Erythematous penile lesion

Previous efforts to diagnose the cause of this patient's rash had been unsuccessful. A biopsy confirmed our suspicions.

Salivary cortisol concentration changes after epidural steroid injection

BACKGROUND

Epidural steroid injections (ESI) are therapeutically useful for the treatment of herniated intervertebral discs and spinal stenosis. However, there is a lack of evidence-based data about the safety of steroids.

OBJECTIVES

The aim of this study was to determine the period of hypothalamus-pituitary-adrenal (HPA) axis suppression by salivary cortisol measurements after a single epidural injection of 40 mg of triamcinolone.

STUDY DESIGN

Clinical observational pilot study.

SETTING

Outpatient follow-up.

METHODS

In this study, 8 patients with lumbar intervertebral disc herniation or spinal stenosis were enrolled. All patients had received ESI (triamcinolone 40 mg) under C-arm guidance. Salivary cortisol concentrations were assessed between 8:00 am and 9:00 am; both before and after ESI (Day 0 [the day prior to injection], 1, 3, 5, 7, 14, 21, 28). Additionally, body weight, blood pressure, 0-10 numeric rating scale (NRS), and fasting blood sugar levels were evaluated.

RESULTS

HPA axis suppression was observed in all patients for 19.9 ± 6.8 days after ESI (salivary cortisol < 0.1 ug/mL). In total, 5 of 8 patients reached baseline salivary cortisol concentrations within the clinical trial period. The time taken to reach baseline concentrations after ESI was 19.4 ± 8.3 days. The period of HPA axis suppression was not correlated with baseline salivary cortisol concentrations, and NRS scores.

LIMITATIONS

Adrenal insufficiency cannot be confirmed by simple salivary cortisol measurements. Furthermore, the period studied was too short for all patients' HPA axis function to reach the baseline value. Finally, the study design does not allow for the confounding effects of pain and stress on cortisol levels.

CONCLUSIONS

HPA axis function was suppressed after ESI until Day 21 and returned to the normal range after 19.9 ± 6.8 days. Therefore, we suggest that the minimal interval between ESI treatments should be at least one month. In addition, we report that salivary cortisol measurements are very useful diagnostic predictors of HPA function.

Randomized controlled trial local injection for treatment of lateral epicondylitis, 5 and 10 mg triamcinolone compared

OBJECTIVE

To compare the efficacy and adverse effects between 5 and 10 mg triamcinolone local injection for treatment of the lateral epicondylitis. The primary outcome was the improvement of pain after 12 weeks of treatment. The secondary outcome was the adverse effects rate.

MATERIAL AND METHOD

One hundred and four patients with lateral epicondylitis were randomly allocated into 2 groups. Group A were injected with 5 mg triamcinolone and group B were injected with 10 mg triamcinolone at the maximum tenderness point at the lateral aspect of the elbow. All the patients were followed-up to 12 weeks. Patient satisfaction, pain score (VAS), degree of tenderness, pain on wrist extension against resistance, grip strength and adverse effects were recorded at 12 weeks after the injection.

RESULTS

Group A (n = 51) had excellent result 80.39%, good 11.76%, slightly improved 1.96% and not improved 5.88%. Group B (n = 53) had excellent result 73.58%, good 16.98%, slightly improved 3.77% and not improved 5.66%. The adverse effects rate were 9.8% in group A and 13.2% in group B. There were no statistically significant in terms of patient satisfaction, pain score, tenderness at lateral epicondyle, grip strength and adverse effect rate.

CONCLUSION

The use of 5 mg triamcinolone was comparable to 10 mg triamcinolone injected locally to treatment of lateral epicondylitis.

[Pathological changes after periocular injection of triamcinolone and hyaluronidase in guinea pigs]

OBJECTIVE

To analyze the pathological change after periocular injection of triamcinolone and hyaluronidase in guinea pigs.

METHODS

Twenty guinea pigs of clean grade were used in this study. The animals were randomly divided into 4 groups (n = 5 each). The right eye was used as intervention side, while the left eye was used as control side. Group A received periocular injection of saline water 0.2 mL at right eyes, Group B received periocular injection of triamcinolone 2 mg (0.2 mL), Group C received periocular injection of hyaluronidase 80 IU (0.2 mL), Group D received periocular injection of triamcinolone 2 mg (0.1 mL) + hyaluronidase 80 IU (0.1 mL). The injection was performed once a week for totally 4 times. One animal from each group was sacrificed at day 3, 7, 14, 28 and 35 after the first injection. The specimens of periocular tissue were obtained for microscopic examination and transmission electron microscopic examination to observe the pathological changes. The expressions of transforming growth factor-beta1 (TGF-beta1) in the granulomas were detected by immunohistochemistry stain method.

RESULTS

Compared with the control side, group A presented no obvious change. Group C presented looser intercellular space than the control group. Foreign-body granulomas was seen in 2nd-5th pathological section of group B and in the third and fifth pathological sections of group D. The size of the granulomas was smaller and the density of fibroblast was lower in group D than those in group B. The immunohistochemistry stain of TGF-beta1 showed strong positive reaction in group B, while weakly positive reaction in group D. The positive staining cells in group D were fewer than those in group B, and the difference was statistically significant (P < 0.05). Most of the fibroblasts in group B presented as pyknic type with oval nucleus, amounts of cytoplasm and cell organs under electron microscope. Comparatively, the fibroblasts in group C and D remain inactive with spindle nucleus, less cytoplasm and cell organs.

CONCLUSION

Repeated periocular injection of triamcinolone may cause the formation of foreign-body granulomas around the injection site, leading to fibrosis and adhesion at later period. The injection combined with hyaluronidase can enhance the diffusion and absorption of triamcinolone, relieving the possible fibrosis.

[Hemicrania continua: characteristics and therapeutic experience in a series of 36 patients]

INTRODUCTION

Hemicrania continua is characterised by a continuous unilateral pain, which frequently gets worse in association with autonomic symptoms. It is probably little known and underdiagnosed. Its diagnosis requires a response to indomethacin, which is not always well tolerated.

AIMS

We report a series of 36 cases of hemicrania continua that were treated in the headache service of a tertiary hospital. We analyse their demographic and clinical features and the therapeutic alternatives to indomethacin.

PATIENTS AND METHODS

Between January 2008 and April 2012, 36 patients (28 females, eight males) were diagnosed with hemicrania continua from among 1800 (2%) who were treated in that service.

RESULTS

The age of onset was 46.3 ± 18.4 years. In four patients (11.1%) there were pain remissions that lasted over three months. The baseline pain was chiefly oppressive or burning with an intensity of 5.2 ± 1.4 on the verbal analogue scale. Exacerbations lasted 32.3 ± 26.1 minutes, were of a predominantly stabbing nature with an intensity of 8.3 ± 1.4, and in 69.4% of cases were accompanied by autonomic symptoms. Altogether 16.7% of the patients did not tolerate indomethacin beyond an indotest and 50% did so with side effects. In 13 cases at least one anaesthetic blockade was performed in the supraorbital or the greater occipital nerve or a trochlear injection of corticoids was carried out with a full response in 53.8% and a partial response in 38.5%.

CONCLUSIONS

Hemicrania continua is not an infrequent diagnosis in a headache clinic and, because it is a treatable condition, further knowledge on the subject is needed. Anaesthetic blockades of the supraorbital or greater occipital nerves or a trochlear injection of corticoids are the therapeutic options that must be taken into consideration when indomethacin is not well tolerated.

Image-guided versus blind glucocorticoid injection for shoulder pain

BACKGROUND

Traditionally, glucocorticoid injection for the treatment of shoulder pain has been performed guided by anatomical landmarks alone. With the advent of readily available imaging tools such as ultrasound, image-guided injections have increasingly become accepted into routine care. While there is some evidence that the use of imaging improves accuracy, it is unclear from current evidence whether or not it improves patient-relevant outcomes.

OBJECTIVES

The aim of this review was to assess whether image-guided glucocorticoid injections improve patient-relevant outcomes compared to landmark-guided or systemic intramuscular injections in patients with shoulder pain.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, via The Cochrane Library), MEDLINE (Ovid), and EMBASE (Ovid) to June 2011. We also searched the World Health Organisation International Clinical Trials Registry Platform (http://www.who.int/trialsearch/Default.aspx) to identify ongoing trials and screened reference lists of retrieved review articles and trials to identify potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised controlled clinical trials that compared image-guided glucocorticoid injection to landmark-guided or systemic intramuscular injection. Outcomes of interest included pain, function, range of motion, proportion of participants with overall improvement and adverse events. There were no restrictions on language or date of publication.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies for inclusion, extracted the data and performed a risk of bias assessment. Disagreement about inclusion or exclusion of individual studies and risk of bias was resolved by a third review author.

MAIN RESULTS

Five studies (290 participants) were included in the review. The image-guided groups in all trials used ultrasound to guide injection. Four studies included participants with rotator cuff disease; in three the comparator was local landmarks to direct injection into the subacromial bursa and in the fourth the comparator was systemic intramuscular injection into the upper gluteal muscles in the buttock region. One study included participants with adhesive capsulitis and injection was directed into the glenohumeral joint by either ultrasound or anatomical landmark guidance.No significant differences between groups were observed with respect to reduction in pain at one to two weeks (two trials, 146 participants, standardized mean difference (SMD) -1.44, 95% CI -4.14 to 1.26), or function at one to two weeks (two trials, 146 participants, SMD 0.95, 95% confidence interval (CI) -1.29 to 3.20; back-translated to mean difference (MD) 4 points, 95% CI -5 to 13, on a 0 to 100 point scale, higher score means better function) or six weeks (three trials, 207 participants, SMD 0.63, 95% CI -0.06 to 1.33; back-translated to MD -3 points, 95% CI -11 to 5, on a 0 to 100 point scale) and the sensitivity analyses did not alter these results. While there was a significant difference between groups with respect to reduction in pain at six weeks favouring image guidance (three trials, 207 participants, SMD -0.80, 95% CI -1.46 to -0.14), there was considerable statistical heterogeneity and after removing trials with inadequate allocation concealment and inadequate blinding in a sensitivity analysis, the difference was no longer significant (one trial, 106 participants, MD -0.60 points, 95% CI -1.44 to 0.24 points on a 9-point scale).No statistical difference in adverse events between groups was identified (10/104 image-guided group versus 16/103 comparator; risk ratio (RR) 0.55, 95% CI 0.17 to 1.85). Minor adverse events reported included transient post-injection pain, facial redness and warmth.

AUTHORS' CONCLUSIONS

Based upon moderate evidence from five trials, our review was unable to establish any advantage in terms of pain, function, shoulder range of motion or safety, of ultrasound-guided glucocorticoid injection for shoulder disorders over either landmark-guided or intramuscular injection. The lack of any added benefit of ultrasound guided subacromial bursal injection over glucocorticoid injection administered into the upper gluteal muscles of the buttock suggests that the benefits of glucocorticoid may arise through systemic rather than local effects. Therefore, although ultrasound guidance may improve the accuracy of injection to the putative site of pathology in the shoulder, it is not clear that this improves its efficacy to justify the significant added cost.

Corticosteroid use for diabetic macular edema: old fad or new trend?

Diabetic retinopathy is the leading cause of blindness in working age individuals in developed countries. Most cases of diabetes related vision loss result from breakdown of the blood-retinal barrier with resultant diabetic macular edema (DME). For over 30 years, laser photocoagulation has been the standard therapy for DME, but most eyes do not experience significant improvements in visual acuity. Intravitreal injections of drugs that inhibit the action of vascular endothelial growth factor (VEGF) lead to gains in vision, but can be expensive and need to be repeated frequently. In addition to VEGF-mediated breakdown of the blood-retinal barrier, recent evidence suggests that inflammation plays an important role in the development of DME. Recognizing this, physicians have injected steroids into the vitreous and developers have created sustained release implants. Intravitreal injections of triamcinolone acetonide lead to rapid resolution of macular edema and significant short-term improvements in visual acuity, but unfortunately, visual acuities diminish when treatment is continued through 2 years. However, intravitreal triamcinolone remains an attractive treatment option for eyes that are pseudophakic, scheduled to undergo cataract surgery, resistant to laser photocoagulation, or require urgent panretinal photocoagulation for proliferative retinopathy. In controlled trials, intraocular implants that slowly release dexamethasone and fluocinolone show promise in reducing macular edema and improving visual acuity. The high incidences of drug related cataracts and glaucoma, however, require that corticosteroids be used cautiously and that patients be selected carefully. The increasing number of patients with DME, the burgeoning cost of medical care and the continuing development of intravitreal steroids suggest that the use of these agents will likely increase in coming years.

Changes in bone mineral density in postmenopausal women treated with epidural steroid injections for lower back pain

BACKGROUND

Therapy with corticosteroids often results in bone loss and corticosteroid-induced osteoporosis. In previous studies, bone mineral density (BMD) has been examined after administration of relatively high oral doses of corticosteroids. However, practitioners use comparatively lower doses of corticosteroids for epidural steroid injections (ESI). The interactions and relationships between BMD and ESI remain to be determined.

OBJECTIVE

The aim of this study was to explore the relationship between BMD and ESI in postmenopausal women treated for lower back pain.

STUDY DESIGN

This study was a retrospective evaluation.

METHODS

We reviewed the medical records of postmenopausal women with lower back pain who were treated with or without ESI. BMD was measured before treatment and one year after treatment in the lumbar spine, femoral neck, and total femur. A total of 90 postmenopausal women were divided into 2 groups. Group 1 patients received medications without ESI; Group 2 patients received ESI more than 4 times, with a cumulative administered triamcinolone dose of > 120 mg.

RESULTS

Decreased BMD was observed in patients treated with ESI. However, no significant difference was observed between or within the groups in terms of mean percentage change from baseline BMD.

LIMITATIONS

First, this study is limited by the fact that it was retrospective. Second, our study did not consider the use of ESI with high-dose corticosteroids. Third, our study did not include any long-term assessments of the effects of ESI on BMD.

CONCLUSIONS

These data suggest that ESI using triamcinolone (over 200 mg) for a period of one year will have a negative effect on BMD in postmenopausal women treated for lower back pain. However, ESI therapy using a maximum cumulative triamcinolone dose of 200 mg in one year would be a safe treatment method with no significant impact on BMD.

Effects of epidural TNF-α inhibitor injection: analysis of the pathological changes in a rat model of chronic compression of the dorsal root ganglion

OBJECTIVES

To evaluate the efficacy of a single direct epidural injection of tumor necrosis factor (TNF)-α inhibitor to reduce the pathological changes in nerve fiber injuries in a rat model of chronic compression of the dorsal root ganglion (CCD).

MATERIALS AND METHODS

A surgical procedure for CCD was performed in 17 adult male F-344 rats. The effects of the epidural TNF-α inhibitors on CCD-induced pathological changes were investigated. Three groups of rats (n = 17) were used: (1) CCD + saline (n = 4), (2) CCD + triamcinolone (n = 5), and (3) CCD + TNF-α inhibitors (n = 8). Their dorsal root ganglia and nerve roots were removed on postoperative day 14. The intraneural edema, demyelination, and Wallerian degeneration of all 17 rats were scored pathologically.

RESULTS

The pathology scores of the rats in the TNF-α inhibitor treatment group (1.38 ± 0.74) indicated a mild degree of intraneural edema compared to the saline treatment group (2.25 ± 0.50, p = 0.041). In addition, rats in the TNF-α inhibitor treatment group (2.13 ± 0.35) had a mild degree of demyelination compared to the saline treatment group (2.75 ± 0.50, p = 0.038) and the triamcinolone treatment group (2.80 ± 0.45, p = 0.019). The differences in the pathology scores for Wallerian degeneration were not statistically significant in all three study groups (p = 0.658).

CONCLUSION

The epidural injection of a TNF-α inhibitor was more effective than a placebo and comparable to triamcinolone in reducing pathological nerve injury progression.

Frontal fibrosing alopecia: a review of 60 cases

BACKGROUND

Frontal fibrosing alopecia (FFA) is a variant of lichen planopilaris primarily affecting postmenopausal women, with a predilection for the frontotemporal hairline.

OBJECTIVES

We sought to examine possible causal associations and review the clinical features, natural history, and response to treatment of patients with FFA attending a specialist hair clinic.

METHODS

This was a case note review of 60 patients with FFA.

RESULTS

The number of patients with FFA seen has increased over the last decade. All were Caucasian women, with significantly above-average affluence scores and were less likely to be smokers. The mean age at presentation was 64 years and average disease duration was 3.4 years (range: 6 months-30 years). Three patients were premenopausal. All patients had frontotemporal involvement, with follicular hyperkeratosis, scarring, and variable perifollicular erythema. Several patients had more unusual patterns: 8 had extensive parietal involvement, 4 had occipital involvement, 1 had asymmetric frontal involvement, and 5 had typical FFA associated with diffuse scalp lichen planopilaris. Eyebrow loss was documented in 73%, eyelash loss in 3%, and body hair loss in 25%. Almost all patients had been treated with superpotent topical steroids. Other treatments included topical calcineurin inhibitors; intralesional triamcinolone acetate; phototherapy; hydroxychloroquine; lymecycline; and prednisolone. Although some treatments may reduce inflammation, their efficacy in controlling the progress of the alopecia was uncertain.

LIMITATIONS

This is a retrospective review.

CONCLUSIONS

FFA is a clinically distinctive condition, the prevalence of which appears to be increasing. It has a generally poor response to treatment. The origin remains uncertain.

Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update

BACKGROUND

Over 45 million Americans suffer from recurrent headaches, and an estimated $11.9 million was spent on doctor's visits for rhinogenic pain last year. Sphenopalatine blocks have been described for various facial pain syndromes, but their use and the type of blockade agents remain controversial. The objective of this study was to demonstrate that endoscopic nerve blocks, using a mixture of bupivicaine and triamcinolone-40, injected into the anterior ethmoid or sphenopalatine regions, can be a relative safe and effective option for refractory pain.

METHODS

The charts of all patients undergoing endoscopic neural blockade, in a private practice setting from 1998 to 2008 were retrospectively reviewed. A 1:1 mixture of 0.5% bupivicaine and triamcinolone acetonide injectable suspension was injected into the patients' anterior ethmoid or sphenopalatine neural distribution, or both, depending on the pain distribution. Charts were reviewed to assess outcomes and any adverse events from nerve blocks.

RESULTS

A total of 882 nerve blocks were administered to 147 patients, over the course of 431 office visits. Four mild complications, 2 moderate complications, and no severe or permanent complications were noted. No permanent visual complications were observed. Of all the charts, 85% had documented effects of the nerve block at follow-up. Of those, 81.3% claimed improvement, 17.9% reported feeling the same, and 0.79% stated they had worse pain.

CONCLUSION

Endoscopic neural blockade appears to be a relatively safe and viable option in the treatment of refractory headache and facial pain with a rhinogenic component.

Sonographically guided percutaneous intralesional triamcinolone injection: a new treatment for mammillary fistulas: preliminary results

We describe a new procedure, sonographically guided intralesional triamcinolone injection, for the treatment of mammillary fistulas. Six patients with mammillary fistulas were enrolled in this prospective study. Clinical improvement was rapid after the first triamcinolone injection. The initial response to treatment was assessed as complete in 4 cases, and the remaining 2 cases resolved successfully with additional injections. On the basis of the excellent results obtained in this study, it is thought that intralesional triamcinolone injection may be a good alternative to surgery.

Tennis elbow: role of local steroid injection

BACKGROUND

Tennis elbow is a condition, characterised by pain and tenderness over the lateral epicondyle of the humerus, and pain on resisted dorsiflexion of the wrist, middle finger, or both. The aim of this randomised controlled trial was to investigate the short term efficacy of local steroid injection compared with oral and topical NSAIDs.

METHODS

Sixty patients (45 male and 15 female) were included in the study. The mean age was 42 years for men and 40 years for women. They were placed in group A and B (30 cases each). Group A received local steroid injection (triamcinolone 20 mg mixed with lignocaine 2% 1 cc) and topical NSAID cream application (diclofenac diethylammonium) twice a day, tab. diclofenac sodium 50 mg twice a day for 3 weeks. Group B received tab diclofenac 50 mg twice a day and, topical NSAID cream application twice a day for 3 weeks. Assessment of patients was made 3 times; first at the start of the study, 2nd time after 6 weeks, and 3rd time after 12 weeks. A blinded assessor rated the elbow complaints of the patients at resisted dorsiflexion of wrist using VAS (0 = no severity, 1-3 mild, 4-6 moderate, 7-9 sever, 10 = maximum severity).

RESULTS

At six weeks, 22 (73.33%) patient in group A had no pain as compared to 7 (23.33%) patients in group B who were pain free (p < 0.0001, chi2 = 38.75). At 12 weeks 27 (90%) patients in group A were pain free compared to group B in which 7 (23.33%) patients were pain free (p < 0.0001, chi2 = 27.56).

CONCLUSION

In patients with tennis elbow, the use of local steroid injection in combination with topical and oral NSAIDs is superior to the use of combination of topical and oral NSAIDs. Better results with combination therapy using local steroid injection may be limited to the short term.

Comparison of topical triamcinolone and oral atorvastatin in treatment of paederus dermatitis Northern Iran

Dermatitis caused by stimulation of beetle paederus, is a common health problem in Northern and some southern parts of Iran. Since by now, traditional medicine and some corticosteroid agents have been used for treatment of dermatitis caused by beetle paederus. Because, there are few researches about classical treatment of the disease at academic level, this study planned to compare the effectiveness of triamcinolone ointment and atorvastatin tablet with placebo in treatment ofpaederus dermatitis in Northern Iran. A randomized double-blind clinical trial was carried out on 30 patients referred to the hospital and clinics at Sari and Neka countries in Northern Iran during 6 months. Patients were randomly divided into two therapeutic equal groups. The first group was triamcinolone ointment twice a day and a placebo atorvastatin tablet daily. The second group was oral atorvastatin one tablet (20 mg) daily and a placebo triamcinolone ointment twice a day. In Seventh day of visits, therapeutic response of the patients in triamcinolone and atorvastatin group were 93.33 and 80%, respectively. No significant differences were found in therapeutic outcome between the two groups (p > 0.05). The results showed both oftriamcinolone ointment and oral atorvastatin had similar effect on paederus dermatitis. Because the paederus dermatitis is a self-limited disease use of topical therapy for treatment of the disease is recommend.

Paraspinal abscess complicated by endocarditis following a facet joint injection⋆

Infectious complications secondary to lumbar facet injections are exceedingly rare, follow an indolent course, and local sequelae include abscess spread or infections of the central nervous system. We present the case of the development of a facet abscess and infective endocarditis, which developed shortly after a lumbar facet injection. With the increase in interventional pain procedures, physicians must be aware of potential infectious complications.

Progression of cataracts following photodynamic therapy combined with intravitreous triamcinolone injection in cases of age-related macular degeneration

BACKGROUND

To present long-term data on the progression of cataracts following photodynamic therapy (PDT) combined with 4 mg intravitreal triamcinolone acetonide (IVTA) for age-related macular degeneration (AMD).

METHODS

Fifty-seven phakic eyes of 56 patients underwent the treatment between October 2004 and November 2006. The follow-up period ranged from 12 to 38 months with 3 months interval of observation and repeated treatment at recurrence.

RESULTS

Cataract progression was noted in 40 eyes 5-21 months after treatment, consisting of 4 eyes between 3 and < 6 months after treatment, 22 eyes between 6 and < 12 months, 8 eyes between 12 and < 18 months, and 6 eyes between 18 and < 24 months. The percentage of the eyes with cataract progression began to decrease 5 months after treatment and, occurred most frequently during the period from 6 months to 12 months after treatment. There was no significant difference in age, follow-up period, or the frequency of the treatment between the cataract progression group and the non progression group. Twenty four eyes underwent surgery 10-31 months after treatment, showing significant improvement in visual acuity.

CONCLUSIONS

This study showed high incidence of cataract during a long-term follow-up after PDT combined with IVTA and significant reduction of visual acuity due to cataract.

Intravitreal triamcinolone versus laser photocoagulation as a primary treatment for diabetic macular oedema--a comparative pilot study

BACKGROUND

Diabetic macular oedema is the leading causes of blindness. Laser photocoagulation reduces the risk of visual loss. However recurrences are common and despite laser treatment, patients with diabetic macular oedema experienced progressive loss of vision. Stabilization of the blood retinal barrier introduces a rationale for intravitreal triamcinolone treatment in diabetic macular oedema. This study is intended to compare the best corrected visual acuity (BCVA) and the macular oedema index (MEI) at 3 month of primary treatment for diabetic macular oedema between intravitreal triamcinolone acetonide (IVTA) and laser photocoagulation.

METHODS

This comparative pilot study consists of 40 diabetic patients with diabetic macular oedema. The patients were randomized into two groups using envelope technique sampling procedure. Treatment for diabetic macular oedema was based on the printed envelope technique selected for every patient. Twenty patients were assigned for IVTA group (one injection of IVTA) and another 20 patients for LASER group (one laser session). Main outcome measures were mean BCVA and mean MEI at three months post treatment. The MEI was quantified using Heidelberg Retinal Tomography II.

RESULTS

The mean difference for BCVA at baseline [IVTA: 0.935 (0.223), LASER: 0.795 (0.315)] and at three months post treatment [IVTA: 0.405 (0.224), LASER: 0.525 (0.289)] between IVTA and LASER group was not statistically significant (p = 0.113 and p = 0.151 respectively). The mean difference for MEI at baseline [IVTA: 2.539 (0.914), LASER: 2.139 (0.577)] and at three months post treatment [IVTA: 1.753 (0.614), LASER: 1.711 (0.472)] between IVTA and LASER group was also not statistically significant (p = 0.106 and p = 0.811 respectively).

CONCLUSIONS

IVTA demonstrates good outcome comparable to laser photocoagulation as a primary treatment for diabetic macular oedema at three months post treatment.

TRIAL REGISTRATION

ISRCTN05040192 (http://www.controlled-trial.com).

[A case of anstomotic stricture after esophagectomy sufficiently treated by endoscopic triamcinolone injection therapy]

We report a case of 50-year-old man with refractory anastomotic stricture after esophagectomy, which was successfully treated with endoscopic triamcinolone injection therapy. He received a curative operation for advanced thoratic esophageal carcinoma (Mt, Type 3, cT3, cN1, MO, Stage III). Anastomotic leakage was occurred as post-operative adverse event, which recovered conservatively, and subsequently resulted in refractory anastomotic stricture. He had a recurrence of dysphagia despite of repeated bougienage and endoscopic balloon dilatation. Four years later, he received an intralesional triamcinolone injection in anastomotic stricture every four weeks. According to the 5 courses of treatment, anastomotic stricture was cured and there was no recurrence confirmed. Intralesional triamcinolone injection may be one of the promising options for the treatment of refractory anastomotic stricture after esophagectomy.

Cheilitis granulomatosa

Melkersson-Rosenthal Syndrome (MRS) is a rare syndrome that is characterized by a triad of facial paralysis, chronic edema of the lip, and a fissured tongue. Most commonly, one element of the triad precedes the development of the other symptoms. We present a case of cheilitis granulomatosa (CG) as a manifestation of incomplete MRS. As the etiology remains unknown, treatment of CG is challenging. Intralesional glucocorticoids remain the first-line treatment, but recurrences are common. We discuss alternative treatment strategies that include combination therapy with other anti-inflammatory agents and biologics, such as infliximab.

Intravitreal Bevacizumab with or without triamcinolone for refractory diabetic macular oedema

We evaluate the effect of intravitreal injections of Bevacizumab (IVB) alone or combined with triamcinolone (IVT) in the first injection for treatment of refractory diabetic macular oedema (DME). Sixty eyes of sixty patients with refractory DME were included. Half of them received injections of IVB (1.25 mg/0.05 ml) or combined IVB and IVT (1.25 mg/0.05 ml and 2 mg/0.05 ml respectively). The primary outcome measure was change in central macular thickness (CMT). Secondary outcome measures were change in best-corrected logMAR visual acuity (BCVA) and incidence of potential adverse events. Central macular thickness was reduced significantly in both the IVB and IVB/IVT groups. At week 24, CMT change compared to the baseline was -93.7 microm (95% CI, -172.2 to -19.26) in the IVB group and -93.1 microm (95% CI, -154.4 to -29.7) in the IVB/IVT group. There was not a significant difference between the IVB and the IVB/IVT groups. Improvement of BCVA was initiated at weeks 6 and 12 in the IVB/IVT and IVB groups respectively. Anterior chamber reaction was noticed in six (20%) and six (20%) eyes respectively in the IVB and IVB/IVT groups the day after injection, and it resolved with no sequel. Elevation of intraocular pressure (IOP) occurred in two eyes (6%) in the IVB/IVT group. Intravitreal injections of Bevacizumab had a beneficial effect on refractory DME in terms of CMT reduction and BCVA improvement. Addition of triamcinolone in the injection seemed to induce earlier visual improvement; however, it did not show any significant additive effect later during follow-up.