Examining Minimal Important Change of the Self-Assessment Scale of Clinical Reasoning in Occupational Therapy

The purpose of the study was to establish and quantify the minimal important change (MIC) value necessary to determine gains or losses in clinical reasoning during student fieldwork assignments as measured by the Self-Assessment of Clinical Reasoning in Occupational Therapy (SA-CROT). This multicenter prospective longitudinal study was conducted with students on their occupational therapy fieldwork in Japan. Two anchor-based methods were used to estimate the MIC values: a receiver operating characteristic-based method and a predictive modeling-based method. The MIC was adjusted based on the percentage of participants who exhibited improvement. Administered were the SA-CROT and the Global Rating of Change (GRC) scale as an anchor. A total of 111 students from 11 occupational therapy educational programs in Japan responded (response rate 29%). Overall, there was a significant difference (p \u3c .001, effect size was r = .80) in SA-CROT before and after fieldwork, and 81% of students showed improvement in the GRC scale. The adjusted MIC value was 3.69, with 95% confidence interval of 2.29–4.97. This anchor-based, adjusted MIC value is the most reliable value to interpret the changes in SA-CROT before and after fieldwork. The SA-CROT\u27s MIC value can be used as a cut-off point from a learner-centered perspective when considering educational methods and environments in fieldwork

Meibum Color and Free Fatty Acid Composition in Patients With Meibomian Gland Dysfunction

Citation: Arita R, Mori N, Shirakawa R, et al. Meibum color and free fatty acid composition in patients with meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015;56:4403-4412. DOI:10.1167/iovs.14-16254 PURPOSE. We measured the components of meibum in patients with meibomian gland dysfunction (MGD) and control subjects and then examined the relation between meibum composition and clinical parameters. METHODS. Thirty-eight patients with MGD (13 men and 25 women; mean age 6 SD, 66.9 6 15.0 years) and 20 control subjects (8 men and 12 women; 64.5 6 6.7 years) were enrolled. Ocular symptom score, keratoconjunctival staining score, tear film breakup time, and Schirmer's test value were determined. Lid margin abnormalities and meibomian gland morphology were assessed for upper and lower eyelids, and meibum properties were evaluated at temporal, central, and nasal sites of each lid. Free fatty acid (FFA) composition of meibum was analyzed by liquid chromatography-Fourier transform mass spectrometry. RESULTS. Upper meibum color score was significantly correlated with epiphora and sticky sensation in MGD patients. Meibum grade, color, or viscosity did not differ significantly among the sites evaluated. A total of 103 species of FFA-including very long chain (such as C 36 and C 37 ) and odd-numbered chain (such as C 17 , C 19 , and C 21 ) FFAs-were detected in meibum. Free fatty acid composition differed between clear and colored (cloudy or yellow) meibum, with unsaturated FFAs tending to be more abundant in colored meibum. CONCLUSIONS. Free fatty acid composition of human meibum correlates with meibum color as determined with a slit-lamp microscope. This finding may provide insight into the pathogenesis of MGD. Keywords: meibomian gland, meibum, meibography, fatty acid P osterior blepharitis, an inflammatory condition of the posterior lid margin, is encountered relatively often in ophthalmic clinics. It is associated with allergic conjunctivitis, infectious conjunctivitis, and, in particular, meibomian gland dysfunction (MGD). 1 Given that 86% of patients with dry eye have been found to manifest MGD, 2 posterior blepharitis is also associated with dry eye. In normal individuals, meibomian gland secretion (meibum) is a clear oily liquid that spreads readily to become the outermost surface of the tear film. It is a complex mixture of lipids of various classes including wax esters, cholesteryl esters, (O-acyl)-x-hydroxy fatty acids (OAHFAs) and their esters, acylglycerols, diacylated diols, free fatty acids (FFAs), cholesterol, and, in smaller amounts, other polar and nonpolar lipids. Although the volume of meibum is small, its components and the changes in these components have been examined as possible disease biomarkers. METHODS Study Design This cross-sectional observational study was conducted at The University of Tokyo Hospital, Itoh Clinic (Saitama City, Saitama), and Maeda Ophthalmic Clinic (Aizuwakamatsu City, Fukushima). Subjects were enrolled from December 2012 to December 2013. The study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board of Tokyo University School of Medicine. All subjects provided written informed consent before entry into the study. Subjects The MGD group included 38 patients (13 men and 25 women; mean age 6 SD, 66.9 6 15.0 years) who were diagnosed with MGD on the basis of Japanese diagnostic criteria (age of ‡20 years; at least one symptom such as an uncomfortable sensation in the target eye; and at least one abnormal lid finding). The control group included 20 individuals (8 men and 12 women; 64.5 6 6.7 years) who had never been diagnosed with blepharitis or MGD, were aged ‡20 years, and had no history of contact lens wear or eye surgery. Subjects with severe systemic illness or with squamous cell debris (collarette) around the base of the eyelashes were excluded. Protocol One eye was selected as the target eye in each subject. Complications, history of contact lens wear or eye surgery, presence of ocular allergy, and concomitant medications were noted as background information. The subjects were also questioned with regard to their experience of 15 subjective symptoms: ocular fatigue, discharge, foreign body sensation, dryness, uncomfortable sensation, sticky sensation, pain, epiphora, itching, redness, heavy sensation, glare, excessive blinking, burning sensation, and ocular discomfort on arising. Each symptom was assessed on a scale of 0 to 3: Lid margin findings were assessed for the upper and lower eyelids with the use of a slit-lamp microscope (TOPCON, Tokyo, Japan). Telangiectasia was assessed on a scale from 0 to 3: 0 ¼ no findings; 1 ¼ mild telangiectasia; 2 ¼ moderate telangiectasia or redness; 3 ¼ severe telangiectasia or redness. Mucocutaneous junction was assessed on a scale of 0 to 3: 0 ¼ Marx's line (ML) courses on the skin side of the meibomian orifice (MO) line and does not touch the MO at all; 1 ¼ parts of ML touch the MO; 2 ¼ ML courses through the MO; 3 ¼ ML courses along the eyelid margin side of the MO. 10 Irregularity, plugging, foaming, and thickness were assessed on a scale from 0 to 2: 0 ¼ no findings; 1 ¼ mild findings; 2 ¼ severe findings. Corneal and conjunctival staining were scored 0 to 9. 11 The fluorescein tear film breakup time (BUT) was measured three times consecutively after the instillation of fluorescein, and the mean value was adopted. Tear fluid production was evaluated by Schirmer's test without anesthesia. Meibomian glands were evaluated for the upper and lower lids with the use of a noncontact meibography system (TOPCON) attached to a slit-lamp microscope. Partial or complete loss of meibomian glands was scored on a scale of 0 to 3 (meiboscore), and meibomian gland distortion was graded on a scale of 0 to 2, as described previously. Meibum was collected at six sites for each target eye: three sites in the upper lid (temporal, central, and nasal) and three sites in the lower lid (nasal, central, and temporal). Powderfree gloves were worn by the collector to avoid contamination. The eyelids were carefully cleaned with a cotton swab dipped in saline before expression of meibum. Meibum was extruded with the use of the Arita Meibomian Gland Compressor (Katena Products, Denville, NJ, USA), and it was collected with a separate stainless steel spatula at each site. Collected meibum was immediately transferred to dry ice for storage. The degree of ease with which meibum was expressed was evaluated semiquantitatively for each of the six collection sites on a scale of 0 to 3: 0 ¼ clear meibum readily expressed; 1 ¼ cloudy meibum expressed with mild pressure; 2 ¼ cloudy meibum expressed with more than moderate pressure; 3 ¼ meibum could not be expressed even with strong pressure. 14 Meibum color was assessed for each site according to three categories (clear, cloudy, yellow) and a scale of 0 or 1: 0 ¼ clear; 1 ¼ colored (cloudy or yellow). Meibum viscosity was also assessed for each site on the basis of three categories (oily, creamy, toothpaste-like) and a scale of 0 or 1: 0 ¼ oily; 1 ¼ nonoily (creamy or toothpaste-like). Lipid Analysis Meibum collection and FFA composition analysis were performed as previously described. 9 Meibum was dissolved in chloroform:methanol (1:1, vol/vol; Wako, Osaka, Japan) and analyzed by liquid chromatography-Fourier transform mass spectrometry (LC-FTMS). Water containing 0.1% ammonium acetate (Sigma-Aldrich Corp., St. Louis, MO, USA) and methanol containing 0.1% ammonium acetate (Sigma-Aldrich Corp.) were used as the mobile phase. We performed a high mass accuracy full scan (m/z of 180-550) with a Q Exactive mass spectrometer (Thermo Scientific, Waltham, MA, USA) to identify individual lipid molecular species. Given that the amount of collected meibum sample was too small to weigh, we corrected for weight differences among samples by normalizing the FFA data by the total peak area before statistical analysis. The percentage peak area was calculated with the following equation: percentage peak area of FFA X ¼ (peak area value of FFA X in sample Y)/(total peak area value of all FFAs in sample Y). The percentage peak area was used as a measure of the content of each FFA among total FFAs in meibum. Statistical Analysis Data are presented as means 6 SD unless indicated otherwise. The frequency of each ocular symptom was compared between the MGD and control groups with Fisher's exact test. Means of parameters were compared between the MGD and control groups or between upper and lower eyelids with Student's t-test. Meibum color and viscosity were compared between the MGD group and the control group, between the upper and lower eyelids, or among temporal, central, and nasal sites with Fisher's exact test. Meibum grade was compared among temporal, central, and nasal sites of each eyelid in the MGD group with one-way analysis of variance. The relations between clinical signs were evaluated with Spearman's correlation analysis. A P value of <0.05 was considered statistically significant. Principal component analysis (PCA) was performed with the use of AI output software 15 (developed at Osaka University) in order to explore the relation between FFA composition of meibum and clinical signs. Principal component analysis is a primary multivariate technique that has been widely adopted in lipidomics, metabolomics, and proteomics. RESULTS Clinical Signs and Meibum Properties Patients were diagnosed with MGD according to the Japanese diagnostic criteria. The distribution of meibum color and viscosity differed significantly between the MGD and control groups at each of the six sites examined. There were no significant differences in meibum color or viscosity among the temporal, central, and nasal sites of the upper or lower eyelids of the MGD group or the control group, or between the upper and lower eyelids at each site in the MGD group Lipid Analysis Liquid chromatography-FTMS was applied to quantify FFAs in meibum and to determine whether their amounts might change in association with ocular symptoms. The highresolution negative electrospray ionization (ESI) mode was adopted to analyze the FFAs in all six meibum samples from each of the 38 MGD patients and 20 control subjects. We detected 103 FFA species with carbon chains of C 12 to C 37 in meibum We also generated a volcano plot comparing FFA species between the clear meibum group and the colored (cloudy or yellow) meibum grou

Echophonocardiographic study of the initial low frequency component of the first heart sound

To investigate the genesis of the initial low frequency component of the first heart sound that precedes the high frequency vibrations associated with closure of the atrioventricular valves, echophonocardiograms of 36 persons were recorded. These included 10 normal subjects and 26 patients with various types of heart disease including mitral valve replacement. Electrocardiograms demonstrated normal sinus rhythm in 23 subjects, atrial fibrillation in 9, complete atrioventricular block in 2 and atrial flutter in 2. In the phonocardiogram, the low frequency component of the first heart sound followed the onset of the QRS complex and preceded the first high frequency component of this sound. The low frequency component occurred simultaneously with the beginning of the final fast closing movement of the mitral valve on he echocardiogram and was found both in normal rhythm and in arrhythmias. However, in arrhythmias its intensity varied on a beat to beat basis, being loudest after a short RR interval or when atrial systole occurred very close to the expected time of ventricular systole. In patients in whom apexcardiograms were recorded, the low frequency component was coincident with or very close to the onset of ventricular systole.It is concluded that the low frequency component of the first heart sound represents vibrations caused by contraction of the left ventricle and deceleration of antegrade blood flow across the mitral valve. Neither atrial contraction nor mitral valve tension is necessary for the production of this soft initial component

Development of MRI Projection Mapping System for Breast-Conserving Surgery in the Operating Room: Preliminary Clinical Results in Invasive Breast Cancer

Aim. To evaluate the feasibility of a newly developed prototype MRI projection mapping (PM) system for localization of invasive breast cancer before breast-conserving surgery. Methods. This prospective study enrolled 10 women with invasive breast cancer. MRI was performed in both prone and supine positions. The tumor location was drawn on the breast skin using palpation and sonography while referring to the prone MRI (i.e., a conventional method). A maximum intensity projection image generated from the supine MRI was projected using our PM system, and the tumor location was drawn. The PM system consisted of a projector and a camera and was used to measure the shape of the breast surface using the structured light method. Breast-conserving surgery was performed based on the conventional method. We compared the tumor size and location between the PM and conventional methods or pathology. Results. There were no significant differences in the maximum diameters of invasive cancers between the PM system and the conventional method or pathology. The maximum discrepancy in tumor location between the PM and conventional method was 3–8 mm. Conclusions. This PM system may support breast-conserving surgery by showing the tumor size and location on the breast surface