Vaginal Lactobacillus fatty acid response mechanisms reveal a novel strategy for bacterial vaginosis treatment

Bacterial vaginosis (BV), a common syndrome characterized by Lactobacillus-deficient vaginal microbiota, is associated with adverse health outcomes. BV often recurs after standard antibiotic therapy in part because antibiotics promote microbiota dominance by Lactobacillus iners instead of Lactobacillus crispatus, which has more beneficial health associations. Strategies to promote L. crispatus and inhibit L. iners are thus needed. We show that oleic acid (OA) and similar long-chain fatty acids simultaneously inhibit L. iners and enhance L. crispatus growth. These phenotypes require OA-inducible genes conserved in L. crispatus and related species, including an oleate hydratase (ohyA) and putative fatty acid efflux pump (farE). FarE mediates OA resistance, while OhyA is robustly active in the human vaginal microbiota and sequesters OA in a derivative form that only ohyA-harboring organisms can exploit. Finally, OA promotes L. crispatus dominance more effectively than antibiotics in an in vitro model of BV, suggesting a novel approach for treatment.

Sub-communities of the vaginal microbiota in pregnant and non-pregnant women

Diverse and non-Lactobacillus-dominated vaginal microbial communities are associated with adverse health outcomes such as preterm birth and the acquisition of sexually transmitted infections. Despite the importance of recognizing and understanding the key risk-associated features of these communities, their heterogeneous structure and properties remain ill-defined. Clustering approaches are commonly used to characterize vaginal communities, but they lack sensitivity and robustness in resolving substructures and revealing transitions between potential sub-communities. Here, we address this need with an approach based on mixed membership topic models. Using longitudinal data from cohorts of pregnant and non-pregnant study participants, we show that topic models more accurately describe sample composition, longitudinal changes, and better predict the loss of Lactobacillus dominance. We identify several non-Lactobacillus-dominated sub-communities common to both cohorts and independent of reproductive status. In non-pregnant individuals, we find that the menstrual cycle modulates transitions between and within sub-communities, as well as the concentrations of half of the cytokines and 18% of metabolites. Overall, our analyses based on mixed membership models reveal substructures of vaginal ecosystems which may have important clinical and biological associations.

Factors associated with hepatitis B and C among adults in Buea, Cameroon: A community-based cross-sectional study

INTRODUCTION

Viral hepatitis is a major cause of death in Africa. A paucity of community-based studies on the determinants of viral hepatitis in Africa impedes efforts to appropriately target prevention, screening, and treatment interventions. We assessed factors associated with hepatitis B virus (HBV) and hepatitis C virus (HCV) in a semi-urban health district in Cameroon.

METHODS

We conducted a community-based, cross-sectional study from 28 February to 15 May 2021 in the Buea Health District in Buea, Cameroon. We recruited a sample of consenting individuals aged over 15 years old. Participants were surveyed for factors associated with HBV/HCV and were screened for HBV surface antigen (HBsAg) and HCV antibody using rapid point-of-care tests. We performed univariable and multivariable logistic regression analyses to identify factors associated with HBsAg and HCV seropositivity.

RESULTS

We screened 1144 participants (66% female) with a median age of 30 years (IQR: 23-44). HBsAg prevalence was 5.7% (95%CI: 4.5-7.2%) and HCV seropositivity was 1.9% (95%CI: 1.3-2.9%). Three people (0.3%) were seropositive for both HBsAg and HCV antibody. Male sex (adjusted OR [aOR] = 2.31; 95%CI: 1.28-4.18) and a history of traditional operation or scarification (aOR = 2.87; 95%CI: 1.67-4.92) were associated with HBsAg. None of the assessed factors was significantly associated with HCV antibody.

CONCLUSION

Men and participants with a history of traditional operation and scarification had higher odds of HBsAg. We did not observe any associations with HCV seropositivity. Prevention and screening efforts among adults in this setting should prioritize men and those with a history of traditional operation and scarification.

Screening and characterization of vaginal fluid donations for vaginal microbiota transplantation

Bacterial vaginosis (BV), the overgrowth of diverse anaerobic bacteria in the vagina, is the most common cause of vaginal symptoms worldwide. BV frequently recurs after antibiotic therapy, and the best probiotic treatments only result in transient changes from BV-associated states to "optimal" communities dominated by a single species of Lactobacillus. Therefore, additional treatment strategies are needed to durably alter vaginal microbiota composition for patients with BV. Vaginal microbiota transplantation (VMT), the transfer of vaginal fluid from a healthy person with an optimal vaginal microbiota to a recipient with BV, has been proposed as one such alternative. However, VMT carries potential risks, necessitating strict safety precautions. Here, we present an FDA-approved donor screening protocol and detailed methodology for donation collection, storage, screening, and analysis of VMT material. We find that Lactobacillus viability is maintained for over six months in donated material stored at - 80 °C without glycerol or other cryoprotectants. We further show that species-specific quantitative PCR for L. crispatus and L. iners can be used as a rapid initial screening strategy to identify potential donors with optimal vaginal microbiomes. Together, this work lays the foundation for designing safe, reproducible trials of VMT as a treatment for BV.

Successful Treatment of Delayed Localized Necrotizing Inflammatory Myositis After Severe Acute Respiratory Syndrome Coronavirus 2 mRNA-1273 Vaccine: A Case Report

Reported adverse reactions to the mRNA-1273 vaccine (Spikevax, Moderna Inc) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) range from mild, local delayed cutaneous reactions to rarer, more serious reactions such as myocarditis. Here, we describe the presentation and successful treatment of delayed, localized necrotizing inflammatory myositis following a third dose of the mRNA-1273 SARS-CoV-2 vaccine. To our knowledge, this is the first report of biopsy-confirmed, delayed inflammatory myositis after administration of an mRNA-1273 SARS-CoV-2 vaccine booster.

Cysteine dependence of Lactobacillus iners is a potential therapeutic target for vaginal microbiota modulation

Vaginal microbiota composition affects many facets of reproductive health. Lactobacillus iners-dominated microbial communities are associated with poorer outcomes, including higher risk of bacterial vaginosis (BV), compared with vaginal microbiota rich in L. crispatus. Unfortunately, standard-of-care metronidazole therapy for BV typically results in dominance of L. iners, probably contributing to post-treatment relapse. Here we generate an L. iners isolate collection comprising 34 previously unreported isolates from 14 South African women with and without BV and 4 previously unreported isolates from 3 US women. We also report an associated genome catalogue comprising 1,218 vaginal Lactobacillus isolate genomes and metagenome-assembled genomes from >300 women across 4 continents. We show that, unlike L. crispatus, L. iners growth is dependent on L-cysteine in vitro and we trace this phenotype to the absence of canonical cysteine biosynthesis pathways and a restricted repertoire of cysteine-related transport mechanisms. We further show that cysteine concentrations in cervicovaginal lavage samples correlate with Lactobacillus abundance in vivo and that cystine uptake inhibitors selectively inhibit L. iners growth in vitro. Combining an inhibitor with metronidazole promotes L. crispatus dominance of defined BV-like communities in vitro by suppressing L. iners growth. Our findings enable a better understanding of L. iners biology and suggest candidate treatments to modulate the vaginal microbiota to improve reproductive health for women globally.

Antigen Presenting Cells Link the Female Genital Tract Microbiome to Mucosal Inflammation, With Hormonal Contraception as an Additional Modulator of Inflammatory Signatures

The microbiome of the female genital tract (FGT) is closely linked to reproductive health outcomes. Diverse, anaerobe-dominated communities with low Lactobacillus abundance are associated with a number of adverse reproductive outcomes, such as preterm birth, cervical dysplasia, and sexually transmitted infections (STIs), including HIV. Vaginal dysbiosis is associated with local mucosal inflammation, which likely serves as a biological mediator of poor reproductive outcomes. Yet the precise mechanisms of this FGT inflammation remain unclear. Studies in humans have been complicated by confounding demographic, behavioral, and clinical variables. Specifically, hormonal contraception is associated both with changes in the vaginal microbiome and with mucosal inflammation. In this study, we examined the transcriptional landscape of cervical cell populations in a cohort of South African women with differing vaginal microbial community types. We also investigate effects of reproductive hormones on the transcriptional profiles of cervical cells, focusing on the contraceptive depot medroxyprogesterone acetate (DMPA), the most common form of contraception in sub-Saharan Africa. We found that antigen presenting cells (APCs) are key mediators of microbiome associated FGT inflammation. We also found that DMPA is associated with significant transcriptional changes across multiple cell lineages, with some shared and some distinct pathways compared to the inflammatory signature seen with dysbiosis. These results highlight the importance of an integrated, systems-level approach to understanding host-microbe interactions, with an appreciation for important variables, such as reproductive hormones, in the complex system of the FGT mucosa.

Modeling the temporal dynamics of cervicovaginal microbiota identifies targets that may promote reproductive health

BACKGROUND

Cervicovaginal bacterial communities composed of diverse anaerobes with low Lactobacillus abundance are associated with poor reproductive outcomes such as preterm birth, infertility, cervicitis, and risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). Women in sub-Saharan Africa have a higher prevalence of these high-risk bacterial communities when compared to Western populations. However, the transition of cervicovaginal communities between high- and low-risk community states over time is not well described in African populations.

RESULTS

We profiled the bacterial composition of 316 cervicovaginal swabs collected at 3-month intervals from 88 healthy young Black South African women with a median follow-up of 9 months per participant and developed a Markov-based model of transition dynamics that accurately predicted bacterial composition within a broader cross-sectional cohort. We found that Lactobacillus iners-dominant, but not Lactobacillus crispatus-dominant, communities have a high probability of transitioning to high-risk states. Simulating clinical interventions by manipulating the underlying transition probabilities, our model predicts that the population prevalence of low-risk microbial communities could most effectively be increased by manipulating the movement between L. iners- and L. crispatus-dominant communities.

CONCLUSIONS

The Markov model we present here indicates that L. iners-dominant communities have a high probability of transitioning to higher-risk states. We additionally identify transitions to target to increase the prevalence of L. crispatus-dominant communities. These findings may help guide future intervention strategies targeted at reducing bacteria-associated adverse reproductive outcomes among women living in sub-Saharan Africa. Video Abstract.

Preventing Infectious Complications of Immunomodulation in COVID-19 in Foreign-Born Patients

Immunomodulating therapies for COVID-19 may carry risks of reactivating latent infections in foreign-born people. We conducted a rapid review of infection-related complications of immunomodulatory therapies for COVID-19. We convened a committee of specialists to formulate a screening and management strategy for latent infections in our setting. Dexamethasone, used in severe COVID-19, is associated with reactivation of latent tuberculosis, hepatitis B, and dissemination/hyperinfection of Strongyloides species and should prompt screening and/ or empiric treatment in appropriate epidemiologic contexts. Other immunomodulators used in COVID-19 may also increase risk, including interleukin-6 receptor antagonist (e.g., tocilizumab) and kinase inhibitors. People with specific risk factors should also be screened for HIV, Chagas disease, and endemic mycoses. Racial and ethnic minorities in North America, including foreign-born persons, who receive immunomodulating agents for COVID-19 may be at risk for reactivation of latent infections. We develop a screening and management pathway for such patients.

1207. Combining standard bacterial vaginosis treatment with cystine uptake inhibitors to block growth of Lactobacillus iners is a potential a target for shifting the cervicovaginal microbiota towards health-associated Lactobacillus crispatus-dominant communities

Background

Cervicovaginal microbiota domination by Lactobacillus crispatus is associated with beneficial health outcomes, whereas L. iners dominance has more adverse associations. However bacterial vaginosis (BV) treatment with metronidazole (MTZ) typically leads to domination by L. iners rather than L. crispatus. L. iners differs from other lactobacilli by its inability to grow in MRS media. We hypothesized that exploring this growth difference would identify targets for selective L. iners inhibition.

Methods

Bacteria were grown anaerobically. Nutrient uptake and metabolism were assessed using UPLC-MS/MS and isotopically labeled substrates. Bacterial genome annotation employed Prodigal, Roary, and EggNOG. Competition experiments with mock mixed communities were analyzed by 16S rRNA gene sequencing. We confirmed result generalizability using a diverse collection of South African and North American strains and genomes.

Results

Supplementing MRS broth with L-cysteine (Cys) or L-cystine permitted robust L. iners growth, while L. crispatus grew without Cys supplementation. Despite their different growth requirements, neither species could synthesize Cys via canonical pathways. Adding the cystine uptake inhibitors S-methyl-L-cysteine (SMC, Fig 1) or seleno-DL-cystine (SDLC) blocked growth of L. iners but not other lactobacilli, suggesting L. iners lacks mechanisms other lactobacilli use to exploit complex exogenous Cys sources. Notably, cydABCD, an operon with Cys/glutathione transport and redox homeostasis activities, is absent from L. iners but present in non-iners Lactobacillus species. Consistent with possible roles for cydABCD in explaining the observed phenotypes, (1) L. iners failed to take up exogenous glutathione and (2) supplementing MRS with reducing agents permitted L. iners growth, which could be blocked by SMC or SDLC. In growth competitions testing L. iners and L. crispatus within mock BV-like communities, SMC plus MTZ outperformed MTZ alone in promoting L. crispatus dominance (Figs 2&3).

Figure 1: S-methyl-L-cysteine (SMC) selectively blocks growth of L. iners but not other cervicovaginal Lactobacillus species in cysteine-supplemented MRS broth. Growth was measured by optical density and inhibition calculated relative to Cys-supplemented no-inhibitor control during exponential growth. Values displayed are median (+/- maximum/minimum) for 3 replicates from a single experiment. In all panels, representative data are shown from 1 of >=2 independent experiments for each bacterial strain and media condition. Results are representative of multiple strains for L. iners (n = 16), L. crispatus (n = 7), and L. jensenii (n = 2).

Figure 2: Relative abundance of L. crispatus, L. iners, or various BV-associated bacteria in mock bacterial communities grown in rich, non-selective media with or without metronidazole (MTZ) and/or SMC. Relative abundance was determined by bacterial 16S rRNA gene sequencing. Data are shown for three representative mock communities with 5 replicates per media condition.

Figure 3: Ratio of L. crispatus to other species in the mock bacterial communities depicted in Figure 2. Statistical significance determined via 1-way ANOVA of log10-transformed ratios with post-hoc Tukey test; selected pairwise comparisons are shown (***, p < 0.001).

Conclusion

L. iners has unique requirements for exogenous cysteine/cystine or a reduced environment for growth. Targeting cystine uptake to inhibit L. iners is a potential strategy for shifting cervicovaginal microbiota towards L. crispatus-dominant communities.

Disclosures

Douglas S. Kwon, MD, PhD, Day Zero Diagnostics (Consultant, Shareholder, Other Financial or Material Support, co-founder)

The cervicovaginal mucus barrier to HIV-1 is diminished in bacterial vaginosis

Bacterial vaginosis (BV), a condition in which the vaginal microbiota consists of community of obligate and facultative anaerobes rather than dominated by a single species of Lactobacillus, affects ~30% of women in the US. Women with BV are at 60% increased risk for HIV acquisition and are 3-times more likely to transmit HIV to an uninfected partner. As cervicovaginal mucus (CVM) is the first line of defense against mucosal pathogens and the home of the resident vaginal microbiota, we hypothesized the barrier function of CVM to HIV may be diminished in BV. Here, we characterized CVM properties including pH, lactic acid content, and Nugent score to correlate with the microbiota community composition, which was confirmed by 16S rDNA sequencing on a subset of samples. We then quantified the mobility of fluorescently-labeled HIV virions and nanoparticles to characterize the structural and adhesive barrier properties of CVM. Our analyses included women with Nugent scores categorized as intermediate (4–6) and BV (7–10), women that were either symptomatic or asymptomatic, and a small group of women before and after antibiotic treatment for symptomatic BV. Overall, we found that HIV virions had significantly increased mobility in CVM from women with BV compared to CVM from women with Lactobacillus crispatus-dominant microbiota, regardless of whether symptoms were present. We confirmed using nanoparticles and scanning electron microscopy that the impaired barrier function was due to reduced adhesive barrier properties without an obvious degradation of the physical CVM pore structure. We further confirmed a similar increase in HIV mobility in CVM from women with Lactobacillus iners-dominant microbiota, the species most associated with transitions to BV and that persists after antibiotic treatment for BV. Our findings advance the understanding of the protective role of mucus and highlight the interplay between vaginal microbiota and the innate barrier function mucus.

Bacterial vaginosis (BV), a condition characterized by the depletion of lactobacillus bacteria in the vagina, is the most common vaginal condition in reproductive age women. BV has been associated with many adverse reproductive and sexual health outcomes, including increased risk of HIV infection. Cervicovaginal mucus is the home to vaginal bacteria and acts as a first line of defense to protect the underlying tissues and cells from infection. Here, we studied the barrier properties of mucus from women with BV compared to women with vaginal bacteria dominated by lactobacilli. We found that mucus from women with BV and women with Lactobacillus iners were permissive to HIV-1, which may allow the virus to more easily reach target cells. These findings are in agreement with the observed increased risk for HIV acquisition seen in women with BV and L. iners bacteria. Furthermore, we found that the barrier against HIV is diminished in women with BV regardless of whether they have symptoms. Our findings highlight the important, yet unexplored interactions between the mucus barrier and the vaginal microbiota and the implications for human health.

Retinal Detachment and Retinal Holes in Retinitis Pigmentosa Sine Pigmento

Retinal detachment and retinal holes in two family members with retinitis pigmentosa sine pigmento are reported. We believe these are the first such cases reported in the literature. We describe the presenting symptoms and management, including cryotherapy, scleral buckling procedure, and sulfur hexafluoride injection (SF6), resulting in stable visual acuity in one case and retinal reattachment and improved visual acuity in the other case.

Peripheral education of the immune system by colonic commensal microbiota

The instruction of the immune system to be tolerant of self, thereby preventing autoimmunity, is facilitated by the education of T cells in a specialized organ, the thymus, where self-reactive cells are either eliminated or differentiated into tolerogenic Foxp3⁺ regulatory T(Treg) cells¹. However, it is unknown whether T cells are also educated to be tolerant of foreign antigens, such as those from commensal bacteria, in order to prevent immunopathology such as inflammatory bowel disease^2–4. Here, we show that encounter with commensal microbiota results in the peripheral generation of Treg cells, rather than pathogenic effectors. We observed that colonic Treg cells utilized T cell antigen receptors (TCRs)different from those used by Treg cells in other locations, implying an important role for local antigens in shaping the colonic Treg cell population. Many of the local antigens appeared to be derived from commensal bacteria based on the in vitro reactivity of common colon Treg TCRs. Interestingly, these TCRs did not facilitate thymic Treg cell development, implying that manycolonic Treg cells arise instead via antigen-driven peripheral Treg cell development. Further analysis of two of these TCRs by the creation of retroviral bone marrow chimeras and a TCR transgenic linerevealed that microbiota indigenous to our mouse colony was required for the generation of colonic Treg cells from otherwise naive T cells. If T cells expressing these TCRs fail to undergo Treg cell development and instead become effector cells, they have the potential to induce colitis, as evidenced by adoptive transfer studies. These results suggest that the efficient peripheral generation of antigen-specific populations of Treg cells in response to an individual’s microbiota provides important post-thymic education of the immune system to foreign antigens, thereby providing tolerance to commensal microbiota.

An antibiotic-responsive mouse model of fulminant ulcerative colitis

BACKGROUND

The constellation of human inflammatory bowel disease (IBD) includes ulcerative colitis and Crohn's disease, which both display a wide spectrum in the severity of pathology. One theory is that multiple genetic hits to the host immune system may contribute to the susceptibility and severity of IBD. However, experimental proof of this concept is still lacking. Several genetic mouse models that each recapitulate some aspects of human IBD have utilized a single gene defect to induce colitis. However, none have produced pathology clearly distinguishable as either ulcerative colitis or Crohn's disease, in part because none of them reproduce the most severe forms of disease that are observed in human patients. This lack of severe IBD models has posed a challenge for research into pathogenic mechanisms and development of new treatments. We hypothesized that multiple genetic hits to the regulatory machinery that normally inhibits immune activation in the intestine would generate more severe, reproducible pathology that would mimic either ulcerative colitis or Crohn's disease.

METHODS AND FINDINGS

We generated a novel mouse line (dnKO) that possessed defects in both TGFbetaRII and IL-10R2 signaling. These mice rapidly and reproducibly developed a disease resembling fulminant human ulcerative colitis that was quite distinct from the much longer and more variable course of pathology observed previously in mice possessing only single defects. Pathogenesis was driven by uncontrolled production of proinflammatory cytokines resulting in large part from T cell activation. The disease process could be significantly ameliorated by administration of antibodies against IFNgamma and TNFalpha and was completely inhibited by a combination of broad-spectrum antibiotics.

CONCLUSIONS

Here, we develop to our knowledge the first mouse model of fulminant ulcerative colitis by combining multiple genetic hits in immune regulation and demonstrate that the resulting disease is sensitive to both anticytokine therapy and broad-spectrum antibiotics. These findings indicated the IL-10 and TGFbeta pathways synergize to inhibit microbially induced production of proinflammatory cytokines, including IFNgamma and TNFalpha, which are known to play a role in the pathogenesis of human ulcerative colitis. Our findings also provide evidence that broad-spectrum antibiotics may have an application in the treatment of patients with ulcerative colitis. This model system will be useful in the future to explore the microbial factors that induce immune activation and characterize how these interactions produce disease.

Comparison of dot chromosome sequences from D. melanogaster and D. virilis reveals an enrichment of DNA transposon sequences in heterochromatic domains

Sequencing and analysis of fosmid hybridization to the dot chromosomes of Drosophila virilis and D. melanogaster suggest that repetitive elements and density are important in determining higher-order chromatin packaging.

Background

Chromosome four of Drosophila melanogaster, known as the dot chromosome, is largely heterochromatic, as shown by immunofluorescent staining with antibodies to heterochromatin protein 1 (HP1) and histone H3K9me. In contrast, the absence of HP1 and H3K9me from the dot chromosome in D. virilis suggests that this region is euchromatic. D. virilis diverged from D. melanogaster 40 to 60 million years ago.

Results

Here we describe finished sequencing and analysis of 11 fosmids hybridizing to the dot chromosome of D. virilis (372,650 base-pairs) and seven fosmids from major euchromatic chromosome arms (273,110 base-pairs). Most genes from the dot chromosome of D. melanogaster remain on the dot chromosome in D. virilis, but many inversions have occurred. The dot chromosomes of both species are similar to the major chromosome arms in gene density and coding density, but the dot chromosome genes of both species have larger introns. The D. virilis dot chromosome fosmids have a high repeat density (22.8%), similar to homologous regions of D. melanogaster (26.5%). There are, however, major differences in the representation of repetitive elements. Remnants of DNA transposons make up only 6.3% of the D. virilis dot chromosome fosmids, but 18.4% of the homologous regions from D. melanogaster; DINE-1 and 1360 elements are particularly enriched in D. melanogaster. Euchromatic domains on the major chromosomes in both species have very few DNA transposons (less than 0.4 %).

Conclusion

Combining these results with recent findings about RNAi, we suggest that specific repetitive elements, as well as density, play a role in determining higher-order chromatin packaging.

Esophageal pseudomass at the thoracic inlet on barium swallow: CT findings

PURPOSE

Our goal was to describe the CT findings in patients with an apparent mass at the thoracic inlet on barium swallow and to further explore its etiology by making appropriate measurements on CT.

METHOD

Barium swallows and CT scans of five patients with esophageal pseudomass were reviewed and compared with CT scans of 65 controls. Anteroposterior (AP) diameters of the thoracic inlet were measured, and the relationships of the esophagus to the trachea were determined on CT.

RESULTS

Absence of a demonstrable mass on CT in patients with an extrinsic impression on barium swallow was associated with narrowed AP diameter of the thoracic inlet (< 5 cm) and the esophagus to the left of the trachea. A significant correlation was observed between the AP diameter of the inlet and the position of the esophagus in relation to the trachea in control subjects (r = 0.52, p < 0.001); with diminished diameter, the esophagus is more frequently located to the left side of the trachea.

CONCLUSION

An apparent mass is simulated by lateral deviation of the lower cervical esophagus, due to diminished available space between the trachea and the esophagus in subjects with a narrow (< 5 cm) AP diameter of the thoracic inlet.

Lung cancer in patients with bullous disease

There have been sporadic reports in the literature of an association between bullous disease of the lung and lung cancer; however, we believe that this clinical association is not well recognized. We present six cases in which bullous disease of the lung and lung cancer coexisted, and review the available literature on the topic. Five of the patients were males, the mean age of presentation was 42 yr (range: 32 to 62 yr), and all of the patients were smokers. Histologically the tumors in all six patients were non-small-cell carcinomas. The significantly younger age of these patients with lung cancer and bullous disease as compared with those reported in the literature with lung cancer but without bullous disease suggests that the association between these two processes is more than just coincidental. The utility of plain radiography and computerized tomography (CT) of the chest in screening patients with bullous disease for lung cancer is discussed.

Laser indirect ophthalmoscope photocoagulation and scleral depression for rhegmatogenous retinal detachment

BACKGROUND

Transconjunctival cryotherapy or laser photocoagulation with simultaneous Eisner funnel scleral depression has been used to treat selected cases of rhegmatogenous retinal detachment. There are no studies to date reporting the use of the laser indirect ophthalmoscope coupled with scleral depression for treating retinal detachment.

METHODS

16 consecutive patients (18 retinal detachments in 17 eyes) were enrolled in a prospective, uncontrolled clinical trial using the laser indirect ophthalmoscope with scleral depression as the sole treatment for retinal detachment. The region immediately surrounding the break where subretinal fluid was present was directly treated rather than demarcated. All patients were treated with local anesthesia in an outpatient setting.

RESULTS

Complete retinal reattachment was initially achieved in 14 (78%) of 18 eyes after scleral depression and laser alone. Significant postoperative complications of scleral depression with laser indirect ophthalmoscope photocoagulation included macular pucker (2 eyes), late recurrent rhegmatogenous retinal detachment without proliferative vitreoretinopathy (1 eye), and late recurrent rhegmatogenous retinal detachment with proliferative vitreoretinopathy (2 eyes). Failure of initial treatment to flatten the retina, late recurrent retinal detachment, macular pucker, or proliferative vitreoretinopathy led to scleral buckling and/or vitrectomy in 6 (86%) of the 7 eyes with clinical detachment and 3 (30%) of the 10 eyes with localized detachment. Final retinal reattachment at the last follow-up examination was achieved in all 17 eyes with subsequent surgical procedures.

CONCLUSION

Although scleral depression with laser indirect ophthalmoscope photocoagulation is a noninvasive outpatient surgical procedure that is capable of flattening selected retinal detachments, its use cannot be recommended because of the relatively high rate of postoperative complications requiring further surgical procedures.

Pars plana vitrectomy for subfoveal macular hemorrhage and choroidal neovascular membranes

1. Choroidal neovascular membranes (CNVM), the abnormal ingrowth of blood vessels from the choroid through Bruch's membrane, remain a major cause of treatable visual loss. 2. Laser photocoagulation is effective in destroying CNVM and preserving central vision in many affected patients. However, laser treatment of subfoveal CNVM irreversibly destroys foveal vision. 3. The utility of vitrectomy techniques for removal of subfoveal macular hemorrhage on CNVM remains unknown pending the results of a randomized, controlled prospective study. 4. Laser photocoagulation remains the treatment of choice for extra- and juxtafoveal CNVM caused by age-related macular degeneration (ARMD), ocular histoplasmosis and idiopathic causes, and for selected subfoveal CNVM caused by ARMD.

External argon laser choroidotomy versus needle drainage technique in primary scleral buckle procedures. A prospective randomized study

PURPOSE

To compare the rates of intraoperative and postoperative complications of external argon laser choroidotomy and needle drainage techniques during scleral buckle procedures for primary retinal detachment.

METHODS

A group of 175 patients undergoing scleral buckling for primary retinal detachment was randomly assigned to undergo either external argon laser choroidotomy or needle drainage. Complications associated with drainage of subretinal fluid were categorized as retinal break, retinal incarceration, or hemorrhage (dot, < or = 1 disc diameter [DD], or > 1 DD), and recorded during surgery and 24 hours after surgery.

RESULTS

In the group that underwent laser choroidotomy, 12 (13%) of 92 patients had complications, including 4 dot hemorrhages, 3 hemorrhages 1 DD or smaller, 3 hemorrhages larger than 1 DD, 1 retinal incarceration, and 1 suprachoroidal hemorrhage. In the group that underwent needle drainage, 13 (16%) of 81 patients had complications, including 3 dot hemorrhages, 4 hemorrhages 1 DD or smaller, 5 hemorrhages larger than 1 DD, and 1 suprachoroidal hemorrhage. No significant difference was noted between the two groups in the incidence of complications (P = 0.657).

CONCLUSION

External argon laser choroidotomy and needle choroidotomy are comparable, safe, and effective ways to drain subretinal fluid during scleral buckle surgery.

Lenticular burns following argon panretinal photocoagulation

Photocoagulation burns of the crystalline lens are a rare complication of posterior segment laser surgery. These burns occur more commonly in eyes with cataracts and with small, high-power, long-duration argon blue-green burns. We describe the first occurrence of lenticular burns caused by a fractured laser fibre optic cord.

Chest roentgenographic abnormalities in IL-2 recipients. Incidence and correlation with clinical parameters

The chest roentgenograms of 54 patients receiving high dose interleukin-2 with or without lymphokine-activated killer cell therapy for advanced cancer were retrospectively reviewed. Thirty-nine patients (72 percent) developed chest roentgenographic abnormalities consisting of pleural effusions, 28 (52 percent); diffuse infiltrates (pulmonary edema), 22 (41 percent); and focal infiltrates, 12 (22 percent). These abnormalities resolved in 30 of 39 (77 percent) patients by four weeks after therapy. Simple pleural effusions were the only residual roentgenographic abnormalities seen and were present primarily in patients receiving IL-2 by bolus intravenous injection (8 of 28) (29 percent) as compared to continuous intravenous infusion (1 of 24) (4 percent) (p = 0.03). Only roentgenographic evidence of pulmonary edema appeared to correlate with the degree of clinical pulmonary toxicity (p = 0.001). The development of chest roentgenographic abnormalities correlated with the administration of IL-2 solely by bolus intravenous injection (p = 0.04), a pretreatment FEV1 of less than 3 L (p = 0.04), and treatment associated bacteremia (p = 0.09), but not with prior therapy, the presence of pulmonary metastases or the degree of systemic capillary leak as measured by percentage of weight gain during therapy. Although the roentgenographic abnormalities did not relate to the number of LAK cells received, two patients developed sudden onset of dyspnea and chest roentgenographic evidence of pulmonary edema shortly after the first LAK cell administration, implying that a direct cause-and-effect relationship exists in some patients. Possible mechanisms for these IL-2 related chest roentgenographic abnormalities and pulmonary toxicity in general are discussed.

A simple method for practicing unimanual pars plana vitrectomy with the binocular indirect ophthalmoscope

Bimanual vitrectomy has become the method of choice for performing closed vitrectomy. In certain situations, visualization is improved by using indirect ophthalmoscopy to see the vitrectomy instrument. A simple method using a +20.00-diopter condensing lens is described as a means of practicing the initially difficult unimanual technique, which requires working in an inverted operative field.

Photocoagulation for serous detachment of the macula secondary to retinal astrocytoma

Retinal astrocytomas are rare, usually asymptomatic, hamartomatous retinal tumors that are most commonly seen in patients with tuberous sclerosis. Serous detachment of the macula is a rare complication of retinal astrocytomas. The first successful treatment with laser photocoagulation of two eyes (two patients) with decreased vision due to a serous detachment of the macula from a retinal astrocytoma is described. Laser photocoagulation should be considered for retinal astrocytomas causing persistent or increasing exudation that is threatening the macula or causing visual loss.

Scleral fixation suture for dislocated posterior chamber intraocular lens

The posterior dislocation of an intraocular lens is a serious complication of extracapsular cataract extraction with implantation of a posterior chamber intraocular lens. We describe a method of repositioning and suturing such a lens, using pars plana techniques. The method we recommend has several advantages over previously described methods, including the use of radially oriented scleral fixation sutures.

Thermal papillitis after dye red photocoagulation of a peripapillary choroidal neovascular membrane

Thermal papillitis is a previously unrecognized complication of photocoagulation for peripapillary choroidal neovascularization. This report describes a patient in whom transient thermal papillitis, choroidal ischemia, and two small branch retinal arteriolar occlusions developed after dye red photocoagulation of an idiopathic peripapillary choroidal neovascular membrane.

Optimal double-contrast visualization of the posteriorly directed duodenal bulb

The posteriorly directed duodenal bulb can be difficult to demonstrate because of the overlapping gastric antrum. A technique is described for displacing the antrum from the bulb while simultaneously distending the barium-coated duodenal bulb with air.

Chronic erosive gastritis resulting in cachexia

Nine patients are reported who presented with severe weight loss of up to 13.6 kg (30 lb) as a result of chronic erosive gastritis. In many the cachexia was sufficient to prompt a search for malignancy but no other lesion was found. The importance of the radiological pursuit of this diagnosis is emphasised. Illustrative case histories are presented.

Chronic erosive gastritis--a recently recognized disorder

We have reviewed the clinical manifestations, endoscopic findings, pathology, and upper gastrointestinal x-rays in 10 patients with chronic erosive gastritis, a disorder that was rarely recognized before the use of double-contrast upper gastrointestinal radiology and endoscopy. The characteristic x-ray appearance is that of a series of 3 to 11-mm nodules, some with central collections of barium, that are distributed along rugal folds and usually extend into the antrum. The endoscopic appearance is similar: small erythematous nodules with shallow central erosions. The pathology differs from that seen in peptic ulcer disease. There are few polymorphonuclear leukocytes and a predominance of plasma cells in the inflammatory infiltrate. Seven of our patients presented with epigastric pain similar to that of peptic ulcer disease; four of these also had anorexia and weight loss. In two other patients anorexia and weight loss were the only symptoms. One patient was asymptomatic. All nine symptomatic patients responded to antacid treatment. However, repeat x-rays demonstrated persistence of the nodules, although the central erosions usually disappeared. The etiology is unknown. Chronic erosive gastritis appears to be a distinct entity different from peptic ulcer disease.

Chronic erosive gastritis--clinical and radiological features

Chronic erosive gastritis has been regarded as an unusual, ill-defined condition of unknown etiology. We report a retrospective study of 40 patients in whom this diagnosis was made relating radiologic findings to patients' age, symptomatology and possible etiologic factors. The condition is more common than previously suspected and requires careful technique combining double contrast and graded compression to demonstrate fine mucosal abnormalities. The radiologic appearance is of mucosal mounds measuring 3-11 mm in diameter with central barium collections and numbering from 3-27 per examination. Antral involvement occurred in 90% of patients, with diffuse involvement of both antrum and body in 58%. Several linear erosions measuring up to 15 mm in length were also demonstrated. Chronic erosive gastritis is most severe and symptomatic between 40 and 60 years, becoming sub-clinical in the elderly. Symptoms mimic those of a peptic ulcer or gastric neoplasm and are more severe the more extensive the disease. Gastric irritants, virus infection and Crohn's disease were possible etiologic factors in some patients in this study.

Adult intussusception presenting with transient intestinal ischemia

A 71-year old woman initially presented with abdominal pain and an x-ray picture of ischemia of the terminal ileum. The ischemic changes were transient and reversed spontaneously. Six months later, she presented with the same complaint and an x-ray picture of ileocolic intussusception. At operation, a lipoma of the ileum was the leading point of the intussusception and ischemic changes of the ileum were evident.

Improved radiographic detection of multiple gastric ulcers

In more than 1,500 double contrast upper gastrointestinal examinations performed January through November 1974, 26 cases of multiple gastric ulcers were diagnosed. This represents 18.6% of the 140 patients who had a demonstrable gastric lesion, and 23.4% of the 111 patients who had either a single gastric ulcer or scar. This technique was developed in a country where gastric carcinoma is common, but in the United States its greatest usefulness will probably be in the detection of subtle mucosal defects such as multiple gastric ulcers, linear ulcers, and erosions. The sensitivity of the routine pharmacologically aided double contrast upper gastrointestinal examination is confirmed by the high incidence of multiple gastric ulcers found.