Evaluating an impression cytology grading system (IC score) in patients with dry eye syndrome

PURPOSE

To evaluate the IC score, a newly developed grading system for the morphological alterations of the ocular surface as a diagnostic tool in relation to type and severity of dry eye disease.

METHODS

Impression cytological specimens of 309 patients with simple dry eye (S-DE), 50 patients with Sjögren's syndrome and dry eye (SS-DE), and 39 patients with connective tissue disease and dry eye (CTD-DE) were examined. In all, 10 different morphological parameters were judged with points (IC subscores) and summarized to the IC score. IC score and subscores were correlated to tear function test results and with each other.

RESULTS

SS-DE patients had the highest IC scores and IC subscores. IC scores and IC subscores correlated significantly with the fluorescein staining of the cornea in all three patient groups. They were correlated to the rose bengal score in SS-DE and S-DE patients. The analysis of the IC subscores showed that there are significant correlations between most of the morphological alterations investigated. This underlines the importance of each parameter for the summarized IC score.

CONCLUSION

The IC score provides detailed information about the morphological alterations of the bulbar conjunctiva. It has proven to be useful for the differentiation of dry eye diseases and might help in the investigation of the pathogenesis of these diseases as well as for follow-up and therapy control.

Meta-analysis of short-acting insulin analogues in adult patients with type 1 diabetes: continuous subcutaneous insulin infusion versus injection therapy

AIMS/HYPOTHESIS

This study aimed to compare the effect of treatment with short-acting insulin (SAI) analogues versus structurally unchanged short-acting insulin (regular insulin) on glycaemic control and on the risk of hypoglycaemic episodes in type 1 diabetic patients using different insulin treatment strategies.

METHODS

We performed a meta-analysis of 27 randomised controlled trials that compared the effect of SAI analogues with regular insulin in patients with type 1 diabetes mellitus. The treatments were administered either via continuous subcutaneous insulin infusion (CSII) or by conventional intensified insulin therapy (IIT) with short-acting insulin injections before meals and basal insulin administered once or twice daily in most cases.

RESULTS

HbA(1)c levels were reported for 20 studies. For studies using CSII, the weighted mean difference between values obtained using SAI analogues and regular insulin was -0.19% (95% CI: -0.27 to -0.12), whereas the corresponding value for injection studies was -0.08% (95% CI: -0.15 to -0.02). For the analysis of overall hypoglycaemia, we used the results from nine studies that reported the mean frequency of hypoglycaemic episodes per patient per month. For studies using CSII, the standardised mean difference between SAI analogues and regular insulin was -0.07 (95% CI: -0.43 to 0.28), whereas for IIT studies the corresponding value was -0.04 (95% CI: -0.24 to 0.16).

CONCLUSIONS/INTERPRETATION

Taking into consideration the low quality of the trials included, we can conclude that use of a short-acting insulin analogue in CSII therapy provides a small, but statistically significant improvement in glycaemic control compared with regular insulin. An even smaller effect was obtained with the use of ITT. The rate of overall hypoglycaemic episodes was not significantly reduced with short-acting insulin analogues in either injection regimen.

Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus

BACKGROUND

In short acting insulin analogues the dissociation of hexamers is facilitated, achieving peak plasma concentrations about twice as high and within approximately half the time compared to regular human insulin. According to these properties this profile resembles the shape of non-diabetic patients more than that of regular human insulins. Despite this theoretical superiority of short acting insulin analogues over regular human insulin, the risk-benefit ratio of short acting insulin analogues in the treatment of diabetic patients is still unclear.

OBJECTIVES

To assess the effect of treatment with short acting insulin analogues versus regular human insulin.

SEARCH STRATEGY

A highly sensitive search for randomised controlled trials combined with key terms for identifying studies on short acting insulin analogues versus regular human insulin was performed using the Cochrane Library (issue 4, 2003), MEDLINE and EMBASE. Date of last search was December 2003.

SELECTION CRITERIA

We included randomised controlled trials with diabetic patients of all ages that compared short acting insulin analogues to regular human insulin. Intervention duration had to be at least 4 weeks.

DATA COLLECTION AND ANALYSIS

Trial selection as well as evaluation of study quality was done by two independent reviewers. The quality of reporting of each trial was assessed according to a modification of the quality criteria as specified by Schulz and Jadad.

MAIN RESULTS

Altogether 7933 participants took part in 42 randomised controlled studies. Most studies were of poor methodological quality. In patients with type 1 diabetes, the weighted mean difference (WMD) of HbA1c was estimated to be -0.1% (95% CI: -0.2% to -0.1%) in favour of insulin analogue, whereas in patients with type 2 diabetes the WMD was estimated to be 0.0% (95% CI: -0.1% to 0.1%). In subgroup analyses of different types of interventions in type 1 diabetic patients, the WMD in HbA1c was -0.2% (95% CI: -0.3% to -0.1%) in favour of insulin analogue in studies using continuous subcutaneous insulin injections (CSII) whereas for conventional intensified insulin therapy (IIT) studies the WMD in HbA1c was -0.1% (95% CI: -0.2% to -0.0%). The WMD of the overall mean hypoglycaemic episodes per patient per month was -0.2 (95% CI: -1.2 to 0.9) and -0.2 (95%CI: -0.5 to 0.1) for analogues in comparison to regular insulin in patients with type 1 diabetes and type 2 diabetes, respectively. For studies in type 1 diabetic patients the incidence of severe hypoglycaemia ranged from 0 to 247.3 (median 20.3) episodes per 100 person-years for insulin analogues and from 0 to 544 (median 37.2) for regular insulin, in type 2 the incidence ranged from 0 to 30.3 (median 0.6) episodes per 100 person-years for insulin analogues and from 0 to 50.4 (median 2.8) for regular insulin. No study was designed to investigate possible long term effects (e.g. mortality, diabetic complications), in particular in patients with diabetes related complications.

REVIEWERS' CONCLUSIONS

Our analysis suggests only a minor benefit of short acting insulin analogues in the majority of diabetic patients treated with insulin. Until long term efficacy and safety data are available we suggest a cautious response to the vigorous promotion of insulin analogues. Due to fears of potentially carcinogenic and proliferative effects, most studies to date have excluded patients with advanced diabetic complications. For safety purposes, we need a long-term follow-up of large numbers of patients who use short acting insulin analogues. Furthermore, we need well designed studies in pregnant women to determine the safety profile for both the mother and the unborn child.

Application of multilevel models to morphometric data. Part 1. Linear models and hypothesis testing

Morphometric data usually have a hierarchical structure (i.e., cells are nested within patients), which should be taken into consideration in the analysis. In the recent years, special methods of handling hierarchical data, called multilevel models (MM), as well as corresponding software have received considerable development. However, there has been no application of these methods to morphometric data yet. In this paper we report our first experience of analyzing karyometric data by means of MLwiN – a dedicated program for multilevel modeling. Our data were obtained from 34 follicular adenomas and 44 follicular carcinomas of the thyroid. We show examples of fitting and interpreting MM of different complexity, and draw a number of interesting conclusions about the differences in nuclear morphology between follicular thyroid adenomas and carcinomas. We also demonstrate substantial advantages of multilevel models over conventional, single‐level statistics, which have been adopted previously to analyze karyometric data. In addition, some theoretical issues related to MM as well as major statistical software for MM are briefly reviewed.

Application of multilevel models to morphometric data. Part 2. Correlations

Multilevel organization of morphometric data (cells are "nested" within patients) requires special methods for studying correlations between karyometric features. The most distinct feature of these methods is that separate correlation (covariance) matrices are produced for every level in the hierarchy. In karyometric research, the cell-level (i.e., within-tumor) correlations seem to be of major interest. Beside their biological importance, these correlation coefficients (CC) are compulsory when dimensionality reduction is required. Using MLwiN, a dedicated program for multilevel modeling, we show how to use multivariate multilevel models (MMM) to obtain and interpret CC in each of the levels. A comparison with two usual, "single-level" statistics shows that MMM represent the only way to obtain correct cell-level correlation coefficients. The summary statistics method (take average values across each patient) produces patient-level CC only, and the "pooling" method (merge all cells together and ignore patients as units of analysis) yields incorrect CC at all. We conclude that multilevel modeling is an indispensable tool for studying correlations between morphometric variables.

Angiotensin receptor blockers as anti-hypertensive treatment for patients with diabetes mellitus: meta-analysis of controlled double-blind randomized trials

AIMS

To assess the evidence for possible reduction of all-cause mortality, cardiovascular morbidity and mortality, and end-stage renal disease in diabetic patients treated with angiotensin II type 1 receptor blockers (ARBs) as an anti-hypertensive treatment.

METHODS

Systematic review and meta-analysis of randomized, double-blind controlled trials of at least 1 year's duration. ARBs were used in the intervention group vs. placebo or standard anti-hypertensive treatment in the control group. The main outcome measures were all-cause mortality, cardiovascular morbidity and mortality, and end-stage renal disease.

RESULTS

Three studies fulfilled the inclusion criteria. Separate analyses were conducted for comparisons of ARBs with groups given placebo and those given standard anti-hypertensive treatment. There was no significant difference in mortality between the ARBs and placebo groups, with an estimated odds ratio (OR) of 0.99 [95% confidence interval (CI) 0.81, 1.20]. There was a non-significant difference in patients treated with ARBs compared with standard anti-hypertensive treatment, with an OR of 0.78 (95% CI 0.45, 1.36). No statistically significant difference in cardiovascular morbidity and mortality between the intervention and placebo groups was found, with an OR of 0.91 (95% CI 0.77, 1.08). When ARBs were compared with standard treatment, the OR was estimated at 0.85 (0.54, 1.33). Data on end-stage renal disease were available for two studies comparing ARBs vs. placebo and showed a statistically significant advantage of ARBs, with an OR of 0.73 (95% CI 0.6, 0.89). As only one study compared end-stage renal disease outcome for ARBs vs. standard treatment, a meta-analysis was not possible. This study reported a considerable benefit of ARBs [OR = 0.73 (0.54, 1.01)] compared with the calcium channel blocker amlodipine.

CONCLUSIONS

ARBs failed to show significant reduction in total mortality and cardiovascular morbidity and mortality in diabetic patients. The only statistical benefit was the reduction of end-stage renal disease compared with placebo. Therefore, at this time ARBs have not proved to be superior to standard anti-hypertensive treatment in diabetic patients.

Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus

BACKGROUND

In short acting insulin analogues the dissociation of hexamers is facilitated, achieving peak plasma concentrations about twice as high and within approximately half the time compared to regular human insulin. According to these properties this profile resembles the shape of non-diabetic patients more than that of regular human insulins. Despite this theoretical superiority of short acting insulin analogues over regular human insulin, the risk-benefit ratio of short acting insulin analogues in the treatment of diabetic patients is still unclear.

OBJECTIVES

To assess the effect of treatment with short acting insulin analogues versus regular human insulin.

SEARCH STRATEGY

A highly sensitive search for randomised controlled trials combined with key terms for identifying studies on short acting insulin analogues versus regular human insulin was performed using the Cochrane Library (issue 1, 2003), MEDLINE and EMBASE. Date of last search was December 2003.

SELECTION CRITERIA

We included randomised controlled trials with diabetic patients of all ages that compared short acting insulin analogues to regular human insulin. Intervention duration had to be at least 4 weeks.

DATA COLLECTION AND ANALYSIS

Trial selection as well as evaluation of study quality was done by two independent reviewers. The quality of reporting of each trial was assessed according to a modification of the quality criteria as specified by Schulz and Jadad.

MAIN RESULTS

Altogether 7933 participants took part in 42 randomised controlled studies. Most studies were of poor methodological quality. In patients with type 1 diabetes, the weighted mean difference (WMD) of HbA1c was estimated to be -0.1% (95% CI: -0.2% to -0.1%) in favour of insulin analogue, whereas in patients with type 2 diabetes the WMD was estimated to be 0.0% (95% CI: -0.1% to 0.1%). In subgroup analyses of different types of interventions in type 1 diabetic patients, the WMD in HbA1c was -0.2% (95% CI: -0.3% to -0.1%) in favour of insulin analogue in studies using continuous subcutaneous insulin injections (CSII) whereas for conventional intensified insulin therapy (IIT) studies the WMD in HbA1c was -0.1% (95% CI: -0.2% to -0.0%). The WMD of the overall mean hypoglycaemic episodes per patient per month was -0.2 (95% CI: -1.2 to 0.9) and -0.2 (95%CI: -0.5 to 0.1) for analogues in comparison to regular insulin in patients with type 1 diabetes and type 2 diabetes, respectively. For studies in type 1 diabetic patients the incidence of severe hypoglycaemia ranged from 0 to 247.3 (median 20.3) episodes per 100 person-years for insulin analogues and from 0 to 544 (median 37.2) for regular insulin, in type 2 the incidence ranged from 0 to 30.3 (median 0.6) episodes per 100 person-years for insulin analogues and from 0 to 50.4 (median 2.8) for regular insulin. No study was designed to investigate possible long term effects (e.g. mortality, diabetic complications), in particular in patients with diabetes related complications.

REVIEWERS' CONCLUSIONS

Our analysis suggests only a minor benefit of short acting insulin analogues in the majority of diabetic patients treated with insulin. Until long term efficacy and safety data are available we suggest a cautious response to the vigorous promotion of insulin analogues. Due to fears of potentially carcinogenic and proliferative effects, most studies to date have excluded patients with advanced diabetic complications. For safety purposes, we need a long-term follow-up of large numbers of patients who use short acting insulin analogues. Furthermore, we need well designed studies in pregnant women to determine the safety profile for both the mother and the unborn child.

Plasma N-terminal pro-brain natriuretic peptide in Type 1 diabetic patients with and without diabetic nephropathy

AIMS

Plasma N-terminal pro-brain natriuretic peptide (NT proBNP) is produced and released from cardiac ventricles; it is elevated in patients with heart failure, hypertension and chronic renal failure. This study aimed to examine the plasma levels of NT proBNP and their relationship in Type 1 diabetic patients with and without diabetic nephropathy.

METHODS

We developed a non-competitive immunoluminometric assay with in-house antibodies to the N- and C-terminal domains of NT proBNP. We compared NT proBNP levels between 47 normoalbuminuric patients (group 1), 12 microalbuminuric patients (group 2) and 12 patients with macroalbuminuria (group 3).

RESULTS

There were significant differences in 24-h systolic and diastolic blood pressure, diabetes duration, serum creatinine, LDL-cholesterol and HbA1c between the three groups; other parameters did not differ significantly. NT proBNP (median and range) levels were 5 (0.75-68), 22 (0.75-82) and 23 (0.75-374) fmol/ml for groups 1-3, respectively. Log-transformed data of NT proBNP were used to compare all three groups (P=0.016). The Pearson correlation between NT proBNP and albuminuria (R=0.27; P=0.02) was positive; HbA1c (R=0.25; P=0.03) and age (R=0.33; P=0.005) correlated significantly as well. On the basis of multiple regression analysis, the adjusted difference remained significant between the three groups.

CONCLUSIONS

This is the first demonstration that NT proBNP levels are significantly higher in Type 1 diabetic patients with albuminuria. This may be caused by a down-regulation of A-type guanylate cyclase-coupled natriuretic peptide receptors in renal tubules or by elevated NT proBNP levels leading to higher glomerular hydraulic pressure or higher capillary permeability and possibly increased albumin excretion. Further studies are required to investigate the potential role of NT proBNP in patients with diabetic nephropathy and such other co-morbidities as cardiovascular disease.

Serum osteoprotegerin is a major determinant of bone density development and prevalent vertebral fracture status following cardiac transplantation

Osteoprotegerin (OPG) is an antiresorptive cytokine and a key regulator of osteoclastogenesis and activity. Since OPG is downregulated by glucocorticoids and cyclosporine A in vitro we examined whether immunosuppressive therapy would play a role in the development of transplantation osteoporosis. We enrolled 57 cardiac transplant recipients (median time since transplantation, 3.2 years (1.1-11.5 years)) in this cross-sectional study. Standardized spinal X-rays as well as hip bone density measurements were performed in all patients. Serum OPG was determined using a commercially available ELISA. Vertebral fractures were present in 56% of the patients. Bone densities of all femoral neck subregions were correlated to serum OPG concentrations (r values between 0.40 and 0.48, all P < 0.005). Multiple regression analysis revealed OPG levels to be independently correlated to femoral neck Z scores (r = 0.49, P = 0.002). After adjustment for age, BMI, neck Z score, renal function, and months since transplantation, serum OPG was the only significant predictor of prevalent vertebral fractures (P = 0.001). In a separate 6-month prospective study of 14 heart transplant recipients receiving calcium and vitamin D serum OPG levels fell by 41% (P = 0.0004) after 3 months and 47% (P = 0.0001) after 6 months following cardiac transplantation. Bone loss at the lumbar spine and femoral neck after 6 months was correlated to the decrease in serum OPG at 6 months (r = 0.82, P < 0.0001, and r = 0.60, P = 0.02, respectively) as well as 3 months after cardiac transplantation (r = 0.65, P = 0.01, and r = 0.69, P = 0.006, respectively). Serum OPG alone accounted for 67% of the variance of lumbar spine bone density changes over the first 6 months posttransplantation. We conclude that serum OPG levels decline consistently in all patients following initiation of immunosuppressive therapy and are independently correlated with changes in bone density. We hypothesize that OPG plays a major role in the development of transplantation osteoporosis.

Vehicles reversing or rolling backwards: an underestimated hazard

OBJECTIVES

A retrospective analysis of injuries caused by vehicles that were reversing or rolling backwards to establish guidelines for prevention was performed.

PATIENTS AND METHODS

Medical records and questionnaires completed by parents for 32 children admitted to the Department of Pediatric Surgery, Graz, within the past eight years, were analysed.

RESULTS

The median age was 2.1 years (1.0-14.0 years). Fourteen of 32 of the cars were driven by family members (43.8%); three were rolling backwards without a driver (9.4%). The median injury severity score was 3 (1-27) and the most common injuries were contusions (40.6%), fractures (31.3%), and lacerations/burns (21.9%). Most incidents occurred in driveways (37.5%) or farmyards (21.9%). Altogether 70.3% of children sustained "run-over" injuries, 29.6% were hit by the rear bumper or injured by a breaking window.

CONCLUSIONS

Toddlers playing in driveways or farmyards are at risk of a injury caused by reversing vehicles/vehicles rolling backwards.

Different policies on prenatal ultrasound screening programmes and induced abortions explain regional variations in infant mortality with congenital malformations

OBJECTIVE

To compare the impact of induced abortions (IA) on the mortality of infants with congenital malformations in four European regions with different policies on IA and prenatal ultrasound screening for congenital malformations.

METHODS

A registry-based collection of data on congenital malformations in four different countries: Ireland (Dublin), Denmark (Funen County), Austria (Styria), and France (Strasbourg).

RESULTS

The proportion of infant deaths with malformations ranged from 23 to 44% of all infant deaths with the highest proportion in Dublin, where IA is not allowed and prenatal ultrasound screening not performed. There were highly significant differences in the prevalences of IA (p < 0.001), fetal deaths (p < 0.01), and deaths in infants with congenital malformations (p < 0.001) between the four regions. The differences in total mortality with congenital malformations (IA + fetal deaths + infant deaths) between regions decreased, and only Strasbourg differs significantly from the other three regions.

CONCLUSION

Prenatal ultrasound screening programmes have only a minor impact on total mortality with congenital malformations from 2nd trimester of pregnancy to 1 year of age, but seem to change the time of death which may be important for both the parents and the community.

A model and application for estimating completeness of registration

Completeness of population-based registration systems is recognized to be an important aspect of the quality of information in registries which has to be examined. In this paper a model is presented which was used to estimate completeness of reporting of Down syndrome data notified to the Styrian Malformation registry between 1985-92. The model introduced is based on the two-source capture-recapture method allowing for time-varying parameters. For estimation of the parameters a discrete-time filtering algorithm was developed. For the used data set, an estimate of completeness derived from this model was in good agreement with an independent estimator based on demographic data and maternal age-specific Down syndrome risks whereas the usual two-source capture-recapture method gave a higher estimate.

Carcinoma of the Larynx: Predictors of Diagnostic Delay

OBJECTIVES

In tumors of the upper aerodigestive tract a dose-response relationship between tumor stage and its prognosis raises the chance of a reduction in the diagnostic delay. The interval between the first symptom and the start of tumor-specific therapy and the influencing factors is not well known. The goals of this study were to investigate the diagnostic delay and the influencing factors and to predict the factors that prolong the diagnostic process.

STUDY DESIGN

Prospective, nonrandomized study.

METHODS

The intervals between first symptom and first consultation of a physician (patient delay) and between first consultation and first tumor-specific therapy (doctor delay) were investigated. Predictors for increased patient or doctor delay were evaluated, and a multiple logistic regression model for increased doctor delay was developed.

RESULTS

The total diagnostic delay (sum of patient and doctor delays) was 3 to 4 months. A multifactorial model for the ratio of odds revealed that for women and glottic cancers (1.73) the chance was twice as high for a doctor delay greater than 30 days, whereas subjects with an increased patient delay (>30 d) had reduced odds of being delayed by the physician.

CONCLUSIONS

The higher chance of extended doctor delay for glottic tumors compared with supraglottic tumors should be reflected in differential therapeutic strategies. Even unspecific lesions of the vocal folds should be followed up at the end of the therapy, at least. Therapies of glottic lesions without final control have the chance of resulting in delays in treatment. Women, especially, should be included in a follow-up examination. On the other hand, patients with increased patient delay have lower odds of longer doctor delay, which may be the result of tumor growth and, consequently, easier diagnosis.

Longitudinal change of white matter abnormalities

A three year follow-up of 273 participants (mean age 60+/-6.1 years) of the Austrian Stroke Prevention Study provides first information on the rate, clinical predictors, and cognitive consequences of MRI white matter hyperintensity in elderly individuals without neuropsychiatric disease. Lesion progression was found in a total of 49 (17.9%) individuals. It was minor in 27 (9.9%) and marked in 22 (8.1%) participants. Diastolic blood pressure (odds ratio 1.07/mmHg) and early confluent or confluent white matter hyperintensities at baseline (odds ratio 2.62) were the only significant predictors of white matter hyperintensity progression. Lesion progression had no influence on the course of neuropsychologic test performance over the observational period.

Chlamydia pneumoniae in multiple sclerosis: humoral immune responses in serum and cerebrospinal fluid and correlation with disease activity marker

Humoral immune responses to Chlamydia pneumoniae (C. pneumoniae) were studied in paired sera and cerebrospinal fluid (CSF) of patients with definite multiple sclerosis (MS) and other inflammatory and non-inflammatory neurological diseases. Seropositivity was not significantly different between these groups. However, C. pneumoniae-specific IgG titers were significantly higher in CSF of MS than in controls. Sixteen out of 52 seropositive MS patients (30.8%) showed intrathecal synthesis of C. pneumoniae-specific IgG but only one of 43 seropositive controls (2.3%). In MS, this was strongly associated with intrathecal synthesis of polyclonal IgG in 13/16 patients. However, these elevated C. pneumoniae antibody titers in CSF did not significantly correlate with disease duration, disease course, clinical or MRI disease activity, disability or presence of oligoclonal IgG in MS.

HLA patterns in patients with nasal polyposis

The etiology of nasal polyposis is still unknown, although risk factors include Aspirin intolerance, asthma, cystic fibrosis and primary ciliary dyskinesia. We studied frequencies of HLA A, B, DR and DQ in patients with nasal polyposis in order to determine a possible genetic component in the multifactorial pathogenesis of nasal polyps. Previous work has suggested an association of HLA-A1B8 with nasal polyposis and Aspirin intolerance. We investigated 89 patients with nasal polyposis, 11 of whom had Aspirin-intolerance, 19 asthma and 22 allergies to inhalation allergens. HLA patterns of these patients were compared to the ones of 1,070 healthy controls. No significant association of HLA-A1B8 was found with nasal polyps in the Aspirin-sensitive subgroup of our patients, but a significant association was seen with HLA-A74 and nasal polyposis.

Association of the vitamin D receptor genotype BB with low bone density in hyperthyroidism

Bone mineral density (BMD) is modulated by genetic and environmental factors or certain diseases. In several conditions such as low calcium intake, an influence of vitamin D receptor (VDR) polymorphisms on BMD has been suggested. In the present study, we investigated the relationship of Bsm I and Fok I polymorphisms of the VDR gene and BMD in patients with hyperthyroidism, a disease that often results in low BMD. Bsm I and Fok I genotypes were determined in 76 postmenopausal hyperthyroid patients and 62 healthy postmenopausal women as controls. Patients and controls were matched for age, time since menopause, and lifestyle factors and were free of estrogen medication. BMD evaluation included axial dual X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (PQCT). Low BMD was defined as -2.5 STD below the young adult mean value. Biochemical parameters investigated were thyroid hormones, osteocalcin, and 25-(OH)-vitamin D3 as well as routine laboratory data. Low BMD was found in 61% of hyperthyroid patients and in only 23% of euthyroid controls. In the group of hyperthyroid patients with low bone density, the BB genotype (VDR Bsm I polymorphisms) was significantly more frequent (39%) than in controls (13%; p = 0.003) and hyperthyroid patients with normal BMD (6%; p = 0.013). The odds ratio (OR) for low BMD in patients with BB genotype was 5.7 (95% CI, 1.7-19.1; p < 0.005) as compared with the Bb and bb genotypes and 5.5 (95% CI, 2.3-13.2; p < 0.0001) for hyperthyroidism alone. The cumulative risk for low BMD in patients with hyperthyroidism and BB genotype was 31.4 (95% CI, 3.9-256; p < 0.0003). VDR Fok I genotypes showed no significant relationship with BMD or other general or bone-specific parameters. Thus, hyperthyroidism and the genetic background of a BB genotype may promote synergistically the development of low BMD in hyperthyroid patients. Screening for the BB genotype in these patients therefore could help to identify those with particularly high risk for the development of low BMD and allow early treatment.

Morphologic characteristics of disciform scarring after radiation treatment for age-related macular degeneration

OBJECTIVE

To investigate the influence of radiation therapy on the development of disciform lesions in patients with age-related macular degeneration (AMD).

DESIGN

A prospective, nonrandomized, comparative trial (patient self-controlled).

PARTICIPANTS

Forty eyes with exudative AMD involving the central fovea in 40 consecutive patients were enrolled in this study.

INTERVENTION

Radiation was administered to the posterior pole with an 8-mV photon beam from a linear accelerator. A dose of 14.4 Gy, 1.8 Gy per day, five fractions per week was delivered through a single port.

MAIN OUTCOME MEASURES

The visual acuity and the morphologic characteristics, demonstrated by fundus photography, fluorescein, and indocyanine green angiography, were investigated before treatment and every 3 months after treatment over a period of 24 months. In 10 patients with bilateral disease the disciform lesions were compared.

RESULTS

Twenty five patients could be followed regularly over the period of 24 months. The disciform lesions occurring after radiation were classified in three types. Type I (10 patients) was characterized by being smaller than 2 DD in size, with little fibrotic tissue underneath the retina, but pronounced retinal pigment epithelial changes. Type II (seven patients) showed extensive growth of the choroidal neovascularization (CNV) extending to and beyond the arcades with angiographically active loops in the peripheral parts. Eight patients had type III lesions develop characterized by a size greater than 2 DD but fewer than 6 DD and by a different amount of fibrotic tissue, hemorrhage, and lipid. Type I scarring was significantly associated with occult CNV without pigment epithelial detachments, whereas type II scarring was associated with classic CNV at the initial presentation (P<0.05).

CONCLUSIONS

Although no severe side effects have been reported after radiation therapy for AMD, a subgroup of patients may experience extensive growth of CNV after radiation, causing greater functional damage than occurs spontaneously.

Bilateral sensorineural hearing disorders in children: etiology of deafness and evaluation of hearing tests

OBJECTIVE

The purpose of this study was to determine the etiology of bilateral sensorineural hearing disorders in children and to evaluate the performed hearing tests by comparison of the results of the objective and subjective tests.

METHODS

The medical history and the hearing tests (behavioral observation audiometry, acoustic evoked potentials and pure tone audiometry) of 106 bilaterally hearing impaired children were analyzed in a retrospective follow-up study.

RESULTS

The total group included 52 males and 54 females. The ages at first diagnosis ranged from 4 months to 11 years with a mean age of 42 months and a median of 33 months. The degree of hearing loss for the better hearing ear was mild in one child, moderate in 28 children, severe in 29 children, profound in 32 children and total in 16 children. The delay between the first examination and diagnosis ranged from 0 to 597 days with a mean of 83 days and a median of 28 days. In 47 children (44%) no cause of hearing impairment could be determined. Nineteen children (18%) had a history of familial hearing loss, 40 (38%) suffered from acquired hearing loss (seven children had prenatal causes, 21 perinatal and 12 postnatal). A comparison between behavioral observation audiometry and brainstem evoked response audiometry revealed a statistically good agreement. Twenty-nine children (32%) showed progressive hearing loss, which was defined as a threshold shift of +10 dB or more in the pure tone average in at least one ear.

CONCLUSIONS

In a significant number of children with early hearing impairments the etiology still remains uncertain. Further research in the field of genetic disorders will diminish this number. Evaluation of hearing tests showed that behavioral observation audiometry still is an excellent tool in the hands of an experienced examiner. The age at identification of hearing disorders in industrialized countries still is unacceptably high. To obtain ideal care of hearing impaired children, universal neonatal hearing screening programs are mandatory.

Synthesis pattern of matrix metalloproteinases (MMPs) and inhibitors (TIMPs) in human explant organ cultures after treatment with latanoprost and dexamethasone

PURPOSE

To determine changes in production of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in the ciliary body, the trabecular meshwork and the retinal pigment epithelium induced by both prostaglandins and corticosteroids.

METHODS

Explant organ cultures were removed by a scleral incision 3 mm posterior to the limbus. Retinal pigment epithelium was grown to confluence. Organ and cell cultures were treated with latanoprost and/or dexamethasone for 72 h. The activity of MMP-2, -3 and -9 was assessed using zymography. The synthesis pattern of MMPs and TIMP-1 and -2 was identified using immunostaining.

RESULTS

Treatment of explant organ cultures with 10 micrograms/ml of latanoprost induced a mean upregulation of MMP-2 by 36%, MMP-3 by 112% and MMP-9 by 156% as seen by zymography. Dexamethasone 500 nm reduced the amounts of secreted MMP-2 by 13%, MMP-3 by 69%. MMP-9 was not detectable in the media of corticosteroid-treated explant organ cultures. The addition of 10 micrograms/ml of latanoprost to dexamethasone-treated cultures increased MMP-2 by 14%, MMP-3 by 43% and MMP-9 by 49%. Using immunohistochemistry we found staining with antibodies against MMP-2, -3, -9 and TIMP-1 and -2 within the ciliary body, and only to a lesser degree in the trabecular meshwork. Latanoprost treatment caused an increase of 29% in MMP-2 (p < 0.0001), 98% in MMP-3 (p < 0.0001) and 108% in MMP-9 (p < 0.0001). Dexamethasone reduced the staining for MMP-2 by 32% (p < 0.0001), for MMP-3 by 33% (p < 0.0001) and for MMP-9 by 83% (p < 0.0001). Almost no change in staining for MMPs was detectable in the trabecular meshwork. Neither latanoprost treatment nor dexamethasone induced significant changes (p < 0.93) in the secretion of TIMPs. In the media of non-treated retinal pigment epithelium (RPE) cells the only MMP detected was MMP-2. RPE cells in culture did not respond to either treatment with a change in their MMP secretion.

CONCLUSION

We detected a profound upregulation of both MMP-3 and MMP-9 and a mild induction of MMP-2 through latanoprost in the ciliary body, but not the trabecular meshwork or RPE cells. Corticosteroids, on the other hand, downregulated MMP expression in both tissues. This inhibiting effect of corticosteroids on MMP production was reversed by latanoprost.

Bunk beds--a still underestimated risk for accidents in childhood?

A retrospective analysis of 218 bunk-bed accidents and a random sample survey with 991 family interviews were performed in order to establish guidelines for bunk-bed accident prevention. Falls from the top bed during sleep (35.1%) or while playing (34.4%) and falling off the ladder (23.2%) are the leading causes of bunk-bed accidents. Of the 218 children, 91 (41.7%) had sustained major injuries, including 3 polytrauma, 7 skull fractures, 44 cerebral concussions, 33 long bone fractures, 2 Lisfranc injuries, and 2 lacerations of the spleen. Of these accidents, 58.3% resulted in minor injuries with 18 fractures in other locations than the long bones or cranial vault, 89 contusions and sprains, 18 skin lacerations and 2 tooth fractures. A total of 23.8% of the accidents occurred in children under 3 years of age. The random sample survey demonstrated that in relation to age groups of children 30.8% (0%-45.8%) of families interviewed had been using bunk beds, with peaks at 3 years (29.8%), 7 years (36.5%) and 11 years (45.8%) of age. Of these bunk beds, 75.3% were equipped with side-rails, 57.3% had placed carpets alongside the bunk bed and 43.0% had used night lights.

CONCLUSION

There is only one recommendation: no bunk beds!!!