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RESULTS. From an estimated 340 residency programs around NYC, recruitment yielded 91 responses, representing 24 specialties and 2306 residents. In 45.1% of programs, at least 1 resident with confirmed COVID-19 was reported. One hundred one resident physicians were confirmed COVID-19-positive, with an additional 163 residents presumed positive for COVID-19 based on symptoms but awaiting or unable to obtain testing. Two COVID-19-positive residents were hospitalized, with 1 in intensive care. Among specialties with more than 100 residents represented, negative binomial regression indicated that infection risk differed by specialty (P = 0.039). In 80% of programs, quarantining a resident was reported. Ninety of 91 programs reported reuse or extended mask use, and 43 programs reported that personal protective equipment (PPE) was suboptimal. Sixty-five programs (74.7%) redeployed residents elsewhere to support COVID-19 efforts. CONCLUSION. Many resident physicians around NYC have been affected by COVID-19 through direct infection, quarantine, or redeployment. Lack of access to testing and concern regarding suboptimal PPE are common among residency programs. Infection risk may differ by specialty.

Objective To identify patterns of inter-expert discrepancy in plus disease diagnosis in retinopathy of prematurity (ROP). Design We developed two datasets of clinical images of varying disease severity (100 images and 34 images) as part of the Imaging and Informatics in ROP study, and determined a consensus reference standard diagnosis (RSD) for each image, based on 3 independent image graders and the clinical exam. We recruited 8 expert ROP clinicians to classify these images and compared the distribution of classifications between experts and the RSD. Subjects, Participants, and/or Controls Images obtained during routine ROP screening in neonatal intensive care units. 8 participating experts with >10 years of clinical ROP experience and >5 peer-reviewed ROP publications. Methods, Intervention, or Testing Expert classification of images of plus disease in ROP. Main Outcome Measures Inter-expert agreement (weighted kappa statistic), and agreement and bias on ordinal classification between experts (ANOVA) and the RSD (percent agreement). Results There was variable inter-expert agreement on diagnostic classifications between the 8 experts and the RSD (weighted kappa 0 – 0.75, mean 0.30). RSD agreement ranged from 80 – 94% agreement for the dataset of 100 images, and 29 – 79% for the dataset of 34 images. However, when images were ranked in order of disease severity (by average expert classification), the pattern of expert classification revealed a consistent systematic bias for each expert consistent with unique cut points for the diagnosis of plus disease and pre-plus disease. The two-way ANOVA model suggested a highly significant effect of both image and user on the average score (P<0.05, adjusted R2=0.82 for dataset A, and P< 0.05 and adjusted R2 =0.6615 for dataset B). Conclusions and Relevance There is wide variability in the classification of plus disease by ROP experts, which occurs because experts have different “cut-points” for the amounts of vascular abnormality required for presence of plus and pre-plus disease. This has important implications for research, teaching and patient care for ROP, and suggests that a continuous ROP plus disease severity score may more accurately reflect the behavior of expert ROP clinicians, and may better standardize classification in the future.

Background From March 2-April 12, 2020, New York City (NYC) experienced exponential growth of the COVID-19 pandemic due to novel coronavirus (SARS-CoV-2). Little is known regarding how physicians have been affected. We aimed to characterize COVID-19 impact on NYC resident physicians. Methods IRB-exempt and expedited cross-sectional analysis through survey to NYC residency program directors (PDs) April 3-12, 2020, encompassing events from March 2-April 12, 2020. Findings From an estimated 340 residency programs around NYC, recruitment yielded 91 responses, representing 24 specialties and 2,306 residents. 45.1% of programs reported at least one resident with confirmed COVID-19: 101 resident physicians were confirmed COVID-19-positive, with additional 163 residents presumed positive for COVID-19 based on symptoms but awaiting or unable to obtain testing. 56.5% of programs had a resident waiting for, or unable to obtain, COVID-19 testing. Two COVID-19-positive residents were hospitalized, with one in intensive care. Among specialties with >100 residents represented, negative binomial regression indicated that infection risk differed by specialty (p=0.039). Although most programs (80%) reported quarantining a resident, with 16.8% of residents experiencing quarantine, 14.9% of COVID-19-positive residents were not quarantined. 90 programs, encompassing 99.2% of the resident physicians, reported reuse or extended mask use, and 43 programs, encompassing 60.4% of residents, felt that personal protective equipment (PPE) was suboptimal. 65 programs (74.7%) have redeployed residents elsewhere to support COVID-19 efforts. Interpretation Many resident physicians around NYC have been affected by COVID-19 through direct infection, quarantine, or redeployment. Lack of access to testing and concern regarding suboptimal PPE are common among residency programs. Infection risk may differ by specialty. Funding AHA, MPB, RWSC, CGM, LRDG, and JDH are supported by NEI Core Grant P30EY019007, and unrestricted grant from RPB. ACP and JS are supported by Parker Family Chair. SXX is supported by University of Pennsylvania.

OBJECTIVE:To evaluate the clinical utility of a quantitative deep-learning derived vascular severity score for retinopathy of prematurity (ROP) by assessing its correlation with clinical ROP diagnosis and by measuring clinician agreement in applying a novel scale. DESIGN:Analysis of existing database of posterior pole fundus images and corresponding ophthalmoscopic examinations using two methods of assigning a quantitative scale to vascular severity. SUBJECTS AND PARTICIPANTS: Images were from clinical exams of patients in theImaging & Informatics in ROP consortium. 4 ophthalmologists and 1 study coordinator evaluated vascular severity on a 1-9 scale. METHODS:A quantitative vascular severity score (1-9) was applied to each image using a deep learning algorithm. A database of 499 images was developed for assessment of interobserver agreement. MAIN OUTCOME MEASURES: Distribution of deep learning derived vascular severityscores with the clinical assessment of zone (I,II,III), stage (0,1,2,3) and extent (<3, 3-6, >6 clock hours) of stage 3 evaluated using multivariable linear regression. Weighted kappa and Pearson correlation coefficients for inter-observer agreement on 1-9 vascular severity scale. RESULTS:For deep learning analysis, a total of 6344 clinical examinations were analyzed. A higher deep learning derived vascular severity score was associated with more posterior disease, higher disease stage, and higher extent of stage 3 disease (P<.001 for all). For a given ROP stage, the vascular severity score was higher in zone I than zone II or III (P<.001). For a given number of clock hours of stage 3, the severity score was higher in zone I than zone II (P=.03 in zone I and P<.001 in zone II). Multivariable regression found zone, stage, and extent were all independently associated with the severity score (P<.001 for all). For inter-observer agreement, mean (±Standard Deviation [SD]) weighted kappa was 0.67 (±0.06) and Pearson Correlation coefficient (±SD) was 0.88 (±.04) on the use of a 1-9 vascular severity scale. CONCLUSIONS:A vascular severity scale for ROP appears feasible for clinical adoption, corresponds with current international classification of ROP severity, and facilitates the use of objective technology such as deep learning to improve consistency of ROP diagnosis.

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A tele-education system for ROP education was effective in improving the diagnostic accuracy of ROP by ophthalmologists-in-training in Mexico. This system has the potential to increase competency in ROP diagnosis and management for ophthalmologists-in-training from middle-income nations.

Klebsiella pneumoniae K1 is a major agent of hepatic abscess with metastatic disease in East Asia, with sporadic reports originating elsewhere. We report a case of abscess complicated by septic endophthalmitis caused by a wzyAKpK1-positive Klebsiella strain in a U.S. resident, raising concern for global emergence. CASE REPORTA 58-year-old female resident of Bronx, New York, who was originally from the Dominican Republic presented with a chief complaint of 1 day of decreased vision in her right eye and concomitant symptoms, including weakness, myalgia, low-grade fever, and right upper quadrant pain for 1 week. She had a history of uncomplicated choledochal cyst resection and Roux-en-Y hepaticojejunostomy approximately 5 years prior to presentation but no history of ocular disease or prior intraocular surgery. She reported subsequent travel to the Dominican Republic but denied travel to Asia at any point before or after her surgery. On the initial ophthalmic examination, visual acuity was 20/60 in the affected eye. Slit-lamp examination revealed moderate conjunctival injection in the right eye, along with 4ϩ cells and hypopyon in the anterior chamber. The fundus view was hazy because of opacity in the anterior segment, but the retina was flat. She was diagnosed with presumed endogenous endophthalmitis. Her vision in the affected eye worsened over the next 24 h. Because of right upper quadrant tenderness on examination, further imaging was performed, revealing a hepatic abscess (7 by 7 by 7 cm) (Fig. 1). The patient reported no history of diabetes, and the serum glucose was normal. She was treated with intravenous levofloxacin, and the abscess was drained percutaneously. Cultures of liver aspirate, blood, and urine grew K. pneumoniae susceptible to expandedand broad-spectrum cephalosporins, ampicillin-sulbactam, levofloxacin, aminoglycosides, and trimethoprim-sulfamethoxazole. The isolate exhibited a hypermucoviscous phenotype, as exemplified by a positive string test (Fig. 2). On the seventh hospital day, her ophthalmologic exam deteriorated; she was found to have a subretinal abscess in the peripheral temporal retina, and retinal detachment was noted (Fig. 3). A sample of vitreous fluid was obtained, which revealed polymorphonuclear leukocytes on Gram stain but a negative culture, and intravitreal injection of ceftazidime was performed. Over the next several weeks, the vitreous debris cleared, and the retina more clearly assumed the configuration of a bullous rhegmatogenous detachment stemming from a break related to the retinal necrosis at the site of the subretinal abscess. The patient underwent a vitrectomy for retinal detachment 2 months after her initial presentation. The patient's subsequent course was complicated by a relapse of abdominal pain and an increase in size of the liver abscess following a transition to oral therapy. An abdominal CT scan conducted 2 months after the completion of an 8-week antibiotic course demonstrated resolution of her liver abscess.Because of the similarity of this case to rep...