Variability of Visual Recovery with Time in Epiretinal Membrane Surgery: A Predictive Analysis Based on Retinal Layer OCT Thickness Changes.

PURPOSE: To correlate postoperative optical coherence tomography (OCT) thickness changes of each retinal layer with different patterns of visual recovery after idiopathic epiretinal membrane (ERM) surgery in a cohort of patients showing no known risk factors for poor visual recovery at preoperative imaging. METHODS: Best corrected visual acuity (BCVA) and OCT images were acquired preoperatively and 1 month, 3 months and 6 months postoperatively. Patients were divided into four groups according to postoperative BCVA improvement: improvement < 15 ETDRS letters (GROUP 1), immediate improvement of BCVA without further improvements at later follow-ups (GROUP 2), immediate improvement of BCVA with further improvements at later follow-ups (GROUP 3) and delayed improvement of BCVA (GROUP 4). RESULTS: Eighty-five patients were included. GROUP1 was the only one characterized by retinal nerve fiber layer (RNFL) thickness increase and ganglion cell layer/central macular thickness (GCL/CMT) ratio decrease at 1 month and outer nuclear layer (ONL) thickness decrease at 3 and 6 months. GROUP 2 was the only one showing a decrease in GCL/inner plexiform layer (GCL/IPL) ratio at 1 month. GROUP 3 and 4 showed higher preoperative RNFL thickness compared to the other, and GROUP 4 manifested a late increase in RNFL thickness at 6 months. CONCLUSIONS: Different patterns of VA recovery are associated with specific layer thickness changes. If further confirmed, this would help detect those cases characterized by poor or delayed visual recovery despite the absence of other known imaging risk factors.

Hypertension: Are Current Guidelines Inclusive of Sex and Gender?

Background: Hypertension (HTN) accounts for one in five deaths of American women. Major societies worldwide aim to make evidence-based recommendations for HTN management. Sex- or gender-based differences exist in epidemiology and management of HTN; in this study, we aimed to assess sex- and gender-based language in major society guidelines. Materials and Methods: We reviewed HTN guidelines from four societies: the American College of Cardiology (ACC), the American College of Emergency Physicians (ACEP), the European Society of Cardiology (ESC), and the Eighth Joint National Committee (JNC8). We quantified the sex- and gender-based medicine (SGBM) content by word count in each guideline as well as identified the gender of guideline authors. Results: Two of the four HTN guidelines (ACC, ESC) included SGBM content. Of these two guidelines, there were variations in the quantity and depth of content coverage. Pregnancy had the highest word count found in both guidelines (422 words in ACC and 1,523 words in ESC), which represented 2.45% and 3.04% of the total words in each guideline, respectively. There was minimal coverage, if any, of any other life periods. The number of women authors did not impact the SGBM content within a given guideline. Conclusions: Current HTN management guidelines do not provide optimal guidance on sex- and gender-based differences. Inclusion of sex, gender identity, hormone therapy, pregnancy and lactation status, menopause, and advanced age in future research will be critical to bridge the current evidence gap. Guideline writing committees should include diverse perspectives, including cisgender and transgender persons from diverse racial and ethnic backgrounds.

Long Curriculum 3.0 in Resident Education: Comprehensive Curriculum in Pediatric and Adolescent Gynecology for Postgraduate Trainees in Obstetrics/Gynecology, Pediatrics, and Adolescent Medicine.

In 2015, the Resident Education Committee of the North American Society for Pediatric and Adolescent Gynecology published the Long Curriculum in Resident Education to provide educators with a comprehensive document to be used in postgraduate medical education. The original curriculum was designed to meet the resident learning objectives for the Council on Resident Education in Obstetrics and Gynecology, the American Board of Pediatrics, and the Royal College of Physicians and Surgeons of Canada and to provide a more intensive, broader learning experience. The curriculum was updated in 2018. This Committee Document is the third updated version (3.0) of the Long Curriculum in Resident Education.

Outcomes of Abrupt Switch to Bevacizumab of Patients Undergoing Aflibercept Intravitreal Injections for Neovascular Age-Related Macular Degeneration in a Tertiary Center in Lombardy, Italy: A Real-Life Retrospective Analysis.

PURPOSE: To assess real-life anatomical and functional outcomes of switch to bevacizumab in patients undergoing aflibercept intravitreal injections for nAMD. METHODS: Retrospective chart review of all patients diagnosed with nAMD and undergoing intravitreal injections of aflibercept who switched to bevacizumab after the resolution XI/1986 of Lombardy Region. RESULTS: Among 128 patients undergoing intravitreal injections, a total of 29 eyes of 29 patients met all inclusion criteria and were included in the statistical analysis. Best corrected visual acuity and central macular thickness did not change significantly (p > 0.05) between baseline, after the loading phase, and at the last follow-up. CONCLUSION: Switching to bevacizumab has been safe and efficacious in patients responding to the loading phase. According to our results, the restrictions imposed by Lombardy Region did not cause any harm to patients undergoing intravitreal anti-VEGF injections.

Resident Education Curriculum in Pediatric and Adolescent Gynecology: The Short Curriculum 3.0.

Exposure to pediatric and adolescent gynecology (PAG) varies across residency programs in obstetrics and gynecology, family medicine, and pediatrics, as well as fellowship programs in adolescent medicine. Nevertheless, these programs are responsible for training residents and fellows and providing opportunities within their programs to fulfill PAG learning objectives. To that end, the North American Society for Pediatric and Adolescent Gynecology has taken a leadership role in PAG education by creating and systematically updating the Short Curriculum. This curriculum outlines specific learning objectives that are central to PAG education and lists essential resources for learners' reference. This updated curriculum replaces the previous 2018 publication with added content, resources, and updated references.

The Proportion of Women Authors and the Inclusion of Sex and Gender Content Among the American College of Cardiology Clinical Practice Guidelines, 2008-2018.

Background: Sex and gender, two important factors affecting health care, should be routinely taken into consideration in clinical practice. Members of the Sex and Gender Health Collaborative Scholarship Committee reviewed clinical guidelines published by the American College of Cardiology (ACC) from 2008 to 2018 to determine if the number of women authors on the writing committee influenced the presence of sex- and gender-specific content and recommendations in each guideline. Methods: We reviewed 33 ACC clinical guidelines from 2008 to 2018 and determined the number of women authors on the writing committee for each guideline. We then reviewed each guideline to identify specific content on sex and/or gender differences as it pertained to the guideline's subject cardiac condition. Results: The median proportion of women authors among the 33 ACC guidelines was 22.2% (interquartile range 4.4-81.1). Only two guidelines (6%) had writing committees with >50% women authors. Overall, 25 of 33 guidelines (75.8%) contained sex and gender content; however, the depth and detail of the sex and gender content varied widely among guidelines. The proportion of women authors was not associated with the presence of sex- and gender-specific content. Conclusions: Our findings demonstrate continued gender disparities in authorship, and changes should be made to increase the inclusion of women in clinical practice guideline writing committees. We propose selecting a sex and gender champion for guideline writing committees and/or including a specific section on sex- and gender-related content in each guideline to ensure inclusion of sex- and gender-specific recommendations in clinical guidelines.

OCT changes of idiopathic epiretinal membrane after cataract surgery.

BACKGROUND: We reviewed our experience in the management of cataract and idiopatic epiretinal membrane surgeries at the Humanitas Research Institute-Milan, Italy- over the past 3 years. METHODS: We conducted a single center retrospective observational case series of patients that underwent sequential cataract and idiopatic epiretinal membrane (ERM) surgeries from 2012-2015 in Humanitas Research Institute. Full data was obtained for 53 eyes of 57 patients. Patients with ERM secondary to uveitis or trauma or associated with simultaneous retinal detachment were excluded. Diabetic retinopathy, glaucoma, age-related macular degeneration, and myopia of more than 6 diopters were exclusion criteria as well. RESULTS: Cataract surgery was not associated with an ERM stage progression at one month follow up, but caused retinal inflammation that resulted in a significant increase in central macular thickness (CMT), macular volume (MV), central macular edema (CME), IS/OS disruption (IS/OS) and neurosensory detachment (NSD). However, there was no significant change in Best corrected visual acuity (BCVA). CONCLUSION: We suggest that patients undergoing cataract surgery in the presence of epiretinal membranes need tight follow up to treat and control eventual macular inflammatory changes and eventual prompt vitrectomy if BCVA is threatened.

Prepubertal Vulvovaginitis.

Vulvovaginitis is a common gynecologic complaint in prepubertal girls. It typically presents with complaints of vulvovaginal itching, burning, irritation, discharge, or skin changes. Prepubertal females have anatomic, physiological, and behavioral factors that most often contribute to the development of symptoms. Careful attention to history and associated complaints will direct evaluation, diagnosis, and treatment. Most cases are nonspecific in origin and treatment includes counseling to patients and parents on hygiene and voiding techniques. Antibiotic treatment for specific pathogens may be indicated. Other less common causes include foreign bodies and lichen sclerosus.

Long Curriculum in Resident Education: Comprehensive Curriculum in Pediatric and Adolescent Gynecology for Postgraduate Trainees in Obstetrics/Gynecology, Pediatrics, and Adolescent Medicine.

In 2015 the Resident Education Committee published the Long Curriculum in Resident Education to provide educators with a comprehensive document to be used in post-graduate medical education. The original curriculum was designed to meet the resident learning objectives for CREOG, RCPSC and ABP and to provide a more intensive, broader learning experience. This Committee Document is an updated version of the 2015 Long Curriculum.

Assessing Weight Status in Adolescent and Young Adult Users of the Etonogestrel Contraceptive Implant.

STUDY OBJECTIVE: There are inconsistent data regarding hormonal contraception and weight. Weight concerns might deter teens from using highly effective contraception such as the etonogestrel subdermal implant (ENG). There is little literature about weight gain and adolescent ENG use; most studies involve adult women. The purpose of this study was to evaluate weight/body mass index (BMI) change in adolescent and young adult ENG users compared with nonusers. DESIGN: Retrospective chart review of 197 ENG users and age, race, BMI, and follow-up time-matched controls. SETTING: Adolescent medicine clinic. PARTICIPANTS: Individuals who had been using ENG for 6 months or more were eligible. A control group of non-ENG users who had been seen during the same period was identified to compare weight/BMI over time. Cases were matched to controls on age, BMI, and race. INTERVENTIONS AND MAIN OUTCOME MEASURES: Electronic medical records were reviewed for weight/BMI change and ENG side effects. The study was designed to have 80% power to detect a 2-kg weight difference between cases and controls. RESULTS: Participant mean age was 17 (±2) years. Mean follow-up was 24.5 (±9.3) months. Forty-three of 197 ENG users removed the implant early; 3/43 (6.3%) patients cited weight gain as the primary reason for removal. Mean weight change for ENG users was +3.6 (±7.8) kg vs +3.1 (±5.9) kg for controls (P = .43); mean BMI change was +1.3 (±2.9) in cases vs +1.0 (±2.3) in controls (P = .204). Overall regression analyses showed no group differences among cases and controls. CONCLUSION: Long-term ENG use did not lead to significant weight gain in this sample of adolescent and young adult women. This study supports the statement that ENGs are an effective and weight-neutral option.

Ocular Onset of Paraneoplastic Pemphigus Presenting as Hyperemic Conjunctivitis and Massive Bilateral Eyelid Ulceration: A Case Report and Literature Review.

INTRODUCTION: Paraneoplastic clinical signs are characterized by a large and heterogeneous variety of manifestations due to several possible underlying neoplasms. Paraneoplastic pemphigus (PNP) is a particular paraneoplastic variety that usually primarily affects the dermic and/or oral mucosa and is characterized by a high rate of mortality (90%). Therefore, it is important to recognize its possible signs early. This report describes a case of ocular paraneoplastic pemphigus (PNP) presenting with recalcitrant eyelid ulceration and hyperemic conjunctivitis caused by an undiagnosed prostate cancer. METHODS: A 77-year-old man was admitted to our department because of recalcitrant hyperemic conjunctivitis in both eyes, complicated with large ulceration of both upper eyelids in spite of topical therapy. After 3 weeks, oral mucositis and bullous dermatitis on the chest and arms developed. RESULTS: Complete slit lamp ocular study, conjunctival swabs, routine hematologic tests, serum neoplasm markers, indirect immunofluorescence study, immunoblotting, and oral mucose biopsy with direct immunofluorescence were performed under the hypothesis of a paraneoplastic sign. Total body computed tomography scan and ultrasound-guided needle prostate biopsy completed the diagnostic process and confirmed the diagnosis of prostate PNP. Complete remission of ocular clinical signs was achieved by treatment of the prostate malignancy with systemic immunosuppressive therapy and chemotherapy.

Pediatric and Adolescent Issues in Underserved Populations.

Children and adolescents in underserved populations have health care risks that are different from those of the adult population. Providers need to be aware of these needs and the available resources. Providers should work with school and community organizations to provide timely and appropriate preventive health care and screen for medical and mental health problems that occur more commonly in these high-risk patient populations.

Minimally invasive motor cortex stimulation for Parkinson's disease.

Extra/intradural strip electrode implantation on motor cortex may be possible minimally invasive neurosurgical method for therapeutic neuromodulation in Parkinson's disease (PD). The aim of this review is to assess motor cortex stimulation (MCS) efficacy and safety in advanced PD. Sixteen published articles were included with a total of 130 PD patients treated. In almost all results are from prospective observational open labeled study, only in two studies blinded assessment was carried out. Negative results are reported in three studies. Significant improvement in motor symptoms with remarkable effect on axial symptoms, L-dopa-induced dyskinesia and quality of life are outlined in thirteen studies. Surgical technique involved implant of four-contact strip electrode over M1 in epidural space with exception of few cases in which implant was carried out in subdural space. Surgical procedure was performed contralateral to most affected side with exception of five patients in which it was carried at dominant hemisphere; in four patients electrode implant was bilateral but stimulation was carried out simultaneously on both sides only in two cases. Complications and adverse events occurred very rarely for extradural MCS whereas with higher rate for subdural MCS. Based on review of current literature extra/intradural MCS represents an alternative to deep brain stimulation (DBS) to surgically treat PD patients who are not candidate for DBS. MCS is a minimally invasive neuromodulation procedure with low morbidity-mortality that can relieve all three major symptoms of PD on both sides simultaneously and bilaterally; it has significant effectiveness on axial symptoms, gait disturbances and therapy complications.

Clinical Recommendation: Vulvovaginitis.

Vulvovaginitis is a commonly encountered condition among prepubertal and adolescent females. The objective of this report is to provide the latest evidence regarding the diagnosis and management of vulvovaginitis in prepubertal and adolescent females. In this systematic review we used the Grading of Recommendations Assessment, Development and Evaluation evidence system. Vulvovaginal complaints are common in the pediatric and adolescent age group. The patient's age in conjunction with history and associated complaints will guide evaluation, diagnosis, and treatment. Treatment should include counseling on hygiene and voiding techniques as well as therapy for any specific pathogens identified.

Paraneoplastic syndrome--unresponsive systemic hypertension and fever as expression of primitive ciliary body carcinoma in a blind painful eye: a case report.

BACKGROUND: The purpose of this study was to present a case of paraneoplastic systemic hypertension and fever in an undiagnosed primary ciliary body carcinoma arising in a painful blind eye. CASE PRESENTATION: A 37-year-old white man with a history of blindness since childhood was enucleated for neovascular glaucoma because of intractable pain in his right eye. A histopathological examination revealed a ciliary body carcinoma. One year later, an invasive recurrence of his orbit and ethmoid was detected and a debulking procedure was performed. He had untreatable fever and multidrug-resistant systemic hypertension for 3 months before the neoplasm diagnosis. He recovered from fever and systemic hypertension only after tumor excision and relapsed 1 year later when synchronous tumor dissemination was shown through a computed tomography scan. Tumor metastases, despite surgery and chemotherapy, caused his death. CONCLUSIONS: Paraneoplastic symptoms such as fever and hypertension may be due to unrecognized ocular malignancy. This case report intends to emphasize the importance of histopathological examination of an enucleated phthisical painful blind eye.

Orbital exenteration: our experience.

INTRODUCTION: We reviewed our experience of the multidisciplinary collaboration between ophthalmologists, head and neck surgeons, neurosurgeons, radiologists and oncologists in the management of extensive tumors treated by orbital exenteration at the Humanitas Research Institute, Milan, Italy, over the past 10 years. METHODS: This is a retrospective cohort study of all patients who underwent orbital exenteration between March 2005 and August 2014 at the Humanitas Research Institute. The 10-year cohort of exenterated patients was identified through operating room notes using the clinical code set of the International Classification of Diseases, 10th revision (ICD-10). RESULTS: A total of 26 patients were identified, including 19 (73.1%) males. The median age was 65.5 years (range 37-87). Eighteen (69.2%) patients had major skin cancers extending to the orbit. Patients were divided into 2 cohorts: cohort 1 comprising patients with sinus or craniofacial cancers requiring orbital exenteration, and cohort 2 comprising patients with advanced periorbital skin cancers. The two cohorts were well matched for sex, age at surgery, degree of invasion, extension of surgical removal, necessity of adjuvant radiotherapy, reconstruction processes, and rehabilitation. CONCLUSIONS: In our experience patients never died of the primary lesion but because of the occurrence of other problems. So we encourage local surgical radicality.

Clinical Recommendation: Labial Adhesions.

Labial adhesions, also known as labial agglutination, are a common finding in prepubertal adolescents. They are defined as fusion of the labia minora in the midline or are termed vulvar adhesions when they occur below the labia minora (inner labia). Patients are often asymptomatic but might present with genitourinary complaints. The decision for treatment is based on symptoms. The mainstay of treatment in asymptomatic patients is conservative, with careful attention to vulvar hygiene and reassurance to parents. In symptomatic patients, topical treatment with estrogen and/or steroid cream is often curative. Less often, corrective surgery is necessary. Recurrence is common until a patient goes through puberty. These recommendations are intended for pediatric and gynecologic health care providers who care for pediatric and adolescent girls to facilitate diagnosis and treatment.

Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative.

PURPOSE: Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities. METHODS: Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2). RESULTS: Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0). CONCLUSIONS: Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.