Corneal reshaping: an experiment with a type I collagen-based vitrigel for remodeling porcine corneas / Remodelamento corneano: relato de um experimento com um vitrigel a base de colágeno tipo I para remodelamento de córneas porcinas

ABSTRACT Purpose: This study aimed to report an experiment designed to determine anatomical changes in porcine corneas following placement of a novel polymer implant into the cornea. Methods: An ex vivo porcine eye model was used. A novel type I collagen-based vitrigel implant (6 mm in diameter) was shaped with an excimer laser on the posterior surface to create three planoconcave shapes. Implants were inserted into a manually dissected stromal pocket at a depth of approximately 200 μm. Three treatment groups were defined: group A (n=3), maximal ablation depth 70 μm; Group B (n=3), maximal ablation depth 64 μm; and group C (n=3), maximal ablation depth 104 μm, with a central hole. A control group (D, n=3) was included, in which a stromal pocket was created but biomaterial was not inserted. Eyes were evaluated by optical coherence tomography (OCT) and corneal tomography. Results: Corneal tomography showed a trend for a decreased mean keratometry in all four groups. Optical coherence tomography showed corneas with implants placed within the anterior stroma and visible flattening, whereas the corneas in the control group did not qualitatively change shape. Conclusions: The novel planoconcave biomaterial implant described herein could reshape the cornea in an ex vivo model, resulting in the flattening of the cornea. Further studies are needed using in vivo animal models to confirm such findings.

RESUMO Objetivo: Relatar um experimento projetado para determinar alterações anatômicas em córneas porcinas após a colocação de um novo implante de polímero na córnea. Métodos: Foi utilizado olho de porco ex vivo. Um novo agente modelador biocompatível, de colágeno tipo 1, com 6mm de diâmetro foi moldado com excimer laser em sua face posterior, para criar três formatos planocôncavos. Os implantes foram inseridos dentro de um bolsão, dissecado manualmente, a 200 micrômetros (μm). Foram definidos três grupos de tratamento: grupo A (n=3), teve a profundidade máxima de ablação de 70 μm; o grupo B (n=3), profundidade máxima de ablação de 64 μm; e o grupo C (n=3), profundidade máxima de ablação de 104 μm, com buraco central. O grupo controle, D (n=3), foi incluído, com a criação do bolsão estromal, porém sem inserir o material. A avaliação desses olhos foi realizada por tomografia de coerência óptica (OCT) e por tomografia corneana. Resultados: A tomografia corneana mostrou uma tendência para diminuição da ceratometria média em todos os 4 grupos. A tomografia de coerência óptica mostrou córneas com implantes localizados no estroma anterior e aplanamento visível, enquanto as córneas não mudaram qualitativamente o formato no grupo controle. Conclusões: O novo implante de biomaterial planocôncavo descrito aqui foi capaz de remodelar a córnea em modelo de animal ex vivo, resultando no aplanamento corneano. Novos estudos são necessários usando modelos animais in vivo para confirmar tais achados.

Transformed Time Series Analysis of First Wave COVID-19: Universal Similarities Found in The Group of Twenty (G20) Countries

As of April 30, 2020, cumulative confirmed coronavirus disease 2019 (COVID-19) cases exceeded 3 million worldwide and 1 million in the US, with an estimated fatality rate of more than 7 percent. Because the occurrence patterns of new confirmed cases and deaths over time are complex and seemingly country-specific, estimating the long-term pandemic spread is challenging. I developed a simple transformation algorithm to investigate the characteristics of the case and death time series per nation and described the universal similarities observed in the transformed time series of 19 nations in the Group of Twenty (G20). A transformation algorithm of the time series data sets was developed with open-source software programs to investigate the universal similarities among the cumulative profiles of confirmed cases and deaths of 19 individual nations in the G20. The algorithm extracted and analyzed statistical information from daily updated COVID-19 pandemic data sets from the European Centre for Disease Prevention and Control (ECDC). Two new parameters for each nation were suggested as factors for time-shifting and time-scaling to define reduced time, which was used to quantify the degree of universal similarities among nations. After the cumulative confirmed case and death profiles of a nation were transformed by using reduced time, most of the 19 nations, with few exceptions, had transformed profiles that closely converged to those of Italy after the onset of cases and deaths. The initial profiles of the cumulative confirmed cases per nation universally showed 3 to 4-week latency periods, during which the total number of cases remained at approximately ten. The latency period of the cumulative number of deaths was approximately half the latency number of cumulative cases, and subsequent uncontrollable increases in human deaths seemed unavoidable because the coronavirus had already widely spread. Immediate governmental actions, including responsive public-health policymaking and enforcement, are observed to be critical to minimize (and possibly stop) further infections and subsequent deaths. In the pandemic spread of infectious viral diseases, such as COVID-19, studied in this work, different nations show dissimilar and seemingly uncorrelated time series profiles of infected cases and deaths. After these statistical phenomena were viewed as identical events occurring at a distinct rate in each country, the reported algorithm of the data transformation using the reduced time revealed a nation-independent, universal profile (especially initial periods of the pandemic spread) from which a nation-specific, predictive estimation could be made and used to assist in immediate public-health policymaking.

Comparison of 20% sulfur hexafluoride with air for intraocular tamponade in Descemet membrane endothelial keratoplasty (DMEK) / Comparação de hexafluoreto de enxofre a 20% com ar para tamponamento intraocular na ceratoplastia endotelial de membrana Descemet (DMEK)

ABSTRACT Purpose: To compare the effect of 20% sulfur hexafluoride (SF6) with that of air on graft detachment rates for intraocular tamponade in Descemet membrane endothelial keratoplasty (DMEK). Methods: Forty-two eyes of patients who underwent DMEK by a single surgeon (A.S.J.) at Wilmer Eye Institute between January 2012 and 2014 were identified; 21 received air for intraocular tamponade and the next consecutive 21 received SF6. The main outcome measure was the graft detachment rate; univariate and multivariate analyses were performed. Results: The graft detachment rate was 67% in the air group and 19% in the SF6 group (p<0.05). No complete graft detachments occurred, and all partial detachments underwent intervention with injection of intraocular air. The percentages of eyes with 20/25 or better vision were not different between the groups (67% vs. 71%). Univariate analysis showed significantly higher detachment rates with air tamponade (OR, 8.50; p<0.005) and larger donor graft size (OR, 14.96; p<0.05). Multivariate analysis with gas but not graft size included showed that gas was an independent statistically significant predictor of outcome (OR, 6.65; p<0.05). When graft size was included as a covariate, gas was no longer a statistically significant predictor of detachment but maintained OR of 7.81 (p=0.063) similar to the results of univariate and multivariate analyses without graft size. Conclusion: In comparison with air, graft detachment rates for intraocular tamponade in DMEK were significantly reduced by 20% SF6.

RESUMO Objetivo: Comparar as taxas de descolamento do botão endotelial com o uso de gás hexafluoreto de enxofre a 20% (SF6) em relação ao ar para o tamponamento intraocular na ceratoplastia endotelial da membrana de Descemet (DMEK). Métodos: Quarenta e dois olhos foram operados com a técnica de DMEK por um único cirurgião (A.S.J.) no Wilmer Eye Institute entre janeiro de 2012 a 2014. Os primeiros 21 olhos receberam ar para o tamponamento intraocular após o enxerto do botão endotelial e os 21 olhos seguintes receberam SF6. O desfecho primário medido foi a taxa de descolamento do botão endotelial por análise univariada e multivariada. Resultados: A taxa de descolamento do botão endotelial foi de 67% no grupo que recebeu ar vs 19% no grupo que recebeu SF6 (p<0,05). Não houve nenhum descolamento total de botão e todos os parciais foram tratados com injeção de ar intraocular. Não houve diferença estatística significativa entre os grupos em relação a AV de 20/25 ou melhor (67% vs 71%). A análise univariada demonstrou maior taxa de descolamento com o tamponamento por ar intraocular (OR 8,50, p<0,005) e com botões doadores maiores (OR 14,96, p<0,05). Na análise multivariada, incluindo gás, mas não o tamanho do botão doador, o tipo de gás usado permaneceu sendo um fator preditivo independente e estatisticamente significativo para o desfecho primário, com OR de 6,65 (p<0,05). Porém, quando o tamanho do botão doador foi incluso como covariável, o gás perdeu a sua significância como preditor de descolamento, mantendo o OR de 7,81 (p=0,063), semelhante as análises univariada e multivariada excluindo o tamanho do botão doador. Conclusão: O uso de gás hexafluoreto de enxofre a 20% (SF6) para o tamponamento intraocular reduz a taxa de descolamento do botão endotelial quando comparado ao uso de ar no DMEK.

Characterization of cryopreserved primary human corneal endothelial cells cultured in human serum-supplemented media / Caracterização de células endoteliais corneanas humanas primárias criopreservadas cultivadas em meio suplementado com soro humano

ABSTRACT Purpose: To compare cryopreserved human corneal endothelial cells (HCECs) grown in human serum-supplemented media (HS-SM) with cryopreserved HCECs grown in fetal bovine serum-supplemented media (FBS-SM). Methods: Three pairs of human corneas from donors aged 8, 28, and 31 years were obtained from the eye bank. From each pair, one cornea was used to start a HCEC culture using HS-SM; the other cornea was grown in FBS-SM. On reaching confluence, the six cell populations were frozen using 10% dimethyl sulfoxidecontaining medium. Thawed cells grown in HS-SM were compared with those grown in FBS-SM with respect to morphology, growth curves, immunohistochemistry, real time-reverse transcriptase polymerase chain reaction (RT-PCR) for endothelial cell markers, and detachment time. Results: No difference in morphology was observed for cells grown in the two media before or after cryopreservation. By growth curves, cell counts after thawing were similar in both media, with a slight trend toward higher cell counts in FBS-SM. Cells grown in both the media demonstrated a similar expression of endothelial cell markers when assessed by immunohistochemistry, although HCEC marker gene expression was higher in cells grown in HS-SM than in those grown in FBS-SM as assessed by RT-PCR. With FBS-SM, there was a tendency of longer detachment time and lower cell passages. Conclusions: HS-SM was similar to FBS-SM for cryopreservation of cultured HCECs as assessed by analysis of cell morphology, proliferation, and protein expression, although marker gene expression was higher in cells grown in HS-SM than in those grown in FBS-SM. Detachment time was longer with FBS-SM and in lower passages.

RESUMO Objetivo: Comparar células endoteliais de córnea humana (HCECs) criopreservadas e cultivadas em meio suplementado com soro humano (HS-SM) com HCEC criopreservadas e cultivadas em meio suplementado com soro bovino fetal (FBS-SM). Métodos: Três pares de córneas humanas de doadores com 8, 28 e 31 anos de idade foram obtidos do banco de olhos e, de cada par, uma córnea foi utilizado para iniciar uma cultura com HS-SM e outra com FBS-SM. Ao atingir a confluência, as populações de células foram congeladas utilizando-se dimetil-sulfóxido 10% no respectivo meio de cultura. Após descongeladas, as células cultivadas em HS-SM foram comparados com as cultivadas em FBS-SM por meio de morfologia, curva de crescimento, imuno-histoquímica, reação em cadeia de Reação em cadeia da polimerase da transcrição reversa em tempo real (RT-PCR) para marcadores de células endoteliais e tempo de descolamento. Resultado: Não foram observadas diferenças morfológicas antes ou após a criopreservação. Curva de crescimento mostrou contagens celulares semelhantes em ambos os meios, com discreta tendência para um maior número em FBS-SM. As células cultivadas em ambos os meios mostraram expressão semelhante de marcadores celulares endoteliais quando avaliadas por imuno-histoquímica, embora a expressão genética de marcadores para HCEC tenha sido maior em HS-SM quando avaliado por RT-PCR. Houve uma tendência de maior tempo de descolamento com FBS-SM e passagens iniciais. Conclusões: HS-SM foi semelhante ao FBS-SM na criopreservação de HCEC cultivadas in vitro quando avaliadas por morfologia celular, proliferação celular e expressão proteica, embora a expressão genética de marcadores endoteliais tenha sido maior em células cultivadas em HS-SM quando comparadas a células cultivadas em FBS-SM. O tempo de descolamento foi maior quando utilizado FBS-SM e em passagens iniciais.

Quantitative analysis of iris parameters in keratoconus patients using optical coherence tomography / Uso de tomografia de coerência óptica na análise quantitativa dos parâmetros irianos em pacientes com ceratocone

ABSTRACTPurpose:To investigate the relationship between quantitative iris parameters and the presence of keratoconus.Methods:Cross-sectional observational study that included 15 affected eyes of 15 patients with keratoconus and 26 eyes of 26 normal age- and sex-matched controls. Iris parameters (area, thickness, and pupil diameter) of affected and unaffected eyes were measured under standardized light and dark conditions using anterior segment optical coherence tomography (AS-OCT). To identify optimal iris thickness cutoff points to maximize the sensitivity and specificity when discriminating keratoconus eyes from normal eyes, the analysis included the use of receiver operating characteristic (ROC) curves.Results:Iris thickness and area were lower in keratoconus eyes than in normal eyes. The mean thickness at the pupillary margin under both light and dark conditions was found to be the best parameter for discriminating normal patients from keratoconus patients. Diagnostic performance was assessed by the area under the ROC curve (AROC), which had a value of 0.8256 with 80.0% sensitivity and 84.6% specificity, using a cutoff of 0.4125 mm. The sensitivity increased to 86.7% when a cutoff of 0.4700 mm was used.Conclusions:In our sample, iris thickness was lower in keratoconus eyes than in normal eyes. These results suggest that tomographic parameters may provide novel adjunct approaches for keratoconus screening.

RESUMOObjetivo:Investigar a relação entre os parâmetros quantitativos irianos e a presença de ceratocone.Métodos:Estudo observacional transversal com quinze olhos de 15 pacientes com ceratocone e 26 olhos de 26 indivíduos normais, pareados por idade e gênero. Parâmetros da íris (área, espessura e diâmetro da pupila) de olhos com ceratocone e olhos sem ceratocone foram medidos usando tomografia de coerência óptica do segmento anterior (AS-OCT), em condições padronizadas de alta luminosidade e ambiente escuro. Com o objetivo de maximizar a sensibilidade, especificidade e identificar o melhor ponto de corte na diferenciação entre ceratocone e indivíduos normais, foi realizada a análise quantitativa da curva característica operacional do receptor (ROC) dos parâmetros de espessura da íris.Resultados:A área e espessura da íris estavam reduzidas nos olhos de pacientes com ceratocone. Observamos que o melhor parâmetro para discriminar indivíduos normais de pacientes com ceratocone foi a espessura média na margem pupilar, tanto em condições de alta luminosidade quanto em ambiente escuro. O desempenho diagnóstico deste parâmetro foi avaliado pela análise quantitativa da área sob a curva ROC (AROC), mostrando AROC de 0,8256, com sensibilidade de 80,0% e especificidade de 84,6% usando um ponto de corte de 0,4125 milímetros de espessura da íris. A sensibilidade aumentou para 86,7%, com um corte de 0,4700 milímetros de espessura da íris.Conclusões:Na amostra deste estudo, a espessura da íris demostrou-se reduzida nos olhos com ceratocone. Estes resultados sugerem que os parâmetros tomográficos podem proporcionar novas informações no auxilio da triagem de pacientes com ceratocone.

Prevalence of Vitamin D Deficiency in Patients Presenting with an Orthopaedic Trauma at a Tertiary Centre in South India - Implications and Protocols for Replacement Therapy

Vitamin D has been the focus of much scientific literature in recent years owing to various studies showing its association with a wide variety of pathological conditions 1,2 . Sun exposure, diet and fortified supplementation account for a bulk of Vitamin D intake in humans. Activation of vitamin D is sequential and requires sun exposure for conversion of 7- dehydrocholesterol to Vitamin D3. Further metabolism in the liver converts Vitamin D3 to 25 –hydroxyvitamin D3. Conversion to its active form 1,25 dihydroxyvitamin D3 (Calcitriol) occurs in the kidneys 2 . The importance of Vitamin D in calcium metabolism and bone health is well known and documented. Controversies exist regarding the true prevalence of hypovitaminosis, however in developing countries the prevalence of vitamin D deficiency in all age groups is probably higher 3 . Adding to this the burden and morbidity of skeletal trauma, persistent deficiency may have a deleterious effect in the injured 4, 5 . Vitamin D, with its positive effect on bone health does play a role in the biology of fracture repair and remodelling 6 . The role of Vitamin D replacement as sole biological effectors in fracture repair may be difficult to quantify and confounded by other variables at play in bone healing. Studies looking at vitamin D levels in orthopaedic patients have also shown significant levels of deficiency and have put forward recommendations for evaluation and supplementation

Novel spatula and dissector for safer deep anterior lamellar keratoplasty / Uso de espátula e dissector para otimização da ceratoplastia lamelar anterior profunda (DALK)

Objective: We describe a novel spatula and dissector to facilitate the big-bubble technique in deep anterior lamellar keratoplasty (DALK). Methods: A 29-year-old man who was diagnosed with bilateral keratoconus underwent deep anterior lamellar keratoplasty (DALK). After 350μm partial thickness incision of the recipient cornea, the Bonfadini dissector was inserted at the deepest point in the peripheral incision and could be advanced to the center of the cornea safely because of its "semi-sharp" tip. After achieving the big-bubble (BB) separation of Descemet membrane (DM) from the overlying stroma, the anterior stromal disc was removed. Viscoelastic material was placed on the stromal bed to prevent uncontrolled collapse and perforation of DM during the paracentesis blade incision into the BB. We could detect the safe opening of the BB using the Bonfadini dissector by the leakage of air bubbles into the viscoelastic material. After injecting viscoelastic material into the BB space, we inserted the Bonfadini spatula into the bigbubble safely because of its curved profile and blunt edges. The groove along the length of the Bonfadini spatula enables safe and efficient incision or the residual stromal tissue using the pointed end of a sharp blade while protecting the underlying DM. After removal of posterior stroma, the donor button was sutured with 16 interrupted 10-0 nylon sutures. Results: This technique and the use of the Bonfadini spatula and dissector facilitate exposure of Descemet membrane. Conclusion: The smooth Bonfadini DALK spatula and dissector facilitate safe and efficient completion of DALK surgery. .

Objetivo: Descrevemos o uso de novos instrumentais cirúrgicos para facilitar a técnica de "big-bubble" na ceratoplastia lamelar anterior profunda (DALK). Métodos: Paciente masculino, 29 anos, foi diagnosticado com ceratocone bilateral e submetido à ceratoplastia lamelar anterior profunda (DALK). Após incisão da córnea receptora numa profundidade de 350μm de espessura parcial, o dissector Bonfadini foi inserido no ponto mais profundo da incisão periférica e pode avançar para o centro da córnea com segurança devido à sua ponta semiafiada. Depois de realizar a "big-bubble" (BB) e atingir a separação da Membrana de Descemet (MD) do estroma sobrejacente, o disco corneano de estroma anterior foi removido. Um viscoelástico foi colocado sobre o leito do estroma remanescente para impedir o colapso não-controlado e perfuração da MD durante a incisão na BB com lâmina de paracentese. Verificamos segurança no rompimento do estroma remanescente com o auxílio do dissector Bonfadini, para liberação da bolha de ar da BB através do viscoelástico. Depois de injetar o viscoelástico no espaço da BB, inserimos a espátula Bonfadini neste espaço, o que demonstrou-se seguro devido ao formato curvo e das bordas arredondadas do instrumental. A chanfradura ao longo do comprimento da espátula Bonfadini permite a incisão pela ponta de uma lâmina afiada, protegendo assim a MD subjacente. Após a remoção do estroma posterior, o botão doador foi suturado com 16 pontos interrompidos de fio nylon 10.0. Resultados: Esta técnica e o uso da espátula Bonfadini e dissector facilitam a exposição de membrana de Descemet. Conclusão: A superfície lisa da espátula Bonfadini e dissector, facilitam a realização segura e eficiente da ceratoplastia lamelar anterior profunda (DALK). .

Repeat selective laser trabeculoplasty can be effective in eyes with initial modest response

To evaluate the effectiveness of repeat selective laser trabeculoplasty [SLT] in eyes exhibiting only a modest response upon initial treatment. Retrospective chart review was conducted of 51 eyes that received initial 360 degree SLT [SLT1] and subsequent SLT [SLT2] from 2003-2011 at a large academic ophthalmology practice. Successful response [S] was a post-treatment 12 month mean IOP reduction >/= 20% from baseline, while modest response [M] was <20% reduction over the same time. Chi-squared and log rank analyses were used to determine if success after SLT2 depended on having successful [S1] or modest [M1] response after SLT1. IOP was significantly reduced from baseline in both SLT1 and SLT2. The proportion of eyes with S2 was not significantly different between those with initial M1 or S1 [36.67% vs. 52.38%, respectively; P = 0.26]. Log rank analysis revealed no differences between M1 and S1 in determining SLT2 success [P = 0.41]. This outcome was similar when the analyses were performed for the right and left eye independently. The proportion of eyes that successfully responded to repeat SLT did not differ based upon whether the response to initial SLT was successful or modest. This raises the possibility that repeat SLT should not be excluded as an option for those eyes that have only a modest initial response

Clinics in diagnostic imaging. 145

A 63-year-old man presented with painless jaundice, loss of appetite and significant weight loss. Cross-sectional imaging showed a diffusely enlarged pancreas, with no significant fat stranding and a hypodense rim on computed tomography, which appeared hypointense on T2-weighted magnetic resonance imaging. There was a narrowed pancreatic duct and features of common bile duct narrowing in the region of the pancreatic head. However, there was no obvious mass seen in the pancreatic head region. These features were classical of autoimmune pancreatitis with diffuse involvement of the gland. Laboratory investigation showed abnormal liver function and the classical sign of raised immunoglobulin G class 4 antibodies. The patient showed dramatic response to high-dose steroids, with resolution of both the laboratory and imaging abnormalities within one month. We discuss the classical imaging features of Type 1 autoimmune pancreatitis, an uncommon condition that needs to be differentiated from pancreatic malignancy.

Selective laser trabeculoplasty: does energy dosage predict response?

Selective laser trabeculoplasty [SLT] is a widely used treatment for open angle glaucoma, producing sustained reductions of intraocular pressure [IOP]. The aim of this study was to evaluate the long-term relationship between SLT energy dosage and IOP reduction. A retrospective review was performed for patients receiving primary SLT therapy, with inclusion of subjects treated with 360degree of SLT. Energy settings were collected upon treatment and IOP was collected at baseline up to 36 months. Pearson's correlation coefficient was used to determine whether there was a significant correlation between SLT energy and IOP reduction at all time points. Kaplan-Meier analysis with log-rank test was performed to determine the differences in IOP reduction >/= 20% from baseline among those treated with low [<85 mJ], medium [85-105 mJ], and high [>105 mJ] energy SLT. A total of 104 eyes [75 patients] were included. The mean total SLT energy was 93.73 mJ [standard deviation [SD] = 21.83 mJ, range: 34.4-122 mJ]. A significant positive correlation [P /= 20% from baseline between the three energy groups, with low energy patients experiencing failure at an earlier time [P = 0.05]. Within the range of total energy examined, there is a positive correlation between total energy used and amount of pressure reduction achieved at up to 3 years of follow-up. This may be useful in determining the optimal energy dosage for maximum effect for patients receiving SLT.

Complimentary imaging technologies in blunt ocular trauma

We describe complimentary imaging technologies in traumatic chorioretinal injury. Color and fundus autofluorescence [FAF] images were obtained with a non-mydriatic retinal camera. Optical coherence tomography [OCT] helped obtain detailed images of retinal structure. Microperimetry was used to evaluate the visual function. A 40-year-old man sustained blunt ocular trauma with a stone. Color fundus image showed a large chorioretinal scar in the macula. Software filters allowed detailed illustration of extensive macular fibrosis. A 58-year-old man presented with blunt force trauma with a tennis ball. Color fundus imaging showed a crescentric area of macular choroidal rupture with fibrosis. FAF imaging delineated an area of hypofluorescence greater on fundus imaging. OCT showed chorioretinal atrophy in the macula. Microperimetry delineated an absolute scotoma with no response to maximal stimuli. Fundus imaging with digital filters and FAF illustrated the full extent of chorioretinal injury, while OCT and microperimetry corroborated the structure and function correlations.

Pars plana Baerveldt tube insertion with pars plana vitrectomy for refractory glaucoma

Glaucoma drainage implants [GDIs] are used for managing recalcitrant glaucoma and are usually placed in the anterior chamber. This approach may lead to complications such as corneal decompensation, and so a pars plana approach is used in at risk eyes. Aims: To compare functional outcomes and complications of 250 mm 2 and 350 mm 2 pars plana Baerveldt tube insertion with pars plana vitrectomy [PPV] [both 20-and 23-gauge] for managing refractory glaucoma. Settings and Design: A retrospective chart review of 38 patients [39 eyes] undergoing combined PPV-Baerveldt procedure for glaucoma recalcitrant to maximal medical treatment or previous filtering procedures with>6 weeks of follow-up. Main outcome measures were visual acuity, intraocular pressure [IOP], number of glaucoma medications, and postoperative complications. Statistical Analysis Used: A paired 't' test was used to evaluate changes in IOP and glaucoma medications, Fisher's exact test was used to compare complication rates, and Kaplan-Meier survival curves were constructed for comparison of overall outcomes. Mean patient age was 62.2 years. Mean follow-up period was 33.7 months, with 36 [92%] eyes followed for>/=6 months. Mean +/- SD preoperative IOP and number of glaucoma medications were significantly reduced by the combined procedure [P<0.05]. Thirty-five [90%] eyes maintained final IOP between 6 and 21 mmHg. Vision improved by>/=2 lines in 10 [26%] eyes, remained stable in 15 [38%] eyes, and decreased in 14 [36%] eyes. Two [5.1%] eyes developed no light perception vision, with one [2.6%] eye becoming phthisical. Twenty-four [62%] eyes developed complications managed with conservative measures. Five [13%] eyes required>/=1 surgeries within a year of the combined procedure. Pars plana Baerveldt tube implantation with PPV can preserve vision, reduce IOP, and decrease the number of glaucoma medications necessary to achieve target IOP in patients with recalcitrant glaucoma

Atypical enhancement pattern of hepatocellular carcinoma with portal vein thrombosis on multiphasic CT

<p><b>INTRODUCTION</b>The 2005 American Association for Study of Liver Diseases (AASLD) diagnostic criteria allow non-invasive diagnosis of hepatocellular carcinoma (HCC) based on their enhancement pattern but we have observed a high incidence of atypical enhancement characteristics in HCC associated with portal vein thrombosis. This study seeks to examine the radiological features of this particular subgroup.</p><p><b>MATERIALS AND METHODS</b>Patients with HCC and portal vein thrombosis who underwent pre-treatment multiphasic CT imaging were drawn from a surgical database. The arterial, portal venous and delayed phase images were assessed qualitatively and quantitatively (with region of interest [ROI] analysis) for lesion hypervascularity and washout. The background enhancement of the left and right lobes of the liver was also quantifi ed by ROI analysis.</p><p><b>RESULTS</b>Twenty-fi ve lesions in 25 patients were selected for analysis. Qualitative analysis showed that 10/25 (40%) lesions demonstrated arterial hypervascularity while 16/25 (64%) lesions showed washout. Ten out of 25 (40%) lesions demonstrated both arterial hypervascularity and washout. Quantitative analysis showed that the average absolute lesion enhancement from precontrast to arterial phases was 49.1 (± 17.1) HU for hypervascular lesions compared to 23.8 (± 16.6) HU for non-hypervascular lesions (P <0.01). The mean absolute enhancement of the background liver parenchyma in the arterial phase was 13.79 (± 7.9) HU for hypervascular lesions compared to 36.6 (± 30.6) HU for non-hypervascular lesions (P = 0.03).</p><p><b>CONCLUSION</b>A large proportion of HCC with portal vein thrombosis lack characteristic arterial hypervascularity, which may be secondary to compensatory increased arterial supply to the background liver. This is a potential pitfall when applying imaging criteria for diagnosis of HCC.</p>

Wash-out of hepatocellular carcinoma: quantitative region of interest analysis on CT

<p><b>INTRODUCTION</b>This study aims to determine if the quantitative method of region-of-interest (ROI) analysis of lesion attenuation on CT may be a useful adjunct to the conventional approach of diagnosis by visual assessment in assessing tracer wash-out in hepatocellular carcinomas.</p><p><b>MATERIALS AND METHODS</b>From a surgical database of 289 patients from 2 institutions, all patients with complete surgical, pathological and preoperative multiphasic CT scans available for review were selected. For each phase of scanning, HU readings of lesion obtained (Lesion(arterial), Lesion(PV) and Lesion(equilibrium)) were analysed using receiver operating curves (ROC) to determine the optimal method and cut-off value for quantitative assessment of tumour wash-out (Lesion(arterial - equilibrium), Lesion(PV - equilibrium) or Lesion(peak - equilibrium)).</p><p><b>RESULTS</b>Ninety-four patients with one lesion each met the inclusion criteria. The area under the curve (AUC) values for Lesion(arterial - equilibrium) (0.941) was higher than the AUC for Lesion(pv - equilibrium) (0.484) and for Lesion(peak - equilibrium) (0.667). Based on ROC analysis, a cut-off of 10HU value for Lesion(arterial - equilibrium) would yield sensitivity and specificity of 91.5% and 80.9%, respectively. ROI analysis detected 9/21 (42.9%) of lesions missed by visual analysis. Combined ROI and visual analysis yields a sensitivity of 82/94 (87.2%) compared to 73/94 (77.7%) for visual analysis alone.</p><p><b>CONCLUSION</b>Using a cut-off of 10 HU attenuation difference between the arterial and equilibrium phases is a simple and objective method that can be included as an adjunct to visual assessment to improve sensitivity for determining lesion wash-out on CT.</p>

Infected pancreatic necrosis--an evaluation of the timing and technique of necrosectomy in a Southeast Asian population

<p><b>INTRODUCTION</b>Acute pancreatitis appears to be less prevalent in multi-ethnic Southeast Asia, where the aetiology also appears to be influenced by ethnicity. As with acute pancreatitis elsewhere, however, pancreatic necrosis is a cause of significant mortality and the aim of this study was to review our institutional experience with pancreatic necrosectomy.</p><p><b>MATERIALS AND METHODS</b>The records of all patients who underwent pancreatic necrosectomy from January 2000 to December 2004 were analysed. Indications for surgery were the presence of infected necrosis, unresolving sepsis attributable to ongoing pancreatitis or the presence of gas in the pancreatic bed on imaging. Surgical debridement was achieved by debridement with closure over drains or by debridement with open packing.</p><p><b>RESULTS</b>The cohort comprised 14 of 373 patients admitted for acute pancreatitis (3.8%), with an overall mortality rate of 29%. All patients had infected necrosis with positive bacteriological cultures. Eight patients (57%) underwent debridement with closure over drains and 6 patients (43%) underwent debridement with open packing. All mortalities occurred in patients who underwent open packing, who were also associated with a higher mean Acute Physiology and Chronic Health Evaluation (APACHE) II score. The mortality rate in patients who underwent debridement less than 4 weeks after admission was 33% (2 of 6), compared with 25% (2 of 8) in patients who underwent debridement after 4 weeks. There were no mortalities in patients operated on after 6 weeks.</p><p><b>CONCLUSION</b>Surgical debridement with closure of drains and a policy of performing delayed necrosectomy are viable in our population.</p>

Evaluation and therapeutic outcome of palpable purpura.

Palpable purpura is the clinical hallmark of leukocytoclastic vasculitis. Its etiology can be varied but often is elusive. Henoch- Schonlein purpura (HSP) is a distinct subtype of hypersensitivity vasculitis of unknown cause occurring primarily in children. IgA deposits in vessels is thought to be diagnostic of HSP. This study is aimed to evaluate the etiology, clinical manifestations and therapeutic outcome in patients with palpable purpura and to assess the relevance of IgA deposits in these patients. Thirty-six patients with palpable purpura were evaluated by history and laboratory investigations including biopsy for histopathology and direct immunofluorescence . Twenty-four patients received treatment with dapsone, steroids or a combination. All patients were followed up at first and third month and then at 6 monthly intervals for a maximum of 2 years.

Polirradiculopatía por citomegalovirus en 2 pacientes con SIDA: tratamiento exitoso con terapia anti retroviral de alto grado de actividad TAAGA / Polyradiculopathy caused by cytomegalovirus in 2 AIDS patients treated successfully with highly active antiretroviral therapy HAART

We report two male patients with AlDS, aged 23 and 30 years old respectively. One was admitted due to a progressive weakness of the left leg and urinary and fecal incontinence. The other was admitted due to a progressive paraparesia without incontinence, but with a severe lumbar pain. In both patients polymerase chain reactions for cytomegalovirus in cerebrospinal fluid were positive. Treatment with ganciclovir, for 21 and 14 days respectively and highly active antiretroviral therapy was started. Both patients experienced recovery of their neurological deficits after 98 and 88 days of therapy, respectively

Effect of solvent residues of Vitex negundo Linn. and Cassia fistula Linn. on pulse beetle, Callosobruchus maculatus Fab. and its larval parasitoid, Dinarmus vagabundus (Timberlake).

Effect of solvent residues of Vitex negundo L. and Cassia fistula L. leaves (0.5 and 1%) was studied on egg laying and adult emergence of Callosobruchus maculatus Fab. and on percentage of larval parasitism by Dinarmus vagabundus (Timberlake). Cowpea seeds treated with methanol and aqueous extract of Vitex, at these concentrations (0.5 and 1%), significantly reduced the number of eggs and emergence of F1 adults of C. maculatus. Both Vitex and Cassia extracts did not affect the percentage of parasitism by D. vagabundus on C. maculatus grubs.

Changes in the haemocyte profile of Spilostethus hospes (Fab) (Heteroptera: Lygaeidae) in relation to eclosion, sex and mating.

Five types of haemocytes have been identified in the haemolymph of Spilostethus hospes. Their morphology and micrometric measurements have been provided. Changes in the total and differential haemocyte population [total haemocyte count (THC) and differtial haemocyte count (DHC)] as well as in the absolute number of haemocytes in circulation have been assessed in relation to eclosion, sex and mating. The haemogram profile was studied prior to and immediately after eclosion and also prior to and after copulation. Though the THC was not significantly different immediately before and after eclosion, there was a significant increase in total count prior to copulation. Mated females registered an increase in total count but there was no appreciable change in the mated males. Granulocytes were the most abundant of the haemocyte types in both the sexes and mating caused a significant increase in the plasmatocyte count in females. Changes in the blood volume as well as the mitotic activity of the haemocytes is also discussed.