International students' perspectives on the genetic counseling application process

Between 2018 and 2023, one percent of matched applicants to North American genetic counseling graduate programs (GCGPs) have been international applicants (IAs). The COVID-19 pandemic led to changes in the GCGP application processes in 2020, most notably the incorporation of virtual interviews and GRE waivers, which uniquely impacted IAs. Twelve international genetic counseling (GC) students who matriculated into a U.S.-based GCGP in 2021 or 2022 participated in this qualitative study (42% of the total enrolled) to understand their application experience. Cost, location of the program, and rapport during interviews were the most important factors identified by IAs to apply to and rank the GCGPs. Shadowing and volunteer experiences relevant to GC were cited as important for applicants to learn about a genetic counseling career, but many had challenges finding opportunities in their home countries. Unique logistical challenges in taking the GRE, transcript evaluation services, and standardized English proficiency tests were described. Although virtual interviews offered the same experience as domestic applicants, the time difference was a major challenge, requiring IAs to interview through the night, creating additional stressors. Nine of 12 were re-applicants and shared that engaging with GCGPs early in the process was beneficial for improving applications and, at times, requesting waivers for transcript evaluation requirements and considering unique volunteering experiences. Participants suggested GCGPs can address barriers by providing more specific information on their websites as it pertains to IAs, and contact information for the international student office. Improving awareness of the applicants' backgrounds, home country experiences, and time zone differences would provide IAs with a more equitable application experience. Addressing these barriers could help promote diversity, equity, and inclusion allowing for more IAs and the growth of the genetic counseling profession.

Building Efficiency and Scaling With a Remote Genetic Counseling Program

Purpose A third-party telemedicine (TM) genetic counseling program was initiated at a large community oncology practice spanning 35 clinical sites with 110 clinicians and 97 advanced practice providers throughout Tennessee and Georgia. Patients and Methods Appropriate patients were referred through the electronic health record (EHR) based on current National Comprehensive Cancer Network guidelines. A combination of TM and genetic counseling assistants enhanced convenience, broadened access, and decreased no-show rates. Physician education for mutation-positive screening recommendations was provided through deep integration of dedicated genetic counseling notes in the EHR. Results From 2019 to 2022, the program expanded from 1 to 20 clinics with referrals growing from 195 to 885. An average of 82% of patients completed genetic counseling consultations over TM with more than 70% completing genetic testing. The average was 4 to 6 days from referral to consultation. The no-show rate was maintained at less than 7%. In 2023, this model supported all 35 clinics across the state. Conclusion Our program illustrates how remote genetic counseling programs are an effective choice for scaling genetics care across a large community oncology practice. Deep integration of TM genetic counseling within the EHR helps identify patients who are high risk and improves test adoption, patient keep rate, and turnaround time, helping to achieve better patient outcomes.

Systematic evidence review and meta-analysis of outcomes associated with cancer genetic counseling

PURPOSE

Genetic counseling (GC) is standard of care in genetic cancer risk assessment (GCRA). A rigorous assessment of the data reported from published studies is crucial to ensure the evidence-based implementation of GC.

METHODS

We conducted a systematic review and meta-analysis of 17 patient-reported and health-services-related outcomes associated with pre- and post-test GC in GCRA in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Twenty-five of 5393 screened articles met inclusion criteria. No articles reporting post-test GC outcomes met inclusion criteria. For patient-reported outcomes, pre-test GC significantly decreased worry, increased knowledge, and decreased perceived risk but did not significantly affect patient anxiety, depression, decisional conflict, satisfaction, or intent to pursue genetic testing. For health-services outcomes, pre-test GC increased correct genetic test ordering, reduced inappropriate services, increased spousal support for genetic testing, and expedited care delivery but did not consistently improve cancer prevention behaviors nor lead to accurate risk assessment. The GRADE certainty in the evidence was very low or low. No included studies elucidated GC effect on mortality, cascade testing, cost-effectiveness, care coordination, shared decision making, or patient time burden.

CONCLUSION

The true impact of GC on relevant outcomes is not known low quality or absent evidence. Although a meta-analysis found that pre-test GC had beneficial effects on knowledge, worry, and risk perception, the certainty of this evidence was low according to GRADE methodology. Further studies are needed to support the evidence-based application of GC in GCRA.

Bifocal Stabilisation of Acute Acromioclavicular Joint Dislocation using Suture Anchor and Temporary K-Wires: A Retrospective Analysis

Introduction

The acromioclavicular joint (ACJ) is a major link connecting the upper limb to the torso. The acromioclavicular and coracoclavicular (CC) ligaments help in stabilising the joint. We feel it is prudent to address both these ligament injuries, to achieve optimum result. This study was undertaken to analyse the results of a simple frugal surgical technique we used to deal with this injury considering stabilisation for both these ligaments.

Materials and methods

In this retrospective study, skeletally mature patients with Type III, IV or V ACJ dislocations who underwent open reduction and stabilisation of the joint with temporary K-wires, repair of the capsule and augmentation of CC ligaments with suture anchors were included. Clinico-radiological and functional outcome was evaluated. Functional assessment of the upper limb was analysed using the Disabilities of Arm, Shoulder, and Hand Score (DASH), Constant shoulder score (CSS) and Oxford shoulder score (OSS).

Results

Clinical and radiological evaluation of the 32 patients who had completed two years from the index surgery, was done. Out of the 37 patients included initially, five were lost in follow-up. Majority of the subjects included were males and type V was the most common injury. Mean pre-operative CC distance on the affected side was 13.92±4.94mm. In the immediate post-operative radiograph, it was 7.63±2.08mm and in the final follow- up was 9.36±2.75mm. Measurements were taken by two independent investigators and inter, and intra-observer reliability were analysed by Interclass correlation coefficient. Excellent functional outcome was noted despite the 1.81±1.50mm average loss of correction. At final follow-up, mean DASH score was 4.67±4.18, Oxford shoulder score was 44.06±2.44 and Constant shoulder score was 86.37±5.81. The severity of the injury had no significant effect on the functional outcome post our method of stabilisation and rehabilitation.

Conclusion

Bifocal fixation restores the multidirectional stability of the disrupted ACJ. Adequate radiological reduction, good functional outcome and simplicity of execution make this technique an undemanding one for use in regular practice.

Implementation of a telemedicine-based genetic counseling program in a large community oncology practice

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Background: Genetic testing is an integral part of cancer care. To optimally facilitate testing, genetic counselors (GC) provide interpretation and direction for treatments in certain applicable solid tumors. A telemedicine (TM) genetic counseling program was initiated in 2019 at Tennessee Oncology, a large community oncology practice spanning over 30 clinical sites throughout Tennessee and Georgia. Methods: Appropriate patients were identified and referred through the Electronic Medical Record (EMR) for genetic testing based on current National Comprehensive Cancer Network (NCCN) guidelines. All counseling sessions were scheduled over TM to the patient’s home to enhance convenience, broaden access, and decrease no-show rates. Physician education regarding result-dependent appropriate screening recommendations per NCCN for mutation positive patients were provided through email communication and dedicated GC notes in the EMR. Results: Between 2019 and 2021, GC referrals per year grew from 195 to 840. Of these referrals, 84.6% of patients completed GC consultations, all of which were facilitated through TM. Of completed consultations, 81.4% underwent testing. Average time from referral to GC consultation was 8-13 business days. The no-show rate was low (< 7%). This program started at 1 clinic in 2019 and is now offered for patient care in 16 clinics across the state. Conclusions: Our program illustrates how remote GC programs are an effective choice for scaling genetics care across a large community oncology practice. Deep integration of TM-based genetic counseling within the EMR helps identify high-risk patients, improves test adoption, patient keep-rate and turn-around-time therefore helping to better patient outcomes. This quality assurance program is an important part of comprehensive cancer care that we can provide to our patients and their families.

De novo EGFR T790M mutations in a community-based oncology practice

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Background: With the 2018 FDA approval of osimertinib for first-line treatment in EGFR-mutated lung cancers, the prevalence of acquired EGFR T790M mutations is expected to decrease, heightening the significance of de novo T790M mutations. Previous studies have reported a wide range of de novo T790M prevalence, and smaller retrospective studies have indicated that germline T790M may comprise the majority of de novo T790M mutations. Here, we assess the frequency of de novo T790M mutations in a community-based setting and report on germline T790M mutations occurring within this population. Methods: Patients with T790M-positive lung cancer were identified using Sarah Cannon’s clinicogenomics database containing information for patients treated within the Sarah Cannon research network. All T790M mutations were detected on tissue- and plasma-based NGS tests delivered as part of routine care. De novo and germline EGFR T790M status was determined via manual electronic health record chart review. When available, allele fraction and %cfDNA values were extracted from the structured NGS report and analyzed separately. Results: Of T790M-positive lung cancers with available pretreatment testing results, 36% (16/44) were confirmed to be T790M+ prior to EGFR TKI exposure; five of these patients received germline testing, and all five were confirmed to have originated in the germline. Two patients with germline T790M mutations detected on testing ordered by external providers were added to our de novo T790M+ patient analysis after chart review. Co-occurring EGFR mutations, including L858R, were detected in pre-TKI samples for 78% (14/18) of de novo T790M+ patients (Table). Co-occurring mutations in TP53, KRAS, PTEN, or RB1 were detected in pre-TKI samples of all patients without co-occurring EGFR mutations. EGFR C797S was observed after osimertinib treatment in one of four patients with post-TKI testing results. Of confirmed germline T790M+ cases with available allele frequencies, 100% (4/4) had allele fractions >0.5 (tissue) and/or %cfDNA values >50% (plasma). Average allele fraction and %cfDNA values were higher for de novo T790M mutations (allele fraction: 0.5 ± 0.2; %cfDNA: 40% ± 20%) than for acquired T790M mutations (allele fraction: 0.3 ± 0.2; %cfDNA: 2% ± 2%). Conclusions: Roughly one-third of T790M mutations detected in real-world settings occur before EGFR TKI exposure and may be associated with germline inheritance. Allele frequency may be a potential indicator of de novo T790M mutations in scenarios where pre-treatment data is not available. Future studies will investigate the impact of de novo T790M mutations on treatment response and evolution of resistance mechanisms in osimertinib-treated patients. [Table: see text]

Increased ease of access to genetic counseling for low-income women with breast cancer using a point of care screening tool

Increased access to genetic counseling services is of prime importance in minority and underserved populations where genetic testing is currently underutilized. Our study tested a point of care screening tool to identify high-risk low-income patients for genetic counseling in a busy county hospital oncology clinic. Eligible breast patients treated at a "safety-net" hospital, were scored into 'high-risk' (> or = 6) or 'low-risk' (< 6) groups using a screening tool on personal and family history of cancer. Genetic counseling and testing were provided at the Vanderbilt Hereditary Cancer Program (VHCP) to all 'high-risk' and some 'low-risk' participants considered to need genetic counseling by their oncologist. Ninety-nine women with a history of breast cancer were enrolled onto the study over a period of 26 months. 53.5% (53/99) had a 'high-risk' score and ethnic predominance of African-American (60.4%). Of these, 67.9% (36/53) were counseled, and 91.6% (33/36) tested with a 9% (3/33) mutation positive rate. In the 'low-risk' group, 28.2% (13/46) still met current NCCN guidelines and were referred by their oncologist. 69.2% (9/13) were counseled and tested. The 'low-risk' group of predominantly Caucasian (41.3%) participants carried a 20% (2/10) mutation positive rate; which was later adjusted to 10% to exclude a mutation not conferring a strong breast cancer risk. The screening tool was well accepted by patients; and increased access to genetic counseling. There was a subset of breast cancer affected women under 45 with no reported family history that failed to be identified. Minor alterations to the tool would enhance concordance with current NCCN guidelines.

Partnership with an independent genetic counselor and standardized screening: Effect on the identification, referral, and genetic testing of eligible patients in a community oncology clinic

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Background: A nine provider, community oncology clinic had limited local access to genetic counseling. Additionally, the practice had no process for identifying appropriate patients for genetic counseling or testing and no method to track referrals and test results. The practice partnered with a contracted genetic counselor and a study was completed to standardize screening and follow-up and to increase referrals and testing. Methods: Baseline data on genetic testing performed in 2018 was obtained from three major genetic testing labs. Based on the NCCN guidelines for genetic assessment, the practice created automated screening reports from the EMR, supplemented by manual chart review, to identify appropriate patients for genetic counseling. Front office, clinical and billing workflows were created. Patients were scheduled to see the counselor via in-person appointments or remotely via a HIPAA compliant telemedicine platform. The genetic counseling sessions included education and consent for testing followed by review and discussion of results. Consultations and genetic testing results were documented in the practice’s EMR. Results: Baseline data showed that the clinic tested 7 patients in 2018; 2 patients in the first quarter. During the pilot from Jan-Mar 2019, 34 patients were referred for genetic counseling; 30 consented to testing. This is a 329% increase over 2018; 1400% for the first quarter. Of the 30 patients tested during the pilot, 6 were positive for a pathogenic mutation. Conclusions: By contracting with a genetic counselor, and establishing procedures for screening, counseling, consenting, testing and follow-up, the practice was able to increase the number of appropriate genetic testing considerably. This process will be scaled to multiple sites of a community practice.

The impact of variant classification on the clinical management of hereditary cancer syndromes

PURPOSE

The reclassification of genetic variants poses a significant challenge for laboratories and clinicians. Variant review has resulted in the reclassification of variants of unknown significance as well as the reclassification of previously established pathogenic and likely pathogenic variants. These reclassifications have the potential to alter the clinical management of patients with hereditary cancer syndromes.

METHODS

Results were reviewed for 1694 patients seen for hereditary cancer evaluation between August 2012 and May 2017 to determine the frequency and types of variant reclassification. Patients with reclassifications with high potential for impact were monitored for alterations in organ surveillance, prophylactic surgery, and cascade testing.

RESULTS

One hundred forty-two variants were reclassified representing 124/1694 (7.3%) patients; 11.3% of reclassifications (16/142) had a high potential for clinical impact with 94% (15/16) altering clinical management of patients with 56% (9/16) changing multiple areas of management.

CONCLUSION

While reclassifications are rare, the impact on clinical management is profound. In many cases, patients with downgraded pathogenic/likely pathogenic variants had years of unnecessary organ surveillance and underwent unneeded surgical intervention. In addition, cascade testing misidentified those at risk for developing cancers, thereby altering the management across generations. The frequency and types of alterations to clinical management highlight the need for timely variant reclassification.

Is it better to be happy or not depressed? Depression mediates the effect of psychological well-being on adverse health outcomes in older adults

OBJECTIVES

To examine the relationship between psychological well-being and depression in older adults and the relative contribution these psychological factors have on risk of functional disability, frailty, and mortality.

METHODS

This is a secondary analysis of 1668 community-dwelling older adults without dementia who participated in the second wave of the Canadian Study of Health and Aging. Baseline assessments of psychological well-being (Ryff scale) and depression (Geriatric Depression Scale; GDS) were collected. At 5-year follow-up, mortality data were collected; frailty and disability in activities of daily living were evaluated using the frailty index (FI) and the Lawton-Brody scale, respectively.

RESULTS

Area under the receiver-operating characteristic curve indicated that GDS and Ryff scores were able to independently discriminate whether individuals were considered frail (C = 0.66; C = 0.59, respectively), had limitations in basic (C = 0.64; C = 0.57, respectively) or instrumental (C = 0.70; C = 0.57, respectively) activities of daily living, or had died (C = 0.63; C = 0.57) at follow-up (all P < 0.01). Regression models in which the Ryff and GDS were included in the same model demonstrated that the GDS significantly predicted frailty, disability, and mortality, whereas the Ryff effect was not significant. Mediation analysis determined that the effect of psychological well-being on adverse outcomes was fully mediated by depression.

CONCLUSIONS

Our results suggest that although both depression and psychological well-being appear to modulate risk for adverse physical health outcomes, depression mediates this relationship. Detecting and treating depressive symptoms should be of high priority in older patients to mitigate risk of future physical health adversities including mortality. Copyright © 2016 John Wiley & Sons, Ltd.

Abstract P3-08-10: Highly accurate hereditary risk assessment tool for low-income breast cancer patients

Introduction: Genetic testing is known to improve outcomes in high-risk women by finding cancers in the earliest most treatable stage or through prophylactic measures. However, these life-saving services may not be available to low-income women due to lack of insurance or access to genetic providers. To address this need, a collaboration between the Hereditary Cancer Clinic at Vanderbilt-Ingram Cancer Center (VICC) and the Robert E. Hardy Cancer Clinic at Nashville General Hospital at Meharry Medical College (MMC) was established in 2015 to systematically screen all MMC breast cancer patients for hereditary traits and refer them for genetic counseling (1). We hypothesized that high risk women could be accurately identified using this clinic based screening tool.

Methods: MMC clinic staff screened breast cancer patients using a 10-item Family Cancer Risk Assessment tool (RISK) that has been designed for use in a busy clinic environment (2). We tested the accuracy of the RISK by comparing the results to a 3-generation pedigree and the current NCCN guidelines for referral of patients to genetic services (3). The project was approved by the IRBs at each institution and study data were collected and managed using RedCap electronic data capture tools hosted at Vanderbilt University (4). Summary statistics and Chi-square for significance were performed.

Results: 73 breast cancer patients completed the RISK during their clinic visits and 41 (56%) had a high-risk score of 6 or more. All 41 patients have been referred for genetic counseling, with 18 (44%) women having completed a pedigree interview over the phone. 11 of these 18 patients (61%) were African-American; 5 (27.7%) were Caucasian; and one each (5% each) were of Asian and Hispanic ancestry. 9/18 were diagnosed &lt; 50 years (Mean entire group =50 yrs; range 36 -57). 5/18 (27.7%) had triple negative markers on pathology and 2/18 were ER+/PR+/Her2+, and the remainder had ER+/PR+/HER2- cancers. Among the 18 patients with full pedigrees, 17 (95%) patients met current NCCN guidelines based on pedigree analysis. The one outlier had a revised RISK score based on updated information obtained during the pedigree interview. Genetic testing was offered to 10 patients seen in VICC clinic and 1 declined testing. The other 8 patients either failed (n=4) or are awaiting an appointment (n=4). No deleterious mutations were seen in those tested. 4 VUSs (BRCA2, NBN, SMARCA4, and RAD51D) were found in 3 of the 9 tested patients. No significant differences were found in race, age or type of tumor.

Conclusion: Point of care risk assessment using the Family Cancer Risk Assessment screening tool is highly accurate for identifying patients at high genetic risk for hereditary breast cancer. While the tool was completed using pen and paper, it could easily be computerized for ease of administration and calculation of risk scores. This approach benefits the busy oncologist in identifying and referring appropriate patients for genetic testing.

1. Funds awarded by GreaterGood.org. 2. Joseph G. et al. 2012 Public Health Genomics. 3. National Comprehensive Cancer Network: Genetic/High-risk Breast_Ovarian (Version 2.2016). 4. Harris et al. 2009. J Biomed Inform.

Citation Format: Wiesner GL, Rao SK, Ashworth DR, Thomas KA, Lammers PE. Highly accurate hereditary risk assessment tool for low-income breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-08-10.

Expression of VP1 protein of serotype A and O of foot-and-mouth disease virus in transgenic sunnhemp plants and its immunogenicity for guinea pigs

Recently, transgenic plants expressing immunogenic proteins of foot-and-mouth disease virus (FMDV) have been used as oral or parenteral vaccines against foot-and-mouth disease (FMD). They exhibit advantages like cost effectiveness, absence of processing, thermostability, and easy oral application. FMDV VP1 protein of single serotype has been mostly used as immunogen. Here we report the development of a bivalent vaccine with tandem-linked VP1 proteins of two serotypes, A and O, present in transgenic forage crop Crotalaria juncea. The expression of the bivalent protein in the transgenic plants was confirmed by Western blot analysis. Guinea pig reacted to orally or parenterally applied vaccine by humoral as well as cell-mediated immune responses including serum antibodies and stimulated lymphocytes, respectively. The vaccine protected the animals against a challenge with the virus of serotype A as well as O. This is the first report on the development of a bivalent FMD vaccine using a forage crop.

KEYWORDS

foot-and-mouth disease; sunnhemp; Agrobacterium tumefaciens; FMDV-VP1 gene; serotype O and A; in planta transformation; transgenic plants; bivalent vaccine.

Inter- relationship between rheumatoid arthritis and periodontitis

BACKGROUND

Periodontal medicine defines a rapidly emerging branch of Periodontology focusing on establishing a strong relationship between periodontal health and systemic health. It is speculated that the major common dysregulation which links Periodontitis with Rheumatoid arthritis (RA) is being played by the mediators of immune inflammatory response.

OBJECTIVES

To determine whether there is any relationship between periodontal disease and Rheumatoid arthritis.

METHODS

A total of 100 patients were included for the present study which was divided into two groups: one group (cases) included 50 patients attending the Department of Orthopedics, Kasturba Medical College, Manipal who were diagnosed of Rheumatoid arthritis. Another subject population included 50 patients as controls attending the Department of Oral Medicine, Manipal College of Dental Sciences, Manipal with age and gender matched with those of rheumatoid arthritis group. Specific measures for periodontitis included plaque index, gingival index, number of missing teeth, and radiographic alveolar bone loss scores. Measures of rheumatoid arthritis included health assessment questionaires, levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Various periodontal parameters were compared between the cases and controls.

RESULTS

The average alveolar bone loss was statistically more severe in Rheumatoid arthritis (RA) group than in the controls although there were similar plaque index in both the groups. The gingival index was statistically higher in the RA group. The Erythrocyte Sedimentation Rate (ESR) and C- Reactive Protein (CRP) levels of RA patients were also significantly associated with the severity of periodontal disease.

CONCLUSION

There was a significant association between Rheumatoid arthritis and Periodontitis which may be due to a common underlying deregulation of the inflammatory response in these individuals.

A single intramuscular injection of rAAV-mediated mutant erythropoietin protects against MPTP-induced parkinsonism

Erythropoietin (Epo) is neuroprotective in a number of preparations, but can lead to unacceptably high and even lethal hematocrit levels. Recent reports show that modified Epo variants confer neuroprotection in models of glaucoma and retinal degeneration without raising hematocrit. In this study, neuroprotective effects of two Epo variants (EpoR76E and EpoS71E) were assessed in a model of Parkinson's disease. The constructs were packaged in recombinant adeno-associated viral (rAAV) vectors and injected intramuscularly. After 3 weeks, mice received five daily injections of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and were killed 5 weeks later. The MPTP-lesioned mice pretreated with rAAV.eGFP (negative control) exhibited a 7- to 9-Hz tremor and slower latencies to move on a grid test (akinesia). Both of these symptomatic features were absent in mice pretreated with either modified Epo construct. The rAAV.eGFP-treated mice lesioned with MPTP exhibited a 41% reduction in tyrosine hydroxylase (TH)-positive neurons in the substantia nigra. The rAAV.EpoS71E construct did not protect nigral neurons, but neuronal loss in mice pretreated with rAAV.EpoR76E was only half that of rAAV.eGFP controls. Although dopamine levels were normal in all groups, 3,4-dihydroxyphenylacetic acid (DOPAC) was significantly reduced only in MPTP-lesioned mice pretreated with rAAV.eGFP, indicating reduced dopamine turnover. Analysis of TH-positive fibers in the striatum showed normalized density in MPTP-lesioned mice pretreated with rAAV.EpoS71E, suggesting that enhanced sprouting induced by EpoS71E may have been responsible for normal behavior and dopaminergic tone in these mice. These results show that systemically administered rAAV-generated non-erythropoietic Epo may protect against MPTP-induced parkinsonism by a combination of neuroprotection and enhanced axonal sprouting.

Effect of tibial tunnel position on arthroscopically assisted anterior cruciate ligament reconstruction using bone-patellar tendon-bone grafts: a prospective study

INTRODUCTION

The aim of this research was to study the effect of the tibial tunnel position in anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) grafts in ensuring optimal knee functioning.

METHODS

A prospective study was conducted on 41 patients who underwent arthroscopically assisted ACL reconstruction using a BPTB graft and who were followed up for a minimum period of two years. The radiographic position of the tibial tunnel was compared with the clinical outcome using the International Knee Documentation Committee (IKDC) and modified Lysholm knee scores at two years after surgery.

RESULTS

Six out of eight patients with a fair outcome based on the modified Lysholm score and five out of eight patients with an abnormal outcome based on the IKDC score had their tibial tunnel within the 10 percent to 25 percent anteroposterior width of the tibial plateau. The tibial tunnel of patients with a fair Lysholm outcome (mean 22.2 percent) was significantly anterior compared to that of those with an excellent (mean 38.1 percent) and good (mean 34.1 percent) outcome (p is less than 0.01). The analysis using the IKDC score showed a similar trend.

CONCLUSION

Placing the tibial tunnel in the anterior 25 percent of the tibial plateau is associated with a poor knee outcome. More predictable results can be achieved through 35 percent to 46 percent anteroposterior placement of the tibial tunnel.

Study of the efficacy of toothpaste containing casein phosphopeptide in the prevention of dental caries: a randomized controlled trial in 12- to 15-year-old high caries risk children in Bangalore, India

Casein phosphopeptide (CPP) has the potential to be added to mouth rinses, gels, toothpastes, chewing gums and confectioneries. Until now CPP has been studied in vitro, in situ and in animals, but clinical trials are lacking. This study was conducted to evaluate the efficacy of CPP-containing toothpaste in preventing dental caries in schoolchildren. The study was conducted among 150 schoolchildren randomly divided into three groups, each using one of three types of toothpastes: (a) containing 2% w/w CPP; (b) containing 1,190 mg/kg fluoride as 0.76% sodium monofluorophosphate (SMFP); (c) placebo toothpaste without CPP or fluoride. Students brushed with the given toothpastes for 24 months. Oral hygiene and caries experience were assessed at baseline, 12 and 24 months. The increments in caries lesions were calculated and analyzed to assess the caries-preventive effect. A significant reduction in caries increment was observed among students using CPP toothpaste or SMFP toothpaste, compared with the group using the placebo toothpaste. The reduction in caries increment was not significantly different between the CPP and SMFP groups. Oral Hygiene Index score increased from the 12-month to the 24-month examination. It is concluded that CPP can be effectively incorporated into calcium carbonate-based toothpaste and that toothpaste containing CPP is effective in preventing caries. Toothpaste containing 2% CPP seemed to have an efficacy similar to paste containing 1,190 mg/kg SMFP in the prevention of caries.

Unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen-year follow-up report

PURPOSE

To assess surgical, visual, refractive, and aesthetic outcomes 13 years after mersilene mesh frontalis sling (MMFS) operation for severe unilateral congenital ptosis performed in 10 infants before 1 year of age.

METHODS

Longitudinal follow-up of an interventional case series by structured ocular examinations, external photographs, and questionnaire-based interviews.

RESULTS

Mean age at surgery was 6.9+/-2.7 months. After a mean follow-up of 13.0+/-0.6 years, one patient (10%) had recurrent ptosis with the upper lid 2 mm below the superior limbus at 3 months postoperatively. Best-corrected visual acuities were within two Snellen lines between the two eyes in all patients. Astigmatic errors were 1.20+/-1.00 D and 1.10+/-1.70 D between operated and unoperated eyes. Four patients had 2 mm lid lag on down-gaze and one of them had 2 mm lagophthalmos. Mean satisfaction scores (scale of 1 to 100) for lid position, cosmesis, function, and to the procedure were 83.3+/-11.8, 77.0+/-22.9, 89.4+/-5.5, and 86.8+/-6.3, respectively. No case of overcorrection, sling extrusion, stitch granuloma, or exposure keratopathy was noted.

CONCLUSIONS

In view of the low recurrence rate (10%) and absence of serious complication or need for revision after 13 years, the use of MMFS seems effective and feasible in infants less than 1 year old. Achieving compatible long-term stability, satisfactory aesthetic, and visual outcomes, MMFS may offer an alternative to delaying operations for autogenous fascia lata harvesting in infants requiring early ptosis correction.

Successful strategies for increasing African American participation in cancer genetic studies: hopeful signs for equalizing the benefits of genetic medicine

OBJECTIVE

To determine whether prior success in recruiting African Americans to an in-house cancer genetics registry could be duplicated when recruiting to a national registry requiring a significantly increased level of commitment. Additionally, to determine which recruitment sources and practices yielded the highest number of African American participants.

METHODS

A retrospective analysis of recruitment sources, practices, and results for recruitment to the Cancer Genetics Network (CGN; a national research registry), from 2000 to 2005 was conducted. These results were compared to previous experience in recruiting African Americans to the Family Cancer Registry (FCR; an in-house registry) during the period 1992-2005.

RESULTS

In the 1st year of recruitment to the CGN, African Americans accounted for 24% of those consenting to participate in the CGN registry from our center. This compares to an average annual rate of 27% for the FCR during the years 1998-2005, and a rate of less than 1% from 1992 to 1998. By 2005, African Americans accounted for 27% of CGN participants recruited through the University of Texas Southwestern Medical Center, one of eighteen participating institutions in the CGN. Hospital-based resources such as cancer treatment clinics and tumor registries yielded the highest percentage of African American participants (66.5%), and self-referral yielded the lowest (0%). Seventy-seven percent of African Americans were actively sought out and recruited from treatment clinics, whereas the vast majority of Caucasian participants were recruited passively during the course of genetic counseling sessions that were scheduled for reasons unrelated to participation in cancer research. There were no known instances of African Americans contacting CGN staff after reading printed recruitment materials or internet advertisements.

CONCLUSIONS

The increased level of commitment required of CGN participants did not deter African Americans from participating in cancer genetics research. Recruitment strategies responsible for dramatically increasing recruitment rates to the FCR from 1998 to 2000 were equally effective when used for recruitment to the CGN. The most effective recruitment sources were high-yield venues such as cancer treatment clinics and tumor registries, and active recruitment methods yielded the highest number of African American participants. Advertising through internet announcements and printed recruitment materials did not appear to be effective.

Monocular blindness due to central retinal artery occlusion in bipolar hemireplacement arthroplasty of the hip

Though rare, perioperative loss of vision after non-ocular surgeries is a disastrous complication. This has been reported after spine surgery or cardiopulmonary bypass surgery. We present an otherwise healthy 54-year-old man who underwent bipolar hemireplacement for a fractured neck of femur, and developed perioperative monocular visual loss due to central retinal artery occlusion, a complication hitherto unreported in hip replacement surgeries. The possible aetiological factors and the measures to prevent this complication are discussed.

Perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis

PURPOSE

To document the disease spectrum and evaluate the presence of perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis (VKC).

METHOD

A case-control study was conducted between November 2004 and July 2005. Patients aged 18 or younger with VKC and age-matched children attending our eye clinic for refractive or orthoptic problems were recruited and compared. Detailed slit-lamp examination was performed noting in particular the presence of perilimbal conjunctival pigmentation, the severity of papillary reaction, and corneal complications of VKC.

RESULTS

A total of 19 patients and 23 controls were evaluated. The presence of bilateral large tarsal or limbal papillae and epithelial defect were significantly associated with symptoms severity (Fisher's exact test, P=0.015 and P=0.035 respectively). All VKC patients were found to have perilimbal conjunctival pigmentation in at least one eye. There was a significant correlation in the colour and density of pigments between the two eyes (Sperman's rho=0.93, P<0.001). None of the controls was found to have such perilimbal conjunctival pigmentation (Fisher's exact test, P<0.001).

CONCLUSION

The presence of perilimbal conjunctival pigmentation appears to be a consistent clinical finding in Chinese patients with VKC and may be a useful diagnostic sign for patients with subtle signs or symptoms.

Uncemented primary press-fit total hip arthroplasty: a 3 to 6 years of experience

PURPOSE

To analyse the 3 to 6 years' clinicoradiological outcome of 45 uncemented total hip arthroplasties performed in 37 patients using cementless Spotorno stem and St Nabor cup.

METHODS

The main indications for surgery were avascular necrosis of the femoral head and rheumatoid arthritis. Younger patients with good bone quality and a trumpet-shaped femur were eligible. A single surgeon performed all the operations using a posterolateral approach. Patients were reviewed at 6 weeks, 3 months, 6 months, and yearly thereafter. The clinical status was recorded using the Harris Hip Score. All radiographs were analysed by 2 independent blinded observers on 2 separate occasions.

RESULTS

The mean follow-up period was 49 months and the mean Harris Hip Score at the latest follow-up was 94. Osseointegration in the form of trabeculae running from the endosteum to the prosthesis surface along with tropism of the calcar was evident in 73% of the hips. None of the remaining hips showed any continuous radio-opaque lines suggestive of a lack of bone ongrowth. Patients with endosteal condensation had better Harris Hip Scores. Intra-operative stability of the implants could fairly predict outcome.

CONCLUSION

Initial clinicoradiological results of uncemented total hip arthroplasty are promising in younger patients with good bone quality and a trumpet-shaped femur.

Medial collateral ligament avulsion from both tibial and femoral attachments: a case report

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee joint. Proximal MCL tears occur more frequently than do distal ones. We report a 28-year-old man with a valgus injury of his left knee joint after a fall from a motorcycle. Magnetic resonance imaging of the affected knee joint revealed complete avulsion of the superficial MCL from both its femoral and tibial insertions. The meniscofemoral portion of the deep part of the MCL was also torn and the medial meniscus was subluxated. Such a pattern, an MCL tear with subluxation of the medial meniscus, is rare.

Desmoplastic round cell tumour of the abdomen

Desmoplastic round cell tumour is a very rare tumour of childhood and young adults, and is not usually suspected as an explanation of intraabdominal or pelvic tumour. We report two cases of desmoplastic round cell tumour of the abdomen in the paediatric age group, occurring in two boys, an 11-year-old and a 13-year-old. We aim to demonstrate the imaging findings and to emphasise the importance of including this tumour in the differential diagnosis of childhood intraabdominal and pelvic tumours.

Global reconstruction of type IIIA open comminuted femoral shaft fracture with segmental bone loss in an 11-year-old girl

An 11-year-old girl with type IIIA open fracture of the femoral shaft and 4.5 cm bone loss, was treated by global reconstruction using a reamed, interlocking, intramedullary titanium nail, following meticulous primary debridement with pulsed lavage irrigation. The nail entry was carefully chosen at the lateral transtrochanteric point in order to avoid any vascular damage to the head of femur. The osteophilic nature of the titanium nail, in addition to the thick periosteum of the paediatric bone, helped satisfactory union despite a hostile environment. The child had 0-90 degrees flexion of the knee without any extensor lag at the last follow-up. To our knowledge, this is the first case described in the literature that proves the efficacy of nailing for such a fracture.

Mechanical failure in intramedullary interlocking nails

PURPOSE

To study clinical and mechanical factors that predispose to failure of interlocking nails.

METHODS

Between October 1996 and December 2002, 286 femoral fractures, 211 tibial fractures, and 47 humeral fractures were repaired using variously designed interlocking nails. Fracture pattern, level and site, nail size and type, weight bearing after nailing, and union status were reviewed after a mean follow-up of 22 months.

RESULTS

Nail failure occurred in 27 fracture repairs (17 femoral, 9 tibial, and one humeral; 13 from our institution and 14 referred from elsewhere). In 55% of failed repairs, the fracture was distal. A high rate of tibial nail failure was noted.

CONCLUSION

Distal fractures and stress concentration at the distal screws predispose to interlocking nail failure and can be prevented by protected weight bearing combined with the use of longer and larger nails. Routine supplementary cancellous bone grafting is unnecessary during renailing surgery when adequate reaming and a larger nail are used.

Thorn prick osteomyelitis of the foot in barefoot walkers: a report of four cases

Walking barefoot is common in developing countries and the feet are therefore exposed to a variety of trivial injuries, some of which lead to cellulitis or abscess formation. If left untreated or improperly managed, osteomyelitis or septic arthritis, usually involving the heel or metatarsals, may follow. In countries with limited resources, the emphasis should be on clinical assessment for diagnosis, and good surgical technique for treatment. We report 4 patients with thorn prick osteomyelitis of the foot due to walking barefoot. All were treated with thorn removal, surgical debridement, and oral ofloxacin. Surgical removal of the thorn is the key to successful treatment and to avoiding recurrent infection.

Techniques in the management of juxta-articular aggressive and recurrent giant cell tumors around the knee

AIM

Juxta-articular aggressive and recurrent giant cell tumors around the knee pose difficulties in management. This article reviews current problems and options in the management of these giant cell tumors.

METHODS

A systematic search was performed on juxta-articular aggressive and recurrent giant cell tumor. Additional information was retrieved from hand searching the literature and from relevant congress proceedings. We addressed the following issues: general consensus on early diagnosis and techniques in its management. In particular, we describe our results with resection arthrodesis performed combining the benefits of both interlocking intramedullary nail and Ilizarov fixator in the management of these tumors around the knee.

RESULTS

Mean operative age of the 22 patients undergoing resection arthrodesis was 35.63 years. Seven lesions were in the tibia and fifteen in the femur. Mean length of the bone defect was 12.34 cm. The mean external fixator index was 7.44 days/cm and the distraction index was 7.88 days/cm. Mean period of follow-up for the patients was 64.5 months. The function of the affected limb was rated excellent in 10 and good and fair in six patients each as per Enneking criteria. No local recurrence of tumor was seen. Seven complications occurred in five patients.

CONCLUSION

Two-ring construct, bifocal bone transport, and early definite plate osteosynthesis with additional bone grafting of the docking site at the end of distraction even before consolidation of the regenerate helps to reduce the problems of pin tract infections drastically. Thin-diameter long intramedullary nail in addition to preserving the endosteal blood supply also prevents mal-alignment of the regenerate. Thus resection arthrodesis using interlocking intramedullary nail and bone transport using Ilizarov fixator is cost effective and effective in achieving the desired goals of reconstruction with least complications in selected patients with specific indications.

Comparison of intra-articular analgesics for analgesia after arthroscopic knee surgery

Post Arthroscopic intra-articular analgesia is a better method to avoid post-operative pain after arthroscopic surgery, thus avoiding the adverse effects of systemic analgesics. In this prospective randomized double blind study conducted on 90 patients, 30 patients in group A received 20 ml of intra-articular saline, 30 patients in Group B received 10 ml of intra-articular saline and 10 ml of 0.25% bupivacaine and 30 patients in Group C received 10 ml of 0.25% bupivacaine, 1 ml (30 mg) of ketorolac and 9 ml of saline intra-articularly. Ambulatory status, duration of analgesia and requirement for supplemented analgesia were compared in these three groups. Patients receiving this intra-articular analgesic combination of bupivacaine and ketorolac required significantly less supplemental postoperative analgesics. This combination significantly prolonged the duration of analgesia. Patients receiving this combination of drugs for intra-articular analgesia ambulated earlier.

Bilateral spontaneous rupture of Achilles tendons: a case report

Spontaneous bilateral rupture of Achilles tendon is rare. Rupture of the Achilles tendon has been described in patients on oral corticosteroid therapy. The sudden dorsiflexion of the plantar-flexed foot is the usual mechanism of injury. Spontaneous bilateral rupture is common in the degenerated tendon, which is often seen in patients with long-term corticosteroid therapy. This case is unusual because the patient has never taken steroids. We discuss the mechanism of injury and other probable causes.

Astigmatism in Chinese preschool children: prevalence, change, and effect on refractive development

AIM

To study the prevalence, type, and progression of astigmatism in Chinese preschool children, and its effect on refractive development.

METHODS

A cross sectional study of preschool children was carried out in two randomly selected kindergartens. A cohort study was performed on a subset of children, five years after initial examination. Refractive error (measured by cycloplegic autorefraction) and axial ocular dimensions (measured by ultrasonography) were the main study outcomes.

RESULTS

522 children participated in the study; the mean age was 55.7 months (SD 10.9; range 27 to 77). Mean cylinder reading was -0.65 D (SD 0.58; range 0.00 to -4.75), and with the rule astigmatism was predominant (53%). In the 108 children studied longitudinally, the mean cylinder reading reduced from -0.62 D to -0.50 D (p = 0.019). The presence of astigmatism in initial examination predisposed the eyes towards greater myopisation (p<0.001). In addition, children with increased astigmatism had greater myopic progression (p<0.001) and axial length growth (p = 0.002).

CONCLUSIONS

This study reports a high prevalence of astigmatism in Chinese preschool children. The presence of astigmatism, and particularly with increasing astigmatism, appears to predispose the children to progressive myopia. Further studies are warranted.

Timing of fornix reconstruction for postoperative conjunctival prolapse

BACKGROUND AND OBJECTIVE

To describe fornix reconstruction for conjunctival prolapse occurring after ocular surgery.

MATERIALS AND METHODS

Two patients with persistent conjunctival prolapse of variable duration following ocular surgery underwent fornix reconstruction using the method described by Barrett. The two patients underwent different surgical methods. In the second patient, no attempt was made to include the malar periosteum.

RESULTS

Case 1 with longer duration of prolapse needed further surgery to excise residual prolapsing conjunctiva that had hyperplastic squamous epithelium. Case 2 in which fornix reconstruction was done 2 months after prolapse showed a good result after only one surgical operation.

CONCLUSION

Forniceal reconstruction is recommended for persistent postoperative conjunctival prolapse. Early surgery appears to have better results.

Corneal topography and Schirmer testing in eyes with the Hudson-Stahli line

PURPOSE

To evaluate corneal topographic features and tear secretion in eyes with the Hudson-Stahli line.

METHODS

Keratometry, computerized videokeratography and Schirmer testing were performed in 50 cases with bilateral Hudson-Stahli line, and 55 controls without the Hudson-Stahli line. Similar tests were performed in 21 subjects with unilateral Hudson-Stahli line.

RESULTS

Corneal topographic features and keratometry in the horizontal meridian were similar in cases and controls, and in fellow eyes of subjects with unilateral Hudson-Stahli line. Keratometry in the vertical meridian in cases (43.01 +/- 2.01) was significantly lesser than in controls (43.94 +/- 1.77) (P = 0.01). This value was not different in fellow eyes of patients with unilateral Hudson-Stahli line. Schirmer testing revealed significantly greater tear secretion in cases (16.72 +/- 4.99 mm) compared to controls (12.57 +/- 3.62 mm) (P < 0.01). In subjects with unilateral Hudson-Stahli line, mean Schirmer values in the eye with the line (17.52 +/- 6.86 mm) were significantly greater than in eyes without (13.67 +/- 4.64 mm) (P = 0.04).

CONCLUSION

Formation of the Hudson-Stahli line may be dependent on the presence of normal tear secretion in the eye.

Combined intravenous pulse methylprednisolone and oral cyclosporine A in the treatment of corneal graft rejection: 5-year experience

PURPOSE

To report the mid-term results of a treatment strategy using topical steroids, intravenous pulse methyl prednisolone and oral cyclosporine A (CSA) for the treatment of acute corneal graft rejection.

METHODS

Noncomparative, interventional case series. Treatment of corneal graft rejection included 1% prednisolone eye drops, intravenous infusion of 500 mg methyl prednisolone, and oral CSA in two regimens--standard dose was 15 mg/kg/day for 2 days, 7.5 mg/kg/day for 2 days, then adjusted to maintain trough blood levels of 100-200 microg/l; low dose was 2 mg/kg/day with no loading dose.

RESULTS

Outcome in 34 eyes of 34 patients (21 M;13 F) aged 60 +/- 17.7 years (range 9-83 years), who presented after an average duration of 6.6 +/- 6.3 days (range 0-30 days) following acute corneal graft rejection, are reported. Twenty-five patients received standard dose CSA while nine patients received the low dose regimen. Mean duration of treatment before reversal of graft rejection was 13.6 +/- 12.1 days (range 3-54 days). Treatment was successful in reversing the graft rejection in 32/34 (94%) eyes. Irreversible graft failure occurred in one eye in each group. During a mean follow-up period of 19.2 +/- 16.7 months (range 1-55 months), further episodes of graft rejection were seen in 1/32 (3%) eyes. Complications due to treatment included: duodenal ulcer in one patient that responded to medical treatment, and transient elevation in serum creatinine levels in three patients, which returned to normal after decrease in dosage or cessation of oral CSA.

CONCLUSION

Our 5-year experience with the use of oral CSA in the treatment of acute corneal graft rejection has shown this treatment approach to be safe and effective in reversing the rejection process. This approach may also protect the graft from subsequent episodes of allograft rejection. A randomised controlled trial to further delineate the role of CSA in reversing acute graft rejection seems warranted.

Topical chloramphenicol for eye infections

Topical chloramphenicol has been widely used in the treatment and prevention of superficial eye infections due to its broad spectrum of activity and low cost. The use of this drug has decreased considerably in the United States since the first case of aplastic anaemia associated with topical chloramphenicol was reported in the 1960s. This medication, however, is still widely used in many other countries. This paper evaluates the evidence for and against the use of topical chloramphenicol in ocular diseases.

Screening and in vitro production of diplodiatoxin from the isolates of Stenocarpella maydis and its toxigenic effect on bacterial strains

Stenocarpella maydis from different maize growing regions in South Africa were collected and screened for the presence of diplodiatoxin. The presence of diplodiatoxin in these isolates was detected by thin layer chromatography and further confirmed by atomic pressure chemical ionization mass spectrometry. Samples containing diplodiatoxin showed a strong positive ion at m/z=307. MC34, MC35, MC43 and MC50 isolates of Potchefstroom region produced high amount of diplodiatoxin, whereas some of the isolates from Potchefstroom (D72, D74, D78, D79 and D80) and Cedara (CH3 and U3H) regions did not contain diplodiatoxin. Experiments were conducted to optimize in vitro production of diplodiatoxin using the isolate MC 43. A varied range of pH (3.0 to 5.0) and various culture media viz., PDB, CME, CLM and MSM were tested. Growth of mycelium and production of diplodiatoxin was maximum in PDB media at pH 4.5 and it was observed that diplodiatoxin was produced in detectable quantity in the cultures older than 6 weeks in this media. Further, diplodiatoxin was isolated and purified from 8-weeks-old cultures of MC43 isolate and confirmed by nuclear mass resolution. The standard and the compound purified showed similar NMR spectrum. Sixty-gram (fresh weight) mycelium yielded 19.52 mg of diplodiatoxin. Effect of diplodiatoxin on the growth of various bacterial strains in agar-gelled LB media was studied. They showed different range of tolerance to diplodiatoxin. The increasing order of tolerance to diplodiatoxin was Stenocarpella maydis < B. cereus < B. subtulus < P. fluorescense < E. coli. Further, the effect of different concentrations (4.88-49.70 microg/mL) of diplodiatoxin on the growth of S. aureus in LB liquid media was studied. Presence of diplodiatoxin in the media reduced cell growth as compared to the control thus, confirming anti-bacterial activity of diplodiatoxin.

The diagnostic value of seminal a-glucosidase enzyme index for sperm motility and fertilizing capacity

OBJECTIVE

To find out the diagnostic value of seminal a-glucosidase enzyme index in the ejaculated semen samples of proven-fertility and primary infertility patients, for the sperm motility and fertilizing capacity.

METHODS

The study which lasted approximately 2 years was carried out in the Andrology Department of the Arab Fertility Center, Jeddah, Kingdom of Saudi Arabia. Eighty-five healthy male patients (age 25-38 years) were admitted into the study. They were divided into 2 main groups as proven-fertility group and primary infertility group. Each group was again subdivided into 4 classes based on the sperm concentrations. The sperm motility assessment was carried out quantitatively by Semi automated Computer assisted Semen analysis using Autosperm analyzer. Simultaneously, a-glucosidase enzyme index was determined in all the semen samples.

RESULTS

The results were tabulated as per the standard sperm motility grades of the World Health Organisation, under the classified sperm concentrations of the study. The progressive motility grades were compared with the enzyme index of a-glucosidase in both the groups. The total progressive motility was found higher in the high-density (classes I and II) than the low-density (classes III and IV) semen samples. The enzyme index readings of the various classes of sperm concentrations were significant (p<0.05) and showed a stepwise fall from 89% +/-9% to 52%+/-3% in the proven fertility group. Although, a similar trend has been observed (48%+/-5% to 20%+/-2%) in the primary infertility group, the enzyme index class II sperm concentration (44%+/-6%) was not found significant with class 1 (48%+/-5%) sperm concentration, but the significance was achieved with the other 2 classes. The readings of enzyme index between the groups were found highly significant (p, 0.001).

CONCLUSION

The enzyme index of a-glucosidase estimations in semen samples may indicate a positive correlation with progressive motility and fertilizing capacity of spermatozoa and may serve as diagnostic value in individuals showing normal levels of sperm concentration and serum androgen.

Capsulorhexis phimosis in retinitis pigmentosa despite capsular tension ring implantation

A 56-year-old man with retinitis pigmentosa presented with dense nuclear sclerosis and scattered zonular loss with laxity confirmed by ultrasound biomicroscopy. He had extracapsular cataract extraction with a 6.0 mm continuous curvilinear capsulorhexis and implantation of a capsular tension ring (CTR) and a single-piece poly(methyl methacrylate) (PMMA) intraocular lens (IOL) in the capsular bag in his left eye. Severe anterior capsule fibrosis and contracture of the capsulorhexis opening with nasal decentration of the IOL were noted 4 months after surgery. A neodymium:YAG (Nd:YAG) laser anterior capsulotomy was performed to prevent further zonular stress and IOL decentration. The centripetal forces of capsular fibrosis after cataract surgery may exceed the centrifugal resistance of the standard CTR and PMMA IOL in patients with retinitis pigmentosa. Such patients must be carefully monitored postoperatively. An Nd:YAG laser anterior capsulotomy is a safe and effective option to manage anterior capsule fibrosis.

Interface fluid after laser in situ keratomileusis

We report a case in which raised intraocular pressure (IOP) was associated with interface fluid after uneventful bilateral laser in situ keratomileusis (LASIK). The patient presented with diffuse lamellar keratitis in both eyes 3 weeks postoperatively that was treated aggressively with topical corticosteroids. A steroid-induced rise in IOP resulted in interface fluid accumulation and microcystic edema. Measurements with the Goldmann tonometer revealed an IOP of 3.0 mm Hg in both eyes. However, Schiotz tonometry recorded a pressure of 54.7 mm Hg in both eyes. Reduction in the dosage of topical corticosteroid and medical treatment of the raised IOP resulted in resolution of the microcystic edema and interface fluid accumulation. This case highlights the inaccuracies of IOP measurement after LASIK and the resulting complications.

Bilateral penetrating keratoplasty--indications, results and review of literature

PURPOSE

To analyze the indications, functional results, and rates of graft rejection and failure after bilateral penetrating keratoplasty (PK) in a major eye care hospital and research center in India.

METHODS

Retrospective review of the case records of 38 patients who underwent bilateral PK and had at least 6 months follow-up after corneal transplantation in the second eye.

RESULTS

The mean age of the 38 patients (20 M, 18 F) was 35 +/- 25 years (range, 0.5 to 79 years). Mean follow-up was 49 +/- 23 months (range, 13.4 to 116.4 months) after surgery in the first eye and 31 +/- 22 months (range, 6.6 to 103.6 months) after surgery in the second eye. The average time interval between surgery in the first and second eye was 18 +/- 10 months (range, 0 to 38 months). The commonest indications for surgery were corneal dystrophies (50%), aphakic bullous keratopathy (21%), and keratoconus (11%). Postoperatively, secondary glaucoma occurred in 2 first and 3 second eyes. Best-corrected visual acuity at last follow-up was > 6/12 in 34% of first eyes and 50% of second eyes, and was < 6/60 in 26% and 18% of first and second eyes respectively. Allograft rejection occurred in 4 of the first eyes and 3 of the second eyes. The two-year graft survival rate in first eyes was 70% and in second eyes was 83%. Worse outcomes were noted in grafts performed for secondary endothelial failure. Earlier graft failure occurred in first eyes (54 +/- 5 months) compared to second eyes (79 +/- 10 months) (Logrank Test p = 0.2311).

CONCLUSIONS

Bilateral penetrating keratoplasty has reasonable success in selected patients. Corneal transplantation in the second eye does not seem to increase the risk of graft rejection in either eye.

Influence of cage density and prior dietary phosphorus level on phosphorus requirement of commercial leghorns

Two studies were conducted to determine whether cage density and prior dietary nonphytate P (NPP) level affect hens' P requirements. In Experiment 1, hens were housed at three cage densities (300, 400, and 600 cm2 or 46.5, 62.0, and 93.0 inches2/hen) and fed four levels of NPP (0.15, 0.25, 0.35, and 0.40%) for 6 wk to determine the effect of cage density on the P requirement. Egg production (EP), feed consumption (FC), egg weight (EW), and egg specific gravity (ESG) were measured to evaluate performance. Cage density influenced EP within Week 1 (P < 0.01), and during Weeks 5 and 6, there was a cage density x NPP-level interaction (P < 0.05). At 300 cm2, EP was more severely affected by 0.15 and 0.25% NPP than at 400 and 600 cm2. A linear decrease (P < 0.001) in FC was observed because of decreased NPP. Hens at 300 cm2 consumed 4 g less feed/hen per d than hens at 400 cm2. A linear decrease in EW was observed as the NPP level decreased (P < 0.01) from 0.25 to 0.15%, and there was no effect of cage density. Experiment 2 was conducted to determine the effect of prior dietary P levels on time required to create a P deficiency. Hens fed 0.4% NPP were divided into two groups and fed 0.25 and 0.4% NPP for 4 wk. At the end of 4 wk, hens fed 0.25% NPP were further divided into three groups and were fed diets containing 0.09, 0.25, and 0.30% NPP for an additional 6 wk. Hens fed 0.4% NPP were divided into three groups and fed diets containing 0.09, 0.4, and 0.45% NPP. Reduction of NPP from 0.4 and 0.25% to 0.09% reduced EP by 8.5 and 6.8%, respectively, within 3 wk. Prior NPP levels had no influence on time required to create a P deficiency in terms of EP. Reduction of NPP from 0.4 and 0.25% to 0.09% reduced (P < 0.05) FC. A decline in FC occurred 2 wk earlier in hens previously fed 0.4% than those fed 0.25% NPP. This result indicates that hens fed 0.4% NPP became P deficient more quickly than hens fed 0.25%. We concluded that cage density and prior NPP level affect the hen P requirements or time required to create a P deficiency.