Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

An Insight Into Systemic Immune Response in Leishmania donovani Mediated Atypical Cutaneous Leishmaniasis in the New Endemic State of Himachal Pradesh, India

Leishmaniasis continues to afflict known and newer endemic sites despite global efforts towards its control and elimination. In this regard, the emergence of newer endemic sites with unusual disease formats is recognized wherein Leishmania donovani complex classically known to cause visceral disease is demonstrated to cause cutaneous manifestation. In this context, atypical cutaneous leishmaniasis (CL) cases caused by L. donovani genetic variants from the newer endemic state of Himachal Pradesh (HP) in India are beginning to be understood in terms of parasite determinants. The atypical CL manifestation further needs to be explored to define host immune correlates with a possible role in driving the unusual disease progression. In the given study, we performed comprehensive systemic-immune profiling of the atypical CL patients from the study area in HP, India, in comparison with the classical visceral leishmaniasis (VL) patients from the northeast region of India. The systemic immune response was studied using ELISA-based assessment of Th1, Th2, Th17, Treg, and Th22 specific plasma cytokine expression pattern and parasite-specific total serum IgG/IgG subclasses. The specified immune correlates are known to exhibit heterogeneous association with the different infecting parasite species, infection load, and co-lateral host immunopathology in classical CL and VL. In the atypical CL patient group, altered expression of IL-10 emerged as the key finding that could potentially fine-tune the Th1/Th17/Th22 effector cytokine axis towards a localized cutaneous manifestation. A reduced expression of IL-10 along with a high IFN-γ/IL-10 ratio as a readout of effective parasite killing defined atypical cutaneous outcome. In contrast, high circulatory IL-10 levels and a depressed IFN-γ/IL-10 ratio were seen in classical VL patients in line with an ineffective parasite-killing cytokine response. Overall, the study highlights new knowledge on host immune correlates in terms of cytokine expression pattern and IgG subclasses that underline atypical disease manifestation such that L. donovani, a generally visceralizing parasite species cause skin localized cutaneous lesions.

Experience of Rituximab Therapy in Pemphigus: A Three-Year Retrospective Study from a Sub-Himalayan State

Background

Pemphigus is a group of auto-immune blistering disorders, characterised clinically by mucocutaneous blisters and erosions and histopathologically by intra-epidermal acantholysis. It was traditionally associated with high morbidity and mortality. The use of rituximab has brought upon a new dawn in the treatment of pemphigus.

Aim

A retrospective analysis to ascertain the efficacy, tolerance, adverse effect profile, remission, and relapse with the use of rituximab.

Material and Methods

A retrospective analysis of all diagnosed pemphigus patients who received rituximab therapy over a period of 3 years was performed. The patient's baseline characteristics, disease duration, clinical presentations, mucosal involvement, disease-severity assessment, and adverse events with rituximab were noted. The outcomes were evaluated based on the definitions of the disease-outcome parameters as early and late endpoints.

Results

Of the 17 pemphigus patients, there were 14 females (82.4%) and three males (17.6%) with a mean age of 35.9 ± 16.5 years (range: 9-65 years). Pemphigus vulgaris (PV) was the predominant type in 11 (64.7%) patients. After rituximab infusion, the 17 patients attained the end of consolidation phase (ECP) within 15 days to 3 months, and the mean duration was 1.24 months. The complete remission (CR on/off) ranged from 0.5 to 35 months, and the mean duration of remission was 21.7 months. Within a median time of 4.2 months, almost 80% patients achieved CR on therapy. Nine (53%) patients were in CR without any therapy till the end of the study period, and eight (47%) were in remission while on minimal therapy.

Conclusion

Rituximab is an efficacious therapeutic agent for pemphigus and is better tolerated and safer to all the previous medications used in the treatment.

A Clinicoepidemiological Study of Psychiatric Co-Morbidity in Hansen's Disease

Introduction

Leprosy is a chronic disease caused by mycobacterium leprae. Chronicity of the disease leads to various psychiatric co-morbidities, which are often undiagnosed and untreated. The main objectives of this study were to evaluate the frequency and nature of psychiatric co-morbidity in patients of Hansen's disease.

Materials and Methods

Seventy confirmed cases of Hansen's disease between the ages of 18 and 60 years attending the department of dermatology of Indira Gandhi Medical College and Hospital, Shimla were evaluated for various manifestations of Hansen's disease and screened for psychiatric co-morbidity using GHQ-12 and diagnosed using ICD-10 checklist. Severity of depression and anxiety was assessed with HAM-D and HAM-A scales, respectively.

Results

The prevalence of psychiatric co-morbidity was found in 27.14% of enrolled patients. Depression was most prevalent in (20%) mental disorder; followed by anxiety disorder (7.14%). Moderate depressive episode was the commonest seen in 11.42% patients whereas 5.71% patients had mild depression. Generalized anxiety disorder was seen in 1.42% whereas 5.71% patients had mixed anxiety disorder. Patients with higher education status, positive family history of leprosy, lepromatous leprosy, and hand deformities were significantly associated with higher psychiatric co-morbidity.

Conclusion

Patients suffering from Hansen's disease have significantly high prevalence of psychiatric co-morbidity complicating the Hansen's disease. High index of suspicion is required to diagnose and treat it.

Leishmania donovani Infection with Atypical Cutaneous Manifestations, Himachal Pradesh, India, 2014-2018

We conducted a molecular study of parasite sequences from a cohort of cutaneous leishmaniasis patients in Himachal Pradesh, India. Results revealed atypical cutaneous disease caused by Leishmania donovani parasites. L. donovani variants causing cutaneous manifestations in this region are different from those causing visceral leishmaniasis in northeastern India.

POS1167 REVIEW OF THE IMPACT OF COVID-19 PANDEMIC ON RHEUMATOLOGY SERVICES AT A LARGE TERTIARY CARE CENTRE IN WALES, UK

Background:

COVID-19 pandemic had an unprecedented impact on the delivery of patient care. Rheumatology services had to rapidly adapt to virtual consultations at the onset of the pandemic. However, providing a high quality and effective service in a virtual setting can be challenging and therefore its prudent to do a formal review and gain patient feedback to ensure that these clinics are fit for purpose.

Objectives:

To evaluate the impact of first wave of COVID-19 pandemic on patients with autoimmune rheumatic conditions, assess delivery of rheumatology outpatient care and record patient feedback.

Methods:

This study included patients on the Rheumatology clinic lists between 3rd and 31st August 2020. An electronic survey questionnaire was developed and the survey link was sent to patients via a text message using secure IT platform. Data was collected on patient demographics, diagnosis, comorbidities, treatments, clinical/ laboratory confirmed COVID-19 diagnosis, treatment interruption, impact on work, personal protective measures taken and views on virtual consultations.

Results:

307 patients responded with 287 complete responses. 73.1%(223) were female and 32.4% (99) were >65 years of age. Rheumatoid arthritis was the most common diagnosis 41.6%(127). Hypertension was the commonest comorbidity 21.4%(64) followed by Chronic lung disease 17.3%(52). 28.8%(85) were on Hydroxychloroquine, 26.7%(79) Methotrexate, 14.2%(42) Sulfasalazine and 13.2%(39) on Prednisolone. 22.3%(66) were on Biologics: Anti TNF 12.8%(38), Tocilizumab 3.7%(11) and Rituximab 3%(9). 52.6%(161) shielded, 16.9%(55) self-isolated and 30.3%(93) only maintained social distance. 197 patients self reported as being vulnerable but based on their treatment,only 167 patiemts met the clinically extremely vulnerable (CEV) criteria and all of those received government shielding letter.

3.6%(11) had lab confirmed COVID-19, 3.2%(10) had clinically suspected COVID-19 infection. 14.3% (43) had their treatment interrupted. 4.6%(14) were unable to work from home or maintain social distancing at work. 59.8%(182) had face-to-face consultation changed to virtual. 63.2%(189) were satisfied, 28%(84) neutral and 8.7%(26) reported dissatisfaction with their consultation. 50.5%(153) were happy to continue with virtual consultation but with an option of face to face only if necessary.For consultations post COVID-19, 59.4%(182) preferred a mixture of face to face and virtual appointments.

Conclusion:

Majority of our patients seem happy with virtual consultations as long as they are assured of a face-to-face consultation if needed. A minority(8.7%) however, were dissatisfied. Some of the suggestions were, use of video consultations and improvement in communication before the virtual appointments. Our survey also shows that our patients have adapted well to virtual consultations and many are keen to have virtual consultation in the longer term. In our survey, only 6.8%(21) patients reported definite or clinically suspected COVID-19. Possible explanations for this include strict compliance with government advice on social distancing/shielding and limited testing at the onset of the pandemic. More patients assumed themselves to be clinically CEV than those who were actually CEV based on their treatment which is not surprising because of high level of anxiety among patients due to rapidly spreading pandemic and multiple sources of information.

This feedback provides useful data which will help us to plan the delivery of rheumatology services post COVID-19 pandemic. While face-to-face patient contact is needed for comprehensive disease assessment, teaching and training, a model for the future is likely to include a combination of face-to-face and virtual consultations. This could allow a greater capacity to see new patients and reduce waiting lists. Patients with uncomplicated and stable disease could be followed up in virtual clinics. There is also a need to formally incorportate the virtual consultations into the curriculum for Rheumatology trainees.

Disclosure of Interests:

None declared.

Leptomonas seymouri Co-infection in Cutaneous Leishmaniasis Cases Caused by Leishmania donovani From Himachal Pradesh, India

Himachal Pradesh in India is a newer endemic state with co-existence of cutaneous and visceral leishmaniasis. The cutaneous leishmaniasis cases are on an increase in the region and reported to be unusually caused by Leishmania donovani with limited molecular validation. In order to molecularly characterize the causative parasite of the cutaneous disease, parasite specific Internal-Transcribed Spacer 1 (ITS1) PCR RFLP and sequence analysis was performed on skin lesional biopsies from cutaneous leishmaniasis patients. Interestingly, we found the presence of Leptomonas seymouri in 38.5% (22/57) of the patients along with L. donovani detected in all the samples. L. seymouri is a monoxenous insect trypanosomatid, generally incapable of infecting humans. In recent years, the parasite is also reported to co-infect humans with L. donovani in visceral and post kala-azar dermal leishmaniasis (PKDL) cases prevalent in northeastern India. The finding of L. seymouri-L. donovani co-infection in unusual cutaneous cases from Himachal Pradesh is the first ever to our knowledge and imply a newer disease paradigm. There is an urgent need to understand the biology of Leptomonas co-infection with L. donovani and its possible role in visceral and/or dermotropic disease outcome. Importantly, L. seymouri co-infection in cutaneous cases and previously reported visceral and PKDL cases needs to be recognized as a newer phenomenon by the leishmaniasis surveillance program in India.

A Study to Compare the Efficacy of Platelet-rich Plasma and Minoxidil Therapy for the Treatment of Androgenetic Alopecia

Background

Androgenetic alopecia (AGA) is the most common cause of hair loss in men with limited treatment options. Platelet-rich plasma (PRP) therapy is one of the newer treatment options in the management of AGA which has shown promising results.

Aims and Objectives

This study was aimed at comparing the clinical efficacy of PRP therapy with minoxidil therapy.

Materials and Methods

In the study, patients were randomized into two groups - Group A (given PRP therapy) and Group B (given minoxidil therapy). Both groups were followed up over a period of 6 months, and final analysis was done with the help of global photography, hair pull test, standardized hair growth questionnaire, patient satisfaction score; in addition, a comparison of platelet counts in PRP was done, to know that if a clinical correlation exists between platelet concentration and clinical improvement. A total of 40 patients clinically diagnosed with AGA were enrolled in the study with 20 patients in each group. Four patients from Group A (PRP) and six patients from Group B (minoxidil) could not complete the treatment for 6 months and were eventually excluded.

Results

At the end of 6 months, 30 patients were evaluated to compare the efficacy of intradermal PRP and topical minoxidil therapy. On global photography, Group A (PRP) was found to have a comparatively better outcome than Group B (minoxidil). In hair pull test, hair growth questionnaire, and patient satisfaction score, Group A was found to be better than Group B. Mean platelet count at baseline was 3.07 ± 0.5 lac/mm, 3 while platelet count in final PRP prepared was 12.4 ± 1.7 lac/mm, and patients with a higher platelet count in PRP had a much better clinical improvement compared to patients with a low platelet count in PRP. Side effects with PRP therapy were minimal with better results which may improve the compliance of the patient.

Conclusion

PRP therapy can be a valuable alternative to topical minoxidil therapy in the treatment of AGA.

Atypical leishmaniasis: A global perspective with emphasis on the Indian subcontinent

BACKGROUND

Among the neglected tropical diseases, leishmaniasis continues to be prevalent in many tropical and subtropical countries despite international, national, and local efforts towards its control and elimination over the last decade. This warrants a critical evaluation of such factors as under-reporting, asymptomatic infections, post kala azar dermal leishmaniasis (PKDL) cases, and drug resistance. In this review, we highlight lesser-understood atypical presentations of the disease involving atypical parasite strains against a background of classical leishmaniasis with a focus on the Indian subcontinent.

METHODS AND FINDINGS

A literature review based on endemic areas, the nature of disease manifestation, and underlying causative parasite was performed with data collected from WHO reports for each country. Searches on PubMed included the term ''leishmaniasis" and "leishmaniasis epidemiology" alone and in combination with each of the endemic countries, Leishmania species, cutaneous, visceral, endemic, non-endemic, typical, classical, atypical, and unusual with no date limit and published in English up to September 2017. Our findings portray a scenario with a wider distribution of the disease in new endemic foci, with new discoveries of parasite-driven atypical disease manifestations in different regions of the world. Unlike the classical picture, some Leishmania species are associated with more than one disease presentation, e.g., the L. donovani complex, generally associated with the visceral form, is now also associated with a cutaneous disease presentation, while L. tropica species complex, known to cause cutaneous disease, can cause viscerotropic disease. This phenomenon points towards the discovery of novel parasite variants as etiologic agents of atypical disease manifestations and represents an excellent opportunity to identify and study genes that control disease virulence and tropism.

CONCLUSIONS

The increased recognition of atypical leishmaniasis as an outcome of parasite variants has major implications for leishmaniasis control and elimination. Identifying molecular correlates of parasite isolates from distinct regions associated with different disease phenotypes is required to understand the current epidemiology of leishmaniasis in regions with atypical disease.

Anagen effluvium secondary to Gloriosa superba ingestion

Anagen effluvium, the shedding of anagen hair, leads to diffuse non-scarring alopecia. We report two cases of anagen effluvium in the same family secondary to the ingestion of tubers of Gloriosa superba, which contains the antimitotic alkaloid colchicine. Both patients developed anagen effluvium and gastroenteritis 1-2 weeks after consuming the tubers. In addition, one of them had bicytopenia, pleural effusion, hematuria and altered liver function tests. Both were managed conservatively and counseled regarding the reversible nature of the hair loss. Follow-up at 3 months showed regrowth of hair in both the cases.

Association study of genetic variants on chromosome 7q31 with susceptibility to normal tension glaucoma in a Japanese population

The caveolin 1 to caveolin 2 (CAV1-CAV2) gene region on chromosome 7q31 has been reported to be associated with susceptibility to primary open angle glaucoma (POAG) and normal tension glaucoma (NTG) in previous studies. We investigated whether genetic variants in the CAV1-CAV2 region are associated with NTG in Japanese patients. Two hundred and ninety-two Japanese patients with NTG and 352 Japanese healthy controls were recruited. We genotyped three single-nucleotide polymorphisms; that is, rs1052990, rs4236601, and rs7795356, in the CAV1-CAV2 gene region and assessed the allelic diversity among cases and controls. The frequency of the minor allele (G) of rs1052990 was significantly decreased in NTG cases compared with controls (P=0.014, OR=0.71), whereas NTG or POAG cases had a significantly higher frequency of the allele than controls in previous studies. Conversely, rs7795356 did not show any significant association with NTG cases, and rs4236601 was monomorphic in the Japanese study population. Our findings did not correspond with previous positive results, suggesting that CAV1-CAV2 variants studied in the present study are not important risk factors for NTG susceptibility in all populations. Further studies are needed to elucidate the possible contribution of the CAV1-CAV2 region to the development of glaucoma.

Endodontic management of mandibular central incisor fused to a supernumerary tooth associated with a talon cusp: a case report

AIM

To report the successful non-surgical endodontic management of a mandibular central incisor fused to a supernumerary tooth associated with a talon cusp.

SUMMARY

Fusion and gemination are developmental anomalies of teeth that may require endodontic treatment. In this article, a case of successful endodontic management of a permanent mandibular right central incisor fused to its supernumerary counterpart associated with a talon cusp is reported. The incidence of fusion in mandibular anteriors is rare. A search of the literature failed to reveal any reports on the fusion of a permanent mandibular central incisor with its supernumerary counterpart associated with a talon cusp. Successful non-surgical endodontic management of a case is reported.

KEY LEARNING POINTS

•  Fused and geminated teeth requiring endodontic treatment present diagnostic and technical challenges. • An exact differentiation between fusion and gemination may not be critically important for treatment. • The use of an operating microscope for detection of additional root canal orifices in complicated cases is recommended.

Inhibitory effects of maternal smoking on the development of severe retinopathy of prematurity

PURPOSE

In this study, the effects of maternal smoking along with other clinical risk factors in developing severe retinopathy of prematurity (ROP) were evaluated.

DESIGN

A case-control study.

METHODS

Records of newborn infants with an estimated postmenstrual age of 32 weeks or less (n=86) were reviewed. ROP grading was evaluated in accordance with the International Classification of Retinopathy of Prematurity. Severe ROP was diagnosed when it progressed to stage 3 with plus disease. The factors were first evaluated using a univariate logistic regression analysis between the groups of severe and non-severe ROP, followed by a multivariate logistic regression analysis using STATA version 10 and R version 2.71.

RESULTS

A low birth weight, a long duration of artificial ventilation and oxygen supplementation, presence of chronic lung disease, and absence of maternal smoking were found to be significantly associated with severe ROP in the univariate logistic regression analysis. In the multivariate logistic regression analysis, maternal smoking was revealed as a significant factor independently associated with the incidence of severe ROP.

CONCLUSIONS

An inhibitory effect of maternal smoking against developing severe ROP is suggested. The mechanism by which smoking may reduce the incidence of severe ROP needs to be further investigated.

Investigation of the association between the GLC3A locus and normal tension glaucoma in Japanese patients by microsatellite analysis

Purpose:

To investigate whether the GLC3A locus harboring the CYP1B1 gene is associated with normal tension glaucoma (NTG) in Japanese patients.

Materials and Methods:

One hundred forty-two Japanese patients with NTG and 101 Japanese healthy controls were recruited. Patients exhibiting a comparatively early onset were selected as this suggests that genetic factors may show stronger involvement. Genotyping and assessment of allelic diversity was performed on 13 highly polymorphic microsatellite markers in and around the GLC3A locus.

Results:

There were decreased frequencies of the 444 allele of D2S0416i and the 258 allele of D2S0425i in cases compared to controls (P = 0.022 and P = 0.034, respectively). However, this statistical significance disappeared when corrected (Pc > 0.05). We did not find any significant association between the remaining 11 microsatellite markers, including D2S177, which may be associated with CYP1B1, and NTG (P > 0.05).

Conclusions:

Our study showed no association between the GLCA3 locus and NTG, suggesting that the CYP1B1 gene, which is reportedly involved in a range of glaucoma phenotypes, may not be an associated factor in the pathogenesis of NTG.

Retrospective analysis and chemotherapy results in extra-nodal NHL patients in a large super-speciality hospital in North India

e19566

Background: We retrospectively analysed records of the Patients visiting the pathology department of Sir Ganga Ram Hospital, New Delhi a super-speciality hospital, between February 2007- February 2008. Out of a total of 16,500 cases, NHL was reported in 154 (0.93%)cases. The median age was 52 yrs and the no. of male patients were 104 and female were 50 making M:F = 2:1. The type of NHL was B-Cell type (CD-20+ve) in 132(85%) and T-Cell type (CD 3+ve) in 22 (15%) cases. Out of 154 patients, 77 were nodal and 77 were extra nodal. Additional features - HIV positivity in 2 patients, autoimmune haemolytic disease in 1 patient and thalessemia major in 1 patient. In extra-nodal group of NHL patients the no. Of male and female patients were 55 & 22 respectively (M:F=2.5:1). Out of 77 extra-nodal cases, 31(20%) were GIT NHL (Stomach -16, Colon-8, Ileum-4, and Duodenum-3) and out of the rest 46 extra-nodal cases the site of origin was - head & neck-14, skin n soft tissues -8, primary CNS-6, testicular-4, para-spinal- 3, breast mass-3, perinephric-2, bones-2 and 1 each in cervix, lung mass, liver and cervical plexus. Methods: A detailed analysis of 31 GIT NHL cases was carried out. 28 out of 31 were B-Cell type and 3 were T-Cell type. 26 out of 31 were diffuse large cell variety, 2 were mixed small & large cell variety and 1 MALT variety. In 2 patients the type of lymphoma could not be ascertained. Bone marrow infiltration was present in 2 out of 31 cases of GIT Lymphoma. Surgery was carried out in 15 of 31 GIT NHL cases and these were arising from Colon, Ileum and Duodenum. No surgery was performed in patients with stomach lymphoma. Results: Of all the extra-nodal cases chemotherapy was given to 39 patients - R-CHOP = 20 patients, CHOP = 13 patients, high dose MTX in primary CNS NHL = 6 patients. CR was achieved 16 out of 20 R-CHOP patients (80%), 8 out of 13 CHOP Patients (61 %) and 4 out of 6 high dose MTX patients (66%).

No significant financial relationships to disclose.

Alkaptonuria and intramedullary calcification

Alkaptonuria is a rare disorder of metabolism caused by deficiency of homogentisic acid oxidase enzyme and characterized by triad of homogentisic aciduria (dark urine), relentlessly progressive arthritis and ochronosis. We have documented a case with typical features of alkaptonuria along with intramedullary calcification which has not been reported in the literature before.

Preferable use of intravitreal bevacizumab as a pretreatment of vitrectomy for severe proliferative diabetic retinopathy

PURPOSE

To evaluate the safety and efficacy of intravitreal injection of bevacizumab advanced to vitrectomy for severe proliferative diabetic retinopathy.

METHODS

Eight eyes of six patients (33-64 years old, all male patients) with severe proliferative diabetic retinopathy were investigated. An intravitreal injection of 1.25 mg bevacizumab was performed 3-30 days prior to planned vitrectomy.

RESULTS

All cases showed minimum bleeding during surgical dissection of fibrovascular membrane. Two cases receiving bevacizumab 7 days before the surgery showed strong fibrosis and adhesion of fibrovascular membrane, resulted in some surgical complications. The cases having intravitreal bevacizumab for shorter time did not show extensive fibrosis.

CONCLUSIONS

The pretreatment of bevacizumab is likely effective in the vitrectomy for severe PDR. The appropriate timing of vitrectomy after bevacizumab injection should be further evaluated.

Efficacy of oxaliplatin, 5 FU and gemcitabine in advanced pancreato-biliary cancer

15182

Background: The treatment of advanced pancreato-biliary cancer remains an unmet need. The drugs known to be effective are oxaliplatin, gemcitabine. Method: The records of twenty patients suffering with cancers of advanced gall bladder (10), common bile duct (3), ampulle of vater (3) and pancreas (4) were analysed. Twenty patients were treated in the year 2006. Median age was 52 years. The common sites of metastatis were liver (12), lymphnodes (10), peritoneum (4), lungs (1). The patients with normal bilirubin & LFT (< 3 times upper limit of normal) were included. The chemotherapy protocol was given as: oxaliplatin 50 mg, leucovorin 30 mg, and 5FU 500 mg/m2 on day 1, 2, & 3. Gemcitabine was given 800 mg/m2 on day 2, 9, and 16. The cycle was repeated every 4 weeks. Response: The regimen was well tolerated. Pancytopenia requiring G-CSF, delays in drug administration occurred in 70% cases. The response was as follows-partial response 6/20 (30%), stable disease 5/20 (25%), progressive disease 9/20 (45%). The median survival was 5.5 months, four patients completed six cycles of chemotherapy and survival for at least 12 months. Conclusion: Oxaliplatin, 5 FU, gemcitabine and leucovorin is an effective chemo-protocol in advanced pancreato-biliary cancer. However, there is a need to improve upon the existing results.

No significant financial relationships to disclose.

The −174G/C interleukin-6 promoter polymorphism influences the development of macular oedema following uncomplicated phacoemulsification surgery

AIM

To determine whether the functional -174 G/C interleukin-6 gene polymorphism is a risk factor for the development of cystoid macular oedema (CMO) following routine uncomplicated phacoemulsification surgery in patients with no established risk factors.

METHODS

A total of 40 patients who underwent routine phacoemulsification surgery as part of a randomised controlled trial comparing the use of postoperative steroid drops against a single sub-tenon injection of triamcinolone were genotyped for the IL-6 -174G/C polymorphism. All patients underwent fluorescein angiography at 30 days and anterior chamber flare measurements pre-operatively and at day 1, 7, and 30.

RESULTS

Angiographic CMO developed in 14 patients of the 40 studied. 9 out of the 14 patients carried the GG genotype (Fisher's exact test P=0.05, Hazard ratio for GG genotype; 4.05 (1.02-16.00)). There was no difference in flare measurements between the GG and Non-GG (GC/CC) group. The two groups were otherwise well matched in terms of age, sex, phacoemulsification energy used intraoperatively, and proportion of patients receiving postoperative triamcinolone or steroid drops.

CONCLUSION

The -174G/C interleukin-6 promoter gene variant appears to modulate the response to phacoemulsification surgery and to influence the development of postoperative CMO. These data suggest a genetic predisposition to this complication.

Different transitions of multifocal electroretinogram recordings between patients with age-related macular degeneration and polypoidal choroidal vasculopathy after photodynamic therapy

AIM

To compare and evaluate the transitions in retinal function after photodynamic therapy (PDT) between age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) using multifocal electroretinograms (mfERGs).

METHODS

10 eyes with choroidal neovascularisation (CNV) secondary to AMD and 11 eyes with CNV secondary to PCV were included in the study. mfERGs were recorded before PDT, and 1 week and 3 months after PDT. mfERG recordings were acquired by a Veris system (V.3.1.3) using a 103 hexagon stimulus. The first-order kernel was used to calculate amplitudes and latencies. Mean amplitudes and latencies from two central rings rated 0-4 degrees of visual angle were analysed and compared with each disease.

RESULTS

In AMD, the mean first negative peak (N1) amplitudes tended to decrease, and the mean first positive peak (N1P1) amplitudes reduced to significant levels (p = 0.047) 1 week after PDT. 3 months after PDT, there were no significant differences in the mean N1 and N1P1 amplitudes compared with pre-PDT values. In PCV, there were no significant changes in the mean N1 and N1P1 amplitudes 1 week after treatment. However, 3 months after PDT, mean amplitudes showed significant increases in N1 (p = 0.008) and N1P1 (p = 0.006) amplitudes compared with pre-PDT values.

CONCLUSIONS

mfERG recording transitions are different between patients with AMD and those with PCV. In patients with AMD, these results may show transient impairments in retinal function 1 week after PDT, but in those with PCV, the efficacy of PDT is superior to the impairment after PDT.

Role of CT angiography in pulmonary embolism and its comparative evaluation with conventional pulmonary angiography

OBJECTIVES : The purpose of this study is to assess the role of spiral CT angiography in suspected cases of pulmonary embolism and to do comparative evaluation of CT angiography with conventional pulmonary angiography. MATERIAL AND METHODS : Twenty five patients of suspected pulmonary embolism (PE) underwent spiral CT angiography from the level of arch of aorta to the dome of diaphragm .Scanning was done with collimation of 5mm and an interval of 5mm at 130 mA and 120 kV. 100 cc of contrast containing 300 mg I/ ml, diluted with 60cc of normal saline in ratio 5:3 was injected at a flow rate of 3ml/sec with a scan delay of 20 seconds. Retro - reconstruction was done at 3mm interval. RESULTS : Spiral CTA showed a sensitivity of 80 % and a specificity of 85.7% for the diagnosis of pulmonary embolism. It also provided ancillary findings in the form of parenchymal and mediastinal structural information. CONCLUSION : CTA is an effective alternative to PA in diagnosis of suspected cases of PE. With its non- invasive nature, low cost, over and above high sensitivity and specificity, it may be used as the first line of investigation in the diagnosis of PE.

Intravitreal triamcinolone will cause posterior subcapsular cataract in most eyes with diabetic maculopathy within 2 years

PURPOSE

To determine the incidence of cataract following intravitreal triamcinolone (IVTA) for diabetic macular oedema.

METHODS

Prospective, non-randomised, interventional cohort case series. A total of 27 eyes of 27 patients with diabetic macular oedema received an intravitreal injection of 4 mg (0.1 ml) of triamcinolone acetonide inferotemporally through the pars plana under direct vision. In 20 patients the fellow eye served as control, whereas seven patients had both eyes injected (not simultaneously). Seven patients had a repeat (second) injection in the same eye. The main outcome measures were cataract and intraocular pressure (IOP) rise of at least 5 mmHg (IOP responder).

RESULTS

The mean follow-up time was 18.9 months (range 13-29 months). A total of 22 (81%) of 27 eyes developed cataract during the follow-up period, of which 20 (74%) were posterior subcapsular in nature. None of the 20 uninjected fellow eyes developed posterior subcapsular cataract. Mean time to cataract formation was 16.2 months. In the seven patients who had both eyes injected, mean time to cataract formation was 16.5 and 17.1 months in the first and second eye, respectively. Mean time to cataract formation in seven eyes receiving a repeat second injection was 17.9 months. There was no significant difference in cataract formation between IOP responders (85%) and non-responders (79%) (P=1.00, Fisher's exact test). Uneventful cataract surgery was performed in six eyes of five patients.

CONCLUSION

This study demonstrates that given appropriate long-term follow-up, the majority of patients, even after a single IVTA injection, will go on to develop cataract, of which posterior subcapsular will be by far the most common.

Macular thickness reduction in eyes with unilateral optic atrophy detected with optical coherence tomography

AIMS

To assess the changes in macular and peripapillary retinal nerve fibre layer (RNFL) thickness in eyes with unilateral optic atrophy and to evaluate the relationship between retinal thickness and visual function.

METHODS

Enrolled were 22 patients with unilateral optic atrophy. Macular thickness at the divided nine areas and peripapillary RNFL thickness in quadrantic sections were measured by optical coherence tomography. Thickness values in the affected eyes were compared with those in the contralateral unaffected eyes. The correlation of foveal thickness with best-corrected visual acuity (BCVA) was evaluated. The correlation between retinal thickness and the remaining visual field area circumscribed with I-4-e isopter in superior and inferior hemifield was assessed.

RESULTS

Macular thinning was observed in all areas (P < 0.001 in each area) other than the fovea (P = 0.068). Peripapillary RNFL thickness decreased in all quadrantic sections (P < 0.001 in each section). The affected to unaffected eye ratio of retinal thickness was more than 0.6 in each area. BCVA did not correlate with foveal thickness (correlation coefficient = 0.094, P = 0.668). Although not statistically significant (P = 0.281, superior hemifield; P = 0.053, inferior hemifield), there was a tendency that eyes with severe visual field loss show more marked retinal thinning.

CONCLUSIONS

Macular thinning with the preserved foveal thickness is a hallmark of eyes with optic atrophy. Together with no correlation between foveal thickness and BCVA, this finding would help in differential diagnosis of macular and optic nerve diseases.

Improved visual acuity and macular thickness 1 week after intravitreal triamcinolone for diabetic macular oedema

PURPOSE

To evaluate the clinical and volumetric improvement 1 week after an injection of intravitreal triamcinolone acetonide in eyes with diabetic macular oedema.

METHODS

Seven phakic eyes of seven diabetic patients diagnosed with clinically significant macular oedema were treated with a single 4-mg intravitreal injection of triamcinolone acetonide (0.1 ml). LogMAR best corrected visual acuity (logMAR BCVA), best corrected reading ability (RA), and central macular thickness (CMT) with optical coherence tomography (OCT) were assessed prior and 1 week subsequent to treatment.

RESULTS

Mean improvement in logMAR BCVA was 0.146 (P=0.03). Mean reduction in CMT was 150.9 mum (P=0.02, Wilcoxon signed-rank test). Mean improvement in RA was 3 lines.

CONCLUSION

Reduction in macular oedema was demonstrated on OCT at 1 week, in most cases associated with improvement in central visual function, in particular, reading ability. Total resolution of diabetic macular oedema may occur at 1 week following intravitreal steroid injection.

Is poor life expectancy a predictive factor in the progression of primary open angle glaucoma?

AIM

To investigate the disease progression and final visual outcome of glaucoma patients with poor life expectancy, compared to matched patients with a longer life expectancy.

METHOD

Visual fields at diagnosis and at the last ophthalmic appointment before death were analysed for glaucoma patients referred between 1991 and 1995, and deceased before the end of 2001. These patients were matched to the patients living beyond 2001. Functional vision was also assessed, and classified as better than the NHS partial sighted criteria.

RESULTS

A total of 61 deceased patients were identified, resulting in 40 matched pairs. In all, 6.5% of the patients with poor life expectancy progressed from functional vision to beyond partial sighted criteria, and none of the matched patients progressed to this extent. At final assessment an association between poor life expectancy and progression beyond functional vision was found existing (P = 0.02), with a lesser association at diagnosis (P = 0.06). Visual field scores of the matched pairs who had test results available for both initial and final assessment (n = 23 pairs) showed no statistically significant difference between the two groups at diagnosis (P = 0.52); However, a significant difference at final the assessment did exist (P = 0.042). No difference between the initial (off medication) intraocular pressures (IOPs) was found (P = 0.82). At the final assessment a significant difference existed (P = 0.025), with the surviving group having a higher final mean pressure (15.9 mmHg, SD 2.8, vs 18.3 mmHg, SD 4.9).

CONCLUSION

Patients with poor life expectancy progressed more than the matched surviving patients, when measured from an initially similar position, despite better IOP control.

N-(2-Chloroethyl)-N-ethyl-2-bromobenzylamine reduces intracellular calcium response to noradrenaline in rat visual cortex

Using the fluorescent indicator Fura-2, we investigated the effects of N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine (DSP-4), a noradrenergic neurotoxin, on intracellular calcium responses to noradrenaline, N-methyl-D-aspartate, and carbamylcholine chloride in brain slices of the rat visual cortex. Noradrenergic depletion in the visual cortex of young rats was induced by DSP-4, and its selectivity was confirmed by two different methods, i.e., immunostaining with anti-dopamine-beta-hydroxylase antibody and biochemical analysis by high-performance liquid chromatography. The treatment with DSP-4 (25 mg/kg i.p., x2) caused disruption of noradrenergic fibers throughout all cortical layers, and reduced the content of noradrenaline to 6.4% of that in the normal control. In the normal cortex, bath-applied noradrenaline (100 microM) increased the intracellular calcium to 123% of the control in terms of the F(340)/F(380) ratio of Fura-2 fluorescence. Quantitative analysis of the F(340)/F(380) ratio was performed in layers II to IV, since the increase was mainly observed in these layers. The intracellular calcium response to noradrenaline was significantly (P<0.0001) reduced in the DSP-4-treated animals to 63.2% of that in the normal control. The response to N-methyl-D-aspartate (100 microM) was also reduced, whereas the response to carbamylcholine chloride, a muscarinic cholinergic agonist (100 microM), was not affected by the DSP-4 treatment. From these findings we suggest that noradrenergic denervation by DSP-4 reduces the intracellular calcium response to noradrenaline through changes in the intracellular signal transduction.