bluuebunny/crossref_metadata_2025 huggingface dataset:
Malignant pleural mesothelioma: recent developments
Authors: Sinn Katharina , Mosleh Berta , Hoda M. Alireza
Published: November 2020

Purpose of review

Malignant pleural mesothelioma (MPM) is a rare, but aggressive tumor with still poor prognosis. In this article, we focus on recent developments in the management of MPM including diagnosis, staging, biomarkers, and treatment strategies.

Recent findings

Molecular markers such as programmed death-ligand 1 (PDL-1), Breast Cancer gene 1-associated protein gene, and cyclin-dependent kinase inhibitor 2A (CDKN2A) have prognostic impact and should be considered for assessment in patient samples. In addition to histological subtype and tumor pattern, tumor volumetry plays an increasing important role in staging, assessment of treatment response, and prediction of survival. Several new blood-based biomarkers have been recently reported including peripheral blood DNA methylation, microRNAs, fibulin, and high-mobility group box 1, but have not been established in clinical routine use yet. Regarding treatment, targeted therapies, immunotherapy, and vaccination are considered as new promising strategies. Moreover, extended pleurectomy/decortication is favored over extrapleural pneumonectomy (EPP) and intensity-modulated radiotherapy represents a possible approach in combination with EPP and pleurectomy/decortication. Intracavitary treatment options are promising and deserve further investigations.

Overall, there has not been a real breakthrough in the treatment of MPM. Further research and clinical trials are needed to evaluate outcome and to identify new potential treatment candidates.
Proximal Nerve Root Involvement in immunoglobulin M Anti–Myelin-Associated Glycoprotein Neuropathy Presenting as Cauda Equina Syndrome
Authors: Fernandes Marco , Calvão-Pires Pedro , Caetano André , Santos Luís
Published: November 2020

Typical distal symptoms in anti–myelin-associated glycoprotein (anti-MAG) neuropathy are believed to be due to the binding of immunoglobulin M to distal nerve terminals. We describe the case of a 56-year-old man diagnosed with immunoglobulin M anti-MAG neuropathy in the setting of Waldenström macroglobulinemia, which developed acute neurological worsening presenting as cauda equina syndrome. Lumbosacral magnetic resonance imaging revealed enlarged nerve roots with diffuse heterogeneous gadolinium enhancement. Treatment with steroids resulted in substantial clinical improvement. Increased recognition of atypical presentations may lead to improved characterization of anti-MAG neuropathy as a more widespread disease.
Polyneuropathy Reveals Origins of Decade-long Gastrointestinal Symptoms in a Patient With Undiagnosed Mitochondrial Neurogastrointestinal Encephalopathy Caused by a Novel Mutation
Authors: Darki Leila , Jalali-Sohi Arash , Beydoun Said R.
Published: November 2020

Mitochondrial neurogastrointestinal encephalopathy (MNGIE) is a rare autosomal recessive disease that manifests with multiorgan presentation characterized by gastrointestinal, extraocular, and both peripheral and central nervous system involvement. MNGIE is caused by mutation in the TYMP (thymidine phosphorylase) gene, resulting in loss of thymidine phosphorylase enzyme activity. This causes its substrates, thymidine and deoxyuridine, to accumulate in tissues and plasma, while also causing secondary alterations in mitochondrial DNA. To date, more than 80 mutations have been reported in this gene. We present herein the clinical, neuroimaging, electrodiagnostic, and molecular findings of a patient with MNGIE caused by a novel homozygous missense mutation (C1175T > G) of the TYMP gene.
What is in the Myopathy Literature?
Authors: Lacomis David
Published: November 2020

This update begins with muscle manifestations of coronavirus 2019. They may include myalgias and elevations in serum creatine kinase. It is unknown whether there is direct muscle invasion and how often the critically ill have muscle sequelae. Regarding autoimmune myopathies, a retrospective study of statin-induced necrotizing myopathy is covered. A relatively large proportion of patients had normal strength at presentation. Examples of dermatomyositis associated with immune checkpoint inhibitors are provided including one with cytokine storm. A report of juvenile dermatomyositis with severe abdominal complications is noteworthy. Two articles address unusual associations with inclusion body myositis, namely, spinocerebellar ataxias and granuloma myositis. In the category of muscular dystrophies, a relatively large single center study of the outcome of scapulothoracic arthrodesis for facioscapulohumeral muscular dystrophy is discussed and a article on anoctaminopathies with pauci- or asymptomatic hyperCKemia.
Regression Discontinuity Designs in Health
Authors: Hilton Boon Michele , Craig Peter , Thomson Hilary , Campbell Mhairi , Moore Laurence
Published: November 2020

Background:

Regression discontinuity designs are non-randomized study designs that permit strong causal inference with relatively weak assumptions. Interest in these designs is growing but there is limited knowledge of the extent of their application in health. We aimed to conduct a comprehensive systematic review of the use of regression discontinuity designs in health research.

Methods:

We included studies that used regression discontinuity designs to investigate the physical or mental health outcomes of any interventions or exposures in any populations. We searched 32 health, social science, and gray literature databases (1 January 1960 to 1 January 2019). We critically appraised studies using eight criteria adapted from the What Works Clearinghouse Standards for regression discontinuity designs. We conducted a narrative synthesis, analyzing the forcing variables and threshold rules used in each study.

Results:

The literature search retrieved 7658 records, producing 325 studies that met the inclusion criteria. A broad range of health topics was represented. The forcing variables used to implement the design were age, socioeconomic measures, date or time of exposure or implementation, environmental measures such as air quality, geographic location, and clinical measures that act as a threshold for treatment. Twelve percent of the studies fully met the eight quality appraisal criteria. Fifteen percent of studies reported a prespecified primary outcome or study protocol.

Conclusions:

This systematic review demonstrates that regression discontinuity designs have been widely applied in health research and could be used more widely still. Shortcomings in study quality and reporting suggest that the potential benefits of this method have not yet been fully realized.
Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons
Authors: Sakızcı Uyar Bahar , Polat Reyhan , Bolat Merve , Donmez Aslı
Published: November 2020

BACKGROUND

Pre-operative anxiety in children has been associated with adverse clinical outcomes such as difficulty in anaesthesia induction, emergence delirium and negative postoperative behavioural changes. Therefore, pre-operative anxiety should be alleviated in both children and clinicians.

OBJECTIVE

We investigated the effect on pre-operative anxiety of premedication with midazolam, playing video games or watching a cartoon about anaesthesia.

DESIGN

A prospective randomised trial.

SETTING

Single-centre study performed between August 2018 and June 2019.

PATIENTS

We enrolled 138 patients aged 5 to 8 years undergoing elective surgery.

INTERVENTIONS

After evaluating baseline (T0) anxiety levels using the modified Yale Pre-operative Anxiety Scale (mYPAS) in the pre-operative holding area, 0.5 mg kg−1 oral midazolam was given to Group M, a tablet with videogame applications was given to Group T, and Group S watched the cartoon ‘Şüko Is Being Operated’. mYPAS values were recorded a further three times: 20 min after the intervention (T1), while entering the operating room (T2), and during mask induction of anaesthesia (T3).

MAIN OUTCOME MEASURES

The primary endpoint was the change in children's anxiety levels from baseline. The secondary endpoint was cooperation during mask induction.

RESULTS

The baseline mYPAS scores were comparable (40.7, 42.6 and 40.7 in groups M, S and T respectively). The mean mYPAS scores at T1 were 32.6, 34.7, 26.8 and at T2 were 38.6, 42.7, 35 in groups M, S and T, respectively. There were significant differences between groups S and T at T1 and T2 (P < 0.001, P = 0.010). A significant decrease was found in Group T compared with both groups M and S from T0 to T1 (P = 0.002). mYPAS values at T3 were 38.3, 43.7, 39.5 in groups M, S and T, respectively, with no difference between the groups (P = 0.224). Mask acceptance scores were similar in all groups (P = 0.912).

CONCLUSIONS

The passive teaching technique of watching a video for reducing anxiety levels was not effective. However, active distraction with videogames was found to be a valuable method to reduce pre-operative anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03530670.
Clinical and laboratory signs of haemophagocytic lymphohistiocytosis associated with pandemic influenza A (H1N1) infection in patients needing extracorporeal membrane oxygenation
Authors: von Bahr Greenwood Tatiana , Holzgraefe Bernhard , Chiang Samuel C.C. , Wang Yini , Tesi Bianca , Bryceson Yenan T. , Henter Jan-Inge
Published: November 2020

BACKGROUND

Severe pandemic influenza has been associated with the hyperinflammatory condition secondary haemophagocytic lymphohistiocytosis (HLH).

OBJECTIVES

To determine the frequency, degree, character and possible cause of influenza-associated HLH in critically ill patients with severe acute respiratory distress syndrome due to influenza A (H1N1) infection requiring extracorporeal membrane oxygenation (ECMO) support at our hospital.

DESIGN

A retrospective observational study.

PATIENTS AND SETTING

Medical data were retrieved retrospectively from 11 consenting patients of thirteen adults infected with pandemic influenza A (H1N1) 2009 requiring ECMO between July 2009 and January 2010 at the ECMO Centre of Karolinska University Hospital, Stockholm, Sweden. All patients were evaluated for HLH using HLH-2004 criteria and HScore.

RESULTS

Eleven patients (median age 31 years) were included in the study and all survived. All patients showed signs of multiple organ dysfunction and pronounced inflammation, more severe in the four patients with HLH who had significantly higher peak serum concentrations of ferritin (P = 0.024), alkaline phosphatase (P = 0.012) and gamma-glutamyl transferase (P = 0.024), lower concentration of albumin (P = 0.0086) and more frequently hepatomegaly (P = 0.048). Abnormal lymphocyte cytotoxicity (lytic units <10) and a low proportion of natural killer (NK) cells were observed in three of four patients with HLH. Notably, we found a significant inverse correlation between serum ferritin concentration and NK cell and cytotoxic T lymphocyte percentages (r

s
 = −0.74, P = 0.0013 and r

s
 = −0.79, P = 0.0025, respectively). One HLH patient received HLH-directed cytotoxic therapy, another intravenous immunoglobulin and the other two no specific HLH-directed therapy.

CONCLUSION

Critically ill patients, including healthy young adults, with pandemic influenza may develop HLH and should be monitored for signs of hyperinflammation and increasing organ dysfunction, and evaluated promptly for HLH because HLH-directed therapy may then be beneficial. The association of low NK percentages with hyperferritinaemia may suggest a role for reduced NK cell numbers, possibly also cytotoxic T lymphocytes, and subsequently reduced lymphocyte cytotoxicity, in the pathogenesis of hyperinflammation and secondary HLH.
Comparative validity and reliability of the WeChat-based electronic and paper-and-pencil versions of the PISQ-12 for collecting participant-reported data in Chinese
Authors: Zhang Chenyu , Sun Zhijing , Yang Jun , Xu Tao , Zhu Lan , Lang Jinghe
Published: November 2020

Objective:

The objective of this study is to assess the consistency between the WeChat-based Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) in Chinese and the paper version and to determine the test–retest reliability of the WeChat questionnaire.

Methods:

A total of 120 women aged between 24 and 69 years were recruited from the outpatient clinic at Peking Union Medical College Hospital and randomly assigned to two groups. All participants completed the WeChat and paper questionnaires twice. Group A completed the paper questionnaire before the WeChat version; Group B completed the WeChat questionnaire before the paper version. Two weeks later, all participants completed the questionnaires in the opposite order. Then, the reliability and validity of the two versions were assessed using Pearson correlation coefficients, intraclass correlation coefficients, and Bland-Altman graphs.

Results:

No significant difference in completion time was found between the two versions of the Chinese PISQ-12 (P = 0.67). Half of the participants (60/120) preferred the WeChat questionnaire, 15% (18/120) preferred the paper form (P < 0.01), and 35% had no preference (42/120). The response time was positively correlated with age (P < 0.01) and negatively correlated with the degree of education (P < 0.01). A Pearson correlation coefficient of 0.92 and an intraclass correlation coefficient of 0.94 indicated strong consistency between the two versions. The WeChat form exhibited strong test–retest reliability (Pearson correlation coefficient, 0.86; intraclass correlation coefficient, 0.86). The Bland-Altman plots supported these results.

Conclusions:

The WeChat questionnaire was preferred over the paper version in a Chinese sample and had excellent consistency with the paper version and high test–retest reliability for collecting data on private topics.
Predictors and prognostic role of low myocardial mechano-energetic efficiency in chronic inflammatory arthritis
Authors: Cioffi Giovanni , Mancusi Costantino , de Simone Giovanni , Ognibeni Federica , Orsolini Giovanni , Dalbeni Andrea , Gatti Davide , Fassio Angelo , Adami Giovanni , Rossini Maurizio , Viapiana Ombretta , Giollo Alessandro
Published: November 2020

Objective:

To assess the variables associated with the status of low myocardial mechano-energetic efficiency (MEE) [the ratio between myocardial left ventricular (LV) work and magnitude of myocardial oxygen consumption] and whether low-MEE is a prognosticator of adverse cardiovascular outcome in patients with chronic inflammatory arthritis.

Methods:

A total of 432 outpatients with established chronic inflammatory arthritis without overt cardiac disease were recruited from March 2014–March 2016; 216 participants were used as comparison group. Low-MEE status was a priori identified by standard echocardiography at rest as less than 0.32 ml/s per g (5th percentile of MEE calculated in 145 healthy individuals). The pre-specified primary end-point of the study was a composite of cardiovascular death/hospitalization. Follow-up ended September 2019.

Results:

MEE was significantly lower in chronic inflammatory arthritis patients than controls (0.35 ± 0.11 vs. 0.45 ± 0.10 ml/s per g; P < 0.001). Low-MEE was detected in 164 patients (38%). Independent predictors of low-MEE were older age, higher SBP, diabetes mellitus, LV concentric geometry and lower LV systolic function. During a follow-up of 36 (21–48) months, a primary end-point occurred in 37 patients (8.6%): 22/164 patients with low-MEE (13.4%) and 15/268 (5.6%) without low-MEE (P = 0.004). Low-MEE predicted primary end-points in multivariate Cox regression analysis [heart rate 2.23 (confidence interval 1.13–4.38), P = 0.02] together with older age, lower renal function and higher LV mass.

Conclusion

: Low-MEE is detectable in more than one-third of patients with chronic inflammatory arthritis and is associated with traditional cardiovascular risk factors and abnormalities in LV geometry and systolic function. In these patients low-MEE is a powerful prognosticator of adverse cardiovascular events.
Endophthalmitis after cataract surgery: an update on recent advances
Authors: Peck Travis J. , Patel Samir N. , Ho Allen C.
Published: November 2020

Purpose of review

Prevention and management of postcataract endophthalmitis remain quite relevant for anterior segment and vitreoretinal surgeons. Although the Endophthalmitis Vitrectomy Study, published in 1996, remains the only level 1 evidence for the management of postcataract endophthalmitis, recent advances have resulted in an evolution of practice patterns. The aim of this review is to summarize the literature regarding postcataract endophthalmitis with a focus on the last 18 months.

Recent findings

The IRIS registry indicates the rates of endophthalmitis are decreasing in the United States, and the outcomes appear to be improving. Intracameral moxifloxacin has become more widely accepted and intracameral vancomycin has been shown to be associated with retinal vasculitis. The role of systemic antibiotics and vitrectomy is unclear and practice patterns vary widely.

Although practice patterns vary, prevention and treatment of endophthalmitis after cataract surgery continues to improve. More uniform guidelines regarding surgical and medical therapy are necessary but the standard of prompt referral to a vitreoretinal specialist for immediate intravitreal antibiotics remains the most important intervention in the management of postcataract endophthalmitis.
Purpurona: A Novel Report of COVID-19-Related Henoch-Schonlein Purpura in a Child
Authors: Jacobi Michal , Lancrei Hayley M. , Brosh-Nissimov Tal , Yeshayahu Yonatan
Published: November 2020

The coronavirus disease 2019 global pandemic is reshaping our understanding of medicine, including the diagnostic approach to common medical presentations. We describe a novel case of a 3-year-old male with a clinical diagnosis of Henoch–Schonlein Purpura vasculitis with concurrent SARS-CoV-2 infection. This case highlights a potentially newly described presentation of coronavirus disease 2019 infection.
Choroidal thickness after phacoemulsification: nonrandomized comparison of postoperative topical ketorolac vs dexamethasone vs combination of ketorolac–dexamethasone eyedrops
Authors: Ghiasian Leila , Abri Aghdam Kaveh , Azizi Ehsan , Abdolalizadeh Parya , Janani Leila , Grzybowski Andrzej , Ghasemi Falavarjani Khalil
Published: November 2020

Purpose:

To compare the effect of topical dexamethasone vs ketorolac vs combined dexamethasone–ketorolac after phacoemulsification on choroidal thickness (CT).

Setting:

Tertiary university-based hospital.

Design:

Prospective nonrandomized comparative case series.

Methods:

Ninety-two eyes of 92 patients were assigned to the 3 groups after uneventful phacoemulsification: Group 1, dexamethasone; Group 2, ketorolac; Group 3, combined dexamethasone–ketorolac applied topically. CT at subfoveal (SFCT), nasal, and temporal as primary and central retinal thickness (CRT) as secondary outcomes were measured preoperatively and at 1 month, 3 months, and 6 months postoperatively using enhanced depth-imaging optical coherence tomography.

Results:

Preoperative CT was similar between the groups (all P > .05). The groups differed in pattern of changes in nasal and temporal CT (both P < .001) although their changes of CRT (P = .13) and SFCT (P = .55) over time were similar. The mean of SFCT at 1 month, 3 months, and 6 months was significantly higher than baseline in dexamethasone (P < .001 for all follow-ups) and combined (P < .001 for both 1 month and 3 months and P = .03 for 6 months) groups, whereas it was not statistically significant in the ketorolac group (P = .07). There was an increase in the nasal and temporal CT in 3 groups, persisted at 6 months in dexamethasone (both P < .001) and ketorolac (both P < .001) groups, whereas the change was not statistically significant at 6 months in the combined group. Choroidal thickness measurements were performed in 31 eyes of 31 patients in group 1, 29 eyes of 29 patients in group 2, and 32 eyes of 32 patients in group 3.

Conclusions:

Dexamethasone and combined groups had statistically significant changes of SFCT after phacoemulsification; however, the ketorolac group did not. The pattern of SFCT changes was similar between 3 groups.
Rotational stability of toric intraocular lenses with a newly modified capsular tension ring
Authors: Zdral John , Werner Liliana , Mamalis Nick , Bontu Sneha , Kennedy Sean , Henderson Bonnie A.
Published: November 2020

Purpose:

To determine whether a newly modified capsular tension ring (CTR) is effective at preventing toric intraocular lens (TIOL) rotation and misalignment.

Setting:

John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

Design:

Experimental study.

Methods:

Ten human cadaver eyes were used to test the ease or difficulty of TIOL rotation in the capsular bag under 3 experimental conditions: a TIOL alone, a TIOL with a standard CTR, or a TIOL with a newly modified CTR with indentations in a sinusoidal pattern. Scores for the ease of IOL rotation were compared by using the nonparametric Friedman analysis of variance test. In addition, both anterior and posterior Miyake-Apple views were filmed to observe the rotational stability of TIOLs in the capsular bag under the 3 test conditions.

Results:

In the ten eyes of five patients, the rotational stability improved with a standard CTR, but further improvement was statistically observed (P < .05) with the newly modified CTR under all test conditions. This was true for both IOLs used (AcrySof and TECNIS toric IOLs), with or without ophthalmic viscosurgical device, and for either clockwise or counterclockwise rotations.

Conclusions:

A newly designed CTR prototype represents a new technology for improving the rotational stability of a TIOL in the capsular bag. Under all test conditions, the prototype performed significantly better than a standard CTR. The results support the use of this new CTR design to improve the accuracy and refractive success of TIOLs.
Capsular tension ring explant complication rate comparison using Miyake-Apple video analysis
Authors: Page Timothy P. , Werner Liliana , Ellis Nathan , Heczko Joshua B.
Published: November 2020

Purpose:

To compare the complication rate and time required to explant standard capsular tension rings (CTRs) vs suture-guided CTRs (SGCTRs).

Setting:

Intermountain Ocular Research Center, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah.

Design:

Experimental study.

Methods:

Eight cadaver eyes were prepared using standard Miyake-Apple protocol with digital video recording. A 4 clock-hour zonular dialysis was created, followed by a capsulorhexis, hydrodissection, and CTR (n = 4) or SGCTR (n = 4) implantation. With the CTR hidden from view by the overlying iris, ophthalmic surgical instruments were used to remove the CTRs. Time required to remove the CTR and any complications were recorded. A limit of 180 seconds was imposed to determine inability to remove the CTR.

Results:

In the standard CTR group (n = 4), removal was associated with high rates of complication (100%). Complications included capsular tears (n = 2), dialysis extension (n = 1), and inadvertent intracapsular cataract extraction (n = 1). The SGCTR group had no complications associated with removal (n = 4). Time required to explant a CTR was significantly reduced from 164.5 seconds with standard CTRs to 6.9 seconds with SGCTRs (P = .001).

Conclusions:

Attempts to remove a standard CTR from the capsular bag was met with a high complication rate. The addition of suture to the leading eyelet of the CTR prior to implantation significantly reduced the time and effort required to remove the CTR and was associated with a significant reduction in complication rates.
Preoperative and perioperative music to reduce anxiety during first-time phacoemulsification cataract surgery in the high-volume setting: randomized controlled trial
Authors: Muddana Satish Kumar , Hess Olivia M. , Sundar Sumathy , Venkatesh Rengaraj
Published: November 2020

Purpose:

To determine whether preoperative and perioperative music exposure reduced patient self-rated anxiety and physiologic indicators of stress during first-time phacoemulsification cataract surgery in the high-volume setting.

Setting:

Aravind Eye Care System, Pondicherry, India.

Design:

Prospective single-masked randomized controlled trial.

Methods:

Patients were provided music before and during first-time phacoemulsification in 1 group and patients underwent surgery without music in another group. Measurements of blood pressure (BP), heart rate, respiration rate, and a Likert scale anxiety rating were collected at preoperative, perioperative, and postoperative timepoints.

Results:

One hundred sixty-five patients (aged 53–65 years) were provided music using a portable MP3 player before and during first-time phacoemulsification, and 165 patients underwent surgery without music. Systolic and diastolic BPs were statistically significantly lower in the music intervention group at the postoperative timepoint, with similar physiologic measures between groups during the perioperative timepoints. In the preoperative period, before music exposure, 62 patients (38%) in the music group reported being very or extremely anxious. After 10 minutes of music exposure, only 7 patients (4%) reported this anxiety level. In the perioperative period, 80 patients (48%) in the intervention group reported feeling not at all or a little anxious, compared with 50 patients (30%) of the control group. In the postoperative period, 139 (84%) music group patients felt not at all or a little anxious postoperatively compared with 92 patients (56%) in the control group.

Conclusions:

Marked reductions in self-reported anxiety preoperatively, intraoperatively, and postoperatively when exposed to music and a statistically significant decrease in postoperative BP showed that music can be an inexpensive and effective solution to improve the patient experience of cataract surgery in the high-volume setting.
Comparison of pulsed and continuous accelerated corneal crosslinking for keratoconus: 1-year results at a single center
Authors: Kang Min-Ji , Hwang Jehyung , Chung So-Hyang
Published: November 2020

Purpose:

To compare the clinical outcomes between pulsed and continuous accelerated crosslinking (CXL) for keratoconus.

Setting:

Hospital.

Design:

Retrospective comparison study.

Methods:

Korean patients who were treated for keratoconus between September 2015 and January 2018 at Seoul St. Mary’s Hospital were included. Eyes were subjected to pulsed accelerated crosslinking (30 mW/cm2 for 8 minutes, 1 second on/1 second off) or continuous accelerated crosslinking (30 mW/cm2 for 4 minutes; delivering 7.2 J/cm2). Outcomes were evaluated after 1 year.

Results:

At 1 year, the 2 groups did not exhibit changes in their corrected and uncorrected distance visual acuity values. The pulsed group (25 eyes in 25 patients) exhibited significantly improved values for sphere (P = .009) and spherical equivalent (P = .033), although no statistically significant difference was observed in the continuous group (20 eyes in 20 patients). All keratometry (k)values (SimKf, SimKs, SimKmean, and Kmax) improved in both groups (all P < .05), although the pulsed group had significantly greater changes in the SimKmean value (P = .036) and the Kmax value (P = .03). Both groups had significantly decreased central and thinnest corneal thicknesses (all P < .001), although the pulsed group had a substantially lower thinnest corneal thickness (P = .017). Corneal densitometry measured using the Pentacam device increased in both groups (all P < .001), with a higher densitometry value in the pulsed group (P = .013). Furthermore, the depth of the demarcation line was deeper in the pulsed group (P = .015).

Conclusions:

Pulsed accelerated crosslinking might provide better postcrosslinking effects than continuous accelerated crosslinking.
Bilateral implantation of a supplementary intraocular pinhole
Authors: Trindade Bruno Lovaglio Cançado , Trindade Fernando Cançado , Trindade Claudio Lovaglio Cançado
Published: November 2020

Purpose:

To evaluate the safety and efficacy of bilateral implantation of a supplementary small-aperture device to treat irregular corneal astigmatism.

Setting:

Private practice.

Design:

Retrospective consecutive case series.

Methods:

Patients with bilateral irregular corneal astigmatism secondary to multiple causes and consented for implantation of the XtraFocus intraocular pinhole (IOPH) were enrolled. The mean follow-up was 27 months (range 5 to 66 months). Patients were assessed in their scheduled follow-up visits and monocular and binocular uncorrected and corrected distance and near visual acuities were recorded. Assessment of darkening vision complaints was also performed after implantation in the first eye and repeated after second-eye surgery.

Results:

Thirty-two eyes of 16 patients were analyzed. The mean monocular and binocular uncorrected distance visual acuities improved from logMAR 1.091 ± 0.208 and 1.078 ± 0.259 preoperatively to 0.342 ± 0.091 (P < .001) and 0.342 ± 0.147 (P = .001) 1 year postoperatively. Three patients were excluded because of darkening vision complaints after surgery in the first eye. No major complications were noted after implantation of the IOPH.

Conclusions:

Bilateral implantation of the XtraFocus IOPH is a safe technique in a selected group of patients. There was improvement in visual acuity sustained over the analyzed period. Postoperative darkening vision complaints vary between individuals and can limit the application of this approach in certain patients.
Prospective comparison of apex-centered vs standard pupil-centered femtosecond laser–assisted capsulotomy in cataract surgery
Authors: Mursch-Edlmayr Anna Sophie , Pomberger Leon Julian , Hermann Philipp , Wagner Helga , Beka Sophie , Waser Klemens , Wendelstein Jascha , Podkowinski Dominika , Laubichler Peter , Siska René , Bolz Matthias
Published: November 2020

Purpose:

To compare the lens tilt after apex-centered capsulotomy with standard pupil-centered capsulotomy.

Setting:

Clinical practice.

Design:

Prospective, randomized, investigator-masked trial.

Methods:

This prospective, randomized, investigator masked study included 40 patients with age-related cataract scheduled for femtosecond laser-assisted cataract surgery (FLACS) in both eyes. The main outcome was the tilt of the intraocular lens (IOL), measured with the IOLMaster 700.

Results:

The study enrolled 80 eyes of 40 patients. The mean distance from the center of the apex-centered capsulotomy to the pupil-centered capsulotomy was 175.8 ± 97.2 μm. The amount of IOL tilt was not significantly reduced with the new technique (P > .05). Tilt orientation was more stable in eyes treated with apex-centered capsulotomy.

Conclusions:

Centration of the capsulotomy on the lens apex in FLACS does not influence the amount of IOL tilt but the orientation stability. The clinical importance of this finding has to be further elucidated.
Five-year long-term outcomes of intrastromal corneal ring segment implantation using the manual technique for keratoconus management
Authors: Costa Jorge Vasco , Monteiro Tiago , Franqueira Nuno , Faria-Correia Fernando , Alfonso Jose , Vaz Fernando
Published: November 2020

Purpose:

To evaluate the long-term effectiveness, safety, and stability of Ferrara-type intrastromal corneal ring segments (ICRS) by manual surgery implantation in patients with keratoconus.

Setting:

Ophthalmology Department, Hospital de Braga, Braga, Portugal.

Design:

Retrospective cohort study.

Methods:

This study included 124 eyes that had ICRS implantation using the manual technique with a follow-up of 5 years. Uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), subjective refraction, keratometry, aberrometry, and pachymetry maps were evaluated preoperatively and at 6 months, 1 year, and 5 years postoperatively. A secondary analysis of all variables was performed comparing 2 subgroups of patients: a group younger than 30 years and a group of 30 years or older.

Results:

At 5 years, both mean UDVA and CDVA improved significantly (P < .0001) from a preoperative value of 0.91 ± 0.36 to 0.46 ± 0.32 logMAR and 0.40 ± 0.27 to 0.22 ± 0.20 logMAR, respectively. Spherical equivalent, refractive cylinder, and all topography values significantly decreased postoperatively (P < .0001). No regression was observed in any visual or topographic parameter during the entire follow-up. Regarding the subgroup analysis, both younger and older patients demonstrated similar and stable results from the preoperative to the 5-year visit, except for minimum pachymetry value change over time.

Conclusions:

Ferrara-type ICRS implantation significantly improved visual acuity, refractive error, and topographic values; the improvement was stable throughout a 5-year follow-up period. This study confirms that ICRS implantation surgery for keratoconus is a stable procedure in a long-term follow-up, regardless of the preoperative patient's age.
Tinnitus Is Associated With Extended High-frequency Hearing Loss and Hidden High-frequency Damage in Young Patients
Authors: Song Zijun , Wu Yongzhen , Tang Dongmei , Lu Xiaoling , Qiao Liang , Wang Jing , Li Huawei
Published: November 2020

Objectives:

To analyze the results of extended high-frequency (EHF) and high-frequency hearing tests in young patients with tinnitus who show normal response in conventional pure-tone audiometry (PTA), and to explore the correlation between tinnitus and hearing loss (HL).

Study Design:

A case–control study.

Setting:

A Tertiary Eye Ear Nose & Throat Hospital of China.

Participants:

Patients with tinnitus, aged 18 to 35 years old, and with normal conventional PTA (125 Hz–8 kHz) were enrolled in the tinnitus group. Volunteers without tinnitus of the same age were enrolled in the control group.

Main Outcome Measures:

The incidence of EHF-HL and the hearing thresholds at each frequency, as well as the distribution of maximum HL frequency and edge frequency in all participants were compared.

Results:

In total, 28 cases (43 ears) were enrolled in the tinnitus group and 34 cases (68 ears) in the control group. The incidence of EHF-HL, average hearing threshold of each frequency ranging from 4 to 16 kHz, and the maximum hearing threshold were significantly higher in the tinnitus group. The edge frequency in the tinnitus group was lower than that in the control group (10.4 ± 3.1 kHz versus 12.3 ± 2.5 kHz, p = 0.010). The dominant tinnitus pitch in cases whose EHF was impaired was positively correlated with the hearing-level loudness of tinnitus (r = 0.627, p < 0.001).

Conclusion:

Patients with tinnitus and normal hearing in conventional PTA showed signs of EHF-HL and hidden damage in the high-frequencies more easily. EHF hearing tests and the follow-up of HF hearing tests are recommended to facilitate early detection of hearing impairment for timely intervention.
A pilot randomized trial of atorvastatin as adjunct therapy in patients with acute venous thromboembolism
Authors: Wang Tzu-Fei , Waller Amanda P. , Lin Ella , Wei Lai , Bartosic Abigail , Riedl Ken , Kerlin Bryce A.
Published: November 2020

Venous thromboembolism (VTE) is the third most common cardiovascular disease and optimizing treatment is essential. In this single-center pilot study, we sought to investigate the effects of statins in addition to anticoagulation in patients with acute VTE. We enrolled patients over 18 with an acute proximal lower extremity deep vein thrombosis with or without pulmonary embolism. Patients were randomized to anticoagulation alone (with either warfarin or rivaroxaban) or anticoagulation and atorvastatin 40 mg daily and followed for 9 months. The primary objective was to determine if adjunct atorvastatin reduced thrombin generation, measured by endogenous thrombin potential and/or peak thrombin concentration. Secondary endpoints included recurrent VTE, arterial thrombosis, bleeding events, lipidomic profiles, and symptoms of post thrombotic syndrome. A total of 21 patients were enrolled (11 anticoagulation only and 10 anticoagulation and atorvastatin) over 3.5 years. Endogenous thrombin potential or peak thrombin was not significantly recued with the addition of atorvastatin. Atorvastatin did significantly reduce the mean LDLs at 3 months, without reduction of either d-dimer or high-sensitivity-C reactive protein. Given the low recruitment rate, continuation of the study was deemed futile and the study was terminated early. Barriers to enrollment and completion of study included the many ineligible patients by exclusion criteria (e.g., preexisting statin use, active malignancy, etc.) and high rate of lost follow-up. The pilot study was terminated early but could inform obstacles for future studies investigating the effects of statins in the management of patients with VTE.
Thromboelastometry-guided neuraxial anesthesia in a parturient with severe thrombocytopenia due to large granular lymphocytic leukemia
Authors: Getrajdman Chloe , Sison Matthew , Yen Colleen , Giordano Morgane , Beilin Yaakov , Katz Daniel
Published: November 2020

Severe thrombocytopenia (platelet count <50 000/μl) in pregnancy is uncommon and is generally considered a contraindication to neuraxial anesthesia. We present a case of a parturient who presented with severe thrombocytopenia secondary to bone marrow failure. After receiving platelet and cryoprecipitate transfusions to correct coagulopathy as verified by thromboelastometry, neuraxial anesthesia was safely utilized.
Difficulty in controlling heavy menstrual bleeding at menarche in a patient with Glanzmann's thrombasthenia
Authors: Kadowaki Sayaka , Makino Shigeru , Mohri Yosuke , Awaguni Hitoshi , Shinozuka Jun , Imashuku Shinsaku
Published: November 2020

Glanzmann's thrombasthenia is a rare inherited autosomal recessive bleeding disorder caused by platelet dysfunction. Adolescent girls with Glanzmann's thrombasthenia may experience problematic heavy menstrual bleeding beginning at menarche; this can be difficult to manage. Here, we report the case of an 11-year-old girl with Glanzmann's thrombasthenia who presented with heavy menstrual bleeding at menarche, which was difficult to control. The vaginal bleeding persisted and did not respond to a treatment with packed red blood cells (16 U total), platelet concentrates (70 U total), or administration (>50 doses) of recombinant activated factor VII (rFVIIa). Eventually, a combination of rFVIIa and hormonal therapy (a combined oral contraceptive pill) was introduced. The bleeding stopped at nearly 1 month from onset of menarche. Thereafter, the condition was managed by monthly subcutaneous administration of a GnRH agonist. Management of severe menorrhagia in adolescent patients with Glanzmann's thrombasthenia requires close collaboration with gynecologists or adolescent medicine specialists. More clinical studies are required to identify an effective combination of rFVIIa and hormonal therapy for this condition.
Pharmacotherapy in pediatric obesity: current evidence and landscape
Authors: Singhal Vibha , Sella Aluma Chovel , Malhotra Sonali
Published: November 2020

Purpose of review

Childhood obesity is escalating globally. Lifestyle and behavioral changes, which are the frequently used interventions in clinical practice, lead to only modest improvements in children with established obesity. Bariatric surgery is currently the most effective obesity treatment but has very limited utilization in pediatric obesity and is preferentially used for children with worsening comorbidities. There exists a massive treatment gap for children suffering with obesity especially after the failure of lifestyle modifications. Pharmacotherapy that is an established management tool in adults is very infrequently used in children. Only two medications, Phentermine and Orlistat are approved by the Food and Drug Administration (FDA) for use in adolescent obesity. Herein, we discuss the current landscape and available literature on the use of antiobesity pharmacotherapy in children.

Recent findings

There are emerging pediatric data about the efficacy of the many weight loss medications that are FDA approved in adults. Moreover, more clinical trials are underway on the rarer, intractable forms of obesity such as monogenic, syndromic, and hypothalamic obesity.

Weight loss medications in children, like adults, have variable efficacy and similar side effect profiles. Rigorous research and improved education of providers about weight loss medications may address the huge treatment gap in severe pediatric obesity.
Chimerism and tolerance: past, present and future strategies to prolong renal allograft survival
Authors: Tantisattamo Ekamol , Leventhal Joseph R. , Mathew James M. , Gallon Lorenzo
Published: November 2020

Purpose of review

Immunological factors are a major cause of kidney allograft loss. Calcineurin inhibitors (CNIs) have improved short-term kidney allograft survival; however, they in turn contribute to long-term kidney allograft loss from chronic CNI nephrotoxicity. Tolerance induction in transplantation can avoid the long-term adverse effects of immunosuppressive medications. This review aims to critically discuss recent efforts in inducing transplantation tolerance.

Recent findings

Tolerance induction mediated by chimerism has shown some promise in minimizing or even complete withdrawal of immunosuppressive treatments in kidney allograft recipients. There has been a number of approaches as varied as the number of centres conducting these trials. However, they can be grouped into those mediated by transient microchimerism and those facilitated by more stable macro or full donor chimerism. The success rates in terms of long-term drug-free graft survival has been limited in microchimerism-mediated tolerance induction approaches. Mixed macrochimerism of less than 50% donor may be unstable with mostly the recipient's native immune system overpowering the donor chimeric status.

Tolerance induction leading to chimerism has been limited to living donor kidney transplantation and additional long-term outcomes are required. Furthermore, immune monitoring after tolerance induction has faced a limitation in studying due to a lack of sufficient study participants and appropriate study controls.

Tolerance induction is one of several strategies used to prolong kidney allograft survival, but it has not been routinely utilized in clinical practice. However, future applications from the trials to clinical practice remain limited to living donor kidney transplantation. Once further data regarding tolerance inductions exist and practicality becomes widely accepted, tolerance induction may shift the paradigm in the field of kidney transplantation to achieve the best possible outcome of ‘One Organ for Life’.
Socioeconomic Differences in Sympathovagal Balance: The Healthy Life in an Urban Setting Study
Authors: van Nieuwenhuizen Benjamin P. , Collard Didier , Tan Hanno L. , Blom Marieke T. , van den Born Bert-Jan H. , Kunst Anton E. , van Valkengoed Irene G.M.
Published: November 2020

Objective

Alterations in sympathovagal balance are associated with cardiovascular disease. If sympathovagal balance differs across socioeconomic groups, it may reflect a mechanism through which disparities in cardiovascular disease occur. We therefore assessed the association between education and occupation with measures of sympathovagal balance in a large multiethnic sample.

Methods

We included cross-sectional data of 10,202 South Asian Surinamese, African Surinamese, Ghanaian, Turkish, Moroccan, and Dutch-origin participants from the Healthy Life in an Urban Setting study. Sympathovagal balance was measured by baroreflex sensitivity (BRS) and the standard deviation of the interbeat interval, calculated from changes in blood pressure and interbeat intervals, from 5-minute recordings. We calculated geometric means and estimated the relative index of inequality, using age- and ethnicity-adjusted linear regression, to quantify the association between education and occupation and sympathovagal balance. In addition, we assessed whether the association was consistent across ethnic groups.

Results

The geometric means of BRS ranged from 8.16 ms/mm Hg (confidence interval [CI] = 7.91–8.43 ms/mm Hg) in low-educated to 14.00 ms/mm Hg (CI = 13.53–14.48 ms/mm Hg) in highly educated women, and from 8.32 ms/mm Hg (CI, 7.97–8.69 ms/mm Hg) in low-educated to 12.25 ms/mm Hg (CI = 11.86–12.66 ms/mm Hg) in highly educated men. High education and occupation were statistically significantly associated with higher BRS and standard deviation of the interbeat interval. Compared with the participants of Dutch origin, a pattern of weaker associations was found in the Surinamese and Ghanaian ethnic groups, but not the Turkish and Moroccan groups.

Conclusions

There is a clear socioeconomic gradient in measures of sympathovagal balance, indicating that sympathovagal balance may play a role in socioeconomic disparities in cardiovascular morbidity and mortality.
COVID-19 Related Medical Mistrust, Health Impacts, and Potential Vaccine Hesitancy Among Black Americans Living With HIV
Authors: Bogart Laura M. , Ojikutu Bisola O. , Tyagi Keshav , Klein David J. , Mutchler Matt G. , Dong Lu , Lawrence Sean J. , Thomas Damone R. , Kellman Sarah
Published: November 2020

Background:

Medical mistrust, a result of systemic racism, is prevalent among Black Americans and may play a role in COVID-19 inequities. In a convenience sample of HIV-positive Black Americans, we examined associations of COVID-19-related medical mistrust with COVID-19 vaccine and COVID-19 treatment hesitancy and negative impacts of COVID-19 on antiretroviral therapy (ART) adherence.

Methods:

Participants were 101 HIV-positive Black Americans (age: M = 50.3 years; SD = 11.5; 86% cisgender men; 77% sexual minority) enrolled in a randomized controlled trial of a community-based ART adherence intervention in Los Angeles County, CA. From May to July 2020, participants completed telephone interviews on negative COVID-19 impacts, general COVID-19 mistrust (eg, about the government withholding information), COVID-19 vaccine and treatment hesitancy, and trust in COVID-19 information sources. Adherence was monitored electronically with the Medication Event Monitoring System.

Results:

Nearly all participants (97%) endorsed at least one general COVID-19 mistrust belief, and more than half endorsed at least one COVID-19 vaccine or treatment hesitancy belief. Social service and health care providers were the most trusted sources. Greater COVID-19 mistrust was related to greater vaccine and treatment hesitancy [b (SE) = 0.85 (0.14), P < 0.0001 and b (SE) = 0.88 (0.14), P < 0.0001, respectively]. Participants experiencing more negative COVID-19 impacts showed lower ART adherence, assessed among a subset of 49 participants [b (SE) = −5.19 (2.08), P = 0.02].

Discussion:

To prevent widening health inequities, health care providers should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, to encourage COVID-19 vaccine and treatment uptake.