The current and future role of the nurse in phlebology: the Canadian experience

Intolerance to rigid contact lenses in keratoconus may occur as a result of epithelial pathology or a suboptimal fitting. The application of a soft lens as a bandage makes it possible to tolerate a rigid lens over it. This study gives the results of 40 eyes in 26 patients who were consecutively fitted with a new aspheric combination lens. Thirty-five eyes (87.5%) showed no discomfort, acceptable wearing time, and visual acuity. Four of these eyes showed an improvement of the corneal condition, eliminating the need for a further piggyback wearing system. Failures were found in five eyes (12.5%), which were caused by giant papillary conjunctivitis (two eyes), severe keratoconus (one eye), difficulty in lens handling and lack of motivation (two eyes). The successful use of an aspheric piggyback combination lens in rigid lens-intolerant keratoconus may preclude early surgical therapy.     

Evolution of C4 photosynthesis in response to changes in carbon and oxygen concentrations in the atmosphere through time

This work is a survey of 82 cases of keratoconus which have been followed up for 1 to 12 years. Among them only 66 were fitted with contact lenses. The contra-indications for them are: 1. a better visual acuity with spectacles than with contact lenses, 2. advanced cases (4th degree of Amsler) whose fitting is impossible, 3. unilateral keratoconus, 4. associated diseases such as trachomatous pannus, allergic kerato-conjunctivitis. Hard corneal lenses are now in use in most of the cases. Scleral lenses are much less used than they were 10 years ago, owing probably to the great improvement of the corneal lenses during this time. These hard corneal lenses have a short Ro (4 to 7 mm), an overall diameter between 8 and 11 mm, and an optic diameter of 5 mm. They are fitted under fluorescein control. The mobility must be good too. One case was fitted with soft lenses. The visual acuity is good and so is the tolerance: 80% of the patients wear their lenses 10 hours a day or more. Contact lenses do not affect the progression of keratoconus thus finally a keratoplasty must be performed in many cases. After the operation a contact lens is very often necessary, but its daily wearing time must be divided by two, to avoid corneal neo-vascularisation. Soft corneal lenses may be used in some cases of keratoconus. They are indicated when the hard lenses are no longer tolerated and before a keratoplasty. The base curves of these soft lenses are not related to the radii of the conic cornea. In most of the cases they are between 7.50 and 8.60 mm. The diameter is large: 14 or 15 mm. The lenses must not move too much: 1 mm up or down when the patient blinks. The edge of the lens must not depress the bulbar conjunctiva and there must be no air bubble under the lens. In many cases a cylindrical spectacle lens is necessary to obtain a good visual acuity. Some authors prefer to fit a hard corneal lens over the soft one: this is the "piggy back" method. Sometimes keratoconus has appeared in patients already fitted during several years to correct a myopic astigmatism. It is not clear whether these keratoconus have been produced or not be the contact lenses.     

Etiology of corneal striae accompanying hydrogel lens wear

Vertical striae in the posterior cornea were produced experimentally in ten human subjects by depriving the anterior corneal surface of its normal oxygen supply and inducing corneal edema. These striae were similar in appearance and time of occurrence to those observed in gel lens wearers. Three subjects also wore gel lenses and developed vertical striae while wearing their lenses. These striae were eliminated by increasing the oxygen concentration at the anterior lens surface. The data confirm many clinical observations which have suggested that verical striae are caused by corneal edema accompanying gel lens wear.     

Aetiology of keratoconus

Keratoconus has a common association with atopic conditions. Most keratoconus patients rub their eyes excessively. Eye-rubbing is considered the dominant aetiological factor in two-thirds of patients with keratoconus who progress to contact lens wear. A classification of keratoconus based on the dominant aetiological factors is proposed. No significant psychoneurotic factor was found in the keratoconus patients compared with patients in the control group.     

Screening of bladder cancer by a combination of transabdominal ultrasonography and urine cytology

We evaluated the presence or absence of bladder cancer by a combination of transabdominal ultrasonography and urine cytology in 60 patients who had been suspected of having bladder cancer. All patients then underwent cystoscopy, and biopsy or resection if necessary, and 24 patients were diagnosed as having bladder cancer. By the combination of ultrasonography and urine cytology the diagnosis was correct in 23 patients accounting for 96% of sensitivity, and the misdiagnosis was made in only one patient who had undergone BCG therapy for carcinoma in situ but had submucosal invasive bladder cancer. Because of the high sensitivity rate, we believe that the combination of transabdominal ultrasonography and urine cytology should be the first-choice examinations for patients who are suspected of having bladder cancer.     

Colocalization of collagen overexpression and inflammatory cell infiltration in the two-kidney one-clip rat model from the early days of hypertension onward

PURPOSE: This study was conducted to determine the agreement and test-retest repeatability of two methods for measuring corneal curvature in keratoconus: keratometry and the First Definite Apical Clearance Lens (FDACL). Our interest in the FDACL procedure stems from the important contact lens-fitting information and documentation of disease progression provided by the FDACL trial lenses and observation of fluorescein patterns. METHODS: The Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study is an observational study that has enrolled 1,209 keratoconus patients to characterize the progression of keratoconus, to determine factors associated with its progression, and to assess its impact on quality of life. Ten percent of the patients were randomly selected at baseline for a retest examination. The baseline examination, which included keratometry and FDACL, was repeated in this sample. The FDACL is the flattest lens in the standardized CLEK trial lens set that vaults the apex of the cone. FDACL provides an estimate of the sagittal height of the cone. RESULTS: The correlation of FDACL with the steep keratometric reading (r = 0.89; p = 0.0001) and the flat keratometric reading (r = 0.83; p = 0.0001) were high. Test-retest repeatability as measured by the intraclass correlation coefficient (ICC) was high: FDACL ICC, 0.97; steep keratometric reading ICC, 0.96; and flat keratometric reading ICC, 0.95. Test-retest repeatability of FDACL remained high in advanced disease. CONCLUSION: FDACL provides a repeatable new procedure for determining disease severity in keratoconus.     

Leukocyte differentials predict short-term clinical outcome following antipsychotic treatment in schizophrenia

PURPOSE: The purpose of the test-retest phase of the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study was to determine the repeatability of the various parts of the CLEK Study protocol. This paper presents the test-retest parameters of the refraction protocol. METHODS: We examined 138 CLEK Study-eligible patients on two occasions (median, 90 days; range, 22 to 268 days). All patients underwent subjective refraction on two occasions, and contact lens over-refractions were performed either over the patient's habitual rigid contact lenses or over a trial rigid contact lens equal in base curve to the steep keratometric reading in nonrigid contact lens wearers. RESULTS: Mean interoccasion differences +/- SD were -0.32 +/- 2.91 D and -0.17 +/- 1.39 D for subjective refraction sphere and cylinder power, respectively, and the mean absolute difference for subjective refraction cylinder axis was 18.1 +/- 20.2 degrees. The mean interoccasion difference +/- SD for high-contrast visual acuity with subjective refraction was 0.38 +/- 10.9 letters correct. Mean interoccasion differences +/- SD were -0.11 +/- 0.81 D and 0.02 +/- 0.67 D for contact lens over-refraction sphere and cylinder power, respectively, and the mean absolute difference for contact lens over-refraction cylinder axis was 11.6 +/- 9.9 degrees. The mean interoccasion difference +/- SD for visual acuity with contact lens over-refraction was 0.50 +/- 5.2 letters correct and 0.71 +/- 6.9 letters correct for high- and low-contrast visual acuity, respectively. CONCLUSIONS: The repeatability of subjective refraction in keratoconus patients is good but somewhat lower than that found in nondiseased eyes. Only 36% of our repeat measures of sphere power from subjective refraction fell within 0.50 D of each other, compared with more than 90% in studies of normal eyes.     

Sibling Adaptation to Childhood Cancer Collaborative Study: the association of sibling adaptation with maternal well-being, physical health, and resource use

OBJECTIVE: To assess the role of heredity in the development of keratoconus. DESIGN: Prospective study. SETTING: Eye clinic providing secondary and tertiary ophthalmic care in Toronto. PATIENTS: Thirty-nine patients with keratoconus (57 eyes) and 48 relatives of 11 patients with keratoconus. The corneal topography of the family members was compared with that of a group of 68 volunteer control subjects (136 eyes) without clinical evidence or a family history of keratoconus. OUTCOME MEASURES: Three quantitative measures derived from computerized videokeratography: the relative steepness of the inferior cornea versus the superior cornea, central corneal power and the difference in central corneal power between the two eyes. All the data were statistically analysed with the use of nonparametric discriminant analysis. RESULTS: Fifteen family members who were believed to be clinically normal on the basis of refraction, keratometry and slit-lamp examination has statistically significant topographic abnormalities suggestive of early or mild keratoconus. CONCLUSIONS: The presence of these findings in family members of patients with keratoconus may represent the incomplete expression of a gene contributing to the development of the condition. Pedigree analysis suggested an autosomal dominant inheritance pattern in 9 of the 11 families. Our results underline the value of videokeratography for accurate family pedigree analysis and the diagnosis of keratoconus.     

Value of the polymerase chain reaction for the detection of Toxoplasma gondii in cerebrospinal fluid from patients with AIDS

To investigate whether the polymerase chain reaction (PCR) on the BI gene of Toxoplasma gondii could contribute to the diagnosis of cerebral toxoplasmosis in patients with AIDS, we retrospectively tested CSF samples from 20 patients with AIDS suspected of having cerebral toxoplasmosis for the presence of T. gondii. Suspicion of cerebral toxoplasmosis was based on accepted criteria. Nine patients with AIDS with IgG antibodies to T. gondii but who were not suspected of having cerebral toxoplasmosis and four patients with AIDS seronegative for T. gondii served as negative control patients. T. gondii was demonstrated by PCR in the CSF from 13 of the 20 patients with AIDS suspected of having cerebral toxoplasmosis but was not demonstrated in the CSF samples from the nine control patients seropositive for T. gondii and the four control patients seronegative for T. gondii. The data were statistically evaluated. This study shows the value of PCR for the detection of T. gondii in CSF for the diagnosis of cerebral toxoplasmosis in patients with AIDS.     

Epikeratoplasty for keratoconus using manually dissected fresh lenticules: 4-year follow-up

BACKGROUND: Epikeratoplasty for keratoconus, in the absence of apical scarring, aims at reducing high irregular myopic astigmatism and provides an ectatic cornea with mechanical support. METHODS: We performed epikeratoplasty on 11 keratoconic corneas using fresh or McCarey-Kaufman preserved, manually dissected donor lenticules. A disparity of 0.5 mm was maintained between the host and the donor. Patients with keratoconus having a preoperative spectacle-corrected visual acuity of less than 6/60 and intolerance to contact lens wear were included in this prospective study. Spectacle-corrected visual acuity, keratometry, and refraction were analyzed over a 4-year follow-up period. RESULTS: Four year follow-up was completed on 10 eyes. Of these, 80% achieved a postoperative spectacle-corrected visual acuity of 6/12 or better. Average postoperative keratometry was 45.79 +/- 2.07 D and a decrease of 4.60 +/- 0.09 D was observed in refractive cylinder. Spherical equivalent showed a significant decrease in myopia of -4.35 +/- 0.26 D. Mean time to stabilization was 8 +/- 2.3 weeks. Epithelial defects occurred in three eyes; two were successfully treated by patching. One lenticule was removed due to graft infection following a persistent epithelial defect. CONCLUSION: Epikeratoplasty for keratoconus is a useful procedure with good long-term visual acuity results and an early stabilizing period.     

Rapid diagnosis of tuberculous meningitis by polymerase chain reaction assay of cerebrospinal fluid

A polymerase chain reaction (PCR) method for the rapid diagnosis of tuberculous meningitis (TBM) was used to study prospectively 47 cerebrospinal fluid (CSF) samples from 45 patients. Twenty CSF samples were from patients with clinically suspected TBM and another 27 samples came from patients without clinically suspected TBM. Mycobacterial DNA was detected in 15 CSF samples (14 from patients with clinically suspected TBM and 1 from a patient not suspected of having TBM). Of the PCR-positive samples, 4 were also positive for mycobacterial culture. However, 32 PCR-negative samples were all culture-negative. All samples were negative for the acid-fast bacillus by direct smear. The single PCR-positive patient in the clinically unsuspected TBM group was initially diagnosed as suffering from aseptic meningitis on the basis of his clinical features. The mycobacterial culture of his CSF specimen was also positive and a revised diagnosis of an aseptic type of TBM was made. The estimations of specificity and sensitivity in this study were 100% and 70% respectively. The results showed that using a PCR to detect mycobacterial DNA in CSF for the early diagnosis of TBM is not only a rapid but also an accurate method.     

Factors associated with the development of vasculitis in rheumatoid arthritis: results of a case-control study

OBJECTIVE: To investigate those characteristics of patients with rheumatoid arthritis (RA) that are associated with the development of rheumatoid vasculitis (RV). METHODS: Demographic and clinical data of 69 patients who had been diagnosed as having RV were compared with those of 138 contemporaneous control patients with RA who were not suspected to have vasculitis. Vasculitis was confirmed histologically in 96% of the subjects with RV. RESULTS: Variables associated with the development of RV were: 1) male gender, presence of increased serum concentrations of rheumatoid factor, joint erosions, subcutaneous nodules, number of disease modifying antirheumatic drugs previously prescribed, treatment (ever) with D-penicillamine or azathioprine; 2) presence of nail fold lesions and any other extrarticular feature one year before the time of diagnosis of RV; 3) treatment with corticosteroids at the time of diagnosis of RV. CONCLUSIONS: The development of RV is associated with male gender, extra-articular features, and a severe course of RA as indicated by the presence of joint destruction and need for intensive treatment with antirheumatic drugs. The strongest association was found with the presence of increased concentrations of rheumatoid factor.     

Staff attitudes to oral health care. A comparative study of registered nurses, nursing assistants and home care aides

The diagnosis of early ectopic pregnancy remains challenging for the gynecologist. Although early detection of a suspected pregnancy has been facilitated by quantitative beta human chorionic gonadotropin studies and ultrasonography, a patient subgroup remains with an ambiguous presentation. In this group of patients, the clinician must rely on microscopic examination of products of conception in a uterine curettage specimen to rule out the presence of an extrauterine pregnancy. The presence of an implantation site, chorionic villi, or trophoblastic tissue in uterine curettage samples is conventionally held as definitive evidence of an intrauterine pregnancy. We present a series of four cases that challenge this convention. In these cases, chorionic villi or an implantation site were identified in uterine samples of pregnant women who each ultimately proved to have an ectopic pregnancy. If clinical suspicion is high, the finding of either chorionic villi or an implantation site should not preclude further workup of a possible ectopic pregnancy. In cases where only a few villi or a single chorionic villus are identified, other signs of intrauterine implantation such as intermediate trophoblastic cells, hyalinized vessels, and a fibrinoid matrix should be sought to establish firmly the diagnosis of an intrauterine pregnancy.     

Need for electroencephalogram video confirmation of atypical absence seizures in children with Lennox-Gastaut syndrome

Children with childhood epileptic encephalopathy (Lennox-Gastaut syndrome) frequently have both multiple seizure types and nonepileptic stereotyped events that are difficult to differentiate. We hypothesize that electroencephalogram (EEG) video monitoring is essential for correct identification of atypical absence seizures in this population. All video/EEG monitoring records on patients with confirmed Lennox-Gastaut syndrome between September 1992 and December 1996 were reviewed for clinical events and EEG changes. A subset of patients with suspected atypical absence seizures during the video/EEG formed the cohort for analysis. Thirty-eight patients had 48 monitoring periods ranging from 1 to 4 days (mean, 2.2 days). Twenty-six monitoring periods captured suspected atypical absence seizures and formed the study cohort. Suspected atypical absence seizures were epileptic seizures in only 27% (7 of 26) of the study cohort. By contrast, parents reliably and correctly identified tonic, atonic, and tonic-clonic seizures in the study cohort. Reliable diagnosis and subsequent counting of atypical absence seizures in patients with Lennox-Gastaut syndrome cannot be made on the basis of observation and/or history alone. Future outpatient studies of investigational anticonvulsant medications for patients with Lennox-Gastaut syndrome should consider parental counts of atypical absence seizures unreliable. We recommend that video/EEG monitoring be done on all Lennox-Gastaut syndrome patients with suspected atypical absence seizures not controlled by medication.     

Perianeurysmal retroperitoneal fibrosis. An unusual cause of renal failure

Retroperitoneal fibrosis causing ureteral obstruction in association with an abdominal aortic aneurysm has been reported infrequently. However, the clinical presentation of patients with this entity and the histopathologic findings at surgery are similar to those in patients with idiopathic retroperitoneal fibrosis. We describe a patient with perianeurysmal fibrosis and bilateral ureteral obstruction who presented with severe renal failure. The diagnosis of an abdominal aortic aneurysm with perianeurysmal fibrosis was made only at the time of surgery to repair bilateral ureteral obstruction. Previous case reports of perianeurysmal fibrosis are reviewed, and possible pathogenetic mechanisms are discussed. It is important to consider the presence of an occult abdominal aortic aneurysm in patients suspected of having retroperitoneal fibrosis because of the serious prognostic and therapeutic implications.     

Atypical hereditary neuropathy with liability to pressure palsies (HNPP): the value of direct DNA diagnosis

We report two patients with suspected hereditary liability to pressure palsies. Neurophysiological studies showed a mixed axonal-demyelinating sensory-motor polyneuropathy with focal slowing of conduction velocities at the common sites of entrapment. Morphological studies on sural nerve biopsy from the proband showed active axonal regeneration without typical tomacula. Molecular analysis confirmed the presence of a deletion of chromosome 17p11.2 in both patients. Our observation confirms the heterogeneity of hereditary liability to pressure palsies and the relevance of DNA testing for the diagnosis of this hereditary neuropathy.     

Human magnetic resonance imaging at 8 T

BACKGROUND: Antibodies to Epstein Barr Virus (EBV) antigens have been used for the diagnosis of nasopharyngeal carcinoma (NPC). While immunofluorescence assays (IFA) of IgA antiviral capsid and early antigens have been the mainstay of this diagnosis, enzyme immunoassays (ELISA) of various EBV antigens are now available. However in almost all of these assays, the sensitivities and specificities have been calculated using blood donors and normal hospital staff as controls, who may not be the most appropriate controls. We wanted to evaluate the usefulness of IFA and ELISA of various EBV antigens in a clinical setting to distinguish between patients with NPC and those suspected of NPC but being biopsy negative. METHODS: Between January 1987 and June 1988, 322 consecutive patients suspected of NPC and who had a post-nasal biopsy were studied. Blood was taken for EBV tests before diagnosis. Tests included IFA and ELISA IgA anti-VCA and anti-EA and ELISA IgA and IgG anti-ribonucleotide reductase, a cloned EA antigen. RESULTS: IFA IgA anti-VCA together with IFA IgA anti-EA both at a cut-off of 1:10 gave the best discrimination between patients with NPC and those suspected of NPC but were biopsy negative. CONCLUSION: The ELISA IgG anti-ribonucleotide reductase test is convenient to perform and looks very promising. An ELISA using a cocktail of cloned EA peptides may be even better.     

A peculiar form of pacemaker syndrome in DDD pacing

We studied two sets of identical twins with keratoconus. The first 21-year-old pair had bilateral fully developed keratoconus and the second 35-year-old pair presented with early bilateral keratoconus detected by videokeratography. To our knowledge, these are the seventh and eighth sets of identical twins with keratoconus reported in the literature. They support the evidence of heredity as a factor in the etiology of keratoconus. Videokeratography proved to be a valuable adjunct for the detection of early keratoconus in a cornea with normal slit-lamp microscopy and photokeratoscopy results. Radial keratotomy in one eye produced an unstable refraction.     

Plasma brain natriuretic peptide in assessment of acute dyspnoea

Recognition of heart failure (HF) may be difficult in patients presenting with acute dyspnoea, particularly in the presence of chronic airways obstruction. Since increased secretion of the cardiac hormones atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) occurs early in the course of HF, we have assessed the value of measuring these hormones in plasma in the diagnosis of suspected HF in 52 elderly patients presenting with acute dyspnoea, and compared values with left-ventricular ejection fraction (LVEF), a standard measure of left-ventricular function, by radionuclide angiography. Patients were enrolled prospectively. On the basis of clinical findings, conventional tests, and response to specific treatment, 20 of the 52 patients were classified as having primary lung disorder (PLD), 12 as HF alone, and 20 as HF with underlying PLD (HF/PLD). Compared with findings in PLD patients, LVEF was significantly depressed in HF and HF/PLD patients (p < 0.001), whereas both plasma ANP and BNP were significantly increased (p < 0.001). Admission plasma BNP concentration more accurately reflected the final diagnosis of HF (93% sensitivity and 90% specificity when BNP > or = 22 pmol/L) than LVEF or plasma ANP concentration. When all patients were considered together, there were strong negative correlations between LVEF and log BNP (r = -0.7, p < 0.001) and log ANP (r = -0.59, p < 0.001). Our finding that plasma BNP is raised in dyspnoeic patients with HF but not in acutely breathless patients with PLD, suggests that rapid BNP assays may assist in the diagnosis of patients with acute dyspnoea.