Unusual orbital foreign bodies.

PURPOSE: To describe the clinical features of patients with unusual orbital foreign bodies. METHODS: The clinical histories, preoperative photographs, imaging studies, and surgical pathologic findings of five patients with unusual orbital foreign bodies are presented. Additionally, published reports pertaining to similar cases were reviewed. RESULTS: The five patients treated by the authors had good outcomes. CONCLUSIONS: An orbital foreign body may be overlooked because a small penetrating wound may be accompanied by minimal or no signs of inflammation early in the clinical course. A careful history and physical examination, imaging studies, and a strong suspicion are helpful for establishing the diagnosis of an orbital foreign body.

The yellow brick road to penicillin: a story of serendipity.

Approximately 14 years elapsed between Sir Alexander Fleming's discovery of penicillin (in 1928) and its full-scale production for therapeutic use (in 1942) in World War II. The following factors were responsible for the delay: a scientific explanation of Fleming's "phenomenon," classification of the fungus secreting the active substance, source of the mold, initial difficulty of other bacteriologists in reproducing Fleming's discovery, identifying the chemical makeup of penicillin, search for other penicillin-producing organisms to enhance production of penicillin, purification and crystallization of penicillin, experiments on animals (chiefly mice) to determine toxicity, hesitancy to administer the drug to humans, standardization of an effective dosage for humans, and search for equipment and financial resources to enhance full-scale production. The adjunctive role of serendipity (chance, happenstance, improbability, and luck) in overcoming these obstacles and in contributing to the successful, scientific conclusion of the penicillin project is an unusual story.

Stability of silica-based, endcapped columns with pH 7 and 11 mobile phases for reversed-phase high-performance liquid chromatography.

The goal of this study was to define practical conditions and limitations of using silica-based, endcapped bonded-phase columns in intermediate and higher pH environments for developing rugged HPLC methods. Bonded-phase degradation in this pH range is a result mainly of silica support dissolution; covalently-bound silane ligands are hydrolyzed very slowly if at all from silica supports at intermediate and higher pH. Based on rates of silica support dissolution determined by chemical measurements and comparable chromatographic studies, we now find that endcapping alkyl-bonded stationary phases increases column longevity at pH 7, compared to non-endcapped columns. As previously determined for non-endcapped packings, we also find that the type of silica support determines the stability of bonded-phase packings. Silicas made by the sol-gel process are more resistant to dissolution than supports made by a silicate-gel (xerogel) process. In addition, endcapping methods apparently affect column stability, with double-endcapping methods apparently superior to single-endcapping approaches. Degradation rates for several endcapped commercial bonded-phase C8 columns were found to be quite variable in highly aggressive pH 7 accelerated-lifetime tests. Column stability in the pH 7-11 range is enhanced by using buffers other than phosphate in the mobile phase, and by excluding higher column temperatures. Certain silica-based endcapped bonded-phase columns can be used for developing rugged methods to at least pH 11 when used with organic buffers at < or = 40 degrees C.

The politics of health care reform.

In many ways the reform debate is a struggle among competing ideologies. The risk we take is that the politics becomes more important than the results. For the ordinary citizen, it matters little who gets the credit. What matters is how well the system addresses the critical issues of access coverage, and cost. The choices are difficult. Those who think we have the resources necessary to conquer all our problems fail to admit that the United States is not the Garden of Eden. It would be nice if government were able to legislate away the negative effects of our human nature. But since that is impossible, we must set realistic goals and establish reasonable priorities. The challenge is before us.

Ophthalmic practice of Charles H. Mayo, M.D.

With no formal training in ophthalmology, Dr. Charles H. Mayo (the younger Mayo brother) undertook the unwanted task of diagnosing ocular disease and managing patients with such disorders in rural southeastern Minnesota during the 20-year period 1889 through 1908. This endeavor was ancillary to a busy general practice in partnership with his father and older brother. A series of his office ledgers provides a daily panorama of the foibles, remedies, and diagnoses associated with an ophthalmic practice during that era.

The cost effectiveness of prenatal care.

This study uses hospital records for 7,000 births in McLennan County, Texas, during the period June 1987-July 1989 to examine the association between prenatal care and birth outcome and the implications for hospital costs of newborn infants. After controlling for a variety of maternal and birth factors, a significant relationship between prenatal care and birth outcome remained. Females who failed to receive prenatal care were almost three times as likely to have a low-birth-weight infant (weighing less than 2,500 grams) than females who did. Using an ordinary least squares (OLS) estimating equation (R2 = .24), the net expected hospital cost savings for females who received prenatal care was over $1,000.

Liberty, equality, fraternity and the delivery of health care in France.

As U.S. policy makers debate President Clinton's health care reform proposal, we need to remind ourselves that no other country has actually solved the health care cost problem. There are no solutions, only alternative approaches to the problem. Proponents of the social insurance model will argue that countries like France have a better system--one that delivers high-quality medical care to everyone with no financial barriers. If the evidence is examined honestly, it becomes clear that the French system, while meeting the goal of universal access, has a long way to go before it solves the spending problem. National health insurance does not guarantee public satisfaction with the system. In a recent survey, over half of the French citizens responded that they felt that their health care system needed fundamental changes or should be completely rebuilt, and only 41 percent were happy with the way the system worked. Citizens in all but two of the ten countries studied by Blendon et al. (1990) had similar responses. Only in Canada and Germany did fewer than half of the respondents desire significant change. A nationalized system can eliminate financial barriers to access but it cannot guarantee that social disparities will be eliminated. National health insurance has actually exacerbated inequalities across social classes in France. Per capita consumption varies as much as 50 percent across income levels and 100 percent between occupational categories. In their quest for social solidarity and equality, the French have given up a lot. Practitioners have suffered an erosion in their real incomes relative to the rest of the population.(ABSTRACT TRUNCATED AT 250 WORDS)

Infrared photography revisited.

Applied infrared photography has changed significantly during the last 40 years. Its medical application has dwindled while its overall use has increased dramatically. An understanding of the electromagnetic spectrum and the relationship between what humans are capable of seeing and what infrared sensitive film can record will lead to a better appreciation of this film's potential application in today's world. Improvements in processing have resulted in greater film speed and the direct conversion of the film to positive transparencies. This latter development will aid individuals who use the film as an educational teaching aid.

Extracellular deposition of eosinophil major basic protein in orbital histiocytosis X.

Although eosinophils are prominent in orbital lesions of patients with histiocytosis X (Langerhans' cell histiocytosis), little is known of their pathogenic significance in the disease. To determine whether eosinophils degranulate and deposit toxic proteins in orbital histiocytosis X, the authors examined lesions by indirect immunofluorescence for localization of the core granule protein (major basic protein) outside of eosinophils. Four patients with histiocytosis X were studied: three with eosinophilic granuloma and one with Hand-Schüller-Christian disease. Tissue eosinophilia was prominent in all specimens; striking extracellular deposition of eosinophil major basic protein was noted in three patients, and focal deposition was present in the fourth patient. Orbital specimens obtained at autopsy from patients without orbital disease were studied as control specimens; no tissue eosinophilia or deposition of eosinophil major basic protein was observed. These findings indicate that eosinophils likely degranulate in lesions of orbital histiocytosis X and may participate in the pathogenesis of the disease.

Clinical course of an incompletely removed cavernous hemangioma of the orbit.

Cavernous hemangioma is a frequent tumor of the orbit in adults. Its complete removal results in dramatic relief of proptosis. The clinical course of an incompletely removed cavernous hemangioma is seldom recorded in the ophthalmic literature. The authors report the behavior of such a tumor that was observed during an 18-year period. Serial computed tomography (CT) documented a long period of slow growth, followed by a shorter interval of arrest, with eventual involution of tumor and relief of proptosis. No treatment was administered during observation.

T-cell lymphoma of the orbit.

In a 52-year-old man with drooping of the right upper eyelid and a palpable mass in the superior temporal quadrant of the right orbit, a biopsy specimen revealed diffuse mixed-type lymphoma with immunostaining evidence of a helper T-cell phenotype. No other foci of lymphoma were found. The orbital lesion was treated with irradiation (total dose, 4,200 cGy administered in 20 treatments). At 4 1/2 years after treatment, the patient had had no recurrence.

Orbital exenteration at the Mayo Clinic. 1967-1986.

Orbital exenteration was performed in 102 patients at the Mayo Clinic during the 20-year period from 1967 through 1986. The surgical procedure was performed for mucormycosis in one patient and for pain and deformity after a severe facial burn in another; in the remaining 100 patients, exenteration was used to treat a neoplastic disorder. Although 19 different neoplasms were encountered, squamous cell carcinoma, basal cell carcinoma, and melanoma constituted 70% of the total. In 82 patients with no known residual tumor or metastases at operation, the 1-year survival rate was 88.6%, the 5-year rate was 56.8%, and the 5-year rate free of recurrence or metastases was 48.3%. In 18 patients with known residual tumor or metastases at exenteration, 55.0% were alive 1 year postoperatively, and the 5-year survival rate was 25.8%. Unusual findings in this series included two patients with metastatic basal cell carcinoma and one patient with a metastatic thyroid Hürthle cell carcinoma.

Management of blepharospasm.

From 1950 through 1984, 123 patients underwent surgical treatment of blepharospasm at the Mayo Clinic. During this period, four different operations (proximal and distal neurectomy and two types of myectomy) were used. Significant recurrent or residual blepharospasm was observed more frequently (P less than 0.01), and need for subsequent operations was greater (P less than 0.01), among patients who had undergone distal neurectomy than among those who had had myectomy. These data support the view that myectomy is a more effective procedure than neurectomy. Initial results with botulinum toxin injection seem to indicate that it is an effective short-term treatment for blepharospasm. However, its long-term efficacy and safety need further study, as does the role it should play in combination with myectomy.

Facial nerve akinesia.

In ophthalmology, increasing attention has been directed to methods of local anesthesia and akinesia that provide complete analgesia and immobilization of the eye conducive to work with the surgical microscope, particularly in operations for cataracts. The volume of anesthetic agent often used to achieve these goals may approach the toxic level of the drug in some patients. A method of producing akinesia of the temporal, zygomatic, and buccal divisions of the facial nerve that requires only a small volume of anesthetic is described. In our experience, this method can, in many cases, provide akinesia of the orbicularis oculi equal in effect to some established methods of infiltrative akinesia that require large doses of anesthetic.

Management of blepharospasm.

From 1950 through 1984, 123 patients underwent surgical treatment of blepharospasm at the Mayo Clinic. During this period, four different operations (proximal and distal neurectomy and two types of myectomy) were used. Significant recurrent or residual blepharospasm was observed more frequently (p less than 0.01) and need for subsequent operations was greater (p less than 0.01) among patients who had undergone distal neurectomy than among those who had had myectomy. These data support the view that myectomy is a more effective procedure than neurectomy. Initial results with botulinum toxin injection seem to indicate that it is an effective short-term treatment for blepharospasm. However, its long-term efficacy and safety need further study, as does the role it should play in combination with myectomy.

Primary malignant mixed tumors of the lacrimal gland. Report of 10 cases.

Ten consecutive cases of malignant mixed tumor (pleomorphic adenocarcinoma) primary in the lacrimal gland were studied for clinical features, pathology, course and prognosis and surgical management. Long-term follow-up data were available on all patients and emphasized the varied nature of the neoplasm. Survival intervals after the initial operation varied and seemed dependent on whether the neoplasm was initially histologically malignant or became malignant during the recurrence of a benign mixed tumor. An en bloc, one-stage removal of neoplasm with attached periorbita and underlying bone is recommended to minimize early dissemination via bone.