Keratoprosthesis: preoperative prognostic categories

PURPOSE

Recent advances aimed at preventing and treating complications after keratoprosthesis surgery have improved prognosis, but it has been suspected that various preoperative diagnoses may carry substantially different postoperative outcomes. This article attempts to clarify the ranking of prognostic categories for patients undergoing keratoprosthesis surgery.

METHODS

A retrospective review of the outcome in a recent series of 63 patient eyes operated at the Massachusetts Eye and Ear Infirmary between 1990 and 1997 and followed up for a minimum of 21 months. Anatomic retention of the device and the loss of vision caused by complications were recorded. The patients were divided into four categories according to preoperative cause.

RESULTS

Anatomically, one keratoprosthesis extruded spontaneously. Another 10 were permanently removed because of complications. Of the 63 eyes, 10 never achieved a visual acuity of at least 20/200 vision because of preexisting retinal or optic nerve damage. The remaining 53 had a visual acuity of 20/200 to 20/20 as follows: Stevens-Johnson syndrome (n = 7), after 2 years: 33%, after 5 years: 0%; chemical burn (n = 17), after 2 years: 64%, after 5 years: 25%; ocular cicatricial pemphigoid (n = 20), after 2 years: 72%, after 5 years: 43%; graft failure in noncicatrizing conditions (dystrophies, degenerations, or bacterial or viral infections) when a repeat graft was expected to have a poor prognosis (n = 19), after 2 years: 83%, after 5 years: 68%. The difference in outcome between the Stevens-Johnson syndrome outcome group and the graft failure group or the ocular cicatricial pemphigoid group was statistically significant. In the group of 53 eyes, visual acuity was restored to 20/200 to 20/20 for a cumulative total of 138 years.

CONCLUSION

Outcome of the keratoprosthesis surgery varied markedly with preoperative diagnosis. Most favorable was graft failures in non-cicatrizing conditions, whereas Stevens-Johnson syndrome was the worst. Ocular cicatricial pemphigoid and chemical burns occupied a middle ground. The difference between the groups seemed to correlate with the degree of past preoperative inflammation.

Endophthalmitis after keratoprosthesis: incidence, bacterial causes, and risk factors

OBJECTIVES

To determine the rate of endophthalmitis in a group of patients with keratoprostheses and to analyze possible risk factors.

METHODS

A total of 108 patient eyes, operated on between 1990 and 2000 with double-plated keratoprostheses, were analyzed with regard to the surface flora, the incidence and cause of bacterial endophthalmitis or sterile vitreitis, the keratoprosthesis design, prophylactic antibiotics, concomitant immunosuppression, and preoperative diagnosis.

RESULTS

Surveillance cultures were obtained from 30 uninfected eyes. The flora was similar to that reported in the normal population and did not vary significantly with time. Thirteen cases of bacterial endophthalmitis occurred 2 to 46 months postoperatively in the patient population that had been followed up for 2 months to 17 years (average, 3 years 4 months). The incidence was 39% in 13 patients with Stevens-Johnson syndrome, 19% in 27 patients with ocular cicatricial pemphigoid, and 7% in 28 patients with ocular burns. Only 1 of the other 40 cases (consisting mostly of repeated graft failures in noncicatrizing conditions) developed endophthalmitis; this patient had a filtering bleb. All endophthalmitis pathogens were gram positive: Streptococcus pneumoniae, 23%; other streptococci, 39%; Staphylococcus aureus, 23%; and Staphylococcus epidermidis, 15%.

CONCLUSIONS

The most important risk factor for endophthalmitis after these keratoprostheses was found to be preoperative diagnosis. The rate of infection was very high in Stevens-Johnson syndrome and ocular cicatricial pemphigoid, moderate in chemical burns, and low in noncicatrizing corneal disease.

Treatment of retinal capillary hemangioma

OBJECTIVE

To report on the methods of treatment and the visual outcome of eyes with retinal capillary hemangioma (RCH).

DESIGN

Retrospective consecutive noncomparative case series.

PARTICIPANTS

Data on 68 patients with RCH were reviewed for the methods of treatment and visual outcome.

METHODS

Statistical analysis using cumulative multinomial logistic regression (generalized estimating equations) was performed to determine significant predictors of visual outcome.

RESULTS

Among 68 patients with RCH with von Hippel-Lindau disease (n = 31) and without von Hippel-Lindau disease (n = 37), we identified 174 RCH in 86 eyes. The overall median age at diagnosis of RCH was 30.8 years (range, 2.8-73.8 years). The RCH was bilateral in 18 cases (26%), and a family history of von Hippel-Lindau disease was positive in 19 cases (28%). Twenty-nine of the tumors (17%) touched the optic disc and were classified as juxtapapillary RCH, and the remaining 145 (83%) were extrapapillary in location. Ninety-nine (58%) RCH were 1.5 mm or smaller in size. The RCH were initially managed by observation (46%), laser photocoagulation (25%), or cryotherapy (23%). Small RCH (< or =1.5 mm in size; 63 of 99; 64%) and those touching the optic disc (14 of 29; 48%) were more likely to be initially observed. Sixty-three (82%) of the 77 RCH that were initially observed remained stable for a median follow-up of 84 months. The remaining 14 progressed and were successfully controlled with laser photocoagulation or cryotherapy. Either laser photocoagulation or cryotherapy was effective as the sole method of treatment in controlling 74% (26 of 35) and 72% (28 of 39) of extrapapillary tumors, with a mean number of 1.2 and 1.1 sessions, respectively. In a multivariate model, the only variables that were significantly related to final vision of </= 20/400 were poor initial vision (P = 0.01, odds ratio [OR], 8.5; 95% confidence interval [CI], 1.7,42) and the presence of retinal/vitreous hemorrhage (P = 0.024, OR, 5.7; 95% CI, 1.3, 25.6).

CONCLUSIONS

RCH can be safely observed initially in selected cases. Laser photocoagulation and cryotherapy are the mainstays of treatment in most cases. Early detection of RCH and treatment before the onset of severe visual loss is recommended.

Efficacy of DHE photodynamic therapy for respiratory papillomatosis: immediate and long-term results

OBJECTIVES/HYPOTHESIS

Recurrent respiratory papillomatosis is a potentially life-threatening disease that affects both children and adults and can result in complete respiratory obstruction. Conventional therapies cannot prevent multiple recurrences. The authors have been evaluating photodynamic therapy (PDT) to treat this disease since 1988. This study compared the efficacy of PDT with dihematoporphyrinether (DHE) with traditional therapy.

STUDY DESIGN

This was a randomized prospective trial of DHE-PDT. Patients were randomly assigned to receive one of two doses of DHE--3.25 mg/kg or 4.25 mg/kg body weight. They were compared with a concurrent control group. Disease extent was evaluated by direct laryngoscopy before treatment and over a 1-year period following treatment. Results were also compared with two historical cohorts of patients treated with lower doses of DHE.

METHODS

Eighty-one patients, ages 4 to 74 years, with moderate to severe recurrent disease were enrolled. Forty-eight received PDT and 33 in the control group were treated with conventional therapy. Both PDT groups received 50 J laser light to activate the drug. Patients received an intravenous infusion of DHE as outpatients 48 to 72 hours before treatment. During direct laryngoscopy, light (630 nm) was delivered by an argon-pumped dye laser. Tissue biopsies were analyzed for presence of human papillomavirus (HPV).

RESULTS

There was notable improvement with either drug dose over the first year. Those receiving 4.25 mg/kg DHE experienced a significantly larger decrease in papilloma growth rate. Three-year follow-up of a subset of patients confirmed that improvement was maintained. There was no impact of DHE-PDT on persistence of HPV DNA.

CONCLUSION

This therapy holds promise for the treatment of laryngeal papillomas.

Therapeutic vaccination with papillomavirus E6 and E7 long peptides results in the control of both established virus-induced lesions and latently infected sites in a pre-clinical cottontail rabbit papillomavirus model

This study was performed to test the therapeutic efficacy of overlapping long E6 and E7 peptides, containing both CD4+ T-helper and CD8+ CTL epitopes, on CRPV-induced lesions, which is an appropriate pre-clinical model for HPV diseases, including recurrent respiratory papillomatosis (RRP). Therapeutic peptide vaccination was able to significantly control wart growth (p < 0.01) and abrogate latent CRPV infection (p = 0.0006) compared to controls. Vaccination was associated with a T(H)1 T cell response, as suggested by a strong DTH skin test, antigen-specific proliferation of PBMC and a minimal IgG antibody response. Thus, this study shows promise for treatment of RRP by vaccination with long peptides.

Retinal capillary hemangioma: a comparison of sporadic cases and cases associated with von Hippel-Lindau disease

OBJECTIVE

To report observations regarding the onset of tumors in patients with retinal capillary hemangiomas (RCH) and comparing sporadic cases with those associated with von Hippel-Lindau (VHL) disease.

DESIGN

Retrospective consecutive case series.

PARTICIPANTS

Sixty-eight patients with RCH managed at a tertiary referral center.

MAIN OUTCOME MEASURES

The data were analyzed for age at diagnosis of RCH, two-hit mutation model, onset of new tumors, and random (Poisson) distribution.

RESULTS

Among 68 patients, we identified 174 RCHs in 86 eyes. Thirty-one patients had VHL disease, and 37 patients were sporadic. The median age at diagnosis in cases with VHL disease was 17.6 years (range, 2.8-46.7 years), and in those without VHL disease it was 36.1 years (range, 7.0-74 years). The age distribution of RCH followed a two-hit mutation model. In eyes with VHL disease, the total number of RCH were distributed randomly as calculated by the Poisson distribution (mean number of tumors = 4). Overall onset of 33 new tumors was documented in 11 eyes (13%) over a median interval of 16 months (range, 3-235 months). All new tumors developed before the age of 47 years. The retinal location of new tumors was similar to the previous tumors with most new tumors located in the superotemporal quadrant (42%) and in the midperipheral retina (58%). Of the 50 patients initially manifesting solitary RCH, only 4 had new tumors develop over a median follow-up duration of 6.4 years (range, 0-33 years). All four cases had VHL disease.

CONCLUSIONS

The median age at diagnosis of RCH in patients with VHL disease was almost 18 years less than those without VHL disease. The age distribution of RCH followed the two-hit mutation model. In VHL disease, the number of RCH is determined randomly. Most of the new RCH develop by the age of 47 years. In the absence of VHL disease, it is unlikely for patients with solitary RCH to develop new tumors.

Histopathology of explanted collar button keratoprostheses: a clinicopathologic correlation

PURPOSE

To compare the histopathology of three PMMA collar button type keratoprosthesis (KPro)/corneal specimens, explanted due to various complications, with that from one KPro/corneal specimen taken postmortem from an otherwise "healthy" enucleated eye.

METHODS

Patient 1 (chemical injury) had no problems for 3 years after KPro placement; the entire eye was obtained postmortem. Patient 2 (repeated graft failures, nonautoimmune disease) developed an "unlaserable" retroprosthesis membrane 4 months after KPro placement. A new KPro was placed. Patient 3 [ocular cicatricial pemphigoid (OCP)] developed tissue melt at the KPro-cornea interface 7 months after KPro placement, and the KPro was replaced. Patient 4 (OCP) developed progressive corneal melt around the KPro 3.5 years after placement resulting in replacement. All KPro/cornea specimens were processed and sectioned for histology with the KPro in place.

RESULTS

All patients exhibited growth of corneal or conjunctival derived epithelium under the KPro front plate. In patients 1 and 2, no epithelial downgrowth was noted and the keratocyte density appeared normal with few inflammatory cells present. Dense fibrous tissue was present behind the KPro in patient 2. Patients 3 and 4 showed massive inflammatory cell infiltration and tissue necrosis with "melt" adjacent to the stem resulting in epithelial downgrowth.

CONCLUSIONS

Corneal inflammation and degradation after KPro placement correlate well with the preoperative diagnostic category. Patients with immune-related corneal surface disease can exhibit marked inflammatory responses leading to necrosis, stromal melting, and the formation of an epithelial fistula. In contrast, patients without autoimmune corneal disease demonstrate a remarkably noninflamed cornea with intact keratocytes and without epithelial ingrowth, commensurate with their clinical appearance.

Sudden Reversible Vitritis After Keratoprosthesis

PURPOSE

To report our experience with late vitritis associated with keratoprosthesis (KPro).

METHODS

Between 1990 and 2003, 218 patients underwent an all-polymethylmethacrylate, collar button-shaped KPro surgery. Eight patients developed a total of 12 episodes of sudden, massive vitritis. Five of these patients had an Ahmed shunt implant, 3 had anterior vitrectomy during surgery, and 4 had a soft contact lens in place. Preoperative diagnoses were multiple graft failures, chemical burn, Stevens-Johnson syndrome, or ocular cicatricial pemphigoid. All patients were maintained on prophylactic topical ofloxacin 0.3% or polymyxin-B/trimethoprim, as well as prednisolone acetate 1% (in 2 cases, medroxyprogesterone 1%), at least twice daily. Vancomycin (14 mg/mL) was also given twice daily in 2 patients.

RESULTS

Vitritis occurred in 8 patients (12 episodes), 2 to 23 months postoperatively. All patients presented with sudden, very marked decrease in vision, with little or no pain, tenderness, conjunctival redness, or discharge. Eight of the 12 events were subjected to vitreous tap and injection of antibiotics and steroids on the day of presentation. Cultures grew Staphylococcus epidermidis, only in liquid (broth) media, in 3 cases; the other 5 showed no growth. The vitritis episodes resolved after 2 to 9 weeks. Full recovery to pre-episode status of a quiet eye with clear vitreous was seen in all patients. Visual acuity recovered almost completely or completely (mental debilitation in one patient made accurate assessment uncertain).

CONCLUSIONS

This phenomenon of sudden vitritis after KPro, with few other symptoms and with complete recovery, would be uncharacteristic of a bacterial endophthalmitis. It may represent a uveitic immune phenomenon.

Photodynamic therapy using m-tetra(hydroxyphenyl) chlorin. An animal model

OBJECTIVE

To evaluate the potent photosensitizer m-tetra (hydroxyphenyl) chlorin (m-THPC) by using rabbits with cottontail rabbit papillomavirus-induced tumors and the canine larynx as model systems.

DESIGN

Nonrandomized control trial.

SETTING

Division of ear, nose, and throat research at a tertiary care teaching hospital.

MATERIALS

Rabbits were used for relative retention ratio studies and tissue tolerance tests. Studies on the swelling of normal tissues in the larynx after photoactivation were done with canines.

INTERVENTION

Animals were injected with 0.3 mg/kg of m-THPC. At varying intervals, tissues were exposed to 652 nm of light.

OUTCOME MEASURES

Outcome measures consisted of four elements: (1) decay of plasma concentration over time, (2) interval to and duration of maximal ratio between drug concentration in normal tissue and tumor, (3) maximal permissible light exposure to normal tissue (skin and laryngeal mucosa) at an optimal interval, and (4) efficacy--number of tumors with partial and complete response.

RESULTS

The largest papilloma to skin ratio (10:1) occurred 4 to 8 days after drug injection. The rabbit skin damage threshold was 40 to 60 J/cm2 at 6 days. The canine laryngeal edema and erythema thresholds were 50 to 70 J. A 75% cure rate of papillomas was achieved with tumors that were less than 100 mm2 in area at light doses that ranged from 25 to 75 J/cm2.

CONCLUSIONS

m-THPC shows efficacy in treating papilloma virus-induced tumors. We present a protocol for rapid optimization of the factors required for tumor destruction with minimal normal tissue damage, thus permitting determination of an optimal therapeutic protocol for any photosensitizer.

Acetylcholine and central respiratory control: perturbations of acetylcholine synthesis in the isolated brainstem of the neonatal rat

The brainstem neurochemical processes which support spontaneous ventilation are not known. Cholinergic transmission may play an important role. If this is true, perturbations in acetylcholine (ACh) turnover should alter ventilatory output in a predictable manner. Using the isolated superfused brainstem-spinal axis from the neonatal rat, the effects of modifiers of ACh synthesis on spontaneous C-4 (phrenic) output were determined. 3-Bromopyruvate and hydroxycitrate, inhibitors of acetyl-CoA (substrate for ACh synthesis) formation, caused depression of the C-4 output in a dose-dependent manner when added to the superfusate. Triethylcholine, a false-transmitter generating choline analog, caused a similar depression. Citrate, a cytosolic precursor to acetyl-CoA formation, caused stimulation of C-4 (phrenic) output. The stimulatory effects of citrate were blocked by the muscarinic cholinergic blocker, atropine. These findings are consistent with the view that the ACh synthetic pathway provides a continuous and important input to the normal brainstem elements that support ventilation.

Induction of E6/E7 expression in cottontail rabbit papillomavirus latency following UV activation

Latent human papillomavirus (HPV) infections are widespread in the genital and respiratory tracts and are a source of recurrent disease. This study used a cottontail rabbit papillomavirus (CRPV) model to determine the presence of E1, E6, and E7 transcripts in latent infection and to determine the temporal change in transcripts following UV activation. We found E1 transcripts in all latently infected sites but no detectable E6 and E7 transcripts, consistent with our earlier studies of HPV6/11 latency. These results suggest that this transcription pattern is broadly characteristic of latent papillomavirus infections. E6/E7 transcripts were detectable within 1 week of irradiation, with maximal induction (approximately 40% of sites) at 2 weeks postirradiation. Papillomas were induced in approximately 26% of irradiated sites after a 3- to 5-week lag. Sites that did not form papillomas by 3 months after irradiation were CRPV DNA positive but E6/E7 RNA negative. Thus, only a subset of latent infections can be induced to express E6/E7 transcripts and form papillomas. We propose that CRPV can be used to study the molecular processes regulating papillomavirus activation.

Effects of biologically produced gold nanoparticles: toxicity assessment in different rat organs after intraperitoneal injection

Gold nanoparticles (GNPs) have different usage in the medical field. The plan of the present research was to evaluate the influence of the biologically produced GNPs on some rat organs. GNPs were produced using Fusarium oxysporum and their presence was confirmed using spectrophotometer, transmission electron microscope (TEM) and X-ray diffraction (XRD) analyses. The non-toxic and toxic doses of GNPs were determined using MTT assay and were injected intraperitoneally into rats in 3 continuous days and their effects on the kidney, liver and testis were analyzed using microscopic technique. Results revealed that GNPs that were produced had 525 nm absorbance peak and average sizes of about 50 nm, with round and hexagonal shapes. Results from the XRD analysis showed the presence of GNPs in the reaction mixture. MTT assay results revealed that GNPs had somehow toxic effects which depend on their doses. Histological examinations indicated that based on the tested organ, the distribution and effects of GNPs were different which in the testis, the non-toxic dose had no effects and in some parts of the liver and kidney, it induced mild changes. The toxic dose of the GNPs in all the three tested organs induced mild changes. In conclusion, the in vitro and in vivo behaviors of the produced GNPs were different and GNPs even in high concentration induced low changes in the rat organs. This may be due to the short exposure and the use of the biologically produced GNPs.

Intrauterine administration of hCG immediately after oocyte retrieval and the outcome of ICSI: a randomized controlled trial

STUDY QUESTION

Does the intrauterine administration of hCG immediately after oocyte retrieval in antagonist cycles with ICSI and fresh embryo transfer (ET) influence the implantation rate or chemical and clinical pregnancy rates?

SUMMARY ANSWER

The intrauterine administration of hCG after oocyte retrieval increases the implantation rate and chemical and clinical pregnancy rates.

WHAT IS KNOWN ALREADY

Over half of IVF/ICSI cycles fail due to implantation failure. Intrauterine administration of hCG, a few minutes before ET, increased the implantation and pregnancy rates in most but not in all studies. The effect of intrauterine administration of hCG, after oocyte retrieval, has not yet been studied.

STUDY DESIGN, SIZE, DURATION

The study was a parallel, triple-blind randomized clinical trial (RCT) performed from September 2015 to February 2016, in a university hospital. We recruited women undergoing antagonist ovarian stimulation, ICSI and ET. For an effect size of 0.2, power of 80% at a significance level of 0.05, we needed 150 participants. Accounting for a 7% dropout rate, a total of 160 women was considered appropriate. A computer-generated randomization list with a block size of 4, with 1:1 allocation was used. The treatment allocation was placed in a sealed, opaque, envelope and picked up consecutively. Immediately after oocyte retrieval, patients in the intervention and control groups were treated with intrauterine injection of hCG and saline, respectively. Participants underwent ET on Day 3. A beta-hCG test was done at 2 weeks. If positive, three transvaginal-ultrasonographies (TVSs) were done at 3, 4 and 10 weeks after ET. The participants were called up thereafter and questioned about the continuity of their pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Of 1990 women attending the infertility clinic of our university hospital, 508 were IVF/ICSI candidates during the study period, and 245 of the patients on an antagonist cycle met the criteria to be invited into our trial. Inclusion criteria were normal ovarian reserve, age ≤41, undergoing ICSI, and fresh ET and normal TSH and prolactin. Uncontrolled chronic disease, severe hydrosalpinx, severe endometriosis, morphologic embryo deficiencies, non-obstructive azospermia and high risk of severe ovarian hyperstimulation syndrome were criteria for exclusion. After taking an informed consent, a total of 158 participants were recruited, of which 80 were randomly allocated to receive intrauterine 500 IU hCG in up to 0.5 ml normal saline and 78 to receive intrauterine 0.5 ml normal saline immediately after oocyte retrieval, during general anaesthesia. ICSI was performed conventionally. The 4-8 cell embryos were transferred on the third day after oocyte retrieval. Implantation rate, chemical and clinical pregnancy rates were analysed and compared between the two groups.

MAIN RESULTS AND THE ROLE OF CHANCE

Patients' demographic and baseline characteristics were comparable. The clinical results showed statistically significant differences between the two groups regarding the biochemical pregnancy rate (59.2 versus 31.3%; P = 0.001; odds ratio (OR) = 1.88; 95% CI, 1.26-2.82; risk difference (RD) = 27.8; 95% CI, 11.2-42.3), implantation rate (37 versus 17%; P = 0.012; OR = 2.29; 95% CI, 1.02-5.14; RD = 20.2; 95% CI, 5.4-33.8), clinical pregnancy rate (50.7 versus 16.4%; P < 0.001; OR = 3.08; 95% CI, 1.71-5.55; RD = 34.3; 95% CI, 18.7-47.6) and ongoing pregnancy rate (40.1 versus 13.4%; P = 0.001; OR = 3.04; 95% CI, 1.55-5.93; RD = 27.4; 95% CI, 12.7-40.6). The abortion and ectopic pregnancy rates were not statistically different between the two groups.

LIMITATIONS, REASONS FOR CAUTION

The insertion of an intrauterine insemination catheter and the injection of a small amount of saline into the uterine cavity (without hCG) may also have some impact on implantation. This effect could be studied by comparing this intervention with another study group without any intrauterine injection.There are no specific side effects mentioned in the literature for the intrauterine administration of hCG, neither were any observed in our study, but it is best to be cautious about probable side effects, because this type of intervention is relatively new and experimental, and deserves more studies before being entered into routine clinical practice.

WIDER IMPLICATIONS OF THE FINDINGS

Intrauterine administration of hCG immediately after oocyte pick up increases its effectiveness; however, further investigations are required before this procedure can be recommended for clinical practice.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by the Women's Health Research Center, Tabriz University of Medical Sciences, Iran. No external funds were used. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

IRCT201206165485N4.

TRIAL REGISTRATION DATE

2 September 2015.

DATE OF FIRST PATIENT'S ENROLMENT

2 September 2015.

Efficacy of intravenous delta-aminolaevulinic acid photodynamic therapy on rabbit papillomas

Endogenously induced protoporphyrin IX (PPIX), a metabolite of delta-aminolaevulinic acid (ALA), has been evaluated as a photosensitising agent for destruction of papillomas in cottontail rabbit papillomavirus-infected Dutch belted and New Zealand rabbits. Three factors were evaluated: (1) relative retention ratio of drug in normal tissue, papilloma and plasma over time; (2) tissue tolerance to treatment factors; and (3) efficacy of treatment protocol. Three drug doses of ALA were examined: 50, 100 and 200 mg kg-1. Actual PPIX concentrations in tissue and plasma were determined spectrophotofluorometrically. The optimal treatment time occurred 3-6 h post ALA injection. The highest PPIX concentration ratio between papilloma and normal skin was 6:1. Different light doses were investigated, using an injection to exposure interval of 3 h and an irradiance of 100 mW cm-2 at a wavelength of 630 nm. Efficacy without risk of significant damage to normal skin was obtained using 100-200 mg kg-1 ALA and 40-60 J cm-2. A long-term (3 months) cure rate of 82% was obtained with a single treatment, provided that papilloma depth did not exceed 8 mm, volume was not more than 1000 mm3 and the plasma concentration of PPIX immediately before exposure was above 500 micrograms ml-1. The short time between injection and treatment and high efficacy, together with PPIX disappearance from plasma and tissue within 24 h, make injected ALA a highly attractive drug for photodynamic therapy.

Follicular fluid PlGF/sFlt-1 ratio and soluble receptor for advanced glycation end-products correlate with ovarian sensitivity index in women undergoing A.R.T

PURPOSE

Considering potential roles of soluble receptor for advanced glycation end products (sRAGE) and placental growth factor (PlGF) in ovarian function and embryo implantation, in the present study we have evaluated the association of these factors and also PlGF/sFlt-1 ratio with the ovarian response and implantation rate by dividing patients according to the OSI.

METHODS

In a cross-sectional study, 90 infertile women who were undergoing ICSI cycle using long protocol were recruited. The patients were divided according to ovarian sensitivity index (OSI). ICSI cycle outcomes were evaluated for each patient and PlGF, sFlt-1 and sRAGE levels of follicular fluid were assayed using commercial ELISA kits.

RESULTS

Follicular fluid (FF) sRAGE levels and PlGF/sFlt-1 ratio were statistically greater in high-responder women than other responders (p < 0.05). Positive correlations were obtained between sRAGE level with the number of oocytes, follicles and OSI level. sRAGE levels with cutoff value of 4.83 (ng/ml) for evaluating the pregnancy outcome showed 81.8 % sensitivity and 60.7 % specificity. Furthermore, there were positive associations between PlGF/sFlt-1 ratio with the number of oocytes, embryos and OSI level.

CONCLUSION

In conclusion, the results of current study supported that good ovarian response is independent of pregnancy outcome. Our results showed that FF levels of sRAGE and PlGF/sFlt-1 ratio could be used as markers for determining the high-responder women. Also, FF sRAGE levels could be a good predictor for ART outcome.

The interplay between hydrogen ions, bicarbonate ions and osmolality in the anterior duodenum modulating gastric function in the conscious calf

1. Gastric emptying, gastric acid and pepsinogen secretion were assessed simultaneously in the conscious calf using the test meal and duodenal perfusion technique (Bell & Mostaghni, 1975).2. Duodenal infusion of NaCl at a constant osmolality of 300 m-osmole/kg, but with pH ranging from 2.0 to 12.0, did not alter the high level of gastric emptying and secretion already reported for isotonic NaCl or NaHCO(3) alone (Bell & Mostaghni, 1975; Bell & Webber, 1979). Gastric function, therefore, is either unaffected by gastric chyme at pH 2.0-12.0 entering the duodenum, or else isotonicity is dominant over pH in activating duodenal receptors which increase motor activity.3. When the pH of the isotonic NaCl was reduced by the addition of HCl to below pH 2.0, inhibition of gastric function occurred in direct proportion to the amount of titratable acid present in the infusate. The H(+) moiety of isotonic duodenal infusates of pH < 2.0 dominates activation of osmoreceptors and so inhibits motor activity.4. When the same amount of acid but at differing concentrations and infusion rates was introduced into the duodenum uniform inhibition of gastric function occurred. This result indicates that duodenal acid receptors respond to acid concentration and flow rate to produce an integrated response in proportion to the amount (concentration x volume) of acid present.5. Isotonic NaHCO(3) solutions adjusted to pH 8.1-12.0 by the addition of NaOH, like isotonic NaCl infusions, did not affect gastric function until pH 11.0-12.0, when significant inhibition occurred. This inhibitory effect of isotonic NaHCO(3) at high pH is probably due to CO(3) (2-), since Na(2)CO(3) and Li(2)CO(3), but not LiCl, produce a similar inhibitory effect on gastric function.6. The inhibitory effect of carbonate gives some support to the existence of a CO(2)-sensor as suggested by Hunt & Knox (1972), whereby increased P(CO2) produced by intracellular or intercellular neutralization of CO(3) (2-) by duodenal H(+) activates acid receptors. But other experiments reported here, where simultaneous perfusion of HCl and excess NaHCO(3) produced a rise in intraluminal P(CO2), did not inhibit gastric function, which is contrary to the idea of a direct intraluminal effect of CO(2) on duodenal receptors.7. The pH, P(O2), P(CO2), HCO(3) (-) and base excess of venous blood showed no detectable change during duodenal infusion of either acidic or alkaline solutions. Metabolic acidosis or alkalosis, therefore, cannot be considered to play any part in controlling gastric function. The results thus corroborate the notion that the receptors controlling gastric function are localized in the intestinal mucosa.8. Our results suggest that interplay between acid and osmolality of gastric chyme occurs in the rostral part of the duodenum to produce a graded inhibitory effect which by negative feedback modulates the gastric effectors that normally activate smooth muscle, parietal cells and zymogen cells.

Ocular adnexal granulocytic sarcoma as the first sign of acute myelogenous leukemia relapse

PURPOSE

To report a case of granulocytic sarcoma involving the eyelids and caruncles after bone marrow transplantation.

METHODS

Case report. A 30-year-old man with acute myeloid leukemia in remission developed multiple friable eyelid and caruncular lesions in addition to two cutaneous lesions on the chest wall and right axilla approximately 3 months after a successful autologous bone marrow transplant.

RESULT

Pathologic examination was consistent with granulocytic sarcoma.

CONCLUSION

This condition should be considered in the differential diagnosis of cutaneous or eyelid masses in patients with a history of leukemia.

Subtotal cystectomy with ileocystoplasty for severe hemorrhagic cystitis after bone marrow transplantation

In a retrospective analysis of hemorrhagic cystitis subsequent to allogeneic bone marrow transplantation, we focused on patients who underwent subtotal cystectomy with ileocystoplasty because stepwise use of conservative treatments had failed. Severe lasting hemorrhagic cystitis (more than 40 days) led to urinary tract obstruction and sepsis that required subtotal cystectomy in 3 of 1300 bone graft patients. Hematuria did not recur after surgery with a satisfactory functional result (follow-up 10 months to 17 years). Subtotal cystectomy with detubularized ileocystoplasty can be used to control life-threatening hemorrhagic cystitis.

Plasma homocysteine concentration and blood pressure in healthy Iranian adults: the Tehran Homocysteine Survey (2003–2004)

Hypertension is a modifiable risk factor for cardiovascular disease, but its aetiology has not been fully elucidated. Recently, attention has been focused on the direct relations of plasma homocysteine (Hcy) to blood pressure (BP). The purpose of this study was to determine the relationship of Hcy with BP and other cardiovascular disease risk factors. This population-based study was a part of the Cardiovascular Risk Factors Survey and has been designed and conducted based on the methodology of the MONICA/WHO Project. A total of 1214 people aged 25-64 years were recruited using cluster sampling and assessed regarding standardized methods. BP was measured in seated position after a 10-min rest period. Blood samples were gathered and analysed according to standard methods. Variables were assessed in 1191 participants (416 men; 775 women). Mean age was higher in hypertensives compared to normotensives (P < 0.001). Mean Hcy was higher in hypertensives, but significant only in men (P < 0.031). Concurrent effects of Hcy, folate and vitamin B12 on hypertension indicated that Hcy acts as a risk factor and folate and vitamin B12 as protective factors; however, after adjustment, just vitamin B12 remained as a protective factor. Although we detected a simple correlation of Hcy with BP in Iranian adults, this relationship was no longer significant after applying an adjustment. In light of our observations, it is likely that the increased Hcy levels reported in hypertensive persons are concomitant rather than a precursor of hypertension.