Screening for age-related macular degeneration using nonstereo digital fundus photographs

Age-related macular degeneration (AMD) is a disease with significant visual morbidity and accounts for the majority of blind registrations in the developed world including the UK. Certain forms of neovascular AMD are amenable to treatment but require expeditious referral to a retinal specialist.

AIM

To evaluate the possibility of using nonstereo fundus photographs as a low-cost screening tool for neovascular AMD.

DESIGN

Retrospective review of patients referred to the macular clinic of a teaching hospital in London.

METHODS

A total of 198 randomised digital fundus photographs, without any other clinical information, were presented to two independent ophthalmic interns who graded them into one of the three categories: normal, age-related maculopathy (ARM), or neovascular age-related macular degeneration (AMD) to determine the urgency of referral to clinic. The results were compared with the known diagnosis for each patient and sensitivities and specificities for each diagnostic category calculated.

RESULTS

The intraobserver Kappa statistic was 0.75 and 0.91 for grader 1 and 2, respectively. The interobserver Kappa was 0.54. The mean sensitivity and specificity for the identification of ARM was 60.5 and 76.3%, respectively The mean sensitivity and specificity for the identification of AMD was 85.7 and 78.8%, respectively.

CONCLUSION

Nonstereo digital fundus photograph is a reasonable screening tool for CNV and may aid in decreasing the visual morbidity it causes by enabling timely referrals and treatment.

Tear film lipid layer thickness and ocular comfort after meibomian therapy via latent heat with a novel device in normal subjects

AIM

This study measures changes in tear film lipid layer thickness (LLT) and ocular comfort in normal subjects after 10 min use of a novel device, which delivers meibomian therapy with latent heat. The device is designed to promote the release of meibomian sebum into the tear film by delivering latent heat to the eyelids, thus thickening the lipid layer. Normal lid movements are maintained, facilitating resurfacing of the tear film.

METHOD

A prospective, controlled, observer masked, single intervention trial in which 24 normal subjects were randomised into three groups. Group I underwent 10 min treatment with the activated device, Group II used the inactivated device for the same duration of time, and Group III had no intervention. The LLT of each subject was measured with a Keeler Tearscope prior and subsequent to the 10-min period. Subjective alteration in ocular comfort was also assessed.

RESULTS

Seven of eight subjects (87.5%) in Group I exhibited an increase in LLT. The mean LLT in this group showed a statistically significant increase (left eyes 1.0 levels, P<0.001, right eyes 0.9 levels, P<0.003) compared to Groups II and III. Six of eight subjects (75%) using the activated device experienced subjective improvement in ocular comfort.

CONCLUSION

Meibomian therapy with this device increases LLT in normal individuals. This implies a more stable tear film, reflected in subjective improvement in ocular comfort.

Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome

AIM

To analyse the outcome of basal cell carcinoma (BCC) excision in a subregional (non-Mohs) oculoplastic service.

METHODS

A single surgeon retrospective series, medical record review of 223 consecutive cases with histologically confirmed eyelid BCC (between 1987 and 2004). Tumour recurrence rate was derived from the 69 patients with a minimum 5 year follow up.

RESULTS

Of the total 223 patients, the surviving 162 were included in this study. The follow up for the whole cohort ranged from 2 months to 120 months. All cases underwent excisional biopsy. 4 mm excision margins were taken in 83% of cases. The pathology revealed 84% complete primary excision. Of those reported incompletely excised 53% contained no tumour at re-excision. 70% of lid defects were treated by primary direct closure. Following confirmed histological clearance the remainder underwent delayed direct closure (2%), full thickness skin or tarsal grafts (13%), local skin and muscle flaps (11%), and spontaneous granulation (laissez faire) (4%). No major complications were noted. There were no recurrences for non-infiltrative BCCs. The overall 5 year and over recurrence rate including previously recurrent BCCs was 4.35%, only one of which was in the primary BCC group (1.6%). All recurrences were in infiltrative BCCs.

CONCLUSIONS

Non-infiltrative BCC excision with 4 mm margins gave a zero recurrence rate. Long term follow up of such patients may be unnecessary. Infiltrative BCCs should be followed up indefinitely. Previous recurrence and infiltrative histology have predictive value for recurrence. We achieved one of the lowest recurrence rates reported in non-Mohs surgical excision. Direct closure was applicable in 72% of cases.

Pulmonary alveolar microlithiasis: CT and pathologic findings in 10 patients

BACKGROUND AND AIM

To evaluate CT findings of pulmonary alveolar microlithiasis and correlate the CT with the pathologic findings.

METHODS

The study included 10 patients with pathologically proven microlithiasis. Two independent observers evaluated the presence, extent and distribution of the CT findings. CT findings were compared with those at autopsy in two patients and with transbronchial biopsy in eight patients.

RESULTS

All patients had a myriad of calcified nodules measuring approximately 1 mm in diameter. Close apposition of the nodules resulted in areas of ground-glass attenuation and consolidation, which were the predominant abnormality on CT in all 10 patients, involving 41% +/- 16.3 (mean +/- SD) and 30% +/- 4.8 of the lung parenchyma, respectively. Calcifications were also seen along interlobular septa, bronchovascular bundles and pleura. Other findings included interlobular septal thickening, thickening of bronchovascular bundles, nodules, and subpleural cysts. There was a solid agreement between the observers for the presence (kappa value; 0.77) and extent (Spearman rank correlation; r = 0.81 to 1.0 p < 0.01) of abnormalities. Autopsy specimens demonstrated microliths in alveolar airspaces and along interlobular septa, bronchovascular bundles and pleura. Subpleural small cysts were shown to represent dilated alveolar ducts.

CONCLUSION

Pulmonary microlithiasis is characterised by the presence of numerous small, calcified nodules, calcifications along interlobular septa, bronchovascular bundles and pleura, ground-glass opacities, consolidation, and subpleural cysts. The cysts represent dilated alveolar ducts.

Unrelated donor bone marrow transplantation for 100 pediatric patients: a single institute's experience

In all, 100 unrelated donor bone marrow transplantations (UD-BMT) were performed in our institute between October 1993 and January 2003. Of 93 evaluable patients, 73 patients had hematological malignancy, 13 had nonmalignancy and seven had lymphoproliferative disease. The estimated 9-year event-free survival (EFS) rate was 57.1+/-5.5% in all patients. In the following analyses of the patients with hematological malignancy, the standard group had significantly better EFS than the high-risk group (61.5+/-7.0 vs 35.6+/-9.7%, P=0.02), and the EFS rate of the tacrolimus (FK-506)+methotrexate (MTX)+/-methylprednisolone prophylactic group for graft-versus-host disease was superior to that of the FK-506 without MTX group (75.7+/-8.0 vs 55.8+/-7.6%, P=0.02). When we compared the EFS rates of the FK506+MTX+/-methylprednisolone (mPSL) group and the HLA-matched related donor BMT group in our institute, these were almost similar (75.7+/-8.1 vs 68.4+/-9.3%). Therefore, UD-BMT using FK-506+MTX+/-mPSL is a safe and useful method for children with hematological malignancy who require allogeneic BMT.

Role of Glucose Side Chains with Serotype-Specific Polysaccharide in the Cariogenicity of Streptococcus mutans

Previously, we isolated and characterized a new Streptococcus mutans strain (serotype k) from human blood and oral cavity samples, and found that the serological properties of serotype k strains were similar to those of a gluA-inactivated mutant strain of MT8148 (MT8148GD). MT8148GD showed significantly lower sucrose-dependent adhesion to glass surfaces, sucrose-independent adhesion to saliva-coated hydroxyapatite, dextran-binding activity, and cell-associated glucosyltransferase (GTF) activity than the parent strain. Further, Western blot analysis revealed reduced GTFB and GTFC expression in serotype k strains as compared to MT8148, though the caries-inducing activities of MT8148GD and a serotype k oral isolate in rats were similar to that of MT8148. We conclude that a glucose side-chain defect in the serotype-specific polysaccharide of S. mutans may be associated with its cariogenicity, though to a lesser extent than its other major surface proteins.

Effect of CYP2C19 polymorphism on the safety and efficacy of omeprazole in Japanese patients with recurrent reflux oesophagitis

BACKGROUND

The polymorphic enzyme cytochrome P450 2C19 affects omeprazole metabolism. This influence on metabolism might affect serum gastrin levels, and safety, during long-term treatment of reflux oesophagitis.

AIM

To examine the relationship between cytochrome P450 2C19 genotype and the safety profile of long-term omeprazole treatment.

METHODS

A total of 119 Japanese patients with recurrent reflux oesophagitis underwent cytochrome P450 2C19 genotyping prior to receiving daily omeprazole 10 mg or 20 mg for 6-12 months, during which adverse event frequency, serum gastrin levels and endoscopic findings were monitored.

RESULTS

The incidences of adverse events, serious adverse events and adverse events leading to withdrawal did not differ between homozygous extensive metabolizer (n = 46), heterozygous extensive metabolizer (n = 53) or poor metabolizer (n = 20) groups. In all genotype groups, serum gastrin increased during the first 3 months of dosing but stabilized thereafter. No significant differences were seen either in the rate of reflux oesophagitis healing or symptom improvement among genotype groups.

CONCLUSIONS

Long-term treatment with omeprazole was well-tolerated in Japanese patients, irrespective of their cytochrome P450 2C19 metabolic genotype, indicating that dose adjustment depending on metabolic genotype is not required during treatment with omeprazole.

Sparse and wavy hair: a new model for hypoplasia of hair follicle and mammary glands on rat chromosome 17

Mutant animals in the skin and hair have been used to identify important genes in biomedical research. We describe a new mutant rat, sparse and wavy hair (swh), that spontaneously arose in a colony of inbred WTC rats. The mutant phenotype was characterized by sparse and wavy hair, which was most prominent at age 3-4 weeks, and was inherited in an autosomal recessive manner. The swh/swh rats showed impaired gain of body weight, and their hair follicles were reduced both in number and size, associated with hypoplasia of the sebaceous glands and the subcutaneous fat tissue. Female swh/swh rats were unable to suckle their offspring. Their mammary glands were hypoplastic, and differentiation of mammary epithelial and myoepithelial cells was impaired. Linkage analysis of 579 backcross rats localized the swh locus to a .35-cM region between D17Rat131 and D17Rat50 in the distal end of rat Chr 17. The swh locus spanned the 3.7-Mb genomic region where 24 genes have been mapped and corresponded to the centromere region of the mouse Chr 2 or the region of the human Chr 10p11.1-p14. None of the genes or loci described in mouse or human hair and skin diseases mapped to these regions. These findings suggest that the rat swh is a novel mutation associated with impaired development of the skin appendages, such as hair follicles, sebaceous glands, and mammary glands, and will provide an experimental model to clarify a gene and mechanisms for development of skin appendages.

Drusen classification in bilateral drusen and fellow eye of exudative age-related macular degeneration

AIM

To assess the value of the modified international classification system in screening high-risk patients with bilateral age-related maculopathy (ARM) from those with lower risk characteristics.

METHODS

In total, 164 digital images of 106 patients with either bilateral ARM (group A) or the fellow eyes of unilateral exudative age-related macular degeneration (AMD) (Group B) were included. Patients with no signs of ARM in both eyes or those with bilateral late AMD were excluded. The images were randomised and then graded by two masked ophthalmologists based on the modified International Classification of ARM.

RESULTS

The interobserver consistency between the two graders was high with a Kappa value of 0.82 (SE 0.34, P<0.0001). There were no significant differences in the distribution of the stages of ARM between the two subgroups. Stage 3 was the most common stage in each group for both graders followed by stage 2a in the bilateral drusen group. Stages 1a, 2a and 2b were equally the next common stage in the fellow eye of chordial neovascularisation group.

CONCLUSION

A screening system based on clinical characteristics would be of value in risk prediction in a clinical setting. Type of Drusen alone, as identified by the modified International grading system, may not be reliably predictive in screening for patients who are at high risk of developing choroidal neovascularisation.

Starch properties of the sago palm (Metroxylon sagu Rottb.) in different soils

We investigated the relationships between starch concentrations and activities of starch synthetic enzymes in sago palms (Metroxylon sagu Rottb.) under acid sulfate and mineral soil conditions. Plants grown naturally that had reached their maturated stage were sampled. We found that the growth in acid sulfate soil is lower than that in mineral soil and that starch granules were larger and there was more amylase activity in acid sulfate soil than in mineral soil. Lower amylase activity in mineral soil could eliminate the degradation of starch, making the smaller granules suitable for storing large amounts of starch in a limited space inside cells.

Antibacterial Activity of Polyphenol Components in Oolong Tea Extract against Streptococcus mutans

The purpose of the present study was to determine the antibacterial activity of oolong tea extract on oral streptococci, including Streptococcus mutans and Streptococcus sobrinus, and to identify the response to its components. Antibacterial activity was found when the extract was added to S. mutans cells in chemically defined medium but not in complex broth media. Further, pretreatment with bovine serum albumin reduced the antibacterial activity. The extract showed antibacterial activity against all of the oral streptococci examined, with the highest activity against S. mutans MT8148R. This activity was found to originate from a monomeric polyphenol-rich fraction, and it was stronger than that of pure polyphenols. Moreover, some combinations of monomeric polyphenols showed the highest level of antibacterial activity. These results suggest that the antibacterial activity of oolong tea extract is caused by a synergistic effect of monomeric polyphenols, which can easily bind to proteins.

Molecular analysis of the inhibitory effects of oolong tea polyphenols on glucan-binding domain of recombinant glucosyltransferases fromStreptococcus mutansMT8148

An oolong tea polyphenol (OTF6) has been shown to possess a strong anti-glucosyltransferase (GTF) activity and inhibit experimental dental caries in rats infected with mutans streptococci. The effects of OTF6 on the functional domains of GTFs of Streptococcus mutans, an N-terminal catalytic domain (CAT), and a C-terminal glucan-binding domain (GBD), were examined. The maximum velocity of glucan synthesis by recombinant GTFB (rGTFB) and GTFD (rGTFD) became significantly slower in the presence of OTF6, however, Km values remained stable when compared in their absence. These results suggest that OTF6 reduces glucan synthesis by non-competitively inhibiting the GBD of S. mutans GTFB and GTFD. Further, the recombinant proteins of CAT (rCAT) and GBD (rGBD) were expressed using Escherichia coli, and purified by affinity column chromatography. rGBD but not rCAT was found to possess dextran-binding activity, which was shown to be inhibited by OTF6. These results indicate that OTF6, a polymeric polyphenol specific for oolong tea is able to reduce glucan synthesis by inhibiting the GBD of S. mutans GTFB.

[Off-pump coronary artery bypass grafting for severe acute coronary syndrome]

Off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) has become a standard procedure, but the indication for the patients with severe acute coronary syndrome (ACS) has not been established. The purpose of this study is to evaluate the role of OPCAB for patients with acute myocardial infarction (AMI) and impending myocardial infarction (IMI). Clinical indication of OPCAB for acute coronary syndrome between November 1997 and December 2002, 14 patients diagnosed ACS out of 220 CABG cases underwent surgery. Twelve male and 2 female with a mean age of 66.3 +/- 7.5 were NYHA grade IV condition before surgery. Three of nine AMI cases and 4 of 5 IMI cases underwent OPCAB. Thirteen cases needed intra-aortic balloon pumping (IABP) support pre-operation, in 1 AMI and 2 IMI cases IABP had to be weaned during operation. The mean graft number was 2.6. Except one AMI case with severe cardiac damage, 13 cases were discharged in NYHA grade I-II condition.

CONCLUSION

In early onset cases with still rising CK-MB, operative risk and result is difficult to evaluate pre-operatively. Equal results could be seen in IMI cases with no previous myocardial damage. We suggest, that in cases without severe myocardial damage, OPCAB could be one alternative treatment.

Tuberculous abdominal aortic pseudoaneurysm penetrating the left psoas muscle after BCG therapy for bladder cancer

We describe a case of a 75-year-old man with abdominal aortic and right femoral tuberculous pseudoaneurysms 32 months after intravesical bacillus Calmette-Guerin therapy for bladder cancer. These aneurysms were probably brought on by systemic infection by Mycobacterium bovis. The infrarenal aorta and right common femoral artery were successfully replaced with an in situ expanded polytetrafluoroethylene graft. Tuberculous pseudoaneurysm after bacillus Calmette-Guerin therapy for malignancy is very rare, and we review the related literature.

The effects of lansoprazole on erosive reflux oesophagitis are influenced by CYP2C19 polymorphism

BACKGROUND

The acid suppressive effect of lansoprazole is influenced by the P450 2C19 (CYP2C19) polymorphism.

AIM

To investigate whether the CYP2C19 genotype is related to the healing of erosive reflux oesophagitis during treatment with lansoprazole.

METHODS

Eighty-eight Japanese patients with erosive reflux oesophagitis were treated with a daily oral dose of 30 mg lansoprazole for 8 weeks. The CYP2C19 genotype, Helicobacter pylori infection status and serum pepsinogen I/II ratio were assessed before treatment. At 4 and 8 weeks, the healing of erosive reflux oesophagitis was evaluated endoscopically.

RESULTS

The healing rates were 57.1%, 69.2% and 72.7% at 4 weeks and 77.4%, 95.0% and 100% at 8 weeks in homozygous extensive metabolizers, heterozygous extensive metabolizers and poor metabolizers, respectively. At 8 weeks, the healing rate of erosive reflux oesophagitis was significantly lower in homozygous extensive metabolizers than in the other two groups (P < 0.05). The H. pylori status and serum pepsinogen I/II ratio had less influence than CYP2C19 polymorphism on the healing rate of erosive reflux oesophagitis.

CONCLUSIONS

The therapeutic effect of lansoprazole on erosive reflux oesophagitis is influenced by the CYP2C19 genotype status. Therefore, a test of CYP2C19 genotype may be useful for the medical treatment of reflux oesophagitis with lansoprazole.

Identification of a new variant of fimA gene of Porphyromonas gingivalis and its distribution in adults and disabled populations with periodontitis

Porphyromonas gingivalis fimbriae are critical for the promotion of bacterial infection. The fimA gene encoding fimbrillin, a subunit of fimbriae, has been classified into five genotypes (types I to V) based on their nucleotide sequences. Using a fimA type-specific PCR assay, our previous study demonstrated a close relationship between P. gingivalis possessing type II and type IV fimA genes and adult periodontitis. In that study, some clinical specimens were found to be positive for both types I- and II- fimA specific primers, likely due to the coexistence of two clonal types or a single clone of an unknown genotype in the samples. In the present study, we cloned a new variant of the fimA gene, designated as type Ib fimA, from P. gingivalis HG1691. The nucleotide sequence of the cloned fimA gene showed a 97.1% homology with that of type I fimA, indicating it as a clonal variant of type I fimA. Organisms with type Ib fimA were detected in 13.5% of periodontitis patients and in 2.9% of periodontal healthy adults. Statistical analysis revealed a strong relationship between periodontitis and specific fimA types such as type Ib [odds ratio (OR) 6.51], type II (OR 77.8), and type IV (OR 7.54). Moreover, type Ib fimA-organisms were also found to be related to periodontitis in Down's syndrome (OR 1.91) and mentally disabled populations (OR 4.00). These findings suggest that P. gingivalis with type Ib fimA is closely associated with the progression of periodontitis, similar to organisms with type II and IV fimA.

Attenuation of glucan-binding protein C reduces the cariogenicity of Streptococcus mutans: analysis of strains isolated from human blood

A blood isolate of Streptococcus mutans strain TW871 shows relatively low homology with MT8148, a reference oral isolate strain, and lacks the serotype-specific polysaccharide antigen, suggesting that other cell-surface structures correlate with cariogenicity. We compared cariogenicity of TW871 with MT8148 (serotype c) and blood isolate TW964 (serotype f) in rats. Strain TW871 showed significantly lower cariogenicity than MT8148 or TW964 and expressed significantly lower sucrose-independent cellular adhesion to saliva-coated hydroxyapatite and dextran-binding activity than strain MT8148. Strains TW871 and TW964 showed a defect in the gbpA gene by Southern hybridization analysis, while sequencing analysis revealed gbpC variation in TW871. These results suggest that variation in GbpC may alter cellular adherence properties and can be correlated with the cariogenicity of S. mutans in this strain.

Distribution of emm genotypes and superantigen genes of Streptococcus pyogenes isolated in Japan, 1994-9

The purpose of this study was to examine characteristic profiles of Streptococcus pyogenes clinical isolates isolated in Japan during 1994-9. Genotyping of the M protein (emm typing) revealed that emm types 12 and 28 were the most common among 316 isolates. Most of the emm12 isolates were isolated from mucosa, while emm58 and emm89 were from skin. Moreover, the emm3 isolates were dominant in invasive infections. The distribution of 6 superantigen genes showed that all isolates harboured the mf gene and many had the speG gene. Invasive isolates were shown to have the ssa gene at a higher rate (76%) than noninvasive (37%). The distribution of superantigens was significantly different between emm types, but not between isolation sites. These results suggest that the distribution of emm types is related to isolation site, whereas superantigen distribution is related to clinical features of S. pyogenes infections.

Carcinoma of the ampulla of Vater associated with other organ malignancies

Because of its location with respect to the biliary system, carcinoma of the ampulla of Vater is considered to manifest earlier in its course of development than carcinoma of the pancreas. The most common physical finding is jaundice, which occurs in 93-100% of cases [1,2]. This retrospective study describes the results of the treatment and prognosis for double primary cancers in which cancer of the ampulla of Vater was associated with malignancies in other organs in 5 patients who were diagnosed and treated at Kurume University Hospital. The patients included 5 men with an average age of 72.8 years. There were 3 synchronous double and 2 metachronous double cancer patients. Regarding prognoses of these patients, 1 patient with associated lung cancer died because of postoperative complications after pneumonectomy, 1 patient died due to carcinomatosa peritonei developing from the ampulla Vater carcinoma, and 1 patient died because of metastatic liver tumors from the ampullary carcinoma. In multiple cancers including ampulla Vater carcinoma, gastrointestinal cancers such as gastric or colon cancer occur frequently. Therefore, a careful gastrointestinal examination should be done preoperatively. We report our experience with 5 cases of ampullary carcinoma associated with malignancies in other organs and review the literature.

Differential and quantitative analyses of mRNA expression of glucosyltransferases from Streptococcus mutans MT8148

Streptococcus mutans produces three glucosyltransferases, coded by gtfB, gtfC, and gtfD, whose cooperative action is essential for sucrose-dependent cellular adhesion. This cellular adhesion plays an important role in the formation of dental plaque and the initiation of dental caries. Since they bear genetic similarities and are large in size, differentiation of their gene expression has been difficult, and little is known about the dynamic process of gtf expression. Using a real-time reverse-transcription/polymerase chain-reaction, we determined the expression of each gtf. Under various conditions, the relative levels of transcription were gtfB > gtfD > gtfC. Sucrose enhanced gtfD expression, whereas it reduced that of gtfB and gtfC, suggesting the presence of independent promoters. Quantitative analyses demonstrated coincidence between the ratio of expression of each gtf and the ratio previously identified as optimal for sucrose-dependent adhesion in vitro, suggesting that S. mutans produces GTF at an optimal ratio to adhere to the tooth surface.

Xanthogranulomatous cholecystitis

Seven cases of xanthogranulomatous cholecystitis are presented, and their clinicopathological appearance is described. Three men and 4 women with xanthogranulomatous cholecystitis, aged 53-72 years old, were reviewed. Five patients had had previous attacks of acute cholecystitis lasting from 3 weeks to 6 months. Abdominal ultrasonography was performed in all patients, and computed tomography in 5 patients. Cholelithiasis and sludge were present in all patients. The gallbladder wall was thickened in all patients. On computed tomography, one patient showed no abnormal finding, and 4 patients had abnormal findings such as increased wall thickness and irregularity, and pericholecystic abnormalities. A diagnosis of gallbladder carcinoma was made preoperatively in 1 patient. During laparotomy, the gallbladders in all patients showed signs of chronic cholecystitis, and cholecystectomies were performed. Histological findings showed xanthogranulomatous cholecystitis, and 4 patients had stones in the gallbladder wall. Despite the characteristic histologic appearance of xanthogranulomatous cholecystitis, radiologic findings are nonspecific, varying from signs observed in other forms of cholecystitis to the appearance of a gallbladder neoplasm. We report here 7 cases of xanthogranulomatous cholecystitis and review the literature.