Long-Term Endothelial Cell Viability After Deep Anterior Lamellar Versus Penetrating Keratoplasty for Keratoconus

OBJECTIVES

We compared long-term endothelial cell survival after penetrating versus after deep anterior lamellar keratoplasty for keratoconus.

MATERIALS AND METHODS

We retrospectively compared 64 eyes of 55 patients who had penetrating keratoplasty and 40 eyes of 37 patients who had deep anterior lamellar keratoplasty for keratoconus (October 2003-February 2021). Best-corrected visual acuity, Goldmann applanation tonometry, fundus examination with 90D lens, and specular microscopy with CEM-530 (Nidek) were performed preoperatively and every 6 months postoperatively. Main outcomes were endothelial cell density, central corneal thickness, and visual acuity. Secondary outcomes were coefficient of variation, hexagonality, graft rejection episodes, and graft clarity.

RESULTS

We found no significant differences between the 2 treatment groups regarding patient age, donor age, preoperative vision, central corneal thickness, and recipient-donor trephine diameters. Mean follow-up was 92.5 months. In deep anterior lamellar keratoplasty, the endothelium was preserved significantly better for 10 years versus for penetrating keratoplasty. Mean endothelial density in penetrating versus deep anterior lamellar keratoplasty was 2006.7 versus 2354.7 cells/mm2 at 1 year (P = .010), 1170.5 versus 2048.2 at 5 years (P <.001), and 972.5 versus 1831.6 at 10 years (P < .001). Cumulative endothelial cell loss was 43% and 19.7% at 10 years for penetrating and anterior lamellar keratoplasty, respectively. Significantly more thickening of central cornea was shown in penetrating keratoplasty after 7 years. Corneal thickness was 583.0 µm in penetrating and 545.1 µm in deep anterior lamellar keratoplasty (P = .002) at 10 years. Vision gain and coefficient of variation were similar. Hexagonality decreased significantly in both groups at 10 years. Rates of rejection were 12.5% in penetrating and 7.5% in deep anterior lamellar keratoplasty. Graft survival rates were 97.5% and 96.9%, respectively.

CONCLUSIONS

In keratoconus, endothelial vitality is better preserved with deep anterior lamellar keratoplasty than with penetrating keratoplasty over a 10-year follow-up.

The Effect of Donor- and Recipient-Related Factors on Corneal Graft Survival in Penetrating Keratoplasty

Purpose: To investigate the impact of donor and recipient factors on graft survival in penetrating keratoplasty (PK).Material and Methods: This retrospective study included 365 eyes that underwent PK using corneas from 231 donors between June 2010 and June 2015. Patients were divided into three groups (group 1: primary endothelial diseases; group 2: iatrogenic endothelial disorders; and group 3: other pathologies with a healthy endothelium) according to PK indications. The primary outcome measure was corneal graft survival at the last visit (clear or opaque). Graft clarity was assessed using Kaplan-Meier survival analysis.Results: The most frequent PK indication was keratoconus (KC) (20.5%) followed by pseudophakic bullous keratopathy (PBK) (18.9%). Donor age had a negative impact on endothelial cell density (ECD) measured by an eye bank specular microscope (p < 0.001). Median best-corrected visual acuity in logarithm of the minimum angle of resolution units increased from 2.1 to 0.8 at 1 year after PK (p < 0.001). The clear graft rate was 96.7% at year 1, 88.8% at year 2, and 85.5% at year 3. Overall graft survival was 84.9% during a median of 39 months (range: 24-79 months) of follow-up. A higher graft survival rate (67.2%) was observed in KC compared to PBK during 6 years (p < 0.001). Recipients younger than 50 years of age showed a better graft survival rate than those older than 70 years of age (p = 0.037). Donor ECD, time between excision and death, and preservation time had no significant effect on graft survival. Frequent graft rejection episodes (GREs) and additional procedures during surgery had a negative impact on graft survival (p < 0.001 and p = 0.014, respectively). A worse graft survival was observed in group 2 compared to groups 1 and 3 (p = 0.042).Conclusions: Young recipient age and KC were associated with a better graft survival. Graft endothelial density and preservation time had no impact on graft survival. PBK, low vision at baseline and year 1, frequent GREs, and additional interventions during surgery had a negative impact on graft survivals.

Acute Unilateral Anterior Ischemic Optic Neuropathy Secondary to Optic Nerve Head Drusen: Report of a Rare Coexistence

A 45-year-old white male noticed on awakening the painless loss of inferior vision in the left eye 2 days ago. He was otherwise well and his medical history was unremarkable. Visual acuity was 20/20 in OD and 20/32 in OS with a left inferior altitudinal defect and right blind spot enlargement demonstrable on visual field test. On fundus examination, both disc margins were blurred and the left disc was diffusely oedematous, with linear haemorrhages in the adjacent nerve fibre layer. Radiologic imaging and laboratory tests were unremarkable. Bilateral optic nerve head drusen (ONHD) was demonstrated by optical coherence tomography and fundus autofluorescence imaging. Unilateral acute non-arteritic anterior ischemic optic neuropathy (NAION) and concomitant bilateral ONHD were diagnosed. NAION may develop secondary to ONHD. Therefore, clinicians should be aware of this rare association and inform the patients about this risk. Patients with ONHD should be followed-up periodically in terms of possible ischemic complications.

Could Buerger's disease cause nonarteritic anterior ischemic optic neuropathy?: a rare case report

We present an interesting case with nonarteritic anterior ischemic optic neuropathy (NAION) accompanied by Buerger's disease. A 43-year-old man was referred to our neuro-ophthalmology clinic with a complaint of visual deterioration in the left eye that started 5 days ago. He suffered from Buerger's disease, and he had acute pain in the right lower limb below the knee. His best corrected visual acuity was 10/10 in the right eye and 2/10 in the left eye by Snellen chart. There was a relative afferent pupil defect in the left eye. The right optic disc was normal on fundus examination, and blurring, hemorrhagic swelling was found at the left optic disc. Inferior altitudinal visual field defect was observed in the left eye. Neurological examination was normal. Computed tomography angiography scan revealed occlusion in the right posterior tibial artery. Brain imaging and laboratory tests such as blood analyses, genetic screening, coagulation, and lipid panels were unremarkable. NAION may occur in patients with Buerger's disease, but it is extremely rare. Therefore, clinicians should be aware of this rare association.

Evaluation of the Effect of Topical Cyclosporine a with Impression Cytology in Dry Eye Patients

Purpose.

This study evaluated the efficacy of topical cyclosporine A 0.05% treatment with impression cytology in dry eye patients.

Methods.

Forty eyes of 40 patients with dry eye were included. Schirmer, tear break-up time, and Ocular Surface Disease Index (OSDI) scores and goblet cell densities were noted before and after 6 months of topical cyclosporine A treatment. Patients were graded clinically and biomicroscopically as follows: grade 1, 12 patients; grade 2, 18; and grade 3, 10 patients.

Results.

Mean age was 57.1±11.8 (23.0–80.0) years. A total of 36 (90%) of the patients were female and 4 (10%) were male. Mean Schirmer test value was 3.2±1.6 (0.0–8.0) mm in the beginning and was 8.4±4.3 (1.0–19.0) mm after 6 months of cyclosporine A topical treatment (p=0.00). At the first visit, mean tear break-up time was 4.4±1.8 (2.0–8.0) seconds. It increased to 11.8±4.8 (2.0–20.0) seconds at the end of the sixth month (p=0.00). Mean clinical grading was 1.9±0.8 (1.0–3.0) and this value regressed to 0.8±1.2 (0.0–3.0) after the treatment (p=0.00). Mean OSDI score was 30.0±11.7 (9.0–50.0) before the treatment and 21.3±11.0 (4.0–47.0) after the treatment (p=0.00). Mean goblet cell density of all cases was 12.3±8.7 before the treatment (2.0–28.0). It increased to 33.0±25.4 (6–70) after the treatment (p=0.04).

Conclusions.

Topical cyclosporine A treatment is effective in grade 1 and grade 2 dry eye patients but results are poor in grade 3 patients.

Topical nepafenac for prevention of post-cataract surgery macular edema in diabetic patients: patient selection and perspectives

Since its first description, the prevention of pseudophakic cystoid macular edema (PCME) continues to pose challenges for ophthalmologists. Recent evidence suggests that prophylaxis is unnecessary in patients without risk factors. Diabetes mellitus is generally considered as a risk factor for the development of PCME after cataract surgery since it causes breakdown of the blood–retinal barrier. Diabetic retinopathy (DR) increases the risk even further. Therefore, prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in diabetic patients, especially if they have DR. NSAIDs block the cyclooxygenase enzymes responsible for prostaglandin production and reduce the incidence of PCME after cataract surgery. Nepafenac seems superior to other NSAIDs in terms of ocular penetration allowing higher and sustained therapeutic levels in retina and choroid. Topical steroids are less effective and may cause intraocular pressure increase limiting their long-term use. Nepafenac is cost effective, when the burden of PCME prevention is compared with the burden of treatment. Prevention is much cheaper and less harmful than invasive treatments like periocular or intravitreal injections. Overall, both nepafenac 0.1% and nepafenac 0.3% are well tolerated. They should be used carefully in patients with compromised corneas such as those with severe dry eye or penetrating grafts. If otherwise healthy cataract patients have ≥2 risk factors, like PCME in the other eye or posterior capsule rupture during surgery, treatment should be considered. Once-daily nepafenac 0.3% dosing may improve postoperative outcomes through increased patient compliance and may reduce treatment burden further. Every patient should be assessed in terms of risks/benefits of the treatment, in individual basis, before cataract surgery.

Comparison of visual and topographic outcomes of deep-anterior lamellar keratoplasty and penetrating keratoplasty in keratoconus

AIM

To compare visual, surgical and topographic outcomes of deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for keratoconus (KC).

METHODS

In this multicenter, prospective, randomized clinical trial 76 eyes of 71 KC patients operated between January 2011 and July 2014 in 2 tertiary referral hospitals were included. Consecutive patients were alternately selected to receive one of the two surgical methods. Thirty eight eyes underwent DALK with the big-bubble technique and 38 eyes underwent PK.

RESULTS

Mean best spectacle corrected visual acuity (BSCVA) at the first postoperative week (P=0.012) and the first postoperative month (P<0.001) was statistically significantly higher in DALK group. The mean BSCVA at 12mo was not significantly different for DALK (0.30±1.99 logMAR) versus PK (0.40±0.33 logMAR) (P=0.104). The 76.3% of the eyes had a BSCVA over 0.5 in DALK and 47.4% in PK group (P=0.009). The 7.9% of the eyes had a BSCVA of 1.0 in DALK and 5.3% in PK group (P=0.644). Mean spherical equivalent was -2.94 D in DALK and -3.09 D in PK group. Mean topographic astigmatism was 4.62 D and 4.18 D respectively. Regular topographic patterns were observed in 31 (81.6%) of DALK and 29 (76.3%) of PK (P=0.574). The most frequent topographic pattern was oblate asymmetric bow tie, seen in 39.5% in DALK and 23.7% in PK.

CONCLUSION

Big bubble DALK provides an earlier visual improvement compare to PK. However, visual and topographic outcomes are similar to those in PK at 1y. Postoperative complications including rejection and intraocular pressure elevation are more frequent in PK. DALK is a safer alternative to PK for KC. However, intraoperative perforation of the Descemet's membrane is a significant complication.

Does the Stage of Keratoconus Affect Optical Coherence Tomography Measurements?

PURPOSE

To employ optical coherence tomography (OCT) to examine the relationship of changes in the retinal nerve fiber layer (RNFL) and macular thickness as well as ganglion cell (GC) parameters with the stage of keratoconus (KC), and to compare these changes with a control group.

METHODS

A total of 84 eyes of 68 patients with KC and 29 eyes of 29 normal age-matched subjects underwent RNFL, macular thickness measurements, and ganglion cell analysis using Cirrus high-definition (HD) OCT. Patients with KC were classified according to the Amsler-Krumeich Classification. The measurements were analyzed in all quadrants for each KC stage and compared with control subjects.

RESULTS

All RNFL, macular thickness, and ganglion cell parameters varied significantly among the groups (all p<0.001, analysis of variance). An increase in the stage of KC was correlated with decreased RNFL thickness, macular thickness, and ganglion cell parameters.

CONCLUSIONS

RNFL, macular thicknesses, and ganglion cell parameters in all KC stages were lower than those in the control group. The RNFL, macular thickness, and ganglion cell parameters of the Grade 1 KC group were most similar to those of the control group. The severity of irregular astigmatism at the same stages of KC had a significant effect on OCT measurements. It may therefore be beneficial to know the amount of change/deviation in OCT measurements in keratoconus patients and to report which parameters exceed the standards so that OCT can be used to correlate the stage of keratoconus with the extent of the ocular disorder.

Comparison of Subtenon Triamcinolone Acetonide Injection with Topical Nepafenac for the Treatment of Pseudophakic Cystoid Macular Edema

PURPOSE

To compare the efficacy and safety of subtenon triamcinolone acetonide (TA) injection with topical nepafenac 0.1% for the treatment of pseudophakic cystoid macular edema (CME).

METHODS

In this prospective study, the TA group comprised 24 eyes and the nepafenac group 24 eyes. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure measurements, and slit-lamp fundoscopy were performed in all subjects at baseline, 1, 2, 3, and 6 months.

RESULTS

Changes in BCVA and CRT over four follow-up visits were statistically significant (p<0.001). The mean CRT decreased from 513.3 to 318.9 μm in the TA group and from 483.7 to 278.0 μm in the nepafenac group. This reduction was statistically significant (p<0.001 for both groups).

CONCLUSIONS

Our visual and OCT results suggest that both treatment modalities are effective with few side-effects. However, nepafenac is more efficacious than subtenon TA in terms of visual gain and its correlation with the reduction in CRT.

Endothelial Cell Viability of Donor Corneas Preserved in Eusol-C Corneal Storage Medium

OBJECTIVES

To evaluate the efficacy of Eusol-C as a corneal storage medium on the survival of donor endothelium.

MATERIALS AND METHODS

Twenty-seven corneas not suitable for transplant were included in this study. All donor corneas were stored in Eusol-C at 4°C. Daily donor corneal endothelial cell counting was performed with an eye bank specular microscope. All corneas were discarded after the study process.

RESULTS

Mean donor age was 51.3 ± 18.8 years (range, 25-94 y). The mean duration between death and corneal excision was 9.5 ± 6.7 hours (range, 3-23 h). Mean endothelial cell density was 2195 ± 383 cells/mm² at the beginning of the preservation (range, 1361-2899 cells/mm²). Donor endothelial cell density was between 1500 to 2000 cells/mm² in 9 corneas, 2000 to 2500 in 11 corneas, 2500 to 3000 in 5, and higher than 3000 in 2 corneas at baseline. Mean endothelial cell density was found 1658 cells/mm² on the eighth day of storage, with a mean endothelial cell loss rate of 24.5%. Corneas stored 9 to 24 days in Eusol-C had a rate of endothelial cell damage of 3.1% per day.

CONCLUSIONS

Although our results revealed a higher endothelial cell loss than previous reports, overall performance of Eusol-C in preserving the donor endothelium may be satisfactory for clinical use.

Effects of rigid contact lenses on optical coherence tomographic parameters in eyes with keratoconus

BACKGROUND

The aim was to evaluate the effect of irregular astigmatism on the retinal nerve fibre layer (RNFL), macular thickness and ganglion cell analysis obtained by spectral domain optical coherence tomography (OCT) in eyes with keratoconus.

METHODS

Fifty-two eyes of 31 patients (20 females) with keratoconus that required correction of irregular astigmatism with rigid gas-permeable (RGP) contact lenses were included to this study. The average, superior, nasal, inferior, temporal and 12 clock hour sector's RNFL, ganglion cell and macular thickness analyses before and 30 minutes after RGP contact lens (Rose K2 -Menicon Z material, David Thomas Contact Lenses Ltd, Northampton, United Kingdom) wear were performed to all patients with Cirrus HD spectral domain optical coherence tomography.

RESULTS

The average thickness of the retinal nerve fibre layer, the thickness at the nasal quadrants and 1-2-3-4 o'clock hour sectors and mean signal strength were increased significantly by RGP contact lens wearing independent of the stage of keratoconus. Central sub-field thickness increased after correction with RGP contact lens (p = 0.037). After wearing RGP contact lenses, changes on ganglion cell analysis were not significant (all p values ≥ 0.111).

CONCLUSIONS

OCT is a widely used device for retinal nerve fibre layer and macular thickness evaluation in patients with glaucoma and macular diseases. The study demonstrates that OCT parameters such as retinal nerve fibre layer, central sub-field thickness and mean signal strength are affected by irregular astigmatism. Correction of irregular astigmatism with RGP contact lenses should be recommended before analysing keratoconic eyes to obtain optimum results on OCT measurements.

Expression characteristics of ARF1 and SAR1 during development and the de-etiolation process

ARF1 (ADP-ribosylation factor 1) and SAR1 (secretion-associated RAS super family) are involved in the formation and budding of vesicles throughout plant endomembrane systems. The molecular mechanisms of this transport have been studied extensively in mammalian and yeast cells. However, very little is known about the mechanisms of coat protein complex (COP) formation and recruitment of COP-vesicle cargoes in plants. To provide insights into vesicular trafficking in Pisum sativum L., we investigated mRNA and protein expression patterns of ARF1 and SAR1 in roots and shoots at early growth stages and in the de-etiolation process. We showed that ARF1 was concentrated mostly in the crude Golgi fractions, and SAR1 was concentrated predominantly in the crude ER fractions of de-etiolated shoots. ARF1 and SAR1 proteins were several times more abundant in shoots relative to roots. In total protein homogenates, the expression level of SAR1 and ARF1 was higher in shoots of dark-grown pea plants than light-grown plants. In contrast, ARF1 was higher in roots of light-grown pea relative to roots of dark-grown pea. With ageing, the ARF1 mRNA in roots was reduced, while SAR1 expression increased. Unlike ARF1 transcripts, ARF1 protein levels did not fluctuate significantly in root and shoot tissue during early development. The relative abundance of SAR1 protein in root tissues may suggest a high level of vesicular transport from the ER to the Golgi. Experimental results suggested that white light probably affects the regulation of ARF1 and SAR1 protein levels. On the other hand, short-term white light affects SAR1 but not ARF1.

Comparison of fibrin glue and suture technique in pterygium surgery performed with limbal autograft

AIM

To compare the efficiency and safety of fibrin glue to suture technique in pterygium surgery performed with limbal autograft.

METHODS

A prospective randomised clinical trial was carried out in 58 eyes of 58 patients operated for primary nasal pterygium. Autologous conjunctival graft taken from the superotemporal limbus was used to cover the sclera after pterygium excision. In 29 eyes, the transplant was attached to the sclera with a fibrin tissue adhesive (Beriplast P) and in 29 eyes with 8-0 Virgin silk sutures. The Mann-Whitney U test was used for statistical analysis. Postoperative patient discomfort (pain, stinging, watering) and biomicroscopic findings (hyperemia, edema) were graded. Patients were followed up at least for six months.

RESULTS

Subconjunctival hemorrhage occured under the graft in one patient in group 1. In seven cases of group 2, sutures were removed at the 15(th) day because of granulomatous tissue reaction. Patient symptoms were significantly less and biomicroscopic findings were better in group 1. Pterygium recurrence was seen in one case of group 1, and 2 cases of group 2. Average surgery cost was higher (P<0.05) and surgery time was shorter (P<0.05) in fibrin group.

CONCLUSION

Using fibrin glue for graft fixation in pterygium surgery causes significantly less postoperative pain and shortens surgery time significantly.

Vascular endothelial growth factor level in the serum of diabetic patients with retinopathy

We determined serum levels of vascular endothelial growth factor (VEGF) at different stages of diabetic retinopathy before laser photocoagulation in 65 patients (31 nonproliferative (Group 1) and 34 proliferative (Group 2)) and in healthy controls (Group 3). VEGF levels in all groups were different. There was a significant correlation between VEGF concentration and HbA1c levels. VEGF may be involved in the prediction of diabetic retinopathy and contributes to endothelial damage in diabetics.

Response to growth hormone with respect to pubertal status on increased dose in idiopathic growth hormone deficiency: an analysis of Turkish children in the KIGS database (Pfizer International Growth Study)

AIM

To compare the growth response to growth hormone (GH) treatment in patients with idiopathic GH deficiency (IGHD) who were prepubertal with the response of those who were pubertal at the onset of GH therapy on an increased GH dose.

PATIENTS AND METHODS

Among the Turkish patients enrolled in the Pfizer International Growth Study (KIGS) database with the diagnosis of IGHD, the growth data over 2 years of GH therapy were analyzed longitudinally of 113 (79 M) prepubertal (Group 1) and 44 (33 M) pubertal (Group 2) patients. Pubertal signs were reported to be present initially or to have appeared within 6 months of GH therapy in Group 2. Mean +/- SD age at onset of therapy was 8.7 +/- 3.5 and 13.5 +/- 1.8 years; height SDS -4.2 +/- 1.4 and -3.2 +/- 1.1 (p < 0.05) in Groups 1 and 2, respectively. Mid-parental height (MPH) SDS did not show a significant difference between the two groups (-1.5 +/- 1.1 vs -1.7 +/- 1.1).

RESULTS

Delta height SDS over 2 years of therapy was significantly higher in Group 1 (1.1 +/- 1.0) than in Group 2 (0.7 +/- 0.6) (p <0.05) in spite of a significantly lower dose of GH (14.6 +/- 3.3 in Group 1 vs 17.0 +/- 3.1 IU/m2/week in Group 2, p < 0.05). Ht--MPH SDS showed an increase from -2.4 +/- 1.7 to -1.4 +/- 1.5 in Group 1 and from -1.5 +/- 1.5 to -0.8 +/- 1.3 in Group 2. Overall delta height SDS showed negative correlations with age (r = -0.32), height SDS (r = -0.41) and height--MPH SDS (r = -0.40) at onset of therapy (p < 0.001).

CONCLUSIONS

These data show that in IGHD the slight increase (15-20%) in the dose of GH during puberty was not adequate to maintain height velocity at the same magnitude as in prepuberty, and thus was not cost effective.

Construction and characterization of a peanut HindIII BAC library

Bacterial artificial chromosome (BAC) libraries have been an essential tool for physical analyses of genomes of many crops. We constructed and characterized the first large-insert DNA library for Arachis hypogaea L. The HindIII BAC library contains 182,784 clones; only 5,484 (3%) had no inserts; and the average insert size is 104.05 kb. Chloroplast DNA contamination was very low, only nine clones, and r-DNA content was 1,208, 0.66% of clones. The depth of coverage is estimated to be 6.5 genome-equivalents, allowing the isolation of virtually any single-copy locus. This rate of coverage was confirmed with the application of 20 overgos, which identified 305 positive clones from the library. The identification of multiple loci by most probes in polyploids complicates anchoring of physical and genetic maps. We explored the practicality of a hybridization-based approach for determination of map locations of BAC clones in peanut by analyzing 94 clones detected by seven different overgos. The banding patterns on Southern blots were good predictors of contig composition; that is, the clones that shared the same size bands and ascribed to the same overgos usually also located in the same contigs. This BAC library has great potential to advance future research about the peanut genome.

Exploratory integration of peanut genetic and physical maps and possible contributions from Arabidopsis

Arachis hypogaea is a widely cultivated crop both as an oilseed and protein source. The genomic analysis of Arachis species hitherto has been limited to the construction of genetic maps; the most comprehensive one contains 370 loci over 2,210 cM in length. However, no attempt has been made to analyze the physical structure of the peanut genome. To investigate the practicality of physical mapping in peanut, we applied a total of 117 oligonucleotide-based probes ("overgos") derived from genetically mapped RFLP probes onto peanut BAC filters containing 182,784 peanut large-insert DNA clones in a multiplex experimental design; 91.5% of the overgos identified at least one BAC clone. In order to gain insights into the potential value of Arabidopsis genome sequence for studies in divergent species with complex genomes such as peanut, we employed 576 Arabidopsis-derived overgos selected on the basis of maximum homology to orthologous sequences in other plant taxa to screen the peanut BAC library. A total of 353 (61.3%) overgos detected at least one peanut BAC clone. This experiment represents the first steps toward the creation of a physical map in peanut and illustrates the potential value of leveraging information from distantly related species such as Arabidopsis for both practical applications such as comparative map-based cloning and shedding light on evolutionary relationships. We also evaluated the possible correlation between functional categories of Arabidopsis overgos and their success rates in hybridization to the peanut BAC library.

Growth hormone and insulin-like growth factor 1 levels and their relation to survival in children with bacterial sepsis and septic shock

OBJECTIVES

Despite improved supportive care, the mortality of sepsis and septic shock is still high. Multiple changes in the neuroendocrine systems, at least in part, are responsible for the high morbidity and mortality. A reduced circulating level of insulin-like growth factor and an elevated level of growth hormone are the reported characteristic findings early in the course of sepsis and septic shock in adults. The aim of this study was to evaluate the changes of growth hormone/insulin-like growth factor 1 axis in sepsis and septic shock and investigate the relationship between these hormones and survival.

METHODS

Fifty-one children with sepsis (S), 21 children with septic shock (SS) and 30 healthy, age- and sex-matched children (C) were enrolled in this study. Growth hormone, insulin-like growth factor 1 and cortisol levels of the sepsis and septic shock groups were obtained before administration of any inotropic agent.

RESULTS

Growth hormone levels were 32.3 +/- 1.5 microIU/mL (range 4-56), 15.9 +/- 0.6 microIU/mL (range 11-28) and 55.7 +/- 2.7 microIU/mL (range 20-70) in S, C and SS groups, respectively. The difference between the growth hormone levels of the S and C groups, S and SS groups, and C and SS groups were significant (P < 0.001). Non-survivors (54.7 +/- 1.6 microIU/mL) had significantly higher growth hormone levels than survivors (29.4 +/- 1.5 microIU/mL) (P < 0.001). Insulin-like growth factor 1 levels were 38.1 +/- 2.1 ng/mL (range 19-100), 122.9 +/- 9.6 ng/mL (range 48-250) and 22.2 +/- 1.9 ng/mL (range 10-46) in the S, C and SS groups, respectively, and the difference between the insulin-like growth factor 1 levels of the S and C, S and SS, and C and SS groups were significant (P < 0.001). Non-survivors (8.8 +/- 1.1 micro g/dL) had significantly lower cortisol levels than survivors (40.9 +/- 2.1 microg/dL) (P < 0.001). We detected a significant difference between the levels of cortisol in non-survivors (19.7 +/- 1.8 microg/dL) and survivors (33.9 +/- 0.9 microg/dL) (P < 0.01).

CONCLUSIONS

There were elevated levels of growth hormone with decreased levels of insulin-like growth factor 1 in children during sepsis and septic shock compared to healthy subjects. In addition, there were even higher levels of growth hormone and lower levels of insulin-like growth factor 1 in non-survivors than in survivors. We think that both growth hormone and insulin-like growth factor 1 may have potential prognostic value to serve as a marker in bacterial sepsis and septic shock in children. As there is insufficient data in the paediatric age group, more studies including large numbers of patients and additionally evaluating cytokines and insulin-like growth factor binding proteins are needed.

Chronic respiratory morbidity following premature delivery--prediction by prolonged respiratory support requirement?

Neonatal chronic lung disease (CLD) is usually diagnosed if an infant remains oxygen dependent beyond 36 weeks postconceptional age (PCA). Our aim was to determine whether a shorter duration of respiratory support accurately predicted subsequent respiratory morbidity. A total of 103 infants, median gestational age 29 weeks (range 23-35), were followed prospectively for 5 years. They had a birth weight of < 1500 g or, if a birth weight of between 1500 and 2000 g, had required neonatal ventilatory support. Parents completed diary cards; their child had positive symptom status if, in any one year, they coughed and/or wheezed on at least 3 days per week for a 4-week period or for at least 3 days following each upper respiratory tract infection. Subsequent respiratory morbidity, positive symptom status in years 1 and 2 or all 5 pre-school years, was related to various definitions of prolonged respiratory support: intermittent positive pressure ventilation dependence > 7 days; oxygen dependence > 28 days and oxygen dependence > 36 weeks PCA. In years 1 and 2, 25 children were symptomatic and 22 in all 5 years. The patients with subsequent respiratory morbidity were distinguished from those without by requiring longer respiratory support (P < 0.05). Logistic regression analysis demonstrated only oxygen dependence beyond 28 days was independently related to subsequent respiratory morbidity (P < 0.01). The positive predictive values and likelihood ratios (95% confidence intervals) for positive symptom status in all 5 years were for intermittent positive pressure ventilation > 7 days 35% (16-53) and 19.5 (1.01-3.76), for oxygen dependency > 28 days 42% (23-61) and 2.20 (1.45-5.02) and for oxygen dependency >36 weeks PCA 35% (13-58) and 1.67 (0.65-4.31).

CONCLUSION

Oxygen dependency at 28 days of age remains a useful criterion on which to diagnose "neonatal" chronic lung disease.

Perinatal lung function measurements and prediction of respiratory problems in infancy

The aim of this study was to determine which lung function test employed in the perinatal period gave the results most significantly associated with respiratory problems in infancy. The ratio of the proportion of time to reach peak tidal expiratory flow to total expiratory time (tPTEF:tE), thoracic gas volume (TGV) and airway resistance (R(aw)) (from which specific conductance (SG(aw)) was calculated) measurements were examined from 85 infants born at or near term. The infants were followed until at least one year of age and described as symptomatic if they wheezed for at least 24 hours. Twenty-three infants were symptomatic in the first year. The symptomatic group, compared to the asymptomatic, had a higher median FRC (p < 0.01) and R(aw) (p < 0.001); their median SG(aw) was lower (p < 0.001). It was possible to obtain tPTEF:tE results from only 61 infants; the median tPTEF:tE did not differ significantly between symptomatic and asymptomatic infants. Logistic regression analysis demonstrated a high R(aw) and FRC, but not a low tPTEF:tE, independently related to positive symptom status. A high R(aw) (>26 cm H2O (1 s(-1))(-1)) was the most sensitive (83%) predictor of subsequent respiratory problems, but all the tests examined had low positive predictive values.

Assessment of prematurely born children at follow-up using a tidal breathing parameter

Prematurely born children frequently have respiratory problems at follow-up. A non-invasive and easily performed lung function test would greatly facilitate their evaluation and appropriate treatment. We have, therefore, assessed whether the shape of the tidal breathing expiratory flow curve would give useful information in such a population. One hundred and twenty traces were randomly selected from plethysmographic measurements of thoracic gas volume and airway resistance made during a follow-up study of a prematurely born population. The children had a median gestational age of 29 (range 23-35, interquartile range 27-31) weeks and postnatal age at the time of measurement of 11 (range 6-24, interquartile range 7-13) months. From the flow and volume signals, the mean time to reach peak tidal expiratory flow as a proportion of the total expiratory time (tPTEF : tE) was determined for each child. The median tPTEF : tE differed significantly between children who, in the neonatal period, had or had not required mechanical ventilation (p < 0.001) and had or had not had an increased inspired oxygen requirement (p < 0.01), and who were or were not symptomatic at follow-up (p < 0.001). Logistic regression analysis demonstrated that a low tPTEF : tE ratio was independently associated with symptom status. These results suggest that assessment of a tidal breathing parameter during follow-up of prematurely born children may be useful. As tPTEF : tE can be measured without sedation, relatively quickly and with simple equipment, potentially large study populations could be investigated, and this technique should now be evaluated in a non-sedated group of young prematurely born children.

A case of ambiguous genitalia with unilateral amelia and unilateral peromelia of the upper limbs

A 7-year-old patient is reported with a 46,XY karyotype, ambiguous genitalia and unilateral amelia and unilateral peromelia of the upper limbs. The external genitalia had essentially a female configuration with labia majora, large clitoris, and narrow vaginal opening. Gonadal tissue was not palpable on either side. The levels of 17-OH progesterone dehydroepiandrosterone sulfate (DHEA-S), androstenedione and luteinizing hormone (LH) were normal, but the level of follicle stimulating hormone (FSH) was elevated minimally. Abdominal ultrasonography (USG) was normal. On pelvic USG, neither uterus nor ovaries were seen. Genitography showed a blind vagina. Gonads, Müllerian and/or Wolffian structures were not observed at laparotomy. Clitoral recession and cut-back vaginoplasty were performed. The occurrence of these findings suggests embryonic testicular regression syndrome with bilateral transverse defect of the upper limbs. The case has been presented because the pattern of the birth defects, including both ambiguous genitalia and unilateral amelia on one side of the upper limbs and unilateral peromelia on the other, have not been described previously.

Perinatal lung function and invasive antenatal procedures

BACKGROUND

Second trimester amniocentesis has been associated with an excess of perinatal lung function abnormalities. Early amniocentesis might have a similar adverse effect, as could other invasive investigations carried out in the first trimester.

METHODS

Plethysmographic measurements of thoracic gas volume (TGV) and airway resistance (Raw), from which specific conductance (sGaw) was calculated, were made in the perinatal period in non-sedated infants. In addition, functional residual capacity (FRC) was measured using a helium gas dilution technique. Measurements were made in 47 infants whose mothers had undergone early amniocentesis, 19 whose mothers had undergone chorion villus sampling, and 25 controls whose mothers had undergone no invasive antenatal procedures.

RESULTS

The infants of mothers who had undergone early amniocentesis had higher TGV (95% CI -6.3 to 1.1 ml/kg) and Raw values (95% CI -10.68 to -5.23 cm H2O/l/s) and lower sGaw (0.11 to 0.84 l/cm H2O.s) and FRC (-5.17 to - 0.87 ml/kg) values than the controls. Infants whose mothers had undergone chorion villus sampling also differed significantly from the controls with higher Raw (-7.59 to -1.99 cm H2O/l/s) and lower sGaw values (0.11 to 0.24 l/cm H2O.s), and had lower Raw values than those in the early amniocentesis group (not significant). Logistic regression analysis, taking into account possible risk factors for abnormal lung function, showed that the procedures performed in the first trimester were independently associated with a high airways resistance.

CONCLUSION

These results suggest that invasive procedures performed in the first trimester of pregnancy have an adverse effect on perinatal lung function.

Inhaled nedocromil sodium in symptomatic young children born prematurely

The efficacy of a non-steroidal anti-inflammatory agent (nedocromil sodium, NS) has been assessed in young children born prematurely who had recurrent respiratory symptoms at follow-up. In a randomized, double-blind cross-over trial, either two puffs of NS (2 mg puff-1) or placebo were administered three times a day via a spacer device and face mask. Fifteen children, median gestational age 27 weeks, birthweight 1100 g and postnatal age 12 months were studied. The symptom score was lower in the last 2 weeks of the active period (median score 26) compared to the run-in period (median score 55) and the last 2 weeks of the placebo period (median score 50), P < 0.01. The maximum possible symptom score for a 2-week period was 210. Compared to the run-in period, children required fewer days of bronchodilator therapy in the last 2 weeks of the active treatment (P < 0.01), but not in the placebo period. Although results of functional residual capacity (FRC) measurements were available on only 13 of the 15 children, these did demonstrate a significant change in FRC over the active, but not the placebo, period. These data suggest that NS is a useful prophylactic agent for children born prematurely and who are symptomatic at follow-up.

Respiratory morbidity in young school children born prematurely--chronic lung disease is not a risk factor?

Children born prematurely and recruited into a prospective follow up study were examined at 5 years of age. Our aim was to determine aetiological associations of respiratory symptoms in such children and, in particular, to determine the importance of severe chronic lung disease (CLD, oxygen dependence beyond 36 weeks post conceptional age). Respiratory status was documented from parental history in 103 children of median gestational age 29 weeks (range 23-35), 17 of whom had suffered from severe CLD. In 90 of the 103 children lung function had been assessed at 1 year of age. Regression analysis revealed that neither severe CLD nor other perinatal variables, but only a family history of atopy, significantly related to a positive symptom status. A high airways resistance at 1 year also significantly related to positive symptom status.

CONCLUSION

Reduction in severe CLD (oxygen dependence beyond 36 weeks postconceptional age) may make relatively little impact on respiratory morbidity in young school children born prematurely.

Respiratory morbidity in preschool children born prematurely. Relationship to adverse neonatal events

Respiratory morbidity, recurrent cough and/or wheeze and lung function abnormalities are common even outside infancy in preschool children born prematurely. Throughout the first 5 years of life, adverse neonatal events such as immaturity at birth and a requirement for prolonged respiratory support are significantly associated with positive symptom status. In the older preschool child, however, there is some evidence to suggest that other factors, such as a family history of atopy, may be equally important. The development of recurrent symptoms even at 4 years of age can be predicted accurately from the results of lung function measurements made in infancy, and hopefully such data will facilitate the introduction of effective intervention strategies. Lung function abnormalities are more marked in symptomatic patients and, in older children, seem to reflect increased airway responsiveness rather than having a significant relationship to adverse neonatal events. The hospital readmission rate for respiratory disorders, however, is certainly adversely affected by extremely low birthweight and neonatal chronic lung disease, as well as current symptom status. These data highlight that strategies to reduce extremely premature delivery and its consequences should favourably influence respiratory morbidity in preschool children.

Differential expression of Fc receptors for IgG by monocytes and granulocytes from neonates and adults

The immature neonatal immune system is thought to result in increased risk of infection. Receptors for the Fc moiety of IgG (Fc gamma R) are important in antibody-mediated clearance of microbes by granulocytes and monocytes/macrophages. As an approach to understanding their role in neonatal life, we have compared the constitutive expression of the three Fc receptors--Fc gamma RI (CD64), Fc gamma RII (CD32) and Fc gamma RIII (CD16)--by neonatal and adult blood monocytes and granulocytes using quantitative immunofluorescence by flow cytometry. Our results confirm that there is a small subpopulation of Fc gamma RIII-positive monocytes in adult blood, and furthermore show that this is absent or at a low percentage in cord blood samples. However, the main population of cord blood monocytes expresses low, but significantly higher levels of Fc gamma RIII than adult monocytes. No differences were seen in the quantitative expression of Fc gamma RI and Fc gamma RII. Neonatal granulocytes expressed significantly higher levels of both Fc gamma RI and Fc gamma RII but significantly lower levels of Fc gamma RIII. The data are discussed in terms of the possible role of cytokines and susceptibility to infection.

Advanced maternal age and smoking: risk factors for admission to a neonatal intensive care unit

The aim of this study was to assess if advanced maternal age and cigarette smoking increased the requirement for admission to the neonatal intensive care unit (NICU) and if those factors acted synergistically. Retrospective analysis was made of 3518 singleton pregnancies receiving antenatal care and delivering at King's College Hospital from 1 January 1992 to 31 December 1992. The maternal age was greater than 35 years in 356 women (10.1% of the total) and 49 (13.8%) of those were cigarette smokers. There was an inverse relationship between maternal age and smoking. Two hundred and fifty-nine infants were admitted to the NICU. Logistic regression analysis revealed a significant relationship between maternal age and admission (p < 0.05), but no independent effect of maternal smoking. The proportion of infants from smoking mothers of advanced age (> 35 years) admitted to the NICU, however, was greater than that from young (< or = 35 years) smoking mothers (p < 0.05). Advanced maternal age does increase the requirement for NICU admission and this effect is enhanced by smoking.

Do parental smoking and history of allergy influence cord-serum IgE?

The associations between parental smoking habits during pregnancy, family history of allergy, and IgE levels in cord-serum IgE (cIgE) were investigated prospectively in 1251 infants. Mean cIgE levels were similar in infants with positive and negative family history of allergy (0.50 and 0.54 kU/l, respectively). In infants with a positive family history of allergy whose mothers smoked more than 10 cigarettes a day, however, the mean cIgE level was significantly higher (0.78 kU/l) than that in infants of nonsmoking mothers (p = 0.011). Similarly, the mean cIgE level was significantly higher in boys (0.61 kU/l) than in girls (0.51 kU/l) of nonsmoking parents (p = 0.03). However, in infants of smoking parents, there was no significant difference in the mean cIgE level between boys and girls. A total of 178 (14%) mothers and 477 (38%) fathers were current smokers, and in 128 (10%) cases, both parents were active smokers. The mean cIgE level tended to be slightly higher in infants of smoking mothers, especially when the mother consumed more than 10 cigarettes a day (0.63 vs 0.54 kU/l) (p > 0.05). Thus, cIgE levels were higher only in genetically prone babies whose mothers consumed more than 10 cigarettes a day.

Epidemiology of meningococcal infections in children in mid-southern part of Turkey

59 patients were treated for meningococcal infections in Cukurova University Faculty of Medicine, Division of Pediatric Infectious Diseases. 50.8% of patients were male, 33.9% were under two years of age and 61% were under five. 78% of patients were admitted to hospital in winter and spring time. Meningococcal meningitis (MM) was present in 39% of patients on admission, however, meningococcemia in 27.1% and meningococcemia and meningococcic meningitis (Meningococcemia + MM) in 33.9%. Fatality rate was 18.6% and no association was found between mortality and clinical type of disease (p > 0.05), but mortality ratio decreased with an increasing age (p < 0.01). No deaths occurred among the 12 patients who received i.v. penicillin treatment shortly before admitting to hospital, on the other hand 11 of 47 patients (23.4%) without such a previous treatment died.

Ethnic origin and lung function of infants born prematurely

BACKGROUND

Ethnic origin has an important influence on the lung function of adults and young children but its effect during infancy, particularly following premature delivery, is unclear.

METHODS

The results from infants of pure Afro-Caribbean (subjects) and pure Caucasian (controls) descent, all of whom were born prematurely (median gestational age 28 weeks), were compared. Fifty subjects were each retrospectively matched with a control for gestational age, sex, and requirement for neonatal ventilation. Lung function measurements were performed at similar postnatal ages in each pair. The median postnatal ages of the two groups at the time of study was seven and eight months, respectively. Lung function was assessed by measurement of functional residual capacity (FRC) by a helium gas dilution technique and plethysmographic measurement of thoracic gas volume (TGV) and airways resistance (Raw), from which specific conductance (sGaw) was calculated.

RESULTS

No differences were found between the subjects and controls regarding FRC or TGV, but Raw was higher and sGaw lower in the subjects. The mean Raw of the subjects was 50.3 cm H2O/1/s and of the controls was 44.1 cm H2O/1/s (95% confidence intervals of the difference 1.5 to 10.9).

CONCLUSIONS

Prematurely born infants of Afro-Caribbean origin have more severe lung function abnormalities at approximately 7-8 months of age than those of Caucasian origin. This merits further investigation.

Functional residual capacity to thoracic gas volume (FRC:TGV) ratio in healthy neonates

Gas trapping has been suggested to be common in healthy newborns in the immediate postnatal period. To determine the veracity of that finding, functional residual capacity (FRC) and thoracic gas volume (TGV) were measured in such a population and the FRC:TGV ratios were related to measurements of airway resistance (RAW). FRC was assessed by a helium gas dilution technique, TGV and RAW by plethysmography. Twenty-four healthy infants born at term were studied at a median age of 2 days (range 1-5 days). None had respiratory problems, nor had their mothers undergone invasive antenatal procedures. Their median FRC, which was 27.1 (range 23.8-32.0) ml kg-1, was significantly lower than their TGV (median 29.8, range 26-33 ml kg-1, P < 0.01). The mean 'within subject' difference between FRC and TGV was 2.5 (range 0.3-5.5) ml kg-1. The median FRC:TGV ratio was 0.93 (range 0.82-0.99). Eight infants had an FRC:TGV ratio less than 0.9, two of whom were studied on the first postnatal day. No infant with a low (< 0.9) FRC:TGV ratio had an abnormal RAW. The differences between FRC and TGV demonstrated in this study were smaller than documented in earlier series, suggesting the degree of gas trapping may previously have been over-estimated.