Prediction of retinopathy progression using deep learning on retinal images within the Scottish screening programme

BACKGROUND/AIMS

National guidelines of many countries set screening intervals for diabetic retinopathy (DR) based on grading of the last screening retinal images. We explore the potential of deep learning (DL) on images to predict progression to referable DR beyond DR grading, and the potential impact on assigned screening intervals, within the Scottish screening programme.

METHODS

We consider 21 346 and 247 233 people with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), respectively, each contributing on average 4.8 and 4.4 screening intervals of which 1339 and 4675 intervals concluded with a referable screening episode. Information extracted from fundus images using DL was used to predict referable status at the end of interval and its predictive value in comparison to screening-assigned DR grade was assessed.

RESULTS

The DL predictor increased the area under the receiver operating characteristic curve in comparison to a predictor using current DR grades from 0.809 to 0.87 for T1DM and from 0.825 to 0.87 for T2DM. Expected sojourn time-the time from becoming referable to being rescreened-was found to be 3.4 (T1DM) and 2.7 (T2DM) weeks less for a DL-derived policy compared with the current recall policy.

CONCLUSIONS

We showed that, compared with using the current retinopathy grade, DL of fundus images significantly improves the prediction of incident referable retinopathy before the next screening episode. This can impact screening recall interval policy positively, for example, by reducing the expected time with referable disease for a fixed workload-which we show as an exemplar. Additionally, it could be used to optimise workload for a fixed sojourn time.

A retrospective cohort study evaluating pregnancy outcomes in women with MIDD

AIMS

The most common pathogenic mitochondrial mutation associated with mitochondrial disease is m.3243A>G. Increased obstetric complications, such as spontaneous abortion, gestational diabetes (GDM), preterm delivery, and preeclampsia, have been reported in women carrying this mutation. We aimed to determine the fetal and maternal outcomes in pregnant women with mitochondrial disease.

METHODS

We retrospectively studied the obstetric and perinatal outcomes in 88 pregnancies of 26 women with genetically confirmed mitochondrial disease (m.3243A>G in the MTTL1 gene (n = 25); m.12258C>A in the MT-TS2 gene (n = 1)). Outcomes included pregnancy related complications, mode of delivery, gestational age at delivery and birthweight.

RESULTS

Mean heteroplasmy rate was 18%. The miscarriage rate was higher than background at 25%. 21 pregnancies (24%) were complicated by GDM; 9 pregnancies (13.6%) had a preterm delivery and 2 of them (3%) an extreme premature delivery < 32 weeks. One woman had preeclampsia and one had a postpartum hemorrhage. The caesarean section (CS) rate was 20%. For every unit increase in maternal heteroplasmy levels there was a 26% increased risk of undergoing an assisted operative vaginal delivery (OR 1.26, 95% CI 1.04-1.53, P = 0.002, Bonferroni corrected P = 0.005) and an 18% increased risk of undergoing a CS (OR 1.18, 95% CI 1.01-1.39, P = 0.01, Bonferroni corrected P = 0.03) compared to a spontaneous vaginal delivery. There was a statistical significant correlation between maternal and offspring heteroplasmy levels. Spearman correlation rho = 0.96, 95% CI 0.78-0.99, P = 0.0002.

CONCLUSION

Women with mitochondrial disease appear to have more frequent obstetric complications including miscarriage and GDM. Pre-pregnancy diagnosis of m.3243A>G will enable the counseling of women and increase awareness of possible obstetric complications.

The HSPB1-p62/SQSTM1 functional complex regulates the unconventional secretion and transcellular spreading of the HD-associated mutant huntingtin protein

Conformational diseases, such as Alzheimer, Parkinson and Huntington diseases, are part of a common class of neurological disorders characterized by the aggregation and progressive accumulation of proteins bearing aberrant conformations. Huntington disease (HD) has autosomal dominant inheritance and is caused by mutations leading to an abnormal expansion in the polyglutamine (polyQ) tract of the huntingtin (HTT) protein, leading to the formation of HTT inclusion bodies in neurons of affected patients. Interestingly, recent experimental evidence is challenging the conventional view by which the disease pathogenesis is solely a consequence of the intracellular accumulation of mutant protein aggregates. These studies reveal that transcellular transfer of mutated huntingtin protein is able to seed oligomers involving even the wild-type (WT) forms of the protein. To date, there is still no successful strategy to treat HD. Here, we describe a novel functional role for the HSPB1-p62/SQSTM1 complex, which acts as a cargo loading platform, allowing the unconventional secretion of mutant HTT by extracellular vesicles. HSPB1 interacts preferentially with polyQ-expanded HTT compared with the WT protein and affects its aggregation. Furthermore, HSPB1 levels correlate with the rate of mutant HTT secretion, which is controlled by the activity of the PI3K/AKT/mTOR signalling pathway. Finally, we show that these HTT-containing vesicular structures are biologically active and able to be internalized by recipient cells, therefore providing an additional mechanism to explain the prion-like spreading properties of mutant HTT. These findings might also have implications for the turn-over of other disease-associated, aggregation-prone proteins.

Can deep learning on retinal images augment known risk factors for cardiovascular disease prediction in diabetes? A prospective cohort study from the national screening programme in Scotland

AIMS

This study's objective was to evaluate whether deep learning (DL) on retinal photographs from a diabetic retinopathy screening programme improve prediction of incident cardiovascular disease (CVD).

METHODS

DL models were trained to jointly predict future CVD risk and CVD risk factors and used to output a DL score. Poisson regression models including clinical risk factors with and without a DL score were fitted to study cohorts with 2,072 and 38,730 incident CVD events in type 1 (T1DM) and type 2 diabetes (T2DM) respectively.

RESULTS

DL scores were independently associated with incident CVD with adjusted standardised incidence rate ratios of 1.14 (P = 3 × 10^-04 95 % CI (1.06, 1.23)) and 1.16 (P = 4 × 10^-33 95 % CI (1.13, 1.18)) in T1DM and T2DM cohorts respectively. The differences in predictive performance between models with and without a DL score were statistically significant (differences in test log-likelihood 6.7 and 51.1 natural log units) but the increments in C-statistics from 0.820 to 0.822 and from 0.709 to 0.711 for T1DM and T2DM respectively, were small.

CONCLUSIONS

These results show that in people with diabetes, retinal photographs contain information on future CVD risk. However for this to contribute appreciably to clinical prediction of CVD further approaches, including exploitation of serial images, need to be evaluated.

Point prevalence audit surveys of respiratory tract infection consultations and antibiotic prescribing in primary care before and during the COVID-19 pandemic in Ireland

BACKGROUND

Respiratory tract infections (RTIs) are the most common reason for prescribing antibiotics in general practice. The COVID-19 pandemic has impacted on antibiotic prescribing and delivery of primary care in Ireland.

OBJECTIVES

To assess the quality of antibiotic prescribing, the impact of the COVID-19 pandemic and identify opportunities for antimicrobial stewardship (AMS) in Ireland.

METHODS

Point prevalence audit surveys for RTI consultations were conducted as part of a European study at three time periods: January-February 2020, March-May 2020 and March-May 2021. Antibiotic prescribing was assessed and comparisons made between the three time periods.

RESULTS

In total, 765 consultations were recorded, which were mainly face to face before the pandemic, but changed to predominantly remote consultations during the pandemic surveys in 2020 and 2021 (82% and 75%). Antibiotics were prescribed in 54% of RTI consultations before the pandemic. During pandemic surveys, this dropped to 23% in 2020 and 21% in 2021. There was a decrease in prescribing of Red (reserve) agents in 2021. Assessment against indication-specific quality indicators showed a high proportion of consultations for bronchitis and tonsillitis resulting in an antibiotic prescription (67% and 85%). Point-of-care testing (POCT) to aid diagnosis of RTIs were utilized in less than 1% of consultations.

CONCLUSIONS

During the COVID-19 pandemic, there was a reduction in antibiotic prescribing. Opportunities identified to support AMS in primary care in Ireland are targeted initiatives to reduce antibiotic prescribing for bronchitis and tonsillitis and introducing POCT to support appropriate antibiotic prescribing.

Association of Maximizing Visible Retinal Area by Manual Eyelid Lifting With Grading of Diabetic Retinopathy Severity and Detection of Predominantly Peripheral Lesions When Using Ultra-Widefield Imaging

IMPORTANCE

Methods that increase visible retinal area (VRA; measured in millimeters squared) may improve identification of diabetic retinopathy (DR) lesions.

OBJECTIVE

To evaluate the association of dilation and manual eyelid lifting (MLL) with VRA on ultra-widefield imaging (UWFI) and the association of VRA with grading of DR severity and detection of predominantly peripheral lesions (PPLs).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, comparative case-control study at the Joslin Diabetes Center, Boston, Massachusetts. Nonmydriatic UWFI with MLL was acquired from a DR teleophthalmology program (Joslin Vision Network [JVN]). A second cohort of mydriatic UWFI was acquired at an academic retina practice (Beetham Eye Institute [BEI]) from November 6, 2017, to November 6, 2018, and with MLL thereafter until November 6, 2019. Fully automated algorithms determined VRA and hemorrhage and/or microaneurysm (HMA) counts. Predominantly peripheral lesions and HMAs were defined as present when at least 1 field had greater HMA number in the peripheral retina than within the corresponding Early Treatment Diabetic Retinopathy Study field. Participants included 3014 consecutive patients (5919 eyes) undergoing retinal imaging at JVN and BEI.

EXPOSURES

Dilation and MLL performed at the time of UWFI.

MAIN OUTCOMES AND MEASURES

Visible retinal area, DR severity, and presence of PPLs.

RESULTS

Of the 3014 participants, mean (SD) age was 56.1 (14.5) years, 1302 (43.2%) were female, 2450 (81.3%) were White, and mean (SD) diabetes duration was 15.9 (11.4) years. All images from 5919 eyes with UWFI were analyzed. Mean (SD) VRA was 665.1 (167.6) mm2 for all eyes (theoretical maximal VRA, 923.9 mm2), 550.8 (240.7) mm2 for nonmydriatic JVN with MLL (1418 eyes [24.0%]), 688.1 (119.9) mm2 for mydriatic BEI images (3650 eyes [61.7%]), and 757.0 (69.7) mm2 for mydriatic and MLL BEI images (851 eyes [14.4%]). Dilation increased VRA by 25% (P < .001) and MLL increased VRA an additional 10% (P < .001). Nonmydriatic MLL increased VRA by 11.0%. With MLL, HMA counts in UWFI fields increased by 41.7% (from 4.8 to 6.8; P < .001). Visible retinal area was moderately associated with increasing PPL-HMA overall and in each cohort (all, r = 0.33; BEI, r = 0.29; JVN, r = 0.36; P < .001). In JVN images, increasing VRA was associated with more PPL-HMA (quartile 1 [Q1], 23.7%; Q2, 45.8%; Q3, 60.6%; and Q4, 69.2%; P < .001).

CONCLUSIONS AND RELEVANCE

Using fully automated VRA and HMA detection algorithms, pupillary dilation and eyelid lifting were shown to substantially increase VRA and PLL-HMA detection. Given the importance of HMA and PPL for determining risk of DR progression, these findings emphasize the importance of maximizing VRA for optimal risk assessment in clinical trials and teleophthalmology programs.

A feasibility study of a pharmacist led proton pump inhibitor deprescribing intervention in older patients in an Irish hospital

Introduction

Proton pump inhibitors (PPIs) are over-prescribed and prescribed inappropriately in the older population and have the potential for long-term adverse effects e.g. increased fracture risk, C. difficile infection, chronic kidney disease and drug interactions (1). Hospitalisation of older patients presents an opportunity for review of the PPI indication and potential for deprescribing.

Aim

The study aimed to assess the feasibility of a pharmacist led intervention to deprescribe inappropriately prescribed PPIs in patients ≥65 years in an Irish teaching hospital.

Methods

A multi-component feasibility intervention consisting of an education session for the medical team, followed by pharmacist-led screening of patients for potential PPI deprescribing, was conducted. The education session was delivered by the pharmacist to a geriatric medical team and the content outlined the prevalence of PPI prescribing, potential long-term effects of PPIs, and implementation of a PPI deprescribing algorithm. Over an eight-week period (May-June 2021), new admissions to the geriatric team were screened daily by the pharmacist and PPI prescribing patterns and indications were recorded. Patients ≥65 years were reviewed for PPI appropriateness based on their medical history and use of a PPI deprescribing algorithm (2). If the PPI was eligible for deprescribing (i.e. dose reduction or discontinuation) this was discussed with the geriatric team and the patient’s primary care general practitioner (GP) and the patient. Patients were counselled and educated on this by the pharmacist. Patients whose PPI was deprescribed were followed up at 4- and 12- weeks post deprescribing to assess their symptoms and satisfaction with deprescribing in the interim period. An online survey was sent to the geriatric team doctors evaluating their views on the study process and implementation of PPI deprescribing in practice; data was analysed descriptively using Microsoft Excel®. Written, informed consent was obtained from all patients and doctors involved.

Results

Of a total of 133 patient charts reviewed over the 8-week period, 94 patients were prescribed a PPI, with esomeprazole 40mg (43/94, 45.7%) being most commonly prescribed PPI, followed by pantoprazole 40mg (17/94, 18.1%). PPIs were inappropriately prescribed as per the indication in 36 cases (36/94, 38.3%). Following GP and Geriatric team discussion, 7/94 (7.4%) of patients were eligible for deprescribing, of which 5 had their PPI dose reduced (5/94, 5.3%). One patient declined the deprescribing, in another case the GP declined the deprescribing recommendation. The 5 patients deprescribed had their esomeprazole 40mg daily dose reduced to 20mg daily. This was sustained at the 12-week follow up and patients reported satisfaction with the change with no negative outcomes reported.

Of the 12 geriatric doctors in the study, 6 completed the online survey. The majority reported barriers to PPI deprescribing being uncertainty regarding the indication (5/6) and being unable to monitor the patient after hospital discharge (5/6). All doctors agreed that pharmacists have a positive role to play in implementing PPI deprescribing.

Conclusion

This study found that esomeprazole 40mg daily was the most commonly prescribing PPI in this hospital cohort, with the majority of PPI prescribing found to be inappropriate according to the indication. The feasibility study resulted in a number of patients having their PPI safely deprescribed with a dose reduction. Despite the limitation of a small sample size and small rates of deprescribing, a strength of the study was that a pharmacist led PPI deprescribing initiative resulted in reducing inappropriate PPI prescribing in older patients, with positive engagement from the geriatric medical team. Further resources and research are required to implement this initiative on a wider scale.

References

(1) Wilsdon TD, Hendrix I, Thynne TR, Mangoni AA. Effectiveness of Interventions to Deprescribe Inappropriate Proton Pump Inhibitors in Older Adults. Drugs Aging. 2017 Apr;34(4):265-287. doi: 10.1007/s40266-017-0442-1. PMID: 28220380.

(2) National Health Service. Proton Pump Inhibitor (PPI): Deprescribing algorithm (adult) [Internet]. [cited 2021 Aug 6]. Available from: https://www.dorsetccg.nhs.uk/Downloads/aboutus/medicines-management/Other Guidelines/prescqipp proton-pump-inhibitor-desprescribing-algorithm.pdf

Exploring the human factors of medication errors in community pharmacy: a mixed methods study

Introduction

Medication errors and near misses in the community pharmacy dispensing process have the potential to adversely impact patient safety. The World Health Organisation has identified the importance of Human factors (HF) in the Patient Safety Curriculum guide (1). However, there is a lack of knowledge on how HF principles have or could be applied in the community pharmacy setting. Adopting a HF approach and using qualitative methods can provide in-depth understanding of factors that contribute to these errors, and contribute to intervention development that may improve patient safety.

Aim

The study aims to investigate the factors contributing to medication dispensing errors and near misses in community pharmacy, and to gather pharmacists’ views of these factors and how these could be mitigated.

Methods

Three Irish community pharmacies were recruited and provided details of the last ten dispensing errors or near misses which occurred. Each error was mapped to the Hierarchical Task Analysis (HTA) steps developed for this study, and mapped to the Systematic Human Error Reduction and Prediction Approach (SHERPA) framework (2). A detailed report was prepared for each pharmacy outlining the error analysis, with recommendations to prevent the errors in future. A qualitative semi-structured interview was conducted with the three pharmacists in the recruited pharmacies to discuss the report, and analysed by thematic analysis.

Results

A total of 30 medication errors/near misses were analysed (10 errors reached the patients and were not administered). The HTA developed outlines 185 subtasks potentially involved in dispensing a prescribed medication. On mapping to the SHERPA framework, selection-based errors were the most frequently reported error category (21/30, 70%); this included incorrect product selection from the shelf (17/30, 56.7%) and incorrect product selection at the point of computer entry (4/30, 13.3%). Of the 75 HTA steps involved across the 30 errors, the most frequent point of error was in the gathering medication steps (47/75, 62.7%), followed by the pharmacist accuracy check steps (16/75, 21.3%) and patient mix up errors (5/30, 16.7%). The pharmacist interview themes found that cognitive burden, fatigue, distraction and staffing deficiencies were reported as increasing the risk of error and near miss. Knowledge gaps and inexperience with certain medications were also reported as contributing to errors. Recommendations to prevent errors included changes to the physical environment (e.g. using product shelf alerts), improved checking processes and taking short mental breaks.

Conclusion

This study found that the most common errors/near misses were at the product selection stage of dispensing, with pharmacy accuracy checks sometimes, but not always, detecting these before they reached the patient. Medication errors occur due to several varying and often interacting factors; cognitive burden and lack of standardised medication checking processes. Despite the small sample size and potential for social desirability bias in the interviews, this study has demonstrated how HF techniques can be applied to the dispensing process as a means of understanding and preventing error occurrence in the community pharmacy.

References

(1) Vosper H, Hignett S. A UK perspective on human factors and patient safety education in pharmacy Curricula. Am J Pharm Educ. 2017;82:6184.

(2) Sutherland A, Ashcroft DM, Phipps DL. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child 2019;104:588-595.

P04 An evaluation of antimicrobial stewardship education in the School of Pharmacy of an Irish university—a mixed methods study

Background

Antimicrobial stewardship (AMS) is essential to control the emergence of antimicrobial resistance (AMR) which has become an international health priority. Education of undergraduate students on AMS and AMR is a strategic objective in the WHO Global Action Plan on AMR and Ireland's National Action Plan.^1,2 Research on AMS/AMR education has focused primarily on medical students with less emphasis on those from other healthcare profession including pharmacy students.

Objectives

To investigate AMS and AMR education in the Pharmacy undergraduate programme in the School of Pharmacy of an Irish University.

Methods

A mixed methods study was conducted. Ten semi-structured interviews were conducted in October 2019 with academic staff to capture their views on AMS education. Participants included staff members from different disciplines, those identified as involved in teaching elements of infectious disease, antibiotics, AMS and related topics, and those involved in curriculum design and approval within the School of Pharmacy. Interview transcripts were analysed by thematic analysis. An electronic survey of 17 questions was emailed to all second to fifth year UCC Pharmacy students in October 2019 to gather students’ views and experiences of AMS education. The survey contained four sections which addressed demographics, AMS, resources and education using open-ended, closed-ended or Likert-scale questions. Ethical approval was obtained.

Results

Six key themes were identified from the ten interviews: (i) curriculum priorities and capacity; (ii) housing of the subject, fragmentation and cohesion; (iii) integration; (iv) communication; (v) teaching methods; and (vi) assessment methods. 113 students participated in the survey (32.3% response rate). 96% agree that a strong knowledge of antimicrobials for their future careers is important, and over 89% of students desire more education on AMR and AMS. Only 43% of students found their AMS education provided sufficient preparation for practice. Students felt most prepared to recognize clinical signs of infection and least prepared for IV to oral switching, interpreting biological marker and de-escalation of antimicrobials. Over 50% of students never used or were not familiar with the national primary care antimicrobial guidelines: www.antibioticprescribing.ie.

Conclusions

Pharmacy students and staff agree that AMS and AMR are important and need enhanced educational focus. Students feel there are gaps in their AMS education and expressed a desire for more education in this area. Improved communication and identification of curriculum priorities by staff could help to establish a more cohesive and comprehensive educational approach to this area.

The protected antimicrobial process in a University Teaching Hospital: a qualitative interview study exploring the knowledge, attitudes, and experiences of healthcare professionals

Background The protected or restricted supply of certain antimicrobials such as linezolid, caspofungin, aztreonam, in the acute hospital setting is an important element of Antimicrobial Stewardship (AMS) programmes to address the growing problem of antimicrobial resistance. This process involves submitting an application for use to be reviewed typically by a Consultant Microbiologist, Infectious Disease Consultant or Antimicrobial Pharmacist. Aim To investigate healthcare professionals’ knowledge, experiences, and attitudes towards the protected/restricted antimicrobials process in order to identify possible methods of optimisation and improvement. Method Semi-structured interviews with stakeholders involved in the protected/restricted antimicrobial prescribing, dispensing and administration process were conducted in September–October 2019 in a 350-bed voluntary, general, acute hospital in Ireland. Interviews were analysed by the Framework method and mapped to the Theoretical Domains Framework (TDF). Results Interviews were conducted with 8 Doctors, 4 Pharmacists and 3 Nurses. TDF domains identified included: ‘Knowledge’; ‘Social/professional role and identity’; ‘Social influences’; ‘Memory, attention and decision processes’; ‘Beliefs about consequences’; ‘Environmental contexts and resources’. The relationship between prescribers and the AMS Team was reported as a facilitator of the process, whereas the inconsistency of the filing and versions of forms on the wards were seen as challenges. Conclusion The results of this study have shown that the existing protected/restricted antimicrobial process is a multi-disciplinary effort with barriers that require attention in order to make future improvements. Standardization of the form across all wards, an electronic version of the form, and structured education around AMS were suggested to optimize the process.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Antimicrobial use and antimicrobial resistance in Enterobacterales and Enterococcus faecium: a time series analysis

BACKGROUND

Irish and European antimicrobial resistance (AMR) surveillance data have highlighted increasing AMR in Enterobacterales and vancomycin resistance in Enterococcus faecium (VRE). Antimicrobial consumption (AC) in Irish hospital settings is also increasing.

METHODS

A retrospective time series analysis (TSA) was conducted to evaluate the trends and possible relationship between AC of selected antimicrobials and AMR in Enterobacterales and vancomycin resistance in E. faecium, from January 2017 to December 2020.

RESULTS

Increased AC was seen with ceftriaxone (p= 0.0006), piperacillin/tazobactam (p = 0.03) and meropenem (p = 0.05), while ciprofloxacin and gentamicin use trended downwards. AMR rates in E. coli, K. pneumoniae and other Enterobacterales were largely stable, an increase in ertapenem resistance in the latter from 0.58% in 2017 to 5.19% in 2020 (p= 0.003) being the main concern. The proportion of E. faecium that was VRE did not changed significantly (64% in 2017; 53% in 2020, p = 0.1). TSA identified a correlation between piperacillin/tazobactam use and the decreasing rate of ceftriaxone resistance in E. coli.

CONCLUSION

Our data suggest that hospital antimicrobial stewardship programme is largely containing, but not reducing AMR in key nosocomial pathogens. An increase in AC following the COVID-19 pandemic appears as yet to have had no impact on AMR rates.

Quality indicators for hospital antimicrobial stewardship programmes: a systematic review

BACKGROUND

Measuring the quality and effectiveness of antimicrobial stewardship (AMS) programmes with quality indicators (QIs) is an area of increasing interest. We conducted a systematic review to identify QIs of AMS programmes in the hospital setting and critically appraise their methodological quality.

METHODS

We searched the Cochrane Library, PubMed, MEDLINE, EMBASE, CINAHL, Scopus/web of science databases and the grey literature for studies that defined and/or described the development process and characteristics of the QIs developed. The Appraisal of Indicators through Research and Evaluation (AIRE) instrument was used to critically appraise the methodological quality of the QI sets.

RESULTS

We identified 16 studies of QI sets consisting of 229 QIs. The QI sets addressed a broad range of areas of AMS in the hospital setting and consisted of 75% process indicators, 24% structural indicators and 1% outcome indicators. There was a wide variation in the information and level of detail presented describing the methodological characteristics of the QI sets identified.

CONCLUSIONS

The QIs identified in this study focused on process and structural indicators with few outcome indicators developed-a major deficiency in this area. Future research should focus on the development of outcome indicators or the use of process or structural indicators linked to outcomes to assess AMS. Testing of the QIs in practice is an essential methodological element of the QI development process and should be included in the QI development study or as planned validation work.

Factors Affecting Predominantly Peripheral Lesion Identification and Grading

Purpose

The purpose of this study was to determine factors affecting predominantly peripheral lesion (PPL) grading, such as qualitative versus quantitative assessment, device type, and severity of diabetic retinopathy (DR) in ultrawide field color images (UWF-CIs).

Methods

Patients with DR had UWF-CI qualitatively graded for PPL using standardized techniques and had hemorrhages/microaneurysms (H/Mas) individually annotated for quantitative PPL grading on two different ultrawide field devices.

Results

Among 791 eyes of 481 patients, 38.2% had mild nonproliferative DR (NPDR), 34.7% had moderate NPDR, and 27.1% had severe NPDR to proliferative DR (PDR). The overall agreement between qualitative and quantitative PPL grading was moderate (ĸ = 0.423, P < 0.001). Agreement rates were fair in eyes with mild NPDR (ĸ = 0.336, P < 0.001) but moderate in eyes with moderate NPDR (ĸ = 0.525, P < 0.001) and severe NPDR-PDR (ĸ = 0.409, P < 0.001). Increasing thresholds for quantitative PPL determination improved agreement rates, with peak agreements at H/Ma count differences of six for mild NPDR, five for moderate NPDR, and nine for severe NPDR-PDR. Based on ultrawide field device type (California = 412 eyes vs. 200Tx = 379 eyes), agreement between qualitative and quantitative PPL grading was moderate for all DR severities in both devices (ĸ = 0.369−0.526, P < 0.001) except for mild NPDR on the 200Tx, which had poor agreement (ĸ = 0.055, P = 0.478).

Conclusions

Determination of PPL varies between standard qualitative and quantitative grading and is dependent on NPDR severity, device type, and magnitude of lesion differences used for quantitative assessment.

Translational Relevance

Prior UWF studies have not accounted for imaging and grading factors that affect PPL, such factors need to be reviewed when assessing thresholds for DR progression rates.

Retinal vascular bed area on ultra-wide field fluorescein angiography indicates the severity of diabetic retinopathy

AIMS

To quantify retinal vascular bed area (RVBA) in square millimetres on stereographically projected ultra-wide field (UWF) fluorescein angiography (FA) in eyes with diabetic retinopathy (DR).

METHODS

A prospective, observational study. Baseline Optos 200Tx UWF FA images of 80 eyes with DR from the DAVE (NCT01552408) and RECOVERY (NCT02863354) studies were stereographically projected at the Doheny Image Reading Center to adjust for peripheral distortion. The early-phase FA frame was used to extract the retinal vasculature as a mask for calculating RVBA. The pixels of the retinal vasculature were automatically computed in square millimetres using manufacturer-provided software.

RESULTS

Eighteen of 80 diabetic eyes were excluded because image quality and contrast were insufficient for automatic extraction of the retinal vasculature from the background fluorescence. The remaining 62 eyes were included in the final analysis. In comparison with age-matched and sex-matched normal controls, eyes with DR had a higher global RVBA for the entire retina (p<0.001), and RVBA correlated with DR severity (p<0.001), with a higher RVBA in eyes with proliferative DR (66.1±16.2 mm²) than in those with non-proliferative DR (56.2±16.6 mm²) or in normal controls (37.2±9.9 mm²). This tendency was also present in the posterior retina and mid-periphery but absent in the far-periphery. RVBA did not correlate with retinal ischaemia (p>0.05).

CONCLUSIONS

Eyes with DR harboured a larger global RVBA for the entire retina than normal controls, and RVBA appeared to indicate DR severity. However, this biomarker was not observed to be a good indicator of retinal ischaemia.

Automated Microaneurysm Counts on Ultrawide Field Color and Fluorescein Angiography Images

BACKGROUND

The severity and extent of microaneurysms (MAs) have been used to determine diabetic retinopathy (DR) severity and estimate the risk of DR progression over time. The recent introduction of ultrawide field (UWF) imaging has allowed ophthalmologists to readily image nearly the entire retina. Manual counting of MAs, especially on UWF images, is laborious and time-consuming, limiting its potential use in clinical settings. Automated MA counting techniques are potentially more accurate and reproducible compared to manual methods.

METHOD

Review of available literature on current techniques of automated MA counting techniques on both ultrawide field (UWF) color images (CI) and fluorescein angiography (FA) images.

RESULTS

Automated MA counting techniques on UWF images are still in the early phases of development with UWF-FA counts being further along. Early studies have demonstrated that these techniques are accurate and reproducible.

CONCLUSION

Automated techniques may be an appropriate option for detecting and quantifying MAs on UWF images, especially in eyes with earlier DR severity. Larger studies are needed to appropriately validate these techniques and determine if they add substantially to clinical practice compared to standard DR grading.

A qualitative process evaluation of the introduction of procalcitonin testing as an antimicrobial stewardship intervention

Background Successful antimicrobial stewardship interventions are imperative in today's environment of antimicrobial resistance. New antimicrobial stewardship interventions should include qualitative analysis such as a process evaluation to determine which elements within an intervention are effective and provide insight into the context in which the intervention is introduced. Objective To assess the implementation process and explore the contextual factors which influenced implementation. Setting An academic teaching hospital in Cork, Ireland. Methods A process evaluation was conducted on completion of a feasibility study of the introduction of a procalcitonin antimicrobial stewardship intervention. The process evaluation consisted of semi-structured face-to-face interviews of key stakeholders including participating (senior) doctors (5), medical laboratory scientists (3) and a hospital administrator. The Consolidated Framework for Implementation Research was used to guide data collection, analysis, and interpretation. Main outcome measures Qualitative assessment of the intervention implementation process, the contextual factors which influenced implementation and identification of improvements to the intervention and its implementation and determine if proceeding to a randomised controlled trial would be appropriate. Results Analysis of the interviews identified three main themes. (1) The procalcitonin intervention and implementation process was viewed positively to support prescribing decisions. Participants identified modifications to procalcitonin processing and availability to improve implementation and allow procalcitonin to be "more of a clinical influence". (2) In the antimicrobial stewardship context the concept of fear of missing an infection and risks of potentially serious outcomes for patients emerged. (3) The hospital context consisted of barriers such as available resources and facilitators including the hospital culture of quality improvement. Conclusion This process evaluation provides a detailed analysis of the implementation of procalcitonin testing as an antimicrobial stewardship intervention. The positive findings of this process evaluation and feasibility study should be built upon and a full randomised controlled trial and economic evaluation should be conducted in a variety of hospital settings to confirm the effectiveness of procalcitonin as an antimicrobial stewardship intervention.

An investigation of the effects of procalcitonin testing on antimicrobial prescribing in respiratory tract infections in an Irish university hospital setting: a feasibility study

BACKGROUND

Diagnostic uncertainty and a high prevalence of viral infections present unique challenges for antimicrobial prescribing for respiratory tract infections (RTIs). Procalcitonin (PCT) has been shown to support prescribing decisions and reduce antimicrobial use safely in patients with RTIs, but recent study results have been variable.

METHODS

We conducted a feasibility study of the introduction of PCT testing in patients admitted to hospital with a lower RTI to determine if PCT testing is an effective and worthwhile intervention to introduce to support the existing antimicrobial stewardship (AMS) programme and safely decrease antimicrobial prescribing in patients admitted with RTIs.

RESULTS

A total of 79 patients were randomized to the intervention PCT-guided treatment group and 40 patients to the standard care respiratory control group. The addition of PCT testing led to a significant decrease in duration of antimicrobial prescriptions (mean 6.8 versus 8.9 days, P = 0.012) and decreased length of hospital stay (median 7 versus 8 days, P = 0.009) between the PCT and respiratory control group. PCT did not demonstrate a significant reduction in antimicrobial consumption when measured as DDDs and days of therapy.

CONCLUSIONS

PCT testing had a positive effect on antimicrobial prescribing during this feasibility study. The successful implementation of PCT testing in a randomized controlled trial requires an ongoing comprehensive education programme, greater integration into the AMS programme and delivery of PCT results in a timely manner. This feasibility study has shown that a larger randomized controlled trial would be beneficial to further explore the positive aspects of these findings.

Retinal Vascular Caliber Association with Nonperfusion and Diabetic Retinopathy Severity Depends on Vascular Caliber Measurement Location

PURPOSE

To evaluate the association of retinal nonperfusion and diabetic retinopathy (DR) severity with location of vascular caliber measurement using ultrawide field (UWF) imaging.

DESIGN

Retrospective image review.

PARTICIPANTS

Adults with diabetes mellitus.

METHODS

All images from subjects with same-day UWF fluorescein angiography (FA) and color imaging were evaluated. Predominantly peripheral lesions (PPL) and DR severity were graded from UWF color images. Nonperfusion was quantified using UWF-FA in defined retinal regions [posterior pole (PP), mid-periphery (MP), far-periphery (FP)]. Retinal vessel calibers were measured at an optic disc centered inner and outer zone.

MAIN OUTCOME MEASURES

Nonperfusion index (NPI) in the PP, MP and FP. Mean arteriole and venule diameter in the inner and outer zones.

RESULTS

Two hundred eighty-five eyes of 193 patients (24.9% mild nonproliferative DR [NPDR], 22.8% moderate NPDR, 37.5% severe NPDR and 14.7% proliferative DR [PDR]) were reviewed. No significant associations between inner zone arteriolar diameter and retinal NPI overall or in any retinal region. In the outer zone, eyes with thinnest arteriolar calibers (quartile 1) were associated with a 1.7- to 2.4-fold nonperfusion increase across all retinal regions compared to the remaining eyes (P = 0.002 [PP] to 0.048 [FP]). In the outer zone, the percentage of eyes in the thinnest quartile of retinal arteriolar diameter increased with worsening DR severity (mild NPDR: 10% vs PDR: 31%, P = 0.007). This association was not observed when measured within the inner zone (P = 0.129). All venular caliber associations were not statistically significant when corrected for potentially confounding factors. Thinner outer zone retinal arteriolar caliber (quartile 1) was more common in eyes with PPL compared to eyes without PPL (34.1% vs 20.8%, P = 0.017) as were thicker outer venular calibers (quartile 4) (33% vs 21.3%, P = 0.036). Presence of PPL was associated with thinner outer zone arteriolar caliber (109.7 ± 26.5μm vs 123.0 ± 29.5μm, P = 0.001).

CONCLUSIONS

The association of vascular caliber with nonperfusion and DR severity differs based upon the retinal location at which vascular caliber is measured. Peripheral arterial narrowing is associated with increasing nonperfusion, worsening DR severity and presence of PPL. In contrast, inner zone retinal arteriolar caliber is not associated with these findings.

Fractal analysis of retinal vasculature in normal subjects on ultra-wide field fluorescein angiography

AIM

To evaluate the fractal feature of the retinal vasculature of normal eyes on a stereographic projected and montaged ultra-wide field (UWF) fluorescein angiography (FA).

METHODS

Prospective, observational, cross-sectional study. Totally 59 eyes of 31 normal subjects were imaged using the Optos 200Tx. Images obtained at different gaze angles stereographically projected and montaged. The early-phase UWF FA frames were processed to segment the retinal vasculature and the results were exported as binary masks. The fractal dimension (FD) was calculated using the box-counting method.

RESULTS

The global FD for the entire retina was 1.6±0.04, with no difference between males and females (1.59±0.04 vs 1.61±0.04, P=0.084) or between right and left eyes (1.6±0.04 vs 1.6±0.05, P=0.61). FD was non-uniformly distributed among four quadrants (P<0.001) and decreased as the distance from the fovea increased (P<0.001). A negative association was observed between FD and age (R=-0.37, P=0.006), and this relationship was observed in the posterior and mid-peripheral retina (P<0.05) but absent in far-periphery (P>0.05).

CONCLUSION

Fractal geometry is non-uniformly distributed across the retina in normal eyes and decreases from the fovea to the far-periphery. Subjects with an older age tend to have a smaller FD, however, the FD in the far-periphery does not appear to be influenced by age.

Symposium review: Multiple-trait single-step genomic evaluation for hoof health

Hoof lesions represent an important issue in modern dairy herds, with reported prevalence in different countries ranging from 40 to 70%. This high prevalence of hoof lesions has both economic and social consequences, resulting in increased labor expenses and decreasing animal production, longevity, reproduction, health, and welfare. Therefore, a key goal of dairy herds is to reduce the incidence of hoof lesions, which can be achieved both by improving management practices and through genetic selection. The Canadian dairy industry has recently released a hoof health sub-index. This national genetic evaluation program for hoof health was achieved by creating a centralized data collection system that routinely transfers data recorded by hoof trimmers into a coherent and sustainable national database. The 8 most prevalent lesions (digital dermatitis, interdigital dermatitis, interdigital hyperplasia, heel horn erosion, sole hemorrhage, sole ulcer, toe ulcer, and white line lesion) in Canada are analyzed with a multiple-trait model using a single-step genomic BLUP method. Estimated genomic breeding values for each lesion are combined into a sub-index according to their economic value and prevalence. In addition, data recorded within this system were used to create an interactive management report for dairy producers by Canadian DHI, including the prevalence of lesions on farm, their trends over time, and benchmarks with provincial and national averages.

Short communication: Time-dependent genetic parameters and single-step genome-wide association analyses for predicted milk fatty acid composition in Ayrshire and Jersey dairy cattle

Milk fat content and fatty acid (FA) composition have great economic value to the dairy industry as they are directly associated with taste and chemical-physical characteristics of milk and dairy products. In addition, consumers' choices are not only based on the nutritional aspects of food, but also on products known to promote better health. Milk FA composition is also related to the metabolic status and physiological stages of cows and thus can also be used as indicator for other novel traits of interest (e.g., metabolic diseases and methane yield). Genetic selection is a promising alternative to manipulate milk FA composition. In this study, we aimed to (1) estimate time-dependent genetic parameters for 5 milk FA groups (i.e., short-chain, medium-chain, long-chain, saturated, and unsaturated) predicted based on milk mid-infrared spectroscopy, for Canadian Ayrshire and Jersey breeds, and (2) conduct a time-dependent, single-step genome-wide association study to identify genomic regions, candidate genes, and metabolic pathways associated with milk FA. We analyzed 31,709 test-day records of 9,648 Ayrshire cows from 268 herds, and 34,341 records of 11,479 Jersey cows from 883 herds. The genomic database contained a total of 2,330 Ayrshire and 1,019 Jersey animals. The average daily heritability ranged from 0.18 (long-chain FA) to 0.34 (medium-chain FA) in Ayrshire, and from 0.25 (long-chain and unsaturated FA) to 0.52 (medium-chain and saturated FA) in Jersey. Important genomic regions were identified in Bos taurus autosomes BTA3, BTA5, BTA12, BTA13, BTA14, BTA16, BTA18, BTA20, and BTA21. The proportion of the variance explained by 20 adjacent SNP ranged from 0.71% (saturated FA) to 1.11% (long-chain FA) in Ayrshire, and from 0.70% (unsaturated FA) to 3.09% (medium-chain FA) in Jersey cattle. Important candidate genes and pathways were also identified, such as the PTK2 and TRAPPC9 genes, associated with milk fat percentage, and HMGCS, FGF10, and C6 genes, associated with fertility traits and immune response. Our findings on the genetic parameters and candidate genes contribute to a better understanding of the genetic architecture of milk FA composition in Ayrshire and Jersey dairy cattle.

Once and Again: Intergenerational Transmission of Parenting

Introduction

Animal and human studies suggest that individual differences in maternal parenting behaviour are transmitted from one generation to the next.

Objective

This study aimed to examine potential psychosocial mechanisms underlying an intergenerational transmission of conceptualization of parenting, including affect, cognition, and parental support.

Methods

In a subsample of 201 first-time mothers participating in the Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) project, we assessed maternal childhood rearing experiences, using the Parental Bonding Instrument and the Childhood Trauma Questionnaire. At 6 months postpartum, mothers completed questionnaires on parenting stress, symptoms of depression, internalization of maternal care regulation and current relationship with mother and father.

Results

We found significant direct associations of maltreatment and rearing by the grandmother with parenting stress at 6 months. These associations were mediated through distinct psychosocial pathways: the association of maltreatment on higher parenting stress was fully mediated through more maternal symptoms of depression (z = 2.297; P = 022). The association between sub-optimal rearing provided by the mother and higher parenting stress was mediated through lower internalization of maternal care regulation (z = -2.155; P = 031) and to a lesser degree through more symptoms of depression (z = -1.842; P = 065). Finally, higher quality rearing by the grandfather was indirectly related to lower parenting stress through positive current relationship with the father (z = -2.617; P = 009).

Conclusions

There are distinct pathways by which early experiences manifest in parenting stress. By understanding the structure of dysregulated parenting, clinicians will have practical information to specifically target maternal motivation, social supports, and depressed mood to disrupt maladaptive parenting cognitions and practices.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Disparity of microaneurysm count between ultrawide field colour imaging and ultrawide field fluorescein angiography in eyes with diabetic retinopathy

AIMS

To compare microaneurysm (MA) counts using ultrawide field colour images (UWF-CI) and ultrawide field fluorescein angiography (UWF-FA).

METHODS

Retrospective study including patients with type 1 or 2 diabetes mellitus receiving UWF-FA and UWF-CI within 2 weeks. MAs were manually counted in individual Early Treatment Diabetic Retinopathy Study (ETDRS) and extended UWF zones. Fields with MAs ≥20 determined diabetic retinopathy (DR) severity (0 fields=mild, 1-3=moderate, ≥4=severe). UWF-FA and UWF-CI agreement was determined and UWF-CI DR severity sensitivity analysis adjusting for UWF-FA MA counts performed.

RESULTS

In 193 patients (288 eyes), 2.4% had no DR, 29.9% mild non-proliferative DR (NPDR), 32.6% moderate (NPDR), 22.9% severe NPDR and 12.2% proliferative DR. UWF-FA MA counts were 3.5-fold higher (p<0.001) than UWF-CI counts overall, 3.2x-fold higher in ETDRS fields (p<0.001) and 5.3-fold higher in extended ETDRS fields (p<0.001) and higher in type 1 versus type 2 diabetes (p<0.001). In eyes with NPDR on UWF-CI (n=246), UWF-FA images had 1.6x-3.5x more fields with ≥20 MAs (p<0.001). Fair agreement existed between imaging modalities (k=0.221-0.416). In ETDRS fields, DR severity agreement increased from k=0.346 to 0.600 when dividing UWF-FA counts by a factor of 3, followed by rapid decline in agreement thereafter. Total UWF area agreement increased from k=0.317 to 0.565 with an adjustment factor of either 4 or 5.

CONCLUSIONS

UWF-FA detects threefold to fivefold more MAs than UWF-CI and identifies 1.6-3.5-fold more fields affecting DR severity. Differences exist at all DR severity levels, thus limiting direct comparison between the modalities. However, correcting UWF-FA MA counts substantially improves DR severity agreement between the modalities.

Association between hypertension and retinal vascular features in ultra-widefield fundus imaging

Objective

Changes to the retinal vasculature are known to be associated with hypertension independently of traditional risk factors. We investigated whether measurements of retinal vascular calibre from ultra-widefield fundus imaging were associated with hypertensive status.

Methods

We retrospectively collected and semiautomatically measured ultra-widefield retinal fundus images from a subset of participants enrolled in an ongoing population study of ageing, categorised as normotensive or hypertensive according to thresholds on systolic/diastolic blood pressure (140/90 mm Hg) measured in a clinical setting. Vascular calibre in the peripheral retina was measured to calculate the nasal–annular arteriole:venule ratio (NA-AVR), a novel combined parameter.

Results

Left and right eyes were analysed from 440 participants (aged 50–59 years, mean age of 54.6±2.9 years, 247, 56.1% women), including 151 (34.3%) categorised as hypertensive. Arterioles were thinner and the NA-AVR was smaller in people with hypertension. The area under the receiver operating characteristic curve of NA-AVR for hypertensive status was 0.73 (95% CI 0.68 to 0.78) using measurements from left eyes, while for right eyes, it was 0.64 (95% CI 0.59 to 0.70), representing evidence of a statistically significant difference between the eyes (p=0.020).

Conclusions

Semiautomated measurements of NA-AVR in ultra-widefield fundus imaging were associated with hypertension. With further development, this may help screen people attending routine eye health check-ups for high blood pressure. These individuals may then follow a care pathway for suspected hypertension. Our results showed differences between left and right eyes, highlighting the importance of investigating both eyes of a patient.

Does Cellular Metabolism from Primary Fibroblasts and Oxidative Stress in Blood Differ between Mammals and Birds? The (Lack-thereof) Scaling of Oxidative Stress

As part of mitonuclear communication, retrograde and anterograde signaling helps maintain homeostasis under basal conditions. Basal conditions, however, vary across phylogeny. At the cell-level, some mitonuclear retrograde responses can be quantified by measuring the constitutive components of oxidative stress, the balance between reactive oxygen species (ROS) and antioxidants. ROS are metabolic by-products produced by the mitochondria that can damage macromolecules by structurally altering proteins and inducing mutations in DNA, among other processes. To combat accumulating damage, organisms have evolved endogenous antioxidants and can consume exogenous antioxidants to sequester ROS before they cause cellular damage. ROS are also considered to be regulated through a retrograde signaling cascade from the mitochondria to the nucleus. These cellular pathways may have implications at the whole-animal level as well. For example, birds have higher basal metabolic rates, higher blood glucose concentration, and longer lifespans than similar sized mammals, however, the literature is divergent on whether oxidative stress is higher in birds compared with mammals. Herein, we collected literature values for whole-animal metabolism of birds and mammals. Then, we collected cellular metabolic rate data from primary fibroblast cells isolated from birds and mammals and we collected blood from a phylogenetically diverse group of birds and mammals housed at zoos and measured several parameters of oxidative stress. Additionally, we reviewed the literature on basal-level oxidative stress parameters between mammals and birds. We found that mass-specific metabolic rates were higher in birds compared with mammals. Our laboratory results suggest that cellular basal metabolism, total antioxidant capacity, circulating lipid damage, and catalase activity were significantly lower in birds compared with mammals. We found no body-size correlation on cellular metabolism or oxidative stress. We also found that most oxidative stress parameters significantly correlate with increasing age in mammals, but not in birds; and that correlations with reported maximum lifespans show different results compared with correlations with known aged birds. Our literature review revealed that basal levels of oxidative stress measurements for birds were rare, which made it difficult to draw conclusions.

Lipoedema – myths and facts, Part 5

The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.

The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.

Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.

In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.

Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.

The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

Relationship Between Retinal Fractal Dimension and Nonperfusion in Diabetic Retinopathy on Ultrawide-Field Fluorescein Angiography

PURPOSE

To correlate fractal dimension (FD) of the retinal vasculature with the extent of retinal nonperfusion area in diabetic retinopathy (DR) on ultrawide-field fluorescein angiography (FA).

DESIGN

Cross-sectional study.

METHODS

Baseline Optos 200Tx ultrawide-field FA images of 80 eyes with DR from the DAVE (NCT01552408) and RECOVERY (NCT02863354) studies were stereographically projected at the Doheny Image Reading Center. The retinal vasculature was extracted from an early-phase FA frame by exploiting the elongated nature of the vessels and then skeletonized for calculation of FD using a box-counting method. The nonperfusion area was delineated by 2 independent, reading center-certified graders who were masked to the study groups and who were using a standardized protocol and then computed in millimeters squared.

RESULTS

While no difference in FD was observed for the entire retina in DR compared with normal control subjects, a significantly smaller FD was found in the far-periphery of the DR eyes (P < .001). FD for the entire retina was negatively associated with global nonperfusion area (R = -0.44; P < .001), and this relationship was also present within the 3 concentric retinal zones (posterior: R = -0.31, P = .016; midperiphery: R = -0.35, P = .007; and far periphery: R = -0.31, P = .015).

CONCLUSIONS

Peripheral FD on ultrawide-field FA is reduced in DR eyes compared with normal eyes and is correlated with severity of retinal nonperfusion. FD can be calculated automatically without the need for correction of peripheral distortion, and therefore it may prove to be a useful surrogate biomarker when precise quantification of nonperfusion is not feasible.

Distribution of Nonperfusion and Neovascularization on Ultrawide-Field Fluorescein Angiography in Proliferative Diabetic Retinopathy (RECOVERY Study): Report 1

PURPOSE

To explore the distribution of nonperfusion area (NPA) on ultrawide-field fluorescein angiography (UWF FA) in proliferative diabetic retinopathy (PDR) and its relationship with the presence of neovascularization of the optic disc (NVD) and distribution of neovascularization elsewhere (NVE).

DESIGN

Prospective, observational case series.

METHODS

Baseline Optos 200Tx UWF FA images of 38 eyes with treatment-naïve early-stage PDR from the RECOVERY (NCT02863354) study were stereographically projected at the Doheny Image Reading Center. Two independent/masked certified graders manually delineated the NPA and the total visible retinal area (TRA). NPA and TRA were then computed in square millimeters using the manufacturer software. Ischemic index (ISI) was calculated by dividing NPA by TRA. NPA and ISI were correlated with the presence and distribution of neovascularization in the corresponding zones.

RESULTS

Eyes with NVD appeared to have more severe global NPA than those without (P = .026). Although the ISI appeared to increase with increasing distance from the foveal center (P < .001), NVE was more likely to be located in the posterior pole than the midperiphery or far-periphery (P < .001). Presence of NVE in the posterior polar retina appeared to demonstrate more severe ischemia in the posterior pole and midperiphery than those without (P < .05), but interestingly, was not correlated with the severity of overall global ischemia or of ischemia in the far-periphery alone (P > .05).

CONCLUSIONS

Whereas the presence of NVD was associated with the severity of global ischemia, the distribution of NVE did not appear to be influenced by the distribution of ischemia.

Nonlinear optical memory effect

Light propagating through random media produces characteristic speckle patterns, directly related to the large multitude of scattering events. These complex dynamics remarkably display robustness to perturbation of the incoming light parameters, maintaining correlation in the scattered wavefront. This behavior is known as the optical memory effect. Here we unveil the properties of the nonlinear optical memory effect, which occurs when an optothermal nonlinearity perturbs the random material. The effect is characterized through a series of pump and probe experiments in silica aerogel, in the visible range. This additional degree of freedom further generalizes the memory effect, opening the road to applications based on the nonlinear response of random media.

A systematic approach to map the adolescent human papillomavirus vaccine decision and identify intervention strategies to address vaccine hesitancy

OBJECTIVES

Unsubstantiated safety concerns with human papillomavirus (HPV) vaccines continue to linger. This study sought to identify factors that influence the adolescent HPV vaccine decision and systematically identify intervention functions and strategies likely to be effective in reducing vaccine hesitancy.

STUDY DESIGN

This is a qualitative focus group study.

METHODS

Focus groups were conducted with female adolescents (aged 14-16 years) in Cork and Kerry. During focus groups, the trained facilitator used a semistructured, Theoretical Domains Framework (TDF)-based topic guide to prompt discussion. Transcripts were thematically analysed using the TDF and Behaviour Change Wheel. Behaviour Change Technique Taxonomy version 1 was used to suggest intervention functions and strategies for addressing HPV vaccine hesitancy.

RESULTS

A total of 50 adolescents (96% vaccinated), participated in 10 focus groups. The key themes were presented by means of the relevant TDF domains. Seven domains were selected as the most relevant: knowledge, social influences, beliefs about capabilities, optimism, beliefs about consequences, emotion and environmental context and resources. Five intervention functions were identified, education, persuasion, enablement, modelling and environmental restructuring, and linked to 11 relevant Behaviour Change Technique (BCTs). Potential intervention strategies were developed.

CONCLUSIONS

This study provided a detailed insight into behavioural factors influencing the vaccine decision-making process. It was identified that awareness and knowledge about HPV and its health sequelae was low. Lack of information is a well-recognised determinant of vaccine hesitancy. Therefore, education was recommended as a key area to address in future intervention studies.

Comparison of Subjective Assessment and Precise Quantitative Assessment of Lesion Distribution in Diabetic Retinopathy

Importance

Predominantly peripheral disease in eyes with nonproliferative diabetic retinopathy (DR) is suggested as a potential strong risk factor for progression to proliferative disease. However, the reliability and optimal method for the assessment of lesion distribution are still uncertain.

Objective

To compare agreement between subjective assessment and precise quantification of lesion burden in ultrawidefield (UWF) images of eyes with DR.

Design, Setting, and Participants

This multisite cross-sectional study examines UWF pseudocolor images acquired from DR screening clinic patients from December 20, 2014, through August 1, 2014. Of 104 cases, 161 eyes with DR were included. Data analysis was conducted from June 1, 2016, through December 1, 2016 at the Doheny Image Reading Center.

Main Outcomes and Measures

Distribution of DR lesions in eyes was assessed subjectively and quantitatively, and eyes were classified as having predominantly central lesions (PCLs) or predominantly peripheral lesions (PPLs). The frequency and surface area (SA) of each lesion type were quantified. Intergrader and subjective vs quantitative classification were compared for level of agreement. Several methods of determining PPL distribution were also compared.

Results

On subjective frequency-based evaluation by graders, 133 eyes were classified as having PCL, and 28 eyes as having PPL. On exact quantification of lesion SA, 121 eyes were classified as PCL, and 40 eyes as having PPL. On SA-based quantification, 134 eyes were classified as having PCL, and 27 eyes as having PPL. There was a significant difference between qualitative and quantitative classification of DR lesion distribution for both frequency-based (mean difference [SD]: PCL, 6 [2]; PPL, 13 [6]; P < .001) and SA-based (mean difference [SD]: PCL, 6 [1]; PPL, 20 [7]; P < .001) methods. Both intergrader reproducibility and subjective vs quantitative agreement were higher with frequency-based classification.

Conclusions and Relevance

Subjective assessment of PPL DR lesions on UWF images differed in some cases from precise quantitative assessments, particularly when considering the area of lesions. These findings highlight the benefit of objective quantitative approaches to DR assessment, which may facilitate the development of a more precise DR scoring system.

Genome-wide association analysis for β-hydroxybutyrate concentration in Milk in Holstein dairy cattle

BACKGROUND

Ketosis in dairy cattle has been shown to cause a high morbidity in the farm and substantial financial losses to dairy farmers. Ketosis symptoms, however, are difficult to identify, therefore, the amount of ketone bodies (mainly β-hydroxybutyric acid, BHB) is used as an indicator of subclinical ketosis in cows. It has also been shown that milk BHB concentrations have a strong correlation with ketosis in dairy cattle. Mid-infrared spectroscopy (MIR) has recently became a fast, cheap and high-throughput method for analyzing milk components. The aim of this study was to perform a genome-wide association study (GWAS) on the MIR-predicted milk BHB to identify genomic regions, genes and pathways potentially affecting subclinical ketosis in North American Holstein dairy cattle.

RESULTS

Several significant regions were identified associated with MIR-predicted milk BHB concentrations (indicator of subclinical ketosis) in the first lactation (SCK1) and second and later lactations (SCK2) in Holstein dairy cows. The strongest association was located on BTA6 for SCK1 and BTA14 on SCK2. Several SNPs on BTA6 were identified in regions and variants reported previously to be associated with susceptibility to ketosis and clinical mastitis in Jersey and Holstein dairy cattle, respectively. One highly significant SNP on BTA14 was found within the DGAT1 gene with known functions on fat metabolism and inflammatory response in dairy cattle. A region on BTA6 and three SNPs on BTA20 were found to overlap between SCK1 and SCK2. However, a novel region on BTA20 (55-63 Mb) for SCK2 was also identified, which was not reported in previous association studies. Enrichment analysis of the list of candidate genes within the identified regions for MIR-predicted milk BHB concentrations yielded molecular functions and biological processes that may be involved in the inflammatory response and lipid metabolism in dairy cattle.

CONCLUSIONS

The results of this study confirmed several SNPs and genes identified in previous studies as associated with ketosis susceptibility and immune response, and also found a novel region that can be used for further analysis to identify causal variations and key regulatory genes that affect clinical/ subclinical ketosis.

Phenotypic investigation of fine milk components in bovine milk and their prediction using mid-infrared spectroscopy

This study aimed to examine the phenotypic variation observed in fine milk components, the use of mid-infrared (MIR) spectroscopy to predict these components, and the correlations with other milk production traits. A total of 4116 milk samples were collected from 414 dairy cows from 44 Canadian herds. Overall 3117 samples were analyzed for casein micelle size, 986 and 937 for total and soluble calcium, respectively, and 2054 for lactoferrin. Individual milk MIR spectra were obtained. Linear mixed models with repeated records were used to test the effects of herd nested within breed, breed, days in milk class, parity, and season on milk components. Lactoferrin content in milk increased with stage of lactation and parity number. Prediction equations were developed by partial least squares regression to predict each milk component using MIR spectroscopy, with the greatest coefficient of determination achieved for lactoferrin (0.55). Pearson correlation coefficients for lactoferrin with somatic cell score and protein percentage were 0.49% and 0.40%, respectively. The estimated correlation increased to 0.53% for predicted lactoferrin and protein percentage. The examined fine milk components exhibited variation, but low accuracies for their MIR prediction may limit the utility of this technology for their phenotyping.

Automated detection of age-related macular degeneration in color fundus photography: a systematic review

The rising prevalence of age-related eye diseases, particularly age-related macular degeneration, places an ever-increasing burden on health care providers. As new treatments emerge, it is necessary to develop methods for reliably assessing patients' disease status and stratifying risk of progression. The presence of drusen in the retina represents a key early feature in which size, number, and morphology are thought to correlate significantly with the risk of progression to sight-threatening age-related macular degeneration. Manual labeling of drusen on color fundus photographs by a human is labor intensive and is where automatic computerized detection would appreciably aid patient care. We review and evaluate current artificial intelligence methods and developments for the automated detection of drusen in the context of age-related macular degeneration.

Symposium review: The choice and collection of new relevant phenotypes for fertility selection

In dairy production, high fertility contributes to herd profitability by achieving greater production and maintaining short calving intervals. Improved management practices and genetic selection have contributed to reversing negative trends in dairy cow fertility, but further progress is still required. Phenotypes included in current genetic evaluations are largely interval and binary traits calculated from insemination and calving date records. Several indicator traits such as calving, health, variation in body condition score, and longevity traits also apply to genetic improvement of fertility. Several fertility traits are included in the selection indices of many countries, but for improved selection, the development of novel phenotypes that more closely describe the physiology of reproduction and limit management bias could be more effective. Progesterone-based phenotypes can be determined from milk samples to describe the heritable interval from calving to corpus luteum activity, as well as additional measures of cow cyclicity. A fundamental component of artificial insemination practices is the observation of estrus. Novel phenotypes collected on estrous activity could be used to select for cows clearly displaying heat, as those cows are more likely to be inseminated at the right time and therefore have greater fertility performance. On-farm technologies, including in-line milk testing and activity monitors, may allow for phenotyping novel traits on large numbers of animals. Additionally, selection for improved fertility using traditional traits could benefit from refined and accurate recording and implementation of parameters such as pregnancy confirmation and reproductive management strategy, to differentiate embryonic or fetal loss, and to ensure selection for reproductive capability without producer intervention. Opportunities exist to achieve genetic improvement of reproductive efficiency in cattle using novel phenotypes, which is required for long-term sustainability of the dairy cattle population and industry.

A landscape of the heritability of Fourier-transform infrared spectral wavelengths of milk samples by parity and lactation stage in Holstein cows

Fourier-transform near- and mid-infrared (FTIR) milk spectral data are routinely collected in many countries worldwide. Establishing an optimal strategy to use spectral data in genetic evaluations requires knowledge of the heritabilities of individual FTIR wavelength absorbances. Previous FTIR heritability estimates have been based on relatively small sample sizes and have not considered the possibility that heritability may vary across parities and stages of the lactation. We used data from ∼370,000 test-day records of Canadian Holstein cows to produce a landscape of the heritability of FTIR spectra, 1,060 wavelengths in the near- and mid-infrared spectrum (5,011-925 cm^-1), by parity and month of the lactation (mo 1 to 3 and mo 1 to 6, respectively). The 2 regions of the spectrum associated with absorption of electromagnetic energy by water molecules were estimated to have very high phenotypic variances, very low heritabilities, and very low proportion of variance explained by herd-year-season (HYS) subclasses. The near- or short-wavelength infrared (SWIR: 5,066-3,672 cm^-1) region was also characterized by low heritability estimates, whereas the estimated proportion of the variance explained by HYS was high. The mid-wavelength infrared region (MWIR: 3,000-2,500 cm^-1) and the transition between mid and long-wavelength infrared region (MWIR-LWIR: 1,500-925 cm^-1) harbor several waves characterized by moderately high (≥0.4) heritabilities. Most of the high-heritability regions contained wavelengths that are reported to be associated with important milk metabolites and components. Interestingly, these 2 same regions tended to show more variability in heritabilities between parity and lactation stage. Second parity showed heritability patterns that were distinctly different from those of the first and third parities, whereas the first 2 mo of the lactation had clearly distinct heritability patterns compared with mo 3 to 6.

Abstract P400: Screening for Hypertension Using Retinal Vascular Calibre in Ultra-Widefield Fundus Imaging

Fundus images from the left eyes of 440 subjects aged 50-59 years enrolled in the Northern Ireland Cohort of Longitudinal Ageing were analyzed. Subjects were categorized as normotensive or hypertensive, according to thresholds on systolic/diastolic blood pressure measurement (140/90 mm Hg) averaged over two sitting measurements in a clinical setting. A fully automatic system to analyze each image used conventional and deep neural network machine learning techniques to locate retinal landmarks and detect, classify and measure retinal vessels. From this data, a measure of the arteriolar-venular ratio (AVR) in the peripheral retina was calculated. Semi-automatic analysis was also performed. Results are presented in Table 1. Subjects had mean age of 54.6 ± 2.9 years; 56.1% (247 of 440) females, with 34.3% (151 of 440) subjects categorized as hypertensive. Narrower arterioles and smaller AVR were observed in subjects with hypertension. This was also observed in fully-automated analysis, however 4% (17 of 440) subjects failed to be processed by the system. In fully-automated analysis the area under a receiver operator characteristic curve of AVR for hypertensive status was 0.69 (95% CI, 0.63 to 0.74).

Table 1 - Results for semi-automated and automated analysis of retinal vessel parameters. *p<0.005

Automated measurement of AVR in ultra-widefield fundus imaging was associated with hypertension. With further development, such as evaluation against diagnosis of hypertension obtained from ambulatory blood pressure monitoring clinics, this system could become a test for undiagnosed hypertension in people attending routine eye health check-ups.