Electrical synapse structure requires distinct isoforms of a postsynaptic scaffold.

Electrical synapses are neuronal gap junction (GJ) channels associated with a macromolecular complex called the electrical synapse density (ESD), which regulates development and dynamically modifies electrical transmission. However, the proteomic makeup and molecular mechanisms utilized by the ESD that direct electrical synapse formation are not well understood. Using the Mauthner cell of zebrafish as a model, we previously found that the intracellular scaffolding protein ZO1b is a member of the ESD, localizing postsynaptically, where it is required for GJ channel localization, electrical communication, neural network function, and behavior. Here, we show that the complexity of the ESD is further diversified by the genomic structure of the ZO1b gene locus. The ZO1b gene is alternatively initiated at three transcriptional start sites resulting in isoforms with unique N-termini that we call ZO1b-Alpha, -Beta, and -Gamma. We demonstrate that ZO1b-Beta and ZO1b-Gamma are broadly expressed throughout the nervous system and localize to electrical synapses. By contrast, ZO1b-Alpha is expressed mainly non-neuronally and is not found at synapses. We generate mutants in all individual isoforms, as well as double mutant combinations in cis on individual chromosomes, and find that ZO1b-Beta is necessary and sufficient for robust GJ channel localization. ZO1b-Gamma, despite its localization to the synapse, plays an auxiliary role in channel localization. This study expands the notion of molecular complexity at the ESD, revealing that an individual genomic locus can contribute distinct isoforms to the macromolecular complex at electrical synapses. Further, independent scaffold isoforms have differential contributions to developmental assembly of the interneuronal GJ channels. We propose that ESD molecular complexity arises both from the diversity of unique genes and from distinct isoforms encoded by single genes. Overall, ESD proteomic diversity is expected to have critical impacts on the development, structure, function, and plasticity of electrical transmission.

Improving Behavioral Healthcare Access Disparities by Training Providers in Disadvantaged Communities - Evidence of Strategy Effectiveness.

BACKGROUND: Inadequate access to behavioral health services disproportionately impacts marginalized populations who live in disadvantaged areas. To reduce this gap, programs dedicated to optimizing behavioral health education and training must focus their efforts to enroll providers who practice in these disadvantaged areas. OBJECTIVE: The Train New Trainers (TNT) fellowship program aims to enhance behavioral health knowledge, skills, and attitudes of primary care providers (PCPs) who deliver care in disadvantaged communities. We evaluate the effectiveness of the TNT recruitment strategy and the use of scholarships for targeting and recruiting PCPs who practice in disadvantaged communities. DESIGN: Observational study. PARTICIPANTS: TNT fellows from 2016 to 2023. MAIN MEASURES: State/federal classifications of medically underserved counties were used to establish scholarship criteria. Area Deprivation Index (ADI) was utilized to provide criterion validity for the use of state/federal criteria in the recruitment strategy, and to evaluate the effectiveness of the program in successfully recruiting PCPs practicing in disadvantaged communities. KEY RESULTS: Practice location data were available for 347 fellows, 88.8% of whom received scholarships. Of the 347 practices, 300 (86.5%) primarily served communities meeting at least one state or federal criterion for medical shortage areas and/or underserved areas. According to ADI scores, 32.3% of practices served areas classified in the highest ADI (ADI decile 9 or 10), with a progressive increase in the proportion of fellows practicing in underserved areas each year; in 2023, 89.9% of practices met federal shortage criteria and 40.5% served areas with the highest deciles of ADI. CONCLUSIONS: The TNT program strategy for recruiting PCPs from high medical need geographical areas is associated with bringing primary care psychiatry education to areas considered underserved and disadvantaged. Equipping PCPs practicing in underserved areas with enhanced knowledge and skills in behavioral medicine has the potential to significantly improve the existing access gap in disadvantaged communities.

Current state and future potential of AI in occupational respiratory medicine.

PURPOSE OF REVIEW: The COVID-19 pandemic has accelerated the pace of technological development relating to pulmonary diseases. The advent of newer technologies, such as Artificial Intelligence (AI), continues to be adapted for diagnostic purposes. AI offers comparable precision to trained physicians under certain circumstances, as well as the unique ability to process the information characteristic of Big Data. With respect to individual susceptibilities/pre-existing diseases, AI seems poised to integrate such individualized information and contribute to a greater implementation of precision medicine. RECENT FINDINGS: AI can match trained clinicians in specific applications, but AI has limitations that require clearly defined questions and a high quality of data. Data collected for this purpose is predicted to increase both in quality and volume, as technology concerned with personal health (FitBit, Apple Watch) proliferates. However, the role of AI with respect to physicians in a clinical setting is still being debated. AI generally aims to increase objectivity through its correlational methodology. SUMMARY: AI continues to be a proliferative field of study. It has defined strengths and weaknesses which, if accounted for, has the potential to increase healthcare access as well as the quality of care delivered.

Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease.

BACKGROUND: Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions. INTRODUCTION: Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction. MATERIALS AND METHODS: Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods. RESULTS: Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training. DISCUSSION: This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique. CONCLUSIONS: Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.

Relevant Biomechanical Variables in Skateboarding: A Literature Review.

Skateboarding, once regarded primarily as a means of transportation and entertainment for youth, has become a recognized professional sport, gaining global popularity. With its recent inclusion in the Olympics, a growing imperative exists to comprehensively understand biomechanics explaining skateboarding performance. This literature review seeks to consolidate knowledge within this domain, focusing on experimental and modeling studies about skateboard riding and tricks. The criteria for study selection encompassed content relevance and publication year, spanning from the last two decades and extending further back to 1980 following cross-referencing of seminal works. Peer-reviewed journal articles, conference proceedings, and books were considered, with comprehensive searches conducted on electronic databases, including SCOPUS, PubMed, Scielo, and Taylor & Francis. Comprehending the biomechanical facets of skateboarding is essential in promoting its use and ensuring safety among all practitioners. Insights into factors such as body kinetics, kinematics, and muscle activation represent a foundational step toward understanding the nuances of this sport with implications for both clinical and biomechanical research. Modern data collection systems such as inertial measurement units (IMU) and electromyography (EMG) offer unprecedented insights into human performance during skateboarding, such as joint range of motion, coordination, and muscle activation, whether in casual riding or executing complex tricks and maneuvers. Developing robust modeling approaches also holds promise for enhancing skateboarding training and performance. Crucially, these models can serve as the initial framework for understanding injury mechanisms and implementing strategies to improve performance and mitigate injury risks.

Actinic Granuloma Complicated by Secondary Syphilis: A Case Report.

Introduction: Actinic granuloma (AG) is a rare skin eruption thought to result from a sun-induced inflammatory response attracting giant cells, which are large, multinucleated, and inflammatory, to form granulomas and degrade surrounding elastic material. Clinically, lesions begin on sun-exposed skin as pink papules and nodules that coalesce into demarcated annular plaques with a hypopigmented center. Histologically, actinic elastosis surrounds the outer annulus ring, with histiocytes and giant cells within the raised border, and the innermost central zone is filled with minimal to absent elastic fibers. Case Presentation: We present a middle-aged female with a pruritic eruption of diffuse erythematous macules and papules coalescing into plaques with mild scale involving the scalp, face, neck, torso, and upper and lower extremities, including the palms and soles, but sparing the ears, bilateral axillae, elbows, and knees. Skin biopsies revealed solar elastosis and abundant multinucleated foreign body giant cells with ingested elastic fibers. The patient's clinical presentation and histopathology were consistent with a diagnosis of AG. Furthermore, spirochete immunostaining of the specimens revealed multiple Treponema pallidum spirochetes throughout the epidermis and dermis. Secondary syphilis with primary chancre was added to the diagnosis. Treatment included oral and topical steroids followed by intravenous penicillin G. After 1 month, all lesions had resolved with post-inflammatory erythema. Conclusion: Our patient differs from the typical presentation in describing intense pruritus with her eruption. This interesting collision reminds clinicians to retain a high index of suspicion for multiple diagnoses in a single patient.

Regulation of Age-Related Lipid Metabolism in Ovarian Cancer.

Although a lot of effort has been dedicated to ovarian cancer (OC) research, the mortality rate is still among the highest in female gynecologic malignancies. The effects of the aged tumor microenvironment are still being undermined despite age being the highest risk factor in ovarian cancer development and progression. In this study, we have conducted RNA sequencing and lipidomics analysis of gonadal adipose tissues from young and aged rat xenografts before and after ovarian cancer formation. We have found significantly higher tumor formation rates and volumes in aged OC xenograft rat models compared to their young counterparts (p<0.05), suggesting the aged adipose microenvironment (AME) is more susceptible to OC outgrowth. We have revealed significant shifts in the gene expression enrichment from groups of young vs. aged rats before tumor formation, groups of young vs. aged rats when the tumor formed, and groups of aged rats before and after tumor formation. We also observed shifts in the lipid components of the gonadal adipose tissues between young and aged rat xenografts when tumors were generated. Additionally, we found that the aged AME was associated with age-related changes in the immune cell composition, especially inflammation-related cells. The top hits showing the most differences between aged and young adipose tissues were eight genes including S100a8, S100a9, Il1rl1, Lcn2, C3, Hba-a1, Fcna, and Pnpla3, 22 lipids including multiple isoforms of free fatty acids (FFA) and triglyceride (TG), as well as four immune cells including neutrophil, myeloid dendritic cell, T cell CD4+ (non-regulatory), and mast cell activation. The functional correlation among S100a8, S100a9, neutrophil, and FFA (18:3) was also determined. Furthermore, FFA (18:3), which was shown to be downregulated in aged xenograft rats, was capable of inhibiting OC cell proliferation. In conclusion, our study suggested that aging promoted OC proliferation through changes in genes/pathways, lipid metabolism, and immune cells. Targeting the aging adipose microenvironment, particularly lipid metabolism reprogramming, holds promise as a therapeutic strategy for OC, which warrants further investigation. Significance: Aging microenvironment of OC may be regulated by S100a8 and S100a9 secreted by adipocytes, preadipocytes, or neutrophils through affecting the lipid metabolism, such as FFA (18:3).

Glaucoma severity at first presentation to an ophthalmologist and risk factors for late presentation in rural Australia: the S1P study.

CLINICAL RELEVANCE: Well-targeted referrals and timely commencement of treatment are essential to limiting vision loss in glaucoma. Optometrists, primary care providers, and public health policymakers can utilise predictors of late to identify and target at-risk populations. BACKGROUND: This study, which aimed to evaluate glaucoma severity at first presentation to an ophthalmologist in a rural Australian population, is the first of its kind in an Australian population. METHODS: Patient records from a large ophthalmology clinic in Port Macquarie, NSW were retrospectively reviewed using the Fight Glaucoma Blindness registry to identify patients who were first diagnosed with glaucoma at an ophthalmology practice in 2020 or 2021. Associations with glaucoma severity at presentation, measured with visual field index (VFI), were analysed using a beta-regression model. Retinal nerve fibre layer measurements were evaluated as a secondary outcome measure using linear regression. RESULTS: From 3548 new patients seen, 110 cases of glaucoma were diagnosed, 95 of whom met inclusion criteria. These comprised 41.8% primary open-angle glaucoma, 32.7% normal-tension glaucoma, 11.8% secondary open-angle glaucoma, 12.7% primary angle closure glaucoma, and 0.9% secondary angle closure glaucoma. The median VFI at presentation was 94.5%, and 71.9% of patients had a VFI ≥ 90%. However, 6.3% of patients presented with a VFI below 50%. Older age, higher intraocular pressure, and worse visual acuity were significantly associated with severity at presentation. No associations were found for remoteness, sex, family history, or glaucoma type. CONCLUSIONS: Glaucoma appears to be diagnosed relatively early in this population. Severity at presentation was associated with age, intraocular pressure, and visual acuity, but not influenced by the social determinants assessed. These findings underscore the importance of frequent comprehensive eye examinations in older patients. Replication in other Australian populations is recommended as the generalisability of these findings is limited.

Flash nanoprecipitation allows easy fabrication of pH-responsive acetalated dextran nanoparticles for intracellular release of payloads.

Acetalated dextran (Ac-Dex) nanoparticles are currently of immense interest due to their sharp pH-responsive nature and high biodegradability. Ac-Dex nanoparticles are often formulated through single- or double-emulsion methods utilizing polyvinyl alcohol as the stabilizer. The emulsion methods utilize toxic organic solvents such as dichloromethane or chloroform and require multi-step processing to form stable Ac-Dex nanoparticles. Here, we introduce a simple flash nanoprecipitation (FNP) approach that utilizes a confined impinging jet mixer and a non-toxic solvent, ethanol, to form Ac-Dex nanoparticles rapidly. Ac-Dex nanoparticles were stabilized using nonionic PEGylated surfactants, D-α-Tocopherol polyethylene glycol succinate (TPGS), or Pluronic (F-127). Ac-Dex nanoparticles formed using FNP were highly monodisperse and stably encapsulated a wide range of payloads, including hydrophobic, hydrophilic, and macromolecules. When lyophilized, Ac-Dex TPGS nanoparticles remained stable for at least one year with greater than 80% payload retention. Ac-Dex nanoparticles were non-toxic to cells and achieved intracellular release of payloads into the cytoplasm. In vivo studies demonstrated a predominant biodistribution of Ac-Dex TPGS nanoparticles in the liver, lungs, and spleen after intravenous administration. Taken together, the FNP technique allows easy fabrication and loading of Ac-Dex nanoparticles that can precisely release payloads into intracellular environments for diverse therapeutic applications. pH-responsive Acetalateddextran can be formulated using nonionic surfactants, such as TPGS or F-127, for intracellular release of payloads. Highly monodisperse and stable nanoparticles can be created through the simple, scalable flash nanoprecipitation technique, which utilizes a confined impingement jet mixer.

Intraocular methotrexate can induce extended remission in some patients in noninfectious uveitis.

PURPOSE: To assess the outcomes of the intravitreal administration of methotrexate in uveitis. METHODS: Multicenter, retrospective interventional case series of patients with noninfectious uveitis. Thirty-eight eyes of 30 patients were enrolled, including a total of 54 intravitreal injections of methotrexate at a dose of 400 µg in 0.1 mL. The primary outcome measure was visual acuity. Secondary outcome measures included control of intraocular inflammation and cystoid macular edema, time to relapse, development of adverse events, and levels of systemic corticosteroid and immunosuppressive therapy. RESULTS: Methotrexate proved effective in controlling intraocular inflammation and improving vision in 30 of 38 eyes (79%). The side effect profile was good, with no reported serious ocular adverse events and only one patient having an intraocular pressure of >21 mmHg. Of the 30 eyes that responded to treatment, 8 relapsed, but 22 (73%) entered an extended period of remission, with the Kaplan-Meier estimate of median time to relapse for the whole group being 17 months. The eight eyes that relapsed were reinjected and all responded to treatment. One eye relapsed at 3 months, but 7 eyes again entered extended remission. Of the 14 patients on systemic therapy at the start of the study, 8 (57%) were able to significantly reduce this following intravitreal methotrexate injection. CONCLUSION: In patients with uveitis and uveitic cystoid macular edema, intravitreal MTX can effectively improve visual acuity and reduce cystoid macular edema and, in some patients, allows the reduction of immunosuppressive therapy. Some patients relapse at 3 to 4 months, but a large proportion (73%) enter an extended period of remission of up to 18 months. This larger study extends the results obtained from previous smaller studies suggesting the viability of intravitreal methotrexate as a treatment option in uveitis.

3D-Printed Artificial Cilia Arrays: A Versatile Tool for Customizable Mechanosensing.

Bio-inspired cilium-based mechanosensors offer a high level of responsiveness, making them suitable for a wide range of industrial, environmental, and biomedical applications. Despite great promise, the development of sensors with multifunctionality, scalability, customizability, and sensing linearity presents challenges due to the complex sensing mechanisms and fabrication methods involved. To this end, high-aspect-ratio polycaprolactone/graphene cilia structures with high conductivity, and facile fabrication are employed to address these challenges. For these 3D-printed structures, an "inter-cilium contact" sensing mechanism that enables the sensor to function akin to an on-off switch, significantly enhancing sensitivity and reducing ambiguity in detection, is proposed. The cilia structures exhibit high levels of customizability, including thickness, height, spacing, and arrangement, while maintaining mechanical robustness. The simplicity of the sensor design enables highly sensitive detection in diverse applications, encompassing airflow and water flow monitoring, braille detection, and debris recognition. Overall, the unique conductive cilia-based sensing mechanism that is proposed brings several advantages, advancing the development of multi-sensing capabilities and flexible electronic skin applications in smart robotics and human prosthetics.

One-year surgical outcomes of the PreserFlo MicroShunt in glaucoma: a multicentre analysis.

BACKGROUND/AIMS: To evaluate the efficacy and safety of the PreserFlo MicroShunt glaucoma device in a multicentre cohort study. METHODS: All consecutive patients who received the microshunt with mitomycin-C (MMC) 0.4 mg/mL from May 2019 to September 2020 in three UK tertiary centres. Primary outcome at 1 year was a complete success, with failure defined as intraocular pressure (IOP) >21 mmHg or <20% reduction, IOP≤5 mmHg with any decreased vision on two consecutive visits, reoperation or loss of light perception vision. Secondary outcomes were IOP, best-corrected visual acuity, medications, complications, interventions and reoperations. We also performed subgroup analyses for severe glaucoma and assessed risk factors for failure. RESULTS: 104 eyes had 1-year follow-up. Complete and qualified success at 1 year were achieved in 51.9% (N=54) and 16.4% (N=17), respectively, and failure occurred in 31.7% (N=33). There was a significant reduction in IOP (mmHg) from preoperatively (23.4±0.8, N=104) to 12 months (14.7±0.6, N=104) (p<0.0001). Antiglaucoma medications also decreased from preoperatively (3.4±0.1, N=104) to 12 months (0.7±0.1, N=104) (p<0.0001). Multivariate analyses showed an association between higher mean deviation and failure (HR 1.055, 95% CI 1.0075 to 1.11, p=0.0227). Complications were hypotony (19.2%; N=20), choroidal detachments (10.6%; N=11), hyphaema (5.8%; N=6) and bleb leak (5.8%; N=6). Needling and 5-fluorouracil injections were performed in 12.5% (N=13) and 33.7% (N=35), respectively, and 11.5% (N=12) required revision surgery. CONCLUSION: The PreserFlo MicroShunt with MMC 0.4 mg/mL showed an overall success rate of 68.3% at 1 year, and led to significant IOP and medication reduction with a low rate of adverse effects.

Sonochemical Internalization of Bleomycin Inhibits Adenocarcinoma Breast Tumor Development in an Orthotopic Rat Model.

One approach to reducing post-operative tumor recurrence and alleviate debilitating side effects of systemic chemotherapy, is work centered on the development of drug activation by focused and targeted externally applied physical energy thus providing site and temporal specificity. One such technique, light mediated photochemical internalization (PCI), has been shown to be a method to obtain enhanced chemotherapy efficacy for a wide variety of anti-cancer agents. A related technology, sonochemical internaization (SCI), is an extension of the PCI concept developed to overcome the limitations of poor light penetration in tissue. SCI utilizes ultrasonic energy, to activate sonosensitizers, co-administered with anti cancer agents. The purpose of the study reported here was to evaluate the inhibitory effects of SCI of bleomycin (BLM), both in vitro and in vivo, on the adenocarcinoma breast tumor rat cell line Mat B III. In vitro, the two aspects of sonication, sonoporation (SP) and sonochemical internalization (SCI) of BLM were examined. In vivo, BLM-SCI significantly inhibited tumor development, following Mat B III implantation, in an orthotopic breast tumor animal model using Fisher rats.

Circle Representation for Medical Object Detection.

Box representation has been extensively used for object detection in computer vision. Such representation is efficacious but not necessarily optimized for biomedical objects (e.g., glomeruli), which play an essential role in renal pathology. In this paper, we propose a simple circle representation for medical object detection and introduce CircleNet, an anchor-free detection framework. Compared with the conventional bounding box representation, the proposed bounding circle representation innovates in three-fold: (1) it is optimized for ball-shaped biomedical objects; (2) The circle representation reduced the degree of freedom compared with box representation; (3) It is naturally more rotation invariant. When detecting glomeruli and nuclei on pathological images, the proposed circle representation achieved superior detection performance and be more rotation-invariant, compared with the bounding box. The code has been made publicly available: https://github.com/hrlblab/CircleNet.

Pediatric Factitious Disorder Perpetuated by Others: A Dermatologist's Duty Beyond the Skin.

Factitious disorders and factitious disorders imposed on another are a prevalent encounter during dermatology visits. Here, we present a case of a pediatric patient who presented with ulcer-like lesions that, based on initial biopsy, suggested an immunobullous etiology. Further exploration revealed her underlying psychiatric disorder. Dermatologists play an integral role in recognizing and initiating "nervous system" management to establish a level of trust with the patient that will ultimately allow bridging to psychiatric care. The case discussed here serves as an example of the successful diagnosis and treatment of a pediatric psychiatric patient by raising clinical suspicion, using investigative techniques, employing separate interviews and the Patient Health Questionnaire-9, and sensitively addressing the relationship between the patient, guardian, and provider within the dermatology clinic.

Preliminary Evaluation of an Order Template to Improve Diagnosis and Testosterone Therapy of Hypogonadism in Veterans.

BACKGROUND: Testosterone therapy is indicated for the treatment of hypogonadism. Evidence-based guidelines recommend testosterone treatment only for men with symptoms and signs of testosterone deficiency and consistently low serum testosterone concentrations; luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measurements and discussion of risks and benefits of testosterone prior to therapy. However, the US Department of Veterans Affairs (VA) Office of the Inspector General (OIG) report found that health care providers were adhering poorly to guideline recommendations for the diagnosis and treatment of men with hypogonadism. METHODS: A prior authorization drug request (PADR) testosterone order template was implemented at VA Puget Sound Health Care System. A retrospective chart review was conducted in veterans who were prescribed testosterone and had no previous prescription in the prior year. Eligible veterans were evaluated 6 months before (pretemplate) and after (posttemplate) implementation of the template, and 3 months after removal of alternative testosterone ordering pathways (posttemplate/no alternative ordering pathways) that were discovered after PADR template implementation. We assessed the proportion of eligible veterans with documented symptoms of testosterone deficiency; appropriate diagnosis and evaluation of hypogonadism with ≥ 2 low serum testosterone and LH and FSH levels; and discussion of risks and benefits of testosterone treatment. RESULTS: In the pretemplate period, only 20 of 80 eligible veterans (25%) had a completed PADR for testosterone. In the posttemplate period, 18 of 45 (44%) eligible veterans had a completed PADR but only 7 (17%) had the testosterone order template completed. In the posttemplate/no alternative ordering pathways period, 13 (68%) and 11 (58%) of 19 eligible veterans had a completed PADR and testosterone order template, respectively. In all 3 periods, documentation of clinical symptoms and a discussion of risks and benefits were similar. In contrast, the proportion of veterans who had ≥ 2 low testosterone levels with LH and FSH levels measured in the posttemplate and posttemplate/no alternative ordering pathways periods were higher (41% and 37%, respectively) vs the pretemplate period (23%). Veterans with documented clinical symptoms, discussion of risks and benefits, and ≥ 2 low testosterone with gonadotropin measurements were 100%, 57%, and 71%, respectively, in the posttemplate/no alternative ordering pathways period. CONCLUSIONS: Implementation of a PADR order template may be a promising approach to improve the diagnosis of hypogonadism and appropriate testosterone therapy in accordance with established evidence-based clinical practice guidelines, particularly in veterans who are receiving new prescriptions.

Brimonidine-induced anterior uveitis and conjunctivitis: clinical and histologic features.

Brimonidine tartarate is a selective alpha2-adrenergic receptor agonist that is indicated for use in the treatment of glaucoma and ocular hypertension. Since its introduction in 1997 there have been a small number of case reports concerning granulomatous anterior uveitis as a late adverse reaction to long-term brimonidine therapy. We report a case of bilateral anterior uveitis and granulomatous papillary conjunctivitis in a 78-year-old gentleman after 2 years of brimonidine therapy. Cessation of brimonidine lead to rapid termination of uveitis. The histologic features of the conjunctiva are described. This has not been previously reported.