Incidence of ocular surface squamous neoplasia in pterygium specimens.

OBJECTIVE: Pterygium and ocular surface squamous neoplasia (OSSN) have been recognized as likely related conditions and share similar risk factors such as ultraviolet radiation and chronic inflammation. The purpose of this study is to review the incidence of OSSN in pathology specimens sent as pterygium at a single tertiary centre between 2010 and 2022. METHODS: This is a retrospective chart review of patients operated on for pterygium between 2010 and 2022 at the University of Montreal Health Centre. Data collected include baseline demographics, results of pathology specimen, and clinical information for cases diagnosed as OSSN on pathology. RESULTS: A total of 1559 patients were operated on for a clinical diagnosis of pterygium between 2010 and 2022, of which 854 patients (55%) were male. A total of 1142 specimens had available pathology reports, and most of the specimens were consistent with pterygium on pathology (1105 of 1142; 97%). There was an unexpected finding of 3 cases of OSSN (3 of 1142; 0.3%). Other diagnosis besides pterygium were seen in 3% of specimens (34 of 1142), including nevus (n = 12), spheroidal degeneration (n = 3), pyogenic granuloma (n = 3), and lymphangiectasia (n = 2). The 3 cases of OSSN included an 81-year-old male of French-Canadian background, a 52-year-old male of South Asian background, and a 59-year-old female of French-Canadian background. The pathology was diagnosed as conjunctival intraepithelial neoplasia (CIN) grade 3, CIN grade 2, and CIN grade 2, respectively. CONCLUSION: The finding of OSSN in pterygium is rare in our population but can be clinically difficult to distinguish. It is important to send all pterygium specimens for pathology.

The policy case for designating EMS teams for vulnerable patient populations: Evidence from an intervention in Boston.

This study documents more than five years of analysis that drove the policy case, deployment, and retrospective evaluation for an innovative service model that enables Boston Emergency Medical Services (EMS) to respond quickly and effectively to investigation incidents in an area of heavy need in Boston. These investigation incidents are typically calls for service from passers-by or other third-party callers requesting that Boston EMS check in on individuals, often those who may appear to have an altered mental status or to be unhoused. First, this study reports the pre-intervention analytics in 2017 that built the policy case for service segmentation, a new Community Assistance Team designated "Squad 80" that primarily responds to investigation incidents in one broad area of the city with high rates of substance abuse and homelessness, helping patients who often refuse ambulance transport connect to social services. Second, this study reports a post-intervention, observational evaluation of its operational advantages and trade-offs. We observe that incidents involving the Community Assistance Team have significantly shorter response times and result in fewer transports to emergency departments than investigation incidents not involving the unit, leading to fewer ambulance unit-hours utilized across the system. This study documents the descriptive analytics that built the successful policy case for a substantive change in the healthcare-delivery supply chain in Boston and how this change offers operational advantages. It is written to be an accessible guide to the analysts and policy makers considering emergency services segmentation, an important frontier in equitable public-service delivery.

Policy-Relevant Indicators of Urban Emergency Medical Services COVID-19-Patient Encounters.

In the first two years of the COVID-19 pandemic, members of Boston Emergency Medical Services, the City of Boston's municipal ambulance service, had 7,689 encounters with confirmed-positive Boston residents. As COVID-19 virus strains continue to infect residents in Boston and across the country, understanding the correlation between population positivity, EMS encounters, and hospitalizations can inform healthcare response. This study examines urban virus-surveillance indicators that can serve as an early warning of the volume of Emergency Medical Services (EMS) encounters with COVID-19 positive patients and subsequently how EMS encounters with confirmed COVID-19 patients can serve as an early indicator of future hospital-demand surges. With daily data from Boston EMS and three other public agencies, we evaluate the relationship between five indicators and confirmed Boston EMS COVID-19 encounters by estimating separate Auto Regressive Integrated Moving Average models and cross-correlating their residuals. This study finds a significant and positive correlation between new COVID-19 cases citywide and EMS encounters 6 days later (p < 0.01), as well as between confirmed EMS encounters with COVID-19 patients and the number of intensive care unit beds occupied 7- and 18 -days later (p < 0.01). This study provides city health leadership needed clarity on the specific ordering and associated time lag in which infections in the population increase, EMS members encounter positive patients, and hospitals deliver care.

Worse Cardiac Arrest Outcomes During The COVID-19 Pandemic In Boston Can Be Attributed To Patient Reluctance To Seek Care.

Delays in seeking emergency care stemming from patient reluctance may explain the rise in cases of out-of-hospital cardiac arrest and associated poor health outcomes during the COVID-19 pandemic. In this study we used emergency medical services (EMS) call data from the Boston, Massachusetts, area to describe the association between patients' reluctance to call EMS for cardiac-related care and both excess out-of-hospital cardiac arrest incidence and related outcomes during the pandemic. During the initial COVID-19 wave, cardiac-related EMS calls decreased (-27.2 percent), calls with hospital transportation refusal increased (+32.5 percent), and out-of-hospital cardiac arrest incidence increased (+35.5 percent) compared with historical baselines. After the initial wave, although cardiac-related calls remained lower (-17.2 percent), out-of-hospital cardiac arrest incidence remained elevated (+24.8 percent) despite fewer COVID-19 infections and relaxed public health advisories. Throughout Boston's fourteen neighborhoods, out-of-hospital cardiac arrest incidence was significantly associated with decreased cardiac-related calls, but not with COVID-19 infection rates. These findings suggest that patients were reluctant to obtain emergency care. Efforts are needed to ensure that patients seek timely care both during and after the pandemic to reduce potentially avoidable excess cardiovascular disease deaths.

Cyanoacrylate Tissue Adhesive for the Treatment of Corneal Thinning and Perforations: A Multicenter Study.

PURPOSE: To examine the outcomes of cyanoacrylate tissue adhesive (CTA) application for impending or frank corneal perforations and assess for predictors of treatment response. METHODS: A multicenter cohort study was conducted to assess the clinical outcomes of adult patients who underwent CTA gluing for impending or frank corneal perforations between 2013 and 2018. The primary outcome was the proportion of successful CTA applications, defined as tectonic stability of the globe without subsequent keratoplasty (KP). Secondary outcomes included visual acuity and success of subsequent surgical interventions, if performed. RESULTS: Fifty-three eyes of 52 patients were included in this study [56% women; mean age at presentation 70 ± 13 years; median length of follow-up of 387 days (interquartile range: 191-704)]. Medical comorbidities were present in 62% of patients. The most common etiologies for perforations included infections (43%) and Sjogren disease (9%). Of the CTA-treated eyes, 22% had a complete resolution of the corneal lesion. Fifty-four percent of patients underwent KP. Longer duration of CTA treatment was associated with CTA success (P = 0.04). For patients requiring KP, 71% were successful and 29% failed. There is no significant difference in the median time delay between patients with successful and failed KPs (P = 0.4). CONCLUSIONS: CTA may be considered a stand-alone treatment for corneal perforations. It yielded a success rate of 22%. Failed CTA treatment occurred quickly, largely because of the severity of presentation. In cases requiring KP, the delay between glue application and surgery did not influence the PK success.

Going Out on a Limb: Do Not Delay Diagnosis of Necrotizing Fasciitis in Varicella Infection.

Necrotizing fasciitis (NF) is a rare complication of varicella zoster (chicken pox) infection. Its diagnosis can be delayed or missed, which increases mortality and morbidity, because it initially presents similarly to cellulitis. We present the case of a 5-year-old boy who presented with a swollen leg, the difficulties in the diagnosis of NF, and a review of the literature. Necrotizing fasciitis complicating varicella zoster in children is associated with 3.4% mortality, although this rises to 13.6% in streptococcal toxic shock syndrome. Seventy-one percent of cases are confirmed as being caused by group A ß-hemolytic Streptococcus. The association of NF with chicken pox is discussed along with the difficulties in diagnosis and treatment options. Necrotizing fasciitis is a surgical emergency and should be considered by all emergency department acute care practitioners in cases of varicella in which fever is enduring and swelling or pain is disproportionate. Because of the difficulty in diagnosis, senior opinion should be sought early.

Optic pathway gliomas in patients with neurofibromatosis type 1: follow-up of 44 patients.

BACKGROUND: Children born with neurofibromatosis type 1 (NF1) have an increased risk of developing optic pathway gliomas (OPGs) during childhood. The aim of this study is to evaluate the clinical course of NF1 patients with OPGs at our institution with respect to visual and endocrinologic morbidity. METHODS: Retrospective case series of patients with OPGs and NF1 seen at the Montreal Children's Hospital, where screening imaging is performed on all NF1 patients. Details on patient demographics, tumor location, and progression of disease were recorded. RESULTS: Of 331 NF1 patient charts reviewed, 44 had confirmed OPG (13%). Average follow-up was 7 years. Mean age at presentation was 6 years, with 16 patients (36%) presenting past age 6. A total of 8 patients were symptomatic secondary to the OPG (defined as decreased vision or precocious puberty), with 5 of the 8 patients receiving treatment. These 8 patients all demonstrated chiasmal and/or retrochiasmal tumor in addition to nerve involvement. Final visual acuity was 20/40 or better in both eyes in 34 patients (77%); central, steady, and maintained in 3 preverbal children; and decreased vision secondary to OPG in 4 children (9%). CONCLUSIONS: OPGs can present and progress beyond the preschool years, and children should be screened with clinical ophthalmological examinations accordingly. The location of OPG as demonstrated on magnetic resonance imaging (MRI) cannot be used as a prognostic indicator because visual outcomes were similar between optic nerve/chiasmal and retrochiasmal tumors.

Traumatic disruption of the optic chiasm.

A 27-year-old man developed a persistent bitemporal hemianopia after severe head trauma sustained in a high-speed motor vehicle accident. The initial brain MRI revealed hemorrhagic contusion of the optic chiasm. A brain MRI performed 4 weeks later demonstrated complete chiasmal transection, a phenomenon rarely documented with imaging.

Immunohistochemical expression of phospho-Akt in uveal melanoma.

The aim of this study was to evaluate the immunohistochemical expression of phospho-Akt and its possible association with clinicopathological features in uveal melanoma. Thirty-four enucleated eyes from 34 patients with choroidal melanoma were included in the study. Patients were divided into two groups based on the treatment received: (1) primary enucleation (n=18); (2) radiotherapy, either external beam or brachytherapy, and enucleation (n=16). Clinicopathological data were obtained. The minimum follow-up time was 72 months. Immunohistochemistry for phospho-Akt was performed using an anti-phospho-Akt (Ser 473) rabbit antibody. The association of phospho-Akt with clinicopathological parameters was investigated in each patient group separately. Phospho-Akt immunostaining was cytoplasmic in both groups. In the primary enucleation group, 10 tumours were phospho-Akt positive (55.5%). Patients with phospho-Akt-positive tumours were older (average 70.8 years versus 59 years, P=0.01) and phospho-Akt immunoreactivity was significantly associated with a higher risk of metastatic disease (Kaplan-Meier analysis, P=0.02). In the radiotherapy and enucleation group, nine tumours were phospho-Akt positive (56.2%). The absence of phospho-Akt expression was correlated with male gender (P=0.02). The following conclusions can be drawn from this study: (1) phospho-Akt immunoexpression was detected in 55.5% of uveal melanomas treated with primary enucleation and in 56.2% of uveal melanomas treated with radiotherapy and enucleation; (2) the association of phospho-Akt immunoexpression with clinicopathological features, including prognosis, merits further study.

Idiopathic intracranial hypertension and sickle cell disease: two case reports.

CASE REPORT: Two patients with sickle cell disease presented with headaches and visual disturbances, typical complaints of this disorder. However, prompt diagnosis of idiopathic intracranial hypertension and initiation of medical therapy lead to improved symptoms and restored vision. Ophthalmologists should consider sickle cell disease to be an independent risk factor for idiopathic intracranial hypertension when a patient is being assessed for visual disturbances. COMMENTS: Although a rare condition, idiopathic intracranial hypertension has several key signs useful in establishing a diagnosis. It is critical to recognize the warning signs and symptoms to prevent devastating ophthalmologic complications. We report the first cases of idiopathic intracranial hypertension in patients with the novel Quebec-Chori beta-chain variant of sickle cell disease.

Leveraging the nation's anti-bioterrorism investments: foundation efforts to ensure a revitalized public health system.

The emerging potential threats of bioterrorism combined with critical existing epidemics facing the United States call for immediate and urgent attention to the U.S. public health system. The foundation world is helping to answer that call and is sounding the alarm that our health defenses must be able to do "double duty" to protect us from the full spectrum of modern health threats. This Special Report presents a selective sample of recent and ongoing grant activities designed to revitalize and modernize the public health infrastructure, which is vital to protecting the nation's health and ensuring its safety.

Distribution of NTS3 receptor/sortilin mRNA and protein in the rat central nervous system.

The neurotensin (NT) receptor, NTS3, originally identified as the intracellular sorting protein sortilin, is a member of a recently discovered family of receptors characterized by a single transmembrane domain. The present study provides the first comprehensive description of the distribution of NTS3/sortilin mRNA and protein in adult rat brain using in situ hybridization and immunocytochemistry. Both NTS3/sortilin mRNA and immunoreactivity displayed a widespread distribution throughout the brain. High levels of NTS3/sortilin expression and immunoreactivity were found in neuronal cell bodies and dendrites of allocortical areas such as the piriform cortex and hippocampus. Regions expressing both high levels of NTS3/sortilin mRNA and protein also included several neocortical areas, the islands of Calleja, medial and lateral septal nuclei, amygdaloid nuclei, thalamic nuclei, the supraoptic nucleus, the substantia nigra, and the Purkinje cell layer of the cerebellar cortex. In the brainstem, all cranial nerve motor nuclei were strongly labeled. NTS3/sortilin mRNA and immunoreactivity were also detected over oligodendrocytes in major fiber tracts. Subcellularly, NTS3/sortilin was predominantly concentrated over intracytoplasmic membrane-bound organelles. Many of the areas exhibiting high levels of NTS3/sortilin (e.g., olfactory cortex, medial septum, and periaqueductal gray) have been documented to contain high concentrations of NT nerve cell bodies and axons, supporting the concept that NTS3/sortilin may play a role in NT sorting and/or signaling. Other areas (e.g., hippocampal CA fields, cerebellar cortex, and cranial nerve motor nuclei), however, are NT-negative, suggesting that NTS3/sortilin also exerts functions unrelated to NT signaling.