Detection and Referral of Orbital and Ocular Injuries Associated With Intimate Partner Violence Following an Educational and Screening Initiative in an Emergency Department.

IMPORTANCE: Intimate partner violence (IPV) is a substantial cause of morbidity and mortality in the US. Previous studies indicate gaps in identifying and referring female patients with IPV-associated orbital and ocular injuries to ancillary services. OBJECTIVE: To determine the number of IPV-associated orbital floor fractures, zygomaticomaxillary complex (ZMC) fractures, and ruptured globes referred to ancillary services in adult female patients following an educational and screening intervention to health care professionals. DESIGN, SETTING, AND PARTICIPANTS: This single-center retrospective quality improvement analysis examined electronic medical records of adult female patients seen in a single level 1 trauma center emergency department and ophthalmology clinic between January 2015 and February 2019, after the initiative began. Female adults who sustained orbital floor fractures, ZMC fractures, or ruptured globes were included. Preinitiative data were previously collected between January 1995 and January 2015 on adult female patients and published. Data analysis for this study occurred from May 2020 to September 2020. INTERVENTIONS: A 2-part, ongoing initiative began January 2015. First, enhancement of IPV screening protocols in the emergency department was conducted. Second, an educational campaign on IPV injury patterns was presented to residents and faculty in ophthalmology, emergency, otolaryngology, and trauma departments. MAIN OUTCOMES AND MEASURES: Comparison of ancillary service involvement preinitiative (January 1995 to January 2015) and postinitiative (January 2015 to February 2019). RESULTS: A total of 216 adult female patients (mean [SD] age, 55.0 [22.7] years; age range, 18-99 years) sustained orbital floor or ZMC fractures postinitiative. A total of 22 of 216 (10.2%) sustained fractures from IPV compared with 31 of 405 (7.6%) preinitiative (95% CI, -2.2% to 7.3%; P = .28). Documented social work referrals (11 of 31 preinitiative vs 20 of 22 postinitiative; difference, 55% [95% CI, 35%-76%]; P < .001), homegoing safety assessments (1 of 31 preinitiative vs 18 of 22 postinitiative; difference, 79% [95% CI, 61%-96%]; P < .001), and law enforcement involvement (7 of 21 preinitiative vs 16 of 22 postinitiative; difference, 50% [95% CI, 26%-74%]; P < .001) were higher in patients who presented after the initiative with orbital floor and ZMC fractures. A total of 51 adult female patients (mean [SD] age, 57.7 [20.8] years; age range 20-93 years) sustained ruptured globes postinitiative. A total of 5 of 51 patients (9.8%) sustained injury due to IPV postinitiative, compared with 5 of 141 (3.5%) preinitiative (95% patients, -2.5% to 15.0%; P = .08). CONCLUSIONS AND RELEVANCE: Following the start of the initiative, referral patterns of adult female patients with IPV-associated orbital fractures improved. Targeted IPV screening of patients with orbital and ocular injuries is essential for effective intervention.

Flipped ophthalmology classroom augmented with case-based learning.

BACKGROUND: Although the flipped classroom model provides an effective way to teach ophthalmology to medical students, there are concerns that it overburdens the learner. The purpose of this study was to assess medical students' perceptions of a case-based flipped classroom style compared with a traditional didactic lecture series and to evaluate the effects of case-based learning on students' confidence in managing common ophthalmic complaints. METHODS: We created an interactive, case-based flipped classroom ophthalmology curriculum. Paired pre- and post-clerkship surveys were distributed to students on the first and last day of the 2-week clerkship. Questions were formatted as statements using a 6-point Likert scale to assess students' prior exposure to a flipped classroom, perceptions of the flipped classroom curriculum, and confidence in evaluating ophthalmic complaints. RESULTS: A total of 75 students were included during the period July 2019 to March 2020. Pre-clerkship questionnaires revealed no preference for either teaching modality. Wilcoxon signed-rank testing comparing pre- and post-clerkship data revealed a significant increase in students' favoring the case-based flipped-classroom model. Participants reported significant reductions in pressure to perform, course burden, and overall anxiety as well as increased confidence in triaging common eye complaints. CONCLUSIONS: The case-based flipped classroom modality prioritizes key learning objectives while increasing student participation and confidence. The reproducibility and accessibility of standardized prepared video lectures and cases may help institutions to better incorporate ophthalmology into preexisting rotations.

Postpartum Recovery From Meningioma-Related Oculomotor Palsy.

BACKGROUND: We summarize a case of transient oculomotor nerve palsy in a pregnant woman with a cavernous sinus meningioma. When pregnant women present with acute ophthalmic signs and symptoms, meningioma should be considered during diagnostic workup given the common proximity of growing meningiomas to visual pathways and ocular motor nerves within the parasellar region. CASE: A 32-year-old woman, gravida 2 para 1, at 37 weeks of gestation, presented with 2 weeks of diplopia, left-sided ptosis, and left periocular headache. There were no signs of preeclampsia. Examination revealed a left mydriatic pupil, complete left-sided ptosis, and motility deficits consistent with a left pupil-involving oculomotor nerve palsy. Magnetic resonance imaging of the brain revealed a cavernous sinus meningioma. Five days after cesarean birth, the ptosis significantly improved; 2 weeks later, the diplopia resolved. CONCLUSION: Pregnancy is associated with increased likelihood of intracranial meningioma growth, particularly in the parasellar region. We highlight a rare case of a transient cranial nerve III palsy in a pregnant patient due to cavernous sinus meningioma and review prior published reports.

Atypical Large Vessel Vasculitis Presenting With Cholestatic Liver Abnormalities: Case-Based Review.

ABSTRACT: Clinicians usually easily recognize cranial manifestations of giant cell arteritis (GCA) such as new-onset headache, jaw claudication, scalp tenderness, and abrupt changes in visual acuity or blindness; however, when presented with an aberrant clinical course, the diagnosis becomes more elusive. In addition to temporal arteries and other extracranial branches of the carotid arteries, large vessel vasculitis (LVV) can also affect other blood vessels including coronary arteries, aorta with its major branches, intracranial blood vessels, and hepatic arteries.Over time, the scope of the symptoms typically associated with LVV has broadened and includes cases of fever of unknown origin accompanied with other constitutional symptoms that can mimic a range of neoplastic and infectious diseases. In up to half of patients with atypical LVV, liver enzyme level elevations with a cholestatic pattern have been observed. Alkaline phosphatase level and γ-glutamyl transferase level elevations tend to be more prevalent in those LVV patients with vigorous inflammatory responses, particularly in those with fever and other nonspecific constitutional symptoms. These patients also have more profound anemia and thrombocytosis. With the exception of rare instances of vasculitides and granulomas affecting the liver tissue, liver biopsy is generally of little help and primarily shows nonspecific changes of fatty liver.In this article, we review 3 patients who were eventually diagnosed with atypical LVV. The diagnosis was confirmed with temporal artery biopsy in 2 patients and with positron emission tomography/computed tomography in 1 patient. The common hepatic abnormality observed in all patients was the elevation of alkaline phosphatase level, which tended to respond rapidly to initiation of immunosuppressive treatment.

Structural Characterization of a Newly Identified Component of α-Carboxysomes: The AAA+ Domain Protein CsoCbbQ.

Carboxysomes are bacterial microcompartments that enhance carbon fixation by concentrating ribulose-1,5-bisphosphate carboxylase/oxygenase (RuBisCO) and its substrate CO2 within a proteinaceous shell. They are found in all cyanobacteria, some purple photoautotrophs and many chemoautotrophic bacteria. Carboxysomes consist of a protein shell that encapsulates several hundred molecules of RuBisCO, and contain carbonic anhydrase and other accessory proteins. Genes coding for carboxysome shell components and the encapsulated proteins are typically found together in an operon. The α-carboxysome operon is embedded in a cluster of additional, conserved genes that are presumably related to its function. In many chemoautotrophs, products of the expanded carboxysome locus include CbbO and CbbQ, a member of the AAA+ domain superfamily. We bioinformatically identified subtypes of CbbQ proteins and show that their genes frequently co-occur with both Form IA and Form II RuBisCO. The α-carboxysome-associated ortholog, CsoCbbQ, from Halothiobacillus neapolitanus forms a hexamer in solution and hydrolyzes ATP. The crystal structure shows that CsoCbbQ is a hexamer of the typical AAA+ domain; the additional C-terminal domain, diagnostic of the CbbQ subfamily, structurally fills the inter-monomer gaps, resulting in a distinctly hexagonal shape. We show that CsoCbbQ interacts with CsoCbbO and is a component of the carboxysome shell, the first example of ATPase activity associated with a bacterial microcompartment.