Neutron Capture on the s-Process Branching Point ^{171}Tm via Time-of-Flight and Activation

The neutron capture cross sections of several unstable nuclides acting as branching points in the s process are crucial for stellar nucleosynthesis studies. The unstable ^{171}Tm (t_{1/2}=1.92  yr) is part of the branching around mass A∼170 but its neutron capture cross section as a function of the neutron energy is not known to date. In this work, following the production for the first time of more than 5 mg of ^{171}Tm at the high-flux reactor Institut Laue-Langevin in France, a sample was produced at the Paul Scherrer Institute in Switzerland. Two complementary experiments were carried out at the neutron time-of-flight facility (n_TOF) at CERN in Switzerland and at the SARAF liquid lithium target facility at Soreq Nuclear Research Center in Israel by time of flight and activation, respectively. The result of the time-of-flight experiment consists of the first ever set of resonance parameters and the corresponding average resonance parameters, allowing us to make an estimation of the Maxwellian-averaged cross sections (MACS) by extrapolation. The activation measurement provides a direct and more precise measurement of the MACS at 30 keV: 384(40) mb, with which the estimation from the n_TOF data agree at the limit of 1 standard deviation. This value is 2.6 times lower than the JEFF-3.3 and ENDF/B-VIII evaluations, 25% lower than that of the Bao et al. compilation, and 1.6 times larger than the value recommended in the KADoNiS (v1) database, based on the only previous experiment. Our result affects the nucleosynthesis at the A∼170 branching, namely, the ^{171}Yb abundance increases in the material lost by asymptotic giant branch stars, providing a better match to the available pre-solar SiC grain measurements compared to the calculations based on the current JEFF-3.3 model-based evaluation.

Long-term evaluation of patients treated with dexamethasone intravitreal implant for macular edema due to retinal vein occlusion

PURPOSE

To evaluate the long-term visual prognosis and complications of patients who received intravitreal Ozurdex injections for the treatment of macular edema (ME) due to retinal vein occlusion (RVO).

METHODS

A total of 17 patients who received Ozurdex injections in our institution as part of the GENEVA study were recalled for examination. Recorded parameters included final visual acuity (VA), final retinal thickness by optical coherence tomography, persistence of ME, and the occurrence of any complications.

RESULTS

Mean follow-up time was 50.5 months. Patients with branch RVO (BRVO) had a more favorable prognosis than central RVO (CRVO), and their mean VA had improved significantly, whereas the mean VA for the patients with CRVO did not improve significantly. Retinal thickness had reduced significantly in the whole group and in each subgroup separately. Complications included 10 patients with cataract progression, 1 with elevated intraocular pressure, and 1 with neovascularization and vitreous hemorrhage.

CONCLUSIONS

This is the first reported long-term evaluation of patients treated with Ozurdex. Our results indicate that it has favorable long-term safety profile, and may have a beneficial effect on the visual prognosis in BRVO even in the absence of continuous treatment. Further research is required to establish the optimal retreatment schedule for Ozurdex.

Promoting older adults' well-being through Internet training and use

The purpose of the current research was to test the psychological impact of learning how to use computers and the Internet in old age, hypothesizing that such activities would contribute to seniors' well-being and personal sense of empowerment. Employing a quasi-experimental research design, we offered a course, conducted in small groups, in computer operation and Internet browsing to 22 older adults (mean age of 80) who went to day-care centers for the elderly or resided in nursing homes. A comparison group of 26 participants (similar in all major respects) was engaged in other activities. Both groups were administered measures of physical functioning, life satisfaction, depression, loneliness and self-control at pre- and post-intervention four months later. Individual semi-structured interviews were conducted with participants who finished the computer course. ANCOVA was employed for controlling the effects of control variables and pre-intervention differences on participants who completed the activities. Results showed a significant improvement among participants in the intervention group in all measures except physical functioning, whereas deterioration in all measures was detected in the comparison group. Computer and Internet use seems to contribute to older adults' well-being and sense of empowerment by affecting their interpersonal interactions, promoting their cognitive functioning and contributing to their experience of control and independence.

Fiberoptic bronchoscopy and bronchoalveolar lavage for the evaluation of pulmonary disease in children with primary immunodeficiency and cancer

BACKGROUND

Patients with childhood cancer or primary immunodeficiencies (PID) are at high risk for developing pulmonary infections and non-infectious complications. The broad differential diagnoses and the critical condition of these patients often drive physicians to start broad-spectrum antibiotic therapy before a definite diagnostic procedure is performed. A definite diagnosis may be achieved in these situations by fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL).

PATIENTS AND METHODS

The records of 58 PIDs and cancer (immunocompromised group) pediatric patients who underwent 62 fiberoptic bronchoscopies between 2000 and 2004 were retrospectively reviewed and compared to 158 non-cancer patients who underwent 182 fiberoptic bronchoscopies during the same period.

RESULTS

The overall diagnostic rate achieved by macroscopic inspection of purulent secretions or hemorrhage, abnormal cell count, and infectious agent isolation in the immunocompromised patients was 84%. A definite organism was recovered in 53.2% of the patients. Probable infection defined as purulent secretions or abnormal cell count without infectious agent isolation was diagnosed in another 21% of the patients. The rate of complications was 30.6%. In the control group, the overall diagnostic rate was 76.9% (n.s) and an infectious agent was demonstrated in 12.1% (P < 0.001). Probable infection was diagnosed in 24.2% (n.s) while the rate of complications was lower (15%) (P < 0.01).

CONCLUSIONS

Rapid and accurate diagnoses were achieved in most procedures performed on immunocompromised patients. Although the rate of complications was higher in the immunocompromised group, they were usually very mild with no mortality. Based on these results, broncoalveolar lavage should be considered as an initial diagnostic tool in pediatric immunocompromised patients with pulmonary complications.

Decreased prevalence of asymptomatic choroidal metastasis in disseminated breast and lung cancer: argument against screening

AIM

To determine the frequency of visually asymptomatic choroidal metastases in patients with disseminated breast and lung carcinomas in order to establish optimal patient management policies.

METHODS

All patients with confirmed metastatic disease treated in our institution between January 2002 and December 2003 were invited to undergo a funduscopic examination and a B-scan ultrasound evaluation.

RESULTS

Of the 169 study participants, 77 had breast cancer (64 with metastases in one organ and 13 with multiple-organ involvement) and 92 had lung cancer (85 with metastases in one organ and 7 with multiple-organ involvement). No patient with metastatic breast cancer and two patients with metastatic lung disease (each with multiple-organ involvement) were found to have choroidal metastases. The choroidal metastases were detected by both the funduscopic and ultrasound examinations.

CONCLUSIONS

The 2.17% incidence of choroidal metastasis in disseminated lung cancer and the 0% incidence in disseminated breast cancer speaks against the practicality of screening for early detection of choroidal metastasis among these patients, even though it would lead to early implementation of appropriate, often vision saving, therapeutic management. Its low incidence probably testifies to progress achieved by enhanced systemic oncological treatment policies that have been introduced into routine patient management over the past few years.

A phase I trial of stereotactic external beam radiation for subfoveal choroidal neovascular membranes in age-related macular degeneration

Effective treatment for neovascular age-related macular degeneration (AMD) is currently limited. Radiation therapy, a therapeutic approach with known antiangiogenic properties, has been investigated as a modality to prevent severe visual loss in AMD. Most of the studies using external beam radiation employed <25 Gy to the whole eye, which is below the dose of radiation that is toxic to the retina and optic nerve ( approximately 50 Gy and approximately 59 Gy, respectively). Stereotactic fractionated external beam radiation (St-EBR) is a method that allows radiation to be delivered to a small, defined area. We investigated the effects of St-EBR in incremental doses up to 40 Gy on neovascular AMD. Patients with clinical signs and fluorescein angiography demonstrating neovascular AMD, visual acuity (VA) better than 20/400 and ineligible for laser treatment (MPS criteria) or who refused to have laser photocoagulation were enrolled in the study. Each patient was treated with radiation at incremental dosages from 20 Gy to 40 Gy. After completion of the radiation course, all patients were followed-up at 3 and 7 weeks and 3, 6, and 12 months. Best-corrected VA (ETDRS), slit-lamp and fluorescein angiographic evaluations were performed at each visit. 94 eyes of 89 patients were treated from October 1997 to April 2000. The VA was 0.82+/-0.35 before treatment, 0.83+/-0.36 at 6 months, and 0.89+/-0.33 at 12 months. No patients suffered any significant acute side effects. No significant benefits in either VA or in membrane size were derived from increasing the doses of radiation. Our results are consistent with trends of a palliative benefit of radiotherapy in neovascular AMD and support further investigation of radiotherapy. Since there is no evidence that therapeutic effectiveness is dose dependent, our data provide no justification for potentially dangerous escalations in radiation dosage for treating neovascular AMD.

Retinal pigment epithelial tear following photodynamic therapy for choroidal neovascularization secondary to AMD

PURPOSE

To describe retinal pigment epithelial tear following photodynamic therapy (PDT) for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).

DESIGN

Retrospective interventional case series.

METHODS

A retrospective study in an institutional practice. We describe seven cases of retinal pigment epithelial (RPE) tear, which developed in seven eyes of seven patients following PDT. All eyes had subfoveal CNV secondary to AMD.

RESULTS

Six eyes had occult subfoveal CNV, and one eye had recurrent classic subfoveal CNV. In five patients, the eye that developed the tear was the second eye, whereas the first eye had a disciform scar. In four eyes, the RPE tear developed after one PDT, in one eye the RPE tear developed after the second PDT, and in two eyes the RPE tear developed after the third PDT. In five of seven cases, there was a significant visual deterioration following the RPE tear.

CONCLUSIONS

RPE tear is a complication that may occur following PDT in particular when the PDT is applied to an occult subfoveal CNV.

Trampoline use as physiotherapy for cystic fibrosis patients

Physicians and physiotherapists who care for CF patients have recommended the use of trampolines as a physiotherapeutic tool for enhancing cardiopulmonary performance, encouraging sputum production, and improving general well-being. Despite some therapeutic and recreational benefits associated with trampoline use, papers in the general pediatric population mostly document an increased incidence of injuries, ranging from minor trauma to spinal cord injuries and even death. The aim of this review is to examine the accumulated published data regarding the use of trampolines, to assess their potential contributions and disadvantages for CF patients, and to define whether trampoline use should be recommended. An extensive search in the published medical literature retrieved approximately 60 articles that primarily dealt with trampolines, out of which only two dealt with CF. The preponderance of these articles are reports pertaining to injuries related to the use of trampolines, with only a few describing the medical, physiologic, and/or psychological benefits of trampolines. Based on the accumulated data, the presumed benefits of trampoline use for CF patients are not proven. Furthermore, the suggested benefits could be acquired using other types of exercise. Weighing the known risks of trampolines against the potential benefits that are not unique to this modality suggests that the use of trampolines for CF should not be recommended.

Systemic inflammatory mediators and cystic fibrosis genotype

Morbidity and mortality in cystic fibrosis patients is mainly attributed to pulmonary infection and inflammation. Chemokines play a pivotal role in the inflammatory process. Although genotype-phenotype correlation in cystic fibrosis patients has been defined, a clear relationship between the defect in the cystic fibrosis transmembrane regulator (CFTR) gene and pulmonary inflammation has not been established. The aim of this study was to assess whether serum chemokines levels in cystic fibrosis patients correlate with genotype and pulmonary function tests, as well as with other clinical characteristics. Serum levels of interleukin-8, RANTES, and monocyte chemoattractant protein-1 were measured in 36 cystic fibrosis patients grouped according to their genotype. Group A included 25 patients who carried two mutations associated with a pathological sweat test and pancreatic insufficiency (deltaF508, W1282X, G542X, N1303K, S549R). Group B included 11 compound heterozygote patients who carried one mutation known to cause mild disease with borderline or normal sweat test and pancreatic sufficiency (3849+10kb C to T, 5T). Associations between chemokine levels, genotype, pulmonary function, Pseudomonas aeruginosa colonization, age, sweat chloride level, and pancreatic and nutritional status were examined. Mean interleukin-8 and monocyte chemoattractant protein-1 levels were significantly higher in group A than group B (11.4 +/- 2.1 pg/ml vs. 5 +/- 0.9 pg/ml and 157 +/- 16 pg/ml vs. 88.8 +/- 16.4 pg/ml, respectively) (P < 0.01). No difference in RANTES levels were found between groups. interleukin-8 levels were inversely related to forced expiratory volume in 1 s (r = -0.37, P < 0.02), while there was no association between the latter and RANTES and monocyte chemoattractant protein-1 levels. The Pseudomonas colonization rate was higher among group A patients than group B (88% vs. 40%, P < 0.01). No relationship was found between measured chemokines and age, sweat chloride levels, and pancreatic and nutritional status. Our study demonstrates an association between interleukin-8, forced expiratory volume, and cystic fibrosis genotype. Hence, elevated interleukin-8 serum levels could serve as an indicator of an early inflammatory process and encourage the initiation of anti-inflammatory treatment.

Sensitivity and positive predictive values of presurgical clinical diagnosis of excised benign and malignant skin tumors: a prospective study of 835 lesions in 778 patients

This article reports on the sensitivity and positive predictive value of clinical diagnosis of benign and malignant skin tumors by expert plastic surgeons in an Israeli clinic. Most published reports have focused on the sensitivity of clinicians' diagnoses, a general measure of the physician's skill that does not predict the rate of accuracy of a physician's diagnoses. Our study of 835 lesions in 778 patients, one of the largest Israeli series, assesses the clinical diagnosis of malignant and benign skin tumors and is one of the few that provide information on the positive predictive value, the measure that is of interest to both physicians and patients. The majority of tumors were benign (56.8 percent), 31.6 percent were malignant, and 11.6 percent were premalignant. Among the 474 benign lesions, 46 percent were nevi. The most common nevi subclass was compound nevi (53 percent), 9 percent of the nevi were dysplastic, and 5 percent were blue nevi. The most common malignant tumor was basal cell carcinoma, accounting for 78 percent of malignant tumors. Although sensitivity for clinical diagnosis of malignancy was 91.3 percent, the positive predictive value for clinical diagnosis of malignancy was 71.3 percent. The sensitivity rate for clinically diagnosing premalignant tumors was 42.3 percent, whereas the positive predictive value for these diagnoses was higher (64.1 percent). The sensitivity rate for diagnosis of all benign lesions was 85.9 percent, and the positive predictive value was 94.2 percent. The sensitivity rate for diagnosis of all nevi was 87.6 percent, and the positive predictive value was 85.7 percent: i.e., only seven of the 218 pathologically proven diagnoses of nevi (3.2 percent) were falsely diagnosed as malignant lesions. Even more interestingly, five of the 223 clinical diagnoses of nevi (2.2 percent) were pathologically proven to be malignant melanomas, and seven were found to be premalignant lesions (3.1 percent). It was concluded that publications which report only on the sensitivity neglect to provide information of interest regarding the positive predictive value. Often, positive predictive value is qualitatively different from the sensitivity, and thus relying only on the sensitivity may lead to incorrect evaluation of a clinical judgment, which may result in erroneous surgical decisions.

Hemodynamic effects of tracheal administration of vasopressin in dogs

BACKGROUND

Intravenous administration of vasopressin during cardiopulmonary resuscitation (CPR) has been shown to be more effective than optimal doses of epinephrine. Earlier studies had been performed on a porcine model, but pigs produce lysine vasopressin hormone, while humans and dogs do not. This study was designed to compare the effects of tracheal vasopressin with those of NaCl 0.9% (placebo) on haemodynamic variables in a dog model.

METHODS

Five dogs were allocated to receive either vasopressin 1.2 U/kg or placebo (10 ml of NaCl 0.9%) via the tracheal route after being anesthetized and ventilated. Haemodynamic variables were determined and arterial blood gases were measured.

RESULTS

All animals of the vasopressin group demonstrated a significant increase of the systolic (from 135+/-7 to 165+/-6 mmHg, P<0.05), diastolic (from 85+/-10 to 110+/-10 mmHg, P<0.05) and mean blood pressure (from 98.5+/-3 to 142.2+/-5, P<0.05). Blood pressure rose rapidly and lasted for more than an hour (plateau effect). Heart rate decreased significantly following vasopressin (from 54+/-9 to 40+/-5 beats per min, P<0.05) but not in the placebo group. These changes were not demonstrated with placebo injection.

CONCLUSION

Tracheal administration of vasopressin was followed by significantly higher diastolic, systolic and mean blood pressures in the vasopressin group compared with the placebo group. Blood gases remained unchanged in both groups. Vasopressin administered via the trachea may be an acceptable alternative for vasopressor administration during CPR, when intravenous access is delayed or not available, however, further investigation is necessary.

Distal arteriovenous fistula to maintain patency of the venous drainage of a latissimus dorsi flap following subclavian vein repair

Successful reconstructive surgery with muscle flaps depends on adequate arterial supply and undisturbed venous drainage. Combining such surgery with reconstructive vascular surgery of a large-caliber vein that is responsible for the venous drainage of the flap poses an additional challenge--the repaired vein's susceptibility to thrombosis. Every attempt must be made to prevent venous outflow obstruction following muscle flap surgery. Data from the vascular surgery literature demonstrate a low success rate for subclavian vein repair. The success rate with venous reconstructive surgery has been greater when a distal arteriovenous fistula accompanied the repair. The present case described the use of a temporary distal cephalic-brachial arteriovenous fistula to maintain the patency of the venous drainage of a pedicled latissimus dorsi muscle flap, following subclavian vein repair, for one-stage coverage of a large chest wall defect.

Ceramide: a potential mediator of apoptosis in human retinal pigment epithelial cells

PURPOSE

To investigate the signal transduction mechanisms involved in the cell death of human retinal pigment epithelial (RPE) cells after their exposure to either hydrogen peroxide (H(2)O(2)) or tri-butyl hydroxperoxide (tBH).

METHODS

Cultured human RPE (hRPE) cells were treated with the chemical oxidants tBH and H(2)O(2) as well as with the synthetic ceramide analogs C(2), C(6), and dihydroceramide for different time periods. Apoptosis was determined by TUNEL staining and annexin-V labeling of phosphatidylserine exposure. Ceramide levels were quantified by the diacylglycerol kinase assay using thin-layer chromatography.

RESULTS

H(2)O(2) and tBH caused a high level of apoptosis in the hRPE cells. At the same time, both of these oxidants induced an early and late increase in the intracellular production of ceramide, a lipid second messenger. Moreover, addition of C(2) and C(6) synthetic ceramides caused a high level of apoptosis in these hRPE cells. In contrast, treatment with the immediate precursor of ceramide, dihydroceramide, resulted in no apoptotic response.

CONCLUSIONS

The results demonstrate that H(2)O(2) and tBH induce apoptosis in hRPE cells and suggest that the underlying signaling mechanism involves ceramide generation.

Atypical reginal vasculitis associated with ticlopidine hydrochloridine use

PURPOSE

To describe two cases of retinal vasculitis shortly after the initiation of ticlopidine hydrochloride (Ticlid, Roche, Kingsland St, NJ) therapy.

METHODS

Case reports of two patients. The first patient was a 43-year-old white woman complaining of spots, floaters, and flashes of lights in both eyes 3 weeks after the initiation of treatment with ticlopidine hydrochloride. The second patient was a 72-year-old woman complaining of decreased visual acuity in the left eye for 2 weeks, 4 weeks after initiating oral administration of ticlopidine hydrochloride.

RESULTS

Both patients had resolution of the vasculitis after the discontinuation of ticlopidine therapy.

CONCLUSION

The temporal relation and the resolution of symptoms after discontinuation of ticlopidine hydrochloride suggest that the vasculitis was related to the ticlopidine hydrochloride administration. Knowledge of this potential complication of ticlopidine hydrochloride is important for the early diagnosis of this possible drug-induced side effect and the cessation of ticlopidine hydrochloride.

Reaching the diagnosis of cystic fibrosis--the limits of the spectrum

BACKGROUND

Cystic fibrosis is the most common life-limiting autosomal recessive genetic disorder in Caucasians. Typically it is a multisystem disease diagnosed by increased chloride levels on sweat testing, with mortality due mainly to progressive respiratory disease. The clinical spectrum of CF has recently been much expanded. Genetic testing for mutant CF transmembrane regulator has revealed atypical cases where sweat test results are borderline or normal. In other patients, genetic mutations cannot be identified but abnormal CFTR function is shown using nasal potential difference measurement.

OBJECTIVES

To highlight the diagnostic and therapeutic dilemmas in cases of atypical cystic fibrosis.

METHODS

We reviewed patients with atypical CF and widely varying phenotype who are managed at Schneider Children's Medical Center of Israel.

RESULTS

Two patients had severe lung disease but little expression in other organs. Accurate diagnosis was essential to enable aggressive therapy in a specialized center. Four other patients are in excellent general health but have symptoms limited to male infertility, heat exhaustion, pancreatitis or transient liver dysfunction, while lung disease is minimal. For these patients, careful counseling is needed to avoid unnecessary upheaval, inappropriately aggressive management, and the psychosocial implications of a CF diagnosis. These dilemmas have increased considerably in our center, as in others worldwide.

CONCLUSION

It is our obligation as clinicians--at the level of both primary physician and referral center--to maintain an ever higher index of suspicion for CF, tempered by a rational program of counseling and management appropriate to the individual.

Strabismus surgery in children with Möbius syndrome

Möbius syndrome is a congenital disorder of facial diplegia associated with lateral gaze paralysis. Although palsy of the sixth and seventh cranial nerves is the minimum diagnostic finding for Möbius syndrome, neuropathologic evidence indicates that this is a more complex syndrome.(1) Clinically, it is characterized by a total absence of facial expression and severe esotropia. Other anomalies may be associated with this syndrome, especially other cranial nerve palsies and Poland syndrome. The etiology of this syndrome has not been clearly established. Brain stem necrosis resulting from a vascular deficiency has been offered as a possible pathogenetic explanation.(2) The strabismus in Möbius syndrome is congenital esotropia with bilateral limitation in abduction. Even though many reports have described the various features of Möbius syndrome, only a few articles have reported the results of strabismus surgery in children, including bimedial rectus muscle recession. (3-5) Some authors report that bilateral medial rectus muscle recession alone has been disappointing; therefore, a combination of a medial rectus muscle recession and a lateral rectus muscle resection was recommended for satisfactory results. (5-7) In more severe cases, muscle transposition was needed to ensure straight position of the eyes in primary gaze. (8-9)

The incidence of hepatitis C virus positive serological test results among cornea donors

Purpose. We have noticed that the incidence of positive serological tests of hepatitis C virus (HCV) among cornea donors in our eye bank is higher than expected. The purpose of this study was to determine the incidence of these positive findings and identify the contributory risk factors.Methods. All corneas procured between June 1993 and June 1997 were included in this retrospective study. In all cases a routine work-up, including serological testing of donors' sera and evaluation of the procured corneas, was performed prior to corneal transplantation. Donors found to be positive for HCV antibodies were compared to our general population of corneal donors, with respect to the demographic, serological and ophthalmological data obtained during the transplantation work-up.Results. All 851 corneas procured from 438 donors were included. Antibodies to HCV were found in 29 donors (6.6%). Following positive test results, 57 corneas (6.7%) were discarded. The time from donors' death to cornea procurement was significantly longer among HCV-positive patients than in the general donor population (12.3 vs. 9.3 h, p<0.0003). No other differences were detected between the two groups.Conclusion. Delay in harvesting of donated corneas may give rise to false positive HCV-antibodies test results, which may be partially responsible for the high rate of positive findings among cornea donors, with consequent tissue wastage.

Forming clinical impressions during the first five minutes of the counseling interview

The influence of earlier formed clinical impressions of the client on later judgments within a counseling session were examined. It was predicted that redundancy in judgments of counselors' clinical impressions of the client after 5 min. and after 30 min. of an interview would be greater for counselor-trainees who are (a) more self-confident about their judgments and (b) lower in cognitive complexity, than other counselor-trainees. A stimulus tape in which a male counselor conducted an initial 30-min. interview with a depressed female client was shown to 80 counselor-trainees. At the 5- and 30-min. marks, the tape was stopped, and the counselor-trainees indicated their clinical impressions of the client. These impressions included written thoughts and ratings of clinical characteristics of the client. Analyses showed that both their self-confidence and cognitive complexity were not associated with differences in redundant judgments.

Improved vitality of experimental random dorsal skin flaps in rats treated with enriched cell culture medium

A defined, serum-free cell culture medium supplemented with nonsteroidal anabolic hormones, insulin, thyroxin, and growth hormone was found to accelerate wound healing by stimulating vascularized granulation tissue formation, epithelialization, and angiogenesis. The aim of this work was to study the effect of cell culture medium on the survival rate of cephalically based random dorsal skin flaps in an animal model. A total of 77 Sprague-Dawley rats were randomized into five treatment groups: pharmacologic delay with cell culture medium, flap enhancement with cell culture medium, surgical delay, biological delay with saline, and control. Statistically significant differences in distal flap necrosis were found among all groups (p<0.003). The rats treated with cell culture medium before flap elevation showed a significant increase in flap viability: a survival rate of 83 percent, compared with the control group, which demonstrated a survival rate of only 58 percent (p<0.0001). The surgical delay and the groups treated with cell culture medium yielded similar results with no significant difference between them. This study indicates that preoperative injection of cell culture medium may play a role in decreasing skin flap necrosis.

Striae distensae of augmented breasts after oral contraceptive therapy

A case of striae distensae (SD) of bilateral augmented breasts following oral contraceptive therapy is presented. Striae maturation and the prevention of additional skin marks was achieved with immediate cessation of oral contraceptive pill therapy and long-term daily topical application of tretinoin cream. It is suggested that patients who are candidates for breast augmentation surgery should be informed of the possible risk of developing SD if they are taking or planning to take the contraceptive pill.

[Prevalence of pigmentary dispersion syndrome in Israel]

Pigmentary dispersion syndrome is a precursor of pigmentary glaucoma whose prevalence in the urban population of USA was found to be 2.45%. We evaluated its prevalence during ocular screening examinations among normal Israelis. We screened for excessive pigmentation on the corneal endothelium with the slit-lamp and determined in each patient best corrected visual acuity, intra-ocular pressure (after mydriasis), condition of the anterior segment, cup-disk ratio, posterior segment abnormalities and questioned about history of any ocular disease and family history of glaucoma. 374 patients (mean age 49 +/- 11) were examined on 10 consecutive days. In 5.9% excessive corneal endothelial pigmentation was found. Intra-ocular pressure (after mydriasis) averaged 15.52 +/- 1.93 mm Hg as compared to 14.73 +/- 2.04 among the rest of our study population, (p = 0.01). The prevalence of suspected pigmentary dispersion syndrome among young adults in Israelis is high.

Partial breast necrosis after MIDCABG via small anterolateral thoracotomy

We report a case in which partial breast necrosis developed after minimally invasive direct coronary artery bypass grafting using an IMA Retractor (Cardio-Thoracic Systems Inc, Cupertino, CA). We suggest that during minimally invasive direct coronary artery bypass grafting in the presence of a large breast, it is advisable to reduce the intraoperative additive forces of pressure and traction caused by the retractor arm on the breast tissue, thus avoiding further excessive compression on the partially compromised blood circulation of the breast.

Hyperbaric oxygen therapy for deep second degree burns: an experimental study in the guinea pig

Most previous animal studies reporting improved epithelialisation and healing of burn wounds under hyperbaric oxygen (HBO) did not include the conventional treatment with topical antibiotics as part of the protocol, and did not compare the effectiveness of HBO therapy with that of normobaric 100% oxygen (NO). The purpose of our study was to compare the results of combined treatment with HBO + silver sulfadiazine (SS) and those of treatment with NO + SS or SS alone. Deep second degree burns were produced on the depilated backs of 54 guinea pigs using a validated burn protocol. The animals were assigned to three treatment groups: HBO + SS, NO + SS, and SS. Dressings were changed daily. HBO was administered at 2 atmospheres absolute (ATA) for 90 min BID, and NO for 90 min BID. The parameters compared among the groups were laser Doppler flowmetry, and burn wound contracture and re-epithelialisation data derived from computerised planimetry of photographs of the wound. No differences in laser Doppler flowmetry results or the magnitude of contracture were found between the groups. Significantly increased re-epithelialisation was observed under NO + SS starting 10 days after the burn (P = 0.02, ANOVA). This significance stems from the difference between the HBO + SS and NO + SS groups (Tukey test). These data indicate that excessively high levels of tissue PO2 might compromise burn healing, and explain our results. A further study comparing combined treatment using a milder HBO protocol + SS and NO + SS is indicated in the search for the optimal HBO regimen.

Temperature-controlled CO2 laser tissue welding of ocular tissues

Lasers can be used for binding tissues by welding, but the clinical application of this method has been limited by the difficulties in defining and maintaining the optimal conditions. Fiberoptic radiometry allows accurate remote temperature measurements for control of laser tissue welding. We evaluated the use of a temperature-controlled tissue welding system to close corneal and corneoscleral wounds. Eighty ex vivo bovine eyes were used for the determination of welding parameters optimal for corneal wound closure. A 4 mm central corneal cut was closed with use of a CO2 laser (600 mw, 0.9 mm spot size), with tissue temperatures ranging from 45-70 degrees C and welding time ranging from 1-30 seconds. Wound strength was measured as burst pressure of the sealed wound. The welding parameters found to cause the strongest wound binding were used to weld a limbal incision of 4 mm in 10 adult albino rabbits. The fellow eye of each animal was used as a control, and the same wound was closed with one 10/0 mersilen suture. Two animals were killed immediately after the procedure, and the eyes were sent for histologic examination. Eight rabbits were followed for 1 month. Clinical examination and refraction were done 1 day, 1 week, 2 weeks, and 1 month after the procedure. Corneal topographic evaluations were done 1 week after the procedure. After 1 month the animals were killed and the eyes were examined histologically. The optimal results of wound binding by laser welding in the enucleated bovine eyes were achieved with 55-60 degrees C and at a welding time of 12-20 seconds. At these parameters the burst pressure of corneal wounds was 70 mm Hg. All laser-welded limbal wounds in the rabbits were tightly closed at the end of procedure and during the follow-up period. The refractive results after laser welding were equal to those of the controlled suture-closed wound. Laser tissue welding combined with tissue temperature monitoring can be used to close corneal wounds.

Transcanalicular laser-assisted dacryocystorhinostomy

BACKGROUND AND OBJECTIVE

Current techniques of laser-assisted dacryocystorhinostomy are mostly endonasal. In this report, the authors describe their technique of laser-assisted dacryocystorhinostomy performed through the canaliculi and the surgical results they achieved.

PATIENTS AND METHODS

Fourteen patients with nasolacrimal duct obstruction underwent transcanalicular laser-assisted dacryocystorhinostomy. The bony ostium was perforated using a fiber optic-transmitting, giant-pulse Nd:YAG laser, with an energy of 0.5 to 4 J per pulse. The total energy used to create an ostium was 18 to 34 J. A silicone tube was inserted through the canaliculi and the ostium into the nasal cavity and kept in place for 5 to 7 months. Patients were observed for 18 to 22 months.

RESULTS

Nine of the 14 patients (64%) reported the disappearance of epiphora following surgery. In 3 patients, no relief of epiphora was obtained. In 1 patient the operation was not completed because of severe nasal bleeding. In another, tearing began 12 months after surgery (6 months after tube removal).

CONCLUSIONS

Transcanalicular laser-assisted dacryocystorhinostomy is a potentially useful method for performing dacryocystorhinostomy. Technical modifications and improvements are needed to increase the success rate.

Intraocular pressure increments after cataract extraction in glaucomatous eyes with functioning filtering blebs

BACKGROUND AND OBJECTIVE

The effects of cataract extraction on intraocular pressure (IOP) were studied in glaucoma patients who had previously undergone trabeculectomy.

PATIENTS AND METHODS

The files of 22 patients with 25 glaucomatous eyes with functioning filtering blebs who underwent cataract extraction were retrospectively reviewed. All patients had undergone pretrabeculectomy examination and had at least 18 months of follow-up after cataract surgery. Visual acuity, IOP, status of the filtering bleb, and the number of medications applied were recorded.

RESULTS

The mean increase in IOP was 3.63 mm Hg, 3.84 mm Hg, 5.4 mm Hg, and 2.8 mm Hg at 3, 6, 12, and 18 months after cataract extraction, respectively. This elevation was statistically significant 3 months postoperatively (P < .001) and remained relatively constant thereafter. The postoperative IOP was still significantly lower than the pretrabeculectomy IOP (P < .001).

CONCLUSIONS

Cataract extraction through corneal incisions in patients with functioning filtering blebs is followed by an increase in IOP. Cataract surgery in these patients does not neutralize the pressure-lowering effect achieved by the trabeculectomy, but it tends to elevate the post-trabeculectomy baseline pressure.

Intraoperative expansion of the palate by the tumescent technique

Intraoperative rapid expansion of soft tissue of the palate is reported. Tissue is recruited by repeated injections of an isotonic solution in a tumescent-like technique, thus producing increasing swelling of the palatal soft tissue. Straight direct closure of palatal clefts and fistulas is achieved with minimal scarring at the midline, no secondary healing of raw surfaces, and satisfactory and encouraging results.

Measurement of head-turn in ocular torticollis

There is a need for a simple and accurate method to measure head-turn in patients who suffer from torticollis secondary to ocular disease. In the technique described here, a fixation object is moved from a point in front of the patient to a point at which the patient's face is straight. The distance that the object is moved is proportional to the amount of head-turn the patient has. With a simple mathematical calculation, the angle of head-turn can be determined, even during a routine clinical evaluation.

["CHARGE" association]

CHARGE association represents a group of congenital anomalies with no clear etiology. The broad array of abnormalities, which involves several systems, has been the basis for the acronym CHARGE: coloboma, heart anomaly, choanal atresia, retarded growth and development, hypoplastic genitalia and ear malformation. We present 3 children with CHARGE association to illustrate the phenotypic variability and note the multidisciplinary treatment they received. It is recommended that this entity be approached in an interdisciplinary, integrated way to allow for faster diagnosis and better prognosis.

Insulin-induced lipohypertrophy treated by liposuction

Lipohypertrophy is one of the local side effects of repeated subcutaneous insulin injections. This case report demonstrates the successful cosmetic and therapeutic treatment of two lipohypertrophic masses in the lower abdomen of a young diabetic patient by suction-assisted lipectomy.

Infected orbital cyst following exenteration

An orbital cyst is a rare complication of orbital trauma and exenteration. Infections of such cysts have not been described, and are potentially dangerous unless treated immediately. The authors describe a case of delayed treatment of such an infected cyst, which resolved following surgical drainage. The potentially hazardous outcome makes knowledge of such cases important.

Anterior segment pathology associated with hypermetropia

Eight children presented who suffered from pathological changes of the anterior chamber as part of Axenfeld-Rieger syndrome. All of them had associated hypermetropia. Hypermetropia in these cases may have resulted from disturbed development of the anterior segment of the eyes during fetal life.

Early postoperative intraocular pressure pattern in glaucomatous and nonglaucomatous patients

PURPOSE

To evaluate intraocular pressure (IOP) changes in the 24 hours following cataract extraction in glaucomatous and nonglaucomatous patients.

SETTING

General Eye Service and Glaucoma Service of the Goldschleger Eye Institute, Tel Hashomer, Israel.

METHODS

Twenty-six nonglaucomatous patients and 13 glaucomatous patients scheduled for routine cataract extraction and intraocular lens implantation were evaluated. In each patient, IOP was measured before cataract surgery and every 4 hours for 24 hours postoperatively. Thirteen of the nonglaucomatous patients were randomly treated with one drop of timolol maleate at the end of surgery (NG-T group). The other 13 nonglaucomatous patients (NG group) and all glaucoma patients (G group) were not treated.

RESULTS

In the NG group, mean preoperative IOP was 13.9 mm Hg. Following surgery, IOP rose steadily to 22.2 mm Hg at 12 hours; it returned to almost presurgical levels at 24 hours. The IOP exceeded 35 mm Hg in only one patient. In the NG-T group, mean preoperative IOP was 16.5 mm Hg and increased to 21.2 mm Hg at 12 hours. The IOP returned to almost presurgical levels at 24 hours. In the G group, mean IOP was 18.8 mm Hg preoperatively and rose to 29.9 mm Hg at 8 hours after surgery. In seven eyes the IOP exceeded 35 mm Hg.

COMMENTS

Our findings of elevated IOP emphasize the need for prophylactic treatment (medical or combined cataract and glaucoma surgery) to prevent IOP spikes in high-risk patients.

Bilateral iridocorneal endothelial syndrome presented as Cogan-Reese and Chandler's syndrome

PURPOSE

Iridocorneal endothelial (ICE) syndrome includes Chandler's syndrome, essential iris atrophy, and the Cogan Reese syndrome. The purpose of this article is to describe a rare case with two forms of the syndrome simultaneously.

METHODS

A case of Cogan Reese syndrome in one eye and Chandler's syndrome in the fellow eye is reported.

RESULTS

During 5 years of follow-up only slight progression, manifested in episodes of blurred vision, occurred because of corneal changes. Glaucoma did not develop.

CONCLUSION

ICE syndrome is considered as unilateral, although cases of bilateral involvement of the same variant have been described. But a simultaneous presentation of two different forms might occur, as in this patient.

Effects of preinterview suggestion on counselor memory, clinical impression, and confidence in judgments

This study examined the effects of schematic preinterview suggestion on counselors' (a) recognition memory of the information presented by the client; (b) clinical impression rating of the client; and (c) confidence in rating clinical impression. Fifty-two Master's-level counselor-trainees were assigned randomly to two conditions of preinterview suggestion about the status of the client (i.e., depression and no depression). After subjects had received appropriate preinterview information (i.e., depression or no-depression content) and had viewed a videotaped counseling interview, information was gathered from them. The results indicated that the preinterview suggestion (a) did not affect counselor-trainees' clinical impression rating of the client; (b) did not affect confidence of rating; and (c) yielded a weak, but significant, confirmatory memory. Implications for the interview setting are discussed.

Use of the giant-pulse Nd:YAG laser for ab-externo sclerostomy in rabbits and humans

The giant-pulse Neodymium:YAG laser, a recently developed laser source, delivers up to 200 W of peak power at pulse widths of 20 or 40 msec. The instrument can create a sclerostomy with minimal surrounding damage and, consequently, relatively little postsurgical inflammation and scarring. We tested its efficacy in performing ab-externo sclerostomy in 10 adult pigmented rabbits and in five patients with end-stage glaucoma. All of the animal eyes were hypotonus immediately after the procedure. However, the intraocular pressure increased gradually, and by the third day, returned to presurgical levels in all of the eyes. All five of the glaucoma patients treated had patent sclerostomies following the procedure. They all had early hypotony, but after 3 months, four of the five sclerostomies apparently failed. The giant-pulse Nd:YAG laser appears useful for performing sclerostomy, but modifications are needed to solve the problems of early hypotony and late closure of the fistulula.

Removal of silicone oil in the management of glaucoma in eyes with emulsified silicone

Glaucoma and emulsification are two complications of silicone oil injection that are often coexisting. This study was undertaken to determine whether removal of emulsified oil has any effect on the management of the glaucoma. A comparison of eyes with and without glaucoma with emulsified oil also was undertaken. Eighteen eyes that underwent removal of emulsified silicone oil more than 6 months after the injection of the oil were reviewed. All eyes were observed for at least 6 months after removal with attached retinas. Eleven eyes had glaucoma at the time of removal. The diagnosis of glaucoma preceded the identification of emulsification in 8 of 11 eyes (73%). Removal of the emulsified oil did not affect the intraocular pressure (IOP) in 10 of the 11 (91%) glaucomatous eyes. The IOP was reduced in one patient. In the glaucoma patients, the final visual acuity was significantly reduced compared with the best corrected visual acuity obtained during the follow-up period (P = 0.016). In the nonglaucoma eyes with emulsified oil, the visual acuity did not significantly deteriorate during follow-up. At the end of the follow-up period, optic atrophy was observed in 9 of 11 (82%) of the eyes with glaucoma compared with two of seven (28%) of eyes without glaucoma. The results suggest that removal of emulsified silicone oil failed to control the glaucoma, and could not change the aggressive nature of the glaucoma in these eyes.

The effect of intracamerally injected ethacrynic acid on intraocular pressure in patients with glaucoma

We studied the effect of ethacrynic acid on intraocular pressure in eyes with advanced open-angle glaucoma. Five to 15 microliters of ethacrynic acid (3.3 to 9.8 micrograms) was injected intracamerally after retrobulbar anesthesia was achieved in five eyes of five patients with advanced glaucoma. Intraocular pressure before treatment ranged from 26 to 46 mm Hg with maximal medical treatment. A reduction in intraocular pressure from 9 to 31 mm Hg was observed in all patients three to 24 hours after treatment, and this effect lasted for three days, with a gradual return of intraocular pressure to pretreatment values one week after treatment. No acute corneal or anterior chamber side effects were observed and results of corneal endothelial cells counts were essentially unchanged two months after treatment. We suggest that ethacrynic acid may represent a new class of antiglaucoma medication. Intracameral administration of ethacrynic acid or a derivative might be contemplated in the future at the time of other ocular surgical procedures to treat short-term intraocular pressure increase.