Descemet's membrane endothelial keratoplasty rejection after SARS-COV2 infection or vaccination: 2-year retrospective study

PURPOSE

To assess the incidence of Descemet's membrane endothelial keratoplasty (DMEK) rejection potentially associated with coronavirus disease 2019 (COVID-19) infection or vaccination, and its association with known rejection risk factors during the first two years of the pandemic.

METHODS

This retrospective study included patients with DMEK rejection between January 2020 and December 2021. Diagnostic criteria were based on symptoms, visual acuity, and other clinical assessments. Risk factors for graft rejection were considered, and a telephone survey was conducted to identify possible preceding COVID-19 infection or vaccination.

RESULTS

Of 58 patients, 44 were included. Six patients (14%) reported COVID-19 infection, with one immediate endothelial graft rejection (EGR) post-infection. After vaccine availability, 13 of 36 patients had EGR at an average of 2.7 months post-vaccination. Five (38%) had immediate EGR following vaccination, four of which had concomitant risk factors for rejection.

CONCLUSION

Although the risk of endothelial graft rejection (EGR) associated with COVID-19 infection or vaccination appears to be extremely low, there may be a causative relationship, especially in patients with pre-existing risk factors for EGR. A temporary increase in anti-rejection treatment following COVID-19 infection or vaccination is recommended, especially in patients with pre-existing risk factors, along with closer monitoring during the subsequent 4 to 8 weeks.

Long-Term Follow-Up of Descemet Stripping Only: Data Up to 7 Years Postoperatively

PURPOSE

The aim of this study was to report long-term follow-up of eyes undergoing Descemet stripping only (DSO).

METHODS

This was a retrospective study including 26 eyes of 20 patients undergoing DSO between December 2015 and November 2022. Eligibility criteria included peripheral endothelial cell count (ECC) >1000 cells/mm2 and symptoms caused by central guttata. Patients underwent a central circular 4-mm descemetorhexis using a reverse Sinskey hook and a pair of descemetorhexis forceps using a peeling technique. Three parameters were measured before surgery and at last follow-up: best-corrected visual acuity (BCVA), central corneal thickness (CCT), and ECC measured centrally and at the periphery.

RESULTS

The mean age was 73 ± 9 years [52-90 years]. The average follow-up period was 23.7 ± 24.8 months [3-84]. Twenty-two eyes responded to DSO with 20 female eyes (91%) and 2 male eyes (9%). The mean postoperative BCVA improved from 0.3 ± 0.17 logMAR to 0.09 ± 0.13 logMAR (P value <0.05). The mean postoperative CCT decreased from 588 ± 41 μm to 546 ± 50 μm (P-value <0.05). The mean postoperative central ECC was 780 ± 257 cells/mm2 [484-1500]. Peripheral ECC decreased postoperatively (1837 ± 407 cells/mm2 preoperatively to 864 ± 340 cells/mm2 postoperatively, P value >0.05). Peripheral endothelial cell polymegathism was stable (average of 26.8% ± 6.8% preoperatively and 30.2% ± 14% postoperatively). Average peripheral endothelial cells polymorphism decreased postoperatively (63.1 ± 20.5% preoperatively to 33% ± 25% postoperatively, P value >0.05). Four eyes did not show improvement after DSO and underwent Descemet membrane endothelial keratoplasty surgery. There were 3 men (75%) and 1 women (25%). The preoperative trend was for nonresponders to have lower BCVA, higher CCT, more abnormal peripheral polymorphism, and polymegathism.

CONCLUSIONS

The results of this study, with up to 7 years follow up, demonstrate the durability of DSO.

Medium to long term follow up study of the efficacy of cessation of eye-rubbing to halt progression of keratoconus

Purpose

To study the progression of keratoconus after cessation of eye rubbing with a minimum follow up of three-years.

Design

Retrospective, monocentric, longitudinal cohort study of keratoconus patients with a minimum of 3 years follow-up.

Participants

One hundred fifty three eyes of seventy-seven consecutive patients with keratoconus were included.

Methods

Initial examination consisted of anterior and posterior segment evaluation using slit-lamp biomicroscopy. At the initial visit, patients were thoroughly informed of their pathology and instructed to stop rubbing their eyes. Eye rubbing cessation was assessed at all the follow-up visits at 6 months, 1 year, 2 years, 3 years, and yearly afterward. Corneal topography using the Pentacam® (Oculus®, Wetzlar, Germany) was used to obtain maximum and average anterior keratometry readings (Kmax and Kmean), as well as thinnest pachymetry (Pachymin, μm) in both eyes.

Main outcome measures

The main outcomes measured were maximum keratometry (Kmax), mean keratometry (Kmean), and thinnest pachymetry (Pachymin) values at various time points to assess for keratoconus progression. Keratoconus progression was defined as a significant augmentation of Kmax (>1D), Kmean (>1D), or significant diminution of Pachymin (>5%) throughout the total follow-up duration.

Results

One hundred fifty three eyes of seventy-seven patients (75.3% males) aged 26.4 years old, were followed for an average of 53 months. Over the course of the follow-up, there was no statistically significant variation of ∆Kmax (+0.04 ± 0.87; p = 0.34), ∆ Kmean (+0.30 ± 0.67; p = 0.27) nor ∆Pachymin (-4.36 ± 11.88; p = 0.64). Among the 26 of the 153 eyes which had at least one criterion of KC progression, 25 admitted continuing eye rubbing, or other at-risk behaviors.

Conclusion

This study suggests that a significant proportion of keratoconus patients are likely to remain stable if close monitoring and strict ARB cessation are achieved, without the need for further intervention.

Dacryolithiasis diagnosis and treatment: a 25-year experience using nasal endoscopy

BACKGROUND

Dacryolith-induced epiphora is caused by a chronic obstruction of the nasolacrimal duct whose aetiology is often specified peroperatively. Dacryocystorhinostomy (DCR) has been often regarded as the gold standard to treat dacryolithiasis. Hasner's valve (HV) incision is a technique to evacuate lithiasis through its physiological track. The purpose of this study was to describe clinical and radiological findings associated with presence of dacryoliths in patients who underwent surgery and to assess the efficacy of these two procedures.

METHODS

This study was a comparative interventional multicentric retrospective study including patients referred for an epiphora. The primary endpoint was to determine clinical and endoscopic findings associated with dacryoliths. The secondary endpoints were to evaluate the performance of CT dacryocystography (CT-DG) in the diagnosis of dacryoliths and the success rate of the surgical treatment 6 months postoperatively.

RESULTS

4677 nasolacrimal ducts (NLDs) (78.0% female, mean age 59.2) were included in the study. 3913 underwent DCR, and 764 underwent HV incision. 291 out of 4677 NLDs (6.2%) were found to have dacryoliths. Presence of mucocele associated to a permeable lacrimal system (OR 8.17 (95% 4.62 to 14.44), p<0.01) was associated with presence of lithiasis peroperatively. Success rates at 6 months were 95.6% for endonasal DCR and 94.6% for incision of HV in dacryolithiasis group (p<0.01). CT-DG had a negative predictive value of 96.3% to detect lithiasis (p<0.01).

CONCLUSION

Strong clinical and endoscopic findings may improve the imputability of dacryoliths in epiphora. Evacuation of dacryolithiasis through its physiological track was first described in this study in adults with similar results to DCR in patients presenting with dacryolithiasis.

Clinical Outcomes of a New Non-Diffractive Extended Depth-of-Focus Intraocular Lens Targeted for Mini-Monovision

Purpose

To assess visual acuity, binocular defocus curve, spectacle independence, and photic phenomena after bilateral same-day cataract surgery with implantation of an extended depth-of-focus intraocular lens (IOL) with mini-monovision.

Methods

Single-center retrospective study including 124 eyes from 62 patients who underwent bilateral implantation of an isofocal EDOF lens [Isopure® (BVI)] with mini-monovision (-0.50 D). Refraction, visual acuity at different distances, binocular defocus curves, spectacle independence, and subjective ratings of picture-referenced photic phenomena were assessed one to two months postoperatively.

Results

The mean postoperative refractive spherical equivalent was -0.15±0.41D in the dominant eyes and -0.46±0.35D in the mini-monovision eyes (p<0.01). Overall, 98.4% and 87.7% of the eyes were within ±1.00D and ±0.50D of the target refraction, respectively. Postoperative monocular corrected distance visual acuity was -0.04±0.07 logMAR. Binocular uncorrected visual acuity was -0.02±0.07, 0.13±0.11and 0.40±0.20 logMAR for far, intermediate and near, respectively. At the visual acuity threshold of 0.20 logMAR (or better) the defocus curve ranged from -1.6D to +0.9D. Reported spectacle-independence was 96% for far distance, 95% for intermediate, and 34% for near. Five percent of patients reported halos, 16% starburst, and 16% glare. Only 7% of all patients considered them bothersome.

Conclusion

In patients undergoing same-day bilateral cataract surgery, an isofocal EDOF lens provided an extended range of functional vision, up to 63 cm, resulting in useful uncorrected near vision, good uncorrected intermediate vision, and excellent uncorrected distance vision. Subjective patient satisfaction in terms of spectacle independence and photic phenomena was high.

Deep Learning Model for the Detection of Corneal Edema Before Descemet Membrane Endothelial Keratoplasty on Optical Coherence Tomography Images

Purpose

Descemet membrane endothelial keratoplasty (DMEK) is the preferred method for treating corneal endothelial dysfunction, such as Fuchs endothelial corneal dystrophy (FECD). The surgical indication is based on the patients' symptoms and the presence of corneal edema. We developed an automated tool based on deep learning to detect edema in corneal optical coherence tomography images. This study aimed to evaluate this approach in edema detection before Descemet membrane endothelial keratoplasty surgery, for patients with or without FECD.

Methods

We used our previously described model allowing to classify each pixel in the corneal optical coherence tomography images as "normal" or "edema." We included 1992 images of normal and preoperative edematous corneas. We calculated the edema fraction (EF), defined as the ratio between the number of pixels labeled as "edema," and those representing the cornea for each patient. Differential central corneal thickness (DCCT), defined as the difference in central corneal thickness before and 6 months after surgery, was used to quantify preoperative edema. AUC of EF for the edema detection was calculated for Several DCCT thresholds and a value of 20 µm was selected to define significant edema as it provided the highest area under the curve value.

Results

The area under the curve of the receiver operating characteristic curve for EF for the detection of 20 µm of DCCT was 0.97 for all patients, 0.96 for Fuchs and normal only and 0.99 for non-FECD and normal patients. The optimal EF threshold was 0.143 for all patients and patients with FECD.

Conclusions

Our model is capable of objectively detecting minimal corneal edema before Descemet membrane endothelial keratoplasty surgery.

Translational Relevance

Deep learning can help to interpret optical coherence tomography scans and aid the surgeon in decision-making.

A175 DISEASE ACTIVITY IN FIRST TRIMESTER IS ASSOCIATED WITH REDUCED GROWTH IN INFANTS BORN TO WOMEN WITH INFLAMMATORY BOWEL DISEASE

Background

Ulcerative colitis (UC) and Crohn’s disease (CD) are chronic inflammatory bowel diseases (IBD) that affect a significant portion of women in childbearing years. It is known that disease activity in early pregnancy negatively impacts obstetrical and perinatal outcomes, but the impact on infant growth is largely unknown.

Aims

The objective of this study was to compare the growth of infants born to women with active IBD during pregnancy versus those born to women with IBD in remission during pregnancy.

Methods

We conducted a prospective cohort study in a Canadian tertiary centre comprised of 98 pregnant women with IBD (63 with UC and 35 with CD) and 13 healthy pregnant women. We collected maternal demographic at trimester 1 and assessed disease activity at each trimester using clinical disease scores and fecal calprotectin. We then collected perinatal outcomes at delivery and followed the infants’ growth and feeding habits up to 12 months of age.

Results

A total of 103 mother-infant pairs were included in the study, of which 88 infants were born to women with IBD, and 15 born to women with active disease at trimester 1. Active disease at trimester 1 was associated with more adverse obstetrical outcomes, reduced 1-minute and 5-minute APGAR scores and more frequent NICU admissions. Infants born to women with active trimester 1 disease had reduced weight-for-age and length-for-age Z scores up to 6 months of age, in the absence of difference in feeding patterns. In addition, women with active disease at trimester 1 had increased expression of IL-8 and IFN-γ compared to those with trimester 1 remission.

Conclusions

Active IBD during first trimester is correlated with decreased infant weight and height up to 6 months of age, suggesting that strict disease control during first trimester, or even preconception, is essential for optimizing infant growth and perinatal outcomes.

Funding Agencies

None

600 Bilateral Upper Limb Compartment Syndrome After Massive Postpartum Haemorrhage

Case Summary

Upper limb compartment syndrome (ULCS) is an uncommon limb-threatening emergency occurring as a result of increased interstitial pressure within osteofascial compartments. The overwhelming majority of causes occur in one limb, with frequent causes including fractures, reperfusion injury and burns. We report the unusual case of bilateral upper limb CS in a previously well 35-year-old female secondary to massive resuscitation following postpartum haemorrhage. The patient received 7 litres of blood products and 4 litres of crystalloid over a period of 8 hours. One hour postoperatively both hands became painful and swollen. Symptoms worsened over the following hour: both forearms were tense to palpate with demonstrable pain on passive extension of bilateral wrists and digits of the left hand, and capillary refill to all digits was brisk. Creatinine kinase was measured at 4,600U/L and bilateral forearm and left-hand fasciotomies were performed. The presence of bulging muscles in both forearms and the left hand confirmed the diagnosis of compartment syndrome, and perfusion was restored to all digits after release of the compartments. The patient later underwent split thickness skin grafting to both forearms and left-hand fasciotomy wounds. After 5 weeks of hand therapy, she regained good function of both hands. Bilateral ULCS is extremely uncommon but has been reported secondary to massive resuscitation, particularly in trauma patients, and we suspect that this was the cause in our patient.

Descemet Membrane Endothelial Keratoplasty for corneal decompensation due to migrating metallic intracorneal foreign bodies in an aphakic eye following a 39-year-old blast injury: A case report

Purpose

To report the use of Descemet Membrane Endothelial Keratoplasty (DMEK) for secondary surgical removal of intraocular foreign bodies (IOFB) years after the trauma as migration occurred through the endothelium, damaging the endothelium, and causing corneal edema.

Observations

We report the case of a blast injury in 1972, that led to left eye traumatic cataract managed with vitrectomy and lensectomy. Although thorough removal was attempted, some corneal and conjunctival foreign bodies remained.

Despite aphakia, the patient maintained acceptable best corrected visual acuity (BCVA) (0.30 LogMAR) but >30 years later, experienced visual deterioration. IOFB protruding through the Descemet membrane (DM) were seen, with extensive edema. Descemet Membrane Endothelial Keratoplasty was performed in an attempt to treat the endothelium and remove the foreign bodies protruding through the DM. The procedure was done uneventfully under sulfur hexafluoride gas (SF6) and the patient improved. Four years after the surgery, BCVA was 0.63, however, 6 years later, a new episode of migrating intracorneal foreign bodies with corneal edema reduced BCVA to 0.40. The decision was made to observe the patient, and delay a second DMEK.

Conclusions and importance

Corneal decompensation caused by IOFB breaching the Descemet membrane can safely be managed with a DMEK. DMEK is feasible even in complex cases and should be attempted due to its lower risk of graft rejection and likely benefits, while saving the option of more aggressive transplantation techniques, such as penetrating keratoplasty, in cases of failure.

Outcomes of pattern scanning laser trabeculoplasty and selective laser trabeculoplasty: Results from the lausanne laser trabeculoplasty registry

PURPOSE

To compare the long-term safety and efficacy of pattern scanning laser trabeculoplasty (PSLT) and selective laser trabeculoplasty (SLT).

METHODS

This was a retrospective database analysis (Lausanne Laser Trabeculoplasty Registry) of patients having had laser trabeculoplasty (LT) prior to 2017 with a minimum follow-up of 1 year. Inclusion criteria were age ≥40 years and diagnosis of ocular hypertension (OHT) and open-angle glaucoma (OAG). Selective laser trabeculoplasty (SLT) eyes were matched to PSLT eyes according to baseline intraocular pressure (IOP), baseline number of ocular hypotensive medications (OHM) and glaucoma diagnosis. Success was defined as an IOP ≤ 20% from baseline or an IOP equal or lower than baseline accompanied by a reduction in OHM. Multivariate regression models were used to study associations between success and baseline clinical parameters.

RESULTS

From 280 eyes in the database, 81 eyes had PSLT and were matched with 81 SLT eyes (162 patients). Mean age was 69.4 ± 12.1 years, and 56.2% were female. Mean IOP was 18.6 ± 5.3 and 18.2 ± 4.1 mmHg at baseline and 15.9 ± 3.0 and 16.0 ± 3.4 mmHg at 12 months and 15.2 ± 2.7 and 16.2 ± 3.4 mmHg at 24 months, for PSLT and SLT, respectively. 60.5% of PSLT and 65.4% of SLT eyes achieved treatment success (p = 0.20). Number of OHM was 1.0 ± 1.0 and 1.4 ± 1.2, respectively (p = 0.052). Baseline IOP (OR = 1.23, p < 0.01) and number of OHM (OR = 1.67, p < 0.01) were associated with success in both PSLT and SLT, while LT modality was not [OR = 0.81 (0.43-1.53), p = 0.52], and a diagnosis of primary OAG was negatively associated (OR = 0.42, p = 0.04).

CONCLUSION

Our study did not find any significant differences between PSLT and SLT in terms of safety and efficacy in patients with OHT and glaucoma. Baseline IOP was associated with higher success rates in both procedures. Additional studies are needed to evaluate the outcomes of PSLT in non-Caucasian populations and the ability of repeat PSLT to achieve additional IOP reduction.

Evaluation of Ischemic Heart Disease Factors in Hemophilia Patients in Khorramabad

BACKGROUND

Evaluation of risk factors associated with coronary artery disease and cardiac health in hemophilia patients is necessary to prevent the onset of ischemic heart disease. In this study, we evaluated the cardiovascular status of hemophilic patients in Lorestan province for the early onset of ischemic heart disease.

METHODS

In this cross-sectional descriptive study, a total of 80 patients presenting severe hemophilia, a detailed questionnaire-based investigation was conducted to analyze the prevalence of cardiovascular risk factors in severe hemophilic patients. In patients with hemophilia, body mass index (BMI), blood pressure, diabetes, LDL, cholesterol and HDL, the risk of cardiovascular death was estimated using a predictive risk predictor algorithm of Europe SCORE.

RESULTS

The mean age of the patients was 25 years, where all the patients were non-diabetic. Echocardiography did not show any wall motion abnormality and changes in the T wave and dysrhythmia were also not seen by ECG. 7 patients had high blood pressure, 11 had abnormal HDL, and 1 had abnormal LDL. In this study, serum LDL and HDL levels were not significantly correlated with age and BMI. Conversely, age and BMI were significantly associated with hypertension. Hypertension was observed in people over the age of 25 years and in overweighed individuals. 78.8% had normal BMI and 21.3% were overweighed. There was no significant correlation between serum LDL, serum HDL, and blood pressure and sex. The levels of abnormal LDL and HDL were higher in men than in women.

CONCLUSION

ECG findings from our study did not report any significant cardiac abnormalities among hemophilic patients. Cardiovascular risk factors were not significantly correlated in these patients.

In Vivo Visualization of Rainbow Glare and Treatment With Undersurface Flap Phototherapeutic Keratectomy

PURPOSE

To analyze a case of unilateral rainbow glare that required repeated undersurface photoablation using an excimer laser.

METHODS

A 31-year-old man with bilateral myopia of 6.50 diopters treated with femtosecond laser-assisted in situ keratomileusis immediately experienced a 2-year life-incapacitating rainbow glare exclusively in the right eye. The laser settings were similar for both eyes, but a subtle raster pattern was noticed intraoperatively in the right eye. Postoperative uncorrected distance visual acuity (UDVA) was 20/12.5, but with important subjective visual quality impairment in the right eye. Slit-lamp examination and investigations were unremarkable except for hyperreflective dots arranged in a regular grating pattern on confocal microscopy in the right eye.

RESULTS

A 10-µm undersurface photoablation was performed with immediate but incomplete improvement of both subjective symptoms and objective reduction of the grating pattern on confocal microscopy. After 12 months, the patient asked for additional treatment and another 10-µm undersurface photoablation was performed, this time with resolution of the symptoms. At last follow-up, 6 months after the second revision, UDVA was maintained with total absence of rainbow glare and no hypermetropic shift was observed.

CONCLUSIONS

Rainbow glare is typically a benign and often spontaneously resolving condition that can rarely cause dramatic life impairment. This case reinforces the hypothesis that it is caused by diffraction created by the raster spot pattern of the femtosecond laser, which can be followed by confocal microscopy. It also further proves that undersur-face photoablation is an efficient, repeatable, and safe treatment for rainbow glare, and should include a thickness of at least 16 to 20 µm. [J Refract Surg. 2020;36(6):400-404.].

Advanced Cases of Birdshot HLA-A29 Retinochoroiditis: Prevalence and Characteristics

PURPOSE

To establish the prevalence, morphological, and functional characteristics and evolution of advanced cases of birdshot retinochoroiditis (BRC).

METHODS

A retrospective review of all BRC cases seen at the Centre for Ophthalmic Specialized Care, Lausanne, Switzerland, with at least 3 years of follow-up since the onset of symptoms. The following parameters were evaluated: demographic characteristics, best-corrected visual acuity (BCVA), fundus photographs, fluorescein (FA) and indocyanine green (ICGA) angiography frames, and visual field evaluation from initial visit to last follow-up.

RESULTS

Out of the 1920 patients with uveitis who were followed from 1995 until 2018, 32 (1.67%) were diagnosed with BRC; 20 of these 32 patients had sufficient data to be included. Three of these twenty patients (15.0%) had severe forms of the disease. Two patients had received insufficient treatment and one progressed despite attempted maximal therapy. The mean BCVA was 0.62 (± 0.42) at presentation, which was already at an advanced stage of the disease, and 0.51 (± 0.37) at last follow-up. The average visual field mean defect (VFMD) was 19.65 (± 4.71 dB) at presentation and 21.40 (± 2.45 dB) at last follow-up. Choroidal inflammatory activity monitored by ICGA decreased from 10.67 (± 9.18) at presentation to 6.67 (± 5.61) at last follow-up. FA revealed mild retinal vasculitis at 6.50 (± 4.76), which remained stable to 4.67 (± 3.20). EDI-OCT estimated choroidal thickness (EDI-OCT-CT) measurements were 246.36 (± 116.93 µm) at presentation and 231.30 (± 120.70 µm) at the last follow-up.

CONCLUSIONS

In our setting, 15% of BRC cases had a severe course and suffered extensive irreversible chorioretinal damage, obviously due to insufficient treatment in two cases. This underlines the importance of correctly diagnosing BRC and initiating therapy as promptly as possible to avoid such outcomes in an otherwise possibly controllable disease.

Farnesoid X receptor - a molecular predictor of weight loss after vertical sleeve gastrectomy?

OBJECTIVE

To determine the expression of the bile acid receptor, farnesoid X (FXR), in human gastric mucosa and investigate correlations between expression and body-mass index (BMI) and in patients with obesity, with changes in weight and BMI following vertical sleeve gastrectomy (VSG).

METHODS

Human gastric mucosa was obtained from normal/overweight individuals (macroscopically-normal tissue following surgery for malignancy) or from patients with obesity (VSG). The expression of FXR and its isoforms (FXRα, FXRβ) were examined by quantitative PCR and compared with the G protein-coupled bile acid receptor, GPBA. In patients with obesity, changes in BMI and weight loss were determined following VSG.

RESULTS

FXRα was the predominant isoform in normal/overweight individuals. FXR expression was higher in patients with obesity but GPBA receptor expression was unchanged. For those with obesity (n = 19), no correlation was found between FXR expression and change in Body-Mass Index (BMI)/month or weight loss/month, taken 3 ± 1 months after surgery, or in BMI or weight at surgery.

CONCLUSIONS

Obesity is associated with increased FXR expression in the gastric mucosa. The findings are preliminary but suggest that this increase in FXR expression is a consequence of obesity, rather than its cause.

Vogt-Koyanagi-Harada Disease and Birdshot Retinochoroidopathy, Similarities and Differences: A Glimpse into the Clinicopathology of Stromal Choroiditis, a Perspective and a Review

The purpose of this work was to give a comprehensive and updated review on two primary stromal choroiditis entities, Vogt-Koyanagi-Harada disease (VKH) and birdshot retinochoroiditis (BRC). Their appraisal has become much more precise thanks to new investigational methods, such as indocyanine green angiography (ICGA) and enhanced depth imaging optical coherence tomography (EDI-OCT), which give substantially improved imaging access to the choroid. In this review, we focus on the crucial changes brought by this progress in the understanding, diagnosis, and management of these disorders. Application of these methods makes it possible to reach an early diagnosis, therefore allowing early treatment, which has led to a profound improvement in outcomes when compared to previous management.

Cerebral organoids reveal early cortical maldevelopment in schizophrenia-computational anatomy and genomics, role of FGFR1

Studies of induced pluripotent stem cells (iPSCs) from schizophrenia patients and control individuals revealed that the disorder is programmed at the preneuronal stage, involves a common dysregulated mRNA transcriptome, and identified Integrative Nuclear FGFR1 Signaling a common dysregulated mechanism. We used human embryonic stem cell (hESC) and iPSC-derived cerebral organoids from four controls and three schizophrenia patients to model the first trimester of in utero brain development. The schizophrenia organoids revealed an abnormal scattering of proliferating Ki67+ neural progenitor cells (NPCs) from the ventricular zone (VZ), throughout the intermediate (IZ) and cortical (CZ) zones. TBR1 pioneer neurons and reelin, which guides cortico-petal migration, were restricted from the schizophrenia cortex. The maturing neurons were abundantly developed in the subcortical regions, but were depleted from the schizophrenia cortex. The decreased intracortical connectivity was denoted by changes in the orientation and morphology of calretinin interneurons. In schizophrenia organoids, nuclear (n)FGFR1 was abundantly expressed by developing subcortical cells, but was depleted from the neuronal committed cells (NCCs) of the CZ. Transfection of dominant negative and constitutively active nFGFR1 caused widespread disruption of the neuro-ontogenic gene networks in hESC-derived NPCs and NCCs. The fgfr1 gene was the most prominent FGFR gene expressed in NPCs and NCCs, and blocking with PD173074 reproduced both the loss of nFGFR1 and cortical neuronal maturation in hESC cerebral organoids. We report for the first time, progression of the cortical malformation in schizophrenia and link it to altered FGFR1 signaling. Targeting INFS may offer a preventive treatment of schizophrenia.

Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids

AIM

Transanal haemorrhoidal dearterialization (THD) has become well established for the treatment of haemorrhoids. In this study we describe a technical modification of this technique, targeted mucopexy (THD TM), and report the results for advanced haemorrhoids.

METHOD

The study included a prospective evaluation of patients with Grade IV (fourth-degree) haemorrhoids operated on with the THD TM technique. This consisted of an initial dearterialization when the haemorrhoidal arteries were transfixed and a second phase of mucopexy, using a different needle from that usually used in the original technique.

RESULTS

From January 2007 to December 2011, 31 consecutive patients with Grade IV haemorrhoids were operated on using the THD TM technique. Postoperative pain was reported by 22 (70%) patients on day 1 and 19 (61%) on day 7, while nine (30%) did not experience any pain at all. Severe pain was reported by only nine (16%) patients. At a mean follow-up of 32 months, two (6.4%) patients required a further intervention for on-going symptoms.

CONCLUSION

Transanal haemorrhoidal dearterialization TM is effective for advanced haemorrhoids.

Seroprevalence of hepatitis E virus immunoglobulin G and M antibodies in adults: a hospital-based study

Sporadic cases of Hepatitis E virus (HEV) infection occur throughout the year in Pakistan. The aim of this study was to determine the prevalence of HEV immunoglobulin (Ig) G and IgM antibodies in 93 hepatitis B and C-negative patients as such patients are not routinely tested further despite having signs and symptoms of hepatitis. Anti-HEV IgG and IgM were detected by the enzyme-linked immunosorbant assay technique. Among them five patients (5.4%) were positive for HEV IgG and IgM, with an average age of 30.95 +/- 15.35 years. Hepatitis E infection was independent of the sex. Liver function tests of hepatitis E-positive IgG and IgM patients showed increased values of serum glutamate oxaloacetate transaminase, serum glutamate pyruvate transaminase, alkaline phosphatase and bilirubin that indicate damaged hapatocytes and malfunctioning of the liver.

Enhanced clearance of Candida albicans from the oral cavities of mice following oral administration of Lactobacillus acidophilus

Orally administered live Lactobacillus acidophilus was assessed for its capacity to enhance clearance from the oral cavity of DBA/2 mice shown previously to be 'infection prone'. L. acidophilus fed to DBA/2 mice significantly shortened the duration of colonization of the oral cavity compared to controls. Enhanced clearance of Candida albicans correlated with both early mRNA gene expression for interleukin (IL)-4 and interferon (IFN)-gamma and expression of their secreted products in cultures of cervical lymph nodes stimulated with Candida antigen. In addition rapid clearance correlated with higher levels of IFN-gamma and nitric oxide in saliva. Delayed clearance, less pronounced levels of the cytokine response, saliva IFN-gamma and nitric oxide, and later mRNA expression for IL-4 and IFN-gamma relative to feeding with the L. acidophilus isolate were noted in mice fed a different Lactobacillus isolate (L. fermentum). These observations indicate significant variations in individual isolates to activate the common mucosal system.

Infection of newborn piglets with Bordetella pertussis: a new model for pertussis

Bordetella pertussis is the causative agent of pertussis or whooping cough. This bacterium is a human pathogen that under experimental conditions also infects selected rodents and primates. Here, we show for the first time that newborn piglets can be infected with B. pertussis when it is delivered intrapulmonarily. Infected piglets displayed fever and respiratory symptoms, such as nasal discharge, nonparoxysmal coughing, and breathing difficulties. Eventually, all infected animals developed severe bronchopneumonia, which in some cases was combined with a fibrinous pleuritits. Immunohistochemical staining revealed the presence of large numbers of B. pertussis cells within airways, adhering to the epithelial lining or phagocytosed by macrophages and neutrophils. Viable bacteria were reisolated from bronchoalveolar lavages and lung lesions for more than 10 days postinfection. The systemic presence of pertussis toxin was shown by hypoglycemia, lymphocytosis, and induction of a clustered pattern of CHO cells by serum and bronchoalveolar lavage samples. Thus, a large-animal model for pertussis was developed, which should complement existing rodent models for identifying the immune responses relevant to the design of new vaccines. In particular, this model should help researchers analyze the roles of both maternal and mucosal immunity in disease protection against pertussis and should ultimately assist in the design of new vaccines for early life protection.

A rapid and accurate method for the determination of plutonium in food using magnetic sector ICP-MS with an ultra-sonic nebuliser and ion chromatography

In the event of a nuclear incident it is essential that analytical information on the distribution and level of contamination is available. An ICP-MS method is described which can provide data on plutonium contamination in food within 3 h of sample receipt without compromising detection limits or accuracy relative to traditional counting methods. The method can also provide simultaneous determinations of americium and neptunium. Samples were prepared by HNO3 closed-vessel microwave digestion, evaporated to dryness and diluted into a mobile phase comprising 1.5 M HNO3 and 0.1 mM 2,6-pyridinedicarboxylic acid. A commercially available polystyrene-divinylbenzene ion chromatography column provides on-line separation of 239Pu and 238U reducing the impact of the 238U1H interference. Oxidation of the sample using H2O2 ensures all Pu is in the Pu(+4) state. The oxidation also displaces Np away from the solvent front by changing the oxidation state from Np(+3) to Np(+4) and produces the insoluble Am(+4) ion. Simultaneous Pu, Am and Np analyses therefore require omission of the oxidation stage and some loss of Pu data quality. Analyses were performed using a magnetic sector ICP-MS (Finnigan MAT Element). The sample is introduced to the plasma via an ultrasonic nebuliser-desolvation unit (Cetac USN 6000AT+). This combination achieves an instrumental sensitivity of 238U > 2 x 10(7) cps/ppb and removes hydrogen from the sample gas, which also inhibits the formation of 238U1H. The net effect of the improved sample introduction conditions is to achieve detection levels for Pu of 0.020 pg g(-1) (4.6 x 10(-2) Bq kg(-1)) which is significantly below 1/10th of the most stringent EU (European Union) legislation, currently 0.436 pg g(-1) (1 Bq kg(-1)) set for baby food. The new method was evaluated with a range of biological samples ranging from cabbage to milk and meat. Recovery of Pu agrees with published values (100% +/- 20%).

Primary role for CD4(+) T lymphocytes in recovery from oropharyngeal candidiasis

Oropharyngeal candidiasis is associated with defects in cell-mediated immunity and is commonly seen in human immunodeficiency virus positive individuals and AIDS patients. A model for oral candidiasis in T-cell-deficient BALB/c and CBA/CaH nu/nu mice was established. After inoculation with 10(8) Candida albicans yeasts, these mice displayed increased levels of oral colonization compared to euthymic control mice and developed a chronic oropharyngeal infection. Histopathological examination of nu/nu oral tissues revealed extensive hyphae penetrating the epithelium, with polymorphonuclear leukocyte microabscess formation. Adoptive transfer of either naive or immune lymphocytes into immunodeficient mice resulted in the recovery of these animals from the oral infection. Reconstitution of immunodeficient mice with naive CD4(+) but not CD8(+) T cells significantly decreased oral colonization compared to controls. Interleukin-12 and gamma interferon were detected in the draining lymph nodes of immunodeficient mice following reconstitution with naive lymphocytes. This study demonstrates the direct requirement for T lymphocytes in recovery from oral candidiasis and suggests that this is associated with the production of cytokines by CD4(+) T helper cells.

Irradiation-induced oral candidiasis in an experimental murine model

The aim of this experiment was to establish a mouse model of irradiation-induced oral candidiasis and to explore the cellular populations and mechanisms by which the infection is cleared from the oral mucosa. BALB/c mice received irradiation to the head and neck equivalent to 800 Rad using a Cobalt 60 gamma source. Both irradiated and non-irradiated mice were infected orally with 1 x 10(8) Candida albicans yeasts. Compared with untreated controls, irradiated animals developed a more severe infection of longer duration, with hyphae penetrating the oral mucosa. Monoclonal antibody depletion of CD4+ but not CD8+ T cells from the systemic circulation prolonged the infection in irradiated mice, but not in controls. Supernatants of submandibular and superficial cervical lymph node cultures from irradiated animals demonstrated significantly higher titers of interleukin-12, but similar levels of interferon-gamma compared with controls. Screening for cytokine production by an RNase protection assay detected only macrophage migration inhibition factor in irradiated and non-irradiated oral tissues from day 8 onwards. The results of this study demonstrate a requirement for CD4+ T cells in the recovery from oral candidiasis induced by head and neck irradiation in mice, and are consistent with a role for Th1-type cytokines in host resistance.

T cells augment monocyte and neutrophil function in host resistance against oropharyngeal candidiasis

The purpose of this study was to identify the cell populations involved in recovery from oral infections with Candida albicans. Monoclonal antibodies specific for CD4+ cells, CD8+ cells, and polymorphonuclear leukocytes were used to deplete BALB/c and CBA/CaH mice of the relevant cell populations in systemic circulation. Monocytes were inactivated with the cytotoxic chemical carrageenan. Mice were infected with 10(8) C. albicans yeast cells and monitored for 21 days. Systemic depletion of CD4+ and CD8+ T lymphocytes alone did not increase the severity of oral infection compared to that of controls. Oral colonization persisted in animals treated with head and neck irradiation and depleted of CD4+ T cells, whereas infections in animals that received head and neck irradiation alone or irradiation and anti-CD8 antibody cleared the infection in a comparable fashion. The depletion of polymorphonuclear cells and the cytotoxic inactivation of mononuclear phagocytes significantly increased the severity of oral infection in both BALB/c and CBA/CaH mice. High levels of interleukin 12 (IL-12) and gamma interferon (IFN-gamma) were produced by lymphocytes from the draining lymph nodes of recovering animals, whereas IL-6, tumor necrosis factor alpha, and IFN-gamma were detected in the oral mucosae of both naïve and infected mice. The results indicate that recovery from oropharyngeal candidiasis in this model is dependent on CD4+-T-cell augmentation of monocyte and neutrophil functions exerted by Th1-type cytokines such as IL-12 and IFN-gamma.

A method for the quantitative analysis of iron speciation in meat by using a combination of spectrophotometric methods and high-performance liquid chromatography coupled to sector field inductively coupled plasma mass spectrometry

The determination of the heme and non-heme iron fractions in raw and cooked beef steak by using spectrophotometric methods and high-performance liquid chromatography coupled to a double-focusing sector field inductively coupled plasma mass spectrometer (HPLC-SF-ICPMS) is reported. Size exclusion chromatography coupled to SF-ICPMS was used to measure the iron-containing biomolecules in the samples. This approach allowed for the direct on-line detection of the most abundant iron isotope 56Fe without interference from 40Ar16O. The HPLC-ICPMS results for the iron speciation analysis of a raw beef steak, used as an analytical quality control (AQC) sample, showed that the main iron biomolecule present was the heme iron-containing protein myoglobin. For the AQC sample, the agreement among the HPLC-ICPMS method, the non-heme iron spectrophotometric method, and the total iron concentration showed 100% recovery of iron. The sum of the different iron-containing compounds determined using the developed HPLC-ICPMS method accounted for all the iron-containing compounds extracted. The analysis of myoglobin in steak by HPLC-ICPMS showed that on cooking the concentration was reduced by 85%. However, a spectrophotometric method specific for heme iron showed that it was still intact, even after heating to 80 degrees C. The measurement of the total iron in the cooked steak and the HPLC extracts by inductively coupled plasma optical emission spectroscopy (ICP-OES) indicated that the extraction method for the HPLC analysis was no longer applicable and that loss of the heme group from the protein rendered it incompatible with the size exclusion separation. The detection limit (concentration equivalent to 3 times the baseline for a blank injection) of the HPLC-ICPMS method was 2.4 ng as iron. The results demonstrate that a combination of analytical methods can be used to provide valuable information about dietary levels of nutritionally important metal-containing compounds as well as the efficiency of established extraction methods for raw and cooked meat samples.

A therapeutic vaccine for mucosal candidiasis

Persistent and recurrent infection of mucosal surfaces with Candida albicans is common, ranging from a nuisance to a life threatening clinical problem. No effective prophylactic or therapeutic vaccine has been developed. We have studied a mouse model of oral candida infection to identify regulatory and effector molecules of T cell activation as parameters of induced immunity, and here describe the use of this model to determine an optimal immunisation strategy. Oral immunisation with the blastospore yeast form (but not subcutaneous immunisation) induced clinical immunity, with a shift in parameters of cytokine response characterised by an early and sustained production of both IFN-gamma and IL-4 from antigen-stimulated cervical node T lymphocytes.

Cellular and cytokine correlates of mucosal protection in murine model of oral candidiasis

Host protection against Candida albicans infection in a model of oral candidiasis involving infection-prone [DBA/2 (H-2(d))] and less infection-prone [BALB/c (H-2(d))] mouse strains was analyzed in terms of antibody and cellular responses, and in terms of cytokine patterns from regional lymph node cells. There was a selective expansion of gamma/delta(+) T-cell receptor cells, which correlated with the patterns of colonization in both mouse strains, with higher numbers of gamma/delta T cells detected in BALB/c mice. Antigen-induced T-cell proliferation was significantly higher in BALB/c mice than in DBA/2 mice. Higher levels of serum immunoglobulin G (IgG) and salivary IgA antibodies were detected in BALB/c mice than in DBA/2 mice, but only after the infection was cleared. The cervical lymph node cells from infected mice were assessed for interleukin-4 (IL-4), IL-12, and gamma interferon (IFN-gamma) mRNA gene expression by reverse transcription-PCR and protein production in the culture supernatants following restimulation in vitro. In BALB/c mice, an early increase in levels of IL-4, IFN-gamma, and IL-12 correlated with rapid elimination of C. albicans. In DBA/2 mice, where resolution of infection was delayed, IL-4 message expression was delayed and the IL-4 secretion level was lower. Neutralization of IL-4 by multiple injections of an anti-IL-4 monoclonal antibody in BALB/c mice resulted in increased carriage rate and delayed clearance of the yeasts. Collectively, the data suggest that the T-cell response to C. albicans in the regional lymph nodes which correlates best with rapid oral clearance of C. albicans is a balanced Th0 cytokine response involving early secretion of both IFN-gamma and IL-4.

The association between varus-valgus alignment and patellofemoral osteoarthritis

OBJECTIVE

Little is known about risk factors for patellofemoral (PF) osteoarthritis (OA). The lateral vector at the PF joint increases the likelihood of lateral PF versus medial PF pathology. Both valgus and varus malalignments affect forces at the PF joint and may predispose to PF OA. We examined whether lateral PF OA is more common than medial PF OA, whether valgus malalignment is more frequent in lateral PF OA than in medial PF OA, and whether knees with PF OA are more often valgus than knees with isolated tibiofemoral (TF) OA.

METHODS

In 292 knee OA patients, we obtained semiflexed, fluoroscopy-confirmed radiographs of the TF joint and weight-bearing, 30 degrees flexion, axial views of the PF joint. Varus-valgus alignment (the angle formed by the intersection of the mechanical axes of the femur and tibia) was measured on a full-limb radiograph.

RESULTS

Lateral PF OA was more common than medial PF OA (P<0.0001). Forty-three of 75 knees with lateral PF OA had valgus malalignment compared with only 5 of 21 patients with medial PF OA (P = 0.0066). Conversely, varus malalignment was more likely in the medial PF OA group. Knees with isolated PF OA were more likely to have valgus malalignment than those with isolated TF OA (P = 0.0002), as were knees with mixed PF-TF OA (P = 0.0006).

CONCLUSION

Varus-valgus alignment may influence the risk of PF OA and, in particular, which compartment is affected.

Retrogenesis: clinical, physiologic, and pathologic mechanisms in brain aging, Alzheimer's and other dementing processes

Data from clinical, electrophysiologic, neurophysiologic, neuroimaging and neuropathologic sources indicates that the progression of brain aging and Alzheimer's disease (AD) deterioration proceeds inversely to human ontogenic acquisition patterns. A word for this process of degenerative developmental recapitulation, "retrogenesis", has been proposed. These retrogenic processes provide new insights into the pathologic mechanism of AD deterioration. An understanding of retrogenic phenonmena can also result in insights into the applicability of retrogenic pathologic mechanisms for non-AD dementing disorders. Management strategies based upon retrogenesis have recently been proposed. Retrogenic pathophysiology also points to previously unexplored pharmacologic approaches to dementia prevention and treatment.