Black box no more: A cross-sectional multi-disciplinary survey for exploring governance and guiding adoption of AI in medical imaging and radiotherapy in the UK.

BACKGROUND: Medical Imaging and radiotherapy (MIRT) are at the forefront of artificial intelligence applications. The exponential increase of these applications has made governance frameworks necessary to uphold safe and effective clinical adoption. There is little information about how healthcare practitioners in MIRT in the UK use AI tools, their governance and associated challenges, opportunities and priorities for the future. METHODS: This cross-sectional survey was open from November to December 2022 to MIRT professionals who had knowledge or made use of AI tools, as an attempt to map out current policy and practice and to identify future needs. The survey was electronically distributed to the participants. Statistical analysis included descriptive statistics and inferential statistics on the SPSS statistical software. Content analysis was employed for the open-ended questions. RESULTS: Among the 245 responses, the following were emphasised as central to AI adoption: governance frameworks, practitioner training, leadership, and teamwork within the AI ecosystem. Prior training was strongly correlated with increased knowledge about AI tools and frameworks. However, knowledge of related frameworks remained low, with different professionals showing different affinity to certain frameworks related to their respective roles. Common challenges and opportunities of AI adoption were also highlighted, with recommendations for future practice.

Predicting perimetric defects from en face maps of retinal nerve fibre layer reflectance.

PURPOSE: To develop criteria to predict visual hemifields with deep perimetric defects based on retinal nerve fibre layer (RNFL) reflectance, in a transparent process whose components can be assessed by independent laboratories analysing data from their own small groups. METHODS: The analysis was carried out in four stages, using three independent groups of patients-30, 33 and 62 participants-with glaucoma and age-similar controls. The first stage used Group 1 to develop a criterion for RNFL reflectance images at 24, 36 or 48 µm below the inner limiting membrane (ILM). The second stage evaluated the criterion using Group 2. The third stage developed a second criterion to improve performance for Groups 1 and 2 combined. The fourth stage evaluated the second criterion with Group 3. Confidence intervals for sensitivity and specificity were then computed by combining results from all three groups. RESULTS: The first criterion identified all hemifields with deep defects and no hemifields from controls, using a within-eye reference for healthy RNFL. For Group 2, specificity remained high but sensitivity was reduced. The second criterion improved sensitivity by using location-specific reference values. For Group 3, sensitivity remained high but reduced specificity was found. Confidence intervals showed substantial overlap for the two criteria. CONCLUSIONS: We developed two criteria to identify patients with deep perimetric defects with high specificity and sensitivity. Several improvements are warranted: automated identification of the fovea-disc angle and optic disc locations, evaluation of normal variation in patterns of RNFL thickness, improved segmentation of ILM and major vasculature, reduction of within-eye variability in RNFL reflectance of healthy eyes, assessment of effects of image quality, assessment of effects of comorbidity and effectiveness of other devices.

Long-term outcomes of cyclophotocoagulation in refractory pediatric glaucoma: treatment response and success in 262 eyes.

PURPOSE: To report the surgical success and response to treatment for children undergoing cyclophotocoagulation (CPC) for refractory pediatric glaucoma. METHODS: The medical records of children with a diagnosis of glaucoma who underwent a first CPC between May 2000 and May 2020 were reviewed retrospectively. The cumulative probability of success was assessed. For definition 1, treatment success was defined as IOP ≤21 mm Hg at all the visits after the first 3 months without the need for additional glaucoma surgery or repeat CPC. For definition 2, repeat CPC did not constitute failure. RESULTS: Of 300 eyes that underwent CPC, we identified 262 eyes eligible for inclusion. The mean age at time of first treatment was 5.33 ± 5.03 years, with a mean follow-up of 4.3 ± 4.2 years (31 eyes having at least 10 years of follow-up). The success rates for definitions 1 and 2 were 26.7% (95% CI, 21.7%-32.4%) and 46.2% (95% CI, 40.2%-52.3%), respectively. Older age was associated with a lower risk of failure after both single CPC (HR, 0.92; 95% CI, 0.88-0.96; P < 0.001) and multiple CPCs (HR, 0.95; 95% CI, 0.90-1.00, P = 0.073). Of the 262 eyes, 107 (41%) had sustained IOP-lowering with a single treatment and 56 (21%) with multiple treatments; 35 (13%) had a transient response, and 64 (24%) had no response. CONCLUSIONS: Glaucoma control through CPC often requires multiple treatments, with around a quarter of children responding suboptimally. Older children are more likely to exhibit successful IOP lowering.

Cyclophotocoagulation versus Ahmed Glaucoma Implant in Neovascular Glaucoma with Poor Vision at Presentation.

Purpose: To evaluate the outcomes of surgical intervention in eyes with neovascular glaucoma (NVG) and poor vision, comparing the Ahmed glaucoma implant with cyclophotocoagulation (CPC). Patients and Methods: This study is a double-armed cohort retrospective review of medical records of patients with NVG who had a visual acuity of 20/200 or less and underwent one of the two procedures as a primary intervention: Ahmed glaucoma valve (AGV) or cyclophotocoagulation (CPC). The study was conducted at King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, from January 2014 to June 2019, with a total study period of 1 year. The main outcome measures included the surgical success rate, changes in intraocular pressure (IOP), the number of antiglaucoma medications, corrected distance visual acuity, and the reoperation rate for glaucoma. Results: The preoperative IOP was 40.4 ± 10.6 mmHg (Median 40) in the CPC group and 39.4 ± 10.2 mmHg (Median 40) in the AGV group (P = 0.6). At 1 year, the IOP ranged from 12.5 to 28 mmHg (Median 18) in the CPC group and 14 to 21.5 mmHg (Median 17) in the AGV group (P = 0.016). Survival analysis showed a 51% success rate in the CPC group and an 89% success rate at 1 year in the AGV group (p>0.0001). Conclusion: CPC and AGV procedures yielded good outcomes with similar IOP levels 12 months after the surgery. However, AGV demonstrated a higher overall success rate and a lower medication requirement than CPC.

Effect of Rice Husk and Wood Flour on the Structural, Mechanical, and Fire-Retardant Characteristics of Recycled High-Density Polyethylene.

Given the rising consumption of plastic products, it is becoming imperative to prioritize the recycling of plastic items as a solution to reducing plastic waste and environmental pollution. In this context, this research focuses on assessing the impact of incorporating rice husk and wood flour into recycled high-density polyethylene (rec-HDPE) to analyze its mechanical properties, flammability, and thermal stability. The combined rec-HDPE content of wood flour and rice husk varied between 0% and 20%. The rec-HDPE content of maleic anhydride grafted polyethylene (MAPE) was fixed at 3%. Mechanical characteristics such as flexural, tensile, and impact strengths were assessed. Cone calorimetry (CC) tests, limited oxygen index (LOI) tests, and horizontal and vertical burning tests were performed to determine the flammability or fire retardancy of these composites. On the other hand, to characterize the thermal characteristics of these composites, thermogravimetric analysis (TGA) was used. To further characterize the fluctuation in these characteristics, scanning electron microscopy (SEM) and infrared spectroscopy (FTIR) studies were carried out. The mechanical characteristics were found to be increased in response to adding rice husk or wood flour. An 8% increase in tensile strength and a 20% increase in elastic modulus enhancement were recorded for a 20% rice husk-added composite. SEM revealed the reason for the variation in tensile properties, based on the extent of agglomeration and the extent of uniform distribution of fillers in rec-HDPE. Following these lines, the 20% rice husk-added composite also showed a maximum increase of around 6% in its flexural strength and a maximum increase of 50% in its flexural modulus. A decrease in impact strength was recorded for rice husk and wood flour-reinforced composites, compared with unreinforced rec-HDPE. Hybrid composites displayed a lack of mechanical strength due to changes in their nature. FTIR tests were performed for a much more elaborate analysis to confirm these results. Twenty percent of rice husk-added rec-HDPE displayed the best thermal properties that were tested, based on TGA and derivative thermogravimetric (DTG) analysis. This 20% composite also displayed the best fire-retardancy characteristics according to UL 94 tests, cone calorimetry tests, and limited oxygen index tests, due to the barrier created by the silica protective layer. These tests demonstrated that the incorporation of both fillers-rice husk and wood flour-effectively enhanced the thermal, mechanical, and fire-retardant attributes of recycled HDPE.

Black box no more: a scoping review of AI governance frameworks to guide procurement and adoption of AI in medical imaging and radiotherapy in the UK.

Technological advancements in computer science have started to bring artificial intelligence (AI) from the bench closer to the bedside. While there is still lots to do and improve, AI models in medical imaging and radiotherapy are rapidly being developed and increasingly deployed in clinical practice. At the same time, AI governance frameworks are still under development. Clinical practitioners involved with procuring, deploying, and adopting AI tools in the UK should be well-informed about these AI governance frameworks. This scoping review aimed to map out available literature on AI governance in the UK, focusing on medical imaging and radiotherapy. Searches were performed on Google Scholar, Pubmed, and the Cochrane Library, between June and July 2022. Of 4225 initially identified sources, 35 were finally included in this review. A comprehensive conceptual AI governance framework was proposed, guided by the need for rigorous AI validation and evaluation procedures, the accreditation rules and standards, and the fundamental ethical principles of AI. Fairness, transparency, trustworthiness, and explainability should be drivers of all AI models deployed in clinical practice. Appropriate staff education is also mandatory to ensure AI's safe and responsible use. Multidisciplinary teams under robust leadership will facilitate AI adoption, and it is crucial to involve patients, the public, and practitioners in decision-making. Collaborative research should be encouraged to enhance and promote innovation, while caution should be paid to the ongoing auditing of AI tools to ensure safety and clinical effectiveness.

Mechanical, Thermal, and Fire Retardant Properties of Rice Husk Biochar Reinforced Recycled High-Density Polyethylene Composite Material.

This study concentrated on the influence of rice husk biochar on the structural, thermal, flammable, and mechanical properties of recycled high-density polyethylene (HDPE). The percentage of rice husk biochar with recycled HDPE was varied between 10% and 40%, and the optimum percentages were found for the various properties. Mechanical characteristics were evaluated in terms of the tensile, flexural, and impact properties. Similarly, the flame retardancy of the composites was observed by means of horizontal and vertical burning tests (UL-94 tests), limited oxygen index, and cone calorimetry. The thermal properties were characterized using thermogravimetric analysis (TGA). For detailed characterization, Fourier transform infrared spectroscopy (FTIR) and scanning electron microscopy (SEM) tests were performed, to elaborate on the variation in properties. The composite with 30% rice husk biochar demonstrated the maximum increase in tensile and flexural strength, i.e., 24% and 19%, respectively, compared to the recycled HDPE, whereas the 40% composite showed a 22.5% decrease in impact strength. Thermogravimetric analysis revealed that the 40% rice husk biochar reinforced composite exhibited the best thermal stability, due to having the highest amount of biochar. In addition, the 40% composite also displayed the lowest burning rate in the horizontal burning test and the lowest V-1 rating in the vertical burning test. The 40% composite material also showed the highest limited oxygen index (LOI), whereas it had the lowest peak heat release rate (PHRR) value (52.40% reduced) and total heat release rate (THR) value (52.88% reduced) for cone calorimetry, when compared with the recycled HDPE. These tests proved that rice husk biochar is a significant additive for enhancing the mechanical, thermal, and fire-retardant properties of recycled HDPE.

Outcome measures in childhood glaucoma: a systematic review of randomized controlled trials.

PURPOSE: To synthesize the outcome measures used by randomized controlled trials (RCTs) for childhood glaucoma. METHODS: MEDLINE, EMBASE, and Scopus were searched from inception to February 17, 2023. Randomized controlled trials and observational studies related to childhood glaucoma were included. Primary and secondary outcomes were extracted and the data was used to generate a literature review. RESULTS: This review identified 42 unique reports pertaining to childhood glaucomas. Most of the studies originated from Egypt, India, and the USA. Intraocular pressure (IOP) outcomes were the most frequent outcomes studied, followed by clinical outcomes and safety outcomes. Clinical outcomes were the most common secondary outcomes studied, followed by IOP outcomes and safety outcomes. CONCLUSIONS: This systematic review found heterogenous outcomes with IOP outcomes as the most studied primary outcome. As the remaining outcomes were not consistently utilized, this review highlights the need for a consensus on studies of pediatric glaucoma.

Structure-function assessment in glaucoma based on perimetric sensitivity and en face optical coherence tomography images of retinal nerve fiber bundles.

Many studies have assessed structure-function relations in glaucoma, but most without topographical comparison across the central 30°. We present a method for assessing structure-function relations with en face images of retinal nerve fiber layer (RNFL) bundles allowing topographical comparison across much of this retinal area. Forty-four patients with glaucoma (median age 61 years) were recruited and tested with Optical Coherence Tomography (OCT) and perimetry. Six rectangular volume scans were gathered, and then montaged to provide en face views of the RNFL bundles. We calculated the proportion of locations showing a perimetric defect that also showed an en face RNFL defect; and the proportion of locations falling on an RNFL defect that also showed a perimetric defect. A perimetric defect for a location was defined as a total deviation (TD) value equal to or deeper than -4 dB. We found that the median (IQR) number of locations with abnormal RNFL bundle reflectance that also had abnormal TD was 78% (60%) and for locations with abnormal TD that also had abnormal RNFL bundle reflectance was 75% (44%). We demonstrated a potential approach for structure-function assessment in glaucoma by presenting a topographic reflectance map, confirming results of previous studies and including larger retinal regions.

Comparison of the Ahmed and Baerveldt Glaucoma Drainage Implants in the Treatment of Primary Congenital Glaucoma.

PURPOSE: To compare the outcomes of the Ahmed glaucoma valve (AGV) (New World Medical, Inc) with the Baerveldt glaucoma implant (BGI) (Johnson & Johnson Vision) in primary congenital glaucoma (PCG). METHODS: This was a retrospective review of children with PCG who underwent AGV or BGI implantation with a minimum follow-up of 6 months. Main outcome measures were intraocular pressure (IOP), the number of glaucoma medications, success rate, complications, and surgical revisions. RESULTS: The study included 153 eyes of 86 patients (120 eyes in the AGV group and 33 eyes in the BGI group), and the mean follow-up period was 58.7 ± 6.9 months in the AGV group and 58.5 ± 5.0 months in the BGI group. At baseline, IOP was lower in the AGV group (33 ± 6.3 vs 36.4 ± 6.1 months; P = .004) and the number of glaucoma medications was comparable between groups (3.4 ± 0.9 vs 3.6 ± 0.5 medication; P = .183). At 5 years, the mean IOP (18.4 ± 5.0 vs 16.3 ± 2.5 mm Hg; P = .004) and number of glaucoma medications (2.1 ± 1.3 vs 1.0 ± 1.0 medication; P = .001) were significantly less in the BGI group. Furthermore, the surgical success was 53.4% in the AGV group and 78.8% in the BGI group (P = .013). CONCLUSIONS: Both the AGV and BGI were successful in providing adequate IOP control in patients with PCG. Long-term follow-up showed that the BGI was associated with a lower IOP, fewer glaucoma medications, and a higher success rate. [J Pediatr Ophthalmol Strabismus. 2023;60(6):448-454.].

Artificial intelligence education for radiographers, an evaluation of a UK postgraduate educational intervention using participatory action research: a pilot study.

BACKGROUND: Artificial intelligence (AI)-enabled applications are increasingly being used in providing healthcare services, such as medical imaging support. Sufficient and appropriate education for medical imaging professionals is required for successful AI adoption. Although, currently, there are AI training programmes for radiologists, formal AI education for radiographers is lacking. Therefore, this study aimed to evaluate and discuss a postgraduate-level module on AI developed in the UK for radiographers. METHODOLOGY: A participatory action research methodology was applied, with participants recruited from the first cohort of students enrolled in this module and faculty members. Data were collected using online, semi-structured, individual interviews and focus group discussions. Textual data were processed using data-driven thematic analysis. RESULTS: Seven students and six faculty members participated in this evaluation. Results can be summarised in the following four themes: a. participants' professional and educational backgrounds influenced their experiences, b. participants found the learning experience meaningful concerning module design, organisation, and pedagogical approaches, c. some module design and delivery aspects were identified as barriers to learning, and d. participants suggested how the ideal AI course could look like based on their experiences. CONCLUSIONS: The findings of our work show that an AI module can assist educators/academics in developing similar AI education provisions for radiographers and other medical imaging and radiation sciences professionals. A blended learning delivery format, combined with customisable and contextualised content, using an interprofessional faculty approach is recommended for future similar courses.

Risk Factors for Glaucoma Drainage Device Exposure in Children: A Case-Control Study.

PURPOSE: To identify the risk factors for glaucoma drainage device (GDD) exposure in children. DESIGN: Retrospective case-control study. METHODS: The study population comprised children (one eye each) who presented with a history of GDD exposure to a tertiary care eye hospital over the period January 2014 to January 2020. Consecutive children (age <18 years) were included. A control group from the same time period (children without GDD exposure) were included in the ratio of 5 controls to every 1 case of exposure. The main outcome measures included risk factors for exposure (univariate and multivariate analysis). RESULTS: A total of 21 eyes (of 21 children with implant exposure) and 115 eyes (of 115 children without exposure) were included in this study. During the same study period, a total of 494 eyes had undergone GDD implantation, giving an estimated incidence of exposure of 4.25%). In the bivariate analysis, GDD exposure was associated with multiple previous ocular surgeries (P = .001), longer follow-up duration (P < .001), combined procedure at the time of primary implantation (P = .002), and a younger age at the time of primary implantation (P = .006). The former 3 risk factors continued to prove a statistically significant association on multivariable regression analysis. Postoperative use of eye lubricants was more common among children in the control group (P = .007). CONCLUSION: In pediatric glaucoma patients, younger age and combined procedure at the time of primary GDD implantation, in addition to multiple previous ocular surgeries, were associated with greater risk of implant exposure. Postoperative use of eye lubricants may be protective.

Efficacy and Safety of Temporary in situ Stenting of Ahmed Glaucoma Valve in Eyes with High Risk of Hypotony.

Introduction and Objective: To describe a novel technique for providing external ligation of the Ahmed glaucoma valve (AGV) to prevent hypotony in eyes at high risk with a 4/0 nylon stent suture and report outcomes compared to ligation with an absorbable vicryl suture and no ligation in terms of efficacy and safety. Methods: This was a retrospective cohort study investigating the efficacy and safety of in situ stenting compared to an absorbable ligature and the standard care, in high risk eyes, of hypotony. It included 116 patients; 34 in Group A (ligation + stent), 27 in Group B (ligation - stent), and 55 in Group C (no ligation). Results: The mean age (in years) of the participants was 53.94±19.01 in Group A, 44.85±29.92 in Group B and 52.62±24.47 in Group C, 59% (n = 20), 63% (n = 17) and 60% (n = 33) were males, respectively. The follow-up period was at least 6 months (Group A: 9.1±4.2 months, Group B: 9.6±3.4 months and Group C: 10.2±6.4 months). The mean baseline Snellen VA (LogMAR) was 1.82±1.34, 1.30±0.98 and 1.34±1.07 and the mean baseline IOP was 32.50±9.48, 28.22±7.12 and 28.33±10.63 mmHg, in Groups A, B and C, respectively. The failure rates, by the Kaplan Meier Survival curve, were higher 27.3% in Group C (no ligation) compared to 20.6% in Group A (ligation + stent) and 18.5% in Group B (ligation - stent) yet not found to be statistically significant (p = 0.4; log rank test). There was lower hypotony 2.9% in Group A and lower complications 25.9% in Group B but no statistical significance was found amongst the groups. Conclusion: In conclusion, temporary nylon in situ stenting of AGV had lower rates of hypotony. Furthermore, lower failure and complication rates were observed in vicryl only ligated AGV, then nylon in situ stented AGV and lastly in standard AGV controls.

Complicated Massive Left Ventricular Thrombus and Surgical Treatment.

BACKGROUND Left ventricular thrombus formation is a serious complication of cardiac diseases and may result in acute embolic events. Early diagnosis and prompt treatment are crucial steps in preventing complications. There is a lack of consensus when it comes to therapy recommendations such as treatment with anticoagulation, thrombolysis, or surgical thrombectomy. CASE REPORT A 74-year-old woman presented with acute peripheral ischemia in the left and right lower limbs. After running a diagnostic workup, we found a history of fatigue and dyspnea in the preceding 2 weeks; and an echocardiographic examination revealed a large floating mass in the left ventricle with a severely reduced LV ejection fraction of 10-15%. Coronary heart disease was diagnosed with stenosis of the circumflex artery and posterior branch of the right coronary artery, but not necessitating acute treatment. The decision to operate on our patient was based on the acute situation and mobile form of the thrombi as to prevent further thromboembolic complications, and the surgical procedure was performed via a median sternotomy using a left ventricular apical approach due to the size and deep embedment in the ventricular trabeculae. CONCLUSIONS To date there is no standardized therapy in the guidelines for treatment of LV thrombi. Surgical thrombectomy can be performed in patients with mobile and protruding thrombi. In such cases surgery should be performed immediately due to the high risk of systemic embolism.

Preliminary Surgical Outcomes of a Trimmed-Plate Aurolab Aqueous Drainage Implant (AADI) in Eyes at High Risk of Hypotony.

Purpose: We describe the technique of trimming the 350 mm2 AADI glaucoma shunt plate and report preliminary results that test the hypothesis that the IOP-lowering efficacy of the trimmed AADI glaucoma shunt is comparable to the Baerveldt 250 mm2 glaucoma drainage implant with a comparable safety profile to the standard AADI implant. Methods: Consecutive patients who had received the modified trimmed-plate AADI, standard AADI and Baerveldt 250 mm2 were included in the study. This included patients with refractory or primary or secondary glaucoma of all ages and eyes with and without previous glaucoma surgery. The decision for trimming the AADI plate was made according to the surgeon's perceived risk of hypotony. Pre-operative, intraoperative and post-operative data were collected from the hospital electronic medical record system. Surgical success was defined as IOP ≥5 mmHg and ≤21 mmHg on two consecutive visits after 3 months, whilst maintaining at least LP vision and avoiding re-operation for glaucoma. Results: The sample consisted of 69 eyes (19 with trimmed-plate AADI implant; 36 eyes with the standard AADI implant and 14 eyes who received a BGI-250). The mean IOP reduction at 1 year was 15 mmHg for the Baerveldt-250, 10 mmHg for the AADI and 13 mmHg for the trimmed-plate AADI. The surgical success rate of the implants over 1 year was 85.7% (95% CI, 53.9-96.2%) for BGI-250, 81.5% (62.6-91.5%) for standard AADI and 78.2% (51.7-91.3%) for the trimmed AADI. Conclusion: Trimming the plate of the AADI manually may provide a safe and low-cost method of obtaining a successful surgical outcome in eyes at high risk of hypotony.

Incidence and outcomes of microbial keratitis after cyclophotocoagulation to treat childhood refractory glaucoma.

PURPOSE: To report the incidence and outcomes of microbial keratitis (MK) following cyclophotocoagulation (CPC) for treatment of refractory childhood glaucoma (CG) at a single center over a period of 6 years. METHODS: In this cohort study, the medical records of children with CG who underwent CPC and subsequently presented with MK from 2014 to 2020 were reviewed retrospectively. Data were collected on age, type of glaucoma, surgeries before MK, CPC parameters, interval between CPC and MK, presenting symptoms of MK, infiltrate location, bacterial isolates, MK treatment, and outcomes. RESULTS: Among the 312 children who underwent CPC during the study period, 37 eyes of 33 children had MK, with an incidence of 1.8% (95% CI, 0.3-3.2). The median interval between CPC and MK was 4 years (IQR, 2.7-7.4). CPC was repeated once in 20 eyes (54%) and twice in 4 (11%). In 20 eyes, there was no pain at MK onset. The primary isolates were Streptococcus pneumoniae (12/27 [22%]) and Staphylococcus epidermis (8/27 [30%]). MK resolved in 17 eyes (46%) after treatment; 8 eyes (22%) underwent evisceration or had phthisis, and keratoplasty failed in 6 eyes (16%). The absence of pain at presentation with MK was negatively associated with resolution (OR = 5.0 [95% CI, 1.1-23.8]; P = 0.04). CONCLUSIONS: The absence of pain at MK onset may be a proxy for neurotrophic keratitis after CPC and is linked to poor response to management.

Surgical outcomes of phakic, pseudophakic and combined phaco-trabeculectomy in a tertiary care centre in Saudi Arabia.

PURPOSE: To compare the outcomes of phakic, pseudophakic and combined phaco-trabeculectomy in eyes of Saudi patients. METHODS: This was a retrospective cohort study. Eyes of patients with primary open angle glaucoma, primary angle closure glaucoma or secondary exfoliation glaucoma (XFG) that underwent phakic (n = 152), pseudophakic (n = 40) or combined phaco-trabeculectomy (n = 45) at the King Khaled Eye Specialist Hospital, Riyadh from January 2012 to December 2017 were included. The primary outcome measure was the success at 3 years after surgery. Complete success was defined as achieving an intraocular pressure (IOP) of ≥ 6 and ≤ 21 mmHg without topical antiglaucoma medications; qualified success as achieving the same IOP criteria with or without the use of glaucoma medications. Cumulative probabilities of failure were computed using Kaplan-Meier survival analysis. We used Cox regression analysis to identify factors associated with treatment failure. Reduction in mean IOP and AGM over time was estimated using mixed-effects linear models. RESULTS: The mean decrease in IOP at 3 years from baseline in the phakic, pseudophakic and combined groups was 12.0 (95% CI, 9.9, 14.1) mmHg, 10.1 (95% 6.3, 13.9) mmHg, and 6.4 (95% CI, 1.9, 11.0) mmHg, respectively, and was not significantly different from each other. The values for qualified success were also comparable: 95.2% (95% CI: 86.7-99.0), 95.3% (95% CI: 76.2-99.9), 92.3% (95% CI: 64.0-99.8). Failure was significantly associated with postoperative suturelysis (p = 0.004), XFG (p = 0.018) and AGM (p = 0.038). CONCLUSIONS: This is the first study to provide relative surgical outcomes of trabeculectomy, phaco-trabeculectomy and pseudophakic trabeculectomy in Saudi Arabia and did not show any significant difference in terms of overall success.

Intermediate-term Visual Outcomes and Complications of Type 1 Boston Keratoprosthesis With and Without Glaucoma Surgery.

PURPOSE: Glaucoma is a cause of comorbidity in patients receiving the Boston keratoprosthesis (KPro). The aim of this study was to report the outcomes of the Boston KPro with or without glaucoma surgery. METHODS: This was a retrospective single-center cohort study. Patients who underwent Boston KPro from March 2009 to February 2019 were included. One eye per patient (the first surgery) was included in this study. Patients were classified into 2 groups: KPro only (group 1) and KPro with any form of glaucoma procedure (group 2). Main outcome measures were Best-corrected visual acuity (BCVA), functional success (BCVA 20/200 or better), anatomical success (retention of KPro at the last follow-up), and complications. RESULTS: Seventy-one eyes were included: 27 eyes (38%) in group 1 and 44 (62%) in group 2. There was no statistically significant difference in BCVA between groups 1 and 2 at each time point. Of the eyes in group 1, 11% lost light perception vision and 4.5% in group 2 ( P = 0.293). There was no difference in anatomical success with 70% in group 1 and 77% in group 2 ( P = 0.703) at the last follow-up, with a median failure time of 18 months. The functional success was 48% for group 1 and 50% for group 2 ( P = 0.541). CONCLUSIONS: Eyes undergoing KPro with glaucoma surgery before or at the same time carry a similar functional and anatomical success to eyes without glaucoma surgery.

Trauma experiences of rural practitioners: A self assessment.

INTRODUCTION: The purpose of this study was to identify, through self-assessment, how comfortable rural emergency medicine (EM) physicians are in treating critically ill trauma patients, the resources available to treat such patients and their comfort with performing trauma procedures. METHODS: An anonymous self-assessment survey was e-mailed to family physicians practising rural EM in Saskatchewan regarding training, hospital resources, demographics and self-reported comfort with rural trauma management. We included physicians who had provided EM care within the past year in Saskatchewan outside of the major trauma centres. Comfort was measured on a Likert scale. RESULTS: One hundred thirteen physicians out of a total of 479 physicians contacted agreed to participate (23.6%). Thirty-nine percent (n = 31) of respondents were comfortable with paediatric trauma, and 46% (n = 37) were comfortable with vascular trauma. Nineteen percent (n = 15) were comfortable with pericardiocentesis and 25% (n = 19) were comfortable with cricothyroidotomy. In the past 12 months, 21% (n = 17) had performed paediatric endotracheal intubation, 1.3% (n = 1) had performed cricothyroidotomy, 28.8% (n = 23) had performed needle thoracentesis and 20% (n = 16) had performed central venous line access. Those who did their residency training outside of Canada were more comfortable with overall trauma care. Those who had taken emergency department echo were generally more comfortable with trauma procedures. Those who had current advanced trauma life support were more comfortable with less frequently encountered aspects of trauma care. CONCLUSIONS: This self-assessment helped us identify which aspects of rural trauma medicine are the most challenging for rural practitioners. It gave us an understanding of the procedures related to trauma medicine that are the most difficult, which critical resources are available and where training could be focused to benefit rural emergency physicians.

Résumé Introduction: Cette étude avait pour but d'identifier, par l'entremise d'une auto-évaluation, l'aisance des urgentologues en milieu rural à traiter les patients polytraumatisés en état critique, les ressources disponibles pour traiter ces patients et l'aisance avec laquelle ils exécutent les interventions de traumatologie. Méthodes: Un questionnaire d'auto-évaluation anonyme a été envoyé par courriel aux médecins de famille qui pratiquent dans les services d'urgence ruraux de la Saskatchewan; le questionnaire portait sur la formation, les ressources hospitalières, les paramètres démographiques et l'aisance rapportée par les répondants quant à la prise en charge des traumatismes en milieu rural. Nous avons inclus les médecins qui avaient dispensé dans l'année écoulée des soins d'urgence à l'extérieur des grands centres de traumatologie en Saskatchewan. L'aisance était mesurée sur une échelle Likert. Résultats: Sur un total de 479 médecins contactés, 113 ont consenti à participer (23.6%). Trente-neuf pour cent (n = 31) des répondants étaient à l'aise avec les traumatismes pédiatriques et 46% (n = 37) avec les traumatismes vasculaires. Dix-neuf pour cent (n = 15) étaient à l'aise avec la ponction péricardique et 25% (n = 19) avec la cricothyroïdotomie. Dans les 12 mois écoulés, 21% (n = 17) avaient exécuté une intubation endotrachéale pédiatrique, 1.3% (n = 1) une cricothyroïdotomie, 28,8% (n = 23) une thoracentèse à l'aiguille et 20% (n = 16) un accès veineux central. Les médecins qui avaient reçu leur formation en résidence à l'extérieur du Canada étaient plus à l'aise avec les soins de traumatologie en général. Les médecins qui avaient suivi le cours d'échographie du département d'urgence étaient en général plus à l'aise avec les interventions de traumatologie. Les médecins qui avaient une certification advanced trauma life support étaient plus à l'aise avec les aspects moins fréquents des soins de traumatologie. Conclusions: Cette auto-évaluation nous a aidés à déterminer quels aspects de la médecine de traumatologie rurale sont les plus problématiques pour les praticiens en milieu rural. Elle nous a permis de comprendre quelles sont les interventions de traumatologie qui sont les plus difficiles, quelles ressources essentielles sont disponibles et sur quels aspects la formation doit se concentrer pour profiter aux urgentologues en milieu rural. Mots-clés: prise en charge des traumatismes en milieu rural, médecine de traumatologie rurale, Trauma, rural, médecine d'urgence.

Alternative access in high-risk patients in the era of transfemoral aortic valve replacement.

BACKGROUND: We aimed to evaluate the outcomes of transapical and transaortic transcatheter aortic valve replacement (TAVR) in high-risk patients who were not suitable for transfemoral access and had a logistic EuroSCORE-I ≥ 25% and Society of Thoracic Surgeons (STS) score >6%. 'STS/ACC TAVR In-Hospital Mortality Risk App' was evaluated. MATERIAL AND METHODS: Between January 2016 and May 2020, 126 patients at very high risk for aortic valve replacement underwent transapical (n = 121) or transaortic (n = 5) transcatheter aortic valve replacement. TAVR was performed using SAPIEN 3™ or ACURATE TA™ prosthesis. RESULTS: The logistic EuroSCORE-I was 40.6 ± 14.0%, the STS-score 7.9 ± 4.6%, and STS/ACC-score 8.4 ± 3.4%. Valve implantation was successful in all patients. Operative, in-hospital and 30-days mortality, were 0, 7.9, and 13.5%, respectively. Survival was 72% at one year and 48% at four years. Expected/observed in-hospital mortality was 1.0 for the STS-score and 1.06 for the STS/ACC-score. Renal failure, low ejection fraction, and postoperative acute kidney injury, hemorrhage, and vascular complications were identified as independent predictors for 30-day mortality. CONCLUSIONS: Transapical and transaortic TAVR in high-risk patients unsuitable for transfemoral access is still a reasonable alternative in these patients. STS and STS/ACC-score appear to be highly accurate in predicting in-hospital mortality in high-risk patients undergoing TAVR.