Dynamic contour tonometry (DCT) versus non-contact tonometry (NCT): a comparison study

In a prospective study we measured the intraocular pressure (IOP) by means of a Non-Contact Tonometer (NCT) and by means of a Pascal Dynamic Contour Tonometer (DCT), and the Central Corneal Thickness (CCT) by means of a contact pachymeter in 294 emmetropic or ametropic eyes. There is a linear relation between NCT and CCT. This linear relation doesn't exist between DCT and CCT. The same measurements were done before and 6 weeks after a Lasik intervention in 58 myopic eyes. Lasik intervention influences NCT but doesn't influence DCT.

Rheumatoid factor and anticitrullinated protein antibodies in rheumatoid arthritis: diagnostic value, associations with radiological progression rate, and extra-articular manifestations

BACKGROUND

Autoantibodies such as rheumatoid factor (RF) and anticitrullinated protein antibodies can be detected in rheumatoid arthritis (RA) sera.

OBJECTIVE

To determine the diagnostic values of RF, anticitrullinated protein antibodies, and the shared epitope (SE), and their associations with radiological progression rates and extra-articular manifestations.

METHODS

Population 1 consisted of sera from 315 patients, consecutively sent for detection of anticitrullinated protein antibodies, of which 264 were used to determine the sensitivity and specificity of RF and of antibodies against three synthetic citrullinated peptides: peptide A (pepA), peptide B (pepB), and CCP2. Population 2 consisted of sera from 180 longstanding RA patients and was used to determine associations of RA associated antibodies and the SE with radiological progression rates and extra-articular manifestations. Antibodies to pepA and pepB were detected by line immunoassay, and antibodies to CCP2 by ELISA. HLA Class II typing was performed by LiPA.

RESULTS

In population 1, we defined adapted cut offs corresponding to a specificity of >/=98.5%. This yielded the following sensitivities: RF 12.8%; anti-pepA antibodies 63.6%; anti-pepB antibodies 54.2%; and anti-CCP2 antibodies 73.7%. In population 2, significant differences in radiological progression rates were found between positive and negative patients for different RA antibodies and the SE. RF, but not anticitrullinated protein antibodies or the SE, were more frequent in patients with extra-articular manifestations.

CONCLUSION

A valid comparison of RA associated antibodies shows superior sensitivity of the anticitrullinated protein antibodies compared with RF. The presence of RA associated antibodies and the SE are indicative for poorer radiological outcome, and presence of extra-articular manifestations is associated with RF but not with anticitrullinated protein antibodies.

The simulated operating theatre: comprehensive training for surgical teams

Surgical excellence is traditionally defined in terms of technical performance, with little regard for the importance of interpersonal communication and leadership skills. Studies in the aviation industry have stressed the role of human factors in causing error and, in an attempt to reduce the occurrence of adverse events, led to the organisation of simulation based training scenarios. Similar strategies have recently been employed for the surgical team with the development of a simulated operating theatre project. This enables technical and non-technical performance of the surgeon and circulating staff to be assessed by experts situated in an adjacent control room, and provides an opportunity for constructive feedback. The scenarios have good face validity and junior surgeons can benefit from the process of learning new technical skills in a realistic environment. The effect of external influences such as distractions, new technology, or a crisis scenario can also be defined, with the ultimate aim of reducing the number of adverse events arising in the real operating room.

The simulated operating theatre: comprehensive training for surgical teams

Surgical excellence is traditionally defined in terms of technical performance, with little regard for the importance of interpersonal communication and leadership skills. Studies in the aviation industry have stressed the role of human factors in causing error and, in an attempt to reduce the occurrence of adverse events, led to the organisation of simulation based training scenarios. Similar strategies have recently been employed for the surgical team with the development of a simulated operating theatre project. This enables technical and non-technical performance of the surgeon and circulating staff to be assessed by experts situated in an adjacent control room, and provides an opportunity for constructive feedback. The scenarios have good face validity and junior surgeons can benefit from the process of learning new technical skills in a realistic environment. The effect of external influences such as distractions, new technology, or a crisis scenario can also be defined, with the ultimate aim of reducing the number of adverse events arising in the real operating room.

Insecticidal properties of a Chenopodium-based botanical

The emulsifiable concentrate UDA-245 based on an essential oil extract from Chenopodium ambrosioides variety near ambrosioides, a North American herbaceous plant, was compared with commercially available pesticides for their effectiveness to control green peach aphid, Myzus persicae (Sulzer) (Homoptera: Aphididae), western flower thrips, Frankliniella occidentalis (Pergande) (Thysanoptera: Thripidae), and greenhouse whitefly, Trialeurodes vaporariorium (Westwood) (Homoptera: Aleyrodidae). Side effects on the whitefly parasitoid Encarsia formosa Gahan (Hymenoptera: Aphelinidae) also were determined. With green peach aphid, UDA-245 at 0.5% concentration was significantly more effective than the control (water) treatment in a laboratory bioassay and significantly more effective than neem oil and the control treatment and as effective as insecticidal soap in a greenhouse assay. With the western flower thrips, UDA-245 at 0.5% was significantly more effective than neem oil, insecticidal soap and the control treatment in a laboratory bioassay, whereas in a greenhouse assay, UDA-245 at 1.0% was the only treatment that maintained control of the western flower thrips 2 wk after the last treatment period. UDA-245 at 0.5% (laboratory bioassay) was significantly more effective in managing greenhouse whitefly than neem oil, endosulfan, and the control treatment and as effective as insecticidal soap. Insecticidal soap proved to be toxic to the parasitoid E. formosa (71.9% mortality), whereas UDA-245 at 0.5% was not significantly more toxic than the control (11.2 and 4.6% mortality, respectively). Our results suggest that a greenhouse integrated pest management (IPM) program using a botanical such as UDA-245 could effectively control infestations of major pests present while having a negligible effect on biological control agents.

Acaricidal properties of a Chenopodium-based botanical

The emulsifiable concentrate UDA-245 [25% EC (vol:vol)], based on an essential oil extract from Chenopodium ambrosioides variety ambrosioides, a North American herbaceous plant, was compared with commercially available pesticides for their effectiveness to control the adult stage and egg hatch of the twospotted spider mite, Tetranychus urticae Koch (Acari: Tetranychidae) and the European red mite, Panonychus ulmi (Koch) (Acari: Tetranychidae). After a laboratory bioassay with adult twospotted spider mites, a 0.5% concentration of UDA-245 was more effective than 0.7% (AI) of neem oil (Neem Rose Defense). After a similar bioassay with the European red mite, a 0.5% concentration UDA-245 was as effective as 0.006% (AI) of abamectin (Avid). UDA-245 at 0.5% significantly reduced egg hatch of the twospotted spider mite, 5 and 9 d after treatment and of the European red mite 6 d after treatment. Egg hatch was significantly lower using 0.006% (AI) of abamectin, 0.7% of neem oil, and 1.0% insecticidal soap than UDA-245. Residual tests indicated that UDA-245 may be persistent in the environment only for a few hours. Only 23% mortality was noted when mites were introduced on bean leaves 1 h after treatment with a 2% concentration of UDA-245. At the recommended dose of 0.5%, UDA-245 was not considered phytotoxic for most plants tested, i.e., lettuce, roses, and tomatoes. Results suggest that a greenhouse integrated pest management program using UDA-245 could effectively and selectively control mite infestations by treating "hot spots" with negligible effect on biological control agents when treating before introduction or when natural enemies are absent.

Acaricidal properties of a Chenopodium-based botanical

The emulsifiable concentrate UDA-245 [25% EC (vol:vol)], based on an essential oil extract from Chenopodium ambrosioides variety ambrosioides, a North American herbaceous plant, was compared with commercially available pesticides for their effectiveness to control the adult stage and egg hatch of the twospotted spider mite, Tetranychus urticae Koch (Acari: Tetranychidae) and the European red mite, Panonychus ulmi (Koch) (Acari: Tetranychidae). After a laboratory bioassay with adult twospotted spider mites, a 0.5% concentration of UDA-245 was more effective than 0.7% (AI) of neem oil (Neem Rose Defense). After a similar bioassay with the European red mite, a 0.5% concentration UDA-245 was as effective as 0.006% (AI) of abamectin (Avid). UDA-245 at 0.5% significantly reduced egg hatch of the twospotted spider mite, 5 and 9 d after treatment and of the European red mite 6 d after treatment. Egg hatch was significantly lower using 0.006% (AI) of abamectin, 0.7% of neem oil, and 1.0% insecticidal soap than UDA-245. Residual tests indicated that UDA-245 may be persistent in the environment only for a few hours. Only 23% mortality was noted when mites were introduced on bean leaves 1 h after treatment with a 2% concentration of UDA-245. At the recommended dose of 0.5%, UDA-245 was not considered phytotoxic for most plants tested, i.e., lettuce, roses, and tomatoes. Results suggest that a greenhouse integrated pest management program using UDA-245 could effectively and selectively control mite infestations by treating "hot spots" with negligible effect on biological control agents when treating before introduction or when natural enemies are absent.

Monitoring auditif et chirurgie du neurinome de l’acoustique

Intraoperative auditory monitoring in acoustic neuroma surgery is used to improve residual hearing. Three techniques are available: monitoring of brainstem auditory evoked potentials, of electrocochleography or of direct eighth nerve compound action potential. The three techniques with their advantages and disadvantages are discussed. The current trend is to monitor brainstem auditory evoked potentials using digital filtering or to monitor the eighth nerve compound action potential.

Novel Protein Kinase C and Matrix Metalloproteinase Inhibitors of Vegetable Origin as Potential Modulators of Langerhans Cell Migration following Hapten-Induced Sensitization

BACKGROUND

Migration and maturation of epidermal dendritic cells, the Langerhans cells (LC), are central events in the initiation of the cutaneous immune response. LC migration from skin to draining lymph nodes is regarded as an indispensable step for the early phase of antigen-specific sensitization. Among the several agents which influence the ability of LC to migrate, previous studies have revealed that matrix metalloproteinases (MMPs) and protein kinase C (PKC) contribute to promoting LC migration. In this work, we studied the effect of two recently developed PKC and MMPs inhibitors of vegetable origin on the migration of in vitro activated LC.

METHODS

The migratory capacity of epidermal and in vitro generated LC was assessed using a reconstituted basement membrane assay (Matrigel), mimicking the prerequisite passage through the dermal-epidermal basement membrane on the way to the lymph nodes.

RESULTS

Contact with chemical allergens, Bandrowski's base or 2,4-dinitrobenzenesulfonic acid (DNBS), triggered migration. In the presence of PKC inhibitors, D-erythro-sphingosine and OX100, or an inhibitor of MMPs, LU105, allergen-induced migration of LC was strongly decreased. The association between OX100 and LU105 was more efficient in modulating the migration of activated LC compared to each molecule tested separately.

CONCLUSIONS

These results showed that PKC and MMPs inhibitors act in synergy to inhibit the migration of activated epidermal dendritic cells in vitro. They underscore the role of PKC and MMPs inhibitors and suggest they may be of relevance for therapeutically regulating epidermal dendritic cell migration in inflammatory dermatoses.

A longitudinal study on postoperative hearing thresholds with the Vibrant Soundbridge device

The Vibrant Soundbridge is a semi-implantable middle ear hearing device used in the rehabilitation of adults with sensorineural hearing loss. In order to evaluate the long-term effects of the implanted part of the device, audiological data from 39 patients implanted over several implant sites across France were collected and analyzed retrospectively. The mean follow-up time was 16 months; 25 patients had a follow-up period of over 1 year. Surgery was uneventful in all cases. The present study of the 39 implanted patients with a mid- to long-term follow-up found a statistically significant modification of hearing thresholds (pre- versus postoperative) for frequencies of 0.5 and 4 kHz. However, the shift of threshold was rather limited (2.79 and 3.34 dB, respectively), and this variation was not statistically different from the evolution of the opposite non-operated ear.

Case record review of adverse events: a new approach

OBJECTIVES

To redesign the existing clinical review form (RF2) used in previous retrospective case record review studies in order to clarify the review process and provide a more powerful analysis of adverse events; and then to ask clinicians to pilot and evaluate the new modular review form (MRF2). The review form is divided into five sections, each with a defined purpose, providing a modular structure.

DESIGN

Design and testing of the MRF2 on a sample of medical and nursing records, and evaluation of the reviewers' responses regarding the new review form.

SETTING

Hospital based teams from eight countries.

RESULTS

The modular review form was reported to be comprehensive, well structured, and clear. Most of the reviewers agreed with the positive statements regarding the review form. Overall, the modular structure was thought to be helpful. Several modifications have been made to the final version to take account of criticisms and suggestions.

CONCLUSIONS

The full potential of case record review has yet to be explored. The benefits of this review form include a modular format which enables reviewers or project leaders to select the focus of their review based on resources and the purpose of the review, and to identify contributory factors which indicate areas for improvement and prevention. The training of reviewers is of vital importance for record review. Record review remains one of the primary methods for assessing the incidence of adverse events and the new format is suitable for both prospective and retrospective review.

Binding of live conidia of Aspergillus fumigatus activates in vitro-generated human Langerhans cells via a lectin of galactomannan specificity

Aspergillus fumigatus is the most common aetiological fungus responsible for human pulmonary aspergilloses. This study investigated the primary contact between Langerhans cells (LC), corresponding to dendritic cells present in pulmonary mucosa and live conidia of A. fumigatus. LC play a key role in antigen presentation for initiation of the primary T cell response. In vitro-generated LC (iLC) were differentiated from cultured human cord blood CD34+ cells and incubated at 4 degrees C or 37 degrees C with fluorescein-isothiocyanate (FITC)-stained conidia or control latex beads. In vitro, conidia were shown by microscopy and cytometry to adhere to iLC in a dose- and time-dependent manner. This adhesion was not limited to iLC because interstitial dendritic and other cells also fluoresced in the presence of conidia-FITC. A lectin other than mannose receptor-type lectin was demonstrated to be responsible of conidial binding. Inhibition of binding was observed with heterologous galactomannan and EDTA, indicating a C-lectin-like receptor with galactomannan structure specificity. After binding only a few conidia were internalized in acidic vesicles, as indicated by the cessation of conidial fluorescence. Conidial binding was followed by activation and maturation of iLC, suggesting that LC present in the lung may play a role in cellular host defence against aspergilloses.

Self-indexing of multiview fringe systems

The algorithm proposed in this paper enables the registration of two three-dimensional surface of an object when recording with a fringe-projection technique from two different viewpoints. Based on the redundancy and a distance minimization between the views, it leads iteratively to the absolute positioning of the surfaces without fringe coding. The robustness of the algorithm is demonstrated on natural shapes reconstructed from a four-head system.

High-dose BCNU followed by autologous hematopoietic stem cell transplantation in supratentorial high-grade malignant gliomas: a retrospective analysis of 114 patients

Conventional treatment of high-grade glioma includes maximal surgical resection followed by external radiation therapy. Despite this treatment, the prognosis for patients is poor. High doses of chemotherapy might be another way to increase the response rate and median survival. Increasing doses of BCNU might be more effective, but also provokes unacceptable myelotoxicity. This dose-limiting toxicity can be circumvented by using autologous blood stem cell rescue. We report our experience of high-dose BCNU followed by transplantation of autologous hematopoietic stem cells in 114 patients with high-grade gliomas. Of the 114 gliomas, 78 were glioblastoma multiforme (GM) (68%), 24 anaplastic astrocytomas (AA) (21%), and 12 anaplastic oligodendrogliomas (OD) (11%). Complete surgical resection was performed for 22 patients (18 GM and 4 AA). The median age was 44 years (range 17-65). A total of 84 patients received autologous hematopoietic stem cells from bone marrow harvest, while 30 patients received granulocyte colony-stimulating factor followed by apheresis and received peripheral blood progenitor cells (PBPC). High dose of BCNU (800 mg/m(2)) was given at least 1 month after neurosurgery. Bone marrow or PBPC was transplanted 48-72 h after chemotherapy. Radiotherapy was started approximately 40 days after transplantation to a total of 60 Gy. Median follow-up was 89 months (19-163). The overall survival (OS) was, respectively, 12 months for GM, 37 months for OD and 81 months for AA. Histological type appeared to be the main discriminating factor, with a worse prognosis for GM. Within the GM population, age, completeness of surgery, and response appeared to be one important prognostic factors. The AA and OD populations were small to reliably assess prognostic factors. On multivariate analysis, the main prognostic factors were histologic type, quality of surgery, and age (P<0.005). Five of 114 patients had lethal complications from the procedure. Four of these patients had a Karnovsky performance score (KPS) of 60%. The protocol thus appears to be feasible but patients should be selected for KPS more than 70%. We observed long-term survivors, although the OS and the time to treatment failure seem to be comparable to that described for other treatment. Additional pilot studies are unlikely to reveal more than a modest benefit from this procedure and therefore a randomized study should be performed.

Withdrawal of TNF-alpha after the fifth day of differentiation of CD34+ cord blood progenitors generates a homogeneous population of Langerhans cells and delays their maturation

Human cord blood CD34+ progenitors cultured in the presence of granulocyte-macrophage colony-stimulating factor (GM-CSF), tumor necrosis factor-alpha (TNF-alpha) and transforming growth factor-beta (TGF-beta) generate a heterogeneous population of dendritic cells (DC), including Langerhans cells (LC). This combination of cytokines has been shown to be crucial for differentiation into LC. After day 5 of culture, TNF-alpha has been maintained in the medium in most studies despite the observation of spontaneous maturation of LC after day 12. Five-day samples of in vitro differentiated LC were cultured in parallel with or without TNF-alpha. The absence of TNF-alpha was shown to: (1) slow down proliferation without triggering apoptotic cell death, (2) enhance the percentage of LC, (3) delay or abrogate the expression of CD83, CD86, HLA-DR and CD208 molecules, and (4) maintain endocytosis by receptor and macropinocytosis. The withdrawal of TNF-alpha abrogated the spontaneous synthesis of matrix metalloproteinases. At day 12, TNF-alpha-deprived LC were less efficient in allogeneic T cell activation than LC cultivated with TNF-alpha. These data indicate that the suppression of TNF-alpha after day 5 maintains cells in an immature state and provides a population with 80% of LC at day 12.

Comparative studies on the secretion and activation of MMPs in two reconstructed human skin models using HaCaT- and HaCaT-ras-transfected cell lines

Matrix metalloproteinases play an important role in tissue regeneration, wound healing and tumor invasion. Our previous studies have shown a higher motility of HaCaT-ras-transfected cells compared with HaCaT or normal human keratinocytes (NHK) in correlation with a higher secretion of MMP-2 (72 kDa) or MMP-9 (92 kDa), according to the medium used for cell cultures. Presently, the expression and activity of MMPs were investigated in two reconstructed skin models, using a dead de-epidermized dermis (DED) or a dermal substitute including living fibroblasts. In all experiments, MMP-9 was essentially secreted by NHK and to a greater extent by HaCaT cells. Its active form (86 kDa) was only detected in both reconstructed skin models according to keratinocyte differentiation. MMP-2 was mainly secreted by living fibroblasts included in the dermal substitute skin model. In this case, its activation was up-regulated when HaCaT cell lines were seeded onto the dermal substitute according to their culture at air/liquid interface as shown for MMP-9. The collagenase MMP-1 and stromelysin-1 (MMP-3), susceptible to activate pro-MMP-2 and -9, respectively, were detected in their inactive form by ELISA. MMP-1 was expressed in both models but MMP-3 required the presence of living fibroblasts. Their activities were not detected using specific fluorogenic substrates. In the skin equivalent model using HaCaT, the extensive secretion and activation of MMP-2 and MMP-9 could explain the defect observed in basal membrane reconstruction, suggesting a direct interaction of HaCaT with fibroblasts.

Prescribing errors in hospital inpatients: their incidence and clinical significance

BACKGROUND

It has been estimated that 1-2% of US inpatients are harmed by medication errors, the majority of which are errors in prescribing. The UK Department of Health has recommended that serious errors in the use of prescribed drugs should be reduced by 40% by 2005; however, little is known about the current incidence of prescribing errors in the UK. This pilot study sought to investigate their incidence in one UK hospital.

METHODS

Pharmacists prospectively recorded details of all prescribing errors identified in non-obstetric inpatients during a 4 week period. The number of medication orders written was estimated from a 1 in 5 sample of inpatients. Potential clinical significance was assessed by a pharmacist and a clinical pharmacologist.

RESULTS

About 36200 medication orders were written during the study period, and a prescribing error was identified in 1.5% (95% confidence interval (CI) 1.4 to 1.6). A potentially serious error occurred in 0.4% (95% CI 0.3 to 0.5). Most of the errors (54%) were associated with choice of dose. Error rates were significantly different for different stages of patient stay (p<0.0001) with a higher error rate for medication orders written during the inpatient stay than for those written on admission or discharge. While the majority of all errors (61%) originated in medication order writing, most serious errors (58%) originated in the prescribing decision.

CONCLUSIONS

There were about 135 prescribing errors identified each week, of which 34 were potentially serious. Knowing where and when errors are most likely to occur will be helpful in designing initiatives to reduce them. The methods developed could be used to evaluate such initiatives.

[Clinical implications of acoustic neuromas growth rate in volumetric study]

OBJECTIVE

The pattern of neuroma growth is of great importance in choosing the appropriate management. This paper tests the clinical impact of tumor growth rate assessed by volumetry. There is a conviction that some slowly growing tumors could be observed for many years.

METHOD AND PATIENTS

Volume measurements were performed on T1- weighted MR images (spin echo sequences) after injection of gadolinium using a special dedicated software. The studied group included 17 patients in whom at least two MRI examinations were carried out and tumor growth was confirmed. The intervals between initial and the first follow-up examination were 14.2 months on the average. In 7 cases tumor evolution was observed in 2 periods (3 MRI studies) and in 4 cases in 3 periods (4 MRI studies).

RESULTS

The growth rate depended on tumors volume and clinical stage (P<0.01). Small tumors can be observed more safely than advanced tumors because their increase in mass is lower.

CONCLUSION

The observation with the tumoral volume measurements appears to be a useful and accurate tool to estimate the tumor growth rate. The growth rate is a major factor for choosing the appropriate management.

Principles of risk and safety

Studies of error and adverse events in medicine have brought a growing awareness of the extent of harm to patients. The psychology of human error strongly suggests that individual liability to error is strongly influenced by the conditions and organisation of the working environment and the nature of the task, in particular the complex and inherently uncertain judgements frequently made in medicine. Research into accidents in medicine and other high risk areas has lead to a much broader concept of causation, with less focus on individuals and more on pre-existing organisational factors. These ideas have been adapted to practical use in healthcare in the analysis of adverse events and in working towards developing safer systems of care. The final section of the paper summarises the implications of this approach for healthcare in terms of an overall systems approach, the need for basic information about clinical incidents, the benefits of systematic investigation and analysis, the nature of safety interventions, the need to study success as well as failure and the need to develop an open, safety aware culture in healthcare.

[The monaural pseudo-stereophonic hearing aid (BAHA) in unilateral total deafness: a study of 29 patients]

For many years, unilateral total deafness has been considered a minor handicap which does not require the fitting of a hearing aid. If the condition did give a major problem, the usual recommendation for this type of hearing loss was a CROS system which, in addition to problems of function and aesthetics, gave poor results. Faced with increasing demands from these patients, and given the good performance of bone conduction implants (BAHA), we decided to try to implant these devices on the deaf side, which allowed, by way of transcranial conduction, stimulation of the functioning ear and the re-establishment of a certain degree of stereophonic hearing. This study of 29 patients who were tested by stereophonic audiometry pre- and post-implantation shows that this type of aiding is beneficial, with improvement of the threshold of intelligibility against background noise of between 5 and 15 dB during Hirsch's test, correction of the "dead angle" on the deaf side, and improvement in localisation of sound in space. From the functional point of view, 88% of patients were satisfied with their aid, which they wore for 8 or 9 hours per day, and had a marked improvement in their hearing performance under various conditions which had proved very difficult for them before they were fitted with the aid. These results all demonstrate the effectiveness of the implant used in this way. The fact that sounds are received on the totally deaf side goes a long way towards establishing satisfactory hearing. True stereophonic hearing could not be established in any of the cases, because this requires input from two ears. It is for this reason that we have termed this type of aid as monaural pseudo-stereophonic.