An evidence-based approach to the routine use of optical coherence tomography

Optical coherence tomography is an imaging technology that has revolutionised the detection, assessment and management of ocular disease. It is now a mainstream technology in clinical practice and is performed by non-specialised personnel in some settings. This article provides a clinical perspective on the implications of that movement and describes best practice using multimodal imaging and an evidence-based approach. Practical, illustrative guides on the interpretation of optical coherence tomography are provided for three major diseases of the ocular fundus, in which optical coherence tomography is often crucial to management: age-related macular degeneration, diabetic retinopathy and glaucoma. Topics discussed include: cross-sectional and longitudinal signs in ocular disease, so-called ‘red-green’ disease whereby clinicians rely on machine/statistical comparisons for diagnosis in managing treatment-naïve patients, and the utility of optical coherence tomography angiography and machine learning

A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease

Background: Currently, no specific collaborative care pathway exists that distinguishes open angle glaucoma from narrow angle or angle closure disease. This study evaluates a newly developed referral and collaborative care pathway specifically for patients with angle closure spectrum disease. Methods: The medical records of consecutive patients referred to the Centre for Eye Health for glaucoma assessment were examined, six months before (Pre Suite) and after (Post Suite) the introduction of a novel referral pathway for anterior chamber angle assessment (Angle Suite). Patient demographic and clinical data, the referral letter and practitioner characteristics were extracted. Results: Angle Suite (n = 77) patients had an appointment much sooner compared to Pre (n = 383) and Post Suite (n = 425) patients (p < 0.0001). Following the introduction of Angle Suites, there was a reduction of incidental angle closure disease found in routine, non-angle closure glaucoma assessment. Onward referral was required by 36.4 per cent of patients referred for suspected angle closure disease, while the rest could be discharged back into the community (13.0 per cent) or reviewed at the Centre for Eye Health (50.6 per cent). Multinomial logistic regression found that the presence of an angle description in the referral letter improved the true positive rate for angle closure disease (p < 0.0001). Conclusions: The clinical pathway may reduce the number of incidental angle closure patients and improved the timeliness of appropriate clinical care delivered to a subset of patients who may benefit from prompt medical attention. This pathway provides an opportunity for appropriately staffed and equipped collaborative care clinics to reduce the burden on tertiary level ophthalmic facilities

Expression, Purification, and Biophysical Characterization of a Secreted Anthrax Decoy Fusion Protein in Nicotiana benthamiana.

Anthrax toxin receptor-mediated drug development for blocking anthrax toxin action has received much attention in recent decades. In this study, we produced a secreted anthrax decoy fusion protein comprised of a portion of the human capillary morphogenesis gene-2 (CMG2) protein fused via a linker to the fragment crystallizable (Fc) domain of human immunoglobulin G1 in Nicotiana benthamiana plants using a transient expression system. Using the Cauliflower Mosaic Virus (CaMV) 35S promoter and co-expression with the p19 gene silencing suppressor, we were able to achieve a high level of recombinant CMG2-Fc-Apo (rCMG2-Fc-Apo) protein accumulation. Production kinetics were observed up to eight days post-infiltration, and maximum production of 826 mg/kg fresh leaf weight was observed on day six. Protein A affinity chromatography purification of the rCMG2-Fc-Apo protein from whole leaf extract and apoplast wash fluid showed the homodimeric form under non-reducing gel electrophoresis and mass spectrometry analysis confirmed the molecular integrity of the secreted protein. The N-glycosylation pattern of purified rCMG2-Fc-Apo protein was analysed; the major portion of N-glycans consists of complex type structures in both protein samples. The most abundant (&gt;50%) N-glycan structure was GlcNAc₂(Xyl)Man₃(Fuc)GlcNAc₂ in rCMG2-Fc-Apo recovered from whole leaf extract and apoplast wash fluid. High mannose N-glycan structures were not detected in the apoplast wash fluid preparation, which confirmed the protein secretion. Altogether, these findings demonstrate that high-level production of rCMG2-Fc-Apo can be achieved by transient production in Nicotiana benthamiana plants with apoplast targeting

A combined convolutional and recurrent neural network for enhanced glaucoma detection.

Glaucoma, a leading cause of blindness, is a multifaceted disease with several patho-physiological features manifesting in single fundus images (e.g., optic nerve cupping) as well as fundus videos (e.g., vascular pulsatility index). Current convolutional neural networks (CNNs) developed to detect glaucoma are all based on spatial features embedded in an image. We developed a combined CNN and recurrent neural network (RNN) that not only extracts the spatial features in a fundus image but also the temporal features embedded in a fundus video (i.e., sequential images). A total of 1810 fundus images and 295 fundus videos were used to train a CNN and a combined CNN and Long Short-Term Memory RNN. The combined CNN/RNN model reached an average F-measure of 96.2% in separating glaucoma from healthy eyes. In contrast, the base CNN model reached an average F-measure of only 79.2%. This proof-of-concept study demonstrates that extracting spatial and temporal features from fundus videos using a combined CNN and RNN, can markedly enhance the accuracy of glaucoma detection

Anterior Chamber Angle Evaluation Using Gonioscopy: Consistency and Agreement between Optometrists and Ophthalmologists

SIGNIFICANCE In our intermediate-tier glaucoma care clinic, we demonstrate fair to moderate agreement in gonioscopy examination between optometrists and ophthalmologists, but excellent agreement when considering open versus closed angles. We highlight the need for increased consistency in the evaluation and recording of angle status using gonioscopy. PURPOSE The consistency of gonioscopy results obtained by different clinicians is not known but is important in moving toward practice modalities such as telemedicine and collaborative care clinics. The purpose of this study was to evaluate the description and concordance of gonioscopy results among different practitioners. METHODS The medical records of 101 patients seen within a collaborative care glaucoma clinic who had undergone gonioscopic assessment by two clinicians (one optometrist and either one general ophthalmologist [n = 50] or one glaucoma specialist [n = 51]) were reviewed. The gonioscopy records were evaluated for their descriptions of deepest structure seen, trabecular pigmentation, iris configuration, and other features. These were compared between clinicians (optometrist vs. ophthalmologist) and against the final diagnosis. RESULTS Overall, 51.9 and 59.8% of angles were graded identically in terms of deepest visible structure when comparing between optometrist versus general ophthalmologist and optometrist versus glaucoma specialist, respectively. The concordance increased when considering ±1 of the grade (67.4 and 78.5%, respectively), and agreement with the final diagnosis was high (>90%). Variations in angle grading other than naming structures were observed (2.0, 30, and 3.9% for optometrist, general ophthalmologist, and glaucoma specialist, respectively). Most of the time, trabecular pigmentation or iris configuration was not described. CONCLUSIONS Fair to moderate concordance in gonioscopy was achieved between optometrists and ophthalmologists in a collaborative care clinic in which there is consistent feedback and clinical review. To move toward unified medical records and a telemedicine model, improved consistency of record keeping and angle description is required

Suboptimal Exposure to Anti-TB Drugs in a TBM/HIV+ Population is not Related to Anti-retroviral Therapy.

A placebo-controlled trial that compares the outcomes of immediate versus deferred initiation of antiretroviral therapy in HIV+ve Tuberculous Meningitis (TBM) patients was conducted in Vietnam in 2011. Here, the pharmacokinetics of Rifampicin, Isoniazid, Pyrazinamide and Ethambutol were investigated in the presence and absence of anti-HIV treatment in 85 patients. Pharmacokinetic analyses show that HIV therapy has no significant impact upon the pharmacokinetics of TB drugs in this cohort. The same population, however, displayed generally low CSF and systemic exposures to rifampicin compared to previously reported HIV –ve cohorts. Elevated CSF concentrations of pyrazinamide on the other hand were strongly and independently correlated with increased mortality and neurological toxicity. The findings suggest that the current standard dosing regimens may put the patient at risk of treatment failure from suboptimal rifampicin exposure, and potentially increasing the risk of adverse CNS events which are independently correlated with pyrazinamide CSF exposure

The PDB database is a rich source of alpha-helical anti-microbial peptides to combat disease causing pathogens

The therapeutic potential of α-helical anti-microbial peptides (AH-AMP) to combat pathogens is fast gaining prominence. Based on recently published open access software for characterizing &#945;-helical peptides (PAGAL), we elucidate a search methodology (SCALPEL) that leverages the massive structural data pre-existing in the PDB database to obtain AH-AMPs belonging to the host proteome. We provide in vitro validation of SCALPEL on plant pathogens (Xylella fastidiosa, Xanthomonas arboricola and Liberibacter crescens) by identifying AH-AMPs that mirror the function and properties of cecropin B, a well-studied AH-AMP. The identified peptides include a linear AH-AMP present within the existing structure of phosphoenolpyruvate carboxylase (PPC20), and an AH-AMP mimicing the properties of the two α-helices of cecropin B from chitinase (CHITI25). The minimum inhibitory concentration of these peptides are comparable to that of cecropin B, while anionic peptides used as control failed to show any inhibitory effect on these pathogens. Substitute therapies in place of conventional chemotherapies using membrane permeabilizing peptides like these might also prove effective to target cancer cells. The use of native structures from the same organism could possibly ensure that administration of such peptides will be better tolerated and not elicit an adverse immune response. We suggest a similar approach to target Ebola epitopes, enumerated using PAGAL recently, by selecting suitable peptides from the human proteome, especially in wake of recent reports of cationic amphiphiles inhibiting virus entry and infection