Size and Shape Matter: Cell Viability of Preloaded Descemet Stripping Automated Endothelial Keratoplasty Grafts in Three Different Carriers

PURPOSE

The aim of this study was to examine endothelial cell loss (ECL) associated with preloaded Descemet stripping automated endothelial keratoplasty (DSAEK) grafts loaded into 3 carriers of different size and shape.

METHODS

Thirty-six donor corneas were prepared for DSAEK and loaded into an EndoGlide Ultrathin (control) (2.0 mm × 3.5 mm lumen, 4.5 mm/4.9 mm incision for scleral tunnel/clear corneal insertion), Descemet membrane endothelial keratoplasty EndoGlide (experimental) (1.1 mm × 1.7 mm lumen, 2.65 mm incision), or round glass Jones tube (experimental) (1.8 mm lumen, 3.0 mm incision). Control grafts were stored for 6 days in Optisol-GS and experimental grafts stored for 24 hours in Life4C before analysis using Calcein AM staining. Grafts were imaged and ECL was analyzed by FIJI segmentation. The statistical significance of ECL was determined using 1-way ANOVA and Tukey post hoc analysis.

RESULTS

There were no significant differences in donor characteristics for grafts in each cohort. ECL for grafts loaded into the EndoGlide Ultrathin was 10.3% ± 2.3% (graft thickness: 60-189 μm, n = 9). ECL for grafts loaded into the Descemet membrane endothelial keratoplasty EndoGlide was 22.2% ± 7.1% (graft thickness: 38-63 μm, n = 9). ECL for thin grafts (34-60 μm, n = 9) loaded into the Jones tube was 24.0% ± 5.0%. ECL for thick grafts (92-119 μm, n = 9) loaded into the Jones tube was 34.2% ± 6.1% ECL ( P < 0.001). Combined regression analysis revealed that graft thickness is directly correlated to ECL ( P < 0.01).

CONCLUSIONS

The size and shape of the carrier can influence the cell viability of preloaded DSAEK grafts. Compared with a larger carrier, smaller lumen carriers are associated with greater ECL. In smaller lumen carriers, ECL increases with increasing DSAEK graft thickness.

Prospective In Vitro Comparison of Kerasave and Optisol-GS Corneal Storage Solutions

PURPOSE

The aim of this study was to compare the performance of Kerasave and Optisol-GS for hypothermic corneal storage for 14 days.

METHODS

This study was a prospective laboratory investigation. Mate corneas were recovered into Kerasave or Optisol-GS (27 pairs) and stored at 2°C to 8°C for 14 days. Corneas were evaluated by trained eye bank technicians, and study parameters were compared between the initial and final evaluations. Endothelial cell density (ECD), hexagonality (HEX), and coefficient of variation (CV) were evaluated by specular microscopy, and central corneal thickness (CCT) was examined by optical coherence tomography after 1, 3, 7, and 14 days of storage. Corneal transparency was scored using slit lamp examination at days 1 and 14.

RESULTS

Average ECD, HEX, and CV for the Kerasave (2653 ± 303 cells/mm 2 , 57 ± 4%, and 36 ± 3%) and Optisol-GS (2623 ± 306 cells/mm 2 , 57 ± 5%, and 36 ± 4%) groups were not significantly different at day 1. There was also no difference at any other study time points (all P > 0.05). ECD did not significantly change from day 1 to day 14 in either group ( P > 0.05), but a statistically significant change in HEX and CV was observed between day 1 and day 14 in both groups ( P < 0.01). Average CCT measured at day 1 for corneas stored in Kerasave was 622 ± 49 μm and those stored in Optisol-GS was 580 ± 35 μm ( P < 0.01). The difference in CCT measurements was not significantly different at day 14 (Kerasave: 674 ± 46 μm vs. Optisol-GS: 647 ± 58 μm, P > 0.05). Corneal transparency was not significantly different between the 2 groups at day 1 or day 14.

CONCLUSIONS

The corneal quality and clinically relevant parameters including ECD, endothelial morphometry, and corneal transparency were not different in corneas stored in Kerasave or Optisol-GS for 14 days. The initial difference in CCT between the 2 groups decreased at day 14. These results demonstrated that Kerasave corneal storage solution preserves the corneal endothelium similarly to Optisol-GS.

Allograft corneal ring segment for keratoconus management: Istanbul nomogram clinical results

PURPOSE

To evaluate the clinical feasibility and visual outcomes of allograft corneal ring segment implantation for the treatment of keratoconus.

METHODS

This case series, included forty-four eyes of 32 patients with a 6-month follow-up. All cases were treated according to the Istanbul nomogram. In the Istanbul Nomogram, corneal tunnels of 4 × 7.5 mm diameters are created at depth of 200 μm and implanted with sterile allograft corneal rings (KeraNaturalTM, Lions VisionGift, Portland, OR, USA) at the cone location. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE) and keratometric values were compared preoperatively versus postoperatively.

RESULTS

There was significant improvement in UDVA, CDVA, SE and topographic keratometric values. The mean preoperative CDVA (Snellen, decimal) increased from 0.29 ± 0.20, to 0.56 ± 0.26 (P < 0.001), at the last visit. There was no statistically significant difference between preoperative and postoperative thinnest pachymetry values (P = 0.509). No major complications or adverse event were observed during and after the operation.

CONCLUSIONS

The results of this pilot study show that sterile allograft corneal ring segments may be safe, effective and enhance the visual performance of keratoconus patients. Larger clinical studies are needed to demonstrate the effectiveness and safety with long term follow-up.

Examination of a Modified Graft Preparation Technique to Induce Double-Scroll Formation and Promote the Use of Younger Descemet Membrane Endothelial Keratoplasty Donor Tissue

PURPOSE

The purpose of this study was to determine whether controlled balanced salt solution (BSS) bursts during graft preparation can safely promote formation of a double-scrolled Descemet membrane endothelial keratoplasty (DMEK) graft in younger donor tissue.

METHODS

DMEK grafts prepared from young donor tissue (average age, 55 years; range, 39-66 years) were floated in BSS to spontaneously form scrolls (N = 10 pairs). Controlled BSS bursts were used to promote double-scroll (DS) formation in 1 member of each pair. Grafts were stained, preloaded, and shipped before cell viability analysis. After appropriate training, a less experienced technician performed this technique on 10 additional corneas. Outcomes measured for both technicians include the success rate for obtaining a DS, scroll conformation after shipping, and endothelial cell loss (ECL).

RESULTS

There was no difference in ECL between grafts subjected to additional manipulation compared with unmanipulated mate grafts (observer 1: 15.2% ± 3.3% vs. 15.2% ± 4.4%, P = 0.99; observer 2: 16.3% ± 2.9% vs. 15.9% ± 4.5%, P = 0.8). A technician experienced with this technique had a 90% success rate, whereas a less experienced technician had a 70% success rate. The mean ECL of the 10 grafts manipulated by the less experienced technician was not significantly different from results obtained from the experienced technician (observer 1: 18.5% ± 6.0% vs. 15.2% ± 3.3%, P = 0.15; observer 2: 18.1% ± 5.6% vs. 16.3% ± 2.9%, P = 0.34). Scrolls maintained their conformation during shipping events.

CONCLUSIONS

Double-scroll graft formation using controlled BSS bursts is a reliable technique that can be performed without causing additional damage to DMEK grafts. This technique may make graft unscrolling easier and can promote the use of younger donor tissue for DMEK.

Primary Graft Failure, Infection, and Endothelial Cell Density in Corneal Transplants With Increased Death-to-Preservation Time

PURPOSE

To ascertain whether death-to-preservation time (DPT) is associated with donor endothelial cell density (ECD), primary graft failure (PGF), and infection.

METHODS

Donor corneas aged older than 10 years with ECD 2000 to 4500 cells/mm2 were procured between 2011 and 2018 by a single eye bank. Donor corneas were analyzed retrospectively for the main outcome measures of PGF, infection, and ECD. Means and proportions of study parameters were compared between corneas with long and short DPT, defined as greater or less than 14 hours, respectively, excluding corneas with a history of intraocular surgery or diabetes. Multivariate analyses were performed using logistic regression, adjusting for donor age at time of death, history of diabetes mellitus, and history of cataract surgery.

RESULTS

Among 12,015 corneas, those with long DPT had a statistically but not clinically significant higher ECD than that of corneas with short DPT (2754 vs. 2724 cells/mm2, P < 0.01). There was no difference in PGF and infections in corneas with long versus short DPT (0.28% vs. 0.26%, P = 0.86; 0.43% vs. 0.29%, P = 0.51, respectively).

CONCLUSIONS

Longer DPT is not associated with a clinically meaningful reduction in donor ECD, PGF, or infection.

Donor DMEK Tissue Characteristics: Association With Rebubble Rate and 6-Month Endothelial Cell Loss

PURPOSE

To determine whether specific donor characteristics influence postoperative rebubble rate and 6-month endothelial cell loss (ECL) in Descemet membrane endothelial keratoplasty (DMEK).

METHODS

A retrospective analysis of a consecutive series of 857 DMEK surgeries using eye bank-prepared donor tissue was performed between September 2013 and April 2018. DMEK graft characteristics including donor age, preoperative endothelial cell density (ECD), preservation time, death-to-preservation time, and donor diabetes status were analyzed for correlation with rebubble rate and 6-month postoperative ECL. Subgroup analyses of donor age, preoperative ECD, preservation time, death-to-preservation time, preparation-to-surgery time, and diabetes severity were also performed. Statistically significant relationships between donor characteristics and rebubble rate or 6-month postoperative ECL were determined using Pearson correlation, one-way analysis of variance, t test, and χ analysis.

RESULTS

The overall rate of rebubble after 857 surgeries performed by 7 surgeons during the study period was 12.6%. There was no significant relationship between postoperative rebubble rate and donor age, preoperative ECD, preservation time, death-to-preservation time, preparation-to-surgery time, or donor diabetes status. The subgroup analysis of these characteristics also yielded no significant relationship with rebubble rate. There was also no significant relationship between 6-month postoperative ECL and analyzed donor factors.

CONCLUSIONS

Donor characteristics such as higher donor age, lower preoperative ECD (<2500), longer preservation time, and donor diabetes did not increase the rebubble rate or the 6-month ECL after DMEK. These results indicate that common surgeon preferences for donor tissues that are younger, fresher, with higher cell count, and without diabetes do not translate into superior postsurgical outcomes.

Ink Retention and Endothelial Cell Viability After the Application of an Orientation Stamp Over an Air Bubble During Descemet Membrane Endothelial Keratoplasty Graft Preparation

PURPOSE

To investigate stamp visibility and endothelial cell loss (ECL) after the application of an orientation mark to Descemet membrane endothelial keratoplasty (DMEK) grafts supported by an air bubble.

METHODS

Eighteen DMEK grafts were prepared at an eye bank using a technique where an orientation mark was applied to the stromal surface of a DMEK graft that was supported by a small air bubble placed at the edge of the 2 endothelial surfaces of the graft. Grafts were evaluated at 2 and 5 days for stamp visibility and at 5 days with calcein-AM staining for ECL. Nine grafts underwent cross-country shipping, and the ECL of shipped and nonshipped grafts was compared using unpaired t test.

RESULTS

All 18 DMEK grafts exhibited a single, solid, readily visible orientation mark 2 and 5 days after preparation with a mean ECL of 13.5% ± 4.9%. Shipping conditions had no effect on stain retention or ECL.

CONCLUSIONS

The application of an orientation stamp to a DMEK graft over an air bubble in an eye bank setting results in a single, solid orientation mark that is readily visible within the period in which most eye bank-prepared tissue is used. This technique produces no further ECL compared with the methods where the orientation stamp is applied through a stromal window. Eye bank technicians and surgeons can be confident that this modified preparation technique results in transplant-quality DMEK grafts with the additional benefit of conserving the stromal cap for use in other anterior lamellar procedures, thereby making efficient use of donor tissue.

Tissue Loss, Processing Time, and Primary Graft Failure in Eye Bank-Prepared Descemet Membrane Endothelial Keratoplasty Grafts Before and After Prestripped to Preloaded Graft Transition

PURPOSE

To examine tissue loss rates, processing time, and primary graft failure (PGF) of "prestripped-only" Descemet membrane endothelial keratoplasty (DMEK) grafts at a single eye bank and how these parameters changed after the introduction of steps to preload tissue among experienced processors.

METHODS

Tissue loss and processing time during DMEK graft preparation as well as PGF were analyzed retrospectively at a single eye bank between 2012 and 2018. Outcomes were assessed in consecutive grafts before and after the introduction of preloading to the eye bank's standard operating procedure.

RESULTS

A total of 1326 grafts were analyzed, composed of the first 663 preloaded DMEK grafts and, for comparison, the 663 DMEK grafts processed immediately before starting the preloaded service. Mean processing time increased from 17.0 ± 3.9 minutes to 26.0 ± 5.4 minutes with the advent of preloading (P < 0.01). Initially, average processing time increased dramatically, with a maximum processing time of 51 minutes, before regressing to the average. No significant difference in the rate of tissue wastage was observed before versus after the implementation of preloaded DMEK (1.2% vs. 1.7%, P = 0.48). PGF occurred in 7 grafts before the preloaded service and 10 grafts after starting the service (1.6% vs. 2.3%, P = 0.47).

CONCLUSIONS

Preloading does not affect tissue wastage for experienced technicians or the PGF rate but increases processing time. Eye banks that are considering adding preloading to their standard operating procedure may need to account for longer processing times in their daily operations.

Electron Beam Sterilization of Poly(Methyl Methacrylate)-Physicochemical and Biological Aspects

Electron beam (E-beam) irradiation is an attractive and efficient method for sterilizing clinically implantable medical devices made of natural and/or synthetic materials such as poly(methyl methacrylate) (PMMA). As ionizing irradiation can affect the physicochemical properties of PMMA, understanding the consequences of E-beam sterilization on the intrinsic properties of PMMA is vital for clinical implementation. A detailed assessment of the chemical, optical, mechanical, morphological, and biological properties of medical-grade PMMA after E-beam sterilization at 25 and 50 kiloGray (kGy) is reported. Fourier transform infrared spectroscopy, thermogravimetric analysis, and differential scanning calorimetry studies indicate that E-beam irradiation has minimal effect on the chemical properties of the PMMA at these doses. While 25 kGy irradiation does not alter the mechanical and optical properties of the PMMA, 50 kGy reduces the flexural strength and transparency by 10% and 2%, respectively. Atomic force microscopy demonstrates that E-beam irradiation reduces the surface roughness of PMMA in a dose dependent manner. Live-Dead, AlamarBlue, immunocytochemistry, and complement activation studies show that E-beam irradiation up to 50 kGy has no adverse effect on the biocompatibility of the PMMA. These findings suggest that E-beam irradiation at 25 kGy may be a safe and efficient alternative for PMMA sterilization.

Toward electron-beam sterilization of a pre-assembled Boston keratoprosthesis

PURPOSE

To evaluate the effects of electron-beam (E-beam) irradiation on the human cornea and the potential for E-beam sterilization of Boston keratoprosthesis (BK) devices when pre-assembled with a donor cornea prior to sterilization.

METHODS

Human donor corneas and corneas pre-assembled in BK devices were immersed in recombinant human serum albumin (rHSA) media and E-beam irradiated at 25 kGy. Mechanical (tensile strength and modulus, and compression modulus), chemical, optical, structural, and degradation properties of the corneal tissue after irradiation and after 6 months of preservation were evaluated.

RESULTS

The mechanical evaluation showed that E-beam irradiation enhanced the tensile and compression moduli of human donor corneas, with no impact on their tensile strength. By chemical and mechanical analysis, E-beam irradiation caused a minor degree of crosslinking between collagen fibrils. No ultrastructural changes due to E-beam irradiation were observed. E-beam irradiation slightly increased the stability of the cornea against collagenase-induced degradation and had no impact on glucose diffusion. The optical evaluation showed transparency of the cornea was maintained. E-beam irradiated corneal tissues and BK-cornea pre-assembled devices were stable for 6 months after room-temperature preservation.

CONCLUSIONS

E-beam irradiation generated no detrimental effects on the corneal tissues or BK-cornea pre-assembled devices and improved native properties of the corneal tissue, enabling prolonged preservation at room temperature. The pre-assembly of BK in a donor cornea, followed by E-beam irradiation, offers the potential for an off-the-shelf, ready to implant keratoprosthesis device.

A cytoskeletal protein complex is essential for division of intracellular amastigotes of Leishmania mexicana

Previous studies in Leishmania mexicana have identified the cytoskeletal protein KHARON as being important for both flagellar trafficking of the glucose transporter GT1 and for successful cytokinesis and survival of infectious amastigote forms inside mammalian macrophages. KHARON is located in three distinct regions of the cytoskeleton: the base of the flagellum, the subpellicular microtubules, and the mitotic spindle. To deconvolve the different functions for KHARON, we have identified two partner proteins, KHAP1 and KHAP2, which associate with KHARON. KHAP1 is located only in the subpellicular microtubules, whereas KHAP2 is located at the subpellicular microtubules and the base of the flagellum. Both KHAP1 and KHAP2 null mutants are unable to execute cytokinesis but are able to traffic GT1 to the flagellum. These results confirm that KHARON assembles into distinct functional complexes and that the subpellicular complex is essential for cytokinesis and viability of disease-causing amastigotes but not for flagellar membrane trafficking.

Electron Beam Irradiated Corneal Versus Gamma-Irradiated Scleral Patch Graft Erosion Rates in Glaucoma Drainage Device Surgery

INTRODUCTION

Patch graft erosion and implant exposure is a known complication of glaucoma drainage device (GDD) surgery. Recently, electron beam (e-beam) irradiated corneal tissue ha s become available; however, limited data exist on the rates of erosion for e-beam irradiated corneal grafts compared to traditional scleral grafts after GDD surgery.

METHODS

This retrospective study examines the records of 253 eyes from 225 adult subjects who underwent GDD surgery with either e-beam irradiated corneal or scleral grafts at the Casey Eye Institute by five surgeons between April 22, 2014 and October 11, 2017. Surgical procedures and the occurrence of graft erosion were determined using billing codes and verified by manual review of electronic health records.

RESULTS

The average age at the time of surgery was 61.3 ± 17.5 years (n = 200) and 60.8 ± 16.8 years (n = 53) for the e-beam irradiated cornea and sclera groups, respectively. The average follow-up time post-surgery was 416 ± 345 days and 495 ± 343 days for the e-beam irradiated cornea and sclera groups, respectively. There were no statistically significant differences in sex, age, follow-up time, and glaucoma diagnosis between the groups; however, the e-beam irradiated cornea group was statistically more likely to have an Ahmed implant as compared to the sclera group. No erosion events were noted in either group.

CONCLUSION

e-Beam irradiated corneal grafts were used 3.8 times more frequently relative to scleral grafts, yet there were no cases of graft erosion in either group during the follow-up period.

Patent Blue V as an Alternative Stain for DMEK Grafts: Safety, Stain Retention, and Feasibility

PURPOSE

To determine whether Patent Blue V (PB) can be used as an alternative dye for staining Descemet membrane endothelial keratoplasty (DMEK) grafts.

METHODS

DMEK grafts from donor corneas were stained with 2.5% PB for 4 minutes (n = 2), 2.5% PB for 10 minutes (n = 2), or 0.06% trypan blue (TB) for 4 minutes (n = 1). The stain intensity of the grafts was compared initially and at different time points over a 15-minute period of balanced salt solution wash using a grading scale based on a serial dilution series of PB. Three additional grafts were stained with 2.5% PB for 10 minutes and used in mock surgeries to assess stain retention after injection and manipulation in a donor eye model for 25 minutes. To assess the safety of PB, DMEK grafts were prepared from 10 pairs of corneas where one cornea was stained with 0.06% TB for 4 minutes and the mate cornea was stained with 2.5% PB for 10 minutes. The grafts were preloaded and stored for 5 days in Optisol-GS at 2°C to 8°C, and endothelial cell loss was quantified using Calcein-AM staining and FIJI segmentation by 2 masked readers.

RESULTS

PB stain intensities were lighter than TB-stained grafts. Grafts stained with 2.5% PB for 10 minutes retained sufficient color for the 25-minute duration of mock surgery. The average endothelial cell loss for PB versus TB grafts was 21.6% ± 5.3% versus 20.2% ± 5.4% (P = 0.202) as determined by reader 1 and 23.6% ± 4.8% versus 21.2% ± 5.8% (P = 0.092) as determined by reader 2.

CONCLUSIONS

PB is a viable alternative dye in DMEK grafts for applications where TB may not be available or approved for use.

Novel Use of Telemedicine for Corneal Tissue Evaluation in Eye Banking: Establishing a Standardized Approach for the Remote Evaluation of Donor Corneas for Transplantation

PURPOSE

To determine the feasibility of using telemedicine consultations in the evaluation of recovered donor corneas for transplant suitability.

METHODS

This study aims to establish and test the minimum imaging requirements for telemedical consultations of corneal tissue by remote eye bank medical directors. Digital images from the slit lamp, optical coherence tomography, and/or specular microscope were assembled into telemedical consults and emailed to 4 eye bank medical directors (M.A.T., J.W., C.S.S., N.K.R.). Feedback on the minimum image requirements for each corneal finding was collected. After establishing a standardized imaging and presentation protocol, test cases were presented to the medical directors to examine the validity of these remote consults. To establish a benchmark for the study's parameters, one medical director (J.W.) examined each case in person after his initial remote review. Examiners were masked to each other's responses.

RESULTS

Minimum image requirements for determination of corneal findings were defined and were specific to each anatomic layer of the cornea (epithelial, stromal, or endothelial). Using a defined set of digital images for a set of common corneal findings, the rate of agreement between remote evaluators, eye bank staff, and the in-person evaluator was 100% (11 of 11 examples). For ambiguous test cases, remote evaluators agreed on 80% of the cases (4 of 5).

CONCLUSIONS

Results from this pilot study suggest that telemedical review of corneal tissue using high-quality digital images may be adequate for accurate identification of specific corneal findings commonly encountered by eye banks.

KHARON Is an Essential Cytoskeletal Protein Involved in the Trafficking of Flagellar Membrane Proteins and Cell Division in African Trypanosomes

African trypanosomes and related kinetoplastid parasites selectively traffic specific membrane proteins to the flagellar membrane, but the mechanisms for this trafficking are poorly understood. We show here that KHARON, a protein originally identified in Leishmania parasites, interacts with a putative trypanosome calcium channel and is required for its targeting to the flagellar membrane. KHARON is located at the base of the flagellar axoneme, where it likely mediates targeting of flagellar membrane proteins, but is also on the subpellicular microtubules and the mitotic spindle. Hence, KHARON is probably a multifunctional protein that associates with several components of the trypanosome cytoskeleton. RNA interference-mediated knockdown of KHARON mRNA results in failure of the calcium channel to enter the flagellar membrane, detachment of the flagellum from the cell body, and disruption of mitotic spindles. Furthermore, knockdown of KHARON mRNA induces a lethal failure of cytokinesis in both bloodstream (mammalian host) and procyclic (insect vector) life cycle stages, and KHARON is thus critical for parasite viability.

Integrating ribosomal promoter vectors that offer a choice of constitutive expression profiles in Leishmania donovani

We have designed a novel series of integrating ribosomal RNA promoter vectors with five incrementally different constitutive expression profiles, covering a 250-fold range. Differential expression was achieved by placing different combinations of synthetic or leishmanial DNA sequences upstream and downstream of the transgene coding sequence in order to modulate pre-mRNA processing efficiency and mRNA stability, respectively. All of the vectors have extensive multiple cloning sites, and versions are available for producing N- or C- terminal GFP fusions at each of the possible relative expression levels. In addition, the modular configuration of the vectors allows drug resistance cassettes and other components to be readily exchanged. In toto, these vectors should be useful additions to the toolkit available for molecular and genetic studies of Leishmania donovani.

Flagellar membrane proteins in kinetoplastid parasites

All kinetoplastid parasites, including protozoa such as Leishmania species, Trypanosoma brucei, and Trypanosoma cruzi that cause devastating diseases in humans and animals, are flagellated throughout their life cycles. Although flagella were originally thought of primarily as motility organelles, flagellar functions in other critical processes, especially in sensing and signal transduction, have become more fully appreciated in the recent past. The flagellar membrane is a highly specialized subdomain of the surface membrane, and flagellar membrane proteins are likely to be critical components for all the biologically important roles of flagella. In this review, we summarize recent discoveries relevant to flagellar membrane proteins in these parasites, including the identification of such proteins, investigation of their biological functions, and mechanisms of selective trafficking to the flagellar membrane. Prospects for future investigations and current unsolved problems are highlighted.

Methotrexate in the treatment of pemphigus vulgaris: experience in 23 patients

BACKGROUND

The standard treatment for patients with pemphigus vulgaris has long consisted of high-dose glucocorticoids. Studies regarding the use of methotrexate in pemphigus vulgaris date back to 1968, but few have quantitatively described a steroid-sparing effect conferred by methotrexate.

OBJECTIVES

We sought to evaluate the efficacy of methotrexate in 23 patients with pemphigus vulgaris, using the drug's steroid-sparing effect as the primary indicator of clinical improvement. We investigated whether methotrexate could be used as monotherapy in some patients.

METHODS

Retrospective chart review was used to analyse the records of patients with pemphigus vulgaris treated with methotrexate at the New York University Langone Medical Center for at least three consecutive months between 2000 and 2012. Diagnosis was made by tissue biopsy and either direct or indirect immunofluorescence tests and enzyme-linked immunosorbent assay.

RESULTS

Improvement in clinical symptoms was observed in 91% of patients. Sixteen patients (70%) were eventually weaned completely off prednisone, with a mean time to discontinuation of 18 months. In total 23% of patients enjoyed a partial steroid-sparing effect, requiring a mean maintenance dose of prednisone of 6·75 mg daily. Two patients (9%) developed possible adverse events requiring cessation of the drug, and one patient received no therapeutic benefit from the drug.

CONCLUSIONS

Methotrexate is a useful and well-tolerated therapy with considerable steroid-sparing effect in patients with pemphigus vulgaris. It may be considered a first-line adjuvant therapy in the treatment of this difficult disease.

The accuracy of chromosomal microarray testing for identification of embryonic mosaicism in human blastocysts

Background

Most previous studies of chromosomal mosaicism in IVF embryos were performed by fluorescence in situ hybridization (FISH) methods. While there are reports implicating chromosome aneuploidy in implantation failure following transfer and pregnancy loss by spontaneous miscarriage, the significance of mosaicism for the developmental potential of growing embryos is unknown. However, the low prevalence of chromosomal mosaicism in chorionic villus sampling and amniotic fluid specimens suggests the presence of selection against mosaic embryos for implantation and early pregnancy. The absence of evidence for selective allocation of abnormal cells to the trophectoderm (TE) of mosaic blastocysts permits these cells to be a good proxy for embryonic mosaicism detection by chromosomal microarrays (CMA). The purpose of this study was to establish the limits of detection and the prevalence of chromosome mosaicism in day 5/6 human embryos using CMA with TE biopsies.

Results

From reconstitution experiments we established log₂ ratio thresholds for mosaicism detection. These studies indicated that chromosomal mosaicism at levels as low as between 25-37% can be consistently identified. Follow-up studies by FISH on non-transferred abnormal embryos confirmed the diagnostic accuracy of CMA testing. The number of cells in a TE biopsy can influence mosaicism detection.

Conclusions

Chromosomal microarrays can detect mosaicism in TE biopsies when present at levels as low as between 25-37% and the prevalence of day 5/6 blastocysts which were mosaic and had no other abnormalities reached 15% among a cohort of 551 embryos examined. Validated protocols for establishing detection thresholds for mosaicism are important to reduce the likelihood of transferring abnormal embryos.

Effects of selenium on development, survival, and accumulation in the honeybee (Apis mellifera L.)

Apis mellifera L. (Hymenoptera: Apidae) is an important agricultural pollinator in the United States and throughout the world. In areas of selenium (Se) contamination, honeybees may be at risk because of the biotransfer of Se from plant products such as nectar and pollen. Several forms of Se can occur in accumulating plants. In the present study, the toxicity of 4 compounds (selenate, selenite, methylselenocysteine, and selenocystine) to honeybee adult foragers and larvae was assessed using dose-response bioassays. Inorganic forms were more toxic than organic forms for both larvae (lethal concentration [LC50] selenate = 0.72 mg L(-1) , LC50 selenite = 1.0 mg L(-1) , LC50 methylselenocysteine = 4.7 mg L(-1) , LC50 selenocystine = 4.4 mg L(-1) ) and foragers (LC50 selenate = 58 mg L(-1) , LC50 selenite = 58 mg L(-1) , LC50 methylselenocysteine = 161 mg L(-1) , LC50 selenocystine = 148 mg L(-1) ). Inorganic forms of Se caused rapid mortality, and organic forms had sublethal effects on development. Larvae accumulated substantial amounts of Se only at the highest doses, whereas foragers accumulated large quantities at all doses. The present study documented very low larval LC50 values for Se; even modest transfer to brood will likely cause increased development times and mortality. The toxicities of the various forms of Se to honeybee larvae and foragers are discussed in comparison with other insect herbivores and detritivores.

KHARON1 mediates flagellar targeting of a glucose transporter in Leishmania mexicana and is critical for viability of infectious intracellular amastigotes

The LmxGT1 glucose transporter is selectively targeted to the flagellum of the kinetoplastid parasite Leishmania mexicana, but the mechanism for targeting this and other flagella-specific membrane proteins among the Kinetoplastida is unknown. To address the mechanism of flagellar targeting, we employed in vivo cross-linking, tandem affinity purification, and mass spectrometry to identify a novel protein, KHARON1 (KH1), which is important for the flagellar trafficking of LmxGT1. Kh1 null mutant parasites are strongly impaired in flagellar targeting of LmxGT1, and trafficking of the permease was arrested in the flagellar pocket. Immunolocalization revealed that KH1 is located at the base of the flagellum, within the flagellar pocket, where it associates with the proximal segment of the flagellar axoneme. We propose that KH1 mediates transit of LmxGT1 from the flagellar pocket into the flagellar membrane via interaction with the proximal portion of the flagellar axoneme. KH1 represents the first component involved in flagellar trafficking of integral membrane proteins among parasitic protozoa. Of considerable interest, Kh1 null mutants are strongly compromised for growth as amastigotes within host macrophages. Thus, KH1 is also important for the disease causing stage of the parasite life cycle.

Effects of selenium accumulation on phytotoxicity, herbivory, and pollination ecology in radish (Raphanus sativus L.)

Selenium (Se) has contaminated areas in the western USA where pollination is critical to the functioning of both agricultural and natural ecosystems, yet we know little about how Se can impact pollinators. In a two-year semi-field study, the weedy plant Raphanus sativus (radish) was exposed to three selenate treatments and two pollination treatments to evaluate the effects on pollinator-plant interactions. Honey bee (Apis mellifera L.) pollinators were observed to readily forage on R. sativus for both pollen and nectar despite high floral Se concentrations. Se treatment increased both seed abortion (14%) and decreased plant biomass (8-9%). Herbivory by birds and aphids was reduced on Se-treated plants, indicating a potential reproductive advantage for the plant. Our study sheds light on how pollutants such as Se can impact the pollination ecology of a plant that accumulates even moderate amounts of Se.

A resource for manipulating gene expression and analyzing cis-regulatory modules in the Drosophila CNS

Here, we describe the embryonic central nervous system expression of 5,000 GAL4 lines made using molecularly defined cis-regulatory DNA inserted into a single attP genomic location. We document and annotate the patterns in early embryos when neurogenesis is at its peak, and in older embryos where there is maximal neuronal diversity and the first neural circuits are established. We note expression in other tissues, such as the lateral body wall (muscle, sensory neurons, and trachea) and viscera. Companion papers report on the adult brain and larval imaginal discs, and the integrated data sets are available online (http://www.janelia.org/gal4-gen1). This collection of embryonically expressed GAL4 lines will be valuable for determining neuronal morphology and function. The 1,862 lines expressed in small subsets of neurons (<20/segment) will be especially valuable for characterizing interneuronal diversity and function, because although interneurons comprise the majority of all central nervous system neurons, their gene expression profile and function remain virtually unexplored.

Both sequence and context are important for flagellar targeting of a glucose transporter

Many of the cilia- and flagella-specific integral membrane proteins identified to date function to sense the extracellular milieu, and there is considerable interest in defining pathways for targeting such proteins to these sensory organelles. The flagellar glucose transporter of Leishmania mexicana, LmxGT1, is targeted selectively to the flagellar membrane, whereas two other isoforms, LmxGT2 and LmxGT3, are targeted to the pellicular plasma membrane of the cell body. To define the flagellar targeting signal, deletions and point mutations were generated in the N-terminal hydrophilic domain of LmxGT1, which mediates flagellar localization. Three amino acids, N95-P96-M97, serve critical roles in flagellar targeting, resulting in strong mistargeting phenotypes when mutagenized. However, to facilitate flagellar targeting of other non-flagellar membrane proteins, it was necessary to attach a larger region surrounding the NPM motif containing amino acids 81-113. Molecular modeling suggests that this region might present the critical NPM residues at the surface of the N-terminal domain. It is likely that the NPM motif is recognized by currently unknown protein-binding partners that mediate flagellar targeting of membrane-associated proteins.

Interaction between dextromethorphan and norpethidine in rats

With increasing interest in the application of dextromethorphan in pain control, it is probable that patients will receive this drug in combination with analgesics such as opioids, giving rise to the potential for previously unobserved drug interactions. The interaction between dextromethorphan, and its pharmacologically active metabolite dextrorphan, and norpethidine, a toxic metabolite of pethidine, was examined in rats. Rats were assigned to receive dextromethorphan (0, 20 or 40 mg/kg) or dextrorphan (0, 15 or 30 mg/kg) combined with norpethidine (0, 28 or 42 mg/kg). The occurrence of seizures, myoclonic jerks and shivering was recorded for 60 min after drug administration. Norpethidine produced dose-related increases in the incidence of seizures, myoclonic jerks and shivering. Dextromethorphan, but not dextrorphan, increased the incidence of these behaviours. It is recommended that extreme caution be exercised if dextromethorphan and pethidine are to be used together.

E2-2 protein and Fuchs's corneal dystrophy

BACKGROUND

Fuchs's corneal dystrophy (FCD) is a leading cause of corneal transplantation and affects 5% of persons in the United States who are over the age of 40 years. Clinically visible deposits called guttae develop under the corneal endothelium in patients with FCD. A loss of endothelial cells and deposition of an abnormal extracellular matrix are observed microscopically. In advanced disease, the cornea swells and becomes cloudy because the remaining endothelial cells are not sufficient to keep the cornea dehydrated and clear. Although rare genetic variation that contributes to both early-onset and typical late-onset forms of FCD has been identified, to our knowledge, no common variants have been reported.

METHODS

We performed a genomewide association study and replicated the most significant observations in a second, independent group of subjects.

RESULTS

Alleles in the transcription factor 4 gene (TCF4), encoding a member of the E-protein family (E2-2), were associated with typical FCD (P=2.3x10(-26)). The association increased the odds of having FCD by a factor of 30 for persons with two copies of the disease variants (homozygotes) and discriminated between case subjects and control subjects with about 76% accuracy. At least two regions of the TCF4 locus were associated independently with FCD. Alleles in the gene encoding protein tyrosine phosphatase receptor type G (PTPRG) were associated with FCD (P=4.0x10(-7)), but the association did not reach genomewide significance.

CONCLUSIONS

Genetic variation in TCF4 contributes to the development of FCD. (Funded by the National Eye Institute and others.)

Recombineering Hunchback identifies two conserved domains required to maintain neuroblast competence and specify early-born neuronal identity

The Hunchback/Ikaros family of zinc-finger transcription factors is essential for specifying the anterior/posterior body axis in insects, the fate of early-born pioneer neurons in Drosophila, and for retinal and immune development in mammals. Hunchback/Ikaros proteins can directly activate or repress target gene transcription during early insect development, but their mode of action during neural development is unknown. Here, we use recombineering to generate a series of Hunchback domain deletion variants and assay their function during neurogenesis in the absence of endogenous Hunchback. Previous studies have shown that Hunchback can specify early-born neuronal identity and maintain 'young' neural progenitor (neuroblast) competence. We identify two conserved domains required for Hunchback-mediated transcriptional repression, and show that transcriptional repression is necessary and sufficient to induce early-born neuronal identity and maintain neuroblast competence. We identify pdm2 as a direct target gene that must be repressed to maintain competence, but show that additional genes must also be repressed. We propose that Hunchback maintains early neuroblast competence by silencing a suite of late-expressed genes.

Pdm and Castor close successive temporal identity windows in the NB3-1 lineage

Neurogenesis in Drosophila and mammals requires the precise integration of spatial and temporal cues. In Drosophila, embryonic neural progenitors (neuroblasts) sequentially express the transcription factors Hunchback, Kruppel, Pdm1/Pdm2 (Pdm) and Castor as they generate a stereotyped sequence of neuronal and glial progeny. Hunchback and Kruppel specify early temporal identity in two posterior neuroblast lineages (NB7-1 and NB7-3), whereas Pdm and Castor specify late neuronal identity in the NB7-1 lineage. Because Pdm and Castor have only been assayed in one lineage, it is unknown whether their function is restricted to neuronal identity in the NB7-1 lineage, or whether they function more broadly as late temporal identity genes in all neuroblast lineages. Here, we identify neuronal birth-order and molecular markers within the NB3-1 cell lineage, and then use this lineage to assay Pdm and Castor function. We show that Hunchback and Kruppel specify first and second temporal identities, respectively. Surprisingly, Pdm does not specify the third temporal identity, but instead acts as a timing factor to close the second temporal identity window. Similarly, Castor closes the third temporal identity window. We conclude that Hunchback and Kruppel specify the first and second temporal identities, an unknown factor specifies the third temporal identity, and Pdm and Castor are timing factors that close the second and third temporal identity windows in the NB3-1 lineage. Our results provide a new neuroblast lineage for investigating temporal identity and reveal the importance of Pdm and Cas as timing factors that close temporal identity windows.

Drosophila Aurora-A kinase inhibits neuroblast self-renewal by regulating aPKC/Numb cortical polarity and spindle orientation

Regulation of stem cell self-renewal versus differentiation is critical for embryonic development and adult tissue homeostasis. Drosophila larval neuroblasts divide asymmetrically to self-renew, and are a model system for studying stem cell self-renewal. Here we identify three mutations showing increased brain neuroblast numbers that map to the aurora-A gene, which encodes a conserved kinase implicated in human cancer. Clonal analysis and time-lapse imaging in aurora-A mutants show single neuroblasts generate multiple neuroblasts (ectopic self-renewal). This phenotype is due to two independent neuroblast defects: abnormal atypical protein kinase C (aPKC)/Numb cortical polarity and failure to align the mitotic spindle with the cortical polarity axis. numb mutant clones have ectopic neuroblasts, and Numb overexpression partially suppresses aurora-A neuroblast overgrowth (but not spindle misalignment). Conversely, mutations that disrupt spindle alignment but not cortical polarity have increased neuroblasts. We conclude that Aurora-A and Numb are novel inhibitors of neuroblast self-renewal and that spindle orientation regulates neuroblast self-renewal.

Child Behavior and Quality of Life in Pediatric Obstructive Sleep Apnea

OBJECTIVE

To assess behavior and quality of life in children with obstructive sleep apnea (OSA) undergoing tonsillectomy and adenoidectomy compared with control children.

DESIGN

Prospective controlled study.

SETTING

Hospital-based pediatric otolaryngology practice.

PARTICIPANTS

Forty-two children (25 boys and 17 girls; mean [SD] age, 5.8 [2.5] years) with OSA confirmed by positive findings on polysomnography undergoing tonsillectomy and adenoidectomy and 41 control children (29 boys and 12 girls; mean [SD] age, 7.3 [3.8] years) with no history of snoring undergoing unrelated elective surgery.

INTERVENTIONS

Parents completed the standardized Child Behavior Checklist and a validated pediatric OSA quality-of-life survey before and 3 months after surgery.

MAIN OUTCOME MEASURES

Child Behavior Checklist T scores and score classifications and quality-of-life survey mean scores.

RESULTS

Change in mean total problem T score was significantly greater in the OSA group (from 51.6 at baseline to 48.3 at follow-up) than in controls (from 45.5 at baseline to 46.7 at follow-up) (P = .03). The improvement in total T score classification (normal vs borderline or abnormal) was significant for children with OSA compared with control children (P = .009). Children with OSA had significant improvements in the quality-of-life survey mean total score and all individual domain scores compared with controls (P<.001).

CONCLUSIONS

Behavioral and emotional difficulties are found in children with documented OSA compared with control children, and they improve after treatment. Large improvements in disease-specific quality of life are also found. Scores on a standardized measure of behavior assessment demonstrated significant correlation with scores on a validated quality-of-life instrument.

Myringotomy and tympanostomy tube placement in children with sickle cell disease

OBJECTIVE

To assess the event rate of myringotomy and tube placement (M&T) in the pediatric patient population with sickle cell disease (SCD).

METHODS

Four hundred and forty-nine children with confirmed SCD have been followed over a period of 11.5 years at two hospital-based pediatric hematology and otolaryngology offices, and three tertiary care hospitals. Children with SCD who had undergone M&T were identified via computer search of International Classification of Diseases codes by the medical records departments of the three hospitals, and from two databases of the hematology offices. The inpatient and outpatient medical records of all children identified were reviewed.

RESULTS

For the 449 patients, mean duration of SCD follow-up was 6.13 +/- 3.36 years. Of these, eight patients (four boys, four girls, mean age 9 +/- 3.5 years; four patients had hemoglobin SC disease, and four patients had sickle cell anemia type SS) underwent M&T. Two children met criteria for severe SCD. The event rate for M&T insertion was 0.29/100 person-years, 95% CI (0.15, 0.58).

CONCLUSIONS

The event rate for M&T in children with SCD, compared to a historical control group, is lower than that of the general population. Type and severity of SCD were not predictive of the need for tube insertion. Children with sickle cell disease do not have an increased rate of M&T insertion.

Reduced Purkinje cell size in the cerebellar vermis of elderly patients with schizophrenia

OBJECTIVE

The authors' goal was to compare the size and linear density of Purkinje cells in the cerebellar vermis of subjects with and without schizophrenia.

METHOD

Blocks of alcohol-fixed cerebellar vermis were dissected at autopsy from the brains of 14 elderly patients with schizophrenia and 13 elderly subjects with no history of neuropsychiatric illness. The blocks of vermis were sectioned and stained with 1% cresyl violet. The linear density and cross-sectional area of Purkinje cells were measured by using computer-assisted image analysis. The subjects with schizophrenia had been assessed with clinical rating scales within 1 year prior to death.

RESULTS

The average cross-sectional areas of Purkinje cells of the patients with schizophrenia were significantly smaller (by 8.3%) than those of the subjects without neuropsychiatric illness. No difference in Purkinje cell linear density was observed between the two groups. Significant correlations were seen between Purkinje cell size and scores on the Mini-Mental State, the Brief Psychiatric Rating Scale, and the antipsychotic drug dose.

CONCLUSIONS

These data indicate cerebellar involvement in schizophrenia; they are also consistent with reports of reduced neuronal size in other brain regions of patients with schizophrenia. These findings support a model of wide-spread central nervous system abnormality in schizophrenia.

The pharmacokinetics of a single dose of artemisinin in subjects with liver cirrhosis. Bach Mai-Amsterdam Research Group on Artemisinin

Artemisinin is mainly eliminated by hepatic transformation. To investigate whether the clearance of artemisinin in patients with liver cirrhosis is different from healthy volunteers, a pharmacokinetic study was performed in male Vietnamese patients with Child B cirrhosis of the liver who received 500 mg of artemisinin orally. The results were compared to those found in a previous study in healthy subjects. The mean (+/- SD) area under the concentration time curve was 2365 (+/- 1761) h ng/ml; the mean (+/- SD) clearance, 382 (+/- 303)L/h. The elimination half life was 4 (+/- 1.3) h extimated by log-linear regression and 2.4 +/- 0.9 h estimated by non-linear regression using a one-compartment first order elimination model. The mean (+/- SD) absorption time was 1.55 (+/- 0.8) h. These results were not different from the results of healthy subjects and show that liver disease has no effect on the availability and clearance of oral artemisinin, indicating that artemisinin has an intermediate hepatic extraction ratio and that there is no significant first pass effect.

The pharmacokinetics of a single dose of artemisinin in patients with uncomplicated falciparum malaria

The pharmacokinetics of artemisinin was studied in 11 Vietnamese patients with uncomplicated falciparum malaria after a single 500 mg oral dose. Curative treatment with mefloquine (15 mg/kg) was provided 24 hr after the artemisinin dose. Artemisinin concentrations were measured by high-performance liquid chromatography with electrochemical detection. The following pharmacokinetic results were found (all mean +/- SD); calculated volume of distribution/bioavailability = 22.8 +/- 16.6 L.kg-1, mean absorption time = 1.16 +/- 0.92 hr, calculated maximum concentration = 364 +/- 250 micrograms.L-1 occurring at 2.88 +/- 1.71 hr after drug intake, and an elimination half-life of 2.72 +/- 1.76 hr. Bioavailability was low. These results do not differ from results in healthy subjects. Parasites disappeared rapidly, with a mean parasite clearance time of 36 hr. No relationship was found between pharmacokinetics and the parasite elimination rate. Tolerance to the single dose of artemisinin was good. No adverse effects were detected. In conclusion, pharmacokinetics of a single dose of artemisinin for uncomplicated falciparum malaria is not different from findings in healthy subjects. A single dose of 500 mg of artemisinin is effective in reducing parasitemia in nonsevere lalciparum malaria and is well-tolerated.