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1. A regionally tailored epidemiological forecast and monitoring program to guide a healthcare system in the COVID-19 pandemic

Author

Philip J. Turk, William E. Anderson, Ryan J. Burns, Shih-Hsiung Chou, Thomas E. Dobbs, James T. Kearns, Seth T. Lirette, Maggie SJ McCarter, Hieu M. Nguyen, Catherine L. Passaretti, Geoffrey A. Rose, Casey L. Stephens, Jing Zhao, and Andrew D. McWilliams

Subjects
COVID-19 pandemic, Public health surveillance, Hospital resources, Forecasting and modeling, Infection prevalence, Effective reproduction number, Infectious and parasitic diseases, RC109-216, Public aspects of medicine, RA1-1270
Abstract

Background: During the COVID-19 pandemic, analytics and predictive models built on regional data provided timely, accurate monitoring of epidemiological behavior, informing critical planning and decision-making for health system leaders. At Atrium Health, a large, integrated healthcare system in the southeastern United States, a team of statisticians and physicians created a comprehensive forecast and monitoring program that leveraged an array of statistical methods. Methods: The program utilized the following methodological approaches: (i) exploratory graphics, including time plots of epidemiological metrics with smoothers; (ii) infection prevalence forecasting using a Bayesian epidemiological model with time-varying infection rate; (iii) doubling and halving times computed using changepoints in local linear trend; (iv) death monitoring using combination forecasting with an ensemble of models; (v) effective reproduction number estimation with a Bayesian approach; (vi) COVID-19 patients hospital census monitored via time series models; and (vii) quantified forecast performance. Results: A consolidated forecast and monitoring report was produced weekly and proved to be an effective, vital source of information and guidance as the healthcare system navigated the inherent uncertainty of the pandemic. Forecasts provided accurate and precise information that informed critical decisions on resource planning, bed capacity and staffing management, and infection prevention strategies. Conclusions: In this paper, we have presented the framework used in our epidemiological forecast and monitoring program at Atrium Health, as well as provided recommendations for implementation by other healthcare systems and institutions to facilitate use in future pandemics.

Published
2024
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2. Remote monitoring following adult cardiac surgery: A paradigm shift?Central MessagePerspective

Author

Kevin W. Lobdell, MD, Shannon Crotwell, BS, CCRN, Larry T. Watts, MD, Bradley LeNoir, MD, John Frederick, MD, Eric R. Skipper, MD, Gregory B. Russell, MS, Robert Habib, PhD, Thomas Maxey, MD, and Geoffrey A. Rose, MD

Subjects
digital health, remote monitoring, quality, safety, value, cardiac surgery, Diseases of the circulatory (Cardiovascular) system, RC666-701, Surgery, RD1-811
Abstract

Background: The Perfect Care (PC) initiative engages, educates, and enrolls adult cardiac surgery patients into a transformational program that includes an app for appointment scheduling, tracking biometric data and patient-reported outcomes, audiovisual visits, and messaging, paired with a digital health kit (consisting of a fitness tracker, scale, and sphygmomanometer). PC aims to reduce postoperative length of stay (LOS) as well as 30-day readmission and mortality. Methods: This was a retrospective review of patients who underwent coronary artery bypass (CAB), valve, or combined CAB and valve procedures at either of the 2 participating hospitals between April 2018 and March 2022. Patients who participated in the PC quality improvement initiative were compared to propensity-matched controls (1:1 matching). The evaluation focused on postoperative LOS and a novel composite measure comprising 30-day readmission and mortality. Results: Remote monitoring (PC) was associated with a shorter postoperative LOS, lower combined rate of 30-day readmission and mortality, and less variation compared to matched non-PC controls. Conclusions: Integrated improvements in postoperative remote monitoring of adult cardiac surgery patients may reduce time in the hospital and post-acute care facilities. Future prioritized efforts include the development of additional, personalized biometric monitoring devices, use of biometric data to augment risk assessment, and investigation of the value of remote monitoring on various patient risk profiles to address potential disparities in care.

Published
2023
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3. Combined immunosuppression and radiotherapy in thyroid eye disease (CIRTED): a multicentre, 2 × 2 factorial, double-blind, randomised controlled trial

Author

Colin M. Dayan, Anne E. Cook, Steven J. Hurel, Daniel S Morris, M J Potts, Jimmy Uddin, Marjorie Tomlinson, Suzannah R Drummond, Rathie Rajendram, Diana Ritchie, Rao Gattamaneni, Daniel G. Ezra, Fion Bremner, Andrew D. Dick, Nicola Harris, Peter N. Taylor, Sue Yarrow, Nicholas Plowman, Richard W J Lee, Sue Jackson, Ewan Kemp, H. Herbert, Helen Garrott, Victoria J. Wilson, Jane M. Olver, Robert Kerrin Hills, Nichola Rumsey, Rajni Jain, Julie Pell, Nachi Palaniappan, Chunhei Li, Olivia C Morris, Catey Bunce, Geoffrey E. Rose, and Carol M. Lane

Subjects
Adult, Male, medicine.medical_specialty, Endocrinology, Diabetes and Metabolism, medicine.medical_treatment, 030209 endocrinology & metabolism, Azathioprine, Placebo, Severity of Illness Index, law.invention, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Endocrinology, Double-Blind Method, Randomized controlled trial, Prednisone, law, Internal medicine, Internal Medicine, Humans, Medicine, Adverse effect, Aged, business.industry, Standard treatment, Chemoradiotherapy, Middle Aged, Prognosis, Graves Ophthalmopathy, Radiation therapy, 030221 ophthalmology & optometry, Female, business, Immunosuppressive Agents, medicine.drug
Abstract

Background: Standard treatment for thyroid eye disease is with systemic corticosteroids. We aimed to establish whether orbital radiotherapy or antiproliferative immunosuppression would confer any additional benefit. Methods: CIRTED was a multicentre, double-blind, randomised controlled trial with a 2 × 2 factorial design done at six centres in the UK. Adults with active moderate-to-severe thyroid eye disease associated with proptosis or ocular motility restriction were recruited to the trial. Patients all received a 24 week course of oral prednisolone (80 mg per day, reduced to 20 mg per day by 6 weeks, 10 mg per day by 15 weeks, and 5 mg per day by 21 weeks) and were randomly assigned via remote computerised randomisation to receive either radiotherapy or sham radiotherapy and azathioprine or placebo in a 2 × 2 factorial design. Randomisation included minimisation to reduce baseline disparities in potential confounding variables between trial interventions. Patients and data analysts were masked to assignment, whereas trial coordinators (who monitored blood results), pharmacists, and radiographers were not. The radiotherapy dose was 20 Gy administered to the retrobulbar orbit in ten to 12 fractions over 2 to 3 weeks. Azathioprine treatment was provided for 48 weeks at 100–200 mg per day (dispensed as 50 mg tablets), depending on bodyweight (100 mg for interaction=0·86). The adjusted odds ratio (ORadj) for improvement in the binary clinical composite outcome measure was 2·56 (95% CI 0·98–6·66, p=0·054) for azathioprine and 0·89 (0·36–2·23, p=0·80) for radiotherapy. In a post-hoc analysis of patients who completed their allocated therapy the ORadj for improvement was 6·83 (1·66–28·1, p=0·008) for azathioprine and 1·32 (0·30–4·84, p=0·67) for radiotherapy. The ophthalmopathy index, clinical activity score, and numbers of adverse events (161 with azathioprine and 156 with radiotherapy) did not differ between treatment groups. In both groups, the most common adverse events were mild infections. No patients died during the study. Interpretation: In patients receiving oral prednisolone for 24 weeks, radiotherapy did not have added benefit. We also did not find added benefit for addition of azathioprine in the primary analysis; however, our conclusions are limited by the high number of patients who withdrew from treatment. Results of post-hoc analysis of those who completed the assigned treatment suggest improved clinical outcome at 48 weeks with azathioprine treatment. Funding: National Eye Research Centre, Above and Beyond, and Moorfields Eye Charity.

Published
2018
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4. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

Author

Ruth Graham, Charlotte Eglinton, Swapna Kunhunny, J Banns, Alison K Wright, Sunil Munshi, C Khuoge, Beverley McClelland, A Benford, Jean Buxton, Maia Beridze, K Deighton, Neha Chopra, Nichola Motherwell, Emily C. O'Brien, Sonia S. Anand, Anand Dixit, Una Poultney, N Beridze, Jessica Beavan, K Dizayee, Thompson G. Robinson, Deborah Howcroft, Alison Sarah rachel Mcloughlin, A Kenton, Derek Esson, A Tittle, L Matter, Kerstin Knops, C Hubbuck, Kath Chapman, R Rangasamay, Ranjan Sanyal, Sarah Lewis, Alpha Anthony, Sarah Board, Janice Irvine, Anna Verrion, Katherine Whittamore, N Khizanishvili, L O'Shea, Lisa Shaw, K Ayes, Tracey Dobson, N Akiashvili, Gill Rogers, Jenny Peters, Alda Remegoso, S S Hansen, James A. White, T Attygalle, Rosalind Brown, Irene Martin, Manesh R. Patel, D O'Kane, Stuart J. Pocock, Khalid Rashed, G Spurling, Sharon Tysoe, Frances Harrington, Margo Henry, Rowilson Jarapa, Julia Hindle, K A Kay, Carinna Vickers, S Duty, Angela Bowring, David Eveson, Saul Sundayi, Mary Kambafwile, Rashmi Kumar, Jack Roffe, Marilyn James, Natalie Temple, R Oliver, Christine Kelly, M Niemierko, J Chembala, S Jones, M Dent, K Chatterjee, S Atkinson, J Tomlinson, S Norman, E Cattermole, P Daboo, Nicola Gilzeane, Anne Hardwick, Pietro Cariga, C Rankin, David A. Wood, Lelia Duley, John Bamford, L Holford, J Good, C Ambulo, S Gomm, Girish Muddegowda, Fiona Wright, M Alao, L Sztriha, Maite D. Rodriguez, Christine Dickson, S Merotra, Helen Bearne, Ann Needle, Emma Mckenzie, Olga Balazikova, Emily Osborne, A Lankester, Rod S Taylor, Pauline Fitzell, Bernard Esisi, E Young, Richard Donnelly, Anu Joyson, Debbie Morgan, Fran Watson, Caroline Mcinnes, C Padilla-Harris, Stephanie McCann, T Ajao, Suzanne Lucas, Inez Wynter, Barbara Longland, Don Sims, Gavin Bateman, Anthony Hemsley, Vera Cvoro, Fiona Kennedy, Peter Langhorne, Adrian Butler, P Jacob, Barry Moynihan, Amit K. Mistri, W Sunman, Hannah Beadle, Polly Scutt, M Garside, Glyn Fletcher, Deborah Walstow, L Ryan, Michelle Fawcett, D Wilkinson, E Gibson, O Orugun, Malcolm R. Macleod, Philip M.W. Bath, Elio Giallombardo, T Kherkheulidze, Lourda Kerin, Clare Doyle, Brigid Hairsine, N Kakabadze, B Wadams, Enas Lawrence, Dinesh Chadha, I Memon, Cheryl L. Perkins, Victoria Sutton, C.B. Patel, A Ravindrane, K Javaid, Mahmud Sajid, T Tsanava, Y Duodu, Timothy J. England, Geoffrey A. Rose, Sheila Nyabadza, Louisa M. Christensen, M Bajoriene, F Faola, J Kok, C Vernon, Aravindakshan Manoj, E Horsley, T Gordon, Linda Cowie, S Hurdowar, D Sandler, Temi Adedoyin, Mandy Couser, C Jenkins, C Pringle, Paula Lopez, Vicky Taylor, James Cunningham, Gillian Courtauld, S Maheswaran, H Rehman, Christine Roffe, M Sein, Carla Richardson, John B. Davis, Nenette Abano, Racquel Carpio, Sheila Mashate, P Christian, Lynn Dixon, Dulka Manawadu, Jeanette Grocott, Peter Owusu-Agyei, P Farren, F K Chan, Komal Ali, Annemarei Ranta, Judith Clarke, Dean Waugh, Stan Heptinstall, M Reader, Nikola Sprigg, John F. Corrigan, Caroline Roughan, F Brodie, Paula Harman, P Webster, Kenneth Smith, Julie Reddan, Angela Willberry, Peter Howard, Kay Finney, S Buddha, C Hewitt, M Zaidi, Tracy Marsden, Heather Gow, Robert A. Dineen, Kimberley Netherton, Kashif Musarrat, Emma Barbon, V Riddell, G Storey, Ahamad Hassan, O Adegbaju, S Wong, Bethan Charles, Bindu Gregary, Rhys Williams, M G Metiu, Nilofer Dayal, C Lawlor, Kirsten E Anderson, R Icart Palau, N Khanom, C Stevenson, Prabel Datta, Betty Mokoena, Kelly Chan, Amanda Hedstrom, Sonia Raj, Y Gruenbeck, D Dellafera, Georgina Butt, A Peacocke, James Okwera, L Mokoena, Holly Maguire, Mohana Maddula, C Bailey, Ian Shread, LáShauntá M. Glover, Elizabeth Keeling, Mari Smith, Jane Powell, A Tevdoradze, Christopher Price, Hannah Rudenko, K Gill, Laura Howaniec, P Lingwood, Katherine Marks, Ivan Iniesta, F Barrett, Barbara Madigan, Emery N. Brown, Katie Flaherty, Gail Hann, Mark Barber, Kelley Storey, Aparna Pusalkar, Jason P. Appleton, Joanne Hiden, R Jolly, Hedley C. A. Emsley, J Chambers, Christina Kruuse, Mairead Osborn, P Lai, Tracy Fuller, David G. Bruce, Robert Namushi, Martin Cooper, Peter Murphy, Naomi Jeyaraj, Hayley Kingwell, A Nair, Robert S.M. Davies, Katrina McCormick, Rachel L. Lakey, Sharon Dealing, F Leslie, Peter Wilkinson, Amitava Banerjee, Penelope Cox, Janice E. O’Connell, N Sikondari, Sandra Leason, Lisa J Woodhouse, Judith Bell, Puneet Dangri, Donna Butler, Judith Dube, Rachel Gascoyne, Amberly Brigden, Debs Kelly, Renuka Erande, Kirsty Harkness, Sarah Trippier, Kirsten Harvey, Georgina Ayres, R Rowland-Axe, E Campbell, Sue Lyjko, Sylvia Szabo, David Mangion, Suzanne Ragab, C Hilaire, Alan A Montgomery, Dawn Tomlin, John Paterson, K Muhidden, Grace Auld, C Keaveney, Hannah Crowther, Lisa Hyatt, Louise E. Jackson, K Castro, Khaled Elfandi, H Russell, S Tennant, Ozlem Redjep, Tim Cassidy, Linda Y Johnson, Amulya Misra, E Khoromana, Catherine Ovington, Stuart Maguire, S Khan, Zoe Mellor, Michael Funnell, Hugh S. Markus, Emma Richards, I Toidze, Colin Smith, R Sivakumar, Janet Wilson, Amina Ahmed, A Mohd Nor, A Barkat, Line Bentsen, K Whysall, Carol L Clarke, N Sengupta, Meena Srinivasan, Balakrishna Kumar, Mgg Soliman, A Thomson, Adrian Barry, Abul Azim, Ed Gamble, H Eccleson, Kelly Marie Shaw, Christine Schofield, Linetty Makawa, Carole Hays, David Hargroves, Jordi Margalef, S Butler, H Webb, Carol Denniss, Samantha Stafford, Faye Shelton, D Forrest, Amanda Buck, Tarn Nozedar, Indira Natarajan, Jane Perez, Susanna R. Stevens, Denise Button, Mary Johnes, Samantha Keenan, Olivia C. Geraghty, Eva Beranova, Emma Jinks, S Hassan, Caroline McGhee, Nicola Persad, Gunaratnam Gunathilagan, Clare Buckley, Jennifer Mitchell, Mike Clarke, Mathew Burn, B Bhaskaran, D Hayward, Lucy Belle Guthrie, S Meenakshisundaram, Anushka Warusevitane, O Speirs, J O'Callaghan, Sudipto Ghosh, Peter Wilding, Helen Cochrane, Susan Clayton, Mandy Doherty, Fiona Price, L Montague, Valerie Hogg, S Arif, Beth Hazel, Margaret Ball, S Johnson-Holland, S Booth, N Rands, Dionne Hove, Teresa Thompson, C Krarup Hansen, Lisa Manning, Andrew Smith, Jo Howe, Jill Greig, Kailash Krishnan, Caroline Watchurst, L Finlay, Sandra Nelson, Toby Black, S Tilby, Zin Naing, D Morse, David Broughton, K Preece, M Platton, M Siddiqui, Angela Dodd, Catrin Blank, Maria Bokhari, Jacqueline Furnace, F Hammonds, Helen Guy, A Lehman, J Hunt, S Windebank, Becky Jupp, K Fotherby, Ruth Bellfield, P Wanklyn, D Hilton, Amy Steele, S Mahmood, N Lobjanidze, Sarah Finlay, L Hunt, M Krasinska-Chavez, Gemma Grimwood, H H Jensen, J. Duignan, Jane Gaylard, Asaipillai Asokanathan, Joanna O'Reilly, J Kessell, Diane Havard, T Fluskey, L Lee-Carbon, Graham Venables, Margi Godfrey, L Boxall, C Douglass, Emelda Veraque, Elaine Amis, M Chowdhury, Rekha Keshvara, Adrian Blight, G Thomas, Marc Randall, S Stoddart, Paul Guyler, Rita Ghatala, Janet T Scott, Kathy J. Jenkins, Sarah Ross, John Aeron-Thomas, C Allcock, J Goodsell, Ifan Jones, D Kakabadze, T T Thomsen, V Petrovic, I. Watson, C Athulathmudali, Hanne Christensen, Susan Crawford, Christine Kamara, James McIlmoyle, Stephen Woodward, Christine McAlpine, Emma Temlett, Gwendoline Wilkes, Benjamin Hyams, L Mills, S Brixey, Raj Shekhar, P Findlay, Markus, Hugh [0000-0002-9794-5996], and Apollo - University of Cambridge Repository

Subjects
Male, medicine.medical_specialty, Georgia, Ticlopidine, Denmark, Hemorrhage, 030204 cardiovascular system & hematology, Risk Assessment, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Ischemia, Recurrence, Modified Rankin Scale, Internal medicine, medicine, Humans, Thrombolytic Therapy, Prospective Studies, cardiovascular diseases, Stroke, Aged, Aspirin, business.industry, Dipyridamole, General Medicine, Guideline, Middle Aged, Clopidogrel, medicine.disease, United Kingdom, Treatment Outcome, Ischemic Attack, Transient, Research Design, Acute Disease, Platelet aggregation inhibitor, Drug Therapy, Combination, Female, business, Platelet Aggregation Inhibitors, 030217 neurology & neurosurgery, New Zealand, medicine.drug
Abstract

Summary Background Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy. Methods We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388. Findings 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67–1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05–3·16, p Interpretation Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice. Funding National Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.

Published
2017

5. List of contributors

Author

Iqbal Ike K. Ahmed, Rana Altan-Yaycioglu, George William Aylward, Augusto Azuara-Blanco, Alessandro Bagnis, Lelio Baldeschi, Michael R. Banitt, Keith Barton, Darrell E. Baskin, Martin Baumeister, Roberto Bellucci, Larry Benjamin, John P. Berdahl, John Brazier, Roy D. Brod, Jens Bühren, Kathryn Burleigh Freidl, Massimo Busin, Louis B. Cantor, Roberto G. Carassa, Joseph Colin, Sarah E. Coupland, Bertil Damato, Steven C. Dresner, William J. Dupps, Tom Eke, Mark J. Elder, Daniel Elies, Javier Elizalde, Daniel Epstein, I. Howard Fine, Mitchell S. Fineman, Harry W. Flynn, Jeffrey Freedman, Arnd Gandorfer, Thomas W. Gardner, Robert A. Goldberg, Saurabh Goyal, Oscar Gris, Carl Groenewald, Jose L. Güell, Shelly R. Gupta, Katie Hallahan, Dennis P. Han, Christos Haritoglou, Heinrich Heimann, Kathy J. Hetzler, Christoph Hintschich, Richard S. Hoffman, Frank G. Holz, Amy K. Hutchinson, Catherine J. Hwang, Srinivas S. Iyengar, Robert L. Johnston, Eugene de Juan, Aylin Kılıç Uzbek, Oliver K. Klaproth Dipl-Ing, Thomas Kohnen, Georgios A. Kontadakis, Daniel Kook, George D. Kymionis, Scott R. Lambert, Scott D. Lawrence, Richard K. Lee, Tina G. Li, Phoebe Lin, Rebecca Anderson Lindsay, Brian C. Little, Angelo Macrì, Marissa R. Malen, Felicidad Manero, Antonio Marinho, Tara A. McCannel, Darlene Miller, Consuela Moorman, Merce Morral, Marlene R. Moster, Peter A. Netland, John D. Ng, Ken K. Nischal, William R. Nunery, Joan O’Brien, Jane Olver, Mark Packer, Marina Papadia, Louis R. Pasquale, Amit Patel, Shuchi B. Patel, Jacob Pe’er, Richard Poetter, Som Prasad, David A. Quillen, Robert Ritch, Geoffrey E. Rose, Paul Rosen Bsc, Thomas W. Samuelson, Andrew P. Schachat, Ann Schalenbourg, Ulrich H. Schaudig, Norman Schorr, Riccardo Scotto, David Sculfor, Carol L. Shields, Jerry A. Shields, Georges Adrien Shun-Shin, Dimitrios S. Siganos, Arun D. Singh, Alison H. Skalet, Jennifer Hasenyager Smith, Jason A. Sokol, George L. Spaeth, Boris V. Stanzel, Timothy J. Sullivan, Ramin Tadayoni, Diamond Y. Tam, Clement C.Y. Tham, Peter J. Timoney, Carlo Enrico Traverso, Anthony G. Tyers, Nicolas Uzcategui, Davide Venzano, David H. Verity, Mark T. Watts, Louisa Wickham, Allison B. Yee, Martin Zehetmayer, and Leonidas Zografos

Published
2012
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6. Neuro-ophthalmology of orbital disease

Author

David H. Verity and Geoffrey E. Rose

Subjects
medicine.medical_specialty, genetic structures, Exophthalmos, business.industry, Eye disease, medicine.disease, eye diseases, Surgery, Optic neuropathy, Neuro-ophthalmology, Pleomorphic adenoma, medicine, Optic nerve, Orbital Diseases, sense organs, medicine.symptom, business, Scleritis
Abstract

In this chapter the presentation and management of common orbital diseases are discussed. An accurate clinical history and assessment are essential, with computed tomography being the imaging of choice. Magnetic resonance imaging provides detail of intrinsic optic nerve disease and orbital apical or intracranial pathology, and ultrasonography is valuable in assessing anterior orbital masses, in particular vascular lesions. Inflammatory lesions require a tissue biopsy before immunosuppression is instituted. Exceptions to this principle are scleritis, myositis, thyroid eye disease, and characteristic orbital apex syndrome, in which delay in immune suppression may jeopardize visual outcome. The term "orbital pseudotumor" is now obsolete. The management of active thyroid eye disease includes immunosuppression and low-dose orbital radiotherapy. Urgent orbital decompression is indicated in the presence of nonresponsive optic neuropathy, and inactive disease is managed by decompression for exophthalmos, and correction of muscle imbalance and lid retraction. Subacute lacrimal gland inflammation, unresponsive to a few weeks of nonsteroidal treatment, may be due to underlying carcinoma and a specialist opinion should be sought without delay. Pleomorphic adenoma, with typical features on imaging, should always be excised intact to avoid subsequent pervasive malignant disease.

Published
2011
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9. Chapter 3 Orbital Disease

Author

Geoffrey E. Rose and David H. Verity

Subjects
Eyelid Skin, genetic structures, Lagophthalmos, business.industry, Fistula, Dacryoadenitis, Arteriovenous malformation, Anatomy, Lacrimal gland, medicine.disease, eye diseases, body regions, medicine.anatomical_structure, medicine, Orbital Diseases, sense organs, Eyelid, business
Abstract

Publisher Summary This chapter describes clinical history in orbital disease, clinical examination for orbital disease, and ancillary tests for orbital disease. It also discusses common orbital diseases—benign orbital diseases and malignant orbital diseases. Eyelid swelling is a common feature of orbital disease and may be due to the actual orbital mass, fat displacement by the mass, or venous congestion resulting from an apical orbital mass. Other eyelid signs include lid retraction, phase lag of the upper lid on slow down-gaze, and incomplete closure (“lagophthalmos”)—all of which are often observed in thyroid orbitopathy. Lid retraction may be primary, resulting from primary levator muscle overaction, or secondary to fibrosis within the inferior rectus—the latter causes excessive co-contraction of the superior rectus and levator muscles. A persistent S-shaped upper lid contour is commonly seen with plexiform neurofibroma and, more rarely, with lacrimal gland infiltrative diseases; a similar, but transient, contour may be seen with dacryoadenitis, often with cutaneous erythema confined within the brow line. Anterior venous anomalies give a blue hue to eyelid skin and xanthomatous lesions may present as a yellow plaque. Episcleral vessels may indicate underlying pathology; fine corkscrew vessels suggest a low-flow dural arteriovenous shunt, whereas marked conjunctival edema with large vessels suggests carotico-cavernous fistula. A high-flow fistula or orbital arteriovenous malformation may have a palpable thrill or audible bruit.

Published
2008
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11. Contributors

Author

James F. Acheson, G.G.W. Adams, Larry Amure, Richard Andrews, Keith Barton, Adam Bates, Alan C. Bird, Jill Bloom, John Brookes, Ben J.L. Burton, Richard O. Collin, Helen L. Cook, Carol Cunningham, Lyndon Da Cruz, Samantha Dandekar, John K.G. Dart, Catherine Egan, Daniel P. Ehrlich, Ahmed N. El-Amir, Paul J. Foster, Wendy Franks, David Gartry, Ted Garway-Heath, David Goh, Zdenek J. Gregor, Thomas Hardy, Richard H. Hart, Hugo Henderson, Graham E. Holder, John L. Hungerford, Timothy L. Jackson, Rajni Jain, Peng T. Khaw, Susan L. Lightman, Natasha Lim, Graham Macalister, Bita Manzouri, Keith Martin, Bernadette McCarry, Patricia McElhatton, Michael Merriman, Michel Michaelides, Moin Mohammed, A.T. Moore, Prithvi Mruthyunjaya, Ian Murdoch, Anil Nambiar, Winifred Nolan, Narciss Okhravi, Carlos E. Pavesio, Gordon T. Plant, Maria Papadopoulos, Poornima Rai, Madhavan Rajan, Mahesh Ramchandani, Yashin Ramkissoon, Marie Restori, Geoff Roberson, Geoffrey E. Rose, Kulwant Sehmi, Dilani Siriwardena, John Sloper, Guy T. Smith, Paul M. Sullivan, Chris Timms, Adnan Tufail, Jimmy Uddin, David H. Verity, and Ananth Viswanathan

Published
2008
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12. List of Contributors

Author

Juan-Carlos Abad, Mark B Abelson, David H Abramson, Martin A Acquadro, Anthony P Adamis, Wesley H Adams, Natalie A Afshari, Everett Ai, Lloyd M Aiello, Lloyd P Aiello, Levent Akduman, Marissa L Albano, Daniel M. Albert, Terry J Alexandrou, Eduardo C Alfonso, Jorge L Alié, Hassan Alizadeh, Ibrahim A Al Jadaan, Sabah Al-Jastaneiah, Calliope E Allen, David Allen, Robert C Allen, Albert Alm, Samar Al-Swailem, Abigail K Alt, Michael M Altaweel, Russell Anderson, Christopher M Andreoli, Sofia Androudi, Leonard PK Ang, Fahd Anzaar, David J Apple, Claudia A Arrigg, Pablo Artal, Penny Asbell, George K Asdourian, Neal Atebara, Pelin Atmaca-Sonmez, Isabelle Audo, Gerd U Auffarth, Robin K Avery, Dimitri T Azar, Ann S Baker, Mark Balles, Scott D Barnes, Donald M Barnett, Neal P Barney, Fina C Barouch, George B Bartley, Jason JS Barton, Irmgard Behlau, Jose I Belda, Jeffrey L Bennett, Timothy J Bennett, Gregg J Berdy, Carlo Roberto Bernardino, Vitaliano Bernardino, Eliot L Berson, Amitabh Bharadwaj, Robert Bhisitkul, Ravinder D Bhui, Jurij Bilyk, Valérie Biousse, Alan C Bird, Norman Paul Blair, Barbara A Blodi, Mark S Blumenkranz, H Culver Boldt, Mark S Borchert, Luigi Borrillo, Gary E Borodic, S Arthur Boruchoff, Swaraj Bose, Michael E Boulton, RW Bowman, Elizabeth A Bradley, Periklis D Brazitikos, Robert Breeze, Neil M Bressler, Susan B Bressler, Alfred Brini, Donald L Budenz, Angela N Buffenn, Scott E Burk, Salim Butrus, David Callanan, J Douglas Cameron, Louis B Cantor, William A Cantore, Jorge Cantu-Dibildox, Victoria Casas, Miriam Casper, Robin J Casten, Yara P Catoira, Jerry Cavallerano, Samantha J Chai, Maria R Chalita, Sherman M Chamberlain, Audrey S Chan, Chi-Chao Chan, Paul Chan, Matthew J Chapin, Karen L Chapman, Eric Chen, Joe Chen, Julie A Chen, Teresa C Chen, Zhou Chen, Patricia Chévez-Barrios, Emily Y Chew, Mark Chiang, James Chodosh, Eva-Marie Chong, Denise Chun, Leo T Chylack, Antonio P Ciardella, Mortimer Civan, Liane Clamen, John I Clark, Glenn Cockerham, Andre Cohen, Elisabeth J Cohen, Kathryn A Colby, Anne L Coleman, Hanna R Coleman, Joseph Colin, J Michael Collier, Grant M Comer, M Ronan Conlon, Kim E Cooper, James J Corbett, Miguel C Coma, Marshall N Cyrlin, Linda R Dagi, Matthew A Dahlgren, Timothy J Daley, Andrea P Da Mata, Bertil Damato, Donald J D'Amico, Reza Dana, Aude Danan-Husson, Helen B Danesh-Meyer, Ronald P Danis, Jason K Darlington, Stefanie L Davidson, Janet L Davis, Elizabeth A Davis, Jose J de la Cruz, Adam G de la Garza, Margaret M DeAngelis, Sheri L DeMartelaere, Joseph L Demer, Avninder Dhaliwal, J Paul Dieckert, Diana V Do, Marshall G Doane, Christopher Dodds, Claes H Dohlman, Guy Donati, Eric D Donnenfeld, Arlene Drack, Thaddeus P Dryja, David Dueker, Jay S Duker, Jennifer A Dunbar, James P Dunn, William J Dupps, Marlene L Durand, Jonathan J Dutton, Chiara M Eandi, Deepak P Edward, Robert A Egan, David A Eichenbaum, Susan E Eklund, Elizabeth C Engle, Kristine Erickson, Bita Esmaeli, Aaron Fay, Leonard Feiner, Sharon Fekrat, Frederick L Ferris, Howard F Fine, Donald C Fletcher, Paul Flikier, Richard P Floyd, Harry W Flynn, Donald S Fong, Ramon L Font, Brian JR Forbes, Rod Foroozan, Bradley S Foster, C Stephen Foster, Jill A Foster, Gary N Foulks, Tamara R Fountain, Gregory M Fox, Thomas F Freddo, Sharon F Freedman, K Bailey Freund, Thomas R Friberg, Alan H Friedman, David Friedman, Deborah I Friedman, Ephraim Friedman, Arthur D Fu, Anne B Fulton, Ahmed Galal, Steven Galetta, Mark Gallardo, Brenda Gallie, Alec Garner, James A Garrity, Damien Gatinel, Steven J Gedde, Craig E Geist, Steve Gerber, Ramon C Ghanem, Jon P Gieser, Michael S Gilmore, Howard V Gimbel, Ilene K Gipson, Tyrone Glover, Robert A Goldberg, Mordechai Goldenfeld, Scott M Goldstein, Cintia F Gomi, Haiyan Gong, John A Gonzales, John Goosey, Justin L Gottlieb, Joshua Gould, Evangelos S Gragoudas, David B Granet, Michael J Greaney, Daniel G Green, Franz Grehn, Jack V Greiner, Craig M Greven, Gregory J Griepentrog, Carl Groenewald, Cynthia L Grosskreutz, Lori Latowski Grover, Vamsi K Gullapalli, Padma Gulur, Jonathan Gunther, Manish Gupta, Mayank Gupta, David R Guyer, Darin R Haivala, Julia A Haller, GM Halmagyi, Lawrence S Halperin, Islam M Hamdi, Steven R Hamilton, Kristin M Hammersmith, Dennis P Han, Ronald M Hansen, J William Harbour, Seenu M Hariprasad, Mona Harissi-Dagher, Shirin E. Hassan, Mark P Hatton, Pamela Hawley, Yasutaka Hayashida, John R Heckenlively, Thomas R Hedges, Alfred D Heggie, Katrinka L Heher, Jeffrey S Heier, J Fielding Hejtmancik, Bonnie A Henderson, Peter S Hersh, Ahmed A Hidayat, Eva Juliet Higginbotham, Tatsuo Hirose, Allen C Ho, ThucAnh T Ho, R Nick Hogan, David E Holck, Nancy M Holekamp, Peter G Hovland, Thomas C Hsu, William C Hsu, Andrew JW Huang, Mark S Hughes, Jennifer Hui, David G Hunter, Laryssa A Huryn, Deeba Husain, Robert A Hyndiuk, Michael Ip, Brian J Jacobs, Frederick A Jakobiec, Lee M Jampol, Harold G Jensen, Fei Ji, David L Johnson, Douglas H Johnson, Mark W Johnson, R Paul Johnson, Robert N Johnson, Karen M Joos, Nancy C Joyce, J Michael Jumper, Ula V. Jurkunas, Alon Kahana, Malik Y Kahook, Elliott Kanner, Kevin Kalwerisky, Henry J Kaplan, Ekaterini C Karatza, Randy Kardon, James A Katowitz, William R Katowitz, Melanie Kazlas, Kelly S Keefe, Lara Kelley, Charles J Kent, Kenneth R Kenyon, Bilal F Khan, Jemshed A Khan, Naheed W Khan, Peng Tee Khaw, Femida Kherani, Eva C Kim, Hee Joon Kim, Ivana K Kim, Jonathan W Kim, Rosa Y Kim, Stella K Kim, Tae-Im Kim, Christina M Klais, Stephen R Klapper, Barbara EK Klein, Guy Kleinmann, Thomas Klink, Dino D Klisovic, Stephen D Klyce, Tolga Kocaturk, Thomas Kohnen, Takeshi Kojima, Tobias Koller, David A Kostick, Joel A Kraut, Chandrasekharan Krishnan, Ronald R Krueger, Joseph H Krug, Sara Krupsky, Rachel W Kuchtey, Ramsay S Kurban, Paul A Kurz, JR Kuszak, Young H Kwon, Thad A Labbe, Deborah L Lam, Jeffrey C Lamkin, Kathleen A Lamping, Anne Marie Lane, Katherine A Lane, Keith J Lane, Jonathan H Lass, Mary G Lawrence, Andrew G Lee, Carol M Lee, Michael S Lee, Paul P Lee, William B Lee, Igal Leibovitch, Bradley N Lemke, Craig A Lemley, Andrea Leonardi, Simmons Lessell, Leonard A Levin, Grace A Levy-Clarke, Julie C Lew, Craig Lewis, Wei Li, Laurence S Lim, Lyndell L Lim, Wee-Kiak Lim, Grant T Liu, John I Loewenstein, McGregor N Lott, Jonathan C Lowry, David B Lyon, Robert E Lytle, Mathew MacCumber, Bonnie T Mackool, Nalini A Madiwale, Francis Mah, Martin A Mainster, Michael H Manning, Steven L Mansberger, Robert E Marc, Mellone Marchong, Dennis M Marcus, Julie A Mares, Brian P Marr, Carlos E Martinez, Robert W Massof, Yukihiro Matsumoto, Cynthia Mattox, Marlon Maus, Cathleen M McCabe, Steven A McCormick, Michael McCrakken, James P McCulley, John A McDermott, H Richard McDonald, Marguerite B McDonald, Peter J McDonnell, Robert McGillivray, Craig A McKeown, James McLaughlin, W Wynn McMullen, Shlomo Melamed, George Meligonis, Efstratios Mendrinos, Dale R Meyer, Catherine B Meyerle, William F Mieler, Michael Migliori, Martin C Mihm, Darlene Miller, David Miller, Joan W Miller, Neil R Miller, David M Mills, Monte D Mills, Tatyana Milman, Lylas Mogk, Marja Mogk, Jordi Monés, Robert Montes-Micó, Christie L Morse, Asa D Morton, Anne Moskowitz, Shizuo Mukai, A Linn Murphree, Robert P Murphy, Timothy G Murray, Philip I Murray, Karina Nagao, Jay Neitz, Maureen Neitz, Peter A Netland, Arthur H Neufeld, Nancy J Newman, Eugene WM Ng, Quan Dong Nguyen, Jerry Y Niederkorn, Robert J Noecker, Robert B Nussenblatt, Joan M O'Brien, Paul D O'Brien, Terrence P O'Brien, Denis O'Day, R Joseph Olk, Karl R Olsen, Sumru Onal, Yen Hoong Ooi, E Mitchel Opremcak, George Ousler, Randall R Ozment, Samuel Packer, Millicent L Palmer, George N Papaliodis, DJ John Park, David W Parke, Cameron F Parsa, M Andrew Parsons, Louis R Pasquale, Neha N Patel, Sayjal J Patel, Thomas D Patrianakos, James R Patrinely, Deborah Pavan-Langston, Eli Peli, Susan M Pepin, Victor L Perez, Juan J Pérez-Santonja, John R Perfect, Henry D Perry, Joram Piatigorsky, Dante Pieramici, Eric A Pierce, Roberto Pineda, Misha L Pless, Howard D Pomeranz, Constantin J Pournaras, William Power, Manvi Prakash, Anita G Prasad, Valerie Purvin, David A Quillen, Graham E Quinn, Melvin D Rabena, James L Rae, Michael B Raizman, Alessandro Randazzo, Narsing A Rao, Christopher J Rapuano, Sherman W Reeves, Carl D Regillo, Elias Reichel, Martin H Reinke, Douglas Rhee, Claudia U Richter, Joseph F Rizzo, Richard M Robb, Anja C Roden, I Rand Rodgers, Merlyn M Rodrigues, Yonina Ron, Geoffrey E Rose, Emanuel S Rosen, James T Rosenbaum, Perry Rosenthal, Strutha C Rouse, Barry W Rovner, Malgorzata Rozanowska, Michael P Rubin, Peter AD Rubin, Shimon Rumelt, Anil K Rustgi, Tina Rutar, Mark S Ruttum, Allan R Rutzen, Edward T Ryan, Alfredo A Sadun, José-Alain Sahel, Leorey Saligan, Sarwat Salim, John F Salmon, Diva R Salomão, David Sami, Michael A Sandberg, Virender S Sangwan, Maria A Saornil, Joseph W Sassani, Rony R Sayegh, Andrew P Schachat, Wiley A Schell, Amy C Schefler, Tina Scheufele, Vivian Schiedler, Gretchen Schneider, Alison Schroeder, Ronald A Schuchard, Joel S Schuman, Ivan R Schwab, Adrienne Scott, Ingrid U Scott, Marvin L Sears, Johanna M Seddon, Theo Seiler, Robert P Selkin, Richard D Semba, Irina Serbanescu, Briar Sexton, Tarek M Shaarawy, Peter Shah, Aron Shapiro, Savitri Sharma, Jean Shein, Debra J Shetlar, M Bruce Shields, Carol L Shields, Jerry A Shields, Bradford J Shingleton, John W Shore, Lesya M Shuba, Guy J Ben Simon, Richard J Simmons, Michael Simpson, Arun D Singh, Omah S Singh, Karen Sisley, Arthur J Sit, David Smerdon, William E Smiddy, Ronald E Smith, Terry J Smith, Neal G Snebold, Lucia Sobrin, John A Sorenson, Sarkis H Soukiasian, George L Spaeth, Richard F Spaide, Monika Srivastava, Sunil K Srivastava, Alexandros N Stangos, Tomy Starck, Walter J Stark, Joshua D Stein, Roger F Steinert, Leon Strauss, Barbara W Streeten, J Wayne Streilein, James D Strong, Ilene K Sugino, Eric B Suhler, Timothy J Sullivan, Jennifer K Sun, Janet S Sunness, Francis C Sutula, Nasreen A Syed, Christopher N Ta, Hidehiro Takei, Jonathan H Talamo, Richard R Tamesis, Madhura Tamhankar, Kristen J Tarbet, Michelle Tarver-Carr, Mark A Terry, Joseph M Thomas, Vance Thompson, Jennifer E Thorne, Matthew J Thurtell, David P Tingey, King W To, Faisal M Tobaigy, Michael J Tolentino, Melissa G Tong, Gail Torkildsen, Cynthia A Toth, Elias I Traboulsi, Michele Trucksis, James C Tsai, Julie H Tsai, David T Tse, Scheffer CG Tseng, Elmer Y Tu, Ira J Udell, Alejandra A Valenzuela, Russell N Van Gelder, Gregory P Van Stavern, Deborah K Vander Veen, Demetrios Vavvas, David H Verity, Paolo Vinciguerra, Paul F Vinger, Nicholas J Volpe, Werner Wackernagel, Sonal Desai Wadhwa, Michael D Wagoner, Nadia K Waheed, David S Walton, Martin Wand, Jie Jin Wang, Scott M Warden, Lennox Webb, David Weber, Daniel Wee, Corey B Westerfeld, Christopher T Westfall, Scott M Whitcup, Valerie A White, William L White, Jason Wickens, Janey L Wiggs, Jacob T Wilensky, Charles P Wilkinson, Patrick D Williams, David J Wilson, M Roy Wilson, Steven E Wilson, Jules Winokur, William J Wirostko, Gadi Wollstein, Albert Chak Ming Wong, Tien Y Wong, John J Woog, Michael Wride, Carolyn S Wu, Darrell WuDunn, Jean Yang, Lawrence A Yannuzzi, Michael J Yaremchuk, R Patrick Yeatts, Richard W Yee, Steven Yeh, Lucy HY Young, Jenny Y Yu, Beatrice YJT Yue, Charles M Zacks, Bruce M Zagelbaum, Maryam Zamani, Marco Zarbin, Leonidas Zografos, and Christopher I Zoumalan

Published
2008
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13. Tumors of the lacrimal gland

Author

Geoffrey E. Rose and Omar M. Durrani

Subjects
Pathology, medicine.medical_specialty, medicine.anatomical_structure, business.industry, medicine, Lacrimal gland, business
Published
2007
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14. List of contributors

Author

Thomas M. Aaberg, Charlotta All-Ericsson, Carryn Anderson, Sophie Bakri, Aubin Balmer, David Sander Bardenstein, Rafael I. Barraquer, Valentina de Belvis, Louise Bergman, Michiel R. de Boer, James P Bolling, Ernest Borden, Norbert Bornfeld, Lex M. Bouter, Julie Bray, Greta R. Bunin, Devron H. Char, Guillermo Luis Chantada, Benson Chen, Patricia Chevez-Barrios, Murali Chintagumpala, Robin Clark, Kimberly Cockerham, Javier Coloma, Sharon Cook, Sarah E. Coupland, Jihan Dennaoui, Karin Dieckmann, Ira J. Dunkel, Omar M Durrani, Jonathan Dutton, Michael A. Dyer, Javier Elizalde, Ralph C. Eagle, Evelyn Fu, Peter Fleming, Robert Folberg, Jill A. Foster, Debra Friedman, Joseph Frucht-Perry, Anat Galor, Roberta E. Gausas, Dan S. Gombos, Evangelos S. Gragoudas, Jennifer Gravette, Carl Groenewald, J. William Harbour, Martin Heur, Joanne Hilden, Paul Hiscott, Santosh Honavar, Jennifer I. Hui, Saskia Marijke Imhof, Martine J. Jager, Bennie H. Jeng, David R. Jordan, Hanneke J.G. Journée-de Korver, Rima F. Jubran, Peter K. Kaiser, Hayyam Kiratli, Tero Kivelä, Stephen R. Klapper, Alfred G. Knudson, Anne Marie Lane, Gerald Langmann, Carlos Leal-Leal, Michael Levien, Hilel Lewis, Karin U. Loeffler, Cari E. Lyle, Roy Ma, Willem Maat, Nancy Mansfield, Eduardo Marback, Anna T. Meadows, Thomas E. Merchant, Edoardo Midena, David Miller, Annette C. Moll, Hardeep Singh Mudhar, Francis Munier, Michael D. Onken, Manuela Orjuela, Lisa Paquette, Michael Andrew Parsons, Bhupendra Patel, Maria Fideliz de la Paz, David Peereboom, Jose Perez-Moreiras, R Poetter, Patrick De Potter, Consuelo Prada, Paul L Proffer, Ian George Rennie, Carlos Rodriguez-Galindo, Geoffrey Edward Rose, Mordechai Rosner, Paul Anthony Rundle, Stefan Sacu, Andrew P. Schachat, Nicoline Elisabeth Schalij-Delfos, Lynn Schoenfield, Ursula Schmidt-Erfurth, Mona Schmutzer, Luann Sculley, Jonathan E. Sears, Stefan Seregard, Rishi P. Singh, Julie Ann Stoner, Mehran Taban, Mehryar Taban, Azzam Taktak, Madhura Tamhankar, Elias I. Traboulsi, Nikolaos Trichopoulos, David T. Tse, Geeta K. Vemuganti, Judith Villablanca, Werner Wackernagel, Allan Wilkinson, Matthew W. Wilson, Leonidas Zografos, and Martin Zehetmayer

Published
2007
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