotropia.

PURPOSE: The purpose of this study was to determine whether surgery for acquired esotropia based on the maximum capacity for motor fusion measured with a prism bar could be used to increase the number of millimeters of bilateral medial rectus recession that could be performed without producing an early overcorrection or a late consecutive exotropia, as a way safely to reduce the need for postoperative wear of glasses or a bifocal. METHODS: Category I patients had residual deviations of esotropia (ET) of 12 PD or more with distance fixation, measured after a full hyperopic correction of +1.50 to +3.25 was placed, and had no significant anisometropia or astigmatism. Category II patients had residual deviations of esotropia of less than 11 PD with distance fixation and had residual deviations of esotropia with near fixation (ET') of at least 10 PD more than esotropia with distance fixation ("clinical high AC/A"). Category III patients had had previous bilateral medial rectus muscle recessions and had recurrent esotropia with near fixation of more than 10 PD. For patients in categories I and II, bilateral medial rectus muscle recessions were performed by using a published dose-response table from the national Prism Adaptation Study but with the maximum capacity for motor fusion as the input parameter instead of the prism-adapted angle. Patients in category III received re-recessions of one or both medial rectus muscles, according to a previously published system, with the distance fusional amplitude as the input parameter. RESULTS: In category I, 24 of 30 (80%) patients needed no glasses after surgery, 1 of 30 had esotropia, and 2 of 30 had exotropia (XT) (10% reoperation rate). In category II, 35 of 36 (98%) patients needed no bifocals after surgery, and 3 of 36 had exotropia (9% reoperation rate). In category III, 10 of 10 patients needed no bifocals, and 2 of 10 had exotropia (20% reoperation rate). CONCLUSIONS: When a postoperative reduction in dependence on continuous wear of an optical appliance is a reasonable goal, the maximum motor fusional capacity, measured with a prism bar, is a good parameter for surgical design.

Unilateral recession and resection in Duane syndrome.

PURPOSE: To assess the efficacy of lateral rectus resection with medial rectus recession in the affected eye of patients with Duane retraction syndrome (DRS) with esotropia and limited abduction, compared with bilateral medial rectus recessions. METHODS: The charts of 9 patients with DRS who underwent a recession-resection procedure and 10 patients with DRS who underwent bilateral medial rectus recessions were reviewed. Ocular ductions (graded from 0 = full duction to -4 = total deficit), severity of retraction, alignment, head position, and binocular single vision field (for study group only) were recorded before and after surgery. RESULTS: Before surgery, the study and control groups did not differ in mean primary position esotropia (16.9 and 18.8 PD, respectively), face turn (16.5 degrees and 15.0 degrees, respectively), average limitation of abduction (-3.9 and -3.7, respectively), or adduction (-0.1 and -0.3, respectively). After surgery, both groups had similar mean face turns (3.9 degrees and 1.0 degrees ), esotropia (3.3 PD and 1.0 PD), and abduction limitation in the affected eye (-2.4 and -2.6). However, mean adduction was significantly worse in the control group than in the study group (-1.5 vs -0.6, P = .02). Globe retraction improved in all control subjects. It worsened in 5 study subjects and did not improve in the other 4. In the study group, 1 patient required reoperation for undercorrection and another was overcorrected. CONCLUSION: Seven of 9 patients with DRS, selected on the basis of esotropia, limited abduction, and mild retraction, benefited from a recession-resection procedure. Abduction improved to the same degree as seen after bilateral medial rectus recessions, with less tendency to limit adduction.

Brucella abortus in coyotes. I. A serologic and bacteriologic survey in eastern Texas.

Prevalence of Brucella abortus serum antibodies in coyotes from east central Texas was determined by the buffered Brucella antigen (card test), rivanol, standard agglutination tube, and cold complement fixation tube tests. Eighteen percent (9 of 51) of the coyotes were positive serologically. B. abortus biotype 1 was isolated from various tissues from 7 of 43 coyotes by bacteriologic culture. Congenital transmission was found.

Saccadic velocities of horizontal rectus muscles in twenty-five normal humans.

We measured horizontal saccadic velocities for 20 degrees saccades in 25 normal humans. Percent differences for various muscle pairs were calculated for each subject. For example, percent differences of the antagonist muscles averaged +4.9 +/- 10% and percent differences of symmetrical muscles averaged -9.2 +/- 9%. This percent difference type of data, previously unreported, allows more accurate detection of pathology in a given patient than comparison of a single saccadic velocity with an average of normals because of large intersubject variability. We also found ways to make the performance of the test more convenient and the calculations significantly more accurate (0.001). These will be described. The average speed of a horizontal rectus saccade was 396 +/- 53 degrees/sec.

A comparison of fast-rate, slow-rate, and silent previewing interventions on reading performance.

Researchers investigated the effects of three different previewing interventions on the oral reading rates of 12 junior and senior high school students with learning disabilities. Under fast-rate listening previewing (FRLP), students were instructed to follow silently as experimenters read from a text at an average rate that was 77.7% faster than the students' current oral reading rate. During slow-rate listening previewing (SRLP), students followed along as experimenters read at an average rate that was 22.5% faster than the students' reading rate. Students were instructed to read passages silently under silent previewing (SP). Immediately following each previewing intervention, students read the same passage aloud. The number of words read correctly per minute and the number of errors per minute served as dependent variables. The results showed statistically significant decreases in error rates under SRLP and SP. The results also showed that SRLP resulted in statistically significantly fewer errors per minute than FRLP. These results suggest that orally reading while students follow along at a rate much higher than their current reading rates may not be as beneficial as reading aloud at slower rates.

Sexuality and related issues in the preadolescent and adolescent female with epilepsy.

Multiple resources for the adult female with epilepsy are noted in the literature. Topics covered include pregnancy, epilepsy, contraception, anticonvulsant medications and issues of sexuality. Adolescence is a time of physiological and psychosocial change. The adolescent faces the usual challenges of this life stage along with the added stress of issues surrounding epilepsy. There is minimal information available for and about adolescents with epilepsy.

PIP: Multiple resources for the adult female with epilepsy are noted in the literature. Topics covered include pregnancy, epilepsy, contraception, anticonvulsant medications and issues of sexuality. Adolescence is a time of physiological and psychosocial change. The adolescent faces the usual challenges of this life stage along with the added stress of issues surrounding epilepsy. There is minimal information available for and about adolescents with epilepsy. Limited information for and about adolescents with epilepsy exists in the literature. Adolescent females with epilepsy may be under more stress than those without such a chronic condition. They and their families have concerns about their social interaction, expansion of independence, and sexuality. When educating the adolescent and her family, nurses should consider the cognitive function of the adolescent, family readiness, changes in seizure control during puberty and menarche, adolescent behavior and antiepileptic drugs, and family education. Nurses must be familiar with questions that parents and siblings of a young child with epilepsy may have concerning sexuality issues. Communication among family members, education about sexuality, and getting professional help when needed are key principles in coping with stressors of sexuality. Perhaps the most effective time to start education on sexuality issues is during preadolescence (6-12 years) and young adolescence. It is important to provide clear, concise information to children and adolescents. Taking one's time, actively listening, being knowledgeable, being open and sincere, providing balanced information and understandable answers, anticipating and facilitating questions, and always following-up on earlier communication enhance effective communication. Research should be conducted to examine the needs and intervention for adolescents with epilepsy so nurses and other health professionals can provide more effective care to these adolescents and their families.

Health care management of children with cognitive and physical disabilities: to treat or not to treat.

Advanced medical technology has provided life support and maintenance for high risk infants. In dramatically increasing numbers, children surviving aggressive intervention as neonates and infants suffer from varying degrees of physical and mental disability. Once these children are stable and grow older difficult medical intervention decisions need to be made. As nurses, we are often in situations involving difficult treatment decisions made by the family and health care team. We need to be aware of our personal beliefs and ethical principles to effectively support family members and participate in decision making. Ethical principles serve as a guide to the decision making process.

Treatment of nonepileptic psychogenic events in adolescent patients using the systems model for intervention.

Nonepileptic psychogenic events in children, adolescents and adults can be difficult to treat. Using a systems framework intervention method resulted in significant reduction in nonepileptic psychogenic events. This method provides for a continuous flow of interaction, feedback and modification among the health care team, family and community. Common goals and plans are defined and implemented with a mechanism for feedback and modification. Using a systems model approach in educating the caregivers resulted in immediate and long-term reduction in nonepileptic psychogenic events.

A three dimensional surgical dose-response schedule for lateral rectus resections for residual congenital/infantile esotropia after large bilateral medial rectus recessions.

PROBLEM: A series of overcorrections after this surgical sequence. SUBJECTS & METHODS: Forward stepwise multiple regression analysis of the effect of bilateral lateral rectus resections, retrieved and tabulated retrospectively from the clinical charts of 50 children with infantile esotropia who had significant residual non- accommodative esotropia after bilateral medial rectus recessions. Analysis allowed for selection among linear and quadratic forms of two relevant predictor variables: the mm of previous bilateral medial rectus recession and the prism diopters of residual esotropia. RESULTS: We found a correlation between the effect of the second surgery (bilateral LR resections) and the two variables. This relation could be expressed by a surgical dose-response schedule-surface with the formula: [2.39 + 0.26 (mm MR recession) Squared + 0.41 (mm LR Resection) Squared = prism diopters of effect]. A corresponding schedule (table) with these two parameters was developed to facilitate clinical application. To test and prove this schedule, we re-studied 19 of the 50 original cases who had had surgery, fortuitously, +/-0.3 mm of our new surgical dose- response surface-schedule plus 10 new cases performed according to the new surface-schedule. For these 29 cases there was only one "failure" at 6 months postop' (3%). As a control, for the 31 cases of the original 50 whose surgery had not been within +/- 0.3 mm of the new schedule, 7/31 (23%) were "failures", all overcorrections. ("Failure" vs. "success" - there were only two categories of outcome - was defined as an esotropia over 8 PD or exophoria over 6 PD.) CONCLUSION: This difference in results, expressed as "successes" of 28/29 vs 24/31, or 97% vs 77% gave, on statistical analysis, a p=0. 053 of rejecting the null hypothesis, which is considered a valid "trend" or marginally "statistically significant" and definitely "clinically-medically significant". We have adopted the regular application of our new surgical dose- response schedule in these cases and recommend it for all such cases. binocular vision; complications, surgical; dose-response surgical schedule; esotropia, congenital/infantile; lateral rectus muscle, resection; outcomes; overcorrections; strabismus surgery; study, retrospective, clinical; surgery, strabismus.

Current practice trends in allergy: results of a united states survey of otolaryngologists, allergist-immunologists, and primary care physicians.

BACKGROUND: Clinical practices for the diagnosis and treatment of allergic disease evolve over time in response to a variety of forces. The techniques used by various physician specialties are not clearly defined and may vary from published descriptions or recommendations in the literature. METHODS: This work is a Web-based survey enrolling 250 U.S. physicians in the following specialties: otolaryngology (ENT), allergy-immunology (A/I), and primary care (PCP). RESULTS: Respondents reported that skin-prick testing is the most common diagnostic testing method, followed by in vitro specific immunoglobulin E (IgE) testing. ENTs were more likely to use intradermal testing compared to other specialties (p = 0.0003 vs A/I; p < 0.0001 vs PCP). Respondents reported a wide distribution in number of allergens tested, regardless of testing method (range, 11 to >60). Significant use of home immunotherapy injections (defined as >10% of immunotherapy patients) ranged from 27% to 36% of physicians, with no statistically significant difference noted based upon specialty. PCPs reported greater use of sublingual immunotherapy (PCP, 68%; A/I, 45%; otolaryngology, 35%; A/I vs PCP, p = 0.005; ENT vs PCP p < 0.001)). CONCLUSION: A variety of allergy testing and treatment methods are employed by U.S. physicians, with some differences noted based upon specialty. Home immunotherapy continues to be employed in allergy practices, and sublingual immunotherapy is a common form of delivery, especially in primary care practices.

Total serum immunoglobulin E as a marker for missed antigens on in vitro allergy screening.

BACKGROUND: The diagnosis of inhalant allergies involves a medical history, physical exam, and allergen sensitivity testing; allergen sensitivity can be assessed by a specific immunoglobulin E (IgE) screen for inhalant allergens. Some patients with clinical suspicion for inhalant allergies have a negative specific IgE screen, but high total IgE. We theorize that elevated total IgE may indicate a false-negative screen caused by "missed allergens" not initially identified. METHODS: Study patients with a negative allergy screen and elevated IgE (>116 kU/L) were identified (n = 26). Control patients (n = 26) were defined as having a negative screen and an IgE <2.95 kU/L. Both groups were tested with an expanded specific IgE panel and completed a questionnaire about other causes of elevated IgE. RESULTS: The expanded panel was positive for inhalant allergens in 4 study patients (15%) and 0 control patients (p = 0.037). Within the study patients, 50% had asthma and 76.9% had chronic sinusitis. Only 2 control patients had asthma (11.5%), p = 0.003; 4 (19.2%) reported chronic sinusitis, p < 0.0001. Food allergen sensitivity was identified in 5 study patients and 1 control, p = 0.083. CONCLUSION: This pilot study evaluated patients clinically suspected of allergy with a negative inhalant IgE screen. Those with a high total IgE were more likely to have a missed inhalant allergen on expanded testing, as well as asthma and chronic sinusitis, compared to those with a low total IgE. Further investigation of "missed antigen" and the role of chronic respiratory inflammatory disease in patients with elevated total IgE is warranted.