Limited English Proficiency and Graves' Disease at an Urban Safety Net Hospital.

INTRODUCTION: Decision-making regarding definitive therapy for Graves' disease requires effective patient-provider communication. We investigated whether patients with limited English proficiency have differences in thyroidectomy outcomes or perioperative management when compared to English proficient (EP) patients at a safety net hospital with high-volume endocrine surgery practice. METHODS: Retrospective study of patients who underwent thyroidectomy (2012-2021) for Graves' disease within a tertiary referral system. Demographics, preoperative factors, and postoperative outcomes were abstracted via chart review and compared between EP and limited English proficient (LEP) patients in univariate analyses. Odds of postoperative complications were assessed via multivariable logistic regression. Time metrics such as time from endocrinology consultation to surgery were compared via Kaplan-Meier analysis and adjusted Cox proportional regression models. RESULTS: Of 236 patients, 85 (36%) had LEP. Low and equivalent complication rates occurred across language groups (<1% permanent). LEP patients had similar odds of thyroidectomy-specific complications (odds ratio = 1.2; 95% confidence interval 0.6-2.4). Adjusted Cox proportional hazards ratios showed that LEP patients experienced significantly shorter time from endocrinology consultation to surgery compared to EP patients [hazard ratio = 0.7; 95% confidence interval 0.5-0.9]. CONCLUSIONS: Thyroidectomy-specific complication rate for patients with Graves' disease was low, and we detected no independent association between complications and English language proficiency. Non-English primary language was independently associated with reduced time from endocrinology consultation to surgery. This finding must be interpreted with nuance and is likely multifactorial. It may reflect a well-organized, efficient system for under-resourced patients, or it may derive from communication barriers that limit robust shared decision-making, thus accelerating time to surgery.

A Comparative Study of Endoscopic versus Percutaneous Epidural Neuroplasty in Lower Back Pain: Outcomes at Six-Month Follow Up.

Background and Objectives: Endoscopic epidural neuroplasty (EEN) facilitates adhesiolysis through direct epiduroscopic visualization, offering more precise neural decompression than that exhibited by percutaneous epidural neuroplasty (PEN). We aimed to compare the effects of EEN and PEN for 6 months after treatment with lower back and radicular pain in patients. Methods: This retrospective study compared the visual analog scale (VAS) and Oswestry disability index (ODI) scores in patients with low back and radicular pain who underwent EEN or PEN with a steering catheter. The medical records of 107 patients were analyzed, with 73 and 34 undergoing EEN and PEN, respectively. Results: The VAS and ODI scores decreased at all time points after EEN and PEN. VAS and ODI scores decreased more in the EEN group than those in the PEN group at 1 day and 1- and 6-months post-procedure, indicating superior pain relief for both lower back and radicular pain through EEN. Conclusions: EEN is a superior treatment of pain control than PEN in lower back and radicular pain patients.

Retired Surgeons as Mentors for Surgical Training Graduates Entering Practice: An Underutilized Resource.

OBJECTIVE: Our study evaluated the willingness of retired surgeons to mentor newly trained surgeons. SUMMARY BACKGROUND DATA: Although mentoring is very important during the transition in practice, many novice surgeons are faced with inadequacy or lack of mentoring. METHODS: A survey regarding mentorship of new surgeons was sent in April 2018 to retired general, colorectal, vascular, and cardiothoracic surgeons that are members of the American College of Surgeons. The analysis of the data was performed in September 2018 and October 2018. RESULTS: A total of 2295 of 5282 surveys were completed (43.4% response rate). Mean age was 79.0 ±â€Š0.8 years, mean retirement age was 63.9 ±â€Š0.1 years, and mean interval since retirement was 15.2 ±â€Š0.9 years. Most retired surgeons were in private practice (66.4%), with other practice environments, including academic teaching hospital (12%), academic/private combination (11.3%), employment by community hospital or health system (6.4%), veteran affairs institution (2.7%), military hospital (1%), and Indian Health Service (0.09%). Approximately a third (31.1%) of respondents were not mentored when they first entered practice. The vast majority (98.3%) of participants considered mentoring beneficial during transition in practice. More than half (51.2%) of retired surgeons are interested in mentoring recently trained surgeons, with most of them (81.8%) willing to mentor even for free. CONCLUSION: Our findings suggest that a significant number of retired surgeons are enthusiastic about mentoring young surgeons during their transition in practice. Specific programs are necessary to meet the needs of newly hired surgeons and better utilize the expertise of retired surgeons.

Fc-saxatilin inhibits VEGF-induced permeability by regulating claudin-5 expression in human brain microvascular endothelial cells.

The disruption of the blood-brain barrier influences the degree of brain damage and prognosis in cerebral ischemia or other brain diseases accompanied by inflammation. Vascular endothelial growth factor (VEGF) released during brain ischemia or inflammation has been implicated in the breakdown of the blood-brain barrier by increasing endothelial permeability. Saxatilin, a disintegrin-containing RGD motif, has been reported to disaggregate platelets via interactions with platelet integrins and to have a thrombolysis effect. Additionally, the Fc-saxatilin fusion protein reduces vascular leakage in cerebral ischemia in mice. In this study, we show that Fc-saxatilin prevents VEGF-induced permeability in human brain microvascular endothelial cells (HBMECs). The activation of Src and Fak, downstream signaling proteins of VEGF in the induction of endothelial permeability, was inhibited by Fc-saxatilin in HBMECs. The downregulation of a tight junction protein, claudin-5, at the protein and mRNA levels by VEGF was recovered by Fc-saxatilin. Our findings suggest that Fc-saxatilin attenuates VEGF-induced endothelial permeability via the regulation of downstream signaling, and this may contribute to its protective effect against vascular leakage in the ischemic brain.

TNF-α-Induced YAP/TAZ Activity Mediates Leukocyte-Endothelial Adhesion by Regulating VCAM1 Expression in Endothelial Cells.

YAP/TAZ, a transcriptional co-activator of Hippo pathway, has emerged as a central player in vessel homeostasis such as sprouting angiogenesis and vascular barrier stabilization, during development. However, the role of YAP/TAZ in pathological angiogenesis remains unclear. Here, we demonstrated that YAP/TAZ is a critical mediator in leukocyte-endothelial adhesion induced by the vascular inflammatory cytokine TNF-α. YAP/TAZ was dephosphorylated, translocated from the cytosol to the nucleus, and activated by TNF-α in endothelial cells. A specific inhibitor of Rho GTPases suppressed the TNF-α-induced dephosphorylation of YAP. Knockdown of YAP/TAZ using siRNA significantly reduced the expression of the leukocyte adhesion molecule VCAM1 induced by TNF-α. The adhesion of monocytes to endothelial cells was also markedly reduced by YAP/TAZ silencing. However, knockdown of YAP/TAZ did not affect TNF-α-induced NF-κB signaling. Overall, these results suggest that YAP/TAZ plays critical roles in regulating TNF-α-induced endothelial cell adhesive properties without affecting the NF-κB pathway, and implicate YAP/TAZ as a potential therapeutic target for treating inflammatory vascular diseases.

Purple Urine Bag Syndrome. A Case Report.

BACKGROUND: Purple urine bag syndrome is a rare, benign phenomenon of bacterial colonization. The syndrome affects mainly women and is usually asymp- tomatic. Factors influencing the development of purple urine bag syndrome stem from the pathophysiology of indigo production by bac- teria, and from extrinsic fac- tors. CASE: This case report de- scribes a woman with a complex history placing her at higher risk for developing this syndrome. However, with conservative management she did not develop any complications from this rare syndrome. CONCLUSION: Although mainly benign, those popu- lations particularly susceptible to this phenomenon are intrinsically at risk for further complications such as sepsis and altered mental status and must be managed accordingly.

Two histopathologically different diseases: hormone receptor-positive and hormone receptor-negative tumors in HER2-positive breast cancer.

The clinical behavior of human epidermal growth factor 2 (HER2)-positive breast cancer, including pathologic complete response rate and pattern of relapse and metastasis, differs substantially according to hormone receptor (HR) status. We investigated various histopathologic features of HER2-positive breast cancer and their correlation with HR status. We retrospectively analyzed tumors of 450 HER2-positive breast cancer patients treated with chemotherapy and 1 year of trastuzumab. HR-/HER2+ tumors showed higher nuclear grade, less tubule formation, higher histologic grade, frequent apocrine features, diffuse and abundant lymphocytic infiltration, strong HER2 immunohistochemical staining (3+), higher average HER2 copy number and HER2/CEP17 ratio, the absence of HER2 genetic heterogeneity, and greater p53 expression than HR+/HER2+ tumors. An inverse correlation was observed between estrogen receptor or progesterone receptor Allred score and average HER2 copy number or HER2/CEP17 ratio. The percentage of ductal carcinoma in situ (DCIS) within the tumor was negatively correlated with ER Allred score, but positively correlated with average HER2 copy number and HER2/CEP17 ratio. Pathologic tumor size and DCIS percentage also showed a significant inverse correlation. Ratio of metastatic to total examined lymph node number was significantly correlated with average HER2 copy number and HER2/CEP17 ratio. High pT stage (hazard ratio, 2.370; p = 0.027), the presence of lymphovascular invasion (hazard ratio, 2.806; p = 0.005), and HR negativity (hazard ratio, 2.202; 1.074-4.513; p = 0.031) were found to be independent prognostic indicators of poor disease-free survival. In conclusion, HR+/HER2+ and HR-/HER2+ breast cancer showed distinct histopathologic features that may be relevant to their distinct clinical behavior.

A DNA vaccine against GII.4 human norovirus VP1 induces blocking antibody production and T cell responses.

Human noroviruses (HuNoVs) are highly contagious and a leading cause of epidemics of acute gastroenteritis worldwide. Among the various HuNoV genotypes, GII.4 is the most prevalent cause of outbreaks. However, no vaccines have been approved for HuNoVs to date. DNA vaccines are proposed to serve as an ideal platform against HuNoV since they can be easily produced and customized to express target proteins. In this study, we constructed a CMV/R vector expressing a major structural protein, VP1, of GII.4 HuNoV (CMV/R-GII.4 HuNoV VP1). Transfection of CMV/R-GII.4 HuNoV VP1 into human embryonic kidney 293T (HEK293T) cells resulted in successful expression of VP1 proteins in vitro. Intramuscular or intradermal immunization of mice with the CMV/R-GII.4 HuNoV VP1 construct elicited the production of blocking antibodies and activation of T cell responses against GII.4 HuNoV VP1. Our collective data support the utility of CMV/R-GII.4 HuNoV VP1 as a promising DNA vaccine candidate against GII.4 HuNoV.

Diabetic Neuropathy and Minimum Effective Anesthetic Concentration of Mepivacaine for Axillary Brachial Plexus Block: A Prospective Observational Study.

Nerves in patients with diabetic neuropathy (DN) show increased susceptibility to local anesthetics, potentially requiring a decreased dose. We investigated whether the minimum effective anesthetic concentration (MEAC) of mepivacaine for successful axillary block is lower in patients with DN than in those without. This prospective observational study included patients with DN (n = 22) and without diabetes (n = 22) at a tertiary care center. Patients received an ultrasound-guided axillary block with 30 mL of mepivacaine for anesthesia. The mepivacaine concentration used in each patient was calculated using Dixon's up-and-down method. A block was considered successful if all four sensory nerves had a score of 1 or 2 within 30 min with no pain during surgery. The primary outcome was the MEAC of mepivacaine, and the secondary outcomes included the minimal nerve stimulation intensity for the musculocutaneous nerve and the occurrence of adverse events. The MEAC50 was 0.55% (95% CI 0.33-0.77%) in patients without diabetes and 0.58% (95% CI 0.39-0.77%) in patients with DN (p = 0.837). The MEAC90 was 0.98% (95% CI 0.54-1.42%) in patients without diabetes and 0.96% (95% CI 0.57-1.35%) in patients with DN (p = 0.949). The stimulation threshold for the musculocutaneous nerve was significantly different between groups (0.49 mA vs. 0.19 mA for patients with vs. without diabetes; p = 0.002). In conclusion, the MEAC of mepivacaine for a successful axillary block is not lower in patients with DN.

Application of high-flow nasal cannula oxygen therapy in patient with pulmonary edema following cesarean-section under combined spinal-epidural anesthesia: A case report.

BACKGROUND: High-flow nasal cannula (HFNC), which overcomes the disadvantages of the existing low flow mask, is an efficient method that can immediately provide a high volume of heated oxygen to the patient.[1] Therefore, this case reports a case in which HFNC was applied to a pregnant with acute respiratory failure. CASE: A 37-year-old woman pregnant (GA 30 + 5 weeks) with twin was diagnosed with preeclampsia. It was decided to perform an emergency Cesarean-section under combined spinal-epidural technique worsening respiratory failure. After delivery, maternal dyspnea was not alleviated applying of O28 L/min via facial mask. Thus, high-flow nasal cannula (HFNC) oxygen therapy was applied (60 L/min, partial pressure of oxygen (FiO2) 80%) and SpO2 subsequently rose to 98% and the patient's dyspnea was resolved. CONCLUSIONS: HFNC is a safe device that can effectively provide oxygen to pregnant with acute respiratory failure.

Causes of Punctal Plug Loss in Sjögren's Syndrome.

PURPOSE: To evaluate the long-term maintenance rate and associated factors of silicone punctal plugs in patients with Sjögren's syndrome (SS). MATERIALS AND METHODS: We retrospectively reviewed the medical records of 163 patients with SS who underwent silicone punctal plug insertion between December 2013 and July 2021 at Severance Hospital. The status of punctal plug insertions was classified into the following three categories by the clinician: maintenance, spontaneous loss, and intended removal. Cox proportional hazards model was used to evaluate the risk factors for spontaneous loss. RESULTS: The mean maintenance period was 12.8±15.3 (median 7.07) months. The rate of spontaneous loss was 58%, and the rate of punctal plug removal by the clinician was 14%. The number of prior plug insertions was a risk factor for spontaneous loss [hazard ratio (HR) 1.055, p=0.035]. The upper eyelid punctum was at a higher risk than the lower one (p=0.042). Small-sized plugs showed a significantly higher risk for spontaneous loss than large-sized ones (HR 1.287, p=0.035). Flow-controller type plugs were more vulnerable to spontaneous loss than complete occluders [Micro Flow™ vs. EagleFlex® (HR 2.707, p=0.008) and Micro Flow™ vs. Ultraplug™ (HR 3.402, p=0.005)]. The most common reason for removal was tear overflow (5.6%). CONCLUSION: In repeated insertion, characteristics of the punctal plug, including the type and size, and location of plug insertion, influenced the spontaneous loss of plugs. The management of punctal plugs, including insertion, maintenance, and removal, requires personalized strategies for versatile situations.

Development of Gelatin-Based Shape-Memory Polymer Scaffolds with Fast Responsive Performance and Enhanced Mechanical Properties for Tissue Engineering Applications.

Shape-memory polymers (SMPs) can be defined as a reversibly changing form through deformation and recovery by external stimuli. However, there remain application limitations of SMPs, such as complicated preparation processes and slow shape recovery. Here, we designed gelatin-based shape-memory scaffolds by a facile dipping method in tannic acid solution. The shape-memory effect of scaffolds was attributed to the hydrogen bond between gelatin and tannic acid, which acts as the net point. Moreover, gelatin (Gel)/oxidized gellan gum (OGG)/calcium chloride (Ca) was intended to induce faster and more stable shape-memory behavior through the introduction of a Schiff base reaction. The chemical, morphological, physicochemical, and mechanical properties of the fabricated scaffolds were evaluated, and those results showed that the Gel/OGG/Ca had improved mechanical properties and structural stability compared with other scaffold groups. Additionally, Gel/OGG/Ca exhibited excellent shape-recovery behavior of 95.8% at 37 °C. As a consequence, the proposed scaffolds can be fixed to the temporary shape at 25 °C in just 1 s and recovered to the original shape at 37 °C within 30 s, implying a great potential for minimally invasive implantation.

Effect of Intraoperative Mitomycin C on the Surgical Outcomes of Ahmed Glaucoma Valve Implantation with Ciliary Sulcus Tube Placement.

PURPOSE: To evaluate the effect of intraoperative mitomycin C (MMC) on the surgical outcomes of ciliary sulcus (CS) Ahmed glaucoma valve (AGV) tube placement. METHODS: A retrospective review of medical records of 54 consecutive patients who underwent AGV implantation with tube placed in CS was performed. Consecutive cases operated without the use of intraoperative MMC from 2017 to 2019 were compared with consecutive cases operated with MMC from 2019 to 2021. Surgical failure was defined as intraocular pressure (IOP) exceeding 21 mmHg in two consecutive visits after postoperative 3 months or ≤30% IOP reduction, IOP ≤5 mmHg in two consecutive visits, or loss of light perception. Kaplan-Meier survival analysis and log-rank test were performed to compare the surgical failure rates. RESULTS: A total of 54 eyes of 54 patients were investigated. Mean follow-up period after AGV implantation was 1.4 ± 0.8 years. The MMC group showed significantly lower IOP during the 1st postoperative month (20.5 ± 8.6 mmHg vs. 15.8 ± 6.4 mmHg, p = 0.027), but the difference did not persist 6 months after the surgery (p = 0.805). The mean number of postoperative antiglaucoma medications was significantly lower in the MMC group in the 1st postoperative month (p = 0.047) but no difference was found at 6 months. No statistical difference was noted in the rates of postoperative complications. Kaplan-Meier survival analysis showed comparable survival rates between MMC group and no MMC group (p = 0.356). CONCLUSIONS: The intraoperative use of MMC significantly lowered IOP in the 1st postoperative month but did not increase 6 months success rates in patients receiving AGV tube placement in CS.

Modified gellan gum-based hydrogel with enhanced mechanical properties for application as a cell carrier for cornea endothelial cells.

Recently, the number of people suffering from visual loss due to eye diseases is increasing rapidly around the world. However, due to the severe donor shortage and the immune response, corneal replacement is needed. Gellan gum (GG) is biocompatible and widely used for cell delivery or drug delivery, but its strength is not suitable for the corneal substitute. In this study, a GM hydrogel was prepared by blending methacrylated gellan gum with GG (GM) to give suitable mechanical properties to the corneal tissue. In addition, lithium phenyl-2,4,6-trimethylbenzoylphosphinate (LAP), a crosslinking initiator, was added to the GM hydrogel. After the photo-crosslinking treatment, it was named GM/LAP hydrogel. GM and GM/LAP hydrogels were analyzed for physicochemical properties, mechanical characterization, and transparency tests to confirm their applicability as carriers for corneal endothelial cells (CEnCs). Also, in vitro studies were performed with cell viability tests, cell proliferation tests, cell morphology, cell-matrix remodeling analysis, and gene expression evaluation. The compressive strength of the GM/LAP hydrogel was improved compared to the GM hydrogel. The GM/LAP hydrogel showed excellent cell viability, proliferation, and cornea-specific gene expression than the GM hydrogel. Crosslinking-improved GM/LAP hydrogel can be applied as a promising cell carrier in corneal tissue engineering.

Bethesda III and IV Thyroid Nodules Managed Nonoperatively After Molecular Testing With Afirma GSC or Thyroseq v3.

CONTEXT: Molecular testing has improved risk stratification and increased nonoperative management for patients with indeterminate thyroid nodules, but data on the long-term outcomes of current molecular tests Afirma Gene Sequencing Classifier (GSC) and Thyroseq v3 are limited. OBJECTIVE: To determine the rate of delayed operation and the false negative rate of the Afirma GSC and Thyroseq v3 in Bethesda III and IV thyroid nodules. METHODS: Prospective follow-up of a single center, randomized, clinical trial comparing the performance of Afirma GSC and Thyroseq v3 in the diagnosis of indeterminate thyroid nodules at the University of California, Los Angeles (UCLA). Consecutive participants who underwent thyroid biopsy in the UCLA health system with Bethesda III and IV cytology from August 2017 to November 2019. The main outcome measure was false negative rate of molecular testing. RESULTS: Of 176 indeterminate nodules with negative or benign molecular test results, 14 (8%) nodules underwent immediate resection, with no malignancies found on surgical pathology. Nonoperative management with active surveillance was pursued for 162 (92%) nodules with benign or negative test results. The median surveillance was 34 months (range 12-60 months), and 44 patients were lost to follow-up. Of 15 nodules resected during surveillance, 1 malignancy was found (overall false negative rate of 0.6%). This was a 2.7 cm minimally invasive Hurthle cell carcinoma that initially tested negative with Thyroseq v3 and underwent delayed resection due to sonographic growth during surveillance. CONCLUSIONS: The majority of Bethesda III/IV thyroid nodules with negative or benign molecular test results are stable over 3 years of follow-up. These findings support the high sensitivity of current molecular tests and their role in ruling out malignancy in indeterminate thyroid nodules.

Coordinated regulation of interferon and inflammasome signaling pathways by SARS-CoV-2 proteins.

Type I and III interferons (IFNs) and the nucleotide-binding domain (NBD) leucine-rich repeat (LRR)-containing receptor (NLR) family pyrin domain containing 3 (NLRP3) inflammasome play pivotal roles in the pathogenesis of SARS-CoV-2. While optimal IFN and inflammasome responses are essential for limiting SARS-CoV-2 infection, aberrant activation of these innate immune responses is associated with COVID-19 pathogenesis. In this review, we focus our discussion on recent findings on SARS-CoV-2-induced type I and III IFNs and NLRP3 inflammasome responses and the viral proteins regulating these mechanisms.

Prediction of Total Soluble Solids and pH of Strawberry Fruits Using RGB, HSV and HSL Colour Spaces and Machine Learning Models.

Determination of internal qualities such as total soluble solids (TSS) and pH is a paramount concern in strawberry cultivation. Therefore, the main objective of the current study was to develop a non-destructive approach with machine learning algorithms for predicting TSS and pH of strawberries. Six hundred samples (100 samples in each ripening stage) in six ripening stages were collected randomly for measuring the biometrical characteristics, i.e., length, diameters, weight and TSS and pH values. An image of each strawberry fruit was captured for colour feature extraction using an image processing technique. Channels of each colour space (RGB, HSV and HSL) were used as input variables for developing multiple linear regression (MLR) and support vector machine regression (SVM-R) models. The result of the study indicated that SVM-R model with HSV colour space performed slightly better than MLR model for TSS and pH prediction. The HSV based SVM-R model could explain a maximum of 84.1% and 79.2% for TSS and 78.8% and 72.6% for pH of the variations in measured and predicted data in training and testing stages, respectively. Further experiments need to be conducted with different strawberry cultivars for the prediction of more internal qualities along with the improvement of model performance.

Kaempferol Interferes with Varicella-Zoster Virus Replication in Human Foreskin Fibroblasts.

Kaempferol, a natural flavonoid abundantly found in plants, is known to have pharmacological properties, such as anti-inflammatory and anti-cancer effects. In this study, we investigated the antiviral effects of kaempferol against a varicella-zoster virus (VZV) clinical isolate in vitro. We found that kaempferol significantly inhibited VZV replication without exhibiting cytotoxicity. Kaempferol exerted its antiviral effect at a similar stage of the VZV life cycle as acyclovir, which inhibits VZV DNA replication. Taken together, our results suggest that kaempferol inhibits VZV infection by blocking the DNA replication stage in the viral life cycle.

Patient selection for corneal topographic evaluation of keratoconus: A screening approach using artificial intelligence.

Background: Corneal topography is a clinically validated examination method for keratoconus. However, there is no clear guideline regarding patient selection for corneal topography. We developed and validated a novel artificial intelligence (AI) model to identify patients who would benefit from corneal topography based on basic ophthalmologic examinations, including a survey of visual impairment, best-corrected visual acuity (BCVA) measurement, intraocular pressure (IOP) measurement, and autokeratometry. Methods: A total of five AI models (three individual models with fully connected neural network including the XGBoost, and the TabNet models, and two ensemble models with hard and soft voting methods) were trained and validated. We used three datasets collected from the records of 2,613 patients' basic ophthalmologic examinations from two institutions to train and validate the AI models. We trained the AI models using a dataset from a third medical institution to determine whether corneal topography was needed to detect keratoconus. Finally, prospective intra-validation dataset (internal test dataset) and extra-validation dataset from a different medical institution (external test dataset) were used to assess the performance of the AI models. Results: The ensemble model with soft voting method outperformed all other AI models in sensitivity when predicting which patients needed corneal topography (90.5% in internal test dataset and 96.4% in external test dataset). In the error analysis, most of the predicting error occurred within the range of the subclinical keratoconus and the suspicious D-score in the Belin-Ambrósio enhanced ectasia display. In the feature importance analysis, out of 18 features, IOP was the highest ranked feature when comparing the average value of the relative attributions of three individual AI models, followed by the difference in the value of mean corneal power. Conclusion: An AI model using the results of basic ophthalmologic examination has the potential to recommend corneal topography for keratoconus. In this AI algorithm, IOP and the difference between the two eyes, which may be undervalued clinical information, were important factors in the success of the AI model, and may be worth further reviewing in research and clinical practice for keratoconus screening.