Ocular telemedicine between Nepal and the USA: prevalence of vitreoretinal disease in rural Nepal.

This study is aimed at reporting experiences with telemedicine between Nepal and the USA and at reporting the prevalence of age-related macular degeneration (AMD) and diabetic retinopathy (DR) in rural Nepal. AMD and DR are becoming more significant factors for non-reversible vision loss in rural Nepal due to increasing life expectancy and urbanisation. The prevalence of DM is low compared with the developed world, but the percentage of diabetics with DR is high, presumably due to limited access to healthcare. The higher prevalence of DM in Hetauda is explained as being due to a more urban lifestyle, dietary habits (more deep-fried food) and more advanced age.

A complicated percutaneous coil embolisation of a large coronary artery fistula.

A coronary artery fistula is a rare cause of cardiac symptoms or signs in an adult. We report here the successful percutaneous treatment of a large fistula in an adult who had suffered an acute myocardial infarction peri-operatively due to a steal phenomenon. Due to the fistula size, a specially constructed occlusion device was utilised for effective treatment.

Malattia leventinese presenting with subretinal neovascular membrane and hemorrhage.

PURPOSE: To report a case of malattia leventinese involving subretinal hemorrhage. METHODS: Case report. RESULTS: Two weeks after initial presentation, the visual acuity of this 34-year-old man decreased to LE: 20/100. Funduscopic evaluation revealed a subretinal hemorrhage involving the center of the foveal in the left eye that was interpreted as secondary to a neovascular membrane on fluorescein angiography. The patient did well after the removal of the submacular material by pars plana vitrectomy. CONCLUSION: Patients with malattia leventinese may occasionally present with submacular hemorrhage. Prompt diagnosis and intervention may enhance the patient's chance for visual improvement.

Efficacy and safety of direct stenting in coronary angioplasty.

BACKGROUND: Direct stenting is the deployment of an intracoronary stent without lesion predilation. Potential advantages include shorter procedural time, lower contrast dose and reduced spiral dissections. There is also the potential financial benefit of less balloon and/or stent usage. Concern still exists among some operators, however, regarding failure of stent deployment and local complications. METHODS: Of 467 consecutive angioplasty cases at the Alfred Hospital between August 1, 1997 and May 22, 1998, direct stenting was attempted in 93 patients (20%). Interventionalist preference determined whether direct stenting was attempted. Vessels with excessive calcification, severe proximal tortuosity or small caliber were typically considered unsuitable for direct stenting. RESULTS: A total of 102 lesions (38 type A, 60 type B, and 4 type C) were treated with direct stenting. Initial deployment was successful in 98 of 102 lesions, with a further 3 lesions successfully stented following predilation. A stent was unable to be deployed in only 1 case; however, the lesion was treated with balloon angioplasty alone. The majority of lesions required only 1 stent (an average of 1.1 stents were used per lesion). Distal complications occurred in 5 patients. In 3 patients, a small distal dissection was successfully stented, and in 1 case embolization of debris occurred down the distal vessel, resulting in a small procedural myocardial infarction. Only 1 patient out of 93 (1%) developed a large distal dissection requiring the deployment of multiple stents, compared with 22 of the remaining 374 patients (5.9%) who underwent conventional angioplasty. This was a significant difference in favor of direct stenting (Chi-square, p < 0.05). When compared with a cohort of patients matched by lesion grade treated with conventional stenting, direct stenting used significantly less contrast per case (154 +/- 7.6 ml compared with 202 +/- 9.5 ml for conventional stenting; p = 0.0001). CONCLUSION: Direct stenting is a safe and effective method for treating coronary artery disease. In appropriately selected cases, it has a low rate of procedural failure and results in less contrast usage and fewer distal complications than conventional angioplasty and stenting.

Arteriovenous adventitial sheathotomy for the treatment of macular edema associated with branch retinal vein occlusion.

PURPOSE: To report arteriovenous adventitial sheathotomy for treatment of macular edema associated with branch retinal vein occlusion. METHODS: Case reports with review. Five eyes of five patients with best-corrected visual acuity of less than 20/200 secondary to branch retinal vein occlusion had pars plana vitrectomy and arteriovenous adventitial sheathotomy and were followed postoperatively for a mean of 6.5 years (range, 5 to 7 years). RESULTS: In four of five eyes, the best-corrected visual acuity improved to 20/30 to 20/70. In the remaining eye, visual acuity remained at finger counting secondary to macular ischemia. CONCLUSION: Arteriovenous adventitial sheathotomy may be beneficial for select patients with poor vision secondary to branch retinal vein occlusion.

How to cope with a visit from the Pope.

A mass gathering always presents a challenge to the medical providers of a city since preparations must be made to cover any potential disasters, big or small. With a prediction of several hundred thousand people coming to the New York City area to participate in the Papal Masses, the New York City-Emergency Medical Services readied its forces of physicians, paramedics, and emergency medical technicians from throughout the region. Extensive multi-agency planning involving a Total Quality Management process was integral to the success of covering the events.

Status asthmaticus in a paramedic following exposure to a roadside flare: a case report.

Highway flares are commonly used by police and emergency service workers to divert traffic away from roadside accidents. We report a case of a 35-yr-old paramedic who developed a sudden, severe asthmatic reaction following a brief exposure to such a flare, necessitating intubation and a prolonged hospitalization.

Irreversible silicone oil adhesion to silicone intraocular lenses. A clinicopathologic analysis.

PURPOSE: To report a newly defined complication of foldable intraocular lenses (IOLs), namely silicone oil-silicone IOL interaction. This is a complication not generally seen by the implanting cataract surgeon but, rather, at a later stage in a patient's postoperative course, by a vitreoretinal surgeon. METHODS: Three clinical case histories, including two explanted silicone IOLs, were submitted for analysis. The submitted silicone lenses were photographed under water, and the nature of the silicone oil coating was documented. RESULTS: In each instance, the silicone coating was manifest as a thick coating with droplet formation on the lens surface that was tenaciously adherent and could not be dislodged by instruments or injection of viscoelastics. CONCLUSION: The use of silicone IOLs in patients with current vitreoretinal disease or those who are at high risk for future vitreoretinal disease that may require silicone oil as part of the therapy should be reconsidered. The authors recommend that information regarding the existence and significance of this complication be printed on all silicone oil and silicone IOL packages and inserts (if not as a warning, at least as an informative comment regarding the existence of this condition). This is a rare but clinically significant complication that will affect the occasional patient treated with both of these modalities.

Branch retinal artery occlusion as the initial sign of giant cell arteritis.

PURPOSE: To describe a patient whose initial sign of giant cell arteritis was a branch retinal artery occlusion. METHODS: We examined a 77-year-old woman who developed arteritic anterior ischemic optic neuropathy three weeks after an isolated non-embolic branch retinal artery occlusion occurred in the same eye. RESULTS: The diagnosis of giant cell arteritis was confirmed by temporal artery biopsy after the patient was treated with intravenous corticosteroids. CONCLUSIONS: Although a rare cause of branch retinal vascular occlusion, giant cell arteritis should be considered in the differential diagnosis of a non-embolic branch retinal artery occlusion in elderly patients.

Alfred Hospital Coronary Care Unit: an acute myocardial infarction quality assurance study.

A six-month prospective study was performed to assess the efficacy of delivering thrombolytic therapy to patients with acute myocardial infarction and admitted to the coronary care unit. Patient characteristics, time from chest pain onset to presentation to emergency department, from presentation to thrombolytic therapy, transfer from emergency department to coronary care unit major interventions and outcome were assessed. One hundred and twenty patients were admitted with acute myocardial infarction, mean age 66 years (26-91), 69% were males. Of these, 50% received thrombolytic therapy. The mean time from chest pain onset to emergency department was 192 +/- 164 minutes, transfer from emergency department to coronary care unit was 195 +/- 150 minutes. The mean time from presentation to emergency department to receiving thrombolytics was 63 +/- 12 minutes. Streptokinase was the choice of thrombolytic in 97%. Thrombolytic therapy was administered in emergency department in 80% of cases. Thirty-eight (63%) patients received thrombolytic therapy within 60 minutes of presentation. Compared to the non-thrombolytic group, the thrombolytic group were younger, 63 vs 69 years, P < 0.01, presented earlier to hospital (192 vs 394 minutes, P < 0.0005), were transferred to coronary care unit sooner (195 vs 472 minutes, P < 0.001), and had more coronary angiograms (29 vs 23, P < 0.02) and PTCA performed 10 vs 3, P < 0.04. There were no significant differences in length of coronary care unit stay, length of hospital stay, patients receiving CABG or death.

Ocular toxicity of intravitreous transforming growth factor-beta 1.

PURPOSE: To evaluate the ocular toxicity of intravitreous transforming growth factor-beta 1 (TGF-beta(1)). METHODS: Eyes of New Zealand white rabbits were injected intravitreally with TGF-beta(1) in doses of 20, 10, 5, 1 or 0.5 micrograms. Electroretinography and clinical examination were performed before and after the injection. At either 10 or 30 days after injection, the eyes were enucleated and examined histologically. The endothelium of fresh corneas, which had received 20 micrograms TGF-beta(1) or nothing, were checked 5 days after injection. RESULTS: Corneal opacity was caused by doses > or = 10 micrograms in 7 of 7 eyes; by doses of 5 micrograms in 3 of 4 eyes; and by doses of 1 microgram in 1 of 4 eyes. Doses > or = 5 micrograms also caused pannus formation in 15 of 16 eyes. Ten days after injection there was some decrease in B-wave amplitude on electroretinography. Thirty days after injection the electroretinographic responses had recovered, except in the eyes injected with 20 micrograms TGF-beta(1), which still showed a decrease in step 1. Histological examination of paraffin sections did not demonstrate significant change. Corneal thickness of the eyes receiving 20 micrograms TGF-beta(1) was twice that of the normal cornea and some corneal endothelial cells lost their hexagonal shape. CONCLUSION: TGF-beta(1) injected intravitreally at doses > or = 1 micrograms is toxic to the cornea. Retinal function is only slightly disturbed by 20 micrograms of TGF-beta(1).

Usefulness of a prototype directional catheter for excimer laser coronary angioplasty in narrowings unfavorable for conventional excimer or balloon angioplasty.

We report clinical and angiographic results in 53 patients with 57 significant coronary or saphenous vein graft narrowings treated with directional excimer laser angioplasty. The target vessels were the left main (1%), anterior descending (32%), circumflex (19%), right coronary artery (39%), and vein grafts (9%). Lesions were morphologic class B1 (18%), B2 (79%), or C (3%), with 40 de novo and 17 restenotic lesions. Adjunctive balloon angioplasty was used in 53 lesions (93%). Mean pre- and postprocedural minimal lumen diameters were 0.6 +/- 0.3 and 1.9 +/- 0.7 mm (p < 0.001), corresponding to a mean diameter stenosis of 72 +/- 20% and 27 +/- 16%. Procedural success rate was 91%. Cumulative risk of death, Q-wave myocardial infarction, or emergency bypass operation was 9% (5 patients). Of patients who had a successful laser procedure, 28 (60%) with 30 lesions underwent angiographic follow-up at 6 +/- 3 months after the procedure. Restenosis rates (> 50% diameter restenosis or acute gain loss) were 37% and 23%, respectively. Four patients underwent bypass, 3 angioplasty, and 1 patient died from cancer. This study demonstrates the feasibility of directional application of laser energy to selected unfavorable narrowings for conventional excimer laser or balloon angioplasty. Further evaluation of this device using the now standard saline infusion technique is necessary to establish its ultimate role as a primary interventional device.

Does the use of new intracoronary interventional devices prolong radiation exposure in the cardiac catheterization laboratory?

OBJECTIVES: The aim of this study was to compare the duration of radiation exposure associated with new percutaneous coronary interventional devices with that associated with conventional balloon angioplasty. BACKGROUND: Radiation exposure levels have been documented to be higher with coronary balloon angioplasty than with routine diagnostic coronary angiography. However, the effect of new interventional devices on radiation exposure has not been studied. METHODS: Fluoroscopic and cineangiographic data from the Mayo Clinic cardiac catheterization laboratory data base of patients having single-segment coronary intervention during a recent 46-month period were retrospectively analyzed. Of 897 patients studied, 646 underwent balloon angioplasty, 138 directional coronary atherectomy (42 with adjunctive balloon angioplasty), 76 excimer laser angioplasty (50 with adjunctive balloon angioplasty) and 37 placement of an intracoronary stent (16 emergencies). RESULTS: Duration of fluoroscopy during balloon angioplasty was 24 +/- 18 min, which was longer than with directional atherectomy (18 +/- 8 min; p = 0.001). Fluoroscopy time was 25 +/- 17 min with laser angioplasty and 29 +/- 15 min with elective stent placement (neither time was significantly different from that with balloon angioplasty). When atherectomy or laser angioplasty was performed with adjunctive balloon angioplasty or if emergency intracoronary stent placement was performed, the duration of fluoroscopy was significantly prolonged compared with balloon angioplasty alone. CONCLUSIONS: Fluoroscopy duration is not prolonged with the use of new interventional coronary devices compared with conventional angioplasty unless adjunctive balloon angioplasty is used or emergency stent placement is required.

The use of perfluorophenanthrene in the removal of intravitreal lens fragments.

We used perfluorophenanthrene as an aid during pars plana vitrectomy in removing lens fragments dislocated posteriorly into the vitreous cavity. We reviewed the records of all patients (nine patients, nine eyes) referred with dislocated lenses who underwent pars plana vitrectomy with perfluorophenanthrene for removal of the lens material at Wills Eye Hospital from July 1, 1991, through Nov. 30, 1991. The lens was dislocated during cataract extraction in eight eyes. One eye had a history of nonpenetrating trauma and lens dislocation. In one eye a retinal tear was noted intraoperatively and treated. Six eyes had postoperative visual acuity of 20/50 or better. In all eyes the lens was removed without further complications. Perfluorocarbon liquids such as perfluorophenanthrene may enhance current techniques by allowing easier and safer removal of displaced lens fragments through the pars plana.

Cardiopulmonary transplantation service establishment in the 1990s: Australia--a developing country?

1. A National Transplantation Service has been established at the Alfred Hospital performing more than 50 transplants per year. 2. Increased access to transplantation technology has facilitated an improvement in national population servicing from 2.7 to 6.2 transplants per million population per year. National funding of A$4.062 million per year has been secured. 3. Basic research into organ preservation has facilitated transcontinental organ procurement. 4. An active lung transplantation program has been established synchronous with the cardiac transplant service activities. 5. MCS program establishment has paralleled clinical transplantation activities. 6. Budget management and cost containment has been achieved through rationalisation of management protocols.