Experimenting With the New Frontier: Artificial Intelligence-Powered Chat Bots in Hand Surgery.

Background: Increased utilization of artificial intelligence (AI)-driven search and large language models by the lay and medical community requires us to evaluate the accuracy of AI responses to common hand surgery questions. We hypothesized that the answers to most hand surgery questions posed to an AI large language model would be correct. Methods: Using the topics covered in Green's Operative Hand Surgery 8th Edition as a guide, 56 hand surgery questions were compiled and posed to ChatGPT (OpenAI, San Francisco, CA). Two attending hand surgeons then independently reviewed ChatGPT's answers for response accuracy, completeness, and usefulness. A Cohen's kappa analysis was performed to assess interrater agreement. Results: An average of 45 of the 56 questions posed to ChatGPT were deemed correct (80%), 39 responses were deemed useful (70%), and 32 responses were deemed complete (57%) by the reviewers. Kappa analysis demonstrated "fair to moderate" agreement between the two raters. Reviewers disagreed on 11 questions regarding correctness, 16 questions regarding usefulness, and 19 questions regarding completeness. Conclusions: Large language models have the potential to both positively and negatively impact patient perceptions and guide referral patterns based on the accuracy, completeness, and usefulness of their responses. While most responses fit these criteria, more precise responses are needed to ensure patient safety and avoid misinformation. Individual hand surgeons and surgical societies must understand these technologies and interface with the companies developing them to provide our patients with the best possible care.

Hamartomatous polyps: Diagnosis, surveillance, and management.

Hereditary polyposis syndrome can be divided into three categories: Ade-nomatous, serrated, and hamartomatous polyps. Hamartomatous polyps, malformations of normal tissue presenting in a disorganized manner, are characterized by an autosomal dominant inheritance pattern. These syndromes exhibit hamartomatous gastrointestinal polyps in conjunction to extra-intestinal manifestations, which require conscientious and diligent monitoring. Peutz-Jeghers syndrome, Cowden syndrome, and juvenile polyposis syndrome are the most common displays of hamartomatous polyposis syndrome (HPS). Diagnosis can be pursued with molecular testing and endoscopic sampling. Early identification of these autosomal dominant pathologies allows to optimize malignancy sur-veillance, which helps reduce morbidity and mortality in both the affected patient population as well as at-risk family members. Endoscopic surveillance is an important pillar of prognosis and monitoring, with many patients eventually requiring surgical intervention. In this review, we discuss the diagnosis, surveillance, and management of HPS.

Impact of the COVID 19 Pandemic on Treatment of nAMD via a Portal-Based Collaboration. / Auswirkung der COVID-19-Pandemie auf die Therapie der nAMD in einer portalbasierten Kooperation.

BACKGROUND: Under the influence of the COVID 19 pandemic and the lockdown in Germany, there were significantly fewer consultations in almost all medical disciplines. Especially given the need for consistent treatment and follow-up of nAMD patients, this can have far-reaching consequences for visual function, especially in elderly patients. METHODS: In a retrospective analysis of nAMD patients, the number of visits (IVI or follow-up), OCTs or IVIs performed and the mean worst visual acuity for the period before and after the first COVID 19-associated lockdown were compared in a portal-based collaboration of 50 eye care practices. Patients were treated according to the pro re nata (PRN) regimen that included intravitreal injection of VEGF inhibitors based on activity criteria in the OCT follow-up. RESULTS: A total of 34,660 visits from 55 months were included in the analysis. Before lockdown (16 March 2020), an average of 81.8% ± 2.1% of patients were regularly checked or treated (every 4 to 5 weeks). With the onset of lockdown, the proportion of patients receiving optimum treatment dropped to 64.0%. Initially, the proportion of OCT follow-ups decreased from 48.4% to 30.9% and, with a delay, the proportion of injections decreased from 57.5% to 45.8%. This was also reflected in the number of OCT follow-ups: 15.5 before, 11.4 during and 17.2 after lockdown (p < 0.001). In 29% of cases, an individual worsening of visual acuity by more than 0.1 logMAR after the end of the lockdown compared to before the lockdown could be observed. On average, mean visual acuity decreased significantly by 0.054 logMAR (p < 10-11). This significant impairment was not reversed again during the remaining observation period, although the number of visits, OCT examinations and IVIs in the following 12 months were at the pre-lockdown level. CONCLUSIONS: The pandemic-related lockdown resulted in unintended treatment breaks in nAMD patients receiving IVI therapy. The decrease in visits as well as in IVIs caused a loss of visual function in the observed cohort. The consistent treatment regimen of nAMD patients was resumed shortly after the lockdown with an immediate normalization of the number of OCT examinations and IVIs. However, a permanent loss of visual function was observed, and this did not improve within a year after the lockdown. This finding highlights the importance of better case management, leading to improved patient adherence in the event of further waves of COVID or other pandemics.

Quantification of Early and Intermediate Age-related Macular Degeneration Using OCT "en face" Presentation. / Quantifizierung der frühen und intermediären altersabhängigen Makuladegeneration mittels OCT-"en-face"-Darstellung.

BACKGROUND: Early and intermediate age-related macular degeneration (AMD) results in drusen deposits under the retinal pigment epithelium (RPE). These early stages of AMD exhibit different risks of progressing to late AMD. To date, early AMD has been classified and quantified by fundus photography. This does not appear to be sensitive enough for clinical trials studying the impact on drusen. SD-OCT with two-dimensional rendering of the segmented slices analysed allows for en face imaging of the drusen. The present trial studied the potential of quantifying early and intermediate AMD by en-face optical coherence tomography (OCT). MATERIAL AND METHODS: Thirty-one eyes of 29 patients in different stages of early and intermediate AMD were studied. To this end, fundus photographs (Kowa VX-10i, Kowa, Tokyo, Japan) and en-face OCT images (RTVue XR Avanti, Optovue, Inc., Fremont, CA, USA) were taken. First, different segmentation levels (6 µm underneath the RPE, on the RPE, 6 µm and 9 µm above the RPE) and different layer thicknesses (5 µm, 10 µm, 20 µm and 30 µm) were analysed to determine the best segmentation for visualising drusen. Drusen were marked manually and their number and surface area calculated. This analysis was then compared with the standardised drusen analyses on fundus photography. Additional changes in early and intermediate AMD such as pigment epithelial detachments (PEDs) and subretinal drusenoid deposits (SDD) as well as small atrophies were also documented and compared. OUTCOMES: The best segmentation for delineating the drusen on the en-face OCT images was found to be a segmentation 6 µm underneath the RPE with a slice thickness of 20 µm. Comparison of drusen quantification on en-face OCT images with the standardised drusen analysis on fundus photography revealed particularly good similarity. Other changes in early and intermediate AMD, such as PEDs, SDD and small atrophies, were easier to assess on the en-face OCT images. CONCLUSIONS: The analysis and quantification of drusen from en-face OCT images with 20 µm segmentation at 6 µm underneath the RPE allows differentiated quantification of various drusen characteristics. Moreover, other changes in early and intermediate AMD can also be analysed. In future observational and clinical trials, this could help quantify drusen.

[Are There Different Phenotypes in Geographic Atrophy of AMD? - Pilot Study on Differentiation Using Multimodal Imaging]. / Gibt es unterschiedliche Phänotypen bei der geografischen Atrophie der AMD? ­ Pilotstudie zur Differenzierung mittels multimodaler Bildgebung.

BACKGROUND: Geographic atrophy (GA) in patients with age-related macular degeneration (AMD) involves a loss of photoreceptors (PR), retinal pigment epithelium (RPE) and choriocapillaris (CC). For treatment decisions, it is crucial to discern which of these layers the damage originates, subsequently spreading to the others. It has long been thought that the RPE, with its accumulation of lipofuscin, is the site of primary damage in the development of GA. However, histological studies have shown that in some patients, the PR are affected first, followed by secondary damage to the RPE and CC, and in others regression of the CC is the first manifestation. The aim of this study was to use multimodal imaging to determine the extent of the damage at the levels of the PR, RPE and CC, to characterise the individual phenotypic variations of GA and to investigate the corresponding functional impairment. PATIENTS AND METHODS: Twenty eyes of 20 patients (mean age 78 years; 14 female, 6 male) with the clinical diagnosis of GA were examined by means of fundus autofluorescence (FAF) to evaluate the damage to the RPE, en face SD-OCT at the level of the PR to characterise the area of cell loss in this layer and OCT angiography (OCT-A, AngioVue, Optovue; 50 µm CC-segmentation with localization below the RPE) to assess regression of the CC. The affected area of each layer was measured. Best-corrected visual acuity (BCVA) test and fundus correlated automated 10° microperimetry (MAIA Microperimetry, CENTERVUE; 4-2 strategy, 68 stimuli) were performed in all patients. The results of these examinations were evaluated and correlated. RESULTS: All eyes showed a different extent of the areas of atrophy in the PR, RPE and CC. The layer with the largest area of atrophy was the RPE in 13 eyes (65%), the PR in 3 eyes (15%) and the CC in 4 eyes (20%). While the visual loss depended entirely on the presence of foveal sparing, microperimetry revealed a correlation between the extent of detectable functional deficit and the largest atrophic area. CONCLUSIONS: Multimodal imaging with FAF, en face OCT, OCT-A and a correlation with microperimetry enables a clinical phenotypic differentiation in GA as well as a more precise characterisation of the associated functional impairment. This confirms clinically the histologically demonstrated diversity of the damaged structure (PR, RPE or CC) in patients with GA. However, the variations identified in this pilot study must be confirmed in Reading Center-based larger cohorts. The approach described here may lead to differentiated consideration of the anatomical and functional aspects of the disease and turn out to be helpful in patient selection as well as in identifying and monitoring future therapeutic approaches.

[Analysis of the "Portal" Care Model - Examination of the Outcome Quality of IVOM Therapy with Regard to Latency Periods in Exudative AMD]. / Analyse des Versorgungsmodells "Portal" ­ Untersuchung der Ergebnisqualität der IVOM-Therapie im Hinblick auf Latenzzeiten bei exsudativer AMD.

BACKGROUND: For many maculopathies, the management of intravitreal injection (IVOM) presents a logistical challenge. To ensure contemporary and timely treatment, patients have to organise their rides to the surgery, and the clinic has to provide enough short term resources. The objective of this study is an evaluation of the IVOM therapy for patients with exudative AMD according to four quality indicators a) latency time within the treatment and monitoring cycle, b) the treatment and monitoring frequency, c) the adherence and d) the medical outcome. MATERIALS AND METHODS: For more than seven years, patients with exudative AMD have been treated by many ophthalmologists using a networked portal system. Therefore, conservative doctors and surgical eye centres exchange treatment-relevant data. In total there are documented 2283 eyes of 1850 patients. We evaluate these electronic medical records retrospectively according to the mentioned quality indicators. RESULTS: This evaluation results in a latency time from OCT monitoring and the start of a new IVOM series of 8.1 working days. Within the first two treatment years, we achieve 10.5 injections and 8.2 monitoring visits in average. After two years, 72.9% of the cases were still in treatment or monitoring. We observed stabilisation of mean visual accuracy of about 0.05 logMAR. CONCLUSIONS: To improve the visual acuity, it is essential to achieve consistent therapy over a long period of time, especially in the case of treatment-relevant exudative AMD. The evaluation of our treatment system demonstrated that the PRN-scheme can be implemented by a cooperatively organised IVOM therapy. It is possible to achieve rapid retreatment and good adherence over many treatment years. For treatment-relevant exudative AMD it is essential for the improvement of the visual accuracy to implement consistent therapy over a long period of time. The evaluation of our treatment system demonstrates that the PRN scheme can be implemented in a cooperatively organised IVOM therapy. It is possible to achieve rapid retreatment and good patients' adherence over many treatment years.

Analysis of the Vascular Morphology of the Fibrotic Choroidal Neovascularization in Neovascular Age-Related Macular Degeneration Using Optical Coherence Tomography Angiography. / Analyse der Gefäßmorphologie der fibrosierten choroidalen Neovaskularisation bei neovaskulärer altersabhängiger Makuladegeneration mittels optischer Kohärenztomografie-Angiografie.

PURPOSE: Choroidal neovascularization (CNV) in neovascular age-related macular degeneration (nAMD) undergoing anti-VEGF therapy transforms into a fibrotic lesion. This fibrovascular transformation is associated with a great variety of functional and morphological effects. The aim of this study was to investigate the vascular morphology of fibrotic CNV, to compare it with its surrounding tissue and to identify phenotypes using optical coherence tomography angiography (OCTA). METHODS: In 18 eyes with fibrotic CNV in nAMD spectral domain OCT (SD-OCT) and OCTA were performed. The automated segmentation lines were manually adjusted. A slab from 60 µm beneath Bruch's membrane to the inner edge of the subretinal hyperreflective material was applied. Quantitative analysis of the vascular morphology was performed using skeletonized OCTA images. RESULTS: Compared to the perilesional rim, the number of segments per area was significantly lower (234.75 ± 25.68 vs. 255.30 ± 20.34 1/mm2, p = 0.0003) within the fibrovascular lesion. Two phenotypes could be identified within the lesion. The phenotypic traits of cluster 1 were few, long and thick vascular segments; Cluster 2 was characterized by many, short and thin vascular segments (number of segments per area: 219.4 ± 18.8 vs. 258.8 ± 13.2 1/mm2, p = 0.00009, segment length: 49.6 ± 2.7 vs. 45.0 ± 1.3 µm, p = 0.0002, vascular caliber: 26.6 ± 1.2 vs. 23.5 ± 1.8 µm, p = 0.003). The clusters did not differ significantly regarding visual acuity (0.52 ± 0.44 vs. 0.54 ± 0.18 logMAR, p = 0.25), differentiability of subretinal (OR = 3.43, CI = [0.30, 39.64], p = 0.6) and intraretinal fluid (OR = 5.34, CI = [0.48, 89.85], p = 0.14). Less normalized ellipsoid zone (EZ) loss could be observed in cluster 1 (131.0 ± 161.3 vs. 892.4 ± 955.6 1/m, p = 0.006). CONCLUSION: In this study the vascular morphology of fibrotic CNV was analyzed using OCTA. Differences between the lesion and a perilesional rim could be detected. Two phenotypes within the fibrovascular lesion were identified. These morphological clusters could indicate different patterns of fibrovascular transformation of the CNV under long-term anti-VEGF therapy and be useful identifying possible predictive biomarkers in future studies.

[Uveitis Masquerade Syndrome: Typical Symptoms and Presentations]. / Uveitis-Masquerade-Syndrome: Leitsymptome und Krankheitsbilder.

The uveitis masquerade syndrome (UMS) describes a series of malignant diseases that mimic inflammatory conditions without belonging to the group of immune-mediated uveitis entities. The correct diagnosis is often difficult to establish, despite a detailed ophthalmological and general medical history using all imaging modalities and interdisciplinary cooperation. In the case of recurrent inflammation, it is very important to consider an UMS, since any delay in proving the underlying diagnosis and initiating the appropriate therapy may be associated with the risk of systemic spread and consecutive deterioration of the prognosis. Often, after all conservative options have been exhausted, the only remaining option to confirm the correct diagnosis might be an intraocular biopsy. The present work focuses on the leading symptoms, differential diagnoses and clinical signs of UMS.

[Peri-/Postoperative Anti-Inflammatory Therapy in Vitreoretinal Interventions]. / Peri-/Postoperative antientzündliche Therapie im Rahmen von vitreoretinalen Eingriffen.

The perioperative treatment of retinal surgery with anti-inflammatory drugs is an everyday procedure for ophthalmologists in Germany. Nevertheless, little data are available to investigate the efficacy of vitreoretinal surgery. Treatment is usually analogous to procedures on the anterior segment of the eye, for which much more robust data are available. In this article, the relevant clinical questions will be answered and, when possible, documented with study data.

Adsorption and reaction of methanol over CeO(X)(100) thin films.

Methanol was adsorbed on oxidized and reduced CeOX(100) thin films to probe the active sites and reaction selectivity of these surfaces compared to those of CeOX(111). Roughly twice as much methoxy was formed on oxidized CeO2(100) compared to that formed on CeO2(111). In addition to more methoxy, hydroxyl is also more stable on CeO2(100). Unlike on CeO2(111), however, methanol on CeO2(100) produced CO, CO2, and H2 in addition to water and formaldehyde. The behavior of CeO2(100) is related to its surface structure, which provides greater access to Ce cations and therefore more active adsorption sites and more highly undercoordinated Ce and O. The undercoordinated O may explain the enhanced dehydrogenation activity leading to CO and H2 formation. The reduction of ceria leads to increased methanol uptake on both CeO2 - X(100) and CeO2 - X(111). However, although the uptake doubled on reduced CeO2 - X(111) compared to the oxidized surface, it increased by only 10% on reduced CeO2 - X(100) compared to that on fully oxidized CeO2(100). Reduction of both surfaces leads to a greater production of CO and H2. Reaction on all surfaces progresses rapidly from methoxy to products. There is no spectroscopic evidence of formyl or formate intermediates. On CeOX(100), carbonate is detected that decomposes into CO2 at high temperature.

Templating of arrays of Ru nanoclusters by monolayer graphene/Ru Moirés with different periodicities.

We have studied the formation of Ru nanocluster arrays on several monolayer graphene/Ru Moiré structures with different relative orientations of the graphene and Ru lattices. Experiments and ab initio calculations clearly show that the presence of a graphene/Ru Moiré does not guarantee the ordered adsorption of Ru nanoclusters. The simultaneous deposition of Ru onto coexisting Moirés demonstrates that a structure with aligned graphene and Ru lattices templates the formation of arrays of small Ru clusters with narrow size spread and adsorption exclusively in a single site (the 'low fcc' site). The other Moirés considered here gave rise to substantially larger clusters with broader size distribution and without detectable site selectivity. Calculations explain these findings via the density of states (DOS) at different sites of the graphene/Ru Moiré. The ordered nucleation of many small clusters instead of incorporation of metal atoms into larger ones requires one Moiré site with a large DOS at the Fermi level, so that the binding of metal adatoms to this site is stronger than to competing sites in the Moiré and to existing metal clusters.

Chemical vapor deposition and etching of high-quality monolayer hexagonal boron nitride films.

The growth of large-area hexagonal boron nitride (h-BN) monolayers on catalytic metal substrates is a topic of scientific and technological interest. We have used real-time microscopy during the growth process to study h-BN chemical vapor deposition (CVD) from borazine on Ru(0001) single crystals and thin films. At low borazine pressures, individual h-BN domains nucleate sparsely, grow to macroscopic dimensions, and coalescence to form a closed monolayer film. A quantitative analysis shows borazine adsorption and dissociation predominantly on Ru, with the h-BN covered areas being at least 100 times less reactive. We establish strong effects of hydrogen added to the CVD precursor gas in controlling the in-plane expansion and morphology of the growing h-BN domains. High-temperature exposure of h-BN/Ru to pure hydrogen causes the controlled edge detachment of B and N and can be used as a clean etching process for h-BN on metals.

Multiple sclerosis and pregnancy: what does the patient think? a questionnaire study.

BACKGROUND: Multiple Sclerosis (MS) is primarily a disease of women in their childbearing years. Pregnancy and puerperium have opposite effects on the course of the disease. Nevertheless, no studies have been carried out yet on the level of information among female MS-patients regarding the interaction between MS and pregnancy. FINDINGS: Demographic data, clinical features of MS, course of MS during pregnancy and puerperium as well as knowledge concerning MS and pregnancy were evaluated by means of a questionnaire in 154 female MS-patients. The level of information was significantly higher (p < 0.001) in women who had been pregnant in the past with the diagnosis MS known at this point of time. Furthermore patients reported about a lower frequency of relapses during pregnancy and a higher frequency of relapses in the first six months after giving birth. CONCLUSIONS: The findings illustrate a lack of knowledge in female MS-patients concerning the interactions of MS and pregnancy. In order to make their own independent decision based on scientific facts known to date, female MS-patients need to be better informed on issues regarding MS and pregnancy.

Lateral manipulation of single-walled carbon nanotubes on H-passivated Si(100) surfaces with an ultrahigh-vacuum scanning tunneling microscope.

Ultrahigh-vacuum (UHV) scanning tunneling microscopy (STM) can be used for the manipulation of individual atoms and molecules into complex arrangements for sensitive electrical and structural characterization. However, the systematic UHV STM manipulation of single-walled carbon nanotubes (SWNTs), high-aspect-ratio molecular wires derived from graphene that exist in both semiconducting and metallic forms, has yet to be reported. In this work, we demonstrate the room-temperature lateral manipulation of approximately 1-nm-diameter SWNTs on UHV-prepared, hydrogen-passivated Si(100) surfaces. We show the reproducible actuation of SWNTs having lengths as small as 13 nm, along with the partial division of a two-tube bundle. Moreover, UHV STM desorption of H at the SWNT/Si interface is introduced as a means of locally strengthening the interaction between the tube and the surface. The UHV STM manipulation scheme described here is potentially extensible to the orientational control of SWNTs interfaced with atomically clean semiconducting surfaces, such as InAs(110), GaAs(110), and unpassivated Si(100), for which first-principles calculations based on density functional theory have been reported recently in the literature.