Thursday, 24 May 2018

Changes in Peripapillar Retinal Nerve Fiber Layer Analized by Td-Oct in Patients with Diabetic Retinopathy that Receive Panretinal Photocoagulation


Objective: Explain changes in peripapillar retinal nerve fiber layer in patients with diabetic retinopathy with criteria to receive panretinal photocoagulation, analyzed by td-oct (stratus) unit.

Material and Methods: A transversal retrospective and observational study was done to study peripapillar nerve fiber layers of 46 eyes from 33 patients using a td-oct (stratus) unit. according to laser application technique, time since application and day of the study, 4 groups of patients were set: the first with patients with less than 30 days since last laser application and day of study. The second with patients with 180 days since laser photocoagulation; the third and fourth groups received panretinal photocoagulation and macular selective laser with an Oct 30 and 180 days after administration of treatment.

Results: The clinically significant finding was in the comparation of the group that received panretinal photocoagulation with oct after 30 days, and the group that received panretinal photocoagulation and oct after 180 days. average thickness was less in the second group, with a statistical significant finding p=0.012 in inferior quadrant.

Conclusion: Administer laser photocoagulation makes changes in retina´s structure and function, there are many different results in accordance to equipment used to apply treatment and to take measurements. the patient must be informed about secondary and adverse effects after the treatment.

Keywords: Diabetic retinopathy; Panretinal photocoagulation; Macular laser; Time-Domain optic coherence tomography; Retinal nerve fiber layer

Wednesday, 23 May 2018

Retina Specialists: How we Think


Purpose: Physicians frequently receive new information on the latest research from many different forms of media. It is interesting to see how they integrate this data and incorporate it into their own practices. This report focuses on physician opinions for the treatment of central serous chorioretinopathy and diabetic macular edema, as well as practice patterns associated with these treatments.
Methods: Retina specialists were surveyed during a lecture at the 2016 Ocular Imaging Conference in Vail, Colorado. Case studies were presented with questions integrated throughout the lecture that were designed to understand how physicians individually handle both specific cases and their specific treatment algorithms. When presented with multiple-choice questions, the audience texted their answers in to the Poll Everywhere application. Responses appeared on the screen in real time and were recorded for later use.
Results: The mean number of responses submitted per question was 30.15. Physicians answered 13 questions about management issues of central serous chorioretinopathy and diabetic macular edema, with some questions resulting in markedly varying answers.
Conclusion: The concept of using an text based polling app is a low cost, easy to use, efficient way to obtain greater audience input in case presentation conferences.

Tuesday, 22 May 2018

Maternal Obesity Increases the Risk of Primary as Well as Secondary Caesarean Section


Maternalobesity is not only associated with pregnancy outcome but also with the mode of delivery. In the present study the impact of maternal prepregnancy weight status on the mode of delivery, in particular on caesarean section rate was tested. The data of 3451 live births taking place at the Viennese University Hospital were analyzed. Maternal somatometrics (height, weight, weight gain) and newborn somatic characteristics (birth weight, birth length, head dimensions, APGAR scores) were documented. Prepregnancy weight status was classified using Body Mass Index (BMI) categories published by the WHO. The caesarean section rate was 15.6%. (6.8% primary CS, 8.8% secondary CS). 24.2% of the mothers were overweight, 9.6% obese and 0.8% morbidly obese before pregnancy. Maternal prepregnancy BMI was significantly associated with newborn size. The relative risk to give birth to a macrosome newborn was significantly increased among overweight (OR 1.46 CI 1.24- 1.72), obese (OR 1.76 CI 1.40-2.19) and morbidly obese mothers (OR 1.51 CI 0.57-3.99). The relative risk of caesarean section increased significantly with increasing prepregnancy weight status (p<0.04). Morbidly obese women showed the significantly highest rate of caesarean section (33.4%; primary CS 16.7%, secondary CS 16.7%). The relative risk of experiencing caesarean section was significantly higher among morbidly obese women than among underweight (OR 3.57 CI 1.85-6.86), normal weight (OR 2.89 CI 1.25-6.69), overweight (OR 2.27 CI 0.99-5-22) and even obese women (OR 2.11 CI 0.94- 4.72). Prepregnancy obesity is clearly a significant risk factor of newborn macrosomia and primary as well as secondary caesarean section.

The prevalence of overweight and obesity as a worldwide epidemic has increased dramatically since the beginning of the 21rst century. In 2008 for the first time in the long history of Homo sapiens, the number of obese people on earth exceeded the number of people who suffer from starvation and malnutrition. Currently more than 1.9 billion adults, 18 years and older, were overweight. Of these over 600 million correspond to the definition of obesity. From the viewpoint of public health this high prevalence of overweight and obesity is a major concern because overweight and especially obesity increase rates of metabolic diseases such as diabetes type II, cardiovascular diseases such as heart disease, stroke, hypertension, but also pancreatitis, osteoarthritis and cancer. Obesity however, is also related to reproductive problems, such as increased infertility rates in women as well as in men. A special problem represents obesity among women of reproductive age. In the United States more than 50% of women ageing between 20 and 39 years are overweight or obese. Europe seems to follow a similar pattern, albeit with some delay. Currently one in five pregnant women can be classified as obese in Europe.

Monday, 21 May 2018

Noninvasive Methods for Treatment of Brain Metastases


Brainmetatases occur in 20-40% of patients with cancer. Median survival of patients who develop brain metastases is relatively short - 4 months. Treatment methods such as Whole Brain Radio Therapy (WBRT), Surgery (S) or Radiosurgery (SRS) prolong survival for 3 to 5 months. Treatment options in brain metastases are as follows: symptomatic tratment, surgery, radiotherapy, chemiotherapy and combination of those. Symptomatic treatment of edema and anticonvulsive therapy are used if necessery and depends on neurological patients status. Surgery has been used for single brain metstasis in patients with good performance status. WBRT alone is a treatment of choice for patients with multiple brain metastases, with single brain metastasis not sutable to surgery or radiosurgery, especially those with an active and disseminated systemic disease. SRS is an external irradiation technique to deliver a relatively large radiation dose in a single fraction to an intracranial small target volume.

Brain metastasis is a common manifestation of disseminated malignancy. In adults, lung, (36-40%), breast cancer (15-25%) and skin melanoma (5-20%) are the most common sources of brain metastases. Less frequent are colon, rectal, kidney, prostate, testicular, ovarian cancer and sarcoma. Cerebral lesion are mainly located in hemispheres (80%), in cerebellum (15%), in the brain stem (5%), being very rare in the basal ganglia, the pineal gland or hypophysis. Are more common than primary brain tumors. Frequency of disclosure is the result: a more effective treatment of the primary tumor, more effective systemic treatment of disseminated disease (clinical or subclinical), the existence of blood - brain barrier for the majority of cytostatic drugs and the introduction of new imaging techniques. Most patients who develop brain metastases have short time survival. The treatment is used: steroids, surgery, radiation therapy and symptomatic treatment. The choice of treatment depends on the age, general condition of the patient, the number and location of metastatic lesions and the severity of the underlying disease. The last decade has created new possibilities for the treatment of metastatic tumors such as radiosurgery and radiochemotherapy combination treatment with radiation.

Treatment options for brain metastases are: symptomatic and specific therapy directed at the area of the tumor or tumors. To the first treatment should antioedematous and anticonvulsants. Causal treatment includes: surgical resection with or without radiotherapy of the whole brain (WBRT), an independent method of WBRT, radiosurgery (SRS), SRS + WBRT, chemotherapy.

Wednesday, 16 May 2018

A Case Report of Uncommon Efficacy and Favorable Safety Profile of Gemcitabine Rechallenge in Metastatic Breast Cancer


Breast cancer affects approximately 12% of women worldwide and results in 14% of all cancer-related deaths. Despite the diffusion of screening programs, about 6% of women still have metastatic disease at the onset presentation. Median Overall Survival (OS) of patients with Metastatic Breast Cancer (MBC) is extremely variable (8 months to 4 years). In the last decades, with the advent of new cytotoxic drugs and targeted therapies, a significant increase in OS of MBC patients has been achieved. Nevertheless, in the majority of cases, after an initial response to treatment, the development of highly aggressive and drug-resistant disease is commonly observed. For these reasons, the current goals are not only the prolongation of OS, but also the improvement of the Quality of Life (QoL) through disease control and drug-related toxicities management. Gemcitabine (2’,2’-difluorodeoxycytidine) is a nucleoside analog that makes its antiproliferative activity through two active metabolites, gemcitabine di- and triphosphate.

 The safety profile is good with a limited,mainly hematological, toxicity. This drug has been approved not only for the treatment of MBC but also for pancreatic lung bladder and ovarian tumors. Even if gemcitabine has been shown to be effective in combination with paclitaxel for the first-line treatment of MBC its use as single agent in pre-treated patients has given only a small benefit in several reports. Here we report the case of a MBC patient that, after several failing attempts with drugs commonly more effective than gemcitabine, achieved the complete remission of disease with this antimetabolite in more than one treatment-line. The overall benefit from the drug lasted more than 10 years. This case report highlights the existence of a small percentage of MBC patients that could obtain a terrific benefit from a low toxic and often underestimated drug for this pathology, in urgent need for new predictive biomarkers.

We describe the case of a 52-year old caucasian woman, in good clinical condition (ECOG performance status: 0), affected by essential hypertension, chronic hepatitis C infection and mild depressive syndrome. In January 1999, she underwent left upper quadrantectomy and ipsilateral axillary lymphadenectomy. The pathology report showed a bifocal invasive ductal carcinoma (stage pT2N3M0); by immunohistochemistry, neoplastic cells stained positive for Her2 (IHC: 3+) and negative for Hormone Receptors (HRs). Chemotherapy (4 cycles of doxorubicin plus paclitaxel q21, followed by CMF 1-8q28, for 4 cycles) and radiotherapy (50 Gy) were performed with adjuvant intent. 

Tuesday, 15 May 2018

Malignant External Otitis with Facial Nerve Paralysis


A 62 years old man was referred to our department experiencing right otalgia, purulent otorrhea, ear loss and a grade III right facial nerve palsy according to the House Brackmann scale. He was affected by decompensated insulin-dependent type 2 Diabetes. The patient had a history of non cholesteatomatous ipsilateral chronic otitis treated with tympano-mastoid surgery 10 years before, without any sign of recurrence.

At the examination there was a purulent discharge from the right ear, the canal appeared red and swollen, the tympanic membrane was not visible and the retro auricular and preauricular areas showed redness and swelling. Meningeal signs were negative, without any cervical lymphadenopathy or any alteration of the blood exams. CT scan showed opacification of the right middle ear and mastoid cavity, with osteolysis of the facial canal and of the tegmen tympani, while MRI with contrast showed a mild enhancement in the meninx.

The scintigrafic evaluation with 99-Technetium confirmed the osteomyelitis with increased uptake of radio-marked Difosfonatein the temporomandibular joint, mastoid cells, semicircular canals, cochlea, middle and inner ear and in the greater wing of the sphenoid bone.

Monday, 14 May 2018

Wrist Arthroplasty Leads to Better Outcomes than Arthrodesis for Treatment of Patients with Advanced Rheumatoid Arthritis of the Wrist: A Review of Literature


Rheumatoid arthritis is a chronic inflammatory condition of unknown a etiology, which can be disabling causing up to 35% of patients with 10 years of symptoms to early retire and carries a high mortality rate. It targets mainly the synovial membrane and articular cartilage of joints leading to joint deformity and instability. Genetic, immunological and environmental factors are thought to cause the disease in such a way that susceptible genes are triggered by infection or environmental factors leading to inappropriate immune response attacking the joints

Around 1% of general population is affected in the UK it is estimated to affect about 0.8% of the population and in some countries, where it is prevalent, it affects about 2% of population above 60 years. Though highest rates are in north Europe and America some studies are showing decrease of incidence in these regions. It is more common in white race affecting elderly in the 5th and 6th decade with women being affected 3 folds more than men.

Wrist and hands are the most common joints affected in rheumatoid arthritis such that by 4 years of the onset of the disease more than 90% of patients would show symptoms of involvement of at least one of these joints. Affection of carpal ligaments and tendons around the wrist would lead to radial deviation of radio carpal joint with ulnar deviation of the fingers at the MCP joint, subluxation of distal ulna and dropped fingers resulting in a zigzag deformity or what is known as caput ulnae syndrome. Half of the patients might have systemic or extra articular manifestations (ExRA). Nodules are the most common ExRA with the cardiovascular system being the most affected and this might be the reason why these patients show a higher mortality rate than the non-ExRA subgroup.

Changes in Peripapillar Retinal Nerve Fiber Layer Analized by Td-Oct in Patients with Diabetic Retinopathy that Receive Panretinal Photocoagulation

                    Objective: Explain changes in peripap...