Search

Acute myeloid leukemia (AML) remains a devastating disease in need of new therapies to improve patient survival. Targeted adoptive T-cell therapies have achieved impressive clinical outcomes in some B-cell leukemias and lymphomas but not in AML. Double-negative T cells (DNTs) effectively kill blast cells from the majority of AML patients and are now being tested in clinical trials. However, AML blasts obtained from ∼30% of patients show resistance to DNT-mediated cytotoxicity; the markers or mechanisms underlying this resistance have not been elucidated. Here, we used a targeted clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) screen to identify genes that cause susceptibility of AML cells to DNT therapy. Inactivation of the Spt-Ada-Gcn5-acetyltransferase (SAGA) deubiquitinating complex components sensitized AML cells to DNT-mediated cytotoxicity. In contrast, CD64 inactivation resulted in resistance to DNT-mediated cytotoxicity. Importantly, the level of CD64 expression correlated strongly with the sensitivity of AML cells to DNT treatment. Furthermore, the ectopic expression of CD64 overcame AML resistance to DNTs in vitro and in vivo. Altogether, our data demonstrate the utility of CRISPR/Cas9 screens to uncover mechanisms underlying the sensitivity to DNT therapy and suggest CD64 as a predictive marker for response in AML patients.

Significant improvements in the survival of patients with hematological cancers following hematopoietic stem cell transplantation provide evidence supporting the potency of immune cell-mediated anti-leukemic effects. Studies focusing on immune cell-based cancer therapies have made significant breakthroughs in the last few years. Adoptive cellular therapy (ACT), and chimeric antigen receptor (CAR) T cell therapy, in particular, has significantly increased the survival of patients with B cell acute lymphoblastic leukemia and aggressive B cell lymphoma. Despite antigen-negative relapses and severe toxicities such as cytokine release syndrome after treatment, CAR-T cell therapies have been approved by the FDA in some conditions. Although a number of studies have tried to achieve similar results for acute myeloid leukemia (AML), clinical outcomes have not been as promising. In this review, we summarize recent and ongoing studies on cellular therapies for AML patients, with a focus on antigen-specific versus -nonspecific approaches.

Background Although the demand for esomeprazole is increasing in veterinary medicine, the pharmacokinetics (PK) and pharmacodynamics of esomeprazole have been described in only a few studies. Objective To determine the PK of 0.5 and 1 mg/kg esomeprazole administered IV q12h and to investigate its effects on intragastric pH in healthy dogs. Animals Six adult Beagles. Methods Open-label, randomized, and crossover design. The dogs received 0.5 or 1 mg/kg esomeprazole IV q12h for 48 hours. Plasma concentrations of esomeprazole were measured by high-performance liquid chromatography-tandem mass spectrometry. Intragastric pH was determined using the Bravo pH monitoring system and recorded as mean percentage time (MPT) for which pH was ≥3 and ≥4 for 24 hours in each group. Results The peak plasma concentration and area under the curve from the time of dosing to the last measurable concentration in the 1 mg/kg group were higher than those in the 0.5 mg/kg group. However, when the dosage normalized, intergroup differences were not significant. The MPTs for which intragastric pH was ≥3 and ≥4 for 48 hours were 88% ± 7% and 81% ± 9% for the 0.5 mg/kg group and 90% ± 9% and 85% ± 11% for the 1 mg/kg group, respectively, with no significant intergroup differences. Conclusions and clinical importance The pharmacokinetic parameters and acid suppressant effect for 0.5 and 1 mg/kg esomeprazole were not significantly different. Furthermore, the efficacy of esomeprazole 0.5 mg/kg IV q12h was sufficient to increase intragastric pH in Beagles.

With recent clinical breakthroughs, immunotherapy has become the fourth pillar of cancer treatment. Particularly, immune cell-based therapies have been envisioned as a promising treatment option with curative potential for leukemia patients. Hence, an increasing number of preclinical and clinical studies focus on various approaches of immune cell-based therapy for treatment of acute leukemia (AL). However, the use of different immune cell lineages and subsets against different types of leukemia and patient disease statuses challenge the interpretation of the clinical applicability and outcome of immune cell-based therapies. This review aims to provide an overview on recent approaches using various immune cell-based therapies against acute B-, T-, and myeloid leukemias. Further, the apparent limitations observed and potential approaches to overcome these limitations are discussed.

To compare the surgical outcomes of medial rectus advancement and lateral rectus recession in postoperative consecutive exotropia with single-stage adjustable suture surgery. Among 1003 patients who underwent bilateral medial rectus recession between November 1996 and March 2013, the patients who required surgery for consecutive exotopia were retrospectively reviewed. Nineteen patients underwent medial rectus advancement and 15 patients underwent lateral rectus recession. All patients underwent single-stage adjustable surgery under topical anesthesia and were followed up for at least 12 months. The mean follow-up duration was 2.4 years. At final follow-up, a successful surgical outcome was found in 12 patients (63.0%) in the medial rectus advancement group and 14 patients (93.3%) in the lateral rectus recession group (P = .039). The change in ocular deviation was correlated with the amount of recession (P = .008) and preoperative angle (P

Background As a co-receptor for fibroblast growth factor 23, klotho plays a pivotal role in phosphate metabolism. The kidney is known to be the main source of soluble alpha-klotho and the principal regulator of its concentration. Previous studies in human participants showed that the concentration of soluble alpha-klotho in serum and urine decreased in chronic kidney disease (CKD) patients. However, no previous study has assessed soluble alpha-klotho levels in dogs. This study aimed to measure serum and urinary alpha-klotho levels in CKD dogs and identify their associations with International Renal Interest Society (IRIS) CKD stages and other parameters known to be associated with CKD. Results Serum and urinary alpha klotho concentrations were measured by a commercially available canine-specific sandwich enzyme-linked immunosorbent assay kit and compared between groups by a nonparametric Kruskal–Wallis test. Spearman’s correlation coefficient was used to evaluate the relationships between variables. A stepwise multiple regression analysis was performed to estimate the effects of independent predictors on klotho concentrations. The urine klotho-to-creatinine ratio (UrKl/Cr) was significantly lower in stage 3 dogs than the control group and was significantly lower in dogs with stage 3 and 4 CKD than in those with stage 1 and 2 disease. UrKl/Cr was negatively correlated with serum symmetric dimethylarginine (sSDMA), blood urea nitrogen (BUN), creatinine, and phosphorus concentration. Serum alpha-klotho concentration in dogs with stages 2 and 3 CKD was significantly lower than those in the control group. There was no significant correlation between serum alpha-klotho and BUN, creatinine, and phosphorus concentrations. No statistically significant differences were observed in UrKl/Cr and serum alpha-klotho concentration between groups based on sex, age, urine protein-to-creatinine ratio (UPC), or blood pressure. Conclusions UrKl/Cr decreased in dogs with advanced CKD, and it was negatively correlated with sSDMA, BUN, creatinine, and phosphorus concentrations. Thus, klotho is associated with CKD and its clinical consequences, including CKD-mineral bone disorder, in dogs. Although serum klotho concentration was negatively correlated with sSDMA levels, it was not apparently related to IRIS CKD stage or other parameters known to be associated with CKD.

Purpose: To analyze the efficacy and safety of standard-dose antimuscarinic treatment on male patients with overactive bladder (OAB) symptoms showing poor efficacy after low-dose antimuscarinics. Materials and Methods: We retrospectively reviewed the data of 566 male patients aged ≥40 with OAB symptoms between January 2017 and June 2018. They were treated with low-dose antimuscarinics for at least 4 weeks and showed poor efficacy; therefore, they were switched to standard dose antimuscarinic treatment (5 mg of solifenacin) for ≥12 weeks. The international prostate symptom score (IPSS) and overactive bladder symptom score (OABSS) at baseline (V0), 4 weeks (V1), and 12 weeks (V2) were analyzed. Post void residual urine volume (PVR) was also recorded. Results: The median age, body mass index, and prostate-specific antigen levels were 69.0 years, 24.2 kg/m2, and 1.24 ng/dL, respectively. The mean value of the total IPSS and OABSS significantly decreased between V0 and V2 (from 16.73 to 13.69 and 7.33 to 5.34, respectively, all p

Summary Despite the demonstration of potent immunosuppressive function of T cell receptor (TCR)-αβ+ double-negative regulatory T cells (DN Tregs), scarce numbers and lack of effective expansion method limit their clinical applications. Here we describe an approach that allows for ∼3500-fold ex-vivo expansion of human DN Tregs within 3 weeks with > 97% purity. Ex-vivo-expanded DN Tregs suppress proliferation of polyclonally stimulated autologous T and B cells in vitro through direct cell-to-cell contact. In vivo, we demonstrate for the first time that infusion of human DN Tregs delayed an onset of xenogeneic graft-versus-host disease (GVHD) significantly in a humanized mouse model. Furthermore, preincubation of ex-vivo-expanded DN Tregs with a mechanistic target of rapamycin (mTOR) inhibitor rapamycin enhanced their immune regulatory function further. Taken together, this study demonstrates that human DN Tregs can be expanded ex vivo to therapeutic numbers. The expanded DN Tregs can suppress proliferation of T and B cells and attenuate GVHD, highlighting the potential clinical use of DN Tregs to mitigate GVHD.

Purpose: To explore the potential of ex vivo expanded healthy donor–derived allogeneic CD4 and CD8 double-negative cells (DNT) as a novel cellular immunotherapy for leukemia patients. Experimental Design: Clinical-grade DNTs from peripheral blood of healthy donors were expanded and their antileukemic activity and safety were examined using flow cytometry–based in vitro killing assays and xenograft models against AML patient blasts and healthy donor–derived hematopoietic cells. Mechanism of action was investigated using antibody-mediated blocking assays and recombinant protein treatment assays. Results: Expanded DNTs from healthy donors target a majority (36/46) of primary AML cells, including 9 chemotherapy-resistant patient samples in vitro, and significantly reduce the leukemia load in patient-derived xenograft models in a DNT donor–unrestricted manner. Importantly, allogeneic DNTs do not attack normal hematopoietic cells or affect hematopoietic stem/progenitor cell engraftment and differentiation, or cause xenogeneic GVHD in recipients. Mechanistically, DNTs express high levels of NKG2D and DNAM-1 that bind to cognate ligands preferentially expressed on AML cells. Upon recognition of AML cells, DNTs rapidly release IFNγ, which further increases NKG2D and DNAM-1 ligands’ expression on AML cells. IFNγ pretreatment enhances the susceptibility of AML cells to DNT-mediated cytotoxicity, including primary AML samples that are otherwise resistant to DNTs, and the effect of IFNγ treatment is abrogated by NKG2D and DNAM-1–blocking antibodies. Conclusions: This study supports healthy donor–derived allogeneic DNTs as a therapy to treat patients with chemotherapy-resistant AML and also reveals interrelated roles of NKG2D, DNAM-1, and IFNγ in selective targeting of AML by DNTs. Clin Cancer Res; 24(2); 370–82. ©2017 AACR.

Simple Summary Persistence of infused cells is an important factor that dictates the outcome of adoptive cellular therapy (ACT). DNT therapy is a novel form of ACT with promising result in treating relapsed or refractory AML in preclinical and early clinical studies. However, in vivo kinetics of human DNTs in cancer-bearing host have not been previously investigated. This study was the first to investigate the persistence of DNTs and ways to improve it in patient-derived xenograft models. DNTs persistence was observed up to 50 days in various organs of leukemia-bearing hosts. However, the detected DNT level was low while significant level of persisting AMLs was observed. To improve the in vivo persistence and therapeutic efficacy of DNTs, we expanded DNTs in the presence of an PI3Kδ inhibitor, idelalisib (Ide). Ide treatment of healthy donor-derived DNTs promoted early memory subsets and improved overall fitness, reducing exhaustion while improving viability. These Ide-induced attributes led to prolonged persistence of DNTs, resulting in superior anti-leukemic activity in vivo. Further, Ide-treated DNTs improved the durability of the treatment response. Collectively, our study highlights the importance of DNT persistence and Ide-mediated improvements in the overall fitness of DNTs, which promote longer persistence in vivo and better treatment outcome. Abstract The double negative T cell (DNT) is a unique subset of T cells with potent anti-leukemic potential. Previously, DNT therapy has been shown to effectively target AML cells in patient-derived xenograft (PDX) models. Further, a recently completed phase I/IIa clinical study demonstrated the safety, feasibility, and potential efficacy in AML patients that relapsed after allogeneic hematopoietic stem cell transplantation. However, the persistence and durability of DNT-mediated anti-leukemic response is less well understood. In this study, we characterized the in vivo persistence of DNTs in PDX models. Further, we improved the efficacy and durability of DNT-mediated activity with phosphoinositide 3-kinase delta (PI3Kδ) inhibition. Mechanistically, DNTs treated with the PI3Kδ inhibitor, Idelalisib (Ide), exhibited early memory phenotype with superior viability and proliferative capacity but less cell exhaustion. Collectively, the findings from this study support the use of Ide-treated DNTs to improve its therapeutic outcome.

To compare segmented retinal layer thicknesses between patients with idiopathic infantile nystagmus (IIN) and controls. This retrospective case-control study included 66 patients with IIN and 66 age-matched controls. The retinal layers were examined using spectral domain optical coherence tomography with autosegmentation. Central foveal thickness (CFT), outer nuclear layer (ONL), and outer segment length (OSL) thickness were measured at the fovea center. Mean values for retinal nerve fiber layer, ganglion cell inner plexiform layer (GCIPL), inner nuclear layer, outer plexiform-outer nuclear layer (OPNL) thicknesses were calculated at two measurement points (nasal and temporal hump points at the macula area). There were no significant between-group differences in age, gender, or refraction error. The CFT was thicker in the IIN group compared with the control group (225.0 μm vs. 217.8 μm, P = 0.017) and OSL was shorter in IIN than in controls (40.0 μm vs. 43.7 μm., P

Background Though immune checkpoint blockade (ICB) against PD-1 has shown success in the treatment of lung cancer, not all patients respond. We have previously shown that adoptive transfer of double negative T (DNT) cells expanded from healthy donors can target leukemia but their role in treating established lung cancer is not clear. Here we explore the role of human DNT cells in targeting late-stage established lung cancer either alone or in combination with Nivolumab (anti-PD-1 antibody) and describe underlying mechanisms. Methods DNT cells from resected lung cancer tissue of patients were analyzed by flow cytometry to determine their infiltration and PD-1 expression. Expansion capacity and anti-tumor function of lung cancer patient and healthy donor DNT cells were compared. Late-stage lung cancer xenograft models were developed to determine the anti-tumor effect of DNT cells alone or in combination with anti-PD-1 antibody, and the level of tumor-infiltrating DNT cells was quantified by histology and characterized by flow cytometry. Results Patient-derived tumor infiltrating lymphocytes contained a lower frequency of DNT cells with a higher expression of PD-1 relative to normal lung tissue. Ex vivo expanded patient- and healthy donor-derived DNT cells showed similar levels of cytotoxicity against lung cancer cells in vitro. Healthy donor-derived DNT cells significantly inhibited the growth of late-stage lung cancer xenografts, which was further augmented by anti-PD-1 through increased DNT cell tumor infiltration. Conclusion This study supports the use of DNT cells for adoptive cellular therapy against lung cancer either alone or in combination with anti-PD-1. Electronic supplementary material The online version of this article (10.1186/s13046-019-1126-y) contains supplementary material, which is available to authorized users.

A 13-year-old castrated male mixed breed dog and a 12-year-old castrated male mixed breed cat were referred to the hospital for the treatment of pulmonary edema and azotemia at the same time. To resolve the pulmonary edema and azotemia, intermittent hemodialysis (HD) was performed using ultrafiltration (UF), and the pulmonary edema, azotemia, other electrolyte and acid-base imbalances were improved. This case study demonstrated that when we encountered pulmonary edema patients with diuretic resistance, severe electrolyte imbalance, and impaired renal function complicated by decongestive therapy using diuretics, UF therapy can be considered a life-saving intervention.

Background While conventional chemotherapy is effective at eliminating the bulk of leukemic cells, chemotherapy resistance in acute myeloid leukemia (AML) is a prevalent problem that hinders conventional therapies and contributes to disease relapse, and ultimately patient death. We have recently shown that allogeneic double negative T cells (DNTs) are able to target the majority of primary AML blasts in vitro and in patient-derived xenograft models. However, some primary AML blast samples are resistant to DNT cell therapy. Given the differences in the modes of action of DNTs and chemotherapy, we hypothesize that DNT therapy can be used in combination with conventional chemotherapy to further improve their anti-leukemic effects and to target chemotherapy-resistant disease. Methods Drug titration assays and flow-based cytotoxicity assays using ex vivo expanded allogeneic DNTs were performed on multiple AML cell lines to identify therapy-resistance. Primary AML samples were also tested to validate our in vitro findings. Further, a xenograft model was employed to demonstrate the feasibility of combining conventional chemotherapy and adoptive DNT therapy to target therapy-resistant AML. Lastly, blocking assays with neutralizing antibodies were employed to determine the mechanism by which chemotherapy increases the susceptibility of AML to DNT-mediated cytotoxicity. Results Here, we demonstrate that KG1a, a stem-like AML cell line that is resistant to DNTs and chemotherapy, and chemotherapy-resistant primary AML samples both became more susceptible to DNT-mediated cytotoxicity in vitro following pre-treatment with daunorubicin. Moreover, chemotherapy treatment followed by adoptive DNT cell therapy significantly decreased bone marrow engraftment of KG1a in a xenograft model. Mechanistically, daunorubicin increased the expression of NKG2D and DNAM-1 ligands on KG1a; blocking of these pathways attenuated DNT-mediated cytotoxicity. Conclusions Our results demonstrate the feasibility and benefit of using DNTs as an immunotherapy after the administration of conventional chemotherapy. Electronic supplementary material The online version of this article (10.1186/s13046-018-0756-9) contains supplementary material, which is available to authorized users.

The purpose of this case report was to present the treatment of continuous renal replacement therapy (CRRT) in dogs with end-stage CKD with uncontrolled uremia. Hemodialysis were carried out 6 patients who failed to improve clinical status with conventional management for CKD. Four dogs with urea reduction ratio (URR) range of 57-72% and 1 dog with URR of 37.3% showed good outcome with decreasing tendency of pre-dialysis Therefore, we suggest that CRRT could be recommended for use in CKD dogs with uncontrolled azotemia or uremia and should be monitor carefully throughout the CRRT.

Bacillus cereus contamination is a major food safety problem for Korean fermented soybean products, but few studies have assessed its potential to cause foodborne illness. The objectives of this study were to investigate the prevalence and characteristics of B. cereus isolated from Korean fermented soybean products. B. cereus was detected in 110 of 162 (67.9%) samples. The highest B. cereus frequency was observed in deonjang (68 of 93 samples, 73.1%) and cheonggukjang (18 of 25, 72.0%); however, nonhemolytic enterotoxin was detected only in 22 of 162 samples (13.6%). Although the tested B. cereus isolates showed diverse pulsotypes according to repetitive sequence-PCR banding patterns, they displayed similar antibiotic sensitivity spectra. The low frequency of enterotoxin detection suggests that the potential risk of B. cereus foodborne illness associated with Korean fermented soybean products is lower than generally presumed. However, considering the prevalence of B. cereus and the high content of fermented soybean products in the Korean diet, it is necessary to constantly monitor the level of contamination with B. cereus and its toxins in such Korean food products.

Aims To compare the surgical outcomes of exotropia patients with cerebral palsy (CP) and controls without CP. Methods 30 patients with exotropia and CP and 60 age-matched controls without CP who underwent bilateral lateral rectus (BLR) recession were retrospectively enrolled. All patients underwent BLR recession according to Parks’ method. Surgical success was defined by esotropia deviation ≤5 PD (prism diopters) and exotropia deviation ≤10 PD. Success rate, cumulative probabilities of success, and postoperative change of angle deviations using a linear mixed model were evaluated. Results Mean postoperative follow-up times were 21.60±8.62 months for the CP group and 25.60±10.82 months for the control group (p=0.081). Mean preoperative deviation was 30.97±10.54 PD in the CP group and 29.75±7.52 PD in the control group (p=0.530), which was reduced to 4.44±7.13 PD and 7.43±7.59 PD, respectively (p=0.093) after BLR recession. Using linear mixed model analysis, the estimated mean postoperative deviation of both groups was in the success range at all times tested. At the final visit, successful surgical outcomes were achieved in 76.7% of the CP group and 56.7% of the control group (p=0.179). Differences in the cumulative probability of surgical success were not statistically significant between the two groups (p=0.106, log rank test). Conclusions CP patients with exotropia showed successful ocular alignment comparable to that of controls after BLR recession of at least 2 years.

To describe the ophthalmological manifestations in patients with childhood onset Leigh syndrome (LS) and investigate the correlation between genotypes and phenotypes in patients with LS.Childhood onset LS was clinically and enzymatically confirmed in a total of 63 patients. Among them, 44 patients who underwent ophthalmologic consultation were included in this study. Patients with LS underwent genotyping for the whole genome of mitochondrial DNA and SURF1 mutations. The clinical demographic and ophthalmologic phenotypes were compared between the good prognosis group and the poor prognosis group.Strabismus (40.9%) was the most frequently observed ophthalmologic manifestation, followed by pigmentary retinopathy (22.5%), optic atrophy (22.5%), ptosis (15.9%), and nystagmus (13.6%). Thirteen patients were exotropes and five patients were esotropes. The mean exodeviation was 29.6±12.5 prism dioptres (PD) and the mean esodeviation was 24.0±8.9 PD. All patients with esotropia reported disease onset at1 year old. Among 26 patients older than 4 years, eight (30.8%) patients had better than 0.4 in the best eye was noted. Eyelid ptosis was a main presenting sign in four patients (9.1%). Among these patients, two patients had m.13513GA mutation in the MT-ND5 gene. Age at onset was 2.47±2.06 years in the good prognosis group and 0.92±0.98 years in the poor prognosis group (p=0.002). Serum lactate peak concentration was 3.23±1.36 mmol/L in the good prognosis group and 4.54±2.31 mmol/L in the poor prognosis group (p=0.051).LS is a group of mitochondrial disorders with variable ophthalmologic manifestations, the most frequent being strabismus in this study. Ptosis could be an initial sign in patients with LS and these patients can be easily misdiagnosed as having juvenile myasthenia gravis.

To evaluate the impact of myopic keratorefractive surgery on ocular alignment. This prospective study included 194 eyes of 97 myopic patients undergoing laser refractive surgery. All patients received a complete ophthalmic examination with particular attention to ocular alignment before and 3 months after surgery. Patients with a mean age of 26.6 years and a mean refractive error of −4.83 diopters (D) myopia were treated. Asymptomatic ocular misalignment was present preoperatively in 46 (47%) patients: a small-angle heterophoria (1–8 prism diopters, PD) in 36%; and a large-angle heterophoria (>8 PD)/heterotropia in 11%. Postoperatively, the change in angles of 10 PD or greater occurred in 3% for distance and 6% for near fixation: in 7% of the patients with orthophoria, in 3% of those with a small-angle heterophoria, and in 18% of those with a large-angle heterophoria/heterotropia. No patient developed diplopia. The preoperative magnitude of myopia or postoperative refractive status was not related to the change in ocular alignment. The higher anisometropia was associated with a decrease in deviation (P=0.041 for distance and P=0.002 for near fixation), whereas the further near point of convergence tended to be related with an increase in near deviation (P=0.055). Myopic refractive surgery may cause a change in ocular alignment, especially in cases with a large-angle heterophoria/heterotropia. There is also a chance of improvement of misalignment in patients with anisometropia.

The safety of fake anti-impotence drugs (fake Viagra : 26 samples, fake Cialis : 25 samples) dis- tributed in Gyeonggi province was studied by monitoring the concentrations of anti-impotence pharmaceutical ingre- dient and their analogues. The concentrations of anti-impotence pharmaceutical ingredient 4 specis and their analogues 17 specis were estimated using by HPLC/PDA, LC-MS/MS. The range of concentration of sildenafil in fake viagra was 40~199 mg/tablet, among them the portion of the concentrations of sildenafil over 150 mg/tablet exceeded 65%. 3 cases in tested samples contained sildenafil and tadalafil. The range of concentration of sildenafil in fake cialis was 102~249 mg/tablet, among them the portion of the concentrations of sildenafil over 150 mg/tablet exceeded 88%. One case in tested samples contained demethylhongdenafil (90 mg/tablet). These results indicate that there were many fake anti-impotence drug contained high level of anti-impotence pharmaceutical ingredients, a sus- tainable monitoring and the blocked distribution of fake anti-impotence drugs recommended.

Many studies have reported comparable risk of hard end points between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) stenosis. However, there are limited data regarding the morbidity associated with ULMCA revascularization. This study sought to compare the cause and risk of readmissions after PCI and CABG for ULMCA stenosis. We evaluated the unadjusted and adjusted risk of readmissions in 1,352 patients (783 PCI treated and 569 CABG treated) who were consecutively enrolled in a multicenter registry of patients with ULMCA stenosis, named the Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease trial. Overall, 206 PCI-treated patients (26.3%) experienced at least 1 readmission after the index procedure during 48.7 ± 16.0 months of follow-up compared with 84 CABG-treated patients (14.8%, p

This study was conducted to evaluate the microbiological hazard on nursery school children's hands and to investigate the reduction effect of hand washing education. A total of 59 nursery school children's hands were tested. The average number of total aerobic bacteria was 3.72 ± 0.38 log CFU/hand. Five children's hands(2 male and 3 female) were positive(14.3%) for the coliform bacteria. These results showed that hand washing education are required repetitively. Among the pathogenic bacteria tested in this study, Staphylococcus aureus and Bacillus cereus were detected in 9(25.7%) and 16(45.7%) out of 35 their hands, respectively. Twelve out of sixteen B. cereus isolates(70.0%) produced enterotoxin. The results indicate that the hand hygiene of nursery school children needs to be improved. Comparing before and after hand washing in educated and non-educated group, the reduction effect of total aerobic bacteria on their hands was 0.42 and 0.60 log CFU/hand, respectively. The educated group showed 0.18 log CFU/hand higher reduction effect than non-educated group but microorganism did not eliminate perfectly. From the results, using a hand sanitizer after washing with soap and the continuous hand washing education are required to control the contaminated bacteria on nursery school children's hands.

Purpose To raise awareness among clinicians about the risk of severe complications after cosmetic conjunctivectomy plus postsurgical topical mitomycin C (MMC) treatment. Methods We retrospectively reviewed the medical records of 48 consecutive patients who received cosmetic wide conjunctivectomy plus postsurgical topical MMC treatment to eliminate conjunctival injection and visited our outpatient clinic between January 2009 and January 2011. Results Forty-four patients (91.67%) developed complications after cosmetic wide conjunctivectomy plus postsurgical topical MMC treatment. Complications included chronic conjunctival epithelial defects (22 patients), scleral thinning with (19 patients) or without (2 patients) calcified plaques, fibrovascular conjunctival adhesion at the muscle insertion site (15 patients), chronic dysfunctional tear syndrome (11 patients), avascular zones (10 patients), abnormal vessel growth (5 patients), lymphangiectasis (3 patients), adhesions of Tenon capsule and the conjunctiva at the extraocular muscle insertion site (1 patient), extraocular muscle fiber exposure (1 patient), and diplopia (9 patients). The mean time between surgery and the onset of diplopia was 1.67 months (range, 1-3 months), and the mean deviation was 11.0 prism diopters (range, 0-25 prism diopters) in the primary position. Three patients underwent strabismus surgery due to incomitant esotropia. Eight patients underwent calcified plaque removal because of severe progression of the calcification. Five patients underwent conjunctival flap operation because of severe progressive scleral thinning. Conclusions Cosmetic wide conjunctivectomy, which has been advertised as a simple and effective surgical option for the treatment of conjunctival injection, has caused disruption in the normal physiology of the ocular surface, which leads to various devastating complications.

Purpose: To determine whether changes in ocular alignment following general anesthesia, as measured by interpupillary distance, can be used as a predictor for surgical outcomes in children with intermittent exotropia. Methods: The authors obtained digital photographs of 40 children with exotropia and 20 children with epiblepharon (control group) before and immediately after induction of general anesthesia in the primary supine position. Differences in the anatomic interpupillary distance (aIPD) for each patient were measured and compared with the preoperative angles of deviation. They were also correlated with surgical outcomes on the first day and 1 year after surgery. Results: All 60 patients demonstrated an increase in aIPD following general anesthesia. The mean change in aIPD in patients with exotropia was similar to that in patients with epiblepharon (3.78% ± 2.53% and 3.15% ± 1.05%, respectively). In patients with exotropia, there was a significant positive linear correlation between the preoperative distance deviation (P) and the change in eye position (A): A = 0.362 P – 4.488, r 2 = 0.476 ( P < .001). Five (71%) of seven patients whose changes were outside the 80% confidence interval for expected values had poor surgical outcomes on the first postoperative day and four had unsatisfactory results 1 year after surgery. Conclusions: Changes in aIPD following general anesthesia were strongly correlated with preoperative angle of deviation. Therefore, they may be a useful predictor of surgical outcomes in children with exotropia.

Nonrefractive accommodative esotropia is a condition that is diagnosed when an emmetropically corrected patient with a high accommodative convergence to accommodation (AC/A) ratio shows orthotropia at distance fixation but displays more than 10 prism diopters of esotropia at near fixation which can be corrected with a +3.00 diopter add lens. The AC/A ratio is the amount of induced convergence that occurs when accommodation is exerted. In normal eyes, the ratio is thought to remain stable without change until presbyopia, after which the AC/A ratio increases [1-3]. However, the change of the AC/A ratio with age in nonrefractive accommodative esotropia has not yet been studied. Nonrefractive accommodative esotropia can be treated with bifocal lenses or miotics [4-9]. Miotics pharmacologically decrease accommodative convergence and correct esotropia at near fixation. Long term effects of miotics have been studied in detail and reports of iris cysts, cataracts, retinal detachment, iridocyclitis and punctal occlusion are abundant in the literature and thus are used only for diagnostic purposes or for short term correction. Bifocal lenses horizontally divide the visual field with a +2.50 - +3.00 diopters add lens in the lower portion and uses the upper and lower portions for distance and near fixation, respectively. Bifocal glasses induce orthotropia for both far and near vision and decrease chances of amblyopia with appropriate development of stereopsis. As patients grow older, some can discontinue the use of bifocal lenses due to spontaneous normalization of the AC/A ratio [10], but others need to keep their bifocal lenses or undergo strabismus surgery in an attempt to eliminate the need for bifocals [11-13]. Surgical options include augmented recession, slanted recession, and recession with posterior fixation suture of the medial rectus muscles [12,14,15]. The AC/A ratio can be calculated in several ways, among which only the lens gradient method gives a true estimate of the ratio. In the lens gradient method, the change in stimulus to accommodation is produced by means of an ophthalmic lens, not a change in viewing distance. Franceschetti and Burian [16] reported that the normal range of the AC/A ratio by the lens gradient method is lower than that by the heterophoria method. The heterophoria method does not account for proximal convergence, which is kept constant in the lens gradient method by performing both measurements at the same distance [17]. Previous studies did not evaluate the AC/A ratio by the lens gradient method, but by heterophoria methods [9,18]. However, in this study we computed the AC/A ratio by the lens gradient method.

Purpose: To evaluate changes in the angle of deviation after spectacle correction in patients who had hyperopia and intermittent exotropia (X(T)) and to determine whether the changes and surgical outcomes differ when compared with those of myopic and emmetropic X(T). Methods: One hundred fourteen patients with X(T) were recruited and allocated into three groups: X(T) with hyperopia (group I; 38 patients), X(T) with emmetropia (group II; 35 patients), and X(T) with myopia (group III; 41 patients). After at least 6 months wearing spectacles, changes in exodeviation were compared. The results of surgery based on the spectacle-corrected distance angle and the ratios of accommodative convergence over accommodation (AC/A) were also assessed. Results: With spectacle correction, the mean exodeviation increased significantly in group I, but did not change in groups II or III. Thirteen patients in group I (34%) showed a more than 10 prism diopters (PD) exotropic shift after wearing spectacles. The mean AC/A ratio in group I was 2.63 (PD/D), whereas in groups II and III the ratios were 4.03 and 4.06, respectively. There was no difference in surgical results among the three groups. Conclusion: Although hyperopic correction in patients with X(T) resulted in a limited increase in exodeviation with a subnormal AC/A ratio, one-third of the patients experienced a significant increase in exodeviation. A spectacle correction trial should be considered before surgery in patients with hyperopia and X(T).

Purpose: To analyze the practical aspects and advantages of one-stage adjustable surgery under topical anesthesia in concomitant horizontal strabismus. Methods: A retrospective review of 363 patients was completed to assess (1) the frequency of need to perform adjustment, (2) the amount and pattern of adjustment, and (3) the final alignment at least 6 months after surgery. Intraoperative adjustment was performed strictly toward the aim of orthophoria or slight overcorrection (heterophoria < 6 prism diopters [PD]) while avoiding diplopia. Results: Of the 363 patients, 261 (72%) required intraoperative adjustment. Of these, 85% of exotropes underwent a decreased amount of surgery compared with the standard amount, whereas 58% of esotropes underwent an increased amount of surgery. Forty-two patients underwent a one-muscle surgery instead of the scheduled two-muscle surgery, and all had less than 35 PD preoperative angle of deviation. Success rates were 83% in all patients with one-stage adjustable sutures and 87% in patients who underwent adjustment. In 42 patients with one-muscle surgery instead of two-muscle surgery, 32 (76%) obtained successful results. Conclusion: Intraoperative adjustment was effective in concomitant horizontal strabismus surgery and can provide the opportunity to avoid a large overcorrection, especially in cases with moderate angle horizontal muscle surgery.

Purpose To investigate surgical management of patients with long-standing antielevation syndrome following unilateral anterior transposition of inferior oblique muscle. Methods We present a series of 3 consecutive patients with significant hypotropia several years after unilateral anterior transposition surgery. An approach combining denervation-extirpation of the inferior oblique muscle and subsequent inferior rectus muscle recession and contralateral superior rectus muscle recession was used to manage all 3 patients. Results Denervation-extirpation surgery alone or with ipsilateral inferior rectus muscle recession were not enough to improve vertical misalignment in these patients. All 3 patients achieved successful results after denervation-extirpation surgery, ipsilateral inferior rectus muscle recession, and contralateral superior rectus muscle recession. Conclusions In this case series, devervation-extirpation surgery on the inferior oblique muscle, ipsilateral inferior rectus recession, and contralateral superior rectus recession improved vertical misalignment in patients with long-standing antielevation syndrome after unilateral anterior transposition of the inferior oblique.

To determine the efficacy of preoperative intravenous ketorolac in reducing intraoperative and postoperative pain and improving patient satisfaction in patients undergoing single-stage adjustable strabismus surgery.A prospective, randomized, placebo-controlled clinical trial was performed with 67 patients who underwent horizontal recti muscle surgery with adjustable sutures. The test group received intravenous ketorolac (60 mg) before surgery, and the control group received intravenous normal saline. Topical 0.5% proparacaine was administered to both groups during surgery. Vital signs including heart rate and blood pressure were recorded every 10 min throughout the surgery. The patients were asked to rate their maximum intraoperative and postoperative pain scores using a numerical pain rating scale. Patient satisfaction was also assessed using a five-point analogue scale.The ketorolac-premedicated patients had less pain both during and after surgery (P = 0.033 and P = 0.024, respectively). There were no differences in vital signs during surgery and patient satisfaction between the two groups.Intravenous ketorolac, when administered preoperatively for single-stage adjustable strabismus surgery under topical anaesthesia, was effective in reducing pain during and after surgery.

The aim of this study was to examine the effect of a brisk walking intervention for 8weeks on isokinetic muscular function factor(strength, power, endurance). The following results were found from the current study: First, Isokinetic muscle function(strength, power, endurance) on in extension and flexion was significant exercise group and interaction in left knee flexion and right knee extension(P in extension and flexion was significant exercise group and interaction in left knee flexion and right knee extension(P in extension and flexion was significant exercise group and interaction in left knee flexion and right knee extension(P

Background Acute gastroenteritis caused by viruses is one of the leading causes of childhood morbidity. Objective The incidence and etiology of virus-associated gastroenteritis during 2001–2005 in Gyeonggi province, South Korea was determined. Study design A total of 10,028 stool specimens were analyzed with enzyme immunoassay, reverse transcription-polymerase chain reaction, and nucleotide sequencing. Phylogenetic analysis of genotype sequences was performed for each of four commonly detected viral pathogens. Results At least one viral agent was detected in 29.0% (2908 of 10,028) of the stool samples. Among these, rotavirus was most numerous (66.7%) followed by norovirus (12.6%), astrovirus (11.9%), and enteric adenovirus (2.6%). Mixed infections were identified in 180 cases (1.8%). Patients aged 1–5 years had the largest proportion 83.6% (2430 of 2908) of virus-positive stool specimens. Viral-mediated gastroenteritis was most common from December to May. The most prevalent strains of rotavirus, adenovirus, astrovirus, and norovirus were G1 type, type 41, G1 type, and GII-1 type, respectively. Conclusions Our finding showed the diversity of viral causative agents of gastroenteritis and the prevalence of each gastroenteritis-associated viral genotype in South Korea.

PURPOSE This study was conducted to investigate the role of the pattern visual evoked potential (pVEP) as a predictor of occlusion therapy for patients with strabismic, anisometropic, and isometropic amblyopia. The secondary aim was to compare the characteristics of pVEP between strabismic and anisometropic amblyopia. METHODS This retrospective comparative case series included 120 patients who had received occlusion therapy or a glasses prescription for correction of strabismic, anisometropic, and isometropic amblyopia (20 patients had strabismic amblyopia, 41 patients had anisometropic amblyopia, and 59 patients had isometropic amblyopia). For each patient, the value of the P100 latency on pVEP at the time of the initial diagnosis of amblyopia was collected. Subsequently, the P100 latency was compared according to types of amblyopia. Fifty of 120 patients (7 patients with strabismic amblyopia, 21 patients with anisometropic amblyopia, and 22 patients with isometropic amblyopia) who were followed-up for longer than 6 months were divided into two groups based on the value of their P100 latency (Group 1, P100 latency 120 msec or less; Group 2, P100 latency longer than 120 msec.) The amount of visual improvement after occlusion therapy or glasses was compared between two study groups. RESULTS The mean P100 latency was 119.7+/-25.2 msec in eyes with strabismic amblyopia and 111.9+/-17.8 msec in eyes with non-strabismic (anisometropic or isometropic) amblyopia (p=0.213). In Group 1, the mean visual improvement after occlusion therapy or glasses was 3.69+/-2.14 lines on Dr. Hahn's standard test chart; in Group 2, the mean improvement was 2.27+/-2.21 lines (p=0.023). CONCLUSIONS The P100 latency on pVEP at the time of initial diagnosis was significantly related to the visual improvement after occlusion therapy or glasses in patients with strabismic, anisometropic, and isometropic amblyopia. Therefore, it was presumed that patients with a delayed P100 latency might have less visual improvement after occlusion therapy or glasses. In addition, there was no apparent difference in P100 latency between patients with strabismic and non-strabismic (anisometropic or isometropic) amblyopia.

To evaluate the risk factors in development of postoperative exotropia following bilateral medial rectus (BMR) recession for esotropia. 108 patients who underwent BMR recession for esotropia between November 1996 and July 2010 were enrolled. 54 patients who required surgery for consecutive exotropia were compared to 54 controls whose angle of deviation showed less than five prism diopters of esotropia at all periods after BMR recession. Amblyopia, dissociated vertical deviation (DVD), refractive error, inferior oblique overaction, and multiple surgery history were evaluated as risk factors for the development of consecutive exotropia. The postoperative changes of angle of deviation were calculated. Amblyopia was found in 27 patients (50.5 %) in the exotropia group, and in six patients (11.1 %) in the control group (P

The aim of the study was to evaluate longitudinal analysis of peripapillary retinal nerve fiber layer (RNFL) and perifoveal ganglion cell–inner plexiform layer (GCIPL) thickness in patients being treated with ethambutol (EMB). This prospective longitudinal cohort study enrolled 37 patients who were treated with EMB for pulmonary tuberculosis. Best-corrected visual acuity, color vision test, automated perimetry, fundus photography, and RNFL and GCIPL thickness were measured at baseline and at 4 and 6 months after the start of EMB treatment, using Cirrus optical coherence tomography. Among 37 patients, EMB-induced optic neuropathy occurred in one patient (2.7 %). In this patient, thickening of the RFNL and thinning of the GCIPL were noted at the onset of symptoms. After discontinuation of EMB, RNFL and GCIPL thickness progressively normalized. Changes in RNFL and GCIPL thickness were not statistically significant in the 36 patients who did not exhibit EMB-induced optic neuropathy-related symptoms during follow-up (all P values > 0.05). Thickening of the peripapillary RNFL and thinning of the perifoveal GCIPL is an effective quantitative and early marker for diagnosis of EMB-induced optic neuropathy.

The ocular and systemic abnormalities of nonsyndromic craniosynostosis are often considered to be less severe than those of syndromic craniosynostosis and are less well described. The purpose of this article was to describe the frequency and nature of ophthalmic abnormalities in children treated for nonsyndromic craniosynostosis by expansion cranioplasty. A retrospective review identified 88 consecutive children with nonsyndromic craniosynostosis who underwent expansion cranioplasty with distraction osteogenesis. Assessment of presence and type of strabismus, refractive error, and amblyopia before and 6 months after surgery was recorded. Children with a mean age of 24.4 months were treated for nonsyndromic craniosynostosis (27 with coronal and 61 with sagittal and/or lambdoid). One-fourth of the patients had a fixation preference. Significant refractive errors were found in 45 (51%) of the 88 patients: hyperopia in 27%, myopia in 5%, and astigmatism in 35%. Anisometropia was present in 20%. Of the 85 patients who completed orthoptic examination, 48 (56%) had strabismus: exodeviation in 26%, esodeviation in 14%, and vertical deviation in 5%. Fourteen patients (16%) had abnormal head posture. Significant refractive error and strabismus were more likely to occur in cases with coronal synostosis. The procedures used for cranial vault expansion improved the abnormal head posture but did not affect the refractive error or ocular misalignment. Of children with nonsyndromic craniosynostosis who need neurosurgical correction, more than half were found to have significant refractive error and strabismus. Our findings support the importance of ophthalmic evaluation in these children.

It is known that binocular function is affected by interocular differences in retinal image size, shape, clarity, and illumination. The present study was performed to systematically examine the effects of interocular differences in retinal illuminance on monocular visual acuity, fusion, and stereopsis.Fifty adults with normal binocularity and a best-corrected visual acuity of 20/20 or better were enrolled. We examined best-corrected visual acuity, fusion, and stereoacuity as monocular retinal illuminance was gradually reduced by increasing neutral density filters from 0.2 neutral density (ND; 63% transmission) to 3.0 ND (0.1% transmission) in increments of 0.2 ND. We measured the smallest size of fusion slide by major amblyoscope, and evaluated stereoacuity with the Titmus test and the Lang test.The best-corrected visual acuity began to decrease significantly when the value of the neutral density filter reached 2.0 ND (1% transmission; p0.01). The level of fusion decreased significantly when monocular retinal illuminance was reduced to 2.0 ND (p0.01). Stereoacuity began to decline significantly when the value of the neutral density filter was 1.4 ND (4% transmission) with the Titmus test and 1.6 ND (2.5% transmission) with the Lang test.A binocularly conducted Titmus test was the most sensitive to the presence of monocularly induced retinal illuminance deterioration.

Purpose: Some patients complain of a foreign body sensation, a burning sensation, or dryness after strabismus surgery. We prospectively investigated the changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery. Patiente and Methods: Corneal and conjunctival sensitivity were assessed with an esthesiometer, tear film breakup time was measured, and the Schirmer test was performed prospectively (preoperatively and 1 week, 1 month, and 3 months postoperatively) in 83 patients (124 eyes) who underwent strabismus surgery at our institution. Resulte: There were no significant changes in corneal sensitivity, tear film stability, or tear secretion after strabismus surgery (P > .05). Conjunctival sensitivity decreased significantly after strabismus surgery (P < .05). Conclusion: Discomfort and dryness after strabismus surgery do not seem to be related to changes in corneal sensitivity, tear film stability, or tear secretion. J Pediatr Ophthalmol Strabismus 2006;43:95-99.

To verify the changes of mesopic and photopic contrast sensitivity function of sound eye whose visual acuity was kept the same after occlusion therapy in the amblyopic children. Fourteen sound eyes of amblyopic children (mean; 7.67 years; S.D., 1.50 years) who kept their visual acuity the same after the occlusion therapy were tested. The children had 6 hours of part-time patch therapy for 3 months prior to this examination. Among 14 amblyopic children, 8 were anisometric and 6 were strabismic amblyopes. Using the visual capacity analyzer which measures the minimal contrast level at from low to high spatial frequencies, the contrast sensitivity of sound eye was measured, under both photopic and mesopic condition, before and after 3 months of occlusion therapy. Comparing the contrast sensitivity of sound eye after the occlusion therapy to that before the occlusion, there was no statistical difference in photopic condition. When it comes to mesopic condition, the contrast sensitivity decreased at the intermediate spatial frequency level (3-13 c.p.d, p=0.028) after the occlusion therapy. The occlusion caused statistically significant decrease in mesopic contrast sensitivity, when the visual acuity was not changed after the occlusion therapy. It may indicate that mesopic contrast sensitivity can be considered as a useful tool for early detection of hidden occlusion amblyopia.

The purpose of this study was to determine possible effects of 12-week Prop Pilates Exercise Program (PPEP) for the fruit farmers (grape, tomato, apple) with musculoskeletal disorders (MSD) on body stability and pain. 131 fruit farmers with MSD were selected and asked to join a 12-week Prop Pilates Exercise Program (PPEP) from 2009 to 2012. The subjects (female=74, male=57) aged 50 to 65 years old voluntarily participated. As a result, it was found that lateral-medial and anterior-posterior of body stability significantly improved in male and female fruit farmers. It was found that pain index (VAS) after 12-week Prop Pilates Exercise Program (PPEP) showed a significant decrease.

To investigate long-term strabismus surgical outcomes and visual prognosis in preadolescent ocular myasthenia gravis (OMG). The medical records of all patients with preadolescent onset OMG who underwent strabismus surgery were reviewed. Thirteen patients met the study inclusion criteria. The main outcomes, including ocular alignment, number of surgeries, and visual acuity at final visit were evaluated. Outcomes were considered successful if there were ≤10 prism diopters (PD) residual horizontal and ≤4 PD residual vertical deviations at final recorded visit. Among 13 patients, diplopia presented in 11 patients (77.8 %). Mean age at disease onset was 5.8 ± 2.7 years (range 1 ∼ 11), mean age at surgery was 20.5 ± 11.3 years (range, 2.5 to 36.6 years), and the time from disease onset to first operation was 14.8 ± 9.6 years (range, 1.5 to 29.6 years). The average length of postoperative follow-up was 4.7 ± 6.6 years (range, 0.5 to 18.9 years). Ocular deviation changed more than 15 PD during stable disease in six patients (46.2 %). No patients underwent more than two surgeries. Successful results were achieved in nine patients (69.2 %) at final recorded visit. In our series, nine patients (69.2 %) with OMG could obtain good binocular alignment at final visit. Therefore, strabismus surgery can be considered in patients with preadolescent onset OMG who have constant angle of deviation despite medical treatment.

Purpose: To study the effect of botulinum toxin type A chemodenervation in sensory strabismus. Methods: Twelve patients with sensory strabismus were treated with an injection of botulinum toxin type A (Botox; Allergan, Irvine, Calif). Botulinum toxin type A was diluted with 0.9% sodium chloride without preservative at a dose that ranged from 1 .25-5 U. A Teflon-coated needle electrode was inserted into the medial reclus muscle in cases of esotropia and into the lateral rectus muscle in cases of exotropia. Four patients were treated with 5=2 injections of botulinum toxin type A. Changes in the angle of strabismus and related complications were followed for >6 months postinjection. Results: The mean deviation before injection was 33.8 prism diopters (?) and the mean corrective effect on the deviation was 72.8% after injection in patients with sensory strabismus. The final deviation in 9 patients was Conclusion: Botulinum toxin type A is likely to prevent muscle contracture and affect muscle and neuronal tissues. This study on the effects of sensory strabismus with botulinum toxin type A injection suggests it has the potential to replace surgery or be used as an adjuvant therapy. Journal of Pediatrie Ophthalmology and Strabismus 2001:38:68-71.

Ruptured extraocular muscle loses its function and shows severe restriction of eye movement even after muscle-to-muscle anastomosis or muscle transposition surgery. We present the case of a patient who developed a large exotropia after near-total rupture of the medial rectus muscle following a blowout fracture.Case report.A 12-year-old girl presented at our clinic with 45 prism diopters' exotropia after a blunt trauma. A forced duction test was unrestricted, and orbital computed tomography showed a medial orbital wall fracture and an impinged medial rectus muscle. Upon surgical exploration, an almost totally ruptured medial rectus muscle was found. The median margin of the ruptured muscle was 6.0 mm from its insertion, and the distal end that we could examine was 15.0 mm from the limbus. Recession-resection surgery combined with intraoperative botulinum toxin A chemodenervation to the ipsilateral lateral rectus muscle achieved a good primary alignment and binocular single visual field, even at a 9-month follow-up.Recession-resection surgery augmented by intraoperative botulinum toxin A chemodenervation to the ipsilateral rectus muscle appears to be highly effective in the treatment of a large exotropia produced by subtotal rectus muscle rupture following orbital wall fracture, with a lower risk of anterior segment ischemia.

In order to invigorate communicative language teaching, until recently the South Korean government actively promoted the hiring of native English speaking teachers (NESTs) at state schools. However, mainly due to constrained budgets, many local offices of education have now started to rapidly cut the number of NESTs. This paper takes a critical approach to examine possible impacts of the recent variation in NEST policy on the disparity in learning opportunities between financially privileged and underprivileged students. We begin with a brief review of the history of NEST employment in South Korean state schools. Then, we delve into whether there are pedagogical advantages in team teaching over sole Korean English Teacher teaching. Later, the current policy's driving forces, potential beneficiaries and victims, and outcome of the policy will be discussed. On the basis of the analysis of the recent trend in NEST policy, suggestions for future policy reforms are provided.