The Effect of Transversus Abdominis Plane Block Timing on Milliequivalents of Opioid Use and Immediate Postoperative Pain Scores in Patients Undergoing Minimally Invasive Hysterectomy: A Retrospective Cohort Study.

STUDY OBJECTIVE: To examine the effect of transversus abdominis plane (TAP) block timing (preoperative or postoperative) on postoperative opioid use (quantified via morphine milligram equivalents; MME) and pain scores in patients undergoing minimally invasive hysterectomy for benign indications. DESIGN: Retrospective, single-institution cohort study SETTING: Academic-affiliated community hospital PATIENTS: A total of 2982 patients were included who underwent a minimally invasive total hysterectomy between January 2018 and December 2022, excluding patients with a malignancy diagnosis, concurrent urogynecological procedure, vaginal hysterectomy, supracervical hysterectomy, or those with baseline narcotic use (opioid use within the 3 months before surgery). Patients were separated into 3 groups: no TAP blocks (n = 1966, 65.9%), preoperative TAP blocks (854, 28.6%), and postoperative TAP blocks (162, 5.4%). INTERVENTIONS: Summary statistics and mixed-effects regression methods were used for data analysis. MEASUREMENTS AND MAIN RESULTS: There was a statistically significant lower mean use of opioids (MME 43.2 vs 53.9, p = .002) among patients who received a TAP block (either pre or postoperatively) than those who did not receive a block. However, when comparing preoperative vs postoperative patients with TAP block, there was no statistically significant difference in mean opioid use (MME 43.4 vs 42.1, p = .752). There were no differences in postoperative pain scores between patients with and without a TAP block, however, more opioids were required in patients who did not receive a TAP block to achieve the same pain scores as those who did receive a TAP block. There was a statistically significant shorter time to discharge for TAP versus patients without TAP block(median 5.5 vs 6.3 hours, p ≤ .001) as well as preoperative versus postoperative patients with TAP block (median 5.3 vs 6.2 hours, p = .001). CONCLUSION: While TAP block use at the time of minimally invasive hysterectomy reduced use of postoperative opioids, the timing of TAP block, either preoperatively or postoperatively, did not significantly affect opioid use. Preoperative compared with postoperative TAP block administration significantly shortened the time to discharge.

Predictors of Intraoperative Difficulty and Postoperative Examination Abnormalities in 164 Orbital Operations.

BACKGROUND: Although orbital fractures are common, prediction of outcomes in orbital surgery can be quite challenging. PURPOSE: We aim to identify predictors of intraoperative difficulty, operating time, and postoperative examination abnormalities in subjects undergoing post-traumatic orbital reconstructions. STUDY DESIGN, SETTING, AND SAMPLE: This is a retrospective cohort study of all consecutive orbital operations performed at a private, Level 1 trauma center in Portland, Oregon, USA over an 82-month period. All subjects that underwent exploration of the internal orbit for traumatic indications during the study period were included in the cohort. PREDICTOR VARIABLES: Four plating styles, surgical approach (transorbital vs transantral), days from injury to first surgery, fracture size (approximated as a rectangle using linear measurements from computed tomography scans), anteroposterior fracture position, and medial wall involvement were examined. OUTCOME VARIABLES: The primary outcome variable was intraoperative difficulty (defined as requiring revision after intraoperative imaging or return to the operating room). Secondary outcome variables included operating time and postoperative examination abnormalities. COVARIATES: Age and sex were included. ANALYSES: χ2 and Regression analyses were performed using a significance level of P < .05. RESULTS: One hundred and sixty four orbital operations were performed (90 isolated injuries and 74 combined orbital/midface injuries) on 155 subjects (73% male, mean age 39.8 years, standard deviation 16.7). In subjects with isolated orbital fractures, medial wall involvement was associated with intraoperative difficulty (P = .01). When using a transantral approach, intraoperative difficulty was more likely in more anterior fractures (P = .02). Plating style was associated with operating time (P = .03), with median times from 81 to 105 minutes (range 21 to 248 minutes). Postoperative examination abnormalities were more likely in the transorbital approach group (P = .01). Neither days to first surgery nor intraoperative difficulty were associated with postoperative examination abnormalities. Postoperative eyelid changes were seen in 13.6% of transorbital approaches and 0% of transantral approaches. Correction of gaze restriction and enophthalmos were more likely than correction of diplopia (P < .01). CONCLUSIONS AND RELEVANCE: Medial wall involvement is associated with intraoperative difficulty in orbital surgery. Anteriorly positioned fractures are better treated transorbitally, while posterior fractures may be amenable to transantral repair, thus avoiding risk of lower eyelid changes.

Differential Effects of Aging in the Macular Retinal Layers, Neuroretinal Rim, and Peripapillary Retinal Nerve Fiber Layer.

PURPOSE: We determined the differential aging effects of the inner 6 layers of the macula in contrast to the minimum neuroretinal rim width (MRW) and peripapillary retinal nerve fiber layer (RNFL) thickness. DESIGN: Cross-sectional, multicenter study. PARTICIPANTS: An approximately equal number of white subjects with a normal ocular and visual field examination in each decade group from 20 to 90 years. METHODS: OCT of the macula, optic nerve head, and peripapillary retina. MAIN OUTCOME MEASURES: Sectoral measurements of the inner 6 layers of the macula; age-related decline of each of these layers; strength of the associations with age of the macular parameters, MRW, and peripapillary RNFL thickness; and association between ganglion cell layer (GCL) thickness and MRW and peripapillary RNFL thickness. RESULTS: The study sample comprised 1 eye of 246 subjects with a median (range) age of 52.9 (19.8-87.3) years. Of the 6 layers, there was a statistically significant decline with age of only the GCL, inner plexiform layer, and inner nuclear layer thickness with rates of -0.11 µm/year, -0.07 µm/year, and -0.03 µm/year, respectively. These rates corresponded to 2.82%, 2.10%, and 0.78% loss per decade, respectively, and were generally uniform across sectors. The rate of loss of MRW and peripapillary RNFL thickness was -1.22 µm/year and -0.20 µm/year, corresponding to 3.75% and 2.03% loss per decade. However, the association of GCL thickness change with age (R2 = 0.28) was approximately twice that of MRW and RNFL thickness (R2 = 0.14 for each). CONCLUSIONS: In concordance with histopathologic studies showing age-related loss of retinal ganglion cell axons, we showed a significant decline in GCL thickness, as well as MRW and peripapillary RNFL thickness. The stronger relationship between aging and GCL thickness compared with the rim or peripapillary RNFL may indicate that GCL thickness could be better suited to measure progression of structural glaucomatous loss.

Orbital Volume Correction in Orbital Floor Fractures: A Comparison of Transorbital and Transantral Techniques.

PURPOSE: We compared the accuracy of orbital volume correction between the transorbital and transantral reconstructive techniques. MATERIALS AND METHODS: A retrospective cohort study was performed of patients who had undergone repair of isolated, unilateral orbital floor blowout fractures at Legacy Emanuel Hospital from 2013 to 2018. A total of 21 patients were identified and included in the predictor variable cohorts of the transorbital versus transantral repair technique. The outcome variable of orbital volume correction was evaluated by comparing the volume of the postoperative repaired orbits with that of the contralateral noninjured orbits. Additional ordinal variables analyzed included the preoperative orbital defect size and analysis of the transantral cohort stratified by the plating technique used. Data were assessed using analysis of variance and paired t tests. RESULTS: A transantral approach was used for orbital repair in 9 patients. In these patients, the postoperative orbital volume in the injured orbit was 2.69% greater than that in the uninjured orbit. The 12 patients who had undergone transantral repair had a postoperative orbital volume in the injured orbit that was 0.56% smaller than that of the uninjured orbit (P = .033). Division of the transantral cohort into 2 different plating techniques identified a less than 1% difference in mean orbital volume correction between the 2 techniques (P = .104). The average defect volume before transorbital repair was 4.87 cm3 compared with 5.22 cm3 for transantral repair (P = .907). CONCLUSIONS: The results from the present study have shown that the accuracy of orbital volume correction using the transantral approach will be comparable to that of the transorbital approach, as shown by a small, but statistically significant, increased accuracy in the volume correction with the transantral approach. Additional investigation to establish clinical correlations with these findings should be conducted.

PAs reduce rounding interruptions in the pediatric intensive care unit.

OBJECTIVE: We investigated the proportion of encounters that were interrupted during family-centered rounds in the pediatric intensive care unit (PICU) to determine whether the use of a physician assistant (PA) significantly affected the proportion of interrupted encounters. METHODS: We evaluated 2,657 rounding encounters in our 24-bed regional referral unit. The duration of each rounding encounter and total rounding duration were recorded. The presence or absence of a PA during each rounding encounter, the occurrence of an interruption, and other potential predictors of interruptions were recorded. RESULTS: The presence of a PA during PICU rounds was significantly associated (P < .001) with a 35.4% lower likelihood of an interruption. CONCLUSIONS: Family-centered rounds in the PICU are less likely to be interrupted when a PA is present. PAs help physicians and improve rounding efficiency by safely and effectively handling certain interruptions.

Predicting conversion to glaucoma using standard automated perimetry and frequency doubling technology.

PURPOSE: To test the hypothesis that development of glaucomatous visual fields can be predicted several years earlier from prior visual field information. METHODS: One-hundred and seven eyes with glaucomatous optic neuropathy (n = 47 eyes) or which were suspicious for glaucoma (n = 60) were prospectively enrolled in a longitudinal study. Visual fields were evaluated on an annual basis using standard automated perimetry (SAP), the original version of frequency doubling technology (FDT) perimetry, and a custom version of FDT that used the 24-2 stimulus pattern. All SAP fields were within normal limits at the initial visit. When the SAP glaucoma hemifield test was 'outside normal limits' or the pattern standard deviation probability was worse than the lower 5th percentile or more than two clustered locations at the p < 0.05 level were present on the pattern deviation probability plot, an eye was defined as being abnormal. We used a classification tree analysis to predict which eyes would convert, using only baseline test results. RESULTS: Classification trees that were constructed using only baseline data had excellent specificity (near 100%) but worse sensitivity (25-50%) for predicting which eyes would convert during follow-up. CONCLUSIONS: Predictive information is present in visual field results, even when they are still within normal limits.

Bruch's Membrane Opening Minimum Rim Width and Retinal Nerve Fiber Layer Thickness in a Normal White Population: A Multicenter Study.

PURPOSE: Conventional optic disc margin-based neuroretinal rim measurements lack a solid anatomic and geometrical basis. An optical coherence tomography (OCT) index, Bruch's membrane opening minimum rim width (BMO-MRW), addresses these deficiencies and has higher diagnostic accuracy for glaucoma. We characterized BMO-MRW and peripapillary retinal nerve fiber layer thickness (RNFLT) in a normal population. DESIGN: Multicenter cross-sectional study. PARTICIPANTS: Normal white subjects. METHODS: An approximately equal number of subjects in each decade group (20-90 years of age) was enrolled in 5 centers. Subjects had normal ocular and visual field examination results. We obtained OCT images of the optic nerve head (24 radial scans) and peripapillary retina (1 circular scan). The angle between the fovea and BMO center (FoBMO angle), relative to the horizontal axis of the image frame, was first determined and all scans were acquired and analyzed relative to this eye-specific FoBMO axis. Variation in BMO-MRW and RNFLT was analyzed with respect to age, sector, and BMO shape. MAIN OUTCOME MEASURES: Age-related decline and between-subject variability in BMO-MRW and RNFLT. RESULTS: There were 246 eyes of 246 subjects with a median age of 52.9 years (range, 19.8-87.3 years). The median FoBMO angle was -6.7° (range, 2.5° to -17.5°). The BMO was predominantly vertically oval with a median area of 1.74 mm(2) (range, 1.05-3.40 mm(2)). Neither FoBMO angle nor BMO area was associated with age or axial length. Both global mean BMO-MRW and RNFLT declined with age at a rate of -1.34 µm/year and -0.21 µm/year, equivalent to 4.0% and 2.1% loss per decade of life, respectively. Sectorially, the most rapid decrease occurred inferiorly and the least temporally; however, the age association was always stronger with BMO-MRW than with RNFLT. There was a modest relationship between mean global BMO-MRW and RNFLT (r = 0.35), whereas sectorially the relationship ranged from moderate (r = 0.45, inferotemporal) to nonexistent (r = 0.01, temporal). CONCLUSIONS: There was significant age-related loss of BMO-MRW in healthy subjects and notable differences between BMO-MRW and RNFLT in their relationship with age and between each other. Adjusting BMO-MRW and RNFLT for age and sector is important in ensuring optimal diagnostics for glaucoma.

Assessment of the reliability of standard automated perimetry in regions of glaucomatous damage.

PURPOSE: Visual field testing uses high-contrast stimuli in areas of severe visual field loss. However, retinal ganglion cells saturate with high-contrast stimuli, suggesting that the probability of detecting perimetric stimuli may not increase indefinitely as contrast increases. Driven by this concept, this study examines the lower limit of perimetric sensitivity for reliable testing by standard automated perimetry. DESIGN: Evaluation of a diagnostic test. PARTICIPANTS: A total of 34 participants with moderate to severe glaucoma; mean deviation at their last clinic visit averaged -10.90 dB (range, -20.94 to -3.38 dB). A total of 75 of the 136 locations tested had a perimetric sensitivity of ≤ 19 dB. METHODS: Frequency-of-seeing curves were constructed at 4 nonadjacent visual field locations by the Method of Constant Stimuli (MOCS), using 35 stimulus presentations at each of 7 contrasts. Locations were chosen a priori and included at least 2 with glaucomatous damage but a sensitivity of ≥ 6 dB. Cumulative Gaussian curves were fit to the data, first assuming a 5% false-negative rate and subsequently allowing the asymptotic maximum response probability to be a free parameter. MAIN OUTCOME MEASURES: The strength of the relation (R(2)) between perimetric sensitivity (mean of last 2 clinic visits) and MOCS sensitivity (from the experiment) for all locations with perimetric sensitivity within ± 4 dB of each selected value, at 0.5 dB intervals. RESULTS: Bins centered at sensitivities ≥ 19 dB always had R(2) >0.1. All bins centered at sensitivities ≤ 15 dB had R(2) <0.1, an indication that sensitivities are unreliable. No consistent conclusions could be drawn between 15 and 19 dB. At 57 of the 81 locations with perimetric sensitivity <19 dB, including 49 of the 63 locations ≤ 15 dB, the fitted asymptotic maximum response probability was <80%, consistent with the hypothesis of response saturation. At 29 of these locations the asymptotic maximum was <50%, and so contrast sensitivity (50% response rate) is undefined. CONCLUSIONS: Clinical visual field testing may be unreliable when visual field locations have sensitivity below approximately 15 to 19 dB because of a reduction in the asymptotic maximum response probability. Researchers and clinicians may have difficulty detecting worsening sensitivity in these visual field locations, and this difficulty may occur commonly in patients with glaucoma with moderate to severe glaucomatous visual field loss.

CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts.

Introduction: Clinical reasoning enables safe patient care and is an important competency in medical education but can be challenging to teach. Illness scripts facilitate clinical reasoning but have not been used to create pediatric curricula. Methods: We created CRISP (Clinical Reasoning with Illness Scripts in Pediatrics), a curriculum comprising four 1-hour learning sessions that deliberately incorporated clinical reasoning concepts and illness scripts to organize how four common chief complaints were taught to family medicine residents on inpatient pediatric rotations. We performed a multisite curriculum evaluation project over 6 months with family medicine residents at four institutions to assess whether the use of clinical reasoning concepts to structure CRISP was feasible and acceptable for learners and instructors and whether the use of illness scripts increased knowledge of four common pediatric chief complaints. Results: For all learning sessions, family medicine residents and pediatric hospitalists agreed that CRISP's format was preferable to traditional didactic lectures. Pre-/posttest scores showed statistically significant increases in family medicine resident knowledge (respiratory distress [n = 42]: pretest, 72%, posttest, 92%; abdominal pain [n = 44]: pretest, 82%, posttest, 96%; acute febrile limp [n = 44]: pretest, 68%, posttest, 81%; well-appearing febrile infant [n = 42]: pretest, 58%, posttest, 73%; ps < .05). Discussion: By using clinical reasoning concepts and illness script comparison to structure a pediatric curriculum, CRISP represents a novel instructional approach that can be used by pediatric hospitalists to increase family medicine resident knowledge about diagnoses associated with common pediatric chief complaints.

Optical Coherence Tomographic Optic Nerve Head Morphology in Myopia III: The Exposed Neural Canal Region in Healthy Eyes-Implications for High Myopia.

PURPOSE: To determine the prevalence and magnitude of optical coherence tomography (OCT) exposed neural canal (ENC), externally oblique choroidal border tissue (EOCBT), and exposed scleral flange (ESF) regions in 362 non-highly myopic (spherical equivalent -6.00 to 5.75 diopters) eyes of 362 healthy subjects. DESIGN: Cross-sectional study. METHODS: After OCT optic nerve head (ONH) imaging, Bruch membrane opening (BMO), the anterior scleral canal opening (ASCO), and the scleral flange opening (SFO) were manually segmented. BMO, ASCO, and SFO points were projected to the BMO reference plane. The direction and magnitude of BMO/ASCO offset as well as the magnitude of ENC, EOCBT, and ESF was calculated within 30° sectors relative to the foveal-BMO axis. Hi-ESF eyes demonstrated an ESF ≥100 µm in at least 1 sector. Sectoral peri-neural canal choroidal thickness (pNC-CT) was measured and correlations between the magnitude of sectoral ESF and proportional pNC-CT were assessed. RESULTS: Seventy-three Hi-ESF (20.2%) and 289 non-Hi-ESF eyes (79.8%) were identified. BMO/ASCO offset as well as ENC, EOCBT, and ESF prevalence and magnitude were greatest inferior temporally where the pNC-CT was thinnest. Among Hi-ESF eyes, the magnitude of each ENC region correlated with the BMO/ASCO offset magnitude, and the sectors with the longest ESF correlated with the sectors with proportionally thinnest pNC-CT. CONCLUSIONS: ONH BMO/ASCO offset, either as a cause or result of ONH neural canal remodeling, corresponds with the sectoral location of maximum ESF and minimum pNC-CT in non-highly myopic eyes. Longitudinal studies to characterize the development and clinical implications of ENC Hi-ESF regions in non-highly myopic and highly myopic eyes are indicated.

Seasonal changes in visual field sensitivity and intraocular pressure in the ocular hypertension treatment study.

PURPOSE: Longitudinal testing plays a key role in glaucoma management. Variability between visits hampers the ability to monitor progression. It has previously been shown that average intraocular pressure (IOP) exhibits seasonal fluctuations. This study examines whether visual field sensitivity also exhibits seasonal fluctuations and seeks to determine whether such fluctuations are correlated to seasonal IOP effects. DESIGN: Comparative case series. PARTICIPANTS: A total of 33 873 visits by 1636 participants enrolled in the Ocular Hypertension Treatment Study. Participants were split into 6 geographic zones according to the prevailing climate in their location. TESTING: At each visit, standard automated perimetry was conducted on each eye, and IOP was measured. MAIN OUTCOME MEASURES: Mixed effects regression models were formed to look for sinusoidal periodic effects on the change in perimetric mean deviation since the last visit (ΔMD) and on IOP, both overall and within each zone. RESULTS: When all the data were included, a significant seasonal effect on ΔMD was found with magnitude 0.06 dB, peaking in February (P < 0.001). Five of the 6 geographic zones exhibited significant seasonal effects on ΔMD, peaking between January and April, with magnitudes ranging from 0.04 dB (P = 0.049) to 0.21 dB (P < 0.001). Zones with greater climactic variation showed larger seasonal effects on ΔMD. All 6 zones exhibited a seasonal effect on IOP, peaking in January or February, with magnitudes ranging from 0.14 to 0.39 mmHg (P ≤ 0.02 in all cases). However, there was no evidence of a significant association between the magnitudes or dates of peaks of the 2 seasonal effects. CONCLUSIONS: The mean deviation was significantly higher in winter than in summer. There is no evidence of an association with seasonal IOP fluctuations. The cause of the seasonal effect on visual field sensitivity is unknown. These findings may help shed light on the glaucomatous disease process and aid efforts to reduce test-retest variability.

Correlating perimetric indices with three nerve fiber layer thickness measures.

PURPOSE: To determine which of three estimates of retinal nerve fiber layer thickness (RNFLT) correlate best with visual field sensitivity measured using standard automated perimetry (SAP). METHODS: Data were collected from 400 eyes of 209 participants enrolled in the Portland Progression Project. These individuals ranged from high-risk suspects to having non-end-stage glaucoma. In each eye, three measures of average RNFLT (spectral domain optical coherence tomography [SDOCT], scanning laser polarimetry [SLP], confocal scanning laser tomography [CSLT]) and SAP (Humphrey HFAII) were performed on the same day. Mean deviation (MD), mean sensitivity (MS), and pattern standard deviation (PSD) were linearized using the equations MD(Lin) = 10(MD*0.1), MS(Lin) = 10(MS*0.1), and PSD(Lin) = 10(PSD*-0.1). Correlations between each of the estimates of RNFLT and each of the functional metrics were calculated (nine total). Pearson correlations and generalized estimating equations (GEE) were used to calculate the strength and significance of the correlations. RESULTS: Linearized MS had the strongest correlation with SDOCT (r = 0.57), intermediate with SLP (r = 0.40), and weakest with CSLT (r = 0.13). When multiple RNFLT measures were included in a GEE model to predict MS(Lin), SDOCT was consistently predictive (p < 0.001) whereas CSLT was never predictive in these multivariate models. Similar findings were observed for MD(Lin) and PSD(Lin). CONCLUSIONS: Average RNFLT estimated from SDOCT predicts SAP status significantly better than average RNFLT estimated from SLP or CSLT.

Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial.

OBJECTIVE: To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities, including American Indian/Alaska Natives. SUBJECTS AND METHODS: We conducted a multicenter, randomized controlled trial and assigned diabetic participants to one of two groups: (1) telemedicine with a nonmydriatic camera or (2) traditional surveillance with an eye care provider. For those receiving telemedicine, the criteria for requiring follow-up with an eye care provider were (1) moderate nonproliferative diabetic retinopathy or higher, (2) presence of clinically significant macular edema, or (3) "unable to grade" result for diabetic retinopathy or macular edema. RESULTS: The telemedicine group (n=296) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group (n=271) (94% versus 56%, p<0.001). The overall prevalence of diabetic retinopathy at baseline was 21.4%, and macular edema was present in 1.4% of participants. In the telemedicine group, 20.5% would require further evaluation with an eye care provider, and 86% of these referrals were because of poor-quality digital images. CONCLUSIONS: Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations, and most did not require follow-up with an eye care provider. Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider. Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations.

Impact of Glucagon-Like Peptide 1 Receptor Agonists in Patients with Hemoglobin A1c of 9% or Greater.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 agonists) are effective hemoglobin A1c (HbA1c) and weight-lowering agents. The treatment effect is unknown in patients with HbA1c of 9% or greater. Objective: The purpose of this study was to evaluate glycemic control and weight loss after adding a GLP-1 agonist in patients with a baseline HbA1c of 9% (75 mmol/mol) or greater. Methods: A single-health system retrospective chart review screened adults with type 2 diabetes mellitus with a baseline hemoglobin A1c of 9% (75 mmol/mol) or greater and were prescribed a GLP-1 agonist for eligibility. The primary outcome assessed was the change in HbA1c from baseline to the first HbA1c check. Secondary outcomes included change in weight (kg) from baseline to the first HbA1c check. Results: Three hundred sixty-two patients were screened of which 151 (41.7%) were included in the final analysis. The mean change in HbA1c from baseline to first HbA1c check for all participants was -2.1% (95% CI: -2.3% to -1.8%; P < .001; -23 mmol/mol [95% CI: -25 to -20 mmol/mol]). The mean change in weight from baseline to first HbA1c check was -2.0 kg (95% CI: -2.6 kg to -1.4 kg; P < .001). Conclusion: In patients with type 2 diabetes mellitus with a baseline HbA1c ≥ 9%, GLP-1 agonist initiation resulted in a significant reduction of both HbA1c and weight compared to baseline. Large, prospective, multisite studies are needed to confirm findings of this retrospective study.

Intraoperative Fluoroscopy Radiation Using OEC 9900 Elite C-arm: Risk and Method for Decreasing Exposure.

ABSTRACT: The use of intraoperative fluoroscopy in surgery produces scattered radiation that can expose all operating room personnel to measurable and, in some cases, substantial radiation doses. The goal of this work is to assess and document potential radiation doses to various staff positions in a simulated standard operating room environment. Adult-sized mannequins wearing standard lead protective aprons were placed at seven positions around large and small BMI cadavers. Doses were recorded in real time at thyroid level with Bluetooth-enabled dosimeters for a variety of fluoroscope settings and imaging views. A total of 320 images were acquired, resulting in 2,240 dosimeter readings from the seven mannequins. Doses were compared to cumulative air kerma (CAK) calculations provided by the fluoroscope. There was a strong correlation between the CAK and the recorded scattered radiation doses ( P < 0.001). Radiation doses could be reduced by manipulating C-arm manual technique settings [e.g., turning off the automatic exposure control (AEC) and using pulse (PULSE) or low dose (LD) settings]. Staff position and patient size also affected the recorded doses. The highest radiation doses were recorded across all settings for the mannequin positioned immediately adjacent to the C-arm x-ray tube. The larger BMI cadaver generated greater scattered radiation than the smaller BMI cadaver for all views and settings. This work provides suggestions for reducing exposure to operating room personnel beyond standard techniques of reducing beam-on time, increasing the distance from the radiation source, and use of shielding. Simple changes in C-arm settings (turning AEC off, avoiding DS setting, use of PULSE or LD settings) can markedly reduce dose to staff.

Asymmetry of Peripapillary Retinal Blood Vessel and Retinal Nerve Fiber Layer Thickness Between Healthy Right and Left Eyes.

Purpose: The purpose of this study was to determine if there is asymmetry in retinal blood vessel (RBV) position and thickness between right and left eyes (R-L) and evaluate whether R-L asymmetry in RBV thickness is related to R-L asymmetry of retinal nerve fiber layer thickness (RNFLT). Methods: We analyzed peripapillary circle scan optical coherence tomography (OCT) examinations from healthy White subjects to measure RNFLT and RBV thickness and position relative to the fovea to Bruch's membrane opening axis, for all visible RBV. The R-L asymmetries of RNFLT and RBV thickness were computed for each A-scan. Four major vessels (superior temporal artery [STA] and superior temporal vein [STV], inferior temporal artery [ITA], and vein [ITV]) were identified using infrared images. Results: We included 219 individuals. The mean (standard deviation) number of RBV measured per eye was 15.0 (SD = 2.2). The position of the STV and STA was more superior in left eyes than in right eyes, by 2.4 degrees and 3.7 degrees, respectively (P < 0.01). There was no region with significant R-L asymmetry in RBV thickness. RNFLT was thicker in right eyes in the temporal superior region and thicker in left eyes in the superior and nasal superior regions, with the asymmetry profile resembling in a "W" shape. This shape was also present in post hoc analyses in two different populations. The R-L asymmetries of RBV and RNFLT at each A-scan were not significantly associated (P = 0.37). Conclusions: There is little R-L asymmetry in RBV, and it is not related to RNFLT asymmetry. This study suggests that R-L RNFLT asymmetry is due to factors other than RBV.

The effect of test variability on the structure-function relationship in early glaucoma.

PURPOSE: To determine whether the weakness of the structure-function relationship could be produced by test variability alone, without implying underlying dissociation between the true rates of structural and functional change. METHODS: Perimetric mean deviation (MD), and rim area (RA) and cup volume (CV) from confocal scanning laser ophthalmoscopy, over six visits, were taken from 166 eyes of 92 participants with high-risk ocular hypertension or suspected/early glaucoma in the Portland Progression Project. Models were created of each measure's variability. A further model predicted the rate of functional change from the rate of structural change. These were used to generate realistic simulated sequences of both functional and structural data with different standard deviations σ between the underlying rates of change. 'Observed' structure-function relationships were calculated. An empirical p-value was derived, equaling the proportion of simulated series for which the 'observed' structure-function dissociation was greater than that seen in patient data. RESULTS: The correlation between the rates of structural (RA) and functional (MD) change was 0.171, consistent with σ < 0.02 dB/yr. Using CV, the correlation was -0.091, consistent with σ < 0.01 dB/yr. By comparison, the models predicted that the standard deviation of the rate of functional change for a healthy eye due to test variability would be 0.18 dB/yr. CONCLUSION: Test variability is sufficiently large that realistic patient data can be simulated without requiring a large variability between the underlying rates of structural and functional change. This absence of implied dissociation is a necessary condition for it to be valid to combine structural and functional measures to improve estimates of functional change and/or to reduce perimetric variability.

Frailty Modeling via the Empirical Bayes Hastings Sampler.

Studies of ocular disease and analyses of time to disease onset are complicated by the correlation expected between the two eyes from a single patient. We overcome these statistical modeling challenges through a nonparametric Bayesian frailty model. While this model suggests itself as a natural one for such complex data structures, model fitting routines become overwhelmingly complicated and computationally intensive given the nonparametric form assumed for the frailty distribution and baseline hazard function. We consider empirical Bayesian methods to alleviate these difficulties through a routine that iterates between frequentist, data-driven estimation of the cumulative baseline hazard and Markov chain Monte Carlo estimation of the frailty and regression coefficients. We show both in theory and through simulation that this approach yields consistent estimators of the parameters of interest. We then apply the method to the short-wave automated perimetry (SWAP) data set to study risk factors of glaucomatous visual field deficits.

Geospatial analysis of blindness within rural and urban counties.

PURPOSE: To determine the associations of blindness within rural and urban counties using a registry of blind persons and geospatial analytics. METHODS: We used the Oregon Commission for the Blind registry to determine the number of persons who are legally blind, as well as licensure data to determine the density of eye care providers (optometrists and ophthalmologists) within each county of the State of Oregon. We used geospatial statistics, analysis of variance, and logistic regression to determine the explanatory variables associated with blindness within counties. RESULTS: We included 8350 individuals who are legally blind within the state of Oregon in the calendar year 2015. The mean observed prevalence of registered blindness was 0.21% and ranged almost 9-fold from 0.04% to 0.58% among counties (p < .001). In univariate models, higher blindness was associated with increasing median age (p = .027), minority race (p < .001), decreased median household income (p < .001), increased poverty within a county (p < .001), and higher density of ophthalmologists (p = .003). Density of optometrists was not associated with prevalence of blindness (p = .89). The final multivariable model showed higher blindness to be associated with lower median household income, higher proportion of black race, and lower proportion of Hispanic race (p < .001 for all). CONCLUSION: Geospatial analytics identified counties with higher and lower than expected proportions of blindness even when adjusted for sociodemographic factors. Clinicians and researchers may use the methods and results of this study to better understand the distribution of individuals with blindness and the associated factors to help design public health interventions.

A Clinical Educational Intervention to Increase HPV Vaccination Rates Among Pediatric Patients Through Enhanced Recommendations.

INTRODUCTION: The human papillomavirus (HPV) causes largely preventable cancers by completing a vaccination series. However, pediatric HPV vaccination rates remain low. Current evidence indicates that integrating five factors creates a high-quality recommendation associated with higher HPV vaccination rates. This quality improvement project aimed to evaluate the impact of an educational intervention to improve the quality of providers' recommendations and subsequent vaccination rates. METHOD: Using the Squire 2.0 Guidelines, clinical staff were observed during well-child visits (aged 11-12 years) before and after the intervention across three Plan-Do-Study-Act cycles. RESULTS: Thirty-nine encounters with mostly (n = 31; 80%) families of color. The quality of vaccine recommendations was improved after the intervention; however, vaccination rates did not increase for the 39 patients. Providers' delivery approach (presumptive vs. conversational) did increase vaccination rates. DISCUSSION: Providers' delivery style appears to be important when making HPV vaccine recommendations.