Response of Vasculitic Peripheral Neuropathy to Intravenous Immunoglobulin

Peripheral neuropathy is a prominent feature of the systemic and secondary vasculitides. Usually, it responds to corticosteroids therapy, but in certain cases it may resist corticosteroid or immunosuppressive treatment, or both. The objective of this study is to present case reports of patients who exhibited various inflammatory diseases, accompanied with vasculitic peripheral neuropathies, for which intravenous immunoglobulin (IVIg) was used for treatment. The study included 10 patients with the following: Sjögren's syndrome (1), systemic lupus erythematosus (2), vaccination-induced vasculitis (1), Churg-Strauss vasculitis (1), mixed cryoglobulinemia (2), polyarteritis nodosa (1), sarcoidosis (1), and scleroderma (1). All developed vasculitic peripheral neuropathy and were treated with 1-13 cycles of high-dose IVIg (2 g/kg body weight). The patients were followed up for 1-5 years after this treatment. Results showed that in all but two patients (mixed cryoglobulinemia associated with hepatitis C and sarcoidosis), neuropathy improved or completely resolved after IVIg treatment. In conclusion, IVIg may be beneficial in cases of resistant vasculitic peripheral neuropathy. IVIg should probably be considered as a sole or adjuvant treatment in patients for whom conventional treatment is contraindicated, or for patients in whom conventional treatment has failed.

Ocular higher-order aberrations in myopia and skiascopic wavefront repeatability

PURPOSE

To study the distribution of ocular higher-order aberrations (HOAs) in a myopic population and to assess the repeatability of HOA measurements determined by a commercially available skiascopic wavefront sensor.

SETTING

Department of Ophthalmology, Assaf Harofeh Medical Center, Zerifin, Israel.

METHODS

Ocular HOAs were examined 3 times across a 6.0 mm naturally dilated pupil in 61 eyes using the Optical Path Difference (OPD)-scan wavefront aberrometer. Root-mean-square (RMS) values of HOAs, total spherical aberration (TSA), total coma (TC), and total trefoil (TT) were analyzed. Correlation analysis was performed to assess the aberration symmetry between right and left eyes. The repeatability of the OPD-scan measurements was assessed by calculating Pearson r correlation coefficients between each pair of measurements and the interclass correlation coefficients between the 3 measurements of each score.

RESULTS

The mean RMS values of HOAs, TSA, TC, and TT were 0.347 microm +/- 0.252 (SD), 0.120 +/- 0.174 microm, 0.165 +/- 0.168 microm, and 0.252 +/- 0.157 microm, respectively. The HOAs, TSA, TC, and TT changed slightly and not significantly with increasing refractive error (all P>.05). The RMS level of HOAs and TTR of the 3rd measurement was significantly different from the 1st and 2nd measurements (P<.05), with overall low correlation between the 3 measurements for the HOAs, TSA, TC, and TT.

CONCLUSIONS

The ocular wavefront aberrations varied greatly from subject to subject. Ocular HOAs were not correlated with refractive error. The repeatability of HOAs measurements with the OPD-aberrometry was low.

Lack of association between anti-phospholipid antibodies (APLA) and Attention Deficit/Hyperactivity Disorder (ADHD) in children

Numerous studies have shown the pathological influence anti-phospholipid antibodies (APLA) have on the physiology of the single neuron as well as the function of the entire human nervous system. The influence is well demonstrated in the antiphospholipid syndrome (APS). This syndrome is characterized by a triad of arterial or venous thrombotic events, recurrent fetal loss and thrombocytopenic purpura. The syndrome exhibits different neurological pathologies such as: chorea, seizures, transverse myelopathy, migraine, cerebral ataxia, hemiballismus and transient global amnesia, which are not fully explained by the procoagulopathic trait of APLA. A study on mice induced with APS demonstrated hyperactive behavior when compared to the control group. The information gathered from these different studies raised the question whether APLA has any part in the etiology of Attention Deficit/Hyperactive Disorder (ADHD) in children.

We compared 41 children diagnosed with ADHD to a control of 28 healthy children. Blood drawn from the two groups was screened using ELISA for the presence of anti-cardiolipin antibodies, antiβ2GP antibodies, anti-phosphatidyleserine antibodies and anti-ethanolamine antibodies. The results show no significant difference in the level of antiphospholipid antibodies (APLA) measured between the children diagnosed with ADHD and the control group.

Ocular higher-order aberrations in eyes with supernormal vision

PURPOSE

To quantify ocular higher-order aberrations (HOAs) in eyes with supernormal vision, that is, natural uncorrected visual acuity (UCVA) > or = 20/15, to analyze the correlation between ocular HOAs and age in these eyes, and to investigate the correlation of HOAs between right and left eyes.

DESIGN

Observational case series.

METHODS

Ocular HOAs were examined across a naturally dilated pupil with a diameter > or = 6.0 mm in 70 eyes of 35 subjects with > or = 20/15 UCVA (mean age 24.3 years +/- 7.7 [SD]) using the Nidek OPD scan wavefront aberrometer. Root-mean-square (RMS) values of HOA, total spherical aberration (TSA), total coma (TC), and total trefoil (TT) were analyzed. Correlation analysis was performed to assess the association between ocular HOAs and age and the correlation of HOAs between right and left eyes.

RESULTS

Mean RMS values were 0.334 +/- 0.192 microm for HOA, 0.110 +/- 0.077 microm for TSA, 0.136 +/- 0.081 microm for TC, and 0.268 +/- 0.220 microm for TT. There were no significant differences in the mean values of HOA, TSA, TC, and TT between right and left eyes. The Pearson correlation coefficient between right and left eyes for TSA was 0.764 (P<.0001). No significant correlation was found between right and left eyes for HOA, TC, and TT. No significant correlation was found between each of the ocular aberrations and age.

CONCLUSIONS

The amount of ocular HOAs in eyes with natural supernormal vision is not negligible, and is comparable to the reported amount of HOAs in myopic eyes.

Increased platelet deposition on extracellular matrix under flow conditions in patients with antiphospholipid syndrome who experience thrombotic events

OBJECTIVE

To assess platelet function under defined flow conditions in patients with antiphospholipid syndrome (APS) and to correlate the results with thrombotic complications and the presence of subsets of antiphospholipid antibodies (aPL), lupus anticoagulant (LAC), and/or anticardiolipin antibodies (aCL).

METHODS

We studied 88 randomized APS patients with or without a history of thrombosis. Seventeen patients with other thrombosis (no APS) and 26 healthy subjects served as controls. Platelet adhesion and aggregation on the extracellular matrix were measured with a cone-and-plate(let) analyzer (CPA) by examining the percentage of total area covered with platelets (surface coverage [SC]) and the mean size of surface-bound objects (average size [AS]) and were compared with platelet responses to different ADP concentrations by conventional aggregometry.

RESULTS

Under defined flow conditions, SC and AS were significantly higher for venous thrombosis and arterial thrombosis in APS patients compared with no thrombosis, other thrombosis, and healthy control groups. The increased platelet adhesion and aggregation in APS patients with thrombotic events was associated with higher levels of von Willebrand factor (vWF) antigen (mean +/- SD 230.6 +/- 51.2%) and ristocetin cofactor activity (181.0 +/- 36.0%). No change in CPA and vWF parameters was found in APS patients with positive results for aPL who did not undergo thrombotic events or in patients with other thrombosis. The CPA parameters were neither associated with the high response of platelets to ADP nor associated with the presence of LAC, aCL, or both. The CPA parameters were similarly increased irrespective of aspirin use. The results suggest that the increased adhesion properties of platelets in APS patients could be mediated by high levels and activity of vWF. This complements the known ability of APS antibodies to enhance platelet response to agonists in conventional aggregometry.

CONCLUSION

The CPA test was found to be valuable in differentiating APS patients with and without thrombotic complications.

Intravenous Immunoglobulin Therapy and Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with diverse manifestations. We suggest that intravenous immunoglobulin (IVIg) therapy may be beneficial and safe for various manifestations in SLE. A structured literature search of articles published on the efficacy of IVIg in the treatment of SLE between 1983 and 2005 was conducted. We searched the terms "IVIg," "intravenous immunoglobulin," "lupus," "SLE," and "systemic lupus erythematosus." The various clinical manifestations of SLE that were reported to be successfully treated by IVIg in case reports include autoimmune hemolytic anemia, acquired factor VIII inhibitors, acquired von Willebrand disease, pure red cell aplasia, thrombocytopenia, pancytopenia, myelofibrosis, pneumonitis, pleural effusion, pericarditis, myocarditis, cardiogenic shock, nephritis, end-stage renal disease, encephalitis, neuropsychiatric lupus, psychosis, peripheral neuropathy, polyradiculoneuropathy, and vasculitis. The most extensive experience is with lupus nephritis. There are only a few case series of IVIg use in patients with SLE with various manifestations, in which the response rate to IVIg therapy ranged from 33 to 100%. We suggest that IVIg devoid of sucrose, at a dose of 2 g/kg over a 5-d period given uniformly and at a slow infusion rate in patients without an increased risk for thromboembolic events or renal failure, is a safe and beneficial adjunct therapy for cases of SLE that are resistant to or refuse conventional treatment. The duration of therapy is yet to be established. Controlled trials are warranted.

Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis: Lessons from long-term followup of patients in the Euro-Lupus Nephritis Trial

OBJECTIVE

In the Euro-Lupus Nephritis Trial (ELNT), 90 patients with lupus nephritis were randomly assigned to a high-dose intravenous cyclophosphamide (IV CYC) regimen (6 monthly pulses and 2 quarterly pulses with escalating doses) or a low-dose IV CYC regimen (6 pulses of 500 mg given at intervals of 2 weeks), each of which was followed by azathioprine (AZA). After a median followup of 41 months, a difference in efficacy between the 2 regimens was not observed. The present analysis was undertaken to extend the followup and to identify prognostic factors.

METHODS

Renal function was prospectively assessed quarterly in all 90 patients except 5 who were lost to followup. Survival curves were derived using the Kaplan-Meier method.

RESULTS

After a median followup of 73 months, there was no significant difference in the cumulative probability of end-stage renal disease or doubling of the serum creatinine level in patients who received the low-dose IV CYC regimen versus those who received the high-dose regimen. At long-term followup, 18 patients (8 receiving low-dose and 10 receiving high-dose treatment) had developed permanent renal impairment and were classified as having poor long-term renal outcome. We demonstrated by multivariate analysis that early response to therapy at 6 months (defined as a decrease in serum creatinine level and proteinuria <1 g/24 hours) was the best predictor of good long-term renal outcome.

CONCLUSION

Long-term followup of patients from the ELNT confirms that, in lupus nephritis, a remission-inducing regimen of low-dose IV CYC followed by AZA achieves clinical results comparable with those obtained with a high-dose regimen. Early response to therapy is predictive of good long-term renal outcome.

Intraocular inflammation in autoimmune diseases

BACKGROUND

The uveal tract represents the vascular organ of the eye. In addition to providing most of the blood supply to the intraocular structures, it acts as a conduit for immune cells, particularly lymphocytes, to enter the eye. Consequently, the uveal tract is represented in many intraocular inflammatory processes. Uveitis is probably a misnomer unless antigens within the uvea are the direct targets of the inflammatory process. A better term of the condition is "intraocular inflammation" (IOI).

OBJECTIVES

To review the presence of IOI in autoimmune diseases, the immunopathogenic mechanisms leading to disease, and treatment.

METHODS

We reviewed the English medical literature by using MEDLINE (1984-2003) employing the terms "uveitis," "intraocular inflammation," and "autoimmune diseases."

RESULTS

An underlying autoimmune disease was identified in up to 40% of patients with IOI, and included spondyloarthropathies, Behcets disease, sarcoidosis, juvenile chronic arthritis, Vogt-Koyanagi-Harada syndrome (an inflammatory syndrome including uveitis with dermatologic and neurologic manifestations), immune recovery syndrome, and uveitis with tubulointerstitial disease. The immunopathogenesis of IOI involves enhanced T-cell response. Recently, guidelines for the use of immunosuppressive drugs for inflammatory eye disease were established and include: corticosteroids, azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, and chlorambucil. New therapies with limited experience include the tumor necrosis factor alpha inhibitors, interferon alfa, monoclonal antibodies against lymphocyte surface antigens, intravenous immunoglobulin (IVIG), and the intraocular delivery of immunosuppressive agents.

CONCLUSION

An underlying autoimmune disease was identified in up to 40% of patients with IOI. Immunosuppressive drugs, biologic agents, and IVIG are employed for the treatment of IOI in autoimmune diseases.

Pericarditis following permanent pacemaker insertion

BACKGROUND

The appearance of pericarditis following insertion of a permanent pacemaker is not widely acknowledged in the literature.

OBJECTIVES

To describe our experience with pericarditis following 395 permanent pacemaker implantations over 2 years.

METHODS

We retrospectively reviewed the medical records of 395 consecutive patients in whom new pacing systems or pacemaker leads had been implanted over a 2 year period. We searched the records for pericarditis that developed within 1 month after pacemaker implantation according to the ICD-9 code. The incidence, clinical picture, response to treatment, and relationship to lead design and location were studied.

RESULTS

Eight cases (2%) of pericarditis following implantation were detected. Clinical manifestations in all patients were similar to those of post-pericardiotomy syndrome and included chest pain (n = 7), friction rub (n = 1), fever (n = 2), fatigue (n = 2), pleural effusion (n = 2), new atrial fibrillation (n = 2), elevated erythrocyte sedimentation rate (n = 4), and echcardiographic evidence of pericardial effusion (n = 8). All affected patients had undergone active fixation (screw-in) lead implantation in the atrial position. The incidence of pericarditis with screw-in atrial leads was 3% compared to 0% in other cases (P < 0.05).

CONCLUSIONS

Pericarditis is not uncommon following pacemaker implantation with active fixation atrial leads. Special attention should be paid to identifying pericardial complications following pacemaker implantation, especially when anticoagulant therapy is resumed or initiated. The use of passive fixation leads is likely to reduce the incidence of pericarditis but this issue should be further investigated.

Eyelash length in children and adolescents with allergic diseases

Long eyelashes may be congenital, acquired in association with certain systemic diseases, or drug induced. In the past, long eyelashes were considered an external sign found in children with allergic diseases. However, this claim has never been examined in a controlled study. We compared the eyelash lengths of allergic children and adolescents with perennial allergic rhinitis, with or without bronchial asthma and atopic dermatitis (n = 60) to those of age- and sex-matched nonallergic controls (n = 80). The eyelashes of the allergic patients were found to be significantly longer than those of the controls: 9.43 +/- 1.39 mm versus 8.45 +/- 1.30 mm (p < 0.001). Eyelash length did not differ between patients with allergic rhinitis only (n = 31; 9.65 +/- 1.43 mm) and patients with allergic rhinitis and other allergic diseases (n = 29; 9.19 +/- 1.31 mm) (p = 0.196). These results indicate that children and adolescents with allergic diseases have longer eyelashes compared to nonatopic controls and that long eyelashes may be a part of the phenotype of the allergic patient.

Obesity is the major determinant of elevated C-reactive protein in subjects with the metabolic syndrome

OBJECTIVE

To investigate the relationship between C-reactive protein (CRP) and various characteristics of the metabolic syndrome.

DESIGN

Population-based cross-sectional study.

SUBJECTS

A total of 1929 subjects undergoing a medical examination in a preventive medicine clinic (age, 50+/-10 y; 63% males).

RESULTS

The proportion of subjects with CRP levels above the cut point generally used to indicate an obvious source of infection or inflammation (>10 mg/l) was 3, 7, and 15% in subjects who were normal weight, overweight, and obese, respectively. Subjects with obesity had markedly higher CRP level compared to patients without obesity regardless of whether they had the metabolic syndrome. However, there was no significant difference in CRP levels between nonobese subjects without the metabolic syndrome and subjects in whom the diagnosis of the metabolic syndrome was based on criteria other than obesity (adjusted geometric mean CRP 1.75 vs 2.08 mg/l, P=0.79). Similarly, CRP levels did not differ among obese subjects with and without the metabolic syndrome (adjusted geometric mean CRP 3.22 vs 3.49 mg/l, P=0.99). There was a linear increase in CRP levels with an increase in the number of metabolic disorders (P(trend) <0.0001), which was substantially diminished after controlling for body mass index (BMI) (P(trend)=0.1). Stepwise multivariate linear regression analysis identified BMI, triglyceride levels, HDL cholesterol levels (inversely), and fasting glucose as independently related to CRP levels. However, BMI accounted for 15% of the variability in CRP levels, whereas triglycerides, HDL cholesterol and fasting glucose levels accounted for only approximately 1% of the variability in CRP levels.

CONCLUSION

Obesity is the major factor associated with elevated CRP in individuals with the metabolic syndrome. CRP levels in the range suggesting a source of infection or inflammation (>10 mg/l) are more common among obese subjects than in nonobese subjects.

Increased C-reactive protein levels in the polycystic ovary syndrome: a marker of cardiovascular disease

The polycystic ovary syndrome (PCOS), one of the most common reproductive abnormalities, shares some components of the metabolic cardiovascular syndrome. Therefore, PCOS patients may represent the largest group of women at high risk for the development of early-onset cardiovascular disease (CVD) and/or diabetes. C-reactive protein (CRP) is a strong independent predictor of future CVD and/or stroke. Only one small published study has looked for such an association (17 PCOS patients vs. 15 controls). The objective of this study was to compare the levels of CRP and other risk factors of CVD in a large group of PCOS patients and controls. CRP measurements were undertaken in 116 PCOS patients and 94 body mass index-matched controls with regular menstrual cycles. Whereas 36.8% of the PCOS patients had CRP levels above 5 mg/liter, only 9.6% of the controls exhibited high CRP levels (P < 0.001). The mean +/- SD was 5.46 +/- 7.0 in the PCOS group vs. 2.04 +/- 1.9 mg/liter in the control (P < 0.001). The body mass index, white blood cell count, TSH, glucose, cholesterol, and homocysteine levels were not significantly different between the two groups. CRP levels are elevated in patients with PCOS and may be a marker of early cardiovascular risk in these patients. High CRP levels may explain why some PCOS women may possibly be at an increased risk for the development of early-onset CVD. Consequently, whether treatment regimens directed toward lowering CVD risk factors should be more aggressive for those PCOS women with increased CRP levels, awaits further clinical experience.

Intravenous immunoglobulins in peripheral neuropathy associated with vasculitis

BACKGROUND

Peripheral neuropathy is a prominent feature of the systemic and secondary vasculitides. Usually, it is responsive to corticosteroids, but in certain cases it may be resistant to corticosteroid or immunosuppressive treatment, or both.

OBJECTIVE

To present patients who exhibited various inflammatory diseases accompanied with vasculitic peripheral neuropathies for which intravenous immunoglobulin (IVIg) was used for treatment.

METHODS

Six patients with Sjögren's syndrome, systemic lupus erythematosus (SLE), vaccination induced vasculitis, Churg-Strauss vasculitis, mixed cryoglobulinaemia associated with hepatitis C infection, or sarcoidosis were included. All developed vasculitic peripheral neuropathy, and were treated with high dose IVIg (2 g/kg body weight). The patients were followed up for 1-5 years after this treatment.

RESULTS

In four patients (Sjögren's syndrome, Churg-Strauss vasculitis, SLE, and vaccination induced vasculitis) the neuropathy resolved after IVIg treatment.

CONCLUSION

IVIg may be beneficial in cases of resistant vasculitic peripheral neuropathy. IVIg should probably be considered as a sole or adjuvant treatment for patients with contraindications to conventional treatment, or alternatively, for patients in whom conventional treatment has failed.

Association between fasting glucose and C-reactive protein in middle-aged subjects

AIMS

C-reactive protein (CRP), a marker of subclinical inflammation, predicts the occurrence of coronary heart disease in healthy subjects. Hyperglycaemia is known to stimulate the release of inflammatory cytokines from various cell types and can lead to the induction and secretion of acute-phase reactants by adipocytes. The aim of the present study was to determine the relation between glycaemic status and CRP in healthy subjects.

METHODS

We studied the relation of high-sensitivity CRP to fasting glucose and other components of the metabolic syndrome in a population-based cross-sectional study (n = 1000; age 50 +/- 9 years).

RESULTS

Plasma CRP levels increased continuously from the lowest quartile of normal fasting glucose level to impaired fasting glucose and to diabetes (ln CRP 0.47 +/- 0.09, 0.95 +/- 0.12, and 1.11 +/- 0.13, respectively; Ptrend < 0.0001). Increasing CRP with higher fasting glucose levels was apparent even among subjects with fasting glucose in the normal range (Ptrend = 0.039), and subjects with fasting glucose level in the upper quartile of normal fasting glucose had higher CRP levels compared with subjects in the lower quartile (P = 0.035). There was a positive crude correlation between CRP and smoking, post-menopausal hormone use, body mass index, fasting glucose, triglycerides, hypertension, and uric acid (r = 0.11-0.36, P = 0.002-0.0001). A negative correlation was found between CRP and HDL-cholesterol (r = 0.12, P < 0.0001) and physical activity (r = 0.11, P = 0.002). After adjustment for potential confounders in a stepwise multivariate linear regression model, fasting glucose remained significantly and independently related to CRP levels (correlation coefficient 0.06; 95% confidence interval 0.014-0.11, P = 0.011).

CONCLUSIONS

Fasting glucose is significantly and positively associated with plasma CRP in middle-aged subjects. CRP levels increase continuously across the spectrum of fasting glucose, beginning in the lowest quartile of normal fasting glucose. This finding suggests that a proinflammatory effect may contribute to the adverse cardiovascular outcome associated with diabetes, impaired fasting glucose, and increasing glucose levels within the normal range.

Systemic side effects of ophthalmic drops

Topical application of ocular drugs may cause serious adverse ocular or systemic side effects. Children are at greater risk for systemic side effects because ocular dosing is not weight-adjusted, and infants are especially vulnerable as a consequence of the inability to efficiently metabolize the drug, and/or an immature blood-brain barrier. Four pediatric patients are reported in whom treatment with topical brimonidine, a selective alpha-2 adrenoceptor agonist, indicated for the treatment of glaucoma, produced somnolence. Anti-glaucoma eyedrops that are not approved for use in children are still used frequently in pediatrics. Therefore, physicians should be aware of possible systemic side effects of ophthalmic drops.

Systemic lupus erythematosus and parvovirus B-19: casual coincidence or causative culprit?

Systemic lupus erythmatosus (SLE) is a multi-system autoimmune disease characterized by auto-reactive cells and auto-antibodies, which can potentially affect all organ systems. Typical organ systems that are affected include the heart, lungs, skin, kidneys, and central nervous system. Its expression is believed to be dependent on various factors such as genetic predisposition, environmental agents, immune dysregulation, crossreactivity with auto-antigens, alterations in auto-antigens, or most likely, a combination of these. Parvovirus B19, a virus which commonly runs an asymptomatic or benign self-limiting course such as erythema infectiosum, transient aplastic crisis, flu-like symptoms, rash, arthalgia, and arthritis, has recently been associated with a number of rheumatic diseases, more specifically with SLE. Like SLE, it can present with multi- systemic symptoms resembling SLE both clinically and serologically. Similarities have been so striking that patients have been initially misdiagnosed with SLE, having fulfilled 3-5 of the criteria of the American College of Rheumatology, currently used for the diagnosis of SLE, only to discover later that they were infected by parvovirus B19. This paper will discuss parvovirus' link to SLE, its similarities and differences, and whether parvovirus can act as a trigger of, or simply mimic, SLE.

[The use of autogenous block graft for augmentation of the atrophic alveolar ridge]

The use of osseointegrated implants has become a standard treatment option in modern dental rehabilitation. Adequate bone quantity and quality is a prerequisite for good esthetic and biomechanical result. Alveolar ridge defects can be the result of trauma, periodontal diseases or other pathologic conditions. In these cases, alveolar ridge augmentation is needed if endosseous implants are to be used. While xenografts, alloplastic bone grafts and allografts have been proposed for alveolar ridge augmentation, the use of autogenous bone grafts represents the "gold standard" for bone augmentation procedures. Either intraoral or extraoral sites may be considered for donor sites. Although the iliac crest is the most common donor site in maxillofacial reconstruction, the mandibular symphysis or ramus offer important advantages like avoidance of general anesthesia, convenience due to the proximity between the donor site and the augmentation site and avoidance of cutaneous scar. Bone harvested from intraoral donor site is less associated with resorption when compared with iliac bone because membranous grafts revascularize more quickly than endocondral bone grafts. The main disadvantage of the intraoral donor sites is the limited amount of available bone. Alveolar ridge augmentation using autologous bone block, can be done during implant placement or staged with implant placement, after bone graft healing. In the staged technique, a better implant positioning and the use of wide diameter implants are possible. The overall implant success is higher in the staged technique. Alveolar ridge augmentation using autogenous block graft is a predictable way of treatment, for the atrophic alveolar ridge before implant placement.

Laser in situ keratomileusis in a combat jet aircraft pilot

Pilots who have had laser in situ keratomileusis (LASIK) surgery are disqualified from flying status in a combat jet aircraft in the United States Navy and Air Force. We report the case of a jet aircraft pilot who had LASIK for myopia. The pilot resumed flights 2 weeks after the procedure and has performed several dozen uneventful daylight flights in a combat jet aircraft. We recommend a clinical study to reevaluate the appropriateness of LASIK in military jet aircraft aviation.