OBJECTIVES: To standardize optic nerve sheath diameter (ONSD) point-of-care ultrasonography (POCUS) and improve its research and clinical utility by developing the ONSD POCUS Quality Criteria Checklist (ONSD POCUS QCC). DESIGN: Three rounds of modified Delphi consensus process and three rounds of asynchronous discussions. SETTING: Online surveys and anonymous asynchronous discussion. SUBJECTS: Expert panelists were identified according to their expertise in ONSD research, publication records, education, and clinical use. A total of 52 panelists participated in the Delphi process. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three Delphi rounds and three asynchronous discussion rounds generated consensus on quality criteria (QC). This started with 29 QC in addition to other QC proposed by expert panelists. The QC items were categorized into probe selection, safety, body position, imaging, measurement, and research considerations. At the conclusion of the study, 28 QC reached consensus to include in the final ONSD POCUS QCC. These QC were then reorganized, edited, and consolidated into 23 QC that were reviewed and approved by the panelists. CONCLUSIONS: ONSD POCUS QCC standardizes ONSD ultrasound imaging and measurement based on international consensus. This can establish ONSD ultrasound in clinical research and improve its utility in clinical practice.
AIM: The study explored the perceptions of final-year Australian dental students, directors of nursing, and consumer representatives toward geriatric education provided at Australian undergraduate dental schools. Findings will strengthen and inform future curricula design for dental schools. METHODS: Semi-structured interviews and focus groups were conducted through videoconferencing and in-person interviews, and analyzed using thematic analysis. RESULTS: Thematic analysis found the major themes to include relationships, curriculum variation, resources, and in-service learning experiences. The participants found gaps in the current delivery of undergraduate dental education. Solutions included greater resourcing through funding and time allocated to supervisors and a curriculum dedicated to gerodontology. CONCLUSIONS: Healthcare professional curriculum design must consider the needs of the learners and stakeholders involved in the health of older people. The focus group participants found multiple barriers and gaps to achieving what is required to adequately prepare dental graduates for an older, frail, and care-dependent population. For curricula to be successful, policymakers and education providers must find solutions to ensure that the oral health needs of older Australians are addressed and managed appropriately.
A 15-year-old female presented with headaches and bilateral vision loss. Fundoscopic examination revealed bilateral optic nerve oedema as well as peripheral retinal haemorrhages. Magnetic resonance imaging of the brain showed findings consistent with bilateral optic neuritis. The patient was started on high dose intravenous corticosteroids but her vision failed to improve. The presence of retinal haemorrhages raised concern that a vasculitis was underlying her symptoms, prompting an extensive work-up, which was unrevealing. Plasmapheresis was initiated and the patient's vision eventually improved to 20/20 in both eyes. Ultimately, she was found to be positive for myelin oligodendrocyte glycoprotein (MOG) antibodies, consistent with a diagnosis of MOG-associated optic neuritis. The patient's course was typical for MOG-associated optic neuritis but her peripheral retinal haemorrhages were atypical, which created diagnostic uncertainty. It is important to be aware of the possibility of retinal findings in this disease. We also review potential causes for retinal haemorrhages in optic neuritis.
The ability to make on-field, split-second decisions is critical for National Football League (NFL) game officials. Multiple principles in visual function are critical for accuracy and precision of these play calls, including foveation time and unobstructed line of sight, static visual acuity, dynamic visual acuity, vestibulo-ocular reflex, and sufficient visual field. Prior research has shown that a standardized curriculum in these neuro-ophthalmic principles have demonstrated validity and self-rated improvements in understanding, confidence, and likelihood of future utilization by NFL game officials to maximize visual performance during officiating. Virtual reality technology may also be able to help optimize understandings of specific neuro-ophthalmic principles and simulate real-life gameplay. Personal communication between authors and NFL officials and leadership have indicated that there is high interest in 3D virtual on-field training for NFL officiating. In this manuscript, we review the current and past research in this space regarding a neuro-ophthalmic curriculum for NFL officials. We then provide an overview our current visualization engineering process in taking real-life NFL gameplay 2D data and creating 3D environments for virtual reality gameplay training for football officials to practice plays that highlight neuro-ophthalmic principles. We then review in-depth the physiology behind these principles and discuss strategies to implement these principles into virtual reality for football officiating.
BACKGROUND: Invasive lobular carcinoma (ILC), the most common special type of breast cancer (BC), has unique clinical behaviour and is different from invasive ductal carcinoma of no special type (IDC-NST). However, ILC further comprises a diverse group of tumours with distinct features. This study aims to examine the clinicopathological and prognostic features of different variants of ILC, with a particular focus on characterising aggressive subtypes. METHODS: A large (n = 7140) well-characterised and histologically reviewed BC cohort with treatment and long-term follow-up data was investigated. The cohort was classified based on the WHO classification of tumours into main histological subtypes, including ILC and IDC-NST. ILCs were further classified into variants. Clinicopathological parameters and patient outcomes in terms of BC-specific survival (BCSS) and disease-free survival (DFS) were evaluated. RESULTS: ILC constituted 11% of the cohort. The most common non-classic ILC variants were pleomorphic (pILC) and solid (sILC), constituting 19% of ILC. Compared to classic and related variants (alveolar, trabecular, papillary, and tubulolobular; cILC), pILC and sILC variants were associated with aggressive tumour characteristics. The histologic grade of ILC was an important prognostic variable. The survival patterns identified an aggressive ILC subtype encompassing pILC and high-grade sILC. These tumours, which comprised 14% of the cases, were associated with clinicopathological characteristics of poor prognosis and had high BC-specific death and recurrence rates compared not only to cILC (p < 0.001) but also to IDC-NST (p = 0.02) patients. Contrasting this, cILC patients had significantly longer BCSS and DFS than IDC-NST patients in the first 10 to 15 years of follow-up. Adjuvant chemotherapy did not improve the outcome of patients with aggressive ILC subtypes. CONCLUSIONS: pILC and high-grade sILC variants comprise an aggressive ILC subtype associated with poor prognostic characteristics and a poor response to chemotherapy. These results warrant confirmation in randomised clinical trials.
Generative AI has revolutionized medicine over the past several years. A generative adversarial network (GAN) is a deep learning framework that has become a powerful technique in medicine, particularly in ophthalmology and image analysis. In this paper we review the current ophthalmic literature involving GANs, and highlight key contributions in the field. We briefly touch on ChatGPT, another application of generative AI, and its potential in ophthalmology. We also explore the potential uses for GANs in ocular imaging, with a specific emphasis on 3 primary domains: image enhancement, disease identification, and generating of synthetic data. PubMed, Ovid MEDLINE, Google Scholar were searched from inception to October 30, 2022 to identify applications of GAN in ophthalmology. A total of 40 papers were included in this review. We cover various applications of GANs in ophthalmic-related imaging including optical coherence tomography, orbital magnetic resonance imaging, fundus photography, and ultrasound; however, we also highlight several challenges, that resulted in the generation of inaccurate and atypical results during certain iterations. Finally, we examine future directions and considerations for generative AI in ophthalmology.
Purpose: Patients with increased intracranial pressure and underlying hypertensive emergency may present with optic disc edema. Papilledema in this setting may be a predisposing risk factor for superimposed non-arteritic anterior ischemic optic neuropathy (NAION). We highlight the role of neuroimaging including diffusion-weighted imaging in magnetic resonance imaging that can help to differentiate visual loss from NAION versus papilledema in fulminant IIH with and without hypertension. Observations: A 46-year-old female presented with acute vision loss in the right eye and transient right hemiparesis. Neuro-ophthalmic examination revealed optic disc edema in both eyes. Magnetic resonance imaging (MRI) of the brain with diffusion-weighted imaging (DWI) sequences showed restricted diffusion in the optic nerve head of the affected eye. Lumbar puncture revealed an elevated opening pressure of 34.8 cm H2O confirming increased intracranial pressure. Additionally, literature searches were conducted in the PubMed, Google Scholar and Embase databases to uncover previous cases of patients with ischemic optic neuropathy and restricted diffusion on MRI. Conclusions and importance: We highlight the shared pathophysiology between optic disc edema related visual loss in NAION and papilledema in IIH. We review the overlapping clinical and radiographic findings in these two conditions which may occur simultaneously. The presence of restricted diffusion in the optic nerve head versus in the optic nerve parenchyma may support a diagnosis of superimposed NAION and might influence the decision to perform surgery in cases of IIH with fulminant visual loss. Although restricted diffusion on MRI DWI sequences is often used to define cytotoxic edema related to ischemic infarction in the brain, this radiographic finding alone should not be used to determine the indication for surgery for papilledema related visual loss in fulminant IIH.
Background: Online physician reviews increase transparency in health care, helping patients make informed decisions about their provider. Language processing techniques can quantify this data and allow providers to better understand patients' experiences, perspectives, and priorities. The objective of this study was to assess patient satisfaction and understand the aspects of care that are valued by patients seeking refractive care using sentiment and word frequency analysis. Methods: Written reviews and Star ratings for members of the Refractive Surgery Alliance Society practicing in the United States were collected from Healthgrades, a popular physician rating website. Surgeons with at least one written review were included in the study. Reviews were scored from -1 (most negative) to +1 (most positive) using Valence Aware Dictionary sEntiment Reasoner (VADER). Reviews were stratified by demographic characteristics, namely gender, region, and years in practice. Word frequency analysis was applied to find the most common words and phrases. Results: A total of 254 specialists and 3104 reviews were analyzed, with an average of 4.4/5 stars and mean 48 ratings each. Most physicians had positive reviews (96%, average VADER â= â0.69). Younger physicians (<20 years since residency) had significantly higher Stars rating than senior peers (>20 years) (P â< â0.001). A similar trend was observed in VADER score (0.71 vs 0.69), although not statistically significant (P â= â0.06). No statistical differences were observed between Stars rating and VADER score by gender (P â= â0.66, P â= â0.83) or by geographical region (P â= â0.74, P â= â0.07). "Staff" (n â= â1269), "professional" (n â= â631), "office" (n â= â523), "questions" (n â= â424), and "friendly" (n â= â386) were frequently used in reviews, along with phrases such as "the staff" (n â= â273) and "my questions" (n â= â174). "Surgery" (n â= â719), "staff" (n â= â576), "procedure" (n â= â251), "experience" (n â= â243), and "professional" (n â= â240) were the most common words in positive reviews, while "surgery" (n â= â147), "office" (n â= â86), "staff" (n â= â54), "time" (n â= â47), and "insurance" (n â= â28) were the most commonly used in negative reviews. Conclusions: Both the average Stars and VADER sentiment score suggest a high satisfaction among refractive patients. Word frequency analysis revealed that patients value non-clinical aspects of care, including interactions with staff, insurance coverage, and wait-times, suggesting that improving non-clinical factors could enhance patient satisfaction with refractive surgery.
BACKGROUND: Soft tissue sarcomas (STS), have significant inter- and intra-tumoral heterogeneity, with poor response to standard neoadjuvant radiotherapy (RT). Achieving a favorable pathologic response (FPR ≥ 95%) from RT is associated with improved patient outcome. Genomic adjusted radiation dose (GARD), a radiation-specific metric that quantifies the expected RT treatment effect as a function of tumor dose and genomics, proposed that STS is significantly underdosed. STS have significant radiomic heterogeneity, where radiomic habitats can delineate regions of intra-tumoral hypoxia and radioresistance. We designed a novel clinical trial, Habitat Escalated Adaptive Therapy (HEAT), utilizing radiomic habitats to identify areas of radioresistance within the tumor and targeting them with GARD-optimized doses, to improve FPR in high-grade STS. METHODS: Phase 2 non-randomized single-arm clinical trial includes non-metastatic, resectable high-grade STS patients. Pre-treatment multiparametric MRIs (mpMRI) delineate three distinct intra-tumoral habitats based on apparent diffusion coefficient (ADC) and dynamic contrast enhanced (DCE) sequences. GARD estimates that simultaneous integrated boost (SIB) doses of 70 and 60 Gy in 25 fractions to the highest and intermediate radioresistant habitats, while the remaining volume receives standard 50 Gy, would lead to a > 3 fold FPR increase to 24%. Pre-treatment CT guided biopsies of each habitat along with clip placement will be performed for pathologic evaluation, future genomic studies, and response assessment. An mpMRI taken between weeks two and three of treatment will be used for biological plan adaptation to account for tumor response, in addition to an mpMRI after the completion of radiotherapy in addition to pathologic response, toxicity, radiomic response, disease control, and survival will be evaluated as secondary endpoints. Furthermore, liquid biopsy will be performed with mpMRI for future ancillary studies. DISCUSSION: This is the first clinical trial to test a novel genomic-based RT dose optimization (GARD) and to utilize radiomic habitats to identify and target radioresistance regions, as a strategy to improve the outcome of RT-treated STS patients. Its success could usher in a new phase in radiation oncology, integrating genomic and radiomic insights into clinical practice and trial designs, and may reveal new radiomic and genomic biomarkers, refining personalized treatment strategies for STS. TRIAL REGISTRATION: NCT05301283. TRIAL STATUS: The trial started recruitment on March 17, 2022.
Hot Temperature , Sarcoma , Humans , Radiomics , Sarcoma/diagnostic imaging , Sarcoma/genetics , Sarcoma/radiotherapy , Genomics , Radiation Dosage
INTRODUCTION: Vasculitides are a heterogeneous group of disorders producing inflammation of blood vessels (e.g. arteries or veins). All major vasculitides potentially have ophthalmological symptoms and signs including visual loss. Co-morbidity, multimorbidity, polypharmacy, and geriatric syndromes all play important roles in patient outcomes for these rheumatic conditions in the elderly. This monograph reviews the NCBI PubMed database (Feb 2023) literature on the neuro-ophthalmic and geriatric considerations in vasculitis. AREAS COVERED: Cogan Syndrome, Granulomatosis with Polyangiitis, Giant Cell Arteritis, Polyarteritis Nodosa, Takayasu Arteritis, Vasculitis epidemiology, and neuro-ophthalmological symptoms. EXPERT OPINION: Geriatric patient care for vasculitis with neuro-ophthalmological manifestations can be complicated by the interplay of multiple co-morbidities, polypharmacy, and specific geriatric syndromes. The valuation and treatment of vasculitis and the complications associated with the disease can negatively impact patient care. Advances in noninvasive imaging and updates in diagnostic criteria have enabled increased identification of patients at earlier stages with less severe disease burden. Novel therapeutic agents can be glucocorticoid sparing and might reduce the adverse effects of chronic steroid use. Holistic care models like the 5 M geriatric care model (mind, mobility, medications, multicomplexity, and matters most) allow patients' needs to be in the forefront with biopsychosocial aspects of a patient being addressed.
Open AI's Sora represents a ground-breaking innovation in AI that can generate lifelike and imaginative visual scenes based on text prompts. However, Sora has also produced some new concerns surrounding artificial video generation in medicine. While Sora is highly promising to enhance patient education, facilitate remote consultations and simulate surgical procedures, AI-generated videos also bring technical, legal, and ethical challenges. In this paper, we explore the clinical and ethical implications of Sora's AI-generated videos in the field of medicine.
