Prediction of the small aperture intraocular lens on visual acuity in patients with keratoconus.

PURPOSE: To investigate the impact of corneal higher-order aberrations (HOAs) on predicted corrected distance visual acuity (CDVA) in patients with keratoconus at varying simulated pupil apertures. SETTING: Ophthalmology clinics, Medical University of South Carolina, USA. DESIGN: Retrospective chart review study. METHODS: 56 eyes with keratoconus were examined using Scheimpflug tomography during routine examinations prior to medical intervention. The severity of keratoconus was graded using the Amsler-Krumeich classification. Zernike analysis was used to obtain corneal aberrations using simulated pupil diameters of 6-, 4-, and 2 mm. These data were extrapolated to obtain the total RMS HOAs for a 1.6 mm simulated pupil to evaluate the potential effect of a small aperture intraocular lens. Correlation analysis was used to study the impact and relative contributions of HOAs on CDVA. Convolution of HOAs from OPD-Scan III (NIDEK) provided a clinical method to predict CDVA with different simulated pupil sizes in corneas with irregular astigmatism. RESULTS: There were statistically significant positive correlations between photopic CDVA and the magnitude of total and individual (coma, spherical aberration and trefoil) HOAs in this cohort of keratoconus subjects. A keratoconus case with the small aperture IOL confirms the improvement in vision due to the pinhole effect. CONCLUSIONS: The small aperture IOL is expected to markedly reduce aberrations in keratoconus patients up to Amsler-Krumeich class 4 severity to levels consistent with the levels seen in healthy patients. Convolution of corneal HO aberrations with the ETDRS chart provides a useful simulation of the impact of pinhole optics in aberrated eyes.

Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center.

Introduction: Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes. Methods: This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts. Results: 4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities. Conclusion: Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center. Level of evidence: Level IV, retrospective study.

The comparison of total energy and protein intake relative to estimated requirements in chronic spinal cord injury.

In chronic spinal cord injury (SCI), individuals experience dietary inadequacies complicated by an understudied research area. Our objectives were to assess (1) the agreement between methods of estimating energy requirement (EER) and estimated energy intake (EEI) and (2) whether dietary protein intake met SCI-specific protein guidelines. Persons with chronic SCI (n = 43) completed 3-day food records to assess EEI and dietary protein intake. EER was determined with the Long and Institute of Medicine (IOM) methods and the SCI-specific Farkas method. Protein requirements were calculated as 0·8-1·0 g/kg of body weight (BW)/d. Reporting accuracy and bias were calculated and correlated to body composition. Compared with IOM and Long methods (P < 0·05), the SCI-specific method did not overestimate the EEI (P = 0·200). Reporting accuracy and bias were best for SCI-specific (98·9 %, -1·12 %) compared with Long (94·8 %, -5·24 %) and IOM (64·1 %, -35·4 %) methods. BW (r = -0·403), BMI (r = -0·323) and total fat mass (r = -0·346) correlated with the IOM reporting bias (all, P < 0·05). BW correlated with the SCI-specific and Long reporting bias (r = -0·313, P = 0·041). Seven (16 %) participants met BW-specific protein guidelines. The regression of dietary protein intake on BW demonstrated no association between the variables (ß = 0·067, P = 0·730). In contrast, for every 1 kg increase in BW, the delta between total and required protein intake decreased by 0·833 g (P = 0·0001). The SCI-specific method for EER had the best agreement with the EEI. Protein intake decreased with increasing BW, contrary to protein requirements for chronic SCI.

Reasons for meal termination, eating frequency, and typical meal context differ between persons with and without a spinal cord injury.

Overeating associated with neurogenic obesity after spinal cord injury (SCI) may be related to how persons with SCI experience satiation (processes leading to meal termination), their eating frequency, and the context in which they eat their meals. In an online, cross-sectional study, adults with (n = 688) and without (Controls; n = 420) SCI completed the Reasons Individuals Stop Eating Questionnaire-15 (RISE-Q-15), which measures individual differences in the experience of factors contributing to meal termination on five scales: Physical Satisfaction, Planned Amount, Decreased Food Appeal, Self-Consciousness, and Decreased Priority of Eating. Participants also reported weekly meal and snack frequency and who prepares, serves, and eats dinner with them at a typical dinner meal. Analysis revealed that while Physical Satisfaction, Planned Amount, and Decreased Food Appeal were reported as the most frequent drivers of meal termination in both groups, scores for the RISE-Q-15 scales differed across the groups. Compared to Controls, persons with SCI reported Physical Satisfaction and Planned Amount as drivers of meal termination less frequently, and Decreased Food Appeal and Decreased Priority of Eating more frequently (all p < 0.001). This suggests that persons with SCI rely less on physiological satiation cues for meal termination than Controls and instead rely more on hedonic cues. Compared to Controls, persons with SCI less frequently reported preparing and serving dinner meals and less frequently reported eating alone (all p < 0.001), indicating differences in meal contexts between groups. Individuals with SCI reported consuming fewer meals than Controls but reported a higher overall eating frequency due to increased snacking (p ≤ 0.015). A decrease in the experience of physical fullness, along with a dependence on a communal meal context and frequent snacking, likely contribute to overeating associated with neurogenic obesity after SCI.

IPEx: A gamification tool for learner application of pharmacologic principles of opioid use, misuse, and addiction.

Opioids are often prescribed to treat chronic pain ailments, despite lack of evidence for many conditions. Prescriptions frequently become the gateway to opioid misuse and abuse. In response to the opioid crisis, medical school educators in the state of Pennsylvania developed core competencies pertaining to opioids and addiction for which all medical students should demonstrate proficiency before graduation. To enable students to achieve these competencies, we developed a web-based app (IPEx) that delivers a gamified experience for learners in which they are (re)exposed to opioid competencies and practice applying pharmacologic principles in the context of a series of longitudinal patient scenarios. Learning and application are measured by student responses to application questions before and after each of five modules. Prior to launching the IPEx tool broadly, we wished to test the application questions; thus, we invited fourth year medical students to complete a 45 question quiz based on IPEx module content. Students had no specific preparation prior to taking the quiz but had been exposed to all content elsewhere in the curriculum. A total of 45 of 141 medical students (32%) opted to complete the quiz (mean score was 47% ± 13%; range 18%-73%). Cronbach alpha for the instrument was .74. These results suggest that the instrument has internal validity, and medical students have room for growth when it comes to application of opioid related competencies, a situation that the IPEx tool may be uniquely suited to remedy.

Objective and subjective measures of sleep initiation are differentially associated with DNA methylation in adolescents.

INTRODUCTION: The onset of puberty is associated with a shift in the circadian timing of sleep, leading to delayed sleep initiation [i.e., later sleep onset time (SOT)] due to later bedtimes and/or longer sleep onset latency (SOL). Several genome-wide association studies (GWAS) have identified genes that may be involved in the etiology of sleep phenotypes. However, circadian rhythms are also epigenetically regulated; therefore, epigenetic biomarkers may provide insight into the physiology of the pubertal sleep onset shift and the pathophysiology of prolonged or delayed sleep initiation. RESULTS: The gene-wide analysis indicated differential methylation within or around 1818 unique genes across the sleep initiation measurements using self-report, actigraphy (ACT), and polysomnography (PSG), while GWAS-informed analysis yielded 67 genes. Gene hits were identified for bedtime (PSG), SOL (subjective, ACT and PSG) and SOT (subjective and PSG). DNA methylation within 12 genes was associated with both subjective and PSG-measured SOL, 31 with both ACT- and PSG-measured SOL, 19 with both subjective and ACT-measured SOL, and one gene (SMG1P2) had methylation sites associated with subjective, ACT- and PSG-measured SOL. CONCLUSIONS: Objective and subjective sleep initiation in adolescents is associated with altered DNA methylation in genes previously identified in adult GWAS of sleep and circadian phenotypes. Additionally, our data provide evidence for a potential epigenetic link between habitual (subjective and ACT) SOL and in-lab SOT and DNA methylation in and around genes involved in circadian regulation (i.e., RASD1, RAI1), cardiometabolic disorders (i.e., FADS1, WNK1, SLC5A6), and neuropsychiatric disorders (i.e., PRR7, SDK1, FAM172A). If validated, these sites may provide valuable targets for early detection and prevention of disorders involving prolonged or delayed SOT, such as insomnia, delayed sleep phase, and their comorbidity.

Survival outcomes of anal adenocarcinoma versus rectal adenocarcinoma: A retrospective cohort study.

BACKGROUND: Anal adenocarcinoma (AA) is a rare malignancy with decreased survival compared to rectal adenocarcinoma (RA). However, AA continues to be treated with similar algorithms compared to rectal cancer with minimal data regarding the efficacy of these treatment algorithms. METHODS: A retrospective chart review of patients with non-metastatic AA at a single tertiary-care institution from 1995 to 2020. This cohort was matched 2:1 to a group of RA patients for comparison. The primary outcome of interest was overall survival rates. RESULTS: Sixteen patients with stages I-III AA were matched to a cohort of RA. There were no significant differences between the cohorts with regard to patient demographics, comorbidities, disease stage or histologic features. There were also no significant differences in treatment modalities between the two cohorts with a majority undergoing multimodal therapy with chemoradiation and surgery. All patients with AA demonstrated significantly worse survival than all patients with rectal adenocarcinoma (five-year survival 47.7% vs. 82.3%, respectively. p < 0.05). When looking at a sub-group of patients who underwent combination chemoradiation and surgery from each cohort, anal adenocarcinoma continued to exhibit lower overall survival (five-year survival 41.6% and 86.4%, respectively. p < 0.05). In a multi-variable model that adjusted for location, American Joint Committee on Cancer (AJCC) stage and treatment pathway, tumor location in the anal canal was an independent predictor of overall survival (Hazard ratio [HR] 2.7, p < 0.05). CONCLUSION: AA has worse survival as compared to RA despite similar treatment. This study highlights the need to evaluate the current classification and treatment pathways to improve outcomes.

Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study.

OBJECTIVE: Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN: A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING: Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS: All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. RESULTS: The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS: Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Statistical Power of Randomized Controlled Trials in Trauma Surgery.

BACKGROUND: Our purpose was to conduct a bibliometric study investigating the prevalence of underpowered randomized controlled trials (RCTs) in trauma surgery. STUDY DESIGN: A medical librarian conducted a search of RCTs in trauma published from 2000 to 2021. Data extracted included study type, sample size calculation, and power analyses. Post hoc calculations were performed using a power of 80% and an alpha level of 0.05. A CONSORT checklist was then tabulated from each study as well as a fragility index for studies with statistical significance. RESULTS: In total 187 RCTs from multiple continents and 60 journals were examined. A total of 133 (71%) were found to have "positive" findings consistent with their hypothesis. When evaluating their methods, 51.3% of articles did not report how they calculated their intended sample size. Of those that did, 25 (27%) did not meet their target enrollment. When examining post hoc power, 46%, 57%, and 65% were adequately powered to detect small, medium, and large effect sizes, respectively. Only 11% of RCTs had complete adherence with CONSORT reporting guidelines and the average CONSORT score was 19 out of 25. For positive superiority trials with binary outcomes, the fragility index median (interquartile range) was 2 (2 to 8). CONCLUSIONS: A concerningly large proportion of recently published RCTs in trauma surgery do not report a priori sample size calculations, do not meet enrollment targets, and are not adequately powered to detect even large effect sizes. There exists opportunity for improvement of trauma surgery study design, conduct, and reporting.

The impacts of total body irradiation on umbilical cord blood hematopoietic stem cell transplantation.

Background: Umbilical cord blood hematopoietic stem cells are commonly used for hematopoietic system reconstitution in recipients after umbilical cord blood transplantation (UCBT). However, the optimal conditioning regimen for UCBT remains a topic of debate. The exact impact of total body irradiation (TBI) as a part of conditioning regimens remains unknown. Objectives: The aim of this study was to evaluate the impacts of TBI on UCBT outcomes. Design: This was a multi-institution retrospective study. Methods: A retrospective analysis was conducted on the outcomes of 136 patients receiving UCBT. Sixty-nine patients received myeloablative conditioning (MAC), in which 33 underwent TBI and 36 did not, and 67 patients received reduced-intensity conditioning (RIC), in which 43 underwent TBI and 24 did not. Univariate and multivariate analyses were conducted to compare the outcomes and the post-transplant complications between patients who did and did not undergo TBI in the MAC subgroup and RIC subgroup, respectively. Results: In the RIC subgroup, patients who underwent TBI had superior overall survival (adjusted hazard ratio [aHR] = 0.25, 95% confidence interval [CI]: 0.09-0.66, p = 0.005) and progression-free survival (aHR = 0.26, 95% CI: 0.10-0.66, p = 0.005). However, in the MAC subgroup, there were no statistically significant differences between those receiving and not receiving TBI. Conclusion: In the setting of RIC in UCBT, TBI utilization can improve overall survival and progression-free survival. However, TBI does not show superiority in the MAC setting.

Awareness and interest in osteopathic manipulative treatment in allopathic medical students.

CONTEXT: Osteopathic manipulative treatment (OMT) is utilized by clinicians to diagnose and treat a variety of musculoskeletal conditions including acute and chronic pain, and other medical conditions. Previous studies have examined attitudes of allopathic (MD) residents toward OMT and have implemented residency-based curricula; however, literature is lacking on the attitudes of MD students toward OMT. OBJECTIVES: The objective of this study was to determine MD students' familiarity with OMT and to evaluate their interest in an elective osteopathic curriculum. METHODS: A 15-item online survey was electronically sent to 600 MD students at a large allopathic academic medical center. The survey assessed familiarity with OMT, interest in OMT and in participating in an OMT elective, educational format preference, and interest in pursuing primary care. Educational demographics were also collected. Descriptive statistics and Fisher's exact test were utilized for categorical variables, and nonparametric tests were utilized for the ordinal and continuous variables. RESULTS: A total of 313 MD students submitted responses (response rate=52.1 %), of which 296 (49.3 %) responses were complete and utilized for analysis. A total of 92 (31.1 %) students were aware of OMT as a modality in treating musculoskeletal disorders. Among the respondents who indicated "very interested" in learning a new pain treatment modality, the majority: (1) observed OMT in a prior clinical or educational setting (85 [59.9 %], p=0.02); (2) had a friend or family member treated by a DO physician (42 [71.2 %], p=0.01); (3) were pursuing a primary care specialty (43 [60.6 %], p=0.02); or (4) interviewed at an osteopathic medical school (47 [62.7 %], p=0.01). Among those interested in developing some OMT competency, the majority: (1) were pursuing a primary care specialty (36 [51.4 %], p=0.01); (2) applied to osteopathic schools (47 [54.0], p=0.002); or (3) interviewed at an osteopathic medical school (42 [56.8 %], p=0.001). A total of 230 (82.1 %) students were somewhat or very interested in a 2-week elective course in OMT; among all respondents, hands-on labs were the preferred method for delivery of OMT education (272 [94.1 %]). CONCLUSIONS: The study found a strong interest in an OMT elective by MD students. These results will inform OMT curriculum development aimed at interested MD students and residents in order to provide them with OMT-specific theoretical and practical knowledge.

The Opaque Language of Sexuality: Medical Students' and Providers' Beliefs About Virginity.

Although virginity is not a medical term and is instead socially constructed, it remains unknown what medical providers believe about the biological basis of virginity. This study explored providers' and medical students' beliefs about virginity and the potential impact of such beliefs on healthcare. This was a concurrent mixed-method survey study of 124 medical students and 216 healthcare providers (Registered Nurse, Physician Assistant, Nurse Practitioner, and Doctor of Medicine) at Penn State Health and The Pennsylvania State University College of Medicine. Participants rated their level of agreement with common misconceptions about virginity on a six-point Likert scale. Open-ended questions gave respondents the opportunity to define virginity and to describe terms like virgin and virginal in the context of sexual experience and the medical lexicon. We identified common themes in the qualitative data using thematic analysis. Frequencies of misconceptions and statistically significant demographic associations were identified in the quantitative data. Definitions of virginity were varied and vague, most with negative connotations. A majority of respondents said that virginity has no biological basis. Many participants identified downsides to use of terms like virgin, virginity, and virginal in medicine. The most prevalent misconceptions about virginity were related to the hymen. Seventeen percent of students and 26% of providers at least somewhat agreed that it was possible to determine whether a person has engaged in vaginal intercourse through a gynecological exam. Misconceptions about virginity persist in medicine and bias, even if unintended, may impact the quality-of-care people with vaginas receive. Language around sexual health should be specific, inclusive, clinically relevant, and free from judgment. Medical education must continue to work to eliminate the concept of a biological basis to virginity.

Understanding Nutritional Knowledge and Experiences in Families With a Child Newly Diagnosed With Type 1 Diabetes.

Nutrition is an integral part of diabetes management. Caregiver nutritional knowledge has been implicated in glycemic management of youth with type 1 diabetes. This study assessed the nutritional knowledge of parents/caregivers of children newly diagnosed with type 1 diabetes. Findings suggest there is a need for more targeted support and training during the initial diagnosis and a desire for more technology-related resources such as virtual nutritionist-guided grocery shopping visits. Integrating these interventions into routine care for children with type 1 diabetes will help address the current gaps in caregiver nutritional literacy and their ability to provide appropriate care.

Characteristics and Outcomes of Right- Versus Left-Sided Early-Onset Colorectal Cancer.

BACKGROUND: Early-onset colorectal cancers are increasing in incidence. Studies reported more left-sided cancers in patients aged <50 years. Some advocate for screening via flexible sigmoidoscopy at age 40 years. OBJECTIVE: The purpose of this study was to investigate characteristics and outcomes in sporadic right- and left-sided early-onset colorectal cancers. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a single, tertiary care institution. PATIENTS: This study included patients aged <50 years diagnosed with colorectal cancer between 2000 and 2018. MAIN OUTCOME MEASURES: We analyzed patient demographics, tumor characteristics, and survival. RESULTS: A total of 489 patients aged 20 to 49 years were identified from 2000 to 2018. The majority of patients were white (90%) and male (57%). The median age at diagnosis was 44 years, and 75% were diagnosed at age 40-49 years. There was a predominance of left-sided tumors (80%). The majority of patients presented with stage 3 (35%) and stage 4 (35%) disease. Right-sided tumors were more likely to have mucinous (24% vs 7.4%; p < 0.001) and signet-ring cell (4.4% vs 1.7%; p < 0.001) histology. There was no difference in age, sex, race, ethnicity, and stage at presentation. Right-sided tumors were associated with lower 5-year overall survival (44% vs 61%; p < 0.005) with the decrease in survival most prominent in right-sided stage 3 tumors (41% vs 72%; p < 0.0001) and in ages 40 to 49 years (43% vs 61%; p = 0.03). Sex, tumor location, increasing stage, and signet-ring cell histology were independent prognostic factors of overall survival. There was no difference in disease-free survival. LIMITATIONS: This study was a retrospective review at a single institution. CONCLUSIONS: The majority of early-onset colorectal cancers arise from age 40 to 49 years with a left-sided predominance but higher mortality in right-sided tumors. These findings provide further evidence in favor of recommending earlier initial screening colonoscopy for colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B892 . CARACTERSTICAS Y RESULTADOS DEL CNCER COLORRECTAL DE INICIO TEMPRANO DEL LADO DERECHO FRENTE AL IZQUIERDO: ANTECEDENTES:Los cánceres colorrectales de aparición temprana están aumentando en incidencia. Los estudios han informado una preponderancia de cánceres en el lado izquierdo en pacientes <50 años, lo que ha llevado a algunos a abogar por la detección con sigmoidoscopia flexible a los 40 años.OBJETIVO:El propósito de nuestro estudio fue investigar las características del tumor y los resultados de los pacientes en cánceres colorrectales esporádicos del lado derecho e izquierdo de aparición temprana.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se realizó en una única institución de atención terciaria.PACIENTES:Pacientes <50 años diagnosticados de cáncer colorrectal entre 2000 y 2018.RESULTADO PRINCIPAL:Analizamos los datos demográficos de los pacientes, las características del tumor, la supervivencia general y la supervivencia libre de enfermedad.RESULTADOS:Se identificaron un total de 489 pacientes de entre 20 y 49 años entre 2000 y 2018. La mayoría de los pacientes eran blancos (90%) y varones (57%). La mediana de edad en el momento del diagnóstico fue de 44 años y el 75% se diagnosticó entre los 40 y los 49 años. Predominó los tumores del lado izquierdo (80%). La mayoría de los pacientes presentaban enfermedad en estadio 3 (35%) y estadio 4 (35%). Los tumores del lado derecho tenían más probabilidades de tener histología mucinosa (24% frente a 7,4%, p < 0,001) y de células en anillo de sello (4,4% frente a 1,7%, p < 0,001). No hubo diferencia en edad, sexo, raza, etnia, estadio AJCC en la presentación. Los tumores del lado derecho se asociaron con una menor supervivencia general a 5 años (44% frente al 61%, p < 0,005) con la disminución de la supervivencia más prominente en los tumores del lado derecho en estadio 3 (41% frente al 72%, p < 0,0001) y en edades 40-49 (43% vs 61%, p = 0.03). El sexo, la ubicación del tumor, el estadio AJCC en aumento y la histología de las células en anillo de sello fueron factores pronósticos independientes de la supervivencia general. No hubo diferencias significativas en la supervivencia libre de enfermedad.LIMITACIONES:Este estudio fue una revisión retrospectiva en una sola institución.CONCLUSIONES:La mayoría de los cánceres colorrectales de aparición temprana surgen entre los 40 y los 49 años con un predominio en el lado izquierdo pero una mayor mortalidad en los tumores del lado derecho. Estos hallazgos proporcionan evidencia adicional a favor de recomendar una colonoscopia de detección inicial más temprana para el cáncer colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B892 . (Traducción-Dr. Ingrid Melo ).

Exact-corrected confidence interval for risk difference in noninferiority binomial trials.

A novel confidence interval estimator is proposed for the risk difference in noninferiority binomial trials. The proposed confidence interval, which is dependent on the prespecified noninferiority margin, is consistent with an exact unconditional test that preserves the type-I error and has improved power, particularly for smaller sample sizes, compared to the confidence interval by Chan and Zhang. The improved performance of the proposed confidence interval is theoretically justified and demonstrated with simulations and examples. An R package is also distributed that implements the proposed methods along with other confidence interval estimators.

Scheimpflug-Derived Corneal Lower and Higher Order Aberrations Post Intrastromal Corneal Ring Segments for Keratoconus.

Intrastromal corneal ring segments (ICRS) improve corneal topographic symmetry and reduce corneal aberrations through regularization of the corneal surface, thereby functioning as a viable surgical intervention for patients with keratoconus. This study aims to evaluate changes in lower- (LOAs) and higher-order aberrations (HOAs) amongst varying pupil sizes pre- and post- ICRS implantation in keratoconus patients. We specifically investigate the impact of pupil size on total corneal HOAs up to the 6th order. Twenty-one eyes that underwent ICRS implantation were included in this prospective interventional study. LOAs and HOAs measurements at the 6 mm, 4 mm, and 2 mm pupil diameters were collected preoperatively and at 6 months postoperatively using the Zernicke analysis function on a Scheimpflug device. ICRS implantation demonstrated a statistically significant effect in vertical coma with a −0.23 reduction (p = 0.015) for a 4 mm pupil size and a −1.384 reduction (p < 0.001) for 6 mm, with no significant effect at 2 mm. Horizontal coma, astigmatism 0°, astigmatism 45°, trefoil 5th order 30°, and RMS HOA demonstrated significant reductions at 4 mm or 6 mm pupil sizes but not at 2 mm. Our analysis demonstrates a favorable effect of ICRS implantation on larger pupil sizes, suggesting the importance of pupil size as it correlates with HOAs reduction.

Fat to lean mass ratio in spinal cord injury: Possible interplay of components of body composition that may instigate systemic inflammation and metabolic syndrome.

OBJECTIVE: To investigate the relationships between percentage fat mass (%FM), percentage lean mass (%LM), and the ratio of %FM to %LM with pro-inflammatory adipokines and metabolic syndrome in individuals with chronic spinal cord injury (SCI). DESIGN: Observational, cross-sectional. Linear and logistic regression were used to examine the associations between the %FM, %LM, and the %FM to %LM ratio with inflammatory markers and metabolic syndrome, respectively. PARTICIPANTS: Seventy chronic SCI men and women. MAIN OUTCOME MEASURES: %FM, %LM, %FM to %LM ratio; fasting lipids, glucose, and tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and high-sensitivity c-reactive protein (hs-CRP); metabolic syndrome as determined by The International Diabetes Federation criteria. RESULTS: There were significant correlations between %FM, %LM and the %FM to %LM ratio with hs-CRP. The %LM beta coefficient value was negative and greater than the beta coefficient value for %FM. The %FM to %LM ratio had the strongest correlation with hs-CRP and showed the only significant relationship with IL-6. There were strong significant correlations between %FM, %LM and the %FM to %LM ratio with metabolic syndrome. However, the %FM to %LM ratio, again, showed the strongest relationship indicating that it may be the best predictor of metabolic syndrome. CONCLUSION: Both higher %FM and lower %LM affect cardiometabolic health and can be used as predictors for metabolic syndrome. However, the %FM to %LM ratio was the best predictor of systemic inflammation and cardiometabolic disorders in this group of SCI participants, suggesting that they both contribute to the statistical model.

Anterior segment reconstruction due to cosmetic iris implants placed in the anterior chamber.

A 27-year-old woman had BrightOcular iris implants placed for cosmetic purposes that changed eye color from brown to blue bilaterally. Of note, BrightOcular implants are not approved by the U.S. Food and Drug Administration (FDA) for use in the United States and have been associated with severe ocular complications. In keeping with their design, they were placed in the anterior chamber (AC) in both eyes of this patient; surgery was performed outside the United States. As has been described previously and tragically in other cases, she developed chronic inflammation, intolerable glare, angle-closure glaucoma, corneal edema, and cataracts in both eyes. For medically unmanageable elevated intraocular pressure (IOP), she underwent diode laser cyclophotocoagulation (CPC) in both eyes, and eventually, an Ahmed tube shunt (New World Medical, Inc.) was placed in the right eye. Although she was advised and urged to have the iris implants removed, despite her ocular issues, she refused removal until intolerable glare and reduced vision ensued. Ultimately, both iris implants were extracted 5 years after implantation by a U.S. surgeon; the procedures resulted in corneal decompensation and progressive cataract development. Subsequent penetrating keratoplasty (PKP) was performed for the right eye, but it failed because of contact with the glaucoma tube shunt. She sought additional consultation and presented with the following findings: corrected distance visual acuity was 20/400 in the right eye and 20/40 in the left eye, IOP of 18 mm Hg in the right eye and 16 mm Hg in the left eye, pupils were nonreactive and fixed, and extraocular muscles and central visual field were normal. Pachymetry was 868 µm in the right eye and 653 µm in the left eye. Anterior segment examination in the right eye revealed a failed corneal graft with 3+ edema, peripheral anterior synechiae (PAS) for 360 degrees, shallow AC, Ahmed tube shunt at the 11 o'clock position and remnant iris adherent to the graft-host junction for 270 degrees, 3+ posterior subcapsular cataract, and 2+ cortical cataract (Figure 1JOURNAL/jcrs/04.03/02158034-202208000-00024/figure1/v/2022-08-01T210317Z/r/image-tiff). The sclera revealed multiple circular and circumferential atrophic blue spots consistent with high-energy transscleral CPC (Figure 2JOURNAL/jcrs/04.03/02158034-202208000-00024/figure2/v/2022-08-01T210317Z/r/image-tiff). In the left eye, she had remnant fixed dilated iris for 270 degrees, missing iris superiorly for 3 clock hours, an adequate AC, and 2+ cortical cataract (Figure 3JOURNAL/jcrs/04.03/02158034-202208000-00024/figure3/v/2022-08-01T210317Z/r/image-tiff). Posterior segment examination revealed a 0.5 cup-to-disc ratio in both eyes with normal vessels, macula, vitreous, and retinal periphery, bilaterally. Given this constellation of findings, how would you proceed?

Challenges in Effective Faculty and Provider Recognition to Enhance Engagement.

BACKGROUND AND OBJECTIVES: Burnout is associated with reduction in patient care time and leaving academic medicine, and is prevalent among faculty, residents, and advanced practice providers. Recognition may positively impact workplace well-being and reduce attrition. The objective of this study was to understand needs and preferences regarding recognition among faculty and providers in a large academic department. METHODS: A survey including quantitative and qualitative elements was sent to faculty and providers to identify whether additional recognition was needed and, if so, to seek potential opportunities to improve recognition, with mixed-methods assessment of results. RESULTS: Fifty-two participants completed the survey (35.9% response rate; 53.8% female, 59.6% faculty); 26.9% reported performing duties at work that are not being recognized, and 19.2% reported seriously considering leaving the institution because they did not feel appreciated. Females were more likely to want tangible goods as a source of recognition (P=.008). While providers preferred to have recommendations for recognition made by office staff (P=.007), associate professors did not (P=.005). Qualitative responses to the survey also revealed concerns regarding favoritism and risk of feeling unappreciated if a recognition system is perceived as unfair. CONCLUSIONS: This survey demonstrated a deficit of recognition and a lack of consensus regarding how or when faculty and providers should be recognized. There were concerns regarding fairness of recognition. Efforts to enhance recognition should avoid assumptions about faculty and provider preferences, and should be attuned to fairness and inclusion.

Diagnoses per Encounter by Telephone, Televideo, and In-Office Visits.

INTRODUCTION: We sought to determine if there are differences between number of International Classification of Disease-10 (ICD-10) codes per visit before and after COVID-19 when comparing in-office visits and between telemedicine vs in-office visits, toward the goal of determining value of telemedicine visits relative to in-office visits. METHODS: We did a chart review study assessing the number of ICD-10 codes noted by providers at a large academic medical institution in 2019 and 2020. Only in-office visits were reviewed in 2019. The focus of analysis was on individual patient visits per visit type; however, a subset of patients who had visits in both 2019 and 2020 were also analyzed. We compared mean number of diagnoses for encounter types using encounter, billing and coding data. RESULTS: We analyzed 211,829 patient encounters. For 2020, 73% were in office. Mean number of diagnoses per encounter for 2019 was 2.65 (in office only), compared with 3.04 in office, 2.76 telephone, and 2.48 televideo for 2020. DISCUSSION: We found an increase in the number of diagnoses addressed during in-office visits from 2019 to 2020. When looking at diagnoses managed per visit, all 3 types of visits had similar complexity. These results may guide future reimbursement policy for telemedicine visits.