Ultrasound biomicroscopic features of spherophakia

Background: Spherophakia is an uncommon diagnosis. This is the first case report of spherophakia evaluated by ultrasound biomicroscopy.
Methods: Ultrasound biomicroscopy is a new diagnostic technique developed by one of the authors and provides images with microscopic resolution of the anterior segment. A patient with spherophakia was evaluated by ultrasound biomicroscopy (Zeiss-Humphrey, 50MHz) before and after YAG laser iridotomy.
Results: Ultrasound biomicroscopic assessment revealed a shallow anterior chamber, a very steep anterior lens curvature, iridolenticular contact, elongated zonules, and an increased distance between the lens equator and the ciliary processes. Angle closure glaucoma was due to a pupil block mechanism. The pupil block was relieved by YAG laser iridotomy.
Conclusions: Ultrasound biomicroscopy is a useful technique to confirm the diagnosis of spherophakia. The pupil block in spherophakia is relieved by YAG laser iridotomy.     

Mechanical Loading Stimulates Differentiation of Periodontal Osteoblasts in a Mouse Osteoinduction Model: Effect on Type I Collagen and Alkaline Phosphatase Genes

The effects of mechanical loading on the osteoblast phenotype remain unclear because of many variables inherent to the current experimental models. This study reports on utilization of a mouse tooth movement model and a semiquantitative video image analysis of in situ hybridization to determine the effect of mechanical loading on cell-specific expression of type I collagen (collagen I) and alkaline phosphatase (ALP) genes in periodontal osteoblasts, using nonosseous cells as an internal standard. The histomorphometric analysis showed intense osteoid deposition after 3 days of treatment, confirming the osteoinductive nature of the mechanical signal. The results of in situ hybridization showed that in control periodontal sites both collagen I and ALP mRNAs were expressed uniformly across the periodontium. Treatment for 24 hours enhanced the ALP mRNA level about twofold over controls and maintained that level of stimulation after 6 days. In contrast, collagen I mRNA level was not affected after 24 hours of treatment, but it was stimulated 2.8-fold at day 6. This increase reflected enhanced gene expression in individual osteoblasts, since the increase in osteoblast number was small. These results indicate that (1) the mouse model and a semiquantitative video image analysis are suitable for detecting osteoblast-specific gene regulation by mechanical loading; (2) osteogenic mechanical stress induces deposition of bone matrix primarily by stimulating differentiation of osteoblasts, and, to a lesser extent, by an increase in number of these cells; (3) ALP is an early marker of mechanically-induced differentiation of osteoblasts. (4) osteogenic mechanical stimulation in vivo produces a cell-specific 2.8-fold increase in collagen gene expression in mature, matrix-depositing osteoblasts located on the bone surface and within the osteoid layer. Received: 9 August 1999 / Accepted: 4 February 2000     

Ebola Policies That Hinder Epidemic Response by Limiting Scientific Discourse

There is an unprecedented epidemic of Ebola virus disease (EVD) in west Africa. There has been a strong response from dedicated health professionals. However, there have also been irrational and fear-based responses that have contributed to misallocation of resources, stigma, and deincentivizing volunteers to combat Ebola at its source. Recently, the State of Louisiana Department of Health and Hospitals issued a ban on those coming from affected countries wishing to attend the annual meetings of American Society of Tropical Medicine and Hygiene and the American Public Health Association, both of which were held in New Orleans. We argue against such policies, question evidence and motivations, and discuss their practical and ethical implications in hampering effective responses to EVD by the scientific community. We aim to shed light on this issue and its implications for the future of public health interventions, reflect on the responsibility of health providers and professional societies as advocates for patients and the public health, and call for health professionals and societies to work to challenge inappropriate political responses to public health crises.On October 28, 2014, 5 days before the annual meeting of the American Society of Tropical Medicine and Hygiene (ASTMH) in New Orleans, the Louisiana Department of Health and Hospitals (DOHH) in conjunction with the Governor''s Office for Homeland Security and Emergency Preparedness announced to all ASTMH attendees that “individuals who traveled to and returned from the countries of Sierra Leone, Liberia or Guinea in the past 21 days, or have had contact with a known EVD [Ebola virus disease] patient in that time period, should NOT travel to New Orleans to attend the conference. Given that conference participants with a travel and exposure history for EVD are recommended not to participate in large group settings (such as this conference) or to utilize public transport, we see no utility in you traveling to New Orleans to simply be confined to your room.” Furthermore, the letter stated that “from a medical perspective, asymptomatic individuals are not at risk of exposing others; however, the State is committed to preventing any unnecessary exposure of Ebola to the general public. In Louisiana, we love to welcome visitors, but we must balance that hospitality with the protection of Louisiana residents and other visitors.”¹While acknowledging recommendations of the Centers for Disease Control and Prevention (CDC) that asymptomatic individuals are not a risk to others, the statement went beyond the CDC guidelines and implied a potential threat from conference attendees, even those without exposure to EVD, based solely on travel history to countries affected by the epidemic. We believe the DOHH should appreciate the negative ramifications of unscientifically based travel bans and quarantine policies and rather, follow evidence-based guidelines to protect the public and avoid legitimizing irrational responses caused by fear.Ironically, the ASTMH is the pre-eminent professional society in tropical medicine, and the annual meeting of the society is an ideal place to share scientific advances in response to EVD, an interchange that benefits both the United States and all countries facing the current epidemic. Prospective conference attendees who are actively engaged in the EVD response were prepared to share their experiences in scientific sessions, but some could not attend. Numerous attendees from west Africa, including countries not directly affected by EVD, may have been afraid to attend because of not knowing whether they would be turned away on arrival. Moreover, the DOHH reiterated their travel ban for attendees of the annual conference of the American Public Health Association held November 15–19 in New Orleans.Ebola virus causes a deadly disease, and it typically occurs in places that have underresourced and overwhelmed health systems; whereas prior outbreaks have been small and contained, the current outbreak in west Africa is of unprecedented scale.² In September of 2014, the World Health Organization declared the current Ebola virus disease (EVD) outbreak a major threat to global health and security and requested that all global health organizations and supporting countries maximize their efforts to combat the disease at its source.³ Sporadic cases in high-income countries have occurred connected to this outbreak. Because the virus is known to be transmitted by physical contact, the risk of an EVD epidemic in countries with well-equipped public health and medical systems is small. In the past, limited quarantine procedures and travel bans have been enacted for highly contagious diseases, such as Severe Acute Respiratory Syndrome (SARS). However, considering limited transmission of Ebola virus to casual contacts, there is no evidence to suggest that these strategies are needed to control EVD. On the contrary, there are detrimental consequences of inappropriately combating the outbreak in this manner. For one, health professionals who are desperately needed to combat the disease at its source are disincentivized to risk their own health.⁴ Current fear-fueled policies issued by several states in the United States are causing significant stigma toward health workers, their families, and the organizations that respond to EVD epidemics; they also marginalize people of west African descent who live in the United States and have not had any exposure to EVD.⁵ This would not be the first time that irrational reactions hampered scientific advancement and harmed patients—during the early Acquired Immune Deficiency Syndrome (AIDS) epidemic, at-risk populations were similarly marginalized.Unfounded policies, such as the Louisiana DOHH response, also have the potential to encourage potentially exposed individuals to travel outside of monitored routes, deny their exposure, and avoid diagnosis and isolation when symptomatic. Instead, the DOHH should adopt policies based on evidence, such as the established protocols of Médecins Sans Frontières and the CDC,⁶ which advise monitoring returned asymptomatic health workers. These are effective and should continue to be the basis for a response to EVD in the United States.In the case of the current EVD epidemic and other public health crises, there is a need for greater advocacy on the part of health professionals and academic and professional institutions. Beyond the responsibility of providers to care for individual patients, health professionals should raise awareness about the public health implications of inappropriate responses and policies to public health crises. The medical community should unite and attack inappropriate policies to better protect our patients and their communities. Broader advocacy at the national level and within professional societies is needed to eschew fear-induced and political decisions and maintain evidence-based, neutral, and destigmatizing responses. Such actions would serve to refocus discussion on the evidence and show solidarity on the part of health professionals with the affected population as well as the heroic providers who have chosen to combat Ebola at its source.     

Ultrasound detection of posterior scleral bowing in young patients with choroidal melanoma

BACKGROUND: In evaluating young patients with choroidal melanomas, which are uncommon in people less than 30 years old, we noted that some had the ultrasound appearance of posterior scleral bowing. The purpose of this study was to determine the incidence of posterior scleral bowing in young patients with choroidal melanoma. METHODS: We reviewed the ultrasonograms of 24 patients less than 30 years of age (mean age 25 years [standard deviation (SD) 4.7 years]) who presented to an ocular oncology service in Toronto between May 1984 and May 1997. In all cases the diagnosis was choroidal melanoma. Histologic specimens were available in six cases. RESULTS: Scleral indentation posterior to the normal curvature of the globe was identified in 14 patients (58%). These patients had a mean tumour height of 4.4 mm (SD 2.0 mm) and mean tumour diameter of 9.5 mm (SD 2.9 mm). In the 10 patients with no scleral bowing the mean tumour height was 5.7 mm (SD 3.1 mm) and mean tumour diameter 11.5 mm (SD 3.8 mm). Pathological study (results available in nine cases in the scleral bowing group and four cases in the group without bowing) showed that all the tumours in the former group and three of those in the latter group were of the more indolent cell types, either mixed with predominantly spindle cells, or spindle cell. The six patients with histologic specimens were all in the scleral bowing group. The histologic features supported the ultrasound finding of posterior scleral bowing. No transscleral invasion occurred over the tumour region. INTERPRETATION: Posterior bowing of the sclera at the tumour site was observed in over half of young patients with choroidal melanoma. This phenomenon can be detected by ultrasonography and has a different appearance from that of choroidal excavation.     

Effects of Combining Propofol and Alfentanil on Ventilation, Analgesia, Sedation, and Emesis in Human Volunteers

Background: Propofol and alfentanil frequently are administered together for intravenous sedation. This study investigated pharmacokinetic and pharmacodynamic interactions between propofol and alfentanil, at sedative concentrations, with specific regard to effects on ventilation, analgesia, sedation, and nausea.

Methods: Ten male volunteers underwent steady-state infusions on 3 separate days consisting of propofol alone, alfentanil alone, or a combination of the two. Target plasma concentrations for propofol were 150, 300, and 600 ng/ml for 1 h at each concentration; for alfentanil it was 40 ng/ml for 3 h. Assessment included serial measurements of (1) ventilatory function (minute ventilation, carbon dioxide production, end-tidal carbon dioxide, ventilatory response to rebreathing 7% CO2); (2) analgesia (subjective pain report in response to graded finger shock and evoked potential amplitude); (3) sedation (subjective rating, observer scores, and digit symbol substitution test); (4) nausea (visual analog scale, 0-100 mm).

Results: During combination treatment, propofol plasma concentration was 22% greater than during propofol alone using replicate infusion schemes (P < 0.009). End-tidal carbon dioxide was unchanged by propofol, and increased equally by alfentanil and alfentanil/propofol combined (Delta end-tidal carbon dioxide 7.5 and 6.2 mmHg, respectively). Analgesia with propofol/alfentanil combined was greater than with alfentanil alone. (Pain report decreased 50% by PA vs. 28% for alfentanil, P < 0.05). Sedation was greater with propofol/alfentanil combined than with alfentanil or propofol alone (digit symbol substitution test 30 for propofol/alfentanil combined vs. 57 for alfentanil, and 46 for propofol, P < 0.05). Nausea occurred in 50% of subjects during alfentanil, but in none during propofol/alfentanil combination treatment.     

Perioperative rofecoxib plus local anesthetic field block diminishes pain and recovery time after outpatient inguinal hernia repair

In this study, we compared pain scores after inguinal herniorrhaphy in patients treated by preincisional local anesthetic field block (PL), or PL combined with perioperative rofecoxib, with controls who received standard care. Seventy-five patients having herniorrhaphy under general anesthesia were randomly assigned to receive a placebo pill preoperatively, and for 5 days postoperatively (CONT); preoperative bupivacaine field block and perioperative placebo (PL); preoperative field block plus rofecoxib, 50 mg preoperatively and for 5 days postoperatively (PLR). Bupivacaine infiltration in the wound at closure, IV fentanyl and acetaminophen/oxycodone were administered postoperatively to all. Discharge time, pain scores (0-10), analgesic use, and satisfaction scores (1-6) were compared using analysis of variance. PLR patients had lower maximum pain scores (worst pain) in the postanesthesia care unit (3.7 versus 5.3, P = 0.02) and at 24 h (5.3 versus 6.8, P = 0.03), were discharged 38 min sooner (P = 0.01), required 28% less oxycodone 0-24 h after discharge (P = 0.04), and reported higher satisfaction scores compared with CONT. Pain in PL was less than CONT for 30 min. There were no differences among the 3 groups after 24 h postoperatively. We conclude that perioperative rofecoxib with PL reduces in-hospital recovery time, decreases pain scores and opioid use, and improves satisfaction scores in the first 24 h after surgery.