bluuebunny/crossref_metadata_2025 huggingface dataset:
Utility of conventional radiographs in the detection of traumatic knee arthrotomies: a retrospective cohort review
Authors: Sleasman Brian T. , Ence Andrew K. , Hewett Lara , Barfield William R. , Reid Kristoff
Published: August 2020

Background:

The most common method to determine a traumatic knee arthrotomy is the saline load challenge. Recent literature has suggested high false-negative and false-positive rates using this method and also has shown that CT was effective in detecting these arthrotomies. The purpose of this study was to evaluate another method of diagnosing these injuries. We hypothesized that plain radiographs of the knee could be an effective alternative study in diagnosing a traumatic arthrotomy.

Methods:

After institutional review board approval, this retrospective cohort review identified 32 patients diagnosed with a traumatic arthrotomy by direct visualization in the operating room and another 32 patients with no evidence of traumatic arthopathy, according to the surgeon. The preoperative anteroposterior and lateral radiographs from both cohorts were blinded and randomized and then submitted to a radiologist to review for the presence of air in the joint space. Sensitivity and specificity were calculated based on radiographic review compared with the gold standard of direct visualization.

Results:

Plain film anteroposterior and lateral knee radiographs had a sensitivity of 78.1% and a specificity of 90.6% with a positive predictive value of 89.3% for diagnosis of traumatic arthrotomy in our cohort.

Conclusions:

Our study suggests that radiographs, which are obtained as standard of care during work-up of knee injuries, have a relatively high sensitivity and specificity and can be used as an adjunct to help diagnose a traumatic arthrotomy of the knee joint.

Level of Evidence:

Level III.
Progress in the management of endometrial cancer (subtypes, immunotherapy, alterations in PIK3CA pathway): data and perspectives
Authors: Oaknin Ana , León-Castillo Alicia , Lorusso Domenica
Published: August 2020

Purpose of review

Changes in molecular classification together with a deeper knowledge of both immune disregulation and phosphatidylinositol-3 kinase (PI3K) pathway alterations are leading to a new endometrial cancer treatment paradigm. This review will address the cutting-edge data in this field.

Recent findings

This article will cover the updated data in endometrial cancer molecular classification and its correlation with the outcomes in randomized clinical trials (e.g., PORTEC-3). Moreover, we will review the latest data regarding checkpoint blockade molecules (CPB) in the recurrent setting and how they are changing the treatment landscape. In addition, the role of the PI3K inhibitors, their activity, and toxicity profile will be described.

As result of the incorporation of molecular classification in our daily practice, the adjuvant treatment in endometrial cancer is rapidly evolving and leading to a new paradigm. The promising data observed with CPB in the recurrent setting have led to the food and drug administration approval of pembrolizumab as monotherapy and in combination with lenvatinib. Additionally, the current outcomes achieved with PI3K inhibitor agents encourage us to continue our clinical research to identify those patients who may benefit the most.
Clinical data, limitations and perspectives on chimeric antigen receptor T-cell therapy in multiple myeloma
Authors: Beauvais David , Danhof Sophia , Hayden Patrick J. , Einsele Hermann , Yakoub-Agha Ibrahim
Published: August 2020

Purpose of review

Despite considerable therapeutic advances over the last decade, multiple myeloma remains an incurable disease. Novel treatment strategies are urgently needed. T cells can be genetically modified to express chimeric antigen receptors (CARs) targeting defined surface antigens on tumor cells. To date, over 90 clinical trials investigating the use of CAR T cells in multiple myeloma have been registered.

Recent findings

Although two CD19-directed CAR T-cell products have been approved, CD19 surface expression on plasma cells is limited or absent and CAR T-cell therapy in multiple myeloma is less advanced. B-cell maturation antigen (BCMA)-directed CAR T cells have shown promising efficacy and safety profiles in various phase I/II clinical trials. However, almost all treated patients continue to relapse. The current focus is therefore on strategies to overcome resistance mechanisms. These include the targeting of other surface antigens, refinements in T-cell signaling and dual-targeting approaches.

CAR T-cell therapy has finally moved into routine clinical use, the first experiments having taken place over 30 years ago. A BCMA-directed product for the treatment of multiple myeloma is expected to be approved shortly. However, further refinements of both CAR T-cell constructs and treatment protocols will be required to boost persistence, overcome resistance and reduce toxicities.
CD19-directed CAR T-cell therapy in B-cell NHL
Authors: Kersten Marie José , Spanjaart Anne Mea , Thieblemont Catherine
Published: August 2020

Purpose of review

CD19-directed chimeric antigen receptor (CAR) T-cell therapy is a valuable new treatment option for patients with relapsed/refractory (R/R) B-cell non-Hodgkin lymphoma. The aim of this review is to give an overview of the pivotal phase I/II trials, emerging real-world evidence and ongoing trials.

Recent findings

For decades, attempts at improvement of the poor prognosis of patients with R/R large B-cell lymphoma with new treatment regimens have been disappointing. Since the first report of CD19-directed CAR-T-cell therapy in 2010, three constructs have been tested in large phase I/II trials and resulted in 30–40% durable responses. This has led to Food and Drug Administration and European Medicines Agency approval for axicabtagene ciloleucel and tisagenlecleucel and filing of the biologics license application for lisocabtagene maraleucel. Emerging real-world evidence seems to confirm the promising results. However, considerable toxicity, mainly cytokine release syndrome and neurotoxicity limits their general applicability and not all patients intended to be treated can be bridged during the manufacturing period due to kinetics of the disease. Randomized phase III clinical trials are being conducted to test anti-CD19 CAR-T-cell therapy in the second-line and several phase II trials are aiming to improve efficacy and decrease toxicity.

CD19-directed CAR-T-cell therapy has become standard of care for aggressive R/R diffuse large B-cell non-Hodgkin lymphoma (DLBCL), but challenges still remain.
The Perceptions of Cancer Patients Regarding the Causes and Preventability of Unplanned Hospital Admissions
Authors: Meisenberg Barry R. , Karpman Mitchell , Tan Jessica , Parlacoski Stephanie , Rhule Jane , Moxley John
Published: August 2020

Objective:

The objective of this study was to determine the attitudes of oncology patients regarding the causes and preventability of unplanned hospitalizations.

Methods:

Convenience sample using a 36-question survey instrument adapted from prior studies of hospital readmissions.

Results:

A total of 95 evaluable patients answered >75% of survey items. Majorities (64%) agreed that they desired to avoid the admission, but disagreed (79%) that their own admission was preventable. Patients did not generally express lack confidence in their overall self-management abilities (only 36% agreed) or dissatisfaction with the level of home support, emotional or equipment (only 11% to 26% agreed). Patients did not complain of an inability to access their oncology care team (only 14% agreed), yet a strong majority (79%) endorsed the idea that emergency department visits represent the “quickest and easiest way to get needed care” and that the “hospital is the best place for me when I am sick” (60%). Overall, 79% indicated that their oncology care team directed them to visit the emergency department for evaluation. Most results did not differ by demographic factors.

Conclusions:

These results differ from previous results that use methods other than a direct patient survey to determine the preventability or root causes of unplanned hospital admissions/ or readmissions. Accordingly, patient support programs may not address the root causes of unplanned admissions. The use of the emergency department for unplanned care may represent local culture and institutions planning reduction efforts should include patent perceptions to plan a holistic solution.
Treatments of Periorbital Hyperpigmentation: A Systematic Review
Authors: Michelle Lauren , Pouldar Foulad Delila , Ekelem Chloe , Saedi Nazanin , Mesinkovska Natasha Atanaskova
Published: August 2020

BACKGROUND

Periorbital hyperpigmentation (POH) is an aesthetic concern for patients. Etiologies of the condition include pigmentary, structural, vascular, and mixed causes.

OBJECTIVE

To systematically review the current literature for treatment of POH.

METHODS

A systematic literature review was performed on PubMed. Search terms included “infraorbital dark circles,” “dark circles,” “periorbital hyperpigmentation,” “idiopathic hyperchromia AND orbital,” “under-eye circles,” “ICHOR (idiopathic cutaneous hyperchromia of the orbital region),” “dark circles” AND “treatment,” and “filler” AND “dark circles.”

RESULTS

A total of 39 studies were included. Effective treatments for POH include lasers, topical creams and serums, fillers, chemical peels, carboxytherapy, plasma-rich platelet injections, blepharoplasty, and normobaric oxygen.

CONCLUSION

Soft tissue fillers and autologous fat grafting are most effective in treating dark circles due to volume loss. Blepharoplasty surgery is best when excessive skin laxity is the underlying cause. Various topical creams and chemical peels are useful in treating pigment-based POH, whereas lasers are mildly to moderately beneficial for both vascular and pigment types. Given the scarcity of high-quality evidence supporting these results, recommendations should be interpreted selectively. Additional randomized clinical trials studying POH will be helpful.
Interpolation Flaps in the Outpatient Mohs Surgery Setting: A Prospective Cohort Study of Patient Pain, Anxiety, and Satisfaction
Authors: Wong Noelle , Godinez-Puig Victoria , Makdisi Joy , Zloty David , Kossintseva Irèn
Published: August 2020

BACKGROUND

Staged interpolation flaps (SIFs) have historically been performed under general anesthesia by specialties outside of dermatologic surgery. However, SIFs performed under local anesthesia by dermatologic surgeons have shown lower or equal complication rates.

OBJECTIVE

To date, no studies have evaluated pain, anxiety, satisfaction, and use of perioperative analgesics in patients undergoing SIFs in an outpatient setting under local anesthesia.

METHODS/MATERIALS

This is a prospective cohort study of 39 patients who received Mohs micrographic surgery and subsequent SIF repair in an outpatient setting under local anesthesia. Pain, anxiety, and satisfaction scores were recorded using 100-point validated visual analog scales. Perioperative analgesic use was quantified.

RESULTS

The defect size was ≥4 cm2 in 72% of patients; 41% had full-thickness (skin/cartilage/mucosa) defects. All pain and anxiety measures were minimal to mild. Pain scores ranged from highest (mean = 39 ± 4.1) on postoperative Day (POD) 1 to lowest (mean = 12.3 ± 2.0) on POD 7. Anxiety scores ranged from highest (mean = 42 ± 4.5) on POD 1 to lowest (mean = 18.5 ± 3.7) on POD 7. Perioperative patient satisfaction was high (mean = 95 ± 1.7). Postoperative narcotic analgesics were prescribed in 15% of patients.

CONCLUSION

Staged interpolation flaps performed under local anesthesia in the outpatient setting are well tolerated with low pain and anxiety, high patient satisfaction, and minimal analgesic use.
Incidence of gastric insufflation at high compared with low laryngeal mask cuff pressure
Authors: Hell Johannes , Pohl Holger , Spaeth Johannes , Baar Wolfgang , Buerkle Hartmut , Schumann Stefan , Schmutz Axel
Published: August 2020

BACKGROUND

The success of ventilation with a laryngeal mask depends crucially on the seal between the mask and the periglottic tissue. Increasing the laryngeal mask's cuff volume is known to reduce oral air leakage but may lead to gastric insufflation.

OBJECTIVE

We hypothesised that a lower cuff pressure would result in less gastric insufflation. We sought to compare gastric insufflation with laryngeal mask cuff pressures of 20 cmH2O (CP20) and 60 cmH2O (CP60) during increasing peak airway pressures in a randomised controlled double-blind cross-over study. We also evaluated the incidence of gastric insufflation at the recommended peak airway pressure of 20 cmH2O or less and during both intermittent positive airway pressure and continuous positive airway pressure.

METHODS

After obtaining ethics approval and written informed consent, 184 patients ventilated via laryngeal mask received a stepwise increase in peak airway pressure from 15 to 30 cmH2O with CP20 and CP60 in turn. Gastric insufflation was determined via real-time ultrasound and measurement of the cross-sectional area of the gastric antrum. The primary endpoint was the incidence of gastric insufflation at the different laryngeal mask cuff pressures.

RESULTS

Data from 164 patients were analysed. Gastric insufflation occurred less frequently at CP20 compared with CP60 (P < 0.0001). Gastric insufflation was detected in 35% of cases with CP20 and in 48% with CP60 at a peak airway pressure of 20 cmH2O or less. Gastric insufflation occurred more often during continuous than during intermittent positive airway pressures (P < 0.01).

CONCLUSION

A laryngeal mask cuff pressure of 20 cmH2O may reduce the risk of gastric insufflation during mechanical ventilation. Surprisingly, peak airway pressure of 20 cmH2O or less may already induce significant gastric insufflation. Continuous positive airway pressure should be avoided due to an increased risk of gastric insufflation.

CLINICAL TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register (DRKS00010583) https://www.drks.de.
Minimum effective volume of 0.5% ropivacaine for ultrasound-guided costoclavicular brachial plexus block
Authors: Wong Ming H. , Karmakar Manoj K. , Mok Louis Y.H. , Songthamwat Banchobporn , Samy Winnie
Published: August 2020

BACKGROUND

Costoclavicular brachial plexus block (CC-BPB) is a relatively new regional anaesthetic technique and there are no data on the minimum effective volume 90 (MEV90) of 0.5% ropivacaine required for an ultrasound-guided CC-BPB.

OBJECTIVE

To determine the MEV90 of 0.5% ropivacaine required to produce surgical anaesthesia with an ultrasound-guided CC-BPB.

DESIGN

Prospective up-down sequential allocation study design.

SETTING

University teaching hospital in Hong Kong from March 2016 to December 2017.

PATIENTS

Forty-eight, ASA physical status I to III patients, aged 70 years or less and scheduled for elective forearm or hand surgery under an ultrasound-guided CC-BPB, were recruited.

INTERVENTION

Ultrasound-guided CC-BPB was performed with the assigned volume of 0.5% ropivacaine. The Dixon ‘up-and-down’ sequential allocation method using the biased coin design was used to determine the MEV90 of 0.5% ropivacaine. The assigned volume of ropivacaine was based on the outcome of the previous patient. After a block failure the next patient received a volume increase of 2 ml. If the block was a success, the next patient was allocated, with a probability of b = 0.11, to receive 2 ml less, or, with a probability of 1 − b = 0.89, the same volume.

MAIN OUTCOME MEASURES

A successful block was defined as a minimum score of 14 of 16 points, using a composite sensory and motor block score at 45 min after the injection. The study was stopped when 45 successful blocks were achieved. MEV90 with 95% confidence interval was calculated using the centred isotonic regression for point and interval dose response studies.

RESULTS

The MEV90 of 0.5% ropivacaine for ultrasound-guided CC-BPB was 20.9 (95% confidence interval, 20.7 to 21.8) ml. The mean ± SD time to readiness for surgery was 31.4 ± 12.60 min.

CONCLUSION

The MEV90 of 0.5% ropivacaine required to produce surgical anaesthesia with an ultrasound-guided CC-BPB is 20.9 ml.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Chinese Clinical Trials Registry (www.chictr.org.cn, ChiCTR-IOR-15007515, principal investigator: Manoj Kumar Karmakar, date of registration: 4 December 2015).

CLINICAL TRIAL NUMBER AND REGISTRY URL

ChiCTR-IOR-15007515, Chinese Clinical Trials Registry (www.chictr.org.cn).
Introduction to Building the Cardio-Obstetric Team
Authors: WOLFE DIANA S.
Published: August 2020

The pregnant cardiac patient has become a national focus in the United States during the 21st century. Maternal mortality in the United States is on the rise, cardiac disease in pregnancy has been identified as the number one indirect cause and has driven the increase in maternal death rate greatly. This may be explained by the increasing number of women with congenital heart disease reaching reproductive age and a higher prevalence of chronic medical diseases. A triad solution includes cardiovascular screening, patient education and a multidisciplinary team. The Cardio Obstetric team is described here.
Polycystic Ovary Syndrome and Medical Conditions
Authors: ROLLENE NANETTE L. , LENTSCHER JESSICA A. , HEMPHILL ASHLEIGH M. , DECHERNEY ALAN H.
Published: August 2020

Polycystic ovary syndrome is a common endocrinopathy that has been associated with many medical conditions across nearly every specialty. This chapter reviews the current understanding of polycystic ovary syndrome and associated medical conditions.
Economic Considerations for Radiation Protection in Medical Settings—Is It Time for a New Paradigm?
Authors: Demeter Sandor J.
Published: August 2020

The full ALARA principle includes “as low as reasonably achievable” taking social and economic factors into consideration. The International Commission on Radiological Protection advises a conventional cost benefit approach (e.g., cost per monetized averted stochastic effects or years of life saved) to consider economic factors. Given small incremental radiation dose reductions to patients, workers, or the public that may be realized in medical settings and the correspondingly small changes to theoretical stochastic effects, a conventional cost benefit approach is less than ideal. This is illustrated in the case studies presented in this paper. Alternate approaches, such as cost per unit of radiation dose averted (e.g., $/μSv averted), cancer induction/fatality probabilistic thresholds, or thresholds relative to natural background radiation may be alternate options. However, the decision regarding what is a “safe” level of radiation and what are reasonable costs to make it “safer” are driven by societal values and may vary from jurisdiction to jurisdiction.
TREATMENT OF SUBRETINAL PERFLUOROCARBON LIQUID BUBBLES COMPLICATING RETINAL DETACHMENT SURGERY USING AIR FOR DRAINAGE
Authors: Lorenzi Umberto , Mora Paolo , Luciani Enrico , Barale Pierre-Olivier , Muraine Marc
Published: August 2020

Purpose:

The authors describe an original technique for treating multiple subretinal perfluorocarbon liquid (PFCL) bubbles complicating previous surgery for rhegmatogenous retinal detachment.

Methods:

To facilitate the induction of macular redetachment and peripheral displacement of the PFCL bubbles, we performed the subretinal injection of filtered air in addition to balanced salt solution. In this setting, the action of the PFCL in the vitreous cavity, combined with globe manipulation, allowed bubbles' displacement and full aspiration.

Results:

A 57-year-old man had a history of repeated pars plana vitrectomies for recalcitrant rhegmatogenous retinal detachment, the latter leading to multiple subretinal PFCL bubbles retained at the posterior pole. The described technique was performed 8 weeks after the last pars plana vitrectomy. A complete flattening of the macular region was obtained with visual improvement.

Conclusion:

Direct injection of air into the subretinal space may represent an effective strategy to help the surgical management of multiple retained PFCL bubbles.
THE ROLE OF CHECKPOINT INHIBITORS IN PARANEOPLASTIC ACUTE EXUDATIVE POLYMORPHOUS VITELLIFORM MACULOPATHY: REPORT OF TWO CASES
Authors: Kemels Dieter , ten Berge Josianne Carina Elvire Maria , Jacob Julie , Schauwvlieghe Pieter-Paul
Published: August 2020

Purpose:

To report on two cases with paraneoplastic acute exudative polymorphous vitelliform maculopathy within one month after the initiation of nivolumab.

Methods:

Case report.

Results:

Two patients with metastatic mucosal melanoma were diagnosed with acute exudative polymorphous vitelliform maculopathy within one month after the initiation of the checkpoint inhibitor nivolumab. Both cases showed a neurosensory retinal detachment and subretinal hyperautofluorescent material, which persisted after discontinuation of nivolumab and treatment with local and/or systemic corticosteroids. In one case, nivolumab was introduced again in a later stage in combination with surgical reduction of the tumor, eventually leading to resolution of the subretinal lipofuscin-rich fluid.

Conclusion:

The development of paraneoplastic acute exudative polymorphous vitelliform maculopathy in melanoma patients can be triggered by treatment with nivolumab. However, achieving tumor control, which may involve continuation of nivolumab, could be the key to success.
Delivering personalized medicine in retinal care: from artificial intelligence algorithms to clinical application
Authors: Jill Hopkins J. , Keane Pearse A. , Balaskas Konstantinos
Published: August 2020

Purpose of review

To review the current status of artificial intelligence systems in ophthalmology and highlight the steps required for clinical translation of artificial intelligence into personalized health care (PHC) in retinal disease.

Recent findings

Artificial intelligence systems for ophthalmological application have made rapid advances, but are yet to attain a state of technical maturity that allows their adoption into real-world settings. There remains an ‘artificial intelligence chasm’ in the spheres of validation, regulation, safe implementation, and demonstration of clinical impact that needs to be bridged before the full potential of artificial intelligence to deliver PHC can be realized.

Ophthalmology is currently in a stage between the demonstration of the potential of artificial intelligence and widespread deployment. Next stages include aggregating and curating datasets, training and validating artificial intelligence systems, establishing the regulatory framework, implementation and adoption with ongoing evaluation and model adjustment, and finally, meaningful human–artificial intelligence interaction with clinically validated tools that have demonstrated measurable impact on patient and healthcare system outcomes. Ophthalmologists should leverage the ability of artificial intelligence systems to glean insights from large volumes of multivariate data, and to interpret artificial intelligence recommendations in a clinical context. In doing so, the field will be well positioned to lead the transformation of health care in a personalized direction.

Video abstract

http://links.lww.com/COOP/A35.
Accelerating ophthalmic artificial intelligence research: the role of an open access data repository
Authors: Kras Ashley , Celi Leo A. , Miller John B.
Published: August 2020

Purpose of review

Artificial intelligence has already provided multiple clinically relevant applications in ophthalmology. Yet, the explosion of nonstandardized reporting of high-performing algorithms are rendered useless without robust and streamlined implementation guidelines. The development of protocols and checklists will accelerate the translation of research publications to impact on patient care.

Recent findings

Beyond technological scepticism, we lack uniformity in analysing algorithmic performance generalizability, and benchmarking impacts across clinical settings. No regulatory guardrails have been set to minimize bias or optimize interpretability; no consensus clinical acceptability thresholds or systematized postdeployment monitoring has been set. Moreover, stakeholders with misaligned incentives deepen the landscape complexity especially when it comes to the requisite data integration and harmonization to advance the field. Therefore, despite increasing algorithmic accuracy and commoditization, the infamous ‘implementation gap’ persists. Open clinical data repositories have been shown to rapidly accelerate research, minimize redundancies and disseminate the expertise and knowledge required to overcome existing barriers. Drawing upon the longstanding success of existing governance frameworks and robust data use and sharing agreements, the ophthalmic community has tremendous opportunity in ushering artificial intelligence into medicine. By collaboratively building a powerful resource of open, anonymized multimodal ophthalmic data, the next generation of clinicians can advance data-driven eye care in unprecedented ways.

This piece demonstrates that with readily accessible data, immense progress can be achieved clinically and methodologically to realize artificial intelligence's impact on clinical care. Exponentially progressive network effects can be seen by consolidating, curating and distributing data amongst both clinicians and data scientists.
Ophthalmic manifestations of coronavirus disease 2019 and ocular side effects of investigational pharmacologic agents
Authors: Olson Daniel J. , Ghosh Arko , Zhang Alice Yang
Published: August 2020

Purpose of review

To compile and report the ocular manifestations of coronavirus disease 2019 (COVID-19) infection and summarize the ocular side effects of investigational treatments of this disease.

Recent findings

Conjunctivitis is by far the most common ocular manifestation of COVID-19 with viral particles being isolated from tears/secretions of infected individuals. Multiple therapeutic options are being explored across a variety of medication classes with diverse ocular side effects.

Eye care professionals must exercise caution, as conjunctivitis may be the presenting or sole finding of an active COVID-19 infection. While no currently studied therapeutic agents have been found to reliably treat COVID-19, early vaccination trials are progressing and show promise. A video abstract is available for a more detailed summary.

Video abstract

http://links.lww.com/COOP/A36.
Ocular trauma during COVID-19 stay-at-home orders: a comparative cohort study
Authors: Wu Connie , Patel Samir N. , Jenkins Thomas L. , Obeid Anthony , Ho Allen C. , Yonekawa Yoshihiro
Published: August 2020

Purpose of review

The aim of this study was to report characteristics of patients presenting with serious ocular injuries during the COVID-19 stay-at-home orders.

Recent findings

Of 1058 patients presenting for emergency evaluation during the stay-at-home order, 62 (5.9%) patients [mean (SD) age, 41.1 (19.2) years; 19 (31%) women; 31 (50%) white] presented with severe ocular trauma. The daily mean (SD) number of patients who presented for emergency evaluation decreased from 49.0 (9) to 36.4 (6) during the quarantine (P < 0.001). Patients presenting during the stay-at-home order were less likely to have health insurance [odds ratio (OR), 0.33; 95% confidence interval (95% CI), 0.13–0.90, P = 0.024], more likely to have a delayed presentation (difference, 22.7 h, 95% CI, 5.8–39.5, P < 0.001, more likely to travel farther to seek emergency care (difference, 10.4 miles, 95% CI, 2.6–18.2, P < 0.001) and more likely to have an injury occur at home (OR, 22.8; 95% CI, 9.6–54.2, P < 0.001). Of injuries occurring at home, there was a significant increase in injuries arising from home improvement projects during the stay-at-home order (28 vs. 0%, P = 0.02).

During the COVID-19 pandemic, patients with ocular trauma were more likely to have injuries sustained at home and have additional barriers to care. These changes underscore a need for targeted interventions to optimize emergent eye care during a pandemic.
Real-world vitreoretinal practice patterns during the 2020 COVID-19 pandemic: a nationwide, aggregated health record analysis
Authors: Xu David , Starr Matthew R. , Boucher Nicholas , Chiang Allen , Yonekawa Yoshihiro , Klufas Michael A. , Khan M. Ali , Cohen Michael N. , Mehta Sonia , Kuriyan Ajay E.
Published: August 2020

Purpose of review

The COVID-19 pandemic has posed an unprecedented challenge to the healthcare community. To reduce disease transmission, national regulatory agencies temporarily recommended curtailment of all nonurgent office visits and elective surgeries in March 2020, including vitreoretinal outpatient care in the USA. The effect of these guidelines on utilization of vitreoretinal care has not been explored to date.

Recent findings

Retinal outpatient visits, new patient visits, intravitreal antivascular endothelial growth factor injections and in-office multimodal retinal imaging has seen a significant decline in utilization in the early phase of the pandemic. Intravitreal injections were performed at a comparatively higher rate than office visits. Utilization appeared to steadily increase in April 2020. Telemedicine visits, enabled by new national legislation for all areas of medicine, have been adopted to a modest degree by the retina community.

In-office retinal care declined in response to the COVID-19 pandemic and national regulatory guidelines limiting nonurgent care. These trends in practice patterns and care utilization may be of interest to vitreoretinal providers and all ophthalmologists at large.
Evaluation of Intranasal Dexmedetomidine as a Procedural Sedative for Ophthalmic Examination of Children With Glaucoma
Authors: Dhingra Deepika , Ghai Babita , Sabharwal Pranshuta , Saini Vikas , Snehi Sagarika , Kaur Manpreet , Pandav Surinder S. , Kaushik Sushmita
Published: August 2020

Precis:

This study evaluated 2 doses of intranasal dexmedetomidine (IND) (3.0 and 3.5 µg/kg) as a procedural sedative for postoperative examination of children with glaucoma. A dose of 3.5 µg/kg was more efficacious and obviated the need for repeated general anesthesia.

Purpose:

This study was carried out to determine the safety and effective dose of IND as a procedural sedative for postoperative follow-up examinations after glaucoma surgery in children in place of repeated examination under anesthesia.

Materials and Methods:

In this prospective randomized double-blinded interventional study, consecutive children aged 6 months to 6 years were randomized to receive 3.0 and 3.5 µg/kg IND using a mucosal atomizer device in the preoperative area of the operating room, under continuous monitoring of vital signs. Intranasal midazolam 0.25 mg/kg was used as a rescue agent in case of inadequate sedation, and general anesthesia was administered in case of persistent failure. All infants underwent a complete anterior and posterior segment evaluation including intraocular pressure and corneal diameter measurements.

Results:

A total of 30 and 31 children aged 23.9±15.0 and 19.2±10.1 months, respectively, received 3.0 and 3.5 µg/kg IND. Adequate sedation was possible in 18 of 30 (60%) children receiving 3.0 µg/kg and 24 of 31 (77.4%) receiving 3.5 µg/kg IND alone (P=0.17). In combination with midazolam, successful sedations were 86.6% versus 100%, respectively (P=0.052). One patient in the 3.5 µg/kg group had ventricular arrhythmia, reversed with dextrose-saline infusion and injection glycopyrrolate.

Conclusions:

IND appears to be a safe and effective procedural sedative for postoperative follow-up examinations of pediatric glaucoma patients at doses of 3 and 3.5 µg/kg. The dose of 3.5 µg/kg was successful in more children.
Intraocular Pressure Peaks After Suprachoroidal Stent Implantation
Authors: Kuusniemi Arvi-Matti , Lindbohm Nina , Allinen Pasi , Harju Mika
Published: August 2020

Précis:

Retrospective analysis of 38 suprachoroidal glaucoma stent implantations showed sudden intraocular pressure (IOP) elevations to >30 mm Hg in 37% of eyes, 39% needing additional glaucoma surgery, and a success rate at 12 months of 24%.

Purpose:

To study the efficacy and safety of suprachoroidal stent in everyday clinical practice at a tertiary glaucoma center.

Materials and Methods:

This retrospective single-center consecutive case series involved patients treated at Helsinki University Hospital with the CyPass Micro-Stent. Preoperative IOP was ≥18 mm Hg. Success was IOP between 6 and 18 mm Hg and lowering of IOP at least 20% from baseline without an increase in glaucoma medications over baseline or use of oral acetazolamide, and no subsequent glaucoma surgery.

Results:

Of the total 38 eyes of 33 patients, 17 had primary open-angle glaucoma, 16 had exfoliative glaucoma, 2 each had uveitic glaucoma or steroid-induced glaucoma, and 1 had pigmentary glaucoma. Median preoperative IOP was 25.8 [interquartile range (IQR), 9.7] mm Hg with a median of 3 (IQR, 2) glaucoma medications. Kaplan-Meier estimate of median survival time was 79 days (95% confidence interval, 37-121 d). Success rate at 12-month follow-up was 24%. Sudden IOP elevation to over 30 mm Hg occurred in 14 eyes (37%). Highest IOP was 68 mm Hg. IOP peaks occurred between 1 week and 8 months after the surgery. In total, 43% of those with IOP elevation to >30 mm Hg had no symptoms. After the CyPass implantation, 15 eyes (39%) needed additional glaucoma surgery within a median of 167 (IQR, 109) days.

Conclusions:

Suprachoroidal stenting in a heterogenous clinical population resulted in a high incidence of sudden IOP peaks with a low success rate.
Beliefs and Attitudes of Ophthalmologists Regarding SLT as First Line Therapy for Glaucoma
Authors: Bonafede Lucas , Sanvicente Carina T. , Hark Lisa A. , Tran Judie , Tran Evelyn , Zhang Qiang , Costello Rose , Myers Jonathan S. , Katz L. Jay
Published: August 2020

Precis:

Targeted educational interventions for physicians may be useful in increasing adoption of selective laser trabeculoplasty (SLT) as first line therapy for the treatment of glaucoma.

Purpose:

SLT is a safe and effective first line treatment for glaucoma, however, it is underutilized. To evaluate barriers for the widespread adoption of this procedure, we assessed the beliefs and attitudes of ophthalmologists. We developed an educational intervention directed to physicians to increase the consideration of SLT earlier in the glaucoma treatment paradigm.

Subjects and Methods:

In this prospective study, an online survey and educational slide presentation was sent to a group of comprehensive ophthalmologists, ophthalmology residents, and glaucoma specialists. Subjects were asked to respond to questions regarding their beliefs and attitudes towards SLT before and after watching the educational slide presentation.

Results:

A total of 53 subjects were enrolled. Before watching the slide presentation, 85% of subjects stated they offer SLT to newly diagnosed patients, although only 28% preferred it over medications. While 52% of physicians reported between 0% and 10% of their newly diagnosed patients receive laser therapy, 47% said they would use it as a first line therapy for all or most newly diagnosed glaucoma patients. Most subjects (94%) stated the educational slide presentation convinced them that SLT is appropriate as a first line therapy for treatment of open angle glaucoma.

Conclusions:

A better understanding of the barriers for utilizing SLT as a first line therapy provides valuable information to help increase the adoption of this safe and effective procedure. A targeted educational intervention may improve acceptance of SLT as first line therapy for open angle glaucoma.
Late-onset Subconjunctival Abscess Secondary to Serratia marcescens Associated With Unexposed Ahmed Glaucoma Valve Implant
Authors: Sosuan George Michael N. , Leuenberger Edgar U.
Published: August 2020

Purpose:

The purpose of this study was to report a rare case of late-onset subconjunctival abscess associated with an unexposed Ahmed glaucoma valve implant secondary to Serratia marcescens, a rare conjunctival pathogen.

Methods:

Case description including clinical imaging and literature review of glaucoma drainage device (GDD)-related infections.

Case Presentation:

A 73-year-old man presented with blurring of vision, redness, and pain on his right eye 2 months after Ahmed glaucoma valve implantation for advanced postpenetrating-keratoplasty glaucoma. The patient was nonsmoker, had fairly controlled type 2 diabetes mellitus on insulin, and had undergone multiple eye surgeries on the right eye. On ocular examination, the conjunctiva was injected with fairly delineated yellowish-white subconjunctival material in the superotemporal quadrant with no associated tube exposure or leak, and the anterior chamber was quiet. The patient was assessed with Ahmed glaucoma valve infection with subconjunctival abscess and was treated by Ahmed glaucoma valve explant with directed systemic and topical antimicrobial therapy. The culture and sensitivity results revealed S. marcescens sensitive to ciprofloxacin, ceftazidime, gentamicin, and amikacin. Despite the virulence of the pathogen, the eye was saved.

Conclusions:

Ahmed glaucoma valve infection with subconjunctival abscess secondary to S. marcescens is rare. GDD-related infections should be suspected in patients presenting with blurring of vision, pain, and redness even in the absence of tube exposure. Early diagnosis and treatment with culture-guided antimicrobial therapy combined with GDD explant is fundamental in optimizing the visual outcome.
Systemic sclerosis-associated interstitial lung disease
Authors: Scallan Ciaran J. , Collins Bridget F. , Raghu Ganesh
Published: August 2020

Purpose of review

In this review, the authors discuss systemic sclerosis-associated interstitial lung disease (SSc-ILD) with a focus on recent developments in diagnosis, surveillance, and management.

Recent findings

With advances in the management of SSc, the importance of ILD has been increasingly recognized and is the leading cause of mortality. Early detection is essential, and a combination of lung function testing and chest imaging are key tools in diagnosis and surveillance. The foundation of treatment is immunomodulation with recent studies identifying several potential new agents. The use of therapies targeting pro-fibrotic pathways have demonstrated significant effects on lung function decline and represent the latest advance in therapy for SSc-ILD.

Recent studies support the use of newer therapies in SSc-ILD including antifibrotic agents. The identification and management of comorbidities is important, and lung transplantation is a viable option for patients with advanced disease.
Critical care of patients with pulmonary arterial hypertension
Authors: Aryal Shambhu , King Christopher S.
Published: August 2020

Purpose of review

Need for intensive care in the patient with pulmonary arterial hypertension is associated with high mortality. This review will provide an overview of causes of ICU admission for patients with pulmonary hypertension and provide guidance on management.

Recent findings

There is a paucity of evidence-based medical literature on management of patients with pulmonary arterial hypertension. This article will summarize the available literature and expert guidance on the topic. Patients with pulmonary arterial hypertension may require ICU care as a direct consequence of decompensated right heart failure. Alternatively, patients with pulmonary arterial hypertension may be affected by the myriad of maladies encountered every day in the ICU including acute respiratory failure, septic shock, and gastrointestinal bleeding. The treatment plan should focus on identifying and treating the cause for decompensation. In addition, optimization of right ventricular preload, reduction of right ventricular afterload, correction of hypotension and augmentation of right ventricular inotropy should be considered.

The approach to ICU care of patients with pulmonary arterial hypertension requires special consideration with regard to intubation and mechanical ventilation and management of volume status and hemodynamics. Whenever possible, these patients should be transferred to centers with experience in treating this complex, vulnerable population.
Advanced therapies for pulmonary embolism
Authors: Hountras Peter , Bull Todd M.
Published: August 2020

Purpose of review

Treatment options for managing patients with acute pulmonary embolism are rapidly evolving. In this review, we discuss the supporting evidence and implementation strategies for these advanced therapeutic modalities.

Recent findings

We review the recent data supporting systemic and catheter directed thrombolytic therapies, mechanical embolectomy, use of extracorporeal membrane oxygen support, and pulmonary embolism response teams in managing patients with acute pulmonary embolism. We discuss the major professional society recommendations regarding their implementation.

A review of advanced therapies for pulmonary embolism.
Obesity as a risk factor for thyroid cancer
Authors: Matrone Antonio , Ferrari Federica , Santini Ferruccio , Elisei Rossella
Published: August 2020

Purpose of review

In this review, we evaluate recent findings related to the association between obesity and thyroid cancer.

Recent findings

During the last several decades, the prevalence of obesity and thyroid cancer have been increasing in parallel on a global scale. Current evidence suggests that the growing incidence of differentiated thyroid cancer (DTC) is pathogenically linked to the spread of obesity, but the biological mechanisms that may explain this connection have been only partially described. Furthermore, unlike other tumors, data on the impacts of obesity on the aggressiveness of DTC and response to treatment of DTC remain conflicting.

Emergent knowledge regarding the links between obesity and thyroid cancer suggests a relevant role for obesity as a risk factor for DTC, with no apparent impact on its aggressiveness.
Use of artificial intelligence and machine learning for estimating malignancy risk of thyroid nodules
Authors: Thomas Johnson , Ledger Gregory A. , Mamillapalli Chaitanya K.
Published: August 2020

Purpose of review

Current methods for thyroid nodule risk stratification are subjective, and artificial intelligence algorithms have been used to overcome this shortcoming. In this review, we summarize recent developments in the application of artificial intelligence algorithms for estimating the risks of malignancy in a thyroid nodule.

Recent findings

Artificial intelligence have been used to predict malignancy in thyroid nodules using ultrasound images, cytopathology images, and molecular markers. Recent clinical trials have shown that artificial intelligence model's performance matched that of experienced radiologists and pathologists. Explainable artificial intelligence models are being developed to avoid the black box problem. Risk stratification algorithms using artificial intelligence for thyroid nodules are now commercially available in many countries.

Artificial intelligence models could become a useful tool in a thyroidolgist's armamentarium as a decision support tool. Increased adoption of this emerging technology will depend upon increased awareness of the potential benefits and pitfalls in using artificial intelligence.
Using a low-carbohydrate diet to treat obesity and type 2 diabetes mellitus
Authors: Westman Eric C. , Yancy William S.
Published: August 2020

Purpose of review

This study will provide a narrative review of the history of the clinical use of low-carbohydrate diets and give a practical example of how to implement a low-carbohydrate diet, with an emphasis on deprescribing medications.

Recent findings

Low-carbohydrate diets have been used since the late 19th century to treat obesity and type 2 diabetes mellitus (T2DM). Recently, clinical research has validated the use of low-carbohydrate diets for individuals affected by obesity and T2DM, and these diets are included in several national clinical guidelines. Because medications are commonly used to treat hypertension and T2DM, special consideration must be made to monitor and reduce these medications to avoid overmedication. Clinic visits and home monitoring of blood pressure and glucose levels are important tools to alert clinicians that a reduction in medication levels may be indicated.

Low-carbohydrate diets have been utilized clinically for many years to treat obesity and T2DM and can be used alongside effective monitoring to safely deprescribe dispensable medications for these diseases.
Reversal of severe hypertriglyceridemia with intermittent fasting and a very-low-carbohydrate ketogenic diet: a case series
Authors: Das Subrat , McCreary Jordan , Shamim Shariq , Kalayjian Tro
Published: August 2020

Purpose of review

To illustrate successful reversal of hypertriglyceridemia using a very-low-carbohydrate ketogenic diet in conjunction with intermittent fasting in two patients.

Recent findings

Hypertriglyceridemia remains an important component of residual risk for atherosclerotic cardiovascular disease. Current guidelines from the AHA/ACC recommend the initiation of a very-low-fat diet to treat persistently elevated triglycerides, whereas the National Lipid Association argues that a very-low-carbohydrate, high-fat diet is contraindicated in severe hypertriglyceridemia. In contrast, we report resolution of two cases of severe hypertriglyceridemia with implementation of very-low-carbohydrate ketogenic diets and intermittent fasting.

Here, we describe two patients who have demonstrated substantial reductions in serum triglycerides, effectively reversing severe hypertriglyceridemia using unconventional dietary methods. Although anecdotal, these cases point to a critical lack of flexibility in current dietary guidelines that hinder their application in clinical practice.
Metacognition Is Uniquely Related to Concurrent and Prospective Assessments of Negative Symptoms Independent of Verbal Memory in Serious Mental Illness
Authors: Faith Laura A. , Lecomte Tania , Corbière Marc , Francoeur Audrey , Hache-Labelle Catherine , Lysaker Paul H.
Published: August 2020

The inability to synthesize information into experience of self and others could be one significant cause of negative symptoms. To explore this possibility, we examined the relationships between baseline metacognition and concurrent and prospective negative symptoms controlling for verbal memory. The participants were 62 adults diagnosed with serious mental illness enrolled in outpatient treatment. Metacognition was measured with the Metacognitive Assessment Scale–Abbreviated, symptoms were assessed using the Brief Psychiatric Rating Scale, and verbal memory was assessed using the California Verbal Learning Test. Significant correlations were found, indicating that poorer overall metacognition was associated with greater levels of negative symptoms assessed concurrently (r = 0.39) and 1 month later (r = 0.36). A significant relationship persisted after controlling for verbal memory and education. These findings support the idea that metacognitive deficits are related to negative symptoms and point to the potential of metacognitive interventions to positively influence negative symptoms.
Raising the Bar
Authors: Medland Jacqueline , Nolan Katrina , McDonagh Annmarie
Published: August 2020

This article describes one hospital’s use of simulation to improve the knowledge, skills, and abilities of an emergency department team regarding the patient experience. Step-by-step instructions are provided on how to conduct the simulations in a way that allows for the practice of new skills in a safe environment—one that promotes reflection, feedback, and learning.