Perception of Canadian ophthalmologists on immediately sequential bilateral cataract surgery: insights and implications.

OBJECTIVE: To evaluate the perception of immediately sequential bilateral cataract surgery (ISBCS) among Canadian ophthalmologists. DESIGN: An anonymous survey was sent to all active members of the Canadian Ophthalmological Society. METHODS: Basic demographic information, cataract surgery practice patterns, and perceived advantages, disadvantages, and concerns regarding ISBCS were collected from respondents. RESULTS: A total of 352 ophthalmologists answered the survey. Among these, 94 respondents (27%) practice ISBCS routinely, 123 (35%) practice ISBCS in exceptional cases, and 131 (37%) do not practice ISBCS. ISBCS practitioners were significantly younger than nonpractitioners (p < 0.001) and had a shorter duration of practice (p < 0.001). The prevalence of ISBCS practitioners also varied significantly by province (p < 0.001): most practitioners who routinely practice ISBCS were from Quebec (n = 44; 48%), where financial disincentives are lowest in the country. The main work setting of ISBCS practitioners was academic centres (n = 39; 42%) as opposed to private or community settings (p < 0.001). The main reason for performing ISBCS was more efficient operating theatre use (n = 142; 65%). The main concerns regarding ISBCS were the risk of bilateral complications (n = 193; 57%) and the lack of refractive outcomes for second-eye surgery (n = 184; 52%). The COVID-19 pandemic positively influenced the view of 152 respondents (43%), but this was mostly among practitioners who already performed ISBCS routinely (n = 77; 84%). CONCLUSIONS: ISBCS practitioners are more likely younger ophthalmologists working in academic centres. Quebec has the highest prevalence of ISBCS practitioners. ISBCS practitioners were positively influenced by the COVID-19 pandemic to offer ISBCS more often compared with non-ISBCS practitioners.

Perception of visual outcomes in patients after delayed compared with immediately sequential bilateral cataract surgery.

PURPOSE: To evaluate patient-reported visual outcomes of immediately sequential bilateral cataract surgery (ISBCS) compared with delayed sequential bilateral cataract surgery (DSBCS). SETTING: Tertiary university teaching hospital of Laval University, Quebec City, Canada. DESIGN: Prospective observational cohort study. METHODS: The Catquest-9SF questionnaire was administered on the day of surgery for ISBCS patients and on the day of first-eye surgery for DSBCS patients who underwent cataract surgery between August and September 2021. The questionnaire was administered again 1 month postoperatively for ISBCS patients and 1 month postoperatively after each surgery for DSBCS patients. RESULTS: 186 patients (ISBCS: n = 152 vs DSBCS: n = 34) were included. At 1 month postoperatively, the Catquest-9SF score of ISBCS patients was significantly lower than that of DSBCS patients after first-eye surgery ( P < .001). Furthermore, the ISBCS group achieved significantly better scores on multiple tasks of the Catquest-9SF, such as reading text in the newspaper ( P < .001) or reading text on television ( P < .001). In multiple linear regression analysis, the type of surgery was the factor most associated with a lower Catquest-9SF score (ß = -0.391, P < .001). 1 month after the second-eye surgery, DSBCS patients had achieved similar Catquest-9SF scores compared with ISBCS patients. CONCLUSIONS: Compared with DSBCS patients, ISBCS patients had significantly greater perceived visual function and fewer vision-related limitations in their daily activities at 1 month postoperatively. This difference lost significance 1 month after the second-eye surgery of DSBCS patients. This patient-reported outcome study did not find evidence of perceived bilateral visual impairment in the early postoperative period after ISBCS.

Characterising the chronicity of dupilumab-associated ocular surface disease: an analysis of a retrospective case series.

BACKGROUND/AIMS: To describe the clinical presentation and treatment response of dupilumab-associated ocular surface disease (DAOSD). METHODS: This is a retrospective case series of atopic dermatitis patients with DAOSD treated with dupilumab. All consecutive patients with atopic dermatitis referred by dermatologists for suspicion of DAOSD between May 2018 and June 2020 were systemically assessed by a single ophthalmologist. Presenting signs of DAOSD, duration of treatment and associated response are described. RESULTS: Twenty-eight patients had DAOSD during the study period. Average age was 45.6±14.8 years and 13 (46%) were female. Average follow-up was 15±10 months. Most presentations consisted in diffuse, inflammatory conjunctivitis (n=19, 68%). Other signs included peripheral corneal infiltrates (n=7, 25%), limbal nodules (n=7, 25%) and dry eye syndrome (n=6, 21%). To control ocular symptoms, tapering of corticosteroid eyedrops was slow: taper duration of strong and mild corticosteroid eyedrops averaged 10±8 weeks and 49±34 weeks, respectively. Four patients (14%) required an increase of corticosteroid eyedrops during taper due to clinical deterioration. Corticosteroid eyedrops were still required at final follow-up among 10 patients (36%). Dupilumab was temporarily stopped in 3 patients (11%), one of which did not wish to resume dupilumab for unrelated reasons. Symptomatic improvement and/or complete resolution was achieved in 25/26 patients at follow-up (96%) with empirical treatment. CONCLUSIONS: DAOSD may follow the course of a chronic illness. Long-term corticosteroid eyedrops were required in many patients and when taper was possible, this was done after a prolonged treatment duration. Most patients' ocular symptoms could be controlled, allowing dupilumab continuation.

Northern Ontario's Obstetrical Services in 2020: A developing rural maternity care desert.

Introduction: Rural maternity care services matter. Obstetrical care in rural Canada has seen concerning trends of service closures and decreasing numbers of family physicians who predominantly provide this service. Such reductions have been shown to have a serious impact on maternal/foetal well-being. Methods: This study investigated the present state of obstetrical services in Northern Ontario, comparing results to those of the last similar survey in 1999. All 40 Northern Ontario communities with hospitals were surveyed, as were the 16 midwife practices in the region. Results: : Of the 35 rural and 5 urban hospitals surveyed, the number not offering obstetrical care has risen from 37.5% in 1999 to 60% in 2020, with all the closures having been rural sites. There have been no re-openings of obstetrics in hospitals that did not offer obstetrics in 1999. Women in the 9 communities that had offered maternity services in 1999, but no longer do in 2020, now travel an average of over 1.5 h to access these services. In those communities that continue obstetrics, but stopped offering caesarean sections, women now travel 2.5 h for this surgery. Although the total number of general physicians remains at the 1999 level, the number offering intrapartum care has dropped by 65% in urban centres and by 49% in rural ones still providing maternity care. Conclusions: Like much of the rural United States, rural Northern Ontario is well on its way to becoming a maternity care desert. As proven in Southern Australia, supportive government policies and programmes should be established and education reform enacted to reverse this concerning trend.

Résumé Introduction: Les services de maternité en région rurale comptent. On observe une tendance préoccupante de fermeture des services d'obstétriques et de réduction du nombre de médecins de famille qui offrent surtout des soins obstétriques dans les régions rurales du Canada. Ces réductions ont montré avoir un impact grave sur le bien-être de la mère et du fœtus. Méthodes: Cette étude s'est penchée sur l'état actuel des services d'obstétriques au nord de l'Ontario, et a comparé ses résultats à ceux de la dernière enquête semblable réalisée en 1999. Les 40 communautés du nord de l'Ontario dotées d'un hôpital ont été incluses dans l'enquête, tout comme les 16 pratiques de sages-femmes de la région. Résultats: Sur les 35 hôpitaux ruraux et les 5 hôpitaux urbains interrogés, le nombre qui n'offrait pas de soins obstétriques est passé de 37,5 % en 1999 à 60 % en 2020, et toutes les fermetures ont eu lieu dans des centres ruraux. Aucun hôpital sans soins obstétriques en 1999 n'avait ouvert un service en 2020. Les femmes des 9 communautés qui offraient des services de maternité en 1999, mais pas en 2020, doivent maintenant faire 1,5 heure de route en moyenne pour accéder à ces services. Dans les communautés qui offrent toujours des services d'obstétrique, mais ne réalisent plus de césariennes, les femmes doivent maintenant faire 2,5 heures de route pour recevoir cette intervention. Même si le nombre total de généralistes demeure le même qu'en 1999, le nombre qui offre des soins périnataux a chuté de 65 % dans les centres urbains et de 49 % dans les centres ruraux qui offrent toujours des soins de maternité. Conclusion: Tout comme dans la majorité des régions rurales des États-Unis, les soins de maternité dans les régions rurales du nord de l'Ontario brilleront sous peu par leur absence. Comme l'a démontré le sud de l'Australie, des politiques et programmes de soutien gouvernemental doivent être mis sur pied et une réforme de l'éducation doit être mise de l'avant pour inverser cette tendance préoccupante. Mots-clés: Soins primaires, première ligne, sage-femme, obstétriques et gynécologie, recherche axée sur les patients, santé et médecine rurale.

Study of a new device for washing and concentrating cryopreserved hematopoietic stem cells and mononuclear cells: a single center experience.

BACKGROUND AIMS: Cryopreserved cellular products, as parts of hematopoietic progenitor cell (HPC) transplants, mononuclear cell reinjections for donor lymphocyte infusion or extracorporeal photopheresis, can be washed before being reinjected into the patient or infused directly, depending on local practices. The aim of washing is to reduce the incidence and severity of adverse reactions (ARs) due to the dimethyl sulfoxide (DMSO) used as a cryoprotective agent and other factors, such as dead cell debris. At the authors' cell therapy laboratory (CTL) in Poitiers, France, as in 76% of Etablissement Français du Sang (EFS) CTLs, all cryopreserved products undergo thawing in a water bath followed by washing with the COBE 2991. As this device will soon cease to be available, an alternative process needs to be assessed. METHODS: The authors compared two closed systems: the authors' semi-automatic system using the traditional centrifugation method (COBE 2991) and an automated device using spinning membrane filtration (Lovo). A total of 72 HPC bags available for research were used. The authors first performed a paired comparison, processing one or two HPC bags washed by each device. A second study was carried out to compare two different washing solutions generally used by EFS CTLs along with variable storage conditions. Finally, the authors studied the efficiency of the Lovo with three or four thawed bags. The main parameters studied were viable CD34+ cell recovery and viability, CD3+ cell recovery, stability up to 6 h after washing, DMSO elimination and center feasibility. RESULTS: The Lovo device showed better CD34+ cell recovery compared with the COBE 2991 while maintaining CD34+ viability and stability over 6 h. Moreover, Lovo efficiency seemed to be independent of the number of thawed bags processed and washing solution used in the authors' study. CD3+ cell recovery met the authors' internal specifications (cell recovery >50%), with similar results seen when processing with either the COBE 2991 or Lovo. Additionally, on average, 97% of DMSO was removed after washing with Lovo, minimizing the risk of ARs. The storage conditions post-processing indicated preferred storage conditions of 7 ± 3°C. Finally, if processing time seemed shorter using COBE 2991 for one bag washed, the Lovo device required only one staff member regardless of the number of HPC bags processed. CONCLUSIONS: The Lovo device seems to provide an opportunity to standardize HPC processing, ensuring patient safety, with, on average, 97% of DMSO removed, while improving recovery of cells of interest and maintaining viability over time in case of delayed transplant. The Lovo device consequently seems to be a serious alternative to the COBE 2991.

Immediately sequential bilateral cataract surgery: an academic teaching center's experience.

PURPOSE: To evaluate the safety and outcomes of immediately sequential bilateral cataract surgery (ISBCS) at a Canadian academic teaching center. SETTING: Tertiary university teaching hospital of Laval University, Quebec City, Canada. DESIGN: Retrospective cohort study. METHODS: 2003 consecutive patients (4006 eyes) who underwent ISBCS under topical anesthesia from January 2019 to December 2019 were included. All charts were retrospectively reviewed. Outcome measures included intraoperative and postoperative complications, postoperative uncorrected distance (UCVA) and pinhole (PHVA) visual acuities, and autorefraction measurements. RESULTS: 4006 eyes from 1218 (60.8%) female and 785 (39.2%) male patients with a mean age of 74 ± 8 years had a mean preoperative visual acuity of 0.503 logMAR (Snellen 20/63). The mean axial length was 23.53 ± 1.37 mm. Most eyes had monofocal intraocular lenses (IOLs) implanted (n = 3738, 93.3%) followed by toric (n = 226, 5.6%), multifocal (n = 25, 0.6%), and multifocal toric (n = 17, 0.4%) IOLs. Intraoperative complications included 14 (0.3%) posterior capsule ruptures with 5 (0.1%) requiring sulcus IOL placement, and 7 (0.2%) partial zonulysis, with 3 requiring capsular tension rings (0.07%). There were no cases of endophthalmitis or toxic anterior segment syndrome. Mean 5-week postoperative UCVA was 0.223 (Snellen 20/33), PHVA was 0.153 (Snellen 20/28) with a mean spherical equivalent of -0.21 diopters. CONCLUSIONS: ISBCS performed following International Society of Bilateral Cataract Surgeons recommended guidelines is a safe procedure. This cohort of 4006 eyes had very few complications, with none attributable to the surgery being done bilaterally. The UCVA, PHVA, and refractive outcomes were good.

The role of novel DMEK graft shapes in facilitating intraoperative unscrolling.

PURPOSE: To evaluate whether the preparation of Descemet membrane endothelial keratoplasty (DMEK) grafts into various shapes affect their propensity to scroll as compared with the conventional circular graft design. METHODS: Prospective randomized laboratory-based study, using nine pre-stripped DMEK corneal grafts unfit for transplantation. Each graft was trephinated into a standard circular 8-mm shape, stained with trypan blue, and then immersed in balanced salt solution (BSS). The width of the DMEK graft scroll was measured, and photographs were obtained. The graft was then cut into one of three pre-selected shapes (four peripheral punches, four radial cuts, Maltese cross). These newly shaped grafts were then replaced in BSS and again photographed. The scroll widths, as well as pre- and post-preparation scroll width-to-height ratios, were calculated and compared. RESULTS: Nine pre-stripped DMEK corneal grafts (mean donor age ± SD 73.1 ± 9.3 years, range 58-85 years) were included. The mean pre-cut scroll widths for the three selected shapes were statistically similar. Following graft preparation into their assigned shapes, the mean post-preparation scroll widths (and corresponding change from pre-preparation measurements) were 1.73 ± 0.16 mm (- 3.6%) for the 4-peripheral punches, 2.59 ± 0.35 mm (+ 0.2%) for the 4-radial cuts and 4.13 ± 0.63 mm (+ 20.1%) for the Maltese cross (P = 0.0013). Therefore, the Maltese cross design resulted in a wider scroll than its pre-preparation control. CONCLUSIONS: Certain DMEK graft shapes may be less prone to scrolling than others. The Maltese cross graft design scrolled less tightly than the other experimental graft shapes. Future studies may elucidate intraoperative scrolling behavior of these DMEK graft shapes within the anterior chamber.

Pre-clinical assessment of the Lovo device for dimethyl sulfoxide removal and cell concentration in thawed hematopoietic progenitor cell grafts.

BACKGROUND: Cryopreserved hematopoietic progenitor cell (HPC) grafts are widely infused to patients with malignant and nonmalignant conditions. Despite reduction of immediate side effects linked to dimethyl sulfoxide (DMSO), cell debris-containing grafts and comparable hematopoietic engraftment between washed and unwashed cryopreserved products, bedside infusion of thawed HPC grafts is still preferred. Introduction of automated devices is important for standardization and consistency of graft manipulation. Additionally, these techniques are likely to be useful for the delivery of innovative cell-based medicinal products that are currently under development. METHODS: In this study, we evaluated three consecutive versions of the Lovo device (Fresenius Kabi) for automated washing of thawed HPC products. A total of 42 HPC products intended for destruction were used. Measured outcomes included viable CD34+ cell recovery, viability, total processing time and post-washing stability. RESULTS: Preliminary data using the prototype Lovo 0.0 to process a single HPC unit showed better recovery and viability of CD34+ cells using a two-cycle than a three-cycle wash, with >95% DMSO elimination. The Lovo 1.0 performed equally well. When simultaneously processing two HPC units, the upgraded Lovo 2.0 device demonstrated comparable CD34+ recovery, DMSO elimination efficiencies and time-saving capacity. Furthermore, washed cell products were stable for 4 hours at room temperature. DISCUSSION: Lovo device satisfies clinically relevant issues: ability to efficiently wash two HPC units simultaneously and compatibility with transport to nearby transplantation centers.

Breeding new forms of life: a critical reflection on extreme variances of bareback sex.

Many men who have sex with men (MSM) express feeling marginalized by discourses within public health and sexual health nursing that determine bareback sex is deviant and unsafe. Their resistance to risk-based discourses can be seen within radical sex practices such as deliberately becoming-infected with HIV (bug-chasing) and breeding-infection (gift-giving). The metaphors of bug-chasing and gift-giving, particularly those spread across global online spaces, can influence the sexual experiences and practices of MSM. A metaphor analysis was conducted of Internet forums discussing HIV chasing and gifting metaphors, and showed a variety of discursive meanings, tactics and effects to the radical sex practice. A radical research approach was used to explore the processes of becoming-infected and breeding-infection as determinant steps in the symbolic resistance of risk-based discourses, as well as the creation of new forms of life and community among MSM. Our analyses demonstrate how the gifting/chasing metaphors express MSM's marginalization as well as their lines of flight from having their practices captured within public health discourses. We hope to offer alternative nursing approaches for thinking through and engaging with transgressive and queer sexual practices.