Rapid-Deployment Versus Conventional Bio-Prosthetic Aortic Valve Replacement.

BACKGROUND: The use of rapid-deployment aortic valve replacement (RD-AVR) has burgeoned in recent years. There are few studies comparing RD-AVR to conventional aortic valve replacement (cAVR) and no studies where both were inserted via full sternotomy. As such, we reviewed our experience and compared the two approaches. METHODS: From 2008 to 2015, 597 patients underwent isolated aortic valve replacement ± coronary artery bypass grafting (CABG) at a single centre. During this period, 41 (7%) patients received RD-AVR and 556 (93%) received cAVR. Of those receiving RD-AVR, surgical access was via full median sternotomy in 40 (98%). Propensity score matching yielded 41 matched pairs. Perioperative outcomes were compared. RESULTS: After propensity score matching, the RD-AVR group had shorter aortic cross clamp (X-clamp) (RD-AVR: 71±33min vs. cAVR: 106±42min, p<0.01) and cardiopulmonary bypass (CPB) times (95±42min vs. 134±47min, p<0.01). There was no difference in 30-day mortality (RD-AVR: 2% vs. cAVR: 2%, p>0.99). RD-AVR patients required shorter mean ventilation (17±25 vs. 63±131hrs, p<0.01) and intensive care unit (ICU) stay (51±45 vs. 108±157hrs, p=0.03) times. RD-AVR also had reduced rates of new postoperative atrial arrhythmias (8% vs. 20%, p=0.02). Total length of postoperative hospital stay was similar. Haemodynamic performance for the RD-AVR was within acceptable limits. CONCLUSIONS: The use of RD-AVR results in shorter X-clamp and CPB times and is associated with reductions in perioperative morbidity. RD-AVR is becoming a valuable component of the surgeon's armamentarium in selected patients. Long-term follow-up will reveal the full potential of these devices.

Human papillomavirus virus (HPV) genotype- and age-specific analyses of external genital lesions among men in the HPV Infection in Men (HIM) Study.

BACKGROUND: Human papillomavirus (HPV) causes external genital lesions (EGLs) in men, including condyloma and penile intraepithelial neoplasia (PeIN). We sought to determine the incidence of pathologically confirmed EGLs, by lesion type, among men in different age groups and to evaluate the HPV types that were associated with EGL development. METHODS: HPV Infection in Men (HIM) study participants who contributed ≥2 visits from 2009-2013 were included in the biopsy cohort. Genotyping by an HPV line-probe assay was performed on all pathologically confirmed EGLs. Age-specific analyses were conducted for incident EGLs, with Kaplan-Meier estimation of cumulative incidence. RESULTS: This biopsy cohort included 2754 men (median follow-up duration, 12.4 months [interquartile range, 6.9-19.2 months]). EGLs (n = 377) were pathologically confirmed in 228 men, 198 of whom had incident EGLs. The cumulative incidence of any EGL was highest among men <45 years old and, for condyloma, decreased significantly over time with age. The genotype-specific incidence of EGL varied by pathological diagnoses, with high- and low-risk genotypes found in 15.6% and 73.2% of EGLs, respectively. Condyloma primarily contained HPV 6 or 11. While PeIN lesions primarily contained HPV 16, 1 PeIN III lesion was positive for HPV 6 only. CONCLUSION: Low- and high-risk HPV genotypes contribute to the EGL burden. Men remain susceptible to HPV-related EGLs throughout the life span, making it necessary to ensure the longevity of immune protection against the most common causative HPV genotypes.

DDE and PCB serum concentration in maternal blood and their adult female offspring.

BACKGROUND: Dichlorodiphenyl dichloroethylene (DDE) and polychlorinated biphenyls (PCBs) can be passed from mother to offspring through placental transfer or breastfeeding. Unknown is whether maternal levels can predict concentrations in adult offspring. OBJECTIVES: To test the association between maternal blood levels of DDE and PCBs and adult female offspring levels of these compounds using data from the Michigan Fisheaters'Cohort. METHODS: DDE and PCB concentrations were determined in 132 adult daughters from 84 mothers. Prenatal exposures were estimated based on maternal DDE and PCB serum levels measured between 1973 and 1991. Levels in adult daughters were regressed on maternal and estimated prenatal exposure levels, adjusting for potential confounders using linear mixed models. Confounders included daughter's age, birth order, birth weight, number of pregnancies, the length of time the daughter was breast-fed, the length of time the daughter breast-fed her own children, last year fish-eating status, body mass index, and lipid weight. RESULTS: The median age of the participants was 40.4 years (range 18.4-65.4, 5-95 percentiles 22.5-54.6%, respectively). Controlling for confounders and intra-familial associations, DDE and PCB concentrations in adult daughters were significantly positively associated with estimated prenatal levels and with maternal concentrations. The proportion of variance in the adult daughters' organochlorine concentrations explained by the maternal exposure levels is approximately 23% for DDE and 43% for PCBs. The equivalent of a median of 3.67 µg/L prenatal DDE and a median of 2.56 µg/L PCBs were 15.64 and 10.49 years of fish consumption, respectively. When controlling for effects of the shared environment (e.g., fish diet) by using a subsample of paternal levels measured during the same time frames (n=53 and n=37), we determined that the direct maternal transfer remains important. CONCLUSIONS: Estimated intra-uterine DDE and PCB levels predicted concentrations in adult female offspring 40 years later. Interpretation of adverse health effects from intra-uterine exposures of persistent pollutants may need to consider the sustained impact of maternal DDE and PCB levels found in their offspring.

Incidence of dislocated and subluxed iris-fixated phakic intraocular lens and outcomes following re-enclavation.

BACKGROUND: The purpose of this study was to establish the incidence of re-enclavation of iris-fixated phakic intraocular lenses in our centre and evaluate outcomes following re-enclavation. DESIGN: Retrospective observational case series. Single surgeon, hospital setting. PARTICIPANTS: Six hundred and nine patients (1218 eyes) implanted with iris-fixated phakic intraocular lenses between 2000 and 2011. METHODS: Eyes requiring re-enclavation were identified, and outcome measures were evaluated 12 months following re-enclavation. MAIN OUTCOME MEASURES: Rate of re-enclavation, uncorrected distance visual acuity and manifest refractive spherical equivalent were measured 12 months following re-enclavation. RESULTS: Twenty-five eyes (2% of eyes overall) of 20 patients required re-enclavation of a dislocated or subluxed phakic intraocular lens. Eight cases (32%) dislocated secondary to trauma and 17 (68%) subluxed spontaneously. No significant difference was detected (P = 0.59) in uncorrected distance visual acuity (logMAR equivalent) 12 months post-re-enclavation (0.18 ± 0.04) compared with that recorded 6 months post-initial uneventful phakic intraocular lens implantation (0.10 ± 0.06). No significant difference was detected (P = 0.95) in mean manifest refractive spherical equivalent 12 months post-re-enclavation (-0.59D ± 0.29D) compared with that recorded 6 months post-initial phakic intraocular lens implantation (-0.57D ± 0.17D). Following re-enclavation, mean endothelial cell count was 2627 ± 101 cells/mm(2) 12 months postoperatively in 16 eyes. This did not differ significantly from that recorded 6 months post-initial phakic intraocular lens implantation in these eyes (P = 1). CONCLUSION: Dislocation and subluxation of iris-fixated phakic intraocular lenses may occur secondary to trauma or spontaneously because of inadequate iris enclavation. Re-enclavation can be carried out successfully with no significant adverse effect on clinical outcomes.

Cellular technology improves transmission success of pre-hospital electrocardiograms.

STUDY OBJECTIVE: In rural settings, long distances and transport times pose a challenge for achieving early reperfusion goals in patients with ST-elevation myocardial infarction (STEMI). This study investigated the association between the method of pre-hospital 12-lead ECG transmission (radio transmission vs. cellular phone transmission) and the success of transmission and legibility of 12-lead ECGs in a rural setting. METHODS: Observational study of pre-hospital 12-lead ECG transmission to the emergency department (ED) in a predominantly rural area. Success of transmission and the legibility of the 12-lead ECG were analyzed to identify barriers to 12-lead ECG transmission and reasons for failed transmission. RESULTS: Emergency medical services performed ECGs on 1140 patients, 917 of which they attempted to transmit, including 43 cases requiring emergent catheterization. Twelve-lead ECG transmission was successful in 236 (70%) of 337 radio attempts and 441 (76%) of 580 cellular attempts (difference 6.0%, 95% CI 1.1-12.1). Legibility increased from 164 (49%) of 337 radio attempts to 389 (67%) of 580 cellular attempts (difference 18.4%, 95% CI 11.8-24.9). CONCLUSION: The success of transmission and legibility of 12-lead ECGs was significantly higher with cellular technology by emergency medical service agencies in comparison to radio transmission. In rural settings with lengthy transport times, utilization of cellular technology for transmission of pre-hospital 12-lead ECGs may improve door-to-balloon times for STEMI patients.

Heterozygous mutations of the kinesin KIF21A in congenital fibrosis of the extraocular muscles type 1 (CFEOM1).

Congenital fibrosis of the extraocular muscles type 1 (CFEOM1; OMIM #135700) is an autosomal dominant strabismus disorder associated with defects of the oculomotor nerve. We show that individuals with CFEOM1 harbor heterozygous missense mutations in a kinesin motor protein encoded by KIF21A. We identified six different mutations in 44 of 45 probands. The primary mutational hotspots are in the stalk domain, highlighting an important new role for KIF21A and its stalk in the formation of the oculomotor axis.

A rare cause of Takotsubo cardiomyopathy related left ventricular apical thrombus requiring surgery.

We present the case of a 48 year-old male with a history of cystic fibrosis who presented with massive haemoptysis and was later found to have Takotsubo cardiomyopathy. He subsequently developed a left ventricular (LV) thrombus which was successfully removed via a left apical ventriculotomy. Surgical management of LV thrombus related to Takotsubo cardiomyopathy is warranted in a selected population of patients and a left apical ventriculotomy provides good access with minimal complications in the post operative setting.

Warm humidified CO2 insufflation improves pericardial integrity for cardiac surgery: a randomized control study.

BACKGROUND: Flooding the surgical field with dry cold CO2 during open-chamber cardiac surgery has been used to mitigate air entrainment into the systemic circulation. However, exposing epithelial surfaces to cold, dry gas causes tissue desiccation. This randomized controlled study was designed to investigate whether the use of humidified warm CO2 insufflation into the cardiac cavity could reduce pericardial tissue damage and the incidence of micro-emboli when compared to dry cold CO2 insufflation. METHODS: Forty adult patients requiring elective open-chamber cardiac surgery were randomized to have either dry cold CO2 insufflation via a standard catheter or humidified warm CO2 insufflation via the HumiGard device (Fisher & Paykel Healthcare, Panmure, Auckland, New Zealand). The primary endpoint was biopsied pericardial tissue damage, assessed using electron microscopy. We assessed the percentage of microvilli and mesothelial damage, using a damage severity score (DSS) system. We compared the proportion of patients who had less damage, defined as DSS<2. Secondary endpoints included the severity of micro-emboli, by visual assessment of bubble load on transesophageal echocardiogram; lowest near infrared spectroscopy; total de-airing time; highest cardio-pulmonary bypass sweep speed; hospital length of stay and complications. RESULTS: A higher proportion of patients in the humidified warm CO2 group displayed conserved microvilli (47% vs. 11%, P=0.03) and preserved mesothelium (42% vs. 5%, P=0.02) compared to the control group. There were no differences in the secondary outcomes. CONCLUSIONS: Humidified warm CO2 insufflation significantly reduced pericardial epithelial damage when compared to dry cold CO2 insufflation in open-chamber cardiac surgery. Further studies are warranted to investigate its potential clinical benefits.

Iris-fixated phakic intraocular lens explantation.

BACKGROUND/AIMS: To evaluate the visual outcomes and indication for surgery in a series of patients who underwent explantation of a phakic intraocular lens (PIOL). METHODS: A retrospective case series of patients who underwent PIOL explantation in our institution was performed. The indication for explantation and visual and refractive outcomes were examined. The method of explantation is described. RESULTS: Twenty-two eyes of 16 patients underwent PIOL explantation with a mean time to explantation of 7 ± 3 years (range 3-11.4). The mean age at explantation was 50.3 ± 9.3 years. Sixteen Artisan PIOLs and six Artiflex PIOLs were explanted. The indications for explanation were cataract development (17/22), endothelial cell loss (4/22) and synechiae formation (1/22). All patients with cataract underwent a combined procedure with explantation and phacoemulsification and the placement of a posterior chamber IOL. Mean corrected vision after explantation was 0.22 ± 0.10 logMAR (range 0.1-0.3 logMAR). One patient with endothelial cell loss required a Descemet's Stripping Endothelial Keratoplasty (DSEK). CONCLUSION: Removal of PIOLs was necessitated most frequently by cataract followed by endothelial cell loss. Both explantation alone and explantation with concurrent phacoemulsification are safe procedures with good visual outcomes and will become more frequent in the future as more patients with PIOLs reach cataractous age.

Systematic review and meta-analysis of long-term outcomes in adults undergoing the Ross procedure.

BACKGROUND: The management of aortic valve disease is becoming increasingly complicated with the evolution of treatment options available to cardiac surgeons and cardiologist. Pulmonary autograft replacement of the aortic valve, commonly known as the Ross procedure, involves excision of the pulmonary valve from the right ventricular outflow tract and implantation in the aortic position. This systematic review aims to evaluate the long-term outcomes, following the Ross procedure. METHODS: An electronic search strategy queried five online medical referencing databases from inception to 21 August 2020. All studies detailing the long-term outcomes of adults undergoing the Ross procedure were included. A random effects model was used to determine pooled continuous data. Enhanced secondary survival analysis was performed on reconstructed individual patient data. RESULTS: Twenty-three studies were included in the qualitative synthesis, including a total of 6,278 patients with a mean follow-up duration of 6.0±2.8 years. Long-term survival was 95.6%, 91.8%, 86.3% and 80.5% at five, ten, fifteen and twenty years, respectively. Freedom from autograft reoperation was 95.7%, 91.2%, 84.9% and 76.1% at five, ten, fifteen and twenty years, respectively. CONCLUSIONS: When performed in experienced centres and for appropriately selected patients, the Ross procedure represents a durable replacement of the aortic valve with excellent long-term survival.

Laboratory and Field Evaluations of a Commercially Available Real-Time Loop-Mediated Isothermal Amplification Assay for the Detection of West Nile Virus in Mosquito Pools.

Although the specific cDNA amplification mechanisms of reverse-transcriptase polymerase chain reaction (RT-PCR) and RT loop-mediated isothermal amplification (RT-LAMP) are very different, both molecular assays serve as options to detect arboviral RNA in mosquito pools. Like RT-PCR, RT-LAMP uses a reverse transcription step to synthesize complementary DNA (cDNA) from an RNA template and then uses target-specific primers to amplify cDNA to detectable levels in a single-tube reaction. Using laboratory-generated West Nile virus (WNV) samples and field-collected mosquito pools, we evaluated the sensitivity and specificity of a commercially available WNV real-time RT-LAMP assay (Pro-AmpRT™ WNV; Pro-Lab Diagnostics, Inc., Round Rock, Texas) and compared the results to a validated real-time RT-PCR assay. Laboratory generated virus stock samples containing ≥ 2.3 log10 plaque-forming units (PFU)/ml and intrathoracically inoculated mosquitoes containing ≥ 2.4 log10 PFU/ml produced positive results in the Pro-AmpRT WNV assay. Of field-collected pools that were WNV positive by real-time RT-PCR, 74.5% (70 of 94) were also positive by the Pro-AmpRT WNV assay, resulting in an overall Cohen's kappa agreement of 79.4% between the 2 tests. The Pro-AmpRT WNV assay shows promise as a suitable virus screening tool for vector surveillance programs provided agencies are aware of its characteristics and limitations.

Choroidal melanoma in a 7-year-old child treated by trans-scleral local resection.

PURPOSE: To report a choroidal melanoma in a 7-year-old child treated by trans-scleral local resection and adjuvant brachytherapy with a family history of neurofibromatosis type I (NF1) and cutaneous melanoma. PATIENT AND METHODS: A 7-year-old child was referred for treatment of a choroidal tumor in her left eye with a differential diagnosis of melanoma, neurilemmoma, leiomyoma, and neurofibroma. Trans-scleral local resection and, subsequently, adjuvant brachytherapy were performed. RESULTS: Histopathology and immunohistochemistry of the specimen diagnosed an amelanotic melanoma of spindle cell type, with a moderately high number of mitoses (7/40 HPF). Multiplex ligation-dependent probe amplification (MLPA) analysis showed two copies of chromosome 3, three copies of the short arm of chromosome 6, and two copies of chromosome 8, strongly suggesting a good prognosis. Postoperative ophthalmic evaluation at 6 months showed no visible tumor and flat retina with visual acuity (VA) of 6/60. CONCLUSIONS: Trans-scleral local resection with adjuvant brachytherapy in children is possible using the same techniques as for adults. Although the follow-up is short, our patient retained the eye with good vision and our cytogenetic studies allowed us to reassure the mother.

5-year prospective follow-up of Artisan phakic intraocular lenses for the correction of myopia, hyperopia and astigmatism.

AIM: To determine the efficacy and safety of Artisan phakic intraocular lenses (IOLs) for refractive error correction. METHODS: A prospective study was conducted on patients undergoing Artisan phakic IOL implantation for myopia, hyperopia or astigmatism from 2002 to 2008. Visual acuity, manifest refractive spherical equivalent (MRSE), endothelial cell counts and higher order aberrations were recorded pre- and postoperatively. RESULTS: One hundred and fifty-one (84 patients) myopic (mean MRSE -11.2 +/- 4.1 D) and 14 (7 patients) hyperopic eyes (mean MRSE 7.1 +/- 1.3 D) were treated. Twenty eyes (11 patients) had toric IOLs to correct astigmatism (mean MRSE -9.05 +/- 6.13 D, mean astigmatism 4.06 +/- 1.26 D). Three months postoperatively, mean MRSE in 37.6% of eyes was within +/-0.5 D, 61.8% within +/-1.0 D and 91.4% within +/-2.0 D. 18.5% underwent keratorefractive surgery to correct residual refractive error. A 1.56-fold increase occurred in 4th order spherical aberration. Endothelial cell loss was 1.45% at 1 year and negligible at 5 years. Fifty-four eyes (29.2%) gained one or more lines of best corrected visual acuity and no eye lost a line. CONCLUSION: Artisan phakic IOLs are safe and effective for refractive error correction.

Laser epithelial keratomileusis in 2010 - a review.

Photorefractive keratectomy, laser epithelial keratomileusis (LASEK) and Epi-LASIK are all variants of a similar type refractive surgery involving laser on the surface of the cornea and differ mainly in management of the epithelium. Although laser in situ keratomileusis (LASIK) is currently the most popular form of refractive surgery, LASEK is the procedure of choice in some patients. We highlight potential complications of LASEK and how these may be managed. Following laser refractive surgery, corneal thickness is reduced, which has implications for intraocular pressure measurement and glaucoma screening and management. This is particularly important following surface laser procedures where no evidence of previous surgery may be visible. In the event that cataract surgery is required at a later date, correct calculation of the appropriate intraocular lens power can be difficult and it thus important that patients are given their preoperative keratometry readings and refraction. Compared with LASIK patients, those who undergo LASEK are considered to be at lower risk of corneal ectasia. Improved understanding of wound healing post LASEK and better postoperative pain management are ongoing challenges.

Complications and visual prognosis in children with aniridia.

PURPOSE: To characterize the ophthalmological findings, assess surgical outcomes, and review visual outcomes in aniridia. METHODS: A retrospective case review was performed and data were collected, including patient demographics, incidence of aniridia-associated keratopathy, glaucoma, cataract, retinal breaks or detachments, optic nerve hypoplasia, macular hypoplasia, poor vision, and nystagmus. All outcomes from surgery, including penetrating keratoplasty, trabeculectomy, Ahmed valve insertion, and cataract extraction, were recorded. RESULTS: Six children (12 eyes) had corneal abnormalities, 4 had optic nerve hypoplasia, 9 had nystagmus, and 2 had retinal detachments. Four patients (7 eyes) required penetrating keratoplasty. Five patients (9 eyes) developed glaucoma and only 1 of the 4 trabeculectomies performed succeeded. Of the 6 Ahmed valve procedures performed, all succeeded in maintaining a satisfactory intraocular pressure but some required needling and 5-fluorouracil. Eight patients developed cataract and 7 required surgery. Visual outcomes were poor despite treatment. Nine patients had Snellen acuity of 6/60 or less and required low visual aids to function. CONCLUSION: Aniridia is a disorder that requires multiple surgeries. It has a poor visual prognosis despite early diagnosis and aggressive management. Newer techniques such as Ahmed valves and Boston keratoprostheses offer hope, but its proliferative nature makes treatment difficult.

Surgical management of non-syndromic ectopia lentis.

AIM: To compare whether aphakic contact lenses or secondary iris-claw intraocular lenses are superior in the refractive management post-pars plana vitreolensectomy in a pedigree with an FBN1 mutation causing non-syndromic ectopia lentis (NSEL) with retinal detachment (RD). METHODS: Eight affected individuals had pars plana vitreolensectomy for bilateral ectopia lentis (EL). Twelve eyes of 6 patients had secondary iris-claw intraocular lenses inserted and 4 eyes of 2 patients were managed with contact lenses. Rhegmatogenous retinal detachment (RRD) was treated when necessary. Pre- and post-operative assessment included visual acuity, endothelial cell count and dilated fundal examination. RESULTS: Macula-on RRD was present in all individuals >18y, 64% (7/11 eyes) presenting post-vitreolensectomy with 57% having bilateral non-synchronous RRD. Surgical aphakia was managed with iris-fixated intraocular lenses (IOL group, n=6), or contact lenses (CL group, n=2). Visual acuity ≥0.3 logMAR (driving standard) was achieved in 75% of IOL group eyes and 25% of the CL group eyes. Mean loss of corneal endothelial cell count in the IOL group was 4% at 2y post-operative. CONCLUSION: In this cohort, refractive management with iris-claw IOLs provided superior outcomes to contact lenses and the authors recommend this as the optimal refractive correction in EL patients.

Secondary glaucoma and visual axis opacification in aphakic and pseudophakic patients following congenital cataract surgery: A 28-year longitudinal case series.

PURPOSE: To determine the incidence, timing and risk factors for glaucoma and visual axis opacification development following surgery for congenital cataract in the first year of life. METHODS: A prospective case series of all cataract surgery performed in Temple Street Children's University Hospital over a 28-year period was conducted. A total of 93 subjects (135 eyes) were analysed. Sixty-two eyes had a primary intraocular lens inserted at the time of surgery; 73 eyes were aphakic. We recorded patient demographics, age at surgery, length of follow-up, rates and time to diagnosis of glaucoma and rates of visual axis opacification. Relative risk analysis was performed to identify potential risk factors for secondary glaucoma and visual axis opacification. RESULTS: Mean length of follow-up was 160.02 ± 64.42 months (13.3 years), range 40-336 months. Final mean LogMAR across all groups was 0.85 ± 0.51 (0.90). Overall 45 (33.33%) eyes developed secondary glaucoma, 12 (19.4%) in pseudophakic eyes and 33 (45.21%) in aphakic eyes. The incidence of glaucoma was highest in bilateral aphakia (relative risk 1.96, p = 0.0240) and in eyes with corneal diameter <9.5 mm (relative risk 1.93, p = 0.0364). There was no significant difference in glaucoma rates between pseudophakia and aphakia in those operated on less than 2.5 months of age. Secondary glaucoma occurred between 3 months to 16.5 years post surgery. Rates of visual axis opacification were lower in aphakia compared to pseudophakia (relative risk 0.59, p = 0.0098). CONCLUSION: Overall glaucoma rates of one-third are similar to those recorded in the infantile aphakic treatment study. It can occur up to 17 years post cataract surgery, evidence that long-term follow-up is imperative.

A FBN1 variant manifesting as non-syndromic ectopia lentis with retinal detachment: clinical and genetic characteristics.

BACKGROUND/OBJECTIVES: Fibrillin-1 (FBN1) mutations cause connective tissue dysgenesis the main ocular manifestation being ectopia lentis (EL), which may be syndromic or non-syndromic. We describe a pedigree with a FBN1 mutation causing non-syndromic EL with retinal detachment (RRD) and their management. SUBJECTS/METHODS: Patients with familial EL with RRD were invited to participate (vitreoretinopathy branch of Target 5000, the Irish inherited retinal degeneration study). All patients signed full informed consent. The study was approved by the Institutional Review Board of the Mater Hospital, Dublin and abided by the Declaration of Helsinki. RESULTS: Seven adults were affected with bilateral EL. All subjects had RRD with bilateral non-synchronous RRD in 57%. CONCLUSIONS: The FBN1 variant described herein confers an increased risk of both EL and RRD and can now be upgraded to 'pathogenic' ACMG status.

Epicardial Adipose Tissue Accumulation Confers Atrial Conduction Abnormality.

BACKGROUND: Clinical studies have reported that epicardial adipose tissue (EpAT) accumulation associates with the progression of atrial fibrillation (AF) pathology and adversely affects AF management. The role of local cardiac EpAT deposition in disease progression is unclear, and the electrophysiological, cellular, and molecular mechanisms involved remain poorly defined. OBJECTIVES: The purpose of this study was to identify the underlying mechanisms by which EpAT influences the atrial substrate for AF. METHODS: Patients without AF undergoing coronary artery bypass surgery were recruited. Computed tomography and high-density epicardial electrophysiological mapping of the anterior right atrium were utilized to quantify EpAT volumes and to assess association with the electrophysiological substrate in situ. Excised right atrial appendages were analyzed histologically to characterize EpAT infiltration, fibrosis, and gap junction localization. Co-culture experiments were used to evaluate the paracrine effects of EpAT on cardiomyocyte electrophysiology. Proteomic analyses were applied to identify molecular mediators of cellular electrophysiological disturbance. RESULTS: Higher local EpAT volume clinically correlated with slowed conduction, greater electrogram fractionation, increased fibrosis, and lateralization of cardiomyocyte connexin-40. In addition, atrial conduction heterogeneity was increased with more extensive myocardial EpAT infiltration. Cardiomyocyte culture studies using multielectrode arrays showed that cardiac adipose tissue-secreted factors slowed conduction velocity and contained proteins with capacity to disrupt intermyocyte electromechanical integrity. CONCLUSIONS: These findings indicate that atrial pathophysiology is critically dependent on local EpAT accumulation and infiltration. In addition to myocardial architecture disruption, this effect can be attributed to an EpAT-cardiomyocyte paracrine axis. The focal adhesion group proteins are identified as new disease candidates potentially contributing to arrhythmogenic atrial substrate.

Prophylaxis of diffuse lamellar keratitis with intraoperative interface steroids in LASIK.

PURPOSE: To investigate the safety and efficacy of intraoperative interface steroids for the prophylaxis of diffuse lamellar keratitis (DLK). METHODS: Two centers analyzed 1210 consecutive procedures in a prospective interventional trial. Center A irrigated the lasered stromal bed with balanced salt solution (BSS), instilled a drop of preserved dexamethasone 0.1% suspension on the stromal bed, and replaced the corneal flap. Center B replaced the flap, inserted a multiple port cannula to irrigate the stromal interface with BSS, then introduced 0.5 mL preservative-free prednisolone sodium phosphate 0.5% solution into the stromal interface with another multiple port cannula. All LASIK procedures after a fixed date received intraoperative interface steroids. Consecutive procedures immediately before this date were used as controls. RESULTS: Center A performed 405 intraoperative interface steroids procedures and contributed 405 controls. Center B performed 200 intraoperative interface steroids procedures and contributed 200 controls. Preoperative refraction and postoperative visual acuity were similar in control and intraoperative interface steroids groups. In center A, 5.7% (30% were stage II) and 2% (all only stage I) of controls and intraoperative interface steroid eyes, respectively, developed DLK; intraoperative interface steroids decreased the rate of DLK by 3.0 times (95% confidence interval: 1.3 to 6.8). In center B, 6.5% of controls developed DLK (15% were stage II); with intraoperative interface steroids, only 1 procedure (0.5%) developed DLK. In both centers, no bilateral DLK or DLK beyond stage I were noted when intraoperative interface steroids were used. CONCLUSIONS: Intraoperative interface steroids safely reduced the incidence and severity of DLK. [J Refract Surg. 2009;25:306-311.]