Pancreas

Memorial Tribute to Rakesh Kumar Tandon, MD, PhD (1941–2020) No abstract available

Role of Bile Acids and Bile Salts in Acute Pancreatitis: From the Experimental to Clinical Studies Acute pancreatitis (AP) is one of the most common gastroenterological disorders leading to hospitalization. It has long been debated whether biliary AP, about 30% to 50% of all cases, is induced by bile acids (BAs) when they reach the pancreas via reflux or via the systemic blood circulation.

The Application of Exosomal MicroRNAs in the Treatment of Pancreatic Cancer and Its Research Progress Despite great progress in the treatment of pancreatic cancer under the efforts of researchers, the survival time of patients with pancreatic cancer is shorter than that of patients with other cancers. Thus, we have a great need for innovative therapeutic methods, including research and development of new drugs and innovation of administration methods. Exosomes are a type of extracellular vesicles wrapped by a lipid bilayer. Thanks to the low clearance ratio and strong specificity of exosomes in circulation, together with in-depth research on the surface protein of exosomes and a targeted modification method, there is a strong potential to apply exosomes in the transfer and even targeted delivery of chemotherapeutics, RNA, and natural products. Particularly, exosomes carrying microRNA show good application prospects in cancer therapy. This article is intended to summarize the progress of research relating to the treatment of pancreatic cancer via exosomal microRNAs.

Delayed Processing of Secretin-Induced Pancreas Fluid Influences the Quality and Integrity of Proteins and Nucleic Acids Objectives Endoscopic pancreatic function tests are used to diagnose pancreatic diseases and are a viable source for the discovery of biomarkers to better characterize pancreatic disorders. However, pancreatic fluid (PF) contains active enzymes that degrade biomolecules. Therefore, we tested how preservation methods and time to storage influence the integrity and quality of proteins and nucleic acids. Methods We obtained PF from 9 subjects who underwent an endoscopic pancreatic function test. Samples were snap frozen at the time of collection; after 1, 2, and 4 hours on ice; or after storage overnight at 4°C with or without RNase or protease inhibitors (PIs). Electrophoresis and mass spectrometry analysis determined protein abundance and quality, whereas nucleic acid integrity values determined DNA and RNA degradation. Results Protein degradation increased after 4 hours on ice and DNA degradation after 2 hours on ice. Adding PIs delayed degradation. RNA was significantly degraded under all conditions compared with the snap frozen samples. Isolated RNA from PF-derived exosomes exhibited similar poor quality as RNA isolated from matched PF samples. Conclusions Adding PIs immediately after collecting PF and processing the fluid within 4 hours of collection maintains the protein and nucleic acid integrity for use in downstream molecular analyses.

Racial Differences in Gastroenteropancreatic Neuroendocrine Tumor Treatment and Survival in the United States Objectives The objective of this study was to evaluate racial differences in cancer treatment and survival in gastroenteropancreatic neuroendocrine tumor (GEP-NET) patients. Methods Using the Surveillance, Epidemiology, and End Results Registry, we identified patients with GEP-NETs of the stomach, small intestine (SI), colon, rectum, appendix, and pancreas diagnosed between 1973 and 2014. Demographic, cancer, and treatment information were collected and compared using χ2 tests. Multivariable logistic and Cox regression were used to determine disparities in receiving treatment and overall survival. Results We identified 19,031 GEP-NET patients: 2839 were non-Hispanic Blacks, 12,832 non-Hispanic Whites, 2098 Hispanics, and 1262 Asians. African Americans and Hispanics with SI and pancreatic NETs were less likely to be treated with surgery (odds ratio, 0.6; 95% confidence interval [CI], 0.46–0.69; odds ratio, 0.71; 95% CI, 0.51–0.99, respectively). African American race was not an independent predictor of survival; there was a strong trend in stomach, SI, and pancreas NETs (hazard ratio [HR], 1.31; 95% CI, 1–1.7; HR, 1.2; 95% CI, 0.99–1.45; HR, 1.22; 95% CI, 1–1.48, respectively). Conclusions Our study provides evidence of racial disparities in treatment and survival across GEP-NET primary sites and racial groups. Further studies should be performed to improve our understanding of the reason for these disparities.

Age-Related Differences in the Prognosis of Pancreatic Cancer According to Perioperative Systemic Therapy Objectives In this study, we retrospectively assessed the feasibility and prognostic efficacy of perioperative chemo(radio)therapy for pancreatic cancer (PC) patients according to age. Methods A total of 556 consecutive patients who underwent curative-intent pancreatectomy for PC between 2000 and 2018 were enrolled. Results Of the 556 patients who underwent resection, 95 (17%) were elderly (age, ≥75 years). Postoperative complications did not significantly differ between the 2 age groups, and postoperative prognoses were also similar (recurrence-free survival [RFS], P = 0.68; overall survival [OS], P = 0.28). In this cohort, 103 patients (19%) underwent preoperative chemo(radio)therapy, and 417 (77%) underwent postoperative chemotherapy. Perioperative therapy was found to be significantly beneficial for younger patients (preoperative therapy: RFS, P = 0.006; OS, P < 0.001; postoperative therapy: RFS, P < 0.001; OS, P < 0.001). Conversely, no significant survival benefit of perioperative therapy was found for the elderly (preoperative therapy: RFS, P = 0.28; OS, P = 0.44; postoperative therapy: RFS, P = 0.77; OS, P = 0.08). Conclusions This study demonstrated that, although perioperative therapy is feasible for selected elderly patients with PC, this approach might not be as beneficial as it is for younger PC patients.

Causes of Death After Neuroendocrine Tumors Diagnosis: A US Population-Based Analysis Objective In this study, we aimed to determine the cause of death (COD) after the diagnosis of neuroendocrine tumors (NET). Methods We used the Surveillance, Epidemiology and End Results (SEER) Program to review patients diagnosed with NET during 2000 to 2016. Patients were followed until death, and different CODs were determined. Results Of 94,399 patients with NETs, 40.9% died during the study period. During the first year of diagnosis, most deaths were from NETs (73%), followed by other cancers (11.2%) and cardiac diseases (4.6%). After more than 10 years, NET deaths decreased to 24.3%, whereas other cancers and cardiac disease became more common. Neuroendocrine tumors were responsible for 42.8%, 63.4%, and 81.2% of deaths in grade I, grade II, and grade III, respectively. For grade I localized NET, other cancers (22.2%) were the most common COD followed by NET (19.7%), whereas in grade 2 localized NET, NET was COD in 31.1% of cases followed by other cancers (22.4%). In metastatic disease, NET was the most common COD regardless of grade. Conclusions For low-grade localized NET, deaths were mostly secondary to non-NET causes. In contrast, NET is responsible for most of deaths in metastatic NET regardless of grade.

A 3-Decade Analysis of Pancreatic Adenocarcinoma After Solid Organ Transplant Objective Solid organ transplant (SOT) recipients have moderately increased risk of pancreatic adenocarcinoma (PAC). We evaluated the incidence and survival of PAC in 2 cohorts and aimed to identify potential risk factors. Methods This study performed a retrospective cohort analysis. Cohort A was extracted from the United Network of Organ Sharing data set and cohort B from SOT recipients evaluated at 3 Mayo Clinic transplant centers. The primary outcome was age-adjusted annual incidence of PAC. Descriptive statistics, hazard ratios, and survival rates were compared. Results Cohort A and cohort B included 617,042 and 29,472 SOT recipients, respectively. In cohort A, the annual incidence rate was 12.78 per 100,000 in kidney-pancreas, 13.34 in liver, and 21.87 in heart-lung transplant recipients. Receiving heart-lung transplant, 50 years or older, and history of cancer (in either recipient or donor) were independent factors associated with PAC. Fifty-two patients developed PAC in cohort B. Despite earlier diagnosis (21.15% with stage I–II), survival rates were similar to those reported for sporadic (non-SOT) patients. Conclusions We report demographic and clinical risk factors for PAC after SOT, many of which were present before transplant and are common to sporadic pancreatic cancer. Despite the diagnosis at earlier stages, PAC in SOT portends a very poor survival.

Survival Outcomes of Adjuvant Chemotherapy Combined With Radiation Versus Chemotherapy Alone After Pancreatectomy for Distal Pancreatic Adenocarcinoma: A Single-Institution Experience Objective We evaluated survival outcomes in patients with distal pancreatic ductal adenocarcinoma (D-PDAC) after distal pancreatectomy (DP) and adjuvant chemotherapy or chemoradiation. Methods A retrospective analysis of patients who underwent DP for D-PDAC from 2000 to 2015 at the Johns Hopkins Hospital was performed. Demographics, baseline risk factors, and type of adjuvant treatment were assessed for associations with overall survival (OS) and disease-free survival (DFS). Comparisons were made with log-rank tests and Cox proportional hazards regression models. Results A total of 294 patients underwent DP for D-PDAC. Of these, 105 patients were followed at the Johns Hopkins Hospital. Forty-five patients received chemotherapy only and 60 patients received chemoradiation. The median OS with chemoradiation was 33.6 months and 27.9 months (P = 0.54) with chemotherapy only. The median DFS was 15.3 months with chemoradiation and 19.8 months with chemotherapy only (P = 0.89). Elevated carbohydrate antigen 19-9, stage II to III disease, splenic vein involvement, and vascular invasion were significant risk factors in multivariate analyses. Conclusions In this retrospective analysis, there were no significant differences in OS or DFS with chemoradiation compared with chemotherapy alone after DP in patients with D-PDAC.

Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study Objectives Studies on the incidence of venous thromboembolism (VTE) in acute pancreatitis (AP) are scarce. We conducted a large database study to evaluate this relationship. Methods Data were extracted from a large electronic health record (Explorys; IBM Watson Health, Armonk, NY). We identified patients with AP in 2018 and 2019, analyzing VTE incidence at 30 days after diagnosis of AP. Univariate and multivariate analyses were performed to identify risk factors associated with VTE. Results A total of 25,620 cases of acute necrotizing pancreatitis (ANP) and 155,800 cases of acute nonnecrotizing pancreatitis (ANNP) were identified. The incidence of VTE was 7.1% for ANP, compared with 2.8% in ANNP (P < 0.001). On multivariate analysis, ANP conferred significantly greater odds of VTE (adjusted odds ratio, 2.78; 95% confidence interval, 2.73–2.84; P < 0.001), independent of other variables. In those with ANP, the presence of VTE was associated with a significantly higher mortality (23.5% vs 15.9%, P < 0.001). Conclusions Acute necrotizing pancreatitis carries near 2.5-fold risk of VTE, and a 3-fold risk of PE, compared with those with ANNP. Venous thromboembolism development in ANP is associated with higher mortality.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Thoracic Imaging

Editors' Recognition for Reviewing in 2020 No abstract available

Establishing Satellite Lung Cancer Screening Sites With Telehealth to Address Disparities Between High-risk Smokers and American College of Radiology–approved Centers of Designation No abstract available

The Regimen of Computed Tomography Screening for Lung Cancer: Lessons Learned Over 25 Years From the International Early Lung Cancer Action Program We learned many unanticipated and valuable lessons since we started planning our study of low-dose computed tomography (CT) screening for lung cancer in 1991. The publication of the baseline results of the Early Lung Cancer Action Project (ELCAP) in Lancet 1999 showed that CT screening could identify a high proportion of early, curable lung cancers. This stimulated large national screening studies to be quickly started. The ELCAP design, which provided evidence about screening in the context of a clinical program, was able to rapidly expand to a 12-institution study in New York State (NY-ELCAP) and to many international institutions (International-ELCAP), ultimately working with 82 institutions, all using the common I-ELCAP protocol. This expansion was possible because the investigators had developed the ELCAP Management System for screening, capturing data and CT images, and providing for quality assurance. This advanced registry and its rapid accumulation of data and images allowed continual assessment and updating of the regimen of screening as advances in knowledge and new technology emerged. For example, in the initial ELCAP study, introduction of helical CT scanners had allowed imaging of the entire lungs in a single breath, but the images were obtained in 10 mm increments resulting in about 30 images per person. Today, images are obtained in submillimeter slice thickness, resulting in around 700 images per person, which are viewed on high-resolution monitors. The regimen provides the imaging acquisition parameters, imaging interpretation, definition of positive result, and the recommendations for further workup, which now include identification of emphysema and coronary artery calcifications. Continual updating is critical to maximize the benefit of screening and to minimize potential harms. Insights were gained about the natural history of lung cancers, identification and management of nodule subtypes, increased understanding of nodule imaging and pathologic features, and measurement variability inherent in CT scanners. The registry also provides the foundation for assessment of new statistical techniques, including artificial intelligence, and integration of effective genomic and blood-based biomarkers, as they are developed.

Private Tour Guide to Pediatric Coronavirus Disease of 2019 and Multisystem Inflammatory Syndrome in Children in 10 Minutes: What Thoracic Radiologists Need to Know Filtering through the plethora of radiologic studies generated in response to the coronavirus disease of 2019 (COVID-19) pandemic can be time consuming and impractical for practicing thoracic radiologists with busy clinical schedules. To further complicate matters, several of the imaging findings in the pediatric patients differ from the adult population. This article is designed to highlight clinically useful information regarding the imaging manifestations of pediatric COVID-19 pneumonia, including findings more unique to pediatric patients, and multisystem inflammatory syndrome in children.

Performance of Chest Computed Tomography in Differentiating Coronavirus Disease 2019 From Other Viral Infections Using a Standardized Classification Background: An expert consensus recently proposed a standardized coronavirus disease 2019 (COVID-19) reporting language for computed tomography (CT) findings of COVID-19 pneumonia. Purpose: The purpose of the study was to evaluate the performance of CT in differentiating COVID-19 from other viral infections using a standardized reporting classification. Methods: A total of 175 consecutive patients were retrospectively identified from a single tertiary-care medical center from March 15 to March 24, 2020, including 87 with positive reverse transcription-polymerase chain reaction (RT-PCR) test for COVID-19 and 88 with negative COVID-19 RT-PCR test, but positive respiratory pathogen panel. Two thoracic radiologists, who were blinded to RT-PCR and respiratory pathogen panel results, reviewed chest CT images independently and classified the imaging findings under 4 categories: "typical" appearance, "indeterminate," "atypical," and "negative" for pneumonia. The final classification was based on consensus between the readers. Results: Patients with COVID-19 were older than patients with other viral infections (P=0.038). The inter-rater agreement of CT categories between the readers ranged from good to excellent, κ=0.80 (0.73 to 0.87). Final CT categories were statistically different among COVID-19 and non-COVID-19 groups (P<0.001). CT "typical" appearance was more prevalent in the COVID-19 group (64/87, 73.6%) than in the non-COVID-19 group (2/88, 2.3%). When considering CT "typical" appearance as a positive test, a sensitivity of 73.6% (95% confidence interval [CI]: 63%-82.4%), specificity of 97.7% (95% CI: 92%-99.7%), positive predictive value of 97% (95% CI: 89.5%-99.6%), and negative predictive value of 78.9% (95% CI: 70%-86.1%) were observed. Conclusion: The standardized chest CT classification demonstrated high specificity and positive predictive value in differentiating COVID-19 from other viral infections when presenting a "typical" appearance in a high pretest probability environment. Good to excellent inter-rater agreement was found regarding the CT standardized categories between the readers.

A Dose Simulation X-Ray Software: An Innovating Tool to Reduce Chest Radiograph Exposure in Children Purpose: Chest radiography is one of the most frequent x-ray examinations performed on children. Reducing the delivered dose is always a major task. The objective of our study was to determine the minimum dose to be delivered while maintaining the image quality of chest radiographs, using dose reduction simulation software. Materials and Methods: We included 60 children who had had a chest radiography in 5 groups established according to the diagnostic reference levels equitably represented by weight ranges. The software simulated for each radiograph 6 additional simulated photonic noise images corresponding to 100%, 80%, 64%, 50%, 40%, and 32% of the initial dose. The 360 radiographs were blindly scored by 2 radiologists, according to the 7 European quality criteria and a subjective criterion of interpretability, using a semiquantitative visual Lickert scale. Results: There was no significant difference in scoring between the reference radiograph (100%) and simulated radiographs at 80% of the dose in children between 5 and 20 kg, 50% of the dose in children between 20 and 30 kg, and between simulated radiographs at 40% of the dose in children over 30 kg. Interobserver reproducibility was moderate to excellent. Conclusion: Chest radiography dose might be reduced by 20% in children between 5 and 20 kg, 50% in children between 20 and 30 kg, and 60% in children over 30 kg, without any difference in the image quality appreciation. Software that produced simulated x-ray with decreasing delivered dose is an innovating tool for an optimization process.

Three-dimensional Ultrashort Echotime Magnetic Resonance Imaging for Combined Morphologic and Ventilation Imaging in Pediatric Patients With Pulmonary Disease Purpose: Ultrashort echotime (UTE) sequences aim to improve the signal yield in pulmonary magnetic resonance imaging (MRI). We demonstrate the initial results of spiral 3-dimensional (3D) UTE-MRI for combined morphologic and functional imaging in pediatric patients. Methods: Seven pediatric patients with pulmonary abnormalities were included in this observational, prospective, single-center study, with the patients having the following conditions: cystic fibrosis (CF) with middle lobe atelectasis, CF with allergic bronchopulmonary aspergillosis, primary ciliary dyskinesia, air trapping, congenital lobar overinflation, congenital pulmonary airway malformation, and pulmonary hamartoma. Patients were scanned during breath-hold in 5 breathing states on a 3-Tesla system using a prototypical 3D stack-of-spirals UTE sequence. Ventilation maps and signal intensity maps were calculated. Morphologic images, ventilation-weighted maps, and signal intensity maps of the lungs of each patient were assessed intraindividually and compared with reference examinations. Results: With a scan time of ∼15 seconds per breathing state, 3D UTE-MRI allowed for sufficient imaging of both "plus" pathologies (atelectasis, inflammatory consolidation, and pulmonary hamartoma) and "minus" pathologies (congenital lobar overinflation, congenital pulmonary airway malformation, and air trapping). Color-coded maps of normalized signal intensity and ventilation increased diagnostic confidence, particularly with regard to "minus" pathologies. UTE-MRI detected new atelectasis in an asymptomatic CF patient, allowing for rapid and successful therapy initiation, and it was able to reproduce atelectasis and hamartoma known from multidetector computed tomography and to monitor a patient with allergic bronchopulmonary aspergillosis. Conclusion: 3D UTE-MRI using a stack-of-spirals trajectory enables combined morphologic and functional imaging of the lungs within ~115 second acquisition time and might be suitable for monitoring a wide spectrum of pulmonary diseases.

Radiation Dose Reduction Using a Novel Fluoroscopy System in Patients Undergoing Diagnostic Invasive Coronary Angiography Background: Invasive coronary angiography (ICA) still causes a significant amount of radiation exposure for patients and operators. In February 2017, the Azurion system was introduced, a new-generation fluoroscopy image acquisition and processing system. Radiation exposure in patients undergoing ICA was assessed comparing the novel Azurion 7 F12 angiography system to its predecessor Allura Xper in a randomized manner. Methods: Radiation exposure was prospectively analyzed in 238 patients undergoing diagnostic ICA. Patients were randomly assigned to the novel Azurion system (119 patients) or its predecessor Allura Xper system (119 patients). In each patient, 8 predefined standard projections (5 left coronary artery, 3 right coronary artery) were performed. Image quality was quantified by grading of the images on the basis of a 5-point grading system. Results: Radiation dose area product was significantly lower in the Azurion group 109 (interquartile range [IQR 75-176] cGy cm2) compared with the Allura Xper group 208 [IQR 134-301] cGy cm2 (P<0.001). Body mass index (26.6 [IQR 23.9-29.7] kg/m2 vs. 26.2 [IQR 24.2-29.4] kg/m2; P=0.607), body surface area (1.96 [IQR 1.81-2.11] m2 vs. 1.90 [IQR 1.77-20.4] m2; P=0.092), and procedure duration (1.5 [IQR 1.2-2.3] min vs. 1.6 [IQR 1.2-2.5] min; P=0.419) were similar in both groups. Images from the Azurion system were at least of equal quality compared with Allura Xper (image quality grade 4.82±0.45 vs. 4.75±0.52, P=0.43). Conclusion: Use of the novel Azurion 7 F12 angiography system resulted in a significant reduction of dose area product in patients undergoing diagnostic ICA by 56%.

Prevalence of Burnout Among Cardiothoracic Radiologists Purpose: Burnout is a psychological syndrome in response to chronic occupational stressors. The prevalence of burnout among medical professionals has been increasing, and recent studies have shown that radiologists are among those affected. We investigated the prevalence of burnout and assessed associated factors among cardiothoracic radiologists. Materials and Methods: Society of Thoracic Radiology members were invited to complete an anonymous cross-sectional survey that included an adapted Maslach Burnout Inventory and questions about demographics, work place characteristics, and stressors. Results: The survey response rate was 33.1% (290/874). Per-item response rate ranged from 94% to 100% with a median of 99%. The prevalence of emotional exhaustion was 66.8% (186/283), depersonalization was 79% (223/283), and low personal accomplishment was 23% (65/280). There were no statistically significant differences between academic and private practice. There was a trend toward worse burnout in women, but this was not statistically significant. Being in early career (0 to 10 y since fellowship) was associated with low personal accomplishment [odds ratio (OR): 2.07, 95% confidence interval (CI): 1.08-3.99]. Those working fewer than 51 hours per week were significantly less likely to report emotional exhaustion (OR: 0.55, 95% CI: 0.33-0.90). The odds of emotional exhaustion for those producing fewer than 7500 work relative value units per year were approximately half of those exceeding that number (OR: 0.46, 95% CI: 0.22-0.95). Conclusions: The prevalence of burnout among cardiothoracic radiologists is comparable to that reported for radiologists in other subspecialties such as musculoskeletal and interventional radiology. High work relative value unit productivity and longer work hours are associated with higher prevalence of burnout.

COVID-19 and its Mimics: What the Radiologist Needs to Know Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the current outbreak of Coronavirus disease 2019 (COVID-19). Although imaging should not be used for first-line screening or diagnosis, radiologists need to be aware of its imaging features, and those of common conditions that may mimic COVID-19 pneumonia. In this Pictorial Essay, we review frequently encountered conditions with imaging features that overlap with those that are typical of COVID-19 (including other viral pneumonias, chronic eosinophilic pneumonia, and organizing pneumonia), and those with features that are indeterminate for COVID-19 (including hypersensitivity pneumonitis, pneumocystis pneumonia, diffuse alveolar hemorrhage, pulmonary edema, and pulmonary alveolar proteinosis).

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Nervous and Mental Disease

Can Trans-Syndromal Prototypes ("Types") Improve Depiction of Complex Psychiatric Cases?: An Alternative Way to Consider Concordant Comorbid Psychiatric Disorders and Their Contexts as Coherent Units for Research, Assessment, and Treatment Planning Background and aims: In many psychiatric settings, patients with complex cases are the rule rather than the exception. These cases are characterized by multidiagnostic conditions, often complicated with distressed social contexts, for which few if any evidence-based practice guidelines exist. The aim of this hypothesis-generating article is to consider whether and how these cases might comprise trans-syndromal prototypes ("types"), coherent units that could serve as the basis for further study, assessment, and treatment planning. Methods: For context, psychiatric and medical visit diagnoses and problem lists noted among principle visit diagnoses and "snapshot" portions of electronic medical records were tabulated for 293 psychiatric outpatients seen consecutively during a 1-week period at a university psychiatric clinic. By considering resulting comorbidity patterns in these records from the perspectives of clinicians caring for these patients, several commonly encountered diagnostic-problem sets emerged as candidate types. Results: Of 293 patients, only 18% had a single diagnosis, 43% had two, 29% had three, and 7% had four or more noted. Occurring in assorted combinations, specific diagnostic areas noted included depressive disorders (68%, the large majority major depressive disorder recurrent), anxiety disorders (60%, the large majority generalized anxiety disorder, with or without panic disorder and/or social anxiety disorder), posttraumatic stress disorder (22%), attention deficit hyperactivity disorder (ADHD) (17%), alcohol and substance abuse disorders (16%), personality disorders (11%), and bipolar disorders (18%). Several illustrative candidate types emerging from this population are described including major anxious depressive disorder, anxiety disorder secondary to ADHD, complex emotional instability disorder, multi-impulsive eating disorder, substance-dependent impoverished personality disorder, painful mood disorder, and complex personal and cultural trauma disorder. Other potential types are identified as well. Conclusions and implications: The types described here are but a small selection, because other settings including community mental health centers, private practices, public and private hospitals, and forensic facilities see a variety of other types as well. The study of types might provide important findings about pathogenesis, course, outcome, and treatment to augment information obtained from examination of individual diagnostic components.

The Problem of Aggregating Validators for Psychiatric Disorders Since the time of the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, evidence for the validity of psychiatric disorders has been expressed in the form of validators, which are instances of particular kinds of evidence. There has never been an explicit discussion of how the validators should be aggregated to come to an overall conclusion about the strength of the evidence for a psychiatric category. We include both the challenges of aggregating validators of the same type and the challenges of aggregating different types of validators. We consider five different alternatives: informal aggregation, weighted informal aggregation (simple evidence hierarchy), formal aggregation, underdetermination, and inclusion of values. Each of the alternatives has different implications. We suggest that, going forward, aggregation of validators should be more explicit, maximizing rigor and reproducibility.

The Role of Guilt and Shame in Psychosocial Functioning in a Sample of Women With Borderline Personality Disorder Individuals diagnosed with borderline personality disorder (BPD) experience significant and pervasive impairment in interpersonal, social, and vocational functioning, and accumulating evidence suggests that impairments in functioning often persist despite significant decreases in symptom severity. Previous research indicates that shame-proneness and guilt-proneness are associated with symptoms of BPD that can affect functioning (such as aggression toward others), but very few studies have examined the impact of shame-proneness and guilt-proneness on validated measures of psychosocial functioning. Forty women with BPD completed measures of shame-proneness and guilt-proneness, psychosocial functioning, and BPD symptom severity. Results from multiple regression analyses indicate that women with BPD who tend to experience higher levels of shame-proneness and lower levels of guilt-proneness report poor performance in school and work settings and in interpersonal relationships. Strengths of the study include the use of a validated measure of functioning as the primary outcome. Limitations and future directions are discussed.

Relationship and Effects of Community Problems on Anxiety and Suicide: A Case-Control Psychological Autopsy Study This study aimed to explore the relationship and the effects of community problems on anxiety and suicide. Data were from a case-control psychological autopsy study (392 suicides and 416 community living controls) carried out in 16 rural counties from three provinces in China. The World Health Organization Suicide Prevention–Multisite Intervention Study on Suicidal behaviors scale of community stress and problems and Spielberger State-Trait Anxiety Inventory were used to measure the community problems and trait anxiety. Spearman's correlation and multivariable regression methods were used to probe the effect of community problems on anxiety and suicide. There were 12 and 6 community problems correlated with anxiety (rs = 0.169, p < 0.001) and suicide (rs = 0.081, p = 0.022), respectively. Medical care, alcohol abuse, superstition, and job security were important community problems for anxiety and suicide. Community problems had stronger correlation with anxiety than suicide. It might be an effective method to reduce anxiety and suicide risk by solving different community problems.

Predicting Posttraumatic Stress and Depression Symptoms Among Frontline Firefighters in China To investigate the prevalence and comorbidity rate of potential posttraumatic stress disorder (PTSD) and depression in frontline firefighters in China, as well as to analyze the related predictive factors for PTSD and depression, our study included 261 firefighters who completed assessments including the Demographic Data Forum, PTSD Checklist for DSM-5, Center for Epidemiological Studies Depression Scale, Chinese version of Perceived Stress Scale, and Perceived Social Support Scale. Among the participants, 1.9% and 11.9% were identified as having potential PTSD and depression, respectively. There was a 9.1% chance of comorbid PTSD among the depressed firefighters and a 60% chance of comorbid depression among the firefighters with PTSD. Perceived stress positively predicted both PTSD and depression; perceived social support negatively predicted both PTSD and depression. Whereas family exogenous support predicted both PTSD and depression, family endogenous support only predicted depression. In addition, PTSD was predicted by rank. Soldiers and sergeants demonstrated higher level of PTSD than officers. Future studies on mental health of firefighters should take factors like perceived stress, social support, and rank into consideration.

Differences in Posttraumatic and Psychosocial Outcomes Among Refugees, Asylum Seekers, and Internally Displaced Persons Refugees, asylum seekers, and internally displaced persons differ in their experiences, potentially affecting posttraumatic outcomes such as posttraumatic stress disorder (PTSD) symptoms, posttraumatic cognitions, and posttraumatic growth (PTG), as well as psychosocial outcomes such as social connection, discrimination, and well-being. We explored these differences in a sample of N = 112 Muslim displaced persons. Results from planned contrasts indicated that refugees reported more PTSD symptoms (t[46.63] = 3.04, p = 0.004, d = 0.77) and more PTG (t[94] = 2.71, p = 0.008, d = 0.61) than asylum seekers. Higher posttraumatic cognitions predicted less social connections across displacement immigration category. The strength of this relationship was more pronounced for asylum seekers than refugees (b = −0.43, p = 0.014). Refugees may focus more on direct threats from others, resulting in more PTSD symptoms, whereas asylum seekers' uncertainty may pose a greater threat, exacerbating posttraumatic beliefs that drive social disconnection.

A Preliminary Investigation of Deficits in Executive Functions of Adults With Attention Deficit Hyperactivity Disorder Several studies over the past two decades have investigated the neuropsychological deficits in children with attention deficit hyperactivity disorder (ADHD), but much less has been done on adults. This study aimed to assess the deficits in executive functions of adults with ADHD, especially in the areas of attention, inhibition, impulsivity, and planning. Twenty-four adults (18 years and older) diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria, and also assessed with Conners' Adult ADHD Rating Scale, participated in the study. Executive functions in cases were compared with 20 matched controls through the three instruments of Tower of London (TOL), Continuous Performance Test (CPT), and Stroop test. Performance of cases was weaker than that of the control group in TOL. The difference was significant in subsequent thinking time in most of the trials and number of movements only at level 2. In CPT, the adults with ADHD made more commission errors. In addition, the ADHD cases made more errors in the word card of the Stroop test, and the time they spent reading all three cards was significantly longer than that of the control group. Our study suggests that several deficits in executive functions related to ADHD persist into adulthood, such as impairments in planning time and set shifting, response inhibition, impulsivity, and visuolingual processing. However, simple (visual-motor processing) and sustained attention might improve with age.

Childhhood Trauma in Schizophrenia Spectrum Disorders: Dissociative, Psychotic Symptoms, and Suicide Behavior Current evidence suggests a high prevalence of childhood trauma (CT) among adult patients diagnosed with schizophrenia spectrum disorders. Exposure to CT might lead to clinical differences eventually observed in these patients. We present a cross-sectional study with 54 patients with schizophrenia spectrum disorder (schizophrenia and schizoaffective disorder). We obtained sociodemographic data, as well as data on CT, dissociation, suicide history, and intensity of positive and negative psychotic symptoms. More than 75% of the patients reported a history of CT. We observed a link between CT and suicidal behavior. Patients showed high rates of dissociation. Dissociative experiences were related to CT, both in terms of intensity of trauma and number of traumas experienced. All CT forms except emotional neglect showed direct correlations with dissociative experiences. We found no correlation between intensity of CT and intensity of positive psychotic symptoms, yet we observed a moderate inverse correlation with negative psychotic symptoms.

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19 The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Internalized Stigma in People With Mood Disorders: Predictors and Associated Factors To analyze the predictors of internalized stigma among people with mood disorders, we conducted an analytical observational cross-sectional study with 108 people with mood disorders in a public service setting in Sao Paulo, Brazil. We applied a sociodemographic and clinical questionnaire, the Internalized Stigma of Mental Illness Scale, the Medication Adherence Scale, the Brief Psychiatric Rating Scale–Anchored, and the Herth Hope Index. We analyzed the data using descriptive statistics, average comparison tests, a correlation test, and multiple linear regression. Internalized stigma was associated with symptomatology, history of aggressive behavior, psychiatric hospitalizations, suicide attempts, hopelessness, nonadherence to psychotropic medications, and unemployment. The predictors of internalized stigma were unemployment, more psychiatric symptoms, history of previous suicide attempts, and less hope. Clinical interventions and investigations for stigma reduction and psychosocial rehabilitation should incorporate the factors associated with self-stigma (aggressive behavior, history of psychiatric hospitalizations, suicide attempts, hopelessness, nonadherence to medication, and unemployment).

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Psychosomatic Medicine

Article Summaries for January 2021 Psychosomatic Medicine, Volume 83, Issue 1 No abstract available

Reduced Heart Rate Variability in Patients With Medically Unexplained Physical Symptoms: A Meta-Analysis of HF-HRV and RMSSD Objective Medically unexplained physical symptoms (MUPS) and related syndromes are common and place a substantial burden on both patients and society. Chronic psychological distress and dysregulation of the autonomic nervous system may be common factors associated with MUPS, although previous studies have reported mixed results. The aims of this meta-analysis are to provide an updated synthesis of studies investigating heart rate variability (HRV) indices associated with autonomic nervous system functioning in three common MUPS syndromes and to explain inconsistencies in previous study findings. Methods Literature search yielded 58 studies comparing HRV indices of reduced parasympathetic activity of healthy individuals with those of patients with chronic fatigue syndrome (npatients = 271), irritable bowel syndrome (npatients = 1005), and fibromyalgia (npatients = 534). Separate random-effects meta-analyses were conducted on studies measuring root mean square of successive differences (RMSSD) and high-frequency HRV (HF-HRV). Results Regardless of syndrome type, patients had significantly lower RMSSD (k = 22, Hedges g = −0.37 [−0.53 to −0.21], p < .001) and HF-HRV (k = 52, Hedges g = −0.69 [−1.03 to −0.36], p < .001) than did healthy individuals. Sample age and publication year explained a substantial variation in RMSSD, whereas controlling for confounders in statistical analyses explained variation in HF-HRV. Conclusions Lower RMSSD and HF-HRV in patients with MUPS versus healthy controls indicates that autonomic nervous system dysregulation, particularly lower parasympathetic activity, may play a role in patients with these conditions. This conclusion may have important implications for the underlying mechanisms and treatment of MUPS and related syndromes.

Socioeconomic Differences in Sympathovagal Balance: The Healthy Life in an Urban Setting Study Objective Alterations in sympathovagal balance are associated with cardiovascular disease. If sympathovagal balance differs across socioeconomic groups, it may reflect a mechanism through which disparities in cardiovascular disease occur. We therefore assessed the association between education and occupation with measures of sympathovagal balance in a large multiethnic sample. Methods We included cross-sectional data of 10,202 South Asian Surinamese, African Surinamese, Ghanaian, Turkish, Moroccan, and Dutch-origin participants from the Healthy Life in an Urban Setting study. Sympathovagal balance was measured by baroreflex sensitivity (BRS) and the standard deviation of the interbeat interval, calculated from changes in blood pressure and interbeat intervals, from 5-minute recordings. We calculated geometric means and estimated the relative index of inequality, using age- and ethnicity-adjusted linear regression, to quantify the association between education and occupation and sympathovagal balance. In addition, we assessed whether the association was consistent across ethnic groups. Results The geometric means of BRS ranged from 8.16 ms/mm Hg (confidence interval [CI] = 7.91–8.43 ms/mm Hg) in low-educated to 14.00 ms/mm Hg (CI = 13.53–14.48 ms/mm Hg) in highly educated women, and from 8.32 ms/mm Hg (CI, 7.97–8.69 ms/mm Hg) in low-educated to 12.25 ms/mm Hg (CI = 11.86–12.66 ms/mm Hg) in highly educated men. High education and occupation were statistically significantly associated with higher BRS and standard deviation of the interbeat interval. Compared with the participants of Dutch origin, a pattern of weaker associations was found in the Surinamese and Ghanaian ethnic groups, but not the Turkish and Moroccan groups. Conclusions There is a clear socioeconomic gradient in measures of sympathovagal balance, indicating that sympathovagal balance may play a role in socioeconomic disparities in cardiovascular morbidity and mortality.

Implicit Affect, Heart Rate Variability, and the Metabolic Syndrome Objective Greater negative affect has been associated with an increased risk of the metabolic syndrome (METs). However, all studies to date have examined this association using explicit affect measures based on subjective ratings of emotional experiences. Prior studies suggest that implicit affect, representing the automatic, prereflective appraisal process involved in conscious emotional experiences, is associated with physiological stress responses independent of explicit affect. Furthermore, low resting heart rate variability (HRV) may increase the risk of stress-related diseases. The goals of this study were to evaluate the associations between implicit and explicit affect and METs and to assess whether these associations were amplified by lower HRV. Methods This secondary analysis of a larger study included 217 middle-aged women who completed measures of implicit affect, explicit affect, high-frequency HRV, and the different components of METs. Results There was a significant interaction between implicit negative affect and HRV predicting METs (odds ratio = 0.57, 95% confidence interval = 0.35–0.92), such that the combination of higher implicit affect and lower HRV was associated with a greater likelihood of METs. Similarly, there was a main effect of implicit negative affect as well as an interaction between implicit negative affect and HRV on the lipid accumulation product (b (standard error) = −0.06 (0.02), 95% confidence interval = −0.11 to −0.02), a combination of waist circumference and triglycerides. Conclusions Higher implicit negative affect in the context of lower HRV may be related to a greater risk of METs. The present findings highlight the relevance of including implicit affect measures in psychosomatic medicine research.

Open- and Closed-Label Placebo and Nocebo Suggestions About a Sham Transdermal Patch Objective Placebo effects may occur when it is known that an inert substance is given (i.e., open-label placebo). It is not yet clear whether these effects are similar to concealed (i.e., closed-label) placebo effects for itch or whether nocebo effects can be induced under open-label conditions. Methods Healthy volunteers (n = 112) were randomized to an open-label (I) or closed-label (II) positive suggestions group, or an open-label (III) or closed-label (IV) negative suggestions group. Participants were told, as cover story, that a transdermal caffeine patch would be applied that positively influences cognitive abilities and, as a side effect, positively or negatively (depending on group allocation) influences itch. Participants in the open-label groups were given a rationale explaining placebo and nocebo effect mechanisms. Itch (the primary outcome) was induced at baseline and postsuggestions by histamine iontophoresis. Results Analyses of variance revealed significantly lower itch in the positive compared with the negative suggestions groups for both open- and closed-label contexts (all, p ≤ .008, Cohen d ≥ 0.47). Self-rated skin response was less severe after positive versus negative suggestions (all, p ≤ .017, Cohen d ≥ 0.33), but no effects on physical skin response were found (all, p ≥ .23, Cohen d ≤ 0.30). Conclusions Itch can be reduced by positive compared with negative suggestions under both open- and closed-label conditions. These findings indicate that open-label suggestions may potentially be a tool to use placebo effects for self-reported outcomes in clinical practice, for example, by explaining the role of expectancy in treatment. It needs to be investigated further under which circumstances an open-label rationale may impact placebo and nocebo effects. Trial Registration:www.trialregister.nl; NTR7174

The Effect of Temporal Information on Placebo Analgesia and Nocebo Hyperalgesia Objective Expectations are known to be key determinants of placebo and nocebo phenomena. In previous studies, verbal suggestions to induce such expectations have mainly focused on the direction and magnitude of the effect, whereas little is known about the influence of temporal information. Methods Using an experimental placebo and nocebo design, we investigated whether information about the expected onset of a treatment effect modulates the start and time course of analgesic and hyperalgesic responses. Healthy volunteers (n = 166) in three placebo and three nocebo groups were informed that the application of an (inert) cream would reduce (placebo groups) or amplify pain (nocebo groups) after 5, 15, or 30 minutes. Two control groups were also included (natural history and no expectations). Participants' pain intensity rating of electrical stimuli administered before and 10, 20, and 35 minutes after cream application was obtained. Results Mixed-method analysis of variance showed a significant interaction between group and time (F(12,262) = 18.172, p < .001, pη2 = 0.454), suggesting that pain variations differed across time points and between groups. Post hoc comparisons revealed that the placebo and nocebo groups began to show a significantly larger change in perceived pain intensity than the no-expectancy control group at the expected time point (p < .05) but not earlier (p > .05). Once triggered, the analgesic effect remained constant over the course of the experiment, whereas the hyperalgesic effect increased over time. Conclusions Our results indicate that temporal suggestions can shape expectancy-related treatment effects, which, if used systematically, could open up new ways to optimize treatment outcome.

Perceived Social Support and Children's Physiological Responses to Stress: An Examination of the Stress-Buffering Hypothesis Objective The current study aimed to examine the stress-buffering effect of children's perceived social support on their hypothalamic-pituitary-adrenocortical axis and autonomic nervous system reactivity to an acute laboratory stressor. Methods A sample of 150 children (aged 9–13 years, mean [standard deviation] age = 10.69 [0.93] years, 74 girls) reported perceived social support, stressful life events, and underwent the Modified Trier Social Stress Test, during which six saliva samples were collected. A two-piece multilevel growth curve model with landmark registration was used to detect trajectory differences in the reactivity and recovery phases of the stress response and account for individual variation in the timing of poststressor peak hormone concentrations. Results The interaction between stressful life events and perceived social support significantly predicted poststressor peak cortisol levels (β = 0.0805, SE = 0.0328, p = .015) and cortisol recovery slope (β = −0.0011, SE = 0.0005, p = .040). Children with more life events and low social support exhibited the lowest poststressor peak cortisol levels and the flattest cortisol recovery slope. In contrast, children high in stressful life events and high in social support displayed cortisol response profiles more similar to those of children with low stressful life events. Conversely, there were no statistically significant two-way interactions of stressful life events and perceived social support on salivary α-amylase parameters (i.e., poststressor peak [p = .38], reactivity slope [p = .81], and recovery slope [p = .32]). Conclusions These results provide preliminary evidence for the buffering effect of children's perceived social support on the association between life stress and hypothalamic-pituitary-adrenocortical axis response profiles.

Psychosocial Work Factors of the Job Strain Model and All-Cause Mortality: The STRESSJEM Prospective Cohort Study Objective The objectives were to examine the prospective associations between psychosocial work factors of the job strain model and all-cause mortality in a national representative cohort of French employees using various measures of time-varying exposure. Methods The study was based on a sample of 798,547 men and 697,785 women for which data on job history from 1976 to 2002 were linked to mortality data from the national death registry. Psychosocial work factors from the validated job strain model questionnaire were imputed using a job-exposure matrix. Three time-varying measures of exposure were explored: current, cumulative, and recency-weighted cumulative exposure. Cox proportional hazards models were performed to study the associations between psychosocial work factors and mortality. Results Within the 1976–2002 period, 88,521 deaths occurred among men and 28,921 among women. Low decision latitude, low social support, job strain, isostrain, high strain, and passive job were found to be risk factors for mortality. The model using current exposure was the best relative-quality model. The associations of current exposure to job strain and mortality were found to have hazard ratios of 1.30 (95% confidence interval [CI] = 1.24–1.36) among men and 1.15 (95% CI = 1.06–1.25) among women. The population fractions of mortality attributable to job strain were 5.64% (95% CI = 4.56%–6.71%) among men and 4.13% (95% CI = 1.69%–6.71%) among women. Conclusions This study supports the role of the psychosocial work factors of the job strain model on all-cause mortality. Preventive intervention to improve the psychosocial work environment may help to prevent mortality in working populations.

An Intervention to Change Illness Representations and Self-Care of Individuals With Type 2 Diabetes: A Randomized Controlled Trial Objective Suboptimal self-care by individuals with diabetes mellitus (DM) is a significant public health concern. The common-sense model (CSM) proposes that illness representations are associated with coping and health outcomes across various conditions. The present study examined the efficacy of a CSM-based intervention in improving illness representations, self-care, self-care self-efficacy, use of adaptive coping strategies, and glycated hemoglobin among individuals with type 2 DM (T2DM). Methods A two-arm randomized controlled trial was used. A total of 455 T2DM patients were recruited from an outpatient DM clinic and randomized to an intervention group that consisted of five weekly group-based education sessions or a control group that received five weekly educational booklets. Evaluation was conducted at baseline and at 1- and 6-month follow-up. Results The 2 × 3 linear mixed-model analysis using a modified intention to treat revealed a significant time by condition interaction effect on level of self-care (F(2,840) = 7.78, p < .001), self-care self-efficacy (F(1.89,794.57) = 14.40, p < .001), and use of adaptive coping strategies (F(1.94,812.93) = 4.75, p = .010) in which participants in the intervention group reported greater improvement in such aspects compared with those in the control group. A significant time effect was observed in some dimensions of illness representations. No significant effect was found in glycated hemoglobin. Participants reported positive feedback to the intervention and perceived improvement in various domains. Conclusions The CSM-based intervention was effective in improving self-care and coping among DM patients. The intervention also demonstrated high feasibility and acceptability. Findings provided important insights in improving health-related outcomes for patients with T2DM using the CSM framework.

Longitudinal Course of Depressive, Anxiety, and Posttraumatic Stress Disorder Symptoms After Heart Surgery: A Meta-Analysis of 94 Studies Objective This study aimed to analyze the longitudinal course of depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms in patients with cardiac disease after heart surgery (HS). Methods We conducted a systematic review and random-effects meta-analysis of cohort studies in patients undergoing HS, measuring anxiety, depressive, and PTSD symptoms before and at least 30 days thereafter. Subgroup and meta-regression analyses, investigation of publication bias, and quality assessment were undertaken. Results We included 94 studies relating to 15,561 patients. HS included coronary artery bypass graft surgery, valve replacement, implantable cardioverter-defibrillator placement, left ventricular assist device placement, heart transplantation, and other types of HS. Across studies, symptoms of depression (g = 0.32; 95% confidence interval [CI] = 0.25 to 0.39; p < .001) and anxiety improved after HS (g = 0.52; 95% CI = 0.43 to 0.62; p < .001), whereas PTSD symptoms worsened (g = −0.42; 95% CI = −0.80 to −0.04; p = .032). The reduction of depression and anxiety levels was more pronounced for patients with underlying coronary artery disease and heart failure and persisted for 1 year after HS, whereas the increase in PTSD symptoms returned to baseline after 6 months. Depression improvement was inversely associated with older age, diabetes, hypertension, and dyslipidemia and positively with baseline heart failure. No additional clinical or demographic variables were associated with the course of anxiety symptoms. Quality of included studies was low overall. Publication bias was nonsignificant. Conclusions Depressive and anxiety symptoms improve for 1 year after HS, whereas PTSD symptoms might worsen. Older patients and those with metabolic comorbidities, valve disease, or ventricular arrhythmias are at higher risk for continued depressive and anxiety symptoms and should be monitored closely.

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Emerging Infectious Diseases

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Ophthalmic Science and Research

Editorial Sharmila Devi Vadivelu TNOA Journal of Ophthalmic Science and Research 2020 58(4):237-238

Dematiaceous fungal keratitis: Clinical and microbiologic experience Pratik Gajanan Kunde, V Anitha, R Meenakshi, SH Fathima TNOA Journal of Ophthalmic Science and Research 2020 58(4):239-244 Objective: The objective was to study the epidemiology, clinical features, and treatment outcomes of dematiaceous fungal keratitis. Design: This was a retrospective, noncomparative, observational study. Materials and Methods: Fifty-nine cases of dematiaceous fungal keratitis seen at tertiary care hospital from January 2017 to June 2018 were analyzed for demographic features, predisposing factors, clinical characteristics, microbiological profile, and treatment outcomes. Statistical Analysis: Mean (standard deviation) and frequency (percentage) were used to represent continuous and categorical variables, respectively. Wilcoxon signed rank test was used for comparative analysis. Results: Of 236 cases of fungal keratitis seen during the study period, dematiaceous fungi were the third most common isolates in 59 cases (25%) after Fusarium (n = 101; 43%) and Aspergillus species (n = 76; 32%). Majority of the patients were adult males (male: female = 2:1) from rural areas (51%) with agricultural occupation (51%). Trauma with vegetable matter was the most common predisposing factor in 27 cases (45.8%). The characteristic macroscopic pigmentation was seen in only eight eyes (13.6%). In our study, 24 (40.7%) patients revealed Curvularia species, followed by Bipolaris and Exserohilum species in 20 cases (33.9%) and 10 cases (17%), respectively. The median time of antifungal therapy was 21 days (interquartile range: 21–41 days). Fifty-four (91.5%) responded to medical therapy, whereas five eyes required surgical intervention. Conclusions: This study signifies the importance of dematiaceous fungi as the important causative agent of fungal keratitis. Medical therapy along with debridement of ulcer alone can be effective in treating patients with superficial infiltrate who seek treatment early.

Advanced keratoconus with very low pachymetry – Can contact lens avoid corneal surgery? Radhika Natarajan, Amrutha Mahalakshmi Anandan, Manokamna Agarwal TNOA Journal of Ophthalmic Science and Research 2020 58(4):245-248 Clinical relevance: Keratoconic eyes with low pachymetric values, precluding safe CXL can show significant improvement in vision with newer scleral Contact lenses(CL), which was not possible with older rigid CLs. Purpose: To describe diagnostic and management difficulties in keratoconic eyes with pachymetry too low for CXL (Collagen Cross linking)necessitating surgery for improving tensile strength, yet having significant improvement in vision with newer rigid contact lenses such that immediate keratoplasty can be deferred. Methods: Case records of 16 patients (20 eyes) were reviewed. All patients had advanced keratoconus with low pachymetric values but had significant improvement in vision with rigid CLs. CXL was not safely feasible in these eyes and immediate surgical treatment for tissue strengthening was deferred as they had good vision with newer rigid CLs. Patients were kept under close observation due to the risk of developing corneal hydrops. Results: Mean age was 25.68 years. Mean best-corrected visual acuity with glasses was 0.54logMAR, whereas, with rigid CLs was 0.18logMAR. Mean steep-keratometry (K) was 62.66D. Mean central pachymetry, highest posterior surface elevation, and pachymetry at thinnest location was 314.4, 119.6 and 313.61microns respectively. Mean follow-up was 4 years. Conclusion: Advanced keratoconic eyes may have pachymetric values too low for CXL, therefore needing keratoplasty for tissue strengthening and yet can have good vision with rigid CLs. Quantitative analysis of further progression of keratoconus in these eyes is difficult as imaging techniques become unreliable in advanced stages of the disease. Significant improvement in vision with newer rigid and scleral CLs makes the decision to operate, purely for tissue building, difficult.

Ocular myasthenia gravis: A case series Sandra C Ganesh, Amrutha Sindhu, Jogitha TNOA Journal of Ophthalmic Science and Research 2020 58(4):249-252 Aim: To report the clinical profile of patients with myasthenia gravis (MG) at a tertiary eye care center in Tamil Nadu. Material and Methods: This is a retrospective case series of patients in a single center between February 2019 and March 2020. Result: We present a series of five cases of ocular myasthenia in the pediatric age group (0–16 years), comprising three males and two females. The patients had varied presentations on the initial examination. Conclusion: It is important to differentiate MG from other diagnostic mimics such as neurological causes such as cranial nerve palsy, myopathies, ocular pathologies, and neuromuscular junction pathologies such as botulism and brainstem tumors. Diagnosis and treatment of myasthenia is done as a team effort of ophthalmologist and neurologist. This study is to reinforce a vigilant lookout for this great masquerader.

Preoperative and postoperative comparison of higher order aberrations in individuals 1 month after small incision lenticule extraction N V Arulmozhi Varman, Aadithreya Varman, Dinesh Balakumar TNOA Journal of Ophthalmic Science and Research 2020 58(4):253-257 Aim: This study analysed the visual outcomes of patients with myopia and myopic astigmatism following Small Incision Lenticule Extraction (SMILE). Visual outcomes were determined by Post-operative refraction, Uncorrected Visual Acuity and aberrometry estimated with iTrace aberrometer post operatively immediately and upto day 30. Results: On Post-Operative day 1, the spherocylinder group, attained an uncorrected visual acuity of 6/6. Materials and Methods: The final post-operative refraction in all cases was within ±0.25 diopters of sphere in 18 eyes and within ±0.50 diopters of sphere in 10 eyes. The aberrometry values recorded on iTrace at the end of 30 days revealed a decrease in the total higher order aberrations. Mean higher order aberration is significantly (P<0.05) reduced in the post-operative status Similarly the pure cylinder group attained uncorrected visual acuity of 6/6 in all eyes on POD 30, with a decrease in higher order aberrations. Mean higher order aberration is significantly (P<0.05) reduced in the post-operative status. The final post-operative refraction in all cases was within ±0.25 diopters of cylinder in 48 eyes, within ±0.50 diopters of cylinder in 16 eyes and within ±0.75 in 14 eyes. Conclusion: SMILE is a successful procedure in treatment of both myopic spherical and cylindrical refractive errors. The faster healing and flapless advantage along with lesser incidence of dry eyes has an edge over conventional laser vision corrective procedures. The other important advantage is the reduction of higher order aberrations and better quality of vision. To conclude SMILE is safe and effective procedure for correction of myopic refractive errors and is also beneficial in reducing higher order aberrations.

A retrospective study of patients with visual impairment: Its magnitude, causes, and acceptance of the low vision Aids in a tertiary eye care hospital Annamalai Odayappan, Tiruvengadakrishnan Nirmala Devi, Girish Velis, Priya Sivakumar, Sivagami Nachiappan TNOA Journal of Ophthalmic Science and Research 2020 58(4):258-261 Aim: The study aims to highlight the importance of a low vision clinic and give a profile of patients presenting to a low vision clinic at a tertiary eye care hospital. Materials and Methods: Design: Retrospective study. Setting: Institutional. Study population: Details of 9,601 patients who presented to our low vision clinic between January 2009 and June 2015 were analyzed from our database. Data obtained include age group, best-corrected visual acuity, cause of low vision, type of low vision aids (LVA) prescribed, acceptance of the device, and the provision of additional rehabilitation services. Statistical Analysis: Categorical variables were given in the frequency tables with percentages. Results: Around 70.7% of patients were found to have low vision and 29.3% were found to have blindness. We note that 65% of the patients were <40 years of age. The major causes of visual impairment were retinitis pigmentosa, macular degeneration, diabetic retinopathy, pathological myopia, optic atrophy, glaucoma, albinism, and congenital nystagmus. LVA was prescribed to 2689 individuals. The most commonly prescribed LVA were spectacle magnifiers, hand, and stand magnifiers. However, the acceptance rate was just 38%. The rest were given either standard spectacles or were referred to rehabilitation centers if the vision was very poor. Conclusion: There is a young population with visual impairment and highly under-utilized low vision services. Improving the acceptance rate of these devices would help enhance the individual's quality of life part of which could be done by reducing the cost of these devices.

Dexamethasone implant – An update Richa Pyare, Jyotirmay Biswas TNOA Journal of Ophthalmic Science and Research 2020 58(4):262-267 Uveitic entities may be infectious or noninfectious in etiology. Corticosteroids remain the first-line treatment for noninfectious posterior uveitis. Intravitreal injections of steroids have been useful in targeted therapy of the posterior segment. However, a host of systemic and local adverse effects limits the usefulness of steroids. Intravitreal implants of dexamethasone with sustained release of the drug over months are a more effective and safer option. Various formulations with varying dosage and lifespan such as retisert, ozurdex, and yutiq are available. Ozurdex has a very successful track record over numerous studies in treating posterior uveitis in adults and children. It is important to rule out infectious causes of uveitis before administering ozurdex. We can achieve optimal control of ocular inflammation with minimal systemic side effects when used judiciously.

Newer anti-vascular endothelial growth factor agents Priya Rasipuram Chandrasekaran TNOA Journal of Ophthalmic Science and Research 2020 58(4):268-273 Ocular angiogenesis is a major cause of ocular morbidity worldwide. Vascular endothelial growth factor (VEGF) is a critical regulator of angiogenesis and vascular permeability with diverse roles both during the development and adulthood. This is believed to be the most powerful mediator of angiogenesis leading to ischemia-induced neovascularization in the retinal and choroidal diseases. Anti-VEGF has revolutionized the treatment of such angiogenic and exudative diseases of the retina and choroid. This article gives a brief view of the newer anti-VEGF agents and their role in retinal diseases.

Current concepts in the management of cyclodialysis Vijayalakshmi A Senthilkumar, Sharmila Rajendrababu TNOA Journal of Ophthalmic Science and Research 2020 58(4):274-279 Cyclodialysis clefts are rare. The most common reason for presentation is blunt ocular trauma followed by various iatrogenic interventions. Although gonioscopy is the gold standard technique, diagnosis is particularly challenging, and various noninvasive techniques such as ultrasound biomicroscopy and the newer anterior segment swept-source optical coherence tomography have been found effective. The management of cyclodialysis clefts should be conservative initially followed by a variety of nonsurgical and surgical modalities to achieve closure. In this article, we report the most recent developments in the diagnosis and surgical and nonsurgical treatment strategies of cyclodialysis cleft. An extensive literature search was done using PubMed and Google Scholar with the search terms such as cyclodialysis cleft, ocular hypotony, hypotony maculopathy, cyclopexy, and cyclotamponade.

Myopia: Current concepts and review of literature Kirandeep Kaur, Bharat Gurnani, Veena Kannusamy TNOA Journal of Ophthalmic Science and Research 2020 58(4):280-287 Myopia is the most common cause of refractive error in children. It is the most common ocular disorder worldwide. Apart from genetic factors, age and environmental factors have also been found to be closely associated as predictors of myopia. A comprehensive literature search was on online platforms using terms Myopia review, onset, progression, treatment, control, updates, bifocals, Atropine, and Orthokeratology. All the relevant articles published in English in last 10 years were analyzed and included. Excessive near work and prolonged screen usage have been proven as definite risk factors apart from genetics. Role of Vitamin D and outdoor activities are still having a controversial stand. Myopia treatment has come a long way from glasses/contact lenses to advanced minimally invasive refractive procedures such as femtosecond-assisted procedures and small incision lenticule extraction. With tremendous improvement in technology and increased dependence on digital devices, control of myopia progression remains a big challenge. Use of bifocals, progressive glasses, rigid contact lenses, and soft bifocals lenses have been studied widely. These all measures seem to do well in initial years, but long-standing results are not encouraging. The results with low-dose atropine have been convincing, but long-term follow-up results are still awaited.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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