Demographic and socioeconomic disparities in receipt of ophthalmology consultation for facial trauma.

OBJECTIVE: Functional outcomes following facial and ocular trauma are time-sensitive and require prompt evaluation to minimise long-term vision loss, yet few studies have systematically evaluated disparities in the management of these cases. This study investigates whether a patient's race/ethnicity, primary language, insurance status, gender or age affects receipt of ophthalmology consultation for facial trauma. METHODS AND ANALYSIS: This study was a retrospective cohort analysis of patients from the Elmhurst City Hospital Trauma Registry in Queens, New York who were seen for facial trauma including open globe injuries and orbital fractures between January 2014 and May 2016. RESULTS: Of the 264 patients included, 43% reported as Hispanic, 23% white, 11% Asian, 8% black and 15% other/unknown. After controlling for confounding variables by multivariable logistic regression, neither race/ethnicity, gender, nor primary language were significantly associated with the likelihood of receiving an ophthalmology consult. However, patients with private insurance had 2.57 times greater odds of receiving an ophthalmology consultation than those with Medicaid or state corrections insurance (95% CI 1.37 to 4.95). As age increased, the likelihood of receiving an ophthalmology consultation decreased (p=0.009); patients 60 years of age and older had one-third the odds of ophthalmology consultation as younger patients (OR 0.33; 95% CI 0.16 to 0.68). CONCLUSIONS: This study highlights that lack of ophthalmology consultation in patients with facial trauma is linked to age and underinsurance. Extra attention must be paid during primary assessments to ensure elderly patients and those with public insurance have equitable access to timely and appropriate care for facial trauma.

Emergence Agitation and Anesthetic Considerations in the Management of Patients With Post-Traumatic Stress Disorder: A Report of Two Cases and a Review of the Literature.

Post-traumatic stress disorder (PTSD) is a psychological disturbance resulting from exposure to a traumatic experience that lasts more than one month. PTSD in the United States has a lifetime prevalence of 3.4% to 26.9% in civilians and 7.7% to 17.0% in military veterans. Emergence agitation (EA) and emergence delirium (ED) are known phenomena in the postanesthetic period. PTSD is closely associated with EA following anesthesia. In addition, EA in patients with PTSD can be severe and challenging to manage. EA is a risk to both patients and healthcare workers. Furthermore, EA has been shown to increase the overall risk of postoperative delirium and complications. Currently, studies on the anesthetic management of patients with PTSD are scarce and limited to case reports. Here, we present a summary of several important published case reports and a brief review of the literature regarding the anesthetic management of PTSD and EA to aid in managing patients with PTSD. In addition, we present two cases of successful EA prevention in patients with severe PTSD. From our review of the literature and the successful prevention of EA in our patients with severe PTSD, we conclude that there is an increased need for overall awareness among anesthesia and perioperative care providers of the effect of PTSD on EA. Anesthesia providers should aim to include as many management recommendations as possible and avoid possible triggers of EA via a multidisciplinary approach. Multiple pharmacological agents have been used for the anesthetic management of PTSD with varying results. Of the agents studied, dexmedetomidine has been found to be the most consistently beneficial.

Medical Student Attitudes Toward the Use of Peer Physical Exam for Learning Fundoscopy.

Background Peer physical examination learning is commonly practiced in medical schools during preclinical curricula and has been shown to improve empathy for patients. While there is literature regarding medical student attitudes toward peer physical exam learning, no studies to date have specifically examined student attitudes toward fundoscopy and dilation of the eyes for the purposes of learning fundoscopy. This study evaluates medical student preferences with regards to learning fundoscopy on peers and explores attitudes toward alternate approaches. Methods First year medical students at the Icahn School of Medicine at Mount Sinai participated in a 2-hour fundoscopy skills workshop in March 2020. Following the session, the authors administered a voluntary survey querying students on attitudes toward peer physical exam learning and its use in learning peer fundoscopy. Primary study endpoints evaluated (1) student attitudes toward the use of peer physical exam learning, (2) learning benefit of the session, including student comfort with conducting the fundoscopy exam, and (3) empathy toward patients experiencing dilation. Secondary endpoints focused on alternative teaching methods and preferences for nonmydriatic fundoscopy. Analysis of survey data was performed using nonparametric Spearman's correlations, chi-square tests, t -tests, and Mann-Whitney U tests. Results A total of 51/138 (37%) students completed the survey, with 78% indicating they felt peer physical exam learning was a helpful instructional method, including for the fundoscopic exam. The session led to improved self-rated fundoscopy skills and empathy for patients. However, when considering learning with dilation versus alternative nonmydriatic techniques, 96% of students indicated a preference for using alternative nonmydriatic techniques. Conclusion This study found that students' attitudes toward fundoscopy generally aligned with their overall peer physical exam preferences. However, they preferred not using dilation and learning with nonmydriatic fundoscopic techniques. Assessing student learning preferences and incorporating novel instructional tools can help facilitate more successful fundoscopy skills acquisition. These considerations are particularly important in the context of COVID-19 and with advances in teleophthalmology.

An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels.

This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.

Is Gastric Bypass a Risk Factor for Complicated Alcohol Withdrawal? Case Report and Literature Review.

Alcohol use disorder and gastric bypass surgery are highly comorbid. Alcohol withdrawal syndrome (AWS) is a common and potentially life-threatening event, requiring nuanced and individually tailored management depending on various clinical factors including patient history, alcohol consumption, comorbidities, and timeline of use. Although increasingly common, the literature for managing alcohol withdrawal in the gastric bypass population is quite limited. We present the case of a 45-year-old woman with a past history of Roux-en-Y gastric bypass admitted for alcohol withdrawal at a psychiatric hospital who experienced a complicated withdrawal despite adhering to standard management guidelines. She had been consuming 8 to 12 standard drinks daily, and she was therefore monitored on a Clinical Institute Withdrawal Assessment for Alcohol. She experienced only minimal withdrawal symptoms up to 48 hours following cessation of alcohol consumption. At 70 hours postcessation, she experienced a witnessed tonic-clonic seizure with associated head trauma with internal bleeding, requiring acute medical intervention. This timeline of withdrawal symptoms is atypical, yet perhaps understood in the context of her past medical history which included gastric bypass surgery. We discuss the potential complicating factors inherent in individuals who have received Roux-en-Y gastric bypass in the past with respect to alcohol metabolism. We discuss the similar considerations with respect to altered metabolism of therapeutics commonly used in managing this condition. Lastly, we include a review of the extent literature on this topic and propose possible considerations for managing this unique but increasingly prevalent clinical scenario.

Manufacturing a chimpanzee adenovirus-vectored SARS-CoV-2 vaccine to meet global needs.

Manufacturing has been the key factor limiting rollout of vaccination during the COVID-19 pandemic, requiring rapid development and large-scale implementation of novel manufacturing technologies. ChAdOx1 nCoV-19 (AZD1222, Vaxzevria) is an efficacious vaccine against SARS-CoV-2, based upon an adenovirus vector. We describe the development of a process for the production of this vaccine and others based upon the same platform, including novel features to facilitate very large-scale production. We discuss the process economics and the "distributed manufacturing" approach we have taken to provide the vaccine at globally-relevant scale and with international security of supply. Together, these approaches have enabled the largest viral vector manufacturing campaign to date, providing a substantial proportion of global COVID-19 vaccine supply at low cost.

Chemical Vapor Deposition Mechanism of Graphene-Encapsulated Au Nanoparticle Heterostructures and Their Plasmonics.

Direct encapsulation of graphene shells on noble metal nanoparticles via chemical vapor deposition (CVD) has been recently reported as a unique way to design and fabricate new plasmonic heterostructures. But currently, the fundamental nature of the growth mechanism of graphene layers on metal nanostructures is still unknown. Herein, we report a systematic investigation on the CVD growth of graphene-encapsulated Au nanoparticles (Au@G) by combining an experimental parameter study and theoretical modeling. We studied the effect of growth temperature, duration, hydrocarbon precursor concentration, and extent of reducing (H2) environment on the morphology of the products. In addition, the influence of plasma oxidation conditions for the surface oxidation of gold nanoparticles on the graphene shell growth is evaluated in combination with thermodynamic calculations. We find that these parameters critically aid in the evolution of graphene shells around gold nanoparticles and allow for controlling shell thickness, graphene shell quality and morphology, and hybrid nanoparticle diameter. An optimized condition including the growth temperature of ∼675 °C, duration of 30 min, and xylene feed rate of ∼10 mL/h with 10% H2/Ar carrier gas was finally obtained for the best morphology evolution. We further performed finite-element analysis (FEA) simulations to understand the equivalent von Mises stress distribution and discrete dipolar approximation (DDA) calculation to reveal the optical properties of such new core-shell heterostructures. This study brings new insight to the nature of CVD mechanism of Au@G and might help guiding their controlled growth and future design and application in plasmonic applications.

Cardiovascular and renal outcomes with SGLT-2 inhibitors versus GLP-1 receptor agonists in patients with type 2 diabetes mellitus and chronic kidney disease: a systematic review and network meta-analysis.

BACKGROUND: Emerging evidence suggests that sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are associated with decreased risk of cardiovascular and renal events in type 2 diabetes mellitus (DM) patients. However, no study to date has compared the effect of SGLT-2 inhibitors with that of GLP-1 RAs in type 2 DM patients with chronic kidney disease (CKD). We herein investigated the benefits of SGLT-2 inhibitors and GLP-1 RAs in CKD patients. METHODS: We performed a systematic literature search through November 2020. We selected randomized control trials that compared the risk of major adverse cardiovascular events (MACE) and a composite of renal outcomes. We performed a network meta-analysis to compare SGLT-2 inhibitors with GLP-1 RAs indirectly. Risk ratios (RRs) with corresponding 95% confidence intervals (CI) were synthesized. RESULTS: Thirteen studies were selected with a total of 32,949 patients. SGLT-2 inhibitors led to a risk reduction in MACE and renal events (RR [95% CI]; 0.85 [0.75-0.96] and 0.68 [0.59-0.78], respectively). However, GLP-1 RAs did not reduce the risk of cardiovascular or renal adverse events (RR 0.91 [0.80-1.04] and 0.86 [0.72-1.03], respectively). Compared to GLP-1 RAs, SGLT-2 inhibitors did not demonstrate a significant difference in MACE (RR 0.94 [0.78-1.12]), while SGLT-2 inhibitors were associated with a lower risk of renal events compared to GLP-1 RAs (RR 0.79 [0.63-0.99]). A sensitivity analysis revealed that GLP-1 analogues significantly decreased MACE when compared to placebo treatment (RR 0.81 [0.69-0.95]), while exendin-4 analogues did not (RR 1.03 [0.88-1.20]). CONCLUSIONS: In patients with type 2 DM and CKD, SGLT-2 inhibitors were associated with a decreased risk of cardiovascular and renal events, but GLP-1 RAs were not. SGLT-2 inhibitors significantly decreased the risk of renal events compared to GLP-1 RAs. Among GLP-1 RAs, GLP-1 analogues showed a positive impact on cardiovascular and renal outcomes, while exendin-4 analogues did not.

Effect of renin-angiotensin system blockers on contrast-induced acute kidney injury in patients with normal or mild-to-moderate reduced kidney function undergoing coronary angiography: A systematic review and meta-analysis.

INTRODUCTION: Contrast-induced acute kidney injury (CI-AKI) is a major complication after coronary angiography (CAG) or percutaneous coronary intervention (PCI) and is associated with increased morbidity and mortality. It remains controversial whether renin-angiotensin system (RAS) blockers increase or decrease CI-AKI. In this meta-analysis, we investigated the association between RAS blockers and CI-AKI in patients with normal kidney function or mild-to-moderate chronic kidney disease (CKD). MATERIALS AND METHODS: We performed a systematic search of PubMed, EMBASE, clinicaltrials.gov, and the Cochrane Library up to December 2019 for studies that assessed the association between RAS blockers and CI-AKI events after CAG/PCI. The primary outcome was the development of CI-AKI. Odds ratios (ORs) with corresponding 95% confidence interval (CI) were synthesized. RESULTS: Five randomized controlled trials (RCTs) and five observational studies were included, accounting for a total of 7,420 patients. Unstratified, RAS blocker administration was significantly associated with an increased risk of CI-AKI (pooled OR = 1.63, 95% CI 1.19 - 2.25, p = 0.003). However, the effect was not observed in RCTs (pooled OR = 1.22, 95% CI 0.54 - 2.74, p = 0.63). Sensitivity analysis in observational studies showed significant association (pooled OR = 1.77, 95% CI 1.22 - 2.55, p = 0.003) with high heterogeneity and evidence of publication bias. CONCLUSION: In patients with relatively-preserved renal function, the association of RAS blockers with an increased risk of CI-AKI after contrast media exposure was inconclusive, as sensitivity analysis showed conflicting results and bias. Although this study did not demonstrate significant evidence, it indicated that clinicians need to be vigilant in assessing the potential risk for RAS blockers to cause CI-AKI in low-risk patients.

Systematic Review of the Association Between Worsening Renal Function and Mortality in Patients With Acute Decompensated Heart Failure.

INTRODUCTION: Outcomes in acute decompensated heart failure (ADHF) have remained poor. Worsening renal function (WRF) is common among patients with ADHF. However, the impact of WRF on the prognosis is controversial. We hypothesized that in patients with ADHF, the achievement of concomitant decongestion would diminish the signal for harm associated with WRF. METHODS: We performed a systematic search of PubMed, EMBASE, and the Cochrane Library up to December 2019 for studies that assessed signs of decongestion in patients with WRF during ADHF admission. The primary outcome was all-cause mortality and heart transplantation. RESULTS: Thirteen studies were selected with a pooled population of 8138 patients. During the follow-up period of 60-450 days, 19.2% of patients died. Unstratified, patients with WRF versus no WRF had a higher risk for mortality (odds ratio [OR], 1.71 [95% confidence interval {CI}, 1.45-2.01]; P < 0.0001). However, patients who achieved decongestion had a similar prognosis (OR, 1.15 [95% CI, 0.89-1.49]; P = 0.30). Moreover, patients with WRF who achieved decongestion had a better prognosis compared with those without WRF or decongestion (OR, 0.63 [95% CI, 0.46-0.86]; P = 0.004). This tendency persisted for the sensitivity analyses. CONCLUSIONS: Decongestion is a powerful effect modifier that attenuates harmful associations of WRF with mortality. Future studies should not assess WRF as an endpoint without concomitant assessment of achieved volume status.

Time to adapt in the pandemic era: a prospective randomized non -inferiority study comparing time to intubate with and without the barrier box.

BACKGROUND: The challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices. Devices such as barrier boxes are being considered as potential adjuncts to full PPE's to limit the aerosol spread. Usage of the barrier box raises concerns of delay in time to intubate (TTI). We designed our study to determine if using a barrier box with glidescope delays TTI within acceptable parameters to make relevant clinical conclusions. METHODS: Seventy-eight patients were enrolled in this prospective non-inferiority controlled trial and were randomly allocated to either group C (without the barrier box) or the study group BB (using barrier box). The primary measured endpoint is time to intubate (TTI), which is defined as time taken from loss of twitches confirmed with a peripheral nerve stimulator to confirmation of end-tidal CO 2. 15 s was used as non-inferiority margin for the purpose of the study. We used an unpaired two-sample single-sided t-test to test our non- inferiority hypothesis (H 0: Mean TTI diff ≥15 s, H A: Mean TTI diff < 15 s). Secondary endpoints include the number of attempts at intubation, lowest oxygen saturation during induction, and the need for bag-mask ventilation. RESULTS: Mean TTI in group C was 42 s (CI 19.2 to 64.8) vs. 52.1 s (CI 26.1 to 78) in group BB. The difference in mean TTI was 10.1 s (CI -∞ to 14.9). We rejected the null hypothesis and concluded with 95% confidence that the difference of the mean TTI between the groups is less than < 15 s (95% CI -∞ to 14.9,p = 0.0461). Our induction times were comparable (67.7 vs. 65.9 s).100% of our patients were intubated on the first attempt in both groups. None of our patients needed rescue breaths. CONCLUSIONS: We conclude that in patients with normal airway exam, scheduled for elective surgeries, our barrier box did not cause any clinically significant delay in TTI when airway manipulation is performed by well-trained providers. The study was retrospectively registered at clinicaltrials.gov (NCT04411056) on May 27, 2020.

Impact of Near-Peer Education in a Student-Run Free Ophthalmology Clinic on Medical Student Teaching Skills.

OBJECTIVE: To determine the impact of near-peer teaching experiences in the ophthalmology branch of the East Harlem Health Outreach Program (EHHOP), a student-run clinic, on teaching skills of fourth-year medical student Teaching Seniors (TS). DESIGN: Mixed-methods observational study, including online survey and telephone interview. SETTING: Student-run ophthalmology clinic affiliated with the Icahn School of Medicine at Mount Sinai and Mount Sinai Hospital, a tertiary-care center in New York, NY. PARTICIPANTS: All EHHOP TS alumni from 2014 to 2019 were eligible for inclusion in our study. All 14 alumni participated in the survey, and 8 participated in the follow-up interview. METHODS: EHHOP ophthalmology TS alumni were surveyed via an online survey and subsequent, optional, individual telephone interview. The web survey queried former TS on the impact of EHHOP ophthalmology experiences on self-reported teaching skills and comfort with teaching. Quantitative analysis of survey questions and qualitative analysis of telephone responses was performed and analyzed for themes. RESULTS: Majority of participants reported increased comfort teaching ophthalmology concepts, teaching the slit-lamp exam, and serving as mentors as a result of their experience. Qualitative analysis of telephone interviews revealed 4 major themes: (1) TS were a self-selected group of individuals with prior interest in teaching, (2) Teaching experiences in EHHOP had a positive impact in many teaching-related domains, (3) TS perceptions of teaching skills gained did not necessarily align with junior students' perceptions of teaching received, and (4) despite increased confidence and satisfaction with teaching experiences, TS desired more formal instruction in teaching. CONCLUSIONS: While TS perceptions of teaching skills gained in EHHOP ophthalmology were overwhelmingly positive, TS still desired formal instruction in teaching. Additionally, the effectiveness of near-peer education in a subspecialty like ophthalmology, with limited formal curricular time, may be more effective later in training, when a more solid foundation of knowledge is acquired.