Comparison of the Astigmatic Power of Toric Intraocular Lenses Using Three Toric Calculators

Purpose

To compare the astigmatic power of toric intraocular lenses (IOLs) obtained from the AcrySof, TECNIS, and iTrace toric calculator in patients with preoperative with-the-rule (WTR) or against-the-rule (ATR) corneal astigmatism.

Materials and Methods

Fifty eyes with cataract and corneal astigmatism greater than 0.75 diopters were enrolled in each group (WTR and ATR). Keratometric values were measured using autokeratometry, an IOLMaster, and an iTrace, which incorporated corneal topography and ray-tracing aberrometry. Based on measured keratometric values, the astigmatic power of each toric IOL was calculated using three toric calculators.

Results

Bland-Altman plots showed good agreement between six pairwise corneal astigmatism values in both groups. The TECNIS calculator tended to suggest a higher astigmatic power of the toric IOL than the AcrySof calculator. With the higher astigmatism and keratometric values from the IOLMaster, in both groups, calculations from the AcrySof and TECNIS calculators resulted in higher calculated astigmatic powers than those from same calculators with autokeratometry-measured values, demonstrating good agreement. With the higher calculated astigmatic power values, the values from the iTrace toric calculator using keratometric values obtained from iTrace ray tracing wavefront aberrometry or iTrace simulated keratometry showed fair to moderate agreement with those from the other calculator-keratometry pairs in both groups.

Conclusion

To achieve the best refractive outcome after toric IOL implantation, understanding the differences in keratometric values between instruments and in calculated astigmatic power among toric calculator programs is necessary. Moreover, systemic analysis of each toric calculator in conjunction with postoperative data is required.     

A kinetic model for vessel-encoded dynamic angiography with arterial spin labeling

The ability to visualize blood flow in a vessel-selective manner is of importance in a range of cerebrovascular diseases. Conventional X-ray methods are invasive and carry risks to the patient. Recently, a noninvasive dynamic angiographic MRI-based technique has been proposed using vessel-encoded pseudocontinuous arterial spin labeling, yielding vessel-selective angiograms of the four main brain-feeding arteries. In this study, a novel kinetic model for the signal evolution in such acquisitions is derived and applied to healthy volunteers and to a patient with Moya-Moya disease. The model incorporates bolus dispersion, T(1) decay and radio frequency effects and is applicable to other angiographic methods based on continuous or pseudocontinuous arterial spin labeling. The model fits the data well in all subjects and yields parametric maps relating to blood volume, arrival time, and dispersion, changes to which may indicate disease. These maps are also used to generate synthesized images of blood inflow without bias from T(1) decay and radio frequency effects, greatly improving collateral vessel visibility in the patient with Moya-Moya disease. Relative volume flow rates in downstream vessels are also quantified, showing the relative importance of each feeding artery. This framework is likely to be of use in assessing collateral blood flow in patient groups.     

Insulin Infusion Computer Calculator Programmed Directly Into Electronic Health Record Medication Administration Record

Background:Computerized insulin infusion protocols have demonstrated higher staff satisfaction, better compliance with protocols, and increased time with glucose in range compared to paper protocols. At University of California San Diego Health (UCSDH), we implemented an insulin infusion computer calculator (IICC) and transitioned it from a web-based platform directly into the electronic medication administration record (eMAR) of our primary electronic health record (EHR).Methods:This is a retrospective analysis of 6306 adult patients at UCSDH receiving intravenous (IV) insulin infusion from March 7, 2013 to May 30, 2019. We created three periods of the study—(1) the pre-eMAR integration period; (2) the eMAR integration period; and (3) the post-eMAR integration period—and looked at the percentage of readings within goal range (90-150 mg/dL for intensive care unit [ICU], 90-180 mg/dL for non-ICU) in patients with and without hyperglycemic emergencies. As our safety endpoints, we elected to look at incidence of blood glucose (BG) readings <70 mg/dL, <54 mg/dL, and <40 mg/dL.Results:Pre-eMAR 69.8% of readings were in the 90-150 mg/dL range compared to 70.2% post-eMAR (P = .03) and 82.7% of readings were in the 90-180 mg/dL range pre-eMAR versus 82.9% (P = .09) post-eMAR in patients without hyperglycemic emergencies. Rates of hypoglycemia with BG <70 mg/dL were 0.43%, <54 mg/dL were 0.07%, and <40 mg/dL were 0.01% of readings pre- and post-eMAR.Conclusions:At UCSDH, our IICC has shown to be safe and effective in a wide variety of clinical situations and we were able to successfully transition it from a web-based platform directly into the eMAR of our primary EHR.     

Rheology and the swallow-safe bolus

Competence in swallowing depends on the physical nature of ingested food and drink, and a person's ability to form a “swallow-safe” bolus. Here is discussed the role of bolus consistency in swallowing, since this has been found to be an important characteristic in evaluation and feeding therapy of dysphagic persons. A basic review of rheology, the study of the deformation and flow of materials, is presented with an emphasis toward quantifying that property of consistency of a bolus that can be safely swallowed by a feeding-impaired person.     

The DURABLE Trial Study Design: Comparing the Safety, Efficacy, and Durability of Insulin Glargine to Insulin Lispro Mix 75/25 Added to Oral Antihyperglycemic Agents in Patients with Type 2 Diabetes

Background

While studies have compared the safety and efficacy of starter insulin regimens in type 2 diabetes, none have evaluated regimen durability (length of time a patient can maintain glycemic control) or the safety and efficacy of subsequent intensification regimens in a large, multinational cohort.

Methods

The DURABLE (Assessing the DURAbility of Basal vs Lispro Mix 75/25 Insulin Efficacy) trial will compare the ability of glargine once daily vs lispro mix 75/25 (75% insulin lispro protamine suspension, 25% lispro) twice daily added to oral antihyperglycemic agents to achieve and maintain hemoglobin A1c (HbA1c) goals. This randomized, open label, parallel study will enroll over 2000 insulin-naïve patients with type 2 diabetes from 11 countries, ages 30 to 80, with HbA1c >7.0% on at least two oral antihyperglycemic agents. At the completion of the 6-month initiation phase, safety and efficacy of the two regimens will be compared. Patients who achieve an HbA1c ≤7.0% at 6 months will continue into the 24-month maintenance phase to evaluate durability.In a substudy, patients not achieving HbA1c ≤7.0% at 6 months may be randomized to one of two intensification comparisons: patients previously on glargine will receive lispro mix 75/25 twice daily or basal/bolus therapy (glargine + thrice-daily mealtime lispro) and patients previously on lispro mix 75/25 will receive lispro mix 50/50 (50% insulin lispro protamine suspension, 50% lispro) thrice daily or basal/bolus therapy.

Results

Upon completion, this trial will provide new information about starter insulin durability, defined as the length of time patients can maintain HbA1c control (HbA1c ≤7.0%, or >7.0% but with an increase of <0.4% from the most recent HbA1c ≤7.0%). Additionally, the study will provide comparative data on HbA1c, blood glucose profiles, 1,5-anhydroglucitol, hypoglycemic episodes, weight change, and insulin dose for starter insulin regimens following 6 and 24 months of treatment, as well as intensified insulin via the 6-month substudy.

Conclusion

This trial aims to broaden clinicians'' understanding of the ability of starter insulin and insulin intensification regimens to achieve and maintain glycemic control in patients with type 2 diabetes.     

Abnormal solid bolus swallowing in the erect position

The routine use of solid boluses in the radiologic evaluation of the pharyngoesophagus has not been described in the literature. Because esophageal perforations have been reported as a result of delayed passage of caustic medications, this study was performed to determine the prevalence of solid bolus delay in a routine symptomatic radiologic population. Solid bolus erect swallowing was performed using either a 13 mm barium tablet or a 10 mm bagel bread sphere; occasionally, both were used. All individuals referred for an upper gastrointestinal (GI) examination or barium swallow who complained of dysphagia, heartburn, or chest pain were evaluated with a solid bolus. Any individual demonstrating gastroesophageal reflux, hiatal hernia, Schatzki's B ring, or esophageal motility disturbance was given a solid bolus as well. Individuals swallowing a sphere showed four times more frequent proximal pharyngoesophageal delay than tablet swallowers. The tablet arrested initially more frequently at both the aorta and lower esophageal sphincter than did the sphere. However, there was twice the total incidence of arrest of all swallowed spheres compared to tablets at the aorta. Approximately the same total number of spheres arrested at the lower esophageal sphincter as tablets. Any delay that allows a solid bolus to be overtaken in the erect position by the peristaltic contraction wave can be considered abnormal. The delays usually occur at anatomic narrowings. A sphere is more sensitive than a tablet in evaluating solid bolus pharyngoesophageal dysfunction in the erect position. Opinions and assertions contained herein are those of the authors and do not represent the official position of the U.S. Navy, Uniformed Services University of the Health Sciences or the Department of Defense.     

Prediction of prostate cancer risk: the role of prostate volume and digital rectal examination in the ERSPC risk calculators

Background

The European Randomized Study of Screening for Prostate Cancer (ERSPC) risk calculators (RCs) are validated tools for prostate cancer (PCa) risk assessment and include prostate volume (PV) data from transrectal ultrasound (TRUS).

Objective

Develop and validate an RC based on digital rectal examination (DRE) that circumvents the need for TRUS but still includes information on PV.

Design, setting, and participants

For development of the DRE-based RC, we studied the original ERSPC Rotterdam RC population including 3624 men (885 PCa cases) and 2896 men (547 PCa cases) detected at first and repeat screening 4 yr later, respectively. A validation cohort consisted of 322 men, screened in 2010-2011 as participants in ERSPC Rotterdam.

Measurements

Data on TRUS-assessed PV in the development cohorts were re-coded into three categories (25, 40, and 60 cm³) to assess the loss of information by categorization of volume information. New RCs including PSA, DRE, and PV categories (DRE-based RC) were developed for men with and without a previous negative biopsy to predict overall and clinically significant PCa (high-grade [HG] PCa) defined as T stage >T2b and/or Gleason score ≥7. Predictive accuracy was quantified by the area under the receiver operating curve. We compared performance with the Prostate Cancer Prevention Trial (PCPT) RC in the validation study.

Results and limitations

Areas under the curve (AUC) of prostate-specific antigen (PSA) alone, PSA and DRE, the DRE-based RC, and the original ERSPC RC to predict PCa at initial biopsy were 0.69, 0.73, 0.77, and 0.79, respectively. The corresponding AUCs for predicting HG PCa were higher (0.74, 0.82, 0.85, and 0.86). Similar results were seen in men previously biopsied and in the validation cohort. The DRE-based RC outperformed the PCPT RC (AUC 0.69 vs 0.59; p = 0.0001) and a model based on PSA and DRE only (AUC 0.69 vs 0.63; p = 0.0075) in the relatively small validation cohort. Further validation is required.

Conclusions

An RC should contain volume estimates based either on TRUS or DRE. Replacing TRUS measurements by DRE estimates may enhance implementation in the daily practice of urologists and general practitioners.     

Importance of Manually Entering Blood Glucose Readings When Wireless-Compatible Meters Are Not Being Used with an Insulin Pump

Background:

The objective was to determine if there were differences in blood glucose monitoring (BGM) data downloaded from insulin pumps of patients who use meters that wirelessly transmit data to their insulin pumps (i.e., wireless group) and those who do not (i.e., nonwireless group).

Methods:

Blood glucose monitoring data were downloaded from the meters and insulin pumps of 47 children and adolescents with type 1 diabetes mellitus. Independent and paired t tests compared BGM data downloaded from meters and BGM data downloaded from insulin pumps.

Results:

There were significant differences in BGM data downloaded from the insulin pumps of patients using wireless meters compared to those using nonwireless meters. Wireless patients appeared to engage in more BGM, had more low and in-range BG readings and fewer very high BG readingss than nonwireless patients. However, a comparison of BGM data downloaded from meters and insulin pumps of nonwireless patients indicated that their insulin pump data significantly underestimated the number of BGM readings conducted, as well as the number of low and in-range readings, while overestimating the number of very high BGM readings.

Conclusions:

Because patients who use nonwireless-compatible meters do not manually enter their low and in-range BGM readings into the insulin pump, BGM data downloaded only from pumps may provide an incomplete representation of BGM frequency or results. It is recommended that patients use meters that directly communicate with pumps or perform bolus calculations. Patients should be educated about the importance of manually entering all BGM readings if they do not use a wireless-compatible meter with their insulin pump.