Ocular motor and vestibular dysfunction in central nervous system lymphoma.

BACKGROUND AND PURPOSE: Diagnosis of lymphoma involving the central nervous system (CNS) is challenging. This study aimed to explore the abnormal vestibular and ocular motor findings in CNS lymphoma. METHODS: A retrospective search of the medical records identified 30 patients with CNS lymphoma presenting ocular motor and vestibular abnormalities from four neurology clinics of university hospitals in South Korea (22 men, age range 14-81 years, mean 60.6 ± 15.2). The demographic and clinical features and the results of laboratory, radiological and pathological evaluation were analyzed. RESULTS: Patients presented with diplopia (13/30, 43%), vestibular symptoms (15/30, 50%) or both (2/30, 7%). In 15 patients with diplopia, abnormal ocular motor findings included ocular motor nerve palsy (n = 10, 67%), internuclear ophthalmoplegia (n = 2, 13%), external ophthalmoplegia (n = 2, 13%) and exophoria (n = 1, 7%). The vestibular abnormalities were isolated in 14 (82%) of 17 patients with vestibular symptoms and included combined unilateral peripheral and central vestibulopathy in three from lesions involving the vestibular nuclei. CNS lymphoma involved the brainstem (53%), cerebellum (33%), leptomeninges (30%), deep gray nuclei (23%) or cranial nerves (17%). Two patients showed the "double-panda" sign by involving the midbrain. CONCLUSIONS: This study expands the clinical and radiological spectra of CNS lymphoma. Neuro-ophthalmological and neuro-otological evaluation may guide the early diagnosis of CNS lymphoma.

The evidence behind robot-assisted abdominopelvic surgery: a meta-analysis of randomized controlled trials.

BACKGROUND: Despite recent advancements, the advantage of robotic surgery over other traditional modalities still harbors academic inquiries. We seek to take a recently published high-profile narrative systematic review regarding robotic surgery and add meta-analytic tools to identify further benefits of robotic surgery. METHODS: Data from the published systematic review were extracted and meta-analysis were performed. A fixed-effect model was used when heterogeneity was not significant (Chi2 p ≥ 0.05, I2 ≤ 50%) and a random-effects model was used when heterogeneity was significant (Chi2 p < 0.05, I2 > 50%). Forest plots were generated using RevMan 5.3 software. RESULTS: Robotic surgery had comparable overall complications compared to laparoscopic surgery (p = 0.85), which was significantly lower compared to open surgery (odds ratio 0.68, p = 0.005). Compared to laparoscopic surgery, robotic surgery had fewer open conversions (risk difference - 0.0144, p = 0.03), shorter length of stay (mean difference - 0.23 days, p = 0.01), but longer operative time (mean difference 27.98 min, p < 0.00001). Compared to open surgery, robotic surgery had less estimated blood loss (mean difference - 286.8 mL, p = 0.0003) and shorter length of stay (mean difference - 1.69 days, p = 0.001) with longer operative time (mean difference 44.05 min, p = 0.03). For experienced robotic surgeons, there were less overall intraoperative complications (risk difference - 0.02, p = 0.02) and open conversions (risk difference - 0.03, p = 0.04), with equivalent operative duration (mean difference 23.32 min, p = 0.1) compared to more traditional modalities. CONCLUSION: Our study suggests that compared to laparoscopy, robotic surgery may improve hospital length of stay and open conversion rates, with added benefits in experienced robotic surgeons showing lower overall intraoperative complications and comparable operative times.

Machine Learning Analysis of Postlaparoscopy Hernias and "I'm Leaving You to Close" Strategy.

INTRODUCTION: Contributing factors to postlaparoscopy hernia are unknown. We hypothesized that postlaparoscopy incisional hernias are increased when the index surgery was performed in teaching hospitals. Laparoscopic cholecystectomy was chosen as the archetype for open umbilical access. MATERIALS AND METHODS: Maryland and Florida SID/SASD databases (2016-2019) wereused to track 1-year hernia incidence in both inpatient and outpatient settings, which was then linked to Hospital Compare, Distressed Communities Index (DCI), and ACGME. Postoperative umbilical/incisional hernia following laparoscopic cholecystectomy was identified using CPT and ICD-10. Propensity matching and eight machine learning modes were utilized including logistic regression, neural network, gradient boosting machine, random forest, gradient boosted trees, classification and regression trees, k nearest neighbors and support vector machines. RESULTS: Postoperative hernia incidence was 0.2% (total = 286; 261 incisional and 25 umbilical) in 117,570 laparoscopic cholecystectomy cases. Days to presentation (mean ± SD) were incisional 141 ± 92 and umbilical 66 ± 74. Logistic regression performed best (AUC 0.75 (95% ci 0.67-0.82) and accuracy 0.68 (95% ci 0.60-0.75) using 10-fold cross validation) in propensity matched groups (1:1; n = 279). Postoperative malnutrition (OR 3.5), hospital DCI of comfortable, mid-tier, at risk or distressed (OR 2.2 to 3.5), LOS >1 d (OR 2.2), postop asthma (OR 2.1), hospital mortality below national average (OR 2.0) and emergency admission (OR 1.7) were associated with increased hernias. A decreased incidence was associated with patient location of small metropolitan areas with <1 million residents (OR 0.5) and Charlson Comorbidity Index-Severe (OR 0.5). Teaching hospitals were not associated with postoperative hernia after laparoscopic cholecystectomy. CONCLUSIONS: Different patient factors as well as underlying hospital factors are associated with postlaparoscopy hernias. Performance of laparoscopic cholecystectomy at teaching hospitals is not associated with increased postoperative hernias.

Continuous-flow left ventricular assist devices associated survival awaiting heart and heart-kidney transplant.

BACKGROUND: Improvement in continuous-flow left ventricular assist device (CF-LVAD) technology has translated to better outcomes for patients on CF-LVAD support as a bridge-to-transplant. However, data are lacking regarding the subset of CF-LVAD patients with renal failure awaiting simultaneous heart-kidney transplant (HKTx). We sought to better understand the characteristics and outcomes of patients in this group. METHODS: The United Network for Organ Sharing (UNOS) database was used to identify adult patients listed for heart transplant (HTx) or HKTx from January 1, 2009 to March 31, 2017. Patients were followed from time on waitlist to either removal from waitlist or transplantation. Demographic and clinical data for HTx and HKTx patients were assessed. Kaplan-Meier analysis assessed waitlist and post-transplant survival. For waitlisted patients, both death and removal from the waitlist due to deteriorating medical condition were considered events. RESULTS: Overall, 26 638 patients registered for transplant were analyzed. 25 111 (94%) were listed for HTx, and 1527 (6%) for HKTx. 7683 (29%) patients listed for HTx had CF-LVAD support. For those listed for HKTx, 441 (28%) underwent dialysis alone, 256 (17%) had CF-LVAD support alone, and 85 (6%) were treated with both CF-LVAD and dialysis. 15 567 (58%) underwent HTx, and 621 (2%) underwent HKTx. In these groups, post-transplant survival was similar (p = 0.06). Patients listed for HKTx treated with both dialysis and CF-LVAD had significantly worse waitlist survival compared to HKTx recipients (p < 0.001). CONCLUSION: Post-transplant survival is comparable between HTx and HKTx, and early survival is similar between HTx patients and those listed for HTx with CF-LVAD support. However, outcomes on the waitlist for HKTx in CF-LVAD patients on dialysis is significantly worse compared to HKTx recipients. This highlights the need to better account for this patient population when allocating organs.

SPONTANEOUS REATTACHMENT OF RHEGMATOGENOUS RETINAL DETACHMENT: Observations of the Vitreoretinal Interface.

PURPOSE: To describe the clinical characteristics and posterior vitreous findings of spontaneous reattachment of rhegmatogenous retinal detachment (SRRRD). METHODS: Eighty-six eyes from 80 patients who were diagnosed with SRRRD (SRRRD group) and 92 eyes from 92 patients who had undergone successful scleral buckling for rhegmatogenous retinal detachment ( group for comparison) were included. Ultrawide field fundus imaging and spectral domain optical coherence tomography were performed to evaluate fundus characteristics and vitreoretinal interface. RESULTS: A significant difference was found in the proportion of complete posterior vitreous attachment between the SRRRD and rhegmatogenous retinal detachment groups (44.2% vs. 19.6%, P < 0.001). The incidence of atypical epiretinal tissue (AET) in the SRRRD group was 14% (12 of 86 eyes), whereas none of the eyes in the rhegmatogenous retinal detachment group exhibited AET. In SRRRD eyes with AET, the visual acuity was lower (logarithm of the minimum angle of resolution, 0.51 ± 0.57 vs. 0.14 ± 0.15, P < 0.001), the mean age was higher (years, 61.7 vs. 39.4, P < 0.001), and the SRRRD lesion extent was wider (clock hours, 5.67 vs. 3.70, P = 0.004) than in SRRRD eyes without AET. CONCLUSION: Compared with the rhegmatogenous retinal detachment group, the SRRRD group had a higher incidence of posterior vitreous attachment. Furthermore, AET was a significant comorbidity in the eyes with SRRRD, particularly in the elderly and the area of presumed reattachment over two quadrants and was related to worse functional outcomes.

Genotypic and Phenotypic Spectrum of Foveal Hypoplasia: A Multicenter Study.

PURPOSE: To characterize the genotypic and phenotypic spectrum of foveal hypoplasia (FH). DESIGN: Multicenter, observational study. PARTICIPANTS: A total of 907 patients with a confirmed molecular diagnosis of albinism, PAX6, SLC38A8, FRMD7, AHR, or achromatopsia from 12 centers in 9 countries (n = 523) or extracted from publicly available datasets from previously reported literature (n = 384). METHODS: Individuals with a confirmed molecular diagnosis and availability of foveal OCT scans were identified from 12 centers or from the literature between January 2011 and March 2021. A genetic diagnosis was confirmed by sequence analysis. Grading of FH was derived from OCT scans. MAIN OUTCOME MEASURES: Grade of FH, presence or absence of photoreceptor specialization (PRS+ vs. PRS-), molecular diagnosis, and visual acuity (VA). RESULTS: The most common genetic etiology for typical FH in our cohort was albinism (67.5%), followed by PAX6 (21.8%), SLC38A8 (6.8%), and FRMD7 (3.5%) variants. AHR variants were rare (0.4%). Atypical FH was seen in 67.4% of achromatopsia cases. Atypical FH in achromatopsia had significantly worse VA than typical FH (P < 0.0001). There was a significant difference in the spectrum of FH grades based on the molecular diagnosis (chi-square = 60.4, P < 0.0001). All SLC38A8 cases were PRS- (P = 0.003), whereas all FRMD7 cases were PRS+ (P < 0.0001). Analysis of albinism subtypes revealed a significant difference in the grade of FH (chi-square = 31.4, P < 0.0001) and VA (P = 0.0003) between oculocutaneous albinism (OCA) compared with ocular albinism (OA) and Hermansky-Pudlak syndrome (HPS). Ocular albinism and HPS demonstrated higher grades of FH and worse VA than OCA. There was a significant difference (P < 0.0001) in VA between FRMD7 variants compared with other diagnoses associated with FH. CONCLUSIONS: We characterized the phenotypic and genotypic spectrum of FH. Atypical FH is associated with a worse prognosis than all other forms of FH. In typical FH, our data suggest that arrested retinal development occurs earlier in SLC38A8, OA, HPS, and AHR variants and later in FRMD7 variants. The defined time period of foveal developmental arrest for OCA and PAX6 variants seems to demonstrate more variability. Our findings provide mechanistic insight into disorders associated with FH and have significant prognostic and diagnostic value.

Transient Vestibular Symptoms Preceding Posterior Circulation Stroke: A Prospective Multicenter Study.

BACKGROUND AND PURPOSE: The recognition of clinical features of transient vestibular symptoms (TVSs) preceding posterior circulation stroke (PCOS) would be informative to discriminate dizziness/vertigo due to vertebrobasilar transient ischemic attack from the acute transient vestibular syndrome. We sought to determine the prevalence and characteristics of TVSs preceding PCOS. METHODS: We performed a prospective multicenter observational study that had recruited 447 patients with PCOS from referral-based 4 university hospitals in Korea. We investigated the timing, pattern, frequency, duration, and accompanying neurological symptoms of TVSs during the 3 months preceding PCOS. RESULTS: The prevalence of TVSs preceding PCOS was 12% (55/447) during the previous 3 months. The TVSs preceding PCOS occurred within 1 week (33%), between 1 week and 1 month (16%), or between 1 and 3 months (51%). The TVSs were mostly dizziness/vertigo with (36%) or without (60%) imbalance, while the remaining 4% had an isolated imbalance. The dizziness/vertigo was spinning in 38% and was aggravated during head position in 45%. The duration of TVSs was mostly a few seconds (55%) or minutes (38%). Approximately 72% of the patients with PCOS had TVSs 1 to 5 times, while 16% had >10 times. Accompanying neurological symptoms, including headache, tinnitus, limb weakness, sensory change, dysarthria, visual field defect, and diplopia, were reported in 11%. CONCLUSIONS: Preceding TVSs can occur in 12% of PCOS during the previous 3 months. Isolated dizziness/vertigo of unknown cause needs to be considered as a vertebrobasilar transient ischemic attack symptom, especially in patients with vascular risk factors. The characteristics of isolated vestibular symptom in vertebrobasilar transient ischemic attacks is highly variable and atypical compared with other transient ischemic symptoms.

Episodic Vestibular Syndrome with Hyperventilation-Induced Downbeat Nystagmus.

Hyperventilation-induced downbeat nystagmus (HV-DBN) has been reported in cerebellar disorders and explained by a loss of the inhibitory cerebellar output via a metabolic effect on cerebellar Ca2+ channels. The aim of this study was to determine the clinical characteristics and underlying pathogenesis of episodic vestibular syndrome (EVS) with HV-DBN. Of 667 patients with EVS, we recruited 22 with HV-DBN and assessed their clinical characteristics, video-oculographic findings, and the results of molecular genetic analyses. The age at symptom onset was 47.5 ± 13.0 years (mean ± SD), and there was a female preponderance (n = 15, 68%). The duration of vertigo/dizziness attacks ranged from minutes to a few days, and 11 patients (50%) fulfilled the diagnostic criteria for vestibular migraine. HV-induced new-onset DBN in 8 patients, while the remaining 14 showed augmentation of spontaneous DBN by HV. The maximum slow-phase velocity of HV-DBN ranged from 2.2 to 11.9°/s, which showed a statistical difference with that of spontaneous DBN (median = 4.95, IQR = 3.68-6.55 vs. median = 1.25, IQR = 0.20-2.15, p < 0.001). HV-DBN was either purely downbeat (n = 11) or accompanied with small horizontal components (n = 11). Other neuro-otologic findings included perverted head-shaking nystagmus (n = 11), central positional nystagmus (n = 7), saccadic pursuit (n = 3), and horizontal gaze-evoked nystagmus (n = 1). Gene expression profiling with a bioinformatics analysis identified 43 upregulated and 49 downregulated differentially expressed genes (DEGs) in patients with EVS and HV-DBN and revealed that the downregulated DEGs were significantly enriched in terms related to the ribosome pathway. Our results suggest that the underlying cerebellar dysfunction would be responsible for paroxysmal attacks of vertigo in patients with EVS and HV-DBN.

Tricuspid regurgitation associated with implantable electrical device insertion: A systematic review and meta-analysis.

BACKGROUND: Implantable cardioverter defibrillator (ICD) and permanent pacemaker (PPM) lead placement may worsen or result in tricuspid regurgitation (TR). While the association between lead placement and the incidence of TR has been established, current understanding of this problem remains incomplete. This systematic review and meta-analysis sought to pool the existing evidence to better understand the occurrence and severity of TR associated with cardiac implantable electrical device (CIED) insertion. METHODS: An electronic search was performed to identify all relevant studies published from 2000 to 2018. Overall, 15 studies were selected for the analysis comprising 4019 patients with data reported on TR development following ICD or PPM lead placement. Demographic information, perioperative clinical variables, and clinical outcome measures, including pre and postoperative echocardiographic TR grade changes, were extracted and pooled for systematic review. RESULTS: Mean patient age was 69 years [95% CI: 64.62-73.59], and 63% [95% CI: 57-68] were male. Devices implanted included ICD in 57% [95%CI: 43-70] and PPM in 41% [95%CI: 31-52]. The most common indications for pacemaker implantation were sick sinus syndrome in 22% [95% CI: 22-37] and AV block in 21% [95%CI:12-34. The commonest indications for ICD implantation were primary and secondary prevention of sudden cardiac death. Atrial fibrillation was present in 37% [95%CI: 28-46] and congestive heart failure in 15% [95%CI: 2-57]. Baseline distribution of TR grades were as follows: grade 0/1 TR in 89% [95%CI: 82-93], grade 2 TR in 8% [95%CI: 5-13], grade 3 TR in 2% [95%CI: 0-7] and grade 4 TR in 2% [95%CI: 1-4]. Post-procedure, grade 0/ 1 TR decreased to 68% [95% CI: 51-81] (p < 0.01), grade 2 TR increased to 21% [15-28] (p < 0.01), grade 3 TR increased to 13% [95%CI: 5-32] (p = 0.02), and grade 4 TR increased to 7% [95%CI: 5-9] (p < 0.01). CONCLUSION: ICD and PPM lead placement is associated with increased TR post-procedure. Further studies are warranted to evaluate changes in TR grade in the long term.

Multi-Robot 2.5D Localization and Mapping Using a Monte Carlo Algorithm on a Multi-Level Surface.

Most indoor environments have wheelchair adaptations or ramps, providing an opportunity for mobile robots to navigate sloped areas avoiding steps. These indoor environments with integrated sloped areas are divided into different levels. The multi-level areas represent a challenge for mobile robot navigation due to the sudden change in reference sensors as visual, inertial, or laser scan instruments. Using multiple cooperative robots is advantageous for mapping and localization since they permit rapid exploration of the environment and provide higher redundancy than using a single robot. This study proposes a multi-robot localization using two robots (leader and follower) to perform a fast and robust environment exploration on multi-level areas. The leader robot is equipped with a 3D LIDAR for 2.5D mapping and a Kinect camera for RGB image acquisition. Using 3D LIDAR, the leader robot obtains information for particle localization, with particles sampled from the walls and obstacle tangents. We employ a convolutional neural network on the RGB images for multi-level area detection. Once the leader robot detects a multi-level area, it generates a path and sends a notification to the follower robot to go into the detected location. The follower robot utilizes a 2D LIDAR to explore the boundaries of the even areas and generate a 2D map using an extension of the iterative closest point. The 2D map is utilized as a re-localization resource in case of failure of the leader robot.

Development of livestock feed additives using porcine blood cells.

Livestock blood discarded during slaughtering has potentially valuable components such as plasma proteins and haemoglobin. Plasma is used as a feed additive following processing via different methods, including spray drying, whereas blood cells have been underutilized. In this study, we developed haemoglobin hydrolysate (HH) and iron-enriched residue (IER) from porcine blood cells and investigated whether their oral administration regulates the immune system and gut microbiota in growing rats. Twenty-one Sprague-Dawley male rats (n = 7) were used during a 4-week trial and were fed a control, HH or IER diet. The ratio of beneficial bacteria such as Lactobacillus and Akkermansia strains increased in rats fed HH or IER diets. Moreover, compared with the control group, the IER group had an elevated ratio of Lactobacillus to Enterobacteria, which is regarded as an index of beneficial aspect in the gut. Phagocytosis of peripheral blood leucocytes was higher in the HH and IER groups than in the control group. The level of plasma immunoglobulin G increased to approximately 72.7 mg/ml and 152.0 mg/ml in the HH and IER groups, respectively, which was significantly (p < 0.05) higher than that in the control group. These results confirm that HH and IER developed in this study may be a potential additive for animal feeds.

Right atrial versus right ventricular HeartWare HVAD position in patients on biventricular HeartWare HVAD support: A systematic review.

In patients with biventricular heart failure or refractory right heart failure following HeartWare HVAD placement, off-label placement of a right-sided HeartWare HVAD has been described both in the right ventricular (RV) and right atrial (RA) positions. We sought to evaluate and compare the outcomes of right-sided HeartWare HVAD using the RA versus RV approach. An electronic search was performed in the English literature to identify all reports of left- and right-heart support with HeartWare HVAD. Of the 1,288 articles identified, 13 articles with 56 cases met inclusion criteria. Patient-level data were extracted and analyzed. The median patient age was 52 years (IQR 33.0-59.0) and 40/50 (80.0%) were male. Overall, 21/56 patients (37.5%) had RA HVAD, while 35/56 (62.5%) had RV HVAD. Most underwent concomitant HVAD placement [RA: 17/21 (81.0%) vs. RV: 31/35 (88.6%), P = .69]. In those who did not, the median time between left and right HVAD was 10 days (IQR 7-14) for RA HVAD and 12 days (IQR 8-30) for RV HVAD (P = .77). The median time of support was 351 days (IQR 136-626) for RA HVAD compared to 135 days (IQR 61-244) for RV HVAD (P = .02). Pump thrombosis occurred at a similar rate [RA: 3/10 (30.0%) vs. RV: 6/20 (30.0%), P = 1], as did GI bleeding [RA: 10/35 (28.6%) vs. RV: 5/21 (23.8%), P = .94] during the follow-up time period. Kaplan-Meier analysis when censored for transplant showed higher survival with RA HVAD compared to RV HVAD (P = .036), with an estimated survival at 1 year of 91.7% (95% CI 77.3-100.0) in RA HVAD versus 66.2% (95% CI 48.9-89.6) for RV HVAD. RA HVAD appears to be a viable option for durable right-sided support with outcomes at least comparable to RV HVAD.

Ventricular arrhythmias following continuous-flow left ventricular assist device implantation: A systematic review.

Ventricular arrhythmias (VA) are not uncommon after continuous-flow left ventricular assist device (CF-LVAD) implantation. In this systematic review, we sought to identify the patterns of VA that occurred following CF-LVAD implantation and evaluate their outcomes. An electronic search was performed to identify all articles reporting the development of VA following CF-LVAD implantation. VA was defined as any episode of ventricular fibrillation (VF) or sustained (>30 seconds) ventricular tachycardia (VT). Eleven studies were pooled for the analysis that included 393 CF-LVAD patients with VA. The mean patient age was 57 years [95%CI: 54; 61] and 82% [95%CI: 73; 88] were male. Overall, 37% [95%CI: 19; 60] of patients experienced a new onset VA after CF-LVAD implantation, while 60% [95%CI: 51; 69] of patients had a prior history of VA. Overall, 88% of patients [95%CI: 78; 94] were supported on HeartMate II CF-LVAD, 6% [95%CI: 3; 14] on HeartWare HVAD, and 6% [95%CI: 2; 13] on other CF-LVADs. VA was symptomatic in 47% [95%CI: 28; 68] of patients and in 50% [95%CI: 37; 52], early VA (<30 days from CF-LVAD) was observed. The 30-day mortality rate was 7% [95%CI: 5; 11]. Mean follow-up was 22.9 months [95%CI: 4.8; 40.8], during which 27% [95%CI: 17; 39] of patients underwent heart transplantation. In conclusion, approximately a third of patients had new VA following CF-LVAD placement. VA in CF-LVAD patients is often symptomatic, necessitates treatment, and carries a worse prognosis.

Clinical implications of LDH isoenzymes in hemolysis and continuous-flow left ventricular assist device-induced thrombosis.

Pump-induced thrombosis continues to be a major complication of continuous-flow left ventricular assist devices (CF-LVADs), which increases the risks of thromboembolic stroke, peripheral thromboembolism, reduced pump flow, pump failure, cardiogenic shock, and death. This is confounded by the fact that there is currently no direct measure for a proper diagnosis during pump support. Given the severity of this complication and its required treatment, the ability to accurately differentiate CF-LVAD pump thrombosis from other complications is vital. Hemolysis measured by elevated lactate dehydrogenase (LDH) enzyme levels, when there is clinical suspicion of pump-induced thrombosis, is currently accepted as an important metric used by clinicians for diagnosis; however, LDH is a relatively nonspecific finding. LDH exists as five isoenzymes in the body, each with a unique tissue distribution. CF-LVAD pump thrombosis has been associated with elevated serum LDH-1 and LDH-2, as well as decreased LDH-4 and LDH-5. Herein, we review the various isoenzymes of LDH and their utility in differentiating hemolysis seen in CF-LVAD pump thrombosis from other physiologic and pathologic conditions as reported in the literature.

Characteristics and outcomes of gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices: A systematic review.

Gastrointestinal bleeding (GIB) is a common adverse event after continuous-flow left ventricular assist device (CF-LVAD) implantation. We sought to evaluate patterns of GIB development and related outcomes in CF-LVAD recipients. An electronic search was performed to identify all articles related to GIB in the setting of CF-LVAD implantation. A total of 34 studies involving 1087 patients were pooled for analysis. Mean patient age was 60 years (95% CI 57-64) and 24% (95% CI 21-28%) were female. The mean time from CF-LVAD implantation to the first GIB was 54 days (95% CI 24-84) with 40% (95% CI 34-45%) of patients having multiple episodes of GIB. Anemia was present in 75% (95% CI 41-93%) and the most common etiology of bleeding was arteriovenous malformations (36% [95% CI 24-50%]). The mean duration of follow-up was 14.6 months (95% CI 6.9-22.3) during which the all-cause mortality rate was 21% (95% CI 12-36%) and the mortality rate from GIB was 4% (95% CI 2-9%). Thromboembolic events occurred in 32% (95% CI 22-44%) of patients with an ischemic stroke rate of 16% (95% CI 3-51%) and a pump thrombosis rate of 8% (95%CI 3-22%). Heart transplantation was performed in 31% (95% CI 18-47%) of patients, after which 0% (95% CI 0-10%) experienced recurrent GIB. GIB is a major source of morbidity among CF-LVAD recipients. While death due to GIB is rare, cessation of anticoagulation during treatment increases the risk of subsequent thrombotic events. Heart transplant in these patients appears to reliably resolve the risk of future GIB.

EN-FACE OPTICAL COHERENCE TOMOGRAPHY IN PATIENTS WITH EPIRETINAL MEMBRANE: Intuitive Method for Predicting Functional Outcomes.

PURPOSE: To evaluate the correlation between en-face optical coherence tomography (OCT) parameters and functional outcomes before and after idiopathic epiretinal membrane (ERM) surgery. METHODS: This retrospective cohort study involved 80 eyes from 80 patients who underwent surgery for idiopathic ERM. Best-corrected visual acuity, metamorphopsia assessment (M-score), and OCT were assessed before surgery and six months after. The adhesive zone (A-zone) and retinal fold, a novel en-face OCT parameter reflecting inner retinal layer changes, were evaluated. Correlations between the area of A-zone and the number of retinal folds on en-face OCT images and other B-scan OCT parameters were evaluated regarding visual outcomes before and after ERM surgery. RESULTS: The defect size of the ellipsoid zone, interdigitation zone, and external limiting membrane were significantly correlated with preoperative and postoperative 6-month best-corrected visual acuity (all P < 0.05). The central foveal thickness, A-zone area, number of marginal retinal folds, and fovea involvement in the A-zone were correlated with the preoperative and postoperative 6-month M-score (all P < 0.05). The A-zone area was significantly associated with the preoperative and postoperative 6-month M-score in a multiple linear regression model (P < 0.001, P = 0.008, respectively), and the number of marginal retinal folds was significantly associated with the preoperative M-score (P < 0.001) and marginally significantly with the postoperative 6-month M-score (P = 0.106). CONCLUSION: The A-zone area and the number of marginal retinal folds were significantly associated with the M-score before and after ERM surgery. These novel en-face OCT parameters can serve as a novel surrogate tool for predicting the functional outcomes in idiopathic ERM.

DEVELOPMENT OF IDIOPATHIC MACULAR HOLE IN FELLOW EYES: Spectral Domain Optical Coherence Tomography Features.

PURPOSE: To investigate the long-term incidence and risk factors of macular hole (MH) development in the fellow eyes of patients with unilateral idiopathic MH. METHODS: The retrospective case-control study involved the fellow eyes of 215 consecutive patients with idiopathic MH. The patients were classified into two groups according to the presence or development of MH in the fellow eye. The spectral domain optical coherence tomography features and clinical characteristics of each group were compared. RESULTS: Twelve (5.6%) patients presented with bilateral MH at the initial visit, whereas 20 (9.3%) initially unilateral patients developed MH in the fellow eye over a median interval of 44 months. Vitreomacular traction and inner foveal cyst were noted more frequently in the baseline spectral domain optical coherence tomography scans of fellow eyes of the bilateral group (P < 0.01). An outer foveal defect was found in five patients (35.7%) of the bilateral MH group (P < 0.01). CONCLUSION: The incidence of MH in fellow eyes was approximately 10%. The presence of outer foveal defect, inner foveal cyst, and vitreomacular adhesion or traction on spectral domain optical coherence tomography in the fellow eye was the risk factor for MH.

Repair of ischemic ventricular septal defect with and without coronary artery bypass grafting.

BACKGROUND AND AIM OF THE STUDY: Ventricular septal defect (VSD) following myocardial infarction (MI) is a relatively infrequent complication with high mortality. We sought to investigate the effect of concomitant coronary artery bypass graft (CABG) on outcomes following post-MI VSD repair. METHODS: Electronic search was performed to identify all relevant studies published from 2000 to 2018. Sixty-seven studies were selected for the analysis comprising 2174 patients with post-MI VSD. Demographic information, perioperative variables, and outcomes including survival data were extracted and pooled for systematic review and meta-analysis. RESULTS: Single-vessel disease was most common (47%, 95% confidence interval [CI], 42-52), left anterior descending coronary artery was the most commonly involved vessel (55%, 95% CI, 46-63), and anterior wall was the most commonly affected territory (57%, 95% CI, 51-63). Concomitant CABG was performed in 52% (95% CI, 46-57) of patients. Of these, infarcted territory was re-vascularized in 54% (95% CI, 23-82). A residual/recurrent shunt was present in 29% (95% CI, 24-34) of patients. Of these, surgical repair was performed in 35% (95% CI, 28-41) and transcatheter repair in 11% (95% CI, 6-21). Thirty-day mortality was 30% (95% CI, 26-35) in patients who had preoperative coronary angiogram, and 58% (95% CI, 43-71) in those who did not (P < .01). No significant survival difference observed between those who had concomitant CABG vs those without CABG. CONCLUSIONS: Concomitant CABG did not have a significant effect on survival following VSD repair. Revascularization should be weighed against the risks associated with prolonged cardiopulmonary bypass.

Comparison of Ocular Motor Findings Between Neuromyelitis Optica Spectrum Disorder and Multiple Sclerosis Involving the Brainstem and Cerebellum.

This study aimed to define the clinical features and involved structures that aid in differentiation of neuromyelitis optica spectrum disorder (NMOSD) from multiple sclerosis (MS) involving the brainstem and cerebellum. We analyzed the clinical and ocular motor findings, and lesion distribution on brain MRIs in 42 patients with MS (17 men, mean age ± SD = 37 ± 12) and 26 with NMOSD (3 men, mean age ± SD = 43 ± 15) that were recruited from two university hospitals in South Korea (whole study population). An additional subgroup analysis was also conducted in 41 patients presenting acute brainstem or vestibular syndrome (brainstem syndrome population). Logistic regression analysis showed that bilaterality of the lesions (p = 0.012) and presence of horizontal gaze-evoked nystagmus (hGEN, p = 0.041) were more frequently associated with NMOSD than with MS in the whole study population. In the brainstem syndrome population, only hGEN (p = 0.017) was more frequent in NMOSD than in MS. The lesions specific for NMOSD were overlapped in the medial vestibular nucleus (MVN) and nucleus prepositus hypoglossi (NPH) at the pontomedullary junction. In conclusion, presence of hGEN and bilateral lesions involving the MVN and NPH favor the diagnosis of NMOSD rather than MS.

Atypical clinical manifestations of Miller Fisher syndrome.

Miller Fisher syndrome (MFS) is characterized by a clinical triad of ophthalmoplegia, ataxia, and areflexia, and is closely associated with serum anti-GQ1b antibody. Although the clinical triad is the cardinal diagnostic clue, a variety of other symptoms and signs beyond the triad have been reported. To elucidate the frequency and characteristics of atypical clinical manifestations of MFS, we recruited 38 patients with MFS and evaluated the symptoms or signs beyond the classic triad. Eleven (29%) of 38 patients had atypical clinical manifestations of MFS such as headache (n = 6), delayed facial palsy (n = 3), divergence insufficiency (n = 2), and taste impairment (n = 2). Headache was localized to the periorbital (n = 3), temporal (n = 2), or whole (n = 1) area. Only one of them showed bilateral papilledema and an elevated opening pressure in cerebrospinal fluid analysis. Delayed facial palsy developed after the other signs have reached nadir (n = 1) or started to improve (n = 2), and did not follow a pattern of descending paralysis with other cranial neuropathies. Two patients showed divergence insufficiency without external ophthalmoplegia, and another two had taste impairment over the entire tongue without the other signs of facial and glossopharyngeal nerve involvements. Our study shows that approximately 30% of MFS patients can have atypical clinical manifestations beyond the classic triad. These results reflect the broad clinical spectrum of MFS, and might be associated with the presence of additional antiganglioside antibodies besides anti-GQ1b in patients with MFS.