Prospects for the Botulinum Toxin Use in the Treatment of Children`s Strabismus. Review

The review presents information concerning the botulinum toxin use in the treatment of children`s strabismus; highlights aspects of the safety and the complications frequency. It contains information about the methods and doses of botulinum toxin injection, and also considers the cases of necessity of further surgery. There are several ways of introducing BTA: the traditional transconjunctival method of administration under the control of electromyography, used by most ophthalmologists, is not acceptable for treating pediatric patients, transconjunctivally into the subtenon space 10 mm from the limbus into the projection zone of the medial rectus muscle using a 1.0 ml tuberculin syringe with 27G needle, introduction to the muscle with the opening of the conjunctiva, which is safer, is carried out under complete visual control and with the release of extraocular muscle. According to the domestic and foreign literature data we can conclude that the injection of botulinum toxin may be an alternative or complement to surgical techniques, injection of botulinum toxin in the treatment of strabismus in children may be an alternative or complement to surgical and pleopto-orthopto-diploptic correction methods, although not in all clinical cases. The treatment approach of such patients should be comprehensive. There are reports that BoNT-A reduces eye deflection in more than 50 % of patients and provides satisfactory long-term results in infants and children. The average safe dose for Botox is 1-3 units for the muscle. The frequency of complications increases with higher doses (especially> 10 units) and with the transconjunctival route of administration without electromyographic control. This clinical example illustrates the effectiveness of botulinum toxin for the non-concomitant strabismus treatment.

A comparative study of Mantoux test and BCG test in diagnosis of childhood tuberculosis

Background: India has one of the highest tuberculosis (TB) burdens globally. However, few studies have focused on TB in young children, a vulnerable population, where lack of early diagnosis results in poor outcomes.Methods: The present study was undertaken to assess the sensitivity and specificity of tuberculin test (Mantoux) and BCG test in diagnosis of childhood tuberculosis and to compare above tests as a diagnostic tool and to assess the impact of factors affecting the test. Mantoux test was done with 1 TU contained in 0.1 ml of PPD R23 with tween 80 solution. BCG test was done using a heat stable freeze-dried vaccine, after fresh reconstitution and injected intradermally in left deltoid region with a tuberculin syringe and 27 G hypodermic needle.Results: Tuberculous cases were more common in malnourished subjects more so with severe malnutrition. While maximum positivity 89% was obtained with BCG test, it was only 63% with Mantoux test, done with 5TU of PPD-RT-23. BCG was always positive whenever PPD was positive in any group of children. Sensitivity of Mantoux test was around 63% whereas that of BCG test was 89%. BCG test was more significantly associated with disease than tuberculin test (p <0.001).Conclusions: BCG test is a very sensitive and specific test for diagnosis of childhood tuberculosis. Mantoux test is affected by malnutrition and severity of disease whereas BCG test is affected only minimally. BCG test is more sensitive than Mantoux test (with 5TU PPD RT 23 Tween 80). A BCG induration of ≥10 mm or Mantoux induration ≥15 mm or an accelerated BCG test is indicative of active disease, irrespective of vaccination status of the patient.

Volumetric Evaluation of Different Obturation Techniques in Primary Teeth Using Spiral Computed Tomography

Background: Various obturation techniques have been evaluated for better filling of the root canals in primary teeth using different methods. Spiral Computed Tomography (SCT) is a new revolution in the pediatric endodontics for assessment of quality of the obturation from 3 dimensions. Objectives: To evaluate the efficiency of 5 different obturation methods in delivering the filling material into the canals of primary teeth using Spiral Computed Tomography scan. Study design: A total of 50 canals of primary teeth were prepared, divided into 5 groups with 10 canals in each group and obturated with Zinc Oxide Eugenol cement using 5 different obturation techniques such as Local anesthetic syringe, Tuberculin syringe, Endodontic plugger, hand held Lentulo-spiral, and Lentulo-spiral mounted on slow speed hand piece. The pre and post obturation volume and finally the Percentage of Obturated Volume (POV) were calculated using SCT scan for each group. The data obtained was statistically analyzed using One-way Analysis of Variance (ANOVA) and Tukey's post-hoc test. Results: Lentulo-spiral hand held showed highest POV value followed by Lentulospiral mounted to hand piece, Tuberculin syringe and Endodontic plugger; whereas Anesthetic syringe had least POV (P &lt; 0.05). Conclusion: Lentulo-spiral hand held is the best obturating technique among the 5 groups evaluated as the canals of this group showed maximum percentage of filled material. However, a further study with large sample size is highly essential.

Neuroprotective effects of herbal cocktail on cerebrovascular dysfunction in rats with induced hyperhomocysteinaemia

Introduction: Hyperhomocysteinaemia (HHcy) is an established risk factor for cardiovascular, cerebrovascular, peripheral vascular diseases and neurodegenerative disease. The effect of this HHcy on vascular diseases could potentially cause vascular pathology features. Experimental studies have demonstrated that Hcy can be neurotoxic to brain, hippocampus area. Methods: The present study was conducted to compare the possible neuroprotective effects of different herbal cocktail in HHcy-induced rats’ brain cerebrovascular dysfunction model. Rats were divided into nine groups: Group I - Controls received the same volume of saline solution (0.5 mL/100 g of body weight). Group II served as HHcy and received homocysteine 0.03 μmol/g of b.w. daily for 30 days. Group III served as HHcy and received homocysteine 0.03 μmol/g of b.w. + Artemisia Judaica extract (AJ) (50 mg/kg per oral by oral feeding needle with tuberculin syringe) daily for 30 days. Group IV served as HHcy and received homocysteine 0.03 μmol/g of b.w.+ Panax ginseng extract (PG) (50 mg/kg per oral by oral feeding needle with tuberculin syringe) daily for 30 days. Group V served as HHcy and received homocysteine 0.03 μmol/g of b.w. + Polygonum multiflorum extract (PM) (400 mg/kg per oral by oral feeding needle with tuberculin syringe) daily for 30 days. Group VI served as HHcy and received homocysteine 0.03 μmol/g of b.w. + AJ + PG with the same dose of previous group daily for 30 days. Group VII served as HHcy and received homocysteine 0.03 μmol/g of b.w. + AJ + PM with the same dose of the previous group daily for 30 days. Group VIII served as HHcy and received homocysteine 0.03 μmol/g of b.w. + PG + PM with the same dose of the previous group daily for 30 days. Group IX served as HHcy and received homocysteine 0.03 μmol/g of b.w. + AJ + PG + PM with the same dose of previous group daily for 30 days. The hippocampus of brain samples was collected at the end of the experiment and measuring oxidative stress markers (CAT, SOD, MDA and NO), inflammatory mediators (IL-6 and BDNF), histopathological examination and comet assay. Results: Revealed data showed that the homocysteine induces SOD, CAT depletion, and an increase in AChE, MDA, NO, IL-6, and BDNF. A mixture of PG and PM or the individual treatments showed an ameliorative response for all parameters. In general, oxidative stress parameters, inflammatory mediator, neurotrophic factor, pathological examination and comet were degenerate against HHcy but did not differ significantly compared to AJ group. Conclusion: Better physiological and histological characteristics were in PG and PM and their combination groups compared with HHcy and ameliorated nearly the control group.

Management of Surgical Complications

•Glaucoma filtration surgery (GFS) has been associated with higher long-term failure rates and a substantially higher risk profile than most other ophthalmic surgeries. •Identifying and properly managing complications associated with GFS is essential in ensuring the best possible outcome. •Infection is a devastating complication of GFS that must be considered in a separate category (please see Chapter 7 for blebitis and bleb-related endophthalmitis). •Complications unique to glaucoma drainage devices (GDD; see Chapter 12) will be discussed at the end of the chapter. •One simple way to diagnose a complication resulting from GFS is to subcategorize possibilities according to the IOP and anterior chamber (AC) depth. •Table 13.1 shows the four potential outcomes after GFS, and the text below provides additional details about each potential complication. •Usually occurs in the first few months after surgery. •The most common complication of trabeculectomy. •Due to progressive episcleral fibrosis and blockage under the scleral flap. •Incidence has decreased due to intraoperative use of antifibrotics. •Bleb appears constricted, shallow, or flat with increased vascularity and loss of microcysts. •Negative Seidel test. •Gonioscopy reveals an open sclerostomy site, which is essential to differentiate from an inadequate fistula or fistula blockage from iris, blood, fibrin, or vitreous. •Anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) may reveal adherence of Tenon’s capsule and conjunctiva to underlying sclera. •Approached in a stepwise fashion. • Decreases rate of episcleral fibrosis in hopes of rescuing the function of the bleb.•Prednisolone acetate 1% every 2 hours for first 1 to 2 weeks, then taper slowly over 2 to 3 months. •Administered if early signs of bleb failure/episcleral fibrosis are present. •Technique •Instill topical anesthesia followed by direct application of a cottontipped pledget approximately 90 to 180 degrees away from the bleb. •Use a 30-gauge needle on a tuberculin syringe to inject 5 mg (0.1 cc) of undiluted 5-fluorouracil (5-FU; available in a concentration of 50 ug/mL) under the conjunctiva at the anesthetized site. •Avoid areas of bleb elevation and areas that show increased conjunctival vascularity.

Disorders of Neuromuscular Transmission

Myasthenia gravis is the most common disorder affecting the neuromuscular junction (incidence: 5 per 100,000). Ocular involvement accounts for initial complaints in 75% of patients. Of patients presenting with ocular myasthenia, 50–80% eventually develop generalized myasthenia, usually within two years of onset. Myasthenia gravis is an autoimmune disease caused by the presence of antibodies against acetylcholine receptors, which leads to decreased number of available receptors (usually less than one-third that of normal). It is associated with other autoimmune diseases, including thymoma, dysthyroidism, sarcoidosis, pernicious anemia, aplastic anemia, and collagen vascular diseases (e.g., rheumatoid arthritis, lupus, ankylosing spondylitis, ulcerative colitis, Sjögren’s syndrome). ■ Side effects: cholinergic (e.g., bradycardia, angina, bronchospasm) ■ Steps for performing Tensilon test: 1. Prepare 10 mg/mL Tensilon in a tuberculin syringe, 0.6 mg atropine in a tuberculin syringe, and 10 mL normal saline. 2. Establish intravenous access using butterfly needle; flush with 1 mL normal saline. 3. Inject 0.2 mL Tensilon, flush with 1 ml normal saline, and wait 1 min for possible side effects. 4. Inject 0.6 mL Tensilon, flush with 1 mL normal saline, then attach atropine syringe. 5. Wait 3 min; improvement of ptosis or diplopia constitutes a positive test. Improvement of ptosis after application of ice for 2 min on the ptotic eyelid constitutes a positive test. The ice test is especially useful for very young, elderly, or ill patients. Improvement of ptosis or ocular alignment after 30–45 min of sleep constitutes a positive test. ■ Repetitive nerve stimulation with supramaximal stimuli delivered at 2–3 Hz: Rapid decrement of the amplitude of compound muscle action potentials (CMAPs) ≥10–15% confirms the diagnosis in 95% of cases. ■ Single-fiber electromyography (EMG; e.g., frontalis muscle) is highly sensitive (88–99% sensitivity). A positive test consists of increased jitter (increased latency between nerve stimulation and action potential of muscle fibers) and increased blockage (response failure). Acetylcholine receptor antibody is not detectable in about 15% of patients. Muscle-specific kinase is detected in 20% patients who have no acetylcholine receptor antibody and is usually detected in patients with generalized myasthenia gravis.

247 SUCCESSFUL ARTIFICIAL INSEMINATION IN THE CORN SNAKE (ELAPHE GUTATTA), USING FRESH AND COOLED SEMEN

The purpose of this investigation was to develop a non-invasive technique to artificially inseminate snakes using the corn snake, Elaphe gutatta, as the model representative for this taxon. Semen was collected by first applying pressure to the lower abdomen in a continuous distal motion toward the cloaca to remove any feces or urates. The cloaca was then gently washed using phosphate-buffered saline, and a more localized pressure was applied to each side of the vent to evert the hemipenes and, subsequently, the ejaculate. The semen was collected using a sterile transfer pipette and placed into 70 to 90 �L of medium (TL-HEPES solution; Cambrex Bio Science, Inc., Baltimore, MD, USA04–616F) in a sterile microcentrifuge tube, and then analyzed for overall motility, rate of forward progression (RFP, 0–5), and concentration. Based on a previously reported procedure, 10 females were inseminated with either fresh (n = 5) or cooled semen (n = 5; refrigerated for 3 days) one week after recovering from a hibernation period required to stimulate reproduction in this species. The overall sperm motility and concentration for females inseminated with fresh or cooled semen was 92%, 9.6 million sperm mL-1; and 85%, 6.1 million sperm mL-1, respectively. Immediately prior to insemination, the same method for expressing feces and urates in the males was applied to the females. The insemination dose (50 �L semen per oviduct) was drawn into a 1-mL latex- and silicone-free tuberculin syringe (Norm-Ject; VWR, Batavia, IL, USA) that was connected to a feeding/dosing needle (EJAY International, Issaquah, WA, USA) with a ball tip to prevent any potential damage during the insemination. The tip of the needle was then moved around the inner tissue of the vent to relax the cloaca, and the insertion continued until resistance was found indicating the vicinity of the oviducts. The extended semen was carefully deposited on both sides, and then the needle was slowly withdrawn. The offspring were tested for parentage to verify the success of the insemination. Blood was collected from the dorsal aorta posterior to the cloaca and stored in 10 mM Tris at 4�C. The DNA was extracted using a phenyl : chloroform : isoamyl alcohol (PCI) extraction method. Eight microsatellite loci were used for the paternity exclusion analysis: Eob�1, Eob�3, Eob�10, Eob�13, Eob�16, Eob�34, Eob�366, and Eob�373 (IDT, Coraville, IA, USA). All males and females in the collection were tested, and parental candidates were excluded if 2 or more allele mismatches occurred. From the total number of females inseminated, 3 females laid 51 eggs. Two females inseminated with cooled semen laid 36 eggs, of which 5 eggs were hatched, and the remaining were either unfertilized (n = 25) or non-viable (n = 6). All 5 hatched eggs were laid by one of the females. The third female inseminated with fresh semen laid 15 eggs, resulting in 5 hatching and 10 unfertilized eggs. The parentage test validated the AI a success as the alleles correlated between the adults and the offspring. In conclusion, artificial insemination was successful using both freshly collected and cooled (3 days) semen. Further studies are underway to improve the success rate in order to maximize the efficiency of this technology, and thus assist in the genetic preservation of endangered snake species.

Use Metric Weight to Express Liquid Doses;Tuberculin Syringe Confused with Insulin Syringe;Duragesic Patch Abuse

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

Multipurpose Rubber Tubing for Use in Tympanocentesis and Pneumatic Otoscopy

We were delighted to read the article, "Simplified Technique for Tympanocentesis" (Kaplan SL, Feigin RD: Pediatrics 62:418, 1978). Indeed, we have tried the combination of rubber tubing, tuberculin syringe, and short beveled needle and found it to be an easy and effective method for aspiration of the middle ear. Using the Welch-Allyn operating otoscope requires only a 3.75-cm (1.5 in) needle. With the diagnostic and fiberoptic pneumatic otoscopes of the same brand, we find it useful to use an 8.8-cm (3.5 in) spinal needle and bend it to 45 degrees approximately at the middle.