The association of breast surgery ASPIRE: breast pain pathway rapid evaluation project - study protocol.

Background: Breast pain accounts for 20-40% of new referrals to breast units in the UK and these patients have a very low risk of breast cancer. Patients have previously been assessed in resource-intensive, cancer-exclusion, one stop clinics, which are now failing to meet government targets due to excessive demand. UK Breast units are increasingly piloting Breast Pain-only Pathways (BPP) to assess these patients, and there is no consensus for the optimal pathway. The aim of this prospective multicentre study is to assess the safety and patient satisfaction of different BPPs to inform future BPP design and implementation. Methods: All UK breast units will be invited to join the ASPIRE study between January 2023 and December 2023. Units with a BPP are invited to submit their pathway for evaluation; and those without a BPP who see patients with breast pain-only in a one stop clinics setting are also invited to join the study to evaluate the traditional pathway model concurrently. Patient satisfaction assessments will be collected after their initial consultation and patient outcomes, including subsequent cancer diagnosis, will be followed up at 12 months to determine if they have cancer diagnosis after discharge to assess pathway safety.

A Case of Chronic Intranasal Cocaine Abuse Masquerading and Exacerbating Underlying Orbital IgG4-Related Disease.

Chronic cocaine use may lead to widespread intranasal inflammation and necrosis. Cases of cocaine use affecting the orbit have been reported in the literature with a clinical spectrum ranging from inflammation-induced p-anti-cytoplasmic neutrophil autoantibodies positive vasculitis to severe midline destructive lesions resulting in orbital apex syndrome. Here, we present a case of chronic intranasal cocaine abuse with midline destruction that initially obscured diagnosis of, and is hypothesized to have exacerbated, underlying IgG4-Related Disease (IgG4-RD) of the orbit over a 2-year period.

Hydrodynamic Relaxation in a Strongly Interacting Fermi Gas.

We measure the free decay of a spatially periodic density profile in a normal fluid strongly interacting Fermi gas, which is confined in a box potential. This spatial profile is initially created in thermal equilibrium by a perturbing potential. After the perturbation is abruptly extinguished, the dominant spatial Fourier component exhibits an exponentially decaying (thermally diffusive) mode and a decaying oscillatory (first sound) mode, enabling independent measurement of the thermal conductivity and the shear viscosity directly from the time-dependent evolution.

Management of periocular cutaneous squamous cell carcinoma with perineural invasion: a case series and literature review.

PURPOSE: To review and elucidate the complex, multimodal management of periocular cutaneous squamous cell carcinoma (SCC) with perineural invasion (PNI), and offer practical, evidence-based patient care recommendations. METHODS: Three exemplary cases of high-risk periocular cutaneous SCC with PNI were selected from a single surgeon's experience. The clinical courses, management, and clinical outcomes, with follow-up intervals of 19, 19, and 24 months after presentation, were reviewed. The English-language literature on PNI, with attention to the management of cutaneous SCC of the head and neck (SCCHN), was reviewed. RESULTS: PNI of cutaneous SCCHN portends aggressive tumor behavior and a worsened prognosis. Treatment is multimodal, with varied combinations of surgical excision, radiotherapy (RT), and systemic chemotherapy. Retrospective reports from multiple institutions involve heterogenous patient populations, treatment strategies, and confounding variables that preclude formulation of a standardized treatment paradigm. Newer, comparative studies of advanced RT techniques (e.g., hyper-fractionation), novel systemic chemotherapeutic agents (e.g., cetuximab, cemiplimab), and varied integrative regimens are providing additional insights. Prompt initiation of adjuvant therapies (within 6-8 weeks of surgery), and careful evaluation of lymphatic basins can increase oncologic control. Utilizing deep-tissue fixation of advancement flaps and eyelid stabilization can enhance functional and aesthetic results. CONCLUSIONS: Management of cutaneous SCC with PNI remains complex and in most cases requires combined-modality therapy directed by a multidisciplinary tumor board. With novel therapies and new treatment patterns, optimal combinations and intensities of individual modalities require further elucidation. The oculofacial plastic surgeon plays a pivotal role - in diagnosis, coordination of interdisciplinary management, thoughtful surgical reconstruction, and postoperative surveillance.

Aesthetic Eyelid Measurements of "Beautiful People": Gender Differences and Application for Thyroid Eye Disease Patients.

There remains a paucity of studies investigating measurements of periocular structures of people popularly seen as "beautiful." Such measurements may be helpful in establishing postoperative goals and measuring aesthetic outcomes. This study (1) identifies aesthetic measurements of the periocular structures in idealized celebrities, (2) determines gender differences in such measurements, and (3) compares these measurements to patients who underwent surgical repair of upper eyelid retraction associated with thyroid eye disease. METHODS: Digital analysis of 38 celebrity photographs in People's "Most Beautiful People" and "Sexiest Man Alive" was performed to measure image-derived (denoted with an "i") margin reflex distance (iMRD1), tarsal platform show (iTPS), brow fat span (iBFS), and iTPS:iBFS ratio. The same analysis was used for 35 women who underwent surgical repair for thyroid eye disease-related upper eyelid retraction. RESULTS: Significant gender differences (P < 0.05) were observed in celebrity metrics, with women having higher upper eyelids (longer iMRD1) (3.30 mm versus 2.50 mm), longer iTPS measurements (3.90 mm versus 2.50 mm), and larger iTPS:iBFS values (0.31 versus 0.20). Postoperative thyroid eye disease patients had significantly higher upper eyelids (longer iMRD1s) (4.80 mm versus 3.30 mm), longer iTPS (5.10 mm versus 3.90 mm), and larger iTPS:iBFS (0.37 versus 0.31) than celebrities. CONCLUSIONS: There are significant gender differences in the periocular metrics of "beautiful people." Optimal aesthetic outcomes may be more effectively obtained by achieving a preferred range of ratios than by relying on independent measurements. Although aesthetic outcomes are multi-factorial, measurements of "beautiful" people provide helpful guidelines to gauge aesthetic outcomes.

Survival outcomes of elderly patients referred to the lower gastrointestinal 2-week wait service.

AIM: The benefit to elderly patients (≥80 years old) of referral to the resource-intensive lower gastrointestinal 2-week wait (LGI-2WW) pathway is unknown. The aim of this study was to investigate the survival outcome of elderly patients referred to a LGI-2WW service. METHOD: This study comprised a retrospective analysis of a prospectively gathered database of patients referred to a single-centre LGI-2WW service and conformed to STROBE guidelines. The primary outcome was all-cause mortality. Statistical analysis was performed with the chi-square test and Kaplan-Meier survival curves compared with the generalized log-rank test. RESULTS: A total of 10 155 patients referred to the LGI-2WW service between 1 January 2015 and 31 December 2018 were analysed; median follow-up was 37.0 months (range 0-66 months). Six hundred and ninety one cancers were diagnosed (6.8% detection rate); 551 (80%) of these were lower GI cancers (LGICas) [517 (75%) colorectal; 34 (5%) anal]. Forty per cent of LGICas were diagnosed via the LGI-2WW service. Patients aged ≥80 years with LGICa were more likely to be treated with palliative intent [age <80 years, 92/360 (26%) vs. age ≥80 years, 105/191 (55%); p < 0.001]. LGICa patients aged <85 years had a survival difference between those treated with curative intent (LGICa-Cur) or palliative intent (LGICa-Pal) (median survival for patients aged 80-84 years: LGICa-Cur 57 months vs. LGICa-Pal 15 months; p < 0.001). Patients aged ≥85 years did not have any survival difference by treatment intent (median survival for patients aged 85-89 years: LGICa-Cur 31 months vs. LGICa-Pal 16 months; p = 0.062; median survival for patients aged ≥90 years: LGICa-Cur 14 months vs. LGICa-Pal 16 months; p = 0.703). CONCLUSION: Patients with LGICa aged ≥85 years have similar survival whether treated with curative or palliative intent. This can inform management discussions with patients and LGI-2WW referral pathway prioritization approaches.

Measuring the Hydrodynamic Linear Response of a Unitary Fermi Gas.

We directly observe the hydrodynamic linear response of a unitary Fermi gas confined in a box potential and subject to a spatially periodic optical potential that is translated into the cloud at speeds ranging from subsonic to supersonic. We show that the time-dependent change of the density profile is sensitive to the thermal conductivity, which controls the relaxation rate of the temperature gradients and hence the responses arising from adiabatic and isothermal compression.

Intimate partner violence as a mechanism of traumatic ocular injury in women.

OBJECTIVE: Determine the prevalence of intimate partner violence (IPV) as a mechanism of traumatic ocular injury in women, typical injury patterns, and the clinical course of affected patients. Encourage IPV screening and safety assessment in patients presenting with characteristic ocular trauma. METHODS: Medical records of 211 female patients with traumatic ocular injuries evaluated at the University of Iowa Hospitals and Clinics between January 1995 and January 2015 were reviewed to determine the rate of IPV as a mechanism of ocular trauma. Twenty-one patients were excluded due to no documented trauma. RESULTS: Leading causes of traumatic ocular injuries in the 190 female patients included were accidental trauma with an inanimate object (n = 70/190, 36.8%), falls (n = 52/190, 27.4%), motor vehicle collisions (n = 21/190, 11.1%), and assault (n = 16/190, 8.4%). In 2.1% of cases (n = 4/190), no mechanism of traumatic injury was documented. Assault was the fourth leading mechanism of injury accounting for 8.4% of cases (n = 16/190), with IPV accounting for more than one third of cases with a documented perpetrator (n = 5/13). No perpetrator was documented in 18.8% (n = 3/16). All 5 patients with IPV-related injuries sustained scleral laceration or rupture; 4 out of 5 patients had no light perception vision and ultimately required enucleation. CONCLUSION: IPV is an important mechanism of traumatic ocular injury. IPV-associated injuries tend to be severe in nature, as demonstrated by the high rate of globe laceration or rupture and subsequent enucleation in the study population. By appropriate screening and referral, ophthalmologists have an opportunity to redirect a potentially devastating course.

Upper Eyelid Response to Topical 0.5% Apraclonidine.

PURPOSE: To describe the change in upper eyelid position in a self-reportedly normal population after the administration of topical 0.5% apraclonidine in each eye. METHODS: One hundred self-reportedly normal subjects received a 1-time administration of topical 0.5% apraclonidine in each eye. Digital photographs were taken at baseline and then 30 and 45 minutes following apraclonidine instillation. Marginal reflex distance 1 was determined via image analysis of acquired digital photographs (image-derived measurements are given the prefix "i" in this study). The horizontal corneal diameter was used as a constant measurement scale in each photograph. RESULTS: The mean increase in i-marginal reflex distance 1 post-administration of 0.5% apraclonidine was +0.70 ± 0.60 mm (range, -0.94 to +2.66 mm) after 30 minutes and +0.68 ± 0.59 mm (range, -0.69 to +2.54 mm) after 45 minutes. Of the 200 total eyelids in 100 subjects, 181 (90.5%) had an increase in i-marginal reflex distance 1 at 30 minutes. Of the 100 subjects, 85 (85%) had a bilateral increase in i-marginal reflex distance 1, 4 (4%) had a bilateral decrease, and 11 (11%) had a unilateral increase with a contralateral decrease. CONCLUSIONS: Given its predominant small-amplitude upper eyelid elevating effect, topical apraclonidine may be a useful off-label alternative treatment for mild upper eyelid ptosis and in eyelid asymmetry due to eyelid retraction through use in the contralateral eye.

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

PURPOSE: To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis. METHODS: A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined. RESULTS: In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair. CONCLUSIONS: Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.

Rethinking Our Definition of Postoperative Success: A Comparative Analysis of Three Upper Eyelid Retraction Repair Techniques Using Novel Metrics to Capture Functional and Aesthetic Outcomes.

PURPOSE: To compare 3 upper eyelid retraction repair techniques and introduce novel metrics, which enhance the analysis of postoperative aesthetic outcomes. METHODS: Retrospective review with Image J 1.48 digital analysis of patients who underwent repair of thyroid-related upper eyelid retraction at the University of Iowa from 1996 to 2014 via 1 of 3 surgical techniques, septum-opening levator recession with Muellerectomy, modified septum-preserving levator recession with Muellerectomy, and modified septum-preserving full-thickness blepharotomy, was conducted. Photographs were obtained preoperatively, 3 to 6 months postoperatively, and at last follow up (>6 months) and evaluated by digital image analysis (denoted by "i"). Outcome measures assessed were marginal reflex distance (iMRD1), temporal-to-nasal ratio, tarsal platform show (iTPS), pupil to visible eyelid crease, brow fat span (iBFS), tarsal platform show to brow fat span ratio (iTPS:iBFS), and tarsal platform show minimizing power (iTPS-minimizing power). RESULTS: A total of 121 eyelids (28 septum-opening levator recession with Muellerectomy, 66 septum-preserving levator recession with Muellerectomy, and 27 septum-preserving full-thickness blepharotomy) from 74 patients were evaluated with a mean follow up of 24.2 months. There were no statistically significant differences between techniques in terms of iMRD1 or temporal-to-nasal ratio reduction at either time point (intertechnique p values of 0.17 to >0.99). The percentage of eyelids from subjects undergoing bilateral intervention that achieved a final iMRD1 between 2.50 mm and 4.50 mm was similar (intertechnique p value of 0.23), with no difference regarding the number of subjects demonstrating iMRD1 symmetry within 1 mm (intertechnique p value of 0.15). Though iTPS elongation was greater at 3 to 6 months with septum-opening compared with the combined septum-preserving techniques (p value of 0.04), this difference was not maintained at final follow up (p value of >0.99). There was no difference in terms of iTPS symmetry at time of final follow up (intertechnique p value of 0.69). The pupil to visible eyelid crease was unchanged in all techniques (p values >0.99). Mean changes in iBFS at final follow up were -1.27 mm, -0.44 mm, and +0.55 mm for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy (p values of 0.01, 0.49, and >0.99, respectively). Mean iTPS:iBFS ratios at final follow up were not statistically different between techniques (intertechnique p value of 0.10) and no difference in symmetry was demonstrated (intertechnique p value of 0.47). Median values for iTPS-minimizing power were: -0.83, -0.93, and -1.01 for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy, respectively (intertechnique p value of 0.54). CONCLUSIONS: Each technique appropriately lowered the eyelid and improved contour without intertechnique variability. Septum-preserving techniques demonstrated less iTPS elongation initially, but this difference was not maintained. The visible eyelid crease height (pupil to visible eyelid crease) remained stable in all techniques, indicating that the iTPS elongation seen with each technique was secondary to reduction in iMRD1 and the iBFS reduction seen with septum-opening levator recession with Muellerectomy was due to brow descent. No intertechnique differences in the amount of iTPS elongation relative to iMRD1 reduction (i.e., the novel iTPS-minimizing power) were seen. Given that each procedure evaluated yielded similar results, technique selection may be guided by surgeon experience and preference.

A Vector Force Model of Upper Eyelid Position in the Setting of a Trabeculectomy Bleb.

PURPOSE: A vector force model for the determination of upper eyelid position in the setting of a trabeculectomy bleb is presented. The model is used to explain the clinical courses of 5 patients with bleb-induced upper eyelid malposition and the efficacy of modalities previously described for the treatment of bleb-induced upper eyelid retraction. The novel use of botulinum toxin in the treatment of bleb-induced eyelid retraction and unique surgical considerations in patients with trabeculectomy blebs undergoing upper eyelid surgery are discussed. METHODS: A vector force analysis was conducted and a force diagram constructed. The clinical and surgical courses of 5 patients with trabeculectomy blebs and upper eyelid malposition were reviewed. The vector force model was applied to these cases and the previously described treatment modalities for bleb-induced upper eyelid retraction. RESULTS: Vector force analysis demonstrates that in the case of trabeculectomy bleb-induced upper eyelid retraction, the net force vector, which represents the sum of all the individual forces acting on the eyelid, has a positive vertical component resulting in superior displacement of the eyelid. In contrast, bleb-induced ptosis results when the net force vector has a negative vertical component. In 3 patients, alterations in the bleb resulted in resolution of upper eyelid malposition. Botulinum toxin was used to achieve a normal upper eyelid position in 1 patient with lateral canthal tendon disinsertion and unilateral eyelid retraction and 1 patient with bilateral eyelid retraction. One patient developed unilateral ptosis in concert with the emergence of a large Tenon cyst that resolved with the treatment of the cyst via eyelid massage. One patient with unilateral ptosis and an ipsilateral bleb underwent external levator advancement but was unable to achieve the desired upper eyelid height as retraction over the bleb occurred with any attempt to elevate the eyelid above a marginal reflex distance of 1.5 mm. The efficacy of previously reported modalities for the treatment of trabeculectomy bleb-induced upper eyelid retraction can be explained by either a reduction in the positive vertical component of the net force vector or augmentation of the negative vertical component. CONCLUSIONS: A vector force model systematically accounts for the multiple determinants of upper eyelid position in the setting of a trabeculectomy bleb. This model provides a framework for the evaluation of bleb-induced upper eyelid malposition and offers a logical, mathematical explanation for the occurrence of bleb-induced upper eyelid retraction and the usefulness of previously reported treatment modalities for this clinical entity.

Shear Viscosity of a Unitary Fermi Gas Near the Superfluid Phase Transition.

We measure the shear viscosity for a resonantly interacting Fermi gas as a function of temperature from nearly the ground state through the superfluid phase transition into the high temperature regime. Further, we demonstrate an iterative method to estimate the local shear viscosity coefficient α(S)(θ) versus reduced temperature θ from the cloud-averaged measurements ⟨α(S)⟩, and compare α(S) to several microscopic theories. We find that α(S) reveals features that were previously hidden in ⟨α(S)⟩.

Anomalous minimum in the shear viscosity of a Fermi gas.

We measure the static shear viscosity η in a two-component Fermi gas near a broad collisional (Feshbach) resonance, as a function of interaction strength and energy. We find that η has both a quadratic and a linear dependence on the interaction strength 1/(k(FI)a), where a is the s-wave scattering length and k(FI) is the Fermi wave vector for an ideal gas at the trap center. For energies above the superfluid transition, the minimum in η as a function of interaction strength is significantly shifted toward the BEC side of resonance, to 1/(k(FI)a)≃0.25.

Genetic diversity of subgroup 1 ilarviruses from Eastern Australia.

This is the first report of the genetic diversity within ilarvirus subgroup 1 from eastern Australia. It supports the separation of tobacco streak virus (TSV) strains from parthenium (Parthenium hysterophorus) and crownbeard (Verbescina encelioides) based on serology and host specificity. It has confirmed one previously described strain of TSV as a member of the species Strawberry necrotic shock virus and another as a new subgroup 1 ilarvirus, ageratum latent virus (AgLV), from Ageratum houstonianum. A multiplex RT-PCR showed that the genetically distinct strains of TSV and AgLV were commonly found in symptomless infections in virus-specific alternative weed hosts growing over a wide geographical range in eastern Australia. TSV has been one of the most damaging viruses in Australian oilseed and pulse crops in recent years, and this study has provided the taxonomic knowledge essential for the development of control programs for these viruses.

Applying research in nutrition education planning: a dietary intervention for Bangladeshi chronic kidney disease patients.

BACKGROUND: Effective nutrition health interventions are theory-based, as well as being drawn from practice and research, aiming to successfully accomplish dietary behavioural changes. However, the integration of theory, research and practice to develop community dietary educational programmes is a challenge that many interventionists feel ill equipped to achieve. METHODS: In the present study, a community-based education programme was designed for Bangladeshi patients with chronic kidney disease and hypertension. The goal of this programme was to reduce dietary salt intake in this population group, with a view to reducing their blood pressure and slowing kidney disease progression. RESULTS: The present study sets out the first four steps of a six-step model for creating a behaviour change programme. CONCLUSIONS: These four steps were concerned with the translation of theory and evidence into intervention objectives, and illustrate how a practical, community-based intervention was developed from behavioural theory, relevant research, knowledge of practice and the target patient group. Steps 5 and 6, which are concerned with implementation and evaluation, will be reported separately.

Polaron-to-polaron transitions in the radio-frequency spectrum of a quasi-two-dimensional Fermi gas.

We measure radio-frequency spectra for a two-component mixture of a 6Li atomic Fermi gas in a quasi-two-dimensional regime with the Fermi energy comparable to the energy level spacing in the tightly confining potential. Near the Feshbach resonance, we find that the observed resonances do not correspond to transitions between confinement-induced dimers. The spectral shifts can be fit by assuming transitions between noninteracting polaron states in two dimensions.

Observation of shock waves in a strongly interacting Fermi gas.

We study collisions between two strongly interacting atomic Fermi gas clouds. We observe exotic nonlinear hydrodynamic behavior, distinguished by the formation of a very sharp and stable density peak as the clouds collide and subsequent evolution into a boxlike shape. We model the nonlinear dynamics of these collisions by using quasi-1D hydrodynamic equations. Our simulations of the time-dependent density profiles agree very well with the data and provide clear evidence of shock wave formation in this universal quantum hydrodynamic system.

Universal quantum viscosity in a unitary Fermi gas.

A Fermi gas of atoms with resonant interactions is predicted to obey universal hydrodynamics, in which the shear viscosity and other transport coefficients are universal functions of the density and temperature. At low temperatures, the viscosity has a universal quantum scale h n, where n is the density and h is Planck's constant h divided by 2π, whereas at high temperatures the natural scale is p(T)(3)/h(2), where p(T) is the thermal momentum. We used breathing mode damping to measure the shear viscosity at low temperature. At high temperature T, we used anisotropic expansion of the cloud to find the viscosity, which exhibits precise T(3/2) scaling. In both experiments, universal hydrodynamic equations including friction and heating were used to extract the viscosity. We estimate the ratio of the shear viscosity to the entropy density and compare it with that of a perfect fluid.

Two novel mastreviruses from chickpea (Cicer arietinum) in Australia.

Two novel mastreviruses (genus Mastrevirus; family Geminiviridae), with proposed names chickpea chlorosis virus (CpCV) and chickpea redleaf virus, are described from chickpea (Cicer arietinum) from eastern Australia. The viruses have genomes of 2,582 and 2,605 nucleotides, respectively, and share similar features and organisation with typical dicot-infecting mastreviruses. Two distinct strains of CpCV were suggested by phylogenetic analysis. Additionally, a partial mastrevirus Rep sequence from turnip weed (Rapistrum rugosum) indicated the presence of a distinct strain of Tobacco yellow dwarf virus (TYDV). In phylogenetic analyses, isolates of Bean yellow dwarf virus, Chickpea chlorotic dwarf Pakistan virus and Chickpea chlorotic dwarf Sudan virus from southern and northern Africa and south-central and western Asia clustered separately from these three viruses from Australia. An Australian, eastern Asian, or south-eastern Asian origin for the novel mastreviruses and TYDV is discussed.