Early entrapment of fourth ventricle following Pseudomonas meningitis in extreme prematurity: Case report.

Trapped fourth ventricle (TFV) as a complication of post-hemorrhagic hydrocephalus (PHH) is widely reported in the pediatric population with a prior history of ventriculo-peritoneal (VP) shunt placement. Characterized by disproportionate dilatation of the fourth ventricle on serial neuro-imaging, it is rarely encountered in the early course of preterm infants and the differentiating clinical features are subtle and non-specific. Clinical alertness and sonographic correlation hold the key to early diagnosis. We report an early emergence of TFV in an extremely low gestational age newborn (ELGAN) following fulminant Pseudomonas aeruginosa meningitis, approach to management, and the neurological outcome. Fourth ventricle entrapment as a complication of perinatally acquired Pseudomonas aeruginosa meningitis in a surviving ELGAN is extremely rare.

Intravitreal bevacizumab in the management of choroidal neovascular membrane secondary to choroidal osteoma.

PURPOSE: To describe a patient with choroidal neovascular membrane (CNVM) secondary to choroidal osteoma treated successfully with intravitreal bevacizumab. METHODS: Case report. A 25-year-old healthy woman presented with complaints of sudden painless decrease in vision in the left eye (OS) of 1 month duration. On examination, visual acuity was 20/20 in the right eye (OD) and counting fingers at 1.5 meters OS. Slit lamp examination was unremarkable. Fundus examination OD was normal; OS demonstrated a flat, opaque, yellowish parapapillary choroidal lesion with adjacent subfoveal grayish membrane associated with minimal subretinal fluid suggestive of a CNVM. B-scan ultrasonography revealed findings consistent with a choroidal osteoma. Fundus fluorescein angiography (FFA) of the left eye revealed a relatively well-defined area of hyperfluorescence that increased in size and intensity in the later phases suggestive of active subfoveal CNVM. Optical coherence tomography (OCT) confirmed the subfoveal CNVM with altered foveal contour and distortion of foveal architecture. A diagnosis of subfoveal CNVM associated with choroidal osteoma was made. The patient was treated with intravitreal bevacizumab 1.25 mg in 0.05 mL OS and repeated 6 weeks later. RESULTS: At the 4-month visit, vision OS improved to 20/125. The FFA and OCT revealed a resolved CNVM. CONCLUSIONS: Intravitreal bevacizumab may be an effective alternative in the management of CNVM secondary to choroidal osteoma. Larger series of such cases need to be studied to further validate our findings.

Characterization of idiopathic macular telangiectasia type 2 by fundus fluorescein angiography in Indian population.

PURPOSE: To characterize the variations in fundus fluorescein angiography (FFA) features in idiopathic macular telangiectasia (IMT) type 2. METHODS: Retrospective observational study. The authors included all the patients with IMT type 2 who underwent FFA during the period from January 2004 to December 2005. The main outcome measures were subretinal neovascularization and number and distance of telangiectasia from the center of the foveal avascular zone. RESULTS: The mean age of 21 patients included in the study was 53.0+/-7.7 years. There were 11 women and 10 men. Six of the 21 patients had a history of diabetes mellitus. Subretinal neovascularization (SRN) was observed in 10 (23.8%) eyes. Subretinal plaque of pigment hyperplasia in the macula was found in 7 (21.9%) eyes, and crystalline yellowish deposits on the retinal surface were seen in 19 (59.4%) eyes. Only one eye had visible retinal telangiectasia. Most had more than 10 telangiectatic lesions in the macular area and the temporal macula was most commonly involved. The mean distance from the center of the foveal avascular zone (FAZ) up to which telangiectasia could be observed was 1340+/-400 microm. The maximum distance from the FAZ at which telangiectasia was identified was 2530 microm. CONCLUSIONS: In IMT type 2, telangiectasia may be seen farther from the parafoveal area.

Evaluation of web-based annotation of ophthalmic images for multicentric clinical trials.

An Internet browser-based annotation system can be used to identify and describe features in digitalized retinal images, in multicentric clinical trials, in real time. In this web-based annotation system, the user employs a mouse to draw and create annotations on a transparent layer, that encapsulates the observations and interpretations of a specific image. Multiple annotation layers may be overlaid on a single image. These layers may correspond to annotations by different users on the same image or annotations of a temporal sequence of images of a disease process, over a period of time. In addition, geometrical properties of annotated figures may be computed and measured. The annotations are stored in a central repository database on a server, which can be retrieved by multiple users in real time. This system facilitates objective evaluation of digital images and comparison of double-blind readings of digital photographs, with an identifiable audit trail. Annotation of ophthalmic images allowed clinically feasible and useful interpretation to track properties of an area of fundus pathology. This provided an objective method to monitor properties of pathologies over time, an essential component of multicentric clinical trials. The annotation system also allowed users to view stereoscopic images that are stereo pairs. This web-based annotation system is useful and valuable in monitoring patient care, in multicentric clinical trials, telemedicine, teaching and routine clinical settings.

Incidence, risk factors of retinopathy of prematurity among very low birth weight infants in Singapore.

INTRODUCTION: To determine the incidence, risk factors and need for surgery for retinopathy of prematurity (ROP) among very-low-birth-weight (VLBW) infants. MATERIALS AND METHODS: This was a retrospective study of all VLBW infants managed by the department over 14 years, from 1988 to 2001. Preterm infants were examined according to the Royal College of Ophthalmologists' guidelines, and retinopathy was graded following the International Classification of ROP. All VLBW infants examined for ROP were included and data were retrieved retrospectively and analysed for maternal, medical, obstetric and neonatal risk factors using logistic regression. RESULTS: Of the 564 VLBW infants who fit the screening criteria, ROP was detected in 165 (29.2%) of VLBW infants; of whom 49% of infants had stage 1 disease, 24% were at stage 2, and 27% were at stage 3 or more. Among 45 infants with stage 3 disease or more, treatment was needed in 62.2% (28/45). No ROP was detected in infants greater than 33 weeks of gestation. Only 0.6 % (1/164) of infants greater than 30 weeks of gestational age (GA) needed surgery for ROP. Using birth weight (BW) criteria, stage 3 ROP was noted only in 1% (6/564) of infants with BW >1000 g. Of all ROP requiring surgery, 89% (25/28) of infants were <1000 g as compared to 11% (3/28) who were >1000 g infants. The median age of onset of ROP was 35 weeks (range, 31 to 41) corrected age. By univariate analysis for threshold ROP, preeclampsia, prenatal betamethasone exposure, gestational age, birth weight, 1-minute Apgar score, hyaline membrane disease (HMD), surfactant usage, hypotension, septicaemia, intraventricular haemorrhage duration of supplemental oxygen, ventilation and chronic lung disease were associated with ROP requiring surgery (i.e., threshold ROP, P <0.05). However, using multiple logistic regression analyses for ROP, maternal preeclampsia [odds ratio (OR), 2.52; confidence interval (CI), 1.32 to 4.7], birth weight (OR, 0.99; CI, 0.996 to 0.999), pulmonary haemorrhage (OR, 4.61; CI, 1.04 to 20.4), duration of ventilation (OR, 1.06; CI, 1.04 to 1.08) and duration of continuous positive airway pressure (CPAP) (OR, 1.02; CI, 1.01 to 1.04) were factors predictive of development of threshold ROP. CONCLUSION: The incidence of ROP among VLBW infants was 29.2%. ROP was strongly associated with smaller, more immature and sicker infants. The median age of onset of ROP was 35 weeks (range, 31 to 40 weeks) postmenstrual age. Infants <30 weeks of GA and/or infant with BW <1000 g are at considerable risk for threshold ROP. The main risk factors for development of threshold ROP by regression analysis are maternal preeclampsia, birth weight, and presence of pulmonary haemorrhage, duration of ventilation and continuous positive pressure ventilation. We suggest that both immaturity and compromised pulmonary function are both important aetiological factors in the development of ROP. Prevention of prematurity, control of preeclampsia, judicious use of ventilation and oxygen therapy are the only promising factors that may reduce the incidence and severity of ROP in this high-risk infant.

Interfacial Engineering of Semiconductor-Superconductor Junctions for High Performance Micro-Coolers.

The control of electronic and thermal transport through material interfaces is crucial for numerous micro and nanoelectronics applications and quantum devices. Here we report on the engineering of the electro-thermal properties of semiconductor-superconductor (Sm-S) electronic cooler junctions by a nanoscale insulating tunnel barrier introduced between the Sm and S electrodes. Unexpectedly, such an interface barrier does not increase the junction resistance but strongly reduces the detrimental sub-gap leakage current. These features are key to achieving high cooling power tunnel junction refrigerators, and we demonstrate unparalleled performance in silicon-based Sm-S electron cooler devices with orders of magnitudes improvement in the cooling power in comparison to previous works. By adapting the junctions in strain-engineered silicon coolers we also demonstrate efficient electron temperature reduction from 300 mK to below 100 mK. Investigations on junctions with different interface quality indicate that the previously unexplained sub-gap leakage current is strongly influenced by the Sm-S interface states. These states often dictate the junction electrical resistance through the well-known Fermi level pinning effect and, therefore, superconductivity could be generally used to probe and optimize metal-semiconductor contact behaviour.

Congenital retinal macrovessel causes reduced retinal sensitivity at the macula.

PURPOSE: To report a case of reduced macular sensitivity at the macula due to congenital retinal macrovessel as measured by liquid crystal display (LCD) microperimetry. METHODS: Case report. RESULTS: We present a patient with normal visual acuity OU, with fundus OS revealing a congenital retinal macrovessel. LCD microperimetry of the macular area OS revealed reduced sensitivity of the superior retina (median sensitivity, 13.0 dB) compared to the inferior retina (median sensitivity, 15.0 dB) based on numerical values of the sensitivity. Such a difference of sensitivity was not found in OD which had a normal fundus ezamination. CONCLUSIONS: The patient's congenital macrovessel may be causing a relative angioscotoma with reduced retinal sensitivity in the superior half of the macula as compared to the inferior half.

Management of vitreous loss during cataract surgery under topical anesthesia with transconjunctival vitrectomy system.

PURPOSE: A new technique to manage posterior capsular rupture with vitreous prolapse into the anterior chamber during phacoemulsification under topical anesthesia using the sutureless self-sealing 25-gauge transconjuctival vitrectomy system. METHOD: In the event of vitreous prolapse into the anterior chamber, the corneal wound is sutured and cleared of vitreous. A trans conjunctival 25-gauge sclerotomy through the pars plana is made. The high speed 25-guage trans-conjunctival vitrectomy system (TVS-25) under topical anesthesia is introduced and vitrectomy is performed to clear the anterior chamber of vitreous. An anterior vitrectomy is also done. A foldable intraocular lens is subsequently inserted. RESULTS: The vitrectomy is performed in a closed chamber maintaining normal intraocular pressure. The high-speed cutter exerts minimal traction on the vitreous. The accessibility to vitreous improves through the pars plana route ensuring more complete removal of the vitreous and restoration of normal anatomy. Topical anesthesia avoids the risks of globe perforation, retrobulbar hemorrhage, and prolonged postoperative akinesia of the eye. CONCLUSIONS: The 25-gauge pars plana incision is small and self-sealing. This makes the procedure fast, effective, painless and safe.

Clinical characteristics of an outbreak of hand, foot and mouth disease in Singapore.

BACKGROUND: We experienced a hand, foot and mouth disease (HFMD) outbreak in late year 2000 in Singapore. Between 14 September 2000 and 14 November 2000, a total of 3526 cases of HFMD were notified. There were 652 patients clinically suspected to have HFMD, who were seen at the Children's Emergency department of KK Women's and Children's Hospital of Singapore. OBJECTIVE OF THE STUDY: To study the clinical profile and virologic isolates of children admitted with HFMD during the outbreak. STUDY DESIGN: A prospective observational study. METHODS: Analysis of clinical features and virologic studies of 129 selected cases of HFMD and herpangina. RESULTS: The median age was 25 months with a range of between 4 months and 11 years. The majority were less than 5 years old (87%). The male-to-female ratio was 1.3:1. The median numbers of day of illness to presentation to the hospital was 3 days. Poor feeding and loss of appetite accounted for 76.7% of the admissions. Symptoms of vomiting were present in 37.2% of the cases. Oral ulcers were found in 96.1%, rashes over hands in 87.6%, over feet in 86.8% and over buttocks in 54.3%. Only 4.7% exhibited no rashes other than oral ulcers and were labelled as herpangina. The median duration of fever was 3 days, ranging from 2 to 7 days. An intravenous drip was required in 68.2% due to poor feeding. Viral cultures were sent in 89.1% of patients of whom 61.7% of patients were positive for viruses. Of the positive cultures, types of viruses isolated were EV71 (enterovirus 71) in 59/71 (83%), Coxsackievirus (A16, A24, A2 B3, B4) in 6/71 (8.4%), EV Untypable in 4/71 (5.6%) and mixed [EV71, echo25, cytomegalovirus (CMV)] in 2/71 (2.8%). EV71 was isolated mostly from stool samples followed by vesicle fluid culture and throat swabs. Two siblings aged 14 months and 2.5 years died during this period at day 5 of illness, their post-mortem examinations showed interstitial pneumonitis of the lungs. EV71 was isolated from the brain, heart, tonsils, intestines, throat and rectal swabs. A raised total white cell count of 14,000/L versus 12,000/L was significantly associated with complicated HFMD (P = 0.04). There was no difference in clinical characteristics of EV71 versus non-EV71 infections. Other viral illnesses, e.g. measles and CMV, may be mistaken for HFMD in the outbreak setting. CONCLUSIONS: HFMD tends to occur in younger children less than 5 years old due to low herd immunity. Poor feeding due to mouth ulcers accounts for admission to hospital requiring intravenous drip. EV71 accounted for the majority (75%) of the positive isolations, followed by coxsackievirus and untypable EV, mixed infection of echovirus or CMV. The yield of virus isolation was highest from stool, followed by vesicles and throat swabs. There is no difference in clinical characteristics of EV71 and non-EV71 virus infections. Enterovirus can cause mild symptoms to fatal death. Two infants died of interstitial pneumonitis and encephalitis.

Long-term follow-up of idiopathic intracranial hypertension: the Iowa experience.

OBJECTIVE: To evaluate recurrent or delayed worsening of papilledema and visual function in patients with idiopathic intracranial hypertension (IIH) followed for more than 10 years. METHODS: This is an Institutional Review Board approved retrospective chart review of 410 patients with the diagnosis of IIH evaluated at the University of Iowa Hospitals and Clinics from January 1984 to January 1996. Of the 410 patients, 20 patients with IIH who were followed over 10 years at the neuro-ophthalmology clinic met the inclusion criteria. Three neuro-ophthalmologists independently evaluated and graded the visual field examinations and optic disc stereo-photographs for each follow-up visit (median = 15). RESULTS: Of the 20 patients, 11 demonstrated a stable course of disease without worsening in papilledema or visual field, and 9 patients worsened after a stable course. Of these 9 patients, 6 patients experienced delayed worsening (range: 28 to 135 months from presentation) and 3 patients had recurrence after resolution of papilledema 12 to 78 months from initial resolution of the IIH. CONCLUSION: Idiopathic intracranial hypertension is a chronic condition that may worsen after a period of stability, warranting long-term follow-up.

A comparative study of epiretinal membranes associated with Eales' disease: a clinicopathologic evaluation.

AIM: To study the histopathologic features and clinical correlation of epiretinal membranes (ERM) obtained from patients of Eales' disease and compare with other vasoproliferative disorders. METHODS: Retrospective analysis of epiretinal membranes submitted for histological evaluation between January 1995 and June 2001, from the patients of diabetic retinopathy and vascular occlusions (Group 1; vaso-occlusive disorders) and of Eales' disease (Group 2; vasoinflammatory disorders). Demographics, pre and postoperative visual acuity, and anatomic and histologic characteristics of membranes were studied. Histopathologic features and clinical outcomes were correlated between the groups. The results were analysed statistically by Student's t-test, Fisher's exact test and Kruskal-Wallis test. RESULTS: This study consisted of 42 patients, 24 in Group 1 and 18 in Group 2. Patients in Group 2 (33.0+/-9.2 years) were significantly younger than the patients in Group 1 (49.9+/-7.6 years) (P< or =0.0001). Final visual acuity of >20/400 was attained in 79.2% (19/24) patients in Group 1 and 83.3% (15/18) in Group 2 (P=1.0). Inflammatory membranes were significantly associated with presumed Eales' disease (94.4 vs 0%) (P< or =0.0001) and fibrovascular membranes with Group 1 (70.8% vs 33.3%) (P=0.028). Mast cells and eosinophils were observed as special features in epiretinal membranes of patients with Eales' disease. CONCLUSIONS: Histological features of ERM in Eales' disease are comparable to other vasoproliferative disorders except for features of inflammation. Presence of mast cells and eosinophils in epiretinal membranes of Eales' disease needs further investigation.

Patterns of cardiac disorders and epidemiology of coronary artery disease in urban population of Ahmedabad.

A hospital based study of coronary artery disease (CAD) was carried out in Gujaratis, admitted to Dr Jivraj Mehta Smarak Health Foundation, Ahmedabad. Total 276 subjects were surveyed. CAD was diagnosed by ECG criteria. Prevalence of CAD in hospital admission was 29.6%. Highest incidence of CAD was seen in the age group of 51 to 60 years. Male/female ratio was 1.6:1. As a single risk factor hypertension was ranked first, next was obesity followed by hyperlipidaemia, diabetes, tobacco habits, and family history of CAD. Overall mortality of CAD was 3.99%, being 1.83% for angina pectoris (AP) and 5.39% for myocardial infarction (MI). Mortality rate was higher in subjects having 2 or more risk factors. Incidence of CAD in young (age < 40 years) was very low (1.09%).

Transfemoral extraction of knotted pulmonary artery catheter in right atrium.

Knotting of a pulmonary artery catheter (PAC) is a rare complication which is usually seen to occur in the right ventricle. We describe knotting of a PAC in the right atrium and its extraction by non surgical means through the femoral route.

Hand, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases.

AIM: An epidemic of hand, foot and mouth disease (HFMD) occurred in Singapore between September and November 2000. During the epidemic, there were four HFMD-related deaths and after the epidemic, another three HFMD-related deaths. This study sought to determine the risk factors predictive of death from HFMD disease. METHODS: The risk factors for fatal HFMD were determined by comparing clinical and laboratory findings between fatal cases (n = 7) and non-fatal controls (n = 131) admitted between September 2000 and April 2001. Enterovirus 71 positive fatal cases (n = 4) and non-fatal controls (n = 63) were also compared. RESULTS: In total, 138 HFMD cases with a mean age of 32 mo were studied. The majority of fatal cases died from interstitial pneumonitis, of whom three also had brainstem encephalitis. Of the 131 non-fatal cases, 3 had concomitant infections (respiratory syncytial virus bronchiolitis, right-sided pneumonia, Haemophilus influenzae type b meningitis), 2 had aseptic meningitis, and 1 each had transient drowsiness, intravenous immunoglobulin-related complications and transverse myelitis. By multivariate logistic regression analysis, atypical physical findings (p = 0.0006), raised total white cell count (p = 0.0128), vomiting (p = 0.0116) and absence of mouth ulcers (p = 0.043) were predictive of a fatal course. Although previous epidemics have described neurogenic pulmonary oedema as the main cause of death, the fatal cases in this study died mainly from interstitial pneumonitis alone or with myocarditis or encephalitis. CONCLUSION: Although HFMD is generally a benign disease, risk factors such as vomiting, absence of mouth ulcers, atypical presentation and raised total white cell count should alert the physician of a fatal course of illness.