In vivo confocal microscopy of climatic droplet keratopathy

We describe the corneal microstructural changes in a patient with spheroidal degeneration using in vivo confocal microscopy. Multiple hypo‐ and hyper‐reflective spherical lesions were observed in the anterior corneal stroma and Bowman's layer ranging from 45 to 220 μm in size. The corneal epithelium, posterior stroma and endothelium were otherwise unaffected. In vivo confocal microscopy demonstrates good correlation with excised histological samples in climatic droplet keratopathy. It provides a non‐invasive technique to examine the living cornea for degenerative disease and acts as a bridge between clinical and laboratory observations.     

THE USE OF PHARMACEUTICALS FOR DIALYSIS PATIENTS. HOW WELL DO WE KNOW OUR PATIENTS' ALLERGIES?

Medication allergies are potentially important but usually poorly documented in patient medical records. Allergy awareness by clinical staff may be low in the haemodialysis population despite their regular attendance for treatment sessions. A cross‐sectional study of 25 patients in a satellite unit was performed. All known allergies were not documented in 36% of patients despite the patients being known to the renal service for more than five years. 81% of allergies were medication allergies. The rest were due to topical agents. 57% (affecting 8 patients) of the medication allergies related to antibiotics (especially penicillin). Four patients had multiple antibiotic allergies. The nature and severity of these allergies was not well documented. This study demonstrates that despite being under long‐term care there remains incomplete information, which is vital for optimal safe practice. Without such information, the potential for adverse events and anaphylaxis is significant in a population that is exposed to numerous pharmaceutical agents and are frequently prescribed antibiotics. Medication histories should be comprehensively re‐evaluated regularly and prescribing should not occur unless the allergy box is completed.     

Alterations of the Cell Cycle Regulators Cyclin D1, Cyclin A, p27, p21, p16, and pRb in Apocrine Metaplasia of the Breast

Abstract:  G1/S transition defects have been a proposed requirement for tumor development. Apocrine metaplasia (APM) in the breast has been held as a sign of benignity. Yet, a number of studies have reported the presence of molecular abnormalities in some forms of APM suggesting a possible oncogenic potential for some of these lesions. We currently investigate the role of some of the cell cycle proteins, previously reported to be de-regulated in breast cancer, in an attempt to assess their significance in APM. Using immunohistochemistry, the expression of cyclin D1, cyclin A, p27, p21, p16, pRb and Ki-67 was examined in 93 cases of APM. The cases were divided into nonpapillary (NAPM) (30 cases) and papillary metaplasia (PAPM) (63 cases). PAPM was further subdivided into simple papillary (SPAPM) (29 cases), complex papillary (28 cases) and highly complex papillary (six cases). For statistical analysis, the last two groups were merged together (CPAPM). The results showed that increased histological complexity was associated with significant increase of proliferative capacity and alterations of the cell cycle control. The median Ki-67 index was 1.5% in SPAPM and 4.8% in the CPAPM. Also, alterations of the cell cycle regulators were significantly higher in the CPAPM than in the SPAPM. NAPM was generally similar to normal breast epithelium. Apocrine cells were negative for p16 while pRb was expressed in all cases. These findings suggest that in complex forms of APM, there is a considerable degree of cellular unrest. This may contribute to increased susceptibility to carcinogenesis.     

Evaluation of emergence delirium in Asian children using the Pediatric Anesthesia Emergence Delirium Scale

Background: Emergence delirium (ED) is a common problem in children recovering from general anesthesia. ED causes disruption in the postanesthetic care unit, making nursing and monitoring more difficult, and is potentially dangerous to the child. The greatest hindrance to understanding ED was the lack of a standardized tool to assess it. The Pediatric Anesthesia Emergence Delirium (PAED) Scale was recently described to measure the degree of ED in children. In this prospective observational study, we sought to evaluate the incidence of ED by grading emergence behavior using the PAED Score in healthy Asian children undergoing outpatient surgery. Methods: Three hundred sixteen children aged 2–12 years undergoing general anesthesia for elective outpatient surgery were included. No premedication was administered. Induction behavior was graded using the induction compliance checklist, and the presence of any excitation on induction documented. Emergence behavior was recorded using the PAED Scale, and the children were separately assessed for clinical agitation. Results: One hundred and thirty‐six children (43%) had PAED Scores >0 and 33 (10.4%) had PAED Scores of ≥10. Only 28 children (8.9%) had clinical agitation consistent with ED, the rest were agitated for other reasons. A score of ≥10 on the PAED Scale was the best discriminator between presence and absence of clinical agitation. The area under the receiver operating characteristic curve for PAED Score of ≥10 was 0.98, with a true‐positive rate (sensitivity) of 0.85 and a false‐positive rate (1‐specificity) of 0.041. Four factors were found to be predictive of ED. These include young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening. Conclusions: The incidence of ED is approximately 10% in our population of healthy, unpremedicated Asian children undergoing day surgery. Young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening were predictive risk factors for ED in our population. A PAED Score of ≥10 was correlated with clinically significant ED and appeared to be the ideal cutoff score for ED.