OP-6 Simulated lamellar and endothelial keratoplasty using three-dimensional printed and thin-film models

*Correspondence, Lana Fu: L.Fu@nhs.net BACKGROUND: Corneal transplantation techniques' evolution has resulted in faster visual recovery, lower immunological rejection, and improved graft survival. However, the number of transplants that can be performed can be limited by a lack of donor corneas, a steep learning curve, and the need for specialised expertise.

METHODS

A literature search was undertaken of Ovid/MEDLINE and PubMed/EMBASE to review current corneal surgery simulation models and best-practice lamellar and endothelial keratoplasty techniques. A DALK simulation model was designed using Fusion 360 (Autodesk, San Rafael, California, USA) and printed with the J850 (Stratasys, Eden Prairie, Minneapolis, USA). A DMEK simulation model was created using thin films to allow the practice of the intraocular DMEK unfolding manoeuvres.

RESULTS

The DALK simulation model was produced with a shore hardness A value consistent with the mammalian cornea. Dimensions of the simulation models were based on the emmetropic model eye. Experienced corneal surgeons performed simulated surgery on the models and evaluated face and content validity.

CONCLUSION

3D printed and thin film models have practical benefits compared with cadaveric models; they do not decompose and can be standardised to model specific surgical scenarios. 3D printing is an innovative technology with applications across many fields, including healthcare. It allows for the creation of customised simulation models for cornea surgical practice with a short lead time and reduced waste.

Tectonic mini-Descemet stripping endothelial keratoplasty (mini-DSEK) in the management of corneal perforation secondary to pediatric blepharokerato conjunctivitis

Blepharokeratoconjunctivitis (BKC) in children can have a broad clinical spectrum. Corneal involvement, including perforation, can occur in severe cases. Management aims to restore anatomical integrity and preserve visual function. We report the outcome of a novel technique, tectonic mini-Descemet stripping endothelial keratoplasty (mini-DSEK), to treat a corneal perforation secondary to BKC in a 14-year-old boy after failure to respond to cyanoacrylate glue application and multilayer amniotic membrane patch grafting. On follow-up 8 months postoperatively, the perforation remained sealed, and visual acuity was preserved. The major advantages of this technique are the avoidance of suture-related complications, reduced risk of immunological rejection, minimized postoperative refractive error, and rapid visual rehabilitation.

A novel case of ocular cicatricial pemphigoid induced by levamisole-adulterated cocaine

AIM

To report a case of ocular cicatricial pemphigoid caused by levamisole-adulterated cocaine.

METHODS

Case report.

RESULTS

A 54-year-old woman with multi-systemic levamisole-induced vasculitis which triggered bilateral cicatrizing conjunctivitis refractory to conventional immunosuppressants due to continued cocaine misuse.

CONCLUSION

Levamisole-induced vasculitis is a significant public health issue due to its popularity as an adulterant to cocaine. Our report suggests that levamisole caused vasculitis and ocular cicatricial pemphigoid in this case. Ocular manifestation of this syndrome is rare.

Long-term follow-up of fenestrated endovascular repair for juxtarenal aortic aneurysm

BACKGROUND

Fenestrated endovascular aneurysm repair (FEVAR) is increasingly being used for juxtarenal aortic aneurysms. The aim of this study was to review long-term results and assess the importance of changing stent-graft design on outcomes.

METHODS

This was a retrospective review of all patients who underwent FEVAR within a single unit over 12 years (February 2003 to December 2015). Kaplan-Meier analysis of survival, and freedom from target vessel loss, aneurysm expansion, graft-related endoleak and secondary intervention was performed. Comparison between outcomes of less complex grafts (fewer than 3 fenestrations) and more complex grafts (3 or 4 fenestrations) was undertaken.

RESULTS

Some 173 patients underwent FEVAR; median age was 76 (i.q.r. 70-79) years and 90·2 per cent were men. Median aneurysm diameter was 63 (59-71) mm and median follow-up was 34 (16-50) months. The adjusted primary technical operative success rate was 95·4 per cent. The in-hospital mortality rate was 5·2 per cent; there was no known aneurysm-related death during follow-up. Median survival was 7·1 (95 per cent c.i. 5·2 to 8·1) years and overall survival was 60·1 per cent (104 of 173). There was a trend towards an increasing number of fenestrations in the graft design over time. In-hospital mortality appeared higher when more complex stent-grafts were used (8 versus 2 per cent for stent-grafts with 3-4 versus fewer than 3 fenestrations; P = 0·059). Graft-related endoleaks were more common following deployment of stent-grafts with three or four fenestrations (12 of 90 versus 6 of 83; P < 0·001).

CONCLUSION

Fenestrated endovascular aneurysm repair for juxtarenal aneurysm is associated with few aneurysm-related deaths in the long term. Significant numbers of secondary interventions are required, but the majority of these can be performed using an endovascular approach.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

The Frequency of Signs of Meibomian Gland Dysfunction in Children with Epidermolysis Bullosa

PURPOSE

To determine the frequency of meibomian gland dysfunction (MGD) in children with epidermolysis bullosa (EB).

DESIGN

Hospital-based cross-sectional study.

PARTICIPANTS

One hundred five children with different forms of EB.

METHODS

Prospective ophthalmic examination of children with EB presenting over seventeen months including meibomian gland assessment using a recognized classification.

MAIN OUTCOME MEASURES

Frequency of MGD.

RESULTS

One hundred five children were recruited, 8.6% with junctional EB, 34.3% with simplex EB, 34.3% with autosomal recessive dystrophic EB, and 22.9% autosomal dominant dystrophic EB. Mean age was 7.42 years (range, 0.08-17.75 years). Ninety-two children (87.62%) demonstrated 1 or more features of MGD.

CONCLUSIONS

Most children with EB exhibit signs of MGD. To the best of our knowledge, this is the first prospective ocular surface evaluation in children with EB to include lid margin evaluation using a recognized classification system. Our findings help explain some of the ocular surface anomalies seen in children with EB.

A prospective comparison between cyclopentolate spray and drops in pediatric outpatients

PURPOSE

To determine whether children tolerate cyclopentolate 1% spray better than drops and to assess the adequacy of cycloplegia achieved by spray for objective refraction.

METHODS

The effects of cyclopentolate 1% drops and spray on distress levels were assessed prospectively using a guardian questionnaire in consecutive patients 10 years of age or younger. Distress was graded at various points during the appointment using a Likert scale of 1 to 10 (1 = no distress, 10 = severe distress). The adequacy of cycloplegia in children receiving cyclopentolate spray and the waiting times were assessed via a Likert questionnaire completed by the examining physician.

RESULTS

The guardians of 72 and 77 children who received cyclopentolate 1% drops or spray, respectively, completed the questionnaire. The children were divided in three age groups: 1 to 4 years, 5 to 7 years, and 8 to 10 years. Children 7 years or younger were significantly less distressed by administration of cyclopentolate 1% spray (P < .005). There was no statistical difference in distress levels in children older than 7 years (P = .9719). Thirteen of the 77 children who received cyclopentolate 1% spray did not have adequate cycloplegia to allow objective refraction.

CONCLUSION

The results demonstrate cyclopentolate 1% spray is less distressing at the time of administration than cyclopentolate 1% drops for children 7 years or younger. However, the cycloplegia achieved is not adequate in a high percentage of children.

The role of HIF in cobalt-induced ischemic tolerance

Understanding the endogenous survival pathways induced by ischemic tolerance may yield targets for neuroprotection from stroke. One well-studied pathway reported to be evoked by preconditioning stimuli is the transcription factor HIF (hypoxia-inducible factor). However, whether HIF induction by ischemic insults is neuroprotective or toxic is still unclear. We examined the ability of three prolyl-hydroxylase inhibitors, which induce HIF, to protect hippocampal cultures from oxygen-glucose deprivation. Hippocampal cultures were exposed to ischemic preconditioning or various concentrations of cobalt chloride, deferoxamine (DFO) or dimethyloxylalyglycine (DMOG), prior to lethal oxygen-glucose deprivation (OGD). Cell survival of neurons and astrocytes was determined with dual-label immunocytochemistry. The induction of HIF targets was assessed in mixed as well as astrocyte-enriched cultures. Ischemic preconditioning, as well as low concentrations of cobalt and DFO, enhanced the survival of neurons following OGD. However, DMOG exacerbates OGD-induced neuronal death. At low concentrations, all three prolyl-hydroxylase (PHD) inhibitors increased the survival of astrocytes. Neuroprotective concentrations of cobalt induced the transcription of the cytokine erythropoietin (EPO) in astrocyte cultures. In addition, pretreatment with recombinant human erythropoietin (rH-EPO) also protected neurons from OGD. Our data suggest that HIF-induced EPO, released from astrocytes, protects neurons from OGD. However, the three PHD inhibitors each exhibited different neuroprotective profiles at low concentrations, suggesting that not all PHD inhibitors are created equal. The protective effects at low doses is reminiscent of HIF involvement in ischemic tolerance, in which sub-lethal insults induce HIF pathways resulting in neuroprotection, whereas the high-dose toxicity suggests that over-activation of HIF is not always protective. Therefore, the choice of inhibitor and dose may determine the clinical utility of these compounds. Deferoxamine exhibited little toxicity even at higher doses, and therefore appears a promising candidate for clinical use.

Evidence of pathway-specific basophil anergy induced by peanut oral immunotherapy in peanut-allergic children

BACKGROUND

In Westernized countries, over 1% of the population is allergic to peanuts or tree nuts, which carries a risk of severe allergic reactions. Several studies support the efficacy of peanut oral immunotherapy (OIT) for reducing the clinical sensitivity of affected individuals; however, the mechanisms of this effect are still being characterized. One mechanism that may contribute is the suppression of effector cells, such as basophils. Basophil anergy has been characterized in vitro as a pathway-specific hyporesponsiveness; however, this has not been demonstrated to occur in vivo.

OBJECTIVE

To evaluate the hypothesis that basophil anergy occurs in vivo due to chronic allergen exposure in the setting of a clinical oral immunotherapy trial.

METHODS

Samples of peripheral blood were obtained from subjects during a placebo-controlled clinical trial of peanut OIT. Basophil reactivity to in vitro stimulation with peanut allergen and controls was assessed by the upregulation of activation markers, CD63 and CD203c, measured by flow cytometry.

RESULTS

The upregulation of CD63 following stimulation of the IgE receptor, either specifically with peanut allergen or non-specifically with anti-IgE antibody, was strongly suppressed by active OIT. However, OIT did not significantly suppress this response in basophils stimulated by the distinct fMLP receptor pathway. In the subset of subjects with egg sensitization, active peanut OIT also suppressed CD63 upregulation in response to stimulation with egg allergen. Allergen OIT also suppressed the upregulation of CD203c including in response to stimulation with IL-3 alone.

CONCLUSION

Peanut OIT induces a hyporesponsive state in basophils that is consistent with pathway-specific anergy previously described in vitro. This suggests the hypothesis that effector cell anergy could contribute to clinical desensitization.

Phasing rectangular apertures

Several techniques have been developed to phase apertures in the context of astronomical telescopes with segmented mirrors. Phasing multiple apertures, however, is important in a wide range of optical applications. The application of primary interest in this paper is the phasing of multiple short pulse laser beams for fast ignition fusion experiments. In this paper analytic expressions are derived for parameters such as the far-field distribution, a line-integrated form of the far-field distribution that could be fit to measured data, enclosed energy or energy-in-a-bucket and center-of-mass that can then be used to phase two rectangular apertures. Experimental data is taken with a MEMS device to simulate the two apertures and comparisons are made between the analytic parameters and those derived from the measurements. Two methods, fitting the measured far-field distribution to the theoretical distribution and measuring the ensquared energy in the far-field, produced overall phase variance between the 100 measurements of less than 0.005 rad(2) or an RMS displacement of less than 12 nm.

Setting up a store‐and‐forward telemedicine service for acute trauma in a hospital trust

Telemedicine is a valuable, but as yet underused, resource for the delivery of health-care to patients. This paper describes the development of a new store-and-forward telemedicine service at the Queen Victoria Hospital, which is a tertiary referral centre for plastic surgery in the United Kingdom. The practical requirements of such a system, and the technical and legal difficulties experienced during the initial stages, are also discussed.

Activation of the tonic GABAC receptor current in retinal bipolar cell terminals by nonvesicular GABA release

Within the second synaptic layer of the retina, bipolar cell (BC) output to ganglion cells is regulated by inhibitory input to BC axon terminals. GABA(A) receptors (GABA(A)Rs) mediate rapid synaptic currents in BC terminals, whereas GABA(C) receptors (GABA(C)Rs) mediate slow evoked currents and a tonic current, which is strongly regulated by GAT-1 GABA transporters. We have used voltage-clamp recordings from BC terminals in goldfish retinal slices to determine the source of GABA for activation of these currents. Inhibition of vesicular release with concanamycin A or tetanus toxin significantly inhibited GABA(A)R inhibitory postsynaptic currents and glutamate-evoked GABA(A)R and GABA(C)R currents but did not reduce the tonic GABA(C)R current, which was also not dependent on extracellular Ca(2+). The tonic current was strongly potentiated by inhibition of GABA transaminase, under both normal and Ca(2+)-free conditions, and was activated by exogenous taurine; however inhibition of taurine transport had little effect. The tonic current was unaffected by GAT-2/3 inhibition and was potentiated by GAT-1 inhibition even in the absence of vesicular release, indicating that it is unlikely to be evoked by reversal of GABA transporters or by ambient GABA. In addition, GABA release does not appear to occur via hemichannels or P2X(7) receptors. BC terminals therefore exhibit two forms of GABA(C)R-mediated inhibition, activated by vesicular and by nonvesicular GABA release, which are likely to have distinct functions in visual signal processing. The tonic GABA(C)R current in BC terminals exhibits similar properties to tonic GABA(A)R and glutamate receptor currents in the brain.

The Ebola virus ribonucleoprotein complex: a novel VP30-L interaction identified

The ribonucleoprotein (RNP) complex of Ebola virus (EBOV) is known to be a multiprotein/RNA structure, however, knowledge is rather limited regarding the actual protein-protein interactions involved in its formation. Here we show that singularly expressed VP35 and VP30 are present throughout the cytoplasm, while NP forms prominent cytoplasmic inclusions and L forms smaller perinuclear inclusions. We could demonstrate the existence of NP-VP35, NP-VP30 and VP35-L interactions, similar to those described for Marburg virus (MARV) based on the redistribution of protein partners into NP and L inclusion bodies. Significantly, a novel VP30-L interaction was also identified and found to form as part of an NP-VP30-L bridge structure, similar to that formed by VP35. The identification of these interactions allows a preliminary model of the EBOV RNP complex structure to be proposed, and may provide insight into filovirus transcriptional regulation.

Resting discharge patterns of macular primary afferents in otoconia-deficient mice

Vestibular primary afferents in the normal mammal are spontaneously active. The consensus hypothesis states that such discharge patterns are independent of stimulation and depend instead on excitation by vestibular hair cells due to background release of synaptic neurotransmitter. In the case of otoconial sensory receptors, it is difficult to test the independence of resting discharge from natural tonic stimulation by gravity. We examined this question by studying discharge patterns of single vestibular primary afferent neurons in the absence of gravity stimulation using two mutant strains of mice that lack otoconia (OTO-; head tilt, het-Nox3, and tilted, tlt-Otop1). Our findings demonstrated that macular primary afferent neurons exhibit robust resting discharge activity in OTO- mice. Spike interval coefficient of variation (CV = SD/mean spike interval) values reflected both regular and irregular discharge patterns in OTO- mice, and the range of values for rate-normalized CV was similar to mice and other mammals with intact otoconia although there were proportionately fewer irregular fibers. Mean discharge rates were slightly higher in otoconia-deficient strains even after accounting for proportionately fewer irregular fibers [OTO- = 75.4 +/- 31.1(113) vs OTO+ = 68.1 +/- 28.5(143) in sp/s]. These results confirm the hypothesis that resting activity in macular primary afferents occurs in the absence of ambient stimulation. The robust discharge rates are interesting in that they may reflect the presence of a functionally 'up-regulated' tonic excitatory process in the absence of natural sensory stimulation.

Otoconin-90 deletion leads to imbalance but normal hearing: a comparison with other otoconia mutants

Our sense of gravitation and linear acceleration is mediated by stimulation of vestibular hair cells through displacement of otoconia in the utricle and saccule (the gravity receptor organ). We recently showed that otoconin-90 (Oc90) deletion led to formation of giant otoconia. In the present study, we determined the extent to which the giant otoconia affected balance and gravity receptor sensory input and compared the findings with other otoconia mutants. We employed a wide spectrum of balance behavioral tests, including reaching and air-righting reflexes, gait, swimming, beam-crossing, rotorod latencies, and a direct measure of gravity receptor input, vestibular evoked potentials (VsEPs). All tests on homozygous adult mutants consistently ranked the order of imbalance as (from worst to best) Nox3(het)<otopetrin 1(tlt)<Oc90 null<Oc90 wild type and C57Bl/6 mice using systematic statistical comparisons of the frequency of occurrence or the severity of abnormal functions. This order coincides with the degree of otoconia deficiencies and is consistent with VsEP measures. Notably, all mice (except Nox3(het)) showed remarkable learned adaptation to peripheral vestibular deficits by staying on the rotating rod significantly longer in each successive trial, and the rate and extent of such learned improvements ranked the same order as their initial balance ability. Despite the vestibular morbidity, Oc90 null mice had normal hearing, as measured by auditory brainstem responses (ABRs) and distortion products of otoacoustic emissions (DPOAEs). The study demonstrates that the remnant otoconia mass in Oc90 nulls does stimulate the gravity receptor organs, which was likely responsible for the improved balance performance relative to strains with absent otoconia. Furthermore, the combination of direct electrophysiological measures and a series of behavioral tests can be used to interpret the imbalance severity arising from altered inputs from the gravity receptor end organ.

Reproductive endocrinology of the largest Dasyurids: characterization of ovarian cycles by plasma and fecal steroid monitoring. Part II. The spotted-tailed quoll (Dasyurus maculatus)

Dasyurids exhibit a range of breeding patterns from semelparity through to an aseasonally polyestrous strategy, but detailed information on the reproductive endocrinology of many species is unavailable. This study aimed to extend our comparative understanding by characterizing the ovarian cycle of the spotted-tailed quoll (Dasyurus maculatus) through measurement of plasma progesterone, and also to investigate fecal sex steroid monitoring as an alternative, non-invasive technique. Longitudinal profiles revealed a biphasic pattern of plasma progesterone, with a significant pro-estrous pulse (0.97+/-0.3ng/ml) up to several weeks prior to onset of the luteal phase (LP). This pro-estrous period was associated with a predominantly cornified vaginal smear, onset of estrus behaviors and copulation. Mean luteal values for plasma progesterone were several fold higher (2.18+/-1.10 ng/ml) than during the follicular phase (FP) (0.75+/-0.02 ng/ml), and were sustained for approximately one month. Fecal progestagens and plasma progesterone were significantly positively associated during the estrous cycle. During the breeding period average concentrations of fecal total estrogens and pregnanediol (PgD) were significantly elevated. Ovarian activity during the FP was marked by increases in fecal estrogens, and rises in PgD which were sustained during the LP. In non-mated females the mean duration of the FP was significantly extended, being approximately twice as long (19.4+/-4.0 d) as for mated females (8.3+/-1.9 d) indicating coitus has some role in timing of ovulation in this species. This study has provided important new information on the reproductive biology of the female spotted-tailed quoll, and further demonstrated the usefulness of non-invasive endocrine techniques for monitoring ovarian cycles in marsupials.

Reproductive endocrinology of the largest dasyurids: characterization of ovarian cycles by plasma and fecal steroid monitoring. Part I. The Tasmanian devil (Sarcophilus harrisii)

There is a strong body of knowledge on the reproductive endocrinology of macropods, but little detailed information is available on the hormonal control of reproduction in other marsupials. This study used plasma and fecal sex steroid monitoring to characterize the estrous cycle of the largest extant dasyurid-the Tasmanian devil (Sarcophilus harrisii). A pro-estrous pulse in plasma progesterone (1.33+/-0.2 ng/ml) occurred several weeks prior to onset of the luteal phase (LP), resulting in a characteristic biphasic pattern during the estrous cycle. This brief, pro-estrous progesterone pulse was associated with a predominantly cornified vaginal smear, and copulation in females paired with males. Mean luteal progesterone concentrations (5.28+/-0.8 ng/ml) were sustained and peaked around day 15 from luteal onset; thereafter, concentrations declined precipitously and returned to baseline around day 25. Females that did not produce young returned to estrus after 33.7+/-5.9 days. Fecal 20alpha-OH-pregnanes analyzed in a pregnanediol assay (PgD) were excreted in consistently higher levels than 20-oxo-pregnanes, but the pattern was similar for the two metabolites, and significantly correlated with fluctuations in plasma progesterone. Fecal total estrogen concentrations were highest during the follicular phase (FP) and accompanied a pro-estrous pulse in fecal progestagens. The mean duration of the estrous cycle was approximately 32 days, with a FP of around 14 days (range 8-23 days), and a luteal phase of around 18 days (range 12-25 days). There were no differences in the length of the LP between mated and non-mated cycles. Gestation length was 17.9+/-1.0 days (range 14-22 days). Fecal steroid monitoring revealed significant differences between the pattern of progestagens and estrogen concentrations during the pregnant and non-mated estrous cycle, suggesting maternal endocrine recognition of pregnancy in the Tasmanian devil.

Visual outcome and corneal changes in children with chronic blepharokeratoconjunctivitis

OBJECTIVE

To describe the cause, management, and effect of chronic blepharokeratoconjunctivitis (BKC) on the cornea and visual function in children.

DESIGN

Noncomparative, interventional, retrospective case series.

PARTICIPANTS

Twenty-seven children with BKC.

METHODS

Presenting age, best-corrected visual acuity (BCVA), refractive error, and any corneal or eyelid pathologic features were recorded. Treatment included modified lid hygiene, topical antibiotics, and steroids. Systemic therapy included oral antibiotics and, from 2003 onward, flaxseed oil as an alternative to long-term antibiotics. Amblyopia therapy included refractive correction, occlusion, or atropine therapy.

MAIN OUTCOME MEASURES

Corneal and eyelid status, visual acuity (VA), and refractive error at final examination.

RESULTS

Mean age at presentation was 6.9 years (range, 7 months-15.9 years), and mean follow-up was 2.3 years (range, 5 months-6.1 years). All patients had discomfort, conjunctival injection, and signs of posterior blepharitis at presentation. Photophobia was reported in 14 patients (52%), whereas anterior eyelid inflammation was noted in 6 (22%). Acne rosacea was confirmed in 3 patients (11%). Corneal involvement occurred in 44 eyes (81%), and a history of recurrent chalazia was seen in 18 patients (67%). Median monocular BCVAs in affected eyes were 0.28 logarithm of the minimum angle of resolution (logMAR) units (interquartile range [IqR], 0.02-0.40) at presentation and 0.02 logMAR units (IqR, 0.00-0.18) at last visit. Best-corrected VA improved in 70% of affected eyes and remained unchanged in 30%. Superimposed amblyopia was present and treated in 15 patients (48%). All 8 patients (20%) who failed to achieve VA of 0.2 logMAR units or better at the final examination had bilateral corneal involvement at presentation. One child experienced a systemic side effect from oral antibiotics. No child had significant side effects from topical treatment. Twelve patients (44%) received flaxseed oil as part of their tapering regimen. A 2-year lag between symptom onset and treatment resulted, on average, in a reduction of 0.06 logMAR units of VA (95% confidence interval, 0.00-0.12; P = 0.054).

CONCLUSIONS

These findings suggest that visual loss may be significant in BKC and that delayed treatment may result in decreased final BCVA. Adequate management needs both topical and systemic treatment. Flaxseed oil may be an effective antiinflammatory nutritional therapy alternative to long-term antibiotics.

The fraction 1 and V protein antigens of Yersinia pestis activate dendritic cells to induce primary T cell responses

The F1 and V antigens of Yersinia pestis, despite acting as virulence factors secreted by the organism during infection, also combine to produce an effective recombinant vaccine against plague, currently in clinical trial. The protective mechanisms induced by rF1 + rV probably involve interactions with dendritic cells (DC) as antigen uptake, processing and presenting cells. To study such interactions, naive ex vivo DC from bone marrow, spleen and lymph node were cultured with rF1, rV or combined antigens and demonstrated to secrete interleukin (IL)-4 and IL-12 into the culture supernatant. Cytokine production in response to pulsing was dependent on the maturity of the bone marrow-derived DC culture, so that pulsed 8-day-old cultures had accumulated significantly more intracellular IL-4 and IL-12 than unpulsed cells. DC, pulsed with rF1 + rV for 2-24 h, were able to prime naive autologous lymph node T cells to proliferate in an antigen dose-dependent manner, with an order of potency of 3d bone marrow-derived DC (BMDC) > 7d BMDC > splenic DC. Significantly, cell-free supernatants from rF1 + rV-pulsed BMDC and splenic DC were also able to induce specific primary responses effectively in naive T cells, suggesting that these supernatants contained stimulatory factor(s). This study suggests an important role for DC, or factors secreted by them, in the induction of protective immunity to plague by the rF1 and rV antigens.

Kinetics of the immune response to the (F1+V) vaccine in models of bubonic and pneumonic plague

Protection against aerosol challenge with > 300 MLD of Yersinia pestis was observed 7 days after a single immunisation of mice with the F1+V vaccine. At day 60, mice were protected against injected challenge (10(7)MLD) in a vaccine dose-related manner. Recall responses to rV in splenocytes ex vivo at day 98 correlated significantly (p<0.001) with the immunising dose-level of V antigen; no memory response or anti-V serum IgG was detected in killed whole cell vaccine (KWCV) recipients. This may explain the susceptibility of KWCV recipients to aerosol challenge and the enhanced protection conferred by the F1+V sub-unit vaccine, particularly since the anti-F1 responses induced by either vaccine were similarly IgG1-polarised.

A sensor to detect the early stages in the development of crystalline Proteus mirabilis biofilm on indwelling bladder catheters

A simple sensor has been developed to detect the early stages of urinary catheter encrustation and avoid the clinical crises induced by catheter blockage. In laboratory models of colonization by Proteus mirabilis, the sensor signaled encrustation at an average time of 43 h before catheters were blocked with crystalline biofilm.

Amniotic membrane transplantation in children with symblepharon and massive pannus

OBJECTIVE

To report our pediatric experience with amniotic membrane transplantation for ocular surface and forniceal reconstruction.

METHODS

Retrospective case review of children who underwent superficial keratectomy, symblepharon lysis, and forniceal reconstruction using amniotic membrane transplantation. The underlying diagnosis, visual acuity, level of discomfort at first and last visits, and surgical details were noted.

RESULTS

Four patients (5 eyes) were included. Two patients had epidermolysis bullosa (1 recessive dystrophic and 1 junctional), 1 had laryngo-onychocutaneous syndrome, and 1 had measles-related keratitis and was positive for human immunodeficiency virus. Their mean age when initially seen was 8.7 years (age range, 4-16 years), and mean follow-up was 18.25 months (range, 12-29 months). The mean visual acuity preoperatively was 1.1 logMAR (logarithm of the minimum angle of resolution) (range, 1-1.3), and postoperatively was 0.7 (range, 0.2-1.2). All patients experienced increased ocular comfort with anatomical restoration of corneal and conjunctival surfaces. Visual acuity improved in 3 eyes. Only the patient with laryngo-onychocutaneous syndrome had recurrence of granuloma, at 9 months after surgery.

CONCLUSION

Amniotic membrane transplantation with symblepharon lysis is effective for ocular surface reconstruction in the management of epidermolysis bullosa and other conditions that cause corneal scarring and symblepharon in children. In this small series, children with epidermolysis bullosa fared better and the effects of surgery lasted longer compared with patients with other causes of symblepharon and massive pannus.

Severe vocal cord dysfunction resistant to all current therapeutic interventions

Vocal cord dysfunction (VCD) is characterised by paradoxical vocal cord adduction during inspiration or throughout the respiratory cycle, it results in wheeze, stridor, cough and dyspnoea. Although asthma and VCD can coexist, patients with VCD are frequently misdiagnosed with refractory asthma. It can severely restrict an individual's level of activity and effective therapeutic control can be difficult to achieve. We report the case of a patient who was treated with all available therapeutic interventions, including intralaryngeal botulinum toxin injection, but failure resulted in a permanent trachesotomy.

Exploring the relationship between severity of dysphonia and voice-related quality of life

OBJECTIVES

To explore whether severity and/or consistency of dysphonia are linked to voice-related quality of life.

DESIGN

Cross-sectional study.

SETTING

Specialist voice clinics, University Teaching Hospital.

PARTICIPANTS

Sixty adult patients attending with a primary complaint of dysphonia. Exclusion criteria were those below 16 years of age, transexual patients and those with a persistent dysphonia of >2 years.

MAIN OUTCOME MEASURES

Voice-related quality of life as assessed by VoiSS. EXPLANATORY FACTORS: Severity of dysphonia as judged by perceptual ratings of voice (GRBAS); a visual analogue scale to judge best, worst and today's voice.

RESULTS

There was a highly significant correlation between perceptual dysphonia severity as assessed by GRBAS and the total, impairment and emotional subsets of the VoiSS questionnaire (r from 0.48 to 0.64). There was a similar and highly significant correlation between best, worst and today's self-rated voice and the total, impairment and emotional subsets of the VoiSS questionnaire (r from -0.40 to -0.60). However, none of the self-rated parameters was demonstrably better at explaining the effect on quality of life.

CONCLUSIONS

An increasingly negative effect on quality of life appears to be associated with an increase in the severity of dysphonia. Further research on the role of quality of life measures in the assessment and treatment of dysphonia would be of value.

Telemedicine in wound healing

Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.

Advances in wound healing: topical negative pressure therapy

In clinical practice many wounds are slow to heal and difficult to manage. The recently introduced technique of topical negative pressure therapy (TNP) has been developed to try to overcome some of these difficulties. TNP applies a controlled negative pressure to the surface of a wound that has potential advantages for wound treatment and management. Although the concept itself, of using suction in wound management is not new, the technique of applying a negative pressure at the surface of the wound is. This paper explores the origins and proposed mechanisms of action of TNP therapy and discusses the types of wounds that are thought to benefit most from use of this system.

Human immune response to a plague vaccine comprising recombinant F1 and V antigens

The human immune response to a new recombinant plague vaccine, comprising recombinant F1 (rF1) and rV antigens, has been assessed during a phase 1 safety and immunogenicity trial in healthy volunteers. All the subjects produced specific immunoglobulin G (IgG) in serum after the priming dose, which peaked in value after the booster dose (day 21), with the exception of one individual in the lowest dose level group, who responded to rF1 only. Three subjects, found to have an anti-rV titer at screening, were excluded from the overall analysis. Human antibody functionality has been assessed by quantification of antibody competing for binding to rV in vitro and also by the transfer of protective immunity in human serum into the naive mouse. Human and macaque IgG competed for binding to rV in vitro with a mouse monoclonal antibody, previously shown to protect mice against challenge with plague, suggesting that this protective B-cell epitope on rV is conserved between these three species. Total IgG to rV in individuals and the titer of IgG competing for binding to rV correlated significantly at days 21 (r = 0.72; P < 0.001) and 28 (r = 0.82; P < 0.001). Passive transfer of protective immunity into mice also correlated significantly with total IgG titer to rF1 plus rV at days 21 (r(2) = 98.6%; P < 0.001) and 28 (r(2) = 76.8%; P < 0.03). However, no significant vaccination-related change in activation of peripheral blood mononuclear cells was detected at any time. Potential serological immune correlates of protection have been investigated, but no trends specific to vaccination could be detected in cellular markers.

A transgenic mouse model for studying the clearance of blood-borne pathogens via human complement receptor 1 (CR1)

Complement receptor 1 (CR1) on the surface of human erythrocytes facilitates intravascular clearance of complement-opsonized pathogens. The need for complement activation can be circumvented by directly coupling the organism to CR1 using a bispecific monoclonal antibody heteropolymer (HP). Lack of a functional homologue to CR1 on mouse erythrocytes has made it difficult to study HP-dependent clearance of pathogens in small animals. We have developed a transgenic mouse that expresses human CR1 on erythrocytes. CR1 antigen is of appropriate size and in a clustered distribution as confirmed by immunoblotting and fluorescence microscopy, respectively. HP that immobilized bacteriophage PhiX174 prototype pathogen to erythrocyte CR1 of the transgenic mice increased the rate of clearance of the virus compared with HP that bound bacteriophage, but not CR1. This transgenic mouse model will allow evaluation of different HPs for their in vivo efficacy and potential as human therapeutics.

Evidence for macular gravity receptor modulation of hypothalamic, limbic and autonomic nuclei

Mice lacking normal vestibular gravity reception show altered homeostatic, circadian and autonomic responses to hypergravity (+G) exposure. Using c-Fos as a marker of neuronal activation, the current study identifies CNS nuclei that may be critical for initiating and integrating such responses to changes in vestibular signaling. This experiment utilized the mutant C57BL/6JEi-het mouse (het), which lacks macular otoconia and thus gravity receptor function. Following 2 h of 2G (2x Earth's gravity) exposure (via centrifugation) the neuronal responses of the het mice were compared with wildtype mice similarly exposed to 2G, as well as het and wildtype 1G controls. Wildtype mice exposed to 2G demonstrated robust c-Fos expression in multiple autonomic, hypothalamic and limbic nuclei, including: the lateral septum, bed nucleus of the stria terminalis, amygdala, paraventricular hypothalamus, dorsomedial hypothalamus, arcuate, suprachiasmatic hypothalamus, intergeniculate leaflet, dorsal raphe, parabrachial and locus coeruleus. The het mice exposed to 2G demonstrated little to null c-Fos expression in these nuclei with a few exceptions and, in general, a similar pattern of c-Fos to 1G controls. Data from this study further support the existence of a complex and extensive influence of the neurovestibular system on homeostatic, circadian and possibly autonomic regulatory systems.

Telemedicine in acute plastic surgical trauma and burns

BACKGROUND

Telemedicine is a relatively new development within the UK, but is increasingly useful in many areas of medicine including plastic surgery. Plastic surgery centres often work on a hub-and-spoke basis with many district hospitals referring to one tertiary centre. The Queen Victoria Hospital is one such centre receiving calls from more than 28 hospitals in the Southeast of England resulting in approximately 20 referrals a day.

OBJECTIVE

A telemedicine system was developed to improve trauma management. This study was designed to establish whether digital images were sufficiently accurate enough to aid decision-making. A store-and-forward telemedicine system was devised and the images of 150 trauma referrals evaluated in terms of injury severity and operative priority by each member of the plastic surgical team.

RESULTS

Correlation scores for assessed images were high. Accuracy of "transmitted image" in comparison to injury on examination scored > 97%. Operative priority scores tended to be higher than injury severity.

CONCLUSIONS

Telemedicine is an accurate method by which to transfer information on plastic surgical trauma including burns.

Sprouting and synaptic reorganization in the subiculum and CA1 region of the hippocampus in acute and chronic models of partial-onset epilepsy

Repeated seizures induce permanent alterations in the hippocampal circuitry in experimental models and patients with intractable temporal lobe epilepsy (TLE). Most studies have concentrated their attention on seizure-induced reorganization of the mossy fiber pathway. The present study examined the projection pathway of the CA1 pyramidal neurons to the subiculum, which is the output of the hippocampal formation in five models of TLE. We examined the laminar pattern of Timm's histochemistry in the stratum lacunosum-moleculare of CA1 in three acute and two chronic models of TLE: intraventricular kainic acid (KA), systemic KA, systemic pilocarpine, chronic electric kindling and chronic i.p. pentylenetetrazol. The laminar pattern of Timm histochemistry in the stratum moleculare of CA1 was permanently remodeled in epileptic models suggesting sprouting of Timm containing terminals from the adjacent stratum lacunosum. Ultrastructural examination confirmed that Timm granules were localized in synaptic terminals. As the source of Timm-labeled terminals in this region was not known, sodium selenite, a selective retrograde tracer for zinc-containing terminals, was iontophoretically injected in vivo in rats exposed to systemic pilocarpine, systemic KA or chronic pentylenetetrazol. The normal projection of CA1 pyramidal neurons to the subiculum is topographically organized in a lamellar fashion. In normal rats, the extent of the injection site (terminals) and the retrogradely labeled pyramidal neurons (cell soma) corresponded to the same number of lamellas. In epileptic rats, the retrograde labeling extended 42-67% farther than the normal dorso-ventral extent including lamellas above and below the expected. This is direct evidence for sprouting of CA1 pyramidal axons into the subiculum and stratum lacunosum-moleculare of the CA1 region confirming the alterations of the laminar pattern of Timm's histochemistry. Sprouting of the CA1 projection to subiculum across hippocampal lamellas might lead to translamellar hyperexcitability, and to amplification and synchronization of epileptic discharges in the output gate of the hippocampal formation.

Protective efficacy of a fully recombinant plague vaccine in the guinea pig

A fully recombinant sub-unit vaccine comprising the protein antigens rF1 + rV has been demonstrated to protect immunised guinea pigs against exposure to 10(5) colony-forming units (CFU) of virulent Yersinia pestis. Additionally, IgG purified from rF1 + rV-immunised guinea pig serum, protected the mouse by passive immunisation against challenge with Y. pestis whereas IgG purified from the serum of guinea pigs immunised with a licensed killed whole cell (KWC) vaccine for plague, protected less well. Guinea pigs immunised with the licensed killed whole cell vaccine developed an IgG titre for fraction 1 (F1) but not for V antigen. The differential in protection conferred on the mouse by passive immunisation with guinea pig IgG, was abrogated by the use of IgG purified from guinea pigs immunised with killed whole cell vaccine supplemented with V antigen. These findings indicate that the reduced efficacy of the licensed killed whole cell vaccine formulation previously observed in the mouse can be attributed to lack of the V antigen. Cross-protection of the mouse with guinea pig IgG suggests that the recognition of neutralising epitopes in the F1 and V proteins is conserved between these two species.

Progression of peripheral joint disease in psoriatic arthritis: a 5-yr prospective study

OBJECTIVE

To assess the evolution of disease subgroups and the frequency of progression of peripheral joint disease in a prospectively studied cohort of patients with psoriatic arthritis (PsA).

METHODS

The cohort was identified as the first consecutive 100 patients attending a psoriatic arthritis clinic and who had been the subject of a previously published cross-sectional retrospective study. Nine of the 100 patients had died, three declined follow-up and one could not be traced. The remaining 87 patients (49 females, 38 males) completed the study proforma at a median follow-up interval of 65 months (range 39-90). An analysis of initial plasma viscosity compared with rates of progression of joint score was performed.

RESULTS

Eighteen patients changed subgroup; 11 had an increase in the number of joints involved, six a decrease, and one changed from an oligoarticular pattern to predominant spondylitis. Within the polyarticular group 37/51 patients had an increase in the number of joints involved. For the whole population, there were significant increases in the number of joints involved (median 6 vs 11, P < 0.001 Wilcoxon signed rank) and Health Assessment Questionnaire scores (median 0.375 vs 0.5, P < 0.001). The median rate of joint progression was 0.42 peripheral joints per year (range 0-7.2). However, the rate of peripheral joint involvement was highest in the first year of arthritis (median 4.0 joints/yr) as measured in 13 patients who had onset within 12 months of baseline assessment. There were no significant differences in skin and nail scores although nine more patients had developed nail disease. There was a significant correlation between the initial viscosity and rate of progression of joint damage (Spearman correlation, P < 0.011).

CONCLUSIONS

Peripheral joint disease is progressive in the majority of patients with PsA and reinforces the need for effective monitoring and treatment.

Delayed ovulation and parturition in a viviparous alpine lizard (Niveoscincus microlepidotus): morphological data and plasma steroid concentrations

The southern snow skink, Niveoscincus microlepidotus, exhibits an unusual biennial reproductive cycle with an extended gestation period of approximately 1 year. Morphological data were gathered on a monthly basis, providing a detailed picture of the reproductive cycle. Vitellogenesis begins in spring, immediately after parturition. Maximum follicular diameter is reached before the winter hibernation period and ovulation occurs the following spring. Embryos are fully developed and reach maximum size by early autumn. Yolk reserves are depleted before winter. Birth of between one and four young occurs the following spring. Plasma progesterone concentrations are low (2.7 +/- 0.9 ng mL(-1)) in post-partum females, begin to rise in autumn in vitellogenic females and peak (38.5 +/- 7.9 ng mL(-1)) in pre-ovulatory females after hibernation. Concentrations are high (15.4 +/- 5.9 ng mL(-1)) in early pregnancy and decline to basal levels before winter and well before birth in spring. Plasma oestradiol concentrations peak during vitellogenesis (1.0 +/- 0.3 ng mL(-1)) and decline to basal levels during pregnancy (0.2 +/- 0.03 ng mL(-1)). A second oestradiol peak occurs before parturition (0.7 +/- 0.2 ng mL(-1)). Thus, functional completion of vitellogenesis and gestation is achieved by autumn in successive years. The mechanisms that defer ovulation and parturition by a further six months are unknown.

Passive protection against Burkholderia pseudomallei infection in mice by monoclonal antibodies against capsular polysaccharide, lipopolysaccharide or proteins

Burkholderia pseudomallei, the aetiological agent of melioidosis, is endemic in south-east Asia and northern Australia, where it is an important cause of human disease. There is no vaccine available and antibiotic therapy is associated with high relapse rates. A panel of seven monoclonal antibodies (MAbs) that recognise capsular polysaccharide, lipopolysaccharide or proteins was produced and their ability to protect mice passively against experimental melioidosis was evaluated. The MAbs were capable of protecting mice against intra-peritoneal challenge with 10(4) cfu/250 MLD of a virulent strain of B. pseudomallei (NCTC 4845), when pooled, and four of the MAbs were individually protective. However, at a higher B. pseudomallei challenge level of 10(6) cfu none of the MAbs afforded protection and only the anti-exopolysaccharide MAbs produced a significantly delayed time to death.