Tinnitus as a Potential Risk Factor for Uveitis: A 14-Year Nationwide Population-Based Cohort Study in Taiwan.

BACKGROUND: Tinnitus and uveitis have shared commonality in pathophysiology in terms of autoimmunity. However, no studies that have linked any association between the conditions of tinnitus and uveitis. METHODS: This is a retrospective study conducted from the Taiwan National Health Insurance database in order to investigate whether tinnitus patients are at increased risk of uveitis. Patients newly diagnosed with tinnitus between 2001 and 2014 were recruited and followed up until 2018. The endpoint of interest was a diagnosis of uveitis. RESULTS: A total of 31,034 tinnitus patients and 124,136 matched comparisons were analyzed. Tinnitus patients were found to have a significantly higher cumulative incidence for uveitis than those without the diagnosis of tinnitus with incidence rate of 1.68 (95% CI 1.55-1.82) per 10 000 person-months for tinnitus group and 1.48 (95% CI 1.42-1.54) per 10 000 person-months for non-tinnitus group. CONCLUSION: Tinnitus patients were found to have increased risk of developing uveitis.

Optical Coherence Tomography Biomarkers in Predicting Treatment Outcomes of Diabetic Macular Edema after Ranibizumab Injections.

Background and Objectives: The identification of possible biomarkers that can predict treatment response among DME eyes is important for the individualization of treatment plans. We investigated optical coherence tomography (OCT)-based biomarkers that may predict the one-year real-life outcomes among diabetic macular edema (DME) eyes following treatment by intravitreal ranibizumab (IVR) injections. Materials and Methods: A total of 65 eyes from 35 treatment-naïve patients with DME treated with ranibizumab injection were recruited. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure (IOP), and OCT scans were retrospectively recorded at baseline before treatment and at 3 months, 6 months, and 12 months after treatment. The OCT scans were evaluated for biomarkers of interest, which included central retinal thickness (CRT), amount and locations of hyperreflective foci (HRF), subretinal fluid (SRF), intraretinal cysts (IRC), large outer nuclear layer cyst (LONLC), ellipsoid zone disruption (EZD), disorganization of retinal inner layers (DRIL), hard exudates (HE), epiretinal membrane (ERM), and vitreomacular interface (VMI). Correlations between these OCT biomarkers and outcome measures (visual and structural) were statistically analyzed. Results: A total of 65 eyes from 35 patients with DME were enrolled. The mean age was 64.2 ± 10.9 years old. Significant improvement in terms of mean BCVA (p < 0.005) and mean CRT was seen at final follow-up compared to baseline. The biomarkers of DRIL, LONLC, and SRF were found to be predictive for at least 50 µm CRT reduction after treatment (with odds ratio of 8.69, 8.5, and 17.58, respectively). The biomarkers of IRC, LONLC, and SRF were predictive for significant improvement in terms of BCVA and CRT after treatment. Finally, the number of HRF was predictive for both BCVA improvement and a CRT reduction of less than 100 µm after treatment. No serious complications were reported during the study. Conclusion: Our study demonstrated the utility of OCT biomarkers as therapeutic predictors of ranibizumab treatment among DME eyes.

MULTIMODAL IMAGING OF ACUTE MULTIFOCAL HEMORRHAGIC RETINAL VASCULITIS: A CASE REPORT.

PURPOSE: To report a case of acute multifocal hemorrhagic retinal vasculitis and demonstrate the multimodal imaging. METHODS: Interventional case report. RESULTS: A 54-year-old woman without significant past medical history complained of redness and blurred vision in both eyes. Her visual acuity was counting fingers and 20/60. Mild conjunctival injection, anterior chamber cells, and vitreous haze were noted. Fundus showed multifocal intraretinal hemorrhages. Fluorescein angiography revealed vasculitic process with intraretinal hemorrhage blocking defects and retinal ischemic changes in both eyes. Anterior chamber tap fluid polymerase chain reaction for varicella zoster virus, herpes simplex virus I/II, cytomegalovirus, and Epstein-Barr virus was unremarkable. Rheumatology was consulted and systemic vasculitis was ruled out. Her vision improved to 20/50 and 20/20 after pulse methylprednisolone therapy, oral methotrexate, and prednisolone treatment. CONCLUSION: Acute multifocal hemorrhagic retinal vasculitis can occur in an immunocompetent patient. Multimodal Imaging is useful in the diagnosis and follow-up. Patients could benefit from early and aggressive immunosuppressive therapy.

Short-Term Effects of Brolucizumab in the Treatment of Wet Age-Related Macular Degeneration or Polypoidal Choroidopathy Refractory to Previous Anti-Vascular Endothelial Growth Factor Therapy.

Background and objectives: To report the initial response to a single intravitreal brolucizumab (IVI-B) injection in wet age-related macular degeneration (wAMD) or polypoidal choroidopathy (PCV) complicated with either persistent subretinal fluid (SRF) or pigment epithelial detachment refractory to previous anti-vascular endothelial growth factor (anti-VEGF) therapy. Material and methods: In this retrospective study, all eyes received a single IVI-B (6 mg/0.05 mL) for wAMD or PCV with treatment-resistant SRF or PED. Outcome measures included assessment in central retinal thickness (CRT), visual acuity, and evaluation for changes in the SRF or PED on OCT. Follow-up was prior to the first brolucizumab injection, then at 1 week and 5 weeks afterwards. Results: In total, 10 eyes of 10 patients (6 women [60%]) were enrolled. Five patients had wAMD and five patients had PCV. Average age of participants was 67.6 years. All patients received one IVI-B. All patients were not treatment-naïve to anti-VEGF agents. At the first week and fifth week following the first IVI-B, seven out of seven patients (100%) had resolved SRF. However, seven out of nine patients (78%) had no improvement of their PED at 5 weeks follow-up. Mean PED height and width before the first IVI-B was 339.77 µm and 2233.44 µm, respectively. Mean PED height and width at the fifthweek following the first IVI-B was 328.125 µm and 2129.5 µm, respectively. Overall mean visual acuity before the first IVI-B was 0.224; and 5 weeks following the first IVI-B was 0.38. Conclusions: Treatment with brolucizumab resulted in anatomical improvement for all patients with persistent SRF. Limited efficacy was seen for persistent PED. Brolucizumab appears to be a safe and effective option for treatment-resistant SRF. Future multicenter collaborative studies are warranted.

Reference values of the carotid elastic modulus using shear wave elastography and arterial stiffness change in coronary slow flow.

PURPOSE: Shear wave elastography (SWE) accurately and sensitively evaluates arterial wall stiffness by quantifying the elastic modulus (EM); however, the absence of reference values has precluded its widespread clinical application. This prospective cohort study aimed to establish reference values for the carotid EM using SWE; investigate the main determinants of the EM; and evaluate EM changes in coronary slow flow (CSF), which is characterized by delayed coronary opacification without evident obstructive lesion in epicardial coronary artery on angiography. METHOD: This study enrolled 169 healthy volunteers and 30 patients with CSF. The carotid maximum EM (EMmax), mean EM, and minimum EM were measured using SWE. CSF was diagnosed by thrombolysis in the myocardial infarction frame count during coronary angiography. RESULTS: No differences were found in the EM between the left and right carotid arteries and between men and women. Multiple linear regression analysis revealed that age was independently correlated with the EMmax, which progressively increased with age. Moreover, smoking had an independent influence on the EM after adjusting for age; smokers had higher EM than non-smokers. Age-specific reference values for the carotid EM were established. The EM was higher in patients with CSF than in controls after adjusting for age and smoking status. CONCLUSIONS: This study first established the reference values for the carotid EM using SWE. Age and smoking status were the main determinants of the EM. Patients with CSF had high EM. SWE can effectively and noninvasively evaluate arterial stiffness in patients with CSF.

Use of Ultra-Widefield Fluorescein Angiography to Guide the Treatment to Idiopathic Retinal Vasculitis, Aneurysms, and Neuroretinitis-Case Report and Literature Review.

PURPOSE: To review the clinical features, diagnosis, and treatment of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) and to report a case with the use of ultra-widefield fluorescein angiography (UWFA) for confirming the precise staging of IRVAN and aid in early treatment. The patient improved after being treated with intravitreal aflibercept injection. RESULTS: A 26-year-old female complained of progressive blurred vision OD for one week. Her BCVA was 0.6 OD and 1.0 OS. Fundus examination showed vitritis, retinal hemorrhage, and vasculitis over bilateral eyes. Fluorescein angiography (FA) with a 55 degree of view revealed aneurysmal dilations of the peripapillary arteriole, peripapillary focal leakage, venous leakage, and capillary nonperfusion area. Stage 2 IRVAN was impressed OU. Oral prednisolone was administered. After four months, she experienced decreased visual acuity OS. Optical coherence tomography (OCT) revealed subretinal and intraretinal fluid with hyperreflective material. One posterior subtenon triamcinolone and one intravitreal aflibercept injection were performed OS, and macular edema subsided. A 105-degree ultra-widefield fluorescein angiography (UWFA) showed multiple peripheral background hypofluorescence areas corresponding to capillary nonperfusion. Retinal neovascularization (NV) was found OS, which had not been revealed by the previous 55-degree FA. Stage 3 IRVAN was made OS and panretinal laser photocoagulation (PRP) was performed. Oral prednisone and cyclosporine were prescribed. Her vision improved to 1.0 OU. CONCLUSION: UWFA provides visualization of peripheral retinal pathology and for precise staging. It also had direct implications in the follow-up and treatment strategy.

Optical Coherence Tomography Biomarkers in Predicting Treatment Outcomes of Diabetic Macular Edema After Dexamethasone Implants.

Purpose: To identify optical coherence tomography (OCT) biomarkers that may predict functional and anatomical outcomes in diabetic macular edema (DME) patients treated with intravitreal dexamethasone (DEX) implant. Materials and Methods: Sixty-four eyes from 50 patients with DME were enrolled. Best-corrected visual acuity (BCVA) and OCT biomarkers including central retinal thickness (CRT), subretinal fluid (SRF), intraretinal cysts (IRC), ellipsoid zone disruption (EZD), disorganization of retinal inner layers (DRIL), hard exudate (HE), hyperreflective foci (HRF), epiretinal membrane (ERM), and vitreomacular interface (VMI) changes were evaluated at baseline and at 3, 6, and 12 months after treatment. Multiple logistic analysis was performed to evaluate each OCT biomarker as a predictive factor for functional and anatomical improvement at the end of treatment. Results: The presence of SRF at baseline was associated with a favorable outcome, with CRT improving by more than 100 µm after treatment from multivariate logistic regression analysis [odds ratio 6.16 (1.75-21.6)]. In addition, baseline SRF predicted a greater CRT improvement from multiple regression analysis (model R-square 0.11, p = 0.006). The reduction of DRIL, SRF, LONLC, IRC, and EZD were correlated with better CRT improvement (more than 100 µm) (P < 0.05). SRF and EZD recovery can also predict better visual prognosis (P < 0.05). Conclusion: OCT biomarkers can be used to predict who may benefit the most after DEX treatment. We suggest that the DEX implant should be considered as a first line treatment in DME patients with SRF.

Reference Values of Carotid Ultrafast Pulse-Wave Velocity: A Prospective, Multicenter, Population-Based Study.

BACKGROUND: Ultrafast ultrasound imaging has been demonstrated to be an effective method to evaluate carotid stiffness through carotid pulse-wave velocity (PWV) with high reproducibility, but a lack of reference values has precluded its widespread use in clinical practice. The aims of this study were to establish reference values of PWV for ultrafast ultrasound imaging in a prospective, multicenter, population-based cohort study and to investigate the main determinants of carotid PWV. METHODS: A total of 1,544 healthy Han Chinese volunteers (581 men [38%]; age range, 18-95 years) were enrolled from 32 collaborating laboratories in China. The participants were categorized by age, blood pressure (BP), and body mass index (BMI). Basic clinical parameters and carotid PWV at the beginning of systole (BS) and at end-systole (ES) were measured using ultrafast ultrasound imaging techniques. RESULTS: PWV at both BS and ES was significantly higher in the left carotid artery than in the right carotid artery. PWV at BS was significantly higher in men than in women; however, no significant difference was noted in PWV at ES between men and women. Multiple linear regression analyses revealed that age, BP, and BMI were independently correlated with PWV at both BS and ES. PWV at BS and ES progressively increased with increases in age, BP, and BMI. Furthermore, age- and sex-specific reference values of carotid PWV for ultrafast ultrasound imaging were established. CONCLUSIONS: Reference values of carotid PWV for ultrafast ultrasound imaging, stratified by sex and age, were determined for the first time. Age, BP, and BMI were the dominant determinants of carotid PWV for ultrafast ultrasound imaging, which should be considered in clinical practice for assessing arterial stiffness.

The Occurrence Rate of Swallowing Disorders After Stroke Patients in Asia: A PRISMA-Compliant Systematic Review and Meta-Analysis.

BACKGROUND: Swallowing disorders (dysphagia) is common in stroke patients. However, the epidemiology of post-stroke dysphagia (PSD) is poorly described. We herein synthesize the data of eligible studies on occurrence rate of dysphagia in Asian populations with stroke. METHODS: We searched the electronic databases (PubMed, Embase and Web of Science) to collect the studies on the prevalence of PSD. We used the Newcastle-Ottawa Scale (NOS) to estimate the quality of studies. The pooled dysphagia occurrence rate was obtained in Asian stroke patients. RESULTS: 40 studies (including 43 observations) from 2318 initial references were selected in the synthetic analysis. The pooled occurrence rate of dysphagia in post-stroke patients was 36.3% (95% CI, 33.3%-39.3%). Meta-regression analysis showed that the "country" and "developing level" may influence the pooled occurrence rate of PSD. CONCLUSION: Dysphagia is common in Asian post-stroke patients. Our meta-analysis may raise concern about evaluating and managing dysphagia in stroke patients.

Effect of pericardial incision on left ventricular morphology and systolic function in patients during coronary artery bypass grafting.

BACKGROUND: Accurate assessment of left ventricular (LV) systolic function is important after coronary artery bypass grafting (CABG). LV ejection fraction (LVEF) is conventionally used to evaluate LV systolic function; deformation parameters can be used to detect subtle LV systolic dysfunction. It is unclear whether an incised pericardium without sutures during CABG could affect LV morphology and function. We investigated the effect of pericardial incision on LV morphology and systolic function during CABG. METHODS: Intraoperative transesophageal echocardiography was performed in 27 patients during elective off-pump beating heart CABG 5 min before and after pericardial incision. LV longitudinal and mid-cavity transversal diameters, sphericity index, volumes, and LVEF were measured. LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and twist obtained by two-dimensional speckle tracking echocardiography were measured simultaneously. RESULTS: LV mid-cavity transversal diameter increased, while the LV sphericity index decreased (P < 0.001) immediately after pericardial incision. The GLS, GCS, and twist significantly decreased, while the GRS notably increased (P < 0.001). The LV volumes and LVEF remained unchanged. CONCLUSIONS: Pericardial incision immediately transformed LV morphology from an ellipsoid to sphere, with decreased longitudinal and circumferential strain and twist, and increased radial strain, while LVEF remained unchanged. This should be considered when evaluating LV systolic function in patients after CABG.

Effects of intensity of arm training on hemiplegic upper extremity motor recovery in stroke patients: a randomized controlled trial.

OBJECTIVE: To investigate the effects of different intensities of arm rehabilitation training on the functional recovery of hemiplegic upper extremity. DESIGN: A randomized controlled trial. INTERVENTIONS: Thirty-two stroke patients meeting the enrolment criteria were randomly divided into three groups: group A (n = 11), group B (n = 10) and group C (n = 11). Each group received arm training for 1 hour, 2 hours and 3 hours a day respectively, 5 days per week, for a period of six weeks. MAIN MEASURES: Motor function was assessed by Fugl-Meyer Assessment, Action Research Arm Test and Barthel Index, carried out before treatment, two weeks, four weeks and six weeks after treatment. RESULTS: When comparing the three groups, the Fugl-Meyer Assessment improvement was more significant in group C (20.50 ± 7.84) than that in group A (11.90 ± 6.52 ) and group B (13.80 ± 6.41) after four weeks of treatment (P < 0.05). The Action Research Arm Test score improvement was more significant in group C (7.30 ± 2.95) than in group A (3.30 ± 2.91 ) (P < 0.05). After six weeks of treatment, the Fugl-Meyer Assessment and Action Research Arm Test score improvements were more significant in group C (24.50 ± 7.96, 10.90 ± 3.60) and group B (19.70 ± 7.09, 8.70 ± 4.62) than in group A (13.00 ± 6.38, 5.30 ± 3.40) (P < 0.05). There were no significant differences of Barthel Index among the three groups (P > 0.05). In each group, Fugl-Meyer Assessment, Action Research Arm Test and Barthel Index scores increased significantly after six weeks of treatment (P < 0.05). CONCLUSIONS: An increase in the intensity of arm training might improve the motor function of the arm after stroke.

Comparison of conventional therapy, intensive therapy and modified constraint-induced movement therapy to improve upper extremity function after stroke.

OBJECTIVE: To compare the effects of 4 weeks of intervention using conventional rehabilitation, intensive conventional rehabilitation and modified constraint-induced movement therapy on the hemiplegic upper extremity in stroke patients. METHODS: Thirty stroke patients (mean age: 63.3, standard deviation 9.63 years; mean time since stroke: 11.33, standard deviation 8.29 weeks) were randomly divided into 3 groups: conventional rehabilitation, intensive conventional rehabilitation, and modified constraint-induced movement therapy (10 individuals in each). Motor function was assessed using the Wolf Motor Function Test before treatment, and 2 weeks and 4 weeks after treatment. RESULTS: The constraint-induced movement therapy and intensive conventional rehabilitation groups improved their function ability scores in the Wolf Motor Function Test significantly more than the conventional rehabilitation group after 2 weeks of treatment (p < 0.05), but all groups reached comparable levels at the end of 4 weeks of intervention. However, only the constraint-induced movement therapy intervention proved to have robust and systematic effects on the function ability scores, as revealed by the large, positive and significant correlation between the initial scores and the scores 2 and 4 weeks after the intervention. The median performance time of the Wolf Motor Function Test decreased significantly in all groups after 4 weeks of treatment (p < 0.05), but only the modified constraint-induced movement therapy group showed significant improvements both 2 and 4 weeks after the initiation of treatment. CONCLUSION: Compared with classical intervention, modified constraint-induced movement therapy showed an apparent advantage over both conventional intervention and intensive conventional rehabilitation for patients after stroke.