Negative Predictive Value of Circulating Tumor Tissue Modified Viral (TTMV)-HPV DNA for HPV-driven Oropharyngeal Cancer Surveillance

PURPOSE

Human papillomavirus (HPV) is causally linked to oropharyngeal squamous cell carcinoma (OPSCC). Consensus guidelines recommend clinical exams and imaging in decreasing frequency as part of posttreatment surveillance for recurrence. Plasma tumor tissue modified viral (TTMV)-HPV DNA testing has emerged as a biomarker which can inform disease status during surveillance.

EXPERIMENTAL DESIGN

This retrospective observational cohort study involved 543 patients who completed curative-intent therapy for HPV-associated OPSCC between February 2020 and January 2022 at eight U.S. cancer care institutions. We determined the negative predictive value (NPV) of TTMV-HPV DNA for recurrence when matched to physician-reported clinical outcome data (median follow-up time: 27.9 months; range: 4.5-154).

RESULTS

The cohort included mostly men with a median age of 61 who had locoregionally advanced disease. HPV status was determined by p16 positivity in 87% of patients, with a positive HPV PCR/ISH among 55%; while pretreatment TTMV-HPV DNA status was unknown for most (79%) patients. Patients had a mean of 2.6 tests and almost half had three or more TTMV-HPV DNA results during surveillance. The per-test and per-patient sensitivity of the assay was 92.5% [95% confidence interval (CI): 87.5-97.5] and 87.3% (95% CI: 79.1-95.5), respectively. The NPV for the assay was 99.4% (95% CI: 98.9-99.8) and 98.4% (95% CI: 97.3-99.5), respectively.

CONCLUSIONS

TTMV-HPV DNA surveillance testing yields few false negative results and few missed recurrences. These data could inform decisions on when to pursue reimaging following first disease restaging and could inform future surveillance practice. Additional study of how pretreatment TTMV-HPV DNA status impacts sensitivity for recurrence is needed.

Acceptability, feasibility and cost of point of care testing for sexually transmitted infections among South African adolescents where syndromic management is standard of care

BACKGROUND

Young people (YP) in southern Africa are at substantial risk of HIV and sexually transmitted infections (STIs). Despite the epidemiological and biological link between STIs and HIV transmission and acquisition, infections such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) remain widely undiagnosed. Syndromic STI management is the standard of care in low- and middle-income countries (LMICs) despite a high prevalence of asymptomatic infections. We conducted an observational study to explore the acceptability, feasibility, and cost of a STI test-and-treat service for YP in Cape Town.

METHODS

YP attending a mobile clinic (MC) and a youth centre clinic (YC) were offered STI screening. Urine testing for CT and NG using a 90-min molecular point-of-care (POC) test on the GeneXpert platform was conducted and treatment provided. Data were collated on demographics, sexual behaviour, presence of symptoms, uptake of same-day treatment, prevalence of CT/NG, and service acceptability.

RESULTS

Three hundred sixty six participants were enrolled (median age 20, 83% female).57% (209/366) of participants tested positive for either CT (126/366, 34%) or NG (57/366, 16%) or co-infection (26/366, 7%). Clinical symptoms were a poor predictor of GeneXpert diagnosed CT or NG, with a sensitivity of 46.8% and 54.0% for CT and NG respectively. Although half of participants initially chose to receive same day results and treatment, only a third waited for results on the day. The majority of participants (91%) rated the service highly via a post-visit acceptability questionnaire.

CONCLUSION

Curable STIs are highly prevalent in this population. STI screening using POC testing was feasible and acceptability was high. The study provides further impetus for moving policy beyond syndromic management of STIs in South Africa.

The path to function: using eye-tracking in a real-world task to understand the performance gap for people with severe mental illness

Introduction

Individuals with severe mental illnesses (SMI) often present the knowledge about a task but in real-time do not perform it fully, or not as efficient as planned. This performance gap may be explained by difficulties with Executive Functions (EF).

Objectives

The aim of the presentation is to describe how people with and without SMI experience and perform grocery task. This, with considering this path from several directions including the subjects’ point of view using eye-tracking device during task performance.

Methods

Forty-three individuals had answered questions in regards to their shopping habits and performed the Test of Grocery Shopping Skills (TOGSS). The actual performance was accompanied by wearing an eye-tracking device which recorded the behavior and eye movement. We hypothesized that significant differences will be found between people with SMI and controls both in the routine grocery habits and in observed performance.

Results

No significant differences in age or gender. The groups differed significantly only in education, with the SMI group having fewer years of education. As a weekly routine, SMI subjects perform less frequent shopping (40%) than control group subjects (67%). TOGSS sub-outcomes indicated performance efficiency (time and redundancy) were significantly higher in the research group than in the matched control group (p <.01), with the SMI group spending a longer time performing the task and entering more aisles than required – redundancy.

Conclusions

These preliminary findings indicate that individuals with SMI spend more time dwelling while selecting ingredients. Besides the path in the supermarket, it might explain their performance in other everyday activities.

Disclosure

No significant relationships.

With both eyes open – translational research using eye-tracking combined with performance-based evaluation among people with severe mental illness

Introduction

Individuals with severe mental illnesses (SMI) often find it hard to perform daily activities such as grocery shopping, which require intact executive functions. The use of performance-based evaluations is valuable, but lacks the subjects’ point of view during task performance.

Objectives

The aim of the current presentation is to bring together performance-based observation and cognitive science methods to provide insights regarding real-life behavior and problem solving in SMI populations.

Methods

In this quasi-experimental study, forty-three individuals performed the Test of Grocery Shopping Skills (TOGSS) while wearing an eye-tracking device. Eye-movement patterns served as a proxy of executive functions in people with and without SMI during a real-life ingredient selection task. We hypothesized that significant differences will be found between people with SMI and controls in TOGSS sub-outcomes as well as in eye-fixation durations.

Results

TOGSS sub-outcomes indicative of performance efficiency (time and redundancy) were significantly higher in the research group compared to matched controls (P<0.01). Average fixation duration was found to be significantly higher for the research group compared to matched controls (P<0.05) for two of the four item-selection tasks.

Conclusions

These preliminary findings indicate that when confronted with a selection task, individuals with SMI spend more dwelling time while selecting ingredients. Further analyses on these data will examine how this time is spent (e.g. focusing on irrelevant information). The outlined approach may prove beneficial in illuminating specific behavioral and physiological difficulties in individuals with SMI, particularly in the evolving Covid-19 situation, which poses novel social and health-related challenges on real-life tasks.

Disclosure

No significant relationships.

Tildrakizumab efficacy and impact on quality of life up to 52 weeks in patients with moderate-to-severe psoriasis: a pooled analysis of two randomized controlled trials

BACKGROUND

Two randomized controlled trials (reSURFACE 1 and 2) have demonstrated the effectiveness of tildrakizumab, a high-affinity, humanized, IgG1κ, anti-interleukin-23 monoclonal antibody, for treating moderate-to-severe plaque psoriasis in the first 28 weeks.

OBJECTIVES

To examine the efficacy of tildrakizumab and its impact on quality of life (QoL) in patients with different levels of week-28 Psoriasis Area and Severity Index (PASI) improvement.

METHODS

Patients treated with tildrakizumab 100 mg or 200 mg from baseline to week 28 were pooled from reSURFACE 1 and reSURFACE 2 and classified into five mutually exclusive week-28 PASI improvement groups for each dose: PASI 0-49, 50-74, 75-89, 90-99 and 100. Mean PASI improvement and Dermatology Life Quality Index (DLQI) 0/1 over time were examined for each group.

RESULTS

Of 1156 patients, 575 were in the 100-mg and 578 in the 200-mg cohorts, respectively. At week 28, 8.3%, 14.3%, 23.8%, 30.4% and 23.1% in the 100-mg and 4.0%, 18.1%, 19.6%, 29.1% and 29.3% in the 200-mg cohort achieved PASI < 50, 50-74, 75-89, 90-99 and 100, respectively. Patients with PASI < 50 at week 28 could be identified as early as week 8, and those with week-28 PASI ≥ 90 had approximately 50% PASI improvement by week 4. Among patients achieving PASI > 50 at week 28 who continued the same dose of tildrakizumab to week 52, mean PASI improvement was maintained or improved over time. Similar results were observed for both doses. Higher proportions of patients achieved DLQI 0/1 in higher week-28 PASI groups, and DLQI 0/1 was maintained or improved to week 52. However, not all patients with PASI 100 had DLQI 0/1.

CONCLUSION

Patients unlikely to respond to tildrakizumab could be identified by week 8, and those likely to achieve a PASI ≥ 90 response could be identified as early as week 4. Week-28 PASI improvement level correlated with QoL improvement.

Transoral Robotic Surgery Total Laryngectomy

OBJECTIVE

The aim of our study is to demonstrate our technique for performing transoral robotic surgical total laryngectomy (TORS-TL) with the use of the da Vinci robotic system.

MATERIALS AND METHODS

We provide a comprehensive description of the TORS-TL operative techniques. Two fresh-frozen human cadavers were selected after ethics approval to describe the appropriate step-by-step surgical resection. We adopted a 5-step procedure that was later applied to 2 of our patients. The first patient presented initially with a squamous cell carcinoma (SCC) in the laryngeal glottis area. A lack of clinical response to initial treatment by chemoradiotherapy led to the decision of performing salvage TL surgery. The second patient had a previous history of head and neck SCC (HNSCC); he had no recurrence of his primary tumor but suffered significantly from postoperative breathing and swallowing difficulties due to severe laryngeal incompetence.

RESULTS

TORS-TL was successfully performed in all cases. The operative time for the cadavers was approximately 65 and 55 min, respectively. It was significantly longer for the patients, 210 and 235 min, respectively, despite the fact that exactly the same steps were followed throughout all procedures. There were no intra- or postoperative complications or surgical morbidity related to the use of the da Vinci system.

CONCLUSION

TORS-SL for SCC was performed in a safe, reliable, and smooth manner and was shown to be successful in treating our patients. We thus believe that our step-by-step surgical technique for TORS-SL is efficient and reproducible.

Acute vocal fold dystonic reaction to propofol: a case report

A 67-year old male underwent uneventful robotic-assisted thoracoscopic resection of a solitary pulmonary fibrous tumor. Immediately following extubation at the completion of the surgical procedure, the patient developed respiratory distress that did not resolve with treatment. Benadryl provided only temporary relief. Midazolam and hydromorphone were given for anxiolysis and analgesia respectively, which provided transient relief of symptoms. Propofol was given to decrease upper airway reflexes. Adequate reversal from nondepolarizing neuromuscular blockade was confirmed with nerve stimulator. A flexible laryngoscope was introduced nasally to visualize the vocal cords, which revealed intermittent tremulousness of the vocal cords, adduction of bilateral vocal cords to the midline, and minimal to absent opening with inspiration, without any apparent injury or blood, saliva, or vomit noted in or around the glottic opening. The patient was then given diazepam and reintubated. Given the patient's history of difficulty breathing after previous surgery and the lack of vocal cord movement, dystonic reaction to propofol was suspected. The patient remained intubated for two hours in the post-anesthesia care unit before being extubated uneventfully.

Acoustic Effects of Asymmetric Laryngeal Activation

Objective: Symmetric activation of laryngeal intrinsic musculature is considered essential for optimal voice production. However, phonatory consequences of asymmetric laryngeal activation are poorly understood. The objective of this study was to investigate the phonatory characteristics of an asymmetrically activated larynx.

Methods: Bilateral recurrent laryngeal nerves (RLNs) were stimulated in a graded fashion (from threshold to maximal activation) in a canine phonation model. 121 combinations of left-right RLN activation states (spanning symmetric and asymmetric activation states) were analyzed for phonatory instabilities (number of bifurcations) in the 1.5s acoustic signal after neuromuscular activation.

Results: Asymmetric laryngeal activation produced frequent phonatory instabilities. Highest levels of instabilities were seen during phonation at extreme asymmetric conditions and asymmetries during near-maximum RLN stimulation. Linear regression models demonstrated significant association ( P < .01) between percent of RLN stimulation and acoustic/aerodynamic measures. Phonation onset time (ms) (Left RLN: Coef = 1.44, CI = 1.01-1.86; Right RLN: Coef = 2.71, CI = 2.29-3.13) and subglottic pressure (kPa) (Left RLN: Coef = 0.01, CI = 0.011-0.014; Right RLN: Coef = 0.01, CI = 0.009-0.013) increased with increasing RLN stimulation. Subglottic airflow (l/min) (Left RLN: Coef = −0.29, CI = −0.36-0.20; Right RLN: Coef = −0.29, CI = −0.37-0.21) and fundamental frequency (Hz) (Left RLN: Coef = −0.59, CI = −0.76-0.42; Right RLN: Coef = −0.24, CI = −0.41-0.07) decreased with increasing RLN stimulation.

Conclusion: Higher levels of asymmetric laryngeal activation are associated with increasing phonatory instabilities. These results can be applied to further characterize asymmetric laryngeal states that lead to vocal irregulaties.

Clinical Thermal Effects of Flexible Fiber CO2 Laser

Objective: To date no clinical investigations have reported on the coagulation effects of flexible fiber CO2 laser delivery to head and neck tissue, the results of which have a direct impact for the progression of transoral laser microsurgery. The objective of the present study was to investigate the histopathologic thermal effects of a flexible fiber CO2 laser delivery system.

Method: A prospective histopathologic analysis of 15 consecutive transoral laser microsurgery specimens using the same CO2 fiber system were subjected to dedicated histopathologic analyses. Repeated coagulation depth measurements of 2 independent clinical pathologists were averaged. Specimens were stratified into lymphoid or epitheloid groups for further comparison.

Results: The mean coagulation depth across all specimens was 81.53 um (SD, 38.73; range, 15.00-360.34). Although the mean coagulation depth in lymphoid tissues (mean, 75.38 um; SD, 15.91) was elevated over the mean depth of epitheloid tissues (mean, 90.74 um; SD, 31.21), there was no significant difference ( P = .11).

Conclusion: With an average coagulation depth of 81.53 um the flexible fiber thermal effect compares favorably to tissue effect of line-of-sight lasers. Epitheloid and lymphoid tissues displayed equivalent coagulative effects. To our knowledge, this is the first clinical description of flexible CO2 laser delivery thermal effects of tissues of the head and neck.

S230 – MRI Findings in Delayed Facial Palsy after Stapedectomy

Objectives

1) To retrospectively review the pathophysiology and radiologic features of delayed facial palsy after stapedectomy. 2) To discuss the management strategy of this unusual problem.

Methods

450 stapedectomies performed at our institution were retrospectively reviewed from 1997 to 2007. A total of 2 patients in this series developed a delayed facial paralysis postoperatively. The clinical presentation, radiographic characteristics on magnetic resonance imaging (MRI), and the management of these patients are presented.

Results

A total of 2 patients out of 450 stapedectomies within a 10-year period developed the rare complication of delayed facial paralysis (postoperative days 12 and 41, respectively). Both patients developed rapidly progressive complete facial nerve paralysis preceded by periauricular pain and dysguesia. No sign of infection was present in the operated ear. MRI with gadolinium of the internal auditory canal demonstrated gadolinium enhancement of the labyrinthine portion of the facial nerve as seen in Bell's palsy. Both patients were treated with oral corticosteroids and antiviral medications. Subsequent imaging revealed decreased enhancement of the facial nerve with complete resolution of facial paralysis.

Conclusions

In the rare complication of delayed facial paralysis after stapedectomy, MR imaging is a useful diagnostic tool to dictate the treatment strategy. Delayed facial paralysis following stapedectomy can be treated medically when the MRI scan demonstrates enhancement of the facial nerve in the labyrinthine segment.

S143 – Benign and Malignant Lipogenic Tumors of the Retropharynx

Objectives

Lipogenic tumors of the retropharyngeal space are neoplasms that can grow to a considerable size before becoming symptomatic. In this study we compare clinical, radiologic, and histologic findings of benign versus malignant lipogenic tumors of the retropharyngeal space.

Methods

Retrospective review of a case series.

Results

2 patients were identified with large lipogenic tumors of the retropharynx. The first patient was 66-year-old female with a 6-week history of progressive airway difficulty and dysphagia requiring tracheostomy and gastrostomy-tube placement. Preoperative imaging revealed a lipoma of the retropharynx. A transcervical excision of her retropharyngeal mass revealed a 10⋉9⋉4.8 cm lipoma. The second patient was a 57-year-old female with a 4-week history of progressive left neck swelling, airway compromise, and odynophagia. Preoperative imaging revealed a heterogeneous mass in the retropharynx with fatty and solid components. After an initial awake tracheostomy a transcervical excision of a 15⋉5.5⋉4.0 cm mass was performed. Pathology revealed liposarcoma with scattered dedifferentiated regions. Postoperative radiation therapy was given for focally positive surgical margins. Both patients are recurrence-free at 36 months follow-up.

Conclusions

Although lipogenic tumors of the retropharyngeal space are rare these cases illustrate that they present at advanced stages, often requiring tracheostomy for airway control. The clinical course of lipomas and liposarcomas can be similar. However, careful inspection of preoperative imaging will heighten suspicion for malignancy, which is critical in surgical planning.

Measurement of leisure time satisfaction in family caregivers

Caregiving is known to limit participation in a variety of roles. Leisure roles are increasingly recognized as important for the well-being of older adults. Little is known, however, about the impact of caregiving on leisure activities, and existing measures are of limited utility in caregiving research. We developed the Leisure Time Satisfaction (LTS) measure to allow further study of the impact of caregiving on caregivers' leisure time satisfaction, the role of leisure in understanding the caregiving process, and whether caregiving interventions improve leisure time satisfaction. The six-item LTS measure shows excellent psychometric properties, including internal consistency, a single factor structure, and convergent validity. Psychometric features are robust across diverse groups of caregivers, including subgroups varying by race/ethnicity and relationship to the care recipient. The LTS measure appears to be a promising tool for inclusion in caregiving research.

Involvement of tumor necrosis factor alpha in hippocampal development and function

Tumor necrosis factor alpha (TNFalpha) is a cytokine produced mainly by cells of the immune system. It is also expressed by brain neurons and glia. The physiological role of TNFalpha in the brain is not yet fully clear. Using TNFalpha-deficient mice, we have examined its role in hippocampal development and function. We report here that TNFalpha is involved in the regulation of morphological development in the hippocampus. TNFalpha-deficient mice exhibited an accelerated maturation of the dentate gyrus region and smaller dendritic trees in CA1 and CA3 regions in young mouse. In addition to its involvement in hippocampal morphogenesis, TNFalpha deficiency specifically improved performance of affected mice in behavioral tasks related to spatial memory. Moreover, lack of TNFalpha increased the expression of nerve growth factor (NGF), but not brain-derived neurotrophic factor (BDNF), following performance of the learning task. Our results suggest that TNFalpha actively influences hippocampal development and function. In adult mice, TNFalpha may interfere with memory consolidation, perhaps by regulating NGF levels.

Double-chambered right ventricle in an adult patient

A 65-year-old male was referred for to our facility for right and left heart catheterization and coronary angiography for evaluation of a ventricular septal defect and to rule out significant coronary artery disease. During the procedure, the patient was diagnosed with a double-chambered right ventricle (DCRV). Most DCRV cases are diagnosed at a young age; presentation in an adult is extremely rare.

A follow-up comparison of study participants and refusers within a rural elderly population

BACKGROUND

Survey rates are known to decline with age. Survey results can be affected by response bias if nonresponders are more, or less, likely than participants to suffer from the condition being studied. For instance, it is possible that older adults with dementia would be less likely to participate in a study of dementing disorders.

METHODS

A random sample of a rural U.S. population aged 65+ years yielded 1,422 participants and 912 refusers in addition to others who were ineligible, inaccessible, or untestable. Participants and refusers were compared on age, sex, 5-year mortality, and causes of death suggestive of dementia as listed on death certificates.

RESULTS

Compared to participants, refusers were significantly older and more likely to be women, with mortality similar to that of participants at approximately 5-year follow-up. Death certificate data revealed no significant differences in reported causes of death indicating or suggesting dementia.

CONCLUSIONS

In this population, those who refused to participate in a dementia survey were not more likely to be ill or demented than those who did participate.

Antidepressant use over time in a rural older adult population: the MoVIES Project

OBJECTIVE

To examine the use of antidepressant drugs over time among community-based older persons.

DESIGN

A longitudinal community study with four approximately biennial data collection waves (1987-1996).

SETTING

A low-socioeconomic status rural older community-based population in Southwestern Pennsylvania.

PARTICIPANTS

A total of 1681 individuals with a mean age of 72.9 years at study entry,

MEASUREMENTS

Antidepressant drug use, demographics, and health services utilization by self-report.

RESULTS

Antidepressant use was reported by less than 5% of the population during all four waves. It was associated with female gender, use of mental health services, presence of five or more depressive symptoms, and use of five or more prescription drugs, but not with age. During the four waves, tricyclics accounted for 84.6%, 85.3%, 78.4%, and 45.5% of total antidepressants used, whereas selective serotonin reuptake inhibitors (SSRIs) accounted for 2.6%, 11.8%, 8.1%, and 36.4%.

CONCLUSIONS

Overall, our data on antidepressant use in this rural older population mirror national trends away from tricyclics and towards SSRIs. Our findings also suggest underutilization of mental health services and antidepressant drugs in this population.

Natural history of isolated atrial flutter in infancy

To clarify the natural history of isolated (i.e., without associated congenital cardiac anomalies) atrial flutter in infancy, we reviewed the clinical course in nine patients who were seen with this arrhythmia in the first year of life (range 1 day to 4 months). Atrial flutter was identified by the typical sawtooth pattern in leads II, III, and aVF of the surface electrocardiogram or the pattern of atrial flutter on an atrial electrogram recorded through the esophagus. The mean cycle length of the atrial flutter was 151 msec (atrial rate 397 beats/min). Six of the nine patients had other perinatal problems, such as immune and nonimmune hydrops fetalis (two patients), pneumonia (one patient), anemia (five patients), or low birth weight (one patient). In all patients the rhythm reverted to normal, either spontaneously (two patients), with overdrive pacing (four patients), or after oral digoxin therapy (three patients). No consistent temporal relationship between digoxin administration and conversion was observed; conversion was instantaneous in the four patients who received atrial overdrive pacing. Four patients were discharged receiving digoxin therapy (6 months to 1 year). One patient had supraventricular tachycardia after discharge that was controlled with digoxin. No recurrence of atrial flutter was observed among the nine patients during a mean follow-up of 6.8 years (range 0.2 to 20 years). We conclude that isolated atrial flutter in infancy is rare, has a good prognosis, may be related to transient perinatal events, and often spontaneously converts to normal sinus rhythm; however, when it does not, it will respond to transesophageal pacing. Acute and chronic digoxin therapy is probably unnecessary.

Reversible suppression of c-myc expression in a human colon carcinoma line by the anticancer agent N-methylformamide

The anticancer agent N-methylformamide (NMF), which at high concentrations (170 mM) induces cultured DLD-1 Clone A human colon carcinoma cells to increase their doubling times and lose their tumorigenicity in nude mice (Cordeiro, R.F., and Savarese, T.M. Cancer Res., 46: 1297-1305, 1986), suppresses the expression of the c-myc protooncogene in these cells in a dose- and time-dependent manner. This suppression involves an inhibition of c-myc transcription rather than an increased degradation of c-myc mRNA, and is reversed if NMF is removed from the culture medium. Expression of the glyceraldehyde 3-phosphate dehydrogenase gene, which is thought to be constitutive, is phosphate dehydrogenase gene, which is thought to be constitutive, is relatively unaffected by NMF treatment. The NMF-mediated decrease in c-myc expression may be associated with the ability of this agent to increase the doubling time of these cells, but there is no direct temporal link between the loss of c-myc expression and the NMF-induced loss of tumorigenicity.

Pathogenesis of experimental lipid keratopathy. An ultrastructural study of an animal model system

The histology and ultrastructure of experimental lipid keratopathy were studied in hypercholesterolemic rabbits in which the insertion of corneal sutures induced vascularization and subsequent lipid deposition in the anterior stroma. Lipid accumulated in the keratocytes, the pericytes and occasionally in the endothelial cells of the capillaries. The lipid-laden keratocytes were concentrated in the region of the capillaries. No lipid was seen in the control rabbits. In the hypercholesterolemic rabbit with sutures, intracellular lipid in the keratocytes was present largely in nonmembrane-limited droplets with smaller amounts of membrane-limited cholesterol crystals and rare numbers of myelin figures. In addition, large, lipid-engorged spherical cells were present. The numerous phagolysosomes seen ultrastructurally suggest that some of these cells probably represent macrophages. Keratocytes and the large, spherical lipid-engorged cells show focal degenerative changes, including pyknotic nuclei, cytoplasmic coagulation and membrane loss, leaving extracellular mixed accumulations of lipid and cytoplasmic organelles. Small numbers of lymphocytes and plasmacytoid cells were present. No corneal lipid was seen in animals with normocholesterolemia, with or without sutures. In hypercholesterolemic animals, a few lipid-laden keratocytes without macrophages were identified even in the absence of vessels. These morphologic studies support the hypothesis that the accumulation of the corneal lipid in this animal model of lipid keratopathy is the result of increased lysosomal uptake of lipid, probably as low density lipoprotein, from the extracellular space by the keratocytes. The rate of metabolism of this lipid is insufficient to clear the cells of the lipid and the subsequent lipid inspissation results in keratocyte death, leading to macrophage accumulation of lipid and free lipid in the stroma.

Branhamella catarrhalis keratitis

Branhamella catarrhalis, formerly known as Neisseria catarrhalis, has structural similarities to Neisseria gonorrhoeae, but is generally considered to be nonpathogenic. We studied the clinical and laboratory data of four previously reported cases and six additional cases of B. catarrhalis keratitis. All patients had a predisposing ocular or systemic condition, or both. There were various clinical characteristics, but in most cases the infiltrate occurred in the central or paracentral cornea. A prompt response to treatment with a cephalosporin and aminoglycoside antibiotic was noted in all cases. Two patients had corneal perforations, which probably resulted from a delay in treatment. Gram-negative diplococci from corneal scrapings may not necessarily represent N. gonorrhoeae.

Corneal ulcer due to Listeria monocytogenes

We present a patient with a corneal ulcer due to Listeria monocytogenes, which has not previously been considered to be a feature of human listeriosis. The ulcer responded to topical and subconjunctival gentamicin and cephaloridine. Subsequent management was complicated by the development of a fibrinous pupillary membrane leading to pupillary block requiring iridotomy and later vitrectomy with trabeculectomy. Listeria monocytogenes may be confused with diphtheroid contaminants seen in corneal ulcer scrapings and is probably underreported as a cause for microbial keratitis.

Surgical results for mitral regurgitation from coronary artery disease

Results of coronary artery bypass grafting with and without mitral valve replacement were analyzed retrospectively in 101 patients with preoperative ischemic mitral regurgitation to determine the effects of severity and surgical treatment of mitral regurgitation on survival. Between 1980 and 1984, a total of 1,475 patients (mean age 59, 77% male) underwent coronary bypass. These patients were divided into three groups: (1) patients without ischemic mitral regurgitation who underwent isolated coronary bypass (1,374; 93%), (2) patients with ischemic mitral regurgitation who underwent isolated coronary bypass without valve replacement (85; 6%), and (3) patients with ischemic mitral regurgitation who underwent combined mitral valve replacement and coronary bypass (16; 1%). Preoperatively, patients with ischemic mitral regurgitation compared to those without regurgitation were significantly older (+6 years, p less than 0.001), had more severe coronary artery disease (p less than 0.001), a higher incidence of congestive heart failure (24% versus 5%, p less than 0.001) and recent myocardial infarction (16% versus 8%, p less than 0.01), and a lower mean ejection fraction (45% versus 61%, p less than 0.001). Operative mortality was significantly increased in patients with ischemic mitral regurgitation who underwent coronary bypass alone (p less than 0.01) and in those who underwent coronary bypass and mitral valve replacement (p less than 0.01)--11% and 19%, respectively--than in the coronary bypass patients without ischemic mitral regurgitation (3.7%). The severity of mitral regurgitation (0 to 4+) proved to be the most significant predictor of operative mortality. The actuarial survival rate at 5 years for the coronary bypass patients without ischemic mitral regurgitation was 85% compared to 91% (p less than 0.05) for the coronary bypass patients without ischemic mitral regurgitation. These results indicate that patients with ischemic mitral regurgitation have a higher prevalence of cardiac risk factors and are at an increased risk of operative mortality. Although the severity of the ischemic mitral regurgitation was strongly predictive of early survival, it proved to have an unexpectedly modest effect on long-term survival after surgical treatment.

Early open radical commissurotomy: surgical treatment of choice for mitral stenosis

Between 1967 and 1979, 411 patients underwent surgical treatment of isolated mitral stenosis at our institution. Open radical mitral commissurotomy was performed in 150 patients (1967-1978; mean follow-up, 46 months; range, 4 to 116 months). Mitral valve replacement using a porcine prosthesis was performed in 74 patients (1976-1979; mean follow-up, 23 months; range, 2 to 48 months). Mitral valve replacement with a cloth-covered Starr-Edwards prosthesis was performed in 187 patients (1967-1975; mean follow-up, 45 months; range, 2 to 106 months). Preoperative characteristics were similar in the three groups. The open commissurotomy and Starr-Edwards groups were followed up to 9 years and the porcine valve group up to 4 years, with 97% follow-up in each group. Life-table analysis (6-month intervals) of all postoperative complications revealed significantly greater complication-free survival for patients who had open radical commissurotomy compared with Starr-Edwards (p less than 0.05) valve replacement. Similar analysis of thromboembolic and warfarin-related complications revealed significantly fewer complications in commissurotomy patients. No significant differences were found (p greater than 0.05) when comparing the need for subsequent reoperation in each group. Operative mortality following open radical mitral commissurotomy (0%; 0 out of 150) was significantly less (p less than 0.05) than after mitral valve replacement in both porcine (8.1%; 6 out of 74) and Starr-Edwards (11.2%; 21 out out 187) groups. Life-table analysis of late cardiac-related mortality revealed a significantly greater cumulative survival rate for the commissurotomy versus the Starr-Edwards groups at all intervals from 12 to 108 months (100 versus 84 +/- 5%, p less than 0.05). No significant differences were noted between commissurotomy and porcine valve groups during the 4-year follow-up period (100 +/- 0% versus 96 +/- 3%, p greater than 0.05). Based on these findings, we conclude that when the anatomy is favorable, the surgical treatment of choice for isolated mitral stenosis is open radical mitral commissurotomy.