Necrotic Eruption of an Inflammatory Melanoma.

This case report describes a vitreous eruption of a choroidal melanoma in a patient aged 64 years who presented with blurry vision.

Diagnostic Confirmation of Choroidal Lymphoma by Anterior Chamber Paracentesis and Aqueous Fluid Flow Cytometry.

PURPOSE: To report the clinical course of patients with diagnostic confirmation of choroidal lymphoma by anterior chamber paracentesis and aqueous fluid flow cytometry. METHODS: Single-center case series. RESULTS: Two patients with choroidal thickening were suspected to have choroidal lymphoma based on clinical findings and ultrasonographic evidence of extrascleral extension. In each case, anterior chamber paracentesis was performed due to the observation of the associated anterior chamber reaction. Flow cytometry detected the presence of a clonal B-cell population consistent with non-Hodgkin's lymphoma. In one case, external beam radiation therapy resulted in a complete therapeutic response. More invasive methods of ocular tissue biopsy were avoided. CONCLUSIONS: Definitive diagnosis in suspected cases of choroidal lymphoma remains challenging. Ocular fluid sampling may be a low morbidity and convenient alternative for confirming a suspected diagnosis in cases associated with cellular infiltration of the intraocular fluids.

Seasonal Variation in the Diagnosis of Retinoblastoma.

PURPOSE: To determine the seasonal variation in the diagnosis of retinoblastoma in a global sample of children and to investigate predictors of seasonal trends. METHODS: Data were collected through a global, multicenter, 1-year cross-sectional analysis that included all treatment- naïve retinoblastoma patients presenting to participating centers between January 1, 2017, and December 31, 2017. Due to variations in days per month, data were normalized to a 30-day/month calendar. Observed data were compared to a simulation study of expected results using a uniform distribution. RESULTS: Patient-level data were available for 4,351 children from 276 centers in 153 countries, of which 3,966 had a month of presentation recorded. There were relative peaks in disease presentation in January and July, with lower counts in November and December (p = .0015). No covariates were found to be significantly associated with the seasonal trend. Two covariates, patient age at presentation and extraocular tumor spread, showed a moderate association with month of presentation. CONCLUSION: Our findings suggest seasonal trends in the presentation of retinoblastoma across the world. However, these trends do not appear to be related to income level of a country, climate, or other covariates. Any connection between seasonal variation of retinoblastoma presentation and retinoblastoma outcomes remains unclear or not present.

Risk factors associated with abandonment of care in retinoblastoma: analysis of 692 patients from 10 countries.

BACKGROUND: Rates of care abandonment for retinoblastoma (RB) demonstrate significant geographical variation; however, other variables that place a patient at risk of abandoning care remain unclear. This study aims to identify the risk factors for care abandonment across a multinational set of patients. METHODS: A prospective, observational study of 692 patients from 11 RB centres in 10 countries was conducted from 1 January 2019 to 31 December 2019. Multivariate logistic regression was used to identify risk factors associated with higher rates of care abandonment. RESULTS: Logistic regression showed a higher risk of abandoning care based on country (high-risk countries include Bangladesh (OR=18.1), Pakistan (OR=45.5) and Peru (OR=9.23), p<0.001), female sex (OR=2.39, p=0.013) and advanced clinical stage (OR=4.22, p<0.001). Enucleation as primary treatment was not associated with a higher risk of care abandonment (OR=0.59, p=0.206). CONCLUSION: Country, advanced disease and female sex were all associated with higher rates of abandonment. In this analysis, enucleation as the primary treatment was not associated with abandonment. Further research investigating cultural barriers can enable the building of targeted retention strategies unique to each country.

Identification of Metastatic Conjunctival Squamous Cell Carcinoma through Neck Palpation.

An 80-year-old male with a distant 10 pack-years smoking history and squamous cell carcinoma (SCCA) of the scalp diagnosed 15 years ago presented with a new right nasal bulbar conjunctival lesion found to be invasive SCCA. The patient was started on interferon alfa-2b for 5 months until there was no evidence of residual disease. During a follow-up visit 10 months after diagnosis and during routine ophthalmic follow-up, an enlarged right submandibular lymph node was found through neck palpation and revealed to be SCCA without extranodal extension. The lesion was likely to have metastasized from his right conjunctival squamous cell carcinoma (CSCCA). Regional lymph nodes are a commonplace of metastasis for CSCCA making neck palpation a reasonable and recommended part of clinical examination to monitor for metastasis. This is the first known case of identifying regional metastasis of CSCCA through neck palpation.

Use of a sutureless aortic valve in reoperative aortic valve replacement.

Objectives: Management of degenerated bioprosthetic aortic valves remains a challenge. Valve-in-valve transcatheter aortic valve replacement (AVR) has limited utility in the presence of small annuli/prosthetic valves. Sutureless valves may offer an advantage over traditional redo AVR by maximizing effective orifice area due to their unique design as well as ease of implant. Methods: Twenty-two patients undergoing redo AVR received a sutureless valve in our institution over the past 5 years. All patients were determined to be poor candidates for valve-in-valve transcatheter AVR due to a combination of small annulus size, low coronary heights, and/or underlying valve characteristics (ie, mechanical valves). Results: Median time from implant to redo AVR was 8 years. One patient died within 30 days. In the 13 patients who had a 21 mm or smaller valve explanted, 5 small, 7 medium, and 1 large Perceval valves were implanted (all with larger internal diameters than the explanted valve). The average postoperative gradient of the cohort valves was 14.8 mm Hg compared with 38.8 mm Hg preoperatively. Conclusions: In addition to their ease of use and rapid deployment, sutureless bioprosthetic aortic valves offer significant physiological advantages in patients with degenerated prosthetic aortic valves and small anatomical annuli. It can also simplify the surgical approach to redo AVR following a Bentall procedure. If long-term durability is confirmed, sutureless valves should be considered in a broader population of patients for both redo and primary aortic valve replacement surgery.

Implementation of telemedicine in the care of patients with aortic dissection.

Telemedicine uses telephone-based or any form of digital communication for remote clinical services. It has been a field of interest for the last century, with broader implementation of telemedicine technologies during the last 25 years. The COVID-19 pandemic was an impetus for the adoption of these technologies globally across all health care services, including patient care, surgical practice, and workflow. As part of the patient engagement work in the Aortic Dissection Collaborative, this topic was identified as an important patient-centered research topic. Telemedicine has been adopted increasingly in vascular surgery; however, there is little evidence on appropriate use of these technologies pertaining to treating patients with aortic dissection or aortopathy in general. This landscape review summarizes the uses of telemedicine applications pre and post pandemic in medicine and vascular surgery, with a particular focus on uses in aortopathy. Using common resource databases, we identified articles related to the history of telemedicine, its current utilization, and application to vascular surgery and/or aortopathy. We briefly review the history of telemedicine and illustrate a range of applications in medicine before the pandemic, along with its rapid uptake globally during the COVID-19 pandemic. The enablers and barriers to using telemedicine are explored, although as a whole there is satisfaction with its integration among patients and providers. To address these, we offer recommendations to address future research as it pertains to telemedicine technologies in aortic dissection.

Barriers to providing healthcare to children living with cerebral palsy in Ghana: A qualitative study of healthcare provider perspectives.

Children with neurodevelopmental disabilities in low- and middle-income countries (LMICs) experience profound health and social inequities. While challenges faced by children living with disabilities and their caregivers have been widely documented, little is known about barriers faced by healthcare providers (HCPs) who serve these children. This study seeks to understand the barriers to testing, diagnosing, referral, and treatment of children living with cerebral palsy (CLWCP) from the perspectives of HCPs in Ghana. This qualitative study was conducted in the Greater Accra region of Ghana. A snowball sampling strategy was used to recruit HCPs from major hospitals, education centers, and health facilities. Data were collected through 11 semi-structured in-depth interviews (IDIs) with HCPs. Using an adapted version of the Sweat & Denison socio-ecological framework (SDSF), barriers to providing healthcare to CLWCPs were organized into superstructural, structural, environmental, relational, individual, and technological levels. We found that barriers to providing healthcare to CLWCPs exist at all levels of the adapted framework. The most salient barriers were identified at the superstructural, structural, and environmental levels. All HCPs expressed frustration with Ghana's health insurance policies and inadequacies of the health systems infrastructures, such as patient assessment rooms, health information systems, and pharmaceutical products for CP care. HCPs also reported that disability-related stigma often discourages providers in training from specializing in the area of developmental disabilities. HCPs emphasized critical challenges related to local perceptions of disability, gender norms and ideologies, and health system policies and infrastructure. Findings highlight the importance of identifying multi-level factors that can influence testing, diagnosing, referral, treatment, and provision of care for CLWCPs in Ghana. Addressing identified challenges from each level of influence may improve CLWCP's experiences throughout the care continuum.

The impact of the COVID-19 pandemic on wellness among vascular surgeons.

The coronavirus disease 2019 (COVID-19) pandemic has placed significant strain on the health and welfare of all health care professionals, including vascular surgeons. This review summarizes the implications of the pandemic on the health and wellness of surgeons and trainees, with a particular focus on those in vascular surgery (VS). A literature review was completed using common resource databases. We provide a brief history of burnout in VS and explore burnout and wellness in VS during this unprecedented pandemic. We then offer recommendations to address mental health needs by the VS workforce and highlight opportunities to address the gaps in the literature. The impact of COVID-19 on the professional and personal lives of surgeons and trainees in VS is notable. More than half of vascular surgeons reported some degree of anxiety. Factors associated with anxiety and burnout include COVID-19 exposure, moral injury, practice changes, and financial impacts. Trainees appeared to have more active coping strategies with dampened rates of anxiety compared to those in practice. Women appear to be disproportionately affected by the pandemic, with higher rates of anxiety and burnout. Groups underrepresented in medicine seemed to have more resilience when it came to burnout, but struggled with other inequities in the health care environment, such as structural racism and isolation. Strategies for addressing burnout include mindfulness practices, exercise, and peer and institutional support. The COVID-19 pandemic has had a substantial mental health impact on the VS workforce globally, as shifts were made in patient care, surgical practice, and work-home life concerns.

Secure Delivery of HIV-Related and Tuberculosis Laboratory Results to Patient Cell Phones: A Pilot Comparative Study.

South Africa processes 5.1 million HIV CD4, viral load (VL), and tuberculosis (TB) tests annually. This pilot non-randomized trial in South Africa explored an intervention ("MatlaMobile") to deliver laboratory results via mobile phone. Adults completing CD4, VL, and/or TB laboratory tests were enrolled-either receiving results by returning to clinic (control, n = 174) or mobile phone (intervention, n = 226). Study staff instructed control participants to return within 6 days (standard-of-care). MatlaMobile instructed intervention participants with clinically actionable results requiring intervention or treatment change (i.e., < 200 CD4 cells per milliliter, ≥ 400 viral copies per milliliter, or TB positive) to return immediately. A greater proportion of intervention participants than controls saw their results within 7 days of enrollment (73% vs. 8.6%, p < 0.001). Among participants instructed to return, more intervention participants (20%, n = 14/70) returned than controls (8.6%, n = 15/174, p = 0.02). MatlaMobile demonstrated that patients can quickly receive and respond appropriately to digital delivery of health information.

Clinical Manifestations of Hyponatremia and Hypernatremia in Under-Five Diarrheal Children in a Diarrhea Hospital.

OBJECTIVE: To study clinical manifestations and outcome of hyponatremia and hypernatremia in children with diarrhea. METHOD: We compared children aged 0-59 months hospitalized from 1 January to 31 December 2013 with hyponatremia (serum sodium <130 mmol/l), hypernatremia (serum sodium >150 mmol/l) and normonatremia (serum sodium 135-145 mmol/l). RESULTS: The case fatality was significantly higher among the children with hypernatremia and hyponatremia than normonatremia. A logistic regression analysis adjusting for potential confounders revealed that children with hyponatremia are more likely to have convulsions, have severe acute malnutrition and be of older age compared with children with normal serum sodium. Children with hypernatremia are more likely to have convulsions and dehydration than normonatremic children (for all p < 0.05). CONCLUSION: Early diagnosis and prompt management of hypo- and hypernatremia by identifying simple clinical predicting factors of these two conditions in diarrheal children <5 years of age is critically important to prevent deaths in such children, especially in resource-limited settings.