Serial Photographs Research Articles

Trend-based Analysis of Ganglion Cell–Inner Plexiform Layer Thickness Changes on Optical Coherence Tomography in Glaucoma Progression

To evaluate the rate of thinning in ganglion cell-inner plexiform layer (GCIPL) thickness by optical coherence tomography (OCT) in glaucomatous eyes and to use a trend-based approach to determine its diagnostic ability for detecting glaucoma progression. Prospective, observational study. Sixty-five patients with primary open-angle glaucoma with a minimum 3-year follow-up involving serial spectral-domain OCT measurement of GCIPL thickness. Patients were divided into a nonprogressor group (n= 38) and a progressor group (n= 27) on the basis of serial red-free photography or visual field tests. The rates of GCIPL thinning in the global region, affected hemifield, and 6 macular sectors, and the minimum thickness, were determined by linear regression and compared between groups. The area under the receiver operating characteristic curves (AUCs) were calculated for each parameter. The GCIPL thinning rates were compared between affected hemifields and unaffected hemifields. The macular GCIPL thinning rates in the progressor and nonprogressor groups and the ability of the GCIPL thinning rate to diagnose glaucoma progression. The GCIPL thinning rate was significantly faster in progressors than in nonprogressors in the global area (P < 0.001); in the affected hemifield (P= 0.001); in the temporal, vertical, and nasal sectors of the affected hemifield (P= 0.017, 0.032, and 0.030, respectively); and in the minimum GCIPL thickness (P < 0.001). In the temporal sectors, the GCIPL thinning rates were significantly faster in the affected than in the unaffected hemifield (P= 0.013). The best GCIPL parameters were the global (AUC= 0.791), minimum (AUC= 0.755), inferior hemifield (AUC= 0.708), and affected hemifield (AUC= 0.702) thinning rates. The global circumpapillary retinal nerve fiber layer thinning rate correlated significantly with the global and inferotemporal sector GCIPL thinning rates (rho= 0.259 and 0.366, respectively). The GCIPL thinning rate on OCT was significantly faster for patients with glaucoma with progression than for those without progression. The GCIPL thinning rate of the temporal sector was faster in the affected than in the unaffected hemifield, suggesting that the glaucomatous damage may progress locally in a specific sequence. Trend-based analysis of GCIPL thickness on OCT may be useful for assessing glaucoma progression objectively and quantitatively.

Abstract 98: Photochemical Tissue Passivation (PTP) Prevents Contracture of Full Thickness Wounds

PURPOSE: Large surface area wounds, resulting from burns, trauma, or iatrogenic injury, often result in significant scarring and wound contracture. Despite treatment with any of the currently available gold-standard therapies, contracture can still develop as a sequelae of the process of normal wound healing, specifically, myofibroblast activity. Photochemical Tissue Passivation (PTP) is a process that induces collagen cross-linking after a tissue is painted with photosensitizing dye and then exposed to visible light. PTP has also been shown to limit myofibroblast activity in healing surgical wounds. PTP is easy to perform and can be complete in minutes, and has been established as a safe treatment modality in animal and human studies. We hypothesize that PTP treatment to wounds can significantly decrease the morbidities associated with wound contracture by reinforcing the wound bed with collagen cross-linking and limiting the fibrotic response during wound healing. METHODS: Full-thickness, excisional 1cm x 1cm wounds were created on the dorsum of C57BL/6 mice. Wounds were either left alone to heal as a control group, or were treated with PTP on the day the wounds were created. Wounds beds on animals in the treatment group received PTP treatment at a fluence of 60J/cm2. Wound areas were measured with serial photography for three weeks, at which time animals were euthanized and wound skin was harvested for histological processing with H&E and Masson’s Trichrome staining. Histology was then reviewed by an expert dermatopathologist. RESULTS: PTP visually prevented wound contracture throughout the study. Wound size on serial photography was calculated as a percentage of the original wound area. Sizes of PTP-treated wounds were almost three times greater than controls after one week (68.6 ± 15% vs 25 ± 9%, p=0.004) and almost seven times greater after two weeks (38.8 ± 22% vs 5.6 ± 6%, p=0.05). At the end of the three-week study, while control wounds had visually completely closed, PTP-treated wounds were not yet closed and were over 10 times larger than control wounds (19.3 ± 20% vs 1.8 ± 2%, p=0.17). On histologic review, PTP treatment promoted increased ingrowth and development of dermal cells, increased vascularity, and development of skin appendages compared to control wounds. CONCLUSION: PTP prevents wound contracture in full-thickness, excisional wounds, and may accelerate the process of wound healing and development. These findings suggest future utility of PTP treatment not only for excisional wounds, but also for wounds with a high incidence of contracture and associated morbidity, including burns and skin-grafts.

Multifocal Toxoplasma Retinochoroiditis in a Nonimmunosuppressed Elderly Patient: Case Report and Brief Review of the Literature

Purpose To raise awareness of ophthalmologists that toxoplasmosis should be considered in the differential diagnosis of multifocal or diffuse necrotizing retinitis in nonimmunosuppressed elderly patients. Methods Interventional case report with serial color fundus photographs, indocyanine green angiography, fluorescein angiography, optical coherence tomography, and chorioretinal biopsy histology. Results A 77-year-old, nonimmunosuppressed man developed extensive multifocal retinochoroiditis with scattered focal hemorrhages and significant vitreous haze. This case posed a significant diagnostic challenge mimicking viral retinitis. Vitreous polymerase chain reaction and chorioretinal biopsy confirmed the diagnosis of toxoplasma retinochoroiditis. Conclusions As demonstrated in this case, toxoplasmosis should be considered as a cause of multifocal and/or diffuse necrotizing retinitis in elderly patients even in the absence of obvious systemic immunosuppression.

On the Principle of Temporal Diminution in Serial Photography.

In some cases our sensory organs are no longer capable of rendering processes in the external world perceptible to us. Their inadequacy expresses itself, for example, in phenomena that involve the kind of expansion of space and time in which the conditions for summary perception are no longer at all present. The resources that aid our immediate sense perception in these circumstances will thus be charged with the task of expanding or diminishing space and time to the extent that the contiguity and succession of events is comprehensible to us. The microscope is thus essentially based upon the principle of spatial expansion, the map on that of spatial diminution. The pertinent contrivances for these purposes are largely derived from the graphic arts. How stereoscopy and instantaneous photography, which is based on temporal expansion, facilitate our perception! In spite of the multifarious applications of photography, one has yet to take the step of employing it in the opposite direction, namely as a means of temporal diminution. We demonstrate that phenomena that take place in too ephemeral and too rapid a succession for our eyes can, with the help of instantaneous photographs in series, be analyzed with our senses as the event passes in a comparatively longer time. Quite analogously, we could also compress into a small duration the moments of an event separated widely from one another in time and thereby give our perception an understanding of the nature thereof.

The response pattern and adherence to oral propranolol among Saudi children treated for infantile hemangioma

BackgroundAlthough the role of oral propranolol in treating IH is now well-recognized worldwide, the variation of treatment effectiveness over time and patients adherence have not been documented among Saudi. ObjectiveTo identify the variation of effectiveness over the treatment period and the adherence to treatment of oral propranolol among Saudi children treated for infantile hemangiomas (IH). Patients and methodsChildren presented for treatment of problematic IH between February 2012 and September 2015 were recruited in a prospective observational study of oral propranolol at 2mg/kg/day. Data about patients’ adherence (categorized based compliance with the scheduled visits and treatment administration), lesion comparative response score (based on the relative improvement compared to previous visit) and possible side-effects were collected during follow-up. Treatment was stopped once the lesions failed to show significant improvement. Serial digital photography was used for response and final outcome assessments. ResultsThirty-six cases were enrolled at a median (range) age of 6 (2–55) months. Cases were classified as 19 minor and 17 major, including 10 with ulcerations. Adherence was poor in 12 (33.3%), moderate in 4 (11.1%) and good in 19 (52.8%). Excluding the poorly adherent, the mean duration of treatment and follow up were 6±3.4 and 7±4.6months, respectively. A mean comparative response score of 1.67 from a maximum of 2 was achieved during the first month of treatment, then gradually diminished reaching 0.19 and 0 at 8 and 10months respectively. Patients who successfully completed 6months of treatment (n=19) were more likely to present with major lesions (68.4% vs. 33.3%, P=0.047) and at an earlier median age (4 vs. 11months, P=0.018). Complete or near complete responses was 47% achieved. All ulcerated lesions healed at a median of 2 (1–4)months. ConclusionThe most dramatic response to treatment appeared during the first month, then progressively diminished toward negligible benefits beyond 8months. Adherence to treatment can pose a challenge to achieving satisfactory outcomes.

Safety and Wound Outcomes Following Genetically Corrected Autologous Epidermal Grafts in Patients With Recessive Dystrophic Epidermolysis Bullosa

Recessive dystrophic epidermolysis bullosa (RDEB) is a devastating, often fatal, inherited blistering disorder caused by mutations in the COL7A1 gene encoding type VII collagen. Support and palliation are the only current therapies. To evaluate the safety and wound outcomes following genetically corrected autologous epidermal grafts in patients with RDEB. Single-center phase 1 clinical trial conducted in the United States of 4 patients with severe RDEB with a measured area of wounds suitable for grafting of at least 100 cm2. Patients with undetectable type VII collagen keratinocyte expression were excluded. Autologous keratinocytes isolated from biopsy samples collected from 4 patients with RDEB were transduced with good manufacturing practice-grade retrovirus carrying full-length human COL7A1 and assembled into epidermal sheet grafts. Type VII collagen gene-corrected grafts (approximately 35 cm2) were transplanted onto 6 wounds in each of the patients (n = 24 grafts). The primary safety outcomes were recombination competent retrovirus, cancer, and autoimmune reaction. Molecular correction was assessed as type VII collagen expression measured by immunofluorescence and immunoelectron microscopy. Wound healing was assessed using serial photographs taken at 3, 6, and 12 months after grafting. The 4 patients (mean age, 23 years [range, 18-32 years]) were all male with an estimated body surface area affected with RDEB of 4% to 30%. All 24 grafts were well tolerated without serious adverse events. Type VII collagen expression at the dermal-epidermal junction was demonstrated on the graft sites by immunofluorescence microscopy in 9 of 10 biopsy samples (90%) at 3 months, in 8 of 12 samples (66%) at 6 months, and in 5 of 12 samples (42%) at 12 months, including correct type VII collagen localization to anchoring fibrils. Wounds with recombinant type VII collagen graft sites displayed 75% or greater healing at 3 months (21 intact graft sites of 24 wound sites; 87%), 6 months (16/24; 67%), and 12 months (12/24; 50%) compared with baseline wound sites. In this preliminary study of 4 patients with RDEB, there was wound healing in some type VII collagen gene-corrected grafts, but the response was variable among patients and among grafted sites and generally declined over 1 year. Long-term follow-up is necessary for these patients, and controlled trials are needed with a broader range of patients to better understand the potential long-term efficacy of genetically corrected autologous epidermal grafts. clinicaltrials.gov Identifier: NCT01263379.

The Clinical Spectrum and a New Theory of Pathogenesis of True Exfoliation Syndrome

To describe the clinical spectrum and a new theory of pathogenesis of true exfoliation syndrome. Cross-sectional and prospective, observational case series. Consecutive patients with characteristic peeling of the anterior lens capsule. After maximal mydriasis, slit-lamp biomicroscopy, and photography, imaging of the anterior capsule and zonules was performed. The condition was classified into 4 clinical stages: annular anterior capsule thickening with a distinct splitting margin (stage 1), an inward detached crescentic flap lying on the anterior lens (stage 2), a floating and folding translucent membrane behind the iris (stage 3), and a broad membrane within the pupil (stage 4). Serial photography was performed at each 3-month follow-up visit. Ultrastructural examination of dislocated lenses and excised anterior capsules was performed. Detached membrane morphologic features, zonular defects, pigment deposition, glaucoma, phacodonesis, and cataract. We enrolled 259 patients (424 eyes). Ages ranged from 52 to 97 years (mean age, 75.2±7.1 years). Eleven patients were associated with trauma (n= 1) or intense heat (n= 10), whereas 248 were idiopathic. Two hundred ten patients were followed up every 3 months, with a mean follow-up of 9.6±6.1 months (range, 3-50 months). The detachment started along the anterior zonular insertions in association with zonular disruption. It progressed centrally to higher stages, manifesting a spectrum of disease. Several stages coexisted in a single eye. At the final visit, including 49 patients who were examined once, there were 70, 87, 85, and 17 patients in stages 1, 2, 3, and 4, respectively. All stages shared common histologic findings consisting of diffuse capsular lamellar separation and anterior zonular disruption. All developed cataract. Pigment deposition on the membrane was present in 178 patients (68.7%). Twenty-six patients (10%) had spontaneous phacodonesis. Eighteen eyes (4.2%) demonstrated secondary delamination. Capsular lamellar separation and anterior zonular disruption are characteristic findings. Aging, heat exposure, and trauma are risk factors. Initial capsular splits occur along the insertions of disrupted anterior zonules. The peeling progresses centrally in association with iris movement and aqueous flow. A second detachment can occur.

Buttock Reshaping With Intramuscular Gluteal Augmentation in an Asian Ethnic Group

Although the definition of what constitutes "beautiful buttocks" has been changing with time, the buttocks are generally perceived as an important element of sexual attraction and beauty in every culture. In Asian culture, "beautiful buttocks" are defined by an aggregate of the following 4 components: S-shaped curvature from the lower back to the buttocks, sufficient muscle volume, sufficient fat volume, and appropriate skin elasticity. The goal of our gluteal augmentation was therefore to restore the back curvature, provide sufficient hip volume (projection), and reposition the point of maximal gluteal projection to be higher than the pubic hair. The purpose of this study was to review the authors' 6-year (2008-2014) experience with intramuscular gluteal augmentation techniques using an oval-shaped smooth-surface silicon elastomer. After intergluteal fusiform incisions were made, we bluntly dissected the subcutaneous tissue deep down to the gluteus maximus muscle by using the xyz method introduced by Dr. Gonzalez. Most of the patients in this case series underwent additional procedures at the time of the gluteal augmentation, whereas 90% of patients underwent concomitant liposuction. The results were assessed objectively using serial photography and subjectively according to patients' assessment on a 5-score scale.The mean rating for patient satisfaction with the procedure was 4.6 of 5, whereas consensus ratings by 2 independent plastic surgeons showed a mean score of 4.2 of 5. The intramuscular gluteal augmentation technique using an oval-shaped smooth surface silicon elastomer resulted in excellent cosmetic outcomes and permitted successful reshaping of the buttocks.

Development of a novel ex vivo equine corneal model.

To develop an ex vivo equine corneal organ culture model. Specifically, to assess the equine cornea's extracellular matrix and cellularity after 7 days using two different culture techniques: either (i) immersion system or (ii) air/liquid interface system, to determine the best ex vivo equine corneal model. Fourteen healthy equine corneas of various breeds. Equine corneas with 2 mm of perilimbal sclera were freshly harvested from 7 horses undergoing humane euthanasia. One corneal-scleral ring (CSR) from each horse was randomly placed in the (i) immersion condition organ culture system (IC), with the contralateral CSR being placed in the (ii) air/liquid interface organ culture system (ALC) for 7 days. All corneas were evaluated using serial daily gross photography, histology, qPCR, and TUNEL assay. corneal-scleral rings placed in the IC (i) had complete loss of corneal transparency on gross photography by 7 days, showed a significant level of corneal stromal disorganization, significantly increased α-SMA levels on qPCR, and apoptosis on TUNEL assay compared to controls. The ALC (ii) had weak stromal disorganization on histopathologic examination and was not significantly different from normal equine corneal controls on all other evaluated parameters. The air-liquid interface organ culture system maintains the equine cornea's extracellular matrix and preserves corneal transparency, while the immersion condition results in near complete degradation of normal equine corneal architecture after 7 days in culture. The air-liquid organ culture is a viable option to maintain a healthy equine cornea in an ex vivo setting for wound healing studies.

Three-dimensional morphology and palaeobiology of the trace fossil Dactyloidites jordii nov. isp. from the Carboniferous of England

The diverse ichnological assemblage from the outcrops near Howick (Northumberland, United Kingdom) is exceptionally well-preserved. Among these Carboniferous ichnotaxa is a new ichnospecies of Dactyloidites. Specimens were collected and processed using high-resolution serial grinding and photography to produce an accurate and precise three-dimensional model of these new burrows in full colour. The model produced in association with petrographic thin sections and field observations is used as the basis for comparison between Dactyloidites jordii nov. isp. and other ichnospecies of Dactyloidites. The current taxonomic status of the ichnogenus is examined and reviewed. D. jordii nov. isp. is a broadly bisymmetrical, stellate to palmate burrow composed of numerous long, narrow rays that exhibit three orders of branching arranged into tiered galleries radiating from a central shaft. The trace maker is suggested to be a vermiform organism with an adaptive burrowing strategy that facilitates alteration of its burrow construction to accommodate suboptimal sediment conditions. The adaptive nature of trace-making organisms and the inherent anisotropy of many burrowed media highlight the need for ichnologists to provide a type series rather than a single holotype, in order to capture the inherent range of common burrow morphologies.

Cosmetic Outcome after Interstitial Brachytherapy Accelerated Partial Breast Irradiation Is Related to the Location of the Lumpectomy Cavity

Cosmetic Outcome after Interstitial Brachytherapy Accelerated Partial Breast Irradiation Is Related to the Location of the Lumpectomy Cavity

Diagnostic Challenges in Inflammatory Choroidal Neovascular Membranes

ABSTRACTPurpose: To describe the clinical presentations of inflammatory choroidal neovascular membranes (CNVMs) and factors leading to their delayed diagnosis.Methods: Retrospective analysis of chart records and digital images of 60 patients (73 eyes) with inflammatory CNVM (January 1998 to December 2013) to obtain demographic and clinical details, particularly the time of the first documentation of inflammatory CNVM by the uveitis specialist, time of its actual appearance on digital images, and the earliest clinical indicators of a CNVM.Results: In total, 14 (19.2%) eyes had a delayed diagnosis of inflammatory CNVMs, of which five developed significant visual loss. The earliest clinical indicators of CNVM that were overlooked initially due to their subtle appearance, included a tiny subretinal hemorrhage (five eyes), peripapillary halo/fluid/scar (eight eyes), and a subfoveal scar (one eye). The causes of uveitis in these eyes included Vogt–Koyanagi–Harada disease (five eyes, 35.7%), tubercular uveitis (five eyes, 35.7%), idiopathic (three eyes, 21.4%), and sympathetic ophthalmia (one eye, 7.1%). Presence of significant background fundus scarring, sunset glow fundus, visually significant cataract, poorly dilating pupil, media haze due to vitritis, cystoid macular edema, and multiple chorioretinal scars in these eyes probably predisposed to delayed detection of an underlying CNVM.Conclusions: A high index of suspicion and comparison of serial fundus photographs to identify the earliest clues of inflammatory CNVMs are important to prevent diagnostic delays and poorer outcomes.

Serial image analysis of Mycobacterium tuberculosis colony growth reveals a persistent subpopulation in sputum during treatment of pulmonary TB

SummaryFaster elimination of drug tolerant ‘persister’ bacteria may shorten treatment of tuberculosis (TB) but no method exists to quantify persisters in clinical samples. We used automated image analysis to assess whether studying growth characteristics of individual Mycobacterium tuberculosis colonies from sputum on solid media during early TB treatment facilitates ‘persister’ phenotyping. As Time to Detection (TTD) in liquid culture inversely correlates with total bacterial load we also evaluated the relationship between individual colony growth parameters and TTD. Sputum from TB patients in Malawi was prepared for solid and liquid culture after 0, 2 and 4 weeks of treatment. Serial photography of agar plates was used to measure time to appearance (lag time) and radial growth rate for each colony. Mixed-effects modelling was used to analyse changing growth characteristics from serial samples. 20 patients had colony measurements recorded at ≥1 time-point. Overall lag time increased by 6.5 days between baseline and two weeks (p = 0.0001). Total colony count/ml showed typical biphasic elimination, but long lag time colonies (>20days) had slower, monophasic decline. TTD was associated with minimum lag time (time to appearance of first colony1). Slower elimination of long lag time colonies suggests that these may represent a persister subpopulation of bacilli.

Paravascular abnormalities in eyes with idiopathic epiretinal membrane.

The purpose was to investigate the paravascular abnormalities (PVA) around the retinal vascular arcades and their post-operative evolution in eyes with epiretinal membranes (ERM). This is an observational case series. Fifty-seven eyes of 55 patients with concurrent PVA and ERM were studied (study group). Forty-one eyes in 41 patients with ERM but no PVA served as controls. Multiple optical coherence tomography (OCT) scans were made along the upper and lower arcades and across the fovea in each patient. Serial fundus photography and OCT scans were performed in eyes receiving an operation. All surgeries were performed by one surgeon. The incidence and location of paravascular retinal cysts, deep cystic spaces underneath the vessels, and paravascular retinal defects, as well as vitreoretinal interface changes, were determined and correlated with macular thickness. In the study group, paravascular retinal cysts were detected in 57 eyes (100%), deep cystic spaces in nine eyes (15.8%), and paravascular lamellar holes in 31 eyes (54.4%). No case had a full-thickness hole. ERM adhesion to the PVA was noted in 16 eyes (28.1%) and internal limiting membrane (ILM) changes over the PVA in 22 eyes (38.6%). Compared with the control, the study group had significantly increased macular thickness. PVA, except lamellar holes, disappeared or decrease in severity after ERM and ILM removal surgery. Different types of PVA are relatively common in eyes with ERM. Our findings suggest that PVA may develop secondary to ERM-induced macular thickening. Except for lamellar holes, most lesions decrease following an operation.

Treatment for Infantile Hemangiomas: Selection Criteria, Safety, and Outcomes Using Oral Propranolol During the Early Phase of Propranolol Use for Hemangiomas.

Despite the increasing popularity of propranolol for treatment of infantile hemangioma (IH), there is need for further evidence of efficacy and safety. This study is a retrospective review of one institution's experience treating IH with propranolol using a standard protocol. Between 2009 and 2014, patients with IH were evaluated for treatment with propranolol. Exclusion criteria included a history of hypoglycemia, respiratory disorders, and cardiovascular disorders. Propranolol, 2 mg/kg/d, was initiated during 48-hour inpatient stay. Weight and complications were monitored. Appearance was assessed by Visual Analog Cosmetic Scale (VACS) via serial photography. Twenty-three patients were treated with propranolol. Average age at initiation of therapy was 14.9 weeks. Twenty-two lesions were on the head and neck, and 1 was on the trunk. Average treatment duration was 54.3 weeks (range 24-148 wk). Treatment was confirmed to be complete in 23 patients at the time of review (91.3%). Two patients were lost to follow-up. Posttreatment color, size, and VACS improved significantly (P < 0.05). There was no significant difference between first and most recent weight. Two patients experienced hypoglycemia, 1 during a diarrheal illness and 1 during inpatient treatment initiation. The authors present a series of patients with IH safely treated with 2 mg/kg/d of propranolol. Using a strict protocol, few complications were observed. Patients achieved significant reduction in size and improvement of the overall appearance of IH.

The fate of facial asymmetry after surgery for "muscular torticollis" in early childhood.

Aims and Objectives:To study wheather the facial features return to normal after surgery for muscular torticollis done in early childhood.Materials and Methods:This is a long-term study of the fate of facial asymmetry in four children who have undergone operation for muscular torticollis in early childhood. All the patients presented late, i.e., after the age of 4 years with a scarred sternomastoid and plagiocephaly, so conservative management with physiotherapy was not considered. All the patients had an x-ray of cervical spine and eye and dental checkup before making a diagnosis of muscular torticollis. Preoperative photograph of the patient's face was taken to counsel the parents about the secondary effect of short sternomastoid on facial features and the need for surgery. After division of sternomastoid muscle and release of cervical fascia when indicated, the head was maintained in a hyperextended position supported by sand bags for three days. Gradual physiotherapy was then started followed by wearing of a Minerva collar that the child wore for a maximum period of time in 24 h. Physiotherapy was continued three times a day till the range of movements of the head returned to normal. During the follow-up, serial photographs were taken to note the changes in the facial features.Results:In all four patients, the asymmetry of the face got corrected and the facial features returned to normal.Conclusion:Most of the deformity of facial asymmetry gets corrected in the first two years after surgery. By adolescence, the face returns to normal.

Anthropometric Effect of Mucoperiosteal Nostril Floor Reconstruction in Complete Cleft Lip.

The primary objective of this study was to investigate whether growth impairment in children with cleft lip is caused by reconstructing the nostril floor using lateral nasal and premaxillary mucoperiosteal flaps. The effects on growth and symmetry of tip rhinoplasty at the time of initial repair, as well as cleft sidedness are similarly investigated. An Institutional Review Board approved, retrospective, single-center study at an academic children's hospital from July 2005 to 2010 was designed. Seventy-four patients with unilateral cleft lip ± palate were followed postsurgical repair of the cleft lip deformity. Serial digital photographs from clinical encounters were analyzed. Anthropometric measurements of 10 soft tissue landmarks were extracted from anteroposterior and submental vertex views at serial visits; growth velocities, defined as c = Δd/Δt, were generated using linear mixed models on selected measurements to study time-related changes on growth. The effects on growth and symmetry of primary tip rhinoplasty on perinasal landmarks and nostril floor reconstruction with medial and lateral nasal mucoperiosteal flaps on perioral and perinasal landmarks were analyzed. Proxies for midfacial height (en-al) and maxillary height (al-ch) were used to evaluate the effect of mucoperiosteal dissection, whereas nostril width, height, and angle were used as proxies to evaluate the effects of tip rhinoplasty. Seventy-four patients met the inclusion criteria. Midface height (En-Al) growth velocity was 0.014 mm/month and maxillary height (Al-Ch) was relatively stable at -0.0059 mm/month with no difference between the subgroups. Nostril height growth was -0.0046 mm/month, nostril width was 0.03 mm/mo, and nostril angle -0.09 °/mo showed no difference between patient with or without primary tip rhinoplasty. Patients with complete cleft showed more asymmetry than those with incomplete clefts in lip and maxillary landmarks at T0 (P < 0.001). Mucoperiosteal reconstruction of the nostril floor at the time of lip repair does not affect anthropometric growth velocities over a 5-year follow-up. Within the limitations of the selected landmarks, primary tip rhinoplasty did not significantly improve symmetry at 5 years, but also did not affect the growth of the nose. Patients with complete clefts display more postoperative asymmetry than those with incomplete clefts.

A new focus of cutaneous leishmaniasis in Jammu division of Jammu and Kashmir State, India.

Cutaneous leishmaniasis in India is mainly confined to the deserts of Rajasthan; some cases have been reported from the dry north-western half of the Indo-Gangetic plain, including Punjab, Himachal Pradesh, Delhi and Varanasi. To highlight a new focus of cutaneous leishmaniasis in the Jammu division of Jammu and Kashmir State, previously a non-endemic area. This report presents the clinico-epidemiological and investigative results of 120 new cases of cutaneous leishmaniasis detected between November 2012 and October 2013. The clinical diagnosis of cutaneous leishmaniasis was made using criteria proposed by Bari and Rahman. It was further confirmed by the demonstration of Leishman-Donovan bodies in Leishman stained slit skin smears and skin biopsy specimens, and/or by a satisfactory response to intra-lesional sodium stibogluconate given weekly for 4 weeks. Serial clinical photographs were taken before giving injections and at the end of the 6 th week. There were 67 females and 53 males with an age range of 8 months to 80 years. The most frequently affected site was the face. Lesions were most commonly of the nodulo-ulcerative type. The number of lesions ranged from 1 to 4. Farmers (28.1%), homemakers (27.2%) and students (27.2%) were significantly over-represented among the occupations (P < 0.001). Skin smears and biopsies were positive for Leishman-Donovan bodies in 50.8% and 44.2% cases, respectively. There is a new focus of cutaneous leishmaniasis in Jammu division which deserves urgent attention from the public health angle. Further epidemiological studies are warranted to establish the identity of the vector and the strain of Leishmania involved.

Efficacy of autologous platelet-rich plasma combined with fractional ablative carbon dioxide resurfacing laser in treatment of facial atrophic acne scars: A split-face randomized clinical trial.

Autologous platelet-rich plasma has recently attracted significant attention throughout the medical field for its wound-healing ability. This study was conducted to investigate the potential of platelet-rich plasma combined with fractional laser therapy in the treatment of acne scarring. Sixteen patients (12 women and 4 men) who underwent split-face therapy were analyzed in this study. They received ablative fractional carbon dioxide laser combined with intradermal platelet-rich plasma treatment on one half of their face and ablative fractional carbon dioxide laser with intradermal normal saline on the other half. The injections were administered immediately after laser therapy. The treatment sessions were repeated after an interval of one month. The clinical response was assessed based on patient satisfaction and the objective evaluation of serial photographs by two blinded dermatologists at baseline, 1 month after the first treatment session and 4 months after the second. The adverse effects including erythema and edema were scored by participants on days 0, 2, 4, 6, 8, 15 and 30 after each session. Overall clinical improvement of acne scars was higher on the platelet-rich plasma-fractional carbon dioxide laser treated side but the difference was not statistically significant either 1 month after the first treatment session (P = 0.15) or 4 months after the second (P = 0.23). In addition, adverse effects (erythema and edema) on the platelet-rich plasma-fractional carbon dioxide laser-treated side were more severe and of longer duration. Small sample size, absence of all skin phototypes within the study group and lack of objective methods for the evaluation of response to treatment and adverse effects were the limitations. This study demonstrated that adding platelet-rich plasma to fractional carbon dioxide laser treatment did not produce any statistically significant synergistic effects and also resulted in more severe side effects and longer downtime.

LONG-TERM EFFICACY OF SYSTEMIC INFLIXIMAB IN RECALCITRANT RETINAL VASCULITIS.

To evaluate the efficacy of systemic infliximab for the induction of remission in patients with retinal vasculitis, inadequately responsive to other immunomodulatory therapy, based on fluorescein angiography grading for retinal vasculitis evaluation. We analyzed 60 patients with retinal vasculitis, from the Massachusetts Eye Research and Surgery Institution in Cambridge, MA. Response to therapy was based on analysis of serial fluorescein angiography and fundus photography, including a baseline angiogram before initiation of infliximab. Sixty patients received infliximab therapy between July 2007 and July 2012 at Massachusetts Eye Research and Surgery Institution for a diagnosis of retinal vasculitis. All had previously showed a poor clinical response to other immunomodulatory regimens, or ceased therapy due to intolerable side effects. The initial dose of infliximab was 5 mg/kg in all patients and remained at this dose for the extent of treatment in 57 (95%) patients. At 6 months, 45 of 51 (88.23%) patients were maintaining remission with therapy, 5 (9.8%) were in partial remission, and 1 patient had failed. At 12 months, 39 of 39 (100%) patients were maintaining remission with therapy. Infliximab is effective for the treatment of recalcitrant noninfectious retinal vasculitis, refractory to conventional immunomodulatory therapy.