Ophthalmic image acquired by ophthalmologists and by allied health personnel as part of a telemedicine strategy: a comparative study of image quality.

OBJECTIVES: This study evaluates the quality of ophthalmic images acquired by a nurse technician trained in teleophthalmology as compared with images acquired by an ophthalmologist, in order to provide a better understanding of the workforce necessary to operate remote care programs. METHODS: A cross-sectional study was performed on 2044 images obtained from 118 participants of the TeleOftalmo project, in Brazil. Fundus and slit-lamp photography were performed on site by an ophthalmologist and by a nurse technician under the supervision of a remote ophthalmologist. Image quality was then evaluated by masked ophthalmologists. Proportion of suitable images in each group was compared. RESULTS: The proportion of concordant classification regarding quality was 94.8%, with a corrected kappa agreement of 0.94. When analyzing each type of photo separately, there was no significant difference in the proportion of suitable images between on-site ophthalmologist and nurse technician with remote ophthalmologist assistance for the following: slit-lamp views of the anterior segment and anterior chamber periphery, and fundus photographs centered on the macula and on the optic disc (P = 0.825, P = 0.997, P = 0.194, and P = 0.449, respectively). For slit-lamp views of the lens, the proportion of suitable images was higher among those obtained by an ophthalmologist (99.6%) than by a technician (93.8%, P < 0.01). CONCLUSIONS: Ophthalmic photographs acquired by a trained technician consistently achieved >90% adequacy for remote reading. Compared with ophthalmologist-acquired photos, the proportion of images deemed suitable achieved a high overall agreement. These findings provide favorable evidence of the adequacy of teleophthalmological imaging by nurse technicians.

The extent of biliary proliferation in liver biopsies from patients with biliary atresia at portoenterostomy is associated with the postoperative prognosis.

BACKGROUND/PURPOSE: In biliary atresia (BA), a derangement in the biliary system remains, despite portoenterostomy performance. Many factors can influence the disease progression rate. This study aimed to analyze the association between biliary proliferation extent in biopsies from BA patients and postoperative prognosis. METHODS: Biliary proliferation was evaluated by a morphometric analysis of the cytokeratin 7 positivity percentage (PCK7) in wedge liver biopsies from 47 BA patients. The extent of fibrosis was evaluated by a fibrosis score (FS). The outcome 1-year native liver survival was correlated, using a multivariable regression analysis, with PCK7, FS, and age at portoenterostomy. RESULTS: The PCK7 ranged between 0.80% and 14.79% (M +/- SD = 7.36% +/- 4.15%). Patients who died or underwent transplantation had higher PCK7 than survivors with their native livers (P < .001). The area under the receiver operating characteristic curve for PCK7 in relation to the outcome was 0.845 (P < .001). The cutoff point of PCK7 for the maximal effect on postoperative prognosis was 10.18% (sensitivity = 0.71, specificity = 0.88). The PCK7 was the only studied variable associated with 1-year native liver survival, independently of age and FS (P = .002). CONCLUSION: The extent of biliary proliferation at portoenterostomy, evaluated by PCK7, was associated with 1-year native liver survival of BA patients.

Biliary atresia: we still operate too late.

OBJECTIVE: To analyze the age at surgery for children with biliary atresia and their survival periods without need for liver transplantation. The study was performed at Hospital de Clínicas de Porto Alegre, in Porto Alegre, state of Rio Grande do Sul, Brazil. METHODS: The medical records of patients operated between 1982 and 2007 who were residents of the state of Rio Grande do Sul were reviewed. RESULTS: Of the 112 cases of children with biliary atresia studied, 38 (33.9%) occurred between 1982 and 1989, 46 (41.1%) between 1990 and 1999 and 28 (25.0%) after 2000. Portoenterostomy was not performed for 12 cases (10.7%). Age at surgery ranged from 25 to 297 days (median: 80.5; IQR25-75: 61.3-109.0 days); for 20.5% of cases, the age was below 60 days. There was no age difference at diagnosis for the three decades in the study. Patients from the countryside (median: 87.0; IQR25-75: 69.0-115.0 days) were referred significantly later (p = 0.007) than those living in Porto Alegre and the metropolitan area (median: 68.0; IQR25-75: 55.5-98.0 days). The ratio of patients younger than 60 days was significantly lower (p = 0.013) for those from the countryside. Survival periods with native liver for all patients was 46.2% in 2 years, falling continuously until reaching 15.3% in 20 years. Patients operated before reaching 60 days of age had longer survival periods with native livers (log rank < 0.0001). CONCLUSIONS: Late performance of portoenterostomy was a constant in the past 25 years, and this delay led to shorter survival periods with native livers for biliary atresia patients.

Atresia biliar: continuamos operando tarde / Biliary atresia: we still operate too late

OBJETIVO: Analisar a idade na cirurgia de crianças com atresia biliar e a sobrevida sem necessidade de transplante de fígado. O estudo foi realizado no Hospital de Clínicas de Porto Alegre. MÉTODOS: Foram revisados os prontuários dos pacientes operados entre 1982 e 2007, residentes no Rio Grande do Sul. RESULTADOS: Dos 112 casos estudados de crianças com atresia biliar, 38 (33,9 por cento) ocorreram de 1982 a 1989, 46 (41,1 por cento) de 1990 a 1999 e 28 (25,0 por cento) a partir de 2000. Em 12 (10,7 por cento) casos, não foi realizada a portoenterostomia. A idade na cirurgia variou de 25 a 297 dias (mediana: 80,5; IIQ25-75: 61,3-109,0 dias); em 20,5 por cento dos casos, a idade das crianças foi menor do que 60 dias. Não houve diferença na idade, no momento do diagnóstico, entre as 3 décadas. Os pacientes do interior do estado (mediana: 87,0; IIQ25-75: 69,0-115,0 dias) foram encaminhados significativamente (p = 0,007) mais tarde do que os da região metropolitana de Porto Alegre (RS) (mediana: 68,0; IIQ25-75: 55,5-98,0 dias). A proporção de pacientes com menos de 60 dias foi significativamente menor (p = 0,013) nos oriundos do interior. A sobrevida com fígado nativo do total dos pacientes foi de 46,2 por cento em 2 anos, diminuindo progressivamente até 15,3 por cento em 20 anos. Os pacientes operados com menos de 60 dias tiveram maior sobrevida com fígado nativo (log rank < 0,0001). CONCLUSÕES: A portoenterostomia se manteve tardia nos últimos 25 anos, e esse atraso determinou menor tempo de sobrevida com fígado nativo nos pacientes com atresia biliar.

OBJECTIVE: To analyze the age at surgery for children with biliary atresia and their survival periods without need for liver transplantation. The study was performed at Hospital de Clínicas de Porto Alegre, in Porto Alegre, state of Rio Grande do Sul, Brazil. METHODS: The medical records of patients operated between 1982 and 2007 who were residents of the state of Rio Grande do Sul were reviewed. RESULTS: Of the 112 cases of children with biliary atresia studied, 38 (33.9 percent) occurred between 1982 and 1989, 46 (41.1 percent) between 1990 and 1999 and 28 (25.0 percent) after 2000. Portoenterostomy was not performed for 12 cases (10.7 percent). Age at surgery ranged from 25 to 297 days (median: 80.5; IQR25-75: 61.3-109.0 days); for 20.5 percent of cases, the age was below 60 days. There was no age difference at diagnosis for the three decades in the study. Patients from the countryside (median: 87.0; IQR25-75: 69.0-115.0 days) were referred significantly later (p = 0.007) than those living in Porto Alegre and the metropolitan area (median: 68.0; IQR25-75: 55.5-98.0 days). The ratio of patients younger than 60 days was significantly lower (p = 0.013) for those from the countryside. Survival periods with native liver for all patients was 46.2 percent in 2 years, falling continuously until reaching 15.3 percent in 20 years. Patients operated before reaching 60 days of age had longer survival periods with native livers (log rank < 0.0001). CONCLUSIONS: Late performance of portoenterostomy was a constant in the past 25 years, and this delay led to shorter survival periods with native livers for biliary atresia patients.