Characteristics of Vitamin A Deficiency Retinopathy at a Tertiary Referral Center in the United States.

PURPOSE: To explore the risk factors and fundus imaging features of vitamin A deficiency retinopathy (VADR) in an academic tertiary referral center in Atlanta, GA, United States, and to propose guidance regarding diagnostic workup and management of affected patients. DESIGN: Single-center retrospective case series. SUBJECTS: Nine patients seen between 2015 and 2021 at the Emory Eye Center diagnosed with VADR. METHODS: Retrospective chart review. MAIN OUTCOME MEASURES: Baseline serum retinol level, Snellen visual acuity, multimodal fundus imaging findings, and electroretinography findings. RESULTS: Nine patients, 4 (44.4%) female, with a median (range) age of 68 (50-75) years were identified. The most common underlying etiologies for vitamin A deficiency included history of gastrointestinal surgery (55.6%), liver disease (44.4%), and nutritional depletion due to low-quality diet (44.4%). Only 1 (11.1%) patient had a history of bariatric surgery. Four (44.4%) patients were on some form of vitamin A supplementation before the diagnosis of VADR. Median (range) serum retinol level was 0.06 (< 0.06-0.19) mg/L. All patients had macular subretinal hyperreflective deposits resembling subretinal drusenoid deposits, although in some cases, these were scant and sparsely distributed. Six eyes of 3 patients with longstanding deficiency had defects in the external limiting membrane (ELM). Three of these eyes additionally had macular areas of complete retinal pigment epithelium and outer retinal atrophy (cRORA). Full-field electroretinography demonstrated severe rod dysfunction and mild to moderate cone system dysfunction. Many findings of VADR were reversible with vitamin A repletion. However, all eyes with ELM defects or cRORA had persistence or continued growth of these lesions. CONCLUSION: Vitamin A deficiency retinopathy is uncommon in the developed world. However, given that early intervention can lead to dramatic visual improvement and avoid potentially permanent retinal damage, retina specialists should be familiar with its clinical presentation. The presence of nyctalopia and subretinal hyperreflective deposits in a patient with a history of gastrointestinal surgery, liver disease, and/or poor diet can be suggestive of this diagnosis, even in the presence of ongoing vitamin A supplementation. Vitamin A supplementation can vary in route and dosage and can be tailored to the individual with serial testing of serum retinol. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Impact of student-run clinic participation on empathy and interprofessional skills development in medical and pharmacy students.

Background: Students participating in student-run clinics (SRCs) have opportunities to develop and practice beneficial skill sets, including empathy and interprofessional collaboration. Objectives: This study aimed to assess whether participation in an underserved SRC impacts the development of empathy and interprofessional skills in pharmacy and medical students. Methods: This study assessed empathy and interprofessional skills development through a self-assessment survey. The survey included the Interpersonal Reactivity Index (IRI) to assess empathy, the Attitudes Towards Health Care Teams/Team Skills Scale (ATHCTS/TSS) to assess interprofessional team dynamics, and a free-text response section. Participants were grouped based on whether they participated in the SRC (intervention group) or did not participate in the SRC (control group). A subgroup analysis was performed based on the participants' discipline (medicine vs. pharmacy). To compare differences in IRI, ATHCTS, and TSS scores between study groups, independent samples t-tests were performed. A thematic analysis was used for qualitative data. Results: There were no statistically significant differences between intervention and control groups in IRI, ATHCTS, or TSS scores. Subgroup analyses showed no significant differences in scores of student pharmacists or medical students. For both disciplines, the thematic analysis revealed the most common positive themes identified were "real-world patient interaction and care," "impact on practice/career development." Alternatively, it revealed the highest reported negative themes identified as "time management and operational difficulties" and "concerns about the quality of/access to care". Conclusions: This study demonstrates that involvement in an SRC neither improves nor hinders a learner's development of empathy and interprofessional team skills. Qualitatively, students reported that participation in an SRC benefited their learning and helped develop their skills, like empathy and team dynamics, in an interprofessional setting. Future research with longitudinal monitoring or alternative assessment tools is recommended.

A Novel Approach to Subretinal Fluid Drainage in Coats'-Related Exudative Retinal Detachment.

Laser is effective at treating exudative retinal detachment (ERD) in Coats' disease. However, with severe ERD, the retina may be in contact with the lens. In such cases, laser can result in cataract formation. This case report of two patients treated at an academic medical center for Coats'-related ERD describes a technique of minimally invasive subretinal fluid drainage to create space between the lens and retina to avoid cataract. Transconjunctival unguarded needle drainage allowed for complete treatment of telangiectatic vessels and resulted in favorable anatomical outcomes in the patients. Transconjunctival unguarded needle drainage is a useful technique for treating severe, Coats'-related ERD, when a bullously detached retina is in contact with the lens. [Ophthalmic Surg Lasers Imaging Retina 2022; 53:407-409.].

Pre- and Posttherapy Risk Factors for Vasculopathy in Pediatric Patients With Craniopharyngioma Treated With Surgery and Proton Radiation Therapy.

PURPOSE: Vasculopathy (VAS) is a significant complication associated with radiation therapy in patients treated for brain tumors. We studied the type, location, severity, timing, and resolution of VAS in children with craniopharyngioma treated with proton radiation therapy (PRT) and evaluated predictors of stenosis (STN) using a novel patient and imaging-based modeling approach. METHODS AND MATERIALS: Children with craniopharyngioma (n = 94) were treated with 54 Gy relative biological effectiveness PRT in a clinical trial, NCT01419067. We evaluated VAS type, location, severity, and resolution. VAS events were segmented and related to their location, operative corridor, PRT dose, and vascular territory to facilitate mixed effect logistic regression modeling of spatial predictors of STN events. RESULTS: Forty-five (47.9%) patients had 111 instances of confirmed VAS (pre-PRT n = 37, 33.3%). The median time to post-PRT VAS was 3.41 years (95% confidence interval, 1.86-6.11). STN events were observed post-PRT in 23.4% (n = 22) of patients. Post-PRT VAS was detected by cerebral angiogram in 9.6% (n = 9), severe in 4.3% (n = 4), and compensated on perfusion in 2.1% (n = 2). Revascularization was required for 5 (5.3%) patients. Postsurgical, pre-PRT VAS, and PRT dose to unperturbed vessels were predictive of STN. The effect of PRT on STN was negligible within the surgical corridor. CONCLUSIONS: VAS often precedes PRT and was the strongest predictor of post-PRT STN. The adverse effect of PRT on STN was only apparent in unperturbed vasculature beyond the operative corridor.

CLINICAL FEATURES AND OUTCOMES OF INFANTS WITH RETINOPATHY OF PREMATURITY WHO FAIL ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY.

PURPOSE: To describe characteristics and outcomes of patients with retinopathy of prematurity who failed intravitreal antivascular endothelial growth factor. METHODS: A retrospective case series of 211 eyes (112 patients) treated with antivascular endothelial growth factor as initial therapy for retinopathy of prematurity at a single academic institution between 2011 and 2019 and an additional 6 eyes (3 patients) referred to us for management of failed antivascular endothelial growth factor. RESULTS: Among the 211 eyes receiving initial treatment at our institution, 17 eyes (11%) failed. Of the 23 total eyes managed by us for failure, 3 eyes (13%) failed after 50-week postmenstrual age. Failure manifested as recurrent plus in 14 eyes (58%), recurrent Stage 3 in 13 eyes (54%) and retinal detachment in 5 eyes (21%). Treatment failures were managed with laser (13 eyes), repeat injection (4 eyes), vitrectomy (2 eyes), or a combination of modalities (4 eyes). Follow-up of ≥6 months was available for 18 of the 23 eyes. The retina was fully attached in 17 eyes, and fixation behavior was present in 10 eyes. CONCLUSION: The most common manifestations of treatment failure were recurrent plus and Stage 3. The failure rate at our institution was 11.0%. A significant proportion of failures occurred after 50-week postmenstrual age. Most failed eyes had favorable anatomical outcomes and over half demonstrated fixation behavior.

Patient Perceptions of SARS-CoV-2 Exposure Risk and Association With Continuity of Ophthalmic Care.

Importance: Patient perceptions regarding the risks of obtaining in-person ophthalmic care during the coronavirus disease 2019 (COVID-19) pandemic may affect adherence to recommended treatment plans and influence visual outcomes. A deeper understanding of patient perspectives will inform strategies to optimize adherence with vision-preserving therapies. Objective: To evaluate perceptions of COVID-19 exposure risk and their association with appointment attendance among patients at high risk of both reversible and irreversible vision loss from lapses in care. Design, Setting, and Participants: This survey study included a nonvalidated telephone survey designed in April and May of 2020 and a retrospective medical record review conducted in parallel with survey administration from May 22 to August 18, 2020. Participants were recruited from 2 tertiary eye care centers (Emory Eye Center in Atlanta, Georgia, and W.K. Kellogg Eye Center in Ann Arbor, Michigan). The study included a random sample of patients with diagnoses of exudative age-related macular degeneration (AMD) or diabetic retinopathy (DR) who received an intravitreal injection between January 6 and March 13, 2020, and were scheduled for a second injection between March 13 and May 6, 2020. Main Outcomes and Measures: Association between perceptions regarding COVID-19 risks and loss to follow-up. Results: Of 1004 eligible patients, 423 (42%) were successfully contacted, and 348 (82%) agreed to participate (participants' mean [SD] age, 75 [12] years; 195 women [56%]; 287 White [82%] patients). Respondents had a mean (SD) of 2.7 (1.1) comorbidities associated with severe COVID-19, and 77 (22%) knew someone with COVID-19. Of all respondents, 163 (47%) were very concerned or moderately concerned about vision loss from missed treatments during the pandemic. Although 208 (60%) believed the COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), exposure at the eye clinic was extremely unlikely or unlikely, 49 (14%) believed it was extremely likely or likely. Seventy-eight participants (22%) were lost to follow-up. Concern regarding COVID-19 exposure during clinic visits (odds ratio [OR], 3.9; 95% CI, 1.8-8.4) and diagnosis of DR (vs AMD) (OR, 8.130; 95% CI, 3.367-20.408) were associated with an increase in likelihood of loss to follow-up. Conclusions and Relevance: Among patients at high risk for vision loss from lapses in care, many expressed concerns regarding the effect of the pandemic on their ability to receive timely care. Survey results suggest that fear of SARS-CoV-2 exposure was associated with a roughly 4-fold increase in the odds of patient loss to follow-up. These results support the potential importance of clearly conveying infection-control measures.

Adolescent and Young Adult Tattooing, Piercing, and Scarification.

Tattoos, piercing, and scarification are now commonplace among adolescents and young adults. This first clinical report from the American Academy of Pediatrics on voluntary body modification will review the methods used to perform the modifications. Complications resulting from body modification methods, although not common, are discussed to provide the pediatrician with management information. Body modification will be contrasted with nonsuicidal self-injury. When available, information also is presented on societal perceptions of body modification.

Office-based care for lesbian, gay, bisexual, transgender, and questioning youth.

The American Academy of Pediatrics issued its last statement on homosexuality and adolescents in 2004. This technical report reflects the rapidly expanding medical and psychosocial literature about sexual minority youth. Pediatricians should be aware that some youth in their care may have concerns or questions about their sexual orientation or that of siblings, friends, parents, relatives, or others and should provide factual, current, nonjudgmental information in a confidential manner. Although most lesbian, gay, bisexual, transgender, and questioning(LGBTQ) youth are quite resilient and emerge from adolescence as healthy adults, the effects of homophobia and heterosexism can contribute to increased mental health issues for sexual minority youth. LGBTQ and MSM/WSW (men having sex with men and women having sex with women) adolescents, in comparison with heterosexual adolescents,have higher rates of depression and suicidal ideation, high errates of substance abuse, and more risky sexual behaviors. Obtaining a comprehensive, confidential, developmentally appropriate adolescent psychosocial history allows for the discovery of strengths and assets as well as risks. Pediatricians should have offices that are teen-friendly and welcoming to sexual minority youth. This includes having supportive, engaging office staff members who ensure that there are no barriers to care. For transgender youth, pediatricians should provide the opportunity to acknowledge and affirm their feelings of gender dysphoria and desires to transition to the opposite gender. Referral of transgender youth to a qualified mental health professional is critical to assist with the dysphoria, to educate them,and to assess their readiness for transition. With appropriate assistance and care, sexual minority youth should live healthy, productive lives while transitioning through adolescence and young adulthood.

Office-based care for gay, lesbian, bisexual, and questioning youth.

While most gay, lesbian, and bisexual teens are quite resilient, the health disparities in working with this vulnerable population can be significant. This review will define and attempt to quantify the number of our sexual minority youth. The review discusses the unique challenges faced by these young people and suggests some evidence-based interventions that have allowed youth to reduce their risk behaviors. The role of homophobia and heterosexism is discussed and how the two issues impact the developing mind of a gay, lesbian, or bisexual teenager. Finally, issues in providing Clinical care and modifying our patient care approaches to providing effective care, is discussed. Essentially, using validated approaches to obtaining a good adolescent psychosocial history, the office-based care for Gay, Lesbian, and Bisexual youth is not different from working with other youth. Many are quite resilient and progress through adolescence without difficulty; others stumble and may fall to mental health issues, substance abuse, and HIV. We must provide excellent care if we are to help this vulnerable population of teenagers.

Integration strategies for using virtual patients in clinical clerkships.

PURPOSE: To explore students' perceptions of virtual patient use in the clinical clerkship and develop a framework to evaluate effects of different integration strategies on students' satisfaction and perceptions of learning effectiveness with this innovation. METHOD: A prospective, multiinstitutional study was conducted at six schools' pediatric clerkships to assess the impact of integrating Web-based virtual patient cases on students' perceptions of their learning during 2004-2005 and 2005-2006. Integration strategies were designed to meet the needs of each school, and integration was scored for components of virtual patient use and elimination of other teaching methodologies. A student survey was developed, validated, and administered at the end of the clerkship to 611 students. Data were analyzed using confirmatory factor analysis and structural equation modeling. RESULTS: A total of 545 students (89%) completed the survey. Overall student satisfaction with the virtual patients was high; students reported that they were more effective than traditional methods. The structural model demonstrated that elimination of other teaching methodologies was directly associated with perceived effectiveness of the integration strategies. A higher use score had a significant negative effect on perceived integration, but a positive effect on perceived knowledge and skills gain. Students' positive perceptions of integration directly affected their satisfaction and perception of the effectiveness of their learning. CONCLUSIONS: Integration strategies balancing the use of virtual patients with elimination of some other requirements were significantly associated with students' satisfaction and their perceptions of improved knowledge and skills.

Computer-assisted instruction in clinical education: a roadmap to increasing CAI implementation.

This reflection is based on the premise that clinical education can be improved by more widespread use of computer-assisted instruction (CAI) and that a roadmap will enable more medical educators to begin using CAI. The rationale for CAI use includes many of its inherent features such as incorporation of multimedia and interactivity yet the use of CAI remains limited, apparently because educators are not convinced about the role for CAI. Barriers to CAI use are discussed including misinterpretation of the literature for CAI effectiveness; a disconnect between CAI developers and the educators who make decisions about CAI use; and the paucity of knowledge regarding how to integrate CAI effectively into clinical education. Specific roles for CAI in undergraduate and graduate medical education can include improving uniformity of instruction, providing documentation of exposure or competence, improving the learners' educational experience or outcomes, and assessment that is matched to learning. Funding for CAI remains an important barrier but the authors believe that this will be overcome when use of CAI becomes more widespread.

The state of undergraduate pediatric medical education in North America: The COMSEP survey.

BACKGROUND/PURPOSE: One mission of all academic medical centers is the education of medical students. The resources allocated to the oversight of this mission vary. The status of pediatric undergraduate medical education and the role of the pediatric clerkship director (PCD) was published in 1995. We sought to provide an updated description by surveying current North American PCDs. METHODS: A survey was designed by members of the Council on Medical Student Education in Pediatrics and administered via the Internet. RESULTS: Eighty-four percent of U.S. PCDs (110/131) and 50% of Canadian PCDs (8/16) completed the survey. Significant differences compared with 1995 include (a) more clerkship directors are assistant professors, women, and generalists; (b) clerkship directors have more time for clerkship activities but less than they perceive that they need; and (c) traditional scholarship is even more difficult to accomplish than in the past. CONCLUSION: The position of PCD is perceived to be a legitimate career track, but most PCDs hold lower academic rank and have less traditional scholarly activity than PCDs did 10 years ago. Although PCDs have more time (40% now vs. 28% in 1995), they still feel that it is not adequate, needing almost 50% of their total time to adequately do their job.

Guiding parents through behavioral issues affecting their child's health: the primary care provider's role.

This short review was presented as part of the Morehouse School of Medicine Fifth Annual Primary Care Conference in October 2005. As child health morbidities and mortalities shift from infectious diseases, child healthcare providers must become more vigilant and aggressive at suspecting, screening for, and intervening in behavioral and developmental problems in early childhood. There is growing evidence about the link between early childhood developmental problems and severe dysfunctions in adulthood, including violence and crime. We must identify families that are at high risk of having behavioral and developmental problems. We must screen for developmental delays at health maintenance visits and use developmental surveillance on other office visits. We must also use the time in anticipatory guidance to help families to understand age-appropriate behaviors and how those behaviors can be modified. If appropriate, referrals must be made to Early Intervention, private therapists, or doctorate level professionals (developmental-behavioral pediatricians, child psychiatrists, or child psychologists).