Scleral fixation of intraocular lenses.

PURPOSE OF REVIEW: To review current, effective and more popular techniques for scleral fixation of intraocular lens (IOLs) and IOL-capsular bag complex. RECENT FINDINGS: Scleral fixation of IOLs became popular, originally with sutured scleral fixated IOLs and later the Scharioth technique of intrascleral haptic fixation. This was further developed as the Glued IOL technique which enjoys widespread adoption all over the world. Recently the Yamane technique has also become popular and is being widely adopted as well. SUMMARY: Scleral fixated IOLs have evolved in the last 2 decades with technical modifications, extended indications and improvised instrumentation. Though sutured and sutureless techniques have been growing equally, the sutureless scleral fixation techniques have attracted special interest. Reduced suture-related complications, technical ease and high-quality functional outcomes may be possible reasons. Sutureless capsular bag fixation also has distinct advantages.

Severity and threshold of peanut reactivity during hospital-based open oral food challenges: An international multicenter survey.

BACKGROUND: Peanut allergy is classically managed by food avoidance. Immunotherapy programs are available at some academic centers for selected patients reacting to small amounts of peanut during food challenge. We aimed to determine and compare reaction thresholds and prevalence of anaphylaxis during peanut oral challenges at multiple specialist allergy centers. METHODS: A retrospective, international survey of anonymized case records from seven specialist pediatric allergy centers from the UK and Ireland, as well as the Australian HealthNuts study. Demographic information, allergy test results, reaction severity and threshold during open oral peanut challenges were collated and analyzed. RESULTS: Of the 1634 children aged 1-18 years old included, 525 (32%) failed their peanut challenge. Twenty-eight percent reacted to 25 mg, while 38% only reacted after consuming 1 g or more of whole peanut. Anaphylaxis (55 [11%]) was 3 times more common in teenagers than younger children and the likelihood increased at all ages as children consuming more peanut at the challenge. Children who developed anaphylaxis to 25-200 mg of whole peanut were significantly older. Previous history of reaction did not predict reaction threshold or severity. CONCLUSIONS: More than a third of the children in this large international cohort tolerated the equivalent of one peanut in an oral challenge. Anaphylaxis, particularly to small amounts of peanut, was more common in older children. Tailored immunotherapy programs might be considered not only for children with low, but also higher reaction thresholds. Whether these programs could prevent heightened sensitivity and anaphylaxis to peanut with age also deserves further study.

Scalp replantation in a cervical spine injury patient: Lessons learnt.

Total scalp avulsion injury with cervical spine injury is rare. This article is to describe the technical difficulties and precautions to be taken during anatomical replantation. The patients with cervical spine injury should not be considered as an absolute contraindication for anatomical replant if patients are fit for general anaesthesia. We found that the supratrochlear and supraorbital vessels which are anterior and superficial temporal vessels which are lateral can be used to replant without much technical difficulty. We conclude that anatomical replant is always better keeping in mind the technical limitations of anatomical replant in case of cervical spine injury.

Successful penile reconstruction following prior arteriovenous loop thrombosis due to undiagnosed protein-S deficiency and exogenous testosterone.

Flap failure from microvascular thrombotic occlusion is a rare but significant cause for unsuccessful reconstructive surgery. We encountered thrombosis of arteriovenous loop in a patient undergoing phallus reconstruction. Further investigations revealed underlying previously asymptomatic hypercoagulable state due to protein-S deficiency in addition to long-term exogenous testosterone administration. Role of thrombophilia testing, thrombogenic potential of testosterone and the need for therapeutic perioperative anti-coagulation in such situations are described here.

Cue to action processing in motor cortex populations.

The primary motor cortex (MI) commands motor output after kinematics are planned from goals, thought to occur in a larger premotor network. However, there is a growing body of evidence that MI is involved in processes beyond action generation, and neuronal subpopulations may perform computations related to cue-to-action processing. From multielectrode array recordings in awake behaving Macaca mulatta monkeys, our results suggest that early MI ensemble activity during goal-directed reaches is driven by target information when cues are closely linked in time to action. Single-neuron activity spanned cue presentation to movement, with the earliest responses temporally aligned to cue and the later responses better aligned to arm movements. Population decoding revealed that MI's coding of cue direction evolved temporally, likely going from cue to action generation. We confirmed that a portion of MI activity is related to visual target processing by showing changes in MI activity related to the extinguishing of a continuously pursued visual target. These findings support a view that MI is an integral part of a cue-to-action network for immediate responses to environmental stimuli.

Population interactions between parietal and primary motor cortices during reach.

Neural interactions between parietal area 2/5 and primary motor cortex (M1) were examined to determine the timing and behavioral correlates of cortico-cortical interactions. Neural activity in areas 2/5 and M1 was simultaneously recorded with 96-channel microelectrode arrays in three rhesus monkeys performing a center-out reach task. We introduce a new method to reveal parietal-motor interactions at a population level using partial spike-field coherence (PSFC) between ensembles of neurons in one area and a local field potential (LFP) in another. PSFC reflects the extent of phase locking between spike times and LFP, after removing the coherence between LFPs in the two areas. Spectral analysis of M1 LFP revealed three bands: low, medium, and high, differing in power between movement preparation and performance. We focus on PSFC in the 1-10 Hz band, in which coherence was strongest. PSFC was also present in the 10-40 Hz band during movement preparation in many channels but generally nonsignificant in the 60-200 Hz band. Ensemble PSFC revealed stronger interactions than single cell-LFP pairings. PSFC of area 2/5 ensembles with M1 LFP typically rose around movement onset and peaked ∼500 ms afterward. PSFC was typically stronger for subsets of area 2/5 neurons and M1 LFPs with similar directional bias than for those with opposite bias, indicating that area 2/5 contributes movement direction information. Together with linear prediction of M1 LFP by area 2/5 spiking, the ensemble-LFP pairing approach reveals interactions missed by single neuron-LFP pairing, demonstrating that cortico-cortical communication can be more readily observed at the ensemble level.

EYELID MARGIN DISEASE (BLEPHARITIS AND MEIBOMIAN GLAND DYSFUNCTION): CLINICAL REVIEW OF EVIDENCE-BASED AND EMERGING TREATMENTS.

ABSTRACT: Blepharitis is a common ophthalmic condition with multiple etiologies and no definitive, universal treatment. The treatment modalities for managing lid margin diseases vary depending on the disease's cause, location, and severity. For anterior blepharitis, management options include eyelid hygiene with warm compresses, eyelid scrubs, baby shampoo, and over-the-counter eyelid cleansers. Topical antibiotics and antibiotic-steroid combination drops/ointments for the eye and eyelid may accompany these. For posterior blepharitis/meibomian gland dysfunction (MGD), at-home warm compress or in-office administration of heat therapy/thermal pulsation treatment that aims to clear obstruction in the meibomian glands and restore meibum secretions to maintain a healthy tear film, are recommended. In addition to the above treatment strategies, various other compounds to manage lid margin diseases are in the late stages of development. This review summarizes the available treatment modalities or those in the pipeline for treating blepharitis and MGD.

The Current State in the Diagnosis of Eyelid Margin Disease: A Clinical Review.

The eyelid margin is vital to ocular surface integrity. Much peer-reviewed literature has been established in eyelid margin inflammation, better known as blepharitis. The purpose is to review and understand the impact of eyelid margin disease. Anterior blepharitis causes inflammation at the eyelash base, ciliary follicles, and the palpebral skin. Posterior blepharitis occurs when there is inflammation with the posterior eyelid margin disease. In common usage, the term "blepharitis" used alone almost always refers to anterior blepharitis. Classification of eyelid margin disease should be based on etiopathogenesis, location, primary vs. secondary, and chronicity. Blepharitis has several etiopathologies (infectious, inflammatory, squamous). MGD can refer to the functional and/or structural problems with the MG. Meibomitis (or meibomianitis) occurs when there is inflammation associated with the MGD. The presence of blepharitis and/or MGD (with or without inflammation) can impact the ocular surface and thereby affect anterior segment and cataract surgeries. This review article evaluates the differential diagnoses of eyelid margin disease, including various forms of blepharitis, MGD, and meibomitis.

Simultaneous reconstruction of continuous hand movements from primary motor and posterior parietal cortex.

Primary motor cortex (MI) and parietal area PE both participate in cortical control of reaching actions, but few studies have been able to directly compare the form of kinematic encoding in the two areas simultaneously during hand tracking movements. To directly compare kinematic coding properties in these two areas under identical behavioral conditions, we recorded simultaneously from two chronically implanted multielectrode arrays in areas MI and PE (or areas 2/5) during performance of a continuous manual tracking task. Monkeys manually pursued a continuously moving target that followed a series of straight-line movement segments, arranged in a sequence where the direction (but not length) of the upcoming segment varied unpredictably as each new segment appeared. Based on recordings from populations of MI (31-143 units) and PE (22-87 units), we compared hand position and velocity reconstructions based on linear filters. We successfully reconstructed hand position and velocity from area PE (mean r (2) = 0.751 for position reconstruction, r (2) = 0.614 for velocity), demonstrating trajectory reconstruction from each area. Combing these populations provided no reconstruction improvements, suggesting that kinematic representations in MI and PE encode overlapping hand movement information, rather than complementary or unique representations. These overlapping representations may reflect the areas' common engagement in a sensorimotor feedback loop for error signals and movement goals, as required by a task with continuous, time-evolving demands and feedback. The similarity of information in both areas suggests that either area might provide a suitable target to obtain control signals for brain computer interface applications.

Budget Impact Analysis of Expanding Gliflozin Coverage in the CKD Population: A French Perspective.

INTRODUCTION: Gliflozins have historically been indicated for type 2 diabetes in France. However, their efficacy has recently been demonstrated in heart failure and chronic kidney disease (CKD), with positive recommendations by Haute Autorité de Santé for gliflozin therapies in these indications. The study objective was to investigate the 5-year budget impact associated with the introduction of gliflozins in addition to standard therapy in people with CKD and elevated albuminuria, regardless of diabetes status, from the perspective of the French healthcare system. METHODS: A budget impact model was developed to estimate the 5-year implications of incorporating gliflozins in the treatment of patients with CKD in France, using efficacy data from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial. Direct medical costs associated with drug acquisition and management, treatment-related adverse events, dialysis and kidney transplantation, and adverse clinical outcomes were considered. Market share forecasts were estimated from historical data and expert opinions. Event rates were derived from trial data, while cost data were sourced from published estimates. RESULTS: The introduction of gliflozins was estimated to be cost saving compared to the no gliflozins scenario, with an expected cumulative 5-year budget impact of -€650 million, driven by slowed disease progression in patients treated with gliflozins, with fewer patients cumulatively progressing to end-stage kidney disease (84,526 vs. 92,062). This, in addition to fewer hospitalisations for heart failure and deaths from any cause, led to substantial medical care cost offsets (kidney-related: - €894 million; hospitalisation for heart failure: - €14.3 million; end-of-life care: - €17.3 million) to the additional drug acquisition (€273 million) and treatment-related adverse events costs (€2.98 million). CONCLUSION: In concert with early diagnosis and proactive management of CKD, the expansion of the gliflozin indications into the French CKD population presents the opportunity to reduce the substantial burden associated with cardio-renal complications which outweighs the additional cost of the new treatment. INFOGRAPHIC.

Modeling Chronic Kidney Disease in Type 2 Diabetes Mellitus: A Systematic Literature Review of Models, Data Sources, and Derivation Cohorts.

INTRODUCTION: As novel therapies for chronic kidney disease (CKD) in type 2 diabetes mellitus (T2DM) become available, their long-term benefits should be evaluated using CKD progression models. Existing models offer different modeling approaches that could be reused, but it may be challenging for modelers to assess commonalities and differences between the many available models. Additionally, the data and underlying population characteristics informing model parameters may not always be evident. Therefore, this study reviewed and summarized existing modeling approaches and data sources for CKD in T2DM, as a reference for future model development. METHODS: This systematic literature review included computer simulation models of CKD in T2DM populations. Searches were implemented in PubMed (including MEDLINE), Embase, and the Cochrane Library, up to October 2021. Models were classified as cohort state-transition models (cSTM) or individual patient simulation (IPS) models. Information was extracted on modeled kidney disease states, risk equations for CKD, data sources, and baseline characteristics of derivation cohorts in primary data sources. RESULTS: The review identified 49 models (21 IPS, 28 cSTM). A five-state structure was standard among state-transition models, comprising one kidney disease-free state, three kidney disease states [frequently including albuminuria and end-stage kidney disease (ESKD)], and one death state. Five models captured CKD regression and three included cardiovascular disease (CVD). Risk equations most commonly predicted albuminuria and ESKD incidence, while the most predicted CKD sequelae were mortality and CVD. Most data sources were well-established registries, cohort studies, and clinical trials often initiated decades ago in predominantly White populations in high-income countries. Some recent models were developed from country-specific data, particularly for Asian countries, or from clinical outcomes trials. CONCLUSION: Modeling CKD in T2DM is an active research area, with a trend towards IPS models developed from non-Western data and single data sources, primarily recent outcomes trials of novel renoprotective treatments.

The clinical effects of new treatments and their costs are often evaluated over a longer time frame than is possible in clinical trials by using computer simulation models. As new treatments are becoming available to treat chronic kidney disease, including in patients with type 2 diabetes, chronic kidney disease models may be used to inform clinical and economic decisions regarding these new treatment options. In the present study, we identified 49 published simulation models of chronic kidney disease used in populations with type 2 diabetes, and reviewed their structures and the data sources they used. The models focused mostly on disease states and outcomes associated with albuminuria (a condition in which the protein albumin is found in the urine) and end-stage kidney disease. Model structures with five disease states, including a kidney disease-free state, three kidney disease states, and death, were the most common. Relatively few models used glomerular filtration rates (a common measure of kidney function) or captured the possibility of an improvement in chronic kidney disease. Important data sources for many models were patient registries, cohort studies, and clinical trials, most conducted several decades ago in high-income countries with a high proportion of White participants. Several models developed in the past 5 years, particularly for Asian countries, instead relied largely or exclusively on country-specific data. In parallel, several individual patient simulations were recently developed from large outcomes trials for new treatments, including from trial subgroups covering specific geographical settings or ethnicities, shortly after trial publication.

Treatments for Chronic Kidney Disease: A Systematic Literature Review of Randomized Controlled Trials.

Delaying disease progression and reducing the risk of mortality are key goals in the treatment of chronic kidney disease (CKD). New drug classes to augment renin-angiotensin-aldosterone system (RAAS) inhibitors as the standard of care have scarcely met their primary endpoints until recently. This systematic literature review explored treatments evaluated in patients with CKD since 1990 to understand what contemporary data add to the treatment landscape. Eighty-nine clinical trials were identified that had enrolled patients with estimated glomerular filtration rate 13.9-102.8 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio (UACR) 29.9-2911.0 mg/g, with (75.5%) and without (20.6%) type 2 diabetes (T2D). Clinically objective outcomes of kidney failure and all-cause mortality (ACM) were reported in 32 and 64 trials, respectively. Significant reductions (P < 0.05) in the risk of kidney failure were observed in seven trials: five small trials published before 2008 had evaluated the RAAS inhibitors losartan, benazepril, or ramipril in patients with (n = 751) or without (n = 84-436) T2D; two larger trials (n = 2152-2202) published onwards of 2019 had evaluated the sodium-glucose co-transporter 2 (SGLT2) inhibitors canagliflozin (in patients with T2D and UACR > 300-5000 mg/g) and dapagliflozin (in patients with or without T2D and UACR 200-5000 mg/g) added to a background of RAAS inhibition. Significant reductions in ACM were observed with dapagliflozin in the DAPA-CKD trial. Contemporary data therefore suggest that augmenting RAAS inhibitors with new drug classes has the potential to improve clinical outcomes in a broad range of patients with CKD.

Autism spectrum disorder in a child with megalencephaly-capillary malformation-polymicrogyria syndrome (MCAP).

Megalencephaly-capillary malformation-polymicrogyria syndrome (MCAP) is a rare disorder that arises as a result of a somatic mosaic mutation in the PIK3CA gene. It characteristically presents with postnatal or congenital megalencephaly, cutaneous capillary malformations, postaxial polydactyly and often segmental or focal body overgrowth. We report a 7-year-old boy with known MCAP who was diagnosed at around 10 months old with a mosaic change in the PIK3CA gene. He was found to have hall-mark clinical signs; macrocephaly and four-limb postaxial polydactyly. Since diagnosis, he has had multiple clinical features, most of which typically present in children with MCAP. He has now been diagnosed with autism spectrum disorder (ASD), demand avoidance and is under assessment for attention deficit hyperactivity disorder. Although some cases have been raised to the M-CM Network, to our knowledge this is the first case of ASD in MCAP to be reported in the literature.

Drug-eluting stents versus bare metal stents for angina or acute coronary syndromes.

BACKGROUND: Coronary artery stents are tiny tubular devices used to 'scaffold' vessels open during percutaneous transluminal coronary angioplasty (PTCA). Restenosis (re-narrowing) of vessels treated with stents is a problem; in order to reduce restenosis, stents that elute drugs over time are now available. However these drug-eluting stents are more expensive and there is a need to assess their clinical benefits prior to recommending their use. OBJECTIVES: To examine evidence from randomised controlled trials (RCTs) to assess the impact of drug eluting stents (DES) compared to bare metal stents (BMS) in the reduction of cardiac events. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4), MEDLINE (1990 - April 2009) and EMBASE (1980 - January 2009) were searched. We carried out handsearching (electronic and manual) up to January 2008. SELECTION CRITERIA: We included RCTs comparing DES with BMS used in conjunction with PTCA techniques in the review. Participants were adults with stable angina or acute coronary syndrome (ACS). We considered published and unpublished sources and included them if they reported outcome data of interest. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data, assessed trial quality assessment and checked decisions within the group. Data extraction included composite event rates (major adverse cardiac event, target vessel failure); death; acute myocardial infarction (AMI); target lesion revascularisation (TLR); target vessel revascularisation (TVR) and thrombosis. Data synthesis included meta-analysis of composite event rate, death, AMI and revascularisation rates, presented as odds ratios with 95% confidence intervals (CI) using a fixed-effect model. We assessed heterogeneity between trials. MAIN RESULTS: We included more than 14,500 patients in 47 RCTs. There were no statistically significant differences in death, AMI or thrombosis between DES and BMS. For composite events, TLR and TVR reductions were evident with use of sirolimus, paclitaxel, everolimus, dexamethasone, zotarolimus and (to a limited extent) tacrolimus-eluting stents. These effects are demonstrated in the longer term follow up. Subgroup analyses (e.g. diabetics) largely mirrored these findings. AUTHORS' CONCLUSIONS: Drug-eluting stents releasing sirolimus, paclitaxel, dexamethasone and zotarolimus reduce composite cardiac events. However, this reduction is due largely to reductions in repeat revascularisation rates as there is no evidence of a significant effect on rates of death, MI or thrombosis. The increased cost of drug-eluting stents and lack of evidence of their cost-effectiveness means that various health funding agencies are having to limit or regulate their use in relation to price premium.

Novel Use of Telemedicine for Corneal Tissue Evaluation in Eye Banking: Establishing a Standardized Approach for the Remote Evaluation of Donor Corneas for Transplantation.

PURPOSE: To determine the feasibility of using telemedicine consultations in the evaluation of recovered donor corneas for transplant suitability. METHODS: This study aims to establish and test the minimum imaging requirements for telemedical consultations of corneal tissue by remote eye bank medical directors. Digital images from the slit lamp, optical coherence tomography, and/or specular microscope were assembled into telemedical consults and emailed to 4 eye bank medical directors (M.A.T., J.W., C.S.S., N.K.R.). Feedback on the minimum image requirements for each corneal finding was collected. After establishing a standardized imaging and presentation protocol, test cases were presented to the medical directors to examine the validity of these remote consults. To establish a benchmark for the study's parameters, one medical director (J.W.) examined each case in person after his initial remote review. Examiners were masked to each other's responses. RESULTS: Minimum image requirements for determination of corneal findings were defined and were specific to each anatomic layer of the cornea (epithelial, stromal, or endothelial). Using a defined set of digital images for a set of common corneal findings, the rate of agreement between remote evaluators, eye bank staff, and the in-person evaluator was 100% (11 of 11 examples). For ambiguous test cases, remote evaluators agreed on 80% of the cases (4 of 5). CONCLUSIONS: Results from this pilot study suggest that telemedical review of corneal tissue using high-quality digital images may be adequate for accurate identification of specific corneal findings commonly encountered by eye banks.

Finasteride improves male pattern hair loss in a randomized study in identical twins.

OBJECTIVES: This study compared the efficacy of finasteride with placebo in the treatment of male pattern hair loss (androgenetic alopecia) in nine pairs of male identical twins. METHODS: In this randomized, double-blind, placebo-controlled, single-center study, one twin from each identical twin pair received finasteride 1 mg/day for one year while the other received placebo. Hair growth was evaluated from standardized clinical photographs, hair counts and patient self-assessment questionnaires. Serum dihydrotestosterone and testosterone levels were analyzed and adverse events recorded. RESULTS: Finasteride significantly improved hair growth at one year compared to placebo (p < 0.05) based on analysis of photographs of the vertex and superior-frontal scalp. These results were consistent with the hair count change measured in the finasteride group, which was superior (p < 0.05) to the change measured in the placebo group. Patient self-assessment demonstrated that treatment with finasteride, in comparison to placebo, led to improvements in scalp hair growth and patients' satisfaction with appearance of hair. No drug-related adverse events were reported during the study. CONCLUSION: Through the use of identical twins, this study provides further evidence that finasteride significantly reduces hair loss progression and restores hair growth in men with male pattern hair loss.

Failure mode analysis of silicon-based intracortical microelectrode arrays in non-human primates.

OBJECTIVE: Brain-computer interfaces (BCIs) using chronically implanted intracortical microelectrode arrays (MEAs) have the potential to restore lost function to people with disabilities if they work reliably for years. Current sensors fail to provide reliably useful signals over extended periods of time for reasons that are not clear. This study reports a comprehensive retrospective analysis from a large set of implants of a single type of intracortical MEA in a single species, with a common set of measures in order to evaluate failure modes. APPROACH: Since 1996, 78 silicon MEAs were implanted in 27 monkeys (Macaca mulatta). We used two approaches to find reasons for sensor failure. First, we classified the time course leading up to complete recording failure as acute (abrupt) or chronic (progressive). Second, we evaluated the quality of electrode recordings over time based on signal features and electrode impedance. Failure modes were divided into four categories: biological, material, mechanical, and unknown. MAIN RESULTS: Recording duration ranged from 0 to 2104 days (5.75 years), with a mean of 387 days and a median of 182 days (n = 78). Sixty-two arrays failed completely with a mean time to failure of 332 days (median = 133 days) while nine array experiments were electively terminated for experimental reasons (mean = 486 days). Seven remained active at the close of this study (mean = 753 days). Most failures (56%) occurred within a year of implantation, with acute mechanical failures the most common class (48%), largely because of connector issues (83%). Among grossly observable biological failures (24%), a progressive meningeal reaction that separated the array from the parenchyma was most prevalent (14.5%). In the absence of acute interruptions, electrode recordings showed a slow progressive decline in spike amplitude, noise amplitude, and number of viable channels that predicts complete signal loss by about eight years. Impedance measurements showed systematic early increases, which did not appear to affect recording quality, followed by a slow decline over years. The combination of slowly falling impedance and signal quality in these arrays indicates that insulating material failure is the most significant factor. SIGNIFICANCE: This is the first long-term failure mode analysis of an emerging BCI technology in a large series of non-human primates. The classification system introduced here may be used to standardize how neuroprosthetic failure modes are evaluated. The results demonstrate the potential for these arrays to record for many years, but achieving reliable sensors will require replacing connectors with implantable wireless systems, controlling the meningeal reaction, and improving insulation materials. These results will focus future research in order to create clinical neuroprosthetic sensors, as well as valuable research tools, that are able to safely provide reliable neural signals for over a decade.

Submental intubation: our experience.

INTRODUCTION: Airway management for patients who suffered midfacial fractures is complicated. In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to both the nasal and oral cavities is necessary. Submental intubation technique is an alternative to nasoendotracheal intubation and tracheostomy in the management of patients with severe midfacial fractures. This procedure is simple to do and has a low morbidity. MATERIAL: Submental intubation-paramedian technique has been used in 15 cases from May 2005-April 2007 in Hosmat Hospital, Bangalore. All patients had fractures disturbing the dental occlusion plus either an associated fracture of the skull base or a displaced nasal fracture. RESULTS: Average duration of procedure was 7 minutes. Average duration of tube in vitro after surgery was 20 hours. There were 2 postoperative complications of tube obstruction which were successfully managed. CONCLUSION: Submental intubation demands certain technical skills but it is simple, rapid and may avoid tracheostomy in selected patients.

Study of papillary carcinoma of thyroid with uncommon sites of metastasis.

Papillary carcinoma of thyroid (PCT) is the most common type of thyroid malignancy and metastasis to cervical lymph nodes is very common [1]. Blood borne metastases from PCT are less frequent than with the other thyroid carcinomas [2]. Uncommon sites include lungs, bone, atrium, cerebrum, kidney, skin [3].We report four cases of papillary carcinoma with uncommon sites of metastasis.One showed tumor emboli of 2.5 cm in internal jugular vein, one had tumor deposit in metacarpal bone and lung, one had a subcutaneous tumor deposit and one was a micropapillary carcinoma with metastasis axillary nodes. All these four cases were classical PCT.

Descemet stripping automated endothelial keratoplasty in eyes with previous trabeculectomy and tube shunt procedures: intraoperative and early postoperative complications.

PURPOSE: To evaluate the intraoperative and early postoperative outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with previous glaucoma filtering surgeries. METHODS: A retrospective review of all DSAEK surgeries performed at one center comparing complications of DSAEK in eyes with previous glaucoma filtering procedures (study eyes) with a time-matched group of all other DSAEK cases (control eyes). RESULTS: There were 28 study eyes, 19 with previous trabeculectomies and 9 with previous glaucoma drainage devices (GDDs) and 431 control eyes. Study group intraoperative complications included 1 compromised bleb and 1 loss of donor tissue because of traumatic manipulation. One intraoperative complication, a perforation of the donor tissue, occurred in the control group. Venting stab incisions were used more often in study eyes (n = 5; 18%) than in control eyes (n = 12; 4.4%) (P = 0.002). GDD tubes were trimmed in 2 eyes (22%). No intraoperative manipulations were used to occlude the glaucoma filters or tubes. Postoperative complications in the study group included 1 dislocation (3.6%) and 1 decentered graft (3.6%) and 1 eye with loss of pressure control (3.6%), whereas in the control group, there were 10 dislocations (2.3%) and 1 decentered graft (0.2%) (P = 0.267 for dislocations and P = 0.118 for decentered grafts). One episode of pupillary block (0.2%) occurred in the control group, and none occurred in the study group. No primary graft failures occurred in either group. CONCLUSIONS: DSAEK surgeries in eyes with previous glaucoma filtering procedures were performed without primary graft failure and with reasonably low dislocation (3.6%) and graft decentration (3.6%) rates. Although the intraoperative complication rate for the study group (7.1%) was higher than the rate for the control group (0.23%), excellent early postoperative outcomes can be achieved when DSAEK is performed in eyes with previous trabeculectomies and GDDs.