Atypical hypertrophy of retinal pigment epithelium manifesting as the first sign of familial adenomatous polyposis

A female patient in her 20s presented to a routine ophthalmology appointment. Medical history was unremarkable. Family history was notable for intestinal cancer of a second-degree relative, diagnosed in her late 60s. Fundus examination revealed bilateral, multiple, flat, oval, pigmented lesions with an irregular halo of atrophy. The patient was diagnosed with atypical congenital hypertrophy of retinal pigmented epithelium. Investigation of extraocular associations was performed, including upper and lower endoscopy, which revealed 500-1000 colonic polyps with a maximum size 25 mm. Pathology did not reveal submucosal invasion. Genetic testing detected an adenomatous polyposis coli mutation (heterozygotic variant c.3183_3187delACAAA p.(Gln1062*)).

Application of optical coherence tomography angiography for microvascular changes in patients treated with hydroxychloroquine: a systematic review and meta-analysis

BACKGROUND

Retinal toxicity with long-term hydroxychloroquine (HCQ) treatment is a major concern. This systematic review aims to assess the application of optical coherence tomography angiography (OCTA) to detect microvascular alterations in patients under HCQ.

METHODS

PubMed, Scopus, Web of Science, and Cochrane Library databases were systematically searched until January 14, 2023. Studies using OCTA as a primary diagnostic method to evaluate the macular microvasculature of HCQ users were included. Primary outcomes were macular vessel density (VD) and foveal avascular zone (FAZ) at the superficial (SCP) and deep (DCP) capillary plexus. Meta-analysis was performed using a random-effects model.

RESULTS

Of 211 screened abstracts, 13 were found eligible, enrolling 989 eyes from 778 patients. High-risk patients due to longer duration of treatment presented lower VD in the retinal microvasculature than those with low-risk in SCP (P = 0.02 in fovea; P = 0.004 in parafovea) and in DCP (P = 0.007 in fovea; P = 0.01 in parafovea). When compared with healthy controls, HCQ users had lower VD in both plexus-no quantitative synthesis was presented.

CONCLUSIONS

Microvascular changes were found in autoimmune patients under HCQ treatment without any documented retinopathy. However, the evidence produced so far does not allow to draw conclusion concerning the effect of drug as studies were not controlled for disease duration.

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

INTRODUCTION

Patients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min.

OBJECTIVES

To assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI.

METHODS

We performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017.

RESULTS

Median DIDO time was 82 min (interquartile range, 61-132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062-1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011).

CONCLUSION

A DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.

Assessment of Functional Outcome Predictors in Patients Undergoing Lumbar Interbody Fusion Surgery: A Single-Centre Analysis

Introduction

Lumbar interbody fusion is a surgical modality performed in selected patients with low back and radicular pain not responding to medical therapy. We aim to evaluate the main predictors of functional outcome, assessed through Oswestry Disability Index (ODI), in patients submitted to a lumbar interbody fusion.

Methods

A sample of 33 patients undergoing lumbar interbody fusion at a neurosurgery department between 2017 and 2020 was selected. In order to assess functional status, ODI was applied before and after surgery. Data related to patients' medical history, current disease, and surgery performed were collected from the clinical process.

Results

In our cohort, functional improvement (pre-surgery ODI - post-surgery ODI) averaged 34.4 ± 23 points, suggesting robust surgical efficacy. We find patients with severe disability or worse to display relevant amelioration of their functional scores (p<0.0001), suggesting that these can benefit from lumbar interbody fusion surgery. The female gender (p=0.007) predicts a better outcome, which was surprising as no sex differences in lumbar fusion outcomes have been reported. Conversely, early symptom recurrence (p=0.015) and need for revision surgery (p=0.032) were found to be negative predictors of post-surgical functional outcome. Rapid return to the activities of daily living (p=0.001) and to work (p=0.002) was associated with post-surgical functional improvement. The underlying diagnosis that led to surgical referral and surgical modality did not affect the functional outcome in our patient cohort. Importantly, patients with previous lumbar surgeries had similar improvements to those who had never been operated on.

Conclusions

Severely disabled patients submitted to lumbar interbody fusion showed significant functional improvement, regardless of the referral diagnosis or the existence of previous lumbar surgeries. Additionally, sustained functional improvement resulted in a return to an active life.

The impact of COVID-19 pandemic on surgical primary retinal detachments

PURPOSE

To describe the impact of COVID-19 pandemic on the presentation characteristics, timings and surgical decisions for primary rhegmatogenous retinal detachment (RRD).

METHODS

Historical cohort including all patients who presented to the Surgical Retina Section at Centro Hospitalar Universitário do Porto (CHUPorto), over a 2-year period were recruited and divided in 2 groups: pre-COVID and COVID groups. The onset of the COVID-19 pandemic was recorded as starting on March 18, 2020, the same day the first pandemic-related lockdown came to effect in Portugal.

RESULTS

This study enrolled four hundred and forty-nine eyes of 443 patients: 272 in the pre-COVID group and 177 in the COVID one. Of the patients, 63.6% were male and the mean±SD age was 63.0±13.2y (range 13 to 92y). Of the eyes, 55.5% (n = 151) presented with macular detachment in the pre-COVID group compared with 66.9% (n = 119) in the COVID group (odds ratio [OR] 1.62; 95% confidence interval [CI], 1.09-3.86; p=0.016). The time from symptoms onset to hospital admission (p=0.021) and from admission to surgery (p<0.001) was longer in the COVID era. In the COVID period, silicone oil (OR 2.03, 95%CI 1.09-3.79, p=0.025) and C3F8 gas (OR 2.42, 95%CI 1.57-3.71, p<0.001) were used more often. No differences in anatomical success or final visual acuity were found.

CONCLUSIONS

The lockdown due to COVID pandemic affected the epidemiology of RRD. The services must adapt to the novel reality and produce backup plans for similar events. Despite the contingencies, the final results were not different between groups.

A rare mutation on alpha-1 antitrypsin deficit and lung fibrosis: case report

Alpha1-antitrypsin deficiency (AATD) is an autosomal codominant disease, and different genetic variants are known, some of which very rare. Usual pulmonary manifestations include emphysema, bronchiectasis and asthma. Pulmonary fibrosis is uncommon. We describe a case of a 64 year old man with an inaugural diagnosis of cirrhosis and lung fibrosis, without emphysema or bronchiectasis, associated with AATD. Further investigation identified a rare variant in heterozigosity (MM_Palermo), usually associated with liver disease. Concomitantly, he had a secondary iron overload, and in the course of the investigation, a type 2 diabetes mellitus installed. The association between AATD and pulmonary fibrosis is rare, however it has been identified in a few studies and case reports, questioning the role of AAT in pulmonary fibrosis. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (4): e2020019)

Seemingly Harmless Differentiated Thyroid Carcinoma Presenting as Bone Metastasis

Thyroid carcinoma is the most common endocrine neoplasia. Differentiated thyroid carcinomas (DTCs) represent the majority of cases, which usually follow an indolent clinical course with low mortality rates. The authors describe two cases of well DTC without classic histological poor prognosis features, presenting as extensive and unresectable osteolytic bone metastases. DTCs are considered harmless tumours, due to their benign and silent behaviour. The authors want to underline the importance of clinical awareness during follow-up in cases of DTC, which can be aggressive in presentation and behaviour. Timely identification and diagnosis of these tumours are essential for prompt treatment initiation and improvement of overall survival.

Multiple switches between GP2015, an etanercept biosimilar, with originator product do not impact efficacy, safety and immunogenicity in patients with chronic plaque-type psoriasis: 30-week results from the phase 3, confirmatory EGALITY study

BACKGROUND

EGALITY was a phase III confirmatory efficacy and safety study conducted in patients with plaque-type psoriasis as a part of totality of evidence gathered during the development of GP2015, an etanercept biosimilar.

OBJECTIVE

To demonstrate equivalent efficacy and comparable safety and immunogenicity of GP2015 and the etanercept originator product (ETN, Enbrel^® ) and evaluate effects of repeated switching between GP2015 and ETN. Results for efficacy, safety and immunogenicity during treatment period (TP) 2 (TP2) are presented pooling the two continued treatment arms (pooled continued) versus the two treatment arms with repeated switches (pooled switched).

METHODS

Patients (n = 531) were randomized 1:1 to self-administer GP2015 or ETN twice-weekly subcutaneously during TP1. Patients with a ≥50% improvement in Psoriasis Area and Severity Index (PASI 50) at week 12 were re-randomized for TP2 to continue the same treatment at once-weekly dosing or to undergo three consecutive treatment switches between GP2015 and ETN until week 30. Patients continued the last-assigned treatment during TP2, until week 52.

RESULTS

Mean (standard deviation [SD]) PASI scores at baseline were similar in patients who underwent multiple switches compared to those with continued treatments during TP2. During TP2, PASI 50, PASI 75 and PASI 90 response rates, percent change from baseline in PASI scores and all other efficacy parameters were similar between the pooled switched and pooled continued treatment groups at all time points. The incidence of treatment-emergent adverse events including injection site reactions was comparable between the pooled switched (36.7%) and pooled continued (34.9%) groups. None of the patients in either treatment group were positive for binding anti-drug antibodies in TP2.

CONCLUSION

Treatment efficacy, safety and immunogenicity were similar between the pooled continued and pooled switched treatments during TP2, indicating that there are no effects in the short term on clinical data of multiple switches between GP2015 and ETN.

GP2015, a proposed etanercept biosimilar: Pharmacokinetic similarity to its reference product and comparison of its autoinjector device with prefilled syringes

Aims

To assess pharmacokinetics (PK) and safety of GP2015, a proposed etanercept biosimilar, in two studies: comparison with etanercept originator (ETN, bioequivalence study) and comparison of GP2015 administered via an autoinjector (AI) or prefilled syringes (PFS, delivery study).

Methods

Both studies were randomized, two‐sequence, two‐period, crossover studies conducted in healthy male subjects. In the bioequivalence study, subjects were randomized to receive a single 50 mg subcutaneous (s.c.) injection of GP2015 or ETN. In the delivery study, subjects were randomized to receive a single 50 mg s.c. injection of GP2015 via AI or PFS. Following a wash‐out period of 35 days, subjects in the bioequivalence study received single 50 mg s.c. injection of GP2015 or ETN, and subjects in the delivery study received single 50 mg s.c. injection of GP2015 via AI or PFS.

Results

The geometric mean ratios (90% confidence interval) of GP2015/ETN for C_max (1.11 [1.05–1.17]), AUC_0–tlast (0.98 [0.94–1.02]) and AUC_0–inf (0.96 [0.93–1.00]) were within the predefined bioequivalence range of 0.80–1.25. The geometric mean ratios (90% confidence interval) of AI/PFS for C_max (1.01 [0.94–1.08]), AUC_0–tlast (1.01 [0.95–1.07]) and AUC_0–inf (1.01 [0.96–1.07]) were also within the range 0.80–1.25. No new safety issues were reported. Three subjects had low titres of non‐neutralising anti‐drug antibodies during a follow‐up visit in the bioequivalence study.

Conclusions

The PK of GP2015 was similar to ETN, demonstrating bioequivalence. The safety profile of GP2015 was consistent with previous reports for ETN. The GP2015 AI provided equivalent dosing and tolerability to the GP2015 PFS.

Immunoexpression of angiogenesis and proliferation markers in patients treated with cyclosporin A

AIM

In the present immunohistochemical study, the expression of vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67 in the gingival tissues of renal transplant patients treated with cyclosporin A was assessed. Gingival overgrowth (GO) frequently occurs in transplant patients receiving immunosuppressive drugs such as cyclosporine and this gingival inflammation might play an important role in the pathogenesis of drug-induced GO.

METHODS

Twenty-eight human gingival biopsies were taken from healthy patients with chronic periodontitis (N.=14 control group), and from renal transplant recipients treated with cyclosporin A (N.=14 test group). The retrieved specimens were immunohistochemically processed and stained for vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67.

RESULTS

The levels of vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67 were found to be significantly different among groups (P>0.001), with patients treated with cyclosporin A showing higher levels of all the analyzed markers compared to control group.

CONCLUSION

In summary, the data from this pilot study suggests that the investigated factors have a role in the inflammation processes associated to immunosuppressive therapy. However, further studies with a larger sample population need to be conducted for an exhaustive knowledge of the mechanisms leading to GO.

Assessing the repair of critical size bone defects performed in a goat tibia model using tissue-engineered constructs cultured in a bidirectional flow perfusion bioreactor

This work evaluated in vivo performance of a tissue-engineered bone-like matrix obtained by culturing cell-scaffold constructs in a flow perfusion bioreactor, designed to enable culture of large constructs, envisioning the regeneration of critical-sized defects. A blend of starch with polycaprolactone scaffolds was seeded with goat bone marrow stromal cells (GBMSCs) cultured in the perfusion bioreactor for 14 days using osteogenic medium. Cell seeded scaffolds cultured in static conditions acted as controls. After 14 days, constructs (42 mm length and 16 mm in diameter) were implanted in critical size defects performed in the tibial bone of six adult goats from which the bone marrow had been collected previously. Explants were retrieved after six and 12 weeks of implantation and characterized using scanning electron microscopy, energy-dispersive spectroscopy, micro-computed tomography and radiographic analysis to assess tissue morphology and calcification. Explants were histologically analyzed, using Hematoxylin & Eosin and Masson Trichrome staining. Results provided relevant information about the performance and functionality of starch with polycaprolactone-goat bone marrow stromal cell constructs in a critical size orthotopic defect performed in a large animal model and demonstrated that culture of the starch with polycaprolactone scaffolds with the autologous cells in perfusion culture provide a good therapy for the healing and regenerative process of bone defects.

Estimación de la prevalencia del trastorno por déficit de atención con o sin hiperactividad (TDAH) en población escolar de la Comunidad Autónoma de Canarias

Este estudio ha tenido por finalidad determinar la prevalencia del Trastorno por Déficit de Atención con o sin Hiperactividad (TDAH) en la Comunidad Autónoma de Canarias, en la población de 6 a 12 años. Para ello, el muestreo utilizado fue polietápico estratificado y proporcional por conglomerados. Los estratos fueron el tipo de colegio, la y el nivel educativo, y los conglomerados fueron los colegios. A partir de una muestra de estudio de 118.467 alumnos escolarizados en centros ordinarios, se obtuvo una muestra al azar de 2.395 alumnos. Se utilizaron las escalas Attention-Deficit/Hiperactivity Disorder Rating Scales IV (ADHD RS-IV) modificadas para padres y maestros. Se encontró una tasa global de prevalencia del 4.9%, de los cuales el 3.1% fueron del subtipo inatento, el 1.1% hiperactivo, y el 0.7% combinado. Solo se encontraron diferencias significativas en función del sexo, donde la incidencia fue superior en varones. Las implicaciones educativas y socio sanitarias de los hallazgos encontrados nos sugieren la importancia de llevar a cabo una identificación, diagnóstico y tratamiento temprano, lo que ayudará a que los niños identificados con TDAH puedan desarrollar todo su potencial, y con ello una reducción importante del gasto público.

Therapeutic monitoring of warfarin: the appropriate response marker

Warfarin is a 4-hydroxycoumarin anticoagulant drug used for the prevention and management of thromboembolic and vascular diseases. It acts through the inhibition of the vitamin K-dependent transcarboxylation reactions that convert precursors of clotting factors into their active form. Appropriate use of warfarin requires patient monitoring and dosage adjustments, to ensure its safety and efficacy. The aim of this work was to clarify the relationship between traditional (prothrombin time, usually expressed as the international normalized ratio; INR) and alternative (clotting factors II and X) warfarin response markers to establish their usefulness for therapeutic drug monitoring. Seventy adult outpatients, aged between 31 and 86 years old, were involved in the study. All subjects received warfarin in a monotherapy regimen and had been on a stable dosing schedule for at least two weeks to assure a steady-state condition. A total of 81 prothrombin times (expressed as INR), and factor II and factor X activity were simultaneously determined. Eleven patients presented repeated measurements at different time periods under the same dosing regimen. The results obtained from regression and cluster analysis showed a close relationship between factors II and X (r = 0.73), a weak correlation between INR and both factor II (r = -0.35) and factor X (r = -0.36), and a very slight dependency between warfarin and the response markers used. In addition, it seems that independent of the selected response marker, in long-term warfarin therapy, reproducible responses can be obtained over time if a steady-state condition is achieved. The coefficients of variation for factors II and X were greater (35.44 and 37.93%, respectively) than INR (14.50%), indicating that INR is a more precise measure than either factor II or factor X. In conclusion, INR appears to be the most appropriate warfarin response marker for therapeutic drug monitoring due to its universality, objectivity as a direct physiological effect measurement, and the available information regarding appropriate endpoints. However, when INR values are not in accordance with patient response therapy, factor II and factor X should be considered as an alternative to optimize warfarin therapy.