A blueprint for the continuation of comprehensive cardiac rehabilitation during the COVID-19 pandemic. An Australian single hospital experience

Background

The COVID-19 pandemic has disrupted cardiac rehabilitation (CR) around the world with an estimated 50–75% of CR programmes discontinuing or reducing services. Alternative models such as TeleHealth have been encouraged and adopted in place of face to face (F2F) CR. There is a paucity of published data on the continuation of F2F CR during the pandemic.

Methods

A retrospective database audit examined the CR participation rates at an Australian quaternary public hospital during the pre-COVID (2018/2019) and in-COVID (2020/2021) periods. Socio-demographic status, diagnosis at CR entry, CR modalities, and outcome measures (wait times, completion rates) were analysed.

Results

There were no COVID-19 cases or cross infections occurring in CR during the in-COVID period. An audit of 1623 consecutive patients who attended our CR programme (pre-COVID n=760: in-COVID n=863) were included in this study. No significant differences were observed in age, male sex, CR wait times and completion rates between the two groups. Participation rates of patients diagnosed with heart failure (CCF) increased (p=0.02) and those who entered CR after elective PCI decreased (p=0.03) during the in-Covid period in comparison with the pre-COVID period. Total F2F CR was maintained in the in-COVID period compared to the pre-COVID period (85%: 89%, p=not significant (NS)). A significant increase in F2F utilising home walking (p<0.0001) and a decrease in F2F utilising supervised exercise (p<0.0001) was seen. TeleHealth, introduced during the in-COVID period, only contributed to 6% of the total CR participation. More detailed results of this study are presented in Table 1 below.

Conclusions

During the COVID-19 pandemic our CR programme adhered to state health orders, recorded zero transmissions, maintained face to face services, and increased CR uptake only partially due to the introduction of TeleHealth. Our blueprint for the successful continuation of CR during COVID involves having expert nursing management, medical CR champions, dedicated CR gym, and well-established, flexible patient-centric programme modalities.

Funding Acknowledgement

Type of funding sources: None.

Detection of Ocular Malignancies

The case notes of new patients attending the oncology clinic at Moorfields Eye Hospital during the first 5 months of 1988 were analysed retrospectively with regard to the origin of the primary referral, the presence of symptoms, the diagnosis and management. Sixty-eight of 94 new patients were diagnosed as having malignant ocular lesions. Of these 68, 47% were first seen and referred by an optician. Half of these patients were asymptomatic at the time of detection.

Patient understanding of genetic information influences reproductive decision making in retinoblastoma

BACKGROUND

Retinoblastoma is the most common malignant tumour of the eye in childhood, with nearly all bilateral tumours and around 17% to 18% of unilateral tumours due to an oncogenic mutation in the RB1 gene in the germline. Genetic testing enables accurate risk assessment and optimal clinical management for the affected individual, siblings, and future offspring.

MATERIAL AND METHODS

We carried out the first UK-wide audit of understanding of genetic testing in individuals with retinoblastoma. A total of 292 individuals aged 16 to 45 years were included.

RESULTS

Patients with bilateral disease were significantly more likely to understand the implications of retinoblastoma for siblings and children. There was a significant association between not knowing the results of genetic testing or not understanding the implications and not having children, particularly in women. Surprisingly, this was also true for individuals treated for unilateral disease with a low risk of retinoblastoma for their offspring.

CONCLUSION

We are concerned that individuals may be making life choices based on insufficient information regarding risks of retinoblastoma and reproductive options. We suggest that improvement in transition care is needed to enable individuals to make informed reproductive decisions and to ensure optimal care for children born at risk of retinoblastoma.

Plaque radiotherapy treatment with ruthenium-106 for iris malignant melanoma

PURPOSE

To report the results of ruthenium-106 plaque radiotherapy for iris malignant melanoma.

METHODS

A retrospective study of 15 patients with pure iris melanoma treated with ruthenium-106 plaque radiotherapy from June 1998 to June 2006. The main outcome measures were tumour control and ocular complications.

RESULTS

Of the 15 patients, 8 had biopsy-proven melanoma (6 incisional and 2 excisional biopsies). In the remaining seven patients enlargement of the lesion was documented. The median follow-up was 96 months (ranging from 14 months to 12 years). Common radiation-related complications included cataract in 9 (60%) patients, dry eyes in 3 (20%) patients and elevated intraocular pressure in 4 (27%) patients. Vision was preserved in 80% of patients. Local tumour control was obtained in all patients.

CONCLUSIONS

Ruthenium-106 plaque radiotherapy is an effective treatment for primary malignant iris melanoma, resulting in excellent local control with preservation of vision. Main complications included cataract, dry eyes, and glaucoma.

Patterns of regional head and neck lymph node metastasis in primary conjunctival malignant melanoma

OBJECTIVE

To correlate patterns of regional lymph node metastasis with the site of origin in primary conjunctival malignant melanoma.

DESIGN

Retrospective analysis (1990-2003) of clinical data.

SETTING

Two London tertiary referral centres.

PARTICIPANTS

12 patients presenting with regional metastases after failed local treatment for conjunctival malignant melanoma.

RESULTS

6 cases predominantly involving the temporal conjunctiva metastasised to the pre-auricular lymph nodes. Two cases predominantly involving the nasal conjunctiva metastasised to the submandibular nodes. Of the two cases with purely multifocal disease, one metastasised to the pre-auricular nodes and another to both submandibular and parotid nodes. One primary conjunctival malignant melanoma had its origin in temporal conjunctiva but metastasised to submandibular nodes, and another case originating from nasal conjunctiva metastasised to pre-auricular nodes.

CONCLUSIONS

Temporal conjunctival melanotic lesions tend to metastasise clinically to pre-auricular lymph nodes and nasal conjunctival melanotic lesions metastasise to the submandibular lymph nodes. Patterns appear consistent with laboratory-based anatomically mapped lymphatic drainage basins of the conjunctiva.

Choroidal metastasis-the initial presentation of breast carcinoma

We report a rare case of a breast carcinoma metastasis in the choroid presenting as the initial symptom of the primary disease.

Development and validation of a patient based measure of outcome in ocular melanoma

BACKGROUND

Patients with uveal melanoma can be treated by a number of modalities. As none of the different treatments offer a survival advantage, a key factor in choosing among treatments is their differential impact on patients' quality of life. A short, patient based questionnaire was developed and validated for evaluating outcomes following treatment for uveal melanoma.

METHODS

The 21 item measure of outcome in ocular disease (MOOD) assesses the patient's view of outcome in terms of visual function and the impact of treatment. The reliability and validity of the three MOOD scores (total, vision, impact) were evaluated in 176 patients who had been treated for uveal melanoma (75 brachytherapy, 78 proton beam radiotherapy, 23 enucleation). Of these, 165 patients also completed the SF-36.

RESULTS

All three MOOD scales met standard criteria for acceptability, reliability, and validity. The proportion of missing data was low, and responses to all items were well distributed across response categories. Internal consistency, assessed by Cronbach's alpha coefficients, exceeded the standard criterion of 0. 70 for all three summary scores. Item total correlations ranged from 0.22 to 0.77 (mean item total correlation 0.58), indicating good homogeneity. Test-retest correlations for all three summary scores exceeded 0.85. Scaling assumptions, assessed by item convergent and discriminant validity correlations, were met for the vision and impact scores. The MOOD showed good content validity, as assessed by review by ophthalmologists and patients. Construct validity was demonstrated by high intercorrelations between the vision and impact scores and the total scale; higher scores for patients who reported being very satisfied compared with those who were not very satisfied and for those who reported persistent red eye compared with those who did not have this complication (known group differences/hypothesis testing); moderate correlations between the MOOD and the SF-36 and visual acuity (convergent validity); and low correlations between the MOOD and age and sex (discriminant validity).

CONCLUSIONS

The MOOD is a practical and scientifically sound patient based measure which can be used in research and audit to evaluate outcomes following treatment for uveal melanoma. It takes 5 minutes to complete and meets standard psychometric criteria for reliability and validity.

Evaluation of tickGARD(PLUS), a novel vaccine against Boophilus microplus, in lactating Holstein-Friesian cows

The effects of vaccination with the Bm 86 vaccine TickGARD(PLUS) against infestation with cattle tick (Boophilus microplus) and of holding cattle on a feedpad until 09:00 hours after the morning milking was tested on 40 mid lactation Holstein cattle using a factorial design. Vaccination resulted in a 56% reduction in tick numbers in the field over one generation, and a 72% reduction in laboratory measures of the reproductive efficiency of ticks. The liveweight gain of vaccinated cattle over 27 weeks was 18.6 kg higher than that of controls, and vaccinated cattle tended to have lower somatic cell count in milk (SCC). There were no other significant differences in measures of production. Cattle kept on the feedpad after the morning milking carried 26% more ticks than those returned immediately to their paddocks.

Commercialisation of a recombinant vaccine against Boophilus microplus

Increasingly, there is need for methods to control cattle tick (Boophilus microplus) infestations by the use of non-chemical technology. This need is brought about by a mixture of market forces and the failure or inadequacy of existing technology. A recombinant vaccine has now been developed against the tick. This vaccine relies on the uptake with the blood meal of antibody directed against a critical protein in the tick gut. The isolation of the vaccine antigen, Bm86, and its production as a recombinant protein is briefly described. The vaccine has been tested in the field, has been taken through the full registration process and is now in commercial use in Australia. A related development has occurred in Cuba. The potential for improvement of the current vaccine and for the development of similar vaccines against other haematophagous parasites is discussed.

Modelling the field efficacy of a genetically engineered vaccine against the cattle tick, Boophilus microplus

The cattle tick Boophilus microplus Canestrini (Ixodidae) is an obligate parasite of bovines in the tropics. Vaccination against the tick, using concealed antigens, has previously been demonstrated to give partial protection which can vary under field conditions. In this paper computer modelling is used to evaluate the potential impact of the vaccine on populations of ticks on grazing cattle. The degree and duration of protection required to maintain tick numbers at acceptable levels is investigated. Results of the computer analyses have been used to guide the further development of the vaccine and to support an application for registration of the vaccine for control of the cattle tick in Australia. They demonstrate the contribution that modelling can make in evaluating the novel impacts that new technologies may have on the host-parasite relationship in different ecological environments.

Conjunctival melanoma after excision of a lentigo maligna melanoma in the ipsilateral eyelid skin

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Bilateral phaeochromocytomas in von Hippel-Lindau disease: diagnosis by adrenal vein sampling and catecholamine assay

Three unrelated patients with von Hippel-Lindau disease had phaeochromocytomas diagnosed as a result of screening in their third decade. All had raised 24-h urinary noradrenaline levels and obvious unilateral adrenal tumours on ultrasound scanning and computed tomography. The contralateral adrenal appeared either normal or equivocally abnormal using the same imaging techniques. Radiolabelled meta-iodo-benzylguanidine uptake and enhanced T2-weighted magnetic resonance signals confirmed the ipsilateral lesion, but showed no abnormality in the contralateral adrenal. Nevertheless, venous sampling demonstrated abnormally elevated noradrenaline:adrenaline ratios (normal < 1) in blood draining both adrenals in all three patients. All underwent bilateral adrenalectomy: histological examination confirmed bilateral phaeochromocytomas in all three patients, with the smaller adrenal showing tumours between 3 and 11 mm in diameter. A fourth patient with von Hippel-Lindau disease was also evaluated because of a left 'suprarenal' mass discovered by ultrasound scanning. Urinary and plasma catecholamines were normal. Computed tomography showed a normal right adrenal, with a left para-aortic mass lying superior to the left adrenal. Magnetic resonance scanning showed an enhanced T2 signal from the mass, which also showed positive uptake with radiolabelled mIBG. At operation, a non-secretory left para-aortic paraganglioma was found. Venous sampling suggested that the left adrenal was normal, and this was confirmed on histology. Venous sampling for catecholamine assays is effective in locating small bilateral phaeochromocytomas and defining a normal adrenal gland, and can be useful in preventing unnecessary or repeat operations in patients with non Hippel-Lindau disease.

Increased expression and mutation of p53 in choroidal melanoma

Using CM-1 antibody directed against the human p53 protein, high levels of mutant p53 protein expression were found in 12 out of 18 malignant choroidal melanomas. In contrast, we failed to observe elevated p53 expression, indicating the absence of p53 mutation in seven choroidal naevi, a potentially premalignant condition that can progress to form malignant melanoma. For two choroidal melanomas, we demonstrated that high levels of p53 protein were accompanied by exon 7 mutations. The mutations were found at codon 238, TGT-->TTT and codon 253, ACC-->AGC. These observations suggest that acquisition of abnormalities of the p53 gene may be an important step in the development of malignant melanoma.

Follow-up of retinoblastoma patients having prenatal and perinatal predictions for mutant gene carrier status using intragenic polymorphic probes from the RB1 gene

We have carried out presymptomatic prediction of mutant gene carrier status in ten individuals with a family history of retinoblastoma. In all cases standard linkage studies were employed using intragenic DNA probes which recognise restriction fragment length polymorphisms. In four cases foetal DNA samples were obtained by chorionic villus sampling, the remaining six were derived from either cord blood samples or venipuncture of neonates. We demonstrated that the mutant gene was inherited by only one of these patients who has subsequently developed bilateral tumours. Six of the other cases have now reached the age beyond which it might have been expected that tumours would develop and are all disease free. It must be concluded that repeated ophthalmological examination of these and future patients shown not to have inherited the mutant gene, is unnecessary.

Electrophoretic assessment of aqueous and serum neurone-specific enolase in retinoblastoma and ocular malignant melanoma

The isoenzyme pattern of enolase was examined in the aqueous humour and serum of patients with retinoblastoma (10 aqueous, 8 sera), malignant melanoma (4 aqueous, 25 sera), and normal subjects undergoing cataract surgery (25 aqueous, 30 sera). The assay we used allowed assessment of all three major isoenzymes, including the gamma gamma isoenzyme (neurone-specific enolase). No enolase was detectable in normal aqueous; alpha alpha isoenzyme was present in the aqueous of one patient with malignant melanoma, while aqueous from all patients with retinoblastoma contained both alpha alpha and gamma gamma. Normal serum contained only an alpha alpha band, while serum from patients with retinoblastoma contained alpha alpha, alpha gamma, and gamma gamma bands (7 sera, 87.5%), or alpha alpha only (1 patient, 12.5%). All sera from patients with malignant melanoma contained the alpha alpha band, with low levels of gamma gamma in 16 (60%). In a single patient with Coats's disease alpha alpha was present in the serum, but no enolase was detected in aqueous. Increased amounts of gamma-containing isoenzymes of enolase are found in both serum and aqueous from patients with retinoblastoma. In malignant melanoma there is often an increase in serum gamma gamma enolase. The assessment of aqueous and serum enolase patterns may be of value in the diagnosis of retinoblastoma and malignant melanoma.

Early diagnosis of the retinopathy of incontinentia pigmenti: successful treatment by cryotherapy

Prospective examination of the ocular fundi was carried out in the newborn female sibling of a girl with incontinentia pigmenti and bilateral retinopathy. At age 3 months the new baby's peripheral retina was found to be avascular in both eyes. At age 2 years progressive vascular proliferation at the watershed area between normal and abnormal retina led to bilateral vitreous haemorrhage. The new vessel tufts promptly regressed when the avascular area in each eye was treated by single-freeze cryotherapy and the blood in the vitreous absorbed. Cicatricial retinopathy was thereby prevented. Prospective retinal examination of newborn female siblings of children with incontinentia pigmenti is advised, with early cryotherapy recommended if progressive neovascularisation is detected.

Local extraocular extension of retinoblastoma following intraocular surgery

Three cases of local extraocular extension of retinoblastoma following intraocular surgery via a transscleral approach have been seen in one centre during a 12-month period. This number represents a significant increase on the previous incidence of this serious complication, which may be related to more widespread use of vitrectomy techniques. Orbital and local lymph node recurrence of retinoblastoma have been associated with a very poor survival rate in the past, and steps must be taken to limit the chance of this happening should an intraocular surgical procedure be performed inadvertently on an eye containing a retinoblastoma. Early enucleation without implant is advised, and adjuvant orbital radiotherapy is strongly recommended, even when there is no histopathological evidence of local extraocular tumour spread.

Genetic and cytogenetic analysis of patients showing reduced esterase-D levels and mental retardation from a survey of 500 individuals with retinoblastoma

The authors have analysed the esterase-D levels in 500 retinoblastoma patients of whom 15 showed red cell enzyme activities of approximately 50% that of normal controls. Chromosome analysis of these 15 patients confirmed the presence of a deletion involving region 13q14 in all cases. Seven of the 15 cases had not previously been diagnosed and all of these showed sub-band deletions within 13q14. None of these seven patients were mentally retarded although the remaining eight who showed larger chromosome deletions demonstrated the full spectrum of psychomotor abnormalities associated with 13q deletions. Two other mentally retarded retinoblastoma patients with normal esterase-D activity showed no karyotypic abnormality, demonstrating that mental retardation cannot be taken to indicate a chromosome deletion in all cases. Eight of the 15 deletion cases were only unilaterally affected. The data presented in this article suggest that esterase-D quantitation could provide the primary means of detection of chromosome deletions in retinoblastoma patients.

Demonstration of bias in series of retinoblastoma

A register of retinoblastoma is being compiled with the aim of complete ascertainment of all cases with a recorded diagnosis of retinoblastoma in the United Kingdom. Sources of ascertainment include patients seen at St Bartholomew's and Moorfields Eye Hospitals, cases recorded in regional cancer registries, and pathology reports. Ascertainment of the Hospital series is complete, but that of the rest of the country is still incomplete. Comparison between the proportions of bilateral and unilateral cases in an age cohort in the Hospital series and the country as a whole shows that the Hospital series is biased towards an excess of bilateral cases.

Mesectodermal leiomyoma of the ciliary body: case report

The clinical, light microscopical, and electron microscopical features of a mesectodermal leiomyoma of the ciliary body are presented. This exceptionally rare and apparently benign tumour is considered to be of neural crest origin. In the case described the tumour cells were seen to contain thin filaments with focal densities and conspicuous numbers of mitochondria, and smooth muscle protein was demonstrated by immunohistochemical means.

Medulloepithelioma (diktyoma)

Sixteen cases of medulloepithelioma are described. Clinical data and follow-up were available on 15. Four patients underwent iridocyclectomy initially; all later needed enucleation and one had an orbital recurrence. The remaining 12 patients underwent primary enucleation. All 15 patients with follow-up are alive with no evidence of tumour recurrence. It is suggested that enucleation be performed for all but the most localised tumour. Rubeosis was noted in 13 of the 16 eyes, and this may assist in making the diagnosis. The World Health Organisation histological classification of medulloepithelioma was applied, but some problems were encountered, particularly where the presence of heteroplastic brain tissue was used as a criterion for teratoid tumour and where rosettes were used as a criterion for malignancy.

Deletion of chromosome region 13q14 is transmissible and does not always predispose to retinoblastoma

During routine screening of retinoblastoma patients for esterase D activity in red blood cell lysates a patient was identified with only 50% of normal enzyme activity. Chromosome analysis showed that this patient had a small deletion within chromosome region 13q14. Parental studies showed that, whereas the father had normal enzyme levels, the mother had esterase D levels which were also 50% of normal and a similar small 13q14 deletion. Ophthalmological examination failed to demonstrate any retinal abnormality in either parent. Thus we present the first case not only of the direct transmission of a 13q14 deletion within a family but also of an individual in whom the deletion has not predisposed to tumour formation.

Cavernous haemangioma presenting as an orbital mass after enucleation for a choroidal melanoma: case report

A patient presented with an ipsilateral orbital mass four years after enucleation for a choroidal malignant melanoma. Clinical examination revealed a darkly coloured mass suggestive of recurrent melanoma. CT scanning indicated a locally extensive tumour. Management was by excision without resort to orbital exenteration. Pathological examination revealed a cavernous haemangioma. The natural history of this tumour is discussed.

Familial uveal melanoma

The cause of uveal melanoma is unknown. In a few cases, however, factors are found in association with the disease which may play some part in the aetiology. One such factor is inheritance. Twelve families have been reported with adequate documentation during the last century in which two or more members have had uveal melanomas. At least some of these may be the result of an inherited disorder. On available data inheritance is most likely autosomal dominant with partial expressivity or incomplete penetrance. This report describes two more families each of which have two members with uveal melanomas.

A chromosomal breakpoint that separates the esterase D and retinoblastoma predisposition loci in a patient with del(13)(q14q31)

A patient with severe mental retardation and other congenital abnormalities who developed retinoblastoma was shown to have a deletion on the long arm of chromosome #13 with breakpoints in regions q14 and q31. Quantitation of enzyme activity of the esterase-D gene which, together with the retinoblastoma locus, is located in region 13q14 showed levels that were equal to those of normal controls. The 13q14 breakpoint, therefore, appears to have occurred between the two loci, which places the esterase D gene in a more proximal position in this band than the retinoblastoma locus.