Quantitative autofluorescence at AMD's beginnings highlights retinal topography and grading system differences: ALSTAR2 baseline.

PURPOSE: To describe baseline quantitative (short-wavelength) autofluorescence (qAF) findings in a large pseudophakic cohort at age-related macular degeneration (AMD)'s beginnings; to assess qAF8 as an outcome measure and evaluate AREDS and Beckman grading systems. METHODS: In the ALSTAR2 baseline cohort (NCT04112667), 346 pseudophakic eyes of 188 persons (74.0 ± 5.5 years) were classified as normal (N=160 by AREDS, 158 by Beckman), early (e)AMD (N=104, 66), and intermediate (i)AMD (N=82, 122). Groups were compared via mean qAF intensities in a 6°- 8° annulus (qAF8) and maps of differences between observations and overall mean, divided by standard deviation (Z-score). RESULTS: qAF8 did not differ significantly among diagnostic groups by either stratification (p = 0.0869 AREDS; p = 0.0569 by Beckman). Notably, 45 eyes considered eAMD by AREDS became iAMD by Beckman. For AREDS-stratified eyes, Z-score maps showed higher centrally located qAF for normal, near the mean in eAMD, and lower values for iAMD. Maps deviated from this pattern for Beckman-stratified eyes. CONCLUSIONS: In a large sample of pseudophakic eyes, qAF8 does not differ overall from normal aging to iAMD but also does not capture the earliest AMD activity in the macula lutea. AREDS classification gives results more consistent with a slow decline in histologic autofluorescence than Beckman classification.

Non-lesional epilepsy does not necessarily convey poor outcomes after invasive monitoring followed by resection or thermal ablation.

OBJECTIVE: We aimed to compare outcomes including seizure-free status at the last follow-up in adult patients with medically refractory focal epilepsy identified as lesional vs. non-lesional based on their magnetic resonance imaging (MRI) findings who underwent invasive evaluation followed by subsequent resection or thermal ablation (LiTT). METHODS: We identified 88 adult patients who underwent intracranial monitoring between 2014 and 2021. Of those, 40 received resection or LiTT, and they were dichotomized based on MRI findings, as lesional (N = 28) and non-lesional (N = 12). Patient demographics, seizure characteristics, non-invasive interventions, intracranial monitoring, and surgical variables were compared between the groups. Postsurgical seizure outcome at the last follow-up was rated according to the Engel classification, and postoperative seizure freedom was determined by Kaplan-Meyer survival analysis. Statistical analyses employed Fisher's exact test to compare categorical variables, while a t-test was used for continuous variables. RESULTS: There were no differences in baseline characteristics between groups except for more often noted PET abnormality in the lesional group (p = 0.0003). 64% of the lesional group and 57% of the non-lesional group received surgical resection or LiTT (p = 0.78). At the last follow-up, 78.5% of the patients with lesional MRI findings achieved Engel I outcomes compared to 66.7% of non-lesional patients (p = 0.45). Kaplan-Meier curves did not show a significant difference in seizure-free duration between both groups after surgical intervention (p = 0.49). SIGNIFICANCE: In our sample, the absence of lesion on brain MRI was not associated with worse seizure outcomes in adult patients who underwent invasive intracranial monitoring followed by resection or thermal ablation.

Workplace Violence in Orthopaedic Surgery: A Survey of Academy of Orthopaedic Surgeons Membership.

INTRODUCTION: Workplace violence (WPV) in US health care is increasing, and many workers are likely to experience WPV during their careers. This study aims to assess the scope of WPV in orthopaedics. METHODS: A 20-item survey adopted from the World Health Organization's 'Workplace Violence in the Health Sector Country Case Studies Research Instruments Survey Questionnaire' was sent to Academy of Orthopaedic Surgeons members, including residents and fellows. Deidentified responses were collected electronically over a 1-month period and assessed. RESULTS: Overall, 1,125 Academy of Orthopaedic Surgeons members participated (5% response rate). Most respondents were male (86%) and identified with the majority ethnic group (80%). WPV of any type was reported by 77.1%. Verbal abuse was the most common type (71.6%), and patients were the most common perpetrators. WPV was most prevalent among traumatologists, tumor surgeons, female surgeons, and those with 0 to 15 years in practice. Female surgeons reported more WPV events per practice year (2.25 versus 0.65, P < 0.01) and increased likelihood of physical threats and physical assaults from coworkers ( P = 0.004). DISCUSSION: WPV in orthopaedic surgery is largely perpetrated by patients and directed toward traumatologists, tumor surgeons, female surgeons, and less experienced surgeons. These data can be used to address safety measures in the workplace.

Repeatability of Rod-Mediated Dark Adaptation Testing in Normal Aging and Early and Intermediate Age-Related Macular Degeneration.

PURPOSE: The vulnerability of rod photoreceptors in aging and early and intermediate age-related macular degeneration (AMD) has been well documented. Rod-mediated dark adaptation (RMDA) is a measure of the recovery of light sensitivity in rod photoreceptors following a bright light. Delays in RMDA during early and intermediate AMD have been widely reported. For RMDA's promise as an outcome for trials targeted at early and intermediate AMD to be realized, excellent test-retest reliability, its repeatability, must be established. METHODS: Test-retest performance in a commonly used RMDA test based on the rod intercept time metric (RIT) was evaluated in participants with early and intermediate AMD and with normal retinal aging with testing approximately 2 weeks apart. The test target was placed at 5° eccentricity superior to the foveal center, an area with maximal rod loss in aging and AMD. Disease severity was identified by a trained and masked grader of fundus photographs using both the AREDS 9-step and Beckman classification systems. Bland-Altman plots and intra-class correlation coefficients (ICC) evaluated repeatability. RESULTS: The analysis sample consisted of 37 older adults (mean age 76 years, standard deviation 5), with approximately one-third of the sample in each of three groups - normal aging, early AMD, and intermediate AMD. For the total sample, the ICC was 0.98. For individual AMD groups for both AREDS 9-step and Beckman classifications, the ICCs were also very high ranging from 0.82 to 0.99. CONCLUSION: We demonstrated that RMDA testing using the RIT metric has excellent repeatability when target location is at 5° in studying older adults from normal aging to intermediate AMD, suggesting the reliable use of this functional measure in trials.

MSG-15: Super-Bioavailability Itraconazole Versus Conventional Itraconazole in the Treatment of Endemic Mycoses-A Multicenter, Open-Label, Randomized Comparative Trial.

Background: Invasive fungal disease caused by dimorphic fungi is associated with significant morbidity and mortality. Super-bioavailability itraconazole (SUBA-itra) is a novel antifungal agent with pharmacokinetic advantages over currently available formulations. In this prospective comparative study, we report the outcomes of patients with endemic fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis). Methods: This open-label randomized trial evaluated the efficacy, safety, and pharmacokinetics SUBA-itra compared with conventional itraconazole (c-itra) treatment for endemic fungal infections. An independent data review committee determined responses on treatment days 42 and 180. Results: Eighty-eight patients were enrolled for IFD (SUBA-itra, n = 42; c-itra, n = 46) caused by Histoplasma (n = 51), Blastomyces (n = 18), Coccidioides (n = 13), or Sporothrix (n = 6). On day 42, clinical success was observed with SUBA-itra and c-itra on day 42 (in 69% and 67%, respectively, and on day 180 (in 60% and 65%). Patients treated with SUBA-itra exhibited less drug-level variability at days 7 (P = .03) and 14 (P = .06) of randomized treatment. The concentrations of itraconazole and hydroxyitraconazole were comparable between the 2 medications (P = .77 and P = .80, respectively). There was a trend for fewer adverse events (AEs; 74% vs 87%, respectively; P = .18) and serious AEs (10% vs 26%; P = .06) in the SUBA-itra-treated patients than in those receiving c-itra. Serious treatment-emergent AEs were less common in SUBA-itra-treated patients (12% vs 50%, respectively; P < .001). Conclusions: SUBA-itra was bioequivalent, well tolerated, and efficacious in treating endemic fungi, with a more favorable safety profile than c-itra. Clinical Trials Registration: NCT03572049.

Water Decontamination Products for Wound Irrigation in Austere Environments: Benchtop Evaluation and Recommendations.

BACKGROUND: Irrigation is used to minimize infection of open wounds. Sterile saline is preferred, but potable water is becoming more widely accepted. However, the large volumes of water that are recommended are usually not available in austere environments. This study determined the long-term antimicrobial effectiveness of military purification powder compared with currently available civilian methods. The study also compared the physical characteristics and outcomes under the logistical constraints. METHODS: Six commercially available water decontamination procedures were used to decontaminate five different sources of water (pond water, river water, inoculated saline, tap water, and sterile saline). Each product was evaluated based on six different parameters: bacterial culture, pH, turbidity, cost, flow rate, and size. RESULTS: All methods of treatment decreased the bacterial count below the limit of detection. However, they had variable effects on pH and turbidity of the five water sources. Prices ranged from $7.95 to $350, yielding 10-10,000L of water, and weighing between 18 and 500g. CONCLUSION: In austere settings, where all equipment is carried manually, no single decontamination device is available to optimize all the measured parameters. Since all products effectively reduced microbial levels, their size, cost, and production capability should be evaluated for the intended application.

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty.

BACKGROUND: African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA. METHODS: Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant. RESULTS: The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02). CONCLUSIONS: The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

The Impact of Smoking on Hospital Course and Postoperative Outcomes in Patients With Fracture-Related Infections.

OBJECTIVES: To assess the relationship between patient smoking status and fracture-related infection (FRI) characteristics including patient symptoms at FRI presentation, bacterial species of FRI, and rates of fracture union. DESIGN: Retrospective cohort study. SETTING: Urban level 1 trauma center. PATIENT SELECTION CRITERIA: All patients undergoing reoperation for FRI from January 2013 to April 2021 were identified through manual review of an institutional database. OUTCOME MEASURES AND COMPARISONS: Data including patient demographics, fracture characteristics, infection presentation, and hospital course were collected through review of the electronic medical record. Patients were grouped based on current smoker versus nonsmoker status. Hospital course and postoperative outcomes of these groups were then compared. Risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection, Staphylococcus epidermidis infection, and sinus tract development were evaluated using multivariable logistic regression. RESULTS: A total of 301 patients, comprising 155 smokers (51%) and 146 nonsmokers (49%), undergoing FRI reoperation were included. Compared with nonsmokers, smokers were more likely male (69% vs. 56%, P = 0.024), were younger at the time of FRI reoperation (41.7 vs. 49.5 years, P < 0.001), and had lower mean body mass index (27.2 vs. 32.0, P < 0.001). Smokers also had lower prevalence of diabetes mellitus (13% vs. 25%, P = 0.008) and had higher Charlson Comorbidity Index 10-year estimated survival (93% vs. 81%, P < 0.001). Smokers had a lower proportion of S. epidermidis infections (11% vs. 20%, P = 0.037), higher risk of nonunion after index fracture surgery (74% vs. 61%, P = 0.018), and higher risk of sinus tracts at FRI presentation (38% vs. 23%, P = 0.004). On multivariable analysis, smoking was not found to be associated with increased odds of MRSA infection. CONCLUSIONS: Among patients who develop a FRI, smokers seemed to have better baseline health regarding age, body mass index, diabetes mellitus, and Charlson Comorbidity Index 10-year estimated survival compared with nonsmokers. Smoking status was not significantly associated with odds of MRSA infection. However, smoking status was associated with increased risk of sinus tract development and nonunion and lower rates of S. epidermidis infection at the time of FRI reoperation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Shadow of Doubt: Is There Implicit Bias Among Orthopaedic Surgery Faculty and Residents Regarding Race and Gender?

BACKGROUND: Orthopaedic surgery continues to be one of the least diverse medical specialties. Recently, increasing emphasis has been placed on improving diversity in the medical field, which includes the need to better understand existing biases. Despite this, only about 6% of orthopaedic surgeons are women and 0.3% are Black. Addressing diversity, in part, requires a better understanding of existing biases. Most universities and residency programs have statements and policies against discrimination that seek to eliminate explicit biases. However, unconscious biases might negatively impact the selection, training, and career advancement of women and minorities who are underrepresented in orthopaedic surgery. Although this is difficult to measure, the Implicit Association Test (IAT) by Project Implicit might be useful to identify and measure levels of unconscious bias among orthopaedic surgeons, providing opportunities for additional interventions to improve diversity in this field. QUESTIONS/PURPOSES: (1) Do orthopaedic surgeons demonstrate implicit biases related to race and gender roles? (2) Are certain demographic characteristics (age, gender, race or ethnicity, or geographic location) or program characteristics (geographic location or size of program) associated with the presence of implicit biases? (3) Do the implicit biases of orthopaedic surgeons differ from those of other healthcare providers or the general population? METHODS: A cross-sectional study of implicit bias among orthopaedic surgeons was performed using the IAT from Project Implicit. The IAT is a computerized test that measures the time required to associate words or pictures with attributes, with faster or slower response times suggesting the ease or difficulty of associating the items. Although concerns have been raised recently about the validity and utility of the IAT, we believed it was the right study instrument to help identify the slight hesitation that can imply differences between inclusion and exclusion of a person. We used two IATs, one for Black and White race and one for gender, career, and family roles. We invited a consortium of researchers from United States and Canadian orthopaedic residency programs. Researchers at 34 programs agreed to distribute the invitation via email to their faculty, residents, and fellows for a total of 1484 invitees. Twenty-eight percent (419) of orthopaedic surgeons and trainees completed the survey. The respondents were 45% (186) residents, 55% (228) faculty, and one fellow. To evaluate response biases, the respondent population was compared with that of the American Academy of Orthopaedic Surgeons census. Responses were reported as D-scores based on response times for associations. D-scores were categorized as showing strong (≥ 0.65), moderate (≥ 0.35 to < 0.65), or slight (≥ 0.15 to < 0.35) associations. For a frame of reference, orthopaedic surgeons' mean IAT scores were compared with historical scores of other self-identified healthcare providers and that of the general population. Mean D-scores were analyzed with the Kruskal-Wallis test to determine whether demographic characteristics were associated with differences in D-scores. Bonferroni correction was applied, and p values less than 0.0056 were considered statistically significant. RESULTS: Overall, the mean IAT D-scores of orthopaedic surgeons indicated a slight preference for White people (0.29 ± 0.4) and a slight association of men with career (0.24 ± 0.3), with a normal distribution. Hence, most respondents' scores indicated slight preferences, but strong preferences for White race were noted in 27% (112 of 419) of respondents. There was a strong association of women with family and home and an association of men with work or career in 14% (60 of 419). These preferences generally did not correlate with the demographic, geographic, and program variables that were analyzed, except for a stronger association of women with family and home among women respondents. There were no differences in race IAT D-scores between orthopaedic surgeons and other healthcare providers and the general population. Gender-career IAT D-scores associating women with family and home were slightly lower among orthopaedic surgeons (0.24 ± 0.3) than among the general population (0.32 ± 0.4; p < 0.001) and other healthcare professionals (0.34 ± 0.4; p < 0.001). All of these values are in the slight preference range. CONCLUSION: Orthopaedic surgeons demonstrated slight preferences for White people, and there was a tendency to associate women with career and family on IATs, regardless of demographic and program characteristics, similar to others in healthcare and the general population. Given the similarity of scores with those in other, more diverse areas of medicine, unconscious biases alone do not explain the relative lack of diversity in orthopaedic surgery. CLINICAL RELEVANCE: Implicit biases only explain a small portion of the lack of progress in improving diversity, equity, inclusion, and belonging in our workforce and resolving healthcare disparities. Other causes including explicit biases, an unwelcoming culture, and perceptions of our specialty should be examined. Remedies including engagement of students and mentorship throughout training and early career should be sought.

Recurrent Severe Maternal Morbidity in an Obstetric Population With a High Comorbidity Burden.

OBJECTIVE: To evaluate the risk of severe maternal morbidity (SMM) in subsequent pregnancies in patients who experienced SMM in a previous pregnancy compared with those who did not. METHODS: We conducted a retrospective cohort study of patients with two or more deliveries at 23 or more weeks of gestation at a single Southeastern U.S. tertiary care center between 2015 and 2018. The primary exposure was SMM including transfusion (transfusion SMM) in a previous pregnancy, as defined by the Centers for Disease Control and Prevention, using International Classification of Diseases, Ninth or Tenth Revision codes. The primary outcome was transfusion SMM in any subsequent pregnancy in the study time frame. Generalized estimating equation models were used to estimate the relative risk (RR) and associated 95% CIs of transfusion SMM in patients with transfusion SMM in a prior pregnancy compared with patients without transfusion SMM in a previous pregnancy. Severe maternal morbidity without transfusion (nontransfusion SMM) and cross-analysis to determine risk of a different type of SMM after a history of SMM were analyzed similarly. RESULTS: Of 852 included patients, transfusion SMM and nontransfusion SMM occurred in 90 (10.6%) and 18 (2.1%), respectively, in the first captured pregnancy and in 79 (9.3%) and 9 (1.1%), respectively, in subsequent pregnancies. Anemia (34.6-40.0%), obesity (33.4-40.4%), substance use disorder (14.2-14.6%), and preeclampsia (12.0-11.4%) were the most prevalent morbidities at first captured and subsequent pregnancies, respectively. There was a 16-fold higher risk of transfusion SMM in a subsequent pregnancy after experiencing transfusion SMM in the first captured pregnancy (57.8% vs 3.5%, RR 16.3 95% CI, 10.8-24.6). Nontransfusion SMM was similarly higher in patients with nontransfusion SMM in their first captured pregnancy compared with those without (16.7% vs 0.7%, RR 23.2 95% CI, 6.3-85.4). Additionally, patients who experienced transfusion SMM in their first captured pregnancies were at sixfold higher risk of developing nontransfusion SMM in a subsequent pregnancy (RR 6.2, 95% CI, 1.7-22.6). However, in cross-analysis of patients who experienced nontransfusion SMM, the risk of transfusion SMM in a subsequent pregnancy was not statistically significant. CONCLUSION: The risks of SMM in subsequent pregnancies after previous SMM are extremely high and are higher than previous estimates. Future studies should estimate the contributions of comorbidities and other structural determinants including social vulnerability to help design interventions to reduce subsequent pregnancy risks.

Description of Cryptococcosis Following SARS-CoV-2 Infection: A Disease Survey Through the Mycosis Study Group Education and Research Consortium (MSG-19).

BACKGROUND: Invasive fungal infections have been described throughout the COVID-19 pandemic. Cryptococcal disease after infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been reported in several isolated case reports and 1 larger case series. We sought to describe cryptococcal infections following SARS-CoV-2 through establishing a database to investigate underlying risk factors, disease manifestations, and outcomes. METHODS: We created a crowdsourced call for cases solicited through the Mycoses Study Group Education and Research Consortium, the Centers for Disease Control and Prevention Emerging Infectious Diseases Network, and infectious diseases Twitter groups. Data were collected in a web-based and secure REDCap survey without personal identifiers. RESULTS: Sixty-nine cases were identified and submitted by 29 separate institutional sites. Cryptococcosis was diagnosed a median of 22 days (interquartile range, 9-42 days) after SARS-CoV-2 infection. Mortality among those with available follow-up was 72% (26/36) for the immunocompetent group and 48% (15/31) for the immunocompromised group (likelihood ratio, 4.01; P = .045). We observed a correlation between disease manifestation (central nervous system infection, proven/probable disseminated disease, and respiratory) and mortality (P = .002). CONCLUSIONS: The mortality rate of 59% for patients with cryptococcosis following SARS-CoV-2 is higher than that of modern Cryptococcus cohorts. There was an association between immunocompromised status and cryptococcal disease manifestations as well as mortality. Moreover, our series emphasizes the need for clinical and laboratory assessment of opportunistic infections beyond 30 days when concerning symptoms develop.

The economic and clinical impact of fast- versus slow-setting cement in primary total knee arthroplasty.

INTRODUCTION: New bone cement products have been developed attempting to shorten their setting time and thus cut down time in the operating room. This study determines whether faster-setting bone cement shortens time in the operating room, and whether the quantity used compromises postoperative TKA outcomes. Additionally, this study looks at cost analyses of the quantity of bone cement used in TKA procedures. MATERIALS AND METHODS: One-hundred and sixty patients at a single institution with primary TKA surgeries between January 2019 and December 2021, and a clinic follow-up of at least one year, were identified. Five cement products used in this time period were identified and categorized by fast- or slow-setting products if their set times were marketed below or above six minutes, respectively. RESULTS: Estimated blood loss was higher in patients receiving fast-setting cements (160.0 vs 126.4 mL; p = 0.0009); however, operative time showed no difference between the cohorts (88.2 vs 89.2 min; p = 0.99). Fewer bags of cement were used for the fast cohort (1.3 vs 1.8 bags; p < 0.0001). The fast group was significantly cheaper on average per patient only when comparing between antibiotic bone cements (p = 0.007). No differences were found in postoperative outcomes between the two groups. CONCLUSIONS: No differences were found in operative times between the fast and slow cemented groups. Fewer bags of faster-setting cement only proved cost saving relative to other antibiotic bone cements studied. Nonetheless, decreased usage of fast cement did not result in any different postoperative outcomes compared to slow cements. LEVEL OF EVIDENCE: III.

Alabama Screening and Intervention for Glaucoma and Eye Health through Telemedicine (AL-SIGHT): Baseline Results.

PURPOSE: To describe baseline results of the Alabama Screening and Intervention for Glaucoma and Eye Health through Telemedicine (AL-SIGHT) for patients at federally qualified health centers (FQHCs). Candidates were persons at risk for glaucoma-associated diseases (GAD) based on age, race/ethnicity, current diagnosis of GAD, family history, and diabetes. DESIGN: Baseline screening visit followed by remote diagnosis and referral for follow-up examinations. METHODS: Patients presenting to FQHCs who were at least 18 years of age were enrolled and underwent screening for acuity, autorefraction, intraocular pressure, visual field testing, and fundus imaging. Results were transmitted to an ophthalmologist at University of Alabama at Birmingham for diagnosis who made referrals for follow-up; follow-up attendance was noted. Questionnaires assessed participants' perspectives on screening. Primary outcomes were rates of disease detection, referral for follow-up, follow-up attendance, and participant satisfaction. RESULTS: Of the 500 participants enrolled (mean age 58 years), 45.6% were African American and 51.6% White. Remote diagnostic evaluation of ocular screening by ophthalmologist revealed 30% GAD, 6.8% diabetic retinopathy, 37.6% cataract, 68.4% refractive error, 9.2% other eye conditions. In all, 47.2% of the participants were referred for follow-up examination and for acuity 20/40 or worse or IOP ≥23 mm Hg in one or both eyes. Follow-up examination attendance was 76.7% for those referred. Participants reported being very satisfied with screening (85.8%) and with the convenience of screening in their primary care clinic (92.2%). CONCLUSIONS: The high percentage of patients diagnosed with treatable eye conditions at telemedicine screening suggest these programs in FQHCs can be effective and scalable nationwide. Attendance when referred for follow-up examination was high. Participants welcomed screenings in their communities.

Cryptococcal Meningoencephalitis in Phenotypically Normal Patients.

Cryptococcosis is an invasive fungal infection found worldwide that causes significant morbidity and mortality among a broad range of hosts. There are approximately 223,000 new cases of cryptococcosis annually throughout the world, and at least 180,000 deaths are attributed to this infection each year. Most of these are due to complications of cryptococcal meningoencephalitis among HIV-infected patients in resource-limited environments. The majority of individuals diagnosed with cryptococcosis have underlying conditions associated with immune dysfunction such as HIV, solid organ transplant, hematologic malignancy, organ failure syndromes, and/or the use of immunosuppressive agents such as glucocorticosteroids and biologic agents. In most clinical series, there is a small proportion of patients with cryptococcosis who are phenotypically normal; that is, they have no clinically obvious predisposition to disease. Cryptococcal meningoencephalitis (CME) presentation and management differ substantially between these normal individuals and their immunocompromised counterparts. In this review, we will focus on CME in the phenotypically normal host and underscore differences in the clinical presentation, management, outcome, and potential risk factors for these patients compared to immunocompromised persons who develop this potential devastating invasive fungal infection.

Intravenous tranexamic acid decreases intraoperative transfusion requirements and does not increase incidence of symptomatic venous thromboembolic events in musculoskeletal sarcoma surgery.

BACKGROUND AND OBJECTIVES: Tranexamic acid (TXA) is poorly studied in patients with bone and musculoskeletal sarcoma due to perceived increased risk of venous thromboembolism (VTE). This study aims to assess the safety and efficacy of intravenous (IV) TXA for patients undergoing surgical resection of primary bone or soft-tissue sarcoma. METHODS: A retrospective, single center review of adult patients with pelvic or extremity sarcoma who underwent surgical resections between January 2005 and March 2020 was performed. Patients between 2005 and 2012 were included as a historical comparison prior to the routine use of IV TXA for all sarcoma resections at our institution. RESULTS: Thirty-nine non-TXA and 59 TXA resections were identified. Two non-TXA patients experienced symptomatic pulmonary embolism compared to zero VTEs amongst TXA patients. IV TXA administered at any dose significantly reduced the probability of intraoperative transfusion (p = 0.003) and the median units of blood transfused at the time of any perioperative transfusion (p = 0.007). Intraoperative times were significantly shorter for TXA patients (128 vs 190 min; p = 0.004). A subset of patients who underwent wide resection with endoprosthetic reconstruction and received TXA similarly showed decreased requirement for intraoperative transfusion (p = 0.014) and decreased procedure times (p = 0.009). CONCLUSIONS: During sarcoma resection, at least 1 g of IV TXA can safely decrease the need for any intraoperative transfusion and the median number of PRBCs transfused by 2 units when any perioperative transfusion is given.

Nail Plate Constructs are Associated with Decreased Rates of Reoperation in Complex Distal Femur Fractures.

OBJECTIVES: To determine if nail plate constructs have lower rates of reoperation to promote bone healing than lateral locking plates in the treatment of distal femur fractures. DESIGN: Retrospective Cohort. SETTING: Single Level 1 trauma centerPatients/Participants: 312 consecutive patients treated operatively for native distal femur fractures (OTA/AO 33A or 33C). INTERVENTION: Reduction and fixation of distal femur fractures with either a lateral locked plate (LLP) or a nail plus plate construct (NPC). MAIN OUTCOME MEASURES: reoperation to promote bone healing at any time after definitive fixation. RESULTS: 279 fractures were treated with LLP and were compared with and 33 fractures treated with NPC constructs. Patient demographics, injury severity score (ISS), and frequency utilization of each construct between different types of OTA/AO classified distal femur fractures were similar. The reoperation rate to promote bone healing was 18.7% (51/273) for LLPs, and 3% (1/33) for NPC constructs. There was no significant difference in surgical site infection (SSI) (p = 0.67). CONCLUSIONS: Utilization of NPC technique demonstrated a significant decrease in rates of reoperation to promote bone healing compared to LLP alone in the treatment of OTA/AO 33A and 33C distal femur fractures. Augmented fixation with NPCs should be considered to treat complex distal femur fractures as it is associated with lower rates of reoperation to promote bone healing in comparison to LLP. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Choriocapillaris Impairment Is Associated With Delayed Rod-Mediated Dark Adaptation in Age-Related Macular Degeneration.

Purpose: Progress toward treatment and prevention of age-related macular degeneration (AMD) requires imaging end points that relate to vision. We investigated choriocapillaris flow signal deficits (FD%) and visual function in eyes of individuals aged ≥60 years, with and without AMD. Methods: One eye of each participant in the baseline visit of the Alabama Study on Early Age-Related Macular Degeneration 2 (ALSTAR2; NCT04112667) was studied. AMD presence and severity was determined using the Age-Related Eye Disease Study (AREDS) grading system. FD% was quantified using macular spectral domain optical coherence tomography angiography (OCTA) scans. Vision tests included rod-mediated dark adaptation (RMDA), best-corrected visual acuity, and contrast sensitivity (photopic and mesopic), and microperimetric light sensitivity (scotopic, mesopic, and photopic). Presence of subretinal drusenoid deposits (SDD) was determined using multimodal imaging. Results: In 410 study eyes of 410 participants (mean [SD] age = 71.7 years [5.9]), FD% was higher in early AMD (mean [SD] = 54.0% [5.5], N = 122) and intermediate AMD (59.8% [7.4], N = 92), compared to normal (52.1% [5.3], N = 196) eyes. Among visual functions evaluated, RMDA showed the strongest association with FD% (r = 0.35, P < 0.0001), followed by contrast sensitivity (r = -0.22, P < 0.0001). Eyes with SDD had worse FD% (58.3% [7.4], N = 87), compared to eyes without SDD (53.4% [6.0], N = 323, P = < 0.0001). Conclusions: Choriocapillaris FD% were associated with AMD severity and with impaired vision, especially RMDA. Reduced metabolic transport and exchange across the choriocapillaris-Bruch's membrane retinal pigment epithelium (RPE) complex, a causal factor for high-risk soft drusen formation, also may impair photoreceptor sustenance from the circulation. This includes retinoid resupply, essential to dynamic rod function.