Echocardiographic assessment of cardiovascular physiology of preterm miniature piglets supported with a pumped artificial placenta system.

OBJECTIVES: We evaluated fetal cardiovascular physiology and mode of cardiac failure in premature miniature piglets on a pumped artificial placenta (AP) circuit. METHODS: Fetal pigs were cannulated via the umbilical vessels and transitioned to an AP circuit composed of a centrifugal pump and neonatal oxygenator and maintained in a fluid-filled biobag. Echocardiographic studies were conducted to measure ventricular function, umbilical blood flow, and fluid status. In utero scans were used as control data. RESULTS: AP fetuses (n = 13; 102±4d gestational age [term 115d]; 616 ± 139 g [g]; survival 46.4 ± 46.8 h) were tachycardic and hypertensive with initially supraphysiologic circuit flows. Increased myocardial wall thickness was observed. Signs of fetal hydrops were present in all piglets. Global longitudinal strain (GLS) measurements increased in the left ventricle (LV) after transition to the circuit. Right ventricle (RV) and LV strain rate decreased early during AP support compared with in utero measurements but recovered toward the end of the experiment. Fetuses supported for >24 h had similar RV GLS to in utero controls and significantly higher GLS compared to piglets surviving only up to 24 h. CONCLUSIONS: Fetuses on a pump-supported AP circuit experienced an increase in afterload, and redistribution of blood flow between the AP and systemic circulations, associated with elevated end-diastolic filling pressures. This resulted in heart failure and hydrops. These preterm fetuses were unable to tolerate the hemodynamic changes associated with connection to the current AP circuit. To better mimic the physiology of the native placenta and preserve normal fetal cardiovascular physiology, further optimization of the circuit will be required.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Association of the Affordable Care Act with Eye-Related Emergency Department Utilization in the United States.

PURPOSE: To investigate the association of the Affordable Care Act (ACA) with nationwide eye-related emergency department (ED) use. DESIGN: Retrospective, cross-sectional study. PARTICIPANTS: All patients who presented to the ED with an eye-related primary diagnosis were eligible for inclusion. METHODS: Nationally representative data from the US Nationwide Emergency Department Sample were used to analyze eye-related ED visits before (2010-2013) and after (2014-2017) the ACA was mandated. All ED visits were categorized as emergent or nonemergent or could not be determined. MAIN OUTCOME MEASURES: The primary outcome was to compare the nationwide and regional incidence of eye-related ED visits per 100 000 US population before (2010-2013) and after (2014-2017) the ACA was mandated. Secondary outcome measures included change in payor status, proportion of urgent versus nonurgent visits, proportion of visits at teaching versus nonteaching hospitals, associated charges, and discharge disposition. RESULTS: A total of 16 808 343 eye-related ED visits occurred in the United States during the study period from 2010 to 2017. Of these, 8 088 203 ED visits occurred before the ACA was mandated (2010-2013), and 8 720 766 ED visits occurred after the ACA was mandated (2014-2017). After the ACA was mandated in 2014, there was an initial decline in incidence of eye-related ED visits from 652.4 per 100 000 population in 2013 to 593.0 per 100 000 population in 2014, followed by a rapid increase in incidence to 658.5 per 100 000 population in 2015, with a further increase to 746.6 per 100 000 population in 2016. The percentage of uninsured patients decreased from 19.0% to 14.3%. The increase in ED use was greatest for individuals in the lowest income quartile (895.1 per 100 000 population in 2013 to 964.0 per 100 000 in 2017). Overall, 44.8% of ED visits were due to nonemergent eye conditions. CONCLUSIONS: Although the ACA increased insurance coverage for Americans, theoretically increasing access to outpatient ophthalmic care, this did not decrease ED reliance for management of ophthalmic conditions. Additional measures beyond expanding insurance coverage may be necessary to provide high-quality, efficient, and equitable outpatient ophthalmic care to all Americans.

Economic evaluation of the e-Health StandingTall balance exercise programme for fall prevention in people aged 70 years and over.

BACKGROUND: globally, falls and fall-related injuries are the leading cause of injury-related morbidity and mortality in older people. In our ageing society healthcare costs are increasing, therefore programmes that reduce falls and are considered value for money are needed. OBJECTIVE: to complete an economic evaluation of an e-Health balance exercise programme that reduced falls and injurious falls in community-dwelling older people compared to usual care from a health and community-care funder perspective. DESIGN: a within-trial economic evaluation of an assessor-blinded randomised controlled trial with 2 years of follow-up. SETTING: StandingTall was delivered via tablet-computer at home to older community-dwelling people in Sydney, Australia. PARTICIPANTS: five hundred and three individuals aged 70+ years who were independent in activities of daily living, without cognitive impairment, progressive neurological disease or any other unstable or acute medical condition precluding exercise. MAIN OUTCOME MEASURES: cost-effectiveness was measured as the incremental cost per fall and per injurious fall prevented. Cost-utility was measured as the incremental cost per quality-adjusted life year (QALY) gained. MAIN RESULTS: the total average cost per patient for programme delivery and care resource cost was $8,321 (standard deviation [SD] 18,958) for intervention participants and $6,829 (SD 15,019) for control participants. The incremental cost per fall prevented was $4,785 and per injurious fall prevented was $6,585. The incremental cost per QALY gained was $58,039 (EQ5D-5L) and $110,698 (AQoL-6D). CONCLUSION: this evaluation found that StandingTall has the potential to be cost-effective in specific subpopulations of older people, but not necessarily the whole older population. TRIAL REGISTRATION: ACTRN12615000138583.

Depressive affect moderates the effects of biological sex on the recognition of facial emotion.

Females show a small processing advantage relative to males in the ability to identify facial expressions of emotion. In laboratory studies, this is expressed as a sex difference in the accuracy of discrimination or in recognition latencies (the time required to identify an expression). Reasons for the sex difference are not well-understood. In the current pilot study, young adults (N = 62) with and without mild to moderate symptoms of depression were asked to discriminate facial images of infants and toddlers expressing six cardinal emotions. Results showed that elevated depressive affect was associated with more rapid recognition of negative emotions by females, and with potentiation of the typically observed sex difference, compared with non-depressed observers. Differences in endogenous affective status might be one proximate factor contributing to a female advantage in emotion recognition.

Post-liver transplantation chronic kidney disease is associated with increased cardiovascular disease risk and poor survival.

Chronic kidney disease (CKD) is common following liver transplantation (LT). We aimed to investigate the frequency, risk factors, and impact of CKD on cardiovascular disease (CVD), graft, and patient survival. We analyzed 752 patients who received LT at the University of Alberta. Development of CKD was defined as eGFR <60 ml/min for greater than 3 months, intrinsic renal disease or presence of end-stage renal disease requiring renal replacement therapy. 240 patients were female (32%), and mean age at LT was 53 ± 11 years. CKD was diagnosed in 448 (60%) patients. On multivariable analysis, age (OR 1.3; P = 0.01), female sex (OR 3.3; P < 0.001), baseline eGFR (OR 0.83; P < 0.001), MELD (OR 1.03; P = 0.01), de novo metabolic syndrome (OR 2.3; P = 0.001), and acute kidney injury (OR 3.5; P < 0.001) were associated with CKD. A higher tacrolimus concentration to dose ratio was protective for CKD (OR 0.69; P < 0.001). CKD was associated with post-transplant CVD (26% vs. 16% P < 0.001), reduced graft (HR 1.4; P = 0.02), and patient survival (HR 1.3; P = 0.03). CKD is a frequent complication following LT and is associated with an increased risk of CVD and reduced graft and patient survival.

Corneal Innervation and Sensation: The Eye and Beyond.

The cornea is one of the most densely innervated and sensitive tissues in the body. In addition to their important sensory functions, corneal nerves induce reflex tear production, blinking, and the release of trophic factors - all of which combined help to maintain the structural and functional integrity of the surface of the eye. Consequently, damage to corneal nerves as a result of disease, surgery, or trauma can lead to diminished corneal sensitivity, epithelial defects, and possible blindness. In this review, we describe commonly used tools that have provided considerable new information on corneal architecture and sensation in healthy and diseased corneas, with special emphasis on changes seen in herpes zoster ophthalmicus, corneal and other therapeutic ocular procedures, antiglaucoma medical therapy, aging, and diabetes. With its potential applications ranging from managing ocular-specific to systemic diseases, the study of corneal innervation has implications for future therapies extending beyond just the eye itself.

Trends in maternal morbidity before and during pregnancy in California.

OBJECTIVES: We examined trends in maternal comorbidities in California. METHODS: We conducted a retrospective cohort study of 1,551,017 California births using state-linked vital statistics and hospital discharge cohort data for 1999, 2002, and 2005. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify the following conditions, some of which were preexisting: maternal hypertension, diabetes, asthma, thyroid disorders, obesity, mental health conditions, substance abuse, and tobacco use. We estimated prevalence rates with hierarchical logistic regression models, adjusting for demographic shifts, and also examined racial/ethnic disparities. RESULTS: The prevalence of these comorbidities increased over time for hospital admissions associated with childbirth, suggesting that pregnant women are getting sicker. Racial/ethnic disparities were also significant. In 2005, maternal hypertension affected more than 10% of all births to non-Hispanic Black mothers; maternal diabetes affected nearly 10% of births to Asian/Pacific Islander mothers (10% and 43% increases, respectively, since 1999). Chronic hypertension, diabetes, obesity, mental health conditions, and tobacco use among Native American women showed the largest increases. CONCLUSIONS: The prevalence of maternal comorbidities before and during pregnancy has risen substantially in California and demonstrates racial/ethnic disparity independent of demographic shifts.

Surface quality of human corneal lenticules after SMILE assessed using environmental scanning electron microscopy.

PURPOSE: To assess the cut quality of the anterior and posterior surfaces of intrastromal refractive lenticules removed during small incision lenticule extraction (SMILE). METHODS: The VisuMax femtosecond laser (500 kHz; Carl Zeiss Meditec, Dublin, CA) was used to perform SMILE on 8 eyes of 5 individuals to correct only myopia (no cylinder). The cut energy index was 26 (equivalent to an energy of 130 nJ) with a 2.5 × 2.5 µm spot/track separation. The lenticule diameter was 6.5 mm with a minimum edge thickness of 15 µm and the cap diameter was 7.3 mm with an intended thickness of 120 µm. After laser treatment, the lenticule was loosened with a spatula and removed with forceps. The extracted lenticules were placed in 2% formalin and sent for imaging with an environmental scanning electron microscope. Images of the anterior and posterior surfaces of the lenticules were obtained at multiple magnifications (100×, 250×, and 500×). Surface quality was evaluated by an investigator who specializes in electron microscopy using three criteria: overall surface regularity, percent of surface irregularity, and position of irregular area. RESULTS: Both the anterior and posterior surfaces of the extracted lenticules were smooth and absent of surface irregularities. The cut edges also appeared uniform. Jagged edges were seen in several images, but were clearly caused by the forceps during extraction. CONCLUSIONS: Using the VisuMax laser to perform SMILE produces smooth cuts absent of surface irregularities.

Development and Evaluation of Aeyeconsult: A Novel Ophthalmology Chatbot Leveraging Verified Textbook Knowledge and GPT-4.

OBJECTIVE: There has been much excitement on the use of large language models (LLMs) such as ChatGPT in ophthalmology. However, LLMs are limited in that they are trained on unverified information and do not cite their sources. This paper highlights a new methodology to create a generative AI chatbot to answer eye care related questions which uses only verified ophthalmology textbooks as data and cites its sources. SETTING: Yale School of Medicine Department of Ophthalmology and Visual Science. DESIGN/METHODS: Aeyeconsult, an ophthalmology chatbot, was developed using GPT-4 (the LLM used to power the publicly available chatbot ChatGPT-4), LangChain, and Pinecone. Ophthalmology textbooks were processed into embeddings and stored in Pinecone. User queries were similarly converted, compared to stored embeddings, and GPT-4 generated responses. The interface was adapted from public code. Both Aeyeconsult and ChatGPT-4 were tested on the same 260 questions from OphthoQuestions.com, with the first response from Aeyeconsult and ChatGPT-4 recorded as the answer. RESULTS: Aeyeconsult outperformed ChatGPT-4 on the OKAP dataset, with 83.4% correct answers compared to 69.2% (p = 0.0118). Aeyeconsult also had fewer instances of no answer and multiple answers. Both systems performed best in General Medicine, with Aeyeconsult achieving 96.2% accuracy. Aeyeconsult's weakest performance was in Clinical Optics at 68.1%, but it still outperformed ChatGPT-4 in this category (45.5%). CONCLUSION: LLMs may be useful in answering ophthalmology questions but their trustworthiness and accuracy is limited due to training on unverified internet data and lack of source citation. We used a new methodology, using verified ophthalmology textbooks as source material and providing citations, to mitigate these issues, resulting in a chatbot more accurate than ChatGPT-4 in answering OKAPs style questions.

Music during cataract surgery: effect on anxiety.

PURPOSE: To determine the effect of playing patient-selected music intraoperatively on patient self-reported anxiety and the amount of sedative administered during cataract surgery. SETTING: Yale New Haven Hospital health system, New Haven, Connecticut. DESIGN: Prospective, randomized, controlled clinical trial. METHODS: Patients were randomized to either a music group or a control group, which had no music played. Patients were blinded to the purpose of the study. On postoperative day 1, patients were consented to participate in the study and asked to complete a 6-question Likert-style survey (modified from the State-Trait Anxiety Inventory) assessing anxiety at baseline and during surgery. Patients' intraoperative and postoperative vitals were recorded. The medication, dosage, and number of sedative injections given were also recorded. Paired t tests were used to assess for significant differences between the 2 groups. RESULTS: 107 patients (mean age 71.2 years) were enrolled in the study. There was no significant difference in baseline anxiety between the 2 groups. Patients randomized to the music group had significantly lower total self-reported anxiety (mean 5.98) than the control group (mean 7.13, P = .006). Moreover, patients exposed to music felt significantly less frightened, nervous, and confused during surgery ( P = .002, .007, and 0.017, respectively). There was no significant difference between the groups in number and dosage of sedatives given. CONCLUSIONS: Playing patient-selected music during cataract surgery is an effective way to decrease anxiety. Music directly affects patient experience and is an inexpensive, low-risk method of reducing patient anxiety during surgery.

Impact of Gender and Underrepresented in Medicine Status on Research Productivity Among Ophthalmology Residency Applicants.

PURPOSE: Insufficient representation of women and underrepresented in medicine (URiM) students remains a problem among the ophthalmology workforce. In the residency selection process, research productivity is an important factor. We aimed to determine the average research output listed by applicants and assess for differences by gender and race. DESIGN: Retrospective cohort study. METHODS: All San Francisco Match applications to the Wilmer Eye Institute for the 2019, 2020, and 2021 ophthalmology residency cycles were retrospectively reviewed. Each applicant's number of published research articles was recorded and subclassified into first-author publications in any field, publications in ophthalmology, and first-author publications in ophthalmology. Multivariable logistic regression was performed to determine factors associated with successful publication. RESULTS: A total of 1376 applications were reviewed. On average, women had a greater number of publications in ophthalmology (2.08 vs 1.73, P = .05) and presentations (4.52 vs 4.09, P = .01) compared with men. Self-identified URiMs were less likely to list publications in ophthalmology (odds ratio [OR] 0.650, P = .05) and first-author publications in ophthalmology (OR 0.570, P = .02) compared to non-URiMs. CONCLUSIONS: Our findings highlight disparities in research productivity by self-identified URiM status. On the other hand, women had similar if not higher research outputs than men. Greater research mentorship and opportunities to support URiM students may facilitate the recruitment of diverse trainees to ophthalmology programs.

The brief executive language screen: sensitivity and specificity in acute to early sub-acute stroke.

INTRODUCTION: Propositional language and underlying executive functions can be impaired post-stroke and affect communication and quality of life. Current stroke screening tools are largely tailored to patients with aphasia, being either non-verbal or focussed on core language skills such as naming and repetition. The Brief Executive Language Screening Test (BELS) is a newly developed cognitive screening tool that assesses memory, oral apraxia, core language, as well as propositional language and associated executive functions that can be impacted and overlooked in stroke patients without aphasia. This study examines BELS sensitivity and specificity, and performance in acute to early sub-acute stroke relative to controls. METHOD: Cross-sectional BELS data from 88 acute left and right hemisphere stroke patients (within 7 weeks of stroke) and 116 age-matched healthy controls were compared using independent samples t-tests. ROC Curve Analysis was performed to determine a cutoff score for the BELS. RESULTS: Left and right stroke patients were reduced on all propositional language subtests, and executive function subtests of inhibition, strategy, and selection. Differences were also observed for Oral Apraxia, Naming, and Memory. By contrast, Word Comprehension and Repetition, and Sentence Completion Initiation (after corrections applied) did not differ between groups. A total BELS score of 79.25/100 was highly sensitive (.89) and specific (.89) when classifying stroke patients and healthy controls. CONCLUSION: The BELS is brief, sensitive, suitable for bedside administration, and can aid in detection and rehabilitation of subtle executive language impairments. This in turn will help improve relationships and quality of life post-stroke.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Fate of Research Articles Reported by Ophthalmology Residency Applicants: What Happens to "Submitted" and "In Preparation" Articles?

OBJECTIVE: As coronavirus disease 2019 affects clinical training opportunities and with the transition of U.S. Medical Licensing Examination Step 1 to pass-fail, research may become increasingly important for evaluating ophthalmology residency applicants. Though publication misrepresentation has been studied among ophthalmology residency applicants, eventual publication rates of incomplete articles remain unknown. We aimed to determine publication rates for manuscripts listed as "submitted" or "in preparation" on ophthalmology residency applications and identify factors associated with unpublished manuscripts. DESIGN: San Francisco Match applications to the Wilmer Eye Institute for the 2019 ophthalmology residency cycle were retrospectively reviewed. Each applicant's number of "published," "submitted," and "in preparation" manuscripts was recorded, then verified 1.5 years later through PubMed, Google Scholar, or journal websites. Unverifiable manuscripts were deemed "unpublished." SETTING: Single academic institution (Wilmer Eye Institute, Baltimore, MD, USA) PARTICIPANTS: All 458 medical students who applied to the Wilmer Eye Institute for the 2019 ophthalmology residency cycle through the San Francisco Match. RESULTS: A total of 458 applications were reviewed. Of 428 "submitted" publications, 126 (29.4%) remained unpublished after 1.5 years. Of 324 manuscripts "in preparation," 215 (66.4%) remained unpublished. In a multivariate model, AOA was associated with not having an unpublished manuscript compared to applicants without AOA (OR: 0.423, p = 0.0163). Gender, Step 1 score, additional degrees, and a research year had no association. CONCLUSIONS: Nearly two-thirds of manuscripts listed as "in preparation" remained unpublished. Specific guidance from research mentors may help applicants better represent their publications in residency applications.

Eyes for Ears: Usage and Efficacy of a Podcast for Ophthalmic Education.

Purpose: To characterize listenership and perceived educational impact of the ophthalmic podcast "Eyes for Ears". Methods: A cross-sectional, internet-distributed, 9-question Qualtrics survey was made available to podcast listeners. Listenership metrics were analyzed from the podcast host platform. Results: From January 10, 2019 to September 2, 2021, the podcast was downloaded over 422,000 times, averaging about 4442 downloads per episode. 209 Qualtrics survey responses were analyzed from podcast listeners with backgrounds in eye care including medical students, residents, fellows, clinicians and technicians. The majority were residents (60.3%), representative of the target audience of the podcast. Listeners reported using the podcast while commuting (81.3%), felt it increased the time they could spend on self-care (63.2%), and thought it improved their fund of knowledge (99.0%). Respondents recalled feeling better prepared for the OKAP or written boards after using this podcast (before median = 50/100 on Likert Scale, IQR 30-65 vs median = 70/100, IQR 56-81, p <0.001). Respondents identified question banks as the most helpful for OKAP studying, followed by podcasts. Podcasts were preferred over articles and lectures in terms of helpfulness (p < 0.001). Conclusion: The Eyes for Ears podcast has achieved a robust international audience. The surveyed audience felt the podcast was useful for their education and well-being.