Inappropriate Use of the Term "Papilledema" in the Medical Literature: A Systematic Review of Case Reports across Specialties

TOPIC

The term "papilledema" is often misused in different ways when describing nonintracranial pressure-related optic disc edema (ODE) or on fundoscopic examination. However, the extent of these errors is unknown among case reports.

CLINICAL RELEVANCE

"Papilledema" refers to ODE secondary to raised intracranial pressure (ICP). Papilledema is a leading reason for referral to neuro-ophthalmologists. In any specialty setting, papilledema must be distinguished from other causes of ODE because it implies a unique pathophysiology and management strategy. If managed inappropriately, papilledema may cause permanent vision loss.

METHODS

Cross-sectional evidence-based study with protocol registered on Open Science Framework (digital object identifier: 10.17605/OSF.IO/BUQS3). From Ovid MEDLINE and EMBASE, we included case reports with "papilledema" in their title, abstract, or article keywords between January 2011 and March 2022. Studies were graded for the following errors: type 1 (using "papilledema" without evidence of elevated ICP), type 2 (declaring "papilledema" on examination before finding evidence of elevated ICP), type 3 (both errors type 1 and 2), or no error.

RESULTS

Among 722 case reports, there was a total of 482 errors (66.8%). There were 12 type 1 errors, 360 type 2 errors, 110 type 3 errors, and 240 studies with no errors. Ophthalmology, neurology, and neurosurgery were the most represented fields, yet only ophthalmology had a low prevalence of errors among all specialties. Regardless, all specialties with at least 10 included reports had a high error prevalence (>30%). Reduced error prevalence was significantly associated with higher impact factor journals, non-open-access publication models, and origin countries with an English official language. Error prevalence was not significantly associated with publication year. Also, the relationship between article citation counts and the prevalence of any type of error did not reach significance. Risk of bias analysis indicated that error occurrence was unrelated to the quality of case report study design.

CONCLUSION

"Papilledema" is widely misused even among ophthalmology case reports. When allowed to propagate, this error can mislead care delivery to patients with ODE. Our results, although limited to case reports, indicate a need for more thorough peer-review standards and neuro-ophthalmology exposure in medical education.

Migraine-Like Positive Visual Phenomena Related to Focal Cortical Lesions with Undetectable Visual Field Defects

Migraines are commonly associated with a visual aura that has a characteristic clinical presentation. Cortical lesions within or in close proximity to the retrochiasmal visual pathways may also present in a manner that mimics migrainous visual phenomena and, in some cases, may be too small to manifest with a visual field defect on formal testing. We present 4 patients (3 females and 1 male) with an average age of 48.5 (range 28-67) years who had migraine-like visual disturbances related to a right temporal meningioma, occipital cavernoma, occipital lobe infarction, and demyelination in the optic radiations, which was the presenting sign of multiple sclerosis. No patient underwent neurosurgical intervention, and 1 patient (occipital lobe infarct) had complete resolution of the symptom after initial presentation. All patients had normal visual fields at follow-up and no thinning evident on optical coherence tomography. Our cases emphasize the importance of a history in assessing patients with transient positive visual phenomena and identify pathology that may present without visual field defects. Clinical features that should raise a doubt about a diagnosis of migraine visual aura include the absence of headache, brief visual disturbance lasting <5 min or those lasting >60 min, and age >40, especially with no past medical history of migraine.

Microglial NMDA receptors drive pro-inflammatory responses via PARP-1/TRMP2 signaling

Chronic neuroinflammation driven by microglia is a characteristic feature associated with numerous neurodegenerative diseases. While acute inflammation can assist with recovery and repair, prolonged microglial pro-inflammatory responses are known to exacerbate neurodegenerative processes. Yet, detrimental outcomes of extended microglial activation are counterbalanced by beneficial outcomes including phagocytosis and release of trophic factors promoting neuronal viability. Our past work has shown that the nuclear enzyme poly(ADP-ribose) polymerase-1 (PARP-1) is a key signaling hub driving pro-inflammatory microglia responses, but the signaling pathway maintaining PARP-1 activation remains elusive. While best understood for its role in promoting DNA repair, our group has shown that PARP-1 activity can be stimulated via Ca²⁺ influx-dependent ERK1/2-mediated phosphorylation. However, to date, the route of Ca²⁺ entry responsible for stimulating PARP-1 has not been identified. A likely candidate is via Ca²⁺ -permeable transient receptor potential melastatin 2 (TRPM2) channels activated downstream of PARP-1 in a cascade that involves ADP-ribose (ADPR) production by poly(ADP-ribose) glycohydrolase (PARG). Here we demonstrate that NMDA receptor (NMDAR) stimulation in primary cultured microglia induces their proliferation, morphological activation and release of pro-inflammatory mediators. These responses were contingent on the recruitment of PARP-1, PARG and Ca²⁺ permeable TRPM2 channels. Furthermore, we show that Ca²⁺ influx is necessary to activate PARP-1/TRPM2 signaling, in an ERK1/2-dependent, but DNA damage independent, manner. Our findings, showing that PARP-1/TRPM2 mediate the pro-inflammatory effects of NMDAR stimulation, provides a unifying mechanism linking elevated glutamate levels to chronic neuroinflammation.

β2 adrenergic receptors and leptin interplay to decrease food intake in chicken

1. The present study was designed to examine the effects of intracerebroventricular (ICV) injection of different α and [Formula: see text] adrenergic receptor antagonists on leptin-induced hypophagia in broiler chickens.2. The study consisted of six experiments. In all experiments, chickens were deprived of feed for 3 h prior to the ICV injections and thereafter were returned immediately to the individual cages and cumulative feed intake, based on the percentage of body weight, was measured at 30, 60 and 120 min post-injection.3. In experiment 1, leptin (2.5, 5 or 10 µg) were injected in birds. In experiment 2, groups received either control solution, prazosin (10 nmol), leptin (10 µg) or a co-injection of prazosin (10 nmol) and leptin (10 µg). The other experiments were conducted as experiment 2, but instead of prazosine (10 nmol), yohimbine (13 nmol) was used in experiment 3, metoprolol (24 nmol) in experiment 4, ICI 118,551 (5 nmol) in experiment 5 and SR 59230R (5 nmol) in experiment 6 were injected either in a group or in combination with leptin (10 µg).4. The results of this study revealed a dose-dependent hypophagic effect of leptin and, in experiment 5, ICV co-injection of ICI118, 551 (5 nmol) and leptin (10 µg) significantly attenuated this effect (P˂0.5). These results suggest that the hypophagic effect of leptin is probably mediated by β2 adrenergic receptors in chickens.

PKK deficiency in B cells prevents lupus development in Sle lupus mice

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the production of autoantibodies that can result in damage to multiple organs. It is well documented that B cells play a critical role in the development of the disease. We previously showed that protein kinase C associated kinase (PKK) is required for B1 cell development as well as for the survival of recirculating mature B cells and B-lymphoma cells. Here, we investigated the role of PKK in lupus development in a lupus mouse model. We demonstrate that the conditional deletion of PKK in B cells prevents lupus development in Sle1Sle3 mice. The loss of PKK in Sle mice resulted in the amelioration of multiple classical lupus-associated phenotypes and histologic features of lupus nephritis, including marked reduction in the levels of serum autoantibodies, proteinuria, spleen size, peritoneal B-1 cell population and the number of activated CD4 T cells. In addition, the abundance of autoreactive plasma cells normally seen in Sle lupus mice was also significantly decreased in the PKK-deficient Sle mice. Sle B cells deficient in PKK display defective proliferation responses to BCR and LPS stimulation. Consistently, B cell receptor-mediated NF-κB activation, which is required for the survival of activated B cells, was impaired in the PKK-deficient B cells. Taken together, our work uncovers a critical role of PKK in lupus development and suggests that targeting the PKK-mediated pathway may represent a promising therapeutic strategy for lupus treatment.