Diabetic Retinopathy Screening with Automated Retinal Image Analysis in a Primary Care Setting Improves Adherence to Ophthalmic Care.

PURPOSE: Retinal screening examinations can prevent vision loss resulting from diabetes but are costly and highly underused. We hypothesized that artificial intelligence-assisted nonmydriatic point-of-care screening administered during primary care visits would increase the adherence to recommendations for follow-up eye care in patients with diabetes. DESIGN: Prospective cohort study. PARTICIPANTS: Adults 18 years of age or older with a clinical diagnosis of diabetes being cared for in a metropolitan primary care practice for low-income patients. METHODS: All participants underwent nonmydriatic fundus photography followed by automated retinal image analysis with human supervision. Patients with positive or inconclusive screening results were referred for comprehensive ophthalmic evaluation. Adherence to referral recommendations was recorded and compared with the historical adherence rate from the same clinic. MAIN OUTCOME MEASURE: Rate of adherence to eye screening recommendations. RESULTS: By automated screening, 8.3% of the 180 study participants had referable diabetic eye disease, 13.3% had vision-threatening disease, and 29.4% showed inconclusive results. The remaining 48.9% showed negative screening results, confirmed by human overread, and were not referred for follow-up ophthalmic evaluation. Overall, the automated platform showed a sensitivity of 100% (confidence interval, 92.3%-100%) in detecting an abnormal screening results, whereas its specificity was 65.7% (confidence interval, 57.0%-73.7%). Among patients referred for follow-up ophthalmic evaluation, the adherence rate was 55.4% at 1 year compared with the historical adherence rate of 18.7% (P < 0.0001, Fisher exact test). CONCLUSIONS: Implementation of an automated diabetic retinopathy screening system in a primary care clinic serving a low-income metropolitan patient population improved adherence to follow-up eye care recommendations while reducing referrals for patients with low-risk features.

Medical Malpractice in Nerve Injury of the Upper Extremity.

Background: Medical malpractice accounts for more than $55 billion of annual health care costs. Updated malpractice risk to surgeons and physicians related to upper extremity peripheral nerve injury has not been published. Methods: A comprehensive database analysis of upper extremity nerve injury claims between 1995 and 2014 in the United States was conducted using the Medical Professional Liability Association Data Sharing Project, representing 24 major insurance companies. Results: Nerve injury in the upper extremity accounted for 614 (0.3%) malpractice claims (total of 188 323). Common presenting diagnoses included carpal tunnel syndrome (41%), upper extremity fractures (19%), and traumatic nerve injuries to the shoulder or upper limb (8%). Improper performance (49% of total claims) and claims without evidence of medical error (19%) were the most common malpractice suits. Orthopedic surgeons were the most frequently targeted specialists (42%). In all, 65% of nerve injury claims originated from operative procedures in a hospital, 59% of claims were dismissed or withdrawn prior to trial, and 30% resulted in settlements. Thirty-three percent of claims resulted in an indemnity payment to an injured party, with an average payout of $203 592 per successful suit. Only 8% of claims resulted in a completed trial and verdict, and verdicts were overwhelmingly in favor of the defendant (83%). Conclusions: Most malpractice claims from peripheral nerve injuries in the United States arise from the management of common diagnoses, occur in the operating room, and allege improper performance. Strategies to reduce malpractice risk should emphasize the management of common conditions and patient-physician communication.

Current and new pharmacotherapeutic approaches for glaucoma.

INTRODUCTION: Glaucoma is the leading cause of irreversible blindness worldwide. Medical therapy is the main line of treatment of open-angle glaucoma (OAG) and ocular hypertension. Despite the expansion of the glaucoma lineup with the newly approved medication classes, many barriers and issues still exist with topical therapy. Novel non-topical drug delivery may address such issues, adding more options to glaucoma pharmacotherapy. AREAS COVERED: This review outlines current topical therapies for glaucoma, in addition to new medications under trials. The issues with topical therapy, in general, are discussed, as well as the new non-topical drug delivery systems. The authors performed a comprehensive search for published studies on glaucoma medical therapy using the electronic database of PubMed and manual search for each medication and non-topical delivery options. The extra- and intraocular delivery methods and the new topical glaucoma medications under research are covered. EXPERT OPINION: Medical management of glaucoma represents a challenge for both patients and clinicians. Noncompliance (e.g. difficulty with administering the eye drops), cost, side effects, and intraocular pressure fluctuation are the major problems with topical therapy. To overcome such barriers, research should continue in developing new medications and innovation of non-topical drug delivery systems.

COVID-19 Pandemic: Impact on psychiatric care in the United States.

The World Health Organization declared the coronavirus outbreak a pandemic on March 11, 2020. Infection by the SARS-CoV2 virus leads to the COVID-19 disease which can be fatal, especially in older patients with medical co-morbidities. The impact to the US healthcare system has been disruptive, and the way healthcare services are provided has changed drastically. Here, we present a compilation of the impact of the COVID-19 pandemic on psychiatric care in the US, in the various settings: outpatient, emergency room, inpatient units, consultation services, and the community. We further present effects seen on psychiatric physicians in the setting of new and constantly evolving protocols where adjustment and flexibility have become the norm, training of residents, leading a team of professionals with different expertise, conducting clinical research, and ethical considerations. The purpose of this paper is to provide examples of "how to" processes based on our current front-line experiences and research to practicing psychiatrists and mental health clinicians, inform practitioners about national guidelines affecting psychiatric care during the pandemic, and inform health care policy makers and health care systems about the challenges and continued needs of financial and administrative support for psychiatric physicians and mental health systems.

Metastatic Squamous Cell Lung Carcinoma to the Optic Nerve Sheath Mimicking Retrobulbar Optic Neuritis.

Lung carcinoma is the second most common malignancy in both men and women, and may metastasize to the orbit relatively early in the disease course. Metastasis to the optic nerve or its sheath is an exceedingly rare occurrence, and diagnosis may be complicated by nonspecific clinical and radiographic features. The authors present a case of squamous cell lung cancer metastatic to the optic nerve sheath, initially diagnosed as optic neuritis based on its equivocal clinical and radiographic features. This is the first histopathologically confirmed case of squamous cell lung cancer metastatic to the optic nerve sheath in the literature.

External Dacryocystorhinostomy: A Comparison Of Ultrasonic Bone Aspiration To High-Speed Drilling.

PURPOSE: Piezosurgical tools utilize high-frequency ultrasonic oscillations to selectively cut mineralized bone and minimize damage to soft tissue and mucosa. The purpose of this study was to directly compare outcomes in external dacryocystorhinostomy (DCR) using a piezoelectric ultrasonic bone aspirator (UBA) versus a high-speed electric drill with a diamond burr. METHODS: A retrospective chart review was conducted on 145 consecutive patients who underwent external DCR by a single oculoplastic surgeon between 2012 and 2017. Collected data included baseline patient characteristics, presenting symptoms, operative details and complications, and postoperative symptoms. RESULTS: One hundred and seventy-three primary external DCRs performed on 145 patients were included in this study. In total, 61.3% of cases were performed with the UBA and 38.7% with the high-speed drill. Most patients were white (92.4%) and female (67.6%), with a mean age of 57.6 years (range 1-93). Surgical success was achieved in 94.3% of patients in the UBA group and 94.0% in the drill group, with no significant differences between the two arms (p=0.36). Patients who experienced persistent nasolacrimal duct obstruction after surgery underwent endoscopic revision. Operative time was shortened for cases utilizing the UBA (38.9 mins) instead of the high-speed drill (44.7 mins; p=0.01). No significant intraoperative complications occurred in either group. CONCLUSION: The UBA offers comparable outcomes and complication rates to more conventional surgical tools for external DCR. Excellent outcomes, ease of adoption, and potential surgical time savings make the UBA an appealing option for both novice and experienced surgeons.

Oxysterol Signatures Distinguish Age-Related Macular Degeneration from Physiologic Aging.

Macrophage aging is pathogenic in numerous diseases, including age-related macular degeneration (AMD), a leading cause of blindness in older adults. Although prior studies have explored the functional consequences of macrophage aging, less is known about its cellular basis or what defines the transition from physiologic aging to disease. Here, we show that despite their frequent self-renewal, macrophages from old mice exhibited numerous signs of aging, such as impaired oxidative respiration. Transcriptomic profiling of aged murine macrophages revealed dysregulation of diverse cellular pathways, especially in cholesterol homeostasis, that manifested in altered oxysterol signatures. Although the levels of numerous oxysterols in human peripheral blood mononuclear cells and plasma exhibited age-associated changes, plasma 24-hydroxycholesterol levels were specifically associated with AMD. These novel findings demonstrate that oxysterol levels can discriminate disease from physiologic aging. Furthermore, modulation of cholesterol homeostasis may be a novel strategy for treating age-associated diseases in which macrophage aging is pathogenic.

Incidence of Palatal Fistula at Time of Secondary Alveolar Cleft Reconstruction.

OBJECTIVE: We aim to establish consistent time points for evaluating palatal fistula incidence to standardize reporting practices and clarify prospective literature. DESIGN: An institutional retrospective chart review was conducted on 76 patients with unilateral or bilateral complete cleft lip and palate who underwent secondary alveolar bone grafting between 2006 and 2015. MAIN OUTCOME MEASURES: Early fistula incidence rates were reported prior to maxillary expansion, and late fistula rates were reported at the time of alveolar bone grafting. Fistula recurrence rates after primary repair were also measured. RESULTS: We found an early fistula incidence rate of 20% (n = 15) and a late fistula rate of 55% (n = 42) at the time of secondary ABG. Fistulae recurred after initial repair in 43% of cases. Fistulae were classified using the Pittsburgh Classification System as type III (33%), type IV (60%), or type V (7%). The presence of a bilateral cleft ( P = 0.01) and history of early fistula repair ( P < 0.01) were associated with late fistula incidence in a univariate analysis. In a logistic regression model, only early fistula repair was associated with late fistula incidence (OR = 17.17) and overall likelihood of recurrence (OR = 70.89). CONCLUSIONS: Early fistulae should be reported prior to orthodontic expansion of the maxillary arch. Late fistulae should be reported at the time of ABG, following palatal expansion. Patients who develop an early fistula after palatoplasty are likely to experience recurrent fistula formation.

SAR and evaluation of novel 5H-benzo[c][1,8]naphthyridin-6-one analogs as Aurora kinase inhibitors.

Several potent Aurora kinase inhibitors derived from 5H-benzo[c][1,8]naphthyridin-6-one scaffold were identified. A crystal structure of Aurora kinase A in complex with an initial hit revealed a binding mode of the inhibitor within the ATP binding site and provided insight for structure-guided compound optimization. Subsequent SAR campaign provided a potent and selective pan Aurora inhibitor, which demonstrated potent target modulation and antiproliferative effects in the pancreatic cell line, MIAPaCa-2. Furthermore, this compound inhibited phosphorylation of histone H3 (pHH3) in mouse bone morrow upon oral administration, which is consistent with inhibition of Aurora kinase B activity.