Management of optic disc pit maculopathy: the European VitreoRetinal society optic pit study.

PURPOSE: To evaluate a variety of techniques, and their anatomical and functional results, for the treatment of optic disc pit maculopathy (ODP-M). A secondary aim was to report on results of secondary procedures in cases of initial failure or recurrence. METHODS: Multicentre retrospective study of 95 eyes with ODP-M, treated by 25 surgeons from 12 countries. Primary outcomes were anatomical resolution of subretinal fluid (SRF), intraretinal fluid (IRF) and visual acuity (VA) at 12 months. RESULTS: Higher rates of SRF and IRF resorption were achieved in eyes treated with pars plana vitrectomy (PPV) compared to external laser with or without tamponade: 64/72 (88.9%) versus 8/14 (57.1%) for SRF (p = 0.003), and 50/59 (84.7%) versus 3/10 (30%) for IRF (p = 0.002). The addition of juxtapapillary laser or internal limiting membrane (ILM) peel during PPV did not improve SRF or IRF resolution. Pars plana vitrectomy (PPV) with tamponade and PPV with tamponade plus endolaser were associated with significant visual gain. In the former group, VA improved from a mean of logMAR 0.91 (20/162), to a mean of logMAR 0.52 (20/66) at 12 months; in the latter group, VA improved from a mean of logMAR 0.82 (20/132) to a mean of logMAR 0.47 (20/59) at 12 months. Retreatments were performed in 14 eyes (15.7%), only enhancing anatomical outcomes. CONCLUSION: Vitrectomy with tamponade had better final outcomes than external laser treatment with or without gas tamponade. Laser endophotocoagulation and ILM peel provided no additional benefit. A secondary treatment resulted in anatomical but not functional improvement.

Usefulness of Controlled Attenuation Parameter and Liver Stiffness Measurement for the Identification of Extended-criteria Donors and Risk-assessment in Liver Transplantation.

BACKGROUND: Controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) are noninvasive surrogates for hepatic steatosis and fibrosis, respectively, and could help identify extended criteria donors in liver transplantation (LT). We aimed to determine the accuracy of CAP/LSM in deceased donors along with post-LT changes. METHODS: Accuracy of preprocurement CAP/LSM to grade/stage steatosis/fibrosis was determined using liver biopsy as reference. Transplant outcomes, including primary nonfunction (PNF) and early allograft dysfunction, were recorded. Recipients underwent CAP/LSM as outpatients. Areas under the receiver operating characteristic curve and regression models were constructed to analyze data. RESULTS: We prospectively evaluated 160 allografts (138 transplanted). Same-probe paired baseline/post-LT CAP was 231 dB/m (181-277)/225 (187-261) (P = 0.61), and LSM 7.6 kPa (6.3-10.8)/5.9 (4.6-8.7) (P = 0.002), respectively. CAP reading was affected by BMI and LSM by ALT, race and bilirubin. Although CAP did not correlate with steatosis from frozen sections (ρ = 0.08, P = 0.47), it correlated with steatosis from permanent sections (ρ = 0.32, P < 0.001) and with oil red O histomorphometry (ρ = 0.35, P = 0.001). CAP identified moderate-to-severe steatosis with an areas under the receiver operating characteristic curve curve of 0.79 (0.66-0.91), for a negative predictive value of 100% at a cutoff value of 230 dB/m. LSM correlated with fibrosis staging (ρ = 0.22, P = 0.007) and it identified discarded allografts with advanced fibrosis/cirrhosis. Patients with no to minimal fibrosis had an LSM of 7.6 (6-10.1) kPa. CONCLUSIONS: Our results are proof-of-concept of the utility of CAP/LSM during organ procurement. Establishing the precise role of these noninvasive tools in the organ allocation process mandates confirmatory studies.

Effect of Finish Line Design and Cement Space Thickness on the Marginal Accuracy of Monolithic Zirconia Crowns / Efeito do desenho da linha de término e da espessura do espaço de cimento na precisão marginal de coroas monolíticas de zircônia

Objective: The purpose of this study was to evaluate the effect of finish line design and cement space thickness on the marginal accuracy of monolithic zirconia crowns. Materials and methods: Thirty crowns were fabricated from translucent zirconia (inCoris TZI) using Cerec in-Lab system and divided into three main groups (10 each) according to the finish line type of the die (knife-edge, chamfer, and shoulder). Every group was divided into two subgroups (5 each) according to cement space thickness (20 and50µm). Optical impressions were taken for the dies using the Cerec scanner and cement space was set twice for every finish line design; 20 and 50 µm. The completed crowns were cemented to the dies and the marginal gap was evaluated. The collected data was statistically analyzed using Mann-Whitney U test and Kruskal-Wallis test and the significance level was set at P ≤ 0.05. Results: Regarding the marginal gap; there was no statistically significant difference between different finish line designs or between different cement space thicknesses. Conclusion: Neither finish line design nor cement space thickness has an effect on the marginal gap of inCoris TZI crowns. (AU)

Declaração do problema: A necessidade de um método minimamente invasivo de preparação de coroa única é inevitável, principalmente com dentes enfraquecidos e com alta probabilidade de irritação pulpar. Portanto, é necessária uma restauração durável e adaptada, com preparação menos invasiva da linha de término. Objetivo: O objetivo deste estudo foi avaliar o efeito do design da linha de término e da espessura do espaço de cimento na precisão marginal das coroas monolíticas de zircônia. Material e Métodos: Trinta coroas foram fabricadas a partir de zircônia translúcida (inCoris TZI) usando o sistema Cerec em laboratório, e divididas em três grupos principais (n = 10), de acordo com o tipo de linha de término da matriz (lâmina, chanfro e ombro). Cada grupo foi dividido em dois subgrupos (5 cada), de acordo com a espessura do espaço do cimento (20 e 50 µm). Impressões ópticas foram obtidas para as matrizes usando o scanner Cerec e o espaço de cimento foi definido duas vezes para cada projeto de linha de chegada: 20 e 50 µm. As coroas confeccionadas foram cimentadas nos moldes e a diferença marginal foi avaliada. Os dados coletados foram analisados estatisticamente pelo teste U de Mann-Whitney e Kruskal-Wallis e o nível de significância foi estabelecido em P ≤ 0,05. Resultados: Em relação ao gap marginal não houve diferença estatisticamente significante entre diferentes projetos de linha de acabamento ou entre diferentes espessuras de espaço de cimento. Conclusão: nem o design da linha de término, nem a espessura do espaço de cimento afetam a folga marginal das coroas inCoris TZI. (AU)

Comparing the peek retina to fundus camera, direct ophthalmoscope and Volk lens for the viewing of the optic disc

Objective: To compare the Peek Retina device with a fundus camera, direct ophthalmoscope and Volk lens. Design and Methodology: The comfort for the patient, efficiency when using the equipment, image quality, time taken, and usability of the equipment were analysed for the four different equipment when the optic disc was viewed. The direct ophthalmoscope, Volk lens and the slit lamp, and a fundus camera were used to view the optic disc in 50 patients at the UWI Optometry Clinic. This four equipment comparison study was done using questionnaires for both the patient and examiner. Results: It was found that peek retina was more comfortable than direct ophthalmoscope and the Volk lens, and it was similar to the fundus camera. Likert scale values showed that the fundus camera was the most efficient and the peek retina the least. The time frame using the fundus camera was the least which was 2.94 minutes compared with using the Volk lens which took the most time of 3.98 minutes. The usability values showed that it was easier to use the fundus camera 1.58 compared to peek retina 2.68, possibly because of the lack of experience with this new device. Conclusion: There was a significant difference among the different devices for the variables examined. The fundus camera was the best at most of the variables and the Peek Retina was the least, while the Volk lens was the most chosen to view the optic disc again due to the clear, stereoscopic and wide view of the back of the eye.

Robotic transmesocolonic Pyelolithotomy of horseshoe kidney.

INTRODUCTION: The purpose of this video is to demonstrate the use of the robot to perform a transmesocolonic pyelolithotomy of a horseshoe kidney. MATERIALS AND METHODS: A 35-year old female presented with vague abdominal pain. CT scan imaging revealed the presence of a left horseshoe kidney with multiple pelvicalyceal stones. The patient was positioned in the supine position. A total of 4 ports were introduced. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. First, the dilated renal pelvis was identified behind the thin mesocolon. The mesocolon was entered and renal pelvis was dissected completely from the surrounding fat. Then, the renal pelvis was opened after adequate dissection and stones were visualized inside the calyces. By Prograsp forceps, stones were removed from all the calyces under vision and were extracted from the assistant trocar. Finally, the pylotomy incision was closed using 4 0 Maxon in a continuous fashion and the mesocolon was closed using 3 0 PDS interrupted sutures. A JP drain was placed. RESULT: Operative time was forty-five minutes, blood loss was 100 ml. The patient was discharged after 48 hours with no immediate complications. CONCLUSION: The utilization of minimal invasive surgery using the robot to extract multiple pelvicalyceal stones from a horseshoe kidney without reflecting the mesocolon proved to be a feasible and novel way in the management of complex stone disease improving the outcome with minimal morbidity.

Robotic transmesocolonic Pyelolithotomy of horseshoe kidney

Introduction The purpose of this video is to demonstrate the use of the robot to perform a transmesocolonic pyelolithotomy of a horseshoe kidney. Materials and Methods A 35-year old female presented with vague abdominal pain. CT scan imaging revealed the presence of a left horseshoe kidney with multiple pelvicalyceal stones. The patient was positioned in the supine position. A total of 4 ports were introduced. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. First, the dilated renal pelvis was identified behind the thin mesocolon. The mesocolon was entered and renal pelvis was dissected completely from the surrounding fat. Then, the renal pelvis was opened after adequate dissection and stones were visualized inside the calyces. By Prograsp forceps, stones were removed from all the calyces under vision and were extracted from the assistant trocar. Finally, the pylotomy incision was closed using 4 0 Maxon in a continuous fashion and the mesocolon was closed using 3 0 PDS interrupted sutures. A JP drain was placed. Result Operative time was forty-five minutes, blood loss was 100 ml. The patient was discharged after 48 hours with no immediate complications. Conclusion The utilization of minimal invasive surgery using the robot to extract multiple pelvicalyceal stones from a horseshoe kidney without reflecting the mesocolon proved to be a feasible and novel way in the management of complex stone disease improving the outcome with minimal morbidity. .

Investigating the impact of the local health care system in controlling blood glucose levels and preventing complications in patients with type 2 diabetes

OBJECTIVES: To determine if the local health-care system controls blood glucose levels and prevents complications in Trinidadian type 2 diabetic subjects. This study also focused on assessing the structures that are established to monitor blood glucose levels of type 2 diabetics in the public health facilities. DESIGN AND METHODS: This study was a cross-sectional retrospective study of 388 adult type 2 diabetic participants. Participants were taken from all four Regional Health Authorities (RHAs) in Trinidad. RESULTS: The mean and SD of fasting blood glucose of participants, over the 3 year monitoring period, was 197ñ61.67 and a standard error of ñ3.13. The blood glucose levels of the participants did not change significantly (p = 0.848). Results showed that the higher the fasting blood sugar values, the more complications a patient presented. Fasting blood sugar values were the standard for monitoring blood glucose levels, however HbA1c and other measures mandated under protocol were absent. CONCLUSIONS: Across all Regional Health Authorities in Trinidad, fasting blood sugar values were found to be out of control and remained high. It was noted that the higher a patient’s fasting blood sugar values, the more complications they presented.

Robotic extramucosal excision of bladder wall leiomyoma.

INTRODUCTION: Multiple case reports and reviews have been described in the literature for bladder wall leiomyoma resection via different approaches. The minimally invasive partial cystectomy remains the most widely accepted technique; however, case reports for enucleation of bladder wall leiomyoma have also been described. The purpose of this video is to demonstrate the robotic extramucosal excision of a bladder wall leiomyoma, without cystotomy, but with complete removal of the muscular layer. MATERIALS AND METHODS: A 35-year old male present with lower urinary tract symptoms and imaging showed bladder wall mass with histopathology showed leiomyoma. The patient consented for mass excision with the possibility of a partial cystectomy. The patient was placed in the supine, 30-degree Trendelenburg position during the procedure. A total of 4 ports were inserted. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. Extramucosal excision was accomplished without cystotomy and muscle approximation was achieved by 2 0 Vicryle. RESULT: The operative time was 90 minutes, blood loss of approximately 50mL and the patient was discharged after 72 hours with no immediate complications and a 6 months follow-up showed no recurrence. CONCLUSION: Such a technique results in complete excision of the tumor, without cystotomy, and also maintains an intact mucosa. These steps, in addition to decreasing the risk of local recurrence, also shorten the period of postoperative catheterization and hospitalization.

Surgical management of exertional anterior compartment syndrome of the leg / Tratamiento quirúrgico del síndrome compartimental anterior de la pierna por esfuerzo excesivo

OBJECTIVE: To describe the characteristic presentation of exertional leg pain in athletes and to discuss the diagnostic options and surgical management of exertional anterior compartment syndrome of the leg in this group of patients. METHODS: Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology. RESULTS: Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. Sixteen patients in a first group of 20 patients with a provisional diagnosis of exertional anterior compartment syndrome of the leg underwent a closed fasciotomy with complete resolution of symptoms. A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia. CONCLUSION: Exertional leg pain is a common presenting complaint of athletes to sports physicians and physiotherapists. Careful analysis can lead to an accurate diagnosis and commencement of effective treatment. Exertional anterior compartment syndrome can be successfully treated utilizing a closed fasciotomy with a rapid return to sport.

OBJETIVO: Describir las manifestaciones características del dolor en la pierna que presentan los atletas, y discutir las opciones de diagnósticos y tratamiento quirúrgico del síndrome compartimental de la pierna en este grupo de pacientes. MÉTODOS: Los datos de una serie de atletas con dolor en la pierna debido al esfuerzo excesivo en los ejercicios, fueron analizados y categorizados según la etiología. RESULTADOS: Sesenta y seis atletas con dolor de piernas debido al esfuerzo excesivo en 102 miembros fueron analizados. Dieciséis pacientes en un primer grupo de 20 pacientes con un diagnóstico provisional de síndrome compartimental anterior de la pierna por esfuerzo experimentaron fasciotomía cerrada con resolución completa de los síntomas. Un segundo grupo de 42 pacientes fueron diagnosticados con síndrome de estrés medial de la tibia, y a un tercer grupo de cuatro pacientes se le confirmó fractura por estrés o sobrecarga de la tibia. CONCLUSIÓN: El dolor de la pierna por esfuerzo en los ejercicios es una queja común con las que los acuden a los médicos y fisioterapeutas de la medicina deportiva. Un análisis cuidadoso puede conducir a un diagnóstico preciso y al comienzo de un tratamiento eficaz. El síndrome compartimental anterior por esfuerzo puede tratarse con éxito utilizando una fasciotomía cerrada que permita un rápido retorno a la actividad deportiva.

Surgical management of exertional anterior compartment syndrome of the leg.

OBJECTIVE: To describe the characteristic presentation of exertional leg pain in athletes and to discuss the diagnostic options and surgical management of exertional anterior compartment syndrome of the leg in this group of patients. METHODS: Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology. RESULTS: Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. Sixteen patients in a first group of 20 patients with a provisional diagnosis of exertional anterior compartment syndrome of the leg underwent a closed fasciotomy with complete resolution of symptoms. A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia. CONCLUSION: Exertional leg pain is a common presenting complaint of athletes to sports physicians and physiotherapists. Careful analysis can lead to an accurate diagnosis and commencement of effective treatment. Exertional anterior compartment syndrome can be successfully treated utilizing a closed fasciotomy with a rapid return to sport.

Screening thoroughbreds for antibodies to the Equine infectious anemia virus.

One hundred and seventy two Thoroughbreds were screened for the presence of anitbodies to the capsid protein, p26 of the equine infectious anemia (EIA)virus using agarose gel immunodiffusion (AGOD) Coggins test. Horses ranged in age from 1 month to 21 years old and were either imported or locally bred. The majority were involved in racing and breeding and were housed either at the Santa Rosa Racing Complex at Arima or at privately owned farms. Complete blood counts (CBCs) were performed on all horses. Low haemoglobin concentrations were found in 18(10.5%), high white blood cell counts in 17 (9.9%) with neutrophilia in 13 (7.6%). Low red blood cell counts were seen in 11 of 154 horses (7.1%). At least 12 horses had evidence of clinical babesiosis, but only 7 were confirmed infected by examination of Giemsa stained blood smears. Racehorses from trinidad and Tobago occasionally move inter-island for racing and increasingly come in contact with foreign horses with the increasing importation of horses from countries known to harbour the virus. All 172 horses tested negative for antibodies to EIA virus. This implies that the strict adherence to import and quarantine regulations may have contributed to keeping the country free from EIA virus. This ongoing study is the first to provide sero-prevalence data and document the prevalence of EIA in the equine population in Trinidad and Tobago.

Screening thoroughbreds for antibodies to the Equine infectious anemia virus.

One hundred and seventy two Thoroughbreds were screened for the presence of anitbodies to the capsid protein, p26 of the equine infectious anemia (EIA)virus using agarose gel immunodiffusion (AGOD) Coggins test. Horses ranged in age from 1 month to 21 years old and were either imported or locally bred. The majority were involved in racing and breeding and were housed either at the Santa Rosa Racing Complex at Arima or at privately owned farms. Complete blood counts (CBCs) were performed on all horses. Low haemoglobin concentrations were found in 18(10.5%), high white blood cell counts in 17 (9.9%) with neutrophilia in 13 (7.6%). Low red blood cell counts were seen in 11 of 154 horses (7.1%). At least 12 horses had evidence of clinical babesiosis, but only 7 were confirmed infected by examination of Giemsa stained blood smears. Racehorses from trinidad and Tobago occasionally move inter-island for racing and increasingly come in contact with foreign horses with the increasing importation of horses from countries known to harbour the virus. All 172 horses tested negative for antibodies to EIA virus. This implies that the strict adherence to import and quarantine regulations may have contributed to keeping the country free from EIA virus. This ongoing study is the first to provide sero-prevalence data and document the prevalence of EIA in the equine population in Trinidad and Tobago.

Combined Monteggia and Galeazzi fractures in a child's forearm

The Monteggia fracture dislocation and Galeazzi fracture dislocation are well recognized in isolation. The incidence of both of these fractures in the same forearm is rare. Only two other cases have been reported. This case report highlights the importance of early diagnosis and treatment of this combined fracture in a multiple trauma patient.

Free vascularized fibula graft for a cystic femoral head and neck lesion in the West Indies.

A case is presented of an 18-year-old athlete with fibrous dysplasia of the femoral neck and head. The approach was by joint plastic and orthopaedic teams, which minimized operating time and allowed the option of vascular bone grafting. The lesion was curetted through a greater trochanteric window and the defect reconstructed with a free vascularized fibula graft with excellent result. Weight bearing was achieved in six months and there was minimal donor site morbidity. We believe the free vascularized fibula graft to be a reconstructive option, in difficult orthopaedic problems, facilitated by microsurgery and there is immense benefit of a joint effort between the orthopaedic and plastic surgical teams.

Free vascularized fibula graft for a cystic femoral head and neck lesion in the West Indies

A case is presented of an 18-year-old athlete with fibrous dysplasia of the femoral neck and head. The approach was by joint plastic and orthopaedic teams, which minimized operating time and allowed the option of vascular bone grafting. The lesion was curetted through a greater trochanteric window and the defect reconstructed with a free vascularized fibula graft with excellent result. Weight bearing was achieved in six months and there was minimal donor site morbidity. We believe the free vascularized fibula graft to be a reconstructive option, in difficult orthopaedic problems, facilitated by microsurgery and there is immense benefit of a joint effort between the orthopaedic and plastic surgical teams

A case report of post-traumatic facial reconstruction in the West Indies.

The radial forearm free flap is one of the most commonly used free flaps in reconstructive surgery. It is a recognized option for facial reconstruction internationally, but, to our knowledge, it has not been widely used in the Caribbean. We present a patient who posed a difficult reconstructive problem, for which the radial forearm free flap was the ideal solution, utilizing the flap's features of a long length of pedicle, large area of coverage, minimal tissue bulk, and options for further cosmetic revision.

Latissimus dorsi muscle flap based on arterial branch to serratus anterior as salvage of a failed bipedicled transverse rectus abdominis muscle flap. A case report.

We present a case of a failed bipedicled (unilateral rectus flap with superior epigastric pedicle preserved and inferior epigastric vessels anastomosed to the thoracodorsal trunk as the second pedicle) transverse rectus abdominis muscle flap that had compromised the dominant pedicle of the latissimus dorsi muscle. A salvage procedure was possible using this muscle as a pedicle flap based on the back-flow from the serratus anterior arterial branch with success. The use of the reconstructive ladder is highlighted.

Latissimus dorsi muscle flap based on arterial branch to serratus anterior as salvage of a failed bipedicled transverse rectus abdominis muscle flap. A case report

We present a case of a failed bipedicled (unilateral rectus flap with superior epigastric pedicle preserved and inferior epigastric vessels anastomosed to the thoracodorsal trunk as the second pedicle) transverse rectus abdominis muscle flap that had compromised the dominant pedicle of the latissimus dorsi muscle. A salvage procedure was possible using this muscle as a pedicle flap based on the back-flow from the serratus anterior arterial branch with success. The use of the reconstructive ladder is highlighted

A case report of post-traumatic facial reconstruction in the West Indies

The radial forearm free flap is one of the most commonly used free flaps in reconstructive surgery. It is a recognized option for facial reconstruction internationally, but, to our knowledge, it has not been widely used in the Caribbean. We present a patient who posed a difficult reconstructive problem, for which the radial forearm free flap was the ideal solution, utilizing the flap's features of a long length of pedicle, large area of coverage, minimal tissue bulk, and options for further cosmetic revision

Pedicled flaps in reconstructive surgery.

An audit was conducted of pedicled flaps used in reconstructive surgery in Trinidad from 1983 to 2000. This consisted of 65 flaps. There were four cases of partial flap necrosis: three involving tram flaps and the other involving the metacarpal artery flap. There were no cases of total flap loss. Pedicled flap coverage provides immediate closure of potentially difficult wounds. This early cover reduces the risk of infection as a result of increasing the blood supply and providing a physical barrier. This contributes to a shorter hospital stay and earlier rehabilitation. Our present team approach with the inclusion of a reconstructive surgeon now allows for uncompromised débridement in trauma and oncological resection.