Laminin-521 Protein Therapy for Glomerular Basement Membrane and Podocyte Abnormalities in a Model of Pierson Syndrome

Background Laminin α5β2γ1 (LM-521) is a major component of the GBM. Mutations in LAMB2 that prevent LM-521 synthesis and/or secretion cause Pierson syndrome, a rare congenital nephrotic syndrome with diffuse mesangial sclerosis and ocular and neurologic defects. Because the GBM is uniquely accessible to plasma, which permeates endothelial cell fenestrae, we hypothesized that intravenous delivery of LM-521 could replace the missing LM-521 in the GBM of Lamb2 mutant mice and restore glomerular permselectivity.Methods We injected human LM-521 (hLM-521), a macromolecule of approximately 800 kD, into the retro-orbital sinus of Lamb2-/- pups daily. Deposition of hLM-521 into the GBM was investigated by fluorescence microscopy. We assayed the effects of hLM-521 on glomerular permselectivity by urinalysis and the effects on podocytes by desmin immunostaining and ultrastructural analysis of podocyte architecture.Results Injected hLM-521 rapidly and stably accumulated in the GBM of all glomeruli. Super-resolution imaging showed that hLM-521 accumulated in the correct orientation in the GBM, primarily on the endothelial aspect. Treatment with hLM-521 greatly reduced the expression of the podocyte injury marker desmin and attenuated the foot process effacement observed in untreated pups. Moreover, treatment with hLM-521 delayed the onset of proteinuria but did not prevent nephrotic syndrome, perhaps due to its absence from the podocyte aspect of the GBM.Conclusions These studies show that GBM composition and function can be altered in vivovia vascular delivery of even very large proteins, which may advance therapeutic options for patients with abnormal GBM composition, whether genetic or acquired.

Evidence of specific cognitive deficits in patients with chronic low back pain under long-term substitution treatment of opioids

BACKGROUND

There is a growing number of patients worldwide being treated with long-term opioids for chronic non-cancer pain, although there is limited evidence for their effectiveness in improving pain and function. Opioid-use related adverse effects, especially in cognitive functioning in these patients, are rarely evaluated.

OBJECTIVES

The present study investigated the cognitive functions of patients with chronic back pain who underwent long-term opioid treatment in comparison with those patients without opioid usage and healthy controls.

STUDY DESIGN

A prospective, nonrandomized, cross-sectional study.

SETTING

Multidisciplinary pain management clinic, specialty referral center, University Hospital in Germany.

METHODS

In a prospective cross-sectional design, 37 patients with chronic back pain who underwent long-term opioid therapy (OP) were compared with 33 patients with chronic back pain without opioid therapy (NO) and 25 healthy controls (HC). Assessment of primary outcome included cognitive function such as information processing speed, choice reaction time, pattern recognition memory, and executive function. Other data included pain, back function, depression and anxiety, use of medication, and education status. The relationship between cognitive functions and anxiety/depression was analysed.

RESULTS

Both patient groups needed significantly longer time in information processing when compared to HC (Group 1: 41.87 ± 20.47 Group 2: 38.29 ± 19.99 Group 3: 30.25 ± 14.19). Additionally, OP patients had significantly reduced spatial memory capacity, flexibility for concept change, and impaired performance in working memory assessment compared to NO patients and HC. The impaired cognitive outcomes were significantly associated with pain intensity, depression scores, and medication use.

LIMITATIONS

Limitations include small number of patients with heterogeneous opioid therapy and the nonrandomized observational nature of the study.

CONCLUSIONS

Our findings give a differential view into the cognitive changes from chronic back pain with and without long-term opioids treatment. Chronic back pain itself impairs some distinct cognitive functions. Long-term opioid therapy adds further cognitive impairment.

Marcus Gunn Jaw-Winking synkinesis in a neonate

This report describes a 9-day-old female infant admitted for hypocalcemic seizures. The hypocalcemia was treated, but the infant was noted to have vesico-ureteral reflux and a mild ptosis of her left eye with rhythmic blinking during bottle feeding. The eye findings were subsequently diagnosed as Marcus Gunn jaw-winking Synkinesis.

Hyoscine skin patches for drooling dilate pupils and impair accommodation: spectacle correction for photophobia and blurred vision may be warranted

Hyoscine skin patches diminish salivation by their anticholinergic action. The aim of reporting this case series is to present the ophthalmic side effects in children, and to highlight the precautions to take. Five children (two males, three females; age range 8-18y) with quadraplegic cerebral palsy (Gross Motor Function Classification System Level V) and profound intellectual impairment, wearing hyoscine skin patches to control excessive salivation, were examined. Binocular visual acuity, pupil reaction, pupil diameter, and dynamic retinoscopy were recorded before and after instilling guttae cyclopentolate 1%. The accommodative responses were compared with the expected norms. Spectacle correction was provided for refractive error and to compensate for lack of accommodation. Tinted lenses were provided for photophobia. Visual assessment was repeated 6 months later. All children had dilated pupils with a mean diameter of 7.8mm (range 7-9mm) before instilling guttae cyclopentolate. Mean pupil constriction to bright light was only 1.8mm (range 1-2mm). Mean resting accommodation was 0.45 dioptres (D; range 0-1D) and no accommodative responses were detected on dynamic retinoscopy. Three children were photophobic. Visual behaviour was seen to improve after the use of appropriate spectacles. Photophobia was relieved by tinted lenses. The anticholinergic effects of hyoscine skin patches can cause photophobia and impair vision due to pupil dilatation and paralysis of accommodation. Appropriate spectacles are recommended.

Interdisciplinary Treatment and Ophthalmological Findings in Parry-Romberg Syndrome

Parry-Romberg syndrome is a rare pathologic process, characterized by progressive hemifacial atrophy. A case of Parry-Romberg syndrome with ocular involvement is reported. A 27-year-old male patient with Parry-Romberg syndrome was interdisciplinary investigated and treated. For reconstruction of hemifacial soft tissues a free vascular parascapular graft was performed. Opthalmological findings included an evident enophthalmos and an eyelid lag with keratopathy and epiphora. Furthermore pupillary disturbances and endothelial precipitates were detectable. Complete fundus examination showed a unilateral optic disc swelling, central vitreous opacities and peripheral pigmentary disturbances. In the presented case of Parry-Romberg syndrome a rare association to ophthalmological involvement could be found. Beside the enophthalmos and eyelid alterations, also a panuveitis with papillitis should be treated by steroid therapy.

Progressive outer retinal necrosis in immunocompetent patients treated initially for optic neuropathy with systemic corticosteroids

PURPOSE

To report two cases of progressive outer retinal necrosis occurring in immunocompetent individuals after treatment with corticosteroids for presumed optic neuropathy.

DESIGN

Observational case report.

SETTING

University-based tertiary eye hospital.

METHODS

Retrospective review of existing clinical records.

RESULTS

Two patients were treated empirically with systemic corticosteroids for suspected inflammatory papillopathy. Subsequently, both were diagnosed with necrotizing herpetic retinitis with features of progressive outer retinal necrosis. Anterior chamber paracentesis confirmed varicella-zoster infection. Both patients were human immunodeficiency virus negative; one patient with rheumatoid arthritis was taking etanercept. Both became completely blind in one eye despite intensive treatment with antiviral medication intravenously and intravitreally.

CONCLUSIONS

Progressive outer retinal necrosis is not confined to patients with underlying severe immunodeficiency, such as acquired immune deficiency syndrome. Initial treatment of acute, unexplained vision loss with systemic corticosteroids may lead to catastrophic visual loss in patients with evolving necrotizing herpetic retinopathy.

Predictive value of the initial quantified relative afferent pupillary defect in 19 consecutive patients with traumatic optic neuropathy

PURPOSE

To study the predictive value of the initial quantified relative afferent pupillary defect (RAPD) in patients with indirect traumatic neuropathy as it relates to final visual outcome.

METHODS

The RAPD was measured and quantified by neutral density filters in patients with unilateral indirect traumatic neuropathy. All patients were treated with megadose methylprednisolone by of the protocol established by the Second National Acute Spinal Cord Injury Study. Patients were followed twice daily during treatment and then at 3-month intervals.

RESULTS

Nineteen patients were enrolled over a 23-month period. Patients ranged in age from 12 to 78 years old; 18 of the 19 patients were male. No patient with an RAPD of 2.1 log units or greater had visual recovery to better than hand motion vision. The 7 patients with an initial RAPD of less than 2.1 log units showed improvement in their RAPD and were found to have vision of 20/30 or better during the follow-up period.

CONCLUSIONS

In patients treated with megadose methylprednisolone with an initial RAPD of less than 2.1 log units, visual acuity improved to 20/30 or better; however, patients with an initial RAPD of 2.1 or greater showed little visual improvement. The initial quantified RAPD appears to have a predictive value related to final visual outcome.

Tissue cadmium and locomotor behavior following acute inhalation exposure to cadmium aerosol in rats

Rats were exposed for 1 h to increasing concentrations of cadmium (Cd) through inhalation of cadmium chloride aerosol using nose-only inhalation chambers and depositions of Cd in lungs, liver and kidneys were measured. Changes in spontaneous locomotor activities were recorded 2 and 7 d after cessation of exposure. A concentration dependent increase in Cd in lungs, liver and kidneys was accompanied by significant alterations in spontaneous locomotor response that was dependent on the air Cd concentrations and the postexposure duration. The study shows decreased spontaneous locomotor activity due to Cd accumulation in tissues.

Cocaine abuse, generalized myasthenia, complete external ophthalmoplegia, and pseudotonic pupil

We present the case of a 29-year-old woman with generalized myasthenia. Myasthenia with complete external ophthalmoplegia was unmasked by cocaine abuse. It was associated with changes of the pupillary motility, including light-near dissociation and positive 0.1% pilocarpine test. Treatment with acetylcholinesterase inhibitors improved the patient's condition rapidly, and led to complete normalization of extraocular movements and pupillary function. To our knowledge, this is the fourth case of cocaine-related myasthenia, and the first case of myasthenia with pseudotonic pupil.

Association of high-dose intravenous methylprednisolone with reversal of blindness from lightning in two patients

OBJECTIVE

To report possibly beneficial effects of treatment with high-dose corticosteroids given intravenously to two patients with loss of vision after lightning strikes.

DESIGN

Case reports.

PARTICIPANTS

Two patients who suffered the effects of a lightning strike.

INTERVENTION

High-dose intravenous methylprednisolone (NASCIS-2 Protocol).

MAIN OUTCOME MEASURES

Vision recovery, pupil responses, and optic nerve appearance.

RESULTS

One patient had unilateral ophthalmoscopically visible abnormality with light perception vision and a relative afferent defect in that eye; vision recovered to 20/25. The other patient had no light perception, nonreactive pupils, and normal fundus examinations in both eyes; vision recovered bilaterally to normal (20/20).

CONCLUSIONS

High-dose intravenous corticosteroid treatment in these patients may have had a role in their visual recovery.

Pupillary dynamics in patients with primary open angle glaucoma

In patients with primary open angle glaucoma (POAG), the evaluation of neurological status is clinically important. A detailed analysis of the pupillary dynamics under the control of the autonomic nervous system was performed in patients with POAG. Pupil size and pupillary light reflex were measured by an infrared videopupillogram in 13 patients with POAG (from 25 to 67 years old) with good oculotensive controls without applications mydriatics nor miotics revealed. Pupillary light reflexes were analyzed by comparing the simulated patterns obtained after the studies with topical autonomic agents. Effects of topical adrenergics (dipivalyl epinephrine: DPE 0.025%) on the pupil were also investigated. Three types of autonomic abnormalities (cholinergic, adrenergic and physiological mydriatic reflex patterns) of the light reflex were detected in 11 eyes of 6 patients, and a normal pattern was found in only 2 eyes of one patient. Afferent pupillary defect (APD) pattern was detected in 13 eyes. Although APD was generally described as a reduced visual input, the degree of APD was not related to the stage of the visual field defect in POAG.