Gelation and thermal characteristics of microwave extracted fish gelatin-natural gum composite gels.

In this study, the gelation and thermal characteristics of microwave extracted fish scale gelatin blended with natural gums such as gum arabic (AG), xanthan gum (XG), guar gum (GG), and tragacanth gum (TG) was evaluated. The nature of interaction and behavior of gelatin in presence of various gums was confirmed by particle size analysis, viscosity profile, FT-IR analysis and turbidity measurements. DSC data revealed that addition of AG, TG and GG remarkably improved the thermal stability of fish gelatin gel. The composite gels of TG, AG, and XG exhibited higher hardness and bloom strength values as compared to pure fish gelatin implying its textural synergy. Based on qualitative descriptive analysis, TG was found to be superior in improving the stability of fish gelatin gel, closely followed by AG. The results suggest that addition of these gums can reduce syneresis and retard melting of gelatin gels at ambient temperature, which are otherwise soft and thermally unstable.

Structural and oxidative stabilization of spray dried fish oil microencapsulates with gum arabic and sage polyphenols: Characterization and release kinetics.

The synergistic efficacy of gum arabic and sage polyphenols in stabilising capsule wall and protecting fish oil encapsulates from heat induced disruption and oxidative deterioration during spray drying was assessed. The emulsions prepared with sodium caseinate as wall polymer, gum arabic as wall co-polymer and sage extract as wall stabiliser was spray dried using a single fluid nozzle. Fish oil encapsulates stabilised with gum arabic and sage extract (SOE) exhibited significantly higher encapsulation efficiency compared to encapsulates containing gum arabic alone (FOE). Scanning electron microscopic and atomic force microscopic images revealed uniform encapsulates with good sphericity and smooth surface for SOE, compared to FOE powder. In vitro oil release of microencapsulates indicated negligible oil release in buffered saline whereas more than 80% of the oil loaded in encapsulates were released in simulated GI fluids. The encapsulates containing sage extract showed a lower rate of lipid oxidation during storage.

Comparative evaluation of gum arabic coating and vacuum packaging on chilled storage characteristics of Indian mackerel (Rastrelliger kanagurta).

The effect of edible coating using gum arabic on biochemical, microbiological, textural and sensory characteristics of fresh gutted mackerel stored at 4 °C was investigated. The results were further compared against the samples packed under vacuum (VP) and conventional polyethylene pouches (CP). Coating with gum arabic (GC) markedly retarded lipid oxidation process in gutted mackerel compared to VP and CP samples. Moreover, VP and CP samples showed higher degree of textural deterioration compared to GC samples. Microbiologically, the shelf life of chilled gutted Indian mackerel was estimated to be 7-8, 17 and 19-20 days for CP, GC and VP samples, respectively. The sensory analysis scores confirmed the efficacy of gum coating in retarding the spoilage process during chilled storage. The current study identifies the potential of edible coating with gum arabic to improve the overall quality of Indian mackerel and extend its storage life during chilled storage.

Postoperative management of trabeculectomy and glaucoma drainage implant surgery.

PURPOSE OF REVIEW: This article describes important aspects of postoperative management after trabeculectomy and glaucoma drainage implant surgery. RECENT FINDINGS: Postoperative management of glaucoma drainage implant surgery includes stabilization of intraocular pressure, possible ligature release, and management of complications such as corneal edema, and tube/plate exposure. Postoperative management of trabeculectomy includes evaluation of bleb encapsulation, management of hypotony, and assessment of need for adjuvant therapy. Recent advances in surgical techniques, device/tissue availability, and imaging continue to shape the postoperative course. SUMMARY: Careful preoperative planning and postoperative care may decrease the likelihood of complications in tube surgery or trabeculectomy.

Neurosurgical intervention in patients with mild traumatic brain injury and its effect on neurological outcomes.

OBJECTIVE: The object of this study was to determine the mortality and neurological outcome of patients with mild traumatic brain injury (mTBI) who require neurosurgical intervention (NSI), identify clinical predictors of a poor outcome, and investigate the effect of failed nonoperative management and delayed NSI on outcome. METHODS: A cross-sectional study of 10 years was performed, capturing all adults with mTBI and NSI. Primary outcome variables were mortality and Glasgow Outcome Scale (GOS) score. Patients were divided into an immediate intervention group, which received an NSI after the initial cranial CT scan, and a delayed intervention group, which had failed nonoperative management and received an NSI after 2 or more cranial CT scans. RESULTS: The mortality rate in mTBI patients requiring NSI was 13%, and the mean GOS score was 3.6 ± 1.2. An age > 60 years was independently predictive of a worse outcome, and epidural hematoma was independently predictive of a good outcome. Logistic regression analysis using independent variables was calculated to create a model for predicting poor neurological outcomes in patients with mTBI undergoing NSI and had 74.1% accuracy. Patients in the delayed intervention group had worse mortality (25% vs 9%) and worse mean GOS scores (2.9 ± 1.3 vs 3.7 ± 1.2) than those in the immediate intervention group. CONCLUSIONS: Data in this study demonstrate that patients with mTBI requiring NSI have higher mortality rates and worse neurological outcomes and should therefore be classified separately from mTBI patients not requiring NSI. Additionally, mTBI patients requiring NSI after the failure of nonoperative management have worse outcomes than those receiving immediate intervention and should be considered separately.

Relationships Between Measures of the Ability to Perform Vision-Related Activities, Vision-Related Quality of Life, and Clinical Findings in Patients With Glaucoma.

IMPORTANCE: To our knowledge, few studies have combined an objective measure of vision-related performance (VRP) and subjective measures of vision-related quality of life (VRQoL) with clinically related visual parameters, particularly in a large, prospective, cohort study setting. OBJECTIVE: To examine the relationships between clinical visual assessments and both a VRP and 2 self-reported VRQoL measurements. DESIGN, SETTING, AND PARTICIPANTS: Patients (N = 161) with moderate-stage glaucoma recruited from the Glaucoma Service at Wills Eye Hospital, Philadelphia, Pennsylvania, were enrolled from May 2012 to May 2014 in an ongoing prospective, 4-year longitudinal observational study. This report includes cross-sectional results from the baseline visit. Patients received a complete ocular examination, automated visual field (VF) test and Cirrus optical coherence tomographic scan. Contrast sensitivity was measured with the Pelli-Robson and the Spaeth-Richman Contrast Sensitivity (SPARCS) tests. Vision-related performance was assessed by the Compressed Assessment of Ability Related to Vision (CAARV) test. Vision-related QoL was assessed by the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25) and a modified Glaucoma Symptom Scale (MGSS). MAIN OUTCOMES AND MEASURES: Correlations between clinical measures and CAARV, NEI-VFQ-25, and MGSS scores. RESULTS: A total of 161 patients were enrolled in the study. The strongest correlation was found between SPARCS score in the better eye and total CAARV score (r = 0.398; 95% CI, 0.235-0.537; P < .001). The CAARV score also correlated with the Pelli-Robson score (r = 0.353; 95% CI, 0.186-0.499; P = .001), VF mean deviation (r = 0.366; 95% CI, 0.200-0.510; P < .001), and VA (r = -0.326, 95% CI = -0.476 to -0.157; P = .003) in the better eye. There were more statistically significant correlations between contrast sensitivity tests and VF mean deviation with VRQoL measurements than with other clinical measures (visual acuity, intraocular pressure, Disc Damage Likelihood Scale, and mean retinal nerve fiber layer thickness). The MGSS scores were lower (worse) in women compared with men (P = .03 for binocular, P = .01 for better eye, and P = .05 for the worse eye). Structural measures (eg, Disc Damage Likelihood Scale, and retinal nerve fiber layer thickness) were generally not informative with respect to VRP or VRQoL. CONCLUSIONS AND RELEVANCE: Contrast sensitivity tests and VF mean deviation were associated with both objective measures of the ability to act and subjective measurements of VRQoL. The strongest correlation was between SPARCS score (contrast sensitivity) in the better eye and total CAARV score. Therefore, measurement of contrast sensitivity should be considered when evaluating patients' VRQoL. The results of this study were limited by the patient population and apply only within the bounds of the tested cohort.

The Use of Ozurdex (Dexamethasone Intravitreal Implant) During Anterior Segment Surgery in Patients with Chronic Recurrent Uveitis.

PURPOSE: To describe the outcomes of concurrent Ozurdex implantation during anterior segment surgery in patients with chronic recurrent uveitis. METHODS: Retrospective chart review. Data recorded from preoperative and 1-, 3-, and 6-month postoperative visits included visual acuity, intraocular pressure (IOP), medications, and clinical examination findings of inflammation. RESULTS: Twelve patients (12 eyes) with chronic, recurrent noninfectious uveitis undergoing cataract extraction (n=9) or intraocular lens (IOL) explantation (n=3) were included. Mean duration of follow-up after Ozurdex implantation was 12.9 months. There was a significant reduction (n=10, P=0.02) in the average number of inflammation recurrences 6 months before surgery compared to 6 months after surgery with Ozurdex in affected eyes. IOP remained stable in the postoperative period. One patient undergoing anterior chamber IOL (ACIOL) explantation experienced migration of Ozurdex into the anterior chamber resulting in corneal edema that resolved after 1 month. CONCLUSIONS: Ozurdex safely and effectively controlled postoperative inflammation in eyes with chronic recurrent uveitis when concurrently implanted during anterior segment surgery in our patients. Caution should be exercised in cases of IOL explantation, as Ozurdex use is now contraindicated in eyes with posterior capsule rupture and ACIOLs.

Effect of age and disc size on rim order rules by Heidelberg Retina Tomograph.

PURPOSE: The ISNT rule for nonglaucomatous eyes suggests that the neuroretinal rim is thickest at the inferior quadrant (I), followed by the superior (S), nasal (N), and temporal (T) quadrants. This study aimed to use Heidelberg Retina Tomograph (HRT III) measurements to assess (a) fulfillment of the ISNT rule and its derivatives in a large normative database and (b) effect of disc size and age on rule fulfillment. PATIENTS AND METHODS: A multicenter, prospective, cross-sectional study of a Caucasian normative database consisting of 280 subjects with normal comprehensive biomicroscopic examination, intraocular pressure <21 mm Hg, and normal automated visual field testing was conducted. Right eye neuroretinal rim and disc area, measured by HRT III, for each of the 4 quadrants were analyzed. Compliance of the rim area to the ISNT rule (I≥S≥N≥T) and its derivates was determined. Effect of age and disc area on rule compliance was further determined. RESULTS: Only 18% of normal eyes had rim areas that complied with the ISNT rule; however, a majority complied to IS (77%) and IST (73%) rules. The temporal quadrant had the smallest rim area [(I,S,N)>T] in 91% of patients. The likelihood of ISNT rule violation was increased in larger discs (χ², P=0.003) but was not affected by age. CONCLUSIONS: The ISNT rule does not apply to neuroretinal rim area as measured by HRT, as only 18% of the eyes complied with the ISNT rule in this normative database. Although the ISNT rule may be more applicable to normal eyes with a smaller disc area, the IS and IST rules seem to better represent the normative database.

Feasibility of Spectral Domain Optical Coherence Tomography Acquisition Using a Handheld Versus Conventional Tabletop Unit.

PURPOSE: Patients afflicted with ocular complications of diabetes represent a diverse demographic who often cannot undergo spectral-domain optical coherence tomography (SD-OCT) imaging of the retina due to postural restraints. Our pilot study compared imaging acquisition methods using SD-OCT in the handheld (HH) mode versus the conventional tabletop (TT) method. METHODS: Our study included 22 undilated eyes of 22 subjects (mean ± SD age, 35.8 ± 16.8 years) imaged using HH and TT iVue SD-OCT (Optovue, Fremont, CA). Statistical analysis was performed using Microsoft Excel 12.2.7 (Microsoft Corporation, Redmond, WA) software with an accepted significance of P < .05. RESULTS: Strong intraclass correlation coefficient was observed for (1) overall (.97), superior (.93), and inferior (.94) ganglion cell complex thickness, and (2) central (.98), inferior (.90), superior (.92), nasal (.94), and temporal (.93) macular retinal thickness. Mean scan quality index was adequate but lower in HH versus TT SD-OCT (62.8 vs 68.1, respectively; P < .0001). Multiple attempts for adequate imaging were required more frequently in HH versus TT SD-OCT (34% vs 5%, respectively; P < .001). CONCLUSION: HH SD-OCT may be a feasible alternative to TT SD-OCT in select situations, especially in patients suffering from diabetic complications with limited mobility.

Topical Cyclosporine A 1% for the Treatment of Chronic Follicular Conjunctivitis.

OBJECTIVE: To evaluate the use of topical cyclosporine A (CSA) 1% in the treatment of chronic follicular conjunctivitis (CFC). METHODS: Retrospective chart review from 2001 to 2012 identified 12 patients (22 eyes) with CFC (mean ± standard deviation [SD] age, 50.2 ± 15.4 years; 75% female; 92% white) treated with CSA. Main outcome measures included inflammation grade, visual acuity, concurrent corticosteroid (CS) therapy, effect on CS taper, and adverse effects. RESULTS: Mean ± SD follow-up time was 11.7 ± 9.7 months. Mean ± SD time from diagnosis to CSA treatment initiation was 2.4 ± 3.2 months. Mean ± SD duration of CSA treatment was 5.8 ± 2.8 months. Four patients (33%) complained of irritation (n = 2), redness (n = 1), itching (n = 1), and burning (n = 1) but none discontinued treatment. Concurrent CSs were tapered off in all patients after a mean ± SD of 5.0 ± 2.5 weeks. Mean ± SD initial vision was 0.078 ± 0.093 logMAR, whereas vision at final examination was 0.056 ± 0.081 logMAR (P = 0.02). Mean ± SD initial inflammation grade of 1.9 ± 1.0 was significantly reduced to final grade of 0.7 ± 0.9 (P = 0.0002). Mean ± SD time to initial inflammation control in 9 patients (75%) was 33.2 ± 24.5 days. Two patients (17%) switched to oral CSA because of lack of inflammation control. CONCLUSIONS: Topical CSA 1% is an effective and well-tolerated therapy that decreased chronic inflammation and tapered topical CS in patients with CFC. The use of CSA in such patients warrants further investigation.

Topical cyclosporine a 1% for the treatment of chronic ocular surface inflammation.

OBJECTIVE: To evaluate the use of topical cyclosporine A (CsA) 1% emulsion in the treatment of chronic ocular surface inflammation (OSI). METHODS: We conducted a retrospective chart review of patients with various forms of OSI treated with topical CsA 1% from 2001 to 2012. RESULTS: Twenty-nine patients (52 eyes) with various forms of OSI, including epidemic keratoconjunctivitis (n=14), chronic follicular conjunctivitis (n=12), Thygeson superficial punctate keratopathy (n=2), and vernal keratoconjunctivitis (n=1), were included. Twenty-seven patients had inflammation refractory to prior therapies. Twenty-four patients received concurrent medications with CsA 1%. Twenty-three of 24 patients on concurrent corticosteroids (CS) were able to taper their use while receiving CsA 1%. Thirteen patients experienced ocular discomfort with CsA 1%; one patient discontinued therapy all together as a result of these side effects; another switched to CsA 0.5% with improvement of adverse symptoms. Inflammation was controlled in 22 (92%) of the 24 patients who received CsA 1% for at least 2 months in duration. CONCLUSION: Topical CsA 1% helps to control inflammation and spares CS use in patients with chronic OSI.

Feasibility of retinal screening in a pediatric population with type 1 diabetes mellitus.

PURPOSE: To study the feasibility of using a nonmydriatic camera to screen children with type 1 diabetes mellitus (DM1) as young as 2 years for diabetic retinopathy. METHODS: Prospective pilot imaging study involving children with DM1 aged 2 to 17 years. The screening consisted of: (1) intake form; (2) measurement of blood pressure, pulse, and oximetry; (3) assessment of visual acuity (SIMAV, Padova, Italy); and (4) nonmydriatic color imaging (Canon CX-1 45° 15.1 megapixel camera; Canon Corp., Tokyo, Japan). Images were assessed for signs of diabetic retinopathy and graded for quality on a scale of 1 to 5 by two clinicians. Kappa coefficient was calculated to determine inter-observer agreement. RESULTS: One hundred four of 106 (98%) children underwent imaging (mean age: 11.1 years, 51% male, 88% white). One (1%) child had nonproliferative diabetic retinopathy and 2 (1.9%) had incidental findings. Only 62% of children had an eye examination within the past year, with children with DM1 for more than 5 years significantly more likely to have done so (P = .03). Children who had an eye examination within the past year were significantly older than their counterparts (P = .01). Images of high quality (grades 4 and 5) were acquired in 178 (86%) eyes, and images of some clinical value (grades ≥ 2) were obtained in 207 (99.5%) eyes. Inter-observer agreement for image quality was 0.896. CONCLUSIONS: The feasibility of using a nonmydriatic camera to screen children as young as 2 years for changes related to diabetic eye disease was demonstrated. Nonmydriatic imaging may supplement standard dilated clinical ophthalmology examinations for select patient populations.

Periocular sebaceous cell carcinoma following chemical burn: a unique case of a Marjolin ulcer.

This study reports a unique case of a Marjolin ulcer in a patient who presented with periocular sebaceous cell carcinoma 16 years after a lye chemical burn. A 68-year-old woman presented with a long history of irregular and tender right upper and lower eyelid margins, periocular erythema, madarosis, trichiasis, ptosis, and chemosis, occurring many years after chemical burn to the area. After eyelid biopsy established the diagnosis of sebaceous cell carcinoma, subsequent map biopsies of the conjunctival surface revealed extensive sebaceous cell carcinoma with pagetoid spread, necessitating anterior exenteration for definitive treatment. This report describes the first case in which a sebaceous cell carcinoma has arisen in the area of a chemical burn. Sebaceous cell carcinomas should be included in the spectrum of Marjolin ulcers, and ophthalmologists should be aware of this entity when evaluating patients with a history of a burn to the eyelids.

Postirradiation periocular granuloma faciale associated with uveitis.

Granuloma faciale is a rare dermatopathologic condition that presents as brown-red plaques, nodules, or papules primarily on the face, with the potential for extrafacial and mucous membrane involvement. A case of an 83-year-old woman with periocular granuloma faciale accompanied by a marked anterior uveitis is presented; an association of periocular granuloma faciale with anterior uveitis has not been previously reported.

Complimentary imaging technologies in blunt ocular trauma.

We describe complimentary imaging technologies in traumatic chorioretinal injury. Color and fundus autofluorescence (FAF) images were obtained with a non-mydriatic retinal camera. Optical coherence tomography (OCT) helped obtain detailed images of retinal structure. Microperimetry was used to evaluate the visual function. A 40-year-old man sustained blunt ocular trauma with a stone. Color fundus image showed a large chorioretinal scar in the macula. Software filters allowed detailed illustration of extensive macular fibrosis. A 58-year-old man presented with blunt force trauma with a tennis ball. Color fundus imaging showed a crescentric area of macular choroidal rupture with fibrosis. FAF imaging delineated an area of hypofluorescence greater on fundus imaging. OCT showed chorioretinal atrophy in the macula. Microperimetry delineated an absolute scotoma with no response to maximal stimuli. Fundus imaging with digital filters and FAF illustrated the full extent of chorioretinal injury, while OCT and microperimetry corroborated the structure and function correlations.

Neurologic outcome of minimal head injury patients managed with or without a routine repeat head computed tomography.

BACKGROUND: Previous studies proposed that routine repeat head computed tomography (RHCT) is of little value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). As of 2003, routine RHCT in these MHI patients was ordered at the discretion of the attending physician. The goal of this study was to compare the neurologic outcomes of MHI patients with an intracranial bleed and a normal NE who were managed with or without a routine RHCT. METHODS: A retrospective chart review of adult patients with MHI presenting to a Level I trauma center from August 2003 to December 2008 was performed. Demographics, injury severity, and HCT findings were collected for patients managed with or without a routine RHCT. Outcome measures included delayed neurologic deterioration, neurosurgical interventions, Glasgow Outcome Scale, and hospital length of stay (LOS). RESULTS: A total of 321 MHI patients with an intracranial bleed had a normal NE 24 hours after presentation. There were no significant differences in demographics, arrival Glasgow Coma Scale score, or injury severity between the 142 (44%) patients managed with RHCT and the 179 (56%) managed without RHCT. No patient had a neurologic deterioration or required a neurosurgical intervention, regardless of initial management. There was no significant difference in the neurologic outcomes, mortality, or discharge dispositions between both groups. Patients managed without an RHCT had significantly shorter LOS (2.2 ± 2.3 days vs. 4.3 ± 6.0 days; p < 0.001) compared with those with RHCT. CONCLUSION: Our study is the first to compare early neurologic outcomes of MHI patients with or without a routine RHCT. Patients managed without an RHCT had similar neurologic outcomes and shorter hospital LOS. Our data suggest that initial HCT followed by serial NEs (not routine RHCT) should be the standard of care in this patient population.

Software-assisted analysis during ocular health screening.

OBJECTIVE: To describe the use of software-assisted analysis of non-mydriatic 45° color fundus images during comprehensive ocular screening. MATERIALS AND METHODS: Software-driven filters (blue [490 nm; nerve fiber layer], green [550 nm; neural retina], and red [610 nm; pigmented retina/choroid]) and an "emboss" (topographic changes) digital filter were used to enhance image analysis during ocular health screening performed using a Canon (Tokyo, Japan) 8.2-megapixel non-mydriatic retinal camera. Intraocular pressure (model TX-f full auto non-contact tonometer; Canon) and visual acuity (SIMAV, Padova, Italy) were also determined. An on-site medical director analyzed the collected data, provided immediate subject feedback, and made recommendations and referrals for general or specialty ophthalmology clinics. RESULTS: Software-assisted analysis was performed on color images from 128 veterans (mean age, 37.5 years; 66% male; 43% white). Software filters allowed efficient image analysis at a rate of 26 eyes/h. Thirteen (10.2%) persons had a finding consistent with a vision-threatening disease and were referred for a dilated fundus examination. CONCLUSIONS: Software-assisted screening permits thorough and efficient evaluation of ocular health during an ocular screening event.

Ocular telehealth screenings in an urban community.

The current U.S. economic recession has resulted in a loss of income, housing, and healthcare coverage. Our major goal in this socioeconomic setting was to provide ophthalmic remote health screenings for urban soup kitchen and homeless populations in order to identify and refer undetected vision-threatening disease (VTD). We assessed visual acuity, blood pressure, pulse/oxygen saturation, body mass index, and intraocular pressure for 341 participants at soup kitchens as part of the homeless outreach program in Newark, NJ. History of diabetes, hypertension, and smoking, last ocular examination, and ocular history were noted. Imaging was performed with an 8.2 megapixel non-mydriatic retinal camera with high-speed Internet ready for off-site second opinion image evaluation. Positive VTD findings were identified in 105 participants (31%) (mean age, 53.6 years), of whom 78% were African American, 73% males, and 62% smokers. We detected glaucoma in 34 participants (32%), significant cataract in 22 (21%), diabetic retinopathy in 5 (5%), optic atrophy in 1 (1%), age-related macular degeneration in 1 (1%), and other retinal findings in 43 (41%). The incidence of VTDs was higher among this cohort than among study groups in previous screenings (31% vs. 12%). This finding shows an increase in ocular morbidity in a younger, at-risk population with elevated rates of hypertension, diabetes, and smoking. Functional visual impairment was 2.5 times higher than the national average (16% vs. 6.4%). Comprehensive, community-based screenings can provide more sensitive detection of VTDs in high-risk groups with low access to ophthalmic care and can be an integral part of recession solutions for improving healthcare.

Utility of repeat head computed tomography in patients with an abnormal neurologic examination after minimal head injury.

BACKGROUND: Previous studies proposed that repeat head computed tomography (RHCT) is of no value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). The goal of our study was to investigate the value of RHCT in patients with MHI with an abnormal NE. METHODS: A retrospective chart review of adult patients presenting to a Level I trauma center from July 2002 to December 2006 with MHI was performed. Demographics, injury severity, and HCT findings were collected. Patients with an abnormal NE at the time of RHCT were divided into three subgroups: acute deterioration NE (AD-NE), persistently abnormal NE (PA-NE), and unknown NE (U-NE). Changes in the management and outcomes after RHCT were compared. RESULTS: One hundred seven patients had a MHI with an abnormal NE. Of those, seven (6.5%) had a change in management after RHCT. At the time of RHCT, 68 patients (63%) had a PA-NE, 21 AD-NE, and 18 U-NE. Six patients (29%) with AD-NE, 1 patient (6%) with an U-NE, and no patients with PA-NE required changes in management after RHCT. Compared with a RHCT, NE had higher positive and negative predictive values in determining the need for management changes. CONCLUSIONS: Of all patients with MHI with an abnormal NE at the time of RHCT, 63% had a PA-NE. Although a RHCT is beneficial to patients with an acutely deteriorating or U-NE, it appears to be of little value in patients with a PA-NE. Compared with RHCT, serial NE may be a stronger predictor for the need for intervention in patients with MHI.