Corticocapsular adhesions and their effect during cataract surgery

PURPOSE: To identify the types of corticocapsular adhesions by their preoperative clinical appearance and evaluate the difficulties they pose during cataract surgery. SETTING: Iladevi Cataract & IOL Research Center, Ahmedabad, India. METHODS: Seventy-six eyes with age-related senile cataract scheduled for phacoemulsification were identified as having corticocapsular adhesions. Preoperatively, the eyes were assessed at the slitlamp to determine the type of corticocapsular adhesions present. During surgery, the surgeon graded nucleus rotation after single-site cortical-cleaving hydrodissection as easy, difficult, or not possible. Additional multiquadrant-focal hydrodissection was performed. The surgeon's impressions of the presence of corticocapsular adhesions and visualization of the furry surface of the epinucleus were noted. RESULTS: Corticocapsular adhesions were confirmed in 86.84% of eyes. Equatorial corticocapsular adhesions alone or in combination were present in 72 eyes (94.74%) eyes, anterior corticocapsular adhesions in 40 (52.74%), and posterior corticocapsular adhesions in 42 (56.26%). Rotation of nucleus was not possible in 47.37% eyes, difficult in 39.47%, and easy in 13.16%. CONCLUSIONS: The surgeon should perform a thorough preoperative slitlamp evaluation in extreme gaze with a fully dilated pupil. Equatorial corticocapsular adhesions, which were present in most eyes, made nucleus rotation difficult. Additional multiquadrant and focal cortical-cleaving hydrodissection helped separate the adhesions and achieve successful rotation.     

Autosomal dominant progressive nephropathy with deafness: linkage to a new locus on chromosome 11q24

Focal segmental glomerulosclerosis (FSGS) and Alport syndrome (AS) are two major causes of end-stage renal disease (ESRD). A few families with autosomal dominant FSGS have been reported with linkage to chromosome 19q13 or 11q22, while AS is usually linked to mutations in type IV collagen (COL4) subunit genes. A phenotype resembling AS may also be seen with myosin heavy chain-9 (MYH9) gene mutations. This study ascertained a multigeneration family (CHP-177) with clinical aspects of both FSGS and AS where we identified a new locus for the trait. A genome-wide scan was performed with 400 markers, and fine mapping was performed for chromosome 11 markers. Data were analyzed by GENEHUNTER and VITESSE under various models. CHP-177 is a 39-member kindred residing near New Delhi, India, with seven affecteds and showed male-to-male transmission. Two members had ESRD. Renal biopsies showed both FSGS lesions and thin glomerular basement membranes. Five of the affecteds also had sensorineural deafness, which involved both low and high frequency in some members. The AS loci, i.e., COL4A3/COL4A4 and MYH9 (LOD scores: -6.1 and -4.3, respectively) and FSGS loci, on 19q13 and 11q22, were excluded from linkage. A significant evidence of linkage was observed for 11q24 region, with a multipoint LOD (z-score) of 3.2 for marker D11S4464 at theta = 0. The z-1 confidence interval for the linked region spans a genetic distance of 7 cM. This study thus reports an autosomal dominant nephropathy with features of both FSGS and AS in which linkage to currently known loci for such phenotypes was excluded and a new locus on 11q24 was identified. The findings suggest further locus heterogeneity for the autosomal dominant nephropathy phenotype.     

Factors influencing physicians' reported use of anticoagulation therapy in nonvalvular atrial fibrillation: a cross-sectional survey

BACKGROUND: Some elderly patients with nonvalvular atrial fibrillation (NVAF) who might benefit from warfarin therapy do not receive it. OBJECTIVE: The goal of this cross-sectional study was to identify physicians' attitudes and beliefs that are associated with their reported use of warfarin in case scenarios. METHODS: A self-administered survey was mailed to a cross-section of general internists randomly selected from a national pool of physicians in the American Medical Association Masterfile. Fourteen clinical vignettes were used, incorporating various comorbid conditions and risk factors for either major bleeding episode or embolic cerebrovascular accident (CVA). The outcome measure was the number of case vignettes for which warfarin was recommended. RESULTS: A total of 142 completed surveys (33% of 426 eligible respondents; 109 men, and 32 women [1 respondent did not provide gender]; mean [SD] age, 45 [10] years) were received. The median number of case vignettes for which warfarin was recommended was 10 (interquartile range, 8-12). We found no relationship between the perceived benefits of warfarin and its use in the case vignettes. However, the perceived risk for warfarin associated hemorrhage was strongly associated with reported warfarin use (P < 0.001). The physicians in our sample provided estimates of the annual rate of warfarin-associated intracerebral hemorrhage that were >10-fold higher than literature-based estimates, and physicians providing higher risk estimates tended to use warfarin less often. On multivariate logistic regression, physicians who recommended warfarin use in more vignettes were less likely to report anticipated regret of committing an error of omission (ischemic CVA in an untreated NVAF patient) (P < 0.001) or a loss-aversive risk preference (P = 0.027), and had a lower perceived annual risk for hemorrhage with warfarin (P < 0.001). Physician age, sex, primary mechanism of reimbursement, academic appointment, and the NVAF patient volume all were unrelated to warfarin use. CONCLUSIONS: Although the decision to use warfarin in NVAF was not driven by the perceived benefit, the perceived risks strongly affected warfarin use. Response bias is a potential limitation, but our data strongly suggest that physicians' attitudes toward anticipated regret and risk aversion can impact on their treatment recommendations.     

Nasopharyngeal angiofibroma: staging and management - a review of the case series report

Juvenile angiofibroma is a rare, highly vascular, histologically benign but locally invasive tumor, affecting predominantly male adolescents. Here we present a case series of 45 patients of nasopharyngeal angiofibroma, their clinical presentation, staging and the various surgical approaches for their excision.     

Double breasting repair of urethral fistula in a patient with perineal abscess secondary to a large urethral stone

We report here a case of urethral fistula managed successfully following incision and drainage for the urethral abscess secondary to a large urethral stone leading to a large diverticulum (another rare condition) by using the technique of double breasting, where we used the redundant urethra and overlying skin.     

An unusual case of solitary scleroma of cheek

Scleroma is a disease of unwashed and occurs in people living in poor unhygienic conditions. Commonly it involves respiratory tract. We encountered a case of scleroma over cheek presenting as a solitary nodule without any sign of nasal scleroma.