Validation of a deep-learning-based retinal biomarker (Reti-CVD) in the prediction of cardiovascular disease: data from UK Biobank.

BACKGROUND: Currently in the United Kingdom, cardiovascular disease (CVD) risk assessment is based on the QRISK3 score, in which 10% 10-year CVD risk indicates clinical intervention. However, this benchmark has limited efficacy in clinical practice and the need for a more simple, non-invasive risk stratification tool is necessary. Retinal photography is becoming increasingly acceptable as a non-invasive imaging tool for CVD. Previously, we developed a novel CVD risk stratification system based on retinal photographs predicting future CVD risk. This study aims to further validate our biomarker, Reti-CVD, (1) to detect risk group of ≥ 10% in 10-year CVD risk and (2) enhance risk assessment in individuals with QRISK3 of 7.5-10% (termed as borderline-QRISK3 group) using the UK Biobank. METHODS: Reti-CVD scores were calculated and stratified into three risk groups based on optimized cut-off values from the UK Biobank. We used Cox proportional-hazards models to evaluate the ability of Reti-CVD to predict CVD events in the general population. C-statistics was used to assess the prognostic value of adding Reti-CVD to QRISK3 in borderline-QRISK3 group and three vulnerable subgroups. RESULTS: Among 48,260 participants with no history of CVD, 6.3% had CVD events during the 11-year follow-up. Reti-CVD was associated with an increased risk of CVD (adjusted hazard ratio [HR] 1.41; 95% confidence interval [CI], 1.30-1.52) with a 13.1% (95% CI, 11.7-14.6%) 10-year CVD risk in Reti-CVD-high-risk group. The 10-year CVD risk of the borderline-QRISK3 group was greater than 10% in Reti-CVD-high-risk group (11.5% in non-statin cohort [n = 45,473], 11.5% in stage 1 hypertension cohort [n = 11,966], and 14.2% in middle-aged cohort [n = 38,941]). C statistics increased by 0.014 (0.010-0.017) in non-statin cohort, 0.013 (0.007-0.019) in stage 1 hypertension cohort, and 0.023 (0.018-0.029) in middle-aged cohort for CVD event prediction after adding Reti-CVD to QRISK3. CONCLUSIONS: Reti-CVD has the potential to identify individuals with ≥ 10% 10-year CVD risk who are likely to benefit from earlier preventative CVD interventions. For borderline-QRISK3 individuals with 10-year CVD risk between 7.5 and 10%, Reti-CVD could be used as a risk enhancer tool to help improve discernment accuracy, especially in adult groups that may be pre-disposed to CVD.

The evolution of refractive surgery training.

PURPOSE OF REVIEW: Although refractive surgery is one of the most commonly performed ophthalmic procedures, there is a relative paucity of literature on residency and fellowship refractive surgery education. The purpose of this article is to review the current state and recent updates to refractive surgery education and to evaluate the safety and visual outcomes of trainee performed refractive procedures. RECENT FINDINGS: Currently, there is no standard refractive surgery curriculum in the United States apart from required mandatory minimum refractive requirements for residents and fellows. Our survey of residency programs confirms that refractive training is extremely varied, ranging from a dedicated refractive rotation with direct surgical experience to only didactics or observation of procedures. There is a proposed standardized framework for refractive surgery training for the military, which may be a starting point in developing a more comprehensive refractive surgery curriculum in residency education. Multiple studies have reinforced the safety of resident and fellow performed refractive surgery. SUMMARY: Refractive surgery is an increasingly popular procedure and a more comprehensive refractive education is paramount. Future studies are needed to determine how best to provide the fundamental training and surgical experience for trainees in the fast-changing landscape of refractive surgery.

Refractive lens exchange - who is getting it, what are they getting, how are they doing?

PURPOSE OF REVIEW: The purpose of this article is to provide a review of the literature on refractive lens exchange and present a retrospective analysis of 55 patients who underwent refractive lens exchange at a single practice. RECENT FINDINGS: Our study substantiates refractive lens exchange as an important option for presbyopic patients, hyperopic patients or patients with extremely high refractive error who desire spectacle independence. SUMMARY: Our study reveals that the refractive lens exchange population is younger than the average cataract population and their primary motivations are to resolve hyperopic or myopic refractive errors, gain spectacle independence, and address near vision loss. A variety of presbyopia-addressing intraocular lens options are available and we present our experience with multifocal, extended depth-of-focus, light-adjustable, and monofocal lenses.

Pandemic Nationalism in South Korea.

As in much of the world, the Coronovirus pandemic has dominated South Korean politics in 2020. Compared to other countries, Seoul's approach has been highly nationalist and politicized, as the ruling party lauded its pandemic response as the global standard and linked it to a larger, leftist-nationalist agenda. This "pandemic-leftist" discourse peaked around the April 15 midterm elections, but subsided the following month, as domestic and foreign setbacks arose. To explain, firstly, a competitive-nationalist race to flatten the infection curve encouraged the government to infringe on the civil liberties of infected patients, and society to stigmatize them. Other countries contained Covid-19 without such rights violations and stigma. Secondly, critics distinguished between the government's relative success in pandemic response and its general failures in economic and foreign policies. Instead of asking other countries to learn from one's country, each country would do well to learn from the experiences of others and to continually improve its own policies.

Social inclusion among mental health service users: A reliability test of the Mini-SCOPE Scale.

AIM AND OBJECTIVES: To evaluate the reliability of the Mini-SCOPE scale through interitem consistency and test-retest consistency, as well as the initial correlation with outcome measures of recovery. BACKGROUND: Adapted from a UK, Social and Communities Opportunities Profile (Mini-SCOPE) is a short version of an social inclusion measurement for English-speaking persons in recovery (PIR) in Singapore. Prior concept mapping sets the stage for this reliability study. DESIGN: This study adopted a nonexperimental, pre- and postdesign to validate the psychosocial measurement tool for community services. METHOD: Convenient sampling was conducted at the various designated clinics. A total of 170 voluntary participants from psychiatric outpatient clinics were recruited for this study. It evaluated the 4-week interval test-retest reliability of the Mini-SCOPE. "AGREE" equator checklist was completed to guide the reporting of clinical practice. "See Supporting Information File S1." RESULT: Outcome demonstrated that the Mini-SCOPE scale has good strength of reliability. CONCLUSION: This study showed that the Mini-SCOPE measurement has the potential to be used for programme evaluation in mental health settings. RELEVANCE TO CLINICAL PRACTICE: Applicable to nurses and other mental health professionals to consider the social and wellness aspects of the patients in their care when planning appropriate services.

Illness management and recovery program for mental health problems: reducing symptoms and increasing social functioning.

AIMS AND OBJECTIVES: To evaluate the effectiveness of the Illness Management and Recovery Program in comparison with the current standard of care in terms of reduction of symptoms, rehospitalisation rates and social functioning in Asia. BACKGROUND: Focus of treatment for Mental Health had been shifted from mere management of symptoms to that of achievement of recovery. In the recovery process, strategies to achieve higher level of functioning were used (Psychiatric Services 2014, 65, 171). However, two main factors hindered clients from attaining recovery: first, the lack of Mental Health resources in the community and second the negative attitudes of healthcare professionals towards mental illness (American Journal of Psychiatric Rehabilitation 2012, 15, 131). Hence, it is essential to implement an effective programme that will train mental health professionals to use more effective techniques and materials in helping the clients to better integrate into society by achieving skills in their attempt to work towards recovery. DESIGN: This study adopts a time series experimental quantitative design. METHODS: Fifty participants who consented to the study were randomly assigned to two groups. Participants in the experimental group received the experimental management and recovery programme, while the control group received standard care management by the community psychiatric nurses for a period of 12 months. RESULTS: Participants in the experimental group reported significantly lower number of admissions, shorter length of stay, lower Brief Psychiatric Rating Scale scores, and also reported significantly higher scores on both the Illness Management and Recovery Scale and the Global Assessment Scale. CONCLUSION: This study demonstrated the effectiveness of IMR in helping Asian people with mental illness to not only reduce symptoms and hospitalisations but also improve social functioning. They have benefitted from the program although they are living in a different cultural setting from where IMR was developed. RELEVANCE TO CLINICAL PRACTICE: The success of this study has raised the standard of care in the community intervention and led more people to their recovery.

Hilar Abnormality in the Left Lung: Left Pulmonary Artery Posterior to the Left Mainstem Bronchus.

The thoracic cavity contains vital cardiovascular and pulmonary structures. Few congenital anatomical variations in the bronchial tree and pulmonary vasculature have been reported. Understanding such variants is crucial during surgical procedures that involve the thorax. During routine dissection of an 89-year-old male cadaver as part of a first-year anatomy course, an anomaly of the bronchial tree was discovered. The left lung hilum was notable for the pulmonary artery being posterior to the mainstem bronchus. The case report describes normal lung development and anatomy and the significance of this novel variation in which has not been previously described in the literature.

Non-invasive chronic kidney disease risk stratification tool derived from retina-based deep learning and clinical factors.

Despite the importance of preventing chronic kidney disease (CKD), predicting high-risk patients who require active intervention is challenging, especially in people with preserved kidney function. In this study, a predictive risk score for CKD (Reti-CKD score) was derived from a deep learning algorithm using retinal photographs. The performance of the Reti-CKD score was verified using two longitudinal cohorts of the UK Biobank and Korean Diabetic Cohort. Validation was done in people with preserved kidney function, excluding individuals with eGFR <90 mL/min/1.73 m2 or proteinuria at baseline. In the UK Biobank, 720/30,477 (2.4%) participants had CKD events during the 10.8-year follow-up period. In the Korean Diabetic Cohort, 206/5014 (4.1%) had CKD events during the 6.1-year follow-up period. When the validation cohorts were divided into quartiles of Reti-CKD score, the hazard ratios for CKD development were 3.68 (95% Confidence Interval [CI], 2.88-4.41) in the UK Biobank and 9.36 (5.26-16.67) in the Korean Diabetic Cohort in the highest quartile compared to the lowest. The Reti-CKD score, compared to eGFR based methods, showed a superior concordance index for predicting CKD incidence, with a delta of 0.020 (95% CI, 0.011-0.029) in the UK Biobank and 0.024 (95% CI, 0.002-0.046) in the Korean Diabetic Cohort. In people with preserved kidney function, the Reti-CKD score effectively stratifies future CKD risk with greater performance than conventional eGFR-based methods.

Pivotal trial of a deep-learning-based retinal biomarker (Reti-CVD) in the prediction of cardiovascular disease: data from CMERC-HI.

OBJECTIVE: The potential of using retinal images as a biomarker of cardiovascular disease (CVD) risk has gained significant attention, but regulatory approval of such artificial intelligence (AI) algorithms is lacking. In this regulated pivotal trial, we validated the efficacy of Reti-CVD, an AI-Software as a Medical Device (AI-SaMD), that utilizes retinal images to stratify CVD risk. MATERIALS AND METHODS: In this retrospective study, we used data from the Cardiovascular and Metabolic Diseases Etiology Research Center-High Risk (CMERC-HI) Cohort. Cox proportional hazard model was used to estimate hazard ratio (HR) trend across the 3-tier CVD risk groups (low-, moderate-, and high-risk) according to Reti-CVD in prediction of CVD events. The cardiac computed tomography-measured coronary artery calcium (CAC), carotid intima-media thickness (CIMT), and brachial-ankle pulse wave velocity (baPWV) were compared to Reti-CVD. RESULTS: A total of 1106 participants were included, with 33 (3.0%) participants experiencing CVD events over 5 years; the Reti-CVD-defined risk groups (low, moderate, and high) were significantly associated with increased CVD risk (HR trend, 2.02; 95% CI, 1.26-3.24). When all variables of Reti-CVD, CAC, CIMT, baPWV, and other traditional risk factors were incorporated into one Cox model, the Reti-CVD risk groups were only significantly associated with increased CVD risk (HR = 2.40 [0.82-7.03] in moderate risk and HR = 3.56 [1.34-9.51] in high risk using low-risk as a reference). DISCUSSION: This regulated pivotal study validated an AI-SaMD, retinal image-based, personalized CVD risk scoring system (Reti-CVD). CONCLUSION: These results led the Korean regulatory body to authorize Reti-CVD.

Cardiovascular disease risk assessment using a deep-learning-based retinal biomarker: a comparison with existing risk scores.

Aims: This study aims to evaluate the ability of a deep-learning-based cardiovascular disease (CVD) retinal biomarker, Reti-CVD, to identify individuals with intermediate- and high-risk for CVD. Methods and results: We defined the intermediate- and high-risk groups according to Pooled Cohort Equation (PCE), QRISK3, and modified Framingham Risk Score (FRS). Reti-CVD's prediction was compared to the number of individuals identified as intermediate- and high-risk according to standard CVD risk assessment tools, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the results. In the UK Biobank, among 48 260 participants, 20 643 (42.8%) and 7192 (14.9%) were classified into the intermediate- and high-risk groups according to PCE, and QRISK3, respectively. In the Singapore Epidemiology of Eye Diseases study, among 6810 participants, 3799 (55.8%) were classified as intermediate- and high-risk group according to modified FRS. Reti-CVD identified PCE-based intermediate- and high-risk groups with a sensitivity, specificity, PPV, and NPV of 82.7%, 87.6%, 86.5%, and 84.0%, respectively. Reti-CVD identified QRISK3-based intermediate- and high-risk groups with a sensitivity, specificity, PPV, and NPV of 82.6%, 85.5%, 49.9%, and 96.6%, respectively. Reti-CVD identified intermediate- and high-risk groups according to the modified FRS with a sensitivity, specificity, PPV, and NPV of 82.1%, 80.6%, 76.4%, and 85.5%, respectively. Conclusion: The retinal photograph biomarker (Reti-CVD) was able to identify individuals with intermediate and high-risk for CVD, in accordance with existing risk assessment tools.

Effect of intraoperative blood pressure on incidence of hematoma in breast reduction mammoplasty.

BACKGROUND: Postoperative hematomas are among the most frequent complications following breast reduction mammoplasty (BRM). Intraoperative hypotension has been implicated in the development of postoperative hematomas following breast reduction. In this study, we performed a retrospective, propensity-matched analysis of patients undergoing primary breast reduction to determine the relationship between intraoperative blood pressure and the development of a postoperative hematoma. METHODS: A retrospective review of all patients that underwent BRM at a single institution from 2017 to 2019 (n = 563) was conducted. Patients who developed a postoperative hematoma were propensity matched to two controls based on body mass index (BMI) and age. The mean systolic blood pressure (SBP) and average mean arterial pressure (MAP) were recorded for each third of the operation. Data were analyzed using conditional logistic regression. RESULTS: Thirty-two patients that developed postoperative hematomas were propensity matched to 64 controls. There was no difference in baseline SBP, diastolic blood pressures, or prevalence of hypertension between groups. There was no significant difference in average SBP or MAP between groups. The average MAP during the first third of the procedure was found to be lower in patients who developed a hematoma (69 vs. 72 mmHg), which approached significance at p = 0.08. Closed suction drains were used in 53% of the hematoma group and 78% of the control group (p = 0.02). CONCLUSION: There does not appear to be an association between intraoperative blood pressure and the incidence of hematoma when comparing patients who developed hematomas after BRM to propensity-matched controls.

Use of Plain Radiography of Uninjured Wrists as Patient-Specific Markers of Successful Reduction of Unilateral Distal Radius Fractures.

BACKGROUND: The standard of care of distal radius fractures requiring operative intervention involves restoration of anatomical alignment radiologically by comparing preoperative films and intraoperative fluoroscopy with established values based on population norms. The objective of this study is to evaluate the use of plain radiographs obtained from the uninjured wrist of patients who present with unilateral displaced distal radius fractures as a measure of successful achievement of anatomical realignment. METHODS: A retrospective review was performed on 133 consecutive patients who presented from August 2020 to August 2021 with a diagnosis of unilateral distal radius fracture as confirmed on 3-view plain radiography. Patients who had bilateral radiographs and underwent open reduction and internal fixation were included. The primary outcome measure was comparison of radial inclination, radial height, tilt, and ulnar variance measured by 3 observers on preoperative, 1-week postoperative, and uninjured contralateral wrist films. RESULTS: Twenty-one patients were included for analysis. Comparison of postoperative radiologic parameters with the contralateral uninjured extremity revealed a mean radial inclination difference of 3.8°, radial height difference of 2.0 mm, volar tilt difference of 6.3°, and ulnar variance difference of 0.9 mm. The average postreduction radial height was found to deviate from contralateral radial height significantly more than from the historic radial height parameter (2.0 vs 0.6 mm, P < .001). CONCLUSION: Attempts at achieving distal radius fracture reduction to within historical normal limits may result in an increased deviation from patient-specific anatomical parameters, especially with respect to radial height.

Frontline Reporting from the Epicenter of a Global Pandemic: A Survey of the Impact of COVID-19 on Plastic Surgery Training in New York and New Jersey.

BACKGROUND: Since the first documented case of coronavirus disease of 2019 (COVID-19), the greater New York City area quickly became the epicenter of the global pandemic, with over 500,000 cases and 50,000 deaths. This unprecedented crisis affected all aspects of health care, including plastic surgery residency training. The purpose of this study was to understand the specific impact of the COVID-19 pandemic on plastic surgery residencies. METHODS: A survey of all plastic surgery residency training programs in the greater New York City area was conducted. The impact to training during the peak months of infection (March and April of 2020) was evaluated using resident education as measured by case numbers, need for redeployment, and staff wellness as primary outcome variables. RESULTS: A total of 11 programs were identified in the region, and seven programs completed the survey, with a response rate 63.6 percent. When comparing productivity in March and April of 2019 to March and April of 2020, a total decrease in surgical volume of 64.8 percent (range, 19.7 to 84.8 percent) and an average of 940 (range, 50 to 1287) cancelled clinic visits per month were observed. These decreases directly correlated with the local county's COVID-19 incidence rates (p = 0.70). A total of 83 percent of programs required redeployment to areas of need, and correlation between local incidence of COVID-19 and the percentage of residents redeployed to non-plastic surgical clinical environments by a given program (ρ = 0.97) was observed. CONCLUSION: As the first COVID-19 wave passes the greater New York area and spreads to the rest of the country, the authors hope their experience will shed light on the effects of the ongoing COVID-19 pandemic, and inform other programs on what to expect and how they can try and prepare for future public health crises.

South Korean Evangelical Narratives on North Koreans and Homosexuals.

This paper analyzes how South Korean (SK), evangelical media discuss two outgroup categories: North Korea and homosexuality. Analysis of SK media over two decades-mainly longitudinal analysis of evangelical newspaper Kidok Sinmun (1998-2019)-generates several findings. First, homosexuality is catching up to North Korea as the leading outgroup in SK Christian discourse. Second, both outgroups are subjects of dual, competing narratives: one (threat) frames outgroups, and their supporters, as threats to the liberties and/or values of Christians; another (outreach), as subjects of Christian love and personal relationship. The threat and outreach narratives, in turn, are, respectively, associated with right-wing and non-right politics on the outgroup. We argue that the dual narratives are shaped by American evangelical culture; cross-national communications (e.g., South Korea and USA); and cross-national events (e.g., presidential elections) that influence the perceived threats posed by, or opportunities to outreach to, outgroup members.

Queer Communities and Activism in South Korea: Periphery-Center Currents.

Research into South Korea's LGBT+ communities is growing but still very limited, especially regarding communities in Busan and other urban areas outside the capital city, Seoul. We collected and analyzed responses from young LGBT+ who resided in the periphery and center and who described the two communities, their activist tactics, the connections/separations between them, and periphery-center characteristics of dialogue with opponents and participation in Korea's conservative, evangelical Christian churches. We reveal attitudinal and behavioral differences between Seoul and Busan (and other outlying areas), and we suggest that the differences reflect, in part, physical, social, and psychological distances between LGBT+ residing in the periphery and center. In time, outlying areas may converge with the center, imitating, though perhaps incompletely, Seoul's strong identity activism and more integrated community, or the periphery may pursue an independent, local identity.

Gay Seouls: Expanding Religious Spaces for Non-Heterosexuals in South Korea.

What Protestant congregations offer spaces for worship and dialogue among persons with different sexual orientations? The academic literature finds or assumes that non-heterosexuals are stigmatized or invisible in theologically conservative congregations and are welcomed in progressive, affirming congregations. This article develops an alternative claim that some conservative or evangelical congregations offer attractive spaces for non-heterosexuals to worship and dialogue. We illustrate with an exploratory study of four congregations in South Korea-two theologically progressive, two evangelical-whose pastors welcomed everybody regardless of sexual orientation or gender identity. The "inclusive-evangelical" congregations retained conservative theology on sexuality (sexual relations only within heterosexual marriage) but offered more empathic dialogue with non-heterosexuals than did most evangelical congregations; they also provided more resources, conventional religious culture, and ties to traditional affective networks than the affirming-progressive congregations. Inclusive-evangelical congregations offer an institutional venue for non-heterosexual Christians in Korea to potentially reconcile three central values: conservative Christianity, traditional (Confucian) affective networks, and expressive individualism.