Deep vein thrombosis and pulmonary embolism in cirrhotic patients:Systematic review

Patients with liver cirrhosis were traditionally believed to be protected against development of blood clots.Lately,studies have shown that these patients may probably be at an increased risk of venous thrombotic complications.Although the hemostatic changes in the chronic liver disease patients and the factors that may predict bleeding vs thrombotic complications remains an area of active research,it is believed that the coagulation cascade is delicately balanced in these patients because of parallel reduced hepatic synthesis of pro and anticoagulant factors.Thrombotic state in cirrhotic patients is responsible for not only portal or non-portal thrombosis[deep vein thrombosis(DVT)and pulmonary embolism(PE)];it has also been associated with progression of liver fibrosis.The use of anticoagulants in cirrhosis patients is a challenging,and often a scary situation.This review summarizes the current literature on the prevalence of venous thrombosis(DVT and PE),risk factors and safety of prophylactic and therapeutic anticoagulation in patients with chronic liver disease.

Role of interventional radiology in the management of acute gastrointestinal bleeding

Acute gastrointestinal bleeding(GIB) can lead to significant morbidity and mortality without appropriate treatment. There are numerous causes of acute GIB including but not limited to infection, vascular anomalies, inflammatory diseases, trauma, and malignancy. The diagnostic and therapeutic approach of GIB depends on its location, severity, and etiology. The role of interventional radiology becomes vital in patients whose GIB remains resistant to medical and endoscopic treatment. Radiology offers diagnostic imaging studies and endovascular therapeutic interventions that can be performed promptly and effectively with successful outcomes. Computed tomography angiography and nuclear scintigraphy can localize the source of bleeding and provide essential information for the interventional radiologist to guide therapeutic management with endovascular angiography and transcatheter embolization. This review article provides insight into the essential role of Interventional Radiology in the management of acute GIB.

Pancreatits after endoscopic retrograde cholangio-pancreatography

Pancreatitis is the most common complication after endoscopic retrograde cholangio-pancreatography (ERCP); the reported incidence of this complication varies from less than 1% to 40%, but a rate of 4%-8% is reported in most prospective studies involving non-selected patients. Differences in criteria for defining pancreatitis, methods of data collection, and patient populations (i.e. number of high-risk patients included in the published series) are factors that are likely to affect the varying rates of post-ERCP pancreatitis. The severity of post-ERCP pancreatitis (PEP) can range from a minor inconvenience with one or two days of added hospitalization with full recovery to a devastating illness with pancreatic necrosis, multiorgan failure, permanent disability, and even death. Although, most episodes of PEP are mild (about 90%), a small percentage of patients (about 10%) develop moderate or severe pancreatitis. In the past, PEP was often viewed as an unpredictable and unavoidable complication, with no realistic strategy for its avoidance. New data have aided in stratifi cation of patients into PEP risk categories and new measures have been introduced to decrease the risk of PEP. As most ERCPs are performed on an outpatient basis, the majority of patients will not develop PEP and can be discharged. Alternatively, early detection of those patients who will go on to develop PEP can guide decisions regarding hospital admission and aggressive management. In the last decade, great efforts have been addressed toward prevention of this complication. Points of emphasis have included technical measures, pharmacological prophylaxis, and patient selection. This review provides a comprehensive, evidence-based assessment of published data on PEP and current suggestions for its avoidance.

Alcoholic hepatitis: A comprehensive review of pathogenesis and treatment

Alcoholic hepatitis(AH)is an acute hepatic inflammation associated with significant morbidity and mortality.Current evidence suggests that the pathogenesis is the end result of the complex interplay between ethanol metabolism,inflammation and innate immunity.Several clinical scoring systems have been derived to predict the clinical outcomes of patients with AH;such as Child-Turcotte-Pugh score,the Maddrey discriminant function,the Lille Model,the model for end stage liver disease scores,and the Glasgow alcoholic hepatitis score.At present,Corticosteroids or pentoxifylline are the current pharmacologic treatment options;though the outcomes from the therapies are poor.Liver trans-plantation as the treatment of alcoholic hepatitis remains controversial,and in an era of organ shortage current guidelines do not recommend transplantation as the treatment option.Because of the limitations in the therapeutic options,it is no doubt that there is a critical need for the newer and more effective pharmacological agents to treat AH.

Applications of endoscopic ultrasound in pancreatic cancer

Since the introduction of endoscopic ultrasound guided fine-needle aspiration(EUS-FNA),EUS has assumed a growing role in the diagnosis and management of pancreatic ductal adenocarcinoma(PDAC).The objective of this review is to discuss the various applications of EUS and EUS-FNA in PDAC.Initially,its use for detection,diagnosis and staging will be described.EUS and EUS-FNA are highly accurate modalities for detection and diagnosis of PDAC,this high accuracy,however,is decreased in specific situations particularly in the presence of chronic pancreatitis.Novel techniques such as contrast-enhanced EUS,elastography and analysis of DNA markers such as k-ras mutation analysis in FNA samples are in progress and might improve the accuracy of EUS in the detection of PDAC in this setting and will be addressed.EUS and EUS-FNA have recently evolved from a diagnostic to a therapeutic technique in the management of PDAC.Significant developments in therapeutic EUS have occurred including advances in celiac plexus interventions with direct injection of ganglia and improved pain control,EUS-guided fiducial and brachytherapy seed placement,fine-needle injection of intra-tumoral agents and advances in EUS-guided biliary drainage.The future role of EUS and EUS in management of PDAC is still emerging.

Reinterpretation of histology of proximal colon polyps called hyperplastic in 2001

AIM： To evaluate how proximal colon polyps interpreted as hyperplastic polyps in 2001 would be interpreted by expert pathologists in 2007.METHODS： ≥ 5 mm in interpreted pathologists 2007 by 3 GI Forty consecutive proximal colon polyps size, removed in 2001, and originally as hyperplastic polyps by general at Indiana University, were reviewed in pathologists.CONCLUSION： Many polyps interpreted as hyperplastic in 2001 were considered sessile serrated lesions by GI pathologists in 2007, but there is substantial inter-observer variation amongst GI pathologists.

原位肝移植术后成功进行内镜下吻合口狭窄治疗:胆总管狭窄的复发率

Background and Study Aims: The development of anastomotic strictures is one of the most common complications of orthotopic liver transplantation (OLT) with choledochocholedochostomy anastomosis. Endoscopic therapy with balloon dilation and/or stent placement is an effective therapy. The aim of this study was to assess the recurrence rate of anastomotic strictures and the features that predict recurrence after previously successful endoscopic therapy. Patients and Methods: We searched the endoscopic retrograde cholangiopancreatography (ERCP) database for all patients who had had an OLT who were undergoing ERCP. The study cohort consisted of post-OLT patients who had a recurrence of anastomotic stricture after initial resolution following a course of endoscopic therapy. Results: A total of 916 OLT operations were performed during the study period from June 1994 to November 2004. Out of this group, 143 patients (15.6%) were diagnosed with anastomotic stricture and underwent a total of 423 ERCPs for endoscopic treatment. Twelve patients who are still undergoing endoscopic therapy were excluded from the analysis. The technical success rate was 96.6%, and the endoscopic therapy was successful in 82%of patients; 18%had a recurrence of cholestasis and ERCP revealed a recurrence of the anastomotic stricture that required intervention. Themean time of follow-up after stent removal was 28 months (range 1-114 months). The study did not reveal any clinical or endoscopic parameters that could predict recurrence, though the presence of a biliary leak at initial ERCP and a longer time to initial presentation were factors that showed a trend toward an increased likelihood of recurrence. Conclusions: Biliary strictures remain a common complication after OLT, and in nearly one in five patients these strictures recur after initially successful endoscopic therapy. There were no clinical or endoscopic parameters identified in this study that predicted recurrence. Further study is needed to determine what type of endoscopic therapy would minimize the risk of stricture recurrence.

超声内镜引导胰腺转移瘤的细针穿刺:一项多中心试验

Background: Metastatic lesions of the pancreas are a rare but important cause of focal pancreatic lesions. The purpose of this study is to describe the EUS features, cytologic diagnoses, and clinical impact of a cohort of patients with pancreatic metastases diagnosed by EUS-guided FNA (EUS-FNA). Methods: Over a 6-year period, in a retrospective, multicenter study, patients had the diagnosis of pancreatic metastases confirmed with EUS-FNA. All examinations were performed by one of 5 experienced endosonographers. The EUS and the clinical findings of pancreatic metastases were compared with those of a cohort with primary pancreatic malignancy. Results: Thirty-seven patients with possible metastases were identified, and 13 were excluded because of diagnostic uncertainty. The remaining 24 underwent EUS-FNA (mean passes 4.1) of a pancreatic mass without complications. Diagnoses included metastases from primary kidney (10), skin (6), lung (4), colon (2), liver (1), and stomach (1) cancer. In 4 (17%), 16 (67%), and 24 (100%) patients, EUS-FNA provided the initial diagnosis of malignancy, tumor recurrence, and pancreatic metastases, respectively. Four (17%) metastases initially were discovered by EUS after negative (n = 3) or inconclusive (n = 1) CT scans. Compared with primary cancer, pancreatic metastases were more likely to have well-defined margins (46%vs. 4%) compared with irregular (94%vs. 54%; p < 0.000 1) margins. No statistically significant difference between the two populations was noted for tumor size, echogenicity, consistency, location, lesion number, or number of FNA passes performed. Conclusions: Pancreatic metastases are an important cause of focal pancreatic lesions and may occasionally be discovered during EUS examination after previously negative or inconclusive CT. Use of immunocytochemistry, when available, may help to confirm a suspected diagnosis. These lesions are more likely to have well-defined EUS margins compared with primary pancreatic cancer.

AN EVALUATION OF BIMATOPROST MONOTHERAPY IN PATIENTS WITH GLAUCOMA OR OCULAR HYPERTENSION PREVIOUSLY TREATED WITH DUAL TIMOLOL/LATANOPROST THERAPY

Objective: To evaluate the safety and efficacy of bimatoprost 0.03% (Lumigan) monotherapy in patients with glaucoma or ocular hypertension previously treated with timolol 0.5% gel-forming solution (Timoptic-XE) and latanoprost 0.005% (Xalatan) dual therapy. Methods: An open-label, multicenter e-valuation of 83 patients. Patients were assigned to dual therapy with latanoprost qPM and timolol gel-forming solu-

Patient interest in video recording of colonoscopy:A survey

AIM:To find if patients are interested in obtaining a video recording of their colonoscopy procedure.METHODS:We conducted a survey of outpatients presenting for colonoscopy regarding their interest in obtaining a video recording of their colonoscopy.RESULTS:Two hundred and forty-eight patients(mean age 57.9 years;57% male) were surveyed.Two hundred and one patients(81%) were interested in obtaining a video recording.No significant predictors of patients' interest in the video recording were identified.After reading a brief educational paragraph explaining missed lesions during colonoscopy,135 patients(54%) were more interested in having a video recording,and none were less interested.One hundred and fifty-six patients(63%) were willing to pay for a video recording.In multivariable analyses,younger age was predictive of willingness to pay for a video recording.Prior history of colorectal cancer and a family history of colorectal cancer were predictive of willingness to pay a greater amount.CONCLUSION:Patients undergoing colonoscopy expressed substantial interest in obtaining a videorecording of their procedure.Awareness of missing lesions during colonoscopy increased interest in having a videorecording.

Kinetics of Iododeoxyuridine release from sodium alginate hydrogel in vitro

Objective To investigate the kinetics of Iododeoxyuridine(IUdR)release from sodium alginate hydrogel cross-linked with varying amounts of calcium chloride, and to optimize sustained release for further periadventitial I125-labeled IUdR delivery to suppress intimal hyperplasia following angioplasty in vivo. Methods Four hydrogels,composed of 0.16 mEq sodium alginate and 200 g IUdR, were cross-linked with calcium chloride to yield ion equivalence (IE) ratios (Calcium: alginate) of 3:1, 4:1, 5:1, or 6:1. 2 ml of normal saline was placed on top of each hydrogel and allowed to remain in contact at 37℃ for up to 30 days. At set time intervals, the concentration and amount of IUdR in the eluate were assayed by high performance liquid chromatography using UV detection and Water symmetry C18 column. The data for accumulated release rate and concentration in the eluate were calculated based on the calibration curve of peak area versus IUdR concentration. The hydrogel morphologic degradations were also observed. Results The hydrogels entrapped 92.9%, 98.6%, 98.4% and 98.6% of the IUdR with 3:1, 4:1, 5:1 and 6:1 IE ratios, respectively. IUdR concentration in eluates from 3:1 IE ratio hydrogel decreased faster than that from other hydrogels over time (P < 0.01). The 4:1, 5:1 and 6:1 IE ratio hydrogels produced more than 10 μm IUdR concentrations in eluates for the first 8 days, while the 3:1 IE ratio hydrogel for 4 days. IUdR release rates of the 4:1, 5:1 and 6:1 IE ratio hydrogels were very close, however they were lower than that of the 3:1 IE hydrogel in the first 48 hours (P < 0.05). At day 30, the 3:1 and 4:1 IE ratio hydrogels had 100% and 88% degradation, but no significant degradation was observed in the other hydrogels. Conclusion The sodium alginate hydrogel with 4:1 IE ratio exhibited an optimal IUdR sustained release and almost complete degradation in 30 days. (J Intervent Radiol, 2006, 15: 293-298)

Total pancreatectomy with islet cell transplantation vs intrathecal narcotic pump infusion for pain control in chronic pancreatitis

AIM: To evaluate pain control in chronic pancreatitis patients who underwent total pancreatectomy with islet cell transplantation or intrathecal narcotic pump infusion.METHODS: We recognized 13 patients who underwent intrathecal narcotic pump(ITNP) infusion and 57 patients who underwent total pancreatectomy with autologous islet cell transplantation(TP + ICT) for chronic pancreatitis(CP) pain control between 1998 and 2008 at Indiana University Hospital. All patients had already failed multiple other modalities for pain control and the decision to proceed with either intervention was made at the discretion of the patients and their treating physicians. All patients were evaluated retrospectively using a questionnaire inquiring about their pain control(using a 0-10 pain scale), daily narcotic dose usage, and hospital admission days for pain control before each intervention and during their last follow-up. RESULTS: All 13 ITNP patients and 30 available TP + ICT patients were evaluated. The mean age was approximately 40 years in both groups. The median duration of pain before intervention was 6 years and 7 years in the ITNP and TP + ICT groups, respectively. The median pain score dropped from 8 to 2.5(on a scale of 0-10) in both groups on their last follow up. The median daily dose of narcotics also decreased from 393 mg equivalent of morphine sulfate to 8 mg in the ITNP group and from 300 mg to 40 mg in the TP + ICT group. No patient had diabetes mellitus(DM) before either procedure whereas 85% of those who underwent pancreatectomy were insulin dependent on their last evaluation despite ICT. CONCLUSION: ITNP and TP + ICT are comparable for pain control in patients with CP however with high incidence of DM among those who underwent TP + ICT. Prospective comparative studies and longer follow up are needed to better define treatment outcomes.

Tumor Volume Associated with Recurrence in Prostate Cancer Patients with Seminal Vesicle Invasion

Objectives: To examine predictors of progression-free survival in men with seminal vesicle invasion (SVI) following radical prostatectomy (RP) for clinically localized prostate cancer. Methods and Materials: Between 1999 and 2009, 1383 men underwent RP at Indiana University. Among them, 115 men were identified with SVI. Disease progression was defined by a rise in PSA ≥ 0.2 ng/ml, receipt of salvage therapy, progression to metastatic disease, or death. After excluding 13 patients for receiving adjuvant therapy, 102 were stratified according to surgical margin (SM) and lymph node (LN) status for Kaplan-Meier analysis of disease progression. Cox proportional hazards analyses of biochemical progression-free survival were undertaken with respect to margin status, pre-operative prostate specific antigen (PSA), tumor volume, age, and post-operative Gleason sum. Stem and leaf plot was undertaken for tumor volume by biochemical PFS. Results: Mean age was 61 years, median Gleason sum was 7, mean tumor volume was 9.7 ml, and mean pre-operative PSA was 13.6 ng/ml. Mean time to disease progression was 17 months. Mean follow-up was 37 months. Kaplan-Meier analysis revealed statistically insignificant differences in progression-free survival stratified by SM and LN status (p = 0.12). Cox univariate analyses revealed tumor volume to be a statistically significant predictor of progression free survival (p = 0.02). Stem and Leaf plot revealed tumor volume to be statistically significantly larger in patients who experienced biochemical recurrence, compared to those who did not. Conclusion: Tumor volume was associated progression-free survival in this cohort of SVI patients, while pathologic Gleason sum, PSA, margin and nodal status were not.

Biodegradation of Polymethylmethacrylate Bone Cement May Not Be a Serious Issue in Total Hip Arthroplasty—Retrieval Study for Knoop Hardness and Young’s Modulus

Introduction: To investigate a long-term in vivo deterioration of polymethylmethacrylate (PMMA) bone cement over time, we evaluated retrieved PMMA cement in terms of chemical elements presenting in the cement using energy dispersive analysis of X-rays;Knoop hardness;and the Young’s modulus using scanning acoustic microscopy. Materials and Methods: For mechanical evaluation, we could neglect the influences of entrapped air bubbles or blood by the use of small specimens. The study was based on thirteen cement samples (six used in the acetabulum and seven in the femur) derived from eight patients (age at revision surgery: mean 72.5, range 68 to 79). All of these samples were Simplex-P?cement. They were functioning well at least ten years after the previous surgery. Duration until revision surgery was ranged 12 to 25 years (average, 17.4 years). The reason for revision was aseptic mechanical loosening. Twenty samples of Simplex-Preg;cement were served by manually mixing as a control. Results: The average of the hardness of the cement was 17.0 ± 1.2 (range, 13.4-20.6). In the control, the hardness was 17.8 ± 1.5 (range, 14.0-24.6). There was no significant difference between these values. The mean of Young’s modulus of the cement was 5.61 ± 0.19 GPa (range, 5.09-6.10). In the control, the modulus was 6.04 ± 0.13 GPa (range, 5.68-6.45). Although the modulus was significantly less than that of the control, there was only 7% decrease in average between twelve and twenty-five years in vivo. Conclusions: Our results suggest that long-term implantation and functional loading in vivo may not be the limiting factor in the mechanical integrity of the bone cement.

特发性胰腺炎ERCP的检查结果:囊性纤维化基因阳性及阴性患者

Abstract Abstract Background: Our series of patients with idiopathic pancreatitis (IP) found a cystic fibrosis (CF) gene abnormality in 19% compared with 3.5% in patients without pancreatitis. Objective: The objective was to determine whether the CF gene predicts more severe ERP findings. Design: This was a retrospective case-control study. Setting and Patients: From July 1998 to August 2004, CF gene analysis was performed in 819 patients with IP via Genzyme Genetics. The panel tests for 70 to 87 alleles and has a detection rate of more than 90% of the cases. Sixty-nine patients (8.4% ) who had at least one CF gene positive mutation were the study cohort. A total of 218 patients with IP and negative CF gene mutation were randomly selected from our database to be in the control group. Main Outcome Measurements: Pancreatograms were evaluated for chronic pancreatitis (CP) based on Cambridge criteria. The results of the gene analysis were not available at the time of pancreatogram interpretation. Results: Among patients positive for the CF gene, 42 (61% ) were women. The mean age at intervention was 40 years (range 14-80 years), and 48 patients (70% ) had cholecystectomy. Among patients who were negative for the CF gene, 147 (67% ) were women. The mean age at intervention was 41 years (range 9-89 years), and 125 patients (57% ) had cholecystectomy. Compared with controls, cases had higher incidence of CP (62% vs. 48% , p = 0.05), grade III CP (35% vs. 18% , p = 0.004), pseudocysts (12% vs. 4% , p = 0.036) and pancreatic strictures (20% vs. 8% , p = 0.008). Limitations: The limitations of the study were (1) retrospective design and (2) the panel used tests only for 70 to 87 alleles (of approximately, 900 CF transmembrane conductance regulator genes known). Conclusions: The mean age at intervention in both groups was similar. CP, grade III CP, pseudocysts, and pancreatic strictures were more common among patients who were CF gene positive.

口服别嘌呤醇不能预防ERCP后胰腺炎发生的频率或严重度

Background: Pancreatitis is the most common major complication of ERCP. Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic allopurinol, an inhibitor of oxygen-derived free radical production, would reduce the frequency and severity of post-ERCP pancreatitis. Methods: A total of 701 patients were randomized to receive either allopurinol or placebo 4 hours and 1 hour before ERCP. A database was prospectively collected by a defined protocol on patients who underwent ERCP. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. Results: The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 12.55% . It occurred in 46 of 355 patients in the allopurinol group (12.96% )- and in 42 of 346 patients in the control group (12.14% ; p = 0.52). The pancreatitis was graded mild in 7.89% , moderate in 4.51% , and severe in 0.56% of the allopurinol group, and mild in 6.94% ,moderate in 4.62% , and severe in 0.58% of the control group. There was no significant difference between the groups in the frequency or the severity of pancreatitis. Conclusions: Prophylactic oral allopurinol did not reduce the frequency or the severity of post-ERCP pancreatitis.

接受胰岛素治疗的2型糖尿病患者非黑色素瘤皮肤癌的发生率下降:一项初步研究

Background: In order to prevent the propagation of genetic mutations, human keratinocytes irradiated with ultraviolet (UV) B light in vitro undergo premature stress- induced senescence or apoptosis. This response to UVB irradiation is dependent on the functional activation of the insulin- like growth factor- 1 receptor (IGF- 1R). Based on this in vitro functional data, we hypothesized that the increased serum levels of insulin in patients with type 2 diabetes may activate the IGF- 1R in skin and lead to a decreased frequency of skin cancer in these patients. Objectives: To determine whether the use of insulin by patients with type 2 diabetes correlated with a change in the incidence in nonmelanoma skin cancer (NMSC). Methods: A historical cohort study identifying the incidence of NMSC following the use of two different pharmacological therapies. The patient population was restricted to caucasians who were at least 50 years old when they began the indicated pharmacological therapy. The first group consisted of 1440 patients who used insulin therapy to treat type 2 diabetes and the second group comprised 4135 patients who used cimetidine to treat their gastrointestinal ailments. An additional group of 6131 patients with diabetes who used noninsulin antidiabetics was added to examine the effect of noninsulin therapies. All patients had regular follow- up visits at the Regenstrief Clinics during the study period between 1980 and 1999. The Regenstrief Clinics is an outpatient facility which serves the general population in Metro- Indianapolis, Indiana, U.S.A. Results: The incidence of NMSC in patients using insulin was significantly lower than in patients using cimetidine (1.25% vs. 2.35% , P < 0.2). The decrease in NMSC in patients with type 2 diabetes correlated specifically with the use of insulin (NMSC incidence insulin- only patients with diabetes: 1- 40% vs. those with diabetes using noninsulin therapies: 2- 35% , P=0.11). Conclusions: Patients using exogenous insulin had a lower risk of developing NMSC and the protective effect of insulin use becomes more distinct with increasing age.

成人近段小肠肠套叠:CT表现和临床意义

Background: According to the clinical literature, intestinal intussusception in adults is rare, is associated with a pathologic lead point, and is usually treated surgically. Nonobstructing small bowel intussusception has been reported as a transient finding on computed tomographic (CT) studies. Methods: We evaluated the radiographic and clinical findings in 24 patients who were found to have 26 proximal small bowel intussusceptions on abdominal CT scans performed for a variety of indications. Results: Twenty patients with intussusceptions had no evide nce of small bowel obstruction. The transient and clinically insignificant nature of 22 intussusceptions in these 20 patients was proven radiologically (n=14), surgically (n=1), or by clinical follow up (n=7). These patients demonstrated a bowel within bowel pattern on multiple contiguous images and absence of stran gulation or intestinal dilatation. No lead points were demonstrated in these pat ients. Three other patients had symptoms of low grade small bowel obstruction a nd were treated conservatively. Extensive follow up investigations showed no re currence of intussusception or a lead point. One patient had high grade obstruc tive intussusception with intestinal ischemia and required surgical resection of necrotic bowel. Conclusions: Proximal small bowel intussusceptions are likely t o be transient and nonobstructive and unlikely to have a significant lead point.

An international survey of classification and treatment choices for group D retinoblastoma

AIM： To determine which IIRC scheme was used by retinoblastoma centers worldwide and the percentage of D eyes treated primarily with enucleation versus globe salvaging therapies as well as to correlate trends in treatment choice to IIRC version used and geographic region. METHODS： An anonymized electronic survey was offered to 115 physicians at 39 retinoblastoma centers worldwide asking about IIRC classification schemes and treatment patterns used between 2008 and 2012. Participants were asked to record which version of the IIRC was used for classification, how many group D eyes were diagnosed, and how many eyes were treated with enucleation versus globe salvaging therapies. Averages of eyes per treatment modality were calculated and stratified by both IIRC version and geographic region. Statistical significance was determined by Chi-square, ANOVA and Kruskal-Wallis tests using Prism. RESULTS： The survey was completed by 29% of physicians invited to participate. Totally 1807 D eyes were diagnosed. Regarding IIRC system, 27% of centers used the Children＇s Hospital of Los Angeles （CHLA） version, 33% used the Children＇s Oncology Group （COG） version, 23% used the Philadelphia version, and 17% were unsure. The rate for primary enucleation varied between 0 and 100% and the mean was 29%. By IIRC version, primary enucleation rates were： Philadelphia, 8%; COG, 34%; and CHLA, 37%. By geographic region, primary enucleation rates were： Latin America, 57%; Asia, 40%; Europe, 36%; Africa, 10%, US, 8%; and Middle East, 8%. However, systemic chemoreduction was used more often than enucleation in all regions except Latin America with a mean of 57% per center （P〈0.0001）. CONCLUSION： Worldwide there is no consensus on which IIRC version is used, systemic chemoreduction was the most frequently used initial treatment during the study period followed by enucleation and primary treatment modality, especially enucleation, varied greatly with regards to IIRC version used and geographic region.

Role of early life exposure and environment on neurodegeneration: implications on brain disorders

Neurodegenerative diseases such as Alzheimer’s disease(AD),Parkinson’s disease(PD),Amyotrophic lateral sclerosis(ALS)and retinal degeneration have been studied extensively and varying molecular mechanisms have been proposed for onset of such diseases.Although genetic analysis of these diseases has also been described,yet the mechanisms governing the extent of vulnerability to such diseases remains unresolved.Recent studies have,therefore,focused on the role of environmental exposure in progression of such diseases especially in the context of prenatal and postnatal life,explaining how molecular mechanisms mediate epigenetic changes leading to degenerative diseases.This review summarizes both the animal and human studies describing various environmental stimuli to which an individual or an animal is exposed during in-utero and postnatal period and mechanisms that promote neurodegeneration.The SNPs mediating gene environment interaction are also described.Further,preventive and therapeutic strategies are suggested for effective intervention.