To determine the diagnostic accuracy of in vivo confocal microscopy (IVCM) for moderate to severe microbial keratitis (MK).
Double-masked prospective cohort study.
Consecutive patients presenting to ...Aravind Eye Hospital, Madurai, India, between February 2012 and February 2013 with MK (diameter ≥3 mm, excluding descemetocele, perforation, or herpetic keratitis).
Following examination, the corneal ulcer was scanned by IVCM (HRT3/RCM, Heidelberg Engineering, Heidelberg, Germany). Images were graded for the presence or absence of fungal hyphae or Acanthamoeba cysts by the confocal microscopist who performed the scan (masked to microbial diagnosis) and 4 other experienced confocal graders (masked to clinical features and microbiology). The regrading of the shuffled image set was performed by 3 graders, 3 weeks later. Corneal-scrape samples were collected for microscopy and culture.
The main outcome measures were sensitivity, specificity, and positive and negative predictive values of IVCM compared with those of a reference standard of positive culture or light microscopy. Sensitivities and specificities for multiple graders were pooled and 95% confidence intervals calculated using a bivariate random-effects regression model.
The study enrolled 239 patients with MK. Fungal infection was detected in 176 (74%) and Acanthamoeba in 17 (7%) by microbiological methods. IVCM had an overall pooled (5 graders) sensitivity of 85.7% (95% confidence interval CI: 82.2%–88.6%) and pooled specificity of 81.4% (95% CI: 76.0%–85.9%) for fungal filament detection. For Acanthamoeba, the pooled sensitivity was 88.2% (95% CI: 76.2%–94.6%) and pooled specificity was 98.2% (95% CI: 94.9%–99.3%). Intergrader agreement was good: κ was 0.88 for definite fungus; κ was 0.72 for definite Acanthamoeba. Intragrader repeatability was high for both definite fungus (κ: 0.88–0.95) and definite Acanthamoeba classification (κ: 0.63–0.90). IVCM images from 11 patients were considered by all 5 graders to have a specific organism present (10 fungus, 1 Acanthamoeba) but had negative results via culture and light microscopy.
Laser scanning IVCM performed with experienced confocal graders has high sensitivity, specificity, and test reproducibility for detecting fungal filaments and Acanthamoeba cysts in moderate to large corneal ulcers in India. This imaging modality was particularly useful for detecting organisms in deep ulcers in which culture and light microscopy results were negative.
Stevens-Johnson syndrome (SJS) is an uncommon, sporadic disease and outbreaks are rare. In November 2013, an outbreak of SJS was identified at Children's Hospital Colorado.
Outbreak cases were ...children aged 5-21 with a discharge diagnosis of SJS admitted from September 1 to November 30, 2013. Medical charts were reviewed using standardized data collection forms. Respiratory specimens were tested for viruses and Mycoplasma pneumoniae (Mp) by polymerase chain reaction (PCR). We conducted a separate 4-year retrospective case-control study comparing hospitalized SJS cases with and without evidence of Mp infection.
During the outbreak, 8 children met SJS criteria. Median age was 11.5 years (range 8-16 years); 5 (63%) were boys and 5 (63%) were Mp-PCR-positive. Of the 5 PCR-positive children, none had preceding medication exposure, and all had radiographic pneumonia. All outbreak Mp isolates were macrolide susceptible. The retrospective case-control analysis showed that Mp-associated SJS episodes (n = 17) were more likely to have pneumonia (odds ratio OR 7.5, confidence interval CI 1.6–35.1), preceding respiratory symptoms (OR 30.0, CI 3.3–269.4) corrected an erythrocyte sedimentation rate ≥35 mg/dL (OR 22.8, CI 2.1-244.9), and ≤3 affected skin sites (OR 4.5, CI 1.2-17.4) than non-Mp-associated SJS episodes (n = 23).
We report the largest outbreak of SJS in children, which was also predominately associated with Mp infection. Mp-associated SJS was associated with a distinct clinical presentation that included less extensive skin disease, an elevated erythrocyte sedimentation rate, and evidence of a preceding respiratory infection.
Context
:
Exercise can cause fluctuations in blood glucose control in type 1 diabetics. For athletes with type 1 diabetes, maintenance of blood glucose within an ideal range may be difficult.
...Objective
:
To determine, in individuals with type 1 diabetes, the effectiveness of the closed loop control system versus the open loop control system in keeping blood glucose levels in the ideal range with exercise.
Data Sources
:
A search of PubMed was conducted in June of 2020 using the Boolean phrases: (closed loop control system OR artificial pancreas) AND type 1 diabetes AND exercise AND ideal range AND adolescents, artificial pancreas AND glucose prediction AND exercise.
Study Selection
:
Titles were reviewed for relevance, the abstract was then assessed for applicability, and finally the full text was examined. Articles were included that examined the percent of time in the ideal blood glucose range when exercise occurred during that day. Articles were excluded that didn’t compare the closed loop and open loop control systems and articles that did not involve exercise.
Data Extraction
:
The PEDro scale was used to determine the methodological quality of the included studies. The measure addressed was the percent of time in the ideal blood glucose range of 70-180 mg/dL. 95% Confidence Intervals and Cohen’s D were calculated for each article.
Data Synthesis
:
The search yielded 268 articles and 3 were selected for inclusion. The two randomized controlled trials scored 9/10 on the PEDro scale and the randomized two-arm crossover clinical trial scored 9/10 on the PEDro scale. Percent time spent in the ideal blood glucose range when exercise was performed was significantly higher in the closed loop group versus the open loop group in each of the three studies. In one randomized control trial, mean time in the ideal range was 71.3% (
SD
= 17.6, 95% CI = 62.5, 80.10) in the closed loop group versus 64.7% (
SD
= 13.3, 95% CI = 58.1–71.4) in the open loop group. Cohen’s D was 0.4. In the second randomized control trial, mean time in the ideal range was 73.5% (
SD
= 8.4, 95% CI = 70.1, 76.9) for the closed loop group versus 50% (
SD
= 26.8, 95% CI = 39.1, 60.9). Cohen’s D was 1.2. The two-arm crossover clinical trial resulted in a mean time in target range of 84.1% (
SD
= 11.5, 95% CI = 79.0, 89.2) in the closed loop group versus 68.7% (
SD
= 13.9, 95% CI = 62.5, 74.9) in the open loop group. Cohen’s D was 1.2.
Conclusions
:
For adolescents with type 1 diabetes who exercise, the closed loop control system maintains blood glucose levels in the ideal range for a longer percent of time versus an open loop system. Each patient should be evaluated on a case-by-case basis with his/her healthcare team. Future research should examine the closed loop control system on specific energy systems.
The objectives of this prospective cohort study were to identify amplitude-integrated electroencephalography (aEEG) background patterns predictive of severe intracranial hemorrhage. Thirty ventilated ...preterm newborns weighing <1,000 g were assessed by an aEEG cerebral function monitor and ultrasound measurement of cerebral blood flow velocity at time of surfactant administration and tracheal suctioning simultaneously during first 48 hours of life. Birth weight was 624 ± 200 g (mean ± S.D.) and gestational age was 25 ± 2 weeks. Background electrical activity was predominantly discontinuous in 72% of infants. A sharp increase in electrical activity/burst density was observed during surfactant administration and tracheal suctioning in most infants, with a 33.5% increase in mean cerebral blood flow velocity. Burst suppression with low voltage was identified in 57% infants with severe intracranial hemorrhage, whereas no infant without hemorrhage exhibited this pattern ( P = 0.014). We conclude that aEEG low-voltage burst suppression might have useful clinical applications with 100% positive predictive value for severe intracranial hemorrhage.
This case report demonstrates the use of novel imaging techniques and functional tests to longitudinally evaluate retinal structure and function after laser retinal injury. The structural and ...functional prognosis could be predicted with clinical findings, high-resolution retinal imaging, and functional testing.
We present a laser retinal injury case in which an adaptive optics scanning laser ophthalmoscope and adaptive optics-based psychophysics were used to examine and monitor retinal structure and function after accidental exposure to a 1-W infrared laser beam.
A 23-year-old patient was unwittingly exposed to a 1-W, 852-nm continuous-wave laser at work as they noticed a small central blurry spot in the right eye. An initial eye examination was done 1 day after exposure, and the right eye's acuity was 20/25 -2 . Posterior segment evaluation revealed disrupted outer retina near the right eye's fovea. Adaptive optics imaging 2 weeks after the exposure revealed a 0.50 × 0.75° elliptical area with irregular borders and abnormal cone reflectivity just below the fovea. Starting at 1-month follow-up, structural recovery was observed on optical coherence tomography (OCT). Subsequent adaptive optics imaging showed significant recovery of cone reflectivity. Importantly, adaptive optics microperimetry showed measurable detection thresholds at all affected retinal locations at 6 months. By 10 months, all sites exhibited normal sensitivities.
Retinal structure and function from laser injury can be visualized and measured with OCT, adaptive optics imaging, and psychophysics. An intact Bruch's membrane on OCT and measurable retinal sensitivity by adaptive optics microperimetry may serve as good biomarkers for retinal recovery.
Acanthamoeba keratitis (AK) is a rare but severe eye disease. A research engagement event, “The Cornea Day,” in London, UK in 2013, identified the lack of credible information about AK and a need for ...practical day to day management strategies. Experiences of 15 AK patients attending The Cornea Day were distilled into a survey that was administered to a wider group of 76 patients, carers, researchers, and clinicians. A Patient Information Leaflet was cocreated and then represented to additional patients for final modification. The AK Patient Leaflet (revised 2019) is available in several languages and used globally.
Outcomes of extremely low gestational age neonates (ELGANs) may be adversely impacted by packed red blood cell (pRBC) transfusions. We investigated the impact of transfusions on neurodevelopmental ...outcome in the Preterm Erythropoietin (Epo) Neuroprotection (PENUT) Trial population.
This is a post hoc analysis of 936 infants 24-0/6 to 27-6/7 weeks' gestation enrolled in the PENUT Trial. Epo 1000 U/kg or placebo was given every 48 h × 6 doses, followed by 400 U/kg or sham injections 3 times a week through 32 weeks postmenstrual age. Six hundred and twenty-eight (315 placebo, 313 Epo) survived and were assessed at 2 years of age. We evaluated associations between BSID-III scores and the number and volume of pRBC transfusions.
Each transfusion was associated with a decrease in mean cognitive score of 0.96 (95% CI of -1.34, -0.57), a decrease in mean motor score of 1.51 (-1.91, -1.12), and a decrease in mean language score of 1.10 (-1.54, -0.66). Significant negative associations between BSID-III score and transfusion volume and donor exposure were observed in the placebo group but not in the Epo group.
Transfusions in ELGANs were associated with worse outcomes. We speculate that strategies to minimize the need for transfusions may improve outcomes.
Transfusion number, volume, and donor exposure in the neonatal period are associated with worse neurodevelopmental (ND) outcome at 2 years of age, as assessed by the Bayley Infant Scales of Development, Third Edition (BSID-III). The impact of neonatal packed red blood cell transfusions on the neurodevelopmental outcome of preterm infants is unknown. We speculate that strategies to minimize the need for transfusions may improve neurodevelopmental outcomes.
Acanthamoeba keratitis (AK) is a rare but severe eye disease. A research engagement event, “The Cornea Day,” in London, UK in 2013, identified the lack of credible information about AK and a need for ...practical day to day management strategies. Experiences of 15 AK patients attending The Cornea Day were distilled into a survey that was administered to a wider group of 76 patients, carers, researchers, and clinicians. A Patient Information Leaflet was cocreated and then represented to additional patients for final modification. The AK Patient Leaflet (revised 2019) is available in several languages and used globally.
Corneal cross-linking (CXL) is typically performed under topical anesthesia, which may be unsuitable in children and individuals with severe anxiety, poor cooperation, or neurodevelopmental issues. ...We describe a technique of CXL under general anesthesia that uses sevoflurane and propofol with laryngeal airway or nasal oxygen cannulas, and forceps or microsponges to stabilize the eye position intraoperatively. We also developed a simple and time-saving technique of bilateral simultaneous CXL, whereby the second eye can undergo CXL concurrently with the first in a staggered fashion. Using this technique, we have been able to eliminate up to 25% of surgical time required in standard bilateral procedures. Postoperatively, multimodal analgesia was administered to ensure patient comfort and prevent excessive eye rubbing. In total, 21 eyes of 13 subjects ≤18 years of age were treated. During a median follow-up of 14.5 months (range, 4-43), the only complication observed was sterile corneal infiltrate in 1 eye that resolved with a short course of corticosteroids.
There is a variability regarding timing of consent and personnel used in patient recruitment for neonatal research. We explored the associations between the study personnel and timing of consent with ...parents' decisional conflict and ultimately their decision to enroll.
This was a multi-site, cross-sectional survey conducted between August 2015 and October 2017. Participants were parents approached to enroll their 24-28-week infant in a clinical trial. Parents completed an interviewer-administered 61-item questionnaire.
Overall, 163 surveys were completed; 105 by parents of enrolled infants and 58 by parents of non-enrolled infants (54.5% participation rate). Neither the individual requesting nor timing of consent was associated with parents' knowledge score, decisional conflict, or decision to enroll. Parents preferred to be approached prenatally and by their infant's doctor.
Study designers and IRBs may allow flexibility in personnel and timing of consent as it is respectful of parents and may enhance trial enrollment.
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