Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers.

Objective: Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes. Background: Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes. Methods: Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses. Results: After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions. Conclusions: VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.

75 Years of the Historic Partnership Between the VA and Academic Medical Centers.

Background: The US Department of Veterans Affairs (VA) conducts the largest health professions education program in the country in partnership with academic medical, nursing, and associated health programs across the nation. After World War II, the VA was pressed to meet the increasing population of veterans needing health care and faced challenges in recruiting clinicians. Observations: The passage of 2 legislative actions, the Servicemen's Readjustment Act and Public Law 79-293, and a key policy memorandum set the foundation for the partnership between the VA and academic medical centers that led to improved medical care for veterans and expansion of health professions education for the VA and the nation. Conclusions: Since passage of these actions, the VA-academic health professions education partnership has grown to involve 113,000 trainees rotating through 150 VA medical centers annually from more than 1400 colleges and universities.

The Role of Screening for Asymptomatic Ocular Inflammation in Sarcoidosis.

PURPOSE: To determine the utility of routine screening ophthalmic exam in patients with systemic sarcoidosis and no history of uveitis. METHODS: Prospective, single-center, observational study conducted at Northwestern University from October 11, 2012 to October 1, 2020 of new patients with biopsy-proven systemic sarcoidosis and no history of uveitis, referred by medical subspecialists for screening ophthalmic exam. RESULTS: Forty-nine patients, with mean age of 51 ± 8.7 years, 59% female, 47% African American, 43% Caucasian, were enrolled. The majority (55%) had no ocular symptoms. The most common location of ocular involvement was the adnexa, in the form of conjunctival nodules (62%) and aqueous tear deficiency (23%). Intraocular inflammation was detected in 6 patients (13%); only 2 had active disease requiring treatment (4%). No asymptomatic patient had ocular involvement necessitating treatment. CONCLUSION: Screening exams are indicated in sarcoidosis patients with ocular symptoms. No benefit of screening was demonstrated in asymptomatic patients.

Automated Pupillometry as an Adjunct to Clinical Examination in Patients With Acute Vision Loss.

BACKGROUND: Despite automated pupillometry's (AP) improved detection of relative afferent pupillary defects (RAPDs) compared with the Swinging Flashlight Test (SFT), AP remains uncommon in clinical practice. This study examined barriers to routine use of AP in evaluation of acute vision loss. METHODS: (1) Ophthalmologists and optometrists' perceptions of AP were captured via electronic survey. (2) Ophthalmologists were presented with clinical vignettes to assess their use of AP in clinical decision-making. (3) Patients presenting with decreased vision to an ophthalmology urgent care clinic underwent manual SFT and AP screening to evaluate ophthalmologists' perceptions of the device. RESULTS: Surveys indicated that clinicians were "neutral" to "somewhat likely" to use AP. In clinical vignettes, more physicians proceeded with workup for optic nerve pathology when presented with an RAPD by AP than SFT (77% vs 26%, P = 0.003). When SFT and AP results were discordant, more physicians proceeded with workup for optic nerve disease when AP was positive and SFT was negative than vice versa (61% vs 18%, P = 0.008). In the clinical study of 21 patients, 50% of RAPDs detected by AP were not detected by SFT, although ophthalmologists rated AP's usefulness as only "neutral" to "somewhat useful." CONCLUSION: Clinicians value pupillary examination and trust AP over SFT; however, widespread adoption and perceived value of AP may depend on its impact on clinical outcomes. Within a comprehensive diagnostic device, AP may be an important tool, but is not necessary to screen for optic nerve disease or evaluate acute vision loss.

Update on sarcoidosis.

PURPOSE OF REVIEW: Sarcoidosis is a multisystem inflammatory disease, characterized by the presence of noncaseating granulomas. Ocular inflammation is often the first manifestation of the disease, and uveitis can be the driving force for treatment. The goal of this review was to provide an update on the relationship between ocular and systemic disease, with a particular focus on cardiac sarcoidosis. RECENT FINDINGS: Chest radiograph remains the best imaging tool for sarcoidosis, although newer modalities, such as whole-body PET scan, cardiac MRI, and chest computed tomography (CT), may provide additional valuable information in select populations. Ocular sarcoidosis is a marker for vascular endothelial dysfunction and increased arterial rigidity. Choroidal involvement is associated with an increased risk of cardiac disease requiring intervention. Cardiac disease continues to be underdiagnosed in patients with sarcoidosis, although it remains a leading cause of death. SUMMARY: Sarcoidosis is a systemic disease, and ophthalmologists should continually assess patients for extraocular manifestations. Although no screening guidelines exist, baseline ECGs on asymptomatic patients might identify those at risk for adverse cardiac events. Patients with symptoms of cardiac disease, including palpitations, chest pain, and dyspnea, should have an evaluation by a cardiologist.

Sarcoidosis in the national veteran population: association of ocular inflammation and mortality.

PURPOSE: To describe the distribution of ocular sarcoidosis in the veteran population and to determine the association between ocular disease and all-cause mortality. DESIGN: Retrospective review. METHODS: The Veterans Health Administration National Patient Care Database information on medical diagnoses, date of diagnosis, age, race, gender, and Veterans Administration medical center station number for site-specific calculations for fiscal years 2010 through 2012 was collected. Mortality data were obtained from the Beneficiary Identification Records Locator Subsystem. The patient cohort was identified with a primary diagnosis of sarcoidosis using International Classification of Disease, ninth edition, code of 135 in outpatient treatment files for the study period. The sarcoidosis patients were divided into those with uveitis or orbital inflammation (defined as ocular inflammation for this study) and those without uveitis or orbital inflammation. Survival analysis was performed using the Cox proportional hazard method. MAIN OUTCOME MEASURE: Association between ocular inflammation and 1-year mortality. RESULTS: Of 15 130 subjects with sarcoidosis, 3364 (22.2%) were evaluated in an eye clinic within a Veterans Administration Medical Center. Most patients were diagnosed with anterior uveitis (n = 1013; 80.7% of ocular inflammation), and the least common diagnosis was orbital granuloma (n = 28; 2.2% of ocular inflammation). Male gender was protective to the development of uveitis (estimate, 0.76; 95% confidence interval, 0.65-0.88; P = 0.0005). The overall 1-year all-cause mortality for all patients with a diagnosis of sarcoidosis was 2.0%. Ocular inflammation was associated with a decrease in 1-year all-cause mortality (simple model: hazard ratio, 0.36; P = 0.0015; complex model: hazard ratio, 0.35; P = 0.013). CONCLUSIONS: Veterans with ocular inflammation had significantly lower 1-year all-cause mortality than those without documented ocular inflammation. The reason for this finding remains to be established.

Sarcoidosis: sex-dependent variations in presentation and management.

Sarcoidosis is an inflammatory disease with a wide range of clinical presentations. The manifestations and prognosis in sarcoidosis are dependent upon not only organ involvement but also age and sex. The purpose of this review is to describe the systemic and ocular manifestations of sarcoidosis with a specific focus on sex-dependent difference in presentation and management. Sarcoidosis is more common in women, particularly in patients who present after age of 50 years. Women with sarcoidosis are more likely to develop cystoid macular edema and the mortality rate is higher than that of men.

Correlation between clinical signs and optical coherence tomography with enhanced depth imaging findings in patients with birdshot chorioretinopathy.

IMPORTANCE: Birdshot chorioretinopathy (BCR) is a bilateral posterior uveitis that typically requires aggressive therapy to prevent loss of vision. Clinical signs of disease activity may be subtle and visual acuity is often preserved despite significant loss of visual function. Optical coherence tomography with enhanced depth imaging (OCT-EDI), a new technology that allows visualization of structures posterior to the retinal pigment epithelium, may be a useful tool to monitor disease activity in these patients. OBJECTIVE: To determine the correlation between symptoms and signs of disease activity in BCR and specific findings on OCT-EDI. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 14 patients treated for BCR in the uveitis clinic at Northwestern University. All patients underwent OCT-EDI (58 scans). Clinical symptoms of photopsias/vibrating vision and signs of macular edema, vitreous haze, and retinal vasculitis were graded; a second grading scale was developed for the evaluation of OCT-EDI. Individual scans of each eye of each patient at each point were graded in a masked fashion. EXPOSURE: Optical coherence tomography with EDI in BCR. MAIN OUTCOMES AND MEASURES: Spearman rank correlation of clinical measures to OCT-EDI measures. RESULTS: The most frequent score in each clinical category was 0 (inactive). In those BCR patients with symptoms (21 eye examinations), the subjective complaint of photopsias/vibrating vision was associated with the objective finding of suprachoroidal fluid on OCT-EDI (P = .003), and the frequency and severity of photopsias correlated with the thickness of the fluid band (Pearson product moment correlation, 0.39). Two of the clinical markers of disease activity measured in this study (vasculitis and vitreous haze) also showed a significant Spearman rank correlation with the presence and amount of suprachoroidal fluid on OCT-EDI (vasculitis, 0.45 [P < .001]; vitreous haze, 0.59 [P < .001]). CONCLUSIONS AND RELEVANCE: The presence of suprachoroidal fluid on OCT-EDI appears to correlate with the subjective complaints of photopsias in patients with BCR and other more easily assessed clinical features such as vasculitis and vitreous haze. Optical coherence tomography with EDI may be a useful tool for objective monitoring of BCR.

TNF inhibition for ophthalmic indications: current status and outlook.

BACKGROUND: Tumor necrosis factors (TNF) are a group of cytokines that play a role in systemic inflammation, stimulating the acute phase reaction. They are involved in systemic rheumatologic conditions such as rheumatoid arthritis and juvenile idiopathic arthritis, as well as ocular inflammatory conditions in the uveitis spectrum. Several drugs were developed to inhibit the action of TNF, thereby reducing inflammation. The three most commonly used TNF inhibitors in the US are etanercept, infliximab, and adalimumab. Newer drugs include certolizumab and golimumab. In this review, we discuss the differences in the mechanism of action, route of administration, indication, and efficacy of TNF inhibitors used in the treatment of ocular inflammation. METHODS: A review of the literature in the PubMed, MEDLINE, and Cochrane databases was conducted to identify clinical trials, comparative studies, case series, and case reports describing the use of tumor necrosis factor inhibitors in uveitis therapy. The search was limited to primary reports published in English with human subjects from 1990 to the present, yielding 5,238 manuscripts. In addition, referenced articles from the initial searches were hand searched to identify additional relevant reports. After title and abstract selection, duplicate elimination, and manual search, 69 papers were selected for analysis. Exclusion criteria included review articles and case reports on the efficacy of etanercept, infliximab, and adalimumab. Manuscripts with fewer than 20 study subjects were excluded if other larger studies existed on the use of the same drug for a particular indication. Studies with <6 months of patient follow-up were also excluded, except in the case where no other data were available. Articles meeting these criteria were then reviewed by the three authors for inclusion in this review. RESULTS: Tumor necrosis factor inhibitors have been shown to decrease inflammation associated with a number of rheumatologic conditions. Three of the five commercially available TNF inhibitors-etanercept, infliximab, and adalimumab-have been studied for their efficacy in treatment of ocular inflammation. Etanercept appears to be inadequate in controlling ocular inflammation and is not recommended for the treatment of uveitis. Infliximab and adalimumab, however, have shown encouraging results in multiple trials. Serious potential side effects such as infection, including reactivation of latent tuberculosis, malignancy, and demyelinating disease, may limit the use of TNF inhibitors in uveitis. Proper screening of patients prior to initiating these therapies may decrease these risks. DISCUSSION: Early success with infliximab and adalimumab has paved the way for new TNF inhibitors and other corticosteroid-sparing drugs to emerge in the treatment of ocular inflammation. Future studies are on the horizon to determine the long-term safety and efficacy of newer TNF inhibitors such as certolizumab and golimumab.

Bilateral simultaneous-onset nongranulomatous acute anterior uveitis: clinical presentation and etiology.

OBJECTIVE To describe the etiology and outcome of patients with simultaneous-onset nongranulomatous bilateral acute anterior uveitis. METHODS The medical records of patients who presented to a single tertiary care center with simultaneous-onset nongranulomatous bilateral acute anterior uveitis between January 1990 and May 2010 were retrospectively reviewed; the clinical presentation, results of diagnostic testing, and outcome data are described. RESULTS A total of 4288 new patients with uveitis were evaluated by the Uveitis Service at the University of Illinois at Chicago Eye and Ear Infirmary between January 1990 and May 2010. Of these new patients, 44 (1%) presented with simultaneous-onset nongranulomatous bilateral acute anterior uveitis. The most common etiologies were postinfectious or drug-induced uveitis (23 of 44 patients [52%]) and idiopathic uveitis (15 patients [34%]). Tubulointerstitial nephritis and uveitis syndrome, HLA-B27-associated uveitis, inflammatory bowel disease, and Kawasaki disease each made up fewer than 5% of diagnoses. Overall, this group of patients was younger than the entire cohort of new patients with uveitis who were evaluated during the same time period (P = .002). For 14 of the 15 patients with at least a year of follow-up (93%), the disease duration was limited (<3 months). Of these 14 patients, 7 (50%) developed recurrent disease, with an average time to first recurrence of 20 months (range, 7.5-40 months) after resolution of the initial inflammatory episode. CONCLUSIONS Simultaneous-onset nongranulomatous bilateral acute anterior uveitis is a rare clinical entity that is more common in younger patients and is most frequently associated with recent infection and/or systemic antibiotic use. Tubulointerstitial nephritis and uveitis syndrome should also be considered as a diagnosis. Diagnostic evaluation should include serum antistreptolysin-O titers, HLA-B27 antigen, and urine ß2 microglobulin levels because these may reveal systemic disease that requires therapy.

Behçet uveitis in the American midwest.

PURPOSE: Behçet disease is most common in Asia, the Middle East, and North Africa (Silk Road). The authors compare clinical presentation and course of Behçet uveitis in patients of Silk Road and non-Silk Road descent. METHODS: Retrospective review of patients evaluated at the University of Illinois January 1983-July 2010. RESULTS: Of 6134 new uveitis patients, 36 with available medical records met diagnostic criteria for Behçet disease. Ten (28%) were of Silk Road origin. Retinal vasculitis was the most common ocular manifestation, followed by panuveitis and retinitis. Ocular and systemic manifestations were similar between groups. Seventy-eight percent were treated with systemic immunosuppression, which reduced inflammatory attack rate. CONCLUSIONS: Behçet disease is uncommon in the midwestern United States. Three-quarters of patients in this series were not of Silk Road descent. Physicians should consider the diagnosis of Behçet disease in any patient with retinal vasculitis or uveitis regardless of ethnicity.

Chronic anterior uveitis in common variable immunodeficiency.

PURPOSE: To describe patients with uveitis and common variable immunodeficiency (CVID). DESIGN: Retrospective observational case series. METHODS: Retrospective review of patients with uveitis and CVID, specifically focusing on clinical presentation and treatment. RESULTS: Three patients with CVID and uveitis were identified. All patients had chronic anterior uveitis. Two required systemic immunosuppression to control uveitis, with one of these patients relapsing after discontinuation of immunoglobulin therapy. One improved on topical steroid therapy; however, follow-up on this patient did not extend beyond 4 months. CONCLUSIONS: CVID can be associated with chronic anterior uveitis. Patients presenting with uveitis should be questioned about frequent infections and autoimmune disorders as part of the uveitis evaluation.

Posterior syphilitic uveitis: clinical characteristics, co-infection with HIV, response to treatment.

PURPOSE: To describe the characteristics and clinical course of patients with active posterior syphilitic uveitis evaluated between 1991 and 2009. METHODS: Retrospective chart review. RESULTS: Thirteen patients with active posterior syphilitic uveitis were identified at a single institution. All were men, and all with available data were men having sex with men (MSM). Ten of 12 (83%) with available data were HIV positive. Four (31%) had a history of syphilis. Clinical findings included infiltrative retinitis, necrotizing retinitis and optic neuritis. Two of 8 patients tested (25%) had a positive Venereal Disease Research Laboratory test in the cerebrospinal fluid. Treatments included intravenous penicillin, intramuscular penicillin and intramuscular ceftriaxone. All treated cases improved and, in some cases, inflammatory lesions completely resolved without scarring. CONCLUSIONS: In this series, syphilitic posterior uveitis presented only in men, and all with available data were MSM. The majority were concomitantly infected with HIV. Clinical presentations varied and all patients demonstrated either significant improvement or complete resolution of inflammation.

Presentation and outcome of patients with punctate inner choroidopathy at a tertiary referral center.

PURPOSE: To describe the clinical course of patients with punctate inner choroidopathy seen at the University of Illinois, with emphasis on development of choroidal neovascularization (CNV). METHODS: Patients with a diagnosis of punctate inner choroidopathy were identified retrospectively. The diagnosis was made clinically based on findings of multiple, small "punched-out" lesions in the posterior pole without intraocular inflammation. Medical records were evaluated for evidence of CNV. RESULTS: Twelve patients with a diagnosis of punctate inner choroidopathy were identified. Average age at presentation was 32 years (range, 24-52 years). Eleven were women, and 11 were white. Eleven patients had available refractive data: 10 were myopic. Eight had CNV at initial presentation, and 1 later developed CNV. Eight had follow-up averaging 4 years (range, 1.4-9.6 years). Of these, five had CNV at initial presentation, and five developed new CNV. Four had multiple CNV membranes. All 6 patients with follow-up of ≥ 3 years had visual acuity at 3 years postpresentation of >20/40 in at least 1 eye. Four had visual acuity >20/40 bilaterally. CONCLUSION: Of punctate inner choroidopathy patients in this series, 75% had CNV, and more than 30% developed multiple neovascular membranes. With treatment, all patients with follow-up of ≥ 3 years had >20/40 vision in at least 1 eye.

Clinical features and diagnostic evaluation of biopsy-proven ocular sarcoidosis.

OBJECTIVES: To compare the clinical characteristics of uveitic sarcoidosis in African American and non-African American patients with biopsy-proven sarcoidosis and to determine which diagnostic test results were most often suggestive of sarcoidosis in patients who were ultimately diagnosed as having the disease. METHOD: Retrospective review of consecutive patients with biopsy-proven sarcoidosis evaluated by the uveitis service between 1989 and 2009. RESULTS: A total of 63 patients with uveitic sarcoidosis were identified: 39 (62%) were African American (P <.001) and 43 (68%) were female. African American patients presented at an earlier age (P <.001) and were more likely to have granulomatous anterior segment inflammation (P <.001). The levels of serum markers angiotensin-converting enzyme and lysozyme were elevated in 40% and 42% of patients tested, respectively. The levels of at least 1 marker were elevated in 18 patients (58%). Imaging study results were reported as consistent with sarcoidosis in 25 patients (69%) who underwent chest radiography and in 19 patients (100%) who underwent computed tomography. CONCLUSIONS: In this series, African American patients were more likely to be diagnosed as having uveitic sarcoidosis and to present with uveitis if they were younger than 50 years. White patients were more likely to present when they were older than 50 years. A clinical picture that included granulomatous anterior segment inflammation was more common in African American patients. The use of serum markers (angiotensin-converting enzyme and lysozyme) positively identified more patients with biopsy-proven sarcoidosis when used in combination with appropriate chest imaging.

Pediatric uveitis secondary to probable, presumed, and biopsy-proven sarcoidosis.

PURPOSE: To describe pediatric patients with uveitis diagnosed as having sarcoidosis. METHODS: Medical records of pediatric patients evaluated between 1987 and 2008 were reviewed to identify those with ocular inflammation in whom a diagnosis of sarcoidosis was considered. A classification system including ocular findings and results of laboratory testing was devised and used to classify likelihood of sarcoidosis. RESULTS: Four hundred sixty children younger than 17 years were evaluated. Based on the classification system designed, 13 patients (2.8%) had probable, presumed, or definite sarcoidosis. The mean age was 11.6 years (range: 5 to 16 years). Elevated angiotensin-converting enzyme was measured in 6 patients and lysozyme in 5 patients. Five of 12 patients in whom chest imaging was performed had signs of sarcoidosis. Anterior segment involvement was non-granulomatous more often than granulomatous. Seven patients had multifocal choroiditis and 4 patients had retinal periphlebitis. CONCLUSION: Ocular sarcoidosis is uncommon in children, even at a tertiary referral center. Pulmonary involvement was detected in slightly less than half of the patients who had imaging, in contrast to previous reports of almost universal lung involvement in children 8 to 15 years old. The classification system of presumed, probable, and definite sarcoidosis presented may be useful in clinical practice.

Etiologies of chronic anterior uveitis at a tertiary referral center over 35 years.

PURPOSE: To describe the epidemiology of chronic anterior uveitis (CAU) at a tertiary center over 35 years. METHODS: Data regarding etiology of CAU was collected from medical records of patients evaluated between 1973-2007. Relative frequencies of each diagnosis of CAU were calculated. Linear regression analyses were performed on the common types of CAU. RESULTS: 5970 patients were evaluated between 1973-2007; 31% carried a diagnosis of CAU. Idiopathic disease was diagnosed in 54% of patients (39 to 72% annually), ocular sarcoidosis in 14% of patients (2 to 20% annually), Fuchs heterochromic iridocyclitis (FHI) in 12% of patients (4 to 22% annually), and juvenile idiopathic arthritis (JIA) in 6% of patients (2 to 13% annually). The frequency of diagnosis of idiopathic CAU decreased over time, with no significant change for sarcoidosis, FHI or JIA. An increase in frequency of diagnosis was observed for HLA-B27-related disease and uveitis related to multiple sclerosis and inflammatory bowel disease. CONCLUSIONS: The relative frequency of idiopathic disease has decreased over the past 35 years at our center. This may be related to an increase in the diagnosis of CAU associated with HLA-B27 positivity, inflammatory bowel disease (including family history) and multiple sclerosis. Despite the advances over the last 35 years, idiopathic disease still comprises at least 39% of our patients with CAU each year.