Maximal Medical Therapy Research Articles

Extracorporeal membrane oxygenation in pediatric cardiac surgery: A retrospective review of trends and outcomes in Scotland.

Introduction:Around 3.2%–8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. The desired outcome is “bridge-to-recovery” in most cases. There is no universally agreed protocol, and given the associated costs and complications rates, the decisions as of when and when not to institute VA ECMO are largely empirical.Methods:A retrospective review of the ECMO database at the Scottish Pediatric Cardiac Services (SPCS) was undertaken. Inclusion criterion encompassed all children (<16 years of age) who were supported with VA ECMO following cardiac surgery between January 2011 and October 2016. The timing of ECMO support was divided into three distinct phases: “endofcase” or intheatre ECMO for patients unable to effectively wean from cardiopulmonary bypass (CPB), ECMO for cardiopulmonary resuscitation (“ECPR”), and Intensive Care Unit ECMO for “failing maximal medial therapy” following cardiac surgery. The patients were analyzed to identify survival rates, adverse prognostic indicators, and complication rates.Results:We identified 66 patients who met the inclusion criterion. 30day survival rate was 45% and survival rate to hospital discharge was 44% (the difference represents one patient). On followup (median: 960 days, range: 42–2010 days), all survivors to hospital discharge were alive at review date. “End-of-case” ECMO showed a trend toward better survival of the three subcategories (“end of case,” ECPR, and ECMO for “failing maximal medical therapy” survival rates were 47%, 41%, and 37.5%, respectively, P = 0.807). The poorest survival rates were in the younger children (<6 months, P = 0.502), patients who had prolonged CPB (P = 0.314) and aortic crossclamp times (P = 0.146), and longer duration of ECMO (>10 days, P = 0.177).Conclusions:Allcomers VA ECMO following pediatric cardiac surgery had survival to discharge rate of 44%. Elective “end-of-case” ECMO carries better survival rates and therefore ECMO instituted early maybe advantageous. Prolonged ECMO support has a direct correlation with mortality.

Role of trabeculectomy in advanced glaucoma: Whether we stand to consider it a bane or a boon today?

To elucidate the role of trabeculectomy in advanced glaucoma. Only patients with primary open-angle glaucoma were selected. All patients who had cup-disc ratio of 0.9 or a near-total cupping were given a trial of aggressive maximum medical therapy for IOP control for at least 4weeks. Target IOP was defined as≤12mmHg. Patients who showed progression were included in the study. A total of 10 patients were selected. Trabeculectomy was performed using limbal-based conjunctival flap. Patients were followed up for a period of 2years for visual acuity, intraocular pressure, visual fields, slit-lamp biomicroscopy and bleb morphology. Mean preoperative intraocular pressure on five drugs was 21.7±3.8mmHg (range 18-27mmHg) on maximum medical therapy. Mean post-operative intraocular pressure was 11±1.78mmHg (range 9-13mmHg) and 11±1.92mmHg (range 9-14mmHg) at 1 month and 6months post-operatively, respectively. Post-operatively, the visual acuity remained stable in 17 patients. It dropped by 1 Snellen line in 2 patients and 2 Snellen lines in 1 patient, respectively, over a period of 6months and later improved to 6/6P following cataract surgery. There was no defined visual field progression in any of the 20 patients. Besides being a cost-effective alternative to medical management, trabeculectomy not only provides a better IOP control but also has a high safety profile when performed by an experienced surgeon.

Severe Orthostatic Hypotension Complicating Multiple Myeloma

Introduction Amyloidosis is a well-recognized complication of multiple myeloma, although isolated vascular amyloidosis of the kidney is relatively rare. Vascular amyloidosis is associated with fewer urinary findings than the more common glomerular amyloidosis, and may present both diagnostic and treatment challenges, particularly when performing renal replacement therapy. Case description We present a 53-year-old man who presented with light-headedness complicated by multiple falls, severe orthostatic hypotension, and acute kidney injury. The patient was ultimately diagnosed with multiple myeloma. His course was complicated by progressively worsening kidney function, which necessitated renal replacement therapy, and persistent symptoms of orthostatic hypotension despite maximal medical therapy. A kidney biopsy revealed light chain cast nephropathy and isolated vascular amyloidosis of the kidney. Hemodialysis and subsequently continuous veno-venous hemodialysis were poorly tolerated due to severe hemodynamic instability. Ultimately, the patient suffered a fatal cardiac arrest. Conclusions This case provides a platform to discuss clinical aspects and diagnosis of vascular-limited renal amyloidosis. In addition, we address the difficulty in managing a patient with severe hemodynamic instability due to this disease.

A Case of Adult Autoimmune Enteropathy in an Ulcerative Colitis Patient

Autoimmune enteropathy (AIE), rare among adults, is characterized by a malabsorptive diarrhea that can mimic inflammatory bowel disease. AIE lacks clear diagnostic markers but can histologically present similar to focal diseases such as celiac disease with more diffuse involvement. Treatment consists of steroids, calcineurin inhibitors, and/or anti-tumor necrosis factor (TNF) therapies. Our patient is a 54-year-old female with history of refractory ulcerative colitis status post total colectomy with end ileostomy who presented one month after her surgery with high ostomy output (HOS) of 4L daily. She had three admissions over the prior seven months for ongoing HOS with ostomy output ranging from 4L to 10L daily despite maximal medical therapy. Her HOS was felt to be due to poor ileal accommodation in the setting of her recent surgery. After a negative work up including infectious and MRI enterography, the patient had an ileoscopy with biopsies showing severe chronic active ileitis. Enteroscopy was performed with esophageal, gastric, and small intestinal biopsies revealing diffuse chronic enteritis with moderate activity concerning for AIE. Repeat enteroscopy and ileoscopy showed similar results and no evidence of enteropathy associated T-cell lymphoma. Although anti-enterocyte antibodies were non-specific, management for AIE was initiated. She was started on budesonide and solumedrol with persistent HOS. She started cyclosporine and later tacrolimus with normalization of ostomy output on tacrolimus. AIE, a rare but severe disorder, can cause significant immune-mediated changes of the intestinal mucosal structure and function. On endoscopy the small bowel can show mucosal scalloping, fissuring, and mosaic patterns. Anti-enterocyte and anti-goblet cell antibodies correlate but are not required. Treatment consists of immunosuppression, often with steroids or infliximab, 6-mercaptopurine, azathioprine, cyclosporine, and tacrolimus. Our case is unique in that this patient had chronic diarrhea attributed to post-surgical complications and ultimately required tacrolimus for symptom control.

Doctor is there anything else that I can do for my glaucoma?: Alternative therapy for glaucoma, what is the evidence?

SummaryThe usual algorithm for the treatment of glaucoma consists of medical or/and laser therapy, followed by surgical intervention if the IOP does not lower to the target or the disease progresses despite maximal medical therapy. Understandingly, just as for many other chronic diseases, patients are willing to do more for their glaucoma in order to prevent progression and ultimately blindness. The question: “Doctor is there anything else that I can do for my glaucoma?” is therefore often asked. Several studies have suggested that some lifestyle habits or alternative therapies may influence glaucomatous neuropathy and many patients admit using them either in conjunction or as replacement of their prescribed glaucoma medication. This talk will focus on the evidence that is behind these therapies. Education of ophthalmologist and patients is of great importance in order to avoid misleading beliefs and erroneous therapies with the risk to harm patients visual function.

Issues related to renal artery angioplasty and stenting.

Renal artery stenosis may play a significant role in the pathogenesis of secondary hypertension, renal dysfunction, and flash pulmonary edema. Currently correction of renal arterial inflow stenosis is reserved for resistant hypertension patients who have failed maximal medical therapy, have worsening renal function and/or unexplained proximal congestive failure. With the recent advances in minimally invasive percutaneous stent placement techniques, open surgical revascularization has been largely replaced by renal artery stenting. The potential benefit of revascularization seemed intuitive; however, the initial enthusiasm and rise in the number of percutaneous interventions have been tempered by many subsequent negative randomized clinical trials that failed to prove the proposed benefits of the percutaneous intervention. The negative randomized trial results have fallen under scrutiny due to trial design concerns and inconsistent outcomes of these studies compared to pivotal trials undertaken under US Food and Drug Administration scrutiny. Treatment of atherosclerotic renal artery occlusive disease has become one of the most debatable topics in the field of vascular disease. The results from recent randomized clinical trials of renal artery stenting have basically limited the utilization of the procedure in many centers, but not every clinical scenario was covered in those trials. There are potential areas for improvement focusing mainly on procedural details and patient selection with respect to catheter based treatment of atherosclerotic renal artery stenosis. We believe, limiting patient selection, enrollment criteria and outcomes measured functioned to reduce the benefit of renal artery stenosis stenting by not enrolling patients likely to benefit. Future studies incorporating potential procedural improvements and that include patients more likely to benefit from renal stenting than were included in ASTRAL and CORAL are needed to more carefully examine specific patient subgroups so that "the baby is not thrown out with the bath water." We also discuss several other concerns related to renal artery stenting which include diagnostic, procedure, indication, and reimbursement issues.

Retinal complicatios after Nd:YAG Laser iridotomy

To identify the retinal complication after Nd:YAG laser iridotomy in patients with angle- closure glaucoma (ACG) Retrospective cross sectional study reviewed the medical records of 177 eyes of 177 patients with ACG with initial intraocular pressure (IOP) above 40 mmHg. All of the patients received maximum tolerable medical therapy (MTMT), followed by laser iridotomy done in 156 eyes and not done in 21 eyes (because of variable causes). In order to follow – up the occurrence of retinal complications all patients underwent detailed retinal examinations. Retinal complications occur rarly after Nd: YAG laser iridotomy in patients with angle – closure glaucoma (ACG). Cystoid macular oedema (CMO) occurred in3(1.92%) of 156 eyes Central serous chorioretinopathy (CSR) occurred in 1(0.64%) of156 eyes. Macular hole in 1(0.64%) of156 eyes. Retinal detachment , Uveal Effusion ,Subhyaloid haemorrhage and Retinal burn not seen in the study .Our data suggest that we can expect retinal complications after laser iridotomy in eyes with AACG (even uncommen), and the incidence increase in females and with advancing age.

Post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis

This study aimed to evaluate post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis. A prospective interventional study of children aged 4-12 years with chronic refractory rhinosinusitis was conducted. A total of 60 children completed follow up. Nasal endoscopy and non-contrast computed tomography of the paranasal sinuses were performed, and both symptoms and their effects on patient quality of life pre- and post-adenoidectomy were evaluated. The most frequent symptoms were nasal obstruction, cough, fever and fatigue, which were experienced by 100 per cent, 90 per cent, 85 per cent and 81.7 per cent of children, respectively. Nasal endoscopy showed oedema and discharge were present in all children. A statistically significant post-operative improvement in sinus and nasal quality of life was seen in 53 children (88.3 per cent). Adenoidectomy is a simple, first-line surgical procedure for managing paediatric chronic rhinosinusitis refractory to maximal medical therapy and leads to an improved quality of life.

One-year efficacy of adjunctive use of Ripasudil, a rho-kinase inhibitor, in patients with glaucoma inadequately controlled with maximum medical therapy

The aim of this study was to evaluate the one-year efficacy, ability to lower intraocular pressure, and tolerability of ripasudil, a rho-kinase inhibitor, in patients with glaucoma inadequately controlled with maximum medical therapy. This prospective, non-comparative, interventional case-series study included 39 patients with primary open-angle glaucoma inadequately controlled with maximum medical therapy before treatment with ripasudil. Ripasudil was administered twice per day as adjunctive therapy to ongoing glaucoma treatment. The primary endpoint was the degree of intraocular pressure reduction after 12months of treatment; the secondary endpoints were the incidence of adverse events. We examined 39 eyes. The intraocular pressure reduction (given as the relative percentage of intraocular pressure reduction) from baseline was -2.6mmHg (-15.5%; 95% confidence interval, -1.1 to -3.9mmHg; P<0.001) after 12months of treatment. The adverse events were conjunctival hyperemia (all patients), blepharitis (three), allergic conjunctivitis (two), punctate keratitis (two), and ophthalmalgia (one). Treatment with ripasudil decreased intraocular pressure in patients with glaucoma that was poorly controlled with maximal medical therapy, and it was well-tolerated.

Revision rates and time to revision following endoscopic sinus surgery: A large database analysis.

Endoscopic sinus surgery (ESS) is performed for patients with chronic rhinosinusitis (CRS) that have failed maximal medical therapy. This study seeks to determine the prevalence of revision surgery and factors predicting the need for revision after ESS using a large statewide surgery database. Large retrospective cohort study using the State Ambulatory Surgery Database for the state of California between 2005 and 2011. We identified over 61,000 patients with CRS who underwent ESS, determined by Current Procedural Terminology code. We identified which patients underwent a repeat surgery, and performed multivariable modeling to determine which factors (nasal polyps, age, gender, insurance, hospital setting, ethnicity) predicted the need for revision. Adjusted odds ratios (AOR) and 95% confidence intervals are presented. Of 61,339 patients who underwent ESS, 4,078 (6.65%) returned for revision ESS during the time period investigated. In a multivariable logistic regression model, positive predictors of revision were a diagnosis of nasal polyps (AOR: 1.20, 95% CI: 1.11-1.29, P < .001) and female gender (AOR: 1.20, 95% CI: 1.11-1.29, P < .001); public insurance was marginally predictive of increased reoperation (AOR: 1.10, 95% CI: 1.00-1.21, P = .048). Patients of Hispanic ethnicity were less likely to have revision surgery (AOR: 0.86, 95% CI: 0.77-0.97, P = .011). Age, income, and hospital setting were not significant predictors. A minority of patients with CRS who undergo ESS will have a revision surgery. This likelihood is increased in female patients and those with nasal polyps, and decreased in patients of Hispanic ethnicity, even when controlling for income, insurance, and hospital setting. 4. Laryngoscope, 128:31-36, 2018.

Nonpharmacologic Therapy for Severe Persistent Asthma

The treatment of asthma largely depends on guideline-based pharmacologic therapies. However, nonpharmacologic therapies for asthma such as pulmonary rehabilitation, focused breathing techniques, and bronchial thermoplasty have an important, yet underappreciated, role. Structured pulmonary rehabilitation programs can reduce dyspnea and increase cardiopulmonary fitness. The educational component of these programs can ensure that therapies are being used appropriately, increase compliance, and decrease health care utilization. Studies have demonstrated a reduction in inflammatory mediators in patients with asthma who are engaged in an exercise program. Focused breathing techniques are commonly used by patients with asthma, yet benefit has not been clearly shown in randomized controlled trials. For the patients with severe asthma who are unresponsive to maximum medical therapy and have evidence of airway remodeling, bronchial thermoplasty has demonstrated long-term improvement in quality of life and reduction in severe exacerbations and health care utilization. Recent airway biopsy studies have demonstrated bronchial thermoplasty's disease-modifying effect on smooth muscle, inflammatory mediators, and bronchial nerve endings. These nonpharmacologic therapies are complementary to current guideline-based treatment, including the use of biologic modifiers, for severe asthma.

Long-term outcomes of cutaneous vesicostomy in patients with neuropathic bladder caused by spina bifida

To evaluate the outcomes of patients who underwent cutaneous vesicostomy for management of neuropathic bladder secondary to spina bifida. We hypothesize that vesicostomy, in select patients, is beneficial to prevent upper urinary tract deterioration (UTD), reduce febrile urinary tract infections (UTIs), and preserve renal function. We performed a retrospective chart review on patients with spina bifida who underwent cutaneous vesicostomy at our institution between 2000 and 2016. Demographic information, indication for vesicostomy, pre and postoperative laboratory/radiologic studies, incidence of febrile UTIs, and urodynamic findings were abstracted. A total of 14 patients (eight females and six males) were identified. The indication for vesicostomy was UTD in four, recurrent febrile UTIs in five, parental request in two, both UTD and recurrent febrile UTIs in two, and both UTI and parental request in one patient. Seven patients had a median of three (range one to five) febrile UTI prior to surgery for cutaneous vesicostomy. Median creatinine level before surgery was 0.26mg/dL (range 0.16-0.97). Either unilateral or bilateral ≥SFU Grade 2 hydronephrosis was present in six patients. Median age at vesicostomy creation was 26.5 months (range 4-96). Mean functional bladder capacity assessed during preoperative urodynamic studies was 107mL (range 20-279), and detrusor sphincter dysynergia was present in all patients. High-grade vesicoureteral reflux (grade ≥3) was present in three patients, all with UTD. Mean follow-up after vesicostomy was 62.4±39.3 months. After vesicostomy, only two of the seven patients with history of febrile UTIs experienced an additional febrile UTI. The median serum creatinine level was 0.36mg/dL (range 0.2-0.58) at last follow-up. Moreover, 11/14 patients had no hydronephrosis and just two patients had unilateral SFU grade 1 hydronephrosis (Table). Worsening UTD, recurrent febrile UTIs, and high-pressure bladder despite maximal medical therapy are several reasons to consider more aggressive management of neuropathic bladders. In young patients, vesicostomy is able to protect the upper urinary tract, decrease rates of febrile UTI, and delay the need for bladder augmentation. Vesicostomy is a safe method for temporary diversion of the lower urinary tract in patients with spina bifida who are refractory to conservative and minimally invasive treatments.

Rationale and design of MultiSELECt: A European Multicenter Study on the Effect of Lipoprotein(a) Elimination by lipoprotein apheresis on Cardiovascular outcomes

BackgroundDyslipidemia is a well-known risk factor for atherosclerosis and subsequent cardiovascular disease (CVD). While low density lipoprotein cholesterol (LDL-C) is well-established and taken into consideration for risk management and therapy, lipoprotein(a) is another established CVD risk factor frequently not undergoing screening due to a lack of medical treatment options. For patients suffering from CVD due to massive elevation of Lp(a) in presence of normal LDL-C levels, lipoprotein apheresis is the only available treatment option. While this constellation is an accepted indication for lipoprotein apheresis (LA) in Germany, prospective studies including a control group are still lacking. ObjectivePrimary objective of this trial is to evaluate the clinical benefit of lipoprotein apheresis on myocardial infarction, PCI, CABG and death from cardiovascular disease in subjects with elevated Lp(a). This study evaluates the clinical benefit of weekly LA in subjects with progressive cardiovascular disease, as accepted by the German Federal Joint Committee (treatment group). Comparator will be well-matched subjects under maximum tolerated lipid lowering therapy without access to LA treatment (control group). MethodsMultiSELECt, is a prospective, multicenter, multinational, two-arm matched-pair cohort study designed to directly compare subjects with significantly elevated Lp(a) approved for LA subsequently undergoing weekly apheresis treatment versus a continuation of maximal medical therapy. The follow-up period will be 2 years after the baseline visit and until at least 60 events of the primary end-point occurred in the control group. A central trial expert committee will review all subjects with respect to their potential indication for LA according to established German guidelines in a blinded fashion. All control subjects will be contacted monthly via telephone visits to compensate for the more frequent visits during apheresis. Approximately 150 matched pairs will be necessary to detect an event reduction of at least 10% in subjects under LA treatment. ConclusionThe MultiSELECt trial provides the unique opportunity to demonstrate the efficiency of LA on CVD in patients with elevated Lp(a) under strongly controlled conditions.

KIT Inhibition by Imatinib in Patients with Severe Refractory Asthma

BackgroundMast cells are present in the airways of patients who have severe asthma despite glucocorticoid treatment; these cells are associated with disease characteristics including poor quality of life and inadequate asthma control. Stem cell factor and its receptor, KIT, are central to mast-cell homeostasis. We conducted a proof-of-principle trial to evaluate the effect of imatinib, a KIT inhibitor, on airway hyperresponsiveness, a physiological marker of severe asthma, as well as on airway mast-cell numbers and activation in patients with severe asthma.MethodsWe conducted a randomized, double-blind, placebo-controlled, 24-week trial of imatinib in patients with poorly controlled severe asthma who had airway hyperresponsiveness despite receiving maximal medical therapy. The primary end point was the change in airway hyperresponsiveness, measured as the concentration of methacholine required to decrease the forced expiratory volume in 1 second by 20% (PC20). Patients also underwent bronchoscopy.ResultsAmong the 62 patients who underwent randomization, imatinib treatment reduced airway hyperresponsiveness to a greater extent than did placebo. At 6 months, the methacholine PC20 increased by a mean (±SD) of 1.73±0.60 doubling doses in the imatinib group, as compared with 1.07±0.60 doubling doses in the placebo group (P=0.048). Imatinib also reduced levels of serum tryptase, a marker of mast-cell activation, to a greater extent than did placebo (decrease of 2.02±2.32 vs. 0.56±1.39 ng per milliliter, P=0.02). Airway mast-cell counts declined in both groups. Muscle cramps and hypophosphatemia were more common in the imatinib group than in the placebo group.ConclusionsIn patients with severe asthma, imatinib decreased airway hyperresponsiveness, mast-cell counts, and tryptase release. These results suggest that KIT-dependent processes and mast cells contribute to the pathobiologic basis of severe asthma. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01097694.)

Original study. Effectiveness of endoscopic posterior nasal neurectomy for the treatment of intractable rhinitis

Abstract BACKGROUND. Chronic rhinitis is a clinical condition affecting more than 20% of the world population. The standard treatment strategy is medical. Surgical management can be considered in patients with intractable rhinitis. Various surgical techniques have been documented with varying success rates, but none of them is considered as a gold standard. Hence, we are studying the effectiveness of posterior nasal neurectomy (PNN) in patients who have intractable rhinitis, refractory to maximum medical therapy. MATERIAL AND METHODS. A prospective study was conducted in the ENT Department, Padmavathy Medical Foundation, Kollam, Kerala, India, from January 2015 to February 2016. Adult patients, in the age group of 20 to 60 years, diagnosed with chronic rhinitis, presenting two or more symptoms of rhinitis, refractory to maximum medical therapy for a period of at least 3 or more years and whose quality of life was significantly affected were enrolled and PNN was done for them. RESULTS. We observed a statistically significant improvement in subjective symptoms and patient quality of life at the end of 6 months post-operatively. CONCLUSION. PNN is a safe and less invasive procedure, which can provide a significant relief in symptoms of intractable rhinitis. Fewer complications and better results make it superior over vidian neurectomy.

Subcutaneous and Sublingual Immunotherapy in Allergic Asthma in Children.

This review presents up-to-date understanding of immunotherapy in the treatment of children with allergic asthma. The principal types of allergen immunotherapy (AIT) are subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). Both of them are indicated for patients with allergic rhinitis and/or asthma, who have evidence of clinically relevant allergen-specific IgE, and significant symptoms despite reasonable avoidance measures and/or maximal medical therapy. Studies have shown a significant decrease in asthma symptom scores and in the use of rescue medication, and a preventive effect on asthma onset. Although the safety profile of SLIT appears to be better than SCIT, the results of some studies and meta-analyses suggest that the efficacy of SCIT is better and that SCIT has an earlier onset than SLIT in children with allergic asthma. Severe, not controlled asthma, and medical error were the most frequent causes of SCIT-induced adverse events.

Treat the Patient, Not the Angiogram.

Opposing Viewpoint, see p 1385 Millions of people are living with refractory angina and ischemic pain despite maximal medical therapy and are told that they have no revascularization option. The most common reason patients are told that they have no option for revascularization is the presence of a coronary chronic total occlusion (CTO).1 Although no rigorous data exist, anecdotally, the majority of CTOs are now approachable with percutaneous techniques using drug-eluting stents owing to advances in the techniques that have resulted in improved success rates regardless of anatomy (>85%) and significant relief of ischemic symptoms while maintaining adequate safety. However, attempt rates for CTO percutaneous coronary intervention (PCI) range from 1% to 16% between institutions.2 The question then arises: Among patients with a good indication for revascularization (particularly those with refractory angina and a CTO), why are so many not offered revascularization options? Here, the Canadian Cardiovascular Society Task Force on Refractory Angina provides some insights: “…[T]he nonrevascularization status will be influenced by the local expertise and operator tolerance to risk.”3 Controversy persists over what constitutes a good indication for CTO PCI. Although observational data are encouraging, it is important to acknowledge that the potential for CTO PCI to improve survival remains unproven. Until such data are available from randomized trials, asymptomatic patients can only be informed about the uncertain benefits …

Glaucoma Mini-Shunt Implantation After Keratoplasty.

To report the outcomes of patients who underwent miniature glaucoma shunt implantation after secondary glaucoma due to keratoplasty. Prospective study of consecutive clinical cases who underwent mini-glaucoma shunt implantation following keratoplasty. In brief, a fornix-based conjunctival flap was performed, approximately 50% thickness scleral flap. Mitomycin C 0.025% placed under Tenon's capsule. A 25-G needle created entry for mini-shunt. Ex-PRESS model P-50 was inserted. Scleral flap and conjunctiva were closed with 10-0 Nylon. STATA 8.0 and SPSS software were used for statistical analysis. Seventeen eyes of 17 patients with a mean age of 39.70 years (SD=18.33, range: 18 to 76). A total of 64.70% were male and 35.30% female. Eleven cases after penetrating keratoplasty, 3 cases after triple procedure, 2 after deep anterior lamellar keratoplasty, and 1 following endothelial keratoplasty. Most of the indications for keratoplasty were keratoconus in 9 cases (52.94%), 4 due to endothelial failure (23.52%), 3 cases of herpetic keratitis (17.64%), and 1 case of post-LASIK ectasia (5.88%). Mean preoperative intraocular pressure was 35.94 mm Hg with maximal medical therapy (SD=9.65, range: 18 to 55). Decreasing intraocular pressure to 12.76 mm Hg postoperatively (SD=2.51, range 10 to 18) (P=0.001). Mean follow-up after mini-glaucoma shunt implantation was 23.76 months (SD=8.73, range: 10 to 35 mo). Preoperative mean uncorrected distance visual acuity (UDVA) was 1.31±0.63 (20/408 Snellen) and postoperative mean UDVA was 0.85±0.40 (20/141 Snellen) (P=0.001). Preoperative mean corrected distance visual acuity (CDVA) was 0.83±0.76 (20/135 Snellen) and postoperative mean CDVA was 0.56±0.44 (20/72 Snellen) (P=0.032). Ex-PRESS miniature glaucoma shunt could be an alternative treatment in postkeratoplasty glaucoma resistant to medical treatment. This technique may be helpful, in trying to avoid corneal damage produced by conventional glaucoma procedures.

Clinical features and predictors of patients with critical limb ischemia who responded to autologous mononuclear cell transplantation for therapeutic angiogenesis.

The clinical features of patients with critical limb ischemia (CLI) who responded to angiogenesis using autologous peripheral blood mononuclear cell transplantation (PB-MNC) have not yet been fully characterized, and there are no useful predictors to judge the curative effect in the early period after PB-MNC. This study sought to clarify the clinical features and predictors in patients with CLI who were successfully treated using PB-MNC. 30 consecutive patients [arteriosclerosis obliterans: 24 patients, thromboangiitis obliterans: 6 patients] who were diagnosed with major amputation despite maximal medical therapy were enrolled in this study. The study endpoint was major amputation within 3months after PB-MNC. The collected data were evaluated for correlation between patients with and without major amputation within 3months after PB-MNC. Six patients underwent major amputation and 1 patient underwent minor amputation. In the patients with major amputation, transcutaneous oxygen tension before PB-MNC and transplanted CD34-positive cells were lower than those of patients without major amputation. In the patients with amputation, interleukin-6 (IL-6) continued to increase after the first PB-MNC, and basic fibroblast growth factor (bFGF) decreased within 3days after the first PB-MNC. PB-MNC was useful for the patients who were managed for inflammation and who had revascularization of the upper-popliteal arteries and two of the infra-popliteal arteries by endovascular and/or surgical revascularization. Variation in IL-6 and bFGF in the early period after PB-MNC could be useful predictors for the requirement of amputation within 3months after PB-MNC.

Síndrome de dirección inadecuada del humor acuoso refractario: una posible complicación de la queratoplastia penetrante

Clinical caseAn 85 year-old woman presented with a flat anterior chamber of the left eye, severe ocular hypertension, and a normal ultrasound examination in the day following a penetrating keratoplasty (PK). The clinical status did not respond to maximum medical therapy, laser posterior capsulotomy, anterior hyaloidotomy, and complete 23 G vitrectomy. The patient refused further intervention, and light perception was lost after 6 months of follow-up. DiscussionThis is the first report of refractory aqueous misdirection syndrome following primary PK. Despite maximum medical and surgical management efforts, aqueous misdirection syndrome subsequent to primary PK may have a catastrophic outcome.