Sarcoidosis: Hiding in Plain Sight

Introduction: Sarcoidosis is a systemic disease that can masquerade as many conditions. Due to its often patchy distribution, myocardial biopsy is only ∼30% sensitive. Herein we present a case of sarcoidosis diagnosed from an extra-cardiac biopsy years after the onset of cardiomyopathy. Case Report: A 54 year old man initially presented with dyspnea and fatigue due to new onset HFrEF of 20%. He had a significant family history of SCD. His workup revealed non-obstructive CAD, a myxomatous mitral valve with bileaflet prolapse and moderate regurgitation, and a cystic structure attached to the tricuspid valve. Given his frequent ventricular ectopy, he was discharged on guideline therapy for HFrEF and a wearable cardioverter defibrillator. Genetic testing for dilated cardiomyopathies revealed EYA4 and TTN variants of unknown significance. A cardiac MRI a few months later demonstrated no abnormal late gadolinium enhancement and persistent systolic dysfunction, so he underwent AICD implant. His course was further complicated by recurrent admissions for supraventricular and ventricular tachyarrhythmias. A cardiopulmonary exercise stress test demonstrated low-risk results. Further evaluation noted prolonged AV conduction. A RHC revealed mild post-capillary pulmonary hypertension and a mildly decreased cardiac index at 2.01 L/min/m2. Months later, he underwent CRT-D upgrade. He started improving functionally until he developed left eyelid swelling, initially thought to be lymphoma. An orbital biopsy revealed non-caseating granulomas. A PET/CT demonstrated FDG uptake within subcarinal lymph nodes but no cardiac uptake. Initially he declined immunomodulatory therapy, but as his symptoms worsened, he started corticosteroids and transitioned to mycophenolate mofetil due to intolerance of methotrexate. Due to disease progression on repeat FDG-PET, he was switched to infliximab. The diagnosis of sarcoidosis can be difficult due to its variable presentation, including heart block, heart failure, ventricular arrhythmias and sudden cardiac death. Cardiac involvement occurs in 25% of cases. Our case was complicated by a cMRI that was negative for cardiac involvement, which emphasizes the importance of complimentary inflammatory imaging with FDG-PET. A multidisciplinary approach is needed that engages sarcoid specialists for earlier diagnosis to ensure rapid initiation of therapy to reduce end-organ dysfunction

Artificial Intelligence-Based Solution in Personalized Computer-Aided Arthroscopy of Shoulder Prostheses

Background: Early recognition of prostheses before reoperation can reduce perioperative morbidity and mortality. Because of the intricacy of the shoulder biomechanics, accurate classification of implant models before surgery is fundamental for planning the correct medical procedure and setting apparatus for personalized medicine. Expert surgeons usually use X-ray images of prostheses to set the patient-specific apparatus. However, this subjective method is time-consuming and prone to errors. Method: As an alternative, artificial intelligence has played a vital role in orthopedic surgery and clinical decision-making for accurate prosthesis placement. In this study, three different deep learning-based frameworks are proposed to identify different types of shoulder implants in X-ray scans. We mainly propose an efficient ensemble network called the Inception Mobile Fully-Connected Convolutional Network (IMFC-Net), which is comprised of our two designed convolutional neural networks and a classifier. To evaluate the performance of the IMFC-Net and state-of-the-art models, experiments were performed with a public data set of 597 de-identified patients (597 shoulder implants). Moreover, to demonstrate the generalizability of IMFC-Net, experiments were performed with two augmentation techniques and without augmentation, in which our model ranked first, with a considerable difference from the comparison models. A gradient-weighted class activation map technique was also used to find distinct implant characteristics needed for IMFC-Net classification decisions. Results: The results confirmed that the proposed IMFC-Net model yielded an average accuracy of 89.09%, a precision rate of 89.54%, a recall rate of 86.57%, and an F1.score of 87.94%, which were higher than those of the comparison models. Conclusion: The proposed model is efficient and can minimize the revision complexities of implants

Effectiveness of Haemophilus influenzae type b conjugate vaccine on radiologically-confirmed pneumonia in young children in Pakistan.

OBJECTIVE: The effectiveness of Haemophilus influenzae type b (Hib) vaccine in preventing severe pneumonia in Asian children has been questioned, and many large Asian countries yet to introduce Hib conjugate vaccine in immunization programs. The primary objective of this study was to assess Hib conjugate vaccine effectiveness (VE) on radiologically-confirmed pneumonia in children born after introduction of Hib conjugate vaccine in Pakistan. STUDY DESIGN: A matched case-control study enrolled cases of radiologically-confirmed pneumonia in several hospitals serving low-income populations during 2009-2011. Cases were matched by age and season with 3 hospital and 5 neighborhood controls. Pneumonia was diagnosed using standardized World Health Organization criteria for chest radiograph interpretation. Matched OR were estimated for VE. RESULTS: A total of 1027 children with radiologically-confirmed pneumonia were enrolled; 975 cases, 2925 hospital controls, and 4875 neighborhood controls were analyzed. The coverage for 3 doses of diphtheria-tetanus-pertussis-hepatitis B-Hib conjugate vaccine was 13.7%, 18%, and 22.7% in cases, hospital controls and neighborhood controls, respectively. Estimated Hib VE for radiologically-confirmed pneumonia was 62% with 3 doses of vaccine using hospital controls and 70% using neighborhood controls. CONCLUSIONS: Hib conjugate vaccine prevented a significant fraction of radiologically-confirmed pneumonia in children in Pakistan. Maximizing impact on child survival needs improved immunization coverage