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Veshesh Patel,1 Parastou Pakravan,1 James Lai,1 Arjun Watane,1,2 Divy Mehra,1 Tiffany Alyssa Eatz,1 Nimesh Patel,1,3 Nicolas A Yannuzzi,1 Jayanth Sridhar1 1Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, Miami, FL, USA; 2Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT, USA; 3Mass, Eye and Ear, Harvard Medical School, Boston, MA, USACorrespondence: Jayanth Sridhar, Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, 33136, USA, Tel +1 305-326-6124, Fax +1 305-326-6417, Email jsridhar1@med.miami.eduPurpose: To describe the indications, outcomes, and complications associated with intraocular lens (IOL) exchange.Patients and Methods: To determine the relative frequency of postoperative complications between techniques for all patients undergoing IOL exchange from May 1, 2014 through August 31, 2020.Results: IOL exchange was performed in 511 eyes of 489 patients (59.7% men; mean age: 67.0 ± 13.9 years, median time from cataract procedure to IOL exchange: 47.5 months). Mean uncorrected visual acuity significantly improved from 20/192 Snellen equivalent (logMAR 0.981) preoperatively to 20/61 (logMAR 0.487) at last follow-up (P < 0.001). Overall, 384 eyes (78.7%) met their desired refractive outcome within ± 1.0 diopter (D). The most frequent complication was cystoid macular edema (CME) (n=39, 7.6%). Iris-sutured technique was associated with significantly greater frequency of subsequent IOL dislocation (10.3%) than 4-point scleral sutured (0%, P = 0.002), anterior chamber IOL (ACIOL, 1.5%, P = 0.01), and 2-point scleral sutured (0%, P = 0.03) techniques. Yamane scleral-fixation technique was associated with significantly greater frequency of developing IOL tilt (11.8%) than ACIOL (0%, P = 0.002), 4-point scleral sutured (1.1%, P = 0.01), 2-point scleral sutured (0%, P = 0.04), and iris-sutured (0%, P = 0.04) techniques.Conclusion: IOL exchange significantly improved uncorrected visual acuity and more than three-quarters of eyes met the refractive goal. Certain techniques were associated with complications, including subsequent dislocation associated with iris-sutured technique and IOL tilt associated with Yamane scleral-fixation technique. This information may help guide surgeons in deciding between procedural techniques for individual patients during IOL exchange preoperative planning.Keywords: intraocular lens, dislocation, Yamane, techniques, cataracts, complications

Veshesh Patel, Landon J Rohowetz, Parastou Pakravan, Meghana Kalavar, Nicolas A Yannuzzi, Jayanth Sridhar Department of Ophthalmology, Bascom Palmer Eye Institute University of Miami, Miami, FL, USACorrespondence: Jayanth Sridhar, Department of Ophthalmology, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL, 33136, USA, Tel +1 305 326-6124, Email jsridhar1@med.miami.eduObjective: To review clinical outcomes of patients with proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH) who underwent pars plana vitrectomy (PPV) with endolaser panretinal photocoagulation (PRP) without retinal detachment (RD) repair.Methods: Retrospective chart review of the rate of postoperative clinical findings and visual acuity in patients with PDR from May 2014 to August 2021.Results: Pars plana vitrectomy with endolaser PRP was performed in 81 eyes of 81 patients (mean age of 62.1 ± 10.5 years). At a median follow-up of 18 months, mean Snellen best-corrected visual acuity (BCVA) significantly improved from 20/774 preoperatively to 20/53 at last follow-up (P < 0.001). Postoperative complications and clinical findings included VH (12.3%), diabetic macular edema (DME) (12.3%), ocular hypertension (8.6%), RD (4.9%), and need for additional PPV (6.2%). Eyes with PRP performed within 6 months before surgery had a lower frequency of developing postoperative VH (5.3%) compared to eyes that received PRP more than 6 months before surgery (27.3%, P = 0.04). Eyes that received preoperative anti-vascular endothelial growth factor (VEGF) treatment (2.0%) had a lower frequency of postoperative VH compared to eyes that did not receive anti-VEGF treatment (14.3%, P = 0.04). Eyes that received intraoperative sub-tenon triamcinolone acetonide developed postoperative DME (4.0%) less frequently than eyes that did not receive sub-tenon triamcinolone acetonide (26.7%, P = 0.04).Conclusion: In patients with PDR and VH, PPV with PRP yielded significant improvements in visual acuity and resulted in overall low rates of recurrent postoperative VH. Preoperative anti-VEGF and PRP laser treatment were associated with lower rates of postoperative VH. Furthermore, intraoperative use of sub-tenon triamcinolone acetonide was associated with a lower rate of postoperative DME. Pars plana vitrectomy with endolaser PRP in conjunction with the aforementioned pre- and intraoperative therapies is an effective treatment for patients with PDR and VH.Keywords: pars plana vitrectomy, panretinal photocoagulation, vitreous hemorrhage, vascular endothelial growth factor, sub-tenon triamcinolone acetonide

Krishnan Chakravarthy,1,2 David Lee,3 Jennifer Tram,1 Samir Sheth,4 Robert Heros,5 Smith Manion,6 Vikas Patel,7 Kyle Kiesel,8 Yousef Ghandour,9 Christopher Gilligan10 1Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA; 2VA San Diego Healthcare System, San Diego, CA, USA; 3Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 4Sutter Health System, Roseville, CA, USA; 5Spinal Diagnostics PC, Tualatin, OR, USA; 6Advent Health Pain Specialists, Merriam, KS, USA; 7Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA; 8Department of Physical Therapy, University of Evansville, Evansville, IN, USA; 9Physical Rehabilitation Network (PRN), University of St. Augustine, San Diego, CA, USA; 10Division of Pain Medicine, Brigham & Women’s Hospital/Harvard Medical School, Boston, MA, USACorrespondence: Krishnan Chakravarthy, Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA, Email kvchakravarthy@health.ucsd.eduAbstract: In this review, we present a comprehensive clinical approach to restorative neurostimulation, a novel form of stimulation for refractory chronic mechanical low back pain, targeting impaired neuromuscular control and degeneration of the multifidus muscle. We focus on patient identification, technique guidance, and review of the scientific background and clinical evidence. As our understanding of back pain grows, there is clear evidence that impaired neuromuscular control and consequent degeneration of the multifidus muscle contribute to mechanical low back pain development and maintenance. We provide clinical guidance regarding an implantable restorative neurostimulation system that targets impaired neuromuscular control. Supported by results from a randomized, active-sham-controlled clinical trial with long-term follow-up, we provide clinicians with a comprehensive overview and practical clinical guidance for the adoption of this therapy modality.Keywords: restorative neurostimulation, multifidus, arthrogenic inhibition, neuromodulation, chronic mechanical low back pain, neuromuscular control

Mansoor M Aman,1 Ammar Mahmoud,2 Timothy Deer,3 Dawood Sayed,4 Jonathan M Hagedorn,5 Shane E Brogan,6 Vinita Singh,7 Amitabh Gulati,8 Natalie Strand,9 Jacqueline Weisbein,10 Johnathan H Goree,11 Fangfang Xing,12 Ali Valimahomed,13 Daniel J Pak,14 Antonios El Helou,15 Priyanka Ghosh,16 Krishna Shah,17 Vishal Patel,1 Alexander Escobar,18 Keith Schmidt,19 Jay Shah,20 Vishal Varshney,21 William Rosenberg,22 Sanjeet Narang23 1Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA; 2Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA; 3The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 4Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA; 5Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA; 6Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA; 7Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA; 8Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 9Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA; 10Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 11Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA; 12Swedish Pain Services, Swedish Health Services, Seattle, WA, USA; 13Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA; 14Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA; 15Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada; 16Remedy Medical Group, San Francisco, CA, USA; 17Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA; 18Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA; 19AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA; 20SamWell Institute for Pain Management, Colonia, NJ, USA; 21Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada; 22Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA; 23Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USACorrespondence: Mansoor M AmanInterventional Pain Medicine, Department of Anesthesiology, Advocate Aurora Health, Oshkosh, WI, 54904, USATel +1 920-456-7715Email aman.mansoorm@gmail.comAbstract: Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.Keywords: cancer pain, neurolysis, ketamine, pain pump, intrathecal drug delivery, neuromodulation, radiofrequency, spinal cord stimulation, vertebral augmentation

Salih Samo,1,2 Falak Hamo,2 Anand S Jain,1 Rushikesh H Shah,1 Vaishali Patel,1 Lucie F Calderon,1 Mengdan Xie,1 Parit Mekaroonkamol,1 Steven A Keilin,1 Qiang Cai1 1Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; 2Division of Gastroenterology, Hepatology and Motility-Department of Medicine, The University of Kansas School of Medicine, Kansas City, KS, USACorrespondence: Qiang CaiEmory University School of Medicine, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USATel +1 404-778-2714Fax +1 404-778-2578Email qcai@emory.eduPurpose: Peroral endoscopic myotomy (POEM) after prior myotomy (PM-POEM) can be technically challenging with possible increased adverse events. We aimed to assess gas leak and mucosal injury incidence during PM-POEM, compared to an index POEM (iPOEM), and post-procedure extubation time.Patients and Methods: A retrospective study comparing PM-POEM to iPOEM from March 2016 to August 2018.Results: There were 21 subjects in the PM-POEM and 56 subjects in the iPOEM. The PM-POEM group was younger (average age 44.33 vs 57.57 years, p=0.0082). Gas leak incidence did not differ between groups (28.6% in PM-POEM vs 14.3% in iPOEM, p=0.148). For cases with imaging available postoperatively, there was a trend towards higher incidence of gas leak in the PM-POEM, but it was not statistically significant (60% vs 42.1%, p=0.359). The post-procedure extubation time was not different between PM-POEM and iPOEM (11.38 vs 9.46 minutes, p=0.93), but it was longer when gas leak occurred (15.92 vs 8.67 minutes, p=0.027). The odds of mucosal injury were four-fold higher (OR, 4.31; 95% CI, 1.32– 14.08), and more clips were used to close mucosal injuries (0.62 vs 0.14 clips, p=0.0053) in the PM-POEM group. More procedures were deemed difficult or challenging in the PM-POEM (33.3% vs 7.1%, p=0.007). The number of clips used to close the mucosotomy was not different between groups (4.05 vs 3.84 clips, p=0.498). Although the myotomy was shorter in PM-POEM, it was not statistically significant (6.38 vs 7.14 cm, p=0.074). However, the procedure was longer in PM-POEM (61.28 vs 45.39 minutes, p=0.0017). There was no intervention or ICU admission required pertinent to the procedure.Conclusion: Performing PM-POEM can be more difficult with more mucosal injuries. Gas leak was associated with a slightly longer post-procedure extubation time, but clinical relevance is unclear given incidence of gas leak was unknown at time of extubation.Keywords: peroral endoscopic myotomy, Heller’s myotomy, achalasia, gas leak, mucosal injury

Vichar Trivedi,1 Yasaira Rodriguez Torres,2 Vaama Patel,2 Pradeepa Yoganathan2 1Wayne State University School of Medicine, Detroit, MI, USA; 2Department of Ophthalmology, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, MI, USACorrespondence: Pradeepa YoganathanDepartment of Ophthalmology, Kresge Eye Institute, Wayne State University School of Medicine, 4717 St. Antoine Street, Detroit, MI, 48201, USAEmail deepayoganathan@gmail.comObjective: To gather data on the most common chief complaints, diagnoses, in-office procedures, and surgeries that presented to the Kresge Eye Institute’s Emergency Clinic in Detroit, Michigan during the COVID-19 state lockdown period to provide data for staff and resource allocation in future waves.Design: Retrospective study.Participants: All patients 18 years or older presenting for ophthalmic consultation to the Kresge Eye Institute Emergency Walk-in Clinic between March 23rd and April 17th, 2020 were included in the study.Methods: All patients who met the inclusion criteria were indexed based on their initial encounter date and patients were stratified by urgent and non-urgent ophthalmic reasons for evaluation. Patient demographics, medical history, chief complaint, diagnosis, and need for surgical intervention and procedures were obtained from the electronic medical records.Results: The most common diagnoses were corneal disease (31.4%), followed by vitreoretinal disease (25.3%), orbit-eyelid pathology (8.8%), and glaucoma-related issues (8.8%). The most common office procedure was intravitreal injections (37.5%) followed by foreign body removal (21.9%), and pan-retinal photocoagulation laser (21.9%). Retina surgery was the most common emergency surgery representing 73.3% of the total, the second most common was keratoplasty (13%).Conclusion: Future implementation of protocols for triaging based on chief complaints can aid in protecting patients and expanding the role of distanced assessment with telemedicine. Suggested management of an emergent clinic requires availability of retina and cornea specialists given the majority of visits, procedures, and surgeries were related to their area of expertise.Keywords: retina, cornea, COVID 19, SARS-CoV-2 infection, COVID-19 pandemic, ophthalmology, clinical protocol, coronavirus disease-19

Vikas Patel,1 Don Kovalsky,2 S Craig Meyer,3 Abhineet Chowdhary,4 Harry Lockstadt,5 Fernando Techy,6 Casey Langel,7 Robert Limoni,8 Philip S Yuan,9 Andy Kranenburg,10 Daniel Cher,11 Gabriel Tender,12 Travis J Hillen13 1Department of Orthopedics, University of Colorado, Aurora, CO, USA; 2Orthopaedic Center of Southern Illinois, Mt. Vernon, IL, USA; 3Columbia Orthopaedic Medical Group, Columbia, MO, USA; 4Overlake Medical Center, Bellevue, WA, USA; 5Bluegrass Orthopaedics, Lexington, KY, USA; 6ClinTech Center for Spine Health, Johnstown, CO, USA; 7The B.A.C.K. Center, Melbourne, FL, USA; 8BayCare Clinic Orthopedics & Sports Medicine, Green Bay, WI, USA; 9Memorial Orthopaedic Surgical Group, Long Beach, CA, USA; 10South Oregon Orthopedics, Medford, OR, USA; 11SI-BONE, Inc., Santa Clara, CA, USA; 12Department of Neurosurgery, Louisiana State University, New Orleans, LA, USA; 13Department of Musculoskeletal Radiology, Washington University St. Louis, St. Louis, MOCorrespondence: Vikas Patel Tel +1 303 724-8936Email Vikas.Patel@CUAnschutz.eduBackground: Prior trials provide strong evidence supporting minimally invasive sacroiliac joint (SIJ) fusion using triangular titanium implants (TTI) for chronic SIJ dysfunction.Objective: To assess the safety and effectiveness of SIJF using a 3D-printed TTI.Methods: Fifty-one subjects with carefully diagnosed SIJ dysfunction underwent SIJF with 3D TTI. Subjects completed pain, disability and quality of life questionnaires at baseline and 3, 6 and 12 months postoperatively. Functional tests were performed in the clinic at each visit. Pelvic CT scans were independently evaluated for radiolucency, bridging bone and other endpoints.Results: Ninety percent had 12-month follow-up. Dysfunction due to pain (Oswestry Disability Index [ODI]) decreased from 52.8 at baseline to 27.9 at 12 months (p< .0001 for change, p=.004 for non-inferiority primary hypothesis). SIJ pain scores improved from 78 preoperatively to 21 at 12-month follow-up (P< .0001). Ninety-six percent experienced an improvement of 20 points or more in VAS SIJ pain by month 12. The percentage of subjects reporting minimal difficulty performing physical activities typically impaired by back/SIJ pain improved significantly for all activities. The proportion of subjects taking opioids for SIJ pain decreased from 57% to 22%. Three physical function tests improved markedly from baseline to 1 year. Positive radiographic findings were observed, including a 70% and 77% rate of bone bridging observed at 6 and 12 months, respectively. There was no evidence of device breakage, migration or subsidence.Conclusion: In this prospective multicenter trial, SIJF with 3D-printed TTI markedly improved pain, disability and quality of life. Results are consistent with 3 prior prospective multicenter trials of a milled implant but suggest accelerated bony fusion with the newer implant. Physical function improved, and high rates of opioid cessation were observed.Level of Evidence: Level II.Keywords: sacroiliac joint pain, sacroiliac joint arthrodesis, chronic low back pain, triangular titanium implants

Vikas Patel,1 Don Kovalsky,2 S Craig Meyer,3 Abhineet Chowdhary,4 Harry Lockstadt,5 Fernando Techy,6 James Billys,7 Robert Limoni,8 Philip S Yuan,9 Andy Kranenburg,10 Daniel Cher,11 Gabriel Tender121Department of Orthopedics, University of Colorado, Aurora, CO, USA; 2Orthopaedic Center of Southern Illinois, Mt. Vernon, IL, USA; 3Columbia Orthopaedic Medical Group, Columbia, MO, USA; 4Overlake Medical Center, Bellevue, WA, USA; 5Bluegrass Orthopaedics, Lexington, KY, USA; 6ClinTech Center for Spine Health, Johnstown, CO, USA; 7The B.A.C.K. Center, Melbourne, FL, USA; 8BayCare Clinic Orthopedics & Sports Medicine, Green Bay, WI, USA; 9Memorial Orthopaedic Surgical Group, Long Beach, CA, USA; 10South Oregon Orthopedics, Medford, OR, USA; 11SI-BONE, Inc., Santa Clara, CA, USA; 12Department of Neurosurgery, Louisiana State University, New Orleans, LA, USABackground: Minimally invasive sacroiliac joint (SIJ) fusion (SIJF) has become an increasingly accepted surgical option for chronic SI joint dysfunction, a prevalent cause of chronic low back/buttock pain.Objective: To report clinical and functional outcomes of SIJF using 3D-printed triangular titanium implants (TTI) for patients with chronic SI joint dysfunction.Methods: A total of 28 subjects with SIJ dysfunction at 8 centers underwent SIJF with 3D TTI and had scheduled follow-up to 6 months (NCT03122899).Results: Mean preoperative SIJ pain score was 79.1 and mean preoperative Oswestry Disability Index (ODI) was 49.9. At 6 months, pain scores decreased by 51 points and ODI decreased by 23.6 points (both p

Ina Mishra,1,2 Clinton Jones,1,3 Vipulkumar Patel,1,2 Sneha Deodhar,1 David P Cistola1,2 1Nanoparticle Diagnostics Laboratory, Institute for Cardiovascular and Metabolic Diseases, Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA; 2Center of Emphasis in Diabetes & Metabolism, Department of Biomedical Sciences, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA; 3Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA Background: The ability to use frozen biobanked samples from cohort studies and clinical trials is critically important for biomarker discovery and validation. Here we investigated whether plasma and serum water transverse relaxation times (T2) from frozen biobanked samples could be used as biomarkers for metabolic syndrome (MetS) and its underlying conditions, specifically insulin resistance, dyslipidemia, and subclinical inflammation. Methods: Plasma and serum aliquots from 44 asymptomatic, non-diabetic human subjects were biobanked at –80°C for 7–9 months. Water T2 measurements were recorded at 37°C on 50 µL of unmodified plasma or serum using benchtop nuclear magnetic resonance relaxometry. The T2 values for freshly drawn and once-frozen-thawed (“frozen”) samples were compared using Huber M-values (M), Lin concordance correlation coefficients (ρc), and Bland–Altman plots. Water T2 values from frozen plasma and serum samples were compared with >130 metabolic biomarkers and analyzed using multi-variable linear/logistic regression and ROC curves. Results: Frozen plasma water T2 values were highly correlated with fresh (M=0.94, 95% CI 0.89, 0.97) but showed a lower level of agreement (ρc=0.74, 95% CI 0.62, 0.82) because of an average offset of –5.6% (−7.1% for serum). Despite the offset, frozen plasma water T2 was strongly correlated with markers of hyperinsulinemia, dyslipidemia, and inflammation and detected these conditions with 89% sensitivity and 91% specificity (100%/63% for serum). Using optimized cut points, frozen plasma and serum water T2 detected hyperinsulinemia, dyslipidemia, and inflammation in 23 of 44 subjects, including nine with an early stage of metabolic dysregulation that did not meet the clinical thresholds for prediabetes or MetS. Conclusion: Plasma and serum water T2 values from once-frozen-thawed biobanked samples detect metabolic dysregulation with high sensitivity and specificity. However, the cut points for frozen biobanked samples must be calibrated independent of those for freshly drawn plasma and serum. Keywords: metabolic syndrome, insulin resistance, hyperinsulinemia, dyslipidemia, inflammation, nuclear magnetic resonance relaxometry, metabolic health screening, diabetes prevention

Edsel B Ing,1 Gabriela Lahaie Luna,2 Andrew Toren,3 Royce Ing,4 John J Chen,5 Nitika Arora,6 Nurhan Torun,7 Otana A Jakpor,8 J Alexander Fraser,9 Felix J Tyndel,10 Arun NE Sundaram,10 Xinyang Liu,11 Cindy TY Lam,1 Vivek Patel,12 Ezekiel Weis,13 David Jordan,14 Steven Gilberg,14 Christian Pagnoux,15 Martin ten Hove21Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, 2Department of Ophthalmology, Queen’s University, Kingston, ON, 3Department of Ophthalmology, University of Laval, Quebec, QC, 4Toronto Eyelid, Strabismus and Orbit Surgery Clinic, Toronto, ON, Canada; 5Mayo Clinic, Department of Ophthalmology and Neurology, 6Mayo Clinic, Department of Ophthalmology, Rochester, MN, 7Department of Surgery, Division of Ophthalmology, Harvard Medical School, Boston, MA, 8Harvard Medical School, Boston, MA, USA; 9Department of Clinical Neurological Sciences and Ophthalmology, Western University, London, 10Department of Medicine, University of Toronto Medical School, Toronto, ON, Canada; 11Department of Medicine, Fudan University Shanghai Medical College, Shanghai, People’s Republic of China; 12Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; 13Departments of Ophthalmology, Universities of Alberta and Calgary, Edmonton and Calgary, AB, 14Department of Ophthalmology, University of Ottawa, Ottawa, ON, 15Vasculitis Clinic, Mount Sinai Hospital, Toronto, ON, CanadaPurpose: To develop and validate a diagnostic prediction model for patients with suspected giant cell arteritis (GCA).Methods: A retrospective review of records of consecutive adult patients undergoing temporal artery biopsy (TABx) for suspected GCA was conducted at seven university centers. The pathologic diagnosis was considered the final diagnosis. The predictor variables were age, gender, new onset headache, clinical temporal artery abnormality, jaw claudication, ischemic vision loss (VL), diplopia, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and platelet level. Multiple imputation was performed for missing data. Logistic regression was used to compare our models with the non-histologic American College of Rheumatology (ACR) GCA classification criteria. Internal validation was performed with 10-fold cross validation and bootstrap techniques. External validation was performed by geographic site.Results: There were 530 complete TABx records: 397 were negative and 133 positive for GCA. Age, jaw claudication, VL, platelets, and log CRP were statistically significant predictors of positive TABx, whereas ESR, gender, headache, and temporal artery abnormality were not. The parsimonious model had a cross-validated bootstrap area under the receiver operating characteristic curve (AUROC) of 0.810 (95% CI =0.766–0.854), geographic external validation AUROC’s in the range of 0.75–0.85, calibration pH–L of 0.812, sensitivity of 43.6%, and specificity of 95.2%, which outperformed the ACR criteria.Conclusion: Our prediction rule with calculator and nomogram aids in the triage of patients with suspected GCA and may decrease the need for TABx in select low-score at-risk subjects. However, misclassification remains a concern.Keywords: temporal artery biopsy, diagnosis, prediction rule, nomogram, giant cell arteritis, validation

Benjamin Farahnik,1 Viraat Patel,2 Kourosh Beroukhim,3 Tian Hao Zhu,4 Michael Abrouk,2 Mio Nakamura,5 Rasnik Singh,3 Kristina Lee,5 Tina Bhutani,5 John Koo5 1University of Vermont College of Medicine, Burlington, VT; 2School of Medicine, University of California, Irvine, 3David Geffen School of Medicine, University of California, Los Angeles, 4University of Southern California Keck School of Medicine, Los Angeles, 5Department of Dermatology, Psoriasis and Skin Treatment Center, University of California, San Francisco, CA, USA Background: The efficacy and safety of biologic and phototherapy in treating moderate-to-severe psoriasis is well known. However, some patients may not respond well to biologic agents or phototherapy on their own and may require combination therapy. Skillfully combining a biologic agent and phototherapy may provide an additive improvement without much increase in risks.Objective: To summarize the current state of evidence for the efficacy and safety of combining biologics with phototherapy in the treatment of moderate-to-severe plaque psoriasis.Methods: We conducted an extensive search on Pubmed database for English language literature that evaluated the use of a combination of biologic and phototherapy for the treatment of moderate-to-severe psoriasis through January 2016. The search included the following keywords: psoriasis, etanercept, adalimumab, infliximab, ustekinumab, biologics, phototherapy, and combination therapy.Results: The primary literature included randomized controlled trials, a head-to-head study, open-label controlled and uncontrolled trials, case series, and case reports. Etanercept was used in over half of the reported cases, but other biologic agents used included ustekinumab, adalimumab, and infliximab. The vast majority of phototherapy was narrowband ultraviolet B (NBUVB) radiation. Most cases reported enhanced improvement with combination therapy. Serious adverse events throughout the study duration were reported in

Radiative transition of an excited baryon to a nucleon with emission of a virtual massive photon converting to dielectron pair (Dalitz decays) provides important information about baryon-photon coupling at low q2 in timelike region. A prominent enhancement in the respective electromagnetic transition Form Factors (etFF) at q2 near vector mesons ρ/ω poles has been predicted by various calculations reflecting strong baryon-vector meson couplings. The understanding of these couplings is also of primary importance for the interpretation of the emissivity of QCD matter studied in heavy ion collisions via dilepton emission. Dedicated measurements of baryon Dalitz decays in proton-proton and pion-proton scattering with HADES detector at GSI/FAIR are presented and discussed. The relevance of these studies for the interpretation of results obtained from heavy ion reactions is elucidated on the example of the HADES results.

No abstract available. Article truncated after 150 words. A Morgagni hernia is a congenital diaphragmatic hernia in which abdominal viscera herniate into the thorax via a defect within an anterior attachment of the diaphragm. As with any bowel-containing hernia, the most feared complication is strangulation with subsequent bowel necrosis. In the present case, a 67-year-old woman presented with a five-day history of acute onset and progressively worsening upper abdominal pain and inability to tolerate oral intake, associated with nausea, vomiting, and mild shortness of breath. A CT revealed a large defect in the right hemidiaphragm consistent with a Morgagni hernia with herniation of the omentum, vessels, and a segment of transverse colon (Figure 1). Findings of bowel ischemia were observed, including (a) pneumatosis intestinalis, seen as cystic foci of air lining the bowel wall, and (b) fluid and fat-stranding adjacent to the affected bowel (Figure 2). Evidence of bowel wall perforation include large volume free air adjacent to …

Stephanie B Engelhard, Vandan Patel, Ashvini K Reddy Department of Ophthalmology, University of Virginia, Charlottesville, VA, USA Background: The purpose of this study was to identify the causes, clinical features, and outcomes of intermediate uveitis, posterior uveitis, and panuveitis in patients managed in a mid-Atlantic tertiary care center.Methods: This was a retrospective observational study of intermediate uveitis, posterior uveitis, and panuveitis patients seen at the University of Virginia from 1984 to 2014. Results: One hundred and fifty-nine intermediate uveitis, posterior uveitis, and panuveitis patients (237 eyes) were identified. The patient population was 54.72% female; 67.30% of patients were Caucasian, and 22.01% were African–American. Mean age at diagnosis was 45.5 years. Mean duration of follow-up was 3.95 years. Mean number of visits to the clinic was 10.35. Of 491 uveitis patients, 26 (5.30%) had intermediate uveitis, 62 (12.60%) had posterior uveitis, and 71 (14.50%) had panuveitis. The leading diagnoses in the intermediate uveitis group were pars planitis (73.08%) and sarcoidosis (11.54%); toxoplasma uveitis (17.74%), multifocal choroiditis (14.52%), undifferentiated posterior uveitis (14.52%), and birdshot chorioretinitis (11.29%) in the posterior uveitis group; and undifferentiated panuveitis (29.58%), post-surgical panuveitis (18.31%), sarcoidosis (12.68%), acute retinal necrosis (12.68%), and toxoplasma uveitis (4.23%) in the panuveitis group. The most common treatment modalities included local steroids (57.23%) and systemic steroids (42.14%). Ocular hypertension was found in 38 patients (23.90%). Glaucoma surgery was performed in 18.24% of patients and cataract surgery in 21.38%. Mean best-corrected visual acuity was 0.66 logMAR at baseline across all anatomical locations and 0.57 logMAR at final follow-up. Best-corrected visual acuity improved or remained stable during follow-up in all groups. Conclusion: The most common diagnoses in our series by anatomical location were pars planitis (intermediate uveitis), toxoplasmosis (posterior uveitis), and undifferentiated uveitis (panuveitis). Panuveitis had significantly worse visual outcomes and higher rates of complications than did intermediate or posterior uveitis, a finding that confirms earlier reports. In this series, unilateral disease, regardless of anatomical location, was associated with poorer visual outcome, in contrast with the findings of other reports. Keywords: visual acuity, intraocular pressure, toxoplasmosis, acute retinal necrosis, toxoplasmosis, birdshot chorioretinitis

The HADES collaboration uses the e+e− production as a probe of the resonance matter produced in collisions at incident energies of 1-3.5 GeV/nucleon at GSI. Elementary reactions provide useful references for these studies and give information on resonance Dalitz decays (R→Ne+e−). Such processes are sensitive to the structure of time-like electromagnetic baryon transitions in a kinematic range where (off-shell) vector mesons play a crucial role. Results obtained in proton-proton reactions and in a commissioning pion-beam experiment are reported and prospects for future pion beam experiments and for first hyperon Dalitz decay measurements are described. The connection with the investigations of medium effects to be continued with HADES in the next years at SIS18 and SIS100 is also discussed.

The Compressed Baryonic Matter (CBM) experiment is a dedicated heavy ion collision experiment at the FAIR facility. It will be one of the first HEP experiments which works in a triggerless mode: data received in the DAQ from the detectors will not be associated with events by a hardware trigger anymore. All raw data within a giventime period will be collected continuously in containers, so-called time-slices. The task of the reconstruction algorithms is to create events out of this raw data stream. In this contribution, the optimization of the reconstruction software in the RICH detector to the free-streaming data flow is presented. The implementation of ring reconstruction algorithms which use time measurements of the hits as an additional parameter is discussed.

Xue Ming1, Martha Mulvey1, Sharanya Mohanty2, Viraj Patel21Department of Neurosciences, University of Medicine and Dentistry New Jersey, New Jersey Medical School, Newark, 2The College of New Jersey, Ewing, NJ, USAAbstract: Clonidine has been used offlabel in children and adolescents with attention deficit and hyperactivity disorders (ADHD) with or without comorbidities. Clonidine extended-release was recently approved by the US Food and Drug Administration for ADHD in children. This review evaluates the efficacy and safety of clonidine extended-release and clonidine in children and adolescents with ADHD. A search of the Medline database and clinical trials register from 1996–2011 yielded ten clinical trials for critical evaluation of efficacy and safety. Eight of the ten trials reviewed were double-blinded and placebo-controlled. Nine of the ten trials utilized multiple outcome measures. Both clonidine extended-release and clonidine, as monotherapy or adjunctive therapy, were reported to be efficacious in treating ADHD symptoms in children and adolescents with or without comorbid disorders in nine of the ten clinical trials. One study showed clonidine to be ineffective in improving performance of a single task, at a specific point in time, in a small number of subjects. All of the studies that evaluated safety reported clonidine and clonidine extended-release to be well tolerated. The side effects of clonidine included somnolence, fatigue, headache, bradycardia, hypotension, and clinically insignificant electrocardiographic changes. However, there are historical anecdotal reports of serious cardiac side effects, including death in cases with other risk factors. None of the studies compared clonidine extended-release with clonidine in subjects with ADHD. Therefore, it is not clear whether clonidine extended-release is advantageous over clonidine, with regard to either efficacy or safety. It is equally unclear whether clonidine or clonidine extended-release is more efficacious in treating ADHD in subjects with comorbid disorders than in those without comorbidities. All the studies reviewed had limitations in their designs and methods. Clonidine and clonidine extended-release could be efficacious and safe for the treatment of ADHD both as monotherapy and as adjunctive therapy with stimulant medications in selected patients. There is a need for clinical trials to determine the long-term efficacy and safety of treatment with clonidine and clonidine extended-release in patients with ADHD.Keywords: attention deficit and hyperactivity disorders, clonidine extended-release, clonidine, comorbidity, safety, efficacy, children

Background: Prasugrel is recommended over clopidogrel in poor/intermediate CYP2C19 metabolizers with acute coronary syndrome (ACS) and planned percutaneous coronary intervention (PCI), reducing the risk of ischemic events. CYP2C19 genetic testing can guide antiplatelet therapy in ACS patients. Objective: The purpose of this study was to evaluate the cost-utility of genotype-guided treatment, compared with prasugrel or generic clopidogrel treatment without genotyping, from the US healthcare provider’s perspective. Methods: A decision model was developed to project lifetime economic and humanistic burden associated with clinical outcomes (myocardial infarction [MI], stroke and major bleeding) for the three strategies in patients with ACS. Probabilities, costs and age-adjusted quality of life were identified through systematic literature review. Incremental cost-utility ratios (ICURs) were calculated for the treatment strategies, with quality-adjusted life years (QALYs) as the primary effectiveness outcome. Relative risk of developing myocardial infarction and stroke between patients with and without variant CYP2C19 when receiving clopidogrel were estimated to be 1.34 and 3.66, respectively. One-way and probabilistic sensitivity analyses were performed. Results: Clopidogrel cost USD19,147 and provided 10.03 QALYs versus prasugrel (USD21,425, 10.04 QALYs) and genotype-guided therapy (USD19,231, 10.05 QALYs). The ICUR of genotype-guided therapy compared with clopidogrel was USD4,200. Genotype-guided therapy provided more QALYs at lower costs compared with prasugrel. Results were sensitive to the cost of clopidogrel and relative risk of myocardial infarction and stroke between CYP2C19 variant vs. non-variant. Net monetary benefit curves showed that genotype-guided therapy had at least 70% likelihood of being the most cost-effective alternative at a willingness-to-pay of USD100,000/QALY. In comparison with clopidogrel, prasugrel therapy was more cost-effective with USD170,000/QALY. Conclusions: Our modeling analyses suggest that genotype-guided therapy is a cost-effective strategy in patients with acute coronary syndrome undergoing planned percutaneous coronary intervention.

Background and purposeOur aim was to test the hypothesis that our recently introduced 4D-dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism without requiring exposure to ionizing radiation.Materials and methodsInclusion criteria were the following: 1) confirmed biochemical diagnosis of primary hyperparathyroidism, 2) preoperative 4D-dynamic contrast-enhanced MR imaging, and 3) surgical cure with >50% decrease in serum parathyroid hormone intraoperatively. 4D-dynamic contrast-enhanced studies were reviewed independently by 2 neuroradiologists to identify the side, quadrant, and number of abnormal glands, and compared with surgical and pathologic results.ResultsFifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease (9 with double-gland hyperplasia; 3 with 3-gland hyperplasia; and 5 with 4-gland hyperplasia). Interobserver agreement (κ) for the side (right versus left) was 0.92 for single-gland disease and 0.70 for multigland disease. Interobserver agreement for the quadrant (superior versus inferior) was 0.70 for single-gland disease and 0.69 for multigland disease. For single-gland disease, the gland was correctly located in 34/37 (92%) patients, with correct identification of the side in 37/37 (100%) and the quadrant in 34/37 (92%) patients. For multigland disease, the glands were correctly located in 35/47 (74%) patients, with correct identification of the side in 35/47 (74%) and the quadrant in 36/47 (77%).ConclusionsThe proposed high spatial and temporal resolution 4D-dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism, with correct gland localization of 92% for single-gland disease and 74% in multigland disease, superior to 4D-CT studies.