What is the Pisa Syndrome? A review

Introduction

Pisa syndrome (PS) is a type of dystonia of rare occurrence, first described in 1972 as an adverse effect of neuroleptic agents. It is used to describe a postural abnormality that includes trunk flexion in the coronal plane and axial rotation, which improves in the supine position.

Objectives

In this work, we aim to conduct a brief review of Pisa Syndrome aetiology, pathophysiology and treatment.

Methods

A non-systematic search was conducted through the PubMed database for “pisa syndrome”. Articles were screened for relevant information on PS aetiology, pathophysiology and treatment.

Results

Pisa syndrome has been associated as an adverse effect of multiple drugs from different classes, mainly antipsychotics, dopaminergic agents and cholinesterase inhibitors. The underlying mechanisms are not yet fully understood. Nevertheless, one of the most consensual hypothesis considers PS as a consequence of a cholinergic-dopaminergic imbalance that can be caused by antipsychotic treatment. Some factors have been associated with increased risk for developing PS such as old age and polypharmacy. PS appears to be better treated with the reduction or interruption of the agent(s) associated with its onset.

Conclusions

Despite its low incidence, Pisa syndrome can occur as a side effect of a number of different medications and the identification of the trigger-drug is fundamental so it can be reduced or interrupted in order to treat this condition.

Disclosure

No significant relationships.

Revisiting the Fabry-Perot reflectivity method for mid-infrared optical index measurement: case study of InGaAs, AlInAs, and InP

We revisit the Fabry-Perot (FP) reflectivity method to measure optical indices in the mid-infrared spectrum. This simple approach can be readily implemented using a standard Fourier transform infrared spectrometer. Measuring samples with multiple heights allows for enhanced precision of the measurement, making the FP method consistent in values and uncertainties with more advanced ellipsometric measurements. An extensive discussion about experimental errors is carried out. Results between 4 and 12 µm for AlInAs, n-doped InGaAs, and InP, which are the most standard materials for quantum cascade lasers, are given.

Response to treatment in NMOSD: the Australasian experience

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is associated with significant morbidity and mortality. Several therapies have been recommended for NMOSD and more recently clinical trials have demonstrated efficacy for three monoclonal antibody therapies. We present a retrospective observational study of treatment response in NMOSD.

METHODS

This was a retrospective, unblinded, observational study of treatment efficacy for rituximab and traditional immunosuppressive therapy in patients with AQP4 antibody positive NMOSD. Treatment efficacy was assessed using annualised relapse rates (ARR), time to first relapse and expanded disability status scale (EDSS) scores.

RESULTS

Complete relapse and treatment data were available for 43/68 (63%) of AQP4 antibody positive NMOSD cases covering 74 episodes of treatment. In a time to first relapse analysis rituximab showed a risk ratio of 0.23 (95% CI 0.08 - 0.65) when compared with no treatment and there was a non-significant reduction in ARR of 35% compared to pre-treatment. β-interferon (p = 0.0002) and cyclophosphamide (p = 0.0034) were associated with an increased ARR compared to pre-treatment. Rituximab (median 4.0 [range 0.0 - 7.0]; p = 0.042) and traditional immunosuppressive therapy (median 4.0 [range 0.0 - 8.0]; p = 0.016) were associated with a lower final EDSS compared to β-interferon (median 6.0 [range 4.0 - 7.5]).

CONCLUSIONS

These data provide additional support for the use of rituximab in preference to traditional immunosuppressive agents and MS disease modifying therapies as first line treatment of NMOSD.

The monocyte/high-density lipoprotein ratio predicts coronary artery disease in heart failure

Background

The monocyte/high density lipoprotein ratio (MHR) is a combined inflammatory marker implicated in atherosclerosis. MHR predicts cerebrovascular disease (CVD) and chronic kidney disease (CKD); it correlates with coronary artery disease (CAD) severity and has been shown to be a prognostic predictor in patients with myocardial infarction. The role of MHR in chronic heart failure (HF) is largely unknown.

Purpose

Assess the ability of MHR to predict CAD in patients with HF

Methods

We conducted a retrospective cohort study in ambulatory patients with HF with left ventricular systolic dysfunction (LVSD) that were followed in our HF clinic from January/2012 to May/2018. We selected all the patients that had performed a diagnostic/therapeutic coronary angiography. Patients with missing data concerning monocyte counts or high-density lipoprotein levels were excluded. The endpoint under analysis was the presence of CAD on coronary angiography. A ROC curve was used to study the ability of MHR to predict CAD. The association of MHR with CAD was assessed by a logistic-regression analysis. A multivariate model was built accounting for age, sex, comorbidities [hypertension, diabetes, peripheral artery disease (PAD), CVD, CKD and inflammatory/auto-immune disease], low-density lipoprotein value, haemoglobin, brain-type natriuretic peptide (BNP), severe LVSD and segmental contractility defects in the echocardiogram. MHR was analysed both as continuous and categorical variable; the cut-off of 16 was chosen based on the ROC curve.

Results

We studied 295 chronic HF patients with LSVD who underwent coronary angiography. Mean age was 67±12 years, 70.8% men and 55.9% with CAD. Patients with CAD were older (69 against 64 years), had significantly higher MHR (19±9 vs. 16±7), higher prevalence of hypertension, diabetes, PAD and CVD, and worse renal function. The area under the curve for the association between MHR and CAD was 0.68 (0.62–0.74), p<0.001. The best MHR cut-off for CAD prediction was 16 - sensitivity: 66.7%, specificity: 65.4%, positive predictive value: 71.0% and negative predictive value: 60.8%. This association was independent of potential confounders. Patients with MHR≥16 had a multivariate-adjusted OR of having CAD of 5.41 (95% CI: 2.40–12.20), p<0.001 when compared to those with lower MHR. When MHR was analysed as a continuous variable the association remained significant.

Conclusions

The MHR is an independent predictor of CAD in chronic HF. Patients with MHR ≥16 have a 71% probability of presenting CAD and a more than 5-fold higher risk compared with those with lower MHR. It is sometimes difficult to ascertain ischemic disease/aetiology in HF patients, particularly in the elderly, frail and/or with advanced CKD. This simple, inexpensive and harmless marker can help clinicians identify patients most likely to have CAD and decide treatment in accordance.

Funding Acknowledgement

Type of funding sources: None.

The prognostic value of monocyte/ high-density lipoprotein ratio in chronic heart failure

Background

The monocyte-high density lipoprotein ratio (MHR) is an inflammation marker that combines monocyte counts, increased in inflammatory states, and high-density lipoprotein (HDL) levels, that appear to have protective and anti-inflammatory properties. It has been studied in chronic kidney disease, primary hypertension, cerebrovascular disease and coronary artery disease (CAD), and has been shown to be positively correlated with disease severity and worse prognosis. Although inflammation is thought to be implicated in heart failure's (HF) pathophysiology, little is known about the role of MHR in the HF setting.

Purpose

To study the prognostic impact of MHR in chronic HF.

Methods

We conducted a retrospective cohort study in ambulatory patients with HF with left ventricular systolic dysfunction (LVSD) that were followed in our HF clinic from January/2012 to May/2018. Patients with no data on monocyte counts or HDL levels in the first appointment were excluded. Endpoint under analysis: all-cause mortality. Patients were categorized according to MHR quartiles: 1st quartile <11, 2nd quartile ≥11 to <15, 3rd quartile ≥15 to <20 and 4th quartile ≥20. A Cox-regression analysis was used to assess association between MHR and all-cause mortality. A multivariate model was built adjusting for age, sex, hypertension, diabetes mellitus (DM), CAD, obstructive sleep apnea, inflammatory/autoimmune disease, atrial fibrillation, anaemia, renal dysfunction, brain-type-natriuretic peptide (BNP), New York Heart Association (NYHA) class, low-density lipoprotein value, prognostic modifying therapy and severe LVSD.

Results

We studied 560 chronic HF patients with LVSD, mean age 70±12 years, 67.5% men, 37.1% in NYHA class I, 44.8% in NYHA class II and the remaining in higher classes. Patients with MHR≥20 (last quartile) were mostly men with higher prevalence of DM and CAD, they more often presented in higher NYHA classes and with worse renal function and higher BNP. No difference existed concerning doses of evidence based-drugs. During a median follow-up of 53 (32–88) months from the index medical appointment 256 patients (45.7%) died. Mortality was similar in the lower three MHR quartiles, being statistically higher in the last quartile. Considering only two groups - MHR <20 and MHR ≥20 - the all-cause mortality rate was of 41.6 vs. 57.6%, respectively, p=0,001. MHR was independently associated with poor survival. In patients presenting with MHR ≥20, the HR of long-term all-cause mortality was 1.42 (95% CI: 1.04–1.93), p=0.03 when compared with those with lower MHR.

Conclusions

Chronic HF patients with MHR ≥20 have a significant 42% increased risk of long-term all-cause death. We reinforce the role of inflammation in chronic HF. The MHR is a practical, inexpensive and widely available parameter that can help clinicians in the identification of chronic HF patients at higher risk of death.

Funding Acknowledgement

Type of funding sources: None.

MRI Patterns Distinguish AQP4 Antibody Positive Neuromyelitis Optica Spectrum Disorder From Multiple Sclerosis

Neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis (MS) are inflammatory diseases of the CNS. Overlap in the clinical and MRI features of NMOSD and MS means that distinguishing these conditions can be difficult. With the aim of evaluating the diagnostic utility of MRI features in distinguishing NMOSD from MS, we have conducted a cross-sectional analysis of imaging data and developed predictive models to distinguish the two conditions. NMOSD and MS MRI lesions were identified and defined through a literature search. Aquaporin-4 (AQP4) antibody positive NMOSD cases and age- and sex-matched MS cases were collected. MRI of orbits, brain and spine were reported by at least two blinded reviewers. MRI brain or spine was available for 166/168 (99%) of cases. Longitudinally extensive (OR = 203), "bright spotty" (OR = 93.8), whole (axial; OR = 57.8) or gadolinium (Gd) enhancing (OR = 28.6) spinal cord lesions, bilateral (OR = 31.3) or Gd-enhancing (OR = 15.4) optic nerve lesions, and nucleus tractus solitarius (OR = 19.2), periaqueductal (OR = 16.8) or hypothalamic (OR = 7.2) brain lesions were associated with NMOSD. Ovoid (OR = 0.029), Dawson's fingers (OR = 0.031), pyramidal corpus callosum (OR = 0.058), periventricular (OR = 0.136), temporal lobe (OR = 0.137) and T1 black holes (OR = 0.154) brain lesions were associated with MS. A score-based algorithm and a decision tree determined by machine learning accurately predicted more than 85% of both diagnoses using first available imaging alone. We have confirmed NMOSD and MS specific MRI features and combined these in predictive models that can accurately identify more than 85% of cases as either AQP4 seropositive NMOSD or MS.

Assessment of the uterine dose in digital mammography and digital breast tomosynthesis

INTRODUCTION

Digital Mammography (DM-2D) and more recently Digital Breast Tomosynthesis (DBT), are two of the most effective imaging modalities for breast cancer detection, often used in screening programmes. It may happen that exams using these two imaging modalities are inadvertently performed to pregnant women. The objective of this study is to assess the dose in the uterus due to DM-2D and DBT exams, according to two main irradiation scenarios: in the 1st scenario the exposure parameters were pre-selected directly by the imaging system, while in the 2nd scenario, the maximum exposure parameters were chosen.

METHODS

The mammography equipment used was a Siemens Mammomat Inspiration. A physical anthropomorphic phantom, PMMA plates (simulating a breast thickness of 6 cm) and thermoluminescent dosimeters (TLDs) were used to measure entrance air kerma values on the phantom's breast and abdomen in order to successively estimate the mean glandular dose (MGD) and the dose in the uterus. For the two irradiation scenarios chosen, two-breast imaging modalities were selected: 1) DBT in Cranio-Caudal (CC) view (with 28 kV and 160 mAs as exposure parameters), 2) DBT and DM in Medio Lateral-Oblique (MLO) and CC views (with 34 kV and 250 mAs as exposure parameters).

RESULTS

In the 1st scenario, the TLD measurements did not detect significant dose values in the abdomen whereas the MGD estimated using the D.R. Dance model was in close agreement with data available in the literature. In the 2nd scenario, there was no significant difference in MGD estimation between the different views, whereas the air kerma values in the abdomen (in DBT mode, CC and MLO) were 0.049 mGy and 0.004 mGy respectively. In CC DM-2D mode the abdomen air kerma value was 0.026 mGy, with no significant detected value in MLO view.

CONCLUSIONS

For the dose in the uterus, the obtained values seem to indicate that DM-2D and DBT examinations inadvertently performed during pregnancy do not pose a significant radiological risk, even considering the case of overexposure in both breasts.

IMPLICATIONS FOR PRACTICE

The accurate knowledge of the doses in DM-2D and DBT will contribute to raise the awareness among medical practitioners involved in breast imaging empowering them to provide accurate information about dose levels in the uterus, improving their radiation risk communication skills and consequently helping to reduce the anxiety of pregnant women undergoing this type of examinations.

Patient experiences with hidradenitis suppurativa: the Hidradenitis Patient Experience survey

BACKGROUND

Better understanding of the experience of people living with hidradenitis suppurativa (HS) is essential to identify gaps in current patient care and inform healthcare decision-making.

AIM

To describe the patient experience of individuals with HS, including their path to diagnosis, symptom control, treatments, healthcare utilization, patient needs and impact on quality of life.

METHODS

The Hidradenitis Suppurativa Patient Experience survey was created, extensively reviewed and disseminated through engaging HS-related patient organizations, physician groups and social media groups.

RESULTS

In total, 537 respondents completed the survey; the mean age was 38 years (range 14-73 years) and 95% (510 of 537) were female. The mean number of treatment types per respondent was 15, and included antibacterial soaps (93.3%; 431 of 462), avoidance of tight clothing (90.9%; 419 of 462), use of oral antibiotics (79.7%; 368 of 462), nonprescription drugs (79.7%; 368 of 462) and topical antibiotics (77.1%; 356 of 262). Pain was poorly controlled in 46% of respondents (184 of 401). HS had a negative impact on the ability to work and attend school for 81% of respondents (337 of 415), with 59% (245 of 415) missing at least 2 days of work a month and 16% (66 of 415) missing > 11 days of work. The mean number of misdiagnoses per respondent was three and the median time to diagnosis was 10 years.

CONCLUSION

Individuals with HS experience a delay in diagnosis and have suboptimal control of the disease. We propose 11 recommendations to improve diagnosis, treatment and quality of life for individuals living with HS.