Clinical factors associated with lower health scores in COVID-19-related persistent olfactory dysfunction

BACKGROUND

Patients with persistent COVID-19 olfactory dysfunction (OD) commonly report parosmia. Understanding the impact of COVID-19 OD and parosmia is critical to prioritizing research and interventions. In this study we investigate the impact of parosmia and other clinical and disease characteristics on health state utility values (HUVs) for those with persistent COVID-19 OD.

METHODS

Patients with a history of COVID-19 diagnosis and persistent OD were recruited from a tertiary medical center and a social media support forum for chemosensory dysfunction. Clinical characteristics and disease-specific symptoms were obtained along with self-reported history of smell function and presence of parosmia. HUVs were calculated using indirect (EuroQol 5-Dimension [EQ-5D]) and direct (VAS) measures.

RESULTS

Our study included 286 subjects (75.52% women) with persistent COVID-19-related OD. Results (mean ± standard deviation) of HUVs based on EQ-5D and VAS were 0.81 ± 0.14 and 0.73 ± 0.21, respectively. Mean self-reported smell function (on a 0-10 scale) was 9.67 ± 1.25 pre-COVID-19, 0.93 ± 2.34 at diagnosis, and 3.39 ± 2.32 at most current assessment. A total of 89.16% of the subjects reported parosmia and 24.13% sought medical care for anosmia. Seeing an MD for OD (p < 0.001), female gender (EQ-5D only, p = 0.002), a history of chronic pain (p < 0.05) and depression/anxiety (EQ-5D only, p < 0.001) predicted worse health. Parosmia and persistent symptoms, such as shortness of breath, were associated with lower EQ-5D and VAS scores, but did not independently predict poorer health scores on multivariable analysis.

CONCLUSION

Persistent COVID-19 OD results in health states comparable to other chronic diseases.

Impact of COVID-19 versus chronic rhinosinusitis/rhinitis associated olfactory dysfunction on health utility and quality of life

Background

Olfactory dysfunction (OD) is associated with both post-viral and inflammatory etiologies such as COVID-19 and chronic rhinosinusitis/rhinitis (CRS/R) respectively, to result in reduced quality of life (QoL). However, the former typically induces a sudden-onset OD while the latter has a gradual presentation. This study aims to establish and compare health utility values (HUVs) and olfactory-specific QoL measurements between patients with COVID-19 and CRS/R related OD.

Methods

This prospective study surveyed COVID-19 and CRS/R patients with self-reported OD using HUV assessments (EuroQol-visual analog scale [EQ-VAS], EuroQol-5 dimension [EQ-5D], time trade-off [TTO]) and olfactory and sinonasal QoL measures (questionnaire of olfactory disorders -negative and positive statements [QOD-NS + PS] and sino-nasal outcome test [SNOT-22]). A subgroup of subjects completed objective olfactory testing. Intergroup mean scores were compared using Mann-Whitney U tests.

Results

One hundred eleven subjects were enrolled: mean age ± SD (43.0 ± 15.4 years), 55.9% female. CRS/R was associated with lower HUVs as measured by EQ-VAS (CRS/R: 0.67 ± 0.18 vs. COVID-19: 0.74 ± 0.19, p = .03) and worse SNOT-22 scores in both overall (CRS/R: 49.03 ± 21.04 vs. COVID-19: 27.58 ± 18.45, p < .001) and subgroup analysis of objectively confirmed OD subjects (CRS/R: 52.40 ± 22.78 vs. COVID-19: 29.84 ± 21.10, p = .01). On the other hand, COVID-19 has greater burden on olfactory-specific QoL (QOD-NS + PS, COVID-19: 23.19 ± 13.73 vs. CRS/R: 17.25 ± 11.38, p = .04). Both groups demonstrated a similar decrease in health using the EQ-5D assessment.

Conclusion

CRS/R associated OD has a more severe impact on general health and sinonasal specific QoL outcomes, while COVID-19 associated OD has a greater burden on olfactory-specific QoL.

Level of evidence

Level 2c.

Open and endoscopic surgery improve survival for squamous and nonsquamous cell nasopharyngeal carcinomas: An NCDB cohort study

BACKGROUND

Nasopharyngeal tumors (NPTs) are primarily treated with nonsurgical therapy. Recent studies have demonstrated endoscopic salvage surgery for NPT recurrences may improve survival relative to reirradiation. However, there are very limited data on open compared with endoscopic approaches for NPTs. We investigated whether endoscopic and open surgical approaches to the nasopharynx improve overall survival for all histologic subtypes of NPTs.

METHODS

We performed a retrospective cohort study using the National Cancer Database (NCDB). All adult patients with NPTs from 2004 to 2016 without distant metastasis who underwent treatment with curative intent were included. We extracted clinical and treatment variables to assess our primary outcome of overall survival.

RESULTS

On univariate analysis, patients undergoing endoscopic surgery, but not open surgery, had significantly improved overall survival relative to those undergoing nonsurgical treatment. Post hoc analysis demonstrated significantly improved overall survival for surgery in patients with minor salivary gland histology, but not squamous cell carcinoma (SCC) histology or by T or N classification. A Cox proportional hazards model was used for multivariate regression. After adjusting for covariates, both endoscopic and open approaches were associated with improved overall survival relative to nonsurgical treatment for all tumor types. A multivariate regression of SCC found that open surgery, but not endoscopic surgery, was significantly associated with improved overall survival.

CONCLUSION

Both endoscopic and open surgical approaches are associated with improved overall survival of patients with NPT. These findings highlight important oncologic validity as endoscopic and robotic platforms to the nasopharynx become more widely adopted.

Association between family history and severity of coronary artery disease in a nationwide sample of patients with a first time myocardial infarction

 

Having an early family history of coronary artery disease (CAD) is strongly associated with incident cardio-vascular disease. In younger patients with acute coronary syndrome, an association between family history and the severity of CAD, determined by the number of affected coronary arteries diagnosed through coronary angiography, has been reported. However, it is unknown if these findings apply to unselected patients with a first-time myocardial infarction (MI) and whether an early family history of other atherosclerotic cardiovascular diseases (ASCVD) affect CAD severity. Therefore, our objective was to investigate the association between a family history of ASCVD and the extent of CAD determined by coronary angiography findings in a large nationwide sample of patients with a first-time MI.

Material and methods

This study included a consecutive sample of 22,686 one-year survivors of first-ever MI aged, 18 to 76 years, identified in the national register SWEDEHEART. Attending the standardized 1-year revisit after MI, from 2006 through 2013. First-degree relatives, defined as parents and full siblings, were identified in the Swedish Multi-Generation Register and data on historical hospitalisations and deaths were extracted. The exposure was defined as having a first-degree relative with records of early ASCVD, defined as a register-verified hospitalisation due to myocardial infarction, any angina with coronary revascularization, stroke or cardiovascular death before the age of 55 in male or 65 years in female relatives. The primary outcome was severity of CAD categorized to four groups: zero-, single-, two- or three-vessel disease as registered in SWEDE-HEART. Left main stem disease was included in the three-vessel category. The distribution of the CAD severity categories was compared between those with and without an early family history of ASCVD using multinomial logistic regression, adjusted for age and sex and using single-vessel disease as the reference group.

Results

We included 22 686 participants (median age 63 [IQR 57–68] years; 27% women), of which 1450 had a family history of early ASCVD. A total of 2134 patients did not have any significant obstructive findings at the first coronary angiography, 10 951 patients had single-vessel disease, 5516 patients had two-vessel disease and 3970 patients had three-vessel or main stem disease. Both two-vessel disease (RRR 1.31, 95% CI 1.14–1.50) and three vessel and/or left main stem disease (RRR 1.29, 95% CI 1.1–1.51) were more common in patients with early family history of ASCVD when adjusting for age and sex, whereas no significant angiographic disease was less common (RRR 0.76, 95% 0.61–0.95).

Conclusion

Patients with a first-time MI and a family history of early ASCVD have an approximately 30% higher risk of advanced coronary artery disease, with more than two affected coronary vessels or left main stem disease.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Heart and Lung Association (Riksförbundet HjärtLung) Graph 1

Investigating the need for therapeutic drug monitoring of imipenem in critically ill patients: Are we getting it right?

BACKGROUND

The drug levels and clearances of imipenem in critically ill patients are not comprehensively described in current literature, yet it is vital that adequate levels be achieved for therapeutic success.

OBJECTIVES

To determine the proportion of critically ill patients treated with imipenem/cilastatin with sub-therapeutic imipenem plasma levels, and to compare the clinical outcomes of those patients with therapeutic levels with those who had sub-therapeutic levels.

METHODS

Trough imipenem plasma levels of 68 critically ill patients from a surgical intensive care unit were measured using a validated high-performance liquid chromatography method. Imipenem trough levels were compared with the minimum inhibitory concentration (MIC) of the causative bacterial agents, based on a target value of 100% time above MIC (¦T &gt;MIC).

RESULTS

The proportion of participants with sub-therapeutic imipenem levels was 22% (95% confidence interval (CI) 13% - 34%). The 14- and 28-day mortality rates in the sub-therapeutic group were 33% and 40%, respectively, compared with 19% (p=0.293) and 26% (p=0.346), respectively, in the therapeutic group. Sub-therapeutic imipenem plasma levels are associated with adjusted hazard ratio of 1.47 (95% CI 0.55 - 3.91).

CONCLUSIONS

The lower proportion of critically ill patients with sub-therapeutic imipenem plasma levels in this study compared with previous studies may be attributed to the practice of higher dosages and the administration method of extended infusions of imipenem/cilastatin in our setting. The results demonstrate a trend of higher mortality in patients with sub-therapeutic imipenem levels, although the results were not statistically significant at this sample size.

The Relationship Between the Functional Gait Assessment and Quality-of-Life Data in Patients Undergoing Vestibular Schwannoma Resection

OBJECTIVE

To examine the relationship between the Functional Gait Assessment (FGA) and quality of life (QOL) measurements relating to balance before and after vestibular schwannoma (VS) resection and to assess the role of preoperative FGA in predicting postoperative QOL.

STUDY DESIGN

A prospective clinical study of adult patients undergoing VS resection between September 2018 and December 2019. FGA was administered 1 week before and after surgery. Dizziness Handicap Inventory (DHI) and Penn Acoustic Neuroma Quality of Life (PANQOL) were administered preoperatively and at 3 months postoperatively.

SETTING

Single tertiary center.

PATIENTS

Patients (age ≥ 18 years old) with VS undergoing microsurgical resection. Excluded were patient with previous surgery or radiation.

INTERVENTION

VS resection.

MAIN OUTCOMES AND MEASURES

Primary outcome: correlation between FGA and QOL surveys. Secondary outcome: correlation between preoperative measurements of balance and postoperative PANQOL.

RESULTS

One hundred thirty-eight patients were analyzed (mean age: 48 years old, 65.9% female). The translabyrinthine approach was most commonly performed. Under multivariate analysis, preoperative FGA significantly correlated with preoperative PANQOL balance score (p < 0.0001), preoperative PANQOL total score (p = 0.0002), and preoperative DHI (p < 0.0001). However, postoperative FGA did not significantly correlate with postoperative PANQOL balance or total scores (p = 0.446 and p = 0.4, respectively), or postoperative DHI (p = 0.3). Univariate analysis demonstrated that preoperative DHI and preoperative FGA were predictive of changes in postoperative PANQOL balance and total scores. However under multivariate analysis, preoperative FGA did not predict changes in postoperative PANQOL balance or total score (p = 0.24; p = 0.28, respectively). Preoperative DHI remained predictive of changes in postoperative PANQOL balance (p = 0.03) score but not of postoperative PANQOL total score (p = 0.37).

CONCLUSIONS

Although FGA and QOL data significantly correlated in the preoperative setting, our results did not suggest that preoperative FGA can be used to determine postoperative QOL. Additionally, the lack of correlation between FGA and QOL measurements in the acute postoperative setting suggests that further research is needed to determine contributors to postoperative QOL.

Assessment of patient recognition of coronavirus disease 2019 (COVID-19)-associated olfactory loss and recovery: a longitudinal study

Background

The clinical course of coronavirus disease 2019 (COVID‐19) olfactory dysfunction remains poorly characterized, often limited by self‐reported measures. Given the logistical challenges of psychophysical testing, understanding the longitudinal relationship between self‐reported and quantitative measures can help accurately identify patients with persistent olfactory dysfunction. This study aimed to longitudinally correlate measured and subjective olfactory function in COVID‐19 subjects.

Methods

A prospective, longitudinal study evaluating subjective and measured olfaction was conducted on ambulatory COVID‐19 subjects. Olfaction scores were obtained using a visual analogue scale (VAS) (0 = anosmia, 10 = normosmia) and the validated 12‐item Brief Smell Identification Test (BSIT). Weekly testing was performed until recovery (BSIT ≥ 9/12 and/or VAS = 10/10) or study completion.

Results

Eighty‐six polymerase chain reaction (PCR)‐positive COVID‐19 subjects were recruited ≤3 days from diagnosis and 52 completed longitudinal testing. Among those with self‐reported smell loss at recruitment, similar levels (75.8%) of objective (BSIT ≥ 9/12) and subjective recovery were obtained using a VAS cutoff ≥8, yet only 30.3% reported complete subjective recovery (VAS = 10). Median times to objective and complete subjective olfactory recovery were 12 ± 2.3 and 24 ± 3.5 days, respectively. Although both measures showed chemosensory improvement, the distributions of objective and full subjective olfactory recovery differed significantly (log rank test χ² = 6.46, degrees of freedom [df] = 1, p = 0.011). Overall correlation between BSIT and VAS scores was moderate to strong across longitudinal follow‐up (r_s = 0.41–0.65).

Conclusion

Self‐reported and psychophysically measured COVID‐19 olfactory dysfunction improve at similar levels and are moderately correlated longitudinally, yet there is a significant delay in complete subjective recovery. Psychophysical testing in conjunction with qualitative assessments may be considered for counseling and follow‐up of patients with COVID‐19 smell loss.

Standardized delivery room management for neonates with a prenatal diagnosis of congenital heart disease: A model for improving interdisciplinary delivery room care

Precise characterization of cardiac anatomy and physiology through fetal echocardiography can predict early postnatal clinical course. Some neonates with prenatally defined critical congenital heart disease have anticipated precipitous compromise during perinatal transition for which specialized, diagnosis-specific delivery room care can be arranged to expeditiously stabilize cardiopulmonary hemodynamics. In this article, we describe our institutional approach to the delivery room care of neonates with prenatally diagnosed congenital heart disease, emphasizing our diagnosis-specific care pathways for newborns with critical disease.

Navigating telemedicine for facial trauma during the COVID-19 pandemic

Importance

The COVID-19 pandemic is changing how health care providers practice. As some telemedicine and telecommunication support tools have been incorporated into the otolaryngology practice in response to safety and access demands, it is essential to review how these tools and services can help facilitate facial trauma evaluation during a time when clinical resources are limited.

Objective

To review applications of telemedicine for the evaluation of facial trauma to better direct utilization of these methods and technologies during times of limited access to clinical resources such as the COVID-19 pandemic.

Methods

A systematic review was conducted using PubMed, Embase, and Web of Science.

Results

After screening 158 titles and abstracts, we identified 16 eligible studies involving facial trauma evaluation using telemedicine. Telemedicine opportunities for facial trauma evaluation have the potential to be developed in the areas of multidisciplinary remote consultations, facial trauma triage, patient engagement, and postoperative follow-up.

Conclusion

The COVID-19 pandemic is posing obstacles for both providers and patients in the delivery of health care at a time of limited clinical resources. Telemedicine may provide a potential useful tool in the evaluation and triage of facial injuries and patient engagement.

Assessment of the Learning Curve for Virtual Surgical Planning in Orbital Fractures

Virtual surgical planning (VSP) is becoming more widely used in maxillofacial reconstruction and can be surgeon-based or industry-based. Surgeon-based models require software training but allow surgeon autonomy. We evaluate the learning curve for VSP through a prospective cohort study in which planning times and accuracy of 7 otolaryngology residents with no prior VSP experience were compared to that of a proficient user after a single training protocol and 6 planning sessions for orbital fractures. The average planning time for the first session was 21 minutes 41 seconds ± 6 minutes 11 seconds with an average maximum deviation of 2.5 ± 0.8 mm in the lateral orbit and 2.3 ± 0.6 mm in the superior orbit. The average planning time for the last session was 13 minutes 5 seconds ± 10 minutes and 7 seconds with an average maximum deviation of 1.4 ± 0.5 mm in the lateral orbit and 1.3 ± 0.4 mm in the superior orbit. Novice users reduced planning time by 40% and decreased maximum deviation of plans by 44% and 43% in the lateral and superior orbits, respectively, approaching that of the proficient user. Virtual surgical planning has a quick learning curve and may be incorporated into surgical training.

Amisulpride-induced agranulocytosis: A case report

Introduction

Agranulocytosis is a potentially life-threatening haematological side effect induced by typical and atypical neuroleptic. When agranulocytosis is associated with a specific anti-psychotic, the medication should be discontinued. This severe side effect is troublesome.

Case report

We report the case of a 60-year-old man, treated with amisulpride for schizophrenia, who developed an agranulocytosis. This patient had been treated with first and second generation anti-psychotic drugs during his life and had already been exposed to many neuroleptics without any signs of toxicity. However, after three days of the introduction of amisulpride he presented a rapid onset agranulocytosis (leukocytes 1.2 G/L and neutrophils 0.4 G/L). After discontinuation of amisulpride, blood count returned to normal. The favorable evolution after discontinuation of treatment: the normality of biological and cytological examinations is in favor of a causal relationship between this severe neutropenia al introduction of amisulpride.

Conclusion

This case report highlights the risk of amisulpride in inducing agranulocytosis, a risk underestimated in regard of the clozapine risk to induce agranulocytosis or neutropenia. For this reason, it seems reasonable to recommend performing a blood count before introduction and during the treatment by anti-psychotics.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A DFT study of Janus structure of S and Se in HfSSe layered as a promising candidate for electronic devices

The transition-metal dichalcogenides are presently being intensively researched because of their unique optoelectronic properties. Further, the success of TMDs in all areas of science without exception has opened the street to find other two-dimensional materials. Based on density functional theory, we study the vibrational and electronic properties of the mixed-phase of S and Se in HfSSe system, i.e, HfSSe monolayer and HfSSe/HfSSe bilayer. In this framework, our systems are full dynamically stable, which shown by their phonon dispersion. Also, we found that the HfSSe (heterolayer) monolayer is an indirect semiconductor (0.63 eV with BLYP), while the HfSSe (alternating) monolayer is a direct semiconductor (0.753 eV with BLYP). Our AA, AB, AA', and AB' of HfSSe/HfSSe (heterolayer) bilayer are indirect band gaps in a range 0.361-0.830 eV, which are promising candidates for electronic devices as field-effect transistors, photodetectors, and other optoelectronics. Nevertheless, HfSSe/HfSSe (alternating) bilayer is a direct bandgap semiconductor with a value of 0.671 eV, when vdW is used.

Patient-Reported Outcome Measures and Provocative Testing in the Workup of Empty Nose Syndrome-Advances in Diagnosis: A Systematic Review

Background

The last 5 years have seen a surge of both clinical and scientific interest in empty nose syndrome (ENS). Although ENS is still considered a controversial diagnosis plagued by a lack of standardized diagnostic criteria, ENS is increasingly becoming recognized as a legitimate, physiologic disease entity. As such, it is important for clinicians to understand the most up-to-date diagnostic tools to assess ENS, confirm the diagnosis, and create a more standardized means to counsel these complex patients.

Objective

Contemporary literature review to discuss diagnostic modalities in the evaluation of ENS, in order to introduce evidence-based diagnostic criteria.

Methods

A systematic review was conducted in PubMed and Embase (2013–2019) using the search term “empty nose syndrome” to identify peer-reviewed articles on the topic of ENS. Articles advancing contemporary methods of ENS diagnosis and testing were included. A quality assessment was conducted using The Rational Clinical Examination Levels of Evidence.

Results

The novel development of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) offers the clinician a validated patient-reported outcome measure to supplement history and physical examination. The in-office cotton test, performed by placing an endoscopically directed cotton plug in the site of tissue loss, may help to identify patients who may benefit from turbinate augmentation. Tools such as the sinus computed tomography scan, computational fluid dynamics, and intranasal trigeminal nerve function testing currently have insufficient evidence to support routine use in the workup of ENS. Up to 66% of ENS patients present with comorbid anxiety or depression.

Conclusion

The ENS6Q and cotton test assist in creating a standardized approach to the evaluation of patients suspected of ENS. These instruments should be used as an adjunct, rather than the sole criteria, on which to ascertain the presumptive diagnosis. Patients suspected of ENS should be screened for comorbid psychological dysfunction.

Utility of Endoscope-Assisted Orbital Fracture Repair for Atraumatic Reduction of Entrapped Muscle Tissue and Surgical Education

Trapdoor fractures can result in extraocular muscle entrapment with resultant pain, diplopia, bradycardia, nausea, and vomiting. Urgent repair is required to minimize the risk of permanent muscle injury and long-term diplopia. Complete fracture visualization is imperative to ensure adequate reduction of the herniated tissue and accurate implant placement when necessary. Orbital floor angulation and prolapsed orbital fat can make visualization of the posterior orbit challenging. Inadequate reduction can lead to reoperation in up to 18% of cases. Because the narrow field of view makes visualization difficult, teaching the surgical technique can be very challenging. We demonstrate the reduction of an entrapped inferior rectus muscle using an endoscope-assisted transconjunctival approach, highlighting its advantages in fracture visualization and surgical training.

[An evolutionist approach of mood disorders from a transcultural perspective]

INTRODUCTION

The objective of this paper is to verify if traits and symptoms defined as pathological and maladjusted in certain contexts may produce adaptive effects in other contexts, especially if they occur in sub-threshold forms.

METHODS

A historical examination of how the symptoms of depression have changed in front of great social changes and an analysis of Sardinian migrants' thymic profiles toward several metropolises.

RESULTS AND CONCLUSIONS

Mood disorders have been increasing since the "English malady" in the 17th century, and we suppose that some forms of mood disorders might have an adaptive advantage. Otherwise, the increase of such an epidemic would have been self-limited. From a sociobiological point of view, it is highly probable that the environment of a rapidly evolving society can select people who are explorers and able to support accelerated biorhythms and that the condition of social change stimulates psychological and psychopathologic changes. It is also possible that hyperthymic persons modulate and create the new environment. If this model can explain the epidemic of mood disorders, its verification should guide future research.

The Prevalence of Cricopharyngeal Webs in Elderly Cadavers

OBJECTIVE

Cricopharyngeal webs (CPW) are a frequent cause of solid food dysphagia. They are difficult to diagnose and are often missed on swallowing fluoroscopy. The prevalence of CPWs is uncertain. The purpose of this study was to determine the prevalence of CPWs in elderly cadavers.

METHODS

Direct laryngoscopy and cervical esophagoscopy were performed in 19 embalmed cadavers by independent two-clinician consensus. Cadaver demographics and the presence and laterality of a CPW were recorded. The prevalence of CPW was calculated, and the size of the cricopharyngeus muscle (CPM) was quantified.

RESULTS

The mean age of the cohort was 83 ( ± 12) years. Fifty-three percent were female, and the mean body mass index was 19.7 ( ± 3). The causes of death were cardiovascular disease (10 of 19), cancer (5 of 19), and respiratory failure (4 of 19). A CPW was present in 68% (13 of 19) of cadavers. Forty-seven percent (9 of 19) had a unilateral web, and 21% (4 of 19) had a bilateral web. There was no laterality predominance (P > 0.05). Forty-two percent (8 of 19) had no CPM prominence; 32% (6 of 19) had a small/moderate CPM prominence; and 26% (5 of 19) had a significant CPM prominence.

CONCLUSION

The prevalence of cricopharyngeal webs in elderly cadavers is high (68%). The clinician should maintain a high index of suspicion for CPWs in patients with no other identifiable etiology of solid food dysphagia.

LEVEL OF EVIDENCE

3b Laryngoscope, 129:63-66, 2019.

Neuropathy by folic acid supplementation in a patient with anaemia and an untreated cobalamin deficiency: a case report

The rising rates of bariatric surgery (BS) are accompanied by neurological complications related to nutrient deficiencies. One of the risk factors for neurological complications in BS patients is poor vitamin and mineral supplementation. Prevention, diagnosis and treatment of these disorders are necessary parts of lifelong care after BS. Particularly important for optimal functioning of the nervous system are vitamin B₁ , B₆ , B₁₂ (cobalamin), E, copper and possibly vitamin B₁₁ (folic acid). In this case report, we narrate about a patient with anaemia and multiple vitamin and mineral deficiencies after Roux-en-Y gastric bypass (RYGB) with an alimentary limb of 150 cm and a biliopancreatic limb of 100 cm. RYGB is associated with an increased risk of vitamin deficiencies, especially a vitamin B₁₂ deficiency. The patient in this case report developed psychiatric-neurological symptoms due to folic acid supplementation in an untreated cobalamin deficiency. Second, we tried to elucidate the vitamin physiology to understand specific mechanisms after BS.

The adverse effects of interferon-free regimens in 149 816 chronic hepatitis C treated Egyptian patients

BACKGROUND

Interferon-free regimens are associated with high sustained virological response; however, associated adverse effects have yet to be fully reported.

AIM

To evaluate the adverse effects associated with the different direct-acting antiviral drug (DAA) regimens in Egyptian patients.

METHODS

This multicenter retrospective study included all adverse effects during and after treatment with DAA regimens of 149 816 chronic hepatitis C treated Egyptian patients. Patients received sofosbuvir (SOF)/ribavirin (RBV) (n = 21 835), SOF/simeprevir (n = 24 215) SOF/daclatasvir (DCV) (n = 58 477), SOF/DCV/RBV (n = 45 188) and paritaprevir/ombitasvir/ritonavir/RBV (n = 101). The duration of treatment varied between 12 and 24 weeks. All changes in the treatment regimens, discontinuation, mortality, and serious side effects were reported.

RESULTS

Adverse effects developed in 2475 (1.7%) (mean age [54 ± 9], male gender [53%]) patients. Serious side effects developed in 68% of these patients, and SOF/RBV was the most common causing regimen (73%, P < 0.001). Anaemia and hyperbilirubinemia were the most common side effects (731/149816, 0.5% and 463/149816, 0.3%, respectively) and SOF/RBV (588/21835, 3% and 353/21835, 1.6%, respectively) showed the highest incidence in the treated patients. Hepatocellular carcinoma and mortality were reported in 0.02% and 0.06% of all treated patients, respectively. Patients with liver cirrhosis showed higher incidence of serious side effects (Log rank P = 0.045) and mortality (Log rank P = 0.025) than patients without liver cirrhosis. Male gender (P = 0.012), lower haemoglobin (P < 0.001), platelets (P < 0.001) and albumin (P = 0.001), higher bilirubin (P = 0.002) and cirrhosis (P < 0.001) were factors associated with serious side effects development.

CONCLUSION

Adverse effects associated with DAAs are few, anaemia being the most common. SOF/RBV regimen showed the highest rate of side effects while SOF/DCV showed the least.

Lipoedema in patients after bariatric surgery: report of two cases and review of literature

Lipoedema is a disorder of adipose tissue that is characterized by abnormal subcutaneous fat deposition, leading to swelling and enlargement of the lower limbs as well as the trunk. This entity is often misdiagnosed as lymphoedema or obesity and, therefore, may be overlooked and missed in patients scheduled for bariatric surgery. Patients with lipoedema who undergo bariatric surgery may have to continue to have extensive lower extremity and trunk adiposity despite adequate weight loss. In this report, we present two patients who had extensive trunk and lower extremity adiposity, one of them before and the other after the bariatric surgery.

Local disease-ecosystem-livelihood dynamics: reflections from comparative case studies in Africa

This article explores the implications for human health of local interactions between disease, ecosystems and livelihoods. Five interdisciplinary case studies addressed zoonotic diseases in African settings: Rift Valley fever (RVF) in Kenya, human African trypanosomiasis in Zambia and Zimbabwe, Lassa fever in Sierra Leone and henipaviruses in Ghana. Each explored how ecological changes and human–ecosystem interactions affect pathogen dynamics and hence the likelihood of zoonotic spillover and transmission, and how socially differentiated peoples’ interactions with ecosystems and animals affect their exposure to disease. Cross-case analysis highlights how these dynamics vary by ecosystem type, across a range from humid forest to semi-arid savannah; the significance of interacting temporal and spatial scales; and the importance of mosaic and patch dynamics. Ecosystem interactions and services central to different people's livelihoods and well-being include pastoralism and agro-pastoralism, commercial and subsistence crop farming, hunting, collecting food, fuelwood and medicines, and cultural practices. There are synergies, but also tensions and trade-offs, between ecosystem changes that benefit livelihoods and affect disease. Understanding these can inform ‘One Health’ approaches towards managing ecosystems in ways that reduce disease risks and burdens.

This article is part of the themed issue ‘One Health for a changing world: zoonoses, ecosystems and human well-being’.

Generic daclatasvir plus sofosbuvir, with or without ribavirin, in treatment of chronic hepatitis C: real-world results from 18 378 patients in Egypt

BACKGROUND

Treatment of chronic hepatitis C using combination of sofosbuvir (SOF) and daclatasvir (DCV) was used in several clinical trials and multicentre studies, which were somewhat limited to genotypes 1-3. The national program in Egypt is using SOF-DCV combination for large scale treatment.

AIM

To assess the efficacy and safety of combined SOF-DCV in treating patients with HCV-G4 in a real-world setting.

METHODS

Data and outcome of chronic HCV patients who were treated for 12 weeks with generic medications: DCV 60 mg plus SOF 400 mg ± ribavirin (RBV) within the national hepatitis C treatment program in Egypt are presented. Treatment-naïve patients without cirrhosis were treated without RBV, and those who had cirrhosis or were treatment-experienced (interferon experienced or SOF experienced) received RBV. Efficacy and safety were assessed, and baseline factors associated with sustained virological response at post-treatment week 12 (SVR12) were explored.

RESULTS

During the first 2 months of the programme, 18 378 patients with HCV-G4 started treatment with SOF-DCV with or without RBV. Overall, 95.1% achieved SVR12 (95.4% among patients treated without RBV and 94.7% for patients treated with RBV, P = .32). Treatment was prematurely discontinued in only 1.5% of patients. The most common events leading to discontinuation were patient withdrawal (n = 76) and pregnancy (n = 5). Five deaths occurred within this group.

CONCLUSIONS

Real-world experience of generic SOF-DCV in patients with chronic HCV-G4 proved to be safe and associated with a high SVR12 rate, in patients with different stages of fibrosis.

Early effects of Epac depend on the fine-tuning of the sarcoplasmic reticulum Ca2+ handling in cardiomyocytes

In cardiac muscle, signaling through cAMP governs many fundamental cellular functions, including contractility, relaxation and automatism. cAMP cascade leads to the activation of the classic protein kinase A but also to the stimulation of the recently discovered exchange protein directly activated by cAMP (Epac). The role of Epac in the regulation of intracellular Ca²⁺ homeostasis and contractility in cardiac myocytes is still matter of debate. In this study we showed that the selective Epac activator, 8-(4-chloro-phenylthio)-2'-O-methyladenosine-3', 5'-cyclic monophosphate (8-CPT), produced a positive inotropic effect when adult rat cardiac myocytes were stabilized at low [Ca²⁺]_o (0.5mM), no changes at 1mM [Ca²⁺]_o and a negative inotropic effect when [Ca²⁺]_o was increased to 1.8mM. These effects were associated to parallel variations in sarcoplasmic reticulum (SR) Ca²⁺ content. At all [Ca²⁺]_o studied, 8-CPT induced an increase in Ca²⁺ spark frequency and enhanced CaMKII autophosphorylation and the CaMKII-dependent phosphorylation of SR proteins: phospholamban (PLN, at Thr17 site) and ryanodine receptor (RyR2, at Ser2814 site). We used transgenic mice lacking PLN CaMKII phosphorylation site (PLN-DM) and knock-in mice with an inactivated CaMKII site S2814 on RyR2 (RyR2-S2814A) to investigate the involvement of these processes in the effects of Epac stimulation. In PLN-DM mice, 8-CPT failed to induce the positive inotropic effect at low [Ca²⁺]_o and RyR2-S2814A mice showed no propensity to arrhythmic events when compared to wild type mice myocytes. We conclude that stimulation of Epac proteins could have either beneficial or deleterious effects depending on the steady-state Ca²⁺ levels at which the myocyte is functioning, favoring the prevailing mechanism of SR Ca²⁺ handling (uptake vs. leak) in the different situations.