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The authors describe the use of cisapride (Propulsid), a potent 5-HT(3) antagonist, in the treatment of visual hallucinations in two patients with vision loss (the Charles Bonnet syndrome).
PURPOSE: To characterize the nature and frequency of Charles Bonnet syndrome in glaucoma patients with low vision. PATIENTS AND METHODS: All patients attending the glaucoma clinic during a period of 10 months who had visual acuity of 20/80 or less in both eyes were included in this study. Each patient was questioned about the occurrence of visual hallucinations. Those who responded positively had a thorough interview relating to the characteristics of the hallucinations. Medical history and social history were taken, followed by a complete ocular examination. RESULTS: Eighty-nine patients met the inclusion criteria. Eleven patients (12.3%), eight men and three women, admitted to having experienced visual hallucinations. Except for one case, the patients did not disclose this experience previously. Eight patients had one repeatable hallucination, and three patients experienced more than one sight. The visions were usually sharp, and the figures were occasionally incomplete. Most hallucinations were chromatic. Frequency of hallucinations varied between daily and weekly, and duration was mostly a few minutes. In addition to glaucoma, nine of the eleven patients had other ocular findings that could have contributed to the reduction of vision. CONCLUSION: Visual hallucinations are not rare in glaucoma patients with low vision. Patients tend to conceal their experience of visual hallucinations, but a discussion of these phenomena with the patient and assurance of their harmless nature will reduce his or her anxiety and concerns.
When one considers the circumstances of his birth, the barriers that he had to overcome, and his abbreviated life span (<46 years), a strong case can be made that Charles Drew, MD, CM, MDSc, was one of the most accomplished surgeons of the 20th Century; yet many practitioners and instructors of the surgical sciences know little or nothing about him. There are others who have heard of him and still harbor popular misconceptions about the circumstances of his death that have been perpetuated by several media outlets. The Southern Surgical Association promotes a substantially more inclusive brand of surgical fellowship than it did during the lifetime of Dr. Drew. We believe that the membership would greatly appreciate knowing some of the details of Dr. Drew's life, particularly his major scientific contributions and his commitment to excellence in patient care, and in the training of young surgeons.
Bethnal Green Asylum was the most notorious of the scandalous early nineteenth-century private madhouses exposed in two parliamentary Select Committees of 1815/16 and 1827. From being vilified as the worst asylum in the country, this huge and important institution was transformed over 15 years into one of the best by two determined men, both Fellows of The Royal Society, John Warburton MD, the proprietor, and Charles James Beverly, the medical superintendent, former naval surgeon, naturalist and Arctic explorer. This paper describes their hitherto unrecorded biographies.
There is a high incidence of mitral valve prolapse (MVP), an abnormal displacement of one or both mitral valve leaflets during systole, in Cavalier King Charles Spaniels (CKCS). In humans, MVP is known to be associated with a low magnesium status. In this study, the plasma magnesium concentration was measured in 30 CKCS without heart failure. It was also investigated whether MVP-severity and degree of regurgitation correlated with plasma magnesium and a number of parameters of the renin-angiotensin system, and whether 4 weeks magnesium supplementation affected plasma magnesium or the high renin/low aldosterone profile associated with MVP. A high prevalence of hypomagnesemia was observed: plasma concentrations < 0.70 mmol/l were found in 15 dogs (50%) before and in 12 dogs (40%) after 4 weeks magnesium supplementation. The mean plasma level was 0.69 +/- 0.07 mmol/l before and 0.71 +/- 0.07 mmol/l after magnesium (P = 0.22). Plasma magnesium concentrations did not correlate with MVP-severity and degree of regurgitation. Plasma aldosterone levels correlated negatively with MVP-severity and positively with the degree of regurgitation, and serum angiotensin-converting enzyme activities correlated negatively with the degree of regurgitation. Magnesium supplementation had no effects on renin and aldosterone nor on the ratio between the two. In conclusion, many CKCS without heart failure have hypomagnesemia whether they are fed supplementary magnesium or not--a finding which may be associated with the high prevalence of MVP in this breed. Further studies, however, are needed to clarify the role of a low magnesium status in canine MVP.
Charles David Kelman was born in Brooklyn, New York, USA, on 23 May 1930 and passed away in Boca Raton, Florida, USA, on 1 June 2004 at the age of 74 years after a long battle with cancer. He received a Bachelor of Science degree from Tufts University in 1950 and completed medical studies at the University of Geneva, Switzerland, in 1956. He was Clinical Professor of Ophthalmology at New York Medical College and an Attending Surgeon at New York Eye and Ear Infirmary and Manhattan Eye, Ear and Throat Hospital. Although a prolific inventor, he will be best remembered for developing phacoemulsification, following his realization while sitting in a dentist's chair, that ultrasonic vibrations could be used to emulsify the aged crystalline lens through a very small incision. His pioneering work revolutionized cataract surgery. He also pioneered cryo-extraction of cataracts, the use of freezing for the repair of retinal detachments and designed numerous ophthalmic instruments and intraocular lenses. Dr Kelman received numerous awards, including the American Academy of Ophthalmology Achievement Award (1970), the Ridley Medal from the International Congress of Ophthalmology (1990), and the Inventor of the Year Award from The New York Patent, Trademark and Copyright Law Association (1992). Most recently (2003), Dr Kelman was honoured by the American Academy of Ophthalmology with the Laureate Recognition award. Dr Kelman was also an accomplished Broadway producer, composer and jazz saxophonist. With his demise, the ophthalmic and medical community lost a famed inventor with multifaceted talents and one of the great ophthalmologists of the twentieth century.
The Sylvia and Charles Viertel Charitable Foundation (http://www.alfredresearch.org/external/viertel.htm) recently celebrated its first decade of support for medical research in Australia. Its contribution to Australian medical research has centred on support of outstanding young people through Senior Medical Research Fellowships and a unique grant-in-aid programme for clinical investigators.
Through some characters in his novels, Charles Dickens recorded observations on the nature of epileptic seizures, their causes and provocation, and their consequences. Three of his main characters, Monks, Guster, and Bradley Headstone, had seizures which Dickens realistically described.
OBJECTIVE: To evaluate retrospectively the efficacy of the suboccipital craniectomy and dorsal laminectomy of C1 with durotomy and placement of a dural graft for treatment of syringohydromyelia (SHM) because of cerebellar tonsil herniation in Cavalier King Charles spaniels (CKCS). This technique is used with great success in human medicine. STUDY DESIGN: Four CKCS diagnosed by Magnetic resonance imaging (MRI) of SHM because of cerebellar tonsil herniation and not responsive to medical therapy underwent a suboccipital craniectomy and dorsal laminectomy of C1 (2 dogs) and of C1 and partial C2 (2 dogs) with durotomy and placement of a dural graft. Three dogs were evaluated neurologically 24 hours, 1 month, and 3 months postoperatively and evaluations were compared with preoperative neurological examination. Repeat MRI took place 3 months postoperatively. RESULTS: Neurological examinations showed neither improvement nor progression of clinical signs 3 months postoperatively. MRI showed no regression of syrinx size 3 months postoperatively. CONCLUSION: Improvement was not seen. Given the progressive nature of the disorder, evaluation over a longer period of time is necessary to detect if progression has stopped. Some modification to the surgical technique is needed to accomplish the same results as in human medicine. A study of a larger population is needed to attain more reliable information. CLINICAL RELEVANCE: Suboccipital craniectomy and dorsal laminectomy of C1 with durotomy and placement of a dural graft is a feasible technique in CKCS, but needs some modification to accomplish the same results as in human medicine.
In the novels of Charles Williams, characters are faced with the mundane but profound choice between "charity and selfishness," the City and Infamy. Williams' "way of exchange" and "doctrine of substitution" have direct parallels in contextual family therapy. In Descent Into Hell, he explores the long-term effects of legacy and the balancing of the relational ledger through the process of "substituted" love. In All Hallows' Eve, the focus is on forgiveness and the opportunity to correct relational mistakes while one is in a purgatorial state. Both novels include parallel processes of relational stagnation/disjunction and rejunction, illustrating the fact that our simple, everyday choices have ultimate significance.
Charles Bonnet syndrome (CBS) is diagnosed when a visually impaired patient without any mental disorder develops visual hallucinations. A survey of patients in a National Leprosarium revealed that the point prevalence of CBS in leprosy was 0.4%. This prevalence appears to be high, as few cases with CBS have been reported. The semeiology of visual hallucinations was typical of CBS. However, the clinical features were different from previous reported cases because of the history of leprosy and associated multi-sensory loss. Patients with leprosy appear to be at increased risk for CBS, due to frequent eye complications combined with sensory loss, ageing, and intact intellectual functions.
The term 'Charles Bonnet syndrome' refers to visual pseudohallucinations occurring especially in elderly people with reduced visual acuity. Despite numerous case reports, few successful methods of treatment have been described. Therapies with classical neuroleptics, antidepressants or benzodiazepines have generally been found to be unpromising. Only with carbamazepine treatment has improvement been observed in a few cases. In the three cases reported here, we successfully treated the condition with the atypical neuroleptic melperone.
A nineteen month old Cavalier King Charles had clinical signs consistent with a cervical myelopathy. Radiologically there was abnormal angulation of the dens with cervical spinal cord compression and a Chiari type malformation of the atlanto-occipital region. The condition and method of investigation is discussed.
Temporomandibular joint dysplasia has been reported in several breeds of dog. Three Cavalier King Charles Spaniel (CKCS) skulls were examined and radiographed during the course of a separate study and all demonstrated changes consistent with bilateral temporomandibular joint dysplasia. Subsequently, skull radiographs from all CKCS dogs examined at the University of Glasgow Veterinary School between 1991 and 2001 were reviewed (n = 26). Only two of these dogs were radiographed specifically for investigation of the temporomandibular joint, although varying degrees of dysplasia were identified in all dogs where the joints were adequately visualized (n = 20). The head of four CKCS cadavers was also radiographed, and similar changes were found. This finding suggests that temporomandibular joint dysplasia is a widespread asymptomatic condition in the CKCS and should be regarded as a normal morphologic variation rather than a pathologic anomaly. Subtle changes are best seen on lateral oblique radiographs, although marked changes are also visible on dorsoventral views. The rotational angle or angle of articulation of each of the dysplastic mandibular condyles was measured and was related to the severity of the dysplastic changes. However, there was overlap between the values calculated for these abnormal joints and normal ones in other breeds, suggesting this measurement was of limited significance and the shape of the components of the temporomandibular joint are more relevant when assessing this joint for the presence of dysplastic changes.
Two-dimensional (2-D) echocardiographic measurement of the left atrium (LA) has the potential to be more accurate than the standard M-mode method, because the LA body can be measured. We evaluated a 2-D method for measuring LA and aorta (AO) in a right parasternal short-axis view and compared it to the M-mode method. An index for LA size (LA/AO) was calculated in 166 cavalier King Charles spaniels, 56 normal and 110 dogs with mitral regurgitation (MR) of varying degrees secondary to chronic valvular disease. In normal dogs, the AO-2-D and LA/AO-2-D did not correlate to body weight (BW) or BW2; whereas, all M-mode values and the LA-2-D were significantly (p < .05) related to both BW parameters. In normal dogs, there was no difference between M-mode and 2-D indices. For all dogs (normal and dogs with MR) there was an 11% bias between the M-mode and 2-D index with the LA/AO-2-D being higher than the LA/AO-M. The association between the mean and the difference of the indices demonstrated a quadratic relationship. Dogs with a mean LA/AO of 2.0-2.5 showed the largest difference between the two indices. Small values for the 2-D coefficients of variation for respiration and stage of diastole were found; 3.4 and 3.1%, respectively. The 2-D index is more sensitive to LA enlargement than the M-mode index.
Oral eosinophilic granuloma is a rare and enigmatic disease in dogs. The clinical, haematological, cytological and histopathological features of three unrelated Cavalier King Charles spaniels with oral ulcers are presented. The disease was characterised by granuloma or plaque formation in the oral cavity. Common clinical signs were clearing the throat, swallowing problems, coughing during and after meals, reduced appetite and difficulty in eating. Haematological findings were not specific. Cytology was considered easier to perform than tissue biopsy due to friability of the tissue, but could not be used to confirm a granuloma diagnosis. The diagnosis of oral eosinophilic granuloma was verified histopathologically in each case. Response to glucocorticoid therapy varied, from complete remission to lack of any visible effect, leading to a guarded prognosis. The aetiology of the disease was not determined; however, the gross and microscopic morphologies of the lesions, their location and the response to corticosteroid therapy was suggestive of hypersensitivity.
Heart rate variability was measured in 81 Cavalier King Charles spaniels to investigate if it could be used to evaluate the severity of mitral regurgitation and to predict decompensation. Heart rate variability was assessed by the natural logarithm of the variance of the R-R intervals for 20 consecutive beats obtained from electrocardiographic recordings. Twenty-two of the dogs were clinically normal and 59 had mitral regurgitation caused by chronic valvular disease. The severity of mitral regurgitation was evaluated by echocardiography and thoracic radiography. Heart rate variability was found to be reduced (P < 0.001) among dogs with severe left atrial and ventricular dilatation and clinical signs of congestion. No significant differences in heart rate variability were found among normal dogs, dogs with only cardiac murmur, and dogs with echoradiographic evidence of slight to moderate left atrial and ventricular dilatation. Overall, an association was found between heart rate variability and left atrial to aortic root ration and left ventricular end diastolic diameters (r = 0.72 and 0.64, respectively, P < 0.001), as well as heart and respiratory rate (r = 0.80 and 0.69, respectively, P < 0.001). Multiregression analysis showed that, in order of importance, heart rate, left atrial diameter and respiratory rate had significant effects on heart rate variability. Among these parameters, heart rate variability and left atrial diameter were found to be most efficient in separating decompensated dogs from compensated. It is concluded that heart rate variability may provide the clinician with valuable information when assessing the severity of mitral regurgitation caused by chronic valvular disease.
Auditory brainstem response audiometry was used to investigate nine Cavalier King Charles spaniels with a history of hearing impairment. Successful recordings were made in all cases. In eight of the dogs, the hearing impairment was between 40 and 85 decibels re normal hearing level. In addition to confirming the degree of impairment in each ear, information was obtained concerning the site of the lesion. The auditory brainstem technique may have an important role to play in assessing treatment outcome. Other applications include screening animals used in breeding programmes as well as working dogs requiring good binaural hearing.