A 27-YEAR-OLD FEMALE WITH MILD BLURRY VISION AND PROLONGED LIGHT ADJUSTMENT IN THE MORNING

PURPOSE

The following case report highlights a rare presentation of chronic myeloid leukemia-associated hyper-viscosity syndrome and provides a brief review of expected findings and treatment outcomes.

METHODS

An otherwise healthy 27-year-old woman presented to the ophthalmology clinic with mild bilateral blurriness (20/20 in both eyes) and prolonged light adaption in the morning for several months. Examination demonstrated severe bilateral venous stasis, white-centered hemorrhages, intraretinal hemorrhage, and peripheral ischemia with diffuse leakage.

RESULTS

Same-day CBC demonstrated a leukocytosis of >600,000. Subsequent bone marrow biopsy confirmed the 9,22 translocation (Philadelphia chromosome). On further examination, the patient had an enlarged cardiac silhouette, cytopenia, and splenomegaly past the umbilicus, consistent with a severe and life-threatening leukostasis.

CONCLUSION

Ocular involvement can occur in acute and chronic leukemia. Five to ten percentage of patients present to an eye physician first, without a known diagnosis. Prompt systemic treatment can result in near-complete reversal of any intraocular injury in most mild-to-moderate cases, as was the case here.

Evolution of asymmetric proptosis during the active phase of thyroid eye disease

PURPOSE

To assess the evolution of proptosis asymmetry during the active phase of bilateral thyroid eye disease (TED).

METHODS

A retrospective study was conducted on patients with bilateral, active TED. Patients were measured by a single observer, using Hertel exophthalmometry from the time of initial presentation, during the active phase of TED, to the stable phase, 24-months later. Asymmetric proptosis was defined as a >2 mm intra-orbital difference in Hertel measurements.

RESULTS

Fifty-one patients were enrolled. Patients presented at a mean time of 1.1 ± 2.9 months following the onset of TED symptoms. Stability of TED was established at 15.7 ± 12.3 months. At initial presentation, 41% of patients demonstrated asymmetric proptosis. Upon reaching the stable phase, asymmetric proptosis persisted in only 22% of patients. A decline in the rate asymmetric proptosis was greatest within the first 3 months of the active phase.

CONCLUSIONS

Asymmetric proptosis is common in the setting of early active TED and decreases by 50% when the stable phase is reached. Therefore, diagnostic imaging is not routinely required to exclude alternative pathology in the cases of asymmetric TED. Perhaps more importantly, this finding supports the surgical paradigm of stable phase, graded orbital decompression, performed when the ultimate globe positions are achieved to avoid late postoperative asymmetry, resulting from the unanticipated evolution of proptosis when surgery is performed during the active phase of TED.

Tacrolimus induced optic neuropathy in post-lung transplant patients: A series of 3 patients

Purpose

Tacrolimus is a commonly used immunosuppressant medication after lung transplantation. In rare cases, tacrolimus causes a medication-induced optic neuropathy (TON) that can lead to significant vision loss.

Observations

In this series, we describe three cases of TON, 1-10 years after medication use. Two patients were young (22yr and 33yr) females with cystic fibrosis. The last case was a 65yr male with idiopathic pulmonary fibrosis. In 2/3 cases tacrolimus serum levels were normal. Visual acuity ranged from 20/20 to 20/300, and vision loss occurred acutely to sub-acutely, over a span of 2-3 months.

Conclusions and importance

As presented here, TON can be highly variable. MRI findings are often non-specific, from normal brain findings to extensive white matter changes. There remains an unclear association with graft-versus-host disease and reduced kidney function. Visual findings are often subtle, including color vision aberration and peripheral visual field deficits, both of which usually require an ophthalmologic evaluation. When diagnosed in a timely fashion, TON is at least partially reversible in up to half of all cases. While rare, the cases described here support post-lung transplant ophthalmologic evaluation in those taking high-risk medications.

Contour Variability in Thyroid Eye Disease with Compressive Optic Neuropathy Treated with Radiation Therapy

Purpose

Few studies have evaluated the methodology by which radiation therapy (RT) for thyroid eye disease and compressive optic neuropathy is performed. The objective of this study was to retrospectively review our experience from a radiation planning standpoint and to determine whether current treatment methods provide adequate dose to target and collateral structures.

Methods

A retrospective review of 52 patients (104 orbits) with bilateral thyroid eye disease and compressive optic neuropathy treated with RT (20 Gy in 10 fractions) at our institution. RT plans were analyzed for target volumes and doses. Visual fields, color plates, and visual acuity were assessed pretreatment and at last available follow-up post RT. A standardized, anatomic contour of the retro-orbital space was applied to these retrospective plans to determine dose to the entire space, rather than the self-selected target structure.

Results

Compared with the anatomic retro-orbital space, the original contour overlapped by only 68%. Maximum and mean dose was 2134 cGy and 1910 cGy to the anatomic retro-orbital space. Consequently, 39.8% of the orbits had a mean dose <19 Gy (<17 Gy 16.4%, <18 Gy 27.6% <19 Gy 37.8%, <20 Gy 59.2%, 20-21 Gy 35.8%, >21 Gy 5%). There was no significant association of improvement in color plates (P = .07), visual fields (P = .77), and visual acuity (P = .62), based on these dose differences. When beam placement was retrospectively adjusted to include a space of 0.5 cm between the lens and the anterior beam edge, there was a 39.4% and 20.3% decrease in max and mean dose to the lens.

Conclusions

Without a standardized protocol for contouring in thyroid eye disease, target delineation was found to be rather varied, even among the same practitioner. Differences in dose to the anatomic retro-orbital space did not affect outcomes in the follow-up period. Although precise contouring of the retro-orbital space may be of little clinical consequence overall, a >0.5 cm space from the lens may significantly reduce or delay cataractogenesis.

The New Ophthalmology Internship: A Trainee Curricular Survey

Background The American Academy of Ophthalmology, in conjunction with the Accreditation Council of Graduate Medical Education (ACGME), has mandated the creation of a linked ophthalmology internship year for all programs by 2021. This mandate provides a unique opportunity to tailor a curriculum specific to the ophthalmology trainee. This study reports the results of a national survey of ophthalmology residents and fellows regarding the relevance and applicability of extramural content to their ophthalmology training.

Methods Using the online portal SurveyMonkey, an anonymous survey was sent to 119 ACGME-accredited ophthalmology residencies. It consisted of nine questions formulated to measure the perceived applicability and relevance of other specialties to ophthalmology training. Responses were summarized with descriptive statistics. Outcomes were compared by one-way analysis of variance with Tukey's post hoc analysis for between group differences and Benjamini–Hochberg for multiple comparisons.

Results Ninety-four respondents (residents and fellows) completed the survey (January–February 2020); 52.1% completed an internal medicine internship, 42.6% transitional, and 5.3% general surgery. Overall, prior internship experience was rated favorably. Otolaryngology and radiology were deemed the most relevant to ophthalmology training. Intensive care unit (ICU) was considered the least beneficial, followed by general surgery, primary care, and pediatrics. Neuroradiology was overwhelmingly preferred over general radiology. The majority of respondents reported minimal exposure to oral and maxillofacial surgery (OMFS) in medical school/internship. When choosing a reason for inclusion in the new curriculum, respondents reported a high level of surgical overlap with otolaryngology, OMFS, and plastic surgery; clinical overlap with neurology; and ophthalmic consultation with emergency medicine.

Conclusion Several specialties—notably otolaryngology, radiology, and neurology—were considered highly relevant but lacking in preresidency exposure. The preference for neuroradiology was almost unanimous. In contrast, general surgery and ICU were found to be minimally relevant. Overall, ophthalmology residents reported a high level of satisfaction with their internship experience, an important consideration when building a curriculum that will appeal to potential applicants. The findings of this survey provide a framework to build a curricular plan based on current resident and fellow experience.

First report of isolation of Aeromonas taiwanensis from India

Genus Aeromonas consists of facultative anaerobic, Gram negative Bacilli which are primary environmental inhabitants worldwide. A recently reported strain of the genus, Aeromonas taiwanensis, was found while studying the presence of infectious marine microbes in a lacustrine wetland in India, making this the first isolation report from the country.

No-Show Rates and Associated Patient Factors in an Ophthalmology Resident Practice

Background In resident family medicine practices, a >20% no-show rate is common, often resulting in suboptimal care. Few studies have evaluated resident ophthalmology practices in a similar fashion. The objective of this study was to determine no-show rates and factors related to missed appointments in a resident-based ophthalmology clinic.

Methods We reviewed 19,237 de-identified appointments over one academic year. Appointments were divided into general clinic visits and subspecialty visits (these two clinics function separately at our institution). The number of days between an appointment being made for a patient and the scheduled visit was defined as “lead time.” Each appointment was labeled “show” or “no-show.” Pertinent factors available in the analysis included lead time to appointment, patients age, month, time of day, practitioner training level (postgraduate years 2 to 4, fellow), and proximity to holiday. Subspecialty clinics included oculoplastics clinic, strabismus clinic, neuro-ophthalmology clinic, uveitis clinic, cornea clinic, glaucoma clinic, and retina clinic. Generalized linear mixed effects models were fit on the no-show status with these factors.

Results The overall no-show rate for general clinic was 31.4%. Longer lead time to appointment, younger age, afternoon appointments, new patients, December appointments, and lower residency level were associated with higher odds of no-show (p ≤ 0.05). The overall no-show rate for subspecialty clinic was 21.8%. Longer lead time to appointment, younger age, and lower residency level were associated with higher odds of no-show (p ≤ 0.05). Patients were significantly less likely to show up for retina clinic, oculoplastics clinic, and glaucoma clinic.

Conclusion The overall no-show rate in our clinic was on the higher end of reported no-show values from other specialties. Patient status and the lead time to appointment play a significant role in patient compliance. The significance of other factors (patient age, subspecialty, time of day, appointment month, and resident level) have been found in previous studies but are not consistent factors across all clinical environments.

Natural history, clinical course and predictors of interval time from initial diagnosis to development of subsequent NSCLC brain metastases

PURPOSE

Non-small cell lung cancer (NSCLC) brain metastases are associated with substantial morbidity and mortality. During recent years, accompanying dramatic improvements in systemic disease control, NSCLC brain metastases have emerged as an increasingly relevant clinical problem. However, optimal surveillance practices remain poorly defined. This purpose of this study was to further characterize the natural history, clinical course and risk factors associated with earlier development of subsequent NSCLC brain metastases to better inform clinical practice and help guide survivorship care.

METHODS

We retrospectively reviewed all institutional NSCLC brain metastasis cases treated with radiotherapy between 1997 and 2015. Exclusion criteria included presence of brain metastases at initial NSCLC diagnosis and incomplete staging information. Interval time to brain metastases and subsequent survival were characterized using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

Among 105 patients within this cohort, median interval time to development of brain metastases was 16 months. Median interval times were 29, 19, 16 and 13 months for Stage I-IV patients, respectively (P = 0.016). Additional independent predictors for earlier development of NSCLC brain metastases included non-adenocarcinomatous histopathology (HR 3.036, P < 0.001), no prior surgical resection (HR 1.609, P = 0.036) and no prior systemic therapy (HR 3.560, P = 0.004). Median survival following intracranial progression was 16 months. Delayed development of brain metastases was associated with better prognosis (HR 0.970, P < 0.001) but not survival following intracranial disease onset.

CONCLUSIONS

Collectively, our results provide valuable insights into the natural history of NSCLC brain metastases. NSCLC stage, histology, prior surgical resection and prior systemic therapy emerged as independent predictors for interval time to brain metastases.

Eye-Drop Abstinence in Glaucoma Patients Admitted to the Hospital Service: A Single Institution Assessment

PURPOSE

Anecdotally, many patients admitted to an inpatient general medicine service do not have their glaucoma eye drops started. The purpose of this study was to determine the extent of eye-drop abstinence after inpatient admission.

DESIGN

Retrospective, cross-sectional, hospital-based study.

PARTICIPANTS

Four hundred seventy-five patients admitted to the general medicine regional hospital service from January 2016 through February 2018 with a known past medical diagnosis of or active outpatient medications for glaucoma.

METHODS

The combination of an administrative database and cross-referenced patient charts were reviewed for demographic data, past medical problems, inpatient orders, intake history and physical, length of stay, and admitting diagnosis.

MAIN OUTCOME MEASURES

The effect of (1) outpatient glaucoma drops reconciliation and (2) recognition of glaucoma as a pertinent past medical problem in a patient's intake history and physical on inpatient eye-drop administration. The overall rate of eye-drop abstinence also was recorded.

RESULTS

Of 475 patients, 46.3% were women, with an average age of 80.2 years (standard deviation, 11.1 years). Average length of stay was 4.61 days (standard deviation, 3.7 days). In total, 63.8% achieved successful administration of medication on the hospital floor, resulting in a 36.2% eye-drop abstinence rate during the hospital stay. Three hundred eighty-six of 475 patients (81.3%) achieved successful glaucoma medication reconciliation. Patients with successful reconciliation had a significantly different rate of eye-drop administration (73.3% vs. 21.0%; P ≤ 0.001). Recognition of glaucoma in the history and physical occurred in only 42.5% of patients. There was a significant difference in eye-drop administration when glaucoma was included in the history and physical (75.7% vs. 55.0%; P ≤ 0.001).

CONCLUSIONS

Glaucoma treatment incurs a high rate of medication noncompliance, especially in the elderly. The present study demonstrates that more than one third of patients admitted to an academic medical center do not receive their glaucoma medications. Patients discharged to nursing homes, subacute rehabilitation, and assisted living facilities rely on appropriate discharge medication reconciliation, resulting in forced abstinence during transition of care. An emphasis on appropriate medical reconciliation and recognition of glaucoma as a pertinent past medical problem will improve rates of eye-drop discontinuation on inpatient admission significantly.

Risk of dry eye syndrome in patients treated with whole-brain radiotherapy

With improvements in systemic therapy, patients with cancer treated with whole-brain radiotherapy (WBRT) are living long enough to develop late toxicities, including dry eye syndrome. In general practice, dose to the lacrimal gland (LG) is not constrained (maximum constraint <40 Gy) in WBRT. The purpose of this study was to measure dose to the LG in WBRT and determine methods for reducing radiation exposure. We conducted a retrospective review of 70 3-dimensional (3D) conformal plans; thirty-six plans with a radiation prescription of 30 Gy in 10 fractions and 34 plans with a prescription of 37.5 Gy in 15 fractions. LGs were contoured in accordance with Freedman and Sidani (2015). Biological effective dose (BED)3 maximum constraints were calculated from 40 Gy and 20 Gy to be 32.17 Gy (30 Gy) and 36.70 Gy (37.5 Gy). Both regimens demonstrated supraorbital blocking by 3 methods: T1, bordering the supraorbital ridge; T2, no contact with supraorbital ridge; and T3, coverage of the supraorbital ridge. Mean dose for the plans with a 30-Gy prescription and the plans with a 37.5-Gy prescription was 27.5 Gy and 35.2 Gy, respectively (p ≤ 0.0001). BED3 maximum constraint (D_max) was violated 16 of 26 (61.5%) in T1 (average D_max: 32.2 Gy), 13 of 28 (46.4%) in T2 (average D_max: 32.1 Gy), and 5 of 18 (27.8%) in T3 (average D_max: 31.8 Gy) for the 30-Gy prescription. D_max was violated in 32 of 32 (100%) in T1 (average D_max: 40.1 Gy), 22 of 22 (100%) in T2 (average D_max: 40.3 Gy), and 14 of 14 (100%) in T3 (average D_max: 39.4) for the 37.5 Gy prescription. Average D_max for the 37.5-Gy prescription was highly significant in favor of T3 (p = 0.0098). Patients who receive WBRT may develop dry eye syndrome as a late toxicity. Constraints are commonly violated with a prescription of 37.5 Gy. Methods to reduce dose include T3 supraorbital blocking, an easily implementable change that may dramatically improve patient quality of life.

The Energy Index Does Not Affect Local Control of Brain Metastases Treated by Gamma Knife Stereotactic Radiosurgery

BACKGROUND

The energy index (EI) is a measure of dose homogeneity within a target volume calculated by the integral dose divided by the product of prescription dose and tumor volume.

OBJECTIVE

To assess whether a higher EI is associated with greater local control for brain metastases (BMs) treated by Gamma Knife radiosurgery (GKRS).

METHODS

We reviewed all patients treated with GKRS for BM at our institution between January 2009 and February 2014. Data on the prescription dose, prescription isodose line, minimum dose, mean dose, integral dose, tumor volume, and EI were collected. Tumor response was assessed by reviewing follow-up brain imaging studies and classified according to the Response Evaluation Criteria in Solid Tumors. Local control per lesion and dosimetric prognostic factors for local control were assessed by univariate and multivariate Cox proportional hazards regression analyses.

RESULTS

Of 213 patients treated, 126 had follow-up imaging available with a median follow-up of 6 months. Three hundred seventy-three individual tumors were analyzed. Of these, 133 showed a complete response, 157 showed a partial response, 46 remained stable, and 37 developed local failure. Tumors with EI ≥1.6 mJ·mL(-1)·Gy(-1) showed a higher rate of complete response. Local control rates at 6, 11, and 17 months were 95.4%, 86.5%, and 81.5%, respectively. On univariate analysis, the following factors were associated with higher rates of local failure: prescription doses of 16 and 18 Gy compared with a prescription dose of 20 Gy. The following factors were associated with a greater rate of local control: maximum dose and mean dose. On multivariate analysis, the only statistically significant factor associated with a greater rate of local failure was prescription dose of 16 Gy compared with 20 Gy.

CONCLUSION

GKRS for BM results in a high rate of local control with an 11-month rate of 86.5%. A higher EI was not significantly associated with a higher rate of local control on multivariate analysis. Prescription dose was found to be the only significant predictor of local control on multivariate analysis.

Breast cancer subtype as a predictor for outcomes and control in the setting of brain metastases treated with stereotactic radiosurgery

We investigated effects of breast cancer subtype on overall survival (OS), local and distant control, and time from initial diagnosis to brain metastases (BM). We also investigated advances in graded prognostic assessment (GPA) scores. A cohort of 72 patients treated for BM from breast cancer with Gamma Knife stereotactic radiosurgery at our institution from 2000 to 2014 had subtyping available and were used for this study. Median follow up for OS was 12 months and for control was 6 months. OS for luminal, HER2, and triple negative subtypes were 26, 20, and 22 months. OS when stratified by Sperduto et al. (J Clin Oncol 30(4):419-425, 2012) and Subbiah et al. (J Clin Oncol 33(20):2239-2245, 2015) GPAs were similar (p = 0.087 and p = 0.063). KPS and treatment modality were significant for OS (p = 0.002; p = 0.034). On univariate analysis, triple negative subtype and >3 BM were trending and significant for decreased OS (p = 0.084; p = 0.047). On multivariable analysis HER2, triple negative, and >3 BM were significant for OS (p = 0.022; p = 0.040; p = 0.009). Subtype was significant for response on a per lesion basis (p = 0.007). Subtype was trending towards significance when analyzing time from initial diagnosis to BM treatment (p = 0.064). Breast cancer subtype is an important prognostic factor when stratifying breast cancer patients with BM. The addition of number of BM to the GPA is a useful addition and should be further investigated. Subtype has an effect on lesion response, and also on rate of development BM after initial diagnosis.

Control of brain metastases from radioresistant tumors treated by stereotactic radiosurgery

Renal cell carcinoma, sarcoma, and melanoma are considered to be "radioresistant" tumor histologies. Brain metastases (BM) from these tumors are considered unlikely to be controlled using the relatively low doses used in whole brain radiotherapy (WBRT). Our objective was to analyze the efficacy of stereotactic radiosurgery (SRS) on local control and overall survival of BM from radioresistant primary tumors. We reviewed all patients who received Gamma Knife Radiosurgery (GKRS) for BM at Columbia University Medical Center between January 2009 and April 2014. All patients were treated using the Gamma Knife Perfexion System. Dosimetric data was collected from treatment plans and metastases were categorized as radioresistant or not. Response was assessed by reviewing follow-up brain imaging studies and classified according to RECIST. Local control and median overall survival were calculated using the Kaplan-Meier method. In total, 373 tumors were analyzed from 126 patients. Of these tumors, 49 (13.1 %) originated from radioresistant cancers. The overall local control rate in the radioresistant cohort was 89.8 and 90.1 % in the non-radioresistant cohort. Univariate and multivariate analyses demonstrated that radioresistance status of the primary tumor had no statistically significant effect on local control with hazard ratios of 1.0 (p = 1.0, 95 % CI 0.388-2.576) and 0.954 (p = 0.926, 95 % CI 0.349-2.603) respectively. Median overall survival for both radioresistant and non-radioresistant cohorts was 20.0 months, with a p value of 0.926. There was no significant difference in local control of BM from radioresistant and non-radioresistant primary tumors treated with GKRS. Both cohorts showed excellent response and local control, suggesting that SRS upfront or in addition to WBRT may be an appropriate strategy in the treatment of BM from radioresistant cancers. Median overall survival for both cohorts was equal, suggesting that improved local control may be associated with an improvement in long-term survival.

Does lung cancer mutation status and targeted therapy predict for outcomes and local control in the setting of brain metastases treated with radiation?

BACKGROUND

We investigated effects of genetic alterations in epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and Kirsten rat sarcoma viral oncogene homolog (KRAS) on overall survival (OS) and local control after stereotactic radiosurgery for brain metastases in non-small cell lung cancer (NSCLC).

METHODS

A cohort of 89 out of 262 NSCLC patients (2003-2013) treated with gamma knife radiosurgery for brain metastases had genotyping available and were selected as our study population.

RESULTS

Median follow-up was 12 months. Median OS rates for the EGFR, KRAS, echinoderm microtubule-associated protein-like 4 (EML4)-ALK mutated, and wild-type cohorts were 17, 7, 27, and 12 months, respectively (P = .019), and for targeted versus nontargeted therapy 21 and 11 months, respectively (P = .071). Targeted therapy was a strong predictor of increased OS on univariate (P = .037) and multivariate (P = .022) analysis. Gender, primary tumor controlled status, recursive partitioning analysis class, and graded prognostic assessment score were associated with OS (P < .05). On multivariate analysis, positive EGFR mutational status was a highly significant predictor for decreased survival (hazard ratio: 8.2; 95% CI: 2.0-33.7; P = .003). However, when we recategorized EGFR-mutant cases based on whether they received tyrosine kinase inhibitor, OS was no longer significantly shorter (hazard ratio: 1.5; P = .471). Median OS for patients with and without local failure was 17 and 12 months, respectively (P = .577). Local failure rates for EGFR, KRAS, EML4-ALK mutated, and wild-type cohorts by lesion were 8.7%, 5.4%, 4.3%, and 5.1%, respectively.

CONCLUSIONS

This study suggests that EGFR tyrosine kinase mutation and ALK translocation results in improved survival to targeted therapies and that mutation status itself does not predict survival and local control in patients with brain metastases from NSCLC.

Ovarian activity at naturally attained oestrus in the sow. An ultrasonographic and LH study

In 6 multiparous crossbred sows (2nd to 4th parity, Swedish Landrace x Swedish Yorkshire), 15 proosestrous-oestrous periods during 2 oestrous cycles were studied after weaning. The animals were controlled for oestrus, and the follicular growth and ovulation in their ovaries were followed by transrectal ultrasonography. Blood was sampled through indwelling catheters for analyses of LH and progesterone (P4). The duration of oestrus (standing reflex) was 47 +/- 12.4 h, and the interval from onset of standing reflex until the end of ovulation was 39 +/- 12.4 h (range 20-64 h). The LH peak concentration was 3.7 +/- 0.8 microgram/l, and the interval from LH peak level until ovulation was 23 +/- 8.4 h (range 8-32 h). The onset of standing reflex occurred in average 13 h before the LH peak level (range -4 - +36 h). The peripheral plasma concentration of P4 showed a normal cyclic pattern in all animals. Low levels (mean levels, 1.1-1.3 nmol/l) were seen during prooestrus and oestrus, high mean levels were found on days 10-16 (45-75 nmol/l) in the oestrous cycle. It was concluded that for an accurate determination of ovulation, each animal has to be examined repeatedly. Ultrasonography is a most valuable tool for this purpose.

Ovarian activity at naturally attained oestrus in the sow. An ultrasonographic and LH study

In 6 multiparous crossbred sows (2nd to 4th parity, Swedish Landrace x Swedish Yorkshire), 15 proosestrous-oestrous periods during 2 oestrous cycles were studied after weaning. The animals were controlled for oestrus, and the follicular growth and ovulation in their ovaries were followed by transrectal ultrasonography. Blood was sampled through indwelling catheters for analyses of LH and progesterone (P4). The duration of oestrus (standing reflex) was 47 +/- 12.4 h, and the interval from onset of standing reflex until the end of ovulation was 39 +/- 12.4 h (range 20-64 h). The LH peak concentration was 3.7 +/- 0.8 microgram/l, and the interval from LH peak level until ovulation was 23 +/- 8.4 h (range 8-32 h). The onset of standing reflex occurred in average 13 h before the LH peak level (range -4 - +36 h). The peripheral plasma concentration of P4 showed a normal cyclic pattern in all animals. Low levels (mean levels, 1.1-1.3 nmol/l) were seen during prooestrus and oestrus, high mean levels were found on days 10-16 (45-75 nmol/l) in the oestrous cycle. It was concluded that for an accurate determination of ovulation, each animal has to be examined repeatedly. Ultrasonography is a most valuable tool for this purpose.

Immobilization hypercalcemia associated with Landry-Guillain-Barré syndrome. Successful therapy with combined calcitonin and etidronate

Two patients with immobilization hypercalcemia associated with Landry-Guillain-Barré syndrome had marked hypercalciuria (890 and 1136 mg/d [22.2 and 28.3 mmol/d]) and radiologic evidence of generalized osteopenia. Parathyroid hormone levels were either low or normal by C-terminal radioimmunoassay. Subtotal parathyroidectomy was performed in the one patient, with no improvement in serum or urinary calcium levels. A bone biopsy specimen revealed decreased cellular activity in the first patient and increased bone resorption in the second patient. Treatment with intravenous saline, furosemide, oral phosphate supplementation, mithramycin, and calcitonin alone was ineffective in lowering serum or urinary calcium levels. However, when subcutaneous calcitonin combined with oral etidronate disodium was used, a reduction in the serum calcium level was observed within two days of therapy. Within one week of the start of this combined therapy, the calcium level returned to normal and urinary calcium excretion was substantially reduced.