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Pravin Patil,1 Niral Karia,2 Shaifali Jain,3 Bhaskar Dasgupta1 1Department of Rheumatology, 2Department of Ophthalmology, 3Department of Radiology, Southend University Hospital, Westcliff, Essex, United Kingdom Abstract: Giant cell arteritis is the most common vasculitis in Caucasians. Acute visual loss in one or both eyes is by far the most feared and irreversible complication of giant cell arteritis. This article reviews recent guidelines on early recognition of systemic, cranial, and ophthalmic manifestations, and current management and diagnostic strategies and advances in imaging. We share our experience of the fast track pathway and imaging in associated disorders, such as large-vessel vasculitis. Keywords: giant cell arteritis, diagnosis, treatment, polymyalgia rheumatica

Organizations nowadays focus on, not implementing ERP systems, but also leveraging ERP systems as part of their digital strategy. They holistically address people, processes, and technology for a digital transformation. Meanwhile, higher education institutions (HEIs) are also facing an imperative need for the implementation of modern technologies to stay competitive and differentiate them as an innovation leader. Higher education management is challenged with maintaining high-level information systems. These systems can generate complex real-time reports for effective resource allocation and better decision making. Enterprise Resource Planning (ERP) systems can help HEIs manage their resources and operations effectively. A study of ERP among 112 HEIs in Egypt was conducted. This study originally investigates the Egyptian HEIs’ perception of the ERP system as a new integrating tool for its value. The results showed that Egyptian HEIs are still at the embryonic level as the majority have not adopted these systems yet. However, ERP value has been undoubtedly perceived by HEIs’ managers. Therefore, the present study fruitfully reflected HEIs’ understanding of the imperative need of ERP systems as strategic systems for their competitiveness. Consequently, the study suggests that Egyptian HEIs and ERP vendors take steps to remove any barriers and accelerate the ERP adoption process. Also, this research contributes to the advancement of ERP concepts and characteristics from HEIs' standpoint and a grants practical verification to the higher education context. Overall, the study advances existing knowledge and research on ERP, strategic management systems, and HEIs.

PurposeTo assess the long-term safety and efficacy of intravitreal triamcinolone acetonide injection in the management of macular oedema caused by central, hemi-, and branch retinal vein occlusion (CRVO, HRVO, or BRVO).MethodsThis prospective, interventional case series included 13 patients (13 eyes) with retinal vein occlusion and macular oedema. They received an intravitreal injection of 4 mg triamcinolone acetonide. Follow-up was for 1 year with repeat injections where appropriate. Outcome measures were visual acuity and macular thickness measured using ocular coherence tomography (OCT).ResultsThere were four patients with CRVO, one with HRVO, and eight with BRVO (13 eyes). Mean duration of symptoms before intravitreal triamcinolone acetonide injection was 6.8 months (SD 4.5 months). Eight eyes (62%) responded well with improved visual acuity and macular thickness 1–3 months postinjection. All eight eyes developed recurrent macular oedema and five received repeat injections. Three patients declined a second injection. No improvement in visual acuity or OCT macular thickness was seen after the second injection with visual acuity returning to baseline levels at 1-year follow-up. Three eyes (23%) showed no response to the initial injection (no improvement in macular thickness or visual acuity). Seven patients (54%) had a rise in intraocular pressure with six (46%) requiring treatment.ConclusionsIntravitreal injection of triamcinolone acetonide is effective as a short-term treatment of macular oedema owing to retinal vein occlusion, improving both visual acuity and macular thickness. However, this effectiveness is not maintained after 1 year despite repeat injections.Eye (2008) 22, 60–64; doi:10.1038/sj.eye.6702518; published online 11 August 2006 [ABSTRACT FROM AUTHOR]

The field of green supply chain is expanding rapidly, and new authors are venturing in this field to conduct further research. Although some literature reviews have beeen conducted over time, a complete list of green supply chain practices is not available. Hence, the objective of this study is to present an up-to-date list of green supply chain practices. To achieve this, the study employed structured review process, as well as critically examined the contents to ensure that the data are filtered from high-quality peer-reviewed journals and from influential authors in this field. 91 high-quality papers were selected from top ten journals in GSCM area to produce the list. A total of 58 green supply chain practices comprising 15 aspects were featured, e.g. reverse logistics, industrial symbiosis, green information technology, green design, carbon management etc. This paper contributes to the existing literature by providing a comprehensive list of aspects and practices of the green supply chain. Finally, limitations and directions for future studies are provided in the conclusion section.

Objectives: Measures of right heart size and function are prognostic in systemic sclerosis-associated pulmonary hypertension (SSc-PH), but the importance of myocardial tissue characterisation remains unclear. We aimed to investigate the predictive potential and interaction of cardiovascular magnetic resonance (CMR) myocardial tissue characterisation and right heart size and function in SSc-PH., Methods: A retrospective, single-centre, observational study of 148 SSc-PH patients confirmed by right heart catheterization who underwent clinically indicated CMR including native myocardial T1 and T2 mapping from 2016 to 2023 was performed., Results: Sixty-six (45%) patients died during follow-up (median 3.5 years, range 0.1-7.3). Patients who died were older (65 vs 60 years, P = 0.035) with more dilated (P < 0.001), hypertrophied (P = 0.013) and impaired (P < 0.001) right ventricles, more dilated right atria (P = 0.043) and higher native myocardial T1 (P < 0.001).After adjustment for age, indexed right ventricular end-systolic volume (RVESVi, P = 0.0023) and native T1 (P = 0.0024) were independent predictors of all-cause mortality. Both RVESVi and native T1 remained independently predictive after adjusting for age and PH subtype (RVESVi P < 0.001, T1 P = 0.0056). Optimal prognostic thresholds for RVESVi and native T1 were ≤38 mL/m2 and ≤1119 ms, respectively (P < 0.001). Patients with RVESVi ≤ 38 mL/m2 and native T1 ≤ 1119 ms had significantly better outcomes than all other combinations (P < 0.001). Furthermore, patients with RVESVi > 38mL/m2 and native T1 ≤ 1119 ms had significantly better survival than patients with RVESVi > 38mL/m2 and native T1 > 1119ms (P = 0.017)., Conclusion: We identified prognostically relevant CMR metrics and thresholds for patients with SSc-PH. Assessing myocardial tissue characterisation alongside right ventricular function confers added value in SSc-PH and may represent an additional treatment target., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Aims: Systemic sclerosis complicated by pulmonary arterial hypertension (SSc-PAH) is a rare condition with poor prognosis. The majority of patients are categorized as intermediate risk of mortality. Cardiovascular magnetic resonance (CMR) is well placed to reproducibly assess right heart size and function, but most patients with SSc-PAH have less overtly abnormal right ventricles than other forms of PAH. The aim of this study was to assess if exercise CMR measures of cardiac size and function could better predict outcome in patients with intermediate risk SSc-PAH compared with resting CMR., Methods and Results: Fifty patients with SSc-PAH categorized as intermediate risk underwent CMR-augmented cardiopulmonary exercise testing. Most patients had normal CMR-defined resting measures of right ventricular (RV) size and function. Nine (18%) patients died during a median follow-up period of 2.1 years (range 0.1-4.6). Peak exercise RV indexed end-systolic volume (ESVi) was the only CMR metric to predict prognosis on stepwise Cox regression analysis, with an optimal threshold < 39 mL/m2 to predict favourable outcome. Intermediate-low risk patients with peak RVESVi < 39 mL/m2 had significantly better survival than all other combinations of intermediate-low/-high risk status and peak RVESVi< or ≥39 mL/m2. In our cohort, ventilatory efficiency and resting oxygen consumption (VO2) were predictive of mortality, but not peak VO2, peak cardiac output, or peak tissue oxygen extraction., Conclusion: Exercise CMR assessment of RV size and function may help identify SSc-PAH patients with poorer prognosis amongst intermediate risk cohorts, even when resting CMR appears reassuring, and could offer added value to clinical PH risk stratification., Competing Interests: Conflict of interest: There are no conflicts of interest in relation to the work in this manuscript. Non-conflicting relationships with industry are detailed as follows: R.V. reports support for attending meetings and travel from Janssen. T.K. reports speaker bureau fees and support for attending meetings and travel from Janssen and Inari. M.F. reports consulting board fees from Alnylam, Alexion, AstraZeneca, Bridgbio/Eidos, Prothena, Attralus, Intellia, Ionis, Cardior, Lexeo, and Pfizer, and research grants from Alnylam, AstraZeneca, Bridgbio, and Pfizer. N.K. reports advisory board fees and support for attending meetings and travel from Janssen. V.H.O. reports speaker fees and support for attending meetings and travel from Boehringer Ingelheim. C.P.D. reports consultancy fees from Janssen, GlaxoSmithKline, Bayer, Sanofi, Boehringer Ingelheim, Roche, CSL Behring, Corbus, Acceleron, Horizon, Arxx, Lilly, Novartis, and Certa, speaker fees from Janssen, GlaxoSmithKline, and Boehringer Ingelheim, and grants from CSL Behring, GlaxoSmithKline, and Abbvie. J.G.C. reports consulting and speaker bureau fees from Bayer, GlaxoSmithKline, Inari, Janssen, and Merck Sharp & Dohme, support for attending meetings and travel from Janssen, and research funding from Janssen. D.S.K. reports speaker and advisory board fees, research funding, and support for attending meetings and travel from Janssen., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Patient safety is crucial in healthcare, with incident reporting vital for identifying and addressing errors. Near-miss incidents, common yet underreported, serve as red flags requiring attention. Nurses' underreporting, influenced by views and system usability, inhibits learning opportunities. The Electronic Reporting System (ERS) is a modern solution, but its effectiveness remains unclear., Objective: This study aimed to investigate the role of the ERS in enhancing the voluntary reporting of near-miss (VRNM) incidents among nurses., Methods: A cross-sectional study was conducted in the Al Dhafra region of the United Arab Emirates, involving 247 nurses from six hospitals. Data were collected using a questionnaire between April 2022 and August 2022. Structural Equation Modelling Partial Least Square (SEM-PLS) was employed for data analysis., Results: The average variance extracted for the ERS construct was 0.754, indicating that the common factor accounted for 75.4% of the variation in the ERS scores. The mean ERS score was 4.093, with a standard deviation of 0.680. For VRNM, the mean was 4.104, and the standard deviation was 0.688. There was a positive correlation between ERS utilization and nurses' willingness to report near-miss incidents. Additionally, our research findings suggest a 66.7% relevance when applied to various hospital settings within the scope of this study., Conclusion: The findings suggest that adopting a user-friendly reporting system and adequate training on the system's features can increase reporting and improve patient safety. Additionally, these systems should be designed to be operated by nursing staff with minimal obstacles., Competing Interests: The authors declared no conflict of interest in this study., (© The Author(s) 2024.)

Aims: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized cause of heart failure. A total of 3-4% of individuals of African descent carry a TTR gene mutation encoding the p.(V142I) variant, a powerful risk factor for development of variant ATTR-CM (ATTRv-CM); this equates to 1.6 million carriers in the United States. We undertook deep phenotyping of p.(V142I)-ATTRv-CM and comparison with wild-type ATTR-CM (ATTRwt-CM)., Methods and Results: A retrospective study of 413 patients with p.(V142I) ATTRv-CM who attended the UK National Amyloidosis Centre (NAC) was conducted. Patients underwent evaluation at time of diagnosis, including clinical, echocardiography, and biomarker analysis; a subgroup had cardiac magnetic resonance (CMR) imaging. A total of 413 patients with ATTRwt-CM, matched for independent predictors of prognosis (age, NAC Stage, decade of first presentation), were used as a comparator group. At time of diagnosis, patients with ATTRv-CM had significant functional impairment by New York Heart Association classification (NHYA class ≥ III; 38%) and 6-min walk test distance (median 276 m). Median 5-year survival in ATTRv-CM patients was 31 versus 59 months in matched patients with ATTRwt-CM (p < 0.001). Patients with ATTRv-CM had significant impairment of functional parameters by echocardiography including biventricular impairment, high burden of regurgitant valvular disease and low cardiac output. Multivariable analysis revealed the prognostic importance of right ventricular dysfunction. CMR and histological analysis revealed myocyte atrophy and widespread myocardial infiltration in ATTRv-CM., Conclusion: p.(V142I)-ATTRv-CM has an aggressive phenotype characterized by myocyte loss and widespread myocardial infiltration which may account for frequent biventricular failure and poor prognosis in this ATTR-CM genotypic subgroup., (© 2023 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background and Aims: Interventional studies in pulmonary arterial hypertension completed to date have shown to be effective in symptomatic patients with significantly elevated mean pulmonary artery pressure (mPAP) (≥25 mmHg) and pulmonary vascular resistance (PVR) > 3 Wood Unit (WU). However, in health the mPAP does not exceed 20 mmHg and PVR is 2 WU or lower, at rest. The ESC/ERS guidelines have recently been updated to reflect this. There is limited published data on the nature of these newly defined populations (mPAP 21-24 mmHg and PVR >2-≤3 WU) and the role of comorbidity in determining their natural history. With the change in guidelines, there is a need to understand this population and the impact of the ESC/ERS guidelines in greater detail., Methods: A retrospective nationwide evaluation of the role of pulmonary haemodynamics and comorbidity in predicting survival among patients referred to the UK pulmonary hypertension (PH) centres between 2009 and 2017. In total, 2929 patients were included in the study. Patients were stratified by mPAP (<21 mmHg, 21-24 mmHg, and ≥25 mmHg) and PVR (≤2 WU, > 2-≤3 WU, and >3 WU), with 968 (33.0%) in the mPAP <21 mmHg group, 689 (23.5%) in the mPAP 21-24 mmHg group, and 1272 (43.4%) in the mPAP ≥25 mmHg group., Results: Survival was negatively correlated with mPAP and PVR in the population as a whole. Survival in patients with mildly elevated mPAP (21-24 mmHg) or PVR (>2-≤3WU) was lower than among those with normal pressures (mPAP <21 mmHg) and normal PVR (PVR ≤ 2WU) independent of comorbid lung and heart disease [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.14-1.61, P = .0004 for mPAP vs. HR 1.28, 95% CI 1.10-1.49, P = .0012 for PVR]. Among patients with mildly elevated mPAP, a mildly elevated PVR remained an independent predictor of survival when adjusted for comorbid lung and heart disease (HR 1.33, 95% CI 1.01-1.75, P = .042 vs. HR 1.4, 95% CI 1.06-1.86, P = .019). 68.2% of patients with a mPAP 21-24 mmHg had evidence of underlying heart or lung disease. Patients with mildly abnormal haemodynamics were not more symptomatic than patients with normal haemodynamics. Excluding patients with heart and lung disease, connective tissue disease was associated with a poorer survival among those with PH. In this subpopulation evaluating those with a mPAP of 21-24 mmHg, survival curves only diverged after 5 years., Conclusions: This study supports the change in diagnostic category of the ESC/ERS guidelines in a PH population. The newly included patients have an increased mortality independent of significant lung or heart disease. The majority of patients in this new category have underlying heart or lung disease rather than an isolated pulmonary vasculopathy. Mortality is higher if comorbidity is present. Rigorous phenotyping will be pivotal to determine which patients are at risk of progressive vasculopathic disease and in whom surveillance and recruitment to studies may be of benefit. This study provides an insight into the population defined by the new guidelines., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Pulmonary hypertension (PH) is common, with an estimated prevalence of approximately 1% that increases with age. Prompt and accurate diagnosis is key to institute timely and appropriate therapy to improve symptoms and prognosis. The international guidelines for the diagnosis and management of PH have recently been updated, with a lowering of the haemodynamic threshold for diagnosis to a mean pulmonary artery pressure >20 mmHg. New diagnostic algorithms and revised indications for screening in at-risk groups have been developed to facilitate early referral to specialist PH centres. This includes fast-track referral pathways for patients who are either clinically high-risk or are at-risk for pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH). This review summarises key changes in the PH guidelines for general physicians who are, most often, the first healthcare professionals to encounter these patients and consequently have a key role as referrers into specialist PH services., (© Royal College of Physicians 2023. All rights reserved.)

Aims: Cardiovascular involvement in systemic sclerosis (SSc) is heterogeneous and ill-defined. This study aimed to: (i) discover cardiac phenotypes in SSc by cardiovascular magnetic resonance (CMR); (ii) provide a CMR-based algorithm for phenotypic classification; and (iii) examine for associations between phenotypes and mortality., Methods and Results: A retrospective, single-centre, observational study of 260 SSc patients who underwent clinically indicated CMR including native myocardial T1 and T2 mapping from 2016 to 2019 was performed. Agglomerative hierarchical clustering using only CMR variables revealed five clusters of SSc patients with shared CMR characteristics: dilated right hearts with right ventricular failure (RVF); biventricular failure dilatation and dysfunction (BVF); and normal function with average cavity (NF-AC), normal function with small cavity (NF-SC), and normal function with large cavity (NF-LC) sizes. Phenotypes did not co-segregate with clinical or antibody classifications. A CMR-based decision tree for phenotype classification was created. Sixty-three (24%) patients died during a median follow-up period of 3.4 years. After adjustment for age and presence of pulmonary hypertension (PH), independent CMR predictors of all-cause mortality were native T1 (P < 0.001) and right ventricular ejection fraction (RVEF) (P = 0.0032). NF-SC and NF-AC groups had more favourable prognoses (P≤0.036) than the other three groups which had no differences in prognoses between them (P > 0.14). Hazard ratios (HR) were statistically significant for RVF (HR = 8.9, P < 0.001), BVF (HR = 5.2, P = 0.006), and NF-LC (HR = 4.9, P = 0.002) groups. The NF-LC group remained significantly predictive of mortality after adjusting for RVEF, native T1, and PH diagnosis (P = 0.0046)., Conclusion: We identified five CMR-defined cardiac SSc phenotypes that did not co-segregate with clinical data and had distinct outcomes, offering opportunities for a more precision-medicine based management approach., Competing Interests: Conflict of interest: The authors declare that there are no conflicts of interest in relation to the work in this manuscript. Non-conflicting relationships with industry are as follows: D.S.K. reports consulting fees, speaker bureau fees and research funding from Johnson & Johnson. A.M.S-R. reports sponsorship from Janssen, Abbvie and Pfizer. B.E.S. reports consulting fees, speaker bureau fees and research funding from Johnson & Johnson, and speaker fees from GSK. C.P.D. reports personal fees from Acceleron, Corbus, Boehringer Ingelheim, Horizon, Johnson & Johnson, Roche, Sanofi, and grants and personal fees from CSL Behrin, GSK and Inventiva. J.G.C. reports consulting fees from Acceleron, consulting and speaker bureau fees from Bayer, GSK and Johnson & Johnson, and research funding from Johnson & Johnson., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: To assess the ability of cardiovascular magnetic resonance (CMR) to (i) measure changes in response to chemotherapy; (ii) assess the correlation between haematological response and changes in extracellular volume (ECV); and (iii) assess the association between changes in ECV and prognosis over and above existing predictors., Methods and Results: In total, 176 patients with cardiac AL amyloidosis were assessed using serial N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiography, free light chains and CMR with T1 and ECV mapping at diagnosis and subsequently 6, 12, and 24 months after starting chemotherapy. Haematological response was graded as complete response (CR), very good partial response (VGPR), partial response (PR), or no response (NR). CMR response was graded by changes in ECV as progression (≥0.05 increase), stable (<0.05 change), or regression (≥0.05 decrease). At 6 months, CMR regression was observed in 3% (all CR/VGPR) and CMR progression in 32% (61% in PR/NR; 39% CR/VGPR). After 1 year, 22% had regression (all CR/VGPR), and 22% had progression (63% in PR/NR; 37% CR/VGPR). At 2 years, 38% had regression (all CR/VGPR), and 14% had progression (80% in PR/NR; 20% CR/VGPR). Thirty-six (25%) patients died during follow-up (40 ± 15 months); CMR response at 6 months predicted death (progression hazard ratio 3.82; 95% confidence interval 1.95-7.49; P < 0.001) and remained prognostic after adjusting for haematological response, NT-proBNP and longitudinal strain (P < 0.01)., Conclusions: Cardiac amyloid deposits frequently regress following chemotherapy, but only in patients who achieve CR or VGPR. Changes in ECV predict outcome after adjusting for known predictors., Competing Interests: Conflict of interest: M.F. is supported by a British Heart Foundation Intermediate Clinical Research Fellowship (FS/18/21/33447). The other authors declare that there is no conflict of interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology.)

Aims: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly diagnosed disease. Echocardiography is widely utilized, but studies to confirm the value of echocardiography for tracking changes over time are not available. We sought to describe (i) changes in multiple echocardiographic parameters; (ii) differences in rate of progression of three predominant genotypes; and (iii) the ability of changes in echocardiographic parameters to predict prognosis., Methods and Results: We prospectively studied 877 ATTR-CM patients attending our centre between 2000 and 2020. Serial echocardiography findings at baseline, 12 months and 24 months were compared with survival. Overall, 565 patients had wild-type ATTR-CM and 312 hereditary ATTR-CM (201 with V122I; 90 with T60A). There was progressive worsening of structural and functional parameters over time, patients with V122I ATTR-CM showing more rapid worsening of left and right ventricular structural and functional parameters compared to both wild-type and T60A ATTR-CM. Among a wide range of echocardiographic analyses, including deformation-based parameters, only worsening in the degree of mitral (MR) and tricuspid regurgitation (TR) at 12- and 24-month assessments was associated with worse prognosis (change at 12 months: MR, hazard ratio 1.43 [95% confidence interval 1.14-1.80], p = 0.002; TR, hazard ratio 1.38 [95% confidence interval 1.10-1.75], p = 0.006). Worsening in MR remained independently associated with poor prognosis after adjusting for known predictors., Conclusion: In ATTR-CM, echocardiographic parameters progressively worsen over time. Patients with V122I ATTR-CM demonstrate the most rapid deterioration. Worsening of MR and TR were the only parameters associated with mortality, MR remaining independent after adjusting for known predictors., (© 2022 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background Ongoing exercise intolerance of unclear cause following COVID-19 infection is well recognized but poorly understood. We investigated exercise capacity in patients previously hospitalized with COVID-19 with and without self-reported exercise intolerance using magnetic resonance-augmented cardiopulmonary exercise testing. Methods and Results Sixty subjects were enrolled in this single-center prospective observational case-control study, split into 3 equally sized groups: 2 groups of age-, sex-, and comorbidity-matched previously hospitalized patients following COVID-19 without clearly identifiable postviral complications and with either self-reported reduced (COVID reduced ) or fully recovered (COVID normal ) exercise capacity; a group of age- and sex-matched healthy controls. The COVID reduced group had the lowest peak workload (79W [Interquartile range (IQR), 65-100] versus controls 104W [IQR, 86-148]; P =0.01) and shortest exercise duration (13.3±2.8 minutes versus controls 16.6±3.5 minutes; P =0.008), with no differences in these parameters between COVID normal patients and controls. The COVID reduced group had: (1) the lowest peak indexed oxygen uptake (14.9 mL/minper kg [IQR, 13.1-16.2]) versus controls (22.3 mL/min per kg [IQR, 16.9-27.6]; P =0.003) and COVID normal patients (19.1 mL/min per kg [IQR, 15.4-23.7]; P =0.04); (2) the lowest peak indexed cardiac output (4.7±1.2 L/min per m 2 ) versus controls (6.0±1.2 L/min per m 2 ; P =0.004) and COVID normal patients (5.7±1.5 L/min per m 2 ; P =0.02), associated with lower indexed stroke volume (SVi:COVID reduced 39±10 mL/min per m 2 versus COVID normal 43±7 mL/min per m 2 versus controls 48±10 mL/min per m 2 ; P =0.02). There were no differences in peak tissue oxygen extraction or biventricular ejection fractions between groups. There were no associations between COVID-19 illness severity and peak magnetic resonance-augmented cardiopulmonary exercise testing metrics. Peak indexed oxygen uptake, indexed cardiac output, and indexed stroke volume all correlated with duration from discharge to magnetic resonance-augmented cardiopulmonary exercise testing ( P <0.05). Conclusions Magnetic resonance-augmented cardiopulmonary exercise testing suggests failure to augment stroke volume as a potential mechanism of exercise intolerance in previously hospitalized patients with COVID-19. This is unrelated to disease severity and, reassuringly, improves with time from acute illness.

Purpose: Randomized clinical trials have demonstrated the safety and efficacy of ocriplasmin in patients with vitreomacular traction (VMT), including those with macular hole (MH). The INJECT study prospectively evaluated ocriplasmin in the setting of clinical practice., Methods: INJECT was a Phase 4, multicenter, prospective observational study. Patients were followed up for 12 months. Assessments included nonsurgical VMT resolution, nonsurgical MH closure, best-corrected visual acuity, occurrence of vitrectomy, and adverse events., Results: The efficacy population (N = 395) received an ocriplasmin injection and had optical coherence tomography-confirmed VMT at baseline. At Day 28, the rate of nonsurgical VMT resolution was 40.7% in the overall group, and the rate of nonsurgical MH closure was 36.0% in the VMT with MH group. At Month 12, the rate of ≥2-line best-corrected visual acuity gain (irrespective of vitrectomy) was 36.8% in the overall group and 59.6% in the VMT with MH group. The percentage of patients who underwent vitrectomy in the study eye was 29.1% in the overall group and 55.6% in the VMT with MH group. Photopsia (9.8%) and vitreous floaters (6.8%) were the most frequent adverse events., Conclusion: The INJECT study showed that ocriplasmin is effective in a clinical setting in patients with VMT, with or without MH. No new safety signals were identified from this large and surgeon-selected patient group, although the significant limitations of the study design without an image reading center and scheduled study visit timings should be noted., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

Purpose: To compare the rates of rhegmatogenous retinal detachment (RRD) following an anterior vitrectomy (AV) alone during cataract surgery, compared to cases requiring a subsequent pars plana vitrectomy (PPV) for dropped nuclear lens fragments (DNLFs)., Methods: Retrospective electronic note review of consecutive patients with a posterior capsular rupture (PCR) requiring either AV or subsequent PPV for DNLF over a 5-year period., Results: A total of 20,235 cataract operations were performed during the defined period with 199 cases (eyes) of PCR (0.98%). One hundred forty-four of these (72.4%) were managed with AV, and the remaining 55 cases were further complicated by DNLF and thus underwent secondary PPVs. A total of 80.0% of cases in the AV group had a final BCVA of 0.30 logMAR or better, and 77.35% in the DNLF group had a BCVA of 0.30 logMAR or better (p = 0.069). Final BCVA was 0.30 (range-0.18 to 3.0) in the AV group and 0.32 (range-0.18 to 1.8) in the DNLF group (p = 0.82). Final BCVA in those patients who suffered a RRD was poorer than the rest of the cohort in the AV group (p = 0.03). Seven of 144 cases in the AV group went on to develop a RRD with a median time of 11 months (range 1-18 months). None of the cases in the DNLF group went on to develop a RRD (P = 0.048)., Conclusion: Following an anterior vitrectomy during complicated cataract surgery, the risk of RRD may be lower in patients who require a subsequent PPV for management of DNLF compared to patients who are managed with anterior vitrectomy alone.

Leukocytoclastic vasculitis (LCV) is a cutaneous small vessel vasculitis characterized by cutaneous manifestations in the form of palpable purpura, and rarely bullae, vesicles, and ulcerations. Although rare, cephalosporins such as cefazolin, should be recognized to have a potential to trigger LCV.

We report a case of an elderly patient in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided definitive diagnosis of mitral-aortic intervalvular fibrosa abscess. This could not be done by two-dimensional transthoracic echocardiography (2DTTE) and two-dimensional transesophageal echocardiography (2DTEE). 3DTEE was also helpful in ruling out associated mitral valve endocarditis, which was initially suspected by 2DTEE leading to a mitral valve sparing surgery. Thus, 3DTEE provided incremental information over 2DTTE and 2DTEE in this patient., (© 2012, Wiley Periodicals, Inc.)

We present an adult with metastatic carcinoid disease affecting the heart, in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over two-dimensional transthoracic echocardiography (2DTTE). Initial 2DTTE was able to demonstrate severe pulmonic and tricuspid regurgitation, but was unable to visualize the posterior leaflet of the tricuspid valve or the right (right anterior) leaflet of the pulmonic valve. Further analysis with 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of both the tricuspid and the pulmonary valves. En face viewing of tricuspid and pulmonary regurgitation vena contractas permitted more reliable quantification of regurgitation severity. In addition, localized, linear, echogenic areas consistent with carcinoid deposits were noted along the inner walls of the right atrium, atrial septum, and inferior vena cava. To the best of our knowledge, endocardial carcinoid deposits have never been reported by 2D or 3D echocardiography. En face viewing of these deposits by 3DTTE enabled measurement of their dimensions and areas. Subcostal examination also identified large circumscribed hepatic lesions consistent with metastatic disease. Neither the carcinoid deposits nor the metastatic lesions were detected by 2DTTE. This case demonstrates the usefulness of 3DTTE as a supplement to 2DTTE in more comprehensively assessing carcinoid involvement of the heart.

We compared findings from intraoperative live/real time three-dimensional transesophageal echocardiography (3DTEE) and two-dimensional transesophageal echocardiography (2DTEE) with surgery in 67 patients having aortic aneurysm and/or aortic dissection. Of these, 20 patients had aortic aneurysm without dissection, 21 aortic aneurysm and dissection, and 26 aortic dissection without aneurysm. 3DTEE diagnosed the type and location of aneurysm correctly in all patients unlike 2DTEE, which missed an aneurysm in one case. There were four cases of aortic aneurysm rupture. Three of them were diagnosed by 3DTEE but only one by 2DTEE, and one missed by both techniques. The mouth of saccular aneurysm, site of aortic aneurysm rupture, and communication sites between perfusing and nonperfusing lumens of aortic dissection could be viewed en face only with 3DTEE, enabling comprehensive measurements of their area and dimensions as well as increasing the confidence level of their diagnosis. In all patients with aortic dissection, 3DTEE enabled a more confident diagnosis of dissection because the dissection flap when viewed en face presented as a sheet of tissue rather than a linear echo seen on 2DTEE which can be confused with an artifact. 2DTEE missed dissection in one patient. In six cases the dissection flap involved the right coronary artery orifice by 3DTEE and surgery. These were missed by 2DTEE. Aortic regurgitation severity was more comprehensively assessed by 3DTEE than 2DTEE. Aneurysm size by 3DTEE correlated well with 2DTEE and surgery/computed tomography scan. In conclusion, 3DTEE provides incremental information over 2DTEE in patients with aortic aneurysm and dissection., (© 2012, Wiley Periodicals, Inc.)

Background: Changes in the myocardium in acute ischemia are dynamic and complex, and the characteristics of myocardial tissue on cardiovascular magnetic resonance in the acute setting are not fully defined. We investigated changes in edema and late gadolinium enhancement (LGE) with serial imaging early after acute myocardial infarction, relating these to global and segmental myocardial function at 6 months., Methods and Results: Cardiovascular magnetic resonance scans were performed on 30 patients with ST-elevation--myocardial infarction treated by primary percutaneous coronary intervention at each of 4 time points: 12 to 48 hours; 5 to 7 days; 14 to 17 days; and 6 months. All patients showed edema at 24 hours. The mean volume of edema (% left ventricle) was 37±16 at 24 hours and 39±17 at 1 week, with a reduction to 24±13 (P<0.01) by 2 weeks. Myocardial segments with edema also had increased signal on LGE at 24 hours (κ=0.77; P<0.001). The volume of LGE decreased significantly between 24 hours and 6 months (27±15% versus 22±12%; P=0.002). Of segments showing LGE at 24 hours, 50% showed resolution by 6 months. In segments with such a reduction in LGE, 65% also showed improved wall motion (P<0.0001). The area of LGE measured at 6 months correlated more strongly with troponin at 48 hours (r=0.9; P<0.01) than LGE at 24 hours (r=0.7). The difference in LGE between 24 hours and 6 months had profound effects on the calculation of salvage index (26±21% at 24 hours versus 42±23% at 6 months; P=0.02)., Conclusions: Myocardial edema is maximal and constant over the first week after myocardial infarction, providing a stable window for the retrospective evaluation of area at risk. By contrast, myocardial areas with high signal intensity in LGE images recede over time with corresponding recovery of function, indicating that acutely detected LGE does not necessarily equate with irreversible injury and may severely underestimate salvaged myocardium.

This paper reviews the current thinking about retinal vein occlusion. It gives an overview of its pathophysiology and discusses the evidence behind the various established and emerging treatment paradigms.

Purpose: To compare the visual outcomes in patients with bilateral implantation of AcrySof ReSTOR multifocal intraocular lenses (IOLs) (Alcon Laboratories) or ReZoom multifocal IOLs (Advanced Medical Optics) 6 months after cataract surgery., Setting: Orsett and Southend Hospital, Essex, United Kingdom., Methods: This study comprised patients who had uneventful bilateral cataract extraction with implantation of ReZoom (n = 50) or ReSTOR (n = 50) multifocal IOLs. Parameters analyzed included binocular uncorrected distance, intermediate, and near acuities; spectacle independence; subjective visual symptoms; and patient satisfaction. All parameters were evaluated 6 months after second-eye surgery., Results: All patients had binocular uncorrected distance visual acuity of 20/32 or better; there was no statistically significant difference between the 2 groups. The mean binocular uncorrected near acuity was 20/26 (J1.22) in the ReSTOR group and 20/34 (J2.34) in the ReZoom group (P<.0001). The mean binocular uncorrected intermediate visual acuity was 20/42 and 20/34, respectively (P = .003). Patients in the ReZoom group reported greater satisfaction with intermediate vision (P = .04). No statistically significant difference was found in satisfaction with near vision. Eighty-six percent of ReSTOR patients and 70% of ReZoom patients did not wear glasses for daily activities; the overall satisfaction was not statistically significantly different between groups. There was no significant difference between groups in photic phenomena., Conclusions: The ReSTOR IOL provided better near vision and the ReZoom IOL better intermediate vision. Both multifocal IOLs gave excellent distance vision. Photic phenomena were comparable and clinically acceptable. ReSTOR patients had greater spectacle independence for near vision and ReZoom patients for intermediate vision. Overall spectacle independence was not statistically significantly different.

Purpose: To evaluate the clinical outcome of intravitreal tissue plasminogen activator (tPA) and expansile gas injection as a minimally invasive treatment for submacular hemorrhage (SMH)., Methods: This study was a retrospective clinical case series examining 104 eyes that received an intravitreal injection of 30-100 mcg of tPA and expansile gas (SF6 or C3F8) for SMH. The main outcomes evaluated were visual acuities (VA), anatomic displacement of submacular blood, and surgical complications., Results: : A total of 85, 77, and 81 eyes were available at 1 week, 3 months, and 12 months follow up, respectively. Postoperatively, > or = 2 Snellen lines improvement were achieved in 43/85 eyes (51%) at 1 week, 49/77 eyes (63%) at 3 months, and 52/81 eyes (64%) at 12 months. Postoperative VA improvement was significantly associated with preoperative VA, submacular blood displacement, and the underlying cause of SMH. Diagnostic postoperative angiogram and clinical examination were possible at 8.2 +/- 7.4 weeks and 9.5 +/- 7.4 weeks, respectively. The observed complications included breakthrough vitreous hemorrhage in 8 eyes (8%) and retinal detachment in 3 eyes (3%)., Conclusions: In this retrospective series, intravitreal injection of tPA and expansile gas was shown to be a safe and effective technique that can improve VA in most eyes with SMH and assist in the diagnosis of the underlying cause.

Background: Mild mental retardation is an enduring and impairing condition. Its prevalence has varied widely across different studies from .5 to over 8%, with higher rates in completely ascertained samples. The current study estimates the prevalence of low IQ in the mental retardation range (intellectual disability) in a population sample and examines the factors that relate to educational identification., Method: A total of 2,730 children in school years 8 and 9 attending local authority schools were assessed in school with the group-administered Cognitive Abilities Test (CAT). A sample of 304 pupils at high, moderate and low risk of mild mental retardation was selected for in-depth study. This included the individually measured full-scale IQ (WISC-III(UK)), the Wechsler Quicktest of attainments, the Strengths and Difficulties Questionnaire from parents and teachers and an abbreviated version of the Social Communication Questionnaire., Results: Of those selected for the in-depth study, 204 (67%) participated, with a greater proportion from the low risk group. A range of prevalence estimates were calculated using different imputation methods and assumptions about individuals not screened. Rates of pupils with WISC IQ < 70 varied from 5.8% to 10.6%. There were no significant gender differences. In contrast to the high prevalence estimates using the WISC, the proportion of pupils scoring in the lowest stanine on the CAT was as expected. Only 15% of those with IQ < 70 had a statement of special educational needs or attended a school for moderate learning difficulties. Behaviour, particularly social communication problems, predicted educational identification., Conclusions: The current study produced a high estimate of the prevalence of mild intellectual disability based on the WISC but not on the CAT. The findings highlight that the majority of mild intellectual disability in the UK would not be detected using registers. Cases that are detected by registers are more behaviourally disturbed than others.