Nodular Syphilis Seen in an HIV-Positive Man: A Case Study.

Syphilis is becoming an increasingly concerning sexually transmitted infection in the primary care setting with a precipitous rise in cases in the USA over the past decade according to the CDC surveillance data. This rise in cases is particularly relevant in military medicine as the greatest increase in cases is among adults in their 20s. Nodular syphilis is a rare presentation of the secondary stage of syphilis, and contrary to the well-known maculopapular rash seen with syphilis infection, little is known about effective treatment of nodular manifestations of the disease. We present a case of a 54-year-old HIV-positive man with nodular secondary syphilis effectively treated with an empiric 2-week course of oral doxycycline. Initial differential diagnosis included erythema nodosum, arthropod vector disease, skin infection, and erythema elevatum diutinum. Biopsy demonstrated granulomatous dermatitis, and serology revealed positive Treponema pallidum antibodies with a rapid plasma reagin of 1:256, confirming the diagnosis of secondary syphilis with granulomatous dermatitis. This case indicates that clinicians should consider this unusual cutaneous presentation of secondary syphilis when evaluating patients with nodular skin lesions, especially in high-risk individuals.

Sine Qua Non: Oncocytoma.

Oncocytomas of the salivary gland are uncommon neoplasms that are characterized by polygonal cells with abundant granular eosinophilic cytoplasm and relatively uniform nuclei. They are benign in nature and have a low recurrence rate with complete surgical excision. Though uncommon, oncocytic and clear cell variants of malignant tumors may histologically mimic oncocytomas and identification of their distinguishing features is essential. A classic example of an oncocytoma is discussed.

An open-source python library for detection of known and novel Kell, Duffy and Kidd variants from exome sequencing.

BACKGROUND AND OBJECTIVES: Next generation sequencing (NGS) has promising applications in transfusion medicine. Exome sequencing (ES) is increasingly used in the clinical setting, and blood group interpretation is an additional value that could be extracted from existing data sets. We provide the first release of an open-source software tailored for this purpose and describe its validation with three blood group systems. MATERIALS AND METHODS: The DTM-Tools algorithm was designed and used to analyse 1018 ES NGS files from the ClinSeq® cohort. Predictions were correlated with serology for 5 antigens in a subset of 108 blood samples. Discrepancies were investigated with alternative phenotyping and genotyping methods, including a long-read NGS platform. RESULTS: Of 116 genomic variants queried, those corresponding to 18 known KEL, FY and JK alleles were identified in this cohort. 596 additional exonic variants were identified KEL, ACKR1 and SLC14A1, including 58 predicted frameshifts. Software predictions were validated by serology in 108 participants; one case in the FY blood group and three cases in the JK blood group were discrepant. Investigation revealed that these discrepancies resulted from (1) clerical error, (2) serologic failure to detect weak antigenic expression and (3) a frameshift variant absent in blood group databases. CONCLUSION: DTM-Tools can be employed for rapid Kell, Duffy and Kidd blood group antigen prediction from existing ES data sets; for discrepancies detected in the validation data set, software predictions proved accurate. DTM-Tools is open-source and in continuous development.

Comparison between carbon monoxide poisoning from hookah smoking versus other sources.

Introduction: Carbon monoxide exposure is a relatively unknown risk of smoking hookah. Dozens of cases of hookah-associated carbon monoxide toxicity have been described over the past decades, but smoking hookah is generally perceived as safe. Only recently have larger series of hookah-associated carbon monoxide toxicity been published. This study evaluates the incidence of hookah-associated carbon monoxide toxicity over 4 years, and compares the exposures from hookah against other carbon monoxide sources.Methods: This is a retrospective cohort study of all patients with carbon monoxide toxicity referred for hyperbaric oxygen therapy at an urban hyperbaric oxygen referral center from January 2015 through December 2018. Cases of hookah-associated carbon monoxide toxicity were compared to patients exposed to other carbon monoxide sources, with an analysis of patient comorbidities, symptomatology, and laboratory evaluation.Results: Over a 48-month period, 376 patients underwent hyperbaric oxygen therapy for carbon monoxide exposure. After exclusions, 265 patients with carbon monoxide toxicity from various sources were analyzed. There were 58 patients with hookah-associated carbon monoxide toxicity (22%). The proportion of hookah-associated carbon monoxide cases increased markedly in the latter years: 2015: 9.5%, 2016: 8.6%, 2017: 24.1%, 2018 41.6%. In the final 2 years analyzed, hookah smoking was the most frequent source of carbon monoxide toxicity referred for therapy. Hookah-associated carbon monoxide patients were younger(28.1 vs. 45.0 years, mean difference 16.8 years, 95% confidence interval: 11.5, 22.1 years, p < 0.001) and more likely to be female (60% vs. 46.6%, p = 0.06) than patients exposed to other carbon monoxide sources. The mean difference in carboxyhemoglobin concentration between hookah associated and those exposed to other carbon monoxide sources was 4.6% (mean 20.1% vs. 24.6%, 95%CI: 1.7, 7.5, p = 0.002).Conclusion: A substantial portion of patients with severe carbon monoxide toxicity was exposed through smoking hookah. The incidence of hookah-related carbon monoxide toxicity appears to be increasing.

Calcium hydroxyapatite deposition disease: Imaging features and presentations mimicking other pathologies.

OBJECTIVE: Calcium hydroxyapatite depositional disease (HADD) is usually asymptomatic and self-limiting; however, when there is an associated inflammatory process or HADD occurs in an unusual location, it may mimic trauma, infection, or neoplasm. The purpose of this article is to review the imaging features of HADD and how to distinguish it from more worrisome entities that can have similar appearances. CONCLUSION: An understanding of the presentations of HADD is important to allow early and confident diagnosis. In particular, familiarity with presentations that resemble more ominous pathologies is essential to avoid costly and time-consuming workup or intervention.

Life-Threatening Allergies: Using a Patient-Engaged Approach.

BACKGROUND: Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to better prepare individuals to manage anaphylaxis in the community. INTRODUCTION: Didactic training as the sole method of anaphylaxis education has been shown to be ineffective. We developed a smartphone-based interactive teaching tool with decision support and epinephrine auto-injector (EAI) training to provide education accessible beyond the clinic. METHODS: This study consisted of two parts: (1) Use of food allergy scenarios to assess the decision support's ability to improve allergic reaction management knowledge. (2) An assessment of our EAI training module on participant's ability to correctly demonstrate the use of an EAI by comparing it to label instructions. RESULTS: Twenty-two adolescents were recruited. The median (range) baseline number of correct answers on the scenarios before the intervention was 9 (3-11). All subjects improved with decision support, increasing to 11 (9-12) (p < .001). The median (range) demonstration score was 6 (5-6) for the video training module group and 4.5 (3-6) for the label group (p < 0.001). DISCUSSION: Results suggest that the use of this novel m-health application can improve anaphylaxis symptom recognition and increase the likelihood of choosing the appropriate treatment. In addition, performing EAI steps in conjunction with the video training resulted in more accurate medication delivery with fewer missed steps compared to the use of written instructions alone. CONCLUSION: The results suggest that mobile health decision support technology for anaphylaxis emergency preparedness may support traditional methods of training by providing improved access to anaphylaxis training in the community setting.

Automatic Identification and Quantification of Extra-Well Fluorescence in Microarray Images.

In recent studies involving NAPPA microarrays, extra-well fluorescence is used as a key measure for identifying disease biomarkers because there is evidence to support that it is better correlated with strong antibody responses than statistical analysis involving intraspot intensity. Because this feature is not well quantified by traditional image analysis software, identification and quantification of extra-well fluorescence is performed manually, which is both time-consuming and highly susceptible to variation between raters. A system that could automate this task efficiently and effectively would greatly improve the process of data acquisition in microarray studies, thereby accelerating the discovery of disease biomarkers. In this study, we experimented with different machine learning methods, as well as novel heuristics, for identifying spots exhibiting extra-well fluorescence (rings) in microarray images and assigning each ring a grade of 1-5 based on its intensity and morphology. The sensitivity of our final system for identifying rings was found to be 72% at 99% specificity and 98% at 92% specificity. Our system performs this task significantly faster than a human, while maintaining high performance, and therefore represents a valuable tool for microarray image analysis.

Comparative analysis of the performance of two different platforms for femtosecond laser-assisted cataract surgery.

PURPOSE: To analyze and compare the intraoperative and postoperative outcomes of cataract surgery performed with two different femtosecond laser platforms. METHODS: Randomized controlled prospective intraindividual comparative study including 90 eyes of 45 patients aged between 61 and 86 years. All eyes underwent bilateral cataract surgery assisted with femtosecond laser technology. Eyes were randomized to one of two different femtosecond laser platforms: Catalys Precision system (Abbott Medical Optics Inc., Santa Ana, CA, USA) (Catalys group), and LenSx system (Alcon-LenSx Inc., Aliso Viejo, CA, USA) (LenSx group). Several intraoperative parameters and changes in corrected distance visual acuity and corneal endothelial density were evaluated and compared. RESULTS: The LenSx group showed a significantly higher cumulative dissipated energy and phacoemulsification power needed compared to the Catalys group (P≤0.043). Likewise, a longer patient interface preparation time, more severe perception of pressure by patient, and more cases of subconjunctival hemorrhage were found in the LenSx group (P≤0.014). A complete capsulotomy was achieved in more cases in the Catalys group compared to the LenSx group (P=0.002). Regarding corneal incisions, no statistically significant differences were found between groups (P≥0.071). The same occurred for postoperative corrected distance visual acuity (P≥0.48), endothelial cell density changes (P≥0.14), and the incidence of corneal edema or flare (P≥0.399). CONCLUSION: Cataract surgery with the two evaluated femtosecond laser platforms is a safe procedure, with reduced phaco time and energy, and preservation of corneal endothelium integrity. However, both systems differ in the performance of capsulotomy and the procedure of docking, with an advantage of the Catalys over the LenSx system.

A high-precision rule-based extraction system for expanding geospatial metadata in GenBank records.

OBJECTIVE: The metadata reflecting the location of the infected host (LOIH) of virus sequences in GenBank often lacks specificity. This work seeks to enhance this metadata by extracting more specific geographic information from related full-text articles and mapping them to their latitude/longitudes using knowledge derived from external geographical databases. MATERIALS AND METHODS: We developed a rule-based information extraction framework for linking GenBank records to the latitude/longitudes of the LOIH. Our system first extracts existing geospatial metadata from GenBank records and attempts to improve it by seeking additional, relevant geographic information from text and tables in related full-text PubMed Central articles. The final extracted locations of the records, based on data assimilated from these sources, are then disambiguated and mapped to their respective geo-coordinates. We evaluated our approach on a manually annotated dataset comprising of 5728 GenBank records for the influenza A virus. RESULTS: We found the precision, recall, and f-measure of our system for linking GenBank records to the latitude/longitudes of their LOIH to be 0.832, 0.967, and 0.894, respectively. DISCUSSION: Our system had a high level of accuracy for linking GenBank records to the geo-coordinates of the LOIH. However, it can be further improved by expanding our database of geospatial data, incorporating spell correction, and enhancing the rules used for extraction. CONCLUSION: Our system performs reasonably well for linking GenBank records for the influenza A virus to the geo-coordinates of their LOIH based on record metadata and information extracted from related full-text articles.

Knowledge-driven geospatial location resolution for phylogeographic models of virus migration.

UNLABELLED: Diseases caused by zoonotic viruses (viruses transmittable between humans and animals) are a major threat to public health throughout the world. By studying virus migration and mutation patterns, the field of phylogeography provides a valuable tool for improving their surveillance. A key component in phylogeographic analysis of zoonotic viruses involves identifying the specific locations of relevant viral sequences. This is usually accomplished by querying public databases such as GenBank and examining the geospatial metadata in the record. When sufficient detail is not available, a logical next step is for the researcher to conduct a manual survey of the corresponding published articles. MOTIVATION: In this article, we present a system for detection and disambiguation of locations (toponym resolution) in full-text articles to automate the retrieval of sufficient metadata. Our system has been tested on a manually annotated corpus of journal articles related to phylogeography using integrated heuristics for location disambiguation including a distance heuristic, a population heuristic and a novel heuristic utilizing knowledge obtained from GenBank metadata (i.e. a 'metadata heuristic'). RESULTS: For detecting and disambiguating locations, our system performed best using the metadata heuristic (0.54 Precision, 0.89 Recall and 0.68 F-score). Precision reaches 0.88 when examining only the disambiguation of location names. Our error analysis showed that a noticeable increase in the accuracy of toponym resolution is possible by improving the geospatial location detection. By improving these fundamental automated tasks, our system can be a useful resource to phylogeographers that rely on geospatial metadata of GenBank sequences. .

Natural language processing methods for enhancing geographic metadata for phylogeography of zoonotic viruses.

Zoonotic viruses represent emerging or re-emerging pathogens that pose significant public health threats throughout the world. It is therefore crucial to advance current surveillance mechanisms for these viruses through outlets such as phylogeography. Despite the abundance of zoonotic viral sequence data in publicly available databases such as GenBank, phylogeographic analysis of these viruses is often limited by the lack of adequate geographic metadata. However, many GenBank records include references to articles with more detailed information and automated systems may help extract this information efficiently and effectively. In this paper, we describe our efforts to determine the proportion of GenBank records with "insufficient" geographic metadata for seven well-studied viruses. We also evaluate the performance of four different Named Entity Recognition (NER) systems for automatically extracting related entities using a manually created gold-standard.

Femtosecond laser-assisted cataract surgery without ophthalmic viscosurgical devices.

PURPOSE: To describe a technique for performing femtosecond laser-assisted cataract surgery without the use of ophthalmic viscosurgical devices (OVDs). METHODS: After laser pretreatment, the anterior chamber is stabilized with balanced salt solution during lens and cortex aspiration. A preloaded intraocular lens is implanted under irrigation. RESULTS: In 23 eyes undergoing surgery without the use of OVDs, no complications were observed within a 1-month follow-up period. The time for surgery and the amount of fluid that went into the eye were similar to those of a standard procedure. There was no remarkable increase in intraocular pressure or corneal thickness. All patients achieved a significant increase in corrected distance visual acuity after surgery. CONCLUSIONS: The significant reduction of phacoemulsification use after femtosecond laser application might render the use of OVDs obsolete in many cases.

Improving accuracy of phakic intraocular lens sizing using high-frequency ultrasound biomicroscopy.

PURPOSE: To assess the efficacy of high-frequency ultrasound biomicroscopy (UBM) in improving the accuracy of phakic intraocular lens (pIOL) sizing by increasing the incidence of acceptable postoperative vault. SETTING: Multiple private practices, United States. DESIGN: Evaluation of diagnostic test or technology. METHODS: This prospective multicenter clinical study evaluated eyes having pIOL (Visian Implantable Collamer Lens) implantation. A retrospective data analysis was performed using UBM measurements (VuMax-II) of preoperative sulcus-to-sulcus (STS) distance and postoperative vault. The regression data and clinical input from investigators were then used to develop a pIOL sizing nomogram. The nomogram used only STS and pIOL power as variables to determine length. Inadequate vault (<90 µm) and excessive vault (>1000 µm) were defined based on peer-reviewed literature. Sizing recommendations using the nomogram were studied prospectively and compared with 2 sizing methods used in the United States that are based on white-to-white (WTW) measurements. RESULTS: One eye was excluded from the analysis because the wrong length pIOL was placed (12.6 mm instead of nomogram-recommended 13.2 mm), resulting in 51 µm of vault. The mean postoperative vault in the remaining 72 cases was 340 µm ± 174 (SD) (range 90 to 952 µm); there were no cases of inadequate or excessive vault with the newly developed UBM nomogram. Sizing methods using WTW measurements would have resulted in different-sized pIOLs in 36% to 69% of cases compared with the STS method. CONCLUSION: There were no cases of inadequate or excessive vault when the UBM nomogram for pIOL sizing was used. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

The Visian myopic implantable collamer lens does not significantly affect axial length measurement with the IOLMaster.

PURPOSE: To compare pre- to postoperative axial length measurements with the IOLMaster (Zeiss Humphrey Systems) to determine whether a correction factor for later intraocular lens (IOL) power calculation is necessary with an Implantable Collamer Lens (ICL; STAAR Surgical) in place. METHODS: The commercially approved Visian ICL was implanted in 60 eyes from 3 separate sites (20 eyes each). Pre- and postoperative axial length measurements were obtained using partial coherence interferometry. RESULTS: The pre- and postoperative axial lengths were highly correlated with an R2 value of 0.9963. For all ranges of axial lengths tested, the use of postoperative axial length instead of preoperative axial length resulted in a <0.1-mm error in axial length measurements. CONCLUSIONS: Based on the SRK formula, a 0.1-mm axial length difference would result in a 0.25-diopter (D) change in calculated IOL power; possibly a 0.20-D change in manifest refraction. These differences are so small as to make any correction to IOL power calculation formula based on the presence of an ICL unnecessary.