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Introdução: Mieloma Múltiplo (MM) é uma neoplasia maligna relacionada à proliferação descontrolada de plasmócitos na medula óssea. Possui diferentes classificações e prognósticos e seus sintomas dependem do sítio acometido. A síndrome da doença inclui hipercalcemia, insuficiência renal, anemia e doença óssea. É um diagnóstico desafiador e de grande impacto na qualidade de vida. Logo, o presente estudo busca compreender as características sociodemográficas e clínicas dos pacientes com diagnóstico de MM em um hospital de grande porte do RS. Metodologia: Estudo transversal, descritivo e quantitativo, aprovado pelo Comitê de Ética em Pesquisa (n° 6.544.927). Foram avaliados 31 pacientes em acompanhamento no ambulatório de Hematologia do Hospital São Vicente de Paulo (HSVP). Analisou-se os dados demográficos, comorbidades e efeitos adversos do tratamento, os quais foram coletados por meio de questionário de autoria própria e os exames laboratoriais do prontuário eletrônico (TASY). Resultados: A média de idade e de tempo desde o diagnóstico foram de 60,6 e 5,45 anos. Predominou o sexo masculino (64,5%), raça branca (71%), religião católica (77,4%), estado civil casado (64,5%) e ensino fundamental incompleto (48,5%). 22,6% dos pacientes relataram uma comorbidade e 51,6% duas ou mais. A de maior prevalência foi hipertensão arterial sistêmica (58,1%), seguida de doença cardiovascular (29%), fratura óssea (25,8%), anemia (19,4%), hipotireoidismo (16,1%), doença pulmonar (12,9%), doença renal crônica (9,7%). Nos efeitos adversos do tratamento, predominou a perda de apetite (61,3%), seguida de perda de peso (58,1%), náuseas/vômitos (58,1%), dificuldade de visão (58,1%), cansaço (54,8%), constipação (51,6%), redução de sensibilidade (48,4%). Discussão: O MM representa 1% de todos os tipos de câncer e 10% das neoplasias hematológicas. De acordo com o Ministério da Saúde, houve 3.064 óbitos por essa doença no BR em 2016. Concordando com a literatura, a maioria dos pacientes eram do sexo masculino com idade entre 60 e 65 anos. A literatura traz a raça negra como fator de risco, mas em nossos dados a raça branca prevaleceu - o que possui relação com a colonização predominantemente europeia no RS. Em um estudo feito no estado do MS, a cor branca também foi predominante, sendo um estado onde 47% da população se declarava branca. Há fatores relacionados ao risco aumentado dessa neoplasia, como exposição à radiação ionizante e a agentes químicos contendo hidrocarbonetos aromáticos, agentes poluentes e agrotóxicos. A maioria dos entrevistados era casada e com ensino fundamental incompleto. Do total, 22 pacientes não eram tabagistas. Sobre as comorbidades, predominou a hipertensão arterial sistêmica, um dado que não surpreende devido à alta prevalência dessa doença na sociedade. A maioria dos pacientes não reportou câncer prévio e poucos eram portadores de doença renal crônica. Conclusão: Compreender o perfil dos pacientes com MM pode contribuir diretamente para o maior conhecimento da doença por parte dos profissionais de saúde, possibilitando diagnóstico precoce e melhor manejo da doença. Ressalta-se que com os dados coletados não é possível correlacionar, com indubitável significância, a incidência de MM em um determinado grupo demográfico. Além disso, a alta prevalência de efeitos adversos reflete a dificuldade de manter a qualidade de vida diante dos tratamentos disponíveis.

Introdução: O mieloma múltiplo (MM) é uma neoplasia maligna de plasmócitos da medula óssea que possui uma grande carga de sintomas, comprometendo a qualidade de vida (QV) e a capacidade funcional dos pacientes. O seu tratamento envolve o uso de fármacos potencialmente causadores de NIPQ, como talidomida, lenalidomida e bortezomibe. A NPIQ é relatada entre 10 e 55% dos pacientes em uso de talidomida e entre 31 e 64% daqueles em uso de bortezomibe. Nesse sentido, objetivou-se avaliar a NPIQ em pacientes em tratamento para MM em um hospital terciário em Passo Fundo (RS). Metodologia: Estudo transversal, descritivo e quantitativo no qual aplicou-se, mediante autorização de Comitê de Ética em Pesquisa (n° 6.544.927), o instrumento Indication for Common Toxicity Criteria – Grading of Peripheral Neuropathy Questionnaire (ICPNQ), que contém três subescalas hipotéticas que avaliou sintomas sensoriais, autonômicos e motores em 23 pacientes que estavam em uso de drogas neurotóxicas no momento da pesquisa. Resultados e discussão: O ICPNQ é usado para avaliação da NPIQ em pacientes com MM. Mediante as respostas dos pacientes é possível uma indicação em relação ao grau CTCAE (Critérios de Terminologia Comum para Eventos Adversos) da NPIQ, de modo que em nosso estudo obteve-se os seguintes resultados: grau 0, assintomático, apenas um (4,3%) paciente; grau I, presença de sintomas sensoriais como dormência, formigamento e alterações proprioceptivas, 5 pacientes (21,7%); grau II, sintomas autonômicos e/ou perda de força, e/ou problemas vivenciados em atividades instrumentais acompanhadas de sintomas sensoriais e/ou dor, 13 pacientes (56,5%); e grau III, problemas nas atividades de autocuidado acompanhadas de sintomas sensoriais e/ou dor e/ou perda de força, 4 pacientes (17,4%). Quanto aos protocolos de tratamento utilizados, 39,1% estavam em uso de talidomida; 39% de bortezomibe; 13% associação de talidomida com bortezomibe e 8,7% em uso de lenalidomida. A neuropatia é um efeito adverso comum da quimioterapia, sendo observado, em nosso estudo, em mais de 95% dos entrevistados. Do mesmo modo, um estudo realizado na Holanda com 56 pacientes portadores de MM, evidenciou que 65% deles relataram graus 2 ou 3 de neuropatia, de acordo com o ICPNQ. Os fármacos empregados no tratamento do MM tem aumentado a sobrevida dos pacientes, porém os efeitos adversos vivenciados impactam negativamente na QV. Tendo em vista que não existem agentes terapêuticos preventivos da NPIQ, os seus instrumentos de mensuração são fundamentais na prática clínica, pois auxiliam os médicos na tomada de decisão frente a manutenção ou redução de doses, visando manter o controle da doença e melhorar os sintomas experimentados pelos pacientes. Deve-se salientar que além da quimioterapia, existem outras potenciais causas de neuropatia, porém, exames mais objetivos como eletroneuromiografia nem sempre estão disponíveis. Conclusão: Com aumento da expectativa de vida, as neoplasias estão entre uma das principais causas de morbimortalidade na população e os pacientes enfrentam os efeitos da quimioterapia na QV. Diante disso, o uso de instrumentos de avaliação da NIPQ, ajudam a compreender o quanto a neuropatia interfere no tratamento oncológico, além de auxiliar os profissionais sobre as medidas cabíveis para assegurar a manutenção do bem estar do paciente durante o tratamento.

Objetivos: A COVID-19 (corona virus disease) é uma doença respiratória causada pelo vírus SARS-CoV-2 (síndrome aguda respiratória severa do coronavírus-2), que surgiu em dezembro de 2019 na China e se espalhou pelo mundo. Devido à urgência no controle e a dificuldade em estabelecer tratamento farmacológico eficaz, as vacinas surgiram como principal alternativa no combate à essa infecção. Os testes com vacinas foram realizados em grupos controlados, e ainda não se sabe exatamente como será a eficácia em populações específicas, principalmente nos idosos. Para auxiliar nesta questão, este trabalho teve como objetivo avaliar a imunidade celular por meio da análise de linfócitos T, após um ano da vacinação com CoronaVac em idosos e profissionais de instituições de longa permanência para idosos (ILPI) do estado de Sergipe. Materiais e métodos: Trata-se de um estudo observacional prospectivo, que empregou imunofenotipagem por citometria de fluxo, para avaliar o perfil fenotípico e funcional de linfócitos T e NK (natural killer), utilizando os marcadores CD3, CD4, CD8, CD56, CD69, CD45, CCR7. As análises foram realizadas nocitômetroAttuneNxT, e os resultados avaliados pelo software FlowJo versão 10.6.1. A estratégia de análise foi a caracterização fenotípica e funcional das populações de linfócitos T CD4+ e CD8+, naïve de memória (CD45RA/CCR7), e dos linfócitos NK ativados e não ativados (CD69). Resultados: Foram avaliados 19 indivíduos, 12 idosos com idade variando de 65 a 89 anos (M = 77), e sete profissionais com idades de 24 a 50 anos (M = 39). Foi observado o aumento na expressão dos LTCD4+ no GI (p = 0,0106), quando comparado ao GC. Em relação aos fenótipos LTCD4+ analisados, houve aumento na expressão do fenótipo efectormemory (CD45RA−/CCR7−) no GI (p = 0,0286). Em contrapartida, o fenótipo naïve (CCR7+/CD45RA+) dos LTCD8+ apresentou diminuição da expressão no GI (p = 0,0298). Em relação à população de linfócitos NK foi demonstrado aumento na expressão dos linfócitos NKCD69+ (ativados) no GI (p = 0,0024). Neste grupo, foi analisada a presença dos fenótipos CD56, e CD3, demonstrando que os idosos apresentaram maior expressão dos fenótipos CD56+ CD3+ (NK-T) e CD56+ CD3− (NK) (p = 0,0165 e p = 0,0202, respectivamente). Discussão: Este estudo demonstrou o aumento na expressão dos linfócitos T CD4+ e do fenótipo efectormemory nos idosos vacinados, corroborando com estudos da literatura que analisaram diversas faixas etárias e variáveis semelhantes. Por sua vez, entre os linfócitos T CD8+, o fenótipo naïve apresentou redução na expressão no grupo de idosos, fato que pode ocorrer devido à imunossenescência, processo fisiológico do envelhecimento em que ocorre alterações na resposta imune. A análise dos linfócitos NK evidenciou aumento na expressão de células CD69+ (ativadas) no grupo de idosos, bem como dos fenótipos NK-T e NK. Conclusão: Conclui-se com este trabalho que os idosos apresentaram maior expressão de linfócitos T CD4+, especialmente os de memória efetora, e dos linfócitos NK ativados. Considerando que a rápida expansão dos linfócitos de memória, induzida pela vacina, pode desempenhar um papel crucial no fortalecimento da imunidade na COVID-19, esses resultados podem fornecer insights valiosos sobre a resposta imunológica em diferentes faixas etárias, especialmente em idosos. Em conjunto com outros estudos similares, esses dados podem auxiliar às estratégias de vacinação, com o objetivo de proteger de forma eficaz os grupos mais vulneráveis.

Objetivos: Este artigo, implantou uma planilha desenvolvida, para controle e avaliação de resposta molecular nos pacientes. Além disso, buscamos identificar o perfil epidemiológico dos casos acompanhados no Ambulatório de Hematologia Oncológica do Hospital São Vicente de Paulo (HSVP) e Hospital de Clínicas de Passo Fundo (HCPF) atendidos desde Janeiro de 2000 até Junho de 2020. Método: Os dados coletados foram tabulados e submetidos à análise estatística descritiva. Resultados: Foram analisados 70 pacientes com leucemia mieloide crônica. Desses, haviam 37 homens (52,8%); a média de idade foi de 62 anos (± 14,5). Em relação ao seu tratamento, todos os pacientes iniciaram a terapia da doença com o medicamento imatinib. No que se refere à resposta em primeira linha, 38 pacientes (54,28%) apresentaram resposta ótima desde o primeiro BCR ABL coletado com 3 meses (10%), mas, após mais 3 meses de acompanhamento, já haviam progredido para resposta ótima (

Mantle cell lymphoma (MCL) is a neoplasm of mature lymphocytes commited to the B-cell lineage. This neoplasm has an aggressive clinical course, with poor response to standard treatment and short overall survival. MCL typical immunophenotype has been described as a mature monoclonal B-cell population with expression of CD19, CD20, CD43, CD45, CD79 and CD5; and negative expression of CD10, CD23 and CD200. Overexpression of cyclin D1 as detected by immunohistochemistry is characteristic of this disease. CD117 or c-kit is a surface protein encoded by the proto-oncogene c-kit which is expressed in normal hematopoietic and neoplastic cells, usually of myeloid lineage. There are few published studies with assessment of CD117 expression on mature B-cell neoplasms (MBCN). In this report, we described a MCL case with aberrant CD117 coexpression as demonstrated by flow cytometry immunophenotyping (FCI). Patient was a 64 year-old male with leukocytosis (39.20 x 109/l) and lymphopenia with normal red blood cell and platelet counts. Peripheral blood FCI with a screening panel evidenced an abnormal population representing 64% of nucleated cells, with expression of CD19, CD45(bright) and CD117. Additional staining of myeloid and lymphoid markers was performed. The neoplastic cells had positive expression of cytCD79a, CD5, CD19, CD20(bright), CD27, CD38, CD45(bright), CD43, CD79b, CD81, HLA-DR and kappa light chain; and were negative for cytCD3, cytMPO, CD10, CD11c, CD23, CD25, CD33, CD34, CD103, CD200 and lambda light chain. CD117 PE (clone 104D2, EXBIO, Praha, CZE) staining was repeated and positive expression was confirmed. FCI findings were compatible with the diagnosis of MCL with aberrant CD117 coexpression. After initial chemotherapy, patient had persistent leukocytosis (19.10 x 109/l) with anemia (hemoglobin of 11.1 g/l). Bone marrow aspirate FCI showed persistence of 37% of neoplastic cells. Unfortunately, patient died from causes unrelated to the disease before the next chemotherapy cycle. CD117 expression is a common finding in acute myeloid leukemia, being less frequently expressed in precursor lymphoid neoplasms and rarely identified in mature neoplasms. There are few studies evaluating CD117 expression in MBCN since its assessment is not part of the diagnostic panels. Assessment of c-kit mRNA expression in different types of lymphomas only identified its expression in CD30-positive cases. A CD117-positive B-cell non-Hodgkin lymphoma (NHL) carrying the t(14;18) translocation has been described in a case report. In another study, CD117 overexpression was identified in 2 out of 17 MCL cases using immunohistochemistry. Also, CD117 expression was identified in four out of 30 diffuse large B-cell lymphoma (DLBCL) cases. There is one large study assessing the distribution and expression of KIT in 824 cases of malignant lymphoma where CD117 expression was assessed with tissue microarray, and only one B-cell follicular lymphoma had positive CD117 expression. The role of CD117 expression on MBCN is still unclear, however, the abnormal expression of this marker has potential to be used for FCI minimal residual disease (MRD) assessment. In conclusion, CD117 expression can be found in MCBN such as MCL and expansion of FCI panel in order to better characterize such abnormal populations is necessary for the correct diagnosis.

Background and Objective: In an effort to limit the risks associated with medical radiation exposure, the last century witnessed the development of dose control mechanisms, recommended by the International Commission on Radiological Protection. This organization recommends the optimization of radiation protection to provide the highest level of safety that may reasonably be achievable. Adhering to the "as low as reasonably achievable" principle, the purpose of this study was to monitor the 18 F-FDG injected activity in PET and optimize the radiation protection through an internal audit process. This monitoring allows the identification of opportunities for improvement in patient care and safety, as well as to establish a periodic review of the medical unit reference levels., Methods: The methodology is based on short run Quesenberry (Q) statistics and normalized nonconstant sample size (Z-chart) control charts. Anonymized data from 512 patients were selected from a set of 18 F-FDG PET/CT (Siemens, Biograph 6) examinations performed during 10 months. The analyzed variable was the ratio between the 18 F-FDG injected activity (MBq) and patient weight (kg)., Results: Mean injected 18 F-FDG activity was 347.811 ± 64.967 MBq corresponding to a mean effective dose of 6.608 ± 1.234 mSv. The ratio between the 18 F-FDG injected activity and the body mass of patients was reduced from 5.243 ± 0.716 to 5.171 ± 0.672 MBq/kg during the statistical data analysis. The study demonstrates that control charts can be a useful tool to signal situations where patients receive an activity significantly different from the standard practice in a medical unit., Conclusion: The use of joint control charts is a suitable tool for detecting nonoptimized radiopharmaceutical administration. This analysis provides opportunities to evaluate and improve the quality of practice in nuclear medicine. This methodology constitutes an internal audit that may help health care professionals to make appropriate decisions to ensure all patients receive the safest and most appropriate care., Competing Interests: The authors declare that there is no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Central and peripheral chemoreceptors are hypersensitized in patients with heart failure with reduced ejection fraction. Whether this autonomic alteration occurs in patients with heart failure with preserved ejection fraction (HFpEF) remains little known. We test the hypothesis that the central and peripheral chemoreflex control of muscle sympathetic nerve activity (MSNA) is altered in HFpEF., Methods: Patients aged 55-80 years with symptoms of heart failure, body mass index ≤ 35 kg/m 2 , left ventricular ejection fraction > 50%, left atrial volume index > 34 mL/m 2 , left ventricular early diastolic filling velocity and early diastolic tissue velocity of mitral annulus ratio (E/e' index) ≥ 13, and BNP levels > 35 pg/mL were included in the study (HFpEF, n = 9). Patients without heart failure with preserved ejection fraction (non-HFpEF, n = 9), aged-paired, were also included in the study. Peripheral chemoreceptors stimulation (10% O 2 and 90% N 2 , with CO 2 titrated) and central chemoreceptors stimulation (7% CO 2 and 93% O 2 ) were conducted for 3 min. MSNA was evaluated by microneurography technique, and forearm blood flow (FBF) by venous occlusion plethysmography., Results: During hypoxia, MSNA responses were greater (p < 0.001) and FBF responses were lower in patients with HFpEF (p = 0.006). Likewise, MSNA responses during hypercapnia were higher (p < 0.001) and forearm vascular conductance (FVC) levels were lower (p = 0.030) in patients with HFpEF., Conclusions: Peripheral and central chemoreflex controls of MSNA are hypersensitized in patients with HFpEF, which seems to contribute to the increase in MSNA in these patients. In addition, peripheral and central chemoreceptors stimulation in patients with HFpEF causes muscle vasoconstriction., (© 2024. Springer-Verlag GmbH Germany.)

Introduction: Gardner Syndrome (GS) is a variant of Familial Adenomatous Polyposis (FAP). FAP is characterized by several precancerous adenomatous intestinal polyps while GS has additional distinct extraintestinal features such as congenital hypertrophy of retinal epithelium (CHRPE), which we describe here., Presentation of Case: 42-year-old male with GS presenting with flashes and floaters observed to have CHRPE-like lesions characteristic of GS., Discussion: Subtle CHRPE findings differentiate pathological, described in the present case, from non-pathological etiologies and may guide further management., Conclusion: Here we present the signs and symptoms that raise suspicion for GS associated with CHRPE and how to approach management late in the disease presentation., Competing Interests: Conflict of interest statement None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: We aimed to perform a systematic review and meta-analysis of randomized controlled trials to evaluate the prophylactic use of pravastatin in pregnant women with high-risk of preeclampsia., Data Sources: PubMed, Embase, Cochrane Central, and Web of Science were searched from inception to August 2023 with no language or filters restriction. The references from included studies, previous systematic reviews, and meta-analyses were manually searched for any additional studies., Study Eligibility Criteria: Randomized controlled trials comparing pravastatin in any dose with placebo or no treatment in pregnant women with high risk for preeclampsia and up to 20 weeks of gestation were included in this meta-analysis., Methods: We used RStudio version 4.2.2 with random effects models to compute pooled risk ratios for prespecified outcomes data. The quality assessment was conducted using version 2 of the Cochrane Risk of Bias Assessment Tool. We also performed a trial sequential analysis to evaluate the reliability of our findings., Results: We included 3 randomized controlled trials comprising 213 patients, of whom 106 (49.8%) were allocated to the pravastatin group. There was no significant effect of pravastatin on the incidence of preeclampsia (risk ratio, 0.62; 95% confidence interval, 0.33-1.14; P=.12)., Conclusion: Our study was unable to demonstrate the benefit of pravastatin for preventing preeclampsia in high-risk pregnant women. Nevertheless, these findings comprised only preliminary studies with a small number of subjects, highlighting the need of well-designed, and adequately powered clinical trials., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to review the published studies that address the sense of coherence and its relationship with the oral health of children and adolescents., Methods: This scoping review was structured according to the review method proposed by the Joanna Brigs Institute and conducted in accordance with PRISMA-ScR guidelines. The research was carried out in the following databases: Medline/ Pubmed ® , Lilacs ® , Scopus © , Cochrane © , Web of Science © , and Embase © ., Results: In this search, 358 studies were found, seven in Cochrane, 90 in PubMed ® , three in Lilacs ® , 101 in Web of Science © , 80 in Scopus © , and 77 in Embase © , totaling 24 publications. The studies were published in nine countries, most of them cross-sectional studies., Conclusions: Most studies have shown that a high sense of coherence (SOC) of both the caregiver and the child/adolescent is related to better oral health behaviors and a lower caries index. No conclusive information was observed on the relationship between SOC and periodontal diseases.

Purpose: To examine the relationship between central macular thickness (CMT) measured by optical coherence tomography (OCT) and visual acuity (VA) in patients with center-involving diabetic macular edema (DME) receiving antivascular endothelial growth factor (anti-VEGF) treatment., Methods: Peer-reviewed articles from 2016 to 2020 reporting intravitreal injections of bevacizumab, ranibizumab, or aflibercept that provided data on pretreatment (baseline) and final retinal thickness (CMT) and visual acuity (VA) were identified. The relationship between relative changes was assessed via a linear random-effects regression model controlling for treatment group., Results: No significant association between the logarithm of the minimum angle of resolution (logMAR) VA and CMT was found in 41 eligible studies evaluating 2667 eyes. The observed effect estimate was a 0.12 increase (95% CI, -0.124 to 2.47) in logMAR VA per 100 µm reduction in CMT after treatment change. There were no significant differences in logMAR VA between the anti-VEGF treatment groups., Conclusions: There was no statistically significant relationship between the change in logMAR VA and change in CMT as well as no significant effect of the type of anti-VEGF treatment on the change in logMAR VA. Although OCT analysis, including measurements of CMT, will continue to be an integral part of the management of DME, further exploration is needed on additional anatomic factors that might contribute to visual outcomes., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Aim: To evaluate whether Porphyromonas gingivalis (P. gingivalis) inoculation could induce cardiac remodelling in rats., Materials and Methods: The study was conducted on 33 Wistar rats, which were distributed in the following experimental groups: not inoculated; inoculated with 1 × 10 8 CFU/ml of bacteria; inoculated with 3 × 10 8 CFU/ml of bacteria. The animals were inoculated at baseline and on the 15th day of follow-up. Blood collection was performed at baseline and 60 min after each inoculation. At 29 days, the animals were subjected to echocardiography and at 30 days to haemodynamic studies before sacrificing them., Results: Impact of the bacteria was more evident in rats that received higher P. gingivalis concentration. Thus, 3 × 10 8 CFU/ml of bacteria increased the rectal temperature and water content in the lung as well as myocardial necrosis and fibrosis. P. gingivalis induced the intensification of DNA fragmentation and increased the levels of malondialdehyde, oxidized proteins, and macrophage expression in the myocardium. These findings were associated with lower LV isovolumetric relaxation time, +dP/dt, -dP/dt, and higher end-diastolic pressure., Conclusions: P. gingivalis bacteraemia is significantly associated with adverse cardiac remodelling and may play a biological role in the genesis of heart failure., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

This study was developed at the intersection of health sciences and anthropology in order to understand the value of traditional Afro-Brazilian Medicine portrayed in houses of Candomblé exploring its member's interactions with the biomedical system of health. The anthropology of health aims to understand the phenomenon of health as a socio-cultural elaboration and from this, develops the notion of cultural health system, the theoretical operator of this study. This proposal can contribute to the challenges faced in the field of collective health by enabling dialogue between cultural health systems, supporting the creation of more effective policies. This ethnographic-inspired article was developed from a specific bibliographic survey, followed by participant observations and interviews with members of the community Ilé Alákétu Asè Ifá Omo Oyá, located in São Paulo. The health practice in candomblé manages to reach gaps left by biomedicine by associating itself in a non-authoritarian, colonialist or exclusive way taking into account the symbolic, cultural, subjective and spiritual processes involved in the processes of illness. This practice brings other possible ways of interpretation, treatment and cure for health problems.

Objective: Bipolar disorder (BD) is a chronic illness with recurrent exacerbations. The objective was to evaluate longitudinal costs related to BD in an employer-sponsored medical plan., Methods: This analysis utilized 5 years of administrative claims data. Claimants with a diagnosis of BD were matched to plan members (1:5) based on age, sex, and years of follow-up., Results: Medical costs for hospitalized BD members were 3.5 times more expensive than the general population (BDhosp = $92.2K vs General population = $26.8K). Average 5-year paid costs among hospitalized members with BD was $107K, $105.4K with cancer, and $103.3K with myocardial infarction (MI)., Conclusions: Hospitalized BD plan members consumed more than 3.5 times the medical resources and were similar in longitudinal costs when compared with members with other costly conditions. These findings highlight the need for novel employer-sponsored programs to help manage BD., Competing Interests: The listed authors do not have any conflicts of interest to disclose., (Copyright © 2021 American College of Occupational and Environmental Medicine.)

Study Objectives: Patients with congestive heart failure (CHF) frequently exhibit an elevated ratio of minute ventilation over CO 2 output (VE/VCO 2 slope) while undergoing exercise tests. One of the factors contributing to this elevated slope is an increased chemosensitivity to CO 2 in that this slope significantly correlates with the slope of the ventilatory response to CO 2 rebreathing at rest. A previous study in patients with CHF and central sleep apnea showed that the highest VE/VCO 2 slope during exercise was associated with the most severe central sleep apnea. In the current study, we tested the hypothesis that in patients with CHF and obstructive sleep apnea (OSA), the highest VE/VCO 2 slope is also associated with the most severe OSA. If the hypothesis is correct, then it implies that in CHF, augmented instability in the negative feedback system controlling breathing predisposes to both OSA and central sleep apnea., Methods: This preliminary study involved 70 patients with stable CHF and a spectrum of OSA severity who underwent full-night polysomnography, echocardiography, and cardiopulmonary exercise testing. Peak oxygen consumption and the VE/VCO 2 slope were calculated., Results: There was significant positive correlation between the apnea-hypopnea index and the VE/VCO 2 slope ( r = .359; P = .002). In the regression model, involving the relevant variables of age, body mass index, sex, VE/VCO 2 slope, peak oxygen consumption, and left ventricular ejection fraction, the apnea-hypopnea index retained significance with VE/VCO 2 ., Conclusions: In patients with CHF, the VE/VCO 2 slope obtained during exercise correlates significantly to the severity of OSA, suggesting that an elevated CO 2 response should increase suspicion for the presence of severe OSA, a treatable disorder that is potentially associated with excess mortality., Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Comparison Between Exercise Training and CPAP Treatment for Patients With Heart Failure and Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/record/NCT01538069; Identifier: NCT01538069., Citation: Bittencourt L, Javaheri S, Servantes DM, Pelissari Kravchychyn AC, Almeida DR, Tufik S. In patients with heart failure, enhanced ventilatory response to exercise is associated with severe obstructive sleep apnea. J Clin Sleep Med. 2021;17(X):1875-1880., (© 2021 American Academy of Sleep Medicine.)

Introduction: In heart transplantation (HT) recipients, several factors are critical to promptly adopting appropriate rehabilitation strategies and may be important to predict outcomes way after surgery. This study aimed to determine preoperative patient-related risk factors that could adversely affect the postoperative clinical course of patients undergoing HT., Methods: Twenty-one hospitalized patients with heart failure undergoing HT were evaluated according to respiratory muscle strength and functional capacity before HT. Mechanical ventilation (MV) time, reintubation rate, and intensive care unit (ICU) length of stay were recorded, and assessed postoperatively., Results: Inspiratory muscle strength as absolute and percentpredicted values were strongly correlated with MV time (r=-0.61 and r=-0.70, respectively, at P<0.001). Concerning ICU length of stay, only maximal inspiratory pressure (MIP) absolute and percent-predicted values were significantly associated. The absolute |MIP| was significantly negatively correlated with ICU length of stay (r=-0.58 at P=0.006) and the percent-predicted MIP was also significantly negatively correlated with ICU length of stay (r=-0.68 at P=0.0007). No associations were observed between preoperative functional capacity, age, sex, and clinical characteristics and MV time and ICU length of stay in the cohort included in this study. Patients with respiratory muscle weakness had a higher prevalence of prolonged MV, reintubation, and delayed ICU length of stay., Conclusion: An impairment of preoperative MIP was associated with poorer short-term outcomes following HT. As such, inspiratory muscle strength is an important clinical preoperative marker in patients undergoing HT.

Purpose: We present a patient with vaso-occlusive retinal vasculitis to summarize this uncommon entity and review the clinical features and management challenges applicable to patients with retinal vasculitis., Observations: A 76-year-old male presented with sudden-onset severe central vision loss. On examination, vitreous hemorrhage, neovascularization of the optic nerve, peripheral segmental periphlebitis, vessel sclerosis, vascular sheathing, and retinal hemorrhages were observed, and a diagnosis of active vaso-occlusive retinal vasculitis was made. The patient then underwent a complete infectious, inflammatory, and neoplastic workup which returned negative. The patient was treated with locally with a sub-Tenon's injection of 40 mg triamcinolone on presentation and later with oral prednisone. At three-month follow-up, vision improved to 20/300 with regressing neovascularization and clearing of vitreous hemorrhage in the right eye (OD)., Conclusions: Considering novel associations of occlusive retinal vasculitis, it is important to recognize that idiopathic occlusive retinal vasculitis, although uncommon, can occur and represents a prototypical disease form. It is imperative that these patients have a complete infectious, inflammatory, and neoplastic workup owing to the possible overlap of masquerade clinical signs and symptoms., Competing Interests: •PW: No disclosures•EC: Consultant (Alcon, Allergan, Chendgu Kanghong Biotechnology, Genentech, Novartis, Ophthotech, Opthea); Cofounder/Equity Holder (Citrus Therapeutics)•DA: Advisory Board, Consultant, Speaker (Alcon, Allergan, Bayer, Genentech, Novartis, Regeneron); Cofounder, Equity Holder (Citrus Therapeutics), (© 2021 The Authors.)

Objectives: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil., Methods: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment., Results: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment., Conclusion: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

The reproductive physiology of fish can be changed by the presence of pollutants in the water, which act as endocrine disrupting compounds (EDC). We evaluated the impacts of water contaminants in polluted reservoirs acting as possible EDC on the reproductive physiology of Astyanax fasciatus and Hoplias malabaricus males. We used biomarkers with different levels of biological organization. Hoplias malabaricus adult males were collected in the summer and winter at five different sites in the Tietê River Basin: the Ponte Nova reservoir (PN), considered a reference site due to the low anthropogenic influence; the Billings reservoir (BIL) at two different branches; and the Guarapiranga reservoir (GUA) at two different branches. Astyanax fasciatus adult males were collected at PN and BIL. BIL and GUA are subjected to great anthropogenic action. We analyzed gonadal histomorphology, testosterone (T), 11-ketotestosterone (11-KT), estradiol (E 2 ) plasma levels, and gene expression of hepatic vitellogenin (vtgA) and pituitary follicle stimulating hormone (fshβ). In the PN reservoir (reference), the biomarkers analyzed in both species did not differ between the periods analyzed. This is an evidence that the animals keep the same reproductive activity during both seasons. The changes in the plasma concentration of gonadal steroids in both species in polluted reservoirs suggest the presence of EDC compounds in the water and/or adjusts of the physiological setpoint to allow the reproduction in such adverse conditions. The use of vtgA as biomarker suggests the presence of estrogenic compounds, mainly in BIL, but with a more evident response of H. malabaricus. However, even considering physiological changes, both species present testes during the maturation phase that allow the reproduction in an environment with a high degree of pollution., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Non-T cell activation linker (NTAL) membrane protein depletion from lipid rafts by alkylphospholipids or downregulation by shRNA knockdown decreases cell viability through regulation of the Akt/PI3K pathway in mantle cell lymphoma and acute promyelocytic leukemia cells. Here, we confirmed that the knockdown of NTAL in acute myeloid leukemia (AML) cell lines was associated with decreased cell proliferation and survival. Similarly, a xenograft model using AML cells transduced with NTAL-shRNA and transplanted into immunodeficient mice led to a 1.8-fold decrease in tumor burden. Using immunoprecipitation, LC-MS/MS analysis, and label-free protein quantification, we identified interactors of NTAL in two AML cell lines. By evaluating the gene expression signatures of the NTAL protein interactors using the PREdiction of Clinical Outcomes from Genomic Profiles database, we found that 12 NTAL interactors could predict overall survival in AML, in at least two independent cohorts. In addition, patients with AML exhibiting a high expression of NTAL and its interactors were associated with a leukemic granulocyte-macrophage progenitor-like state. Taken together, our data provide evidence that NTAL and its protein interactors are relevant to AML cell proliferation and survival and represent potential therapeutic targets for granulocyte-macrophage progenitor-like leukemias., Competing Interests: Conflict of interest The authors declare no competing interests., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: to describe professionals' perceptions about the therapeutic effectiveness of group care., Method: a descriptive, exploratory, qualitative research of the type of intervention carried out with 30 professionals from Psychosocial Care Centers for Alcohol and Drugs in a municipality in center-westerns Brazil, from March to April 2019. Self-applicable instruments and round circles were used. The emerging data were submitted to content analysis., Results: professionals perceive the benefits of group practices and relate them to some therapeutic factors in the group. It is evident the little formal and systematized knowledge about the group process elements., Final Considerations: the therapeutic effectiveness of group processes is compromised due to absence of systematic records that allow to perceive the therapeutic progress of users, even though professionals perceive the emergence of therapeutic factors of the groups in the context of psychosocial care.

Purpose: The purpose of this study was to assess the development of sleep-disordered breathing (SDB) symptoms and the relationship between the amount of increased vertical dimension and severity of SDB symptoms in healthy children wearing orthodontic removable appliances with posterior bite planes.
Methods: The Obstructive Sleep Apnea-18 (OSA-18) questionnaire and Pediatric Sleep Questionnaire (PSQ) were used as data collecting tools. The questionnaires were filled out by 16 parents of children who had an anterior crossbite with Class I skeletal pattern. The data were collected three times: one month pre-insertion of the appliance; one day post-insertion; and one month post-insertion.
Results: There were no significant differences between the OSA-18 or PSQ results collected at different times. Pearson's correlation revealed no significant relationship between the posterior bite plane thickness and the difference in scores ( P >0.05).
Conclusion: Short-term treatment using such appliances does not initiate SDB symptoms, and the amount of increased posterior bite plane thickness does not relate to the severity of SDB symptoms. (J Dent Child 2019;86(3):145-9).

Purpose: The objective of this study was to analyze the layers of yellow ligament in lumbar canal stenosis and disk herniation., Methods: Eighteen ligaments were harvested from patients with lumbar spinal canal stenosis. Twenty-nine normal samples from lumbar spine disk herniation patients served as control. All surgical procedures were the same. Ligaments were stained in hematoxylin and eosin; picrosirius-hematoxylin for collagen; Weigert's resorcin-fuchsin for elaunin, oxytalan and elastic fibers; and transmission electron microscopy. Immunohistochemistry was performed for Il-6; Il-10; and CD-31, PGP9.5. Results are described in means and standard error (mean ± SE), and all analyses adopted the significance level of P < 0.05., Results: Spinal stenosis ligaments were 2.5 × thicker. Control superficial ligaments presented a large number of thick, compact collagen fibers and a significant amount of oxytalan and mature elastic fibers. The deep layer presented a large number of mature elastic fibers. In the stenosis group, collagen was thinner and compacted in both layers. There was no difference in the interleukin profile among groups. The deep portion of the stenosis group presented a higher number of vessels and nerves., Conclusion: Two layers compose the elastic system of the normal ligamentum flavum, where the deep portion is mainly responsible for its elasticity (elaunin fibers), while its resistance depends on the concentration of oxytalan fibers, which are more present in the superficial layer. Ligamentum flavum in the stenosis samples presents more mononuclear infiltrate and more degraded elastic fibers with a higher number of vessels in its deep portion. These slides can be retrieved under Electronic Supplementary Material.

Background: Mast cell tumours (MCTs) constitute almost 25% of cutaneous neoplasms in dogs. Their biological behaviour is predicted using histopathological grading which is based on several subjective criteria that are vulnerable to intra- and interobserver variability. To improve the prediction of the biological behaviour, several complementary markers have been studied. The integrity of the extracellular matrix (ECM) may play a protective role against tumoral progression, and favour cellular proliferation, angiogenesis, invasion and metastases when altered., Hypothesis/objectives: To evaluate the quantification of collagen and elastic fibres as prognostic markers for MCTs., Animals: Thirty-eight random cases of canine cutaneous MCT surgically treated with wide margins were included., Methods and Materials: Intratumoral collagen and elastic fibres were identified and quantified on histological sections stained with Masson's trichrome, Picrosirius red and Verhoeff; the results were compared with histopathological grades, mortality due to the disease and postsurgical survival., Results: Morphometric analysis revealed a significant relationship between histopathological grade and intratumoral collagen index (CoI). In addition, the CoI was considered an independent indicator for mortality and postsurgical survival., Conclusions and Clinical Importance: These results support the importance of the CoI in the grading and prognosis of MCTs, suggesting that preservation and/or synthesis of collagen have the potential to become targets for MCT therapeutics., (© 2019 ESVD and ACVD.)

Anatomy is traditionally regarded as a difficult, non-motivating course involving a large body of theoretical and practical content, and it is often associated with high levels of dropout and failure. Given the relevance of the topic, we propose an alternative active multisensory teaching tool consisting of the construction of a low-fidelity anatomical model assembled into an articulated equine skeleton. Model construction and assembly assists students in the recognition of the topography and anatomical boundaries of the equine abdominal digestive system. Digestive system organs (liver, pancreas, stomach, small and large intestines) were constructed using common, easily available materials, such as newspaper, balloons, laminated rubber sheets, and polyethylene cylinders. The method described in this study is a low-cost, user-friendly teaching tool that is potentially applicable across different academic disciplines and that can also be used to construct models of other systems and species. However, it should be combined with other anatomy teaching methods because it does not provide detailed representation of specific digestive system organ features.

Meta-analytic evidence indicates that mood and psychotic disorders are associated with both omega-3 polyunsaturated fatty acid (omega-3 PUFA) deficits and progressive regional gray and white matter pathology. Although the association between omega-3 PUFA insufficiency and progressive neuropathological processes remains speculative, evidence from translational research suggests that omega-3 PUFA insufficiency may represent a plausible and modifiable risk factor not only for enduring neurodevelopmental abnormalities in brain structure and function, but also for increased vulnerability to neurodegenerative processes. Recent evidence from human neuroimaging studies suggests that lower omega-3 PUFA intake/status is associated with accelerated gray matter atrophy in healthy middle-aged and elderly adults, particularly in brain regions consistently implicated in mood and psychotic disorders, including the amygdala, anterior cingulate, hippocampus, prefrontal cortex, and temporal cortex. Human neuroimaging evidence also suggests that both low omega-3 PUFA intake/status and psychiatric disorders are associated with reductions in white matter microstructural integrity and increased rates of white matter hyperintensities. Preliminary evidence suggests that increasing omega-3 PUFA status is protective against gray matter atrophy and deficits in white matter microstructural integrity in patients with mood and psychotic disorders. Plausible mechanisms mediating this relationship include elevated pro-inflammatory signaling, increased synaptic regression, and reductions in cerebral perfusion. Together these associations encourage additional neuroimaging research to directly investigate whether increasing omega-3 PUFA status can mitigate neuropathological processes in patients with, or at high risk for, psychiatric disorders.

In this work, we present the efficacy of photodynamic therapy against yeast cells in an animal model. We tested two photosensitizers, methylene blue and protoporphyrin IX. Thirty-seven female BALB-c mice with a body mass of 20-25 g were used. To achieve persistent vaginitis, estrus was induced by subcutaneous injection of 0.1 mg/mL estradiol valerate applied weekly. Three days after pseudo-estrus, intravaginal inoculation with Candida albicans was performed. Mice were anesthetized with ketamine (80 mg/kg) and xylazine (10 mg/kg) by intraperitoneal injection before inoculation, and antimicrobial photodynamic therapy (aPDT) was performed 5 days after fungal inoculation. Two photosensitizers were tested, methylene blue (MB; 100 μM) and protoporphyrin IX (PpNetNI; 10 μM). Two custom-made LEDs emitting light at 660 and 630 nm at approximately 800 mW each were used for irradiation. The aPDT treatment reduced the fungal colony-forming units (CFUs) by one order of magnitude for the MB (p = 0.020) and PpNetNI (p = 0.018) photosensitizers. Seven days after the treatment, there were significantly fewer CFUs compared to the control group (p = 0.041 and p = 0.035 for MB and PpNetNI, respectively), but this was not increased compared to the initial number immediately after aPDT. Using aPDT as a therapeutic option to decrease fungal infection in a vaginal candidiasis model resulted in a significant reduction in the C. albicans population. Both photosensitizers were effective for preventing reinfection within 7 days. The aPDT also had no effect on the vaginal mucosa at the ultrastructural level. In addition to the fungicide effect, we observed reduced swelling and lack of the formation of abscesses, microabscesses coating the cornified epithelial layer, and the accumulation of neutrophils in the submucosa.

Background: Exercise and CPAP improve OSA. This study examined the effects of exercise in patients with heart failure (HF) and OSA., Methods: Patients with HF and OSA were randomized to the following study groups: control, exercise, CPAP, and exercise + CPAP., Results: Sixty-five participants completed the protocol. Comparing baseline vs 3 months, the mean apnea-hypopnea index (AHI) did not change significantly (in events per hour) in the control group, decreased moderately in the exercise group (28 ± 17 to 18 ± 12; P < .03), and decreased significantly more in the CPAP group (32 ± 25 to 8 ± 11; P < .007) and in the exercise + CPAP group (25 ± 15 to 10 ± 16; P < .007). Peak oxygen consumption, muscle strength, and endurance improved only with exercise. Both exercise and CPAP improved subjective excessive daytime sleepiness, quality of life, and the New York Heart Association functional class. However, compared with the control group, changes in scores on the 36-item Medical Outcomes Study Short Form Survey and Minnesota Living with Heart Failure Questionnaire were only significant in the exercise groups., Conclusions: In patients with HF and OSA, our preliminary results showed that exercise alone attenuated OSA and improved quality of life more than CPAP. In the landscape treatment of OSA in patients with HF, this analysis is the only randomized trial showing any treatment (in this case, exercise) that improved all the studied parameters. The results highlight the important therapeutic benefits of exercise, particularly because adherence to CPAP is low., (Copyright © 2018. Published by Elsevier Inc.)

Heart failure (HF) is associated with morbidity and mortality. Real-time three-dimensional echocardiography (RT3DE) may offer additional prognostic data in patients with HF. The study aimed to evaluate the prognostic value of real-time three-dimensional echocardiography (RT3DE). This is a prospective study that included 89 patients with HF and left ventricular ejection fraction (LVEF) < 0.50 who were followed for 48 months. Left atrium and ventricular volumes and functions were evaluated by RT3DE. TDI and two-dimensional echocardiography parameters were also obtained. The endpoint was a composite of death, heart transplantation and hospitalization for acute decompensated HF. The mean age was 55 ± 11 years, and the LVEF was 0.32 ± 0.10. The composite endpoint occurred in 49 patients (18 deaths, 30 hospitalizations, one heart transplant). Patients with outcomes had greater left atrial volume (40 ± 16 vs. 32 ± 12 mL/m 2 ; p < 0.01) and right ventricle diameter (41 ± 9 vs. 37 ± 8 mm, p = 0.01), worse total emptying fraction of the left atrium (36 ± 13% vs. 41 ± 11%; p = 0.03), LVEF (0.30 ± 0.09 vs. 0.34 ± 0.11; p = 0.02), right ventricle fractional area change (34.8 ± 12.1% vs. 39.2 ± 11.3%; p = 0.04), and greater E/e' ratio (19 ± 9 vs. 16 ± 8; p = 0.04) and systolic pulmonary artery pressure (SPAP) (50 ± 15 vs. 36 ± 11 mmHg; p < 0.01). In multivariate analysis, LVEF (OR 4.6; CI 95% 1.2-17.6; p < 0.01) and SPAP (OR 12.5; CI 95% 1.8-86.9; p < 0.01) were independent predictors of patient outcomes. LVEF and the SPAP were independent predictors of outcomes in patients with HF.

Purpose: Proliferative vitreoretinopathy (PVR) is the most common cause of recurrent retinal detachment (RD). We sought to determine the predictive factors of recurrent PVR formation and the need for additional vitreoretinal surgical intervention after uncomplicated primary RD repair., Methods: This is a retrospective single-center case-control study of consecutive patients with PVR formation after uncomplicated RD repair. Logistic regression was used to assess factors associated with recurrent PVR formation., Results: Thirty-seven eyes (37 patients) who had recurrent RD secondary to PVR formation were included. Among those, 27 eyes needed one additional surgery, whereas the remainder 10 eyes required two or more additional surgeries. In the univariate analysis, patients who had cystoid macular edema (CME) after the second surgery were 8.33 times (crude odds ratio [COR], 95% confidence interval [CI]: 1.23-56.67, p =0.0302) more likely to have recurrent PVR formation compared to those who did not have CME after the second surgery. Similarly, those who had epiretinal membrane (ERM) after the second surgery were 8.00 times (COR, 95% CI: 1.43-44.92, p =0.0182) more likely to have recurrent PVR formation compared to those who did not have ERM after the second surgery. In the multivariate analysis, patients who had ERM after the second surgery were 8.20 times (adjusted odds ratio [AOR], 95% CI: 1.08-62.40, p =0.0422) more likely to develop recurrent PVR compared to those who did not have ERM after the second surgery, when adjusted for age, sex, and CME after the second surgery., Conclusion: ERM and CME are potential predictive factors for recurrent PVR formation after uncomplicated primary RD repair. Early recognition and treatment of ERM and CME may be critical to prevent subsequent PVR formation and improve visual outcomes., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Heart failure is characterized by the inability of the cardiovascular system to maintain oxygen (O2) delivery (i.e., muscle blood flow in non-hypoxemic patients) to meet O2 demands. The resulting increase in fractional O2 extraction can be non-invasively tracked by deoxygenated hemoglobin concentration (deoxi-Hb) as measured by near-infrared spectroscopy (NIRS). We aimed to establish a simplified approach to extract deoxi-Hb-based indices of impaired muscle O2 delivery during rapidly-incrementing exercise in heart failure. We continuously probed the right vastus lateralis muscle with continuous-wave NIRS during a ramp-incremental cardiopulmonary exercise test in 10 patients (left ventricular ejection fraction <35%) and 10 age-matched healthy males. Deoxi-Hb is reported as % of total response (onset to peak exercise) in relation to work rate. Patients showed lower maximum exercise capacity and O2 uptake-work rate than controls (P<0.05). The deoxi-Hb response profile as a function of work rate was S-shaped in all subjects, i.e., it presented three distinct phases. Increased muscle deoxygenation in patients compared to controls was demonstrated by: i) a steeper mid-exercise deoxi-Hb-work rate slope (2.2±1.3 vs 1.0±0.3% peak/W, respectively; P<0.05), and ii) late-exercise increase in deoxi-Hb, which contrasted with stable or decreasing deoxi-Hb in all controls. Steeper deoxi-Hb-work rate slope was associated with lower peak work rate in patients (r=-0.73; P=0.01). This simplified approach to deoxi-Hb interpretation might prove useful in clinical settings to quantify impairments in O2 delivery by NIRS during ramp-incremental exercise in individual heart failure patients.

Purpose: To describe the clinical course of a patient with Acanthamoeba keratitis, who despite prompt treatment progressed to histopathology-confirmed Acanthamoeba retinitis and endophthalmitis., Methods: Case report., Results: A healthy 30-year-old male wearing soft contact lens was diagnosed with Acanthamoeba keratitis and treated medically and surgically over the course of 1 year with presumed resolution of the infection. Yet, his infection recurred with documented spread to sclerokeratitis, and overwhelming endophthalmitis. Concerns about extra-ocular spread prompted a therapeutic enucleation with histopathologic evidence of Acanthamoeba organisms throughout the globe., Conclusion: This is a case of a severe recurrent Acanthamoeba infection presenting initially as keratitis, followed by sclerokeratitis and histolopathology-confirmed endophthalmitis. This case demonstrates that despite persistent medical and surgical intervention, eradication of organisms may not be possible.

Purpose: To report a case of central retinal artery occlusion (CRAO) in a young human immunodeficiency virus (HIV)-infected patient recently started on highly active antiretroviral therapy., Methods: Case report observation of a 33-year-old HIV-infected patient who developed a CRAO after starting highly active antiretroviral therapy., Results: Elevated triglycerides caused by starting highly active antiretroviral therapy preceded the development of CRAO in an HIV-infected patient., Conclusion: Atherosclerotic vascular disease is an important complication of HIV therapy, which can ultimately lead to cardiovascular disease. An unusual case of a young patient developing a CRAO after the initiation of highly active antiretroviral therapy is reported. In the patient, the authors expound that elevated lipids from efavirenz/emtricitabine/tenofovir resulted in carotid atherosclerosis, ultimately leading to CRAO. Eye care providers, as well as the internal medicine colleagues, should be aware of the possibility of this devastating condition in HIV-infected patients on antiretroviral therapy.

Background and Objective: To assess the effect on best-corrected visual acuity (BCVA) and efficacy of the intravitreal sustained-release 0.7 mg dexamethasone implant (Ozurdex; Allergan, Irvine, CA) in patients with recalcitrant diabetic macular edema (DME)., Patients and Methods: Meta-analysis utilizing the MOOSE framework and a random effects model. Studies included adults undergoing treatment with Ozurdex for DME. The methodologic quality of each study was assessed using the MINORS and the Cochrane Collaboration Risk of Bias for randomized studies., Results: A total of 3,859 patients among 15 studies were included in the final analysis. The mean difference in BCVA was a gain of four lines or 20 Early Treatment of Diabetic Retinopathy Study letters with Ozurdex at a mean follow-up period of 6 months., Conclusions: Treatment with Ozurdex is associated with significant mean improvement in visual acuity. Clinicians should have a multimodality approach to treating DME and be aware of this treatment option in those who have a suboptimal response to anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:160-166.]., (Copyright 2017, SLACK Incorporated.)