Our laboratory is investigating the suprachoroidal and intravitreal injection of topotecan using microneedles in a rabbit model of retinoblastoma (Fig 2). Therapeutic options for retinoblastoma have rapidly evolved in recent years, with a paradigm shift in standard treatment protocols toward the targeted delivery of chemotherapeutic agents. Increased use of intra-arterial and intravitreal types of chemotherapy with focal consolidation, along with the reduced use of systemic chemotherapy, enucleation, and external beam radiotherapy, has contributed to improved rates of survival and globe salvage while also minimizing unwanted treatment-related adverse events. However, these approaches are not without complications, and a need still exists to weigh the risks and benefits of treatment and to evaluate their long-term effects. New therapies being investigated include novel carriers and routes for local drug delivery as well as molecularly targeted therapies. Our under- Suprachoroidal Injection Suprachoroidal injection with microneedles is a route of targeted drug delivery to the choroid and retina that poses minimal risk of extraocular tumoral spread, because the vitreous and subretinal spaces are not entered. In a rabbit model, bevacizumab was determined to be A B safe and effective when injected into the suprachoroidal space; high concentrations were found in the posterior segment tissues. When the microneedle injects compounds into the supraciliary space, these C D compounds posteriorly spread into the suprachoroidal space. Survival of retinoblastoma in less-developed countries impact of socioeconomic and health-related indicators. Targeted retinoblastoma management: when to use intravenous, intra-arterial, periocular, and intravitreal chemotherapy. Retinoblastoma management: advances in enucleation, intravenous chemoreduction, and intra-arterial chemotherapy. The International classification of retinoblastoma predicts chemoreduction success. High-risk retinoblastoma based on international classification of retinoblastoma: analysis of 519 enucleated eyes. Incidence of pineal gland cyst and pineoblastoma in children with retinoblastoma during the chemoreduction era. Results of combined chemotherapy and radiotherapy for advanced intraocular retinoblastoma. Chemoreduction plus focal therapy for retinoblastoma: factors predictive of need for treatment with external beam radiotherapy or enucleation. Pathologic risk-based adjuvant chemotherapy for unilateral retinoblastoma following enucleation. Retinoblastoma patients with high risk ocular pathological features: who needs adjuvant therapy? Safety evaluation of ocular drug delivery formulations: techniques and practical considerations. Histopathologic findings in eyes with retinoblastoma treated only with chemoreduction. Chemosensitivity profiles of primary and cultured human retinoblastoma cells in a human tumor clonogenic assay. The technique of ophthalmic arterial infusion therapy for patients with intraocular retinoblastoma. Selective ophthalmic arterial 108 Cancer Control injection therapy for intraocular retinoblastoma: the long-term prognosis. Intra-arterial chemotherapy for retinoblastoma in 70 eyes: outcomes based on the international classification of retinoblastoma. Intra-arterial chemotherapy (ophthalmic artery chemosurgery) for group D retinoblastoma. Effect of intraarterial chemotherapy on retinoblastoma-induced retinal detachment. Ophthalmic artery chemosurgery for the management of retinoblastoma in eyes with extensive (>50%) retinal detachment. Combined, sequential intravenous and intra-arterial chemotherapy (bridge chemotherapy) for young infants with retinoblastoma. Superselective intraophthalmic artery chemotherapy in a nonhuman primate model: histopathologic findings. Intra-ophthalmic artery chemotherapy triggers vascular toxicity through endothelial cell inflammation and leukostasis. Supraselective intra-arterial chemotherapy: evaluation of treatment-related complications in advanced retinoblastoma.
This means that it is able to image the ciliary body, unlike optical coherence tomography. Although these parameters are important in angle closure, no firm cut-off values have been established at this stage. Even though there are statistically significant differences between the groups, overlap and the small clinical differences that could make these be difficult to reliably separate. Several anatomical locations have been highlighted as regions of interest in angle closure disease, and these have been subsequently used to differentiate subtypes of the disease. As a result, adjunctive imaging technologies may assist in determining the most appropriate treatment for the individual patient. Pupil block angle closure Firstly, in the pupillary block aetiology, aqueous humour cannot pass from the posterior chamber to the anterior chamber due to iridolenticular touch. Importantly, 25 However, similar to optical coherence tomography, there are a number of limitations to ultrasound biomicroscopy, one of which is confusion as to where to put the apex of the angle when measuring it in degrees (at the level of the scleral spur, or at the level of the greatest angle depth). This is even in the context of studies that suggest that diagnoses of plateau iris should be made with ultrasound biomicroscopy in the presence of an anterior positioned ciliary body. One sign is the characteristic hook-like insertion of the iris into the angle, and the otherwise flat iris plane towards the pupil. Interestingly, the angle width may range from wide open to the ciliary body to almost closed (apposition), depending on the patient. Although it has been described to be the most common cause of angle closure disease, its therapeutic treatment, typically through the application of a laser peripheral iridotomy, frequently results in residual, chronic closure. In such cases, it becomes apparent that it is not the sole aetiology underpinning angle closure disease, and other differentials such as plateau iris, a phacomorphic component or other secondary retroiridal causes should be explored (see more below). There is a constellation of anterior segment parameters used to describe the risk for pupil block. Parameters such as the anterior chamber depth and the angle width are common amongst a slew of techniques including gonioscopy. The advent of advanced imaging techniques such as optical coherence tomography have led to the development of alternative measurements such as the trabecular iris angle, angle opening distance and trabecular iris surface area. However, whilst these parameters may be useful in identifying patients at risk of angle closure disease, no single parameter is used for the diagnosis of pupil block as a solitary aetiology. This reflects one of the issues with considering pupil block in isolation, as it commonly coexists with other aetiologies of angle closure disease and only through the application of therapeutic intervention, such as peripheral iridotomy, can they be revealed. As mentioned above, it is common to find patients that have residual angle closure even after laser peripheral iridotomy, and the most common cause of this residual closure is plateau iris syndrome. Note that it is only referred to as "syndrome" if it follows unsuccessful initial treatment using iridotomy106 (occurring in up to a third of patients107); the term "plateau iris configuration" is used if sufficient pupillary block is relieved with treatment. One of the prime techniques used to visualise plateau iris configuration is ultrasound biomicroscopy. As light waves from optical coherence tomographs cannot penetrate the scleral or uveal tissue, the configuration of the ciliary body can be difficult to determine using such noninvasive techniques alone. Ultrasonography, on the other hand, produces sound waves that are able to penetrate into deeper tissue, at the cost of technique resolution. Even though it is a relatively older technique in comparison to optical coherence tomography, it is likely less readily available. It is subject to substantial intra- and inter-individual variability, depending on factors such as application pressure, practitioner positioning and patient positioning. For this reason, other options for imaging and diagnosing plateau iris are needed for more widespread clinical use. Although optical coherence tomography has limitations in penetrating the ocular tissues to visualise the ciliary body, it is able to very readily image the iris-cornea-angle relationship. As one of the characteristic features of plateau iris is its distinctive hook-like shape of the iris as it enters the angle, optical coherence tomography is able to capture this information readily and with arguably greater repeatability in comparison to ultrasound biomicroscopy. From this, clinicians may be able to infer or strongly suspect a plateau iris configuration. Another potential iris sign is the flatness of 27 Diplomate case 4: Primary angle closure 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 Lens-induced or phacomorphic angle closure Thirdly, lens-induced or phacomorphic angle closure occurs as a result of a large and thickened cataractous lens which pushes the peripheral and central iris forward. However, unlike uncomplicated plateau iris configuration, the anterior chamber depth tends to be shallow, corresponding to the increase in lens thickness. The lens thickness may be difficult to visualise en face, and even with gonioscopy.
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Creating it is one way we can give back to the profession that has enriched our lives and sustained our careers. We strive to create a resource that answers questions, solves problems, reviews concepts and makes your clinical life easier. He is an attending physician at the Eye Center in both the Adult Primary Care service and the Advanced Care Ocular Disease service. Etiologies include acquired mitochondrial dysfunction (chronic progressive external ophthalmoplegia), muscle fibrosis and degeneration (myotonic dystrophy and oculopharyngeal-muscular dystrophy) and dysfunction of neuromuscular junction signaling due to acetylcholine receptor autoantibodies (myasthenia gravis). It should be noted that age, gender and race may influence these measurements, causing small variations. Patients with this condition demonstrate a decreased marginal reflex distance and palpebral fissure height, but an increased margin-crease distance and normal or increased levator function in the involved eye. The type of surgery depends greatly upon levator function; aponeurosis advancement is usually performed in cases where good levator function still exists. Diagnostic evaluation is critical in such instances, and, in addition to a comprehensive ocular examination, the workup may involve neuroimaging, diagnostic medications. Levator muscle resection is typically employed when the levator function is >5mm, while brow/frontalis suspension procedures are required when levator function is <5mm. During the ice-pack test, a bag of crushed ice or a cold pack is placed over the closed eye for two minutes. As with the sleep test, improvement in ptosis following this is suggestive of myasthenia. Not only hard contact lens wear but also soft contact lens wear may be associated with blepharoptosis. The liberal use of artificial tear products is recommended for all entropion patients, regardless of the etiology. Another temporary measure that has been described with some success is the use of cyanoacrylate glue, applied to an induced crease in the lower eyelid for involutional entropion. The sutures remain in place for one to four weeks, depending upon the surgeon and the material used. In cicatricial cases, surgical repair may include excision of the scar with a tarsal plate graft from preserved sclera, ear cartilage or hard palate (in most severe circumstances), along with conjunctival and mucous membrane grafting using buccal grafts or amniotic membrane tissue. Temporary management of involutional entropion with octyl-2-cyanoacrylate liquid bandage application. Long-term efficacy of botulinum toxin A for treatment of blepharospasm, hemifacial spasm, and spastic entropion: a multicentre study using two drug-dose escalation indexes. Botulinum toxin treatment for crocodile tears, spastic entropion and for dysthyroid upper eyelid retraction. Long-term surgical outcomes of Quickert sutures for involutional lower eyelid entropion. Orbicularis oculi muscle transposition for repairing involutional lower eyelid entropion. Grasp the lower eyelid skin between the thumb and forefinger between the inferior border of the tarsal plate and the inferior orbital rim. Facial and orbital swelling or orbital emphysema can literally force the lids shut. Here, a lid retractor can be placed in between the eyelids and used as a speculum to achieve lifting of the superior lid or lowering of the inferior lid. Since blunt ocular trauma involving the eye or face is the result of being struck by an object at velocity, upon contact a shock wave within the local area is generated. If the eye settles inferiorly or medially into the exposed sinus, enophthalmos with restricted ocular motility will be present with or without loss of facial sensation. This is often visible as "soft" or "puffy" swelling and known as orbital emphysema. However, the most commonly encountered sign is the presence of discharge and concretions upon canalicular compression. Characteristic to canaliculitis is a "soft stop" while probing the horizontal canaliculus.
There are insufficient data to recommend screening in ambulatory elderly beneficiaries including those with diabetes. Definitions for sepsis & organ failure & guidelines for the use of innovative therapies in sepsis. Viral quantification may be appropriate for prognostic use including baseline determination, periodic monitoring, and monitoring of response to therapy. Signs and symptoms of acute retroviral syndrome characterized by fever, malaise, lymphadenopathy and rash in an at-risk individual. The frequency of viral load testing should be consistent with the most current Centers for Disease Control and Prevention guidelines for use of anti-retroviral agents in adults and adolescents or pediatrics. Nucleic acid quantification techniques are representative of rapidly emerging & evolving new technologies. When used in concert, the accuracy with which the risk for disease progression and death can be predicted is enhanced. This may occur because the antibody response (particularly the IgG response detected by Western Blot) has not yet developed (that is, acute retroviral syndrome), or is persistently equivocal because of inherent viral antigen variability. The patient has signs and symptoms of acute retroviral syndrome with fever, malaise, lymphadenopathy, and skin rash. Revised classification system for human immunodeficiency virus infection in children less than 13 years of age. These include primary disorders such as anemia, leukemia, polycythemia, thrombocytosis and thrombocytopenia. Many treatments and therapies affect the blood or bone marrow, and blood counts may be used to monitor treatment effects. The symptoms of hematological disorders are often nonspecific, and are commonly encountered in patients who may or may not prove to have a disorder of the blood or bone marrow. Furthermore, many medical conditions that are not primarily due to abnormalities of blood or bone marrow may have hematological manifestations that result from the disease or its treatment. Testing of patients who are asymptomatic, or who do not have a condition that could be expected to result in a hematological abnormality, is screening and is not a covered service. An example is as follows: evaluation prior to invasive procedures or operations of patients with personal or family history of bleeding or who are on heparin therapy Limitations 1. The need to repeat this test is determined by changes in the underlying medical condition and/or the dosing of heparin. Extrinsic pathway factors are produced in the liver and their production is dependent on adequate vitamin K activity. Deficiencies of factors may be related to decreased production or increased consumption of coagulation factors. Warfarin blocks the effect of vitamin K on hepatic production of extrinsic pathway factors. The need to repeat this test is determined by changes in the underlying medical condition and/or the dosing of warfarin. Serum iron may also be altered in acute and chronic inflammatory and neoplastic conditions. High concentrations are found in hemosiderosis (iron overload without associated tissue injury) and hemochromatosis (iron overload with associated tissue injury). Serum ferritin can be useful for both initiating and monitoring treatment for iron overload. Transferrin and ferritin belong to a group of serum proteins known as acute phase reactants, and are increased in response to stressful or inflammatory conditions and also can occur with infection and tissue injury due to surgery, trauma or necrosis. Iron studies may be appropriate in patients after treatment for other nutritional deficiency anemias, such as folate and vitamin B12, because iron deficiency may not be revealed until such a nutritional deficiency is treated. Serum ferritin may be appropriate for monitoring iron status in patients with chronic renal disease with or without dialysis.
It increased further during the launch, presumably from the Gx forces, to 15 to 17 cm H2O (11 to 12. This reduction was rapid, occurring during the first minute of entering microgravity, and remained within 1 to 2 cm H2O (0. Furthermore, they report increased left ventricular end diastolic volume, stroke volume, and cardiac output, likely the result of the chest wall changing shape and expanding in the absence of gravity. White and Blomqvist used a 3-compartment cardiovascular model to simulate the relaxation of the chest in microgravity (White and Blomqvist 1998). However, little evidence exists of filtration into the extravascular space in the head and neck during spaceflight. The authors suggest that the initial interstitial swelling is a result of a rapid blood shift, which is detected as a plasma volume expansion and is followed by a more gradual extravascular shift from the legs over the course of 2 hours. Bioimpedance detected extravascular volume leaving the thigh and the calf, but not entering the chest, suggesting that this volume was being absorbed into the vascular space. They suggest that this decrease in plasma oncotic pressure is a result of the change from filtration to absorption in the capillary beds below the heart. The filtration coefficient (Kf) takes into account the permeability of the capillary membranes to water, which is dependent on surface area and hydrostatic conductance. The reflection coefficient is used to correct for the fact that not all plasma proteins are effective in retaining water, and is different in various vascular beds. Although plasma oncotic pressure initially decreased, it returned to baseline by the end of 8 hours of bed rest. Subcutaneous and intramuscular colloid osmotic pressure in the face and neck did not change. Parazynski and coworkers suggest that the significantly elevated net Transcapillary pressure gradient in the head and neck is the reason for cephalic edema during bed rest and spaceflight. They further suggest that capillaries above the heart may be more permeable to protein filtration than those below the heart, similar to the results by Leach et al. Hargens measured interstitial pressure in the lower leg muscles and subcutaneous tissues and reported a decrease in tissue pressure of 7. He also hypothesized that lower leg vascular absorption results in decreased vascular oncotic pressure and, coupled with increased cephalic capillary pressure, results in filtration in the upper body. Several years later, in a separate review, Hargens further postulated that the reduced tissue weight in microgravity results in lower interstitial fluid pressure, further shifting the Starling balance to net filtration during spaceflight (Hargens and Watenpaugh 1996). Capillary pressure is significantly elevated and interstitial fluid pressure does not significantly change. Cephalad edema may be further exacerbated in spaceflight by changes in microvascular water permeability. This would be possible in spaceflight if the gravity-induced hydrostatic pressure gradients in the cerebral interstitium were removed. They also suggest that radiation exposure during spaceflight may alter endothelial protein structure such that cells shrink, increasing permeability between cell junctions. Exposure to microgravity causes a cephalad fluid shift secondary to the removal of the hydrostatic pressure gradient. This reduction in tissue compression likely plays a role in extravasation of fluid, resulting in overall reduced plasma volume and cephalic edema. Figure 34 Flow diagram of predicted blood and fluid volume changes during spaceflight. Arterial and Venous Resistance Brief exposures to weightlessness during parabolic flight induces increased cardiac dimensions, cardiac output, and stroke volume (Caiani et al. Elevated cardiac output and stroke volume persist during short-duration space flight; the highest values are recorded early in the mission but still remaining above preflight standing values after a week of weightlessness (Prisk et al. Despite no significant change in common carotid artery and femoral artery diameter during 4 to 6 months of spaceflight, common carotid artery flow increased during the first month, but decreased to preflight levels by 3 to 6 months of spaceflight. The jugular vein is distended in both real and simulated microgravity, while the femoral vein is only distended in real microgravity. Reproduced from Arbeille P, and others with permission of Springer-Verlag, obtained via Copyright Clearance Center, Inc.
Syndromes
Amazingly, the two groupsof patients showed comparable improvementafter surgery: pain diminished, they took fewer pills, and they could exercise more. TheItalians concluded that the very act of surgery had produced a placeboeffect in their patients. Yet I confess that whenever I see the placebo effect up close, I marvel at the resourcefulness of a human mindthat can fashion healing from a transaction of trust and deception. Franz Anton Mesmer (who gave us the epigram mesmerize) "cured" patients with his Animal Magnetism theories. Kings of England andFrance treated scrufulouspatients with the Royal Touch for seven hundred years. Two nineteenth-century French physicians advocated directly contradictory methods of treatment. Raymond at Salpetriere in Paris suspended his patients by their feet to allow blood to flow to their heads. Norman Cousinshas remarked, "Indeed, many medical scholars have believed that the history of medicineis actually the history of the placebo effect. Sir William Osler underlined the point by observing that the human species is distinguished from the lowerorder byits desire to take medicine. Considering the nature of nostrums taken over the centuries, it is possible that another distinguishing feature of the speciesis its ability to survive medication. I had never used ultrasound, which was being toutedin medical literature and in advertisements as a breakthroughtreatmentfor reducingscartissue andrelieving stiffness in joints. Mary argued one day about the wisdom ofinvesting in an ultrasound sound machinein all of India was humming away in her department. Partly to mollify me, Mary agreed to supervise a test on a hundred patients who had stiffness of the finger joints. Theirinitial range of motion was recorded so that at the end we could compare objective results. The charts clearly showed that ultrasound treat ment had worked in all the ways advertised. He switched on the machine, it hummed, and heheld a glass of water under the ultrasound applicator head. The surface of the water remained smooth,and a puz- A few weeks later, a representative from the company that had sold us the machine droppedbytoseeif all was well. Somewhere, locked inside their higher brains, a missing hand or leg perseveres in vivid memory. Invisible toes curl, imaginary hands grasp things,a "leg" feels so sturdy that a patient rolls out of bed expecting to stand on it. The sensations vary: a feeling of pins-and-needles, a nagging awarenessof heator cold, the pain of phantom nails dig- ging into phantom palms, or perhaps just an enduringsense that the limbis still "there. Sometimes sen- Amongan unfortunate few, this phantom limbsensation includes long-term pain, a pain like no other. They feel large nuts being screwed onto phantom fingers, razors slashed across phantom arms, nails pounded through phantom feet. Nothing gives a doc- sations fade away only partially, so that the brain retains the perception of a hand-but no arm-dangling from a shoulder stump. Smoking contributed to I observed a strange encounter with severe phantom limb pain during University College days. Bryce a single cigarette would cause enough vasoconstriction to bring on excruciating pain. An obstinate man, Bryce had adamantly rejected any thought of amputation,and Godderwas struggling to keep his patient from overdependence on pain medication. The pain existed at stage three only, in his mind, but that was sufficiently torturous. Bryce had a richly developed felt image reinforced by feedback from the cut nerves in the stump. Godder explained to us students that the leg, which should have been amputated two years before, had achieved an could feel the phantom calf muscles go into ischemic cramp, and now hehadnoprospectofrelief. Andif all else fails, the Phantom limb syndrome demonstrates a kind of homeostasis of pain. At an amputationsite the cut nerves will branch out and try to connect with the stump of their own axon; unable tofindit, they form knots of futile nerve twigs (often surgeons have to go back in and cut these neuromas).
Some lymph nodes and tissues need to be incised so that the internal portions can be observed. Lymph nodes should be sliced in thin parallel slices to expose the body of the node. Tuberculosis lesions, some abscesses, and other conditions are exposed by incision of lymph nodes. The wrist rolling motion that you will learn from your mentor permits you to observe both sides of the slice. In large establishments, inspectors are assigned to cover one of these areas and rotate to different sites according to a rotation pattern. At small or very small establishments, the inspector may perform all of the post-mortem inspection procedures on each animal. The differences reflect variations in anatomy, diseases, and method of dressing that the establishment uses. In general, when abnormalities are observed while performing inspection, the following actions must take place: 1. If the disease or condition of the head, organ, or carcass is localized, have the establishment trim the affected tissues. If the disease or condition is generalized and affects the majority of the head, organ, or carcass retain it for veterinary disposition. We will walk through the general steps involved in swine post-mortem inspection as an example of post mortem inspection procedures. The post-mortem inspection procedures for other species are shown in the Appendix of this module. You will learn more about making veterinary dispositions when we cover the module Multi Species Dispositions. For example, for swine post mortem, the example we will be using, you will need to learn how to locate and identify the mandibular lymph nodes in the head; the mesenteric, hepatic, and tracheobrochial lymph nodes in the viscera; the lungs, heart, and the liver; and the kidneys of a carcass. Example: Swine head inspection the head inspection procedures for swine are as follows: 1. When abnormal conditions are observed, retain the head for veterinary disposition. The inspector must condemn the head if any amount of tuberculosis is found in the head during head inspection. The head is usually stamped at the viscera inspection station and the nodes in the jowls removed and condemned as required. When slight, small, well-encapsulated abscesses are found on head inspection, the carcass should be tagged. When well-marked or extensive abscesses are seen, the carcass should be tagged by the head inspector. Ultimately, the disposition of the extensive or well-marked abscessed head will be condemnation (probably at the viscera inspection station) and the affected areas in the jowl will be removed and condemned. Swine with atrophic rhinitis may have a characteristic nose disfiguration, absence of nasal turbinate bones, and small amounts of pus or exudate in the nasal sinuses. The turbinate soft tissues may be present, but they are folded against the nasal cavity wall since the supporting bony structure has disappeared. Since this condition is usually localized, head tissues can be removed without contamination and saved for food. Remember, you must be able to determine at all times which parts belong to a carcass (310. Hog rings these should have been removed as part of the cleaning operation prior to head inspection. If action in #1 does not result in proper presentation, direct the designated establishment employee to stop the line and remove the condition if it cannot be removed prior to the carcass leaving the inspection area.
Plain gut suture is probably the best choice when difficult or inconvenient removal is anticipated. It is more difficult to tie than silk, has inferior knot-holding properties, and forms a hard knot which may irritate tissues. Chromic gut suture has chromic salts deposited on the outer surface or within the entire strand, providing greater resistance to absorption. Basic shapes include straight, three-eighths circle, half circle, and five-eighths circle. The immediate needle return from the tissue when using a curved needle is an advantage, and the half circle is easier to use in confined locations. Needle points may be tapered or cutting, the latter being more useful for thick resistant tissues. Conventional cutting needles are triangular in crosssection with a cutting edge on the inside of the curve. The reverse cutting needle has the third cutting edge on the outside of the needle curvature, minimizing tissue laceration. Sutures may be threaded through the needle or attached in the non-cutting end (swagged). Swagged needles are more expensive, but less time-consuming, and cause less tissue damage on penetration. The most popular needle is the three-eighths circle with a reverse cutting point (Meyer and Antonini, 1989). The butyl and isobutyl forms of cyanoacrylate are the most acceptable in the oral cavity; the methyl form (super glue) is toxic to tissues. Cyanoacrylates are capable of cementing living wet tissues and are exfoliated in 4 to 7 days. Clinically, cyanoacrylate reduced flap fixation time by 10 to 15 minutes per quadrant, providing firm fixation of the conservative flaps used in this study. The authors concluded that the use of cyanoacrylate appeared to have no effect on probing depth, recession, or attachment level. Levin (1980) reported no adverse tissue reaction to this material in a review of 872 periodontal procedures in 725 patients. McGraw and Caffesse (1978) reported no evidence of cyanoacrylate under the tissue flaps, and there appeared to be less inflammation in the early stages of healing when compared to sutures. The authors caution that because cyanoacrylate is irritating to respiratory and ocular tissues, extreme caution must be employed during its use. Sutures were removed on the eighth postoperative day; block sections were obtained at 2 hours, and at 1, 3, 7, and 14 days. Regarding methodology, the interrupted suture should be used when tissue positioning is not a problem. The sling suture is used to position the flap at different levels around individual teeth. The continuous sling saves time in placement and the anchor suture is useful in positioning a single papilla. Finally, the vertical mattress suture is used when it is desirable to avoid suture placement beneath flap margins. Newell and Brunsvold (1985) described a vertical mattress suture for esthetic purposes in anterior regions of the mouth. If used with the "curtain procedure," a vertical mattress suture allows the palatal flap to adapt tightly to the underlying bone while retaining the facial papilla in its original position. According to the authors, long thin papillae are best treated with vertical mattress sutures while short wide papillae are best treated with horizontal mattress sutures. Incisions and suturing: Some basic considerations about each in periodontal flap surgery. A modification of the "curtain technique" incorporating an internal mattress suture. Zinc oxide-eugenol dressings generally contain between 40 and 50% free-eugenol, which has been shown to cause tissue necrosis and delayed healing. Non-eugenol dressings may contain zinc oxide, various oils or fats, rosin, and bacteriostatic or fungicidal agents. Tannic acid was originally added to dressings to facilitate hemostasis but has since been removed because of its associative potential for liver damage.
The ability to contain the spread of infection stood at the frontier of medicine in 1939. Yet four years later we residents were - experimenting with a new medication that promised what no drug before had dared to promise: penicillin, possibly the greatest single advance in medical history, had comeinto use. He worked in a cluttered, mildly chaotic laboratory, and his research often showed a touch of whimsy. Bacteria would in effect sign their own names: "egg" or "tears," for example, on an agar surface coated with egg white or humantears. He was trying to grow staphylococci bacteria, not mold, and on the edges of the dish, colonies of staph glow brightly, like galaxies at the edge of the universe. And aroundthe patch of molditself the agar plate is dark; no bacteria are visible. Stil, Fleming kept enough of the mold (a rare one,as it turned out) growing to sup- For twelve years, off and on, Fleming worked with penicillin. Despite its remarkable ability to kill harmful bacteria, penicillin showedlittle potential as a drug: it was toxic and unstable and ply himself and others. He could not have picked a worse toward Dunkirk, Florey performedhisfirst clinical tests on mice, - injecting them first with streptococci, then with penicillin. The experiment showed so much promisethat Florey, after learning of time to launch an expensive research project: his application for a governmentgrantarrived three days after Britain declared war on Germany. Once Florey had learned to purify the drug and increase its potency, it took only a small amountof penicillin to kill bacteria. In 1945 I conducted tests on behalf of the Medical Research Council to determine the right dosage to cure babies of staphylococcus infections in the bloodstream. Wefound that a daily dose of 1,000 units penicillin per kilogram of body weight would suffice to kill all traces of the infection. Today, because of resistant strains, a doctor would need to prescribe a hundred times that amount. This enormouseffort produced a grand total of twenty-nine pounds of purified peni- had myfirst direct contact with penicillin. At Leavesdon, an evacuation hospital, I treated some of the victims of the British retreats cillin in 1943. British authorities restricted the drug to use by servicemen andcarefully meted out supplies to approved hospitals. I was doing rotations at London suburban hospitals when I at Boulogne and Dunkirk. Soldiers selected for treatmentbelieved they would gain an wound,this stuff will keep you alive," the rumor went. Distillers had not perfected the purification process and the thick, yellowish solution was highly irritable to livingtissue. We could only give it intramuscularly, preferably in the buttocks, where the needle could sink deep. It was in the Leavesdon evacuation hospital in those early the Frightened Hero Jake had been evacuated from the beaches of Boulogne. Jake somehow pulled himself out of his foxhole, crawled over to his friend, and, his own shattered legs trailing behind him, dragged himself and were a mess. He managedto wriggle overto the relative safety of a foxhole, where he looked down and sawthathis legs his friend backto safety. Jake had beenselected for the new penicillin therapy to combat severe secondary infections in his legs. According to his - when his buddies were awake and he had muchelse to concentrate on, but the wake-upcalls at 2:00 and 5:00 A. Nowtell me, why are you giving us so much trouble over a needle prick in your backdle prick, Doc. But here in the ward, I have only one thing to think aboutall nightin bed: that needle. Having heard his story from othersoldiers, I had a vivid mental picture of the bat- nighttime needle. Those two images, brought together by our conversation, underscored an importantfact about pain: pain takes place in the mind, nowhereelse. But the night nurse gave me an equally vivid picture ofJake the coward, his face contorted in fear, awaiting the pain system whatit wants to be told. Later, in the total absence of any competing activity or thought, an oversize penicillin needle made a far more compelling and urgentcase for While dealing with Jake, I also grasped the wisdom thatlay behind the approach to medicine we learned in those days.
During the same period 8 patients presented with similar symptoms but failed to respond to Cluneal Nerve injection but did res- Cluneal Nerve Radiofrequency Ablation provided excellent or good results in 26/28 (93%) patients during their follow-up period of the treatment of the Cluneal Nerve trigger points and Muscle Balance Physiotherapy reversed the symptoms in 5/33 cases over Keywords: Cluneal Nerve Trigger Points; Low Back Pain; Sciatica; Failed Back Surgery; Radiofrequency Ablation Citation: Martin Knight. A Radiofrequency Treatment Pathway for Cluneal Nerve Disorders 02 Background Anatomy lumbar fascia. They found that the superior Cluneal nerves are constrained within a tunnel consisting of the thoracolumbar fascia and Sacro-tuberous and Long Posterior Sacroiliac Ligament [3,12]. On clinical grounds, the lead author classified Trigger Points related to the leashes of Cluneal Nerves into the three groups as shown fascia. Throughout, anatomical nomenclature has varied [3-9] with Superior Cluneal nerves loosely classified as originating from in figure 1 this grouping excludes the inferior (infra-pelvic) Cluneal nerves. Some of the Superior Cluneal nerves pass over the iliac crest nerves produce Lateral Cluneal Nerve Trigger Points located above, on or below the iliac crest, lateral to the iliac crest tubercle and are Figure 1: Anatomy of Cluneal Nerves. A Radiofrequency Treatment Pathway for Cluneal Nerve Disorders berous ligament to form the Medial Cluneal Nerve Trigger Points closely approximating the sacro-iliac joint [3]. Once the irritation has caused swelling of the nerve then the nerves and encompassing tissues above or below the sheath. A Radiofrequency Treatment Pathway for Cluneal Nerve Disorders occasion the symptoms were so marked that there was local allodynia over the pelvic rim and buttock. Whilst pain was the predominant feature, paraesthesiae into the limb was a frequent symptom and even extended into the foot. On 04 Patients with radicular sensory or motor deficit were excluded from this study although in wider practice the combination is found the combination of Medial and Superior Cluneal Nerve trigger point irritation can symptoms radiating over the buttock, posterior the superior and lateral leashes of the Cluneal nerves can produce pain and paraesthesiae radiating along the anterolateral thigh and on rarer occasions the symptoms pass into the shin and foot. The Medial Cluneal Nerve trigger point pain is frequently mis-diag- ting, getting out of a chair (mimicking the "instability catch"), or be aggravated by walking or turning in bed and often causes difficulty in Diagnostic therapeutic pathway neal pain sources, the diagnostic therapeutic pathway shown in Figure 3 was adopted. To determine the relative contribution to the predominant presenting symptoms of low back pain and buttock pain from axial or Clu- Because Cluneal Nerve irritation is usually linked to pelvic malposture (anteversion or retroversion) the pain can increase when sit- Figure 3: Diagnostic Therapeutic Pathway. However, such displacement irritates the nerve in the foramen where the locus of the pain may really exist. If displacement of the facet joint reproduced the predominant presenting symptoms, then it might be considered a progenitor of the 05 ners may choose to inject the facet joint with steroids. Following the chosen injection, Figure 4 demonstrates the subsequent therapeutic protocol. But if this pathway fails then the patient becomes a candidate for Transforaminal Endoscopic Lumbar Decompression and Citation: Martin Knight. An "Excellent" result was defined as complete improvement in pain scores and restoration of functionality. The skin was sterilised, and each provocative site injected with subdermal lignocaine 1% both locally and horizontally in line with the nerve. A 22-gauge needle was then advanced to the evocative points and inance Physiotherapy was recommended to consolidate the benefit. Cluneal nerve radiofrequency ablation tion with the patient standing in 200 of flexion. Where trigger points were intensely tender then 40mg of Kenalog was added to the Depomedrone for more effective relief. The patient was mobilised and completed a pain diary three times a day until review at 6 weeks. During this period the patient participated in Muscle Balance Physiotherapy and postural alignment re-training. The line of anaesthesia is ideally placed above or medial to the the presumed point where the nerve was exiting the fascial tunnel or area of soft tissue tethering. The skin was sterilised with Betadine (or Hibitane), where the patient was allergic to iodine) and draped. The anaesthetist pro- the patient was placed prone on a Knight Sheffield radiolucent table (Royal Hallamshire Hospital Bioengineering Department, Shef- iliac crest rim. Ablation may A Radiofrequency Treatment Pathway for Cluneal Nerve Disorders also be required where the nerves emerge under the gluteal fascia to achieve adequate control of the trigger point sensitivity. The efficacy of the ablation was monitored by applying pressure to the previously provocative zone after ablation had been effected and questioning whether pain still persisted. Ablation was deemed sufficient once the target trigger point was no longer painful. It is necessary to be aware that this nerve splits into multiple groups on either the medial Superior Cluneal nerve leashes usually split to pass on either side of a palpable "tell-tale" lipoma. Feeling for this may assist 08 Figure 5: Cluneal Nerve Ablation probe positioned at points on either side of the "Guideline" lipoma around which pass the superior Cluneal nerves.
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