Percutaneous cecostomy: 25-year two institution experience

BACKGROUND

Reports of technical success, adverse events, and long-term outcome of percutaneous cecostomy in children are limited.

OBJECTIVE

To characterize technical success, 30-day severe adverse events, and long-term outcome of percutaneous cecostomy at two centers.

MATERIALS AND METHODS

A retrospective review of hospital course and long-term follow-up (through May 2022) of percutaneous cecostomy tubes placed May 1997 to August 2011 at two children's hospitals was used. Outcomes assessed included technical success (defined as successful tube placement into the colon allowing antegrade colonic enemas), length of stay, 30-day severe adverse events, surgery consults, surgical repair, VP shunt infection, ongoing flushes, tube removal, duration between maintenance tube exchanges, and deaths.

RESULTS

A total of 215 procedures were performed in 208 patients (90 institution A, 125 institution B). Tubes were placed for neurogenic bowel (72.1%, n = 155) and functional constipation (27.9%, n = 60). Technical success was 98.1% (211/215) and did not differ between centers (p = 0.74). Surgical repair was required for bowel leakage in 5.1% (11/215) and VP shunt infection was managed in 2.1% (2/95). Compared to functional constipation, patients with neurogenic bowel had higher % tube remaining (65.3% [96/147] versus 25.9% [15/58], p < 0.001) and higher ongoing flushes at follow-up (42.2% [62/147] versus 12.1% [7/58], p < 0.001). Tube removal for dissatisfaction occurred in 15.6% [32/205] and did not differ between groups (p = 0.98). Eight deaths due to co-morbidity occurred after a median of 7.4 years (IQR 9.3) of tube access.

CONCLUSION

Percutaneous cecostomy is technically successful in the vast majority of patients and provided durable access in most. Bowel leakage and VP shunt infection are uncommon, severe adverse events.

Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion

BACKGROUND

While chest tube placement with pleural fibrinolytic medication is the established treatment of pediatric empyema, treatment failure is reported in up to 20% of these children.

OBJECTIVE

Standardizing fibrinolytic administration among interventional radiology (IR) physicians to improve patient outcomes in pediatric parapneumonic effusion.

MATERIALS AND METHODS

We introduced a hospital-wide clinical pathway for parapneumonic effusion (1-2 mg tissue plasminogen activator [tPA] twice daily based on pleural US grade); we then collected prospective data for IR treatment May 2017 through February 2020. These data included demographics, co-morbidities, pediatric intensive care unit (PICU) admission, pleural US grade, culture results, daily tPA dose average, twice-daily dose days, skipped dose days, pleural therapy days, need for chest CT/a second IR procedure/surgical drainage, and length of stay. We compared the prospective data to historical controls with IR treatment from January 2013 to April 2017.

RESULTS

Sixty-three children and young adults were treated after clinical pathway implementation. IR referrals increased (P = 0.02) and included higher co-morbidities (P = 0.005) and more PICU patients (P = 0.05). Mean doses per day increased from 1.5 to 1.9 (P < 0.001), twice-daily dose days increased from 38% to 79% (P < 0.001) and median pleural therapy days decreased from 3.5 days to 2.5 days (P = 0.001). No IR patients needed surgical intervention. No statistical differences were observed for gender/age/weight, US grade, need for a second IR procedure or length of stay. US grade correlated with greater positive cultures, need for chest CT/second IR procedure, and pleural therapy days.

CONCLUSION

Interventional radiology physician standardization improved on a clinical pathway for fibrinolysis of parapneumonic effusion. Despite higher patient complexity, pleural therapy duration decreased. There were no chest tube failures needing surgical drainage.

Modes of Failure in Venous Thromboembolism Prophylaxis

Venous thromboembolism (VTE) is associated with potentially preventable in-hospital morbidity and mortality. Although evidence-based guidelines are widely available, their application in clinical practice varies markedly. VTE prophylaxis involves a multistep dynamic process that can fail at various points during hospital stay. Our aim was to identify defects in VTE prophylaxis. Upon admission, our patients undergo VTE risk stratification and orders for prophylaxis are entered. All patients that fulfill the criteria for the Patient Safety Indicator (PSI)-12, as defined by the Agency for Healthcare Research and Quality, are prospectively entered in a database. From a review of 138 PSI-12 patients, only 21 had correct risk stratification and appropriate chemoprophylaxis during their hospital stay; 70 had been incorrectly stratified, with 28 of these patients receiving incorrect prophylaxis due to incorrect stratification, thus delaying the correct administration of chemoprophylaxis for >24 h. Inadequate application of mechanical prophylaxis was noted in 114 patients. VTE prophylaxis relies on correct risk stratification, ordering appropriate pharmacomechanical measures and, finally, the delivery of this treatment throughout the hospital stay. A large percentage of patients who had a thromboembolic complication received inadequate prophylaxis. This study identifies potential areas for intervention to improve VTE prophylaxis.

Stratifying fibrinolytic dosing in pediatric parapneumonic effusion based on ultrasound grade correlation

BACKGROUND

Complicated pleural effusion prolongs the hospital course of pneumonia. Chest tube placement with instillation of fibrinolytic medication allows efficient drain output and decreases hospital stay.

OBJECTIVE

To evaluate experience with lower fibrinolytic dose for parapneumonic effusions and to assess potential dose stratification based on a simple ultrasound grading system.

MATERIALS AND METHODS

We retrospectively reviewed the medical record to identify children and young adults who received fibrinolytic therapy for parapneumonic effusion and had chest tube placement by an interventional radiology service at a single children's hospital. We assessed tissue plasminogen activator (tPA) dosing and treatment duration, as well as the need for a second pleural procedure or surgical drainage. Diagnostic US images were classified as showing less than 50% pleural echogenicity (grade 1) or greater than 50% pleural echogenicity (grade 2) and were correlated with clinical parameters.

RESULTS

Of 32 patients with parapneumonic effusion, all except one received at least some 1-mg tPA doses. Dosing was solely 1-mg tPA in 81% of subjects; 19% of subjects also received 2-mg tPA doses. Mean fibrinolytic duration was 3.1 days for grade 1 effusions compared to 5.4 days for grade 2 effusions. A second pleural procedure was required in 15.6% of children. Pleural drainage with fibrinolytic therapy was successful in 97%; only one child required surgical drainage. Grade 2 US differed significantly from grade 1 US, with grade 2 occurring in younger patients (P < 0.0001), smaller patients (P < 0.0001), those needing a second procedure (P = 0.001), those with positive pleural culture or polymerase chain reaction test (P = 0.006), and those with longer treatment duration (P = 0.03).

CONCLUSION

A lower 1-mg dosing regimen of tissue plasminogen activator was effective in all children with less complex (grade 1 US imaging) parapneumonic effusions. Grade 2 US images correlated with younger and smaller children, presence of a pleural organism, and longer or more complicated chest tube duration.

Compared with feeding infants breast milk or cow-milk formula, soy formula feeding does not affect subsequent reproductive organ size at 5 years of age

BACKGROUND

Literature reports suggest that phytochemicals, such as isoflavones found in soybeans, impair reproductive function in animals and raise the possibility that consuming soy infant formula could alter hormonally sensitive organ development in children.

OBJECTIVE

This study compared reproductive organs volumes and structural characteristics in children at age 5 y who were enrolled in the Beginnings study long-term cohort.

METHODS

Breast bud, uterus, ovaries, prostate, and testes volumes and characteristics were assessed by ultrasonography in 101 children (50 boys and 51 girls) aged 5 y who were breastfed (n = 35) or fed cow-milk formula (n = 32) or soy formula (n = 34) as infants. Analyses were adjusted for race, gestational age, and birth weight.

RESULTS

Among girls, no significant differences were found in breast bud, ovarian, or uterine volumes; counts of ovaries with cysts; ovarian cysts numbers; ovarian cyst size; and uterine shape between the diet groups. Among boys, no significant differences were found in breast bud, testes, or prostate volumes or structural characteristics between the diet groups.

CONCLUSIONS

In this cohort, no early infant feeding effects were found on reproductive organs volumes and structural characteristics in children age 5 y. The follow-up of these children through puberty is planned and should help delineate potential early infant feeding effect on reproductive function later in life.

Are the Peer Assessment Rating Index and the Index of Treatment Complexity, Outcome, and Need suitable measures for orthognathic outcomes?

The aim of this study was to determine which of two occlusal indices were the most appropriate for use in the assessment of orthognathic outcome. The indices used were the Peer Assessment Rating (PAR) Index and the Index of Treatment Complexity, Outcome, and Need (ICON). These indices were validated against the subjective assessments of treatment outcome and treatment improvement obtained from a panel of experienced orthodontic consultants. For the subjective assessment, intraexaminer agreement for ranking treatment outcome, from patient study models (30 models), was good. Interexaminer agreement for ranking treatment outcome, in the same way, was good or moderate. Intraexaminer agreement for ranking treatment improvement (30 start and finish pairs of models) was very good or good. Interexaminer agreement for ranking treatment improvement ranged from good to fair. All the patient study models were scored using PAR and ICON. The level of correlation between PAR and ICON scores of treatment outcome and the subjective ranking of treatment outcome was significant (P < 0.001). The level of correlation between PAR and ICON scores of treatment improvement and the subjective ranking of treatment improvement was also significant (P < 0.001). It is concluded that both PAR and ICON are suitable indices for assessing the clinical outcome of combined orthodontic treatment and orthognathic surgery.

Predicting the sites of metastases from lung cancer using molecular biologic markers

BACKGROUND

The use of molecular markers in staging non-small cell lung cancer (NSCLC) has been supported in retrospective prognostic models but has not been evaluated in predicting sites of metastases.

METHODS

Pathologic specimens were collected from 202 patients after complete resection for stage I NSCLC, who were subsequently found to have no metastases at 5 years (n = 108), isolated brain metastases (n = 25), or other distant metastases (n = 69). A panel of eight molecular markers of metastatic potential was chosen for immunohistochemical analysis of the tumor: p53, erbB2, angiogenesis factor viii, EphA2, E-cadherin, urokinase plasminogen activator (UPA), UPA receptor, and plasminogen activator inhibitor.

RESULTS

Patients with isolated brain relapse had significantly higher expression of p53 (p = 0.02) and UPA (p = 0.002). The quantitative expression of E-cadherin was used to predict the site of metastases using recursive partitioning: 0 of 92 patients with E-cadherin expression of 0, 1, or 2 developed isolated cerebral metastases; 0 of 33 patients with E-cadherin expression of 3 with UPA of 1 or 2 and ErbB2 of 0 developed brain metastases. Of the remaining patients at risk (UPA = 3), the risk of isolated cerebral metastases was 21 of 57 patients (37%).

CONCLUSIONS

This study demonstrates that molecular markers may predict the site of relapse in early stage NSCLC. If validated in an ongoing prospective study, these results could be used to select patients with isolated brain metastases for adjuvant therapy, such as prophylactic cranial irradiation.

Tumor marker expression is predictive of survival in patients with esophageal cancer

BACKGROUND

This study was designed to determine the prognostic value of immunohistochemical tumor marker expression in a population of patients with node-negative esophageal cancer treated with complete resection alone.

METHODS

Resection specimens were collected from 61 patients with node-negative T1 (n = 31), T2 (n = 14), and T3 (n = 16) esophageal cancer. A panel of 10 tumor markers was chosen for immunohistochemical analysis, based on associations with differing oncologic mechanisms: apoptosis (p53), growth regulation (transforming growth factor-alpha, epidermal growth factor receptor, and Her2-neu), angiogenesis (factor VIII), metastatic potential (CD44), platinum resistance (p-glycoprotein and metallothionein), 5-fluorouracil resistance (thymidylate synthetase), and carcinogenic detoxification (glutathione S-transferase-pi).

RESULTS

Complete resection was performed in all patients (44 adenocarcinoma, 17 squamous cell carcinoma), with no operative deaths. Multivariable analysis demonstrated a significant relationship between cancer-specific death and the following variables: low-level P-gp expression (p = 0.004), high-level expression of p53 (p = 0.04), and low-level expression of transforming growth factor-alpha (p = 0.03). In addition, the number of involved tumor markers present was strongly predictive of negative outcome (p = 0.0001).

CONCLUSIONS

This study supports the prognostic value of immunohistochemical tumor markers, specifically the expression pattern of P-gp, p53, and transforming growth factor-alpha, in patients with esophageal carcinoma treated with complete resection alone.

Correlation of FDG-PET imaging with Glut-1 and Glut-3 expression in early-stage non-small cell lung cancer

PURPOSE

To correlate FDG activity on PET with the expression of glucose transporter proteins Glut-1 and Glut-3 in patients with early stage non-small cell lung cancer (NSCLC).

METHODS

Over a 5 year period, all patients with a PET scan and clinical stage I NSCLC underwent an immunohistochemical analysis of their tumor for Glut-1 and Glut-3 expression. The amount of FDG uptake in the primary lesion was measured by a standardized uptake ratio (SUR) and correlated with immunohistochemical results.

RESULTS

Seventy-three patients with a mean age of 66 years had clinical stage I disease. The final pathologic stage showed 64 patients with stage IA/B disease, eight with stage IIA disease, and one patient with pathologic stage IIIA (T1N2) disease. Glut-1 transporter expression was significantly higher than Glut-3 (P<0.0001), and although there was some association between the SUR and Glut-1 (P=0.085) and SUR and Glut-3 (P=0.074) expression, this did not reach statistical significance.

CONCLUSIONS

Glut-1 and Glut-3 transporter expression did not demonstrate a statistically significant correlation with FDG uptake in potentially resectable lung cancer. It appears that these transporters alone do not affect the variation in FDG activity in early stage NSCLC.

Comparison of methods of measuring HER-2 in metastatic breast cancer patients treated with high-dose chemotherapy

PURPOSE

HER-2 is overexpressed in 20% to 30% of human breast cancer and is associated with poor outcome. Studies suggest an association between HER-2 overexpression and resistance to alkylating agents. To further evaluate this relationship, we assessed the interaction of HER-2, measured by different methods, and outcome after dose intensification with alkylating agents in metastatic breast cancer.

PATIENTS AND METHODS

From 1988 to 1995 at Duke University, 425 patients with metastatic breast cancer were enrolled in a study of high-dose alkylating agents (HDC) with autologous cellular support after doxorubicin-based therapy (AFM). HER-2 was measured in serum for shed extracellular domain (ECD) and in tissue by immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH).

RESULTS

HER-2 ECD was positive in 29% (19 of 65) of patients pre-AFM and in 11.7% (34 of 290) pre-HDC. Higher pre-AFM and higher pre-HDC HER-2 ECD predicted worse overall survival (P =.045 and P =.0096, respectively). HER-2 overexpression by IHC and FISH showed no correlation with worse disease-free survival or overall survival. FISH and ECD were highly specific for IHC (97.3% and 97.7% respectively). However, ECD had a low sensitivity for IHC-only 22% of patients with HER-2 in the primary tumor shed ECD into the serum.

CONCLUSION

These data suggest that the method of measuring HER-2 is important in predicting clinical outcome. HER2 ECD may identify a poor prognosis subgroup of HER-2-positive tumors. Lack of association of HER2 by IHC/FISH with worse outcome suggests that therapy with AFM and/or HDC therapy may be able to overcome the effect of this prognostic factor or it may not be a prognostic factor in this setting.

The prognostic value of molecular marker analysis in patients treated with trimodality therapy for esophageal cancer

The purpose of this study was to define the prognostic value of a group of molecular tumor markers in a well-staged population of patients treated with trimodality therapy for esophageal cancer. The original pretreatment paraffin-embedded endoscopic esophageal tumor biopsy material was obtained from 118 patients treated with concurrent cisplatin + 5-fluorouracil (5-FU) + 45 Gy radiation followed by resection from 1986 until 1997 at the Duke University Comprehensive Cancer Center. Three markers of possible platinum chemotherapy association [metallothionein (MT), glutathione S-transferase-pi (GST-pi), P-glycoprotein (P-gp or multidrug resistance)] and one marker of possible 5-FU association [thymidylate synthase (TS)] were measured using immunohistochemistry. The median cancer-free survival was 25.0 months, with a significantly improved survival for the 38 patients who had a complete response (P < 0.001). High-level expression of GST-pi, P-gp, and TS were associated with a decreased survival. MT was not significant in this population. Multivariate analysis identified high-level expression in two of the platinum markers (GST-pi and P-gp) and the 5-FU marker TS as independent predictors of early recurrence and death. In conclusion, this investigation measured three possible markers associated with platinum and one possible marker associated with 5-FU in a cohort of esophageal cancer patients. Independent prognostic significance was observed, which suggests that it may be possible to predict which patients may benefit most from trimodality therapy. These data need to be reproduced in a prospective investigation.

Hypermethylated APC DNA in plasma and prognosis of patients with esophageal adenocarcinoma

BACKGROUND

The adenomatous polyposis coli (APC) locus on chromosome 5q21-22 shows frequent loss of heterozygosity (LOH) in esophageal carcinomas. However, the prevalence of truncating mutations in the APC gene in esophageal carcinomas is low. Because hypermethylation of promoter regions is known to affect several other tumor suppressor genes, we investigated whether the APC promoter region is hypermethylated in esophageal cancer patients and whether this abnormality could serve as a prognostic plasma biomarker.

METHODS

We assayed DNA from tumor tissue and matched plasma from esophageal cancer patients for hypermethylation of the promoter region of the APC gene. We used the maximal chi-square statistic to identify a discriminatory cutoff value for hypermethylated APC DNA levels in plasma and used bootstrap-like simulations to determine the P: value to test for the strength of this association. This cutoff value was used to generate Kaplan-Meier survival curves. All P values were based on two-sided tests.

RESULTS

Hypermethylation of the promoter region of the APC gene occurred in abnormal esophageal tissue in 48 (92%) of 52 patients with esophageal adenocarcinoma, in 16 (50%) of 32 patients with esophageal squamous cell carcinoma, and in 17 (39.5%) of 43 patients with Barrett's metaplasia but not in matching normal esophageal tissues. Hypermethylated APC DNA was observed in the plasma of 13 (25%) of 52 adenocarcinoma patients and in two (6.3%) of 32 squamous carcinoma patients. High plasma levels of methylated APC DNA were statistically significantly associated with reduced patient survival (P =.016).

CONCLUSION

The APC promoter region was hypermethylated in tumors of the majority of patients with primary esophageal adenocarcinomas. Levels of hypermethylated APC gene DNA in the plasma may be a useful biomarker of biologically aggressive disease in esophageal adenocarcinoma patients and should be evaluated as a potential biomarker in additional tumor types.

Molecular biologic substaging of stage I lung cancer according to gender and histology

BACKGROUND

This study is designed to assess molecular biologic substaging according to gender and histology in patients with stage I non-small cell lung cancer (NSCLC).

METHODS

Pathologic specimens were collected from 408 consecutive patients after complete resection for stage I NSCLC, with follow-up of at least 5 years. A panel of nine molecular markers was chosen for immunohistochemical analysis of the tumor: recessive oncogenes p53 and bcl-2, the protooncogene erbB-2, KI-67 proliferation index, retinoblastoma oncogene (Rb), epidermal growth factor receptor (EGFr), angiogenesis factor viii, sialyl-Tn antigen (STN), and CD-44. Cox proportional hazards regression analysis was used to construct a risk model for cancer-specific survival according to marker status, gender, and histologic subtype.

RESULTS

Among men, the only molecular marker associated with decreased cancer-specific survival is erbB-2; among women, there are four markers: p53, Rb, CD-44, and factor viii. Among patients with squamous cell carcinoma, the only molecular marker associated with decreased cancer-specific survival is erbB-2; among patients with adenocarcinoma (AC), there are three markers: p53, CD-44, and factor viii. Multivariable analysis of interactions among molecular markers, gender, and histology demonstrates two important relationships (hazard ratio): p53+/women (2.269) and CD-44+/AC (2.266).

CONCLUSIONS

Molecular biologic substaging of patients with stage I NSCLC demonstrates differential cancer-specific survival according to marker expression, gender, and histologic subtype.

A biologic risk model for stage I lung cancer: immunohistochemical analysis of 408 patients with the use of ten molecular markers

OBJECTIVE

The standard treatment of patients with stage I non-small cell lung cancer is resection of the primary tumor; however, the recurrence rate is 28% to 45%. This study evaluates a panel of molecular markers in a large population of patients with stage I non-small cell lung cancer to determine the prognostic value of each marker and to create a biologic risk model.

METHODS

Pathologic specimens were collected from 408 consecutive patients after complete resection for stage I non-small cell lung cancer at a single institution, with follow-up of at least 5 years. A panel of 10 molecular markers was chosen for immunohistochemical analysis of the primary tumor on the basis of differing oncogenic mechanisms. Local tumor expansion requires growth regulating proteins (epidermal growth factor receptor, the protooncogene erb-b2); apoptosis proteins (p53, bcl-2); and cell cycle regulating proteins (retinoblastoma recessive oncogene, KI-67). Local tumor invasion requires angiogenesis (factor viii). The development of distant metastases involves the expression of adhesion proteins (CD-44, sialyl-Tn, blood group A). Cox proportional hazards regression analysis was used to construct an independent risk model for cancer recurrence and death.

RESULTS

Multivariable analysis demonstrated significantly elevated risk for the following molecular markers: p53 (hazard ratio, 1.68; P =.004); factor viii (hazard ratio, 1.47 P =. 033); erb-b2 (hazard ratio, 1.43; P =.044); CD-44 (hazard ratio, 1. 40; P =.050); and retinoblastoma recessive oncogene (hazard ratio, 0. 747; P =.084).

CONCLUSIONS

Five molecular markers were associated with the risk of recurrence and death, representing independent metastatic pathways: apoptosis (p53), angiogenesis (factor viii), growth regulation (erb-b2), adhesion (CD-44), and cell cycle regulation (retinoblastoma recessive oncogene). This study demonstrates the validity of this molecular biologic risk model in patients with stage I non- small cell lung cancer.

Neutrophil mediated microvascular injury in acute, experimental compartment syndrome

The purpose of this study was to determine the contribution of neutrophils and tissue xanthine oxidase to the skeletal muscle microvascular dysfunction in an ex vivo model of acute compartment syndrome. Adult dogs were rendered neutropenic or depleted of tissue xanthine oxidase before gracilis muscle isolation. Compared with continuously perfused, nonischemic muscles, acute, experimental compartment syndrome resulted in a dramatic increase in microvascular permeability, muscle neutrophil content, and muscle vascular resistance. Neutropenia prevented, whereas xanthine oxidase depletion had no effect on, the microvascular dysfunction and muscle neutrophil infiltration elicited by experimental compartment syndrome. These results suggest that neutrophils contribute to the microvascular dysfunction and blood flow distribution abnormalities elicited by acute, experimental compartment syndrome.

A cephalometric evaluation of patients presenting with persistent digit sucking habits

Persistent digit sucking habits are an important aetiological factor for malocclusion, and patients with persistent habits are frequently referred for orthodontic treatment. The present study investigated the effects of digit sucking habits on vertical and anteroposterior dentofacial characteristics by employing a cephalometric analysis of patients with persistent digit sucking habits compared with patients without such habits. Significant differences were seen in maxillary prognathism, relative prognathism, maxillary incisor angulation, interincisal angle, maxillary length and maxillary plane angulation. No significant differences were observed for mandibular prognathism or length, maxillary mandibular plane angle, cranial base measurements nor any measurement of facial height. The digit sucking group were also found to have a larger variation of lower incisor angulation than the controls, although no significant difference in the mean value for this variable was detected. It is concluded that persistent digit sucking may cause largely dentoalveolar change, together with some minor effects on the skeletal pattern.

Belle Maudsley Lecture. Digits, dummies and malocclusions

When considering the aetiology of malocclusion in general, factors are often cited as having a genetic basis or an environmental basis. An individual malocclusion is likely to be a result of the variable effects of multiple environmental influences, upon an equally variable genetic predisposition. One of the most tangible 'environmental' factors is that of sucking habits involving digits or dummies. This review considers the nature of these habits, their effects on the developing dentition and methods used to combat the problem.

p53 overexpression in formalin-fixed, paraffin-embedded tissue detected by immunohistochemistry

Mutation and overexpression of the p53 gene have been noted in a wide range of human cancers and are thought to play a role in malignant transformation. Previously, immunohistochemical detection of p53 has been possible only in fresh-frozen tissues. We examined p53 expression in paraffin-embedded tissues from 50 epithelial ovarian cancers and 25 primary breast cancers with a modified immunohistochemical (IHC) technique developed in this laboratory, using monoclonal antibody (MAb) PAb1801. The 75 cases were selected from a group of patients in whom the expression levels had already been assessed in a fresh-tissue IHC assay. An identical staining reactivity was observed in both formalin-fixed, paraffin-embedded tissue and fresh-frozen tissue in 48 of 50 (96%) epithelial ovarian cancers and in 23 of 25 (92%) primary breast cancers. Immunodetection of p53 in paraffin-embedded tissue blocks will be a useful alternative to the standard fresh-tissue assay and can accurately reflect the level of p53 expression in human tumors.

Risk factors for complications following pediatric epikeratoplasty

We studied the prevalence and types of complications that occurred in children treated with epikeratoplasty to identify risk factors. A review of the clinical records of 88 consecutive patients (106 eyes; 114 procedures) revealed that no complications occurred in 58 grafts (54%). Refractive complications (refractive error greater than 3.00 diopters spherical equivalent from emmetropia or astigmatism greater than 3.00 diopters) occurred in 30 eyes (28%). Medical complications occurred in 22 eyes (19%); these included epithelial defects (14 grafts), interface opacities (six grafts), graft vascularization (eight grafts), graft infection (two grafts), graft necrosis (five grafts), graft haziness (four grafts) or opacification (11 grafts), and graft dehiscence (three grafts). Eleven grafts (10%) were removed and five eyes received new grafts. Epikeratoplasty in children will be more successful if risk factors such as patient age less than one year, microcornea, corneal endothelial cell dysfunction, mental retardation, and combining the procedure with cataract surgery are avoided.

In vitro transfer of rabbit corneal epithelium from carriers to denuded corneas or cryolathed lenticules

Rabbit corneal basal epithelial cells seeded onto fixed gelatin membranes or commercial collagen shields formed 3 to 5 cell layers after 1 to 3 weeks of culture at 35 degrees C in nutrient medium. The cells grew better, by comparison, in the collagen shields and eventually formed a multilayered tissue that resembled the stratified morphology of native epithelium. Transfer of multilayered cultures (prior to stratification) from these carriers in vitro to denuded corneal buttons or cryolathed lenticules resulted in complete adhesion of the grafted tissue to the underlying recipient buttons after 24- to 48-h incubations. After mechanically removing the carriers, most of the epithelial cells remained attached to the stromal surface. Our experimental findings indicated that both kinds of carriers may be suitable for epithelial transplantation, although the collagen shield is probably superior because of its better biocompatibility and physical characteristics.

Reassembly of the corneal epithelial adhesion structures following human epikeratoplasty

Ten epikeratoplasty lenticules removed after surgery were obtained for immunohistochemical and electron microscopic analysis to determine the pattern of re-formation of corneal epithelial adhesion structures. Antibodies to laminin and type VII collagen were used to determine the presence of basement membrane and anchoring fibrils, respectively. Electron micrographs were used to determine the percentage of basal cell membrane occupied by hemidesmosomes, the area of basal lamina per 100 microns of basal cell membrane, and the average maximum depth of penetration of anchoring fibrils into the stoma. Nine normal corneas served as controls. Compared with normal corneas (24.5% of basal cell membrane occupied by hemidesmosomes; 32.0 microns 2 basal lamina per 100 microns of basal cell membrane), lenticules removed for optical reasons had near-normal hemidemosomes as early as 10 weeks following surgery (mean, 20.3%). The area of basement membrane was reduced (16 microns 2 basal lamina per 100 microns of basement cell membrane). During the course of 2 to 3 years, irregularities and duplications of the basement membrane were noted. Compared with normal corneas, the two lenticules removed for persistent defects had a marked reduction of hemidesmosomes and basement membrane present under epithelium at 3 and 4 weeks (9.6% of basal cell membrane occupied by hemidesmosomes and 13.6 microns 2 basal lamina per 100 microns of basal cell membrane, and 5.4% of basal cell membrane occupied by hemidesmosomes and 7.2 microns 2 basal lamina per 100 microns of basal cell membrane, respectively.

In vitro penetration of human corneal epithelium by Acanthamoeba castellanii: a scanning and transmission electron microscopy study

Human corneal buttons were exposed to Acanthamoeba castellanii trophozoites and cysts for 12 hours at 35 degrees C. The buttons examined by light microscopy and scanning and transmission electron microscopy had severe epithelial ulceration and penetration by trophozoites. Observations on trophozoites below the surface suggest that penetration is accomplished by both secreted cytolytic enzymes and phagocytosis. It is likely that the secretion of one or more enzymes constitutes the initial step in preparing the host tissue for endocytosis or that the secretory mechanism is used by the amebas to move through the outer squamous layer to the basement epithelium where phagocytosis occurs. Based on this study and a previous study, it appears that entry into the cornea is a two-step process involving adherence and penetration by trophozoites.

In vitro intercellular adherence of Acanthamoeba castellanii: a scanning and transmission electron microscopy study

Human corneal buttons were exposed to trophozoites and cysts of Acanthamoeba castellanii for 12 hours. Examination of the buttons by scanning electron microscopy showed numerous trophozoites on the surface of the epithelium. Trophozoites examined by transmission electron microscopy had limited regions of attachment to the epithelium but extensive regions of attachment to each other. Attachment regions were characterized as plaque-like maculae of an incomplete desmosome junction. Firm attachment mechanisms may explain how penetration of the human cornea occurs.

The effect of currently available contact lens disinfection systems on Acanthamoeba castellanii and Acanthamoeba polyphaga

Contact lens disinfection systems were evaluated for their effectiveness in killing Acanthamoeba castellanii and Acanthamoeba polyphaga trophozoites and cysts. Amoebae were inoculated into commercially available contact lens cleaning and soaking solutions. At intervals varying from 30 minutes to 24 hours, solutions were filtered. The filters were removed and cultured for Acanthamoeba organisms. Striking differences were observed in the abilities of the different disinfecting solutions to kill the organisms. Solutions containing chlorhexidine were effective at very short exposure times. Solutions containing benzalkonium chloride required slightly longer exposure times but were faster than solutions containing only thimerosal. Solutions containing sorbate, polyaminopropyl biguanide, or polyquaternium-1 were not effective at killing Acanthamoeba organisms in the time allotted for the experiment. Solutions containing hydrogen peroxide were quite effective if the agent was not prematurely catalyzed. A. polyphaga generally required longer exposure to disinfectants than did A. castellanii for complete inhibition to occur.

Acanthamoeba keratitis and contact lens wear: the patient is at fault

The avoidance of nonsterile solutions is important to curtailing Acanthamoeba keratitis, a serious infection that has been found to occur with all types of contact lens (CL) wear. Increased patient education, revised recommendations regarding the use of tap and distilled water, and improved disinfecting systems are vital to preventing infection. These precautions are particularly important since it appears that Acanthamoeba, unlike Pseudomonas, may not require an epithelial defect to establish corneal infection and, once in the cornea, may not respond to drug therapy or surgical extirpation. Unfortunately, many patients receive poor lens care instructions or cannot be relied on to follow appropriate routines. Finding a foolproof means of lens disinfection for them is critical. Recently, several disinfection systems were tested against Acanthamoeba castellanii and Acanthamoeba polyphaga cysts and trophozoites to see which might prove most effective. Effective systems included heat disinfection at 70 to 80 degrees C for 10 min, 3% hydrogen peroxide for 2-3 h, 0.001% thimerosal with edetate for 4 h, 0.005% benzalkonium chloride with edetate and reagent for 4 h, and either 0.001% chlorhexidine for 4 h or 0.004% chlorhexidine for 1 h. Thus, for patients who are careless or persist in using nonsterile rinsing solutions, it appears that at least some methods of disinfection will help prevent Acanthamoeba infection.

Acanthamoeba keratitis associated with contact lenses: six consecutive cases of successful management

We examined and treated six patients with acanthamoeba keratitis associated with contact lens wear from 1981 to 1988. Five patients were treated with topical neomycin-polymyxin B-gramicidin (Neosporin) and propamidine isethionate (Brolene) drops. The patients were followed up for an average of 32 months (range 16-75 months). Two patients underwent penetrating keratoplasty at 22 and 26 months after the onset of symptoms and have maintained clear grafts with no evidence of recurrence. In four patients corneal infiltrates cleared on topical medication. All six patients have 6/6 best corrected vision. Early diagnosis and medical treatment alone can result in resolution of corneal infiltrates due to acanthamoebae. With this initial therapy we have had no treatment failures.

Acanthamoeba keratitis. A growing problem in soft and hard contact lens wearers

Eleven contact lens-wearing patients presented with Acanthamoeba keratitis. Eight cases were culture- and/or stain-positive for Acanthamoeba and three were presumed to have Acanthamoeba keratitis based on history and clinical findings. Six wore daily wear soft contact lenses, two wore extended-wear soft contact lenses, one wore a polymethylmethacrylate hard contact lens, one wore a gas-permeable hard contact lens, and one wore a Saturn lens (combined hard and soft lens). Four patients used distilled water and salt tablet saline, three used tap water and salt tablet saline, two used tap water rinse, two used well water rinse or storage, and one used intravenous (IV) saline. It is apparent that all contact lens wearers are at some risk for Acanthamoeba keratitis developing if proper contact lens care is not maintained. Of great concern is the inability of most current chemical sterilization methods to kill the organism if the lens becomes contaminated. Heat disinfection will kill Acanthamoeba trophozoites and cysts but the lens must not be placed into contaminated solutions afterward. Prevention is very important because medical and surgical treatment failures are frequent. Eye care practitioners who fit contact lenses are advised to use heat disinfection for low-water content stock soft contact lenses, and to use hydrogen peroxide without a catalyst for a minimum of 6 hours for all other stock lens fitting sets, to specifically inquire about contact lens care habits used by their patients, and to discourage the use of homemade saline solutions.

The rapid detection of Acanthamoeba in paraffin-embedded sections of corneal tissue with calcofluor white

Acanthamoeba keratitis is a difficult diagnosis to make with routine stains and cultures. Gram's, Giemsa, and hematoxylin-eosin stains do not differentially stain Acanthamoeba, making the detection of organisms difficult. Trophozoite and cyst forms in paraffin-embedded corneal tissue sections can be rapidly and differentially stained with calcofluor white. Under the fluorescence microscope, the trophozoites are bright red-orange, and cyst cell walls fluoresce bright apple-green with red-orange cytoplasm. Retrospective identification can be made by destaining hematoxylin-eosin-stained sections. Digesting background corneal tissue with trypsin or collagenase and hyaluronidase solutions helps to more readily identify trophozoites.

Corneal biopsy in chronic keratitis

Failure to identify the causative agent makes the treatment of chronic keratitis difficult. Inability to obtain a definitive diagnosis may be related to the depth of the pathogen within the cornea, partial or inappropriate treatment that interferes with diagnostic cultures, or fastidious growth characteristics of the organism in culture. Biopsy by lamellar keratectomy provides sufficient tissue for culture and for histopathologic evaluation by histochemistry, immunohistopathology, and, if necessary, electron microscopy. Consultation with an ophthalmic pathologist before biopsy can prevent inappropriate handling of the specimen, which may preclude essential diagnostic procedures. Many studies can be done within 24 hours of biopsy, often permitting rapid identification of the pathogen and prompt institution of appropriate therapy.

Fate of lyophilized xenogeneic corneal lenticules in intrastromal implantation and epikeratophakia

The antigenicity of intrastromal and epikeratophakia xenografts of lyophilized corneal tissue was evaluated in nonimmune and immune recipients. Lyophilized feline lenticules were implanted into intrastromal pockets in unsensitized rabbits and rabbits sensitized to the donor cat. In both cases, the grafts remained clear. Sensitized rabbits with clear intrastromal grafts received fresh tissue penetrating keratoplasty grafts from the same donor cat, placed adjacent to the intrastromal grafts. The fresh tissue penetrating keratoplasty grafts were rapidly rejected, while the lyophilized intrastromal grafts remained clear. Cats sensitized to rabbits received lyophilized and rehydrated epikeratophakia grafts shaped from rabbit cornea; these lyophilized grafts also remained clear for the 3-month period of the study. The results indicate that lyophilized and rehydrated corneal stroma, which is devoid of living cells, is not antigenic and is not subjected to immunologic attack, even in cases where the donor and host are of different species and the host has been previously immunized to the donor.

Chronic keratitis caused by Mycobacterium gordonae

We treated a patient with chronic keratitis caused by Mycobacterium gordonae, a slow-growing, atypical mycobacterium not previously reported as a cause of corneal infection. The patient was a 34-year-old man who was hit in the eye with some vegetable matter while gardening. Initially, the patient was treated for a presumptive diagnosis of herpes simplex keratitis. Because of progression of the keratitis, a lamellar corneal biopsy was performed 3 1/2 years later and the definitive diagnosis was made. Subsequently, a penetrating keratoplasty was performed and the patient's condition then remained stable. The diagnosis of atypical mycobacterium should be considered in a patient with an indolent corneal ulcer. Lamellar corneal biopsy may disclose the pathogen when the infection is deep, chronic, or partially treated.

Radial keratoneuritis as a presenting sign in Acanthamoeba keratitis

Three myopic patients who wore soft contact lenses developed unilateral Acanthamoeba keratitis that presented with unusual infiltrates that appeared to be located along the corneal nerves. These infiltrates were found in the midstroma, beginning paracentrally, and extending to the limbus in a radial pattern. The epithelium overlying these infiltrates was intact. In two patients, the central epithelium had a stippled, almost dendritiform appearance leading to the misdiagnosis of herpes simplex keratitis. Cultures from corneal scrapings of two patients and cultures of a corneal biopsy from one patient, which included an area of presumed neural involvement, grew Acanthamoebae. All three patients used homemade saline solutions (salt tablets dissolved in distilled water). In one patient, Acanthamoebae were found in the contact lens case solution. In our recent experience, Acanthamoebae have also been found in the distilled water bottle and the saline solution made from distilled water and salt tablets in two additional patients with A. keratitis. Distilled water, which is not sterile, has proven to be one potentially avoidable source of A. keratitis in contact lens wearers.

Floppy eyelid syndrome. Management including surgery

Six overweight patients, five men and the first woman to be reported, are described with floppy eyelid syndrome. Five patients had bilateral ocular involvement. Only two patients were free of other ocular surface problems. Concurrent diagnoses included blepharitis, keratoconjunctivitis sicca, lagophthalmos, medicamentosal conjunctivitis, molluscum contagiosum, and masquerade syndrome. Five patients responded to appropriate therapy, which included shielding the eyes during sleep. Three patients underwent a horizontal lid tightening procedure, which resulted in permanent correction of their floppy eyelids and resolution of their ocular signs and symptoms.

Acanthamoeba keratitis associated with soft contact lenses

Three patients (a 13-year-old girl, a 25-year-old man, and a 22-year-old woman) who used daily-wear soft contact lenses, sterilized with saline made from distilled water and salt tablets, developed Acanthamoeba keratitis. Acanthamoeba was cultured from the contact lens solution of one patient. This patient, in whom the diagnosis was made by corneal biopsy early in the clinical course, was successfully treated with topical neomycin-polymyxin, miconazole, and propamidine isethionate. The other two patients underwent penetrating keratoplasty. One of these patients, who received a graft early in the clinical course, developed a recurrence of disease in the graft, whereas the other, who received the graft 18 months after the initial symptoms, has maintained a clear corneal transplant with useful vision.

Mucus fishing syndrome

Twenty-five patients are described with a variety of external ocular diseases including keratoconjunctivitis sicca, blepharitis, and allergic conjunctivitis, who presented with persistence of symptoms of irritation, foreign body sensation, and apparent excessive mucus production, with mild conjunctival inflammation despite appropriate treatment of the underlying disease. All patients were found to have evidence of trauma to the conjunctival epithelium due to mechanical removal of the excess mucus from the surface of the globe or inferior cul-de-sac. The surface irritation created by the mechanical damage led to a further increase in mucus production, creating a cycle that we have termed mucus fishing syndrome. Cessation of this behavior coupled with ongoing therapy of the underlying disease led to resolution of signs and symptoms in all patients.

The spinal cord ventral root: an afferent pathway of the hind-limb pressor reflex in cats

1. In anaesthetized cats the sciatic nerve was cut and the central end was stimulated at a high frequency and voltage. This caused an increase in arterial blood pressure and a rise in heart rate. The pressure response was diminished by dorsal root section but not completely eliminated until ventral root section (L4-S3). The tachycardia response was abolished by dorsal root section alone. 2. In other cats capsaicin was injected intra-arterially into the hind limb, causing elevations in both blood pressure and heart rate. Similar to the sciatic nerve stimulation experiments, the pressor response was principally reduced by dorsal root section but was further significantly decreased by ventral root section (L1-S3). The rise in heart rate was prevented by dorsal root section alone. 3. It is concluded that, in cats, the afferent pathway of the pressor response to sciatic nerve stimulation and to hind-limb capsaicin injection are conducted principally in the dorsal roots but also to a small extent in the ventral roots of the spinal cord. Although the tachycardia response appears to be conducted only through the dorsal roots, it is possible that at lower resting heart rates and by stimulation of a large population of the unmyelinated skeletal muscle afferents, the ventral root is a functional pathway.