James D. Reynolds

Bone Mineral Density in Women with Depression

BACKGROUND Depression is associated with alterations in behavior and neuroendocrine systems that are risk factors for decreased bone mineral density. This study was undertaken to determine whether women with past or current major depression have demonstrable decreases in bone density. METHODS We measured bone mineral density at the hip, spine, and radius in 24 women with past or current major depression and 24 normal women matched for age, body-mass index, menopausal status, and race, using dual-energy x-ray absorptiometry. We also evaluated cortisol and growth hormone secretion, bone metabolism, and vitamin D-receptor alleles. RESULTS As compared with the normal women, the mean (+/-SD) bone density in the women with past or current depression was 6.5 percent lower at the spine (1.00+/-0.15 vs. 1.07+/-0.09 g per square centimeter, P=0.02), 13.6 percent lower at the femoral neck (0.76+/-0.11 vs. 0.88+/-0.11 g per square centimeter, P<0.001), 13.6 percent lower at Wards triangle (0.70+/-0.14 vs. 0.81+/-0.13 g per square centimeter, P<0.001), and 10.8 percent lower at the trochanter (0.66+/-0.11 vs. 0.74+/-0.08 g per square centimeter, P<0.001). In addition, women with past or current depression had higher urinary cortisol excretion (71+/-29 vs. 51+/-19 micrograms per day [196+/-80 vs. 141+/-52 nmol per day], P=0.006), lower serum osteocalcin concentration (P=0.04), and lower urinary excretion of deoxypyridinoline (P=0.02). CONCLUSIONS Past or current depression in women is associated with decreased bone mineral density.

Screening Examination of Premature Infants for Retinopathy of Prematurity

This statement revises a previous statement on screening of preterm infants for retinopathy of prematurity (ROP) that was published in 2006. ROP is a pathologic process that occurs only in immature retinal tissue and can progress to a tractional retinal detachment, which can result in functional or complete blindness. Use of peripheral retinal ablative therapy by using laser photocoagulation for nearly 2 decades has resulted in a high probability of markedly decreasing the incidence of this poor visual outcome, but the sequential nature of ROP creates a requirement that at-risk preterm infants be examined at proper times and intervals to detect the changes of ROP before they become permanently destructive. This statement presents the attributes on which an effective program for detecting and treating ROP could be based, including the timing of initial examination and subsequent reexamination intervals.

Severity of Neonatal Retinopathy of Prematurity Is Predictive of Neurodevelopmental Functional Outcome at Age 5.5 Years

Objective. The purpose of this study was to assess the relation between neonatal retinopathy of prematurity (ROP) in very low birth weight infants and neurodevelopmental function at age 5.5 years. Methods. Longitudinal follow-up of children occurred in 2 cohorts of the Multicenter Cryotherapy for Retinopathy of Prematurity Study. The extended natural history cohort followed 1199 survivors of <1251 g birth weight from 5 centers. The threshold randomized cohort (ThRz) followed 255 infants <1251 g from 23 centers who developed threshold ROP and who consented to cryotherapy to not more than 1 eye. At 5.5 years both cohorts had ophthalmic and acuity testing and neurodevelopmental functional status determined with the Functional Independence Measure for Children (WeeFIM). Results. Evaluations were completed on 88.7% of the extended natural history cohort; 87% had globally normal functional skills (WeeFIM: >95). As ROP severity increased, rates of severe disability increased from 3.7% among those with no ROP, to 19.7% of those with threshold ROP. Multiple logistic regression analysis demonstrated that better functional status was associated with favorable visual acuity, favorable 2-year neurological score, absence of threshold ROP, having private health insurance, and black race. Evaluations were completed on 87.4% of the ThRz children. In each functional domain, the 134 children with favorable acuity in their better eye had fewer disabilities than did the 82 children with unfavorable acuity: self-care disability 25.4% versus 76.8%, continency disability 4.5% versus 50.0%, motor disability 5.2% versus 42.7%, and communicative-social cognitive disability 22.4% versus 65.9%, respectively. Conclusion. Severity of neonatal ROP seems to be a marker for functional disability at age 5.5 years among very low birth weight survivors. High rates of functional limitations in multiple domains occur in children who had threshold ROP, particularly if they have unfavorable visual acuity.

Incidence and Severity of Retinopathy of Prematurity in Vietnam, a Developing Middle-Income Country

BACKGROUND Although retinopathy of prematurity (ROP) is a leading cause of childhood blindness, its impact in lower income countries is not well documented. The World Health Organization has proclaimed that infants at risk for ROP should have screening eye examinations and access to treatment. PATIENTS AND METHODS A prospective study was conducted from January 1 through December 31, 2001, at Tu Du Hospital in Ho Chi Minh City for premature infants who weighed 1,500 g or less at birth or were 33 gestational weeks or younger. Serial examinations were used to classify ROP, and treatment outcomes were noted. RESULTS Two hundred twenty-five consecutive infants were included in the data analysis. Birth weights ranged from 900 to 2,000 g (mean, 1,512 g). Gestational ages ranged from 26 to 36 weeks (mean, 31 weeks). ROP was present in 103 (45.8%) of the 225 infants. In infants who weighed 1,250 g or less at birth, the ROP rate was 81.2% (26 of 32 infants). Threshold ROP was present in 9.3% of the 225 infants but in 25% of the 32 infants. Twenty-four eyes received treatment, whereas 16 lacked the family resources. Of the 24 treated eyes, 18 (75%) had a favorable outcome. Of the 16 untreated eyes, only 3 had a favorable outcome. CONCLUSIONS ROP incidence is high in Vietnam, similar to that in the United States. However, larger, older infants are at risk in Vietnam and the rate of severe ROP seems to be higher. This necessitates an ROP screening paradigm different from that currently used in the United States.

The Management of Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is a major problem in both highly developed countries and countries with emerging technology. The incidence of ROP has been stable over the last 2 decades despite improvements in neonatology. Threshold ROP occurs in about 5% of premature infants in the US with birthweights <1.25kg. Despite treatment, a sizable minority will become blind (up to 20 to 30%).The pathophysiology of ROP can be separated into 2 phases. Phase I is hyperoxia-vasocessation. Phase II is hypoxia-vasoproliferation. The former occurs immediately following premature birth. The provision of supplemental oxygen causes retinal hyperoxia, a down regulation of vascular endothelial growth factor (VEGF) and a consequent cessation of normal retinal vascularisation. Systemic factors and increasing retinal metabolic demands cause a shift to phase II when a relative retinal hypoxia develops. This hypoxia stimulates VEGF production, leading to renewed vascularisation. This can be the resumption of normal vascularisation or abnormal neovascularisation, depending on local retinal responses.The management of ROP begins with a reliable evidence-based screening protocol. All interested parties must cooperate in developing and implementing foolproof screening protocols. Hospital officials, nursery personnel, neonatologists and ophthalmologists all have areas of responsibility in ensuring adequate screening.ROP management involves prevention, interdiction and correction. Prevention includes: adequate prenatal care which minimises premature birth, and appropriate systemic intensive care which lessens the tissue hyperoxia/hypoxia swings. Pharmacological vitamin E supplementation has largely been abandoned and ambient light reduction has been shown to be ineffective. The value of inositol supplementation and angiogenesis inhibitors in preventing ROP is presently under investigation.Interdiction concentrates on ablation of the peripheral avascular retina, thus dramatically decreasing VEGF production. Both cryotherapy and laser photocoagulation are effective; however, unfortunately, poor outcomes persist despite treatment. Supplemental oxygen administration has so far proven ineffective in limiting ROP progression.Finally, correction focuses on vitrectomy/retinal detachment repair. While anatomically successful, this procedure is often unsuccessful in terms of restoration of vision (<5% success rate).In conclusion, despite improvements in neonatology, ROP, potentially leading to blindness, continues to be a common problem associated with prematurity. Future management success must concentrate on discovering new modes of treatment, especially prevention.

Risk Factors Associated with Retrolental Fibroplasia

The eyes of infants who were premature or had exposure to increased ambient oxygen from 1979 to 1981 were examined. Of 1012 neonates, 19 were found to have acute retrolental fibroplasia (RLF) grade III or worse in at least one eye. Sixteen also had chronic lung disease (CLD), and when compared to 25 control patients who had CLD but not grade III or more RLF, they were found to consistently have lower blood CO2 tensions (PCO2), lower pH values, higher inspired oxygen concentrations (FIO2S) and a higher incidence of seizure disorders (100% vs. 48%). We could not show that an elevated PCO2 increased the risk for developing RLF. Infants with either chronic lung disease or chronic lung disease and seizures had a high risk for developing RLF grade III (39% and 57%, respectively).

A Histopathologic Study of Bilateral Aphakia with a Unilateral Intraocular Lens in a Child

A 7-year-old boy who had had electrically induced cataracts since he was 6 months old underwent a lens extraction by phacoemulsification in his right eye. He later refused to wear a contact lens. When the boy was 10 year old, the lens of his left eye was removed by phacoemulsification and an intraocular lens was implanted. The intraocular lens functioned well and was tolerated by the boy until he died in an automobile accident at the age of 16 years. A histopathologic study of the eyes, which were obtained post mortem, showed a decreased corneal endothelial cell population, mild focal atrophy of iris structures, and mild lymphocytic infiltration in the implanted eye. Vitreous liquefaction and epiretinal membrane formation occurred in both eyes.

Needle sterility during strabismus surgery

BACKGROUND Infection after strabismus surgery is uncommon and its cause remains unanswered. The source of the bacteria and the manner in which it enters the eye is often unknown. Most pediatric ophthalmologists now use 5% povidone-iodine to reduce the bacterial population before surgery. The needles used during strabismus surgery may be a source of bacterial contamination. METHODS One hundred six needles were cultured after their use in strabismus surgery. RESULTS Sixteen of 106 needles (15.1%) and 15 of 61 cases (24.6%) were culture positive. The organisms recovered closely resembled indigenous bacterial flora. CONCLUSION This study suggests that the needles used during strabismus surgery may be the source of bacteria that can lead to infections after strabismus surgery.

Hyperplastic persistent pupillary membrane--surgical management.

Two infants, aged three days and six weeks, respectively, presented with dense extensive persistent pupillary membranes as sporadic isolated findings. A clear central pupillary aperture was unable to be achieved with mydriatic agents. The patients were treated by surgical removal of the membranes at age five days and six months respectively. Surgery was without complication and visual development has been normal. We suggest that early intervention in the first weeks or months of life is necessary to prevent the development of amblyopia. If mydriasis is unsuccessful, surgery is recommended followed by optical correction and occlusion therapy as necessary.

Expert Diagnosis of Plus Disease in Retinopathy of Prematurity From Computer-Based Image Analysis

IMPORTANCE Published definitions of plus disease in retinopathy of prematurity (ROP) reference arterial tortuosity and venous dilation within the posterior pole based on a standard published photograph. One possible explanation for limited interexpert reliability for a diagnosis of plus disease is that experts deviate from the published definitions. OBJECTIVE To identify vascular features used by experts for diagnosis of plus disease through quantitative image analysis. DESIGN, SETTING, AND PARTICIPANTS A computer-based image analysis system (Imaging and Informatics in ROP [i-ROP]) was developed using a set of 77 digital fundus images, and the system was designed to classify images compared with a reference standard diagnosis (RSD). System performance was analyzed as a function of the field of view (circular crops with a radius of 1-6 disc diameters) and vessel subtype (arteries only, veins only, or all vessels). Routine ROP screening was conducted from June 29, 2011, to October 14, 2014, in neonatal intensive care units at 8 academic institutions, with a subset of 73 images independently classified by 11 ROP experts for validation. The RSD was compared with the majority diagnosis of experts. MAIN OUTCOMES AND MEASURES The primary outcome measure was the percentage of accuracy of the i-ROP system classification of plus disease, with the RSD as a function of the field of view and vessel type. Secondary outcome measures included the accuracy of the 11 experts compared with the RSD. RESULTS Accuracy of plus disease diagnosis by the i-ROP computer-based system was highest (95%; 95% CI, 94%-95%) when it incorporated vascular tortuosity from both arteries and veins and with the widest field of view (6-disc diameter radius). Accuracy was 90% or less when using only arterial tortuosity and 85% or less using a 2- to 3-disc diameter view similar to the standard published photograph. Diagnostic accuracy of the i-ROP system (95%) was comparable to that of 11 expert physicians (mean 87%, range 79%-99%). CONCLUSIONS AND RELEVANCE Experts in ROP appear to consider findings from beyond the posterior retina when diagnosing plus disease and consider tortuosity of both arteries and veins, in contrast with published definitions. It is feasible for a computer-based image analysis system to perform comparably with ROP experts, using manually segmented images.