bluuebunny/crossref_metadata_2025 huggingface dataset:
Solitary Vulvar Syringoma With Deep Extension; Potential for Misdiagnosis as the Microcystic Adnexal Carcinoma (MAC)
Authors: Regmi Aayushma , Zelman Brandon , Mudaliar Kumaran M. , Speiser Jodi J.
Published: February 2023

A 43-year-old woman presented with a palpable, pruritic, minimally painful right vulvar lesion. Physical examination revealed approximately 2.0-cm tender nodule at 70’ clock in the right labia majora. Histological sections of the excision specimen showed an unremarkable epidermis with large, well-circumscribed dermal proliferation with extension to the reticular dermis. Within this proliferation are small solid and ductal structures relatively evenly distributed in the sclerotic stroma. The epithelial elements consisted of monomorphous cuboidal cells and assumed round, oval, curvilinear, or have other peculiar geometric shapes, including “comma-like” or “tadpole”-like configurations. The tumor cells were positive for CEA, EMA, and estrogen receptor and negative for progesterone receptor. The clinical presentation and the deep extension of the tumor were similar to the microcystic adnexal carcinoma. Although a syringoma generally presents with multiple lesions and usually involves the superficial dermis, a syringoma with deep extension was favored based on the lack of follicular differentiation, atypia, mitoses, and perineural invasion. Microcystic adnexal carcinoma and syringoma have a morphologic overlap and are misdiagnosed in 30% of the cases. Thus, it is exceptionally important for pathologists to be aware of and be able to distinguish these entities. To the best of our knowledge, this is the first case of a solitary, painful vulvar syringoma with deep extension.
Concurrent Presentation of Mycosis Fungoides and Primary Cutaneous Marginal Zone LPD: Clinicopathological Study of 4 Cases and Literature Review
Authors: Prieto-Torres Lucía , Machan Salma , Haro Rosario , Cerroni Lorenzo , Requena Luis , Rodríguez-Pinilla Socorro María
Published: February 2023

Background:

Mycosis fungoides is rarely associated to B-cell malignancies, and the few reported cases are mainly internal lymphomas involving secondarily the skin (ie, chronic lymphocytic leukemia).

Objectives:

The aim of our study is to describe the clinical and histopathological features of 4 patients presenting with 2 concurrent primary cutaneous lymphomas and review the pertinent literature.

Methods:

We identified 4 cases of concurrent primary cutaneous lymphomas in our institutions. An extracutaneous lymphoma was ruled out on the basis of a complete work out. We performed a PubMed search to identify reported cases of primary cutaneous composite or concurrent lymphomas.

Results:

Eleven cases of primary cutaneous concurrent lymphomas have been described in the literature. Counting all together (our cases and the cases previously described in the literature), mycosis fungoides was the most frequent primary cutaneous T-cell lymphoma (TCL) (13/15), followed by 1 case of peripheral TCL-NOS and 1 case of subcutaneous panniculitis–like TCL. Regarding the associated primary cutaneous B-cell lymphomas, 8/15 cases consisted of low-grade B-cell lymphomas [that is, 5 marginal zone lymphoma (in the most recent classification reclassified as marginal zone lymphoproliferative disorder, MZLD, 2 follicular-center B-cell lymphoma (primary cutaneous follicle-center lymphoma) and 1 low-grade NOS B-cell lymphoma]; 4/15 were associated to Epstein–Barr virus; 1 case consisted of a methotrexate-associated lymphoproliferative disease, and 2 cases consisted of primary cutaneous diffuse large B-cell lymphoma-leg type.

Conclusions:

Primary cutaneous concurrent lymphomas are exceptional. Clinicopathological correlation and a complete workout to reach the correct diagnosis may guide the appropriate treatment in each case.
Aesthetic Concerns of Chin Augmentation With Hyaluronic Acid Soft Tissue Filler in Chinese: A Prospective, Observational Study
Authors: Li Xin-Rui , Hong Wei-Jin , Li Zhen-Hao , Luo Cheng-En , Jiang Xuan-Yu , Luo Sheng-Kang
Published: February 2023

BACKGROUND

The chin is an important facial structure that directly affects the overall contour of the face. The key to achieving a beautiful, effective, and safe chin injection is to make a good facial assessment and use an appropriate injection technique to achieve the best injection effect.

OBJECTIVE

In this article, the authors will discuss cosmetic concepts for the chin area and verify the effectiveness of chin augmentation techniques.

MATERIALS AND METHODS

Chin volume injections were performed on 23 Asian female subjects and 15 Asian male subjects. Demographic and imaging data were collected, and the facial aesthetic length was calculated. The authors also measured the length of beautiful chins, as evaluated by 2 plastic surgeons, and the ratios of chins from “The 100 Most Beautiful/Handsome Faces in China” published by TCC Asia in 2020.

RESULTS

The mean volume of chin filling was 1.89 ± 0.74 mL in female subjects and 2.68 ± 1.28 mL in male subjects. The ideal length of the chin was equal to that of the nasal dorsum in male subjects, and the ideal chin-to-nasal dorsum ratio was 0.9 in female subjects.

CONCLUSION

In this study, the authors investigate sex differences in chin aesthetics among the Chinese population and introduce an aesthetic and anatomical approach to chin injection.
Analysis of the clinical features and risk factors of death in patients with mushroom poisoning
Authors: Yang Yan , Shao Ruifei , Xue Jinfang , Lou Xiran , Ning Deyuan , Chen Guobing
Published: February 2023

Background

Wild edible mushrooms are rich in nutrition and popular with people; however, few laboratory studies are available about the predictability of outcomes among patients with mushroom poisoning. Therefore, this study aimed to analyze the clinical features and death risk factors of patients with mushroom poisoning.

Methods

Patients with mushroom poisoning admitted to the hospital from 2015 to 2021 were retrospectively evaluated.

Results

A total of 197 patients with mushroom poisoning were enrolled in this study, of which 100 (50.76%) were males, and the mortality was 10.66% (21/197). Patients who died were more likely to have demonstrated a long latency, high alanine aminotransferase, aspartate aminotransferase, direct bilirubin, total bilirubin (TB), activated partial thromboplastin time, prothrombin time, international normalized ratio, creatinine, and blood urea nitrogen. Multiple logistic regression analysis indicated that TB level greater than or equal to 34.2 μmol/L had the greatest lethal risk and could increase the risk of death by 14.588 times (odds ratio: 15.588; 95% confidence interval: 2.088–116.351), which indicated that TB was an independent risk factor of death in patients with acute mushroom poisoning.

Conclusion

Bilirubin concentration was associated with the increased likelihood of mortality. Total bilirubin was the independent risk factor of mushroom poisoning.
Esketamine use for anesthesia induction in an ectopic pregnancy patient with hemorrhagic shock: a case report
Authors: Liu Xiaojie , Hua Zhen , Dong He , Zhuo Yanli , Chu Haichen , Li Tianjun
Published: February 2023

Background

Anesthesia induction is challenging in patients with hemodynamic instability. Esketamine has hypnotic, analgesic, and sympathomimetic effects and is the only anesthetic that can increase sympathetic tension. Therefore, it may be more suitable for patients with hypovolemic shock.

Case summary

A 40-year-old female patient presented to the emergency department with new-onset abdominal pain and vaginal bleeding for 2 hours. Menstruation of the patient was regular, her self-reported urine pregnancy test was positive half a month earlier, and she had been diagnosed at another hospital 12 days earlier based on a positive blood human chorionic gonadotropin test. Gynecological ultrasonography demonstrated no pregnancy sac in utero, confirming ectopic pregnancy. Emergency laparoscopy for ectopic pregnancy should be performed immediately. We administered esketamine for induction.

Conclusion

Esketamine-based total intravenous anesthesia results in mild hypotension in ectopic pregnancies with hemorrhagic shock.
Acute infectious purpura fulminans: case report of a medical emergency
Authors: Li Xueying , Ma Yaqian , Sun Qichao , Hu Ruihan , Liu Zhi , Liu Xiaowei
Published: February 2023

Background

Purpura fulminans (PF), characterized by the sudden onset of large, rapidly spreading hemorrhagic skin infarctions and associated disseminated intravascular coagulation, is an uncommon medical emergency. Early recognition, prompt antibiotic therapy, and intensive supportive care are essential to reduce the mortality rate of this disease.

Case Presentation

We report the case of a 28-year-old Chinese man with acute infectious PF. He initially presented with a fever, which rapidly progressed to septic shock, followed by skin lesions and disseminated intravascular coagulation. Computed tomography imaging revealed superior and inferior mesenteric vein thromboses. Although the etiology of the patient’s infection was unclear, the patient received early fluid resuscitation, empiric antibiotic therapy, and blood product replacement, which resulted in gradual clinical improvement.

Conclusion

Sepsis-associated PF may be reversible with timely empirical therapeutic interventions; however, the severity of PF should not be underestimated, and treatment should be tailored to individual patients.
Treatment of prolonged clonidine-induced autonomic instability with midodrine: a case report about a new approach or a cautionary tale?
Authors: Malouf Saada , Henry Catherine , Pemberton Lara , Rotella Joe-Anthony
Published: February 2023

Background

Clonidine is a centrally acting α2 adrenergic and imidazoline-1 receptor agonist that can cause somnolence, bradycardia, and hypotension within several hours of ingestion. Less well-described but observed by us locally is the observation that patients presenting after large overdoses including clonidine can have prolonged autonomic instability. As a result, they may require many days in hospital before recovery. We have previously used midodrine as an indirect antagonist with good effect; however, there are no previous reports of its use for this indication.

Case presentation

We present the case of a young female patient who developed prolonged autonomic instability following a large overdose of clonidine (coingested with smaller doses of escitalopram + lisdexamfetamine) that was treated with midodrine but complicated by a type 2 non-ST segment elevated myocardial infarction.

Conclusion

Midodrine seems to ameliorate this protracted instability and may provide a means to decrease hospital length of stay in appropriate individuals.
Twenty-four-Year Trends in Incidence and Mortality of Nephrotic Syndrome: A Population-Based Cohort Study
Authors: Vestergaard Søren Viborg , Birn Henrik , Jensen Simon Kok , Sørensen Henrik Toft , Nitsch Dorothea , Christiansen Christian Fynbo
Published: February 2023

Background:

With the increasing prevalence of risk factors for nephrotic syndrome, updated epidemiologic data on the syndrome are needed. We examined its age- and sex-specific incidence, histopathology, and mortality over 24 years.

Methods:

This nationwide cohort study included all adults with first-time-recorded nephrotic syndrome in Denmark during 1995–2018 using the Danish National Patient Registry. We obtained data on age, sex, hospital-diagnosed comorbidities, and histopathologic findings. We computed overall, and age- and sex-specific, incidence rates of nephrotic syndrome, 1- and 5-year mortality by calendar period, and 1-year hazard ratios (HRs) of death using Cox models.

Results:

We identified 3,970 adults with first-time nephrotic syndrome diagnosis. Incidence was highest in men and increased with age to 11.77 per 100,000 person-years (95% confidence interval [CI]: 10.21–13.32) in men aged 80+ years, and 6.56 per 100,000 person-years (95% CI: 5.71–7.41) in women aged 80+ years. Incidence of nephrotic syndrome increased from 3.35 per 100,000 person-years (95% CI: 3.12–3.58) in 1995–2000 to 4.30 per 100,000 person-years (95% CI: 4.05–4.54) in 2013–2018. Over time, 1-year mortality of nephrotic syndrome was stable at 13%–16%, but HR of death was 0.54 (95% CI: 0.42–0.69), adjusted for age, sex, and comorbidities, in 2013–2018 compared with 1995–2000. Subdistribution of glomerulopathies was stable over time with membranous nephropathy and minimal change disease being the most common.

Conclusion:

During 1995–2018, the incidence of recorded adult nephrotic syndrome increased slightly, and the adjusted mortality of nephrotic syndrome decreased markedly. Whether these findings reflect changes in epidemiology or awareness and coding of nephrotic syndrome, remains to be clarified.
Distribution and Prevalence of Serotypes of Group B Streptococcus Isolated from Pregnant Women in 30 Countries: A Systematic Review
Authors: Maria Silva Marta , Alcântara Silva Érica , Novais Teixeira Oliveira Caline , Cordeiro Santos Maria Luísa , Lima Souza Cláudio , Freire de Melo Fabrício , Vasconcelos Oliveira Márcio
Published: February 2023

Objective

This review aimed to compile scientific data on the distribution and prevalence of group B Streptococcus (GBS) serotypes isolated from pregnant women across 30 countries from 2010 to 2019.

Methods

This was a systematic review that addresses the distribution and prevalence of GBS in pregnant women. The search included studies published between January 2010 and December 2019 in PubMed, Virtual Health Library (BVS), ScienceDirect, SciELO (Scientific Electronic Library Online), and LILACS databases. We also surveyed relevant articles published in English, Spanish, and Portuguese between February and April 2020. Original articles, Communication, Short report, Theses, and Dissertations were included. The prevalence of GBS colonization, method for capsular serotyping, antimicrobial resistance, and distribution and prevalence of serotypes were extracted from each study.

Results

In all, 785 publications were identified. After applying the eligibility criteria, 48 articles were included for the final systematic analysis; most articles were from Asia and were published during the years 2014 to 2017. For the identification of serotypes, most studies used the polymerase chain reaction technique. There were records of all 10 GBS serotypes, namely, Ia, Ib, and II–IX, among the countries analyzed. Antibiotic resistance was mainly associated with strains of serotypes Ia–V.

Conclusion

This review showed that GBS serotypes are distributed differently in the 30 analyzed countries, with serotypes Ia, Ib, and II to V being the most prevalent. Furthermore, our results highlighted the relationship of GBS with maternal colonization, implications for neonates, and antibiotic resistance.
Care Bundles: Enhanced Recovery After Delivery
Authors: Hu Ling-Qun , Lysandrou Plato J. , Minehart Rebecca , Wang Jing-Ping , Xia Yun , Hu Yiling , Worly Brett
Published: February 2023

The care of obstetrics patients has improved dramatically over the past few decades. Unfortunately, rates of cesarean section remain high, and decreasing this rate requires close care and follow-up in the prenatal outpatient setting. Counseling regarding cesarean delivery and vaginal delivery is imperative. Opportunities still exist in helping patients objectively weigh the decision for cesarean delivery versus vaginal delivery. Additional developments have occurred in the intrapartum and the postpartum setting, with an aim to improve patient and neonatal outcomes. Changes have been implemented for patients undergoing cesarean delivery including preoperative and intraoperative treatment of pain, nausea, and vomiting, as well as postoperative care bundles that improve patient outcomes. Innovations have also occurred in the care of postpartum patients after vaginal delivery, again with improvements in patient outcomes. This article summarizes the current evidence, provides care recommendations, and identifies the next steps in improving obstetrics care.
Development and Evaluation of a Height-Based Tobramycin Initial Dosing Nomogram for the Treatment of Adult Cystic Fibrosis Pulmonary Exacerbations
Authors: El Hassani Mehdi , Thirion Daniel J. G. , Koloskoff Kevin , Matouk Elias , Simard Chantale , Cloutier Isabelle , Pilote Sylvie , Marsot Amélie
Published: February 2023

Tobramycin is widely used to treat pulmonary exacerbations of cystic fibrosis. Height has been previously found to be significantly more predictive of tobramycin pharmacokinetics than body weight. This study aimed to develop a height-based initial dosing nomogram and evaluate its performance in peak concentration (Cmax) precision relative to standard and fixed dosing. Monte Carlo simulations were performed to develop a nomogram representing the doses required to reach Cmax targets at different heights. Cmax data observed at 2 clinical centers [McGill University Health Centre (MUHC) and Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ-UL)] were compared with population-predicted Cmax using the doses derived from the nomogram alongside a fixed dose. Height-based dosing resulted in significantly less variable-predicted Cmax values [coefficient of variation (CV) MUHC = 15.7% and IUCPQ-UL = 10.8%] than the Cmax values observed in clinical practice (CV MUHC = 30.0% and CV IUCPQ-UL = 26.9%) and predicted Cmax values obtained from a fixed dose (CV MUHC = 21.2% and CV IUCPQ-UL = 16.3%). An initial dosing nomogram was developed to help reduce pharmacokinetic variability in the observed Cmax. More precise dosing would allow for better clinical outcomes in adult patients with cystic fibrosis.
Effect of Therapeutic Plasma Exchange on Itraconazole Pharmacokinetics: A Case Study
Authors: Seah Vincent , Sreeharan Thulashigan , Kocic Danijela , Reuter Stephanie E. , Girgis Laila , Marriott Deborah J. E. , Stocker Sophie L.
Published: February 2023

The authors present the case of a 34-year-old male patient who underwent therapeutic plasma exchange (TPE) for amyopathic dermatomyositis. Immunosuppression resulted in Aspergillus lentulus pulmonary infection, requiring treatment with super bioavailable-itraconazole. Therapeutic itraconazole concentrations were attained after 2 weeks of treatment after dose adjustments. Interestingly, a substantial reduction in plasma itraconazole concentration was observed during TPE, which was attributed to an insufficient delay between the dosing of itraconazole and TPE initiation. Furthermore, there was an increase in plasma concentration post-TPE, which presumably reflects the redistribution of itraconazole from peripheral compartments back into plasma. This was confirmed by sampling of the TPE plasmapheresate, which revealed that changes in plasma concentration overestimated itraconazole clearance. These findings highlight that the pharmacokinetics of itraconazole are altered during TPE, which should be considered when timing drug administration and obtaining plasma concentrations.
An Unusual Case of Low Vancomycin Exposure Despite Extremely High Vancomycin Doses Accompanied by Renal Toxicity: A Grand Round
Authors: van Schip Anne M. , van Diemen Jeske J. K. , van Hest Reinier M. , Harris Vanessa C.
Published: February 2023

This grand round describes the case of a patient who received 10 grams (143.5 mg/kg) of vancomycin every 24 hours via continuous infusion, in whom the highest observed level was only 15.4 mg/L. Despite subtherapeutic levels, renal impairment was encountered, which resolved after the discontinuation of vancomycin. Glomerular hyperfiltration was found through nuclear glomerular filtration rate measurement, which likely explains the need for high doses (>6 grams per 24 hours continuous infusion) without reaching therapeutic serum levels.
Diabetes Is Negatively Associated With Meeting Physical Activity Time-Intensity Guidelines in Patients With Claudication
Authors: Gardner Andrew W. , Montgomery Polly S. , Zhang Shangming , Pomilla William A. , Wang Ming , Shen Biyi , Liang Menglu
Published: February 2023

Purposes:

We determined the percentage of patients with peripheral artery disease (PAD) and claudication who meet the 2018 physical activity (PA) time-intensity guidelines, and we identified the clinical characteristics associated with the status of meeting the guidelines.

Methods:

Five hundred seventy-two patients were assessed on their daily ambulatory activity for 1 wk with a step activity monitor, and were evaluated on whether or not they achieved 150 min/wk of moderate-intensity PA.

Results:

Thirty-one percent (n = 175) of the patients with PAD met the PA time-intensity guidelines and 69% (n = 397) did not. In a final multivariable logistic regression model identifying the independent predictors of meeting the PA time-intensity guidelines from clinical characteristics, diabetes was the only significant variable entered (OR = 0.310: 95% CI, 0.175-0.538; P < .001) and was associated with a 69% lower chance of meeting the guidelines. Patients with diabetes spent less daily time in moderate-intensity ambulatory PA than patients without diabetes (15 ± 13 min/d vs 23 ± 20 min/d; P < .001).

Conclusions:

Thirty-one percent of patients with PAD and claudication met the PA time-intensity guidelines. Furthermore, patients with diabetes were least likely to meet the PA time-intensity guidelines, as they had a 69% lower chance than patients without diabetes. The clinical significance is that PAD patients who have diabetes are particularly susceptible to being physically sedentary, and are therefore prime patients who should be encouraged to increase their daily PA.
The Impact of Underlying Obstructive Sleep Apnea Treatment on Exercise Capacity in Patients With Pulmonary Hypertension Undergoing a Cardiac Rehabilitation Program
Authors: Sykes Alexandra Vaio , Sonners Christine , Schmickl Christopher N. , Raphelson Janna , Swiatkiewicz Iwona , Roberts Erin , Feldman Erica , Malhotra Atul , Taub Pam R.
Published: February 2023

Purpose:

Obstructive sleep apnea (OSA)–related pulmonary hypertension (PH) can often be reversed with treatment of OSA via continuous positive airway pressure. We hypothesized that treatment of OSA would be associated with a greater improvement in exercise capacity (EC) with cardiac rehabilitation (CR), especially in patients with PH as compared with those who are untreated.

Methods:

We reviewed medical records of 315 consecutive patients who participated in CR. Pulmonary hypertension status was assessed on the basis of peak tricuspid regurgitant velocity (>2.8 m/sec) on pre-CR echocardiograms. The OSA status (no, untreated, or treated OSA) was determined on the basis of results from sleep studies, continuous positive airway pressure device data, and physician notes. Exercise capacity was assessed by measuring metabolic equivalents (METs) using a treadmill stress test before and after CR.

Results:

We included 290 patients who participated in CR with available echocardiographic data: 44 (15%) had PH, and 102 (35%) had known OSA (30 treated and 72 untreated). Patients with OSA versus those with no OSA were more likely to have PH (P = .06). Patients with PH versus no-PH were associated with significantly lower baseline METs in crude and adjusted analyses (P ≤. 004). The PH and OSA status in isolation were not associated with changes in METs (P > .2) with CR. There was a significant interaction between OSA treatment and PH in crude and adjusted analyses (P ≤.01): treatment vs no treatment of OSA was associated with a clinically and statistically greater improvement in METs in patients who participated in CR with but not without PH.

Conclusion:

Baseline PH was associated with decreased baseline EC but did not attenuate CR-related improvements in METs. However, in the subset of OSA patients with PH, OSA therapy was associated with improved EC after CR.
Characteristics and Predictors of Postural Control Impairment in Patients With COPD Participating in a Pulmonary Rehabilitation Program
Authors: Pichon Romain , Ménard Mathieu , Haering Diane , Crétual Armel , Beaumont Marc
Published: February 2023

Purpose:

Postural control impairment has been identified as a potential extrarespiratory manifestation in patients with chronic obstructive pulmonary disease (COPD). The aims of this study were to identify clinical factors that characterize patients with reduced postural control, to examine the correlation between clinical factors and postural control and to determine predictors of an impaired postural control among COPD participants enrolled in a pulmonary rehabilitation (PR) program.

Methods:

This study is a secondary analysis of an observational study (PARACHUTE). The baseline assessment of the PR program was used for the analysis. Postural control impairment was defined using the Brief BESTest score (BBT).

Results:

Participants (n = 73) were included in the analysis, 43 of them were classified in the reduced postural control group. The between-group comparison (non-reduced vs reduced postural control) identified differences for partial pressure in oxygen (PaO
2), Saint George Respiratory Questionnaire (SGRQ) total score and subscores (SGRQ-Symptoms, SGRQ-Activities, and SGRQ-Impact), COPD assessment test (CAT), and anxiety score of the Hospital Anxiety and Depression Scale. The BBT score was significantly correlated with maximal inspiratory pressure (MIP), SGRQ, SGRQ-Symptoms, SGRQ-Impact, Falls Efficacy Scale, modified Medical Research Council Scale, 6-min walk test, and PaO
2. Logistic regression identified SGRQ-Symptoms, PaO
2, MIP, and body mass index (BMI) as predictors of the presence of reduced postural control.

Conclusion:

Low quality of life (QoL) and PaO
2 and high anxiety seem to be discriminative characteristics of patients with COPD with reduced postural control. Furthermore, QoL, PaO
2, inspiratory muscle strength, and BMI seem to be acceptable predictors of the presence of postural control impairment.
Disparities in Adherence to Concussion Clinical Care Recommendations in a Pediatric Population
Authors: Mohammed Fairuz N. , Master Christina L. , Arbogast Kristy B. , McDonald Catherine C. , Sharma Shelly , Kang Boping , Corwin Daniel J.
Published: February 2023

Objective:

To characterize the relationship of sociodemographic factors to adherence to provider recommendations for pediatric concussion.

Setting:

Primary care (PC) practices within the Children's Hospital of Philadelphia network.

Participants:

Patients aged 5 to 18 years old who presented to any PC site for concussion from September 26, 2019, to December 31, 2019.

Design:

Retrospective medical record review.

Main measures:

The primary outcome was adherence to follow-up recommendations as defined by (1) continued follow-up until provider clearance to return to full activity; (2) no more than 2 no-show visits; and (3) for those referred to specialty care (SC), attending at least 1 visit. We compared adherence by race/ethnicity, insurance, age, sex, injury mechanism, and repeat head injury using bivariate and multivariate analyses. A secondary outcome of referral to SC was compared by sociodemographic factors.

Results:

A total of 755 patients were included. Overall, 80.5% of the patients met adherence criteria. Following adjustment, non-Hispanic Black patients and publicly insured/self-pay patients were less likely to adhere to recommendations than non-Hispanic White patients (adjusted odds ratio [AOR] = 0.60; 95% CI, 0.37-1.00) and privately insured patients (AOR = 0.48; 95% CI, 0.30-0.75), respectively. When assessing differences in referral to SC, non-Hispanic Black patients and publicly insured/self-pay patients were more likely to receive a referral than their non-Hispanic White peers (OR = 1.56; 95% CI, 1.00-2.45) and privately insured patients (OR = 1.56; 95% CI, 1.05-2.32), respectively.

Conclusion:

This study highlights disparities in adherence to concussion care recommendations, with non-Hispanic Black and publicly insured/self-pay patients less likely to adhere to follow-up recommendations than non-Hispanic White and privately insured patients, respectively. These disparities may impact recovery trajectories. Future studies should aim to identify specific individual- and system-level barriers preventing adherence to care in order to ultimately inform targeted interventions to achieve equity in care delivery and outcomes.
Long-Term Risk for Mood and Anxiety Disorders After Pediatric Traumatic Brain Injury: A Population-Based, Birth Cohort Analysis
Authors: Esterov Dmitry , Witkowski Julie , McCall Dana M. , Weaver Amy L. , Brown Allen W.
Published: February 2023

Objective:

To determine whether exposure to traumatic brain injury (TBI) before 10 years of age is associated with development of a mood or anxiety disorder by 25 years of age, and whether sex or injury severity influences this risk.

Setting:

Olmsted County, Minnesota.

Participants:

A total of 5518 persons born from January 1, 1976, through December 31, 1982.

Design:

Population-based, birth cohort study. Children sustaining TBI before 10 years of age (index date) were confirmed by manual record review and classified by injury severity using the Mayo Classification System. Each TBI case was age- and sex-matched to 2 referents from the same birth cohort without a history of TBI at the index date. Cox proportional hazards models were fit to compare the risk of a subsequent clinically diagnosed mood or anxiety disorder by 25 years of age between TBI cases and referents. Separate analysis was performed stratified by sex and injury severity.

Main Measures:

Incidence of mood and anxiety disorders determined through clinical diagnostic codes and manual record review.

Results:

The study included 562 children (238 females [42.3%] and 324 males [57.7%]) with TBI before 10 years of age (mean [SD] age at TBI: 4.7 [2.8] years). At least 1 mood or anxiety disorder was diagnosed for 115 persons with TBI and 215 referents. No statistically significant association existed between childhood TBI status and anxiety disorder (adjusted hazard ratio [aHR], 1.01 [95% confidence interval (CI), 0.71-1.43]; P = .97) or mood disorder (aHR, 1.16 [95% CI, 0.92-1.47]; P = .21). However, females who sustained TBI had a significantly increased risk of a subsequently diagnosed mood disorder compared with age-matched female referents (aHR, 1.40 [95% CI, 1.04-1.89]; P = .03).

Conclusions:

This study suggests that isolated TBI before 10 years of age is not significantly associated with an increased risk of anxiety or mood disorder by 25 years of age, though females may be at an increased risk.
PREDICTION OF MACULAR HOLE SIZE PROGRESSION BASED ON BASELINE OPTICAL COHERENCE TOMOGRAPHY FINDINGS
Authors: Moussa George , Jalil Assad , Patton Niall , Sabatino Francesco , Jasani Kirti , Dhawahir-Scala Felipe , Sousa David Cordeiro , Ivanova Tsveta
Published: February 2023

Purpose:

To quantify the rate of idiopathic macular hole progression from presentation and identify factors that may influence stratification and urgency for surgical listing based on the initial optical coherence tomography scans.

Methods:

The minimal linear diameter (MLD), base diameter (BD), and hole height on nasal and temporal sides of idiopathic macular hole were measured on spectral domain optical coherence tomographies, on initial presentation and just before surgery. Mean hole height, hole height asymmetry (absolute difference between nasal and temporal height), MLD/BD, and MLD change per day (MLD/day) were calculated for each patient. Multivariable linear regression analysis with MLD/day as the dependent variable was performed to identify significant risk factors for MLD progression. Minimal linear diameter was grouped to quintiles: 1: ≤290 µm, 2: >290 µm and ≤385 µm, 3: >385 µm and ≤490 µm, 4: >490 µm and ≤623 µm, and 5: >623 µm.

Results:

In 161 eyes (157 patients), we report significant associations with MLD/day: 1) MLD/BD (P = 0.039) (i.e., wide BD relative to MLD lead to faster progression of MLD), 2) hole height asymmetry (P = 0.006) (larger absolute difference between nasal and temporal hole height lead to faster progression), and 3) days between scans (P < 0.001) (longer duration between scans had reduced MLD/day, indicating more rapid increase initially then plateaux), and relative to MLD Quintile 1, MLD Quintile 3 (P = 0.002) and MLD Quintile 4 (P = 0,008), and MLD Quintile 5 (P < 0.001) all lead to a reduced MLD/day rate on multivariable regression.

Conclusion:

In addition to finding that the previously reported initial smaller MLD is a risk factor for rapid MLD progression, we report two novel findings, large hole height asymmetry and a low MLD/BD (wide base relative to MLD), that represent significant risk factors. These factors should be taken into consideration on presentation to stratify timing of surgery.
CORRELATION BETWEEN INFLAMMATORY FOCI REACTIVATION AND ATROPHY GROWTH IN EYES WITH IDIOPATHIC MULTIFOCAL CHOROIDITIS
Authors: Airaldi Matteo , Zicarelli Federico , Forlani Veronica , Casaluci Marco , Oldani Marta , Staurenghi Giovanni , Invernizzi Alessandro
Published: February 2023

Purpose:

To correlate the number of inflammatory reactivations in atrophic foci of multifocal choroiditis (MFC) with their growth rate over a 4-year span.

Methods:

Comparative case series. Optical coherence tomography scans of patients affected by MFC were reviewed to identify reactivations within or at the margin of atrophic MFC foci. The area of selected lesions was semiautomatically delineated on fundus autofluorescence images and recorded at yearly intervals for a total follow-up of 4 years. The main outcome was the difference in annual square-root transformed area growth rate between lesions that reactivated and lesions that did not.

Results:

Sixty-six foci of 30 eyes of 24 patients were included. All MFC foci enlarged over time, but the annual growth rate was more than double in lesions that reactivated compared with those that did not (mean [SD], 0.051 [0.035] vs. 0.021 [0.015] mm/year, P < 0.001), despite starting from comparable baseline areas. For each additional inflammatory reactivation, the annual growth rate increased by more than 20% (+0.009 mm/year, 95% CI [0.006, 0.012], P < 0.001).

Conclusion:

Increasing number of reactivations of atrophic foci led to proportional increments in their growth rate, highlighting the need for a tight control of inflammatory relapses in patients affected by MFC.
SYRINGE DESIGN AND FILLING TECHNIQUE AFFECT ACCURACY OF ANTI–VASCULAR ENDOTHELIAL GROWTH FACTOR INTRAVITREAL INJECTIONS
Authors: Krauthammer Mark , Harel Gal , Moisseiev Elad
Published: February 2023

Purpose:

To evaluate the effect of syringe design and filling technique on the accuracy of anti–vascular endothelial growth factor delivery.

Methods:

Volume output was measured with three syringe designs: a 1.0-mL slip-tip syringe, a 1.0-mL Luer-lock syringe, and a ranibizumab prefilled syringe—using two filling techniques (“upward” and “downward”) and two fluids (water and bevacizumab). A total of 300 simulated injections were performed. Accuracy was determined by difference from the intended volume of 50 µL and by mean absolute percentage error.

Results:

Volume outputs were significantly different between syringe designs, with mean values of 61.99 ± 4.18 µL with the 1-mL slip-tip syringe, 57.43 ± 4.95 µL with the Luer-lock 1-mL syringe, and 51.06 ± 4.74 µL with the ranibizumab syringe, making the latter the most accurate syringe. There were 37 cases (12.3%) of underdosing below 50 µL, the majority of which occurred with the ranibizumab syringe. The “downward” technique reduced the occurrence of air bubbles.

Conclusion:

Intravitreal injections using 1.0-mL syringes are less accurate than using the ranibizumab prefilled syringe, which has a low-volume and low dead-space plunger design. The variability in volume output may result in less predictable treatment response, especially in cases of underdosing, which were more common with the ranibizumab syringe.
CHARACTERISTICS OF THE MACULAR MICROVASCULATURE IN IDIOPATHIC EPIRETINAL MEMBRANE PATIENTS WITH AN ECTOPIC INNER FOVEAL LAYER
Authors: Yu Hwa-Young , Na Yong-Jin , Lee Sung-Chul , Lee Min-Woo
Published: February 2023

Purpose:

To identify the characteristics of the retinal microvasculature in epiretinal membrane patients with ectopic inner foveal layer (EIFL).

Methods:

Patients were classified into two groups: those without EIFL (Group 1) and those with EIFL (Group 2). The vessel density (VD), perfusion density (PD), and the foveal avascular zone (FAZ) parameters were compared using optical coherence tomography angiography. Linear regression analysis was performed to identify the optical coherence tomography angiography parameters associated with best-corrected visual acuity.

Results:

The VD of the central area in Group 1 and Group 2 was 11.6 ± 3.3 and 17.2 ± 2.8 mm−1, respectively (P < 0.001), the PD of the central area was 21.7 ± 6.2 and 32.0 ± 5.5%, respectively (P < 0.001), and the FAZ area was 0.24 ± 0.11 and 0.09 ± 0.08 mm2, respectively (P < 0.001). Based on the linear regression analysis, the VD of the central area (B = 0.018, P = 0.003), the PD of the central area (B = 0.009, P = 0.004), and FAZ area (B = −0.489, P = 0.013) were significantly associated with best-corrected visual acuity in patients with epiretinal membrane.

Conclusion:

The VD and PD of the foveal area were significantly higher in patients with EIFL, and the FAZ area was lower in patients with EIFL than in those without EIFL. In addition, the VD and PD of the foveal area were negatively associated with best-corrected visual acuity, and the FAZ area was positively associated with best-corrected visual acuity in patients with epiretinal membrane.
DIRECT MACULAR HOLE MANIPULATION RESULTS IN HIGH SUCCESS RATE IN SECONDARY MACULAR HOLE REPAIR
Authors: Schönbach Etienne M. , Knight Darren K. , Wu Chris Y. , Arevalo J. Fernando , Bittencourt de Souza Luiza , Cheng Lingyun , Chhablani Jay , Delalibera Pacheco Kátia , Feucht Nikolaus , Kozak Igor , Maia André , Maier Mathias , Roizenblatt Marina , Smiddy William E. , Sobol Warren M. , Freeman William R.
Published: February 2023

Purpose:

To investigate closure rates and functional outcomes of surgery for refractory and recurrent macular holes (MHs) in a real-world setting.

Methods:

Retrospective review of secondary MH surgeries.

Results:

A total of 72 eyes from 72 patients were included. Eyes had a mean of 1.51 surgeries before inclusion into this study with a mean MH size of 762 µm and a mean baseline logarithm of the minimum angle of resolution best-corrected visual acuity of 1.11 (∼20/260 Snellen). Closure rates were 89.3% for tissue transplantation, 77.3% for internal limiting membrane (ILM) flaps, 92.9% for MH manipulation, and 12.5% for repeat ILM peeling (P < 0.05). Best-corrected visual acuity changes in logarithm of the minimum angle of resolution from baseline to postoperative month six were +0.29 for ILM peeling alone (15 Early Treatment Diabetic Retinopathy Study letters worse), −0.39 for MH manipulation (20 Early Treatment Diabetic Retinopathy Study letters improved), −0.23 for tissue transplantation (13 Early Treatment Diabetic Retinopathy Study letters improved), and −0.2 for ILM flaps (10 Early Treatment Diabetic Retinopathy Study letters improved; P < 0.05).

Conclusion:

Secondary MH closure is possible using various surgical techniques with acceptable anatomical closure rates. Repeat ILM peeling is associated with the lowest closure rates and poorest functional results. To distinguish between techniques would require a large sample size of approximately 750 eyes.
Peripheral Intravascular Catheter-Assisted Sutureless Scleral Fixation of Three-Piece Intraocular Lenses: A Novel Technique
Authors: Radice Paolo , Carini Elisa , Matteucci Martina , Ranno Stefano , Lucchini Sara , Govetto Andrea
Published: February 2023

Purpose:

To describe and report the anatomical and functional outcomes of a novel sutureless peripheral intravascular catheter (PIVC)-assisted scleral fixation of three-piece IOL.

Methods:

A retrospective chart review of all patients who underwent scleral fixation surgery performed by a single surgeon was conducted. In all cases, a novel scleral fixation technique of three-piece IOL was performed with the aid of a 24-gauge PIVC cannula. Patients were followed up at postoperative months 1, 3, and 6.

Results:

Thirteen eyes of 12 patients were included in the analysis. Preoperatively, mean best-corrected visual acuity was 1.26 ± 0.82 LogMar (20/364 Snellen Equivalent), and it improved significantly at all follow-up endpoints being of 0.52 ± 0.25 LogMar at 1 month (20/66 Snellen Equivalent, P = 0.02), 0.4 ± 0.22 LogMar at 3 months (20/50 Snellen Equivalent, P = 0.007) and 0.37 ± 0.2 LogMar (20/47 Snellen Equivalent, P = 0.008) at 6 months postoperatively. No serious intraoperative or postoperative complications were registered. Postoperatively, there were no cases of conjunctival erosions. Over the follow-up period, in all the included cases, the IOL remained centered and stable.

Conclusion:

The PIVC-assisted scleral fixation technique may be a safe and reliable surgical option for secondary IOL placement in cases of insufficient capsular support.
MACULAR MORPHOLOGY AFTER MACULAR HOLE SURGERY USING THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE
Authors: Mizuguchi Tadashi , Horiguchi Masayuki , Kakehi Sayaka , Ito Yasuki
Published: February 2023

Purpose:

To investigate the influence of an excess inverted internal limiting membrane (ILM) flap that covers the fovea in idiopathic macular hole surgery on postoperative visual acuity and macular morphology.

Methods:

This retrospective study included 66 patients with an idiopathic macular hole who underwent vitrectomy using the inverted ILM flap technique. They were divided into three groups: normal morphology (N), detached ILM (D), or ILM proliferation (P) in the parafoveal area. They were followed up for at least 6 months, and their best-corrected visual acuity, central retinal thickness, and parafoveal retinal thickness were measured.

Results:

There were no significant differences in preoperative or postoperative mean best-corrected visual acuities or postoperative CRTs among the groups. The postoperative inferior parafoveal retinal thicknesses were 319.2 ± 38.0, 377.1 ± 60.6, and 373.1 ± 67.3 µm in the N, D, and P groups, respectively (P vs. D group, P = 0.963; P vs. N group, P = 0.008; N vs. D group, P = 0.004).

Conclusion:

Regardless of the postoperative morphology of the inverted ILM flap, there was no effect on postoperative best-corrected visual acuity or CRT.
Multiple organ dysfunction syndrome and disseminated intravascular coagulation causing extensive multiple Amalric triangular choroidal infarctions
Authors: Lee Ivan J. , Pulido Jose S. , Regillo Carl D. , Leys Monique
Published: February 2023

Purpose:

To present a case of extensive bilateral choroidal infarctions from multiple organ dysfunction syndrome (MODS) and disseminated intravascular coagulation (DIC)

Methods:

A retrospective case report. The medical and imaging records, including fundus photography, optical coherence tomography, fluorescein angiography and visual fields were reviewed.

Patient:

A 49-year-old female presented after a failed suicidal attempt from drug overdose. The patient was subsequently intubated for acute hypoxic respiratory failure with presumed septic shock from aspiration pneumonia while requiring exogenous adrenergic support. Her hospital course was further complicated by development of multiple organ dysfunction syndrome and disseminated intravascular coagulation. The patient complained of blurry vision in both eyes after regaining consciousness.

Results:

Fundus photography showed bilateral dot-blot hemorrhages and cotton wool spots followed by multiple areas of triangular granular pigmentation, consistent with choroidal infarcts. Fluorescein angiography revealed delayed patchy filling, followed by late staining. Optical coherence tomography showed diffuse thinning of the choroid with overlying retina pigment epithelium atrophy. Goldmann visual field displayed discrete areas of visual field deficits. At the most recent visit, the best corrected final visual acuity remained 20/100 OD and 20/30 OS.

Conclusion:

DIC has been associated with choroidal infarcts. We present a case of extensive bilateral choroidal infarction in a patient with combined DIC and MODS consistent with Amalric choroidal triangular sign.
Two cases of von Hippel-Lindau syndrome-associated retinal hemangioblastoma treated with belzutifan
Authors: Grimes Joseph M , Gershkovich Alexandera , Bogomolny Dmitry , Marr Brian P
Published: February 2023

Purpose:

To describe two cases of retinal hemangioblastoma (RH) regression following treatment with belzutifan in patients with von Hippel-Lindau (VHL) syndrome.

Methods:

Clinical information was extracted from the charts and tumor imaging of two patients with VHL-associated RH.

Results:

In case 1, a 40-year-old man was treated with belzutifan for spine hemangioblastomas after diagnosis of a 2.0x2.0x1.3 mm left eye RH temporal to the macula associated with intraretinal edema, subretinal fluid, and mild retinal traction. In case 2, a 66-year-old woman presented with a right eye 2.0x1.5x1.3 mm juxtapapillary lesion with subretinal fluid, intraretinal fluid, and nasal traction, and a 4.0x3.5x1.1 mm inferior mid-periphery lesion with subretinal fluid, intraretinal fluid, and active exudation. She was treated for 2.5 years with belzutifan for renal cell carcinoma on the National Institutes of Health trial. The patient in case 1 demonstrated a 10% reduction in largest tumor diameter and 8% reduction in thickness, along with improving subretinal fluid, intraretinal edema, and retinal traction, after 4 weeks of treatment. After 2.5 years of treatment, the patient in case 2 demonstrated similar margins of her now fibrotic-appearing juxtapapillary lesion with a 45% reduction in thickness, along with resolved subretinal fluid and greatly improved intraretinal fluid and traction. The inferior lesion demonstrated 12.5% reduction in largest diameter, 36% reduction in thickness, and was without active subretinal fluid or exudation. Neither patient demonstrated new lesions while on-treatment.

Conclusion:

Belzutifan is a promising treatment for RH with the potential for both rapid and sustained tumor regression.
Comparison of Ocular Wavefront Aberration Measurements Obtained Using Two Hartmann–Shack Wavefront Aberrometers
Authors: Koh Shizuka , Inoue Ryota , Iwamoto Yuuri , Mihashi Toshifumi , Soma Takeshi , Maeda Naoyuki , Nishida Kohji
Published: February 2023

Objectives:

To assess agreement between measurements of ocular wavefront aberrations obtained using the Pentacam AXL Wave (Oculus Optikgeräte GmbH) (Aberrometer A) and KR-1W (Topcon Corp) (Aberrometer B), both of which are based on the Hartmann–Shack principle.

Methods:

In this prospective case–control study, ocular wavefront aberrations measurements were obtained using both aberrometers in patients with keratoconus (KC) and control participants. Ocular wavefront aberrations were measured through the natural pupil without dilation using both devices in a dark room. For both aberrometers, accommodation was inhibited by automatically adding fogging. The individual Zernike coefficients from the second to fourth order were compared between the two aberrometers for a 4-mm pupil diameter.

Results:

Twenty-six KC and 29 control eyes were assessed. Statistically significant correlations (P<0.05) were observed for all Zernike coefficients, except for Z4
−2 in the control group. Bland–Altman analysis indicated good agreement between aberrometers and no statistically significant differences in the control group. However, in the KC group, patterns of proportional error were observed in vertical coma Z3
−1 (r=0.338, P=0.008), trefoil Z4
−4 (r=0.701, P=0.003), secondary astigmatism Z4
−2 (r=0.348, P=0.025), and spherical aberrations Z4
0 (r=0.407, P=0.012).

Conclusions:

The Zernike coefficient values measured by the two aberrometers were well correlated in the control and KC groups. However, in eyes with KC, Aberrometer B tended to present greater values in several Zernike coefficients than Aberrometer A, suggesting that wavefront measurements obtained using the two aberrometers are not interchangeable in patients with KC.