Cardiovascular risks of androgen receptor targeted agents in prostate cancer: a systematic review and meta-analysis.

INTRODUCTION: Androgen receptor targeted agents (ARTA) have increasingly been incorporated into treatment regimens for various stages of prostate cancer. Patients are living longer with prostate cancer, and thus have a higher cumulative exposure to the treatment and its accompanying side effects, especially those of cardiovascular disease. We aim to assess the differences in the incidence of cardiac-related adverse events after treatment of prostate cancer with ARTA versus placebo. METHODS: Three databases were thoroughly searched for relevant articles. The PICOS model was used to frame our clinical question, with which 2 independent authors went through several rounds of screening to select the final included studies. Meta-analysis was done using the Cochran-Mantel-Haenszel Method. Quality assessment was carried out with the Cochrane Risk of Bias tool RoB 2. RESULTS: The use of ARTA in prostate cancer increases the incidence of cardiac-related adverse events (RR: 1.56, 95% CI: 1.29-1.90, p < 0.00001), such as hypertension (RR: 1.69, 95% CI: 1.46-1.97, p < 0.00001), ischaemic heart disease (RR: 1.84, 95% CI: 1.36-2.50, p < 0.0001), and arrhythmia (RR: 1.38, 95% CI: 1.11-1.71, p = 0.004), although this did not manifest in an increased incidence of cardiac arrests/deaths (RR: 1.28, 95% CI: 0.87-1.88, p = 0.21). DISCUSSION: ARTA increases the risk of cardiac-related adverse events, hypertension, ischaemic heart disease and arrhythmia. Armed with this knowledge, we will be better poised to manage cardiac risks accordingly and involve a cardiologist as required when starting patients on ARTA.

Management of acute testicular pain in children: changing trends with improvements in scrotal ultrasonography over 18 years.

Introduction: Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testicular torsion. We aimed to evaluate the performance of scrotal US in diagnosing testicular torsion over the past 18 years in our institution and determine the factors contributing to the length of wait times for it. Methods: A retrospective review was conducted of boys who presented with acute scrotal pain from 2014 to 2015. US reports, operative findings, final diagnosis and key time points of the patients' journey (time to emergency department consultation, time to admission, time to US and time to operating theatre [OT]) were collected. US performance results were compared with those observed in a historical cohort from 1998 to 2004. Wait times were compared between operated and non-operated patients. Results: Data from 519 boys with a mean age of 9.15 years was collected. Of these, 438 (84.4%) boys had undergone initial scrotal US; of these scrotal US cases, 28 were surgically explored, with 23 confirmed to have torsion. Another five cases were explored without prior US, and all were confirmed to have torsion. Performance analysis of US showed a sensitivity of 100% and a specificity of 98.8%. There was no significant difference between wait times of operated and non-operated patients. Time to US (P < 0.0001, r = 0.96) and time to OT (P < 0.0001, r = 0.64) correlated significantly with the total time from presentation to surgery. Conclusion: There has been an improvement in the diagnostic performance of scrotal US for testicular torsion over the past 18 years. Quality improvement programmes targeted at reducing wait times for patients presenting with acute scrotum should target time to US and time to OT.

Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation.

Studies show that conservative management in acute uncomplicated appendicitis (AUA) is an alternative to surgery. This study aims to determine factors affecting parental preference in management of AUA and their decision for research participation. We conducted surveys on parents whose children were admitted with suspicion of appendicitis but later confirmed not to have appendicitis. Information on appendicectomy versus conservative treatment with antibiotics was provided using a fixed script and standard information leaflet. Questionnaires covered factors influencing decisions, opinions regarding research, treatment preference and demographic data. We excluded parents not fluent in English. Of 113 respondents, 71(62.8%) chose antibiotics, 39(34.5%) chose appendicectomy, and 3(2.7%) had no preference. Reasons given for choosing antibiotics were fear of surgical risks and preferring less invasive treatment. Those choosing appendicectomy expressed preference for definitive treatment and fear of recurrence. Majority were against randomisation (n = 89, 78.8%) and blinding (n = 90, 79.7%). Over half found difficulty involving their child in research (n = 65, 57.5%). Most thought that research is important (66.4%) and beneficial to others (59.3%). Parents who perceived their child as healthy found research riskier (p = 0.039). Educated parents were more likely to find research beneficial to others (p = 0.012) but less accepting of randomisation (p = 0.001).Conclusion: More parents appear to prefer conservative treatment for acute uncomplicated appendicitis. Researchers must consider parental concerns regarding randomisation and blinding.What is Known:• Conservative management of acute uncomplicated appendicitis in paediatric patients is safe and effective, sparing the child the need for an operation; however, neither conservative nor surgical management is proven to be superior.• Randomised controlled trials provide the highest level of evidence, but it is challenging to recruit paediatric patients as participants in such clinical trials.What is New:• More parents prefer conservative management of uncomplicated appendicitis over surgical management for their children due to fear of surgical risks and complications• Randomisation in trial design is significantly associated with a parent's decision to reject their child's participation in a clinical trial.

Stroke mortality audit using the Structured Judgement Review method.

Mortality data provided by the Sentinel Stroke National Audit Programme demonstrated the Royal Cornwall Hospitals Trust (RCHT) to have a higher than national average mortality ratio.1 In response to this, the RCHT stroke department undertook a mortality review of patients admitted with stroke making use of the Structured Judgement Review (SJR) process.2The review found all patients were deemed as receiving adequate, good or excellent care. There were no cases where death was deemed as definitely avoidable. The team found the SJR to be a useful, validated tool for mortality review though recognised specific limitations to its use and wider limitations within our review process. Focused areas for improvement derived from the review included improving compliance with local palliative care guides, improved documentation, links with primary care via Care Quality Commission atrial fibrillation group and consideration of improved scanning facilities. We also acknowledged wider unaccounted factors which may impact stroke mortality and thus influence perceived mortality ratios.

Orbscan II anterior elevation changes following corneal collagen cross-linking treatment for keratoconus.

PURPOSE: To analyze anterior corneal elevation changes on Orbscan II following corneal collagen cross-linking (CXL) with riboflavin. METHODS: This retrospective study included 8 patients (14 eyes) with keratoconus who underwent CXL, with a mean follow-up of 7 months (range: 5 to 10 months). Pre- and postoperative (at last clinic attendance) anterior elevation difference maps were examined for overall patterns of change. On preoperative maps, distances from maximum anterior elevation to pupil center and to topographic geometric center were compared between the two patterns identified. Pre- and postoperative topography, best spectacle-corrected visual acuity (BSCVA), and refraction were also compared between the two patterns. RESULTS: Two patterns of anterior elevation change were visually identified: (1) paracentral steepening, no change, or flattening centrally; and (2) central steepening. The preoperative maps of eyes that manifested pattern 1 had shorter mean distances for maximum anterior elevation to pupil center (1.70 vs. 2.27 mm) and maximum anterior elevation to geometric center (1.45 vs. 1.99 mm) than those that resulted in pattern 2. Mean maximum topographic simulated keratometry decreased (P = .004) and mean irregularity indices at 3 mm (P =.03) and 5 mm (P =.04) were reduced postoperatively in pattern 1 eyes; all increased in pattern 2 eyes. Mean BSCVA improved postoperatively for both patterns. Mean preoperative myopia decreased in pattern 1 eyes by 0.44 diopters (D), whereas it increased for pattern 2 eyes by 1.83 D. CONCLUSIONS: Corneal shape change influenced by anisotropy of collagen distribution is a factor in the outcome of CXL treatment for keratoconus.

Effect of intraocular surgery and ketamine on aqueous and serum cytokines.

PURPOSE: To determine the effect of intraocular surgery and anesthesia on aqueous and serum cytokines. METHODS: Patients undergoing routine cataract surgery under general and local (peribulbar) anesthesia were randomized to those given general anesthetic with and without the use of ketamine and those having local anesthesia. Aqueous and serum levels of cytokines were collected at commencement of surgery and were determined by an immunoassay using multi-analyte biochip array technology at 18 h post-operatively. RESULTS: At 18 h postoperative, all patients (37) showed significant and many fold increases in their aqueous levels of interleukin (IL)-1alpha, IL-1beta, IL-4, IL-6, IL-8, vascular endothelial growth factor (VEGF), tumor necrosis factor (TNF)-alpha, interferon (IFN)-gamma, epidermal growth factor (EGF), and monocyte chemotactic protein (MCP)-1. There was little to no increase in IL-2 and IL-10. Significant increases in some cytokines (EGF, IL-6, and IFN-gamma) in the serum were also found (p=0.038). There were no significant differences in aqueous cytokine levels following the use of ketamine or between those patients who had general and local anesthesia (0.11

Outcomes of sulcus implantation of Array multifocal intraocular lenses in second-eye cataract surgery complicated by vitreous loss.

PURPOSE: To evaluate the outcomes of implantation of the Array((R)) multifocal intraocular lens (IOL) (model SA-40N, AMO) in the ciliary sulcus in second-eye cataract surgery complicated by vitreous loss. SETTING: Department of Ophthalmology, Arrowe Park Hospital, Wirral, United Kingdom. METHODS: This retrospective study comprised 15 patients who had complicated second-eye cataract surgery with loss of posterior capsule support leading to sulcus implantation of an Array multifocal IOL. The patients were recalled for assessment. Objective evaluation included uncorrected and corrected distance and near visual acuities, complications, and IOL centration. Subjective assessment was performed using a questionnaire that included the VF-14 index of visual function; the questions were related to satisfaction with vision, limitations from halos and glare, and the frequency of spectacle wear. RESULTS: Fourteen eyes (93%) had postoperative visual improvement. The best corrected distance acuity was 6/12 or better in 11 eyes (73%). The best corrected near acuity was J2 or better in 12 eyes (80%). The IOL was well centered in 11 eyes (73%) and slightly decentered in 4 eyes (27%). Subjectively, patients indicated a high level of satisfaction with their distance and near vision. The VF-14 indicated high levels of visual function, with 73% of patients having a score higher than 90 (out of 100). Seventy-three percent of patients were not troubled by glare or halos, and 40% did not wear spectacles. CONCLUSION: Implantation of the Array multifocal IOL in the sulcus during complicated phacoemulsification led to good visual outcomes based on objective and subjective patient measures.

Total encapsulation and asymmetric deformation of an intraocular lens.

We report a case of marked anterior capsule contraction after uneventful cataract surgery in an 82-year-old women. The patient had implantation of a single-piece foldable acrylic intraocular lens (IOL) after phacoemulsification through a 3.0 mm superior corneal incision. Between 1 month and 5.5 months after surgery, significant anterior capsule contraction ensued with total encapsulation of the lens. The resultant fibrotic reaction, which had a localized tangential component, caused an asymmetric deformation and mild IOL displacement. The patient was treated on separate occasions with a neodymium:YAG laser anterior capsulotomy and surgical capsulotomy to release tension on the lens and clear the visual axis.