Outcomes of upfront plerixafor use for mobilization in germ cell tumor patients.

High-dose chemotherapy with autologous hematopoietic stem cell transplantation (auto-HSCT) improved 5-year overall survival rates in relapsed/refractory germ cell tumors (GCTs) from 10% to 52%. Nearly 30% of GCT patients are deemed poor mobilizers after receiving several lines of prior therapy. There is limited data available regarding upfront plerixafor use in GCT patients. We predicted upfront plerixafor use would increase the amount of stem cells collected preventing subsequent mobilizations and improve time to curative therapy. A retrospective, single center, chart review of adult GCT patients who received plerixafor upfront for mobilization at a single center between January 1, 2013 and August 31, 2021 was performed. The primary objective was to evaluate the rate of successful peripheral blood CD34+ cell collections. Secondary objectives consisted of describing the impact of plerixafor use on mobilization and assessing auto-HSCT related outcomes. Sixteen patients received plerixafor upfront after an average of three prior lines of therapy (range: 2-5 lines). Successful collection (≥4 × 106 CD34+ cells/Kg collected within four days) was achieved in 15 (94%) patients in a median of one apheresis day (interquartile range: 1-2 days). All patients proceeded to an initial auto-HSCT and 12 patients (75%) completed both transplants as planned. Survival at 12 months was 50%. The significantly higher amount of CD34+ cells collected over less apheresis days demonstrated the clinical utility of upfront plerixafor and its potential to facilitate more efficient stem cell mobilization. There is a need for larger randomized studies with upfront plerixafor use in this unique patient population.

Artificial Intelligence-Generated Draft Replies to Patient Inbox Messages.

Importance: The emergence and promise of generative artificial intelligence (AI) represent a turning point for health care. Rigorous evaluation of generative AI deployment in clinical practice is needed to inform strategic decision-making. Objective: To evaluate the implementation of a large language model used to draft responses to patient messages in the electronic inbox. Design, Setting, and Participants: A 5-week, prospective, single-group quality improvement study was conducted from July 10 through August 13, 2023, at a single academic medical center (Stanford Health Care). All attending physicians, advanced practice practitioners, clinic nurses, and clinical pharmacists from the Divisions of Primary Care and Gastroenterology and Hepatology were enrolled in the pilot. Intervention: Draft replies to patient portal messages generated by a Health Insurance Portability and Accountability Act-compliant electronic health record-integrated large language model. Main Outcomes and Measures: The primary outcome was AI-generated draft reply utilization as a percentage of total patient message replies. Secondary outcomes included changes in time measures and clinician experience as assessed by survey. Results: A total of 197 clinicians were enrolled in the pilot; 35 clinicians who were prepilot beta users, out of office, or not tied to a specific ambulatory clinic were excluded, leaving 162 clinicians included in the analysis. The survey analysis cohort consisted of 73 participants (45.1%) who completed both the presurvey and postsurvey. In gastroenterology and hepatology, there were 58 physicians and APPs and 10 nurses. In primary care, there were 83 physicians and APPs, 4 nurses, and 8 clinical pharmacists. The mean AI-generated draft response utilization rate across clinicians was 20%. There was no change in reply action time, write time, or read time between the prepilot and pilot periods. There were statistically significant reductions in the 4-item physician task load score derivative (mean [SD], 61.31 [17.23] presurvey vs 47.26 [17.11] postsurvey; paired difference, -13.87; 95% CI, -17.38 to -9.50; P < .001) and work exhaustion scores (mean [SD], 1.95 [0.79] presurvey vs 1.62 [0.68] postsurvey; paired difference, -0.33; 95% CI, -0.50 to -0.17; P < .001). Conclusions and Relevance: In this quality improvement study of an early implementation of generative AI, there was notable adoption, usability, and improvement in assessments of burden and burnout. There was no improvement in time. Further code-to-bedside testing is needed to guide future development and organizational strategy.

Building Pandemic-Resilient Primary Care Systems: Lessons Learned From COVID-19.

On January 30, 2023, the Biden Administration announced its intention to end the existing COVID-19 public health emergency declaration. The transition to a "postpandemic" landscape presents a unique opportunity to sustain and strengthen pandemic-era changes in care delivery. With this in mind, we present 3 critical lessons learned from a primary care perspective during the COVID-19 pandemic. First, clinical workflows must support both in-person and internet-based care delivery. Second, the integration of asynchronous care delivery is critical. Third, planning for the future means planning for everyone, including those with potentially limited access to health care due to barriers in technology and communication. While these lessons are neither unique to primary care settings nor all-encompassing, they establish a grounded foundation on which to construct higher-quality, more resilient, and more equitable health systems.

Exploring Co-occurring POLE Exonuclease and Non-exonuclease Domain Mutations and Their Impact on Tumor Mutagenicity.

POLE driver mutations in the exonuclease domain (ExoD driver) are prevalent in several cancers, including colorectal cancer and endometrial cancer, leading to dramatically ultra-high tumor mutation burden (TMB). To understand whether POLE mutations that are not classified as drivers (POLE Variant) contribute to mutagenesis, we assessed TMB in 447 POLE-mutated colorectal cancers, endometrial cancers, and ovarian cancers classified as TMB-high ≥10 mutations/Mb (mut/Mb) or TMB-low <10 mut/Mb. TMB was significantly highest in tumors with "POLE ExoD driver plus POLE Variant" (colorectal cancer and endometrial cancer, P < 0.001; ovarian cancer, P < 0.05). TMB increased with additional POLE variants (P < 0.001), but plateaued at 2, suggesting an association between the presence of these variants and TMB. Integrated analysis of AlphaFold2 POLE models and quantitative stability estimates predicted the impact of multiple POLE variants on POLE functionality. The prevalence of immunogenic neoepitopes was notably higher in the "POLE ExoD driver plus POLE Variant" tumors. Overall, this study reveals a novel correlation between POLE variants in POLE ExoD-driven tumors, and ultra-high TMB. Currently, only select pathogenic ExoD mutations with a reliable association with ultra-high TMB inform clinical practice. Thus, these findings are hypothesis-generating, require functional validation, and could potentially inform tumor classification, treatment responses, and clinical outcomes. SIGNIFICANCE: Somatic POLE ExoD driver mutations cause proofreading deficiency that induces high TMB. This study suggests a novel modifier role for POLE variants in POLE ExoD-driven tumors, associated with ultra-high TMB. These data, in addition to future functional studies, may inform tumor classification, therapeutic response, and patient outcomes.

Teprotumumab-Related Adverse Events in Thyroid Eye Disease: A Multicenter Study.

PURPOSE: To assess the duration, incidence, reversibility, and severity of adverse events (AEs) in patients with thyroid eye disease (TED) treated with teprotumumab. DESIGN: Multicenter, retrospective, observational cohort study. PARTICIPANTS: Patients with TED of all stages and activity levels treated with at least 4 infusions of teprotumumab. METHODS: Patients were treated with teprotumumab between February 2020 and October 2022 at 6 tertiary centers. Adverse event metrics were recorded at each visit. MAIN OUTCOME MEASURES: The primary outcomes measure was AE incidence and onset. Secondary outcome measures included AE severity, AE reversibility, AE duration, proptosis response, clinical activity score (CAS) reduction, and Gorman diplopia score improvement. RESULTS: The study evaluated 131 patients. Proptosis improved by 2 mm or more in 77% of patients (101/131), with average proptosis improvement of 3.0 ± 2.1 mm and average CAS reduction of 3.2 points. Gorman diplopia score improved by at least 1 point for 50% of patients (36/72) with baseline diplopia. Adverse events occurred in 81.7% of patients (107/131). Patients experienced a median of 4 AEs. Most AEs were mild (74.0% [97/131]), 28.2% (37/131) were moderate, and 8.4% (11/131) were severe. Mean interval AE onset was 7.9 weeks after the first infusion. Mean resolved AE duration was 17.6 weeks. Forty-six percent of patients (60/131) demonstrated at least 1 persistent AE at last follow-up. Mean follow-up was 70.2 ± 38.5 weeks after the first infusion. The most common type of AEs was musculoskeletal (58.0% [76/131]), followed by gastrointestinal (38.2% [50/131]), skin (38.2% [50/131]), ear and labyrinth (30.5% [40/131]), nervous system (20.6% [27/131]), metabolic (15.3% [20/131]), and reproductive system (12.2% [16/131]). Sixteen patients (12.2%) discontinued therapy because of AEs, including hearing loss (n = 4), inflammatory bowel disease flare (n = 2), hyperglycemia (n = 1), muscle spasms (n = 1), and multiple AEs (n = 8). CONCLUSIONS: Adverse events are commonly reported while receiving teprotumumab treatment. Most are mild and reversible; however, serious AEs can occur and may warrant treatment cessation. Treating physicians should inform patients about AE risk, properly screen patients before treatment, monitor patients closely throughout therapy, and understand how to manage AEs should they develop. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Breakthrough invasive fungal infections on isavuconazole prophylaxis in hematologic malignancy & hematopoietic stem cell transplant patients.

BACKGROUND: Isavuconazole (ISA) is a newer antifungal used in patients with history of hematologic malignancies and hematopoietic transplant and cellular therapies (HM/TCT). Although it has a more favorable side-effect profile, breakthrough invasive fungal infections (bIFIs) while on ISA have been reported. METHODS: In this single-center retrospective study evaluating HM/TCT patients who received prophylactic ISA for ≥7 days, we evaluated the incidence and potential risk factors for bIFIs. RESULTS: We evaluated 106 patients who received prophylactic ISA. The patients were predominantly male (60.4%) with median age of 65 (range: 21-91) years. Acute myeloid leukemia (48/106, 45.3%) was the most common HM, with majority having relapsed and/or refractory disease (43/106, 40.6%) or receiving ongoing therapy (38/106, 35.8%). Nineteen patients (17.9%) developed bIFIs-nine proven [Fusarium (3), Candida (2), Mucorales plus Aspergillus (2), Mucorales (1), Colletotrichum (1)], four probable invasive pulmonary Aspergillus, and six possible infections. Twelve patients were neutropenic for a median of 28 (8-253) days prior to bIFI diagnosis. ISA levels checked within 7 days of bIFI diagnosis (median: 3.65 µg/mL) were comparable to industry-sponsored clinical trials. All-cause mortality among the bIFI cases was 47.4% (9/19).We also noted clinically significant cytomegalovirus co-infection in 5.3% (1/19). On univariate analysis, there were no significant differences in baseline comorbidities and potential risk factors between the two groups. CONCLUSION: ISA prophylaxis was associated with a significant cumulative incidence of bIFIs. Despite the appealing side-effect and drug-interaction profile of ISA, clinicians must be vigilant about the potential risk for bIFIs.

"Prolonged" venoarterial extracorporeal membrane oxygenation support for respiratory failure: Outcome in an infant.

Extracorporeal membrane oxygenation (ECMO) is a form of extracorporeal life support which provides cardiorespiratory support to patients with potentially reversible pathophysiological processes. ECMO has evolved over the past few decades as a standard technology for neonatal severe respiratory support. However, its use in the pediatric population has increased only since 2009. We report a case of a 9-month infant who required a prolonged (789 h) venoarterial ECMO for severe acute respiratory distress consequent to pneumonia probably secondary to aspiration. He was discharged after this prolonged ECMO run without any obvious unfavorable outcome and is neurodevelopmentally sound at a 26-month follow-up.

Accidental Intraarterial Placement of a Venous Cannula: When In Doubt Take It Out!-A Case Report.

An artery may be entered on the dorsum of the hand with the mistaken belief that it is a vein. Intraarterial injection of drugs is one of the dreadful consequences of accidental intraarterial cannulation. In this case of a 3-month-old infant, we emphasize the fact that careful observation can prevent unintentional intraarterial drug injection via an 'assumed intravenous' cannula and prevent the associated morbidity. When there is a suspicion of an intraarterial placement of venous cannula, it is of paramount significance to confirm before the injection of medications. Aberrant arterial anatomy should be kept in mind, particularly in children on the dorsum of the hand, where placement of an intravenous cannula is usually considered safe.

Genome-wide identification and characterization of ABC transporter superfamily in the legume Cajanus cajan.

Plant ATP-binding cassette (ABC) protein family is the largest multifunctional highly conserved protein superfamily that transports diverse substrates across biological membranes by the hydrolysis of ATP and is also the part of the several other biological processes like cellular detoxification, growth and development, stress biology, and signaling processes. In the agriculturally important legume crop Cajanus cajan, a genome-wide identification and characterization of the ABC gene family was carried out. A total of 159 ABC genes were identified that belong to eight canonical classes CcABCA to CcABCG and CcABCI based on the phylogenetic analysis. The number of genes was highest in CcABCG followed by CcABCC and CcABCB class. A total of 85 CcABC genes were found on 11 chromosomes and 74 were found on scaffold. Tandem duplication was the major driver of CcABC gene family expansion. The dN/dS ratio revealed the purifying selection. The phylogenetic analysis revealed class-specific eight superclades which reflect their functional importance. The largest clade was found to be CcABCG which reflects their functional significance. CcABC proteins were mainly basic in nature and found to be localized in the plasma membrane. The secondary structure prediction revealed the dominance of α-helix. The canonical transmembrane and nucleotide binding domain, signature motif LSSGQ, Walker A, Walker B region, and Q loop were also identified. A class-specific exon-intron pattern was also observed. In addition to core elements, different cis-acting regulatory elements like stress, hormone, and cellular responsive were also identified. Expression profiling of CcABC genes at various developmental stages of different anatomical tissues was performed and it was noticed that CcABCF3, CcABCF4, CcABCF5, CcABCG66, and CcABCI3 had the highest expression. The results of the current study endow us with the further functional analysis of Cajanus ABC in the future.

Changes in low-acuity patient volume in an emergency department after launching a walk-in clinic.

Objective: Unscheduled low-acuity care options are on the rise and are often expected to reduce emergency department (ED) visits. We opened an ED-staffed walk-in clinic (WIC) as an alternative care location for low-acuity patients at a time when ED visits exceeded facility capacity and the impending flu season was anticipated to increase visits further, and we assessed whether low-acuity ED patient visits decreased after opening the WIC. Methods: In this retrospective cohort study, we compared patient and clinical visit characteristics of the ED and WIC patients and conducted interrupted time-series analyses to quantify the impact of the WIC on low-acuity ED patient visit volume and the trend. Results: There were 27,211 low-acuity ED visits (22.7% of total ED visits), and 7,058 patients seen in the WIC from February 26, 2018, to November 17, 2019. Low-acuity patient visits in the ED reduced significantly immediately after the WIC opened (P = 0.01). In the subsequent months, however, patient volume trended back to pre-WIC volumes such that there was no significant impact at 6, 9, or 12 months (P = 0.07). Had WIC patients been seen in the main ED, low-acuity volume would have been 27% of the total volume rather than the 22.7% that was observed. Conclusion: The WIC did not result in a sustained reduction in low-acuity patients in the main ED. However, it enabled emergency staff to see low-acuity patients in a lower resource setting during times when ED capacity was limited.

Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being.

Importance: Understanding of the interplay between the electronic health record (EHR), health care team relations, and physician well-being is currently lacking. Approaches to cultivate interpersonal interactions may be necessary to complement advancements in health information technology with high-quality team function. Objective: To examine ways in which the EHR, health care team functioning, and physician well-being intersect and interact. Design, Setting, and Participants: Secondary qualitative analysis of semistructured interview data from 2 studies used keyword-in-context approaches to identify excerpts related to teams. Thematic analysis was conducted using pattern coding, then organized using the relationship-centered organization model. Two health care organizations in California from March 16 to October 13, 2017, and February 28 to April 21, 2022, participated, with respondents including attending and resident physicians. Main Outcome and Measures: Across data sets, themes centered around the interactions between the EHR, health care team functioning, and physician well-being. The first study data focused on EHR-related distressing events and their role in attending physician and resident physician emotions and actions. The second study focused on EHR use and daily EHR irritants. Results: The 73 respondents included attending physicians (53 [73%]) and resident physicians (20 [27%]). Demographic data were not collected. Participants worked in ambulatory specialties (33 [45%]), hospital medicine (10 [14%]), and surgery (10 [14%]). The EHR was reported to be the dominant communication modality among all teams. Interviewees indicated that the EHR facilitates task-related communication and is well suited to completing simple, uncomplicated tasks. However, EHR-based communication limited the rich communication and social connection required for building relationships and navigating conflict. The EHR was found to negatively impact team function by promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication. In addition, interviewees expressed that physician EHR-related distress affects interactions within the team, eroding team well-being. Conclusions and Relevance: In this study, the EHR supported task-oriented and efficient communication among team members to get work done and care for patients; however, participants felt that the technology shifts attention away from the human needs of the care team that are necessary for developing relationships, building trust, and resolving conflicts. Interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.

Slit-lamp assisted TORic Marker (STORM): A novel corneal axis marker.

Background: Toric Intraocular lenses (IOLs) are supposed to be aligned at a particular axis for spectacle-free vision for distance. The evolution of topographers and optical biometers has made it quite achievable for us to aim the target. However, the result sometimes remains unpredictable. A big aspect of this depends on the preop axis marking for toric IOL alignment. Errors in axis marking have been reduced recently with the array of different toric markers in the market, but still we see postoperative refractive surprises due to faulty marking. Purpose: In this video, we present a novel slit lamp-based toric marker innovation, STORM, which gives us a hands-free approach to a reliable and accurate axis marking on the cornea. The axis marker is a simple modification to our age-old marker, with the advantage of no touch and slit-lamp assistance, which will make it error free and easy to use. Synopsis: The present innovation answers the problem statement of stable, economical, and accurate marking solution. Many a times, hand-holding devices create inaccurate and stressed condition while marking the cornea before corneal surgery. Highlights: The invention can be used for marking of accurate and easy astigmatic axis of a toric IOL preoperatively, that is, before the surgery. If the appropriate device is used to mark the cornea, it would impact the outcome of surgery. This device also makes the patient and the surgeon comfortable to mark the cornea with accuracy and without hesitation. Video link: https://youtu.be/4MVM7HRwz70.

Melphalan on day -1 versus day -2 in patients with plasma cell disorders undergoing autologous stem cell transplant.

High-dose melphalan-based autologous stem cell transplant (ASCT) remains a standard of care for plasma cell disorders (PCDs). Currently, there is variability in the literature surrounding the timing of melphalan administration to avoid potential cytotoxic effects, although the administration has been safely proposed when given at least 8 hours prior to stem cell infusion. The objectives of this study were to assess differences in safety and efficacy outcomes between day -1 and day -2 single-dose melphalan administration in patients undergoing ASCT for PCDs. A retrospective chart review was performed at our institution comparing patients receiving melphalan on day -1 to an equal number of patients receiving melphalan on day -2. The primary endpoint was time to neutrophil engraftment from stem cell infusion. Univariate analyses were performed. Mean time to neutrophil engraftment from stem cell infusion was identical at 10.7 days for both cohorts (p = 0.88). Mean time to platelet engraftment from stem cell infusion was shorter with day -1 administration (17.4 vs. 18.6 days, p = 0.06). Mean time to neutrophil and platelet engraftment from melphalan infusion were significantly shorter with day -1 administration. Similar outcomes were observed for length of hospitalization, infection- and mucositis-related toxicities, hematologic response, transplant-related mortality, and overall survival. Our findings show no difference in time to neutrophil engraftment from stem cell infusion and a trend toward shorter time to platelet engraftment with day -1 administration. Based on our study, day -1 melphalan administration is an acceptable and safe practice.

International Globe and Adnexal Trauma Epidemiology Study (IGATES): Visual outcomes in open globe injuries in rural West India.

BACKGROUND/OBJECTIVES: To evaluate the factors influencing final visual outcome after surgical repair of open globe injuries (OGIs) in a rural population using the International Globe and Adnexal Trauma Epidemiology Study (IGATES) online registry. SUBJECTS/METHODS: Retrospective cohort study of patients with OGI. OGIs were identified from the IGATES database at a tertiary referral eye care centre in rural West India over a period of 12 years. Patient demographics, clinical and pre-operative factors affecting final visual outcome was evaluated. RESULTS: A total of 791 eyes with OGIs were included in data analysis. 11 eyes that were lost to follow-up and 12 eyes with incomplete data were excluded. Most of the patients were male (559, 70.6%) and mean age of all patients was 23.9 years ± 19.4 years. Occupational hazards (including domestic housework) (307, 38.8%) and leisure play (324, 41.0%) were the leading causes of OGI. The most common mechanism of injury was being struck by a wooden stick (250, 31.6%). Univariate analysis of pre-operative variables showed initial visual acuity (VA), zone of injury, size of wound, structures involved in the injury and presence of infection were significant prognostic factors for worse final visual outcome (p < 0.001). Multivariate analysis showed VA ≤ 3/60 or worse at presentation had statistically significantly higher odds ratio of ending up with worse visual outcomes (p < 0.012). CONCLUSIONS: Males in working age groups suffer from OGIs more frequently, usually from agricultural and pastoral activities. Initial VA, zone 3 injuries, corneoscleral wound, large wound size and presence of post-traumatic infections are significant prognostic factors.

Allaying Pediatric Preoperative Anxiety, Where are we Now? - A Nationwide Survey.

Background: Preoperative anxiety (PA) in children is a common phenomenon associated with various negative patient outcomes. Allaying PA is accepted as a standard of care, but its use is not universal and often overlooked. This survey is designed to evaluate the nationwide current practice patterns and attitudes of anesthesiologists toward the practice of allaying PA in children. Materials and Methods: A questionnaire of 25 questions, including information on methods of relieving PA in children, reasons for noncompliance, and associated complications, was framed. It was circulated among members of the Indian Society of Anaesthesiologists through an online survey of Google Forms and manually. Results: Four hundred and fifty anesthesiologists were surveyed. Responses were predominantly from anesthesiologists practicing in medical colleges across the country. Although 97% of the surveyed respondents practiced anxiety-relieving strategies, only 37% used it consistently. Seventy-three percent of anesthesiologists practiced both pharmacological and nonpharmacological techniques. The most common reason for avoiding premedication was an anticipated difficult airway (88%). Inadequate sedation was a commonly reported problem. Ninety-five percent of participants felt that PA-relieving strategies should be integral to pediatric anesthesia practice. The most common reason for not following these practices was an inadequate hospital infrastructure (67%). Ninety-seven percent of the participants believed that more awareness is required on this crucial perioperative issue. Conclusion: Only 37% of the surveyed anesthesiologists consistently used some form of PA-relieving strategy and the practice varied widely. Further improvement and team approach involving anesthesiologists, surgeons, and nurses is required to ensure the quality of pediatric PA-relieving services and establish it as a standard of care.

Perceptual learning with hand - eye coordination as an effective tool for managing amblyopia: A prospective study.

Purpose: Amblyopia is a serious condition resulting in monocular impairment of vision. Although traditional treatment improves vision, we attempted to explore the results of perceptual learning in this study. Methods: This prospective cohort study included all patients with amblyopia who were subjected to perceptual learning. The presenting data on vision, stereopsis and contrast sensitivity were documented in a pretested online format, and the pre- and post-treatment information was compared using descriptive, cross-tabulation and comparative methods on SPSS 2.2. The mean values were obtained, and P < 0.05 was considered statistically significant. Results: The cohort consisted of 47 patients (23 females and 24 males) with a mean age of 14.11 ± 7.13 years. A statistically significant improvement was detected in visual acuity after the perceptual learning session, and the median follow-up period was 17 days. Also, significant improvements were observed in stereopsis but not in the visual outcomes among the age groups. Conclusion: Perceptual learning with hand-eye coordination is an effective method for managing amblyopia. This approach can improve vision in all age groups. However, visual improvement is significantly influenced by ocular alignment.

Incidental Appendiceal Tumors During Appendectomy: A Nineteen-Year Retrospective Review at a Municipal Hospital.

Non-operative management of appendicitis (NOMA) has recently gained popularity, but a concern is that NOMA might miss appendiceal neoplasms. We conducted a retrospective review of 1694 appendectomies done for acute appendicitis at our institution between January 2001 and December 2019 to study the incidence and distribution of appendiceal tumors. We identified 24 appendiceal neoplasms (1.43%), including 9 Low Grade Appendiceal Mucinous Neoplasms (LAMNs), 6 neuroendocrine tumors (NETs), 6 mucoceles, and one each of adenocarcinoma, endometrioma, and neurofibroma. Tumor occurrence had two age peaks, with LAMNs prominent in the 5th and 6th decades of life and NETs in the 2nd and 3rd decades. All patients under age 40 had benign disease. Presence of appendicoliths was independent of the presence of neoplasms. All cases were managed per National Comprehensive Cancer Network (NCCN) guidelines, with twenty cases cured by appendectomy alone. Given these, we conclude that NOMA is safe for patients under 40.

Deciphering the enigma of astigmatism in cataract surgery.

Background: With about 87% of patients with cataracts having astigmatism, management of astigmatism in cataract surgery not only yields an improved unaided visual acuity and image quality but also higher patient satisfaction. The video will give a step-wise guide to cataract surgeons to manage astigmatism with cataracts. Purpose: To hit the bull's eye as far as target refraction is concerned, it is necessary to understand the benefits and limitations of currently available cutting-edge technology and formulae and apply them to the cataract surgery practice. The purpose of the video is to make sure that we have no surprises in our Toric intraocular lens (IOL) planning. Synopsis: After a brief introduction to available modalities for the treatment of astigmatism, a step-wise approach to diagnostics is discussed, which will include the role of corneal topography and aberrometers and their application to planning Toric IOLs. Appropriate planning, implementation, and execution in form of preoperative and intraoperative pearls of using Toric IOLs are shown in the video. This will be followed by troubleshooting and case-based discussions and future perspectives including the possible role of corneal biomechanics. Highlights: What this video adds new is the importance of topography, interpretation of Belin‒Ambrosio display map and the equivalent keratometry reading (EKR) map, aberrometry, and higher order aberration (HOA) analysis and role of biomechanics in Toric IOL planning. Video also highlights the importance of posterior corneal astigmatism and accurate axis marking. With a case-based approach and relevant examples, we are trying to decipher the enigma of astigmatism by giving a step-wise approach for the same. Online Video Link: https://youtu.be/5VuEY_6NdQA.