Effect of Topical Losartan in the Treatment of Established Corneal Fibrosis in Rabbits.

Purpose: The purpose of this study was to evaluate the safety and efficacy of topical losartan in the therapeutic treatment of established corneal scaring fibrosis at 1 month after alkali burn in rabbits. Methods: Standardized alkali burns were performed in 1 eye of 24 rabbits with 0.75N NaOH for 15 seconds. Corneas were allowed to heal and develop scaring of the cornea for 1 month. Twelve eyes per group were treated with 50 µL of topical 0.8 mg/mL losartan in balanced salt solution (BSS), pH 7.0, and 12 eyes were treated with vehicle BSS 6 times per day. Six corneas were analyzed at 1 week or 1 month in each group. Standardized slit lamp photographs were obtained at the end point for each cornea and opacity was quantitated using ImageJ. Corneoscleral rims were cryofixed in optimum cutting temperature (OCT) solution and combined duplex immunohistochemistry for myofibroblast marker alpha-smooth muscle actin (α-SMA), mesenchymal cell marker vimentin, and TUNEL assay for apoptosis was performed on all corneas. Results: Topical losartan was effective in the treatment of established stromal fibrosis following alkali burn injury to the rabbit cornea. Stromal myofibroblast density was decreased and stromal cell apoptosis was increased (included both α-SMA-positive myofibroblasts and α-SMA-negative, vimentin-positive cells) at both 1 week and 1 month in the topical losartan-treated compared with vehicle-treated groups. Conclusions: Topical losartan is effective in the treatment of established stromal fibrosis in rabbits. Most myofibroblasts disappear from the stroma within the first month of losartan treatment. Longer treatment with topical losartan is needed to allow time for corneal fibroblast regeneration of the epithelial basement membrane (in coordination with epithelial cells) and the removal of disordered extracellular matrix produced by myofibroblasts.

Corneal stromal localization of TGF beta isoforms in spontaneous persistent epithelial defects after PRK in rabbits.

The purpose of this study was to evaluate transforming growth factor beta (TGFß) isoform localization in rabbit corneas with spontaneous persistent epithelial defects (PEDs) after photorefractive keratectomy (PRK). Four cryofixed corneas from a previously reported series of PEDs in rabbits that had PRK were evaluated with triplex immunohistochemistry (IHC) for TGFß3, myofibroblast marker alpha-smooth muscle actin (α-SMA) and mesenchymal marker vimentin. One cornea had sufficient remaining tissue for triplex IHC for TGFß1, TGFß2, or TGFß3 (each with α-SMA and vimentin) using isoform-specific antibodies. All three TGFß isoforms were detected in the subepithelial stroma at and surrounding the PED. Some of each TGFß isoform co-localized with α-SMA of myofibroblasts, which could be TGFß isoform autocrine production by myofibroblasts or TGFß-1, -2, and -3 binding to these myofibroblasts.

Topical Losartan Inhibition of Myofibroblast Generation in Rabbit Corneas With Acute Incisions.

PURPOSE: The purpose of this study was to study whether deep central corneal incisions close during topical losartan treatment and the effect of topical losartan on myofibroblast generation after incisions in rabbit corneas. METHODS: Rabbits (12) had a 0.35-mm deep radial incision from the center of the cornea into the limbus in 1 eye that was approximated with a single 10-0 nylon suture 1 mm inside the limbus. The incision was treated with 50 µL of topical 0.8 mg/mL losartan or 50 µL of balanced salt solution vehicle 6 times per day for 1 month. Standardized slitlamp photographs of the central incisions were analyzed for opacity with ImageJ before euthanasia. Triplex IHC was performed on cryofixed corneas for myofibroblast marker alpha-smooth muscle actin, mesenchymal cell marker vimentin, and basement membrane marker laminin alpha-5. Stromal α-SMA-positive myofibroblasts surrounding the incisions were quantitated with ImageJ. RESULTS: Topical losartan compared with vehicle did not affect closure of the radial incisions or the opacity that developed surrounding the incisions at 1 month after injury. Topical losartan compared with vehicle did significantly decrease the average density of stromal myofibroblasts surrounding the incisions. CONCLUSIONS: Topical losartan, a known inhibitor of transforming growth factor beta signaling, did not affect closure of deep corneal incisions. Losartan decreased myofibroblast generation surrounding nearly full-thickness radial corneal incisions compared with vehicle. The opacity at the incisions was not significantly affected by losartan-likely because corneal fibroblasts that develop in the stroma adjacent to the incisions were not changed by the losartan compared with the vehicle.

Concurrent immune checkpoint inhibition and selective immunosuppressive therapy in patients with immune-related enterocolitis.

PURPOSE: Immune checkpoint inhibitor (ICI) therapy is often suspended because of immune-related enterocolitis (irEC). We examined the effect of resumption of ICIs with or without concurrent selective immunosuppressive therapy (SIT) on rates of symptom recurrence and survival outcomes. METHODS: This retrospective, multicenter study examined patients who were treated with ICI and developed irEC requiring SIT (infliximab or vedolizumab) for initial symptom control or to facilitate steroid tapering between May 2015 and June 2020. After symptom resolution, patients were restarted either on ICI alone or on concurrent ICI and SIT at the discretion of the treating physicians. The associations between irEC recurrence and treatment group were assessed via univariate analyses and multivariate logistic regression. Cox proportional hazards model was used for survival analysis. RESULTS: Of the 138 included patients who required SIT for initial irEC symptom control, 61 (44.2%) patients resumed ICI without concurrent SIT (control group) and 77 (55.8%) patients resumed ICI therapy with concurrent SIT: 33 with infliximab and 44 with vedolizumab. After symptom resolution, patients in the control group were more commonly restarted on a different ICI regimen (65.6%) compared with those receiving SIT (31.2%) (p<0.001). The total number of ICI doses administered after irEC resolution and ICI resumption was similar in both groups (four to five doses). Recurrence of severe colitis or diarrhea after ICI resumption was seen in 34.4% of controls compared with 20.8% of patients receiving concurrent SIT. Concurrent SIT was associated with reduced risk of severe irEC recurrence after ICI resumption in a multivariate logistic regression model (OR 0.34; 95% CI 0.13 to 0.92; p=0.034). There was no difference in survival outcomes between patients in the control group and patients concurrently treated with SIT. CONCLUSION: After resolution of irEC symptoms, reinitiation of ICI with concurrent SIT is safe, reduces severe irEC recurrence, and has no negative impact on survival outcomes.

Therapeutic visual rehabilitation in a patient with high hyperopia and flat cornea years after radial keratotomy.

A 51-year-old man was referred for refractive surgery evaluation. Spectacle dependence and poor visual quality in both eyes was his chief complaint. He cannot tolerate contact lenses. Corrected distance visual acuity (CDVA) was 20/40 in both eyes. Manifest refraction was +5.25 -2.25 @ 90 (20/40) in the right eye and +6.25 -2.25 @ 105 (20/40) in the left eye. The patient had a history of radial keratotomy (RK) almost 30 years ago in both eyes and at the slitlamp presented 8 RK incisions, proportionally spaced between one another. All incisions were closed, and there were no relevant signs of scarring. The patient denied any history of ocular trauma, systemic disease, or medications. Corneal topography with different technologies revealed an irregular pattern with marked central flattening in both eyes, with some points below 30 diopters (D) (Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A862 and http://links.lww.com/JRS/A863, respectively). There were no signs of cataract, and fundus examination was normal. Optical coherence tomography (OCT) of the right eye revealed a more homogeneous thickness pattern, little variation between the thinnest and thickest areas, and adequate transparency (Figure 1JOURNAL/jcrs/04.03/02158034-202306000-00018/figure1/v/2023-05-31T172126Z/r/image-tiff). In the left eye, there is wide variability between the thinnest and thickest stromal points, with annular thinning and central thickening (Figure 2JOURNAL/jcrs/04.03/02158034-202306000-00018/figure2/v/2023-05-31T172126Z/r/image-tiff). Both eyes show marked epithelial irregularity. Considering this patient's current ocular status, how would you reach visual rehabilitation? Because he is contact lens intolerant, would you consider surface ablation, for example, photorefractive keratectomy (PRK) with mitomycin-C (MMC)? If that were the case, would you think of an optimized or a topography-guided (TG) treatment? Would you immediately consider a corneal transplant option? Would you instead consider a more conservative approach? Which one and why?

Characteristics and Outcomes of Cancer Patients With Venous Thromboembolic Events After Treatment With Immune Checkpoint Inhibitors.

OBJECTIVE: This study aimed to describe the clinical characteristics and outcomes of patients with venous thromboembolism (VTE) after Immune checkpoint inhibitors (ICI), focusing on patients with gastrointestinal (GI) immune-related adverse events (irAE). METHODS: In this retrospective, single-center study, we report the clinical outcomes of adult cancer patients who developed a VTE within 2 years of ICI initiation. Patients were excluded if alternate causes of VTE were present apart from malignancy and cancer therapy. The cohort was classified into those with GI-irAE, non-GI-irAE, and no irAE. A control group with ICI exposure without irAE and VTE was selected for comparative analysis. RESULTS: Of all ICI-treated patients, 1891 (17.2%) were diagnosed with VTE. In all, 501 (4.6%) had no etiology for VTE aside from malignancy and cancer therapy. Of these, 137 patients were included and classified as: 44 GI-irAE, 42 non-GI-irAE, and 51 no irAE. Chemotherapy within 6 months of ICI therapy was associated with increased VTE risk. There was no difference in the clinical course between those exposed to chemotherapy versus ICI therapy alone, time from ICI initiation to VTE, and VTE type, recurrence, or related hospitalization. While there was no difference in VTE-related mortality, the GI-irAE group was associated with lower all-cause mortality and superior overall survival. CONCLUSION: Combined ICI and chemotherapy use increased VTE risk. There is a similar disease course of VTE after ICI exposure, regardless of other irAEs. Co-existing GI-irAE with VTE is associated with superior overall survival. Prospective studies are needed to evaluate the relationship between ICI therapy and VTE and irAE impact on VTE outcomes.

Endoscopic Coil Embolization for Refractory Intrahepatic Biliary Duct Leak.

Bile leaks may be seen after blunt and penetrating trauma, as well as iatrogenic injury from surgical procedures. There are many articles on endoscopic treatment options for the management of biliary leaks, including sphincterotomy, endoscopic stent, or nasobiliary drain placement. Data, however, are scarce regarding the management of persistent biliary leaks after the initial intervention. We present a case of endoscopic coil embolization to treat a refractory bile leak after initial endoscopic sphincterotomy and stent placement in a patient with a grade IV liver laceration due to a gunshot wound.

Clinical Characteristics and Outcomes of Patients with Positive Celiac Serology and Cancer Therapy Exposure.

Objectives: The prevalence of celiac disease (CD) among cancer patients is unknown, yet new cases of CD occur after cancer therapy exposure. The aim of this study was to describe the clinical course and endoscopic features of patients with positive celiac serology (PCS) post-cancer therapy exposure (PCTE) as compared to those with no cancer therapy exposure (NCTE). Methods: A retrospective study of adult patients with PCS at MD Anderson Cancer Center between March 2009 and May 2020. Patients with positive tTG IgA, tTG IgG, and/or EMA IgA were categorized into cases with NCTE and PCTE. Clinical course, endoscopic and histologic features, and treatments were compared between the two groups. Results: Of the 4,345 patients screened for celiac serology, 21 (0.5%) met inclusion criteria. 12 were PCTE, with a median time of 258 days (173-930 days) from initiation of the last cancer therapy. Those PCTE had a higher rate of diarrhea (75% vs 22%, p = 0.030), malnutrition and death. A gluten-free diet was initiated in 82% PCTE vs 89% NCTE, with the majority experiencing symptom resolution. There were no significant differences in endoscopic and histologic features. 17 patients met criteria for CD diagnosis. Conclusions: Our findings suggest that CD may be under-diagnosed in cancer patients. Patients with PCS after cancer therapy may present with diarrhea, nutritional deficiencies, and malnutrition, yet a gluten-free diet may be efficacious in treatment management. Therefore, CD should be considered when treating cancer patients. Given the relative proximity of PCS to cancer therapy exposure, future studies should investigate the association of cancer and cancer therapy with the development of CD.

Validation of an educational game about first aid for schoolchildren.

OBJECTIVES: to validate the content and appearance of an educational game about first aid for schoolchildren with experts in education and health. METHODS: this is a methodological, quantitative and descriptive research, carried out using the Delphi technique, using an online collection instrument, covering 55 items of the game. Content and appearance assessment was performed by 26 judges. The data were analyzed using Content Validity index. RESULTS: the final prototype is presented in a board format, composed of four buildable pawns and 117 cards between questions, alerts and challenges. Overall Content Validity index of 0.95 and greater than 0.8 was obtained for all items in two Delphi rounds. CONCLUSIONS: the educational game validated by experts is a pedagogical tool for teaching first aid to schoolchildren as an option to traditional educational practices.

Clinical Characteristics and Outcomes of Oral Mucositis Associated With Immune Checkpoint Inhibitors in Patients With Cancer.

BACKGROUND: Immune checkpoint inhibitor (ICI) therapy predisposes patients to immune-related adverse events (irAEs). Data are limited regarding the incidence, management, and outcomes of one such irAE: mucositis. In this study, we evaluated the clinical characteristics, disease course, treatment, and outcomes of ICI-mediated mucositis. METHODS: This was a retrospective, single-center study of patients who received ICI therapy and developed oral mucositis at The University of Texas MD Anderson Cancer Center from January 2009 to September 2019. Inclusion criteria included age ≥18 years, a diagnosis of oral mucositis and/or stomatitis based on ICD-9 and ICD-10 codes, and therapy using CTLA-4 or PD-1/L1 inhibitors alone or combined with other agents. RESULTS: We identified 152 patients with a mean age of 60 years, 51% of whom were men. Of the sample patients, 73% had stage IV cancer, with melanoma the most common (28%). Median time from ICI initiation to mucositis was 91 days. The most common clinical presentation of mucositis was odynophagia and/or oral pain (89%), 91% developed CTCAE grade 1-2 mucositis, and 78% received anti-PD-1/L1 monotherapy. Compared with anti-PD-1/L1-based therapy, anti-CTLA-4-based therapy was more frequently associated with earlier onset of mucositis (73 vs 96 days; P=.077) and a lower rate of symptom resolution (76% vs 92%; P=.029); 24% of patients required immunosuppressive therapy, which was associated with longer symptom duration (84 vs 34 days; P=.002) and higher mucositis recurrence rate (61% vs 32%; P=.006). ICI interruption was associated with worse survival (P=.037). Mucositis recurrence, immunosuppressant use, and presence of other irAEs did not affect survival. CONCLUSIONS: For ICI-mediated mucositis, a diagnosis of exclusion has not been well recognized and is understudied. Although the clinical symptoms of mucositis are mostly mild, approximately 25% of patients require immunosuppression. Mucositis recurrence can occur in approximately 39% patients. Our results showed that ICI interruption compromises overall survival.

Elevated transaminases and hypoalbuminemia in Covid-19 are prognostic factors for disease severity.

Prognostic markers are needed to understand the disease course and severity in patients with Covid-19. There is evidence that Covid-19 causes gastrointestinal symptoms and abnormalities in liver enzymes. We aimed to determine if hepatobiliary laboratory data could predict disease severity in patients with Covid-19. In this retrospective, single institution, cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19, we found that elevations of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and Alkaline Phosphatase (AP) at any time during hospital admission increased the odds of ICU admission by 5.12 (95% CI: 1.55-16.89; p = 0.007), 4.71 (95% CI: 1.51-14.69; p = 0.01) and 4.12 (95% CI: 1.21-14.06, p = 0.02), respectively. Hypoalbuminemia found at the time of admission to the hospital was associated with increased mortality (p = 0.02), hypotension (p = 0.03), and need for vasopressors (p = 0.02), intubation (p = 0.01) and hemodialysis (p = 0.002). Additionally, there was evidence of liver injury: AST was significantly elevated above baseline in patients admitted to the ICU (54.2 ± 15.70 U/L) relative to those who were not (9.2 ± 4.89 U/L; p = 0.01). Taken together, this study found that hypoalbuminemia and abnormalities in hepatobiliary laboratory data may be prognostic factors for disease severity in patients admitted to the hospital with Covid-19.

Validation of an educational game about first aid for schoolchildren / Validación de un juego educativo sobre primeros auxilios para escolares / Validação de jogo educativo sobre primeiros socorros para crianças escolares

ABSTRACT Objectives: to validate the content and appearance of an educational game about first aid for schoolchildren with experts in education and health. Methods: this is a methodological, quantitative and descriptive research, carried out using the Delphi technique, using an online collection instrument, covering 55 items of the game. Content and appearance assessment was performed by 26 judges. The data were analyzed using Content Validity index. Results: the final prototype is presented in a board format, composed of four buildable pawns and 117 cards between questions, alerts and challenges. Overall Content Validity index of 0.95 and greater than 0.8 was obtained for all items in two Delphi rounds. Conclusions: the educational game validated by experts is a pedagogical tool for teaching first aid to schoolchildren as an option to traditional educational practices.

RESUMEN Objetivos: validar el contenido y apariencia del juego educativo de primeros auxilios para niños en edad escolar con expertos en el campo de la educación y la salud. Métodos: investigación metodológica, cuantitativa y descriptiva, realizada mediante la técnica Delphi utilizando un instrumento de recolección en línea, cubriendo 55 ítems del juego. La evaluación de contenido y apariencia fue realizada por 26 jueces. Los datos se analizaron mediante el índice de validación de contenido. Resultados: el prototipo final del juego se presenta en formato de tablero, compuesto por cuatro peones ensamblables y 117 cartas que incluyen preguntas, alertas y desafíos. Se obtuvo un índice de validación de contenido general de 0,95 y superior a 0,8 para todos los ítems, en dos rondas Delphi. Conclusiones: el juego educativo validado por los expertos es una herramienta pedagógica para la enseñanza de primeros auxilios a escolares como opción a las prácticas educativas tradicionales.

RESUMO Objetivos: validar o conteúdo e a aparência do jogo educativo sobre primeiros socorros para crianças em idade escolar com experts da área da educação e saúde. Métodos: pesquisa metodológica, quantitativa descritiva, realizada por meio da técnica Delphi a partir de instrumento de coleta online, contemplando 55 itens do jogo. A avaliação do conteúdo e aparência foi realizada por 26 juízes. Os dados foram analisados a partir do Índice de Validação de Conteúdo. Resultados: o protótipo final do jogo apresenta-se em formato de tabuleiro, composto por quatro peões montáveis e 117 cartas entre perguntas, alertas e desafios. Obteve-se Índice de Validação de Conteúdo geral de 0,95 e superior a 0,8 em todos os itens, em duas rodadas Delphi. Conclusões: o jogo educativo validado pelos experts é uma ferramenta pedagógica para o ensino de primeiros socorros com crianças escolares como opção às práticas educativas tradicionais.

The use of smartphones in ophthalmology: technological development and application / O uso de smartphones na oftalmologia: desenvolvimento tecnológico e aplicação

Objective: Technological development has promoted several advances in society, including the creation of smartphones, which have been increasingly used in medicine, especially in ophthalmology. This study aimed to review the use of smartphones in ophthalmology. Methods: In January of 2020, the MEDLINE and LILACS databases were selected to provide articles containing the terms "Ophthalmology" and "Smartphone", filtering the results between the years of 2015 and 2019. The evaluated outcomes were finally included into the following categories in the discussion: "Visual acuity", "Amblyopia and strabismus", "Anterior segment", "Posterior segment", "Glaucoma", "Community patient education and assistance" and "Neurophthalmology". Results: Smartphones can be useful in several different areas of ophthalmology and can provide the patients better understating and adhesion to their treatment. Conclusion: Applications can be used as tools to facilitate the work of several professionals and improve the understanding of patients about their clinical conditions.

Objetivo: O desenvolvimento tecnológico tem promovido diversos avanços na sociedade, incluindo a criação de smartphones, que têm sido cada vez mais utilizados na medicina, principalmente na oftalmologia. O objetivo deste estudo foi revisar o uso de smartphones na oftalmologia. Métodos: Durante o mês de janeiro de 2020, as bases de dados MEDLINE e LILACS foram selecionadas para buscar artigos contendo os termos "Oftalmologia" e "Smartphone", filtrando os resultados entre os anos de 2015 e 2019. Os dados avaliados foram, finalmente, incluídos nas seguintes categorias na discussão: "Acuidade visual", "Ambliopia e estrabismo", "Segmento anterior", "Segmento posterior", "Glaucoma", "Assistência e educação ao paciente da comunidade" e "Neuroftalmologia". Resultados: Os smartphones podem ser úteis em diversas áreas da oftalmologia e fornecem melhor compreensão e adesão dos pacientes ao tratamento. Conclusão: O uso de aplicativos pode ser utilizado como ferramenta para facilitar o trabalho de diversos profissionais e melhorar o entendimento dos pacientes sobre suas condições clínicas.

Elevated D-Dimer Is Associated with Multiple Clinical Outcomes in Hospitalized Covid-19 Patients: a Retrospective Cohort Study.

D-dimer is a prognostic marker for Covid-19 disease mortality and severity in hospitalized patients; however, little is known about the association between D-dimer and other clinical outcomes. The aim of this paper was to define a threshold of D-dimer to use in hospitalized patients with Covid-19 and to assess its utility in prognosticating in-hospital mortality, development of an acute kidney injury (AKI), and need for hemodialysis, vasopressors, or intubation. This is a single-center, retrospective, cohort review study of 100 predominantly minority patients (94%) hospitalized with Covid-19. The electronic medical record system was used to collect data. Receiver operating characteristics (ROC) and area under the curve (AUC) analysis were used to determine optimal thresholds of peak D-dimer, defined as the highest D-dimer obtained during admission that was clinically meaningful. Odds ratios were then used to assess the relationship between peak D-dimer thresholds and clinical outcomes. D-dimer > 2.1 µg/mL and > 2.48 µg/mL had > 90% sensitivity and > 50% specificity for predicting need for vasopressors (AUC 0.80) or intubation (AUC 0.83) and in-hospital mortality (AUC 0.89), respectively. Additionally, D-dimer > 4.86 µg/mL had a 100% sensitivity and 81% specificity for predicting the need for hemodialysis (AUC 0.92). Furthermore, peak D-dimer > 2.48 µg/mL was associated with in-hospital mortality (p < 0.001), development of an AKI (p = 0.002), and need for intubation (p < 0.001), hemodialysis (p < 0.001), and vasopressors (p < 0.001). Peak D-dimer > 2.48 µg/mL may be a useful threshold that is prognostic of multiple clinical outcomes in hospitalized patients with Covid-19.

Nutrition Education on the Wards: A Self-Study Module for Improving Medical Student Knowledge of Nutrition Assessment and Interventions.

Introduction: Nutrition plays a key role in the prevention and treatment of disease. Hospitalized patients are often malnourished, which is a major contributor to medical complications, decreased quality of life, lengthened medical stay, increased health care costs, and mortality. However, medical students continue to have inadequate education in nutrition and report feeling poorly trained in nutrition. We proposed an online module that could be used by medical students as a self-study activity to learn about key signs for the diagnosis of malnutrition and the nutrition interventions available in the hospital setting. Methods: Third- and fourth-year medical students at Rutgers Robert Wood Johnson Medical School in medicine, surgery, and critical care clerkships were given access to an online nutrition education module discussing the signs of malnutrition in hospitalized patients and the interventions available in the inpatient setting. A premodule and postmodule survey was given via email at the beginning and at the end of the clerkship. A one-sample t test was used to assess the relationship between the mean scores of the pre- and postmodule surveys. Results: One hundred nine out of 255 students responded to the premodule survey. Thirty-two students completed the module and postmodule survey. There was a significant difference in mean scores between students who completed the module and postmodule survey compared to the overall student population prior to having access to the module. Discussion: Medical students have limited training in nutrition education, and our findings show that a self-study online module can improve students' knowledge.

The Model for End-Stage Liver Disease-Sodium Score at Admission Is Prognostic of Covid-19 Disease Severity.

Covid-19 is a systemic viral respiratory illness that can cause gastrointestinal manifestations. There is evidence that Covid-19 can infect liver tissue and may cause transaminemia. A prognostic model is needed to aid clinicians in determining disease severity. The Model for End-Stage Liver Disease-Sodium (MELD-Na) score is a mortality assessment tool in liver transplant patients that has been found to be prognostic in other clinical situations. This study aimed to determine if the MELD-Na score was associated with disease severity in patients with Covid-19, as assessed by multiple clinical outcomes including death within 30 days of discharge and development of an acute kidney injury (AKI). This is a retrospective cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19. The 30-day MELD-Na score was found to be significantly higher in those who died (14.38 ± 6.92) relative to those who survived (9.68 ± 5.69; p = 0.03). Additionally, patients with a MELD-Na score greater than 10 were found to have higher risk of developing an AKI (odds ratio (OR) 3.31 (1.08, 10.17); p = 0.03), need for hemodialysis (OR 9.69 (1.74, 53.96); p = 0.007), require vasopressors (OR 4.55 (1.22, 16.99); p = 0.02), and have a longer hospital stay (OR 4.17 (1.05, 16.47); p = 0.03). The MELD-Na score may serve as a useful clinical scoring system for prognosis in patients admitted to the hospital with Covid-19.

A Novel Mobile Application for Preoperative and Intraoperative Assessments of Intrastromal Corneal Ring Segments Implantation for Keratoconus.

PURPOSE: To develop a mobile app that allows photographs to be captured and edited under the overlay of images and projection of a protractor with 360 degrees axis markings, which enables the surgeon to accurately visualize the programmed and marked alignment where the intrastromal corneal ring segments (ICRS) will be implanted, detecting possible marking errors. METHODS: A codesign methodology was chosen to develop the Eye Axis Check application. After app development, measurements were obtained, and comparisons were made between manual marks and ICRS alignment with and without the app in 13 eyes that had undergone ICRS implantation for keratoconus. The mobile app was made available to 15 ophthalmic surgeons in different cities to assess its usability. RESULTS: The users approved the developed application for ease of use and utility. No difference was found between the markings made manually and those made with the app, and the mean difference between ICRS centralization and assessment made by the app was 4.84 degrees (95% confidence interval: -5.32 to 15.01; P = 0.3193). On comparison of the agreement between app measurements and manual measurements for the ICRS centration, no significant differences were found, and excellent concordance (0.991) and a strong positive linear correlation (0.984) were observed. CONCLUSIONS: A mobile app for preoperative planning and intraoperative ICRS alignment was developed and revealed to be useful and easy to use, allowing the surgeon to visualize the programmed alignment where the ICRS will be implanted.

Mobile App for Pre- and Intraoperative Assessment of Astigmatism Correction with Toric Intraocular Lenses in Cataract Surgery.

PURPOSE: To develop a mobile app that allows capturing and editing of photographs, performs image transposition and projection of a protractor with 360° axis markings, and permits accurate visualization of programmed alignment for the positioning of toric intraocular lenses (IOLs). METHODS: In this prospective case series study, a codesign methodology was chosen to develop the Eye Axis Check application. After app development, measurements were obtained and comparisons were made between manual marks and toric IOL alignment without and with the app in 30 eyes that had undergone cataract surgery with toric IOLs. The mobile app was made available to 15 ophthalmic surgeons in different cities to assess its usability. RESULTS: The users approved the developed application for its ease of use and utility. The mean difference between the markings made manually and those made with the app was 1° (±2°; range: 0°-5°), and the mean difference between the IOL position and the assessment made by the app was 3° (±3°; range: 0°-12°). Upon comparison of the agreement between the app measurements and the manual measurements for the IOL angle, no significant differences were found, and an excellent concordance (0.997) and a strong positive linear correlation (0.995) were observed. CONCLUSION: A mobile app for preoperative planning and intraoperative toric IOL alignment was developed and revealed to be useful and easy to use.

Pharmacoepidemiology of the antiglaucoma drugs in Brazil from 2012 to 2018 / Farmacoepidemiologia das drogas antiglaucomatosas no Brasil de 2012 a 2018

Abstract Purpose: To outline the epidemiological profile of clinical treatments for glaucoma provided by the Brazilian Unified Health System (SUS, acronym in Portuguese) between January 2012 and December 2018. Methods: A quantitative and descriptive study was conducted using available data based on the outpatient information system from SUS (SIA/SUS, acronym in Portuguese). The variables were monocular treatment with first, second, and third-line drugs; monocular treatment with combinations of two drugs and three drugs from different lines; binocular treatment with first, second, and third-line drugs; and binocular treatment with combinations of two drugs and three drugs from different lines. Results: During the analysis period, the prevalence of clinical therapies for glaucoma increased from 2012 to 2017 and decreased from 2017 to 2018. Of the clinically treated patients, 96% were carriers of binocular glaucoma. Among the regions of Brazil, the Northeast had the highest prevalence of binocular glaucoma (about 60% of the number of cases), and the most common therapy was combinations of two drugs from different lines. The Southeast region had the highest concentration of monocular glaucoma (53% of cases), and the predominant therapy was combinations of three drugs from different lines. The Midwest region had the lowest prevalence of monocular-treatments for glaucoma (less than 6%). Conclusion: In Brazil, the highest number of treatments offered by the public health system was in the Northeast and Southeast regions. There is a high national prevalence and potential for the morbidity of this disease. Therefore, it is necessary to strengthen programs aimed at early diagnosis and appropriate treatment to reduce adverse outcomes.

Resumo Objetivo: Traçar o perfil epidemiológico do tratamento clínico para o glaucoma no Brasil fornecido pelo Sistema Único de Saúde (SUS), no período de janeiro de 2012 a dezembro de 2018. Métodos: Estudo quantitativo e descritivo, utilizando a base de dados disponível no Sistema de Informações Ambulatoriais do SUS (SIA/SUS). As variáveis utilizadas foram: tratamento monocular com drogas de primeira, de segunda e de terceira linha; tratamento monocular com combinações de duas drogas e de três drogas de diferentes linhas; tratamento binocular com drogas de primeira, de segunda e de terceira linha; e tratamento binocular com combinações de duas drogas e de três drogas de diferentes linhas. Resultados: Durante o período analisado, a prevalência de terapias clínicas para o glaucoma aumentou entre 2012 e 2017 e diminuiu entre 2017 e 2018. Dos pacientes tratados clinicamente, 96% eram portadores de glaucoma binocular. Entre as regiões do Brasil, o Nordeste teve a maior prevalência de glaucoma binocular (cerca de 60% do número de casos), e a terapia mais comum foi a combinação de duas drogas de diferentes linhas. A região Sudeste teve a maior concentração de glaucoma monocular (53% dos casos), e a terapia predominante foi a combinação de três drogas de diferentes linhas. A região Centro-Oeste apresentou a menor prevalência de tratamentos monoculares para o glaucoma (menos de 6%). Conclusão: No Brasil, o maior número de tratamentos oferecidos pelo sistema público de saúde foi nas regiões Nordeste e Sudeste. Existe uma alta prevalência nacional e um alto potencial para morbidade desta doença. Portanto, é necessário fortalecer programas voltados para o diagnóstico precoce e para o tratamento adequado a fim de reduzir os resultados adversos.