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A growing body of evidence suggests that sleep is critical for the adaptive processing and consolidation of emotional information into long-term memory. Previous research has indicated that emotional components of scenes particularly benefit from sleep in healthy groups yet sleep-dependent emotional memory processes remain unexplored in clinical cohorts, including those with obstructive sleep apnea (OSA). This line of research is important as it will add to the understanding of how disrupted sleep in OSA contributes to both impaired cognition and emotion dysregulation.To test the hypothesis that individuals with OSA will have impaired sleep-dependent memory consolidation with the greatest impact being on memory for emotional content.In this study, a group of newly diagnosed OSA patients (n=26; 10 female, average age 42.5) and a matched group of healthy controls (n=24; 13 female average age 37) were enrolled into the study at Beth Israel Deaconess Medical Center. Participants encoded scenes with negative or neutral foreground objects placed on neutral backgrounds prior to a night of polysomnographically recorded sleep. In the morning they completed a recognition test in which old and new scene objects and backgrounds, presented separately and one at a time, were judged as old, new, or similar compared to what had been previously viewed.OSA patients had a deficit in recognition memory for the scenes. Overall recognition-the ability to recognize old items as either old or similar-was impaired across all scene elements, both negative and neutral objects and backgrounds, while specific recognition-correctly identifying old items as old-was impaired only for negative objects. Across all participants, successful overall recognition correlated positively with sleep efficiency and REM sleep, while successful specific memory recognition correlated only with REM sleep.Our findings indicate that fragmented sleep and reduced REM sleep, both hallmarks of OSA, are associated with disruptions in general memory impairment and veridical memory for emotional content, which could alter emotional regulation and contribute to comorbid emotional distress in OSA.

Previous studies have reported higher qualification characteristics for anesthesiologists, neurosurgeons, orthopedic surgeons, and otolaryngologists serving as defense (versus plaintiff) medical malpractice expert witnesses. We assessed such characteristics for radiologist expert witnesses.Using the Westlaw legal research database, we identified radiologists serving as experts in all indexed medical malpractice cases between 2010 and 2019. Online databases were used to identify years of practice experience and scholarly bibliometrics. Using Medicare claims, individual radiologist practice types and mixes were ascertained. Radiologists testifying at least once each for defense and plaintiff were excluded from our defense-only versus plaintiff-only comparative analysis.Initial Boolean searches yielded 1,042 potential cases; subsequent manual review identified 179 radiologists testifying in 231 lawsuits: 143 testified in one case (58 defense, 85 plaintiff) and 36 testified in multiple cases (10 defense-only, 14 plaintiff-only, 12 both). The 68 defense-only experts had fewer years of practice experience than the 99 plaintiff-only experts (28.3 versus 31.8 years, P = .02), but the two groups were otherwise similar in both practice type (44.6% versus 54.9% academic, P = .62) and mix (63.8% versus 65.8% practiced as subspecialists, P = .37) and as well as numbers of publications (60.5 versus 62.8, P = .86), citations (1,994.1 versus 2,309.2, P = .56), and h-indices (17.2 versus 16.8, P = .89).In contrast to other specialists, radiologists serving as medical malpractice expert witnesses for defense and plaintiff display similar qualifications across various characteristics. Published practice parameter guidelines and experts' ability to blindly review archived original images might together explain this interspecialty discordance.

A 10-year-old boy with unilateral cryptorchidism and renal aplasia displayed features of unilateral congenital pupil sparing third cranial nerve palsy with exotropia manifesting novel dysinnervation encompassing synergistic divergence with upshoot, convergence on attempted upgaze, gaze-evoked phasic conjugate torsion, and gaze-evoked nystagmus. Congenital third nucleus/nerve hypoplasia with secondary dysinnervation is classfied as congenital cranial dysinnervation disorder (CCDD). It is speculated that miswiring between prenuclear structures, otolithic pathways, interstitial nucleus of Cajal (INC), nucleus prepositus hypoglossi, and third and sixth nerve nuclei likely resulted in this novel dysinnervation. Cryptorchidism and renal aplasia if seen may point towards an overlapping phenotype with Duane-radial ray syndrome and acro-renal-ocular/IVIC syndromes.

Recent research on inferior vena cava (IVC) filter utilization in the United States has largely focused on national aggregate Medicare datasets, showing recent declines. Whether these national Medicare trends are generalizable across regions and payer populations is unknown. We studied recent state-level variation in IVC filter utilization across both Medicare and private insurance populations.Using large individual beneficiary claims-level Medicare research identifiable files and a proprietary U.S. research database of the commercially insured population, we identified all billed IVC filter placement procedures performed between 2009 and 2015. We compared population-adjusted utilization rates by state and payer type.Between 2009 and 2015, IVC filter utilization across the United States declined by 36.3% (from 177.9 to 113.3 procedures per 100,000 beneficiaries) in the Medicare population and by 26.6% (from 32.7 to 24.0 procedures per 100,000 beneficiaries) in the privately insured population. For the Medicare population, state-level utilization rates varied 5.2-fold, from 48.4 to 251.3 procedures per 100,000 beneficiaries in Alaska and New Jersey, respectively. For the private insurance population, rates varied 5.5-fold, from 10.8 to 59.5 procedures per 100,000 beneficiaries in Oregon and Michigan, respectively. Nationally, utilization in the Medicare population was 5.0 times higher than that in the private insurance population (range by state, from 2.0 times higher in Hawaii to 11.1 times higher in Utah). Despite the national decline, utilization in Medicare and private insurance populations increased in five and seven states, respectively. State-level IVC filter utilization rates for the Medicare population correlated strongly with those for the privately insured population (r = 0.74; p0.001). In both the Medicare and privately insured populations, utilization rates correlated moderately with beneficiary age (r = 0.44 and r = 0.50, respectively; p0.001 for both).IVC filter utilization rates vary dramatically by state and payer population, and they likely depend in part on the age of the covered population. To better identify demographic and socioeconomic drivers of utilization, future research should prioritize nonaggregate multipayer claims-level approaches.

The presented work is a sincere effort to exhibit content-based image retrieval (CBIR) system utilized for extracting images from large databases. It makes use of image features like texture and color. Local binary pattern (LBP)-based operator brings about the information related to image texture by taking into consideration the surrounding pixel values. In spite of having its own advantages, this feature is not that superior at capturing the image’s information related to color. The present work rectifies this disadvantage by incorporating an extra color feature by the name quaternion polar complex exponential transform (QPCET) in addition to the LBP-based feature in the image retrieval system. The integrated QPCET- and LBP-based CBIR system exhibits better average retrieval efficiency compared to other accessible techniques tested on different benchmark databases.

Isolated brain stem tuberculoma constitutes about 5% of all intracranial tuberculomas. A case of isolated inferior rectus palsy with downbeat nystagmus due to presumed midbrain tuberculoma in an immunocompetent patient is described here. This report documents a rare entity of a combination of partial third nerve palsy with pupil involvement along with downbeat nystagmus.

Background: Recovery of Bell`s phenomenon after levator resection is unpredicatable. Delayed recovery can result in vision threatening corneal complications. Aim: To study the variability of Bell’s phenomenon and time taken for its recovery following levator resection for blepharoptosis and to correlate it with the amount of resection. Methods: A prospective observational study was conducted on 32 eyes of 32 patients diagnosed as unilateral simple congenital blepharoptosis who underwent levator resection at a tertiary care center between July 2013 and May 2015. Patients were followed up for 5 months and correction of ptosis, type of Bell`s, duration of Bell`s recovery and complications were noted. Results: The study group ranged from 16-25 years with 15:17 male: female ratio. There were 9 mild, 16 moderate and 7 severe ptosis. Satisfactory correction was achieved in all cases. Good Bell`s recovery occurred in 13 eyes on first post-op day, in 2-14 days in 19 eyes and 28 days in 1 eye. Inverse Bell`s was noted along with lid oedema and ecchymosis in 2 patients. Large resections (23-26mm) were associated with poor Bell`s on the first postoperative day (p=0.027, Fisher`s exact test). However, the duration required for recovery of Bell`s phenomenon did not show any significant difference with the amount of resection. (p=0.248, Mann Whitney test). Larger resections resulted in greater lagophthalmos (correlation=0.830, p Conclusion: Close monitoring for Bell`s recovery is required following levator resection.

Background Despite a variety of evidence-based guidelines documents, imaging is anecdotally commonly used in the setting of children with headaches, but the frequency of such imaging is unknown. We assessed the use of and estimated costs of imaging utilization in children with headaches at a pediatric hospital. Materials and Methods Retrospectively reviewing charts of all relevant imaging examinations in 2015, we focused on radiology reports with indications containing the terms “headache” or “migraine” and excluded patients who fulfilled evidence-based criteria in support of obtaining imaging. All radiology results were recorded and categorized as normal, likely causative, possibly causative, or unlikely causative of headache. Societal costs were estimated using allowable Medicare fees, and losses of total facility time were estimated using scheduled examination slots. Results In 2015, 4,257 imaging studies were performed for indications of headache or migraine. Of these, 3,098 (73%) met our exclusion criteria, meaning they had appropriate indications, and 1,159 (27%) were presumably imaged outside of guideline recommendations. Overall, 19.8% (230 of 1,159) had diagnoses that were likely or potentially causative of headaches, and 71.2% (825 of 1,159) were normal. The remainder had findings unlikely to cause headaches. The total estimated societal cost of imaging studies for presumed primary headache imaging at our institution in 2015 was $322,422. The loss of imaging time was 845.3 hours. Conclusion Given the large number of normal examinations and the inappropriate use of radiography, imaging utilization in children with headaches can likely be improved. In addition to reducing ionizing radiation and the need for sedation, reductions in unnecessary imaging would result in societal cost savings and increase imaging capacity for other patients.

Background: Low patient enrollment in randomized clinical trials (RCTs) escalates costs, leads to under-representation of real-world patient populations, and delays generation of knowledge. Limited data exists on why patients decline participation in RCTs and what factors may lead to increased participation rates. Methods: In-person and telephone interviews were conducted with 19 patients with congestive heart failure who declined participation in RCTs. Interviews were conducted using a structured interview guide. Interviews were transcribed verbatim, and qualitative descriptive analysis was performed. Results: Participants’ median age was 63 years (IQR 51.5-69), 42% were female, and 53% were Black or African-American. Only 6 participants could accurately describe the intervention and clearly understood design of the trial in which they were asked to participate. Most participants made the decision not to participate quickly; only 1 participant took time to deliberate. The most common reasons for not participating were concern for adverse events from the intervention being studied (n=15) and perception of participation being too burdensome (n=10). The most common suggestion provided to increase participant recruitment was involving primary care physicians or cardiologists known to the patients. Conclusion: These findings suggest that patients often decide not to participate in clinical trials quickly, with relatively minimal understanding of the trial. Reasons for declining were heterogeneous, but the most common suggestions for improvement were engaging physicians known to them in the process of recruitment and making participation less burdensome. Addressing these issues may reduce barriers to participation and enhance respect for patients.

Due to ever-increasing explosion of multimedia and storage devices available, accessing large image databases becomes inevitable. Furthermore, the availability of high-speed Internet has raised drastically the level of multimedia exchange by users across cyberspace every second. Hence, content-based image retrieval is gaining importance day by day. Therefore, this work proposes content-based image retrieval based on moments in edge map of different transforms such as Walsh–Hadamard transform (WHT), discrete cosine (DCT), and discrete wavelet transform (DWT). The first- and second-order moments of edges of these transform coefficients are combined with moments of color and color objects to improve the average retrieval efficiency. It has been shown that DWT exhibits better average retrieval efficiency compared to FWHT and DCT on Corel data base.

Introduction A growing body of evidence suggests that sleep is critical for the processing and consolidation of emotional information into long-term memory. Previous research has indicated that emotional components of scenes particularly benefit from sleep in healthy groups, yet sleep dependent emotional memory processes remain unexplored in many clinical cohorts, including those with obstructive sleep apnea (OSA). Methods In this study, a group of newly diagnosed OSA patients (n=26) and a matched group of healthy controls (n=24) encoded scenes with negative or neutral foreground objects placed on neutral backgrounds prior to a night of polysomnographically recorded sleep. In the morning, they completed a recognition test in which objects and backgrounds were presented separately and one at a time. Results OSA patients have a deficit in both overall gist memory and the specific recognition memory for the scenes. Impairment of gist recognition was across all elements of the scenes, both negative and neutral objects and backgrounds [main effect of group: F(1,48) = 13.5, p=0.001], while specific recognition impairment was exclusively found for negative objects [t(48)=2.0, p=0.05]. Across all participants, successful gist recognition correlated positively with sleep efficiency (p=0.001) and REM sleep (p=0.009), while successful specific memory recognition correlated only with REM sleep (p=0.004). Conclusion Our findings indicate that fragmented sleep and reduced REM sleep, both hallmarks of OSA, significantly disrupt distinct memory processes for emotional content. Gist memory is universally impacted, while memory for specific details appears to have a greater deterioration for negative aspects of memories. These memory affects may have impacts on complex emotional processes, such as emotion regulation, and could contribute to the high comorbid depressive symptoms in OSA. Support (if any) The authors would like to thank the funding sources awarded to author ID for supporting this research: NIH grant # K23HL103850 and American Sleep Medicine Foundation grant #54-JF-10. Author TJC is currently funded by the Research Training Program in Sleep, Circadian and Respiratory Neurobiology (NIH T32 HL007901) through the Division of Sleep Medicine at Harvard Medical School and Brigham & Women’s Hospital.

Introduction The Apolipoprotein E (APOE)-ε4 genotype is a marker of susceptibility for late-onset Alzheimer’s disease (AD). Sleep disturbances may accelerate the aging process and increase the risk for future development of cognitive impairment and dementia. Given that the pathophysiological process of AD can predate its clinical manifestations by years or even decades, the aim of this study was to assess the role of the APOε4 allele on sleep-dependent memory consolidation in cognitively healthy adults. Methods 16 healthy APOE-ε4 carriers (mean age=49.9±13.7) and 32 healthy non-carriers (age=45.7±12.9) were included in the main analysis. Baseline screening included the Epworth Sleepiness Scale, Morningness-Eveningness scale, Wechsler Adult Intelligence Scale (WAIS) and Beck Depression Inventory (BDI), as well as a baseline polysomnogram (PSG), which also served as an adaptation night. Participants subsequently underwent an overnight testing session, which included computer sessions of the Psychomotor Vigilance Task (PVT) and the declarative Verbal Paired-Associates Task (VPA) in the evening followed by a full night PSG and repeat PVT and VPA sessions in the morning. For further reference, we added an age matched group of 16 non-carriers with newly diagnosed obstructive sleep apnea (OSA, age=48.1±15.1), who underwent the same study procedures. Results APOE-ε4 carriers had higher BDI (p=0.04) and ESS (p=0.01) scores than non-carriers. There were no significant group differences for sleep macrostructure. Evening VPA performance was similar for both groups (p=0.77). The following morning, APOE-ε4 carriers improved by 7.5±6.4 % from the evening before, compared to 13.5±7.0% for the healthy non-carriers (p=0.005). OSA subjects improved by 5.0± 8.1%, which was similar to APOE-ε4 carriers (p=0.34). Conclusion To our knowledge, this is the first study to reveal that healthy APOE-ε4 carriers while showing similar initial learning (encoding) on a declarative memory task compared to healthy controls, exhibit a deficit in sleep-dependent memory consolidation, similar to patients with obstructive sleep apnea. Consequently, this study provides evidence that impaired sleep-related memory processes could be an important harbinger in otherwise healthy individuals, who are at high risk for AD. Support (if any) NIH grant # K23HL103850 (Ina Djonlagic) and American Sleep Medicine Foundation grant #54-JF-10 (Ina Djonlagic)

In a boy aged 6 years left unilateral congenital ptosis with medial rectus-levator palpebrae superioris (MR-LPS) synkinesis; the coexisting hitherto unreported likely lateral rectus-superior rectus (LR-SR) dysinnervation is reported. Ocular movements were full and cover test did not reveal any ocular misalignment. Such a presentation can only arise from two concurrent dysinnervations: first one between inferior and superior divisions of third nerve and second one between third and sixth cranial nerve. The dysinnervation may conform to a forme-fruste TUBB3 (Tubulin, Beta 3 Class III Gene) pathogenic variant phenotype and may be classed as a novel congenital cranial dysinnervation disorder (CCDD).

AIMS: Hyperlacrimation due to ocular surface or lid abnormality was ruled out and apposition of lower punctum to globe was checked. SUBJECTS AND METHODS: This was a pilot study at a tertiary eye care center where 40 patients of proximal canalicular block 0.05). Complications include tube extrusion, dislocation, conjunctival overgrowth, and sump syndrome. CONCLUSION: Laser and external CDCRs are both effective and safe procedures for the treatment of proximal canalicular blocks with comparable success rates and complications.

Here, we report a rare case of bilateral medial rectus palsy following closed head injury. An adult male had an accidental fall which rendered him unconscious. This was followed by diplopia and restricted ocular motility. He received supportive medical therapy. He was examined for systemic medical and ophthalmic findings. Routine laboratory tests and imaging techniques were employed as per the symptoms. Diffusion-weighted imaging on magnetic resonance imaging proved it to be a rare presentation of small bilateral midbrain infarct. He recovered fully after 8 months.

The sump syndrome was initially described in relation to patients who had undergone external dacryocystorhinostomy. Here we report a case of sump syndrome that developed following laser conjunctivodacryocystorhinostomy (CDCR) due to tube displacement after a bout of forceful sneezing. Unlike cases of external dacryocystorhinostomy where flaps are sutured, there is a potential space created by the sac remnants in laser CDCR. Hence, any displacement of the tube will lead to the improper drainage of secretions with superadded infections of the contents (as occurred in this case). Therefore, in laser CDCR, it is imperative to create an appropriately placed osteotomy with a correctly sized tube that is well secured to avoid displacement along with patient education regarding tube care.

Silicon rods are widely employed for frontalis sling suspension. However, on passing through the tissues, at times, the silicon rod gets detached from the stainless steel needle. This occurs more commonly in patients of blepharophimosis syndrome, in which hypoplasia of superior orbital rim with deficiency of skin between lid and brow, causes difficulty in passage of the needle when it is manipulated upwards from lid towards the brow. To overcome these problems we describe the use of an 18 G intravenous catheter to railroad the needle with the silicon rod, obviating the blind upward maneuvers with the needle and protecting against the damage to the silicon rod –needle assembly. The technique is easily reproducible, safe and can be used in all silicon rod suspensions.

Many oculoplastic conditions like ectropion, entropion, ptosis, lid lacerations, canalicular trauma and dacryocystitis are commonly seen in everyday practice of any ophthalmologist. Delay in treatment of entropion and ectropion can lead to blindness due to development of secondary changes in cornea. Neglecting a child with severe ptosis can result in irreversible visual loss. Incorrect primary repair of lacerated lid and failure to repair the torn canaliculi are difficult to handle at a later stage even by an expert surgeon. Long-standing blocked distal lacrimal passages may result in suppurative infections with skin excoriation. This review elucidates the correct approach to some common oculoplastic diseases so as to achieve a timely intervention and referral and thereby avoid preventable complications.

Single loop fixation of posterior chamber intraocular lens in the presence of partial capsular support is usually performed by creation of additional scleral flap or tunnel. This extra port may expose the suture holding the intraocular lens or the tucked-in lens haptics to the outside environment thereby increasing the risk of endophthalmitis. We describe a technique of single loop fixation where the scleral tunnel is created adjacent to the site with the absent capsule, the leading haptic is placed on the capsular scaffold, the trailing haptic is tied to 9-0 polypropylene, and the suture is then secured to the inner edge of the scleral lip with enough tension to center the optics and the wound is then closed. The suture knot gets buried within the scleral tunnel with no external communication and does not require a separate port. It is an easy, safe, fast and reproducible technique with a lens tilt of less than 2°.

Context: Conjunctivodacryocystorhinostomy (CDCR) is the procedure of choice for proximal canalicular blocks. However, the complications of tube migration and extrusion limit its widespread practice. Aim: The aim of this study is to evaluate the efficacy and complications of the new “mirror tuck technique” for fixation of lacrimal bypass glass tube without holes in proximal canalicular blocks in laser CDCR. Materials and Methods: A prospective interventional study was conducted in forty consecutive eyes of adult patients, undergoing 980 nm diode laser CDCR for proximal canalicular blocks. After creating the tract under endoscopic guidance, the collar of the glass tube was fixed to the conjunctiva with 6-0 prolene suture by “mirror tuck technique.” Success was defined as the absence of extrusion of tube with patent tract and relief in epiphora at 1 year of follow-up. Results: Both anatomical and functional success was achieved in 39 (97.5%) cases. Tube displacement occurred in one patient suffering from allergic conjunctivitis in which the tube had to be removed. A temporary heaviness was reported by 5 (12.5%) patients till about 2 weeks. Conjunctival overgrowth over the tube occurred in 1 (2.5%) eye at 5 months which was excised and treated with application of 0.02% mitomycin C with no subsequent recurrence. There were no cases of suture abscess or suture intolerance warranting tube removal. Conclusion: “Mirror tuck technique” is an effective method for tube fixation (for tube without holes) in CDCR. However, it is important to position the conjunctival opening so as to leave sufficient space for passage of sutures for anchorage medially.

Human parvovirus B19 (B19V) causes myriads of clinical diseases; however, owing to lack of awareness and undetermined clinical impact, it has failed to become a virus pathogen of global concern. Cryptically, B19V causes significant morbidity and mortality. Half of the world population and 60 per cent of Indians are known to be serologically naive and are at risk of acquiring B19V infections. Cumulatively, our data showed 21.3 per cent B19V-infected patients with juvenile chronic arthropathy, recurrent abortions, multi-transfused thalassaemia and leukaemia. In addition, B19V-infected cases that ended fatally included patients with pure red cell aplasia, fulminant hepatitis and haemophagocytic syndrome. Novel clinical associations of B19V observed were amegakaryocytic thrombocytopaenia, myositis and non-occlusive ischaemic gangrene of bowel. B19V possesses multiple receptors which are distributed widely in human tissues. Vascular endothelial cell infection by B19V causes endothelialitis and vasculitic injuries besides antibody-dependent enhancement which empowered B19V to cause multiorgan diseases. Owing to lack of suitable animal model for B19V, true causal role remains to be determined, but numerous reports on B19V infections substantiate a causal role in multiorgan diseases. Hence, B19V infections need to be recognized, investigated and treated besides making efforts on vaccine developments.

Presentation A 60 year old female presented to our clinic in July 2015 with complaints of left eye epiphora, and painless gradually increasing mass in the medial canthal area for 4 months. Probing revealed hard stop. At the time the mass was above the MCT and appeared separate from lacrimal sac. She was advised biopsy, but was lost to follow-up, only to present 6months later with a massive increase in the size of mass. There was no history of bloody discharge. On Examination, both eyes had senile cataract with BCVA of 6/24 in Right eye and absent light perception in left eye. A single, irregular, diffuse, firm mass was present in the medial canthal area of left eye, measuring approximately 2.5cmX2.5cm in size, with 3mm horizontal dystopia and blackish skin pigmentation. It involved the medial part of both upper and lower lid, lacrimal sac and canaliculi. It was non tender, immobile, with no surface ulcerations or pulsations. Excessive watering was present in the left eye, syringing could not be done since puncta were not visualized. There were no other swellings, no lymphadenopathy, and no history of significant weight loss. Hematological investigations were normal. Neuroimaging revealed a well-defined heterogenously enhancing solid lesion in the region of medial canthus of Left eye, about 2.3X2.8X1.7cm, involving the extraconal space, causing scalloping and widening of Left lacrimal fossa and NLD, and mild lateral displacement of the globe. Incisional biopsy showed tumor tissue composed of clusters of malignant cells-pleomorphic with high nuclear-cytoplasmic ratio, vesicular nuclei and prominent eosinophillic macronuclei. Foci of melanin pigment deposition were seen, leading to a diagnosis of malignant melanoma of the lacrimal sac. Metastatic work-up revealed lytic lesions in left frontal and right parietal skull bones and fibronodular opacities in upper and middle lobes of right lung, alongwith mediastinal lymphadenopathy. Hence the final staging was T4aN0M1c. No surgical treatment was planned and instead patient was referred for palliative systemic chemotherapy and radiotherapy. Discussion Malignant melanoma is a malignancy of the pigmentproducing melanocytes. It usually affects the skin and rarely