Epidemiologic Evaluation of Retinopathy of Prematurity Severity in a Large Telemedicine Program in India Using Artificial Intelligence.

PURPOSE: Epidemiological changes in retinopathy of prematurity (ROP) depend on neonatal care, neonatal mortality, and the ability to carefully titrate and monitor oxygen. We evaluate whether an artificial intelligence (AI) algorithm for assessing ROP severity in babies can be used to evaluate changes in disease epidemiology in babies from South India over a 5-year period. DESIGN: Retrospective cohort study. PARTICIPANTS: Babies (3093) screened for ROP at neonatal care units (NCUs) across the Aravind Eye Care System (AECS) in South India. METHODS: Images and clinical data were collected as part of routine tele-ROP screening at the AECS in India over 2 time periods: August 2015 to October 2017 and March 2019 to December 2020. All babies in the original cohort were matched 1:3 by birthweight (BW) and gestational age (GA) with babies in the later cohort. We compared the proportion of eyes with moderate (type 2) or treatment-requiring (TR) ROP, and an AI-derived ROP vascular severity score (from retinal fundus images) at the initial tele-retinal screening exam for all babies in a district, VSS), in the 2 time periods. MAIN OUTCOME MEASURES: Differences in the proportions of type 2 or worse and TR-ROP cases, and VSS between time periods. RESULTS: Among BW and GA matched babies, the proportion [95% confidence interval {CI}] of babies with type 2 or worse and TR-ROP decreased from 60.9% [53.8%-67.7%] to 17.1% [14.0%-20.5%] (P < 0.001) and 16.8% [11.9%-22.7%] to 5.1% [3.4%-7.3%] (P < 0.001), over the 2 time periods. Similarly, the median [interquartile range] VSS in the population decreased from 2.9 [1.2] to 2.4 [1.8] (P < 0.001). CONCLUSIONS: In South India, over a 5-year period, the proportion of babies developing moderate to severe ROP has dropped significantly for babies at similar demographic risk, strongly suggesting improvements in primary prevention of ROP. These results suggest that AI-based assessment of ROP severity may be a useful epidemiologic tool to evaluate temporal changes in ROP epidemiology. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Scale-free dynamics of COVID-19 in a Brazilian city.

A common basis to address the dynamics of directly transmitted infectious diseases, such as COVID-19, are compartmental (or SIR) models. SIR models typically assume homogenous population mixing, a simplification that is convenient but unrealistic. Here we validate an existing model of a scale-free fractal infection process using high-resolution data on COVID-19 spread in São Caetano, Brazil. We find that transmission can be described by a network in which each infectious individual has a small number of susceptible contacts, of the order of 2-5. This model parameter correlated tightly with physical distancing measured by mobile phone data, such that in periods of greater distancing the model recovered a lower average number of contacts, and vice versa. We show that the SIR model is a special case of our scale-free fractal process model in which the parameter that reflects population structure is set at unity, indicating homogeneous mixing. Our more general framework better explained the dynamics of COVID-19 in São Caetano, used fewer parameters than a standard SIR model and accounted for geographically localized clusters of disease. Our model requires further validation in other locations and with other directly transmitted infectious agents.

Low-volume ultrasound-guided supraclavicular block in a multicomorbid patient for emergency vascular surgery - In COVID-19 era.

Supraclavicular block is the most commonly used block in upper limb surgeries, right from the day it was introduced into clinical practice in Germany by Kulenkampff in 1911. The block underwent many changes in its application due to the advent of peripheral nerve stimulator and ultrasonographic application in regional anesthesia. This case report focuses on supraclavicular block's application in a multicomorbid patient, the drug dose required, and how the scope of regional anesthesia can be extended in times of pandemic, like coronavirus disease 2019 (COVID-19), in coming future.

International Classification of Retinopathy of Prematurity, Third Edition.

PURPOSE: The International Classification of Retinopathy of Prematurity is a consensus statement that creates a standard nomenclature for classification of retinopathy of prematurity (ROP). It was initially published in 1984, expanded in 1987, and revisited in 2005. This article presents a third revision, the International Classification of Retinopathy of Prematurity, Third Edition (ICROP3), which is now required because of challenges such as: (1) concerns about subjectivity in critical elements of disease classification; (2) innovations in ophthalmic imaging; (3) novel pharmacologic therapies (e.g., anti-vascular endothelial growth factor agents) with unique regression and reactivation features after treatment compared with ablative therapies; and (4) recognition that patterns of ROP in some regions of the world do not fit neatly into the current classification system. DESIGN: Review of evidence-based literature, along with expert consensus opinion. PARTICIPANTS: International ROP expert committee assembled in March 2019 representing 17 countries and comprising 14 pediatric ophthalmologists and 20 retinal specialists, as well as 12 women and 22 men. METHODS: The committee was initially divided into 3 subcommittees-acute phase, regression or reactivation, and imaging-each of which used iterative videoconferences and an online message board to identify key challenges and approaches. Subsequently, the entire committee used iterative videoconferences, 2 in-person multiday meetings, and an online message board to develop consensus on classification. MAIN OUTCOME MEASURES: Consensus statement. RESULTS: The ICROP3 retains current definitions such as zone (location of disease), stage (appearance of disease at the avascular-vascular junction), and circumferential extent of disease. Major updates in the ICROP3 include refined classification metrics (e.g., posterior zone II, notch, subcategorization of stage 5, and recognition that a continuous spectrum of vascular abnormality exists from normal to plus disease). Updates also include the definition of aggressive ROP to replace aggressive-posterior ROP because of increasing recognition that aggressive disease may occur in larger preterm infants and beyond the posterior retina, particularly in regions of the world with limited resources. ROP regression and reactivation are described in detail, with additional description of long-term sequelae. CONCLUSIONS: These principles may improve the quality and standardization of ROP care worldwide and may provide a foundation to improve research and clinical care.

Photo-responsive liposomes composed of spiropyran-containing triazole-phosphatidylcholine: investigation of merocyanine-stacking effects on liposome-fiber assembly-transition.

A spiropyran-containing triazole-phosphatidylcholine (SPTPC) was synthesized through a copper-catalyzed azide alkyne cyclo-addition (CuAAC) reaction. In water, SPTPCs self-assembled and a spontaneous spiropyran-to-merocyanine (SP-to-MC) isomerization occurred, resulting in coexistence of liposomes and fibers, and switching from the spiropyran (SP) to the merocyanine (MC) isomeric structure induced a reversible transition between these molecular assemblies. Study of the self-assembly of SPTPCs and photo-induced liposome-fiber assembly-transition revealed that the presence of MC enabled additional inter-membrane interaction during self-assembly and that the MC-stacking effect was the driving force for the assembly-transition. Exposure to UV light induced switching from SP to MC, where the planar structure of MC and the confinement of MC led to enhanced MC-stacking. The effect of MC-stacking was both advantageous and disadvantageous: MC-stacking perturbed the hydrophobic phase in the bilayer membrane and facilitated the liposome-to-fiber transition, otherwise the MC-stacking retarded switching of MC to SP, and caused an incomplete recovery of MC to SP during fiber-to-liposome recovery, thus a fatigue of SP was induced by MC-stacking during the liposome-to-fiber transition cycle. To decrease the intermolecular interactions and suppress MC-stacking, photo-inert triazole-phosphatidylcholine (TPC) was incorporated to prepare two-component TPC/SPTPC-liposomes, which exhibited better recovery kinetics. The photo-adaptive behavior of TPC/SPTPC-liposomes confirmed the disturbance of bilayer membranes by inter-membrane MC-stacking and the formation of MCTPC-enriched phases in the bilayer membrane.

Step-growth Production of Nanogels for Use as Macromers with Dimethacrylate Monomers.

A series of functional nanogels were synthesized by a step-growth mechanism that involved diisocyanate addition to a modest stoichiometric excess of multi-thiols. Nanogels with sizes less than 10 nm were obtained as room temperature liquids with residual thiol groups used to attach methacrylate functionality. Depending on nanogel structure, bulk nanogel properties varied widely, as did the properties of the nanogel-derived and nanogel-modified polymers. Photopolymerization of the reactive nanogels in combination with a dimethacrylate monomer showed dramatically enhanced reaction rate and conversion compared with the dimethacrylate homopolymer. Polymerization shrinkage/ stress as well as mechanical properties of the polymer networks were controlled by changing the ratio of nanogels and dimethacrylate monomers used in formulations. Thus, this study shows the potential of step-growth nanogels for beneficial changes in resin reactivity and application-based performance.

Photopolymerizable nanogels as macromolecular precursors to covalently crosslinked water-based networks.

We present a strategy for directly and efficiently polymerizing aqueous dispersions of reactive nanogels into covalently crosslinked polymer networks with properties that are determined by the initial chemical and physical nanogel structure. This technique can extend the range of achievable properties and architectures for networks formed in solution, particularly in water where monomer selection for direct polymerization and the final network properties are quite limited. Nanogels were initially obtained from a solution polymerization of a hydrophilic monomethacrylate and either a hydrophilic PEG-based dimethacrylate or a more hydrophobic urethane dimethacrylate, which produced globular particles with diameters of 10-15 nm with remarkably low polydispersity in some cases. Networks derived from a single type of nanogel or a blend of nanogels with different chemistries when dispersed in water gelled within minutes when exposed to low intensity UV light. Modifying the nanogel structure changes both covalent and non-covalent secondary interactions in the crosslinked networks and reveals critical design criteria for the development of networks from highly internally branched, nanoscale prepolymer precursors.

Intra- and inter-rater reliability of maximum inspiratory pressure measured using a portable capsule-sensing pressure gauge device in healthy adults.

BACKGROUND: Measurement of maximum inspiratory pressure is the most prevalent method used in clinical practice to assess the strength of the inspiratory muscles. Although there are many devices available for the assessment of inspiratory muscle strength, there is a dearth of literature describing the reliability of devices that can be used in clinical patient assessment. The capsule-sensing pressure gauge (CSPG-V) is a new tool that measures the strength of inspiratory muscles; it is easy to use, noninvasive, inexpensive and lightweight. OBJECTIVE: To test the intra- and inter-rater reliability of a CSPG-V device in healthy adults. METHODS: A cross-sectional study involving 80 adult subjects with a mean (± SD) age of 22±3 years was performed. Using simple randomization, 40 individuals (20 male, 20 female) were used for intrarater and 40 (20 male, 20 female) were used for inter-rater reliability testing of the CSPG-V device. The subjects performed three inspiratory efforts, which were sustained for at least 3 s; the best of the three readings was used for intra- and inter-rater comparison. The intra- and inter-rater reliability were calculated using intraclass correlation coefficients (ICCs). RESULTS: The intrarater reliability ICC was 0.962 and the inter-rater reliability ICC was 0.922. CONCLUSION: Results of the present study suggest that maximum inspiratory pressure measured using a CSPG-V device has excellent intraand inter-rater reliability, and can be used as a diagnostic and prognostic tool in patients with respiratory muscle impairment.

HISTORIQUE: La mesure de la pression inspiratoire maximale est la méthode la plus utilisée en pratique clinique pour évaluer la force des muscles inspiratoires. Même si de nombreux dispositifs sont conçus pour effectuer cette mesure, très peu de publications décrivent la fiabilité de ceux qui peuvent être utilisés pour l'évaluation clinique des patients. Les capsules manométriques (CM-V), un nouvel outil, mesurent la force des muscles inspiratoires. Ils sont faciles à utiliser, non invasifs, peu coûteux et légers. OBJECTIF: Vérifier la fiabilité intraévaluateurs et interévaluateurs d'un CM-V chez des adultes en santé. MÉTHODOLOGIE: Des chercheurs ont réalisé une étude transversale par randomisation simple auprès de 40 adultes (20 hommes, 20 femmes) pour les tests de fiabilité intraévaluateurs et de 40 adultes (20 hommes, 20 femmes) d'un âge moyen (± ÉT) de 22±3 ans pour les tests de fiabilités interévaluateurs. Les sujets ont effectué trois efforts inspiratoires soutenus pendant au moins trois secondes. La meilleure des trois lectures servait à la comparaison intraévaluateurs et interévaluateurs. La fiabilité intraévaluateurs et interévaluateurs a été calculée au moyen de coefficients de corrélation intraclasse (CCI). RÉSULTATS: Le CCI de fiabilité intraévaluateurs était de 0,962 et le CCI de fiabilité interévaluateurs, de 0,922. CONCLUSION: D'après les résultats de la présente étude, la pression inspiratoire maximale mesurée au moyen de la CM-V a une excellente fiabilité intraévaluateurs et interévaluateurs et peut être utilisée comme outil diagnostique et pronostique chez les patients ayant un déficit des muscles respiratoires.

Prevalence of Unscreened Premature Infants Presenting With Advanced Stages of Retinopathy of Prematurity in South India: An Analysis of 220 Eyes.

PURPOSE: To evaluate the demographic profile of premature infants presenting with stage 4B and stage 5 retinopathy of prematurity (ROP) at a tertiary referral center in South India. METHODS: This was a retrospective review including all premature infants with stage 4B and 5 ROP between January 1, 2015 and December 31, 2022. Parameters included the newborns born at the tertiary care nursery of various institutes, gestational age, birth weight, age at presentation to the hospital, risk factors, screening details, neonatal intensive care unit details, reason for consultation, and timing of referral to the center. RESULTS: Two hundred twenty eyes of 110 premature infants were included. Of 110 infants, 6 were born within the same city and 104 were from other districts or states. Mean birth weight was 1,125 ± 360 g and mean gestational age at birth was 28 ± 2 weeks. Mean age was 42 ± 82 weeks and median age at presentation was 17 weeks (range: 2.86 to 591 weeks). Male-to-female infant ratio was 1.34:1. Fifty (45.4%) infants had bilateral stage 5 ROP, 17 (15.4%) had stage 5 in one eye and stage 4B in the other eye, 15 (13.6%) had bilateral stage 4B and 23 (20.9%) had stage 4B in one eye and stage 4A/stage 3 in the other eye. Five (4.5%) had stage 5 in one eye and vitreous hemorrhage/stage 4A in the other eye. Among those with bilateral stage 5 ROP, 90% were from neighboring districts/states. Fifty-two (47.27%) infants underwent vitreoretinal surgery. Of 110 infants, 28 (25.45%) were self-referred (late presentation due to family-related issues), 80 (72.73%) were referred by ophthalmologists either after a few sessions of late screening or for further management, 1 (0.91%) was referred through telescreening, and 1 was referred from pediatricians directly to the hospital. CONCLUSIONS: This study highlights the importance of awareness of the disease and screening of premature infants. Lack of these two factors leads to late presentation of these infants with advanced stages and serious implications. [J Pediatr Ophthalmol Strabismus. 2024;61(5):339-343.].

Unilateral Biportal Endoscopic Discectomy for Adjacent Segment C7-D1 Disk with O-Arm Navigation: A Unique Case Report.

CASE: 43-year-old man with an adjacent segment C7-D1 left paracentral and foraminal disk and left-hand grip weakness underwent unilateral biportal endoscopic discectomy with O-arm navigation. The patient underwent C5-6 and C6-7 anterior cervical discectomy and fusion (ACDF) 10 years ago and was asymptomatic for nearly 10 years. CONCLUSION: In revision of the cervical spine with a short neck, cervicothoracic junctional disks can be precisely located using O-arm navigation and effectively removed with a minimally invasive unilateral biportal endoscopy approach.

Utility of Asymmetric Multilevel Pontes Osteotomy in Ankylosing Spondylitis with Scoliosis using Ultrasonic Bone Scalpel: Case Report.

Introduction: Ankylosing spondylitis is a spondyloarthropathy that commonly involves the axial skeleton with predilection to the sacro-iliac joints and spine. The disease frequently results in a smooth globular kyphotic deformity of the spine; however, a coronal plane scoliotic deformity is extremely rare. We present a unique case of scoliotic deformity in a patient diagnosed with ankylosing spondylitis. To the best of our knowledge, following a review of the literature, this appears to be the first report of this kind. Case Report: A 23-year-old male patient presented with chronic back pain, stiffness, and a truncal shift of the body. He had a rigid left-sided thoracolumbar curve measuring 41° with a coronal imbalance of 3.6 cm. We present a case report on scoliosis deformity correction performed with a four-level asymmetric pontes osteotomy using a bone scalpel with excellent correction of the scoliotic deformity that was well maintained at 2-year follow-up. Conclusion: Scoliosis in ankylosing spondylitis has not been documented in literature. We report the complete correction of the deformity, which is well maintained at the 2-year follow-up.

An Atypically Displaced Scaphoid Fracture With Proximal Fragment in the Flexor Compartment of the Forearm: A Case Report.

CASE: This case report details the rare presentation of a scaphoid waist fracture in a 27-year-old right-hand-dominant man, with an atypical displacement of the proximal fracture fragment into the flexor compartment of the forearm. Urgent open reduction and internal fixation using a Herbert screw were performed, resulting in fracture union and favorable wrist function at the 1-year follow-up. CONCLUSION: This case serves as a reminder that tailored, timely interventions for challenging scaphoid fractures can yield favorable long-term results, underscoring the significance of individualized approaches in fracture management.

Management of Progressive Unilateral Tibia Vara in a 3-Year-Old Child with Focal Fibrocartilaginous Defect: A Case Report.

CASE: A 3-year-old boy with unilateral tibia vara was diagnosed with focal fibrocartilaginous dysplasia (FFCD) of the left proximal tibia. Because of progressive deformity with intercondylar distance of 9 cm and tibia metaphyseal-diaphyseal angle of 28°, the child was treated with curettage of the lesion and lateral proximal tibia hemiepiphysiodesis with 8 plates. The deformity was corrected within 12 months, the implant was removed, and the child is being followed up till skeletal maturity. CONCLUSION: Curettage of the lesion and guided growth with an 8-plate is a viable treatment method for FFCD of the proximal tibia with progressive tibia vara deformity.

Impact of RB1 gene screening from blood collected on a single day from 411 family members of 113 Retinoblastoma survivors in India.

OBJECTIVES: To analyse the profile and implication of genetic testing in a cohort of retinoblastoma (RB) patients and their families conducted on a single day during World Retinoblastoma Awareness Week 2017. METHODS: Retrospective analysis of blood samples were collected from 411 subjects, including 113 probands at a camp organised for RB awareness and were analysed for RB1 mutations by Sanger sequencing and Multiplex Ligation-dependent Probe Amplification (MLPA). If germline mutations were detected, the parents and siblings of the proband were tested for the same mutation. RESULTS: Germline RB1 mutations were identified in 61/113(54%) probands with a mutation detection rate of 96% (47/49) and 22% (14/64) for bilateral and unilateral RB, respectively. Ten novel pathogenic mutations were identified. Splice mutation was most common (31%) followed by nonsense mutation (26%). The mean age at RB diagnosis was significantly lower in patients having germline RB1 mutation (mean 10.7 months ±2.5) compared to those without (mean 27.2 months ±6.5) (p = <0.0001). Parental transmission of the mutant allele was detected in 15/61(25%) cases of which 11(18%) parents were unaffected indicating incomplete penetrance. The origin of the variant allele was both paternal (n = 7) and maternal (n = 4) wherein 5 were bilateral and 6 unilateral. CONCLUSIONS: The detection of a germline mutation impacts the proband and family members due to its implications on change in prognosis, frequency of subsequent evaluations, screening for ocular and non-ocular cancers, and surveillance of family and future progeny.

Functional Outcome of Mechanical Alignment in Total Knee Arthroplasty Surgery: A Short-Term Cohort Study at an Indian Tertiary Care Hospital.

Background: In severe arthritis cases, goal of total knee arthroplasty (TKA) management is to attain pain-free joint and restore the overall limb alignment. There are limited short-term studies published from Indian hospitals that investigated the importance of neutral mechanical component alignment in TKA patients. Methods: Retrospective and prospective study was conducted at the Department of orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune from June 2020 to September 2022. Enrolled patients were assessed preoperatively and postoperatively using clinical examination, radiological assessment and functional outcomes through the Oxford knee score, Knee society score and VAS score. Results: 204 patients enrolled, and 267 knees were evaluated for the study. Osteoarthritis was the commonest diagnosis (254 knees, 95.13%). Pre-operatively, 92.13% knees were varus, 4.87% valgus and 3% neutral while post-operatively, 51.69% were varus, 16.1% were valgus, and 32.32% were with neutral axis. Majority of patients with a pre-operative neutral axis converted to varus axis (62.5%), while most valgus axis cases preoperatively converted to a neutral axis (53.84%). For pre-operative varus subgroup, the majority patients with < 10° pre-operative axis converted to neutral (41.28%). Majority patients with 10°-20° pre-operative axis remained varus (60.53%) and with > 20° pre-operative axis remained varus (78.26%). Functional outcome parameters were significantly improved at follow-up (P < 0.05). Conclusion: Short-term postoperative functional scores were significantly improved in postoperative cases, with the postoperative alignment of 0° ± 3° relative to the mechanical axis was achieved. Thus, postoperative neutral mechanical alignment of 0° ± 3° can be the standard of care for patients undergoing TKA.

Dual-mobility implants in primary and revision total hip arthroplasty: A systematic review and meta-analysis.

Purpose: Total hip arthroplasty (THA) is a common and successful operation. However, dislocation remains a significant cause of implant failure in fixed-bearing designs. This study investigated the effect of dual-mobility implants (DM) compared to fixed-bearing (FB) implants on all-cause revisions, revisions due to dislocation, post-operative complications and functional scores in patients undergoing primary and revision THA. Methods: A systematic review was performed including studies that compared DM with FB implants in primary or revision THA according to PRISMA guidelines, and was registered in PROSPERO (ID CRD42023403736). The Cochrane Library, Embase, MEDLINE, Web of Science, and Scopus were searched from the time of database inception to March 12, 2023. Eligible studies underwent meta-analysis and risk of bias assessment using the ROBINS-I tool. Treatment effects were assessed using odds ratios and data were pooled using a random-effects maximum-likelihood, where appropriate. Results: Eight comparative, non-randomised studies involving 2810 DM implants and 3188 FB implants were included. In primary THA, there was an imprecise estimate of the difference in all-cause revision (OR 0.82, 95 % CI 0.25-2.72) and a significant benefit for the DM cohort in revision due to dislocation (OR 0.08, 95 % CI 0.02-0.28). In revision THA, the DM cohort showed benefit in all-cause revision (OR 0.57, 95 % CI 0.31-1.05) and revision due to dislocation (OR 0.14, 95 % CI 0.04-0.53). DM implants were associated with a lower incidence of implant dislocation and infection. The analysis of functional outcomes was limited due to reporting limitations. No intraprosthetic dislocations were observed. Conclusion: The results suggest that contemporary DM designs may be advantageous in reducing the risk of all-cause revision, revision due to dislocation, and post-operative complication incidence at mid-term follow-up. Further high-quality prospective studies are needed to evaluate the long-term risk profile of this design, especially in the revision context.

The scope of artificial intelligence in retinopathy of prematurity (ROP) management.

Artificial Intelligence (AI) is a revolutionary technology that has the potential to develop into a widely implemented system that could reduce the dependence on qualified professionals/experts for screening the large at-risk population, especially in the Indian scenario. Deep learning involves learning without being explicitly told what to focus on and utilizes several layers of artificial neural networks (ANNs) to create a robust algorithm that is capable of high-complexity tasks. Convolutional neural networks (CNNs) are a subset of ANNs that are particularly useful for image processing as well as cognitive tasks. Training of these algorithms involves inputting raw human-labeled data, which are then processed through the algorithm's multiple layers and allow CNN to develop their own learning of image features. AI systems must be validated using different population datasets since the performance of the AI system would vary according to the population. Indian datasets have been used in AI-based risk model that could predict whether an infant would develop treatment-requiring retinopathy of prematurity (ROP). AI also served as an epidemiological tool by objectively showing that a higher ROP severity was in Neonatal intensive care units (NICUs) that did not have the resources to monitor and titrate oxygen. There are rising concerns about the medicolegal aspect of AI implementation as well as discussion on the possibilities of catastrophic life-threatening diseases like retinoblastoma and lipemia retinalis being missed by AI. Computer-based systems have the advantage over humans in not being susceptible to biases or fatigue. This is especially relevant in a country like India with an increased rate of ROP and a preexisting strained doctor-to-preterm child ratio. Many AI algorithms can perform in a way comparable to or exceeding human experts, and this opens possibilities for future large-scale prospective studies.