Adaptive optics scanning laser ophthalmoscopy and optical coherence tomography (AO-SLO-OCT) system for in vivo mouse retina imaging

Optical coherence tomography (OCT) and scanning laser ophthalmoscopy (SLO) are imaging technologies invented in the 1980s that have revolutionized the field of in vivo retinal diagnostics and are now commonly used in ophthalmology clinics as well as in vision science research. Adaptive optics (AO) technology enables high-fidelity correction of ocular aberrations, resulting in improved resolution and sensitivity for both SLO and OCT systems. The potential of gathering multi-modal cellular-resolution information in a single instrument is of great interest to the ophthalmic imaging community. Although similar instruments have been developed for imaging the human retina, developing such a system for mice will benefit basic science research and should help with further dissemination of AO technology. Here, we present our work integrating OCT into an existing mouse retinal AO-SLO system, resulting in a multi-modal AO-enhanced imaging system of the living mouse eye. The new system allows either independent or simultaneous data acquisition of AO-SLO and AO-OCT, depending on the requirements of specific scientific experiments. The system allows a data acquisition speed of 200 kHz A-scans/pixel rate for OCT and SLO, respectively. It offers ∼6 µm axial resolution for AO-OCT and a ∼1 µm lateral resolution for AO-SLO-OCT imaging.

Tracking distinct microglia subpopulations with photoconvertible Dendra2 in vivo

Background

The ability to track individual immune cells within the central nervous system has revolutionized our understanding of the roles that microglia and monocytes play in synaptic maintenance, plasticity, and neurodegenerative diseases. However, distinguishing between similar subpopulations of mobile immune cells over time during episodes of neuronal death and tissue remodeling has proven to be challenging.

Methods

We recombineered a photoconvertible fluorescent protein (Dendra2; D2) downstream of the Cx3cr1 promoter commonly used to drive expression of fluorescent markers in microglia and monocytes. Like the popular Cx3cr1–GFP line (Cx3cr1^+/GFP), naïve microglia in Cx3cr1–Dendra2 mice (Cx3cr1^+/D2) fluoresce green and can be noninvasively imaged in vivo throughout the CNS. In addition, individual D2-expressing cells can be photoconverted, resulting in red fluorescence, and tracked unambiguously within a field of green non-photoconverted cells for several days in vivo.

Results

Dendra2-expressing retinal microglia were noninvasively photoconverted in both ex vivo and in vivo conditions. Local in vivo D2 photoconversion was sufficiently robust to quantify cell subpopulations by flow cytometry, and the protein was stable enough to survive tissue processing for immunohistochemistry. Simultaneous in vivo fluorescence imaging of Dendra2 and light scattering measurements (Optical Coherence Tomography, OCT) were used to assess responses of individual microglial cells to localized neuronal damage and to identify the infiltration of monocytes from the vasculature in response to large scale neurodegeneration.

Conclusions

The ability to noninvasively and unambiguously track D2-expressing microglia and monocytes in vivo through space and time makes the Cx3cr1–Dendra2 mouse model a powerful new tool for disentangling the roles of distinct immune cell subpopulations in neuroinflammation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-021-02285-x.

New mouse for tracking microglia and all mononuclear phagocytes both ex and in vivo within the CNS over time.

Dendra2 protein is stable enough to survive tissue processing for immunohistochemistry and flow cytometry quantification.

Simultaneous fluorescence imaging of Dendra2 and light scattering measurements can be used to assess the immune response to retinal damage.

Chronic in vivo imaging reveals mixed populations of microglia and monocytes during retinal degeneration.

Loss of the K+ channel Kv2.1 greatly reduces outward dark current and causes ionic dysregulation and degeneration in rod photoreceptors

Vertebrate retinal photoreceptors signal light by suppressing a circulating “dark current” that maintains their relative depolarization in the dark. This dark current is composed of an inward current through CNG channels and NCKX transporters in the outer segment that is balanced by outward current exiting principally from the inner segment. It has been hypothesized that K_v2.1 channels carry a predominant fraction of the outward current in rods. We examined this hypothesis by comparing whole cell, suction electrode, and electroretinographic recordings from K_v2.1 knockout (K_v2.1^−/−) and wild-type (WT) mouse rods. Single cell recordings revealed flash responses with unusual kinetics, and reduced dark currents that were quantitatively consistent with the measured depolarization of the membrane resting potential in the dark. A two-compartment (outer and inner segment) physiological model based on known ionic mechanisms revealed that the abnormal K_v2.1^−/− rod photoresponses arise principally from the voltage dependencies of the known conductances and the NCKX exchanger, and a highly elevated fraction of inward current carried by Ca²⁺ through CNG channels due to the aberrant depolarization. K_v2.1^−/− rods had shorter outer segments than WT and dysmorphic mitochondria in their inner segments. Optical coherence tomography of knockout animals demonstrated a slow photoreceptor degeneration over a period of 6 mo. Overall, these findings reveal that K_v2.1 channels carry 70–80% of the non-NKX outward dark current of the mouse rod, and that the depolarization caused by the loss of K_v2.1 results in elevated Ca²⁺ influx through CNG channels and elevated free intracellular Ca²⁺, leading to progressive degeneration.

Microglia Activation and Inflammation During the Death of Mammalian Photoreceptors

Photoreceptors are highly specialized sensory neurons with unique metabolic and physiological requirements. These requirements are partially met by Müller glia and cells of the retinal pigment epithelium (RPE), which provide essential metabolites, phagocytose waste, and control the composition of the surrounding microenvironment. A third vital supporting cell type, the retinal microglia, can provide photoreceptors with neurotrophic support or exacerbate neuroinflammation and hasten neuronal cell death. Understanding the physiological requirements for photoreceptor homeostasis and the factors that drive microglia to best promote photoreceptor survival has important implications for the treatment and prevention of blinding degenerative diseases like retinitis pigmentosa and age-related macular degeneration.

The Atoh7 remote enhancer provides transcriptional robustness during retinal ganglion cell development

The retinal ganglion cell (RGC) competence factor ATOH7 is dynamically expressed during retinal histogenesis. ATOH7 transcription is controlled by a promoter-adjacent primary enhancer and a remote shadow enhancer (SE). Deletion of the ATOH7 human SE causes nonsyndromic congenital retinal nonattachment (NCRNA) disease, characterized by optic nerve aplasia and total blindness. We used genome editing to model NCRNA in mice. Deletion of the murine SE reduces Atoh7 messenger RNA (mRNA) fivefold but does not recapitulate optic nerve loss; however, SEdel/knockout (KO) trans heterozygotes have thin optic nerves. By analyzing Atoh7 mRNA and protein levels, RGC development and survival, and chromatin landscape effects, we show that the SE ensures robust Atoh7 transcriptional output. Combining SE deletion and KO and wild-type alleles in a genotypic series, we determined the amount of Atoh7 needed to produce a normal complement of adult RGCs, and the secondary consequences of graded reductions in Atoh7 dosage. Together, these data reveal the workings of an evolutionary fail-safe, a duplicate enhancer mechanism that is hard-wired in the machinery of vertebrate retinal ganglion cell genesis.

Temporal speckle-averaging of optical coherence tomography volumes for in-vivo cellular resolution neuronal and vascular retinal imaging

It has been recently demonstrated that structures corresponding to the cell bodies of highly transparent cells in the retinal ganglion cell layer could be visualized noninvasively in the living human eye by optical coherence tomography (OCT) via temporal averaging. Inspired by this development, we explored the application of volumetric temporal averaging in mice, which are important models for studying human retinal diseases and therapeutic interventions. A general framework of temporal speckle-averaging (TSA) of OCT and optical coherence tomography angiography (OCTA) is presented and applied to mouse retinal volumetric data. Based on the image analysis, the eyes of mice under anesthesia exhibit only minor motions, corresponding to lateral displacements of a few micrometers and rotations of a fraction of 1 deg. Moreover, due to reduced eye movements under anesthesia, there is a negligible amount of motion artifacts within the volumes that need to be corrected to achieve volume coregistration. In addition, the relatively good optical quality of the mouse ocular media allows for cellular-resolution imaging without adaptive optics (AO), greatly simplifying the experimental system, making the proposed framework feasible for large studies. The TSA OCT and TSA OCTA results provide rich information about new structures previously not visualized in living mice with non-AO-OCT. The mechanism of TSA relies on improving signal-to-noise ratio as well as efficient suppression of speckle contrast due to temporal decorrelation of the speckle patterns, enabling full utilization of the high volumetric resolution offered by OCT and OCTA.

Aperture phase modulation with adaptive optics: a novel approach for speckle reduction and structure extraction in optical coherence tomography

Speckle is an inevitable consequence of the use of coherent light in imaging and acts as noise that corrupts image formation in most applications. Optical coherence tomographic imaging, as a technique employing coherence time gating, suffers from speckle. We present here a novel method of suppressing speckle noise intrinsically compatible with adaptive optics (AO) for confocal coherent imaging: modulation of the phase in the system pupil aperture with a segmented deformable mirror (DM) to introduce minor perturbations in the point spread function. This approach creates uncorrelated speckle patterns in a series of images, enabling averaging to suppress speckle noise while maintaining structural detail. A method is presented that efficiently determines the optimal range of modulation of DM segments relative to their AO-optimized position so that speckle noise is reduced while image resolution and signal strength are preserved. The method is active and independent of sample properties. Its effectiveness and efficiency are quantified and demonstrated by both ex vivo non-biological and in vivo biological applications.

Monocyte infiltration rather than microglia proliferation dominates the early immune response to rapid photoreceptor degeneration

Background

Activation of resident microglia accompanies every known form of neurodegeneration, but the involvement of peripheral monocytes that extravasate and rapidly transform into microglia-like macrophages within the central nervous system during degeneration is far less clear.

Methods

Using a combination of in vivo ocular imaging, flow cytometry, and immunohistochemistry, we investigated the response of infiltrating cells in a light-inducible mouse model of photoreceptor degeneration.

Results

Within 24 h, resident microglia became activated and began migrating to the site of degeneration. Retinal expression of CCL2 increased just prior to a transient period of CCR2⁺ cell extravasation from the retinal vasculature. Proliferation of microglia and monocytes occurred concurrently; however, there was no indication of proliferation in either population until 72–96 h after neurodegeneration began. Eliminating CCL2-CCR2 signaling blocked monocyte recruitment, but did not alter the extent of retinal degeneration.

Conclusions

These results demonstrate that the immune response to photoreceptor degeneration includes both resident microglia and monocytes, even at very early times. Surprisingly, preventing monocyte infiltration did not block neurodegeneration, suggesting that in this model, degeneration is limited by cell clearance from other phagocytes or by the timing of intrinsic cell death programs. These results show monocyte involvement is not limited to disease states that overwhelm or deplete the resident microglial population and that interventions focused on modulating the peripheral immune system are not universally beneficial for staving off degeneration.

Electronic supplementary material

The online version of this article (10.1186/s12974-018-1365-4) contains supplementary material, which is available to authorized users.

Adaptive-optics SLO imaging combined with widefield OCT and SLO enables precise 3D localization of fluorescent cells in the mouse retina

Adaptive optics scanning laser ophthalmoscopy (AO-SLO) has recently been used to achieve exquisite subcellular resolution imaging of the mouse retina. Wavefront sensing-based AO typically restricts the field of view to a few degrees of visual angle. As a consequence the relationship between AO-SLO data and larger scale retinal structures and cellular patterns can be difficult to assess. The retinal vasculature affords a large-scale 3D map on which cells and structures can be located during in vivo imaging. Phase-variance OCT (pv-OCT) can efficiently image the vasculature with near-infrared light in a label-free manner, allowing 3D vascular reconstruction with high precision. We combined widefield pv-OCT and SLO imaging with AO-SLO reflection and fluorescence imaging to localize two types of fluorescent cells within the retinal layers: GFP-expressing microglia, the resident macrophages of the retina, and GFP-expressing cone photoreceptor cells. We describe in detail a reflective afocal AO-SLO retinal imaging system designed for high resolution retinal imaging in mice. The optical performance of this instrument is compared to other state-of-the-art AO-based mouse retinal imaging systems. The spatial and temporal resolution of the new AO instrumentation was characterized with angiography of retinal capillaries, including blood-flow velocity analysis. Depth-resolved AO-SLO fluorescent images of microglia and cone photoreceptors are visualized in parallel with 469 nm and 663 nm reflectance images of the microvasculature and other structures. Additional applications of the new instrumentation are discussed.

A community-based cohort of 201 consecutive patients with primary Sjögren's syndrome in Israel: Ashkenazi patients compared with those of Sephardic descent

OBJECTIVE

To determine the spectrum and prevalence of the varied manifestations, associated conditions and laboratory abnormalities of patients with primary Sjögren's syndrome in Israel and compare them between individuals of Sephardic and Ashkenazi descent and with data from the literature.

METHODS

A retrospective study of a cohort of 201 consecutive patients diagnosed and followed at a single academic medical center. All cases were diagnosed using stringent criteria according to the American European Concensus Group including a labial minor salivary gland biopsy in all cases.

RESULTS

Patients' mean age was 57 years and 84% were women. Overall, more than 98% of patients had sicca symptoms of dry eyes and mouth. About 35% of the cohort had hematological manifestations--primarily immune cytopenias, protein immunoelectrophoresis abnormalities and lymphoma. About 20% had associated neurological conditions (not only peripheral but often central nervous system) and 15% had pulmonary involvement. In addition, thyroid disease, liver disease, vascular or cutaneous manifestations, synovitis, ocular and renal disease could be found. In fact, the presenting manifestation was extraglandular or an abnormal test result in 39% of the patients.

CONCLUSION

No significant differences were found in glandular or extraglandular manifestations or laboratory test results between Ashkenazi and Sephardic patients, despite their genetic differences. A negative history of sicca symptoms effectively rules out primary Sjögren's syndrome in this cohort. These symptoms may not be volunteered by patients and the large variety of extraglandular involvement patterns and associated conditions observed may dominate the patient's presentation, and mandate physicians' awareness and a high index of suspicion for a timely diagnosis.

A simple technique for minor salivary gland biopsy appropriate for use by rheumatologists in an outpatient setting

Minor salivary gland biopsy is a potentially simple procedure with high diagnostic value used primarily in the diagnosis of Sjögren's syndrome. We summarise our experience performing a simplified biopsy procedure, which is modified to allow its use by rheumatologists and other non-surgical physicians in an outpatient setting.

Agranulocytosis in Sjögren's syndrome: two case reports and analysis of 11 additional reported cases

OBJECTIVES

To report 2 patients who presented with agranulocytosis that was found to be immune-mediated and associated with occult primary Sjögren's syndrome (primary SS) and to identify and study similar cases reported in the literature.

METHODS

Two patients encountered in 2 large medical centers over a period of 5 years were studied in detail. All reported cases of agranulocytosis in primary SS identified through a MEDLINE search were reviewed.

RESULTS

Two patients presented with marked systemic symptoms alone or associated with recurrent infections. Agranulocytosis with either a pattern of maturation arrest or a hypercellular reactive bone marrow was found and was associated with "acute phase" markers, hypergammaglobulinemia, a small paraprotein peak, and high rheumatoid factor titers. A diagnosis of immune-mediated agranulocytosis associated with an occult primary SS was established and was successfully treated with intravenous immunoglobulins or prednisone. Both patients subsequently developed skin vasculitis. This rare association of agranulocytosis and Sjögren's syndrome was identified in 11 other cases and was the presenting manifestation of primary SS in 10 of 13 (77%) patients.

CONCLUSIONS

Agranulocytosis should be recognized as a rare but well-established association of primary SS. Bone marrow neutrophil production may be affected, or neutrophils may be destroyed in the circulation, by both humoral and cellular immune-mediated mechanisms. Agranulocytosis or neutropenia should be added to the varied hematologic manifestations of primary SS and may be its presenting feature and an important clue to diagnosis.

Sudden sensorineural hearing loss as a first manifestation of systemic lupus erythematosus: association with anticardiolipin antibodies

Sudden sensorineural hearing loss is a rarely reported manifestation of systemic lupus erythematosus (SLE). This condition has been most frequently seen in individuals with concomitant anticardiolipin antibody (ACL) syndrome, although a direct causal relationship remains unconfirmed. We report an unusual case of a young male with sudden unilateral hearing loss as the first manifestation of SLE. This individual was also found to be ACL positive and subsequently presented with other thrombotic manifestations compatible with this syndrome. The literature regarding this condition is reviewed and the significance of this case in fortifying the association of anticardiolipin antibodies and sensorineural hearing loss is discussed.

Cactus thorn arthritis: case report and review of the literature

Synovitis secondary to penetrating plant thorn injuries is an infrequently reported event. Despite its wide geographic distribution, thorns from the prickly pear cactus (Optunia ficusindica) are a rare source of this type of inflammatory arthritis. We hereby present an unusual case of an individual who developed an acute monoarthritis of the knee shortly after sustaining a penetrating cactus thorn injury. The clinical and pathophysiologic features of cactus thorn arthritis are reviewed and the unusual features present in this individual are highlighted. Treatment options, with an emphasis on rapid diagnosis and therapeutic interventions, are discussed. Increased physician awareness and recognition of this unusual but not rare entity are essential as a means of improving clinical outcome.

Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group

BACKGROUND

Adverse drug events (ADEs) are common in hospitalized patients, but few empirical data are available regarding the strength of patient risk factors for ADEs.

METHODS

We performed a nested case-control study within a cohort that included 4108 admissions to a stratified random sample of 11 medical and surgical units in 2 tertiary care hospitals during a 6-month period. Analyses were conducted on 2 levels: (1) using a limited set of variables available for all patients using computerized data available from 1 hospital and (2) using a larger set of variables for the case patients and matched controls from both hospitals. Case patients were patients with an ADE, and the matched control for each case patient was the patient on the same unit as the case patient with the most similar prevent length of stay. Main outcome measures were presence of an ADE, preventable ADE, or severe ADE.

RESULTS

In the cohort analysis, electrolyte concentrates (odds ratio [OR], 1.7), diuretics (OR, 1.7), and medical admission (OR, 1.6) were independent correlates of ADEs. Independent correlates of preventable ADEs in the cohort analysis were low platelet count (OR, 4.5), antidepressants (OR, 3.3), antihypertensive agents (OR, 2.9), medical admission (OR, 2.2), and electrolyte concentrates (OR, 2.1). In the case-control analysis, exposure to psychoactive drugs (OR, 2.1) was an independent correlate of an ADE, and use of cardiovascular drugs (OR, 2.4) was independently correlated with severe ADEs. For preventable ADEs, no independent predictors were retained after multivariate analysis.

CONCLUSIONS

Adverse drug events occurred more frequently in sicker patients who stayed in the hospital longer. However, after controlling for level of care and preevent length of stay, few risk factors emerged. These results suggest that, rather than targeting ADE-prone individuals, prevention strategies should focus on improving medication systems.

Music therapy and chiropractic: an integrative model of tonal and rhythmic spinal adjustment

There is a philosophical basis for the integration of treatment using music therapy and chiropractic. Perception is intimately linked to the nervous system. A relationship between spinal integrity and consciousness does exist. We can see that as spinal distortions diminish and awareness increases, there is a natural attraction toward the higher or more loving state of consciousness. Rhythms of healing and suffering are a key concept in combining music therapy with chiropractic manipulation. Donald Epstein's conceptualization of the rhythmic stages of consciousness corresponding to prescribed physiological patterns serves as a starting point for the use of rhythm in the healing process. Using interactive music, the music therapist can help facilitate a change in the patient's physical or emotional state. This occurs when the practitioner establishes an initial connection or musical validation of the patient's emotional state and assists the healing process by improvising supportive music while suggesting possibilities for resolution. We believe that the power of music can be used as a significant tool in chiropractic work to aid individuals in their healing process.

Limulus amebocyte lysate assay for detection of endotoxin in patients with sepsis syndrome. AMCC Sepsis Project Working Group

Clinical predictions alone are insufficiently accurate to identify patients with specific types of bloodstream infection; laboratory assays might improve such predictions. Therefore, we performed a prospective cohort study of 356 episodes of sepsis syndrome and did Limulus amebocyte lysate (LAL) assays for endotoxin. The main outcome measures were bacteremia and infection due to gram-negative organisms; other types of infection were secondary outcomes. Assays were defined as positive if the result was > or = 0.4 enzyme-linked immunosorbent assay units per milliliter. There were positive assays in 119 (33%) of 356 episodes. Assay positivity correlated with the presence of fungal bloodstream infection (P < .003) but correlated negatively with the presence of gram-negative organisms in the bloodstream (P = .04). A trend toward higher rates of mortality in the LAL assay-positive episodes was no longer present after adjusting for severity. Thus, results of LAL assay did not correlate with the presence of bacteremia due to gram-negative organisms or with mortality after adjusting for severity but did correlate with the presence of fungal bloodstream infection.

Tuberculosis testing. Physician attitudes and practice

OBJECTIVE

To assess physician agreement with and adoption of American Academy of Pediatrics' (AAP) recommendations on tuberculosis screening in children.

DESIGN AND PARTICIPANTS

Survey of a random sample of 1272 community pediatricians and family physicians (excluding academic institutions) in 4 mid-Atlantic states and the District of Columbia.

RESULTS

The response rate was 66%. Seventy-five percent of the respondents were aware of the 1994 AAP screening recommendations. Most (64%) test children at low risk periodically (at age 1 year, preschool age, and adolescent age), and 81% test children at high risk annually. Eighty-one percent of the respondents estimated that 10% or less of their patients were at high risk for tuberculosis. Most use patient-specific factors, geographic or community prevalence, or both as principal criteria to determine risk. Eighty-seven percent used multiple-puncture tests in 1993; this declined to 55% in 1994. Multiple-puncture tests are still used exclusively by 29% of the respondents. Ninety-one percent of those using multiple-puncture tests and 19% of those using the Mantoux test allow parents to read the test reaction. Forty-six percent of the respondents believed that if a return visit was required for reading the test reaction, 50% or less of their patients would return. Only 22% of the respondents adhere to the 1994 AAP recommendations regarding frequency, testing method, and reading the test reaction. Factors associated with adherence to AAP recommendations included physician and practice characteristics and knowledge of AAP recommendations.

CONCLUSIONS

Physician practice of tuberculosis testing varies widely; most do not adhere to the 1994 AAP recommendations. Most physicians vary the frequency and testing method based on a patient's risk status. The use of multiple-puncture tests has declined, although they are still widely used. Accurate reading of screening tests remains a major concern.

Association of serum beta-hCG levels with myosalpingeal invasion and viable trophoblast mass in tubal pregnancy

OBJECTIVE

To test the hypothesis that myosalpingeal invasion and viable trophoblast mass are associated with serum beta-hCG levels in tubal-ampullary pregnancy.

METHODS

Twenty-seven salpingectomy specimens of tubal-ampullary pregnancies were assessed for the presence or absence of myosalpingeal invasion. The mass of viable trophoblast was quantified in terms of the number of high-power fields (x400) occupied. The cases were stratified into three groups: small, less than one field; medium, one or two fields; and large, more than two fields and/or embryo present. Beta-hCG was measured before the procedure (mIU/mL, Third International Standard).

RESULTS

The mean (+/- standard error of the mean) beta-hCG level for the nine cases exhibiting myosalpingeal invasion was significantly higher than for the 18 cases without invasion (13,665 +/- 2986 versus 2169 +/- 870 mIU/mL; P = .0001). Beta-hCG levels greater than or equal to 5400 mIU/mL predicted myosalpingeal invasion in eight of nine cases (positive predictive value 89%). In contrast, levels less than 5400 mIU/mL were associated with lack of myosalpingeal invasion in 17 of 18 cases (negative predictive value 94%). The volume of trophoblast mass correlated with both beta-hCG levels (r = 0.647, P = .0003) and myosalpingeal invasion (r = 0.735, P = .0001). There was no invasion in the 13 cases in the group with small trophoblast mass, whereas two of five cases in the medium-mass group displayed myosalpingeal invasion. In this group, the mean beta-hCG for cases with myosalpingeal invasion was higher than in the cases without invasion (16,917 +/- 117 versus 3799 +/- 1094 mIU/mL; P = .003). In the group with large trophoblast mass, seven of nine specimens showed myosalpingeal invasion.

CONCLUSION

Both myosalpingeal invasion and viable trophoblast mass correlate positively with serum levels of beta-hCG. Myosalpingeal invasion is highly likely when beta-hCG levels reach 5400 mIU/mL.

Diagnosis and treatment of rheumatoid arthritis

Rheumatoid arthritis is a chronic, inflammatory, connective-tissue disease that has well-defined clinical and laboratory characteristics. The management of rheumatoid arthritis requires an aggressive multidisciplinary treatment combining both pharmacologic and nonpharmacologic measures. Using this approach, most patients with rheumatoid arthritis can maintain their functional capacity while having their pain and suffering relieved.

New incision for penile surgery

We present a recent modification of the surgical incision used for patients with Peyronie's disease of the dorsal penile shaft and/or who require a concomitant complete dorsal vein ligation procedure. This approach spares the penile skin from trauma and torsion, and allows for improved access to the more proximal penile shaft. Our experience to date has demonstrated no evidence of increased morbidity with excellent cosmetic results.

Upper tract transitional cell carcinoma following treatment of superficial bladder cancer with BCG

Eighty-two consecutive patients treated with intravesical bacillus Calmette-Guerin (BCG) for recurrent superficial bladder tumors were evaluated for development of metachronous upper tract tumors (UTT). All patients had normal upper tract studies within three months of starting BCG treatment. With a median follow-up of sixty-two months (range 25 to 124), 11 patients (13.4%) were found to have UTT. The median interval between initiation of BCG therapy and diagnosis of the UTT occurrence was thirty-eight months (range 7 to 110). All patients were asymptomatic when the UTT was diagnosed. An abnormal surveillance intravenous or retrograde pyelogram was the method of diagnosis in 8 patients. Positive cytology alone directed diagnoses in 2 patients, and 1 patient was diagnosed in the workup of hematuria. Overall upper tract cytology was positive in 7 of 11 patients. Nephroureterectomy was performed in 9 patients and 2 had ureteroscopic biopsy and fulguration. Median follow-up after treatment of UTT was thirty-two months (range 3 to 80). UTT pathologic stage was Pa in 2 patients, P1 in 1 patient, and P2 or higher in 8 patients. Distant metastasis developed in 7 patients, 2 patients have recurrent superficial bladder tumors, and 2 patients are free of disease. The reported incidence in the literature for UTT tumors in patients with previous superficial or muscle invasive tumors ranges from 1.6 percent to 8.5 percent. The 13.4 percent incidence of UTT in the present study demonstrates the increased risk for patients in this series who were selected for BCG therapy. These risk factors include high tumor grade, associated carcinoma in situ (CIS), multiple tumors, T1 tumors, and failure of prior intravesical therapy. The fact that all patients were asymptomatic at the time of diagnosis of UTT emphasizes the importance of long-term periodic surveillance with radiographic and cytologic studies of the upper tracts for patients with similar risk factors.

Reevaluation of prostate biopsy after definitive radiation therapy

We have previously reported (1987) that a positive biopsy from a clinically normal prostate eighteen months or more after interstitial Iodine 125 or external beam irradiation predicted disease progression. In the present study, all biopsies were reexamined by the same pathologist (LEL) and correlated with long-term patient status. Of twenty-six positive biopsy specimens, twenty-two were reconfirmed as positive and four were reassigned to a negative diagnosis (false positive = 15%). Seventy-two of seventy-seven negative specimens were available for reexamination and seventy were reconfirmed as negative while two were reassigned to a positive diagnosis (false negative = 2%). A statistically higher incidence of local and/or distant failure for patients with positive biopsy specimens compared with patients with negative biopsy specimens was again confirmed (p = < 0.001). However, there is a group of patients with a positive biopsy (17%) who remain clinically free of disease at greater than ten years of follow-up. Therefore, a positive biopsy is not an absolute indication of imminent failure. Our results demonstrate the technical difficulty and potential error in interpreting prostate biopsies after radiation therapy. Therapeutic decisions should be based not only on biopsy histology but must also weigh the patient's initial tumor stage and grade, current clinical examination, PSA level, age, and health.

Reduced natural killer cell activity in patients with systemic sclerosis. Correlation with clinical disease type

Natural killer (NK) cell number and function were determined in 69 systemic sclerosis (SSc) patients (41 with diffuse cutaneous SSc, 24 with limited cutaneous SSc, and 4 with scleroderma in an overlap syndrome). The results were compared with those obtained from 5 patients with Raynaud's disease and from 27 normal controls. Natural and antibody-dependent killing was reduced in the total group of SSc patients compared with controls, but these differences were primarily attributable to patients with the diffuse form of the disease who were seen early in their illness (less than 5 years after onset). NK cell numbers were not significantly reduced in patients compared with controls, although lower numbers were observed in individuals with early diffuse disease. Other clinical parameters, such as treatment with D-penicillamine or the presence of scleroderma-specific autoantibodies, did not exert an independent effect on NK cell function. These findings suggest a possible central role for NK cells in the pathogenesis of SSc.

The psycho-flexed hand

Five mentally disturbed patients had flexion contractures of the middle, ring, and little fingers of one or both hands. All gave a history of psychiatric illness manifested by depression. Since no organic etiology for the contractures was found, the authors name this condition the "psycho-flexed hand." Four of the five patients were middle-aged women who suffered long-term depression, hypochondriasis, and/or schizophrenia. The patients' severely contracted fingers often macerated the palm. Manipulation under anesthesia and splinting only temporarily relieved the contractures. Multiple complications occurred following splinting and hand therapy, as well as surgery. Therefore, caution is urged when attempting surgical correction before resolving the mental illness.

Chronic posttraumatic radial instability of the thumb metacarpophalangeal joint

Radial collateral ligament injuries accounted for 35% of 26 patients undergoing surgery for lateral instability of the thumb metacarpophalangeal joint in a 3-year period. Nine patients with chronic radial instability presented with significant disability but with a symptom complex distinct from the weak pinch and grasp of chronic ulnar instability. Functional and clinical stability was obtained in these patients with a surgical procedure that consisted of repair of the callateral ligament at the site of injury, distal advancement of the abductor pollicis brevis tendon, and repair of the abductor aponeurosis.