Grayson W. Armstrong

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY TO ASSESS PIGMENT EPITHELIAL DETACHMENT.

Retinal pigment epithelial detachment (PED) is the anatomical separation of the retinal pigment epithelium (RPE) from the underlying Bruch membrane. Retinal PEDs are most commonly associated with age-related macular degeneration (AMD), but are also seen in other retinal disorders, such as central serous chorioretinopathy, neoplastic, inflammatory, or iatrogenic conditions. In AMD, PED can be categorized into drusenoid, serous, vascularized, or mixed categories; however, multiple PED types may be found in the same patient. Drusenoid and serous PEDs are primarily a feature of nonneovascular AMD. In contrast, sub-RPE (Type 1) choroidal neovascularization (CNV) is associated with vascularized PEDs and is most commonly correlated with neovascular (wet) AMD. Early diagnosis and treatment of CNV is crucial to ensure superior visual outcomes. Therefore, it is important to be able to differentiate between various types of PED because their natural history, prognosis, and treatment options differ. Fluorescein angiography (FA) is the current gold standard for diagnosing and assessing PEDs. However, FA is invasive, time consuming, provides only a two-dimensional image, and has a minimal but significant risk profile that includes nausea, allergy, and, rarely, anaphylaxis. Although other imaging modalities such as indocyanine green angiography (ICGA), fundus autofluorescence, and spectral domain optical coherence tomography (SD-OCT) are useful in identifying specific characteristic findings of various types of PEDs, all modalities have unique limitations and drawbacks. Given the complex variety of clinical appearances and imaging characteristics of PEDs in AMD and other retinal disorders, it is often necessary to use multimodal imaging to assess PEDs. Optical coherence tomography angiography (OCTA) is a noninvasive, depth-resolved, non–dye-based, and rapid technique for visualizing retinal and choroidal vasculature and various planes of retinal tissues. It is capable of providing en face, detailed, threedimensional images of PEDs and CNV. The purpose of this study was to visualize, assess, and describe the spectrum of retinal findings associated with various types of PEDs through the use of OCTA without the need for invasive dyes.

Assessment of Tobacco Habits, Attitudes, and Education Among Medical Students in the United States and Italy: A Cross-sectional Survey

Objectives Medical students represent a primary target for tobacco cessation training. This study assessed the prevalence of medical students’ tobacco use, attitudes, clinical skills, and tobacco-related curricula in two countries, the US and Italy, with known baseline disparities in hopes of identifying potential corrective interventions. Methods From September to December 2013, medical students enrolled at the University of Bologna and at Brown University were recruited via email to answer survey questions assessing the prevalence of medical students’ tobacco use, attitudes and clinical skills related to patients’ smoking, and elements of medical school curricula related to tobacco use. Results Of the 449 medical students enrolled at Brown and the 1426 enrolled at Bologna, 174 Brown students (38.7%) and 527 Bologna students (36.9%) participated in this study. Italian students were more likely to smoke (29.5% vs. 6.1%; p<0.001) and less likely to receive smoking cessation training (9.4% vs. 80.3%; p<0.001) than their American counterparts, even though the majority of students in both countries desired smoking cessation training (98.6% at Brown, 85.4% at Bologna; p<0.001). Additionally, negative beliefs regarding tobacco usage, the absence of formal training in smoking cessation counseling, and a negative interest in receiving specific training on smoking cessation were associated with a higher risk of not investigating a patient’s smoking status during a routine history and not offering tobacco cessation treatment to patients. Conclusions Medical curricula on tobacco-related health hazards and on smoking cessation should be mandatory in order to reduce smoking among medical students, physicians, and patients, thereby improving tobacco-related global health.

Vulnerable Populations in the Underuse of the US Health Care System by Persons With Diabetes Mellitus and Diabetic Macular Edema

Vulnerable Populations in the Underuse of the US Health Care Systemby PersonsWith Diabetes Mellitus andDiabeticMacular Edema To the Editor We read with great interest the recent article by Bressler et al1 describing the current state of diabetic eye care in the United States. The lack of clinical eye care being provided to patients with diabetes mellitus is both alarming and concerning, especially in light of advances in visionpreserving treatment for diabetic macular edema (DME). Diabetes, amongother chronicdiseases, is increasingat an alarming rate in the United States. Ample evidence demonstrates thatwithin theUnitedStates and internationally,more than 40% of cases (sometimes as many as 70%) may go undiagnosed.2Theproblemofunderdiagnosis isgreaterwithin socioeconomicallydeprivedandethnicminoritygroups.3Given the case definition in this article (self-reported diabetes from theNationalHealthandNutritionExaminationSurveysample), it is likely that a substantialnumberof cases in the samplehave beenoverlooked.The scaleofunderscreeningandundertreatment of DMEmay be even greater than we think. The data from Bressler and colleagues’ study suggest a greater relative proportion of ethnic minorities and populations with lower socioeconomic status among the diabetic groups with diabetic retinopathy (DR) and DME.1 Patients of lower socioeconomic status have previously been shown to have reduced access to vision-preserving services.3 Thismay explain, at least in part, the increased relative prevalence of DR and DME among these vulnerable groups. The Patient Protection and Affordable Care Act and Medicaid expansion in many states may help alleviate this access issue. The Patient Protection and Affordable Care Act mandates zerocost diabetic screenings to patients, reducing financial barriers to diagnosis. Additionally, new quality initiatives may push clinicians to optimize visual outcomes among diabetic patients. Thepercentage of patientswithDRandDME in this study whowere told byphysicians that theyhad retinopathy is startlingly low. New and innovative strategies, alongwith proper education of both patients and physicians, must be adopted to ensure timely diagnosis and effective management of DR andDME to prevent long-term visual complications of diabetes. Previous studieshave successfullyuseddemographic factors to predict patients at risk for not attending DR screening visits with health care professionals.4 While this important study estimates the current undertreatment of DME, ongoing health care reform in the United Statesandtheanticipatedchanges incoverage for themostvulnerablepopulationsnecessitate reassessmentof access to care aswell as outcomes of screening and treatment following full implementationof thePatient Protection andAffordableCare Act. We eagerly anticipate the results of these studies.

Fostering reflective capacity with interactive reflective writing in medical education: Using formal analytic frameworks to guide formative feedback to students' reflective writing.

As learner (GWA) and educator (HSW) engaging in interactive reflective writing (IRW) for fostering reflective capacity (RC), we read Song & Stewart’s ‘‘Reflective writing (RW) in medical education’’ (2012) with interest. We concur with teaching reflection (with IRW) as a ‘‘clinically relevant skill’’ for ‘‘medical and humanistic effectiveness’’. We however note negative references to student perceptions of RW and to rubrics applied to ‘‘reflectiveness of student writing’’ which ‘‘would likely confer a significant burden of time and energy on faculty’’. In this regard, we express concern with their omitting salient developments within RW curricula potentially contributing to ‘‘buy-in’’ for such pedagogy (learners/faculty). These include user-friendly formal analytic frameworks (Wald et al, 2010, Reis et al, 2010, Wald et al, 2012) for feedback consistency/ effectiveness, i.e. guiding faculty in crafting quality individualized written feedback to RW (hence ‘‘IRW’’) fostering RC, ‘‘priming’’ participants with student/faculty IRW manuals, and training facilitators for effective small group collaborative feedback to narratives – all geared toward promoting a more in-depth reflective process. Feedback from interprofessional faculty development workshops I (HSW) have conducted on formative feedback to RW using a ‘‘cognitive schema’’ of such frameworks as well as from learners on formative feedback to RW has been positive. Quality formative feedback to learners’ RW can guide ‘‘thinking about thinking’’ rather than the authors’ concern regarding ‘‘to try to manage and prescribe the way students think’’. From a personal perspective (GWA), reflecting upon clinical experience with RW (about successful smoking cessation patient counseling over multiple medical visits) served as a nidus for a broader shift in my perspective on personal/professional satisfaction as a medical professional. Through RW, I realized I was beginning to draw satisfaction from patient interactions instead of purely from successful medical treatment/patient outcomes. The act of RW, its use as springboard to collaborative peer reflection in small group (facilitated with personalized feedback – HSW) and gaining further insights through written feedback helped me explore my response to this clinical encounter, challenge preconceptions, and appreciate the value of adding peer perspectives to my own reflective process, skills I plan on utilizing in the future. IRW exercises reinforced my belief in the value of selfreflection in medical practice. Educators and learners are challenged to foster using a reflective skills ‘‘toolkit’’ with technical skills for reflective professionalism within clinical encounters (in clerkships and beyond) for competent and compassionate patient-centered health care. Effective implementation of IRW as a vehicle for fostering RC through evaluation/interpretation of clinical experience, we assert, can help meet this challenge.

Fundus autofluorescence imaging in hereditary ATTR amyloidosis with ocular involvement

Abstract Fundus autofluorescence (AF) is a non-invasive technique for the evaluation of intrinsic autofluorescence of the tissues within the eye. In recent years, autofluorescence has become an important diagnostic tool for the assessment of various ocular diseases. A previous study has found that ex vivo Aβ amyloid plaques in the retina of a transgenic mouse model appear hyper-autofluorescent (hyper-AF) under specific wavelengths (excitation at 830 nm, emission at 630). We report the first description of hyper-AF ocular findings in a case of transthyretin-related familial amyloid polyneuropathy (FAP) associated with ocular involvement using AF imaging. A 47-year-old woman from Italy presented to our institution with a history of early onset FAP with ocular involvement due to the rare amyloidogenic transthyretin Glu54Lys mutation. AF imaging showed hyper-AF amyloid deposits associated with retinal vessels in both eyes and a hyper-AF amyloid deposit anterior to the optic disk in the right eye. Conclusion and Relevance: Further studies in FAP patients with different types of genetic mutations and various disease-stages are needed to better establish if non-invasive AF imaging is useful in detecting ocular amyloidosis.

Health Policy in Medical Education: A Renewed Look at a Timely and Achievable Imperative.

American Medical Colleges’ Graduation Questionnaire. This source of data has been used for many previous studies including our prior evaluation of perceptions relating to health policy. In this study, our analyses were conducted at the individual level and adjusted for student characteristics, student preferences, and medical school characteristics. Among health policy components, 11 of 13 had statistically significant changes. These findings are unlikely to occur by chance and more likely to reflect actual changes in perceptions. I do agree that the reason for these changes in perceptions is unclear. In fact, we stated in our innovation report that these findings could reflect changes in medical curricula, individual efforts by students to obtain new knowledge, or influence from mass media.

Motor Vehicle Crash-Associated Eye Injuries Presenting to U.S. Emergency Departments

Introduction Motor vehicle crashes (MVCs) are a leading cause of injury in the United States (U.S.). Detailed knowledge of MVC eye injuries presenting to U.S. emergency departments (ED) will aid clinicians in diagnosis and management. The objective of the study was to describe the incidence, risk factors, and characteristics of non-fatal motor vehicle crash-associated eye injuries presenting to U.S. EDs from 2001 to 2008. Methods Retrospective cross-sectional study using the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) from 2001 to 2008 to assess the risk of presenting to an ED with a MVC-associated eye injury in relation to specific occupant characteristics, including age, gender, race/ethnicity, disposition, and occupant (driver/passenger) status. Results From 2001 to 2008, an estimated 75,028 MVC-associated eye injuries presented to U.S. EDs. The annual rate of ED-treated eye injuries resulting from MVCs declined during this study period. Males accounted for 59.6% of eye injuries (95% confidence interval [CI] 56.2%–63.0%). Rates of eye injury were highest among 15–19 year olds (5.8/10,000 people; CI 4.3–6.0/10,000) and among African Americans (4.5/10,000 people; CI 2.0–7.1/10,000). Drivers of motor vehicles accounted for 62.2% (CI 58.3%–66.1%) of ED-treated MVC eye injuries when occupant status was known. Contusion/Abrasion was the most common diagnosis (61.5%; CI 56.5%–66.4%). Among licensed U.S. drivers, 16–24 year olds had the highest risk (3.7/10,000 licensed drivers; CI 2.6–4.8/10,000). Conclusion This study reports a decline in the annual incidence of ED-treated MVC-associated eye injuries. The risk of MVC eye injury is greatest among males, 15 to 19 year olds and African Americans.

Eye Injuries in Elderly Adults Presenting to U.S. Emergency Departments

the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This study was funded by a pilot grant from the University of Pennsylvania Minority Aging Research for Community Health Center (National Institute on Aging P30AG031043). Author Contributions: Mark D. Neuman: obtaining funding; study concept and design; acquisition, analysis, and interpretation of data; writing first draft of manuscript; critical revision of manuscript; final approval of submitted manuscript. Said A. Ibrahim: obtaining funding, study concept and design, analysis and interpretation of data, critical revision of manuscript, final approval of submitted manuscript. Frances A. Barg: study design, analysis and interpretation of data, critical revision of manuscript, final approval of submitted manuscript. Chidimma Osigwe: acquisition and analysis of data, critical revision of manuscript, final approval of the submitted manuscript. Jason H. Karlawish: obtaining funding, study concept and design, interpretation of data, critical revision of manuscript, final approval of submitted manuscript. Sponsor’s Role: The study sponsor had no role in design, methods, subject recruitment, data collections, analysis, or preparation of the paper.

Physicians and political advocacy.

Physicians may involve themselves in political advocacy as long as it does not damage patient relationships or erode access to health care. They may, in fact, have an obligation to do so.

Enhanced Depth Imaging Optical Coherence Tomography of Posterior Globe Rupture

Occult globe rupture is a rare but potentially devastating result of eye trauma. The authors present a case of a woman who sustained blunt trauma to the right eye resulting in a peripapillary circumferential posterior globe rupture. Clinically, the eye maintained good vision and normal intraocular pressure with a clear media, though subretinal fluid and retinal hemorrhage were present overlying the scleral defect. Enhanced depth imaging spectral-domain optical coherence tomography (EDI SD-OCT) revealed a sharp step-off of the sclera, choroid, and Bruchs membrane/retinal pigment epithelium, with overlying intact and contiguous inner retina, corresponding to a posterior globe rupture. Following conservative management, the subretinal fluid resolved and visual acuity improved to 20/20 over a month period, whereas the posterior globe step-off remained stable. This case demonstrates the potential for occult open globe injuries with preserved visual function in cases of blunt ocular trauma, and the first to document EDI SD-OCT findings of a posterior globe rupture. Multimodal imaging may help in the evaluation and diagnosis of suspected posterior segment globe rupture. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e171-e172.].