Early deep anterior lamellar keratoplasty for fungal keratitis poorly responsive to medical treatment.

PurposeTo investigate the efficacy of early therapeutic deep anterior lamellar keratoplasty (DALK) in eradicating fungal keratitis that is poorly responsive to medical treatment.Patients and methodsTwenty-three eyes (23 patients) underwent early therapeutic DALK within 15 to 50 days from the onset of symptoms. The adopted eligibility criteria for early DALK included the following: active fungal keratitis affecting the optical zone with ulcer confined in the 6.00 mm central cornea; deeper than 150 µm but not exceeding 300 µm; and poorly responsive to medical treatment.ResultsThe big bubble technique was accomplished in 74% (17) of eyes, whereas manual dissection was performed in the remaining 26% (6) of eyes. Histopathological examination did not show any sign of fungal colonization in the peripheral and deep stromal lamellae in any case. All grafts were transparent postoperatively, and no recurrence of infection occurred. Median best spectacle corrected visual acuity significantly improved from 2.0 (1.0 interquartile range) logMAR to 0.1 (0.1 interquartile range) logMAR (P<0.01). The mean follow-up was 32±10 months. Neither episode of rejection nor graft failure was noted during the follow-up period.ConclusionEarly DALK could represent a safe therapeutic approach to eradicate fungal keratitis that affects the optical zone and is poorly responsive to medical treatment.

In vivo corneal confocal microscopy as a novel non-invasive tool to investigate cardiac autonomic neuropathy in Type 1 diabetes.

AIMS: To investigate whether small nerve fibre degeneration detected using corneal confocal microscopy is associated with cardiac autonomic neuropathy in people with Type 1 diabetes. METHODS: Thirty-six people with Type 1 diabetes and 20 age- and sex-matched healthy control subjects were enrolled. Tests to determine heart rate response to deep-breathing (expiratory-to-inspiratory ratio), heart rate response to lying-to-stand test (30:15 ratio) and blood pressure response to standing were performed to detect cardiac autonomic neuropathy. Corneal confocal microscopy was performed to assess: corneal nerve density and corneal nerve beadings; branching pattern; and nerve fibre tortuosity. RESULTS: Compared with control participants, participants with Type 1 diabetes had fewer (mean ± SD 45.4 ± 20.2 vs 92.0 ± 22.7 fibres/mm²; P < 0.001) and more tortuous corneal nerve fibres (20 participants with Type 1 diabetes vs four control participants had nerve tortuosity grade 2/3; P = 0.022) and fewer beadings (mean ± SD 15.1 ± 3.5 vs 20.6 ± 5.0; P < 0.001). Of the participants with Type 1 diabetes, 11 met the criteria for the diagnosis of cardiac autonomic neuropathy. Corneal nerve density was significantly lower in participants with cardiac autonomic neuropathy than in those without (mean ± SD 32.8 ± 16.4 vs 51.7 ± 18.9 fibres/mm²; P = 0.008). This difference remained significant after adjustment for age (P = 0.02), gender (P = 0.04), disease duration (P = 0.005), insulin requirement (P = 0.02) and neuropathy disability score (P = 0.04). CONCLUSION: This study suggests that corneal confocal microscopy could represent a new and non-invasive tool to investigate cardiac autonomic neuropathy in people with Type 1 diabetes. Larger studies are required to define the role of corneal confocal microscopy in the assessment of cardiac autonomic neuropathy.

Diffusion-weighted magnetic resonance for prediction of response after neoadjuvant chemoradiation therapy for locally advanced rectal cancer: preliminary results of a monoinstitutional prospective study.

PURPOSE: To evaluate diffusion-weighted imaging (DWI) for assessment of treatment response in locally advanced rectal cancer (LARC) 8 weeks after neoadjuvant chemoradiotherapy (CRT). METHODS AND MATERIALS: A total of 28 patients with LARC underwent magnetic resonance imaging (MRI) prior to and 8 weeks after CRT. Tumor volume (TV) was calculated on T2-weighted MRI scans as well as the apparent diffusion coefficient (ADC) was calculated using Echo-planar DWI-sequences. All data were correlated to surgical results and histopathologic tumor regression grade (TRG), according to Mandard's classification. Post-treatment difference ADC (%ΔADC) and TV (%ΔTV) changes at 8 weeks were compared complete response (CR; TRG1) and non-complete response tumors (non-CR; TRG2-5). RESULTS: The mean % ADC increase of CR group was significantly higher compared to non-CR group (77.2 ± 54.63% vs. 36.0 ± 29.44%; p = 0.05). Conversely, the mean % TV reduction did not significantly differ in CR group from non-CR group (73.7% vs. 63.77%; p = 0.21). Accordingly, the diagnostic accuracy of the mean % ADC increase to discriminate CR from non-CR group was significantly higher than that of the mean % TV reduction (0.913 vs. 0.658; p = 0.022). No correlation was found between mean % TV reduction and TRG (rho = 0.22; p = 0.3037), whereas a negative correlation between mean % ADC increase and TRG was recorded (r = -0.69; p = 0.006). CONCLUSION: The mean % ADC increase appears to be a reliable tool to differentiate CR from non-CR after CRT in patients with LARC.

The adverse event profile of zonisamide: a meta-analysis.

The first aim of our study was to analyze the adverse events statistically significantly associated with zonisamide, through a systematic review and meta-analysis of available randomized placebo-controlled trials (RCTs). The second aim was to compare these results with those obtained from an analysis of non-RCTs and observational studies. Randomized controlled trials were identified using Medline (PubMed), EMBASE (Ovid), and Cochrane CENTRAL, from 1990 to September 2012. RevMan version 5.1 and OpenMeta[Analyst] were used for analyses of RCT and non-RCTs, respectively. Six eligible studies with 1184 patients between 12 and 80 years of age were included in RCTs analysis. Fifteen adverse events were investigated. In this first part of the analysis, no adverse events were statistically significantly associated with zonisamide. In the non-RCT analysis, a high incidence of weight loss and headache was found. In RCTs, zonisamide was statistically significantly associated with an increased risk of adverse event-related study withdrawals [RR (99% CI) = 1.81 (1.07-3.08)]. Although our study revealed no statistically significantly associated adverse effects (AEs) with zonisamide, this is very likely a consequence of the small numbers in the RCTs available. The limited data available from the studies appear to reveal no major safety concerns related to zonisamide. However, the high incidence of weight loss and headache in the non-RCTs suggests that these AEs could be of clinical significance.

New waves. Hospitals struggle to meet the challenge of multiculturalism now--and in the next generation.

Multiculturalism means different things to different people. For hospital executives, there are a number of major implications inherent in the rapidly expanding diversity of the United States. Beginning on page 23, we look at the ethnic diversity issues hospitals face as employers. A consensus has developed that more minority young people must be encouraged to enter health care administration and clinical care; but there are a variety of obstacles to be overcome. Then, beginning on page 29, we examine the many challenges hospitals struggle with as their patient populations become more and more diverse, and in many cases, change very quickly. Problems in dealing with an array of languages, cultures and backgrounds can put up major barriers to effective patient care. Providers must understand the cultural assumptions that patients bring with them.

Mind & body medicine. A new paradigm?

Innovative techniques to enhance patient healing are being explored, and the term used to describe them is "mind/body medicine." What's new about the phenomenon? Traditional physicians are taking a closer look.

Hospitals cope with America's new 'family value'.

It's not a new problem, but the attention it's getting is growing every day. Domestic violence, or family violence, a concept that encompasses child abuse, partner abuse, and elder abuse, is being understood more and more as a trauma to the nation's families. Very often it's hospitals, particularly hospital emergency departments, that are the first community organization that the abused person sees for examination or treatment. The question is, are hospitals prepared? In a comprehensive look at the problem and some possible approaches to solving it, Hospitals senior correspondent Frank Sabatino talks to the experts in every area touching on this complex, tragic societal issue.

Vendors worry: will health reform place technology on trial?

The outcome of the reform debate will have an enormous impact on the health care vendor community as well as on providers. With arguments swirling about regarding such issues as technology costs, vendors offer their views of reform.