Calvary Wakefield Hospital

Central retinal artery occlusion results in sudden, painless, usually permanent loss of vision in the affected eye. There is no proven, effective treatment to salvage visual acuity and a clear, unmet need for an effective therapy. In this work, we evaluated the efficacy of intravenous tissue-type plasminogen activator (IV alteplase) in a prospective cohort study and an updated systematic review and meta-analysis. We enrolled consecutive patients with acute central retinal artery occlusion within 48 hours of symptoms onset and with a visual acuity of <20/200 from January 2009 until May 2019. The primary outcomes were safety and functional visual acuity recovery. We compared rates of visual recovery between those treated with alteplase within 4.5 hours of symptom onset to those who did not receive alteplase (including an analysis restricted to untreated patients presenting within the window for treatment). We incorporated these results into an updated systematic review and patient-level meta-analysis. We enrolled 112 patients, of whom 25 (22.3% of the cohort) were treated with IV alteplase. One patient had an asymptomatic intracerebral hemorrhage after IV alteplase treatment. Forty-four percent of alteplase-treated patients had recovery of visual acuity when treated within 4.5 hours versus 13.1% of those not treated with alteplase (P=0.003) and 11.6% of those presenting within 4 hours who did not receive alteplase (P=0.03). Our updated patient-level meta-analysis of 238 patients included 67 patients treated with alteplase within 4.5 hours since time last known well with a recovery rate of 37.3%. This favorably compares with a 17.7% recovery rate in those without treatment. In linear regression, earlier treatment correlated with a higher rate of visual recovery (P=0.01). This study showed that the administration of intravenous alteplase within 4.5 hours of symptom onset is associated with a higher likelihood of a favorable visual outcome for acute central retinal artery occlusion. Our results strongly support proceeding to a randomized, placebo-controlled clinical trial.

A clear surgical field is critical during endoscopic sinus surgery (ESS). Hypotensive anesthesia and cardiac output (CO) may optimize the surgical field; however, evidence of their effect on bleeding and cerebral blood flow is conflicting. The aim of this study was to evaluate the effect of blood pressure (BP) and CO on intraoperative bleeding and middle cerebral artery blood flow velocity (Vmca ) during ESS. This was a prospective randomized controlled trial. Patients undergoing ESS for chronic rhinosinusitis at a tertiary institution in 2013 were randomized to receive BP manipulation using target-controlled noradrenaline infusion during surgery to either their left or right sinuses. The contralateral side in each patient served as control. Bleeding was scored using a 0 to 10 point bleeding assessment scale (BAS, 0-10) and Vmca was measured using transcranial Doppler ultrasonography every 10 minutes or when surgically opportune, and time-matched with BP and CO. Data was analyzed using Bland-Altman methods. A total of 105 time points were collected across a mean arterial pressure (MAP) range of 32 to 118 mmHg. Significant correlations were demonstrated between MAP and Vmca (r = 0.7, p < 0.0001), MAP and BAS (r = 0.50, p < 0.0001), CO and Vmca (r = 0.57, p < 0.0001), and CO and BAS (r = 0.42, p < 0.0001). The best surgical fields were seen at 40 to 59 mmHg MAP. However, MAP below 60 mmHg produced >50% reduction in Vmca in more than 10% of time points. Balancing surgical visibility with organ perfusion remains a challenge. The results of this study show that moderate hypotension significantly improves the surgical field; however reducing BP below 60 mmHg may risk cerebral hypoperfusion.

Chronic venous ulceration has been associated with dysfunction of the calf muscle pump (CMP). CMP ejection fraction can be used as an index of pump activity and is typically measured using air or strain gauge plethysmography (APG and SPG respectively) but both methods are technically complex and frequently exhibit poor reproducibility. In this study the ejection fraction of the CMP was assessed using bioelectrical impedance analysis (BIA). Calf resistance was recorded continuously at discrete frequencies (range 5 – 1000 kHz) using an Impedimed SFB7. Sensing electrodes were placed 20 cm apart over the calf muscle of the leg with the proximal electrode 7 cm distal to the crease at the back of the knee. Current input electrodes were placed at the base of the toes and fingers. Recordings were obtained from subjects undertaking the standard sequence of postural changes used to assess CMP activity: supine position with leg elevated (10 min); standing (5 min); plantar flexion of the ankle (10 repetitions in 10 seconds). Resistances representing residual volume and the functional venous volumes were determined from the resistance-time plots to calculate.

Among the many causes of peripheral neuropathy are diabetes, drug side-effects, human immunodeficiency virus (HIV) infection, leprosy, vitamin deficiency, alcohol abuse and inherited nerve disorders. Very often the underlying pathology is reversible if an underlying cause can be removed, a peripheral nerve having the potential to regenerate over many months. In the interim, and sometimes indefinitely, discomforts must be treated symptomatically. Consequences such as Charcot joints and plantar ulcers may be seen if the distal limb sites are not protected from damage. Autonomic neuropathy causes syncope, bladder atony, anhidrosis and dry mouth. Persistent and severe neuropathic pain requires trial of the response to one or more of the range of drugs in the classes antidepressants, anticonvulsants and antidysrhythmics (pp. 106–107).

The advance health care directive (or ‘anticipatory direction’) is an important component of the preparation by any individual for a time when some deterioration in individual competence is regarded as possible. It has been recommended as an important component of a routine medical examination at (say) the age of 75 years, or at the time of admission to an aged care facility. It becomes particularly relevant when the diagnosis of a potentially fatal condition has been made, and death and dying are a prospect requiring consideration. It provides an opportunity to clarify the range of possible outcomes and to indicate preferences for care. It can relieve family members and physicians of some of the burden of difficult decision-making.

Stroke is usually a dramatic event; unlike the progressive neurological deterioration of amyotrophic lateral sclerosis (ALS) or Parkinson's disease, and its outcome is difficult to predict. The sudden onset of stroke may call for urgent interventions to reduce progression or extension of brain damage, including administration of aspirin, thrombolytic drugs and blood pressure reduction, plus supportive care – intravenous (I-V) hydration, investigation of cause, prevention of deep vein thrombosis (DVT), early mobilization and appropriate diet. From that acute presentation approximately one third will die within days, one third will achieve a complete or partial recovery, and one third will not improve, and risk further deterioration and eventual death. That last group will be left with severe brain damage, be at risk of severe disability and major discomforts; it is for them that palliative management is most appropriate.