Predicting serious complications in patients with cancer and pulmonary embolism using decision tree modelling: the EPIPHANY Index.

BACKGROUND: Our objective was to develop a prognostic stratification tool that enables patients with cancer and pulmonary embolism (PE), whether incidental or symptomatic, to be classified according to the risk of serious complications within 15 days. METHODS: The sample comprised cases from a national registry of pulmonary thromboembolism in patients with cancer (1075 patients from 14 Spanish centres). Diagnosis was incidental in 53.5% of the events in this registry. The Exhaustive CHAID analysis was applied with 10-fold cross-validation to predict development of serious complications following PE diagnosis. RESULTS: About 208 patients (19.3%, 95% confidence interval (CI), 17.1-21.8%) developed a serious complication after PE diagnosis. The 15-day mortality rate was 10.1%, (95% CI, 8.4-12.1%). The decision tree detected six explanatory covariates: Hestia-like clinical decision rule (any risk criterion present vs none), Eastern Cooperative Group performance scale (ECOG-PS; <2 vs ⩾2), O2 saturation (<90 vs ⩾90%), presence of PE-specific symptoms, tumour response (progression, unknown, or not evaluated vs others), and primary tumour resection. Three risk classes were created (low, intermediate, and high risk). The risk of serious complications within 15 days increases according to the group: 1.6, 9.4, 30.6%; P<0.0001. Fifteen-day mortality rates also rise progressively in low-, intermediate-, and high-risk patients: 0.3, 6.1, and 17.1%; P<0.0001. The cross-validated risk estimate is 0.191 (s.e.=0.012). The optimism-corrected area under the receiver operating characteristic curve is 0.779 (95% CI, 0.717-0.840). CONCLUSIONS: We have developed and internally validated a prognostic index to predict serious complications with the potential to impact decision-making in patients with cancer and PE.

The prognostic impact of additional intrathoracic findings in patients with cancer-related pulmonary embolism.

AIM: To assess the prevalence and prognostic significance of additional intrathoracic findings (AIFs) in patients with cancer and pulmonary embolism (PE). AIFs were considered alterations other than the characteristic ones intrinsic to PE or changes in cardiovascular morphology. METHODS: Subjects have been taken from a Spanish national multidisciplinary and multicenter study of PE and cancer who were treated between 2004 and 2015. The endpoint was the appearance of serious complications or death within 15 days. RESULTS: The registry contains 1024 eligible patients; 41% diagnosed by computed tomography pulmonary angiography versus 59% by non-angiographic CT. Serious complications occurred within 15 days in 18.9%, [95% confidence interval (CI), 16.6-21.4%] and 9.5% (95% CI 7.9-11.5%) died. At least one AIF was seen in 72.6%. The most common AIFs were as follows: pulmonary nodules (30.9%), pleural effusion (30.2%), tumor progression (28.3%), atelectasis (19.0%), pulmonary infarct (15.2%), emphysema (13.4%), pulmonary lymphangitic carcinomatosis (4.5%), and pneumonia (6.1%). Patients with AIF exhibited a higher complication rate at 15 days: 21.9% versus 13.0%, odds ratio (OR) 1.8 (95% CI 1.2-2.8), P = 0.03, and 15-day mortality: 15.0% versus 7.3%, OR 1.9 (95% CI 1.1-3.2), P = 0.020. Patients with pneumonia, pneumothorax, pulmonary edema, pulmonary nodules, tumor progression, pulmonary fibrosis, and pleural effusion showed an excess of adverse events. CONCLUSIONS: Additional intrathoracic findings are highly prevalent and significantly impact prognosis in patients with PE and cancer, making them germane to the classification of this population.

Keratolimbal autograft transplantation as a possible new treatment of Lisch epithelial corneal dystrophy. / Trasplante autólogo de limbo como nuevo tratamiento de la distrofia corneal epitelial de Lisch.

CASE REPORT: The case concerns 64-year-old woman with visual acuity of 20/40 in the right eye. Slit-lamp examination revealed a grey, feathery corneal opacification with intraepithelial microcysts compatible with Lisch epithelial corneal dystrophy (LECD). It was treated with epithelial debridements, contact lenses and mitomycin C, but the opacification recurred within months. The removal of limbus sector and autologous limbal transplantation (KLAT) were used successfully without recurrence. CONCLUSIONS: After removal of damaged limbus, KLAT should be considered as a treatment option for asymmetric LECD when other treatments have failed.

Factors Associated with HPV Vaccine Awareness in a Population-Based Sample of Hispanic Women in Puerto Rico.

OBJECTIVES: The objective of this study was to investigate the factors associated with HPV awareness among women aged 16 to 64 years, among underserved minority Hispanic women living in Puerto Rico. METHODS: A population-based, cross-sectional sample of 566 women, ages 16 to 64 years, living in the San Juan metropolitan area were surveyed regarding sexual behavior, HPV knowledge, and HPV vaccine uptake. Data was analyzed using descriptive statistics and multivariate logistic regression. RESULTS: Overall, 64.8 % of the women in the sample had heard about the HPV vaccine. Among those in the recommended catch-up vaccination age range (16-26 years, n = 86), 4.7 % had received at least one dose of the HPV vaccine. Of those aware of the availability of the HPV vaccine, most had learned about it through the media, whereas, only 39.6 % had learned about it from a physician. Multivariate logistic regression analysis showed that HPV awareness (OR 8.6; 95 % CI 5.0-14.8) and having had an abnormal Pap smear (OR 2.0; 95 % CI 1.2-3.4) were associated with HPV vaccine awareness (p < 0.05). CONCLUSION: HPV vaccine awareness among Hispanic women in the San Juan metropolitan area of Puerto Rico continues to be low. Strong recommendations from physicians and participation in HPV vaccine educational efforts are essential if the rate of HPV vaccination is to increase in the targeted population. Compared to the USA, and to their US Hispanic counterparts, a health disparity with regard to HPV vaccine awareness and coverage is evident in Puerto Rico; targeted action to deal with this disparity is urgently needed.

On the necessity of new decision-making methods for cancer-associated, symptomatic, pulmonary embolism.

BACKGROUND: Acute symptomatic pulmonary embolism (PE) varies in its clinical manifestations in patients with cancer and entails specific issues. The objective is to assess the performance of five scores (PESI, sPESI, GPS, POMPE, and RIETE) and a clinical decision rule to predict 30-day mortality. METHODS: This is an ambispective, observational, multicenter study that collected episodes of PE in patients with cancer from 13 Spanish centers. The main criterion for comparing scales was the c-indices and 95% confidence intervals (CIs) of the models for predicting 30-day mortality. RESULTS: 585 patients with acute symptomatic PE were recruited. The 30-day mortality rate was 21.3 (95% CI; 18.2-24.8%). The specific scales (POMPE-C and RIETE) were equally effective in discriminating prognosis (c-index of 0.775 and 0.757, respectively). None of these best performing scales was superior to the ECOG-PS with a c-index of 0.724. The remaining scores (PESI, sPESI, and GPS) performed worse, with c-indexes of 0.719, 0.705, and 0.722, respectively. The dichotomic "clinical decision rule" for ambulatory therapy was at least equally reliable in defining a low risk group: in the absence of all exclusion criteria, 30-day mortality was 2%, compared to 5% and 4% in the POMPE-C and RIETE low-risk categories, respectively. CONCLUSION: The accuracy of the five scales examined was not high enough to rely on to predict 30-day mortality and none of them contribute significantly to qualitative clinical judgment.

Keratitis caused by Absidia corymbifera in an immunocompetent male with no corneal injuries.

Case Report A healthy 55-years-old male went to emergency due to a white infiltrate in the left eye without corneal trauma which partially responds to antibiotic treatment. The infiltrate worsened by the use of topical steroids. Direct microscopic evaluation and Gram stain are a valuable diagnostic tool for the detection of Absidia filaments. There is a successful treatment with anphotericin and posaconazole. Discussion Keratitis caused by Zygomicetes are unusual. This is a rare condition in healthy patients with no corneal trauma. The treatment with amphotericin and posaconazole are synergistic against filamentous fungi.

Amblyopia secondary to iris cyst.

CLINICAL CASE: A 5 year-old child diagnosed with moderate anisometropic amblyopia secondary to primary cyst of iris pigment epithelium. He was evaluated with ultrasound biomicroscopy (BMU) and optical coherence tomography (OCT) of anterior segment. DISCUSSION: The OCT, although with some limitations, is a useful tool to study the anterior segment. It is probably more recommendable than BMU in the childhood.

[Relationship between donor-receptor interface and visual acuity in DSAEK]. / Relación entre la interfase donante/receptor y la agudeza visual en trasplante corneal tipo DSAEK.

OBJECTIVE: To evaluate the relationship between best corrected visual acuity and donor-recipient interface resulting after Descemet's Stripping with Automated Endothelial Keratoplasty (DSAEK). METHODS: Retrospective review of 46 clinical histories after DSAEK intervention in which 22 patients who fulfilled the inclusion criteria (two with bilateral DSAEK), were studied. All were operated on by the same ophthalmologist from January 2010 until April 2011. Surgical indications were: 19 (72.2%) bullous keratopathy, 3 (12.5%) Fuchs endothelial dystrophy, and 2 (8.3%) previous failed keratoplasty. The visual acuity (VA) was recorded preoperatively, and at three and six months after the operation; the latter two being compared with the interface between donor and recipient after DSAEK measured in a Scheimpflug corneal topography camera (Pentacam(®) model). RESULTS: After DSAEK surgery 19 eyes had improved visual acuity at three months, and 20 eyes at six months (P<.001). This improvement was compared with the decrease in optical density of the resulting donor-receptor interface, with apositive and significant relationship being found between them (Rho interface 3 months, and improved AV 6 months 0.44, P<.001). However, the interface is negatively and significantly related with visual acuity (Rho 3 m: -0.41, P=.045). Also, patients who had a denser stroma had a worse postoperative visual acuity in relative terms when compared with those who had a less damaged stroma. CONCLUSIONS: Patients undergoing DSAEK with worse preoperative visual acuity had a greater improvement visual in absolute values and however, they may have achieved a lower relative visual acuity than could be related to a higher refractive interface, as a result of a more damaged preoperative corneal stroma.

[Corneal toxicity due to amantadine]. / Toxicidad corneal por amantadina.

CASE REPORT: A 64 year-old female with Parkinson disease treated with amantadine for two years who suddenly suffered bilateral corneal oedema. It was initially treated as herpetic endotheliitis without improvement as we lacked information on her chronic treatment. The corneal oedema finally resolved after withdrawing the drug. DISCUSSION: Amantadine hydrochloride may produce endothelial dysfunction. Once the amantadine treatment is stopped, the corneal oedema may be reversible but endothelial density remains low. An ophthalmologist examination should be performed before the initiation of amantadine treatment in order to establish a risk: benefit ratio, especially in those patients with low endothelial density or any endothelial anomaly.

The prognostic impact of additional intrathoracic findings in patients with cancer-related pulmonary embolism

Aim. To assess the prevalence and prognostic significance of additional intrathoracic findings (AIFs) in patients with cancer and pulmonary embolism (PE). AIFs were considered alterations other than the characteristic ones intrinsic to PE or changes in cardiovascular morphology. Methods. Subjects have been taken from a Spanish national multidisciplinary and multicenter study of PE and cancer who were treated between 2004 and 2015. The endpoint was the appearance of serious complications or death within 15 days. Results. The registry contains 1024 eligible patients; 41% diagnosed by computed tomography pulmonary angiography versus 59% by non-angiographic CT. Serious complications occurred within 15 days in 18.9%, [95% confidence interval (CI), 16.6-21.4%] and 9.5% (95% CI 7.9-11.5%) died. At least one AIF was seen in 72.6%. The most common AIFs were as follows: pulmonary nodules (30.9%), pleural effusion (30.2%), tumor progression (28.3%), atelectasis (19.0%), pulmonary infarct (15.2%), emphysema (13.4%), pulmonary lymphangitic carcinomatosis (4.5%), and pneumonia (6.1%). Patients with AIF exhibited a higher complication rate at 15 days: 21.9% versus 13.0%, odds ratio (OR) 1.8 (95% CI 1.2-2.8), P = 0.03, and 15-day mortality: 15.0% versus 7.3%, OR 1.9 (95% CI 1.1-3.2), P = 0.020. Patients with pneumonia, pneumothorax, pulmonary edema, pulmonary nodules, tumor progression, pulmonary fibrosis, and pleural effusion showed an excess of adverse events. Conclusions. Additional intrathoracic findings are highly prevalent and significantly impact prognosis in patients with PE and cancer, making them germane to the classification of this population (AU)

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Toxicidad corneal por amantadina / Corneal toxicity due to amantadine

Caso clínico: Mujer de 64 años en tratamiento con amantadina durante 2 años por enfermedad de Parkinson, que presentó edema corneal bilateral de inicio brusco. Inicialmente se trató como una endotelitis herpética sin mejoría, al desconocer la medicación empleada por la enferma. Finalmente el edema se resolvió tras la suspensión del fármaco. Discusión: El hidrocloruro de amantadina puede producir disfunción endotelial. El edema corneal puede ser reversible tras su suspensión, pero la densidad endotelial permanece baja. Sería necesario realizar un control oftalmológico previo al inicio del tratamiento para valorar el riesgo/beneficio del mismo, sobre todo en los pacientes que presenten baja densidad endotelial o un endotelio alterado (AU)

Case report: A 64 year-old female with Parkinson disease treated with amantadine for two years who suddenly suffered bilateral corneal oedema. It was initially treated as herpetic endotheliitis without improvement as we lacked information on her chronic treatment. The corneal oedema finally resolved after withdrawing the drug. Discussion: Amantadine hydrochloride may produce endothelial dysfunction. Once the amantadine treatment is stopped, the corneal oedema may be reversible but endothelial density remains low. An ophthalmologist examination should be performed before the initiation of amantadine treatment in order to establish a risk: benefit ratio, especially in those patients with low endothelial density or any endothelial anomaly (AU)

Queratitis por Absidia corymbifera en paciente inmunocompetente sin traumatismo corneal previo / Keratitis caused by Absidia corymbifera in an immunocompetent male with no corneal injuries

CASO CLÍNICO: Varón sano de 55 años sin antecedente de traumatismo corneal acude a urgencias por un infiltrado en el ojo izquierdo que responde parcialmente a tratamiento antibiótico tópico. Tras la introducción de corticoterapia tópica presenta un importante empeoramiento de la úlcera. El examen directo y la tinción de Gram permiten un rápido diagnóstico de las hifas de Absidia. Presenta buena respuesta al tratamiento combinado de anfotericina y posaconazol. DISCUSIÓN: Las queratitis por Zygomycetes son raras. Es rara la afectación de pacientes sanos sin antecedentes de traumatismo corneal. El tratamiento combinado de anfotericina y posaconazol ejerce un efecto sinergico contra hongos filamentosos

CASE REPORT: A healthy 55-years-old male went to emergency due to a white infiltrate in the left eye without corneal trauma which partially responds to antibiotic treatment. The infiltrate worsened by the use of topical steroids. Direct microscopic evaluation and Gram stain are a valuable diagnostic tool for the detection of Absidia filaments. There is a successful treatment with anphotericin and posaconazole. DISCUSSION: Keratitis caused by Zygomicetes are unusual. This is a rare condition in healthy patients with no corneal trauma. The treatment with amphotericin and posaconazole are synergistic against filamentous fungi

Ambliopía secundaria a quiste de iris / Amblyopia secondary to iris cyst

CASO CLÍNICO: Varón de 5 años de edad con ambliopía anisometrópica meridional secundaria a quiste de epitelio pigmentario de iris. Es evaluado mediante biomicroscopia ultrasónica (BMU) y tomografía de coherencia óptica de polo anterior (OCT Visante). DISCUSIÓN: La OCT de polo anterior, aunque con limitaciones, es una herramienta útil en la evaluación de lesiones de polo anterior. Puede ser preferible, en la infancia, a la BMU

CLINICAL CASE: A 5 year-old child diagnosed with moderate anisometropic amblyopia secondary to primary cyst of iris pigment epithelium. He was evaluated with ultrasound biomicroscopy (BMU) and optical coherence tomography (OCT) of anterior segment. DISCUSSION: The OCT, although with some limitations, is a useful tool to study the anterior segment. It is probably more recommendable than BMU in the childhood (AU)

Relación entre la interfase donante/receptor y la agudeza visual en trasplante corneal tipo DSAEK / Relationship between donor-receptor interface and visual acuity in DSAEK

Objetivo: Evaluar la relación entre la agudeza visual (AV) mejor corregida y la interfase donante-receptor resultante tras realizar una queratoplastia endotelial automatizada con pelado de la membrana de Descemet (DSAEK). Métodos: Se revisaron 46 historias clínicas de pacientes intervenidos con técnica DSAEK, de las cuales cumplían criterios de inclusión 22 pacientes (dos de ellos con DSAEK bilateral). Todos ellos fueron intervenidos por un mismo oftalmólogo desde enero del 2010 hasta abril del 2011. Las indicaciones quirúrgicas fueron: queratopatía bullosa 19 (72,2%), distrofia endotelial de Fuchs tres (12,5%) y agotamiento endotelial tras queratoplastia previa dos (8,3%).Se recogió la AV preoperatoria y al tercer y sexto mes postoperatorio, comparándose en estas dos últimas la interfase existente entre donante y receptor tras DSAEK medida en cámara Scheimpflug de topógrafo corneal (Pentacam-HR, Oculus®, Wetzlar, Alemania). Resultados: Tras la cirugía con DSAEK, la mejora en la AV fue en 19 ojos al tercer mes y en 20 ojos al sexto mes postoperatorio (p < 0,001). Dicho cambio en la AV se comparó con la disminución de la densidad óptica de la interfase donante-receptor resultante, encontrando una relación positiva y significativa entre estas (Rho interfase 3 meses y cambio de AV 6 meses: 0,44; p < 0,001). Sin embargo, la interfase se relacionó negativa y significativamente con la AV (Rho 3 m: –0,41; p = 0,045). Además, los pacientes que presentaban un estroma más denso conseguían AV postoperatorias peores en términos relativos si se comparaban con los que presentaban un estroma menos dañado. Conclusiones: Los pacientes sometidos a DSAEK con AV prequirúrgicas peores experimentan una mejora visual mayor en valores absolutos y, sin embargo, alcanzarían una AV menor relativa que se podría relacionar con una interfase más refringente, como consecuencia de un estroma corneal preoperatorio más alterado (AU)

Objective: To evaluate the relationship between best corrected visual acuity and donor-recipient interface resulting after Descemet's Stripping with Automated Endothelial Keratoplasty (DSAEK). Methods: Retrospective review of 46 clinical histories after DSAEK intervention in which 22 patients who fulfilled the inclusion criteria (two with bilateral DSAEK), were studied. All were operated on by the same ophthalmologist from January 2010 until April 2011. Surgical indications were: 19 (72.2%) bullous keratopathy, 3 (12.5%) Fuchs endothelial dystrophy, and 2 (8.3%) previous failed keratoplasty.The visual acuity (VA) was recorded preoperatively, and at three and six months after the operation; the latter two being compared with the interface between donor and recipient after DSAEK measured in a Scheimpflug corneal topography camera (Pentacam® model). Results: After DSAEK surgery 19 eyes had improved visual acuity at three months, and 20 eyes at six months (P < 0.001). This improvement was compared with the decrease in optical density of the resulting donor-receptor interface, with apositive and significant relationship being found between them (Rho interface 3 months, and improved AV 6 months 0.44, P <0 .001). However, the interface is negatively and significantly related with visual acuity (Rho 3 m: –0.41, P = 0.045). Also, patients who had a denser stroma had a worse postoperative visual acuity in relative terms when compared with those who had a less damaged stroma. Conclusions: Patients undergoing DSAEK with worse preoperative visual acuity had a greater improvement visual in absolute values and however, they may have achieved a lower relative visual acuity than could be related to a higher refractive interface, as a result of a more damaged preoperative corneal stroma (AU)