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"Shah, Chirag"
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Aflibercept for exudative AMD with persistent fluid on ranibizumab and/or bevacizumab
Objective To investigate the effect of aflibercept 2.0 mg in cases resistant to ranibizumab 0.5 mg and/or bevacizumab 1.25 mg treatment. Purpose To evaluate the anatomic and visual effect of intravitreal aflibercept 2.0 mg in cases of exudative age-related macular degeneration (AMD) with persistent fluid on optical coherence tomography (OCT) despite regular ranibizumab 0.5 mg and/or bevacizumab 1.25 mg treatment at 1 and 6 months. Methods Retrospective review at Ophthalmic Consultants of Boston, Boston, Massachusetts, USA of exudative AMD cases with persistent fluid on regular ranibizumab 0.5 mg and/or bevacizumab 1.25 mg treatment switched to intravitreal aflibercept 2.0 mg treatment and followed for 6 months. Tabulated data included details of prior treatments, best available visual acuity, central subfoveal thickness on registered spectral domain OCT before and after aflibercept injection centred on the anatomic fovea and macular description before and after aflibercept injection. Results A total of 353 eyes with exudative AMD were switched to aflibercept during the study period. Of these, 28 eyes in 28 patients had persistent fluid after an average of 20 regular ranibizumab/bevacizumab injections (range 7–37). At 1 month, 89% (25 eyes) showed anatomic improvement and 18% (five eyes) were dry after a single aflibercept injection. Central subfoveal thickness improved from 295 to 272 microns (p<0.001) after one aflibercept injection. After an average of 4.4 aflibercept injections (range 3–6) over 6 months, the central subfoveal thickness remained improved (274 microns, p=0.008); 64% (18 eyes) showed anatomic improvement and a quarter of eyes (25%, seven eyes) were dry. Visual acuity did not improve at 1 month (logarithm of minimum angle of resolution (logMAR) 0.54, Snellen 20/69, p=0.64) or 6 months (logMAR 0.57, Snellen 20/76, p=0.49). Treatment was well tolerated with no adverse events reported. Conclusions A significant proportion of exudative AMD cases with persistent fluid on OCT despite regular ranibizumab 0.5 mg and/or bevacizumab 1.25 mg treatment respond anatomically to aflibercept 2.0 mg. Visual acuity did not improve. Aflibercept may be beneficial anatomically in cases of exudative AMD treated with persistent fluid on ranibizumab and/or bevacizumab.
Journal Article
Beyond enhanced recovery after surgery (ERAS): Evolving minimally invasive colectomy from multi-day admissions to same-day discharge
Early discharge is increasingly important in the resource-limited COVID era. Some groups have reported early experiences with same day discharge (SDD) after colectomy. We implemented a routine SDD protocol and report the evolution in our program's outcomes.
We studied a retrospective cohort of robotic colorectal surgeries from 2016 to 2022. Colectomies were analyzed as a sub-group and stratified by year.
The cohort comprised 535 cases, of which 483 were colectomies. Annual case volume increased from 58 to 180 cases (p < 0.001). Operative console time concordantly decreased by 33% (p < 0.001). Average length of stay decreased from five to one days. By 2022, 58% of colectomies were selectively discharged on the same day of surgery. Complication and readmission rates remained constant.
SDD is feasible and safe in selected patients. We illustrate the practical evolution of a surgical practice toward routine SDD, and discuss the factors we found critical to this transition.
•Despite advances of ERAS, colectomy still usually demands 1–2 day inpatient stay.•Early, limited data exists on same-day-discharge (SDD) after colectomy.•We analyze longitudinal outcomes after starting routine SDD during the era.•In the last year, over half of patients underwent SDD successfully.•Multi-disciplinary pathways and advanced robotic surgical techniques were crucial.
Journal Article
Eye-Opener: A Case Report of Eyelid Taping as Presenting Symptom of Myasthenia Gravis
Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction that can cause various symptoms provoking a visit to the emergency department (ED). In this case, we present a 54-year-old female who reported having her eyes \"taped open\" for the last two months. Her history and physical exam findings in the ED raised suspicion for MG. The patient was subsequently admitted and started on pyridostigmine. An elevated acetylcholinesterase receptor-binding antibody level confirmed the diagnosis of MG. This case report highlights the characteristic progressive weakness of facial muscles in MG, emphasizing the importance of early recognition of MG symptoms by emergency clinicians in order to initiate appropriate management and prevent respiratory compromise and morbidity.
Neurology, neurologic exam, myasthenia gravis, emergency medicine.
Journal Article
Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer-related lymphedema
Background
This analysis was performed to assess the impact of early intervention following prospective surveillance using bioimpedance spectroscopy (BIS) to detect and manage breast cancer-related lymphedema (BCRL).
Methods
From 8/2010 to 12/2016, 206 consecutive patients were evaluated with BIS. The protocol included pre-operative assessment with L-Dex as well as post-operative assessments at regular intervals. Patients with L-Dex scores >10 from baseline were considered to have subclinical BCRL and were treated with over-the-counter (OTC) compression sleeve for 4 weeks. High-risk patients were defined as undergoing axillary lymph node dissection (ALND), receiving regional nodal irradiation (RNI), or taxane chemotherapy. Chronic BCRL was defined as the need for complex decongestive physiotherapy (CDP).
Results
Median follow-up was 25.9 months. Overall, 17% of patients had one high-risk feature, 8% two, and 7% had three. 9.8% of patients were diagnosed with subclinical BCRL with highest rates seen following ALND (23 vs. 7%,
p
= 0.01). Development of subclinical BCRL was associated with ALND and receipt of RNI. At last follow-up, no patients (0%) developed chronic, clinically detectable, BCRL. Subset analysis was performed of the 30 patients undergoing ALND. Median number of nodes removed was 18 and median number of positive nodes was 2. 77% received taxane chemotherapy, 62% axillary RT, and 48% had elevated BMI. Overall, 86% of patients had at least one additional high-risk feature, 70% at least two, and 23% had all three. Seven patients (23%) had abnormally elevated L-Dex scores at some point during follow-up. To date, none has required CDP.
Conclusions
The results of this study support prospective surveillance utilizing BIS initiated pre-operatively with subsequent post-operative follow-up measurements for the detection of subclinical BCRL. Intervention triggered by subclinical BCRL detection with an elevated L-Dex score was associated with no cases progressing to chronic, clinically detectable BCRL even in very high-risk patients.
Journal Article
Incidence and clinical features of post-injection endophthalmitis according to diagnosis
PurposeTo compare the incidence and clinical features of endophthalmitis after intravitreal antivascular endothelial growth factor (VEGF) therapy for diabetic eye disease, neovascular age-related macular degeneration (AMD) and retinal vein occlusion (RVO).MethodsMulticentre, retrospective, consecutive case–control study. All patients treated with intravitreal bevacizumab, ranibizumab or aflibercept for diabetic eye disease, neovascular AMD or RVO between 1 January 2009 and 30 September 2013 at three retina practices were included in this study. The total number of anti-VEGF injections administered for the three indications was calculated using billing records. Endophthalmitis cases were identified using both endophthalmitis log sheets and billing records. Patient charts were reviewed to confirm that endophthalmitis was directly related to anti-VEGF injection and to record clinical features and culture results.ResultsDuring the study period, a total of 353 978 intravitreal anti-VEGF injections were performed. Presumed infectious endophthalmitis occurred in 119 of 296 017 injections performed for neovascular AMD (1/2487, 0.040%), 12 of 24 541 for diabetic eye disease (1/2045, 0.049%) and 4 of 32 418 for RVO (1/8104, 0.012%). χ2 analysis found endophthalmitis rates to be higher in diabetic eye disease compared with RVO (p=0.010) and higher in neovascular AMD compared with RVO (p=0.014), while diabetic eye disease and neovascular AMD (p=0.517) had similar rates. The average age of the overall neovascular AMD patient population (81.9 years) was significantly older than the diabetic eye disease (64.7 years, p<0.001) and RVO (73.4 years, p<0.001) populations.ConclusionsEndophthalmitis rates appear to be lower in eyes with RVO compared with diabetic eye disease and neovascular AMD, possibly due to impaired immunity in diabetics and waning immunity in the generally older AMD population.
Journal Article
Initial development and testing of an exhaled microRNA detection strategy for lung cancer case–control discrimination
For detecting field carcinogenesis non-invasively, early technical development and case–control testing of exhaled breath condensate microRNAs was performed. In design, human lung tissue microRNA-seq discovery was reconciled with TCGA and published tumor-discriminant microRNAs, yielding a panel of 24 upregulated microRNAs. The airway origin of exhaled microRNAs was topographically “fingerprinted”, using paired EBC, upper and lower airway donor sample sets. A clinic-based case–control study (166 NSCLC cases, 185 controls) was interrogated with the microRNA panel by qualitative RT-PCR. Data were analyzed by logistic regression (LR), and by random-forest (RF) models. Feasibility testing of exhaled microRNA detection, including optimized whole EBC extraction, and RT and qualitative PCR method evaluation, was performed. For sensitivity in this low template setting, intercalating dye-based URT-PCR was superior to fluorescent probe-based PCR (TaqMan). In application, adjusted logistic regression models identified exhaled miR-21, 33b, 212 as overall case–control discriminant. RF analysis of combined clinical + microRNA models showed modest added discrimination capacity (1.1–2.5%) beyond clinical models alone: all subjects 1.1% (
p
= 8.7e−04)); former smokers 2.5% (
p
= 3.6e−05); early stage 1.2% (
p
= 9.0e−03), yielding combined ROC AUC ranging from 0.74 to 0.83. We conclude that exhaled microRNAs are qualitatively measureable, reflect in part lower airway signatures; and when further refined/quantitated, can potentially help to improve lung cancer risk assessment.
Journal Article
The impact of early detection and intervention of breast cancer‐related lymphedema: a systematic review
Breast cancer‐related lymphedema (BCRL) has become an increasingly important clinical issue as noted by the recent update of the 2015 NCCN breast cancer guidelines which recommends to “educate, monitor, and refer for lymphedema management.” The purpose of this review was to examine the literature regarding early detection and management of BCRL in order to (1) better characterize the benefit of proactive surveillance and intervention, (2) clarify the optimal monitoring techniques, and (3) help better define patient groups most likely to benefit from surveillance programs. A Medline search was conducted for the years 1992–2015 to identify articles addressing early detection and management of BCRL. After an initial search, 127 articles were identified, with 13 of these studies focused on early intervention (three randomized (level of evidence 1), four prospective (level of evidence 2–3), six retrospective trials (level of evidence 4)). Data from two, small (n = 185 cases), randomized trials with limited follow‐up demonstrated a benefit to early intervention (physiotherapy, manual lymphatic drainage) with regard to reducing the rate of chronic BCRL (>50% reduction) with two additional studies underway (n = 1280). These findings were confirmed by larger prospective and retrospective series. Several studies were identified that demonstrate that newer diagnostic modalities (bioimpedance spectroscopy, perometry) have increased sensitivity allowing for the earlier detection of BCRL. Current data support the development of surveillance programs geared toward the early detection and management of BCRL in part due to newer, more sensitive diagnostic modalities. Increasing data supports the role of early detection and treatment of breast cancer‐related lymphedema. New diagnostic modalities have increased sensitivity allowing for the earlier detection of lymphedema.
Journal Article