The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Immediate sequential bilateral cataract surgery (ISBCS): A single-site experience of 41 patients during the COVID-19 pandemic.

Background: The practice of immediate sequential bilateral cataract surgery (ISBCS) was more widely adopted in the UK during the COVID-19 pandemic, in response to limited surgical capacity and the risk of nosocomial infection. This study reports on a single site experience of ISBCS in Northern Ireland. Methods: Data was collected prospectively between 17th November 2020 and 30th November 2021. The ISBCS surgical protocol, recommended by RCOphth and UKISCRS, was followed. Primary outcomes measures were: postoperative visual acuity (VA), refractive prediction accuracy, intraoperative and postoperative complications. Results: Of 41 patients scheduled, 39 patients completed ISBCS and two patients underwent unilateral surgery (n=80 eyes). Mean age at the time of surgery was 71.6 years (standard deviation (SD) ±11.8 years). Median preoperative VA was 0.8 logMAR (range: PL to 0.2 logMAR). Seventeen (20.9%) eyes were highly myopic and 9 (11.1%) eyes were highly hypermetropic. Median cumulative dissipated phacoemulsification energy was 15.7 sec (range: 1.8 sec to 83.4 sec). Median case time was 10.4 min (range: 4.3 min to 37.1 min).One eye (1.3%) developed iritis secondary to a retained tiny cortical fragment. Four eyes (5.0%, n=3 patients) developed cystoid macular oedema, with full resolution. On wide field imaging, an asymptomatic unilateral peripheral suprachoroidal haemorrhage was noted in two highly myopic patients (axial lengths of 27.01mm and 25.05mm respectively). The posterior pole was spared, and both resolved spontaneously without any visual impairment. Conclusions: In our initial experience, ISBCS was found to be a safe approach to cataract surgery. Our patient cohort included eyes with dense cataracts and high ametropia. Further studies are required to assess patient reported outcome measures and the possible economic benefits of ISBCS in our local population.

Management of open globe injury: a narrative review.

Open globe injuries are a significant global cause of visual loss, including unilateral and bilateral blindness. Prognosis is predicted by injury severity, with lower presenting visual acuity and more posterior injuries associated with poor visual outcomes, although even the most severely injured eyes with no perception of light vision may regain some visual function. In addition to severity of the primary injury, the secondary injuries and complications causing poor outcomes include proliferative vitreoretinopathy (PVR) and endophthalmitis. Endophthalmitis is common after open globe injury, affecting up to 16.5% of patients. Systemic antibiotic prophylaxis is commonly used, with a limited evidence base, while intraocular antibiotics are less commonly used but have stronger supporting evidence of efficacy. Endophthalmitis rates are also reduced by prompt primary repair, which may also support recovery of visual acuity. PVR is not prevented or treated by any pharmacologic interventions in current clinical practice, but the incidence of post-traumatic PVR may be reduced by early vitrectomy within the first 4-7 days after injury. Ocular trauma training is often limited in Western ophthalmic surgical training programmes, and patients with ocular trauma often require the input of multiple subspecialists. In this context, it is important that patients have an overview and coordination of the different aspects of their care, with ownership by one lead clinician.

Program evaluation of a telepsychiatry service for older adults connecting a university-affiliated geriatric center to a rural psychogeriatric outreach service in Northwest Ontario, Canada.

BACKGROUND: Weekly telepsychiatry consultations have been provided since 2002 to six communities in Northwest Ontario. Staff from a single community psychogeriatric outreach service who work within these communities facilitate the referrals. METHODS: The program evaluation included (a) a chart review of the last 100 referrals, (b) analysis of patient and staff evaluations, (c) a survey mailed to all physicians in referring communities, and (d) three focus groups of staff working in local community agencies. RESULTS: The mean age at the time of consultation was 76.7 years. Sixty-eight percent of patients were females. The most frequent diagnoses were dementia (54%), depression (28%), and mild cognitive impairment (19%). The most frequent medication recommendations were antidepressants or cholinesterase inhibitors. Two hundred ninety-four patient assessments and case consultations were carried out between 2002 and 2009. Post-session evaluation surveys rated the provision of information, whether objectives were met, and overall usefulness of recommendations. The mean scores for these questions on a 5-point scale were between 4.6 and 4.85. Referring physicians were confident and satisfied with the recommendations made for their patients. All planned to continue to use telepsychiatry as a care option for the future. The focus groups added useful information about challenges and potential barriers to utilizing the program. CONCLUSIONS: The program was rated as being highly valued across all modalities of evaluation. Members of the referring team believe that access to a geriatric psychiatrist has broadened the team's knowledge base, its use of assessment tools, and increased their ability to better construct their patients' treatment plans.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Telepsychogeriatrics: a new horizon in the care of mental health problems in the elderly.

BACKGROUND: The use of telemedicine for the care of mental health problems has developed significantly over the last decade thanks to the emergence of a number of stable telepsychiatry programs in many countries. Parallel to this development, this care modality has also targeted specific populations with higher difficulty in gaining access to mental health services such as the elderly. Telepsychogeriatrics is expected to have an increasing role in providing care to geographically isolated rural communities, with a particular focus on long-term care facilities, in light of the high prevalence of psychiatric disorders in these centers and the lack of available specialized care. METHODS: A thorough search of the literature was conducted using Medline, Web of Science, and PsychINFO databases in order to gather available evidence on the applicability of telepsychiatry, specifically the use of videoconferencing for remote consultation, in the elderly population with mental disorders. A succinct description of the selected studies is given along with a general reflection on the state-of-the-art in the field of psychogeriatric clinical practice and research. RESULTS: Research on the use of telemedicine in this age group has taken into account their special characteristics, and has focused on demonstrating its applicability, the acceptance and satisfaction of elderly users and their healthcare providers, the possibility of carrying out cognitive and diagnostic assessments, and the efficiency of these programs. CONCLUSIONS: Despite limited experience, telepsychogeriatrics appears to be a viable option, well accepted by patients, including those having dementia. More systematized studies are needed in this new field based on larger sample sizes, including comparison with traditional consultations and assessment of the clinical outcomes.

Methanogenic capacity and robustness of hydrogenotrophic cultures based on closed nutrient recycling via microbial catabolism: Impact of temperature and microbial attachment.

A biological methanation system based on nutrient recycling via mixed culture microbial catabolism was investigated at mesophilic (37 °C) and thermophilic (55 °C) temperatures. At mesophilic temperatures, the formation of biofilms on two different types of material was assessed. Results showed that with intense mixing the biofilm reactors presented methanogenic capacities (per working volume) 50% higher than the ones operated with suspended cultures. Gas feeding rates of 200 L/L/d were achieved at a H2/CO2 to CH4 conversion efficiency of above 90% by linking two reactors in series. Furthermore the robustness of the cultures was assessed under a series of inhibitory conditions that simulated possible process interferences at full scale operation. Full recovery after separate intense oxygenation and long starvation periods was observed within 2-5 days.

Hydrology of the North Klondike River: carbon export, water balance and inter-annual climate influences within a sub-alpine permafrost catchment.

Arctic and sub-arctic watersheds are undergoing significant changes due to recent climate warming and degrading permafrost, engendering enhanced monitoring of arctic rivers. Smaller catchments provide understanding of discharge, solute flux and groundwater recharge at the process level that contributes to an understanding of how larger arctic watersheds are responding to climate change. The North Klondike River, located in west central Yukon, is a sub-alpine permafrost catchment, which maintains an active hydrological monitoring station with a record of >40 years. In addition to being able to monitor intra-annual variability, this data set allows for more complex analysis of streamflow records. Streamflow data, geochemistry and stable isotope data for 2014 show a groundwater-dominated system, predominantly recharged during periods of snowmelt. Radiocarbon is shown to be a valuable tracer of soil zone recharge processes and carbon sources. Winter groundwater baseflow contributes 20 % of total annual discharge, and accounts for up to 50 % of total river discharge during the spring and summer months. Although total stream discharge remains unchanged, mean annual groundwater baseflow has increased over the 40-year monitoring period. Wavelet analysis reveals a catchment that responds to El Niño and longer solar cycles, as well as climatic shifts such as the Pacific Decadal Oscillation. Dedicated to Professor Peter Fritz on the occasion of his 80th birthday.

Closed nutrient recycling via microbial catabolism in an eco-engineered self regenerating mixed anaerobic microbiome for hydrogenotrophic methanogenesis.

A novel eco-engineered mixed anaerobic culture was successfully demonstrated for the first time to be capable of continuous regeneration in nutrient limiting conditions. Microbial catabolism has been found to support a closed system of nutrients able to enrich a culture of lithotrophic methanogens and provide microbial cell recycling. After enrichment, the hydrogenotrophic species was the dominating methanogens while a bacterial substratum was responsible for the redistribution of nutrients. q-PCR results indicated that 7% of the total population was responsible for the direct conversion of the gases. The efficiency of H2/CO2 conversion to CH4 reached 100% at a gassing rate of above 60v/v/d. The pH of the culture media was effectively sustained at optimal levels (pH 7-8) through a buffering system created by the dissolved CO2. The novel approach can reduce the process nutrient/metal requirement and enhance the environmental and financial performance of hydrogenotrophic methanogenesis for renewable energy storage.

Integration of Power to Methane in a waste water treatment plant - A feasibility study.

The integration of a biomethanation system within a wastewater treatment plant for conversion of CO2 and H2 to CH4 has been studied. Results indicate that the CO2 could be utilised to produce an additional 13,420m3/day of CH4, equivalent to approximately 133,826kWh of energy. The whole conversion process including electrolysis was found to have an energetic efficiency of 66.2%. The currently un-optimised biomethanation element of the process had a parasitic load of 19.9% of produced energy and strategies to reduce this to <5% are identified. The system could provide strategic benefits such as integrated management of electricity and gas networks, energy storage and maximising the deployment and efficiency of renewable energy assets. However, no policy or financial frameworks exist to attribute value to these increasingly important functions.

Life cycle assessment of biohydrogen and biomethane production and utilisation as a vehicle fuel.

Environmental burdens for the production and utilisation of biomethane vehicle fuel or a biohydrogen/biomethane blend produced from food waste or wheat feed, based on data from two different laboratory experiments, have been compared. For food waste treated by batch processes the two stage system gave high hydrogen yields (84.2l H2kg(-1) VS added) but a lower overall energy output than the single stage system. Reduction in environmental burdens compared with diesel was achieved, supported by the diversion of waste from landfill. For wheat feed, the semi continuously fed two stage process gave low hydrogen yields (7.5l H2kg(-1) VS added) but higher overall energy output. The process delivers reduction in fossil fuel burdens, and improvements in process efficiencies will lead to reduction in CO2 burdens compared with diesel. The study highlights the importance of understanding and optimising biofuel production parameters according to the feedstock utilised.

Life cycle assessment of biogas infrastructure options on a regional scale.

A life cycle assessment has been completed of potential biogas infrastructures on a regional scale. Centralised and distributed infrastructures were considered along with biogas end uses of Combined Heat and Power (CHP) and injection to the gas grid for either transport fuel or domestic heating end uses. Damage orientated (endpoint) life cycle impact assessment method identified that CHP with 80% heat utilisation had the least environmental impact, followed by transport fuel use. Utilisation for domestic heating purposes via the gas grid was found to perform less well. A 32% difference in transportation requirement between the centralised and distributed infrastructures was found to have a relatively small effect on the overall environmental impact. Global warming impacts were significantly affected by changes in methane emissions at upgrading stage, highlighting the importance of minimising operational losses.

Successful models for telehealth.

Telemedicine and telehealth programs are generally more complex than their traditional on-site health care delivery counterparts. A few organizations have developed sustainable, multispecialty telemedicine programs, but single service programs, such as teleradiology and teledermatology, are common. Planning and maintaining a successful telemedicine program is challenging, and there are often barriers to developing sustainable telehealth programs. This article reviews some important aspects of developing a telehealth program, and provides two examples of currently operating successful model programs.