Cosmetic Filler Blindness: Recovery After Repeated Hyaluronidase Injections.

BACKGROUND: The rise of cosmetic injectables has involved new clinical scenarios related to complications. The scenario of hyaluronic acid (HA) aesthetic interventional-induced visual loss has become more recognized. Although this complication is rare, there can be delayed recognition and treatment, with limited opportunity to evaluate potential treatments and establish best practice guidelines. OBJECTIVES: The authors report a case of documented visual recovery with extra-orbital and intra-orbital hyaluronidase. Central retinal artery occlusion is an ischemic event requiring urgent intervention. The authors hope to assist protocols being developed for HA aesthetic interventional-induced visual loss. METHODS: Following loss of vision, 675 international units (IU) of hyaluronidase was given immediately to the injection site and extra-orbital area. Within 4 hours, 3000 IU intra-orbital and 1500 IU extra-orbital hyaluronidase were given. RESULTS: Visual loss in a 38-year-old female, following ipsilateral nasal injection of 0.15 mL of HA filler Juvéderm Voluma via the nasal tip, was documented at no perception of light with afferent pupil defect, central retinal artery occlusion, and fundoscopy showing a cherry red spot. This was associated with cerebral irritation and magnetic resonance imaging ischemia. Hyaluronidase was injected as described above. The following day, visual acuity (VA) in the affected eye recovered to 6/18 with a relative superior visual field scotoma. The VA improved to 6/6 at 1 month. CONCLUSIONS: The authors believe immediate injection followed by high dose intra-orbital and extra-orbital injection of hyaluronidase had a positive effect in this case. Recovery of vision was remarkable, from no perception of light to 6/6, documented at a tertiary referral eye hospital.

Intraocular solitary extramedullary plasmacytoma presenting as unilateral anterior and intermediate uveitis preceded by refractory glaucoma.

BACKGROUND: Solitary extramedullary plasmacytoma (SEP) is a localised proliferation of monoclonal plasma cells involving soft tissue with no or minimal bone marrow involvement and no other systemic evidence of multiple myeloma. Intraocular involvement is exceedingly rare. CASE PRESENTATION: We report a 78-year-old man who was referred with glaucoma in the right eye. He subsequently developed anterior chamber (AC) inflammation and refractory glaucoma then dense vitritis. A vitrectomy was performed with the biopsy revealing numerous plasma cells with atypical findings. In conjunction with the flow cytometry results, and a systemic work up excluding multiple myeloma, a diagnosis of SEP was made. The patient was treated with ocular external beam radiotherapy with resolution of the intraocular inflammation and control of the intraocular pressure. He remains well with no local recurrence and no development of multiple myeloma over a follow up period of 2.5 years. CONCLUSIONS: This is the first case report of SEP presenting as intraocular inflammation without a uveal tract mass.

Implementation of modified team-based learning within a problem based learning medical curriculum: a focus group study.

BACKGROUND: While Problem Based Learning (PBL) has long been established internationally, Team-based learning (TBL) is a relatively new pedagogy in medical curricula. Both PBL and TBL are designed to facilitate a learner-centred approach, where students, in interactive small groups, use peer-assisted learning to solve authentic, professionally relevant problems. Differences, however, exist between PBL and TBL in terms of preparation requirements, group numbers, learning strategies, and class structure. Although there are many similarities and some differences between PBL and TBL, both rely on constructivist learning theory to engage and motivate students in their learning. The aim of our study was to qualitatively explore students' perceptions of having their usual PBL classes run in TBL format. METHODS: In 2014, two iterations in a hybrid PBL curriculum were converted to TBL format, with two PBL groups of 10 students each, being combined to form one TBL class of 20, split into four groups of five students. At the completion of two TBL sessions, all students were invited to attend one of two focus groups, with 14 attending. Thematic analysis was used to code and categorise the data into themes, with constructivist theory used as a conceptual framework to identify recurrent themes. RESULTS: Four key themes emerged; guided learning, problem solving, collaborative learning, and critical reflection. Although structured, students were attracted to the active and collaborative approach of TBL. They perceived the key advantages of TBL to include the smaller group size, the preparatory Readiness Assurance Testing process, facilitation by a clinician, an emphasis on basic science concepts, and immediate feedback. The competitiveness of TBL was seen as a spur to learning. These elements motivated students to prepare, promoted peer assisted teaching and learning, and focussed team discussion. An important advantage of PBL over TBL, was the opportunity for adequate clinical reasoning within the problem solving activity. CONCLUSION: Students found their learning experience in TBL and PBL qualitatively different. There were advantages and disadvantages to both. This suggests a hybrid approach utilising the strengths of both methods should be considered for wide scale implementation.

Implementation of team-based learning in year 1 of a PBL based medical program: a pilot study.

BACKGROUND: A traditional and effective form of teaching within medical education has been Problem Based Learning (PBL). However, this method of teaching is resource intensive, normally requiring one tutor for every ten students. Team-based learning (TBL) has gained recent popularity in medical education, and can be applied to large groups of up to 100 students. TBL makes use of the advantages of small group teaching and learning, but in contrast to PBL, does not need large numbers of teachers. This study sought to explore the efficacy of using TBL in place of PBL in Year 1 of a medical program. METHODS: In Year 1 of the medical program, two iterations of TBL, with 20 students, were run following four iterations of PBL within the Cardiology teaching block. Student feedback following PBL and TBL was collected by questionnaire, using closed and open ended questions. Additionally, individual and team tests were held at the beginning of each TBL class, and results of each week were compared. RESULTS: All students (n = 20) participated in the test in week 1, and 18/20 students participated in week 2. In total, 19/20 (95%) of students completed the questionnaires regarding their PBL and TBL experiences. The use of small groups, the readiness assurance tests, immediate feedback from an expert clinician, as well as time efficiency were all aspects of the TBL experience that students found positive. The clinical problem-solving activity, however, was considered to be less effective with TBL. There was a significant improvement (p = 0.004) in students' score from the week 1 assessment (median = 2) to the week 2 (median = 3.5) assessment. Interestingly, all teams but one (Team 1) achieved a lower score on their second week assessment than on their first. However, the lowest performing team in week 1 outperformed all other teams in week 2. CONCLUSION: Students favoured many aspects of the TBL process, particularly motivation to do the pre-reading, and better engagement in the process. Additionally, the application of TBL principles meant the sessions were not reliant upon a large teacher to student ratio. Students, however, highlighted the need for more time within TBL for clinical problem-solving.

The effect of 6 days of sodium phosphate supplementation on appetite, energy intake, and aerobic capacity in trained men and women.

Ingestion of an acute dose of phosphate has been shown to attenuate energy intake in the subsequent meal. This raises the question of whether the practice of phosphate supplementation over a number of days by athletes to enhance performance also influences energy intake. This study investigated the effect of 6 d of phosphate supplementation on appetite and energy intake, as well as aerobic capacity, in trained individuals. Twenty participants completed two 6-d phases of supplementation with either sodium phosphate (50 mg/kg of fat-free mass per day) or a placebo in a double-blinded, counterbalanced design. On Days 1, 2, and 6 of supplementation, a laboratory meal was provided to assess appetite and ad libitum energy intake. All other food and drink consumed during each supplementation phase were recorded in a food diary. After the 6 d of supplementation, peak aerobic capacity (VO(2peak)) was assessed. There was no difference in energy intake at the laboratory meal after an acute dose (i.e., on Day 1; placebo 2,471 ± 919 kJ, phosphate 2,353 ± 987 kJ; p = .385) or prolonged supplementation with sodium phosphate (p = .581) compared with placebo. Likewise, there was no difference in VO(2peak) with phosphate supplementation (placebo 52.6 ± 5.2 ml · kg(-1) · min(-1), phosphate 53.3 ± 6.1 ml · kg(-1) · min(-1); p = .483). In summary, 6 d of sodium phosphate supplementation does not appear to influence energy intake. Therefore, athletes supplementing with sodium phosphate can do so without hindering their nutritional status. However, given that phosphate supplementation failed to improve aerobic capacity, the ergogenic benefit of this supplement remains questionable.

Clinical Teacher Training for health professionals: From blended to online and (maybe) back again?

BACKGROUND: The Clinical Teacher Training (CTT) programme was originally developed as an interprofessional, blended learning programme, to support health professionals working across health services within Australia, although it has also been delivered internationally. With the disruption of COVID-19, we rapidly moved to 'online only' delivery. We sought to modify the programme, ensuring that the constructivist paradigms important for our learner experience through the original blended format were maintained in the online platform. APPROACH: Consisting of 10 modules on a range of topics, the new CTT online only programme was facilitated online across 6 weeks with asynchronous and synchronous assessable activities, and provision of peer and facilitator feedback. The learning outcomes for each module were similar to the 'blended learning' format. The new programme was delivered three times throughout 2020 and completed by a total of 208 health professionals from across 10 metropolitan and rural health districts. EVALUATION: The focus of our evaluation was on the programme's final 2020 iteration, for which we had ethics approval. Participants (n = 59) were from diverse health professions, across five metropolitan and rural health districts. We prioritised the learner experience in constructing our evaluation strategy. Quantitative and qualitative data were collected by post-course questionnaire and analysed using descriptive statistics and thematic analysis. Twenty participants (34%) responded to the post-course questionnaire. Participants valued the structure, topics, clear outcomes, timeframe, online resources, small group activities, feedback and the flexibility and accessibility afforded by online only delivery. However, participants identified a need for additional 'real-time' engagement in activities. Faculty were surprised by the time required to adequately facilitate online learning, and similarly, valued the real-time interactions. IMPLICATIONS: The online only CTT programme provided an excellent, scalable framework to ensure continued provision of a relevant and accessible training resource for clinicians working in metropolitan and regional/rural health services. Learner-reported achievement of programme learning outcomes was not negatively impacted by online only delivery. Balancing these resource advantages with learner preferences and our desire to build active teaching networks, we will continue to host the majority of the programme online, while offering short face-to-face sessions within local contexts.