Dermoscopy can be safely and reliably used in ophthalmology.

Objective: To determine if dermoscopy, a technique widely utilized in dermatology for improved diagnosis of skin lesions, can be used comfortably for evaluating periorbital, eyelid, and conjunctival lesions. Design: Proof-of-concept study in which a technique for performing dermoscopy near the eye was developed, related educational material was prepared, and a protocol for dermoscopic image capture was created. Methods: Technicians used the developed materials to learn to take high-quality pictures with a 10x dermoscope attached to a standard cell phone camera. The images were assessed for diagnostic utility by an oculoplastic surgeon and two dermatologists. Participants: 115 patients recruited from ophthalmology clinics from July 2021 to April 2023 were photographed, yielding 129 lesions with high-quality dermoscopic images as assessed by an oculoplastic surgeon and two dermatologists. Results: Technicians reported a significant increase in confidence (measured on a 1-10 scale) with dermoscopy after training (pre-instruction mean = 1.72, median = 1, mode = 1, IQR = 1.25 vs mean = 7.69, median = 7.75, mode = 7 and 8, IQR = 1.5 post-instruction. Wilcoxon rank sum test with continuity correction, W = 0, p < 0.001, paired t = 13.95, p < 0.0001). Incorporating a contact plate with a 4 × 4mm reticule on the dermoscope aided in photographing ocular and periocular lesions. Conclusion: Medical support staff in eye-care offices can be taught to use dermoscopes to capture high-quality images of periorbital, eyelid, and conjunctival lesions. Dermoscopy illuminates diagnostic features of lesions and thus offers a new avenue to improve decision-making in ophthalmology. Dermoscopy can be incorporated into telemedicine evaluations by ophthalmologists, oculoplastic surgeons, or affiliated dermatologists for triage of or rendering advice to patients and for planning of surgery if needed.

Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Program Pilot Study on Eye Drop Instillation Technique and Self-Efficacy.

PURPOSE: To assess the Support, Educate, Empower (SEE) personalized glaucoma coaching program impact on (1) eye drop instillation technique and (2) eye drop instillation self-efficacy. DESIGN: Prospective pre-post pilot study. PARTICIPANTS: Patients with a diagnosis of glaucoma or ocular hypertension taking ≥1 glaucoma medication, ≥40 years old, spoke English, self-administered their eye drops, and ≤80% adherent to their glaucoma medication by electronic monitoring. METHODS: Eye drop administration was video recorded before the first SEE in-person coaching session, which included teaching eye drop instillation techniques using a motivational interviewing-based approach. At the third and final in-person counseling session 6 months later, eye drop administration was video recorded. Participants' self-efficacy was assessed using the validated Eye Drop Technique Self-Efficacy Scale (EDTSES) survey at baseline and 1 month after completion of the program. Before and after intervention videos were assessed by an observer masked to time point. Before versus after intervention comparisons were made using McNemar's and paired t tests. MAIN OUTCOME MEASURES: The main outcome was change in participants' eye drop instillation technique as measured by (1) accuracy of an eye drop landing on the eye, (2) ability to instill an eye drop on the first attempt, and (3) contaminating the bottle by contact with ocular surface, eyelashes, and skin. The secondary outcome measure was before versus after change in the EDTSES score (6 items, each assessed on a 3-point Likert scale, with higher scores indicating better self-efficacy). RESULTS: Thirty-nine participants completed the SEE intervention, 38 with before and after EDTSES scores and 31 with video recordings. Six of 31 participants instilling drops outside the eye before intervention improved their technique after intervention, whereas 2 participants worsened (P = 0.157). From before to after intervention, participants demonstrated significant improvement in not touching the ocular surface (P = 0.046), the eyelashes (P = 0.020), or the skin (P = 0.025) with the bottle tip. A significant increase was found in eye drop instillation self-efficacy from an average score of 2.6 (standard deviation [SD], 0.3) to 2.8 (SD, 0.2) on the EDTSES score (P = 0.007). CONCLUSIONS: The SEE program significantly decreased eye drop bottle contamination, increased eye drop instillation self-efficacy, and demonstrated an insignificant increase in ability to instill drops successfully and accurately.

The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration.

OBJECTIVE: To implement a standardized tracheostomy pathway that reduces length of stay through tracheostomy education, coordinated care protocols, and tracking patient outcomes. METHODS: The project design involved retrospective analysis of a baseline state, followed by a multimodal intervention (Trach Trail) and prospective comparison against synchronous controls. Patients undergoing tracheostomy from 2015 to 2016 (n = 60) were analyzed for demographics and outcomes. Trach Trail, a standardized care pathway, was developed with the Iowa Model of Evidence-Based Practice. Trach Trail implementation entailed monthly tracheostomy champion training at 8-hour duration and staff nurse didactics, written materials, and experiential learning. Trach Trail enrollment occurred from 2018 to 2019. Data on demographics, length of stay, and care outcomes were collected from patients in the Trach Trail group (n = 21) and a synchronous tracheostomy control group (n = 117). RESULTS: Fifty-five nurses completed Trach Trail training, providing care for 21 patients placed on the Trach Trail and for synchronous control patients with tracheostomy who received routine tracheostomy care. Patients on the Trach Trail and controls had similar demographic characteristics, diagnoses, and indications for tracheostomy. In the Trach Trail group, intensive care unit length of stay was significantly reduced as compared with the control group, decreasing from a mean 21 days to 10 (P < .05). The incidence of adverse events was unchanged. DISCUSSION: Introduction of the Trach Trail was associated with a reduction in length of stay in the intensive care unit. Realizing broader patient-centered improvement likely requires engaging respiratory therapists, speech language pathologists, and social workers to maximize patient/caregiver engagement. IMPLICATIONS FOR PRACTICE: Standardized tracheostomy care with interdisciplinary collaboration may reduce length of stay and improve patient outcomes.

Current landscape in motoneuron regeneration and reconstruction for motor cranial nerve injuries.

The intricate anatomy and physiology of cranial nerves have inspired clinicians and scientists to study their roles in the nervous system. Damage to motor cranial nerves may result from a variety of organic or iatrogenic insults and causes devastating functional impairment and disfigurement. Surgical innovations directed towards restoring function to injured motor cranial nerves and their associated organs have evolved to include nerve repair, grafting, substitution, and muscle transposition. In parallel with this progress, research on tissue-engineered constructs, development of bioelectrical interfaces, and modulation of the regenerative milieu through cellular, immunomodulatory, or neurotrophic mechanisms has proliferated to enhance the available repertoire of clinically applicable reconstructive options. Despite these advances, patients continue to suffer from functional limitations relating to inadequate cranial nerve regeneration, aberrant reinnervation, or incomplete recovery of neuromuscular function. These shortfalls have profound quality of life ramifications and provide an impetus to further elucidate mechanisms underlying cranial nerve denervation and to improve repair. In this review, we summarize the literature on reconstruction and regeneration of motor cranial nerves following various injury patterns. We focus on seven cranial nerves with predominantly efferent functions and highlight shared patterns of injuries and clinical manifestations. We also present an overview of the existing reconstructive approaches, from facial reanimation, laryngeal reinnervation, to variations of interposition nerve grafts for reconstruction. We discuss ongoing endeavors to promote nerve regeneration and to suppress aberrant reinnervation and the development of synkinesis. Insights from these studies will shed light on recent progress and new horizons in understanding the biomechanics of peripheral nerve neurobiology, with emphasis on promising strategies for optimizing neural regeneration and identifying future directions in the field of motor cranial neuron research.

Covalent thiol adducts arising from reactive intermediates of cocaine biotransformation.

Exposure to cocaine results in the depletion of hepatocellular glutathione and macromolecular protein binding in humans. Such cocaine-induced responses have generally been attributed to oxidative stress and reactive metabolites resulting from oxidative activation of the cocaine tropane nitrogen. However, little conclusive data exists on the mechanistic pathways leading to protein modification or the structure and specificity of cocaine-derived adduction products. We now report a previously uncharacterized route of cocaine bioactivation leading to the covalent adduction of biological thiols, including cysteine and glutathione. Incubation of cocaine with biological nucleophiles in an in vitro biotransformation system containing human liver microsomes identified a monooxygenase-mediated event leading to the oxidation of, and subsequent sulfhydryl addition to, the cocaine aryl moiety. Adduct structures were confirmed using ultra-high performance liquid chromatography coupled to high resolution, high mass accuracy mass spectrometry. Examination of assays containing transgenic bactosomes expressing single human cytochrome P450 isoforms determined the role of P450s 1A2, 2C19, and 2D6 in the oxidation process resulting in adduct formation. P450-catalyzed aryl epoxide formation and subsequent attack by free nucleophilic moieties is consistent with the resulting adduct structures, mechanisms of formation, and the empirical observation of multiple structural and stereo isomers. Analogous adduction mechanisms were maintained across all sulfhydryl-containing nucleophile models examined; N-acetylcysteine, glutathione, and a synthetic cysteine-containing hexapeptide. Predictive in silico calculations of molecular reactivity and electrophilicity/nucleophilicity were compared to the results of in vitro assay incubations in order to better understand the adduction process using the principles of hard and soft acid and base (HSAB) theory. This study elucidated a novel metabolic pathway that may be of particular significance to the clinical and forensic toxicology of cocaine and provides analytical tools and methods that can be applied to the determination of these conjugates in humans, opening a new area of research on cocaine biotransformation and toxicology.

Evaluation of in vitro metabolic systems for common drugs of abuse. 1. Cocaine.

This study examined the efficacy of four common in vitro assay systems in producing metabolic profiles consistent with in vivo data for drugs of abuse. Cocaine (COC) was selected for this study because of its complex biotransformation pathways, diverse metabolic processes and because extensive Phase I and Phase II metabolomic examination of COC has not yet been reported by means of in vitro assay. COC metabolism was assessed with a series of common in vitro assay systems (human liver microsomes, cytosol and human liver S9 fraction and horseradish peroxidase) using liquid chromatography-tandem mass spectrometry with multiple reaction monitoring. Qualitative and quantitative differences in analyte production were noted among the various active Phase I and Phase II metabolic systems. Assay incubation time was found to be a determining factor in metabolic profile, specifically with primary versus secondary metabolite formation. Regioselective arene hydroxylation of COC was conclusively documented in human hepatic metabolic models, while peroxidase-based assay systems displayed less selectivity in oxidative aryl biotransformation. Results demonstrate the applicability of in vitro systems in studying COC metabolite production and the impact of assay selection and variation in method parameters on metabolite profiles for this important drug of abuse.