Neoadjuvant Chemotherapy in a Case of Nonresectable Papillary Squamous Cell Carcinoma of the Palpebral Conjunctiva.

The role of neoadjuvant chemotherapy (NACT) in eyelid and orbital malignancies is not well defined. It has been tried with good success in cases of eyelid sebaceous gland carcinoma but there is very limited literature on its role in cases of ocular surface squamous neoplasia. A 54-year-old man presented with gradually increasing swelling of the right upper eyelid for the past 2 years. On examination, a large friable papillary mass was found covering the entire conjunctival surface (T3N0M0). Incisional biopsy from the mass was suggestive of papillary squamous cell carcinoma. There was no lymph node or distant metastasis as confirmed by whole-body positron emission tomography-CT scan. A trial of NACT (3 cycles of paclitaxel and cisplatin) was given and the mass shrunk in size considerably making it amenable to surgical resection. The conjunctival surface healed completely and there was no recurrence at 1 year of follow up. NACT can be tried in unresectable large ocular surface neoplasia to make the tumor more amenable to surgical resection.

Validation of a pre-endoscopy risk score for predicting the presence of gastric intestinal metaplasia in a U.S. population.

BACKGROUND AND AIMS: Surveillance of gastric intestinal metaplasia (GIM) may lead to early gastric cancer detection. Our purpose was to externally validate a predictive model for endoscopic GIM previously developed in a veteran population in a second U.S. METHODS: We previously developed a pre-endoscopy risk model for detection of GIM using 423 GIM cases and 1796 control subjects from the Houston Veterans Affairs Hospital. The model included sex, age, race/ethnicity, smoking, and Helicobacter pylori infection with an area under the receiver-operating characteristic curve (AUROC) of .73 for GIM and .82 for extensive GIM. We validated this model in a second cohort of patients from 6 Catholic Health Initiative (CHI)-St Luke's hospitals (Houston, Tex, USA) from January to December 2017. Cases were defined as having GIM on any gastric biopsy sample and extensive GIM as involving both the antrum and corpus. We further optimized the model by pooling both cohorts and assessing discrimination using AUROC. RESULTS: The risk model was validated in 215 GIM cases (55 with extensive GIM) and 2469 control subjects. Cases were older than control subjects (59.8 vs 54.7 years) with more nonwhites (59.1% vs 42.0%) and H pylori infections (23.7% vs 10.9%). The model applied to the CHI-St Luke's cohort had an AUROC of .62 (95% confidence interval [CI], .57-.66) for predicting GIM and of .71 (95% CI, .63-.79) for predicting extensive GIM. When the Veterans Affairs and CHI-St Luke's cohorts were pooled, discrimination of both models improved (GIM vs extensive GIM AUROC: .74 vs .82). CONCLUSIONS: A pre-endoscopy risk prediction model was validated and updated using a second U.S. cohort with robust discrimination for endoscopic GIM. This model should be evaluated in other U.S. populations to risk-stratify patients for endoscopic GIM screening.

Update on the Diagnosis and Management of Acute Colonic Pseudo-obstruction (ACPO).

PURPOSE OF REVIEW: Acute Colonic Pseudo-obstruction (ACPO) is a cause of large intestinal dilation and obstruction without any physical transition point. It remains difficult to diagnose and treat. We review the recent updates on diagnosis and management of ACPO. RECENT FINDINGS: Recent guidelines have posited that conservative management can be tried in most cases of ACPO, but that early decompression and surgery should be considered. Use of neostigmine is still a viable option but there is also promising data on pyridostigmine as well as prucalopride. Resolution of ACPO should be followed by daily use of polyethylene glycol (PEG) to help prevent recurrence. ACPO warrants early and accurate diagnosis with exclusion of alternate causes of large bowel dilation. Conservative management can be attempted for 48-72 h in those with cecal diameters < 12 cm and without signs of peritonitis and perforation. Early escalation of management should be attempted with neostigmine followed by endoscopy and/or surgery as needed, given that longer periods of dilation are associated with worse outcomes. There is promising new evidence for use of pyridostigmine and prucalopride, but further trials are needed prior to incorporating them into regular use. Finally, studies are lacking regarding prevention of ACPO after initial resolution.

High Neutrophil-Lymphocyte Ratio and Delta Neutrophil-Lymphocyte Ratio Are Associated with Increased Mortality in Patients with Hepatocellular Cancer.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) has been proposed as a prognostic biomarker for cirrhosis and non-liver malignancies. We aimed to evaluate the prognostic value of NLR in a diverse cohort of patients with hepatocellular carcinoma (HCC). METHODS: We performed a retrospective study of patients diagnosed with HCC between 2008 and 2017 at two large US health systems. We used Cox proportional hazard and multivariable ordinal logistic regression models to identify factors associated with overall survival and response to first HCC treatment, respectively. Primary variables of interest were baseline NLR and delta NLR, defined as the difference between pre- and post-treatment NLR. RESULTS: Among 1019 HCC patients, baseline NLR was < 5 in 815 (80.0%) and ≥ 5 in 204 (20.0%). Patients with NLR ≥ 5 had a higher proportion of infiltrative tumors (36.2% vs 22.3%), macrovascular invasion (39.6% vs 25.5%), metastatic disease (20.6% vs 11.4%), and AFP > 200 ng/mL (45.6% vs 33.8%). Baseline NLR ≥ 5 was independently associated with higher mortality (median survival 4.3 vs 15.1 months; adjusted HR 1.70, 95%CI 1.41-2.06), with differences in survival consistent across BCLC stages. After adjusting for baseline covariates including NLR, delta NLR > 0.26 was also independently associated with increased mortality (HR 1.42, 95%CI 1.14-1.78). In a secondary analysis, high NLR was associated with lower odds of response to HCC treatment (20.2% vs 31.6%; adjusted OR 0.55, 95%CI 0.32-0.95). CONCLUSIONS: In a large Western cohort of patients with HCC, high baseline NLR and delta NLR were independent predictors of mortality. IMPACT: NLR is an inexpensive test that may be a useful component of future HCC prognostic models.

Nutrition from the kitchen: culinary medicine impacts students' counseling confidence.

BACKGROUND: Although a poor diet is the number one risk factor for early death in the United States and globally, physicians receive little to no training in dietary interventions and lack confidence counseling patients about lifestyle modifications. Innovative, interprofessional strategies to address these gaps include the emergence of culinary medicine, a hands-on approach to teaching the role of food in health outcomes. We sought to assess the impact of a culinary medicine elective on counseling confidence, awareness of an evidence-based approach to nutrition, and understanding of the role of interprofessional teamwork in dietary lifestyle change among medical students at one undergraduate medical school. METHODS: We administered pre- and post-course surveys to two cohorts of medical students (n = 64 at pre-test and n = 60 at post-test) participating in a culinary medicine enrichment elective. Chi-square analysis was used to assess the relationship between participation in the course and a positive response to each survey item. RESULTS: Compared with the baseline, students participating in culinary medicine were more likely to feel confident discussing nutrition with patients (29% vs 92%; p < 0.001), to feel familiar with the Mediterranean diet (54% vs. 97%; p < 0.001), and to understand the role of dietitians in patient care (37% vs. 93%; p < 0.001). CONCLUSIONS: Culinary medicine shows promise as an impactful educational strategy among first-year medical students for increasing counseling confidence, promoting familiarity with evidence-based nutrition interventions, and augmenting understanding of the role of interprofessional engagement to address lifestyle-related disease.

Corneal foreign body post laser in-situ keratomileusis: Diagnosis, management, outcome and review of literature.

Purpose: To report a case of metallic corneal foreign-body (CFB) penetrating the Laser in situ keratomileusis (LASIK) flap and its successful outcome. To highlight usefulness of Anterior Segment Optical Coherence Tomography (ASOCT) in diagnosis and management of post-LASIK CFB. To enumerate other similar cases published in literature. Method: A 30-year-old male presented to the emergency department of a tertiary eye care centre with a metallic CFB. He had undergone uneventful LASIK elsewhere 4-years back. He was unaware of any trauma. CFB removal was attempted elsewhere but abandoned as CFB appeared deeply embedded. ASOCT showed CFB had penetrated LASIK flap and lodged into midstroma, 207 µm deep. CFB was successfully removed in operation theatre along with the application of cyanoacrylate glue and bandage contact lens. A review of literature for CFB in post-LASIK patients was done through PubMed search. Result: Postoperative course was uncomplicated and there was a follow up period of 4 months. Vision improved to unaided 20/20 and N/6 from preoperative 20/60 and N/10. Review of literature of 24 patients showed Post-LASIK FB was more common in males (79%). None of the patients except for one had protective eye-wear. Metallic FB was most common followed by organic FB. Flap complications were present in seven patients. Diffuse lamellar keratitis (DLK) and epithelial ingrowth were the most common post-FB removal complications occurring in six (25%) and four (16.6%) patients respectively. Conclusion: Post-LASIK patients with CFB need to be inspected for flap related complications. CFB can be successfully removed, although DLK, epithelial ingrowth, microbial keratitis, astigmatism, can occur post-CFB removal. ASOCT can delineate CFB and flap related details and thus is an additional useful imaging tool in such scenarios.

Hyperreflective Ganglion Cell Layer Band in Gyrate Atrophy.

We have described the hyperreflective ganglion cell layer band (HGCB) in a series of cases of gyrate atrophy. Clinical fundus examination and multimodal imaging which included optical coherence tomography (OCT) was done in all cases. Four patients (one male, three female) were studied. In all four cases, a hyperreflective band was noted in the ganglion cell layer. In three patients, the band was continuous, and in one patient, the band was patchy. To conclude, HGCB is a novel OCT sign in gyrate atrophy and can be valuable in prognostication of disease. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Bilateral Central serous chorioretinopathy in a case of surgically treated Optic Disc Pit maculopathy.

PURPOSE: To report occurrence of central serous chorioretinopathy(CSCR) which mimicked recurrence of ODP maculopathy in a young adult in whom surgery for the same had been done. METHODS: Clinical fundus examination and multimodal imaging which included optical coherence tomography(OCT) and fundus autofluorescence(FFA) was done. RESULTS: Patient had undergone surgery for ODP maculopathy. At 1 year follow up, there was recurrence of subretinal fluid at the macula. Fundus fluorescein angiography was done and the presence of ink blot pattern leakage clinched the diagnosis of CSCR, ruling out ODP maculopathy. CONCLUSION: CSCR is a great masquerade and correct diagnosis is very important to prevent permanent visual impairment. Subretinal fluid(SRF) associated with ODP must be examined carefully to rule out other pathologies like CSCR. Serous macular detachment after surgery for ODP maculopathy has been done, does not necessarily mean recurrence of the maculopathy. Other pathologies like CSCR should be ruled out. This case highlights the importance of multimodal imaging along with clinical signs in correct diagnosis and treatment of conditions with overlapping features like CSCR and ODP maculopathy.

Subretinal hyporeflective globule: A novel OCT finding in central serous chorioretinopathy.

PURPOSE: To describe the subretinal hyporeflective globule in cases of central serous chorioretinopathy (CSC). METHODS: A retrospective analysis of consecutive cases of CSC presenting to a tertiary eye care center in eastern India was conducted. Subretinal hyporeflective globules were identified as small globular lesions below the external limiting membrane/ellipsoid zone, but above the RPE layer. They had a hyperreflective border with a hyporeflective core and a clear posterior tail of hyper-transmission. RESULTS: The present study analyzed 137 eyes of 137 patients. Eighty (58.4%) eyes had acute disease at presentation, 48 (35%) eyes had chronic disease, and eight (5.8%) eyes had resolved CSC. Subretinal hyporeflective globules were seen in 27 (21.8%) eyes, of which choroidal caverns were seen in seven (5.1%) eyes. Twenty-five eyes with chronic CSC and only two eyes with acute CSC had subretinal hyporeflective globules. Three eyes with resolved CSC had subretinal hyporeflective globules. CONCLUSION: We describe subretinal hyporeflective globule as a novel optical coherence tomography (OCT) finding in cases of CSC and describe its clinical correlates.

Pupil vignetting artifact on optical coherence tomography angiography.

PURPOSE: To discuss the features of an artifact on optical coherence tomography angiography (OCTA), termed "pupil vignetting artifact," and describe how it may masquerade as true chorioretinal pathology. DESIGN: This was a retrospective, observational case series. METHODS: The authors studied 12 eyes at a vitreoretinal clinic in Eastern India, reviewing a dark shadow such as an artifact on OCTA images. RESULTS: In all 12 eyes, there was an appearance of a dark shadow on OCTA imaging, located at the macula, superior, superotemporal, or superonasal to the fovea, which did not correspond to any ischemic area responsible for flow-void or any media opacity casting a posterior shadow. It was believed to be an artifact caused by the vignetting effect of the pupil as the incident OCT beam clips the iris during OCTA scanning, and therefore reduces the amount of total light incident on the retina. The variability in the size, shape, and location of the artifact is contributed by a few factors such as variable angle of incident light on the pupil, pupillary dynamics, and curvature of the retinal surface. CONCLUSION: Pupil vignetting artifact is a unique undescribed phenomenon appearing at the macula on OCTA imaging that can masquerade as numerous true chorioretinal pathologies. This article aims to describe this artifact to avoid misinterpretation and further confusion in real-life clinical practice.

Multicolor imaging: Current clinical applications.

Multicolor (MC) imaging is an innovative pseudocolor fundus imaging modality based on confocal scanning laser ophthalmoscopy. It effectively scans the retina at different depths to create a composite image. The green reflectance image depicts the middle retinal while blue reflectance image provides images of the retinal surface. The infrared reflectance image depicts retinal structures at the level of outer retina and choroid. We systematically analyze published case reports, case series, and original articles on MC imaging where it has helped in discovering additional clinical features of retinal diseases not readily apparent on conventional color fundus photography and played a role in monitoring the response to treatment.

Angular Sign of Henle Fiber Layer Hyperreflectivity in Purtscher and Purtscher like Retinopathy.

ABSTRACT: Angular Sign of Henle Fiber Layer Hyperreflectivity (ASHH) is a marker of Henle Fibre layer ischemia. Our aim is to describe ASHH as a novel OCT sign in Purtscher and Purtscher like retinopathy. Here we present 3 Cases, one classical Purtscher Retinopathy and 2 Purtscher like Retinopathy who had ASHH on SD OCT imaging. Modalities like Colour fundus photography, cross-sectional OCT, OCT angiography (OCTA) and fluorescein angiography were used. Presence ASHH in Purtscher Retinopathy and Purtscher like retinopathy points towards a deep capillary plexus insult and has prognostic implications.

Concomitant paracentral acute middle maculopathy and acute macular neuroretinopathy in eyes post-blunt trauma.

Purpose: To analyze the imaging characteristics and the clinical course of patients showing concomitant paracentral acute middle maculopathy (PAMM) and acute macular neuroretinopathy (AMN) post-blunt trauma. Methods: PAMM and AMN lesions post-blunt trauma diagnosed on enhanced depth imaging optical coherence tomography (EDI-OCT) were recruited for the study. Results: : Thirteen eyes of 13 individuals with a history of blunt trauma were included in the study, of whom 11 (85%) were males. Mean age of the patients was 33.62 (range 16-67) years. Mean visual acuity at presentation and the last visit was 1.67 log of minimum angle of resolution (logMAR) and 0.82 logMAR, respectively. Mean interval between trauma and imaging was 5.08 (range 1-15) days. All patients had unilateral involvement, with the right eye being involved in 10 patients (77%). All patients had concomitant PAMM and AMN lesions. Conclusion: : Presence of coincident PAMM and AMN suggests a common pathophysiologic etiology, but the description of concomitant PAMM and AMN in the setting of blunt trauma to eye is hitherto unreported. Identifying AMN in a setting of PAMM requires meticulous examination of the OCT and OCTA images. It can be a cause of suboptimal visual recovery in such eyes.

Systematic review with meta-analysis: incidence of variceal hemorrhage in patients with cirrhosis undergoing transesophageal echocardiography.

BACKGROUND: The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by cardiology professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. AIM: To perform a systematic review to quantify the risk of bleeding complications in patients with cirrhosis following TEE. METHODS: Two reviewers searched Ovid MEDLINE, MEDLINE In-Process and EMBASE databases from January 1992 to May 2021 for studies reporting bleeding complications from TEE in patients with cirrhosis. We calculated the pooled incidence rate of bleeding events using the metaprop command with a random effect model. RESULTS: We identified 21 studies comprising 4050 unique patients with cirrhosis; 9 studies (n = 3015) assessed the risk of intraoperative TEE during liver transplant (LT) and 12 studies (n = 1035) assessed bleeding risk in patients undergoing TEE for other indications. The pooled incidence of bleeding post-TEE was 0.37% (95% CI 0.04-0.94%) across all studies. Bleeding complications were low among patients undergoing TEE during LT as well as those undergoing TEE for other diagnostic reasons (0.97% vs. 0.004%) and among studies with mean MELD >18 compared to those with mean MELD <18 (0.43% vs. 0.08%). Few studies had a comparator arm, and data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were limited across studies. CONCLUSIONS: The risk of bleeding complications following TEE is low in patients with cirrhosis, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.

A Systematic Review of Repeat Fecal Occult Blood Tests for Colorectal Cancer Screening.

Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality. Failure to complete repeat tests may compromise screening effectiveness. We conducted a systematic review of repeat FOBT across diverse health care settings. We searched MEDLINE, Embase, and the Cochrane Library for studies published from 1997 to 2017 and reported repeat FOBT over ≥2 screening rounds. Studies (n = 27 reported in 35 articles) measured repeat FOBT as (i) proportion of Round 1 participants completing repeat FOBT in Round 2; (ii) proportion completing two, consecutive FOBT; or (iii) proportion completing ≥3 rounds. Among those who completed FOBT in Round 1, 24.6% to 89.6% completed repeat FOBT in Round 2 [median: 82.0%; interquartile range (IQR): 73.7%-84.6%]. The proportion completing FOBT in two rounds ranged from 16.4% to 80.0% (median: 46.6%; IQR: 40.5%-50.0%), and in studies examining ≥3 rounds, repeat FOBT ranged from 0.8% to 64.1% (median: 39.2%; IQR: 19.7%-49.4%). Repeat FOBT appeared higher in mailed outreach (69.1%-89.6%) compared with opportunistic screening (24.6%-48.6%). Few studies examined correlates of repeat FOBT. In summary, we observed a wide prevalence of repeat FOBT, and prevalence generally declined in successive screening rounds. Interventions that increase and maintain participation in FOBT are needed to optimize effectiveness of this screening strategy.

Split- versus single-dose preparation tolerability in a multiethnic population: decreased side effects but greater social barriers.

BACKGROUND: This study was performed to compare patient-reported tolerability and its barriers in single- vs. split-dose 4-L polyethylene glycol (PEG) bowel preparation for colonoscopy in a large multiethnic, safety-net patient population. METHODS: A cross-sectional, dual-center study using a multi-language survey was used to collect patient-reported demographic, medical, socioeconomic, and tolerability data from patients undergoing outpatient colonoscopy. Univariate and multivariate analyses were used to identify demographic and clinical factors significantly associated with patient-reported bowel preparation tolerability. RESULTS: A total of 1023 complete surveys were included, of which 342 (33.4%) completed single-dose and 681 (66.6%) split-dose bowel preparation. Thirty-nine percent of the patients were Hispanic, 50% had Medicaid or no insurance, and 34% had limited English proficiency. Patients who underwent split-dose preparation were significantly more likely to report a tolerable preparation, with less severe symptoms, than were patients who underwent single-dose preparation. Multiple logistic regression revealed that male sex and instructions in the preferred language were associated with tolerability of the single-dose preparation, while male sex and concerns about medications were associated with tolerability of the split-dose preparation. CONCLUSIONS: In a large multiethnic safety-net population, split-dose bowel preparation was significantly more tolerable and associated with less severe gastrointestinal symptoms than single-dose preparation. The tolerability of split-dose bowel preparation was associated with social barriers, including concerns about interfering with other medications.