A case report and review of filamentary keratitis.

BACKGROUND: Filamentary keratitis is most often a chronic corneal condition, characterized by filaments attached at one or both ends to the cornea. Patients often experience foreign body sensation, grittiness, discomfort, photophobia, blepharospasm, and increased blinking. Filamentary keratitis is commonly the result of aqueous deficient dry eye syndrome. Management options include lubrication, punctal occlusion, removal of filaments, hypertonic saline, mucolytic agents, anti-inflammatory agents, and therapeutic contact lenses. CASE REPORT: A 58-year-old man came to us with acute symptoms of pain, photophobia, and redness x 2 days 0.S. The diagnosis of filamentary keratitis was made based on the clinical findings of positively staining mucus strands attached to the superior cornea. The patient was also found to have dry eye, blepharitis, and floppy eyelid syndrome. Numerous treatment regimens were implemented, including lubrication with non-preserved artificial tears, lubricating ointment, and topical steroids. The patient's condition was finally best managed with silicone plug punctal occlusion and therapeutic contact lenses. CONCLUSION: Filamentary keratitis can be a recurrent and incapacitating condition that may prove difficult to manage.     

Comanagement of patients with congestive heart failure by family physicians and cardiologists: frequency, timing, and patient characteristics

BACKGROUND: Many patients with congestive heart failure (CHF) receive care solely from a primary care physician, while some receive care from both a primary care physician and a cardiologist. Patients in the latter type of care relationships have not been described. The principal objectives of our study were to determine what percentage of patients with CHF are comanaged, the characteristics of comanaged CHF patients, and when in the natural history of CHF this relationship is initiated. METHODS: A retrospective record review was conducted of all patients who met the modified Framingham criteria for the diagnosis of CHF in a large community-based family practice office. Comanagement was defined as an ongoing relationship with a cardiologist characterized by a minimum of one visit to the cardiologist's office in the year of evaluation. We divided the natural history of CHF into 4 stages to describe the timing of the initial referral to the cardiologist: I Prediagnosis; II Diagnosis; III Progression; and IV Terminal. RESULTS: Of 151 patients identified with CHF, 36% of the patients were comanaged by a primary care physician and a cardiologist. The comanagement relationship often began early in the development of CHF, 20% at stage I and 54% at stage II. The patients who were comanaged were younger, predominately men, had a greater frequency of myocardial infarction, were more likely to have decreased systolic function, were on more cardiac medications, and had fewer hospitalizations for CHF exacerbations compared with CHF patients managed solely by family physicians. CONCLUSIONS: Comanagement of patients with CHF is a common occurrence, and comanaged CHF patients have distinct characteristics from those managed solely by family physicians. These results have implications for the quality and cost of caring for patients with CHF and suggest that more detailed study is required.     

A comparison between long-term survivors of Hodgkin's disease and their siblings on fatigue level and factors predicting for increased fatigue.

PURPOSE: To compare the level of fatigue in survivors of Hodgkin's disease and their siblings, and to explore factors associated with increased fatigue. METHODS: Survivors of Hodgkin's disease 5 years or more from diagnosis and their siblings completed a questionnaire study. Fatigue level was measured using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) instrument, with lower scores reflecting increased fatigue. Multiple regression models were used to identify factors associated with fatigue level in the two populations. RESULTS: Five hundred and eleven survivors (median age 44 years; range 16-82) and 224 siblings (median age 44 years; range 16-79) returned the completed questionnaire. The response rates were 61% and 58%, respectively. Compared with siblings, survivors were significantly more likely to report the presence of cardiac disease (26% versus 16%; P = 0.001) and hypothyroidism (65% versus 3%; P <0.001), and had a significantly lower mean FACIT-F score (40.7 and 42.2; P = 0.05). On multivariable analysis, factors significantly associated with increased fatigue in survivors were reports of cardiac disease (P <0.001), psychiatric condition (P <0.001), history of tobacco use (P = 0.004) and low exercise frequency (P = 0.03). For siblings, the only independent factor associated with increased fatigue was low exercise frequency (P = 0.03). CONCLUSIONS: Survivors of Hodgkin's disease were more fatigued than their siblings. The difference was modest but statistically significant. The significant association between fatigue and cardiac disease suggests the importance of screening for underlying cardiac dysfunction in survivors with symptoms of fatigue. The association between fatigue and smoking history may be due to exacerbation of late medical complications of Hodgkin's disease by tobacco use.     

Degradation and resilience in Louisiana salt marshes after the BP-Deepwater Horizon oil spill

More than 2 y have passed since the BP-Deepwater Horizon oil spill in the Gulf of Mexico, yet we still have little understanding of its ecological impacts. Examining effects of this oil spill will generate much-needed insight into how shoreline habitats and the valuable ecological services they provide (e.g., shoreline protection) are affected by and recover from large-scale disturbance. Here we report on not only rapid salt-marsh recovery (high resilience) but also permanent marsh area loss after the BP-Deepwater Horizon oil spill. Field observations, experimental manipulations, and wave-propagation modeling reveal that (i) oil coverage was primarily concentrated on the seaward edge of marshes; (ii) there were thresholds of oil coverage that were associated with severity of salt-marsh damage, with heavy oiling leading to plant mortality; (iii) oil-driven plant death on the edges of these marshes more than doubled rates of shoreline erosion, further driving marsh platform loss that is likely to be permanent; and (iv) after 18 mo, marsh grasses have largely recovered into previously oiled, noneroded areas, and the elevated shoreline retreat rates observed at oiled sites have decreased to levels at reference marsh sites. This paper highlights that heavy oil coverage on the shorelines of Louisiana marshes, already experiencing elevated retreat because of intense human activities, induced a geomorphic feedback that amplified this erosion and thereby set limits to the recovery of otherwise resilient vegetation. It thus warns of the enhanced vulnerability of already degraded marshes to heavy oil coverage and provides a clear example of how multiple human-induced stressors can interact to hasten ecosystem decline.     

Quality of Depression among Suicidal Inpatient Youth

This study examined the relationship between suicidality and dependent and self-critical depression among adolescents. Ninety-six adolescents participated: 32 suicidal inpatients, 32 nonsuicidal inpatients and 32 healthy controls. The groups were matched for gender, age and education. Participants completed the Depressive Experience Questionnaire for Adolescents (DEQ-A), the Cognition Checklist (CCL), and the Multi-Attitude Suicidal Tendencies Scale (MAST). Results indicated that suicidal adolescents have significantly higher levels of self-critical and dependent depression, compared to nonsuicidal inpatients and healthy controls. The distinctive quality of depression among suicidal adolescents suggests assessment and treatment strategies for these individuals.     

Impact of diagnostic and end-of-induction Curie scores with tandem high-dose chemotherapy and autologous transplants for metastatic high-risk neuroblastoma: A report from the Children's Oncology Group

Background

Diagnostic mIBG (meta-iodobenzylguanidine) scans are an integral component of response assessment in children with high-risk neuroblastoma. The role of end-of-induction (EOI) Curie scores (CS) was previously described in patients undergoing a single course of high-dose chemotherapy (HDC) and autologous hematopoietic cell transplant (AHCT) as consolidation therapy.

Objective

We now examine the prognostic significance of CS in patients randomized to tandem HDC and AHCT on the Children's Oncology Group (COG) trial ANBL0532.

Study design

A retrospective analysis of mIBG scans obtained from patients enrolled in COG ANBL0532 was performed. Evaluable patients had mIBG-avid, International Neuroblastoma Staging System (INSS) stage 4 disease, did not progress during induction therapy, consented to consolidation randomization, and received either single or tandem HDC (n = 80). Optimal CS cut points maximized the outcome difference (≤CS vs. >CS cut-off) according to the Youden index.

Results

For recipients of tandem HDC, the optimal cut point at diagnosis was CS = 12, with superior event-free survival (EFS) from study enrollment for patients with CS ≤ 12 (3-year EFS 74.2% ± 7.9%) versus CS > 12 (59.2% ± 7.1%) (p = .002). At EOI, the optimal cut point was CS = 0, with superior EOI EFS for patients with CS = 0 (72.9% ± 6.4%) versus CS > 0 (46.5% ± 9.1%) (p = .002).

Conclusion

In the setting of tandem transplantation for children with high-risk neuroblastoma, CS at diagnosis and EOI may identify a more favorable patient group. Patients treated with tandem HDC who exhibited a CS ≤ 12 at diagnosis or CS = 0 at EOI had superior EFS compared to those with CS above these cut points.     

Prevalence and prognostic implication of restenosis or dilatation at the aortic coarctation repair site assessed by cardiovascular MRI in adult patients late after coarctation repair

Background

Cardiovascular magnetic resonance (CMR) is ideal for assessing patients with repaired aortic coarctation (CoA). Little is known on the relation between long-term complications of CoA repair as assessed by CMR and clinical outcome. We examined the prevalence of restenosis and dilatation at the repair site and the long-term outcome in patients with repaired CoA.

Methods and results

CMR imaging and clinical data for adult CoA patients (247 patients aged 33.0 ± 12.8 years, 60% male), were analyzed. The diameter of the aorta at the repair site was measured on CMR and its ratio to the aortic diameter at the diaphragm (repair site-diaphragm ratio, RDR) was calculated. Restenosis (RDR ≤ 70%) was present in 31% of patients (and significant in 9% [RDR < 50%]), and dilatation (RDR > 150%) in 13.0%. A discrete aneurysm at the repair site was observed in 9%. Restenosis was more likely after resection and end–end anastomosis, whereas dilatation after patch repair. Systemic hypertension was present in 69% of patients. Of the hypertensive patients, blood pressure (133 ± 20/73 ± 10 mm Hg) was well controlled in 93% with antihypertensive therapy. Mortality rate over a median length of 5.9 years was low (0.69% per year, 95% CI: 0.33–1.26), but significantly higher than age-matched healthy controls (standardised mortality ratio 2.86, CI 1.43–5.72, p < 0.001).

Conclusion

Restenosis or dilatation at the CoA repair site as assessed by CMR is not uncommon. Medium term survival remains good, however, albeit lower than in the general population. Life-long follow-up and optimal blood pressure control are likely to secure a good longer term outlook in these patients.