Assessing the Quality of Patient Information for Vestibular Schwannoma on the Open Source Video Sharing Platform YouTube.

BACKGROUND: Patients frequently use the internet to gain information and make decisions about their health conditions. This work aims to assess the quality of information about Vestibular Schwannoma on a popular video sharing platform, YouTube (Alphabet Inc.). OBJECTIVES: To assess quality of the most popular vestibular schwannoma videos using recognized scoring systems and whether video quality metrics correlated with video popularity based on metadata analysis. SETTING: Public domain. STUDY DESIGN: Cross-sectional Study. METHODS: The YouTube website was systematically searched on separate days with a formal search strategy to identify videos relevant to vestibular schwannoma. Each video was viewed and scored by three independent assessors, using scores for quality and disease specific accuracy. Popularity metrics were analyzed and compared to video quality. Patient surveys were conducted to further assess their perspectives of the included videos. RESULTS: A total of 23 YouTube videos were included. In terms of Essential and Ideal Video Completeness Criteria, the mean scores ranged from 4.8 to 5.0 (out of 12), indicating moderate video quality. The average DISCERN score ranged from 30.0 to 36.7, indicating lower reliability. The mean JAMA scores ranged from 1.96 to 2.48, indicating average quality. Based on metrics including DISCERN and JAMA instruments, the information in the YouTube videos were of low to average quality and reliability. Rater scoring was reliable. Viewer engagement correlated poorly with video quality except for JAMA metrics. CONCLUSION: Video quality on YouTube with respect to Vestibular Schwannoma is of low to average quality. Viewer engagement and popularity correlated poorly with video quality. Clinicians should direct their patients to high quality videos and should consider uploading their own high-quality videos.

Ventilatory support in Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis.

INTRODUCTION: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are blistering cutaneous disorders that often manifest with epidermal and mucosal necrosis. In extreme cases, the upper or bronchial airways are threatened, necessitating intubation and mechanical ventilation. This systematic review and meta-analysis examines the prevalence of mechanical ventilation (MV) in patients with SJS or TENS, despite maximal medical therapy, and additionally aims to identify the risk factors associated with this requirement. MATERIALS AND METHODS: A systematic review of the literature was performed using the PRISMA guidelines and meta-analysis of proportions. RESULTS: Six articles were included, with pooled total of 18648 cases. The weighted prevalence of MV was 27.5% (95%CI 17.8-39.9%). The need for MV was more closely associated with TEN, compared to SJS (OR 4.40, 95%CI 2.73-7.10, I2=48%, p<.00001.) Risk factors associated with the need for MV included bacteremia (OR 5.02, 95%CI 2.87-8.79, I2=0%, p<.00001), shock/organ failure on admission (OR 261.99, 95%CI 21.88-3137, I2=71, p<.0001), total body surface area (TBSA) >30% (OR 4.47, 95%CI 1.41-14.20, I2=71, p=.01.). CONCLUSION: Limited published evidence with significant heterogeneity exists within the literature regarding the need for MV in SJS and TEN. Greater cutaneous involvement, and more critically unwell patients appear more likely to require MV.

The role of topical N-acetylcysteine in ocular therapeutics.

N-acetylcysteine (NAC) was first discovered as a mucolytic agent in 1960. We investigate the role of topical NAC in ocular therapeutics, including its mechanism of action, current applications, and adverse effects. A systematic search of peer-reviewed articles identified 106 references including in vitro, in vivo and clinical studies on the use of NAC in the treatment of ocular diseases. NAC can be synthetically manufactured, and its mechanisms of action include mucolysis, scavenging hydroxyl radicals, and modulation of inflammatory cascades. These unique properties contribute to the diverse applications of NAC, including its steroid-sparing potential. NAC has been used topically in the treatment of corneal wounds, chemical injuries, keratitis, dry eye disease and meibomian gland dysfunction. The clinical benefits of NAC are evident over a wide range of concentrations, the most common being 5-10% topical NAC applied four times daily. Adverse effects such as corneal necrosis are rare, but have been reported with higher doses. NAC also has potential applications in laser epithelial keratomileusis, diabetic eye disease, retinitis pigmentosa, senile nuclear cataracts, macular degeneration, and cigarette smoke-induced corneal damage. Recently, chitosan-NAC has been used as a nanocarrier for the topical administration of medications to the ocular surface. Owing to its potent antioxidant, anti-inflammatory and mucolytic properties, topical NAC has had extensive use in the treatment of ocular pathology.

Effect of age and gender in non-smokers with oral squamous cell carcinoma: Multi-institutional study.

BACKGROUND: In developing countries, oral squamous cell carcinoma (OSCC) is predominantly a cancer affecting older males who smoke tobacco. In countries with effective public health strategies, smoking rates are declining rapidly. It is not clear if patients who develop OSCC without these traditional risk factors represent a clinically distinct cohort with different prognosis. A recent analysis found that elderly non-smoking females with OSCC had significantly worse prognosis, concluding that this was a distinct patient population with poorer survival. The primary aim of this study was to determine the effect of gender and age on prognosis in OSCC, and the interaction between these two variables. METHODS: Multinational multi-institutional data were collected from six sites. The primary outcome of interest was disease specific survival (DSS). Time to local, regional, and distant recurrence were investigated as secondary outcomes. RESULTS: 3379 patients with OSCC were included. Males had significantly worse DSS compared to females (HR 1.24, 95% CI 1.08-1.43, p = 0.003). Females <70 years of age had significantly better DSS compared to females ≥70 years of age (HR 0.69, 95% CI 0.51-0.94, p < 0.001) but elderly females had similar DSS to males, regardless of age. When age was divided into three groups, the middle-aged group (45-69 years) had a significantly better DSS compared to elderly patients (HR 0.87, 95%CI 0.78-0.96, p < 0.001), however younger patients had similar DSS to elderly patients. When the effect of age (young v middle v elderly) was compared in each gender, young and middle-aged females had the most favourable DSS (log-rank p < 0.001). Middle-aged females who smoked had a 10% survival advantage compared to middle-aged males that smoked at five years. CONCLUSIONS: Age, gender, tumour subsite, and smoking status are important drivers of survival in OSCC. However, gender appears to be the most important predictor with young and middle-aged females having the most favourable prognosis.

Young age is not a predictor of disease specific survival in oral cancer: A multi-institutional study.

BACKGROUND: Over the last few decades evidence has accumulated for increasing incidence of oral cavity squamous cell carcinoma (OSCC) in a younger cohort. Prior studies examining the effect of age at diagnosis on prognosis have produced conflicting data. METHODS: A multi-institutional cohort study was performed across 6 different sites in Australia, Canada, India and Singapore. Disease-free (DFS), overall (OS) and disease-specific (DSS) survival were analysed. The association of the number of adverse features with survival outcomes was investigated. RESULTS: From 3179 patients, age was a significant predictor of OS with patients older than 45 years having a 66% increased risk of death (HR 1.66, 95%CI 1.33 - 2.07, p < 0.001). The number of adverse features was a significant predictor of OS with 3 or more adverse features having a 199% increased risk (HR 2.99, 95%CI 2.61-3.43. p < 0.001). The estimate effect was greater in patients ≤ 45 years (HR 3.49 vs HR 2.81). Age was not a significant predictor of DSS with similar rates of death from OSCC in multivariable models. The number of adverse features was a significant predictor of DFS with ≥ 3 adverse features having a 140% increased risk of death. The number of adverse features was a significant predictor of DSS with ≥ 3 adverse features having a 230% increased risk of disease specific death. CONCLUSIONS: Age is not an independent predictor of disease specific mortality in OSCC. Differences in outcomes are due to the confounding effect of adverse clinicopathological features and the ability to tolerate surgery and adjuvant therapy.

Recurrent laryngeal nerve injury following single- and multiple-level anterior cervical discectomy and fusion: a meta-analysis.

BACKGROUND: Recurrent laryngeal nerve (RLN) palsy is a common and potentially debilitating complication of anterior cervical discectomy and fusion (ACDF). The relationship between the risk of RLN palsy and the number of operated levels remains unclear, and no previous studies address potential differences between short- and long-term RLN injury following ACDF. METHODS: Electronic searches of PubMed, Cochrane, ScienceDirect and Google Scholar were performed from database inception to June 2019. Relevant studies reporting the rate of RLN palsy for patients undergoing ACDF for cervical spine pathology were identified according to predetermined inclusion and exclusion criteria. Statistical analysis was performed using fixed effects and random effects modelling. I2 and Q statistics were used to explore heterogeneity. RESULTS: Five studies with a total of 3,514 patients were included in the meta-analysis. The incidence of RLN palsy was found to be 1.2%. There were no statistically significant differences in the rate of RLN palsy between multiple- and single-level ACDF [odds ratio (OR) 1.04; 95% CI: 0.56-1.95; P=0.891, I2=0%]. There were similarly no statistically significant differences in RLN palsy rates for multiple- and single-level ACDF when patients were stratified based on length of follow-up of less than or greater than 12 months. CONCLUSIONS: This analysis suggests that there is no statistically significant association between the number of ACDF operative levels and the risk of short- or long-term RLN palsy.

Dysphagia rates in single- and multiple-level anterior cervical discectomy and fusion surgery: a meta-analysis.

BACKGROUND: To conduct a meta-analysis to assess dysphagia complicating single-level and multiple-level (≥2) anterior cervical discectomy and fusion (ACDF) surgery. METHODS: Electronic searches were performed using four electronic databases from their inception to December 2017. Relevant studies reporting the rate of dysphagia as an endpoint for patients undergoing ACDF for degenerative disease, myelopathy, cervical canal stenosis or ossification of the posterior longitudinal ligament were identified according to prior inclusion and exclusion criteria. Statistical analysis was performed using a fixed effect model. P-scores were used to rank the levels of ACDF based on the rate of dysphagia. I2 was used to explore heterogeneity. RESULTS: Ten studies were identified and included in the systematic review and meta-analysis, with a total of 4,018 patients identified; 2,362 patients underwent single-level ACDF, while 1,656 underwent multiple level (≥2 ACDF). The mean age ranged from 49.45 to 57.77 years. Mean follow-up time ranged from 2 days to 27.3 months. Overall, meta-analysis demonstrated a statistically significant higher dysphagia rate for multiple-level ACDF (6.6%) than for single-level ACDF (4%) (P heterogeneity =0.151, OR =1.42, 95% CI: 1.05-1.91, I2=32%). CONCLUSIONS: Dysphagia is a relatively common complication in the early postoperative period following ACDF and may cause patients significant discomfort and distress. This meta-analysis demonstrates a higher rate of dysphagia with multiple-level ACDF than with single-level ACDF at a period of 12-24 months.

Total intravenous versus inhalational anesthesia in endoscopic sinus surgery: A meta-analysis.

OBJECTIVE: Achieving optimal intraoperative surgical field visibility and minimizing blood loss are two important parameters in endoscopic sinus surgery (ESS). The aim of this meta-analysis was to compare two total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) to determine if either conferred superior outcomes of these and other parameters based on randomized control trials (RCTs) only. METHODS: The recommended Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed, and searches of electronic databases from inception to September 2018 identified 157 articles for screening. Data were extracted and analyzed using meta-analysis of proportions. RESULTS: In total, we identified 15 RCTs that satisfied our selection criteria. There were 828 ESS cases described, with 391 (47%) and 437 (53%) being managed by TIVA and IA, respectively. Pooled analysis demonstrated significantly superior visibility scores for TIVA compared to IA based on 10-point grading scores (P = 0.049, visual analog scale; P = 0.009, Wormald scale) and 5-point grading scores (P = 0.002, Boezaart scale). Blood loss was significantly less following TIVA (P = 0.003), with no significant difference in intraoperative heart rate (P = 0.70) or mean arterial pressure (P = 0.96). Additionally, duration of surgery (P = 0.16) and anesthesia (P = 0.39) were comparable between the two approaches. CONCLUSION: This meta-analysis indicates that TIVA has the potential to confer superior surgical field visibility and reduce intraoperative blood loss compared to IA in ESS. Currently, there are significant heterogeneity concerns in this meta-analysis, which temper any expectations that either approach is absolutely superior to the other. Caution should be exercised when interpreting these results until further validation can be achieved. LEVEL OF EVIDENCE: 1A Laryngoscope, 130:575-583, 2020.

Recurrence rates following surgical excision of periocular basal cell carcinomas: systematic review and meta-analysis.

Background: Basal cell carcinomas (BCCs) remain one of the most common non-melanoma skin cancers (NMSCs). Surgical options include primary excision with predetermined margins, frozen section controlled excision, and Mohs micrographic surgery (MMS). There is no randomized study comparing recurrence rates between different surgical techniques for periocular BCCs.Methods: A meta-analysis of proportions was conducted for recurrence rates. Meta-regression was used for subgroup analysis to compare results in those undergoing MMS versus FSE or paraffin controlled sections (WLE).Results: The pooled recurrence rate for periocular BCCs excised via MMS was 2.9% (95% CI 1.9-4.4%) over an average of 48.8 ± 14.9 months. The pooled recurrence rate for FSE was 1.9% (95% CI 1.9-2.4%) over an average of 70.7 ± 48.0 months. By comparison, the pooled recurrence rate following WLE was 5.9% (95% CI 3.9-8.9%) over an average of 49.2 ± 29.3 months. Meta-regression demonstrated that the recurrence rate for WLE was significantly higher compared to MMS and FSE techniques (p<.001) but similar for MMS and FSE (p=.65).Conclusions: Our results highlight the importance of intraoperative margin assessment in the management of BCCs in order to reduce recurrence. These factors should be taken into consideration in the workup and management of patients with periocular BCCs.

Efficacy of fine focal spot technique in CT angiography of neck.

OBJECTIVES: Focal spot size partially defines spatial resolution of a CT system. Many CT tubes have two focal spot sizes, with the finer one allowing more detailed imaging at the cost of photon intensity and increased heat production. Improved X-ray technology and advancement of various generations of iterative reconstruction allow the use of fine focal spot technique in CT angiography. CT neck angiography (CTNA) has been commonly performed as part of stroke imaging or in the trauma setting. This prospective study aimed to assess the efficacy of fine focal spot scanning in vessel clarity improvement, vessel calcification and arterial pulsation artefact reduction on CTNA. METHODS AND MATERIALS: Consecutive adult patients of all ages and genders who presented for CTNA were included. All CTNA were scanned with standard focal spot size (SFSS) of 1 × 1 mm in first 4 months while the CTNA in the following 4 months with fine focal spot size (FFSS) of 0.5 × 1 mm. Vessel clarity, calcification and arterial pulsation artefact of arch of aorta, brachiocephalic, subclavian, common carotid, carotid bifurcation, internal carotid, external carotid and vertebral arteries were assessed randomly using a 5-point scale by two blinded radiologists. Results were compared. RESULTS: There were 43 patients (mean age 60) with 97 calcified arterial segments in SFSS and 48 patients (mean age 62) with 113 calcified arterial segments in FFSS. 30 % of patients had > 50% carotid artery stenosis. No occlusion or dissection was found in the remaining arteries. Mann-Whitney test showed FFSS performed significantly better for vessel clarity (U: 48238.50, p < .001,r: 0.556) and calcification artefact reduction (U: 2040.50, p < .001,r: 0.564). There was no significant reduction for arterial pulsation artefact. CONCLUSION: Fine focal spot technique improves vessel clarity and reduces calcification blooming artefact in CTNA. These benefits may potentially improve the assessment of arterial luminal stenosis and vessel wall pathology, including plaque morphology. ADVANCES IN KNOWLEDGE: Beam hardening artefact from calcification particularly in the vessel wall can often reduce the clarity of vessel lumen thus affect accurate assessment of luminal stenosis. Fine focal spot technique has the advantages of reducing beam-hardening artefact of vessel wall calcifications and improving vessel wall clarity, thus it may potentially improve the assessment of arterial luminal stenosis and vessel wall pathology, including plaque morphology. It may become an important CT imaging technique in near future.

Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: There is a relatively high risk of anastomotic leak in low anterior resection (LAR), associated with significant morbidity and mortality. This systematic review and meta-analysis aims to compare diverting stoma vs. no stoma for LAR in terms of leak rates, reoperations, mortality rates and complication rates. METHODS: We systematically performed electronic searches of databases Ovid Medline, PubMed, CCTR, CDSR, ACP Journal Club and DARE from inception to present. Only randomized controlled trials comparing LAR for rectal cancer with versus without stoma diversion were included for analysis. Main outcomes were anastomotic leak, reoperation rate and mortality. Secondary outcomes included other operative and stoma-related complications. RESULTS: Eight randomized controlled trials were included in the study for qualitative and quantitative analyses. A significantly longer operative duration for patients with stoma diversion was seen (WMD 19.50 min; 95% CI: 7.38, 31.63; I2=0%, P=0.002). The pooled rate for anastomotic leak was significantly lower for those with stoma diversion (6.3% vs. 18.3%; RR 0.36; 95% CI: 0.24, 0.54; I2=0%; P<0.00001). There was lower reoperation rate for patients with stoma diversion compared to no stoma (5.9% vs. 16.7%; RR 0.40; 95% CI: 0.26, 0.60; I2=0%; P<0.00001). No significant difference was found in terms of leak-related mortality between stoma vs. no-stoma cohorts (0.47% vs. 1.0%; P=0.51). CONCLUSIONS: The present meta-analysis suggests a diverting or defunctioning stoma following LAR for rectal cancers can reduce anastomotic leak and reoperation rates, without increased risk of mortality or other complications.

Changing biological disease modifying treatment for paediatric uveitis in the real world.

IMPORTANCE: Paediatric uveitis is a severe sight-threatening uveitis due to disease progression and treatment failure. Biological agents are a promising new treatment. This study provides real-world data on their use from Sydney, Australia. BACKGROUND: Traditionally corticosteroids and non-biological immunosuppressive agents were used to treat paediatric uveitis, often with poor outcomes. DESIGN: Retrospective, chart review over an 8-year period at a tertiary referral eye hospital. PARTICIPANTS: A total of 27 paediatric uveitis patients treated with biological agents. METHODS: Chart review of demographic data and treatment outcomes. MAIN OUTCOME MEASURES: Treatment efficacy (corticosteroid-sparing effect, topical steroid cessation/reduction, reduction in systemic-steroid sparing agents, change in intraocular inflammation, visual acuity and central macular thickness); treatment failure; and adverse events. Data were collected at biological initiation, 6 weeks, 6 months and 12 months. RESULTS: Biological therapy over 1 year was effective with prednisolone dose reduced to <5 mg/day in five of six patients (83%), number of systemic steroid-sparing agents was reduced to ≤1 in two of four patients (50%) and cessation of topical steroid achieved in 12/41 of eyes (29%). Improvement of anterior chamber cells by two grades occurred in 20/25 eyes (80%), improvement of logMAR to ≤0.3 occurred in 12/18 eyes (67%) and macular oedema decreased in 4/5 eyes (80%). Treatment failure occurred in six eyes (13.01%) and five patients (18.5%) developed an adverse reaction. CONCLUSIONS AND RELEVANCE: Biological therapy was effective in paediatric patients with uveitis. Intraocular inflammation improved with maintained visual acuity, systemic corticosteroid dose decreased and there was a low frequency of adverse events.

Comparing the outcomes of severe versus mild/moderate ptosis using closed posterior levator advancement.

Traditionally, posterior eyelid surgical approaches such as Müller's muscle-conjunctival resection (MMCR) have been utilised with great success for mild cases of ptosis, with external levator approaches having been used for more severe cases of ptosis. We present a new technique which we label closed posterior levator advancement (CPLA) for the correction of all grades of ptosis. This article is a retrospective cohort study reviewing patients with mild, moderate, and severe ptosis over a 6-year period, treated by a single surgeon using CPLA. Minimum follow-up was 3 months. Patients with good levator function (levator palpebrae superioris (LPS) function >10 mm) without concomitant procedures were subdivided based on margin-to-reflex-distance-1 (MRD1) into mild-to-moderate ptosis (MRD1 > 1.5 mm) and severe ptosis (MRD1 ≤ 1.5 mm) cohorts. The outcome measures were preoperative and postoperative MRD1, lid contour, intereye symmetry, complications, and revision rates. 393 eyes of 313 patients were identified. 91 eyes in the mild-to-moderate cohort had a preoperative MRD1 of 2.38 mm, and 302 eyes in the severe cohort had a preoperative MRD1 of 0.27 mm. Postoperatively, MRD1 was 3.86 mm and 3.49 mm, respectively. There were no significant complications in both cohorts, and revision rates were 3.3% (3 of 91 eyes) in the mild-to-moderate and 2% (6 of 302 eyes) in the severe cohorts. Upper-eyelid contour was satisfactory in 98.2% of eyes, and 97.5% intereye symmetry within 1 mm was observed. Our results show an effective correction of all ptosis grades with satisfactory cosmetic outcomes and low complication and revision rates.

Orbital Cellulitis and Secondary Angle Closure: A Rare Presentation of Choroidal Melanoma.

We describe a case of choroidal melanoma initially presenting with orbital cellulitis, fulminant conjunctival swelling, and secondary angle closure. Despite treatment with intravenous antibiotics, the patient's condition did not improve. With further investigations including ultrasound scan and magnetic resonance imaging, a high-density lesion was found within the globe. Characteristic imaging findings suggested a malignant origin and the lesion was found to be a melanoma on histopathological analysis.

Closed Posterior Levator Advancement in Severe Ptosis.

BACKGROUND: Repair of blepharoptosis from the posterior eyelid approach has usually been done utilizing a Müller's muscle-conjuctival resection (MMCR) or an "open sky" technique. We present a new technique to advance the levator muscle from the posterior-approach in a closed fashion that can be used in patients with severe involutional ptosis. METHODS: A retrospective chart review was performed for consecutive patients with severe involutional blepharoptosis during a 6-year period treated by a single surgeon with a Closed Posterior Levator Advancement. The inclusion criteria were good levator function (≥ 10 mm), graded response to phenylephrine (change in lid height, 0-5 mm), and no concomitant procedures. Severe involutional blepharoptosis was defined as a margin-to-reflex-distance-1 (MRD1) of ≤ 1.5 mm. Follow-up for all patients was a minimum of 9 months. The main outcome variables were MRD1, upper eyelid contour, intereye symmetry, and reoperation rates. RESULTS: Three hundred three eyes from 192 patients, with severe ptosis were identified. The average age was 65 years, and the mean preoperative MRD1 was 0.3 mm. Postoperatively, mean MRD1 was 3.5 mm with a median improvement of 3.2 mm. The upper eyelid contour was deemed to be satisfactory by patient and surgeon in 98.3% of eyes. Intereye symmetry was excellent in 96% of our cohort. An overall revision rate of 1.8% was found. CONCLUSIONS: We present a new technique that involves an advancement of the levator muscle in a closed posterior eyelid approach. The technique has produced satisfactory outcomes in our cohort of patients with severe ptosis with a low revision rate.

Anti-vascular endothelial growth factor for neovascular age-related macular degeneration: a meta-analysis of randomized controlled trials.

BACKGROUND: To evaluate the relative efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) agents for the treatment of neovascular age-related macular degeneration (AMD). METHODS: Systematic literature review identifying RCTs comparing anti-VEGF agents to another treatment published before June 2016. Efficacy assessed by mean change in best corrected visual acuity (BCVA) and central macular thickness (CMT) from baseline at up to 2 years followup. Safety assessed by proportions of patients with death, arteriothrombotic and venous thrombotic events, and at least one serious systemic adverse event at up to 2 years of followup. RESULTS: Fifteen RCTs selected for meta-analysis (8320 patients). Two trials compared pegaptanib, and three trials compared ranibizumab versus control. Eight trials compared bevacizumab with ranibizumab. Two trials compared aflibercept with ranibizumab. There were no significant differences between bevacizumab and ranibizumab for BCVA at 1 or 2 years (weighted mean difference = - 0.57, 95% CI - 1.55 to 0.41, P = 0.25 and weighted mean difference = - 0.76, 95% CI - 2.25 to 0.73, P = 0.32, respectively). Ranibizumab was more effective in reducing CMT at 1 year (weighted mean difference = 4.49, 95% CI 1.13 to 7.84, P = 0.009). Risk ratios comparing rates of serious systemic adverse events at 1 and 2 years were slightly out of favour for bevacizumab. Aflibercept compared with ranibizumab demonstrated similar mean change in BCVA, reduction in CMT, and safety at 1 year. CONCLUSIONS: Bevacizumab and ranibizumab had equivalent efficacy for BCVA, while ranibizumab had greater reduction in CMT and less rate of serious systemic adverse events. Aflibercept and ranibizumab had comparable efficacy for BCVA and CMT. This provides information to balance comparable effects on vision and risk of adverse events between anti-VEGF agents.

Outcomes of Primary Total Knee Arthroplasty in Patients With Parkinson's Disease.

BACKGROUND: Parkinson's disease is a degenerative disorder causing rigidity, bradykinesia, and tremor of the motor system. There is significant paucity of evidence regarding whether total knee arthroplasty (TKA) is of benefit in patients with both Parkinson's disease and osteoarthritis. We aimed to compare outcomes and complications of TKA between patients with Parkinson's disease and those without. METHODS: A cohort of 43 knees from 35 patients with Parkinson's disease who received a primary TKA between January 2004 and December 2015 were retrospectively extracted from a private clinical database held by 2 surgeons and compared to an age and gender-matched control group of 50 knees from 41 patients. TKAs were performed by 2 surgeons at 1 tertiary private hospital.The indication for TKA in both groups was osteoarthritis. Difference between preoperative and 1-year range of movement (ROM) and 12-point Oxford Knee Score (OKS) was assessed using Student's unpaired t-test. Postoperative complications and revision procedures were also recorded during the follow-up period. The minimal clinically important difference for OKS at 1-year follow-up, defined as improvement of ≥6, was also assessed. RESULTS: In the Parkinson's group, mean ROM improvement was 14° (100° preoperatively to 114° at 12 months), compared to 12° in the control group (102°-114°, respectively). Mean OKS improvement was 15 in the Parkinson's group (23 preoperatively to 38 at 12 months) compared to 17 in the control group (23 and 40, respectively.) No significant difference was identified between the 2 groups for either ROM (P = .96) or OKS (P = .45.) All Parkinson's patients achieved the minimal clinically important difference at 1-year follow-up. There were no mortalities during the study follow-up period and no significant difference in complication rates between the 2 groups (P = .41). CONCLUSION: Parkinson's disease was not associated with poorer functional outcomes or increased complications compared to controls in our study. We suggest that Parkinson's disease is not an absolute contraindication to TKA.

Value of temporal artery biopsy length in diagnosing giant cell arteritis.

BACKGROUND: Giant cell arteritis (GCA) is considered an ophthalmological emergency with severe sight and life-threatening sequelae. Temporal artery biopsy (TAB) is the current gold standard for the diagnosis of GCA; however, the required length of biopsy remains an issue of contention in the literature. METHODS: Retrospective case-control study of a consecutive cohort of 545 patients who had undergone TABs across five hospitals between 1 January 1992 and 1 January 2016. In patients with either positive or negative TABs, we collected age, sex, biopsy length and erythrocyte sedimentation rate (ESR). RESULTS: A total of 538 patients were included in the final analysis. Of these, 23.4% of TABs were positive, with the average length being 17.6 mm. There was a significant difference in means for positive (19.9 mm) and negative (16.8 mm) biopsies (P = 0.0009). Each millimetre increase in TAB length increased the odds of a positive TAB by 3.4% (P = 0.024). A cut-off point of ≥15 mm increased the odds of a positive TAB by 2.25 compared with a TAB <15 mm (P = 0.003). We also found that ESR ≥50 mm/h was a very strong predictor for a positive TAB result (P < 0.0001). CONCLUSION: Biopsy length and ESR were significant predictors of a pathological diagnosis of GCA. We also found that the optimal length threshold predictive for GCA was 15 mm in order to avoid a false-negative GCA diagnosis. Although TAB remains the gold standard for diagnosis, clinicians should refer to both clinical and pathological data to guide their management.

Full blood count as an ancillary test to support the diagnosis of giant cell arteritis.

BACKGROUND: Temporal artery biopsy is considered the investigation of choice to diagnose definitively giant cell arteritis (GCA) in patients with compatible symptoms. However it is invasive and not completely sensitive. Serum markers, particularly erythrocyte sedimentation rate (ESR), can be supportive, but are not definitive in individual cases. AIMS: To investigate whether indices derived from the full blood count, including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were associated with a positive biopsy in patients with suspected GCA. METHODS: The clinical and pathological details of 537 patients undergoing temporal artery biopsy at our institution from 1992 to 2015 were reviewed. RESULTS: In univariate analysis high platelets (odds ratio (OR) 4.44, P < 0.001), NLR (OR 1.81, P = 0.02), PLR (OR 3.25, P < 0.001), C-reactive protein (CRP) (OR 3.00, P < 0.001), ESR (OR 3.62, P < 0.001) and increased age (OR 1.03, P = 0.006) were strongly associated with a positive biopsy. In multivariate modelling only high platelets (P < 0.001) and ESR (P = 0.049) maintained significance. CONCLUSIONS: We conclude that the presence of thrombocytosis and high NLR, PLR, ESR and CRP can all be used clinically to support the diagnosis of GCA prior to biopsy. Of particular note, in multivariate modelling the presence of thrombocytosis is a stronger predictor of a positive temporal artery biopsy than ESR. Therefore, careful consideration of the findings in a full blood count can be used to predict the likelihood of a positive temporal artery biopsy in patients with suspected GCA.