Tumor necrosis factor (TNF-alpha) in conjunction with interferon-gamma (IFN-gamma) plays an important role in lymphocyte recruitment and granuloma formation in mycobacterial diseases. Lepromatous leprosy infections are typically associated with low to absent T cell responses and the absence of INF-gamma secretion. Chemokines such as IL-8, MCP-1, and MIP-1beta, have also been shown to recruit neutrophils and lymphocytes to the site of mycobacterial infections. We have studied IL-8 expression in relation to TNF-alpha and TGF-beta in monocytes from lepromatous patients (LL) as compared with healthy endemic controls. In endemic controls, no spontaneous expression of IL-8, TNF-alpha, and TGF-beta was observed, but BCG and M. leprae induced activation of all three cytokines. Lepromatous leprosy monocytes spontaneously expressed high levels of IL-8 and TGF-beta but negligible levels of TNF-alpha. A further increase in IL-8 secretion or gene expression by BCG or M. leprae was not significant. BCG, but not M. leprae, was able to stimulate TNF-alpha activation in lepromatous leprosy subjects. TGF-beta responses in LL were parallel to those of IL-8. This suggests a vigorous and active ongoing IL-8 response in lepromatous disease that is independent of TNF-alpha activation. Therefore, in the absence of IFN-gamma and TNF-alpha activation, IL-8 may assume a pivotal role in cell recruitment in leprosy patients with disseminated mycobacterial infections.

Blindness and visual impairment are major causes of noncommunicable diseases in Pakistan. Two national population-based blindness surveys conducted in 1988 and 2002-04 demonstrated a reduction in prevalence of blindness from 1.78% to 0.9% with a significant drop in cataract blindness as a result of accelerated nationwide interventions and eye care integration in primary health care. In addition, between 2006 and 2008, 88 facilities were upgraded as a result of the national eye health programme. These measures resulted in a 279% increase in eye outpatient attendances and a 375% increase in eye surgeries performed. Investment in human resources development and policy change contributed significantly to the sustainability of the programme. Key challenges facing the programme include aligning national eye health strategies with health system strengthening informed through health systems research. This paper attempts to document this extraordinary success.

Figure 2Figure-of-eight suture through mucosa and submucosa, but not skin, placed across the lumen and tied in place. Maintaining constant pressure during arthroscopic surgery by manually pumping a pressure infusion bag is tedious, tiring and may cause repetitive strain injuries to the forearm; loss of pressure during the procedure is common. We have, therefore, developed a connector between the pressure infuser bag and one lead of the dual-channel, selfcompensating, tourniquet inflation unit. We typically pressurise up to 100 mmHg for routine arthroscopies. This simple and cheap device has proven to be very useful by both surgeons and theatre staff in providing a constant clear view during arthroscopic procedures. Transhiatal chest drainage after oesophagectomyOrientating fluoroscopic images during surgery can be testing when the visual field is small or lacking definite reference points. A simple and effective technique is described to assist orientation during hip arthrograms and peri-acetabular osteotomies. The anterior superior iliac spines are palpated and a metal ruler

Objective:Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller’s Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported.Methods:Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon (Rigiflex Microvasive®) dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention.Results:Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years), 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis (20 died due to non-procedure related causes and another 68 were lost during follow up). Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation.Conclusion:Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate.

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17We developed mid-infrared optoacoustic microscopy (MiROM), a bond-18 selective imaging modality that overcomes water/tissue opacity and depth 19 limitations of mid-infrared sensing allowing uncompromised live-20 cell/thick-tissue mid-infrared microscopy with up to three orders of 21 magnitude higher sensitivity than other vibrational imaging modalities; 22 such as Raman. We showcase the functional label-free biomolecular 23 imaging capabilities of MiROM by monitoring the spatiotemporal 24 dynamics of lipids and proteins during lipolysis in living adipocytes. Since 25MiROM, contrary to Raman modalities, is not only able to detect lipids and 26 proteins, but also important metabolites such as glucose without the need 27

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On behalf of my co-authors I thank you for the opportunity to respond to the letter from Forshaw et al. Their results between 2000 and 2003 of 168 oesophageal resections associated with an in-hospital mortality of 1.3% are indeed impressive and one can understand their reluctance to The Royal College of Surgeons of England Letters and comments Contributors to this section are asked to make their comments brief and to the point. Letters should comply with the instructions to authors at http://www.rcseng.ac.uk/publications/ annals/authorinstructions.html. Tables and figures should only be included if absolutely essential and no more than five references should be given. The editor reserves the right to shorten letters and subedit contributions to ensure clarity.