Ascites Is a Poor Prognostic Factor in Advanced Pancreatic Adenocarcinoma and May Be Undertreated: A Prospective Cohort Study.

INTRODUCTION: Pancreatic ductal adenocarcinoma is associated with significant morbidity and mortality as most patients present with advanced disease. The development of ascites has been associated with poor outcomes and further characterization and contemporary management strategies are needed. METHODS: A total of 437 patients enrolled in the Gastrointestinal Biobank at Cedars-Sinai Medical Center who had epithelial pancreatic malignancy were included in the prospective cohort group. Overall, 41.7% of patients included in this study developed ascites. Most patients with ascites (>80%) had high serum-ascites albumin gradient ascites. In both univariate and multivariate analysis, a history of ≥1 form of chemotherapy was significantly associated with ascites. Estimated median overall survival in patients with ascites was significantly lower than in patients without ascites, 473 days vs 573 days, and ascites had a hazard ratio of 1.37. RESULTS: Patients with ascites who received diuretics and indwelling peritoneal catheter had an estimated median survival of 133 days from diagnosis of ascites, and those who received only the indwelling peritoneal catheter without diuretics had an estimated median survival of only 54 days. The estimated median survival from the diagnosis of ascites was 92 days, and the median time to puncture was 7 days. The median time from first tap to death was 45 days. DISCUSSION: The use of diuretics is lower than would be expected for patients with pancreatic ductal adenocarcinoma with elevated serum-ascites albumin gradient. Other therapies such as beta blockers should be investigated in this subset of patients. The etiology of ascites in these patients is poorly understood, and further research is needed to establish treatment guidelines and improve outcomes.

Evaluating the accuracy of a cataract surgery simulation video in depicting patient experiences under conscious anesthesia.

PURPOSE: To evaluate the accuracy of a point-of-view cataract surgery simulation video in representing different subjective experiences of patients undergoing the procedure. METHODS: One hundred consecutive post-cataract-surgery patients were shown a short simulation video of the surgery obtained through a porcine eye model during the first postoperative week. Patients then answered a multiple-choice questionnaire regarding their visual and tactile intraoperative experiences and how those experiences matched the simulation. RESULTS: Of the patients surveyed (n = 100), 78% (n = 78) recalled visual experiences during surgery, 11% recalled pain (n = 11), and 6.4% (n = 5) recalled frightening experiences. Thirty-six percent of patients (n = 36) were interviewed after their second cataract surgery; there was no statistically significant difference between anxiety scores reported before the first eye surgery and second eye surgery (p = 0.147). Among all patients who recalled visual experiences (n = 78), nearly half (47.4%) reported that the video was the same/similar to their experience. Forty-eight percent of the patients recommended future patients to watch the video before their procedures, and more than a third (36%) agreed that watching the video before surgery would have helped them to relax. CONCLUSIONS: Our model reflects the wide range of subjective patient experiences during and after surgery. The high percentage of patients who found the video accurate in different ways suggests that, with more development, point-of-view cataract simulation videos could prove useful for educational or clinical use. Further research may be done to confirm the simulation's utility, by screening the video for subjects before operations.

Combination L-Glutamine with Gemcitabine and Nab-Paclitaxel in Treatment-Naïve Advanced Pancreatic Cancer: The Phase I GlutaPanc Study Protocol.

Advanced pancreatic cancer is underscored by progressive therapeutic resistance and a dismal 5-year survival rate of 3%. Preclinical data demonstrated glutamine supplementation, not deprivation, elicited antitumor effects against pancreatic ductal adenocarcinoma (PDAC) alone and in combination with gemcitabine in a dose-dependent manner. The GlutaPanc phase I trial is a single-arm, open-label clinical trial investigating the safety of combination L-glutamine, gemcitabine, and nab-paclitaxel in subjects (n = 16) with untreated, locally advanced unresectable or metastatic pancreatic cancer. Following a 7-day lead-in phase with L-glutamine, the dose-finding phase via Bayesian design begins with treatment cycles lasting 28 days until disease progression, intolerance, or withdrawal. The primary objective is to establish the recommended phase II dose (RP2D) of combination L-glutamine, gemcitabine, and nab-paclitaxel. Secondary objectives include safety of the combination across all dose levels and preliminary evidence of antitumor activity. Exploratory objectives include evaluating changes in plasma metabolites across multiple time points and changes in the stool microbiome pre and post L-glutamine supplementation. If this phase I clinical trial demonstrates the feasibility of L-glutamine in combination with nab-paclitaxel and gemcitabine, we would advance the development of this combination as a first-line systemic option in subjects with metastatic pancreatic cancer, a high-risk subgroup desperately in need of additional therapies.

Diagnosis and conservative management of sural neuropathy: a case report.

Nerve entrapments in the lower extremity are rare and can be difficult to diagnose. Here we describe a Canadian Armed Forces veteran with left posterior-lateral calf pain. The patient's condition was previously misdiagnosed as a left-sided mid-substance Achilles tendinosis, which subsequently led to mismanagement, persistent pain and severe functional limitations. After performing a thorough evaluation, we diagnosed the patient with chronic left-sided sural neuropathy secondary to entrapment within the gastrocnemius fascia. The patient's physical symptoms abated completely with chiropractic care, while overall disability improved substantially after taking part in an interdisciplinary pain program. The objectives of this case report are to describe a challenging differential diagnosis of sural neuropathy, and present conservative whole-person management options according to the patient's needs and goals.

La compression des nerfs dans les membres inférieurs est rare et peut être difficile à diagnostiquer. Nous décrivons ici le cas d'un vétéran des Forces armées canadiennes souffrant d'une douleur postéro-latérale gauche au mollet. L'état du patient avait été diagnostiqué à tort comme une tendinite achilléenne moyenne du côté gauche, ce qui a entraîné une mauvaise prise en charge, une douleur persistante et de graves limitations fonctionnelles. Après une évaluation approfondie, nous avons diagnostiqué chez le patient une neuropathie surale chronique du côté gauche, secondaire à une compression du fascia gastrocnémien. Les symptômes physiques du patient ont complètement disparu grâce aux soins chiropratiques, tandis que l'incapacité globale s'est considérablement améliorée après avoir participé à un programme interdisciplinaire de lutte contre la douleur. Les objectifs de ce rapport de cas sont de décrire un diagnostic différentiel difficile de neuropathie surale et de présenter des options de gestion conservatrice de la personne entière en fonction des besoins et des objectifs du patient.

Role of FGF10/FGFR2b Signaling in Homeostasis and Regeneration of Adult Lacrimal Gland and Corneal Epithelium Proliferation.

Purpose: Fibroblast growth factor 10 (FGF10) is involved in eye, meibomian, and lacrimal gland (LG) development, but its function in adult eye structures remains unknown. This study aimed to characterize the role of FGF10 in homeostasis and regeneration of adult LG and corneal epithelium proliferation. Methods: Quantitative reverse transcription PCR was used for analysis of FGF10 expression in both early postnatal and adult mouse LG, and RNA sequencing was used to analyze gene expression during LG inflammation. FGF10 was injected into the LG of two mouse models of Sjögren's syndrome and healthy controls. Flow cytometry, BrdU cell proliferation assay, immunostaining, and hematoxylin and eosin staining were used to evaluate the effects of FGF10 injection on inflammation and cell proliferation in vivo. Mouse and human epithelial cell cultures were treated with FGF10 in vitro, and cell viability was assessed using WST-8 and adenosine triphosphate (ATP) quantification assays. Results: The level of Fgf10 mRNA expression was lower in adult LG compared to early postnatal LG and was downregulated in chronic inflammation. FGF10 injection into diseased LGs significantly increased cell proliferation and decreased the number of B cells. Mouse and human corneal epithelial cell cultures treated with FGF10 showed significantly higher cell viability and greater cell proliferation. Conclusions: FGF10 appears to promote regeneration in damaged adult LGs. These findings have therapeutic potential for developing new treatments for dry eye disease targeting the ability of the cornea and LG to regenerate.

Development of a low resource exercise rehabilitation application for musculoskeletal disorders to help underserved patients in a primary care setting.

Objective: We set out to create a Family Medicine EHR (electronic health record) embedded exercise application. This was done to evaluate the utility of the exercise app for providers and to understand the usefulness of the exercise app from the perspective of patients. Methods: This exercise application was developed through an iterative process with repeated pre-testing and feedback from an interprofessional team and embedded into the EHR at an academic family medicine clinic. Anecdotal feedback from patients was used to inform pre-testing adaptations. Results: The application required six iterations prior to clinical utility. It had several features that clinicians and patients felt were beneficial. These features involved a customizable exercise directory with pre-made templated plans which could be further modified. To overcome accessibility barriers, the application was developed to include digital and printable copies with an integrated direct email option for ease of remote sharing with patients. Conclusion: A customizable, open-source exercise application was developed to facilitate provider exercise prescription and support patient self-management. This project may be useful for other providers interested in developing similar programs to address musculoskeletal conditions in their patients. Next steps are to undertake pilot testing of the app with broader provider and patient feedback.

Objectif: Concevoir une application d'exercices intégrés au DES (dossier de santé électronique) de la médecine familiale. Cela visait à évaluer l'utilité de l'application d'exercices pour les prestataires et à en comprendre l'utilité du point de vue des patients. Méthodologie: Cette application d'exercices a été élaborée au moyen d'un processus itératif mettant en oeuvre une mise à l'essai répétée et une rétroaction d'une équipe interprofessionnelle et intégrée dans le DES d'une clinique universitaire de médecine familiale. Une rétroaction secondaire de patients a contribué aux adaptations de mise à l'essai. Résultats: L'application a dû être répétée six fois avant l'utilité clinique. Selon les cliniciens et les patients, plusieurs fonctions ont présenté un avantage. Il s'agissait notamment d'un répertoire d'exercices personnalisable assorti de modèles de plans préconçus et modifiables par la suite. Afin de surmonter les obstacles d'accessibilité, l'application était conçue pour comprendre des versions numériques et imprimables dotées d'une option de courriel direct intégré pour faciliter le partage à distance avec les patients. Conclusion: Une application d'exercices personnalisable et ouverte visait à faciliter la prescription d'exercices par les prestataires et à soutenir le traitement autonome des patients. Ce projet peut être utile à d'autres prestataires souhaitant élaborer des programmes semblables pour traiter les problèmes musculosquelettiques de leurs patients. Les étapes suivantes consistent à entreprendre des mises à l'essai de l'application avec un retour d'information plus large de la part des prestataires et des patients.

The Effect of Anti-Inflammatory Topical Ophthalmic Treatments on In Vitro Corneal Epithelial Cells.

Purpose: To compare the effect of three commonly prescribed anti-inflammatory eye drops on corneal epithelial cells in vitro. Methods: Three different lines of human corneal epithelial cells were tested: primary cells cultured from donor tissue, commercially available primary cells, and immortalized cells. Cells were seeded on 96-well plates and treated with the following eye drops: cyclosporine 0.05%, lifitegrast 5%, and tacrolimus 0.03% or 0.1%. Exposure times tested were 30 seconds, 1 minute, 2 minutes, 1 hour, 2 hours, 4 hours, and 24 hours. Brightfield images and viability assays were analyzed 48 to 72 hours after the initiation of treatments. At least five replicates were tested per drug and time exposure. Results: Commercially obtained primary cells showed reduced viability following 1 hour with tacrolimus 0.1% (8%; P = 0.043%) and 4 hours with tacrolimus 0.03% (17%; P = 0.042%). Lifitegrast exposure reduced primary cell viability after 4 hours (10%; P = 0.042). Cell viability in primary cells was not deleteriously affected following exposure to cyclosporine for up to 4 hours. A similar trend was observed in both primary cells cultured from donor tissue and immortalized human corneal epithelial cells, demonstrating greater decreases in cell viability in tacrolimus compared to lifitegrast and cyclosporine. Light microscopy imaging for analysis of cell morphology and confluence supported the results. Conclusions: Tacrolimus showed the highest impact on corneal epithelium survival in vitro, and cyclosporine proved the most protective. Translational Relevance: Comparing anti-inflammatory eye drops on corneal epithelial cells in vitro may inform eye drop selection and development for clinical purposes.

Recent developments in anterior capsulotomy for cataract surgery.

PURPOSE OF REVIEW: Successful anterior capsulotomy is an important step in cataract surgery. This article reviews the various anterior capsulotomy techniques available to surgeons to optimize the step, including those that have become available since the introduction of femtosecond-laser-assisted cataract surgery (FLACS). Studies comparing the relative advantages of each technique will be emphasized. RECENT FINDINGS: Manual continuous curvilinear capsulorhexis (CCC) and FLACS remain the two most widely studied techniques for achieving anterior capsulotomy. Each technique has been shown to be effective for a wide range of patients and cataract surgery complications. Meta-analyses have shown that FLACS provides similar results to manual CCC for long-term cataract surgery outcomes. Several alternative methods for anterior capsulotomy have been described, which aim to provide some of the advantages of laser capsulotomy at a lower cost; among these, precision pulse capsulotomy (PPC) and selective laser capsulotomy (SLC) have been investigated the most in the literature so far. SUMMARY: Cataract surgeons have an increasing number of techniques for anterior capsulotomy available. Manual CCC and FLACS remain the most widely used, and most well studied. The latest techniques, PPC and SLC, have shown promise in the few studies performed since they were introduced.

Reported 1-year prevalence of occupational musculoskeletal disorders in Ontario chiropractors.

BACKGROUND: Chiropractors are a particular subset of health care professionals that reportedly suffer occupational musculoskeletal disorders (MSDs), yet they have received minimal attention to date regarding mitigating risks of occupational injury. Our study determined the prevalence of occupationally-related MSDs in the preceding year, their bodily distribution, severity, and practice-related changes in practicing chiropractors in the province of Ontario. METHODS: We conducted a cross-sectional survey of chiropractors who were members of the Ontario Chiropractic Association (OCA) from January to March 2019. A three-part online survey was developed to ask chiropractors about specific details of MSDs they experienced in the past year and any practice-related changes they made as a result. Responses from participants provided both quantitative and qualitative data. Prevalence estimates were derived for quantitative data. Qualitative data were stratified by themes that were further divided into categories and subcategories. Demographic variables of the respondents and OCA membership were compared to determine representativeness. RESULTS: From the 432 responses (11.8% response rate), 59.1% reported experiencing an occupationally-related MSD in the past year. Survey respondents were demographically representative of the OCA membership. MSDs were most commonly reported for the lower back (38.3%), wrists/hands (38.1%) and neck (37.4%). Positioning/performing manipulation was the most common occupational activity for MSD of the upper extremity (53.1%) and lower back (34.8%). Chiropractors largely reported their MSDs did not prevent them from doing their normal work (77.4%), despite the fact that 43.2% reported experiencing their MSDs for more than 30 days in the previous year. Common reported work modifications were grouped under themes of practice and physical changes. Practice changes included reducing patient volume, hiring personnel and scheduling. Physical changes included using different office equipment, selecting different techniques requiring lower force and altering their hand contacts or body position when treating patients. CONCLUSIONS: One-year prevalence of occupational MSDs from this study are comparable to previously reported estimates in chiropractors. These data suggest that chiropractors continue with their regular workload despite their MSDs, thereby increasing their chances of presenteeism. Chiropractors changing technique or technique parameters due to their MSDs provides direction for future research to reduce exposure to occupational MSD risk factors.

Hand hygiene and instrument sanitization in ophthalmology clinics.

PURPOSE OF REVIEW: This article reviews the various challenges in infection control in eye clinics and successful measures taken to prevent nosocomial infections. RECENT FINDINGS: The Center for Disease Control recommends hand-washing when hands are visibly soiled, and after direct contact with patients, and inanimate objects such as medical equipment. Published studies have identified poor hygiene in clinical settings as a major cause of nosocomial outbreaks, particularly in cases of epidemic keratoconjunctivitis (EKC). Some studies of EKC outbreaks are able to support direct observation of hygiene lapses with molecular analysis that can match viral strains on particular instruments to those found in infected patients. Although most studies are about adenoviral infection and tonometer use, researchers have found viral and bacterial loads on other common surfaces, indicating a need for further research. SUMMARY: Proper hygiene in eye clinics requires special attention because of the potential to examine many patients at a time and because multiple instruments are often used during a single exam. Studies reinforce the link between hygiene and outbreak prevention, and more research can be done to determine the specific links between certain instruments and nosocomial infections.

Assessing attitudes of patient-centred care among students in international chiropractic educational programs: a cross-sectional survey.

Background: Patient-centred care is internationally recognized as a foundation of quality patient care. Attitudes of students towards patient-centred care have been assessed in various health professions. However, little is known how chiropractic students' attitudes towards patient-centred care compare to those of other health professions or whether they vary internationally, and between academic programs. Objective: To assess the association of select variables on student attitude towards patient-centred care among select chiropractic programs worldwide. Methods: We conducted a cross-sectional study using the Patient-Practitioner Orientation Scale (PPOS) to assess students' patient-centred attitudes towards the doctor-patient relationship. Eighteen items were scored on a 1 to 6 Likert scale; higher scores indicating more patient-centredness. All students from seven chiropractic educational programs worldwide were invited to complete an online survey. Results were analyzed descriptively and inferentially for overall, sharing and caring subscales. General linear regression models were used to assess the association of various factors with PPOS scores. Results: There were 1858 respondents (48.9% response rate). Student average age was 24.7 (range = 17-58) years and 56.2% were female. The average overall PPOS score was 4.18 (SD = 0.48) and average sharing and caring subscale scores were 3.89 (SD = 0.64) and 4.48 (SD = 0.52), respectively. There were small but significant differences in all PPOS scores by gender, age, and program. Year/semester of study within a program typically was not associated with scores, neither was history of previous chiropractic care nor having family members who are health professionals. Conclusion: This is the first international study assessing students' attitudes of patient-centred care in chiropractic educational programs. We found small but significantly different PPOS scores between chiropractic programs worldwide that did not change across year/semester of study. Scores tended to be lower than those reported among medical students. Observed differences may be related to curricular content, extent of patient exposure and/or regional cultural realities.