A Multisite Retrospective Review of Direct Oral Anticoagulants Compared to Warfarin in Adult Fontan Patients

PURPOSE

Direct oral anticoagulants (DOACs) are not recommended in adult Fontan patients (Level of Evidence C). We hypothesized that DOACs are comparable to warfarin and do not increase thrombotic and embolic complications (TEs) or clinically significant bleeds.

METHODS

We reviewed the medical records of adult Fontan patients on DOACs or warfarin at three major medical centers. We identified 130 patients: 48 on DOACs and 107 on warfarin. In total, they were treated for 810 months on DOACs and 5637 months on warfarin.

RESULTS

The incidence of TEs in patients on DOACs compared to those on warfarin was not increased in a statistically significant way (hazard ratio [HR] 1.7 and p value 0.431). Similarly, the incidence of nonmajor and major bleeds in patients on DOACs compared to those on warfarin was also not increased in a statistically significant way (HR for nonmajor bleeds in DOAC patients was 2.8 with a p value of 0.167 and the HR for major bleeds was 2.0 with a p value 0.267). In multivariate analysis, congestive heart failure (CHF) was a risk factor for TEs across both groups (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.6) and bleed history was a risk factor for clinically significant bleeds (OR = 6.8, 95% CI = 2.7-17.2).

CONCLUSION

In this small, retrospective multicenter study, the use of DOACs did not increase the risk of TEs or clinically significant bleeds compared to warfarin in a statistically significant way.

Endoscope-Assisted Sutureless Intrascleral Haptic Fixation of a Posterior Chamber Intraocular Lens

Purpose:

In eyes with compromised capsule support, sutureless scleral fixation is a popular method of placing a posterior chamber intraocular lens (PCIOL). We describe an endoscope-assisted sutureless technique for intrascleral fixation of a 3-piece PCIOL.

Methods:

Eyes of patients who had endoscope-assisted scleral-fixated intraocular lens (SFIOL) implantation were examined retrospectively. The technique comprised direct capture of the IOL haptic with a forceps through a pars plana sclerotomy with subsequent haptic fixation into scleral tunnels created with a 26-gauge needle. The endoscope was used to visualize haptic positioning under the iris and ensure proper centration of the IOL.

Results:

Thirteen eyes of 13 patients were examined. The mean age of the patients was 68.2 years (range, 38-87 years), and the mean follow-up was 13.6 months (range, 5-23 months). The indications for surgery were a subluxated IOL (6 eyes), postoperative aphakia (5 eyes), and a subluxated cataract (2 eyes). The mean best-corrected visual acuity ± SD improved significantly from 1.2 ± 0.6 logMAR preoperatively to 0.6 ± 0.7 logMAR at last the follow-up (paired Welch t test; t10 = 2.69; P = .023). IOL stability and centration were maintained in all patients.

Conclusions:

Endoscopic visualization during sutureless SFIOL implantation helped improve haptic localization, minimize intraoperative complications, and achieve excellent IOL centration.

Nocturnal normobaric hyperoxia treatment in a case of chronic diabetic macular edema

PURPOSE

To study the long-term anatomic and physiologic effects of nocturnal normobaric hyperoxia (NNBH) in a patient with treatment-resistant diabetic macular edema (DME).

METHODS

A 64-year-old diabetic man with bilateral DME requiring regular anti-VEGF treatments in both eyes was started on 5 LPM (40% FiO2) NNBH treatment 6-h per night. Visual acuity, OCT measurements of retinal thickness and volume, as well as the number of injections given in each eye were retrospectively examined one year prior and prospectively after initiation of NNBH, as well as before and after a planned 1-month discontinuation of NNBH.

RESULTS

The patient received 12 anti-VEGF injections in the year prior to beginning NNBH treatment (4 OD; 8 OS) and did not require any injections after commencing NNBH treatment. Visual acuity improved and stabilized to 20/20 and macular edema rapidly resolved in both eyes following initiation of NNBH. After a planned 1-month NNBH vacation, DME recurred but quickly resolved once NNBH treatment was restarted.

CONCLUSION

This model case demonstrates that a 6-h NNBH regimen can be successful in treating DME and improving vision, without the need for intravitreal injections. NNBH is a more acceptable treatment regimen compared to 24-h continuous oxygen delivery and may provide a less invasive alternate method for treating DME in patients with diabetes. Further study is warranted.

Intravitreal Methotrexate for Recalcitrant Epiretinal Membrane Reproliferation

This article reports a case of a 65-year-old woman with recalcitrant recurrent epiretinal membrane (ERM) treated with revision vitrectomy and membrane peeling followed by 12 weekly intravitreal methotrexate injections. Visual acuity and central macular thickness significantly improved, and no ERM recurrence developed 7 months after surgery. This case represents the first documented use of methotrexate to treat surgically resistant ERM reproliferation and indicates a potential for its use in cases that do not respond to standard treatment. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:49-51.].

Effect of Hometown Seasonality on Undergraduate Students' Risk of Developing Seasonal Affective Disorder

Seasonal affective disorder (SAD) is a prevalent and potentially serious medical condition. Young adults are at particularly high risk. However, it is unknown if college students whose hometowns are in geographic areas with less seasonal variability, such as in the state of Hawai'i, are particularly vulnerable if they attend schools in areas with seasonal variability. An adapted version of the Seasonal Patterns Assessment Questionnaire (SPAQ) was administered to students at 3 universities to test this hypothesis. Surveys were administered twice: a baseline (T0) assessment in the fall and a follow-up (T1) assessment in the winter and were administered in the second month of each semester. A linear regression model was constructed to identify potential risk factors for developing seasonal fluctuations in mood (SPAQ scores T1-T0). Study subjects (n=115) from non-seasonal hometowns had a 1.6-point greater increase in SPAQ score than students from seasonal hometowns (-0.26 ± 3.88 vs 1.35 ± 3.03; P =.01). This difference is independent of demographic and lifestyle predictors (linear regression coefficient: β = 1.73; standard error = 0.68; P =.012). Interestingly, SPAQ score changes of students from seasonal hometowns did not differ significantly from 0 (t = -0.97; P =.33), indicating that they did not generally experience seasonal shifts in depressive symptoms. Students from less seasonal hometowns and counselors at seasonal institutions should be aware that these students could be more at risk of developing depressive symptoms and address these concerns before interfering with students' daily and academic lives.

Anterior versus posterior endoscopic cyclophotocoagulation: comparison of indications, populations, and outcomes

PURPOSE

To examine how indications, patient characteristics, and outcomes differ between anterior and posterior approaches of endoscopic cyclophotocoagulation (ECP) in the treatment of glaucoma.

METHODS

This is a retrospective chart review of 9 anterior and 20 posterior ECP cases (n = 29).

RESULTS

Posterior ECP cases were typically associated with a dramatic increase in intraocular pressure (IOP), whereas the anterior ECP was associated with chronically elevated pressures. The initial IOPs in mm Hg of posterior ECP cases (26.8 non-NVG; 35.2 NVG) were much greater than anterior ECP cases (17.8), and a greater overall reduction in IOP was observed in the posterior versus anterior ECP cases (10.3 posterior non-NVG; 21.3 posterior NVG; 3.6 anterior, P < .001). With procedural success defined as 6-month post-operative IOP falling within normal ranges and a decrease in either IOP or number of prescribed glaucoma medications, the success rate of ECP was 92% for posterior NVG, 89% for anterior and 75% for posterior non-NVG cases (P = .34), similar to the previous literature. Of the four unsuccessful cases, two resulted in a normal IOP but lacked a drop in pressure or reduction in medication burden, one resulted in a 6-point drop in IOP but remained at 23 mm Hg, and one resulted in phthisis bulbi (3%) from an initial pressure above 40 mm Hg.

CONCLUSION

Endoscopic cyclophotocoagulation is an effective and safe procedure for severe glaucoma cases from both an anterior and posterior approach. Ophthalmologists should consider this procedure as part of their glaucoma treatment arsenal.

Relative Retinal Blood Flow: A Novel and Informative Measure of Unilateral Retinal Vein Occlusion Severity

Purpose

This study quantifies retinal vascular blood flow affected by unilateral central or branch retinal vein occlusion (CRVO or BRVO). We created a new, unitless metric for the severity of these diseases—relative blood flow (RBF)—and contextualized it with subject demographics, ocular presentation, and systemic conditions. Finally, we explored its efficacy as a predictor of future outcomes.

Methods

Data were collected from 20 control subjects and 32 clinically diagnosed CRVO (n = 15) or BRVO (n = 17) patients. We used laser speckle flowgraphy to quantify blood flow as mean blur rate and present RBF as the ratio between the blood flow in a subject's diseased and undiseased eyes. Because of our demonstration that blood flow has high intrapatient (between eyes and over time) but low interpatient correlation in eyes of healthy subjects, any differences between eyes can be attributed to the disease. These data were correlated with subject demographics and disease characteristics.

Results

In CRVO and BRVO eyes, average blood flow decreased by 26% and 7%, respectively. In CRVO, occlusion duration, central macular thickness, intraocular pressure, diabetes, previous laser and injection treatments, and injection within three months after measurement were significantly associated with RBF. In BRVO, no significant associations with RBF were found.

Conclusions

Blood flow in CRVO and BRVO was reduced compared to the unaffected fellow eye in most patients. RBF was useful in determining the severity of RVOs and predicting future treatment needs.

Translational Relevance

RBF is a promising new and informative metric for quantifying the severity of unilateral RVOs.

Rapid reduction of macular edema due to retinal vein occlusion with low-dose normobaric hyperoxia

PURPOSE

We investigated the effects of a relatively inexpensive, non-invasive, short-term treatment with low-dose normobaric hyperoxia (NBH) on macular edema in patients with retinal vein occlusion (RVO).

METHODS

Participants with macular edema associated with RVO were treated with 5 LPM of NBH via facemask (40% fraction of inspired oxygen, FIO2) for 3 h. Patients with non-fovea involving edema who elected to be observed returned for a second treatment 1 month later to test reproducibility.

RESULTS

A 3-h session of NBH (n = 45) resulted in decreased maximum macular thickness (MMT) (mean 7.10%, t₃₄=9.63 P<.001) and central macular thickness (CMT) (mean 4.64%, t₃₄=6.90, P<.001) when compared to untreated eyes with RVO measured over the same period of time (n = 12) or their healthy fellow eye (n = 34; MMT:t₃₄=-9.60, P<.001;CMT: t₃₄=-6.72, P<.001). Patients who had a second NBH treatment 1 month later experienced a recurrence of their edema, but demonstrated a similar significant reduction in MMT and CMT after the second NBH treatment.

CONCLUSIONS

Three-hour treatment with 40% FIO2 NBH results in a significant reduction in MMT and CMT. This study supports an ischemic mechanism for macular edema associated with retinal vein occlusion.

TRANSLATIONAL RELEVANCE

Short-term low-dose normobaric hyperoxia is a simple, inexpensive, and ubiquitous treatment that may provide an alternate or adjunctive approach to treating macular edema in patients who are resistant to or cannot afford anti-VEGF medications.

Medicare reimbursement to ophthalmologists: a comparison of Hawai'i to other states

When Medicare publically released data on payments made to specific physicians in April of 2014, it quickly became apparent that a large portion of 2012 Medicare reimbursements went to ophthalmologists. Part of the reason for this unusually high level of reimbursement was thought to be the cost of injectable drugs such as ranibizumab (brand name Lucentis). This study was designed to compare Hawai'i ophthalmologists' Medicare reimbursements with those of other states. In 2012, Medicare payment to ophthalmologists in Hawai'i was $18.2 million. Hawai'i ranked third in the nation in terms of percentage of total reimbursement going to ophthalmologists at 11.1% and 34th (8.2%) in percentage of ophthalmologist reimbursements going to injectable biological products. Hence, the high percentage of reimbursement going to ophthalmologists in Hawai'i is unlikely due to high use of injectable medications. Further research, based on a more detailed analysis of clinical data, is needed to determine how to slow the growth of health care costs while promoting high-value, effective care, not only for ophthalmic services but in other high-cost areas as well.

Practical approaches to incidental findings in brain imaging research

A decade of empirical work in brain imaging, genomics, and other areas of research has yielded new knowledge about the frequency of incidental findings, investigator responsibility, and risks and benefits of disclosure. Straightforward guidance for handling such findings of possible clinical significance, however, has been elusive. In early work focusing on imaging studies of the brain, we suggested that investigators and institutional review boards must anticipate and articulate plans for handling incidental findings. Here we provide a detailed analysis of different approaches to the problem and evaluate their merits in the context of the goals and setting of the research and the involvement of neurologists, radiologists, and other physicians. Protecting subject welfare and privacy, as well as ensuring scientific integrity, are the highest priorities in making choices about how to handle incidental findings. Forethought and clarity will enable these goals without overburdening research conducted within or outside the medical setting.

History of medical ethics and perspectives on disparities in minority recruitment and involvement in health research

The legitimate and successful recruitment of minorities as research participants in clinical trials should be addressed from an ethical and historical perspective. To gain an appreciation of the challenges, to develop strategies and to overcome the disparities of minority involvement in clinic trials, it is essential to be cognizant of previous violations and abuses of ethics and human rights. Also significant are major legislation, regulations and federal initiatives that resulted from those abuses. From history, we have learned we cannot generalize data and assume that, if we have the majority group in clinical trials, then we can accurately apply that data to minorities. There are cultural and environmental differences; thus, it is absolutely crucial that researchers approach recruitment of minority groups with cultural competence and cultural sensitivity. Federal regulations and legislation set the framework for protection of human participants in research.

History of medical ethics and perspectives on disparities in minority recruitment and involvement in health research

The legitimate and successful recruitment of minorities as research participants in clinical trials should be addressed from an ethical and historical perspective. To gain an appreciation of the challenges, to develop strategies and to overcome the disparities of minority involvement in clinic trials, it is essential to be cognizant of previous violations and abuses of ethics and human rights. Also significant are major legislation, regulations and federal initiatives that resulted from those abuses. From history, we have learned we cannot generalize data and assume that, if we have the majority group in clinical trials, then we can accurately apply that data to minorities. There are cultural and environmental differences; thus, it is absolutely crucial that researchers approach recruitment of minority groups with cultural competence and cultural sensitivity. Federal regulations and legislation set the framework for protection of human participants in research.

Enzymatic amplification of hepatitis B virus DNA in serum compared with infectivity testing in chimpanzees

The in vivo infectivity titration of hepatitis B virus (HBV) has been biologically standardized in terms of chimpanzee infectious dose (CID50). The polymerase chain reaction (PCR) was used for in vitro enzymatic amplification of HBV DNA and comparison with CID50. Serial dilutions of human serum specimens containing HBV adw (CID50 10(-7] and ayw (CID50 10(-7.5] were tested to determine the reproducibility and sensitivity of PCR for the detection of HBV DNA. The detection limit of HBV DNA in serum using PCR was 10(-8) for either amplification of HBV DNA extracted from serum or direct amplification of HBV DNA in proteolyzed serum. The amplification efficiency of PCR in proteolysates was not significantly reduced by using a 0.25% concentration (vol/vol) of nonionic detergents and 2.5% concentration (vol/vol) of digested human serum. Thus, PCR is a specific and rapid method for in vitro detection of HBV DNA that is more sensitive than the in vivo infectivity titration of HBV by chimpanzee inoculation. Therefore, if HBV-related DNA cannot be detected by PCR in specimens or biologic products, they probably do not contain infectious HBV.

Antibodies to synthetic peptides from the preS1 region of the hepatitis B virus (HBV) envelope (env) protein are virus-neutralizing and protective

Hepatitis B virus (HBV) envelope (env) proteins contain three antigenic domains designated S, preS2 and preS1. Studies with synthetic peptide immunogens demonstrated the role of preS2 epitopes in protection against HBV infection. The preS1 domain is implicated in virus-cell receptor interactions suggesting that anti-preS1-specific antibodies should neutralize the infectivity of HBV by blocking virus attachment to cells. We present here evidence that an antiserum to a peptide from the preS1 sequence, anti-preS(21-47), is virus-neutralizing and that active immunization of chimpanzees with a longer peptide derived from the preS1 sequence, preS(12-47), elicits antibodies protective against HBV infection. These results establish the role of the preS1 domain in the process of virus neutralization and the potential of synthetic preS1 analogues for hepatitis B vaccination.

Successful postexposure vaccination against hepatitis B in chimpanzees

To study the effect of postexposure vaccination, four chimpanzees were vaccinated with hepatitis B (HB) vaccine 4, 8, 48, and 72 hr, respectively, after intravenous injection of an infectious hepatitis B virus (HBV) inoculum. The second and third vaccine inoculations were given 2 and 6 weeks later, i.e., at considerably shorter intervals than recommended either for ordinary prophylactic vaccination or for postexposure vaccination in combination with hepatitis B immune globulin (HBIG). The chimpanzees were followed for 1 year. None showed HBs-antigenemia, liver enzyme elevation (ALT), or histopathological alterations in liver biopsies. Late appearance of anti-HBc was observed only in the serum of the animal whose series of vaccination started 72 hr after HBV inoculation. An unvaccinated control chimpanzee, which received the HBV inoculum only, developed clinical hepatitis B with ALT-elevations and HBs-antigenemia within 2 months of the experimental HBV inoculation. These results indicate that postexposure vaccination against hepatitis B begun within 48 hr after HBV exposure, with short intervals between the vaccine injections, can protect against hepatitis B infection also when concomitant HBIG-prophylaxis is not given.

Retrovirus-like particles in hepatocytes of patients with transfusion-acquired non-A, non-B hepatitis

Retrovirus-like particles 60-85 nm in diameter were observed in the cytoplasm of hepatocytes in liver biopsies obtained during the acute and chronic phases of non-A, non-B hepatitis (NANBH) in three patients with transfusion-acquired disease. The particles appeared in dilated endoplasmic reticulum cisternae as well as in enlarged Golgi vesicles. No such particles were seen in hepatocytes in liver biopsies similarly obtained during the acute or chronic phases of NANBH from 11 additional patients with NANBH who did not acquire their disease following blood transfusion. Particle-associated reverse transcriptase activity (peak activity at a density of 1.14 gm/ml) was present in the sera of all three "particle-positive" patients and also in 42% of the "particle-negative" patients. The retrovirus-like particles described here were apparently unrelated to the previously described human T cell lymphocytotropic retroviruses (HTLV), since none of the 14 patients studied had antibodies in their serum directed against antigens of any of the three known HTLVs.

Detection of reverse transcriptase activity in association with the non-A, non-B hepatitis agent(s)

Particle-associated reverse transcriptase activity was detected in four human serum specimens and in two plasma-derived products, all of which had been shown to transmit non-A, non-B hepatitis (NANBH) to other human beings and/or chimpanzees. Reverse transcriptase activity was also detected in all twelve sera from patients with acute or chronic NANBH. In contrast, reverse transcriptase activity was found in only 2 of 49 serum specimens from healthy plasma donors and laboratory workers. Sucrose density gradient fractions of two of the infectious human sera (peak reverse transcriptase activity at 1.14 g/ml) transmitted NANBH to chimpanzees. Biochemical and enzymatic data indicate that the NANBH agent(s) is a retrovirus or is retrovirus-like.

The prevalence of congenital heart disease among the population of a metropolitan cleft lip and palate clinic

The entire infant population of the Tufts-New England Medical Center Cleft Palate Clinic was reviewed, and the prevalence rates of congenital cardiac anomalies were calculated. The overall prevalence rate of congenital heart disease among the facial cleft clinic population was 6.7%, with a prevalence rate of 9.1% among patients with submucous cleft palate, 7.7% with congenital palato-pharyngeal incompetence, 0% with cleft lip only, 5.3% with unilateral cleft lip and palate, 12.5% with bilateral cleft lip and palate, 4.3% with cleft palate only, 13.6% with Pierre-Robin anomaly, 7.1% with cleft lip and palate and a syndrome diagnosis, 16.7% with cleft palate and a syndrome diagnosis.

Chemical characterization of an alkali-labile bond in the polypeptide of proline reductase from Clostridium sticklandii

In previous studies, it was shown that a 4600-dalton pyruvate-containing peptide is released from proline reductase by mild alkali treatment. The alkali-sensitive bond proved to be between Ser-Glu, and it was suggested that an ester, rather than a peptide linkage, might be involved. In the present study, the effects of additional esterolytic reagents, (I) LiBH4 and (II) NH2OH, on proline reductase have been investigated and compared with 0.1 N NaOH-induced cleavage. Treatment with reagents I and II released a peptide identical with the peptide released by alkali as judged by electrophoretic mobility on thin layer sheets, COOH-terminal analyses, and amino acid compositional studies. The glutamic acid residue is converted to alpha-amino-delta-hydroxyvaleric acid after reductive cleavage with LiBH4. The liberation of the peptide fragment by the relatively specific esterolytic reagent, LiBH4, provides additional support of the presence of an ester linkage in native proline reductase.

A pyruvate-containing peptide of proline reductase in Clostridium sticklandii

Proline reductase in Clostridium sticklandii is composed of 10 apparently identical subunits. Each subunit contains a pyruvate residue that became labeled when the cell culture was supplemented with [14C]serine. No NH2-terminal amino acid was detected either by dansylation, by Edman degradation, or by aminopeptidase M digestion. The results suggest that the NH2 terminus may be blocked by pyruvate. A pyruvate-containing peptide, also blocked at the NH2 terminus, was isolated from the NH2-terminal portion of proline reductase. From amino acid analysis the peptide was found to be rich in basic amino acids and to have a molecular weight of 4621. Its COOH-terminal amino acid was found to be serine and since the peptide was released from proline reductase by very mild alkali hydrolysis, it is suspected that an ester bond is involved.

Purification and properties of proline reductase from Clostridium sticklandii

Proline reductase of Clostridium sticklandii is a membrane-bound protein and is released by treatment with detergents. The enzyme has been purified to homogeneity and is estimated by gel filtration and sedimentation equilibrium centrifugation to have a molecular weight of 298,000 to 327,000. A minimum molecular weight of 30,000 to 31,000 was calculated on the basis of sodium dodecyl sulfate-acrylamide gel electrophoresis and amino acid composition. Amino acid analysis showed a preponderance of acidic amino acids. No tryptophan was detected in the protein either spectrophotometrically or by amino acid analysis. A total of 20 sulfhydryl groups measured by titration of the reduced protein with 5,5'-dithiobis(2-nitrobenzoic acid) is in agreement with 20 cystic acid residues determined in hydrolysates of performic acid-oxidized protein. No molybdenum, iron, or selenium was found in the pure protein. Although NADH is the physiological electron donor for the proline reductase complex, the purified 300,000 molecular weight reductase component is inactive in the presence of NADH in vitro. Dithiothreitol, in contrast, can serve as electron donor both for unpurified (putative proline reductase complex) and purified proline reductase in vitro.

In vivo kinetics of nitrogenase formation in Clostridium pasteurianum

Clostridium pasteurianum exhibits diauxic growth when grown in the presence of both NH(3) and N(2); no nitrogenase activity or formation was detected either serologically or by activity during growth on NH(3). During the 60-min lag that ensued after NH(3) was consumed and before growth resumed, molybdoferredoxin and azoferredoxin were first detected by activity measurements and serologically at 25 and 40 min, respectively. With the use of rifampin and dactinomycin, it was found that azoferredoxin messenger ribonucleic acid was initiated between 25 and 30 min after the inception of the lag and was completed by 38 min. An explanation of these results and their relation to possible models for the regulation of nitrogenase is given.