BILATERAL EYE PATCHING MAY IMPROVE CLINICAL OUTCOMES FOR ACUTE PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

Evaluate preoperative bilateral eye patching (BEP) on subretinal fluid and vision in acute primary rhegmatogenous retinal detachments (RRDs).

METHODS

Retrospective nonrandomized interventional study of 335 patients with RRD undergoing BEP until surgery (BEP cohort) and separated by the percentage of full-time compliance: high (≥90%), medium (>90% but ≥50%), and low (<50%). Those declining BEP were included (control). All underwent surgery and were followed for ≥3 months. Imaging was obtained immediately before surgery. Best-corrected visual acuity was measured at the longest follow-up and immediately before surgery. SRF and foveal status immediately before surgery were analyzed.

RESULTS

Two hundred and forty and 95 patients were in BEP and control cohorts, respectively. Thirty patients presented immediately before surgery for analysis. High (64%) and medium (35%) compliance showed significantly greater ( P < 0.01) SRF reduction compared with low (4%) and control (3%). Mac-off RRD showed significantly greater ( P < 0.01) foveal reattachment with high (29%) and medium (8%) compliance compared with low (2%) and control (1%). Mac-on RRD demonstrated no significant differences ( P ≥ 0.51) in final best-corrected visual acuity among high (0 logarithm of the minimum angle of resolution [logMAR] [median], 20/20 Snellen), medium (0.10 logMAR, 20/25 Snellen), low (0.10 logMAR), and control cohorts (0.10 logMAR). Mac-off RRD demonstrated significantly better final best-corrected visual acuity with high compliance (0.30 logMAR, 20/40 Snellen) compared with low (0.40 logMAR, 20/50 Snellen; P = 0.04) and control (0.60 logMAR, 20/80 Snellen; P = 0.02).

CONCLUSION

Preoperative BEP can stabilize or improve subretinal fluid in acute primary RRD. Patients with BEP >50% of the time experienced the greatest benefits.

PROPHYLACTIC TREATMENT OF LATTICE DEGENERATION IN FELLOW EYES AFTER REPAIR OF UNCOMPLICATED PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To evaluate prophylactic treatment (PTx) of lattice degeneration (LD) on retinal tear (RT) and rhegmatogenous retinal detachment (RRD) risk in fellow eyes of patients after primary RRD repair in the first eye.

METHODS

This was a consecutive case series with cohort control involving patients with RRD repair from January 1, 2013, through December 31, 2017. Patients received PTx (PTx cohort) or no PTx (No-PTx cohort) in fellow eye with 5-year follow-up. Primary outcome measure was proportion with new fellow eye RT/RRD. Secondary outcomes included logarithm of minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) and status of myopia, posterior vitreous detachment, and pseudophakia.

RESULTS

Four hundred ninety-eight patients were divided into 146 and 352 in PTx and No-PTx cohorts, respectively. PTx cohort developed significantly ( P < 0.05) fewer RT/RRD (17%) than No-PTx cohort (41%). PTx significantly ( P < 0.05) lowered RT/RRD irrespective of posterior vitreous detachment and myopia status. PTx patients undergoing phacoemulsification demonstrated significantly ( P < 0.05) less RT/RRD (22%) than No-PTx cohort (31%). There was no significant ( P = 0.96) final BCVA difference between PTx (median = 0 logMAR) and No-PTx (median = 0 logMAR) cohorts.

CONCLUSION

PTx of asymptomatic fellow eye LD reduced RT/RRD risk.

Evaluation of Outcomes of Acute Cataract Surgery-Related Endophthalmitis Using a Novel Management Algorithm Based on Presenting Risk Factors

PURPOSE

Develop treatment algorithm for acute endophthalmitis (AE) following cataract surgery.

METHODS

Retrospective single-center, non-randomized interventional study involving patients with AE divided into cohorts according to our novel scoring system, the Acute Cataract surgery-related Endophthalmitis Severity (ACES) score. Total score ≥3 points indicated need for urgent pars plana vitrectomy (PPV; within 24 hours), whereas <3 points indicated urgent PPV was unnecessary. Patients were retrospectively evaluated for visual outcomes based on whether their clinical course followed with or deviated from ACES score recommendations. Main outcome was best-corrected visual acuity (BCVA) at 6-month or longer after treatment.

RESULTS

Total of 150 patients were analyzed. Patients whose clinical course followed the ACES score recommendation for immediate surgery had significantly (P < 0.01) better final BCVA (median = 0.18 logMAR, 20/30 Snellen) compared to those that deviated (median = 0.70 logMAR, 20/100 Snellen). For those where the ACES score deemed urgent PPV was unnecessary, no significant (P = 0.19) difference was observed between patients that followed with (median = 0.18 logMAR, 20/30 Snellen) and those that deviated from (median = 0.10 logMAR, 20/25 Snellen) recommendation.

CONCLUSIONS

The ACES score may potentially provide critical and updated management guidance at presentation for when to recommend urgent PPV for patients suffering from post-cataract surgery AE.

DELAYED ONSET Cutibacterium (FORMERLY Propionibacterium ) acnes ENDOPHTHALMITIS TRIGGERED BY INTRAVITREAL STEROID INJECTION

PURPOSE

We report a case of delayed onset Cutibacterium acnes ( C. acnes , formerly Propionibacterium acnes or P. acnes ) endophthalmitis with the onset triggered by intravitreal steroid injection (triamcinolone acetonide) in a pseudophakic patient, 7 years after cataract surgery.

METHODS/PATIENTS

A 67-year-old man presented with gradual worsening of vision, eye redness, and photosensitivity that started a month after intravitreal triamcinolone acetonide injection (Triescience, 4 mg/0.1 mL, Alcon Labs, Fort Worth, TX) for cystoid macular edema secondary to branch retinal vein occlusion in the right eye. The patient had undergone cataract surgery with intraocular lens in that eye 7 years prior. Examination showed the visual acuity of counting fingers at 3 feet and conjunctival injection, with 2+ anterior chamber cell and 2+ vitreous haze. Uveitis work up including angiotensin-converting enzyme, QuantiFERON Gold, and syphilis IgG screen was negative. Diagnostic pars plana vitrectomy with intravitreal injection of antibiotics was performed, and vitreous sample was sent for detailed laboratory analysis.

RESULTS

Vitreous fluid analysis was positive for C. acnes and negative for viral, fungal, and malignant cells. Although the patient received intravitreal antibiotics injection twice, the intraocular infection and inflammation persisted which eventually required an intraocular lens and capsular bag removal, followed by insertion of a secondary intraocular lens later.

CONCLUSION

Delayed onset C. acnes endophthalmitis may be triggered by an intravitreal steroid injection in pseudophakic patients.

Clinical Factors and Outcomes of Acute-Onset Endophthalmitis Following Small-Gauge Pars Plana Vitrectomy Surgery

BACKGROUND AND OBJECTIVES

Describe risk factors, findings, and outcomes of acute endophthalmitis (AE) following small-gauge pars plana vitrectomy (PPV).

PATIENTS AND METHODS

This was a retrospective single-center, nonrandomized study of post-PPV AE patients from 2013 to 2021. All received vitreous biopsy before treatment. Patients were divided into cohorts: 1) PPV within 3 days of diagnosis (Urgent-PPV), and 2) no urgent PPV (Other-treatment [Tx]). Main outcome was best-corrected visual acuity (BCVA) at 6 months.

RESULTS

Twenty-one patients were analyzed. Epiretinal membrane was most common indication for PPV (48%). Incidence was 0.074%. Culture-positive rate was 57%. For final BCVA, there was no significant (P = 0.85) difference between Urgent-PPV (median = 0.40 logMAR) and Other Tx cohorts (median = 0.35 logMAR). Sclerotomy wounds were not sutured in 71% of patients. Approximately 24% and 38% of patients analyzed had either no tamponade or partial tamponade, respectively.

CONCLUSION

Tamponade agents and sclerotomy suturing may be important factors when evaluating post-small-gauge PPV-associated AE. Further studies are necessary for clarification. [Ophthalmic Surg Lasers Imaging Retina 2023;54:xx-xx.].

Microscope-Integrated OCT-Guided Volumetric Measurements of Subretinal Blebs Created by a Suprachoroidal Approach

Purpose

To investigate the use of imaging modalities in the volumetric measurement of the subretinal space and examine the volume of subretinal blebs created by a subretinal drug delivery device utilizing microscope-integrated optical coherence tomography (MIOCT).

Methods

An MIOCT image-based volume measurement method was developed and assessed for accuracy and reproducibility by imaging ceramic spheres of known size that were surgically implanted into ex vivo porcine eyes. This method was then used to measure subretinal blebs created in 10 porcine eyes by injection of balanced salt solution utilizing a subretinal delivery device via a suprachoroidal cannula. Bleb volumes obtained from MIOCT were compared to the intended injection volume.

Results

Validation of image-based volume measurements of ceramic spheres showed accuracy to ±0.029 µL (5.6%) for objects imaged over the posterior pole and ±0.025 µL (4.8%) over peripheral retina. The mean expected injection volume from extraocular tests of the suprachoroidal cannula was 66.44 µL (σ = 2.4 µL). The mean injection volume as measured by the MIOCT imaging method was 54.8 µL (σ = 12.3 µL), or 82.48% of expected injection volume.

Conclusions

MIOCT can measure the volume of subretinal blebs with accuracy and precision. The novel suprachoroidal approach using a subretinal delivery device was able to deliver greater than 80% of expected injection volume into the subretinal space, as assessed by MIOCT.

Translational Relevance

MIOCT provides a method for visualization, and analysis of images enables surgeons to quantify and evaluate the success of subretinal drug delivery via a suprachoroidal approach.

pCONUS 2 and pCONUS 2-HPC for the treatment of wide-necked intracranial aneurysms: Periprocedural, 6-month, and early 2-year follow-up outcomes

BACKGROUND/PURPOSE

pCONUS 2 and pCONUS 2-HPC are novel neck-bridging devices designed to support endovascular coil occlusion of wide-necked intracranial bifurcation aneurysms. This study summarises periprocedural outcomes, 6-month, and early 2-year follow-up results following its introduction in an interventional neuroradiology centre.

MATERIALS/METHODS

This prospective, single-arm study assessed 20 aneurysms treated over a 40 month time period from time of procedure to 2 years post-procedure. Data collected included patient demographics, aneurysm features, and intraprocedural, 6-month, and 2-year post-procedural complications and angiographic features.

RESULTS

The mean age of the cohort was 59+-SD 7.7 years. 16 unruptured aneurysms were treated (pCONUS 2 13/16, pCONUS 2-HPC 3/16) and 4 ruptured aneurysms were treated with pCONUS 2-HPC. Unruptured cases received dual antiplatelet therapy pre- and post-procedure while ruptured cases received single antiplatelet therapy. 9/20 aneurysms were located at the MCA bifurcation and 7/20 at the basilar tip. The remaining 4 aneurysms were at various bifurcations in the anterior circulation. 11/20 were small (<10mm) and 9/20 were large (10-25mm). There was one periprocedural complication: a retroperitoneal bleed. There were no post-procedural intracranial complications or at 6-months follow-up. At 6 months, satisfactory occlusion was achieved in 94% of cases (15/16). There was one delayed death at 2-year follow-up from an unrelated cause.

CONCLUSION

pCONUS 2 and pCONUS 2-HPC have excellent short and medium-term safety profiles and clinical outcomes with no procedure-related mortality or morbidity and good occlusion rates at 6-month follow-up. The use of pCONUS 2-HPC with single antiplatelet therapy is feasible and did not cause any complications.

Lightweight Learning-Based Automatic Segmentation of Subretinal Blebs on Microscope-Integrated Optical Coherence Tomography Images

PURPOSE

Subretinal injections of therapeutics are commonly used to treat ocular diseases. Accurate dosing of therapeutics at target locations is crucial but difficult to achieve using subretinal injections due to leakage, and there is no method available to measure the volume of therapeutics successfully administered to the subretinal location during surgery. Here, we introduce the first automatic method for quantifying the volume of subretinal blebs, using porcine eyes injected with Ringer's lactate solution as samples.

DESIGN

Ex vivo animal study.

METHODS

Microscope-integrated optical coherence tomography was used to obtain 3D visualization of subretinal blebs in porcine eyes at Duke Eye Center. Two different injection phases were imaged and analyzed in 15 eyes (30 volumes), selected from a total of 37 eyes. The inclusion/exclusion criteria were set independently from the algorithm-development and testing team. A novel lightweight, deep learning-based algorithm was designed to segment subretinal bleb boundaries. A cross-validation method was used to avoid selection bias. An ensemble-classifier strategy was applied to generate final results for the test dataset.

RESULTS

The algorithm performs notably better than 4 other state-of-the-art deep learning-based segmentation methods, achieving an F1 score of 93.86 ± 1.17% and 96.90 ± 0.59% on the independent test data for entry and full blebs, respectively.

CONCLUSION

The proposed algorithm accurately segmented the volumetric boundaries of Ringer's lactate solution delivered into the subretinal space of porcine eyes with robust performance and real-time speed. This is the first step for future applications in computer-guided delivery of therapeutics into the subretinal space in human subjects.

Prompt Improvement of an Enlarging Pigment Epithelial Detachment Following Intravitreal Dexamethasone in Neovascular Age-Related Macular Degeneration

Purpose:

This report discusses a case of neovascular age-related macular degeneration with mixed serous pigment epithelial detachment (PED) that was unresponsive to antivascular endothelial growth injections but responded to the addition of intravitreal steroid injection.

Methods:

We report a case.

Results:

A 75-year-old woman with neovascular age-related macular degeneration developed a mixed serous PED in her right eye. Three monthly aflibercept (Eylea, Regeneron) treatments led to resolution of associated intraretinal fluid; however, the mixed serous and fibrovascular PED significantly increased in size. The addition of intravitreal dexamethasone (Ozurdex, Allergan) to monthly aflibercept led to prompt flattening of the PED. Three months later, the PED recurred despite continued administration of monthly aflibercept.

Conclusions:

This case supports a growing body of research that PEDs unresponsive to antivascular endothelial growth injections may respond to intravitreal steroid injections.

The role of awake craniotomy in reducing intraoperative visual field deficits during tumor surgery

Objective:

Homonymous hemianopia due to damage to the optic radiations or visual cortex is a possible consequence of tumor resection involving the temporal or occipital lobes. The purpose of this review is to present and analyze a series of studies regarding the use of awake craniotomy (AC) to decrease visual field deficits following neurosurgery.

Materials and Methods:

A literature search was performed using the Medline and PubMed databases from 1970 and 2014 that compared various uses of AC other than intraoperative motor/somatosensory/language mapping with a focus on visual field mapping.

Results:

For the 17 patients analyzed in this study, 14 surgeries resulted in quadrantanopia, 1 in hemianopia, and 2 without visual deficits. Overall, patient satisfaction with AC was high, and AC was a means to reduce surgery-related complications and cost related with the procedure.

Conclusion

AC is a safe and tolerable procedure that can be used effectively to map optic radiations and the visual cortices in order to preserve visual function during resection of tumors infiltrating the temporal and occipital lobes. In the majority of cases, a homonymous hemianopia was prevented and patients were left with a quadrantanopia that did not interfere with daily function.

Dry eye specific quality of life in veterans using glaucoma drops

PURPOSE

To evaluate the frequency of ocular surface symptoms and their potential impact on dry eye specific quality of life (QoL) in patients using versus not using glaucoma medications.

MATERIAL AND METHODS

The study was a single-center, cross-sectional survey of patients seen at the Miami Veterans Affairs (VA) ophthalmology and optometry clinics from June to August, 2010. Patients were invited to complete the Dry Eye Questionnaire 5 (DEQ5) and the Impact of Dry Eye on Everyday Life (IDEEL) at their visit. Of 1348 patients seen in the Miami VA eye clinics during this three-month period, 467 patients completed the DEQ5 and 391 responded to both questionnaires. Outcome measures comprised ocular surface symptoms and their impact on dry eye specific QoL in patients using versus not using glaucoma drops.

RESULTS

An increasing number of glaucoma drops was significantly associated with an increased percentage of severe dry eye symptoms: no medications, 25% (n=89/353); 1 or 2 medications, 27% (n=17/62); 3 or more medications, 40% (n=21/52); p=0.03 (Armitage's test for linear-trend in proportions). There was an association between increasing number of drops and decreasing emotional well-being scores (linear p<0.001; quadratic p=0.029). Black patients had higher dry eye symptoms and lower emotional QoL scores compared to white patients at every level of medication use.

CONCLUSION

An increasing number of glaucoma medications were associated with an increased frequency of severe dry eye symptoms and decreased emotional QoL. Additionally, dry eye specific emotional QoL was more severely affected in black versus white patients.

Glutamic acid decarboxylase (anti-GAD) & tissue transglutaminase (anti-TTG) antibodies in patients with thyroid autoimmunity

BACKGROUND & OBJECTIVES

Several autoimmune disorders have been reported to be associated with autoimmune thyroiditis and may coexist with other organ-specific autoantibodies. The aim of the present study was to evaluate the presence of tissue transglutaminase (anti-TTG) and glutamic acid decarboxylase (anti-GAD) antibodies in patients suffering from autoimmune thyroiditis as diagnosed by anti-thyroid peroxidase (anti-TPO) antibodies, which may indicate high risk for developing celiac disease or type 1 diabetes mellitus.

METHODS

Five thousand children and 2800 adults were screening as part of a general health examination done on a voluntary basis in four different parts of Delhi. A total of 577 subjects positive for anti-TPO antibody constituted the cases. Equal number of age and sex matched anti-TPO antibody negative controls were randomly selected from the same cohort to form paired case control study. The cases and controls were further divided into two groups as follows: group-1 (children and adolescent <18 yr), group-2 (adults >18 yr). Serum samples of cases and controls were analysed for thyroid function test (FT3, FT4, and TSH), anti-TTG and anti-GAD antibodies.

RESULTS

A total of 1154 subjects (577 cases and 577 controls) were included in this study. Hypothyroidism was present in 40.2 per cent (232) cases compared to only 4.7 per cent (27) in controls (P<0.001). Anti-TTG and anti-GAD antibodies were present in 6.9 and 12.5 per cent subjects among cases compared to 3.5 per cent (P=0.015) and 4.3 per cent (P=0.001) in controls, respectively. Only anti-GAD antibody were significantly positive in cases among children and adolescents (P =0.0044) and adult (P=0.001) compared to controls. Levels of anti-TTG and anti-GAD antibodies increased with increasing titre of anti-TPO antibody.

INTERPRETATION & CONCLUSIONS

Our findings showed high positivity of anti-GAD and anti-TTG antibodies among subjects with thyroid autoimmunity. It is, therefore, important to have high clinical index of suspicion for celiac disease or type 1 diabetes mellitus in patients with autoimmune thyroiditis.

Bone health in healthy Indian population aged 50 years and above

One thousand six hundred healthy subjects aged more than 50 years, residing in Delhi, were evaluated for bone mineral metabolic parameters. High prevalence of osteoporosis (35.1% subjects) was observed in this population. Bone mineral density (BMD) correlated positively with body mass index (BMI) and negatively with PTH levels. No correlation was observed with serum 25(OH)D levels.

INTRODUCTION

To assess the bone health status in elderly Indians and compare peripheral DXA (pDXA) with central DXA in evaluation of osteoporosis.

METHODS

The study involved 1,600 healthy subjects more than 50 years of age residing in Delhi, India, who underwent anthropometric, biochemical, and hormonal evaluation. BMD was measured by DXA at lumbar spine, hip, and distal radius; and by pDXA at forearm and calcaneum.

RESULTS

Seven hundred ninety-two males and 808 postmenopausal females, with a mean age of 57.67 ± 9.46 years were evaluated. Osteoporosis was present in 35.1% subjects (M-24.6%, F-42.5%) and osteopenia in 49.5% (M-54.3%, F-44.9%). Prevalence of osteoporosis increased with age in females, but not in males. BMD at all sites, except distal radius, was positively correlated with BMI (r=0.037, p=0.14). Total body BMD was negatively correlated with alkaline phosphatase (r= -0.184, p<0.00001) and PTH levels (r= -0.099, p<0.00001), respectively. No significant correlation was observed between serum 25(OH)D levels and BMD at any site. BMD at forearm and calcaneum, measured using pDXA, showed strong positive correlation with BMD measured by central DXA. pDXA had sensitivity of 88%, specificity of 55%, and negative and positive predictive values of 89% and 52%, respectively, at T-score -2.5 at peripheral sites compared to central DXA.

CONCLUSIONS

A high prevalence of osteoporosis was observed in elderly Indian subjects. pDXA has high negative predictive value, making it a useful tool in population screening for osteoporosis.

Vitamin D status in healthy Indians aged 50 years and above

INTRODUCTION

There is widespread prevalence of vitamin D deficiency from new-born to infancy, childhood and adult male and females (non-pregnant, pregnant and lactating). However, there is limited information of the vitamin D status in elderly Indians.

MATERIAL AND METHODS

The study was carried in 1346 healthy subjects more than 50 years of age residing in Delhi, India. These subjects, who were divided in two groups: Group-1 (50-< 65 years) and Group-2 (> or = 65 years), underwent anthropometric, biochemical and hormonal evaluation for vitamin D status Bone mineral density was measured by dual X-ray absorptiometry.

RESULTS

There were 643 males and 703 females, with a mean age of 58.0 +/- 9.5 years (range 50-84 years). Vitamin D deficiency [VDD, serum 25(OH)D levels < 20 ng/ml) was present in 1228 (91.2%) and Vitamin D insufficiency [VDI, serum 25(OH)D levels 20-< 30 ng/ml] in 92 (6.8%). There was no significant difference in prevalence of either VDD or VDI between two age groups and sexes. Serum 25(OH)D levels were negatively correlated with PTH levels (r -0.027, p <0.00001) and BMI (r -0.128, p 0.05). Prevalence of secondary hyperparathyroidism increased from 14.1% to 43.1% from VDI to severe VDD. PTH levels started rising at vitamin D level < 30 ng/ml. However, more than 50% of subjects with severe VDD had PTH levels within normal range. High prevalence of osteopenia (50.2%) and osteoporosis (31.2%) was observed in this population.

CONCLUSION

Hypovitaminosis D is universal above the age of 50 years in north India. Absence of a PTH response was observed in more than 50% of individuals with VDD, the cause of which merits further evaluation. Normal bone mass was observed in only 18.6% of study subjects.

Vitamin D nutritional status of exclusively breast fed infants and their mothers

BACKGROUND

Vitamin D nutrition has a profound effect on the development of an infant. Vitamin D status of mothers and their infants are closely correlated. While hypovitaminosis D has emerged as a significant public health problem across all age groups, there is limited information of this condition in lactating mothers and their breast fed infants.

AIM

To evaluate the vitamin D status of lactating mothers and their breast fed infants.

SUBJECTS AND METHODS

180 healthy lactating mothers and exclusively breast fed infants, 2-24 weeks old, were recruited for the study. The mother-infant pairs underwent concurrent clinical, biochemical and hormonal evaluation for calcium-vitamin D-PTH axis.

RESULTS

The mean serum 25(OH)D values in lactating mothers was 27.2 +/- 14.6 nmol/l (10.9 +/- 5.8 ng/ml), while that of their infants was 28.9 +/- 20.8 nmol/l (11.6 +/- 8.3 ng/ml). Serum 25(OH)D levels <25 nmol/l (10 ng/ml) were found in 47.8% of the mothers and 43.2% of the infants. Among these, elevated PTH levels (>54 pg/ml) were seen in 59.3% of the mothers and 69.6% of the infants. A highly significant negative correlation was found between serum 25(OH)D and PTH in mothers (r = -0.480, p = 0.01) and their infants (r = -0.431, p = 0.01). A strong positive correlation was seen of 25(OH)D levels in mother-infant pairs (r = 0.324, p = 0.001).

CONCLUSIONS

A high prevalence of vitamin D deficiency was found in lactating mothers and their exclusively breast fed infants. Infants born to mothers with hypovitaminosis D had 3.8 times higher risk of developing hypovitaminosis D as compared to those born to mothers with normal vitamin D levels.

Comparison of clinical and histopathological evaluation of tonsils in pediatric and adult patients

The aim of this study was to determine clinical features that could predict the presence of tonsillar malignancy in children and adults. A retrospective review of the histopathologic reports of the children, who underwent tonsillectomy (753 cases) during the past 16 years (January 1991-December 2006) in a busy district general hospital, was undertaken. We compared the results to the pre-operative data of the patients, for risk factors of malignancy. Such proposed risk factors were tonsillar asymmetry, palpable firmness, visible lesions, neck adenopathy, history of malignancy, and systemic symptoms. The same data (history, risk factors and histopathologic results) were reviewed for an adult group (>16 years old, 1,027 cases) who underwent tonsillectomy during that period, and the results of the two groups were compared. In the pediatric group only one case was diagnosed as lymphoma (0.13%) and the rest as chronic inflammation (47%), reactive tonsil tissue (26%), lymphoid hyperplasia (19%) and actinomycosis (8%). In the lymphoma case, the diagnosis was suspected preoperatively by history and clinical manifestations. In the adult group, there were 21 cases of malignancy out of 1,027 cases (2.04%), again with one or more positive risk factors in the pre-surgery history. Based on our review, it is concluded that histopathology of tonsillectomy is not necessary in children unless there is clinical suspicion based on preoperative findings. A protocol based on proposed risk factors which may be predictive of possible malignancy can be used as a guide to intraoperative histology.

Pott′s puffy tumor following an insect bite

Pott's puffy tumor, a feature of osteomyelitis of the frontal bone, is a rare entity, especially in adults. Sir Percival Pott originally described this condition as a complication of trauma to the frontal bone. This is also a recognized complication of fronto-ethmoidal sinusitis. We present a rare case of Pott's puffy tumor caused by an insect bite presenting initially as a preseptal cellulitis and explore its pathogenesis and management.

Clinical performance indicators at hysterectomy

The short-term complications of hysterectomy in 184 women have been documented over 12 months against a panel of clinical performance indicators in a district general hospital. One hundred and fifty-nine operations (159/184, 86.4%) were performed by the abdominal route; 25/184 (13.6%) by the vaginal route. Clinical indications for hysterectomy varied from menorrhagia (75/184, 40.7%) to Stage III/IV endometriosis (10/184, 5.4%). Clinical performance indicators (cPI) were triggered in 32/184 (17.4%) cases; 19/ 184 (10.3%) triggered a single performance indicator, 9/184 (4.9%) triggered two performance indicators and 4/184 (2.2%) triggered three performance indicators. Combining the number of hysterectomies performed per annum (HYST 1), with the proportion of cases triggering three or more clinical performance indicators (HYST 2) and the rate of hysterectomy for histologically normal uteri weighing less than 120 g excluding genital prolapse (HYST 3) provides a profile of the operation for comparison with other clinical services.

Mechanical forces imposed on echinoid eggs during spawning: mitigation of forces by fibrous networks within egg extracellular layers

Many echinoderms spawn large numbers of eggs in rapid spawning bouts directly into the water column. During spawning, the eggs pass from the gonad along a narrow oviduct and through a rigid gonopore before reaching the water. As the eggs traverse this pathway, they are exposed to shear stress induced by the development of a velocity gradient within the fluid formed by the eggs. In some species, the diameter of the eggs is larger than the diameter of the gonopore. In these cases, the eggs also experience strain resulting from compression of the egg as it passes through the relatively small gonopore. The magnitude of shear stress experienced by eggs differs among species depending upon the viscosity of the eggs. The degree of strain experienced by eggs differs among species depending upon the relative sizes of the egg and gonopore and also changes within species as they grow. Recent evidence suggests that these forces have the propensity to damage eggs, thereby reducing their fertilizability, or to destroy them. Experimental evidence shows that the jelly coat around the eggs can protect them from shear stresses and reduce the strain imposed on them under a compressive force. Echinoderm eggs are surrounded by a jelly coat that has a composite structure of irregularly arranged fibrous networks embedded in a jelly matrix. These fibrous networks have characteristics that are similar to those of engineered and biological materials that are known to reduce the transmission of mechanical forces to other structures. Given this similarity to other materials, three possible mechanisms for the action of the jelly coat may be identified. First, the apparent viscosity of the eggs of echinoids declines as the rate at which they are sheared during spawning increases. This reduction in viscosity with increasing shear rate (shear-thinning) may, in part, be due to the structure of the jelly coat and its resultant non-Newtonian nature. Second, experimental evidence indicates that the jelly coat preferentially deforms under a compressive load, reducing the transmission of that load to the egg. Third, the jelly (but not the fibers in the coating) may deform in a nearly viscous manner. In this case, the fibers may serve to provide an elastic ‘backbone’ to the layer and remain in place to stiffen the outer layer of the egg. The composite structure of the jelly coat and the morphology of the fibrous network are likely to be critical to all these mechanisms.

HLA-DQ and TAP2 genes in patients with insulin-dependent diabetes mellitus

We examined the prevalence of HLA-DRB1, DQB1, DQA1 and TAP2 genes in children with insulin-dependent diabetes mellitus (type 1 diabetes). These HLA and TAP2 alleles were identified by dot-blot analysis of polymerase chain reaction (PCR)-amplified genomic DNA with sequence-specific oligonucleotide probes. The results show that those DQB1 alleles, which carry non-aspartic acid at position 57, in conjunction with DQA1 alleles carrying arginine at position 52, are strongly associated with susceptibility to type 1 diabetes. The prevalence of the TAP2* 0201 allele in diabetic patients was significantly lower than that in normal controls. Analysis of the data suggests that DQ alleles have the primary association with type 1 diabetes and that the association of TAP2 alleles with the disease is secondary.

HLA-DPB1 alleles in patients with rheumatoid arthritis

The distribution of HLA-DPB1 alleles was studied in 94 adult Caucasian RA patients (65 = seropositive, 29 = seronegative) and 40 normal controls. The DPB1 alleles were defined by oligonucleotide typing of polymerase chain (PCR)-amplified genomic DNA. The prevalence of the DPB1*0402 allele was higher in seropositive RA patients and DPB1*0201 was higher in seronegative RA patients. These differences were not significant, however. It is likely that DPB1 alleles do not play an important role in susceptibility to RA.

Seronegative rheumatoid arthritis and HLA-DR4

OBJECTIVE

To investigate the prevalence of HLA-D region antigens in patients with seronegative rheumatoid arthritis (RA).

METHODS

The distribution of HLA-D region antigens was studied in 33 patients with seronegative RA. All patients were followed for at least 3 years, during which tests for IgM rheumatoid factor were negative on at least 3 occasions. HLA-D region antigens were defined by serological and molecular techniques (oligonucleotide typing).

RESULTS

Our data demonstrate that DR4 was significantly (p < 0.021) increased in patients (45.5%) compared to normal controls (22.9%). Although the prevalence of DR1 was essentially the same in patients (15.2%) as in healthy controls (14.3%), the frequency of DR1 and/or DR4 was significantly (p < 0.018) increased in patients (60.6%) compared to healthy subjects (35.7%). The prevalence of remaining DR antigens and of DQ and DP specificities in patients with seronegative RA was not different from that in healthy controls.

CONCLUSION

Our results together with those published by other investigators suggest that both seropositive and seronegative RA are associated with DR4 and may therefore share the same immunogenetic bases.

Immunogenetics of polymyalgia rheumatica

The distribution of HLA-D region antigens was studied in 17 patients with well-documented polymyalgia rheumatica (PMR). HLA-D region antigens were defined by the oligonucleotide typing of polymerase chain reaction (PCR)-amplified genomic DNA. The results demonstrate that the prevalence of DR4 was significantly higher (p < 0.0002; RR = 8.10) in patients (70.6%) compared to normal controls (22.9%), and the frequency of DR1 and/or DR4 in patients (82.4%) was also higher (p < 0.0006; RR = 8.40) than that in normal healthy controls (35.7%). Of the subtypes of DR4,Dw13 was significantly higher (p < 0.002; RR = 9.30) in patients (29.4%) than in normal controls (4.3%). However, these data must still be confirmed by other investigators. The distribution of the remaining DR antigens and of the DQ and DP alleles in patients did not differ significantly from those in controls. The results suggest immunogenetic similarity between PMR and late onset rheumatoid arthritis in elderly populations.

Allogeneic blood transfusion-induced enhancement of tumor growth: two animal models showing amelioration by leukodepletion and passive transfer using spleen cells

Allogeneic blood transfusions have been reported to induce immunomodulation in recipients of blood products. While the mechanism(s) of this immunomodulatory effect is unknown, it has been suggested that this effect of allogeneic blood transfusions could adversely affect patients with a malignant disorder. These concerns have been supported by a number of nonrandomized, mainly retrospective, clinical studies which indicate that allogeneic blood transfusions can adversely affect prognosis following the surgical treatment of oncology patients. Recently, we have shown that allogeneic blood transfusions enhance primary tumor growth and increase metastatic pulmonary nodule formation in inbred mice. The tumor growth-promoting activity of allogeneic blood transfusions was studied also using outbred rabbits. In this present study, we demonstrate that the tumor growth-promoting effect of allogeneic blood transfusions is mediated by donor leukocytes and that this effect can be abolished by their removal before transfusion. We show also that the allogeneic blood transfusion tumor growth-promoting effect can be passively transferred to naive animals (both mice and rabbits) using spleen cells from allogeneically transfused animals. In these experiments, numbers of metastatic pulmonary nodules were significantly increased in both mice and rabbits that had received spleen cells from allogeneically transfused animals compared with those that had received spleen cells from syngeneically transfused animals, or from animals that had been transfused with leukodepleted allogeneic blood.