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Levodopa-carbidopa intestinal gel (LCIG) has shown to be efficacious in motor and non-motor symptoms (NMS). Nevertheless, studies with patient Quality of Life (QoL) as a primary endpoint are scarce. To assess the effect of LCIG on Advanced Parkinson’s Disease (APD) patients QoL. Secondarily, the impact on motor symptoms and NMS, emotional well-being, treatment satisfaction, and caregiver QoL, stress, disease burden, anxiety, depression, and work impairment were also investigated. In this prospective, 6-month multicenter postmarketing observational study, LCIG was administered to 59 patients with APD. Endpoints were assessed using validated scales and questionnaires. LCIG significantly improved patient QoL (PDQ-39 mean change ± standard deviation from baseline, −12.8 ± 14.6; P P = 0.0002), NMS (NMSS, −35.7 ± 31.1; P P = 0.0297), fatigue (PFS-16, −0.6 ± 1.0; P = 0.0003), depression (BDI-II, −5.1 ± 9.4; P = 0.0002), anxiety (BAI, −6.2 ± 9.6; P P P = 0.0234), but the clinical relevance of this finding is questionable. The serious adverse events reported were similar to those previously described for LCIG. In patients with APD, LCIG improves QoL, motor symptoms and NMS, emotional well-being, and satisfaction with the treatment. Improvement in patient QoL is associated with improvements in motor complications, NMS, anxiety, depression, apathy and fatigue. Improvements in patients’ QoL does not correspond with improvements in caregivers’ QoL or burden.

For public health agencies, the pragmatic need to bring together science and practice to affect public health outcomes manifests in the implementation of prevention strategies with the best available evidence. Knowledge translation makes scientific findings understandable to the knowledge user, often through synthesis of the best available evidence. Implementation science promotes the adoption and integration of evidence through prevention strategies implemented within various contexts. Working together, knowledge translation and implementation science can promote the uptake and advancement of scientific and practice-based evidence for strategies that will have the greatest impact across a variety of contexts. Violence Prevention in Practice (VPP) is an online resource designed to help practitioners select, adapt, implement, and evaluate multiple prevention strategies included in five technical packages developed by Centers for Disease Control’s Division of Violence Prevention. A technical package translates the best available evidence into a core set of prevention strategies intended to be broadly implemented. VPP supports communities in using the technical package strategies in combination, drawing on key implementation science principles. In this article, we explain the process for developing VPP and provide a framework that can be used to develop similar guidance in other health promotion areas. The framework explains how both general components, such as selection and adaptation, come together with strategy-specific implementation guidance. Distinct from typical planning models, VPP is not designed as a linear stepwise process, and it allows practitioners to use one or more components alone, as well as helps practitioners link across components as needed.

Introduction: The main challenge of Parkinson’s disease in women of childbearing age is managing symptoms and drugs during pregnancy and breastfeeding. The increase in the age at which women are having children makes it likely that these pregnancies will become more common in future. Objectives: This study aims to define the clinical characteristics of women of childbearing age with Parkinson’s disease and the factors affecting their lives, and to establish a series of guidelines for managing pregnancy in these patients. Results: This consensus document was developed through an exhaustive literature search and a discussion of the available evidence by a group of movement disorder experts from the Spanish Society of Neurology. Conclusions: Parkinson’s disease affects all aspects of sexual and reproductive health in women of childbearing age. Pregnancy should be well planned to minimise teratogenic risk. A multidisciplinary approach should be adopted in the management of these patients in order to take all relevant considerations into account. Resumen: Introducción: El manejo de la enfermedad de Parkinson en la mujer en edad fértil nos plantea como principal reto el manejo de la enfermedad y los fármacos durante el embarazo y lactancia. El aumento de la edad gestacional de la mujer hace más probable que la incidencia de embarazos pueda incrementarse. Objetivo: Definir las características clínicas y los factores que condicionan la vida de la mujer en edad fértil con enfermedad de Parkinson y definir una guía de actuación y manejo del embarazo en estas pacientes. Desarrollo: Este documento de consenso se ha realizado mediante una búsqueda bibliográfica exhaustiva y discusión de los contenidos llevadas a cabo por un grupo de expertos en trastornos del movimiento de la Sociedad Española de Neurología. Conclusiones: La enfermedad de Parkinson afecta a todos los aspectos relacionados con la salud sexual y reproductiva de la mujer en edad fértil. Se debe planificar el embarazo en las mujeres con enfermedad de Parkinson para minimizar los riesgos teratogénicos sobre el feto. Se recomienda un abordaje multidisciplinar de estas pacientes para tener en cuenta todos los aspectos implicados.

Despite advances in the sexual violence (SV) prevention field, practitioners still face challenges with identifying indicators to measure the impact of their prevention strategies. Public data, such as existing administrative and surveillance system data, may be a good option for organizations to examine trends in indicators for the purpose of program evaluation. In this article, we describe a framework and a process for identifying indicators with public data. Specifically, we present the SV Indicator Framework and a five-step indicator review process, which we used to identify indicators for a national SV prevention program. We present the findings of the indicator review and explain how the process could be used by evaluators and program planners within other developing topic areas. Tracking indicators with public data, in conjunction with other evaluation methods, may be a viable option for state-level program evaluations. We discuss limitations and implications for practice and research.

The TotaltrackTM is a new video laryngeal mask, which combines a supraglottic airway with a videolaryngoscope. We evaluated the performance of this device in an observational study in 300 adult patients. The Totaltrack was inserted at the first attempt and the glottis seen in all cases. In 249 patients (83%; 95%CI 78.7-87.3%) the glottis was seen at the first attempt. Adequate ventilation and tracheal intubation were achieved in all patients. The median time to visualisation of vocal cords, to confirmation of ventilation and to successful tracheal intubation was 5 s, 13 s and 24 s, respectively. Nineteen patients (6.3%; 95%CI 3.55-9.05%) suffered minor complications, such as mucosal lesion or blood staining. The Totaltrack appears effective for airway management.

In late 2019, a novel coronavirus initially related to a cluster of severe pneumonia cases in China was identified. COVID-19 cases have rapidly spread to multiple countries worldwide. We present a typical laboratory confirmed case of COVID-19 pneumonia, that was hospitalized due to hypoxemia but did not require mechanical ventilation. Although initially the patient was evaluated with a favorable outcome, in the third week of the disease, the symptomatology deteriorated due to a massive hypertensive pneumothorax with no known previous risk factor. Since the first cases of COVID-19 have been described, pneumothorax was characterized as a potential, though uncommon, complication. It has been reported that diffuse alveolar injury caused by SARS-CoV-2 can cause alveolar rupture, produce air leakage and interstitial emphysema. Although uncommon, pneumothorax should be listed as a differential diagnosis for COVID-19 patients with sudden respiratory decompensation. As a life-threatening event, it requires prompt recognition and expeditious treatment.

Aim To develop consensus recommendations about good clinical practice rules for caring end-of-life patients. Methods A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when >95% answers were completely agree or >90% were agree or completely agree; and weak consensus when >90% answers were completely agree or >80% were agree or completely agree. Results The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient’s needs; support and care; palliative sedation, and after death care. Conclusions The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.

Acute cervical pathology may lead to serious airway compromise resulting from anatomical distortion secondary to obstruction or deviation of the upper airway, scenarios where any airway device can be fallible. Passage of a fiberoptic bronchoscopy to expose the glottis may be very difficult and tracheostomy may be impractical or risky in advanced cases. We present the use of the TotalTrack VLM to secure the airway for emergent surgery in 2 uncooperative patients with difficult airway due to Ludwig's angina and neck hematoma, respectively, both accompanied by trismus.

Acute cervical pathology may lead to serious airway compromise resulting from anatomical distortion secondary to obstruction or deviation of the upper airway, scenarios where any airway device can be fallible. Passage of a fiberoptic bronchoscopy to expose the glottis may be very difficult and tracheostomy may be impractical or risky in advanced cases. We present the use of the TotalTrack VLM to secure the airway for emergent surgery in 2 uncooperative patients with difficult airway due to Ludwig's angina and neck hematoma, respectively, both accompanied by trismus.

Corynebacterium striatum strains have been increasingly reported as etiological agents of nosocomial infections and outbreaks in industrialized and developing countries. However, there are few studies focused on the virulence potential of C. striatum. A growing body of research supports the use of Caenorhabditis elegans as a model host for investigating the virulence potential of pathogenic bacteria, including corynebacteria. In the present study, chemotaxis behaviour, mortality, and morphological changes were investigated in nematodes infected by four C. striatum strains isolated from different clinical sites, and with different MDR profiles and PFGE types. The results showed chemotaxis of nematodes towards C. striatum. Nematode death (> 60%) was detected from the first day post-infection with all strains tested, but at different levels, independent of biofilm formation on catheter surfaces and differences in growth temperature between nematodes (20 °C) and mammals (37 °C). C. striatum 2369/II multidrug-resistant (MDR; from tracheal aspirate of a patient undergoing endotracheal intubation) and 1961/III multidrug-sensitive (MDS; urine) strains led to 100% mortality in worms. Survival of nematodes was observed until 4 days post-infection with the C. striatum 1954/IV MDS strain isolated from a surgical wound (13%) and 1987/I MDR strain isolated from a patient with a lower respiratory tract infection (39%). The Dar phenotype was observed post-infection with all MDS and MDR strains except 1954/IV. All strains showed the capacity for bagging formation. Star formation was observed only with strains that led to 100% nematode mortality. In conclusion, C. striatum was found to exert virulence for C. elegans. Variations in nematode morphological changes and levels of mortality indicate differences in the virulence potential of C. striatum independent of clinical isolation site, capacity for biofilm formation, and MDR and PFGE profiles.

Sexual violence (SV) is a global public health problem that is impacted by social norms and gender inequity. In the United States, nearly 1 in 5 women have experienced rape or attempted rape and 1 in 17 men have been made to sexually penetrate someone in their lifetime. SV also shares many risk and protective factors with other violence types experienced throughout the lifespan. Researchers and practitioners still face challenges with tracking implementation of SV prevention strategies and demonstrating public health impacts. Centers for Disease Control and Prevention (CDC) administers the national Rape Prevention Education Program (RPE) to address SV risk and protective factors and prevent first SV occurrences. From 2016–2017, RPE’s 50 state and four territorial recipients funded 485 local organizations to implement prevention strategies in over 1 300 sites. CDC monitored implementation and risk and protective factors addressed by its recipients. In addition, CDC supported 12 recipients to use publicly available data to track SV outcomes within their state. The majority of prevention strategies (75%) were developed in practice settings, but most of these strategies aligned with CDC’s STOP SV technical package, a core set of SV prevention strategies based on the best available evidence. Most recipients implement educational strategies intended to impact knowledge and behaviors and community strategies to impact social norms. Fewer strategies, however, focus on improving gender equity through economic and leadership opportunities. RPE recipients identified publicly available data to measure some SV outcomes, as well as other data sources within their states. RPE is the first U.S. national program to track implementation of prevention strategies and linked SV indicators. Recipients may need greater support to implement gender equity-focused strategies. Publicly available combined with state-specific data sources may be an effective way for CDC to build the case for national public health impacts.

Statement of Purpose The Centres for Disease Control and Prevention (CDC) funds health departments in all 50 states, DC, and 4 US territories to implement sexual violence (SV) prevention strategies through the Rape Prevention and Education (RPE) program. Although the evidence-base for SV prevention has grown in the last decade, most RPE awardees implement prevention strategies they developed in practice. Some practice-based strategies may have potential for public health impact, but they have not been evaluated. CDC used the Systematic Screening and Assessment (SSA) Method to identify prevention strategies in practice that are ready for more evaluation. Methods The SSA Method includes six steps and integrates a review of nominated prevention strategies by subject matter experts with evaluability assessment. CDC solicited nominations from RPE awardees and sub-awardees within three focus areas: (1) creating safe and protective environments, (2) promoting healthy social norms that protect against SV, and (3) using gender equity approaches. A group of 12 independent reviewers rated these prevention strategies using 11 criteria and met to discuss top-rated nominations. Results CDC received 40 nominations and selected 20 prevention strategies for onsite evaluability assessment based on ratings and expert input. Site visitors then conducted evaluability assessments and developed summary reports for independent reviewers to rate. Presenters will describe findings from the first round of evaluability assessments and highlight innovations within the SV field. Conclusions/Significance Using the SSA Method can greatly advance the injury prevention field by identifying a large pool of prevention strategies that may be ready for more evaluation and using less resource-intensive methods to prioritise strategies with the greatest potential for public health impact prior to investing in rigorous evaluations. The SSA also brings together innovations that already have traction in a field with scientific methods, which could accelerate the widespread adoption of evidence-based prevention strategies.

This article presents what the authors consider to be among the top 20 practice innovations since the inception of the National Center for Injury Prevention and Control in 1992. The innovations embody various characteristics of successful public health programs and have contributed to declines in violence, motor vehicle, residential fire, and other injury rates over the past 20 years. Taken together, these innovations have reduced the burden of violence and injury and have influenced current practice and practitioners in the United States and worldwide.

Purpose To evaluate treatment of juxtapapillary choroidal melanoma with plaque radiotherapy and to investigate the role of supplemental transpupillary thermotherapy (TTT). Design Retrospective, comparative case series. Participants We included 650 consecutive eyes with juxtapapillary choroidal melanoma within 1 mm of the optic disc. Methods Eyes with juxtapapillary choroidal melanoma receiving plaque radiotherapy over a 31-year period from October 1974 to November 2005 were included in the study. The TTT and no TTT groups were analyzed separately and compared. Main Outcome Measures Local tumor control, metastasis, and tumor-related mortality. Results The median basal tumor diameter was 10 mm (range, 1.5–21) and median thickness was 3.5 mm (range, 0.5–14.8). In 481 eyes (74%), the tumor was directly adjacent to the optic disc and in 169 eyes (26%) the posterior tumor margin was between 0.1 and 1.0 mm from the optic disc. The circumpapillary extent of the tumor was 8 clock-hours in 79 eyes (12%). Plaque radiotherapy using iodine-125 in 616 eyes (95%), cobalt-60 in 19 eyes (3%), iridium-192 in 12 eyes (2%), and ruthenium-106 in 3 eyes ( P P P P = 0.020). Conclusions Plaque radiotherapy for juxtapapillary melanoma provides local tumor control in approximately 80% of eyes at 10 years. In subjects who received TTT, there was slight but nonsignificant improved local tumor control and lower metastatic rate. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Background. Intimate partner violence (IPV) has been recognized as a public health problem since the late 20th century. To spur IPV prevention efforts nationwide, the DELTA PREP Project selected 19 state domestic violence coalitions to build organizational prevention capacity and catalyze IPV primary prevention strategies within their states. Objective. DELTA PREP’s summative evaluation addressed four major questions: (1) Did coalitions improve their prevention capacity during the project period? (2) Did coalitions serve as catalysts for prevention activities within their states during the project period? (3) Was initial prevention capacity associated with the number of prevention activity types initiated by coalitions by the end of the project? (4) Did coalitions sustain their prevention activities 6 months after the end of the project period? Results. DELTA PREP achieved its capacity-building goal, with all 19 participant coalitions integrating prevention within their organizations and serving as catalysts for prevention activities in their states. At 6 months follow up, coalitions had sustained almost all prevention activities they initiated during the project. Baseline prevention capacity (Beginner vs. Intermediate) was not associated with the number of prevention activity types coalitions implemented by the end of the project. Conclusion. Service and treatment organizations are increasingly asked to integrate a full spectrum of prevention strategies. Selecting organizations that have high levels of general capacity and readiness for an innovation like integrating a public health approach to IPV prevention will likely increase success in building an innovation-specific capacity, and in turn implementing an innovation.

Purpose : This study attempted to assess the toxicity and possible preliminary benefits from teh administration of low-dose external beam irradiation for age-related macular degeneration (ARMD). The premise of the treatment is that radiation induces regression and/or promotes inactivation of the subretinal neovasculature which would result in reabsorption of fluid and blood. This would reduce the risk for further leakage or bleedings, as well as subretinal fibrosis. Consequently, the beneficial effect could be translated into stabilization of visual acuity and prevention of progression of the wet ARMD with the possibility for slight improvement. Methods and Materials : Allegheny University Department of Radiation Oncology treated 41 patients prospectively from January through October 1995 with low-dose irradiation for wet-type macular degeneration. A total of 39 patients were treated with a total dose of 14.4 Gy in eight fractions of 1.8 Gy/fraction over 10–13 elapsed days. The first two patients were treated with a total dose of 10 Gy in fivefractions of 2 Gy. Patients were evaluated at 2–3 weeks and 2–3 months. Some of the patients (6.7%) had laser treatment in the study eye: 21.9% (9) once, 5% (2) twice, 9.7% (4) thrice or more. Subjective visual acuity and toxicity data were collected on all patients. Results : At 2–3 weeks after treatment 29 patients (70%) retained their visual acuity without change, 10 (24.5%) stated they had improved vision, adn 2 (4.8%) stated their vision continued to decrease. At 2–3 months after treatment, 27 patients (65.8%) had no change in their vision, 11 (27%) had an improvement in their vision, and 3 (7.2%) had a decrease in visual acuity. Six patients of 41 in the treated group had acute transient side effects. Conclusion : Our observation in this group of 41 patients support the conclusion that many patients will have improved or stable vision after treatment with low-dose irradiation for age-related wet-type macular degeneration.

Purpose To evaluate plaque radiotherapy for iris melanoma. Design Prospective noncomparative interventional case series. Methods For 38 patients, custom-designed plaque radiotherapy using iodine 125 isotope was applied overlying the cornea with a tumor apex dose of 80 Gy. The main outcome measures were tumor control and ocular complications using Kaplan-Meier estimates and Cox proportional hazards regression analysis. Results In all cases, the melanoma was nonresectable owing to large or discohesive tumor. The tumor configuration was nodular in 24 cases (63%) and flat (diffuse) in 14 (37%). The mean tumor basal diameter was 9 mm (range 4 to 13 mm). Solid tumor extended into the anterior chamber angle in 36 eyes (95%). Tumor seeds were noted on the iris stroma for a mean of 7 clock hours and in the anterior chamber angle for a mean of 4 clock hours. Five-year follow up revealed tumor metastasis in 0% and tumor recurrence in 8% of patients. Visual acuity of 20/200 or worse was found in 16% at 5 years. Radiation-related complications at 5 years included corneal epitheliopathy (9%), cataract (70%), and neovascular glaucoma (8%). No patients developed corneal necrosis, scleral necrosis, retinopathy, or papillopathy. After treatment, the combined incidence of tumor-related and radiation-related elevated intraocular pressure at 5 years was 33%. Enucleation was necessary in 13% at 5 years, for tumor recurrence (n = 3) and patient preference (n = 1). Conclusions Plaque radiotherapy is a useful alternative to enucleation for eyes with nonresectable iris melanoma. Tumor control is 92% at 5 years, but related complications, especially cataract and elevated intraocular pressure, should be anticipated.

To describe the principles and preliminary results of plaque brachytherapy for selected orbital malignancies.A custom-designed Iodine-125 plaque, designed to deliver a target dose of 50 Gray, was placed surgically in the region from which an orbital malignancy was partially resected. The mean dose to the target area was 50 Gray. The initial and follow-up patient data were reviewed.Of the 8 patients, the diagnosis was adenoid cystic carcinoma of the lacrimal gland (4 cases), orbital invasion by basal cell carcinoma (2), orbital extension of conjunctival melanoma (1), and metastatic carcinoma (1). Of the 4 with adenoid cystic carcinoma, there was microscopic residual tumor after excision and orbital exenteration was considered. Three have tumor control with follow-up of 1, 3, and 6 years. One patient required exenteration for recurrence separate from the field of brachytherapy and is free of tumor after 10 years. All 4 patients are alive and well with tumor control. Of the 2 patients with orbital extension of basal cell carcinoma, tumor control without recurrence has been achieved in both after 2 years. The patient with orbital metastasis responded to plaque radiotherapy, with no orbital recurrence, but died of systemic metastasis. The patient with orbital melanoma had local orbital recurrence separate from the area of irradiation and is currently being treated for systemic metastasis.Based on preliminary observations, plaque radiotherapy appears to be a reasonable alternative to exenteration and external irradiation for selected orbital malignancies.

Objective To assess treatment complications and tumor control after plaque radiotherapy for large posterior uveal melanomas measuring 8 mm or greater in thickness. Design Prospective noncomparative interventional case series. Participants Three hundred fifty-four patients each of whom had a posterior uveal melanoma measuring 8 mm or greater in thickness treated with plaque radiotherapy. Main outcome measures The four endpoints included (1) poor final visual acuity (20/200 or worse), (2) enucleation, (3) local tumor recurrence, and (4) metastasis. The clinical data regarding patient features, tumor features, and radiation parameters were analyzed for their impact on the four main outcomes using Cox proportional hazards regression models. Results Using Kaplan-Meier estimates, final visual acuity was poor in 57% at 5 years and 89% at 10 years follow-up. Using multivariate analysis, the most important risk factors for poor visual acuity included retinal invasion by melanoma, increasing patient age, iodine 125 (I 125 ) isotope, and 106 ) isotope. Using Kaplan-Meier estimates, local tumor recurrence was found in 9% at 5 years and 13% at 10 years follow-up. Using multivariate analysis, risk factors for tumor recurrence included Ru 106 radioisotope and ciliary body involvement with tumor. Tumor-related metastases were found in 30% at 5 years and 55% at 10 years follow-up. Using multivariate analysis, risk factors for metastases included inferotemporal meridian, anterior extension of the tumor to the iris root, increasing tumor base, and posterior margin Conclusions Plaque radiotherapy provided tumor control at 10 years in 87% of patients with selected large posterior uveal melanomas (>8 mm thick) that otherwise would have been managed with enucleation. The large intraocular mass and associated features and radiation complications led to poor visual acuity in most patients. At 10 years follow-up, enucleation was necessary in 34% of patients, and metastasis developed in 55% of patients.

PURPOSE: To determine the outcome of plaque radiotherapy in the treatment of macular choroidal melanoma and to identify the risk factors associated with the development of radiation complications, tumor recurrence, and metastasis. METHODS: Chart analysis of 630 consecutive patients (630 eyes) with macular choroidal melanoma managed by plaque radiotherapy between July 1976 and June 1992. RESULTS: The median largest basal tumor diameter was 10 mm, and the median tumor thickness was 4 mm. By means of Kaplan-Meier estimates, visually significant maculopathy developed at 5 years in 40% of the patients, cataract in 32%, papillopathy in 13%, and tumor recurrence in 9%. Vision decrease by 3 or more Snellen lines was found in 40% of the patients at 5 years. Sixty-nine eyes (11%) were enucleated because of radiation complications and recurrence. Twelve percent of the patients developed metastasis by 5 years and 22% by 10 years. Results of multivariate Cox proportional hazards analyses showed that the significant predictors for tumor recurrence were a distance of tumor margin from the optic disk of less than 2 mm ( P = .003) and retinal invasion ( P = .009). The significant variables that were predictive of metastasis included tumor thickness greater than 4 mm ( P = .02) and largest basal tumor diameter greater than 10 mm ( P = .03). CONCLUSIONS: Plaque radiotherapy offers a 91% 5-year local tumor control rate for macular choroidal melanoma. Despite good local tumor control, the risk for metastasis is 12% at 5 years and 22% at 10 years. In 11% of the patients, enucleation eventually became necessary because of radiation complications and tumor recurrence.

The treatment of uveal melanoma is controversial. The treatment methods include enucleation and other techniques designed to preserve the eye, such as local resection, plaque radiotherapy, charged particle radiotherapy, laser photocoagulation, and thermotherapy. Plaque radiotherapy and charged particle radiotherapy provide tumor control and patient survival comparable with enucleation. Plaque radiotherapy may be associated with fewer anterior segment complications, but the posterior segment complications appear to be similar using either plaque radiotherapy or charged particle radiotherapy. Thermotherapy is emerging as an important adjuvant treatment to maintain control of uveal melanoma after radiotherapy.

Local control of unresectable esophageal carcinomas remains a significant problem in spite of aggressive treatments. External beam radiation therapy, chemotherapy, and combined modality treatment have all been employed with limited success. Here we review the existing literature and our own experience with external beam radiation followed by low-dose-rate or high-dose-rate intracavitary radiation for carcinoma of esophagus. The addition of intracavitary brachytherapy to external beam irradiation is well tolerated, causes no significant toxicity, and improves local control. Low-dose-rate intracavitary boost compared to high-dose-rate intracavitary boost has the advantage of a greater margin of safety, requires a single application, does not require highly sophisticated computerized technology, and is accompanied with fewer high-grade toxicities. Combined modality therapy consisting of concomitant infusional chemotherapy, external beam irradiation, and low-dose-rate intracavitary boost needs to be investigated. Semin. Surg. Oncol. 13:185–189, 1997. © 1997 Wiley-Liss, Inc.

Patients with primary ocular tumors are seen infrequently in the medical profession, and most of these patients are referred to specialty centers which has resulted in a good study population. In the past, ocular tumors were treated with enucleation, but the current emphasis is now on organ preservation with sparing of all or partial visual acuity. In the management of these tumors, plaque brachytherapy and particle beam therapy have been used more frequently as an alternative to enucleation. A multi-institutional study, the Collaborative Ocular Melanoma Study (COMS), is currently underway, organized by the National Eye Institute. The COMS isotope of choice is Iodine-125 (I-125). Recurrence after plaque therapy is approximately 15%, although it may be as high as 37% at 15 years for metastatic disease. In one study, nondiffuse iris melanoma has been controlled in 93% of patients by custom plaques utilizing I-125. Plaque brachytherapy also utilizes I-125 for the treatment of retinoblastoma tumors either as primary therapy or following external beam radiation. Currently, through the utilization of plaque radiation therapy, enucleation may be avoided in the majority of patients, and many patients may retrieve some visual acuity. We will review plaque brachytherapy techniques, diagnosis, staging, and some of the pertinent literature of the two most frequently encountered primary ocular tumors: choroidal melanoma, sometimes referred to as uveal melanoma, with an incidence of approximately 1,500 new cases per year in the adult population; and retinoblastoma, the most common intraocular primary malignancy found in childhood, with a frequency of approximately 250 [corrected] new cases per year.

Rett syndrome is a severe and incapacitating neurological disease caused by a structural defect in the short arm of the X chromosome (Xq28). It affects females and consists of multiple and progressive neurological impairments that start from a young age, leading to lifelong disability and dependency. Scoliosis appears in more than 50% of patients and requires surgical correction in cases where the curvature is severe. Pre-anaesthetic assessment is essential in order to identify the risk factors and thus reduce the morbidity and mortality associated with the surgical procedure. We present the case of a patient affected by this syndrome and scoliosis, who was scheduled to have an instrumented thoracolumbar spine arthrodesis with general anaesthesia, which passed without incident. We evaluate the specific details of this syndrome, its potential complications, and its management from an anaesthetic point of view, emphasising the control of postoperative pain using a double epidural catheter with an infusion of local anaesthetics and fentanyl.

Purpose : This study attempted to assess the toxicity and possible preliminary benefits from teh administration of low-dose external beam irradiation for age-related macular degeneration (ARMD). The premise of the treatment is that radiation induces regression and/or promotes inactivation of the subretinal neovasculature which would result in reabsorption of fluid and blood. This would reduce the risk for further leakage or bleedings, as well as subretinal fibrosis. Consequently, the beneficial effect could be translated into stabilization of visual acuity and prevention of progression of the wet ARMD with the possibility for slight improvement. Methods and Materials : Allegheny University Department of Radiation Oncology treated 41 patients prospectively from January through October 1995 with low-dose irradiation for wet-type macular degeneration. A total of 39 patients were treated with a total dose of 14.4 Gy in eight fractions of 1.8 Gy/fraction over 10–13 elapsed days. The first two patients were treated with a total dose of 10 Gy in fivefractions of 2 Gy. Patients were evaluated at 2–3 weeks and 2–3 months. Some of the patients (6.7%) had laser treatment in the study eye: 21.9% (9) once, 5% (2) twice, 9.7% (4) thrice or more. Subjective visual acuity and toxicity data were collected on all patients. Results : At 2–3 weeks after treatment 29 patients (70%) retained their visual acuity without change, 10 (24.5%) stated they had improved vision, adn 2 (4.8%) stated their vision continued to decrease. At 2–3 months after treatment, 27 patients (65.8%) had no change in their vision, 11 (27%) had an improvement in their vision, and 3 (7.2%) had a decrease in visual acuity. Six patients of 41 in the treated group had acute transient side effects. Conclusion : Our observation in this group of 41 patients support the conclusion that many patients will have improved or stable vision after treatment with low-dose irradiation for age-related wet-type macular degeneration.

Chondrodysplasia punctata syndrome is a group of rare congenital diseases that give rise to malformations, mainly skeletal, linked to the premature calcification of structures. There is little in the literature in the field of Anaesthesiology on this despite there being some clinical manifestations, particularly the possibility of difficult airway, which may be of importance during the peri-operative period. During the first years of life, the patients affected are often subjected to repeated surgery to correct their malformations. We describe the anaesthetic treatment during orthopaedic surgery of a paediatric patient with Conradi-Hunermann type chondrodysplasia punctata, highlighting the managementof the airway using a laryngeal mask in combination with balanced general anaesthesia with remifentanil. We also present a review of the characteristics of the different entities of these syndromes, with special emphasis on the aspects most relevant to the anaesthesiologist.

We used a qualitative community case study design to examine stakeholder responses to naturally occurring asbestos (NOA), a newly emerging environmental threat. The community of interest represents the first residential setting in the United States to receive substantial federal, state and local regulatory attention where NOA exposures largely resulted from local development. Because NOA is an emerging problem that will require evidence-based public health responses in the United States and elsewhere, we explored stakeholder responses to NOA and examined how these responses fit with what is known about individual, community and institutional responses to environmental hazards. The convergence of findings from multiple data sources, including interviews with stakeholder groups and documents, revealed a myriad of challenges associated with environmental and public health interventions in this community. What unfolded was consistent with the social sciences literature about communities facing similar hazards. 'Natural' and 'human-made' elements, the toxic nature of the threat and inadequate institutional responses to the threat combined to spark community conflict and other significant challenges. Implications for improved public health practice are discussed.

Choroidal hemangiomas are rare, congenital, benign vascular tumors of the choroid that have a wide range of symptomatology, signs, associated systemic features, clinical course and treatment options. There are two types of choroidal hemangiomas: circumscribed and diffuse. Circumscribed choroidal hemangiomas are usually small with a mean diameter of 7 mm, located in the posterior choroid within 3 mm of the foveola and occasionally in the subfovea. The subfoveal tumors tend to cause visual loss early in life due to the anterior displacement of the retina by the underlying tumor. Patients with parafoveal tumors remain asymptomatic until the 3rd or 4th decade of life. External ocular exam in these patients is usually unremarkable.

An 8-month-old infant with advanced bilateral retinoblastoma was managed with enucleation of the right eye and chemotherapy and radiotherapy of the left eye. Three years after treatment, an ill-defined, nonpigmented mass was noted in the anophthalmic right socket. Excisional biopsy revealed an amelanotic melanoma of the conjunctiva with superficial orbital invasion. There has been no tumor recurrence during 20 months of follow-up. J Pediatr Ophthalmol Strabismus 2007;44:300-302. AUTHORS Drs. Mahajan, C. Shields, Mashayekhi, and J. Shields are from the Oncology Service and Dr. Eagle is from the Department of Pathology, Wills Eye Institute, Thomas Jefferson University, Philadelphia, Pennsylvania. Dr. Freire is from the Department of Radiation Oncology, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, Pennsylvania. Originally submitted September 11, 2005. Accepted for publication September 22, 2005. Address correspondence to Carol L. Shields, MD, Oncology Service, Wills Eye Institute, 840 Walnut Street, Philadelphia, PA 19107. Supported in part by the Eye Tumor Research Foundation, Philadelphia, Pennsylvania (C. Shields); the Rosenthal Award of the Macula Society (C. Shields); the Paul Kayser International Award of Merit in Retina Research, Houston, Texas (J. Shields); and the Noel T. and Sara L. Simmonds Endowment for Ophthalmic Pathology, Wills Eye Institute, Philadelphia, Pennsylvania (R. Eagle).

The most common primary intraocular tumor is uveal melanoma, with an incidence of 6 cases per million per year (Sphields And Shields 1992a). In the United States, it represents less than 0.2% of all cancers (American Cancer Society 1990).

Among the different options for the treatment of retinoblastoma, plaque brachytherapy has become an important tool, as either the primary or the secondary modality, in selected cases.

In recognition of NCIPC's role in creating a safer world, we brought together 20 contributions for this Journal of Safety Research Anniversary Supplement that represents the breadth of our work while acknowledging that we cannot truly represent the depth of the work over the past two decades. The Center's current focal and cross-cutting areas are highlighted in the articles of this Supplement and cover a range of activities from violence prevention, unintentional injury, to acute care and rehabilitation. The Supplement also contains contributions from partners and highlights the resources of the Center.

Macular degeneration is the leading cause of severe irreversible blindness in the Western world (Bressler et al. 1988; Hyman et al. 1983). Most patients develop the “dry” form characterized by slowly progressive atrophy of the macular choroid and retina with mild to moderate loss of central vision. In contrast, a minority of patients develop the “wet” form of macular degeneration, which is characterized by the development of subretinal neovascularization, leakage, and scarring. Wet macular degeneration can be a rapid process destroying central vision in a matter of days, weeks, or months. Such subretinal neovascular events have been associated with age-related macular degeneration (ARMD), diabetes, high myopia, histoplasmosis, and laser photocoagulation. Clearly, the ability to control or stop neovascularization would be helpful in the management of these diseases.

There are several options for management of ciliary body melanoma, including plaque radiotherapy, charged particle irradiation, local resection, and enucleation. The choice of therapy depends on many factors, and plaque radiotherapy is often used.To determine the outcome of plaque radiotherapy in the management of ciliary body melanoma and to identify the risk factors associated with the development of radiation complications, tumor recurrence, metastasis, and melanoma-related death after plaque radiotherapy of ciliary body melanoma.We analyzed the clinical records of 136 patients with ciliary body melanoma who were treated with plaque radiotherapy between July 1976 and June 1992.The median follow-up period was 70 months. Using Kaplan-Meier survival estimates, the most frequent radiation complication at 5 years' follow-up was cataract, developing in 48% of the patients, followed by neovascular glaucoma (21%), retinopathy (20%), scleral necrosis (12%), and vitreous hemorrhage (11%). Visual acuity decrease (byor =3 Snellen lines) was noted in 40% of the patients at 5 years. Kaplan-Meier estimates showed that 8% of the patients developed recurrence, 28% had metastasis, and 22% died of melanoma-related causes by 5 years. Univariate analysis demonstrated that the factors predictive of radiation cataract were superonasal (P = .003) and inferior tumor meridian (P = .02) compared with inferonasal meridian and apex dose rate greater than 57 cGy/h (P = .05). The development of neovascular glaucoma was significantly related to iris involvement with the ciliary body tumor (P.001). The factors predictive of development of radiation retinopathy were base dose rate greater than 230 cGy/h (P = .03) and the presence of diabetes mellitus (P = .05). The only predictor of metastasis was tumor thickness greater than 7 mm (P = .02). The risk factors for melanoma-related death were the presence of metastasis (P.001), tumor thickness greater than 7 mm (P = .02), and recurrence (P = .02). Multivariate analyses showed that the most significant variables predictive of the development of scleral necrosis were intraocular pressure greater than 15 mm Hg (P.001) and tumor thickness greater than 7 mm (P = .007). The most significant predictive factors for vitreous hemorrhage were visual acuity of 20/40 to 20/200 (P = .02) and intraocular pressure greater than 15 mm Hg (P = .02). The best subset of independent predictors of vision decrease were mushroom tumor shape (P = .002), age older than 61 years (P = .006), and superonasal meridian (P = .04). The risks for melanoma-related death were presence of metastasis (P.001) and tumor thickness greater than 7 mm (P = .01). There was no group of significant variables predictive for radiation cataract, neovascular glaucoma, retinopathy, tumor recurrence, and metastasis in multivariate analysis.Plaque radiotherapy offers 92% 5-year local control rate for ciliary body melanoma. Metastasis occurs in 28% of the patients treated with this method by 5 years. Patients with tumors greater than 7 mm in thickness are at greater risk than patients with thinner tumors for metastatic disease and melanoma-related death. Major radiation complications include radiation cataract, neovascular glaucoma, retinopathy, and scleral necrosis.

Adenoid cystic carcinoma of the lacrimal gland is a malignant neoplasm that is generally found in adults and is usually managed by orbital exenteration and supplemental external beam irradiation or chemotherapy. A recent report has suggested that the tumor may have a less malignant course in children. We describe a case of adenoid cystic carcinoma of the lacrimal gland that simulated a dermoid cyst clinically and radiographically in a 9-year-old boy. The patient was treated with local surgical resection of the mass, followed by orbital plaque brachytherapy. Based on a review of the literature and our recent experience, the advisability of a more conservative approach to this tumor in selected cases is discussed. Although no prognostic conclusions can be drawn on the basis of a single case report with short follow-up, the relatively earlier detection of this tumor made possible by modern orbital imaging studies may allow total removal at an earlier stage and prevent orbital exenteration in a patient with normal vision. Recent developments suggest that there may be a basis for reassessing the advisability of a radical approach to the management of adenoid cystic carcinoma of the lacrimal gland in selected cases.

Objective This study aimed to determine whether the long-term melanoma-specific mortality rate of patients with a primary choroidal or ciliary body melanoma treated by enucleation is appreciably lower than that of similar patients treated by plaque radiation therapy. Design Retrospective, nonrandomized, comparative clinical trial. Participants A previously reported group of 237 patients, 140 treated by enucleation and 97 treated by cobalt-60 (Co-60) plaque between May 1976 and June 1980, and a residual group of 122 patients, 51 treated by enucleation and 71 treated by Co-60 plaque, were identified by variable-by-variable range matching. Intervention Primary treatment by enucleation or Co-60 plaque radiation therapy was performed. Main outcome measures Melanoma-specific mortality and duration of post-treatment survival were measured. Results The melanoma-specific mortality rate was substantially worse in the original enucleation subgroup over the entire 15-year follow-up interval; however, differences in baseline prognostic factors between the subgroups are likely to explain the difference in survival curves. After elimination of patients with nonoverlapping values of individual clinical variables to adjust for recognized intergroup differences at baseline, there was no significant or clinically important difference in the 15-year mortality curves of the residual subgroups. The relative rate ratio for the treatment effect in the residual patients was 0.97 (95% confidence interval, 0.51–1.86). There was no late downturn in the survival curve of the plaque-treated patients or late crossing of the curves. Conclusion A large difference in survival between equivalent groups of patients with primary choroidal or ciliary body melanoma treated by enucleation versus plaque radiation therapy appears to be unlikely.

Purpose: This study was undertaken to assess the toxicity and possible benefits from the administration of low-dose external-beam irradiation for Age-Related Macular Degeneration (ARMD). The premise of the treatment is that radiation induces regression and/or promotes inactivation of the subretinal neo-vasculature, resulting in reabsorption of fluid and blood thus reducing the risk for further leakage or bleeding, as well as subretinal fibrosis. Clinically, the beneficial effect could be translated into stabilization of visual acuity and prevention of progression of the wet type of ARMD with the possibility for some visual improvement. Methods and Materials: Allegheny University Hospitals, Hahnemann, Department of Radiation Oncology, treated 278 patients prospectively beginning in January 1995 with low-dose irradiation for wet-type macular degeneration. Two hundred forty-nine patients were treated with a total dose of 14.40 Gy in eight fractions of 1.80 Gy over 10-13 elapsed days, and 27 patients with 20 Gy at 2 Gy per fraction over 12-15 days. The first two patients were treated to a total dose of 10.00 Gy in five fractions of 2.00 Gy. Patients were evaluated at 2-3 weeks and 2-3 months. A percentage (36.7%) of the patients had previously received laser treatments in the study eye, 21.9% once, 5% twice, 9.7% three or more. Subjective visual acuity and toxicity data was collected on all patients. Results: At 2-3 weeks after treatment 195 patients (70%) retained their visual acuity without change, 68 patients (24.5%) stated they had improved vision, and 15 patients (4.8%) stated their vision continued to decrease. Two to 3 months after treatment, 183 patients (65.8%) had no change in their vision. 75 patients (27%) patients had an improvement in their vision, and 20 patients (7.2%) had a decrease in visual acuity. Transient acute reactions occurred in 14 of the 278 patients treated. Conclusion: Our observations in this group of 278 patients support the conclusion that many patients will have improved or stable vision after treatment with low-dose irradiation for age related wet type macular degeneration.

Background: Radiotherapy is effective for the management of most uveal metastases, and standard external beam radiotherapy is generally administered during a 3- to 4-week period. For those patients in whom external beam radiotherapy or other methods fail or those patients with solitary uveal metastases, plaque radiotherapy may be an alternative method. Objective: To determine the effectiveness of plaque radiotherapy for the management of uveal metastasis. Methods: A retrospective review of 36 patients with uveal metastases who were examined at the Oncology Service at Wills Eye Hospital, Philadelphia, Pa, and treated with plaque radiotherapy. The clinical findings and follow-up data of the primary tumor and the uveal metastasis were analyzed. Results: Of the 36 patients, 27 (75%) received plaque treatment as primary therapy for the uveal metastasis and 9 (25%) received plaque treatment as secondary therapy after failure of the uveal tumor to respond to external beam radiotherapy, chemotherapy, or hormonal therapy. During treatment, 22 patients (61%) had no other systemic metastasis and 14 (39%) had controlled systemic metastasis. No patients had active metastasis elsewhere. The uveal metastasis was solitary and well circumscribed in all but 1 patient; it measured a mean of 11 mm in basal dimension and 4 mm in thickness. The mean time for treatment was 86 hours, and the mean therapeutic dose was 68.80 Gy to the tumor apex and 235.64 Gy to the tumor base. Regression of the uveal metastasis was documented in 34 patients (94%) during a mean follow-up of 11 months. As early as 3 months after treatment, the mean tumor thickness had decreased to 2 mm. Plaque radiotherapy salvaged 5 of the 6 eyes that had failed prior external beam radiotherapy. Radiation retinopathy, radiation papillopathy, or both were found in 3 patients (8%) and occurred at a mean of 8 months after treatment. At the last examination, 18 patients (50%) were alive (11 with and 7 without active systemic metastasis) and 18 (50%) were dead from systemic metastasis. Conclusions: Plaque radiotherapy is an effective method for treating selected solitary uveal metastasis. It offers a high degree of tumor control, especially for those eyes in which other methods have failed. Plaque treatment is provided during a short period, minimizing the time demand for these patients with a limited life expectancy.

Prostate cancer is the most common as well as the most frequently irradiated malignancy involving the genitourinary tract. In 1995, the American Cancer Society anticipates that in the United States there will be 244 000 new cases diagnosed with 40 400 deaths due to the disease process American Cancer Society 1995). In addition, it is among the most successfully treated cancers of the genitourinary tract in terms of both definitive outcome and metastatic presentations.

Objectives To evaluate efficacy, patient tolerance, and adverse effects of CyberKnife radiosurgery for the treatment of intraocular and periocular lymphoma. Methods Retrospective case series of 13 patients who underwent CyberKnife radiosurgery was conducted. Results Fourteen eyes of 13 patients were included. The tissue location of the lymphoma was orbit (7 eyes), conjunctiva (3 eyes), choroid (2 eyes), and retina (2 eyes). The lymphoma type was classified as extranodal marginal zone B-cell lymphoma in 7 eyes (50%), diffuse large B-cell lymphoma in 3 eyes (21%), follicular lymphoma in 2 eyes (14%), and benign reactive lymphoid hyperplasia in 2 eyes (14%). The mean treatment dose was 1718 centigrays (cGy) (range, 1350-2250 cGy) given over a mean of 5 days (range, 3-5 days) with a mean dose rate of 320 cGy per fraction. Complete tumor resolution without local recurrence over a mean follow-up of 23 months was documented in all cases. Radiation-associated adverse effects included mild dry eye in 2 patients and cataract in 1 patient with conjunctival lymphoma. There was no radiation retinopathy or papillopathy, and visual acuity was preserved or improved in 13 eyes and decreased in 1 eye due to the presence of cataract. Conclusions CyberKnife radiosurgery is a well-tolerated technique for the treatment of intraocular and periocular lymphoma, allowing for local resolution of the lesions. An important benefit is that treatment was completed over 5 days.