Matched Analysis of Surgical Versus Percutaneous Revascularization for Left Main Coronary Disease.

BACKGROUND: Percutaneous coronary intervention (PCI) is being performed more frequently for left main coronary artery disease (LMCAD). This study evaluated a real-world propensity-matched analysis of surgical vs percutaneous revascularization for LMCAD. METHODS: Adults (≥18 years of age) at a single academic institution undergoing coronary artery bypass grafting (CABG) or PCI for left main stenosis greater than or equal to 50% between 2010 and 2018 were examined. Greedy propensity-matching techniques were used to generate well-matched cohorts, and Kaplan-Meier analysis was used to compare survival. Multivariable Cox models were created for 5-year mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: A total of 1091 patients with LMCAD were identified (898 CABG, 193 PCI). Patients undergoing PCI were significantly older (77 years of age vs 68 years of age; P < .001), more likely to have heart failure (26.94% vs 13.14%; P < .001), and less likely to have 3-vessel disease (42.49% vs 65.59%; P < .001). Propensity matching yielded 215 CABG and 134 PCI well-matched patients. In the matched analysis, 1-year (77.61% vs 88.37%) and 5-year (48.77% vs 75.62%) survival were lower with PCI. Rates of MACCE at 5 years were also higher with PCI (64.93% vs 32.56%; P < .001). Rates of both myocardial infarction (19.40% vs 7.44%; P = .001) and repeat revascularization (26.12% vs 7.91%; P < .001) were higher with PCI. After risk adjustment, CABG remained associated with reduced risk of mortality (hazard ratio, 0.40; 95% confidence interval, 0.29-0.54; P < .001) and MACCE (hazard ratio, 0.37; 95% confidence interval, 0.28-0.48; P < .001) at 5 years. CONCLUSIONS: This real-world, propensity-matched analysis demonstrates substantial advantages in survival and MACCE with CABG for LMCAD, supporting surgical revascularization in this clinical setting in appropriate operative candidates.

Outcomes in Multivessel Coronary Disease Stratified by The Society of Thoracic Surgeons Risk.

BACKGROUND: Surgical risk stratified outcomes after contemporary revascularization strategies have not been well described. We report these outcomes in patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for multivessel coronary disease. METHODS: A total of 5836 patients with multivessel disease who underwent CABG (n = 4420) or PCI (n = 1416) were included in this retrospective observational analysis. Data were stratified based on The Society of Thoracic Surgeons risk score. A score less than 4% was considered low risk and a score greater than or equal to 4% was considered intermediate-high risk. Outcomes included mortality, inpatient readmissions, and repeat revascularizations. RESULTS: In the CABG population, 3863 (87.3%) were low risk and 557 (12.6%) were intermediate-high risk. The 5-year mortality for the low-risk cohort was 10.9% (95% confidence interval [CI], 9.83%-12.05%), and for the intermediate-high-risk cohort it was 40.1% (95% CI, 35.76%-44.54%). Among those undergoing PCI, 1163 (82.1%) were low risk, while 249 (17.6%) were intermediate-high risk. The 5-year mortality for the low-risk cohort was 21.6% (95% CI, 19.10%-24.26%), and for the intermediate-high-risk cohort it was 61.8% (95% CI, 54.72%-68.70%). CONCLUSIONS: This study reports outcomes stratified by surgical risk after PCI or CABG in patients with multivessel coronary disease. These data can help guide the revascularization strategy choice for individual patients.

A New Method for Visualizing Drusen and Their Progression in Flood-Illumination Adaptive Optics Ophthalmoscopy.

Purpose: Drusen are dynamic sub-RPE deposits that are risk factors for late-stage age-related macular degeneration (AMD). Here we show a new imaging method using flood-illumination adaptive optics (FIAO) that reveal drusen with high contrast and resolution. Methods: A fovea-centered 4° × 4° FIAO image and eight surrounding images with gaze displaced by ±2° vertically and horizontally were acquired. Clinical color fundus and spectral-domain optical coherence tomography were acquired for clinical grading and comparison. Custom software registered overlapping FIAO images and fused the data statistically to generate a fovea-centered 4° × 4° gaze-dependent image. Our dataset included 15 controls (aged 31-72) and 182 eyes from 104 AMD patients (aged 56-92), graded as either normal aging (n = 7), and early (n = 12), intermediate (n = 108) and late AMD (n = 42); 27 had subretinal drusenoid deposits (SDDs), and 83 were imaged longitudinally. Results: No gaze varying structures were detected in young eyes. In aging eyes with no evidence of age-related changes, putative drusen <20 µm in diameter were visible. Gaze-dependent images revealed more drusen and many smaller drusen than visible in color fundus images. Longitudinal images showed expansion and fusion of drusen. SDDs were lower contrast, and RPE atrophy did not yield a consistent signal. Conclusions: Gaze-dependent imaging in a commercially available FIAO fundus camera combined with image registration and postprocessing permits visualization of drusen and their progression with high contrast and resolution. Translational Relevance: This new technique offers promise as a robust and sensitive method to detect, map, quantify, and monitor the dynamics of drusen in aging and AMD.

Somatic KRAS mutation affecting codon 146 in linear sebaceous nevus syndrome.

Linear Sebaceous Nevus Syndrome is a rare disorder that presents with nevus sebaceus in association with corneal dermoids, colobomas, choroidal osteomas, and arachnoid cysts. It is thought to represent a mosaic RASopathy. These are disorders characterized by postzygotic somatic mutation in genes involved in RAS/MAPK signaling pathway. In this report we describe two patients with linear sebaceous nevus syndrome found to have mutations in codon 146 of KRAS with evidence of mosaicism. This specific mutation has previously been reported in Oculoectodermal Syndrome and Encephalocraniocutaneous Lipomatosis, two other mosaic RASopathies with predominantly cerebrooculocutaneous manifestations. These findings suggest that, while initially classified as different syndromes, these disorders should be evaluated and managed as a spectrum of related disorders.

Seizure-related injuries in inadequately treated epilepsy patients: A case-control study.

PURPOSE: To compare epilepsy-related injuries in untreated or inadequately treated patients and patients on adequate treatment. METHODS: In a cross-sectional case-control study, seizure-related injuries in patients who were either on no treatment or inadequate treatment were compared with another group of patients receiving appropriate evidence-based epilepsy treatment. The inadequately treated patients or 'cases' were drawn from an outreach epilepsy clinic while the adequately treated patients or 'controls' were recruited from a tertiary care facility providing comprehensive epilepsy management. RESULTS: The odds of injury were eight times higher in inadequately treated patients or cases compared to the adequately treated patients or controls. After adjusting for gender, epilepsy duration, seizure frequency, current medication, and number of AEDs, the odds of injury were 15. 8 times higher in the cases. Major injuries such as burns, fractures, and tooth injuries were also higher in the cases. CONCLUSION: Untreated or inadequately treated epilepsy patients have a significantly higher risk of injuries. With adequate treatment, some of the risks of injury can be mitigated.

Developing a pediatric ophthalmology telemedicine program in the COVID-19 crisis.

PURPOSE: To describe our methodology for implementing synchronous telemedicine during the 2019 novel coronavirus (COVID-19) pandemic. METHODS: A retrospective review of outpatient records at a single children's hospital from March 21 to April 10, 2020, was carried out to determine the outcome of already-scheduled face-to-face outpatient appointments. The week leading up to the March 21, all appointments in the study period were categorized as follows: (1) requiring an in-person visit, (2) face-to-face visit that could be postponed, and (3) consultation required but could be virtual. Teams of administrators, schedulers, and ophthalmic technicians used defined scripts and standardized emails to communicate results of categorization to patients. Flowcharts were devised to schedule and implement telemedicine visits. Informational videos were made accessible on social media to prepare patients for the telemedicine experience. Simultaneously our children's hospital launched a pediatric on-demand e-consult service, the data analytics of which could be used to determine how many visits were eye related. RESULTS: A total of 237 virtual ophthalmology consult visits were offered during the study period: 212 were scheduled, and 206 were completed, of which 43 were with new patients and 163 with returning patients. Following the initial virtual visit, another was required on average in 4 weeks by 21 patients; in-person follow-up was required for 170 patients on average 4.6 months after the initial virtual visit. None needed review within 72 hours. The pediatric on-demand service completed 290 visits, of which 25 had eye complaints. CONCLUSIONS: With proper materials, technology, and staffing, a telemedicine strategy based on three patient categories can be rapidly implemented to provide continued patient care during pandemic conditions. In our study cohort, the scheduled clinic e-visits had a low no-show rate (3%), and 8% of the on-demand virtual access for pediatric care was eye related.

Diagnosing Lyme Carditis Presenting With Complete Heart Block.

Diagnosing self-limited conduction abnormality of Lyme carditis in absence of pathognomonic skin rash or history of tick bite is challenging but necessary to avoid placement of pacemaker particularly in young patients. High degree of clinical suspicion, rapidly progressing conduction block and prompt response to antibiotics may help in diagnosis.

The Probable Mechanism of Traumatic Angle Recession and Cyclodialysis.

During blunt ocular trauma, the anteroposterior compressive forces confronted lead to consequent equatorial expansion of the globe. This may result in ciliary body trauma, typically manifesting as angle recession or cyclodialysis. The authors hypothesize that a likely asymmetric contraction between the longitudinal and circular ciliary fibers, and an intrinsic weak "oblique buffer zone" creates a plane of separation between the 2, resulting in angle recession. When stronger forces are met with, the equatorial expansion of the sclera may outperform the ability of the ciliary body to follow it, and the taut longitudinal ciliary fibers may subsequently disinsert from the scleral spur causing cyclodialysis. In addition to this, the routinely thought dismembering aqueous jets directed toward the angle may also accentuate ciliary body trauma. Therefore, the vivid distractive external forces along with the complex ciliary muscle anatomy and differential functionality may play a crucial role in causation of post-traumatic angle recession and cyclodialysis.

Increasing antibiotic resistance in Clostridioides difficile: A systematic review and meta-analysis.

BACKGROUND: Decreases in clinical response of Clostridioides difficile to antibiotics used for its treatment have raised concerns regarding antibiotic resistance. We conducted a systematic review and meta-analysis to study the resistance rates of C. difficile to various antibiotics over time. METHODS: We systematically searched MEDLINE, Embase, and Web of Science from inception through 03/31/2017 for observational studies assessing antibiotic resistance rates in C. difficile. Weighted summary estimates were calculated using inverse variance heterogeneity models [MetaXL software (v. 5.3)]. A priori subgroup analyses were done (by study year, continent, susceptibility testing method, origin of isolates); ribotype 027 strains were analyzed separately. RESULTS: From 1982 to 2017, 60 studies (8336 isolates) were analyzed. Fifty-three studies reported vancomycin resistance; weighted pooled resistance (WPR), 2.1% (95% CI, 0%-5.1%; I2 = 95%). Fifty-five studies reported metronidazole resistance; WPR, 1.9% (95% CI, 0.5%-3.6%; I2 = 89%). Compared to the period before 2012, vancomycin resistance increased by 3.6% (95% CI, 2.9%-4.2%; P < 0.001) after 2012, and metronidazole resistance decreased by 0.8% (95% CI, 0.1%-1.5%; P = 0.02). No isolates were resistant to fidaxomicin. CONCLUSION: Resistance of C. difficile to vancomycin is increasing, with a smaller, declining resistance to metronidazole; there is significant heterogeneity between studies. Ongoing monitoring of resistance to commonly used antibiotics is required.

Pathomechanism of traumatic indirect choroidal rupture.

The probable chain of events responsible for choroidal rupture is as follows. During high-speed orbital injuries, the protective ocular reflexes position the eye in an elevated, and abducted position. At this point in time, the anteroposterior compressive forces on to the globe create an eccentrically positioned circle of damaging currents along the posterior ocular coats against a relatively static optic nerve. Because of this eccentricity, a longer radius of curvature is expected to lie along the temporal half of the globe leading to an elastic recoil of the retinal and scleral layers and a fracture along the RPE-Bruch's-Choriocapillaris complex manifesting clinically as choroidal rupture.

Ocular Adnexal Amyloidosis: A Mass Spectrometric Analysis.

PURPOSE: Ocular adnexal amyloidosis (OAA) may represent localized manifestation of an underlying systemic process. Accurate identification of the amyloid fibrils can guide the systemic evaluation and treatment. The aim of this study was to characterize subtypes of OAA using immunohistochemistry and mass spectrometric analysis and to correlate with ocular involvement and systemic association. DESIGN: Retrospective case series. METHODS: Review of patients with OAA subtyped by immunohistochemistry and mass spectrometric analysis at the Cleveland Clinic from June 1995 to June 2017. RESULTS: While immunohistochemistry identified AL amyloid protein in 67% (4/6) of specimens tested, mass spectrometry identified AL amyloid protein in all specimens (10/10). AL lambda was identified in 5 (50%) samples, kappa in 3 (30%), and both kappa and lambda light chains in 2 (20%). The 5 cases of conjunctival amyloidosis were either AL lambda only (3 cases) or both lambda and kappa (2 cases). There were 3 cases that had associated systemic involvement. Two of these had eyelid skin involvement and AL kappa amyloidosis and the other patient had uveal involvement and AL lambda amyloidosis. CONCLUSIONS: Primary amyloidosis-AL is the most common form diagnosed by mass spectrometric analysis in patients with OAA. Immunohistochemistry is ineffective in the characterization of the amyloid deposits in a significant number of cases. Evaluation to exclude systemic involvement or associated underlying lymphoproliferative disorder is warranted.

Low Risk of Primary Clostridium difficile Infection With Tetracyclines: A Systematic Review and Metaanalysis.

Background: The choice of antibiotics for systemic infections in patients with a high risk of Clostridium difficile infection (CDI) remains a clinical practice dilemma. Although some studies suggest that tetracyclines may be associated with a lower risk of CDI than other antibiotics, other results are conflicting. We conducted a systematic review and metaanalysis of studies that assessed the risk of CDI with tetracyclines compared to other antibiotics. Methods: We conducted a systematic search of Medline, Embase, and Web of Science from January 1978 through December 2016 to include studies that assessed the association between tetracycline use and risk of CDI. Weighted summary estimates were calculated using generalized inverse variance with a random-effects model using RevMan 5.3. Study quality was assessed using the Newcastle-Ottawa scale. Results: Six studies (4 case control, 2 cohort) with patient recruitment between 1993 and 2012 were included. Metaanalysis using a random-effects model, demonstrated that tetracyclines were associated with a decreased risk of CDI (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.47-0.81; P < .001). There was significant heterogeneity, with an I2 of 53% with no publication bias. Subgroup analysis of studies that evaluated the risk of CDI with doxycycline alone also demonstrated a decreased risk of CDI (OR, 0.55; 95% CI, 0.40-0.75; P < .001). Conclusions: Metaanalyses of existing studies suggest that tetracyclines may be associated with a decreased risk of CDI compared with other antimicrobials. It may be reasonable to use tetracyclines whenever appropriate to decrease CDI associated with antibiotic use.

Comparative study of anatomical landmark-guided versus ultrasound-guided suprascapular nerve block in chronic shoulder pain.

BACKGROUND: Suprascapular nerve block (SSNB) is an effective method for the treatment of shoulder disorders. The present study was conducted to evaluate and compare the effectiveness of SSNB under ultrasonographic guidance with anatomical landmark-guided (LMG) technique in the treatment of chronic shoulder pain. MATERIALS AND METHODS: A total of fifty patients with shoulder pain were enrolled in the present prospective randomized study. Patients in Group I (n = 25) received SSNB using the anatomical LMG as technique described by Dangoisse, in whom a total of 6 ml of drug (5 ml of 0.25% bupivacaine and 40 mg methylprednisolone) was injected. Group II patients (n = 25) were given SSNB using the ultrasound guidance with the same amount of drug. Pain was measured using visual analog scale (VAS), range of motion and Shoulder Pain and Disability Index (SPADI) were recorded. Observations were recorded before the block, immediately after the block, and 1 and 4 weeks after the block. RESULTS: There was no statistically significant difference between the VAS score, range of motion and SPADI before the procedure (P > 0.05) in both the groups. Both the groups showed statistically similar improvement of VAS, range of motion and SPADI at 4-week (P > 0.05) follow-up. In Group I, VAS decreased from baseline value of 6.64 ± 1.50-2.04 ± 0.94 at 4 weeks (P < 0.001). In Group II, the VAS decreased from 6.92 ± 1.00 to 1.84 ± 1.03 at 4 weeks (P < 0.01). CONCLUSION: In our study, both the techniques have produced comparable relief of pain, improvement in shoulder movement, and decreased SPADI 4 weeks after the block.

Evaluation of efficacy of dexmedetomidine versus propofol for sedation in children undergoing magnetic resonance imaging.

BACKGROUND: A deep level of sedation is required for magnetic resonance imaging (MRI) in children to ensure optimum image quality. The present study was conducted to evaluate the efficacy and safety of dexmedetomidine versus propofol for sedation in children undergoing MRI. MATERIALS AND METHODS: A total of sixty children aged 2-10 years, having physical status 1 or 2 according to the American Society of Anesthesiologists, undergoing MRI were included in the study. Group D: (n = 30) received injection dexmedetomidine 2 µg/kg for 10 min followed by continuous infusion of 1.0 µg/kg/h. Group P (n = 30) received injection propofol 1 mg/kg bolus followed by continuous infusion of 100 µg/kg/min. RESULTS: The mean time for onset of sedation in Group D was much longer than in Group P (P = 0.000). Mean duration of sedation was comparable in the two groups. The number of patients requiring increased infusion of study drug was significantly higher in Group D (30%) as compared to Group P (16.7%) (P < 0.05). The average recovery time in Group D was much longer than in Group P (P < 0.001). CONCLUSION: Propofol had an advantage of providing rapid onset of sedation and quicker recovery time. Dexmedetomidine resulted in a better preservation of respiratory rate and oxygen saturation, so it may be more suitable in children who are prone to respiratory depression. Hence, both the drugs could achieve required sedation in children posted for MRI.