The Great Contrast Shortage of 2022-Lessons learnt in Australia.

INTRODUCTION: Computed tomography (CT) imaging is one of the most commonly used diagnostic tools. Iodine-based contrast media (IBCM) are frequently administered intravenously to improve soft tissue contrast in a wide range of CT scans. Supply chain disruptions triggered by the SARS-CoV-19 pandemic led to a global shortage of IBCM in mid-2022. The purpose of this study was to explore the impact of this shortage on the delivery of healthcare in Western Australia. METHODS: We performed a single-centre retrospective analysis of the provision of CT studies, comparing historical patterns to the shortage period. We focussed our attention on the total number of CT scans (noncontrast CT [NCCT] and contrast-enhanced CT [CECT]) and also specifically CT pulmonary angiogram (CTPA) and CT neck angiogram with or without inclusion of circle of Willis (CTNA) examinations. We also examined whether a decrease was compensated by increasing frequency of alternate examinations such as ventilation/perfusion (V/Q) scans, carotid Doppler ultrasound studies and Magnetic Resonance Angiograms (MRAs). RESULTS: Since 2012, there has been an approximate linear increase in the frequency of CT examinations. During the period of contrast shortage, there was an abrupt drop-off by approximately 50% in the CECT, CTPA and CTNA groups compared with the preceding 6 weeks (49%, 55% and 44%, respectively, with P < 0.001 in all cases). During the contrast shortage, the frequency of V/Q scans increased fivefold (from 13 to 65; P < 0.001). However, the provision of carotid Doppler ultrasound studies and MRAs remained approximately stable in frequency across recent time intervals. CONCLUSION: Our findings demonstrate that the IBCM shortage crisis had a very significant impact on the delivery of healthcare. While V/Q scans could (partially) substitute for CTPA studies in suspected pulmonary emboli, there appeared to be no valid alternative for CTNA studies in stroke calls. The unexpected and critical shortage of IBCM forced healthcare professionals to conserve resources, prioritise indications, triage patients based on risk, explore alternate imaging strategies and prepare for similar events recurring in the future.

The emerging association between bronchiectasis and systemic sclerosis: assessing prevalence and potential causality.

BACKGROUND: Bronchiectasis has been observed in association with systemic sclerosis (SSc). Theorised aetiology includes aspiration related to oesophageal dysmotility, immunosuppressant medication use and the direct effect of collagen deposition on airway calibre. AIMS: To detail bronchiectasis prevalence in an SSc population who have had a high-resolution computed tomography (HRCT) of the thorax. We assessed whether oesophageal dysmotility, demographic variables, SSc duration or subclass were associated with bronchiectasis. METHODS: Participants in the Australian Scleroderma Cohort Study (ASCS) with a HRCT were included. The ASCS provided demographic and clinical data. HRCT studies were reviewed for bronchiectasis, oesophageal dilatation and interstitial lung disease (ILD). Traction bronchiectasis associated with ILD was recorded as a separate entity to bronchiectasis. Oesophageal dysmotility was defined by symptoms and/or oesophageal dilatation. RESULTS: Of the 256 participants, 16.4% (n = 42) had bronchiectasis. Logistic regression analysis revealed no significant association between bronchiectasis and oesophageal dysmotility (observed in 95.7%), any demographic variable, SSc duration or subclass. A negative association between bronchiectasis and ILD was observed (P = 0.009; odds ratio 0.322; 95% confidence intervals 0.137-0.756). CONCLUSION: Those with SSc appear to have an increased risk for bronchiectasis. Since bronchiectasis was not more frequent in participants with a longer duration of SSc, we hypothesise that its development is not related to immunosuppression alone. Oesophageal dysmotility was almost universal in our population such that its effect on bronchiectasis development could not be concluded. A negative association between bronchiectasis and ILD reflects that bronchiectasis occurring alongside ILD was recorded as a separate entity.

Lower ocular pulse amplitude with dynamic contour tonometry is associated with biopsy-proven giant cell arteritis.

OBJECTIVES: To determine the role of the ocular pulse amplitude (OPA) from Pascal dynamic contour tonometry in predicting the temporal artery biopsy (TABx) result in patients with suspected giant cell arteritis (GCA). DESIGN: Prospective validation study. PARTICIPANTS: Adults aged 50 years or older who underwent TABx from March 2015 to April 2017. METHODS: Subjects on high-dose glucocorticoids more than 14 days or without serology before glucocorticoid initiation were excluded. The OPA from both eyes was obtained and averaged just before TABx of the predominantly symptomatic side. The variables chosen for the a priori prediction model were age, average OPA, and C-reactive protein (CRP). Erythrocyte sedimentation rate (ESR), platelets, jaw claudication, and eye findings were also recorded. In this study, subjects with a negative biopsy were considered not to have GCA, and contralateral biopsy was performed if the clinical suspicion for GCA remained high. An external validation set (XVAL) was obtained. RESULTS: Of 109 TABx, 19 were positive and 90 were negative. On univariate logistic regression, the average OPA had 0.60 odds for positive TABx (p = 0.03), with no statistically significant difference in age, sex, CRP, ESR, or jaw claudication. In suspected GCA, an OPA of 1 mm Hg had positive likelihood ratio 4.74 and negative likelihood ratio 0.87 for positive TABx. Multivariate regression of the prediction model using optimal mathematical transforms (inverse OPA, log CRP, age >65 years) had area under the receiver operating characteristic curve (AUROC) = 0.85 and AUROCXVAL = 0.81. CONCLUSIONS: OPA is lower in subjects with biopsy-proven GCA and is a statistically significant predictor of GCA.

Reactivation of Herpes Zoster Keratitis With Corneal Perforation After Zoster Vaccination.

PURPOSE: We present a case of reactivated herpes zoster keratouveitis of 6 years duration with corneal perforation requiring penetrating keratoplasty shortly after inoculation with herpes zoster vaccine (Zostavax, Merck, Quebec, Canada). METHODS: Retrospective case report. RESULTS: A 67-year-old woman with a 5-year history of recurrent unilateral herpes zoster keratouveitis in her right eye presented with another recurrence 2 weeks after Zostavax vaccination. Three months later, she developed descemetocele and 2 months afterward, corneal perforation, which was managed by penetrating keratoplasty. Immunohistopathological examination disclosed positive staining for varicella zoster virus in most of the keratocytes adjacent to the descemetocele and perforation, most vividly in the deeper two-thirds of the stroma where the keratocytes were most dense, but not in corneal epithelium or endothelium. Electron microscopic examination showed universally severely degenerated corneal keratocytes in the corneal stroma adjacent to the perforation with variable numbers of herpes virus capsids present in half of these cells. Only a rare normal-appearing keratocyte was identified in the more peripheral corneal stroma. CONCLUSIONS: We present a case of reactivation of herpes keratouveitis shortly after vaccination with Zostavax in a patient with previous herpes zoster ophthalmicus. We demonstrate, for the first time, ultrastructural evidence consistent with inactive virus capsids in diffusely degenerated keratocytes in the extracted corneal tissue.

Secondary corneal amyloidosis after perforating corneal trauma: A series of 5 cases and review of the literature.

We retrospectively reviewed the clinical and surgical histories of 5 patients with traumatic secondary corneal amyloidosis, a relatively rare sequela of nonsurgical and surgical perforating corneal trauma. Four had history of nonsurgical trauma, and 1 had surgical trauma to the cornea. Three specimens were obtained by penetrating keratoplasties and 2 by excision of the cornea during evisceration of the ocular contents. All the corneal specimens showed full-thickness scars of a prior perforating wound with congophilic amyloid deposits that exhibited apple-green birefringence under polarized light and dichroism. All cases had variable degrees of predominantly chronic nongranulomatous inflammation. Ultrastructural examination in 1 patient disclosed 8-nm diameter fibrils in disarray, consistent with amyloid. Amyloid P immunostaining was positive in all 3 patients tested for this protein.

Usefulness of a red chromagen in the diagnosis of melanocytic lesions of the conjunctiva.

IMPORTANCE: Immunohistochemical analyses may assist in the diagnosis of precancerous and cancerous conjunctival lesions. OBJECTIVE: To use Vector Red (VR) to identify an immunologic marker that is sensitive for all melanocytes and another that is sensitive and specific for activated and/or atypical conjunctival melanocytic lesions (MLs). DESIGN, SETTING, AND PARTICIPANTS: Eight specimens each of control lesions (normal conjunctiva and normal uvea as well as choroidal melanoma) and 8 from the diagnostic categories (conjunctival nevus, primary acquired melanosis with mild or no atypia, primary acquired melanosis with moderate to severe atypia, and conjunctival melanoma) that provided sufficient quantity and quality of tissue were available for processing. The specimens were obtained from the Ophthalmic Pathology Laboratory, The Ottawa Hospital, from 2005 to 2013. The specimens were immunolabeled with human melanoma black 45 (HMB45), melanoma antigen recognized by T cells 1 (Melan-A), S100, and Ki67 using VR and a double panmelanoma cocktail (dPANMEL) using 3,3'-diaminobenzidine (DAB) and VR. The HMB45-immunolabeled specimens were additionally developed with DAB, with and without overnight bleaching with hydrogen peroxide, 4%. Data were collected by 2 pathologists who were masked to sample grouping. MAIN OUTCOMES AND MEASURES: Differentiation between benign and malignant MLs based on immunomarker profile. RESULTS: Immunoreactivity was best visualized in specimens with VR. Melan-A labeled all melanocytes (100% sensitivity; panmelanocyte marker) without discriminating between benign and malignant lesions (0% specificity). Atypical melanocytes were most specifically labeled with HMB45 (96% specificity, 97% sensitivity; atypia marker). In primary acquired melanosis specimens, we found that the percentage of HMB45 (P < .001), S100 (P < .001), and Ki67 (P ≤ .02) positivity increased significantly with worsening atypia. CONCLUSIONS AND RELEVANCE: We recommend VR, which rarely requires specimen bleaching, as the standard substrate for immunohistochemical analysis of conjunctival MLs. We found Melan-A and HMB45 to best characterize MLs. In conjunctival MLs, the use of VR with Melan-A and HMB45 provides substantial sensitivity for all melanocytes and for atypical melanocytes, respectively, and reduces specimen-processing time for laboratories performing immunohistochemistry on MLs.

Ocular metastasis of lung adenocarcinoma with ELM4-ALK translocation: A case report with a review of the literature.

Choroidal metastasis is the most common intraocular neoplasm and is associated with significant morbidity. In a small percentage of patients, ocular manifestation may be the initial presentation of a systemic malignancy and can be diagnostically difficult to distinguish from ocular primary malignancies. Herein, we present a case of a never-smoker whose ocular pathology was integral to the diagnosis and management of a lung adenocarcinoma harboring a rare oncogene. Through this case, we have explored important diagnostic and therapeutic considerations of pulmonary metastases to the choroid.

Dacryops: a series of 5 cases and a proposed pathogenesis.

IMPORTANCE: Lacrimal gland ductal cysts (dacryops) are uncommon, occurring anywhere that lacrimal gland tissue is present. While dacryops has long been recognized, its pathogenesis has not been well established. OBSERVATIONS: Five cases of dacryops were identified at the Ottawa Hospital over a 3-year period (2009-2012). Histopathological examination showed immunoreactivity to IgA on the luminal surface of the epithelial ductal cyst and mild chronic inflammation in the underlying stroma or lacrimal gland. CONCLUSIONS AND RELEVANCE: Our results suggest that a multifactorial mechanism leads to dacryops including chronic inflammation, an immune response, and IgA hypersecretion with an osmotic effect, all contributing to the cyst formation. Further research on the pathogenesis is recommended.

Post-LASIK ectasia treated with intrastromal corneal ring segments and corneal crosslinking.

Corneal ectasia is a serious complication of laser in situ keratomileusis (LASIK). We report the case of a 29-year-old man who underwent LASIK in both eyes and in whom corneal ectasia developed in the left eye 3 years after surgery. He was treated sequentially with intraocular pressure-lowering medication, intrastromal corneal ring segment (ICRS) implants, and collagen cross-linking. Vision improved and the ectasia stabilized following treatment. Combined ICRS implantation and collagen cross-linking should be considered early in the management of post-LASIK ectasia.

Bilateral necrobiotic xanthogranuloma of the eyelids followed by a diagnosis of multiple myeloma 20 years later.

A uniquely indolent case of necrobiotic xanthogranuloma with bilateral, periorbital involvement was presented. This patient presented with cutaneous eyelid lesions of 20 years' duration. Although symptomless, the patient underwent testing for hematologic malignancy, which led to a diagnosis of multiple myeloma. A review of the literature revealed that this is the longest interval between the onset of the skin manifestations and the diagnosis of the systemic malignancy in this rare disease.

Psychometric properties of a new tool to assess task-specific and global competency in cataract surgery.

BACKGROUND AND OBJECTIVE: To establish and validate an assessment tool of cataract surgery performed by residents suitable for a competency-based curriculum. PATIENTS AND METHODS: A three-component evaluation tool was created based on review of the literature and was refined using a modified Delphi technique. Faculty surgeons viewed two videos of cataract surgery, performed by a novice and an expert, and completed the evaluation tool. Results were analyzed for the psychometric properties. RESULTS: Evaluators concluded the scale had excellent face validity. Construct validity showed the scale to reliably distinguish (P < .001) between novice (30.3 ± 6.1) and experienced (48.3 ± 7.2) surgeons. Internal consistency of the scale was high, with Cronbach's alpha equal to 0.981. Inter-rater reliability was high with an intraclass correlation coefficient equal to 0.811 (F(df) = 53.2 (25), P < .001). CONCLUSION: The tool has excellent face validity, content validity, and reliability. Its task-specific, global-index scale and quantitative data form make it a valuable tool to assess residents' surgical skills.

Deaf children with autism spectrum disorders.

Epidemiological studies investigating the prevalence of autism have increased in recent years, within the United States and abroad. However, statistics as to how many of those children may also have a comorbid hearing loss is lacking. The prevalence of school-administrator reported diagnosis of autism spectrum disorders (clinical diagnosis [DSM-IV] and/or IDEA classification) among children with hearing loss in the US was estimated from the 2009­2010 Annual Survey of Deaf and Hard of Hearing Children and Youth conducted by the Gallaudet Research Institute. Results indicate that during the 2009­2010 school year 1 in 59 children (specifically 8-year olds) with hearing loss were also receiving services for autism; considerably higher, than reported national estimates of 1 in 91 (Koganet al. in Pediatrics 124(4):1­8, 2009) and 1 in 110 (CDC 2007) for hearing children. Significantly more children with profound hearing loss had a comorbid diagnosis of autism than those with milder forms of hearing loss. These results are discussed, while highlighting the need for increased awareness and research in a population that has thus far received little services or attention.

Bilateral benign reactive lymphoid hyperplasia of the conjunctiva in a pediatric patient.

A 13-year-old boy presented with asymptomatic, bilateral, nasal bulbar conjunctival lesions. Excisional biopsy of the larger lesion showed a mature, mixed lymphocytic infiltrate with germinal centers, consistent with a diagnosis of benign reactive lymphoid hyperplasia, a rare condition in children.

Low volume contrast CTPA in patients with renal dysfunction.

INTRODUCTION: The study aims to evaluate a method for and technical feasibility of performing CT pulmonary angiography (CTPA) with just 30 mL of contrast. METHODS: Twenty-four patients with renal dysfunction suspected of having pulmonary embolus underwent CTPA using 30 mL of contrast. A modified acquisition protocol was employed where sequential monitoring of the central superior vena cava (SVC) was performed following injection of contrast. Scanning was triggered at the first visualised arrival of contrast within the SVC. Hounsfield unit (HU) measurements were performed at the main pulmonary artery to the subsegmental branches to determine the adequacy of each study. RESULTS: The level of pulmonary arterial enhancement achieved was high, averaging 247 HU across all measured arteries. Average enhancement within more peripheral lobar, segmental and subsegmental arteries was also greater than 200. Only one study was considered non-diagnostic. CONCLUSION: Low-volume CTPA is technically feasible and provides excellent enhancement of the pulmonary arterial tree.

First report of Gordonibacter pamelaeae bacteremia.

We report the first case of Gordonibacter pamelaeae bacteremia, identified by phenotypic tests and 16S rRNA sequencing in a patient with disseminated rectosigmoid carcinoma and responsive to amoxicillin-clavulanate. The bacterium was a nonsporulating, anaerobic, gram-positive, nonmotile, coccobacillus that was catalase, arginine dihydrolase, and arginine acrylamidase positive. The gastrointestinal tract is probably its reservoir.