Comparison of disease severity in glaucoma patients identified by screening in the 1990s and in routine clinical care in the 2010s in Sweden

BACKGROUND AND PURPOSE

In a previous study comparing the amount of visual field damage at presentation in patients having open-angle glaucoma (OAG) identified through screening and in patients diagnosed in routine clinical practice in the 1990s, the damage was considerably worse in the clinically diagnosed patients. In the present study we compare visual field damage at presentation in the same 402 screened patients with that seen in 281 newly detected previously untreated patients clinically diagnosed in the 2010s.

METHODS

The perimetric visual field index mean deviation (MD) was compared in the two groups of patients.

RESULTS

In the clinical patients diagnosed with bilateral visual field damage the median MD was -5.1 dB in the better eye and -13.0 dB in the worse eye. In the screened patients the median MD in the better eye was -6.5 dB and -11.5 dB in the worse eye. The differences between the clinical and screened patients were non-significant, p = 0.28 and p = 0.67 respectively. More clinical patients had severe visual field loss, defined as MD less than -20 dB, in the worse eye than in the screened patients, 18.5% versus 12.7% respectively, p = 0.037.

CONCLUSION

The visual field damage at presentation in clinically diagnosed OAG patients has improved in the past 20 years, but the proportion of patients with severe visual field loss in at least one eye, almost 20%, is still unacceptably high considering that severe visual field damage at presentation is the most important risk factor for later development of glaucoma blindness.

Electronic health record-based patient tracking by emergency medicine physicians

OBJECTIVES

Emergency medicine (EM) physicians commonly track the progress of former patients to learn about their clinical outcome. While some studies have described the behavior, little is known about the specific information sought during tracking. The objective of this study was to determine how often EM physicians track patients and the motivations, strategies, and barriers to tracking.

METHODS

In June 2019 we surveyed EM physicians practicing at six hospitals. We defined patient tracking as viewing the chart of a patient who was no longer under the physician's care or contacting the patient or the patient's subsequent providers to learn about the patient's progress. The survey asked respondents how often they track patients, by what mechanisms, and for what reasons. The survey also asked what information physicians sought when tracking and what barriers to tracking exist.

RESULTS

Of the 156 EM physicians invited to respond, 111 completed the survey (72% response rate). Of those, 109 (98%) reported tracking their patients, and residents reported tracking a higher percentage of patients than attendings. Reasons for tracking included an unusual or complex case (98%), uncertain diagnosis (89%), and concern about a potential error (48%). Most respondents (86%) said that knowledge gained from patient tracking changed their subsequent practice patterns, and almost all respondents (98%) strongly agreed or agreed that tracking helps physicians avoid future mistakes. The most commonly sought information types during tracking were the hospital discharge summary or emergency department note from the index visit, test results since the index visit, and new diagnoses added since the index visit. Physicians cited time limitations and difficulty accessing information as the leading barriers to tracking.

CONCLUSIONS

Patient tracking is nearly ubiquitous among surveyed EM physicians, who find it valuable for learning and patient safety.

Cultural Problems Associated with the Implementation of eHealth

A major hurdle in eHealth implementation is that it is difficult to put into practice. In this study, the primary aim was to identify the main barrier associated with implementing eHealth. This study surveyed IMIA members from May to November 2015. From the results, it is clear that medical professionals were recording most of their data by hand. This paper culture is a paradigm that is difficult to break. Cultural factors are the primary barrier in eHealth implementation.

Why Patient Centered Care Coordination Is Important in Developing Countries? Contribution of the IMIA Health Informatics for Development Working Group

Patient Centered Care Coordination (PCCC) focuses on the patient health care needs. PCCC involves the organization, the patients and their families, that must coordinate resources in order to accomplish the goals of PCCC. In developing countries, where disparities are frequent, PCCC could improve clinical outcomes, costs and patients satisfaction.

OBJECTIVE

the IMIA working group Health Informatics for Development analyzes the benefits, identifies the barriers and proposes strategies to reach PCCC.

METHODS

Discussions about PCCC emerged from a brief guide that posed questions about what is PCCC, why consider PCCC important, barriers to grow in this direction and ask about resources considered relevant in the topic.

RESULTS

PCCC encompasses a broad definition, includes physical, mental, socio-environmental and self care. Even benefits are proved, in developing countries the lack of a comprehensive and integrated healthcare network is one of the main barriers to reach this objective. Working hard to reach strong health policies, focus on patients, and optimizing the use of resources could improve the performance in the devolvement of PCCC programs. International collaboration could bring benefits. We believe information IT, and education in this field will play an important role in PCCC.

CONCLUSION

PCCC in developing countries has the potential to improve quality of care. Education, IT, policies and cultural issues must be addressed in an international collaborative context in order to reach this goal.

Distribution of vasopressin in the forebrain of spotted hyenas

The extreme virilization of the female spotted hyena raises interesting questions with respect to sexual differentiation of the brain and behavior. Females are larger and more aggressive than adult, non-natal males and dominate them in social encounters; their external genitalia also are highly masculinized. In many vertebrates, the arginine vasopressin (VP) innervation of the forebrain, particularly that of the lateral septum, is associated with social behaviors such as aggression and dominance. Here, we used immunohistochemistry to examine the distribution of VP cells and fibers in the forebrains of adult spotted hyenas. We find the expected densely staining VP immunoreactive (VP-ir) neurons in the paraventricular and supraoptic nuclei, as well as an unusually extensive distribution of magnocelluar VP-ir neurons in accessory regions. A small number of VP-ir cell bodies are present in the suprachiasmatic nucleus and bed nucleus of the stria terminalis; however, there are extensive VP-ir fiber networks in presumed projection areas of these nuclei, for example, the subparaventricular zone and lateral septum, respectively. No significant sex differences were detected in the density of VP-ir fibers in any area examined. In the lateral septum, however, marked variability was observed. Intact females exhibited a dense fiber network, as did two of the four males examined; the two other males had almost no VP-ir septal fibers. This contrasts with findings in many other vertebrate species, in which VP innervation of the lateral septum is consistently greater in males than in females.

[Isolated hemi-ataxia as a sign of mesencephalic lacunar infarction]

INTRODUCTION

Lesions of the dento-rubro-thalamo-cortical pathway may cause homolateral or contralateral hemiataxia, depending on whether they are found above or below the decussation which occurs at the level of the inferior colliculus. Most mesencephalic infarctions causing hemiataxia also show oculomotor involvement with nuclear or fascicular lesions of the third cranial nerves. This was not seen in the case we report.

CLINICAL CASE

We describe the case of a diabetic patient with a permanent right appendicular hemiataxia, without oculomotor involvement, caused by a lacunar infarct shown on MR imaging which was situated in the antero-external part of the left superior mesencephalum.

CONCLUSIONS

This case helps to clarify the topography of the thalamic radiations of the mesencephalic calotte, including the decussated superior dento-rubro-thalamic pathway to the red nucleus. Involvement of this, situated in the mesencephalic lateral vascular territory causes contralateral hemiataxia.

Androstenedione effects on the vasopressin innervation of the rat brain

The steroid hormone androstenedione profoundly influences the development and expression of sexual and aggressive behavior. The neural basis of these effects are, however, poorly understood. In this study we evaluated androstenedione's ability to maintain vasopressin peptide levels in the gonadal steroid-responsive vasopressin cells of the bed nucleus of the stria terminalis and the centromedial amygdala, and their projections. Adult male rats were castrated and given testosterone, androstenedione or no hormonal treatment for five weeks. Their brains were then processed for vasopressin immunoreactivity. Androstenedione and testosterone treatment were equally effective in preventing the reduction of vasopressin immunoreactivity associated with castration. Androstenedione may therefore be able to mimic the effects of testosterone on testosterone-responsive neural systems.

Effects of the selective serotonin reuptake inhibitor fluoxetine on social behaviors in male and female prairie voles (Microtus ochrogaster)

The selective serotonin reuptake inhibitor fluoxetine modifies social behavior in a number of species, including humans. Because the neural substrates for social behavior in prairie voles are sexually dimorphic, we tested whether the effects of fluoxetine on these behaviors differ by sex. Parental and pair-bonded voles were chronically treated with fluoxetine or saline and subsequently tested for parental responsiveness. Fluoxetine-treated animals displayed a longer latency to exhibit parental responsiveness than did saline-treated controls (p < 0.02), but they did not differ in other aspects of parental care. There were no sex differences in the effects of fluoxetine on parental behavior. After completion of the tests for parental behavior, the subjects were tested for aggressive behavior using the resident-intruder paradigm. Fluoxetine-treated males displayed less aggressive behavior than their saline-treated counterparts (p < 0.02). Although we did not find any effects of fluoxetine on aggressive behavior in females, no significant interaction was found between sex and treatment. Fluoxetine did not alter nonsocial behaviors. The findings suggest that serotonin influences social behavior in prairie voles.

Masculine sexual behavior is disrupted in male and female mice lacking a functional estrogen receptor alpha gene

Masculine sexual behavior is regulated by testosterone (T). However, T can be metabolized to form estrogens or other androgens, which then activate their own receptors. We used knockout mice lacking a functional estrogen receptor alpha (ER alpha) gene to test the hypothesis that, following aromatization, T acts via the ER alpha to activate normal masculine sexual behavior. After gonadectomy and T replacement, wild-type (WT) male and female mice displayed masculine behavior. However, given the same T treatment, little masculine behavior was displayed by mice of either sex that lack a normal copy of the ER alpha gene. In particular, the latency to display masculine sex behavior and the number of mount attempts per trial were significantly reduced in the ER alpha- mice compared to WT littermates (P < 0.05). In addition, we found that in both sexes, ER alpha- mice have a smaller cluster of androgen receptor immunoreactivity in the bed nucleus of the stria terminalis. Using adult ER alpha- mice we were unable to determine whether these genotypic differences are due to organizational or activational effects. However, it is clear that the ER alpha plays a key role in the expression of masculine sexual behavior and in the regulation of androgen receptors in a neuronal cell population involved in the display of motivated behaviors.

Effects of photoperiod and androgen on pituitary function and neuropeptide staining in Siberian hamsters

Short photoperiods decrease gonadotropin secretion in Siberian hamsters, but it is unknown whether the negative feedback effects of androgens are amplified under such conditions, as is the case in other species. Photoperiod regulates the synthesis and secretion of gonadotropin-releasing hormone (GnRH), beta-endorphin, and arginine vasopressin (AVP), which influence gonadotropin release and sexual behavior but are themselves regulated by gonadal steroid hormones. To determine the role of androgen in these effects of daylength, immunostaining and gonadotropin concentrations were examined after 8 wk of exposure to long or short days (LD or SD). Animals were either left intact, castrated, or castrated with immediate or delayed replacement of testosterone (T). We also investigated effects of age on photoperiodic influences on brain peptides and serum hormone levels. Serum prolactin concentrations were regulated by photoperiod and by gonadal status in LD hamsters. Effects of T on follicle-stimulating hormone secretion were more pronounced in SD hamsters. Older hamsters were generally less responsive to effects of daylength on pituitary function. Photoperiod and gonadal status regulated the number of AVP-immunoreactive (ir) cells in the bed nucleus of the stria terminalis and the medial amygdala. Androgen treatment yielded more AVP-ir neurons in LD than in SD. Photoperiod influenced the number of GnRH-ir cells only in the medial septum of castrated hamsters. Daylength regulated beta-endorphin-ir neurons in intact hamsters, but not in castrates. Only among old hamsters did photoperiod affect the influence of T on beta-endorphin staining in neurons and fibers. Such fiber staining was unaffected by photoperiod in intact and T-treated castrate hamsters, but was reduced in SD castrates. We conclude that daylength modulates the effects of androgen on gonadotropin secretion and influences the effect of T on neuropeptide staining in regionally specific patterns that depend on the age of the animal and its history of prior steroid exposure.

[Hemiballismus heralding thrombosis of the basilar artery]

We present a patient with top-of-the-basilar syndrome that was preceded by hemiballismus and progressed to coma and tetraplegia. Magnetic resonance imaging showed extensive infarction in the basilar artery territory. Cerebral angiography confirmed basilar artery obstruction. The patient died in spite of anticoagulation therapy.