Case Review Of Patients Research Articles

Packing density and long-term occlusion after transcatheter vessel embolization with soft, bare-platinum detachable coils

Objective: The objective of this study was to examine packing density and long-term recanalization rates after embolization with soft, bare-platinum ruby coils in the gastroduodenal artery (GDA). Materials and Methods: Retrospective case review of patients with hepatic malignancy who underwent coil occlusion of the GDA for radioembolization or hepatic arterial infusion chemotherapy between November 2013 and July 2018. Data on patient demographics, GDA diameter, length of coil pack, and distance between GDA origin and most proximal coil were collected. Packing density was calculated as the ratio between the volume of inserted coils and the volume of the vessel area that were filled with coil. The primary outcome was the rate of GDA recanalization, determined by review of hepatic arteriograms at follow-up. Results: Long-term occlusion free of recanalization was observed in 97.8% (88/90) of patients over a median follow-up time of 13.4 ± 11.3 months. Median vessel packing density was 55% (interquartile range 41–71) and procedural technical success was achieved in 100% (90/90) of patients. Of the 90 patients (72 men; mean age 63.8 ± 7.5 years), mean GDA diameter was 4.0 ± 0.8 mm and the proximal coil distance from GDA origin was 8.6 ± 3.0 mm. Mean coil pack length was 21.2 ± 7.6 mm. Recanalization occurred in 2.2% (2/90) of patients. No increase in recanalization rates with distal coil placement was observed. Conclusions: The study demonstrates high levels of technical success and low rates of recanalization (2.2%) when high packing densities (55%) are achieved using soft, bare-platinum ruby coils. The rate of recanalization at follow-up compares favorably to previously reported literature.

134 Levosimendan Use in Patients With Severe Heart Failure: A Single-Centre Descriptive Study

The role and indications for levosimendan use in patients with heart failure are unclear. To investigate the context and clinical course of patients with severe heart failure who receive levosimendan. This study is a single-centre, retrospective case review of patients who received levosimendan between December 2018 and January 2020. Outcomes included patient disposition, re-hospitalisations, and adverse events. Twenty-three patients were included. Seven patients had ischaemic cardiomyopathy. Left ventricular ejection fractions ranged from 8% - 30%. Sixteen patients received levosimendan to facilitate weaning off continuous inotropes. Eleven of these did so successfully and were discharged, two required a left ventricular assist device (LVAD) prior to discharge, and three died in hospital (two were for palliative treatment only). Four patients received levosimendan for poor diuresis in the setting of cardiorenal syndrome, of whom three were discharged without requiring dialysis and one died in hospital. Three patients received levosimendan as first-line therapy for cardiogenic shock and all were discharged. Amongst the 19 discharged, six patients were discharged with a plan for outpatient assessment of heart transplant candidacy. Of these, two patients subsequently received transplants and one died at home while on the waitlist. Seven of the 19 patients that were discharged were re-admitted with cardiac decompensation, two of which required LVAD implantation. We have successfully used levosimendan in patients with heart failure to achieve the following goals: 1) weaning of continuous inotropes in patients with cardiogenic shock to facilitate discharge from hospital and 2) bridging patients to further advanced heart failure therapies.

RARE-50. PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA – OUTCOMES IN THE ‘HAEMATOLOGY ERA’

Abstract BACKGROUND Primary CNS lymphoma (PCNSL) requires a biopsy for diagnosis. Administration of corticosteroids can lead to inconclusive results and delay diagnosis. The aim of this study was to compare outcomes of patients treated under haematology compared to radiation oncologists. METHODS Retrospective case review of patients treated under radiation oncology (2006–2010) and haematology (2011–2016). RESULTS 121 cases were identified (median age 63 years; range 19–84). Median WHO performance status (PS) was 1. Fourteen patients (11.6%) required repeat biopsy. 10 patients were managed palliatively due to poor PS. 67 cases were managed under haematology. Median symptom duration was 28 days (range 2–540). Median time from MRI to diagnosis was 18 days (range 6–232). 66 patients received chemotherapy, 1 received radiotherapy. Median overall survival (OS) was 8 months (95%CI:0.7–15.3), 5-year OS was 22.4%. 44 cases were managed under radiation oncology. Median symptom duration was 28 days (range 2–365). Median time from MRI to diagnosis was 16 days (range 6–309). 34 patients received radiotherapy first-line, 10 received chemotherapy. Median OS was 7 months (95%CI:0–21.5), 5-year OS was 15.9%. Multivariate analysis demonstrated PS (HR 2.02 (95%CI: 1.08–3.76)) and symptom duration (HR 0.63 (95%CI: 0.41–0.96)) to be significant prognostic indicators for OS. CONCLUSION The outcomes from the ‘haematology era’ are similar to those achieved by radiation oncologists. Delay in diagnosis leads to worse outcomes and highlights the ongoing need to streamline the patient pathway to improve outcomes.

The Presence of Wnt Signaling Mutations in Patients With Diabetic Retinopathy.

The relationship between poor hemoglobin A1c (HbA1c) control and risk of proliferative diabetic retinopathy (PDR) is well known. Nevertheless, some patients have discordant disease (controlled HbA1c and severe PDR or vice versa). One potential explanation for this discrepancy is the presence of underlying genetic mutations in the Wingless-related integration site (Wnt) signaling pathway. However, minimal clinical data exist on the presence of Wnt signaling mutations in patients with diabetes mellitus (DM) and the correlation with diabetic retinopathy. Retrospective, nonconsecutive case review of patients with type 1 or 2 DM who underwent genetic testing for at least 1 recognized Wnt signaling pathway mutation from 2011 to 2016. The clinical course and retinal images were reviewed for patients with identifiable mutations. Thirty-six patients, ages 13 to 79 years, consented for genetic analysis. Three patients (8.3%) exhibited at least 1 recognized genetic mutation in the Wnt signaling pathway. Case 1 was a 65-year-old female with type 1 diabetes for > 20 years, HbA1c <7.0%, and no findings of diabetic retinopathy (Tetraspanin 12). Case 2 was a 13-year-old male with type 1 diabetes for 8 years, moderate HbA1c control (7.6-8.3%), and absence of diabetic retinopathy (Norrin). Case 3 was a 48-year-old male with severe PDR requiring multiple laser and antivascular endothelial growth factor (anti-VEGF) treatments despite well-controlled HbA1c (6.0%) (Frizzled-4). Wnt signaling pathway mutations exist in patients with DM. Further studies investigating the prevalence and clinical significance of these mutations in a larger diabetic population are warranted. Identification of these patients with genetic testing may enable earlier medical intervention.

Atypical Schwannoma: A 10-year experience.

The goal of this study was to describe the clinical presentation associated with atypical schwannoma of the cerebellopontine angle, characterize the pathologic findings and describe the long-term outcome. The study design was retrospective case review of patients with the histopathologic diagnosis of atypical and benign schwannoma of the cerebellopontine angle diagnosed at the study institution over a 10-year period. Tertiary referral center. Demographic data of the cohort were recorded. Findings on pathology were evaluated. Initial treatment and post-operative course was recorded. Main outcome measures were clinical presentation, including cranial nerve deficits at the time of presentation, complication and recurrence rates. At presentation, a somewhat accelerated course of cranial nerve deficit was noted among patients with atypical schwannoma as compared to benign schwannoma. In the immediate post-operative period, there were no differences noted in the complication rate. Atypical schwannomas appear to have higher recurrence rate compared to benign schwannomas. Atypical schwannoma is an intermediate disease process with an accelerated clinical course and higher recurrence rate as compared to vestibular schwannoma. Traditional operative approaches may be employed without increased concern for post-operative complications. Thorough counseling and close follow-up should be offered to these patients given the higher recurrence rate. Larger studies are required to determine if these patients need more frequent MRIs for long-term surveillance.

843 Crohn’s Strictures Open With Anti-Mycobacterial Antibiotic Therapy (AMAT): A Retrospective Review

INTRODUCTION: Approximately one third of patients with Crohn’s disease (CD) will develop strictures within 10 years of diagnosis, commonly in the terminal ileum and ileocecal valve (ICV). Strictures often lead to abdominal pain, obstruction and are a risk factor for developing internal fistulae and cancer. Current treatment involves endoscopic balloon dilatation or strictureplasty. However, this may result in postoperative complications or recurrence. Recent evidence suggests that Mycobacterium avium ssp paratuberculosis may be a causative agent of CD and anti-mycobacterial antibiotic therapy (AMAT) has been shown to induce remission significantly better than placebo. The effects of AMAT on strictures has not been reported. AIM: To report the outcomes of AMAT in patients with CD and an ileal stricture/s. METHODS: This is a single centre retrospective (January 1995-December 2018) case review of patients diagnosed with CD, who had ileal stricture on colonoscopy and were treated with AMAT which comprised a combination of clarithromycin, rifabutin, and clofazimine, some with added ethambutol, ciprofloxacin, metronidazole or tinidazole. Symptoms, colonoscopy reports, biochemistry and concurrent medications were reviewed and recorded at pre-treatment and 6, 12, 18 and &gt;24 months on treatment. RESULTS: Forty-three patients (24 male, 16-56 yrs) with an average age of 31 yrs, and 5 yrs (0-27 yrs) after diagnosis were included. At pre-treatment, 17 patients had stricturing of the ICV, 25 had stricturing of the ileum and one had stricturing in both the ileum and ICV. Of the patients who had follow up colonoscopy data (N = 32), after &gt;24 months of AMAT, 22/32 patients (69%) had complete resolution and 2/32 patients had partial resolution of their strictures. Interestingly, after resolution of stricture on AMAT one patient ceased treatment. At 36 month follow up post cessation of AMAT the patient’s ileocecal stricture had returned. Further treatment with AMAT resulted in resolution of the stricture. CONCLUSION: AMAT for CD is effective in opening Crohn’s strictures avoiding the need for repeated dilatations or surgery. These observations suggest that stricturing in CD may be mediated by mycobacterial infection, as reported in tuberculosis strictures. To our knowledge, CD strictures have not previously been reported to open using medical therapy. Further prospective documentation is required to better define this positive effect of AMAT, including rate of resolution.

Ultrasonography of Injury to the Parathyroids During a Thyroidectomy

Objective: Explore the characteristics of parathyroid injury during thyroid surgery and the potential for sonography to reduce the risk of parathyroid injury. Methods: Retrospective analysis was conducted on 39 patient cases, with parathyroid injury (including 29 cases of total thyroidectomy plus central lymph node dissection and 10 cases of total thyroidectomy). Sonography and related medical laboratory testing were performed pre- and postsurgery. Clinical symptoms and associated postsurgical gland changes were compared and analyzed according to the relevant laboratory values. Results: The patient case review demonstrated that the total number of glands decreased by 43 compared with preoperation, with 25 glands in the upper pair and 18 glands in the lower. There were 33 glands with uneven echo and blurred edges, with 20 in the upper pair and 13 in the lower pair. The damage rate of the upper gland (45/76) was higher than that of the lower gland (31/76) ( P &lt; .05). A total of 69.7% (23/33) of gland blood flow signals were reduced compared with preoperation, of which 10 showed uneven enhancement when the contrast-enhanced ultrasound reached its peak. Conclusion: Thyroid surgery can easily damage parathyroid glands, especially during a total thyroidectomy, with lymph node dissection. Sonography of the parathyroid glands in patients with postoperative hypocalcemia can provide imaging surveillance and mitigate the damage of these glands postsurgically.

Reversal of Severe Multiorgan Failure Associated With Sickle Cell Crisis Using Plasma Exchange: A Case Series.

Red blood cell exchange (RBCE) is the standard of care for patients with sickle cell disease (SCD) who present with severe vaso-occlusive crisis (VOC). However, subsets of these critically ill patients have progressive multiorgan failure (MOF) despite RBCE therapy. The purpose of this case series is to describe the use of plasma exchange (PLEX) for the treatment of SCD-related MOF that is refractory to RBCE. A retrospective case review of patients with severe MOF from sickle cell crisis unresponsive to RBCE who underwent PLEX in a 14-bed adult medical intensive care unit (ICU) at a tertiary care university hospital over a 4-year time period. Key laboratory data including complete blood count, indices of hemolysis, and markers of organ failure were recorded before and after both RBCE and PLEX. Our primary objective is to evaluate the effectiveness of PLEX, in addition to RBCE, on organ dysfunction, laboratory indices, and mortality. Of the 7 patients, 6 survived. Of the patients who survived, all remained hemodynamically stable during PLEX sessions and showed both clinical and laboratory evidences of improvement in hemolysis and organ function. Average time from completion of first PLEX treatment to initial laboratory signs of organ failure reversal for patients who survived was 15.6 hours, the average length of stay in the ICU was 5.6 days, and the average total length of stay in the hospital was 14 days. Plasma exchange, in addition to RBCE, may be a novel synergistic treatment option to decrease risk of mortality in patients with refractory VOC and MOF.

Beneficial visual outcome of vitrectomy and delamination surgery for tractional complications of diabetic retinopathy in a cohort of black patients.

Poor visual outcomes have recently been reported in black patients undergoing vitrectomy and delamination surgery for complications of proliferative diabetic retinopathy. We therefore investigated the outcome of surgery on a similar cohort of black patients and examined for potential predictors of visual success. A single-centre retrospective case review of consecutive black patients who underwent vitrectomy and delamination surgery for complications of PDR between July 2010 and September 2017. The primary outcome measure was change in visual acuity (VA) at 6 months post-operatively. Multiple linear regression analysis was performed to evaluate determinants of change in VA. A total of 44 eyes of 44 patients were included. Mean age was 53.7 (range: 24.3-75.8) years. In all, 43% were male. A total of 52% had adjunctive pre-operative anti-VEGF therapy. Mean pre-operative VA was 1.49 logMAR ± 0.73 (range 0.18 to 2.6 logMAR). Mean change in VA at 6 months was a gain of 0.59 ± 0.94 logMAR (range 1.9 logMAR acuity loss to 2.5 logMAR acuity gain). Four cases required further surgery to treat rhegmatogenous detachment. The acuity of 68% improved by 0.3 or more logMAR. Silicone oil was used as primary tamponade in 7%. Pre-operative VA and use of silicone oil significantly predicted VA decline at 6 months (p = 0.001 and p = 0.007). The majority of our cohort derived visual benefit from vitrectomy and delamination for PDR-related complications. Improvement in VA was comparable to outcomes from the UK National Ophthalmic Database report. Silicone oil should be avoided these patients if possible.

Preventing the O in OHVIRA (Obstructed Hemivagina Ipsilateral Renal Agenesis): Early Diagnosis and Management of Asymptomatic Herlyn–Werner–Wunderlich Syndrome

IntroductionHerlyn–Werner–Wunderlich syndrome (HWWS) is a rare variant of Mullerian ductal anomaly associated with ipsilateral renal agenesis. Most patients are diagnosed after menarche with complications of uterovaginal obstruction, genitourinary infection and pelvic adhesions. Patients often undergo additional operations for misdiagnosis or treatment of complications. Our institution manages several HWWS patients diagnosed before symptoms by screening for antenatally-diagnosed renal agenesis. This study aims to improve the presymptomatic management of HWWS patients. MethodsWe carried out retrospective case review of patients diagnosed with HWWS from 2010 to 2017 on patient demographics, symptoms, clinical course and operative management and summarize the sparse literature published to date. ResultsThere were 8 patients with HWWS but only 2 symptomatic patients presented acutely with hematocolpos requiring urgent vaginal surgery. The other six patients had early diagnosis through postnatal ultrasound screening. No patient required further operation for diagnosis or complications related to obstructed hemivagina. ConclusionOur case series and literature review show that the majority of prepubertal patients with HWWS do not require early gynecological surgery. We recommend that female babies with renal agenesis should be screened for HWWS syndrome with ultrasound. Early diagnosis and presymptomatic elective surgery may prevent urogynecological complications that cause fertility and renal impairment. Study designCase series, level IV evidence.

PB1798 EFFICACY AND TOLERABILITY OF R‐MINICHOP IMMUNOCHEMOTHERAPY IN ELDERLY PATIENTS WITH HIGH GRADE NON‐HODGKIN LYMPHOMA: REAL WORLD EXPERIENCE AT A RURAL UK HOSPITAL.

Background:The increasing incidence of high grade Non‐Hodgkin Lymphoma in aging populations places a significant burden on healthcare systems. Co‐morbidity, frailty, and reduced organ and physiological reserve contribute to treatment‐related complications. R‐miniCHOP is emerging as the standard of care for these patient with good efficacy and tolerability in clinical trial settings. We reviewed our single centre experience of delivering R‐miniCHOP therapy to elderly patients with high grade lymphoma over a 5 year period in a rural British hospital.Aims:We sought to assess the clinical efficacy and tolerability of attenuated immunochemotherapy (R‐miniCHOP) in elderly patients with high grade lymphoma in a ‘real‐world’ setting with medium term follow up of up to 7 years.Methods:We conducted a retrospective case review of patients who presented to our haematology service with aggressive non‐Hodgkin lymphoma and received R‐miniCHOP attenuated immunochemotherapy as outpatient therapy between 2012 and 2017. Patients received rituximab (375 mg/m2), cyclophosphamide (400 mg/m2), doxorubicin (25 mg/m2) and vincristine (1 mg/m2) on day 1 of each cycle, and prednisolone (40 mg/m2) on days 1‐5. We examined baseline patient characteristics, ECOG performance status, Ann Arbor stage, serum lactate dehydrogenase (LDH) concentration and International Prognostic Index (IPI) at diagnosis. Furthermore, we undertook a review of interim or post chemo disease response by PET/CT imaging and determined renal, cardiac, hepatic and bone marrow toxicities in all patients with follow up until January 2019. A route cause analysis was undertaken for all patients who had died during the follow‐up period.Results:We identified 23 patients treated with R‐miniCHOP between 2012 and 2017. Median age at diagnosis was 82 years (range 74‐88) and 52% were female. Diffuse large B‐cell lymphoma (DLBL) was the most common diagnosis (74%). Mean serum [LDH] at diagnosis was 320U/L (range 162‐1202U/L). Ann Arbor staging and IPI are detailed in Table 1 but patients of all IPI stage were represented in our cohort. The mean number of immunochemotherapy cycles administered was 4 (range 1‐8) and only 3 patients required dose/regimen modifications. Fatigue (52%), peripheral neuropathy (26%), and alopecia (22%) were the most commonly identified toxicities. Two patients (9%) experienced significant cardiotoxicity with echocardiographic evidence of reduced left ventricular ejection fraction. There were no intensive care admissions or deaths related to neutropenic sepsis. Overall, 30% of patients experienced a partial treatment response and a further 39% were in clinical remission at the time of reporting. Ten patients (43%) died over the follow up period, with 5 deaths attributable to disease progression, 1 died of GI bleeding which may have been associated with chemotherapy and the other 4 died of alternative unrelated causes.Summary/Conclusion:In our single centre experience at a small rural general hospital, attenuated immunochemotherapy proves an efficacious and generally well‐tolerated treatment regimen for elderly patients with high grade non‐Hodgkin lymphoma and can provide lasting remissions for a substantial number of patients in this age group. These data are broadly in line with a previous phase 2 study of R‐miniCHOP in patients aged over 80 years with DLBL and support the continued use of this regimen in elderly patients with high grade NHL receiving treatment in a variety of settings. (Peyrade et al., Lancet Oncology 2013).image

Development of a Quality Improvement Curriculum in a Pediatric Emergency Medicine Fellowship.

Quality improvement (QI) is a science of systematic analysis and improvement of health care delivery systems. Working knowledge of QI models is imperative to professional development of future pediatric emergency medicine practitioners. The Accreditation Council for Graduate Medical Education has established a list of QI and patient safety expectations for trainees. In order to address educational needs in this area, we have created a novel QI curriculum for pediatric emergency medicine fellows that include didactic sessions, active participation in QI projects, and mentorship by QI faculty. As a part of the curriculum, fellows are required to participate in variety of QI and patient safety activities, such as Morbidity and Mortality conferences, QI and Patient Case Review committees, and Clinical Care Guideline work groups. As a measure of success, fellows who have participated in this curriculum have shared their successful QI work at the local and national levels. This goal of this report is to share our experience in order to provide other institutions a framework for their own curriculum development.

Effectiveness and safety of physician–pharmacist collaborative care for rheumatoid arthritis patients: The Changi General Hospital’s experience

Background: Increasing demand for follow-up of rheumatoid arthritis has encouraged pharmacists to collaborate with physicians to assist with patient care. Objective: The aim of this study was to assess the effectiveness and safety of the collaborative care model in a rheumatoid arthritis clinic. Methods: We performed a retrospective review of patient case notes and medication records from March 2013 to February 2016. The effectiveness and safety of collaborative care was examined in pre-implementation (standard care) versus post-implementation (collaborative care) cohorts. All patients were assessed for 12 months. Effectiveness of clinic was measured using the percentage of patients that achieved optimal doses of non-biologic disease-modifying anti-rheumatic drugs (nb-DMARDs). Clinic safety performance was evaluated based on the percentage of patients in each cohort that achieved compliance to in-house hospital guidelines on nb-DMARD monitoring. Other clinic safety factors monitored included the incidence and characteristics of nb-DMARD-associated adverse drug events. Results: Thirty-eight patients who had received standard care and collaborative care were reviewed. More patients receiving collaborative care achieved nb-DMARD dose optimization within a year of initiation of therapy (68.4% vs 39.5%; p-value &lt; 0.05). Compliance to safety recommendations from hospital guidelines on nb-DMARD monitoring was significantly higher in the collaborative care group (70.6% vs 44.1%; p-value &lt; 0.05). Collaborative care resulted in a higher incidence of nb-DMARD-associated adverse drug events being detected (26.3% vs 18.4%; p-value &lt; 0.05). The most common adverse drug events were gastrointestinal (29.4%), dermatological (17.6%), and hematologic (17.6%), the majority being mild in severity. Conclusion: Collaborative rheumatoid arthritis care contributed to improvements in nb-DMARD dose optimization, compliance to hospital guidelines on monitoring, and the detection of nb-DMARD-related adverse drug events.

Effectiveness of peer pressure on computed tomography use for dizziness/vertigo patients.

Dizziness/vertigo is a common complaint in the emergency department (ED). We aimed to evaluate the effect of peer pressure on decision making in emergency physicians (EPs) to use computed tomography (CT) for patients with dizziness/vertigo.We conducted a before-and-after retrospective case review of patients who visited the ED with dizziness/vertigo. EPs were categorized into 3 groups according to seniority (in years of experience: >12, 7–12, and <7). The rate of CT use for EPs, patient number, and CT use were e-mailed monthly to update the EP team on the benchmark rate and shape of the behavior.Among the 1657 (preintervention) and 1508 (postintervention) patients with dizziness/vertigo, 320 (19.3%) and 230 (15.3%), respectively, underwent brain CT. A decrease in the rate of CT use was observed in the postintervention group (odds ratio [OR] = 0.743, 95% confidence interval [CI] = 0.615–0.897), especially in junior EPs (years of experience, <7; OR = 0.667, 95% CI: 0.474–0.933) and younger patients (age, <60) (OR = 0.625, 95% CI: 0.453–0.857).The intervention strategy created peer pressure through e-mail reminders and decreased the rate of CT use for patients with isolated dizziness/vertigo, especially in junior EPs and younger patients.

Calcification of hydrophilic acrylic intraocular lenses following secondary surgical procedures in the anterior and posterior segments

AimsTo report 15 cases of intraocular lens (IOL) calcification following intraocular surgery and to identify common risk factors.MethodsA retrospective case review of patients with IOL calcification reported from the Royal...

Successes and Challenges of Optimal Trauma Care for Rural Family Physicians in Kansas

Kansas has a regionalized trauma system with formal mechanisms for review, however, increased communication with rural providers can uncover opportunities for system process improvement. Therefore, this qualitative study explored perceptions of family medicine physicians staffing emergency departments (ED) in rural areas, specifically to determine what is going well and what areas needed improvement in relation to the trauma system. A focus group included Kansas rural family physicians recruited from a local symposium for family medicine physicians. Demographic information was collected via survey prior to the focus group session, which was audiotaped. Research team members read the transcription, identified themes, and grouped the findings into categories for analysis. Seven rural family medicine physicians participated in the focus group. The majority were male (71%) with the mean age 46.71 years. All saw patients in the ED and had treated injuries due to agriculture, falls, and motor vehicle collisions. Participants identified successes in the adoption and enforcement of standardized processes, specifically through level IV trauma center certification and staff requirements for Advanced Trauma Life Support training. Communication breakdown during patient discharge and skill maintenance were the most prevalent challenges. Even with an established regionalized trauma system in the state of Kansas, there continues to be opportunities for improvement. The challenges acknowledged by focus group participants may not be identified through patient case reviews (if conducted), therefore tertiary centers should conduct system reviews with referring hospitals regularly to improve systemic concerns.

Gestational gigantomastia: a patient case review and literature review

Gestational gigantomastia (GG) or gravidic macromastia is defined as a disorder characterized by a diffuse, extreme and incapacitating enlargement of one or both breast during pregnancy. Gestational Gigantomastia is a very rare condition with a little over a 100cases reported in history. Gigantomastia has been seen to occur in the face of normal hormonal profile. Due to increase in breast mass, the overlying skin is stretched and may undergo necrosis which in the face of pregnancy can cause severe mastitis and haemorrhage.&#x0D; We present a rare case of GG in a 36-year-old para 7 gravida 8, Zambian woman at 28weeks gestation with classical features of typical GG with normal hormonal profile with respect with pregnancy. She was managed conservatively on Bromocriptine 5mg once a day during pregnancy and postpartum until breast size had reduced to near normal prepregnancy size.&#x0D; We report a rare case of “True gigantomastia which develops rapidly during pregnancy, undergoes regression after delivery, and recurs with subsequent pregnancies” in Zambia.

Lower eyelid excursion: A functional and cosmetically relevant parameter in the treatment of lower eyelid retraction

The purpose of this study was to assess and quantify lower lid excursion following repair of lower lid retraction. In this retrospective cohort study, a case review of patients who had undergone ear cartilage grafting for lower lid retraction was undertaken. Surgical correction involved the placement of autologous cartilage between the tarsal plate and lower lid retractors. Measurements taken preoperatively and postoperatively were the marginal reflex 2 (MRD2) and the lower scleral show (LSS). The lower lid excursion on downgaze (LLE) was measured only postoperatively with a comparison made between operated eyes and control eyes. Thirteen eyelids of 10 patients were included in the study. Preoperatively, MRD-2 ranged from 4 to 8 mm (6.5 ± 1.5 mm) - mean ± SD. Postoperatively, MRD-2 ranged from 4 to 6 mm (5.1 ± 0.7 mm). The difference in mean MRD2 was statistically significant (p < 0.05). Preoperatively, LSS ranged from 0 to 5 mm (2.5 ± 1.6 mm). Postoperatively, LSS ranged from 0-1 mm (0.1 ± 0.3 mm). The difference in mean LSS was statistically significant (p < 0.01). Postoperatively, all lower eyelids achieved movement on downgaze. On the operated eyes, the eyelid excursion ranged from 2 to 5 mm (3.1 ± 1.0 mm) on downgaze. On the nonoperated (control) eyes (where the operations were not performed bilaterally), the eyelid excursion ranged from 1 to 4 mm (2.8 ± 1.2 mm). There was no statistically significant difference in the lid excursion of operated and nonoperated eyes (p > 0.05). It is possible to correct lower lid retraction in both primary and secondary positions of gaze if an appropriate surgical technique is employed.

Negative hearing effects of a single course of IV aminoglycoside therapy in cystic fibrosis patients

Objective: Identify hearing effects of a single course of intravenous (IV) aminoglycoside antibiotics (AGs) therapy in adult cystic fibrosis (CF) patients. Determine whether the change is large enough to enable a proof-of-concept study of a new drug preventing AG-associated hearing loss.Design: Retrospective case review of CF patients with sequential audiograms ± an intervening course of IV AG therapy.Study sample: 84 patients with no intervening IV AG treatment, 38 patients undergoing a single course of IV AGs.Results: Using ASHA ototoxicity metrics, 45% of adult CF patients in the Single-IV group met the criteria for ototoxicity compared to 23% of the No-IV patients. Other hearing metrics including the average maximal threshold shift (TS) and average high frequency TS showed highly significant differences between groups. Testing only participants with mild or greater pre-therapy high frequency hearing loss further increased the differences between the two groups by every metric tested.Conclusion: Adult CF patients exposed to a single course of IV AGs have significantly greater TS than patients without IV AG exposure. Patients with mild to moderate hearing loss prior to AG-IVs are at increased risk of developing ototoxicity from subsequent parenteral AG therapy.

Surgical outcomes of a new affordable non-valved glaucoma drainage device and Ahmed glaucoma valve: comparison in the first year

BackgroundA new low-cost, indigenously manufactured, non-valved glaucoma drainage device (GDD) has been introduced and its design is based on the Baerveldt Glaucoma Device. We aim to demonstrate the efficacy and...