COVID-19 Computed tomography patterns in renal replacement therapy patients / Padrões de tomografia computadorizada da COVID-19 em pacientes em terapia renal substitutiva

ABSTRACT Introduction: Lung diseases are common in patients with end stage kidney disease (ESKD), making differential diagnosis with COVID-19 a challenge. This study describes pulmonary chest tomography (CT) findings in hospitalized ESKD patients on renal replacement therapy (RRT) with clinical suspicion of COVID-19. Methods: ESKD individuals referred to emergency department older than 18 years with clinical suspicion of COVID-19 were recruited. Epidemiological baseline clinical information was extracted from electronic health records. Pulmonary CT was classified as typical, indeterminate, atypical or negative. We then compared the CT findings of positive and negative COVID-19 patients. Results: We recruited 109 patients (62.3% COVID-19-positive) between March and December 2020, mean age 60 ± 12.5 years, 43% female. The most common etiology of ESKD was diabetes. Median time on dialysis was 36 months, interquartile range = 12-84. The most common pulmonary lesion on CT was ground glass opacities. Typical CT pattern was more common in COVID-19 patients (40 (61%) vs 0 (0%) in non-COVID-19 patients, p < 0.001). Sensitivity was 60.61% (40/66) and specificity was 100% (40/40). Positive predictive value and negative predictive value were 100% and 62.3%, respectively. Atypical CT pattern was more frequent in COVID-19-negative patients (9 (14%) vs 24 (56%) in COVID-19-positive, p < 0.001), while the indeterminate pattern was similar in both groups (13 (20%) vs 6 (14%), p = 0.606), and negative pattern was more common in COVID-19-negative patients (4 (6%) vs 12 (28%), p = 0.002). Conclusions: In hospitalized ESKD patients on RRT, atypical chest CT pattern cannot adequately rule out the diagnosis of COVID-19.

RESUMO Introdução: Doenças pulmonares são comuns em pacientes com doença renal em estágio terminal (DRET), dificultando o diagnóstico diferencial com COVID-19. Este estudo descreve achados de tomografia computadorizada de tórax (TC) em pacientes com DRET em terapia renal substitutiva (TRS) hospitalizados com suspeita de COVID-19. Métodos: Indivíduos maiores de 18 anos com DRET, encaminhados ao pronto-socorro com suspeita de COVID-19 foram incluídos. Dados clínicos e epidemiológicos foram extraídos de registros eletrônicos de saúde. A TC foi classificada como típica, indeterminada, atípica, negativa. Comparamos achados tomográficos de pacientes com COVID-19 positivos e negativos. Resultados: Recrutamos 109 pacientes (62,3% COVID-19-positivos) entre março e dezembro de 2020, idade média de 60 ± 12,5 anos, 43% mulheres. A etiologia mais comum da DRET foi diabetes. Tempo médio em diálise foi 36 meses, intervalo interquartil = 12-84. A lesão pulmonar mais comum foi opacidades em vidro fosco. O padrão típico de TC foi mais comum em pacientes com COVID-19 (40 (61%) vs. 0 (0%) em pacientes sem COVID-19, p < 0,001). Sensibilidade 60,61% (40/66), especificidade 100% (40/40). Valores preditivos positivos e negativos foram 100% e 62,3%, respectivamente. Padrão atípico de TC foi mais frequente em pacientes COVID-19-negativos (9 (14%) vs. 24 (56%) em COVID-19-positivos, p < 0,001), enquanto padrão indeterminado foi semelhante em ambos os grupos (13 (20%) vs. 6 (14%), p = 0,606), e padrão negativo foi mais comum em pacientes COVID-19-negativos (4 (6%) vs. 12 (28%), p = 0,002). Conclusões: Em pacientes com DRET em TRS hospitalizados, um padrão atípico de TC de tórax não pode excluir adequadamente o diagnóstico de COVID-19.

Incidence of contrast-associated acute kidney injury: a prospective cohort / Incidência de lesão renal aguda associada ao contraste: uma coorte prospectiva

ABSTRACT Introduction: Contrast-associated acute kidney injury (CA-AKI) is a deterioration of kidney function that occurs after the administration of a iodinated contrast medium (ICM). Most studies that defined this phenomenon used older ICMs that were more prone of causing CA-AKI. In the past decade, several articles questioned the true incidence of CA-AKI. However, there is still a paucity of a data about the safety of newer ICM. Objective: To assess the incidence of CA-AKI in hospitalized patients that were exposed to computed tomography (CT) with and without ICM. Methods: Prospective cohort study with 1003 patients who underwent CT in a tertiary hospital from December 2020 through March 2021. All inpatients aged > 18 years who had a CT scan during this period were screened for the study. CA-AKI was defined as a relative increase of serum creatinine of ≥ 50% from baseline or an absolute increase of ≥ 0.3 mg/dL within 18 to 48 hours after the CT. Chi-squared test, Kruskal-Wallis test, and linear regression model with restricted cubic splines were used for statistical analyses. Results: The incidence of CA-AKI was 10.1% in the ICM-exposed group and 12.4% in the control group when using the absolute increase criterion. The creatinine variation from baseline was not significantly different between groups. After adjusting for baseline factors, contrast use did not correlate with worse renal function. Conclusion: The rate of CA-AKI is very low, if present at all, with newer ICMs, and excessive caution regarding contrast use is probably unwarranted.

RESUMO Introdução: Lesão renal aguda associada ao contraste (LRA-AC) é uma deterioração da função renal que ocorre após a administração de meio de contraste iodado (MCI). A maioria dos estudos que definiram esse fenômeno utilizaram MCI mais antigos, mais propensos a causar LRA-AC. Na última década, diversos artigos questionaram a verdadeira incidência de LRA-AC. Entretanto, ainda há escassez de dados sobre a segurança dos MCI mais novos. Objetivo: Avaliar a incidência de LRA-AC em pacientes hospitalizados expostos à tomografia computadorizada (TC) com e sem MCI. Métodos: Estudo de coorte prospectivo com 1.003 pacientes submetidos a TC em hospital terciário, de dezembro/2020 a março/2021. Todos os pacientes internados com idade ≥ 18 anos que realizaram TC nesse período foram selecionados. A LRA-AC foi definida como aumento relativo de creatinina sérica de ≥ 50% em relação ao valor basal ou aumento absoluto de ≥ 0,3 mg/dL dentro de 18 a 48 horas após a TC. Utilizamos o teste qui-quadrado, teste de Kruskal-Wallis e modelo de regressão linear com splines cúbicos restritos para análises estatísticas. Resultados: A incidência de LRA-AC foi 10,1% no grupo exposto ao MCI e 12,4% no grupo controle ao usar o critério de aumento absoluto. A variação da creatinina em relação ao valor basal não foi significativamente diferente entre os grupos. Após ajuste para fatores basais, o uso de contraste não se correlacionou com pior função renal. Conclusão: A taxa de LRA-AC é muito baixa, caso exista, com MCIs mais novos, e a cautela excessiva quanto ao uso de contraste provavelmente não se justifica.

Microcomputed-Tomographic Analysis of the Root Canal Morphology of the Mandibular First Molars in a Malaysian Subpopulation Using Two Classification Systems / Análisis por Tomografía Microcomputada de la Morfología del Conducto Radicular de los Primeros Molares Mandibulares en una Subpoblación de Malasia Utilizando dos Sistemas de Clasificación

SUMMARY: This work investigated the morphology of the root canal system of the mandibular first molar in a Malaysian subpopulation. Using micro-computed tomography with an isotropic resolution of 22 µm, 140 mandibular first molars were scanned. MIMICS software was used for segmentation, 3-D reconstruction and analysis of the acquired images. The canal configuration was described using Vertucci [supported by the supplementary configurations proposed by Sert & Bayirli (2004)] and Ahmed et al. (2027), coding systems. The chi-square test was used to assess the association between qualitative variables. By non-considering intercanal communications, Vertucci types IV (17.1%) and I (76.4%) were the most frequently reported configurations in the mesial and distal roots, respectively. Of the reported configurations, 24.3% and 4.3% were non-classifiable by Vertucci system in the mesial and distal roots, respectively. Up to 63.6% and 9.3% of the reported configurations were non- classifiable, and type I was the most frequent when considering intercanal communications (7.1% and 76.4% in the mesial and distal roots, respectively). According to Ahmed et al., system, almost half of the sample had more than four digits (47.9%), followed by the 3-digits category (20.71%). In both systems, a significant association was found between the canal configuration and the root type (p<0.001). The mandibular first molar of this Malaysian subpopulation demonstrated a wide range of root canal morphology. When compared to the Vertucci system, the system developed by Ahmed et al., successfully classified all molars configurations despite their level of complexity. The complex canal anatomy of mandibular first molars in this subpopulation warrants special attention during root canal treatment procedures.

En este trabajo se investigó la morfología del sistema de conductos radiculares del primer molar mandibular en una subpoblación de Malasia. Utilizando tomografía microcomputada con una resolución isotrópica de 22 µm, se escanearon 140 primeros molares mandibulares. Se utilizó el software MIMICS para segmentar (enmascarar), reconstruir en 3D, visualizar y analizar las imágenes adquiridas. La configuración del canal se describió utilizando Vertucci respaldado por las configuraciones complementarias propuestas por Sert & Bayirli (2004)] y Ahmed et al. (2017, 2020), sistemas de codificación. Se utilizó la prueba de chi-cuadrado para evaluar la asociación entre variables cualitativas. Sin considerar las comunicaciones intercanales, los tipos Vertucci IV (17,1%) y I (76,4%) fueron las configuraciones reportadas con mayor frecuencia en las raíces mesiales y distales, respectivamente. De las configuraciones reportadas, el 24,3 % y el 4,3 % fueron no clasificables por el sistema de Vertucci en las raíces mesial y distal, respectivamente. Hasta el 63,6 % y el 9,3 % de las configuraciones reportadas fueron no clasificables, siendo la tipo I la más frecuente al considerar las comunicaciones intercanales (7,1 % y 76,4 % en las raíces mesiales y distales, respectivamente). Según Ahmed et al. (2017, 2020) en el sistema, casi la mitad de la muestra tenía más de cuatro dígitos (47,9 %), seguido por la categoría de 3 dígitos (20,71 %). En ambos sistemas se encontró una asociación significativa entre la configuración del canal y el tipo de raíz (p<0,001). El primer molar mandibular de esta subpoblación de Malasia demostró una amplia gama morfológica del conducto radicular. En comparación con el sistema Vertucci, el sistema desarrollado por Ahmed et al. (2017, 2020) clasificaron con éxito todas las configuraciones de los molares a pesar de su nivel de complejidad. La compleja anatomía del canal de los primeros molares mandibulares en esta subpoblación merece una atención especial durante los procedimientos de tratamiento de conducto.

Herramientas para el tamizaje de aneurisma de aorta abdominal / Tools for abdominal aortic aneurysm screening

Introducción. El aneurisma de la aorta abdominal (AAA) es la dilatación de la aorta abdominal mayor de 1,5 veces el diámetro esperado. Su prevalencia es variable, con tasas reportadas de hasta el 12,5 %. Se considera como causa de muerte de más de 10.000 personas al año en los Estados Unidos. El objetivo de esta revisión de la literatura fue describir los factores de riesgo y las herramientas de tamizaje de AAA. Métodos. Se realizó una búsqueda de la literatura utilizando dos ecuaciones en bases de datos electrónicas, empleando términos seleccionados de "Medical Subject Heading" (MeSH) y "Descriptores en Ciencias de la Salud" (DeCS). Se evaluó la calidad de los estudios con la herramienta STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Resultados. Se recolectaron 40 artículos y a partir de ellos se construyó el texto de revisión, identificando en estos, los factores de riesgo asociados al desarrollo de AAA, tales como sexo masculino, tabaquismo, hipertensión arterial, antecedente familiar y obesidad, entre otros. La diabetes mellitus parece actuar como factor protector. Dentro de los instrumentos de tamizaje, el ultrasonido abdominal es uno de los más usados. Conclusión. El AAA es una patología multifactorial. En la actualidad la ultrasonografía de aorta es el método de elección para el tamizaje, permitiendo la detección precoz. El tamizaje de AAA con métodos no invasivos, como el ultrasonido, es útil sobre todo en zonas con prevalencia alta de la patología y en pacientes con determinados factores de riesgo.

Introduction. Abdominal aortic aneurysm (AAA) is a dilation of the abdominal aorta greater than 1.5 times the expected diameter. Its prevalence is variable, with reported rates of up to 12.5%. It is considered the cause of death of more than 10,000 people a year in the United States. The objective of this literature review was to describe risk factors and screening tools for AAA. Methods. A literature search was conducted using two equations in electronic databases, using terms selected from "Medical Subject Heading" (MeSH) and "Descriptors in Health Sciences" (DeCS). The quality of the studies was evaluated with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) tool. Results. Forty articles were collected and from them the review text was constructed, identifying the risk factors associated with the development of AAA, such as male sex, smoking, high blood pressure, family history and obesity, among others. Diabetes mellitus seems to act as a protective factor. Among the screening instruments, abdominal ultrasound is one of the most used. Conclusion. AAA is a multifactorial pathology. Currently, aortic ultrasonography is the method of choice for screening, allowing early detection. Screening for AAA with non-invasive methods, such as ultrasound, is useful especially in areas with a high prevalence of this pathology and in patients with certain risk factors.

Tumor pseudopapilar sólido de páncreas, una neoplasia inusual / Solid Pseudopapillary Tumor of the Pancreas, an Unusual Neoplasm

Presentación del caso. Se trata de una mujer de 26 años que presentó dolor en epigastrio e hipocondrio izquierdo, con aumento del perímetro abdominal y pérdida de 5 kg de peso corporal. En el examen físico se detectó una masa de gran tamaño en el epigastrio, con bordes regulares, ligeramente dolorosa al tacto y no móvil. Los estudios de imagen revelaron una neoplasia mixta en el cuerpo y cola pancreática. Intervención terapéutica. Se practicó una esplenopancreatectomía corpo-caudal, con extirpación completa del tumor. Evolución clínica. La paciente recibió cuidados especializados y vigilancia estrecha posquirúrgica en la unidad de cuidados intensivos, sin presentar complicaciones relevantes. Tras el alta hospitalaria, la paciente refirió un buen estado general en los controles de seguimiento, que incluyeron una tomografía realizada a los 12 meses, donde no se evidenciaron restos o recidivas tumorales

Case presentation. A 26-year-old woman who presented with pain in the epigastrium and left hypochondrium, with increased abdominal perimeter and loss of 5 kg of body weight. Physical examination revealed a large mass in the epigastrium, with regular borders, slightly painful to the touch and non-mobile. Imaging studies revealed a mixed neoplasm in the pancreatic body and tail. Treatment. A corpo-caudal splenopancreatectomy was performed, with complete removal of the tumor. Outcome. The patient received specialized care and close postoperative surveillance in the intensive care unit, with no relevant complications. After hospital discharge, the patient reported a good general condition in the follow-up controls, which included a computed tomography scan performed after 12 months, where no tumor remnants or recurrences were evidenced

Uso de la tomografía corporal total en pacientes con heridas de arma de fuego y hemodinámicamente inestables: ¿Rompiendo paradigmas de atención inicial? / Whole-body computed tomography in hemodynamically unstable patients with gunshot wounds: A paradigm shift in trauma management?

Introducción. El objetivo del estudio fue analizar el impacto del uso de la tomografía corporal total en la evaluación de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables atendidos en un centro de referencia de trauma. Métodos. Se realizó un estudio analítico, retrospectivo, con base en un subanálisis del registro de la Sociedad Panamericana de Trauma ­ Fundación Valle del Lili. Se incluyeron los pacientes con trauma penetrante por proyectil de arma de fuego atendidos entre 2018 y 2021. Se excluyeron los pacientes con trauma craneoencefálico severo, trauma leve y en condición in extremis. Resultados. Doscientos pacientes cumplieron los criterios de elegibilidad, 115 fueron estudiados con tomografía corporal total y se compararon con 85 controles. La mortalidad intrahospitalaria en el grupo de tomografía fue de 4/115 (3,5 %) vs 10/85 (12 %) en el grupo control. En el análisis multivariado se identificó que la tomografía no tenía asociación significativa con la mortalidad (aOR=0,46; IC95% 0,10-1,94). El grupo de tomografía tuvo una reducción relativa del 39 % en la frecuencia de cirugías mayores, con un efecto asociado en la disminución de la necesidad de cirugía (aOR=0,47; IC95% 0,22-0,98). Conclusiones. La tomografía corporal total fue empleada en el abordaje inicial de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables. Su uso no se asoció con una mayor mortalidad, pero sí con una menor frecuencia de cirugías mayores.

Introduction. This study aims to assess the impact of whole-body computed tomography (WBCT) in the evaluation of patients with penetrating gunshot wounds (GSW) who are hemodynamically unstable and treated at a trauma referral center. Methods. An analytical, retrospective study was conducted based on a subanalysis of the Panamerican Trauma Society-FVL registry. Patients with GSW treated between 2018 and 2021 were included. Patients with severe cranioencephalic trauma, minor trauma, and those in extremis were excluded. Patients with and without WBCT were compared. The primary outcome was in-hospital mortality, and the secondary outcome was the frequency of major surgeries (thoracotomy, sternotomy, cervicotomy, and/or laparotomy) during initial care. Results. Two hundred eligible patients were included, with 115 undergoing WBCT and compared to 85 controls. In-hospital mortality in the WBCT group was 4/115 (3.5%) compared to 10/85 (12%) in the control group. Multivariate analysis showed that WBCT was not significantly associated to mortality (aOR: 0.46; 95% CI 0.10-1.94). The WBCT group had a relative reduction of 39% in the frequency of major surgeries, with an associated effect on reducing the need for surgery (aOR: 0.47; 95% CI 0.22-0.98). Conclusions. Whole-body computed tomography was employed in the initial management of patients with penetrating firearm projectile injuries and hemodynamic instability. The use of WBCT was not associated with mortality but rather with a reduction in the frequency of major surgery.

El dilema clínico frente a los pacientes con ergometría positiva y prueba de perfusión miocárdica con SPECT normal / The clinical dilemma facing patients with positive stress test and normal SPECT myocardial perfusion imaging

La evaluación de la perfusión miocárdica con SPECT combina una prueba de esfuerzo (ergometría o estrés farmacológico) junto a imágenes de perfusión con radioisótopos. Este estudio es útil para establecer el diagnóstico de enfermedad arterial coronaria, estratificar el riesgo de infarto y tomar decisiones terapéuticas. Un resultado normal aporta un alto valor predictivo negativo, es decir, una muy baja probabilidad de que el paciente presente eventos cardiovasculares. El hallazgo de signos de isquemia en la ergometría podría poner en jaque el valor predictivo negativo de una perfusión normal. En presencia de este resultado, el paso siguiente es evaluar los predictores de riesgo en la ergometría, el riesgo propio del paciente en función de los antecedentes clínicos y el puntaje cálcico coronario, cuando este se encuentra disponible. Ante la presencia concomitante de otros marcadores de riesgo se sugiere completar la evaluación con un estudio anatómico.El uso de nuevas tecnologías podría mejorar la precisión en la predicción de eventos. (AU)

Assessment of myocardial perfusion with SPECT combines a stress test (ergometry or pharmacological stress) with radioisotope perfusion imaging. This test is helpful to diagnose coronary artery disease, stratify the risk of heart attack, and make therapeutic decisions. A normal result provides a high negative predictive value; therefore, the probability of cardiovascular events is very low. Signs of ischemia on an ergometry could jeopardize the negative predictive value of normal perfusion. In this clinical setting, the next step is to evaluate the risk predictors in the stress test, the individual risk based on the clinical history, and the coronary calcium score when available. Given the simultaneous presence of other risk markers,completing the evaluation with an anatomical study is suggested. The use of new technologies could improve the accuracy of event prediction. (AU)

Evolução da Captação Miocárdica de 18F-FDG em Paciente com Diagnóstico de Cardiotoxicidade / Progression of Myocardial 18F-FDG Uptake in a Patient with Cardiotoxicity

Resumo O objetivo deste relato é mostrar a evolução da cardiotoxicidade (CTX) por quimioterápicos em paciente com linfoma por exames de imagens, destacando a importância da captação miocárdica de flúor-18 fluordeoxiglicose (18F-FDG) pela tomografia por emissão de pósitrons, acoplada à tomografia computadorizada (PET/CT). Feminino, 43 anos, com linfoma uterino, submetida a histerectomia, três esquemas de quimioterapia (QT), sucessivamente, e radioterapia. Apresentou episódios de insuficiência cardíaca aguda dois anos após QT. Ecocardiograma mostrou redução da fração de ejeção do ventrículo esquerdo (FEVE). Análise retrospectiva do 18F-FDG PET/CT observou elevação da captação miocárdica em todos os exames durante o seguimento oncológico. Apesar da remissão oncológica, a paciente desenvolveu IC com FEVE reduzida. Durante a QT, ocorreu aumento difuso e significativo da captação miocárdica de 18F-FDG, que precedeu a queda do desempenho cardíaco, e pareceu refletir alterações metabólicas nos cardiomiócitos relacionadas à CTX. A análise da captação miocárdica de 18F-FDG modificaria o desfecho cardiológico da paciente? Esse questionamento é relevante, visto que outros pacientes podem se beneficiar desse método como marcador precoce de CTX. Os exames de imagem são imprescindíveis no acompanhamento de pacientes com risco de CTX. O ecocardiograma permanece como principal auxílio diagnóstico, porém o 18F-FDG PET/CT pode estar surgindo como uma poderosa ferramenta para um diagnóstico mais precoce dessa condição clínica.

Abstract The objective of this case report was to present the progression of chemotherapy-induced cardiotoxicity in a patient with lymphoma, highlighting the importance of myocardial fluor-18-fluorodeoxyglucose (18F-FDG) uptake by positron emission tomography coupled with computed tomography (PET/CT). 43-year-old female patient with uterine lymphoma, who underwent hysterectomy followed by three chemotherapy regimens and radiotherapy. The patient had episodes of acute heart failure two years after chemotherapy. Echocardiogram revealed a reduction in left ventricular ejection fraction (LVEF). A retrospective analysis of 18F-FDG PET/CT showed an increase in myocardial uptake in all tests performed during oncologic treatment. Despite disease remission, the patient developed heart failure with reduced LVEF. During chemotherapy, there was a diffuse, significant increase in myocardial 18F-FDG uptake, which preceded the decrease in myocardial performance and seemed to reflect metabolic changes in cardiomyocytes, related to cardiotoxicity. Would an analysis of myocardial 18F-FDG uptake yield a different cardiac outcome in this patient? This question is relevant, considering that other patients may benefit from the use of PET as an early marker of cardiotoxicity. Imaging tests are essential in the follow-up of patients at risk of cardiotoxicity. Although echocardiography remains the main imaging test in the diagnosis of cardiotoxicity, 18F-FDG PET/CT may be a powerful tool for the early diagnosis of this condition.

Partial regression of peripapillary myelinated nerve fibers after non-arteritic anterior ischemic optic neuropathy / Regressão parcial das fibras nervosas peripapilares mielinizadas após neuropatia óptica isquêmica anterior não arterítica

ABSTRACT A 71-year-old woman presented a non-arteritic anterior ischemic optic neuropathy in an optic nerve with previously registered superonasal peripapillary myelinated nerve fibers. Her past medical history was significant for controlled systemic hypertension, hyperlipidemia, and diabetes mellitus. The physiologic cup was absent in both optic discs. Non-arteritic anterior ischemic optic neuropathy mainly affected the temporal and inferior sectors of the peripapillary retinal nerve fiber layer, as could be demonstrated by retinal nerve fiber layer optical coherence tomography and optic disc optical coherence tomography angiography. Unlike other published reports, just a slight regression of the myelinated nerve fibers was observed after 1 year of follow-up. This occurred because ischemia mainly affected the temporal and inferior peripapillary sectors, whereas myelinated nerve fibers were superonasal to the optic disc.

RESUMO Uma mulher de 71 anos de idade apresentou neuropatia óptica isquêmica anterior não arterítica no nervo óptico com fibras nervosas peripapilares mielinizadas previamente registradas. Seu histórico médico foi significativo para hipertensão arterial sistêmica controlada, hiperlipidemia e diabetes mellitus. Em ambos os discos ópticos, a tacícula fisiológica esteve ausente. A neuropatia óptica isquêmica anterior não arterítica afetou principalmente os setores temporal e inferior da camada de fibras nervosas da retina peripapilar, como demonstrado pela tomografia de coerência óptica da camada de fibras nervosas da retina e pela angiotomografia de coerência óptica do disco óptico. Ao contrário de outros relatórios publicados, apenas uma ligeira regressão das fibras nervosas mielinizadas foi observada após um ano de acompanhamento. Isto pode ser explicado pelo fato da isquemia ter afetado principalmente os setores temporal e inferior peripapilares, enquanto as fibras nervosas de mielina eram nasal superior ao disco óptico.

Macular perfusion changes in people administered two types of COVID-19 vaccines: optical coherence tomography angiography study

ABSTRACT Purpose: To evaluate macular chorioretinal flow changes on optical coherence tomography angiography, in participants who received inactivated and messenger RNA (mRNA) vaccines to prevent coronavirus disease 2019 (COVID-19). Methods: In this prospective cohort study, healthy participants who received two doses of an inactivated COVID-19 vaccine (CoronaVac) and then one dose of an mRNA vaccine (BNT162b2) were examined before and after each vaccination. Ophthalmologic examination and imaging with optical coherence tomography angiography were performed during each visit. We evaluated vascular densities in the superficial and deep capillary plexuses in foveal, parafoveal, and perifoveal areas; the foveal avascular zone; and choriocapillaris flows (in 1- and 6-mm-diameter areas). Results: One eye in each of the 24 participants was assessed. Superficial capillary plexus vascular densities in the parafoveal area were significantly lower after the second dose of the CoronaVac vaccine than after the first dose. In the deep capillary plexus, vascular attenuation was observed only in the parafoveal region after the first CoronaVac dose. However, in all regions, the deep capillary plexus vascular densities and subfoveal choriocapillaris flow were significantly decreased after the second CoronaVac dose. After the BNT162b2 dose, the superficial capillary plexus vascular densities, the deep capillary plexus vascular densities, and subfoveal choriocapillaris flow of most regions were significantly lower than those before vaccinations. Conclusion: Vascular attenuation, observed particularly after the second dose of the CoronaVac vaccine, may explain the pathogenesis of postvaccine ocular ischemic disorders reported in the literature. However, these disorders are extremely rare, and the incidence of thrombotic events caused by COVID-19 itself is higher.

Choroidal macrovascular and capillary alterations in eyes with idiopathic epiretinal membranes

ABSTRACT Purpose: To evaluate the choroidal vascular alterations and effect of surgical treatment in the setting of idiopathic epiretinal membranes. Methods: The structure of the choroid was studied in 33 patients with unilateral idiopathic epiretinal membrane using optical coherence tomography with enhanced depth imaging and optical coherence tomography angiography. Eyes with epiretinal membrane underwent 25-gauge vitrectomy with epiretinal membrane and internal limiting membrane peeling. The choroidal vascularity index, Haller layer/choroidal thickness ratio, and choriocapillaris flow density were used to evaluate changes in choroidal structure after surgery and compare with the healthy fellow eyes. Results: The choroidal vascularity index and Haller layer/choroidal thickness ratio of the eyes with epiretinal membrane were higher than those of the fellow eyes at baseline (p=0.009 and p=0.04, respectively) and decreased postoperatively compared with preoperative values (p=0.009 and p=0.001, respectively). The choriocapillaris flow of eyes with epiretinal membrane was lower than that of the fellow eyes at baseline (p=0.001) and increased after surgery compared with the preoperative value (p=0.04). The choroidal vascularity index, Haller layer/choroidal thickness ratio, and choriocapillaris flow values of the healthy fellow eyes were comparable at baseline and final visit. In eyes with epiretinal membrane, the final choroidal vascularity index correlated with the final choriocapillaris flow (r=-0.749, p=0.008) in the multivariate analysis. Conclusion: Idiopathic epiretinal membrane appears to affect the choroidal structure with increased choroidal vascularity index and Haller layer/choroidal thickness ratio and decreased choriocapillaris flow. These macrovascular (choroidal vascularity index and Haller layer/choroidal thickness) and microvascular (choriocapillaris flow) alterations appear to be relieved by surgical treatment of the epiretinal membranes.

Influence of the dilution method on the intraocular duration of C3F8 in vitrectomy for macular hole: a randomized clinical trial

ABSTRACT Purpose: To compare the injection of small amounts of undiluted C3F8 with the traditional gas injection in vitrectomy for macular hole treatment. Methods: This clinical trial included 26 individuals divided into two groups. Group 1 received an intravitreal injection of 0.9-1.0 mL of 100% C3F8, and Group 2 received 15-20 mL of 20% C3F8. Results: The median intraocular gas duration was 31 days in Group 1 and 34 in Group 2. The median letter gains in corrected distance visual acuity for the 26th postoperative week were 20 letters in Group 1 and 12.5 in Group 2. The median intraocular pressure was normal in both groups. Primary anatomical success was 11/13 in both groups. Conclusions: The use of C3F8 gas in a small undiluted volume is an alternative that slightly reduces the duration of the gas without negatively affecting the anatomical and visual response.

Littoral cell angioma of the spleen: case report and literature review

ABSTRACT Littoral cell angioma is an extremely rare splenic vascular tumor originating from the cells lining the splenic red pulp sinuses. Approximately 150 cases of littoral cell angioma have been reported since 1991. Its clinical manifestation is usually asymptomatic and is mostly diagnosed as an incidental finding through abdominal imaging. Herein, we present a case of littoral cell angioma in a 41-year-old woman with no previous comorbidities, which initially presented as a nonspecific splenic lesion diagnosed on imaging in the emergency room. The patient was treated through laparoscopic intervention.

Measurement of optic nerve sheath diameter on computed tomography for the differentiation of transient ischemic attacks

SUMMARY OBJECTIVE: The objective of this study was to investigate whether the measurement of mean optic nerve sheath diameter in patients with transient ischemic attack could be used to distinguish between control groups, the acute ischemic stroke group, and subgroups within the acute ischemic stroke category. METHODS: Retrospectively, the mean optic nerve sheath diameters of patients aged 18 years and older belonging to control, transient ischemic attack, acute ischemic stroke, and subgroups within the acute ischemic stroke category were measured with initial computed tomography conducted in the emergency department. RESULTS: Out of the 773 patients included in the study, 318 (41.1%) were in the control group, 77 (10%) had transient ischemic attack, and 378 (49%) were categorized as stroke patients. The average mean optic nerve sheath diameter was significantly higher in both the stroke and transient ischemic attack groups compared with the control group (p<0.001 for both comparisons). Furthermore, the mean optic nerve sheath diameter in the stroke subgroups was significantly higher than in both the transient ischemic attack and control groups (p<0.001 for all comparisons). In transient ischemic attack patients, the mean optic nerve sheath diameter showed a significant ability to predict transient ischemic attack (AUC=0.913, p<0.001), with a calculated optimal cutoff value of 4.72, sensitivity of 94.8%, and specificity of 73.9%. CONCLUSION: The mean optic nerve sheath diameter of patients in the transient ischemic attack group was lower compared with those in the stroke subgroups but higher compared with the control group.

Manually prepared lamellae for Descemet stripping endothelial keratoplasty (Pachy-DSEK): comparison of four dissection depths / Lamelas manualmente dissecadas para transplante endotelial de córnea (Pachy-DSEK): comparação entre quatro profundidades de dissecção

ABSTRACT Purpose: This study aimed to compare four depths of manual dissection for the preparation of Descemet stripping endothelial keratoplasty lamellae. Methods: Eye bank corneas were randomized into four groups according to dissection depths: Pachy-100 (incision depth = central corneal thickness-safety margin of 100 µm), Pachy-50 (safety margin of 50 µm), Pachy-0 (no safety margin), and Pachy+50 (incision depth = central corneal thickness + 50 µm). All endothelial lamellae were prepared using a standardized method of manual dissection (Pachy-DSEK). The central, paracentral (3.0-mm zone), and peripheral (6.0-mm zone) lamella thicknesses and incision depths were measured by optical coherence tomography. The 3.0-mm and 6.0-mm zone central-to-peripheral thickness ratios were calculated. Results: Endothelial perforation occurred only in the Pachy+50 group (n=3, 30%). Central lamella's thickness in Pachy-100, Pachy-50, Pachy-0, and Pachy+50 groups measured 185 ± 42 µm, 122 ± 29 µm, 114 ± 29 µm, and 58 ± 31 µm, respectively (p<0.001). The overall 3.0- and 6.0-mm C/P ratios were 0.97 ± 0.06 and 0.92 ± 0.14, respectively. Preoperative donor characteristics were not correlated with most thickness outcomes. The planned incision depth correlated significantly with most lamella's thickness parameters (p<0.001). The overall thickness of the lamella negatively correlated with the planned incision depth (p<0.001, r=-0.580). The best outcome was found in the Pachy-0 group, as 75% of the lamellae measured <130 µm and there was no endothelial perforation. Conclusions: By using a standardized method of dissection, most manually prepared lamellae presented a planar shape. Setting the incision depth to the central corneal thickness did not result in endothelial perforation and a high percentage of ultrathin lamellae was achieved.

RESUMO Objetivo: Comparar quatro profundidades de dissecção manual usadas no preparo de lamelas para transplante endotelial. Métodos: Córneas humanas de treinamento disponibilizadas foram randomizadas em quatro grupos: Pachy-100 (profundidade de incisão = espessura corneana central - margem de segurança de 100 µm), Pachy-50 (margem de segurança de 50 µm), Pachy-0 (sem margem de segurança) e Pachy+50 (profundidade de incisão = espessura corneana central + 50 µm). Todas as lamelas foram dissecadas através um método padronizado e já publicado (Pachy-DSEK). As espessuras das lamelas (centro, zona de 3,0mm e zona de 6,0mm) foram medidas com tomografia de coerência óptica. A razão de espessura centro-periferia foi calculada aos 3,0 e 6,0 mm de diâmetro. Resultados: Perfuração endotelial ocorreu apenas no grupo Pachy+50 (n=3, 30%). A espessura central da lamela nos grupos Pachy-100, Pachy-50, Pachy-0 e Pachy+50 foi de 185 ± 42 µm, 122 ± 29 µm, 114 ± 29 µm, e 58 ± 31 µm, respectivamente (p<0,001). As razões C/P aos 3,0 e 6,0 mm foram de 0,97 ± 0,06 e 0,92 ± 0,14, respectivamente. Os parâmetros de características do doador não se correlacionaram com os resultados de espessura de lamela. A profundidade planejada de incisão se correlacionou com a maioria dos parâmetros de espessura de lamela (p<0,001). A espessura de lamela se correlacionou negativamente com a profundidade planejada da incisão (p<0.001, r=-0,580). O melhor resultado foi observado no grupo Pachy-0, em que 75% das lamelas mediram abaixo de 130 µm e não houve perfuração endotelial. Conclusão: Através de um método padronizado de dissecção, a maioria das lamelas endoteliais apresentou uma configuração planar. O planejamento de profundidade de incisão igual à espessura corneana central resultou em alta porcentagem de lamelas ultrafinas sem ocorrência de perfuração.

Morphofunctional evaluation of peripapillary retinoschisis associated with myopic posterior staphyloma and hyaloid traction: does it cause peripapillary vitreoretinal traction? / Avaliação morfofuncional da retinosquise peripapilar associada ao estafloma posterior miópico e à tração hialoidea: isso causa tração vitreo-retiniana peripapilar?

ABSTRACT This case report presents the details of a 33-year-old female patient who was referred to a specialized retina service because of mild vision loss in her right eye). The patient's visual acuity was 20/25 in right eye and 20/50 in the left eye (; amblyopic); the spherical equivalent was -12.75 diopters (right eye) and -14.75 diopters (left eye). Multimodal retinal imaging showed peripapillary schisis in both the inner and outer retinal layers, grade II posterior vitreous detachment, and a tessellated fundus. Using Humphrey perimetry and MP-3 microperimetry, the functional evaluation indicated macular sensitivity within normal limits and decreased sensitivity in the peripapillary region, especially in right eye. The pattern-re versal visual evoked potential was measured. The N75 and P100 latency and amplitude in right eye were within normal values for checks of 1º. However, the amplitude was low for checks of 15′. Highly myopic patients who have posterior staphyloma that involves the optic nerve are susceptible to posterior hyaloid traction, and the resulting peripapillary vitreous traction may compromise vision.

RESUMO Este relato de caso apresenta um paciente feminino de 33 anos encaminhado para um serviço especializado de retina devido à leve perda de visão em olho direito. A acuidade visual foi de 20/25 no olho direito e 20/50 no olho esquerdo, o equivalente esférico foi de -12,75 dioptrias e -14,75 dioptrias, respectivamente. Avaliações multimodais revelaram isquese peripapilar nas camadas internas e externas da retina, descolamento vítreo posterior grau II e fundo tesselado. Avaliação funcional com perimetria Humphrey e microperimetria MP-3 revelaram sensibilidade macular normais e diminuição da sensibilidade na região peripapilar, especialmente no olho direito. Potencial visual evocado de padrão reverso apresentou no olho direito latência e amplitude N75 e P100 dentro dos valores normais para verificação de 1º. Entretanto, a amplitude foi baixa para a de 15′. Pacientes alto míopes com esfiloma posterior envolvendo o nervo óptico são suscetíveis à tração da hialoide posterior. Portanto a tração vitreopapilar resultante pode causar comprometimento da visão.

Longitudinal evaluation of RTVue optical coherence tomography in patients with glaucoma and suspected glaucoma and stable visual fields / Avaliação longitudinal da tomografia de coerência óptica RTVue em pacientes glaucomatosos e suspeitos de glaucoma com campos visuais estáveis

ABSTRACT Purpose: To longitudinally compare isolated structural parameters obtained using RTVue optical coherence tomography in patients with glaucoma and suspected glaucoma with stable visual fields. Methods: All patients were required to have a reliable SITA Standard 24-2 Humphrey Visual Field test. Visual field stability was defined as having <5 points with p<5% and/or having no points with p<1% and/or p<0.05% in the glaucoma progression analysis comparison graph. Furthermore, the glaucoma assessment strategy was used in optical coherence tomography. Results: The study included 75 eyes from 75 patients, 43 of which had glaucoma and 32 had suspected glaucoma. The mean visual field intervals were 29.57 ± 9.65 months between the first and third tests. No visual field parameter variations (mean deviation, pattern standard deviation, and visual field index) and no retinal nerve fiber layer or optic disk parameter variations between the first and third tests were observed (p>0.05 for all), and no retinal nerve fiber layer parameter variations throughout the study were observed, except for optic disk parameters presenting with cup volume changes (p=0.004). However, ganglion complex cells presented a progressively decreased average ganglion cell complex parameter, with a variability of -0.98% ± 3.71% (p=0.04) between the first and third tests. By contrast, the global loss volume progressively increased throughout the study, with a variability of 14.71% ± 44.52% (p=0.04) between the first and third tests. The inferior ganglion cell complex parameter was significantly decreased between the first and third tests (p=0.02). Conclusion: The present findings suggest that patients with glaucoma or suspected glaucoma with stable visual fields may present structural ganglion complex cell progression as assessed using RTVue optical coherence tomography.

RESUMO Objetivo: Comparar longitudinalmente os parâmetros estruturais isolados obtidos através da tomografia de coerência óptica RTVue em pacientes glaucomatosos e suspeitos de glaucoma com campos visuais estáveis. Métodos: Todos os incluídos deveriam ter Campimetria Computadorizada Humphrey Sita Standard 24-2 confiáveis. A estabilidade campimétrica foi definida se apresentassem menos de cinco pontos com p<5% e/ou nenhum ponto com p<1% e/ou p<0,05% no gráfico de comparação do Glaucoma Progression Analysis. Para a tomografia de coerência óptica, foi utilizado a estratégia de avaliação para glaucoma. Resultados: Foram incluídos 75 olhos de 75 pacientes: 43 com glaucoma e 32 suspeitos. A média dos intervalos do campo visual entre o 1o e 3o exame, foi de 29,57 ± 9,65 meses. Não houve variação para os parâmetros do campo visual (desvio médio, desvio padrão e índice da função visual) entre o primeiro e o último exame (p>0,05 para todos). Não houve variação dos parâmetros da camada de fibras nervosas da retina ao longo do estudo, enquanto que para os parâmetros do disco óptico, apenas cup volume apresentou mudança (p=0,004). Em relação à camada de células ganglionares da retina, notou-se uma redução progressiva na espessura média da Ganglionar Complex Cells com uma variabilidade entre o primeiro e último exame de -0,98 ± 3,71% (p=0,04). Quanto ao Global loss volume, houve um aumento progressivo ao longo do estudo com uma variabilidade entre o primeiro e último exame de 14,71 ± 44,52% (p=0,04). O parâmetro inferior do Ganglionar Complex Cells também reduziu significativamente entre o 1o e 3o exames (p=0,02). Os demais parâmetros da tomografia de coerência óptica RTVue se mantiveram estáveis entre o 1o e 3o exames. Conclusão: Os presentes achados sugerem que pacientes glaucomatosos ou com suspeita de glaucoma e com campos visuais estáveis, podem apresentar progressão estrutural na camada de células ganglionares da retina avaliada por meio da tomografia de coerência óptica RTVue.

Effect of levetiracetam on ocular perfusion measure with optical coherence tomography angiography / Efeito do levetiracetam na medição da pressão de perfusão ocular com angiotomografia de coerência óptica

ABSTRACT Purpose: To evaluate using optical coherence tomography angiography the macular and optic nerve head blood flow in pediatric patients with epilepsy treated with levetiracetam for at least 12 months. Methods: This study included 33 pediatric patients with epilepsy and 30 sex- and age-matched healthy volunteer children were included in the study. Optical coherence tomography angiography was used to evaluate the optic nerve head and macular perfusion changes. The mean ocular perfusion pressures were also calculated. Patients who were using multiple antiepileptic drugs or had a prior history of using different drugs were excluded. Results: The choriocapillaris flow area was significantly lower in the Study Group than in the Control Group (p=0.006). However, the foveal avascular zone and vessel densities of the macula in the superficial capillary plexus, deep capillary plexus, and optic nerve head of the study group were not significantly different from those of the control group (p>0.05). Moreover, no significant difference in means of mean ocular perfusion pressure was found between the two groups (p=0.211). No obvious correlation was found between treatment duration and optical coherence tomography angiography parameters or mean ocular perfusion pressure. Conclusion: Choroidal perfusion was reduced in children taking levetiracetam compared with that in the control group, whereas retinal perfusion was not affected in this optical coherence tomography angiography study.

RESUMO Objetivo: Avaliar através de angiotomografia de coerência óptica o fluxo sanguíneo macular e da cabeça do nervo óptico em pacientes pediátricos com epilepsia tratados com levetiracetam por pelo menos 12 meses. Método: Trinta e três pacientes pediátricos com epilepsia e 30 crianças voluntárias saudáveis pareadas por sexo e idade foram incluídos no estudo. A angiotomografia de coerência óptica foi utilizada para avaliar as alterações da perfusão da cabeça do nervo óptico e da macular. As médias das pressões de perfusão ocular também foram calculadas. Pacientes em uso de múltiplas drogas antiepilépticas ou com história prévia de uso de diferentes drogas foram excluídos do estudo. Resultado: A área do fluxo coriocapilar foi significativamente menor no Grupo Estudo do que no Grupo Controle (p=0,006). Entretanto, a zona avascular foveal e as densidades vasculares no plexo capilar superficial e profundo da região macular e na cabeça do nervo óptico não foram significativamente diferentes daquelas de olhos saudáveis (p>0,05). Também não houve diferença significativa entre os dois grupos em relação às médias da pressão de perfusão ocular (p=0,211). Nenhuma correlação aparente foi encontrada entre a duração do tratamento e os parâmetros da angiotomografia de coerência óptica ou a média da pressão de perfusão ocular. Conclusão: Em crianças usando levetiracetam, a perfusão coroidal mostrou-se reduzida em comparação ao grupo controle, enquanto a perfusão retiniana não foi afetada neste estudo com angiotomografia de coerência óptica.