A rare case of a long-standing, extensive and invasive conjunctival melanoma without systemic metastasis.

Conjunctival melanoma is an uncommon and malignant tumor of the ocular surface with the propensity for metastasis and death. Despite the grim outlook, the factors predicting poor prognosis are slowly being uncovered given the rarity of the disease. Here, we present a rare and surprising case of a long standing, extensive, and invasive conjunctival melanoma that, despite multiple factors predicting a poor prognosis, had no systemic metastatic disease. We hope that by reviewing in depth the various factors that may explain our patient's unusual course of illness we can add to our growing understanding of conjunctival melanoma.

Rejuvenating multiple true-false: proposing fairer scoring methods.

INTRODUCTION: The COVID-19 pandemic has reached a phase where many have been infected at least once. Healthcare workers were not spared from being infected. This study aimed to determine the period prevalence of COVID-19 among the paediatric healthcare workers in Negeri Sembilan as the country transitioned into an endemic phase of the pandemic. Additionally, we investigate potential sociodemographic and occupational characteristics associated with SARS-CoV-2 infection among healthcare workers. MATERIALS AND METHODS: A cross-sectional study was conducted among the healthcare workers in the paediatric department at three public specialist hospitals in Negeri Sembilan between 15 and 21 April 2022. Data were collected through a self-administered questionnaire. RESULTS: Out of the 504 eligible healthcare workers, 493 participated in this study (response rate 97.8%). The overall prevalence of COVID-19 (11 March 2020-15 April 2022) among healthcare workers was 50.9%. The majority (80.1%) were infected during the Omicron wave two months before the survey. Household contacts accounted for 35.9% of infection sources. The proportion of non-doctors in the COVID-19-infected group was significantly higher compared to the non-infected group (74.1% vs 64.0%, p=0.016). The COVID-19-infected group had a higher proportion of schoolgoing children (44.6% vs 30.6%, p=0.001) and children who attended pre-school/sent to the babysitter (49.0% vs 24.4%, p<0.001). There were no significant differences between infection rates among the healthcare workers working in the tertiary hospital and the district hospitals. There were also no significant differences in the proportion of COVID-19- infected doctors and nurses when analysed by seniority. CONCLUSION: Our study provided an estimate on the prevalence of COVID-19 among paediatric healthcare workers in Negeri Sembilan and the factors associated with infection, which captures the extent and magnitude of this pandemic on the state's paediatric department. Most infections resulted from household contact, with a higher proportion of infected healthcare workers having young children.

Moving from long case to scenario-based clinical examination: Proposals for making it feasible.

INTRODUCTION: Our faculty used one long case (LC) and three short cases for the clinical component of the final professional examinations. During the COVID-19 pandemic, the LC had to be replaced with scenario-based clinical examination (SBCE) due to the impracticability of using recently hospitalised patients. While keeping the short case component as usual, the LC had to be replaced with SBCE in 2020 for the first time at a short notice. To evaluate the positive and negative aspects of SBCE and LC to determine the feasibility of replacing LC with SBCE in future examinations. MATERIALS AND METHODS: We compared the LC scores of three previous years with those of the SBCE and studied the feedback of the three stakeholders: students, examiners, and simulated patients (SPs), regarding their experience with SBCE and the suitability of SBCE as an alternative for LC in future examinations. RESULTS: The SBCE scores were higher than those of the LC. Most of the examiners and students were not in favour of SBCE replacing LC, as such. The SPs were more positive about the proposition. The comments of the three stakeholders brought out the plus and minus points of LC and SBCE, which prompted our proposals to make SBCE more practical for future examinations. CONCLUSION: Having analysed the feedback of the stakeholders, and the positive and negative aspects of LC and SBCE, it was evident that SBCE needed improvements. We have proposed eight modifications to SBCE to make it a viable alternative for LC.

Dropping the non-core subjects from undergraduate final professional examination: How it would impact the results.

INTRODUCTION: Observing the dearth of distinctions in the two decades of final professional medical examinations (FPE) caused concern. Multiple True False (MTF) tests with penalty scoring pulling down the scores was considered one reason. Another possible reason was having too many subjects covered in the MTF and Best Answer Question (BAQ) papers. This study aimed to explore the impact of dropping the non-core subjects with minimal inputs from MTF and BAQ papers and the students' views in this regard. MATERIALS AND METHODS: We examined the students' performance in the core and non-core subjects in MTF and BAQ papers and the impact of dropping the non-core subjects' contribution to the students' scores of the recent four final professional examinations. We also surveyed the opinions of the students, who took the FPE in the year 2000. RESULTS: The failure rates were significantly higher in noncore than core subjects (p < 0.001) except in one MTF paper. The mean scores were significantly lower in non-core than core subjects in all the four FPEs (p < 0.05) except in one MTF paper. Dropping the non-core subject items from MTF and BAQ showed an improvement in the scores of MTF, theory total, and most grand totals resulting in two more students reaching distinction status. A mere 3.8% of the students could thoroughly revise the non-core subjects before the FPE. Two-fifth of them believed that non-core subjects had a significant impact on theory performance. Only 31.5% favoured dropping the non-core subjects, and an equal number preferred a status quo, while the rest suggested a reduction in their weightage. CONCLUSION: Most of the students considered the non-core subjects important in their career. However, very few of them could revise these subjects for the professional examination. The study demonstrated that dropping the non-core subjects from MTF and BAQ improved the students' final scores and helped more students to attain distinction status.

Intraoperative use of indocyanine green and trypan blue mixed with fibrin glue in the excision of periocular cystic lesions.

PURPOSE: This case series describes the use of tissue fibrin glue mixed with dye to facilitate the excision of eight orbital and periorbital cystic lesions of various complexity. OBSERVATIONS: The fibrin glue was colored with indocyanine green dye (ICG) or trypan blue and injected intraoperatively into the lesions. The glue was then allowed to harden, and the lesions were excised. The dyed glue outlined the wall of the cysts, kept them formed and allowed for complete excision with ease. None of the cases had recurrence. As an observation, ICG showed superior delineation than trypan blue. CONCLUSIONSAND IMPORTANCE: The use of colored fibrin glue is a helpful technique in the delineation and excision of cystic lesions. Delineating the wall of the cyst with the dyed glue simplified the surgery and prevented complications such as injury to surrounding vital structures and reduced the likelihood of recurrence. ICG may be superior to trypan blue but a comparative controlled study is needed to assess the difference.

Optic Nerve Sheath Melanoma Presenting as a Central Retinal Vein Occlusion.

A 64-year-old woman, with a history of diabetes and melanoma, developed a central retinal vein occlusion (CRVO) in her left eye. On exam, she had severe disc edema with retinal nerve fiber layer thickening, and anterior deformation of the peripapillary retinal pigment epithelium (RPE)/Bruch membrane layer (ppRPE/BM) toward the vitreous on spectral domain optical coherence tomography (SD-OCT) suggesting an optic nerve sheath (ONS) meningioma. Magnetic resonance imaging findings and ONS biopsy later confirmed a metastatic melanoma. This case demonstrates that the shape of the RPE/BM on SD-OCT may aid in the decision to consider imaging in patients with isolated CRVO.

Silicone oil pupillary block: an exception to combined argon-Nd:YAG laser iridotomy success in angle-closure glaucoma.

OBJECTIVES: To examine the rate of laser iridotomy failure at the University of Cincinnati Glaucoma Service, Cincinnati, Ohio, during the last 10 years and to evaluate the importance of silicone oil pupillary block glaucoma (SOPBG) as a causal factor. METHODS: We retrospectively reviewed the operative records of all 1711 eyes that underwent laser iridotomy for the treatment of pupillary block angle-closure glaucoma between January 1, 1996, and December 31, 2005. The occurrence, etiology, timing, and rate of laser iridotomy failure were assessed with SOPBG cases analyzed separately. RESULTS: Analyses using the chi(2) test demonstrated significantly higher laser iridotomy failure rates for 13 eyes with SOPBG compared with 1698 eyes with non-SOPBG for all 3 timing outcomes (immediate, 15.4% vs 0%; short term, 92.3% vs 2.5%; and long term, 38.5% vs 0.1%; all P < .0001). To achieve long-term patency, SOPBG iridotomy failures required, on average, 2.7 laser iridotomy procedures, 4.1 periocular steroid injections, and 0.7 intracameral tissue plasminogen activator injections. CONCLUSIONS: Eyes with SOPBG require extensive resources to prevent laser iridotomy failure. In managing SOPBG, ophthalmologists should anticipate the need for additional laser treatment and use adjunctive steroids and intracameral tissue plasminogen activator to enhance long-term patency and avert invasive surgical procedures.

Effects of mitral valve surgery on static lung function and exercise performance.

Lung function at rest was assessed in 50 patients before and six months after mitral valve surgery. There were small increases in spirometric volumes (FEV1 and vital capacity) with decreases in total lung capacity and residual volume, but no change in carbon monoxide transfer factor or transfer coefficient (KCO). Progressive exercise tests performed before and after operation in 19 of the patients confirmed an improved exercise capacity after surgery. The patients with the greatest symptomatic improvement in breathlessness were also those who achieved the greatest increase in maximum work load and the greatest decrease in ventilation for a given oxygen consumption. Depression of the ST segment of the electrocardiogram and frequent ventricular ectopic beats on exercise remained common after surgery and may have been due to digoxin treatment.

Nifedipine in the prevention of asthma induced by exercise and histamine.

Eight young men with documented exercise-induced asthma each performed two standard exercise tests and underwent two histamine challenges on separate days after double blind administration of either 20 mg nifedipine or placebo. The response to exercise was assessed by the maximal fall in forced expiratory volume in one second (FEV1) and to inhaled histamine by calculating the dose that produced a 20% fall in FEV1 (PC20). After premedication with nifedipine, the severity of exercise-induced asthma was significantly reduced (mean percent fall in FEV1, 6%, compared with 24% after placebo) and reactivity to histamine was reduced (geometric mean PC20, 1.68 mg X ml-1, compared with 0.46 mg X ml-1 after placebo). These results imply that nifedipine has a direct action on bronchial smooth muscle contractility but they do not exclude an additional effect on the secretion of chemical mediators from mast cells.

Role of lung scanning in assessing the resectability of bronchial carcinoma.

Ventilation and perfusion lung scans were performed in 58 patients before operation for bronchial carcinoma to determine in which patients the lung scan was most useful for assessing mediastinal spread and resectability of the tumour. Perfusion of the affected lung was less with larger and more centrally situated tumours. Perfusion was also less for left-sided than for right-sided tumours but this is explained by the normal differential perfusion of the right and left lungs. The lung scan was unhelpful in predicting resectability of peripheral tumours, but with central tumours if perfusion of the affected lung was less than 25% of the total perfusion the lesion was likely to be non-resectable because of spread to the mediastinum. Airways obstruction was present in 67% of the patients but did not interfere with the interpretation of the scans. In most cases ventilation scans provided no additional information, and the use of krypton-81 m as a sensitive indicator of regional ventilation did not improve on the predictive value of the perfusion scan.

Dose-response study of inhaled salbutamol powder in chronic airflow obstruction.

Dose-response relationships for salbutamol were studied in eight patients suffering from chronic airflow obstruction with no asthmatic features. Each inhaled, double blind, in randomised order 0, 200, 400, 800, and 1600 micrograms salbutamol on five successive mornings. Before and at intervals up to six hours after the inhalation FEV1, vital capacity, maximum inspiratory and expiratory flow-volume curves, and 12-minute walking distances were measured. Analysis of variance of the results indicated significant dose-response relationships and showed the larger doses to have a longer duration of action. Simple spirometric tests were as useful in providing objective evidence of benefit as maximum inspiratory flows or the 12-minute walking distance.

Relation between severity of mitral valve disease and results of routine lung function tests in non-smokers.

The effects of mitral valve disease on lung function have been studied in 26 non-smoking patients by relating values for lung volumes and carbon monoxide transfer factor (TLCO) to various indices of cardiac function measured at catheterisation. In general, more severe mitral disease was associated with greater abnormalities of lung function. Reductions of the one-second forced expiratory volume, vital capacity, TLCO and transfer coefficient, and increase in residual volume were all significantly related to the severity of mitral valve disease. In addition, the cardiothoracic ratio, measured radiographically, showed an inverse correlation with both vital capacity and total lung capacity. Although some of the consequences of mitral valve disease on lung function resemble those of primary airway disease, useful distinguishing points are the relative normality of the forced expiratory ratio and the absence of an increase in total lung capacity.

A general practice survey of the incidence of Mycoplasma pneumoniae infections.

An epidemiological survey was carried out at two centres in the north of England (Liverpool and Sunderland). One hundred and twenty patients were included in this survey to determine the relative incidence of Mycoplasma pneumoniae infections in patients who present to their physician with an acute lower respiratory tract infection. Data were available at the end of the survey in 115 patients. Only one patient had a positive test for M.pneumoniae. There were nine patients who had a positive antibody test for either influenza or para-influenza. Four patients had a positive test for respiratory syncytial viruses. This survey points out the problems in the clinical diagnosis of respiratory infections in general practice.