Novel Management of Ocular Surface Inflammation in Patients With Ocular Graft-Versus-Host Disease in the Setting of Cataract Surgery.

PURPOSE: To report the outcomes of cataract surgery in patients with ocular graft-versus-host disease (oGVHD) using a novel preoperative immunomodulatory regimen in a collaborative subspecialty care setting. METHODS: Retrospective case series of patients with oGVHD who underwent cataract surgery using a novel preoperative immunomodulatory regimen in a collaborative care setting. A preoperative regimen consisting of pooled human immune globulin 1%, autologous serum 50%, and methylprednisolone 1% eye drops was prescribed. Outcome measures included visual acuity (VA), ocular surface disease index (OSDI) score, lissamine green staining, and complications with a minimum of 2 years of follow-up. RESULTS: Thirty-five eyes from 20 patients with oGVHD were studied. The mean age was 59 years (range 30-70 years). A healthy comparison group included 35 eyes from 24 patients with a mean age of 63 years (range 44-74 years). At the 2-year follow-up, the mean corneal staining score was 2.3/15, the mean OSDI score was 37.5, and the mean VA was 20/30 (logarithm of the minimal angle of resolution 0.17). The global complication rate was 2.8% at the last follow-up with no difference versus a healthy comparison group. CONCLUSIONS: A collaborative care model improving ocular surface health before cataract surgery with dry eye and cataract subspecialists can optimize outcomes in patients with oGVHD.

Outcomes of Blacks Versus Whites with Cardiomyopathy.

Racial disparities in health outcomes have been widely documented in medicine, including in cardiovascular care. While some progress has been made, these disparities have continued to plague our healthcare system. Patients with cardiomyopathy are at an increased risk of death and cardiovascular hospitalizations. In the present analysis, we examined the baseline characteristics and outcomes of black and white men and women with cardiomyopathy. All patients with cardiomyopathy (left ventricular ejection fraction (LVEF) < 50%) cared for at University of Pittsburgh Medical Center (UPMC) between 2011 and 2017 were included in this analysis. Patients were stratified by race, and outcomes were compared between Black and White patients using Cox proportional hazard models. Of a total of 18,003 cardiomyopathy patients, 15,804 were white (88%), 1,824 were black (10%) and 375 identified as other (2%). Over a median follow-up time of 3.4 years, 7,899 patients died. Black patients were on average a decade younger (p <0.001) and demonstrated lower unadjusted all-cause mortality (hazard ratio [HR]: 0.83%; 95% CI 0.77 to 0.90; p < 0.001). However, after adjusting for age and other comorbidities, black patients had higher all-cause mortality compared to white patients (HR: 1.15, 95% CI 1.07 to 1.25; p < 0.001). These differences were seen in both men (HR:1.19, 95% CI 1.08 to 1.33; p < 0.001) and women (HR:1.12, 95% CI 0.99 to 1.25; p = 0.065). In conclusion, our data demonstrate higher all-cause mortality in black compared to white men and women with cardiomyopathy. These findings are likely explained, at least in part, by significantly higher rates of comorbidities in black patients. Earlier interventions targeting these comorbidities may mitigate the risk of progression to heart failure and improve outcomes.

Incidence and Predictors of Complications During Cryoballoon Pulmonary Vein Isolation for Atrial Fibrillation.

BACKGROUND: Cryoballoon pulmonary vein isolation (PVI) has emerged as an alternative to radiofrequency PVI for atrial fibrillation (AF). Data are lacking to define the rates and predictors of complications, particularly phrenic nerve injury (PNI). METHODS AND RESULTS: We evaluated a single-center prospective registry of 450 consecutive patients undergoing cryoballoon PVI between 2011 and 2015. Patients were 59±10 years old, 26% were women, 58% had hypertension, their mean CHA2DS2VASc score was 1.7±1.3, 30% had persistent atrial fibrillation, and 92% received a second-generation 28-mm balloon. Predefined major complications were persistent PNI, pericardial effusion, deep vein thrombosis, arteriovenous fistula, atrioesophageal fistula, bleeding requiring transfusion, stroke, and death. PNI was categorized as persistent if it persisted after discharge from the laboratory. Logistic regression was performed to identify predictors of complications and specifically PNI. We identified a major complication in 10 (2.2%) patients. In 49 (10.8%) patients, at least transient PNI was observed; only 5 persisted beyond the procedure (1.1%). All cases of PNI resolved eventually, with the longest time to resolution being 48 days. We also describe 2 cases of PNI manifesting after the index hospitalization. Regression analysis identified 23-mm balloon use (16.3% versus 5.2%, odds ratio 2.94, P=0.011) and increased age (62.8±7.7 versus 58.7±0.12 years, odds ratio 1.058, P=0.014) as independent significant predictors of PNI. There were no significant predictors of major complications. CONCLUSIONS: In a large contemporary cohort, cryoballoon PVI is associated with low procedural risk, including lower rates of PNI than previously reported. Older age and 23-mm balloon use were associated with PNI. Our low rate of PNI may reflect more sensitive detection methods, including compound motor action potential monitoring and forced double-deflation.

Improved Resource Utilization With Similar Efficacy During Early Adoption of Cryoballoon Pulmonary Vein Isolation as Compared to Radiofrequency Ablation for Paroxysmal Atrial Fibrillation.

BACKGROUND: Cryoballoon pulmonary vein isolation (PVI) is an alternative to radiofrequency (RF) PVI for the treatment of paroxysmal atrial fibrillation (AF). Treatment effect, complication rates, and hospital length of stay are not well established with early use of cryoballoon PVI as compared to more experienced performance of RF PVI. PURPOSE: We reviewed the early experience of cryoballoon PVIs for paroxysmal AF performed by 3 operators at our institution compared to their most recent RF PVIs. All repeat procedures were excluded. Patients were assessed for recurrence of AF at 6 months after the procedure, including a 3-month blanking period. Complications, procedure time, and hospital length of stay were recorded. METHODS: Consecutive patients presenting to the ER with ECG-documented AF at an urban teaching hospital were treated according to a guideline-based care protocol, including a patient toolkit at ER discharge, and systematic referral to a rapid access AF clinic. Consenting patients received questionnaires on AF knowledge, patient satisfaction, and the AFEQT questionnaire at first visit and three-month follow-up. RESULTS: Final analysis included 50 cryoballoon PVIs and 50 RF PVIs. There was no significant difference in baseline characteristics or percentage of patients wearing a home monitor (80% for cryoballoon vs 80% for RF). Symptomatic improvement was experienced by 96% of cryoballoon PVI as compared to 86% of RF PVI patients (p=0.08). Freedom from AF at 6 months was similar between the two groups (70% for cryoballoon and 70% for RF, p=1). Complications were seen in 6% of cryoballoon procedures as compared to 10% of RF procedures (p=0.46). Hospital length of stay was significantly shorter in the cryoballoon group (1.6 vs 3.4 nights, p=0.003). CONCLUSION: At the time of its adoption, cryoballoon PVI is associated with shorter procedure times and hospital length of stay as compared to RF PVI in experienced operators while maintaining similar efficacy outcomes and complication rates.

Oral health knowledge, attitudes and behavior of elementary school teachers in India / Conhecimento, atitudes e comportamento de professores do ensino primário da Índia sobre saúde oral

Objective: This study assessed the oral hygiene attitudes and behavior of elementary school teachers, and determined the influence of variables likelanguage used in class and gender on oral health knowledge, attitudes and behavior. Methods: A stratified random sampling was done to collect a representative sample of teachers fromthe Udaipur district. The total sample encompassed 126 teachers who teach in Hindi, India?s official language along with English, and 104 teachers who teach in English. Of the 230 filled out questionnaires, 12 (5.2%) were rejected either because the answers were inconsistent, such as two replies to the same question, or because the answer was blank. Results: Teachers who taught in English were more likely to brush their teeth twice daily(77.6%) than those who taught in Hindi (63.3%). All teachers who taught in English used tooth paste while only 71.7% of those who taught in Hindi did. Most females (53.1%) used a soft brush to brush their teeth and were more likely (84.4%) to brush twice daily than males. The brushing frequency differed significantly between genders. All female teachers stated that regular tooth brushing prevents tooth decay. Conclusion: Most school teachers presented acceptable knowledge, attitudes and behavior. Teachers should be made aware of their responsibility as rolemodels, and school staff should be given incentives to encourage their participation.

Objetivo: Este estudo avaliou as atitudes e comportamento dos professores do ensino primário com relação à higiene oral e determinou a influência de variáveis, como o idioma usado na sala de aula e o sexo, sobre o conhecimento, atitudes e comportamento com relação à saúde oral. Métodos: Uma amostragem aleatória estratificada foi realizada para a coleta de dados de uma amostra representativa de professores do distrito de Udaipur na Índia. A amostra completa consistiu de 126 professores que ensinam em hindi, um dos idiomas oficiais da Índia junto com o inglês, e 104 professores que ensinam em inglês. Dos 230 questionários preenchidos, 12 (5,2%) foram rejeitados porque havia respostas inconsistentes, por exemplo, duas respostas para a mesma pergunta, ou respostas em branco. Resultados: Professores que ensinavam em inglês (77,6%) eram mais propensos a escovar os dentes duas vezes ao dia que professores que ensinavam em hindi (63,3%). Todos os professores que ensinavam em inglês usavam creme dental enquanto que apenas 71,7% dos que ensinavam em hindi o fazia. A maioria das mulheres (53,1%) usava uma escova macia para escovar os dentes, e as mulheres eram mais propensas (84,4%) que os homens a escovar duas vezes ao dia. A frequência de escovação entre homens e mulheres diferiu significativamente. Todas as mulheres afirmaram que escovação regular previne a cárie dentária. Conclusão: A maioria dos professores apresentou conhecimento, atitudes e comportamento aceitáveis com relação à saúde oral. Os professores devem estar cientes de sua responsabilidade como exemplo para os alunos e os funcionários da escola deveriam receber incentivos para estimular sua participação.