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Gallbladder blunt trauma is uncommon and represents about 1.8% of blunt abdominal injuries. In combination with other organic injuries and previous surgical procedures, diagnosis may be a challenge. We report a case of a patient who was previously admitted for surgery and recovered after an abdominal trauma with a primary diagnosis of small fracture of the liver. An accurate diagnosis was delayed because of silent clinical presentation. Surgical cholecystectomy was performed. [ABSTRACT FROM AUTHOR]

In this review we summarise the recent developments regarding the experimental and clinical use of mesenchymal stem cells (MSCs), focusing mainly on the treatment of gastrointestinal disorders. Next to their relevance in the field of regenerative medicine and immunology, this population of cells has also raised great expectations for possible applications in cancer therapy. While clinical trials were able to demonstrate the efficacy of MSCs in cases of inflammatory bowel disease and degenerative conditions of the liver, controversial results have been presented regarding their antineoplastic potential in gastrointestinal tumours. MSCs can differentiate into a large variety of specialised cells. They are capable of regulating both wound healing and immune responses through paracrine and endocrine signalling. Moreover, MSCs can be transfected with a great number of different therapeutic genes - considering their ability to selectively migrate towards neoplastic tissues, this feature allows for targeted therapy of solid tumours. Transfected genes can be designed so that they are expressed exclusively in the vicinity of the tumour, eventually triggering apoptosis in cancer cells. In this review, we demonstrate the natural distribution of exogenously applied MSCs in the host. Furthermore, we mention various methods of tracking MSCs in vivo and different parameters of administration that tend to influence therapeutic outcome (e.g., origin of MSCs, mode of application, or the potency of transfected genes). Finally, this review points out the hazards of MSC therapy, emphasising the risks related to their widespread clinical use., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To investigate the impact of KRAS mutation variants on the activity of regorafenib in SW48 colorectal cancer cells., Materials & Methods: Activity of regorafenib was evaluated in isogenic SW48 KRAS wild-type (WT) and mutant cells. Subcutaneous xenografts (KRAS WT and G12C mutant variants) in NOD/SCID mice were analyzed to elucidate the effect of regorafenib treatment in vivo., Results: Compared with KRAS WT cells, all mutant variants seemed associated with some degree of resistance to regorafenib-treatment in vitro. In vivo, activation of apoptosis (TUNEL) and reduction of proliferation (Ki67) after treatment with regorafenib were more pronounced in KRAS WT tumors as compared with G12C variants., Conclusion: In SW48 cells, exon 2 mutations of the KRAS gene may influence antitumor effects of regorafenib.

Background: Desmoid-type fibromatosis (DTF) is a "locally aggressive, but not metastasizing" proliferation of soft tissues that is difficult to diagnose pre-operatively. Surgical en bloc resection of abdominal DTF can be difficult or an overtreatment. The diagnosis is therefore crucial for the decision making to minimize unnecessary morbidity., Case Report: A 33-year old female patient with an incidental intra-operative diagnosis of a 20 cm mesenteric mass involving the duodenum, jejunum, ileum and right colon underwent extended resection for a DTF. A review of the literature, limited only to mesenteric localization of DTF, was performed for the diagnosis, treatment and outcome., Results: Twentyfive cases of DTF have been analyzed. Pre-operative diagnosis was suspected in 20% but 95,2% of all the patients underwent resection without pre-operative diagnosis. In two cases, intra-operative, frozen section diagnosis was unsuccessfully attempted. Complications were reported in 12%, recurrence in 4%, and mortality in 0% of the patients., Conclusion: Pre-operative diagnosis of mesenteric DTF is challenging in most cases, but it can avoid unnecessary extended surgery. Efforts should be made to achieve a correct pre-operative diagnosis based on more reliable imaging and pathological features, to help in decision making.

The Achilles' heel of pancreatic surgery is the management of the pancreatic stump. Leakage from pancreatic anastomosis with subsequent fistula, abscess formation, sepsis, or bleeding is one of the most common causes of morbidity and mortality, and it also contributes significantly to prolonged hospitalization and increased hospital expenses. Many surgical methods have been developed aimed at reducing the incidence of post-operative pancreatic fistula. However, the best technique for pancreatico-enteric reconstruction continues to be disputed. Herein, we describe an interim analysis of 35 consecutive pancreatico-duodenectomies, all with the same standardized technique that combines microsurgical technique for duct-to-mucosa pancreatico-jejunostomy with the routine use of fibrin sealant. The rate of leakage of pancreaticojejunostomy was 5,7% (n=2), all of which were grade A fistulas, treated conservatively. The increased precision of magnification instruments and microsurgical technique for duct to mucosa anastomosis, combined with routine sealing of the pancreatic anastomosis are key factors to efficiently manage the pancreatic stump. The good results obtained and especially the minimal rate of fistula suggests that this technical solution is a safe, feasible and reliable approach for pancreatic reconstruction after pancreatico-duodenectomy.

Introduction: Many surgical options exist to treat rectal prolapse with different indications, feasibility and results in urgent and complicated cases. These include perineal or abdominal approaches including rectopexy with or without resection. Perineal approaches have reduced surgical invasivity and hospital stay if compared to transabdominal approaches by open surgery or laparoscopy. Up to now there was still a clear dividing line for surgical treatment between the perineal approach, used more for complicated emergency case while the transabdominal open, or laparoscopic approach more common in elective surgery, but more complex to perform., Presentation of Case: A 37 year old female patient affected by psychiatric disease presented with an unreducible second recurrence of a complicated rectal prolapse. The patient was treated with a third Altemeier procedure but now performed under laparoscopic control. The patient recovered promptly without any complication or recurrence up to the 24 months follow-up., Discussion: To the best of our knowledge, this is the first case report describing the combined laparoscopic-perineal approach for the treatment of a complicated recurrence of rectal prolapse. The technical feasibility, the rapidity, the optimal outcome and the rationale behind this option all suggest that this laparoscopic assistance certainly allows an implementation of the effectiveness, safety and results of an established effective perineal approach., Conclusion: This combined approach has the advantage of maintaining the simplicity and rapidity of conventional perineal surgery, adding the advantages of abdominal control and avoiding the risks, the invasivity, and the longer duration of more complex laparoscopic procedures., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To determine the efficacy of an automated, interactive, telephone-based health communication intervention for improving glaucoma treatment adherence among patients in 2 hospital-based eye clinics., Method: A total of 312 patients with glaucoma (18-80 years of age) were enrolled in a randomized controlled trial at 2 eye clinics located in hospitals in the southeastern United States. These patients were considered nonadherent because they did not take their medication, refill their medication, and/or keep their appointments. The treatment group received an automated, interactive, tailored, telephone-based health communication intervention and tailored print materials. The control group received usual care., Main Outcome Measures: Adherence with medication taking, prescription refills, and appointment keeping measured by interviews, medical charts, appointment records, and pharmacy data., Results: A statistically significant increase was found for all adherence measures in both the intervention and control groups. Interactive telephone calls and tailored print materials did not significantly improve adherence measures compared with controls., Conclusions: During the study period, patient adherence to glaucoma treatment and appointment keeping improved in both study arms. Participation in the study and interviews may have contributed. Strategies that address individuals' barriers and facilitators may increase the impact of telephone calls, especially for appointment keeping and prescription refills., Application to Clinical Practice: Glaucoma patient care should include reminders about consistent use of medication and the importance of keeping appointments. More frequent, and personalized, telephone contact may be helpful to patients who are known to be nonadherent., Trial Registration: clinicaltrials.gov Identifier:NCT00794170.

Cholecystoduodenal fistula, a rare complication of biliary lithiasis, occurs in 0.5% to 3% of patients affected by cholelithiasis. Diagnosis is not easy and is usually incidental at surgery. The literature guidelines call for a laparoscopic approach to treating these patients; here, however, we report a case of a very elderly patient in which, among other reasons, open surgery was the treatment of choice to decrease morbidity and mortality.

Aim: In elderly the incidence of the emergency gastric ulcer complications, perforation and bleeding are increasing, with a difficult management of these patients for their concomitant diseases. The aim of this work is to analyze the therapeutical approach of emergency gastric ulcer complications in elderly patients, in order to establish the factors affecting the morbidity and mortality., Methods: Patients older than 70 years, presenting gastric ulcer, observed in a tertiary University Hospital from 1995 to 2003, have been considered for the present study. Two groups of diseases have been examined: ulcer perforation and bleeding ulcer. Age, sex, risk factors, comorbidity, methods of diagnosis, ulcer characteristics, treatment, morbidity, mortality, hospitalization time and follow-up have been considered in each group., Results: Thirteen elderly patients with perforated gastric ulcer have been observed: 9 (69.2%) females and 4 (30.8%) males with a mean age of 80.5 years (range 70-90). Four patients were hospitalized in suburban hospital with an average time between the diagnosis and the surgery of 36 h, while the remnants were hospitalized directly in our Department with a medium waiting time of about 2 h. The surgical procedures were: simple closure with omentum patch in 11 cases (84.6%), and antrectomy in 2 cases (15.4%), in which the antrum was multiply perforated. Two patients presented an ulcer larger than 2 cm treated with simple suture and omental patch without morbidity and mortality. Three patients (23%) died postoperatively, due to septic shock, ventricular fibrillation and intraoperative massive haemorrhage, 2 of these patients came from other hospitals. Twenty-eight elderly patients with bleeding gastric ulcer have been observed during the same period: 13 (46.4%) females and 15 (53.6%) males with a mean age of 79.6 years (range 71-91). Except 2 patients submitted to endoscopic treatment both with adrenaline injection, all the remnant patients were managed with medical therapy (H2-receptor antagonist or proton pump inhibitors and in 7 patients [24.1%] antihaemorrhage drugs), and clinical observation, with a endoscopic control 3-4 days after from the first endoscopy. One of the 2 patients endoscopically treated developed a ulcer perforation after 11 days, and the other one rebled, without possibility of any kind of treatment due to his instable condition of health. Three patients (10.7%) died during their hospital stay not for causes strictly due to the gastric haemorrhage., Conclusions: Our results suggest that the early diagnoses and early treatment are 2 basic factor on the prognosis of elderly patients with perforated gastric ulcer. The choice between simple closure, with or without vagotomy, or gastrectomy depends from preoperative and operative health conditions of the patient. In patients with ulcer larger than 2 cm, Graham's technique can be performed safely if the preoperative and intraoperative conditions are favourable. Elderly patients with gastric ulcer bleeding show an high risk of morbidity and mortality, related to the risk factors like non steroid anti-inflammatory drugs (NSAIDs) intake or smoke. Repeated endoscopy and antiulcer drugs can manage the high stage patients of Forrest's classification with a low rate of morbidity and mortality. According to literature surgical treatment should be reserved after the second failure of endoscopic treatment.

Background: Ocular toxocariasis is a rare infection caused by the nematode larvae of toxocara canis, which is commonly found in dogs. Human transmission is usually via geophagia, the ingestion of food contaminated with the toxocara eggs, or contact with infected puppies, often resulting in devastating ocular and/or systemic effects. Distribution is worldwide; however, a higher incidence is demonstrated in the United States., Methods: A 17-year-old black woman sought treatment at a neighborhood health center with a report of gradual decrease in vision from her left eye over a 3-month period. Her ocular and systemic histories were unremarkable. Anterior segment evaluation revealed no signs of anterior uveitis. The posterior pole showed a 1.5 DD, round, raised, white, subretinal lesion adjacent to the fovea with an overlying serous retinal detachment and retinal hemorrhage., Results: She was referred to a retinologist who performed both fluorescein and indocyanine green (ICG) angiographies. A serum toxocara ELISA test was also ordered. Fluorescein angiography revealed hyperfluorescence consistent with the granuloma. The ICG demonstrated an occult choroidal neovascular membrane (CNV) underlying the area of hemorrhage inferotemporal to the granuloma., Conclusion: This paper illustrates the case presentation and includes an extensive review of the ocular and systemic manifestations of toxocariases. A description of ICG videoangiography, therapeutic approaches, and management will also be discussed.

Background: Indocyanine green (ICG) is a sterile, water-soluble, tricarbocyanine dye that can be used in fundus angiography as an adjunct to sodium fluorescein. It has a peak spectral absorption of 805 nm in blood plasma or blood, as compared with fluorescein, which has a peak spectral absorption of 465 nm. Because the absorption and emission of ICG lies around 835 nm, transmission of energy by the retinal pigment epithelium (RPE) and serosanguinated material is more efficient in this region than in the region of visible light energy. ICG has the property of being approximately 98% bound to blood protein, disallowing extravasation of excessive dye in the highly fenestrated choroidal vasculature., Methods: The characteristics of ICG are discussed, including administration and dosage, adverse reactions and use of infrared filters for fundus photography. In addition, two cases are presented to illustrate the clinical application of ICG for diagnosis and treatment of choroidal neovascular membranes., Results: ICG videoangiography can be used to reveal subfoveal choroidal neovascular membranes not previously identified with fluorescein; angiograms can also be used to dramatically highlight retinal and choroidal changes., Conclusions: The use of ICG for fundus videoangiography provides a more accurate and complete evaluation in certain cases of subretinal and choroidal disease.

The diagnosis and management of aniseikonia has become a lost art. Refractive surgery and intraocular lens implantation has created a new patient population of anisometropia. Measurement of aniseikonia through instrumentation such as the space eikonometer is not readily available. Therefore, estimating the degree of aniseikonia based on the dioptral differences between the two eyes may be the most practical approach. The optical principles of spectacle magnification can be translated by the prescribing eye doctor to reduce ocular image disparity. Contemporary lens designs, such as hi-index and aspherics, allow the practitioner to modify shape and power factors to achieve higher levels of aniseikonic correction in a cosmetically fashionable pair of spectacles.

Background: Analysis of visual disturbances in the central 10 degrees provides valuable data for the low vision clinician. Amsler grid testing in the visually impaired can be poorly visible and it can be difficult to transcribe results. Automated perimeters will accurately map retinal defects, but the equipment is expensive and this technique is time consuming. An Amsler grid was modified using principles of luminance and contrast to improve its accuracy, and its efficacy was compared to an automated perimeter., Methods: Eighteen visually impaired patients (28 eyes) were prospectively evaluated at the Emory Low Vision Laboratory. Each patient had three central threshold visual field tests: automated perimetry (Humphrey model 690), conventional Amsler Grid, and Illuminated High Contrast Macular Grid (IHCMG). The Humphrey central 10-2 threshold automated visual field examination was performed to map the patient's retinal function., Results: The Humphrey analysis identified (mean +/- one standard deviation) 2.4 +/- 1.4 defects per patient with an average percent defect area of 33.4 +/- 14.8 degrees. The IHCMG technique was not significantly different from the Humphrey technique for identifying the number of defects (2.25 +/- 1.5) (p > 0.05) or the percent defect area (26 degrees +/- 20 degrees) (p > 0.05). The conventional Amsler grid technique significantly under-evaluated the retinal defects compared to the Humphrey analysis of the number of defects (p < 0.01) and percent area of defects (p > 0.001)., Conclusions: The IHCMG technique can be used as a simple, rapid and accurate analysis of the central 10 degrees visual field in the low vision patient.

Background: Sarcoidosis is frequently overlooked as a cause of optic neuropathy. A cascade of immune interactions has been cited in the pathogenesis. Optic nerve involvement can be the initial manifestation of systemic disease, making the diagnosis even more elusive. Compatible clinicoradiographic and abnormal laboratory findings along with histologic evidence of noncaseating granuloma are necessary to secure the diagnosis of sarcoidosis., Methods: A case report is presented of a 41-year-old patient with severe papillitis and a junctional scotoma as the first declaration heralding neurosarcoidosis (NS). Co-management with a neuroophthalmologist at an academic teaching hospital prompted the necessary diagnostic studies to preserve vision., Results: Sarcoidosis was diagnosed on the basis of the patient's clinical presentation of rapid vision loss, enlarging mass in the anterior visual pathway revealed by CT and MRI, as well as increased uptake of gallium in the lungs and lacrimal glands. Also considered in the differential diagnosis were glioblastoma, lymphoma, and demyelinating disease., Conclusions: This case represents an example of triage referral involving optometry and academic ophthalmology. Rapid intervention with intravenous corticosteroids should be considered in the face of atypical optic neuritis with a suspected inflammatory etiology.

The systemic conditions described in this paper are (1) sarcoidosis, (2) tuberculosis, (3) toxoplasmosis, and (4) histoplasmosis. The lung is the primary target organ of granulomatous involvement for each of these disorders. This and other similarities may confuse the diagnostic picture; however, appropriate understanding of clinical, epidemiologic, pathophysiologic, immunologic, radiologic, and serologic features assists in clearly establishing a diagnosis. The goals of this paper are to help the clinician develop a working knowledge of these four conditions, as well as an understanding of which tests are appropriate to order, how to interpret their results, and which treatment and management strategies to consider.

Central retinal vein occlusion (CRVO) is a common retinal vasculopathy typically affecting adults in the fifth to seventh decade of life. Systemic disease, particularly hypertension, is often a contributing factor in this sight-threatening condition. CRVO in young adults, however, is an uncommon occurrence with relatively few reported cases in the ophthalmic literature. Two studies performed on young adults (less than 40 years of age) presenting with CRVO revealed that, in most cases, there was not a strong correlation with hypertension or other systemic diseases. In more severe cases, namely those with poor visual outcome from the ischemic type of CRVO, there was a strong correlation with cardiovascular disease and diabetes mellitus. Systemic inflammatory conditions represent a small contributing factor in patients presenting with CRVO. This paper reports on a 21-year-old female with non-ischemic CRVO who was serologically positive for syphilis.

Juvenile X-linked retinoschisis (JXR) is a vitreoretinal dystrophy affecting males only. The macular and peripheral retinal alterations associated with this disorder are very specific. Initially, a stellate-shaped foveal schisis forms; as the patient becomes older, chronic retinal pigment epithelial disturbance leads to macular degeneration. Peripheral retinoschisis may also occur, but is only identified in about half of all patients with JXR. These changes, which represent degenerating vitreous, may be complicated by retinal breaks due to the thin layer of the schisis. This paper presents five cases of JXR in patients ranging from ages 4-70 years and discusses and photodocuments the progression of related retinal changes. A table of differential diagnoses is also included.

Duane's retraction syndrome (DRS) is a congenital abnormality of ocular motility that occurs in about 1% of strabismic patients. Three types have been described and the clinical features include incomitant horizontal strabismus, restricted motility and globe retraction. Head turn, upshoot or downshoot of the adducted eye, and bilaterality may occasionally be present. Since strabismus is invariably present in DRS, careful assessment of extraocular motility should be performed on all children with a suspected or confirmed eye turn. Early diagnosis may save practitioners and parents hours of time and financial investment with orthoptic and surgical management attempts. A case of DRS is presented.

Macular coloboma is a congenital retinochoroidal defect of the macular region. It is a bilateral, nonprogressive condition that is associated with decreased visual acuity and nystagmus. A case of a 14-year-old boy with an unusual presentation of extensive macular colobomata is described. Location of the lesions differentiated this case from true or typical retinochoroidal colobomata. Differential diagnosis also includes postinflammatory scarring.

Alcohol amblyopia is a disorder that affects a small percentage of alcoholic patients, most of whom are nutritionally deficient. A battery of tests is required to make the diagnosis including color vision and field testing. Once the diagnosis is made, physical, emotional, and visual rehabilitation should be undertaken. A case of alcohol amblyopia is presented along with optometric management techniques.