A phase III study of belatacept-based immunosuppression regimens versus cyclosporine in renal transplant recipients (BENEFIT study)

Belatacept, a costimulation blocker, may preserve renal function and improve long-term outcomes versus calcineurin inhibitors in kidney transplantation. This Phase III study (Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial) assessed a more intensive (MI) or less intensive (LI) regimen of belatacept versus cyclosporine in adults receiving a kidney transplant from living or standard criteria deceased donors. The co-primary endpoints at 12 months were patient/graft survival, a composite renal impairment endpoint (percent with a measured glomerular filtration rate (mGFR) <60 mL/min/1.73 m(2) at Month 12 or a decrease in mGFR > or =10 mL/min/1.73 m(2) Month 3-Month 12) and the incidence of acute rejection. At Month 12, both belatacept regimens had similar patient/graft survival versus cyclosporine (MI: 95%, LI: 97% and cyclosporine: 93%), and were associated with superior renal function as measured by the composite renal impairment endpoint (MI: 55%; LI: 54% and cyclosporine: 78%; p < or = 0.001 MI or LI versus cyclosporine) and by the mGFR (65, 63 and 50 mL/min for MI, LI and cyclosporine; p < or = 0.001 MI or LI versus cyclosporine). Belatacept patients experienced a higher incidence (MI: 22%, LI: 17% and cyclosporine: 7%) and grade of acute rejection episodes. Safety was generally similar between groups, but posttransplant lymphoproliferative disorder was more common in the belatacept groups. Belatacept was associated with superior renal function and similar patient/graft survival versus cyclosporine at 1 year posttransplant, despite a higher rate of early acute rejection.

A phase III study of belatacept versus cyclosporine in kidney transplants from extended criteria donors (BENEFIT-EXT study)

Recipients of extended criteria donor (ECD) kidneys are at increased risk for graft dysfunction/loss, and may benefit from immunosuppression that avoids calcineurin inhibitor (CNI) nephrotoxicity. Belatacept, a selective costimulation blocker, may preserve renal function and improve long-term outcomes versus CNIs. BENEFIT-EXT (Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial-EXTended criteria donors) is a 3-year, Phase III study that assessed a more (MI) or less intensive (LI) regimen of belatacept versus cyclosporine in adult ECD kidney transplant recipients. The co-primary endpoints at 12 months were composite patient/graft survival and a composite renal impairment endpoint. Patient/graft survival with belatacept was similar to cyclosporine (86% MI, 89% LI, 85% cyclosporine) at 12 months. Fewer belatacept patients reached the composite renal impairment endpoint versus cyclosporine (71% MI, 77% LI, 85% cyclosporine; p = 0.002 MI vs. cyclosporine; p = 0.06 LI vs. cyclosporine). The mean measured glomerular filtration rate was 4-7 mL/min higher on belatacept versus cyclosporine (p = 0.008 MI vs. cyclosporine; p = 0.1039 LI vs. cyclosporine), and the overall cardiovascular/metabolic profile was better on belatacept versus cyclosporine. The incidence of acute rejection was similar across groups (18% MI; 18% LI; 14% cyclosporine). Overall rates of infection and malignancy were similar between groups; however, more cases of posttransplant lymphoproliferative disorder (PTLD) occurred in the CNS on belatacept. ECD kidney transplant recipients treated with belatacept-based immunosuppression achieved similar patient/graft survival, better renal function, had an increased incidence of PTLD, and exhibited improvement in the cardiovascular/metabolic risk profile versus cyclosporine-treated patients.

The helix-loop-helix protein Id-2 enhances cell proliferation and binds to the retinoblastoma protein

Cell growth and differentiation are usually antagonistic. Proteins of the basic helix-loop-helix (bHLH) family bind DNA and play important roles in the differentiation of specific cell types. Id proteins heterodimerize with bHLH transcription factors, blocking their activation of lineage-specific gene expression and thereby inhibiting cellular differentiation. To examine the effect of Id-2 on cell proliferation, we overexpressed Id-2 in the human osteosarcoma cell line U2OS. Id-2 expression in U2OS reduced the serum requirement for growth and stimulated cellular proliferation by shortening the doubling time and increasing the percentage of cells in S phase. We demonstrated that Id-2 expression was able to reverse the inhibition of cellular proliferation and the block in cell cycle progression mediated by the product of the retinoblastoma tumor suppressor gene pRB. This effect was not associated with changes in the state of pRb phosphorylation in transfected cells. In vitro, unphosphorylated pRb from cell lysates specifically bound Id-2 but was not able to bind a mutated form of Id-2 lacking the HLH domain that also did not antagonize the growth arrest by pRb. In vitro-synthesized pRb containing mutations within the E1A/large T-binding pocket did not bind Id-2. However, wild-type pRb was able to bind to a region of Id-2 corresponding to only the HLH domain. In vivo, a physical association between Id-2 and pRb was seen in cross-linked extracts from SAOS-2 cells transfected with Id-2 and pRb. Our data identify a role for Id-2 in the regulation of cellular proliferation and suggest that the interaction between Id-2 and pRB is a molecular pathway over which synchronous changes in growth and differentiation are mediated in vivo.

Pandemic spread of an O3:K6 clone of Vibrio parahaemolyticus and emergence of related strains evidenced by arbitrarily primed PCR and toxRS sequence analyses

Vibrio parahaemolyticus O3:K6 strains responsible for the increase in the number of cases of diarrhea in Calcutta, India, beginning in February 1996 and those isolated from Southeast Asian travelers beginning in 1995 were shown to belong to a unique clone characterized by possession of the tdh gene but not the trh gene and by unique arbitrarily primed PCR (AP-PCR) profiles (J. Okuda, M. Ishibashi, E. Hayakawa, T. Nishino, Y. Takeda, A. K. Mukhopadhyay, S. Garg, S. K. Bhattacharya, G. B. Nair, and M. Nishibuchi, J. Clin. Microbiol. 35:3150-3155, 1997). Evidence supporting a hypothesis that this clone emerged only recently and is spreading to many countries was obtained in this study. Of 227 strains isolated in a hospital in Bangladesh between 1977 and 1998, only 22 strains isolated between 1996 and 1998 belonged to the new O3:K6 clone (defined by the serovar, the tdh and trh typing, and AP-PCR profiles). The O3:K6 strains isolated from clinical sources in Taiwan, Laos, Japan, Thailand, Korea, and the United States between 1997 and 1998 were also shown to belong to the new O3:K6 clone. The clonality of the new O3:K6 strains was also confirmed by analysis of the toxRS sequence, which has been shown to be useful for phylogenetic analysis of the members of the genus Vibrio. The toxRS sequences of the representative strains of the new O3:K6 clone differed from those of the O3:K6 strains isolated before 1995 at least at 7 base positions within a 1,346-bp region. A new PCR method targeted to 2 of the base positions unique to the new O3:K6 clone was developed. This PCR method could clearly differentiate all 172 strains belonging to the new O3:K6 clone from other O3:K6 strains isolated earlier. One hundred sixty-six strains belonging to 28 serovars other than O3:K6 were also examined by the new PCR method. The tdh-positive and trh-lacking strains that belonged to the O4:K68 and O1:K untypeable serovars and were isolated in three countries and from international travelers beginning in 1997 gave positive results. The AP-PCR profiles of these strains were nearly identical to those of the new O3:K6 clone, and their toxRS sequences were 100% identical to that of the new O3:K6 clone. The results suggest that these strains may have diverged from the new O3:K6 clone by alteration of the O:K antigens. In conclusion, this study presents strong evidence for the first pandemicity in the history of V. parahaemolyticus and reports a novel toxRS-targeted PCR method that will be useful in epidemiological investigation of the cases associated with the current pandemic spread.

Upregulation of alkaline phosphatase and pyrophosphate hydrolysis: potential mechanism for uremic vascular calcification

Pyrophosphate is a potent inhibitor of medial vascular calcification where its level is controlled by hydrolysis via a tissue-nonspecific alkaline phosphatase (TNAP). We sought to determine if increased TNAP activity could explain the pyrophosphate deficiency and vascular calcification seen in renal failure. TNAP activity increased twofold in intact aortas and in aortic homogenates from rats made uremic by feeding adenine or by 5/6 nephrectomy. Immunoblotting showed an increase in protein abundance but there was no increase in TNAP mRNA assessed by quantitative polymerase chain reaction. Hydrolysis of pyrophosphate by rat aortic rings was inhibited about half by the nonspecific alkaline phosphatase inhibitor levamisole and was reduced about half in aortas from mice lacking TNAP. Hydrolysis was increased in aortic rings from uremic rats and all of this increase was inhibited by levamisole. An increase in TNAP activity and pyrophosphate hydrolysis also occurred when aortic rings from normal rats were incubated with uremic rat plasma. These results suggest that a circulating factor causes pyrophosphate deficiency by regulating TNAP activity and that vascular calcification in renal failure may result from the action of this factor. If proven by future studies, this mechanism will identify alkaline phosphatase as a potential therapeutic target.

Immunosuppression with belatacept-based, corticosteroid-avoiding regimens in de novo kidney transplant recipients

Current immunosuppressive regimens in renal transplantation typically include calcineurin inhibitors (CNIs) and corticosteroids, both of which have toxicities that can impair recipient and allograft health. This 1-year, randomized, controlled, open-label, exploratory study assessed two belatacept-based regimens compared to a tacrolimus (TAC)-based, steroid-avoiding regimen. Recipients of living and deceased donor renal allografts were randomized 1:1:1 to receive belatacept-mycophenolate mofetil (MMF), belatacept-sirolimus (SRL), or TAC-MMF. All patients received induction with 4 doses of Thymoglobulin (6 mg/kg maximum) and an associated short course of corticosteroids. Eighty-nine patients were randomized and transplanted. Acute rejection occurred in 4, 1 and 1 patient in the belatacept-MMF, belatacept-SRL and TAC-MMF groups, respectively, by Month 6; most acute rejection occurred in the first 3 months. More than two-thirds of patients in the belatacept groups remained on CNI- and steroid-free regimens at 12 months and the calculated glomerular filtration rate was 8-10 mL/min higher with either belatacept regimen than with TAC-MMF. Overall safety was comparable between groups. In conclusion, primary immunosuppression with belatacept may enable the simultaneous avoidance of both CNIs and corticosteroids in recipients of living and deceased standard criteria donor kidneys, with acceptable rates of acute rejection and improved renal function relative to a TAC-based regimen.

Patient characteristics, diagnosis, and treatment of non-contact lens related Acanthamoeba keratitis

AIM

To review the clinical characteristics, diagnosis, and visual outcome in patients with non-contact lens related Acanthamoeba keratitis and compare the findings with reported series of contact lens associated Acanthamoeba keratitis.

METHODS

Medical and microbiology records of 39 consecutive patients with a diagnosis of Acanthamoeba keratitis, at a tertiary eyecare centre in India between January 1996 and June 1998, were analysed retrospectively.

RESULTS

A majority of the patients presented with poor visual acuity and large corneal stromal infiltrates (mean size 38.20 (SD 26. 18) mm). A predisposing factor was elicited in 19/39 (48.7%) patients (trauma 15, dirty water splash three, leaf juice one). None of the patients had worn contact lenses. Most patients (26/39 (66. 6%)) came from a low socioeconomic background. Complaint of severe pain was not a significant feature and radial keratoneuritis was seen in 1/39 (2.5%) patients. A ring infiltrate was present in 41.1% of cases. A clinical diagnosis of fungal keratitis was made in 45% of the patients before they were seen by us. However, all patients were diagnosed microbiologically at our institute based on demonstration of Acanthamoeba cysts in corneal scrapings (34/39) and/or culture of Acanthamoeba (34/39). Treatment with biguanides (PHMB, 15/38 (39.4%), PHMB with CHx, 23/38 (60.5%), one patient did not return for treatment) resulted in healing with scar formation in 27 out of 31(87.0%) followed up patients (mean time to healing 106.9 days). Overall visual outcome was poor with no statistical difference between cases diagnosed within 30 days (early) or 30 days after (late) start of symptoms. The visual outcome in cases requiring tissue adhesive (five) and keratoplasty (three) was also poor.

CONCLUSIONS

This is thought to be the largest series of cases of Acanthamoeba keratitis in non-contact lens wearers. In such cases, the disease is advanced at presentation in most patients, pathognomonic clinical features are often not seen, disease progression is rapid, and visual outcome is usually poor. Possible existence of Acanthamoeba pathotypes specifically associated with non-contact lens keratitis and unique to certain geographical areas is suggested.

Keratomycosis: clinical and microbiologic experience with dematiaceous fungi

OBJECTIVE

To assess the significance of dematiaceous fungi in the causation of keratomycosis.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Eighty-eight cases of dematiaceous fungal keratitis seen at the L. V. Prasad Eye Institute, Hyderabad, India from January 1991 through December 1996.

INTERVENTION

Only culture-proven cases were analyzed.

MAIN OUTCOME MEASURES

Predisposing factors, clinical characteristics, microbiology, treatment methods, and outcome.

RESULTS

Of 557 cases of fungal keratitis seen during the study period, dematiaceous fungi were the etiologic agents in 88 (15.7%), after Fusarium in 210 (37.6%) and Aspergillus species in 170 cases (30.4%), respectively. Trauma was the most common predisposing factor (47.7%). Fifty-three eyes (61.3%) had the classical clinical picture of yellow-white, dry raised infiltrate with feathery hyphate edges at initial examination. The characteristic macroscopic pigmentation was seen in only 24 eyes (27.27%). Septate branching fungal filaments were identified in 78 smears (88.63%) on light microscopy, of which 5 (5.7%) also showed the presence of bacteria. Curvularia species dominated the spectrum (22.7%). Treatment was started in 48 eyes with topical antifungal agents, whereas 37 received both oral and topical antifungal agents. Outcome data were available for 68 cases. Forty-nine (72%) responded to medical therapy, whereas 13 eyes required therapeutic penetrating keratoplasty and 6 eyes had to be eviscerated.

CONCLUSIONS

This is the largest series of keratitis caused by dematiaceous fungi reported to date. It clearly brings out the clinical importance of this group of corneal infections.

Ciprofloxacin-resistant Pseudomonas keratitis

OBJECTIVE

To determine ciprofloxacin resistance of corneal isolates of Pseudomonas and to review the clinical response to topical therapy in cases of ciprofloxacin-resistant Pseudomonas keratitis, where medical therapy was begun with 0.3% ciprofloxacin.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Medical and microbiology records of 141 culture-proven cases of Pseudomonas keratitis, examined between January 1991 and June 1998, were reviewed retrospectively.

METHODS

All isolates of the Pseudomonas species from corneal scrapings were tested for their susceptibility to routinely used antibiotics by the Kirby-Bauer disc-diffusion method. The minimum inhibitory concentration of ciprofloxacin was determined by the agar-dilution method for most of the isolates found resistant to ciprofloxacin. Clinical response to initial therapy with 0.3% ciprofloxacin was determined in cases of keratitis caused by ciprofloxacin-resistant Pseudomonas.

MAIN OUTCOME MEASURES

Resistance of Pseudomonas isolates to ciprofloxacin and clinical response to initial therapy with 0.3% ciprofloxacin.

RESULTS

By use of the in vitro antimicrobial susceptibility test, 22 cases of keratitis caused by ciprofloxacin-resistant Pseudomonas were identified. The minimum inhibitory concentration of ciprofloxacin for these isolates was > or =16 microg/ml (mean = 43 microg/ml). Gentamicin resistance occurred in 63.6% of isolates also, but 90.9% ciprofloxacin-resistant isolates were susceptible to amikacin. Fifteen (76.7%) of 19 patients who initially received ciprofloxacin did not show any clinical improvement even after 3 days of intensive medical therapy. The infiltrate resolved in all 8 cases where the antibiotic therapy was modified on the basis of susceptibility test. Four eyes were subjected to penetrating keratoplasty, and three were eviscerated following failure of treatment with ciprofloxacin.

CONCLUSION

True resistance to ciprofloxacin is emerging in ophthalmology even among Pseudomonas isolates; therefore, the empiric treatment of infectious keratitis with ciprofloxacin monotherapy must be critically reviewed at this time.

In vitro susceptibility of bacterial keratitis pathogens to ciprofloxacin. Emerging resistance

OBJECTIVE

To examine in vitro susceptibility of bacterial keratitis pathogens to ciprofloxacin.

DESIGN

Retrospective review.

PARTICIPANTS

The authors examined in vitro susceptibility of 1558 corneal isolates from 1303 patients with culture-proven bacterial keratitis seen at the LV Prasad Eye Institute in Hyderabad, India, during the 6-year period between March 1, 1991, and June 30, 1997.

RESULTS

Of 1558 corneal isolates, 478 (30.7%) were not sensitive to ciprofloxacin. Among the isolates, 355 (32.5%) of the 1091 gram-positive cocci were not sensitive to ciprofloxacin, and 2 (10%) of the 20 gram-positive bacilli, 22 (13.3%) of the 165 gram-negative organisms, and 99 (35.1%) of the 282 Actinomycetes and related organisms were not sensitive to ciprofloxacin. Results from chi-square for trends analysis showed a trend of significantly increasing ciprofloxacin insensitivity in bacteria between 1992 and 1997 (P = 0.011).

CONCLUSION

This is the first report of significantly increasing ciprofloxacin insensitivity among corneal pathogens. Although the lowered cost and convenience of dispensing a single, commercially available antibiotic such as ciprofloxacin in the initial treatment of bacterial keratitis is desirable, the emergence of ciprofloxacin resistance is a significant finding in this series, and the clinician should proceed with caution in the initial empiric treatment of bacterial keratitis with ciprofloxacin.

Chemical and hormonal determinants of vascular calcification in vitro

Vascular calcification is a complex process that is dependent not only on the physicochemical effects of Ca, PO(4), and pH, but also on smooth muscle factors that may be regulated by these ions as well as by 1,25-dihydroxyvitamin D(3) (calcitriol) and parathyroid hormone (PTH). These minerals and hormones were tested in a model of medial calcification in rat aorta maintained in culture for 9 days. Calcification was quantitated as incorporation of (45)Ca, alkaline phosphatase activity was measured in aortic homogenates, and osteopontin production was measured from immunoblots of culture medium. At 1.8 mM Ca (1.46 mM free), calcification occurred at or above 2.8 mM PO(4). At 3.8 mM PO(4), calcification occurred at or above 1.10 mM free [Ca]. At a constant [Ca] x [PO(4)], calcification varied directly with [Ca] and inversely with [PO(4)]. Calcification was directly related to pH between 7.19 and 7.50 but not altered by PTH or calcitriol. Alkaline phosphatase activity and osteopontin production were increased by Ca, PO(4), calcitriol, and PTH. We conclude that calcification of rat aorta in vitro requires elevation of both [Ca] and [PO(4)], and that [Ca] rather than [PO(4)] or the product of the two is the dominant determinant. The induction of alkaline phosphatase and osteopontin indicates that Ca and PO(4) have effects in addition to simple physicochemical actions. Although PTH and calcitriol did not increase calcification in vivo, they have effects on smooth muscle that could influence calcification in vivo. Calcification is enhanced by alkalinity within the range produced during hemodialysis.

Penetrating keratoplasty in children

PURPOSE

To determine the success of penetrating keratoplasty in the presence of various pediatric corneal abnormalities.

METHODS

We performed a retrospective study of pediatric corneal grafts at L.V. Prasad Eye Institute, Hyderabad, India. Outcome of pediatric corneal transplantation was evaluated in terms of anatomic and optical success and factors contributing to poor graft survival. On the basis of the corneal pathology, patients were divided into three categories: congenital, acquired nontraumatic, and acquired traumatic.

RESULTS

A retrospective analysis of 154 penetrating keratoplasties performed in 140 children, aged 14 years or younger, was done. The average follow-up was 1.3 years (range, 1 week-5 years). Grafts remained clear in 102 (66.2%) of 154 eyes. Clear grafts were achieved in 30 (63.8%) of 47 eyes with congenital opacities, 12 (54.5%) of 22 eyes with opacities from trauma, and 60 (70.6%) of 85 eyes with acquired nontraumatic opacities. Most (26 of 52) of the graft failures occurred during the first 26 weeks after surgery. Survival analysis revealed the probability of a graft remaining clear at the end of 26 weeks as 80% (SE, 3.39%). Poor graft survival could be correlated with those younger than 5 years (p = 0.0341) and performance of anterior vitrectomy (p = 0.0002). Most grafts failed because of allograft rejection (42.3%), infectious keratitis (26.9%), or secondary glaucoma (13.4%). Postoperatively, 53 eyes had > or =20/400 vision, 29 of which had > or =20/50. Vision could not be assessed in 33 eyes because of the young age.

CONCLUSION

Whereas anatomic success of pediatric keratoplasty is increasing, optical success continues to remain less than satisfactory. Early surgical intervention and intensive amblyopia therapy may promote visual recovery.

The efficacy of anal fistula plug in fistula-in-ano: a systematic review

AIMS

To assess the efficacy of anal fistula plug (AFP) procedure for the treatment of fistula-in-ano especially the complex fistulas.

METHOD

The database of PUBMED, MEDLINE, SCOPUS, EMBASE and COCHRANE LIBRARY for the period 1995-2009 was searched. A systematic analysis was carried to evaluate the success rate of AFP procedure in fistula-in-ano.

RESULTS

A total of 25 studies were extracted and 12 (n = 317) were finally included in the systematic review. The follow-up period ranged from 3.5 to 12 months. The AFP procedure had a success rate (patient cure rate) ranging from 24% to 92%. In complex fistula-in-ano in prospective studies (8/12 studies), the success rate was 35-87%. The success rate in patients with Crohn's disease was 29-86%. The success rate in the patients with single tracts was 44-93% and in patients with multiple tracts, success ranged from 20% to 71%. The abscess formation/sepsis rate was 4-29% (11/108) and the plug extrusion rate was 4-41% (42/232-19%).

CONCLUSION

Anal fistula plug procedure has a success rate ranging from 24% to 92% in different studies. In prospective studies of complex fistula-in-ano, there was a moderate success rate of 35-87%. As AFP is associated with low morbidity and sepsis, it appears to be a safe procedure. Further randomized controlled trials studying objective parameters of fistula healing are needed to substantiate these findings.

Nitric oxide stimulates the activity of a 72-kDa neutral matrix metalloproteinase in cultured rat mesangial cells

We recently demonstrated that stimulation of inducible nitric oxide synthase (iNOS) activity reduced the accumulation of collagen and fibronectin in cultured rat mesangial cells. Therefore, we examined whether nitric oxide (NO) influenced the activity of a 72 kDa neutral matrix metalloproteinase by these cells in vitro. Enzyme activity was assessed in a biotin-avidin ELISA and by zymography. Exposure of mesangial cells to the cytokines, interferon (IFN)-gamma and lipopolysaccharide (LPS), increased gelatinolytic activity by 325 +/- 60% (P < 0.025). Co-incubation with 20 mM L-arginine caused a further increase in matrix metalloproteinase levels. Addition of L-NAME, an inhibitor of iNOS, reversed the IFN-gamma/LPS-induced rise in gelatinolytic activity. Incubation with the exogenous NO donor, S-nitroso-N-acetyl-D,L-penicillamine (SNAP), resulted in a dose dependent increase in metalloproteinase activity (P < 0.01). The NO-induced changes in metalloproteinase activity were also demonstrable by zymography. These data indicate that NO modulates the activity of a 72 kDa neutral matrix metalloproteinase and suggest that altered NO production may contribute to the development of glomerulosclerosis and tubulointerstitial fibrosis in chronic renal disease states.

Sodium valproate for painful diabetic neuropathy: a randomized double-blind placebo-controlled study

BACKGROUND

Various drugs are effective in the management of painful diabetic neuropathy, but none is completely satisfactory. We previously found sodium valproate to be effective and safe in a short-term study.

AIM

To test the effectiveness and safety of sodium valproate in the management of painful diabetic neuropathy over 3 months.

DESIGN

Randomized double-blind placebo-controlled study.

METHODS

Consecutive attending patients with type 2 diabetes mellitus with painful neuropathy were asked to participate in the trial: 48 agreed. Five were excluded: three with HbA(1c) > 11, one with too low a pain level and one who withdrew consent. The remaining 43 were given either drug (group A) or placebo (group B). Each patient was assessed clinically. Quantitative assessment of pain was done by McGill Pain Questionnaire, Visual Analogue Score and Present Pain Intensity, at the beginning of the study, after 1 month and after 3 months. Motor and sensory nerve conduction velocities were measured initially and after 3 months. Liver function tests and other adverse drug-related effects were assessed periodically.

RESULTS

Of the 43 patients, four dropped out: one in group A and three in group B. There was significant improvement in pain score in group A, compared to group B, at 3 months (p < 0.001). Changes in electrophysiological data were not significant. The drug was well-tolerated by all patients, except one, who had raised serum AST and ALT levels after 1 month of treatment, and whose treatment was discontinued.

DISCUSSION

Sodium valproate is well-tolerated, and provides significant subjective improvement in painful diabetic neuropathy.

Bilateral infectious keratitis after laser in situ keratomileusis: a case report and review of the literature

OBJECTIVE

To report a case of bilateral infectious keratitis after simultaneous bilateral laser in situ keratomileusis (LASIK) and to explore appropriate preventive, diagnostic, and therapeutic measures.

DESIGN

Interventional case report and literature review.

INTERVENTION

A 22-year-old woman had bilateral corneal infiltrates after simultaneous bilateral LASIK. The same set of instruments was used for surgery on both eyes. Corneal scrapings from the edge of the infiltrate and underneath the flap were taken for microscopic examination and inoculation on culture media. Treatment consisted of irrigation of stromal bed with amikacin sulphate (2.5%) solution along with half hourly instillation of amikacin (2.5%) and cefazolin (5%) eye drops.

MAIN OUTCOME MEASURES

Causative organism and response to medical treatment.

RESULTS

Culture revealed a significant growth of Mycobacterium chelonae from the corneal scrapings of both eyes. There was progressive thinning of corneal stroma in the right eye requiring cyanoacrylate tissue adhesive application. The left eye showed progressive worsening after initial response and required penetrating keratoplasty.

CONCLUSIONS

The risk of bilateral sight-threatening complications must be kept in mind when contemplating bilateral simultaneous LASIK. Nontuberculous mycobacteria should be considered as an etiologic agent in cases of infectious keratitis occurring after LASIK. Microbiology work-up of a specimen collected directly from the site of lesion can help in early diagnosis and institution of appropriate therapy.

The value of corneal transplantation in reducing blindness

PURPOSE

To analyse the role of keratoplasty in reducing world blindness due to corneal diseases.

METHODS

Review of published literature. We collected and analysed articles published in the English language literature related to the prevalence and causes of blindness in different parts of the world, causes of corneal blindness, and outcome of corneal transplantation for various corneal diseases.

RESULTS

A total of 80% of the world's blind live in developing countries. Retinal diseases are the most important causes of blindness (40-54%) in established economy nations while cataract (44-60%) and corneal diseases (8-25%) are the most common causes of blindness in countries with less developed economies. Keratitis during childhood, trauma, and keratitis during adulthood resulting in a vascularized corneal scar and adherent leucoma are the most frequent causes of corneal blindness in developing countries. Corneal diseases are responsible for 20% of childhood blindness. Nearly 80% of all corneal blindness is avoidable. The outcome of keratoplasty for vascularized corneal scar and adherent leucoma is unsatisfactory, necessitating repeat surgery in a high proportion of these cases. Other barriers for keratoplasty in these nations are suboptimal eye banking, lack of trained human resources, and infrastructure.

CONCLUSIONS

Since the developing world carries most of the load of corneal blindness and the major causes of corneal blindness are corneal scar and active keratitis, development of corneal transplantation services need a comprehensive approach encompassing medical standards in eye banking, training of cornea specialists and eye banking personnel and exposure of ophthalmologists to care of corneal transplants for better follow-up care. However, concerted efforts should be made to develop and implement prevention strategies since most corneal blindness is preventable.

Expanding multiple antibiotic resistance among clinical strains of Vibrio cholerae isolated from 1992-7 in Calcutta, India

Antimicrobial susceptibilities of Vibrio cholerae strains isolated from cholera patients admitted to the Infectious Diseases Hospital, Calcutta, India for 6 years were analysed to determine the changing trends; 840 V. cholerae strains isolated in 1992-1997 were included in this study. Among V. cholerae serogoup O1 and O139, ampicillin resistance increased from 1992 (35 and 70%, respectively) to 1997 (both serogroups 100%). Resistance to furazolidone and streptomycin was constantly high among V. cholerae O1 strains with gradual increase in resistance to other drugs such as ciprofloxacin, co-trimoxazole, neomycin and nalidixic acid. V. cholerae O139 strains exhibited susceptibilities to furazolidone and streptomycin comparable with those of O1 strains. However, after initial increase in resistance to chloramphenicol and co-trimoxazole, all the V. cholerae O139 strains became susceptible to these two drugs from 1995 onwards. Both V. cholerae O1 and O139 remained largely susceptible to gentamicin and tetracycline. V. cholerae non-O1, non-O139 strains, in contrast, exhibited high levels of resistance to virtually every class of antimicrobial agents tested in this study especially from 1995. Kruskal-Wallis one-way analysis showed that V. cholerae O1 Ogawa serogroup exhibited significant yearly increase in resistance to nine antibiotics followed by non-O1 non-O139 and O139 strains to six antibiotics and two antibiotics respectively. Interesting observation encountered in this study was the dissipation of some of the resistant patterns commonly found among V. cholerae non-O1 non-O139 or O1 serogroups to the O139 serogroup and vice versa during the succeeding years.

Corneal ulceration in the elderly in Hyderabad, south India

AIMS

To report demographic, microbiological, therapeutic, anatomical, and visual results of corneal ulceration in the elderly patients seen at a tertiary eye care centre in south India.

METHODS

102 consecutive cases of microbial keratitis in patients 65 years and older were studied. Inclusion criteria were: (i) presence of corneal stromal infiltrate upon slit lamp examination; and (ii) microbiological evaluation of corneal scrapings for suspected microbial keratitis.

RESULTS

The principal predisposing factors identified in this study were ocular disease (38.2%), previous ocular surgery in the same eye (29.4%), trauma (17.6%), and severe systemic disease (16.7%). Contact lens wear was associated with only two cases (2.0%). 99 organisms were isolated in cultures of corneal scrapings from 74 (72.5%) of the 102 cases. Staphylococcus epidermidis (31.1%), filamentous fungi (25.7%), and Streptococcus pneumoniae (13.5%) were the most common isolates. 12 eyes (11.8%) required surgery, 15 (14.7%) eventually required evisceration, and nine (9.6%) of the 94 followed patients achieved an unaided vision of 20/60 or better at last follow up.

CONCLUSIONS

This work represents the largest recent single centre study on (non-viral) microbial keratitis in the elderly, its management, and outcomes of therapy. While the predisposing factors differ from those of general population, the spectrum of microbes responsible for keratitis in the elderly appears to reflect the local microbial flora rather than a predilection for elderly patients. Delay in diagnosis and systemic conditions associated with advancing age probably contribute to poorer outcome from therapeutic measures.

Outcome of pterygium surgery: analysis over 14 years

AIM

To report the outcome of pterygium surgery performed at a tertiary eye care centre in South India.

METHODS

Retrospective analysis of medical records of 920 patients (989 eyes) with primary and recurrent pterygia operated between January 1988 and December 2001. The demographic variables, surgical technique (bare sclera, primary closure, amniotic membrane transplantation (AMT), conjunctival autograft (CAG), conjunctival-limbal autograft (CLAG), or surgical adjuvants), recurrences and postoperative complications were analysed.

RESULTS

A total of 496 (53.9%) were male and 69 (7.5%) had bilateral pterygia. Bare sclera technique was performed in 267 (27.0%) eyes, primary conjunctival closure in 32 (3.2%), AMG in 123 (12.4%), CAG in 429 (43.4%), and CLAG in 70 (7.1%). Adjuvant mitomycin C was used in 44 (4.4%) cases. The mean duration of follow-up was 8.9+/-17.0 and 5.9+/-8.8 months for unilateral primary and recurrent pterygia, respectively. The overall recurrence rate was 178 (18.0%). Following primary and recurrent unilateral pterygium excision respectively, recurrences were noted in 46 (19.4%) and 1 (33.3%) eyes after bare sclera technique, five (16.7%) and 0 after primary closure, 28 (26.7%) and 0 with AMG, 42 (12.2%) and five (31.3%) with CAG, and nine (17.3%) and two (40%) with CLAG. Recurrences were significantly more in males with primary (23.3 vs 10.7%, P<0.0001) and recurrent (26.7 vs 0%, P=0.034) pterygia, and in those below 40 years (25.2 vs 14.8%, P=0.003).

CONCLUSION

CAG appears to be an effective modality for primary and recurrent pterygia. Males and patients below 40 years face greater risk of recurrence. Bare sclera technique has an unacceptably high recurrence. Prospective studies comparing CAG, CLAG, and AMG for primary and recurrent pterygia are needed.

Outbreak of influenza in a neonatal intensive care unit

An outbreak of influenza A/Victoria/3/75 (H3N2) involving five infants in a neonatal intensive care unit is described. The clinical signs and symptoms were indistinguishable from those seen in bacterial sepsis. There was no evidence of meningoencephalitis. All infants recovered without any sequelae.

Ocular nocardia infections with special emphasis on the cornea

Nocardia are aerobic, gram-positive, nonmotile and branching filamentous bacteria. Corneal infection by Nocardia is rare. Trauma is the most common predisposing factor. Isolated case reports of nocardial infection associated with contact lens wear and laser in situ keratomileusis (LASIK) have been reported. The clinical picture usually consists of superficial patchy infiltrates, which may be arranged in a wreath pattern. Presence of gram-positive, branching, beaded filaments that stain with 1% acid-fast stain (using 1% sulfuric acid, modified Kinyoun's method) in smears of corneal scrapings is suggestive of nocardial infection. Nocardia grow on commonly used media as tiny, white, dry colonies. Available knowledge and clinical experience suggest that although sulfacetamide eyedrops can be tried as the initial drug, trimethoprim-sulfamethoxazole and amikacin are effective drugs. Once therapy is initiated, the infiltrate responds promptly and resolves, forming a corneal scar with or without vascularization, and good visual recovery can be expected.

Divalproex sodium in the management of post-herpetic neuralgia: a randomized double-blind placebo-controlled study

BACKGROUND

Post-herpetic neuralgia is difficult to treat. Divalproex sodium (valproic acid and sodium valproate in molar ratio 1:1) has been used successfully in the management of various painful neuropathies.

AIM

To study the effectiveness and safety of divalproex sodium in the management of post-herpetic neuralgia.

DESIGN

Randomized double-blind placebo-controlled trial.

METHODS

We enrolled 48 consecutively attending out-patients with post-herpetic neuralgia, out of whom three were excluded (two had insufficient pain, one withdrew consent). Quantification of pain was by Short Form-McGill pain questionnaire (SF-MPQ), visual analogue scale (VAS), present pain intensity score (PPI) and 11 point Likert scale (11 PLS) at the beginning of the study, after 2 weeks, 4 weeks and at the end of the study (8 weeks). We also assessed patients' global impression of change by questionnaire at the end of the study.

RESULTS

After 8 weeks treatment with 1000 mg/day divalproex sodium, there was significant reduction in pain: SF-MPQ, 20.47 +/- 2.29 to 11.90 +/- 6.52 (p < 0.0001); PPI 4.0 +/- 0.52 to 1.95 +/- 1.29 (p < 0.0001); VAS 70.17 +/- 9.21 to 31.27 +/- 29.74 (p < 0.0001) and 11 PLS 6.97 +/- 0.73 to 3.63 +/- 2.34 (p < 0.0001) in comparison to placebo (means +/- SEM). The 'global impression of change' questionnaire showed much or moderate improvement in pain in 58.2% of patients receiving divalproex vs. 14.8% of those receiving placebo. The drug was well tolerated by all patients, except one who developed severe vertigo after 10 days of treatment.

DISCUSSION

Divalproex sodium provides significant pain relief in patients of post-herpetic neuralgia, with very little incidence of adverse reactions. These data provide a basis for longer trials in a larger group of patients.

Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis

AIM

A systematic review was carried out to analyse continence at 2 years or more after lateral internal sphincterotomy (LIS) for chronic anal fissure (CAF).

METHOD

PubMed, MEDLINE, Scopus, Embase, Ovid, SCI, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar were used to search the literature from 1969-2012 for studies reporting a follow-up of more than 2 years after LIS for CAF. The primary outcome parameter analysed was continence. The secondary outcome parameters included success rate, recurrence, incidence of postoperative abscess and fistula formation and patient satisfaction.

RESULTS

Of 324 studies screened, 22 (n = 4512) were included. The mean follow-up period ranged from 24-124 months. The overall continence disturbance rate was 14% (95% CI 0.09-0.2). Weighted analysis showed flatus incontinence in 9% (95% CI 0.04-0.16), soilage/seepage in 6% (95% CI 0.03-0.1), accidental defaecation in 0.91% (95% CI 0.003-0.02), incontinence to liquid stool in 0.67% (95% CI 0.001-0.02) and incontinence to solid stool in 0.83% (95% CI 0.003-0.02) of patients.

CONCLUSION

The long-term risk of continence disturbance after lateral internal sphincterotomy is significant. Randomized controlled trials with a long follow-up are needed to substantiate these findings and to redefine its role in the treatment of chronic anal fissure.