Evaluating a Novel AI Tool for Automated Measurement of the Aortic Root and Valve in Cardiac Magnetic Resonance Imaging.

Objective Evaluating an artificial intelligence (AI) tool (AIATELLA, version 1.0; AIATELLA Oy, Helsinki, Finland) in interpreting cardiac magnetic resonance (CMR) imaging to produce measurements of the aortic root and valve by comparison of accuracy and efficiency with that of three National Health Service (NHS) cardiologists. Methods AI-derived aortic root and valve measurements were recorded alongside manual measurements from three experienced NHS consultant cardiologists (CCs) over three separate sites in the northeast part of the United Kingdom. The study utilised a comprehensive dataset of CMR images, with the intraclass correlation coefficient (ICC) being the primary measure of concordance between the AI and the cardiologist assessments. Patient imaging was anonymised and blinded at the point of transfer to a secure data server.  Results The study demonstrates a high level of concordance between AI assessment of the aortic root and valve with NHS cardiologists (ICC of 0.98). Notably, the AI delivered results in 2.6 seconds (+/- 0.532) compared to a mean of 334.5 seconds (+/- 61.9) by the cardiologists, a statistically significant improvement in efficiency without compromising accuracy. Conclusion AI's accuracy and speed of analysis suggest that it could be a valuable tool in cardiac diagnostics, addressing the challenges of time-consuming and variable clinician-based assessments. This research reinforces AI's role in optimising the patient journey and improving the efficiency of the diagnostic pathway.

Can a reconstruction algorithm in major acetabular bone loss be successful in revision hip arthroplasty?

Aims: The aims of this study were to determine the success of a reconstruction algorithm used in major acetabular bone loss, and to further define the indications for custom-made implants in major acetabular bone loss. Methods: We reviewed a consecutive series of Paprosky type III acetabular defects treated according to a reconstruction algorithm. IIIA defects were planned to use a superior augment and hemispherical acetabular component. IIIB defects were planned to receive either a hemispherical acetabular component plus augments, a cup-cage reconstruction, or a custom-made implant. We used national digital health records and registry reports to identify any reoperation or re-revision procedure and Oxford Hip Score (OHS) for patient-reported outcomes. Implant survival was determined via Kaplan-Meier analysis. Results: A total of 105 procedures were carried out in 100 patients (five bilateral) with a mean age of 73 years (42 to 94). In the IIIA defects treated, 72.0% (36 of 50) required a porous metal augment; the remaining 14 patients were treated with a hemispherical acetabular component alone. In the IIIB defects, 63.6% (35 of 55) underwent reconstruction as planned with 20 patients who actually required a hemispherical acetabular component alone. At mean follow-up of 7.6 years, survival was 94.3% (95% confidence interval 97.4 to 88.1) for all-cause revision and the overall dislocation rate was 3.8% (4 of 105). There was no difference observed in survival between type IIIA and type IIIB defects and whether a hemispherical implant alone was used for the reconstruction or not. The mean gain in OHS was 16 points. Custom-made implants were only used in six cases, in patients with either a mega-defect in which the anteroposterior diameter > 80 mm, complex pelvic discontinuity, and massive bone loss in a small pelvis. Conclusion: Our findings suggest that a reconstruction algorithm can provide a successful approach to reconstruction in major acetabular bone loss. The use of custom implants has been defined in this series and accounts for < 5% of cases.

Bowman Layer Marking for Correct Placement of Corneal Allogeneic Intrastromal Ring Segments.

ABSTRACT: Corneal allogeneic intrastromal ring segments (CAIRS) refer to the placement of allogeneic rings and segments in intrastromal channels within the cornea. Currently, a deepithelialized donor cornea is used as the allogeneic source for CAIRS and the cut ring is turned sideways and implanted so that the thickness can be varied by varying the distance between the concentric trephine blades. In addition, to obtain a greater effect, CAIRSs are preferred to be implanted with the Bowman layer (BL) facing the corneal apex and posterior stroma facing limbally. Being flexible tissue, it is, however, important to prevent twisting and to maintain correct orientation. We describe a simple technique of marking the BL with a gentian violet surgical marker to simplify CAIRS insertion. BL marking allows easy visibility of twists and helps identify improper orientation, thus allowing correct insertion of CAIRS.

How Would Nature See Our Corneal Triumphs? The LXXIX Edward Jackson Lecture.

PURPOSE: To describe discrepancies between clinical observation and current teachings in corneal endothelial disease, particularly in Fuchs endothelial dystrophy and its potential association with primary open angle glaucoma. DESIGN: Perspective. METHODS: A perspective is presented on Fuchs dystrophy, a disorder that commonly presents with a compromised endothelium but minimal stromal edema, indicating that the corneal imbibition pressure is relatively "too high." RESULTS: The discrepancy between the relative lack of stromal edema in the absence of an endothelial cell layer cannot be explained by the current theories involving a circulatory pumping mechanism over the endothelial cell layer, but may point to the following: (1) secondary involvement of the corneal endothelium in Fuchs dystrophy; (2) separate hydration systems for maintaining the imbibition pressure (vertical static hydration) and corneal nutrition (horizontal dynamic hydration); (3) the cornea as net contributor of aqueous humor; (4) a close relationship between the corneal imbibition and intraocular pressure, with potentially a shared regulatory system; and (5) a potential steroid-type hormone dependency of this regulatory system. CONCLUSIONS: Clinical observation shows that the stromal imbibition pressure is "too high" in Fuchs endothelial dystrophy, indicating that it may not primarily be an endothelial disease, but a type of "corneal glaucoma."

Trends in adolescent emotional problems in Wales between 2013 and 2019: the contribution of peer relationships.

BACKGROUND: Epidemiological evidence shows a substantial increase in adolescent emotional problems in many countries, but reasons for this increase remain poorly understood. We tested change in emotional problems in a national sample of young people in Wales in 2013, 2017 and 2019 using identical symptom screens, and examined whether trends were accounted for by changes in youth friendship quality and bullying. METHODS: The present study of 230,735 11-16-year olds draws on repeat cross-sectional data obtained on three occasions (2013, 2017 and 2019) in national school-based surveys in Wales (conducted by the School Health Research Network). Emotional problems were assessed with a brief validated symptom screen (the SCL-4). RESULTS: There was a significant increase in emotional problem scores between 2013 and 2019 (b[95% CI] = 1.573 [1.380, 1.765]). This increase was observed for all ages and was more pronounced for girls than boys (interaction b [95% CI] = 0.229 [0.004, 0.462]) and for young people from less affluent families (interaction b [95% CI] = -0.564[-0.809, -0.319]). Of the total sample, 14.2% and 5.7% reported frequent face-to-face and cyberbullying respectively. There were modest decreases in friendship quality and increases in rates of bullying between 2013 and 2019, but accounting for these changes did not attenuate estimates of the population-level increase in emotional problems. CONCLUSIONS: This study provides evidence of a substantial increase in emotional problems among young people in Wales, particularly for young people from less affluent backgrounds. Changes in bullying or friendship quality did not explain this increase.

Intracorneal ring segment implantation in advanced Keratoconus.

PURPOSE: To compare the clinical outcomes of intracorneal ring segment (ICRS) implantation in eyes with advanced vs. mild/moderate keratoconus (KCN). METHODS: A retrospective analysis of 141 eyes of 111 patients with KCN who underwent ICRS implantation. Preoperative maximum keratometry (Kmax) was <57 diopters (D) in 70 eyes and >57 D in 71 eyes. Postoperatively, corrected distance visual acuity (CDVA), Kmax, and intraoperative and postoperative complications were assessed at 1 day, 1 month, and 1 year. RESULTS: Corneas with a preoperative Kmax >57 D experienced greater reduction in axial curvature after ICRS implantation than corneas with a preoperative Kmax <57 D (7.0 D vs. 5.5 D, p=0.005) and gained more Snellen lines of CDVA (3 vs. 1, p<0.001) by 1 year postoperatively. The incidences of the most prevalent complications (explantation, extrusion, and infectious keratitis) did not differ significantly between the two groups (p=0.29, p=0.99, p=0.98). CONCLUSIONS: The visual and topographic effects of ICRS implantation are greater in eyes with more advanced KCN, with no increase in the incidence of the most common complications.

DMEK Without Postoperative Supine Posturing.

PURPOSE: The purpose of this study was to describe the incidence of graft detachment after Descemet membrane endothelial keratoplasty (DMEK) without postoperative supine posturing. METHODS: A total of 106 eyes of 84 patients with Fuchs endothelial corneal dystrophy or bullous keratopathy (BK) were operated by a single experienced surgeon with DMEK with a 99% anterior chamber air bubble fill, recovered in an upright (seated) position, and then discharged without instructions to remain supine. Postoperatively, all eyes were evaluated for graft detachment through anterior segment optical coherence tomography at predetermined intervals (1 d, 1 wk, and 1 mo). Detachments were regarded as clinically significant if they subtended 30% of the total graft surface area or involved the visual axis. RESULTS: Clinically significant graft detachments were observed in 23 of 106 eyes (22%) in the no-supine posturing cohort, including 22 of 85 eyes (26%) operated for Fuchs endothelial corneal dystrophy and 1 of 21 eyes (5%) operated for BK. Compared with a historical comparison group of eyes undergoing DMEK with 48 hours of postoperative supine posturing, the risk of graft detachment was not increased. In both cohorts, 6% of operated eyes required regrafting for either persistent detachment or primary graft failure. No additional intraoperative or postoperative complications were experienced. CONCLUSIONS: Particularly in eyes operated for BK, the supine posturing requirement after DMEK may be eliminated without increasing the absolute risk for clinically significant graft detachment.

Endodiathermal Tautening of Floppy or Irregular Iris in Endothelial Keratoplasty (Iridodiathermy).

ABSTRACT: Floppy or irregular irides may be seen during endothelial keratoplasty in complex cases or in eyes with damaged irides and may cause uneven air fill, retro-pupillary air escape, anterior bowing of iris, forward movement of lens-iris diaphragm, shallowing of anterior chamber (AC), bellowing and floppiness of iris, uneven AC depth, difficulty in inserting and opening graft, iris trauma, intraoperative bleeding, and iridodialysis. We present a technique of iridodiathermy for tautening and flattening such irides. With continuous irrigation using AC maintainer, the bipolar endodiathermy probe tip is applied in localized spots to midperipheral iris in the affected area with power and duration adjusted to induce mild localized shrinkage and tightening of iris stroma. Such iris tautening decreases its floppiness and prevents anterior bowing, excessive mobility, irido-corneal touch, and peripheral anterior synechiae formation. It provides a stable AC with regular depth and improved, uniform, and nonmigratory air fill, thus decreasing intraoperative challenges.

Clinical outcomes of Descemet membrane endothelial keratoplasty performed in eyes with keratoconus and corneal endothelial dysfunction.

PURPOSE: To evaluate the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) performed in eyes with comorbid keratoconus (KCN) and corneal endothelial dysfunction. METHODS: Twenty-five consecutive eyes of 14 patients with comorbid stable KCN underwent DMEK for corneal endothelial dysfunction; best spectacle corrected visual acuity (BSCVA), maximum corneal curvature (Kmax), maximum corneal power (Pmax), central corneal thickness (CCT), and intra- and postoperative complications were assessed. RESULTS: Excluding eyes requiring re-transplantation for primary graft failure (n = 3), all eyes showed improvement in BSCVA, reaching ≥ 20/40 (0.5) in 86%, ≥ 20/25 (0.8) in 55%, and ≥ 20/20 (1.0) in 27% by one month postoperatively; 90%, 76%, and 48% by 6 months postoperatively; and 88%, 76%, and 47% by 12 months postoperatively. CCT decreased from 571µm preoperatively to 485µm at 1 month (p < 0.001) and 481µm at 12 months (p < 0.001). Kmax decreased by a median of 1.4 diopters (D) at 1 month (p = 0.003) and 3.1 D at 12 months (p = 0.021), and every eye with a preoperative Kmax ≥ 46 D demonstrated flattening. Pmax decreased by 2.1 D at 1 month (p = 0.001) and 4.0 D at 12 months (p = 0.016). CONCLUSION: DMEK is technically feasible in eyes with comorbid KCN and may give excellent outcomes visual and refractive outcomes, including significant corneal flattening, which may potentially create a visually significant hyperopic shift in patients with severely ectatic corneas.

Bowman Layer Onlay Graft for Recurrent Corneal Erosions in Map-Dot-Fingerprint Dystrophy.

PURPOSE: The purpose of this study was to describe a case with recurrent corneal erosions who was treated with a Bowman layer (BL) onlay graft. METHOD: BL onlay transplantation was performed. RESULTS: In a 79-year-old female patient who presented with bilateral map-dot-fingerprint dystrophy and a history of recurrent painful corneal erosions, BL onlay grafting was performed to restore the corneal surface. At 1 month postoperatively, the epithelium was smooth over the graft, and until 1.5 years postoperatively, the patients had no complaints and no recurrence of the epithelial corneal erosion. CONCLUSIONS: In the described case, the transplantation of an isolated BL graft as an onlay proved to be an effective treatment for painful chronic recurrent erosions in the context of map-dot-fingerprint dystrophy in a patient who had undergone numerous unsuccessful previous treatments.

DMEK with endophotocoagulation and cyst wall removal for corneal endothelial decompensation due to iris cyst.

PURPOSE: Iris cysts may arise secondary to surgical or nonsurgical trauma, potentially leading to corneal decompensation via mechanical injury to the adjacent endothelium. However, no well-established protocol exists for the treatment for corneal edema arising therefrom. OBSERVATIONS: A 58-year-old white male presented with an iris mass of his left eye; it occupied 1/3rd the anterior chamber volume and directly contacted the corneal endothelium. The cornea was diffusely edematous, and best corrected visual acuity (BCVA) measured 20/70 (0.3). Corneal endothelial decompensation secondary to iris cyst was diagnosed. Treatment consisted of endophotocoagulation and vitrectomy probe removal of the cyst wall, with Descemet membrane endothelial keratoplasty (DMEK) also performed as a single, combined procedure. The patient subsequently experienced a resolution of his corneal edema and disappearance of his iris cyst, without recurrence of either condition. BCVA improved to 20/25 (0.8). CONCLUSIONS AND IMPORTANCE: Iris cyst may be a rare cause of corneal decompensation. Viable treatment may entail a single-stage procedure involving endophotocoagulation and vitrectomy probe application to the cyst wall combined with DMEK.

Non-Epithelial Ovarian Cancers: How Much Do We Really Know?

Non-epithelial ovarian cancers (NEOC) are a group of uncommon malignancies that mainly includes germ cell tumours (GCT), sex cord-stromal tumours (SCST), and some extremely rare tumours, such as small cell carcinomas and sarcomas. Each of these classifications encompasses multiple histologic subtypes. The aetiology and molecular origins of each sub-group of NEOC require further investigation, and our understanding on the genetic changes should be optimised. In this article, we provide an update on the clinical presentation, pathology, genetics, treatment and survival of the main histological subtypes of the GCT and the SCST, as well as of ovarian small cell carcinomas. We also discuss miRNA expression profiles of NEOC and report the currently active clinical trials that include NEOC.

Physiotherapists perceived role in managing anxiety in patients with relapsing-remitting multiple sclerosis: a mixed-methods study.

BACKGROUND: Anxiety is common for people with Multiple Sclerosis (PwMS) and is higher in those with relapsing-remitting MS (RRMS) and in community-based samples. Anxiety can impact self-efficacy, pain, fatigue, engagement in physical activity and treatment adherence, all of which influence the rehabilitation process. Little is known about how physiotherapists manage anxiety in PwMS and the challenges associated with anxiety throughout the rehabilitation process, in community and outpatient settings. METHODS: A mixed-methods design, combining a cross-sectional survey and semi-structured interviews with UK-physiotherapists, was used to answer the research question. To inform the qualitative study, a cross-sectional survey collected data from physiotherapists working in neurology to understand the impact and management of anxiety in people with MS (PwMS) during rehabilitation. Analysis used descriptive statistics and the findings formed the interview guide. Semi-structured interviews with specialist physiotherapists explored barriers and facilitators to managing anxiety in PwMS in community and outpatient settings, identified perceived physiotherapy training needs and offered suggestions to develop physiotherapy research and practice. Themes were derived inductively. RESULTS: The survey suggested how PwMS present with anxiety, its impact during rehabilitation, physiotherapy management practices, and physiotherapist skills and training needs. Five semi-structured interviews with specialist physiotherapists expanded on the survey findings and identified five main themes: Understanding the MS journey, modifying assessment and treatment, anxiety management toolbox, lagging behind Musculoskeletal Physiotherapy, and gaining knowledge and skills. CONCLUSION: Physiotherapists encounter anxiety in PwMS in community and outpatient rehabilitation and perceive they have a role in managing it as it presents. Facilitators included communication, listening skills and opportunities to develop strong therapeutic relationships. Poor training and support, lack of clinical guidelines and limited research evidence were considered barriers. Clinically relevant learning opportunities, interprofessional working, and greater support through clinical supervision is recommended to better develop physiotherapy practice.

Surgical peripheral iridotomy creation during intraocular surgery by intraocular diathermy probe-a novel technique.

A novel technique for the creation of surgical iridotomies using a bipolar diathermic probe is described. In a cohort comprising 19 eyes of 18 patients, a 100% patency rate was achieved, with no intra- or postoperative complications.

Psychoeducation Intervention Effectiveness to Improve Social Skills in Young People with ADHD: A Meta-Analysis.

OBJECTIVE: Attention Deficit Hyperactivity Disorder (ADHD) can be associated with limited understanding of the condition and poor social skills. Some evidence favors a psychoeducational approach, but little is known about the effectiveness of psychoeducation. METHODS: Systematic review and meta-analysis of studies assessing psychoeducational interventions that aim to improve social skills of young people with ADHD. RESULTS: Ten studies, including 943 participants, reported across 13 papers met the inclusion criteria. Although effect sizes were small, findings suggest the included interventions significantly improved social skills in young people with ADHD. CONCLUSIONS: Results show promise for psychoeducational behavioral interventions . However, the recommendations that can be developed from existing evidence are somewhat limited by the low quality of studies. Further rigorous trials are needed. In addition, future research should consider the long-term outcomes for these interventions, they should be iteratively co-designed and research should consider the context they intend to be delivered in.

Acute Hydrops After Bowman Layer Transplantation for Keratoconus May Indicate that Descemet Membrane Rupture Is Secondary to Hydrops.

PURPOSE: The aim of this study was to review the postoperative course and imaging features of 7 eyes that presented with corneal hydrops after Bowman layer (BL) transplantation was performed for advanced keratoconus to determine the potential mechanisms of hydrops formation. METHODS: A retrospective analysis was performed of 7 eyes of 5 patients with advanced keratoconus that underwent midstromal BL transplantation at 2 tertiary referral centers and developed acute corneal hydrops on average 64 (±30) months (range 14-104 months) postoperatively. Corneal tomography and anterior segment optical coherence tomography (AS-OCT) images were reviewed to document the postoperative and posthydrops course. RESULTS: For all eyes, the post-BL transplantation course was uneventful until hydrops development. Despite stable postoperative topographies in 5 of 7 eyes, eyes developed hydrops with typical hypodense areas on AS-OCT that were limited to the stromal layers posterior to the BL graft. With AS-OCT (6/7 eyes), 2 eyes showed a break in Descemet membrane, whereas Descemet membrane was intact across the cornea in 2 eyes; in 2 eyes, the images were inconclusive. All patients admitted to continued eye rubbing, and all but 1 had a clinically significant allergy and/or atopic constitution. Most eyes (5/7) showed a relatively quick (visual) recovery within 1 to 4 months after hydrops. CONCLUSIONS: Hydrops formation in keratoconic corneas after midstromal BL transplantation may indicate that a break in Descemet membrane is secondary to hydrops development (and not vice versa). With a midstromal BL graft in situ limiting hydrops dimensions, resolution of the hydrops seemed relatively quick with recovery to prehydrops visual acuity in most eyes.

Preimplantation dehydration for corneal allogenic intrastromal ring segment implantation.

Corneal allogenic intrastromal ring segments (CAIRS) are semicircular pieces of donor corneal stroma, which may be surgically implanted to flatten keratoconic corneas. These segments can be trimmed to different thicknesses; whereas thicker segments confer greater flattening, their bulk renders them more technically challenging to insert. Consequently, thinner segments are often preferred, especially for starting surgeons. Here, we describe a technique for transiently thinning CAIRS to facilitate easy insertion, thereby permitting the use of thicker segments to achieve the maximal flattening effect.

Angiogenesis and Anti-Angiogenic Treatment in Prostate Cancer: Mechanisms of Action and Molecular Targets.

Prostate cancer (PC) is the most common cancer in men and the second leading cause of cancer-related death worldwide. Many therapeutic advances over the last two decades have led to an improvement in the survival of patients with metastatic PC, yet the majority of these patients still succumb to their disease. Antiagiogenic therapies have shown substantial benefits for many types of cancer but only a marginal benefit for PC. Ongoing clinical trials investigate antiangiogenic monotherapies or combination therapies. Despite the important role of angiogenesis in PC, clinical trials in refractory castration-resistant PC (CRPC) have demonstrated increased toxicity with no clinical benefit. A better understanding of the mechanism of angiogenesis may help to understand the failure of trials, possibly leading to the development of new targeted anti-angiogenic therapies in PC. These could include the identification of specific subsets of patients who might benefit from these therapeutic strategies. This paper provides a comprehensive review of the pathways involved in the angiogenesis, the chemotherapeutic agents with antiangiogenic activity, the available studies on anti-angiogenic agents and the potential mechanisms of resistance.