Proceedings of the Third American Association of Oral and Maxillofacial Surgeons Anesthesia Patient Safety Conference.

The 3rd Anesthesia Patient Safety Conference of the American Association of Oral and Maxillofacial Surgeons was held at the Daniel M Laskin Institute for Oral and Maxillofacial Surgery Education and Innovation at American Association of Oral and Maxillofacial Surgeons headquarters in Rosemont, Illinois on June 6, 2022. The conference provided a platform to scrutinize collective errors, explore optimal practices, comprehend the concepts and principles of human complacency, assessing the system's capacity to handle deviations from the norm, and contemplate ideas and initiatives to enhance our practice model. These safety conferences are designed to foster collaborative, proactive conversations and understand best practices in safe delivery of anesthetic care to our patients.

Rare Optic Neuropathy in a Jamaican Couple Linked to Cassava Root Consumption.

We report central visual loss with selective papillomacular bundle damage in a Jamaican couple, husband and wife, with long-term cassava root consumption. The two cases presented independently with gradual central visual loss. Examination revealed bilateral temporal pallor of the optic nerve head and automated static perimetry demonstrated a central or caecocentral scotoma in each patient. Optical coherence tomography findings are described. The only mutual risk factor, reported independently, was long-term cassava consumption. Cessation of cassava intake and vitamin supplementation resulted in partial recovery of visual function. As thiocyanate levels in urine were not measured, the aetiology in these patients is not definitively confirmed, but chronic cassava consumption should be considered in similar cases as a rare cause of potentially reversible optic neuropathy.

Using Natural Language Processing to Identify Different Lens Pathology in Electronic Health Records.

PURPOSE: Nearly all published ophthalmology-related Big Data studies rely exclusively on International Classification of Diseases (ICD) billing codes to identify patients with particular ocular conditions. However, inaccurate or nonspecific codes may be used. We assessed whether natural language processing (NLP), as an alternative approach, could more accurately identify lens pathology. DESIGN: Database study comparing the accuracy of NLP versus ICD billing codes to properly identify lens pathology. METHODS: We developed an NLP algorithm capable of searching free-text lens exam data in the electronic health record (EHR) to identify the type(s) of cataract present, cataract density, presence of intraocular lenses, and other lens pathology. We applied our algorithm to 17.5 million lens exam records in the Sight Outcomes Research Collaborative (SOURCE) repository. We selected 4314 unique lens-exam entries and asked 11 clinicians to assess whether all pathology present in the entries had been correctly identified in the NLP algorithm output. The algorithm's sensitivity at accurately identifying lens pathology was compared with that of the ICD codes. RESULTS: The NLP algorithm correctly identified all lens pathology present in 4104 of the 4314 lens-exam entries (95.1%). For less common lens pathology, algorithm findings were corroborated by reviewing clinicians for 100% of mentions of pseudoexfoliation material and 99.7% for phimosis, subluxation, and synechia. Sensitivity at identifying lens pathology was better for NLP (0.98 [0.96-0.99] than for billing codes (0.49 [0.46-0.53]). CONCLUSIONS: Our NLP algorithm identifies and classifies lens abnormalities routinely documented by eye-care professionals with high accuracy. Such algorithms will help researchers to properly identify and classify ocular pathology, broadening the scope of feasible research using real-world data.

Integrating robotics into wildlife conservation: testing improvements to predator deterrents through movement.

Background: Agricultural and pastoral landscapes can provide important habitat for wildlife conservation, but sharing these landscapes with wildlife can create conflict that is costly and requires managing. Livestock predation is a good example of the challenges involving coexistence with wildlife across shared landscapes. Integrating new technology into agricultural practices could help minimize human-wildlife conflict. In this study, we used concepts from the fields of robotics (i.e., automated movement and adaptiveness) and agricultural practices (i.e., managing livestock risk to predation) to explore how integration of these concepts could aid the development of more effective predator deterrents. Methods: We used a colony of captive coyotes as a model system, and simulated predation events with meat baits inside and outside of protected zones. Inside the protected zones we used a remote-controlled vehicle with a state-of-the art, commercially available predator deterrent (i.e., Foxlight) mounted on the top and used this to test three treatments: (1) light only (i.e., without movement or adaptiveness), (2) predetermined movement (i.e., with movement and without adaptiveness), and (3) adaptive movement (i.e., with both movement and adaptiveness). We measured the time it took for coyotes to eat the baits and analyzed the data with a time-to-event survival strategy. Results: Survival of baits was consistently higher inside the protected zone, and the three movement treatments incrementally increased survival time over baseline except for the light only treatment in the nonprotected zone. Incorporating predetermined movement essentially doubled the efficacy of the light only treatment both inside and outside the protected zone. Incorporating adaptive movement exponentially increased survival time both inside and outside the protected zone. Our findings provide compelling evidence that incorporating existing robotics capabilities (predetermined and adaptive movement) could greatly enhance protection of agricultural resources and aid in the development of nonlethal tools for managing wildlife. Our findings also demonstrate the importance of marrying agricultural practices (e.g., spatial management of livestock at night) with new technology to improve the efficacy of wildlife deterrents.

Identification of biaryl sulfone derivatives as antagonists of the histamine H3 receptor: discovery of (R)-1-(2-(4'-(3-methoxypropylsulfonyl)biphenyl-4-yl)ethyl)-2-methylpyrrolidine (APD916).

The design of a new clinical candidate histamine-H(3) receptor antagonist for the potential treatment of excessive daytime sleepiness (EDS) is described. Phenethyl-R-2-methylpyrrolidine containing biphenylsulfonamide compounds were modified by replacement of the sulfonamide linkage with a sulfone. One compound from this series, 2j (APD916) increased wakefulness in rodents as measured by polysomnography with a duration of effect consistent with its pharmacokinetic properties. The identification of a suitable salt form of 2j allowed it to be selected for further development.

A Systematic Analysis of the Impact of an Ambulatory Ophthalmology Urgent Care Clinic.

Importance A same-day ophthalmic urgent care clinic can provide efficient eye care, a rich educational environment, and can improve patient experience. Objective The aim of this study was to systematically evaluate volume, financial impact, care metrics, and the breadth of pathology of urgent new patient encounters based on their site of initial presentation. Design, Setting, and Participants A retrospective analysis was performed on consecutive urgent new patient evaluations in our same-day triage clinic at the Henkind Eye Institute at Montefiore Medical Center between February 2019 and January 2020. The cohort of patients who presented directly to this urgent care clinic were referred to as the "TRIAGE" group. Patients who initially presented to an emergency department (ED), and were subsequently referred to our triage clinic, are referred to as the "ED + TRIAGE" group. Main Outcomes and Measures Visits were evaluated on a variety of metrics, including diagnosis, duration, charge, cost, and revenue. Furthermore, return to the ED or inpatient admission was documented. Results Of 3,482 visits analyzed, 2,538 (72.9%) were in the "TRIAGE" group. Common presenting diagnoses were ocular surface disease ( n = 486, 19.1%), trauma ( n = 342, 13.5%; most commonly surface abrasion n = 195, 7.7%), and infectious conjunctivitis ( n = 304, 12.0%). Patients in the "TRIAGE" group, on average, were seen 184.6% faster (158.2 vs. 450.2 minutes) than patients in the "ED + TRIAGE" group ( p < 0.001). The "ED + TRIAGE" group were furthermore found to generate 442.1% higher charges ($870.20 vs. 4717.70) and were associated with 175.1% higher cost ($908.80 vs. 330.40) per patient. The hospital was found to save money when noncommercially insured patients with ophthalmic complaints presented to the triage clinic instead of the ED. Patients seen in the triage clinic had a low rate of readmission to the ED ( n = 42, 1.2%). Conclusions and Relevance A same-day ophthalmology triage clinic provides efficient care, while providing a rich learning environment for residents. Less wait time with direct access to subspecialist care can help improve quality, outcome, and satisfaction metrics.

Refractive surgery and the glaucoma patient.

PURPOSE OF REVIEW: Patients considering corneal refractive surgery undergo extensive preoperative testing, but current protocols may not address the management of glaucoma appropriately. This review outlines the current body of literature on the diagnostic and management challenges that exist in the treatment of glaucoma patients undergoing laser ablative surgery, and makes recommendations to improve current perioperative protocols. RECENT FINDINGS: As permanent structural alterations to the cornea after laser-assisted in-situ keratomileusis surgery make Goldmann applanation tonometry inaccurate, the advent of new diagnostic modalities and recommendations to accurately measure postoperative intraocular pressure (IOP) and subtle damage to the optic nerve have been further analyzed and tested. SUMMARY: As IOP is the only modifiable risk factor in the treatment of glaucoma to date, traditional diagnostic and treatment algorithms may not be appropriate for refractive surgery patients. Glaucoma remains a relative contraindication to refractive procedures, but as new diagnostic modalities emerge, our ability to diagnose and manage these patients may improve. More uniform recommendations need to be implemented to improve our long-term management of these patients.

The Relationship Between Corneal Biomechanics and Intraocular Pressure Dynamics in Patients Undergoing Intravitreal Injection.

PRECIS: A higher "corneal resistance factor" (CRF) was associated with greater intraocular pressure (IOP) elevation after intravitreal injection of bevacizumab. Both higher "corneal hysteresis" (CH) and CRF were associated with more rapid IOP recovery postinjection. PURPOSE: The purpose of this study was to evaluate the relationship between measurable corneal biomechanical properties and acute IOP elevation after rapid intraocular volume expansion from the routine intravitreal injection. MATERIALS AND METHODS: A total of 100 patients necessitating unilateral intravitreal injection with 0.05 mL of bevacizumab for retinal pathology were analyzed before injection with Goldmann Applanation Tonometry to measure IOP, Ocular Response Analyzer (ORA) to measure corneal biomechanical properties, and optical biometry to calculate globe measurements. IOP and ORA were measured again within 5 minutes of the injection and then IOP measurements were taken every 10 minutes until the IOP was ≤150% of the preinjection IOP. Linear regression and logistic regression were used to test variables associated with acute IOP increase. A Cox proportional hazard model accounting for preinjection IOP and postinjection IOP was used to test the effect of CH or CRF on the time required to return to 150% of baseline IOP. RESULTS: Higher CRF was associated with greater immediate postinjection IOP (P=0.026) elevation. A preinjection IOP>15.5 mm Hg moderately predicted postinjection IOP≥35 mm Hg (area under the receiver operating characteristics curve=0.74). A preinjection IOP>18.5 mm Hg combined with CH poorly predicted postinjection IOP>50 mm Hg (area under the receiver operating characteristics curve=0.67). A higher CH [hazard ratio (HR)=1.24; 95% confidence interval (CI)=1.08-1.42; P=0.002] and preinjection IOP (HR=1.16; 95% CI=1.09-1.22; P<0.001), along with a lower immediate postinjection IOP (HR=0.93; 95% CI=0.90-0.95; P<0.001), were each independently associated with quicker IOP recovery postinjection. Similar results were seen in the Cox model examining CRF and IOP recovery. CONCLUSIONS: Higher CRF and preinjection IOP were independently associated with greater postinjection IOP elevations. ORA metrics did not greatly strengthen the prediction of patients who would have postinjection IOP>50 mm Hg. Higher CH and CRF were associated with faster IOP recovery after intravitreal injection, demonstrating the dynamic relationship between ocular biomechanical properties and aqueous outflow pathways.

Occipital tip injury with homonymous central scotoma: OCT-NFL and RGC correlation.

PURPOSE: To report one case of homonymous paracentral scotoma with corresponding optical coherence tomography (OCT) findings in a young woman after injury to the left occipital lobe tip. OBSERVATIONS: A young woman with past medical history of Hodgkin's lymphoma and large B-cell lymphoma metastatic to the left occipital lobe status post resection presented to the eye clinic with a chief complaint of a "blind spot" in the right eye since her surgery. Humphrey visual field (HVF) showed a right homonymous paracentral scotoma corresponding to the non-decussating and decussating optic radiation for central vision originating from the left lateral geniculate nucleus (LGN). OCT confirmed atrophy of the right nasal hemifovea with fibers originating from the papillomacular bundle and the left temporal hemifovea with fibers originating from the superior temporal segment of the optic nerve. These fibers correspond to the central vision involved with the left posterior occipital lobe tip. CONCLUSIONS AND IMPORTANCE: We report a case of right homonymous central vision loss as a result of injury to the left posterior occipital lobe tip with certain unique features. Here, a small lesion in the posterior visual pathway led to a relatively large loss of ganglion cell layer.

Discovery and structure-activity relationship of (1R)-8-chloro-2,3,4,5-tetrahydro-1-methyl-1H-3-benzazepine (Lorcaserin), a selective serotonin 5-HT2C receptor agonist for the treatment of obesity.

The synthesis and SAR of a novel 3-benzazepine series of 5-HT2C agonists is described. Compound 7d (lorcaserin, APD356) was identified as one of the more potent and selective compounds in vitro (pEC50 values in functional assays measuring [(3)H]phosphoinositol turnover: 5-HT2C = 8.1; 5-HT2A = 6.8; 5-HT2B = 6.1) and was potent in an acute in vivo rat food intake model upon oral administration (ED50 at 6 h = 18 mg/kg). Lorcaserin was further characterized in a single-dose pharmacokinetic study in rat (t1/2 = 3.7 h; F = 86%) and a 28-day model of weight gain in growing Sprague-Dawley rat (8.5% decrease in weight gain observed at 36 mg/kg b.i.d.). Lorcaserin was selected for further evaluation in clinical trials for the treatment of obesity.

Effects of biodegradable hydrogel spacer injection on contralateral submandibular gland sparing in radiotherapy for head and neck cancers.

Xerostomia is the most common late toxicity after head and neck radiation. We demonstrate injection of a hydrogel spacer anteriorly displacing the submandibular gland. This procedure enables reduced dose to the displaced submandibular gland in cadaveric models of oropharynx cancer treated with IMRT, with potential implications in reducing xerostomia risk.

A Novel Absorbable Radiopaque Hydrogel Spacer to Separate the Head of the Pancreas and Duodenum in Radiation Therapy for Pancreatic Cancer.

PURPOSE: We assessed the feasibility and theoretical dosimetric advantages of an injectable hydrogel to increase the space between the head of the pancreas (HOP) and duodenum in a human cadaveric model. METHODS AND MATERIALS: Using 3 human cadaveric specimens, an absorbable radiopaque hydrogel was injected between the HOP and duodenum by way of open laparotomy in 1 case and endoscopic ultrasound (EUS) guidance in 2 cases. The cadavers were subsequently imaged using computed tomography and dissected for histologic confirmation of hydrogel placement. The duodenal dose reduction and planning target volume (PTV) coverage were characterized using pre- and postspacer injection stereotactic body radiation therapy (SBRT) plans for the 2 cadavers with EUS-guided placement, the delivery method that appeared the most clinically desirable. Modeling studies were performed using 60 SBRT plans consisting of 10 previously treated patients with unresectable pancreatic cancer, each with 6 different HOP-duodenum separation distances. The duodenal volume receiving 15 Gy (V15), 20 Gy (V20), and 33 Gy (V33) was assessed for each iteration. RESULTS: In the 3 cadaveric studies, an average of 0.9 cm, 1.1 cm, and 0.9 cm HOP-duodenum separation was achieved. In the 2 EUS cases, the V20 decreased from 3.86 cm3 to 0.36 cm3 and 3.75 cm3 to 1.08 cm3 (treatment constraint <3 cm3), and the V15 decreased from 7.07 cm3 to 2.02 cm3 and 9.12 cm3 to 3.91 cm3 (treatment constraint <9 cm3). The PTV coverage improved or was comparable between the pre- and postinjection studies. Modeling studies demonstrated that a separation of 8 mm was sufficient to consistently reduce the V15, V20, and V33 to acceptable clinical constraints. CONCLUSIONS: Currently, dose escalation has been limited owing to radiosensitive structures adjacent to the pancreas. We demonstrated the feasibility of hydrogel separation of the HOP and duodenum. Future studies will evaluate the safety and efficacy of this technique with the potential for more effective dose escalation using SBRT or intensity-modulated radiation therapy to improve the outcomes in patients with unresectable pancreatic cancer.

Revisiting Ciliary Muscle Tendons and Their Connections With the Trabecular Meshwork by Two Photon Excitation Microscopic Imaging.

PURPOSE: To elucidate the anatomy of the trabecular meshwork (TM) and its connection to ciliary muscle (CM) tendons with two photon excitation microscopic (TPEM) imaging. METHODS: The human aqueous outflow pathway was imaged in an unfixed and nonembeded state by using an inverted TPEM. Laser (Ti:Sapphire) was tuned at 850 nm for emission. Backscatter signals of second harmonic generation (SHG) and autofluorescence (AF) were collected through 425/30-nm and 525/45 emission filters, respectively. Multiple, consecutive, and overlapping image stacks (z-stacks) were acquired to generate three-dimensional data sets. RESULTS: Collagen and elastin structures of the TM were successfully visualized with TPEM. The TM and CM tendons were found to contain both collagen and elastin fibers. What appears to be juxtacanalicular tissue (JCT) was identified by its honeycomb-like appearance in AF images. Tracing CM tendons from their origins and to their insertions revealed that elastin fibers of CM tendons were connected to the elastin network within the trabecular lamellae. The CM tendons converged or diverged along their course, forming intricate networks with the TM. The CM tendon fiber density varied depending on its location within the aqueous outflow pathway with tendons near the JCT found to be the most dense, and in a fine-tooth comb arrangement. CONCLUSIONS: By using TPEM imaging, new details of the human aqueous outflow pathway were elucidated. This high-resolution imaging technique revealed the intricate interconnections between the TM and CM tendons.

The differential pupillary response to 2.5% phenylephrine in patients taking tamsulosin.

PURPOSE: To determine if a pharmacological test could be developed to determine iris dilator dysfunction in patients taking tamsulosin. METHODS: Patients taking tamsulosin and controls were recruited from the Urology and Ophthalmology clinics at the Montefiore Medical Center. The patient's right eye (OD) was dilated with phenylephrine hydrochloride 2.5% and tropicamide 1%. The patient's left eye (OS) was dilated with tropicamide 1% alone. Forty minutes after dilation, pupillary diameter was measured in both eyes. RESULTS: Thirty-eight tamsulosin subjects and 43 controls met the inclusion criteria for the study. The tamsulosin-treated patients dilated less with phenylephrine than controls (0.61±0.4 vs. 1.10±0.45 mm, respectively P<0.001). Receiver operating characteristic curves comparing maximal pupillary dilation versus differential pupillary dilation in tamsulosin patients relative to controls shows a greater area under the curve for differential dilation (0.8 vs. 0.6, respectively). A correlation between smooth muscle dysfunction and length of time on tamsulosin was observed. Patients using tamsulosin for <1 month had an average OD-OS difference of 0.85±0.5 mm. Patients who were on tamsulosin for >1 month had an average OD-OS difference of 0.52±0.32 mm (P<0.01, Mann-Whitney). CONCLUSION: Patients treated with tamsulosin demonstrated a significantly decreased iris dilatory response to the selective adrenergic effects of phenylephrine compared to controls. Additionally, it appears that longer duration of exposure to tamsulosin increases the likelihood of dilator dysfunction.

PCR diagnostics underestimate the prevalence of avian malaria (Plasmodium relictum) in experimentally-infected passerines.

Several polymerase chain reaction (PCR)-based methods have recently been developed for diagnosing malarial infections in both birds and reptiles, but a critical evaluation of their sensitivity in experimentally-infected hosts has not been done. This study compares the sensitivity of several PCR-based methods for diagnosing avian malaria (Plasmodium relictum) in captive Hawaiian honeycreepers using microscopy and a recently developed immunoblotting technique. Sequential blood samples were collected over periods of up to 4.4 yr after experimental infection and rechallenge to determine both the duration and detectability of chronic infections. Two new nested PCR approaches for detecting circulating parasites based on P. relictum 18S rRNA genes and the thrombospondin-related anonymous protein (TRAP) gene are described. The blood smear and the PCR tests were less sensitive than serological methods for detecting chronic malarial infections. Individually, none of the diagnostic methods was 100% accurate in detecting subpatent infections, although serological methods were significantly more sensitive (97%) than either nested PCR (61-84%) or microscopy (27%). Circulating parasites in chronically infected birds either disappear completely from circulation or to drop to intensities below detectability by nested PCR. Thus, the use of PCR as a sole means of detection of circulating parasites may significantly underestimate true prevalence.

Design and evaluation of novel biphenyl sulfonamide derivatives with potent histamine H(3) receptor inverse agonist activity.

Antagonism of the histamine-H(3) receptor is one tactic being explored to increase wakefulness for the treatment of disorders such as excessive daytime sleepiness (EDS) as well as other sleep or cognitive disorders. Phenethyl-R-2-methylpyrrolidine containing biphenylsulfonamide compounds were shown to be potent and selective antagonists of the H(3) receptor. Several of these compounds demonstrated in vivo activity in a rat model of (R)-alpha-methyl histamine (RAMH) induced dipsogenia, and one compound (4e) provided an increase in wakefulness in rats as measured by polysomnographic methods. However, more detailed analysis of the PK/PD relationship suggested the presence of a common active metabolite which may preclude this series of compounds from further development.

Discovery and SAR of new benzazepines as potent and selective 5-HT(2C) receptor agonists for the treatment of obesity.

We report on the synthesis, biological evaluation and structure-activity relationships for a series of 3-benzazepine derivatives as 5-HT(2C) receptor agonists. The compounds were evaluated in functional assays measuring [3H] phosphoinositol turnover in HEK-293 cells transiently transfected with h5-HT(2C), h5-HT(2A) or h5-HT(2B) receptors. Several compounds are shown to be potent and selective 5-HT(2C) receptor agonists, which decrease food intake in a rat feeding model.