Proton beam radiotherapy for choroidal and ciliary body melanoma in the UK-national audit of referral patterns of 1084 cases

INTRODUCTION

Proton beam therapy has been utilised for the treatment of uveal melanoma in the UK for over 30 years, undertaken under a single centre. In the UK, all ocular tumours are treated at one of four centres. We aimed to understand the variation in referral patterns to the UK proton service, capturing all uveal melanoma patients treated with this modality.

METHODS

Retrospective analysis of data regarding all patients treated at the Clatterbridge Proton service between January 2004 and December 2014.

RESULTS

A total of 1084 patients with uveal melanoma were treated. The mean age was 57 years (range 9-90 years), basal diameter of 11.5 mm (range 2.0-23.4 mm) and tumour thickness of 3.9 mm (range 0.1-15.4 mm). The majority were TNM stage I (39%) or II (36%). The distance to the optic nerve varied from 0 to 24.5 mm with 148 (14%) of patients having ciliary body involvement. There were variations in the phenotypic characteristic of the tumours treated with protons from different centres, with London referring predominantly small tumours at the posterior pole, Glasgow referring large tumours often at the ciliary body and Liverpool sending a mix of these groups.

DISCUSSION

In the UK, common indications for the use of proton treatment in uveal melanoma include small tumours in the posterior pole poorly accessible for plaque treatment (adjacent to the disc), tumours at the posterior pole affecting the fovea and large anterior tumours traditionally too large for brachytherapy. This is the first UK-wide audit enabling the capture of all patients treated at the single proton centre.

Experience of menopause in aboriginal women: a systematic review

Every woman experiences the menopause transition period in a very individual way. Menopause symptoms and management are greatly influenced by socioeconomic status in addition to genetic background and medical history. Because of their very unique cultural heritage and often holistic view of health and well-being, menopause symptoms and management might differ greatly in aboriginals compared to non-aboriginals. Our aim was to investigate the extent and scope of the current literature in describing the menopause experience of aboriginal women. Our systematic literature review included nine health-related databases using the keywords 'menopause' and 'climacteric symptoms' in combination with various keywords describing aboriginal populations. Data were collected from selected articles and descriptive analysis was applied. Twenty-eight relevant articles were included in our analysis. These articles represent data from 12 countries and aboriginal groups from at least eight distinctive geographical regions. Knowledge of menopause and symptom experience vary greatly among study groups. The average age of menopause onset appears earlier in most aboriginal groups, often attributed to malnutrition and a harsher lifestyle. This literature review highlights a need for further research of the menopause transition period among aboriginal women to fully explore understanding and treatment of menopause symptoms and ultimately advance an important dialogue about women's health care.

Topical mitomycin C chemotherapy in the management of ocular surface neoplasia: a 10-year review of treatment outcomes and complications

INTRODUCTION

The use of topical mitomycin C (MMC) has gained popularity in the management of ocular surface neoplasia. The aim of this study is to determine outcomes and complications following such treatment.

METHODS

This study is a retrospective review of patients treated with topical MMC for ocular surface neoplasia, including primary acquired melanosis (PAM), melanoma, corneal-conjunctival intraepithelial neoplasia (CCIN), squamous cell carcinoma (SCC) and sebaceous gland carcinoma (SGC). Data regarding diagnosis, short- and long-term outcomes, and short- and long-term complications, were recorded.

RESULTS

58 patients were identified, with a mean age of 63 years and mean follow-up of 36 months. 21 received MMC as primary therapy and 37 as surgical adjuvant. The regimen was 0.04% MMC four times a day for 3 weeks on, 3 weeks off, 3 weeks on, with topical steroid and lubricants throughout. Initial clinical response was either partial or complete in 93%. Overall, 26% developed recurrent disease at a mean of 13 months post treatment. Recurrence rates by pathology were 20% PAM, 25% melanoma, 0% CCIN, 67% SCC and 57% SGC. Short-term complications occurred in 52%, but only 7% required treatment cessation. Long-term complications such as persisting keratoconjunctivitis, epiphora and corneal problems, occurred in 31%.

CONCLUSION

The results confirm the effectiveness of topical MMC chemotherapy in the management of ocular surface neoplasia. Self-limiting short-term complications were common; however, limbal stem cell deficiency appears to be a significant long-term complication of treatment, occurring in 12%.

Small margin excision of periocular basal cell carcinomas

AIMS

To analyse the outcome of small margin (up to 2 mm) excision of primary clinically well-defined periocular basal cell carcinomas (BCCs).

METHODS

Retrospective evaluation of 90 well-demarcated primary BCCs having a minimum follow-up of 36 months. All patients underwent excision of the tumour with maximum margins of 2 mm. Resulting defects were, if possible, closed directly. Reconstruction of defects requiring flaps or grafts was delayed until receipt of the histological report which was obtained in all cases.

RESULTS

One-stage excision and direct closure was performed in 67 patients (74.4%). In 23 patients (25.6%) reconstruction was delayed by 4 days to enable receipt of the histopathology report. Histological assessment confirmed complete excision after the first excision in 78 (86.7%) rising to 83 (92.2%) after two excisions. The mean follow-up was 47.5 (SD 9.1) months. Of the 12 cases with incompletely excised lesions, seven of the patients chose not to have any more surgery, and only one of these recurred. There were two other recurrences, and in both of them the lesion had initially been reported as completely excised. Overall the recurrence rate in our study was 3.3% (n = 3).

CONCLUSIONS

Our recurrence rate compares well with published results following conventional excision of BCCs. In the absence of availability of Mohs surgery, well-demarcated nodular basal cell carcinomas can be safely excised using smaller margins than conventionally practised.

British Oculoplastic Surgery Society (BOPSS) National Ptosis Survey

AIM

To assess the results of primary aponeurotic ptosis surgery among UK ophthalmic oculoplastic surgeons, from both the surgeon's and patient's perspective; also to inform and encourage good clinical practice by generating outcomes for individual surgeons, units and for benchmarking purposes.

METHODS

A prospective, web-based, non-comparative, interventional study was conducted over a period of 1 year commencing January 2005 and ending December 2005. The data-entry sheet for the preoperative, operative and postoperative data was completed and submitted online via the British Oculoplastic Surgery Society website. Surgical results were assessed objectively (by the surgeon) by measuring the upper lid margin reflex distance (uMRD) and the interlid difference in: MRD, lid show, skin crease and lid contour with the outcome graded as: success, partial success or failed. Surgical results were also assessed subjectively (by the patient) with the outcome graded as: completely satisfied, significantly improved, no change or worse than before the operation.

RESULTS

Three hundred and sixty-five patients undergoing primary aponeurotic ptosis repair, from 40 different consultant-led teams with a declared oculoplastic interest and expertise, originating from 27 units across the UK were entered into the study. Using objective criteria, success was achieved in 128/223 (57%) cases, with significantly greater degrees of success seen in patients with mild ptosis and for surgeons who performed ptosis surgery more frequently. Using subjective criteria, 184/282 (65%) of patients were completely satisfied, with a further 89/282 (32%) judging themselves significantly improved. The patients' assessment of the surgery was less critical than that of the surgeons: 46/138 (33%) of patients who were completely satisfied and 37/72 (51%) of those who were significantly improved did not meet the criteria for a successful surgical outcome. The re-operation rate was 8/313 (2.6%).

CONCLUSIONS

The authors have generated a valid series of surgical outcomes both for individuals, units and the UK as a whole, expressed in both objective and subjective terms for what we regard as the signature procedure for an oculoplastic surgeon: aponeurotic ptosis surgery. Individual results have been communicated to our members, which will allow them to compare their results with true peer-group-generated figures and will aid appraisal and ultimately revalidation.

Floppy iris behaviour during cataract surgery: associations and variations

AIM

To assess the association of floppy iris behaviour during cataract surgery with use of alpha-1-antagonists and diabetes mellitus.

METHODS

1842 eyes of 1786 patients undergoing phacohoemulsification surgery were prospectively enrolled. The use of commonly prescribed alpha-1-antagonists and the presence or absence of diabetes mellitus were noted. The occurrence of any of the features of the intraoperative floppy iris syndrome (IFIS) was noted by surgeons blinded to the patient's history.

RESULTS

57% of patients receiving tamsulosin showed features of IFIS compared with 1% of the non-tamsulosin group (p<0.001). Of these, more than half the patients manifested the syndrome in an incomplete form. Only 1 of the 51 patients receiving other alpha-1-antagonists had IFIS. Diabetes was also not associated with IFIS (p = 1).

CONCLUSIONS

Tamsulosin is significantly associated with floppy iris behaviour during cataract surgery. But not all of these patients will necessarily show all or any features of IFIS. The floppy iris syndrome is likely to represent a continuum of severity. Various undefined factors, diabetes not being one of them, may have a contributory role. Non-selective alpha-1-antagonists are unlikely to be associated with IFIS.

The not-so-lazy-T: A modification of medial ectropion repair

Medial involutional ectropion without excessive lateral canthal tendon laxity is often corrected using the lazy-T procedure. This procedure however carries a potential risk of canalicular damage, and locating the lower lid retractors can be difficult. We have developed a modification. Replacing the tarso-conjunctival diamond with a subconjuctival pocket posterior and inferior to the punctum, into which the lower lid retractors are advanced from the base of the wedge excision, which effectively ensures plication of the lower lid retractors while maintaining a straightforward procedure. The follow-up data on five procedures showed surgical and symptomatic success in all patients, without complications. These results confirm the efficacy of this modification of the lazy-T procedure in the correction of medial lower lid ectropion.

The effect of aspirin and warfarin therapy in trabeculectomy

AIM

The management of patients on antiplatelet and anticoagulation therapy (APACT) in glaucoma surgery currently has no specific recommendations. We aimed to establish the risk of haemorrhagic complications and surgical outcome in patients on APACT in glaucoma surgery.

METHODS

We retrospectively examined 367 consecutive trabeculectomies performed between 1994 and 1998. Preoperatively 60 (16.4%) patients were on APACT (55 on aspirin and five on warfarin). The incidence of hyphaema and haemorrhagic complications between patients with and without APACT was documented. Surgical success was defined in two categories as an intraocular pressure (IOP) <21 mmHg and an IOP <16 mmHg 2 years following trabeculectomy with and without antiglaucoma medication.

RESULTS

None of the patients on aspirin suffered significant intra or postoperative haemorrhage. Aspirin was associated with a significantly higher risk of hyphaema (P=0.0015) but this was not found to significantly affect IOP control at 2 years. Patients on warfarin suffered haemorrhagic complications and trabeculectomy failure.

CONCLUSIONS

Aspirin appears to be safe to continue with during trabeculectomy. Patients on aspirin have an increased risk of hyphaema following trabeculectomy. This however does not appear to affect surgical outcome. Warfarinised patients are at risk of serious bleeding complications. They require careful monitoring pre- and postoperatively and are at risk of trabeculectomy failure.

Hair loss in cancer chemotherapeutic patients

The hair loss in 8 cancer patients aged between 18 and 60 years on chemotherapy was studied. All had diffuse moderate alopecia within 1 month of starting treatment. Of the 8, 3 had only telogen hairs and 3 had high dystrophic hair count. Both anagen and telogen effluvium are implicated.

Is growth a valid outcome measure of dialysis clearance in children undergoing peritoneal dialysis?

OBJECTIVE

Our study evaluated growth as a clinical outcome measure of peritoneal dialysis (PD) adequacy in children with end-stage renal disease (ESRD).

DESIGN

This retrospective single-center study was carried out in our tertiary-care medical center.

PATIENTS

The study enrolled 24 patients who initiated dialysis after January 1, 1995, and who had been on dialysis for a minimum of 1 year.

RESULTS

The weekly mean total [PD + residual renal function (RRF)] creatinine clearance (C(Cr)) and Kt/V(urea) were 70.3 +/- 18 L per 1.73 m2 and 3.45 +/- 0.73, respectively. Of the 24 patients, 12 (50%) were anuric. The mean height standard deviation score (SDS) changed to -1.78 at the end of 1 year from -1.58 at baseline. Catch-up growth (positive delta height SDS) was observed in 9 patients (37%), 7 of whom (78%) had residual renal function (RRF). In contrast, only 5 of 15 patients (33%) with a negative deltaSDS for height had RRF (p < 0.025). The mean height SDS in patients with RRF improved to -1.64 from -1.78; in patients without RRF, it worsened to -1.90 from -1.37 (p = 0.01). While the weekly total Kt/V(urea) in patients with RRF (3.53) was similar to that in patients without RRF (3.37, p = 0.6), only the native Kt/V(urea) had a significant (but weak) positive correlation with delta height SDS (r2 = 0.17, p = 0.04). In contrast, the total weekly C(Cr) was significantly higher (p = 0.001) in patients with RRF (81.1 L/1.73 m2) as compared with those without RRF (59.5 L/1.73 m2). However, only the native C(Cr)--and not the dialysis C(Cr)--had a significant (but weak) positive correlation with delta height SDS (r2 = 0.17, p = 0.04).

CONCLUSIONS

These preliminary data provide evidence for a correlation between solute clearance and growth, with RRF exerting a significant influence on that outcome. The Kt/V(urea) data also appear to contradict the presumed equivalence of PD and native clearance in children with ESRD.

What are the clinical correlates of adequate peritoneal dialysis?

The efficacy of peritoneal dialysis in terms of the clearance of small molecules such as urea and creatinine is referred to as "adequacy." Treatment guidelines and adequacy targets have been developed and distributed by the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) in an effort to reduce variations in end-stage renal disease (ESRD) treatment. Much effort has been made to determine the correlation between dialysis dose and various clinical outcome measures (eg, hospitalization, mortality) in adults in an attempt to define the optimal dialysis dose. The delineation of this issue in the pediatric ESRD population is more complex because of the small number of patients and the need to define sensitive outcome measures that are unique to children. The review addresses the possible clinical correlates of dialysis adequacy in children that exist today and the additional data on the topic that needs to be collected in the future.

Measurement of urinary concentration: a critical appraisal of methodologies

The measurement of urine concentration provides information concerning the kidney's ability to appropriately respond to variations in fluid homeostasis. It also assists in the interpretation of other tests performed on the same urine specimen. The gold standard of estimating urinary concentration is the measurement of its osmolality; however, this procedure is not readily available to the practicing physician. Therefore, urine concentration is usually determined by measurement of its specific gravity (SG), which provides a fair estimate of urine osmolality. Over the years numerous tests have been developed to measure urine SG in a simple, quick, reliable and easily available method. These tests measure SG either directly (e.g., gravimetry) or by indirect methods (e.g., refractometry and reagent strip). All these tests have certain limitations based on their underlying physical principles. Specific gravity as measured by refractometry is influenced by proteinuria, such that for each 10 g/l protein the SG increases by 0.003. SG is also influenced by glucosuria such that it increases by approximately 0.002 per 10 g/l glucose when compared with urinary osmolality. Unlike osmolality, which is only affected by the number of particles, refractometry is affected by number, mass and chemical structure of the dissolved particles; hence large molecules like radiographic contrast or mannitol will increase SG relative to osmolality. The reagent strip is minimally affected by glucose, mannitol or radiographic contrast. However, it is affected by urinary pH such that only urine in the pH range of 7.0-7.5 can be correctly interpreted. The measurement of SG by reagent strip is based on the ionic strength of the urine and thus is significantly affected by the ionic composition of the urine and by proteins which have an electric charge in solution. In our experience, SG measured by the refractometer is consistently more accurate than the reagent strip. For the clinician who is interpreting urine SG results, it is important to be aware of these limitations and understand the reasons for possible potential errors of each particular method.

Chest wall peritoneal dialysis catheter placement in infants with a colostomy

The presence of a colostomy in infants with end-stage renal disease (ESRD) receiving peritoneal dialysis (PD) is associated with an inherent risk for contamination and the development of a PD catheter-associated infection. A two-piece presternal catheter designed to reduce the incidence of such infections has been used in a small number of children, but the implantation of the catheter is technically difficult, and there is a risk of disconnection of the two parts secondary to rapid patient growth in the first year of life. Alternatively, a conventional Swan neck catheter, larger than typically required, can be placed with its exit site located on the chest wall. Over the past three years, we adopted this novel approach in two patients with ESRD and a colostomy in whom PD catheters were placed at ages 4 days and 12 days, respectively. During a combined follow-up of 50 months, only one episode of peritonitis and no episodes of exit-site or tunnel infection have been observed. This experience supports the use of this unique approach to PD catheter placement in infants with ESRD and a colostomy.

Sieving coefficient inaccuracies during hemodiafiltration in patients with hyperbilirubinemia

Hemodiafiltration has assumed an important role in the supportive therapy of critically ill patients. The viability of the filter used for hemodiafiltration can be monitored by estimating the sieving coefficient of small molecules such as creatinine and/or urea. We report on three patients with severe hyperbilirubinemia whose creatinine sieving coefficient was spuriously elevated as a result of discordance in the accuracy of creatinine measurement in plasma and ultrafiltrate respectively. This discordance was a consequence of lack of bilirubin clearance during hemodiafiltration. As a result, while the plasma creatinine determination by the kinetic Jaffe method was negatively influenced by the hyperbilirubinemia, the ultrafiltrate creatinine was not. This report is the first to document the lack of bilirubin clearance during hemodiafiltration and its impact on the calculation of sieving coefficient based on creatinine. The use of urea as the solute for determining the sieving coefficient allows for an accurate estimate and provides a valid means of monitoring this parameter in the setting of hyperbilirubinemia.

C1q nephropathy presenting as rapidly progressive crescentic glomerulonephritis

C1q nephropathy is an immune complex glomerulonephritis defined by the presence of mesangial immunoglobulins and complement deposits, most notably C1q, and the absence of clinical and laboratory evidence of systemic lupus erythematosus. Histology in C1q nephropathy is characterized by a slight to severe increase in mesangial cellularity and matrix, with or without segmental sclerosis. C1q nephropathy usually presents with nephrotic-range proteinuria in older children and young adults, and has a poor response to steroids. Patients may have decreased creatinine clearance at presentation, but progression to end-stage renal disease (ESRD) is slow. Severe crescentic glomerulonephritis has not been reported in C1q nephropathy. We describe a 3-year-old Hispanic girl who presented with renal insufficiency. Kidney biopsy showed C1q nephropathy with severe crescentic glomerulonephritis. The clinical and serological evaluation ruled out systemic lupus erythematosus or other immunological or infectious etiologies. In spite of immunosuppressive therapy, she progressed to ESRD within 14 weeks and is currently on chronic peritoneal dialysis. The atypical features of C1q nephropathy observed in our patient, which have not been described in earlier reports, are an early age of onset, severe crescentic glomerulonephritis, and rapid progression to ESRD. C1q nephropathy should be added to the differential diagnosis of glomerulonephritis in young children and in the patient with crescentic glomerulonephritis.

Tenckhoff catheters prove superior to cook catheters in pediatric acute peritoneal dialysis

Peritoneal dialysis (PD) is the most common form of renal replacement therapy in infants and young children with acute renal failure (ARF). The two most commonly used catheters for performing acute PD are the Cook catheter (CC), placed at the bedside, and the surgically placed Tenckhoff catheter (TC). In the present study, we compared the complications and survival rates of the two catheters. The records of 59 children (age, 1 day to 16.7 years) who underwent PD for ARF from March 1989 through June 1999 in our hospital were reviewed. The initial (primary) catheter was a TC in 22 patients and a CC in 37 patients. The age of the patients who received a primary TC (2.8 +/- 4.5 years) was no different than the age of those with a primary CC (1.4 +/- 2.0 years; P = not significant). The duration of use (mean +/- SD) of TCs (16.5 +/- 14.2 days) was significantly greater than the duration of CC use (4.9 +/- 4.2 days; P < 0.001). Only two patients with a TC (9%) developed complications, whereas 18 patients with a CC (49%) developed complications, 13 of whom required catheter replacement (P < 0.01). Thirty-five patients (59%) recovered renal function after undergoing dialysis for 11.5 +/- 8.0 days. Twenty-three of those patients (66%) required dialysis for more than 5 days. Only 4 patients with a primary CC had successful completion of dialysis without catheter-associated complications compared with 15 patients with a primary TC. Kaplan-Meier survival analysis showed that by day 6 of dialysis, only 46% of primary CCs were functioning without complications compared with 90% of TCs that were free of complications. We conclude that the use of a CC is associated with significantly more complications than a TC, and nearly one half of the CCs are likely to be nonfunctional beyond 5 days of dialysis, at a time when two thirds of the patients are still expected to be undergoing dialysis. Therefore, when possible, a TC should be the catheter of choice when initiating acute PD in children. In those patients for whom a CC is chosen as the initial catheter, an elective change to a TC should be considered once dialysis is expected to extend beyond 5 days.

Capnocytophaga canimorsus peritonitis in a pediatric peritoneal dialysis patient

Capnocytophaga canimorsus, a bacterium rarely encountered by clinicians, was responsible for the development of peritonitis in an 18-year-old white male on automated peritoneal dialysis following the puncture of his dialysis tubing by a domestic cat. Although more than 100 cases of septicemia caused by C. canimorsus have been reported, this is the first report of the organism causing peritonitis in a patient receiving peritoneal dialysis. Of interest, the patient had a prior episode of peritonitis secondary to Pasteurella multocida, also following transmission from the same cat.

Bilateral nephrectomy reverses hypothyroidism in congenital nephrotic syndrome

A state of biochemical hypothyroidism is commonly seen in infants with congenital nephrotic syndrome (NS) and therefore the current recommendation is to place all patients with congenital NS on supplemental thyroid preparations. We report our experience in five children with congenital NS in whom thyroid supplementation was discontinued following bilateral nephrectomy and initiation of renal replacement therapy. Immediately after nephrectomy, thyroid function tests normalized, except serum thyroid-stimulating hormone (TSH) concentration, which initially rose, but normalized later. This observation supports the hypothesis that hypothyroidism in these patients is secondary to the chronic massive proteinuria and is not the result of a defect intrinsic to the thyroid gland itself. Abatement of massive proteinuria enables discontinuation of thyroid supplementation, and a transient rise in TSH in the early post-nephrectomy stage should be potentially expected.

Apple juice malabsorption: fructose or sorbitol?

Carbohydrate malabsorption after apple juice ingestion may produce abdominal symptoms and diarrhea, especially in children. The carbohydrates suggested to play roles in this process are fructose, as it is present in excess of glucose, and sorbitol. Absorption of the carbohydrates in apple juice was investigated in 17 children and 12 adults by means of the hydrogen breath test. Apple juice was given at a dose of 15 ml/kg body weight, with a maximum of 375 ml. Fructose (0.6 g/kg) and sorbitol (0.06 g/kg), alone and in combination, were administered in amounts similar to their contents in apple juice (fructose as excess over glucose content). Apple juice malabsorption, as judged by a peak breath H2 excretion of > or = 20 ppm, was found in 11 children (65%) and 4 adults (33%). Of those malabsorbing apple juice, 7 of 11 children malabsorbed fructose, 1 of 11 sorbitol, and 4 of 11 the combination; the four adults absorbed all test solutions completely. We could not find an additive effect of sorbitol on breath H2 excretion after fructose ingestion. Peak breath H2 concentrations after apple juice ingestion (mean +/- SEM: 43 +/- 7 ppm) were higher than those with fructose (23 +/- 5 ppm; p < 0.05) or the fructose-sorbitol combination (20 +/- 5 ppm; p < 0.05). Fructose, and not sorbitol, is the sugar responsible for the increase in breath H2 after apple juice consumption and therefore for the diarrhea accompanying excessive apple juice consumption in toddlers.

Periventricular hemorrhage in term newborns originating from germinal matrix

Six term newborns, presenting with seizures, in whom cranial sonogram showed isolated periventricular hemorrhage (SEH) are described. Age of onset of seizures ranged from day one of birth to day twenty-one. Seizures appeared spontaneously in previously healthy newborns in three cases. All but one survived, and three have near normal development. Isolation of hemorrhage to the periventricular area suggests germinal matrix to be the source of hemorrhage in these cases. These cases also emphasize the need to consider diagnosis of IVH in term-newborns presenting with seizures.

Hemobilia in a child with liver abscess

Hemobilia in children is rare and has so far been described only as a complication of blunt abdominal trauma. A case of hemobilia secondary to liver abscess treated successfully by selective arterial embolization is described. Hemobilia should be considered in any case of gastrointestinal hemorrhage before any operative intervention is undertaken.