Surgical techniques for Baerveldt glaucoma implant removal.

Purpose: To describe two surgical techniques for removing Baerveldt-350 Glaucoma Implants (BGI-350). Observations and plan: A 91-year-old female with history of bilateral BGI-350s and prior history of tube associated endophthalmitis in the left eye requiring tube removal and resultant phthisis was referred for tube erosion and hypopyon in the right only-seeing eye, and we recommended tube removal. On exam, the left phthisical eye still had a BGI-350 plate attached under the lateral rectus muscle by one anchoring stalk, as it had not been fully removed previously, and the patient recalled severe pain during attempted tube removal in the left eye. We performed concurrent removal of both BGI-350s under general anesthesia. We describe a surgical technique for removing a BGI-350 when the conjunctiva does not need to be spared for future surgery. We also present a second case of BGI-350 removal with a different technique that aims to spare the conjunctiva for future surgery. Conclusions and importance: BGI-350s can develop complications requiring repositioning, revision, or removal. Improper removal of BGI-350s can lead to patient discomfort and future complications. We highlight two different techniques to remove a BGI-350, depending on whether the conjunctiva is intended to be spared for future surgery or not. With either technique, we advocate for general anesthesia and a posterior scleral traction suture to provide patient comfort and optimal exposure of the surgical field.

PET imaging of TREM1 identifies CNS-infiltrating myeloid cells in a mouse model of multiple sclerosis.

Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the central nervous system (CNS) that causes substantial morbidity and diminished quality of life. Evidence highlights the central role of myeloid lineage cells in the initiation and progression of MS. However, existing imaging strategies for detecting myeloid cells in the CNS cannot distinguish between beneficial and harmful immune responses. Thus, imaging strategies that specifically identify myeloid cells and their activation states are critical for MS disease staging and monitoring of therapeutic responses. We hypothesized that positron emission tomography (PET) imaging of triggering receptor expressed on myeloid cells 1 (TREM1) could be used to monitor deleterious innate immune responses and disease progression in the experimental autoimmune encephalomyelitis (EAE) mouse model of MS. We first validated TREM1 as a specific marker of proinflammatory, CNS-infiltrating, peripheral myeloid cells in mice with EAE. We show that the 64Cu-radiolabeled TREM1 antibody-based PET tracer monitored active disease with 14- to 17-fold higher sensitivity than translocator protein 18 kDa (TSPO)-PET imaging, the established approach for detecting neuroinflammation in vivo. We illustrate the therapeutic potential of attenuating TREM1 signaling both genetically and pharmacologically in the EAE mice and show that TREM1-PET imaging detected responses to an FDA-approved MS therapy with siponimod (BAF312) in these animals. Last, we observed TREM1+ cells in clinical brain biopsy samples from two treatment-naïve patients with MS but not in healthy control brain tissue. Thus, TREM1-PET imaging has potential for aiding in the diagnosis of MS and monitoring of therapeutic responses to drug treatment.

Safety and Efficacy of Resident-Performed Gonioscopy-Assisted Transluminal Trabeculotomy.

PRCIS: GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature. PURPOSE: Report outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) performed by PGY-3 and PGY-4 residents. METHODS: A retrospective chart review was performed for patients undergoing resident-performed GATT. Eyes with previous traditional glaucoma surgery (trabeculectomy or aqueous shunt) or neovascular glaucoma were excluded from this analysis. The primary aim was to assess whether resident-performed GATTs demonstrated success rates comparable with the GATT literature. Surgical success was defined as intraocular pressure (IOP)<21 mmHg, and an IOP reduction of 20% from baseline, and no subsequent IOP-lowering surgery. The secondary and tertiary aims were to describe complication rates and operating times for resident-performed GATTs, respectively. RESULTS: A total of 50 eyes from 40 patients with various types of glaucoma were included. Eyes either underwent resident-performed GATT-alone (N=9) or GATT+cataract extraction with intraocular lens implantation (CEIOL) (N=41). The surgical success rate at 6 months was 71% for GATT-alone and 42% for GATT+CEIOL. Three eyes required subsequent IOP-lowering surgery. The hyphema rate was 16% at postoperative week 1 and 6% at postoperative month 1. The IOP spike (>30 mmHg) rate was 18%. Mean surgical time for both GATT-alone and GATT+CEIOL was longer for PGY-4s than for PGY-3s, attributable to less attending assistance during PGY-4 cases and more resident-performed cataracts in PGY-4 GATT+CEIOL cases (85%) compared with PGY-3 cases (35%). CONCLUSIONS: GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature.

Impact of Resident-Led Small-Group Learning Sessions on Preclinical Students' Perceptions of Ophthalmology.

Introduction Resident physicians have a significant role in the education of medical students, and limited research has demonstrated that positive interactions with residents are linked with enhanced students' perceptions of a specialty. Minimal research on residents as teachers has been done in ophthalmology, and no research has examined the impact of residents as teachers on the perceptions of preclinical students. This is an important area of interest because ophthalmology conducts an early match. The competitiveness of the field increases the importance of early involvement in research and clinical activities. This study aimed to assess the role of a resident-led workshops as a vehicle for exposing preclinical students to ophthalmology. Methods A 2-hour workshop on the Ophthalmology Clinical Skills was held at the University of Cincinnati College of Medicine in November 2018. The workshop was conducted by seven ophthalmology residents, and the learners were 15 first-year and 11 second-year medical students. The workshop format consisted of a 30-minute introductory lecture on the field of ophthalmology, followed by a 60-minute small-group clinical skills' session focusing on direct ophthalmoscopy and slit lamp examination. Preworkshop and postworkshop surveys were administered to the medical students, and Student's paired sample t -test was used to assess the differences in responses before and after the workshop. Results Students' average interest in ophthalmology rose ( p = 0.049) as did their likeliness to approach a resident for career advice ( p = 4.65 × 10 -6 ) and their likeliness to attend the Secrets of the Match Lunch talk, a yearly talk held by a student matched into ophthalmology ( p = 0.002). Conclusion These results suggest that resident intervention can have a positive impact on preclinical students' perceptions of ophthalmology and may be a good educational strategy to foster their positive attitudes toward the field.

Peroxisome proliferator-activated receptor gamma co-activator-1 alpha in depression and the response to electroconvulsive therapy.

BACKGROUND: The transcriptional coactivator peroxisome proliferator-activated receptor-γ coactivator (PGC-1α), termed the 'master regulator of mitochondrial biogenesis', has been implicated in stress and resilience to stress-induced depressive-like behaviours in animal models. However, there has been no study conducted to date to examine PGC-1α levels in patients with depression or in response to antidepressant treatment. Our aim was to assess PGC-1α mRNA levels in blood from healthy controls and patients with depression pre-/post-electroconvulsive therapy (ECT), and to examine the relationship between blood PGC-1α mRNA levels and clinical symptoms and outcomes with ECT. METHODS: Whole blood PGC-1α mRNA levels were analysed in samples from 67 patients with a major depressive episode and 70 healthy controls, and in patient samples following a course of ECT using quantitative real-time polymerase chain reaction (qRT-PCR). Exploratory subgroup correlational analyses were carried out to determine the relationship between PGC-1α and mood scores. RESULTS: PGC-1α levels were lower in patients with depression compared with healthy controls (p = 0.03). This lower level was predominantly accounted for by patients with psychotic unipolar depression (p = 0.004). ECT did not alter PGC-1α levels in the depressed group as a whole, though exploratory analyses revealed a significant increase in PGC-1α in patients with psychotic unipolar depression post-ECT (p = 0.045). We found no relationship between PGC-1α mRNA levels and depression severity or the clinical response to ECT. CONCLUSIONS: PGC-1α may represent a novel therapeutic target for the treatment of depression, and be a common link between various pathophysiological processes implicated in depression.

In-Transit Metastasis From Squamous Cell Carcinoma.

BACKGROUND: In-transit metastasis from cutaneous squamous cell carcinoma (SCC) is an uncommon form of metastasis through lymphatics and occurs more commonly in immunosuppressed patients. OBJECTIVE: To identify cases of in-transit SCC and determine patient characteristics, tumor features, management, and prognosis. METHODS AND MATERIALS: A multicenter case series treated by Australian and New Zealand clinicians. RESULTS: In 31 patients, median age was 72 years (range 52-99) and 68% were immunocompetent. Tumors occurred on the head and neck in 94% of cases, with 71% of all tumors occurring on the scalp, forehead, or temple. The median time to presentation with in-transit SCC from treatment of the initial tumor was 5 months. Management included surgery (94%), radiotherapy (77%), chemotherapy (10%), and reduction of immunosuppression (3%). Median follow-up was 12 months. Overall survival at 3 and 5 years were 27% and 13%, respectively. CONCLUSION: In-transit metastases are described in 31 patients, of whom the majority was immunocompetent. The scalp, forehead, and temple were the most common sites. New clinical and histological diagnostic criteria are proposed. Prognosis was poor with 5-year survival of 13%. Recommended management is a combination of surgery and adjuvant radiotherapy. Reduction of any iatrogenic immunosuppression should be considered.

An expanding sexual economy along National Route 3 in Luang Namtha Province, Lao PDR.

With some of the lowest development indicators in Southeast Asia, remote upland areas of the Lao People's Democratic Republic are among the poorest in the region. The advent of improved transport and communication links, along with opportunities for wage employment, have accelerated the growth of a cash economy in traditionally isolated farming communities of Luang Namtha Province. Interviews and focus group discussions with young people, women in the sexual service business and health workers indicate that the lure of the new economy is wooing villagers away from their agrarian roots. Motorbikes and mobile phones have expanded the sexual territory of indigenous youth at a time when international commerce and a cash economy along improved highways are bringing new people into the region. Among the concerns for their health and safety are at-risk behaviours involving alcohol and sexual practices, especially HIV and sexually transmitted infections. Of particular concern is the sexual trade in the province with a predominance of young, poorly educated Khmou women providing sexual services in a growing number of entertainment places.

The use of quilted full thickness skin grafts in the lower limb--reliable results with early mobilization.

Quilted full thickness skin grafts were used to cover surgical defects in the lower limb following excision of skin lesions in 92 cases. Patients were mobilised early and discharged home. 93.4% of grafted area had taken by 2 weeks post operatively. Minimal after care is required and highly acceptable cosmetic donor and graft sites were achieved.