The BONSAI (Brain and Optic Nerve Study with Artificial Intelligence) deep learning system can accurately identify pediatric papilledema on standard ocular fundus photographs

BACKGROUND

Pediatric papilledema often reflects an underlying severe neurologic disorder and may be difficult to appreciate, especially in young children. Ocular fundus photographs are easy to obtain even in young children and in nonophthalmology settings. The aim of our study was to ascertain whether an improved deep-learning system (DLS), previously validated in adults, can accurately identify papilledema and other optic disk abnormalities in children.

METHODS

The DLS was tested on mydriatic fundus photographs obtained in a multiethnic pediatric population (<17 years) from three centers (Atlanta-USA; Bucharest-Romania; Singapore). The DLS's multiclass classification accuracy (ie, normal optic disk, papilledema, disks with other abnormality) was calculated, and the DLS's performance to specifically detect papilledema and normal disks was evaluated in a one-vs-rest strategy using the AUC, sensitivity and specificity, with reference to expert neuro-ophthalmologists.

RESULTS

External testing was performed on 898 fundus photographs: 447 patients; mean age, 10.33 (231 patients ≤10 years of age; 216, 11-16 years); 558 normal disks, 254 papilledema, 86 other disk abnormalities. Overall multiclass accuracy of the DLS was 89.6% (range, 87.8%-91.6%). The DLS successfully distinguished "normal" from "abnormal" optic disks (AUC 0.99 [0.98-0.99]; sensitivity, 87.3% [84.9%-89.8%]; specificity, 98.5% [97.6%-99.6%]), and "papilledema" from "normal and other" (AUC 0.99 [0.98-1.0]; sensitivity, 98.0% [96.8%-99.4%]; specificity, 94.1% (92.4%-95.9%)].

CONCLUSIONS

Our DLS reliably distinguished papilledema from normal optic disks and other disk abnormalities in children, suggesting it could be utilized as a diagnostic aid for the assessment of optic nerve head appearance in the pediatric age group.

DNA Sequencing of CD138 Cell Population Reveals TP53 and RAS-MAPK Mutations in Multiple Myeloma at Diagnosis

Multiple myeloma is a hematologic neoplasm caused by abnormal proliferation of plasma cells. Sequencing studies suggest that plasma cell disorders are caused by both cytogenetic abnormalities and oncogene mutations. Therefore, it is necessary to detect molecular abnormalities to improve the diagnosis and management of MM. The main purpose of this study is to determine whether NGS, in addition to cytogenetics, can influence risk stratification and management. Additionally, we aim to establish whether mutational analysis of the CD138 cell population is a suitable option for the characterization of MM compared to the bulk population. Following the separation of the plasma cells harvested from 35 patients newly diagnosed with MM, we performed a FISH analysis to detect the most common chromosomal abnormalities. Consecutively, we used NGS to evaluate NRAS, KRAS, BRAF, and TP53 mutations in plasma cell populations and in bone marrow samples. NGS data showed that sequencing CD138 cells provides a more sensitive approach. We identified several variants in BRAF, KRAS, and TP53 that were not previously associated with MM. Considering that the presence of somatic mutations could influence risk stratification and therapeutic approaches of patients with MM, sensitive detection of these mutations at diagnosis is essential for optimal management of MM.

Large Intron Inversions in Romanian Patients with Hemophilia A-First Report

Background and Objectives: Despite the vast heterogeneity in the genetic defects causing hemophilia A (HA), large intron inversions represent a major cause of disease, accounting for almost half of the cases of severe HA worldwide. We investigated the intron 22 and intron 1 inversion status in a cohort of Romanian unrelated patients with severe HA. Moreover, we evaluated the role of these inversions as relative risk factors in inhibitor occurrence. Materials and Methods: Inverse shifting-a polymerase chain reaction method was used to detect the presence of intron 22 and intron 1 inversions in 156 Romanian patients with HA. Results: Intron inversion 22 was found in 41.7% of the patients, while intron 1 inversion was detected in 3.2% of the patients. Overall, large intron inversions represented the molecular defect in 44.9% of the studied patients. Our findings are in accord with previously published reports from Eastern Europe countries and with other international studies. The risk of inhibitor development was higher in patients with inversion 1 compared to the patients with HA without any inversion detected. Conclusions: The current study demonstrates the major causative role of large intron inversions in severe HA in Romanian patients. Moreover, our study confirms the contribution of intron 1 inversion in inhibitor development.

The Significance of CD20 Intensity Variance in Pediatric Patients with B-Cell Precursor Acute Lymphoblastic Leukemia

B-cell precursor acute lyphoblastic leukemia (ALL) is a common pediatric malignancy and patients may have significant benefits from monoclonal antibodies therapy with increased survival rates. Positive CD20 expression is identified in about half of these patients and its presence may serve as a prognostic factor in disease evolution. We performed a retrospective study including 114 patients diagnosed with B-ALL and evaluated the expression of CD20 through flow cytometry at diagnosis and on day 15. Additional immunophenotypic analyses as well as cytogenetic and molecular genetic analyses were also performed. We observed an increase in the mean fluorescence intensity (MFI) of CD20 between diagnosis-1.9 (1.2-3.26) and day 15: 6.17 (2.14-27.4), (p < 0.0001). Furthermore, we assessed that both diagnosis and day 15 CD20 MFI had an impact on RFS and OS, respectively, for cut-off values of >8.08 at diagnosis and >28.65 at day 15. In conclusion, CD20 expression appears to be a poor prognostic feature of B-ALL in pediatric patients. In this study, stratification of the outcome by the intensity of CD20 has implications concerning the allocation to rituximab-based chemotherapy and may offer new, potentially useful information for pediatric patients with B-ALL.

Controversial Flow Cytometry Monitoring of a Relapse Case of Pediatric T Cell Acute Lymphoblastic Leukemia: A Case Report

Acute lymphoblastic leukemia (ALL) is the most frequent childhood cancer, with 80-85% represented by B cell ALL and only 15% by T cell ALL. T Cell ALL (T-ALL) carries a more reserved prognosis compared to B Cell ALL (B-ALL) with regard to response to treatment, risk of relapse, and overall survival. Progress made in current monitoring protocols such as via flow cytometry immunophenotyping (FCM) and by PCR-based amplification of antigen-receptor genes led to improved management of patients with ALL and superior rates of survival. Nevertheless, challenges remain in some clinical cases. This manuscript describes a unique case of T-ALL and raises awareness of such clinical challenges. The article presents an overview of the flow cytometry immunophenotyping at diagnosis and during treatment of a pediatric patient with T-ALL from Fundeni Clinical Institute. In this case, in spite of various therapeutic measures such as first-line chemotherapy for high risk group, salvage chemotherapy (FLAG), conditioning regimen (FLU-BU-TT-ATG), and stem cell transplant, a chemoresistance clone continued to be present.

Day 15 and Day 33 Minimal Residual Disease Assessment for Acute Lymphoblastic Leukemia Patients Treated According to the BFM ALL IC 2009 Protocol: Single-Center Experience of 133 Cases

Introduction: Childhood acute lymphoblastic leukemia (ALL) is a hematologic malignancy characterized by the acquisition of several genetic lesions in the lymphoid progenitors with subsequent proliferation advantage and lack of maturation. Along the years, it has been repeatedly shown that minimal residual disease (MRD) plays an important role in prognosis and therapy choice. The aim of the current study was to determine the prognostic role of MRD in childhood ALL patients in conjunction with other relevant patient and disease characteristics, thus showing the real-life scenario of childhood ALL. Patients and Methods: The retrospective study includes childhood ALL patients that were treated according to the BFM ALL IC 2009 between January 2016 and December 2018 at the Fundeni Clinical Institute, Bucharest, Romania. Results: None of the variables significantly influenced the induction-related death in our study. None of the variables independently predicted relapse-free survival (RFS) with the highest tendency for statistical significance being represented by poor prednisone response. Non-relapse mortality (NRM) was independently predicted by age, prednisone response, and day 33 flow cytometry-MRD (FCM-MRD). Overall survival (OS) was independently predicted by prednisone response and day 33 FCM-MRD. Event-free survival (EFS) was independently predicted by age, prednisone response, and day 33 FCM-MRD. Conclusion : Prednisone response, day 15 FCM-MRD, day 33 FCM-MRD, and the risk group represent the most important factors that in the current study independently predict childhood ALL prognosis.

Clinical characteristics in patients with hereditary amyloidosis with Glu54Gln transthyretin identified in the Romanian population

BACKGROUND

In Romania, 23 patients have been diagnosed with hereditary transthyretin amyloidosis (ATTRh), 18 of whom have the Glu54Gln mutation. This retrospective cohort included all patients with Glu54Gln-mutated ATTRh who were diagnosed in Romania from 2005 to 2018.

RESULTS

Of 18 patients, 10 were symptomatic, five were asymptomatic carriers and three died during the study. All originated from North-East Romania. Median age at symptom onset was 45 years; median age at death was 51 years. All patients had cardiac involvement, including changes in biomarkers (mean N-terminal-pro B-type natriuretic peptide: 2815.6 pg/ml), electrocardiography (15% atrial fibrillation, 38% atrioventricular block, 31% right bundle block), and echocardiography (mean interventricular septum: 16 mm, mean left ventricular ejection fraction: 49%). Scintigraphy showed myocardial radiotracer uptake in all patients. In addition, 92% of patients had polyneuropathy at diagnosis and 53% had carpal tunnel syndrome; 69% exhibited orthostatic hypotension and 31% suffered from diarrhea. No renal or liver involvement was observed.

CONCLUSIONS

This is the largest Glu54Gln-mutated ATTRh cohort diagnosed to date, and to our knowledge the first describing this variant worldwide. Clinical features of this variant are early onset, neurological and cardiac involvement, aggressive disease progression and short survival. Early diagnosis and therapeutic intervention have potential to improve prognosis in ATTRh.

Thermodynamic signatures of quantum criticality in cuprate superconductors

The three central phenomena of cuprate (copper oxide) superconductors are linked by a common doping level p*-at which the enigmatic pseudogap phase ends and the resistivity exhibits an anomalous linear dependence on temperature, and around which the superconducting phase forms a dome-shaped area in the phase diagram¹. However, the fundamental nature of p* remains unclear, in particular regarding whether it marks a true quantum phase transition. Here we measure the specific heat C of the cuprates Eu-LSCO and Nd-LSCO at low temperature in magnetic fields large enough to suppress superconductivity, over a wide doping range² that includes p*. As a function of doping, we find that C_el/T is strongly peaked at p* (where C_el is the electronic contribution to C) and exhibits a log(1/T) dependence as temperature T tends to zero. These are the classic thermodynamic signatures of a quantum critical point^3-5, as observed in heavy-fermion⁶ and iron-based⁷ superconductors at the point where their antiferromagnetic phase comes to an end. We conclude that the pseudogap phase of cuprates ends at a quantum critical point, the associated fluctuations of which are probably involved in d-wave pairing and the anomalous scattering of charge carriers.

Therapy-related myelodysplastic syndrome after successful treatment of acute promyelocytic leukemia: case report and literature review

In the 2016 revision of the World Health Organization classification the term therapy-related myeloid neoplasia (t-MN) defines a subgroup of acute myeloid leukemia (AML) comprising patients who develop myelodysplastic syndrome (MDS-t) or acute myeloid leukemia (AML-t) after treatment with cytotoxic and/or radiation therapy for various malignancies or autoimmune disorders. We report the case of a 36 year old patient with t-MN (t-MDS) after achieving complete remission (CR) of a PML-RARA positive acute promyelocytic leukemia (APL) at 32 months after diagnosis. Initially classified as low risk APL and treated according to the AIDA protocol - induction and 3 consolidation cycles - the patient achieved a complete molecular response in September 2013 and started maintenance therapy. On follow-up PML-RARA transcript remained negative. In January 2016 leukopenia and thrombocytopenia developed and a peripheral blood smear revealed hypogranular and agranular neutrophils. Immunophenotyping in the bone marrow aspirate identified undifferentiated blast cells that did not express cytoplasmic myeloperoxidase. The cytogenetic study showed normal karyotype. The molecular biology tests not identified PMLRARA transcript. A diagnosis of t-MDS (AREB-2 - WHO 2008) was established. Treatment of AML was started with 2 “3+7” regimens and 1 MEC cycle. Two months from diagnosis, while in CR, an allogeneic HSCT from an unrelated HLA compatible donor was performed after myeloablative regimen. An unfavorable clinical evolution was followed by death on day 9 after transplantation. The occurrence of t-MNs during CR of APL represents a particular problem in terms of follow-up and differential diagnosis of relapse and constitutes a dramatic complication for a disease with a favorable prognosis.

This work was supported by the grants PN 41-087 /PN2-099 from the Romanian Ministry of Research and Technology

Chronic myelomonocytic leukemia “myelodysplastic type’’ in transformation to acute myeloid leukemia – diagnostic and therapeutic options: case report and literature review / Leucemie mielomonocitară cronică forma mielodisplazică în transformare spre leucemie acută mieloidă – diagnostic și opțiuni terapeutice: prezentare de caz și revizuirea literaturii

Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder that is characterized by the presence of an absolute monocytosis (1 × 10^ 9/l) in the peripheral blood, the overlap of myelodisplastic aspects and myeloproliferative aspects in the bone marrow and tendency to transform into acute myeloid leukemia. CMML is considered to be the most aggressive chronic myeloid leukemia. We present the case of a 48 years old woman who was hospitalized in March 2013 in the Center of Hematology and Bone Marrow Transplantation for anemia related symptoms. Initial investigations showed anemia, relative monocytosis (10% monocytes of the WBC differential) with an increasing absolute number of monocytes (> 1,000/μl) in the following months. Initial exploration of the bone marrow (aspirate and bone marrow biopsy and immunohistochemistry IHC tests) revealed elements of trilinear dysplasia and an increased percentage of myeloblasts (11-14%). In the next four months myeloblasts percentage remained below 20% (8-14%) and it has been observed a gradually increasing of monocytoid elements (> 20%). Immunophenotyping in the bone marrow aspirate identified a monocytic proliferation with high percentage (8%) of immature cells. The karyotype reported the presence of clones with t (1;3). Initially diagnosed as RAEB-2 (WHO) the case was recomitted in CMML-type 2 with a progression to acute myeloid leukemia (AML). Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has been performed after getting the best possible therapeutic response with AML chemotherapy type (complete remission). Allo-HSCT was performed using myeloablative conditioning, 12 months after diagnosis. The patient is now in complete remission, 24 months after allo-HSCT.

Toxicity induced by radiochemotherapy with weekly paclitaxel versus weekly cisplatin in patients with advanced head and neck cancer

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Background: Head and neck cancers represent about 8 % of the total solid cancer cases. For advanced head and neck cancer (HNC) patients, the effects of disease and the side effects of aggressive treatments have the potential to severely affect quality of life. Combined chemoradiotherapy increase rates of locoregional control, but it may cause severe side effects, mainly painful mucositis. In our study we evaluated the chemoradiotherapy induced toxicities in patients treated with concomitant radiochemotherapy using weekly paclitaxel or cisplatin for advanced head and neck cancer. Methods: From April 2003 to December 2005 46 patients with locally advanced head and neck cancer were enrolled onto this study. Patients characteristics: 35 male and 11 female; mean age 62,5; performance status ECOG 0–1, carcinoma histological confirmed. All patients received external beam radiation using DT= 45 Gy, 1,8 Gy/fr, 5 fr/week in combination with chemotherapy: arm A (20 pts) - Paclitaxel 35 mg/mp days 1,8,15,22,29; arm B (26 pts)- Cisplatin 20 mg/mp days 1,8,15,22,29. Results: 40 patients have completed the planed treatment; 4 patients have interrupted treatment because of toxicity; there were 2 toxic death due to neutropenic sepsis and metabolic disorders in arm A. Toxicity grade 3–4 was hematological - neutropenia - 14, 6 % pts in arm A vs. 7, 8 % pts in arm B; gastrointestinal - nausea 6,7 % pts in arm A vs. 5,6% pts in arm B; neurological - neuropathy 5,4 % pts in arm A vs. 0 pts in arm B; dermatological - radic dermitis 4,3% in arm A vs. 4,1% in arm B; oral mucositis 33,6% in arm A vs 27,8% in arm B. All this patients received analgesics and anti-inflammatory drugs, systemic and/or topical. Other toxicities were not significantly related. Conclusions: This study confirmed that radiochemotherapy has shown to provide clinical benefit response and disease stabilization in patients with locally advanced head and neck cancer. Unfortunately, this concomitant therapy was significantly associated with hematological toxicities and oral mycosis. The most severe side effect was oral mycositis grade 3–4, especially in the paclitaxel arm.

No significant financial relationships to disclose.

[Orthoptic treatment efficiency in convergence insufficiency treatment]

We studied a group of 162 patients(89 females, 73 males), with ages between 15-30 years, who complained of blurred vision at near work. 98 patients(60.4%) were diagnosed with convergence insufficiency (C.I.), the rest of 64 patients(39.6%) had: low refractive errors, heterophoria and intermittent heterotropia. Patients with convergence insufficiency were divided in 3 groups: group 1(34 patients--34.6%) were treated with orthoptic exercises and near point exercises at home, group 2 (34 patients--34.6%) were treated with only near point exercises at home and control group 3 (30 patients--30.8%) without treatment. The result of the treatment of C.I. was good at 25 patients(73.5%) of group 1, at 8 patients(23.5%) of group 2 while in group 3 at only one patient the symptoms disappeared.

[Retinoschisis--the clinical associations and therapeutic possibilities]

Retinoschisis is a vitreo retinal dystrophy characterized by splitting of the neuroretinal layers. The paper presents two cases of retinoschisis associated with retinal detachment. As a particularity, one patient was diagnosed with von Willebrand disease and the other one, with otomandibular dysostosis (Francois-Haustrade). There are presented therapeutical methods used in this two cases: Laser, Argon photocoagulation, transscleral cryopexia, scleral buckling and also the functional and anatomical results.

[Serpiginous choroiditis--the diagnostic problems]

Serpiginous choroiditis is a very rare ocular disease with an unknown etiology. This paper presents the case of a patient with serpiginous choroiditis and the diagnosis problems of this case.

[The results of multimodal treatment in retinoblastoma]

The paper is a retrospective study about complex treatment (surgery, chemotherapy and radiotherapy) in a group of 25 patients with retinoblastoma. The best results were in patients with early diagnosis, who came soon after surgery for chemotherapy and radiotherapy. Non presentation for chemotherapy and radiotherapy was the main cause of therapeutical fail.

Diurnal behaviour of some salivary parameters in patients with diabetes mellitus (protein concentration, amylase activity, density)--note I

The study was carried out on 31 diabetic patients of both sexes hospitalised in the Clinical Hospital of Diabetes and Nutritional Diseases "Dr. I. Cantacuzino". They were divided in 2 groups: patients with insulin-dependent diabetes (IDDM) and noninsulin-dependent diabetes (NIDDM) and compared with a group of control non-diabetic subjects. Total mixed saliva was sampled in the morning (07:30-08:00) and in the afternoon (17:30-18:00) without stimulation and tested for amylase activity, proteins and density. The study revealed that the density and the amylase activity have the same diurnal behaviour for the diabetic patients and healthy control subjects either. The only difference was the amplitude of maximal activity (in the morning for density and in the afternoon for the amylase activity). Salivary proteins have a similar diurnal behaviour for both diabetic groups (maximal values in the morning and minimal values in the afternoon) in contrast to healthy control subjects that presented less obvious diurnal changes.

Diurnal behaviour of some salivary parameters in patients with diabetes mellitus (flow rate, pH, thiocianat, LDH activity)--note II

The study was performed on 31 diabetic patients of both sexes, divided in 2 groups: group I--17 patients with insulin-dependent diabetes (IDDM) and group II--14 patients with noninsulin-dependent diabetes (NIDDM) and compared with a control group of 16 non-diabetic subjects. Mixed saliva was sampled without stimulation during 2 periods of the day: 07:30-08:00 before breakfast and 17:30-18:00 before dinner. We determined: salivary flow rate, pH with Merck indicator and, after homogenization, the thiocianat with the FeCl3 method and LDH activity (the Norbert method adapted in our laboratory for saliva). Our study showed the same diurnal changes in flow rate and salivary pH in both diabetic and control groups: minimal values in the morning and maximal ones in the afternoon. In non-smoking diabetic patients the salivary thiocianat had maximal values in the morning and minimal ones in the afternoon; similar behaviour, but less obvious was observed in smoking diabetic patients and in the control group regardless of the smoking habit. LDH activity showed unsignificant diurnal variations in the diabetic patients. In the control group we found a significant decrease of LDH activity in the afternoon. The discussion is about the implication of these salivary parameters in the pathology of oral cavity: gingivitis, periodontitis and caries in diabetic patients.

[Fibrinolysis during pregnancy. The pre- and postpartal changes]

Our previous research as well as data in literature (Yuasas, Ishizawa M.--1992) emphasised increased plasma fibrinolytic activity (PFA) in women during labor. Starting from these data we have tried to observe plasma fibrinolytic activity studied through euglobulin lysis time (ELT) in women during pregnancy and after delivery. We studied 25 healthy pregnant women aged between 18 and 30 years which were tested in the seventh month, during labour and at 48 hours after delivery. Blood samples were taken from the antecubital vein by venous puncture. The study showed an increased PFA (shortened ELT) only during labor; in the seventh month and at 48 hours after delivery ELT had almost the same values.

[The effect of continuous illumination and an inverse rhythm (light-darkness) on fibrinolysis]

The studies of chronobiology on biological phenomena revealed the existence of a human internal mechanism ("biological clock") which controls biological events according to each function of the body. Most of the programmed and genetically fixed rhythms can be changed and synchronized by external factors. Starting from these data and from our previous studies which emphasised an intradian rhythm of the proteolytic blood coagulation and fibrinolytic systems we observed the behaviour of the fibrinolytic system in modified environmental conditions (continuous illumination and inversed day-night rhythm). Our experiments were performed on 180 Wistar rats both male and female, submitted to continuous illumination and inversed rhythm for 1, 3 and 5 weeks. We studied plasma fibrinolytic activity (PFA) through euglobulin lysis time (ELT) at three different moments of the day: 8:30, 18:30 and 8:30 the next day. The study revealed intradian variations of PFA regardless of the type and time of submission. Thus: continuous illumination for 1, 3, 5 weeks determined a decrease of PFA (prolonged ELT) during the second part of the day, less important at 5 weeks. Inversed day-night rhythm for 1 and 3 weeks determined the same intradian behaviour of PFA but less important than continuous illumination. PFA variations in our experimental conditions suggest an alteration of its biological rhythm.