Ranibizumab pretreatment in diabetic vitrectomy: a pilot randomised controlled trial (the RaDiVit study).

PurposeOur aim was to evaluate the impact of intravitreal ranibizumab pretreatment on the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy. The objective was to determine the feasibility of a subsequent definitive trial and estimate the effect size and variability of the outcome measure.Patients and methodsWe performed a pilot randomised double-masked single-centre clinical trial in 30 participants with tractional retinal detachment associated with proliferative diabetic retinopathy. Seven days prior to vitrectomy surgery, participants were randomly allocated to receive either intravitreal ranibizumab (Lucentis, Novartis Pharmaceuticals UK Ltd, Frimley, UK) or subconjunctival saline (control). The primary outcome was best-corrected visual acuity 12 weeks following surgery.ResultsAt 12 weeks, the mean (SD) visual acuity was 46.7 (25) ETDRS letters in the control group and 52.6 (21) letters in the ranibizumab group. Mean visual acuity improved by 14 (31) letters in the control group and by 24 (27) letters in the ranibizumab group. We found no difference in the progression of tractional retinal detachment prior to surgery, the duration of surgery, or its technical difficulty. Vitreous cavity haemorrhage persisted at 12 weeks in two of the control group but none of the ranibizumab group.ConclusionRanibizumab pretreatment may improve the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy by reducing the extent of post-operative vitreous cavity haemorrhage. However, the effect size appears to be modest; we calculate that a definitive study to establish a minimally important difference of 5.9 letters at a significance level of P<0.05 would require 348 subjects in each arm.

Radon contribution to the total effective dose of uranium miners.

Exposure to radon and its decay products is one of the three parts that create the total effective dose of uranium miners. Photons from gamma radiation and exposition to long-lived alpha emitters which are members of uranium family are the other two parts. The monthly total effective dose of uranium miners in mine Rozna I (Czech republic) is determined by the personal dosemeter ALGADE, which ensures the continual individual monitoring of all three parts. The exposed dosemeters are evaluated in the National Institute for Nuclear, Chemical and Biological Protection in Kamenna near Pribram. This paper describes the individual parts of miners' total effective dose considering the different types of work activities and workplaces. The main input data are the evaluation results of the uranium miners' personal dosemeters ALGADE in mine Rozna I in the time period from 2000 till 2012.

Long-term patency of a RaK collagen vascular prosthesis - single centre results during a 10 year follow-up.

The aim of this retrospective study was to evaluate the results of vascular operations based on the RaK prostheses, with a particular attention paid to their long-term patency. The study included 105 patients who were operated on in the period from 1992 to 1996. Vascular surgery was performed in the aortofemoral area and the underlying diagnoses were Leriche syndrome, asymptomatic abdominal aortic aneurysm, iliac artery stenosis or occlusion and symptomatic abdominal aortic aneurysm. During the mean follow-up time of 96 months (range 28-144), 8 patients (7.6 %) were lost to follow-up and 23 patients (21.9 %) died. At 12, 36, 60 and 120 months after surgery, the prostheses were patent in 99 %, 98 %, 93 % and 89 % of the patients, respectively. It is concluded that the RaK collagen prosthesis is the device of high quality and parameters comparable with the other types of knitted vascular prostheses currently used (Tab. 3, Fig. 4, Ref. 17).

Pilot randomised controlled trial of face-down positioning following macular hole surgery.

OBJECTIVE: This was a pilot randomised controlled trial (RCT) to investigate the effect of post-operative face-down positioning on the outcome of macular hole surgery and to inform the design of a larger definitive study. METHODS: In all, 30 phakic eyes of 30 subjects with idiopathic full-thickness macular holes underwent vitrectomy with dye-assisted peeling of the ILM and 14% perfluoropropane gas. Subjects were randomly allocated to posture face down for 10 days (posturing group) or to avoid a face-up position only (non-posturing group). The primary outcome was anatomical hole closure. RESULTS: Macular holes closed in 14 of 15 eyes (93.3%; 95% confidence interval (CI) 68-100%) in the posturing group and in 9 of 15 (60%; 95% CI 32-84%) in the non-posturing group. In a subgroup analysis of outcome according to macular hole size, all holes smaller than 400 µm closed regardless of posturing (100%). In contrast, holes larger than 400 µm closed in 10 of 11 eyes (91%; 95% CI 58-99%) in the posturing group and in only 4 of 10 eyes (40%; 95% CI 12-74%) in the non-posturing group (Fisher's exact test P=0.02). CONCLUSION: Post-operative face-down positioning may improve the likelihood of macular hole closure, particularly for holes larger than 400 µm. These results support the case for a RCT.

A review of exposures to radon, long-lived radionuclides and external gamma at the Czech uranium mine.

This paper presents the results of the personal exposure monitoring conducted in the RoZná uranium mine in the Czech Republic. In this mine, which has been operated since the late 1950s, personal ALGADE dosemeters have been used since 1998. A group of 600 miners employed during the period 2000-09 has been analysed. Annual exposures to radon decay products, long-lived alpha emitters and external gamma radiation are described. These components play an essential role in the estimation of the total effective dose. The dependence of the exposures on the type of mining job is also assessed.

Quantifying the buildup in extent and complexity of free exploration in mice.

To obtain a perspective on an animal's own functional world, we study its behavior in situations that allow the animal to regulate the growth rate of its behavior and provide us with the opportunity to quantify its moment-by-moment developmental dynamics. Thus, we are able to show that mouse exploratory behavior consists of sequences of repeated motion: iterative processes that increase in extent and complexity, whose presumed function is a systematic active management of input acquired during the exploration of a novel environment. We use this study to demonstrate our approach to quantifying behavior: targeting aspects of behavior that are shown to be actively managed by the animal, and using measures that are discriminative across strains and treatments and replicable across laboratories.

Assessment of the total effective dose of miners in the underground Rozná Uranium Mine in the Czech Republic during the period 2004-2009.

The paper discusses the situation in the Czech Republic regarding past and present uranium mining activities with emphasis on the evaluation of the exposure of underground miners in the Rozná Uranium Mine, which is currently the only active mine in the country and practically in the entire European Union. The total effective dose has been summarised taking into account all three major components, namely radon short-lived decay products, long-lived alpha emitters in ore dust and penetrating external gamma radiation. The average and maximum values of the effective dose as well as the collective effective dose of underground miners are also presented. The purpose of the paper is to document the miners' exposures during a period of 6 years in a uranium mine where conditions including the ore grade and methods of mining showed recently some changes that may affect the individual components of the total effective dose.

[Ruptured mycotic aneurysm of the abdominal aorta managed using a superficial femoral vein graft--a case review]. / Rupturované mykotické aneuryzma brisní aorty resené graftem z vena femoralis superficialis--kazuistika.

Mycotic aneurysm of the abdominal aorta is a rare, but potentially lethal disorder because of the risk of rupture. It presents a permanent problem in vascular surgery. Despite recent advances in endovascular procedures, one of the available surgical interventions generally remains the method of choice. The authors present the case of a patient with a ruptured mycotic aneurysm of the abdominal aorta who urgently underwent aorto-biiliac reconstruction by an autologous superficial femoral vein graft. The patient's post-operative condition with the absence of complications is in agreement with the good results achieved with this technique by surgeons abroad, and gives support to the notion that this approach is superior to other surgical treatments of mycotic aneurysms.

Intravitreal triamcinolone versus laser photocoagulation for persistent diabetic macular oedema.

AIM: To determine if repeated intravitreal triamcinolone improves best corrected visual acuity at 1 year compared with conventional laser therapy for persistent diabetic macular oedema. METHODS: 88 eyes with persistent clinically significant macular oedema, after at least one prior laser photocoagulation, were included in this prospective randomised controlled trial. 43 patients were randomised to 4 mg of intravitreal triamcinolone (TA) and 45 to laser photocoagulation. The primary endpoint was the proportion of patients who improved by 15 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters at 12 months in TA versus laser groups. Secondary endpoints were the change in mean best corrected visual acuity, difference in macular thickness and macular volume and adverse event reporting in particular elevated intraocular pressure at 12 months. RESULTS: Improvement in > or =15 ETDRS letters occurred in two of 42 patients in the TA group (4.8%) and in five of 41 (12.2%) patients in the laser group (p = 0.265). At baseline, the mean ETDRS scores at baseline were 54.4 letters in the TA group and 53.0 letters in the laser group. At 12 months, these were 54.5 and 54.6, respectively. Optical coherence tomography showed a reduction in central macular thickness of 82.0 microm with TA and 62.3 microm with laser at 12 months. There was one case of sterile endophthalmitis. 22 out of 43 patients in the triamcinolone group required ocular antihypertensives. CONCLUSION: This study did not show a benefit from intravitreal triamcinolone over conventional laser therapy for patients with chronic diabetic macular oedema.

Macular holes: vitreoretinal relationships and surgical approaches.

Idiopathic full-thickness macular holes develop as a result of anteroposterior and tangential traction exerted by the posterior vitreous cortex at the fovea. Vitreoretinal relationships during the development of macular holes can be demonstrated in detail by ocular coherence tomography, facilitating an improved understanding of their pathogenesis and guiding clinical management. Surgical strategies for the repair of macular holes are designed to relieve vitreofoveal traction and to promote flattening and reapposition of the macular hole edges by intraocular gas tamponade. A period of face-down positioning postoperatively is conventionally advised. However, the evidence to support this recommendation is weak and practice varies considerably. Surgical removal of the inner limiting membrane (ILM) is advocated to ensure thorough removal of any tangential tractional components including any residual cortical vitreous. Current evidence suggests that ILM peeling can improve anatomical outcomes but the effect on visual function is less predictable; unsuccessful attempts to peel the ILM can be associated with poor visual outcome. The use of vital dyes can facilitate visualisation of the ILM and help achieve complete, atraumatic peeling. Indocyanine green dye can enable high rates of macular hole closure but has been associated with poorer visual outcomes suggesting a dose-dependent toxicity. Trypan blue dye offers an alternative that may have a more favourable risk profile. An improved understanding of vitreoretinal relationships may facilitate a tailored approach to surgery in individuals with macular holes. Vitrectomy to relieve anteroposterior traction is central in the management of all full-thickness holes. The use of long-acting gases, prolonged face-down positioning, and ILM peeling may be more valuable for larger holes, longstanding holes, and those that have failed to close following conventional surgery.

[Blood vessel reconstruction infections: a practical view]. / Infekce tepenných rekonstrukcí: praktický pohled.

Infection represents a serious complication in vascular surgery. The average of 2-3% of reconstructions are involved. The article offers a review of current diagnosis and treatment of infection after vascular reconstruction. Emphasis is put on early diagnosis and its impact on prognosis of patients. We summarize the practical potential of surgical treatment. The situation is illustrated by our results from the years 2004-2006. During the last 3 years 19 patients were operated on for infection of the arterial reconstruction (15 ways aorto-femoral and 4 ways femoro-popliteal bypass). The main agent was Staphylococcus aureus (9 patients, i.e. 47.4%). In most cases explantation of the whole infected reconstruction was performed (13 patients). The early mortality rate is 26.3%. Amputation was necessary in 6 patients (i.e. 31.5%). Our results are fully comparable to those from other centres of vascular surgery.

Concentration of haemodynamic and inflammatory related cytokines in diabetic retinopathy.

AIM: There are changes in blood flow during the clinical stages of diabetic retinopathy with increasing leukostasis and secondary elaboration of cytokines. This study evaluated the vitreous concentrations of haemodynamic-related (endothelin-1 (ET-1) and nitric oxide (NO)), inflammatory and anti-inflammatory (interleukin-1 receptor antagonist, IL-1 Ra) cytokines in the diabetic patients (with nonproliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR)), compared them with those of control patients (full thickness macular hole, FTMH) and correlated to macular structural indices. METHOD: Vitreous samples from five FTMH patients representing normal controls were analysed together with the vitreous samples of 15 patients with NPDR and five with PDR. The vitreous concentrations of nitrite (total NO), ET-1, and prostacyclin was determined using ELISA kits (R&D Systems, Minneapolis, MN, USA) according to the manufacturer's instructions. A sandwich luminescent immunoassay technique was used to determine IL-1beta and IL-1 Ra concentrations. RESULTS: In the different clinical groups, there were no differences in the vitreous NO and prostacyclin concentrations. In NPDR, the median ET-1 concentration (0.7 pg/ml SD +/-0.8 pg/ml) was significantly reduced (P<0.05), compared to PDR (6.35 pg/ml SD +/-0.6 pg/ml) and FTMH (3.6 pg/ml SD +/-0.14 pg/ml). Its concentration also positively correlated with foveal thickness and macular volume (P<0.05) in patients with NPDR and macular oedema. IL-1 beta was detected in PDR, and diabetic patients demonstrated a lower concentration of the anti-inflammatory cytokine IL-1 Ra. CONCLUSION: Reduced concentrations of ET-1 in NPDR may reflect the haemodynamic changes of NPDR. The IL-1 Ra concentration suggests a change in the anti-inflammatory environment of the diabetic retina.

Urgent pedal bypass grafting for salvage of a critically ischaemic limb with a thrombosed popliteal aneurysm.

The absence of infra-popliteal runoff in patients with acute limb-threatening ischaemia due to thrombosed popliteal aneurysm entails a high risk of amputation. If sufficient runoff cannot be restored by thrombolysis of crural arteries or by thrombectomy, the only chance to salvage the limb is pedal bypass grafting. The authors present a clinical case of acute lower limb ischaemia in a patient with popliteal aneurysm thrombosis and occlusion of the crural arteries treated successfully with urgent pedal bypass grafting with distal anastomosis to the dorsal pedal artery.

Pedal bypass grafting on arteriographically invisible foot arteries detected by duplex ultrasound for limb salvage.

AIM: In this study the long-term outcomes in patients undergoing pedal bypass grafting were evaluated and the risk of graft occlusion was related to whether, preoperatively, the pedal arteries were visualized by angiography or not and were only detected by duplex ultrasonography. METHODS: In 2000-2005, 81 pedal bypass grafts were performed in patients with chronic critical lower-limb ischemia, of which 54 (66.7%) had diabetes. Tissue loss (SVS/ISCVS-category 5) was recorded in 68 (84%) limbs and rest pain (SVS/ISCVS-category 4) in 13 (16%) limbs. In 24 limbs (29.6%) bypass grafts were implanted on the pedal arteries that had not been visualized by preoperative angiography, but had been detected only by duplex ultrasound. RESULTS: During the follow-up (median, 17 months; range, 3-69 months), 18 grafts (22.2%) failed. Seven limbs had to be treated by early thrombectomy, which resulted in long-term graft patency and limb salvage. The early postoperative mortality rate was 2.5%. Cumulative primary and secondary graft patency rates, and limb-salvage rates were 70.2%, 80.2% and 82.4%, respectively. No significant difference in graft occlusion was found between the patients with visible and those with not visible pedal arteries on preoperative arteriograms (Fisher's exact test). CONCLUSIONS: Duplex ultrasonography is a reliable modality for detection of target pedal arteries not visualized by preoperative arteriography and it helps reduce the number of patients with non-operable arterial occlusion disease by about 25%.

[Infection in vascular reconstructive surgery]. / Infekce v rekonstrukcní cévní chirurgii.

PURPOSE: Infection is one of the most serious complications in vascular surgery. METHODS: We summarize the patients operated on in our clinic during a 3-year period for infection of the arterial reconstruction. RESULTS: 577 primary arterial reconstructions were performed in the region of abdominal aorta and lower limb arteries during the years 2003-2005. In the same period 17 patients were operated on for infection of the arterial reconstruction grade III of Szilagyi (13x aortofemoral, 4x femoropopliteal region). The main agent of infection was Staphylococcus aureus (47.1%). In most cases the therapy involved revision of the infected groin (10x) with subsequent explantation of the reconstruction (7 patients). Eight extraanatomic reconstructions were performed. Three patients died during the follow-up (2 within 30 days of an operation). The one year mortality rate is 17.6%. Amputation was necessary in 6 patients (i.e. 35.3%) CONCLUSIONS: Handling vascular infection still remains a challenging diagnostic and therapeutic problem.

Vascular shunt of the optic disc resembling neovascularization in a diabetic patient with optic disc drusen.

PURPOSE: To report an insulin-dependent diabetic patient who was referred by the diabetic screening clinic as having proliferative diabetic retinopathy who was found to have bilateral optic disc drusen with optociliary shunt resembling neovascularization on the disc. METHODS: Complete ocular evaluation including a fluorescein angiography was performed. RESULTS: Fundus examination showed signs of mild nonproliferative diabetic retinopathy in the right eye and the presence of well-defined optic disc drusen in both eyes with a peculiar vascular abnormality resembling neovascularization on the right disc. The central retinal vein pulsation was normal on digital examination. Autofluorescence confirmed the presence of the optic disc drusen in both eyes. Fluorescein angiography showed no leakage from the optociliary shunt. The vascular abnormality has remained stable for 2 years. CONCLUSIONS: This case highlights the correlation of optic disc drusen and optociliary shunts which in diabetic patients can be misdiagnosed as neovascularization.

[Rupture of the renal artery aneurysm in a patient with symptoms of a systemic connective tissue disorder--A case review]. / Ruptura aneuryzmatu renální tepny u pacientky s projevy systémového postizení pojiva--kazuistika.

The renal arteries aneurysms are relatively rare, however, their rupture has a high mortality rate. The authors present a case-review of a 38-year old female, hospitalized with a pain in the left lumbar region, lasting for 24 hours, which spread into the mesogastrium and the left groin. Upon angiographic examination, the left renal artery aneurysm was detected. Embolization was conducted, aiming to save the kidney, however, it proved unsuccessful and was complicated by a rupture of the aneurysm. Consequently, urgent nephrectomy was completed. Prior to the procedure, massive haemorrhaging from the right groin following angiography, was managed. Relapsing haemorrhaging from the right groin and development of a major retroperitoneal haematoma, complicated the postoperative course and required repetitive postoperative revisions. The accidental finding of a minor aneurysm of the lienal artery, the patient's constitution, her anamnestic data and the complicated course of hospitalization, suggested the systemic connective tissue disorder. Furthermore, the authors discuss contemporary diagnostic and therapeutic approach to the renal arteries aneurysms.

Diabetic macular oedema: pilot randomised trial of pars plana vitrectomy vs macular argon photocoagulation.

INTRODUCTION: Focal macular photocoagulation for clinically significant macular oedema (CSME) is the proven method for treatment of this condition, but with little chance of visual improvement. Pars plana vitrectomy (PPV) may produce resolution of macular oedema and improvement in visual acuity. However, there have been no randomised trials to ascertain role of vitrectomy in the management of persistent CSME. METHODS: Patients with persistent CSME despite previous macular photocoagulation and Snellen visual acuity 6/15 to 6/60 were recruited. Dilated fundoscopy, best-corrected visual acuity including Early Treatment Diabetic Retinopathy Study (ETDRS) vision, ocular coherence tomography and fundus fluorescein angiography (FFA) at baseline and up to 12 months post-treatment was performed. Exclusion criteria were signs of posterior vitreous detachment, macular traction or the taut posterior hyaloid face syndrome, or macular ischaemia on FFA. In all, 20 patients were randomised (10 in each arm) to either standard macular photocoagulation or PPV and removal of the posterior hyaloid face. RESULTS: Of the 20 patients recruited, seven patients completed the protocol in the vitrectomy and eight in the laser arms, respectively. There was little evidence of any difference in the foveal thickness at 12 months between the two treatment arms despite a gradual improvement. Only one patient, from the vitrectomy arm, suffered moderate visual loss (defined as loss of 15 ETDRS letters) (our primary outcome). DISCUSSION: In this pilot RCT, standard PPV provides little visual benefit compared to macular photocoagulation, but a larger definitive study is required to confirm this early appraisal.