Hypomorphic CDHR1 variants may result in retinitis pigmentosa with relative preservation of cone function

PURPOSE

Retinitis pigmentosa (RP) associated with biallelic variants in CDHR1 has rarely been reported, and detailed phenotyping data are not available. RP implies relative preservation of foveal cones, when compared to cone-rod dystrophy associated with biallelic null variants in CDHR1. We hypothesize that RP may occur in association with one or more hypomorphic CDHR1 alleles.

MATERIALS AND METHODS

Retrospective report of a 48-year-old patient with CDHR1-associated RP with a hypomorphic missense variant c.562 G>A, p. (Gly188Ser) and a novel, unreported variant affecting a canonical splice acceptor site (c.784-1 G>C). Clinical examination, multimodal retinal imaging, electroretinography, visual field testing, and mesopic microperimetry were undertaken 8 years apart. Scotopic microperimetry was also performed. The DNA sequence context of the variants was examined to identify theoretical CRISPR-Cas9 base-editing strategies.

RESULTS

The patient presented at 35 years with a 12-year history of nyctalopia. His best corrected visual acuity was 20/20. Clinical presentation, multimodal retinal imaging studies, electroretinography, and mesopic microperimetry were typical of a progressive rod-cone dystrophy (i.e. classic RP). There were no scotomas within the central field as would be expected at this age in CDHR1-associated cone-rod dystrophy. Scotopic microperimetry suggested some preservation of macular cone over rod function, although both were severely impaired. A suitable CRISPR adenine base editor was identified that could theoretically correct the missense variant c.562 G>A, p. (Gly188Ser).

CONCLUSIONS

CDHR1-associated RP shows a relative preservation of cone function in the presence of a presumed hypomorphic allele and may be considered a hypomorphic disease phenotype. Further work is required to identify modifying factors that determine disease phenotype since macular dystrophy, with relative sparing of rods, may also occur with hypomorphic CDHR1 alleles.

A systematic review of the current availability of mobile applications in eyecare practices

BACKGROUND

There is an increasing shift towards non-communicable eye diseases (NCEDs) because of a demographic transition. Incorporation of telemedicine into everyday clinical practice is becoming increasingly popular. We sought to carry out a systematic review to look at which applications on portable devices are available for use in eyecare practices for patients with NCEDs, specifically refractive error, diabetic retinopathy, age-related macular degeneration (AMD) and glaucoma.

METHODS

Pubmed, EMBASE, Medline, PsychInfo databases were systematically searched using keywords and MeSH terms. Eligible articles included peer-reviewed, original full text articles evaluating apps for use on portable devices aimed at patients with NCEDs.

RESULTS

The initial search yielded 100 studies. Nine studies met the inclusion criteria, and an additional eight studies were identified through reference screening. Of the included studies, 29.4%% (n = 5) evaluated applications aimed for use to identify refractive errors, 35.3% (n = 6) aimed at patients with glaucoma, 23.5% (n = 4) for use by patients with AMD, 11.7% (n = 2) for the non-specific monitoring of visual acuity/fields. 76.5% (n = 13) of the studies showed that the application evaluated was an effective and reliable tool compared to clinical standards.

CONCLUSIONS

Portable device applications in patients with NCED have been shown to be effective. The use of these apps for patients is limited to either diagnostic or monitoring use. There is scope for apps which encompass other aspects of patient care that have been used in other specialties that may be applied to ophthalmic patients, including those with an educational aim which have a role in increasing compliance.

Patient Perceptions on Data Sharing and Applying Artificial Intelligence to Health Care Data: Cross-sectional Survey

Background

Considerable research is being conducted as to how artificial intelligence (AI) can be effectively applied to health care. However, for the successful implementation of AI, large amounts of health data are required for training and testing algorithms. As such, there is a need to understand the perspectives and viewpoints of patients regarding the use of their health data in AI research.

Objective

We surveyed a large sample of patients for identifying current awareness regarding health data research, and for obtaining their opinions and views on data sharing for AI research purposes, and on the use of AI technology on health care data.

Methods

A cross-sectional survey with patients was conducted at a large multisite teaching hospital in the United Kingdom. Data were collected on patient and public views about sharing health data for research and the use of AI on health data.

Results

A total of 408 participants completed the survey. The respondents had generally low levels of prior knowledge about AI. Most were comfortable with sharing health data with the National Health Service (NHS) (318/408, 77.9%) or universities (268/408, 65.7%), but far fewer with commercial organizations such as technology companies (108/408, 26.4%). The majority endorsed AI research on health care data (357/408, 87.4%) and health care imaging (353/408, 86.4%) in a university setting, provided that concerns about privacy, reidentification of anonymized health care data, and consent processes were addressed.

Conclusions

There were significant variations in the patient perceptions, levels of support, and understanding of health data research and AI. Greater public engagement levels and debates are necessary to ensure the acceptability of AI research and its successful integration into clinical practice in future.

A 'Real Life' Service Evaluation Model for Multidisciplinary Thyroid Eye Services

BACKGROUND/AIMS

There is no universal consensus on the practical implementation and evaluation of the Amsterdam Declaration on Graves Orbitopathy in a Multidisciplinary Thyroid Eye Disease (MDTED) pathway. Recent recommendations from the UK TEAMeD-5 and BOPSS initiative highlight the importance of prevention, screening, and prompt referral of patients with moderate to severe and sight-threatening thyroid eye disease to multidisciplinary (MDTED) clinics and recommends annual auditing. We propose a practical service evaluation model with Key Performance Indicators (KPI) that are achievable and could be implemented across most TED pathways.

MATERIAL AND METHODS

We conducted a service evaluation from an integrated TED pathway in London with three MDTED clinics. Data was collected retrospectively from consecutive TED patients included: 1) Patient demographics, 2) Referral to first appointment time, 3) Documented smoking cessation and selenium supplementation advice, 4) Presenting disease activity and severity, 5) Investigations and treatments, including radio-iodine, 6) Time from decision to treatment initiation, 7) Initial and subsequent thyroid status.

RESULTS

The median age was 49.0 yrs, 77.5% (183/236) were female and 49.5% (101/204) Afro-Caribbean or Asian. At their first clinic attendance, 47.6% (110/231) were biochemically euthyroid and 76.7% (79/103) at discharge. All 23.1% (52/225) current smokers received smoking cessation advice and 64.8% (153/236) received selenium supplementation advice. Intravenous methylprednisolone was given to 33.9% (80/236) patients and 12.7% (30/236) received second-line immunosuppression. All 7.2% (17/236) patients with sight-threatening disease received treatment within two weeks of diagnosis.

CONCLUSIONS

This study forms a waymark for other units using TEAMeD-5 and BOPSS audit criteria. Dedicated electronic patient records with ongoing data capture, including quality of life assessments, and diagnostic coding would significantly aid future auditing, improve patient care, and facilitate a national audit of TED management. A future survey when the TED standards have become embedded would be instructive to see whether this has improved TED care.

Association of Other Autoimmune Diseases With Thyroid Eye Disease

BACKGROUND

Thyroid eye disease (TED) is a potentially disfiguring and sight-threatening autoimmune (AI) orbitopathy, affecting up to 400,000 people in the UK. There are no accurate early predictors of TED severity. Although polyautoimmunity has been shown to affect AI disease severity, its influence on TED severity has never been investigated. The prevalence of polyautoimmunity among TED patients is also unclear, with discordant results reported in the literature. This study evaluates the prevalence of non-thyroid/"other" AI (OAI) conditions in an ethnically diverse TED cohort and assesses how polyautoimmunity affects TED severity and activity.

METHODS

A retrospective study of patients presenting to multidisciplinary TED clinics across three North-West London hospitals between 2011 and 2019. Data collected included: 1) demographics; 2) OAI conditions and management; 3) endocrine management of thyroid dysfunction; 4) details of TED and clinical activity score at presentation.

RESULTS

Two hundred and sixty-seven patients with a median age of 46 (35-54) years were included, 79.4% were female and 55% were Black, Asian and minority ethnic (BAME). Thirty-seven patients (13.9%) had OAI conditions, with rheumatoid arthritis (3.7%), vitiligo (3.0%) and psoriasis (3.0%) among the most prevalent. Of patients with OAI conditions, 43.2% (16/37) required immunosuppression prior to TED onset. Non-immunosuppressed patients with OAI conditions had a significantly higher clinical activity score at presentation than TED-only and previously immunosuppressed patients (p=0.02). No significant differences were observed in thyroid receptor antibody titers between these groups.

CONCLUSIONS

This study finds a 13.9% prevalence of OAI conditions among TED patients. Patients with OAI conditions overall have a tendency for more severe and significantly more clinically active TED than those without OAI conditions. Larger, prospective studies are warranted to further evaluate polyautoimmunity as an early predictor of TED severity.

Surgical and medical management of small bowel gastrointestinal stromal tumors: A report of the Dutch GIST registry

BACKGROUND

A cohort of 201 patients with small bowel gastrointestinal stromal tumors (GIST) treated between January 1st, 2009 and December 31st, 2016 in five GIST expertise centers in the Netherlands was analyzed. Goal of this study was to describe the clinical, surgical and pathological characteristics of this rare subpopulation of GIST patients, registered in the Dutch GIST registry.

METHODS

Clinical outcomes and risk factors of patients with small bowel GIST who underwent surgery or treated with systemic therapy were analyzed. A classification was made based on disease status at diagnosis (localized vs. metastasized).

RESULTS

201 patients with small bowel GIST were registered of which 138 patients (69%) were diagnosed with localized disease and 63 patients (31%) with metastatic disease. Approximately 19% of the patients had emergency surgery, and in 22% GIST was an accidental finding. In patients with high risk localized disease, recurrence occurred less often in patients who received adjuvant treatment (4/32) compared to patients who did not (20/31, p < 0.01). Disease progression during palliative imatinib treatment occurred in 23 patients (28%) after a median of 20.7 (range 1.8-47.1) months. Ongoing response was established in 52/82 patients on first line palliative treatment with imatinib after a median treatment time of 30.6 (range 2.5-155.3) months.

CONCLUSION

Patients with small-bowel GIST more frequently present with metastatic disease when compared to patients with gastric GIST in literature. We advocate for Prospective registration of these patients and investigate the use of surgery in patients with limited metastatic disease.

Early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resections: an integrated systematic review and meta-analysis of published randomized controlled trials

AIMS

The objective of this study was to evaluate the surgical outcomes and feasibility of early loop defunctioning ileostomy closure, within 2 weeks of index surgery, in patients undergoing distal colorectal resection.

METHODS

A systematic review of the literature on published randomized controlled trials reporting the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection using the principles of meta-analysis on RevMan 5.4 statistical software was undertaken.

RESULTS

Four randomized, controlled trials on 446 patients evaluating the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing low colorectal resection were analysed. There were 176 patients in the early closure group and 270 patients in the delayed closure group. The risk of anastomotic leak [risk ratio 0.37 (CI: 0.10-1.42), P = 0.15], anastomotic stenosis [risk ratio 4.79 (CI: 0.23-98.47), P = 0.31] and postoperative complications [risk ratio 0.75 (CI: 0.48-1.16), P = 0.19] was similar in both groups. In addition, there was no significant difference between the groups with regard to the duration of operation [standardized mean difference -0.49 (CI: -01.09, -0.12), P = 0.12] and length of hospitalization [standardized mean difference -0.04 (CI: -0.25, -0.18), P = 0.75].

CONCLUSIONS

Early closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection is feasible with comparable outcomes to delayed closure.

Persistent Mullerian Duct Syndrome: an interesting case report

Transverse testicular ectopia is an uncommon disorder of testicular ectopia. Nearly thirty percent of the cases is associated with Persistent mullerian duct syndrome which is characterized by karyotypically normal males with retained mullerian derivatives. Understanding the natural process of the condition and the association with malignant potential will allow for a better understanding of the optimal surgical approach. This is a case report of young male presented a left sided inguinal hernia in which the sac contained both testes and uterus. The literature review of the syndrome will be discussed.

Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer

AIM

A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer.

METHOD

An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers.

RESULTS

Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy.

CONCLUSION

Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.

Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Purpose

Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.

Methods

Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.

Results

The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.

Conclusion

In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

Quantification of non-specific binding of magnetic micro- and nanoparticles using cell tracking velocimetry: Implication for magnetic cell separation and detection

The maturation of magnetic cell separation technology places increasing demands on magnetic cell separation performance. While a number of factors can cause sub-optimal performance, one of the major challenges can be non-specific binding of magnetic nano- or microparticles to non-targeted cells. Depending on the type of separation, this non-specific binding can have a negative effect on the final purity, the recovery of the targeted cells, or both. In this work, we quantitatively demonstrate that non-specific binding of magnetic nanoparticles can impart a magnetization to cells such that these cells can be retained in a separation column and thus negatively impact the purity of the final product and the recovery of the desired cells. Through experimental data and theoretical arguments, we demonstrate that the number of MACS magnetic particles needed to impart a magnetization that is sufficient to cause non-targeted cells to be retained in the column to be on the order of 500-1,000 nanoparticles. This number of non-specifically bound particles was demonstrated experimentally with an instrument, cell tracking velocimeter, CTV, and it is demonstrated that the sensitivity of the CTV instrument for Fe atoms contained in magnetic nanoparticles on the order of 1 x 10(-15) g/mL of Fe.

Novel monoclonal antibody that enhances natural killer (NK) cell cytotoxicity against multiple myeloma (MM): Preclinical data and interim phase I clinical trial results

3032

Background: MM is increasing in incidence and remains incurable. NK cells have modest killing activity against MM cells in part because of inhibitory signals from HLA class 1 antigens which act via the KIR receptors on NK cells. A novel anti-KIR blocking antibody (1–7F9 named IPH 2101) enhances patient NK cell cytotoxicity against autologous MM tumor cells in vitro and appears safe in an ongoing phase 1 clinical trial. Methods: NK cells from healthy controls or patients were pre-treated with IPH 2101 or IgG4 isotype control and co-cultured with MM cell lines or autologous MM tumor targets. NK cell production of interferon-gamma (IFN-γ) or granzyme B (GrB) were measured by ELISPOT. An open-label, single-agent, phase 1 dose escalation study of IPH 2101 is being conducted in patients with relapsed/refractory MM. KIR binding, pharmacokinetics, pharmacodynamics, effects on NK cell maturation, and biological effects of IPH 2101 are being monitored in all patients. Results: At an effector to target (E:T) ratio of 1:1, IPH 2101 significantly enhances NK cell IFN-γ release against MM targets (mean 33 spots/well ± 12, SEM vs. 11 ± 0.3, p = 0.005). At an E:T ratio of 10:1, IPH 2101 enhances NK cell cytotoxicity, by GrB release, of patient NK cells against autologous MM tumor cells (mean 111 spots/well ± 14, SEM vs 56 ± 10, p = 0.002). By Western blot, IPH 2101 may reduce levels of src, a kinase known to be involved in inhibitory KIR signaling. Dose escalation in the phase 1 study has been completed from 0.0003 mg/kg to 0.075 mg/kg in 14 evaluable patients. At the highest dose tested, KIR occupancy has been detected at a mean 95% ± 1.4 at 2 hours post dose, lasting up to 56% ± 18 during 2 weeks post dose. At this dose level, PK data show good correspondence with previous modeling activity. No deleterious effect on NK cell maturation has been seen. IPH 2101 has been well tolerated to date. Conclusions: IPH 2101 improves autologous NK cell killing of MM tumor cells by blocking inhibitory KIR. In the ongoing clinical trial, the antibody appears safe and well tolerated at the doses tested. This immunotherapeutic approach may hold promise as treatment for MM and further study is warranted.

[Table: see text]

Treatment of Alhagi Residues with Tartaric Acid for the Removal of Zn(II) Ions from Aqueous Solution

Alhagi cellulose tartrate (ACT) with a high carboxyl group content was prepared by treatment of Alhagi residues (AR) with tartaric acid (TA) at high temperature. Factors influencing the reaction were investigated, viz. tartaric acid concentration, dehydration temperature, particle size and dehydration time. The prepared Alhagi cellulose tartrate samples were characterized using FT-IR spectroscopy and by estimation of the carboxyl group content. The esterified samples were utilized for the adsorptive removal of Zn(II) ions from aqueous solution with all the factors influencing the process being studied. These factors were the pH value of the adsorbate solution, the adsorbent concentration, agitation time and temperature.

The Langmuir and Freundlich models were applied to the data obtained from the adsorption studies. It was demonstrated that the Alhagi cellulose tartrate samples could be used effectively for the adsorption of Zn(II) ions from aqueous solutions. The thermodynamics constants of the adsorption process, viz. ΔH0, ΔS0 and ΔG0, were evaluated. The results showed that the adsorption of Zn(II) ions onto ACT was exothermic and spontaneous. The adsorption data followed second-order kinetics, with the equilibrium data being only satisfactorily described by the Langmuir isotherm.

Therapy-related myelodysplasia and leukemia occur infrequently following VP-16 priming and autotransplantation without total body irradiation

The use of VP-16 for stem cell mobilization has been cited as a significant risk factor for the development of therapy-related myelodysplasia/leukemia (tMDS/tAML) following autologous transplantation. The present study analyzed a large cohort of patients who underwent autotransplantation following stem cell mobilization with VP-16 and radiation-free preparation in order to determine the risk of tMDS/tAML. The estimated incidence of 9.9% at 7 years suggests that in the absence of TBI, VP-16 priming is not associated with an increased incidence of tMDS/tAML.

Cubital tunnel syndrome. Treatment by decompression without transposition of ulnar nerve

Cubital tunnel syndrome is the second most common entrapment neuropathy in the upper limb; however, surgical treatment of the ulnar nerve entrapment at the elbow remains controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy, subcutaneous, submuscular or intramuscular anterior transposition of the ulnar nerve) has proven optimal regarding long-term results. This paper presents the experience of treating cubital tunnel syndrome with simple decompression in 40 patients. Three months after surgery 23/36 patients did not feel any pain in their operated hands. In 11/36 cases we observed an improvement of preoperative pain. Sensory disturbances disappeared completely in 24/40 cases. 11/40 patients reported an improvement of preoperative dysesthesia or hypesthesia. In 12/22 patients we observed complete recovery of preoperative pareses of adductor muscle of thumb or hypothenar muscles weakness. 7/22 cases demonstrated an improvement of these pareses. In total 28 patients (70 %) had an excellent outcome without residual symptoms. For 5 patients treatment results were classified as good with slight residual pain and sensory disturbance (12.5 %). In 4 cases (10 %) we only observed a fair outcome with persistent severe sensory and motor deficits but slow improvement over the last three months. Three patients did not demonstrate any improvement (7.5 %). The mean duration of postoperative disablement in our working patients (18/40) was 28 days. In summary, simple decompression of the ulnar nerve seems to be an adequate and successful minimally invasive technique for the treatment of cubital tunnel syndrome.

Stereotactic biopsies guided by an optical navigation system: technique and clinical experience

Frame-based stereotactic biopsies are time-consuming procedures making necessary head fixation in a ring, explicit coordinate calculation and setting of the parameters. Frameless systems make many of these intermediate steps unnecessary, impose less mechanical restrictions regarding access to the lesions, and with slight modifications can be used to perform stereotactic biopsies. A special adaptation designed to fix the holder and the biopsy instrument is described. The neuronavigation optical tracking system of Radionics was used. CT scans were performed with 6 skin markers. Calibration was performed after head fixation in the Mayfield clamp. Mean calibration error was 2.19 +/- 0.81 mm. The light-emitting diode holder of the pointer was fixed into 2 Leila arms and moved under visual control based on CT images. The target point was selected, Leila arms fixed and a burr hole performed. The cannula was introduced to the target, being fitted with a depth stop in a length identical to that of the pointer on the screen. If necessary a second trajectory was easily selected. 49 patients underwent a frameless stereotactic biopsy. All targets except seven were superficial or in the white matter. In selected cases the biopsies were taken from deep-seated lesions. A histological diagnosis was obtained in 100 % of the cases. Four cases deteriorated postoperatively, two of these related to intratumoral bleeding. Navigation is a simple and effective method to perform biopsies of superficial and relatively large lesions. Frame-based procedures are restricted to brainstem tumors and lesions less than 1.5 cm in diameter.

Gastric perforation in a case of gastric volvulus

We describe a case of organoaxial gastric volvulus in which the axis was through the body of the stomach. The intraabdominal part of the volvulus was complicated by bleeding from two necrotic ulcers, one of which was perforated by the tip of a nasogastric tube.