Comparison of non-absorbable silk and absorbable polyglactin sutures for external ptosis repair.

Purpose: The authors compare the outcomes and revision rates for external levator aponeurotic advancement for the treatment of involutional ptosis using non-absorbable silk and absorbable polyglactin sutures.Methods: An IRB-approved retrospective chart review identified 121 patients who underwent external levator advancement for involutional ptosis between 2015 and 2016 by the senior author (JBH).  All patients underwent ptosis repair using either 5-0 polyglactin 910 on a S-14 spatulated needle or 6-0 silk on a G-1 reverse cutting needle for the aponeurotic advancement. Ptosis etiologies other than involutional ptosis were excluded. Patients with >0.5 mm of upper lid height asymmetry post-operatively underwent surgical adjustment. Demographics, clinical findings and revision rates were collected and analyzed from follow-up visits.Results: 116 patients (190 eyelids) met inclusion criteria. Fewer ptosis repairs performed using silk sutures necessitated adjustment when compared to those using polyglactin (1/73 [1.4%] vs. 14/117 [12.0%], p = 0.010). Silk direct connection sutures had no better stability than polyglactin direct connection sutures (p = 0.16), but silk hang-back sutures were significantly superior to polyglactin hang-back sutures (p = 0.035).  Thirteen out of fifteen (86.7%) revisions were advancements to raise the eyelid, while two (13.3%) were recessions.Conclusion: Non-absorbable silk suture may be superior to absorbable polyglactin, necessitating fewer surgical revisions. Silk demonstrated superiority to polyglactin when a hang-back suture was employed. Since the need to place direct or hang-back sutures cannot be made pre-operatively, the authors modified their technique to utilize silk sutures for external aponeurotic ptosis repair.

Pharmacokinetics of a commercially available product and a compounded formulation of extended-release levetiracetam after oral administration of a single dose in cats.

OBJECTIVE: To compare pharmacokinetics of levetiracetam in serum and CSF of cats after oral administration of extended-release (ER) levetiracetam. ANIMALS: 9 healthy cats. PROCEDURES: Cats received 1 dose of a commercially available ER levetiracetam product (500 mg, PO). Thirteen blood and 10 CSF samples were collected over a 24-hour period for pharmacokinetic analysis. After 1 week, cats received 1 dose of a compounded ER levetiracetam formulation (500 mg, PO), and samples were obtained at the same times for analysis. RESULTS: CSF concentrations of levetiracetam closely paralleled serum concentrations. There were significant differences between the commercially available product and the compounded formulation for mean ± SD serum maximum concentration (Cmax; 126 ± 33 µg/mL and 169 ± 51 µg/mL, respectively), Cmax corrected for dose (0.83 ± 0.10 µg/mL/mg and 1.10 ± 0.28 µg/mL/mg, respectively), and time to Cmax (5.1 ± 1.6 hours and 3.1 ± 1.5 hours, respectively). Half-life for the commercially available product and compounded formulation of ER levetiracetam was 4.3 ± 2.0 hours and 5.0 ± 1.6 hours, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: The commercially available product and compounded formulation of ER levetiracetam both maintained concentrations in healthy cats 12 hours after oral administration that have been found to be therapeutic in humans (ie, 5 µg/mL). Results of this study supported dosing intervals of 12 hours, and potentially 24 hours, for oral administration of ER levetiracetam to cats. Monitoring of serum concentrations of levetiracetam can be used as an accurate representation of levetiracetam concentrations in CSF of cats.

Pigmented Epithelioid Melanocytoma of the Cheek, Orbit, and Intracranial Cavity: A Case Report.

Pigmented epithelioid melanocytoma (PEM) of the skin has been rarely reported in ophthalmology. The purpose of this case report is to present a young male born with a progressive, hyperpigmented lesion involving the orbit and intracranial cavity diagnosed as PEM. The case is unique given the young age and the size, multifocality, and growth of this tumor. Identification of this lesion is paramount due to its low-grade malignant potential.

Practice variation and resource use in the evaluation of pediatric vasovagal syncope: are pediatric cardiologists over-testing?

Syncope is a common problem in children and adolescents. Usually vasovagal in etiology, this benign problem often results in considerable testing and expense. We sought to define the current practice, practice variation, and resource utilization as well as evaluate a screening strategy for syncope at an academic tertiary care center. We reviewed the medical records of all patients age 8 to 19 years who presented with syncope between January 1994 and January 2012 and collected data regarding demographics, history, physical examination, and diagnostic tests. Practice variation was evaluated based on provider experience and subspecialty. The sensitivity and specificity of history, physical examination, and electrocardiogram (ECG) to identify a cardiac cause for syncope were calculated. Of the 617 patients studied, a cardiac cause for syncope was found in 15 (2 %). A screening strategy consisting of history, physical examination, and ECG was 100 % sensitive and 55 % specific for diagnosing a cardiac cause for syncope. Despite having a negative screen, 314 (54 %) patients had a total of 334 additional tests at an average charge of $983/patient. Although practice variation existed, it was not explained by provider experience or electrophysiology training. Factors associated with increased testing included greater number of clinic visits and increased frequency of events, whereas those associated with decreased testing included increased number of syncopal episodes and history of psychiatric medication use. A more standardized approach to syncope is needed to decrease resource use and cost while maintaining quality of care.