The carbon footprint of surgical operations: a systematic review update

INTRODUCTION

Sustainability in healthcare is a rapidly developing area of research with recent formal recognition from institutions around the world. We completed an update of a systematic review published in 2020. The aims of this review were to determine the reported carbon footprints of surgical operations in hospitals worldwide, identify variations in reported carbon footprints and highlight carbon hotspots associated with surgery.

METHODS

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The MEDLINE®, Embase® and Cochrane Library databases were searched, and eligibility criteria applied. The study characteristics, scope of product inventory and results were extracted and synthesised. A quality assessment of each study was completed to inform the reliability of the research.

RESULTS

1,308 articles were identified and 7 met the inclusion criteria for the review. The carbon footprint ranged from 28.49kg to 505.1kg carbon dioxide equivalents (CO2e). Medical devices and consumables were the greatest contributor to emissions, with material production and manufacture representing the majority of this carbon hotspot. There were significant methodological limitations and a lack of consistency in carbon footprint calculations between studies.

CONCLUSIONS

This systematic review identifies medical devices and consumables as the largest carbon hotspot where healthcare providers should target their sustainability initiatives. Nevertheless, the number of studies was limited and the quality of the evidence was weak. We recommend that researchers in healthcare sustainability develop international standards for conducting and reporting such studies. This would allow for comparison of individual studies and facilitate meta-analysis of cumulative evidence. A reliable evidence base is a prerequisite for identifying optimal interventions to ensure societal benefits.

Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate

AIMS

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

PATIENTS AND METHODS

Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale.

RESULTS

In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group.

CONCLUSION

The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.

Rotator cuff surgery in patients with rheumatoid arthritis: clinical outcome comparable to age, sex and tear size matched non-rheumatoid patients

Aims This study aimed to compare the clinical outcomes of rotator cuff repair in patients with rheumatoid arthritis with those of patients who have no known history of the disease. We hypothesised that the functional outcomes are comparable between patients and without rheumatoid arthritis and may be affected by the level of disease activity, as assessed from C-reactive protein (CRP) level and history of systemic steroid intake. Patients and methods We conducted a retrospective review of the institutional surgical database from May 1995 to April 2012. Twenty-nine patients with rheumatoid arthritis who had rotator cuff repair were enrolled as the study group. Age, sex, and tear size matched patients with no disease who were selected as the control group. The mean duration of follow-up was 46 months (range 24-92 months). Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) questionnaire, Constant score and visual analogue scale (VAS). All data were recorded preoperatively and at regular postoperative follow-up visits. CRP was measured preoperatively as the disease activity marker for rheumatoid arthritis. Medication history was thoroughly reviewed in the study group. Results In patients with rheumatoid arthritis, all shoulder functional scores improved after surgery (ASES 56.1-78.1, Constant 50.8-70.5 and VAS 5.2-2.5; P < 0.001). The functional outcome of surgery in patients with rheumatoid arthritis was comparable to that of the control group (difference with control: ASES 78.1 vs. 85.5, P = 0.093; Constant 70.5 vs. 75.9, P = 0.366; VAS 2.5 vs. 1.8, P = 0.108). Patients with rheumatoid arthritis who had an elevated CRP level (> 1 mg/dl) showed inferior clinical outcomes than those with normal CRP levels. Patients with a history of systemic steroid intake showed inferior functional outcomes than those who had not taken steroids. Conclusions Surgical intervention for rotator cuff tear in patients with rheumatoid arthritis improved the shoulder functional outcome comparable to that in matched patients without rheumatoid arthritis. Elevated preoperative CRP level and history of systemic steroid intake portend inferior functional outcome in patients with rheumatoid arthritis.

Profile of von Willebrand factor antigen and von Willebrand factor propeptide in an overall TIA and ischaemic stroke population and amongst subtypes

INTRODUCTION

Von Willebrand factor propeptide (VWF:Ag II) is proposed to be a more sensitive marker of acute endothelial activation than von Willebrand factor antigen (VWF:Ag). Simultaneous data on VWF:Ag and VWF:Ag II profiles are very limited following TIA and ischaemic stroke.

METHODS

In this prospective, observational, case-control study, plasma VWF:Ag and VWF:Ag II levels were quantified in 164 patients≤4weeks of TIA or ischaemic stroke (baseline), and then ≥14days (14d) and ≥90days (90d) later, and compared with those from 27 healthy controls. TIA and stroke subtyping was performed according to the TOAST classification. The relationship between VWF:Ag and VWF:Ag II levels and platelet activation status was assessed.

RESULTS

'Unadjusted' VWF:Ag and VWF:Ag II levels were higher in patients at baseline, 14d and 90d than in controls (p≤0.03). VWF:Ag levels remained higher in patients than controls at baseline (p≤0.03), but not at 14d or 90d after controlling for differences in age or hypertension, and were higher in patients at baseline and 90d after controlling for smoking status (p≤0.04). 'Adjusted' VWF:Ag II levels were not higher in patients than controls after controlling for age, hypertension or smoking (p≥0.1). Patients with symptomatic carotid stenosis (N=46) had higher VWF:Ag and VWF:Ag II levels than controls at all time-points (p≤0.002). There was no significant correlation between platelet activation status and VWF:Ag or VWF:Ag II levels.

CONCLUSIONS

VWF:Ag and VWF:Ag II levels are increased in an overall TIA and ischaemic stroke population, especially in patients with recently symptomatic carotid stenosis. VWF:Ag II was not superior to VWF:Ag at detecting acute endothelial activation in this cohort and might reflect timing of blood sampling in our study.

Complete mitochondrial genome of the Amur hedgehog Erinaceus amurensis (Erinaceidae) and higher phylogeny of the family Erinaceidae

We sequenced and characterized the complete mitogenome (KX964606) of the Amur hedgehog Erinaceus amurensis to provide more data for comparative mitogenomics of the genus Erinaceus (Erinaceidae). The mitogenome of E. amurensis is a circular molecule 16,941 bp long, consisting of a control region and a conserved set of 37 genes containing 13 protein-coding genes, 22 tRNA genes, and two rRNA genes (12S rRNA and 16S rRNA). The mitogenome of E. amurensis is AT-biased, with a nucleotide composition of 33.9% A, 21.1% C, 32.6% T, and 12.4% G. The mitogenomes of E. amurensis and the closely related hedgehog species E. europaeus, excluding the control region (66.7%), share over 90% sequence similarity. According to the inter-generic relationship based on six mitogenomes described from five genera of Erinaceidae, the subfamilies Erinaceinae and Galericinae are strongly supported as monophyletic groups, with each genus well placed within its own subfamily. Within the subfamily Erinaceinae, E. amurensis is a sister species to E. europaeus, and the relationship between Hemiechinus and Erinaceus is strongly supported. Within the subfamily Galericinae, the clade of Hylomys + Neotetracus was sister to that of Echinosorex, with clades supported by high values. Our findings will help to understand the codon usage pattern and molecular evolution of E. amurensis, and provide insight into inter-generic relationships within the family Erinaceidae. In future studies, the inclusion of mitogenomes from other genera would greatly enhance our understanding of higher phylogeny within the Erinaceidae.

The psychometric properties of the Quantitative-Checklist for Autism in Toddlers (Q-CHAT) as a measure of autistic traits in a community sample of Singaporean infants and toddlers

Background

There is growing research evidence that subclinical autistic traits are elevated in relatives of individuals with autism spectrum disorder (ASD), continuously distributed in the general population and likely to share common etiology with ASD. A number of measures have been developed to assess autistic traits quantitatively in unselected samples. So far, the Quantitative-Checklist for Autism in Toddlers (Q-CHAT) is one of very few measures developed for use with toddlers as young as 18 months, but little is known about its measurement properties and factor structure.

Methods

The present study examined internal consistency, factor structure, test-retest stability, and convergent validity of the Q-CHAT in a sample of toddlers in Singapore whose caregivers completed the Q-CHAT at 18 (n = 368) and 24 months (n = 396).

Results

Three factors were derived accounting for 38.1 % of the variance: social/communication traits, non-social/behavioral traits, and a speech/language factor. Internal consistency was suboptimal for the total and speech/language scores, but acceptable for the social/communication and non-social/behavioral factor scores. Scores were generally stable between 18 and 24 months. Convergent validity was found with the Pervasive Developmental Disorders subscale of the Child Behavior Checklist (CBCL) completed by caregivers when their children were 24 months. Q-CHAT total scores in this sample were higher than those reported in other unselected samples from the UK.

Conclusions

The Q-CHAT was found to have a three-factor structure, acceptable internal consistency for its two main factor scores (social/communication and non-social/behavioral), normally distributed scores in an unselected sample, and similar structure and measurement properties as those reported in other published studies. Findings are discussed in relation to existing literature and future directions for the validation of the Q-CHAT.

Biological nutrient and organic removal from meat packing wastewater with a unique sequence of suspended growth and fixed-film reactors

A unique sequence of anaerobic filter/suspended anaerobic/aerobic (AO) reactor/aerobic filter system was developed to alleviate the drawbacks of conventional suspended growth and fixed growth systems. An anaerobic filter (AF) was used to efficiently produce volatile fatty acids (VFAs) prior to the aerobic suspended growth. A second anaerobic reactor was installed in the A/O return activated sludge line to improve phosphorus uptake by potentially controlling glycogen accumulating organisms (GAOs). One biological aerobic filter (BAF) was used for nitrification followed by an anoxic filter for denitrification and a second BAF was used for effluent polishing. The meat packing wastewater had a biochemical oxygen demand (BOD) of 853 mg/L and total nitrogen (T-N) and total phosphorus (T-P) concentrations of 61.1 mg/L and 5.8 mg/L, respectively. The BOD removal efficiency was 99.0-99.7% and the suspended solids (SS) concentration in the effluent was below 10 mg/L. The T-N removal efficiency was maintained at greater than 75.0% except at low C/N ratios. A high T-P removal efficiency, 74.7-83.9%, was also obtained when the system was operated at a hydraulic retention time of 15.7 hrs. The AF successfully produced VFAs that aided in phosphorus removal. Additionally, recycled concrete aggregate used as attachment media in the biological filters continuously provided micronutrients and stabilized the pH.

Liposome-complexed adenoviral gene transfer in cancer cells expressing various levels of coxsackievirus and adenovirus receptor

PURPOSE

Loss of coxsackievirus and adenovirus receptor (CAR) is frequently observed in malignant cancer, hampering adenoviral gene therapy approaches. Complexing adenovirus with cationic liposomes can increase adenoviral transgene expression, particularly in cells with CAR-deficiency. We investigated whether other factors such as lipid composition might be involved in determining the efficiency of liposome-complexed adenoviral gene transfer in cancer cells.

MATERIAL AND METHODS

Human cancer cell lines with different expression levels of CAR were infected with a GFP transgene. The efficiency of transgene expression was assessed by determining GFP expression using FACS analysis.

RESULTS

The efficiency of liposome-complexed adenoviral gene transfer was dependent on the lipid composition constituting liposomes. Polyethylene glycol (PEG)-containing liposomes were most effective in increasing liposome-complexed adenoviral gene transfer. In CAR-deficient cells, use of PEG-containing liposomes enhanced adenoviral gene transfer, whereas in CAR-expressing cells enhancement varied depending on cell type. In some CAR-expressing cells, the effect of liposome complexing was even comparable to that in CAR-deficient cells. Increased adenoviral transgene expression following complexing with PEG-containing liposomes correlated with liposome uptake in cancer cells.

CONCLUSIONS

Liposome-complexed adenoviral gene transfer appears to depend on lipid composition and the level of liposome uptake by cancer cells, in addition to CAR levels. Our study suggest that these multiple factors should be considered in designing liposome-complexed adenoviral vectors to improve outcomes of current adenoviral cancer gene therapies.

Prolonged blood circulation of methotrexate by modulation of liposomal composition

Prolonged circulation by liposomal incorporation has been shown to enhance the therapeutic efficacy of drugs in many cases. The purpose of this study was to investigate whether the prolonged circulation of methotrexate (MTX) can be achieved by modulating the liposomal compositions. Various compositions of liposomes were prepared with 2:1 of phosphatidylcholine (PC) and cholesterol (CH) with or without distearoylphosphatidyl-ethanolamine-N-poly(ethyleneglycol) 2000 (DSPE-PEG). The MTX encapsulation efficiency depended on the type of PC used. It also appeared to increase by inclusion of DSPE-PEG. The size of liposomes decreased by the inclusion of DSPE-PEG. The inclusion of DSPE-PEG lowered the plasma-induced release of MTX from EggPC/CH and DPPC/CH liposomes, suggesting its enhancement effect on the liposomal stability. After intravenous injection to rats, the pharmacokinetics and biodistribution of MTX were significantly changed by liposomal incorporation and also by the composition of liposomes. The total body clearance of MTX incorporated in EggPC/CH, DPPC/CH, EggPC/CH/DSPE-PEG, and DPPC/CH/DSPE-PEG liposomes decreased 4.4-, 14.9-, 24.5-, and 53.1-fold, compared with that of free MTX. The ratio of MTX concentration in blood to liver and spleen after injection of DPPC/CH, EggPC/CH/DSPE-PEG, and DPPC/CH/DSPE-PEG liposomes was 5.4-, 8.5-, and 13.5-fold higher than that of EggPC/CH liposomes. Furthermore, the accumulation of MTX in the kidney, one of the organs in which MTX exhibits its toxicity, was significantly lowered by liposomal incorporation, especially by DSPE-PEG-containing liposomes. Taken together, DPPC/CH/DSPE-PEG liposomes most effectively prolonged the blood circulation, and reduced hepatosplenic and kidney uptake of MTX. DPPC/CH/DSPE-PEG liposomes may have potential as an efficient delivery system for MTX.

Effect of sodium chloride on the gelation temperature, gel strength and bioadhesive force of poloxamer gels containing diclofenac sodium

Liquid suppository systems composed of poloxamers and bioadhesive polymers were easy to administer to the anus and mucoadhesive to the rectal tissues without leakage after the dose. However, a liquid suppository system containing diclofenac sodium could not be developed using bioadhesive polymers, since the drug was precipitated in this preparation. To develop a liquid suppository system using sodium chloride instead of bioadhesive polymers, the physicochemical properties such as gelation temperature, gel strength and bioadhesive force of various formulations composed of diclofenac sodium, poloxamers and sodium chloride were investigated. The mixtures of P 407 (15%) and P 188 (15-20%) existed as a liquid at room temperature, but gelled at physiological temperature. Diclofenac sodium significantly increased the gelation temperature and weakened the gel strength and bioadhesive force, while sodium chloride did the opposite. Furthermore, the poloxamer gels with less than 1.0% of sodium chloride, in which the drug was not precipitated, were inserted into the rectum of rabbits without difficulty and leakage, and retained in the rectum of rats for at least 6 h. Our results suggested that a thermosensitive liquid suppository system with sodium chloride and poloxamers was a more physically stable and convenient rectal dosage form for diclofenac sodium.

Altered pharmacokinetics and liver targetability of methotrexate by conjugation with lactosylated albumins

To enhance the liver targetability, methotrexate (MTX) was conjugated with albumin previously substituted with varying content of lactose (L0, L5, and L24). The uptake of MTX by rat hepatocytes in vitro increased according to the increase in the lactose content on the albumin conjugates. The MTX level in the plasma and various organs was determined by counting the radioactivity of [3H]MTX and by HPLC assay, separately, to monitor the in vivo fate of MTX not only as total, regardless of forms of MTX, but also as free/intact MTX level. Conjugation of MTX with albumin alone provided the enhanced delivery of MTX to the liver, accompanied by decreased accumulation in the kidney, but by increased accumulation in other nontarget organs such lung, heart, and spleen. Lactosylation of albumin conjugates further enhanced the delivery of MTX to the liver in a lactose content-dependent manner, accompanied by decreased accumulation of MTX in the lung and heart as well as kidney. The total MTX level accumulated in the liver was 2.9-, 4.1-, and 11.0-fold higher at 1 h and 5.4-, 7.0-, and 16.5-fold higher at 4 h after injection of MTX-L0, L5, L24 albumin conjugates compared with MTX alone. MTX conjugates with lactosylated albumin provided low but prolonged level of free/intact MTX in the liver. Taken together, the pharmacokinetics and liver targetability of MTX could be favorably modulated by controlling the lactose content on the albumin conjugates. Lactosylated albumin conjugation might also provide prolonged and targeted delivery of other drugs for the treatment of liver diseases.

Development of a novel dosage form for intramuscular injection of titrated extract of Centella asiatica in a mixed micellar system

Titrated extract of Centella asiatica (TECA), a drug used in treating systemic scleroderma, is poorly water-soluble. A conventional dosage form for the intramuscular injection of TECA, propylene glycol (PG)-based TECA solution, causes severe pain after intramuscular injection. To improve the solubility of TECA and reduce pain after injection, mixed micellar systems composed of 10% surfactant mixture (Tween 20 and Tween 85) and 90% phosphate-buffered saline, pH 7.0 (PBS) were prepared. As the ratio of Tween 20 to Tween 85 increased from 0:10 to 10:0, the solubility of TECA in the mixed micellar systems increased from 7- to 26-fold compared to that in PBS (pH 7.0). The droplet size of micelles gradually decreased with the increasing ratio of Tween 20 to Tween 85 from 0:10 to 4:6, followed by an abrupt decrease in size above the ratio of 6:4. Furthermore, the micellar systems prepared with Tween 20 and Tween 85 at the ratio of 6:4, 8:2 or 10:0 could solubilize TECA more than 10 mg/ml and the resultant droplet sizes were less than 2 microm. No significant changes were observed in the droplet sizes and asiaticoside contents in these micellar formulations during storage, indicating these systems are stable for at least 60 days. Their osmotic pressures were remarkably lower than those of PG-based TECA solution and similar to that of saline solution, irrespective of dilution ratios. Most importantly, they markedly reduced the number of writhes compared with PG-based TECA solution after injection to mice. All of these results suggest that these three TECA micellar formulations prepared with Tween 20 and Tween 85 improved the solubility of TECA and reduced pain following injection, possibly due to the decrease in osmotic pressure. Thus, these micellar formulations composed of optimum ratios of Tween 20 and Tween 85 may have a potential as dosage forms for the intramuscular injection of a poorly water-soluble TECA.

Gene medicine : a new field of molecular medicine

Gene therapy has emerged as a new concept of therapeutic strategies to treat diseases which do not respond to the conventional therapies. The principle of gene therapy is to introduce genetic materials into patient cells to produce therapeutic proteins in these cells. Gene therapy is now at the stage where a number of dinical trials have been carried out to patients with gene-deficiency disease or cancer. Genetic materials for gene therapy are generally composed of gene expression system and gene delivery system. For the dinical application of gene therapy in a way which conventional drugs are used, researches have been focused on the design of gene delivery system which can offer high transfection efficiency with minimal toxicity. Currently, viral delivery systems generally provide higher transfection efficiency compared with non-viral delivery systems while non-viral delivery systems are less toxic, less immunogenic and manufacturable in large scale compared with viral systems. Recently, novel strategies towards the design of new non-viral delivery system, combination of viral and non-viral delivery systems and targeted delivery system have been extensively studied. The continued effort in this area will lead us to develop gene medicine as 'gene as a drug' in the near future.

Grb2 downregulation leads to Akt inactivation in heregulin-stimulated and ErbB2-overexpressing breast cancer cells

ErbB2 can be activated by its own overexpression or be transactivated by the heregulin polypeptide growth factor. Activation of ErbB2 leads to breast cancer cell proliferation, presumably by inducing the activation of extracellular signal-regulated kinases 1,2 (Erk1,2) and Akt. We have previously reported that the growth factor receptor bound protein-2 (Grb2) is required for the proliferation of ErbB2-overexpressing breast cancer cells. We investigated here whether Grb2 protein plays a role in heregulin-stimulated proliferation. Grb2 protein inhibition led to growth inhibition of heregulin-stimulated breast cancer cells, but not Erk1,2 inactivation. These findings are similar to our earlier observations in ErbB2-overexpressing cells. Since Akt can also be activated by heregulin, the effects of Grb2 inhibition on Akt were examined. Akt was inactivated following Grb2 downregulation in heregulin-stimulated breast cancer cells. We then examined the effects of Grb2 downregulation on Akt in ErbB2-overexpressing cells in the absence of heregulin. Similar to heregulin-stimulated cells, Grb2 inhibition also led to Akt inactivation in ErbB2-overexpressing breast cancer cells. Our results indicate that the activation of ErbB2 by heregulin or by its overexpression requires Grb2 to stimulate the Akt pathway to propagate mitogenic signals.

Effect of mitomycin-C on posterior capsule opacification in rabbit eyes

PURPOSE

To determine whether mitomycin-C can inhibit posterior capsule opacification (PCO) without causing ocular toxicity.

SETTING

Yonsei Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea.

METHODS

Mitomycin-C dissolved in sodium hyaluronate (0.2 cc of 0.2 mg/mL) was injected into the empty capsular bag for 3 minutes after endocapsular phacoemulsification in rabbit eyes. Three months after surgery, the obstruction rate of visible light caused by PCO was measured using an optical power meter.

RESULTS

The mean obstruction rate of visible light was 81.0% +/- 8.3% (SD) in the control group in which sodium hyaluronate without mitomycin-C was used, 30.5% +/- 10.1% in the group in which mitomycin-C was dissolved in sodium hyaluronate, and 71.9% +/- 6.8% in the group in which mitomycin-C was dissolved in a balanced salt solution. Statistically significant differences were found among all 3 groups.

CONCLUSIONS

Our results suggest that the application of mitomycin-C dissolved in sodium hyaluronate effectively reduces PCO in rabbit eyes.

Scleral fixation technique using 2 corneal tunnels for a dislocated intraocular lens

Several techniques are used to reposition dislocated intraocular lenses (IOLs). Most place a suture loop around the end of the haptic. However, in cases of a dislocated capsular bag containing the IOL, a dislocated IOL with a large haptic, or a miotic pupil, it is not easy to see the haptic ends to place the suture loop. We describe a scleral fixation technique that uses 2 corneal tunnels. A double-armed 10-0 polypropylene suture loop can be introduced through 1 corneal tunnel and placed around any accessible part of the haptic with the help of a bent 26 gauge needle. This modified technique is an easy and effective way to reposition the IOL.

Multiple peripheral nerve compressions related to malignantly transformed hereditary multiple exostoses

Autosomal dominantly transmitted hereditary multiple exostoses is an uncommon disorder consisting of multiple projections of bone capped by cartilage. The lesions are most numerous in the metaphyses of long bones but may appear on flat bones. Sarcomatous transformation occurs in 1-25% of patients. We report a 33-year-old man with sciatica, previously diagnosed as hereditary multiple exostoses, presenting with multiple peripheral nerve compressions. Electrodiagnostic studies showed profound axon-loss multiple neuropathies involving the sciatic, superior gluteal, and inferior gluteal nerves. Magnetic resonance imaging of the left pelvis showed a large mass in the sacral area that was suggestive of a chondrosarcoma. An open intralesional excision biopsy confirmed chondrosarcoma transformed from chondromatosis. Excision of the lesion was effective in eliminating the impingement of nerves and retarding progressive osseous growth. We suggest that malignant transformation be suspected in cases with focal compression neuropathy of patients known to have multiple exostoses. Osteochondroma as a possible cause for compression neuropathy is discussed.

Effect of 0.2% brimonidine in preventing intraocular pressure elevation after Nd:YAG laser posterior capsulotomy

BACKGROUND AND OBJECTIVE

To determine the prophylactic effect of 0.2% brimonidine in reducing the elevated intraocular pressure (IOP) in patients undergoing Nd:YAG laser posterior capsulotomy.

PATIENTS AND METHODS

The 81 patients (81 eyes), who underwent Nd:YAG laser posterior capsulotomy, were allocated to two treatment groups. One drop of 0.2% brimonidine or vehicle was instilled 1 hour preoperatively and one drop immediately after capsulotomy. IOPs were measured preoperatively and 1, 2, 3, and 24 hours postoperatively.

RESULTS

Intraocular pressure decreased from the baseline in the brimonidine group by the third postoperative hour (P<0.05), while the vehicle group exhibited an increase. Intraocular pressure elevations of 5 mm Hg or greater occurred in 7.3% (3/41) in the brimonidine group compared to 20.0% (8/40) in the vehicle group. IOP elevations of 10 mm Hg or greater occurred in 2.4% (1/41) in the brimonidine group compared to 7.5% (3/40) in the vehicle group.

CONCLUSIONS

One drop of 0.2% brimonidine instilled 1 hour preoperatively and immediately after capsulotomy was found to be efficacious and safe in preventing IOP elevations that frequently follow Nd:YAG laser posterior capsulotomy.

Nocardia Keratitis After Traumatic Detachment of a Laser in situ Keratomileusis Flap

PURPOSE

Nocardia are gram-positive bacteria existing ubiquitously in the environment; they can cause keratitis. Nocardia asteroides keratitis occurred in the interface between the stromal bed and flap after traumatic detachment of the flap 4 months after an initially uncomplicated laser in situ keratomileusis (LASIK) procedure.

METHODS

Nocardia asteroides keratitis was confirmed by culture. Therapy included topical and oral trimethoprim-sulfamethoxazole.

RESULTS

Thirteen months after the trauma, the patient's spectacle-corrected visual acuity was 20/20 with a manifest refraction of -2.25 -1.00 x 30 degrees.

CONCLUSIONS

The immediate steps of management consisting of surgically lifting the corneal flap, rapid microbial identification, and proper treatment with specific antibiotics resulted in the successful treatment of Nocardia asteroides keratitis in a traumatized eye after LASIK.

The effective concentration and exposure time of mitomycin-C for the inhibition of lens epithelial cell proliferation in rabbit eyes

The proliferation of residual lens epithelial cells following cataract surgery is assumed to be a major cause of posterior capsular opacification. To assess the efficacy of mitomycin-C in preventing posterior capsular opacification, we determined the effective concentration and exposure time of mitomycin-C in inhibiting rabbit lens epithelial cell proliferation. The fourth-passaged rabbit lens epithelial cells were maintained for one day and then exposed to mitomycin-C for 1, 2, 3, and 5 minutes, respectively. There were 9 different plating concentrations of mitomycin-C with two-fold serial dilution. The maintenance of the phenotypic properties of lens epithelial cells was confirmed by continuous transcription of lambda-crystalline mRNA determined by reverse transcription-polymerase chain reaction and the polymorphism of the restriction fragment. Cell proliferation was assayed with 3H-thymidine incorporation into DNA. The fourth-passaged cells maintained the expression of lambda-crystalline mRNA, suggesting that they are phenotypically authentic lens epithelial cells. The effective concentrations and exposure time of mitomycin-C were 0.1 mg/ml for 1 minute and 2 minutes, and 0.025 mg/ml for 2 minutes. By these results, we postulated that mitomycin-C at relatively short incubation times could be clinically used for prevention of posterior capsular opacification after cataract surgery.

The effect of the haptic portion of intraocular lens on the development of posterior capsular opacification in rabbit

Using a white rabbit model, the effect of the haptic portion of the intraocular lens (IOL) and intracapsular ring on the development of posterior capsular opacification (PCO) after extracapsular cataract extraction (ECCE) with phacoemulsification was studied. Implantation of both the intracapsular ring and IOL developed less PCO than implantation of the IOL alone. ECCE followed by implantation of the intracapsular ring alone also developed less PCO than ECCE alone. Through this experimental work in a rabbit model, it could be conceived that the haptic portion of IOL and the intracapsular ring can prevent the development of PCO.

Degradation of chloronitrobenzenes by a coculture of Pseudomonas putida and a Rhodococcus sp

A single microorganism able to mineralize chloronitrobenzenes (CNBs) has not been reported, and degradation of CNBs by coculture of two microbial strains was attempted. Pseudomonas putida HS12 was first isolated by analogue enrichment culture using nitrobenzene (NB) as the substrate, and this strain was observed to possess a partial reductive pathway for the degradation of NB. From high-performance liquid chromatography-mass spectrometry and 1H nuclear magnetic resonance analyses, NB-grown cells of P. putida HS12 were found to convert 3- and 4-CNBs to the corresponding 5- and 4-chloro-2-hydroxyacetanilides, respectively, by partial reduction and subsequent acetylation. For the degradation of CNBs, Rhodococcus sp. strain HS51, which degrades 4- and 5-chloro-2-hydroxyacetanilides, was isolated and combined with P. putida HS12 to give a coculture. This coculture was confirmed to mineralize 3- and 4-CNBs in the presence of an additional carbon source. A degradation pathway for 3- and 4-CNBs by the two isolated strains was also proposed.

Recanalization of obstructed Tenckhoff peritoneal dialysis catheter: wire/stylet manipulation combined with endoluminal electrocauterization

We report the results of fluoroscopically guided wire/stylet manipulation combined with endoluminal electrocauterization in seven patients with obstructed Tenckhoff peritoneal dialysis catheters. In preparation for clinical application, electrocauterization was performed using a stone basket to recanalize surgically removed Tenckhoff catheters obstructed with omental fat ingrowing through the side holes. All ingrowing omental fat was removed easily by electrocauterization with the rotating movement of a stone basket. The technique was then applied in vivo in seven cases with ingrowing omental fat and malpositioned catheter; six (86%) were successfully recanalized. Among those six cases with initial success, four maintained good catheter function with durable patency (mean 261.3 days). No significant complication was noted.

Ideal size of an intraocular lens for capsular bag fixation

PURPOSE

To determine the ideal size of an intraocular lens (IOL) for proper capsular bag fixation in different sizes of evacuated capsular bags.

SETTING

Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea, and Storm Eye Institute Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

Fifteen eyes obtained post-mortem were divided by crystalline lens size into three groups. Intraocular lenses of five different sizes were implanted in each capsular bag. The arc of contact between the haptics and capsular equator and the capsular bag distortion with each IOL were measured and compared using posterior-view analysis.

RESULTS

The arc of contact was directly proportional to the IOL size and inversely related to the lens size. The smallest arc of contact was 2.0 mm with the smallest IOL implanted in the largest lens group. The maximum capsular bag distortion was 2.6 mm in the case of the largest IOL implantation in the smallest lens group.

CONCLUSION

Implanting an IOL smaller than 12.5 mm in a large capsular bag can result in unstable fixation, while implanting an IOL larger than 12.5 mm in a small capsular bag can result in excessive stretching and distortion of the capsular bag and surrounding zonules.

Analysis of zonular-free zone and lens size in relation to axial length of eye with age

PURPOSE

To evaluate the anatomical relationships of the zonular-free zone (ZFZ) of the anterior capsule and crystalline lens diameter in relation to the axial length of the eye with age.

SETTING

Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea, and Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHOD

Various ocular structures in 122 eyes obtained post-mortem were measured without prior preparation. The correlation between age, anterior-posterior (A-P) length and globe size, and diameters of the cornea, crystalline lens, and ZFZ were analyzed.

RESULTS

The average A-P globe length, and corneal, lens, and ZFZ diameters were 24.48, 11.67, 9.65, and 6.93 mm, respectively. There was no significant relationship between A-P length and globe size and corneal diameter in different age groups. The ZFZ size varied negligibly among age groups. There was a statistically significant correlation between lens diameter and age (correlation coefficient = 0.2647; P < .01) and lens diameter and A-P globe length (correlation coefficient = 0.3183; P < .001).

CONCLUSIONS

When choosing an intraocular lens, one should consider the patient's age and the A-P globe length. Six eyes (5%) showed unusual anterior insertion of zonular attachment, which reminds us to be prudent with a large paracentral capsulorhexis.

Anterior shift of zonular insertion onto the anterior surface of human crystalline lens with age

OBJECTIVE

This study aimed to investigate the age-related changes in the position of zonular insertion onto the anterior lens capsule.

DESIGN

The study design was an experimental cadaveric eye study.

PARTICIPANTS

Two hundred twenty-three cadaveric eyes (range, 16-100 years old) from eye banks in the United States were studied.

INTERVENTION

The zonular insertion onto the anterior capsule was detected using a modified posterior photographic technique.

MAIN OUTCOME MEASURES

The distances from the anterior zonular insertion (AZI) to the lens equator and to the ciliary sulcus, size of zonular-free zone, lens diameter, ciliary sulcus diameter, and axial length of the globe were measured.

RESULTS

Multiple regression analysis showed that age, lens diameter, and axial length of the globe had significant correlations with AZI (r2 = 0.748), among which age showed the highest relevance with AZI. Multiple regression equation was expressed as AZI = (0.0079 x age) + (0.202 x lens diameter) - (0.041 x axial length of the globe) + 0.0114. The increase in AZI was accompanied by a decrease in the size of zonular-free zone with age (r = -0.206, P < 0.001).

CONCLUSION

Aging correlates with an increase in the distance from the anterior zonular insertion to the lens equator and a decrease in zonular-free zone.

Homogeneous liposome immunoassay for insulin using phospholipase C from Clostridium perfringens

A new homogeneous liposome immunoassay system was developed in which analyte-phospholipase C conjugates are used instead of complement or melittin. This system was applied for the determination of insulin. Liposomes incorporated with calcein as a marker were prepared by the reverse-phase evaporation method. The lysis of liposomes was determined by measuring the fluorescence intensity of calcein released from liposomes and it was increased with increasing concentration of phospholipase C. Insulin was conjugated to phospholipase C by a three-step procedure with hetero-bifunctional crosslinking reagents, succinimidyl 4-(N-maleimidomethyl)cyclohexane-1-carboxylate and 3-(2-pyridyldithio)propionic acid N-hydroxysuccinimide ester. The lytic activity of phospholipase C was not affected by the reaction for conjugation. Both p-nitrophenylphosphatidylcholine hydrolytic activity and liposome lytic activity of insulin-phospholipase C conjugate were inhibited in the presence of insulin antiserum. However, lower concentration of conjugate and shorter incubation time were required when liposomes were used in the inhibition study. The antibody inhibition of conjugate-induced lysis could be reversed by addition of a competing amount of free insulin. The standard calibration curve was obtained in the range between 4 and 130 microIU/ml (r = 0.994). The detection limit (8 microIU/ml) was comparable with those of conventional heterogeneous enzyme immunoassays. This new assay approach offers a simple, sensitive, and inexpensive testing procedure for determining ultratrace amounts of bioactive substances.

[Anatomical evaluation of the anterior capsular zonular free zone in the human crystalline lens (age range, 50 approximately 100 years)]

It is important to determine the anterior capsular zonular free zone (ZFZ) in order to minimize the risk of zonular disinsertion. From this point of view the size of the ZFZ of normal suspended lenses was directly measured in 199 human eyes obtained postmortem. The cornea was completely excised and the iris removed to allow clear visualization of the anterior surface of the lens to the equator. After measuring lens diameter with a caliper, a 4 mm continuous curvilinear capsulorhexis was performed, and lens substrate was completely removed by phacoemulsification. Care was taken to minimize trauma to the zonules during surgery. The anterior insertion of the zonules was identified at high power magnification; the size of the ZFZ was measured with a caliper. The mean age was 75.5 +/- 10.3 (+/-SD) years (age range, 50 approximately 100 years). The mean diameter of the lenses was 9.72 +/- 0.31 mm. The mean diameter of the ZFZ was 6.83 +/- 0.35 mm. Statistical analysis revealed no significant correlation between the size of the ZFZ and age, or between the size of the ZFZ and lens diameter. The present study indicates that the size of the ZFZ was constant regardless of age or lens diameter.

Role of protein kinase C isozymes in activation of human immunodeficiency virus type 1 in chronically infected promonocytic cells: evidence against a role of PKC beta 1

Protein kinase C (PKC) plays an important role in activation of human immunodeficiency virus type 1 (HIV-1). Because of a molecular and biochemical heterogeneity of PKC, we have studied the effects of PKC isozymes in HIV-1 activation in a latently infected promonocytic cell line, U1, using various PKC isozyme agonists. 12-Deoxyphorbol 13-phenylacetate (dPP), an agonist of both Ca(++)-dependent and Ca(++)-independent isozymes, and thymeleatoxin (TT), an agonist of Ca(++)-dependent PKC isozymes, induced HIV-1 production at 10 nM with increase in a concentration dependent manner, whereas 12-deoxyphorbol 13-phenylacetate 20-acetate (dPPA), an PKC beta I isozyme agonist, did not induce viral production at 100 nM. We verified that dPPA induced translocation of PKC beta isozyme with the isozyme-specific monoclonal antibody using flow cytometry. This study demonstrates that activation of PKC isozymes leads to an induction of latent HIV-1 in U1 cells whereas PKC beta I isozyme may not be important.

Liposome immunoassay (LIA) with antigen-coupled liposomes containing alkaline phosphatase

Immunoliposomes were prepared and their immunoassay applications investigated. Liposomes were prepared from cholesterol and phospholipids including maleimidobenzoylphosphatidylethanolamine (MBPE) for conjunction with thiol-containing antigens. Alkaline phosphatase (APase) was entrapped in the liposome and BSA, the antigen, was modified by reaction with 3-(2-pyridyl-dithio)propionyl N-hydroxysuccinimide ester (SPDP) to introduce thiol groups for efficient coupling. BSA-coupled liposomes (immunoliposomes) were incubated with anti-BSA serum, complement, and then with APase substrate. The amount of coupled BSA was affected by the reaction time, the composition of the liposome and the BSA concentration in the reactant. The amount of enzyme released from immunoliposomes as a final result of the immunoreaction increased with increasing concentrations of complement and antibody. The liposome immunoassay offers a relatively rapid and simple testing procedure to quantitatively or qualitatively determine the presence or absence of antibodies, or antigenic materials for diagnostic purposes.

Water resource development and prevention of malaria

The construction of dams across the mouths of major tidal rivers in the development of the Kranji Reservoir, Western Catchments Scheme and the Sungei Seletar Reservoir in Singapore created suitable environmental conditions for the propagation of anopheline brackish-water breeders. The employment of foreign contract workers from malarious areas for the projects further increased the potential risk of malaria transmission. However, constant vigilance and environmental management aimed at the permanent elimination of vector breeding habitats, supplemented with chemical control and anti-parasite measures successfully prevented the reintroduction of malaria in these highly receptive and vulnerable areas.

Epidemiological aspects of an outbreak of dengue fever/dengue haemorrhagic fever in Singapore

A nation-wide outbreak of 260 cases of DF/DHF with 1 death occurred in Singapore from Apr-Sept 1986. The outbreak originated from 3 separate foci of transmission at the western, south-eastern and north-eastern parts of the island and then spread to other dengue receptive urban and suburban areas. The morbidity rate was highest in young male Chinese adults between 15 and 24 years of age. The outbreak was rapidly brought under control through destruction of adult Aedes mosquitoes, surveys and source reduction of larval breeding habitats, health education and to a certain extent law enforcement. The Aedes population was high in the main foci of transmission although the overall house index was only 1.1. Other factors which could have precipitated the outbreak included waning herd immunity of the human population and continuous introduction of dengue virus into the country.