Flipped classroom approach to global outreach:cross-cultural teaching of horizontal strabismus to Chinese ophthalmology residents

AIM:To evaluate the flipped classroom model for teaching horizontal strabismus didactics in an ophthalmology residency program in China as part of a visiting professorship from the United States.METHODS:Residents from an ophthalmology residency program in China were invited to participate in flipped classroom sessions taught by an experienced American ophthalmology faculty in 2018.Residents were instructed to watch a pre-class video lecture prior to the in-class-casebased activity.Content tests(5 Ophthalmic Knowledge Assessment Program style questions)and surveys were administered before and after the classroom sessions(100%response rate).These results were compared to that of an American cohort who were taught the same content.RESULTS:The Chinese cohort of 12 residents preferred the flipped classroom to the traditional classroom at higher rates than the American cohort of 40 residents(92%vs 55%,P=0.04)and felt that all ophthalmology topics would be appropriate for the flipped classroom teaching style(P-values between 0.008 and<0.001).In both Chinese and American cohorts,we found that the exotropia curriculum saw a small but significant improvement in performance following the flipped classroom session(P=0.025 for Chinese residents;P=0.001 for US residents),whereas scores in both groups for the esotropia course did not significantly improve.CONCLUSION:This is the first study to evaluate the flipped classroom model implemented by a visiting ophthalmology professor in a global outreach setting.The flipped classroom sessions are viewed favorably by the Chinese residents relative to the US cohort with a modest impact on knowledge.Decreased in-person interpreter requirement and increased student engagement make this model valuable in cross-cultural visiting professorship settings.Finally,the flipped classroom may lend itself well to a virtual format to prevent the transmission of COVID-19,although such a format requires further study.

Application of single-cell omics in inflammatory bowel disease

Over the past decade,the advent of single cell RNA-sequencing has revolutionized the approach in cellular transcriptomics research.The current technology offers an unbiased platform to understand how genotype correlates to phenotype.Single-cell omics applications in gastrointestinal(GI)research namely inflammatory bowel disease(IBD)has become popular in the last few years with multiple publications as single-cell omics techniques can be applied directly to the target organ,the GI tract at the tissue level.Through examination of mucosal tissue and peripheral blood in IBD,the recent boom in single cell research has identified a myriad of key immune players from enterocytes to tissue resident memory T cells,and explored functional heterogeneity within cellular subsets previously unreported.As we begin to unravel the complex mucosal immune system in states of health and disease like IBD,the power of exploration through single-cell omics can change our approach to translational research.As novel techniques evolve through multiplexing single-cell omics and spatial transcriptomics come to the forefront,we can begin to fully comprehend the disease IBD and better design targets of treatment.In addition,hopefully these techniques can ultimately begin to identify biomarkers of therapeutic response and answer clinically relevant questions in how to tailor individual therapy to patients through personalized medicine.

Diabetes exacerbates inflammatory bowel disease in mice with dietinduced obesity

BACKGROUND The increased prevalence of inflammatory bowel disease(IBD)among patients with obesity and type 2 diabetes suggests a causal link between these diseases,potentially involving the effect of hyperglycemia to disrupt intestinal barrier integrity.AIM To investigate whether the deleterious impact of diabetes on the intestinal barrier is associated with increased IBD severity in a murine model of colitis in mice with and without diet-induced obesity.METHODS Mice were fed chow or a high-fat diet and subsequently received streptozotocin to induce diabetic-range hyperglycemia.Six weeks later,dextran sodium sulfate was given to induce colitis.In select experiments,a subset of diabetic mice was treated with the antidiabetic drug dapagliflozin prior to colitis onset.Endpoints included both clinical and histological measures of colitis activity as well as histochemical markers of colonic epithelial barrier integrity.RESULTS In mice given a high-fat diet,but not chow-fed animals,diabetes was associated with significantly increased clinical colitis activity and histopathologic markers of disease severity.Diabetes was also associated with a decrease in key components that regulate colonic epithelial barrier integrity(colonic mucin layer content and epithelial tight junction proteins)in diet-induced obese mice.Each of these effects of diabetes in diet-induced obese mice was ameliorated by restoring normoglycemia.CONCLUSION In obese mice,diabetes worsened clinical and pathologic outcomes of colitis via mechanisms that are reversible with treatment of hyperglycemia.Hyperglycemia-induced intestinal barrier dysfunction offers a plausible mechanism linking diabetes to increased colitis severity.These findings suggest that effective diabetes management may decrease the clinical severity of IBD.

Perforated duodenal ulcer:An unusual manifestation of allergic eosinophilic gastroenteritis

Spontaneous perforation of a duodenal ulcer secondary to allergic eosinophilic gastroenteritis(EGE) has not been previously reported. We present such a case in a teenager who presented with peritonitis. After exploration and operative repair of his ulcer, he continued to experience intermittent abdominal pain, and further evaluation revealed eosinophilic gastroenteritis in the setting of multiple food allergies. His EGE resolved after adhering to a restrictive diet. Both duodenal ulcers and EGE are very rarely seen in pediatric patients. EGE has a variable presentation depending on the layer(s) of bowel wall affected and the segment of the gastrointestinal tract that is involved. Once diagnosed, it may respond to dietary changes in patients with recognized food allergies, or to steroids in patients in whom an underlying cause is not identified. Our case highlights the need to keep EGE in the differential diagnosis when treating pediatric patients with duodenal ulcers. The epidemiology, pathophysiology, and treatment of EGE are also discussed, along with a review of the current literature.

Survey of current retinopathy of prematurity practices in China

AIM:To understand retinopathy of prematurity(ROP)screening and treatment preferences among Chinese ophthalmologists.METHODS:A Chinese language survey was administered anonymously using Web Q(Catalyst,Seattle,WA,USA)among Chinese ROP screeners from December 2016 to January 2017.RESULTS:Among 70 ophthalmologists contacted,65 responded(93%;78%female,mean age 40 y,57%pediatric ophthalmologists and 25%retina specialists).Most used screening criteria of birth weight≤2 kg(62%)with variation in cut-off gestational age(≤37 wk,34%;≤34 wk,22%;≤32 wk,31%).Ret Cam(Natus Medical Incorporated,Pleasanton,CA,USA)wide-field fundus photography assisted most screeners(72%)and was exclusively used by many(29%).Among 55 ophthalmologists treating ROP,anti-vascular endothelial growth factor(VEGF)was preferred over laser for both zoneⅠ(76%vs 24%)and zoneⅡROP(58%vs 42%).Retina specialists(P=0.004)and ophthalmologists with>3 mo of training(P=0.03)were more likely to use antiVEGF over laser for zoneⅠROP.Lack of laser training(8/20,40%),access(6/20,30%)and anesthesia(4/20,20%)were common barriers to laser treatment.CONCLUSION:Chinese ROP screeners favor antiVEGF injection and Ret Cam imaging for ROP management.A better understanding of ROP screening and treatment informs future research and education efforts in China.

Estimated additional lifetime risk of cancer attributable to diagnostic CT in a pediatric bone marrow transplant cohort: Experience at a single academic institution

Purpose: To determine the frequency of CT procedures in a cohort of bone marrow transplant patients and estimate the effective dose from each CT procedure as well as rough estimates of lifetime attributable risk (LAR) of cancer (both incidence and mortality). Background: Pediatric patients who undergo bone marrow transplant benefit greatly from the diagnostic power of computed tomography, but due to the need for frequent imaging, these patients are repeatedly exposed to the carcinogenic potential of ionizing radiation. Methods: CT Imaging and patient parameters were collected from a retrospective cohort of bone marrow transplant patients. Dosimetry was estimated as a function of age, dose length product (DLP), and scan region based on published DLP to effective dose tables. Lifetime attributable risk (LAR) of cancer as a function of age, gender, and organ specific dose was derived from BEIR VII phase 2 estimates. Results: 44 patients with bone marrow transplant were included and ranged in age from 7 months to 20 years (average age, 9 years). The average number of CT studies per patient was 3.2 over the 15 month period. The average effective dose for each study was 5.9 +/– 4.5 mSv. Cumulative effective dose to each patient was 20 +/– 32 mSv. It was estimated that in this cohort, the CT imaging performed over a 15-month period on a 64-slice scanner led to a lifetime additional risk of cancer incidence of 5 in 1000 and a lifetime additional risk of cancer mortality of 2 in 1000. Conclusion: Diagnostic CT is important in the assessment and management of ill patients following bone marrow transplant. The risk of ionizing radiation leading to additional development of cancer merits using as low a CT technique as reasonable to achieve a diagnostic study.

SNPs and TFBS Associated with High Altitude Sickness

The rSNPs for the genes AKT3 (rs4590656), EGLN1 (rs480902), eNOS3 (rs1007311), and VEGFA (rs699947, rs13207311, rs1570360, rs2010963) have been significantly associated with the physiological parameters in high altitude sickness Han or Tibetan Chinese patients at the Qinghai-Tibetan plateau. The alleles of each rSNP have been found to create unique transcriptional factor binding sites for transcription factors that affect the process of hypoxia gene expression in this high altitude hypoxia environment.

A Rare Case of Chronic Recurrent Multifocal Osteomyelitis with Undifferentiated Juvenile Idiopathic Arthritis, Uveitis, and Psoriasis

We report here a 17-year-old boy with a complicated presentation of undifferentiated juvenile idiopathic arthritis, vision-threatening uveitis and chronic recurrent multifocal osteomyelitis (CRMO) in the pelvis. His severe iritis needed subtenon injections and only responded to infliximab after failing multiple biologics. Unfortunately he later developed infliximab-associated psoriasis. A combination of infliximab and ustekinumab induced remission of his arthritis, osteomyelitis, uveitis and psoriasis without experiencing severe infections.

Perspectives on perioperative management of children’s surgical conditions during the COVID-19 pandemic in low-income and middle-income countries:a global survey

Background Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019(COVID-19)pandemic.We surveyed providers of children’s surgical care working in low-income and middle-income countries(LMICs)to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.Methods A survey of children’s surgery providers in LMICs was performed.Respondents reported how their perioperative practice had changed in response to COVID-19.They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform.Changes in surgical practice reported by respondents were analyzed thematically.Results A total of 132 responses were obtained from 120 unique institutions across 30 LMICs.117/120 institutions(97.5%)had issued formal guidance on delaying or limiting elective children’s surgical procedures.Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities(82%in LICs vs 99%in lower middle-income countries and 100%in upper middle-income countries,p=0.036).Although 122(97%)providers believed cases should be limited during a global pandemic,there was no procedure where more than 61%of providers agreed cases should be delayed or canceled.Conclusions There is little consensus on which procedures should be limited or delayed among LMIC providers.Expansion of testing capacity and local,context-specific guidelines may be a better strategy than international consensus,given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.