Long-term future risk of severe exacerbations: Distinct 5-year trajectories of problematic asthma.

BACKGROUND: Assessing future risk of exacerbations is an important component of asthma management. Existing studies have investigated short- but not long-term risk. Problematic asthma patients with unfavorable long-term disease trajectory and persistently frequent severe exacerbations need to be identified early to guide treatment. AIM: To identify distinct trajectories of severe exacerbation rates among "problematic asthma" patients and develop a risk score to predict the most unfavorable trajectory. METHODS: Severe exacerbation rates over five years for 177 "problematic asthma" patients presenting to a specialist asthma clinic were tracked. Distinct trajectories of severe exacerbation rates were identified using group-based trajectory modeling. Baseline predictors of trajectory were identified and used to develop a clinical risk score for predicting the most unfavorable trajectory. RESULTS: Three distinct trajectories were found: 58.5% had rare intermittent severe exacerbations ("infrequent"), 32.0% had frequent severe exacerbations at baseline but improved subsequently ("nonpersistently frequent"), and 9.5% exhibited persistently frequent severe exacerbations, with the highest incidence of near-fatal asthma ("persistently frequent"). A clinical risk score composed of ≥2 severe exacerbations in the past year (+2 points), history of near-fatal asthma (+1 point), body mass index ≥25kg/m2 (+1 point), obstructive sleep apnea (+1 point), gastroesophageal reflux (+1 point), and depression (+1 point) was predictive of the "persistently frequent" trajectory (area under the receiver operating characteristic curve: 0.84, sensitivity 72.2%, specificity 81.1% using cutoff ≥3 points). The trajectories and clinical risk score had excellent performance in an independent validation cohort. CONCLUSIONS: Patients with problematic asthma follow distinct illness trajectories over a period of five years. We have derived and validated a clinical risk score that accurately identifies patients who will have persistently frequent severe exacerbations in the future.

Improving the interaction between the ophthalmology and histopathology departments.

PURPOSE: The purpose of this study was to improve communication between the ophthalmology and histopathology departments at Royal Hallamshire Hospital, Sheffield, by effectively changing the structure and completion of the histopathology request form through the process of a successful audit. This aimed to ensure that comprehensive information was made available to the histopathologist. METHODS: An audit was performed by review of 710 histopathology request forms, completed by the ophthalmology department, over a 1-year period, between July 2005 and June 2006 inclusive. Results were used to re-model the ophthalmic histopathology request form. New forms were circulated and all forms completed over a 3-month period, between January 2008 and March 2008, were reviewed, thus closing the audit loop. RESULTS: On the basis of audit results of 710 histopathology request forms, a new histopathology request form was created, which was easier to complete. Review of the 224 new histopathology request forms showed improved percentages of completion of important sections of the form. CONCLUSIONS: Through the audit process we have created a new ophthalmic histopathology request form that is more user-friendly for the ophthalmologist and more consistently provides the necessary information for the ophthalmic histopathologist. This has improved efficiency and effectiveness of communication between the specialities, which should contribute to minimise the chances of medical error and improved turnaround times for the planning and delivery of patient care.

Serum uric acid levels in optic neuritis.

Uric acid, an antioxidant, is reduced in multiple sclerosis (MS). Patients with gout have a reduced incidence of MS. Optic neuritis (ON), often the first manifestation of MS, is not known to be associated with reduced uric acid. Patients with recent onset of ON were investigated to determine whether uric acid levels were reduced at presentation. Twenty-one patients with ON were included, 17 females and 4 males. The mean (SD) serum uric acid in the ON female group was 184.4 ( +/-55.1) micromol/L (range, 116-309 micromol/L), whilst in the control group it was 235.2 (+/- 50.2) micromol/L (range, 172-381 micromol/L). The difference was statistically significant (chi2 = 8.93, P = 0.003). In the small male cohort, mean (SD) serum uric acid was 305 (+/- 52.1) micromol/L, whilst in the control group it was 328 (+/- 80.4) micromol/L. These differences were not statistically significant. Reduced antioxidant reserve is possibly an early pathogenic mechanism in inflammatory demyelination, and raises the possibility that low uric acid levels could be an indicator of disease activity. Since optic neuropathies of other causes were not investigated, future research needs to determine whether low uric acid represents a unique feature of optic neuritis or is seen in other optic neuropathies.

Differences in the management of amblyopia between European countries.

BACKGROUND: Amblyopia treatment is not standardised and differences between centres and countries have not been systematically investigated. This survey compares the different patterns of orthoptic treatment of amblyopia in the United Kingdom (UK) and three German speaking countries (GSC). METHODS: Questionnaires were sent to orthoptists in the UK and the GSC asking for their preferred choices of treatment of amblyopia between the ages of 6 months to 10 years. RESULTS: The following significant differences in management of amblyopia were found: (1) the number of hours of occlusion per week was higher in the GSC, p<0.0001, (2) orthoptists in the GSC treat amblyopia up to an older age. Orthoptists in the GSC and in the UK predicted similar treatment outcomes. CONCLUSION: Orthoptists in the GSC usually treat patients more intensively and for longer, while the prediction of visual outcome does not differ significantly between countries. These results highlight the lack of standardisation in the treatment of the various types of amblyopia.

Angiotropic lymphoma occurring in a lacrimal sac oncocytoma.

This report describes a case of angiotropic variant of diffuse large B cell lymphoma within a benign oncocytoma of the lacrimal sac. The occurrence of this rare lymphoma within a benign neoplasm has not been documented previously. An 87 year old woman presented with a swelling over the area of the left lacrimal sac, which histological examination revealed to be an oncocytoma. Many small blood vessels within the tumour were filled with large cytologically atypical cells, which stained positively for leucocyte common antigen and a B cell antigen, CD20, confirming the presence of a large B cell non-Hodgkin's lymphoma of angiotropic type. Angiotropic lymphoma is a very rare and usually highly aggressive variant of non-Hodgkin's lymphoma, which classically involves the central nervous system and skin, but has been described within most organs. Its occurrence within a benign neoplasm is probably coincidental, although a close association between oncocytic epithelium and normal lymphoid cells is recognised in Warthin's tumour of salivary and lacrimal glands.

Phacoemulsification cataract surgery and unplanned anterior vitrectomy--is it bad news?

PURPOSE: The aim of this study was to determine the final visual outcome of patients who undergo complicated phacoemulsification cataract surgery in which the posterior capsule is compromised and vitrectomy was required. METHODS: Data were collected for patients operated on over an 18-month period from the 1st of January till the 24th of June 1999 at the Department of Ophthalmology, Leicester Royal Infirmary. All grades of surgeons were included and patients were identified from the theatre logbook. A standard proforma was completed and the data evaluated. RESULTS: A total of 2538 phacoemulsification cataract operations were performed over this duration. Of these, 2446 (96.4%) had uncomplicated phacoemulsification cataract surgery while 92 (3.6%) required anterior vitrectomy. In order to allow for a more accurate interpretation of the visual outcome, patients were divided into two groups, depending on whether or not there was pre-existing eye disease at initial listing.Sixty-five patients did not have pre-existing eye disease. From this, notes were available for 57 patients, whereby the best-corrected visual acuity (BCVA) was obtained postoperatively. Vision of 6/12 or better was used to define acceptable postoperative vision. This group consisted of 49 patients (86%): five had visual acuities of 6/12, 26 = 6/9, one = 6/7.5 and 17 = 6/6. There were eight (14%) patients with poor visual outcome, largely represented by patients with cystoid macular oedema (8.8%). The most frequent stage of vitreous loss was during primary phacoemulsification in 46 (50%). Irrigation and aspiration, which resulted in 21 (23%) instances, followed this. The rate of posterior capsule rupture and anterior vitrectomy during phacoemulsification cataract surgery is 2% when performed by consultants, 4% by specialist registrars and staff grades and 10% by senior house officers. CONCLUSION: This study looks at the final visual outcome of patients who underwent unplanned anterior vitrectomy during routine phacoemulsification cataract surgery, in a university teaching hospital in the United Kingdom. It includes all levels of surgeons with varying experience. The rate of vitreous loss in this study for phacoemulsification cataract surgery is 3.6%. Patients who undergo complicated phacoemulsification cataract surgery do comparatively well.