Case report of post streptococcal multifocal choroiditis in a young pregnant female: A success story.

BACKGROUND: Multifocal choroiditis (MFC) is described as a chronic bilateral progressive inflammatory outer chorioretinopathy, that usually affects healthy myopic Caucasian women with no associated systemic/ocular diseases. This patient had a severe acute presentation of aggressive multifocal choroiditis that was treated with systemic steroids. CASE PRESENTATION: This is a retrospective case report of a 30-year-old, white, European, female who was 10 weeks pregnant. She had bilateral severe vision loss and rapidly progressive rash and arthritis. The patient was extensively investigated for inflammatory and infectious etiologies by a multidisciplinary team including rheumatology and obstetrics and gynecology. Antistreptolysin levels were moderately raised. Serial retinal optical coherence tomography scans were performed and were critical for assessing disease activity and demonstrating the extent of retinal and choroidal lesions. CONCLUSION: This was a challenging case as the patient was pregnant. Nevertheless, a multidisciplinary team, opted for treatment with systemic steroids which then lead to recovery of her vision.

Toxoplasmosis Related Neuroretinitis: More than Meets the Eye.

BACKGROUND: The intracellular protozoan Toxoplasma (T. gondii) is a parasitic infection, normally asymptomatic in immunocompetent patients. It often manifests ophthalmically, with focal necrotizing retinitis, and is more rarely associated with vitritis and anterior uveitis. Neuroretinitis, which results in severe, painless visual loss, optic disc edema, and a macular star, is an unusual first presentation of toxoplasmosis which despite being rare, when it does occur tends to affect young, immunosuppressed patients. CASE PRESENTATION: This case report describes a 34-year-old, white, European, immunocompetent female, who developed sudden visual loss and was found to have optic disc edema and stellate macular exudates. She was managed in an ophthalmic unit in the UK, a country with a low prevalence of toxoplasmosis Following extensive investigation, confirming Toxoplasma the standard anti-toxoplasmosis treatment was commenced, resulting in visual improvement over the following 6 months. CONCLUSION: Toxoplasmic neuroretinitis should be considered with no background of systemic illness and in the absence of classical risk factors.

Sequence of mixed ophthalmic operating lists: A national survey of UK consultants.

Ophthalmic surgical operating lists include intraocular and extraocular procedures, as well as clean non-infectious and dirty infectious cases. Patient age, diabetic status, local or general anaesthesia must be considered during ophthalmic theatre scheduling. Traditionally children and 'clean cases' are prioritised. However, factors such as the need for an interpreter, patient transport and latex allergy affect the sequencing of ophthalmic lists. An electronic survey was sent to all UK ophthalmology consultants through the Royal College of Ophthalmologists registry, enquiring about their preference in sequencing mixed theatre lists, what operations they considered clean and dirty, and the presence of departmental protocol for list sequencing. There was a 16.9% response rate (n = 222/1311). A majority of 75.2% (n = 167/222) had mixed operating lists of intraocular and extraocular cases. Of those performing mixed operating lists, 44.3% (n = 74/167) stated they would operate on intraocular cases before extraocular cases, and 92.8% (n = 155/167) would perform 'clean' before 'dirty' cases. Fifty-nine per cent (n = 98/167) have a departmental protocol to help determine list order. This survey has demonstrated that there is a trend to perform 'clean' before 'dirty' and intraocular before extraocular cases. Given the results of the survey, we outline our recommendation on how to sequence mixed ophthalmic theatre lists.

Comparison between different techniques for treatment of submacular haemorrhage due to Age-Related Macular Degeneration.

PURPOSE: To compare the outcome of vitrectomy, subretinal tissue plasminogen activator (TPA), and gas with and without subretinal air versus Intravitreal TPA and gas in the treatment of submacular haemorrhage (SMH) due to Neovascular age related macular degeneration. METHODS: We analysed the notes of 29 cases presented with SMH in the period between 01/2016 and 09/2018 at James Cook University Hospital. Presenting visual acuity (BCVA), size and location of SMH, Procedure done, final BCVA at 6 months and any surgical complications were recorded. 11 Cases (Group 1) received intravitreal TPA (50 µg in 0.1 ML), 0.3 ml of pure sulfur hexafluoride (SF6). 18 cases (Group 2) received 23 G Pars Plana vitrectomy, Subretinal TPA injection (25 µg in 0.1 ml), and 20% SF6 gas filling. Group 2 was further divided into 2A (10 patients) who received only subretinal TPA and group 2B (8 patients) who received additional 0.1 ml subretinal air. RESULTS: The mean BCVA at presentation was 0.0068 in group 1 and 0.0067 in group 2 (p = 0.8734). The mean postoperative BCVA at 6 months was 0.31 in group 1 and 0.58 in group 2 (p = 0.0015). Subgroup analysis of group 2 didn't show statistically significant difference in outcome when adding subretinal air to the vitrectomy procedure (p = 0.7009). CONCLUSION: Vitrectomy, gas and subretinal TPA has more successful displacement rate and better visual outcome than Intravitreal TPA & Gas alone in treating SMH involving the fovea in age-related macular degeneration. Additional subretinal air doesn't seem to improve the outcome in cases having vitrectomy.

Comparison of 640-Slice Multidetector Computed Tomography Versus 32-Slice MDCT for Imaging of the Osteo-odonto-keratoprosthesis Lamina.

PURPOSE: To investigate the efficacy of 640-slice multidetector computed tomography (MDCT) for detecting osteo-odonto laminar resorption in the osteo-odonto-keratoprosthesis (OOKP) compared with the current standard 32-slice MDCT. METHODS: Explanted OOKP laminae and bone-dentine fragments were scanned using 640-slice MDCT (Aquilion ONE; Toshiba) and 32-slice MDCT (LightSpeed Pro32; GE Healthcare). Pertinent comparisons including image quality, radiation dose, and scanning parameters were made. RESULTS: Benefits of 640-slice MDCT over 32-slice MDCT were shown. Key comparisons of 640-slice MDCT versus 32-slice MDCT included the following: percentage difference and correlation coefficient between radiological and anatomical measurements, 1.35% versus 3.67% and 0.9961 versus 0.9882, respectively; dose-length product, 63.50 versus 70.26; rotation time, 0.175 seconds versus 1.000 seconds; and detector coverage width, 16 cm versus 2 cm. CONCLUSIONS: Resorption of the osteo-odonto lamina after OOKP surgery can result in potentially sight-threatening complications, hence it warrants regular monitoring and timely intervention. MDCT remains the gold standard for radiological assessment of laminar resorption, which facilitates detection of subtle laminar changes earlier than the onset of clinical signs, thus indicating when preemptive measures can be taken. The 640-slice MDCT exhibits several advantages over traditional 32-slice MDCT. However, such benefits may not offset cost implications, except in rare cases, such as in young patients who might undergo years of radiation exposure.

Oral feeding following laryngectomy: early or delayed?

A best evidence topic in otolaryngology was written according to a structured protocol. The question addressed was: In patients having undergone laryngectomy, does the timing of oral feeding lead to a higher post-operative complication rate? 172 papers were found using the described protocol. Five of these papers were chosen to describe the best evidence to address the question. The authors, date and country of publication, study type, patient group, outcomes and key results of these papers have been represented in a table. All of these studies demonstrate that initiation of early feeding in patients post-laryngectomy provides no increased risk of development of pharyngocutaneous fistulas than delayed initiation of feeding. One study demonstrated a statistically significant reduction in hospitalisation of patients after early post-operative feeding. Therefore despite problems with study design, the literature concludes that early feeding is as safe as delayed feeding and may reduce the hospitalisation period. Further powered studies are required before recommendations on explicit inclusion criteria and feeding regimen details can be made.

Evidence based management for paediatric burn: new approaches and improved scar outcomes.

Little evidence has been produced on the best practice for managing paediatric burns. We set out to develop a formal approach based on the finding that hypertrophic scarring is related to healing-time, with durations under 21 days associated with improved scar outcome. Incorporating new advances in burn care, we compared outcomes under the new approach to a cohort treated previously. Our study was a retrospective cross-sectional case note study, with demographic, treatment and outcome information collected. The management and outcome of each case was assessed and compared against another paediatric burns cohort from 2006. 181 burns presenting across a six month period were analysed (2010 cohort) and compared to 337 children from a previous cohort from 2006. Comparison of patients between cohorts showed an overall shift towards shorter healing-times in the 2010 cohort. A lower overall rate of hypertrophic scarring was seen in the 2010 cohort, and for corresponding healing-times after injury, hypertrophic scarring rates were halved in comparison to the 2006 cohort. We demonstrate that the use of a structured approach for paediatric burns has improved outcomes with regards to healing-time and hypertrophic scarring rate. This approach allows maximisation of healing potential and implements aggressive prophylactic measures.

Laparoscopic simulation for all: two affordable, upgradable, and easy-to-build laparoscopic trainers.

BACKGROUND: Laparoscopic surgery has established itself as the approach of choice for a multitude of operations in general, urological, and gynecological surgery. A number of factors make performing laparoscopic surgery technically demanding, and as such it is crucial that surgical trainees hone their skills safely on trainers before operating on patients. These can be highly expensive. Here, we describe a novel and upgradable approach to constructing an affordable laparoscopic trainer. METHODS: A pattern was produced to build an upgradable laparoscopic trainer for less than $100. The basic model was constructed from an opaque plastic crate with plywood base, 2 trocars, and 2 pairs of disposable laparoscopic instruments. A laptop, a light emitting diode (LED), and a fixed webcam were utilized to visualize the box interior. An enhanced version was also created, as an optional upgrade to the basic model, featuring a neoprene-trocar interface and a simulated mobile laparoscope. RESULTS: The described setup allowed trainees to gain familiarity with laparoscopic techniques, beginning with simple manipulation and then progressing through to more relevant procedures. Novices began by moving easy-to-grasp objects between containers and then attempting more challenging manipulations such as stacking sugar cubes, excising simulated lesions, threading circular mints onto cotton, and ligating fastened drinking straws. These techniques have introduced the necessity of careful instrument placement and have increased trainees' dexterity with laparoscopy. CONCLUSIONS: Here, we have outlined an upgradable and affordable alternative laparoscopic trainer that has given many trainees crucial experience with laparoscopic techniques, allowing them to safely improve their manual skill and confidence.

Surgical management of chronic subdural haematoma: one hole or two?

A best evidence topic in neurosurgery was written according to a structured protocol. The question addressed was: In patients undergoing craniostomy for the evacuation of chronic subdural haematoma, does the use of two burr-holes compared to one burr-hole improve clinical outcomes? A total of 238 papers were identified using the reported search protocol. Four of these articles represented the best evidence to answer the clinical question. The authors, date and country of publication, study type, patient group, outcomes and key results of these papers have been represented in a table. Three out of four studies showed that there was no significant difference in prevalence or rate of haematoma recurrence between two burr-hole craniostomy or one burr-hole craniostomy. Two studies demonstrated shorter hospital stay with two burr-hole craniostomy. Furthermore, one study showed increased rates of wound infection with one burr-hole craniostomy. Therefore, the clinical bottom line is that performing either two burr-hole craniostomy or one burr-hole craniostomy does not provide specific differences in patient outcome improvement following surgery for chronic subdural haematoma, however further research is required owing to the flawed methodology of existing studies.

The polo-like kinase inhibitor BI 2536 exhibits potent activity against malignant plasma cells and represents a novel therapy in multiple myeloma.

OBJECTIVE: Polo-like kinase 1 (Plk1) is a regulator of the cell cycle that has been implicated in the pathology of many cancers. We have investigated whether this kinase plays a role in multiple myeloma (MM) using the Plk1 inhibitor BI 2536. MATERIALS AND METHODS: We have used six MM cell lines and six patient-derived samples to determine the effects of the Plk1 inhibitor, BI 2536, on cell viability, apoptosis, and cytokinesis. We have also examined the effect of the microenvironment on these parameters and the effects of BI 2536 in combination with other antimyeloma agents. RESULTS: We show that MM cell lines and patient samples express PLK1 and that cell death by apoptosis occurs when Plk1 is inhibited. Cells treated with BI 2536 accumulate in the G(2)/M phase of the cell cycle causing endoduplication. The effects of BI 2536 are not abrogated when cells are cultured on extracellular matrix components, in the presence of interleukin-6, or with bone marrow stromal cells. CONCLUSIONS: Plk1 inhibition leads to cell death in MM cell lines and patient myeloma samples. Our data suggest that inhibition of Plk1 may have potential use as a therapeutic strategy in multiple myeloma.