Breaking the barriers: Methodology of implementation of a non-mydriatic ocular fundus camera in an emergency department.

Despite evidence that non-mydriatic fundus cameras are beneficial in non-ophthalmic settings, they are only available in a minority of hospitals in the US. The lag from research-based evidence to change in clinical practice highlights the complexities of implementation of new technology and practice. We describe the steps used to implement successfully a non-mydriatic ocular fundus camera combined with optical coherence tomography (OCT) in a general emergency department (ED) using Kotter's 8-Step Change Model. We prospectively collected the number of trained personnel in the ED, the number of imaging studies obtained each week during the first year following implementation, and we documented major achievements each month, as well as outcome measures, barriers to implementation and possible solutions. Between 12 and 42 patients were imaged per week, resulting in a total of 1274 patients imaged demonstrating sustained usage of non-mydriatic fundus camera/OCT in the ED one year after implementation. The implementation process was contingent upon multidisciplinary collaboration, extensive communication, coordinated training of staff, and continuous motivation. The future will likely include the use of artificial intelligence deep learning systems for automated interpretation of ocular imaging as an immediate diagnostic aid for ED or other non-eye care providers.

Remote Diagnosis of Retinal Detachment in an Emergency Department Using Nonmydriatic Hybrid Ocular Imaging.

Background: Ocular emergencies are commonly evaluated in general emergency departments (ED) where ophthalmologists are rarely available. Nonmydriatic ocular imaging combining color fundus photographs and optical coherence tomography (NMFP-OCT) can help with rapid remote triage by ophthalmologists. We evaluated the rate at which retinal detachments (RDs) can be diagnosed with NMFP-OCT in the ED. Methods: Quality improvement project with prospective collection of data on RD patients who had NMFP-OCT obtained by ED staff over 1 year. Photographs were interpreted remotely by ophthalmologists and all patients underwent an in-person ophthalmologic examination in the ED to confirm the presence of a RD. Results: A total of 63 eyes (58 patients) had a RD, among which 53 (84.1%) had strong suggestion of RD on ocular imaging (34 [54%] were seen on both color and OCT nerve/macula; 11 [17.5%] were seen on color but missed on OCT; 8 [12.7%] were missed on color but seen on OCT). Ten RDs (15.9%) were missed on both color and OCT because of peripheral location of the RD (4, 40%), vitreous hemorrhage (4, 40%), or poor image quality (2, 20%). A total of 40 out of 58 patients were not seen by an eye care provider prior to reaching our ED and 10 had an inappropriate stroke workup for acute vision loss of presumed vascular origin. Conclusion: NMFP-OCT of the posterior pole obtained by ED staff revealed the RD in 84.1% of eyes, allowing for rapid remote triage of patients with visual symptoms and avoiding unnecessary testing when the diagnosis of RD is confirmed.

Usage of Dermoscopy as an Effective Diagnostic Tool in Pityriasis Alba: A Prospective Observational Study Among Children in a Suburban Hospital in South India.

BACKGROUND: Hypopigmented patches in patients with skin of color are usually a cause of concern. Pityriasis alba is a common skin condition that causes visible patches of hypopigmentation in children and adolescents. In addition to the cosmetic impairment, parents are concerned about the diagnosis of vitiligo and leprosy which also cause hypopigmented patches and have negative social implications. Dermoscopy is a useful diagnostic aid that is acquiring prominence in diagnosing a variety of skin diseases. Few studies exist that validate the use of dermoscopy as an effective tool in the diagnosis of Pityriasis alba. OBJECTIVE: To evaluate the effectiveness of dermoscopy by correlating the clinical features of Pityriasis alba with dermoscopic images. METHODS: Hypopigmented patches in 16 patients that were clinically diagnosed as Pityriasis alba were examined with a DermLite DL200 Hybrid dermoscope (Dermlite, CA, USA). All the dermoscopic images were photographically recorded and the findings were noted and correlated with the clinical stages of the disease. RESULTS: Out of the 40 patches examined in 16 patients, dermoscopic images of white structureless spots, scaling, indistinct borders and normally pigmented hairs were consistently present in all the patches to propose these as the four dermoscopic criteria for the diagnosis of Pityriasis alba. Areas of light brown pigmentation, 17 (42.5%), erythema, 3 (7.5%), and faint pigmented network,11 (27.5%) were the other features noted in some of the patches. CONCLUSION: In an ethnic South Indian population where the skin color is predominantly brown, hypopigmented patches are visibly obvious and concerning. Pityriasis alba, Pityriasis versicolor, Vitiligo, Nevus depigmentosus, and Leprosy are the five common conditions seen among children of which Pityriasis alba is the most prevalent. Offering the right diagnosis is essential for the correct management as well as excluding more serious conditions such as leprosy and vitiligo. In this study, Dermoscopy provided a valuable diagnostic aid in achieving this objective.

A Cross-Sectional Clinical Investigation of Organisms Causing Vaginal Discharge in Patients in Rural Tamil Nadu, India.

Background and aims Abnormal vaginal discharge is a prevailing gynecological problem among women in the reproductive age group. Vaginal discharges have multiple etiologies, and the present study was conducted with the objective of determining the prevalence of common organisms causing vaginal discharge and correlating with its various types of clinical presentations in those women attending a rural health centre of a medical college in Tamil Nadu, India. Materials and methods The study was a cross-sectional descriptive study, conducted in a rural health center of a teaching hospital in Tamil Nadu, India, from February 2022 to July 2022. All the patients clinically having the symptoms of vaginitis and with a discharge were included in this study, and postmenopausal women and pregnant women were excluded. Data was collected from a total of 175 patients. Results The mean (SD) age of the study population was 34.8 (6.9) years. Almost half, 91 (52%), of the study participants were in the age group of 31-40 years. Bacterial vaginosis was found in 74 (42.3%) and was the most common cause of abnormal vaginal discharge in our study participants, followed by vulvovaginal candidiasis, 34 (19.4%). There were significant associations between high-risk sexual behavior and the presence of co-morbidities with abnormal vaginal discharge. Conclusion The most common causes of abnormal vaginal discharge were found to be bacterial vaginosis followed by vulvovaginal candidiasis. The study results help to initiate early appropriate treatment for effective management of a community health problem.

An Automated Pipeline for Differential Cell Counts on Whole-Slide Bone Marrow Aspirate Smears.

The pathologic diagnosis of bone marrow disorders relies in part on the microscopic analysis of bone marrow aspirate (BMA) smears and the manual counting of marrow nucleated cells to obtain a differential cell count (DCC). This manual process has significant limitations, including the analysis of only a small subset of optimal slide areas and nucleated cells, as well as interobserver variability due to differences in cell selection and classification. To address these shortcomings, we developed an automated machine learning-based pipeline for obtaining 11-component DCCs on whole-slide BMAs. This pipeline uses a sequential process of identifying optimal BMA regions with high proportions of marrow nucleated cells, detecting individual cells within these optimal areas, and classifying these cells into 1 of 11 DCC components. Convolutional neural network models were trained on 396,048 BMA region, 28,914 cell boundary, and 1,510,976 cell class images from manual annotations. The resulting automated pipeline produced 11-component DCCs that demonstrated a high statistical and diagnostic concordance with manual DCCs among a heterogeneous group of testing BMA slides with varying pathologies and cellularities. Additionally, we demonstrated that an automated analysis can reduce the intraslide variance in DCCs by analyzing the whole slide and marrow nucleated cells within all optimal regions. Finally, the pipeline outputs of region classification, cell detection, and cell classification can be visualized using whole-slide image analysis software. This study demonstrates the feasibility of a fully automated pipeline for generating DCCs on scanned whole-slide BMA images, with the potential for improving the current standard of practice for utilizing BMA smears in the laboratory analysis of hematologic disorders.

Ankle Swelling in Patients With Type 1 Neurofibromatosis: A Report of Two Cases With Rare Presentation of Common Genodermatosis.

Neurofibromatosis type 1 is characterized by multiple cutaneous neurofibromas of varying sizes along with skeletal, neurologic, and ophthalmic features. Solitary swellings in neurofibromatosis type 1 are not commonly encountered except in the form of plexiform neurofibromas. We report two cases with neurofibromatosis type 1 presenting with solitary swelling in the ankles which were proven to be the diffuse type of neurofibroma, radiologically and histopathologically. Diffuse type neurofibroma presenting as ankle swelling in type 1 neurofibromatosis has not been reported before.

Tumour-associated macrophages exhibit anti-tumoural properties in Sonic Hedgehog medulloblastoma.

Medulloblastoma, which is the most common malignant paediatric brain tumour, has a 70% survival rate, but standard treatments often lead to devastating life-long side effects and recurrence is fatal. One of the emerging strategies in the search for treatments is to determine the roles of tumour microenvironment cells in the growth and maintenance of tumours. The most attractive target is tumour-associated macrophages (TAMs), which are abundantly present in the Sonic Hedgehog (SHH) subgroup of medulloblastoma. Here, we report an unexpected beneficial role of TAMs in SHH medulloblastoma. In human patients, decreased macrophage number is correlated with significantly poorer outcome. We confirm macrophage anti-tumoural behaviour in both ex vivo and in vivo murine models of SHH medulloblastoma. Taken together, our findings suggest that macrophages play a positive role by impairing tumour growth in medulloblastoma, in contrast to the pro-tumoural role played by TAMs in glioblastoma, another common brain tumour.