SMJ

E-ISSN 2228-8082

Volume 74, Number 9, September 2022

MONTHLY

Siriraj Medical Journal

The world-leading biomedical science of Thailand

By Kanchalika Julthongpipat, et al.

ORIGINAL ARTICLE REVIEW ARTICLE

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Siriraj Medical Journal SMJ‌

Volume 74, Number 9, September 2022

ORIGINAL ARTICLE

537 Factors Predicting Prolonged Postoperative Ileus in Patients Undergoing Major Gastrointestinal Surgery

Chutiporn Banyong, et al.

548 Outcomes of Decompression with Multi-Segment Long Instrumented Fusion in Lumbar Degenerative Disease

Areesak Chotivichit

555 Clinical Characteristics and Outcome of Bleb-Related Infection in Glaucoma Patients

Sakaorat Petchyim, et al.

562 Long-Term Rehabilitation Outcomes of Neurological Patients: A Multicenter Study

Donruedee Srisuppaphon, et al.

570 Development of Simulation Model for Transradial Catheterization Practice for Physicians

Kanchalika Julthongpipat, et al.

575 Histopathological and Clinical Features of Methotrexate-Associated Lymphoproliferative Disorders and Post-Transplant Lymphoproliferative Disorders

Preeyawat Ngamdamrongkiat, et al.

590 Development and Validation of a New Design Self-assessment logMAR Visual Acuity Test (“Chudjane” iPhone- and iPad-based Application) in a Normal Eyes Population

Nuttawut Rodanant, et al.

600 Visual Field Parameters and Pupil Size Measured Through and Compared between Colored Contact Lenses and Clear Contact Lenses: A Prospective Comparative Pilot Study in Asian Population

Atiporn Thuangtong, et al.

REVIEW ARTICLE

604 Malignancy of the Lymph Node: How General Practitioners and Pathologists can Achieve a Definitive Diagnosis

Sanya Sukpanichnant

SMJ

SIRIRAJ MEDICAL JOURNAL

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Yik Ying Teo (National University of Singapore, Singapore) Harland Winter (Massachusetts General Hospital, USA)

Philip A. Brunell (State University of New York At Buffalo, USA) Noritaka Isogai (Kinki University, Japan)

Yuji Murata (Aizenbashi Hospital, Japan)

Keiichi Akita (Tokyo Medical and Dental University Hospital, Japan) Shuji Shimizu (Kyushu University Hospital, Japan)

David S. Sheps (University of Florida, USA)

Robin CN Williamson (Royal Postgraduate Medical School, UK) Tai-Soon Yong (Yonsei University, Korea)

Anusak Yiengpruksawan (The Valley Robotic Institute, USA) Stanlay James Rogers (University of California, San Francisco, USA) Kyoichi Takaori (Kyoto University Hospital, Japan)

Tomohisa Uchida (Oita University, Japan)

Yoshiki Hirooka (Nagoya University Hospital, Japan)

Hidemi Goto (Nagoya University Graduate School of Medicine, Japan) Kazuo Hara (Aichi Cancer Center Hospital, Japan)

Shomei Ryozawa (Saitama Medical University, Japan) Christopher Khor (Singapore General Hospital, Singapore) Yasushi Sano (Director of Gastrointestinal Center, Japan) Mitsuhiro Kida (Kitasato University & Hospital, Japan) Seigo Kitano (Oita University, Japan)

Ichizo Nishino (National Institute of Neuroscience NCNP, Japan)

Masakazu Yamamoto (Tokyo Women’s Medical University, Japan) Dong-Wan Seo (University of Ulsan College of Medicine, Korea) George S. Baillie (University of Glasgow, UK)

G. Allen Finley (Delhousie University, Canada)

Sara Schwanke Khilji (Oregon Health & Science University, USA) Matthew S. Dunne (Institute of Food, Nutrition, and Health, Switzerland) Marianne Hokland (University of Aarhus, Denmark)

Marcela Hermoso Ramello (University of Chile, Chile) Ciro Isidoro (University of Novara, Italy)

Moses Rodriguez (Mayo Clinic, USA)

Robert W. Mann (University of Hawaii, USA)

Wikrom Karnsakul (Johns Hopkins Children’s Center, USA)

Frans Laurens Moll (University Medical Center Ultrecht, Netherlands) James P. Dolan (Oregon Health & Science University, USA)

John Hunter (Oregon Health & Science University, USA) Nima Rezaei (Tehran University of Medical Sciences, Iran) Dennis J. Janisse (Subsidiary of DJO Global, USA)

Folker Meyer (Argonne National Laboratory, USA)

David Wayne Ussery (University of Arkansas for Medical Sciences, USA) Intawat Nookaew (University of Arkansas for Medical Sciences, USA)

Victor Manuel Charoenrook de la Fuente (Centro de Oftalmologia Barraquer, Spain)

Karl Thomas Moritz

(Swedish University of Agricultural Sciences, Sweden)

Nam H. CHO (University School of Medicine and Hospital, Korea)

Watchara Kasinrerk (Chiang Mai University, Thailand)

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Pornchai O-Charoenrat (Siriraj Hospital, Mahidol University, Thailand)

Rungroj Krittayaphong (Siriraj Hospital, Mahidol University, Thailand) Wiroon Laupattrakasem (Khon Kaen University, Thailand)

Anuwat Pongkunakorn (Lampang Hospital, Thailand) Nopporn Sittisombut (Chiang Mai University, Thailand)

Vasant Sumethkul (Ramathibodi Hospital, Mahidol University, Thailand) Yuen Tanniradorm (Chulalongkorn University, Thailand)

Saranatra Waikakul (Siriraj Hospital, Mahidol University, Thailand) Pa-thai Yenchitsomanus (Siriraj Hospital, Mahidol University, Thailand) Surapol Issaragrisil (Siriraj Hospital, Mahidol University,Thailand) Jaturat Kanpittaya (Khon Kaen University, Thailand)

Suneerat Kongsayreepong (Siriraj Hospital, Mahidol University, Thailand)

Statistician: Saowalak Hunnangkul (Mahidol University, Thailand)

Nopphol Pausawasdi (Siriraj Hospital, Mahidol University, Thailand) Supakorn Rojananin (Siriraj Hospital, Mahidol University, Thailand) Jarupim Soongswang (Siriraj Hospital, Mahidol University, Thailand) Suttipong Wacharasindhu (Chulalongkorn University, Thailand) Prapon Wilairat (Mahidol University, Thailand)

Pornprom Muangman (Siriraj Hospital, Mahidol University, Thailand)

Ampaiwan Chuansumrit

(Ramathibodi Hospital, Mahidol University, Thailand)

Sayomporn Sirinavin

(Ramathibodi Hospital, Mahidol University, Thailand)

Vitoon Chinswangwatanakul

(Siriraj Hospital, Mahidol University, Thailand)

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Factors Predicting Prolonged Postoperative Ileus in Patients Undergoing Major Gastrointestinal Surgery

Chutiporn Banyong, M.N.S.*, Wallada Chanruangvanich, D.N.S.**, Orapan Thosingha, D.N.S.**, Varut Lohsiriwat, M.D., Ph.D.***

*Faculty of Nursing, Mahidol University, **Department of Surgery, Faculty of Nursing, Mahidol University, Bangkok 10700, Thailand, ***Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: This study aimed to investigate the rate of prolonged postoperative ileus (PPOI) and its predictive factors focusing on age, body mass index, smoking status, postoperative mobilization, and preoperative anxiety and depression among patients undergoing major gastrointestinal surgery.

Materials and Methods: This prospective observational study included patients who underwent elective major

gastrointestinal surgery in a super tertiary hospital in Thailand. The data were collected using a uniform case record form including the Hospital Anxiety and Depression Scale and Fagerstrom Test for Nicotine Dependence. PPOI was defined using criteria of Vather et al. (2013). Predictive factors for PPOI were determined by multivariate analysis. Results: A total of 123 patients were enrolled, with an average age of 59.8 ± 12.7 years. The most common indication for surgery was gastrointestinal malignancy (96 patients, 78%), followed by an open approach (75 patients, 61%) and a combined general and epidural anesthesia (58 patients, 47%). Approximately 30% of patients had a history of smoking. Preoperative anxiety and depression were equally found in nine patients (7%). Twenty-seven patients (22%) experienced PPOI. The significant predictive factors of PPOI were having preoperative anxiety (OR = 6.26, 95% CI = 1.22–44.41, p = 0.046) and being unable to ambulate on postoperative day 1 (OR = 3.26, 95% CI =

1.25–8.50, p = 0.015).

Conclusion: Preoperative anxiety and delayed postoperative ambulation were two predictors for PPOI in this study. Some interventions to reduce preoperative anxiety and encourage early postoperative ambulation should be considered in patients undergoing major elective gastrointestinal surgery.

Keywords: Prolonged postoperative ileus; PPOI; major gastrointestinal surgery (Siriraj Med J 2022; 74: 537-547)

INTRODUCTION

Postoperative ileus (POI), or the temporary dysfunction of bowel motility, is one the most common complications following surgeries involving the gastrointestinal tract. It seems to be an inevitable event since the development of POI is induced in response to the surgery.1,2 Normally, POI is expected to resolve 2-3 days after surgery as a mechanism of bowel recovery.3 Therefore, POI that

lasts longer than this period is usually considered to be a pathological abnormality, or prolonged POI (PPOI). A wide variety of cutoff times and criteria have been used by studies to determine PPOI; however, 8-32% of patients suffer from PPOI following surgery.4–13

PPOI is known to burden both patients and the health care system. Numerous studies have reported that patients with PPOI are prone to develop postoperative

Corresponding author: Wallada Chanruangvanich E-mail: wallada.cha@mahidol.ac.th

Received 6 March 2022 Revised 7 April 2022 Accepted 10 May 2022 ORCID ID: https://orcid.org/0000-0002-2593-389X http://dx.doi.org/10.33192/Smj.2022.64

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

complications4,9,13 that can lead to negative outcomes such as a prolonged length of stay9–11, increased reoperation rate and readmission rate6,9,11,14, and increased mortality rate.15 In terms of the health care system, PPOI increases the use of medical resources as well as the economic burden of the treatment.13

The literature has shown that several methods can reduce the incidence of PPOI such as laparoscopic surgery,7,9 chewing gum,16,17 coffee consumption,18 postoperative administration of mosapride19, and early enteral feeding.20,21 However, some interventions are not applicable in the clinical setting due to several limitations such as patients’ condition and health care providers’ competency. Moreover, although interventions are applied, the incidence of PPOI remains.

Several factors are associated with the development of PPOI such as age,6,7 body mass index (BMI),5,6,22 smoking status,4,6 time to first ambulation,12 previous abdominal surgery,5 and operative time.6 These factors have been shown to predict PPOI, mostly in retrospective studies of colorectal surgery patients, but conflicting results have been found. Therefore, the factors predicting PPOI in major gastrointestinal surgery remain unclear. In this study, the investigators selected factors based on their potential effect on gastrointestinal motility reported in the literature, including age, BMI, smoking status, preoperative anxiety and depression, and time to first ambulation.

In the literature, advanced age is known to increase the risk, severity, and duration of PPOI due to an imbalance between proinflammatory processes and pro- and anti- inflammatory mechanisms in older adults.23 In obese patients, it is more difficult to manipulate the fatty tissue surrounding the internal organs, thus resulting in more tissue inflammation and a higher rate of PPOI.24 Smoking might cause delayed bowel motility as a consequence of nicotine consumption.25 Anxiety and depression can release catecholamine, which affects the sympathetic innervation of the gastrointestinal tract, thus inhibiting bowel motility.26,27 Lastly, delayed ambulation might cause a lack of stretch stimulation to the gastrointestinal tract, which is a key factor to enhance intestinal smooth muscle motility and a lack of stimulation to parasympathetic innervation activity, thus decreasing intestinal smooth muscle motility.28

Therefore, the purpose of the study was to prospectively

determine whether age, BMI, smoking status, time to first ambulation, and preoperative anxiety and depression predict PPOI in major gastrointestinal surgery in Thailand. In particular, the knowledge of such risk factors is crucial, as they could be used to screen patients with a high

probability of PPOI, monitor them closely, and manage them suitably to prevent the development of PPOI.

MATERIALS AND METHODS

The sample size was calculated based on a previous study of intraabdominal surgery in which the rate of PPOI was 32.4%.13 With a power of test of 80% and a significance level of 5% (two-sided test), a sufficient sample size was 123 patients.

Population and samples

The study was conducted in adult patients (aged ≥ 18 years) scheduled for major gastrointestinal surgery in the Faculty of Medicine at Siriraj Hospital, Thailand from February to September 2020. The inclusion criteria were 1) having elective major gastrointestinal surgery;

2) having good consciousness (Glasgow Coma Score ≥ 13); 3) having a Mini-cog score ≥ 3 (patients aged ≥ 60 years); 4) having the ability to walk (with or without assistance); and 5) having the ability to communicate in the Thai language. Patients were excluded from the study if they underwent major gastrointestinal surgery due to trauma or laparoscopic cholecystectomy and appendectomy. Moreover, they were withdrawn from the study if they needed a postoperative ventilator or were discharged before postoperative day 4 and were unable to be contacted by phone.

Instruments

1. Patient record form: The data were collected by interviewing patients and from patients’ files. They were divided into three parts. Part 1 (demographic and preoperative data) included sex, age, height, weight, BMI, diagnosis, comorbidity, history of previous abdominal surgery, history of smoking, and method of bowel preparation. Part 2 (intra-operative data) included surgical approach, procedure, anesthetic technique, operative time, and estimated blood loss. Part 3 (postoperative data) included opioid used, time to first enteral feeding, time to first flatus and stool, time to first ambulation, nasogastric tube insertion, complications, reoperation, and length of postoperative stay.

2. Hospital Anxiety and Depression scale (HADS) Thai version.29 The questionnaire was a self-reported survey comprising 14 items (seven items on the anxiety subscale and seven items on the depression subscale). It was interpreted from its scoring system (0–21 points) as non-case (0–7), doubtful case (8–10), and confirmed case (11–21). The questionnaire was translated into the Thai language and tested with patients with cancer.29 Both subscales presented good internal consistency, with

   
   

   Cronbach’s alpha coefficients of 0.8551 for the anxiety subscale and 0.8259 for the depression subscale. The questionnaire was used to identify preoperative anxiety and depression in patients undergoing gastrointestinal surgery.30 Before the study, the questionnaire was tested with 30 patients undergoing major gastrointestinal surgery; the Cronbach’s alpha coefficient was 0.82 (unpublished data).

3. The Fagerstrom Test for Nicotine Dependence (FTND) Thai version.31 The FTND was a self-reported questionnaire comprising six items. The total possible score ranged from 0 to 10. A score of 0–4 was considered as very low to low nicotine dependence, 5 as moderate nicotine dependence, and 6–10 as high to very high nicotine dependence. The intraclass correlation coefficient of the Thai version of the FTND was 0.83 and the Cronbach’s alpha was 0.52.31

4. Prolonged postoperative ileus: The development of PPOI was determined based on the definition of PPOI by Vather et al.,32 which included five criteria; 1) nausea or vomiting, 2) the lack of tolerance to an oral diet within 24 hours, 3) the absence of flatus in 24 hours, 4) abdominal distension, and 5) radiologic results of ileus. PPOI was determined if at least two of the criteria were met on the fourth day after surgery. Radiologic evidence of ileus was assessed using the hospital database and the result was confirmed by a physician.

Data collection

Patients who met the inclusion criteria were approached preoperatively on an individual basis and informed about the details of the study together with the right to withdraw at any time. They were ensured that participation in this study would not affect the care and treatment they received. Once patients agreed to participate in the study, they were asked to provide written consent. The data were obtained through questionnaires, interviews, and patients’ files. On the first day of admission, patients were asked to complete the HADS questionnaire (15-20 minutes). Patients who had a history of smoking were also asked to complete the FTND questionnaire (5-10 minutes).

The investigators revisited patients on postoperative day 4 between 9 and 10 a.m. to assess whether they had experienced PPOI. However, during the data collection period, if patients needed a ventilator, they were withdrawn from the study. If patients were discharged before postoperative day 4, the investigators called them on postoperative day 4 to assess the development of PPOI.

This prospective observational study was approved by the institutional ethics committee, Faculty of Medicine Siriraj Hospital, Mahidol University (Si 838/2019).

Statistical analysis

The data were analyzed by SPSS version 25 and descriptive statistics were generated. The relationships among the variables were analyzed using a Chi-square test. The powers of the predictive factors were analyzed using binary logistic regression. A p-value of 0.05 was considered to be statistically significant.

RESULTS

During the study period, 132 patients initially met the inclusion criteria. However, nine patients were later excluded from the study: four because their operation was canceled, three because a prolonged postoperative ventilator was used, and two were lost in follow-up. As a result, 123 patients were enrolled, with an average age of 59.8 ± 12.7 years and 52% men. The most common indication for surgery was gastrointestinal malignancy (96 patients, 78%), followed by an open approach (75 patients, 61%) and a combined general and epidural anesthesia (58 patients, 47%). Nearly half (46%) had a history of previous abdominal surgery. The details of patients’ demographics and operative characteristics are shown in Table 1.

Approximately 30% of patients had a history of smoking and one-third of them had high to very high nicotine dependence (FTND score 6–10) (Table 2). The same proportion of patients had anxiety and depression preoperatively (7.3% and 7.3%, respectively) (Table 3). After the operation, around 50% of patients had their first oral feeding on postoperative day 1, first flatus on postoperative day 1, and first stool on postoperative day 2. Up to one-third got out of bed on postoperative day 2. Complications except PPOI were found in 9.8% of patients. Only 1.6% of patients required reoperation.

The median postoperative length of stay was five days (IQR 5-7).

As detailed in Table 4, PPOI was observed in 22% of patients undergoing elective major gastrointestinal surgery. In the PPOI group, most patients could not tolerate an oral diet within the first 24 hours (77.8%), had abdominal distension (70.4%), and had nausea/ vomiting (66.7%). Only a few patients had an absence of flatus/stool over 24 hours on postoperative day 4 (26%). In particular, PPOI was confirmed by X-ray in 63% of patients with PPOI.

Univariate analysis revealed that having preoperative anxiety (p = 0.025) and starting ambulation on or after postoperative day 2 (p = 0.004) were significantly associated with PPOI (Figs 1 & 2). According to the multivariate analysis, the significant predictive factors of PPOI were having preoperative anxiety (OR = 6.26,

TABLE 1. Patient characteristics and the development of prolonged postoperative ileus (PPOI) (n = 123).

TABLE 1. Patient characteristics and the development of prolonged postoperative ileus (PPOI) (n = 123). (Continue)

Characteristics

Overall n (%)

PPOI

No (n = 96)

Yes (n = 27)

Bowel preparation

TABLE 1. Patient characteristics and the development of prolonged postoperative ileus (PPOI) (n = 123). (Continue)

TABLE 2. Fagerstrom Test for Nicotine Dependence (FTND) and development of prolonged postoperative ileus (PPOI) (n = 39).

TABLE 3. Hospital Anxiety and Depression Scale (HADS) and development of prolonged postoperative ileus (PPOI) (n = 123).

TABLE 4. Development of prolonged postoperative ileus (PPOI) (n = 123).

Fig 1. Association between preoperative anxiety and prolonged postoperative ileus.

Fig 2. Association between time to first ambulation and prolonged postoperative ileus.

95% CI = 1.218–44.411, p = 0.046) and ambulation on or after postoperative day 2 (OR = 3.26, 95% CI = 1.254–8.501, p = 0.015) (Table 5).

DISCUSSION

This study demonstrated that 22% of patients undergoing major gastrointestinal surgery developed PPOI based on the criteria recommended by Vather et al.,32 which have been validated and widely used to determine PPOI in several international studies. This study also found that preoperative anxiety and delayed postoperative ambulation were two significant predictors of PPOI. Interestingly, both preoperative anxiety and depression were investigated as psychological distress using HADS in this study, but only anxiety was a significant predictor of PPOI. Several recent studies have addressed the problem of clinical anxiety in elective surgery.30,34–36

Preoperative anxiety in surgical patients develops for several reasons such as fear of complications, postoperative pain, disability, and death.34,36 The association between psychological distress and changes in gastrointestinal function has been established in many studies.37,38 It is known to alter autonomic innervation, specifically stimulated sympathetic innervation, which relaxes the smooth muscle, thus decreasing bowel motility. Another reason might be the release of catecholamine, which is triggered by psychological distress and causes altered mucosal blood flow.26,27

Our findings of anxiety (not depression) as a PPOI predictor were consistent with the study by Paine et al.,39 who examined the relationship between anxiety and depression as well as 24-hour catecholamines in patients with untreated high blood pressure and highlighted that only anxiety is associated with sympathetic innervation

TABLE 5. Univariate and multivariate analysis of the risk factors for prolonged postoperative ileus (PPOI) following major gastrointestinal surgery.

*Statistically significant (p-value < 0.05)

Abbreviations: CI; Confidence interval, OR; Odds ratio, BMI; Body mass index, HADS; Hospital Anxiety and Depression Scale, FTND; Fagerstrom Test for Nicotine Dependence, POD; Postoperative day

activation. Therefore, anxiety and depression might affect the gastrointestinal tract through a different mechanism. Another study of 162 surgical patients also confirmed a correlation between preoperative anxiety and delayed gastrointestinal recovery.40

The present study also demonstrated that delayed ambulation was significantly associated with PPOI, which concurred with a population-based study in New Zealand in which delayed ambulation was found to

influence PPOI following elective colorectal surgery.12 Meanwhile, early ambulation has been shown to enhance patients’ overall recovery, including facilitating bowel motility.41 Morisawa et al.28 also found that the bowel sound of critically ill patients is significantly increased after passive exercise. They explained that ambulation can induce gastrointestinal motility by stretching the gastrointestinal tract and stimulating its parasympathetic innervation activity. Moreover, Kumar et al.42 found that

bowel cleansing is more adequate in patients without ambulation difficulty. Interestingly, as no definition of early ambulation was specified, the results of the study suggested that early ambulation (i.e., postoperative day 1) is recommended, especially to reduce the development of PPOI following major gastrointestinal surgery.

Age was not identified as a significant predictor of PPOI in this study. This concurred with prior studies of colorectal surgery.5,8,9,12,14,22 BMI was also unable to predict PPOI in this study, again consistent with previous studies.4,7-9,12,14 Lastly, smoking status was not significantly associated with PPOI in this study, in line with the findings of previous research.5,9,12

Although this was a prospective study, some limitations need to be addressed. First, all types of major gastrointestinal surgery were included given that the extent of surgery may vary depending on the nature of the disease (benign versus malignancy) and organ involvement. Second, due to the relatively small number of smokers, the power of smoking could not be determined in this study. Lastly, although PPOI was defined by the international definition proposed by Vather et al.,32 PPOI may manifest beyond the period of study or after discharge. An extended period of study could provide additional information for calculating the risk factors for the delayed presentation of PPOI.

CONCLUSION

PPOI occurred in 22% of patients following major gastrointestinal surgery. Preoperative anxiety and delayed postoperative ambulation were significant predictors of PPOI. Therefore, it is reasonable that preoperative anxiety should be assessed and treated (if present) under a multidisciplinary team approach. Early ambulation on the first day after the operation is also encouraged alongside effective nursing care and pain control.

ACKNOWLEDGEMENTS

As the first author, I am indebted to my advisors for their invaluable guidance throughout this study. I would also like to express my sincere thanks to the nursing staff and participants at this tertiary hospital who kindly supported me in every aspect.

Abbreviations

POI; Postoperative Ileus

PPOI; Prolonged Postoperative Ileus BMI; Body Mass Index

HADS; Hospital Anxiety and Depression Scale FTND; The Fagerstrom Test for Nicotine Dependence

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Outcomes of Decompression with Multi-Segment Long Instrumented Fusion in Lumbar Degenerative Disease

Areesak Chotivichit, M.D.

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: To evaluate the results of DLF in MDLS performed by a single experienced spine surgeon for both radiographic and clinical outcomes.

Materials and Methods: The database of single-institution was retrospectively reviewed. To identify MDLS patients who had undergone DLF (> 2 levels) between 2007 and 2017. Clinical presentation, radiographic measurements, perioperative complications, and postoperative results were analyzed. The Oswestry disability index (ODI) and EuroQol five dimensions’ questionnaire (EQ-5D-5L) were used to evaluate the outcomes comparing the preoperative and the most recent postoperative results.

Results: In total, 84 patients (23 males and 61 females) were enrolled, with an average age of 64.4±8.6 (46-81) years

old. Among these, 39 patients had fusion to L5 and 45 patients had fusion to the sacrum. Mean operative time was

66.9+23.4 minutes per level (range: 22.2-140) and the average length of stay was 10.7+5.7 days (range: 5-39). The mean estimated blood loss was 290.6+168.5 ml (range: 21.4-666.7). Average follow-up was 50.0+29.8 months (range: 0.5-124). The average preoperative ODI score was 60.6+16.3 (28-97.8) and 24.2+17.3 (0-71.1) postoperatively, while the average preoperative and postoperative EQ-5D-5L scores were 0.161+0.268 and 0.818+0.225, respectively. Both these clinical scores (ODI and EQ-5D-5L) showed a statistically significant improvement (p < 0.001). Finally, 13% (11/84) of patients had further surgery.

Conclusion: Decompressive laminectomy and long spinal fusion performed in patients with multi-level deteriorating

lumbar spinal stenosis are safe and effective in terms of the patients’ quality of life and disability improvement.

Keywords: Lumbar spinal stenosis; multi-level fusion; quality of life; disability; Oswestry disability index (Siriraj Med J 2022; 74: 548-554)

INTRODUCTION

Degenerative disease of the lumbosacral spine can result in back pain, neurogenic claudication due to spinal stenosis, and deformity (both in the coronal and sagittal plane). Surgical treatment for this problem usually consists of a posterior spinal fusion, decompression, and correcting the deformity.1,2 Long fusion (more than 2

levels) is contemplated for more extensive cases, such as a posterior spinal fusion from L2 to L5 to the sacrum. In patients with deformity, either scoliosis or flat back, an extended fusion up to the thoracic spine or the S2 iliac is required. The surgery is considered quite extensive because of the long operating time, blood loss, and high complication rate.

Corresponding author: Areesak Chotivichit E-mail: areesak.cho@mahidol.ac.th

Received 23 June 2021 Revised 9 February 2022 Accepted 27 March 2022 ORCID ID: https://orcid.org/0000-0001-6172-9258 http://dx.doi.org/10.33192/Smj.2022.65

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

This study aimed to evaluate the results of such procedures performed by a single experienced spine surgeon, in terms of both the radiographic and clinical outcomes.

MATERIALS AND METHODS

This study was first obtained by the Siriraj Institutional Review Board approval (Si 031/2012). The study involved a retrospective review of the medical records in the institutional database covering the period between February 2007 to August 2017. The inclusion criteria were patients with the lumbar degenerative disease with spinal stenosis who had undergone long posterior spinal fusion (more than 2 levels) with titanium pedicle screw and rod (Orthipesia®).

Data collection

The data collected were related to the patients’ demographic data, including gender, age at surgery, comorbidities, procedure information, implant type, estimated blood loss (EBL), postoperative complications, hospital length of stay (LOS), neurological outcomes, reoperation, time of operation, intraoperative complications, graft type, radiographic findings, and mortality. Radiographic assessments using lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and Cobb angle. The Oswestry disability index (ODI)3 and EuroQol-5 Dimensions Questionnaire (EQ-5D-5)4 were designed to evaluate the outcomes by comparing preoperative and most current postoperative results to assess the outcomes. The frequencies for categorical and ordinal variables, as well as the averages, standard deviations, and ranges for quantitative data, were determined using descriptive

comprising 23 males and 61 females. The average age of patients was 64.4±8.6 years old (range: 46–81) and the average BMI was 26.5±4.1 (range: 15.5–37.2). The mean operative time was 66.9±23.4 minutes per level (range: 22.2–140) and the average length of stay was 10.7±5.7 days (range: 5–39). The mean estimated blood loss was 290.6±168.5 ml (range: 21.4–666.7). The average follow-up was 50.0+29.8 months (range: 0.5–124). The average number of fused levels was 4.46+1.85 (ranges 3–9). There were 37, 20, 7, 4, 7, 5, and 4 patients who had

fusion involving 3, 4, 5, 6, 7, 8, and 9 levels, respectively, while 39 patients had fusion to L5 and 45 patients had fusion to the sacrum. The patients’ demographic data are summarized in Table 1.

The average preoperative LL, PI, PT, and SS were

28.98 ± 17.31(-11–81), 51.98 ± 11.41 (30–76), 27.57 ±

9.36 (3–58), and 24.39 ± 10.24 (-8–49), respectively. The average postoperative LL, PI, PT, and SS were 33.75 ± 13.7 (2–60), 52.49 ± 11.02 (30–77), 25.16 ± 8.05 (0–42), and

27.22 ± 8.44 (5–46), respectively. There were significant differences in LL, PT, SS, and Cobb angle (Table 2). When comparing between patients who were fused at L5 and to the sacrum, there were no significant differences in all parameters. The data are shown in Table 3. In patients with degenerative scoliosis (Cobb’s angle of more than 10 degrees), the average Cobb’s angle was improved from 23.47 ± 11.20 to 15.11 ± 10.14 degrees.

In terms of clinical outcomes, both the ODI and EQ- 5D-5L scores showed a statistically significant improvement (p < 0.001). The average preoperative ODI score was 60.6±16.3 (28–97.8) and 24.2±17.3 (0–71.1) postoperatively. The average preoperative and postoperative EQ-5D-5L

statistics. For continuous variables, the Mann–Whitney                              U-test was used, and for categorical variables, the Chi-

square test was used. For p-values of <0.05, statistical

significance was assumed, and odds ratios were calculated with the interval of 95 % confidence.

Surgical procedure

In a typical procedure, the patients were situated in a prone post. The paraspinal muscles were then dissected using a midline incision. Pedicular screws were placed on both sides, and decompressive laminectomy was accomplished. Posterolateral fusion was achieved using a local or iliac crest autograft. The operative surgeon determined the number of decompressive levels and fusion levels.

RESULTS

TABLE 1. Demographic data of the patients.

Data Average

Age (year) 64.4 ± 8.6 (46, 81)

BMI (kg/m2) 26.5 ± 4.1 (15.5, 37.2)

Operative time (minute) 66.9 ± 23.4 (22.2,140)

Length of stay (day) 10.7 ± 5.7 (5, 39)

Estimated blood loss (ml) 290.6 ± 168.5 (21.4, 666.7)

Number of fused levels (level) 4.46+1.85 (3–9)

Follow-up (month) 50 ± 29.8 (0.5, 124)

In total, 84 patients were included in this study,          

TABLE 2. Preoperative and postoperative radiographic measurements.

TABLE 3. Radiographic measurements and outcomes comparing fusion to L5 and fusion to the sacrum.

Clinical Measurement

Mean preoperative Mean postoperation Within group Between groups

(degree) (degree) p-value p-value

LL

Fusion to L5 (n = 19) 29.36 ± 19.33 33.21 ± 13.56

PI

Fusion to L5 (n = 19)

Fusion to the sacrum (n = 31)

53.28 ± 11.40

50.82 ±11.42

53.28 ± 9.97

51.80 ± 11.96

0.439

0.411

Fusion to the sacrum (n = 31) 28.64 ± 15.51 34.23 ± 13.97

0.557 0.962

PT

Fusion to L5 (n = 19) 29.18 ± 10 26.56 ± 7.84

SS

Fusion to L5 (n = 19)

Fusion to the sacrum (n = 31)

24.26 ± 8.40

24.50 ± 11.73

26.72 ± 7.55

27.66 ± 9.21

0.660

0.758

Fusion to the sacrum (n = 31) 26.14 ± 8.63 23.91 ± 8.11

0.797 0.108

Cobb

Fusion to L5 (n = 19) 15.56 ± 9.45 10.69 ± 6.73

ODI

Fusion to L5 (n = 19)

Fusion to the sacrum (n = 31)

60.4 15.7

60.7 17.0

24.9 17.9

23.7 17.2

<0.001

<0.001

0.840

Fusion to the sacrum (n = 31) 15.84 ± 13.91 10.80 ± 11.10

0.916 0.932

EQ-5D-5L

Fusion to L5 (n = 19) 0.114 0.236 0.799 0.221 <0.001

Fusion to the sacrum (n = 31) 0.189 0.285 0.831 0.231 <0.001

0.712

Abbreviations: LL; Lumbar lordosis, PI; Pelvis index, PT; Pelvis tilt, SS; Sacral slope, Cobb; Cobb’s angle ODI; Oswestry Disability Index, EQ-5D-5L; EUROQOL 5 Dimensions 5 Levels

scores were 0.161+0.268 and 0.818+0.225, respectively. The outcomes for patients who had scoliosis before the surgery also improved postoperatively for both scores (ODI from 64.32 ± 15.02 to 23.45 ± 16.78 and EQ-5D-

5L from 0.179 ± 0.313 to 0.828 ± 0.221). Additionally, significant clinical improvements were found in both the L5 and sacral fusion groups.

There were cases of 8 dura tears (9.5%). Three patients needed a revision of the pedicle screw due to breaching of the pedicle causing radicular pain. Two patients developed hematoma postoperatively, which required surgical removal at postop days 3 and 5, respectively. Also, massive bleeding due to a segmental artery tear occurred in one patient; while one patient developed a transient ischemic attack; one had superficial wound infection, which required a debridement; one patient had acute cholecystitis; one patient developed left common iliac vein thrombosis; one patient required exploration

of the nerve root and removal of the pedicle screw at the L4–5 level, and one patient developed pneumonia postoperatively.

Overall, 11 out of the 84 patients (13.1%) needed further surgery. Three of the 39 patients who had fusion to L5 had extended fusion through the L5–S1 level at 4, 12, and 30 months, respectively, due to a further symptomatic degenerative change in the L5–S1 level. Four of the 45 patients who had fusion through the L5–S1 disc had a revision of the L5–S1 level at 3, 5, 10, and 12 months, respectively, due to displacement of the PEEK in two patients and loosening of the S1 screw in the two other patients. Overall, three patients (3.57%) had extended fusion proximally at 30, 48, and 114 months, respectively. One patient had a proximal junctional fracture and required extended fusion to T4 at 2 months (Figs 2 & 3).

Fig 1. A 61-year-old female underwent a long fusion. The outcomes and Cobb angle were improved postoperatively (ODI from 86.67 to 17.78, EQ5d5L from -0.089 to 1, and Cobb angle from 48 to 17).

Fig 2. A 57-year-old female underwent long fusion from T10 to L5 due to degenerative adult scoliosis with stenosis (a). She had extended fusion to S1 using rod connectors and PEEK rods at nine and a half years (114 months) after the first surgery (b)

Fig 3. A 72-year-old female underwent long fusion from T10 to S2 due to degenerative adult scoliosis with stenosis (a). She had extended fusion to T4 due to proximal junctional fracture at 2 months (b).

DISCUSSION

Degenerative lumbar spinal stenosis (DLS) is a common disease in the elderly. The prevalence of DLS was reported as 5.7–9.3% in a Japanese population and increased with age.5,6 In terms of radiographic evaluation, the magnetic resonance image (MRI) of the lumbar spine is the gold standard. Srisajjakul and Chawalparit reported the positive predictive values of multiplanar reconstruction computed tomography (MPR-CT) in assessing the central canal stenosis, lateral canal stenosis, and foraminal stenosis were 77.7%, 75% and 50%, respectively. So, the MPR-CT may be considered as a choice of radiographic assessment in DLS patients who had contraindication for MRI.7

The current study showed that decompression with multi-segment long instrumented fusion could significantly improve the sagittal profile and clinical score (both ODI and EQ-5D-5L) compared within the preoperative period. These results were related not only to simple degenerative spinal stenosis but also to degenerative scoliosis. Interestingly, the results for a lower instrumented fusion level (L5 vs. the sacrum) did not show a statistically significant difference. Meanwhile, the complication rate was 23.8% (20/84), but surgical- related complications occurred at 17.85%.

The current study concurred with the results of previous research. However, there is some controversy between limited/long fusion and selective/limited decompression. Sun et al. reported the treatment results from 42 patients, Patients with multi-segment lumbar spinal stenosis and single-segment regressive spondylolisthesis were separated into two groups, comprising 22 patients with selective or 20 with multi-segmental compression and fusion. The results showed all the clinical scores (VAS, ODI, and

SF-36) at one-year follow-up and three-year follow-up. Both groups were improved considerably compared with their preoperative scores (p < 0.01), but no significant differences between the groups were detected at moment in time. However, the multi-segmental compression and fusion group had a longer operative duration and more blood leak. Also, 15 % of the patients in the multi- segmental compression and fusion group had advanced postoperative instability at the adjacent segments above the fused segments at the 3-year follow-up.1 Lee et al, performed a systematic meta-analysis comparing short limited fusion versus extended fusion with deformity correction in balanced de novo degenerative scoliosis with lumbar spinal stenosis. Six studies involving 362 patients (divided into two groups: 202 short fusions and 160 long fusion) were included in the analysis and the results showed that both groups had a decreased Cobb angle, C7 plumb, and ODI at the final follow-up. Additionally, the lengthy fusion group had showed a significant reduction in Cobb angle and the C7 plumb. However, the short fusion group had lower blood leak (average difference, 739.9 mL) and a shorter operative time (average difference, 68.0 minutes) compared to the long fusion group. Finally, it was concluded that short fusion may be a reasonable option and have a lower risk of curve progression.8

Postoperative constipation is a common problem

in spine surgery. Siripohn et al conducted a prospective randomized controlled trial comparing only standard nursing care and standard nursing care combined with Thai traditional medicine of abdominal massage (TTMAM group) in patients who underwent lumbar laminectomy. The TTMAM group had a larger percentage of patients who had their first feces between 3 days of surgery and

had reduced abdominal distension on the third day following surgery. Additionally, the TTMAM group’s mean patient satisfaction score was greater.9

In the present day, the role of minimally invasive surgery has substantially increased. Fan et al. Compared posterior lumbar interbody fusion (PLIF) clinical results versus minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in 60 patients who had 3-level degenerative lumbar spinal stenosis. They found no significant variations in back VAS, leg VAS, SF-36, fusion condition, ODI, and difficulties at 12-month follow-up between the two groups (p > 0.05). However, the MIS- TLIF group had significantly less blood leak, a shorter hospital stay (p < 0.05), and a lower back VAS than those in the PLIF group at 6-month follow-up (p < 0.05).10 Wu et al, showed that a combination of microendoscopic discectomy and minimally invasive transforaminal lumbar interbody fusion in 26 multilevel degenerative lumbar spinal stenosis patients with spondylolisthesis compared with 27 traditional PLIF patients had several advantages, including lower blood loss, less injury to the paraspinal soft tissue, a shorter incision, shorter bed rest time, improved outcomes, and shorter recovery times. However, there were no significant differences between the two groups’ operation times or ODI scores.11 Unfortunately, only open techniques were covered in that study.

Son et al. compared the outcomes between

decompression alone versus fusion in elderly patients with two-level or more lumbar spinal stenosis. The results showed that there were no significant differences between the two groups with respect to age, follow-up period, surgical levels, or preoperative condition, though it was found that correction of the lumbar lordosis angle was better in the fusion group at follow-up. However, other clinical outcomes, including VAS, ODI, and Odom’s criteria, were not significantly different, but the operation duration. In the decompression-alone group, estimated blood loss and surgical complications were much lower. As a result, the authors concluded that decompressive laminectomy alone was effective in patients with two or more levels of lumbar spinal stenosis who also had a poor general condition or osteoporosis.12 In Thailand, Keorochana et al. conducted a prospective observational study in 31 degenerative lumbar scoliosis patients with spinal stenosis and reported the effects of decompression and instrumented fusion with a pedicular screw plate system. All of the end indicators, including the pain scales, walking ability, ODI, and Roland Morris score, showed a substantial improvement (p 0.05). Five patients, however, experienced serious problems, with two of them requiring re-operation.2

The limitations of the present study include its retrospective nature, a small number of patients, a wide range of follow-up periods, and the use of a single-center database. A large, multi-center, well-controlled study also comparing various fusion techniques could provide additional information about how multi-segment lumbar spinal stenosis is treated in Thailand.

CONCLUSION

This is the first study from Thailand reporting the treatment outcomes of decompression with multi- segment instrumented fusion in lumbar degenerative disease patients. The results showed statistically significant improvements both in the clinical and radiographic results. Additionally, only 13% of patients needed further surgery.

ACKNOWLEDGMENTS

The authors would like to thank Miss Supani Duangkaew for editing the manuscript and assisting in its preparation for journal submission.

What is already known on this topic?

The previous study reported good results from decompressive laminectomy and fusion in terms of pain, disability, and quality of life improvements. The use of minimally invasive surgery, including MIS-TLIF or a microendoscopic discectomy combination, also provided non-inferior results with the benefits of lower bleeding and a shorter length of hospital stay.

What this study adds?

The present study showed that decompressive laminectomy and fusion in multi-level spinal stenosis, including degenerative lumbar scoliosis, improved the patients’ radiographic outcomes, quality of life, and disability. Also, a lower instrumented level (L5 vertebra or the sacrum) provided good results. However, surgical- related complications (including dural tear, hardware complication, and hematoma) were not uncommon.

Potential conflicts of interest

The authors confirm they have no potential conflicts of interest relevant to this article to declare.

REFERENCES

1. Sun W, Xue C, Tang XY, Feng H, Yuan F, Guo KJ, et al. Selective versus multi-segmental decompression and fusion for multi-segment lumbar spinal stenosis with single-segment degenerative spondylolisthesis. J Orthop Surg Res. 2019;14(1):46.

2. Keorochana G, Tawonsawatruk T, Laohachareonsombat W, Wajanavisit W, Jaovisidha S. The results of decompression and

   
   

   instrumented fusion with pedicular screw plate system in degenerative lumbar scoliosis patients with spinal stenosis: a prospective observational study. J Med Assoc Thai. 2010;93(4): 457-61.

3. Sanjaroensuttikul N. The Oswestry low back pain disability questionnaire (version 1.0) Thai version. J Med Assoc Thai. 2007;90(7):1417-22.

4. Sakthong P, Sonsa-Ardjit N, Sukarnjanaset P, Munpan W. Psychometric properties of the EQ-5D-5L in Thai patients with chronic diseases. Qual Life Res. 2015;24(12):3015-22.

5. Yabuki S, Fukumori N, Takegami M, Onishi Y, Otani K, Sekiguchi M, et al. Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci. 2013;18(6):893-900.

6. Ishimoto Y, Yoshimura N, Muraki S, Yamada H, Nagata K, Hashizume H, et al. Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population-based cohort in Japan: the Wakayama Spine Study. Osteoarthritis Cartilage. 2012;20(10):1103-8.

7. Srisajjakul S, Chawalparit O. Multiplanar Reconstruction Computed Tomography of Lumbar Spinal Stenosis in Correlation with Surgical Findings: Initial Experience. Siriraj Med J. 2003; 55(8):478-90.

8. Lee CH, Chung CK, Sohn MJ, Kim CH. Short Limited Fusion

   Versus Long Fusion With Deformity Correction for Spinal Stenosis With Balanced De Novo Degenerative Lumbar Scoliosis: A Meta-analysis of Direct Comparative Studies. Spine (Phila Pa 1976). 2017;42(19):E1126-E32.

9. Siripohn P, Visavajarn P, Suwannatrai U, Suwannatrai S, Butdapan P, Ruangchainikom M. The Effects of the Thai Traditional Medicine of Abdominal Massage on Defecation in Post Lumbar Laminectomy Patients. Siriraj Med J. 2019;71(3): 214-9.

10. Fan G, Wu X, Yu S, Sun Q, Guan X, Zhang H, et al. Clinical Outcomes of Posterior Lumbar Interbody Fusion versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in Three-Level Degenerative Lumbar Spinal Stenosis. Biomed Res Int. 2016;2016:9540298.

11. Wu H, Yu WD, Jiang R, Gao ZL. Treatment of multilevel degenerative lumbar spinal stenosis with spondylolisthesis using a combination of microendoscopic discectomy and minimally invasive transforaminal lumbar interbody fusion. Exp Ther Med. 2013;5(2):567-71.

12. Son S, Kim WK, Lee SG, Park CW, Lee K. A comparison of the clinical outcomes of decompression alone and fusion in elderly patients with two-level or more lumbar spinal stenosis. J Korean Neurosurg Soc. 2013;53(1):19-25.

Clinical Characteristics and Outcome of Bleb-Related Infection in Glaucoma Patients

Sakaorat Petchyim, M.D., Subongkoch Subhadhirasakul, M.D., Darin Sakiyalak, M.D., Pichsaran Vessadapan, M.D., Ngamkae Ruangvaravate, M.D.

Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: To study the clinical characteristics, causative organism, treatment, and clinical outcomes of bleb-related infection.

Materials and Methods: The medical charts of patients who were diagnosed with bleb-related infection, including blebitis and bleb-related endophthalmitis (BRE), from September 2001 to December 2019 at Siriraj Hospital were reviewed. The patients’ demographic data, clinical characteristics, microorganisms found, treatment, and clinical outcomes were explored.

Results: We found a total of 42 eyes from 41 patients had been diagnosed with blebitis (11 eyes) and BRE (31 eyes)

over the 18-year study period. More than 80% of the patients had experienced pain and redness as the presenting symptoms. The most common bleb characteristic in BRE was purulent bleb (74.2%), while in blebitis it was bleb injection (45.5%). Bleb leakage was documented in 27.3% and 22.6% of patients with blebitis and BRE, respectively. Among the 41 patients, 10 had a history of minor trauma before the onset of infection, such as a rubbed eye, foreign body entering into the eye, water splashed into the eyes, or the eyes had been washed with soap. The yield of vitreous culture in bleb-related endophthalmitis was 48.3%. The most common microorganisms were Streptococcus

spp., Enterococcus spp., and Haemophilus Influenzae. Generally, the treatment for blebitis at our institute is broad

spectrum topical and systemic antibiotics, while intravitreal broad spectrum antibiotics are added to the treatment regimen for BRE patients. For BRE in our cohort, 11 eyes required vitrectomy and 7 eyes had undergone bleb excision. Treatment for blebitis tended to have a good visual outcome, with a stable visual prognosis for 9 out of the 11 eyes diagnosed with blebitis. However, most of the BRE eyes had a worsened visual outcome. Enterococcus

spp. and Haemophilus Influenzae resulted in poor visual outcomes.

Conclusion: The clinical characteristics of bleb-related infection in our patients were pain and redness. One fourth of patients had a history of minor trauma to the eye. To prevent bleb-related infection, the importance of patient education after trabeculectomy should be highlighted. Patients with presenting symptoms and unwanted behavior that could result in bleb infection should be identified and receive treatment alongside education.

Keywords: Bleb infection; blebitis; bleb-related endophthalmitis; clinical; sign; symptom; outcome; predisposing behavior; trauma, patient education (Siriraj Med J 2022; 74: 555-561)

INTRODUCTION

Trabeculectomy is the standard glaucoma treatment and usually reserved as the last resort after intolerable

side effects or disease progression become apparent despite the administration of the maximum tolerable topical medications. Glaucoma shunt surgery can cause

Corresponding author: Sakaorat Petchyim E-mail: sakaoratpoy@gmail.com

Received 20 September 2021 Revised 22 May 2022 Accepted 23 May 2022 ORCID ID: https://orcid.org/0000-0002-7550-8605 http://dx.doi.org/10.33192/Smj.2022.66

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

decrease number of endothelial cell count1 as a long term complication. Trabeculectomy which appear to be safer for endothelial but the most serious complication of trabeculectomy is bleb-related infection. Even though, the incidence of bleb-related infection is rare at only 0.4–0.6%,1-10 such infection could lead to permanent visual loss and disability. Most studies divide bleb-related infection into two categories depending on the location of the infection: blebitis, which is infection of the bleb and is localized in the anterior segment, and bleb-related endophthalmitis, which is an infection of the bleb and entire globe.

The understanding of the disease presentation, risk factors, causative organism, and outcome of treatment is important to prevent a disastrous outcome of bleb-related infection. The most common causative organisms of bleb-related infection are Streptococcus

spp., Staphylococcus spp., Haemophilus influenzae, and

Enterococcus spp.9,11,12 Blebitis is usually treated with intensive topical antibiotics.6 The treatment of bleb-related endophthalmitis usually involves intravitreal antibiotics injection, mostly vancomycin and ceftazidime, although pars plana vitrectomy is performed as an alternative approach in some cases.6,11,12 The visual outcomes of bleb-related endophthalmitis have been reported as: improved (50%), declined (24%), and remained the same (26%).12 Previous studies found that the risk factors of bleb-related infection were the use of anti-fibrotic agents, such as mitomycin-C or 5-fluorocil3,9,10,13,14; inferior bleb approach10,11,13,15; fornix-based conjunctival flap16; bleb leakage1,6,11,17,18; bleb manipulation11,19, such as bleb needling; and underlying diseases, such as diabetes20 and blebitis.20

Even though trabeculectomy is not an uncommon surgery in the Southeast Asia region in terms of the number of procedures at 122.6-234.0 procedures/1 million persons/year21, the lack of studies on bleb-related infection is still a problem. Moreover, differences in educational background, personal hygiene, culture, and healthcare accessibility can result in different courses of the disease, as reported in previous studies conducted in other regions. The clinical and microbiological characteristics of bleb- related infection can help guide the ophthalmologist to provide better patient education for improving long-term care regarding post-operative infection prevention and early diagnosis.

Therefore, the primary outcome of this study was to study the symptoms and signs of bleb-related infection. The secondary outcomes were to study the risk factors, causative organism, treatment, and outcome of treatment of bleb-related infection in Siriraj Hospital, Thailand.

MATERIALS AND METHODS

Before we reviewed the medical records, approval for the study was obtained from the Siriraj Institutional Review Board committee, Siriraj Hospital, Mahidol University. We searched the Siriraj Hospital coding database for all patients who were diagnosed with blebitis or bleb endophthalmitis or both. We retrospectively reviewed the records of the patients who were diagnosed with blebitis or bleb-related endophthalmitis or both by diagnosis or by referral to Siriraj Hospital and who were treated at Siriraj Hospital between September 2001 and December 2019. Patients who had a controversial diagnosis of bleb-related infection were excluded from this study. Blebitis was defined as a presumed bleb infection in an eye after filtering surgery when the vitreous was not clinically involved.2 Bleb-related endophthalmits was defined as an infection invading the anterior chamber and eventually passing into the vitreous.2 The patients’ demographic data, trabeculectomy procedure, co-ocular diseases, diagnosis of glaucoma, management of post- trabeculectomy, signs and symptoms, specimen culture, treatment of bleb-related infection, and outcome of the treatment were reviewed. Stable visual acuity means visual acuity is not deteriorated by more than 2 lines of the Snellen chart or changed from hand movement to the projection of light.

Descriptive statistics were used to evaluate the

patients’ baseline demographic data, location of the bleb approach, the use of anti-fibrotic agents, type of glaucoma, signs and symptoms of bleb-related infection, the causative microorganism from the culture, type and route of treatment, visual outcome, and post-infection glaucoma status.

RESULTS

After a review of 18 years’ medical records, 42 eyes of 41 patients were identified as having been diagnosed with bleb-related infection. The patients’ demographic data are shown in Table 1.

The average age at the time of bleb-related infection presentation was 58.5 years old (range 5-87 years old). Seventy-three percent of the patients had bleb endophthalmitis. Nearly a half of patients (47.6%) had underlying primary open angle glaucoma (Table 1).

Symptoms and signs

Blebitis

As shown in Table 2, the most common ocular symptom was redness in 8 eyes (72.7%) follow by pain in 54.5% of patients. All the blebitis patients had conjunctival injection followed by an injected bleb in 45.5% of patients.

TABLE 1. Patients’ demographic data.

Demographic data

Number

(42 eyes, 41 patients)

Sex

Male 29

Female 12

TABLE 2. Signs and symptoms of BRI.

Almost all the patients (91%) had an anterior chamber reaction, with 54.54% of patients having marked anterior chamber cells. The only patient who didn’t have an anterior chamber reaction had purulent bleb. Most of the blebitis cases had normal fundus (81.8%).

Bleb-related endophthalmitis

In contrast to blebitis, 90.3% of patients presented with pain. All the patients had conjunctival injection followed by purulent bleb in 74.2% of patients. Overall, 93% of BRE patients had marked anterior chamber cells with 64.5% of BRE patients having hypopyon. More than half (64.5%) of the patients had obscured fundus (64.5%) (Table 2).

Events

Most the bleb-related infection patients did not have a history of any trauma before. However, two patients had rubbed the affected eye before they were diagnosed as Enterococcus BRE. Three patients had a history of a foreign body in the affected eye, such as dust or an insect. The vitreous culture results of these three patients were Haemophilus, Streptococcus, and Staphylococcus. Two patients had a history of water spreading into the affected eye, with one occurring while cooking and another while praying. One patient had stabbed her finger in the affected eye while washing her face, and another patient had washed the affected eye with soap after eye irritation.

Underlying diseases

The most common underlying diseases found in bleb-related infection were diabetes mellitus in 12/41 patients (29.3%, Blebitis 6/11 BRE 6/31) and hypertension in20/41 patients (48.8%).

History of trabeculectomy procedure

The trabeculectomy site, intraoperative use of anti-fibrotic agents, and types of conjunctival flap and bleb manipulations are shown in Table 3. None of the recorded eyes with trabeculectomy had any other surgery combined or intraoperative complications. Only one eye needed long-term (10 months) topical steroid use after trabeculectomy due to co-morbid ocular disease (chronic anterior uveitis). No long-term topical antibiotics were used.

Bleb manipulations, including 5-fluorouracil subconjunctival injection and bleb needling, were done more than 4 months before the bleb-related infection. There was no history of glue application or tissue plasminogen activator injection before bleb-related infection in our institution.

Characteristics

Number

(42 eyes)

TABLE 3. History of trabeculectomy and bleb characteristics in BRI patients.

Trabeculectomy procedure Bleb location

Superior 39

Inferior 3

Intraoperative anti-fibrotic agent used

In BRE patients, 13 eyes had fornix-based conjunctival flap while 7 eyes had limbal-based conjunctival flap with 11 eyes with no record of conjunctival flap type.

The mean duration from trabeculectomy to bleb- related infection was 65.4 months (range 0.33-192.0 months). The characteristics of the blebs before infection are shown in Table 3, with the most common being avascular bleb (55.9%) followed by cystic bleb (52.9%) and bleb leakage (32.4%) There was no characteristics of tense and opaque blebs in the bleb-related infections.

Organisms Blebitis

The eye discharges from three eyes were sent for culture and the results were Staphylococcus spp. for two

eyes and no growth of culture for one eye. The aqueous fluid of three eyes and vitreous of four eyes were sent for analysis and no growth was reported for all (Table 4). There was one eye which both eye discharge and aqueous were sent for culture. The result came back with Staphylococcus spp. from eye discharge.

Bleb-related endophthalmitis

In 29 out of a total of 31 eyes with bleb-related endophthalmitis, there was a 48.5% positive rate from the vitreous cultures, in contrast with blebitis, where the yield of the aqueous cultures was zero (Table 4). There were 9 eyes which the specimens were taken from both aqueous and vitreous. Three eyes had positives vitreous culture and 2 eyes had positive result from both specimens with the same causative agents.

Treatment

All the blebitis patients received topical antibiotics. The medication regimens were combined fortified vancomycin and fortified fortum in 5 eyes, combined fortified vancomycin and fortified amikacin in 3 eyes, and combined fortified cefazolin and fortified amikacin, topical levofloxacin, and topical moxifloxacin each in 1 eye. Five of 11 blebitis patients received subconjunctival antibiotics injection. The most common type of antibiotics was subconjunctival vancomycin and ceftazidime injection

for 4 cases. Meanwhile intracameral antibiotics injection was applied in only 3 patients. Five patients underwent intravitreal antibiotics injection, comprising combined vancomycin and ceftazidime. Systemic antibiotics were prescribed in 9 patients, including oral levofloxacin in 4 patients, clarithromycin in 2 patients, ofloxacin in 2 patients, and combined intravenous vancomycin and amikacin in 1 patient.

All the bleb-related endophthalmitis patients received topical antibiotics, comprising combined fortified vancomycin and fortified ceftazidime in 22/31 eyes (71%), combined fortified vancomycin and fortified amikacin in 7/31 eyes (22.6%), combined fortified cefazolin and gentamicin in 1 eye, and moxifloxacin in 1 eye. There were 16 and 8 eyes with bleb-related endophthalmitis that received subconjunctival and intracameral antibiotics, respectively. Additionally, 11 eyes underwent vitrectomy. Intravitreal antibiotics were injected in 27 eyes, with the most common being combined vancomycin and ceftazidime in 21 eyes, followed by combined vancomycin and amikacin in 3 eyes, combined vancomycin–ceftazidime–amikacin in 1 eye, combined amikacin and clindamycin in 1 eye, and cefazolin in 1 eye. Most bleb-related endophthalmitis patients were prescribed systemic antibiotics (30 eyes), including combined vancomycin and ceftazidime in 15/30 (50%), and oral levofloxacin in 7/30 (23.33%). Bleb excision was performed in 7 eyes.

Outcomes Blebitis

The visual acuity outcome in all eyes after blebitis had subsided was the same as that at baseline before infection. By converting visual acuity to logMAR unit, there was no difference between pre- and post-blebitis. Pre- blebitis was 0.88±1.500 and post blebitis was 0.93±1.497. The glaucoma status was stable in 4 eyes without topical anti-glaucoma being added; however, 3 eyes needed more topical anti-glaucoma after the infection to control the disease, and 4 eyes proceeded toward needing penetrating glaucoma surgery.

Bleb-related endophthalmitis

The visual acuity after the treatment of bleb-related endophthalmitis after 1 year was stable in 9 eyes, but deteriorated by more than 2 lines of the Snellen chart or changed from hand movement to the projection of light in 16 eyes. Using logMAR visual acuity, there was significant deterioration of visual acuity after bleb related endophthalmitis (Mean difference -1.66 ±1.837 95% CI

-2.422 to -0.906 p-value = 0.00). Before BRE logMAR visual acuity was 0.57±0.723compare to 2.24±1.888 after the event. The glaucoma status progressed in 27 eyes, including to phthisis bulbi in 13 eyes (42%).

DISCUSSION

This was a study of 42 bleb-related infection cases over 18 years since the first electronic medical records were implemented at the Medical Educational Center, Siriraj Hospital.

Our results showed that pain and redness were the most common ocular symptoms of bleb-related infection. Meanwhile, conjunctival injection was found in all cases of bleb-related infection. Severe anterior chamber reactions (e.g., marked anterior chamber cells, hypopyon, and plasmoid reaction) were reported frequently in bleb-related endophthalmitis. Fundus examination was also hardly performed in bleb-related endophthalmitis. The most common bleb characteristic in bleb-related endophthalmitis was purulent bleb, supported by a “white-on-red” appearance. Most the bleb-related infection patients did not have any history of ocular trauma. However, 24% of the bleb-related infection cases had a history of ocular trauma. There were 2 patients with a history of eye rubbing who were diagnosed with Enterococcus bleb-related endophthalmitis. It is known

that Enterococcus spp. can be found in the gastrointestinal

tract of humans, and these endophthalmitis cases indicate low hygiene activities. Patients who had a history of water spreading to the eyes had culture negative organisms or

low-virulence organisms (Morexella spp.). Nobody had a history of infection from swimming. Some activities reflect insufficient self-care in post-trabeculectomy.

Lehmann reported diabetes was the main risk factor of bleb-related infection.3 The prevalence of diabetes in patients aged 45-54 years old in Thailand was 9.8%.4 Diabetes was present in 13% of glaucoma patients.5 Our first finding reported diabetes in bleb-related infection in 29.3% of cases, which was higher than the prevalence of diabetes in glaucoma patients. Our second finding showed that mitomycin-C was used in 61.9% of procedures. Many studies have found mitomycin-C to be associated with bleb-related infection.3,6-10 However, recent practice has shifted to mitomycin-C rather than 5-FU. This might result in more percentage of bleb infection in patients who had used mitomycin-C to augment trabeculectomy. Therefore, it was difficult to interpret the association of mitomycin-c use with bleb-related infection. Evidence of chronic blepharitis,11 the presence of nasolacrimal duct obstruction,12 and fornix-based conjunctival flap9 were associated with bleb-related infection. However in our study there was not enough number of eyes and lots of missing data to concluded that fornix-based conjunctival flap is associated with bleb related infection. From previous studies fornix based conjunctival flap as a risk factor of having bleb related infection is still controversy.13 The number of the eyes having fornix based conjunctival flap is greater which may result from the recent prefer practice of flap type.

In term of other possible risk factors in this study,

we did not find any history of other ocular diseases except conjunctivitis in our bleb-related infection study. Keep in mind that this finding is one of the limitations in this study due to retrospective nature which result from the completeness of medical record. Bleb manipulation was reported as a risk factor of bleb-related infection.12,14 Our findings demonstrated that no bleb-related infection occurred after recent (< 1 month) bleb manipulation. We found that the most common bleb characteristics were cystic and avascular blebs. This could be explained by the thin wall of cystic blebs or micropores, which may allow microorganisms to get into the bleb leading to bleb-related infection.

Previous studies have found Streptococcus spp. and

Staphylococcus spp.8,12,15,16 to be causes of bleb-related endophthalmitis. The causative organisms of bleb-related endophthalmitis in our study were not only Streptococcus spp., but also Haemophilus Influenzae, and Enterococcus faecalis. In the Enterococcus bleb-related endophthalmitis eyes, the patients all had a history of avascular cystic bleb. In the eyes with both aqueous and vitreous specimens

were taken, the positive result have found in vitreous cultures. Therefore it supported that vitreous culture had important role in diagnosing BRE.

Blebitis had a better visual outcome than bleb- related endophthalmitis in our subjects. There was a stable visual outcome in bleb-related endophthalmitis in 9 eyes, with no organism identification in the culture of 6 eyes. The visual outcome in all our Enterococcus bleb- related endophthalmitis cases was no light perception, ending up in phthisis bulbi. Therefore, patients with a history of rubbing eyes should be wary of Enterococcus

bleb-related endophthalmitis. Also, once Enterococcus

bleb-related endophthalmitis is diagnosed, aggressive and urgent treatment must be delivered and the possible visual outcome should be forewarned to patients. Most importantly, patient education about appropriate self-care after trabeculectomy should be highlighted, particularly regarding eye rubbing and the need for eye protection when doing activities with a high risk of water, dust, or foreign bodies ingress into the eye.

The key limitation of our study to note is the retrospective study design. Bleb-related infection is a rare trabeculectomy complication, thus resulting in a small sample size. However, we reported almost all the aspects and cases of bleb-related infection in our tertiary care medical center in Thailand, which could be beneficial in terms of ensuring patient education to prevent bleb-related endophthalmitis. The symptoms, clinical signs, prognosis, and treatment regimen can present a gross picture for the ophthalmologist to be able to better deal with the bleb-related infection.

CONCLUSION

Bleb-related infection is a rare complication of glaucoma surgery. The clinical characteristics include pain and redness. One fourth of patients in our study had a history of minor trauma to the eye. Appropriate health education for glaucoma patients after trabeculectomy should be provided. Patients with presenting symptoms and unwanted behavior that could result in bleb-related infection should be identified and receive treatment alongside education.

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   Patients. Siriraj Med J. 2021;73(4):252-8.

2. Brown RH, Yang LH, Walker SD, Lynch MG, Martinez LA, Wilson LA. Treatment of Bleb Infection After Glaucoma Surgery. Arch Ophthalmol. 1994;112(1):57-61.

3. Lehmann OJ, Bunce C, Matheson MM, Maurino V, Khaw PT, Wormald R, et al. Risk factors for development of post- trabeculectomy endophthalmitis. Br J Ophthalmol. 2000;84(12): 1349.

4. Aekplakorn W, Stolk RP, Neal B, Suriyawongpaisal P, Chongsuvivatwong V, Cheepudomwit S, et al. The Prevalence and Management of Diabetes in Thai Adults. Diabetes Care. 2003; 26(10):2758.

5. Mitchell P, Smith W, Chey T, Healey PR. Open-angle Glaucoma and Diabetes: The Blue Mountains Eye Study, Australia. Ophthalmology. 1997;104(4):712-8.

6. Greenfield DS, Suñer IJ, Miller MP, Kangas TA, Palmberg PF, Flynn HW, Jr. Endophthalmitis After Filtering Surgery With Mitomycin. Arch Ophthalmol. 1996;114(8):943-9.

7. Higginbotham EJ, Stevens RK, Musch DC, Karp KO, Lichter PR, B ergstrom TJ, et al. Bleb-related Endophthalmitis after Trabeculectomy with Mitomycin C. Ophthalmology. 1996;103(4):650-6.

8. Kangas TA, Greenfield DS, Flynn HW, Parrish II RK, Palmberg

   P. Delayed-onset endophthalmitis associated with conjunctival filtering blebs. Ophthalmology. 1997;104(5):746-52.

9. Luebke J, Neuburger M, Jordan JF, Wecker T, Boehringer D, Cakir B, et al. Bleb-related infections and long-term follow-up after trabeculectomy. Int Ophthalmol. 2019;39(3):571-7.

10. Yamamoto T, Sawada A, Mayama C, Araie M, Ohkubo S, Sugiyama K, et al. The 5-year incidence of bleb-related infection and its risk factors after filtering surgeries with adjunctive mitomycin C: collaborative bleb-related infection incidence and treatment study 2. Ophthalmology. 2014;121(5):1001-6.

11. Kim E-A, Law SK, Coleman AL, Nouri-Mahdavi K, Giaconi JA, Yu F, et al. Long-Term Bleb-Related Infections After Trabeculectomy: Incidence, Risk Factors, and Influence of Bleb Revision. Am J Ophthalmol. 2015;159(6):1082-91.

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Long-Term Rehabilitation Outcomes of Neurological Patients: A Multicenter Study

Donruedee Srisuppaphon, M.D.*, Pranee Lukkanapichonchut, M.D.**, Nualpis Intaratep, M.D.***, Vilai Kuptniratsaikul, M.D.****

*Sirindhorn National Medical Rehabilitation Institute, Ministry of Public Health, Nonthaburi, Thailand, **Department of Rehabilitation Medicine, Ratchaburi Hospital, Ministry of Public Health, Ratchaburi, Thailand, ***Department of Rehabilitation Medicine, Maharat Nakhon Ratchasima Hospital, Ministry of Public Health, Nakhon Ratchasima, Thailand, ****Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

ABSTRACT

Objective: To evaluate functional outcomes in patients three years after rehabilitation and to identify factors significantly associated with improvement.

Materials and Methods: This prospective cohort study was carried out in nine tertiary centers to compare functional outcomes (Barthel Index; BI) at discharge with scores at three-year follow-up among various diagnoses and types of admissions. Related factors were evaluated for association with improvement in functional score.

Results: Three hundred and eighteen patients (mean age: 54 years; 60% male) were included. More than half of all

patients suffered from a spinal cord injury. After three years, 35% of patients were still receiving physical therapy. Only those who were admitted for intensive rehabilitation showed significant improvement after three years. One hundred and ten patients or 35.8% showed significant improvement over time. A univariate analysis showed type of diagnosis, type of admission, onset to admission interval, BI at discharge, and presence of depression and complications at follow-up to be significantly associated with improvements in functional score in the follow-up period. Using a multivariate analysis, only the type of diagnosis, low BI at discharge, and absence of depression and complications at follow-up related to functional improvement.

Conclusion: One-third of patients had sustained functional improvements from rehabilitation three years after

discharge. Participants admitted into intensive rehabilitation showed significant improvements in functional scores between discharge and follow-up. TBI diagnosis, low BI at discharge, absence of depression and complications at follow-up related to long-term functional improvement at the three-year mark.

Keywords: Rehabilitation; treatment outcome; inpatients; functions; multicenter study (Siriraj Med J 2022; 74: 562-569)

INTRODUCTION

One of the principal objectives of rehabilitation is to enhance a person’s functional status so he/she can participate in normal activities of daily living and social activities, both of which contribute to a better quality of life. Studies from many countries, including a large multicenter trial and three dataset reviews, have

shown the effectiveness and efficiency of inpatient rehabilitation to facilitate improvement in or return of patient’s normal level of function.1–4 Several studies have reported factors that predict functional outcomes at discharge from rehabilitation, including age, onset to rehabilitation admission interval (OAI), length of stay (LOS), admission functional status, admission cognitive

Corresponding author: Vilai Kuptniratsaikul E-mail: vilai.kup@mahidol.ac.th

Received 20 September 2021 Revised 22 May 2022 Accepted 23 May 2022 ORCID ID: https://orcid.org/0000-0001-8348-0369 http://dx.doi.org/10.33192/Smj.2022.67

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

level, diagnosis, intensity of rehabilitation program, and certain characteristics of impairments.1–3,5,6 In order to achieve the ultimate goal of personal independence and social participation, functional performance needs to be retained long after rehabilitation.

Most studies explore long-term outcomes in stroke patients,7–9 but some also look at outcomes in patients with a traumatic brain injury.10–13 As such, functional measurement tools used to evaluate these two patient population groups vary substantially. Only a few studies compare a patient’s functional status between rehabilitation discharge and long-term community outcome.9–11

Factors reported as being significantly associated with long-term functional outcomes in brain injury patients include age, type of impairment, functional level during admission, functional level at discharge, ability to follow commands before discharge, duration of minimally conscious state, and diagnosis.8,10,11,13

In Thailand, there are no rehabilitation units dedicated to a specific type of disorder. All patients in Thailand in need of functional restoration are admitted to general rehabilitation wards located mostly in general hospitals and university hospitals.14 Data relating to long-term functional outcomes after discharge from inpatient rehabilitation in Thailand is scarce. Accordingly, the aim of this study was to evaluate functional outcomes of patients with neurological conditions after three years of rehabilitation in Thailand, and to identify factors associated with functional outcomes.

MATERIALS AND METHODS

In 2012, two thousand and eighty-one patients from fourteen medical centers participated in a prospective multicenter study to investigate the effectiveness and efficiency of inpatient rehabilitation services in Thailand.14 Of those, nine centers agreed to participate in this three- year follow-up study of functional outcomes in patients admitted for inpatient rehabilitation. The ethical review committee of each participating center approved this multicenter study (Si: 393/2015). Patients aged above 18 admitted to inpatient rehabilitation facilities in 2012 were included. Those no longer having regular follow- up appointments were contacted via telephone to come back for a checkup. Written informed consent was given by all enrolled study participants.

Demographic and clinical data included age, gender, onset-to-admission interval (OAI), length of stay, marital status, diagnosis, requirements for caregiver, discharge location, and type of admission. Participants were examined by a rehabilitation physician for functional status using the Barthel Index (BI)15 at their three-year follow-up visit.

The BI ranges from 0-20, with a higher score indicating better functional status. The BI score at three-year follow- up was compared to the BI score at discharge among various diagnoses and types of admission. In addition, the number (%) of patients with different levels of disability severity was analyzed for association between discharge and three-year follow-up.

The type of admission was classified as either intensive or non-intensive rehabilitation. Patients admitted in the intensive program included people who could tolerate rehabilitation at least three hours per day, five days per week. Patients admitted in the non-intensive program satisfied one or more of the following criteria14:

1) patient could tolerate rehabilitation less than two hours per day; 2) admitted for investigation; 3) admitted so that their caregiver could receive training; and/or,

4) admitted to be treated for complications. Readmission after discharge from inpatient rehabilitation wards was also recorded. Complications were recorded as none or having complications, including pain, spasticity, shoulder subluxation, joint contracture, pressure ulcer, pneumonia, incontinence, dysphagia, and depression. Depression was evaluated using the Patient Health Questionnaire (PHQ- 9) with a score greater than nine indicating depression.16

Statistical analysis

Demographic and clinical data was analyzed descriptively. A paired t-test was used to analyze changes in BI scores at discharge (BIDC) and at three-

year follow-up (BIFU) among various diagnoses and types

of admission. The McNemar’s test was used to compare severity of disabilities at discharge and three-year follow- up. Factors related to changes in functional score were analyzed using the Student’s t-test and one-way analysis of variance (ANOVA) for categorical data. The Pearson’s and Spearman’s rank correlation coefficient tests were applied for continuous data. All factors with a p-value of less than 0.10 in univariate analysis was included in a multiple linear regression analysis. A p-value of less than

0.05 was regarded as being statistically significant. All statistical analyses were performed using SPSS Statistics version 18 (SPSS, Inc., Chicago, IL, USA).

RESULTS

Among the 1,431 patients admitted to nine hospitals in Thailand in 2012, we were able to track 628 (43.89%). Of those, 109 had died, 201 declined to participate, and the remaining 318 patients were included in this study (Fig 1). Ninety-four patients were readmitted to the hospital after discharge in the three-year follow-up period, and approximately half of those had more than

Fig 1. Flow diagram of study enrollment process

one admission due to complications. The majority of complications were urinary tract infection (UTI) and pressure ulcer, and a small number of patients had pneumonia, deconditioning, or recurrent stroke.

The average age of patients was 54, with 60% being male. More than half of all patients suffered from spinal cord injuries (SCI). Approximately 80% of study patients also required assistance from a caregiver. More than half (53.6%) of patients were admitted at some point in time for intensive rehabilitation (Table 1).

The Barthel Index (BI) compared type of diagnosis and type of admission at discharge and the follow-up period as shown in Table 2. The changes in BI score at follow-up and discharge revealed statistically significant improvements regarding stroke, SCI, and traumatic brain injury (TBI). Patients with TBI showed the greatest increase in functional score. In addition, only those who were admitted for intensive rehabilitation showed significant improvements at the three-year follow-up.

Association between functional score (BI) at discharge and at the three-year follow-up by severity of disability

is shown in Table 3. Almost half of all patients (46.3%) remained at the same level of ability, while 110 (35.8%) showed signs of improvement over time. Only 55 patients (17.9%) had functional deterioration at the three-year follow-up mark.

A univariate analysis revealed type of diagnosis (p=0.039), type of admission (p=0.025), onset-to-admission interval (OAI) (p=0.034), BI at discharge (p<0.001), presence of depression at follow-up (p=0.015), and presence of complications at follow-up periods (p=0.059) to be significantly associated with improvement in functional

score at follow-up. A multivariate analysis identified four factors that were either negatively or positively associated with improvements in functional score at three-year follow-up. TBI diagnosis positively correlated with improvements in functional score at follow-up (p=0.048). A low BI score at discharge (p<0.001), presence of complications at follow-up (p=0.011), and presence of depression at follow-up (p=0.023) all negatively correlated with improvements in functional score at follow-up (Table 4).

TABLE 1. Demographics and clinical characteristics of study participants.

Variables

TABLE 2. Barthel Index compared between discharge and follow-up for type of diagnosis and type of admission.

A p-value <0.05 indicates statistical significance; #Paired t-test

Abbreviations: BI; Barthel Index, SCI; spinal cord injury, TBI; Traumatic brain injury

TABLE 3. Association between functional score at discharge and functional score at the three-year follow-up by severity of disability (N=307).

Severity of functional score (BI) at 3-year follow-up, n (%)

Severity of functional score (BI)

at discharge n (%)

Very severely Severely disabled disabled

(BI: 0-4) (BI: 5-9)

Moderately disabled

(BI: 10-14)

Mildly disabled

(BI: 15-19)

Independent

(BI: 20)

Very severely disabled 25 (8.1%) 9 (2.9%) 2 (0.7%) 1 (0.3%) 0 (0.0%)

Severely disabled

(BI: 5-9)

9 (2.9%)

13 (4.2%)

10 (3.3%)

14 (4.6%)

1 (0.3%)

(BI: 0-4)

Moderately disabled 6 (2.0%) 13 (4.2%) 51 (16.6%) 33 (10.7%) 13 (4.2%)

Mild disabled

(BI: 15-19)

0 (0.0%)

2 (0.7%)

17 (5.5%)

37 (12.1%)

27 (8.8%)

(BI: 10-14)

Independent 0 (0.0%) 0 (0.0%) 0 (0.0%) 8 (2.6%) 16 (5.2%)

(BI: 20)

McNemar’s test: p-value<0.001

Abbreviation: BI, Barthel Index

DISCUSSION

Three years after discharge from rehabilitation, our study found that one-third of all patients had sustained functional improvement, while almost half remained at the same level of disability, and one-fifth had functional deterioration. Wade and Hewer reported the outcomes at six months post-stroke and found that 65.7% of patients saw an improvement while the condition of 6.2% declined.17 Our results are in contrast against those in a study by Kuptniratsaikul, et al. who reported that 51.5% of patients had improved functional level while 12.8% saw a decline one year post-stroke.18 These studies confirm the natural course of functional recovery in which significant improvement occurs within 6-12 months, with a subsequent observed tendency of the patient’s functional level to stabilize or decline thereafter. It is important to emphasize that in addition to our study which enrolled stroke patients (25.4%), we also enrolled patients with SCI (53.3%) and TBI (3.5%). More than 80% of participants were admitted with sub-acute neurological conditions and therefore, the course of recovery discussed here is probably applicable.

In addition to observed significant improvements in functional score at three-year follow-up, patients admitted

for intensive rehabilitation showed apparent sustainability of functional status, which is consistent with previous findings.14,19,20 Pattanasuwanna and Kuptniratsaikul performed a retrospective study in stroke patients admitted between 2010-2014 to investigate five-year outcomes,19 and Rinkaewkan and Kuptniratsaikul performed a retrospective study in patients admitted for SCI rehabilitation between 2006-2010.20 Those studies revealed that stroke and SCI patients admitted for intensive rehabilitation had better functional improvements (change in BI score) than groups admitted for non-intensive rehabilitation. These differences may be due to the fact that patients admitted for intensive therapy were deemed able to tolerate a three-hour per day program. Taken together, these findings also confirm previously reported findings that intensive rehabilitation is effective for improving functional status in any disease.14

Regarding factors that significantly correlate with an

improved Barthel Index score over time, our study found four. A multivariate analysis showed that diagnosis of TBI positively associated with improved BI at follow-up, low BI at discharge, and that presence of depression at follow-up, and presence of complications at follow-up negatively associated with improved BI. This result aligns

TABLE 4. Univariate and multivariate analysis for factors significantly associated with changes in Barthel Index score (BIFU - BIDC).

BI score

Marital status 0.659 - - -

P-values <0.1 and <0.05 indicate statistical significance in univariate and multivariate analysis, respectively

Abbreviations: SE; standard error, OAI; onset-to-admission interval, LOS; length of stay, BI; Barthel Index, FU; follow up, DC; discharge

with those from a study by Katz, et al.,11 which suggests that TBI patients have a better chance of recovery than non-TBI patients. The functional status at admission or discharge from rehabilitation has also been demonstrated to be an indicator of level of ability or disability in the long-term in many studies.8,10,11,21-24 As there is a variety of measurement tools being used, it is difficult to directly compare the results reported among studies.

Cognitive function is one factor that can predict functional outcomes at discharge from rehabilitation. Rehabilitation doctors do TMSE for cognitive function screening as a routine during inpatient service. In addition, only stroke patients with good potential are suitable for receiving rehabilitation program. That means they should have good co-operation, be able to follow command and retain 24-hour memory. These can represent fair to good cognitive function. Depression, another important factor, is one of our obstacles to rehabilitation program. It could affect co-operation and final outcomes. Every inpatient in rehabilitation ward was also screened for depression as a routine procedure. Other studies reported the fact that depression is an independent indicator of poor functional status in the long-run.18,25,26

Concerning complications, Rinkaewkan and Kuptniratsaikul conducted a retrospective study in 201 SCI patients admitted to rehabilitation wards between 2006-2010. They found an absence of comorbidity and the ability to undertake an intensive rehabilitation program to be associated with increased functional score after rehabilitation.20

Discharge to home is one of the final outcomes which represents successful rehabilitation program. Our country could not provide skilled nursing facilities like other western countries, so one of our goals is patients being discharged to home after receiving full rehabilitation program. In addition, some patients still had disabilities that needed help at discharge. Caregiver was a key person to help patients complete those functions at home. However, to minimize the burden of caregiver, they had to learn how to help patients independent before being discharged. Rehabilitation team should also concern burden of caregiver as well as patients’ quality of life.27,28 This study had some limitations such as the fact that

only 318 of 1,431 patients from nine medical centers could be recruited, which is a relatively small study population. In contrast, a study conducted in the United States was able to collect rehabilitation outcome data of more than 200,000 patients in more than 300 rehabilitation centers over an eight-year period.29,30 In countries lacking long- term data collection systems like Thailand, the analyzed information is from a relatively small number of patient

records and from postal surveys, which are associated with low response rates.7,11–13 Moreover, it may be inferred that data from these two methods would probably reflect more well-disciplined patients that maintained contact with health care providers. It is also, therefore, possible that the health status and functional level of participants included in the present study would be better than the health status and functional level of participants who failed to follow-up. It should also be noted that funding limitations prevented the research team from visiting patients at their homes. Further complicating the patient recruitment process was that some patients lived in rural areas which are inconveniently far from a rehabilitation center, so many declined to participate. A further study with more participants would be helpful in confirming long-term functional outcome findings reported in this study.

CONCLUSION

More than one-third of patients had sustained improvements in functional level three years after discharge from inpatient rehabilitation. Participants admitted for intensive rehabilitation showed significant improvements in functional scores between discharge and three-year follow-up. A multivariate analysis revealed TBI diagnosis to be positively correlated, and low BI at discharge, presence of depression, and presence of complications at follow-up to be negatively correlated with long-term functional improvements.

ACKNOWLEDGEMENTS

We are grateful to all of the rehabilitation staff in the nine tertiary centers. We are also grateful to our patients and their families for their cooperation. The authors would like to thank Ms. Pimpagee Pornmusigawan for her assistance with the coordination of data collection, and Ms. Julaporn Poolium for statistical analyses.

Conflicts of interest: All authors declare no personal or professional conflicts of interest regarding any aspect of this study.

Sources of funding: Our study was supported by the Royal College of Physiatrists of Thailand and partly supported by the Faculty of Medicine Siriraj Hospital, Mahidol University.

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2. Kuptniratsaikul V, Wattanapan P, Wathanadilokul U, Sukonthamarn K, Lukkanapichonchut P, Ingkasuthi K, et al. A Multicenter Study of Efficiency for Rehabilitation Service: A Comparison between Institutes. J Thai Rehabil Med. 2014;24:76-85.

3. Joa KL, Han TR, Pyun SB, Rah UW, Park JH, Kim YH, et al. Inpatient stroke rehabilitation outcomes in Korea derived from the Korean Brain Rehabilitation Centers’ online database system for the years 2007 to 2011. J Korean Med Sci. 2015;30: 644-50.

4. Turner-Stokes L, Vanderstay R, Stevermuer T, Simmonds F, Khan F, Eagar K. Comparison of rehabilitation outcomes for long term neurological conditions: A cohort analysis of the Australian rehabilitation outcomes centre dataset for adults of working age. PLoS One. 2015;10:e0132275.

5. Bode RK, Heinemann AW. Course of functional improvement after stroke, spinal cord injury, and traumatic brain injury. Arch Phys Med Rehabil. 2002;83:100-6.

6. Wang H, Camicia M, Terdiman J, Hung YY, Sandel ME. Time to inpatient rehabilitation hospital admission and functional outcomes of stroke patients. PM R. 2011;3:296-304.

7. Dijkerman HC, Wood VA, Hewer RL. Long-term outcome after discharge from a stroke rehabilitation unit. J R Coll Physicians Lond. 1996;30:538-46.

8. Mutai H, Furukawa T, Araki K, Misawa K, Hanihara T. Long- termoutcomeinstrokesurvivorsafterdischargefrom aconvalescent rehabilitation ward. Psychiatry Clin Neurosci. 2013;67:434-40.

9. Andersen HE, Eriksen K, Brown A, Schultz-Larsen K, Forchhammer BH. Follow-up services for stroke survivors after hospital discharge - A randomized control study. Clin Rehabil. 2002;16: 593-603.

10. Blicher JU, Nielsen JF. Does long-term outcome after intensive inpatient rehabilitation of acquired brain injury depend on etiology? Neuro Rehabilitation. 2008;23:175-83.

11. Katz DI, Polyak M, Coughlan D, Nichols M, Roche A. Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up. Prog Brain Res. 2009;177: 73-88.

12. Saifee TA, Kassavetis P, Pareés I, Kojovic M, Fisher L, Morton L, et al. Inpatient treatment of functional motor symptoms: A long-term follow-up study. J Neurol. 2012;259:1958-63.

13. Whyte J, Nakase-Richardson R, Hammond FM, McNamee S, Giacino JT, Kalmar K, et al. Functional outcomes in traumatic disorders of consciousness: 5-year outcomes from the National Institute on Disability and Rehabilitation Research traumatic brain injury model systems. Arch Phys Med Rehabil. 2013;94: 1855-60.

14. Kuptniratsaikul V, Wattanapan P, Wathanadilokul U, Sukonthamarn K, Lukkanapichonchut P, Ingkasuthi K, et al. The effectiveness and efficiency of inpatient rehabilitation services in Thailand: A prospective multicenter study. Rehabilitation Process and Outcome. 2016;5:13-18.

15. Collin C, Wade DT, Davies S, Horne V. The barthel ADL index: A reliability study. Disabil Rehabil. 1988;10:61-63.

16. Lotrakul M, Sumrithe S, Saipanish R. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry. 2008;8:46.

17. Wade DT, Hewer RL. Functional abilities after stroke: Measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry. 1987;50:177-82.

18. Kuptniratsaikul V, Kovindha A, Piravej K, Dajpratham P. First-Year Outcomes after Stroke Rehabilitation: A Multicenter Study in Thailand. ISRN Rehabilitation. 2013;2013: 1-6.

19. Pattanasuwanna P, Kuptniratsaikul V. Inpatient rehabilitation outcomes in patients with stroke at Thailand’s largest tertiary referral center : A 5-year retrospective study. J Sci Res Stud. 2017; 4:208-16.

20. Rinkaewkan P, Kuptniratsaikul V. The effectiveness of inpatients rehabilitation for spinal cord patients in Siriraj hospital. Spinal Cord. 2015;53:591-7.

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24. Meyer MJ, Pereira S, McClure A, Teasell R, Thind A, Koval J, et al. A systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation. Disabil Rehabil. 2015;37:1316-23.

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29. Graham JE, Granger C V., Karmarkar AM, Deutsch A, Niewczyk P, Divita MA, et al. The uniform data system for medical rehabilitation: Report of follow-up information on patients discharged from inpatient rehabilitation programs in 2002- 2010. Am J Phys Med Rehabil. 2014;93:231-44.

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Development of Simulation Model for Transradial Catheterization Practice for Physicians

Kanchalika Julthongpipat, B.Tech.*, Chatkanok Dumavibhat, M.D.**, Korakoth Towashiraporn, M.D.** , Puttinun Patpituck, Ph.D.*

*Veinitatphattana School, Medical Educational Technology Program, Faculty of Medicine Siriraj Hospital, **Her Majesty Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: This study tested different types of silicone rubber material to assess the most durable with properties that best simulated the human skin and vascular. The optimal materials were used to produce a transradial catheterization simulation model to train medical practitioners and tested the improvement of the training with a medical simulation model.

Materials and Methods: Three types of silicone rubber were tested for their suitability as artificial skin and vascular

for transradial catheterization simulation model. Eighteen fellowship physicians assessed the simulator’s operational effectiveness and recorded their satisfaction with the training.

Results: Silicone rubbers were tested for realism and capability for repetitive training. Silicone rubber RTV-01 was

the most durable for simulating the artificial skin, while silicone rubber RTV-03 was the most durable for simulating the artificial vascular with statistically significant results recorded by Kaplan-Meier analysis (P < 0.1). Satisfaction assessment results of the 18 participants using a Likert scale (5 points) returned total average scores of model’s efficacies as 4.41 and total average scores of model’s usefulness as 4.59.

Conclusion: The materials were used for transradial catheterization simulation to enhance fellowship trainees’

learning efficiency through practice. The fellowship trainees became familiar with the equipment, gained a higher completion rate, and increased confidence in treatment planning.

Keywords: Transradial catheterization; medical simulation model; silicone rubber (Siriraj Med J 2022; 74: 570-574)

INTRODUCTION

Coronary artery disease (CAD) or ischemic heart disease (IHD) is the leading annual cause of death worldwide.1 Coronary angiography (CAG) is the gold standard procedure used to diagnose blocked areas in coronary arteries. Vascular access for coronary angiography can be performed via the femoral artery at the groin or via the radial artery at the wrist. A transradial catheterization procedure is safer than a femoral artery approach. The patient recovers faster, with a reduced risk of complications

after the procedure2-4; however, vascular system access via the radial artery requires skillful catheter insertion into a smaller vessel than the femoral artery.

Currently, diagnostic cardiac catheter training is performed directly on patients under the supervision of a senior fellowship or staff physician. The Siriraj Hospital Faculty of Medicine has modernized instruction methods that now promote outcome-based education5, with learning and teaching styles focusing more on treatment outcomes. Practical approaches are now encouraged to supplement

Corresponding author: Puttinun Patpituck E-mail: puttinun.pat@mahidol.ac.th

Received 19 April 2022 Revised 8 August 2022 Accepted 8 August 2022 ORCID ID: https://orcid.org/0000-0002-2669-7999 http://dx.doi.org/10.33192/Smj.2022.68

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

lectures.6 However, patient numbers are often insufficient to allow students adequate medical practice for many of the procedures, and as a result, some students lack confidence when treating patients. Practicing simulation techniques allows the students to gain experience before performing in real operation settings. Simulated training methods improve confidence and proficiency, allowing detailed preparation of each treatment step.7-15 Due to the recent coronavirus COVID-19 pandemic, medical institutions actively adapt their teaching approaches to prevent infection. The medical model is the best learning tool to enhance medical practitioners’ skills to the fullest potential without concerns.16 Practitioners can practice individually with the model to compensate for practicing with patients. Moreover, the medical model can reduce instructional costs by repetitively use and being able to create the format related to instructors’ guidance.17

A previous study demonstrated higher operation

success rates after simulation training.18 A VIST-C endovascular simulator is currently used in some cardiac catheterization practices. This high-precision device assists in practicing procedures as primarily visual responses in functional systems covering a wide range of vascular pathologies and standardized clinical complication situations in examination training. Using simulation scenarios significantly improved cardiac catheterization skills through training and reduced real device training process time in the Cath Lab.19 A TSP simulation model was previously developed to train interventional cardiologists in cardiac catheterization. X-ray image simulation (fluoroscopy) and a wide variety of vascular pathology using 3D programs have also been used to assist real learning. Rating test results of the interventional cardiologists indicated the suitability of using simulation models; however, these results were not extensively tested because only interventional cardiologists were enrolled in the study.20 Commercially available catheterization simulators include the ANGIO Mentor Suite produced by Simbionix Simulators, with simulation training of basic skills in Electrophysiology. However, this test does not cover the actual circulatory vascular system, while the simulation model looks like a box, lacks realism and does not match actual operation procedures. Simulation models for transradial catheterization operations are limited by their high cost.21 Previous studies investigated the use of simulation models to practice complex procedures, with results showing reduced procedure time, fluoroscopy time and contrast media volume.22 Studies on teamwork or computational safety of skilled participants are limited compared to assessments on simulation model realism and functionality.23 To overcome these limitations, a half-

body human-size simulation model was developed for trainee physicians to practice transradial catheterization via the radial artery in the wrist. The study subjects were fellowship students in the Interventional Cardiology Program.

MATERIALS AND METHODS

Artificial skin and radial artery selection steps following: 1) The three silicone rubber specimens that were all readily accessible on the market were analyzed. Each of the three types of silicone rubber had a Shore hardness value similar to human skin and the radial artery. Human skin has a Shore A hardness grade of 10 to 20, while the radial artery has a Shore A hardness grade of 37 to 39.24-25 2) The silicone rubber specimens were repeatedly punctured with an actual needle 20Gx1/4 1 in the exact location until a defect occurred as needle marks and tearing of the material. Survival analysis followed the Kaplan-Meier method. 3) Three experts evaluated the material qualities used to create the model. A questionnaire was used to collect information from the interventional cardiologist participants for model reliability, including Intraclass Correlation Coefficient (ICC) statistic, and 10 points were evaluated. 4) This experimental research measured the efficiency and satisfaction of the research population as 18 fellowship students from the Interventional Cardiology Program who had previous and no previous operation experience.

A half-body human-size simulation model, 108 cm

high and 53 cm wide was created to improve transradial catheterization practice skills for the trainee physicians. Suitable materials were used to replicate the skin and artificial blood vessels. Three cardiologists conducted the testing procedure on 18 fellowship physicians in interventional cardiology studying the sub-discipline of cardiovascular disease treatment. Training using the simulation model consisted of two steps 1. vascular access and 2. catheter insertion to the coronary artery. (Figs 1 & 2)

Fig 1. Transradial catheterization simulation model

Fig 2. Coronary artery angiography training using the simulation model

RESULTS

Silicone rubber durability test

Silicone rubber durability was tested by determining the number of needle punctures until leaving a needle mark and tear. (Fig 3) The durability results of simulated skin showed statistically significant differences at the 0.1 level (Kaplan-Meier method). RTV-01 silicone rubber gave a higher durability rate and minor damage than RTV-02 and RTV-03. The RTV-01 silicone rubber punctured the needle 75 times until leaving a needle mark, while the vascular access sheath was inserted 8 times until leaving a tear. (Chart 1)

The durability results of simulated vascular showed RTV-03 a higher durability rate and minor damage than RTV-02 and RTV-01, with statistically significant differences at the 0.1 level (Kaplan-Meier method). RTV-03 was able to puncture the needle to the skin 70 times until leaving a needle mark, and the vascular access sheath was inserted 12 times until leaving a tear. (Chart 2)

Fig 3. Survival analysis showing the needle punctures until the silicone rubbers were damaged

Reliability test results from the three cardiologists using Intraclass Correlation Coefficient (ICC) model analysis

The ICC values from the three cardiologists by estimating the three types of silicone rubber that were used to create the simulation skin, ICC = 0.88 (95% CI = 0.70 – 0.96). For vascular simulation, ICC = 0.88 (95% CI = 0.70 – 0.96) the expert confidence assessment results indicated consistency between the three experts and that they were of excellent reliability.

Satisfaction survey results from the fellowship of Internal Medicine Cardiology using a 5-point Likert scale

Values of resistance during needle puncture and catheter insertion were realistic with mean average score of 4.22. Skin softness and elasticity were real with an average score of 4.33. The shape of the simulation model was maintained after the procedure with an average score

Chart 1. The simulated skin durability analysis (Kaplan-Meier) The number of needle punctures (left), and vascular access sheath insertion (right)

Chart 2. The simulated vascular durability analysis (Kaplan-Meier) The number of needle punctures (left), and vascular access sheath insertion (right)

of 4.50. The anatomical accuracy had an average score of

4.33. The blood flow was realistic with an average score of 4.33. The appearance of the model was suitable for usage with an average score of 4.78, and the total mean satisfaction of model performance had an average score of 4.41. These results showed that satisfaction with the performance of the model was at the highest level.

Satisfaction results showed that the simulation model enhanced the experience of the trainees with an average score of 4.67, reduced pressure before attending to an actual patient with an average score of 4.61 and increased confidence and readiness of the trainees with an average score of 4.56. Practicing the procedure in a controlled environment helped the trainees to prepare for potential problems with an average score of 4.50 and reduced the risk of performing the design on the patient with an average score of 4.61. The process for practicing the operation was realistic with an average score of 4.61, while total mean satisfaction with model usefulness

recorded an average score of 4.59. These results showed that satisfaction with using the simulation model was at the highest level.

CONCLUSION

Simulation-based operational training is a valuable tool to increase learning efficiency and allows the fellowship trainees to practice operational techniques with the surgical equipment. Despite some simulators in cardiac catheterization training lacked realism due to their unrealistic form.19,20 Lack of realism affects the surgical practice, which causes trainees to lack understanding of the procedure and the use of equipment. Therefore, researchers created a half-body human-size model to simulate an actual operation in which a patient is lying down on a surgical bed. Skin and vascular were mimicked as accurately as possible in terms of physical characteristics and capable of repetitive training. The materials can be reused and not accessible to tearing or leaving traces in operation. With

Fig 4. Transradial catheterization training

realistic and capability for repetitive training, transradial catheterization simulation motivates the fellowship trainees to become familiar with the equipment, gain a higher completion rate and increase confidence in treatment planning.

Recommendation

The study participants recommended developing a simulated pulse to the model that would make the practice of radial artery catheterization more realistic. A pulse would allow the participants to insert the needle correctly and reduce errors and damage to the skin and blood vessels.

ACKNOWLEDGMENTS

The authors would like to extend their deepest thanks for the support from Veinitatphattana School, Faculty of Medicine Siriraj Hospital, Mahidol University, and Her Majesty Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University for their contributions to the design and development of the simulator, as well as providing the location for testing and offering clinical advice.

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18. Barsuk JH, McGaghie WC, Cohen ER, O’Leary KJ, Wayne DB. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009;37(10):2697-701.

19. Schimmel DR, Sweis R, Cohen ER, Davidson C, Wayne DB. Targeting clinical outcomes: Endovascular simulation improves diagnostic coronary angiography skills. Wiley Online Library. 2015;87:383-8.

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Histopathological and Clinical Features of Methotrexate-Associated Lymphoproliferative Disorders and Post-Transplant Lymphoproliferative Disorders

Preeyawat Ngamdamrongkiat, M.D.*, Emvalee Arromdee, M.D.**, Attapong Vongwiwatana, M.D.***, Weerapat Owattanapanich, M.D.****, Sanya Sukpanichnant, M.D.*

*Department of Pathology, **Division of Rheumatology, ***Division of Nephrology, ****Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: To study histopathological and clinical features of methotrexate-associated lymphoproliferative disorders (MTX-LPD) and post-transplant lymphoproliferative disorders (PTLD).

Material and Methods: A retrospective study on 30 cases of MTX-LPD and 2 cases of PTLD from 2006 to 2021. Results: By histopathology, the MTX-LPD group had 21 cases of lymphoma (MTX-Lymphoma) and 9 cases of reactive changes (MTX-Reactive). The PTLD group included diffuse large B-cell lymphoma and polymorphic PTLD (1 case each). The distinctive findings in MTX-Lymphoma and PTLD were association with Epstein-Barr

virus (EBV) (8/12 cases, 66.7%) and CD30 positivity (13/18 cases, 72.2%). The MTX-LPD group had median MTX dosage of 10 mg/week, median MTX cumulative dosage of 2,613.75 mg, and median duration of MTX usage of 2,186 days. The 14 MTX-LPD and PTLD patients has median duration to response after the varied interventions of 47 days and the time to the first complete remission (CR) of 126 days. The MTX-Reactive patients had a significantly higher absolute lymphocyte count, younger median age, fewer B symptoms, higher rate of single site involvement, less extranodal involvement, shorter duration to response, less time to enter CR, and higher CR rate than the MTX- Lymphoma patients (p < 0.05).

Conclusion: Histopathology in MTX-LPD and PTLD patients can vary from reactive changes to lymphoma. EBV

study and CD30 immunostaining help identify MTX-LPD and PTLD. History of MTX usage and other causes of immunodeficiency should be considered before diagnosing lymphoma. MTX discontinuation or reduction of immunosuppressant dosage are recommended before administrating combined chemotherapeutic agents in unresponsive cases.

Keywords: Methotrexate-associated lymphoproliferative disorders; post-transplant lymphoproliferative disorders; other iatrogenic immunodeficiency-associated lymphoproliferative disorders (Siriraj Med J 2022; 74: 575-589)

INTRODUCTION

Methotrexate (MTX) is an anti-metabolite of folic acid, used as an anti-neoplastic drug in many neoplasms (including malignant lymphoma) and as an immunosuppressive drug for autoimmune diseases.1

But MTX has been associated with lymphoproliferative disorders (LPD) secondary to immunosuppression.2-4 The revised 4th edition of the World Health Organization (WHO) Classification of Tumours of Haematopoietic and Lymphoid Tissues (WHO-HAEM4R) recognizes 4 types

Corresponding author: Sanya Sukpanichnant E-mail: sanya.suk@mahidol.ac.th

Received 18 July 2022 Revised 7 August 2022 Accepted 8 August 2022 ORCID ID: http://orcid.org/0000-0002-9724-2692 http://dx.doi.org/10.33192/Smj.2022.69

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

of immunodeficiency-associated LPD: post-transplant lymphoproliferative disorder (PTLD), lymphomas associated with HIV infection, lymphoproliferations associated with primary immune disorders, and other iatrogenic immunodeficiency-associated LPD that includes MTX- associated LPD (MTX-LPD).5 Recently, the 5th edition of the WHO classification of lymphoid tumours (WHO- HAEM5) has been introduced as a review article since 22 June 2022 proposing a three-part nomenclature for LPD and lymphomas arising in the setting of immune deficiency/ dysregulation: 1) histological diagnosis (hyperplasia, polymorphic LPD, mucocutaneous ulcer, or lymphoma classified as for immunocompetent patients); 2) viral association (EBV or KSHV/HHV8); and 3) immune deficiency/dysregulation setting (inborn error or immunity, HIV infection, posttransplant, autoimmune disease, iatrogenic/therapy-related, or immune senescence).6

The risk and type of MTX-LPD are varied upon the

type of immunosuppressive agents used in addition to MTX, the degree of immune deficiency, and the nature of the underlying disorder being treated. Even though the disease is being more recognized now, there are no definitive diagnostic criteria and histologic categories. The diagnosis is based solely on LPD found in patients with a history of MTX usage who recover spontaneously after MTX discontinuation.2,3 On the contrary, MTX- LPD patients with aggressive clinical courses at times fail to regress after MTX discontinuation.7 It is unclear when MTX-LPD patients should receive chemotherapy after MTX discontinuation and the response may differ depending on the histopathology of MTX-LPD. Recently, The EBV real-time PCR test value in the peripheral blood8 and programmed cell death-ligand 1 (PD-L1) expression in the lymphoma cells9 were associated with spontaneous regression in MTX-LPD. Moreover, MTX-LPD patients previously treated with tumor necrosis factor-alpha or Janus kinase (JAK) inhibitors prior to MTX-LPD onset had more aggressive disease.10

This study aimed to investigate the histopathological

and clinical features of MTX-LPD and PTLD, specifically of any distinct features to help pathologists identify these cases without knowing any clinical data, to clarify the differences in characteristics between MTX-LPD subcategories, and to identify MTX-LPD requiring chemotherapy upfront.

MATERIALS AND METHODS

Patients and tissue samples

This study was approved by the Institutional Review Board, Faculty of Medicine Siriraj Hospital, Mahidol University (SIRB) (Si 408/2021). For the MTX-LPD

group, we compared the list of 14,139 patients with MTX treatment at Siriraj Hospital during January 2006 and May 2021 from the Department of Pharmacy and the Siriraj Informatics and Data Innovation Center to the archive list in the pathology laboratory information system (LIS) to identify the patients with a history of MTX usage and the histopathology of LPD. For the PTLD group, we searched for the cases diagnosed in the pathology LIS during the same period. We found MTX-LPD patients with lymphoma diagnosis (MTX- Lymphoma) 32 cases, MTX-LPD patients with reactive changes (MTX-Reactive) 21 cases, and PTLD patients 7 cases. The cases that lacked hematoxylin and eosin (H&E) staining and/or immunostained slides were excluded. Finally, we identified MTX-Lymphoma patients 21 cases, MTX-Reactive patients 9 cases, and PTLD patients 2 cases.

Patients were defined as having primary autoimmune

disease by the information in the medical records. We defined MTX-LPD in patients receiving MTX at the time of diagnosis of LPD. In patients with underlying rheumatoid arthritis (RA), we evaluated the disease activity score in 28 joints count with 3 variables (DAS28- 3) based on clinical and laboratory data 6 months prior to LPD diagnosis, which included the number of tender joints and number of swollen joints out of 28 joints, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP) calculated by http://www.das-score.nl.11 All slides were re-evaluated by two pathologists (PN and SS) to record histopathologic features as listed in Table 1 and the disease diagnosis was made according to the WHO- HAEM4R.5

Immunohistochemical study (IHC) and Epstein–Barr virus-encoded small RNA (EBER) in situ hybridization (ISH)

The immunohistochemical study and EBV ISH were performed in an automated staining machine (The Ventana BenchMark XT automated slide-staining system, Tucson, AZ, USA). The IHC panels were listed in Table 2. Immunostained slides and the EBER ISH slides were re-evaluated by two pathologists (PN and SS).

Statistical analysis

Continuous demographic data were presented as the median and range. Categorical demographic data were presented as a percentage. Statistical analysis was performed to investigate the associations between the clinical and laboratory variables and the diagnosis of MTX-LPD by using Fisher’s exact test or Mann-Whitney tests, as appropriate (SPSS Statistics, v. 18.0; SPSS, Inc.,

TABLE 1. List of histopathologic features recorded for evaluation in the study.

Histopathologic features How to record

Residual lymphoid follicle presence or absence

Tissue necrosis presence or absence

Vascular invasion presence or absence

Sclerosis partial fibrous septa or absence

Polymorphic reaction: Neutrophil Eosinophil

Plasma cells

presence of ≥ 1 cell/HPF* presence of ≥ 1 cell/HPF

presence of ≥ 2 cell/HPF

Histiocytic aggregation presence or absence

Hodgkin-Reed-Sternberg-like (HRS-like) cells presence or absence

* HPF: high power microscopic field images were obtained under microscopy using a 40x objective lens with a field area of 0.159 mm2.5

Chicago, IL, USA). A p-value < 0.05 was considered to be statistically significant. The cumulative 1-year and 5-year overall survival (OS) rates were analyzed using survival curves and were estimated by the Kaplan-Meier method and compared using log-rank tests.

RESULTS

Patient characteristics

In the 21 cases of the MTX-Lymphoma group, there were RA 17 cases, systemic lupus erythematosus 1 case, idiopathic exfoliative dermatitis 1 case, juvenile idiopathic arthritis 1 case, and idiopathic orbital inflammation 1 case. In the 9 cases of the MTX- Reactive group, there were RA 5 cases, antiphospholipid syndrome 1 case, ankylosing spondylitis 1 case, psoriasis 1 case, and Behçet disease 1 case.

Comparison of the clinical characteristics of the MTX-Lymphoma and MTX-Reactive patients (Table 3) showed that the MTX-Reactive patients had a significantly higher absolute lymphocyte count, younger median age, fewer B symptoms, a higher rate of single site involvement, less extranodal involvement, shorter duration to response, less time to CR, and a higher CR rate than the MTX- Lymphoma patients (p <0.05).

Among the RA patients were DAS28-3 ESR available in 18 patients (13 MTX-Lymphoma and 5 MTX-Reactive) and DAS28-3 CRP available in 2 MTX-Lymphoma.7 Interestingly, 5 MTX-Lymphoma patients had low RA

disease activity (DAS28-3 CRP < 3.2) while 8 MTX- Lymphoma patients and 5 MTX-Reactive patients had moderate RA disease activity (DAS28-3 CRP > 3.2 but

< 5.1) (Table 3).

The median MTX dosage at diagnosis of MTX- Lymphoma (7.5 mg/week) was lower than that of MTX- reactive (10 mg/week) (p = 0.071) but the median MTX cumulative dosage at LPD diagnosis of MTX-Lymphoma (2,880 mg) was higher than that of MTX-Reactive (665 mg) (p = 0.167). The median MTX usage duration at LPD diagnosis of MTX-Lymphoma (2,440 days) was longer that that of MTX-Reactive (410 days) (p = 0.288) (Table 3).

Of the 2 PTLD patients, one was a 59-year-old man when PTLD first developed. He had received a living- related kidney transplant for his idiopathic end-stage renal disease 8 years before PTLD diagnosis. He had received cyclosporin (125 mg/day), prednisolone (5 mg/day), and mycophenolic acid (720 mg/day) as immunosuppressants. His EBV PCR titer was less than 5,000 copies/µL and his anti-EBV IgG was more than 1:320. The other case was a 16-year-old man when PTLD first developed. He had received matched-unrelated donor hematopoietic stem cell transplantation for his aplastic anemia 90 days before PTLD diagnosis. He only received mycophenolate mofetil as an immunosuppressant at 40 mg/kg/day. His EBV PCR titer was less than 5,000 copies/µL and his anti-EBV IgG was 1:80.

TABLE 2. Immunohistochemical study panels used in the study.

Abbreviations: CGAP, Cytotoxic granule-associated protein; EBV LMP, EBV latent membrane protein; GCB, Germinal center B-cell; MCL, Mantle cell lymphoma; RTU, Ready to use

TABLE 3. Comparison of the clinical characteristics of MTX-Lymphoma and MTX-Reactive patients.

DAS28-3, disease activity score 28-joint count–3 variables.

asome patients had more than one presenting symptoms.

blung, liver, spleen, kidney, salivary gland, lacrimal gland, and brain.

Histopathology and immunohistochemistry

The histopathology findings and immunohistochemistry results are demonstrated in Table 4. The histopathology in the MTX-Lymphoma group (21 cases) included B-cell lymphoma 16 cases (76.2%), T-cell lymphoma 3 cases

(14.3%), classic Hodgkin lymphoma (CHL) 1 case (4.8%) and EBV-associated LPD (EBV+ LPD) 1 case (4.8%). The most common histological pattern was DLBCL (8 cases, 38.1%). The other types included peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) (3 cases, 14.3%), marginal zone lymphoma (MZL)/ mucosa-associated lymphoid tissue lymphoma (2 cases, 9.5%), and one each (4.8%) for CHL, lymphomatoid granulomatosis (LYG), intravascular large B-cell lymphoma (IVL), mantle cell lymphoma (MCL), B-lymphoblastic lymphoma (B-LBL) and EBV+ LPD. The last 2 cases could be diagnosed as unclassifiable B-cell lymphoma (case no. 15 & 16) because they lacked comprehensive immunostaining for a definite diagnosis.

Other histopathologic findings found in the lesions were as follows: residual follicles in 4 of 21 cases (19%), tissue necrosis in 8 (38.1%), vascular invasion in 4 (19%),

sclerosis in 6 (28.6%), histiocytic aggregation in 3 (14.3%), HRS-like cell in 9 (42.9%), plasma cell reaction in 6 (28.6%), eosinophil reaction in 3 (14.3%), and neutrophil reaction in 1 (4.8%). The majority of lesional cells were large atypical lymphoid cells with varying numbers of admixed inflammatory cells among the lesional cells. The distinctive ancillary findings in MTX-Lymphoma and PTLD were EBV study and CD30 positivity. We found positive EBV LMP-1 (3 of 5 cases, 60%), positive EBER ISH (8 of 12 cases, 66.7%) and CD30+ cells (13 of 18

cases, 72.2%).

The histopathology in the MTX-Reactive group (9 cases) included mixed paracortical and follicular hyperplasia 5 cases (55.6%), follicular hyperplasia 2

cases (22.2%), paracortical hyperplasia 1 case (11.1%) and florid follicular hyperplasia 1 case (11.1%).

The histopathology in the 2 cases of PTLD included DLBCL 1 case and polymorphic PTLD 1 case.

Bone marrow status

Twenty MTX-LPD patients underwent bone marrow biopsy for staging. Two of them (10%) had diffuse involvement, another two (10%) minimal involvement by scattered lesional cells, and the remaining 16 cases (80%) negative marrow staging. One of the 2 PTLD patients had minimal involvement by scattered lesional cells and the other negative marrow staging.

Treatment and survival outcome

Details of the treatments and outcomes of the

MTX-Lymphoma, MTX-Reactive, and PTLD cases are demonstrated in Table 5. The median follow-up was 394 days.

Only 6 of the 21 MTX-Lymphoma patients (28.6%) discontinued MTX as the first-line management (cases no. 1, 13, 15, 17, 20, and 21). Only 2 cases had spontaneous regression (cases no. 1 and 17) while 3 cases died (cases no. 13, 15, and 20; case no. 15 with progressive disease and case no. 20 with septic shock), and the other lost to follow-up (case no. 21). Among the cases that responded to MTX discontinuation alone, case no. 1 with histopathology of DLBCL had complete remission (CR) at 64 days after MTX discontinuation. Case no. 17 with histopathology of PTCL, NOS had partial remission at 20 days after MTX discontinuation; then computed tomography (CT) at 383 days after MTX discontinuation confirmed CR. Case no. 16 with unclassifiable B-cell lymphoma received prednisolone at the time of MTX discontinuation but lost to follow-up for 2 years but upon return to the hospital, physical examination showed no lymphadenopathy.

In this retrospective study, many patients did not

have full records for the exact duration of the response after intervention, so the duration of the response shown in Table 3 refers to the evaluation after diagnosis. The median duration to response in 27 combined MTX-LPD and PTLD patients was 47 days (range, 0-329 days). The median duration to first CR in 20 combined MTX-LPD and PTLD patients was 126 days (range, 0-774 days).

Ten of the 21 MTX-Lymphoma patients (47.6%) discontinued MTX and simultaneously received combined chemotherapeutic agents (CMT) as the first-line management (cases no. 2-7, 9, 14, 18, and 19), 6 cases are still alive at the time of the report writing (5 without disease in cases no. 4, 5, 7, 9, and 14; while case no. 2 received only 1 cycle of R-CHOP and developed congestive heart failure but still alive with disease). Three cases died due to septic shock (cases no. 3, 6, and 18) and the other case lost to follow- up at 104 days after receiving the first-line management (case no. 19). There were 6 cases that achieved CR after MTX discontinuation and simultaneous CMT, including DLBCL 4 cases (cases no. 4, 5, 6, and 7), MZL 1 case (case no. 9), and B-LBL 1 case (case no. 14). The time to CR ranged from 110 to 344 days, with a median of 163 days. Two MTX-Lymphoma patients developed relapse of the disease (cases no. 6 and 9) based on examination of the bone marrow and lymph node, respectively. Case no. 6 had progressive disease after relapse and died. Case no. 9, however, could achieve CR after relapse and is still alive without disease.

Two of the 21 MTX-Lymphoma patients (9.5%)

received only surgery as the first-line management without discontinuation of MTX or any CMT (cases no. 8 and 10).

TABLE 4. Histopathology and immunohistochemistry of MTX-Lymphoma, MTX-Reactive, and PTLD patients.

Case Histopathology Residual Tumor Vascular Sclerosis Histiocytes Polymorphic HRS- Tumor No. follicles Necrosis invasion aggregation reaction like cell cell size

EBV-

LMP-1

EBER CD30

MTX-Lymphoma

TABLE 4. Histopathology and immunohistochemistry of MTX-Lymphoma, MTX-Reactive, and PTLD patients. (Continued)

*, focal positive; -, negative; +, positive

Abbreviations: B-LBL, B-lymphoblastic lymphoma/leukemia; B-Lym, B-cell lymphoma, unclassifiable; CHL, classic Hodgkin lymphoma; DLBCL, diffuse large B-cell lymphoma; EBER, Epstein–Barr virus-encoded small RNA in situ hybridization; EBV, Epstein–Barr virus; EBV LMP-1, Epstein-Barr virus latent membrane protein-1; Eo, eosinophil; F, follicular hyperplasia; F*, florid follicular hyperplasia; HRS, Hodgkin–Reed–Sternberg; IVL, intravascular large B-cell lymphoma; L, large; LYG, lymphomatoid granulomatosis; M, medium; MALT, mucosa-associated lymphoid tissue lymphoma; MCL, mantle cell lymphoma; MZL, marginal zone lymphoma; NA, not available; Neu, neutrophil; P, partial fibrous septa; PH, paracortical hyperplasia; PC, plasma cell; Poly-PTLD, polymorphic post-transplant lymphoproliferative disorder; PTCL, NOS, peripheral T-cell lymphoma, not otherwise specified; S, small.

TABLE 5. Diagnosis, treatment, and outcome of MTX-Lymphoma, MTX-Reactive, and PTLD patients.

TABLE 5. Diagnosis, treatment, and outcome of MTX-Lymphoma, MTX-Reactive, and PTLD patients. (Continued)

TABLE 5. Diagnosis, treatment, and outcome of MTX-Lymphoma, MTX-Reactive, and PTLD patients. (Continued)

Abbreivations: APS, anti-phospholipid syndrome; AZA, azathioprine; B-LBL, B-lymphoblastic lymphoma/leukemia; B-Lym, B-cell lymphoma, unclassifiable; BM, bone marrow; BSC, best supportive care; CHL, classic Hodgkin lymphoma; CQ, chloroquine; CR, complete remission; CS, cyclosporin; F/U, follow-up; DLBCL, diffuse large B-cell lymphoma; HCQ, hydroxychloroquine; IED, idiopathic exfoliative dermatitis; IOL, idiopathic orbital inflammation; IPI, international prognostic index; IVL, intravascular large B-cell lymphoma; JIA, juvenile idiopathic arthritis; LFM, Leflunomide; LN, lymph node; LRKT, living-related kidney transplant; LYG, lymphomatoid granulomatosis; MALT, mucosa-associated lymphoid tissue lymphoma; MCL, mantle cell lymphoma; MA, mycophenolic acid; MM, mycophenolate mofetil; MTX, methotrexate; MUD-HSCT, match-unrelated hematopoietic stem cell transplant; MZL, marginal zone lymphoma; NA, not available; Not CR = not in complete remission (PD, PR or SD); NP, nasopharynx; PD, progressive disease; Poly-PTLD, polymorphic posttransplant lymphoproliferative disorder; PR, partial remission; PSL, prednisolone; PTCL, NOS, peripheral T-cell lymphoma, not otherwise specified; RA, rheumatoid arthritis; RI, reduction of immunosuppressants; RL, reactive lymphadenitis; SD, stable disease; SLE, systemic lupus erythematosus; SpA, ankylosing spondylitis; SSZ, sulfasalazine; ThaiPOG-ALL, Thai pediatric oncology group treatment protocol for acute lymphoblastic leukemia.

Case no. 8 (aged 86 years) refused to receive any further treatment after surgery due to concerns about the side effects from CMT. The patient achieved CR 402 days after surgery as evaluated by CT and is still alive without detectable disease at 1,638 days after surgery. Case no. 10 lost to follow-up at 151 days after surgery before receiving any CMT according to the plan of treatment. Of the 2 PTLD patients, the patient with DLBCL (case no. 22) achieved CR after immunosuppressants discontinuation and the completion of 6 cycles of CHOP. One year later, the patient had relapsed disease at the tonsils and received DA-EPOCH regimen for 6 cycles with rituximab for 4 courses. The patient achieved CR and is still alive. The patient with polymorphic PTLD (case no. 23) received a decreased dose of immunosuppressants and 4 courses of rituximab as the first-line management. Unfortunately, the patient died of a superimposed infection. Of the 9 MTX-Reactive patients, only 2 cases discontinued MTX as the first-line management (cases no. 24 and 29); the others continued receiving MTX, but

2 of these 7 cases lost to follow-up. The 2 cases with MTX discontinuation and the other 5 cases with continued MTX had spontaneous regressions of the lymph node. The MTX-Reactive group tended to have a better survival rate when compared with the MTX-Lymphoma group, but without statistical significance (p = 0.065), and the PTLD group, with statistical significance (p = 0.034). The MTX-Lymphoma group tended to have better 1-year and 5-year survival rates than the PTLD group, but without statistical significance (p = 0.685) (Fig 1).

DISCUSSION

MTX-LPD is still not very well understood in terms of its definition, pathogenesis, prognosis, and treatment, but there are studies available in the literature to help us better understand and handle the disease. MTX-LPD is highly heterogeneous with various clinical presentations, histopathology, and disease progression. Our retrospective study categorized MTX-LPD according to histopathology and found that DLBCL was the most common pattern

Fig 1. One-year and five-year cumulative survivals between patients of MTX-Reactive, MTX-Lymphoma, and PTLD.

in the MTX-Lymphoma group in concordance with previous reports,2-4,12-16 but PTCL, NOS in our study was higher than in other reports; the reason is not known. Moreover, we encountered various kinds of the MTX- Lymphoma group, not only the common entities like DLBCL, PTCL, NOS, or CHL, but also MZL, MCL, and uncommon entities, like LYG and IVL.

Residual lymphoid follicles and vascular invasion were not common in our cases. However, tissue necrosis was frequently found in our MTX-Lymphoma cases; albeit, it can also be found in other lymphomas with aggressive behavior.12 Histiocyte aggregation and plasma cell reaction were also frequently found in MTX-Lymphoma cases, but the significance and association with MTX have not been yet established.12 Interestingly, Hodgkin-Reed- Sternberg-like cells were surprisingly common among the MTX-Lymphoma cases, but the significance and association with MTX have not been established yet either.12

A panel of immunostaining may give some additional information in these cases. In addition to the positivity of EBER ISH and/or EBV LMP-1 immunostaining, CD30 positivity in scattered large cells was found in many cases in our MTX-Lymphoma group, including DLBCL and PTCL, NOS. The 2 cases in our study (case no. 1 DLBCL and case no. 17 PTCL, NOS) showed regression of the lymph nodes after MTX discontinuation as the first-line management, corresponding to the expected clinical course of MTX-LPD.2-4,12-16 Both cases showed EBV+ tumor cells by EBER and/or EBV LMP-1 as well as scattered CD30+ large cells, in agreement with previous reports.13 These EBV association and CD30 positivity may help identify MTX-LPD,12,13,17-19 but the distinction from de novo lymphoma with EBV association and/or CD30 positivity has not been studied.

Among the 9 MTX-Lymphoma cases in our study who had MTX discontinuation and who received CMT as first-line management, 3 of them died of septic shock that might or might not have been a consequence of the chemotherapy. One may wonder what would have happened if these patients had only MTX discontinuation so that they could have avoided the risk of superimposed infection following chemotherapy. As MTX-LPD is not a well-known entity, this may be the reason why MTX-Lymphoma patients often received a diagnosis of lymphoma instead of MTX-LPD, so that most patients received chemotherapy. This is problematic because the recommended management of MTX-LPD is to discontinue MTX and to wait for a response,20 but there is no consensus about how long to wait for the response or how to assess the response. The response after MTX discontinuation

reported in the literature varied from spontaneous to more than 8 weeks in some studies.7,20 Our study had only 2 cases who responded to MTX discontinuation alone; one with histopathology of DLBCL that showed a response at 63 days after discontinuation. The other with histopathology of PTCL, NOS that showed a response at 20 days after discontinuation. These observations were in agreement with previous studies.7,20 So, the administration of CMT in these patients may expose them to unnecessary risks from the chemotherapeutic agents. The MTX-Reactive group may not have even needed MTX discontinuation, since 5 of these cases showed a spontaneous regression despite continuing MTX.

The PTLD cases in our series did not have EBV serology tests, so we cannot be certain whether there was an EBV donor/recipient serology mismatch or not. Our polymorphic PTLD case died of superimposed infection despite the dosage of immunosuppressants being reduced and the patient receiving rituximab simultaneously according to the standard of care for LPD after hematopoietic stem cell transplant;21 the superimposed infection seemed not to be related to the LPD treatment. The other PTLD case with histopathology of DLBCL was not EBV-associated; the patient had immunosuppressants discontinued and received R-CHOP according to the standard of care for LPD after solid organ transplant,21 leading to CR. Despite relapse, the patient achieved second CR by salvage R-DA-EPOCH.

More than half of this group of patients had RA and interestingly about one-third of them had low disease activity index (DAS28-3) at LPD diagnosis. Thus, disease activity may not be useful to distinguish any group of patients. However, this study had a small sample size and may not be able to give adequate results.

Among the findings in the MTX-Reactive patients significantly different from MTX-Lymphoma patients, most of them held true for any reactive versus lymphoma comparisons. However, one of the interesting findings in our study was the absolute lymphocyte count. We found that the MTX-Reactive patients had a significantly higher median absolute lymphocyte count than the MTX-Lymphoma patients (1,938.3 vs. 780.8 cells/μl) (p = 0.028). This was in agreement with the report by Kurita et al. of peripheral blood lymphocyte counts of less than 1,000 cells/μl being found in their MTX-Lymphoma group more than in their MTX-Reactive group.12 Saito et al. reported that the median lymphocyte count in persistent MTX-LPD was lower than in regressive MTX- LPD, with statistical significance,22 but Nakano et al. reported that the median lymphocyte count in persistent MTX-LPD was higher than in regressive MTX-LPD,

though without statistical significance.16 The absolute lymphocyte count may need further validation in a larger cohort to determine whether it can be used as one of the predictor for the regression of MTX-LPD.

Due to the small sample size of the study, we could not construct any link between the histopathology and the clinical features, the response after the discontinuation of MTX or immunosuppressants, or other clinical courses among the cases between the MTX-Lymphoma and PTLD groups. For the same reason, we could not find the pathognomonic histopathology for the pathologists to identify MTX-LPD without reviewing the medical records. We could not find a helpful clue to predict which case should respond to MTX discontinuation alone and which case would need upfront CMT unless we wait for a certain time to see the response of MTX discontinuation.20 Further study should emphasize a comparison between MTX-Lymphoma patients with the same histopathology and, if applicable, a determination of clonality and genetic landscapes for any prominent features that would be helpful for pathologists to reach a diagnosis of MTX-LPD.

Based on this retrospective study, it is clear that

we need in the future a comprehensive database to identify patients who have been receiving MTX so that this important piece of information can be linked to the laboratory information system for pathologists at the time of making a diagnosis. It could be very problematic if pathologists diagnose lymphoma without knowing that the patient is under MTX treatment, because the patient may be treated with chemotherapy for lymphoma without trying MTX discontinuation first. This could be harmful to the patient, because the side effects of chemotherapy may outweigh the benefit and can lead to death in some cases.

In conclusion, MTX-LPD and PTLD are highly heterogeneous diseases with a wide variety clinical spectrum and histopathology. Definitive diagnostic criteria and histopathologic categories for MTX-LPDs are yet to be established. Identifying MTX, other immunosuppressive drugs, and the immunodeficiency status of the patient are crucial in establishing the diagnosis. Immunostaining for CD30, EBV LMP-1, and EBER ISH study may be helpful to alert pathologists to consider MTX-LPD prior to making a diagnosis of lymphoma. MTX discontinuation is still the first-line management before the administration of chemotherapy in unresponsive cases of MTX-lymphoma, and similarly, lowering immunosuppressive drugs used in PTLD needs to consider with the hope of spontaneous regression of PTLD.

ACKNOWLEDGMENTS

The authors Emvalee Arromdee, Attapong Vongwiwatana, Weerapat Owattanapanich, and Sanya Sukpanichnant were supported by a Chalermphrakiat Grant, Faculty of Medicine Siriraj Hospital, Mahidol University. The authors thank Dr. Saowalak Hunnangkul from the Clinical Epidemiology Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, for support with the statistical analysis.

Conflict of interest statement: The authors do not have any conflict of interest to declare.

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12. Kurita D, Miyoshi H, Ichikawa A, Kato K, Imaizumi Y, Seki R, et al. Methotrexate-associated lymphoproliferative disorders in patients with rheumatoid arthritis: clinicopathologic features and prognostic factors. Am J Surg Pathol. 2019 Jul;43:869-84.

13. Ichikawa A, Arakawa F, Kiyasu J, Sato K, Miyoshi H, Niino D, et al. Methotrexate/iatrogenic lymphoproliferative disorders in rheumatoid arthritis: histology, Epstein-Barr virus, and clonality are important predictors of disease progression and regression. Eur J Haematol. 2013;91:20-8.

14. Yamakawa N, Fujimoto M, Kawabata D, Terao C, Nishikori M, Nakashima R, et al. A clinical, pathological, and genetic characterization of methotrexate-associated lymphoproliferative disorders. J Rheumatol. 2014;41:293-9.

15. Tokuhira M, Saito S, Okuyama A, Suzuki K, Higashi M, Momose S, et al. Clinicopathologic investigation of methotrexate- induced lymphoproliferative disorders, with a focus on regression. Leuk Lymphoma. 2018;59:1143-52.

16. Nakano K, Saito K, Nawata A, Hanami K, Kubo S, Miyagawa I, et al. Clinical aspects in patients with rheumatoid arthritis complicated with lymphoproliferative disorders without regression after methotrexate withdrawal and treatment for

    arthritis after regression of lymphoproliferative disorders. Mod Rheumatol. 2021;31:94-100.

17. Satou A, Tabata T, Miyoshi H, Kohno K, Suzuki Y, Yamashita D, et al. Methotrexate-associated lymphoproliferative disorders of T-cell phenotype: clinicopathological analysis of 28 cases. Mod Pathol. 2019;32:1135-46.

18. Yamada K, Oshiro Y, Okamura S, Fujisaki T, Kondo S, Nakayama Y, et al. Clinicopathological characteristics and rituximab addition to cytotoxic therapies in patients with rheumatoid arthritis and methotrexate-associated large B lymphoproliferative disorders. Histopathology. 2015;67:70-80.

19. Koens L, Senff NJ. Vermeer MH, Willemze R, Jansen PM. Methotrexate-associated B-cell lymphoproliferative disorders presenting in the skin: A clinicopathologic and immunophenotypical study of 10 cases Am J Surg Pathol. 2014;38:999-1006.

20. Tokuhira M, Tamaru J-I, Kizaki M. Clinical management for other iatrogenic immunodeficiency-associated lymphoproliferative disorders. J Clin Exp Hematop. 2019;59:72-92.

21. Dierickx D, Vergote V. Management of Post-transplant Lymphoproliferative Disorders. Hema Sphere, 2019;3:74-7.

22. Saito S, Kaneko Y, Yamaoka K, Tokuhira M, Takeuchi T. Distinct patterns of lymphocyte count transition in lymphoproliferative disorder in patients with rheumatoid arthritis treated with methotrexate. Rheumatology (Oxford). 2017;56:940-6.

Development and Validation of a New Design Self- assessment logMAR Visual Acuity Test (“Chudjane” iPhone- and iPad-based Application) in a Normal Eyes Population

Nuttawut Rodanant, M.D., Comkrit Mahasith, M.D., Somanus Thoongsuwan, M.D., Nopasak Phasukkijwatana, M.D., Supalert Prakhunhungsit, M.D.

Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: To validate and further design the “Chudjane” application (app), a new design self- assessment logMAR test for distance visual acuity (VA), by comparing the results against the use of a standard numeric ETDRS chart in normal eye population.

Materials and Methods: In total, 52 volunteers who had a normal eye exam and best-corrected VA score by numeric

ETDRS (NE) chart equal to or better than 6/6 (logMAR score 0.00 or less) were included. The “Chudjane” app with 3 patterns of optotypes (Arabic numbers (AN), Tumbling-E (TE) and Landolt-C (LC)) was used twice to assess VA individually.

Results: The mean VA in each test NE, AN, TE, LC from the first round were -0.06, -0.10, -0.08 and -0.04, respectively

compared to -0.07, -0.12, -0.09 and -0.05 from the second round respectively. Comparing results from the first and second round revealed that NE and LC had higher test-retest reliability (ICC=0.712, 0.789 respectively) than AN and TE (ICC=0.140, 0.495 respectively). For validity, result from NE was compared to each app test using the second round values. Modified Bland-Altman plot showed the mean differences (95% LOA) for NE-AN, NE-TE and NE-LC of 0.05 (-0.11 to 0.20), 0.02 (-0.11 to 0.15) and -0.03 (-0.19 to 0.13) respectively. Simple linear regression analysis of the difference (i.e. NE-AN, NE-TE and NE-LC) on NE showed that the difference did not depend on the NE value with slope close to zero.

Conclusion: The study demonstrated that by using the «Chudjane» application, LC had higher test-retest reliability

and higher validity than TE and AN compared to the standard ETDRS chart.

Keywords: Self-assessment; visual acuity; mobile application (Siriraj Med J 2022; 74: 590-599)

INTRODUCTION

Visual acuity is the most commonly performed measurement of visual function in clinical practice. It is used to establish the need for a full evaluation of visual function and to inform the clinical decisions of ophthalmologists.1

Several optotypes are used in clinical practice, such as Arabic numbers (AN), Landolt-C (LC), and Tumbling-E (TE). Landolt-C and Tumbling-E are commonly used for assessing the vision of children, as well as for illiterate and non-English-speaking people; the results are determined by four orientations of the letters.2-4 Landolt-C has been

Correspondence: Nuttawut Rodanant E-mail: rodanant@gmail.com

Received 9 February 2022 Revised 5 June 2022 Accepted 6 June 2022 ORCID ID: http://orcid.org/0000-0002-9349-2459 http://dx.doi.org/10.33192/Smj.2022.70

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

adopted as the primary standard optotype for visual acuity testing.2 Arabic numbers (AN) are usually used in the clinical setting because patients are more familiar with this optotype, which comprise the numbers 0-9, which are typically recognized unequally.

Snellen’s chart is the most common method for assessing visual acuity1, mostly because it is easy and quick to use. However, it has some limitations, such as the nongeometric progression of the optotype size from line to line and the variable numbers of letters on each line.5,6

The ETDRS chart is the best-known logMAR chart, and is also used for most major research studies. It overcomes the limitations of Snellen’s chart, as it incorporates geometric progression (step down of 0.10 log units from line to line) and equal numbers of letters on each line (5 letters per line). For the tests, each character is valued at 0.02 logMAR units per letter that is read correctly.7

The “Chudjane” test application (app) was designed such that it could be utilized by a user to self-assess their personal visual acuity and the app automatically summarized and reported the results of the visual acuity in logMAR units, together with the duration of the test. We measured Visual Acuity at “distance” 4 meters (same as standard ETDRS) using both iPad & iPhone together, iPad as a chart at distance and iPhone as a remote control connected to iPad via Bluetooth that can select optotypes, characters and sizes as described

in methods.

The limitations of standard ETDRS chart were memorization effect, patients could remember the fix characters on light box chart, and ETDRS character size changed in steps of 0.1 logMAR. This app was designed to prevent the memorization effect, and to be more fine- scale than the standard ETDRS chart.

In Thailand, like in most countries, smartphone use has been increasing every year (69.6% of the total population possessed a smartphone in 2018).8 The development of healthcare applications has been increasing and there are now more than 100 visual acuity test applications available; albeit only a small number of them have been validated.9

Perera et al. performed a study in 2015 on the reliability and accuracy of 11 visual acuity applications on smartphones and reported that their accuracy varied from about 4.4%–39.9%.10

In the present study, the “Chudjane” test app was compared with a standard numeric ETDRS chart for assessing its validity agreement, reliability and duration of the test.

MATERIALS AND METHODS

Study participants

In total, 52 participants who were over 18 years old, healthy, Thai, could read Arabic numbers and who had no ocular disease by a slit lamp biomicroscope examination (except a refractive error that could be corrected by glasses to get best corrected visual acuity (BCVA) equal to or better than 6/6 (logMAR score 0.00 or less) which is the standard for normal eye visual acuity) were included in the study. The exclusion criteria included those who could not cooperate due to physical or mental disease and those who had a history of cycloplegic drugs or anesthetics allergy.

We validated the sample size based on an equivalence study (z-test), which indicated we required a sample size of 45 eyes to achieve 95% power with a significance level of 0.05 in order to detect an equivalence limit difference of 0.10 logMAR. We chose to use 0.10 logMAR because it represents a significant difference (95% confidence interval)7 for test–retest variations. The standard deviation of difference was 0.20 logMAR, which was based on Bastrawrous et al.’s study.1 Lastly, an allowance of 15% was made for drop-outs, so the calculated sample size was 52 eyes.

n = Sample size

α = Type-I error = 5% (Z = 1.645) β = Type-II error = 5% (Z = 1.645)

σ = Standard deviation of differences б = Effect size (lμ-μ0l ∕σ)

μ-μ0 = Equivalence limit of differences

Ethics

The cross-sectional study adhered to the tenets of the declaration of Helsinki and was approved by the Ethics Committee of the Siriraj Institutional Review Board (COA no. Si 696/2018). Informed consent was obtained from all participants. The objectives of the study, examination process, benefits, and risks of the study were explained to all participants. All the participants gave their signed consent to participate.

“Chudjanes” test app

The app was written for the iOS platform, and this study used an iPad Pro 10.5” and iPhone 7 Plus for the testing. (Fig 1) The iPad was the main display device

Fig 1. 1A–1C: iPad screen showing each optotype at 1.0 logMAR.

1D: iPhone screen in the remote controller mode while adjusting the size of the optotype.

1E–1G: iPhone screen in the remote controller mode while choosing the answers.

and displayed the optotypes located at 4 meters from the participant being tested. The iPhone served as a remote controller that was connected to the iPad via Bluetooth. (Fig 2) The brightness of the display on both devices was set to 100%.

The “Chudjane” test app was developed based on the logMAR chart, and was designed such that it could be utilized by a user to self-assess their personal visual acuity.

Three types of optotypes (Arabic numbers, Tumbling-E, and Landolt-C) were used and these could be selected as different options.

Arabic numbers (AN) consisted of the numbers 0 to 9, which were ordered in the same way as with a standard numeric ETDRS chart.

The Tumbling-E and Landolt-C optotypes consisted of 4 orientations of E or C (0º, 90º, 180º, and 270º).

This app was designed so that it could randomize all the characters of each optotype to prevent the memorization effect.

The size of the optotypes on the iPad could be controlled by the iPhone and the character size changed in steps of 0.1 logMAR for the Arabic numbers (AN) and

0.01 logMAR for the Tumbling-E (TE) and Landolt-C (LC) characters (allowing TE and LC to be more fine- scale than the standard ETDRS chart (NE) and AN by a factor of up to 10 times).

The app started with a single character displayed on the iPad, which equaled 1.0 logMAR on the ETDRS chart. The test subject used the iPhone to control and

Fig 2. Left: The participant looks at the optotype on the iPad display, which was at a distance of 4 m away, while controlling the app using the iPhone7 plus. Right: Showing the distance between the iPad and iPhone, which was 4 m.

adjust the character size on the iPad display until it was the smallest size that they could still read, and then recorded the result on the app.

For the AN optotype, the app automatically selected the character size that matched the smallest character size in the test subject’s records. Then it selected 5 numbers the same as on the Standard ETDRS chart to make 1 test set (equal to 1 line of the ETDRS).

For Tumbling-E (TE) and Landolt-C (LC) optotypes, the app used the smallest size that was recorded in the test subject’s records and randomly selected 5 characters for each test set.

The test subject selected the answer on the iPhone that they believed matched the character on the iPad. After the first test set was completed, the results were automatically analyzed and the system response depended on the following 2 conditions.

In the first condition, if the test subject chose the correct answer for more than 2 out of the 5 characters (the subject got ≥3 correct) in each test set, the size of the 5 characters in the next test set was automatically reduced by 1 step. This condition was repeated until the correct answers in the last test set were less than three out of the 5 characters (the subject got ≤2 correct) or reached -0.3 logMAR. Then, the test was finished.

In the second condition, if the test subject chose the correct answer for less than 3 out of the 5 characters (the subject got ≤2 correct) in each test set, the size of the 5 characters in the next test set was automatically enlarged by 1 step. This condition was repeated until the correct answers in the test set were more than two out of the 5 characters (the subject got ≥3 correct). Then the character size in the last test set was reduced by 1 step, and the test was finished.

After the test subject had finished all the tests, the app automatically summarized and reported the results of the visual acuity in logMAR units, together with the duration of the test.

Scoring

The app scored the test subjects in 2 parts.

Part 1 Arabic numbers (AN): The score was 0.1 logMAR for each test set (5 characters), which equaled 1 line of the standard ETDRS chart. Each character was valued at 0.02 logMAR.

Part 2 Tumbling-E (TE) and Landolt-C (LC):

Each character was valued at 0.002 logMAR because the progression of the optotypes was 0.01 logMAR for each test set (5 characters).

Testing protocol

1. All the participants underwent distant visual acuity testing using a back-illuminated 4-meters numeric ETDRS (NE) chart with the same chart and in the same environment. For all the tests, the presenting acuity was measured with the usual eyesight correction if worn. The duration of the test was also recorded.

2. The test subject’s eyes were completely examined by a slit lamp biomicroscope to detect any abnormalities.

3. All the test subjects were given a demonstration on how to use the app.

4. The test subjects used the app to test their visual acuity by themselves.

5. After they had finished the first test (first round of testing) they were allowed to rest for about 15 minutes, and then they were tested again (second round of testing).

6. The test subjects’ fundus was examined.

   Statistical analysis

   All the visual acuity measurements were converted to logMAR units, and the duration of the tests was converted to seconds. Data were summarized as mean ± SD. Test- retest reliability of NE, 3 App results (i.e., AN, TE and LC) from the first and second round was assessed via scatter plot, intraclass correlation coefficient (ICC, using a 2-way random effect model, absolute agreement and single measure) and classic Bland-Altman plot (X-axis = average from the first and second round as “true” value, Y-axis = difference) along with a simple linear regression line of the difference (Y) on the average (X).

   Regarding the validity of app results compared to NE (gold standard), only data from the second round were used and analyzed by scatter plot and modified Bland- Altman plot (X-axis = NE, Y-axis = difference) with a simple linear regression line. Simple linear regression line and its 95% confidence band is applied to determine if the difference between NE and each app result depends on the true value. Slope (b) of the linear regression line that is close to zero indicates that the difference between NE and each app result does not depend on the true value. P-value of slope that is greater than 0.05 reveals that the population slope is zero.

   Paired t-test was performed to test the difference

   in duration of test (second) from the first and second round.

   Statistical analyses were performed using PASW 18 and MedCalc Statistical software version 19.6.4.

   
   

   RESULTS

   There were 52 subjects (44 females) aged 21 to 54 with mean of 33.3 ± 7.9 years.

   The mean logMar in each test, i.e., NE, AN, TE, and LC, were -0.06, -0.10, -0.08, and -0.04, respectively, in the first round of testing, and were -0.07, -0.12, -0.09, and -0.05, respectively, in the second round of testing (Table 1).

   For test-retest reliability of NE and app results from the first and second round, ICC for NE and LC were quite high (0.712 and 0.789) compared to only 0.140 and

   0.495 for AN and TE respectively (Table 2). The classic Bland-Altman plot of the difference between the first and second round revealed that the all mean differences were very close to zero with the mean (bias) of 0.01, 0.02, 0.02 and 0.01 for NE, AN, TE and LC respectively (Fig 3). However, NE has the narrowest 95% LOA of

   -0.04 to 0.07 whereas AN had the widest 95% LOA of

   -0.19 to 0.23. TE and LC had similar 95% LOA of -0.13

   to 0.16 and -0.11 to 0.12 respectively.

   
   

   
   

   TABLE 1. Results of the tests from the first and second round.

   
   

   
   

   logMAR: Mean ± SD
   	First round	Second round
   Numeric EDTRS chart (NE)	-0.059 ± 0.036	-0.072 ± 0.041
   “Chudjane test” app Numbers on app (AN)	-0.097 ± 0.076	-0.117 ± 0.085
   Tumbling-E on app (TE)	-0.077 ± 0.073	-0.094 ± 0.074
   Landolt-C on app (LC)	-0.037 ± 0.088	-0.046 ± 0.091

   
   

   TABLE 2. Test-Retest reliability between results from the first and second round.

   
   

   	ICC@	95% CI
   Numeric EDTRS chart (NE)	0.712	0.492 to 0.836
   “Chudjane test” app Numbers on app (AN)	0.140	-0.124 to 0.388
   Tumbling-E on app (TE)	0.495	0.269 to 0.671
   Landolt-C on app (LC)	0.789	0.662 to 0.871

   @ ICC (Intraclass Correlation Coefficient): 2-way random effect model, Absolute agreement, Single measure

   
   

   1. Scatter plot: NE1, NE2

      
      

      
      

      (c) Scatter plot: AN1, AN2

      
      

      
      

      (e) Scatter plot: TE1, TE2

      
      

      
      

      (g) Scatter plot: LC1, LC2

      
      

      
      

      Fig 3. Test-retest reliability for NE, AN, TE and LC.

   2. Classic Bland-Altman plot: NE1, NE2

(d) Classic Bland-Altman plot: AN1, AN2

(f) Classic Bland-Altman plot: TE1, TE2

1. Classic Bland-Altman plot: LC1, LC2

   
   

   The logMAR of each app test was compared to NE. The mean difference (bias) of NE - AN, NE - TE, and NE – LC were 0.04, 0.02 and -0.02 respectively, in the first round of testing, and 0.05, 0.02 and -0.03 in the second round of testing (Fig 4). The upper limit of all 95%CIs of the mean difference was not greater than 0.1 logMAR. Validity of app test were assessed using values from the second round via scatter plots, modified Bland-Altman plots and simple linear regression line (Fig 5). The 95% LOA for AN were a little wider than those for TE and LC (-0.11 to 0.20, -0.11 to 0.15 and -0.19 to 0.13 for AN,

   TE and LC respectively). The simple linear regression line of the difference between NE and each app result

   (Y) on NE (X) revealed that all slopes were close to zero and not statistically significant (slope = 0.222, 0.214 and 0.028; p-value = 0.402, 0.342 and 0.917 for AN, TE and LC respectively, (Table 3) indicating that the difference between NE and each app result did not depend on the NE.

   The average duration (seconds) of the NE, AN, TE, and LC tests were 33.8, 56.8, 162.2 and 145.7, respectively,

   in the first round of tests, and 32.0, 49.4, 155.7, and 143.9, respectively, in the second round of tests (Table 4). The duration of the test from the first round was a little higher

   than the second round with the mean difference of 1.8, 7.4, 6.5 and 1.7 seconds respectively and not statistically significant (p-values > 0.1).

   There were no adverse events reported from performing any of the tests.

   
   

   DISCUSSION

   The number of individuals who use smartphones and tablets is increasing annually. There has also been a significant increase in smartphone and tablets usage among health professionals.11,12 Currently, there are at least 100 vision test apps, but few have been validated.9 This study aimed to develop and validate a new visual acuity app for use on the iPhone and iPad that anyone could use to test their visual acuity by themselves.

   This Chudjane app was a new design that aimed to decrease the gap in the optotype size, which is currently ten times that of the standard EDTRS chart while still being based on logMAR scale progression to make the optotype size change more continuous. This would be expected to make the app more precise than tests performed using the old conventional chart. This app was also designed to decrease limitations of standard ETDRS chart that all fix characters were shown on light box chart. By using

   
   

   
   

   Fig 4. Comparison between NE and app results from the first and second round.

   1. Scatter plot: NE2, AN2

      (c) Scatter plot: NE2, TE2

      (e) Scatter plot: NE2, LC2

   2. Modified Bland-Altman plot: NE2, AN2