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Context: Beliefs about the safety and effectiveness of current anesthetics have resulted in many newborns being circumcised without the benefit of anesthesia.Objective: To compare ring block, dorsal penile nerve block, a topical eutectic mixture of local anesthetics (EMLA), and topical placebo when used for neonatal circumcision. The placebo represented current practice, with no anesthetic for neonatal circumcision.Design: A randomized controlled trial.Setting: Antenatal units in 2 tertiary care hospitals in Edmonton, Alberta.Participants: A consecutive sample of 52 healthy, full-term, male newborns, aged 1 to 3 days.Interventions: Physiological and behavioral monitoring occurred in a series of trials: baseline, drug application, preparation, circumcision, and postcircumcision. Surgical procedures defined the following 4 stages of the circumcision: cleansing, separation, clamp on, and clamp off. Methemoglobin level was assessed 6 hours after surgery.Main Outcome Measures: Heart rate, cry, and methemoglobin level.Results: Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high-pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). The 3 treatment groups all had significantly less crying and lower heart rates during and following circumcision compared with the untreated group. The ring block was equally effective through all stages of the circumcision, whereas the dorsal penile nerve block and EMLA were not effective during foreskin separation and incision. Methemoglobin levels were highest in the EMLA group, although no newborn required treatment.Conclusions: The most effective anesthetic is the ring block; EMLA is the least effective. It is our recommendation that an anesthetic should be administered to newborns prior to undergoing circumcision. [ABSTRACT FROM AUTHOR]

Safia A Nazarali, Steven A Narod Women's College Research Institute, Women's College Hospital, and The University of Toronto, Toronto, Ontario, Canada Abstract: Tamoxifen has been used as a treatment for women who have been diagnosed with breast cancer for roughly four decades and has been approved as chemoprevention for over ten years. Although tamoxifen has been proven to be beneficial in preventing breast cancer in high-risk women, its use has not been widely embraced. To some extent, this is due to several of its side effects, including an increased risk of endometrial cancer and pulmonary embolism, but these serious side effects are rare. The risks and benefits of tamoxifen chemoprevention should be considered for each patient. Keywords: tamoxifen, breast cancer, women, chemoprevention

Objective: This study aimed to evaluate the long-term graft survivability of locally prestripped versus imported prestripped Descemet membrane endothelial keratoplasty (DMEK) grafts in Edmonton., Design: Prospective cohort study of patients who underwent DMEK surgery between January 1, 2020, and December 31, 2020., Participants: All patients receiving a DMEK transplant during the study period in Edmonton., Methods: Two local technicians were trained to prestrip DMEK grafts in Edmonton. When available, local tissue was prestripped for DMEK surgery; otherwise, prestripped DMEK grafts were imported from an accredited American eye bank. Patient characteristics and DMEK graft characteristics and DMEK survivability were evaluated and compared between the 2 groups., Results: Thirty-two locally prestripped DMEK grafts and 35 imported prestripped DMEK grafts were used during the study period. Donor cornea characteristics and patient characteristics were similar between the 2 groups. Best-corrected visual acuity improved up to 6 months postoperatively and was 0.2 logMAR in the locally prestripped DMEK group and 0.2 logMAR in the imported DMEK group (p = 0.56). Rebubble rates were 25% in the locally prestripped DMEK group and 19% in the imported DMEK group (p = 0.43). There was 1 primary graft failure in each group (p = 0.93). Endothelial cell density decreased by 37% in the locally prestripped DMEK group and by 33% in the imported DMEK group 2 years after transplantation., Conclusions: The long-term survivability of locally prepared DMEK grafts is comparable with that of DMEK grafts imported from American eye banks., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: Intravitreal injections (IVIs) are the most frequently performed intraocular procedure in Canada. Povidone-iodine (PI) is the current gold standard for antisepsis for IVI and is widely used; chlorhexidine (CH) is a possible alternative antiseptic agent. This study aims to compare rates of endophthalmitis after IVI with 0.05% chlorhexidine with a 4% alcohol base antisepsis to rates of endophthalmitis after IVI with 10% PI antisepsis., Design: Retrospective cohort study., Subjects: Eyes that received IVI between May 2019 and October 2022 at a group retina practice in Edmonton, Canada., Methods: Eyes at a single center received focal conjunctival application of either 10% PI antisepsis or 0.05% CH in 4% alcohol antisepsis for 30 seconds before each IVI., Main Outcome Measure: Rates of endophthalmitis between the PI and CH groups., Results: A total of 170 952 IVIs were performed during the study period. A total of 31 135 were performed using CH prophylaxis compared with 139 817 with PI prophylaxis. Among all IVIs there were 49 total cases of endophthalmitis, 29 in the PI group (0.021%) and 20 in the CH group (0.064%). There was a statistically significant difference in the rates of endophthalmitis between the 2 groups (P < 0.001). The odds ratio for developing endophthalmitis with CH antisepsis was 3.1 (95% confidence interval, 1.9-5.2) compared with PI antisepsis. There were increased odds of developing endophthalmitis with aflibercept injection compared with bevacizumab (odds ratio, 3.48; 95% confidence interval, 2.09-7.24)., Conclusions: There is a statistically significant difference in rates of endophthalmitis between alcohol-based CH and PI antisepsis for IVI in our patient population utilizing the methods discussed. In our center, alcohol-based CH is now considered a second-line antiseptic agent. Further studies are warranted to further assess the endophthalmitis rate utilizing these 2 antiseptic agents., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Non-melanoma skin cancer (NMSC), which includes both Bowen's disease (BD) and superficial basal cell carcinoma (sBCC), is the most commonly diagnosed cancer in Canada. BD and sBCC are amenable to minimally invasive treatments however, large-scale studies assessing long-term outcomes are lacking, particularly regarding the timing and duration of non-invasive combination treatments., Objective: Examine the clinical cure rate of BD and sBCC using a combination treatment consisting of a single cycle of cryotherapy followed by a three to four-week course of topical 5-fluorouracil (5-FU)., Methods: Retrospective chart review at a single center. Inclusion criteria included histology-proven sBCC or BD treated with either a combination protocol, cryosurgery, or 5-FU alone., Results: 310 biopsy-confirmed cases of BD and 176 biopsy-confirmed cases of sBCC were analyzed. Of these, 229 cases of BD and 61 cases of sBCC were treated with cryosurgery and immediate 5-FU application, yielding a clearance rate of 90% and 86.9% at 6 months from initial treatment., Conclusion: Cryosurgery followed by immediate 5-FU use may be an effective mode of treatment for BD and sBCC, negating the need for invasive procedures and allowing for increased accessibility. Further studies with longer follow-up intervals, comparisons with other non-invasive treatments, and evidence of histologic cure are required. J Drugs Dermatol. 2023;22(12):1166-1171. doi:10.36849/JDD.7378.

Background: There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations., Objectives: To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care., Search Methods: We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section., Selection Criteria: We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy., Data Collection and Analysis: We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available., Main Results: We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other)., Authors' Conclusions: There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review., (Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.)

Epidermal keratinocytes are enriched with at least nine connexins that are key regulators of epidermal homeostasis. The role of Cx30.3 in keratinocytes and epidermal health became evident when fourteen autosomal dominant mutations in the Cx30.3-encoding GJB4 gene were linked to a rare and incurable skin disorder called erythrokeratodermia variabilis et progressiva (EKVP). While these variants are linked to EKVP, they remain largely uncharacterized hindering therapeutic options. In this study, we characterize the expression and functional status of three EKVP-linked Cx30.3 mutants (G12D, T85P, and F189Y) in tissue-relevant and differentiation-competent rat epidermal keratinocytes. We found that GFP-tagged Cx30.3 mutants were non-functional likely due to their impaired trafficking and primary entrapment within the endoplasmic reticulum (ER). However, all mutants failed to increase BiP/GRP78 levels suggesting they were not inducing an unfolded protein response. FLAG-tagged Cx30.3 mutants were also trafficking impaired yet occasionally exhibited some capacity to assemble into gap junctions. The pathological impact of these mutants may extend beyond their trafficking deficiencies as keratinocytes expressing FLAG-tagged Cx30.3 mutants exhibited increased propidium iodide uptake in the absence of divalent cations. Attempts to rescue the delivery of trafficking impaired GFP-tagged Cx30.3 mutants into gap junctions by chemical chaperone treatment were ineffective. However, co-expression of wild type Cx30.3 greatly enhanced the assembly of Cx30.3 mutants into gap junctions, although endogenous levels of Cx30.3 do not appear to prevent the skin pathology found in patients harboring these autosomal dominant mutations. In addition, a spectrum of connexin isoforms (Cx26, Cx30, and Cx43) exhibited the differential ability to trans-dominantly rescue the assembly of GFP-tagged Cx30.3 mutants into gap junctions suggesting a broad range of connexins found in keratinocytes may favourably interact with Cx30.3 mutants. We conclude that selective upregulation of compatible wild type connexins in keratinocytes may have potential therapeutic value in rescuing epidermal defects invoked by Cx30.3 EKVP-linked mutants., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lucaciu, Figliuzzi, Neumann, Nazarali, Del Sordo, Leighton, Hauser, Shao, Johnston, Bai and Laird.)

Objective: To determine the incidence and risk factors for steroid response in patients undergoing combined phacoemulsification cataract extraction (PCE) and microinvasive glaucoma surgery with either trabecular microbypass stent implantation (iStent) or ab interno trabeculectomy (Trabectome)., Design: Retrospective, noncomparative, single-institutional observational chart review., Participants: Consecutive patients with open-angle glaucoma who underwent PCE with iStent or Trabectome with 3 months of follow-up., Methods: Data were collected from patient charts, including pre- and postoperative intraocular pressure (IOP) following application of topical corticosteroid on postoperative visits for at least 3 months. A steroid response was defined as an IOP rise of greater than 5 mm Hg beginning at least 3 days after surgery with no other obvious explanation and with IOP < 20 mm Hg following rapid tapering or withdrawal of the steroid., Results: A total of 118 eyes from 89 patients, average age of 71.4 ±12.1 years, were included. Overall, a steroid response was seen in 12.7% of eyes (n = 15), and no difference was noted between Trabectome (11.8%) and iStent (13.6%, p = 0.782) eyes. Axial length (AL; p = 0.01), younger age (p = 0.009), traumatic glaucoma (p = 0.004), and normal-tension glaucoma (NTG; p = 0.0048) were significant predictors of steroid response in a multivariate analysis. In eyes with AL ≥ 25 mm, the steroid response rate was 40%, in contrast to eyes with AL < 25 mm, where it was 10.2%., Conclusion: A steroid response develops in approximately 1 in 8 patients undergoing PCE with Trabectome or iStent. Young age, AL > 25 mm, traumatic glaucoma, and NTG were found to be significant predictors of steroid response., (Copyright © 2021 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: The global prevalence of hypertension in children and adolescents has increased over the past 2 decades and is the strongest predictor of adult hypertension. South Asians have an increased prevalence of metabolic syndrome associated risk factors including abdominal obesity, diabetes, and hypertension. All these factors contribute to their increased cardiovascular disease burden. Accurate and early identification of hypertension in South Asian children is a necessary aspect of cardiovascular disease prevention. Ambulatory blood pressure monitoring (ABPM) is considered the gold-standard for pediatric blood pressure (BP) measurement. However, its utilization is limited due to the lack of validated normative reference data in diverse, multiethnic pediatric populations., Objective: The primary objective is to establish normative height-sex and age-sex-specific reference values for 24-h ABPM measurements among South Asian children and adolescents (aged 5-17 years) in Ontario and British Columbia, Canada. Secondary objectives are to evaluate differences in ABPM measurements by body mass index classification, to compare our normative data against pre-existing data from German and Hong Kong cohorts, and to evaluate relationships between habitual movement behaviors, diet quality, and ABPM measurements., Design: Cross-sectional study, quasi-representative sample., Setting: Participants will be recruited from schools, community centers, and places of worship in Southern Ontario (Greater Toronto and Hamilton area, including the Peel Region) and Greater Vancouver, British Columbia., Participants: We aim to recruit 2113 nonoverweight children (aged 5-17 years) for the primary objective. We aim to recruit an additional 633 overweight or obese children to address the secondary objectives., Measurements: Ambulatory BP monitoring measurements will be obtained using Spacelabs 90217 ABPM devices, which are validated for pediatric use. The ActiGraph GT3X-BT accelerometer, which has also been validated for pediatric use, will be used to obtain movement behavior data., Methods: Following recruitment, eligible children will be fitted with 24-h ABPM and physical activity monitors. Body anthropometrics and questionnaire data regarding medical and family history, medications, diet, physical activity, and substance use will be collected. Ambulatory BP monitoring data will be used to develop height-sex- and age-sex-specific normative reference values for South Asian children. Secondary objectives include evaluating differences in ABPM measures between normal weight, overweight and obese children; and comparing our South Asian ABPM data to existing German and Hong Kong data. We will also use compositional data analysis to evaluate associations between a child's habitual movement behaviors and ABPM measures., Limitations: Bloodwork will not be performed to facilitate recruitment. A non-South Asian comparator cohort will not be included due to feasibility concerns. Using a convenience sampling approach introduces the potential for selection bias., Conclusions: Ambulatory BP monitoring is a valuable tool for the identification and follow-up of pediatric hypertension and overcomes many of the limitations of office-based BP measurement. The development of normative ABPM data specific to South Asian children will increase the accuracy of BP measurement and hypertension identification in this at-risk population, providing an additional strategy for primary prevention of cardiovascular disease., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Childhood obesity is a growing epidemic with numerous global health implications. Over the past few years, novel insights have emerged about the contribution of adult obesity to cancer risk, but the evidence base is far more limited in children. While pediatric patients with acute lymphoblastic leukemia (ALL) are at risk of obesity, it is unclear if there are potential causal mechanisms by which obesity leads to ALL development. This review explores the endocrine, metabolic and immune dysregulation triggered by obesity and its potential role in pediatric ALL's genesis. We describe possible mechanisms, including adipose tissue attraction and protection of lymphoblasts, and their impact on ALL chemotherapies' pharmacokinetics. We also explore the potential contribution of cytokines, growth factors, natural killer cells and adipose stem cells to ALL initiation and propagation. While there are no current definite causal links between obesity and ALL, critical questions persist as to whether the adipose tissue microenvironment and endocrine actions can play a causal role in childhood ALL, and there is a need for more research to address these questions.

BACKGROUND: Cabin pressurization is the process by which aircraft maintain a comfortable and safe environment for passengers flying at high altitudes. At high altitudes, most patients can tolerate changes in pressurization; however, passengers at high risk of hypoxia may experience ischemic events. The purpose of this study was to evaluate variations in pressurization of commercial aircraft at cruising altitude and describe its relevance in relation to patients with non-arteritic anterior ischemic optic neuropathy (NAION). METHODS: Altimeters were used to measure altitude and cabin altitude at cruising altitude aboard 113 commercial flights, including 53 narrow-body and 60 wide-body aircraft. RESULTS: Cabin altitude ranged from 4232 ft to 7956 ft at cruising altitudes ranging from 30,000 ft to 41,000 ft. The mean cabin altitude for all flights was 6309 876 ft. Narrow-body aircraft had a significantly higher mean cabin altitude (6739 829 ft) compared to wide-body aircraft (5929 733 ft). For all flights, the mean cruising altitude was 35,369 2881 ft with narrow-body aircraft cruising at a lower altitude of 34,238 2389 ft compared to wide-body aircraft at 36,369 2925 ft. Newer generation aircraft had a mean cabin altitude of 6066 837 ft, which was lower than the mean cabin altitude of older aircraft (6616 835 ft). DISCUSSION: Innovation in flight design has offered the ability for aircraft to fly at greater altitudes while maintaining lower cabin altitude. Those at high risk of hypoxia-induced complications may consider aircraft type when air travel is required. Nazarali S, Liu H, Syed M, Wood T, Asanad S, Sadun AA, Karanjia R. Aircraft cabin pressurization and concern for non-arteritic anterior ischemic optic neuropathy . Aerosp Med Hum Perform. 2020; 91(9):715719.

Purpose: To characterize the presentation of Terson syndrome, the occurrence of a vitreous hemorrhage in association with intracranial hemorrhage, and report on the outcomes of vitrectomy at two major centers in Canada., Methods: Retrospective chart review of consecutive patients with Terson syndrome undergoing vitrectomy by retina specialists over the last 10 years. Primary outcome was the change in best-corrected visual acuity (BCVA) at 3 months from baseline. Secondary outcomes included the association between baseline BCVA and final BCVA, and the association between final BCVA and timing of surgery (early vs. later than 90 days)., Results: A total of 14 eyes of 11 patients were included. The mean time between observation of intraocular hemorrhage and vitrectomy was 160 days. Baseline preoperative BCVA was logarithm of the minimum angle of resolution 1.57 ± 1.03 (Snellen 20/740), which improved to logarithm of the minimum angle of resolution 0.53 ± 0.82 (Snellen 20/70) at the final postoperative follow-up, P = 0.01. Baseline BCVA was not significantly correlated with final BCVA, Spearman's rho = 0.016, P = 0.957. Final BCVA did not significantly differ between those who had surgery before 90 days compared with after 90 days, P = 0.087., Conclusion: Vitrectomy is safe and effective and should be considered for nonclearing vitreal bleeding due to Terson syndrome. Ocular hemorrhaging in Terson syndrome can be observed conservatively for spontaneous improvement without the risk of reduced visual potential. Ophthalmic evaluation should be considered promptly after intracranial hemorrhage.

Objective: Clerkship at the University of British Columbia (UBC) Medical School encompasses a variety of models: traditional rotation-based clerkship; distributed rotation-based clerkship at sites across the province; and a longitudinal integrated community clerkship. The purpose of this study was to: (i) Evaluate the undergraduate ophthalmology clerkship experience at UBC to compare outcomes and experiences across the various sites and models; and (ii) Apply educational theories to evaluation outcomes in order to improve curriculum design for clerkship programs., Design: Cross-sectional evaluation of the ophthalmology clerkship program at UBC., Methods: Using a logic model, we identified inputs, activities, and outputs of the ophthalmology clerkship experience at each site at UBC. Site directors and administrators were contacted for information regarding program curriculum and delivery, and outcomes were described using written exam and clinical assessment scores as well as student and instructor feedback (questionnaires with narrative responses)., Results: Site directors and administrators from all clerkship sites participated in the study. Clerkship experiences across all sites (rotation-based and integrated community clerkship) were found to be unique in contexts and clinical activities. There were no significant differences noted between outcomes in the rotation-based sites., Conclusion: Clerkship experiences can be delivered in various contexts and through varied clinical settings, yet provide an equivalent student learning experience. As longitudinal and distributed clerkship models gain traction in medical education around the world, there are lessons for undergraduate medical education both in ophthalmology and in other areas., (Copyright © 2019 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To develop an angle surgery training model for training an array of microincisional glaucoma surgery (MIGS) procedures., Methods: We describe a method for preparing an angle surgery training model using human cadaveric corneoscleral rims. The model provides realistic tactile tissue simulation and excellent angle visualization requiring bimanual technique. Corneoscleral rims may be used multiple times and are prepared at low cost, allowing for a high volume of practice surgeries., Results: This model allows for practice in bimanual surgical training using the gonioscopy lens for visualize alongside surgical tools. The in vivo surgical conditions and limited tactile feedback are recreated using human cadaveric eyes which nonhuman models fail to provide. Our model is prepared at low cost, with relative ease and also provides appropriate positioning of Schlemm canal and for high volume of practice as the canal can be used in 90-degree segments., Conclusions: Few angle surgery training models currently exist and none provide these necessary features. The model presented here aims to meet the growing demand for adequate training models required for technically advanced MIGS techniques.

Purpose: To assess a new training model (Tackdriver) for new-generation microinvasive glaucoma surgeries (MIGS)., Setting: Resident training centers in Canada., Design: Evaluation of technology., Methods: Human cadaver corneoscleral rims recovered after Descemet-stripping endothelial keratoplasty or not suitable for transplantation were acquired from an eye bank. The tissue was fixated with a single tack through the center of the cornea, which was inverted in a concave fashion. A water-based medical lubricant was used for placement of a goniolens after visualization of the anterior chamber and the trabecular meshwork. Microbypass stent (iStent) insertion and gonioscopy-assisted transluminal trabeculotomy (GATT) were practiced on this model. The model was qualitatively assessed for ease of preparation, accuracy of surgical simulation, and the number and variety of MIGS procedures that can be performed., Results: Efficient high-volume training was performed for microbypass stent insertion using first-generation and second-generation microbypass stents. The GATT procedure was also performed as a final step in a titratable fashion in 90-, 180-, or 270-degree segments or a complete 360-degree treatment. The model simulated bimanual angle surgery with good fidelity., Conclusions: The training model allowed for high-volume bimanual MIGS training for techniques such as microbypass stent insertion and removal as well as GATT. Preparation was relatively simple, efficient, and cost-effective compared with other models. Inverting the specimen allowed the trainee to practice MIGS techniques independent of the tissue's corneal clarity. Other MIGS techniques and angle training procedures can be adopted to this model., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the efficacy and safety of ab interno trabeculectomy with Trabectome in juvenile open-angle glaucoma (JOAG) patients., Design: Prospective cohort study., Methods: Evaluation of the 12-month results of 2 patient groups receiving ab interno trabeculectomy: group 1, eyes with no prior incisional surgery; group 2, eyes that had prior incisional cataract or glaucoma surgery., Results: Group 1, 40 eyes (average age 31 ± 7 years), had a significant reduction in intraocular pressure (IOP) of 10.6 mm Hg at 12 months from a baseline of 27.4 mm Hg (p = 0.01), and the number of glaucoma medications reduced by 0.4 (p = 0.80). Four eyes (10%) within the study period required a secondary glaucoma surgery. Group 2, 20 eyes (average age 27 ± 8 years), had a significant reduction in IOP of 8.8 mm Hg from a baseline of 27.1 mm Hg (p = 0.06), and the number of glaucoma medications reduced by 1.4 (p = 0.36). Five eyes (25%) from this group underwent a secondary glaucoma surgery within 12 months., Conclusion: After 1 year of follow-up, ab interno trabeculectomy appears to be an effective and safe intervention for patients with JOAG; however, a reduction in use of topical medications may not be observed in those receiving ab interno trabeculectomy as a primary procedure., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Exfoliation syndrome (XFS) is a systemic disease with significant ocular manifestations, including glaucoma and cataract. The disease impacts close to 70 million people globally and is now recognised as the most common identifiable cause of open-angle glaucoma. Since the discovery of XFS 100 years ago by Dr John G. Lindberg, there has been considerable advancement in understanding its pathogenesis and resulting clinical implications. The purpose of this paper is to summarise information regarding the epidemiology, pathophysiology, ocular manifestations and systemic associations of XFS with the objective of sharing clinical pearls to assist in early detection and enhanced management of patients., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Glaucoma following penetrating keratoplasty (PKP) remains the leading cause of blindness following PKP. Patients with post-PKP glaucoma can be managed medically and surgically. Evidence studying glaucoma surgical techniques following PKP is limited, but suggests the possibility for high-risk complications, including graft failure. Minimally invasive glaucoma surgeries offer an alternative. We report the first case of post-PKP glaucoma managed with gonioscopy-assisted transluminal trabeculotomy (GATT). The patient was a 33-year-old man with a history of keratoconus who underwent PKP in his right eye. On presentation, his visual acuity was 20/60 and intraocular pressure was 48 mm Hg OD. He underwent GATT and cataract phacoemulsification. Following 22 months of follow-up, the patient's visual acuity was 20/30 and intraocular pressure 13 mm Hg, off all glaucoma medications. This case demonstrates GATT may be a good surgical option for post-PKP glaucoma, given the ability to perform future incisional surgery and avoidance of high-risk complications associated with traditional glaucoma surgeries.

Objective: To develop a standardized process for reviewing daily patient lists and identifying potential risks of misidentification. Our goal was to develop a proactive approach to identify and eliminate risks of patient misidentification., Methods: Assessment of current patient identification practices took place over a period of 4 weeks. Using a process map, a patient survey was developed to determine the encounter points when patient identification was confirmed. This information was used to develop a standardized protocol for review of daily appointment lists., Results: Review of daily appointment lists was completed to identify potential similar/same name risks. A standardized manual process of chart review, flagging, and tracking was developed., Conclusions: The name alert process resulted in a simple manual process for identifying which patients have a higher name risk and allowed care providers to take preventative action to decrease potential risk of incorrect diagnostic testing, procedure, or medication administration., (Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the efficacy and safety of endoscopic cyclophotocoagulation (ECP) versus trabeculectomy with mitomycin C (trab) in combination with cataract surgery., Materials and Methods: We evaluated the 6-month results of patients undergoing phacoemulsification (phaco) with either ECP or trab. The primary outcome was mean intraocular pressure (IOP) at 6 months; secondary outcomes were change in glaucoma medications, visual acuity, intraocular inflammation, and postoperative complications. Complete success was a target IOP of <21 mmHg and >6 mmHg without glaucoma medications. Qualified success was target IOP achieved through glaucoma medications., Results: We evaluated 53 eyes of 53 patients; 24 (45.3%) eyes were treated with ECP-phaco and 29 (54.7%) with trab-phaco. At 6 months, there was no significant difference in mean IOP of the two groups (ECP-phaco 14.2 ± 3.6 mmHg; trab-phaco 13.0 ± 2.5 mmHg; P = 0.240). Six (25.0%) ECP-phaco eyes and 20 (69.0%) trab-phaco eyes achieved complete success ( P = 0.002). Qualified success was achieved in 18 (75.0%) ECP-phaco eyes and 9 (31.0%) trab-phaco eyes ( P = 0.002). The mean reduction of medication from baseline was significant (ECP-phaco 1.2 ± 1.1; trab-phaco 2.1 ± 1.5; P = 0.020). ECP-phaco resulted in more IOP spikes on the 1 st postoperative day ( P = 0.040) and more anterior cellular reaction at 1 week and 1 month compared to trab-phaco ( P < 0.05). The rate of postoperative complications was not significantly different between groups., Conclusion: At 6 months, ECP-phaco demonstrated similar improvements in IOP and visual acuity compared to trab-phaco. However, ECP-phaco patients had higher incidences of immediate postoperative IOP spikes and anterior chamber inflammation as well as requiring additional medications postoperatively., Competing Interests: There are no conflicts of interest.

Background: Ophthalmology residents on call at the Royal Alexandra Hospital identified workplace disorganization and lack of standardization in emergency eye examination rooms as an impediment to efficient patient treatment., Objective: The aim of the study was to use the "6S Lean" model to improve workflow in eye examination rooms at the Royal Alexandra Hospital., Methods: With the assistance of quality improvement consultants, the "6S Lean" model was applied to the current operation of the emergency eye clinic examination rooms. This model, considering 8 waste categories, was then used to recommend and implement changes to the examination rooms and to workplace protocols to enhance efficiency and safety., Results: Eye examination rooms were improved with regards to setup, organization of supplies, inventory control, and maintenance. All targets were achieved, and the 5S audit checklist score increased by 33 points from 44 to 77., Conclusions: Implementation of the 6S methodology is a simple approach that removes inefficiencies from the workplace. The ophthalmology clinic removed waste from all 8 waste categories, increased audit results, mitigated patient and resident safety risks, and ultimately redirected resident time back to patient care delivery., (Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Nicotinamide, an amide form of vitamin B3, has shown the potential to treat a variety of dermatological conditions, including acne, rosacea, and atopic dermatitis. Recent studies have demonstrated the role of nicotinamide, in both topical and oral forms, as a chemopreventive agent against skin cancer. Its anti-carcinogenic role may be due to its ability to enhance DNA repair and prevent ultraviolet (UV)-induced immunosuppression, which is known to contribute to the progression of pre-malignant lesions. Furthermore, nicotinamide is a precursor of essential coenzymes for many important reactions in the body, including the production of nicotinamide adenine dinucleotide (NAD). NAD is a key coenzyme in the synthesis of adenosine triphosphate (ATP), which transports chemical energy within cells. Therefore, nicotinamide plays a significant role in supporting energy-dependent cellular processes, including DNA repair.

Purpose: The photopic negative response (PhNR) is a slow negative component of a flash photopic full-field ERG that has been shown to be specific for retinal ganglion cell (RGC) activity. Direct evaluation of RGC function is desirable in patients with Leber's hereditary optic neuropathy (LHON) in which the loss of central acuity can make it difficult to monitor patients with standard metrics. The purpose of this study was to evaluate the use of PhNR as an objective noninvasive clinical metric in LHON., Methods: Full-field photopic ERG recordings were collected in subjects with the mt.11778G>A/ND4 LHON mutation using a red on blue stimulus. The PhNR was identified using a computer-based automated detection system, and data were manually examined to remove movement artifacts., Results: The PhNR amplitude was compared between controls (n = 13), carriers (n = 17), and affected (n = 6). Mean PhNR amplitude decreased significantly across groups (P < 0.0001). Post hoc Tukey's test revealed a significant decrease in PhNR amplitude between carriers and controls (P < 0.05) and between carriers and affected (P < 0.01)., Conclusions: We are able to demonstrate that the PhNR amplitude is significantly decreased in patients affected by LHON compared to carriers in a well-described pedigree. Surprisingly, there was also a decrease in PhNR in carriers, suggesting potential subclinical RGC dysfunction in some carriers. This is important in patients affected with LHON who typically have a dense central scotoma. The PhNR may be a useful objective outcome measure for future clinical trials.

Objective: To evaluate the effectiveness of mandibular advancement appliances (MAAs) for treatment of pediatric obstructive sleep apnea (OSA)., Methods: Several electronic databases (The Cochrane Database, EMBASE, Healthstar, MEDLINE, PubMed) were systematically searched, as well as a limited grey literature (Google Scholar) and manual searches. A health sciences librarian helped with the selection of Medical Subject Headings (MeSH), key words, and combinations of key words with truncations to account for any differences in controlled terminology in the different databases. Only studies that evaluated the effects of MAAs in children with OSA were pursued., Results: Only 4 articles satisfied all inclusion criteria. Selected studies were retrospective except one study that was a quasi-randomized clinical trial. High risk of bias (Cochrane Risk of Bias assessment) was judged in all included studies. Based on the limited available evidence use of MAAs in a POSA population may result in improvements in Apnea Hypopnea Index (AHI) scores. However complete normalization of AHI scores was not demonstrated. Heterogeneity in study designs and collected information precluded meta-analysis., Limitations: There are significant weaknesses in the existing evidence due primarily to absence of control groups, small sample sizes, lack of randomization and short-term results. Determination of AHI scores with MAAs still in the mouth should be avoided., Conclusions: The current limited evidence may be suggestive that MAAs result in short-term improvements in AHI scores, but it is not possible to conclude that MMAs are effective to treat pediatric OSA. Medium- and long-term assessments are still required., (© The Author 2015. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

There are approximately 100 genes which when mutated are known to predispose to one or more forms of cancer. Currently, genetic testing is offered for many of these, either as single genes or as multi-gene panels. Features of hereditary cancer include a positive family history of cancer, early age of onset and the appearance of multiple primary cancers in one individual. In some cases multiple cancers may be of the same site (e.g., bilateral breast cancer) and in other cases they may be at different sites. Various combinations of cancer sites may be indicative of specific cancer syndromes such as the breast ovarian cancer syndrome. Genetic testing should be offered to individuals who have experienced multiple primary cancers in some circumstances, the genetic counselor should review the ages of sites of cancer, their pathologic features and the family history of cancer as part of the pre-test evaluation., (© 2014 UICC.)

A child with respiratory distress was found to have been given an antibiotic which was reconstituted with methadone. A delay in standard emergency room management led to a delay in diagnosis and treatment.