Prevalence Of Endoscopy Related Injuries and Its Impact on Clinical Practice: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopy related musculoskeletal injuries (ERI) are commonly reported but its exact prevalence and clinical impact remains obscure. We conducted a systematic review and meta-analysis of the present literature to answer these questions.

METHODS

MEDLINE, Embase and Scopus databases were searched for studies evaluating ERI in gastroenterologists, and surgeons. The co-primary outcome was to assess prevalence of endoscopy related injuries ie. Carpal tunnel syndrome (CTS), De Quervain's tenosynovitis (DQTS) and hand numbness. The other co-primary outcome was to assess prevalence of endoscopy related pain syndromes in the present literature.

RESULTS

Twelve studies including 4563 respondents were included. Majority of the participants were males (3321, 72.7%) and most were right-handed (86.2%). The career prevalence of CTS as pooled from ten studies was 5.3% (95% CI: 1.5%, 8.9%, I2=97.1%), while prevalence of DQTS as reported by five studies was 8.5% (95% CI 0.1%, 17.0%). The pooled prevalence of thumb pain, neck pain and back pain was 25.4%, 23.1% and 19.7% respectively but the prevalence varied according to the type of questionnaires used. Only 341 of 864 (39.4%) respondents had received prior training in ergonomics while 623 of 889 (69.0%) respondents expressed a desire for further training in ergonomics. Overall, there is a moderate risk of bias in the present literature.

CONCLUSION

Endoscopy related injuries of CTS, DQTS and endoscopy related pain are very common. These injuries can be severe, requiring surgery, and lead to loss of productivity. Most gastroenterologist report an unmet need for training in proper ergonomics of endoscopy.

Incidence and risk factors for recurrence of ampullary adenomas after endoscopic papillectomy: Comparative analysis of familial adenomatous polyposis and sporadic ampullary adenomas in an international multicenter cohort

OBJECTIVES

Endoscopic papillectomy (EP) is a minimally invasive therapy for the management of ampullary adenomas (AA). We conducted this multicenter study to assess the incidence of and factors related to the recurrence of AA after EP in patients with familial adenomatous polyposis (FAP) compared to sporadic AA.

METHODS

We included patients who underwent EP for AA at 10 tertiary hospitals. Adenomatous tissue at the resection site at the time of surveillance endoscopies was considered recurrent disease.

RESULTS

In all, 257 patients, 100 (38.9%) with FAP and 157 (61%) patients with sporadic AA, were included. Over a median of 31 (range, 11-61) months, recurrence occurred in 48/100 (48%) of patients with FAP and 58/157 (36.9%) with sporadic AA (P = 0.07). Two (2%) FAP patients and 10 (6.3%) patients with sporadic AA underwent surgery for recurrence. On multivariable regression analysis, the recurrence in FAP was higher than in sporadic patients after the first year of follow-up. AA size (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.001, 1.056), periampullary extension (HR 2.5, 95% CI 1.5, 4.01), and biliary duct dilation (HR 2.04, 95% CI 1.2, 3.4) increased the risk, while en bloc resection (HR 0.6, 95% CI 0.41, 0.9) decreased the risk of recurrence.

CONCLUSION

Recurrence rates are high after EP. Most recurrences in sporadic patients occur within the first year of follow-up, but after the first year of follow-up in patients with FAP. Recurrences are higher with larger adenomas, biliary duct dilation, and periampullary extensions, and may be mitigated by en bloc resection. These factors should be considered in decision-making with the patients.

An Unusual Case of a Pharyngeal Fistula to the Cervical Spine Causing Osteomyelitis

SIGNIFICANCE STATEMENT

Pharyngeal fistulas to the cervical spine resulting in vertebral osteomyelitis are a rare, yet clinically important, complication of total laryngectomy performed in conjunction with chemoradiotherapy or radiation therapy. This complication is likely underdiagnosed and can have a high mortality rate. It is very important that clinicians are aware of this complication as early diagnosis and management may improve patient outcomes.

Device malfunctions with use of EUS-guided fine-needle biopsy devices: Analysis of the MAUDE database

Background

The safety of endoscopic ultrasound-guided tissue acquisition through fine-needle biopsy devices is well-established in clinical trials. The real-world experience of using these devices is not known. The authors analyzed the postmarketing surveillance data from the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database to answer this question.

Methods

The Food and Drug Administration MAUDE database from January 2012 to June 2022 was accessed to evaluate for device malfunctions and patient-related adverse consequences of these malfunctions.

Results

There were 344 device-related issues. Most issues were due to detachment or breakage of the device (n = 185 [53.7%]). Seventy-six of the breakages (40.8%) occurred during the procedure, whereas 89 cases (47.8%) occurred while removing the needle from the endoscope. The most common site of tissue biopsy at the time of needle breakage was the pancreas (44 [23.8%]).The common patient-related adverse events were retained foreign body (n = 50 [14.5%]) followed by bleeding (16, 4.6%). Six patients (3.4%) required a second intervention for removal of the retained foreign bodies including surgery in 2 cases. The device breakage damaged the endoscope in 3 cases (1.7%), and there was 1 case of needlestick injury to the nurse.

Conclusion

The fine-needle biopsy devices can be associated with needle breakage and bending; these adverse events were not previously reported. Needle breakages can result in a retained foreign body that may require additional procedures including surgery. These real-world findings from the MAUDE database may inform clinical decisions and help improve clinical outcomes.

Unique case of a GLI1 amplified biphasic mesenchymal tumor of the orbit

GLI1-altered mesenchymal tumors are an emerging entity in soft tissue pathology. In the head and neck region, they are most commonly in the tongue. Limited published data indicate a propensity for local recurrence, regional spread, and distant metastasis in both GLI1-rearranged and GLI1-amplified tumors. The purpose of this report is to present the rare case of a GLI1-amplified spindle cell tumor of the orbit and a focused review of the literature. A 54-year-old woman presented with proptosis, eye pain, and ocular motility restriction in the left eye. Imaging demonstrated a tumor occupying the superomedial intraconal orbit that was distinct from the extraocular muscles, optic nerve, and globe. The tumor was totally resected with a combined open transorbital and endoscopic, endonasal approach. Pathological analysis demonstrated a spindled and epithelioid mesenchymal tumor with diffuse nuclear GLI1 expression. PCR-based, next*-generation sarcoma fusion panel was negative for GLI1 fusions, including GLI1::ACTB fusions; however, DDIT3 breaks apart fluorescence in situ hybridization (FISH), which can be used as a surrogate for GLI1 alterations due to proximity to 12q13.3, showing amplification. Post-operatively, the patient had recovered visual acuity. She received adjuvant radiation therapy (60 Gy in 30 fractions). Surveillance for recurrence, regional spread, and distant metastasis has been negative at a 6-month follow-up. Ultimately, we report the first case of a GLI1-amplified mesenchymal neoplasm of the intraconal orbit managed with gross total resection via a combined approach followed by adjuvant radiation therapy.

Therapies for non-alcoholic fatty liver disease: A 2022 update

The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly increasing and lifestyle interventions to treat this disease by addressing the underlying metabolic syndrome are often limited. Many pharmacological interventions are being studied to slow or even reverse NAFLD progression. This review for hepatologists aims to provide an updated understanding of the pathogenesis of NAFLD, current recommended therapies, and the most promising treatment options that are currently under development.

Cirrhotic coagulopathy: A rebalanced hemostasis

Cirrhosis has been regarded as a hypocoagulable state associated with an increased risk of bleeding. But patients with cirrhosis also have a high incidence of thrombotic complications, challenging this dogma. We now recognize that in cirrhosis there is a simultaneous decrease in both clotting and anticlotting factors, leading to a new equilibrium. Conventional coagulation tests such as the platelet count and prothrombin time do not assess the reduced anticoagulation factors in cirrhosis and overestimate the bleeding risk, and any intervention based on these test results can lead to thrombotic complications. This article reviews the changes in hemostasis associated with cirrhosis, newer tests for assessing coagulation, and preprocedural minimization of coagulopathy.

The Prevalence of the Celiac Disease in Patients with Dyspepsia: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with celiac disease (CeD) can commonly present with symptoms of dyspepsia. We conducted a systematic review and meta-analysis of the present literature to assess the prevalence of CeD in patients diagnosed with dyspepsia.

METHODS

We searched MEDLINE and EMBASE databases for the keywords: celiac disease, coeliac disease, anti-gliadin, tissue transglutaminase antibody, anti-endomysial antibody, dyspepsia and functional gastrointestinal disorder. All the studies published from January 1991 till May 2021 were included. Diagnosis of CeD was based on the European Society of Pediatric Gastroenterology, Hepatology and Nutrition guidelines. A random-effects model was used to pool the data.

RESULTS

Twenty-one studies screening 10,275 patients with dyspepsia were included. The pooled seroprevalence of CeD based on a positive anti-tissue transglutaminase antibody and/or anti-endomysial antibody was 4.8% (95% CI [2.8, 6.7%], I² = 87.7%). The pooled biopsy-confirmed CeD prevalence was 1.5% (95% CI [1.0, 1.9%]; I² = 59.8%) in these patients. Both seroprevalence (Odds ratio: 1.8; 95% CI [0.8, 4.0%]; I² = 0%) and prevalence of biopsy-confirmed CeD (Odds ratio: 1.4; 95% CI [0.8, 2.4]; I² = 0%) were not higher in patients with dyspepsia compared to controls. There was a moderate risk of selection bias and significant heterogeneity in the pooled results.

CONCLUSIONS

The pooled prevalence of CeD in patients with dyspepsia was 1.5% and it was not significantly higher than the general population. These results do not support screening of patients with dyspepsia for CeD.

The association of D-dimers with mortality, intensive care unit admission or acute respiratory distress syndrome in patients hospitalized with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

AIM

To determine if D-dimers are elevated in individuals with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who have adverse clinical outcomes including all-cause mortality, intensive care unit (ICU) admission or acute respiratory distress syndrome (ARDS).

METHODS

We conducted a systematic review and meta-analysis of the published literature in PubMed, Embase and Cochrane databases through April 9, 2020 for studies evaluating D-dimer levels in SARS-COV-2 infected patients with and without a composite clinical endpoint, defined as the presence of all-cause of mortality, Intensive care unit (ICU) admission or acute respiratory distress syndrome (ARDS). A total of six studies were included in the meta-analysis.

RESULTS

D-dimers were significantly increased in patients with the composite clinical end point than in those without (SMD, 1.67 ug/ml (95% CI, 0.72-2.62 ug/ml). The SMD of the studies (Tang et al, Zhou et al, Chen et al), which used only mortality as an outcome measure was 2.5 ug/mL (95% CI, 0.62-4.41 ug/ml).

CONCLUSION

We conclude that SARS-CoV-2 infected patients with elevated D-dimers have worse clinical outcomes (all-cause mortality, ICU admission or ARDS) and thus measurement of D-dimers can guide in clinical decision making.

Prevalence of celiac disease in patients with short stature: A systematic review and meta-analysis

BACKGROUND AND AIM

Short stature is a common extraintestinal manifestation of celiac disease (CeD). We conducted a systematic review and meta-analysis to assess the global prevalence of CeD in patients presenting with short stature.

METHODS

We searched Medline and EMBASE databases for the keywords "celiac disease, coeliac disease, anti-gliadin, tissue transglutaminase antibody, anti-endomysial antibody, short stature and growth retardation." All the studies published from January 1991 to May 2020 were included. Patients without any prior evaluation for short stature were classified as all-cause short stature, while prior evaluated patients, where no cause was found for short stature, were classified as idiopathic short stature. The diagnosis of CeD was based on the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines. A random-effects model was used to pool the data.

RESULTS

Seventeen studies screening 3759 patients (1582 with all-cause short stature and 2177 with idiopathic short stature) were included. The pooled seroprevalence of CeD based on positive anti-tissue transglutaminase antibody and anti-endomysial antibody was 11.2% (95% CI 4.0-21.2%; I²  = 86%) and 9.7% (95% CI 2.7-20.2%; I²  = 95%) for all-cause and idiopathic short stature, respectively. Similarly, pooled prevalence of biopsy-confirmed CeD was 7.4% (95% CI 4.7-10.6%; I²  = 76%) and 11.6% (95% CI 4.1-22.2%; I²  = 97%), for all-cause and idiopathic short stature, respectively. There was an overall severe risk of selection bias and significant heterogeneity in the pooled results.

CONCLUSIONS

Approximately one in 14 patients with all-cause short stature and one in nine patients with idiopathic short stature had biopsy-confirmed CeD. Therefore, evaluation for CeD may be prudent in all patients with short stature.

Multi-drug resistant, biofilm-producing high-risk clonal lineage of Klebsiella in companion and household animals

Antimicrobial resistance is a global emergency which needs one health approach to address. The present study was conducted to detect the prevalence of beta-lactamase and biofilm-producing Klebsiella strains in rectal swabs (n = 624) collected from healthy dogs, cats, sheep and goats reared as companion or household animals in India. The dogs and cats were frequently exposed to third- or fourth-generation cephalosporins for therapy. The sheep and goats were occasionally exposed to antibiotics and had environmental exposure. Phenotypical ESBL (n = 93) and ACBL (n = 88)-producing Klebsiella were isolated significantly more (P < 0·05) from companion animals than household animals. Majority of the Klebsiella possessed bla_CTX-M-15 . The sequences bla_CTX-M-15.2 , bla_CTX-M-197 and bla_CTX-M-225 are reported first time from the companion animals. All ACBL-producing isolates possessed bla_AmpC . The present study detected 65·8% of Klebsiella strains as biofilm producers possessing the studied biofilm associated genes. The isolates showed phenotypical resistance against chloramphenicol, tetracycline, doxycycline, co-trimoxazole, ampicillin, cefotaxime/clavulanic acid. The present study showed that companion and household animals (dogs, cats, sheep, goats) may act as a carrier of ESBL/biofilm-producing, multi-drug resistant, high-risk clonal lineage of Klebsiella.

A Randomized Control Trial of Thromboelastography-Guided Transfusion in Cirrhosis for High-Risk Invasive Liver-Related Procedures

BACKGROUND AND AIM

Hemostasis in cirrhosis is dynamic and balanced. Thromboelastography (TEG) assesses global coagulation status. We aimed to assess whether TEG-guided blood product transfusions result in lower blood product requirements in patients with cirrhosis undergoing invasive liver-related procedures as compared to the conventional standard of care (SOC).

METHODS

In this open-label, randomized controlled trial, cirrhosis patients with coagulopathy, undergoing invasive liver-related procedures, were randomized to either TEG-guided blood product transfusion or SOC. The primary outcome was difference in the amount of fresh frozen plasma (FFP) and platelet units transfused between the two groups. The secondary outcome was procedure-related bleeding complications within 5 days and any complications until 28 days.

RESULTS

From November 2017 till June 2019, 58 patients were recruited (29: TEG and 29: SOC). Most common procedures performed were percutaneous liver biopsy (n = 48), followed by transjugular intrahepatic portosystemic shunt (n = 2), percutaneous acetic acid injection (n = 2), and transarterial chemoembolization (n = 2). There were no differences in baseline demographics, hemostatic profile, and types of procedures between the two groups. Only nine patients in TEG group received transfusions compared to all patients in SOC (31% vs 100%; P < 0.001). In TEG group, six (20.7%) received FFP (P = 0.753 vs. SOC), two (6.9%) received platelets (P < 0.001 vs. SOC), and 1(3.4%) patient received both FFP and platelet (P ≥ 0.999 vs. SOC) transfusion. None of the patients in either group developed procedure-related bleeding complications until 5 days post-procedure. The complication rates at 28-day follow-up were similar between the groups.

CONCLUSION

TEG-guided blood product transfusion strategy reduces blood product transfusion without increased risk of bleeding in cirrhotic patients undergoing invasive liver-related procedures (CTRI/2017/12/010822).

Systematic review with meta-analysis: impact of baseline resistance-associated substitutions on the efficacy of glecaprevir/pibrentasvir among chronic hepatitis C patients

BACKGROUND

The effect of baseline resistance-associated substitutions (RAS) on the sustained virologic response at 12 weeks (SVR12) among chronic hepatitis C (CHC) patients receiving the second generation, pan-genotypic glecaprevir/pibrentasvir (G/P) regimen is unclear.

AIM

To assess the effect of RAS on the SVR12 in CHC patients treated with G/P regimen.

METHODS

The EMBASE, MEDLINE and Cochrane central register of controlled trials databases were searched for relevant studies published before 1 March 2019. The principal outcome was to compare the SVR12 in CHC patients with and without baseline RAS, particularly in genotype-1, genotype-3 and direct-acting anti-virals (DAAs) failure patients. The outcomes were pooled using a random-effects model and odds ratio (OR) was calculated. The risk of bias was assessed using the Cochrane risk of bias tools for randomised and nonrandomised interventional studies.

RESULTS

After initially identifying 410 studies, 3302 patients from 17 studies were included. Among 50 cases of virologic failures, 48% had genotype-3 infection, 44% genotype-1 infection and 36% DAA-failure patients. Baseline RAS were present in 44(88%) patients. The most common NS5a and NS3 mutations were Y93H and A166S respectively. The odds of SVR12 were significantly reduced in patients with any baseline RAS (NS3 and/or NS5a) (OR 0.32, 95%C I[0.15, 0.65], I²  = 0%) and NS5a substitutions (OR 0.36, 95%CI [0.18,0.73]). The impact of RAS on SVR12 was significant among genotype-3 patients, but not among genotype-1 or DAA-failure cases. The presence of Y93H and A30K mutations significantly impacted SVR12 rates in genotype-3 patients.

CONCLUSION

Baseline NS3 or NS5a RAS, especially the NS5a substitutions-A30K, Y93H, decrease the odds of achieving SVR12 in genotype-3 CHC patients.

Persistent or incident hyperammonemia is associated with poor outcomes in acute decompensation and acute-on-chronic liver failure

Background and Aim

The effect of elevated ammonia on organ failures (OF), apart from hepatic encephalopathy, in patients with acute decompensation (AD) of cirrhosis and acute‐on‐chronic liver failure (ACLF) is unclear. We aimed to assess the effect of persistent or incident hyperammonemia on OF and outcomes in patients with AD and ACLF.

Methods

A total of 229 patients with ACLF and 83 with AD were included. Arterial ammonia was measured on day 1 and day 3 of admission. Persistent or incident hyperammonemia was defined as a level of ≥79.5 μmol/L on day 3. The changes in ammonia levels during the first 3 days were analyzed with respect to the complications and outcomes.

Results

At admission, the median level of arterial ammonia was higher in ACLF compared to AD patients (103 vs 86 μmol/L, P < 0.001). Persistent or incident hyperammonemia was noted in 206 (66.0%) patients and was more frequent in ACLF compared to AD patients (70.7 vs 53.0%, P = 0.013). Patients with persistent or incident hyperammonemia, compared to those without it, developed a higher proportion of new‐onset OF during hospitalization involving liver (P = 0.018), kidney (P = 0.001), brain (P = 0.005), coagulation (P = 0.036), circulation (P = 0.002), and respiratory (P = 0.003) issues and had higher 28‐day mortality (log‐rank test, P < 0.001). After adjustment for chronic liver failure consortium ACLF score, persistent or incident hyperammonemia (hazard ratio, 3.174) was independently associated with 28‐day mortality. The presence of infection was an independent predictor of persistent or incident hyperammonemia.

Conclusion

Persistent or incident hyperammonemia during first 3 days of hospitalization in patients with AD or ACLF is associated with increased risk of OF and death.

Overview of recycled concrete research through development years (2004-2018)

Along with the urbanization process, large amount of construction and demolition (C&D) waste during the construction, reconstruction, expansion or demolition of buildings is generated. Meanwhile, the impact on environment due to natural aggregate mining has become increasingly significant. These factors have driven the building industry to look for environmentally friendly materials and focusing on sustainable construction. Through nearly a decade of research, recycled concrete (RC) made with recycled aggregates manufactured from construction and demolition (C&D) waste has shown a competitive performance compared to natural materials and has already achieved industrial application. Researches on sustainably recycled concrete have become an essential part of sustainable development and continue to play a vital role for future research.

This paper engages in the discussion and the overview of research done by the Research Group for Recycled Concrete Structures and Construction at Tongji University, Shanghai. The first part discusses the necessary mechanical and durability properties of recycled concrete with recycled aggregate as well as recycled powder focusing on workability, strength, Poisson’s ratio, stress-strain behaviour along with carbonation, chloride penetration shrinkage and creep. The second part throws light on the elements and structures made with recycled aggregate concrete (RAC), discussing the behaviours of RAC components and structures.

Index-TB guidelines: Guidelines on extrapulmonary tuberculosis for India

Extrapulmonary tuberculosis (EPTB) is frequently a diagnostic and therapeutic challenge. It is a common opportunistic infection in people living with HIV/AIDS and other immunocompromised states such as diabetes mellitus and malnutrition. There is a paucity of data from clinical trials in EPTB and most of the information regarding diagnosis and management is extrapolated from pulmonary TB. Further, there are no formal national or international guidelines on EPTB. To address these concerns, Indian EPTB guidelines were developed under the auspices of Central TB Division and Directorate of Health Services, Ministry of Health and Family Welfare, Government of India. The objective was to provide guidance on uniform, evidence-informed practices for suspecting, diagnosing and managing EPTB at all levels of healthcare delivery. The guidelines describe agreed principles relevant to 10 key areas of EPTB which are complementary to the existing country standards of TB care and technical operational guidelines for pulmonary TB. These guidelines provide recommendations on three priority areas for EPTB: (i) use of Xpert MTB/RIF in diagnosis, (ii) use of adjunct corticosteroids in treatment, and (iii) duration of treatment. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, which were evidence based, and due consideration was given to various healthcare settings across India. Further, for those forms of EPTB in which evidence regarding best practice was lacking, clinical practice points were developed by consensus on accumulated knowledge and experience of specialists who participated in the working groups. This would also reflect the needs of healthcare providers and develop a platform for future research.

Regression of invasive conjunctival squamous carcinoma in an HIV-positive patient on antiretroviral therapy

Case history of an African woman presenting with advanced HIV and a painful conjunctival lesion is presented. A conjunctival biopsy revealed invasive squamous cell carcinoma, with orbital invasion on computed tomography scan. She was commenced on antiretroviral therapy. She refused surgery to remove the eye and orbital contents (exenteration), and was referred to palliative care. Gradually, her immune status and ocular symptoms improved. At ophthalmic review, the tumour had apparently completely regressed. This unprecedented phenomenon may be due to antiretroviral therapy. Discussion covers conjunctival carcinoma and behaviour of HIV-related tumours with antiretroviral therapy. Antiretroviral drugs may offer a better alternative to disfiguring surgery in the future.

Ultrastructural changes in the sublingual salivary gland of prenatal buffalo (Bubalus bubalis)

Aim:

The present study was aimed to elucidate ultrastructural changes in the development of sublingual salivary gland of buffalo during prenatal life.

Materials and Methods:

The study was carried out on sublingual salivary gland of 36 buffalo fetuses ranging from 13.2 cm curved crown-rump length (CVRL) (88^th day) to full term. The fetuses were categorized into three groups based on their CVRL.

Results:

The cells lining the terminal tubules were undifferentiated with poorly developed cytoplasmic organelles but lacked secretory granules (SGs) at 13.2 cm CVRL (88^th day). The SGs appeared first in the form of membrane-bound secretory vesicles with homogeneous electron-dense as well as electron-lucent contents at 21.2 cm CVRL (122^nd day); however, mucous acinar cells contained electron-lucent granules, while serous secretory cells as well as serous demilunes showed electron-dense granules at 34 cm CVRL (150^th day) of prenatal life. At 53.5 cm CVRL (194^th day), both mucous and serous acini were differentiated by the density of SGs.

Conclusion:

The cytoplasm of acinar cells was filled with mitochondria, rough endoplasmic reticulum, and Golgi profiles in mid and late fetal age groups. The SGs were increased in number during the late fetal age group. The myoepithelial cells (MECs) were located at the base of the acinar cells as well as intercalated and striated ducts and were stellate in shape. The ultrastructure of MEC revealed a parallel stream of myofilaments in the cytoplasm and its processes. The mucous cells were predominantly present in the sublingual salivary gland and were pyramidal in shape.

Ocular phototherapy

Phototherapy can be translated to mean 'light or radiant energy-induced treatment.' Lasers have become the exclusive source of light or radiant energy for all applications of phototherapy. Depending on the wavelength, intensity, and duration of exposure, tissues can either absorb the energy (photocoagulation, thermotherapy, and photodynamic therapy (PDT)) or undergo ionization (photodisruption). For phototherapy to be effective, the energy has to be absorbed by tissues or more specifically by naturally occurring pigment (xanthophyll, haemoglobin, and melanin) within them. In tissues or tumours that lack natural pigment, dyes (verteporphin, Visudyne) with narrow absorption spectrum can be injected intravenously that act as focal absorbent of laser energy after they have preferentially localized within the tumour. Ocular phototherapy has broad applications in treatment of ocular tumours. Laser photocoagulation, thermotherapy, and PDT can be delivered with low rates of complications and with ease in the outpatient setting. Review of the current literature suggests excellent results when these treatments are applied for benign tumours, particularly for vascular tumours such as circumscribed choroidal haemangioma. For primary malignant tumours, such as choroidal melanoma, thermotherapy, and PDT do not offer local tumour control rates that are equivalent or higher than those achieved with plaque or proton radiation therapy. However, for secondary malignant tumours (choroidal metastases), thermotherapy and PDT can be applied as a palliative treatment. Greater experience is necessary to fully comprehend risks, comparative benefits, and complication of ocular phototherapy of ocular tumours.

Does neurologic deterioration help to differentiate between pseudoprogression and true disease progression in newly diagnosed glioblastoma multiforme?

Enlarging or new lesions frequently appear on magnetic resonance imaging (mri) after concurrent administration of radiation therapy and temozolomide in glioblastoma multiforme (gbm) patients. However, in nearly half such cases, the observed radiologic changes are not due to true disease progression, but instead are a result of a post-radiation inflammatory state called "pseudoprogression." Retrospective studies have reported that neurologic deterioration at the time of the post-chemoradiotherapy mri is found more commonly in patients with true disease progression. We report a gbm patient with both radiologic progression on the post-chemoradiotherapy mri and concomitant neurologic deterioration, and we caution against incorporating clinical deterioration into the management schema of patients with possible pseudoprogression.

Is tobacco smoking protective for sarcoidosis? A case-control study from North India

BACKGROUND

While tobacco smoking is commonly believed to be negatively associated with the occurrence of sarcoidosis, the relationship of environmental tobacco smoke (ETS) exposure with sarcoidosis is largely un-explored. We studied the impact of active smoking and ETS exposure on disease severity in newly diagnosed cases of sarcoidosis from India.

METHODS

Data on demographic variables, smoking habits and exposure to environmental tobacco smoke (ETS) among non-smoker sarcoidosis patients was collected prospectively. Presence of smoking and ETS exposure were compared among cases and controls. Among the sarcoidosis patients, clinical manifestations, radiology, spirometry and histopathological grading of lung biopsy were compared between the smokers vs. non-smokers and ETS exposed vs. not-exposed.

RESULTS

We studied 98 newly diagnosed cases of sarcoidosis and 196 age, sex and religion- matched healthy volunteers. The study group comprised of 62 (63%) men and 36 (37%) women. The prevalence of smoking was similar in cases and controls (12.2% vs. 15.3%, p = 0.48). Among the never smoker patients with sarcoidosis, 20 (23%) reported ETS exposure vis-a-vis 57 (34%) in the matched controls. A conditional logistic regression analyses showed insignificant negative association with active smoking (OR 0.75; 95% CI, 0.35-1.56) or ETS exposure (OR 0.58; 95% CI, 0.32-1.06) after adjusting for age, gender, religion, and education. There were no differences in the clinical manifestations, radiological staging, spirometry and histopathological grading of lung biopsy in any of the group comparisons studied.

CONCLUSION

Smoking or ETS exposure may not have significant negative association with sarcoidosis. Also, tobacco smoke might not have any effect on the clinical behavior or disease severity in sarcoidosis. The belief that smoking is protective for sarcoidosis is not substantiated in this study and appears to be misfounded.

Survival with retinoblastoma in the USA: 1975-2004

BACKGROUND

The purpose of this study was to determine the survival of retinoblastoma in the USA over a 30-year period from 1975 to 2004 using a systematic review of existing databases.

METHODS

Nine hundred and ninety-two cases of retinoblastoma (International Classification of Oncology (ICDO-3) codes C69.2 (retina) and C69.9 (eye, NOS)) were derived from the Surveillance, Epidemiology and End Results (SEER) program database in the USA from 1975 to 2004. All 17 current SEER registries were utilised to allow for optimal patient volume for statistical analysis. Survival rates were calculated by the Kaplan-Meier method and differences evaluated with logrank and Wilcoxon tests. Cause of death was obtained and reviewed for all deceased patients. All retinoblastoma patient records were reviewed for treatments given and occurrence of second malignant neoplasms.

RESULTS

There were a total of 990 distinct patients with retinoblastoma. Almost all cases (99.1%) were reported by the hospitals, and histopathological confirmation was available in 87.7% of cases. Over the period of 30 years (1975-2004), the 5-year observed actuarial survival rate increased from 92.3% (1975-84) to 93.9% (1985-94) to 96.5% (1995-2004). The difference in rates was statistically significant (Wilcoxon = 6.2393, p = 0.0442). The proportion of cases treated with radiotherapy first increased from 20.5% in 1975-9 to 34.6% in 1985-9 and then sharply decreased to 6.5% in 2000-4.

CONCLUSIONS

Over the last 30 years, there has been a gradual improvement in 5-year survival of children with retinoblastoma in the USA.

Dosimetric comparison of 106Ru and 125I plaques for treatment of shallow (<or=5 mm) choroidal melanoma lesions

The aim of this study was to compare dosimetric parameters between iodine-125 ((125)I) and ruthenium-106 ((106)Ru) plaques of similar sizes in the treatment of choroidal melanomas. The study design included retrospective double planning of each case. 26 consecutive patients with choroidal melanomas measuring 5 mm or less in thickness were included. Dose distributions were calculated using Plaque Simulator treatment-planning software for a prescription of 85 Gy to the tumour apex. Doses to the outer sclera, lens, fovea and optic disc were obtained for each case using appropriately sized plaques of each isotope. Statistical inferences were made using the non-parametric Wilcoxon signed rank test. The mean dose to the macula, disc and lens was 18%, 53% and 89% less, respectively, with (106)Ru than with (125)I. Scleral doses were greater for (106)Ru. The use of collaborative ocular melanoma study dosimetry results in even higher mean doses to the macula, disc, lens and sclera. Two-dimensional dose distributions and dose volume histograms demonstrated the increase in dose outside the tumour volume using (125)I. This comparison shows that, for tumours not exceeding 5 mm in thickness, the use of (106)Ru plaques has the potential to reduce the radiation dose to nearby normal structures and possibly lower the risk of radiation-induced visual loss.

Incidence of retinoblastoma in the USA: 1975-2004

BACKGROUND

The purpose of this study was to determine the age-adjusted incidence of retinoblastoma in the USA over a 30-year period from 1975 to 2004 using a review of existing databases.

METHODS

Six hundred and fifty-eight patients with retinoblastoma (International Classification of Oncology (ICDO-3) codes C69.2 (retina) and C69.9 (eye, NOS)) were derived from the Surveillance, Epidemiology, and End Results (SEER) program database in the USA from 1975 to 2004. Nine historical SEER registries were utilised. The significance of trend in age-adjusted incidence rate was determined using the chi(2) test, and 95% CIs were calculated. The patients were stratified according to age at diagnosis, laterality, gender and race.

RESULTS

There were a total of 658 cases of retinoblastoma, representing 6.1% of all childhood cancers under age 5 years. The mean age-adjusted incidence of retinoblastoma in the USA was 11.8 per million children aged 0-4 years (95% CI 10.9 to 12.8). There was no significant trend in age-adjusted incidence for all races/genders, nor was there any significant variation of incidence between races or between genders. The proportion of bilateral cases (26.7%) versus unilateral cases (71.9%) remained stable over the 30-year period.

CONCLUSIONS

The mean age-adjusted incidence rate of retinoblastoma of 11.8 cases per million children aged 0-4 years in the USA is similar to rates reported from European countries. The age-adjusted incidence rate of retinoblastoma in the USA has remained stable for the last 30 years.

Ciliary body naevus

PURPOSE

To describe clinical, ultrasound biomicroscopy (UBM), and histopathologic characteristics of benign melanocytic tumors of the ciliary body.

DESIGN

Consecutive case series.

METHODS

Six patients with a pigmented ciliary body tumour underwent complete ophthalmic examination and UBM, with histopathologic examination carried out on three cases.

RESULTS

Six patients presented with a pigmented iridociliary mass, with central displacement of iris root. UBM revealed a stromal mass arising in pars plicata and/or pars plana in all six with a cyst in three cases (intrinsic=1 and extrinsic=2). Iridocyclectomy was performed because of documented growth in three cases, and all three cases proved to be ciliary body spindle-cell naevus. The other three patients have remained stable.

CONCLUSIONS

On clinical basis and with available ancillary studies, ciliary body naevi cannot be reliably differentiated from ciliary body melanocytoma and ciliary body melanoma. Even with clinically documented growth, the lesions may prove to be ciliary body naevi.

Bovine pericardium (Tutopatch) wrap for hydroxyapatite implants

PURPOSE

To evaluate bovine pericardium (Tutopatch) as a wrapping material for hydroxyapatite implants in patients undergoing enucleation for uveal melanoma.

METHOD

Prospective cohort study of patients who had enucleation for uveal melanoma between January 2003 and August 2003 were included in the study. Any patient with less than 3 months follow-up was excluded. Enucleation was performed under general anaesthesia followed by insertion of hydroxyapatite implants wrapped in bovine pericardium (Tutopatch). The recti muscles were sutured directly to the wrap. The tenon's capsule and conjunctiva were closed in two layers. A conformer was inserted at 1 week and artificial eye at 2-3 months. The patients were followed up regularly and were assessed for cosmetic result, exposure of implant, and the need for any further surgical procedures.

RESULTS

A total of 19 patients (seven male and 12 female) were included in the study. Median age at diagnosis was 63 years (range 38-80 years). Median follow-up was 26 months (range 22-30 months). No patient developed postoperative complications of wound dehiscence. The overall cosmetic result was excellent in all the patients. The rate of postoperative complications compared favourably with published data using other wrapping materials/implants.

CONCLUSION

Tutopatch is a safe wrapping material for hydroxyapatite orbital implants in patients undergoing enucleation for uveal melanoma.

Proton beam therapy for iris melanoma: a review of 15 cases

AIM

To report results of proton beam therapy for iris melanoma.

METHODS

A retrospective case series of 15 patients with nonresectable iris melanomas treated with proton beam therapy between August 1998 and August 2004. The main outcome measures were (1) local tumour control, (2) complications, and (3) eye retention.

RESULTS

Of the 15 cases, 11 patients showed documented growth (including two cases of local recurrence following iridocyclectomy) while a further three cases were biopsy-proven melanoma. One patient presented with a newly acquired vascular nodule of the iris associated with angle seeding and glaucoma. Tumour control at mean follow-up of 34 months was 93% (14 of 15 eyes). Common complications included glaucoma in 53% (five patients had glaucoma prior to irradiation), dry eye (27%) and cataract in three patients (20%). Eye retention was possible in 80% (12 cases).

CONCLUSION

Proton beam therapy is an effective treatment for cases of nonresectable iris melanoma. The major complications are cataract and glaucoma.