Long term follow up of patients with MNV3 treated with intra-vitreal Aflibercept.

PURPOSE: MNV3 or Retinal angiomatous proliferation is a subtype of neovascular age-related macular degeneration (nAMD). We present the 5 year long term visual and anatomical outcomes of patients with MNV3 lesions treated with intravitreal Aflibercept. METHODS: This is a prospective study of treatment naïve patients with reading centre graded MNV3 lesions. After the loading phase, the patients received intravitreal Aflibercept as per the View study up to year 3, thereafter it was given on a prn basis. At each visit, best corrected visual acuity (BCVA) and optical coherence tomography (OCT) central macular thickness (CMT) was measured. RESULTS: Thirty one patients reached study completion. Mean BCVA of treated eyes had decreased by 0.6 ETDRS letters at the end of year 5 compared with baseline. At study completion, 81% of eyes had stable vision while 19% of eyes had gained 15 letters or more. At study end, 26% of eyes had BCVA of 6/12 or better, while 19% had lost 15 letters or more (all had central foveal photoreceptor loss). There was a maximal mean reduction in CMT of 164 microns (p = <0.0001) while 68% of maculae were fluid free at study completion. Eighty seven percent of treated eyes developed nascent GA, of which in 74% of eyes was involving the fovea. DISCUSSION: Despite initial improvement in mean BCVA, the improvement in BCVA was not maintained despite good overall control of the MNV3 lesions. The loss of BCVA was most likely due to the majority of eyes developing centre involving macular atrophy.

Postoperative vasoplegia in lung transplantation: incidence and relation to outcome in a single-centre retrospective study.

BACKGROUND: The incidence and clinical importance of vasoplegia after lung transplantation remains poorly studied. We describe the incidence of vasoplegia and its association with complications after lung transplantation. METHODS: Perioperative data of 279 lung transplant recipients operated on from 2015 to 2020 in a UK hospital were analysed retrospectively. RESULTS: Vasoplegia occurred in 41.6% of patients after lung transplantation (mild, 31.0%; moderate, 55.2%; severe, 13.8%). Compared with non-vasoplegic patients, vasoplegic patients had a higher incidence of any acute kidney injury, defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria (78.5% vs 65%, P=0.015), renal replacement therapy (47.4% vs 24.5%, P<0.001), and delayed chest closure (18.4% vs 9.2%, P=0.025); were ventilated longer (70 [32-368] vs 34 [19-105] h, P<0.001); and stayed longer in the ICU (12.9 [5-30] vs 6.8 [3-20] days, P<0.001). Mortality at 30 days and 1 yr was higher in patients with vasoplegia (11.2% vs 5.5% and 20.7% vs 11.7%, P=0.039, respectively). Severe vasoplegia represented a predictor of longer-term mortality (hazard ratio=1.65, P=0.008). Underlying infectious disease, increased BMI, higher preoperative pulmonary artery systolic pressure and bilirubin levels, lower glomerular filtration rate, and increased fresh frozen plasma transfusion were predictors of vasoplegia severity. Neutrophilia, leucocytosis, and increased C-reactive protein were associated with vasoplegia, but release of the neutrophil activation markers myeloperoxidase and heparin-binding protein was similar between groups. CONCLUSIONS: Influenced by preoperative status as well as procedural factors and inflammatory response, vasoplegia is a common and critical condition after lung transplantation with worse short-term outcomes and long-term survival.

Early diagnosis of surgically curable lung cancer is commonly serendipitous.

AIMS: Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis. METHODS: This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. Symptoms or signs recorded were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. The lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance. RESULTS: Three hundred and ten patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician and 96 (31%) patients were asymptomatic. Incidental diagnosis was demonstrated in 121 (39.4%) patients. Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12) and 28% chest pain (n=12). CONCLUSIONS: In New Zealand, a large amount of lung cancer is still diagnosed incidentally with symptoms of cough, dyspnoea and chest pain. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Performance of the AusSCORE II and STS Score for Coronary Artery Bypass Grafting in a New Zealand Population.

BACKGROUND: The updated Australian System for Cardiac Operative Risk Evaluation (AusSCORE II) and the Society of Thoracic Surgeons (STS) Score are well-established tools in cardiac surgery for estimating operative mortality risk. No validation analysis of both risk models has been undertaken for a contemporary New Zealand population undergoing isolated coronary bypass surgery. We therefore aimed to assess the efficacy of these models in predicting mortality for New Zealand patients receiving isolated coronary artery bypass grafting (CABG). MATERIAL AND METHODS: A prospective database was maintained of patients undergoing isolated CABG at a major tertiary referral centre in New Zealand between September 2014 and September 2017. This database collected the patients' demographic, clinical, biochemical, operative and mortality data. The primary outcome measure was the correlation between the predicted AusSCORE II and STS Score mortality risks and the observed 30-day mortality events for all patients in the database using discrimination and calibration statistics. Discrimination and calibration were assessed using receiver operating characteristic (ROC) curves and the Hosmer-Lemeshow test respectively. RESULTS: A total of 933 patients underwent isolated CABG during the 3-year study period. There were seven deaths in the study cohort occurring within 30 days of surgery. Discrimination analysis demonstrated the area under the ROC curve (AUC) of the AusSCORE II and STS Score as 88.2% (95% CI: 85.9-90.2, p<0.0001) and 92.1% (95% CI: 90.2-93.7, p<0.0001) respectively. Calibration analysis revealed Hosmer-Lemeshow test p-values for the AusSCORE II and STS Score as 0.696 and 0.294 respectively. DISCUSSION: ROC curve analysis produced very high and statistically significant AUC values for the AusSCORE II and STS Score. Hosmer-Lemeshow test analysis revealed that both risk scoring tools are well calibrated for our study cohort. Therefore, the AusSCORE II and STS Score are both strongly predictive of 30-day mortality for isolated coronary artery bypass grafting surgery in our New Zealand patient population. Both risk models have performed with excellent discrimination and calibration. There is, however, a need to consider the performance of these risk stratification models in other cardiac surgical procedures outside isolated coronary bypass surgery where appropriate.

Thoracic oesophageal cancer as a cause of stridor: a literature review.

An 83-year-old woman, with a background of treated squamous cell oesophageal cancer, presented with a 3-week history of stridor. Of note, the patient had no risk factors for oesophageal cancer other than age. Clinical examination was unremarkable apart from stridor. Laboratory investigations, including arterial blood gas on room air, were unremarkable. Radiological examination revealed a 4.5×3.5×3.6 cm mass involving the posterior trachea and invading the tracheal orifice. Oesophagogastroduodenoscopy and rigid bronchoscopy confirmed an extensive tumour arising from the lower oesophagus and invading the trachea, causing 90% airway obstruction for a 6 mm length ending 1.5 cm above the carina. Biopsy revealed a poorly differentiated carcinoma with foci of squamous cell carcinoma. Unfortunately, the patient passed away 2 months after palliative tracheal stent placement.