Diagnostic issues faced by a rare disease healthcare network during Covid-19 outbreak: data from the Campania Rare Disease Registry

Background

The aims of this study were: to investigate the capacity of the rare disease healthcare network in Campania to diagnose patients with rare diseases during the outbreak of Covid-19; and to shed light on problematic diagnoses during this period.

Methods

To describe the impact of the Covid-19 pandemic on the diagnosis of patients with rare diseases, a retrospective analysis of the Campania Region Rare Disease Registry was performed. A tailored questionnaire was sent to rare disease experts to investigate major issues during the emergency period.

Results

Prevalence of new diagnoses of rare disease in March and April 2020 was significantly lower than in 2019 (117 versus 317, P < 0.001 and 37 versus 349, P < 0.001, respectively) and 2018 (117 versus 389, P < 0.001 and 37 versus 282, P < 0.001, respectively). Eighty-two among 98 rare disease experts completed the questionnaire. Diagnostic success (95%), access to diagnosis (80%) and follow-up (72%), lack of Personal Protective Equipment (60%), lack of Covid-19 guidelines (50%) and the need for home therapy (78%) were the most important issues raised during Covid-19 outbreak.

Conclusions

This study describes the effects of the Covid-19 outbreak on the diagnosis of rare disease in a single Italian region and investigates potential issues of diagnosis and management during this period.

Clinical features of serous retinopathy observed with cobimetinib in patients with BRAF-mutated melanoma treated in the randomized coBRIM study

BACKGROUND

Serous chorioretinopathy has been associated with MEK inhibitors, including cobimetinib. We describe the clinical features of serous retinopathy observed with cobimetinib in patients with BRAF V600-mutated melanoma treated in the Phase III coBRIM study.

METHODS

In the coBRIM study, 493 patients were treated in two randomly assigned treatment groups: cobimetinib and vemurafenib (n = 247) or vemurafenib (n = 246). All patients underwent prospective ophthalmic examinations at screening, at regular intervals during the study, and whenever ocular symptoms developed. Patients with serous retinopathy were identified in the study database using a group of relevant and synonymous adverse event terms.

RESULTS

Eighty-six serous retinopathy events were reported in 70 patients (79 events in 63 cobimetinib and vemurafenib-treated patients vs seven events in seven vemurafenib-treated patients). Most patients with serous retinopathy identified by ophthalmic examination had no symptoms or had mild symptoms, among them reduced visual acuity, blurred vision, dyschromatopsia, and photophobia. Serous retinopathy usually occurred early during cobimetinib and vemurafenib treatment; median time to onset was 1.0 month. Most events were managed by observation and continuation of cobimetinib without dose modification and resolved or were resolving by the data cutoff date (19 Sept 2014).

CONCLUSIONS

Cobimetinib treatment was associated with serous retinopathy in patients with BRAF V600-mutated melanoma. Retinopathy was generally asymptomatic or mild. Periodic ophthalmologic evaluations at regular intervals and at the manifestation of any visual disturbance are recommended to facilitate early detection and resolution of serous retinopathy while patients are taking cobimetinib. Trial Registration Clinicaltrials.gov (NCT01689519). First received: September 18, 2012.

Tinnitus program at Brasília University Medical School

Over the last 6 months, all patients seen at the otologic clinic of Brasília University Medical School answered a questionnaire designed to identify and describe the symptom of tinnitus. A total of 500 patients reported and described this symptom. They underwent physical examination, laboratory tests and audiological evaluation. In their order of frequency, presbycusis, chronic otitis media, otosclerosis, acoustic trauma, Menière's disease, ototoxicity, and vestibular schwannoma were found. Tinnitus was rated as minor in 81%, moderate in 18%, and severely disabling in 1%. Those who requested treatment for tinnitus were treated medically. Central vasodilators, vestibular suppressants, calcium channel blockers, anticholinergic drugs, anticonvulsant drugs, and gingko biloba were used with variable results. Tinnitus maskers were not used, but hearing prostheses were fitted when indicated. Treatment failed in the 1% with severe disabling tinnitus, and they were entered in a double-blind, randomized protocol for intratympanic dexamethasone injection. Under topical anesthesia, 0.2 ml of a 4-mg/ml dexamethasone solution (0.8 mg per injection) or 0.2 ml of normal saline was injected just posterior to the umbo. Patients remained supine for 20 minutes with the injected ear up and received four injections at 1-week intervals. Preliminary results are reported. Tinnitus is a very frequent symptom among our otologic patients, but most of them would not mention the symptom spontaneously, probably because for 81% it was mild. Curiously, the 5% of the severely disabling type tend to exhibit no clear cause, whereas the mild and moderate cases usually have an identifiable etiology.

Biodegradation of MTBE and BTEX in an aerobic fluidized bed reactor

An aerobic fluidized bed reactor (FBR) was operated for the removal of methyl tert-butyl (MBE) and benzene, toluene, ethylbenzene, and p-xylene (BTEX) from water. The reactor was seeded with a mixed culture adapted to MTBE. Granular activated carbon (GAC) was used as the biological attachment medium. Influent MTBE to the reactor was 7.8 mg/L MTBE, with a flow rate of 22.7 L/day, and an empty bed contact time of 1 hour. The acclimation period required was relatively short, about 30 days before reaching an average stable effluent concentration of 18.5 +/- 10 microg/L. BTEX was introduced to the feed at an equivalent chemical oxygen demand (COD) as the MTBE at day 225 and was biodegraded spontaneously with no apparent acclimation period required. The average influent of each of the four BTEX compounds was about 2 mg/L, and the range of the average effluent concentrations wae 1.4-2.2 microg/L. After achieving 180 days of stable performance with BTEX addition, the total low rate to the reactor was gradually increased by 20% increments to 160% of the original flow (36.4 L/day). Increases by 20% and 40% had no apparent effect on reactor performance, but increase by 60% required 30 days before effluent quality returned to previous values. Composition of the culture was monitored throughout operation of the reactor using denaturing gradient gel electrophoresis (DGGE). The culture consisted of Flavobacteria-Cytophaga and organisms with high similarity to the known MTBE degrader PM1.

[Micro-mesoscopic study of the lateral wall of the human cavernous sinus]

The authors studied the structures of human cavernous sinus in its interior as well as on the lateral wall, utilizing thick, frontal, sequential sections. They show the significance of this wall, frequently used as surgical accessway to diseases encountered within this venous structure of the dura-mater.