In response to the COVID-19 pandemic, primary care practices across the United States have transitioned from in-person visits to virtual visits. However, there is limited information regarding the facilitators and barriers to the implementation of such a transition. The objective of this study was to evaluate the short-term implications of rapid transition to video visits at Stanford Primary Care through qualitative interviews with key stakeholders.

Exfoliation syndrome (XFS) is the commonest known risk factor for secondary glaucoma and a significant cause of blindness worldwide. Variants in two genes, LOXL1 and CACNA1A have been previously associated with XFS. To further elucidate the genetic basis of XFS, we collected a global sample of XFS cases to refine the association at LOXL1, which previously showed inconsistent results between populations, and to identify new variants associated with XFS. We identified a rare, protective allele at LOXL1 (p.407Phe, OR = 25, P =2.9 × 10−14) through deep resequencing of XFS cases and controls from 9 countries. This variant results in increased cellular adhesion strength compared to the wild-type (p.407Tyr) allele. A genome-wide association study (GWAS) of XFS cases and controls from 24 countries followed by replication in 18 countries identified seven genome-wide significant loci (P < 5 × 10−8). Index variants at the new loci map to chromosomes 13q12 (POMP), 11q23.3 (TMEM136), 6p21 (AGPAT1), 3p24 (RBMS3) and 5q23 (near SEMA6A). These findings provide biological insights into the pathology of XFS, and highlight a potential role for naturally occurring rare LOXL1 variants in disease biology.

The first PCC orientation training integrated with simulation was effective and logistically feasible. The train to success concept with repetitive practice was highly valued by participants. Continuation and expansion of this novel multi-institutional training is planned.

New technologies for delivery of drugs, such as small molecules and biologics, are of growing interest among clinical and pharmaceutical researchers for use in treating anterior segment eye disease. The challenge is to deliver effective drugs at therapeutic concentrations to the targeted ocular tissue with minimal side effects. To achieve this, a better understanding of the unmet needs, what is required of the various methods of delivery to achieve successful delivery, and the potential challenges of anterior segment drug delivery is necessary and the primarily aim of this review. This review covers the various physiological and anatomical barriers that exist for effective delivery to the targeted tissue of the eye, the pathological conditions of the anterior segment, and the unmet needs for treatment of these ocular diseases. Second, it reviews the novel delivery technologies that have the potential to maintain and/or improve the drug's therapeutic index and improving both patient adherence for chronic therapy and potential patient outcomes. This review bridges the pharmaceutical and clinical research/challenges and provides a detailed overview of anterior segment drug delivery accomplishments thus far, for researchers and clinicians.

Background Endoscopic placement of hilar stents is an accepted palliative therapy for patients with advanced, unresectable cholangiocarcinoma. However, whether unilateral versus bilateral stent placement provides optimal relief continues to be a subject of debate. The aim of this study was to compare the technical and clinical outcomes in patients with inoperable cholangiocarcinoma who received unilateral or bilateral self-expanding metal stents (SEMS). MethodsWe conducted a multicenter, international retrospective study of 187 patients with cholangiocarcinoma who received unilateral or bilateral SEMS. Outcomes included, but were not limited to, technical success, clinical success, adverse events, stent occlusion, and survival time.Results were further stratified based on the Bismuth classification.Results Fifty patients received unilateral stents and 137 patients received bilateral stents. All patients achieved technical success. The clinical success rates were 86% for unilateral stents and 82.5% for bilateral stents (P>0.99). Clinical success was not statistically different for either group when stratified by the Bismuth classification (P=0.62 and P=0.72 respectively). There were significantly more adverse events in the bilateral stents group (11.7% vs. 0%, P=0.007). There was no greater risk of stent occlusion when bilateral stents were used (unadjusted P=0.71, adjusted P=0.81). There was a greater risk of death for patients who received bilateral SEMS (hazard ratio 1.78, 95% confidence interval 1.09-2.89; P=0.02).Conclusions Unilateral and bilateral drainage had similar technical and clinical success rates. However, bilateral stents had a higher risk of death and more adverse events. Therefore, unilateral SEMS placement is sufficient for relief of biliary obstruction secondary to cholangiocarcinoma.

IMPORTANCE Exfoliation syndrome, an inherited systemic disorder of elastin and extracellular matrix (ECM), is associated with the LOXL1 gene locus. Pelvic organ prolapse is a common connective tissue disorder that affects women. The presence of an association between exfoliation syndrome (exfoliation of the lens capsule) and pelvic organ prolapse was investigated as part of the Utah Project on Exfoliation Syndrome (UPEXS).OBJECTIVE To examine the association between exfoliation syndrome and pelvic organ prolapse using the Utah Population Database, a comprehensive resource linked to medical records. DESIGN, SETTING, AND PARTICIPANTSA 2-pronged approach was used. In substudy A, a cross-sectional analysis was performed to determine the association between pelvic organ prolapse and exfoliation syndrome in women enrolled in Medicare in Utah from calendar year 1992 to 2009 (n = 132 772). In substudy B, the risk of incident exfoliation syndrome from January 1, 1995, to December 31, 2014, was estimated in a cohort of women aged 30 to 65 years at baseline with a diagnosis of pelvic organ prolapse (n = 5130) compared with birth year-matched women serving as controls who did not have pelvic organ prolapse (n = 15 338). MAIN OUTCOMES AND MEASURES Exfoliation syndrome outcome was defined byInternational Classification of Diseases, Ninth Revision, diagnosis codes for exfoliation syndrome or exfoliation glaucoma (366.11 or 365.52, respectively). In substudy A, odds ratios (ORs) from unconditional logistic regression models were used to estimate the exfoliation syndrome risk in women with pelvic organ prolapse compared with those without pelvic organ prolapse. In substudy B, hazard ratios (HRs) from Cox proportional hazards models were used to estimate incident exfoliation syndrome risk in patients with pelvic organ prolapse (without exfoliation syndrome history) compared with unaffected controls. Models were adjusted for age, years enrolled, parity, and race/ethnicity. RESULTSOf the 132 772 women enrolled in Utah Medicare from 1992 to 2009, the mean [SD] age at the last enrollment was 82.2 [7.7] years. Pelvic organ prolapse was associated with a 1.56-fold increased risk of exfoliation syndrome in Medicare beneficiaries (OR, 1.56; 95% CI, 1.42-1.72) in substudy A. We observed a 48% increased incident risk of exfoliation syndrome in women aged 30 to 65 years at baseline who had a pelvic organ prolapse diagnosis compared with controls during 20 years of follow-up (HR, 1.48; 95% CI, 1.14-1.91). CONCLUSIONS AND RELEVANCEThe diagnosis of exfoliation syndrome was more frequent in women with pelvic organ prolapse in the Utah Population Database, a robust population-based resource, thus supporting an association of exfoliation syndrome with a nonocular systemic condition. Systemic conditions with altered ECM metabolism, such as pelvic organ prolapse, may share common biological pathways with exfoliation syndrome. LOXL1 dysregulation, thought to occur in exfoliation syndrome, may be a contributing factor.

Background and study aims Stent migration is a common complication of fully-covered self-expanding metal stents (FCSEMS), but the rate of clinically relevant migration as defined by stent migration followed by reintervention via endoscopy for stent replacement is unknown. The goal of this study is to gain insight into the total migration rate and clinically relevant migration rate of different types of FCSEMS placed within benign and malignant strictures with specific attention paid to stent manufacturer, diameter, and length. Patients and methods Multicenter retrospective analysis of endoscopic data from patients with FCSEMS placed within benign or malignant strictures. FCSEMS used included a variety of sizes and manufacturers. Results A total of 369 patients were included, 161 of whom had benign strictures and 208 of whom had malignant strictures. The total migration rate and clinically relevant migration rate in benign strictures were 30 % and 17 %, respectively. For benign strictures, Wallflex stents had a clinically relevant migration rate of 15 %, compared to Endomaxx stents with 19 %, and Evolution stents with 25 % (P = 0.52). The total migration rate and clinically relevant migration rates in malignant strictures were 23 % and 14 %, respectively. Evolution stents had a significantly higher clinically relevant migration rate (29 %) than the Wallflex stents (7 %) and the endomaxx stents (12 %), P = 0.003. Conclusion This study is the largest to investigate migration rates for FCSEMS in benign and malignant strictures. Clinically relevant migration is a relatively common occurrence with all stent types studied and better anti-migration features are needed.

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