Search

Erythema annulare centrifugum (EAC) is a reactive phenomenon of the skin that has been reported to occur in association with numerous conditions, including infections.1 It commonly presents with annular, erythematous plaques with a fine desquamation in the inner portion of the advancing edge.2 In the last year, a wide spectrum of cutaneous manifestations has been associated with SARS-CoV-2 infection, including acral areas of erythema with vesicles or pustules, other vesicular eruptions, urticarial lesions, maculopapular eruptions and livedo or necrosis.3,4.

Adenoma of the nipple is a very uncommon benign neoplasm of lactiferous ducts. Its clinical presentation is variable and it can be easily misdiagnosed as a malignancy such as mammary Paget disease or breast intraductal carcinoma. Although dermoscopy and imaging tests such as ultrasonography or mammography can be of help, histological examination is mandatory to confirm the diagnosis. We describe the clinical, dermoscopic, and histopathological findings in a patient with nipple adenoma and discuss the clinical and histological differential diagnosis as well as the different treatment options.

Summary Background The percutaneous gastrostomy tube (PG) is an effective and safe way for the delivery of enteral nutrition. The aim of this study was to identify predictive factors for mortality after PG placement. Material and methods An observational and analytical cohort study was conducted. All endoscopic or radiological percutaneous gastrostomy tubes placed between January 2009 and July 2016 were evaluated. Mortality was the dependent variable. Initial clinical and analytical patient features and the development of complications during follow-up were recorded. Cox regression models were used to evaluate the risk of mortality associated to the studied variables. Hazard ratios with the corresponding 95% confidence intervals were retrieved from these models. Results A total of 289 patients underwent PG placement (57% male). The mean age was 70.1 (SD 13.6) years. The median follow-up period was 8.7 (IQR 18) months. One hundred and seventy-four patients died during the follow-up period. The overall mortality rate was 4.8 per 100 patients-month. The highest mortality rate was during the first month after PG placement (13.2 per 100 patients-month), subsequently decreasing. Multivariate regression analysis showed that age (HR1year = 1.01; p = 0.015), Charlson comorbidity index ≥4 (HR = 1.69; p = 0.011), the presence of degenerative neurological disease (HR = 1.69; p = 0.012) or malignancy (HR = 2.02; p = 0.012) and the development of aspiration pneumonia during the follow-up period (HR = 3.29; p = 0.001) were statistically significant independent predictive risk factors associated with mortality. A model to predict survival probability prior to placing the PG was developed from the variables of the multivariate analysis. Conclusion Mortality after PG placement is high. Older age, higher comorbidity and the development of aspiration pneumonia are predictive factors for mortality. A more careful selection of candidates for PG placement should be done to improve the patient prognosis after the procedure.

Objective: To compare visual quality in patients implanted with Tecnis® monofocal (ZCB00) and multifocal (ZMB00) intraocular lenses taking into account their optical quality measured in vitro with an eye model. Methods: In total, 122 patients participated in this study: 44 implanted with monofocal and 78 with multifocal intraocular lenses. Measurements of visual acuity and contrast sensitivity were performed. The optical quality of the intraocular lenses was evaluated in three image planes (distance, intermediate and near) using an eye model on a test bench. The metric considered was the area under the curve of the modulation transfer function. Results: Optical quality at the far focus of the monofocal intraocular lens (area under the curve of the modulation transfer function = 66.97) was considerably better than that with the multifocal lens (area under the curve of the modulation transfer function = 32.54). However, no significant differences were observed between groups at the distance-corrected visual acuity. Distance-corrected near vision was better in the multifocal (0.15 ± 0.20 logMAR) than that in the monofocal group (0.43 ± 0.21 logMAR, p Conclusion: Patients implanted with multifocal ZMB00 achieved a distance visual acuity similar to those implanted with monofocal ZCB00, but showed significantly better intermediate and near visual acuity. A correlation was found between intraocular lenses’ optical quality and patients’ visual acuity. Contrast sensitivity was very similar between the multifocal and monofocal groups.

Interstitial granulomatous dermatitis (IGD) is a rare dermatosis generally seen in the setting of rheumatic diseases, but also hematological disorders, internal malignances, infections, or drug induced. Herein, we report an exceptional case of an IGD with a clear chronological association with tocilizumab onset and cessation in a patient with adult-onset Still's disease. We review the granulomatous cutaneous reactions so far reported with this novel therapy: sarcoidosis, granuloma annulare, and IGD. Tocilizumab is a humanized anti-interleukin 6 receptor monoclonal antibody useful for the treatment of various systemic inflammatory disorders. Lately, it has found useful also for granulomatous diseases such as giant cell arteritis and even a promising response in IGD. Therefore, we believe our case adds the possibility of an IGD presenting as a paradoxical reaction.

To compare visual quality between subjective tests and optical devices using near-infrared (NIR) light in patients implanted with monofocal, multifocal and enlarged depth-of-focus (EDoF) intraocular lenses (IOLs). Cross-sectional study enrolling patients aged between 55 and 75 (axial length between 22 and 25 mm) bilaterally implanted with Tecnis IOLs (Johnson & Johnson) four months previously: 40 patients (80 eyes) with monofocal ZCB00, 41 patients (82 eyes) with bifocal diffractive ZMB00 and 48 patients (96 eyes) with EDoF Symfony. They were examined using subjective and objective tests. The subjective tests comprised visual acuity (VA) with ETDRS charts, contrast sensitivity (CS) with Pelli–Robson and CSV-1000E tests, and clear vision range (CVR). The objective tests using NIR light were performed with the KR-1 W wavefront analyzer and the OQAS. In the subjective tests, the monofocal group achieved the best outcomes in some of the VA and CS sections, while the bifocal group obtained the worst outcomes in some of the CS sections. In the objective tests, the bifocal group achieved the best results for VA and CS. Discrepancies between pseudoaccommodation range and CVR were found in the bifocal and EDoF groups. Assessment of visual quality using NIR light implies greater bias for diffractive lenses than for EDoF lenses. This bias may be even greater with devices using longer light wavelengths or Hartmann–Shack technology. The difference in wavelength between NIR and visible light leads to dimming of near-vision focus and magnification of distance focus.

This article studies the relationship between two metrics, the area under the modulation transfer function (MTFa) and the energy efficiency (EE), and their ability to predict the visual quality of patients implanted with multifocal intraocular lenses (IOLs). The optical quality of IOLs is assessed in vitro using two metrics, the MTFa and EE. We measured them for three different multifocal IOLs with parabolic phase profile using image formation, through-focus (TF) scanning, three R, G, B wavelengths, and two pupils. We analyzed the correlation between MTFa and EE. In parallel, clinical defocus curves of visual acuity (VA) were measured and averaged from sets of patients implanted with the same IOLs. An excellent linear correlation was found between the MTFa and EE for the considered IOLs, wavelengths and pupils (R2 > 0.9). We computed the polychromatic TF-MTFa, TF-EE, and derived mathematical relationships between each metrics and clinical average VA. MTFa and EE proved to be equivalent metrics to characterize the optical quality of the studied multifocal IOLs and also in terms of clinical VA predictability. Ministerio de Economía y Competitividad y fondos Feder (DPI2016-76019-R).

Within the COVID-19 pandemic context, the WHO has proposed a list of medicines to treat patients with severe acute respiratory syndrome (SARS-CoV-2). An analysis of their ocular side effects was performed. Only chloroquine and hydroxychloroquine were found to have an ocular impact in the medium and long-term. Detailed search strategies were performed in EMBASE, MEDLINE, SCOPUS and WOS Core Collection. Additionally, the worldwide ongoing clinical trials including chloroquine or hydroxychloroquine were evaluated, and their proposals of drug administration and exclusion criteria analyzed. In general, high maximum cumulative doses of chloroquine or hydroxychloroquine are being used for a short period in 135 currently underway clinical trials (to 21st April 2020). Typically, the doses were 2 to 5 times greater than the AAO recommendation (adjusted to weight) to avoid toxic retinopathy, the most undesirable ocular side effect. Maximum cumulative doses up to 12,000 mg for chloroquine and 18,000 mg for hydroxychloroquine were found. In prophylaxis clinical trials, 72,000 mg and 22,500 mg were the maximum cumulative doses for hydroxychloroquine and chloroquine respectively. Only 48% of the clinical trials considered retinal impairment as an exclusion criterion, and just one referred to an ophthalmic examination previous to study inclusion. How chloroquine and hydroxychloroquine treatment affect patients with a previous retinal condition is still poorly understood. A comprehensive ophthalmological examination 6 months after treatment is recommended in this subgroup. This review provides an overview of this topic and sheds light on the challenges visual caregivers may face regarding these repurposed drugs.

O presente estudo relata o atendimento a uma usuaria com o diagnostico de Artrite Reumatoide (AR) e as intervencoes terapeuticas ocupacionais desenvolvidas por academicos do curso de Terapia Ocupacional da Universidade Federal de Santa Maria, buscando explanar as potencialidades do contato entre cliente e academico. As praticas foram realizadas por meio de visitas domiciliares, em parceira com uma unidade de saude do municipio de Santa Maria, RS. No desenvolvimento das acoes, houve a escuta das demandas da cliente e de sua familia, sendo as principais: a necessidade de orientacoes para a realizacao de transferencia e as dificuldades do uso da cadeira de banho. Desse modo, foi elaborado um plano de tratamento que engloba intervencoes e atividades que nortearam os atendimentos. Foi observado, a partir dessa vivencia, o fortalecimento de uma rede de assistencia a saude, constituida entre Estrategia de Saude da Familia e Universidade, fato que favoreceu o cuidado e a qualidade de vida do sujeito acompanhado. A realidade em que a usuaria estava inserida foi considerada durante todo o desenvolvimento das acoes. Portanto, a construcao do conhecimento advindo das atividades praticas favoreceu a criacao de um pensamento reflexivo e um saber significativo. Abstract This study was to describe interventions performed by academics of the Occupational Therapy course of the Federal University of Santa Maria, seeking to explain the potential of the contact between client and academic. The practices were held in partnership with the health unit in the county of Santa Maria, RS, through home visits. The study reports the attendance to the female user with a diagnosis of Rheumatoid Arthritis (RA) and developed occupational therapeutic interventions. There was the listening to the customer's demands and his family; the main ones being, the need for: guidelines for carrying out the transfer and the difficulties of using the shower chair. Thus, was elaborated a treatment plan containing measures and activities that guided the sessions. It was observed from the practices, the strengthening of a health care network, composed of the Family Health Strategy and Academy; wich favored the care and quality of life of the subject. The reality in which the user was inserted was responsible for guiding actions. Therefore, the construction of knowledge from practical activities made students create reflective thinking and meaningful learning. Keywords: Family Health Strategy; Home Visit; Occupational therapy.

Purpose To identify differences in neuronal tissue from retinal and brain structures in children born small for gestational age (SGA) with no abnormality in neonatal brain ultrasonography and no previous neurological impairment, and to evaluate the relationship between retinal structure and brain changes in school-age children born SGA. Methods Two cohorts of children were recruited: 25 children born SGA and 25 children born with an appropriate birth weight according to gestational age. All the children underwent an ophthalmic examination, which included retinal imaging using spectral-domain optical coherence tomography, and a brain MRI. MRI images were automatically segmented and global and regional brain volumes were obtained. Results Although visual function did not differ between both groups, the complex ganglion cell and inner plexiform layers (GCL-IPL) was thinner in SGA children. Total intracranial volume, and global grey and white matter volumes in brain and cerebellum were correlated with birthweight centile, as were certain regional volumes (temporal and parietal lobes, hippocampus and putamen). Abnormal GCL-IPL measurements accurately identified SGA children with the most severe grey and white matter changes in the brain. Conclusions SGA children, both preterm and term born, showed evidence of structural abnormalities in the retina, which may be an accurate and non-invasive biomarker of neuronal damage in brain tissue.

Prematurity and low birth weight are known risk factors for cognitive and developmental impairments, and school failure. Visual perceptual and visual motor skills seem to be among the most affected cognitive domains in these children.To assess the influence of prematurity and low birth weight in visual cognitive skills and school performance.We performed a prospective cohort study, which included 80 boys and girls in an age range from 5 to 13. Subjects were grouped by gestational age at birth (preterm,37 weeks; term, 37-42 weeks) and birth weight (small for gestational age (SGA),10th centile; appropriate weight for gestational age (AGA), ≥10th centile). Each child underwent full ophthalmologic assessment and standardized testing of visual cognitive abilities (Test of Visual Perceptual Skills and Test of Visual Analysis Skills). Parents completed a questionnaire on school performance in children.Figure-ground skill and visual motor integration were significantly decreased in the preterm birth group, compared with term control subjects (figure-ground: 45.7 vs 66.5, p=0.012; visual motor integration, TVAS: (9.9 vs 11.8, p=0.018), while outcomes of visual memory (29.0 vs 47.7, p=0.012), form constancy (33.3 vs 52.8, p=0.019), figure-ground (37.4 vs 65.6, p=0.001), and visual closure (43.7 vs 62.6 p=0.016) testing were lower in the SGA (vs AGA) group. Visual cognitive difficulties corresponded with worse performance in mathematics (r=0.414, p=0.004) and reading (r=0.343, p=0.018).Specific patterns of visual perceptual and visual motor deficits are displayed by children born preterm or SGA, which hinder mathematics and reading performance.

Kounis syndrome is defined as the coincidental occurrence of allergic reaction and acute coronary syndrome secondary to vasospasm. Anti-inflammatory drugs are included as one of the multiple causes. Current data available about this syndrome come from case reports. We present the case of a patient who suffered Kounis syndrome with cardiogenic shock and asystole after intravenous infusion of Metamizole, and in which no lesions were observed in coronariography. Resumo: A síndrome de Kounis é definida como a ocorrência concomitante de reação alérgica e síndrome coronariana aguda secundária ao vasoespasmo. Os medicamentos anti-inflamatórios estão incluídos como uma das múltiplas causas. Os dados atuais disponíveis sobre essa síndrome são provenientes de relatos de casos. Apresentamos o caso de um paciente que apresentou síndrome de Kounis com choque cardiogênico e assistolia após infusão intravenosa de metamizol, e no qual não foram observadas lesões na coronariografia. Keywords: Kounis syndrome, Metamizole, Cardiogenic shock, Asystole, Palavras-chave: Síndrome de Kounis, Metamizol, Choque cardiogênico, Assistolia

OBJECTIVE To assess changes in the retinal nerve fiber layer (RNFL) and macula in subjects with cardiovascular risk factors or subclinical ischemia. DESIGN Prospective and observational study. METHODS A total of 152 healthy men underwent cardiovascular examination, including quantification of subclinical atheroma plaques by artery ultrasound scans, blood analysis, and a complete ophthalmic evaluation, including spectral-domain optical coherence tomography. The variables registered in cardiovascular examination were quantification of classic major risk factors, subclinical atheroma plaques by artery ultrasound scans, and analytical records. The ophthalmic evaluation registered RNFL and macular thickness. RESULTS Mean subject age was 51.27±3.71 years. The 40 subjects without classic cardiovascular risk factors did not show differences in RNFL and macular thicknesses compared with the 112 subjects with at least one risk factor (except in sector 9 that showed higher thicknesses in subjects with ≥1 risk factor). Comparison between the group of subjects with and without atheroma plaques revealed no differences in RNFL and macular thicknesses. The sub-analysis of subjects with subclinical atheroma plaques in the common carotid artery revealed a significant reduction in central macular thickness in the left eye compared with the right eye (p = 0.016), RNFL in the superior quadrant (p = 0.007), and the 11 o'clock sector (p = 0.020). Comparison between smokers and nonsmokers revealed that smokers had significant thinning of the central macular thickness (p = 0.034), the nasal RNFL quadrant (p = 0.006), and the 3 and 5 o'clock sectors (p = 0.016 and 0.009). CONCLUSIONS Classic cardiovascular risk factors do not cause RNFL or macular thickness reduction, but tobacco smoking habit reduces nasal RNFL thickness. Subclinical atherosclerosis in the common carotid artery associates a reduction in central macular and nasal RNFL quadrant thicknesses in the left eye compared with the right eye.

Introducción:la nutrición parenteral total (NPT) es una modalidad de soporte nutricional indicada en aquellas situaciones donde el enfermo no puede cubrir sus requerimientos nutricionales por vía enteral. A pesar de ser una terapia segura y efi caz, no está exenta de complicaciones, entre las que cabe destacar, por su frecuencia, la hipertrigliceridemia. La etiología de esta complicación metabólica es compleja y multifactorial. Objetivos: el objetivo de este trabajo fue determinar los factores de riesgo asociados al desarrollo de hipertrigliceridemia en pacientes adultos hospitalizados no críticos que reciben NPT a corto plazo y evaluar el efecto que una emulsión lipídica enriquecida en ácidos grasos poliinsaturados omega-3 ejerce sobre esta complicación metabólica. Material y métodos: estudio observacional retrospectivo de cohortes donde se ha incluido a pacientes hospitalizados adultos no críticos que precisaron NPT durante un periodo superior a siete días. Se consideró la presencia de hipertrigliceridemia cuando los niveles plasmáticos de triglicéridos fueron superiores a 200 mg/dl. Las emulsiones lipídicas empleadas fueron una mezcla al 50% de triglicéridos de cadena larga (LCT) y de cadena media (MCT) o una combinación al 40% LCT/50% MCT/10% omega-3. Se recogieron variables clínicas, nutricionales y bioquímicas. Las determinaciones analíticas se realizaron antes del comienzo de la NPT y semanalmente hasta su retirada. Los factores predictores de la aparición de hipertrigliceridemia fueron identifi cados mediante modelos de regresión logística multivariante. Resultados: fueron incluidos 101 pacientes (61, 4% varones), de los cuales el 33% desarrolló hipertrigliceridemia. En el análisis multivariante los factores de riesgo independientes asociados a la presencia de hipertrigliceridemia fueron los niveles plasmáticos iniciales de triglicéridos, el índice de masa corporal (IMC) y un aporte de glucosa en la NPT superior a 3, 1 g/kg/día. La infusión de una emulsión lipídica enriquecida con ácidos grasos omega-3 se asoció con un descenso no signifi cativo del riesgo de aparición de hipertrigliceridemia. Conclusión: la situación clínica metabólica del paciente y la dosis de hidratos de carbono en la NPT resultan fundamentales en el desarrollo de la hipertrigliceridemia relacionada con la NPT. La administración de una emulsión lipídica enriquecida en ácidos grasos omega-3 es segura, aunque no se asoció a un efecto protector signifi cativo sobre el riesgo de aparición de esta complicación metabólica. Introduction: Total parenteral nutrition (TPN) is a kind of nutritional support indicated for patients whose clinical situation makes it impossible to cover their nutritional requirements enterally. Despite the fact that TPN is a safe and effective therapy, some complications have been described. One of the most frequent is hypertriglyceridemia. The etiology of this metabolic complication is complex and multifactorial. Objetive: The aim of this work was to determine risk factors associated with the development of hypertrilgyceridemia in adult inhospital non critical patients who carry TPN for a short term. A secondary aim was to evaluate the effect that a lipid emulsion fortified with omega-3 poliunsaturated fatty acids causes on this metabolic complication. Material and methods: This is an observational retrospective cohort study, in which adult inhospital non critical patients have been included. Only those who needed TPN during more than seven days were included. Hypertriglyceridemia was defined as plasma triglycerides levels higher than 200 mg/dl. The lipid emulsions were composed whether by a combination of 50% long-chain (LCT) and medium-chain (MCT) triglycerides or 40% LCT/50% MCT/10% omega-3. Clinical, nutritonal and biochemical parameters were included. Analitical samples were obtained before starting TPN, and weekly until withdrawal. Multivariate logistic regression analysis was used to identify predictive factors of the appearance of hypertriglyceridemia. Results: One hundred and one patients were included (61.4% male). Thirty-three per cent of them developed hypertriglyceridemia. In the multivariate analysis the independent risk factors associated with the presence of hypertriglyceridemia were the initial plasmatic triglycerides levels, the body mass index (BMI) and an input of glucose in the TPN higher than 3.1 g/kg/day. The infusion of a lipid emulsion fortified with 3-omega fatty acids was associated with a nonsignificant reduction of the risk of appearance of hypertriglyceridemia. Conclusion: The patient’s clinical metabolic situation, as well as the load of carbohydrates in the TPN are essential for the development of the TPN-associated hypertriglyceridemia. The administration of a lipid emulsion fortified with omega-3 fatty acids is safe, even though it was not associated with a significant protective effect over the risk of appearance of this metabolic complication.

Background Infants born prematurely or with low birth weight are at increased risk of visual perceptual impairment. Face recognition is a high-order visual ability important for social development, which has been rarely assessed in premature or low birth weight children. Aims To evaluate the influence of prematurity and low birth weight on face recognition skills. Methods Seventy-seven children were evaluated as part of a prospective cohort study. They were divided into premature and term birth cohorts. Children with a birth weight below the 10th centile were considered small for gestational age. All children underwent a full ophthalmologic assessment and evaluation of face recognition skills using the Facial Memory subtest from the Test of Memory and Learning. Results Premature infants scored worse on immediate face recognition compared to term infants. However, after adjusting for birth weight, prematurity was not associated with worse outcomes. Independent of gestational age, outcomes of low birth weight children were worse than those of appropriate birth weight children, for immediate face recognition (odds ratio [OR], 5.14; 95% confidence interval [CI], 1.32–21.74) and for face memory (OR, 4.48; 95% CI, 1.14–16.95). Conclusions Being born small for gestational age is associated with suboptimal face recognition skills, even in children without major neurodevelopmental problems.

Objective To report normal reference values for peripapillary retinal nerve fibre layer (RNFL) thickness and optic disc parameters in children from a community population. Methods The authors performed a cross-sectional study examining RNFL and optic nerve head (ONH) properties in 358 children aged between 6 and 13 years with no ocular disease. All children underwent an ophthalmic examination that included visual acuity (logMAR), stereopsis assessment (TNO) and optical coherence tomography (Cirrus OCT Zeiss, ‘Optic Disc Cube 200×200’ protocol). One eye from each subject selected at random was finally analysed. The authors evaluated the influence of height, gender and age on measurements. Results High-quality scan data were obtained from 357 children and 344 were finally included. The mean age (SD) was 9.16 (1.7) years and the mean (SD) RNFL average thickness was 98.46 (10.79) μm. The temporal quadrant showed the thinnest RNFL (69.35±11.28 μm), followed by the nasal (71.30±13.45 μm), superior (123.65±19.49 μm) and inferior (130.18±18.13 μm) quadrants. The mean rim area (SD) and disc area (SD) were 1.59 (0.33) and 2.05 (0.39) mm 2 , respectively. The average cup to disc (C:D) ratio (SD) was 0.43 (0.19). The authors found no differences in any of the parameters with regard to weight, height and gender. Conclusions This study demonstrates normative values of RNFL thickness and ONH parameters in a sample of Caucasian children from the general population.

Resumen Introduccion Evaluar la prevalencia de anticuerpos frente a las celulas parietales gastricas (ACP) en pacientes con enfermedad tiroidea autoinmune (ETI). Material y metodos Estudio descriptivo transversal con inclusion de pacientes con ETI. Se determino la presencia de ACP. Se definieron como titulos elevados de anticuerpos antitiroideos (ATAS) niveles de anticuerpos antiperoxidasa o antitiroglobulina superiores al percentil 75. Mediante modelo de regresion logistica se evaluo la contribucion independiente de las siguientes variables a la presencia de ACP positivos: edad, sexo, hemoglobina, volumen corpuscular medio (VCM), dosis/k de levotiroxina (LT4), duracion de la ETI y titulos elevados de ATAS. Resultados Se incluyeron 148 pacientes (137 mujeres) con edad de 45,7 (DE 15) anos y duracion de la enfermedad de 4,5 (DE 4) anos. De ellos, 43 (29%) tenian enfermedad de Graves y 105 (71%) hipotiroidismo primario. El percentil 75 fue para anticuerpos anti-peroxidasa 420 U/ml y para anticuerpos antitiroglobulina 200 U/ml. Los ACP fueron positivos en 30 pacientes, con una prevalencia global del 20,3%. Titulos iguales o superiores a 1/640 aparecieron en 19 pacientes (12,8%). El unico factor predictivo independiente de ACP positivos fue la presencia de titulos elevados de ATAS ( Odds Ratio [OR] = 3; intervalo de confianza [IC] 95%: 1,1 – 8,6; p = 0,04). El unico factor predictivo independiente de ACP positivos a titulos iguales o superiores a 1/640 fue tambien la presencia de titulos elevados de ATAS (OR = 7,3; IC 95% 1,6 – 32,7; p = 0,009). Conclusiones La prevalencia de ACP positivos en pacientes con ETI fue del 20%. La presencia de titulos elevados de ATAS incrementa el riesgo de aparicion de ACP positivos.

Introduction The posterior epidural migration of a fragment of lumbar disc herniation is a rare clinical presentation. Case report We report the case of a 76-year-old male patient with back pain and progressive paraparesis in the lower limbs, with the emergence of a cauda equina syndrome 4 days after admission. MRI showed lumbar spondylosis and a well-defined intra-spinal mass in the posterior epidural space. Surgical resection of the epidural mass was performed. The pathological study revealed an intervertebral disc fragment; thus, it was a complete migration of a herniated lumbar disc. The patient was healed after surgery and specific rehabilitation treatment. Conclusions Patients with posterior migration of disc fragment may present with severe neurological deficits, such as cauda equina syndrome. Because the radiological images of disc fragments are similar to those of other lesions, such as metastasis, synovial cyst, dural abscess or haematoma, definitive diagnosis is made by excision and pathological study. Emergency surgery is required to prevent severe neurological deficits.

To assess retinal morphology changes in patients born at different stages of prematurity, accounting for the presence or absence of retinopathy of prematurity (ROP) and comorbidity, using spectral-domain optical coherence tomography (SD OCT).Retrospective cohort study.Preterm and term infants underwent an ophthalmologic assessment (best-corrected visual acuity, stereoacuity, cycloplegic refraction and funduscopy). Retinal layers were imaged, segmented, and measured by SD-OCT. In total 114 full term controls and 60 preterm children, classified as late preterm (32-36 weeks gestational age), early preterm (32 weeks of gestational age) without ROP, and early preterm with previously treated ROP, were included in the study.No retinal structure differences were observed in preterm infants with no treated ROP compared to term infants. Early preterm infants with previous treated ROP had decreased retinal nerve fiber layer (RNFL) thickness in the superior and nasal quadrants, increased RNFL in the temporal quadrant, and a thinner ganglion cell and inner plexiform layer complex (GCL-IPL). Low birthweight percentile was associated with increased foveal thickness and ganglion cell damage (RNFL and GCL-IPL) independent of gestational age. Among all the coexisting events, inflammation and hypoxia were correlated with more severe detrimental effects.In the absence of treated ROP, prematurity was not associated with disturbed retinal structure. Severe ROP and low birthweight were related to neuronal and axonal damage in the inner retinal layers. Detailed comorbidity should be reviewed when evaluating preterm infants.

A 62-year-old woman with a past medical history of rheumatoid arthritis was referred to the Department of Dermatology because of an enlarging cutaneous lesion on the right thumb which resembled a soft tissue infection. She had received antibiotics without significant improvement. Clinical examination revealed an erythematous nodule involving almost the whole surface of the distal phalanx with spontaneous drainage of countless of small yellowish ovoid granules. Histopathologic study of these structures showed an inner core of amorphous acidophilic material with some interspersed chronic inflammatory cells and a surrounding thin fibrin layer. Special stains and cultures were negative for parasites, bacterium and mycobacterium. Magnetic resonance imaging (MRI) revealed distension of the first and fifth finger flexor sheaths and common finger flexor sheath. These areas were filled by fluid and multiple small nodular lesions. A diagnosis of non-infectious rice body tenosynovitis was rendered and surgical removal was performed. Total recovery was observed with no evidence of recurrence after 6 months of follow-up. To our knowledge, this is the first report of rice body tenosynovitis presenting as a pseudoinflammatory cutaneous lesion with evolution to a cutaneous fistula with drainage of rice grain-like structures. The description of this impressive and peculiar clinical and histopathologic picture is important to further recognize similar cases.

Purpose To determinate the physiological asymmetry of retinal measurements in the pediatric population with Fourier-domain optical coherence tomography (Cirrus HD-OCT). Design Prospective cross-sectional study. Methods Three hundred and fifty-seven healthy children were recruited. All subjects underwent a comprehensive ophthalmologic examination and an evaluation of the retinal nerve fiber layer (RNFL), optic nerve head, and macula with Cirrus OCT. Differences between right and left eyes were calculated and values were compared by means of a paired t test. Normal ranges of interocular differences were established as the 2.5th and the 97.5th percentiles. The correlations between right and left eyes were assessed by the intraclass correlation coefficients. Results Mean best-corrected visual acuity (logMAR) was −0.01. Differences in the average RNFL between right and left eyes were not statistically significant. The RNFL in the right eyes was thicker in the temporal and nasal quadrants, whereas the left eyes showed thicker RNFL in the superior quadrant. The interocular difference tolerance limits for average RNFL and macular thicknesses were 13.00 μm and 23.20 μm, respectively. There was a strong correlation for all the parameters between the right and the left eyes. Conclusions The asymmetry of retinal parameters might be more valuable than the absolute values in assessing certain early diseases. The interocular differences in average RNFL and macular thickness of normal individuals should not exceed 13 μm and 23 μm, respectively, if measured with Cirrus HD-OCT.

Biliopancreatic diversion is a predominantly malabsorptive bariatric procedure that can lead to the development of several nutrition complications, including fat-soluble vitamin deficiencies. Routine supplementation with vitamins and trace elements and a strict medical follow-up are essential to prevent these nutrition risks. Vitamin A deficiency is common after bariatric surgery but rarely causes clinical symptoms. Case reports have described ophthalmological and fetal complications associated with vitamin A deficiency after malabsorptive bariatric surgery. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. The simultaneous occurrence of phrynoderma and ocular symptoms secondary to hypovitaminosis A after bariatric surgery is exceptional. The authors describe a man who presented follicular hyperkeratosis with nyctalopia and xerophthalmia that had appeared 1 year after biliopancreatic diversion. He admitted poor compliance with diet and daily supplementation of vitamins and oligoelements. Serum vitamin A levels were decreased. Treatment with high doses of vitamin A was associated with a clear improvement of cutaneous and ocular lesions with complete resolution after 2 months. The patient was readmitted 2 years later because of the reappearance of cutaneous lesions and micronutrient deficiency. Revisional bariatric surgery was performed. The authors review and discuss the relationship between phrynoderma, malnutrition, and vitamin A deficiency.

Francisco Hernandez Altemir1,2, Sofia Hernandez Montero3,4,5, Susana Hernandez Montero6, Elena Hernandez Montero7 and Manuel Moros Pena8 1University of Zaragoza, 2European Association for Cranio-Maxillofacial Surgery and the Head and Neck Surgery, 3Association and the New Head and Neck Spain Association 4University Master of Oral Implants and Prostodontic, UAX Madrid, 5Zaragoza University, 6Zaragoza University (Medicine Oral and Pathology) Endodontic, 7ORL Viladecans Hospital and Institute Garcia Ibanez of Otoneurosurgery, Barcelona 8Pediatric and Cartoonist Spain

Purpose To evaluate the peripapillary retinal nerve fiber layer (RNFL) thickness obtained with spectral-domain optical coherence tomography (OCT) in obstructive sleep apnea syndrome (OSA) patients, as a biological marker of neuronal damage. Methods Sixty-four OSA patients and one hundred twenty-nine healthy controls were prospectively selected. Only one eye per subject was randomly chosen. AOS patients were classified in three groups according to apnea/hipopnea index: mild, moderate and severe. All participants had intraocular pressure less than 21 mmHg and performed at least a reliable standard automated perimetry (SAP). Peripapillary RNFL thicknesses were measured with Cirrus OCT (Carl Zeiss Meditec, Dublin, Ca). After checking for a normal distribution of variables, differences between both groups were tested by Student t test. Results Age was 50.6 ± 9.3 years in control eyes and 47.8 ± 11.5 years in AOS patients (p = 0.09). Mean deviation of SAP was -0.50 ± 1.0 dB and -1.4± 2.3 dB, in control and AOS patients, respectively (p

Purpose To evaluate the agreement between the Moorfields regression analysis classification (MRA) of the Heidelberg retina Tomograph 3 (HRT3; Heidelberg Engineering, Heidelberg, Germany) and the functional classification of white-on-white Heidelberg Edge Perimetry (HEP, Heidelberg Engineering). Methods Fifty-seven normal subjects and 89 age-matched glaucoma subjects were selected.Only one eye per subject was randomly included in the statistical analysis. All glaucoma patients had an intraocular pressure higher than 21 mmHg and abnormal Humphrey visual fields. The glaucoma group was divided into three subsets, according to the subject’s level of visual field loss (Hodapp-Parrish-Anderson score). All participants underwent a comprehensive ophthalmic examination, at least a reliable Humphrey perimetry, at least a reliable HEP and imaging with the HRT3. The agreement between color-coded classifications of both, MRA and HEP, was calculated for each sector of the optic nerve head: nasal-superior Results Mean age was 52.9 ± 9.5 years in the control group and 55.5 ± 9.7 years in the glaucoma group (p=0.104). In the control group, the best agreement was found for NI sector (100%), while the worst agreement was observed for TI sector (93%). Patients with mild glaucoma (n=59) had the best agreement at NS sector (79.7%) while patients with moderate glaucoma (n=18) had the best agreement at NS, TS and TI sectors (88.9%), and patients with severe glaucoma (n=12) had the best agreement at NS, TS, TI and T sectors (83.3%). Conclusion In general, MRA and functional classification of HEP showed moderate to good agreement. The best agreement between both classifications was observed in healthy and patients with mild glaucoma.

Purpose To evaluate the relationship between Standard Automated Perimetry (SAP) performed with Humphrey perimeter (Carl Zeiss Meditec, EEUU) and a new white-white perimetry tested with Heidelberg Edge Perimeter (HEP, Heidelberg Engineering, Alemania). Methods Fourty-three subjects (healthy and with different levels of glaucomatous damage subjects) were prospectively and consecutively selected. Only one eye per subject was included in the study. All of them underwent at least one reliable perimetry with each device. 24-2 SITA standard was used with Humphrey perimeter and 24-2 ASTA standard algorithm was tested with HEP in all subjects. After checking the normal values of variables by Kolmogorov-Smirnov test, Pearson’s correlation coefficients were calculated between global indices of both devices: mean deviation (MD), pattern standard deviation (PSD) and visual field index (VFI). Results Mean age was of 58.41±12.4 years. Subjects had mean IOP values of 18.24±3.6 mmHg. No differences were found in mean MD values (p=0.127): -2.82±4.8 dB and -1.54±2.6 dB between Humphrey and HEP, respectively. No differences were found in mean PSD values (p=0.290) between Humphrey (3.11±3.1) and HEP (2.52±1.9). The strongest correlations were observed between PSDs (0.788; p

Purpose To compare the results obtained between Humphrey Perimeter (Carl Zeiss Meditec, EEUU) and Heidelberg Edge Perimeter (HEP, Heidelberg Engineering, Alemania) tested in a group of glaucomatous patients. Methods A total of 23 eyes of 23 glaucomatous patients were prospectively and consecutively selected. All of them had basal IOP values higher than 20 mmHg and glaucomatous optic nerve head. They were examined with Standard Automated Perimetry (SAP) using 24-2 SITA standard and HEP perimetry using 24-2 ASTA standard algorithm. They performed at least one reliable perimetry with each device. Spearman‘s correlation coefficients were calculated between global indices of both devices: mean deviation (MD), pattern standard deviation (PSD) and visual field index (VFI). Results Mean age was of 65.07±8.67 years. Subjects had mean IOP values of 24.43±1.90 mmHg. The mean MD values were -6.73±6.23 and -2.89±3.26 measured with Humphrey and HEP perimeters respectively. And the mean PSD values were 6.07±3.62 and 3.80±2.45 measured with Humphrey and HEP perimeters respectively. The strongest correlations were observed between MDs (0.683; p=0.001) and between PSDs (0.619; p=0.003). Conclusion Humphrey and HEP perimeter correlated well in some global values. Further studies are required to evaluate the clinical usefulness of HEP perimeter in glaucoma patients.

Purpose To compare the main indices of flicker FDF perimetry (FDF, Heidelberg Engineering, Germany) with standard automated perimetry (SAP). Methods Twenty healthy subjects and twenty-three glaucoma patients were prospectively and consecutively selected. Glaucomatous patients had an intraocular pressure higher than 21 mmHg and glaucomatous optic disc appearance. All of them underwent at least one reliable perimetry with each device. SAPs were performed with a FDF perimeter (24-2 ASTA-Standard test) and Humphrey perimeter (Carl Zeiss (24-2 SITA standard algorithm). The Kolmogorov Smirnov test was applied to check that the data were normally distributed. Only one eye per subject was included in the study. Pearson correlations were calculated between both devices : mean deviation (MD), pattern standard deviation (PSD), and visual field index (VFI). Results Mean age was 58.41±12,4 years. MD of SAP was -2.82 ± 4.8 dB, and MD of FDF was -4.47 ± 4.8 dB (p=0.123); PSD of SAP was 3.11 ± 3.1, and PSD of FDF was 3.14 ± 1.4 (p = 0.953). The correlations between MDs were 0.521 (p

Purpose To compare the main indices of flicker FDF perimetry (FDF, Heidelberg Engineering, Germany) with standard automated perimetry (SAP) in glaucoma patients. Methods Twenty-three open-angle glaucoma patients were prospectively and consecutively selected. Glaucomatous patients had an intraocular pressure higher than 21 mmHg and glaucomatous optic disc appearance. All of them underwent at least one reliable perimetry with each device. SAPs were performed with a FDF perimeter (24-2 ASTA-Standard test) and Humphrey perimeter (Carl Zeiss (24-2 SITA standard algorithm). The Kolmogorov Smirnov test was applied to check that the data were normally distributed. Only one eye per subject was included in the study. Spearman correlations were calculated between both devices : mean deviation (MD), pattern standard deviation (PSD), and visual field index (VFI). Results : Mean age was 65.07±8.67 years. MD of SAP was -6.73 ± 6.23 dB, and MD of FDF was -7.70 ± 5.84 dB (p=0,123); PSD of SAP was 6.07 ± 3.62, and PSD of FDF was 3.91 ± 1.89 (p = 0.953). The correlations between MDs were 0.736 (p 0.05) Conclusion Moderate correlations were found between main visual field indices both devices. Altough no differences were found, FDF tends to present MD values lower than Humphrey.

espanolIntroduccion. Es frecuente que en los pacientes con patologia general diversa y del territorio oral y maxilofacial tengamos que dotarles de medios extraordinarios para facilitar la alimentacion y aspiracion digestiva. Presentamos una nueva metodologia para la instalacion de lo que denominamos Sondas Digestivas Ectopicas (SDE). Material y Metodo. Empleamos las sondas digestivas convencionales, solo que haciendolas llegar al tramo digestivo por lo que denominamos vias ectopicas de instalacion y entre las mas habituales en nuestras manos estaria, la sonda digestiva pericraneal o submental o a traves de heridas y trayectos creados o no del territorio craneofacial. Presentamos un caso clinico de un paciente con fracturas conminutadas del territorio craneomaxilofacial al que la SDE se instalo en la region temporal y supracigomatica izquierda. Resultados. Conseguimos con esta nueva metodologia evitar tecnicas mas agresivas como la gastrostomia percutanea o quirurgica y evitar el uso de los la via nasal u oral, cuando estos no son practicables o no estan indicados manteniendo una via fiable de aspiracion y alimentacion digestiva. Conclusiones. Los beneficios de esta tecnica deben hacer que incorporemos la SDE en nuestro arsenal terapeutico. EnglishIntroduction. Patients with a variety of general pathologies and oral and maxillofacial pathologies often require extraordinary measures for to ensure enteral feeding and aspiration. We report a new method for inserting what we call "ectopic enteral tubes" (EET). Material and Method. Conventional enteral tubes are inserted into the digestive tract using "ectopic" insertion routes. At present, the most common routes available are the pericranial or submental routes, as well as wounds and trajectories that are present or created expressly for this purpose in the craniofacial area. We report the clinical case of a patient with comminuted fractures of the temporal and left suprazygomatic region, where the EET was inserted. Results. This new method obviates the need for more aggressive techniques, such as surgical or percutaneous gastrostomy, and the use of natural facial orifices when not practicable or not indicated while maintaining a viable route for enteral feeding and aspiration. Conclusions. EET is a useful addition to our therapeutic arsenal.

Both endotracheal intubation and the laryngeal mask are already established and have their specific applications. The Combitube SA applied submentally is useful for patients with serious craniomaxillomandibular fractures, particularly those which disturb the occlusion and cause serious haemorrhage with attendant difficulties for intubation. Combitube SA used via the submental route will facilitate fracture reduction and temporary maintenance of fractures, so that bleeding, pain and airway problems may be managed more easily until alternative intubation has been achieved.

The submental route for endotracheal intubation is well known and this paper reports the use of the same route for the laryngeal mask airway. This technique can be used whenever it is considered too awkward to perform submental, transoral or transnasal endotracheal intubations. When the surgery has been completed, the mouth is left open to allow the laryngeal mask to be removed; it cannot be left in place in cases of intermaxillary fixation. It is necessary to detach the laryngeal mask orally, never submentally, as it is impossible to remove the mask via the submental route.

Summary An intra-arterial chemotherapy procedure in patients with malignant tumours in the oral and maxillo-facial region which, from the vascular point of view, can be dependent on the external carotid artery and/or its branches is presented. Particularly for the prevention of catheter infection, obstruction, etc., a subcutaneous pouch, connected to the infusion catheter, is implanted subcutaneously in the submastoid region.

Once the patient has been intubated, the vertex of the scalp and the nasotracheal tube are scrubbed and aseptically prepared. Careful washing of the scalp and hair is also done the night before surgery, and the area is protected with a sterile cap in the case of scheduled patients. After the aseptic preparation, two silk sutures (0 or 00) are placed pericranially and around the corrugated tubing with an atraumatic needle (Figure). It is important to maintain sufficient distance between the entry and exit of every suture, i.e., approximately 2 or 3 cm, to

The optical quality of a set of IOLs (modeling set: one monofocal and two bifocals) was assessed through focus by the area under the modulation transfer function (MTFa) metric and related to the visual acuity (VA) defocus curves of pseudophakic patients implanted with said IOLs. A non-linear relationship between the MTFa and clinical VA was obtained with an asymptotic limit found to be the best VA achievable by the patients. Two mathematical fitting functions between clinical VA and MTFa were derived with high correlation coefficients (R-2 >= 0.85). They were applied to the MTFa obtained from a different set of IOLs with advanced designs (trial set: one extended range of vision -ERV-, one trifocal ERV and one trifocal apodized) to predict VA versus defocus of patients implanted with these IOLs. Differences between the calculated VA and the clinical VA for both fitting models were within the standard deviation of the clinical measurements in the range of -3.00 D to 0.00 D defocus. thus proving the suitability of the MTFa metric to predict clinical VA performance of new IOL designs. (C) 2018 Optical Society of America under the terms of the OSA Open Access Publishing Agreement

A technique of intubation is presented, which can be a valuable alternative to tracheostomy. The tube is passed through a submental incision into the oral cavity.