Clinicoradiological and prognostic features of COVID-19-associated acute disseminated encephalomyelitis

INTRODUCTION

The Covid-19 pandemic has resulted in a spark in interest in the subject given the high exposure rate to viral antigens in the form of infections and vaccines. It is expected that acute disseminated encephalomyelitis (ADEM) cases see a rise in incidence during this period. Given the plethora of Covid-19-related central nervous system (CNS) involvement, it is important to be aware of the varied presentations of ADEM.

CASE REPORTS

In this paper, we report 3 cases of ADEM following Covid-19 infection. Patients presented with polyfocal neurological symptoms 6 to 18 days after respiratory symptoms onset. The diagnosis of Covid-19 was made based on nasal swab reverse transcriptase-polymerase chain reaction (RT-PCR) and chest computerized tomography (CT).

DISCUSSION

These cases illustrate both classic and atypical presentations requiring exclusion of a spectrum of CNS conditions to be able to retain the diagnosis of ADEM. Consequently, we stress the importance of context, clinical examination and MRI findings in the differentials. In addition, we discuss workup, and particularly, the indication of brain biopsy. Also, the paper discusses options in therapy and the prognosis. The prognosis of covid-associated ADEM is dependent on the extent of pathology intrinsic to ADEM and the intrication of the prognosis of Covid-19 infection.

CONCLUSION

The key message in these 3 cases is that clinicians should have a low threshold of suspicion of ADEM in the Covid-19 context, adopt appropriate workup strategies, and initiate adequate treatment for better outcomes.

Intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts

BACKGROUND

Despite the availability of different therapeutic modalities, treatment of recalcitrant common warts is still challenging. Cervarix (GlaxoSmithKline, Brentford, UK), a recombinant bivalent human papillomavirus (HPV) vaccine, has shown promising efficacy in the treatment of warts.

OBJECTIVES

To evaluate the beneficial effects and tolerability of intramuscular versus intralesional bivalent HPV vaccine in the treatment of recalcitrant common warts.

METHODS

The study included 44 adult patients with multiple recalcitrant common warts; 22 patients received intramuscular injection of bivalent HPV vaccine at 0, 1, and 6 months or until complete clearance of warts, and the other 22 patients received intralesional injection of 0.1 to 0.3 mL of bivalent HPV vaccine into the largest wart at 2-week intervals until complete clearance or for a maximum of 6 sessions.

RESULTS

Complete clearance of warts was observed in 18 patients (81.8%) of the intralesional group and 14 patients (63.3%) of the intramuscular group; however, the difference was not statistically significant. Adverse effects were transient and insignificant, and no recurrence was reported in either group.

LIMITATIONS

Small study sample and different dosing schedules.

CONCLUSIONS

Bivalent HPV vaccine, particularly by intralesional injection, seems to be a potential therapeutic option for the treatment of multiple recalcitrant common warts.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Modelling mass and heat transfer in nano-based cancer hyperthermia

We derive a sophisticated mathematical model for coupled heat and mass transport in the tumour microenvironment and we apply it to study nanoparticle delivery and hyperthermic treatment of cancer. The model has the unique ability of combining the following features: (i) realistic vasculature; (ii) coupled capillary and interstitial flow; (iii) coupled capillary and interstitial mass transfer applied to nanoparticles; and (iv) coupled capillary and interstitial heat transfer, which are the fundamental mechanisms governing nano-based hyperthermic treatment. This is an improvement with respect to previous modelling approaches, where the effect of blood perfusion on heat transfer is modelled in a spatially averaged form. We analyse the time evolution and the spatial distribution of particles and temperature in a tumour mass treated with superparamagnetic nanoparticles excited by an alternating magnetic field. By means of numerical experiments, we synthesize scaling laws that illustrate how nano-based hyperthermia depends on tumour size and vascularity. In particular, we identify two distinct mechanisms that regulate the distribution of particle and temperature, which are characterized by perfusion and diffusion, respectively.

[Transarterial chemoembolization (TACE) in hepatocellular carcinoma: technique, indication and results]

To present current data on technique, indications and results of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). The principle of TACE is the intra-arterial injection of chemotherapeutic drug combinations like doxorubicin, cisplatin and mitomycin into the hepatic artery, followed by lipiodol injection, Gelfoam for vessel occlusion and degradable microspheres. The side effects and complications after TACE range from fever, upper abdominal pain and vomiting to acute or chronic liver cell failure. The palliative effect in unresectable HCC using TACE allows local tumor control in 15 to 60% of cases and 5-year survival rates ranging from 8-43%. The potentially curative treatment option allows local tumor control from 18-63%. The neoadjuvant treatment option of TACE in combination with other treatment options like percutaneous ethanol injection (PEI) or radiofrequency ablation (RFA) reach local tumor control rates between 80-96%. The bridging effect of TACE before liver transplantation reaches 5-year survival rates from 59-93%. The symptomatic therapy option of TACE is used to counteract pain directly caused by HCC and acute/subacute bleeding in the HCC. The local tumor response reaches up to 88% and the bleeding control is from 83 to 100%.

CONCLUSION

TACE is a potentially curative, palliative, neoadjuvant, bridging and symptomatic therapy option for local and diffuse HCC.

Cardiovascular effects of lepadiformine, an alkaloid isolated from the ascidians Clavelina lepadiformis (Müller) and C. moluccensis (Sluiter)

The effects of lepadiformine, a natural marine alkaloid isolated from the ascidians Clavelina lepadiformis (Müller) and C. moluccensis (Sluiter), were studied in vivo by arterial blood pressure (aBP) recordings and electrocardiograms (ECG) in anaesthetised rats and in situ by peripheral vascular pressure recordings on perfused rabbit ear. Transmembrane resting (RP) and action (AP) potentials were also recorded by intracellular microelectrodes on electrically stimulated left ventricular papillary muscle and spontaneously beating atrium isolated from rat and frog hearts, respectively. Intravenous injection of lepadiformine (6mg/kg) produced marked bradycardia and a lengthening of ECG intervals as well as a transient decrease of aBP, which rapidly returned to normal. The decrease of aBP may have been related to a vasoconstrictor effect observed in the perfused ear experiment. Lepadiformine did not alter RP, but significantly lengthened the repolarising phase of AP in rat papillary muscle and frog atrium. Lepadiformine also mimicked the effect of Ba(2+) (0.2mM) on the rat AP repolarising phase. Moreover, the lengthening of the AP in frog atrium induced by lepadiformine still developed after the delayed outward K(+) current (I(K)) was blocked by tetraethylammonium (10mM). These observations suggest that lepadiformine-induced lengthening of AP duration was not due to a decrease of I(K), but may reasonably be attributed to a reduction of the inward rectifying K(+) current (I(K1)). This blockade of I(K1) could account for the cardiovascular effects of lepadiformine in vivo and in vitro and suggests that lepadiformine has antiarrhythmic properties.

Antifungal metabolites from the marine sponge Pachastrissa sp.: new bengamide and bengazole derivatives

This paper reports the studies of components of an undescribed sponge in the genus Pachastrissa sp., collected along the Djibouti coast. The extract showed activity against Candida albicans. Six new bengazoles (1-6) and a new bengamide, named bengamide L (16), in addition to the known bengazoles (7-11), bengamides A (12), B (13), E (14), and F (15), and a lactone (17) are described in this paper. All structures were determined on the basis of spectroscopic studies.

Anaemia and intestinal parasitic infections among school age children in Behera Governorate, Egypt. Behera Survey Team

Anaemia is considered a serious public health problem in Egypt, although updated population-based data are lacking. Similarly, data on prevalence and intensity of infection with intestinal parasites, which are considered one possible cause of anaemia, are available only from small, unrepresentative sample surveys. The present research was implemented on an entire Governorate representative sample. The aim of the study was to assess the prevalence of anaemia and intestinal parasites in the area and to evaluate the role of each parasite in the epidemiology of anaemia among school age children. At the end of the survey, results of faecal analyses from direct smear and the Kato-Katz examination techniques were available from 1844 and 1783 children respectively, as well as haemoglobin levels measured by spectrophotometer from 1238 children aged 6-12 years. The prevalence of anaemia in the area was high (90 per cent), but very few serve forms were detected (< 2 per cent). Prevalence of intestinal parasites was high only for protozoa (Giardia intestinalis 24.7 per cent Entamoeba histolytica 17.5 per cent) and Schistosoma mansoni (20.7 per cent). From analysis of the results, Fasciola infection appeared to be highly endemic, even among children (3 per cent), and emerged as the factor most strongly correlated with low levels of haemoglobin (p < 0.0001). The effect of Fasciola on haemoglobin levels was related to the intensity of infection with this parasite. The role of S. mansoni as a risk factor for anaemia was supported by the present study. Among the protozoa, G. intestinalis was significantly correlated with low haemoglobin levels (p < 0.05). The present results substantiated similar findings from smaller studies. In future research, the relationship between Fasciola infection and anaemia needs to be studied with a well-controlled longitudinal design.

Immunoglobulin-A and the pathogenesis of schistosomal glomerulopathy

Several observations suggest that the evolution of schistosomal glomerulopathy into clinically overt and progressive disease may involve pathogenetic mechanisms other than simple glomerular deposition of parasitic antigens. In a previous study, IgA was suggested to be a mediator of late glomerular lesions in this disease. This issue is further addressed in this work. The study includes 32 patients with hepatosplenic schistosomiasis, of whom 16 had overt glomerular involvement, along with four control groups: (a) 15 healthy volunteers; (b) 15 patients with simple intestinal mansoniasis; (c) 17 patients with non-schistosomal chronic liver disease; and (d) 21 subjects with primary nephrotic syndrome not associated with schistosomiasis. Routine assessment was done for all subjects including confirmatory tests for schistosomal infection, liver and renal function tests, hepatitis viral markers and abdominal ultrasonography. The total serum concentrations of IgG, IgM, IgA were measured, as well as their respective circulating immune complexes, rheumatoid factors, anti-gliadin- and anti-DNA-antibodies. Liver and renal biopsies were obtained from the relevant groups and studied by light microscopy. Renal biopsies were also examined by immunofluorescence. Patients with simple intestinal schistosomiasis had a significant increase in IgM antigliadin antibodies. Those complicated with hepatosplenic involvement also had a significant increase in the mean IgG anti-gliadin antibodies, IgG rheumatoid factor and IgM anti-DNA activity. Cases further complicated by overt glomerular disease showed a distinct IgA predominance, mainly expressed in the serum anti-gliadin antibody pool and anti-DNA activity. This profile was essentially similar to that observed in control cirrhotics. There was a significant increase in the frequency of IgA glomerular deposits in renal biopsies obtained from patients with overt schistosomal glomerulopathy, in contrast to control nephrotics. The deposits were mainly mesangial, but were also encountered in subendothelial, subepithelial and peritubular locations. Their frequency was significantly higher with more advanced lesions as seen by light microscopy. The relevance of these data is discussed, leading to the following conclusions: (a) serum IgA-anti-gliadin and -anti-DNA antibodies, and glomerular IgA deposits are markers of significant renal involvement in patients with hepatosplenic schistosomiasis. (b) IgA may be involved in the pathogenesis of advanced glomerular pathology when superimposed on parasite-induced lesions. (c) There is a significant increase in serum auto-reactivity in hepatosplenic schistosomiasis, which may also have pathogentic implications. (d) Increased production by the inflammatory bowel lesions, impaired clearance by the fibrotic livers and probable switching of immunoglobulin synthesis are suggested to explain the observed IgA predominance in those who develop renal complications.

Intramuscular gold decreases cytokine expression and macrophage numbers in the rheumatoid synovial membrane

OBJECTIVES

Cytokines, released from mononuclear cells (MNC) are mediators of joint destruction in rheumatoid arthritis (RA). The mechanisms of action of gold salts used in the treatment of RA are unknown. The aim of this study was to investigate cytokine expression and intensity of MNC infiltrate in the RA synovial membrane (SM) following treatment with sodium aurothiomalate (SAT).

METHODS

Sequential blind needle biopsies were obtained at entry into the study and at two and 12 weeks after the start of SAT therapy in 10 patients with active RA. SMs were stained with a panel of monoclonal antibodies to assess cytokine expression (IL-1 alpha, IL-1 beta, TNF-alpha, IL-6, and GM-CSF).

RESULTS

There was a significant decrease in IL-1 alpha, IL-1 beta, IL-6 and TNF-alpha expression 12 weeks after treatment (p < 0.004, p < 0.002, p < 0.009 and p < 0.004 respectively). This was noted in the lining layer, the perivascular aggregates and the connective tissue areas. Detailed examination of the MNC infiltrate showed a significant reduction in inflammatory monocytes (MONO) in the lining layer at two weeks (p < 0.03). A decrease in the number of CD68+ macrophages (MAC) was noted in the perivascular and connective tissue areas at 12 weeks. No significant changes were observed in the number of T and B cells and blood vessels.

CONCLUSION

The results suggest that gold may suppress RA disease activity by diminishing MONO and MAC numbers and consequently monokine production in the SM.

The septum orbitale in ptosis surgery

The septum orbitale is an important landmark in ptosis surgery. It is structure that is difficult to identify and very easy to damage. In a series of 34 ptosis operations using a modified transcutaneous approach, we have shown that the septum orbitale can be readily identified, dissected and re-sutured after resection of the aponeurosis of the levator palpebrae superioris muscle.

The use of mannitol in intraocular surgery

100 ml of 20% Mannitol given between 30 and 60 minutes prior to surgery effectively lowers the intraocular pressure and increases the anterior chamber depth. Larger volumes give an almost identical drop in pressure and identical increase in depth of the anterior chamber although they act more rapidly and over a longer period. Rebound rise in intraocular pressure does not occur within the first two hours.