Anaesthetic management of a pregnant patient undergoing meningioma resection: A case report.

The management of intracranial malignancies in pregnancy poses unique challenges to the perioperative team. We describe the successful surgical management of a meningioma in a 28-year-old previously healthy patient, in her third trimester of pregnancy, who first presented with a generalised seizure. Without clear guidelines on the management of intracranial malignancies in pregnancy, a multidisciplinary approach was essential in providing a management plan for the patient's seizures and on the timing of her surgical intervention. Hormone-mediated tumour growth was a significant factor in opting for urgent surgical intervention and we discuss the current evidence linking hormones to tumour growth in pregnancy.

Technical Trick: Traction Table-Assisted Lateral Decubitus Patient Positioning in Cephalomedullary Nailing of Geriatric Intertrochanteric Femur Fractures.

SUMMARY: Cephalomedullary nail fixation of geriatric intertrochanteric femur fractures is, and will continue to be, performed by most orthopaedic surgeons. The influence of technical factors on outcome is clear, and it is imperative that orthopaedic surgeons use contemporary strategies to achieve adequate reduction and fixation. The lateral patient position on a traction table potentially confers several advantages which surgeons can use to achieve quality outcomes even in patients who have challenging body morphology and/or fracture anatomy. A preferred surgical technique for lateral positioning is presented here and a case series comparing supine versus lateral nailing procedures. Lateral positioning was used more frequently in obese patients and by trauma-trained surgeons, and the results equal or exceed those in supine cases with respect to reduction and placement of fixation. Training surgeons in lateral nailing can deliver a reproducible strategy for reduction and fixation in straightforward and complex cases. By mastering the setup and technique on more simple cases, surgeons can be better prepared for the more complex where advantages of lateral nailing are even more apparent.

Internal Joint Stabilizer: A Safe Treatment for Traumatic Elbow Instability.

OBJECTIVES: To report early results of the "Internal Joint Stabilizer of the Elbow" (IJS-E) in the treatment of terrible triad injuries and other unstable traumatic elbow dislocations. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seventeen patients with traumatic elbow instability treated with IJS-E over a 2-year period; 7 of whom sustained terrible triad-type injuries. INTERVENTIONS: Open reduction internal fixation with the "IJS-E". MAIN OUTCOME MEASURES: Elbow stability and arc of motion were assessed radiographically and clinically. Disabilities of the Arm, Shoulder and Hand scores were collected by telephone. RESULTS: All elbows were radiographically stable at the time of IJS-E removal. Mean time of follow-up was 9 months from index operation (range, 2.5-24 months). Mean elbow arc of motion was restored to flexion-extension 92 degrees (range, 5-125; SD, 31 degrees) and forearm pronation-supination 139 degrees (range, 0-180; SD, 48 degrees). Mean Disabilities of the Arm, Shoulder and Hand score was 22.2 (range, 7.5-45.7; SD, 13.3) for patients at least 1 month from surgery on the ipsilateral extremity. Five patients (30%) developed complications, and -2 (12%) required revision for implant failure. CONCLUSIONS: The IJS-E offered reliable treatment of traumatic elbow instability, particularly terrible triad-type injuries. It permited early range of motion and was effective in restoring elbow stability. We believe that the use of this relatively novel system should be further explored. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lund University Cardiac Assist System Induced Liver Laceration and Anterior Cord Infarction After Cardiac Arrest: A Case Report.

We describe a hepatic laceration and subsequent anterior spinal artery syndrome in a 21-year-old man, secondary to prolonged cardiopulmonary resuscitation with a Lund University Cardiac Assist System (LUCAS2) mechanical cardiac compression device. We briefly review the current literature pertaining to hepatic injury from trauma due to cardiopulmonary resuscitation. The etiology of the anterior spinal artery syndrome in this patient is discussed. This case highlights that intra-abdominal causes of hypotension should be considered in patients after a prolonged resuscitation attempt. Extending focused cardiac ultrasound to exclude intra-abdominal free fluid should be routinely considered in these patients.

What does basic science tell us about the use of uterotonics?

Pharmacotherapy with uterotonics remains the mainstay of the management for post-partum haemorrhage. Clinical studies evaluating the efficacy of these drugs are fraught with confounders, which may influence uterine contractility and blood loss. For this reason, a range of techniques have been developed to study myometrial function in vitro, allowing for the comparison of various drugs in a controlled-simulated physiological environment. In this review, we focus on the main classes of uterotonic drugs and outline their molecular and physiological basis of action. We explore the evidence related to appropriate drug dosing and relative efficacy, and compare the evidence gleaned from clinical and in vitro studies. We discuss the mechanism of oxytocin desensitisation and how basic science has helped us understand this phenomenon. We also discuss the in vitro research findings for each of the main classes of uterotonic drugs that have contributed to an improved understanding of the management of post-partum haemorrhage and, ultimately, better care for mothers.

The effect of i-gel® insertion on the accuracy of cricothyroid membrane identification in adult females: a prospective observational study.

BACKGROUND: Identification of the cricothyroid membrane is frequently inaccurate in females because of less distinct anatomy compared with males. Supraglottic airway devices cause ventral displacement of the laryngeal structures. We investigated if this would impact on the accuracy of cricothyroid membrane identification using palpation. METHODS: We recruited 64 adult females who underwent assessment by volunteer participants with and without a sited i-gel® supraglottic airway device. The primary outcome was accuracy in identifying the cricothyroid membrane. Secondary outcomes included distance from participant estimate to actual cricothyroid membrane location and perceived difficulty using a visual analogue scale. Ultrasound images were analysed to determine the effect of the i-gel® on the anatomical structures relevant to cricothyroidotomy. RESULTS: The cricothyroid membrane was identified correctly in 42/64 subjects with the i-gel® in place (66%) vs 23/64 of controls (36%; P<0.001, mean difference 30%; 95% confidence interval, 12-47%). VAS (P<0.001) and distance to the cricothyroid membrane (P<0.001) decreased in the intervention group. Analysis of the ultrasound image series showed a reduction in the mean angle between the cricothyroid membrane and anterior wall of the trachea in the i-gel® group, because of the more ventral position of the cricoid cartilage compared with control images (166° vs 151°, P<0.001). CONCLUSIONS: The presence of the i-gel® improved accuracy of identifying the cricothyroid membrane using palpation in females. The cricoid cartilage was pushed ventrally by the i-gel® in the hypopharynx, creating a more palpable prominence. It may therefore be advantageous to retain a sited supraglottic airway, rather than remove it, before performing emergency cricothyroidotomy.

Validation of Novel Metrics from the Accommodative Dynamic Profile.

Objective and subjective methods of assessing time taken for accommodative change (ToAC) include accommodative dynamics (AD) and accommodative facility (AF). This study investigates the validity of novel metrics derived from the AD-profile and explores their relationship with AF. AD were assessed using a modified open-field autorefractor in 43 healthy adults. Non-linear regression curves were fitted to the data to derive: latency-of-accommodation (nLoA) and -disaccomodation (nLoD), Time-for-accommodation (ToA) and -disaccommodation (ToD), and objective-ToAC (oToAC). Latencies were also calculated through visual inspection of the AD data as in previous studies (pLoA and pLoD). AF was used to assess subjective-ToAC. Statistical analysis explored the relationships between the AD-metrics and AF. Subjects were assessed on three visits to examine intra- and inter-observer repeatability. nLoA and nLoD were greater than pLoA (p = 0.001) and pLoD (p = 0.004) respectively. nLoA and nLoD also demonstrated greater intra- and inter-observer repeatability than pLoA and pLoD. AF demonstrated a moderate, inverse correlation with ToA (p = 0.02), ToD (p = 0.007), and oToAC (p = 0.007). ToD was the single best accommodative predictor of AF (p = 0.011). The novel method for deriving latency was more repeatable, but not interchangeable with the techniques used in previous studies. ToD was the most repeatable metric with the greatest association with AF.

Developments in contact lens measurement: A comparative study of industry standard geometric inspection and optical coherence tomography.

PURPOSE: The aim of this study was to compare a developmental optical coherence tomography (OCT) based contact lens inspection instrument to a widely used geometric inspection instrument (Optimec JCF), to establish the capability of a market focused OCT system. METHODS: Measurements of 27 soft spherical contact lenses were made using the Optimec JCF and a new OCT based instrument, the Optimec is830. Twelve of the lenses analysed were specially commissioned from a traditional hydrogel (Contamac GM Advance 49%) and 12 from a silicone hydrogel (Contamac Definitive 65), each set with a range of back optic zone radius (BOZR) and centre thickness (CT) values. Three commercial lenses were also measured; CooperVision MyDay (Stenfilcon A) in -10D, -3D and +6D powers. Two measurements of BOZR, CT and total diameter were made for each lens in temperature controlled saline on both instruments. RESULTS: The results showed that the is830 and JCF measurements were comparable, but that the is830 had a better repeatability coefficient for BOZR (0.065mm compared to 0.151mm) and CT (0.008mm compared to 0.027mm). Both instruments had similar results for total diameter (0.041mm compared to 0.044mm). CONCLUSIONS: The OCT based instrument assessed in this study is able to match and improve on the JCF instrument for the measurement of total diameter, back optic zone radius and centre thickness for soft contact lenses in temperature controlled saline.

Does rebound tonometry probe misalignment modify intraocular pressure measurements in human eyes?

Purpose. To examine the influence of positional misalignments on intraocular pressure (IOP) measurement with a rebound tonometer. Methods. Using the iCare rebound tonometer, IOP readings were taken from the right eye of 36 healthy subjects at the central corneal apex (CC) and compared to IOP measures using the Goldmann applanation tonometer (GAT). Using a bespoke rig, iCare IOP readings were also taken 2 mm laterally from CC, both nasally and temporally, along with angular deviations of 5 and 10 degrees, both nasally and temporally to the visual axis. Results. Mean IOP ± SD, as measured by GAT, was 14.7 ± 2.5 mmHg versus iCare tonometer readings of 17.4 ± 3.6 mmHg at CC, representing an iCare IOP overestimation of 2.7 ± 2.8 mmHg (P < 0.001), which increased at higher average IOPs. IOP at CC using the iCare tonometer was not significantly different to values at lateral displacements. IOP was marginally underestimated with angular deviation of the probe but only reaching significance at 10 degrees nasally. Conclusions. As shown previously, the iCare tonometer overestimates IOP compared to GAT. However, IOP measurement in normal, healthy subjects using the iCare rebound tonometer appears insensitive to misalignments. An IOP underestimation of <1 mmHg with the probe deviated 10 degrees nasally reached statistical but not clinical significance levels.

Impact of soft contact lens edge design and midperipheral lens shape on the epithelium and its indentation with lens mobility.

PURPOSE: To evaluate the influence of soft contact lens midperipheral shape profile and edge design on the apparent epithelial thickness and indentation of the ocular surface with lens movement. METHODS: Four soft contact lens designs comprising of two different plano midperipheral shape profiles and two edge designs (chiseled and knife edge) of silicone-hydrogel material were examined in 26 subjects aged 24.7 ± 4.6 years, each worn bilaterally in randomized order. Lens movement was imaged enface on insertion, at 2 and 4 hours with a high-speed, high-resolution camera simultaneous to the cross-section of the edge of the contact lens interaction with the ocular surface captured using optical coherence tomography (OCT) nasally, temporally, and inferiorly. Optical imaging distortions were individually corrected for by imaging the apparent distortion of a glass slide surface by the removed lens. RESULTS: Apparent epithelial thickness varied with edge position (P < 0.001). When distortion was corrected for, epithelial indentation decreased with time after insertion (P = 0.010), changed after a blink (P < 0.001), and varied with position on the lens edge (P < 0.001), with the latter being affected by midperipheral lens shape profile and edge design. Horizontal and vertical lens movement did not change with time postinsertion. Vertical motion was affected by midperipheral lens shape profile (P < 0.001) and edge design (P < 0.001). Lens movement was associated with physiologic epithelium thickness for lens midperipheral shape profile and edge designs. CONCLUSIONS: Dynamic OCT coupled with high-resolution video demonstrated that soft contact lens movement and image-corrected ocular surface indentation were influenced by both lens edge design and midperipheral lens shape profiles.

Adult presentation of interrupted aortic arch: case presentation and a review of the medical literature.

Interrupted aortic arch (IAA) is a rare congenital abnormality that presents in infancy. Isolated cases have been reported in adulthood, which are likely presentations of severe coarctation of the aorta. We present two such cases of adult presentation of IAA and a review of previously reported cases in the medical literature and current recommendations for management and follow-up of these patients.

The transcription factor Sox11 is a prognostic factor for improved recurrence-free survival in epithelial ovarian cancer.

BACKGROUND: Current prognostic molecular markers for epithelial ovarian cancer (EOC) are insufficient. The aim of the current study was to investigate the role of Sox11 in EOC. METHODS: Using an in silico transcriptomic screen, Sox11 was identified as a potential EOC biomarker. Sox11 protein expression was evaluated using immunohistochemistry (IHC) in 76 EOC cases, which were analysed using automated algorithms to develop a quantitative scoring model. RESULTS: Sox11 mRNA expression was upregulated in EOC compared to normal tissues. Automated analysis of Sox11 in the EOC cohort revealed high expression of Sox11, in 40% of tumours, who had an improved recurrence-free survival (RFS) (p=0.002). Multivariate analysis confirmed that Sox11 was an independent predictor of improved RFS after controlling for stage and grade. CONCLUSIONS: These data suggest that Sox11 is a new prognostic marker in EOC. Loss of Sox11 is associated with a decreased RFS and a more aggressive phenotype.