A ten-year comparison of treatment and outcomes of cancer-associated thrombosis to non-cancer venous thromboembolism: from traditional anticoagulants to direct oral anticoagulants

DOACs have emerged as first-line treatment in most cancer-associated thrombosis (CAT), representing a paradigm shift in its management. However, CAT management remains challenging and requires careful risk-benefit considerations. A retrospective analysis of CAT presentations to a tertiary referral centre from January 2011 to December 2020. Outcomes in CAT patients were compared to VTE patients without malignancy. Subgroup analysis was also conducted for CAT according to anticoagulation type. 514 CAT cases from 491 patients were identified from 3230 total VTE cases. CAT patients had higher rates of major VTE (PE and/or proximal DVT) compared to patients without malignancy (78.4% vs. 66.8%, p < 0.001). CAT patients also had higher rates of VTE recurrence (HR 1.66, 95%CI 1.23-2.26), major bleeding (HR 3.41, 95%CI 2.36-4.93), VTE-related mortality (HR 2.59, 95%CI 1.46-4.62) and bleeding-related mortality (HR 2.66, 95%CI 1.05-6.73). There were no significant differences in rates of VTE recurrence, major bleeding, VTE-related mortality or fatal bleeding between CAT patients treated with DOACs, enoxaparin or warfarin. In the subgroup of CAT treated with DOACs, there was no significant difference in rates of GI bleeding compared to the enoxaparin subgroup (HR 0.17, 95%CI 0.02-1.26). CAT was associated with a larger clot burden and higher rates of VTE recurrence, major bleeding and mortality compared to VTE patients without malignancy in this large real-world study. This study demonstrated no significant differences in complication rates for CAT patients treated with DOACs over enoxaparin, suggesting that DOACs can be safely used in most cases of CAT.

Isolated Ocular Relapse of Acute Myeloid Leukaemia Post Allogeneic Stem Cell Transplant

We present a rare case of a 39-year-old female with extramedullary relapse of acute myeloid leukaemia (AML) isolated to the left eye 2 months post allogeneic haematopoietic stem cell transplant. She initially presented with painless left eye erythema, swelling, and visual impairment. Initial ophthalmology review revealed conjunctival chemosis, raised intraocular pressure, and serous retinal detachments. She was initially treated for suspected orbital cellulitis with intravenous antibiotic and antifungal therapy but clinically progressed so was then treated with intravenous corticosteroids. One week later, she progressed to angle-closure glaucoma with development of a hypopyon and an enlarging subconjunctival mass. She proceeded to urgent subconjunctival biopsy and drainage of subretinal fluid which confirmed extramedullary relapse of AML. Notably, further investigation found no evidence of bone marrow or central nervous system relapse. She proceeded to localized radiotherapy with gradual resolution of the subconjunctival mass and serous retinal detachment and was for consideration of donor lymphocyte infusions and azacitidine therapy; unfortunately, she developed respiratory sepsis and passed away despite maximal efforts. This case represents a rare and unusual presentation of isolated ocular extramedullary relapse of AML and emphasises the importance of early ophthalmology involvement and tissue biopsy when there is high clinical suspicion of the disease.

A ten-year review of the impact of the transition from warfarin to direct oral anticoagulant - Has venous thromboembolism treatment become safer?

BACKGROUND

The introduction of direct oral anticoagulants (DOAC) has resulted in a paradigm shift in the management of venous thromboembolism (VTE). We evaluate the impact of the transition to DOAC, over the last decade, on overall VTE clinical outcomes including in first unprovoked major VTEs.

METHOD

A retrospective analysis of all VTE admissions in non-cancer patients from January 2011 to December 2020 at Northern Health, Victoria, Australia. "Warfarin era" included events that occurred between January 2011 and December 2014 and "DOAC era" from January 2016.

RESULTS

There were 2687 cases involving 2508 patients (45.9 % males; median age 63 years). 98 % were symptomatic and 1261 events (47 %) were unprovoked. 1003 events occurred during the warfarin era (79 % warfarin, 6 % DOAC) and 1479 during the DOAC era (18 % warfarin, 70 % DOAC). While recurrent thrombosis during the acute phase of treatment was comparable, there were fewer recurrences during the long-term preventative phase of treatment in the DOAC era compared to warfarin era (HR 0.602, 95 % CI: 0.393-0.924, p0.020). Clinically significant bleeding events were lower in the DOAC era (HR 0.623, 95 % CI: 0.395-0.985, p = 0.043). A subanalysis of first unprovoked major VTE events (n = 602) demonstrated a significant reduction in recurrent VTE during the long-term preventative phase of treatment in the DOAC era (HR 0.296, 95 % CI: 0.097-0.901, p = 0.032) with no difference in clinically significantly bleeding rates (HR 0.529, 95 % CI 0.219-1.280, p = 0.158) between the eras.

CONCLUSION

Treatment outcomes for VTE appear to have improved over time with reduced rate of thrombotic and clinically significant bleeding complications in the DOAC era.

A Thermodynamic Model for Interpreting Tryptophan Excitation-Energy-Dependent Fluorescence Spectra Provides Insight Into Protein Conformational Sampling and Stability

It is now over 30 years since Demchenko and Ladokhin first posited the potential of the tryptophan red edge excitation shift (REES) effect to capture information on protein molecular dynamics. While there have been many key efforts in the intervening years, a biophysical thermodynamic model to quantify the relationship between the REES effect and protein flexibility has been lacking. Without such a model the full potential of the REES effect cannot be realized. Here, we present a thermodynamic model of the tryptophan REES effect that captures information on protein conformational flexibility, even with proteins containing multiple tryptophan residues. Our study incorporates exemplars at every scale, from tryptophan in solution, single tryptophan peptides, to multitryptophan proteins, with examples including a structurally disordered peptide, de novo designed enzyme, human regulatory protein, therapeutic monoclonal antibodies in active commercial development, and a mesophilic and hyperthermophilic enzyme. Combined, our model and data suggest a route forward for the experimental measurement of the protein REES effect and point to the potential for integrating biomolecular simulation with experimental data to yield novel insights.

Global coagulation assays in patients with diabetes mellitus

BACKGROUND

There is significant heterogeneity in the incidence and severity of diabetes-associated vascular complications and there is no routine biomarker that accurately predicts these outcomes. This pilot study investigates the role of global coagulation assays in patients with diabetes mellitus.

METHODS

In this cross-sectional study, patients with diabetes not on anticoagulation or dialysis and without active malignancy were recruited from endocrinology clinics. Blood samples were collected for global coagulation assays including thromboelastography (TEG), thrombin generation using calibrated automated thrombogram (CAT), and fibrin generation and fibrinolysis using the overall hemostatic potential (OHP) assay. The results were compared with healthy controls.

RESULTS

A total of 147 adult patients including 19 with type 1 diabetes (T1DM), 120 with type 2 diabetes (T2DM), and eight with latent autoimmune diabetes were recruited. Compared with 153 healthy controls, patients with diabetes demonstrated higher maximum amplitude (68.6 vs 60.2 mm, p < 0.001) on TEG, and higher OHP (9.3 vs 6.4, p < 0.001) with comparable CAT parameters. Patients with T2DM were more hypercoagulable than those with T1DM on most biomarkers. Higher maximum amplitude, velocity index, and OHP were associated with increased risk of complications (C-stat 0.82). Patients with history of microvascular complications appear to have more hypercoagulable thrombin and fibrin generation than those without.

CONCLUSION

Patients with diabetes have more hypercoagulable profiles on global coagulation assays, particularly patients with T2DM and those with microvascular complications. Further studies with longitudinal follow-up are ongoing to evaluate the utility of global coagulation assays in predicting long-term patient outcomes.

OP0010 EFFECTIVENESS OF THE MAKING IT WORK™ PROGRAM AT IMPROVING PRESENTEEISM AND WORK CESSATION IN WORKERS WITH INFLAMMATORY ARTHRITIS – RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Background:

Arthritis often leads to presenteeism (decreased at-work productivity), missed days from work and permanent work disability, leading to reduced quality of life and high costs to individuals and society. Yet, health services addressing the employment needs of people with arthritis are lacking.

Objectives:

We evaluated the effectiveness of the Making-it-WorkTM(MiW) program, an online self-management program developed to help people with inflammatory arthritis (IA) deal with employment issues.

Methods:

A multi-center RCT evaluated the effectiveness of MiW at improving presenteeism and preventing work cessation (WC) over two years. Participants were recruited from rheumatologist practices, consumer organizations and arthritis programs, in three Canadian provinces. Eligibility criteria: diagnosis of IA, employed, age 18-59, and concerned about ability to work. Participants were randomized 1:1 to MiW or usual care plus printed material on workplace tips. MiW consists of five online self-learning modules and group meetings, and individual vocational counselling and ergonomic consultations. Questionnaires were administered every 6 months. Outcomes were presenteeism [Rheumatoid Arthritis Work Instability Scale (RA-WIS)], time to WC ≥ 6 months, and time to WC ≥ 2 months (secondary outcome). Baseline characteristics (age, gender, ethnicity, occupation, education, disease duration and self-employment) were collected. Intention-to-treat (ITT) longitudinal analysis of RA-WIS using linear mixed effect regression models with 2-year comparison as primary endpoint and survival analysis for time to WC using Kaplan-Meier and Cox Proportional Hazard models were performed. Robustness analyses were conducted by using various missing values imputation methods like last observation carried forward, imputation using worse possible outcomes and model-based multiple imputations; using square root transformation of RA-WIS outcome; and adjusting for baseline covariates. SAS version 9.4 was used.

Results:

A total of 564 participants were recruited, with 478 (84.75%) completing 2-year follow-up. Baseline characteristics were similar between groups. Mean RA-WIS scores were significantly lower in the intervention group from 6 months onwards, with the greatest difference observed at 2 years (-1.78, 95%CI: -2.7, -0.9, p < .0001), yielding a standardized effect size of 32%. Satisfactory robustness was observed. Work cessation occurred less often in intervention than control groups, but only reached statistical significance for WC ≥ 2 months (WC ≥ 6 months: 31 versus 44 events, aHR 0.70, 95%CI: 0.44, 1.11, p = 0.13; WC ≥ 2 months: 39 versus 61 events, aHR: 0.65, 95%CI: 0.43, 0.98, p = 0.04).

Conclusion:

Results of the RCT reveal the program was effective at improving presenteeism and preventing short-term WC. Effectiveness at preventing long-term work disability will be assessed at 5 years. This program fills one of the most important and costly unmet needs for people with inflammatory arthritis.

References:

[1]Carruthers EC, Rogers P, Backman CL, et al. “Employment and arthritis: making it work” a randomized controlled trial evaluating an online program to help people with inflammatory arthritis maintain employment (study protocol).BMC Med Inform Decis Mak. 2014;14:59. Published 2014 Jul 21. doi:10.1186/1472-6947-14-59

Disclosure of Interests:

Andre Luquini: None declared, Yufei Zheng: None declared, Hui Xie: None declared, Catherine Backman: None declared, Pamela Rogers: None declared, Alex Kwok: None declared, Astrid Knight: None declared, Monique Gignac: None declared, Dianne Mosher: None declared, Linda Li: None declared, John Esdaile: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Speakers bureau: Medexus/Medac, Diane Lacaille: None declared

A pilot evaluation of Arthritis Self-Management Program by lay leaders in patients with chronic inflammatory arthritis in Hong Kong

The objectives of this paper are to evaluate the efficacy of a community-based lay-led Arthritis Self-Management Program (ASMP) among patients with chronic inflammatory arthritis and evaluate the effectiveness of "shared care collaboration" between hospital and community. We trained 17 lay leaders and recruited patients with chronic inflammatory arthritis via a new shared-care model between hospital rheumatology centers and community organizations. Participants were allocated to interventional group or a wait list control group. Evaluations were completed before, after (6 weeks), and 3 months after ASMP. We performed analysis of covariance with adjustment with age, sex, marital status, education, employment, duration of illness, and disability at baseline. A total of 65 participants and 32 controls completed the study. The mean (SD) age and duration of illness were 52.0 (11.4) and 5.6 (7.3) years, 90.7 % were female, 80.4 % had rheumatoid arthritis; 25.8, 53.6, and 12.4 % referrals were from hospitals, community organizations, and patient self-help groups, respectively. The interventional group had significantly less pain (p = 0.049 at 6 weeks), used more cognitive coping methods (p = 0.008 at 6 weeks, p = 0.041 at 3 months) and practiced more aerobic exercise (p = 0.049 at 6 weeks, p = 0.008 at 3 months) after adjustment of covariance. The interventional group had a trend of improvement in self-efficacy, fatigue, self-rated health, and health distress. A community-based lay-led ASMP showed positive beneficial effects on participants with chronic inflammatory arthritis. Shared-care collaboration between hospitals, community organizations, and patient self-help groups was demonstrated.

Is benchmarking possible in audit of early outcomes after operations for head and neck cancer?

There is a need for a validated means of adjusting for case mix in morbidity audits of patients with cancer of the head and neck. To address this, we did a multicentre audit of 3 U.K. NHS cancer networks that treat patients with head and neck cancer, to compare the incidence of early adverse postoperative outcomes and to develop a means of adjusting for case mix. We did a retrospective and prospective audit of the case notes of 901 consecutive patients who had 1034 operations for squamous cell carcinoma (SCC) of the head and neck under general anaesthesia at 3 NHS hospitals. Analysis of raw data showed postoperative 30-day mortality (n=17) to be consistent between sites (1.7%-1.9%) but 30-day complication rates varied more (34%-49%). Logistic regression models predicting morbidity discriminated well (area under the curve 0.74-0.76). Adjusted morbidity rates for the 3 units were compared on a funnel plot with 95% and 99% confidence intervals to account for random variation. It is possible to benchmark surgical performance by focusing on early postoperative outcomes in head and neck surgery. Morbidity is common and usually has a considerable impact on recovery, bed occupancy, cost, and the patient's perception of the quality of care.

Revisiting the dioecy-polyploidy association: alternate pathways and research opportunities

The evolutionary transition from hermaphroditism (combined sexes) to dioecy (separate sexes) is associated with whole genome duplication (polyploidy) in several flowering plant genera. Moreover, there is evidence for transitions in the opposite direction, i.e. a loss of dioecy with an increase in ploidy. Here, we review evidence for these associations, synthesize previous ideas on the mechanism underlying the patterns and explore alternative pathways. Specifically, we examine potential ecological and genetic mechanisms, differentiated by whether ploidy or gender (functional sex expression of the plant) changes are the primary cause and whether the effect is direct or indirect. An analysis of 22 genera variable for both ploidy and gender indicates that gender monomorphism (hermaphroditism, monoecy) is more common among diploid than polyploid species, whereas gender dimorphism (dioecy, gynodioecy, subdioecy) is more frequent among polyploid species. The transition from diploid hermaphroditic to polyploid gender-dimorphic taxa may arise directly through changes in gender as a result of genome duplication through genomic rearrangements or homeologous recombination, or changes in gender may result in increased unreduced gamete production leading to polyploid formation. Alternatively, the transition may occur through the indirect effects of genome duplication on mating system and inbreeding depression, which favor selection for unisexuality, or habitat shifts associated with unisexuality may simultaneously cause increased unreduced gamete production. Novel mechanisms for transitions in the opposite direction (from dioecy to hermaphroditism with increase in ploidy) include disruption of genetic sex determination and the benefits of reproductive assurance. We highlight key questions requiring further attention and promising approaches for answering them and better clarifying the genesis of sexual system polyploidy associations. See also the sister article focusing on animals by Wertheim et al. in this themed issue.

Predictive values of calcaneal quantitative ultrasound and dual energy X ray absorptiometry for non-vertebral fracture in older men: results from the MrOS study (Hong Kong)

Calcaneal QUS is comparable to DXA in predicting non-vertebral fractures in older Chinese men.

INTRODUCTION

The predictive values of calcaneal quantitative ultrasound (QUS) and dual-energy X-ray absorptiometry (DXA) for non-vertebral fractures in older Chinese men were examined.

METHODS

One thousand nine hundred twenty-one Chinese men aged 65-92 years had calcaneal QUS and axial DXA bone mineral density (BMD) measurements. The incidence of non-vertebral fractures was documented. Cox regression and receiver operating curve (ROC) analysis were used to examine the associations of QUS parameters and BMD with the incidence of non-vertebral fractures.

RESULTS

The duration of follow-up was (mean ± SD) 6.5 ± 1.7 years. One hundred thirty-one non-vertebral fractures were recorded, 71 of which were major fragility fractures. Broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI) were significantly associated with non-vertebral fractures and major fragility fractures, with age and fracture history-adjusted hazard ratio (95% CI) of 1.23 (1.03, 1.47) and 1.32 (1.10, 1.59) per standard deviation reduction, respectively, for non-vertebral fractures; 1.32 (1.04, 1.68) and 1.43 (1.11, 1.84), respectively, for major fragility fractures. Age and fracture history-adjusted areas under ROC curves of hip or spine BMDs were significantly greater than that of BUA or QUI in predicting major fragility fractures, but not in predicting all non-vertebral fractures. The addition of BUA or QUI had no effect on AUCs of total hip BMD alone.

CONCLUSIONS

The ability of calcaneal QUS to predict non-vertebral fractures was comparable to that of axial BMD by DXA, but was inferior to BMD in predicting major fragility fractures in older Chinese men.

Cross-city comparison of indoor air temperatures in air-conditioned spaces

Field measurements were collected through physical measurements and observations in the cities of Seoul, Korea; Eugene and Portland, Oregon; and Yokohama, Japan, during the fall, winter, and summer seasons from 2005 to 2006. A total of 1733 data sets were collected (Seoul - 713; Oregon - 807; Yokohama - 213) in variety of multi-use buildings with the goal of examining operative temperatures and conditions encountered during everyday life. Of the four cities measured, winter and autumn indoor operative temperatures were highest in Seoul and lowest in Yokohama when normalized to outdoor conditions. In contrast, summer indoor operative temperatures were highest in Yokohama and lowest in Oregon. Clothing levels changed seasonally, and differences were observed between 'long-term occupants', 'residents', and 'transients.'

Cognitive-behavioral treatment groups for people with chronic physical illness in Hong Kong: reflections on a culturally attuned model

This study describes and evaluates a cognitive-behavioral treatment group for people with chronic physical illness in Hong Kong. We developed a group protocol based on the understanding that Chinese people generally prefer a structured group format, expect group leaders to be active and directive, and are not used to expressing opinions and emotions in groups. The experimental and waitlist control groups had 38 and 35 participants, respectively. A standardized questionnaire was administered to all participants before and after the group treatment. Results suggest that members of the experimental group showed improvements in mental health, negative automatic thoughts, and negative emotions when compared to those in the waitlist control groups, and at the end of group treatment. Implications for designing and running a culturally attuned CBT group for Chinese people are discussed.

Twenty-year audit of percutaneous liver biopsy in a major Australian teaching hospital

BACKGROUND

To examine the changes in indications, patient characteristics, safety and outcomes in consecutive patients undergoing percutaneous core liver biopsies in a major Australian teaching hospital over a period of two decades.

METHODS

A retrospective audit was carried out on all percutaneous core liver biopsies from a single institution between 1996 and 2005. This was combined with 10 years of data already reported on for the years 1986-1995 to detect trends in indications and outcomes.

RESULTS

Medical records from 1398 patients were included for analysis. Over a 20-year period, the most common indications for liver biopsy were hepatitis C (37.8%), hepatitis B (26.4%) and abnormal liver function tests (22.2%). Twelve major complications (1.0%) were seen; 10 episodes of haemorrhage, 1 bile leak and 1 visceral perforation. Seven of these patients had an abnormal baseline coagulation profile; a significant risk for major haemorrhage (P < 0.001), resulting in three deaths. All deaths occurred in inpatients with major comorbidities. Minor complications occurred in 13.6% of patients, with multiple passes a significant risk factor. Whereas the overall major and minor complication rates were independent of operator experience inadequate specimens were more frequently obtained by the registrar.

CONCLUSION

This large series extending over two decades shows that despite advances in biopsy techniques, the rates of both minor and major complications remain significant. Of particular concern are the procedure-related deaths. Identifying factors that may increase risk requires further scrutiny and careful patient selection needs to be undertaken.

Delayed neuropsychiatric impairment after carbon monoxide poisoning from burning charcoal

Poisoning by carbon monoxide from burning charcoal has become one of the popular and lethal ways of attempting suicide in Hong Kong. Survivors of the carbon monoxide poisoning often face acute and delayed adverse problems in both their physical and mental health. We report two cases of delayed onset neuropsychiatric complications caused by carbon monoxide poisoning from burning charcoal. These symptoms were characterised by a latent period, followed by an abrupt and profound deterioration in the neurocognitive function with a seemingly reversible course. The literature is reviewed regarding the aetiology, pathophysiology, and management of this condition. Regular monitoring of their neurocognitive function and forewarning of this potential complication to the survivors of carbon monoxide poisoning and their families should be essential.

HIP1 functions in clathrin-mediated endocytosis through binding to clathrin and adaptor protein 2

Polyglutamine expansion in huntingtin is the underlying mutation leading to neurodegeneration in Huntington disease. This mutation influences the interaction of huntingtin with different proteins, including huntingtin-interacting protein 1 (HIP1), in which affinity to bind to mutant huntingtin is profoundly reduced. Here we demonstrate that HIP1 colocalizes with markers of clathrin-mediated endocytosis in neuronal cells and is highly enriched on clathrin-coated vesicles (CCVs) purified from brain homogenates. HIP1 binds to the clathrin adaptor protein 2 (AP2) and the terminal domain of the clathrin heavy chain, predominantly through a small fragment encompassing amino acids 276-335. This region, which contains consensus clathrin- and AP2-binding sites, functions in conjunction with the coiled-coil domain to target HIP1 to CCVs. Expression of various HIP1 fragments leads to a potent block of clathrin-mediated endocytosis. Our findings demonstrate that HIP1 is a novel component of the endocytic machinery.

Human ABCA1 BAC transgenic mice show increased high density lipoprotein cholesterol and ApoAI-dependent efflux stimulated by an internal promoter containing liver X receptor response elements in intron 1

By using BAC transgenic mice, we have shown that increased human ABCA1 protein expression results in a significant increase in cholesterol efflux in different tissues and marked elevation in high density lipoprotein (HDL)-cholesterol levels associated with increases in apoAI and apoAII. Three novel ABCA1 transcripts containing three different transcription initiation sites that utilize sequences in intron 1 have been identified. In BAC transgenic mice there is an increased expression of ABCA1 protein, but the distribution of the ABCA1 product in different cells remains similar to wild type mice. An internal promoter in human intron 1 containing liver X response elements is functional in vivo and directly contributes to regulation of the human ABCA1 gene in multiple tissues and to raised HDL cholesterol, apoAI, and apoAII levels. A highly significant relationship between raised protein levels, increased efflux, and level of HDL elevation is evident. These data provide proof of the principle that increased human ABCA1 efflux activity is associated with an increase in HDL levels in vivo.

Comparison of tissue injury between laparosonic coagulating shears and electrosurgical scissors in the sheep model

STUDY OBJECTIVE

To compare laparosonic coagulating shears (LCS), which use ultrasonic energy, and unipolar diathermy scissors with respect to depth of tissue injury.

DESIGN

Prospective observational study (Canadian Task Force classification I).

SETTING

A reproduced surgical setting.

SUBJECTS

An anesthetized sheep.

INTERVENTION

We laparoscopically harvested uterine horn and bowel tissue.

MEASUREMENTS AND MAIN RESULTS

Tissue was transected while hemostasis was maintained. Two pathologists examined tissue independently, and each was blinded as to the instrument used for harvesting. Clinical characteristics and tissue injury created by the instruments were compared.

CONCLUSION

Subjectively, LCS appeared to produce less smoke plume than diathermy scissors. It also produced greater tissue damage than unipolar electrosurgery on settings of 35 W cut and 30 W coagulate.

Laparoscopic presacral neurectomy - retrospective series

A retrospective audit of medical records was conducted for one surgeon (AL). All patients who underwent laparoscopic presacral neurectomy for severe midline dysmenorrhoea were identified. Details of the preoperative symptoms, clinical findings and operative records were studied. Improvement of dysmenorrhoea was assessed according to a pain scale. Twelve patients who had a laparoscopic presacral neurectomy performed were identified. Eight patients reported significant improvement of symptoms, with a further two reporting mild improvement. Two patients failed to show any improvement of symptoms. We believe that the role of laparoscopic presacral neurectomy should be limited to patients with severe midline dysmenorrhoea not responding to the medical therapy. It may be a supplementary procedure to laparoscopic resection of endometriosis or adhesiolysis.

Deeply infiltrating endometriosis: implications, diagnosis, and management

Deeply infiltrating endometriosis was described in the early part of the last century. Only recently, has there become a greater awareness and understanding of this form of endometriosis aided in part by advances in laparoscopic surgical technology in techniques. The clinical implications of the disease as well as diagnosis and current management are reviewed.

Laparoscopic presacral neurectomy: a review

Dysmenorrhea can be a severe and debilitating symptom in many women. Although most women may find adequate relief of symptoms from pharmacological approaches, there remain a few with resistant pain. Presacral neurectomy, although technically challenging, may be offered after other approaches are unsuccessful. The operation is now performed increasingly by the laparoscopic approach, which has revived this operation in some centers. The anatomy, technique, and indications as well as a review of the literature supporting this operation are reviewed. The potential complications of this operation are discussed also.

Incisional hernia in a 5 mm laparoscopic port site incision

Herniation of omentum or bowel through laparoscopic incision sites is uncommon. Herniations through 5 mm ports sites are very rare, with less than a handful described in the literature. Undoubtedly however, with the increasing interest.

Symptomatic age-related macular degeneration in Asian patients

PURPOSE

To characterize retinal and fluorescein angiographic findings of Asian patients with symptoms secondary to age-related macular degeneration (ARMD).

METHODS

We retrospectively reviewed 453 consecutive medical records corresponding to fluorescein angiograms performed between November 1992 and November 1995 to identify Asian patients with symptomatic ARMD. Presenting visual symptoms, best-corrected Snellen visual acuities, and retinal examination findings were determined from the medical records. Fundus photos and fluorescein angiograms were reviewed.

RESULTS

There were 26 symptomatic eyes in 19 Asian patients with a median age of 73 years. Presenting visual symptoms included decreased visual acuity (19 eyes), metamorphopsia (5 eyes), or scotoma (2 eyes). Retinal findings included occult choroidal neovascularization (CNV) in 5 (19%) eyes, serous pigment epithelial detachment (PED) in 8 (31%) eyes, PED with CNV in 5 (19%) eyes, drusen in 5 (19%) eyes, retinal pigment epithelial atrophy in 1 (4%) eye, vitreous hemorrhage in 1 (4%) eye, and a disciform scar in 1 (4%) eye.

CONCLUSION

In this cohort of Asian patients with ARMD, the majority of symptomatic eyes had either CNV (46%) or serous PED (31%).