Faculty Bibliography

BACKGROUND/UNASSIGNED:Hydroxychloroquine (HCQ) is a cornerstone of systemic lupus erythematosus (SLE) management. However, the medication can accumulate within organs and cause toxicity including retinopathy. HCQ is usually discontinued once ocular toxicity is diagnosed, but this is not always sufficient to avoid further damage. Whether retinal injury progresses following HCQ cessation, and which patients are at risk, is of great interest. Prior studies examining progression after HCQ discontinuation are sparse and limited by small sample sizes, and none specifically examine patients with SLE. This study aimed to identify predictors of progression of HCQ-induced retinopathy in SLE patients after medication discontinuation. METHODS/UNASSIGNED:We queried the NYU Lupus Cohort to identify patients with documented HCQ-induced retinopathy who discontinued HCQ and had at least one optical coherence tomography (OCT) follow-up to assess for progression. Demographic information, cumulative HCQ dose, duration of therapy, presence of chronic kidney disease or tamoxifen use, SLE disease activity, and ophthalmologic follow-up intervals were collected. Two ophthalmologists independently reviewed OCT and Humphrey visual field data to confirm retinopathy, grade its severity, and determine progression following drug discontinuation. Statistical analysis was performed using Student's t-test or Wilcoxon rank-sum test for continuous variables and Chi-square or Fisher's exact test for categorical variables. RESULTS/UNASSIGNED:Twenty-one patients with confirmed HCQ retinopathy were included. The mean duration of HCQ therapy preceding diagnosis was 16.2 years and the mean cumulative exposure was 1884 g. Retinal toxicity progressed in 6 patients (28.6%) despite HCQ discontinuation. There appeared to be a trend towards a greater likelihood of progression with more severe retinal toxicity at the time of diagnosis. However, there were no differences between progressors and non-progressors with respect to age at diagnosis, duration or cumulative HCQ exposure, SLE disease activity, tamoxifen use, chronic kidney disease, or guideline-concordant care. CONCLUSIONS/UNASSIGNED:Nearly thirty percent of patients with SLE and HCQ retinopathy progressed despite drug discontinuation. No baseline clinical predictors were associated with progression, though there was a descriptive trend toward greater risk with more severe baseline retinopathy. These data emphasize the importance of continued ocular surveillance for progression of toxicity after discontinuation.

BACKGROUND: Youth in juvenile detention centers are at a high risk for sexually transmitted disease (STD). The current study assesses the trends of chlamydia and gonorrhea (GC) infections and treatment among females within a single county's juvenile correctional facilities. METHODS:This is a retrospective review of aggregate data of female adolescents between 12 and 18 years old who underwent STD screening from 2009 to 2016 in San Bernardino County. RESULTS:Chlamydia infections among adolescent females increased from 11.8% in 2009 to 17.0% in 2016 (p = 0.0002), and GC infections increased from 1.3% in 2009 to 6.0% in 2016 (p < 0.0001). Treatment rates of chlamydia were stable, ranging from 66.7% to 70.8% of positive female adolescents were treated between 2009 and 2016 (p=0.1752). The treatment rate for GC increased from 33% in 2009 to 78.3% in 2016, but annual trends were not statistically significant (p=0.8419). CONCLUSIONS:Chlamydia and GC infections among female adolescents discovered during routine screening upon booking into a county juvenile detention system increased over the study time period. Effective collaboration between public health and various community organizations is needed to improve awareness and prevention of STDs amongst at-risk adolescents.

PURPOSE/OBJECTIVE:To describe a case of endogenous endophthalmitis from Streptococcus dysgalactiae subspecies equisimilis in the setting of an aortic valve abscess Methods: Retrospective case report. RESULTS:A 72-year-old white male presented with fevers, encephalopathy, and decreased vision in his left eye. His visual acuity was 20/20 in his right eye and finger counting in the left eye. Workup revealed an aortic valve abscess. Examination of his left eye revealed dense anterior chamber fibrin and no view of the retina. B-scan ultrasonography revealed loculated hyperechoic areas consistent with vitreous inflammation. A vitreous tap and injections with vancomycin and ceftazidime were performed. Visual acuity worsened to no-light perception 5 days later. Vitreous and blood cultures grew Streptococcus dysgalactiae subspecies equisimilis. He received another intravitreal injection of vancomycin with no improvement. CONCLUSIONS:Streptococcus dysgalactiae subspecies equisimilis is an emerging pathogen and may cause severe intraocular infections with a poor visual outcome.

Objective: Endothelial dysfunction in childhood obesity may precede cerebrovascular damage and cognitive impairment in adulthood. A noninvasive proxy of microvascular health is required to identify the risk for microvascular damage in obese children. DESIGN AND METHODS: The associations of hippocampal volumes and global cerebral atrophy were assessed with retinal vessel caliber in 40 normal BMI controls and 62 obese age-matched nondiabetic adolescents and the contribution of inflammation, obesity, and insulin resistance to retinal vessel caliber was evaluated. RESULTS: Compared to controls, obese adolescents had smaller retinal arterioles (8.3% decrease, P < 0.05) and wider venules (5.4% increase, P < 0.01). Larger retinal arteriole diameters were associated with less global cerebral atrophy (B = -0.24 [95% confidence interval, CI: -0.48, -0.002]) and larger hippocampal volumes (B = 0.01 [95% CI: 0, 0.02]). Venule diameters (B = 84.2 [95% CI: 30.3, 138.1]) were predicted by inflammation (fibrinogen). Arteriolar diameters were predicted by insulin resistance, indicated by logHOMA (homeostatic model assessment, HOMA) values (B = -17.03 [95% CI: -28.25, -5.81)] and body mass index (BMI) (B = -.67 [95% CI: -1.09, -0.24)]. All analyses were adjusted for mean arterial pressure, sleep apnea, and vessel diameter. CONCLUSIONS: Measures of brain health, BMI, and insulin resistance are associated with retinal vessel caliber. If confirmed in larger studies, retinal arteriolar caliber may serve as a possible noninvasive proxy for brain atrophy in obese adolescents, and the identification of elevated risk for cerebral microvascular disease in adulthood.

BACKGROUND:sexually transmitted infection (STI) screening in pregnancy provides an excellent opportunity for secondary prevention. OBJECTIVE:to document the epidemiology of HIV, hepatitis B, and syphilis among pregnant women at a Guatemalan national hospital. RESULTS:from 2004 to 2009, 118 (0.76%) of 15 563 of women tested in the prenatal clinic had HIV infection, 29 (0.22%) of 13 028 women tested had hepatitis B virus infection, and 78 (0.60%) of 13 027 had a positive test for syphilis. From August 1, 2007 through December 31, 2009, 29 482 women were tested in the obstetrical emergency room. A total of 63 were HIV positive (0.21%), 48 had hepatitis B (0.16%), and 196 had syphilis (0.66%). Of the 9196 births between August 2007 and July of 2008, 33 (0.36%) were to HIV-infected mothers. CONCLUSION/CONCLUSIONS:these 3 STIs were uncommon in our population and did not increase in incidence during the study period. HIV maternal-to-child transmission (MTCT) prevention programs were feasible in our setting.

OBJECTIVE: To determine the impact of insulin resistance short of diabetes on the arteriolar-to-venular ratio (AVR) and whether AVR is related to cerebral atrophy. DESIGN: Cross-sectional study. PARTICIPANTS: Forty-six nondiabetic subjects with normal glucose tolerance and varying degrees of insulin resistance ranging in age from 43 to 77 years. METHODS: Insulin resistance was assessed by fasting insulin and the homeostasis model assessment. Arteriolar-to-venular ratio was determined using digital retinal photography with a nonmydriatic camera, and retinal data were analyzed using a reliable semiautomated method. Cerebral atrophy was derived by means of manual tracing and thresholding procedures on structural magnetic resonance images. MAIN OUTCOME MEASURES: Arteriolar-to-venular ratio and cerebral atrophy. RESULTS: Hyperinsulinemia negatively impacted AVR. Furthermore, AVR was associated with cerebral atrophy. Both of these findings were independent of the effects of age and hypertension. CONCLUSIONS: These novel findings indicate that insulin resistance short of diabetes and independent of age and hypertension has a negative impact on retinal vessel health. Moreover, impaired retinal vessel health related to brain atrophy also was independent of hypertension and white matter hyperintensities. Given the connections between retinal and cerebral vasculature, this may offer a partial explanation for the presence of cognitive and brain abnormalities among individuals with insulin resistance. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article