London SE5 9RS Research Articles

Bronchopulmonary MDR protein expression may protect against COVID-19 infection.

aDepartment of Nuclear Medicine, King’s College Hospital, London bSri Shankara Cancer Hospital and Research Institute, Bangalore, India Received 18 June 2020 Accepted 14 August 2020 Correspondence to A. Michael Peters, MD, Department of Nuclear Medicine, King’s College Hospital, Denmark Hill, Brixton, London SE5 9RS, UK, Tel: +44 203 299 3440; e-mail: [email protected]

Thyroid dysfunction in drug reaction with eosinophilia and systemic symptoms (DRESS): an unusual manifestation of systemic drug hypersensitivity

British Journal of DermatologyVolume 168, Issue 5 p. 1130-1132 Correspondence Thyroid dysfunction in drug reaction with eosinophilia and systemic symptoms (DRESS): an unusual manifestation of systemic drug hypersensitivity H. Cookson, H. Cookson Department of Dermatology, King’s College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this authorD. Creamer, D. Creamer Department of Dermatology, King’s College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this authorS. Walsh, S. Walsh Department of Dermatology, King’s College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author H. Cookson, H. Cookson Department of Dermatology, King’s College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this authorD. Creamer, D. Creamer Department of Dermatology, King’s College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this authorS. Walsh, S. Walsh Department of Dermatology, King’s College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author First published: 25 April 2013 https://doi.org/10.1111/bjd.12169Citations: 14 Sarah Walsh. E-mail: sarahwalsh1@nhs.net Funding sources: none. Conflicts of interest: D.C. and S.W. are contributors to the RegiSCAR group. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume168, Issue5May 2013Pages 1130-1132 RelatedInformation

Adding New Perspectives to the Kaleidoscope of Remission Criteria in Rheumatoid Arthritis

Remission has many meanings. In some medical contexts it indicates lessened disease severity. In other contexts it implies the disease has disappeared. Concepts of remission in rheumatoid arthritis (RA) reflect both models. Some definitions indicate only low disease activity states. Other definitions suggest the absence of disease, with undetectable symptoms, signs, and disease markers. Critically, remission differs from “cure,” which implies RA will never return. Current opinion favors restricting remission to patients with either no or minimal synovitis, without longterm structural or functional sequelae. The seminal report by Pinals, et al in 1981 concluded “complete” RA remission indicates the “total absence of articular and extraarticular inflammation and immunological activities”1. However, many years later, uncertainties remain on how to define genuine remission states. The introduction of new therapeutic options and strategies over the past decade has made remission an achievable goal. An immediate consequence of this perspective is the need for an accurate and uniform way to identify remission. Although there are many definitions, remission does not yet have an internationally accepted gold standard. Remission criteria differ between studies, and remission rates vary depending on the remission criteria used. We have previously noted these variations2. Some remission criteria use categorical descriptions; the original American College of Rheumatology (ACR) remission criteria are one important example1. However, these criteria are very stringent and too few patients achieve this goal to make the definition a useful outcome to discriminate between patients in clinical trial settings, or to make it a realistic outcome in the routine clinic setting. Consequently, many variants have been described. Continuous composite measures are often used to define remission; the most commonly used are the low scores using the Disease Activity Score (DAS3) or its modifications such as DAS28–erythrocyte sedimentation rate (DAS-ESR) … Address correspondence to Dr. H.Y. Ma, Department of Rheumatology, GKT School of Medicine, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RS, UK. E-mail: margaret.ma{at}nhs.net

Lymphadenopathy and splenomegaly in an HIV-infected man

South London Specialist Virology Centre, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom Virus Reference Department, Microbiology Services Colindale, 61 Colindale Avenue, London NW9 5HT, United Kingdom Department of Histopathology, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom Department of HIV/Genitourinary Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom

Re: Limitations of current definitions of miscarriage using mean gestational sac diameter and crown–rump length measurements: a multicenter observational study

Re: Limitations of current definitions of miscarriage using mean gestational sac diameter and crown–rump length measurements: a multicenter observational study

Clinical heterogeneity and underlying pathophysiological mechanisms of lateral flexion of the trunk in Parkinson’s disease

We read with interest the article by Di Matteo et al. [1] about different EMG patterns in lateral flexion of the trunk (LFT) in Parkinson’s disease (PD). A similar view would be valuable considering the clinical presentation; we would like to emphasize the clinical heterogeneity of LFT in PD, and to make some pathophysiological considerations apropos of a case. A 74-year-old woman with a 2-year history of rightpredominant PD treated with rasagiline 1 mg/day developed a slowly progressive abnormal trunk flexion unnoticed by the patient 10 months after pramipexole addition (0.18 mg tds). Neurological examination showed a mildmoderate akinetic-rigid syndrome (motor UPDRS score: 20) without any other sign suggesting atypical parkinsonism. A continuous LFT to the right with a slight forward flexion which worsened with walking and resolved with passive mobilization or when lying back was noted (Fig. 1). The patient denied any motor complication of the disease or LFT fluctuation with dopaminergic medication. Pramipexole was withdrawn and she was progressively started on levodopa/carbidopa up to 100/25 mg tds. LFT was completely resolved 4 weeks later and parkinsonian symptoms were markedly improved (motor UPDRS score: 12). Unfortunately, an EMG study of the paravertebral muscles was not performed. Although the patient was under-treated with pramipexole, the temporal relationship between LFT and dopamine agonist initiation, the lack of fluctuations of the abnormal posture and the improvement after drug withdrawal (with a minimal dose of levodopa) point to a pramipexole-induced LFT. Heterogeneity of clinical presentation and prognosis [2–6] resulted in attempts to better define LFT in PD [7, 8], distinguishing between irreversible-chronic forms characterized by rigidity and mediated by non-dopaminergic neurotransmitters, acute-subacute dystonic forms in both, off [5] and on periods [6] as a consequence of levodopa plasma level fluctuations, and drug-induced forms (DIF) associated to dopaminergic treatment changes (mainly after dopamine agonist initiation) [1–4]. The latter may resolve after prompt drug discontinuation, therefore its early diagnosis has important clinical implications. DIF are clinically similar to LFT associated to antipsychotic treatment, known as Pisa syndrome [9, 10], however the use of this term to designate them in PD patients is a matter of controversy [7, 8]. This important distinction was not made by Di Matteo et al. [1] and different types of postural abnormalities are included under the generic term LFT. The great clinical variability of LFT in PD, even in patients presenting with DIF, points to the involvement of different pathophysiological mechanisms. Close temporal relationship between postural abnormalities and dopaminergic therapy, and its reversibility after drug withdrawal [2, 4, 6], suggest a strong dopaminergic contribution. Dopaminergic asymmetrical transmission [3] or a cholinergic-dopaminergic imbalance [11] have been proposed; nevertheless, there is no clear DIF laterality and patients can deviate to the side more affected by parkinsonian symptoms [4–6] or contralaterally [1, 3, 4] suggesting the contribution of other neurotransmitter systems in certain cases, such as serotonergic and adrenergic [2, 12]. E. de Pablo-Fernandez (&) Neurology Department, King’s College Hospital, Denmark Hill, London SE5 9RS, UK e-mail: edepablofernandez@nhs.net

The Dorsal Hippocampal Commissure: When Functionality Matters

The Dorsal Hippocampal Commissure: When Functionality Matters

Primum non nocere, deinde philosophare

We read with interest the article entitled Retroauricular Video-Assisted ‘‘Gasless’’ Thyroidectomy: Feasibility Study in Human Cadavers [1]. This article describes a new ‘‘distant access’’ minimally invasive surgical approach to the thyroid gland. The article presents for the first time the retroauricular hairline incision approach to the thyroid gland using the endoscopic assistance gasless technique. The proposed technique allowed hemithyroidectomy to be performed through an 11.8 ± 1.2-cm incision [2] in six human cadavers. In our opinion, the surgical technique described by the authors is limited to hemithyroidectomy. Total thyroidectomy could be performed through a bilateral retroauricular access. We think the 11.8 ± 1.2-cm incision is quite large for a video-assisted approach to the thyroid gland and that a double-size incision due to the bilateral approach is not justified for a total thyroidectomy. This extensive access is not justified for either minimally invasive surgery or open surgery. Kocher’s cervicotomy, video-assisted thyroidectomy (VAT), and minimally invasive video-assisted thyroidectomy (MIVAT) remain the best options for thyroidectomy or parathyroidectomy. A surgical access far from the targeted organ can increase the risk of infection and can damage important structures not identified in reaching the thyroid gland. The described procedures entail an increased risk of damage to the great auricular nerve, lesser occipital nerve, facial nerve, accessory nerve, hypoglossal nerve, digastrics muscle, styloyoid muscle, internal jugular vein, external carotid artery, phrenic nerve, and vagus nerve. The risk of infection also is increased due to the proximity of the incision to less clean areas of the body (ear and hair). Because of the high increased risks added with this procedure, we think the most important thing in surgery is primum non nocere, deinde philosophare (do not harm first, philosophize later). The authors mention that the end point of the study was to achieve gland resection with identification and preservation of the recurrent laryngeal nerve. Because the study was conducted with human cadavers, preservation of the nerve could not be identified with certainty. The authors have recorded 100% success in a cold, bloodless setting, but we know that every time the camera is moved, the risk of causing damage to important anatomic structures is increased [3], especially with the gasless technique. The authors mention two added complications: dysthesia of the earlobe and alopecia at the incision site. These complications preclude the good cosmetic results they mention as an end point desired by the patient. To achieve good cosmetic results, plastic surgery after a classic Kocher’s cervicotomy would be more appropriate. In fact, the authors have written that ‘‘overall patient satisfaction with the resultant scar on a visual analogue scale was significantly higher in patients in the retroauricular cohort as compared with patients having a traditional cervical incision’’ [2]. This underscores the importance of the cosmetic result for the patient, but the citation is incorrect because in the mentioned study, the authors compare a lateral neck upper incision with retroauricular access. Therefore, it is not possible to know whether the patient prefers a classic G. Galata (&) M. Mulla Department of Surgery, King’s College Hospital, NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK e-mail: g.galata@libero.it

Striatal 123I-Ioflupane SPECT abnormality in sporadic Creutzfeldt–Jakob disease

A 61-year-old man presented with a 9 month history of progressive coordination, speech and memory problems as well as a 20 lb weight loss. He had fatigue, daytime somnolence and anxiety. Past personal and family medical histories were non-contributory. Examination demonstrated poor recall [Mini Mental State Examination (MMSE) 27/30, losing three points for memory]. He had an unsteady gait, could not tandem walk, had a fine upper limb postural tremor and had mild limb apraxia. The remainder of his neurological exam was normal. Investigations for a cerebellar syndrome were initiated. Full blood count, electrolytes, liver enzymes, B12, folate, thyroid-stimulating hormone (TSH), free T4, autoantibodies (mitochondrial, anti-gastric parietal cell, liver kidney microsomal, anti-smooth muscle, antinuclear antibody, anti-neutrophil cytoplasmic antibody), immunoglobulins, serum protein electrophoresis, copper, caeruloplasmin, manganese, neuronal antibodies (anti Ri, Yo, Hu), voltage-gated K channel antibodies, TSH receptor binding antibody and thyroid peroxisome antibodies were normal or negative. Cerebrospinal fluid (CSF) glucose and protein were normal, and there were no cells. The diagnosis of multiple system atrophy-cerebellar phenotype was considered. One year into the illness, dopamine transporter imaging (DAT) using 123I-Ioflupane single-photon emission computed tomography (SPECT) showed equivocally abnormal appearance qualitatively. After standard processing protocols, which involves attenuation correction during reconstruction, quantification of specific to non-specific ratios showed reduced caudate and putamen uptake bilaterally (see Fig. 1 for qualitative appearance and ratios), the right putamen having the lowest ratio. Subsequent brain magnetic resonance imaging (MRI) revealed T2 hyperintensity and corresponding restricted diffusion of the basal ganglia and thalami bilaterally as well as the cingulate gyri, right middle frontal gyrus and left parietal cortex, suggestive of sporadic Creutzfeldt–Jakob disease (CJD) (Fig. 2). Electroencephalogram (EEG) was normal. Within weeks, startle myoclonus developed, and he died shortly thereafter. Autopsy confirmed the diagnosis of sporadic CJD. A single published case of DAT in CJD also revealed reduced pre-synaptic putaminal uptake [1], and together with our case, suggests dopaminergic pathway dysfunction in CJD. These in vivo findings are in agreement with a recent pathologic study of the nigrostriatal pathway in sporadic CJD in which Vital et al. [2] found both preand post-synaptic cell loss in the nigrostriatal system. The loss of dopaminergic neurons in the substantia nigra correlated with the loss of neurons in the caudate and putamen. Interestingly, the patient previously reported by Ragno et al. [1] had an extrapyramidal syndrome while our patient had a cerebellar syndrome yet also had abnormal DAT imaging. In our patient, the DAT imaging appearance was not felt to be typical of idiopathic Parkinson’s disease. C. Hinnell M. Samuel (&) Department of Neurology, King’s College Hospital, 9th Floor, Ruskin Wing, Denmark Hill, London SE5 9RS, UK e-mail: m.samuel@nhs.net

Visual outcome of ranibizumab therapy for neovascular age related macular degeneration in the black population: a report of five cases

Neovascular age related macular degeneration (AMD) is relatively uncommon in the black population. We report the 12-month outcome of ranibizumab therapy in five black patients with choroidal neovascular membrane (CNV) secondary to AMD. Retrospective analysis of a prospective audit database maintained for all patients on ranibizumab therapy in a retinal specialist unit that caters to a multi-ethnic cohort in London, United Kingdom. At 12 months, all the 5 patients maintained stable vision (loss of less than 15 ETDRS letters). However, none of them gained more than 15 ETDRS letters. All eyes showed early subretinal fibrosis while 2 patients showed extended areas of retinal pigment atrophy. Our case studies indicate that ranibizumab stabilizes the vision in black patients with CNV secondary to AMD but they tend to develop early subretinal fibrosis and retinal pigment atrophy.

Demodex and skin infection: fact or fiction

Department of Dermatology, King's College Hospital, London, UK Correspondence to Roderick Hay, MD, Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, UK E-mail: [email protected]

The EFSUMB guidelines for contrast-enhanced ultrasound are comprehensive and informative for good clinical practice: will radiologists take the lead?

A study group organized by the European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) has issued an up-to-date set of guidelines on the clinical application of contrast-enhanced ultrasound (CEUS) [1]. The first set of guidelines for the application of contrast agents to the practice of ultrasound were published in 2004 [2], and the present set of guidelines are directed towards those not intimately involved in the field, whose perception is that rapid advances in technology and techniques can be difficult to follow, as well as experienced users of CEUS. The initial guidelines concentrated on CEUS applications in the liver, but the present guidelines recognize the expanding role of CEUS and include recommendations for its use in (i) the kidney, (ii) vesicoureteric reflux, (iii) the pancreas, (iv) trauma and (v) the cerebral circulation. The guidelines include good clinical practice recommendations for the use of CEUS, and are exceptionally comprehensive without being lengthy. Detailed descriptions of the procedure techniques, the interpretation of findings and its limitations are included. The study group readily acknowledge the shortcomings of a CEUS examination; these are the exact limitations that occur with all ultrasound examinations. When the baseline ultrasound examination is disappointing, then the CEUS examination is also likely to disappoint — an important caveat for those incorporating techniques of CEUS into their practice. Recommendations for investigator training are also included, with the likelihood that practitioners of CEUS would need to have attained at least a Level 2 of competency, if not higher. Currently, there are four agents licensed for use in Europe: Levovist (Schering, Berlin, Germany), Optison (GE Healthcare, Oslo, Norway), Definity (BristolMeyers Squibb, Uxbridge, UK) and SonoVue (Bracco, Milan, Italy).The sole indication to date for Optison and Luminity is for cardiac use. Practitioners in Japan have the advantage of access to another agent: Sonazoid (GE Healthcare, Oslo, Norway). Levovist, the oldest agent (having been introduced in 1996), is not sufficiently robust to be used adequately with the newer low mechanical index (MI) techniques. It does, however, have the characteristic of late phase ‘‘trapping’’ in the liver, a feature not demonstrated by some of the newer agents (except for Sonazoid) but which has been exploited to good effect in the past [3]. Current recommendations do not promote the use of high MI techniques to investigate liver lesions in the late phase, citing technical difficulties [1]. As a consequence, the most widely used agent currently for radiological indications in Europe is SonoVue This agent is particularly suited for the low MI techniques for the detection and characterization of focal liver lesions, with studies indicating that CEUS is as good, if not better, than contrast-enhanced CT [4, 5]. With CEUS, a ‘‘black hole’’ at the end of the portal venous phase almost always indicates a secondary malignant lesion (if a cyst has been excluded on the baseline examination) [1]. The usefulness of CEUS is not in doubt. Many new applications outside the traditional investigation of parenchymal liver lesions have developed or are evolving, with assessment of blunt abdominal trauma in the emergency room being particularly attractive [6]. The establishment of a standard CEUS ‘‘Bosniak’’ classification of renal cysts is also a possibility [7]. The list of useful applications grows as more investigators report their findings; however, the technique has not been fully embraced by the radiological community, despite the proven usefulness of CEUS. Uptake is slow, particularly in the UK, although ‘‘hot spots’’ exist. The European radiological community shows more interest in the use of CEUS, particularly in Italy. Japan and China are driving clinical practice with CEUS. However, there is a Address correspondence to: Paul S Sidhu, Department of Radiology, King’s College Hospital, Denmark Hill, London SE5 9RS, UK. E-mail: paul.sidhu@kch.nhs.uk The British Journal of Radiology, 81 (2008), 524–525

Interpretation of postmortem toxicology: more complicated than it might seem ??? Part 1

SummaryThe aim of postmortem toxicology is to help establish the role that drugs or other poisons played in a death, or in events immediately before death. It was thought that concentrations of poisons measured in blood obtained at autopsy reflected the situation perimortem. However, we now know tha

RAISING THE BENCHMARK FOR THE 21ST CENTURY—THE 1000 CATARACT OPERATIONS AUDIT AND SURVEY: OUTCOMES, CONSULTANT-SUPERVISED TRAINING, AND SOURCING NHS CHOICE

New York Medical College, New York, NY Original study reprint requests: Farhan H Zaidi, Department of Ophthalmology, Kings, College Hospital, Denmark Hill, London SE5 9RS, UK. E-mail address: [email protected].

Sexual health: overview

Globalization has had a profound impact on many aspects of health, particularly sexual health. Increasing international mobility has resulted in greater potential exposure of overseas travellers to sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). There has been increased migration of people from resource poor or transitional economies where there is a higher prevalence of STDs and HIV. There has also been growing diversity in the sex industry in the UK, in part as a result of a recent influx of migrant workers, often in association with sex trafficking. These changes present unique challenges in the delivery of effective sexual health care. The aim of this series of three articles is to highlight some of the topical issues in sexual health of relevance to an occupational health physician. A high proportion of travellers have sex while abroad, and may be at particular risk of acquiring a sexually transmitted infection, as a result of greater levels of unsafe sexual behaviour with new partners. The first article examines the impact of travel on sexual health and provides an outline of the pre-travel advice and sexual health assessment of the returning traveller. Hamlyn et al. [1] review the epidemiology of sexual risk behaviours among travellers. They examine strategies to minimize exposure to STDs and blood-borne viruses in specific high-risk groups, including the young, gay men, sex tourists, military personnel and expatriates. The additional risks of occupationally acquired HIV infection faced by health care workers and elective medical students working in endemic areas are also highlighted. In the second article, Spice [2] describes the changing demography and diversity of the sex industry in the UK. This includes the increasing use of Internet and mobile phone technologies, the growth of sex trafficking and the influx of workers from the transitional economies of Eastern Europe and Russia. In one recent survey based in London, less than a quarter of sex workers were from the UK. Sex workers are themselves increasingly diverse including transgender, male commercial sex workers and the nature of their work. The workplace is also diverse, ranging from traditional street workers to work in offstreet premises such as massage parlours and increasingly private addresses. Spice reviews the main health challenges in sex workers (STDs, violence, drug use and mental health) and the different types of services available, including outreach and drop-in clinics and harm reduction strategies. Although there has been a reduction in occupational needlestick injuries with the increasing adoption of safer ‘sharp’ technology such as sheathed and retractable needles, there remains a problem of underreporting and poor knowledge of procedures to follow in the event of an incident. The third article [3] reviews the current evidence for use of occupational HIV post-exposure prophylaxis, and current approaches to risk assessment and management. The evaluation of the source patient where possible has become increasingly important because of the significant rate of HIV drug resistance among HIV-1-infected patients receiving antiretroviral therapy. The drug regimens are often poorly tolerated, andHamlyn summarizes thekey adverse events of which the supervising physician should be aware. Common to all three areas are the challenges in research methodology. In the absence of any large prospective randomized controlled trials, evidence for the efficacy of occupational post-exposure prophylaxis is based on a single-case control study of occupational exposure to HIV in 33 infected health care workers. This is in addition to data from animal primate models and exposure to simian immunodeficiency virus, which may not be generalizable to humans because of exposure to a different virus to HIV, and differences in drug metabolism and dosing between animals and humans. For example, in studying the sexual health of travellers, most studies have been cross-sectional and descriptive rather than prospective and analytical, have lacked control groups and are confounded by recall bias of sexual behaviours. Furthermore, travellers are a heterogeneous population making targeted interventions difficult; and STDs may be diagnosed some time after travel, so it may be difficult to link an infection with a risk exposure while travelling. Research into commercial sex work is similarly hampered by small and unrepresentative study populations due to problems gaining access and trust among sex workers. As a result, researchers are Department of HIV/GUM, Kings College London, 10 Cutcombe Road, London SE5 9RS, UK.

Imaging in neuroradiology

IntroductionImaging in neuroradiologyNaomi SibtainNaomi SibtainDepartment of Neuroimaging King's College Hospital Denmark Hill London SE5 9RS UKSearch for more papers by this authorPublished Online28 Jan 2014https://doi.org/10.1259/imaging/27422172SectionsPDF/EPUBFull Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail About"Imaging in neuroradiology." Imaging, 19(2), p. 6 Next article FiguresReferencesRelatedDetails Volume 19, Issue 2June 2007Pages: 6-190 © The British Institute of Radiology History Published onlineJanuary 28,2014 Metrics Download PDF

Intravitreal injection: balancing the risks

Intravitreal triamcinolone (iVTA) had gathered pace in the management of retinal diseases. By simply searching with the string ‘intravitreal triamcinolone’ in PubMed, it returns over 400 publications, with over 300 in the past 2 years. Despite the large number of publications, there are still very limited data on long-term efficacy (over 12 months). Furthermore, if one considers sham-controlled prospective randomised clinical trials (RCT) only, the efficacy is in doubt. One of the original RCT in using iVTA in neovascular age-related macular degeneration (AMD) showed a negative result. Similar results were obtained in a more recent study on central retinal vein occlusion over 4 months. The difference between vision changes was significant only at 1 month. There was no meaningful difference in the occurrence of neovascularisation of the iris between the two groups. The only RCT with positive results is on diabetic macular oedema over 6 months from Jonas et al. The control group was only 12 eyes and laser treatment was not offered. When laser treatment was offered, there were no differences. Furthermore, when macular grid laser was performed 3 weeks after iVTA, visual outcome was better than iVTA alone especially at 6 months. However, the complications of using iVTA are numerous; intraocular pressure rise and cataract are common occurrences. In a retrospective analysis in Southampton, the ocular morbidity is high as well as the case report of ocular perforation and inadvertent administration of intralenticular injection. One would probably consider in the face of the lack of evidence that is unacceptably high. Nevertheless, the introduction of this off-label treatment has not received any political problems in the UK. It is apparent to us that as triamcinolone is widely available in the NHS hospital formulary, is relatively inexpensive and hence can be used without going through any funding request nor special committees. It has become widely available. Nonetheless, failure to communicate to patients that iVTA treatment is off-label, might have medicolegal implication. So are we seeing the same with the introduction of off-label used of Avastin? Several editorials in the UK, including in this journal as well as the British Journal of Ophthalmology, have discussed the issues. As a recap, Avastin and Lucentis have presented with us an unprecedented dilemma. Lucentis is licensed in the US in June 2006 and is likely to be licensed in Europe, including the UK, in the first quarter of 2007. The clinical trial results of Lucentis were nothing short of amazing, with over 95% of patients attaining stabilisation and up to 40% with significant visual improvement. However, Lucentis is considered expensive. In the USA, Lucentis is priced at USD$1950 per single use vial, given either monthly or of injections every 3 months after a three dose loading phase given every month. This reduced dosing regimen led to less impressive results than regular monthly dosing (PIER study, unpublished data). Avastin is derived from the same murine antibody as Lucentis, has similar binding sites, but is a significantly larger molecule with potentially less effective retinal penetration. The affinity to those binding sites are of the order of 16-fold less. Nonetheless, in animal models, Avastin stays in the eye longer, although the half-life of Avastin when administered intravitreously in humans, is yet to be determined, and when given systemically in man for colorectal cancer, the half-life of Avastin has been reported at 21 days, significantly greater than 2 h with Lucentis. Hence, longer eye exposure of Avastin and increased systemic exposure compared to Lucentis might balance out the lower VEGF-binding affinity and the slower retinal penetration. On the basis of small-scale animal studies, Avastin may be safe leading to extensive but short-term, uncontrolled, widespread use in Laser and Retinal Research Unit, King’s College Hospital, Denmark Hill, London SE5 9RS, UK

Head and neck imaging

IntroductionHead and neck imagingS E J Connor and P S RichardsS E J Connor1Neuroradiology DepartmentKing's College Hospital NHS Foundation Trust Denmark Hill London SE5 9RS, 2Department of Diagnostic ImagingBart's and The London NHS Trust Queen Elizabeth II Wing St Bartholomew's Hospital London EC1A 7BE UKSearch for more papers by this author and P S Richards1Neuroradiology DepartmentKing's College Hospital NHS Foundation Trust Denmark Hill London SE5 9RS, 2Department of Diagnostic ImagingBart's and The London NHS Trust Queen Elizabeth II Wing St Bartholomew's Hospital London EC1A 7BE UKSearch for more papers by this authorPublished Online:28 Jan 2014https://doi.org/10.1259/imaging/19171382SectionsPDF/EPUBFull Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail About"Head and neck imaging." Imaging, 19(1), p. iv Previous article FiguresReferencesRelatedDetails Volume 19, Issue 1March 2007Pages: 1-iv © The British Institute of Radiology History Published onlineJanuary 28,2014 Metrics Download PDF

Acute Appendicitis In Identical Twins

Simultaneous cases of appendicitis in identical twins are extremely rare. We report identical twins who presented with similar features of appendicitis within 5 days of each other. CASE HISTORIES CASE 1 The first patient was a 14 year old girl from South African origin who presented with a 36 hour history of central abdominal pain which later localised to the right iliac fossa. There was no significant past medical history. Clinical examination revealed a temperature of 38°C, with local peritonism in the right iliac fossa. Labarotory investigations did not reveal leucocytosis. The patient underwent a routine appendicectomy without any complications. The appendix was mildly inflamed, confirmed on histology, in a retrocaecal position. She was later discharged on the second post-operative day. CASE 2 The identical twin of the first patient presented five days after her sister with a 24 hour history of right iliac fossa pain. Her past medical history was unremarkable. On examination, she had a temperature of 37.8°C and was tender in the right iliac fossa. Her blood results were also normal without any evidence of leucocytosis. The patient underwent an uncomplicated appendicectomy through a lanz incision. The appendix was inflamed in a retrocaecal position. Histology confirmed the diagnosis. She made an excellent post operative recovery and was discharged on the second post-operative day. DISCUSSION Simultaneous cases of acute appendicitis are extremely rare and only five cases have been reported in the literature.1,2,3,4,5 Genetic factors have been implicated by some authors. Basta et al. performed a retrospective analysis of the families of 80 patients with acute appendicitis. They showed familial aggregation and polygenic transmission when compared to similar ‘control' families.5 All of the twins evaluated in the literature presented in the first or second decade within a day of each other. Appendicitis was also confirmed on histology. Although the South African twins presented slightly further apart, it is interesting that both were pyrexial and did not show leucocytosis. Furthermore, both had their appendix in the retrocaecal position. There are not sufficient cases in the literature to conclude whether genetics or coincidence is responsible for this presentation. However, one would imagine that there would be more reported cases of simultaneous appendicitis amongst identical twins given the 1 in 300 chance of twin pregnancy. CORRESPONDENCE TO Amyn Haji MA MBBChir MRCS(Lon) MRCS(Ed), Specialist Registrar, South East Thames Rotation Kings College Hospital, Denmark Hill, London SE5 9RS Tel. 07970292532 Fax. 02086911060 Email: amynhaji113@aol.com

Preface: Advances and methods in liver surgery

Consultant Surgeon, King's College Hospital, London, UK Correspondence to Nigel Heaton, Liver Transplant Surgical Service, King's College Hospital, Denmark Hill, London SE5 9RS, UK E-mail: [email protected]