Contact Lens Fitting in Patients with Keratoconus - A Retrospective Assessment of 200 Patients. / Verlauf der Kontaktlinsenanpassung bei Keratokonus ­ eine retrospektive Untersuchung bei 200 Patienten.

BACKGROUND AND PURPOSE: Nowadays, keratoconus (KC) is very well treatable in a stage-oriented manner. A wide range of designs and materials of contact lenses (CL) are available for the treatment of KC. The aim of this study was to evaluate the possibilities, the possible challenges and the visual outcome of lens fitting in KC eyes. PATIENTS AND METHODS: This retrospective study includes data from 200 patients who received a lens fitting trial in our contact lens service between 2006 and 2016. We documented ophthalmological parameters, the type of prescribed CL, the number of required trial lenses and possible causes of the failure of the lens fitting. RESULTS: The mean age at initial lens fitting was 33.9 ± 12.5 years. In 98.8% of the cases, the fitting was performed with rigid gas permeable lenses, in 90.1% with four-curve lenses. Of the total number of aspheric lenses prescribed, 87.5% were fitted in keratoconus stages "1" to "2" (topographic keratoconus classification; Oculus Keratograph). Back surface toric lenses or bitoric lenses were fitted to 61.7% in keratoconus stages "2 - 3" to "4". Before patients received their final CL, a median of 2 trial lenses were required (max. 16). Mean visual acuity with lens correction was 0.8 ± 0.2 at the initial fitting, mean visual acuity with glasses correction was 0.5 ± 0.3. In 7.7% of the eyes, the KC lens fitting was discontinued due to the advanced stage of keratoconus, requiring a corneal transplant. Reasons for discontinuing contact lens fitting included lens intolerance (2.3%), application problems (0.3%) or acute corneal hydrops (0.3%). Discontinuation of lens wearing due to incompatibilities or application problems occurred in only four cases (1.1%) in the further course after lens fitting. CONCLUSIONS: The use of contact lenses is an integral part of the stage-appropriate therapy of keratoconus. Good visual acuity can be achieved in all stages of keratoconus with a low drop-out rate. In most cases, the adjustment is carried out with rigid gas permeable lenses with a four-curve geometry. In initial stages, aspherical lenses may be sufficient. Toric lenses can be fitted in advanced stages when rotationally symmetrical lenses cannot achieve a satisfactory fit. If contact lenses have been successfully fitted, there are only a few cases in which patients abandon their contact lenses because of intolerance.

Sex, age, and other barriers for prosthetic referral following amputation and the impact on survival.

BACKGROUND: Despite advances in peripheral vascular disease treatment, lower extremity amputation continues to be necessary in a significant number of patients. Up to 80% of amputees are not referred for prosthetic fitting. The factors contributing to referral decisions have not been adequately investigated, nor has the impact of prosthetic referral on survival. We characterized differences between patients who were successfully referred to our in-house prosthetists and those who were not, and identified factors associated with prosthetic referral and predictive of survival. METHODS: This was a retrospective analysis of all patients who underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to June 30, 2017. Data regarding age, sex, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, end-stage renal disease, prior coronary artery bypass graft surgery, congestive heart failure, tobacco use, American Society of Anesthesiologists (ASA) score, previous arterial procedure, chronic obstructive pulmonary disease, statin use, postoperative ambulatory status, level of amputation, stump revision, and referral for prosthesis were collected. Survival was determined from a combination of sources, including the Social Security Death Master Index, multiple genealogic registries, and internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis referral. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality. RESULTS: There were 293 patients included in this study. Mean age was 66 years, and mean BMI 27 kg/m2. The majority of patients were male (69%), white (53%), with diabetes (65.4%) and hypertension (77.5%), and underwent below-the-knee amputation (BKA) (73%). Prosthetic referral occurred in 123 (42.0%). Overall 5-year survival was 61.7% (95% confidence interval [CI], 55.9%-68.1%) (BKA 64.7% [95% CI, 57.9%-72.3%]; above-the-knee amputation 53.8% [95% CI, 43.4%-66.6%]). On multivariate analysis, age >70 years, female sex, diabetes, ASA score 4 or 5, and current tobacco use were associated with no referral for prosthetic fitting. Patients with BMI 25 to 30, a previous arterial procedure, BKA, and history of stump revision were more likely to be referred. Factors associated with decreased survival were increasing age, higher ASA class, black race, and BMI; prosthetic referral was seen to be protective. CONCLUSIONS: We identified multiple patient factors associated with prosthetic referral, as well as several characteristics predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. Further research is needed to determine whether the factors identified as associated with nonreferral are markers for patient characteristics that make them clinically unsuitable for prosthetic fitting or if they are symptoms of unconscious bias or of the patient's access to care.

Scanning Electron Microscopic Assessment of Stent Coating Integrity in Jailed Wire Technique for Bifurcation Treatment.

OBJECTIVES: To assess the impact of different guidewires on stent coating integrity in jailed wire technique (JWT) for bifurcation treatment. BACKGROUND: JWT is commonly adopted to protect side branch in provisional one-stent strategy for coronary bifurcation lesions. However, this technique may cause defects in stent coatings. The degree of coating damage caused by different types of jailed wires remains unknown. METHODS: A fluid model with a bifurcation was established to mimic the condition in vivo. One-stent strategy was performed with three types of guidewire (nonpolymer-jacketed wire, intermediate polymer-jacketed wire, and full polymer-jacketed wire) tested for JWT. Scanning electron microscopy (SEM) was used to evaluate stent coating integrity and wire structure. The degrees of coating defects were recorded as no, slight, moderate, and severe defects. RESULTS: A total of 27 samples were tested. Analyses of SEM images showed a significant difference in the degree of coating damage among the three types of wire after the procedure of JWT (P < 0.001). Nonpolymer-jacketed wire could inevitably cause a severe defect in stent coatings, while full polymer-jacketed wire caused the least coating damages. Besides, there were varying degrees of coil deformation in nonpolymer-jacketed wires, while no surface damage or jacket shearing was observed in full polymer-jacketed wires. CONCLUSIONS: Although nonpolymer-jacketed wire has long been recommended for JWT, our bench-side study suggests that full polymer-jacketed wire may be a better choice. Further clinical studies are needed to confirm our findings.

A novel, low-cost transradial socket fabrication method using mass-producible components and expanding rigid foam.

BACKGROUND: Millions of people in low- and middle-income countries lack access to prosthetic care. A well-fitting, durable socket is important for prosthesis comfort and function, but conventional fabrication techniques require highly trained clinicians and specialized equipment. OBJECTIVES: To increase access to prosthetic care by developing a simple, low-cost socket fabrication method that does not require specialized equipment or electricity, and can be performed by persons with minimal prosthetic training. STUDY DESIGN: Socket fabrication methods and socket function were evaluated in a pilot feasibility study. TECHNIQUE: We describe a rapid method for fabricating a rigid foam socket directly over the residual limb, with a mass producible, strong, cosmetically appealing plastic outer shell. We fabricated sockets for four individuals with unilateral transradial amputations and evaluated socket function. RESULTS: An individual with no formal prosthetic training was able to fabricate sockets and assemble a functional, comfortable prosthesis system within 90 min. All necessary supplies can be provided in a kit for under US$100. DISCUSSION: Further work is required to determine durability, assess comfort, refine suspension methods, and to develop instructional materials. CONCLUSIONS: We developed a simplified, inexpensive method to fabricate sockets on the residual limb using expandable foam with an integrated cosmetic/structural covering (i.e. an exoskeletal system), for persons with transradial amputation. A transradial prosthesis socket can be fabricated in around 90 min. and all necessary materials, tools, and written instructions for fabrication and fitting can be provided in a kit. Specialized equipment and electricity are not required. Instructions for fabrication and fitting can be provided in multiple languages using online videos.

Knee Prosthesis in the Computer Era.

Over the past two decades, computer assistance has revolutionalized surgery and has enabled enormous advancements in knee prosthesis surgery. Total knee arthroplasty (TKA) is a hot topic of orthopaedic research. Reflecting population dynamics, its use continues to increase, especially in high demand populations. Therefore, efforts to achieve the best fit and precise alignment in TKA continue. Computer assistance is valuable for knee prosthesis surgeons in this regard. This manuscript investigated the use of computer assistance in knee prosthesis surgery. The effects of computer use on important facets of knee prosthesis surgery, such as precision, clinical aspects, and costs, were examined. Moreover, an overall review of the recent literature on the navigation and personalized cutting guides was conducted.

Usefulness of the Right Parasternal Echocardiographic View to Improve the Hemodynamic Assessment After Valve Replacement for Aortic Stenosis.

Right-parasternal-view (RPV) often provides the best hemodynamic assessment of the aortic-valve-stenosis by echocardiography. However, no detailed study on patients with aortic prosthesis is available. Thus, RPV usefulness is left as an anecdotical notion in this context. We aimed to define feasibility and clinical-impact of RPV before and soon-after percutaneous implantation (TAVI) or surgical (SAVR) aortic-valve-replacement (AVR) for AS. Patients with severe-AS electively referred for AVR between September-2019 and February-2020 were prospectively evaluated. Echocardiographic examinations inclusive of apical and RPV to measure aortic-peak-velocity , gradients and area (AVA) were performed the day before AVR and at hospital discharge and compared by matched-pair-analysis. Forty-seven patients (mean age 79 ± 8 years, 63% female, ejection-fraction 61 ± 6%) referred for SAVR (24 [51%]) or TAVI (23 [49%]) were enrolled. RPV was feasible in 45 patients (96%) before-AVR but in only 32 after-AVR (68%), particularly after SAVR (50%) than TAVI (87% p = 0.005). RPV remained the best acoustic window after TAVI in 75% of cases. Hemodynamic assessment of TAVI, but not SAVR, invariably benefit from RPV versus apical evaluation (aortic-peak-velocity: 2.57 ± 0.39 vs 2.23 ± 0.47 m/sec, p = 0.002; mean gradient: 15 ± 5 vs 12 ± 5 mm Hg, p = 0.01). Five (11%) patients presented severe patient-prosthesis-mismatch, 4 of which were detectable only by RPV. This pilot-experience demonstrates that RPV feasibility is slightly reduced after AVR. RPV can improve the hemodynamic assessment of the prosthetic valve versus apical view, including the detection of patient-prosthesis-mismatch. Furthermore, when RPV is the best acoustic windows in patients with severe AS, it generally remains so after-TAVI.

A Prospective Assessment of an Adjustable, Immediate Fit, Transtibial Prosthesis.

BACKGROUND: There exists a need for an adjustable socket to accommodate residual limb volume and shape changes. Further, limb loss rates globally are rising and there is a large unmet need for affordable and accessible prosthetic systems. OBJECTIVE: To assess the utility of an immediate fit modular prosthetic system (iFIT Prosthetics, LLC). DESIGN: Prospective feasibility study involving a 2-week single-group pre-post intervention study. SETTING: Physical Medicine and Rehabilitation gait laboratory. PARTICIPANTS: Participants were at least 6 months post amputation and walking with a conventional prosthesis. They were free of skin wounds, other neurological disorders, and severe pain conditions. METHODS: Participants were fit with an immediate fit prosthesis and instructed to wear it for a 2-week evaluation period. They were given a progressive wearing schedule and they completed outcome measurements at the 2-week follow-up. MAIN OUTCOME MEASUREMENTS: Self-reported satisfaction, gait biomechanics, and intrasocket peak pressures. RESULTS: Twenty-six participants entered the study, with 22 completing the single group pre-post study. They averaged 50 years (SD ±10.2) of age; four were female. Sixteen were dysvascular and 10 were traumatic in etiology. Significant differences (P = .03) in self-reported satisfaction were found in favor of the iFIT device 29.33 (SD ± 4.51) versus the conventional device 25.52 (SD ± 6.8). No falls or limb ischemia were reported. Gait biomechanics revealed no differences across any temporal characteristics. Intrasocket peak pressures were significantly lower for the iFIT prostheses overall (P = .0014), at the anterior tibia (P = .0002), and the lateral side of the residual limb (P = .013). CONCLUSIONS: The iFIT transtibial prosthetic system appears to be safe in this short-term single-group pre-post study. This study provided preliminary evidence to support the feasibility of the iFIT system. It compared favorably to participants' conventional prostheses across all outcome measures. With its cost, adjustability, and accessibility advantages, this device may prove useful for persons with transtibial amputations. A larger multicenter study is needed to confirm these results. LEVEL OF EVIDENCE: III.

In vivo assessment of the anterior scleral contour assisted by automatic profilometry and changes in conjunctival shape after miniscleral contact lens fitting.

PURPOSE: To compare the shape of the anterior sclera of candidates to scleral lens (ScCL) fitting with regular and irregular corneas and analyze the changes induced in the shape of the sclero-conjunctiva after ScCL wear. METHODS: Thirty-five eyes of 18 subjects (19 eyes with irregular corneas and 16 with regular corneas) were consecutively recruited. Three measures of sclero-conjunctival shape were taken with Eye Surface Profiler (ESP, Eaglet Eye, Houten, The Netherlands). Tangent angles and ocular sagittal heights (OC-SAG) were analyzed at different chords from 13 to 17mm in the nasal, temporal, superior and inferior regions. The 19 eyes with irregular cornea were selected to wear ScCL and the changes in their sclero-conjunctival surface parameters were compared before and after 3h of lens wear. RESULTS: Irregular corneas showed higher OC-SAG values than regular corneas in all the chords analyzed, with statistical significant differences in the temporal region. Regarding tangent angles, regular corneas showed lower values (flatter surface), with statistical significant differences at 8 and 8.50mm on the nasal and 8.50mm on the temporal region. Some changes were seen in sclero-conjuctival shape after short-term ScCL wear. There was an augment in OC-SAG after 3h of scleral lens wear and a reduction on tangent angles, namely on the nasal region at 7.5mm and 8.00mm chord lengths, which is coincidental with the landing zone of ScCL. CONCLUSIONS: ESP shows mild differences in scleral shape between eyes with regular and irregular corneas. ESP might be valuable in quantifying the mechanical impact of the ScCL on the anterior eye surface.

Scleral lens fitting and assessment strategies.

PURPOSE: To describe prescriber reported scleral lens fitting and assessment strategies. METHODS: The SCOPE (Scleral Lenses in Current Ophthalmic Practice Evaluation) study group designed and administered an IRB approved, electronic survey (REDCap) regarding current scleral lens fitting and assessment methods. The survey was distributed to attendees of the 2017 Global Specialty Lens Symposium. RESULTS: 95 practitioners responded to the survey. Over half of the respondents, 58% (55/95) reported fitting scleral lenses for less than five years (new prescribers), and 42% (40/95) reported fitting scleral lenses for more than five years (experienced prescribers). There was a statistically significant difference between their initial use of technology (χ2 = 21.117, p < 0.0005) in selection of a diagnostic lens. New prescribers consider base curve first (60%, 33/55), while experienced prescribers considered sagittal depth first (63%, 25/40) in their initial scleral lens selection. All of the experienced lens prescribers (100%, 39/39) reported estimating central clearance by comparing thickness of the post-lens tear reservoir to scleral lens thickness using a slit lamp beam at least some of the time, and 62% of new scleral lens prescribers (34/55; χ2 = 19.175, p < 0.0005) reported doing so. All (100%, 40/40) experienced prescribers schedule scleral lens follow-ups at a specific time and assess conjunctival compression (100%, 40/40), conjunctival staining (100%, 39/39), and corneal staining (100%,40/40) after lens removal. CONCLUSIONS: Practitioners with varying backgrounds and experience have added sclerals to their lens inventories. However, definite guidelines for fitting have not been developed. The results of a survey are provided; demonstrating that among practitioners with greater than 5 years of scleral lens experience, a consensus has emerged for best practices. Strategies for lens evaluation, which may inform future efforts at generating scleral fitting standards are described.

Assessment of a practitioner's perception of scleral contact lens complications.

PURPOSE: The purpose of this survey was to better understand scleral lens (SL) practitioners' fitting preferences and minor SL complications and their subsequent treatments. METHOD: Practitioners who attended the 2017 Global Specialty Lens Symposium were asked to complete an electronic questionnaire that was created by the investigators, a survey that asked practitioners about their SL fitting experience and preferences, their patients' experience with poor SL wetting, SL fogging, ocular symptoms (redness, pain/discomfort, dryness), and blurred central and side vision, and how the practitioners treated these conditions. RESULTS: This study analyzed data from 164 SL practitioners. The practitioners had been in practice for 16.3 ± 13.4 years, had been fitting SL for 5.5 ± 5.0 years, and fit 7.4 ± 7.1 SL/month. Practitioners preferred a SL with a final central corneal clearance of ∼200 µm and an overall diameter between 15.1 mm to 16.5 mm. Poor SL wetting (90.8% of practitioners documented condition), SL fogging (84.8%), blurred central vision (40.2%), ocular redness (34.8%), ocular dryness (24.4%), ocular pain/discomfort (20.7%), and blurred side vision (12.8%) were encountered by the practitioners. Practitioners preferred treating poor wetting and fogging with lens removal, cleaning, and reapplication, blurred central vision with a lens power change, blurred side (peripheral) vision, ocular redness, and ocular pain with a lens parameter change, and dryness with artificial tears. CONCLUSIONS: Most SL practitioners preferred a SL central corneal clearance of ∼200 µm, and they occasionally encountered SL-related complications in their practice, which they treated similarly to corneal gas permeable CLs.

On the Cost of Introducing Speech-Like Properties to a Stimulus for Auditory Steady-State Response Measurements.

Validating hearing-aid fittings in prelingual infants is challenging because typical measures (aided audiometry, etc.) are impossible with infants. One objective alternative uses an aided auditory steady-state response (ASSR) measurement. To make an appropriate measurement, the hearing aid's signal-processing features must be activated (or deactivated) as if the ASSR stimulus was real speech. Rather than manipulating the hearing-aid settings to achieve this, an ASSR stimulus with speech-like properties was developed. This promotes clinical simplicity and face validity of the validation. The stimulus consists of narrow-band CE-Chirps®, modified to mimic the International Speech Test Signal (ISTS). This study examines the cost of introducing the speech-like features into the ASSR stimulus. Thus, 90 to 100 Hz ASSRs were recorded to the ISTS-modified stimulus as well as an equivalent stimulus without the ISTS modification, presented through insert phones to 10 young normal-hearing subjects. Noise-corrected ASSR magnitudes and clinically relevant detection times were estimated and analyzed with mixed-model analyses of variance. As a supplement, the observed changes to the ASSR magnitudes were compared with an objective characterization of the stimuli based on modulation power. The main findings were a reduction in ASSR magnitude of 4 dB and an increase in detection time by a factor of 1.5 for the ISTS-modified stimulus compared with the standard. Detection rates were unaffected given sufficient recording time. For clinical use of the hearing-aid validation procedure, the key metric is the detection time. While this varied considerably across subjects, the observed 50% mean increase corresponds to less than 1 min of additional recording time.

Computed Tomography Assessment for Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement has become a mainstream therapeutic option for patients with severe aortic stenosis who are at intermediate risk or high risk for surgical valve replacement. Computed tomography (CT) is now the standard imaging modality for preoperative vascular access planning an aortic annular sizing. This article reviews the established and potential future roles of CT in transcatheter aortic valve replacement.

Assessment of the fit of removable partial denture fabricated by computer-aided designing/computer aided manufacturing technology.

OBJECTIVE: To assess the level of evidence that supports the quality of fit for removable partial denture (RPD) fabricated by computer-aided designing/computer aided manufacturing (CAD/CAM) and rapid prototyping (RP) technology. Methods: An electronic search was performed in Google Scholar, PubMed, and Cochrane library search engines, using Boolean operators. All articles published in English and published in the period from 1950 until April 2017 were eligible to be included in this review. The total number of articles contained the search terms in any part of the article (including titles, abstracts, or article texts) were screened, which resulted in 214 articles. After exclusion of irrelevant and duplicated articles, 12 papers were included in this systematic review.  Results: All the included studies were case reports, except one study, which was a case series that recruited 10 study participants. The visual and tactile examination in the cast or clinically in the patient's mouth was the most-used method for assessment of the fit of RPDs. From all included studies, only one has assessed the internal fit between RPDs and oral tissues using silicone registration material. The vast majority of included studies found that the fit of RPDs ranged from satisfactory to excellent fit. Conclusion: Despite the lack of clinical trials that provide strong evidence, the available evidence supported the claim of good fit of RPDs fabricated by new technologies using CAD/CAM.

A qualitative study of the challenges of providing pre-prosthetic rehabilitation in rural South Africa.

BACKGROUND: There is a known shortage of rehabilitation staff in rural settings and a sharp increase in the number of lower limb amputations being performed. A lack of adequate pre-prosthetic rehabilitation will result in worse physical and psychological outcomes for a person with a lower limb amputation, and they will not be eligible to be fitted with a prosthesis. OBJECTIVE: To explore therapists' experiences with providing pre-prosthetic rehabilitation in a rural setting. STUDY DESIGN: A qualitative descriptive approach was used to collect and analyse data. METHODS: Data were collected from 17 purposively sampled therapists in five district hospitals in a rural community in South Africa. Data were collected in two rounds of focus groups to explore the challenges of providing pre-prosthetic rehabilitation in rural South Africa. RESULTS: The main themes identified in the study were (1) a lack of government health system support, (2) poor socioeconomic circumstances of patients and (3) cultural factors that influence rehabilitation. These themes all negatively influence the therapists' ability to follow up patients for pre-prosthetic rehabilitation after discharge from hospital. A lack of adequate pre-prosthetic rehabilitation is a substantial barrier to prosthetic fitting in rural South Africa. Patients who do not receive pre-prosthetic rehabilitation have a poorly shaped residuum or other complications such as knee or hip joint contractures which disqualifies them from being referred to prosthetic services. CONCLUSION: Therapists involved in this study identified the most important barriers to patients having access to prosthetic services. Clinical relevance Pre-prosthetic rehabilitation provides care of the residuum; maintenance or improvement of physical strength, joint range of motion and referral to a prosthetist. By exploring the challenges known to exist in this service, we can identify potential ways to reduce these barriers and improve the lives of those who use it.

Iodine-Starch test for assessment of hyperhidrosis in amputees, evaluation of different methods of application.

PURPOSE: Hyperhidrosis is a common problem for amputees. The iodine-starch test is frequently used to assess hyperhidrosis, but a method for its application has not been described for amputees. METHODS: We performed an unblinded comparison of the iodine-starch test using various methods to protect the prosthesis in 10 prosthetic limb users with hyperhidrosis. RESULTS: Plastic wrap produced a diffuse pattern of sweating in 70% of subjects. Forty percent had complaints about this method, and 50% experienced leakage of iodine stain onto prosthetic liners. The prosthetic sheath produced a focal or multifocal reaction in 100% of subjects after 10 min of ambulation. Eighty percent had minor leakage onto the liner, and complaints were noted in 10%. The proportion that experienced diffuse sweating was significantly higher in the plastic wrap condition (p = 0.016; difference in proportions = 70%; 95% confidence interval = 32-100%). The prosthetic sock was tested in four subjects and all had at least mild complaints; three had minor leakage onto the liner. Repeated complaints and lack of stain prevention led to discontinuation with this method. CONCLUSIONS: Of the three methods, the sheath produces a focal or multifocal reaction after 10 min of ambulation and tends to cause less subject complaints. It should be the preferred method to apply the iodine-starch test to amputees. Implications for rehabilitation Hyperhidrosis is a common problem in amputees which negatively affects quality of life. The iodine-starch test is commonly used to guide treatment decisions for hyperhidrosis, but a preferred method for applying it in amputees has not been described. This study describes different methods for applying the iodine-starch test. A prosthetic sheath covering should be the preferred method for the iodine-starch test in amputees.

Scleral Lens Clearance Assessment with Biomicroscopy and Anterior Segment Optical Coherence Tomography.

SIGNIFICANCE: It is important to be able to accurately estimate the central corneal clearance when fitting scleral contact lenses. Tools available have intrinsic biases due to the angle of viewing, and therefore an idea of the amount of error in estimation will benefit the fitter. PURPOSE: To compare the accuracy of observers' ability to estimate scleral contact lens central corneal clearance (CCC) with biomicroscopy to measurements using slit-lamp imaging and anterior segment optical coherence tomography (AS-OCT). METHODS: In a Web-based survey with images of four scleral lens fits obtained with a slit-lamp video imaging system, participants were asked to estimate the CCC. Responses were compared with known values of CCC of these images determined with an image-processing program (digital CCC) and using the AS-OCT (AS-OCT CCC). Bland-Altman plots and concordance correlation coefficients were used to assess the agreement of CCC measured by the various methods. RESULTS: Sixty-six participants were categorized for analysis based on the amount of experience with scleral lens fitting into novice, intermediate, or advanced fitters. Comparing the estimated CCC to the digital CCC, all three groups overestimated by an average of +27.3 ± 67.3 µm. The estimated CCC was highly correlated to the digital CCC (0.79, 0.92, and 0.94 for each group, respectively). Compared with the CCC measurements using AS-OCT, the three groups of participants overestimated by +103.3 µm and had high correlations (0.79, 0.93, and 0.94 for each group). DISCUSSION: Results from this study validate the ability of contact lens practitioners to observe and estimate the CCC in scleral lens fittings through the use of biomicroscopic viewing. Increasing experience with scleral lens fitting does not improve the correlation with measured CCC from digital or the AS-OCT. However, the intermediate and advanced groups display significantly less inter-observer variability compared with the novice group.

Cost-effectiveness of bone-anchored prostheses using osseointegrated fixation: Myth or reality?

BACKGROUND: In principle, lower limb bone-anchored prostheses could alleviate expenditure associated with typical socket manufacturing and residuum treatments due to socket-suspended prostheses. OBJECTIVE: This study reports (a) the incremental costs and (b) heath gain as well as (c) cost-effectiveness of bone-anchored prostheses compared to socket-suspended prostheses. STUDY DESIGN: Retrospective individual case-controlled observations and systematic review. METHODS: Actual costs were extracted from financial records and completed by typical costs when needed over 6-year time horizon for a cohort of 16 individuals. Health gains corresponding to quality-adjusted life-year were calculated using health-related quality-of-life data presented in the literature. RESULTS: The provision of bone-anchored prostheses costed 21% ± 41% more but increased quality-adjusted life-years by 17% ± 5% compared to socket-suspended prostheses. The incremental cost-effectiveness ratio ranged between -$25,700 per quality-adjusted life-year and $53,500 per quality-adjusted life-year with indicative incremental cost-effectiveness ratio of approximately $17,000 per quality-adjusted life-year. Bone-anchored prosthesis was cost-saving and cost-effective for 19% and 88% of the participants, respectively. CONCLUSION: This study indicated that bone-anchored prostheses might be an acceptable alternative to socket-suspended prostheses at least from a prosthetic care perspective in Australian context. Altogether, this initial evidence-based economic evaluation provided a working approach for decision makers responsible for policies around care of individuals with lower limb amputation worldwide. Clinical relevance For the first time, this study provided evidence-based health economic benefits of lower limb bone-anchored prostheses compared to typical socket-suspended prostheses from a prosthetic care perspective that is essential to clinicians and decision makers responsible for policies.

Mild-moderate congenital hearing loss: secular trends in outcomes across four systems of detection.

BACKGROUND: Universal newborn hearing screening (UNHS) targets moderate or greater hearing loss. However, UNHS also frequently detects children with mild loss that results in many receiving early treatment. The benefits of this approach are not yet established. We aimed to (i) compare language and psychosocial outcomes between four hearing loss detection systems for children aged 5-8 years with congenital mild-moderate hearing loss; (ii) determine whether age of detection predicts outcomes; and (iii) compare outcomes between children identified via well-established UNHS and the general population. METHODS: Linear regression adjusted for potential confounding factors was used throughout. Via a quasi-experimental design, language and psychosocial outcomes were compared across four population-based Australian systems of hearing loss detection: opportunistic detection, born 1991-1993, n = 50; universal risk factor referral, born 2003-2005, n = 34; newly established UNHS, born 2003-2005, n = 41; and well-established UNHS, born 2007-2010, n = 21. In pooled analyses, we examined whether age of detection predicted outcomes. Outcomes were similarly compared between the current well-established UNHS system and typically developing children in the Early Language in Victoria Study, born 2003, n = 1217. RESULTS: Age at diagnosis and hearing aid fitting fell steadily across the four systems. For moderate losses, mean expressive language (P for trend .05) and receptive vocabulary (P for trend .06) improved across the four systems, but benefit was not obvious for mild losses. In pooled analyses, diagnosis before age six months predicted better language outcomes for moderate losses. Children with mild-moderate losses exposed to well-established UNHS continue to experience expressive language scores well below children in the general population (adjusted mean difference -8.9 points, 95% CI -14.7 to -3.1). CONCLUSIONS: Treatment arising from UNHS appears to be clearly benefitting children with moderate hearing losses. However, rigorous trials are needed to quantify benefits, versus costs and potential harms, of early aiding of children with mild losses.

Patient Impressions of Possible Catastrophic Outcomes after Diabetic Foot Ulceration.

BACKGROUND: Diabetes Mellitus (DM) and its complications are well studied; patients with diabetes may suffer from neuropathy and vascular issues, and associated with these, lower extremity ulceration. Ulcers are often refractory to treatment, and can be difficult for both patients and clinicians to manage. Such complications may lead to amputations, which in turn are a risk factor for death. However, in certain situations amputation may be the only option available, and may be used as reconstructive surgery, restoring function. The impacts of ulceration, amputation, use of prostheses, and other complications of diabetes on Quality of Life (QOL) are well studied. Similarly, the impact of QOL on overall health has been studied in some detail. OBJECTIVE: Not as well understood are patient expectations regarding amputation and ulceration, and patient knowledge of these outcomes. Specifically, it is not fully understood how patients view these complications prior to their occurrence. In this review we survey the literature for studies discussing these attitudes. Our objective was to perform a systematic review of the medical literature to understand how patients understand and anticipate the potential negative outcomes of ulceration and amputation. We also aimed to identify areas where there are gaps in patient knowledge, which could be addressed by clinicians. RESULTS: Our study yielded articles regarding impressions of patients with diabetes about their general health and outcomes. However, we did not discover much literature directly concerning attitudes toward catastrophic lower extremity outcomes before they occurred. We also identified that patients lack knowledge of management and complications of diabetes; both of these gaps provide an opportunity to better direct care for such patients.

The influence of traumatic transfemoral amputation on metabolic cost across walking speeds.

BACKGROUND: Recent literature indicates equivalent costs of walking can be achieved after a transtibial amputation when the individual is young, active, and/or has extensive access to rehabilitative care. It is unknown if a similar cohort with transfemoral amputation can also achieve lower metabolic costs of walking than previously reported. OBJECTIVE: Compare metabolic cost in individuals with a transfemoral amputation to controls and to the literature across a range of walking speeds. STUDY DESIGN: Cross-sectional. METHODS: A total of 14 individuals with a unilateral transfemoral amputation (27 ± 5 years, N = 4 mechanical knee, N = 10 microprocessor knee) and 14 able-bodied controls (26 ± 6 years) walked at self-selected and four standardized speeds. Heart rate, metabolic rate (mL O2/kg/min), metabolic cost (mL O2/kg/m), and rating of perceived exertion were calculated. RESULTS: Self-selected speed was 8.6% slower in the transfemoral amputation group ( p = 0.031). Across standardized speeds, both metabolic rate and metabolic cost ranged from 44%-47% greater in the transfemoral amputation group ( p < 0.001), heart rate was 24%-33% greater ( p < 0.001), and perceived exertion was 24%-35% greater ( p < 0.009). CONCLUSION: Although the transfemoral amputation group was relatively young, physically fit, and had extensive access to rehabilitative care, the metabolic cost of walking fell within the ranges of the literature on older or presumably less fit individuals with transfemoral amputation. Clinical relevance Developments in prosthetic technology and/or rehabilitative care may be warranted and may reduce the metabolic cost of walking in individuals with a transfemoral amputation.