Greater distance to an academic medical center is associated with poorer melanoma prognostic factors: The University of Colorado Experience.

INTRODUCTION: Numerous studies report a correlation between distance to diagnostic provider in an academic medical center and poorer prognosis ofdisease. Limited research on this topic exists with respect to melanoma. METHODS: This was a retrospective chart review of 1,463 adults (≥18 years) initially diagnosed with melanoma between 2006-2016. Associations between distance traveled and Breslow depth and presence of metastatic disease were assessed via cumulative and binary logistic regression models, adjusting for patient and tumor characteristics. RESULTS: Subjects traveling ≥50 miles had 58% greater odds of having an increased Breslow depth than those traveling less than that distance (OR: 1.58; 95% CI: 1.24-2.01; p<0.0001), and had four times the odds of presenting with metastatic disease (OR: 4.04; 95% CI: 3.00-5.46; p<0.0001). DISCUSSION: We highlight the correlation between increased distance to our academic medical center with greater Breslow depths and the presence ofmetastatic disease at presentation. CONCLUSION: Future studies assessing other factors and regional differences that limit access to diagnosis might help improve screening efforts to prevent poorer prognosis for patients in these areas.

Quality of Life Outcomes Among Patients Being Screened for Cytomegalovirus Retinitis in Thailand.

PURPOSE: Cytomegalovirus (CMV) retinitis can have debilitating impacts on quality of life (QOL), but few contemporary studies have characterized these ramifications. This study assessed the impact of CMV retinitis on vision-related QOL for those living with HIV/AIDS in Thailand. METHODS: QOL was assessed as part of a prospective interventional cohort study of patients referred to a tertiary hospital in Thailand for CMV retinitis screening. A validated vision-related QOL questionnaire was administered at the baseline screening visit and at the 6-month study visit. Multivariable linear regression models were performed to determine the effect of CMV retinitis diagnosis on QOL score. RESULTS: A total of 152 participants completed the QOL questionnaire at their initial clinic visit. At baseline, a diagnosis of CMV retinitis diagnosis was significantly associated with decreased QOL score: unilateral retinitis was associated with a 0.11 (95% CI: -0.26-0.03) decrement in QOL, and bilateral retinitis was associated with a 0.33 (95% CI: -0.51-0.16) decrement (joint P-value = 0.0009). For the 78 participants with a 6-month visit, changes in QOL from baseline were small and not significant. A diagnosis of CMV retinitis was still associated with decreased QOL score at 6 months (joint P-value = 0.03). CONCLUSIONS: This study found that vision-related QOL was lower in those with CMV retinitis, especially with bilateral involvement, and did not improve after treatment among those with follow-up. These findings reinforce the debilitating clinical manifestations of this disease, and support efforts for earlier screening to detect CMV retinitis before impacts on QOL have occurred.

COVID-19 and Lung Cavitation: A Clue to Pathogenesis?

Description Lung cavitation as a complication of COVID-19 is rare. A 56-year-old male presented with lung cavitation, small volume hemoptysis, and violaceous discoloration of the right great toe, 5 weeks after diagnosis with COVID-19 pneumonia. The digital changes were consistent with previously described microvascular changes called "COVID toe." CT angiography of the chest was negative for pulmonary embolism but showed a 2.5 x 3.1 x 2.2 cm cavitation within the right lung. Extensive evaluation for commonly implicated infectious and autoimmune causes was negative. We concluded that the cavitary lung lesions were likely a complication of COVID-19 pneumonia and may implicate microangiopathy as an important component of pathogenesis. This case highlights a rare complication of COVID-19 of which clinicians should be aware.

Clinic-Based Eye Disease Screening Using Non-Expert Fundus Photo Graders at the Point of Screening: Diagnostic Validity and Yield.

PURPOSE: The intent of this study was to determine the diagnostic accuracy of several diagnostic tests for age-related macular degeneration (AMD), diabetic retinopathy (DR), glaucoma, and cataract, as well as the proportions of patients with eye disease from each of 3 enrolling clinics. DESIGN: Diagnostic accuracy study. METHODS: Patients ≥50 years old in a diabetes, thyroid, and general medicine clinic were screened using visual acuity, tonometry, and fundus photography. Photographs were graded at the point-of-screening by non-ophthalmic personnel. Participants with positive screening test results in either eye and a 10% random sample with negative results in both eyes were referred for an in-person, reference-standard ophthalmology examination. RESULTS: Of 889 participants enrolled, 229 participants failed at least 1 test in either eye, of which 189 presented for an ophthalmic examination. An additional 76 participants with completely normal screening test results were referred for examination, of which 50 attended. Fundus photography screening had the highest yield for DR (sensitivity: 67%; 95% confidence interval [CI]: 39%-87%), visual acuity screening for cataract (sensitivity: 89%; 95% CI: 86%-92%), and intraocular pressure screening for glaucoma or suspected glaucoma (sensitivity: 25%; 95% CI: 14%-40%). The burden of disease was relatively high in all 3 clinics, with at least 1 of the diseases of interest (ie, AMD, DR, glaucoma or suspected glaucoma, or cataract) detected in 25% of participants (95% CI: 17-35%) from the diabeteses clinic, 34% (95% CI: 22%-49%) from the thyroid clinic, and 21% (95% CI: 13%-32%) from the general clinic. CONCLUSIONS: Non-expert eye disease screening in health clinics may be a useful model for detection of eye disease in resource-limited settings.

Association of Federal Regulations in the United States and Canada With Potential Corneal Donation by Men Who Have Sex With Men.

Importance: Federal policy in the United States prohibits corneal donation by men who have had sex with another man (MSM) in the preceding 5 years, whereas Canada enforces a 12-month ban. The potential consequences of these policies on corneal donations should be evaluated. Objective: To estimate the number of potential corneal donations associated with MSM deferral policies in the United States and Canada. Design, Setting, and Participants: A nonvalidated telephone survey study was conducted of all 65 eye banks in the United States and Canada to investigate how many potential corneal donors were disqualified in 2018 because of federal MSM restrictions. Published demographic data were also used to arrive at a separate estimate. Survey data were gathered from May 2019 to February 2020. Main Outcomes and Measures: Eye banks were asked if they keep records of referrals disqualified specifically because of the federal MSM restrictions and, if so, how many referrals they disqualified in 2018 owing to MSM status. Results: Fifty-four of 65 eye banks (83%) responded to the survey, with 30 eye banks reporting they do not keep specific records of MSM deferrals. The remaining 24 eye banks reported disqualifying 360 referrals in 2018 because of MSM status, equating to 720 corneas. The 24 eye banks accounted for 46.2% of corneal donations in the United States and Canada in 2018, yielding an estimate of approximately 1558 corneas rejected that year because of MSM status. A separate estimate using published MSM demographic data indicates that up to 3217 potential corneal donations may have been disqualified in 2018 because of these federal policies. Conclusions and Relevance: Findings suggest that between 1558 and 3217 corneal donations were disqualified in 2018 because of federal regulations prohibiting corneal donation by men who have had sex with another man in the preceding 5 years in the United States or 1 year in Canada. With modern virologic testing that is reliable within days of HIV exposure and given the global shortage of corneal tissue, these policies should be reevaluated using current scientific evidence to increase the availability of vision-restoring surgery worldwide.

Comparison of Smartphone Photography, Single-Lens Reflex Photography, and Field-Grading for Trachoma.

Conjunctival examination for trachomatous inflammation-follicular (TF) guides public health decisions for trachoma. Smartphone cameras may allow remote conjunctival grading, but previous studies have found low sensitivity. A random sample of 412 children aged 1-9 years received an in-person conjunctival examination and then had conjunctival photographs taken with 1) a single-lens reflex (SLR) camera and 2) a smartphone coupled to a 3D-printed magnifying attachment. Three masked graders assessed the conjunctival photographs for TF. Latent class analysis was used to determine the sensitivity and specificity of each grading method for TF. Single-lens reflex photo-grading was 95.0% sensitive and 93.6% specific, and smartphone photo-grading was 84.1% sensitive and 97.6% specific. The sensitivity of the smartphone-CellScope device was considerably higher than that of a previous study using the native smartphone camera, without attachment. Magnification of smartphone images with a simple attachment improved the grading sensitivity while maintaining high specificity in a region with hyperendemic trachoma.

Smartphone photography as a possible method of post-validation trachoma surveillance in resource-limited settings.

BACKGROUND: Validation of trachoma elimination requires monitoring after discontinuation of trachoma program activities, though such evaluations are not commonly done. METHODS: Conjunctival examinations and smartphone photography were performed on a random sample of pre-school children from 15 villages in a region of Burkina Faso thought to have eliminated trachoma. RESULTS: No clinically active trachoma was detected by in-field or photographic evaluation. Smartphone images demonstrated high agreement with field grading (>99% concordance). CONCLUSIONS: Trachoma appears to have been eliminated from this area of Burkina Faso. Smartphone cameras may be a useful aid for monitoring in resource-limited settings.

Accuracy of computer-assisted vertical cup-to-disk ratio grading for glaucoma screening.

PURPOSE: Glaucoma screening can be performed by assessing the vertical-cup-to-disk ratio (VCDR) of the optic nerve head from fundus photography, but VCDR grading is inherently subjective. This study investigated whether computer software could improve the accuracy and repeatability of VCDR assessment. METHODS: In this cross-sectional diagnostic accuracy study, 5 ophthalmologists independently assessed the VCDR from a set of 200 optic disk images, with the median grade used as the reference standard for subsequent analyses. Eight non-ophthalmologists graded each image by two different methods: by visual inspection and with assistance from a custom-made publicly available software program. Agreement with the reference standard grade was assessed for each method by calculating the intraclass correlation coefficient (ICC), and the sensitivity and specificity determined relative to a median ophthalmologist grade of ≥0.7. RESULTS: VCDR grades ranged from 0.1 to 0.9 for visual assessment and from 0.1 to 1.0 for software-assisted grading, with a median grade of 0.4 for each. Agreement between each of the 8 graders and the reference standard was higher for visual inspection (median ICC 0.65, interquartile range 0.57 to 0.82) than for software-assisted grading (median ICC 0.59, IQR 0.44 to 0.71); P = 0.02, Wilcoxon signed-rank test). Visual inspection and software assistance had similar sensitivity and specificity for detecting glaucomatous cupping. CONCLUSION: The computer software used in this study did not improve the reproducibility or validity of VCDR grading from fundus photographs compared with simple visual inspection. More clinical experience was correlated with higher agreement with the ophthalmologist VCDR reference standard.

Visual acuity outcomes in cytomegalovirus retinitis: early versus late diagnosis.

AIMS: To determine if early dilated fundus examination for cytomegalovirus (CMV) retinitis leads to better visual outcomes in areas with limited HIV care, where patients may have long-standing retinitis before they are diagnosed with HIV. METHODS: Twenty-four eyes of 17 patients with CMV retinitis who were seen at an urban HIV clinic in Chiang Mai, Thailand, were included in this retrospective cohort study. Participants were divided into two groups based on the amount of time from the first documented CD4 count below 100 cells/mm3 to the first eye examination for CMV retinitis. Average visual acuity in each group was calculated at the time CMV retinitis was first detected, and then at 3, 6 and 12 months after diagnosis. RESULTS: The group of patients who received an eye examination within approximately 4 months of the initial low CD4 count measurement had better baseline visual acuity (median 20/30,IQR 20/20 to 20/60) compared with patients who presented later (median 20/80, 20/60 to hand motion); p=0.03). Visual acuity did not change significantly during the 12-month study period in either the early group (p=0.69) or late group (p=0.17). CONCLUSION: In this study, patients who were examined sooner after a low CD4 count had better vision than patients who were examined later. Routine early screening of patients with CD4 counts under below 100 cells/mm3 may detect earlier disease and prevent vision loss.

Dietary diversity and nutritional status among children in rural Burkina Faso.

Background: Burkina Faso has a seasonal malnutrition pattern, with higher malnutrition prevalence during the rainy season when crop yields are low. We investigated the association between dietary diversity and nutritional status among children aged 6-59 mo during the low crop yield season in rural Burkina Faso to assess the role of dietary diversity during the lean season on childhood nutritional status. Methods: Caregivers reported the dietary diversity of the past 7 d, consisting of 11 food groups, summed into a scale. Anthropometric measurements were taken from all children. Height-for-age (HAZ), weight-for-height (WHZ) and weight-for-age (WAZ) z-scores were calculated based on 2006 WHO standards. Stunting, wasting and underweight were defined as HAZ, WHZ and WAZ <-2 SD, respectively. Multivariable regression models adjusting for potential confounders including household food insecurity and animal ownership were used to assess the relationship between anthropometric indices and dietary diversity. Results: Of 251 children enrolled in the study, 20.6% were stunted, 10.0% wasted and 13.9% underweight. Greater dietary diversity was associated with greater HAZ (SD 0.14, 95% CI 0.04 to 0.25) among all children. There was no association between dietary diversity and wasting or mid-upper arm circumference in this study. Conclusions: Increasing dietary diversity may be an approach to reduce the burden of stunting and chronic malnutrition among young children in regions with seasonal food insecurity.

Effect of Antibiotics on Short-Term Growth among Children in Burkina Faso: A Randomized Trial.

Antibiotics improve both weight and height gain in randomized trials of preschool children with preexisting morbidity. Here, we assess the effect of a short course of three different antibiotics (amoxicillin, azithromycin, and cotrimoxazole) on short-term linear and ponderal growth in a population-based sample of preschool children in rural Burkina Faso. We randomized households with at least two children in the Nouna district, Burkina Faso, to a 5-day course of amoxicillin, azithromycin, cotrimoxazole, or placebo. Within each antibiotic-randomized household, one child was randomly assigned to receive the antibiotic and the other to receive the placebo. Weight and height measurements were taken at baseline and 30 days following the last study medication dose. Weight-for-height Z (WHZ), height-for-age Z (HAZ), and weight-for-age Z (WAZ) scoreswere calculated based on the 2006 World Health Organization standards. Of the 124 households and 248 children enrolled, 229 had anthropometry measurements at 1 month and were analyzed. Children randomized to amoxicillin gained significantly more weight compared with both the placebo household (mean difference 317 g, 95% confidence interval [CI]: 115-519 g) and placebo sibling (mean difference 315 g, 95% CI: 147-482 g) controls. Growth velocity in g/kg/day, and WHZ and WAZ scores were higher in amoxicillin-treated children compared with placebo households and siblings. There were no differences in weight gain in children randomized to azithromycin or cotrimoxazole compared with placebo households or placebo siblings. There were no differences in height gain or HAZ across any of the study arms. Amoxicillin may have short-term growth-promoting effects in healthy children.