Importance of Higher-Order Aberrations on Both Anterior and Posterior Surfaces After Pterygium Surgery

PURPOSE

The purpose of this study was to investigate the changes in higher-order aberrations (HOAs), coma, and spherical aberrations (SAs) on the anterior, posterior, and total corneal surfaces after pterygium excision.

METHODS

In this single-center study, we examined 19 eyes of 15 patients who underwent pterygium excision at Yokohama Minami Kyosai Hospital between January 2017 and December 2017. We also evaluated 25 eyes of 25 age-matched patients with no history of ocular disease as the control group. Corneal topography, total HOAs, coma, and SAs in all regions at 4 and 6 mm diameters were evaluated using anterior segment optical coherence tomography (CASIA SS-1000, Tomey, Japan). The pterygium area and extent were also assessed.

RESULTS

Significant improvements in the HOAs, coma, and SAs at both diameters were observed in the total and anterior corneas from the first postoperative month. Notably, the posterior cornea showed significant improvements in HOAs (4 mm: P < 0.001 [log HOAs]; 6 mm: P = 0.001 [log HOAs]) and coma (4 mm: P = 0.003 [log coma], 6 mm: P = 0.002 [log coma]) within both diameters at 1 month postoperatively. A strong correlation was identified among the pterygium area, posterior HOAs, and coma (Spearman correlation = 0.651). Pterygium induced 2 D of astigmatism when extension exceeded 2.1 mm.

CONCLUSIONS

HOAs in both the anterior and posterior corneas improved after pterygium excision. This finding underscores the importance of considering corneal aberrations on both anterior and posterior surfaces in pterygium management.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Gender-based differences in the job titles and lifestyles in the cataract and refractive surgery society in Japan

To investigate sex differences in the titles and lifestyles of Japanese ophthalmologists, we evaluated work places and private lives. Retrospective cross-sectional study. The study included 1721 members (1344 males and 377 females) of the Japanese Society of Cataract and Refractive Surgery. An online, anonymized questionnaire was distributed to the society members. The questionnaire included 40 questions to collect data on profiles, lifestyles, job title, families, spouses, children, household chores, child-rearing, and work satisfaction. In total, 219 members (144 males and 75 females; 53.4 ± 1.0 and 51.3 ± 9.9 years old, respectively) completed the questionnaire. The job title, working time, annual income, marriage rate, and the number of children significantly differed between male and female respondents. Female respondents had greater responsibilities toward house chores, child care, and nursing, whereas several male doctors had spouses who did not work or worked for shorter times, earned a lower income, and contributed greater toward family responsibilities. Female respondents changed their job titles after having children more frequently than male respondents. Both males and females had limited time available for community activities and volunteer work. There were no significant differences in daily sleep duration. Both sexes were equally satisfied with their career choice of ophthalmology; however, fewer females recommended ophthalmology as a career for students and children compared to males. There are significant sex differences among ophthalmologists in Japan in terms of family responsibilities; this topic has received insufficient attention.

Ultrasound Assessment of Abdominal Muscle Thickness With and Without Lumbopelvic Pain in Pregnant Women

OBJECTIVES

Lumbopelvic pain (LPP) is a very common cause of discomfort during pregnancy, but its etiology remains unclear. The association between abdominal muscle thickness and LPP in pregnant women has not been studied extensively, despite the significant abdominal changes that occur during pregnancy. This study aimed to examine the relationship between abdominal muscle thickness and LPP in pregnant women.

METHODS

In this study, 49 pregnant women in their second trimester participated. The intensity of LPP was assessed using a numerical rating scale. Ultrasound imaging was used to measure the thickness of abdominal muscles, including the rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles. Participants were classified into two groups, the LPP group and non-LPP group, and the abdominal muscle thickness was compared between the two groups. The statistical significance level was set at P < .05.

RESULTS

There were 24 and 25 participants in the LPP and non-LPP groups, respectively. Internal oblique (IO) thickness was significantly thinner in the LPP group than in the non-LPP group (5.4 ± 0.2 mm versus 6.1 ± 0.2 mm; P = .042). Multivariate logistic regression analysis showed that IO thickness was significantly associated with LPP (odds ratio, 0.516; 95% confidence interval, 0.284-0.935; P = .019).

CONCLUSIONS

This study suggested that LPP in second trimester pregnancy might be related to IO thickness. Further longitudinal studies are needed to understand the role of this muscle as an LPP risk factor for pregnant women.

First Dark Matter Search with Nuclear Recoils from the XENONnT Experiment

We report on the first search for nuclear recoils from dark matter in the form of weakly interacting massive particles (WIMPs) with the XENONnT experiment, which is based on a two-phase time projection chamber with a sensitive liquid xenon mass of 5.9 ton. During the (1.09±0.03)  ton yr exposure used for this search, the intrinsic ^{85}Kr and ^{222}Rn concentrations in the liquid target are reduced to unprecedentedly low levels, giving an electronic recoil background rate of (15.8±1.3)  events/ton yr keV in the region of interest. A blind analysis of nuclear recoil events with energies between 3.3 and 60.5 keV finds no significant excess. This leads to a minimum upper limit on the spin-independent WIMP-nucleon cross section of 2.58×10^{-47}  cm^{2} for a WIMP mass of 28  GeV/c^{2} at 90% confidence level. Limits for spin-dependent interactions are also provided. Both the limit and the sensitivity for the full range of WIMP masses analyzed here improve on previous results obtained with the XENON1T experiment for the same exposure.

Searching for Heavy Dark Matter near the Planck Mass with XENON1T

Multiple viable theoretical models predict heavy dark matter particles with a mass close to the Planck mass, a range relatively unexplored by current experimental measurements. We use 219.4 days of data collected with the XENON1T experiment to conduct a blind search for signals from multiply interacting massive particles (MIMPs). Their unique track signature allows a targeted analysis with only 0.05 expected background events from muons. Following unblinding, we observe no signal candidate events. This Letter places strong constraints on spin-independent interactions of dark matter particles with a mass between 1×10^{12} and 2×10^{17}  GeV/c^{2}. In addition, we present the first exclusion limits on spin-dependent MIMP-neutron and MIMP-proton cross sections for dark matter particles with masses close to the Planck scale.

Search for New Physics in Electronic Recoil Data from XENONnT

We report on a blinded analysis of low-energy electronic recoil data from the first science run of the XENONnT dark matter experiment. Novel subsystems and the increased 5.9 ton liquid xenon target reduced the background in the (1, 30) keV search region to (15.8±1.3)  events/(ton×year×keV), the lowest ever achieved in a dark matter detector and ∼5 times lower than in XENON1T. With an exposure of 1.16 ton-years, we observe no excess above background and set stringent new limits on solar axions, an enhanced neutrino magnetic moment, and bosonic dark matter.

Material radiopurity control in the XENONnT experiment

The selection of low-radioactive construction materials is of the utmost importance for rare-event searches and thus critical to the XENONnT experiment. Results of an extensive radioassay program are reported, in which material samples have been screened with gamma-ray spectroscopy, mass spectrometry, and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$^{222}$$\end{document}222Rn emanation measurements. Furthermore, the cleanliness procedures applied to remove or mitigate surface contamination of detector materials are described. Screening results, used as inputs for a XENONnT Monte Carlo simulation, predict a reduction of materials background (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\sim $$\end{document}∼17%) with respect to its predecessor XENON1T. Through radon emanation measurements, the expected \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$^{222}$$\end{document}222Rn activity concentration in XENONnT is determined to be 4.2 (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$^{+0.5}_{-0.7}$$\end{document}-0.7+0.5) \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\upmu $$\end{document}μBq/kg, a factor three lower with respect to XENON1T. This radon concentration will be further suppressed by means of the novel radon distillation system.

Infectious keratitis after corneal crosslinking for keratoconus caused by levofloxacin-resistant microorganisms

Introduction

We present seven cases of infectious keratitis after corneal crosslinking (CXL) to attenuate keratoconus progression.

Methods

Of 524 consecutive patients who underwent CXL, 7 cases (4 males and 3 females; 21.5 ± 7.1 years) developed postoperative infectious keratitis were retrospectively reviewed. CXL was performed using the Dresden protocol or an accelerated protocol involving epithelial removal.

Results

All cases appeared normal on the day after surgery, but subsequently developed eye pain, blurred vision, corneal infiltration, inflammation of the anterior chamber, and ciliary injection on day 2 or 3. Methicillin-resistant Staphylococcus aureus was cultured from two eyes, methicillin-sensitive Staphylococcus aureus from two eyes, and Streptococcus pneumoniae from one eye. All detected bacteria were resistant to levofloxacin (LVFX). Five of the seven cases, especially four of the five severe cases with hypopyon, had a history of atopic dermatitis. All cases were observed after 2015.

Conclusions

Infectious keratitis after CXL caused by microbes resistant to LVFX is increasing. In addition to careful postoperative observation of the cornea, preoperative evaluation of bacteria within the conjunctival sac evident on nasal swab cultures may be useful to identify potentially problematic microbes and inform the selection of appropriate antibiotics.

Corneal Cross-Linking for Paediatric Keratoconus: A Systematic Review and Meta-Analysis

All corneal cross-linking techniques attenuated disease progression in patients with pediatric keratoconus for at least one year based on a meta-analysis. A standard and accelerated technique led to marked improvement in visual acuity. We determined the efficacy and safety of corneal cross-linking (CXL) in pediatric keratoconus by conducting a systematic review and meta-analysis. The PubMed and Cochrane databases were searched for relevant studies on the effects of standard, transepithelial, and/or accelerated CXL protocols in patients aged 18 years or younger. Standardized mean differences with 95% confidence intervals were calculated to compare the data collected at baseline and 12 months. The primary outcomes were maximum keratometry (Kmax) and uncorrected visual acuity (UCVA), and the secondary outcomes were the thinnest corneal thickness (TCT), best-corrected visual acuity (BCVA), and manifest refraction spherical equivalent or cylindrical refraction. Our search yielded 7913 publications, of which 26 were included in our systematic review and 21 were included in the meta-analysis. Standard CXL significantly improved the Kmax, UCVA, and BCVA, and significantly decreased the TCT. Accelerated CXL significantly improved UCVA and BCVA. In the transepithelial and accelerated-transepithelial CXL methods, each measurable parameter did not change after treatments. All CXL techniques attenuated disease progression in patients with pediatric keratoconus for at least one year. Standard and accelerated CXL led to marked improvement in visual acuity.

Validation of the World Health Organization/ International Society of Hypertension (WHO/ISH) cardiovascular risk predictions in Sri Lankans based on findings from a prospective cohort study

Introduction and objectives

There are no cardiovascular (CV) risk prediction models for Sri Lankans. Different risk prediction models not validated for Sri Lankans are being used to predict CV risk of Sri Lankans. We validated the WHO/ISH (SEAR-B) risk prediction charts prospectively in a population-based cohort of Sri Lankans.

Method

We selected 40–64 year-old participants from the Ragama Medical Officer of Health (MOH) area in 2007 by stratified random sampling and followed them up for 10 years. Ten-year risk predictions of a fatal/non-fatal cardiovascular event (CVE) in 2007 were calculated using WHO/ISH (SEAR-B) charts with and without cholesterol. The CVEs that occurred from 2007–2017 were ascertained. Risk predictions in 2007 were validated against observed CVEs in 2017.

Results

Of 2517 participants, the mean age was 53.7 year (SD: 6.7) and 1132 (45%) were males. Using WHO/ISH chart with cholesterol, the percentages of subjects with a 10-year CV risk <10%, 10–19%, 20%-29%, 30–39%, ≥40% were 80.7%, 9.9%, 3.8%, 2.5% and 3.1%, respectively. 142 non-fatal and 73 fatal CVEs were observed during follow-up. Among the cohort, 9.4% were predicted of having a CV risk ≥20% and 8.6% CVEs were observed in the risk category. CVEs were within the predictions of WHO/ISH charts with and without cholesterol in both high (≥20%) and low(<20%) risk males, but only in low(<20%) risk females. The predictions of WHO/ISH charts, with-and without-cholesterol were in agreement in 81% of subjects (ĸ = 0.429; p<0.001).

Conclusions

WHO/ISH (SEAR B) risk prediction charts with-and without-cholesterol may be used in Sri Lanka. Risk charts are more predictive in males than in females and for lower-risk categories. The predictions when stratifying into 2 categories, low risk (<20%) and high risk (≥20%), are more appropriate in clinical practice.

Auditory brainstem responses in adults with autism spectrum disorder

OBJECTIVE

To investigate possible differences in the auditory peripheral and brainstem functions between adults with autism spectrum disorder (ASD) and neurotypical (NT) adults.

METHODS

Click-evoked auditory brainstem responses (ABRs) were obtained from 17 high-functioning ASD adults (aged 21-38 years) and 20 NT adults (aged 22-36 years). A relatively large number of stimulus presentations (6000) were adopted, and ABRs by horizontal and vertical electrode montages were evaluated, in order to allow precise evaluations of early ABR components.

RESULTS

Waves I, II, III, and V were identified in the vertical electrode montage, and wave I and the summating potential (SP) in electrocochleograms were identified in the horizontal electrode montage. There were no significant group differences in the wave I, II, III, and V latencies or the interpeak latencies (IPLs) in the vertical electrode montage. In the horizontal montage, the ASD adults exhibited significantly shortened SP latencies compared with the NT adults, whereas there was no significant group difference in the wave I latency.

CONCLUSION

The ASD adults may have the abnormalities of processing more in the peripheral auditory system than in the brainstem.

SIGNIFICANCE

The current study suggests that the peripheral abnormality is associated with ASD.

Evaluation of the Physiological Corneal Intrastromal Riboflavin Concentration and the Corneal Elastic Modulus After Violet Light Irradiation

Purpose

KeraVio is a corneal crosslinking treatment modality that utilizes violet light (VL)-emitting glasses and topical epithelium-on riboflavin administration. We focus on the new KeraVio protocol without riboflavin. This study aims to quantify the physiological intrastromal concentrations of riboflavin in corneas without riboflavin decreases and evaluate the biomechanics of corneas after VL irradiation.

Methods

Twelve human donor corneas were included in this study and randomly categorized into four groups. The corneas underwent four imbibition techniques (physiological riboflavin without drops, epithelial [epi]-on with 0.05% flavin adenine dinucleotide [FAD], epi-off with FAD, and 0.1% riboflavin epi-off). Corneas in the FAD epi-on, FAD epi-off, and riboflavin epi-off groups were instilled with the respective solution every 2 minutes for 30 minutes. An ex vivo experiment was conducted with 24 porcine corneas arranged into three treatment groups and one control group. Corneas in the KeraVio with FAD epi-on group were treated with VL irradiation at 0.31 mW/cm² for 4.8 hours (5.4 J/cm²) and simultaneously received FAD drops every 30 minutes during the VL irradiation. Corneas in the group with KeraVio without FAD epi-on were only treated with VL irradiation (5.4 J/cm²).

Results

We identified the original physiological riboflavin of human corneal stroma at a concentration of 0.31 ± 0.03 µg/g, but its value was approximately 39-fold smaller than that in the 0.1% riboflavin epi-off group. The group with KeraVio without FAD and the standard corneal crosslinking group showed a significant increase in biomechanical stability compared with the controls, whereas the elastic modulus in the treated groups was equivalent.

Conclusions

We preliminarily identified physiological riboflavin in human corneas without adding riboflavin drops. The VL exposure may strengthen the corneal biomechanics without requiring the use of additional riboflavin drops.

Translational Relevance

We preliminarily identified physiological riboflavin in the human cornea without adding riboflavin drops. VL irradiation without riboflavin drops may increase the corneal stiffness using physiological riboflavin.

222 Rn emanation measurements for the XENON1T experiment

The selection of low-radioactive construction materials is of utmost importance for the success of low-energy rare event search experiments. Besides radioactive contaminants in the bulk, the emanation of radioactive radon atoms from material surfaces attains increasing relevance in the effort to further reduce the background of such experiments. In this work, we present the 222 Rn emanation measurements performed for the XENON1T dark matter experiment. Together with the bulk impurity screening campaign, the results enabled us to select the radio-purest construction materials, targeting a 222 Rn activity concentration of 10 μ Bq / kg in 3.2 t of xenon. The knowledge of the distribution of the 222 Rn sources allowed us to selectively eliminate problematic components in the course of the experiment. The predictions from the emanation measurements were compared to data of the 222 Rn activity concentration in XENON1T. The final 222 Rn activity concentration of ( 4.5 ± 0.1 ) μ Bq / kg in the target of XENON1T is the lowest ever achieved in a xenon dark matter experiment.

Search for Coherent Elastic Scattering of Solar ^{8}B Neutrinos in the XENON1T Dark Matter Experiment

We report on a search for nuclear recoil signals from solar ^{8}B neutrinos elastically scattering off xenon nuclei in XENON1T data, lowering the energy threshold from 2.6 to 1.6  keV. We develop a variety of novel techniques to limit the resulting increase in backgrounds near the threshold. No significant ^{8}B neutrinolike excess is found in an exposure of 0.6  t×y. For the first time, we use the nondetection of solar neutrinos to constrain the light yield from 1-2 keV nuclear recoils in liquid xenon, as well as nonstandard neutrino-quark interactions. Finally, we improve upon world-leading constraints on dark matter-nucleus interactions for dark matter masses between 3 and 11  GeV c^{-2} by as much as an order of magnitude.

A novel mitral stenosis assessment using projected transmitral gradient improves the diagnostic and prognostic yields of doppler-based gradient

Background

Transmitral gradient (TMG) is highly dependent on hemodynamic state, leading to discordance between TMG and mitral valve area (MVA). The effect of heart rate (HR) and stroke volume (SV) on TMG among patients with mitral stenosis (MS) is poorly understood.

Purposes

We aimed to (1) develop a formula for projected TMG (proTMG) for assessment of MS severity under varying hemodynamics; (2) assess the prognostic value of proTMG in patients with MS.

Methods

All patients evaluated for suspected MS without ≥moderate other valve disorder at our tertiary center between 2001 and 2017 were analyzed. Projected TMG is the expected gradient under normal flow (SV 80–94 ml and HR 60–79 bpm), and was modeled based on the observed impact of HR and SV on TMG by multiple regression analysis. The data were randomly split (2:1) into training and testing sets. The improvement in agreement between MVA and proTMG was evaluated. Composite cardiac events including all-cause death and mitral valve interventions were compared according to TMG grade using TMG and proTMG. Severe and moderate MS were defined as MVA ≤1.5 cm2 and 1.5–2.0 cm2 respectively, by the continuity equation. MVA ≤1.0 cm2 was considered as very severe MS.

Results

Of 4973 patients with suspected MS (age 73±12 years, 33% male), severe MS was present in 437 (9%, including 98 with very severe MS) and moderate MS in 934 (19%). In 838 patients with normal HR and SV, very severe, severe and moderate MS corresponded to TMG ≥12 mmHg, ≥6 mmHg and 4–6 mmHg, respectively. In the training set (n=3315), the median [interquartile range] of HR and SV were 70 [61–80] bpm and 97 [83–113] mL in men (n=1120), and 72 [63–82] bpm and 84 [71–97] mL in women (n=2195), respectively. The impact of HR and SV on TMG for men and women were 0.07 and 0.08 mmHg per 1 bpm increase in HR (95% confidence interval [CI] 0.06–0.07 and 0.07–0.08), and 0.03 and 0.05 mmHg per 1 mL increase in SV (95% CI 0.03–0.03 and 0.04–0.05), respectively. Therefore, the final formula to calculate proTMG was: proTMG=TMG-0.07(HR-70)-0.03(SV-97) in men and proTMG=TMG-0.08(HR-72)-0.05(SV-84) in women. In the testing set (n=1658), the proTMG (kappa=0.63, 95% CI 0.60–0.66) had better agreement with MS severity by MVA than TMG (kappa=0.28, 95% CI 0.24–0.32). To explore the prevalence of patients reclassified using proTMG, in 98 with TMG ≥12 mmHg, proTMG remained ≥6 mmHg. Of 657 with TMG 6–12 mmHg, proTMG remained ≥6 mmHg in 356 (54%), and decreased to &lt;6 mmHg in 301 (46%). In patients with TMG 6–12 mmHg, proTMG ≥6 mmHg was associated with higher probability of cardiac events compared with &lt;6 mmHg during follow-up of 2.8±3.1 years (Figure).

Conclusion

We propose a novel concept of projected TMG defined as the expected transmitral gradient at normal HR and SV levels. This improved the diagnostic yield of Doppler TMG measurements for MS severity assessment and identified a low-risk subset of patients with elevated TMG due to high HR or SV.

Funding Acknowledgement

Type of funding source: None

The prevalence and natural history of mitral annulus calcification

Background

There is a paucity of data about the prevalence and natural history of mitral annular calcification (MAC).

Purposes

In a large cohort of patients undergoing clinically-indicated echocardiography, we aimed to evaluate the prevalence and the natural history of MAC, and the frequency of associated mitral valve dysfunction (MVD).

Methods

Retrospective review of all patients who underwent echocardiographic evaluation at our institution between January 1st and December 31st 2015. The patients were stratified into 3 groups: MAC with MVD, MAC without MVD, no MAC. MVD was defined as moderate or greater mitral regurgitation (MR) or stenosis (MS). The 3 groups were compared for baseline clinical and echocardiographic characteristics and all-cause mortality during follow-up.

Results

Of 24,415 evaluated patients, 5478 (22%) had MAC. Patients with MAC were older (75±10 vs. 60±16 years, p&lt;0.01) and more often female (46% vs. 43%, p&lt;0.01). MVD was more frequently observed in patients with MAC (16% vs. 7%, p&lt;0.01); moderate or greater MR was found in 10% of patients with MAC vs. 6% without MAC (p&lt;0.01) and MS in 7% vs. 0.5% (p&lt;0.01). In patients with MAC, those with MVD were more often female and more frequently had creatinine ≥2mg/dl and moderate or greater aortic stenosis (AS) than those without MVD (Fig. A). Kaplan-Meier survivals at 1 year were 75% in patients with MAC and MVD, 87% in those with MAC without MVD, and 92% in those without MAC (Fig B). Adjusted for age, sex, diabetes, creatinine ≥2 mg/dl, coronary artery disease, left ventricular ejection fraction &lt;50%, and AS, MAC was associated with higher all-cause mortality (adjusted hazard ratio1.4, 95% confidence interval: 1.3–1.5, p&lt;0.01); combined MAC and MVD was associated with the highest mortality during follow-up of 2.5±1.8 years.

Conclusion

In a large cohort of patients undergoing echocardiographic evaluation, the prevalence of MAC was 22%. MV dysfunction was more than twice as prevalent in patients with MAC as without. Patients with MAC had higher all-cause mortality than patients without MAC. Among patients with MAC and mitral valvular dysfunction, adjusted mortality was two-fold higher compared to those without MAC.

Funding Acknowledgement

Type of funding source: None

Symptoms and natural history in patients with isolated severe calcific mitral stenosis

Background

Prevalence of calcific mitral stenosis (MS) increases with age. Mitral valve interventions for calcific MS are often delayed until symptoms are severely limiting because the natural history of calcific MS and its relation to cardiac symptoms or comorbidities have not been well assessed.

Objectives

We assessed the prevalence of symptoms, comorbidities and determinants of all-cause mortality in patients with severe calcific MS.

Methods

We retrospectively investigated adults with echocardiographic isolated severe MS, defined as mitral valve area (MVA by the continuity equation) ≤1.5 cm2, from July 2003 to December 2017. Among them, calcific MS was identified as obstruction of left ventricular inflow due to degenerative calcification of the mitral annulus using echocardiography and, whenever available, operative findings including histopathological examination. Inactivity was defined as requirement for assistance with activities of daily living. Follow up was obtained by review of medical records.

Results

Of 491 patients with isolated severe MS, calcific MS was present in 200 (41%; age 78±11 years, 18% men, 32% with atrial fibrillation). Charlson Comorbidity Index (CCI) was 5.1±1.7 and 14 (7%) were inactive. MVA and transmitral gradient (TMG) were 1.26±0.19 cm2 and 8.1±3.8 mmHg, respectively. Symptoms were present at baseline in 120 (60%) including dyspnea in 97, chest discomfort in 12, syncope in 3, lower extremity edema in 3, thrombosis in 3 and fatigue in 2. Of them, mitral valve interventions including surgical or transcatheter mitral valve replacement and mitral valve bypass were performed in 27 (23%): within 1 year after index TTE in 23 (19%) and at 2, 4, 5 and 6 years in 1 each. Of 80 patients without symptoms at index TTE, 20 (25%) developed symptoms at mean 2.9±3.2 years and interventions were performed in 5 (6%). Of 168 who did not receive interventions, 60 (36%) did not develop symptoms during follow up, 58 (35%) were considered to have moderate MS, 46 (27%) were not offered surgery because of high risk due to advanced age, multiple comorbidities or heavy calcification, and 2 (1%) declined interventions. During follow-up of 2.8±3.0 years, Kaplan-Meier survival at 1 and 3 years without intervention were 72% and 52%, respectively (Fig. A). Inactivity, CCI &gt;5, left ventricular ejection fraction (LVEF) &lt;50%, TMG ≥8 mmHg (the mean TMG) and right ventricular systolic pressure (RVSP) ≥50 mmHg were independently associated with mortality (Fig. B). Symptoms were associated with referral for interventions (OR 3.43, 95% CI 1.22–9.65; p=0.019), but not with mortality.

Conclusion

Patients with isolated severe calcific MS had a high burden of comorbidities and had high mortality without intervention. Symptoms were common (60%), but were not associated with mortality. TMG ≥8 mmHg, RVSP ≥50 mmHg, LVEF&lt;50%, CCI &gt;5 and inactivity were independently associated with mortality.

Funding Acknowledgement

Type of funding source: None

Factors associated with endothelial cell density loss post Descemet membrane endothelial keratoplasty for bullous keratopathy in Asia

PURPOSE

To investigate the factors associated with endothelial survival after Descemet's membrane endothelial keratoplasty (DMEK) in eyes of Asian patients with bullous keratopathy (BK).

METHODS

In this retrospective, consecutive interventional case series, 72 eyes of 72 patients who underwent DMEK were evaluated. Best corrected visual acuity (BCVA) and corneal endothelial cell density (ECD) were assessed at 12 months postoperatively. Multiple regression analysis was performed to assess parameters such as age, sex, axial length, preoperative visual acuity, re-bubbling, the ratio of graft to cornea area, iris damage scores, types of filling gases, air or SF6 volume in the anterior chamber (AC) on postoperative day 1, and ECD loss rates at 12 months postoperatively.

RESULTS

BCVA improved significantly at 12 months after DMEK (P < .001). The rate of ECD loss at 12 months after DMEK was 54.4 ± 16.1%. Multiple linear regression analysis showed that a larger ratio of graft to corneal area (P = 0.0061) and higher donor ECD (P = 0.042) were the primary factors for a lower ECD loss rate at 12 months after DMEK.

CONCLUSION

A relatively larger graft size compared to the host cornea and more donor ECD might help endothelial survival in patients with BK. Moreover, for such patients, the surgeon should attempt to use a relatively larger graft size when performing DMEK, particularly in Asian eyes.

Baseline factors predicting the need for corneal crosslinking in patients with keratoconus

INTRODUCTION

The primary purpose of crosslinking is to halt the progression of ectasia. We retrospectively assessed the condition of keratoconus patients who were followed-up at least twice after the initial examination to evaluate keratoconus progression, to identify definitive factors to predict a later need for corneal crosslinking (CXL).

METHODS

The medical charts of 158 eyes of 158 keratoconus patients (112 males and 46 females; mean age, 27.8 ± 11.7 years), who were followed up at the Department of Ophthalmology, Keio University School of Medicine at least twice after the initial examination to evaluate keratoconus progression were retrospectively reviewed. Best-spectacle corrected visual acuity, intraocular pressure, steepest corneal axis on the anterior float (Ks), thinnest corneal thickness according to Pentacam® HR, and corneal endothelial cell density were assessed. Gender, age, onset age of keratoconus, history of atopic dermatitis, and Pentacam® indices were also recorded. CXL was performed when the eye showed significant keratoconus progression, an increase in the steepest keratometric value, or an increase in the spherical equivalent or cylinder power of the manifest refraction by more than 1.0 D versus the respective values 2 years prior. Predictor variables and the requirement for CXL were analyzed using logistic regression.

RESULTS

Fifty-eight eyes required CXL treatment. The best predictor of the requirement for CXL was patient age, followed by the Pentacam® Rmin (the minimum sagittal curvature evaluated by Pentacam®) value. The incidence of CXL was 86.4% in the < 20 years age group, with an Rmin of ≤ 5.73 mm, whereas 10.8% in the ≥ 27 years age group with an Rmin > 5.73 mm underwent treatment.

CONCLUSIONS

An age of < 20 years and an Rmin value of ≤ 5.73 mm predicted keratoconus progression and the requirement for CXL treatment in the near future.

Delayed Leukoencephalopathy: A Rare Complication after Coiling of Cerebral Aneurysms

BACKGROUND AND PURPOSE

Delayed leukoencephalopathy is a rare complication that occurs after endovascular coiling of cerebral aneurysms. We aimed to describe a clinical picture of delayed leukoencephalopathy and explore potential associations with procedural characteristics.

MATERIALS AND METHODS

We considered endovascular coiling procedures for cerebral aneurysms performed between January 2006 and December 2017 in our institution with follow-up MRIs. We used logistic regression models to estimate the ORs of delayed leukoencephalopathy for each procedural characteristic.

RESULTS

We reviewed 1754 endovascular coiling procedures of 1594 aneurysms. Sixteen of 1722 (0.9%) procedures demonstrated delayed leukoencephalopathy on follow-up FLAIR MR imaging examinations after a median period of 71.5 days (interquartile range, 30-101 days) in the form of high-signal changes in the white matter at locations remote from the coil mass. Seven patients had headaches or hemiparesis, and 9 patients were asymptomatic. All imaging-associated changes improved subsequently. We found indications suggesting an association between delayed leukoencephalopathy and the number of microcatheters used per procedure (P = .009), along with indications suggesting that these procedures required larger median volumes of contrast medium (225 versus 175 mL, OR = 5.5, P = .008) as well as a longer median fluoroscopy duration (123.6 versus 99.3 minutes, OR = 3.0, P = .06). Our data did not suggest that delayed leukoencephalopathy was associated with the number of coils (P = .57), microguidewires (P = .35), and guiding systems (P = .57).

CONCLUSIONS

Delayed leukoencephalopathy after coiling of cerebral aneurysms may have multiple etiologies such as foreign body emboli, contrast-induced encephalopathy, or hypersensitivity reaction to foreign bodies.

Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial

BACKGROUND

Gemcitabine plus cisplatin (GC) is the standard treatment of advanced biliary tract cancer (BTC); however, it causes nausea, vomiting, and anorexia, and requires hydration. Gemcitabine plus S-1 (GS) reportedly has equal to, or better, efficacy and an acceptable toxicity profile. We aimed to confirm the non-inferiority of GS to GC for patients with advanced/recurrent BTC in terms of overall survival (OS).

PATIENTS AND METHODS

We undertook a phase III randomized trial in 33 institutions in Japan. Eligibility criteria included chemotherapy-naïve patients with recurrent or unresectable BTC, an Eastern Cooperative Oncology Group Performance Status of 0 - 1, and adequate organ function. The calculated sample size was 350 with a one-sided α of 5%, a power of 80%, and non-inferiority margin hazard ratio (HR) of 1.155. The primary end point was OS, while the secondary end points included progression-free survival (PFS), response rate (RR), adverse events (AEs), and clinically significant AEs defined as grade ≥2 fatigue, anorexia, nausea, vomiting, oral mucositis, or diarrhea.

RESULTS

Between May 2013 and March 2016, 354 patients were enrolled. GS was found to be non-inferior to GC [median OS: 13.4 months with GC and 15.1 months with GS, HR, 0.945; 90% confidence interval (CI), 0.78-1.15; P = 0.046 for non-inferiority]. The median PFS was 5.8 months with GC and 6.8 months with GS (HR 0.86; 95% CI 0.70-1.07). The RR was 32.4% with GC and 29.8% with GS. Both treatments were generally well-tolerated. Clinically significant AEs were observed in 35.1% of patients in the GC arm and 29.9% in the GS arm.

CONCLUSIONS

GS, which does not require hydration, should be considered a new, convenient standard of care option for patients with advanced/recurrent BTC.

CLINICAL TRIAL NUMBER

This trial has been registered with the UMIN Clinical Trials Registry (http://www.umin.ac.jp/ctr/index.htm), number UMIN000010667.

A prospective, randomized clinical study comparing accelerated corneal collagen crosslinking with 5% NaCl hypertonic saline for bullous keratopathy in Asian eyes

BACKGROUND

We compared the clinical outcomes of accelerated corneal collagen crosslinking (CXL) and 5% NaCl hypertonic saline (HS) for the treatment of symptomatic bullous keratopathy (BK).

METHODS

A randomized controlled trial was held at Department of Ophthalmology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan. Twenty-three eyes of 23 consecutive patients with symptomatic BK were enrolled. The etiology of BK included pseudophakic BK, previous keratoplasty, previous endotheliitis, previous glaucoma surgery, trauma, herpes infection, as well as unknown causes. Eleven eyes received epi-off accelerated CXL (with epithelial abrasion and 18 mW/cm ultraviolet A irradiation for 5 minutes) and 12 eyes received HS instillation. In addition to the usual ophthalmic examination, the best-corrected visual acuity (BCVA) and central corneal thickness (CCT) were determined. The CCT was measured using anterior segment optical coherence tomography before and up to 6 months after treatments. Subjective symptoms of pain, blurred vision, photophobia, and irritation were also recorded.

RESULTS

The follow-up was completed for all patients in the CXL group. However, 6 patients in the HS group requested CXL treatments after 3 months. The BCVA was not significantly changed during the study periods in both groups. The CCT was significantly thinner in the CXL group compared to the HS group at 1 and 6 months (P = .015 and 0.144, respectively). Among the subjective symptoms recorded, irritation was significantly lower in the CXL group at 1 month (P = .013).

CONCLUSIONS

Accelerated CXL may produce transient improvement in pain and corneal edema in patients with BK.

P1786Impact of surgery for mitral regurgitation at the time of aortic valve replacement

Background

Functional mitral regurgitation (MR) is expected to improve after aortic valve replacement (AVR) in patients with severe aortic stenosis (sAS) and MR. However, little is unknown about the impact of AVR on organic MR and whether concomitant mitral valve surgery (MVS) improves outcomes in patients with sAS and MR.

Purpose

We assessed the impact of AVR on MR severity according to MR mechanism. We also assessed the clinical outcomes in patients with sAS and MR that underwent AVR with vs without MVS.

Methods

We retrospectively investigated patients who received surgical AVR or transcatheter aortic valve implantation (TAVI) from 2008 to 2017. We identified patients with effective mitral regurgitant orifice area (ERO) ≥10 mm2 by the proximal isovelocity surface area method with transthoracic echocardiography. The change in MR after AVR was considered significant when there was at least one grade difference. We compared the all-cause mortality of patients with sAS and MR that underwent AVR with vs without MVS according to MR mechanism and patient age.

Results

We included 326 patients with sAS and MR (age 80 [Interquartile range 72–85] years, 53% male, 21% history of myocardial infarction). Organic and functional MR were present in 69% and 31%, respectively. Of these, 240 underwent AVR alone (AVR group) including TAVI in 112 while 86 underwent AVR and MVS (MVS group) including mitral valve replacement in 38 and mitral valve repair in 48. The median ERO at baseline was 17 (14–21) mm2 in AVR and 24 (19–33) mm2 in MVS (p<0.001). Improvement in MR was observed in 58% of AVR and 91% of MVS (p<0.001). In AVR group, organic MR improved as frequently as functional MR (58% vs. 59%, p=0.96). Predictors for improvement in organic MR were absence of atrial fibrillation and moderate or greater MR, and in functional MR, the only predictor was decrease in LV end-systolic diameter after AVR. During mean follow-up of 2.4±2.3 years, moderate or greater MR was observed in 23% of AVR and 7% of MVS (p=0.002). All-cause mortality was similar in AVR and MVS groups for organic and functional MR (hazard ratio for MVS group 0.68, 95% CI: 0.40–1.10, p=0.13 in organic MR and 0.62, 95% CI 0.29–1.22, p=0.68 in functional MR). All-cause mortality was lower in MVS group compared with AVR group in patients <80 years, and was similar in patients ≥80 years (Figure).

Conclusion

In patients with sAS and MR, MR improves after AVR, even in the majority of patients with organic MR. Compared with isolated AVR, concomitant MVS was associated with better prognosis in patients <80 years.

Descemet's membrane endothelial keratoplasty for pseudoexfoliation syndrome: a case series

Background

To evaluate the clinical outcomes and features of Descemet’s membrane endothelial keratoplasty (DMEK) for eyes with pseudoexfoliation syndrome (PEX).

Methods

In this retrospective study, 37 DMEK cases were reviewed from available medical records. Patients who exhibited endothelial dysfunction derived from PEX or Fuchs endothelial corneal dystrophy (FECD) and successfully underwent cataract surgery about four weeks before DMEK were enrolled. The best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), endothelial cell density (ECD), and incidence of intra-operative/post-operative complications of DMEK were analyzed.

Results

This study included 14 eyes of 14 patients (PEX: n = 6, FECD: n = 8). There was no primary graft failure. In the PEX group, BSCVA improved from 0.67 ± 0.28 at the preoperative point to 0.43 ± 0.14 at 1 month, 0.27 ± 0.10 at 3 months, and 0.19 ± 0.08 at 6 months after DMEK. The donor corneal ECD was 2704 ± 225 cells/mm² at the preoperative point and decreased to 1691 ± 498 cells/mm² at 1 month, 1425 ± 366 cells/mm² at 3 months, and 1281 ± 340 cells/mm² (52.7 ± 11.7% less than ECD of the donor graft) at 6 months after DMEK. None of the patients required rebubbling. When compared with the FECD group, no statistical difference was observed in CCT (p = 0.821); BSCVA (p = 0.001) and the reduction rate of ECD (p = 0.010) were relatively worse.

Conclusions

DMEK is effective for the treatment of endothelial dysfunction due to PEX.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1130-1) contains supplementary material, which is available to authorized users.

Corneal cross-linking for keratoconus caused by compulsive eye rubbing in patients with Tourette syndrome: Three case reports

RATIONALE

Eye rubbing is an important risk factor for keratoconus progression. Tourette syndrome (TS) is a neurological disorder, and approximately 50% of individuals with TS exhibit obsessive-compulsive behaviors including eye rubbing. We report the effects of corneal cross-linking (CXL) on the progression of keratoconus combined with psychiatric treatment for 3 patients with TS.

PATIENTS' CONCERNS

Three cases, 24-year-old male, 14-year-old male, and 17-year-old male, were all referred to our institute, due to decreased visual acuity.

DIAGNOSIS

All 3 patients were diagnosed with progressive keratoconus. They were found to rub their eyes, and were also diagnosed with TS by psychiatrists.

INTERVENTION

Upon diagnosis of keratoconus, we performed CXL on 1 eye of each patient.

OUTCOMES

After CXL, there was no further progression. Psychiatric medication was also required.

LESSONS

For patients with keratoconus caused by eye rubbing due to TS, CXL seems to be effective when done in association with psychiatric treatment.

Incidence and risk factors for metabolic syndrome among urban, adult Sri Lankans: a prospective, 7-year community cohort, follow-up study

BACKGROUND

The metabolic syndrome (MetS) is a clustering of abdominal obesity, diabetes and prediabetes, high cholesterol and high blood pressure, that confers an increased risk of cardiovascular disease. There is limited data on incidence of MetS from South Asia. This study investigated incidence and risk factors for new onset MetS in an urban adult Sri Lankan population.

METHODS

Subjects (selected by age-stratified random sampling from the Ragama Medical Officer of Health area) were screened initially in 2007 (35-64 years) and re-evaluated in 2014 (42-71 years). On both occasions they were assessed by structured interview, anthropometric measurements, liver ultrasound, and biochemical/serological tests. MetS was diagnosed on International Diabetes Federation (IDF-2006) criteria. Total body fat (TBF) and visceral fat percentage (VFP) were measured in 2014, using body impedance method. Incidence and factors at baseline, associated with new onset MetS, were investigated among those who presented for re-evaluation.

RESULTS

2985 (99.1%) [1636 (54.8%) women (54.8%); median age (IQR) 53 (47-59) years] from the initial cohort in 2007 had complete data. 2148 (71.9%) [1237 (57.6%) women; median age (IQR) 60 (54-66) years] attended follow-up. 949 of them [701 (73.9%) women; median age (IQR) 60 (54-65) years] had MetS (prevalence 47.2%, 95% CI 45.0-49.4%). Of 1246 who did not have MetS in 2007, 265 [178 (67.1%) women, median age (IQR) 57 (51-64) years] had developed MetS after 7 years (annual incidence 3.5% (95% CI 2.4-4.5%). Females (OR = 4.9, 95% CI 3.4-7.4), BMI > 23 kg/m² in 2007 (OR = 1.6 per unit increase, 95% CI 1.5-1.7), weight gain (by 2-5% OR = 2.0, 95% CI 1.1-3.5; by > 5% OR = 2.2, 95% CI 1.4-3.4), and increase in waist circumference (by 2-5% OR = 7.0, 95% CI 4.0-12.2; by > 5% OR = 13.4, 95% CI 8.3-22.4) from baseline and presence of non-alcoholic fatty liver disease (NAFLD) in 2007 (OR = 1.70, 95% CI 1.04-2.76) were associated new onset MetS. Those with MetS had abnormal VFP and TBF in 2014 [P < 0.001].

CONCLUSION

In this study, annual incidence of MetS was 3.5%. Female gender, BMI > 23 kg/m² and NAFLD in 2007 and increase in weight and waist circumference from baseline were significantly associated with new onset MetS. Obesity was the best predictor of future MetS.

Quantitative evaluation of corneal epithelial edema after cataract surgery using corneal densitometry: a prospective study

PURPOSE

The optical density of the cornea can be evaluated quantitatively by "densitometry" using a rotating Scheimpflug camera. Densitometry allows evaluation of corneal opacity in the anterior segment of the eye by quantitative measurement of scattering light. In the present investigation, we evaluate quantitatively minimal subclinical corneal edema after cataract surgery using densitometry.

METHODS

Fifty four eyes of 34 patients who underwent cataract surgery were enrolled. Measurement of corneal density was performed using Pentacam® before and on days 1, 3 and 7 after surgery.

RESULTS

Densitometry scores increased from 18.12 ± 1.76 before cataract surgery to 21.03 ± 3.84 on day 1 (P < 0.001) and 19.90 ± 2.46 on day 3 (P = 0.018), but recovered to 19.44 ± 1.58 on day 7 (P = 0.131). Total corneal thickness was 549.1 ± 32.7 μm before surgery and increased to 582.7 ± 46.3 μm on day 1 (P = 0.001), but recovered to 566.4 ± 29.7 μm on day 3 (P = 0.097). Densitometry reading correlated positively with corneal thickness (correlation coefficient = 0.13, P = 0.003).

CONCLUSIONS

Densitometry is useful to detect corneal edema that is not detectable by slit-lamp examination.

Lean non-alcoholic fatty liver disease (lean NAFLD): characteristics, metabolic outcomes and risk factors from a 7-year prospective, community cohort study from Sri Lanka

INTRODUCTION

While patients with non-alcoholic fatty liver disease (NAFLD) are mostly overweight or obese, some are lean.

METHODS

In a community-based follow-up study (baseline and follow-up surveys performed in 2007 and 2014), we investigated and compared the clinical characteristics, body composition, metabolic associations and outcomes, and other risk factors among individuals with lean (BMI < 23 kg/m²) NAFLD, non-lean (BMI ≥ 23 kg/m²) NAFLD and those without NAFLD. To investigate associations of selected genetic variants, we performed a case-control study between lean NAFLD cases and lean non-NAFLD controls.

RESULTS

Of the 2985 participants in 2007, 120 (4.0%) had lean NAFLD and 816 (27.3%) had non-lean NAFLD. 1206 (40.4%) had no evidence of NAFLD (non-NAFLD). Compared to non-lean NAFLD, lean NAFLD was commoner among males (p < 0.001), and had a lower prevalence of hypertension (p < 0.001) and central obesity (WC < 90 cm for males, < 80 cm for females) (p < 0.001) without prominent differences in the prevalence of other metabolic comorbidities at baseline survey. Of 2142 individuals deemed as either NAFLD or non-NAFLD in 2007, 704 NAFLD individuals [84 lean NAFLD, 620 non-lean NAFLD] and 834 individuals with non-NAFLD in 2007 presented for follow-up in 2014. There was no difference in the occurrence of incident metabolic comorbidities between lean NAFLD and non-lean NAFLD. Of 294 individuals who were non-NAFLD in 2007 and lean in both 2007 and 2014, 84 (28.6%) had developed lean NAFLD, giving an annual incidence of 4.1%. Logistic regression identified the presence of diabetes at baseline, increase in weight from baseline to follow-up and a higher educational level as independent risk factors for the development of incident lean NAFLD. NAFLD association of PNPLA3 rs738409 was more pronounced among lean individuals (one-tailed p < 0.05) compared to the whole cohort sample.

CONCLUSION

Although lean NAFLD constitutes a small proportion of NAFLD, the risk of developing incident metabolic comorbidities is similar to that of non-lean NAFLD. A PNPLA3 variant showed association with lean NAFLD in the studied population. Therefore, lean NAFLD also warrants careful evaluation and follow-up.

The combination of strip meniscometry and dry eye-related quality-of-life score is useful for dry eye screening during health checkup: Cross-sectional study

Strip meniscometry (SM) is a new method for quantification of tear volume using meniscometry strips inserted into the tear meniscus for 5 seconds. The dry eye (DE)-related quality-of-life score (DEQS) questionnaire comprises 15 questions regarding bothersome ocular symptoms and their impact on daily life. These 2 examinations require a relatively short time and are appropriate as screening tests. We evaluated the sensitivity and specificity of SM and DEQS for screening for DE syndrome during general health checkup.This study included 333 right eyes from 333 soldiers (331 men, 2 women; mean age, 42.8 ± 8.8 years) who underwent health checkups at the Yokosuka Medical Squadron between November and December 2013. We administered the DEQS questionnaire to the subjects. The fluorescein tear film break-up time and fluorescein and rose bengal staining scores were evaluated. A positive outcome was considered when DEQS >15 and SM scores <5 mm. We compared DEQS and SM between a DE group, suspected-DE group and normal group.Thirty-four (11%) soldiers were diagnosed with definite DE based on the Japanese DE diagnostic criteria. The sensitivities of SM, DEQS, and SM combined with DEQS for definite DE were 71%, 79%, and 59%, respectively, whereas the corresponding specificities were 85%, 91%, and 97%, respectively. None of the enrolled subjects experienced complications such as eye pain or discomfort, except for 1 soldier (0.003%) with conjunctivochalasis, who experienced irritation upon SM.The results of our study indicate that the combination of SM and DEQS is useful for the detection of DE with high sensitivity and specificity during routine health check-up.

The proportion of ocular surface diseases in untreated patients with epiphora

PURPOSE

Various ocular surface disorders, such as dry eye, infectious and non-infectious inflammation, anatomical anomalies in lid structure, and/or obstruction of the tear outflow tract, can cause epiphora. However, few reports have described the proportions of causative diseases in patients with epiphora. Therefore, we investigated the frequent causes of epiphora in older adult patients.

MATERIALS AND METHODS

We enrolled 220 patients (70 men, 150 women) who visited a primary eye care clinic from January 2016 to August 2017 with lacrimation as a chief complaint. The mean age of the patients was 61.3±10.9 years. The causes of epiphora were assessed by slit-lamp examinations, dry eye tests, fluorescein disappearance tests, and lacrimal pathway washing.

RESULTS

The causes of epiphora were dry eye in 96, conjunctivochalasis in 56, lacrimal obstruction in 30, conjunctivitis in 20, trichiasis in 16, and facial palsy in 2 patients. Ocular surface diseases were identified in 187 of the 220 (85%) patients who complained of epiphora. Conjunctivochalasis was observed in 36 of the 96 (38%) patients with dry eye. Among the patients with dry eye, 99% had short break-up time type dry eye, with the random break type being the most frequent type (61/96; 64%) in patients with epiphora.

CONCLUSION

Among older adult patients whose main complaint was epiphora, 85% had ocular surface diseases. In contrast, only 15% of patients had lacrimal diseases. Short break-up time dry eye, especially the random break type, was the most frequently observed form of dry eye in our cohort.

Effects of Trans-4-Aminomethylcyclohexane Carboxylic Acid as an Antifibrinolytic Agent on Arterial Wall and Experimental Atherosclerotic Lesions in Rabbits

Effects of trans-4-aminomethylcyclohexane carboxylic acid (t-AMCHA) as an antifibrinolytic agent on the experimental arteriosclerosis produced by cholesterol feeding and on the experimental thromboembolism induced by autogenous fibrin clot injection were observed in rabbits. Effect of inhibited fibrinolysis on the arterial wall itself was also observed.

Administration of 500 mg/kg body weight of t-AMCHA highly inhibited the lysis time of serum, but there was no influence on the plasma fibrinogen level.

There was no significant difference in the cholesterol level, sudanophilia of the aorta and the accumulation of foam cells in the aorta and pulmonary arteries between t-AMCHA + cholesterol group and cholesterol group.

Edema in the subendothelial layer of the aorta and elastic pulmonary artery, proliferation and swelling of the endothelial cells, and edema of the subendothelial layer of large muscular pulmonary arteries were increased in the incidence and severity in t-AMCHA treated animals. Localized intimai fibrous thickening was found in large muscular artery in t-AMCHA treated animals. Small fibrin thrombi and angitis were rarely found in muscular pulmonary artery in t-AMCHA treated animals.

Fibrinolytic activity of blood and dissolution of clots in the pulmonary arteries were depressed by t-AMCHA treatment in the animals injected autogenous fibrin clots, while the inflammatory reaction in the arterial wall was less severe as compared with that of untreated animals.

It was reasonable to presume that the inhibition of fibrinolysis would promote the development of atherosclerosis through its influence on the fibrin dissolution on and in the arterial wall, and on the vascular permeability of the arterial wall.

Corneal crosslinking for keratoconus in Japanese populations: one year outcomes and a comparison between conventional and accelerated procedures

PURPOSE

We retrospectively investigated the efficacy of corneal crosslinking (CXL) on progressive keratoconus in a Japanese population and compared the outcomes of conventional and accelerated CXL.

STUDY DESIGN

A retrospective cohort study METHODS: A total of 108 consecutive eyes in 95 patients (75 men; 21.9 ± 6.2 years) with progressive keratoconus were enrolled. The epithelium was ablated in all eyes. After presoaking the corneal stroma in riboflavin, UV-A was irradiated at 3.0 mW/cm² (conventional CXL) for 30 min on 23 eyes and 18.0 mW/cm² for 5 min (accelerated CXL) on 85 eyes. Best spectacle-corrected visual acuity (BSCVA), manifest refraction, keratometric value, corneal thickness, corneal endothelial cell density (ECD), intraocular pressure, and complications were evaluated at 1, 3, 6, and 12 months after the procedure.

RESULTS

BSCVA, manifest refraction, ECD, and corneal thickness did not change significantly after both procedures. The keratometric value was significantly decreased from the preoperative value at 12 months (p < 0.001). Progression to more than 1.0 D after CXL was observed in 10 eyes (9.3%). The ΔKmax was negatively associated with preoperative Kmax (p < 0.001) and positively associated with preoperative thinnest corneal thickness (p < 0.001). Both treatment modules showed no significant difference in all parameters.

CONCLUSION

CXL was as effective in treating keratoconus in Japanese patients as in individuals of other ethnicities. Overall, CXL could be performed using either the conventional or accelerated approach to halt the progression of keratoconus in Japanese populations.

Descemet membrane endothelial keratoplasty using ophthalmic viscoelastic devices for eyes with laser iridotomy-induced corneal endothelial decompensation: Analysis of 11 eyes

Graft insertion into the anterior chamber is one of the most important procedures for successful Descemet membrane endothelial keratoplasty (DMEK). Especially in eyes with fragile zonular fibers and a shallow anterior chamber, smooth graft insertion tends to become more difficult. Ophthalmic viscoelastic devices (OVDs) can usually help to retain the space in the anterior chamber and to improve the safety of manipulations during various ophthalmic surgeries. Therefore, we postulated that graft insertion into the anterior chamber could be improved by their use. The purpose of this study is to investigate the availability and efficacy of OVDs during graft insertion in DMEK surgery.A total of 11 eyes of 9 patients with bullous keratopathy who underwent DMEK were retrospectively analyzed. The cause of bullous keratopathy was corneal endothelial decompensation following laser iridotomy in all eyes. We used low viscous dispersive OVD (Opegan) to maintain the anterior chamber depth during graft insertion in all of the eyes.The graft insertion was uneventful in all of the eyes. The inserted graft was attached to the back surface of the cornea. However, 2 eyes needed rebubbling, and after rebubbling, all of the 2 grafts completely attached to the back surface of the cornea. The best spectacle-corrected visual acuity significantly improved 6 months after surgery (P < .001) and the central corneal thickness significantly decreased (P < .001).The use of OVD facilitates safer graft insertion during DMEK, and subsequently prevents endothelial cell loss, which leads to a successful procedure.

Amnwiotic Membrane Transplantation as a Treatment for Sterile Infiltration and Corneal Melting after Corneal Crosslinking for Keratoconus

We report a case of corneal melting through sterile infiltration presumably due to excessive use of nonsteroidal anti-inflammatory eye drops after corneal crosslinking (CXL). It was treated using steroids combined with amniotic membrane transplantation (AMT). A 33-year-old man with progressing keratoconus underwent left eye CXL. We prescribed betamethasone and levofloxacin eye drops 5 times daily and diclofenac sodium eye drops 3 times daily for 3 days. Three days after CXL, there was a persistent epithelial defect and the left corneal stroma was clouded. His visual acuity remained unchanged. We prescribed betamethasone hourly and 20 mg prednisolone daily. At 1 week after CXL, the corneal epithelial defect and infiltration were unchanged. He had not stopped using diclofenac at the prescribed time. On day 17, we performed AMT and his cornea and visual acuity improved. AMT may be effective against persistent epithelial defects and corneal melting after CXL.

A systematic review of heart failure dyadic self-care interventions focusing on intervention components, contexts, and outcomes

BACKGROUND

Having support from an informal carer is important for heart failure patients. Carers have the potential to improve patient self-care. At the same time, it should be acknowledged that caregiving could affect the carer negatively and cause emotional reactions of burden and stress. Dyadic (patient and informal carer) heart failure self-care interventions seek to improve patient self-care such as adherence to medical treatment, exercise training, symptom monitoring and symptom management when needed. Currently, no systematic assessment of dyadic interventions has been conducted with a focus on describing components, examining physical and delivery contexts, or determining the effect on patient and/or carer outcomes.

OBJECTIVE

To examine the components, context, and outcomes of dyadic self-care interventions.

DESIGN

A systematic review registered in PROSPERO, following PRISMA guidelines with a narrative analysis and realist synthesis.

DATA SOURCES

PubMed, EMBASE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials were searched using MeSH, EMTREE terms, keywords, and keyword phrases for the following concepts: dyadic, carers, heart failure and intervention. Eligible studies were original research, written in English, on dyadic self-care interventions in adult samples.

REVIEW METHODS

We used a two-tiered analytic approach including both completed studies with power to determine outcomes and ongoing studies including abstracts, small pilot studies and protocols to forecast future directions.

RESULTS

Eighteen papers - 12 unique, completed intervention studies (two quasi- and ten experimental trials) from 2000 to 2016 were reviewed. Intervention components fell into three groups - education, support, and guidance. Interventions were implemented in 5 countries, across multiple settings of care, and involved 3 delivery modes - face to face, telephone or technology based. Dyadic intervention effects on cognitive, behavioral, affective and health services utilization outcomes were found within studies. However, findings across studies were inconclusive as some studies reported positive and some non-sustaining outcomes on the same variables. All the included papers had methodological limitations including insufficient sample size, mixed intervention effects and counter-intuitive outcomes.

CONCLUSIONS

We found that the evidence from dyadic interventions to promote heart failure self-care, while growing, is still very limited. Future research needs to involve advanced sample size justification, innovative solutions to increase and sustain behavior change, and use of mixed methods for capturing a more holistic picture of effects in clinical practice.

Topographic characteristics after Descemet's membrane endothelial keratoplasty and Descemet's stripping automated endothelial keratoplasty

PURPOSE

To investigate the topographic characteristics of the posterior corneal surface after Descemet's endothelial membrane keratoplasty (DMEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK) and their effects on postoperative visual acuity.

METHODS

Nineteen eyes of 19 patients after DMEK, 23 eyes of 23 patients after DSAEK, and 18 eyes of 18 control subjects were retrospectively analyzed. Best spectacle-corrected visual acuity (BSCVA), aberration factors (higher-order aberrations [HOAs], spherical aberrations [SAs], and coma aberrations [Comas] at 6.0 mm) were evaluated preoperatively and at 1, 3, and 6 months postoperatively. The posterior refractive pattern of the topography map was classified into 5 grades (0-5) (posterior color grade) using anterior segment optical coherence tomography. Correlations between BSCVA and some factors (abbreviation factors, posterior color grade) were analyzed.

RESULTS

BSCVA was significantly better after DMEK than after DSAEK (P < 0.001). Posterior HOAs, SAs, and Comas after each type of endothelial keratoplasty were significantly greater compared to control (P < 0.01). Posterior HOAs, total/anterior/posterior SAs, and posterior color grade were significantly lower in the DMEK group than in the DSAEK group at 3 months (P < 0.024 [posterior HOAs], P = 0.047 [total SA], P < 0.001 [anterior SAs], P = 0.021 [posterior SAs], and P < 0.001 [posterior color grade]) and 6 months postoperatively (P = 0.034 [posterior HOAs], P < 0.001 [total SAs], P < 0.001 [anterior SAs], P = 0.013 [posterior SAs], and P = 0.004 [posterior color grade]). BSCVA was significantly correlated with HOAs, SAs, and posterior color grade (P < 0.001 for all except anterior HOAs [P = 0.004]).

CONCLUSIONS

High posterior color grades were associated with larger aberration factors and had a negative effect on visual function after endothelial keratoplasty. Rapid improvement of visual function after DMEK may be attributed to less change at the posterior surface.

Flattening effect of corneal cross-linking depends on the preoperative severity of keratoconus

A retrospective observational study was conducted to validate the effect of corneal cross-linking (CXL) on eyes with progressing keratoconus, depending on severity.In total, 45 eyes of 33 patients (age: 23.9 ± 6.8 years, range: 14-42 years) with progressive keratoconus who underwent CXL were enrolled. Examinations were performed at pre-, 1, 3, 6, and 12 months after surgery. In addition to a slit lamp microscopy, measurement of visual acuity, the steepest keratometric value (Kmax), the thinnest corneal thickness (TCT), and the corneal endothelial cell density (ECD) were assessed. Change in Kmax (ΔKmax) was calculated by subtracting the preoperative Kmax from the 12-month postoperative Kmax.CDVA, TCT, and ECD did not change significantly throughout the follow-up period. Kmax was 56.4 ± 7.2 D preoperatively and 54.3 ± 5.6 D at 12 months after CXL (P = .174). The average value of ΔKmax was -2.23 ± 4.31 D at 12 months after CXL. ΔKmax was negatively correlated with preoperative Kmax (ρ = -0.5517, P = .0001), and positively correlated with preoperative TCT (ρ = 0.4791, P = .0012). However, no correlation was observed between Kmax and patient age or the decrease ratio of ECD.The more flattening was obtained after CXL in cases with the more advanced keratoconus. No complication, including corneal endothelial damage, was observed even in advanced cases.

Techniques for Learning Descemet Membrane Endothelial Keratoplasty for Eyes of Asian Patients With Shallow Anterior Chamber

Supplemental Digital Content is Available in the Text.

Purpose:

To describe several essential surgical techniques that overcome difficulties in performing Descemet membrane endothelial keratoplasty (DMEK) for inexperienced surgeons, especially those who perform DMEK on eyes of Asian patients.

Methods:

Nine eyes of 9 Asian patients with bullous keratopathy who underwent DMEK were analyzed retrospectively. All patients were given a diuretic such as d-mannitol or acetazolamide shortly before surgery, with retrobulbar anesthesia and a Nadbath facial nerve block. Core vitrectomy before DMEK was performed in several cases in which a high vitreous pressure during surgery was predicted. The donor graft was stained with trypan blue, and a 25-G anterior chamber maintenance cannula was used to maintain the anterior chamber depth during graft insertion in all eyes.

Results:

The cornea became clear in all eyes. The best spectacle-corrected visual acuity had improved significantly 6 months after the surgery compared with preoperative values (P = 0.026). The corneal endothelial cell density was 1371 cells per square millimeter at postoperative 6 months.

Conclusions:

Although DMEK is technically difficult, especially for inexperienced surgeons who operate on eyes of Asian patients, controlling anterior chamber pressure using various manipulations may help to prevent iatrogenic primary graft failure and lead to successful DMEK.

Use of four asymmetric marks to orient the donor graft during Descemet's membrane endothelial keratoplasty

Introduction

Maintaining the correct orientation of the donor graft is important during Descemet's membrane endothelial keratoplasty (DMEK). We describe a new method of marking the donor graft prior to DMEK.

Methods

Twelve eyes of 10 patients with bullous keratopathy who underwent DMEK were retrospectively analysed. Donor discs were created by stripping the endothelium-Descemet's membrane layer from corneoscleral buttons. Four semicircular marks, two 1.0 mm and two 1.5 mm in diameter, were created at the edge of the donor disc. The small and large marks were paired. Each donor graft was inserted into the anterior chamber, unfolded and attached to the posterior corneal stroma with an air bubble.

Results

The inserted grafts were all appropriately orientated when attached to the back surfaces of the corneas. The two pairs of asymmetric marks afforded valuable guidance. Even when the graft was partially folded or decentred, and one pair of marks was obscured, the other pair was always visible to indicate graft orientation. Best spectacle-corrected visual acuity improved significantly in all patients (p<0.001). Compared with the preoperative endothelial cell density of the donor graft, that of the corneal endothelium had decreased 44.0%±10.0% by 6 months after surgery.

Conclusions

Two pairs of asymmetrical semicircular marks placed on the edge of the donor graft allowed appropriate graft orientation during DMEK.