Performance of a deep neural network in teledermatology: a single-centre prospective diagnostic study.

BACKGROUND: The use of artificial intelligence (AI) algorithms for the diagnosis of skin diseases has shown promise in experimental settings but has not been yet tested in real-life conditions. OBJECTIVE: To assess the diagnostic performance and potential clinical utility of a 174-multiclass AI algorithm in a real-life telemedicine setting. METHODS: Prospective, diagnostic accuracy study including consecutive patients who submitted images for teledermatology evaluation. The treating dermatologist chose a single image to upload to a web application during teleconsultation. A follow-up reader study including nine healthcare providers (3 dermatologists, 3 dermatology residents and 3 general practitioners) was performed. RESULTS: A total of 340 cases from 281 patients met study inclusion criteria. The mean (SD) age of patients was 33.7 (17.5) years; 63% (n = 177) were female. Exposure to the AI algorithm results was considered useful in 11.8% of visits (n = 40) and the teledermatologist correctly modified the real-time diagnosis in 0.6% (n = 2) of cases. The overall top-1 accuracy of the algorithm (41.2%) was lower than that of the dermatologists (60.1%), residents (57.8%) and general practitioners (49.3%) (all comparisons P < 0.05, in the reader study). When the analysis was limited to the diagnoses on which the algorithm had been explicitly trained, the balanced top-1 accuracy of the algorithm (47.6%) was comparable to the dermatologists (49.7%) and residents (47.7%) but superior to the general practitioners (39.7%; P = 0.049). Algorithm performance was associated with patient skin type and image quality. CONCLUSIONS: A 174-disease class AI algorithm appears to be a promising tool in the triage and evaluation of lesions with patient-taken photographs via telemedicine.

Real-world treatment patterns of rheumatoid arthritis in Brazil: analysis of DATASUS national administrative claims data for pharmacoepidemiology studies (2010-2020).

Our study assessed DATASUS as a potential source for pharmacoepidemiologic studies in rheumatoid arthritis (RA) in the Brazilian population focusing on treatment patterns and determinants of initiating or switching to a novel therapy. This was a descriptive database study of RA patients with at least one claim of RA and ≥ 2 claims of disease-modifying anti-rheumatic drug (DMARD); conventional synthetic (cs), biologic (b) or targeted synthetic (ts) DMARD with more than 6 months of follow-up from 01-Jan-2010 to 31-Dec-2020. Analyses were stratified for SUS-exclusive and SUS+ private user cohorts. We identified 250,251 patients with RA in DATASUS: mean age of 58.4 years, majority female (83%) and white (58%). 62% were SUS-exclusive and 38% SUS+ private. Most common bDMARDs were adalimumab and etanercept. Age (adjusted odds ratio 1.78 [50+]; 95% CI 1.57-2.01), SUS exclusive status (0.53; 0.47-0.59), distance to clinic [160+ km] (0.57; 0.45-0.72), and pre-index csDMARD claims (1.23; 1.08-1.41) were independent predictors of initiating a novel oral tsDMARD. Switching from bDMARD to tsDMARD, associations were similar, except for the direction of associations for SUS exclusive status (adjusted hazard ratio 1.10; 1.03-1.18), distance to clinic (1.18; 1.03-1.35), and number of previous bDMARD (0.15; 0.14-0.16). DATASUS is a source suitable for treatment-related analyses in RA reflecting the public health system in Brazil.

Case Report of Novel Genetic Variant in KCNT1 Channel and Pharmacological Treatment With Quinidine. Precision Medicine in Refractory Epilepsy.

Case introduction: In this work we present a female infant patient with epilepsy of infancy with migrating focal seizures (EIMFS). Although many pharmacological schemes were attempted, she developed an encephalopathy with poor response to antiepileptic drugs and progressive cerebral dysfunction. Aim: To present the pharmacological response and therapeutic drug monitoring of a paediatric patient with a severe encephalopathy carrying a genetic variant in KCNT1 gene, whose identification led to include quinidine (QND) in the treatment regimen as an antiepileptic drug. Case report: Patient showed slow rhythmic activity (theta range) over left occipital areas with temporal propagation and oculo-clonic focal seizures and without tonic spasms three months after birth. At the age of 18 months showed severe impairments of motor and intellectual function with poor eye contact. When the patient was 4 years old, a genetic variant in the exon 24 of the KCNT1 gene was found. This led to the diagnosis of EIMFS. Due to antiepileptic treatment failed to control seizures, QND a KCNT1 blocker, was introduced as a therapeutic alternative besides topiramate (200 mg/day) and nitrazepam (2 mg/day). Therapeutic drug monitoring (TDM) of QND plasma levels needed to be implemented to establish individual therapeutic range and avoid toxicity. TDM for dose adjustment was performed to establish the individual therapeutic range of the patient. Seizures were under control with QND levels above 1.5 mcg/ml (65-70 mg/kg q. i.d). In addition, QND levels higher than 4.0 mcg/ml, were related to higher risk of suffering arrhythmia due to prolongation of QT segment. Despite initial intention to withdrawal topiramate completely, QND was no longer effective by itself and failed to maintain seizures control. Due to this necessary interaction between quinidine and topiramate, topiramate was stablished in a maintenance dose of 40 mg/day. Conclusion: The implementation of Precision Medicine by using tools such as Next Generation Sequencing and TDM led to diagnose and select a targeted therapy for the treatment of a KCNT1-related epilepsy in a patient presented with EIMFS in early infancy and poor response to antiepileptic drugs. QND an old antiarrhythmic drug, due to its activity as KCNT1 channel blocker, associated to topiramate resulted in seizures control. Due to high variability observed in QND levels, TDM and pharmacokinetic characterization allowed to optimize drug regimen to maintain QND concentration between the individual therapeutic range and diminish toxicity.

Hyperbaric oxygen therapy for the placement of dental implants in irradiated patients: systematic review and meta-analysis.

This study was a systematic review with meta-analysis to evaluate the influence of hyperbaric oxygen therapy (HBOT) on the survival of dental implants placed in patients who had had radiotherapy for cancer of the head and neck. A systematic literature search was conducted using the PubMed/Medline, Science Direct, Embase and the Cochrane Library, between January 1985 and July 2018. The study observed the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) declaration and norms, and the systematic review was duly recorded in the PROSPERO (International prospective register of systematic reviews) database. Inclusion and exclusion criteria were applied, and all articles were selected on the basis of PICO questions. The process of eligibility and quality evaluation yielded three studies for statistical analysis. Based on the survival rates, there was no evidence that the risk of an implant failing was different between the patients who received HBOT and those who did not. Moreover, the risk of an implant failing did not depend on the anatomical site. HBOT exerted no beneficial influence on the survival rates of implants placed in irradiated patients, and the risk of an implant failing did not depend on its location.

Long-term success of dental implants in patients with head and neck cancer after radiation therapy.

The purpose of this study was to analyze the long-term success and factors potentially influencing the success of dental implants placed in patients with head and neck cancer who underwent radiation therapy with a minimum total dose of 50Gy during the years 1995-2010. Thirty-five patients (169 dental implants) were included in this study. Data on demographic characteristics, tumour type, radiation therapy, implant sites, implant dimensions, and hyperbaric oxygen therapy (HBOT) were obtained from the medical records and analyzed. Implant survival was estimated using Kaplan-Meier survival curves. Seventy-nine dental implants were placed in the maxilla and 90 in the mandible. The mean follow-up after implant installation was 7.4 years (range 0.3-14.7 years). The overall 5-year survival rate for all implants was 92.9%. Sex (P<0.001) and the mode of radiation therapy delivery (P=0.005) had a statistically significant influence on implant survival. Age, time of implantation after irradiation, implant brand and dimensions, and HBOT had no statistically significant influence on implant survival. Osseointegrated dental implants can be used successfully in the oral rehabilitation of patients with head and neck cancer with a history of radiation therapy. Risk factors such as sex and the mode of radiation therapy delivery can affect implant survival.

The long-term outcome of patients with hypertensive cardiomyopathy.

The prognosis of dilated cardiomyopathy due to hypertension (HT-DCM) is surprisingly unknown, particularly in the absence of coronary disease and diabetes. We aimed at investigating the long-term outcome and the predictors of mortality in patients with left ventricular systolic dysfunction exclusively due to hypertension. From October 1995 to May 2001, 90 consecutive patients with echocardiographic fractional shortening (FS) < 30% and 29 control patients with FS > or = 30% were included. Obstructive coronary disease was excluded by dipyridamole myocardial perfusion imaging in all patients and coronary angiography in 60. After a mean follow-up of 4.3+/-1.6 years, the total mortality rate of HT-DCM was twice as much higher than that of patients without left ventricular systolic dysfunction (P = 0.01). In HT-DCM, the 5-year mortality rate was 26%. Univariate analyses selected age and creatinine for being positively related to mortality, and body mass index, FS and blood pressure during follow-up for being negatively related to mortality. Neither the improvement of left ventricular FS nor the decrease in left ventricular mass index was related to survival. Multivariate analysis identified (hazard ratio; 95% confidence interval) age (1.08; 1.02-1.13), body mass index (0.86; 0.75-0.98), and baseline FS (0.88; 0.78-0.98) as independent predictors of mortality. In conclusion, poor survival in HT-DCM can be anticipated by the severity of left ventricular systolic dysfunction and advanced age. Instead of ominous signs, high blood pressure and body mass may predict a more favourable prognosis.

Resting metabolic rate in obese, premenopausal black women.

In the United States, obesity is more prevalent in black than in non-Hispanic white women. Because low resting metabolic rate (RMR) has been suggested as a risk factor for weight gain, we compared RMR in 22 black and 20 white obese [body mass index (BMI; in kg/m2) range: 28.9-48.6 and 26.9-44.1, respectively], weight-stable, premenopausal, nondiabetic women. RMR was measured on two or three different occasions within a 1-wk period. The black and white groups did not differ significantly in age, degree of fitness, BMI, fat mass, or fat-free mass (FFM). In each group, RMR was predicted independently by FFM but not by age, degree of fitness, body fat mass, or body fat distribution. The slopes of the equations predicting RMR from FFM in black and white groups were not significantly different. However, the black women had significantly lower RMRs than the white women after adjustment for FFM measured by five body-composition models: dual-photon X-ray absorptiometry (DXA), hydrodensitometry, total body water, a three-compartment model, a four-compartment model, as well as for the absolute total-body potassium content as a measure of metabolically active FFM. By each analysis, the black women had significantly lower (P < 0.01) FFM-adjusted RMR than the white women; this difference ranged from 671 to 889 kJ/d depending on the body-composition method used to estimate FFM. This could contribute to the difference in the prevalence of obesity in the populations represented by these groups.

Left ventricular hypertrophy predicts outcome of hypertension regardless of the type of ventricular arrhythmia present.

Left ventricular hypertrophy is associated with an increased cardiovascular mortality in hypertension. A potential role of ventricular arrhythmias is debated but not yet determined. The purpose of this study was to evaluate whether the presence of arrhythmias would ascribe any additional risk to cardiovascular mortality beyond that related to the presence of left ventricular hypertrophy. From November 1988 to February 1991, 40 mild to severe hypertensive patients (mean SBP, DBP 183/117 mm Hg) were submitted to clinical, echocardiographic and electrocardiographic evaluations complemented by 24-h Holter monitoring and then followed until November 1996. The Kaplan-Meier method supplemented by the Cox multiple regression model were performed to identify the variable(s) associated with fatal cardiovascular outcome. Twelve cardiovascular fatalities occurred as a consequence of sudden death (n = 4), stroke (n = 4), heart failure (n = 2) and myocardial infarction (n = 2). In comparison with patients who survived, those dying from cardiovascular causes had a greater percentage of electrocardiographic left ventricular hypertrophy (83 vs 36%, P = 0. 0037) and couplets of ventricular ectopic beats (58 vs 18%, P = 0. 0467). In addition, they showed larger left ventricular diastolic diameter (60 +/- 10 vs 53 +/- 8 mm), mass index (248 +/- 67 vs 154 +/- 57 g/m2) and posterior wall thickness (12 +/- 2 vs 10 +/- 2 mm), as well as shorter left ventricular fractional shortening (0.23 +/- 0.8 vs 0.32 +/- 0.9). Univariate analysis showed that electrocardiographic left ventricular hypertrophy and strain, mass index, end-systolic wall stress, fractional shortening and the presence of couplets were significantly related to cardiovascular mortality. However, only mass index was shown to be independently associated with cardiovascular death. In conclusion, left ventricular hypertrophy predicts cardiovascular outcome, regardless of the presence of other signs of cardiac damage, including ventricular arrhythmia.

Opportunistic actinomycosis in osteoradionecrosis of the jaws in patients affected by head and neck cancer: incidence and clinical significance.

Actinomycosis is occasionally an opportunistic infection occurrence in patients with osteoradionecrosis (ORN). A retrospective study (1992-97) of 50 patients with ORN of the jaws was done to evaluate the incidence and its clinical significance in the management of ORN. Actinomycosis was diagnosed in 12% of ORN cases. In 36 of the 50 patients including five cases of actinomycosis, the ORN was considered to be resolved after treatment. The median treatment duration of ORN was significantly longer (P<0.007) in patients with actinomycosis (29.7 months) than those without the disease (13.4 months). In conclusion, bone biopsy should be considered in cases of ORN with unsatisfactory response to its specific therapies, aiming to identify possible opportunistic actinomycosis infection.

Effect of highly active antiretroviral therapy on cytomegalovirus antigenaemia in AIDS patients.

To assess the effect of highly active antiretroviral therapy (HAART) on cytomegalovirus (CMV) antigenaemia in AIDS patients, 70 patients with CD4+ cell counts < or = 50/mm3 and positive anti-(CMV) immunoglobulin G (IgG) were tested at 15-30 day intervals for CMV antigenaemia. We selected those patients who had been followed up for more than 3 months. Three patient profiles were defined: A, followed up before the introduction of HAART; B, followed up before and after the use of HAART; and C, followed up after the use of HAART. Thirty-nine patients were included, 12 in group A, 17 in group B, and 10 in group C. Group A patients presented a lower median CD4+ cell count compared with groups B and C patients (9, 122 and 127 cells/mm3, respectively), with the increase in the last 2 groups being related to the use of HAART (P<0.001). A lower proportion of positive antigenaemia was observed in group B after the introduction of HAART compared with the time before HAART (P=0.02). HAART caused an immunological improvement and was found to be associated with negativity of CMV antigenaemia.

Management of refractory osteoradionecrosis of the jaws with surgery and adjunctive hyperbaric oxygen therapy.

This retrospective study aimed to determine the effectiveness of surgery and hyperbaric oxygen (HBO) treatment in the management of refractory osteoradionecrosis (ORN) of the jaws. Of the 18 patients who had undergone this treatment, 14 patients had complete healing, 3 patients had improved and one patient did not show any improvement. Of the 14 patients who had complete healing, only 4 still had a discontinuity defect of the mandible but they declined additional reconstructive surgery. In conclusion, surgery/HBO therapy showed satisfactory results in the management of refractory ORN of the jaws.

Management of solid ameloblastoma of the jaws with liquid nitrogen spray cryosurgery.

OBJECTIVE: This study evaluated the results of the use of curettage followed by liquid nitrogen spray cryosurgery in a number of solid or multicystic ameloblastomas of the jaws and the postoperative complications related to this treatment modality. STUDY DESIGN: Thirty-six patients with solid ameloblastoma of the jaws were treated with curettage followed by cryosurgery. The cryotherapy consisted of hand instrumented curettage of the bone lesion followed by three freezing cycles, of 1 minute each, of the remaining bone cavity with liquid nitrogen spray. Postoperative complications were evaluated clinically and radiographically. RESULTS: Local recurrence occurred in 11 (30.6%) patients. Excepting local recurrence, postoperative complications were frequent but not severe: wound dehiscence (5.5%), paraesthesia (5.5%), infection (5.5%), and pathologic fracture (11.1%). CONCLUSION: Management of solid or multicystic ameloblastomas of the jaws with curettage followed by cryosurgery may decrease the local recurrence rate and also to reduce the initial indication of resection with continuity defect.

Ultrasonography evaluation of bone lesions of the jaw.

The ultrasonographic aspects of 72 intraosseous lesions of the jaws were evaluated to identify the usefulness of this type of examination. The principal aim of ultrasonography was to recognize the lesion's content before surgical treatment. Four groups of lesions were classified after the definitive histopathologic examination: lesions with solid, liquid, dense liquid, and mixed contents. The initial ultrasonography examination was in agreement with the histopathologic findings in 24 (92.3%) cases with solid content, 17 (73.9%) cases with liquid content, 7 (7.7%) cases with dense liquid content, and 13 (92.8%) cases with mixed content. On the basis of the results of this study, we propose the use of ultrasonography as a complementary examination for intraosseous lesions of the jaws. If a liquid component is identified in ultrasonography, a surgical procedure should be performed immediately. Otherwise, if a lesion with solid component is identified, it should be biopsied for histopathologic examination and final diagnosis before definitive surgery.

Public awareness of Lyme disease in obstetric, pediatric, and student settings in northwestern Connecticut.

The purpose of this study has been to survey the attitudes and understandings of Lyme disease by pregnant women, mothers, and ninth-grade students in Northwestern Connecticut. A sample of 100 obstetrical patients from two private obstetric offices, 100 mothers from four private pediatric offices, and 200 students from four secondary schools was asked to complete a 15 question survey about Lyme disease. In all groups, the responses indicated some misconceptions or a lack of knowledge about the manifestations, diagnosis, and treatment of Lyme disease, as well as about the transmission of Borrelia burgdorferi. This information indicates that better public education about Lyme disease is important.

Osteoradionecrosis of the jaws: a retrospective study of the background factors and treatment in 104 cases.

PURPOSE: This study analyzed potential risk factors in patients who received radiation therapy and then developed osteoradionecrosis (ORN). PATIENTS AND METHODS: A group of 104 patients who developed osteoradionecrosis of the jaws were reviewed treated between 1972 and 1992. RESULTS: The most common affected site was the mandible (99 cases, 95.2%), followed by the maxilla (5 cases, 4.8%). Among all cases, 93 (89.4%) were induced-trauma ORN, and 11 (10.6%) were spontaneous ORN. The following risk factors were considered as predisposing factors for the appearance of ORN: Anatomic location of the tumor, tumor surgery, total radiation dose, dose rate/day, mode of radiation delivery, time from radiation therapy until the onset of ORN, and dental status. ORN developed more frequently with oral cancer than other head and neck cancers. The size of the tumor seemed not to influence the incidence of ORN except when the tumor invade the adjacent bone. Type of radiation delivery total bone dose, and modes of radiation appeared to influence the risk of ORN occurrence. After conservative treatment, 44 (42.3%) cases had complete healing and resolution 34 (32.6%) cases had a stable, chronic ORN process, and 26 (25.1%) cases had acute and progressive ORN. CONCLUSION: An understanding of the risk factors is important in preventing ORN after radiation therapy.

[Lower limb repair. Bipedicled fasciocutaneous flap. A new technical approach]. / Reparação dos membros inferiores. Retalho fasciocutâneo bipediculado. Nova abordagem técnica.

The authors present an anatomical study of a fasciocutaneous flap of the lower limb and its clinical application. Sixteen patients with loss of cutaneous substance and exposure of the leg bone were operated on. The bipedicled fasciocutaneous flap presented by the authors allows the coverage of large areas of the lower limb in the initial stage of treatment. Preservation of the superficial venous system allows for a better vascularization of the flap and, thus, for the use of larger flaps.

The hemodynamics of vein grafts: measurement and meaning.

The long-term patency of infrainguinal vein grafts appears to depend primarily on the size and quality of the venous conduit. Therefore, those quantities which directly relate to the conduit's ability to act as a transporter of blood, namely internal diameter and longitudinal impedance (Z(L)), have predictive value for patency. Autologous grafts of good quality frequently remain patent even with compromised outflow. Therefore, those quantities that are outflow dependent, including deltaP, flow, velocity, shear stress, and resistance, carry less predictive value for long-term performance.

[Autologous fat transplantation in rats]. / Transplante autólogo de gordura em ratos.

The authors perform an experimental study in rats to demonstrate the integration of fat cells transplanted from the inguinal region to the dorsal region of the same animal. Histological studies were performed with the material removed and with the material injected. Final results show the transplanted fat cell integration after 360 days.