Calciphylaxis, beware the ophthalmic mimic: A case series

PURPOSE

We present two atypical cases of calciphylaxis presenting with ocular ischemic pathology - both without the hallmark cutaneous manifestations - to raise awareness of this rare yet highly disabling condition.

OBSERVATIONS

We report two cases of ophthalmic calciphylaxis presenting as (1) anterior ischemic optic neuropathy (AION) and cilioretinal artery occlusion in a 76-year-old woman with pre-dialysis kidney failure, and (2) AION with contralateral central retinal artery occlusion (CRAO) in a 44-year-old man on hemodialysis.

CONCLUSION AND IMPORTANCE

These cases highlight the need for judicious clinical suspicion of calciphylaxis in patients with kidney failure, presenting with microvascular ischemic ophthalmic pathology such as AION or CRAO. Confirmation with temporal artery biopsy is essential to direct targeted individualized multi-disciplinary treatment of calciphylaxis and avoid unnecessary steroid exposure in cases masquerading as giant cell arteritis (GCA).

Morganella morganii and Enterococcus faecalis endophthalmitis following intravitreal injection

BACKGROUND

Endophthalmitis following intravitreal injection is a potentially devastating complication of anti-VEGF injections. Post-injection endophthalmitis due to Enterococcus faecalis is rare, and no previous case of Morganella morganii endophthalmitis after intravitreal injection has been reported.

CASE PRESENTATION

We present the first reported case of Morganella morganii and Enterococcus faecalis endophthalmitis after intravitreal injection in an immunocompetent patient in the absence of recent ocular surgery. Our patient presented with hand movement visual acuity one day after anti-VEGF injection and demonstrated no clinical improvement despite repeated intravitreal ceftazidime and vancomycin injections. A decision was made to proceed with early vitrectomy given failure of intravitreal antibiotics. Visual acuity improved to 6/90 at 12 weeks after vitrectomy without any evidence of disease recurrence.

CONCLUSIONS

Post-injection endophthalmitis due to concurrent Morganella morganii and Enterococcus faecalis infections can have visually devastating consequences despite repeated empirical and targeted intravitreal antibiotics. Lack of clinical improvement following intravitreal antibiotics should warrant consideration of early vitrectomy. Our experience is a pertinent reminder of the ever-growing threat of uncommon and multi-resistant bacteria that must be considered when treating infections such as post-injection endophthalmitis.

Optimising vitrectomy operation note coding with machine learning

BACKGROUND

The accurate encoding of operation notes is essential for activity-based funding and workforce planning. The aim of this project was to evaluate the procedural coding accuracy of vitrectomy and to develop machine learning, natural language processing (NLP) models that may assist with this task.

METHODS

This retrospective cohort study involved vitrectomy operation notes between a 21-month period at the Royal Adelaide Hospital. Coding of procedures were based on the Medicare Benefits Schedule (MBS)-the Australian equivalent to the Current Procedural Terminology (CPT®) codes used in the United States. Manual encoding was conducted for all procedures and reviewed by two vitreoretinal consultants. XGBoost, random forest and logistic regression models were developed for classification experiments. A cost-based analysis was subsequently conducted.

RESULTS

There were a total of 1724 procedures with individual codes performed within 617 vitrectomy operation notes totalling $1 528 086.60 after manual review. A total of 1147 (66.5%) codes were missed in the original coding that amounted to $736 539.20 (48.2%). Our XGBoost model had the highest classification accuracy (94.6%) in the multi-label classification for the five most common procedures. The XGBoost model was the most successful model in identifying operation notes with two or more missing codes with an AUC of 0.87 (95% CI 0.80-0.92).

CONCLUSIONS

Machine learning has been successful in the classification of vitrectomy operation note encoding. We recommend a combined human and machine learning approach to clinical coding as automation may facilitate more accurate reimbursement and enable surgeons to prioritise higher quality clinical care.

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

Capturing uveal melanoma (UM) global practice patterns and clinical outcomes in the collaborative ocular melanoma natural history (OMNi) study (NCT04588662)

TPS9610

Background: Geographical differences in the management of primary UM, surveillance for recurrence, and care of metastatic disease have emerged based upon local expertise, treatment availability and insurance coverage. We have initiated accrual to OMNi (NCT04588662), an ambispective database developed to provide contemporary real-world data of UM, capturing its natural history and serving as a virtual biospecimen repository. The overall objectives of OMNi are to characterize regional/international UM management practice patterns and associated clinical outcomes in an effort to inform best practice recommendations. Methods: OMNi utilizes the Pulse Infoframe Healthie platform, a globally compliant platform which enables the structured collection of data mapped to Observational Medical Outcomes Partnership. The data fields created permit longitudinal capture of data including baseline patient and tumor characteristics, treatment of primary lesion and outcomes, surveillance patterns, time to disease recurrence, treatment of recurrent disease with outcomes, and survival. Inclusion criteria include a diagnosis of uveal melanoma and the ability to provide written informed consent for participation in the prospective registry or an institutional waiver by the IRB/ethics committee for retrospective data collection without written informed consent. We have initiated data collection at 3 US and 3 Australian centers, with 184 patients enrolled to date. Based upon feasibility assessment, we anticipate retrospective data entry for ̃2,000 patients and annual recruitment of ̃700 patients once all centers are active. Data collected in this OMNi collaboration, which will include additional US, UK and Australian sites, will facilitate new insights, hypothesis testing, as well as clinical trial development and conduct, and through a governance structure, will be made accessible for research. The OMNi dataset can serve and aid in interpretation of clinical trial outcomes in the real-world, facilitate cutting-edge research, and accelerate the development of diagnostics and therapeutics. Clinical trial information: NCT04588662.

PHACOVITRECTOMY FOR PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT REPAIR: A Retrospective Review

PURPOSE

To analyze the single surgery success rate and anterior segment complications related to phacoemulsification and intraocular lens implantation in a series of patients undergoing phacovitrectomy for all types of primary rhegmatogenous retinal detachment.

METHODS

We performed a retrospective interventional case series on 302 eyes undergoing phacovitrectomy for primary rhegmatogenous retinal detachment repair between November 1, 2016, and February 2, 2019, in Edmonton, Canada. Primary outcomes included single surgery retinal reattachment rate and anterior segment complications. Secondary outcomes included the effects of proliferative vitreoretinopathy and macula and/or peripheral internal limiting membrane peeling on the rate of surgical success.

RESULTS

The single surgery success rate of phacovitrectomy for all types of primary rhegmatogenous retinal detachment was 85.1%. The presence of proliferative vitreoretinopathy was associated with lower surgical success (odds ratio, 0.33; P = 0.01). Macular internal limiting membrane peeling was associated with higher surgical success (odds ratio, 2.4; P = 0.05). Anterior segment complications included posterior capsular opacification (28.8%), posterior synechiae (10.9%), and posterior capsular rupture (2.3%).

CONCLUSION

Phacovitrectomy is a safe and effective treatment option for the primary repair of rhegmatogenous retinal detachments. This study provides evidence to support the safe incorporation of phacoemulsification and intraocular lens implantation with retinal surgery.

Effect of a free healthcare policy on health services utilisation for non-malarial febrile illness by children under five years in Burkina Faso: an interrupted time series analysis

OBJECTIVE

To assess the effect of a free healthcare policy for children under five years old implemented in Burkina Faso since April 2016, on the use of health care of non-malarial febrile illnesses (NMFI).

METHODS

To assess the immediate and long-term effect of the free healthcare policy in place, we conducted an interrupted time series analysis of routinely collected data on febrile illnesses from three urban primary health centres of Ouagadougou between 1 January 2015 and 31 December 2016.

RESULTS

Of the 39 046 febrile cases reported in the study period, 17 017 NMFI were included in the study. Compared to the period before the intervention, we observed an immediate, non-statistically significant increase of 7% in the number of NMFI (IRR = 1.07; 95% CI = 0.75, 1.51). Compared to the trend that would have been expected in absence of the intervention, the results showed a small but sustained increase of 6% in the trend of monthly number of NMFI during the intervention period (IRR = 1.06; 95%CI = 1.01, 1.12).

CONCLUSION

Our study highlighted an increase in the uptake of healthcare services, specifically for NMFI by children under five years of age, after the implementation of a free care policy. This analysis contributes to informing decision makers on the need to strengthen the capacities of healthcare centres and to anticipate the challenges of the sustainability of this policy.

The effect of gender inequality on HIV incidence in Sub-Saharan Africa

OBJECTIVE

We aimed to quantify the extent to which country-level trends in HIV incidence in Sub-Saharan Africa (SSA) were influenced by gender inequalities, measured by gender gaps in educational attainment, income, and a Gender Inequality Index (GII).

STUDY DESIGN

We examined the relation between gender inequality and HIV incidence using country-level panel data from 24 SSA countries for the period between 2000 and 2016.

METHODS

Our goal was to estimate the relation between within-country changes in gender inequality and HIV incidence. We compared results from fixed effects and random effects models for estimating the effect of gender inequalities on changes in HIV incidence. Based on the results of the Hausman test, the fixed effects model was selected as the preferred approach.

RESULTS

HIV incidence decreased by nearly one-half over the period from 2000 to 2016. We estimated that a one percent increase in the GII was associated with a 1.6 percent increase in HIV incidence (95% confidence interval = [0.21%; 3.00%]), after adjusting by country-level socio-economic and governance variables.

CONCLUSIONS

Our study suggests that addressing gender inequalities is a potential strategy to reduce HIV incidence in the SSA region. To control HIV infection, policymakers and public health practitioners should support relevant interventions for promoting gender equality. Further work is needed to identify specific interventions to improve gender inequality and to examine their impacts on changes in HIV incidence.

Convolutional Neural Networks for Automated Fracture Detection and Localization on Wrist Radiographs

PURPOSE

To demonstrate the feasibility and performance of an object detection convolutional neural network (CNN) for fracture detection and localization on wrist radiographs.

MATERIALS AND METHODS

Institutional review board approval was obtained with waiver of consent for this retrospective study. A total of 7356 wrist radiographic studies were extracted from a hospital picture archiving and communication system. Radiologists annotated all radius and ulna fractures with bounding boxes. The dataset was split into training (90%) and validation (10%) sets and used to train fracture localization models for frontal and lateral images. Inception-ResNet Faster R-CNN architecture was implemented as a deep learning model. The models were tested on an unseen test set of 524 consecutive emergency department wrist radiographic studies with two radiologists in consensus as the reference standard. Per-fracture, per-image (ie, per-view), and per-study sensitivity and specificity were determined. Area under the receiver operating characteristic curve (AUC) analysis was performed.

RESULTS

The model detected and correctly localized 310 (91.2%) of 340 and 236 (96.3%) of 245 of all radius and ulna fractures on the frontal and lateral views, respectively. The per-image sensitivity, specificity, and AUC were 95.7% (95% confidence interval [CI]: 92.4%, 97.8%), 82.5% (95% CI: 77.4%, 86.8%), and 0.918 (95% CI: 0.894, 0.941), respectively, for the frontal view and 96.7% (95% CI: 93.6%, 98.6%), 86.4% (95% CI: 81.9%, 90.2%), and 0.933 (95% CI: 0.912, 0.954), respectively, for the lateral view. The per-study sensitivity, specificity, and AUC were 98.1% (95% CI: 95.6%, 99.4%), 72.9% (95% CI: 67.1%, 78.2%), and 0.895 (95% CI: 0.870, 0.920), respectively.

CONCLUSION

The ability of an object detection CNN to detect and localize radius and ulna fractures on wrist radiographs with high sensitivity and specificity was demonstrated.© RSNA, 2019.

Saphenous Nerve Block From Within the Knee Is Feasible for TKA: MRI and Cadaveric Study

BACKGROUND

Surgeon-performed periarticular injections and anesthesiologist-performed femoral nerve or adductor canal blocks with local anesthetic are in common use as part of multimodal pain management regimens for patients undergoing TKA. However, femoral nerve blocks risk causing quadriceps weakness and falls, and anesthesiologist-performed adductor canal blocks are costly in time and resources and may be unreliable. We investigated the feasibility of a surgeon-performed saphenous nerve ("adductor canal") block from within the knee at the time of TKA.

QUESTIONS/PURPOSES

(1) Can the saphenous nerve consistently be identified distally on MRI studies, and is there a consistent relationship between the width of the femoral transepicondylar axis (TEA) and the proximal (cephalad) location where the saphenous nerve emerges from the adductor canal? With these MRI data, we asked the second question: (2) Can we utilize this anatomic relationship to simulate a surgeon-performed intraoperative block of the distal saphenous nerve from within the knee with injections of dyes after implantation of trial TKA components in cadaveric lower extremity specimens?

METHODS

A retrospective analysis of 94 thigh-knee MRI studies was performed to determine the relationship between the width of the distal femur at the epicondylar axis and the proximal location of the saphenous nerve after its exit from the adductor canal and separation from the superficial femoral artery. These studies, obtained from one hospital's MRI library, had to depict the saphenous nerve in the distal thigh and the femoral epicondyles and excluded patients younger than 18 years of age or with metal implants. These studies were performed to evaluate thigh and knee trauma or unexplained pain, and 55 had some degree of osteoarthritis. After obtaining these data, TKA resections and trial component implantation were performed, using a medial parapatellar approach, in 11 fresh cadaveric lower extremity specimens. There were six male and five female limbs from cadavers with a mean age of 70 years (range, 57-80 years) and mean body mass index of 20 kg/m (range, 15-26 kg/m) without known knee arthritis. Using a blunt-tipped 1.5-cm needle, we injected 10 mL each of two different colored solutions from inside the knee at two different locations and, after 30 minutes, dissected the femoral and saphenous nerves and femoral artery from the hip to the knee. Our endpoints were whether the saphenous nerve was bathed in dye and if the dye or needle was located in the femoral artery or vein.

RESULTS

Based on the MRI analysis, the mean ± SD TEA was 75 ± 4 mm in females and 87 ± 4 mm in males. The saphenous nerve exited the adductor canal and was located at a mean of 1.5 ± 0.16 times the TEA width in females and a mean of 1.3 ± 0.13 times the TEA width in males proximal to the medial epicondyle. After placement of TKA trial components and injection, the proximal injection site solution bathed the saphenous nerve in eight of 11 specimens. In two cachectic female cadaver limbs, the dye was located posteriorly to the nerve in hamstring muscle. The proximal blunt needle and colored solution were directly adjacent to but did not penetrate the femoral artery in only one specimen.

CONCLUSIONS

This study indicates, based on MRI measurements, cadaveric injections, and dissections, that a surgeon-performed injection of the saphenous nerve from within the knee after it exits from the adductor canal seems to be a feasible procedure.

CLINICAL RELEVANCE

This technique may be a useful alternative to an ultrasound-guided block. A trial comparing surgeon- and anesthesiologist-performed nerve block should be considered to determine the clinical efficacy of this procedure.

Creating a digital retinoscope by combining a mobile smartphone camera and a retinoscope

We present our experience creating a digital retinoscope by combining a mobile smartphone camera and a retinoscope. We found this digital retinoscope to be useful for demonstrating and documenting abnormal retinoscopic reflexes in teaching retinoscopy. This report explains how the digital retinoscope is assembled and provides examples of the range of normal and abnormal reflexes that can be captured. A short video showcases the reflexes being obtained in real time.

Intrahepatic cholangiocarcinoma: pathogenesis and rationale for molecular therapies

Intrahepatic cholangiocarcinoma (ICC) is an aggressive malignancy with very poor prognosis. Genome-wide, high-throughput technologies have made major advances in understanding the molecular basis of this disease, although important mechanisms are still unclear. Recent data have revealed specific genetic mutations (for example, KRAS, IDH1 and IDH2), epigenetic silencing, aberrant signaling pathway activation (for example, interleukin (IL)-6/signal transducer and activator of transcription 3 (STAT3), tyrosine kinase receptor-related pathways) and molecular subclasses with unique alterations (for example, proliferation and inflammation subclasses). In addition, some ICCs share common genomic traits with hepatocellular carcinoma. All this information provides the basis to explore novel targeted therapies. Currently, surgery at early stage is the only effective therapy. At more advanced stages, chemotherapy regimens are emerging (that is, cisplatin plus gemcitabine), along with molecular targeted agents tested in several ongoing clinical trials. Nonetheless, a first-line conclusive treatment remains an unmet need. Similarly, there are no studies assessing tumor response related with genetic alterations. This review explores the recent advancements in the knowledge of the molecular alterations underlying ICC and the future prospects in terms of therapeutic strategies leading towards a more personalized treatment of this neoplasm.

[Birth preparedness in antenatal care: effects of health center characteristics]

AIM

Counseling relating to birth preparedness is an essential component of the WHO Focused Antenatal Care model. During the antenatal visits, women should receive the information and education they need to make choices to reduce maternal and neonatal risks. The objective of this study conducted among women attending antenatal visits in rural Burkina Faso was to search for a link between the characteristics of the center delivering the health care and the probability of being exposed to information and advice relating to birth preparedness.

METHODS

A multilevel study was performed using survey data from women (n=464) attending health centres (n=30) in two rural districts in Burkina Faso (Dori and Koupela). The women were interviewed using the modified questionnaire of the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO).

RESULTS

Women reported receiving advice about institutional delivery (72%), signs of danger (55%), cost of institutional delivery (38%) and advice on transportation in the event of emergency (12%). One independent factor was found to be associated with reception of birth preparedness advice: number of antenatal visits attended. Compared with women from Dori, women from Koupela were more likely to have received information on signs of danger (OR=3.72; 95%CI: 1.26-7.89), institutional delivery (OR=4.37; 95%CI: 1.70-10.14), and cost of care (OR=3.01; 95%CI: 1.21-7.46). The reduced volume of consultations per day and the availability of printed materials significantly remain associated with information on the danger signs and with the institutional delivery advices. Comparison by center activity level showed that women attending health centers delivering less than 10 antenatal visits per day were more likely to receive information on signs of danger (OR=2.63; 95%CI: 1.12-6.24) and to be advised about institution delivery (OR=6.30; 95%CI: 2.47-13.90) compared to health centers delivering more than 20 antenatal visits per day. Women attending health centres equipped with printed materials (posters, illustrated documents) were more likely to receive information on signs of danger (OR=4.25; 95%CI: 1.81-12.54) and be advised about institutional delivery (OR=6.85; 95%CI: 3.17-14.77).

CONCLUSION

Efforts should be made to reach women with birth preparedness messages. Rural health centres in Burkina Faso need help to upgrade their organizational services and provide patients with printed materials so they can improve antenatal care delivery.