Risk of serious intracranial pathology in children presenting with acute acquired comitant esotropia.

OBJECTIVE: Acute acquired comitant esotropia (AACE) is defined as a sudden-onset constant nonaccommodative esodeviation. The purpose of this study was to determine the risk of serious intracranial pathology in children presenting with AACE. DESIGN: Retrospective observational cohort study. SETTING: Tertiary care pediatric hospital. METHODS: The study included consecutive children who met the diagnostic criteria for AACE and had neuroimaging at a tertiary care pediatric hospital between 2000 and 2020. Patients were identified by searching the radiology database for all children who underwent neuroimaging for esotropia. The primary outcome measure was the proportion of patients with serious intracranial pathology. Secondary outcomes included risk factors for finding likely causative intracranial pathology and the proportion of patients with incidental findings. RESULTS: A total of 107 patients met the inclusion criteria. Most of the patients (75.7%) had normal neuroimaging. The next most common result was an incidental finding unrelated to the esotropia (18.7%). Five patients (4.7%) had findings with uncertain contribution to esotropia, including 3 cases of type I Chiari malformation. A serious intracranial pathology was found in 1 patient (0.9%) who had a cerebellar medulloblastoma. CONCLUSION: In this large series of pediatric patients with AACE who underwent neuroimaging, there was a small but nontrivial risk of serious intracranial pathology. In these patients, it is advisable either to obtain neuroimaging or to monitor closely for the development of concerning signs or symptoms.

Incidence and risk factors for musculoskeletal disorders of the elbow in baseball pitchers: a systematic review of the literature.

OBJECTIVE: To determine the incidence and risk factors of musculoskeletal disorders of the elbow in baseball pitchers. DESIGN: Systematic review. DATA SOURCES: Medline, CINAHL, Cochrane, PubMed and SportDiscus from onset to July 7, 2018. ELIGIBILITY CRITERIA: Eligible studies included randomized controlled trials, cohort studies and case-control studies. Independent pairs of reviewers screened titles and abstracts for eligibility. Relevant articles were critically appraised for internal validity using the SIGN criteria. We included low risk of bias studies in our best evidence synthesis. RESULTS: We retrieved 4502 articles, 39 were critically appraised and nine had a low risk of bias. These were included in the evidence synthesis. The incidence of musculoskeletal disorders of the elbow ranges from 2.3% in adolescent pitchers to 40.6% in youth pitchers. Evidence suggests that pitch characteristics, inadequate rest, biomechanical and anthropometric factors may be risk factors of UCL tears. SUMMARY/CONCLUSION: Baseball pitchers develop musculoskeletal disorders of the elbow. There is little high-quality evidence to understand the etiology. Preliminary evidence suggests the risk factors are multifactorial.PROSPERO Trial Registration Number: CRD42018092081.

OBJECTIF: Établir l'incidence et facteurs de risque de troubles musculosquelettiques du coude chez le lanceur de baseball. MÉTHODOLOGIE: Revue exhaustive. SOURCES DES DONNÉES: Medline, CINAHL, Cochrane, PubMed et SportDiscus depuis le début jusqu'au 7 juillet 2018. CRITÈRES D'ADMISSIBILITÉ: Les études admissibles étaient des essais comparatifs à répartition aléatoire, des études de cohortes et des études de cas-témoins. Des pairs examinateurs indépendants ont trié des titres et des résumés satisfaisant les critères d'admissibilité. On a évalué la validité interne des articles pertinents en utilisant les critères SIGN. On a tenu compte d'un faible risque d'études faussées dans notre meilleure synthèse de preuves. RÉSULTATS: Sur les 4 502 articles retenus, 39 ont été évalués d'une façon critique; neuf présentaient un risque de parti pris. Ceux-ci ont été inclus dans la synthèse de preuves. L'incidence des troubles musculosquelettiques du coude variait de 2,3 % chez les lanceurs adolescents à 40,6 % chez les jeunes lanceurs. Les données semblent indiquer que les caractéristiques du lancer, un repos insuffisant, des facteurs biomécaniques et anthropométriques pourraient être des facteurs de risque de déchirure du ligament collatéral de l'ulna (LCU). RÉSUMÉ/CONCLUSION: Les lanceurs de baseball développent des troubles musculosquelettiques au coude. Il existe peu de preuves de grande qualité permettant de comprendre l'étiologie de ces troubles. Les données préliminaires semblent indiquer que les causes sont multifactorielles.Numéro d'enregistrement d'essai PROSPERO : CRD42018092081.

Yield of screening blood work and MRI of the brain and orbits in the work-up of unilateral chronic optic neuropathy.

BACKGROUND/OBJECTIVES: No guidelines exist for the investigation of treatable causes of chronic optic neuropathy, including sarcoidosis, lupus, and syphilis. The purpose of this study was to determine the diagnostic yield of screening blood work (ACE (Angiotensin Converting Enzyme) for sarcoidosis, Antinuclear Antibodies (ANA) for lupus, CMIA (chemiluminescence microparticle enzyme immunoassay) for syphilis) and contrast-enhanced MRI brain and orbits in atypical unilateral chronic optic neuropathy. SUBJECTS/METHODS: Retrospective review from February 2012 to June 2018 at a neuro-ophthalmology practice. Six hundred and eighty-three consecutive charts with optic neuropathy were reviewed. Inclusion criteria were unilateral chronic optic neuropathy and a work-up including contrast-enhanced MRI brain and orbits, CBC, ESR, CRP, ANA, CMIA, and ACE. Exclusion criteria were optic nerve swelling in either eye on initial assessment or an established cause of optic neuropathy. The main outcome measure was diagnostic yield. RESULTS: Fifty-seven patients were included. One patient had elevated ACE, seven had positive ANA titers, and three had positive CMIA. Zero patients were diagnosed with sarcoidosis, one patient was diagnosed with lupus-related optic neuropathy, and one patient was diagnosed with syphilitic optic neuropathy. The diagnostic yield of ACE was 0%, ANA was 1.75%, and CMIA was 1.75%. MRI revealed planum sphenoidale meningioma causing compressive optic neuropathy in one patient, giving it a diagnostic yield of 1.82%. CONCLUSION: Routine screening blood work (ACE, ANA, CMIA) and MRI brain and orbits for chronic idiopathic unilateral optic neuropathy has low diagnostic yield, especially if clinical suspicion for syphilis, lupus, and sarcoidosis is low. MRI should still be performed in all cases in order to rule out compressive lesions.

Bacterial Keratitis in Toronto: A 16-Year Review of the Microorganisms Isolated and the Resistance Patterns Observed.

PURPOSE: To review the incidence, distribution, current trends, and resistance patterns of bacterial keratitis isolates in Toronto over the past 16 years. METHODS: Microbiology records of suspected bacterial keratitis that underwent a diagnostic corneal scraping and cultures from January 1, 2000, through December 31, 2015, were retrospectively reviewed. The distribution of the main isolated pathogens and in vitro laboratory minimum inhibitory concentration testing results were used to identify resistance patterns. RESULTS: A total of 2330 corneal scrapings were taken over 16 years. A pathogen was recovered in 1335 samples (57.3%), with bacterial keratitis accounting for 1189 of the positive cultures (86.0% of all isolates). The total number of gram-positive and gram-negative isolates was 963 and 324, respectively. Coagulase-negative Staphylococcus and Pseudomonas aeruginosa were the most common gram-positive and gram-negative bacteria isolates, respectively. A decreasing trend in the number of isolates in gram-positive bacteria (P = 0.01), specifically among Staphylococcus aureus (P < 0.0001) and Streptococcus species (P = 0.005), was identified. When analyzing the susceptibilities of gram-positive and gram-negative isolates, an increasing trend in antibiotic resistance was observed in erythromycin (P = 0.018), ceftazidime (P = 0.046), and piperacillin/tazobactam (P = 0.005). The susceptibility of tested gram-positive microorganisms to vancomycin was 99.6%. CONCLUSIONS: There has been a decreasing trend in the number of isolates in gram-positive microorganisms over the past 16 years. An increasing trend in resistance for various antibiotics against gram-negative and gram-positive isolates was identified. High susceptibility to vancomycin reinforced the empirical use of fortified tobramycin and vancomycin in the initial management of severe bacterial keratitis.

Sequential pterygium excision with conjunctival autograft in the management of primary double-headed pterygia.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of sequential pterygium excision with conjunctival autograft (PECA) in the management of double-headed pterygia. METHODS: All patients who underwent a sequential PECA procedure for double-headed pterygia from 2004 to 2009 were included in this retrospective, noncomparative, interventional case series. The recurrence rate and visual outcomes after this procedure were determined. RESULTS: Nine eyes of 8 patients with doubled-headed pterygia undergoing sequential PECA were identified. Of 18 PECA procedures, 1 recurrence (5.56%) was found. The single recurrence was observed nasally in the right eye (first site operated) of a female patient 55 months after the second PECA procedure. None of the operated eyes lost any lines of corrected distance visual acuity, and 22% gained at least 1 line of corrected distance visual acuity. CONCLUSIONS: In this series, harvesting the conjunctival autograft from the same site several months later does not appear to increase the rate of recurrence. Sequential PECA is a safe and effective method of addressing double-headed pterygia.

Evolving surgical techniques of and indications for corneal transplantation in Ontario: 2000 - 2012.

OBJECTIVE: To evaluate trends in indications for and preferred surgical techniques of corneal transplantation in Ontario over a 12-year period. DESIGN: Retrospective review of recipient information forms collected by Eye Bank of Canada (Ontario Division). PARTICIPANTS: Patients who received corneal transplantation in Ontario between 2000 and 2012, totaling 11,725 corneal transplants performed. METHODS: Database containing information collected from recipient information forms maintained by the Eye Bank of Canada (Ontario Division) was reviewed. Corneal transplants performed between July 1, 2000, and June 30, 2012, in Ontario were analyzed. Surgeons complete recipient information forms at the time of corneal transplant surgery. Of the 11,725 available recipient information forms, 10,906 (93%) were sufficiently complete to meet the inclusion criteria and were included in the study. RESULTS: Since 2009, Fuchs endothelial dystrophy overtook pseudophakic corneal edema as the leading indication for corneal transplantation. Since the shift toward lamellar keratoplasty in 2006, there has been a significant decrease in number of corneal transplants performed with penetrating keratoplasty (PKP; p = 0.0016) and a significant increase in Descemet stripping automated endothelial keratoplasty (DSAEK; p = 0.0069) and deep anterior lamellar keratoplasty (p = 0.0108). The gap between number of PKPs and DSAEKs performed each year is progressively narrowing. From July 1, 2011, to June 30, 2012, 514 PKPs were performed compared with 420 DSAEKs. From 2011 to 2012, 83% of corneal transplants indicated by Fuchs endothelial dystrophy were performed with DSAEK, whereas only 13% were performed with PKP. CONCLUSIONS: Six years since initial implementation, partial thickness transplantation continues to increase in popularity. Corneal tissue supply and demand will need to reflect these changes in the field of corneal transplantation.

Changes in primary care physician's management of low back pain in a model of interprofessional collaborative care: an uncontrolled before-after study.

BACKGROUND: Tracking how clinicians treat patients provides an opportunity to explore how the clinical management of common musculoskeletal disorders evolves over time. We present an uncontrolled before-after study of a primary care physician's management of low back pain and describe how his involvement in an interprofessional collaborative practice was associated with a change in the management of patients with low back pain. METHOD: Data from the electronic medical record of one primary care physician who participated in a study of a model of chiropractic-medical collaboration were retrospectively collected. Records of a sample of consecutive patients prior to the start (i.e. pre-study, n = 51) and at the end of the collaborative study (i.e. study, n = 49) were collected. RESULTS: Demographics were similar in both groups but median number of physician visits (2.5 and 1.0), average prescriptions per patients (1.24 and 0.47), and total number of narcotic prescriptions (14 and 6) differed between pre-study and study groups, respectively. Separate analysis of only the records of low back pain study patients revealed that 61% were referred for chiropractic care during the study period. Patients who were not referred had more neurological deficits and leg pain but back pain severity and average number of prescriptions was about the same. Referred patients in the study group had about 25% fewer physician visits and imaging requests. CONCLUSION: Based on this study of a single primary care physician, we hypothesize that doctors may change their prescribing behaviours and consultation rate for patients with low back pain when engaged in interprofessional collaborative care. Further research is required to test this observation in the population.