Should enucleation only be considered if the eye is painful?

I currently work at the Eye Center at UCHealth alongside providers specializing in plastic surgery and repair around the eye and enucleation. I've spoken to a lot of the providers previously about enucleation. Most have come to the consensus that enucleation is preferred to a "dead eye" visually. Our standards are to only perform enucleation if the eye is painful or if there is no vision within the eye (though the patient may fill out consent if there is very little light perception). However, should we enucleate if there is no hope to restore the eye now that there is hope to restore some function of the retina via the Argus II prosthetic? So the Argus II prosthetic is quite situational in that a patient would need a healthy retina and would have to have functioning vision in the past to use it, however, it can provide hope to those who suffer from retinal pigmentosa, which is a degenerative genetic condition that affects the retina's rods and cones. Similar to age-related macular degeneration, there are many genetic factors or genes that could put you at risk of retinal pigmentosa. Hence, there is no cure for the syndrome, and there have only been a few studies conducted that show vitamin A can slow the progression of the genetic disease. Although most providers would take a conservative stance on surgical intervention, they generally would usually advocate for enucleation when there is no light perception in the eye for aesthetic reasons as well as safety from future diseases affecting the eye. With new advancements in medicine such as prosthetics that can give back light perception via electrical pulses / flashing light which can restore some functional vision via light perception, it has been shown to make a difference in giving higher independence who have previously central and peripheral vision due to retinal pigmentosa. So then should policies at hospitals change to only allow for enucleation if the eye is causing the patient severe pain, and should we still advocate for enucleation if there is hope to restore vision via prosthetics later on in life, despite the aesthetic and possibly preventative benefits it can bring?

Here are some sources I used to form your own opinion:

https://www.aao.org/eye-health/diseases/what-is-retinitis-pigmentosa

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005308/

A Secondary Circulatory system: Post a cardiovascular event

Cardiovascular diseases, specifically coronary artery disease (CAD) are the leading cause of death in first world countries. Typical surgical treatment for this is angioplasty and coronary artery bypass graft (CABG). Angioplasty refers to the opening or widening of the blocked or narrow artery to improve blood flow, usually followed by a stent placement to keep the artery from collapsing. (John Hopkins University, 2024). A CABG is taking a healthy artery/ vein from elsewhere in the body and attaching the new artery/vein in the heart near the blockage to bypass the blockade, for restored blood flow (John Hopkins University, 2024).  

Although such procedures may be required soon after a cardiac emergency, the body does have its own way of restoring its own blood flow. This phenomenon is known as coronary collateral circulation. This is described as an alternative source blood supply to an area of ischemia. This has also been shown to occur in areas of smaller infarcts or ventricular aneurysm formation, that is the body creates collateral arteries leading to improved ventricular function, therefore fewer cardiac events and improved survival. (Seiler, 2003) This process occurs through angiogenesis and arteriogenesis. These new blood vessels develop from a pre-existing plexus by sprouting. Endothelial cells, pericytes (capillaries) and smooth muscle cells are required for the maturation of the vessels, specifically larger vessels. This is not only used for the creation of new vessel growth but also in simple tissue repair and regeneration, like wound healing. Upon injury to the blood vessel, inflammatory mediations and growth factors are released leading to vasodilation (Seiler, 2003). This leads to a positive feedback loop, enhancing vascular permeability and increased numbers of monocytes and macrophages (Seiler, 2003). These inflammatory mediators also release metalloproteinases to dissolve the surrounding injury and the basal membrane of the previous vessel (Seiler, 2003). The lack of oxygen sensitizes the endothelial cells to upregulate various growth factors. These endothelial cells attach to the neighboring vessels, migrate, proliferate, thus creating a new vessel in the lumen (Seiler, 2003). Post an ischemia event, arteriogenesis becomes visible within two weeks.

Preventing CAD and therefore a cardiovascular emergency is crucial and straightforward. Exercise has also been shown to help in the development of arteriogenesis. The shear forces at the vessel wall in response to increased blood flow lead to collateral connections (Seiler, 2003). Pressure from inside the blood vessels augments substantially in response to endurance exercise training (Seiler, 2003). Therefore, let’s prevent CAD by exercising and staying healthy!

Why You Should Sleep-In Over the Weekend!

As busy STEM students, we are no strangers to the many hours of studying that often lead to sleep deprivation. However, our intellectual passions and subsequent lack of study/sleep balance may increase our risk of cardiovascular disease (CVD).

Recently, a study on more than 90,000 individuals recorded in UK BioBank data conducted by researchers at the National Center for Cardiovascular Disease in Beijing, China, found that individuals who took the time to catch-up on sleep over the weekends had a 20% lower risk of developing CVD. 

Compiling data from around 90,903 subjects and seeking to evaluate the relationship between compensatory weekend sleep and heart disease, particularly in those diagnosed with Type II Diabetes, the researchers grouped, in quartiles, sleep data recorded using accelerometers. These quartiles were divided from most compensated sleep to least: Q1 (n = 22,474) having the least amount of compensated sleep, with approximately -16.05 to - 0.26 hours (having slept less), Q2 (n = 22,901) having - 0.26 to + 0.45 hours, Q3 (n = 22,692) having + 0.45 to + 1.28 hours, and Q4 (n = 22,695) having the most compensatory sleep at + 1.28 to + 16.06 hours. 

Within the study, sleep deprivation was self-reported, with individuals reporting less than 7 hours of sleep/night defined as experiencing sleep deprivation. As such, a total of 19,816 (or 21.8%) of participants were defined as being sleep deprived. While the rest of the cohort may have experienced the occasional bout of inadequate sleep, their daily hours of sleep, on average, did not meet the sleep deprivation criteria. 

Additionally, hospitalization records and cause of death registry information was used to diagnose cardiovascular diseases, including ischemic heart disease (IHD), heart failure (HF), atrial fibrillation (AF), and stroke.

Having a median follow-up of nearly 14 years, individuals in the group with the highest amounts of compensatory sleep (Q4) were ~19% less likely to develop heart disease than those with the least amount of compensatory sleep (Q1). Additionally, in the subgroup of patients with almost daily sleep deprivation, those with the most compensatory sleep had a 20% reduced risk of developing CVD than those with the least. This analysis did not reveal and significant differences between men and women. 

TL;DR - Don't continue to stress yourself out between Friday and Monday! Turn off your alarms, draw the blinds, and let your body catch-up on some sleep! It may help guarantee you a healthier heart. 

- Via

Source: Hu, J., Wang, X., Cheng, L., Dang, K., Ming, Z., Tao, X., Xu, X., Sarker, S. K., & Li, Y. (2024). Sleep patterns and risks of incident cardiovascular disease and mortality among people with type 2 diabetes: a prospective study of the UK Biobank. Diabetology & metabolic syndrome, 16(1), 15. https://doi.org/10.1186/s13098-024-01261-8

Brain Computer Interface (BCI)

 Brain Computer Interface 

What if we could control devices with thought alone? Brain computer interface is bringing this possibility to reality along with hope for neurodegenerative diseases by changing the brains physiology. 

Neurodegenerative diseases like Parkinson's, Alzheimers, and multiple sclerosis account for 6.8 million deaths per year (WHO, 2007). With little to no known cures for many of these diseases, scientists have turned towards a new technology, one that is trained to mimic the CNS. Using electrodes to read brain signals, it generates outputs based on the individuals intentions.

BCI's can be worn like an EEG cap or implanted, as seen with Elon Musk's Neuralink. Both record electrical flow, brain waves, and synaptic excitations which is helpful as neurodegenerative diseases give off different waves (Lindquist, 2024).

The information gathered from both forms is used to enhance connectivity in the areas of the brain affected by the disorder and has shown positive results among patients experiencing Schizophrenia (Ruiz, 2013). BCI has shown to increase synaptic plasticity with only an hour of use (Nierhaus, 2019), and allows patients to observe how their thoughts and behaviors impact their brains connectivity and physiology in real time. During therapy, patients complete activities on a screen with only their brains while also seeing their brains reactions. This gives the patient coping techniques on how they can affect their brains physiology on their own. On another note, the information gathered can also help those with damage to areas of the body and with movement of prosthetic limbs.

This is a really interesting topic for me that I have increasingly looked at because I used to go with my brother to his BCI therapy after school everyday. He wore an EEG cap and the doctor had him move things on a screen and play video games with his brain to treat his neurodegenerative disorder. I also use a machine called NeurOptimal to retrain my brain.

The system, while very effective for many disorders, still has flaws and opens the discussion for data privacy, how data will be used, and additionally what control the individual will have if they choose an implant form. If you have time check out Pager the monkey he's my favorite to show when I talk about BCI.

The good, the bad, the ugly, use of cognitive enhancers

 What are Cognitive Ehnacers?

    Cognitive enhancers are classified as prescription drugs that are prescribed to those who have ADD(Attention Deficit Disorder) and ADHD(Attention Deficit Hyperactivity Disorder). Such drugs are known as Adderall and Ritalin, which are known for helping restore focus and help those who take the drugs with their studies.

The Good

   Cognitive enhancers ( Adderall and Ritalin), are a stimulated prescription that has recently gained popularity, for their stimulants in "
increase wakefulness, motivation, and aspects of cognition, learning, and memory"(National Institute on Drug Abuse). These prescription drugs have been known to help those who suffer from disorders such as ADD and ADHD.

Those who have these disorders find it very hard to get simple tasks or work done, the use of prescription drugs can restore focus and help get needed tasks done such as school work or even work, work.

Others who don't suffer from ADD or ADHD also find the use of Cognitive Enhancers to be a great aid, especially when it comes to academics, students found the drug to be a great aid to staying focused in school.

The use of these Cognitive enhancers is and does prove to be a great aid for those who need assistance to stay focused on their projects, the prescription drug has also proved to be really helpful for students and even professionals, "The practice is now reported by some professionals to increase their productivity, by older people to offset declining cognition" (Institute on Drug Abuse).

The Bad

With the popularity of Cognitive Enhancer among students and professionals alike, the drug has become available for non-medical use, those who don't have a prescription can and will start using the drugs irresponsibly.

In turn, those who overuse the drug can encounter health risks "including addiction, cardiovascular events, and psychosis."(National Institute on Drug Abuse). Among the health risks, there have also been debates over the use of the drug in a professional setting and in school,(such as individuals who take the drug having an edge over those who don't), There could also be the idealization that one must take medicines to be competitive.

Not only that but the introduction to abusing cognitive enhancers can lead to the possibility of abusing other more dangerous drugs.

The Ugly

   The use of Cognitive Enhancers has now been made publicly and steadily available for students and professionals alike to purchase, and this has led to the irresponsible use of the medication, But what if the use of Cognitive Enhancers could be controlled, one such way would the regulation use of the drug to public and strictly limiting the drug to those who have been diagnosed with ADD or ADHD.

This could solve the problem but there is also the issue that student could get their hands on the medication, One such way to control  the use, especially among students, could be informing them of the side effects and helping those students who are affected by drug abuse or prevent the students from being introduced to drug abuse altogether.

In general, the limiting use of Cognitive Enhancers should strictly be provided to those who need it rather than just being readily available to the public.

Reference/Citation:

NIDA. 2023, June 12. What classes of prescription drugs are commonly misused?. Retrieved from https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-classes-prescription-drugs-are-commonly-misused on 2024, September 28

 

Human x Pig Xenotransplantation

The limited supply of donor organs has been a problem for several decades, and currently, there are over 100,000 individuals on the national transplant waiting list in the US. However, xenotransplantation can potentially reduce the shortage of access to organs. Within the last couple of years, there have been more research efforts focused on creating donor organs and grafts from pigs, involving editing out various genes using CRISPR and using non-human primates for trial. Utilizing knockout pigs has become advantageous because pigs reach reproductive maturity quickly and have anatomical organs similar to humans. Yet, there are physiologic differences in the functional and metabolic capabilities between human allografts and pig xenografts that must be accounted for. These differences include genetic protein structures and subsequent functions that can lead to graft incompatibility. Specifically, porcine lung, heart, pancreas, and kidney allografts can sustain life in non-human primates, while porcine livers have physiologic differences that cause life-threatening complications. Therefore, proper comparison and clinical analysis between recipients of xenografts and allografts are crucial to progress science further.

The first reported xenotransplant took place on January 7, 2022, at the University of Maryland, Baltimore involving a 10G-pig xenoheart transplant in a living human. During the early weeks after the transplant, the heart performed well in the absence of rejection. However, during the 8th week post-transplant, the patient’s status began to decline and he passed away from multiorgan failure. That said, hyperacute rejection was not the cause of his death, instead, the xenograft prolonged the life of this patient. Due to this, other xenotransplant trials began to be performed involving kidney transplantation. On September 24, 2021, Dr. Robert Montgomery transplanted a kidney from an alpha 1,3-galactosyltransferase gene-knockout pig into a brain-dead patient. This trial concluded that the kidney produced urine and clear creatinine while showing no hyperacute rejection. These trials, among others within the past years, have advanced the medical field and provided a promising solution for the organ shortage. While this is so, xenotransplantation has raised ethical concerns relating to human/animal welfare, hyperacute rejection, risk of infection, and the possibility of zoonotic disease transmission. Overall, xenotransplantation can potentially reduce the transplant waitlist while expanding the eligibility of transplants to more candidates. However, there is a need for more research and trials as well as the consideration of the social and ethical concerns with utilizing porcine organs for human life and benefits.

Bell's Palsy or Stroke?

     Common signs of a stroke, such as facial weakness and slurred speech, can be alarming and reason for an ambulance to the emergency room, especially for older or susceptible individuals. However, some of these symptoms may be confused with Bell’s palsy, and for good reason. To illustrate, Bell’s palsy tends to be characterized by facial weakness and drooping of the lips, which overlap with many common stroke symptoms. However, the similarities end here as Bell’s palsy is a temporary and benign condition since it only affects a facial nerve while strokes are serious medical emergencies that are caused by damage to brain tissue usually due to a blood clot or ruptured blood vessel. Thus, without further examination, these two conditions initially appear to be very similar, which emphasizes the necessity of thorough and accurate medical practices to determine the condition and best course of treatment. From my shadowing experience, physicians tend to order MRI or CT scans to observe if any brain infarctions, or tissue damage, has occurred since physical examinations may not be conclusive. Furthering this notion, even though Bell’s palsy should not affect speech and cause aphasia, slurred speech may not be conclusive since some patients may naturally speak in a slightly slurred manner. Overall, rigorous testing should be conducted for each case before a decisive diagnosis is made.

    Such was the case for a 66-year-old woman who presented to the emergency department with weakness on one side of her face, recent nausea, and slightly slurred speech. After general exams and blood labs were run, her blood clotting results appeared normal, and her CT scans showed no abnormalities. Even after MRI scans were performed for further analysis, no obvious clot or hemorrhage could be detected. Despite these findings, the patient’s hypertension and physical state upon arrival made the possibility of a stroke much more likely than Bell’s palsy. As a result, the scans were re-evaluated by a neuroradiologist who noticed very small tissue damage near the pons, or brainstem. After a follow-up review with the stroke clinic, the patient suffered no permanent injuries and was prescribed stroke prevention medication. As such, it is crucial for healthcare professionals to continue being meticulous and open-minded when diagnosing patients, especially since many conditions can manifest themselves in a myriad of ways with varying causes.