A national house-staff audit of medical prophylaxis in medical patients for the PREVENTion of Venous ThromboEmbolism (PREVENT-VTE).

We established a national audit to assess the thromboprophylaxis rate for venous thromoembolism (VTE) in at risk medical patients in acute hospitals in the Republic of Ireland and to determine whether the use of stickers to alert physicians regarding thromboprophylaxis would double the rate prophylaxis in a follow-up audit. 651 acute medical admission patients in the first audit and 524 in the second re-audit were recruited. The mean age was 66.5 yrs with similar numbers of male and female patients and 265 (22.6%) patients were active smokers. The first and second audits identified 549 (84%) and 487 (93%) of patients at-risk for VTE respectively. Of the at-risk patients, 163 (29.7%) and 132 (27.1%) received LMWH in the first and second audit respectively. Mechanical thromboprophylaxis was instigated in 75 (13.6%) patients in the first and 86 (17.7%) patients in the second audit. The placement of stickers in patient charts didn't produce a significant increase in the number of at risk patients treated in the second audit. There is unacceptably low adherence to the ACCP guidelines in Ireland and more complex intervention than chart reminders are required to improve compliance.

Polyuronides in Avocado (Persea americana) and Tomato (Lycopersicon esculentum) Fruits Exhibit Markedly Different Patterns of Molecular Weight Downshifts during Ripening.

Avocado (Persea americana) fruit experience a rapid and extensive loss of firmness during ripening. In this study, we examined whether the chelator solubility and molecular weight of avocado polyuronides paralleled the accumulation of polygalacturonase (PG) activity and loss in fruit firmness. Polyuronides were derived from ethanolic precipitates of avocado mesocarp prepared using a procedure to rapidly inactivate endogenous enzymes. During ripening, chelator (cyclohexane-trans-1,2-diamine tetraacetic acid [CDTA])-soluble polyuronides increased from approximately 30 to 40 [mu]g of galacturonic acid equivalents (mg alcohol-insoluble solids)-1 in preripe fruit to 150 to 170 [mu]g mg-1 in postclimacteric fruit. In preripe fruit, chelator-extractable polyuronides were of high molecular weight and were partially excluded from Sepharose CL- 2B-300 gel filtration media. Avocado polyuronides exhibited marked downshifts in molecular weight during ripening. At the postclimacteric stage, nearly all chelator-extractable polyuronides, which constituted from 75 to 90% of total cell wall uronic acid content, eluted near the total volume of the filtration media. Rechromatography of low molecular weight polyuronides on Bio-Gel P-4 disclosed that oligomeric uronic acids are produced in vivo during avocado ripening. The gel filtration behavior and pattern of depolymerization of avocado polyuronides were not influenced by the polyuronide extraction protocol (imidazole versus CDTA) or by chromatographic conditions designed to minimize interpolymeric aggregation. Polyuronides from ripening tomato (Lycopersicon esculentum) fruit extracted and chromatographed under conditions identical with those used for avocado polyuronides exhibited markedly less rapid and less extensive downshifts in molecular weight during the transition from mature-green to fully ripe. Even during a 9-d period beyond the fully ripe stage, tomato fruit polyuronides exhibited limited additional depolymerization and did not include oligomeric species. A comparison of the data for the avocado and tomato fruit indicates that downshifts in polyuronide molecular weight are a prominent feature of avocado ripening and may also explain why molecular down-regulation of PG (EC 3.2.1.15) in tomato fruit has resulted in minimal effects on fruit performance until the terminal stages of ripening.

Accuracy and cost of intraoperative lymph node frozen sections at radical prostatectomy.

AIM: To assess the value of intraoperative diagnostic examination of frozen sections of lymph nodes removed during radical prostatectomy. METHODS: Pelvic lymph nodes from patients with prostatic carcinoma were obtained (1) as frozen sections during radical prostatectomy, to exclude patients from non-curative surgery, and (2) as paraffin sections postoperatively from lymphadenectomy performed at radical prostatectomy, to stage the tumour and assess need for adjuvant treatment. Findings from the two approaches were used to assess the accuracy and cost of frozen section diagnosis, and to judge the results of omitting intraoperative diagnosis. RESULTS: In 82 patients frozen section revealed metastasis in six (7.3%), and metastases were found in a further four (4.9%) on paraffin sections (false negatives). Of the 195 patients undergoing staging lymphadenectomy (without frozen section), metastatic cancer was seen in nine cases (4.6%). The frozen section cost of metastatic cancer detection per patient was calculated as 7516 Pounds (550 Pounds x 82/6), with an associated false negative rate of 33%. CONCLUSIONS: Frozen section diagnosis of metastatic carcinoma in pelvic lymph nodes before radical prostatectomy has a high false negative rate and is costly. It may not be justified with the observed low incidence of lymph node metastasis.

A comparison of latanoprost and dorzolamide in patients with glaucoma and ocular hypertension: a 3 month, randomised study. Ireland Latanoprost Study Group.

AIMS: To compare the effects on intraocular pressure (IOP) and side effects of monotherapy with either latanoprost or dorzolamide in patients with glaucoma or ocular hypertension. METHODS: 224 patients with open angle glaucoma or ocular hypertension were recruited to a 3 month open labelled study. Previous glaucoma medications were washed out and the patients were randomised to receive either latanoprost 0.005% once daily or dorzolamide 2% three times daily. RESULTS: Of 224 patients 213 were included in the analysis of efficacy. After 3 months, latanoprost reduced mean baseline diurnal IOP from 27.2 (SD 3.0) mm Hg by 8.5 (3.3) mm Hg. The corresponding figures for dorzolamide were 27.2 (3.4) and 5.6 (2.6) mm Hg. The difference of 2.9 mm Hg (95% CI: 2.3-3.6) was highly significant (p<0.001, ANCOVA). Latanoprost reduced IOP at peak by 8.6 mm Hg (32%) compared with 6.2 mm Hg (23%) for dorzolamide, and the difference of 2.4 mm Hg was significant (p<0.001, ANCOVA). The corresponding figures at trough were 8.1 mm Hg (31%) for latanoprost and 4.7 mm Hg (17%) for dorzolamide, a significant difference of 3.4 mm Hg (p<0.001, ANCOVA). Both drugs were well tolerated systemically and locally. CONCLUSION: Latanoprost was superior to dorzolamide in reducing the IOP, judged both from the effect on IOP at peak and trough and by the effect on diurnal IOP.

Effect on intraocular pressure of local anaesthesia in eyes undergoing intraocular surgery.

A total of 104 eyes undergoing intraocular surgery were studied to investigate the effect on intraocular pressure (IOP) of peribulbar and retrobulbar anaesthesia in eyes with and without glaucoma. Forty eyes had glaucoma. Intraocular pressure was measured before, immediately after, and 5 minutes after injection of local anaesthetic. Mean IOP rose by 5.8 mm Hg at 1 minute (p < 0.01) and 0.7 mm Hg at 5 minutes (p > 0.05). However, in eyes not receiving external ocular compression after the 1 minute measurement (n = 70, 67%), IOP was still 3.6 mm Hg higher than baseline (p < 0.01), compared with 5.2 mm Hg lower than baseline (p < 0.01) where compression was used. Patients with glaucoma experienced higher and more persistent increases in IOP than those without glaucoma. The increase in IOP varied greatly between patients: the maximum rise was 25 mm Hg, and in one glaucoma patient an IOP of 50 mm Hg occurred, persisting for 5 minutes. At 1 minute, 14 of the glaucoma subjects (35%) had experienced an IOP rise of > or = 10 mm Hg, and four (10%) a rise of > or = 20 mm Hg. These results suggest that the changes in IOP in patients with glaucoma, with an acute increase in IOP being succeeded by an acute decrease on entry into the anterior chamber, may be hazardous. The implications for clinical practice are discussed.

Retinopathy of prematurity: systemic complications associated with different anaesthetic techniques at treatment.

BACKGROUND: Treatment of retinopathy of prematurity (ROP) in the UK is subject to considerable regional variation in terms of anaesthetic support. Change in practice at St Mary's neonatal medical unit from topical to general anaesthesia and, subsequently, to sedation/analgesia allowed comparison of the impact of these three modalities on infants' early postoperative course in a consecutive, non-randomised, observational study. METHODS: The study population consisted of 30 babies undergoing treatment of threshold ROP. Twelve were treated using topical anaesthesia alone (group A), six using general anaesthesia (group B), and 12 using sedation/analgesia combined with elective intubation and artificial ventilation (group C). Daily measurements of infant health were recorded starting 4 days preoperatively and continuing for 7 days postoperatively to facilitate the formulation of a cardiorespiratory stability index as follows: (0) improvement from baseline, (1) no change from baseline, (2) mild instability, (3) marked instability, and (4) life threatening event. RESULTS: Within the first 48 hours postoperatively in group A 5/12 showed mild instability and 4/12 showed marked instability (including three babies suffering life threatening events requiring emergency resuscitation). In group B within the first 48 hours postoperatively 1/6 showed mild and 1/6 showed marked instability, and in group C 5/12 babies showed mild instability alone. There was a significant difference for cardiorespiratory stability scores between the three groups overall for the 7 days postoperatively (repeated measures ANOVA, p = 0.018). CONCLUSIONS: Premature infants undergoing cryotherapy for ROP who were treated using topical anaesthesia alone had more severe and protracted cardiorespiratory complications.

Surgically induced necrotising sclerokeratitis (SINS)--precipitating factors and response to treatment.

The clinical features, treatment, and visual outcome of 52 eyes from 43 patients who developed scleritis following surgery were reviewed. In all patients the scleral inflammation developed adjacent to a surgical wound. Ninety six per cent had necrotising disease and 23% also had evidence of secondary posterior scleritis. Many different types of ocular surgery were implicated and the majority (75%) of the patients had two or more surgical procedures before the onset of the scleritis. Although cataract extraction through a limbal incision resulted in the largest subgroup, scleritis also followed glaucoma, strabismus, and retinal detachment surgery. The latent period between surgery and the appearance of inflammation was short (mean 9 months) except for a small group in whom scleritis occurred many years after squint surgery. Sixty three per cent of patients had evidence of a systemic disease. Early diagnosis and aggressive medical treatment significantly improved the visual outcome. The precipitating factors, pathogenesis, and course of this condition are discussed.

Peripheral contrast sensitivity in glaucoma and ocular hypertension.

Contrast sensitivity has been measured in patients with glaucoma and ocular hypertension, the latter graded into high, medium, and low risk clinical groups. Measurements were made centrally and peripherally at 10 degrees, 15 degrees, 20 degrees, and 25 degrees off-axis at each of the four meridians 45 degrees, 135 degrees, 225 degrees, and 315 degrees. A sine wave grating of 1.9 cycles/degree, reversing at 1 Hz was used. It was displayed on a 100-Hz refresh rate monitor. Normal values were established to compare those from 41 eyes from patients with either primary open angle glaucoma (POAG) with minimal field loss detectable on a Humphrey perimeter, or raised IOP and/or disc changes but no field loss (OH). Those with POAG had normal central contrast sensitivity, but at 20 degrees and 25 degrees eccentricity the values were greater than 2 standard deviations above the normal mean. This was also the case for high risk OH, but not for low risk patients. All the high risk patients except one who had abnormal peripheral contrast sensitivity had possible field defects (threshold elevation at one or more points more than 5 but less than 10 dB above normal mean). Only one of those with normal peripheral contrast sensitivity had such 'suspect points'. The results are assessed in terms of screening of glaucoma suspects.

Theoretical and practical performance of a concentric bifocal intraocular implant lens.

Some results from a survey of 43 patients who had a monofocal intra-ocular-lens (IOL) in one eye and a concentric bifocal intra-ocular-lens in the fellow eye are reported. Twenty patients with 6/9 or better post-operative visual acuity in both eyes, participated in the main part of the study. Optical transfer functions for the bifocal lens showed that, compared to an optimal single-vision correction, there is a 50% contrast degradation of the distance retinal image across all spatial frequencies above around 3 c/deg. For the patients in the main study, there was a close correspondence between practical measurement of contrast sensitivity and the theoretical predictions of the modulation transfer functions. Measuring contrast sensitivity proved an effective means of assessing misalignment of the bifocal IOLs.

Glycans of the trabecular meshwork in primary open angle glaucoma.

AIMS: Glycan expression was compared in glaucomatous trabecular meshwork (TM) and normal TM in order to determine any differences which may reflect pathological changes underlying primary open angle glaucoma (POAG). METHODS: Resin embedded TM from trabeculectomy specimens from 15 eyes with POAG and from 12 eyes with normal anterior segments were probed with a panel of biotinylated lectins and an avidin-peroxidase revealing system at the light microscope level. Statistical analyses were performed on the comparative staining results. RESULTS: The lectins ConA and ePHA showed strong staining in all areas of both glaucomatous and normal TM; ePHA staining of Schlemm's canal (SC) from POAG TM was significantly less than that from normal TM (ePHA-SC p = 0.04). The lectins PSA, LCA, and SNA bound moderately strongly to SC endothelium and weakly to the endothelium of the corneoscleral meshwork (CSM); glaucomatous SC endothelial binding was significantly less than that of normal SC endothelium for PSA and LCA (PSA-SC p = 0.002, LCA-SC p = 0.002). STA and DSA showed moderately strong binding while WGA, ECA, AHA, and MPA bound weakly throughout the TM; for DSA and MPA this staining was significantly greater in POAG than in normal TM (DSA-SC p = 0.001, DSA-CSM p = 0.002, MPA-SC p = 0.01, MPA-CSM p = 0.02). Jac stained strongly throughout the TM and showed no significant difference in POAG compared with normal TM (Jac-SC p = 0.6, Jac-CSM p = 1). 1PHA, SBA, DBA, CTA, UEA-1 and LTA did not bind to glaucomatous TM or normal TM. There were no age-related changes seen. CONCLUSIONS: The expression of some complex and hybrid, bisected and non-bisected N-linked glycans is significantly diminished in glaucomatous TM compared with normal TM. Some glycans with multiple N-acetylglucosamine residues and O-linked glycans with terminal and subterminal galactosyl groups are significantly increased in POAG TM. Glycan expression does not change significantly with age in POAG or normal TM.

Long term results of diode laser cycloablation in complex glaucoma using the Zeiss Visulas II system.

AIM: To investigate the safety and efficacy of the Zeiss Visulas II diode laser system in the reduction of intraocular pressure (IOP) in patients with complex glaucoma. METHODS: The authors analysed the medical records of patients who underwent trans-scleral diode laser cycloablation (TDC) at the Manchester Royal Eye Hospital during a 34 month period. 55 eyes of 53 patients with complex glaucoma were followed up for a period of 12-52 months (mean 23.1 months) after initial treatment with the Zeiss Visulas II diode laser system. RESULTS: Mean pretreatment IOP was 35.8 mm Hg (range 22-64 mm Hg). At the last examination, mean IOP was 17.3 mm Hg (range 0-40 mm Hg). After treatment, 45 eyes (82%) had an IOP between 5 and 22 mm Hg; in 46 eyes (84%) the preoperative IOP had been reduced by 30% or more. The mean number of treatment sessions was 1.7 (range 1-6). At the last follow up appointment, the mean number of glaucoma medications was reduced from 2.1 to 1.6 (p<0.05). In 10 eyes (18%), post-treatment visual acuity (VA) was worse than pretreatment VA by 2 or more lines. CONCLUSIONS: Treatment with the Zeiss Visulas II diode laser system can be safely repeated in order to achieve the target IOP. Treatment outcomes in this study were similar to those from previously published work using the Iris Medical Oculight SLx laser.

The clinical and endocrine assessment of three different antiandrogen regimens combined with a very long-acting gonadotrophin-releasing hormone analogue.

Tumor flare is reported in up to 40% of patients treated with gonadotrophin-releasing hormone analogues for prostate cancer. In order to investigate the optimal way to eliminate tumor flare, we have treated patients with one of three different antiandrogen regimens used in combination with gonadotrophin-releasing hormone (GnRH) agonist. The early results of this study are presented here. Thirty patients with advanced symptomatic disease were randomized to receive either cyproterone acetate 50 or 100 mg three times daily or flutamide 250 mg three times daily given for 1 week before and during the first month of GnRH agonist treatment. The endocrine profiles of these patients were compared with those of historic controls treated with depot agonist alone. Three patients treated with low-dose cyproterone acetate and one with flutamide developed a transient exacerbation of their disease. No patients treated with the higher-dose cyproterone acetate regimen developed tumor flare. No patients treated with cyproterone acetate had an increase in serum testosterone above baseline following depot GnRH agonist implantation. All patients treated with flutamide had increases in serum testosterone, but this did not significantly increase further with implantation. This study suggests that all patients receiving GnRH agonist treatment should be pretreated with cyproterone acetate 100 mg three times daily for 1 week before implantation and for the first treatment month.

Lymphograms in prostatic carcinoma: false-positive and false-negative assessments in radiology.

Forty patients with prostatic carcinoma underwent lymphography and pelvic lymphadenectomy. Node-by-node comparisons between radiology and histology findings yielded high false-negative rates for the lymphogram as a staging tool. False-positive and false-negative rates depend on the viewpoint taken: we argue that these rates should be expressed in terms of the disease, not the in vivo test. Lymphography has serious defects as a staging manoeuvre, but pelvic lymphadenectomy carries greater morbidity and mortality in its train.

Macrophages during fibrosis following scleral fistulising surgery in a rat model.

PURPOSE: Glaucoma filtration surgery can fail in a minority of patients as a result of fibrosis in the subconjunctival bleb space and closure of the scleral fistula. In this study, the rat eye has been used as an experimental model for fistulising surgery in order to evaluate the clinical manifestation of bleb failure with the morphological events of the wound healing process. METHODS: A conjunctival bleb was successfully formed in 25 rats and was examined daily using slit lamp microscopy to evaluate postoperative inflammation and the presence of a bleb. At defined post-operative time points, serial frozen sections of eyes were stained immunohistochemically using a panel of monoclonal antibodies directed against known surface markers on rat immune/inflammatory cells. Positively stained cells were counted (a) in the bleb site, (b) at the sclerostomy and (c) at the suture site. RESULTS: Following an initial post-operative inflammation, a surgically formed sclerostomy and conjunctival bleb underwent a granulation and scarring response so that by 7-19 days the bleb had disappeared. Using the monoclonal antibodies applied in this study, it was possible to show that macrophages most likely play a major and pivotal role throughout the sequence of events that lead to repair of the fistula and closure of the bleb. It was also noted that the presence of an otherwise inert nylon suture used to close the incised conjunctiva can serve as a focus for macrophages. CONCLUSION: The rat has been successfully used as an experimental model of fistulising surgery and its subsequent failure. The use of a panel of monoclonal antibodies directed against specific surface markers on immune-inflammatory cells, highlighted macrophages to be prominent in all stages of this wound healing process.

Bovine surfactant therapy and retinopathy of prematurity.

We reviewed the results of three randomized clinical trials of prophylactic bovine surfactant therapy on babies under 30 weeks gestational age to assess the effects of this treatment on the frequency and severity of retinopathy of prematurity (ROP). Of the 119 babies who received surfactant treatment, 54 (45.4%) had ROP compared to 33 (47.1%) of the 70 babies in the control group. Stage 2 ROP or greater was noted in 10 (8.4%) babies in the treatment group and in 10 (14.3%) of the untreated group. Prophylactic bovine surfactant replacement therapy does not have a significant effect on the frequency of ROP in preterm babies. The severity of ROP also appears to be unaffected by surfactant.