Application of Aspiration-Assisted Percutaneous Venous Removal of Right Atrial Thrombus in a Critically Ill Patient: A Case Study and Clinical Management Overview.

We herein present a complex case of a 50-year-old female with catheter-related atrial thrombus (CRAT). This patient with end-stage renal disease on hemodialysis presented with angioedema leading to respiratory failure. She was subsequently intubated, and the pre-procedural course was complicated by a cardio-respiratory arrest, and anoxic brain injury. The patient's hemodialysis catheter placement in the superior vena cava (SVC) potentially correlated with the development of the right atrial thrombus. The patient was treated percutaneously as she presented with complex morbidities. The mass was successfully removed via aspiration-assisted percutaneous right heart bypass, a procedure that utilizes a vacuum system to remove thrombi. Post-procedure, the patient remained stable and continued supervised care.

Utility of ClassDojo for Real-Time Formative Assessment of Professionalism in Pre-clerkship Medical Education.

Medical education needs real-time documentation of professionalism for feedback and improvement. "ClassDojo™" is a behavioral tracking mobile app used in elementary education in USA with limited presence in medical education. A protocol adapting ClassDojo™ in pre-clerkship curriculum was developed and implemented. ClassDojo™ serves as an effective means of formative assessment of medical students' professionalism.

Accuracy of Intraocular Lens Power Formulas Modified for Patients with Keratoconus.

PURPOSE: To assess the accuracy of intraocular lens (IOL) power formulas modified specifically for patients with keratoconus (Holladay 2 with keratoconus adjustment and Kane keratoconus formula) compared with normal IOL power formulas (Barrett Universal 2, Haigis, Hoffer Q, Holladay 1, Holladay 2, Kane, and SRK/T). DESIGN: Retrospective consecutive case series. PARTICIPANTS: A total of 147 eyes of 147 patients with keratoconus. METHODS: Data from patients with keratoconus who had preoperative IOLMaster biometry were included. A single eye per qualifying patient was randomly selected. The predicted refraction was calculated for each of the formulas and compared with the actual refractive outcome to give the prediction error. Subgroup analysis based on the steepest corneal power measured by biometry (stage 1: ≤48 diopters [D], stage 2: >48 D and ≤53 D, and stage 3: >53 D) was performed. MAIN OUTCOME MEASURE: Prediction error. RESULTS: On the basis of the mean absolute prediction error (MAE), the formulas were ranked as follows: Kane keratoconus formula (0.81 D), SRK/T (1.00 D), Barrett Universal 2 (1.03 D), unmodified Kane (1.05 D), Holladay 1 (1.18 D), unmodified Holladay 2 (1.19 D), Haigis (1.22 D), Hoffer Q (1.30 D), and Holladay 2 with keratoconus adjustment (1.32 D). The Kane keratoconus formula had a statistically significant lower MAE compared with all formulas (P < 0.01). In stage 3 keratoconus, all nonmodified formulas had a hyperopic mean prediction error ranging from 1.72 to 3.02 D. CONCLUSIONS: The Kane keratoconus formula was the most accurate formula in this series. The SRK/T was the most accurate of the traditional IOL formulas. All normal IOL formulas resulted in hyperopic refractive outcomes that worsened as the corneal power increased. Suggestions for target refractive aims in each stage of keratoconus are given.

Randomized, Controlled, Double-Masked, Multicenter, Pilot Study Evaluating Safety and Efficacy of Intranasal Neurostimulation for Dry Eye Disease.

Purpose: We assess the safety and effectiveness of intranasal neurostimulation to promote tear production via the nasolacrimal pathway in subjects with dry eye disease. Methods: A multicenter, randomized, controlled, double-masked pilot study was conducted in adults with dry eye diagnosis and at least one eye with corneal fluorescein staining ≥2 in at least one region or a sum of all regions ≥5 (National Eye Institute grading), basal Schirmer test score ≤10 mm, a cotton-swab stimulated Schirmer score ≥7 mm higher, and an Ocular Surface Disease Index score ≥23. Subjects were randomized to receive active intranasal neurostimulation or sham control intranasal stimulation 4 to 8 times per day. Assessments were scheduled before (unstimulated) and during (stimulated) device application at days 0, 7, 14, 30, and 90. The primary effectiveness endpoint was stimulation-induced change in Schirmer test (with anesthesia) score. Primary safety measure was incidence of device-related adverse events (AEs). Results: Fifty-eight subjects were randomized at nine sites in Australia and New Zealand; 56 completed the 90-day study. Stimulation-induced change in Schirmer score was significantly greater with active intranasal (mean ± SEM, 9.0 ± 2.0) than sham control intranasal stimulation (0.4 ± 0.6; P < 0.001) at day 90. Similar results were observed at days 0, 7, 14, and 30 (P < 0.001). No serious device-related AEs were observed. Mild nosebleed, the most common device-related AE, was reported in five (16.7%) subjects. Conclusions: Intranasal neurostimulation was effective in inducing acute tear production after 90 days of use and generally was well tolerated in subjects with dry eye disease.

Influence of Data Parsing on Contrast Enhanced Ultrasound Exams.

RATIONALE AND OBJECTIVES: To explore the influence of data parsing (either selection of frames at set time intervals or by an experienced sonographer) of contrast-enhanced ultrasound (CEUS) exams on physician diagnoses and confidence levels. MATERIALS AND METHODS: Forty consecutive CEUS exams consisting of 10 cases each of indeterminate liver lesions, indeterminate renal lesions, renal cell carcinoma postablation follow-up, and hepatocellular carcinoma postchemoembolization follow-up were selected for analysis. Exams were parsed into sets consisting of five images selected by the performing sonographer and sets containing systematically stored frames every 10, 30, and 60 seconds. Three blinded physicians then reviewed the cine loop and each set of images in randomized order and provided a diagnosis and confidence level. RESULTS: For all clinical applications investigated, no statistically significant differences in diagnostic performance measures or reader confidence were observed between review of the entire cine loop and images selected by the performing sonographer (p > 0.42). Diagnostic performance at 10-second intervals did not show statically significant changes compared to the full cine loop review for all applications (p > 0.18), although reader confidence decreased. At 30-60-second intervals, both diagnostic performance and reader confidence showed statistically significant reduction compared to review of the full cine loop (p < 0.045). CONCLUSIONS: Transfer and review of large cine loops from CEUS exams represent a potential barrier to adoption within the United States workflows. This study demonstrates that images selected by a performing trained sonographer may provide the same value without the review time and data storage costs needed for full cine loop review. Parsing by time points reduced reader confidence and diagnostic performance.

The disruption management model.

Within all organisations, business continuity disruptions present a set of dilemmas that managers may not have dealt with before in their normal daily duties. The disruption management model provides a simple but effective management tool to enable crisis management teams to stay focused on recovery in the midst of a business continuity incident. The model has four chronological primary headlines, which steer the team through a quick-time crisis decision-making process. The procedure facilitates timely, systematic, rationalised and justified decisions, which can withstand post-event scrutiny. The disruption management model has been thoroughly tested within an emergency services environment and is proven to significantly support clear and concise decision making in a business continuity context.

Late-onset persistent Descemet's membrane detachment following uncomplicated clear corneal incision cataract surgery.

We report the case of a 76-year-old man who developed a late-onset Descemet's membrane detachment (DMD) 5 months after uncomplicated cataract surgery. Despite two air tamponade procedures that initially appeared successful, the DMD continued to return. After careful examination it was found that a surgical entry wound may have been scarred open (fish-mouthing), which continually promoted Descemet's membrane to detach. Excision of the abnormal scar led to an almost complete resolution of the DMD. To our knowledge, this is the first report of a pathological (fish-mouthing) entry wound causing a persistent, late DMD. We discuss the reasons why the management of late DMDs requires careful consideration.

Comparison of grafted and non-grafted patients with corneal astigmatism undergoing cataract extraction with a toric intraocular lens implant.

BACKGROUND: Toric intraocular lenses (IOLs) are advocated as an effective treatment for both regular corneal-based astigmatism and cataract in both non-penetrating keratoplasty and penetrating keratoplasty (PK) patients. The aim of this analysis is to compare postoperative outcomes for both PK and non-PK patients to determine whether or not the past PK is relevant when calculating the appropriate IOL and predicting the postoperative results. METHODS: A retrospective analysis was performed on 14 non-PK and eight PK patients who underwent cataract surgery and astigmatism correction with a Rayner toric IOL. Preoperatively, best spectacle-corrected visual acuity, biometry and refractive data were recorded. Postoperative analysis at 1 month looked at best-uncorrected visual acuity (BUVA), refractive data and IOL axis. Statistical analysis was undertaken to test for differences in outcomes between the PK and non-PK groups. RESULTS: Preoperatively, a significant difference was seen between cylinder and astigmatism and not between sphere, axial length or anterior chamber depth. Analysis of preoperative best spectacle-corrected visual acuity, IOL error predictability, IOL rotational stability and refractive outcomes revealed no difference between PK and non-PK groups, but a significant difference was seen postoperatively with PK patients having worse BUVA. CONCLUSION: Toric IOLs are an effective means for treating both regular corneal-based astigmatism and cataract in both PK and non-PK patient groups. Analysis of results revealed similar trends for both groups in all areas except postoperative BUVA. Further studies are planned to better understand why PK patient's BUVA did not fit the trend of the other results.

Quality of vision and graft thickness in deep anterior lamellar and penetrating corneal allografts.

PURPOSE: To compare visual function after deep anterior lamellar keratoplasty (DALK) with visual function after penetrating keratoplasty (PK) for keratoconus and correlate this with corneal thickness. DESIGN: Retrospective case series. METHODS: Twenty-three patients (32 eyes) with unilateral or bilateral DALK or PK for keratoconus were analyzed for visual quality after suture removal. Evaluation included measurement of visual acuity, contrast sensitivity, and higher order aberrations (HOAs) (WaveScan; Visx, Santa Clara, California, USA). Readings were performed with both spectacle and rigid contact lens correction of refractive error. Total and residual stromal thickness after DALK was measured using optical coherence tomography (OCT) and correlated to visual quality. RESULTS: Eyes after PK had better visual acuity than eyes after DALK (P = .018). Subgroup analysis of DALK eyes revealed that the level of visual acuity was related to the thickness of residual recipient corneal stroma. Eyes with a recipient corneal bed thickness of <20 microm had visual acuities similar to eyes with a PK, whereas those with a recipient thickness of >80 microm had a significantly reduced visual acuity (P = .0009). Contrast sensitivity was similar in DALK and PK eyes. There was no significant difference in HOAs between eyes with DALK or PK. CONCLUSIONS: These data suggest that the main parameter for good visual function after DALK for keratoconus is the thickness of residual recipient stromal bed. An eye with a DALK with a residual bed of <20 microm can achieve a similar visual result as a PK.

Keratitis after intracorneal ring segment insertion for keratoconus.

We report a case of sterile keratitis after Ferrara intracorneal ring (Ferrara Ophthalmics) implantation into the right cornea of a keratoconus patient who also suffered from atopic blepharoconjunctivitis. The keratitis resolved within a few days after removal of the Ferrara rings. Ocular atopy with sterile keratitis should be considered in the differential diagnosis of keratitis after the insertion of intracorneal ring segments, which can be easily treated by ring removal.

Induction of replication in human corneal endothelial cells by E2F2 transcription factor cDNA transfer.

PURPOSE: Corneal endothelial cells in humans do not replicate to any meaningful extent. Diminishing density of the cell monolayer with age and in the disease states is a major cause of loss of corneal transparency. This study was conducted to test the hypothesis that overexpression of the transcription factor E2F2 results in replication in nonproliferating human corneal endothelial cells. METHODS: Whole human corneas were incubated for 2 hours in a solution of recombinant E1(-)/E3(-) adenovirus incorporating cDNA encoding E2F2 and green fluorescent protein (GFP) under control of a bidirectional promoter and subsequently maintained in ex vivo culture. Control specimens were incubated with an identical virus bearing the GFP sequence only, or virus-free medium. Efficiency of gene transfer and localization was examined by fluorescence microscopy. En face confocal microscopy of the corneal endothelial surface was used to image recombinant E2F2 expression. 5-bromodeoxyuridine (BrdU) incorporation was used to examine progression to the S phase. Changes in density of the corneal endothelium were quantified by specular microscopy and counting of trypan-blue-stained cells. Apoptosis was tested with a TUNEL assay. RESULTS: Recombinant proteins were expressed predominantly in the endothelium and in a high proportion of endothelial cells in the first week after exposure to virus, diminishing thereafter. Compared with the control, transduction with E2F2 resulted in progression from the G(1) to the S phase in a significant number of cells and in increased cell density. Apoptosis was not found to any significant extent. CONCLUSIONS: Overexpression of the transcription factor E2F2 in nonmitotic human corneal endothelial cells results in short-term expression, cell-cycle progression, and increased monolayer cell density.

Modulation of human dendritic-cell function following transduction with viral vectors: implications for gene therapy.

Genetic modification of dendritic-cell (DC) function is an attractive approach to treat disease, either using mature DCs (mDCs) to immunize patients, or immature DCs (iDCs) to induce tolerance. Viral vectors are efficient at transducing DCs, and we have investigated the effect of transduction with a variety of viral vectors on the phenotype and function of DCs. Adenovirus (Ad), human immunodeficiency virus (HIV), equine anemia virus (EIAV), and Moloney murine leukemia virus (MMLV) all up-regulate costimulatory molecules and major histocompatibility complex (MHC) class II expression on DCs, as well as, in the case of Ad and lentiviral vectors, inducing production of Th1 and proinflammatory cytokines. Following transduction there is activation of double-stranded (ds) RNA-triggered pathways resulting in interferon (IFN) alpha/beta production. In addition, the function of virally infected DCs is altered; iDCs have an increased, and mDCs a decreased, ability to stimulate a mixed lymphocyte reaction (MLR). Viral transduction of mDCs results in up-regulation of the indoleamine 2,3-dioxygenase (IDO) enzyme, which down-regulates T-cell responsiveness. Inhibition of IDO restores the ability of mDCs to stimulate an MLR, indicating that IDO is responsible for the modulation of mDC function. These data have important implications for the use of viral vectors in the transduction of DCs.

Modulation of costimulation by CD28 and CD154 alters the kinetics and cellular characteristics of corneal allograft rejection.

PURPOSE: To examine the effect of modulating the lymphocyte costimulation pathways through CD28 and CD154 (CD40 ligand) in a model of corneal allograft rejection, with particular interest in changes in the observed features of rejection. METHODS: CD28 knock-out (CD28KO) and wild-type BALB/c control mice received corneal grafts from fully major histocompatibility complex (MHC)-mismatched C3H donors and were treated with CTLA4-Ig and/or anti-CD154 Ab on days 0, 2, and 4 after transplantation. Proliferation of BALB/c and CD28KO T cells in response to C3H stimulators was examined in a mixed lymphocyte reaction (MLR) in the presence of CTLA4-Ig or anti-CD154 Ab. RESULTS: Corneal allograft survival in wild-type BALB/c mice (median survival time [MST] 14 days) was significantly prolonged by blockade of the costimulatory pathways with CTLA4-Ig or anti-CD154 Ab (MST 21 days and 25 days respectively). MST in recipients treated with CTLA4-Ig and anti-CD154 Ab in combination was 29 days, not significantly longer than graft survival in single-treatment groups. MST in CD28KO recipients was 46 days and was not prolonged after treatment with anti-CD154 Ab (MST, 43 days). A similar result was found in the MLR, in which anti-CD154 Ab had no effect on proliferation of CD28KO compared with wild-type T cells. In CTLA4-Ig-treated CD28KO, grafts were rejected at an accelerated tempo, similar to that in wild-type BALB/c recipients (MST 16 days). More severe graft injury after the onset of rejection in untreated allograft recipients was accompanied by a higher number of graft-infiltrating CD45(+) cells, but similar proportions of CD4(+) and CD8(+) cells. CONCLUSIONS: CD28- and CD154-mediated costimulation have significant functional roles in corneal allograft rejection. Agents that modulate CD28 and CD154 pathways delay onset and reduce the severity of observed allograft rejection. However, their use in combination did not have an additive effect, MLR data indicating that the CD40-CD154 system depends on a functioning CD28 costimulatory pathway.