Intravitreal Infliximab for the Treatment of Proliferative Vitreoretinopathy (FIXER): A Randomized Controlled Phase II Trial.

OBJECTIVE: To study the safety and efficacy of intravitreal infliximab administered at the conclusion of pars plana vitrectomy (PPV) in the treatment of proliferative vitreoretinopathy (PVR) associated with rhegmatogenous retinal detachment (RRD). DESIGN: Randomized controlled phase II clinical trial. SUBJECTS: Patients with primary RRD and grade C PVR, according to the updated Retina Society Classification. METHODS: Sixty-six patients were randomized in a 1:1 ratio to undergo PPV and silicone oil (SO) injection with or without intravitreal injection of 1 mg/0.05 mL of infliximab in the air-filled globe before SO injection at PPV conclusion. Surgeons were masked to treatment allocation until PPV conclusion. MAIN OUTCOME MEASURES: The primary outcome measure was anatomic success (defined as complete retinal reattachment without a tamponade at 6 months post SO removal). Secondary outcome measures were final best-corrected visual acuity (BCVA), single-operation success rate (SOSR), rate of recurrent detachment, central macular thickness (CMT) by macular OCT, macular function by multifocal electroretinogram, and macular vascular density (VD) by OCT angiography. RESULTS: Sixty eyes of 60 patients, 30 eyes in each group, completed the study. At baseline, there were no differences regarding age, gender, history of trauma, lens status, duration of RRD, BCVA, intraocular pressure (IOP), intraocular inflammation (IOI), detachment extent in clock hours, number/size of breaks, presence of vitreous hemorrhage, axial length, or grade/extent of PVR between both groups. For the outcome measures, 30 eyes in the infliximab group achieved anatomic success vs. 29 eyes in the control group. The SOSR was higher in the infliximab group (26) vs. the control (23), but this was not statistically significant (P = 0.317). Final logarithm of the minimum angle of resolution BCVA was better in the infliximab group (mean, 0.96; standard deviation [SD], 0.4; Snellen equivalent ≈ 20/180) vs. the control (mean, 1.14; SD, 0.4); Snellen equivalent ≈ 20/280; P = 0.044). There were no differences regarding IOP, IOI, time of SO removal, macular function, CMT, or VD. CONCLUSIONS: Pars plana vitrectomy with SO tamponade with or without intravitreal infliximab is effective in treating PVR-associated RRD. Infliximab may be associated with modest improvement in final visual outcomes but not anatomic outcomes. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Nomograms and prognosis for superficial esophageal squamous cell carcinoma.

In recent years, endoscopic resection, particularly endoscopic submucosal dissection, has become increasingly popular in treating non-metastatic superficial esophageal squamous cell carcinoma (ESCC). In this evolving paradigm, it is crucial to identify factors that predict higher rates of lymphatic invasion and poorer outcomes. Larger tumor size, deeper invasion, poorer differentiation, more infiltrative growth patterns (INF-c), higher-grade tumor budding, positive lymphovascular invasion, and certain biomarkers have been associated with lymph node metastasis and increased morbidity through retrospective reviews, leading to the construction of comprehensive nomograms for outcome prediction. If validated by future prospective studies, these nomograms would prove highly applicable in guiding the selection of treatment for superficial ESCC.

Endoscopic ultrasound-guided radiofrequency ablation of pancreatic tumors.

PURPOSE OF REVIEW: Surgery is a cornerstone in the management of pancreatic cancer and precancerous pancreatic lesions. However, many patients are not suitable candidates for surgery at the time of diagnosis for various reasons. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) appears to be a promising treatment option for patients who are ineligible for surgery for management of pancreatic adenocarcinoma (PDAC), and pancreatic neuroendocrine tumors (PNETs), and pancreatic cystic lesions (PCLs). RECENT FINDINGS: EUS-RFA may serve as an adjunct to chemotherapy or palliative measures for inoperable cases of PDAC. Given its feasibility and efficacy, EUS-RFA has an evolving niche as a minimally invasive and potentially definitive treatment for PNETs and high-risk PCLs such as intraductal papillary mucinous neoplasms (IPMNs). EUS-RFA is a generally well tolerated procedure, with abdominal pain and acute pancreatitis being the most common adverse effects, though the risk can be mitigated through prophylactic measures. SUMMARY: There is an increasing body of evidence to support the use of EUS-RFA in managing pancreatic lesions, either as definitive, adjunctive, or palliative treatment, depending on lesion type.

Endoscopic Ultrasound-Guided Needle-Based Confocal Endomicroscopy as a Diagnostic Imaging Biomarker for Intraductal Papillary Mucinous Neoplasms.

Pancreatic cancer is on track to become the second leading cause of cancer-related deaths by 2030, yet there is a lack of accurate diagnostic tests for early detection. Intraductal papillary mucinous neoplasms (IPMNs) are precursors to pancreatic cancer and are increasingly being detected. Despite the development and refinement of multiple guidelines, diagnosing high-grade dysplasia or cancer in IPMNs using clinical, radiologic, endosonographic, and cyst fluid features still falls short in terms of accuracy, leading to both under- and overtreatment. EUS-guided needle-based confocal laser endomicroscopy (nCLE) is a novel technology that allows real-time optical biopsies of pancreatic cystic lesions. Emerging data has demonstrated that EUS-nCLE can diagnose and risk stratify IPMNs more accurately than conventional diagnostic tools. Implementing EUS-nCLE in clinical practice can potentially improve early diagnosis of pancreatic cancer, reduce unnecessary surgeries of IPMNs with low-grade dysplasia, and advance the field of digital pathomics. In this review, we summarize the current evidence that supports using EUS-nCLE as a diagnostic imaging biomarker for diagnosing IPMNs and for risk stratifying their degree of neoplasia. Moreover, we will present emerging data on the role of adding artificial intelligence (AI) algorithms to nCLE and integrating novel fluid biomarkers into nCLE.

Revisiting degron motifs in human AURKA required for its targeting by APC/CFZR1.

Mitotic kinase Aurora A (AURKA) diverges from other kinases in its multiple active conformations that may explain its interphase roles and the limited efficacy of drugs targeting the kinase pocket. Regulation of AURKA activity by the cell is critically dependent on destruction mediated by the anaphase-promoting complex (APC/CFZR1) during mitotic exit and G1 phase and requires an atypical N-terminal degron in AURKA called the "A-box" in addition to a reported canonical D-box degron in the C-terminus. Here, we find that the reported C-terminal D-box of AURKA does not act as a degron and instead mediates essential structural features of the protein. In living cells, the N-terminal intrinsically disordered region of AURKA containing the A-box is sufficient to confer FZR1-dependent mitotic degradation. Both in silico and in cellulo assays predict the QRVL short linear interacting motif of the A-box to be a phospho-regulated D-box. We propose that degradation of full-length AURKA also depends on an intact C-terminal domain because of critical conformational parameters permissive for both activity and mitotic degradation of AURKA.

Selective targeting of non-centrosomal AURKA functions through use of a targeted protein degradation tool.

Targeted protein degradation tools are becoming a new therapeutic modality, allowing small molecule ligands to be reformulated as heterobifunctional molecules (PROteolysis Targeting Chimeras, PROTACs) that recruit ubiquitin ligases to targets of interest, leading to ubiquitination and destruction of the targets. Several PROTACs against targets of clinical interest have been described, but detailed descriptions of the cell biology modulated by PROTACs are missing from the literature. Here we describe the functional characterization of a PROTAC derived from AURKA inhibitor MLN8237 (alisertib). We demonstrate efficient and specific destruction of both endogenous and overexpressed AURKA by Cereblon-directed PROTACs. At the subcellular level, we find differential targeting of AURKA on the mitotic spindle compared to centrosomes. The phenotypic consequences of PROTAC treatment are therefore distinct from those mediated by alisertib, and in mitotic cells differentially regulate centrosome- and chromatin- based microtubule spindle assembly pathways. In interphase cells PROTAC-mediated clearance of non-centrosomal AURKA modulates the cytoplasmic role played by AURKA in mitochondrial dynamics, whilst the centrosomal pool is refractory to PROTAC-mediated clearance. Our results point to differential sensitivity of subcellular pools of substrate, governed by substrate conformation or localization-dependent accessibility to PROTAC action, a phenomenon not previously described for this new class of degrader compounds.

AURKA destruction is decoupled from its activity at mitotic exit but is essential to suppress interphase activity.

Activity of AURKA is controlled through multiple mechanisms including phosphorylation, ubiquitin-mediated degradation and allosteric interaction with TPX2. Activity peaks at mitosis, before AURKA is degraded during and after mitotic exit in a process strictly dependent on the APC/C coactivator FZR1. We used FZR1 knockout cells (FZR1KO) and a novel FRET-based AURKA biosensor to investigate how AURKA activity is regulated in the absence of destruction. We found that AURKA activity in FZR1KO cells dropped at mitotic exit as rapidly as in parental cells, despite absence of AURKA destruction. Unexpectedly, TPX2 was degraded normally in FZR1KO cells. Overexpression of an N-terminal TPX2 fragment sufficient for AURKA binding, but that is not degraded at mitotic exit, caused delay in AURKA inactivation. We conclude that inactivation of AURKA at mitotic exit is determined not by AURKA degradation but by degradation of TPX2 and therefore is dependent on CDC20 rather than FZR1. The biosensor revealed that FZR1 instead suppresses AURKA activity in interphase and is critically required for assembly of the interphase mitochondrial network after mitosis.This article has an associated First Person interview with the first authors of the paper.

Optical coherence tomography angiography reveals progressive worsening of retinal vascular geometry in diabetic retinopathy and improved geometry after panretinal photocoagulation.

PURPOSE: To quantify vessel tortuosity and fractal dimension of the superficial capillary plexus (SCP) of the macula in different stages of diabetic retinopathy (DR), and following panretinal photocoagulation (PRP) using optical coherence tomography angiography (OCTA). METHODS: 75 eyes of 75 subjects were divided into five groups; healthy controls, diabetes with no clinical DR, non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR) and patients who received PRP for PDR (PDR+PRP).For vessel tortuosity, SCP slabs from 3x3 mm macular OCTA scans were processed using imageJ (NIH, USA), where large perifoveal vessels were traced and their length was measured with tortuosity calculated as the ratio between the actual length and the straight Euclidean length. For fractal dimension, SCP slabs were processed and imported to Fractalyse (ThéMA, France), where box-counting analyses produced fractal dimension values. RESULTS: We found a significant difference in vessel tortuosity and fractal dimension between the five groups (one-way ANOVA, p < 0.001both). NPDR and PDR had significantly more tortuous vessels and lower fractal dimension compared to healthy controls (Tukey HSD: p = 0.02, 0.015,0.015 and <0.001, respectively). Fractal dimension was also significantly lower in NPDR and PDR compared to eyes with no clinical DR (p <0.001 both), and in PDR compared to NPDR (p = 0.014). Following PRP, vessel tortuosity was significantly lower and fractal dimension was higher in PDR+PRP compared to PDR (p = 0.001 and 0.031, respectively). CONCLUSIONS: We used macular OCTA scans to demonstrate significantly higher perifoveal large vessel tortuosity, and lower fractal dimension in NPDR and PDR compared to healthy controls. Vessel tortuosity shows more dramatic normalization than fractal dimension and could be explored as a sensitive marker for successful PRP.

Rhombencephalitis in cocaine-induced nasal septal perforation and skull base erosion.

Rhombencephalitis is a rare and potentially fatal condition involving the brainstem, with infectious, autoimmune, and paraneoplastic etiologies. We present a patient presenting with left-extremity weakness and dysphonia who had brainstem imaging findings suggestive of rhombencephalitis. We suspect that the case was due to inoculation of the brainstem from nasopharyngeal adenoviral infection. Due to heavy cocaine use, extensive basiocciput erosion led to direct contact between the brainstem and the nasopharyngeal mucosa. The patient's milder clinical course might have been due to some degree of pre-existing immunity against adenovirus. Additionally, clinicians need to be aware of the proximity of the brainstem to the nasopharynx when there is basiocciput erosion, due to the potential risk of injury during instrumentation.

Pattern of Childhood Uveitis in Egypt.

Purpose: To report the pattern of childhood-onset uveitis observed in Egypt from May 2010 to May 2017 Methods: Retrospective evaluation of the data of all patients with uveitis diagnosed before the age of 16 and visiting uveitis referral clinics in 5 Egyptian Governorates (Alexandria, Cairo, Al Bohayra (Damanhour), Al Gharbeya (Tanta), and Sohag) between May 2010 and May 2017. Results: A total of 413 uveitis patients were enrolled. These included 219 male and 194 female patients. Uveitis was bilateral in 68.3% of the patients. The most frequently observed ocular complications were cataract, glaucoma, and cystoid macular edema. The percentage of children with a visual acuity ≥1.00 logMAR in at least one eye by the final visit was 21.8%. Conclusion: Pediatric uveitis is a vision-threatening condition which caused more than one-fifth of the children in this study to lose vision in one or both eyes.

Know the name: acute epiploic appendagitis-CT findings and review of literature.

Epiploic appendages are normal pedunculated peritoneal fat containing outpouchings bordering tenia coli on the anti-mesenteric surface of the colon, extending from caecum to the rectosigmoid. Functions are currently unknown, though some postulate them a blood reservoir. The epiploic appendages can become inflamed, with clinical presentations mimicking that of diverticulitis or acute appendicitis. However, unlike acute diverticulitis or appendicitis, epiploic appendagitis are treated conservatively with antibiotics. Currently, the estimated rate of correct preoperative diagnosis of epiploic appendagitis is 2.5%, but due to benign nature of epiploic appendagitis, it is important to appropriately diagnose it preoperatively and thus preventing unnecessary surgical interventions. Clinical features include focal area of pain, often with normal white blood cell count, that often is common in other differential diagnoses. CT scan plays a crucial role in diagnosis and shows an oval fatty density solid lesion along anterior colonic wall surface, surrounded by a rim of fat stranding. Treatment is conservative and involves use of anti-inflammatory medication.

Splenic rupture from babesiosis, an emerging concern? A systematic review of current literature.

Babesiosis is a relatively common tick-borne parasitic infection of erythrocytes primarily affecting the northeastern United States. Babesiosis' prevalence and presentation have earned it the monikers "malaria of the northeast" and "Nantucket fever". Clinical presentation ranges from asymptomatic infection to severe infection including acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulopathy (DIC) or death. Since 2008, there have been a number of reports of splenic rupture in patients with the disease. We seek to provide a further understanding of this process, with the report of a case of splenic rupture followed by a systematic review of the current literature. We found that 87% of splenic rupture secondary to babesiosis occurred in male patients who are otherwise healthy, with an average of 56 years. Computed tomography is a reliable mode of diagnosis, and hemoperitoneum is the most common imaging finding. Patients with splenic rupture due to human babesiosis were successfully treated by various management strategies, such as conservative non-operative approach, splenic artery embolization, and splenectomy. The modality of treatment depends on patient's clinical course and hemodynamic stability, although spleen conserving strategy should be considered first whenever possible.

Constitutive regulation of mitochondrial morphology by Aurora A kinase depends on a predicted cryptic targeting sequence at the N-terminus.

Aurora A kinase (AURKA) is a major regulator of mitosis and an important driver of cancer progression. The roles of AURKA outside of mitosis, and how these might contribute to cancer progression, are not well understood. Here, we show that a fraction of cytoplasmic AURKA is associated with mitochondria, co-fractionating in cell extracts and interacting with mitochondrial proteins by reciprocal co-immunoprecipitation. We have also found that the dynamics of the mitochondrial network are sensitive to AURKA inhibition, depletion or overexpression. This can account for the different mitochondrial morphologies observed in RPE-1 and U2OS cell lines, which show very different levels of expression of AURKA. We identify the mitochondrial fraction of AURKA as influencing mitochondrial morphology, because an N-terminally truncated version of the kinase that does not localize to mitochondria does not affect the mitochondrial network. We identify a cryptic mitochondrial targeting sequence in the AURKA N-terminus and discuss how alternative conformations of the protein may influence its cytoplasmic fate.

Dedifferentiated parosteal osteosarcoma of the calvaria.

Dedifferentiated parosteal osteosarcoma is a rare tumor and is even rarer when involving the skull bones. We present a case of a 57-year-old man with a partially ossified progressive enlarging left skull mass in the left temporoparietal region, with erosion of the outer table. Radiological diagnosis of dedifferentiated parosteal osteosarcoma was suggested, and histopathology confirmed the diagnosis.

Emphysematous osteomyelitis of the forefoot.

Emphysematous osteomyelitis is a very rare, potentially fatal infection that requires immediate diagnosis and prompt treatment. Emphysematous osteomyelitis is usually considered whenever intraosseous gas is detected on imaging. Most organisms implicated in emphysematous osteomyelitis are members of the Enterobacteriaceae family or anaerobes; sometimes the infection is polymicrobial. We report a case of emphysematous osteomyelitis of the forefoot in a 33-year-old man with type 1 diabetes mellitus.

Retained Wooden Foreign Body in the Second Metatarsal.

The foot is considered the second most common location for foreign bodies. The most common foreign bodies include needles, metal, glass, wood, and plastic. Although metallic foreign bodies are readily seen on plain film radiographs, radiolucent bodies such as wood are visualized poorly, if at all. Although plain radiography is known to be ineffective for demonstrating radiolucent foreign bodies, it is often the first imaging modality used. In such cases, complete surgical extraction cannot be guaranteed, and other imaging modalities should be considered. We present a case of a retained toothpick of the second metatarsal in a young male patient who presented with pain in the right foot of a few weeks' duration. Plain radiography showed an oval cyst at the base of the second metatarsal of the right foot. Magnetic resonance imaging revealed a toothpick penetrating the second metatarsal. The patient recalled stepping on a toothpick 8 years previously. Surgical exploration revealed a 2-cm toothpick embedded inside the second metatarsal.

Clinical and Neuroimaging Findings in Thalamic Territory Infarctions: A Review.

The thalamus is a part of the diencephalon, containing numerous connections between the forebrain and subcortical structures. It serves an important function as a relay center between the cerebral cortex and the subcortical regions, particularly with sensory information. The thalamus also plays a major role in regulating arousal and the levels of awareness. Distinct vascular distribution of the thalamus give rises to different syndromic presentation of thalamic nuclei infarcts. The clinical records and available imaging studies of patients with confirmed thalamic territory infarcts on magnetic resonance imaging (MRI) at the University Hospital of Rochester were reviewed and analyzed. This analysis was then used to provide an effective summary of thalamic vascular anatomy, the clinical symptoms, and syndromes associated with strokes in the affected territories. Specifically, we review the syndromes associated with classic vascular territories, including the anterior, paramedian, inferolateral, and posterior thalamic nuclei, that are supplied by the polar (tuberothalamic), paramedian, inferolateral (thalamogeniculate), and posterior choroidal arteries, respectively. In addition, we will also review the variant thalamic territories and associated infarction syndromes of the anteromedian, central, and posterolateral territories. This review article is aimed to better the clinical and radiologic understanding as well as the diagnosis of classic and variant thalamic territory infarcts. This article will also briefly touch on the recovery of function after thalamic infarcts.

Cocaine abuse: Longitudinal MR imaging of lasting diffused leukoencephalopathy.

Cocaine use has been known to cause a number of adverse neurological conditions, such as cerebral ischemia and posterior reversible leukoencephalopathy. The radiologic appearance of cocaine-induced leukoencephalopathy is confounded by a common contaminant, levamisole, which is also known to cause multifocal leukoencephalopathy. However, we encountered a case of diffuse leukoencephalopathy in a patient with cocaine use that had extensive involvement of the cerebral white matter, globus pallidi as well as the cerebellum. Our case also presented with a severe clinical presentation, with the patient demonstrating minimal neurologic response after a prolonged period of critical care management. The severe clinical course and diffuse radiologic involvement of our case differs from previously reported cases of cocaine- or levamisole-induced leukoencephalopathy.

Idiopathic Giant Hepatic Artery Pseudoaneurysm.

Hepatic artery pseudoaneurysm (HAP) incidence is rising due to more common use of endoscopic and percutaneous hepatic interventions. HAP is potentially fatal, as it could lead to sudden life-threatening hemorrhage. HAP can be intrahepatic or extrahepatic. On computed tomography angiogram (CTA) and magnetic resonance angiogram (MRA), HAP follows blood pool on multiphasic examination, with brisk arterial enhancement that washes out, similar to the abdominal aorta on later phases. We present a case of idiopathic giant HAP in an 82-year-old male. Currently, angioembolization is replacing surgery as the initial modality of choice for management of this condition.