COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

Comparison of a standard locking screw versus a double-threaded cortical compression screw for fixation of die-punch fragments in distal radius fractures with volar plating.

The aim of this study was to use a compression screw in the epiphyseal medial orifice of a volar plate to reduce and stabilize the die-punch fragment in distal radius fractures (DRF) undergoing open reduction and internal fixation (ORIF). The main hypothesis was that the range of motion (ROM) in supination would be poorer when a standard screw was used. Our case series included 19 patients with an average age of 59 years (24-91) (SD -35.32) (10 male patients and 9 females) who underwent ORIF of DRFs with a volar plate. Group I included 10 patients in which the die-punch fragment was fixed with a standard locking screw and group II included the 9 patients in which the die-punch fragment was fixed with an angle stable compression screw through both cortices. At the 6-month follow-up visit, the average ROM in flexion was 83% in group I and 81% in group II (-2.327 [-13.657; 8.960]), the ROM in extension was 91% and 89% (-2.754 [-13.410; 7.602]), the ROM in pronation was 100% and 102% (+3.178 [-5.242; 11.457]), the ROM in supination 100% and 97% (-3.171 [-10.825; 4.537]), the pain level was 0.6/10 and 1/10 (+0.106 [-0.809; 0.977]), the QuickDASH score was 8.1/100 and 17.17/100 (+5.790 [-2.934; 15.012]), the PRWE was 6.2/100 and 22/100 (+13.109 [4.416; 22.779]) and the grip strength was 95% and 74% of the contralateral side (-12.478 [-24.832; 0.538]). No complications, nonunions or revision surgery were reported in the two groups. One case of secondary displacement of the die-punch fragment occurred in each group. The main hypothesis was not proven. In conclusion, despite what several biomechanical studies have suggested, the use of double-threaded compression screws for die-punch fragment fixation in DRFs does not improve the clinical outcomes compared to standard locking screws.

Outcomes of Gartland type III supracondylar fractures treated using Blount's method.

BACKGROUND: Supracondylar fractures of the elbow with major displacement are usually treated by surgical pinning and less often non-operatively as described by Blount. The objective of this study was to assess the clinical and radiological outcomes of Gartland type III supracondylar fractures treated at least 3 years earlier using Blount's method. HYPOTHESIS: Blount's method produces good outcomes after more than 3 years when used to treat Gartland type III supracondylar fractures of the humerus. METHODS: A single-centre retrospective study was done in paediatric patients who were seen within 24hours after sustaining a Gartland type III supracondylar fracture then re-evaluated at least 36 months after treatment. Closed reduction was performed either in the operating room under general anaesthesia or in the radiology suite under procedural sedation. The upper limb was then immobilised for 4 weeks using the cuff-and-collar method described by Blount (mean elbow flexion, 134°). The child was evaluated and radiographs obtained at the outpatient clinic on days 7 and 14. Functional outcomes were assessed using the 1962 SoFCOT criteria and Flynn's criteria and the radiological outcome using Baumann's angle, the humero-condylar angle, and distal fragment rotation. From 2009 to 2013, 22 patients met the inclusion criteria. Mean follow-up was 57 months. RESULTS: Clinical outcomes assessed using the 1962 SoFCOT criteria were very good in 15 patients and good in the remaining 7 patients. The rate of satisfactory outcomes according to Flynn's criteria was 100%. At last follow-up, mean Baumann's angle was 68°, mean humerocondylar angle was 42°, and 2 patients had residual rotation of the distal fragment. CONCLUSION: This work confirms the effectiveness of Blount's method for treating Gartland type III supracondylar fractures. We advocate routine first-line treatment of these fractures using Blount's method in the absence of vascular compromise and instability. LEVEL OF EVIDENCE: IV, retrospective study.

IL-10 and TGF-beta immunoregulatory cytokines rather than natural regulatory T cells are associated with the resolution phase of Vogt-Koyanagi-Harada (VKH) syndrome.

The pro-inflammatory cytokines play a critical role in the initiation and propagation of ocular autoimmune diseases. Regulation of these cytokines is generally mediated by the immunoregulatory cytokine such as IL-10 or TGF-beta. In this study, we investigated the immunoregulatory cytokine profile and frequency of natural regulatory T cells (nTregs) in patients with Vogt-Koyanagi-Harada (VKH). We obtained the peripheral blood mononuclear cells (PBMC) from patients with VKH and healthy controls. The cytokine profile from supernatants of PBMC cultured with or without phytohaemagglutinin (PHA) was measured by ELISA, the percentage of CD4(+) Foxp3(+) and CD25(high)Foxp3(+) T regulatory cells were analysed by flow cytometry, and the transcriptional level of Foxp3 expression was analysed by real-time quantitative PCR. The immunoregulatory cytokines, TGF-beta and IL-10, increased in patients with VKH in the inactive stage of the disease. We observed no significant difference in the CD4(+) Foxp3(+) and CD25(high)Foxp3(+) T cells as well as no reduction in FOXP3 mRNA expression in the patients with VKH when compared to healthy controls. We showed in our work, an increase in IFN-gamma secretion by PBMC of patients with VKH in the active stage of the disease when compared to healthy controls and patients in the inactive stage. Our data suggest that IL-10 and TGF-beta cytokines, rather than nTregs are associated with the resolution phase of the disease and may have a more relevant role in controlling this disease.

A follow-up study of Toxoplasma gondii infection in southern Brazil.

PURPOSE: To understand better the natural history of ocular toxoplasmosis by reexamining a well-characterized population in Southern Brazil. METHODS: Ophthalmological examination and serologic tests for Toxoplasma gondii infection were performed in 1997 on 383 individuals who had undergone the same evaluation in 1990. RESULTS: Of 109 seronegative subjects in 1990, 21 (19.3%) became seropositive by 1997, and 2 (1.5% of previously seronegative patients; 9.5% of those known to have seroconverted) developed ocular toxoplasmosis. Seroconversion occurred more frequently in individuals under 17 years of age (16 of 46 patients, 34.8%) than in those greater than 17 years of age (5 of 63 patients, 7.9%; p = 0.002). Of 131 seropositive individuals who did not have ocular lesions in 1990, 11 (8.3%) had typical toxoplasmic lesions in 1997. Of the 13 individuals with non-specific hyperpigmented small retinal lesions in 1990, 3 (23%) presented with typical lesions in 1997. CONCLUSIONS: Acquired T. gondii infection can result in late development of ocular lesions. Small, non-specific hyperpigmented retinal lesions may represent sites of T. gondii infection in seropositive individuals.

Resolution of microsporidial keratoconjunctivitis in an AIDS patient treated with highly active antiretroviral therapy.

PURPOSE: To report the outcome of microsporidial keratoconjunctivitis in a patient with acquired immunodeficiency syndrome (AIDS) after highly active antiretroviral therapy without any specific treatment for microsporidiosis. METHODS: Case report. A 42-year-old woman diagnosed with AIDS and severe immunodepression (CD4+ of 9 cells/mm(3) and viral load of 460,000/mm(3)), antiretroviral naive, presented with cerebral toxoplasmosis and microsporidial keratoconjunctivitis in the right eye documented by conjunctival scraping and electron microscopy. RESULTS: The patient was treated with a combination of indinavir, stavudine, and lamivudine, besides sulfadiazine and pyrimethamine. No specific treatment for the microsporidial keratoconjunctivitis was attempted. One month later, the keratoconjunctivitis had disappeared. CONCLUSION: This case suggests that microsporidial keratoconjunctivitis in the setting of AIDS and severe immunodepression can be effectively managed with highly active antiretroviral therapy alone.

Cystoid macular edema in patients with acquired immune deficiency syndrome and cytomegalovirus retinitis.

PURPOSE: To describe cystoid macular edema in patients with acquired immune deficiency syndrome treated with highly active anti-retroviral therapy, who had or had not already had cytomegalovirus retinitis. MATERIALS AND METHODS: Case report. RESULTS: Five acquired immune deficiency syndrome (AIDS) patients, successfully treated with highly active anti-retroviral therapy, were studied. Two had inactive cytomegalovirus retinitis and cystoid macular edema in both eyes. Two had inactive cytomegalovirus retinitis in both eyes and cystoid macular edema in one eye. One patient had inactive cytomegalovirus retinitis in one eye and cystoid macular edema in both eyes. CONCLUSIONS: Cystoid macular edema may occur in AIDS patients treated with highly active anti-retroviral therapy even in cases without previous retinitis.

Hypopyon in a patient with presumptive diffuse unilateral subacute neuroretinitis.

PURPOSE: To report a case of diffuse unilateral subacute neuroretinitis (DUSN) that developed an acute iridocyclitis with hypopyon. METHODS: Case report. We describe a 21-year-old male with clinical diagnosis of DUSN who developed a sudden and severe acute iridocyclitis with hypopyon after one year of follow-up that resolved after treatment with systemic corticosteroids. RESULTS: Anterior chamber paracentesis was performed and cultures were negative. Cytologic studies disclosed the presence of eosinophils. CONCLUSIONS: This unusual ocular finding may be related to the death of the nematode in the course of the disease.

Treatment of cytomegalovirus retinitis with an intraocular sustained-release ganciclovir implant.

The objective of this prospective study was to evaluate the efficacy and complications of the use of an intraocular sustained-release ganciclovir implant for the treatment of active cytomegalovirus (CMV) retinitis in AIDS patients. Thirty-nine eyes of 26 patients were submitted to ocular surgery. All patients underwent complete ocular examination before and after surgery. The surgical procedure was always done under local anesthesia using the same technique. The mean time for the surgical procedure was 20 min (range, 15 to 30 min). The average follow-up period was 3.7 months. Of all patient, only 4 presented recurrence of retinitis after 8, 8, 9 and 2 months, respectively. Three of them received a successful second implant. All 39 eyes of the 26 patients presented healing of retinitis as shown by clinical improvement evaluated by indirect binocular ophthalmoscopy and retinography. Retinitis healed within a period of 4 to 6 weeks in all patients, with clinical regression signs from the third week on. Six (15.4%) eyes developed retinal detachment. None of the patients developed CMV retinitis in the contralateral eye. The intraocular implant proved to be effective in controlling the progression of retinitis for a period of up to 8 months even in patients for whom systemic therapy with either ganciclovir or foscarnet or both had failed. The intraocular sustained-release ganciclovir implant proved to be a safe new procedure for the treatment of CMV retinitis, avoiding the systemic side effects caused by the intravenous medications and improving the quality of life of the patients.

Treatment of cytomegalovirus retinitis with an intraocular sustained-release ganciclovir implant

The objective of this prospective study was to evaluate the efficacy and complications of the use of an intraocular sustained-release ganciclovir implant for the treatment of active cytomegalovirus (CMV) retinitis in AIDS patients. Thirty-nine eyes of 26 patients were submitted to ocular surgery. All patients underwent complete ocular examination before and after surgery. The surgical procedure was always done under local anesthesia using the same technique. The mean time for the surgical procedure was 20 min (range, 15 to 30 min). The average follow-up period was 3.7 months. Of all patient, only 4 presented recurrence of retinitis after 8, 8, 9 and 2 months, respectively. Three of them received a successful second implant. All 39 eyes of the 26 patients presented healing of retinitis as shown by clinical improvement evaluated by indirect binocular ophthalmoscopy and retinography. Retinitis healed within a period of 4 to 6 weeks in all patients, with clinical regression signs from the third week on. Six (15.4 percent) eyes developed retinal detachment. None of the patients developed CMV retinitis in the contralateral eye. The intraocular implant proved to be effective in controlling the progression of retinitis for a period of up to 8 months even in patients for whom systemic therapy with either ganciclovir or foscarnet or both had failed. The intraocular sustained-release ganciclovir implant proved to be a safe new procedure for the treatment of CMV retinitis, avoiding the systemic side effects caused by the intravenous medications and improving the quality of life of the patients.

Manifestaçöes oculares do paciente infectado pelo HIV atendido no Departamento de Oftalmologia da Universidade Federal de Säo Paulo / Ocular manifestations of the HIV infected patients at the Departamento de Oftalmologia da Universidade Federal de Säo Paulo

Objetivo. Avaliar as manifestações oculares do paciente HIV positivo. Materiais e Métodos. É um estudo retrospectivo em 1100 pacientes ambulatoriais HIV positivo em três anos com ficha padrão e exame oftalmológico completo, atendidos no Departamento de Oftalmologia da Escola Paulista de Medicina. Resultados. Dos 1100 pacientes, 869 (79 por cento) eram do sexo masculino e 231 (21 por cento) do feminino. Os fatores de risco mais importantes foram: homossexualidade masculina em 303 (27,55 por cento), heterossexualidade em 272 (24,73 por cento), usuários de drogas endovenosas em 168 (15,27 por cento) e causa indeterminada ou não revelada em 246 (22,36 por cento). As queixas oculares mais freqüentes foram: 432 (39,27 por cento) pacientes com baixa da acuidade visual; 138 (12,55 por cento) com embaçamento visual; 64 (5,82 por cento) com dor ocular, 186 (16,9 por cento) com queixas inespecíficas e 235 (21,36 por cento) pacientes não apresentavam qualquer queixa. As manifestações oculares mais freqüentes foram: retinite por CMV em 246 (22,36 por cento) dos pacientes; exsudatos algodonosos em 110 (10 por cento), blefarite em 51 (4,64 por cento) e toxoplasmose ocular em 48 (4,36 por cento). Conlcusão. Houve progressão da doença entre os heterossexuais e aumento da incidência no sexo feminino nesta população estudada. Os que apresentavam queixas oculares foram a maioria. A manifestação ocular mais freqüente foi a retinite por CMV em 246 (22,36 por cento). Encontramos 10 por cento de exsudatos algodonosos.

Intraocular inflammatory reactions without focal necrotizing retinochoroiditis in patients with acquired systemic toxoplasmosis.

PURPOSE: To describe the occurrence of intraocular inflammatory reactions as the sole ophthalmic manifestation of acquired systemic toxoplasmosis. METHODS: Review of medical records for 10 patients with uveitis and evidence of recent Toxoplasma gondii infection. RESULTS: Patient ages ranged from 3 to 51 years. Ocular symptoms were present in each of eight adult patients. Inflammation was unilateral in nine patients; it manifested as vitreous humor cells and haze (10 patients), anterior chamber cells (seven patients), and retinal vasculitis (seven patients). No patient had necrotizing retinochoroiditis upon initial examination. Inflammation resolved in each of nine patients who had follow-up examinations. Foci of retinitis or inactive retinochoroidal scars were seen in four of these nine patients during follow-up examinations, at intervals of 2.0 weeks to 2.5 years after initial examination. CONCLUSIONS: Retinal vasculitis and associated inflammatory reactions may be the only ophthalmic disorder during the early stages of a newly acquired T. gondii infection. Later development of retinitis or scars consistent with toxoplasmic retinochoroiditis in the same eyes suggests that the initial, isolated inflammation may be caused by the presence of parasites in retinal tissue. These cases may have implications for understanding the original source of retinal infection in patients who have recurrent toxoplasmic retinochoroiditis and for treatment of newly acquired T gondii infection.

[Ocular manifestations in HIV infected patients attending the department of ophthalmology of Universidade Federal de São Paulo]. / Manifestações oculares do paciente infectado pelo HIV atendido no Departamento de Oftalmologia da Universidade Federal de São Paulo.

PURPOSE: To evaluate ocular manifestations of HIV-infected patients. MATERIAL AND METHODS: A retrospective study of 1,100 HIV positive out patients in 3 years with a standard complete ophthalmological exam. RESULTS: Eight hundred and sixty nine (79%) of the 1,100 patients studied were male and 231 (21%) female. The most important risk factors were: male homosexuality in 303 cases (27.55%), heterosexuality in 272 (24.73%), endovenous drugs use in 168 (15.27%), and unknown cause in 246 (26.36%). Related to ocular complains, we found 432 (39.27%) patients with decreased visual acuity, 138 (12.55%) with visual hazy, 64 (5.82%) with ocular pain, 186 (16.9%) with inspecific complaints, and 235 (21.36%) with no complains. The most frequent ocular manifestations were: CMV retinitis in 246 (22.36%), cotton wool spots in 110 (10%), blepharitis in 51 (4.64%), and toxoplasmosis in 48 (4.36%). CONCLUSION: The increase of disease ratio was observed among heterosexual and females in this specific population. Patients with ocular complains were 79.42%. The most frequent ocular manifestations was CMV retinitis, in 246 (22.36%). We found also 10% of cotton wool spots.

Hyphema after peribulbar anesthesia for cataract surgery in Fuchs' heterochromic iridocyclitis.

PURPOSE: To describe an unusual ocular sign in one patient with Fuchs' heterochromic iridocyclitis at cataract surgery. METHODS: We describe a patient with Fuchs' heterochromic iridocyclitis and cataract who developed a 1 mm hyphema observed two minutes after peribulbar anesthesia for cataract surgery. RESULTS: The patient was found to have an equivalent of the Amsler-Verrey sign. It appeared after peribulbar anesthesia and before any instrument touched the globe. It did not interfere with surgery and disappeared completely by day 2. CONCLUSION: The appearance of a hyphema after peribulbar anesthesia in Fuchs' heterochromic iridocyclitis is an unusual sign that may have the same pathophysiology as the Amsler-Verrey sign.

Toxoplasmose ocular em Venda Nova do Imigrante, ES, Brasil / Ocular toxoplasmosis at Venda Nova do Imigrante, ES, Brasil

Realizamos um estudo amostral populacional para melhor conhecer a prevalência de toxoplasmose ocular em Venda Nova do Imigrante, ES e compará-la co a prevalência de lesöes em outras regiöes do Brasil. De 1074 pessoas examinadas , 11.27 por cento foram diagnosticadas como portadoras de toxoplasmose ocular, baseado em achados fundoscópicos. Esta prevalência foi superior à existente nos Estados Unidos (0.6 por cento) e em Säo Paulo (9 por cento), mas inferior à de Erechin, RS (17.7 por cento). Foram encontrados quatro casos familiares (2 famílias com dois irmäos näo gêmeos e 2 famílias com casos de mäes e filhos afetados), sugerindo toxoplasmose adquirida. A acuidade visual foi igual ou inferior a 20/200 em 7 por cento dos olhos com lesöes oculares devido a presença de lesöes maculares.

Cytomegalovirus antigenemia in acquired immunodeficiency syndrome patients with untreated cytomegalovirus retinitis.

PURPOSE: To determine the frequency of cytomegalovirus (CMV) viremia in patients with acquired immunodeficiency syndrome (AIDS) and untreated CMV retinitis using conventional cell culture isolation and the sensitive CMV antigenemia assay. METHODS: We examined 24 AIDS patients with ophthalmologic diagnosis of untreated CMV retinitis and 24 AIDS patients without present or past retinitis (control patients) from three medical centers between September 1992 and March 1994. Cytomegalovirus antigenemia was detected by an indirect peroxidase staining in 300,000 cytocentrifuged neutrophils, using a mixture of murine monoclonal antibodies directed against the pp65 lower matrix protein of CMV. RESULTS: Positive antigenemia was demonstrated in eight (33.3%) of the 24 retinitis patients and in none of the 24 control patients (P < .001). Only two of the eight antigenemia-positive patients had a concurrent positive CMV isolation from blood leukocytes by conventional cell culture assay. CONCLUSIONS: These results emphasize the risk of extraocular disease in AIDS patients with CMV retinitis because the virus is often present in peripheral blood leukocytes. The CMV antigenemia assay may be a simple and rapid means of identifying those patients with unilateral retinitis at highest risk of developing CMV retinitis of the fellow eye or of visceral CMV disease if intravitreal injections or implants are used as sole treatment for CMV retinitis.

Herpes zoster peripheral ulcerative keratitis in patients with the acquired immunodeficiency syndrome.

The purpose of this study was to describe the clinical characteristics and course of peripheral ulcerative keratitis (PUK) secondary to herpes varicella-zoster virus in patients with the acquired immunodeficiency syndrome (AIDS). Three AIDS patients with ocular herpes zoster infection (mean age at onset, 33.0 years; range, 30-42) developed PUK. The three patients had skin involvement, and two of them had bilateral keratouveitis. All were treated with high-dose oral acyclovir (4 g/day) with or without topical antiviral therapy. Two of the patients responded well to oral acyclovir, but one of them stopped the treatment, and bilateral progressive outer retinal necrosis and lethal encephalitis developed. The third patient had a recurrent episode of inflammation with PUK, extensive stromal scarring, and deep neovascularization. AIDS patients with herpes varicella-zoster virus infection may have severe and protracted corneal manifestations, including PUK. The correct diagnosis and aggressive early long-term systemic antiviral treatment must be instituted to control inflammation, ulcer progression, and complications.