Simultaneous tectonic Descemet stripping endothelial keratoplasty and tectonic Bowman layer transplant for the management of corneal perforation

AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to tectonic penetrating keratoplasty(t-PKP).METHODS:Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included.The technique for DSEK was modified depending on individual requirements.The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture.Success was measured by the ability of this procedure to close a corneal perforation.RESULTS:All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period.Reinterventions were relatively common:2 cases required amniotic membrane transplant for persistent epithelial defects.One case required DSEK rebubbling.One case developed angle closure glaucoma requiring surgical peripheral iridectomy.CONCLUSION:Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.

Rising incidence,progression and changing patterns of liver disease in Wales 1999-2019

BACKGROUND Liver disease incidence and hence demand on hepatology services is increasing.AIM To describe trends in incidence and natural history of liver diseases in Wales to inform effective provision of hepatology services.METHODS The registry is populated by International Classification of Diseases-10(ICD-10)code diagnoses for residents derived from mortality data and inpatient/day case activity between 1999-2019.Pseudo-anonymised linkage of:(1)Causative diagnoses;(2)Cirrhosis;(3)Portal hypertension;(4)Decompensation;and(5)Liver cancer diagnoses enabled tracking liver disease progression.RESULTS The population of Wales in 2019 was 3.1 million.Between 1999 and 201973054 individuals were diagnosed with a hepatic disorder,including 18633 diagnosed with cirrhosis,10965 with liver decompensation and 2316 with hepatocellular carcinoma(HCC).Over 21 years the incidence of liver diseases increased 3.6 fold,predominantly driven by a 10 fold increase in non-alcoholic fatty liver disease(NAFLD);the leading cause of liver disease from 2014.The incidence of cirrhosis,decompensation,HCC,and allcause mortality tripled.Liver-related mortality doubled.Alcohol-related liver disease(ArLD),autoimmune liver disease and congestive hepatopathy were associated with the highest rates of decompensation and all-cause mortality.CONCLUSION A 10 fold increase in NAFLD incidence is driving a 3.6 fold increase in liver disease in Wales over 21 years.Liver-related morbidity and mortality rose more slowly reflecting the lower progression rate in NAFLD.Incidence of ArLD remained stable but was associated with the highest rates of liver-related and all-cause mortality.

Instrumental detection of cystic duct stones during laparoscopic cholecystectomy

Residual cystic duct stones (CDSs) after cholecystectomy have been recognized as a cause of post cholecystectomy pain. This study was undertaken to determine the incidence of CDSs during laparoscopic cholecystectomy(LC). A cohort of 330 consecutive patients (80 males and 250females) undergoing LC between November 2006 and May2010 was studied. Their age ranged between 16 and 88 years(median 50, IQR: 36.62). The data were prospectively collected of preoperative liver function tests, imaging, the presence of intraoperative CDSs, and common bile duct stones at on-table cholangiogram. CDSs were detected intraoperatively in 64 of the 330 patients (19%). Ultrasound failed to detect CDSs in any of these cases. Deranged liver function tests were noted in 73% of the patients with CDSs and in 57% without CDSs Common bile duct stones were detected in 9% (29) of the 330patients. CDSs occur commonly at routine cholecystectomy, and preoperative investigations are not helpful in their diagnosis As CDSs may lead to postoperative morbidity, they should be actively sought out during surgery if present.

钙泊三醇/二丙酸倍他米松软膏获得PASI 50和PASI 75的回顾性分析

Background: The US National Psoriasis Foundation recently recommended that PASI 50 and PASI 75 response rates be used in clinical trials to enable comparisons across studies of different psoriasis therapies. To date, these response rates have not been reported for the two-compound ointment containing calcipotriol and betamethasone dipropionate (Daivobet/Dovobet; LEO Pharma, Ballerup, Denmark). Further, in order to compare Daivobetwith other therapeutics recently presented to the European regulatory authorities and the FDA, comparison with the biologicals, efalizumab, etanercept and alefacept, were also made. Objectives: To present the PASI 50 and PASI 75 results for the two-compound ointment containing calcipotriol and betamethasone dipropionate. Methods: Data from six phase III studies conducted with the two-compound ointment were pooled and the PASI 50 and PASI 75 response rates calculated for patients with severe (PASI≥17) or less severe disease (PASI < 17) at treatment commencement. Results for the biological therapies, efalizumab, etanercept and alefacept, were obtained from relevant published phase III studies. Results: PASI 50 and PASI 75 were achieved by more patients treated with the two-compound ointment than with the individual components. In patients with severe disease, the PASI 50 response rate after 4 weeks’treatment was 88.8%with the two-compound ointment, 69.2%with betamethasone dipropionate, 53.8%with calcipotriol, and 30.0%with ointment vehicle. In comparison, 12 weeks’treatment with the biologicals resulted in PASI 50 response rates of 59%with efalizumab, 74%with etanercept, and 56%with alefacept. Conclusions: The two-compound ointment is effective, producing a PASI 50 and PASI 75 response in greater than 80%and 50%of patients, respectively, regardless of psoriasis severity.

Fibula pro-tibia vs standard locking plate fixation in an ankle fracture saw bone model

BACKGROUND Locking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure.Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation.With locking plates,the strength of this fixation construct can be further enhanced.There is lack of evidence currently on the merits of tibiapro-fibula augmented locking plate fixation of unstable ankle fractures.AIM To assess if there is increased strength to failure,in an ankle fracture saw bone model,with a fibula pro-tibia construct when compared with standard locking plate fixation.METHODS Ten osteoporotic saw bones with simulated supination external rotation injuries were used.Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct.The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis.All fixations were tested in axial external rotation to failure on an electromagnetic test frame(MTS 858 Mini-Bionix test machine,MTS Corp,Eden Praire,MN,United States).Torque at 30 degrees external rotation,failure torque,and external rotation angle at failure were compared between both groups and statistically analyzed.RESULTS The fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation(4.421±0.796 N/m vs 1.451±0.467 N/m;t-test P=0.000),as well as maximum torque at failure(5.079±0.694N/m vs 2.299±0.931 N/m;t-test P=0.001)compared to the standard locking plate construct.The fibula pro-tibia construct also had a lower external rotation angle at failure(54.7±14.5 vs 67.7±22.9).CONCLUSION The fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model.There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.

Analysis of pathomechanisms involved in side effects of menthol treatment in respiratory diseases

Menthol is frequently used in over the counter medications for common colds and coughs. It was formerly considered to be under the class of herbal medicine, but identification of menthol receptor (TRPM8) moved it from the class of herbal medicine to the molecular pharmacology. It has been documented that menthol reduces dyspnoea and nasal obstruction via stimulation of nasal cold or flow receptors. It has also antitussive and antiirritative effect. Menthol can also induce adverse reactions such as airway irritation, dyspnoea, chest tightness and potentially respiratory failure, mainly in children. The mechanisms responsible for adverse reactions of menthol are not known completely. The adverse reactions of menthol could be due to its effects on TRPA1 channel, relevant to airway irritation. Higher concentrations of menthol stimulate TRPA1 channel causing airway irritation. It also increases mucus production and at the same time reduces cilliary activity leading to mucus stagnation. As the adverse effects were reported mainly at the night it is supposed that suppressed cough reflex during sleep potentiated by menthol induced cough suppression might be responsible for lack of airway mucus clearing and obliteration of small airways. Adverse effects could also be due to consequences of reflexes induced by the menthol action on trigeminal afferents, like apnoea or bronchoconstriction. Menthol is effective in relieving respiratory symptoms, but cough and cold medications should be used with caution. Recommendations are low concentrations of menthol used locally (intranasal) and not combined with camphor or cineole, as they may have additive effects and should be avoided in children under 2 years. Further data are necessary to completely elucidate potential risks of over the counter menthol medication in children but based on the meta analysis of documented case reports, menthol can be used safely if its contraindications for use are followed as with any other over the counter medications.

Survival Rates Following Skeletal Metastases—A Twenty-Year Analysis

Introduction: The aims of this study were to establish an estimate of the prognosis and to identify the variables predictive of survival following the diagnosis of metastatic bone disease. Materials and Methods: Ninety-seven patients diagnosed with skeletal metastases confirmed by histological examination between 1991 and 2010 were selected. Data were retrospectively collected including age and sex, sites and histology of the primary tumour and skeletal metastases, presence of visceral metastases, pathological fracture, and the treatment received. Results: Ninety-three patients (95.9%) were deceased. The overall rate of survival was 47% at 6 months, 31% at one year and 10% at three years. Multivariate analysis confirmed the grade of malignancy, age and systemic therapy as independent predictors of survival. Discussion and Conclusion: The prognosis of patients with skeletal metastases should be estimated according to the site and histology of the primary tumour, grade of malignancy and age at the time of presentation.

造口周围变应性接触性皮炎:病例报道及文献综述

Allergic contact dermatitis (ACD) is a rare cause of peristomal skin problems. Only 23 cases have previously been reported in the literature. We report the case of a colostomy patient with a severe disabling blistering peristomal dermatitis. Patch testing to a British Contact Dermatitis Society standard series, medicaments and a plastics and glues series was negative. Patch testing to the patient’s own products gave a positive reaction (+) at D2 and D4 to Dansac. soft paste and Stomahesive. paste. Further patch testing to the components of Dansac. soft paste showed a positive (+) reaction at D2 and D4 to ester of polymethyl vinyl/maleic acid copolymer (Gantrez.-ES) only. Thisisthe first reported case of ACD due to Dansac.softpaste. ACD to Gantrez. has previously been reported but in different products. We also review the other previously reported cases of ACD causing peristomal dermatitis and stress the importance of patch testing in these cases, in particular to the patient’s own products, as avoidance of identified allergens can have a large impact on the quality of life.

在日常临床工作中使用一次性棱镜眼压计测量眼内压

Aim: To establish the reliability, efficacy, and safety of disposable prism tonometry and validate its routine use for screening as well as monitoring of glaucoma. Methodology: Intraocular pressure (IOP) of 400 eyes of 200 consecutive patients who attended the general ophthalmic clinic was checked with both the Goldmann applanation tonometer and a disposable tonometer prism by an experienced examiner after obtaining informed consent. The data were statistically analysed. Results: The mean difference in the IOP between the two types of prismswas 0.1 mmHg (SD ± 1 mmHg). Conclusion: Disposable prism tonometry provides a reliable, effective, and safe alternative to Goldmann reusable prism tonometry for routine screening as well asmonitoring of glaucoma with the advantages of eliminating the need for chemical disinfection and therefore eliminating the risk of crossinfection.

成人社区和医院获得性肺炎的诊断和管理：NICE指南概要

这是一系列BMJ基于现有的最好证据得出的新指南概要之一。他们尤其对临床实践提出了重要建议，特别是在不确定或存在争论的方面。社区获得性肺炎是一种常见的疾病，发病率相当高。在英国，医院住院患者中此病大约有20％的死亡率。因下呼吸道感染就诊于全科医生的成年人，大约有5％-12％诊断该病，并且22％～42％的患者最终住院0。既往指南的遵守情况一直欠佳，并且这种在实践中的变化会导致并不理想的结果。

妊娠与乳腺癌

妊娠期乳腺癌与非妊娠期乳腺癌的预后相似终止妊娠改麦乳腺癌预后的证据不足罹患乳腺癌后妊娠不影响治疗的结果乳腺癌治疗后与再次妊娠之间理想的时间同隔尚不清楚