POS0784 LOW COMPLEMENT LEVELS ARE ASSOCIATED WITH HIGHER MORTALITY IN HOSPITALIZED PATIENTS WITH POSITIVE ANTIPHOSPHOLIPID ANTIBODIES

Background

Antiphospholipid Syndrome is an autoimmune disease characterized by increased risk for vascular thrombosis (arterial and/or venous) thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. The mechanisms by which aPLs induce thrombosis are unclear; several have been suggested, among them complement activation.(1-2) The complement system is a system of enzymes and regulatory proteins of the innate immune system that play a crucial role in the inflammatory response to various pathogenic stimuli. The complement and coagulation pathways are interconnected, and expanding evidence indicates that complement may be activated in patients with antiphospholipid syndrome (3-5).

Objectives

Our study was intended to better characterize the complicated relations between antiphospholipid antibodies and complement activation among hospitalized patients with antiphospholipid syndrome and its impact on short- and long-term prognosis

Methods

A retrospective cohort studies. Clinical and prognostic data of hospitalized patients with antiphospholipid syndrome and a measurement of complement levels (C3 or C4) were obtained. Rates of long-term mortality, one-year mortality, deep vein thrombosis (DVT), and pulmonary emboli (PE) were compared between patients with low complement levels and patients with normal complement levels. Low complement was defined as C3 < 90 mg/dl or C4 < 10 mg/dl. A multivariate analysis was performed to control for Anticardiolipin levels, β₂ macroglobulin levels and RVVT ratio.

Results

Complete data was available for 6,599 patients, of which 712 (11%) had low complement levels. The median age of the cohort was 47.7, and most of the patients were females (56%). Patients with low complement levels had significantly higher mortality rates 30% vs. 18%, p < 0.001 for long-term mortality (Figure 1) and 15% vs. 5%, p < 0.001 for 1 year mortality when compared to patients with normal complement levels. DVT and PE rates were similar (4% vs 3.8%, P = 0.78 and 4% vs 2.4%, P = 0.13 respectively). Results of the multivariate analysis (Table 1) were consistent and showed that patients with low complement levels had 111% higher mortality rates (CI 1.52-2.90, P < 0.001).

Table 1.

Multivariate Analysis for long term mortality

Multivariate AnalysisOR (CI)pLow Complement2.11 [1.52, 2.90]<0.001Anticardiolipin IGG1.00 [1.00, 1.01]0.243Anticardiolipin IGM0.99 [0.98, 1.00]0.084β₂ IGM1.01 [1.00, 1.01]0.017β₂ IGG1.00 [0.99, 1.00]0.663RVVT Ratio0.99 [0.63, 1.52]0.954Figure 1.

Cumulative 10-Year survival

Conclusion

In hospitalized patients with high aPLs, low complement levels are associated with significantly higher mortality rates. This finding is in correlation with recent literature, suggesting an important role for complement activation in APS.

References

[1]Chaturvedi S, Brodsky RA, McCrae KR. Complement in the pathophysiology of the antiphospholipid syndrome. Front Immunol. 2019 Mar 14;10:449.

[2]Bu C, Gao L, Xie W, Zhang J, He Y, Cai G, et al. beta2-glycoprotein i is a cofactor for tissue plasminogen activator-mediated plasminogen activation. Arthritis Rheum. 2009 Feb;60(2):559–568.

[3]Tedesco F, Borghi MO, Gerosa M, Chighizola CB, Macor P, Lonati PA, et al. Pathogenic role of complement in antiphospholipid syndrome and therapeutic implications. Front Immunol. 2018 Jun 19;9:1388.

[4]Oku K, Nakamura H, Kono M, Ohmura K, Kato M, Bohgaki T, et al. Complement and thrombosis in the antiphospholipid syndrome. Autoimmun Rev. 2016 Oct;15(10):1001–1004.

[5]Salmon JE, Girardi G, Holers VM. Complement activation as a mediator of antiphospholipid antibody induced pregnancy loss and thrombosis. Ann Rheum Dis. 2002 Nov;61 Suppl 2:ii46–50.

Disclosure of Interests

None declared

Long-term prediction of mortality and comparative treatment benefit following percutaneous or surgical revascularization

Background

The SYNTAX score II 2020 (SSII-2020), which was derived and externally validated from randomized trials, was designed to predict death following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel disease and/or left main disease. We aimed to investigate its value in identifying the safest modality of revascularization in a non-randomized setting.

Methods

Five-year mortality was assessed in 7362 patients with three-vessel disease and/or left main disease enrolled in a Japanese PCI/CABG registry. New-generation drug eluting stents and imaging guidance became the default PCI strategy during enrolment of the last cohort. The discriminative ability of the SSII-2020 for 5-year mortality was assessed using Harrell's C statistic (C-index). Agreement between observed and predicted rates of all-cause mortality following either PCI or CABG and treatment benefit (absolute risk difference) for this outcome were assessed by calibration plots.

Results

The SSII-2020 had helpful discrimination (C-index = 0.72) and good calibration (intercept = −0.11, slope = 0.92) for 5-year mortality. The absolute risk difference in mortality between CABG and PCI (treatment benefit) was well calibrated when the whole population was grouped into quarters according to the predicted absolute risk difference of 5-year mortality. The observed differences in survival in favor of CABG were 4.2% (0.1 to 8.2%, log-rank p=0.05) and 8.5% (3.8 to 13.2%, log-rank p&lt;0.01) in the respective third and fourth quarters. In contrast, the observed differences in survival were not significantly different in either the first (3.0% [−0.8 to 6.8%, log-rank p=0.12]) or the second quarter (1.3% [−2.4 to 5.1%, log-rank p=0.39]).

Conclusions

The SSII-2020 is well able to predict death at 5 years – and the mortality difference between PCI and CABG, and therefore has the potential to support decision making on revascularization in patients with three-vessel disease and/or left main coronary artery disease.

Funding Acknowledgement

Type of funding sources: None.

A standard set of testing methods reliably enumerates spores across commercial milk powders

Contamination of dairy powders with sporeforming bacteria is a concern for dairy processors who wish to penetrate markets with stringent spore count specifications (e.g., infant powders). Despite instituted specifications, no standard methodology is used for spore testing across the dairy industry. Instead, a variety of spore enumeration methods are in use, varying primarily by heat-shock treatments, plating method, recovery medium, and incubation temperature. Importantly, testing the same product using different methodologies leads to differences in spore count outcomes, which is a major issue for those required to meet specifications. As such, we set out to identify method(s) to recommend for standardized milk powder spore testing. To this end, 10 commercial milk powders were evaluated using methods varying by (1) heat treatment (e.g., 80°C/12 min), (2) plating method (e.g., spread plating), (3) medium type (e.g., plate count milk agar), and (4) incubation time and temperature combinations (e.g., 32°C for 48 h). The resulting data set included a total of 48 methods. With this data set, we used a stepwise process to identify optimal method(s) that would explain a high proportion of variance in spore count outcomes and would be practical to implement across the dairy industry. Ultimately, spore pasteurized mesophilic spore count (80°C/12 min, incubated at 32°C for 48 h), highly heat resistant thermophilic spore count (100°C/30 min, incubated at 55°C for 48 h), and specially thermoresistant spore enumeration (106°C/30 min, incubated at 55°C for 48 h) spread plating on plate count milk agar were identified as the optimal method set for reliable enumeration of spores in milk powders. Subsequently, we assessed different powder sampling strategies as a way to reduce variation in powder spore testing outcomes using our recommended method set. Results indicated that 33-g composite sampling may reduce variation in spore testing outcomes for highly heat resistant thermophilic spore count over 11-g and 33-g discrete sampling, whereas there was no significant difference across sampling strategies for specially thermoresistant spore enumeration or spore pasteurized mesophilic spore count. Finally, an interlaboratory study using our recommended method set and a modified method set (using tryptic soy agar with 1% starch) among both university and industry laboratories showed increased variation in spore count outcomes within milk powders, which not only was due to natural variation in powders but also was hypothesized to be due to technical errors, highlighting the need for specialized training for technicians who perform spore testing on milk powders. Overall, this study addresses challenges to milk powder spore testing and recommends a method set for standardized spore testing for implementation across the dairy industry.

Facing the Ethical Challenges: Consumer Involvement in COVID-19 Pandemic Research

Consumer involvement in clinical research is an essential component of a comprehensive response during emergent health challenges. During the COVID-19 pandemic, the moderation of research policies and regulation to facilitate research may raise ethical issues. Meaningful, diverse consumer involvement can help to identify practical approaches to prioritize, design, and conduct rapidly developed clinical research amid current events. Consumer involvement might also elucidate the acceptability of flexible ethics review approaches that aim to protect participants whilst being sensitive to the challenging context in which research is taking place. This article describes the main ethical challenges arising from pandemic research and how involving consumers and the community could enable resolution of such issues.

Shackled Imagination: Literary Illusions about Blindness

This article reviews the ways blind characters have been depicted by writers from Sophocles ( c 429 BC) to James Dickey (AD 1987). Blindness as usually tragic metaphor predominates in literature through the ages, except for certain popular romances and novels by blind writers. Well-known blind characters throughout the literature and fictional creations of writers of the past two decades are discussed in detail, and discussed in relation to stereotypes of blind people.

0681 Comparison Of Upper Airway Stimulation Outcomes Between Regions And Bmi Groups From The Adhere Registry

Introduction

As factors influencing Upper Airway Stimulation (UAS) effectiveness in obstructive sleep apnea (OSA) patients are of interest, we compared changes in apnea hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) based on region and baseline body mass index (BMI).

Methods

Patients (15≥AHI≤65) of the ADHERE registry with AHI at one-year were grouped by region (Europe (EU) vs United States (US)), and BMI (≤32kg/m2 vs 32-35kg/m2). T-tests and equivalence testing (if the former non-significant) was performed using two-one-sided t-tests. Equivalence margin for AHI was set between -5 and 5 and -2 and 2 for ESS.

Results

By December 2019, 553 of 1600 patients completed 1-year follow-up. Average age was 60±11, 75% male, BMI 29±4 kg/m2, ESS=11±6. Median AHI decreased from 33 to 10, median ESS decreased from 11 to 6. Response defined by 50% AHI reduction and &lt;20 was 70%. Both regions had similar improvements in median AHI (EU: 33 to 10, US: 34 to 10, p &lt; 0.001 vs baseline), median ESS (EU: 12 to 7; US: 11 to 6, p&lt;0.001 vs baseline), and treatment response (EU: 71%, US: 68%). The mean AHI and ESS difference between regions met the equivalence margin. (AHI: mean difference: 0.34, CI:-1.78, 2.46, ESS: mean difference: 0.57, CI:-0.04, 1.19). Mean change in AHI at 1-year was equivalent in BMI groups (≤32 kg/m2 vs 32-35 kg/m2 respectively) median difference: -19.6 vs. -18.8; mean difference: -0.48, (CI:-3.95, 2.97) However, treatment response ratio was different; 73% vs. 60%, p=0.02, i.e. higher BMI patients were less likely to achieve AHI &lt; 20. ESS scores were equivalent; median: 6 vs. 7; mean difference: -0.33, CI: [-1.16, 0.47].

Conclusion

UAS influence on OSA severity defined by AHI and sleepiness was similar irrespective of region and BMI category, however, treatment response defined by 50% AHI reduction and &lt;20 was greater in those with lower BMI.

Support

The statistical support was provided by Inspire Medical System.

Nevertheless, She Resisted - Role of the Environment on Listeria monocytogenes Sensitivity to Nisin Treatment in a Laboratory Cheese Model

The growth of Listeria monocytogenes on refrigerated, ready-to-eat food products is a major health and economic concern. The natural antimicrobial nisin targets the bacterial cell wall and can be used to inhibit L. monocytogenes growth on cheese. Cell wall composition and structure, and therefore the efficacy of cell wall acting control strategies, can be severely affected by environmental and stress conditions. The goal of this study was to determine the effect of a range of pH and temperatures on the efficacy of nisin against several strains of L. monocytogenes in a lab-scale, cheese model. Cheese was made with or without the addition of nisin at different pH and then inoculated with L. monocytogenes; L. monocytogenes numbers were quantified after 1, 7, and 14 days of incubation at 6, 14, or 22°C. While our data show that nisin treatment is able to reduce L. monocytogenes numbers, at least initially, growth of this pathogen can occur even in the presence of nisin, especially when cheese is stored at higher temperatures. Several environmental factors were found to affect nisin efficacy against L. monocytogenes. For example, nisin is more effective when cheese is stored at lower temperatures. Nisin is also more effective when cheese is made at higher pH (6 and 6.5), compared to cheese made at pH 5.5, and this effect is at least partially due to the activity of cell envelope modification genes dltA and mprF. Serotype was also found to affect nisin efficacy against L. monocytogenes; serotype 4b strains showed lower susceptibility to nisin treatment compared to serotype 1/2 strains. Overall, our results highlight the importance of considering environmental conditions specific to a food matrix when developing and applying nisin-based intervention strategies against L. monocytogenes.

Mapping the undergraduate dermatology curriculum: a useful tool towards implementation of national recommendations

BACKGROUND

Despite the high prevalence of skin complaints in primary care and secondary care, dermatology undergraduate (UG) education remains inconsistent across medical schools. The British Association of Dermatologists (BAD) published a revised national UG curriculum in 2016 to guide UK medical schools on the minimum competencies required in dermatology.

AIM

The aim of the study was to determine the alignment of the BAD UG curriculum with the dermatology curriculum of the University of Nottingham School of Medicine.

METHODS

A curriculum mapping study was undertaken with the development of an electronic searchable database tool to map key areas.

RESULTS

Of the 70 intended learning outcomes (ILOs) for dermatology in the medical school, 55 (79%) were mapped to the BAD curriculum, while 14 (20%) required modifications to align them with the BAD ILOs. Two BAD ILOs were unspecified in the current curriculum, and one was deemed redundant.

CONCLUSION

Curriculum mapping is a useful tool to standardize local dermatology ILOs to national recommendations and provides transparency to stakeholders for implementation of the dermatology curriculum.

Bedding and bedding management practices are associated with mesophilic and thermophilic spore levels in bulk tank raw milk

Mesophilic and thermophilic spore-forming bacteria represent a challenge to the dairy industry, as these bacteria are capable of surviving adverse conditions associated with processing and sanitation and eventually spoil dairy products. The dairy farm environment, including soil, manure, silage, and bedding, has been implicated as a source for spores in raw milk. High levels of spores have previously been isolated from bedding, and different bedding materials have been associated with spore levels in bulk tank (BT) raw milk; however, the effect of different bedding types, bedding management practices, and bedding spore levels on the variance of spore levels in BT raw milk has not been investigated. To this end, farm and bedding management surveys were administered and unused bedding, used bedding, and BT raw milk samples were collected from dairy farms (1 or 2 times per farm) across the United States over 1 yr; the final data set included 182 dairy farms in 18 states. Bedding suspensions and BT raw milk were spore pasteurized (80°C for 12 min), and mesophilic and thermophilic spores were enumerated. Piecewise structural equation modeling analysis was used to determine direct and indirect pathways of association among farm and bedding practices, levels of spores in unused and used bedding, and levels of spores in BT raw milk. Separate models were constructed for mesophilic and thermophilic spore levels. The analyses showed that bedding material had a direct influence on levels of spores in unused and used bedding as well as an indirect association with spore levels in BT raw milk through used bedding spore levels. Specific bedding and farm management practices as well as cow hygiene in the housing area were associated with mesophilic and thermophilic spore levels in unused bedding, used bedding, and BT raw milk. Notably, levels of spores in used bedding were positively related to those in unused bedding, and used bedding spore levels were positively related to those in BT raw milk. The results of this study increase the understanding of the levels and ecology of mesophilic and thermophilic spores in raw milk, emphasize the possible role of bedding as a source of spores on-farm, and present opportunities for dairy producers to reduce spore levels in BT raw milk.

Longitudinal assessment of dairy farm management practices associated with the presence of psychrotolerant Bacillales spores in bulk tank milk on 10 New York State dairy farms

The ability of certain spore-forming bacteria in the order Bacillales (e.g., Bacillus spp., Paenibacillus spp.) to survive pasteurization in spore form and grow at refrigeration temperatures results in product spoilage and limits the shelf life of high temperature, short time (HTST)-pasteurized fluid milk. To facilitate development of strategies to minimize contamination of raw milk with psychrotolerant Bacillales spores, we conducted a longitudinal study of 10 New York State dairy farms, which included yearlong monthly assessments of the frequency and levels of bulk tank raw milk psychrotolerant spore contamination, along with administration of questionnaires to identify farm management practices associated with psychrotolerant spore presence over time. Milk samples were first spore pasteurized (80°C for 12 min) and then analyzed for sporeformer counts on the initial day of spore pasteurization (SP), and after refrigerated storage (6°C) for 7, 14, and 21 d after SP. Overall, 41% of samples showed sporeformer counts of >20,000 cfu/mL at d 21, with Bacillus and Paenibacillus spp. being predominant causes of high sporeformer counts. Statistical analyses identified 3 management factors (more frequent cleaning of the bulk tank area, the use of a skid steer to scrape the housing area, and segregating problem cows during milking) that were all associated with lower probabilities of d-21 Bacillales spore detection in SP-treated bulk tank raw milk. Our data emphasize that appropriate on-farm measures to improve overall cleanliness and cow hygiene will reduce the probability of psychrotolerant Bacillales spore contamination of bulk tank raw milk, allowing for consistent production of raw milk with reduced psychrotolerant spore counts, which will facilitate production of HTST-pasteurized milk with extended refrigerated shelf life.

Laboratory rearing of wild Arctic cod Boreogadus saida from egg to adulthood

The techniques and protocols used to successfully capture, transport and breed Arctic cod Boreogadus saida, as well as to rear their larvae through to adulthood are summarized. Breeding B. saida will increase the opportunity to study this fish species, which is a critical part of the Arctic food web.

Upper thermal limits of the hearts of Arctic cod Boreogadus saida: adults compared with larvae

Wild adult and reared larval Boreogadus saida were acclimated to 3·5° C before testing their cardiac response to acute warming. Heart rate transition temperatures during warming were similar for adult and larval hearts, except that the maximum temperature for heart rate was 3° C warmer for adults. Thus, in a rapidly warming Arctic Ocean, the upper temperature limit for larval rather than adult B. saida appears more likely to dictate the southern range of the species.

The stereotypical molecular cascade in neovascular age-related macular degeneration: the role of dynamic reciprocity

This review summarises our current understanding of the molecular basis of subretinal neovascularisation (SRNV) in age-related macular degeneration (AMD). The term neovascular AMD (NVAMD) is derived from the dominant early clinical features of haemorrhage, fluid, and lipid in the subretinal space (SRS) and the historical role of fluorescein angiography in detecting the presence of NV tissue. However, at the cellular level, SRNV resembles an aberrant but stereotypical tissue repair response that incorporates both an early inflammatory phase and a late fibrotic phase in addition to the neovascular (NV) component that dominates the early clinical presentation. This review will seek not only to highlight the important molecules involved in each of these components but to demonstrate that the development of SRNV has its origins in the earliest events in non-NV AMD pathogenesis. Current evidence suggests that this early-stage pathogenesis is characterised by complement-mediated immune dysregulation, leading to a state of chronic inflammation in the retinal pigment epithelium/Bruch's membrane/choriocapillaris complex. These initial events can be seamlessly and inextricably linked to late-stage development of SRNV in AMD by the process of dynamic reciprocity (DyR), the ongoing bidirectional communication between cells, and their surrounding matrix. Moreover, this correlation between disease onset and eventual outcome is reflected in the temporal and spatial correlation between chronic inflammation, NV, and fibrosis within the reparative microenvironment of the SRS. In summary, the downstream consequences of the earliest dysfunctional molecular events in AMD can result in the late-stage entity we recognize clinically as SRNV and is characterized by a spectrum of predictable, related, and stereotypical processes referred to as DyR.

Prevailing attitude amongst current senior intercounty hurlers to head and facial protection: a pilot study

BACKGROUND

Head and facial injury is a major cause of morbidity associated with the game of hurling. Yet, little is known about either players' experience of these injuries and their prevention with safety devices.

AIMS

To survey the attitude of some of the country's senior intercounty players towards the use of protective head and facial devices and their experience of injuries relating to the head and face.

METHODS

A questionnaire-based study. Player attitude to the use of protective devices will be reported here.

RESULTS

Forty-five players completed the survey. Thirty-two (71%) players currently wear helmets with 28 (87.5%) of these also wearing faceguards. Twenty-four (75%) players have been injured despite wearing a helmet and/or faceguard. Thirteen (40.6%) players expressed frustration with helmet performance.

CONCLUSIONS

Injury is an unavoidable feature of hurling. To this end perhaps more should be done to involve players in overall apparatus design and safety.

Prevalence of head and facial trauma in current senior intercounty hurlers

Head and facial injury are a major cause of morbidity associated with the game of hurling. A questionnaire-based study was undertaken to survey the attitude of some of the country's top senior intercounty players towards the use of protective head and facial wear and their experience of injuries relating to the head and face. Player's experience of head and facial injury will be reported here. Forty five players completed the survey. Thirty nine players (86.7%) have received injuries to the head and face during their careers. Thirteen (33.3%) of these players received such injuries on at least 5 occasions. Twenty five players (64.1%) have received eye injuries, 14 (56%) of which were described as serious by the players. Only 6 (42.9%) of these 14 players underwent a subsequent eye examination. In conclusion, these findings underscore the necessity of both compulsory head and facial protection and less haphazard access to specialist care.

Edible mushroom (Agaricus bisporus) lectin modulates human retinal pigment epithelial cell behaviour in vitro

The retinal pigment epithelium (RPE) plays a major role in the development of proliferative vitreoretinopathy (PVR). In particular, RPE cells are implicated in generating the contraction forces seen. The present study was undertaken to investigate whether human RPE binds a lectin from the common edible mushroom, Agaricus bisporus, and to evaluate the effect of any binding on RPE-mediated matrix contraction in an in vitro model of PVR. Fluorescein isothiocyanate (FITC)-labelled Agaricus bisporus lectin (ABL) was used to study binding of lectin to normal retina, PVR scar tissue specimens and cultured human RPE. The effect of a 3-day exposure of ABL on human RPE-mediated contraction was evaluated using 2- and 3D RPE-populated collagen matrices. Effect of ABL on cell adhesion was measured using a collagen type I adhesion assay and determining the relative cellular attachment using absorbance readings. The normal RPE monolayer did not stain with FITC-ABL while PVR scar tissue stained intensely. Staining of in vitro RPE was characteristic but time-dependent. ABL caused a dose-dependent inhibition of RPE-mediated contraction of both 2D (one-way ANOVA, F = 7.94, p < 0.008) and 3D collagen matrices (one-way ANOVA, F = 164.955, p < 0.001). Pre-incubation of ABL with RPE in the 2D model caused a dramatic arrest of contraction (one-way ANOVA, F = 20.1, p < 0.001) that was due to a dose-dependent inhibition of adhesion (one-way ANOVA, F = 15.603, p < 0.001). Recovery of contraction was partially reversible on removal of ABL and was dependent on initial concentration of the lectin. ABL inhibits contraction and adhesion of human RPE cells in vitro without apparent cytotoxicity. It therefore deserves consideration as a potential therapeutic agent in the prevention and treatment of PVR and other non-ocular anomalous wound-healing processes.

Improving the oral hygiene of institutionalized mentally retarded clients

PURPOSE

The quality of oral health care of persons with mental retardation has been reported in the literature to be less than that of their normal peers. The purpose of this study, set in a Midwest institution for persons with developmental retardation, was to determine if a change in policy followed by staff training and monitored by an interested third party would improve the oral hygiene of clients living on wards.

METHODS

Methods used to train staff in proper toothbrushing were developed. Three living units were randomly selected for study: control, training plus accountability (experimental group I), and training without accountability (experimental group II). The direct care staff of both experimental groups were trained in proper toothbrushing techniques. Staff of the control group received no training. A dental hygienist visited the living unit periodically to evaluate and provide feedback on the plaque index scores taken by the caregivers in both experimental groups.

RESULTS

The plaque indexes of group I showed significant improvement over the control group and group II.

CONCLUSION

The results of this pilot study support the other findings of higher plaque indexes for residents with mental retardation and that modifying toothbrushing policies and staff training are not as critical to the improvement of the clients' oral hygiene as is the presence of an involved, interested third party.

Long-term follow-up of ischaemic retinopathy in the antiphospholipid syndrome with lupus-like disease

PURPOSE

Antiphospholipid syndrome (APS), as an acquired prothrombotic disorder, is increasingly being recognised as an important cause of systemic venous and arterial thrombosis. The defining feature of the condition is the presence of raised levels of antibodies to negatively charged phospholipids in the serum.

METHODS

We describe 2 cases of APS with ocular involvement and review the recent literature. Both patients experienced acute visual loss. It was the presenting symptom in one case--a finding that led to the diagnosis of the syndrome.

RESULTS

Management with anticoagulation therapy, in which the International Normalised Ratio (INR) has been maintained at or above 3, resulted in reperfusion of the ischaemic retina and stabilisation of the retinopathy in one patient, whilst in the other case, where the INR was less than 3, irreversible visual loss occurred.

CONCLUSION

Anticoagulation with warfarin appears to result in reperfusion of ischaemic retina with stabilisation of the neovascular process when the INR is greater than 3.

The influence of retinopathy of prematurity on ocular growth

PURPOSE

Retinopathy of prematurity (ROP) stage 3 eyes that require treatment have a greater tendency to myopia compared with eyes with mild ROP. As the mechanisms controlling this myopia are as yet ill understood, we undertook this study to investigate what effect the initial stage of ROP and modality of treatment had on ocular growth.

METHODS

Eighty-five children were assessed. All children were refracted and underwent 'through-the-lid' biometry using the Zeiss Humphrey biometer 820. The printout obtained was then recorded on video so that the scan could be captured on computer for formal calibration and measurement by a masked observer. Differences in the distribution of variables between the stages of ROP were analysed by one-way analysis of variance, non-parametric Kruskal-Wallis one-way analysis of variance or Mann-Whitney U-test as appropriate.

RESULTS

A difference between the stages of ROP was apparent only for posterior segment length (PSL) (R: p = 0.03; L: p = 0.05) and a borderline difference for anterior chamber depth (ACD) (R: p = 0.06; L: p = 0.06). However, if stage 3 was divided into categories of treated and untreated, axial length (AL) achieved borderline significance (R: p = 0.07; L: p = 0.05) but with no difference between laser-treated and the other stages for AL. Lens thickness (LT) also appears to be influenced by type of treatment (R: p = 0.06; L: p = 0.13). Myopia was associated with stage 3 (R + L: p = 0.0001) and if stage 3 was subdivided the significance was maintained only for the laser- and cryotherapy-treated eyes.

CONCLUSIONS

Laser-treated eyes were less myopic than those treated with cryotherapy. AL does not explain all the myopia found in stage 3 treated eyes. The study confirms the tendency towards anterior segment arrest in stage 3 ROP.

Modulation of retinal pigment epithelial cell behavior by Agaricus bisporus lectin

PURPOSE

To determine whether Agaricus bisporus lectin (ABL) binds retinal pigment epithelial cells (RPEs), to conduct a preliminary viability study of RPEs exposed to ABL, and to evaluate the effects of ABL on RPE proliferation and RPE-mediated matrix contraction in vitro.

METHODS

Using cultured bovine RPEs, immunohistochemistry was used to study ABL binding. Morphologic and trypan blue exclusion techniques were used for toxicity studies. The effect of ABL on RPE proliferation was investigated by [methyl-3H]-thymidine incorporation. The effect of ABL on RPE-mediated matrix contraction was evaluated with RPE-populated three-dimensional collagen matrices.

RESULTS

ABL bound to RPE cells. This binding was inhibited by asialomucin. No change in RPE morphology or trypan blue exclusion compared with controls was observed in RPEs incubated with 5 to 60 microg/ml ABL for 3 days. Twenty-four-hour incubations of RPEs with ABL significantly inhibited RPE proliferation in a dose-dependent way, 40 microg/ml ABL inhibited proliferation by 83% (SE 14, P<0.05). ABL showed a dose-dependent significant inhibition of RPE-mediated collagen matrix contraction over 3 days, with 93% inhibition compared with controls by 40 microg/ml lectin (P<0.05). The inhibitory effect of ABL on proliferation and gel contraction was partly reversible after eliminating ABL from the culture medium.

CONCLUSIONS

Bovine RPE cells bind ABL, and preliminary evaluations suggest that levels of ABL that are nontoxic to the cells potently inhibit RPE proliferation and RPE-mediated matrix contraction. ABL deserves further investigation as a potential inhibitor of RPE proliferation and cell-mediated matrix contraction in anomalous reparative processes such as proliferative vitreoretinopathy and as a laboratory tool for RPE behavioral studies.

Acute intraoperative suprachoroidal haemorrhage in ocular surgery

PURPOSE/BACKGROUND

Acute intraoperative suprachoroidal haemorrhage (AISH) is the most sight-threatening complication of ocular surgery. We investigated the visual outcomes following this intraoperative event, patient characteristics that may predispose to it and the clinical features that may be of prognostic significance.

METHODS

The records of 45 cases of AISH collected from ophthalmic centres in the United Kingdom, Republic of Ireland and Switzerland were reviewed. Two satisfactory controls in terms of operative procedure, surgeon, age (+/- 5 years) and gender were found for each of 33 of our cases. Systemic and ocular characteristics were compared for cases and controls, and the visual results of all cases of AISH are analysed.

RESULTS

Cases and controls differed only in terms of axial length and pre-operative intraocular pressure, both of which were significantly greater for eyes that experienced an AISH (p < 0.05). Ten eyes (22.2%) achieved a final Snellen acuity of 6/12 or better. Statistically significant associations with a final acuity of counting fingers or worse included spontaneous nuclear expression (p = 0.02), retinal detachment (p < 0.0001), four-quadrant suprachoroidal haemorrhage (p = 0.007) and vision of perception of light or worse at the first dressing (p = 0.0001). Four of the 6 eyes that experienced an AISH during phacoemulsification surgery had a visual outcome of 6/12 or better, and this was significantly greater than for cases involving extracapsular cataract surgery (p = 0.004).

CONCLUSION

The results indicate that longer axial length and higher pre-operative intraocular pressure are associated with increased risk of AISH. Poor visual results are more likely following spontaneous nuclear expression, retinal detachment, four-quadrant suprachoroidal haemorrhage or vision of perception of light or worse at the first dressing. The results also suggest that AISH complicating a phacoemulsification procedure has a more favourable visual prognosis than AISH that occurs during extracapsular cataract surgery.

Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care

BACKGROUND

Effective new strategies that complement primary care are needed to reduce disability risks and improve self-management of chronic illness in frail older people living in the community.

OBJECTIVE

To evaluate the impact of a 1-year, senior center-based chronic illness self-management and disability prevention program on health, functioning, and healthcare utilization in frail older adults.

DESIGN

A randomized controlled trial.

SETTING

A large senior center located in a northeast Seattle suburb. The trial was conducted in collaboration with primary care providers of two large managed care organizations.

PARTICIPANTS

A total of 201 chronically ill older adults seniors aged 70 and older recruited through medical practices.

INTERVENTION

A targeted, multi-component disability prevention and disease self-management program led by a geriatric nurse practitioner (GNP).

MEASUREMENTS

Self-reported Physical function, physical performance tests, health care utilization, and health behaviors.

RESULTS

Each of 101 intervention participants met with the GNP from 1 to 8 times (median = 3) during the study year. The intervention group showed less decline in function, as measured by disability days and lower scores on the Health Assessment Questionnaire. Other measures of function, including the SF-36 and a battery of physical performance tests, did not change with the intervention. The number of hospitalized participants increased by 69% among the controls and decreased by 38% in the intervention group (P = .083). The total number of inpatient hospital days during the study year was significantly less in the intervention group compared with controls (total days = 33 vs 116, P = .049). The intervention led to significantly higher levels of physical activity and senior center participation and significant reductions in the use of psychoactive medications.

CONCLUSIONS

This project provides evidence that a community-based collaboration with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults. Linking organized medical care with complementary community-based interventions may be a promising direction for research and practice.

Management of Irish patients with intraocular melanoma referred to Liverpool, England

PURPOSE

This study reviews the results of patients referred from Ireland for treatment of an intraocular melanoma at the Ocular Oncology Service at St Paul's Eye Unit, Liverpool.

PATIENTS AND METHODS

There were 57 patients with a median age of 55 years. Management included plaque radiotherapy (14), proton beam radiotherapy (17), local resection (10), endoresection (6), and enucleation (10). Fifty-two tumours involved the choroid. The tumours had a mean diameter of 11.4 mm and a mean thickness of 5.2 mm.

RESULTS

The follow-up period had a median of 267 days. Retention of the eye was achieved in all 47 cases who underwent conservative management. Ninety percent of patients retained a vision of counting fingers, with an acuity of 6/12 or better in 50%.

CONCLUSION

This group of patients gives an indication of the results that can be expected when uveal melanoma is managed by a variety of conservative techniques in a specialised ocular oncology service.

Recent immigration and the misery of motherhood: a discussion of pertinent issues

In this paper it is assumed that the high rates of misery experienced by most new mothers in contemporary Western society are socially and culturally induced. Women from non-English-speaking backgrounds (NESB) recuperate from the stress of birth, often further complicated by morbidity from intervention, frequently alone and without practical household help. They often embark on their new mothering role with little support or guidance. In a Western society which markets a romanticized Anglo image of motherhood, where happy, contented, smiling babies and glamorous mothers appear as the norm, it is not surprising that women from NESB find becoming a mother in Australia difficult. Their difficulties are exacerbated as they frequently come from cultures where women are nurtured, valued and supported at this time in their lives. These women are often socially isolated in their new country, within an alien health system and separated from their normal birth and postpartum practices. Their misery can only be imagined, as mostly it is hidden and suffered alone. Providing a diagnosis of depression in women who are unhappy, but not clinically depressed, is likely to be even less helpful and more damaging for NESB women than for Anglo-Australian women. A diagnosis of depression excuses Western society for accepting responsibility for alleviating the isolation of new mothers by labelling them as 'sick'.

Pulsatile ocular blood flow in eyes with untreated choroidal melanoma

PURPOSE

To investigate the effect of choroidal melanoma on pulsatile ocular blood flow (POBF).

METHODS

Seventeen patients (10 men and 7 women) with unilateral untreated choroidal melanoma and 22 controls matched for age and sex were studied. Intraocular pressure (IOP), pulse amplitude (PA) and POBF were measured using the OBF Tonograph. In each patient, mean inter-ocular differences were analysed using the paired t-test. The correlation coefficient between tumour thickness and POBF was calculated. To assess the variation of this parameter, the coefficient of variation for three repeated readings was determined for healthy and affected eyes.

RESULTS

In the control group, there was no significant difference between eyes in any parameter. In patients with melanoma, there was no significant difference in IOP and PA between affected and unaffected eyes. Mean POBF was significantly higher in affected eyes (1040 microliters min-1) than unaffected eyes (876 microliters min-1) (p = 0.003). There was no correlation between tumour thickness and absolute POBF (r = -0.24) or between tumour thickness and inter-ocular difference in POBF between affected and unaffected eyes (r = -0.17). Mean coefficient of variation of three repeated readings of POBF was 7.76% in healthy eyes and 8.97% in affected eyes.

CONCLUSIONS

These findings suggest a high tumour blood flow or a global increase in choroidal blood flow in the presence of melanoma. POBF measurement may be useful in the clinical assessment of eyes with choroidal melanoma.