Publications by authors named "Michael Singer"

194 Publications

Clinical Characteristics and Outcomes of Eyes with Intraocular Inflammation after Brolucizumab: Post Hoc Analysis of HAWK and HARRIER.

Ophthalmol Retina 2021 May 7. Epub 2021 May 7.

Ophthalmology, Sorbonne University, APHP, Paris, France.

Purpose: This analysis of the pivotal phase III HAWK and HARRIER trials aimed to provide insights on the timing of presentation, management, and outcomes of intraocular inflammation (IOI)-related adverse events (AEs), as reported by investigators in these trials.

Design: Post hoc analysis of investigator-reported IOI-related AEs in HAWK and HARRIER.

Participants: Of 1088 brolucizumab-treated eyes (3 mg or 6 mg), 49 eyes experienced at least 1 IOI-related AE and were included in this analysis.

Methods: Reports of IOI-related AEs were analyzed and descriptive statistics were provided for outcome measures.

Main Outcome Measures: Incidence and description of eyes with IOI-related AEs, timing of presentation, management, clinical outcomes, and brolucizumab treatment after the first IOI-related AE.

Results: A total of 70 IOI-related AEs were reported in 49 eyes. Prior to the onset of first IOI-related AE, eyes received a mean (standard deviation [SD]) of 3.9 (2.2) brolucizumab injections. Median (25th-75th percentile) time to first IOI-related AE from the last administered brolucizumab injection was 18.0 (4.0-29.0) days. Of the 70 AEs, 61 (87.1%) were treated, the majority with topical corticosteroids; systemic and intraocular corticosteroids were used for 3 AEs each. Overall, inflammation resolved completely in 39 (79.6%) eyes, resolved with sequelae in 5 (10.2%) eyes, and did not resolve in 5 (10.2%) eyes by end-of-study. Overall, mean (SD) best-corrected visual acuity (BCVA) change from baseline to end-of-study, before AE to the lowest BCVA in 3 months after AE, and from before AE to end-of-study were -0.84 (20.6), -16.31 (17.6), and -0.22 (18.9) ETDRS letters, respectively. Of the 36 (73.5%) eyes that continued on brolucizumab after first IOI-related AE, 24 completed the trials and 12 discontinued; mean (SD) BCVA change in these eyes was 2.6 (17.6), 7.8 (13.2), and -7.7 (21.3) ETDRS letters, respectively, from baseline to end-of-study. The remaining 13 (26.5%) eyes were not treated with brolucizumab after first IOI-related AE and had mean (SD) BCVA change of -10.4 (25.5) ETDRS letters from baseline to end-of-study.

Conclusions: Findings of this analysis highlight the need for continued vigilance and monitoring for any signs of IOI-related events in patients receiving brolucizumab.
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http://dx.doi.org/10.1016/j.oret.2021.05.003DOI Listing
May 2021

Colonizations cause diversification of host preferences: a mechanism explaining increased generalization at range boundaries expanding under climate change.

Glob Chang Biol 2021 Apr 25. Epub 2021 Apr 25.

Theoretical and Experimental Ecology Station, CNRS, 09200, Moulis, France.

As species' poleward range limits expand under climate change, generalists are expected to be better colonists than specialists, extending their ranges faster. This effect of specialization on range shifts has been shown, but so has the reverse cause-effect: in a global meta-analysis of butterfly diets it was range expansions themselves that caused increases of population-level diet breadth. What could drive this unexpected process? We provide a novel behavioral mechanism by showing that, in a butterfly with extensive ecotypic variation, Edith's checkerspot, diet breadths increased after colonization events as diversification of individual host preferences pulled novel hosts into population diets. Subsequently, populations that persisted reverted towards monophagy. We draw together three lines of evidence from long-term studies of 15 independently-evolving populations. First, direct observations showed a significant increase of specialization across decades: in recent censuses, eight populations used fewer host genera than in the 1980's while none used more. Second, behavioral preference-testing experiments showed that extinctions and recolonizations at two sites were followed, at first by diversification of heritable preference ranks and increases of diet breadth, and subsequently by homogenization of preferences and contractions of diet breadth. Third, we found a significant negative association in the 1980's between population-level diet breadth and genetic diversity. Populations with fewer mtDNA haplotypes had broader diets, extending to 3-4 host genera, while those with higher haplotype diversity were more specialized. We infer that diet breadth had increased in younger, recently-colonized populations. Preference diversification after colonization events, whether caused by (cryptic) host shifts or by release of cryptic genetic variation after population bottlenecks, provides a mechanism for known effects of range shifts on diet specialization. Our results explain how colonizations at expanding range margins have increased population-level diet breadths, and predict that increasing specialization should accompany population persistence as current range edges become range interiors.
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http://dx.doi.org/10.1111/gcb.15656DOI Listing
April 2021

Intraoperative Nerve Monitoring in Thyroidectomies for Malignancy: Does it Matter?

Am Surg 2021 Jan 31:3134821991967. Epub 2021 Jan 31.

Department of Otolaryngology, Head & Neck Surgery, Division of Thyroid & Parathyroid Surgery, 24016Henry Ford Hospital, Detroit, MI, USA.

Background: Recurrent laryngeal nerve (RLN) injury and postoperative hypocalcemia are potential complications of thyroidectomy, particularly in malignancy. Intraoperative nerve monitoring (IONM) remains controversial. We sought to evaluate the impact of IONM on these complications using a national data set.

Methods: The American College of Surgeons National Surgical Quality Improvement Program thyroidectomy-targeted data set was queried for patients who underwent thyroidectomies from 2016 to 2017. Patients were grouped according to IONM use. Logistic regression models were constructed to evaluate associations of variables with 30-day hypocalcemic events (HCEs) and RLN injury. Associations were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). A subgroup analysis was performed of patients with malignancy.

Results: A total of 9527 patients were identified; 5969 (62.7%) underwent thyroidectomy with IONM and 3558 (37.3%) without. By multivariable analysis, IONM had protective associations with HCE (OR = .81, 95% CI = .68-.96; = .013) and RLN injury (OR = .83, 95% CI = .69-.98; = .033). Malignancy increased risk of HCE (OR = 1.21, 95% CI=1.01-1.45; = .038) and RLN injury (OR = 1.22, 95% CI = 1.02-1.46; = .034). A large proportion (5943/9527, 62.4%) of patients had malignancy; 3646 (61.3%) underwent thyroidectomy with IONM and 2297 (38.7%) without. In the subgroup analysis, IONM had stronger protective associations with HCE (OR = .73, 95% CI = .60-.90; = .003) and RLN injury (OR = .76, 95% CI = .62-.94; = .012).

Discussion: Malignancy was associated with increased risk of HCE and RLN injury. Intraoperative nerve monitoring had a protective association with HCE and RLN injury, both overall, and in the malignant subgroup. Intraoperative nerve monitoring was correlated with improved thyroidectomy outcomes, especially if the indication was malignancy. This warrants further study to clarify cause and effect.
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http://dx.doi.org/10.1177/0003134821991967DOI Listing
January 2021

Exploring groundwater and soil water storage changes across the CONUS at 12.5 km resolution by a Bayesian integration of GRACE data into W3RA.

Sci Total Environ 2021 Mar 19;758:143579. Epub 2020 Nov 19.

School of Earth and Environmental Sciences, Cardiff University, CF103AT Cardiff, UK; Geodesy and Earth Observation Group, Institute of Planning, Aalborg University, Rendburggade 14, 9000 Aalborg, Denmark.

Climate variability and change along with anthropogenic water use have affected the (re)distribution of water storage and fluxes across the Contiguous United States (CONUS). Available hydrological models, however, do not represent recent changes in the water cycle. Therefore, in this study, a novel Bayesian Markov Chain Monte Carlo-based Data Assimilation (MCMC-DA) approach is formulated to integrate Terrestrial Water Storage changes (TWSC) from the Gravity Recovery and Climate Experiment (GRACE) satellite mission into the W3RA water balance model. The benefit of this integration is its dynamic solution that uses GRACE TWSC to update W3RA's individual water storage estimates while rigorously accounting for uncertainties. It also down-scales GRACE data and provides groundwater and soil water storage changes at ~12.5 km resolution across the CONUS covering 2003-2017. Independent validations are performed against in-situ groundwater data (from USGS) and Climate Change Initiative (CCI) soil moisture products from the European Space Agency (ESA). Our results indicate that MCMC-DA introduces trends, which exist in GRACE TWSC, mostly to the groundwater storage and to a lesser extent to the soil water storage. Higher similarity is found between groundwater estimation of MCMC-DA and those of USGS in the southeastern CONUS. We also show a stronger linear trend in MCMC-DA soil water storage across the CONUS, compared to W3RA (changing from ±0.5 mm/yr to ±2 mm/yr), which is closer to independent estimates from the ESA CCI. MCMC-DA also improves the estimation of soil water storage in regions with high forest intensity, where ESA CCI and hydrological models have difficulties in capturing the soil-vegetation-atmosphere continuum. The representation of El Niño Southern Oscillation (ENSO)-related variability in groundwater and soil water storage are found to be considerably improved after integrating GRACE TWSC with W3RA. This new hybrid approach shows promise for understanding the links between climate and the water balance over broad regions.
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http://dx.doi.org/10.1016/j.scitotenv.2020.143579DOI Listing
March 2021

Effects of Long-Term DME Control With 0.2 µg/Day Fluocinolone Acetonide Implant on Quality of Life: An Exploratory Analysis From the FAME Trial.

Ophthalmic Surg Lasers Imaging Retina 2020 11;51(11):658-667

Background And Objective: Exploratory investigation of the effect of diabetic macular edema (DME) control with the 0.2 µg/day fluocinolone acetonide (FAc) intravitreal implant on quality of life (QOL) outcomes.

Patients And Methods: Post-hoc analysis of patients from the FAME study who received the FAc implant and had answered the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25) at baseline and Year 3 (N = 324). Patients were divided into quartiles (area under the curve [AUC]-central subfield thickness [CST]/day; n = 81/quartile). NEIVFQ-25 and best-corrected visual acuity (BCVA) changes were analyzed per quartile during a period of 3 years.

Results: NEI-VFQ-25 scores were significantly higher in patients with low AUC-CST/day (Quartiles 1 [P < .001] and 2 [P = .004]). Increases in NEIVFQ-25 subscale scores correlated with AUC-CST/day quartiles. BCVA significantly improved in patients with the lowest AUC-CST/day (Quartiles 1 and 2 [P < .001]).

Conclusion: There was a positive and sustained correlation between the long-term control of DME and patient-reported QOL outcomes for up to 3 years following a single FAc implant in patients with controlled DME. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:658-667.].
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http://dx.doi.org/10.3928/23258160-20201104-10DOI Listing
November 2020

Evaluation of Strain Transition Properties between Cast-In Fibre Bragg Gratings and Cast Aluminium during Uniaxial Straining.

Sensors (Basel) 2020 Nov 4;20(21). Epub 2020 Nov 4.

Chair of Metal Forming and Casting, Technical University of Munich (TUM), 85748 Garching, Germany.

Current testing methods are capable of measuring strain near the surface on structural parts, for example by using strain gauges. However, stress peaks often occur within the material and can only be approximated. An alternative strain measurement incorporates fibre-optical strain sensors (Fiber Bragg Gratings, FBG) which are able to determine strains within the material. The principle has already been verified by using embedded FBGs in tensile specimens. The transition area between fibre and aluminium, however, is not yet properly investigated. Therefore, strains in tensile specimens containing FBGs were measured by neutron diffraction in gauge volumes of two different sizes around the Bragg grating. As a result, it is possible to identify and decouple elastic and plastic strains affecting the FBGs and to transfer the findings into a fully descriptive FE-model of the strain transition area.We thus accomplished closing the gap between the external load and internal straining obtained from cast-in FBG and generating valuable information about the mechanisms within the strain transition area.It was found that the porosity within the casting has a significant impact on the stiffness of the tensile specimen, the generation of excess microscopic tensions and thus the formation of permanent plastic strains, which are well recognized by the FBG. The knowledge that FBG as internal strain sensors function just as well as common external strain sensors will now allow for the application of FBG in actual structural parts and measurements under real load conditions. In the future, applications for long-term monitoring of cast parts will also be enabled and are currently under development.
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http://dx.doi.org/10.3390/s20216276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662606PMC
November 2020

Expert Opinion on Management of Intraocular Inflammation, Retinal Vasculitis, and Vascular Occlusion after Brolucizumab Treatment.

Ophthalmol Retina 2020 Sep 29. Epub 2020 Sep 29.

York Teaching Hospital NHS Foundation Trust, University of York, York, United Kingdom.

Purpose: Recent reports have described a spectrum of uncommon findings of intraocular inflammation (IOI), retinal vasculitis, or retinal vascular occlusion in patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal injection (IVI) of brolucizumab. We present guidance on the clinical presentation of this spectrum and propose recommendations for management of these events.

Design: PubMed literature review and expert opinion panel.

Participants: A working group of international medical experts and Novartis medical personnel.

Methods: The working group deliberated on the clinical presentations and used a 3-pronged approach to develop management recommendations based on (1) critical appraisal of scientific literature; (2) clinical insights from the HAWK and HARRIER trials, postmarketing reports, and assessments from an independent Safety Review Committee (SRC); and (3) their clinical experience.

Main Outcome Measures: Management recommendations for a spectrum of ocular inflammatory events after treatment with brolucizumab or other anti-vascular endothelial growth factors (VEGFs).

Results: Based on insights gained from the available information and the expertise of the contributors, recommendations were proposed for ocular examinations, imaging modalities, and treatment strategies for management of this spectrum of events. Patients should be educated to promptly report any relevant or persistent symptoms after IVI to facilitate timely intervention. Patients diagnosed with IOI should be evaluated for concomitant retinal vasculitis or retinal vascular occlusive events. Clinical examination can be augmented with multimodal imaging techniques, including widefield imaging, fluorescein angiography (with peripheral sweeps), and OCT. Once confirmed, the ongoing brolucizumab treatment should be suspended and intensive treatment with potent corticosteroids (topical, subtenon, intravitreal, or systemic) is recommended, which may be supplemented with other treatment strategies depending on the severity. Based on the clinical outcome of these events, individualized treatment with locally available standard of care should be considered for the underlying nAMD.

Conclusions: These recommendations emphasize the need for early diagnosis, prompt and timely intervention, intensive treatment, and frequent monitoring to minimize the risk of progression of these events. The proposed recommendations may facilitate a consistent management approach of this spectrum of ocular inflammatory events should they arise in nAMD after treatment with brolucizumab or other anti-VEGFs.
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http://dx.doi.org/10.1016/j.oret.2020.09.020DOI Listing
September 2020

Impact of a specialty trained billing team on an academic otolaryngology practice.

Am J Otolaryngol 2020 Nov - Dec;41(6):102720. Epub 2020 Sep 10.

Department of Otolaryngology - Head & Neck Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI 48202, USA. Electronic address:

Purpose: To determine how the incorporation of specialty specific training for coders within a focused billing team affected revenue, efficiency, time to reimbursement, and physician satisfaction in an academic otolaryngology practice.

Materials And Methods: Our academic otolaryngology department recently implemented a new billing system, which incorporated additional training in otolaryngology surgical procedures for medical coders. A mixed model analysis of variance was used to compare billing outcomes for the 6 months before and 6 months after this new approach was initiated. The following metrics were analyzed: Current Procedural Terminology codes, total charges, time between services rendered and billing submission, and time to reimbursement. A survey of department physicians assessing satisfaction with the system was reviewed.

Results: There were 4087 Current Procedural Terminology codes included in the analysis. In comparing the periods before and after implementation of the new system, statistically significant decreases were found in the mean number of days to coding completion (19.3 to 12.0, respectively, p < 0.001), days to posting of charges (27.0 to 15.2, p < 0.001), days to final reimbursement (54.5 to 27.2, p < 0.001), and days to closure of form (179.2 to 76.6, p < 0.001). Physician satisfaction with communication and coder feedback increased from 36% to 64% after initiation of the new program.

Conclusions: The implementation of additional specialty training for medical coders in the otolaryngology department of a large medical system was associated with improved revenue cycle efficiency. Additionally, this model appears to improve physician satisfaction and confidence with the coding system.
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http://dx.doi.org/10.1016/j.amjoto.2020.102720DOI Listing
December 2020

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment.

Head Neck 2020 12 21;42(12):3779-3794. Epub 2020 Sep 21.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA.

Background: Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

Methods: A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

Results: Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

Conclusion: After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.
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http://dx.doi.org/10.1002/hed.26472DOI Listing
December 2020

Preference Provides a Plethora of Problems (Don't Panic).

Authors:
Michael C Singer

Annu Rev Entomol 2021 01 14;66:1-22. Epub 2020 Sep 14.

Station d'Écologie Théorique et Expérimentale, CNRS et Université Paul Sabatier, 09200 Moulis, France; email:

This review was solicited as an autobiography. The "problems" in my title have two meanings. First, they were professional difficulties caused by my decision to study oviposition preferences of butterflies that were not susceptible to traditional preference-testing designs. Until I provided video, my claim that the butterflies duplicate natural post-alighting host-assessment behavior when placed on hosts by hand was not credible, and the preference-testing technique that I had developed elicited skepticism, anger, and derision. The second meaning of "problems" is scientific. Insect preference comes with complex dimensionality that interacts with host acceptability. Part Two of this review describes how my group's work in this area has revealed unexpected axes of variation in plant-insect interactions-axes capable of frustrating attempts to derive unequivocal conclusions from apparently sensible experimental designs. The possibility that these complexities are lurking should be kept in mind as preference and performance experiments are devised.
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http://dx.doi.org/10.1146/annurev-ento-022720-061725DOI Listing
January 2021

Peripheral extent of the choroidal circulation by ultra-widefield indocyanine green angiography in healthy eyes.

Br J Ophthalmol 2020 Aug 22. Epub 2020 Aug 22.

Doheny Eye Institute, Los Angeles, California, USA

Aim: To analyse the peripheral extent of choroidal circulation using ultra-widefield (UWF) indocyanine green angiography (ICGA) in healthy eyes.

Methods: UWF ICGA images of 55 eyes of 36 healthy subjects were captured using the Optos California (Optos, Dunfermline, United Kingdom) in this prospective observational study. Images were analysed to locate the peripheral extent of the visible choroidal circulation, and the boundary was marked in ImageJ (v1.52). Each pixel annotated as the border of the choroidal circulation was projected individually to its anatomically correct location on the three-dimensional model eye, and spherical trigonometry was applied (using the Optos software) to calculate its respective radial distance from the centre of the optic disc in metric units (corrected by stereographic projection) for each quadrant.

Results: The mean area of the peripheral extent was estimated to be 893.2 mm (95% CI: 844.2 to 942.3 mm). The mean distance (range) of this boundary from optic nerve centre was 18.22 mm (95% CI: 14.0 to 23.14 mm). Multiple regression analysis with age, gender, axial length or ethnicity showed no relationship. There was excellent inter-grader reproducibility, with intraclass correlation coefficients of 0.95 (95% CI: 0.80 to 0.99, <0.001) for distance and 0.99 (95% CI: 0.988 to 0.999, <0.001) for area measurements.

Conclusions: The peripheral choroidal boundary may be defined using UWF ICGA. Knowledge of the normal extent and its variability is essential to understand the impact of disease on the choroidal vasculature.
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http://dx.doi.org/10.1136/bjophthalmol-2020-316412DOI Listing
August 2020

Salivary and lacrimal dysfunction after radioactive iodine for differentiated thyroid cancer: American Head and Neck Society Endocrine Surgery Section and Salivary Gland Section joint multidisciplinary clinical consensus statement of otolaryngology, ophthalmology, nuclear medicine and endocrinology.

Head Neck 2020 11 19;42(11):3446-3459. Epub 2020 Aug 19.

Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.

Background: Postoperative radioactive iodine (RAI) administration is widely utilized in patients with differentiated thyroid cancer. While beneficial in select patients, it is critical to recognize the potential negative sequelae of this treatment. The prevention, diagnosis, and management of the salivary and lacrimal complications of RAI exposure are addressed in this consensus statement.

Methods: A multidisciplinary panel of experts was convened under the auspices of the American Head and Neck Society Endocrine Surgery and Salivary Gland Sections. Following a comprehensive literature review to assess the current best evidence, this group developed six relevant consensus recommendations.

Results: Consensus recommendations on RAI were made in the areas of patient assessment, optimal utilization, complication prevention, and complication management.

Conclusion: Salivary and lacrimal complications secondary to RAI exposure are common and need to be weighed when considering its use. The recommendations included in this statement provide direction for approaches to minimize and manage these complications.
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http://dx.doi.org/10.1002/hed.26417DOI Listing
November 2020

Fractal analysis of retinal vasculature in normal subjects on ultra-wide field fluorescein angiography.

Int J Ophthalmol 2020 18;13(7):1109-1114. Epub 2020 Jul 18.

Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA 90086, USA.

Aim: To evaluate the fractal feature of the retinal vasculature of normal eyes on a stereographic projected and montaged ultra-wide field (UWF) fluorescein angiography (FA).

Methods: Prospective, observational, cross-sectional study. Totally 59 eyes of 31 normal subjects were imaged using the Optos 200Tx. Images obtained at different gaze angles stereographically projected and montaged. The early-phase UWF FA frames were processed to segment the retinal vasculature and the results were exported as binary masks. The fractal dimension (FD) was calculated using the box-counting method.

Results: The global FD for the entire retina was 1.6±0.04, with no difference between males and females (1.59±0.04 1.61±0.04, =0.084) or between right and left eyes (1.6±0.04 1.6±0.05, =0.61). FD was non-uniformly distributed among four quadrants (<0.001) and decreased as the distance from the fovea increased (<0.001). A negative association was observed between FD and age (=-0.37, =0.006), and this relationship was observed in the posterior and mid-peripheral retina (<0.05) but absent in far-periphery (>0.05).

Conclusion: Fractal geometry is non-uniformly distributed across the retina in normal eyes and decreases from the fovea to the far-periphery. Subjects with an older age tend to have a smaller FD, however, the FD in the far-periphery does not appear to be influenced by age.
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http://dx.doi.org/10.18240/ijo.2020.07.15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7321948PMC
July 2020

Predictors of Early Diabetic Retinopathy Regression with Ranibizumab in the RIDE and RISE Clinical Trials.

Clin Ophthalmol 2020 17;14:1629-1639. Epub 2020 Jun 17.

Genentech, Inc., South San Francisco, CA, USA.

Purpose: To investigate the predictors of early diabetic retinopathy (DR) improvement in the RIDE/RISE (NCT00473382/NCT00473330) clinical trials.

Patients And Methods: In RIDE/RISE, adult patients with vision loss due to diabetic macular edema (DME) were randomized to monthly intravitreal ranibizumab 0.3 or 0.5 mg (n=502 total) or sham (n=257). DR severity was graded (using the Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale). In this post hoc analysis of RIDE/RISE, eyes with baseline DR score ≥35 were evaluated for ≥2-step improvements, and eyes with baseline DR score ≥43 were evaluated for ≥3-step improvements. The characteristics associated with ≥2- or ≥3-step DR improvement at months 3 or 6 were assessed using univariate and/or multivariable analyses.

Results: The percentage of eyes with a ≥2- or ≥3-step DR improvement was 20.1% and 3.7% at month 3 and 31.2% and 5.8% at month 6. Odds of ≥2-step DR improvement at months 3 or 6 were significantly greater in eyes with moderately severe to severe nonproliferative DR (NPDR) at baseline versus less severe or more severe DR (both <0.0001). At month 6, odds of ≥2-step DR improvement were significantly greater in eyes with no DME at month 3 (=0.008). Most patients with ≥3-step DR improvement at months 3 or 6 had proliferative DR (PDR) at baseline (83.3% and 66.7%).

Conclusion: The strongest predictors of DR response to ranibizumab at month 6 were baseline DR severity and DME quiescence at month 3. Eyes with the most robust early improvements had moderately severe or severe NPDR or PDR at baseline.
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http://dx.doi.org/10.2147/OPTH.S247061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306476PMC
June 2020

In Response to Regarding Surgical Impact of a Dedicated Endocrine Surgeon on an Academic Otolaryngology Department.

Laryngoscope 2020 11 26;130(11):E705. Epub 2020 Mar 26.

Department of Otolaryngology Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A.

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http://dx.doi.org/10.1002/lary.28624DOI Listing
November 2020

Contrasting responses to climate change at Himalayan treelines revealed by population demographics of two dominant species.

Ecol Evol 2020 Feb 28;10(3):1209-1222. Epub 2020 Jan 28.

School of Biological Sciences Plymouth University Plymouth UK.

Alpine treelines are expected to shift upward due to recent climate change. However, interpretation of changes in montane systems has been problematic because effects of climate change are frequently confounded with those of land use changes. The eastern Himalaya, particularly Langtang National Park, Central Nepal, has been relatively undisturbed for centuries and thus presents an opportunity for studying climate change impacts on alpine treeline uncontaminated by potential confounding factors.We studied two dominant species, and , above and below the treeline on two mountains. We constructed 13 transects, each spanning up to 400 m in elevation, in which we recorded height and state (dead or alive) of all trees, as well as slope, aspect, canopy density, and measures of anthropogenic and animal disturbance.All size classes of plants had lower mortality above treeline than below it, and young plants (<2 m tall) were at higher density above treeline than below. shows little evidence of a position change from the historic treeline, with a sudden extreme drop in density above treeline compared to below. Recruitment, as measured by size-class distribution, was greater above treeline than below for both species but is confined to ~25 m above treeline whereas is luxuriantly growing up to 200 m above treeline. . Evidence suggests that the elevational limits of have shifted upward both because (a) young plants above treeline benefited from facilitation of recruitment by surrounding vegetation, allowing upward expansion of recruitment, and (b) temperature amelioration to mature plants increased adult survival. We predict that the current pure stand of growing above treeline will be colonized by that will, in turn, outshade and eventually relegate to be a minor component of the community, as is the current situation below the treeline.
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http://dx.doi.org/10.1002/ece3.5968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7029064PMC
February 2020

What Do Your Patients Think of You? An Analysis of 84 230 Physician Review Website Reviews in Ophthalmology.

Ophthalmology 2020 03 17;127(3):426-427. Epub 2019 Oct 17.

Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2019.10.016DOI Listing
March 2020

Distribution and Location of Vortex Vein Ampullae in Healthy Human Eyes as Assessed by Ultra-Widefield Indocyanine Green Angiography.

Ophthalmol Retina 2020 05 18;4(5):530-534. Epub 2019 Nov 18.

Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California. Electronic address:

Purpose: To study the number and distribution of vortex ampullae in healthy eyes using ultra-wide field (UWF) indocyanine green angiography (ICGA).

Design: Prospective, observational study.

Participants: Thirty-six eyes of 36 healthy participants with no evidence of ocular or systemic disease.

Methods: The UWF ICGA images (central and peripheral steered) were captured using the Optos California (Optos, Dunfermline, United Kingdom) instrument. The images were projected stereographically to correct for peripheral distortion and obtain accurate measurements. All images were graded and analyzed for number, location, and distance of the vortex vein ampullae from the center of optic nerve.

Main Outcome Measures: Mean number and the distance of ampullae from the center of optic nerve in all quadrants.

Results: The mean number of ampullae observed by UWF ICGA was 8.0±2.1 (range, 5-13). The mean distance of a vortex vein ampulla from the optic nerve was 14.2±1.1 mm (range, 10.3-17.7 mm). The frequency of ampullae was higher in the superior and inferior quadrants than the nasal and temporal quadrants. Ampullae were never observed in the 3- or 9-o'clock meridians. Multiple regression analysis showed no relationship with age, gender, axial length, or ethnicity. Excellent intergrader reproducibility was found between graders with an intraclass correlation coefficient (distance measurements: intraclass correlation coefficient, 0.99; 95% CI, 0.979-0.999; P < 0.001; number of ampullae: intraclass correlation coefficient, 0.99; 95% CI, 0.988-0.999; P < 0.001).

Conclusions: The number of discrete vortex vein ampullae that can be discerned by UWF ICGA in healthy individuals is greater frequently and substantially than the 4 that are traditionally thought to drain the major quadrants. Considerable variability in the number and position of the ampullae may be apparent in healthy individuals.
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http://dx.doi.org/10.1016/j.oret.2019.11.009DOI Listing
May 2020

Dietary specialization is conditionally associated with increased ant predation risk in a temperate forest caterpillar community.

Ecol Evol 2019 Nov 11;9(21):12099-12112. Epub 2019 Oct 11.

Department of Biological Sciences University of New Mexico Albuquerque NM USA.

The enemy-free space hypothesis (EFSH) contends that generalist predators select for dietary specialization in insect herbivores. At a community level, the EFSH predicts that dietary specialization reduces predation risk, and this pattern has been found in several studies addressing the impact of individual predator taxa or guilds. However, predation at a community level is also subject to combinatorial effects of multiple-predator types, raising the question of how so-called multiple-predator effects relate to dietary specialization in insect herbivores. Here, we test the EFSH with a field experiment quantifying ant predation risk to insect herbivores (caterpillars) with and without the combined predation effects of birds. Assessing a community of 20 caterpillar species, we use model selection in a phylogenetic comparative framework to identify the caterpillar traits that best predict the risk of ant predation. A caterpillar species' abundance, dietary specialization, and behavioral defenses were important predictors of its ant predation risk. Abundant caterpillar species had increased risk of ant predation irrespective of bird predation. Caterpillar species with broad diet breadth and behavioral responsiveness to attack had reduced ant predation risk, but these ant effects only occurred when birds also had access to the caterpillar community. These findings suggest that ant predation of caterpillar species is density- or frequency-dependent, that ants and birds may impose countervailing selection on dietary specialization within the same herbivore community, and that contingent effects of multiple predators may generate behaviorally mediated life-history trade-offs associated with herbivore diet breadth.
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http://dx.doi.org/10.1002/ece3.5662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854387PMC
November 2019

Treatment of central serous chorioretinopathy with topical NSAIDs.

Clin Ophthalmol 2019 15;13:1543-1548. Epub 2019 Aug 15.

Medical Center Ophthalmology Associates, San Antonio, TX, USA.

Purpose: Central serous chorioretinopathy (CSCR) is a common retinopathy that is often observed until resolution. The purpose of this study is to evaluate the effects of topical nonsteroidal anti-inflammatory drugs (NSAIDs) on timing of CSCR recovery.

Methods: An IRB-approved retrospective review was conducted on patients that had been diagnosed with a new-onset, symptomatic case of CSCR. Patients were either observed only (13 untreated eyes) or treated with topical bromfenac or nepafenac (14 eyes) over an average of about a 4-5 week follow-up period.

Results: There was no statistical significance between central macular thickness (CMT) and visual acuity of treatment and control groups at the initial presentation. However, at the follow-up visit, CMT reductions in the treatment group were significantly higher than in the control group (<0.006).

Conclusion: Use of topical NSAIDs in the treatment of acute CSCR leads to a faster rate of reduction in the subretinal fluid volume over a follow-up period of a few weeks.
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http://dx.doi.org/10.2147/OPTH.S202047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699520PMC
August 2019

A faster parathyroidectomy: Techniques to shorten non-surgical operating room time.

Am J Otolaryngol 2019 Nov - Dec;40(6):102292. Epub 2019 Sep 10.

Department of Otolaryngology - Head and Neck Surgery, Henry Ford Health System, 2700 West Grand Boulevard, Detroit, MI 48202, United States of America. Electronic address:

Objective: To assess the capacity of different techniques to reduce non-operative times during parathyroid surgery. The impact of monitored anesthesia care (MAC) instead of general anesthesia, and the pre-operative placement of a second peripheral intravenous catheter (PIV) were analyzed.

Methods: A retrospective case series at an academic medical center was performed to study patients undergoing parathyroidectomy by a single surgeon between November 2013 and October 2016. Three operating room (OR) time measurements were compared: pre-incision time, post-closure time, and total OR time.

Results: Surgeries performed under MAC (n = 21) had statistically shorter pre-incision (33.2 min vs. 39.7 min, p < .001), post-closure (10.1 min vs. 16.2 min, p = .002), and total operative times (113.0 min vs. 151.5 min, p < .001) compared to those in which general anesthesia (n = 169) was used. Of the 169 patients who underwent general anesthesia, 25 had a second PIV placed preoperatively and 144 had only a single PIV. All 3 time periods were statistically shorter in patients who had a second PIV versus those who had only a single PIV (pre-incision 32.2 min vs. 41.0 min, p < .001; post-closure 12.2 min vs. 16.9 min, p < .001; total 117.9 min vs. 157.4 min, p < .001).

Conclusions: In patients undergoing parathyroid surgery in which ioPTH levels will be used, the placement of a second PIV in the pre-operative holding area and performance of surgery under MAC can significantly shorten non-operative and total OR time.
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http://dx.doi.org/10.1016/j.amjoto.2019.102292DOI Listing
April 2020

Aridity is expressed in river topography globally.

Nature 2019 09 16;573(7775):573-577. Epub 2019 Sep 16.

Earth Research Institute, University of California Santa Barbara, Santa Barbara, CA, USA.

It has long been suggested that climate shapes land surface topography through interactions between rainfall, runoff and erosion in drainage basins. The longitudinal profile of a river (elevation versus distance downstream) is a key morphological attribute that reflects the history of drainage basin evolution, so its form should be diagnostic of the regional expression of climate and its interaction with the land surface. However, both detecting climatic signatures in longitudinal profiles and deciphering the climatic mechanisms of their development have been challenging, owing to the lack of relevant global data and to the variable effects of tectonics, lithology, land surface properties and human activities. Here we present a global dataset of 333,502 river longitudinal profiles, and use it to explore differences in overall profile shape (concavity) across climate zones. We show that river profiles are systematically straighter with increasing aridity. Through simple numerical modelling, we demonstrate that these global patterns in longitudinal profile shape can be explained by hydrological controls that reflect rainfall-runoff regimes in different climate zones. The most important of these is the downstream rate of change in streamflow, independent of the area of the drainage basin. Our results illustrate that river topography expresses a signature of aridity, suggesting that climate is a first-order control on the evolution of the drainage basin.
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http://dx.doi.org/10.1038/s41586-019-1558-8DOI Listing
September 2019

Relationship Between Retinal Fractal Dimension and Nonperfusion in Diabetic Retinopathy on Ultrawide-Field Fluorescein Angiography.

Am J Ophthalmol 2020 01 29;209:99-106. Epub 2019 Aug 29.

Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California, USA; Department of Ophthalmology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA. Electronic address:

Purpose: To correlate fractal dimension (FD) of the retinal vasculature with the extent of retinal nonperfusion area in diabetic retinopathy (DR) on ultrawide-field fluorescein angiography (FA).

Design: Cross-sectional study.

Methods: Baseline Optos 200Tx ultrawide-field FA images of 80 eyes with DR from the DAVE (NCT01552408) and RECOVERY (NCT02863354) studies were stereographically projected at the Doheny Image Reading Center. The retinal vasculature was extracted from an early-phase FA frame by exploiting the elongated nature of the vessels and then skeletonized for calculation of FD using a box-counting method. The nonperfusion area was delineated by 2 independent, reading center-certified graders who were masked to the study groups and who were using a standardized protocol and then computed in millimeters squared.

Results: While no difference in FD was observed for the entire retina in DR compared with normal control subjects, a significantly smaller FD was found in the far-periphery of the DR eyes (P < .001). FD for the entire retina was negatively associated with global nonperfusion area (R = -0.44; P < .001), and this relationship was also present within the 3 concentric retinal zones (posterior: R = -0.31, P = .016; midperiphery: R = -0.35, P = .007; and far periphery: R = -0.31, P = .015).

Conclusions: Peripheral FD on ultrawide-field FA is reduced in DR eyes compared with normal eyes and is correlated with severity of retinal nonperfusion. FD can be calculated automatically without the need for correction of peripheral distortion, and therefore it may prove to be a useful surrogate biomarker when precise quantification of nonperfusion is not feasible.
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http://dx.doi.org/10.1016/j.ajo.2019.08.015DOI Listing
January 2020

Butterflies embrace maladaptation and raise fitness in colonizing novel host.

Evol Appl 2019 Aug 26;12(7):1417-1433. Epub 2019 Feb 26.

Theoretical and Experimental Ecology Station UMR 5321 CNRS and Paul Sabatier University Moulis France.

We illustrate an evolutionary host shift driven by increased fitness on a novel host, despite maladaptation to it in six separate host-adaptive traits. Here, local adaptation is defined as possession of traits that provide advantage in specific environmental contexts; thus individuals can have higher fitness in benign environments to which they are maladapted than in demanding environments to which they are well adapted. A population of the butterfly adapted to a long-lived, chemically well-defended host, had traditionally been under natural selection to avoid the ephemeral, less-defended . The lifespan of was so short that it senesced before larvae entered diapause. After logging killed in clear-cut patches and controlled burning simultaneously extended lifespan, insect fitness on in clearings suddenly became higher than on in adjacent unlogged patches. was rapidly colonized and preference for it evolved, but insects feeding on it retained adaptations to in alighting bias, two aspects of postalighting oviposition preference, dispersal bias, geotaxis, and clutch size, all acting as maladaptations to . Nonetheless, populations boomed on in clearings, creating sources that fed pseudosinks in unlogged patches where was still used. After c. 20 years, butterfly populations in clearings disappeared and the metapopulation reverted to -feeding. Here we show, via experimental manipulation of oviposition by local -adapted and imported -adapted butterflies, that the highest survival at that time would have been from eggs laid in clearings by butterflies adapted to . Second highest were locals on . In third place would have been locals on in clearings, because local females maladaptively preferred senescent plants. had been colonized despite maladaptation and, after successional changes, abandoned because of it. However, the abandoned could still have provided the highest fitness, given appropriate adaptation. The butterflies had tumbled down an adaptive peak.
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http://dx.doi.org/10.1111/eva.12775DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6691209PMC
August 2019

The effects of temporary intraocular pressure spikes after intravitreal dexamethasone implantation on the retinal nerve fiber layer.

Clin Ophthalmol 2019 27;13:1079-1086. Epub 2019 Jun 27.

Medical Center Ophthalmology Associates , San Antonio, TX, USA.

The dexamethasone (DEX) implant is known to cause temporary intraocular pressure (IOP) spikes after implantation. The purpose of this study is to determine if IOP spikes after DEX implant cause significant thinning in the retinal nerve fiber layer (RNFL). A total of 306 charts were reviewed with 48 and 21 patients meeting inclusion criteria for the cross-sectional and prospective groups, respectively. Cross-sectional inclusion criteria: IOP spike ≥22 mmHg up to 16 weeks after DEX implant, DEX implant in only 1 eye per patient, and spectral-domain optical coherence tomography (OCT) RNFL imaging of both eyes ≥3 months after IOP spike. Prospective inclusion criteria: OCT RNFL performed within 1 year prior to DEX implantation, IOP spike ≥22 mmHg up to 16 weeks after DEX implant, and OCT RNFL performed ≥3 months after IOP spike. The average RNFL thickness in the contralateral eye was used as the control in the cross-sectional group. Institutional review board approval was obtained. In the cross-sectional group, there was no statistically significant difference in the mean RNFL thicknesses in the treated vs untreated eyes (80.4±15.5 μm and 82.6±15.8 μm, respectively; =0.33) regardless of treatment diagnosis, magnitude of IOP spike, or history of glaucoma. In the prospective group, mean RNFL thicknesses before and after IOP spikes ≥22 mmHg were similar (78.0±14.8 μm and 75.6±13.6 μm, respectively; =0.13). Temporary elevation of IOP after DEX implantation when treated with topical IOP lowering drops does not appear to lead to a meaningful change in RNFL thickness.
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http://dx.doi.org/10.2147/OPTH.S201395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602526PMC
June 2019

Increased prevalence of neural monitoring during thyroidectomy: Global surgical survey.

Laryngoscope 2020 04 30;130(4):1097-1104. Epub 2019 Jul 30.

Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School Boston, Massachusetts, U.S.A.

Objective: To investigate intraoperative nerve monitoring (IONM) use among thyroid surgeons.

Methods: A 25-question survey was used to assess attitudes regarding IONM use. Surveys were sent to surgeons registered to the American Academy of Otolaryngology-Head and Neck Surgery, International Association of Endocrine Surgeons, and American Head and Neck Society.

Results: Among 1,015 respondents, 83% reported using IONM (65.1% always using IONM and 18.1% reporting selective use). For selective users, a majority reported using IONM for reoperative cases (95.1%) and in cases with preoperative vocal cord paralysis (59.8%). When comparing location, there was a significant difference in IONM implementation (P < 0.001), with 70.4% of North American responders using it ubiquitously compared to 27.4% of non-North American responders. Preoperative laryngeal exam was performed more universally by North American surgeons and more selectively by non-North American surgeons (P < 0.001). Other attitudes toward their implementation and the postoperative laryngeal exam were similar. Surgeons ≤45 years of age and those with ≤15 years of practice used IONM more than their peers (P < 0.001). Thyroid surgery volume, fellowship training, and type of practice had no bearing on IONM use.

Conclusion: The prevalence of IONM in thyroid and parathyroid surgeries has increased significantly over the past decade, with 83% of surgeons using IONM in some or all cases. Although IONM use may be more ubiquitous in North America, attitudes toward its implementation and pre- and postoperative laryngeal exams are fairly uniform. IONM use is more prevalent among younger surgeons, whereas its use has no correlation with thyroid surgery volume or type of practice.

Level Of Evidence: 4 Laryngoscope, 130:1097-1104, 2020.
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http://dx.doi.org/10.1002/lary.28210DOI Listing
April 2020

Keystone mutualism influences forest tree growth at a landscape scale.

Ecol Lett 2019 Oct 26;22(10):1599-1607. Epub 2019 Jul 26.

Department of Biology, Wesleyan University, Middletown, CT, USA.

Interactions between ants and phloem-feeding herbivores are characterised as a keystone mutualism because they restructure arthropod communities and generate trophic cascades. Keystone interactions in terrestrial food webs are hypothesised to depend on herbivore community structure and bottom-up effects on plant growth. Here, we tested this prediction at a landscape scale with a long-term ant-exclusion experiment on hickory saplings in the context of spatial variation in herbivore community structure and habitat quality. We quantified top-down effects of ants, herbivore communities as well as abiotic factors impacting hickory shoot growth. We found that ants influenced shoot growth via strong, context-dependent, compensatory effects, with clear cascading benefits only when phloem-feeders were present and chewing herbivore abundance was high. By contrast, while several landscape variables predicted hickory growth, they did not mediate the strength of cascading effects of ants. These results suggest that ant/sap-feeder mutualisms may regulate forest productivity by mediating effects of multiple herbivore guilds.
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http://dx.doi.org/10.1111/ele.13352DOI Listing
October 2019

Rivaroxaban treatment of cancer-associated venous thromboembolism: Memorial Sloan Kettering Cancer Center institutional experience.

Res Pract Thromb Haemost 2019 Jul 24;3(3):349-356. Epub 2019 May 24.

Department of Medicine/Division of Hematologic Oncology Memorial Sloan Kettering Cancer Center New York New York.

Background: Low-molecular-weight heparin has been the preferred treatment of cancer-associated thrombosis (CAT); however, emerging data support the use of direct oral anticoagulants (DOACs).

Objectives: The Memorial Sloan Kettering Cancer Center Clinical Pathway has served as the institutional guideline for the use of rivaroxaban to treat CAT since 2014. Key elements are to recommend against use of a DOAC in patients with active gastrointestinal (GI) or genitourinary tract lesions, and a prespecified dose reduction in the elderly (75+ years old). We present our institutional experience for treatment of CAT.

Methods: From January 2014 through September 2016, 1072 patients began rivaroxaban treatment for CAT; 91.9% had a solid tumor, 8.1% had hematologic malignancies, and 75% of patients with solid tumors had metastatic disease. All patients with CAT treated with rivaroxaban were included in this analysis, regardless of adherence to the Clinical Pathway.

Results: The 6-month cumulative incidence of recurrent venous thromboembolism and major bleeding were 4.2% (95% confidence interval [CI], 2.7%-5.7%) and 2.2% (95% CI, 1.1%-3.2%), respectively. The incidence of clinically relevant non-major bleeding leading to discontinuation of rivaroxaban for at least 7 days was 5.5% (95% CI,  3.7%-7.1%), and 73.3% of major bleeds occurred in the GI tract. The 6-month cumulative mortality rate was 22.2% (95% CI, 19.4%-24.9%). The elderly had similar rates of recurrent thrombosis and bleeding as those aged under 75 years.

Conclusion: Our institutional experience suggests that in appropriately selected patients, rivaroxaban may be used for treatment of CAT with promising safety and efficacy.
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http://dx.doi.org/10.1002/rth2.12215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611365PMC
July 2019

Editorial overview: Communication in multitrophic interactions - new analytical approaches and emerging ecological consequences.

Curr Opin Insect Sci 2019 04;32:iii-v

Entomologist Research Associate, BetaHatch, 1421 S 192nd St, SeaTac, WA, 98148, United States. Electronic address:

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http://dx.doi.org/10.1016/j.cois.2019.04.004DOI Listing
April 2019

Surgical impact of a dedicated endocrine surgeon on an academic otolaryngology department.

Laryngoscope 2020 03 6;130(3):832-835. Epub 2019 May 6.

Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A.

Objectives: Endocrine surgery is emerging as a dedicated subspecialty in otolaryngology. We assess the impact of an endocrine surgeon on an academic otolaryngology department's thyroid and parathyroid surgery volume.

Methods: A retrospective study of overall endocrine caseloads and resident case logs at a single academic center in the Midwest was performed. All thyroid and parathyroid cases performed by the otolaryngology department at an academic center from 2011 to 2017 were reviewed. In September 2012, an otolaryngologist who had completed an American Head and Neck Society endocrine surgery fellowship joined the faculty. The volume of endocrine surgery performed by the residents was also analyzed. Comparison of means and linear regression models were performed.

Results: From 2011 to 2012, the department performed a mean of 77 thyroid and 11.5 parathyroid surgeries annually. After the endocrine surgeon joined the department, this increased to an average of 212.8 thyroidectomies (P < 0.01) and 72.4 parathyroidectomies (P < 0.01) a year. The head and neck surgeons and generalists still performed an average of 42.4 thyroidectomies and 2.6 parathyroidectomies a year. For graduating residents, the average number of thyroid/parathyroid cases increased from 42.5 in 2012 to 151 in 2016.

Conclusion: The addition of a fellowship-trained endocrine surgeon substantially increased the thyroid and parathyroid surgical volume of the otolaryngology department. Importantly, generalists and head and neck surgeons in the department continued to perform a significant number of these cases. Departments seeking similar surgical growth and expanded resident experience may consider the value of engaging a dedicated endocrine surgeon.

Level Of Evidence: 4 Laryngoscope, 130:832-835, 2020.
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http://dx.doi.org/10.1002/lary.28041DOI Listing
March 2020