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Breeze J, Whitford A, Gensheimer WG, Berg C. Physiological and radiological parameters predicting outcome from penetrating traumatic brain injury treated in the deployed military setting. BMJ Mil Health 2024; 170:228-231. [PMID: 36028282 DOI: 10.1136/military-2022-002118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/07/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Penetrating traumatic brain injury (TBI) is the most common cause of death in current military conflicts, and results in significant morbidity in survivors. Identifying those physiological and radiological parameters associated with worse clinical outcomes following penetrating TBI in the austere setting may assist military clinicians to provide optimal care. METHOD All emergency neurosurgical procedures performed at a Role 3 Medical Treatment Facility in Afghanistan for penetrating TBI between 01 January 2016 and 18 December 2020 were analysed. The odds of certain clinical outcomes (death and functional dependence post-discharge) occurring following surgery were matched to existing agreed preoperative variables described in current US and UK military guidelines. Additional physiological and radiological variables including those comprising the Rotterdam criteria of TBI used in civilian settings were additionally analysed to determine their potential utility in a military austere setting. RESULTS 55 casualties with penetrating TBI underwent surgery, all either by decompressive craniectomy (n=42) or craniotomy±elevation of skull fragments (n=13). The odds of dying in hospital attributable to TBI were greater with casualties with increased glucose on arrival (OR=70.014, CI=3.0399 to 1612.528, OR=70.014, p=0.008) or a mean arterial pressure <90 mm Hg (OR=4.721, CI=0.969 to 22.979, p=0.049). Preoperative hyperglycaemia was also associated with increased odds of being functionally dependent on others on discharge (OR=11.165, CI=1.905 to 65.427, p=0.007). Bihemispheric injury had greater odds of being functionally dependent on others at discharge (OR=5.275, CI=1.094 to 25.433, p=0.038). CONCLUSIONS We would recommend that consideration of these three additional preoperative clinical parameters (hyperglycaemia, hypotension and bihemispheric injury on CT) when managing penetrating TBI be considered in future updates of guidelines for deployed neurosurgical care.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - A Whitford
- Gaza Barracks, Joint Hospital Group, Catterick, UK
| | - W G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center Joint Base Andrews, Prince George's County, Maryland, USA
| | - C Berg
- Department of Neurosurgery, Wright-Patterson Air Force Base, Dayton, Ohio, USA
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Travor MD, Levine ES, Catomeris AJ, Purt B, Gensheimer WG, Justin GA, Trevino JD, Haagsma JA, Colyer MH, Staudt AM. Disability-Adjusted Life Years Resulting from Ocular Injury among Deployed Service Members, 2001-2020. Ophthalmology 2024; 131:534-544. [PMID: 38008289 DOI: 10.1016/j.ophtha.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023] Open
Abstract
PURPOSE To quantify the burden of ocular injuries on deployed US service members by calculating disability-adjusted life years (DALYs). DESIGN Retrospective, observational cohort study. PARTICIPANTS US service members with ocular injuries sustained in combat zones from January 1, 2001 to May 19, 2020. METHODS Health states and duration of injuries were identified using data from the Defense and Veterans Eye Injury and Vision Registry. These health states were mapped to disability weights from the Global Burden of Disease (GBD) study. Average duration of injury or illness was calculated until remission or death. For the latter, life expectancy at age of sustaining injury, as identified from US Life Tables from the National Vital Statistics Reports 2020, was used. Using Defense Manpower Data Center reports capturing number of service members deployed per year, incidence rates were calculated for ocular injury and DALYs. MAIN OUTCOME MEASURES Disability-adjusted life years of ocular injury. RESULTS Seventeen thousand five hundred fifty-five patients sustained ocular injury that incurred DALYs. In total, these injuries resulted in 11 214 DALYs (average, 0.64 DALYs per included patient and 20.6 DALYs per 10 000 US service members per year). Severe impairment of distance vision (77.9%) and blindness (10.6%) were the primary contributors of DALYs. Although only 9.3% of patients sustained a permanent ocular injury, permanent disability accounted for 99.5% of total DALYs. The average yearly incidence rate of ocular injury was 32.0 cases per 10 000 US service members. Foreign body was the most frequent injury type (2754 occurrences), followed by abrasion (2419 occurrences) and multiple injury types (1429 occurrences). The most DALYs occurred in patients with multiple injury types (2485 DALYs), followed by abrasion (accounting for 725 DALYs) and foreign body (accounting for 461 DALYs). DISCUSSION We report higher average DALYs per case ratio among US service members compared with the general population studied by the GBD study, highlighting the differences in probabilities of permanent injury between the two studies. Our study provides understanding of the impact of ocular injuries on active-duty service members and lays the groundwork for further research and interventions to mitigate their burden. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Mark D Travor
- Ophthalmology Section, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily S Levine
- Ophthalmology Section, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew J Catomeris
- Ophthalmology Section, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Boonkit Purt
- Walter Reed-Uniformed Services University Department of Surgery, Uniformed Services University, Bethesda, Maryland; Department of Ophthalmology, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
| | - William G Gensheimer
- Ophthalmology Section, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Ophthalmology Section, White River Junction VA Medical Center, White River Junction, Vermont
| | - Grant A Justin
- Walter Reed-Uniformed Services University Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Jennifer D Trevino
- Department of Data Analytics and Epidemiology, The Geneva Foundation, JBSA Fort Sam Houston, San Antonio, Texas
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marcus H Colyer
- Walter Reed-Uniformed Services University Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Amanda M Staudt
- Department of Data Analytics and Epidemiology, The Geneva Foundation, JBSA Fort Sam Houston, San Antonio, Texas.
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Patterson TJ, Kedzierski A, McKinney D, Ritson J, McLean C, Gu W, Colyer M, McClellan SF, Miller SC, Justin GA, Hoskin AK, Cavuoto K, Leong J, Rousselot Ascarza A, Woreta FA, Miller KE, Caldwell MC, Gensheimer WG, Williamson T, Dhawahir-Scala F, Shah P, Coombes A, Sundar G, Mazzoli RA, Woodcock M, Watson SL, Kuhn F, Halliday S, Gomes RSM, Agrawal R, Blanch RJ. The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis. Ophthalmology 2024; 131:557-567. [PMID: 38086434 DOI: 10.1016/j.ophtha.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 02/12/2024] Open
Abstract
TOPIC Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Tim J Patterson
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Beflast, United Kingdom
| | | | - David McKinney
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Beflast, United Kingdom
| | - Jonathan Ritson
- Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom; Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Chris McLean
- Epsom and St Helier University Hospitals NHS Trust, Epsom, United Kingdom
| | - Weidong Gu
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Marcus Colyer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Scott F McClellan
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Sarah C Miller
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Grant A Justin
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Duke Eye Center, Duke University Hospitals, Durham, North Carolina
| | - Annette K Hoskin
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Kara Cavuoto
- Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - James Leong
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrés Rousselot Ascarza
- Consultorios Oftalmológicos Benisek-Ascarza, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kyle E Miller
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Ophthalmology, Navy Medical Center Portsmouth, Portsmouth, Virginia
| | - Matthew C Caldwell
- Department of Ophthalmology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - William G Gensheimer
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; White River Junction Veterans Administration Medical Center, White River Junction, Vermont
| | - Tom Williamson
- Department of Ophthalmology, St. Thomas Hospital, London, United Kingdom
| | | | - Peter Shah
- Birmingham Institute for Glaucoma Research, Birmingham, United Kingdom; Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew Coombes
- Department of Ophthalmology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gangadhara Sundar
- Department of Ophthalmology, National University Hospital, Singapore, Republic of Singapore
| | - Robert A Mazzoli
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Malcolm Woodcock
- Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom
| | - Stephanie L Watson
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ferenc Kuhn
- Helen Keller Foundation for Research and Education, Birmingham, Alabama
| | | | - Renata S M Gomes
- Research & Innovation, BRAVO VICTOR, London, United Kingdom; Northern Hub for Veterans and Military Families Research, Northumbria University, Newcastle, United Kingdom
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore; Lee Kong Chian School of Medicine, Singapore, Republic of Singapore; Duke NUS Medical School, Singapore, Republic of Singapore
| | - Richard J Blanch
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Neuroscience & Ophthalmology, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom.
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Patterson TJ, Gu W, Colyer M, McClellan SF, Justin GA, Hoskin AK, Cavuoto K, Leong J, Ascarza AR, Gensheimer WG, Williamson T, Dhawahir-Scala F, Shah P, Sundar G, Woodcock M, Agrawal R, Blanch RJ. Reply. Ophthalmol Retina 2024; 8:e10-e11. [PMID: 38349314 DOI: 10.1016/j.oret.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 04/07/2024]
Affiliation(s)
- Tim J Patterson
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Belfast, United Kingdom
| | - Weidong Gu
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Marcus Colyer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Scott F McClellan
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Grant A Justin
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Duke Eye Center, Duke University Hospitals, Durham, North Carolina
| | - Annette K Hoskin
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Kara Cavuoto
- Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - James Leong
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; The University of Sydney, Save Sight Institute, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Andrés Rousselot Ascarza
- Consultorios Oftalmológicos Benisek-Ascarza, Ciudad Autónoma de Buenos Aires, C1115ABB Buenos Aires, Argentina
| | - William G Gensheimer
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; White River Junction Veterans Administration Medical Center, White River Junction, Vermont
| | - Tom Williamson
- Department of Ophthalmology, St Thomas Hospital, London, United Kingdom
| | | | - Peter Shah
- Birmingham Institute for Glaucoma Research, Birmingham, United Kingdom; Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Gangadhara Sundar
- Department of Ophthalmology, National University Hospital, Singapore
| | - Malcolm Woodcock
- Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore; Singapore Eye Research Institute, Singapore; Lee Kong Chian School of Medicine, Singapore; Duke NUS Medical School, Singapore
| | - Richard J Blanch
- Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Neuroscience & Ophthalmology, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Royal Centre for Defence Medicine, Birmingham, United Kingdom.
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Gensheimer WG. Custom Iris Prosthesis for Subtotal Traumatic Aniridia From Combat Ocular Trauma. Mil Med 2024; 189:e443-e447. [PMID: 37534897 DOI: 10.1093/milmed/usad278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 08/04/2023] Open
Abstract
Traumatic aniridia from combat ocular trauma can cause visual disability. A 41-year-old male Army Veteran was referred for evaluation of light sensitivity and glare secondary to subtotal traumatic aniridia of his left eye from an improvised explosive device blast. A custom-made artificial iris prosthesis was implanted in the ciliary sulcus and secured using Gore-Tex sutures. After surgery, the patient reported improvement of his light sensitivity and quality of life. The custom iris prosthesis is a surgical option for visual disability resulting from traumatic aniridia from combat ocular trauma.
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Affiliation(s)
- William G Gensheimer
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
- Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
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Patterson TJ, McKinney D, Ritson J, McLean C, Gu W, Colyer M, McClellan SF, Miller SC, Justin GA, Hoskin AK, Cavuoto K, Leong J, Ascarza AR, Woreta FA, Miller KE, Caldwell MC, Gensheimer WG, Williamson T, Dhawahir-Scala F, Shah P, Coombes A, Sundar G, Mazzoli RA, Woodcock M, Kuhn F, Watson SL, Gomes RSM, Agrawal R, Blanch RJ. The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis. Ophthalmol Retina 2023; 7:972-981. [PMID: 37406735 DOI: 10.1016/j.oret.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
TOPIC This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Tim J Patterson
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Belfast
| | - David McKinney
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Belfast
| | - Jonathan Ritson
- Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom; Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Chris McLean
- Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom
| | - Weidong Gu
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Marcus Colyer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Scott F McClellan
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Sarah C Miller
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Grant A Justin
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Duke Eye Center, Duke University Hospitals, Durham, North Carolina
| | - Annette K Hoskin
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Kara Cavuoto
- Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - James Leong
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; The University of Sydney, Save Sight Institute, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Andrés Rousselot Ascarza
- Consultorios Oftalmológicos Benisek-Ascarza, Ciudad Autónoma de Buenos Aires, C1115ABB Buenos Aires, Argentina
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kyle E Miller
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Ophthalmology, Navy Medical Center Portsmouth, Portsmouth, Virginia
| | - Matthew C Caldwell
- Department of Ophthalmology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - William G Gensheimer
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; White River Junction Veterans Administration Medical Center, White River Junction, Vermont
| | - Tom Williamson
- Department of Ophthalmology, St Thomas Hospital, London, United Kingdom
| | | | - Peter Shah
- Birmingham Institute for Glaucoma Research, Birmingham, United Kingdom; Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew Coombes
- Department of Ophthalmology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
| | - Gangadhara Sundar
- Department of Ophthalmology, National University Hospital, Singapore
| | - Robert A Mazzoli
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Malcolm Woodcock
- Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom
| | - Ferenc Kuhn
- Helen Keller Foundation for Research and Education, Birmingham, Alabama
| | - Stephanie L Watson
- The University of Sydney, Save Sight Institute, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Renata S M Gomes
- BRAVO VICTOR, Research & Innovation, London, United Kingdom; Northern Hub for Veterans and Military Families Research, Northumbria University, Newcastle, United Kingdom
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore; Singapore Eye Research Institute, Singapore; Lee Kong Chian School of Medicine, Singapore; Duke NUS Medical School, Singapore
| | - Richard J Blanch
- Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Neuroscience & Ophthalmology, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom.
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Chung RT, Legault GL, Stowe JS, Miller KE, Moccia MA, Cooper MR, Little JR, Gensheimer WG. Applying a Military Teleophthalmology Mobile App in a Noncombat Emergent Care Setting. Mil Med 2023; 188:e2909-e2915. [PMID: 36394286 DOI: 10.1093/milmed/usac345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/29/2022] [Accepted: 10/21/2022] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Teleophthalmology has a natural role in the military due to the inherent organization of its medical system, which provides care to patients in remote locations around the world. Improving access to ophthalmic care enhances force readiness because ocular trauma and disease can cause vision impairment or blindness and can occur anywhere service members are located. Recently, a secure, Health Insurance Portability and Accountability Act-compliant mobile phone application (app) for teleophthalmology called Forward Operating Base Expert Telemedicine Resource Utilizing Mobile Application for Trauma (FOXTROT) was beta tested in Afghanistan and demonstrated that this solution can improve and extend ophthalmic care in a deployed environment. There are few civilian or military teleophthalmology solutions for ocular trauma and disease in an urgent or emergent ophthalmic care setting. Civilian teleophthalmology solutions have largely been developed for disease-specific models of care. In this work, we address this gap by testing the FOXTROT app in a non-deployed, emergent care setting. MATERIALS AND METHODS We evaluated the use of the teleophthalmology mobile phone app (FOXTROT) in a non-deployed military setting at the Malcolm Grow Medical Clinics and Surgery Center at Joint Base Andrews in Maryland. Consults from the emergent care center were placed by providers using the app, and the on-call ophthalmologist responded with treatment and management recommendations. The primary outcomes were response within the requested time, visual acuity tested in both eyes, agreement between the teleophthalmology and the final diagnosis, and the number of communication or technical errors that prevented the completion of consults. The secondary outcomes were average response time and the number of consults uploaded to the medical record. RESULTS From October 2020 to January 2022, 109 consults were received. Ten consults had communication or technical errors that prevented the completion of consults within the app and were excluded from the analysis of completed consults. Of the 99 completed consults, responses were given within the requested time in 95 (96.0%), with the average response time in 11 minutes 48 seconds (95% confidence interval, 8 minutes 57 seconds to 14 minutes 41 seconds). Visual acuity was tested in both eyes in 56 (56.6%). There was agreement between the teleophthalmology diagnosis and the final diagnosisin 40 of 50 (80.0%) consults with both a teleophthalmology and final diagnosis. Ninety-eight (99.0%) consults were uploaded to the patient's medical record. CONCLUSIONS Beta testing of a teleophthalmology mobile phone app (FOXTROT) in a noncombat emergent care setting demonstrated that this solution can extend ophthalmic care in this environment at a military treatment facility. However, improvements in the reliability of the platform are needed in future developments to reduce communication and technical errors.
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Affiliation(s)
- Robert T Chung
- Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
| | - Gary L Legault
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jennifer S Stowe
- US Army Aeromedical Research Laboratory, Fort Rucker, AL 36362, USA
| | - Kyle E Miller
- Department of Surgery, Uniformed Services University, Bethesda, MD 20814, USA
- Department of Ophthalmology, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Michelle A Moccia
- Warfighter Eye Center, Joint Base Andrews, Joint Base Andrews, MD 20762, USA
| | - Mabel R Cooper
- Telemedicine & Advanced Technology Research Center (TATRC), Fort Detrick, MD 21702, USA
| | - Jeanette R Little
- Telemedicine & Advanced Technology Research Center (TATRC), Fort Detrick, MD 21702, USA
- Digital Health Innovation Center (DHIC), Fort Gordon, GA 30905, USA
- US Army Medical Research and Development Command (MRDC), Fort Detrick, MD 21702, USA
| | - William G Gensheimer
- Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
- Section of Ophthalmology, White River Junction VA Medical Center, White River Junction, VT 05001, USA
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Abstract
Importance The coronavirus disease 2019 pandemic has highlighted the need to expand telemedicine solutions. Objective To beta test a secure teleophthalmology mobile app at military treatment facilities in Afghanistan. Design, Setting, and Participants This prospective case series included 16 military treatment facilities at diverse roles of care including forward operating bases in Afghanistan and 1 location outside of Afghanistan. Thirty point-of-care medics and medical professionals were included from September to November 2019. Interventions Users placed teleophthalmology consults on their mobile phone using the mobile eye care app, and an expeditionary ophthalmologist stationed at a military hospital in Afghanistan responded. Users graded the mobile app using a rating scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied. Main Outcomes and Measures Mean initial response time, agreement between the teleophthalmology diagnosis and final diagnosis, treatment and management following recommendations outlined in the Joint Trauma System clinical practice guidelines, prevention of the need for aeromedical evacuation, user satisfaction, and security and the Health Insurance Portability and Accountability Act compliance of consult. Results There were 28 consults placed over 6 weeks by 18 different users that were received by the expeditionary ophthalmologist. The mean (SD) patient age was 30.3 (9.8) years. Most patients were male (26 [93%]) and active duty US military (22 [78%]). The mean initial response time was 3 minutes 58 seconds (95% CI, 2 minutes 30 seconds to 5 minutes 26 seconds). There was agreement between the teleophthalmology diagnosis and final diagnosis in 24 consults (86%; 95% CI, 72%-100%). The treatment and management followed recommendations outlined in the Joint Trauma System Clinical Practice Guidelines for Eye Trauma: Initial Care in 28 consults (100%). Teleophthalmology consultation prevented the need for aeromedical evacuation in 4 consults (14%; 95% CI, 0.7%-28%). The patient returned to duty in 15 consults (54%; 95% CI, 34%-73%). Median overall satisfaction was 5 (minimum, 3; maximum, 5). All 28 consults (100%) were secure and compliant with the Health Insurance Portability and Accountability Act. Conclusions and Relevance While only a limited number of consults were evaluated, this study suggests that teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones.
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Affiliation(s)
- William G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, Maryland.,Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, Maryland
| | - Kyle E Miller
- Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, Maryland.,Department of Ophthalmology, Navy Medical Center Portsmouth, Portsmouth, Virginia
| | - Jennifer Stowe
- US Army Aeromedical Research Laboratory, United States Army Medical Research and Development Command, Fort Rucker, Alabama
| | - Jeanette Little
- Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, Maryland
| | - Gary L Legault
- Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, Maryland.,Department of Ophthalmology, Brooke Army Medical Center, San Antonio, Texas
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Breeze J, Gensheimer WG, DuBose JJ. Penetrating Neck Injuries Treated at a U.S. Role 3 Medical Treatment Facility in Afghanistan During Operation Resolute Support. Mil Med 2020; 186:18-23. [PMID: 33007083 DOI: 10.1093/milmed/usaa252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/24/2020] [Accepted: 07/30/2020] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
Introduction
Military trauma registries can identify broad epidemiological trends from neck wounds but cannot reliably demonstrate temporal casualty from clinical interventions or differentiate penetrating neck injuries (PNI) from those that do not breach platysma.
Materials and Methods
All casualties presenting with a neck wound to a Role 3 Medical Treatment Facility in Afghanistan between January 1, 2016 and September 15, 2019 were retrospectively identified using the Emergency Room database. These were matched to records from the Operating Room database, and computed tomography (CT) scans reviewed to determine damage to the neck region.
Results
During this period, 78 casualties presented to the Emergency Room with a neck wound. Forty-one casualties underwent surgery for a neck wound, all of whom had a CT scan. Of these, 35/41 (85%) were deep to platysma (PNI). Casualties with PNI underwent neck exploration in 71% of casualties (25/35), with 8/25 (32%) having surgical exploration at Role 2 where CT is not present. Exploration was more likely in Zones 1 and 2 (8/10, 80% and 18/22, 82%, respectively) compared to Zone 3 (2/8, 25%).
Conclusion
Hemodynamically unstable patients in Zones 1 and 2 generally underwent surgery before CT, confirming that the low threshold for exploration in such patients remains. Only 25% (2/8) of Zone 3 PNI were explored, with the high negative predictive value of CT angiography providing confidence that it was capable of excluding major injury in the majority of cases. No deaths from PNI that survived to treatment at Role 3 were identified, lending evidence to the current management protocols being utilized in Afghanistan.
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Affiliation(s)
- John Breeze
- Royal Centre for Defence Medicine, University Hospitals Birmingham, Birmingham, UK
| | - William G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD, 20762, USA
| | - Joseph J DuBose
- Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA
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Blanch RJ, Kerber MT, Gensheimer WG. Deployed ophthalmic workload in support of US and NATO operations in Afghanistan. BMJ Mil Health 2020; 167:408-412. [PMID: 32139414 DOI: 10.1136/bmjmilitary-2019-001379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 11/03/2022]
Abstract
PURPOSE The extent and types of ophthalmic disease and non-battle injury (DNBI) seen by expeditionary ophthalmologists at deployed military medical treatment facilities have not previously been reported. We aim to characterise the extent and type of ophthalmic pathology including DNBI at a US military medical treatment facility in Afghanistan. METHODS We conducted a retrospective non-interventional cohort study of all patients seen by ophthalmologists at Craig Joint Theater Hospital at Bagram Airfield (BAF), Afghanistan, between 1 October 2018 and 31 August 2019. RESULTS There were 281 patients seen in 540 separate encounters, of which 146 patients seen were active duty military stationed at BAF with DNBI, of a population at risk of 6000 personnel. Diagnoses managed included open and closed globe injury, bacterial and herpetic keratitis and retinal detachment, with the most common being dry eye, corneal abrasion/foreign body, blepharitis, chalazion and uveitis. Thirteen patients (5%) required aeromedical evacuation out of theatre and 39 patients were aeromedically transferred within theatre for assessment. Expert consensus estimated that 89 patients (36%) would be likely to require aeromedical evacuation out of theatre without ophthalmic input. CONCLUSIONS The rate of ophthalmic DNBI among deployed US, UK and coalition forces at BAF was 2.65% per year, of whom 97% were returned to duty (95% of all patients). We estimate that evacuation and loss to unit would increase from 5% to 36% without an ophthalmologist present. The low number of within-theatre aeromedical transfers suggests that the local presence of an ophthalmologist at a patient's deployed medical treatment facility affects access to deployed ophthalmic care.
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Affiliation(s)
- Richard J Blanch
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom .,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom.,Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - M T Kerber
- United States Air Force Academy, Colorado Springs, Colorado, USA
| | - W G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, Maryland, USA
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Guo S, Sarfaraz NR, Gensheimer WG, Krieger A, Kang JU. Demonstration of Optical Coherence Tomography Guided Big Bubble Technique for Deep Anterior Lamellar Keratoplasty (DALK). Sensors (Basel) 2020; 20:s20020428. [PMID: 31940877 PMCID: PMC7013995 DOI: 10.3390/s20020428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/03/2022]
Abstract
Deep anterior lamellar keratoplasty (DALK) is a highly challenging procedure for cornea transplant that involves removing the corneal layers above Descemet’s membrane (DM). This is achieved by a “big bubble” technique where a needle is inserted into the stroma of the cornea down to DM and the injection of either air or liquid. DALK has important advantages over penetrating keratoplasty (PK) including lower rejection rate, less endothelial cell loss, and increased graft survival. In this paper, we successfully designed and evaluated the optical coherence tomography (OCT) distal sensor integrated needle for a precise big bubble technique. We successfully used this sensor for micro-control of a robotic DALK device termed AUTO-DALK for autonomous big bubble needle insertion. The OCT distal sensor was integrated inside a 25-gauge needle, which was used for pneumo-dissection. The AUTO-DALK device is built on a manual trephine platform which includes a vacuum ring to fix the device on the eye and add a needle driver at an angle of 60 degrees from vertical. During the test on five porcine eyes with a target depth of 90%, the measured insertion depth as a percentage of cornea thickness for the AUTO-DALK device was 90.05%±2.33% without any perforation compared to 79.16%±5.68% for unassisted free-hand insertion and 86.20%±5.31% for assisted free-hand insertion. The result showed a higher precision and consistency of the needle placement with AUTO-DALK, which could lead to better visual outcomes and fewer complications.
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Affiliation(s)
- Shoujing Guo
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21218, USA;
- Correspondence: ; Tel.: +1-443-858-6100
| | - Nicolas R. Sarfaraz
- Department of Mechanical Engineering, University of Maryland, College Park, MD 20742, USA; (N.R.S.); (A.K.)
| | - William G. Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD 20762, USA;
| | - Axel Krieger
- Department of Mechanical Engineering, University of Maryland, College Park, MD 20742, USA; (N.R.S.); (A.K.)
| | - Jin U. Kang
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21218, USA;
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Nandigam K, Soh J, Gensheimer WG, Ghazi A, Khalifa YM. Cost analysis of objective resident cataract surgery assessments. J Cataract Refract Surg 2015; 41:997-1003. [DOI: 10.1016/j.jcrs.2014.08.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 07/26/2014] [Accepted: 08/01/2014] [Indexed: 10/23/2022]
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Gensheimer WG, Kleinman DM, Gonzalez MO, Sobti D, Cooper ER, Smits G, Loxley A, Mitchnick M, Aquavella JV. Novel Formulation of Glycerin 1% Artificial Tears Extends Tear Film Break-Up Time Compared with Systane Lubricant Eye Drops. J Ocul Pharmacol Ther 2012; 28:473-8. [DOI: 10.1089/jop.2011.0053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - David M. Kleinman
- Department of Ophthalmology, Flaum Eye Institute, Rochester, New York
- Eyeon Therapeutics, Inc., Rochester, New York
| | - Mithra O. Gonzalez
- Rocky Mountain Lions Eye Institute, University of Colorado Denver, Aurora, Colorado
| | - Deepak Sobti
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Gerard Smits
- Computer and Statistical Consultants, Inc., Santa Barbara, California
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Gensheimer WG, Reddy SY, Mulconry M, Greves C. Abiotrophia/Granulicatella tubo-ovarian abscess in an adolescent virginal female. J Pediatr Adolesc Gynecol 2010; 23:e9-12. [PMID: 19682931 DOI: 10.1016/j.jpag.2009.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Accepted: 05/26/2009] [Indexed: 11/28/2022]
Abstract
Tubo-ovarian abscess (TOA) is a common acute complication of pelvic inflammatory disease (PID). It can also develop as a complication of pelvic or abdominal surgery, malignancy, and intra-abdominal processes such as appendicitis. In premenopausal women, PID is the most common cause of tubo-ovarian abscess. We report a case of tubo-ovarian abscess in a virginal adolescent female with no past surgical history and no known history of appendicitis, inflammatory bowel disease, or cancer. Cultures of the tubo-ovarian abscess drainage grew Abiotrophia/Granulicatella species. This case supports including TOA in the broad differential diagnosis for abdominal pain with fever in adolescent females regardless of sexual history.
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Affiliation(s)
- William G Gensheimer
- University of Rochester School of Medicine and Dentistry, Department of Obstetrics and Gynecology, Rochester, New York 14642, USA
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