Drugs & Aging

Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines Abstract The risk of atherosclerotic cardiovascular disease rises with age and remains the leading cause of death in older adults. Evidence for the use of statins for primary prevention in older adults is limited, despite the possibility that this population may derive significant clinical benefit given its increased cardiovascular risk. Until publication of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the Management of Blood Cholesterol, and the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, guidelines for statin prescription in older adults remained unchanged despite new evidence of possible benefit in older adults. In this review, we present key updates in the 2018 and 2019 guidelines and the evidence informing these updates. We compare the discordant recommendations of the seven major North American and European guidelines on cholesterol management released in the past 5 years and highlight gaps in the literature regarding primary prevention of cardiovascular disease in older adults. As most cardiovascular events in older adults are nonfatal, we ask how clinicians should weigh the risks and benefits of continuing a statin for primary prevention in older adults. We also reframe the concept of deprescribing of statins in the older population, using the Geriatrics 5Ms framework: Mind, Mobility, Medications, Multi-complexity, and what Matters Most to older adults. A recent call from the National Institute on Aging for a statin trial focusing on older adults extends from similar concerns.

Optimizing Drug Therapies in Patients with COPD in the US Nursing Home Setting Abstract Chronic obstructive pulmonary disease (COPD) can be a disabling disease, and the impact on older adults is particularly evident in the nursing home setting. Chronic obstructive pulmonary disease is present in about 20% of nursing home residents, most often in women, and accounts for significant healthcare utilization including acute care visits for exacerbations and pneumonia, as well as worsening heart disease and diabetes mellitus. The emphasis on hospital readmissions is particularly important in nursing homes where institutions have quality measures that have financial implications. Optimizing drug therapies in individuals with COPD involves choosing medications that not only improve symptoms, but also decrease the risk of exacerbations. Optimizing the treatment of comorbidities such as heart disease, infections, and diabetes that may affect COPD outcomes is also an important consideration. Depending on the nursing home setting and the patient, the options for optimizing COPD drug therapies may be limited owing to patient-related factors such as cognition and physical impairment or available resources, primarily reimbursement-related issues. Choosing the best drug therapy for COPD in older adults is limited by the difficulty in assessing respiratory symptoms using standardized assessment tools and potentially decreased inspiratory ability of frail individuals. Because of cognitive and physical impediments, ensuring optimal delivery of inhaled medications into the lungs has significant challenges. Long-acting bronchodilators, inhaled corticosteroids, and roflumilast decrease the risk of exacerbations, although inhaled corticosteroids should be used judiciously in this population because of the risk of pneumonia and oropharyngeal side effects. Treatment of COPD exacerbations should occur early and consideration should be made to the benefits and risks of systemic corticosteroids and antibiotics. Clinical research in the COPD population in nursing homes is clearly lacking, and ripe for discovery of effective management strategies.

Use of Cholinesterase Inhibitors in Non-Alzheimer's Dementias Abstract Non-Alzheimer's dementias constitute 30% of all dementias and present with major cognitive and behavioral disturbances. Cholinesterase inhibitors improve memory by increasing brain acetylcholine levels and are approved symptomatic therapies for Alzheimer's disease (AD). They have also been investigated in other types of dementias with potential cholinergic dysfunction. There is compelling evidence for a profound cholinergic deficit in Lewy Body dementia (LBD) and Parkinson's disease dementia (PDD), even to a greater extent than AD. However, this deficit is difficult to objectivize in vascular dementia (VaD) given the increased comorbidity with AD. Furthermore, there is minimal to no evidence for cholinergic loss in frontotemporal dementia (FTD). Although cholinesterase inhibitors showed significant improvement in cognitive, behavioral, and functional measures in both LBD and PDD clinical trials, only rivastigmine is approved for PDD, due to the heterogeneity of the scales used, the duration of trials, and the limited sample sizes impacting data interpretation. Similarly, the interpretation of findings in VaD trials are limited by the lack of pre-defined inclusion criteria for 'pure VaD' and the wide heterogeneity of patients enrolled with respect to location and extent of cerebrovascular disease. In FTD patients, cholinesterase inhibitors were mostly associated with worsening of cognitive and behavioral symptoms. In non-AD dementias, cholinesterase inhibitors were well tolerated, with increased reports of mild to moderate cholinergic side effects and a non-significant trend for increased cardio and cerebrovascular events with rivastigmine in VaD, justifying their cautious use on a case-by-case basis, especially when there is evidence for cholinergic deficit.

Going Beyond the Guidelines in Individualising the Use of Antihypertensive Drugs in Older Patients Abstract Hypertension is commonly diagnosed in older patients, with increasing cardiovascular (CV) risk as systolic blood pressure (BP) increases. Maximising CV risk reduction must be reconciled with minimising the risk of treatment-related harms and burden, especially among frail, multi-morbid and older old patients who have been excluded from most randomised trials. Contemporary clinical guidelines, based on such trials, differ in their recommendations as to threshold levels warranting treatment with antihypertensive drugs (AHDs) and target levels that should be achieved. In optimising AHD prescribing in older patients, we propose the following decision framework: decide therapeutic goals in accordance with patient characteristics and preferences; estimate absolute CV risk; measure and profile BP accurately in ways that account for lability in BP levels and minimise error in BP measurement; determine threshold and target BP levels likely to confer net benefit, taking into account age, co-morbidities, frailty and cognitive function; and consider situations that warrant AHD deprescribing on the basis of potential current or future harm. In applying this framework to older persons, and based on a review of relevant randomised trials and observational studies, individuals most likely to benefit from treating systolic BP to no less than 130 mmHg are those of any age who are fit and have high baseline systolic BP (≥ 160 mmHg); high CV risk, i.e. established CV disease or risk of CV events exceeding 20% at 10 years; previous stroke or transient ischaemic attack; heart failure; and stage 3–4 chronic kidney disease with proteinuria. Individuals most likely to be harmed from treating BP to target systolic < 140 mmHg are those who have no CV disease and aged over 80 years; moderate to severe frailty, cognitive impairment or functional limitations; labile BP and/or history of orthostatic hypotension, syncope and falls; or life expectancy < 12 months. Treatment should never be so intense as to reduce diastolic BP to < 60 mmHg in any older person. At a time when guidelines are calling for less conservative management of hypertension in all age groups, we contend that a more temperate approach, such as that offered here and based on the totality of available evidence, may assist in maximising net benefit in older patients.

Did Generic Clopidogrel Commercialization Affect Trends of ER Consultations and Hospitalizations in the Population Treated with Clopidogrel? Abstract Background Clopidogrel has been widely used to prevent atherothrombotic events. Since 2011, pharmacists have offered their patients the opportunity to switch to generic clopidogrel, an economic alternative. Whether bioequivalence of generic cardiovascular drugs translates into clinical equivalence at a population level remains unclear and needs to be further documented. Objective We aimed to evaluate the impact of generic clopidogrel commercialization on adverse events (AEs): hospitalizations or emergency room (ER) consultations. Methods This is an interrupted time series analysis using the Quebec Integrated Chronic Disease Surveillance System. We included all patients ≥ 66 years old who were users of the brand-name clopidogrel or a generic version (n = 6) 24 months before and up to 12 months after generics commercialization. Rates of AEs were computed, and periods before and after generics commercialization were analyzed by segmented regression models along with exploratory analyses (generic vs. brand name). Sensitivity analyses were also performed using stratification of the time series by (1) sex, (2) the number of prevalent cardiovascular comorbidities, and (3) socioeconomic status. Results Time series were constituted of 89,525 clopidogrel users (mean age 78 years, 45% women, 71% ischemic heart disease, 34% stroke). For all users, there was a mean rate of 157 AEs per 1000 user-months, stable trend before (−0.1% [95% confidence interval −0.3 to 0.1] and after (0.0% [− 0.5 to 0.6]) generics commercialization. In exploratory analyses, once generic clopidogrel versions were commercialized, rates of AEs were 19.2% (95% CI 11.7–26.7) higher for generic versus brand-name users. This difference persisted up to 1 year. Sensitivity analyses yielded similar results. Conclusions The population treated with clopidogrel had similar rates of hospitalizations or ER consultations before and after generics commercialization. However, differences in rates of hospitalizations or ER consultations between generic and brand-name clopidogrel users may represent a drug safety signal which remains to be validated. Using a different study design, permitting adjustment for potential confounders, could be useful in this regard.

Population Pharmacokinetic/Pharmacodynamic Modeling of O -Desmethyltramadol in Young and Elderly Healthy Volunteers Abstract Background Age-related changes in the concentration–effect relationship of (+)-O-desmethyl-tramadol [(+)-ODM], tramadol's active metabolite, are not documented in the elderly. Objective The objective of this study was to characterize, in elderly and young subjects, the (+)-ODM pharmacokinetic and pharmacodynamic relationship to examine the effect of age after single-dose administration of tramadol 200 mg extended-release tablets. Methods A population analysis of a double-blind, randomized, placebo-controlled, two-period cross-over study including 13 elderly (aged ≥75 years) subjects with mild renal insufficiency and 16 young (aged 18–40 years) subjects was conducted. For 48 h post-dose, blood samples were collected and pain tolerance thresholds measured using an electrically stimulated pain model. A pharmacokinetic/pharmacodynamic model incorporating a one-compartment pharmacokinetic model for (+)-ODM parameterized with first-order formation rate, clearance (CL/fm), volume of distribution (V/fm) and a sigmoid maximum effect (Emax) model incorporating baseline (E0) and placebo effect was used. Results Maximum plasma concentrations of (+)-ODM occurred later and plasma concentrations declined more slowly in the elderly than in young subjects. In the elderly, V/fm was 76% larger and CL/fm 16% slower. Baseline (E0) and sensitivity (C50) for pain tolerance were similar between young and elderly subjects. However, the Emax parameter was 2.5 times higher in the elderly and maximum possible treatment-related effect was 169 (135–221) in the young and 194 (149–252) in the elderly; that is, 15% higher in the elderly. Conclusions This exploratory analysis suggests that age-related differences exist in the distribution and elimination of (+)-ODM, including a 76% larger distribution outside the central compartment and 16% slower clearance of (+)-ODM. These pharmacokinetic changes are associated with a 15% higher maximum possible treatment-related effect and carry the potential for greater efficacy but also the potential for increased side effects at the same dose in elderly subjects. Clinicaltrials.gov identifier: NCT02329561.

Reducing Psychotropic Drug Use in Nursing Homes in Belgium: An Implementation Study for the Roll-Out of a Practice Improvement Initiative Abstract Background and Objective Psychotropic drug use is high in nursing homes in Belgium. A practice improvement initiative (including education, professional support and the transition towards person-centred care) achieved significant reductions in psychotropic drug use. The initiative outline was transcribed into a general intervention template, and consequently implemented in five nursing homes (in mixed locations and with a mixed character) in preparation for a future broader roll-out in Belgium. The impact of the intervention on the use of psychotropic drugs in these five nursing homes is reported in this paper. Methods The general intervention template was fitted into the individual nursing home setting. Education for the nursing home personnel on psychotropic drugs and non-pharmacological alternatives, as well as details for a transition to person-centred care was provided. Psychotropic drug use was recorded using a dynamic cohort study design with cross-sectional observations (November 2016–November 2017). Results At baseline, participants' (n = 677) mean age was 85.6 years (range 54–109 years), with 72.6% female. Mean medication intake was 8.5 (range 1–22), predominantly central nervous system drugs (Anatomic Therapeutic Chemical classification N, 88.8%). Long-term (> 3 months) psychotropic drug use (62.0%) and concomitant psychotropic drug use (31.5% taking two or more medications) were high. After 12 months, the prevalence of long-term psychotropic drug use decreased significantly (from 62.0 to 52.9%, p < 0.001), likewise the combined use of psychotropic drugs (from 31.5 to 24.0%, p = 0.001). The decrease in the prevalence of antidepressant and hypnosedative use was significant (respectively, from 32.2 to 23.4%, p < 0.001, and from 35.3 to 28.7%, p = 0.006) in contrast to antipsychotic use (from 17.1 to 15.9%, p = 0.522). Conclusions The stand-alone adaptation of the previously reported initiative using a general template was possible. This intervention resulted in a significant decrease in psychotropic drug use (predominantly hypnosedatives and antidepressants) among nursing home residents after 12 months.

Prasterone: A Review in Vulvovaginal Atrophy Abstract Vulvovaginal atrophy (VVA) is a progressive condition commonly seen in postmenopausal women. The cessation of ovarian estrogen secretion and a fall in serum levels of dehydroepiandrosterone (DHEA), the remaining source of estrogens and androgens, are thought to promote the development of VVA in this population. Intravaginal prasterone (Intrarosa®) is a synthetic form of DHEA indicated for the treatment of VVA in postmenopausal women presenting with moderate to severe symptoms in the EU; prasterone is also approved in the USA for the treatment of dyspareunia due to menopause. Approval for the treatment of VVA was based on the results of the phase III ERC-231 and -238 trials in which intravaginal prasterone 6.5 mg/day significantly improved the signs and symptoms of VVA (as assessed by the percentage of parabasal and superficial cells, vaginal pH and the severity of dyspareunia) compared with placebo. The beneficial effects of prasterone were also evident during 52 weeks' treatment in the phase III ERC-230 safety trial. Prasterone was generally well tolerated, with the most common treatment-emergent adverse event being application site discharge. During 52 weeks of treatment with prasterone, changes in serum concentrations of estrogenic and androgenic metabolites of DHEA increased from baseline but remained within the normal postmenopausal ranges. Thus, intravaginal prasterone is an effective and generally well-tolerated option for the treatment of VVA in postmenopausal women.

Systemic Treatment of Prostate Cancer in Elderly Patients: Current Role and Safety Considerations of Androgen-Targeting Strategies Abstract Prostate cancer commonly affects older men, with one out of five patients being diagnosed at 75 years or older. Elderly patients are more likely to have reduced performance and nutritional status, increased comorbidities, polypharmacy, and altered host-dependent pharmacokinetics and pharmacodynamics. Moreover, elderly patients are often underrepresented in clinical trials, mainly because of comorbidities and decline in performance status. The International Society of Geriatric Oncology recommends management of elderly patients according to fitness and personal preference, rather than chronological age. Since androgen signaling has a nodal role in prostate cancer progression, androgen-targeting agents remain the mainstay of systemic therapy for this disease. However, the potential benefit of these treatments may be compromised by toxicity, especially in elderly patients. Hence, management decisions require evidence-based consideration of both potential benefits and risks on an individualized basis. Furthermore, especially elderly patients should undergo geriatric screening and must be actively monitored during treatment to detect adverse events early and prevent complications. A personalized and vigilant approach could provide the elderly patient with the optimal benefits of existing and emerging prostate cancer treatments, while sparing them the risks of excessive toxicity and avoiding overtreatment.

Efficacy and Adverse Events of Immunotherapy with Checkpoint Inhibitors in Older Patients with Cancer Abstract The number of older patients with cancer is increasing as a result of the ageing of Western societies. Immune checkpoint inhibitors have improved cancer treatment and are associated with lower rates of treatment-related toxicity compared with chemotherapy in the general population. Nonetheless, immune checkpoint inhibitors have potentially serious immune-related adverse events, which might have a greater impact on older and more vulnerable patients and potentially influence treatment efficacy and quality of life. Previous clinical trials have shown no major increase in immune-related adverse events; however, older patients are underrepresented and relatively healthy in these trials. Observational studies suggest that older and more vulnerable patients may be at a higher risk of immune-related adverse events and early treatment discontinuation. Geriatric assessment could help identify older patients who will benefit from immune checkpoint inhibitors.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Fudan Journal of the Humanities and Social Sciences

Intellectual Humility and Owning One's Limitations Abstract Intellectual humility is a worthwhile virtue. Whitcomb et al. (Philos Phenomenol Res 94(3):520, 2017) recently propose a novel account of intellectual humility. According to this account, intellectual humility consists of proper attentiveness to and owning of one's intellectual limitations. We argue that this account is in accordance with empirical work on intellectual humility, but it has two problems. It leaves open the possibility that one can be both intellectually humble and arrogant and that it does not adequately explain the strangeness associated with self-attribution of intellectual humility. Subsequently, we explore an interesting connection between intellectual humility and ignorance. Our view is that intellectual humility can lead to ignorance in the internalist sense, but this is acceptable, in that intellectual humility also gives rise to valuable epistemic standings, such as understanding and wisdom.

There are no Justified True Beliefs in Gettier Cases Abstract According to the standard interpretation of Gettier cases, they can be used to form significant challenges to the tradition of defining knowledge as justified true beliefs (hereafter "JTB"). This position naturally assumes that varieties of target beliefs involved in typical Gettier cases are all JTBs, namely, unified beliefs which are simultaneously justified and true. But I do not think this is true. Conversely, every target belief in typical Gettier cases should be cashed out as one or more beliefs, none of which is a genuine JTB. In short, there is no JTB in Gettier's JTB-hostile vignettes at all. Hence, no matter whether the JTB account of knowledge is correct or not, Gettier cases are not really relevant to it. In addition, although I agree to Mizrahi's (Logos Episteme 7(1):31–44, 2016) general observation that face-values of target beliefs cannot be taken for granted in all Gettier cases, I have made a further claim that there is no cross-board methodology to disambiguate the target beliefs in all Gettier cases.

An Indian Quasi-Fregean Theory of Number Abstract A very interesting account of the reference of number words in classical Indian philosophy was given by Maheśa Chandra (1836–1906) in his Brief Notes on the Modern Nyāya System of Philosophy and its Technical Terms (BN), a primer on Navya-Nyāya terminology and doctrines. Despite its English title, BN is a Sanskrit work. The section on "number" (saṃkhyā) provides an exposition of a theory of number which can account for both the adjectival and the substantival use of number words in Sanskrit. According to D. H. H. Ingalls (1916–1999), some ideas about the reference of number words in BN are close to the Frege–Russell theory of natural number. Ingalls's comparison refers to a concept of number in Navya-Nyāya which is related to the things numbered via the so-called "circumtaining relation" (paryāpti). Although there is no theory of sets in Navya-Nyāya, Navya-Naiyāyikas do have a realist theory of properties (dharma) and their theory of number is a theory of properties as constituents of empirical reality, anchored to their system of ontological categories. As shown by George Bealer, properties can serve the same purpose as sets in the Frege–Russell theory of natural number. In the present paper, we attempt a formal reconstruction of Maheśa Chandra's exposition of the Navya-Nyāya theory of number, which accounts for its affinity to George Bealer's neo-Fregean analysis. As part of our appraisal of the momentousness and robustness of the "circumtaining" concept of number, we show that it can be cast into a precise recursive definition of natural number and we prove property versions of Peano's axioms from this definition.

American Roth Abstract An analysis of the Philip Roth's sustained pursuit of his American identity mixed with his engagement with the trope of the American Adam is the center of this paper. From the outset of his career, Roth has sought to be understood as an American, not Jewish, writer. But as his career unfolded, the challenges of sustaining his American identity grew, whether in Portnoy's Complaint, Sabbath's Theatre or the American Trilogy. The confrontation between American and Judaic identities increasingly became his subject as his Jewish roots threatened his American identity stemming from a Protestant, if not Puritan, literary heritage. Coleman Silk and Swede Levov from The Human Stain and American Pastoral represent the challenge best summarized by Abe Ravelstein in Bellow's eponymous novel when he remarks that "as a Jew you are also an American, but somehow you are not." The paradox of Roth's entanglement with the trope of the American Adam is that he both pursues and denies this identity, accepting its heroism but acknowledging its impossibility. One moment he publically declares "if I'm not an American, I am nothing," but on the other, to be Roth he knows he must violate the Adamic ideal, prepared to renounce neither his American nor Jewish identities.

People's Justice: Socialist Law and Equity in China, 1921–1945 Abstract When people's justice was conceived in Republican China, it brought with it a socialist conceptualisation of law and equity, by which the prefix of 'people' was not merely a superfluous addition to the term of 'justice'. On the contrary, it emphasised a people-oriented approach in as much practising the law as correcting the law where arose a rigidity during its application. Such elements as class inequality and the supremacy of state interests were found therein, alongside with Mao's emphasis on the mass line policy. By dividing the period from 1921 to 1945 into three sections, namely 1921–1927, 1927–1934 and 1935–1945, this article aims to give a brief discussion of the evolution of people's justice, both as a concept and as a system of laws, in China, which may help us to better appreciate the socialist notions and traditions of law and equity.

River Cultures in World History—Rescuing a Neglected Resource Abstract This paper argues that historians have all but ignored the study of rivers and their impact on the development of human society. Apart from a somewhat terse acknowledgment of the importance of rivers in the development of ancient civilizations, from the Huang He to the Ganges, the Nile, and the Amazon, historians have by and large limited themselves to studying individual rivers, while ignoring the potential of comparative analysis of rivers. I call for a broader engagement by historians of all aspects of rivers, including their role in transportation, fishing, agriculture, industry, recreation, and the environment, people's cultural response to rivers, and the legal regimes that have grown up around them, with special reference to the role of rivers as political boundaries.

Land Reclamation in the Rhine and Yangzi Deltas: An Explorative Comparison, 1600–1800 Abstract In the early sixteenth century, the deltas of Rhine and Yangzi faced comparable ecological crises, but neither of these riverine societies was deterred by the mounting challenges. They independently developed divergent ways to not only defend against the encroaching water, but also reclaim new land from the water. This paper aims to examine the factors in the making of that transformation in these two riverine societies and to ask how they took different paths, why, and what were the implications of that divergence. In asking these questions, particular attention will be paid to the significance of technological and institutional breakthroughs in the Dutch case, such as highly efficient windmills for pumping water, the mapping of cadastral surveys with triangulation, the centralization of power in the local water boards (heemraden), and the involvement of the financial market. In the Chinese case, we focus on the importance of the developing domestic market, the relationship between state and society in local water management, and the formation of unique local land reclamation organizations.

Singular Terms for Numbers? Abstract In natural language, number-words can be used in two different syntactic ways: adjectivally, i.e., with the syntactic status of an adjective, as in (1) 'Mars has two moons,' and nominally, i.e., with the syntactic status of a noun phrase, as in (2) 'Two is even.' This syntactic difference is often taken to correspond to a difference in semantic function: adjectival number-words function as predicables, whereas nominal number-words function as singular terms. The view that nominal number-words function as singular terms is typically supported by appeal to certain tests for singular-termhood, tests that stem from the (neo-)Fregean tradition. In this paper, I argue that these tests do not support the view of nominal number-words as singular terms.

Freedom of Indifference: Its Metaphysical Credentials According to Crusius Abstract In the history of philosophy, voluntarists—that is, philosophers committed to some version of the freedom of indifference—have worried about its metaphysical credentials, but only a few, at least to my knowledge, have attempted to argue for more than its mere existence. Freedom of indifference is the option to choose between opposites in a given situation. In this paper, I present the ambitious attempt of the German pre-Kantian philosopher Christian August Crusius (1715–1775) to argue for the claim that we have freedom of indifference as a matter of hypothetical necessity. The point is that, in his view, there can be no actual world without freedom of indifference. This is not a logical but a metaphysical truth. I argue that a possible (motivational) reason for Crusius's choice to tread this slippery path is that he attempts to bestow some metaphysical dignity on the freedom of indifference. As a consequence, this metaphysical value of freedom of indifference shapes the relation between the divine and free, rational agents in a way that is completely different from a rationalist's conception such as Leibniz's. In this paper, I give a plausible interpretation of a metaphysical argument that has been neglected in the relevant literature.

Conceptualizing and Measuring Global Justice: Theories, Concepts, Principles and Indicators Abstracts The paper focuses on the conceptualization and measurement of global justice and discusses theories, concepts, evaluative principles, and methodologies related to the study of global justice. In this paper, we seek to clarify how to conceptualize global justice, how conceptual indicators can be selected and justified by theories, and how those indicators can be conceptually consistent with the concept of global justice. Global justice is a broad concept that is composed of multi-level and multidimensional aspects belonging to both normative and empirical realities. A coherent and integrated theoretical framework that covers the normative basis and various empirical dimensions is therefore much needed in order to address some of the basic and important questions under study. The paper seeks to synthesize the multiple theories and conceptions of global justice that exist in the academic discourse and literature into three main theoretical approaches to global justice—rights based, good based, and virtue based. These three approaches are a good sample of and reflect well the strengths of the different theoretical, intellectual and cultural traditions at play in the study of global justice. From this perspective, the synthesis of the three approaches is meant to provide us with a coherent theoretical framework that serves as the normative basis and justifies the selection of indicators for measurement.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Anesthesia & Analgesia

Time-Out and Distraction: Performing Checklists After the Plane Has Taken Off No abstract available

Ventilator Mode Does Not Influence Blood Loss or Transfusion Requirements During Major Spine Surgery: A Retrospective Study BACKGROUND: Blood loss during adult spinal deformity surgery is multifactorial. Anesthetic-related factors, such as mode of mechanical ventilation, may contribute to intraoperative blood loss. The aim of this study was to determine the influence of ventilator mode and ventilator parameters on intraoperative blood loss and transfusion requirements in patients undergoing prone position spine surgery. METHODS: This single-center retrospective study examined electronic medical records of patients ≥18 years of age who underwent elective prone position spine surgery between May 2015 and June 2016. Associations between ventilator mode and ventilator parameters with intraoperative estimated blood loss (EBL), packed red blood cells (PRBCs), fresh-frozen plasma (FFP), cryoprecipitate and platelet transfusions, and subfascial drain output were examined using multiple linear regression models controlling for age, sex, American Society of Anesthesiologist (ASA) physical status score, body mass index (BMI), preoperative blood coagulation parameters and laboratory values, operative levels, cage constructs, osteotomies, transforaminal lumbar interbody fusions, laminectomies, reoperation, spine surgery invasiveness index, and operative time. In a secondary analysis, EBL, blood product transfusions, and postoperative drain output were compared between pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) propensity score–matched cohorts. RESULTS: Nine hundred forty-six records were reviewed, and 822 were included in the analysis. After adjusting for confounding, no statistically significant associations were observed between mode of ventilation and intraoperative EBL (estimate, −1.77; 95% confidence interval [CI], −248.23 to 244.68; P = .99) or blood product transfusions (PRBC: estimate, −9.34; 95% CI, −154.08 to 135.40; P = .90; FFP: estimate, −2.60; 95% CI, −58.73 to 53.52; P = .93; cryoprecipitate: estimate, −13.81; 95% CI, −70.33 to 42.71; P = .63; platelets: −7.43; 95% CI, −38.84 to 23.98; P = .64). After propensity score matching (n = 27 per group), no significant differences were observed in EBL (mean difference, 525 mL; 95% CI, −15 to 1065; P = .056) or blood transfusions (PRBC: mean difference, 208 mL; 95% CI, −23 to 439; P = .077; FFP (mean difference, 34 mL; 95% CI, −17 to 84; P = .19); cryoprecipitate (mean difference, 55 mL; 95% CI, −24 to 133; P = .17); or platelets (mean difference, 26 mL; 95% CI, −12 to 64; P = .18) between PCV and VCV groups. CONCLUSIONS: In prone position spine surgery, neither mode of mechanical ventilation nor airway pressure is associated with intraoperative blood loss or need for allogeneic transfusion. Use of modern ventilation strategies using lung protective techniques may mitigate differences in blood loss previously observed between PCV and VCV modes. Accepted for publication May 30, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Lauren K. Dunn, MD, PhD, Department of Anesthesiology, University of Virginia, PO Box 800710, Charlottesville, VA 22908. Address e-mail to lak3r@virginia.edu. © 2019 International Anesthesia Research Society

Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization Deciding whether to pursue elective surgery is a complex process for older adults. Comprehensive geriatric assessment (CGA) can help refine estimates of benefits and risks, at times leading to a delay of surgery to optimize surgical readiness. We describe a cohort of geriatric patients who were evaluated in anticipation of elective abdominal surgery and whose procedures were delayed for any reason. Themes behind the reasons for delay are described, and a holistic framework to guide preoperative discussion is suggested. Accepted for publication June 12, 2019. Funding: This study received the Specialty Care Education Center of Excellence Grant from the Office of Academic Affiliations of the US Veterans Health Administration. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Serena P. Wong, DO, Division of Geriatrics, Department of Medicine, Duke University Medical Center, DUMC Box 3003, Durham, NC 27710. Address e-mail to serena.wong@duke.edu. © 2019 International Anesthesia Research Society

Preemptive and Preventive Pain Psychoeducation and Its Potential Application as a Multimodal Perioperative Pain Control Option: A Systematic Review The common treatment for postoperative pain is prescription opioids. Yet, these drugs have limited effect in preventing chronic pain from surgical intervention and have in part contributed to the opioid epidemic. Recently, preemptive analgesia and multimodal analgesia have been proposed with widely gained acceptance in addressing the pain issues. However, both analgesic approaches have been focused on pharmacological means while completely neglecting the psychological aspect. To address this epidemic, we have conducted a systematic review of preoperative educational methods to explore its application as both a preemptive and a preventive psychological approach to decrease postsurgical pain and improve outcome. Preemptive psychoeducation occurs before surgery and would include information about regional or neuraxial analgesia, while preventive psychoeducation occurs throughout the perioperative period. The content and presentation of preemptive psychoeducation can help patients form accurate expectations and address their concerns of surgical outcome, leading to a significant decrease in patients' anxiety levels. By addressing the psychological needs of patients through preoperative education, one can decrease postoperative recovery time and postsurgical acute pain. Reduced postsurgical acute pain results in fewer opioid prescriptions, which theoretically lowers the patient's risk of developing chronic postsurgical pain (CPSP), and potentially offers a novel concept using preemptive pain psychoeducation as a part of multimodal pain management solution to the opioid epidemic. Accepted for publication May 28, 2019. Funding: Departmental/institutional. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Ban C. H. Tsui, MD, FRCPC, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, 3rd Floor, Room H3584, MC 5640, Stanford, CA 94305. Address e-mail to bantsui@stanford.edu. © 2019 International Anesthesia Research Society

In Response No abstract available

Hematologic Challenges in the Critically Ill No abstract available

Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study BACKGROUND: Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depression. This study tested the hypothesis that PDPH in obstetric patients is associated with significantly increased postpartum risks of major neurologic and other maternal complications. METHODS: This retrospective cohort study consisted of 1,003,803 women who received neuraxial anesthesia for childbirth in New York State hospitals between January 2005 and September 2014. The primary outcome was the composite of cerebral venous thrombosis and subdural hematoma. The 4 secondary outcomes were bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year postdelivery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using the inverse probability of treatment weighting approach. RESULTS: Of the women studied, 4808 (0.48%; 95% CI, 0.47–0.49) developed PDPH, including 264 cases (5.2%) identified during a readmission with a median time to readmission of 4 days. The incidence of cerebral venous thrombosis and subdural hematoma was significantly higher in women with PDPH than in women without PDPH (3.12 per 1000 neuraxial or 1:320 vs 0.16 per 1000 or 1:6250, respectively; P < .001). The incidence of the 4 secondary outcomes was also significantly higher in women with PDPH than in women without PDPH. The aORs associated with PDPH were 19.0 (95% CI, 11.2–32.1) for the composite of cerebral venous thrombosis and subdural hematoma, 39.7 (95% CI, 13.6–115.5) for bacterial meningitis, 1.9 (95% CI, 1.4–2.6) for depression, 7.7 (95% CI, 6.5–9.0) for headache, and 4.6 (95% CI, 3.3–6.3) for low back pain. Seventy percent of cerebral venous thrombosis and subdural hematoma were identified during a readmission with a median time to readmission of 5 days. CONCLUSIONS: PDPH is associated with substantially increased postpartum risks of major neurologic and other maternal complications, underscoring the importance of early recognition and treatment of anesthesia-related complications in obstetrics. Accepted for publication June 12, 2019. Funding: J.G. is supported by an R03 from the Agency for Healthcare Research and Quality (1 R03 HS025787-01). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Jean Guglielminotti, MD, PhD, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 W 168th St, PH5-505, New York, NY 10032. Address e-mail to jg3481@cumc.columbia.edu. © 2019 International Anesthesia Research Society

Update on Congenital Diaphragmatic Hernia Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH. Accepted for publication June 4, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Debnath Chatterjee, MD, FAAP, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, B090, Aurora, CO 80045. Address e-mail to debnath.chatterjee@childrenscolorado.org. © 2019 International Anesthesia Research Society

Bispectral Index During Maintenance of Total Intravenous Anesthesia: Frequency of Out of Recommended Range and Impact of Patients' Characteristics: A Brief Report Little is known about respecting the recommended range of bispectral index (BIS) in practice. This exploratory retrospective analysis of 138 robotic surgical patients having received total intravenous anesthesia shows that BIS was between 40 and 60 during 61.3% ± 25.2% (mean ± standard deviation [SD]) of maintenance, >60 during 3.1% ± 5.5%, and <40 during 35.7% ± 26.9%. Burst suppression was present during 17.8% ± 22.2%. Female sex is associated with increased periods of BIS <40 (P = .002) as is body mass index (BMI) <26 (P = .012). Increased age is associated with increase in burst suppression (P = .005). A larger study is required to confirm the role of patients' factors on the number of periods of low BIS. Accepted for publication May 23, 2019. Funding: This work was supported by grants from Hospital Foch. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Marc Fischler, MD, Department of Anesthesiology, Hospital Foch, 40 Rue Worth, Suresnes, France. Address e-mail to m.fischler@hopital-foch.org. © 2019 International Anesthesia Research Society

Ketamine Administration During Hospitalization Is Not Associated With Posttraumatic Stress Disorder Outcomes in Military Combat Casualties: A Matched Cohort Study BACKGROUND: Ketamine is routinely used within the context of combat casualty care. Despite early concerns that ketamine administration may be associated with elevated risk of posttraumatic stress disorder (PTSD), more recent evidence suggests no relationship. Because PTSD occurs with regular frequency in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Service Members (SMs) and combat-related injuries are associated with higher likelihood of PTSD, it is important to investigate the relationship between ketamine exposure during inpatient medical and surgical care and PTSD symptoms in OIF/OEF SMs. METHODS: Medical record data from OIF/OEF SMs medically evacuated from combat (N = 1158) included demographic characteristics, injury severity, body areas injured, and PTSD Checklist (PCL) scores. The primary analysis assessed the association between ketamine versus nonketamine exposure on positive PTSD screen (logistic regression) and PCL scores (linear regression) after using 1:1 propensity score matching to adjust for available potential confounding variables. Because there were 2 primary outcomes, the binary positive PTSD screen (yes/no) and continuous PCL score, the significance level was set at P ≤ .025. In sensitivity analyses, propensity scores were used to match ketamine to nonketamine records in a 1:4 ratio, as well as to conduct inverse probability treatment weighting (IPTW). Regressions examining the relationship between ketamine exposure and outcomes were repeated for unconditional, 1:4 matching, and IPTW models. RESULTS: In the sample, 107 received ketamine and 1051 did not. In the logistic regression, the probability of a positive PTSD screen was not significantly different between ketamine versus nonketamine patients (odds ratio [OR] = 1.28; 95% confidence interval [CI], 0.48–3.47; P = .62). In the linear regression, PCL scores were not significantly different between ketamine versus nonketamine patients (mean difference = 1.98 [95% CI, −0.99 to 4.96]; P = .19). The results were consistent in the unconditional, 1:4 matching, and IPTW models. CONCLUSIONS: No differences in PTSD screening risk or symptom levels between ketamine exposed and nonexposed were found. Given the small sample size, wide CIs of the effects, and additional confounds inherent to retrospective studies, future studies are needed to examine the complex relationships between ketamine and psychological symptoms. Accepted for publication June 5, 2019. Funding: The present study was funded on a cooperative agreement from the US Army Medical Research and Materiel Command through the Uniformed Services University. The authors declare no conflicts of interest. The opinions and assertions herein are those of the authors and do not necessarily reflect official policy or position of the Uniformed Services University, the Department of Defense, or The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc (HJF). Reprints will not be available from the authors. Address correspondence to Krista B. Highland, PhD, Defense and Veterans Center for Integrative Pain Management, Department of Military & Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852. Address e-mail to khighland@dvcipm.org. © 2019 International Anesthesia Research Society

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

RETINA - Current Issue

Understanding Intravitreal Silicone Oil Droplets Due to Intravitreal Injections No abstract available

ATYPICAL MACULAR HOLES Purpose: To study the etiology, clinical features, management options, and visual prognosis in various types of atypical macular holes (MHs). Methods: A review of the literature was performed, which focused on the etiopathogenesis of atypical or secondary MHs, their differentiating clinical features, management strategies, and varied clinical outcomes. Idiopathic or age-related, myopic, and traumatic MHs were excluded. Results: Atypical or secondary MHs arise out of concurrent ocular pathologies (dystrophy, degeneration, or infections) and laser/surgery. The contributing factors may be similar to those responsible for idiopathic or typical MHs, i.e., tangential or anteroposterior vitreofoveal traction or cystoid degeneration. The management is either observation or treatment of the underlying cause. The prognosis depends on the background pathology, duration of disease, and baseline visual acuity governed by the size of MH and morphologic health of underlying RPE and photoreceptors. The closer the morphology of atypical MH is to that of an idiopathic MH, the better the surgical outcome is. Conclusion: With the advancements in retinal imaging, atypical MHs are now more frequently recognized. With increasing understanding of the underlying disease processes, and improvement in investigations and surgical treatment, management of atypical MHs may improve in the future.

CLINICAL FEATURES OF LACQUER CRACKS IN EYES WITH PATHOLOGIC MYOPIA Purpose: To analyze the morphologic features of lacquer cracks (LCs), compare their detectability by different imaging instruments, and determine their progressive pattern. Methods: The medical records of 47 highly myopic eyes of 33 patients with LCs were reviewed. Fundus fluorescein angiography was used as the primary method of identifying LCs, and the detection rate was compared with that by fundus autofluorescence and optical coherence tomography. Results: A total of 176 LCs were detected in the 47 eyes. Lacquer cracks were detected more frequently in the temporal (44.3%) than the inferior (30.7%), superior (17.0%), and nasal (8.0%) quadrants of the retina. The detection rate of LCs was 98% in fundus photographs and 85% by fundus autofluorescence and optical coherence tomography. A progression of the LCs was observed in 22 of the 41 eyes with a follow-up period of ≥1 year. The progression patterns were an increase in the number (18 of 41, including 5 eyes in which new LCs had a branching pattern), elongation (4 of 41), and progression to patchy atrophy (6 of 41). Conclusion: Lacquer cracks can be detected noninvasively by fundus autofluorescence and optical coherence tomography; however, improvements are necessary to detect all of the lesions. Lacquer cracks frequently progress with time, and an increase in the number of LCs was the most frequent progression pattern.

RAPID PROGRESSION OF FOVEOMACULAR RETINOSCHISIS IN YOUNG MYOPICS Purpose: To describe a foveomacular retinoschisis that has not been described. Methods: Patients with foveomacular retinoschisis were included. Exclusion criteria included refractive error over −6.00 diopters, presence of posterior staphyloma, positive RS1-gene mutation, family history of retinoschisis, optic disk abnormalities, or glaucoma. Vitrectomy was performed on eyes with functional or structural deterioration. Results: Seventeen eyes from 10 patients (15–30 years old, 8 females and 2 males) with foveoschisis were recruited, with bilateral involvement in 7 patients and unilateral in 3 patients. Vitrectomy was performed in 13 eyes (13/17, 76.5%). Seven eyes (6 patients) were operated soon after the first presentation because of poor vision and severe foveoschisis. Six eyes (6 patients) were operated 2 weeks to 13 months later because of deterioration of vision and foveoschisis. Preoperative vision was 20/134 ± 20/165, and postoperative vision was 20/25 ± 20/57, with visual improvement of 6.9 (4–14) lines. The mean postoperative follow-up period was 36.5 (15–69) months. Four eyes (4 patients) were asymptomatic, despite progression of foveoschisis. Three eyes (3 patients) maintained normal macula structures. Conclusion: We report a foveomacular retinoschisis characterized by young age of onset, female predominant, no highly myopia, mostly bilateral involvement, and rapid progression of foveoschisis and visual acuity. Vitrectomy is effective in restoring anatomical structure and stabilize vision.

FIVE-YEAR OUTCOMES OF INTRAVITREAL RANIBIZUMAB FOR CHOROIDAL NEOVASCULARIZATION IN PATIENTS WITH PATHOLOGIC MYOPIA Purpose: To determine the 5-year outcome of intravitreal ranibizumab (IVR) for myopic choroidal neovascularization (CNV). Method: We retrospectively analyzed the medical records of 51 eyes of 51 consecutive patients with myopic CNV who had been treated with IVR with a minimum follow-up period of 5 years after the initial IVR injection. The factors that predicted the best-corrected visual acuity (BCVA) at 5 years after IVR were determined by multiple regression analysis. Results: The mean age of the subjects was 63.6 years, and the mean axial length was 29.4 mm. The mean number of IVR was 1.6, and 34 eyes (66.7%) had only a single IVR. At the baseline and at the 1-year, 2-year, 4-year, and 5-year period, the mean BCVAs were 20/49, 20/37, 20/41, 20/45, and 20/42, respectively. Stepwise multiple regression analysis showed that the BCVA at 5-year period was significantly correlated with the baseline BCVA, the number of IVR injections, and the size of the CNV-related macular atrophy. Conclusion: Intravitreal ranibizumab provide a 5-year visual benefit in eyes with myopic CNV compared with the natural course. A lack of enlargement of the CNV-related macular atrophy, a better baseline BCVA, and a minimum number of IVR injections were associated with better visual outcomes.

POSTERIOR STAPHYLOMAS IN EYES WITH RETINITIS PIGMENTOSA WITHOUT HIGH MYOPIA Purpose: To describe features of posterior staphylomas in nonhighly myopic eyes with retinitis pigmentosa (RP). Methods: The retrospective observational case series study included patients with RP and an axial length of <26.5 mm and searched for eyes with posterior staphylomas. All study participants underwent fundus photography and optical coherence tomography. Results: The study identified 13 eyes of 7 patients with a narrow macular staphyloma. Mean age was 40.9 ± 17.9 years (range 9–62 years) and mean axial length was 24.90 ± 0.69 mm. The staphyloma edges corresponded to the margin between the retinal atrophic area in the fundus midperiphery and the relatively unaffected fundus center. On vertically orientated optical coherence tomography images, the staphyloma edges showed a slight inward protrusion of the sclera and a ring-like localized choroidal thinning with choroidal rethickening in direction toward the fovea and toward the periphery of the fundus. The upper and lower staphyloma edges did not differ in steepness. The thickness of the subfoveal choroid (138.6 m ± 50.1 µm) was thinner than the normal range after adjusting for age and axial length in all eyes. Two eyes with advanced RP in the macula showed a subfoveal choroidal thickness of 95 µm and 88 µm. Conclusion: Narrow macular staphylomas can occur in nonhighly myopic eyes with RP and, in contrast to staphylomas in highly myopic eyes, show a less marked thinning of the subfoveal choroid. The occurrence of posterior staphylomas in nonhighly myopic eyes with RP may provide hints to unravel the etiology of posterior staphyloma formation.

INTRAVITREAL GAS INJECTION WITH LASER PHOTOCOAGULATION FOR HIGHLY MYOPIC FOVEOSCHISIS: Technique and Outcome Purpose: To evaluate the effects of gas tamponade combined with laser photocoagulation without vitrectomy in patients with highly myopic foveoschisis. Methods: This retrospective noncomparative case series included 30 eyes of 23 patients with highly myopic foveoschisis who were treated by intravitreal injection of 0.5 to 0.7 mL C3F8 combined with laser photocoagulation 1 week later, and remained in the face-down position for 3 weeks. The patients were followed up for at least 6 months after the treatment. The refractive status, best-corrected visual acuity, and anatomical parameters of retina observed with the optical coherence tomography before and after the treatment were recorded. Results: The mean age of the 23 patients (6 men and 17 women) was 50.4 ± 15.1 years. The average follow-up duration was 20.8 ± 20.6 months. At the final follow-up, 23 eyes (76.7%) completely (17 eyes) or partially (6 eyes) resolved. Seventeen eyes had complete data of optical coherence tomography parameters, the mean central foveal thickness decreased significantly from 505.24 ± 466.22 μm to 186.41 ± 95.36 μm (P = 0.01), and the mean maximal macular thickness from 687.88 ± 397.00 μm to 313.65 ± 83.07 μm (P = 0.001). The mean final logarithm of the minimum angle of resolution best-corrected visual acuity (Snellen equivalent) of the 30 eyes ranged from 1.6 (20/800) to 0.2 (20/32), showing a slight improvement from 0.91 ± 0.44 (20/163) preoperatively to 0.90 ± 0.39 (20/160) postoperatively (P = 0.87). Conclusion: C3F8 tamponade combined with laser photocoagulation could be an alternative treatment for highly myopic foveoschisis.

MORPHOLOGIC CHARACTERISTICS OF MACULAR HOLE AND MACULAR HOLE RETINAL DETACHMENT ASSOCIATED WITH EXTREME MYOPIA Purpose: To investigate the surgical results and morphologic characteristics of macular hole (MH) and macular hole retinal detachment (MHRD) associated with extreme myopia. Methods: We retrospectively reviewed consecutive cases with axial length ≥28 mm who were treated with pars plana vitrectomy for MH or MHRD. The choroidal and scleral thickness at the fovea, presence of dome-shaped macula, and the height of posterior staphyloma 3 mm from the fovea were measured from postoperative optical coherence tomography images. Results: Significant improvement in visual acuity was obtained postoperatively in both MH (16 eyes; 15 patients) and MHRD (19 eyes; 18 patients) groups (P < 0.05). Final MH closure rate was not significantly different between the groups (MH: 15/16, MHRD: 14/19, P = 0.19). Axial length was not significantly different between the groups (MH: 30.5 ± 1.5 mm, MHRD: 29.6 ± 1.3 mm, P = 0.098). Eyes with MH had significantly greater choroidal thickness (MH: 61.9 ± 66.0 μm, MHRD: 24.1 ± 19.8 μm, P = 0.045), greater scleral thickness (MH: 294 ± 77 μm, MHRD: 232 ± 89 μm, P = 0.008), higher frequency of dome-shaped macula (MH: 6/16, MHRD: 1/19, P = 0.032), and lower staphyloma height (MH: 190 ± 113 μm, MHRD: 401 ± 156 μm, P < 0.001). Conclusion: Surgical outcomes were generally favorable. The pathogenetic differences between the two conditions may be attributable to differences with respect to eye morphology.

PHOTODYNAMIC THERAPY AS PRIMARY TREATMENT FOR SMALL CHOROIDAL MELANOMA Purpose: To report outcomes of photodynamic therapy (PDT) as primary treatment for small amelanotic choroidal melanoma. Methods: Retrospective interventional case series of 12 patients with small choroidal melanoma treated with standard-fluence PDT (83 seconds; 50 J/cm2) using verteporfin. Outcome measures: Tumor regression, subretinal fluid resolution, best-corrected visual acuity, and PDT complications. Results: There were 12 eyes with melanoma, demonstrating amelanotic (10 [83%]) or lightly pigmented (n = 2, 17%) appearance. The mean tumor thickness was 2.7 mm (median, 2.8; range 1.8–3.7 mm). After PDT, mean follow-up was 56 months (median, 53; range, 14–91). Outcomes revealed complete tumor regression after 1 session (n = 3, 25%), 2 sessions (n = 3, 25%), and 3 sessions (n = 2, 17%) of PDT, reduced to mean thickness of 2.1 mm (median, 2.0; range 1.2–3.4 mm). Tumors that failed to regress (n = 4, 33%) were further controlled with transpupillary thermotherapy (n = 1) or plaque brachytherapy (n = 3). Subretinal fluid, present in six eyes, demonstrated resolution (n = 5) or progression (n = 1), and one tumor developed new subretinal fluid after PDT (n = 1). Visual outcome was stable (n = 11 eyes) or improved (n = 1). Photodynamic therapy complications included local retina pigment epithelium atrophy at the site of treatment in 3 (25%) eyes, with no effect on macular or optic nerve function. Conclusion: Primary PDT resulted in complete tumor regression of small amelanotic choroidal melanoma in 67% at mean 5 years, with no major effect on visual acuity.

ROUTINE FUNDUS SCREENING OF FAMILIES OF CHILDREN WITH RETINOBLASTOMA: A Prospective Study of 131 Consecutive Families Purpose: To discuss the importance of routine ophthalmic examination of parents and siblings of retinoblastoma (RB) patients. Methods: Prospective nonrandomized observational/interventional case series of consecutive families of 131 RB patients. Results: Routine ophthalmic examination of families (parents and siblings) of 131 consecutive newly diagnosed RB patients, including 262 parents and 23 siblings, revealed spontaneously regressed RB in at least 1 parent of 10 (8%) patients and active RB in at least 1 sibling of 3 (2%) patients. Of the 10 parents with spontaneously regressed RB, the lesions were unilateral (n = 7) or bilateral (n = 3). The regression patterns (n = 13) were comparable with postirradiation regression patterns Type 1 (n = 3), Type 2 (n = 2), Type 3 (n = 2), and Type 4 (n = 3), and spontaneous phthisis bulbi (n = 3). Fundus screening of siblings revealed active RB in at least 1 sibling of 3 (2%) patients. Of these 3 siblings, 2 had unilateral and 1 had bilateral disease. The mean age at detection of RB was 15 months (median, 6 months; range, 2–36 months). The disease was unilateral in 2 and bilateral in 1 patient. Based on International Classification of Intraocular Retinoblastoma, the tumors (n = 4) were classified as Group A (n = 2) and Group B (n = 2). Conclusion: Routine fundus screening of siblings allows for early detection of RB in otherwise asymptomatic children. Detection of spontaneously regressed RB in parents may act as a surrogate marker for germline RB1 mutation and is helpful in genetic counseling.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Advances in Skin & Wound Care - Current Issue

Treating Persons Who Inject Drugs: The Need for Holistic and Respectful Care No abstract available

Are You Following Your Reimbursement "Playbook"? No abstract available

Nonviral Injection-Related Injuries in Persons Who Inject Drugs: Skin and Soft Tissue Infection, Vascular Damage, and Wounds GENERAL PURPOSE To explore skin and soft-tissue infections and vascular damage in persons who inject drugs and relate these changes to wound development and care. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant should be better able to: 1. Review the issues surrounding wound infections in persons who inject drugs. 2. Describe the risk factors and manifestations of wound infections in persons who inject drugs. 3. Summarize the treatment options for wound infections in persons who inject drugs. The number of persons who inject drugs (PWIDs) is increasing. The literature has placed a substantial focus on the association between injection drug use and the transmission of blood-borne viral infections such as HIV and hepatitis C, but there is less extant research on other injuries such as skin and soft tissue infections (SSTIs), vascular damage, and associated wounds. Both SSTIs and vascular injury can result in marked morbidity and mortality and wounds that are slow to heal, likely to reoccur, and lifelong. The aims of this article are to (1) explore SSTIs and vascular damage in PWIDs and (2) relate these changes to wound development and care. Providers must address the health and psychosocial problems of PWIDs; take physical, psychosocial, and substance use histories; and develop multifocal plans of care. Finally, care must be provided in a nonjudgmental manner.

Use of Thermal Imaging to Identify Deep-Tissue Pressure Injury on Admission Reduces Clinical and Financial Burdens of Hospital-Acquired Pressure Injuries A deep-tissue pressure injury (DTPI) is a serious type of pressure injury that begins in tissue over bony prominences and can lead to the development of hospital-acquired pressure injuries (HAPIs). Using a commercially available thermal imaging system, study authors documented a total of 12 thermal anomalies in 9 of 114 patients at the time of admission to one of the study institution's ICUs over a 2-month period. An intensive, proven wound prevention protocol was immediately implemented for each of these patients. Of these 12 anomalies, 2 ultimately manifested as visually identifiable DTPIs. This represented a 60% reduction in the authors' institution's historical DTPIs/HAPI rate. Because these DTPIs were documented as present on admission using the thermal imaging tool, researchers avoided a revenue loss associated with nonreimbursed costs of care and also estimated financial benefits associated with litigation expenses known to be generated with HAPIs. Using thermal imaging to document DTPIs when patients present has the potential to significantly reduce expenses associated with pressure injury litigation. The clinical and financial benefits of early documentation of skin surface thermal anomalies in anatomical areas of interest are significant.

25-Hydroxyvitamin D Deficiency: Impacting Deep-Wound Infection and Poor Healing Outcomes in Patients With Diabetes BACKGROUND The Kingdom of Bahrain has a high incidence of diabetes and associated foot complications. Simultaneously, low 25-hydroxyvitamin D (25[OH]D) levels are common in this population and may be associated with the traditional clothing used in desert climates. METHODS This investigation compared 25(OH)D levels and glycemic control with quantifiable wound healing parameters in a prospective, analytic, nonexperimental, cross-sectional pilot study. Consecutive consenting adult patients (N = 80) who presented to the regional wound care unit in January 2016 with either an existing or new wound were included. Collected data included three-dimensional wound photography, NERDS and STONEES criteria, and an X-ray with a positive probe-to-bone test. Blood values for 25(OH)D and hemoglobin A1c (HbA1c) were collected simultaneously. RESULTS Diabetes mellitus (types 1 and 2) was present in 90% of the sample patients. No patient had sufficient 25(OH)D levels; 15% had insufficient levels (30–50 ng/mL), and deficiency (levels <#20 ng/mL) was found in 85% of the sample. Males were slightly less affected by 25(OH)D deficiency compared with females (82.4% vs 91.3%). Poor glycemic control (HbA1c levels >#6.8%) was found in 69.4% (n = 50) of the persons with diabetes included in the sample. Those with both diabetes mellitus and a 25(OH)D deficiency (76.3%; n = 61) were more likely to demonstrate healing difficulty (40.9%; n = 25) or present with a stalled or deteriorating wound (44.2%, n = 27). A 3° F or higher periwound surface temperature elevation over a mirror image site was present in 82.5% of all wounds. Exposed bone in the ulcer base was found in 50% of the cases. For persons with diabetes, general linear modeling statistical analysis (adjusted R2 value = 47.9%) linked poor wound healing with three studied variables: 25(OH)D deficiency, poor glycemic control, and an exposed bone in the wound bed. CONCLUSIONS Vitamin D may be an overlooked factor in the pathophysiology of diabetic foot ulcer development and subsequent delay in wound healing outcomes. The authors recommend adding 25(OH)D deficiency to the list of multifactorial aggravating factors providers should consider correcting in this subgroup of patients.

Gelatin-Collagen Nonwoven Scaffold Provides an Alternative to Suprathel for Treatment of Superficial Skin Defects OBJECTIVE: To evaluate the effect of a new biologic gelatin-collagen nonwoven scaffold compared with a more common synthetic wound dressing on the healing of superficial wounds. METHODS: Three superficial wounds with a depth of 0.5 mm and a length of 2.4 cm were created on the flanks of six minipigs using a skin dermatome. One wound on each pig was treated with the new nonwoven scaffold, one with the more common synthetic wound dressing, and one functioned as an untreated control wound. All three wounds were then covered with a semipermeable, sterile, transparent film. RESULTS: After 7 days, complete wound closure of all wounds could be detected; epidermal thickness and the number of epidermal cells of all treated wounds were significantly increased compared with the control wounds. The nonwoven dressing showed slightly better results compared with the more common dressing. CONCLUSIONS: The nonwoven scaffold is an interesting and competitive material for promoting epidermal wound healing. Because it is a biologic dressing, it degenerates completely and does not have to be removed from the wound. Further research should be conducted to compare this new dressing with other currently available wound treatments.

Managing Your Workflow to Meet Regulations No abstract available

Nonviral Injection-Related Injuries in Persons Who Inject Drugs: Skin and Soft Tissue Infection, Vascular Drainage, and Wounds No abstract available

A Comparison of Three Dressing Methods for Pilonidal Sinus Surgery Wound Healing OBJECTIVE To evaluate the effect of different dressing methods on the wound healing process after pilonidal sinus surgery. METHODS In this clinical trial, 60 patients undergoing pilonidal sinus surgery were randomly assigned to one of three groups. In the first group, hydrogel or alginate and hydrocolloid compounds were used as a standard occlusive dressing method. A modified dressing method was used for the second group, in which transparent hydrocolloid films were replaced by Vaseline gauze. The third group was treated using gauze swabs soaked in normal saline. The length and depth of the studied wounds were recorded once a week for a month. During dressing changes, patient pain was recorded using an 11-point numeric rating scale. The collected data were analyzed by descriptive and inferential statistical methods. RESULTS There was a significant reduction in wound length after 2 weeks in all three groups (P < .05), and the pain experienced by the first and second groups was significantly lower than the third group. However, the modified method used for the second group was associated with a lower cost. CONCLUSIONS Considering the beneficial results of using modern dressings for wound healing and reducing the severity of associated pain, providers may want to consider using modified wound dressings after pilonidal sinus surgery. Study authors recommend that providers receive training on how to use these products.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com