PURPOSEFUL GAS-INDUCED RESORPTION OF SUBMACULAR FLUID IN MACULA-OFF RETINAL DETACHMENTS (PERSIMMON STUDY).

PURPOSE: To examine the visual outcomes in patients with macula-off rhegmatogenous retinal detachments with intentional submacular fluid retention after pars plana vitrectomy (PPV) or PPV/scleral buckle surgery (PPV/SB). METHODS: Patients with macula-off retinal detachments were included if they had a PPV or PPV/SB without drainage retinotomy or perfluorocarbon liquid to flatten the retina. RESULTS: The mean age of the patients was 65.0 years. The mean presenting vision was 20.0 Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Six months after repair, the vision improved to 62.9; 75.4% of patients had 20/40 or better at best achieved visual acuity. Pseudophakic eyes had better vision compared with phakic eyes ( P = 0.049). Patients younger than 80 years had better best achieved vision ( P = 0.0118) compared with patients 80 years or older. Patients with initial vision better than or equal to 20/100 had better best achieved vision ( P = 0.016) compared with those with initial vision worse than 20/100. CONCLUSION: Leaving submacular fluid after macula-off retinal detachments surgery was not detrimental for visual outcomes or anatomic success for retinal detachments repair and may lead to better visual outcomes for patients, specifically for those patients younger than 80 years, who are pseudophakic, and have presenting vision 20/100 or better.

Results of patients with neovascular age-related macular degeneration managed by a treat-extend-stop protocol without recurrence.

PURPOSE: To assess vision, injection quantity, initial lesion size, and final anatomic status in patients with nAMD completing the treat-extend-stop (TES) protocol. METHODS: Patients with nAMD received ≥ 3 monthly anti-VEGF injections followed by 1-2 week injection interval extensions, with intra/subretinal fluid resolution on SD-OCT, to 12 weeks. With quiescent disease, and 2 quarterly injections, patients were monitored alone beginning at 4 weeks extending by 1-2 week intervals until quarterly monitoring. RESULTS: Eighty-eight of 143 eyes with nAMD completed the TES protocol without disease recurrence. Sixteen (18.2%) developed sub-foveal geographic atrophy (GA), 25 (28.4%) developed fibrovascular scarring (FV) and 47 (53.4%) developed regressed choroidal neovascularization (rCNV) with 16.9 ± 13.3 average injections between the 3 groups which was not statistically significant. Average treatment time was 30.3 ± 26.1 months and subsequent follow-up was 23.2 ± 19.8 months. Average lesion size for FV was 18.77 ± 10.8mm2 vs. GA at 12.00 ± 9.99mm2 vs. regressed CNV at 7.12 ± 6.5mm2 (p < 0.05). Pre, post, and final vision for GA was 39.6 letters (20/160) vs. 32.7 letters (20/200 + 2, p = 0.4725) vs. 25.0 letters (20/320, p = 0.0865); FV was 22.4 letters (20/400 + 2) vs. 11.6 letters (20/640, p = 0.0351) vs. 11.0 letters (20/640 + 1, p = 0.0226), and rCNV was 56.4 letters (20/80 + 1) vs. 69.5 letters (20/40, p < 0.001) vs. 67.3 letters (20/40-2, p = 0.0016). In the rCNV group, 17/46 eyes gained ≥ 3 lines and 30/46 eyes achieved ≥ 20/40 vision. Non-central GA expanded 0.226 ± 0.126 mm vs. 0.225 ± 0.098 mm during and after treatment completion over 24 months (p = 0.99). CONCLUSIONS: Central GA or FV portends worse visual outcomes vs. rCNV after cessation of therapy. Anti-VEGF therapy may not affect the rate of GA expansion. Final anatomic character and location are key determinants of final vision.

Consistent Long-Term Therapy of Neovascular Age-Related Macular Degeneration Managed by 50 or More Anti-VEGF Injections Using a Treat-Extend-Stop Protocol.

PURPOSE: To examine the clinical results for patients with neovascular age-related macular degeneration (nAMD) who were managed with a treat-extend-stop (TES) protocol and received 50 or more injections of anti-vascular endothelial growth factor (VEGF) agents. DESIGN: Retrospective case study. PARTICIPANTS: Data for patients from a private retina practice meeting the following criteria were included: diagnosis of nAMD and having received 50 or more intravitreal injections of anti-VEGF agents. METHODS: The patients' baseline visual acuity (VA; obtained using Snellen charts and converted to Early Treatment Diabetic Retinopathy Study [ETDRS] letters), age, length of follow-up, anti-VEGF agents used, and interval between treatments were obtained. These data were examined through the 51st injection and at the last follow-up examination. Patients were excluded if they lost significant vision because of a diagnosis unrelated to AMD during therapy. MAIN OUTCOME MEASURES: Visual acuity and complications. RESULTS: Seventy-one eyes of 67 patients were identified who met inclusion criteria. The mean age of patients was 83.0 years. Women made up 58.2% of the study population, whereas men constituted 41.8%. The mean initial VA was 55.6 ETDRS letters. The mean duration of follow-up at the 51st visit for an injection was 6.5 years, and the mean duration of follow-up at the last visit was 8 years. The mean number of injections at final follow-up was 63.7. The mean interval between treatments at the 51st follow-up was 5.4 weeks, and the mean follow-up at the last examination was 6.4 weeks. Mean VA at the 51st injection was 65.3 letters, and the mean change from baseline was 9.7 letters (P < 0.001, Student paired t test). The mean vision gained at last follow-up was 8.7 letters from baseline (P < 0.001), or 64.3 letters. CONCLUSIONS: In this study, patients gained a mean of 2 ETDRS lines after 50 injections. This study had a mean follow-up of 8 years, and 35.2% of eyes had a 3-line or more gain in VA at the last follow-up examination. Patients who require consistent long-term anti-VEGF therapy, managed with a TES protocol, are likely able to maintain or improve their vision.

Futility and the care of surgical patients: ethical dilemmas.

Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is "qualitative futility" which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician-patient communication, these authors have advocated for methods of improving communication and strengthening the patient-physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision.

Impression of Primary Care Follow-Up After a PICU Admission: A Pilot Survey of Primary Care Pediatricians.

OBJECTIVES: The majority of PICU general follow-up occurs with primary care providers. Our objective was to investigate primary care pediatricians': 1) comfort with and barriers to caring for children after a PICU admission, 2) knowledge of and screening for post-intensive care syndrome in pediatrics (PICS-P), and 3) resource needs. DESIGN: Pilot cross-sectional survey study. SETTING: Metropolitan Detroit, Michigan from September 2022 to March 2023. SUBJECTS: Primary care pediatricians. MEASUREMENT AND MAIN RESULTS: The survey included 15 questions on provider demographics, comfort with and barriers to caring for children after a PICU admission, knowledge of and screening practices for PICS-P, and resource needs. The median values for continuous data and frequencies for categorical data were calculated. The survey response rate was 17% (26/152). The median age was 38.5 years (interquartile range 34-52 yr) and 19 of 26 (73%) were female. In case studies, 26 of 26 (100%) were "very comfortable" resuming care for a patient with a straightforward bronchiolitis PICU admission while 8 of 26 participants (31%) were "somewhat uncomfortable" and 1 of 26 (4%) was "not at all comfortable" with caring for a patient after a complex acute respiratory distress syndrome PICU admission. Seven of 26 participants (27%) were familiar with the term "post-intensive care syndrome in pediatrics." Over 50% screened for four of five PICS-P domains. Key barriers were care coordination with specialists, discomfort or difficulties with managing new home equipment, and inadequate or missing documentation. CONCLUSIONS: In this pilot study, approximately one-third of primary care pediatricians had knowledge of PICS-P. Participants experienced numerous care barriers. Our findings suggest future research could engage improved study methods and designs, and focus on interventions to support primary care-provided PICU follow-up.

Surgical Macular Hole Closure Without a Gas Tamponade.

Purpose: This work aims to evaluate the outcomes of a series of macular hole (MH) surgical procedures in patients who had pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peel and without gas tamponade. Methods: Patients from a retina specialty clinic who had MHs were identified for this interventional case series. Patients with small MHs were offered inclusion into the trial. Patients with larger MHs were excluded. They underwent standard 3-port PPV and ILM peel without gas or air to treat small MHs. The main outcomes that we measured were closure of MH and visual results. Results: Small MHs in 5 patients were managed with PPV and ILM peel alone. The average preoperative hole size at its narrowest width was 227 µm (range, 173-294 µm). Four of 5 patients (80%) had successful hole closure without a gas tamponade and improved vision; 1 patient did not have hole closure and was treated with an in-office gas bubble to close the hole. The average preoperative vision at 3 months was 20/80- (54 Early Treatment Diabetic Retinopathy Study [ETDRS] letters) and improved to 20/30-2 (73 ETDRS letters) in the 4 patients whose MHs were closed with surgery without a gas bubble. This was statistically significant (P = .003). The hole that did not close initially without gas tamponade was the largest in the series. Conclusions: Patients with small MHs can be successfully treated with a vitrectomy and ILM peel alone without a gas tamponade.

Assessing the size at maturity, spawning, and condition of the truncate soft-shell clam (Mya truncata) of southern Baffin Island, Nunavut, Canada.

The truncate soft-shell clam Mya truncata is an important source of country food for Inuit communities across the territory of Nunavut, Canada. M. truncata also plays an important role in marine ecosystems, yet there is little understanding of their life history and condition in Canadian Arctic waters. To provide a foundation on which aspects of the life history and condition of M. truncata of Baffin Island can be monitored in the future with a changing climate and fishery development, this study estimated size at maturity and provides insights into the spawning cycle and weight-length condition indices of clams from inner Frobisher Bay and the north shore of the Hudson Strait. Male and female M. truncata exhibited similar lengths at 50% attainment of sexual maturity, 31 mm and 32 mm shell length (SL), respectively. Most (77%) of the sexually mature M. truncata collected from inner Frobisher Bay in late August and 35% of clams collected from the Hudson Strait in early September were in the ripe stage of gonadal development. These results lead us to suggest a spring spawning season and that M. truncata invest in gonadal development for the next year's spawning during the late summer-early autumn ice-free season while phytoplankton concentrations are high. Dry bodyweight-SL relationships were used to show that M. truncata condition can differ significantly over small and large spatial scales based on plotted 95% confidence intervals.

Does Prophylactic Oral Zinc Reduce the Risk of Contracting COVID-19?

Objective In this study, we aimed to investigate whether zinc provided in Age-Related Eye Disease Study 2 (AREDS2) vitamins is associated with a decreased risk of contracting coronavirus disease 2019 (COVID-19). Materials and methods We conducted a retrospective observational cohort study involving patients at a retina-only practice who were provided a questionnaire at each visit to assess whether they were symptomatic of or had contracted COVID-19. Those who answered yes to testing positive for COVID-19 were retrospectively analyzed and categorized based on their AREDS2 vitamin use, and a Pearson's chi-squared test was performed. Demographic data and past ocular history were also analyzed. Results A total of 8,426 unique patients, including 2,111 with a diagnosis of age-related macular degeneration (AMD), were seen from April 1, 2020, to April 9, 2021. A total of 110 patients (1.3%) reported contracting COVID-19 and had positive COVID-19 tests. The average age of those who had contracted COVID-19 in this study was 68.3 years; 51.8% were male, 30.1% had AMD, 28.2% had diabetic retinopathy, 24.5% had surgical retinal disease, 11.8% had retinal vascular disease, and 4.5% had other disease states. Of the COVID-19-positive patients, 27.3% (30/110) took AREDS2 vitamins, while 72.7% (80/110) patients did not. A chi-squared analysis was performed, which was not statistically significant (p=0.667). Conclusions Oral zinc supplementation, in the form of AREDS2 vitamins, is not associated with a protective effect against contracting COVID-19.

Long term results of patients with neovascular age-related macular degeneration switched from other anti-VEGF agents to intravitreal Aflibercept.

BACKGROUND: This study explores the long term anatomic and functional results of patients who were switched to intravitreal aflibercept injections (IAI) after being initially managed with other anti-VEGF agents for neovascular age-related macular degeneration (nAMD). METHODS: Patients with nAMD were included if they started with another anti-VEGF agent and were switched to IAI. Subjects had at least 3 years of consistent therapy with IAI and at least 1 injection quarterly. RESULTS: Eighty-eight patients had at least 3 years of treatment while 58 of those patients, had at least 4 years of IAI. Average treatment time with other anti-VEGF agents was 32 months prior to switching. Baseline best corrected vision (VA) was 59.4 letters (20/70 + 2). At time of switch, VA increased significantly to 66.7 letters (20/50 + 2). At 3 months after switch, VA increased significantly to 69.0 (20/40-) letters. After 3 years of consistent IAI, vision was 67.5 letters (20/40-2), and for those patients that completed 4 years of therapy, the average VA was 66.0 letters (20/50 + 2), with a gain of 6.6 letters over baseline vision. 32.1% of patients gained 3 or more lines of vision. Initial central macular thickness (CMT) was 369 µm, which improved to 347 µm at time of switch, and further improved at 3 months to 301 µm and was maintained over time. CONCLUSION: Patients switched to IAI can maintain vision over the long term. Patients treated on average for 5.7 years, had a visual gain of 8.1 letters after 3 years and 6.6 letters after 4 years of IAI therapy. CMT significantly improved following the switch and was maintained.

A feasibility study to determine the use of baited pots in Greenland halibut (Reinhardtius hippoglossoides) fisheries, supported by the use of underwater video observations.

High incidental catches of Greenland shark (Somniosus microcephalus) in Nunavut's Greenland halibut (Reinhardtius hippoglossoides) fishery has led to studies on the feasibility of capturing Greenland halibut with baited pots. In this study, catch rates among six experimental pots are compared. In addition to this, underwater video observations of Greenland halibut interacting with two of these experimental pot types are quantified in order to help provide recommendations on future pot designs. Catch rates of Greenland halibut differed among pots with different entrance mesh types, and none of the pots produced substantial amounts of bycatch. Strings of pots were deployed within a narrow corridor between baited gillnets targeting Greenland halibut, which may have affected catch results. Video observations revealed Greenland halibut entangled by their teeth significantly more often in entrance funnels constructed with 50 mm than with 19 mm clear monofilament netting and the entrance rate was 45% higher with the 19 mm netting. Greenland halibut that successfully entered a pot repeatedly became entangled by their teeth in 58 mm netting used in the side and end panels and in a horizontal panel used to separate the pot into a lower and upper chamber. The majority (80%) of Greenland halibut were observed to approach a pot against the current. The downstream entrance was aligned with the current in 52% of the observed Greenland halibut approaches. Seventy percent of entry attempts and 67% of successful entries occurred when fish approached against the current and when the entrance was aligned with the current. These observations lead to recommendations that future studies consider developing a four entrance pot to ensure an entrance is always aligned with bottom currents. Based on these observations of entanglements, it is recommended to use 19 mm clear monofilament netting in the entrance funnel, 100 mm polyethylene netting in the exterior panels, and 19 mm polypropylene netting in the horizontal panel when targeting Greenland halibut. Three Greenland sharks were observed interacting with the pots in the video sets, but none were captured or damaged the pots during the potting experiments, providing validity to the use of pots to mitigate the capture of Greenland shark in Nunavut territorial waters.

Effects of monofilament nylon versus braided multifilament nylon gangions on catch rates of Greenland shark (Somniosus microcephalus) in bottom set longlines.

The Greenland shark (Somniosus microcephalus) is the main bycatch species in established and exploratory inshore longline fisheries for Greenland halibut (Reinhardtius hippoglossoides) on the east coast of Baffin Island, Canada. Bycatch and entanglement in longline gear has at times been substantial and post-release survival is questionable when Greenland sharks are released with trailing fishing gear. This study investigated the effect of the type of fishing line used in the gangion and gangion breaking strength on catch rates of Greenland shark and Greenland halibut in bottom set longlines. Circle (size 14/0, 0° offset) hooks were used throughout the study. Behavior of captured sharks, mode of capture (i.e., jaw hook and/or entanglement), level of entanglement in longline gear, time required to disentangle sharks and biological information (sex, body length and health status) were recorded. Catch rates of Greenland shark were independent of monofilament nylon gangion breaking strength and monofilament gangions captured significantly fewer Greenland sharks than the traditional braided multifilament nylon gangion. Catch rates and body size of Greenland halibut did not differ significantly between gangion treatments. Although most (84%) of the Greenland sharks were hooked by the jaw, a high percentage (76%) were entangled in the mainline. The mean length of mainline entangled around the body and/or caudal peduncle and caudal fin was 28.7 m. Greenland sharks exhibited cannibalistic behavior with 15% of captured sharks cannibalized. All remaining sharks were alive and survived the disentanglement process which can be attributed to their lethargic behavior and lack of resistance when hauled to the surface. Thus, as a conservation measure fishers should be encouraged to remove trailing fishing gear prior to release. Our results are used to demonstrate benefits to the fishing industry with regard to an overall reduction in the period of time to disentangle sharks and damage to fishing gear by switching from braided multifilament to monofilament gangions in Greenland halibut longline fisheries.

Central Serous Chorioretinopathy in Elderly Patients Mimicking Occult Neovascular Age-Related Macular Degeneration.

PURPOSE: To describe elderly patients with central serous chorioretinopathy (CSCR) mimicking occult neovascular age-related macular degeneration (nAMD). MATERIALS AND METHODS: The records of 522 patients with initial diagnoses of nAMD over one year were reviewed to determine characteristics meeting diagnostic criteria for CSCR with three or more months of follow-up. Patients were evaluated by clinical examination, fluorescein angiography (FA) and optical coherence tomography (OCT). At the time of initial evaluation, patients were either monitored, treated with anti-VEGF therapy or with combination anti-VEGF and photodynamic therapy (PDT). When no response to anti-vascular endothelial growth factor (anti-VEGF) treatment was observed, the diagnosis of CSCR was favored and patients were observed with close follow-up. The Student's t-test was used for statistical analysis; a p-value < 0.05 was considered statistically significant. RESULTS: Eleven elderly patients met diagnostic criteria for CSCR among 522 patients initially diagnosed with nAMD. Average age was 75.9 years, and average follow-up was 16.9 months. Average presenting visual acuity was 20/50+2 (67.9 ± 5.9 ETDRS letters), and choroidal thickness was 232.0 ± 69.4 µm. After observation or treatment, the average vision improved to 20/40+ (70.5 ± 7.8 ETDRS letters, p=0.289). When intravitreal bevacizumab was given, no changes were observed for patients' neurosensory retinal detachments (NSRD). When NSRD changes were observed, they likewise did not correlate to the timing of anti-VEGF treatment. For patients who were monitored alone, one patient lost one line of vision, one gained one line, one gained two lines, and one gained three lines. One patient subsequently developed a choroidal neovascular membrane (CNVM) during initial follow-up with visual improvement after anti-VEGF treatment. Four patients developed CNVM overall with long term follow-up. CONCLUSION: CSCR in elderly patients can mimic occult CNVM, especially on FA. In this group, many patients were monitored without treatment, which typically resulted in stable or improved vision. Careful monitoring is required because of possible development of CNVM.

Rapid displacement of subretinal hemorrhage from a choroidal neovascular membrane with intravitreal C3F8 gas and face-down positioning.

PURPOSE: To describe a case of rapid displacement of subretinal hemorrhage (SRH) from a choroidal neovascular membrane (CNV) with intravitreal injection of C3F8 gas. OBSERVATIONS: A 66-year-old patient presented in clinic with count fingers (CF) vision from a fibrovascular scar in the right eye (OD) and 20/30 vision in the left eye (OS) with butterfly dystrophy. His left eye developed a CNV and was managed with monthly intravitreal anti-VEGF agents for 29 months. Five days after a ranibizumab treatment, the patient developed a moderate subfoveal hemorrhage. The vision decreased from 20/30 to 20/50. He elected to monitor the disease process. Eleven days later the vision decreased to 20/200, and he consented to intravitreal injection of 0.3 cc of 100% C3F8 with face-down positioning. The patient received an anterior chamber paracentesis to manage the intraocular pressure. The patient had near complete displacement of subretinal hemorrhage and fluid in less than 2 hours. He then had repeat OCT and fundus photos to document the rapid displacement. His vision returned to 20/30-2 twelve days later, at which point the subretinal fluid and blood had been completely displaced from the macula. CONCLUSIONS AND IMPORTANCE: The patient had rapid displacement of subretinal hemorrhage and fluid with intravitreal C3F8. New blood filling the space of pre-existing neurosensory fluid from the active CNV likely enhanced displacement. Timely intervention before stable clot formation was helpful for ease of displacement of the subretinal hemorrhage.

Elemental Composition, Phosphorous Uptake, and Characteristics of Growth of a SAR11 Strain in Batch and Continuous Culture.

In this study, a strain of SAR11 subgroup IIIa (termed HIMB114) was grown in seawater-based batch and continuous culture in order to quantify cellular features and metabolism relevant to SAR11 ecology. We report some of the first direct measurements of cellular elemental quotas for nitrogen (N) and phosphorus (P) for SAR11, grown in batch culture: 1.4 ± 0.9 fg N and 0.44 ± 0.01 fg P, respectively, that were consistent with the small size of HIMB114 cells (average volume of 0.09 µm3). However, the mean carbon (C) cellular quota of 50 ± 47 fg C was anomalously high, but variable. The rates of phosphate (PO4 3-) uptake measured from both batch and continuous cultures were exceptionally slow: in chemostats growing at 0.3 day-1, HIMB114 took up 1.1 ± 0.3 amol P cell-1 day-1, suggesting that <30% of the cellular P requirement of HIMB114 was met by PO4 3- assimilation. The mean rate of leucine incorporation, a measure of bacterial production, during late-log-phase growth of batch HIMB114 cultures was 0.042 ± 0.02 amol Leu cell-1 h-1 While only weakly correlated with changes in specific growth rates, the onset of stationary phase resulted in decreases in cell-specific leucine incorporation that were proportional to changes in growth rate. The rates of cellular production, respiratory oxygen consumption, and changes in total organic C concentrations constrained cellular growth efficiencies to 13% ± 4%. Hence, despite a small genome and diminutively sized cells, SAR11 strain HIMB114 appears to grow at efficiencies similar to those of naturally occurring bacterioplankton communities.IMPORTANCE While SAR11 bacteria contribute a significant fraction to the total picoplankton biomass in the ocean and likely are major players in organic C and nutrient cycling, the cellular characteristics and metabolic features of most lineages have either only been hypothesized from genomes or otherwise not measured in controlled laboratory experimentation. The dearth of data on even the most basic characteristics for what is arguably the most abundant heterotroph in seawater has limited the specific consideration of SAR11 in ocean ecosystem modeling efforts. In this study, we provide measures of cellular P, N, and C, aerobic respiration, and bacterial production for a SAR11 strain growing in natural seawater medium that can be used to directly relate these features of SAR11 to biogeochemical cycling in the oceans. Through the development of a chemostat system to measure nutrient uptake during steady-state growth, we have also documented inorganic P uptake rates that allude to the importance of organic phosphorous to meet cellular P demands, even in the presence of nonlimiting PO4 3- concentrations.

Clinical Outcomes After Unilateral Adrenalectomy for Primary Aldosteronism.

Importance: In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of antihypertensive medications with a subsequent decreased risk of cardiovascular and/or cerebrovascular morbidity and drug-induced adverse effects. Objective: To evaluate the change in BP and use of antihypertensive medications within an international cohort of patients who recently underwent surgery for primary aldosteronism. Design, Setting, and Participants: A cohort study was conducted across 16 referral medical centers in Europe, the United States, Canada, and Australia. Patients who underwent unilateral adrenalectomy for primary aldosteronism between January 2010 and December 2016 were included. Data analysis was performed from August 2017 to June 2018. Unilateral disease was confirmed using computed tomography, magnetic resonance imaging, and/or adrenal venous sampling. Patients with missing or incomplete preoperative or follow-up data regarding BP or corresponding number of antihypertensive medications were excluded. Main Outcomes and Measures: Clinical success was defined based on postoperative BP and number of antihypertensive medications. Cure was defined as normotension without antihypertensive medications, and clear improvement as normotension with lower or equal use of antihypertensive medications. In patients with preoperative normotensivity, improvement was defined as postoperative normotension with lower antihypertensive use. All other patients were stratified as no clear success because the benefits of surgery were less obvious, mainly owing to postoperative, persistent hypertension. Clinical outcomes were assessed at follow-up closest to 6 months after surgery. Results: On the basis of inclusion and exclusion criteria, a total of 435 patients (84.6%) from a cohort of 514 patients who underwent unilateral adrenalectomy were eligible. Of these patients, 186 (42.3%) were women; mean (SD) age at the time of surgery was 50.7 (11.4) years. Cure was achieved in 118 patients (27.1%), clear improvement in 135 (31.0%), and no clear success in 182 (41.8%). In the subgroup classified as no clear success, 166 patients (91.2%) had postoperative hypertension. However, within this subgroup, the mean (SD) systolic and diastolic BP decreased significantly by 9 (22) mm Hg (P < .001) and 3 (15) mm Hg (P = .04), respectively. Also, the number of antihypertensive medications used decreased from 3 (range, 0-7) to 2 (range, 0-6) (P < .001). Moreover, in 75 of 182 patients (41.2%) within this subgroup, the decrease in systolic BP was 10 mm Hg or greater. Conclusions and Relevance: In this study, for most patients, adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. Furthermore, a significant proportion of patients with postoperative, persistent hypertension may benefit from adrenalectomy given the observed clinically relevant and significant reduction of BP and antihypertensive medications.

Plastic Surgery's Contributions to Surgical Ethics.

We review Kevin Chung and colleagues' 2009 Plastic and Reconstructive Surgeryarticle, "A Systematic Review of Ethical Principles in the Plastic Surgery Literature," which shows that only 110 of the more than 100,000 plastic surgery articles clearly focus on ethical principles. The four fundamental ethical principles (i.e., respect for autonomy, beneficence, nonmaleficence, and justice) were differentially emphasized, with respect for autonomy being most common. Despite the number of ethical issues faced by plastic surgeons, this systematic review found that a relatively small fraction of the plastic surgery literature has focused on ethical principles. Here, we highlight the importance of this analysis and discuss how its findings might be extrapolated from plastic surgery ethics to surgical ethics writ large.

Greenland shark (Somniosus microcephalus) feeding behavior on static fishing gear, effect of SMART (Selective Magnetic and Repellent-Treated) hook deterrent technology, and factors influencing entanglement in bottom longlines.

The Greenland Shark (Somniosus microcephalus) is the most common bycatch in the Greenland halibut (Reinhardtius hippoglossoides) bottom longline fishery in Cumberland Sound, Canada. Historically, this inshore fishery has been prosecuted through the ice during winter but winter storms and unpredictable landfast ice conditions since the mid-1990s have led to interest in developing a summer fishery during the ice-free season. However, bycatch of Greenland shark was found to increase substantially with 570 sharks captured during an experimental Greenland halibut summer fishery (i.e., mean of 6.3 sharks per 1,000 hooks set) and mortality was reported to be about 50% due in part to fishers killing sharks that were severely entangled in longline gear. This study investigated whether the SMART (Selective Magnetic and Repellent-Treated) hook technology is a practical deterrent to Greenland shark predation and subsequent bycatch on bottom longlines. Greenland shark feeding behavior, feeding kinematics, and variables affecting entanglement/disentanglement and release are also described. The SMART hook failed to deter Greenland shark predation, i.e., all sharks were captured on SMART hooks, some with more than one SMART hook in their jaw. Moreover, recently captured Greenland sharks did not exhibit a behavioral response to SMART hooks. In situ observations of Greenland shark feeding show that this species uses a powerful inertial suction mode of feeding and was able to draw bait into the mouth from a distance of 25-35 cm. This method of feeding is suggested to negate the potential deterrent effects of electropositive metal and magnetic alloy substitutions to the SMART hook technology. The number of hooks entangled by a Greenland shark and time to disentangle and live-release a shark was found to increase with body length.

Recurrence Rate of Choroidal Neovascularization in Neovascular Age-Related Macular Degeneration Managed with a Treat-Extend-Stop Protocol.

PURPOSE: To examine visual outcomes and recurrence rates in patients with choroidal neovascularization (CNV) resulting from neovascular age-related macular degeneration (nAMD) with successful cessation of therapy using a treat-extend-stop (TES) protocol. DESIGN: Cohort study. PARTICIPANTS: Three hundred eighty-five eyes of 321 patients with nAMD identified in clinical practice and treated with a TES protocol between 2008 and 2016. METHODS: Retrospective review of patients initially managed with 3 anti-vascular endothelial growth factor (VEGF) injections at 4-week intervals; treatment was extended if the macula remained "dry" based on spectral-domain OCT, using a TES protocol. Treatment was stopped if warranted and was reinitiated if there was a new or recurrent CNV. MAIN OUTCOME MEASURES: Percentage of eyes meeting criteria for treatment cessation and percentage experiencing recurrence after treatment cessation, average time to recurrence, and visual function at each of these time points, including recovery of vision after reinstitution of therapy. RESULTS: A total of 37.3% of eyes met criteria for treatment cessation, with an average follow-up of 27 months. Overall recurrence rate was 29.4% at a mean time interval of 14 months for patients who stopped anti-VEGF therapy. In those patients whose CNV recurred, 54.8% recurred in the first year and 26.2% recurred in the second year after treatment was stopped. Average initial vision was 20/70 and improved to 20/50 (P < 0.001) after patients met criteria for cessation of therapy. A mean loss of vision occurred with recurrence (20/60; P < 0.003). However, once therapy was reinitiated, visual acuity recovered to the level at TES completion and wasn't statistically different than at final treatment (20/50; P < 0.34). Overall, 54.8% of eyes that demonstrated a recurrence of CNV had final vision of 20/40 or better compared with 45% of patients at the time of recurrence and 60% before recurrence. CONCLUSIONS: After completing the TES protocol, 29.4% of patients showed recurrence of CNV. Patients who lost vision with recurrence recovered to the level of vision at treatment cessation with reinstitution of therapy. Patients managed with a TES protocol may stop therapy successfully and maintain improved vision even if the CNV recurs.