Prevalence and Risk Factors of Blindness Among Primary Angle Closure Glaucoma Patients in the United States: An IRIS Registry Analysis.

PURPOSE: To assess the prevalence and risk factors of blindness among patients newly diagnosed with primary angle closure glaucoma (PACG) in the United States. DESIGN: Retrospective cross-sectional study. METHODS: Eligible patients from the American Academy of Ophthalmology (AAO) Intelligent Research in Sight (IRIS) Registry had newly diagnosed PACG, defined as: 1) observable during a 24-month lookback period from index date of PACG diagnosis; 2) no history of eye drops, laser, or cataract surgery unless preceded by a diagnosis of anatomical narrow angle (ANA); and 3) no history of glaucoma surgery. Logistic regression models were developed to identify risk factors for any (one or both eyes) or bilateral (both eyes) blindness (visual acuity ≤20/200) at first diagnosis of PACG. RESULTS: Among 43,901 eligible patients, overall prevalence of any and bilateral blindness were 11.5% and 1.8%, respectively. Black and Hispanic patients were at higher risk of any (odds ratios [ORs] 1.42 and 1.21, respectively; P < .001) and bilateral (ORs 2.04 and 1.53, respectively; P < .001) blindness compared with non-Hispanic White patients adjusted for ocular comorbidities. Age <50 or >80 years, male sex, Medicaid or Medicare insurance product, and Southern or Western practice region also conferred a higher risk of blindness (OR > 1.28; P ≤ .01). CONCLUSIONS: Blindness affects 1 of 9 patients with newly diagnosed PACG in the IRIS Registry. Black and Hispanic patients and Medicaid and Medicare recipients are at significantly higher risk. These findings highlight the severe ocular morbidity among patients with PACG and the need for improved disease awareness and detection methods.

Feasibility, performance and acceptability of an innovative vital signs monitor for sick newborns in Western Kenya: A mixed-methods study.

Introduction: Low- and middle-income countries (LMICs) account for 99% of the global neonatal mortality. Limited access to advanced technology, such as bedside patient monitors contributes to disproportionately poor outcomes for critically ill newborns in LMICs. We designed a study to assess the feasibility, performance, and acceptability of a low-cost wireless wearable technology for continuous monitoring of sick newborns in resource-limited settings. Methods: This was a mixed-methods implementation study conducted between March and April 2021 at two health facilities in Western Kenya. Inclusion criteria for newborns monitored included: age 0 to 28 days, birthweight ≥2.0 kg, low-to-moderate severity of illness at admission and the guardian's willingness to provide informed consent. Medical staff who participated in monitoring the newborns were surveyed about their experience with the technology. We used descriptive statistics to summarize our quantitative findings and qualitative data was coded and analyzed as an iterative process to summarize quotes on user acceptability. Results: The results of the study demonstrated that adoption of neoGuard was feasible and acceptable in this setting. Medical staff described the technology as safe, user-friendly and efficient, after successfully monitoring 134 newborns. Despite the positive user experience, we did observe some notable technology performance issues such as a high percentage of missing vital signs data. Conclusion: The results of this study were critical in informing the iterative process of refining and validating an innovative vital signs monitor for patients in resource-limited settings. Further research and development are underway to optimize neoGuard's performance and to examine its clinical impact and cost effectiveness.

Accuracy and reliability of a wireless vital signs monitor for hospitalized patients in a low-resource setting.

Objective: The purpose of this study was to evaluate the accuracy and reliability of neoGuard in comparison to a conventional bedside monitor on patients in a low-resource clinical setting. Design: This was a single-arm methods comparison study involving the use of a wearable vital signs monitor (neoGuardTM) versus a conventional bedside monitor (Edan iM8). Setting: The study was conducted at Jinja Regional Referral Hospital, a tertiary care hospital situated in Eastern Uganda. Participants: Thirty patients (10 male, 20 female) were enrolled from the adult recovery ward at JRRH. Participants were eligible for the study if they were at least 18 years of age, had 2 sets of normal vital sign measurements obtained 1 h apart, and were able and willing to provide informed consent. Main Outcome and Measures: The primary outcome measures were (i) bias (mean deviation) and (ii) limits of agreement [95% CI]. Bland-Altman plots were generated to illustrate the level of agreement between the neoGuardTM technology and the Edan iM8 monitor. Results: Bland-Altman analysis was performed for 24 participants; datasets from six participants were excluded due to missing or invalid measurements. Findings showed a moderate level of agreement for measurement of SpO2, PR, and RR, with >80% of subject means falling within the predefined acceptability limits. However, there was also notable variation in accuracy between subjects, with large standard deviations observed for measurement of all four parameters. While the level of agreement for measurement of temperature was low, this is partly explained by limitations in the comparison method.

Developing Medical Technologies for Low-Resource Settings: Lessons From a Wireless Wearable Vital Signs Monitor-neoGuard.

The neoGuard™ technology is a wireless wearable vital signs monitor attached to a patient's forehead to continuously measure oxygen saturation, pulse rate, respiratory rate and temperature. Developed with feedback from more than 400 health workers, primarily in East Africa, the product has been designed to meet the unique constraints of low-resource settings. This perspective piece by the innovators of neoGuard™ and some of their key partners examines the complicated journey of taking a medical technology from concept through clinical validation and finally to market. By shedding light on some of the most critical steps and common challenges encountered along the pathway to commercialization, the authors hope that their experiences will provide some valuable insights to other aspiring innovators in this space.

Response criteria for intraocular retinoblastoma: RB-RECIST.

Standardized guidelines for assessing tumor response to therapy are essential for designing and conducting clinical trials. The Response Evaluation Criteria In Solid Tumors (RECIST) provide radiological standards for assessment of solid tumors. However, no such guidelines exist for the evaluation of intraocular cancer, and ocular oncology clinical trials have largely relied on indirect measures of therapeutic response-such as progression-free survival-to evaluate the efficacy of treatment agents. Herein, we propose specific criteria for evaluating treatment response of retinoblastoma, the most common pediatric intraocular cancer, and emphasize a multimodal imaging approach for comprehensive assessment of retinoblastoma tumors in clinical trials.

Psychosocial and Physiologic Characteristics of Patients with Non-epileptic Events: A Retrospective Study.

Background The main focus of this study is to aid early identification of psychogenic non-epileptic seizure (PNES) patients by identifying physical and psychosocial characteristics to reduce the health care burden, to reduce the unnecessary use of anti-epileptic medications and their side effects, and maximizing cost-effective use of video electroencephalography (VEEG). Methods We analyzed PNES subject data from VEEG monitoring performed at the Epilepsy Center at the Marshall University School of Medicine. We reviewed more than 360 episodes in 54 subjects older than 18 years (mean age ± standard deviation (SD): 48 ± 12.97 years; 83% female). Results We found that most of our PNES patients were older than 45 years of age (66.7%), females (83.3%); obese (66.6%) or overweight (18.5%); either single (33.3%), separated (7.4%), divorced (22.2%), or widowed (14.8%); of low education, unemployed (either received government assistance (83.3%) or disability benefits (57.4%)) with associated physical illness (85.2%) and psychiatric illness (96.3%).  Conclusion Our study adds to the current knowledge of the sociodemographic and sociocultural variability of PNES. It might enable early diagnosis and management of patients with PNES.

Tumour size criteria for Group D and E eyes in the International Classification System for Retinoblastoma: effects on rates of globe salvage and high-risk histopathologic features.

PURPOSE: To determine the significance of large tumour size as a criteria for classifying advanced intraocular retinoblastoma, analysing rates of globe survival and high-risk (HE) histopathologic features. METHODS: Retrospective chart review of 212 eyes diagnosed with Group D (111 eyes) or Group E (101 eyes) retinoblastoma in at least one eye from January 1, 2006 to December 31, 2016 using the Los Angeles (LA) Classification System (no tumour size criteria for Group E). The 111 Group D tumours were then reclassified to Group E using 10, 12, 14, 16, 18 mm tumour size criteria, as determined by ultrasound or magnetic resonance imaging dimensions. RESULTS: For eyes in the original LA classification, 66.7% of Group D and 10.5% of Group E eyes undergoing globe preservation therapy avoided enucleation or radiotherapy (p < 0.0001; median follow-up of 33.0 months). In the LA classification, 8.5% of Group D and 26.3% of Group E enucleated globes had HE histopathologic features (p = 0.0065). When Group D eyes with tumours meeting the size criteria were reclassified to Group E, 65.7-74.4% of Group D and 16.1-36.7% of Group E eyes avoided enucleation or radiotherapy. Applying the tumour size criteria, 0-10.9% of Group D and 20.7-23.8% of Group E eyes had HE histopathologic features. CONCLUSION: Our retrospective analysis suggests that a large tumour size criteria for Group E retinoblastoma have no clinical basis, given that the LA classification system provided the greatest separation in globe salvage rates between Group D and E eyes. The LA classification system was also able to show a statistically significant difference in the rates of HE histopathologic features between Group D and E eyes. To avoid discrepancies in the literature, we recommend that centres use one uniform system for classifying advanced intraocular retinoblastoma.

Trends in Radiation Practices for Female Ocular Oncologists in North America: A Collaborative Study of the International Society of Ocular Oncology.

BACKGROUND: The aim of this study was to determine the known radiation exposure, attitudes, and consequent risk modifications among female ocular oncologists in North America who routinely administer radioactive plaque brachytherapy treatment and are members of the International Society of Ocular Oncology. METHODS: Nineteen female ocular oncologists completed an anonymous 17-question radiation exposure survey. RESULTS: Eleven of the participants chose to routinely wear lead protection during surgery; 8 did not. Fifteen of 19 participants reported using an unloaded "nonactive" template to prepare for plaque implantation. During pregnancy, 11 of 13 participants continued to perform plaque brachytherapy. Eight of these 11 undertook measures to decrease radiation exposure self-reported as lead wear and other. The average reported anxiety regarding fertility was 2.1 (SD, 2.2) on a scale from 1 to 10. CONCLUSION: This study corroborates prior literature that surgeons' exposure to radiation during plaque brachytherapy is minimal. Nonetheless, there remains some anxiety regarding exposure risk to women, due to potential effects on fertility and fetal health. We found variability in exposure monitoring, required training, and precautions during pregnancy amongst this group of surgeons. Improved education and clearer pregnancy guidelines may equip female ocular oncologists with optimal knowledge regarding risk of radiation exposure.

Integrated Treatment during the Intravitreal Melphalan Era: Concurrent Intravitreal Melphalan and Systemic Chemoreduction.

BACKGROUND: Intravitreal injection of melphalan (IVM) is safe and effective for the treatment of seeding in retinoblastoma. Current protocols require weekly injections during examination under anesthesia (EUA). To avoid additional anesthesia exposure for these children, IVM was initiated at the EUA concurrent with the 4th cycle of systemic chemoreduction in a series of 6 patients with persistent seeding. METHODS: A retrospective review was completed to assess treatment response compared to all patients at our center treated with IVM and systemic chemotherapy. Overall, 6 eyes of 6 patients were included; salvage therapy included systemic chemoreduction with vincristine, etoposide, and carboplatin and IVM for persistent seeding. RESULTS: IVM was initiated in all eyes at cycle 4 of their chemotherapy. Success in eradicating vitreous seeds was 100%; overall salvage rate was 67%. Anterior toxicity was observed in 2 out of 6 eyes and posterior toxicity in 4 out of 6 eyes. CONCLUSION: The concurrent chemoreduction and IVM protocol demonstrated a similar efficacy of globe salvage while sparing children additional EUAs. However, the increased rates of observed melphalan-related toxicities for concurrent therapy are concerning. Further clinical experience is necessary to define the best initiation time and dosing schedule for IVM.

Iris Hypoplasia as the Presenting Sign of Retinoblastoma in a Child With a 13q Deletion.

Germline partial chromosomal deletions of the entire RB1 gene (13q deletions), account for 6% of the RB1 mutational spectrum. The authors report the rare case of one patient with suspected bilateral iris heterochromia who actually had iris hypoplasia (often masquerading as heterochromia) and bilateral retinoblastoma, due to 13q deletion syndrome. [J Pediatr Ophthalmol. 2018;55:e10-e13.].

Decreased Rates of Inpatient Hypoglycemia Following Implementation of an Automated Tool in the Electronic Medical Record for Identifying Root Causes.

OBJECTIVE: The objective was to identify root causes of hypoglycemia on medicine inpatient units using an automated tool. Data collected will guide educational interventions aimed at improving patient care and safety by decreasing rates of hypoglycemia. METHODS: A survey was conducted among RNs to identify risk factors for hypoglycemia. Survey data were used to create a hypoglycemia root cause survey tool in the EMR. RNs were prompted to utilize the tool when blood glucose (BG) < 70 mg/dL. Once the most common modifiable cause of hypoglycemia was identified, an educational intervention for safe and effective use of insulin was launched. This strategy was designed to empower the care team to reduce the insulin dose when appropriate to prevent future hypoglycemic episodes. RESULTS: BG data were compared from March and April in 2016 and 2017. Rates of hypoglycemia (BG < 70 mg/dL) decreased from 2.3% to 1.5%; BG values in target range (70-180 mg/dL) increased from 59.4% to 65.7%; hyperglycemia (BG > 180 mg/dL) decreased from 38.3% to 32.8% (all P values < .001). The number of patients with recurrent hypoglycemia (3 or more episodes) decreased from 5.7% to 2.2% ( P = .044). CONCLUSIONS: The two most frequent modifiable causes of hypoglycemia (insulin and nutrition) were identified by an RN survey and confirmed by chart review. A targeted educational intervention addressing safe and effective insulin dosing resulted in a significant decrease in both hypoglycemia and recurrent hypoglycemia. This was associated with an improvement in overall glycemic control. Ongoing clinician education regarding insulin and nutrition accompanied by discussions between RNs and prescribers to address hypoglycemic events in real-time could continue to lower the rate of occurrence.

Effect of Age on Response to Therapy and Mortality in Patients With Thyroid Cancer at High Risk of Recurrence.

Context: Age at diagnosis has been identified as a major determinant of thyroid cancer-specific survival, with older patients being at higher risk for mortality, but the association of age with risk of recurrence has not been studied to date. Objective: To examine the effect of a patient's age on response to therapy and disease-specific mortality in a cohort of thyroid cancer patients at high risk of recurrence, as defined by the American Thyroid Association (ATA) risk stratification system. Design: Retrospective cohort study of 320 patients, median age 49.3 years, with follicular cell-derived thyroid carcinoma classified at ATA high risk and followed for a median of 7 years. Main Outcome Measures: Association of age with response to therapy, overall mortality, disease-specific mortality, and timing of metastases. Results: Age was a major determinant of response to therapy. There was a significantly larger percentage of excellent responders among young patients (age <55) than among old patients (age ≥55), 40.3% vs 27.5%, P = 0.002, respectively, whereas the proportion of structural incomplete responders was higher in the old group compared with the young group, 53% vs 33%, P = 0.002, respectively. ATA high-risk young patients with a structural incomplete response to therapy had a significantly better disease-specific survival than old patients (74% vs 12%, P < 0.001, respectively). Conclusions: Age was a key predictor of response to therapy and disease-specific survival in ATA high-risk thyroid cancer patients. Its incorporation as a variable in the ATA risk stratification system would improve its power to predict response to therapy as well as mortality.

Not All Seeds Are Created Equal: Seed Classification Is Predictive of Outcomes in Retinoblastoma.

OBJECTIVE: Intravitreal chemotherapy has emerged as an important modality for treating vitreous seeding in retinoblastoma. A classification system has been described as predictive of response to intravitreal melphalan (IVM) in patients treated predominantly with primary intra-arterial chemotherapy. The objective of this study is to evaluate the outcomes of retinoblastoma treated with intravenous chemotherapy and IVM as salvage for vitreous seeding, and further to determine whether vitreous seed classification (dust, spheres, cloud) is predictive of the total number and dose of IVM injections required for treatment in this cohort. DESIGN: A nonrandomized retrospective review. PARTICIPANTS: Retinoblastoma patients treated at a single center with intravenous chemotherapy and IVM. METHODS: Retrospective review of patients with vitreous seeding from retinoblastoma treated with intravenous chemotherapy and IVM from 2012 to 2016. MAIN OUTCOME MEASURES: Primary outcome measure was eradication of seeds and globe salvage. Secondary measures included IVM-associated toxicity and complications. RESULTS: Overall, 28 eyes of 25 patients were included, with a total of 110 IVM injections. By seed classification, eyes with dust (n = 15) required a median of 3 injections, spheres (n = 8) required 4 injections, and clouds (n = 5) required 6 injections. Spherical seeds were only seen in recurrent vitreous seeding. Of the 28 treated eyes, 9 were enucleated, 6 for recurrent retinal disease, resulting in an overall globe salvage rate of 68%. The salvage rate secondary to active retinoblastoma was 79%. Dust classification was the most prevalent seeding type of the 9 enucleated eyes. There was 100% regression of vitreous seeds after intravitreal injection and no eye was treated with radiation or enucleated for seeding. Twelve eyes demonstrated grade 3 or greater IVM-associated retinal or anterior segment toxicity post injection. Mean follow-up was 33 months (range, 9-51 months). CONCLUSIONS: IVM is an effective treatment for vitreous seeding after intravenous chemotherapy for retinoblastoma. As with eyes treated with intra-arterial chemotherapy, seed classification is predictive of the total number and dose of IVM injections in eyes treated with intravenous chemotherapy. Eyes with clouds required significantly more injections than eyes with dust or spheres.

Long-term outcomes of Group D retinoblastoma eyes during the intravitreal melphalan era.

BACKGROUND: To evaluate outcomes of Group D retinoblastoma (Rb) eyes during the intravitreal melphalan era. PROCEDURE: Retrospective chart review of patients diagnosed with Group D Rb from 2011 to 2016 was done. Overall, 76 Group D eyes of 68 patients were included; salvage therapy included systemic chemoreduction with vincristine, etoposide, and carboplatin with local consolidation, followed by intravitreal injection of melphalan for recurrent or persistent seeding. External beam radiation was not used as a treatment modality. Primary outcome measurement was globe salvage. RESULTS: Of 76 Group D eyes, 24 were enucleated primarily and 52 were treated with intent to salvage the globe. Systemic chemoreduction salvaged 25 of 52 eyes (48%). Tumor recurrences were diagnosed in 27 eyes (52%); five with massive retinal recurrences underwent enucleation and 22 were treated with intravitreal melphalan injection. Of the 22 injected eyes, 14 (64%) were salvaged and eight required enucleation primarily for retinal recurrences. Success in eradicating vitreous seeds was 100%. The Kaplan-Meier 3-year survival estimate for treated eyes is 76.5% (95% CI: 61.4-86.3). Median follow-up for the group of 76 Group D eyes was 29.5 months (SD 17.9 months). CONCLUSION: During a 6-year period that included the initiation of intravitreal melphalan at our institution, the salvage rate of treated Group D eyes was 75% (39/52 eyes). Intravitreal melphalan was utilized for ocular salvage in 42% (22/52 eyes). Systemic chemoreduction combined with intravitreal melphalan for seeding demonstrated a high overall salvage rate for Group D eyes in this cohort.

Clinical efficacy of a novel sonic infusion system for periorbital rhytides.

Aging skin is a leading concern of most men and women seeking cosmetic dermatologic consultation. Various in-office procedures as well as topical at-home regimens, are generally prescribed to reduce the signs of aging, but relatively few provide immediate clinical benefit. A novel sonic infusion system that combines sonic micro-massage with an anti-aging serum was studied to determine its immediate effect on a wide range of patients with periocular rhytides. Clinical improvement of periocular rhytides was achieved after a single sonic infusion treatment (30 seconds/eye). Patients with more severe rhytides and those older than 40 years of age showed the best clinical results.

Laser treatment of dark skin: an updated review.

The growing diversification of the patient population coupled with the increasing demand for cosmetic laser rejuvenation has highlighted the need to develop cutaneous laser systems and establish treatment protocols for patients with a wide range of skin conditions and phototypes. Recent technologic advancements have provided viable treatment options to achieve clinical outcomes that were previously only attainable in patients with lighter skin tones. This review provides an updated discussion of the range of laser treatments available for pigmented skin and sets the stage for further advancements. Pigment-specific laser technology with green, red, or near-infrared light targets a variety of pigmented lesions such as lentigines, ephelides, café-au-lait macules, and melanocytic nevi as well as tattoos and unwanted hair. Short-pulsed alexandrite, ruby, and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for pigmented lesions and tattoos, whereas their longer pulse-width laser counterparts are used for laser-assisted hair removal. Vascular lesions and hypertrophic scars can be treated with a variety of vascular-specific lasers, but it is the pulsed dye laser (PDL) that has long been the gold standard treatment for these lesions due to its high specificity for hemoglobin and its ability to improve skin surface texture in children and adults. Laser skin resurfacing techniques for photodamaged skin and atrophic scars have been optimized with fractional technology to produce excellent clinical outcomes and minimal complication risks. Radiofrequency and nonablative lasers are also used to provide skin tightening and collagen remodeling with virtually no postoperative recovery.

The accuracy and reliability of 3D CT/MRI co-registration in planning epilepsy surgery.

OBJECTIVE: To investigate the accuracy and reliability of 3D CT/MRI co-registration technique for the localization of implanted subdural electrodes in the routine epilepsy presurgical evaluation, in so doing assess its usefulness in planning the tailored resection of epileptic focus. METHODS: Four external anatomic fiducial makers were used for co-registration of volumetric pre-implant brain MRI and post-implant head CT using Curry 5.0 software in 19 epilepsy presurgical candidates. The location of subdural electrodes derived from the co-registration was compared to that obtained by intra-operative digital photographs by using gyral/sulcal patterns and cortical vasculature as anatomic markers. RESULTS: The mean localization error was 4.3+/-2.5 mm in all 19 patients. However, the mean localization error was 3.1+/- 1.3 mm in 13 patients with all four reliable fiducial markers; whereas the mean localization error was 6.8+/-2.4 mm in 6 patients with two or three reliable fiducial markers. CONCLUSION: Visualization of subdural electrode positions on a patient's cortex can be accurately performed in the routine clinical setting by 3D CT/MRI co-registration. However, the accuracy of co-registration is dependent upon having reliable surface fiducial markers. In practice, confirmation of location accuracy, such as with intra-operative digital photographs, is necessary for planning of tailored resective surgery. SIGNIFICANCE: The combination of 3D CT/MRI co-registration and intra-operative digital photography techniques provides a practical and effective algorithm for the localization and validation of implanted subdural electrodes.

Cytomegalovirus-specific cell-mediated immunity in HIV-infected children on HAART.

The objectives of this study were to define the magnitude, time course, and virologic and immunologic correlates of HAART-associated reconstitution of cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) in pediatric HAART recipients. Thirty-five HIV-infected CMV-seropositive subjects < or = 22 years on or about to receive HAART had CMV-CMI measured by responder cell frequency (RCF) and interferon-gamma (IFN-gamma) secretion over 3 years. RCF was detected in 33, 52, 38, and 28% before HAART and at years 1, 2, and > or = 3, respectively. Corresponding percentages for IFN-gamma were 100, 85, 100, and 38%. Neither RCF nor IFN-gamma was significantly associated with CD4% before or after HAART initiation. Lower HIV replication was associated with a higher proportion of subjects with positive RCF, but not IFN-gamma. There were no clinical CMV manifestations during the study. HIV-infected children did not demonstrate a significant increase in CMV-CMI with longer HAART duration, which suggests that CMV immunereconstitution involves more complex immunologic and virologic interactions than previously anticipated.