Re-establishing Lacrimal drainage by Canaliculorhinostomy, after dacryocystectomy - A viable option in symptomatic patients

Purpose

To evaluate the outcome and efficacy of a modified technique of canaliculo-dacryocystorhinostomy (canaliculoDCR) in the complete absence of lacrimal sac, as a means to re-establish lacrimal drainage in post dacryocystectomy(DCT) patients.

Methods

A retrospective, non-randomised interventional study including 15 proven and established post DCT patients with intact canaliculi of at least 7- 8mm. The patients presented with bothersome tearing to the Oculoplasty clinic from January 2017 to January 2018. Patients were operated by a single surgeon (ST). Procedure involved creating a bony ostium of optimum size, internal membranectomy and the nasal mucosal flap anchored appropriately to create a passage in line with the common canaliculus(CC). Adjunctively bicanalicular intubation and mitomycin- C (MMC) were used.

Results

Of the 15 patients who were operated,10 females and 5 males, 14 (93.33%) had functionally and anatomically patent lacrimal passage after the modified canaliculoDCR, 1 (6.66%) was symptomatically better with partial regurgitation of clear fluid. 3(20%) had tube prolapse after first month post operatively, which although significant, was not related to the technique. They were repositioned as an office procedure and retained thereafter till removal, no other tube related or MMC related sequelae was seen. No intra operative complication was encountered.

Conclusion

With a success rate of 93.33% and a resultant patent lacrimal tear drainage passage and trivial complication such as tube prolapse, we can conclude, this technique of modified canaliculoDCR in post DCT patients is a safe and effective procedure with promising results, thereby avoiding cumbersome methods and maintenance of Jones tube while at the same time providing symptomatic relief to the patients.

Congenital uveal malignant melanoma- A rare case report

Purpose

To report a rare case of congenital uveal malignant melanoma from Indian subcontinent in an infant with multiple cutaneous naevi and no distant metastasis.

Observation

An 8 month old male child presented with proptosis and black discoloration in the right eye since birth. Enucleation of the right eye was performed and specimen sent for histopathology and immunohistochemical analysis. Results were strongly suggestive of a malignant melanoma of uvea. No metastasis was found on MRI scan of brain, chest and abdomen. Patient is on close follow up and will be subjected to metastasis workup every 6 months.

Conclusion and importance

This entity of congenital uveal malignant melanoma is rather rare with very few reported cases across the globe and needs further understanding of its correct line of treatment.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1

Purpose

COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.

Methods

This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.

Results

Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).

Conclusion

: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

P889Clinical significance of four-dimensional flow magnetic resonance imaging measurement of turbulent kinetic energy for hypertrophic obstructive cardiomyopathy

Purpose

The aims of this study were to investigate the relationship between TKE value and echocardiographic findings, clinical symptoms and evaluate the usefulness of 4D flow MRI to distinguish hypertrophic obstructive cardiomyopathy (HOCM) from non-obstructive HCM (HNCM).

Methods

From April 2018 to January 2019, 18 hypertrophic obstructive cardiomyopathy (HOCM) and 14 non-obstructive HCM (HNCM) patients underwent 4D flow MRI. We investigated TKE value calculated by 4D flow MRI, echocardiographic findings; left ventricular pressure gradient (LVPG), mitral regurgitation (MR) and clinical symptom.

Results

HOCM was defined by the 30 mmHg or greater of LVPG (HOCM: 87.7±47.3 mmHg, HNCM; 5.8±7.8 mmHg, p<0.001). TKE value in HOCM patients was significantly higher than HNCM (14.2±4.7 mJ vs. 9.0±4.6 mJ, p<0.001). There was a significant positive linear relationship between TKE value and LVPG (r=0.488, p=0.046). There was no significant relationship between NYHA functional class and TKE value (p=0.47) or LVPG (p=0.11). ROC curve analysis showed that optimal cut off point of TKE value between HOCM and HNCM (sensitivity=95%, specificity=62%, AUC=0.798) was 9.270 mJ. Multiple linear regression showed that there was significant association between severity of MR and combination of TKE (p=0.015) or LVPG (p–=0.012). A representative case demonstrated the significant reduction of TKE value 1 week and 3 months after alcohol septal reduction compared with that obtained before the procedure (Figure)

Conclusion

Our findings suggest that 4D Flow MRI can effectively evaluate the energy dissipation associated with LV outflow tract obstruction and TKE value is useful for identifying HOCM. TKE value also can be the novel parameter of the severity of HOCM.

P3852Twenty-eight-year temporal trends of treatment strategy and short-term outcomes in patients with high-risk pulmonary embolism: impact of ESC guidelines changes

Background

Thrombolysis has been recommended for high-risk pulmonary embolism (PE) in ESC guidelines, used as a reference in Japan. Recently, indication of thrombolysis for acute PE has been limited with recent guideline revision. Little is known regarding trends of treatment strategy and mortality in high-risk PE patients.

Purpose

To clarify temporal trends of treatment strategy and short-term outcomes in high-risk PE patients.

Methods

A retrospective analysis of therapeutic interventions and short-term outcomes was performed for 52 consecutive high-risk PE patients including cardiac arrest. According to timing of ESC guidelines update (2000, 2008 and 2014), patients were divided into four time periods: 1992 to 2000, 2001 to 2008, 2009 to 2014, and 2015 to 2018.

Results

Mean age and proportion of male were not different over the period. Nosocomial case decreased from 100% to 25% (p<0.01). Postoperative cases (relative contraindication for thrombolysis) included 43% of all patients. Cardiac arrest and VA-ECMO use were 42% and 21% of all patients. Any thrombolytic therapy including catheter-directed intervention showed a non-significant decrease trend (92%-87%-71%-44%, p=0.067). Temporary or retrieval IVC filter insertion showed a significant downward trend (36%-80%-54%-22%, p=0.025). The entire study 30-day mortality was 23%. There was no significant difference in 30-day mortality over the periods (14%-27%-14%-44%, p=0.303). However, major bleeding decreased significantly (71%-40%-7%-22%, p=0.004) (Table).

Table 1 1992–2000 (n=14) 2001–2008 (n=15) 2009–2014 (n=14) 2015–2018 (n=9) p Age (years) 54±12 59±17 64±13 65±16 0.224 Male 29% 13% 29% 44% 0.269 Any thrombolytic therapy 92% 87% 71% 44% 0.067 Catheter-directed therapy 86% 87% 71% 0% <0.01   with thrombolytics (92%) (83%) (90%)   without thromboloytics (8%) (17%) (10%) Only intravenous thrombolysis 8% 7% 7% 44% 0.038 Temporary/retrieval IVC filter 36% 80% 54% 22% 0.025 ICU stay (days) 15±14 10±18 5±4 8±8 0.206 30-day mortality 14% 27% 14% 44% 0.303 Major bleeding 71% 40% 7% 22% 0.004

Conclusion

The temporal analysis identified a decreased trend in any thrombolytic therapy and IVC filter insertion in high-risk PE. The study also found a decreasing trend in major bleeding.

Differentiation of circulating neural progenitor cells in vitro on fibrin-based composite -matrix involves Wnt- β-catenin-like signaling

Isolation of progenitors with regenerative potential and their in vitro induction to specific lineage may be necessary for effective cell transplantation outcome. Earlier, we standardized specific niche for derivation of neural progenitor cells (NPCs) from circulating mononuclear cells to neural like cells (NLC) in vitro, for applications in neural regeneration. The current study analysed the prospective involvement of signaling mechanism for in vitro lineage commitment of circulating NPCs. Preferred mechanism selected was Wnt-like signaling because this is one of the pathways implicated in the central nervous system (CNS) development and homeostasis. We sought to determine the activation of Wnt3a-specific genes in the standardized NPC culture system. To start with, it was found that when standardized NPC culture niche was supplemented with Wnt 3a protein, no additional morphological changes happen. Chemical inhibitors of the pathway retarded NPC to NLC conversion both in the absence and presence of supplemented Wnt-3a. In earlier studies, involvement of the niche constituents- fibronectin (FN), laminin (La) and fibrin (Fib)- for NPC growth and differentiation was established. In an attempt to study the role of these adhesive proteins by adding antibodies against FN, La & Fib together, molecular level signaling changes seen were comparable to that occur in response to Wnt3a chemical inhibitor. Therefore, induction of Wnt 3a-like signal from the matrix-dependent niche constituents may be implicated in the differentiation of NPC to NLC. The results substantiate the potential applications of the fibrin-based composite niche in neural engineering for regeneration.

Bioengineered fibrin-based niche to direct outgrowth of circulating progenitors into neuron-like cells for potential use in cellular therapy

OBJECTIVE

Autologous cells are considered to be the best choice for use in transplantation therapy. However, the challenges and risks associated with the harvest of transplantable autologous cells limit their successful therapeutic application. The current study explores the possibility of isolating neural progenitor cells from circulating multipotent adult progenitor cells for potential use in cell-based and patient-specific therapy for neurological diseases.

APPROACH

To enable the selection of neural progenitor cells from human peripheral blood mononuclear cells, and to support their lineage maintenance, the composition of a fibrin-based niche was optimized. Morphological examination and specific marker analysis were carried out, employing a qualitative/quantitative polymerase chain reaction followed by immunocytochemistry to: (i) characterize neural progenitor cells in culture; (ii) monitor proliferation/survival; and (iii) track their differentiation status.

MAIN RESULTS

The presence of neural progenitors in circulation was confirmed by the presence of nestin(+) cells at the commencement of the culture. The isolation, proliferation and differentiation of circulating neural progenitors to neuron-like cells were directed by the engineered niche. Neural cell isolation to near homogeneity was confirmed by the expression of β-III tubulin in ∼95% of cells, whereas microtubule associated protein-2 expression confirmed their ability to differentiate. The concentration of potassium chloride in the niche was found to favour neuron-like cell lengthening, cell-cell contact, and expressions of synaptophysin and tyrosine hydroxylase.

SIGNIFICANCE

The purpose of this research was to find out if peripheral blood could serve as a potential source of neural progenitors for cell based therapy. The study established that neural progenitors could be selectively isolated from peripheral blood mononuclear cells using a biomimetic niche. The selected cells could multiply and slowly differentiate into neuron-like cells. These neuron-like cells expressed functional proteins-tyrosine hydroxylase and synaptophysin. Early progenitors that proliferate while expressing β-III tubulin could be harvested from the culture, suggesting their potential use in cell transplantation therapy.

Contrasting biofunctionalization strategies for the enhanced endothelialization of biodegradable vascular grafts

Surface modification of biodegradable vascular grafts is an important strategy to improve the in situ endothelialization of tissue engineered vascular grafts (TEVGs) and prevent major complications associated with current synthetic grafts. Important strategies for improving endothelialization include increasing endothelial cell mobilization and increased endothelial cell capture through biofunctionalization of TEVGs. The objective of this study was to assess two biofunctionalization strategies for improving endothelialization of biodegradable polyester vascular grafts. These techniques consisted of cross-linking heparin to graft surfaces to immobilize vascular endothelial growth factor (VEGF) or antibodies against CD34 (anti-CD34Ab). To this end, heparin, VEGF, and anti-CD34Ab attachment and quantification assays confirmed the efficacy of the modification strategy. Cell attachment and proliferation on these groups were compared to unmodified grafts in vitro and in vivo. To assess in vivo graft functionality, the grafts were implanted as inferior vena cava interpositional conduits in mice. Modified vascular grafts displayed increased endothelial cell attachment and activity in vivo, according to microscopy techniques, histological results, and eNOS expression. Inner lumen diameter of the modified grafts was also better maintained than controls. Overall, while both functionalized grafts outperformed the unmodified control, grafts modified with anti-CD34Ab appeared to yield the most improved results compared to VEGF-loaded grafts.

Abstract P6-11-03: Follow up of breast cancer patients who underwent gamma knife radiosurgery for a diagnosis of brain metastases: A single institutional experience

Background: Breast cancer (BC) is the second most common cause of brain metastases in the United States. We performed a retrospective analysis of BC patients (pts) in the Yale Gamma Knife Radiosurgery (GKRS) database treated for brain metastases (mets) to report overall survival (OS) from time of GKRS, and to identify factors that predict improved survival outcomes.

Methods: We performed retrospective review of the Yale database of BC pts treated with standard GKRS technique for brain mets from 2000 to May 2013. Treatment doses typically ranged from 16 to 24 Gy prescribed to the 40-85% isodose surfaces. Overall survival (OS) for each patient was calculated from the date of first GKRS treatment of brain metastases. Variables included age, Karnofsky Performance Status (KPS), pre/post whole-brain radiation treatment (WBRT) and/or surgical resection, and # of brain mets treated (1-4 vs ≥5).

Results: A total of 80 BC pts were identified, with a mean age of 56.2 yrs; KPS 40-60 in 8pts (10%), 70-80 in 13 (16%), 90-100 in 41 (51%), unknown in 18 (23%); ER+ in 38 (48%), ER- in 38 (48%), unknown in 4 (5%); HER2 + in 38 (48%), HER2- in 33 (41%), indeterminate in 3 (4%) and unknown in 6 (8%). BC subtypes are Luminal A (ER+/HER2-) in 16 (20%), Luminal B (ER+/HER2+) in 19 (24%), HER-2(ER-/HER2+) in 17 (21%), Basal (ER-/HER2-) in 17 (21%), unknown in 11 (14%). Number of brain mets at time of first GKRS ≥5 in 32 (40%); prior WBRT in 30 (38%); WBRT post GKRS in 9 (11%); surgical resection for brain mets in 13 (16%) prior to GKRS and post GKRS in 9 (11%); 16% had ≥3 GKRS. Median time from primary BC dx to brain mets is 62.8 months (m) (range 46.2-81.6); with no significant difference among subtypes. Median OS from GKRS is 13.1 m (7.6-21.9); median OS from brain mets is 18.8 m (11.7-23.9). On univariate analysis, factors associated with significant improved OS from time of GKRS included HER-2 subtype (p = 0.005), KPS 90-100 (p = 0.008), good control of systemic disease (p = 0.017), pre (p = 0.041) and post GKRS surgical resection (p = 0.02). Age, pre or post WBRT, # of brain mets (1-4 vs. 5) were not significant predictors of OS from time of GKRS. In a multivariate Cox analysis (46 cases), HER-2 subtype remained a significant predictor of improved OS from time of GKRS; (HR) 0.26, 95%CI 0.08 to 0.8, p-value = 0.02. There was a trend in favor of surgical resection of brain mets pre GKRS (HR 0.14, 95% CI 0.02 to 1.15, p-value = 0.067

Conclusion: GKRS offers good local control for BC pts with brain mets, and is a reasonable option for pts with ≥5 brain mets. Our results show no associated survival benefit for administration of WBRT pre/post GKRS. HER-2 subtype is a significant predictor of improved survival in BC pts undergoing GKRS for brain mets.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-11-03.

Epiblepharon in East asian patients: the singapore experience

PURPOSE

To describe the demographics, presenting symptoms, indications for surgery, and surgical outcomes of epiblepharon correction in a tertiary care hospital in Singapore.

DESIGN

Retrospective review of patients who underwent surgery by 2 surgeons in a referral oculoplastic practice at the National University Health System, Singapore, from 2001 to 2007.

PARTICIPANTS

A total of 108 patients who underwent surgery for clinically significant epiblepharon.

INTERVENTION

Modified Hotz procedure or suture correction for patients in whom conservative treatment failed.

MAIN OUTCOME MEASURES

Comparison of symptoms, keratopathy, and recurrence on follow-up between the 2 procedures.

RESULTS

The mean age of the patients was 9.0 years, with an age range of 0.5 to 68 years. Of the patients, 51.9% were male. The majority were Chinese (n = 102). Seventy-four (68.5%) patients were symptomatic. Eighty-nine patients (82.4%) had keratopathy. In 98 patients (90.7%) both eyes were affected, and the majority of patients (75.0%) had epiblepharon of the lower lids. Initial treatment for the majority was lubricants (n = 71, 65.7%). The main indications for surgery were symptoms and keratopathy, with 37.9% of patients having both, and 44.4% and 15.7% of patients having either keratopathy or symptoms alone, respectively. Surgical correction consisted mostly of a modified Hotz procedure (n = 88, 81.5%), lid-everting sutures (n = 9, 8.3%), and others, including upper lid blepharoplasty with lid crease formation (n = 11, 10.2%). Outcomes were good, with the majority (n = 88, 81.5%) of lids being well corrected. Complications included undercorrection, overcorrection, wound dehiscence, and wound infections.

CONCLUSIONS

Symptomatic epiblepharon, usually associated with keratopathy and commonly seen in children of East Asian descent, often requires surgical intervention with good surgical outcome. Increased awareness among ophthalmologists and pediatricians dealing with this ethnic group and age is emphasized. Contrary to the current practice of expectant observation, definitive surgical management should be considered when symptoms or keratopathy is present.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Validating breast self examination as screening modalities for breast cancer in eastern region of Nepal: a population based study

Breast cancer is one of the most common causes of death in many developed countries amongst middle-aged women and is becoming common in developing countries as well.

AIMS AND OBJECTIVES

The objective of this study was to evaluate the performance of Breast Self Examination (BSE) against examination conducted by the trained health personnel.

METHODOLOGY

A descriptive evaluative study was conducted among women aged 15 to 60 years undertaken in urban and rural areas. It was a population-based study and non-probability sampling method was used for data collection. Respondents conducted Breast Self Examination on their own, and then investigators did clinical examination of breasts of the respondents to verify their findings.

RESULTS

Mean age of the respondents was 34.54 +/- 9.12 years. Nearly half (44.8%) of the respondents were illiterate. On comparison of each variable of breast self- examination with the physical examination of breast, it was observed that size of the breasts and lump found in the breast had significant relation to performance during examination (P<0.1). The result of Kappa test showed 68% agreement between findings of examinations done by the experts and respondents.

CONCLUSION

Breast Self Examination can be used as an important tool for primary prevention of breast cancer in Nepal, where sophisticated method like screening mammography for general public cannot afford.

Molecular dynamics of mouse acetylcholinesterase complexed with huperzine A

Two molecular dynamics simulations were performed for a modeled complex of mouse acetylcholinesterase liganded with huperzine A (HupA). Analysis of these simulations shows that HupA shifts in the active site toward Tyr 337 and Phe 338, and that several residues in the active site area reach out to make hydrogen bonds with the inhibitor. Rapid fluctuations of the gorge width are observed, ranging from widths that allow substrate access to the active site, to pinched structures that do not allow access of molecules as small as water. Additional openings or channels to the active site are found. One opening is formed in the side wall of the active site gorge by residues Val 73, Asp 74, Thr 83, Glu 84, and Asn 87. Another opening is formed at the base of the gorge by residues Trp 86, Val 132, Glu 202, Gly 448, and Ile 451. Both of these openings have been observed separately in the Torpedo californica form of the enzyme. These channels could allow transport of waters and ions to and from the bulk solution.

Mouse acetylcholinesterase unliganded and in complex with huperzine A: a comparison of molecular dynamics simulations

A 1 ns molecular dynamics simulation of unliganded mouse acetylcholinesterase (AChE) is compared to a previous simulation of mouse AChE complexed with huperzine A (HupA). Several common features are observed. In both simulations, the active site gorge fluctuates in size during the 1 ns trajectory and is completely pinched off several times. Many of the residues in the gorge that formed hydrogen bonds with HupA in the simulation of the complex now form hydrogen bonds with other protein residues and water molecules in the gorge. The opening of a "backdoor" entrance to the active site that was found in the simulation of the complex is also observed in the unliganded simulation. Differences between the two simulations include overall lower structural rms deviations for residues in the gorge in the unliganded simulation, a smaller diameter of the gorge in the absence of HupA, and the disappearance of a side channel that was frequently present in the liganded simulation. The differences between the two simulations can be attributed, in part, to the interaction of AChE with HupA.

Rapid binding of a cationic active site inhibitor to wild type and mutant mouse acetylcholinesterase: Brownian dynamics simulation including diffusion in the active site gorge

It is known that anionic surface residues play a role in the long-range electrostatic attraction between acetylcholinesterase and cationic ligands. In our current investigation, we show that anionic residues also play an important role in the behavior of the ligand within the active site gorge of acetylcholinesterase. Negatively charged residues near the gorge opening not only attract positively charged ligands from solution to the enzyme, but can also restrict the motion of the ligand once it is inside of the gorge. We use Brownian dynamics techniques to calculate the rate constant kon, for wild type and mutant acetylcholinesterase with a positively charged ligand. These calculations are performed by allowing the ligand to diffuse within the active site gorge. This is an extension of previously reported work in which a ligand was allowed to diffuse only to the enzyme surface. By setting the reaction criteria for the ligand closer to the active site, better agreement with experimental data is obtained. Although a number of residues influence the movement of the ligand within the gorge, Asp74 is shown to play a particularly important role in this function. Asp74 traps the ligand within the gorge, and in this way helps to ensure a reaction.

Correlation between rate of enzyme-substrate diffusional encounter and average Boltzmann factor around active site

The utility of the average Boltzmann factor around the active site of an enzyme as the predictor of the electrostatic enhancement of the substrate binding rate is tested on a set of data on wild-type acetylcholinesterase and 18 charge mutants recently obtained by Brownian dynamics simulations. A good correlation between the average Boltzmann factors and the substrate binding rate constants is found. The effects of single charge mutations on both the Boltzmann factor and the substrate binding rate constant are modest, i.e., < 5 fold increase or decrease. This is consistent with the experimental results of Shafferman et al. but does not support their suggestion that the overall rate of the catalytic reaction is not limited by the diffusional encounter of acetylcholinesterase and its substrate.