Atypical Pulmonary Metastasis of Prostate Adenocarcinoma: A Rare Phenomenon.

Prostate cancer can metastasise to the lung. Most common presentations described in the literature are solitary pulmonary nodules, lymphangitic spread and, rarely, pleural effusion. We describe a case of prostate adenocarcinoma with diffuse bilateral reticulonodular and lymphangitic pulmonary metastasis, and malignant pleural effusion while being on androgen deprivation therapy. LEARNING POINTS: Lymphangitic metastasis of prostate cancer to the lung with diffuse reticulonodular infiltrate is a rare presentation.In chemical castration-sensitive prostate cancer, prostate-specific antigen (PSA) levels can be improving but the patient can still develop new distant metastases.

Race/Ethnicity Analysis of Vascular Alterations in Optical Coherence Tomography Angiography in Diabetic Patients.

PURPOSE: Racial and ethnic minorities have a higher prevalence of diabetic retinopathy (DR) and present at advanced stages of disease. In an urban hospital population, we investigated microvascular differences in optical coherence tomography angiography (OCTA) between racial/ethnic groups while adjusting for socioeconomic status (SES). METHODS: 3 × 3 mm2 macular OCTA scans were obtained for analysis of foveal avascular zone (FAZ) area, FAZ perimeter as well as superficial (SCP) and deep capillary plexus (DCP) vessel density (VD), vessel length density (VLD), and adjusted flow index (AFI). SES was measured using the Area Deprivation Index. Multivariable regression models were used to adjust estimates for relevant confounders. RESULTS: 217 non-diabetic and 1,809 diabetic patients were included in the study, consisting of 42.2% Hispanic, 24.9% non-Hispanic (NH) Asian, 6.8% NH Black, 9.7% NH White and 16.3% Other patients. NH White was used as the reference group. Hispanic, NH Asian, and NH Black patients had significantly greater FAZ areas and FAZ perimeters, and lower DCP VD and VLD, among both non-diabetic and diabetic patients (Benjamini-Hochberg adjusted P-values <0.05). The addition of SES scores in the models did not modify any regressions significantly. CONCLUSIONS: In patients with and without diabetes, racial and ethnic minorities have significant retinal microvasculature differences when compared to NH White patients, regardless of SES. These differences are pronounced in DCP and may predispose racial/ethnic minorities to worse outcomes in DR, thus widening disparities in ophthalmic care.

METformin for the MINimization of Geographic Atrophy Progression (METforMIN): A Randomized Trial.

Purpose: Metformin use has been associated with a decreased risk of age-related macular degeneration (AMD) progression in observational studies. We aimed to evaluate the efficacy of oral metformin for slowing geographic atrophy (GA) progression. Design: Parallel-group, multicenter, randomized phase II clinical trial. Participants: Participants aged ≥ 55 years without diabetes who had GA from atrophic AMD in ≥ 1 eye. Methods: We enrolled participants across 12 clinical centers and randomized participants in a 1:1 ratio to receive oral metformin (2000 mg daily) or observation for 18 months. Fundus autofluorescence imaging was obtained at baseline and every 6 months. Main Outcome Measures: The primary efficacy endpoint was the annualized enlargement rate of the square root-transformed GA area. Secondary endpoints included best-corrected visual acuity (BCVA) and low luminance visual acuity (LLVA) at each visit. Results: Of 66 enrolled participants, 34 (57 eyes) were randomized to the observation group and 32 (53 eyes) were randomized to the treatment group. The median follow-up duration was 13.9 and 12.6 months in the observation and metformin groups, respectively. The mean ± standard error annualized enlargement rate of square root transformed GA area was 0.35 ± 0.04 mm/year in the observation group and 0.42 ± 0.04 mm/year in the treatment group (risk difference = 0.07 mm/year, 95% confidence interval = -0.05 to 0.18 mm/year; P = 0.26). The mean ± standard error decline in BCVA was 4.8 ± 1.7 letters/year in the observation group and 3.4 ± 1.1 letters/year in the treatment group (P = 0.56). The mean ± standard error decline in LLVA was 7.3 ± 2.5 letters/year in the observation group and 0.8 ± 2.2 letters/year in the treatment group (P = 0.06). Fourteen participants in the metformin group experienced nonserious adverse events related to metformin, with gastrointestinal side effects as the most common. No serious adverse events were attributed to metformin. Conclusions: The results of this trial as conducted do not support oral metformin having effects on reducing the progression of GA. Additional placebo-controlled trials are needed to explore the role of metformin for AMD, especially for earlier stages of the disease. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Serratia marcescens Endocarditis in Prosthetic Valves.

Serratia marcescens endocarditis is a rare occurrence. We describe a case of Serratia endocarditis in a patient with a prosthetic valve. The clinical course was complicated by widespread embolic phenomena causing stroke, gangrene of extremities, and septic emboli to the lungs, spleen, and eyes. She was not considered suitable for surgery due to severe consumptive coagulopathy and thrombocytopenia in the setting of widespread emboli. The patient was transitioned to do not resuscitate status and discharged to a long-term care facility with a grave prognosis explained to the family.

Association of Male Sex and Microvascular Alterations on Optical Coherence Tomography Angiography in Diabetes.

Purpose: Epidemiologically, men have a higher incidence, severity, and progression of diabetic retinopathy (DR) than women. We investigated microvascular differences between men and women with diabetes on optical coherence tomography angiography (OCTA). Methods: Three × 3 mm OCTA macula scans of non-diabetic and patients with diabetes were obtained. Vascular parameters included parafoveal vessel density (VD), vessel length density (VLD), and flow index (FI) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) as well as foveal avascular zone (FAZ) area and perimeter. Multivariable linear regression was used for statistical analysis. Results: There were 1809 patients with diabetes and 217 non-diabetic participants that were included in this study. Diabetic individuals included those with no DR (n = 1356), mild non-proliferative DR (NPDR; n = 286), moderate NPDR (n = 126), and severe NPDR/proliferative DR (PDR; n = 41). Male sex was significantly associated with smaller FAZ area/perimeter and lower DCP VLD in both non-diabetic subjects and patients with diabetes. Male sex in the diabetic group was additionally associated with lower SCP VD/VLD and DCP VD. Addition of an interaction between male sex and diabetes status in the interaction analysis showed that being male and diabetic conferred increased reduction in DCP VD and VLD compared to sex-based changes in non-diabetics. Larger FAZ perimeter, lower SCP VD/VLD, and lower DCP VLD were associated with poorer visual acuity in diabetics. Conclusions: On OCTA, male patients with diabetes may have more severe microvascular disease especially in the DCP compared to women. Translational Evidence: Sex-based alterations in diabetic microvascular disease has the potential to influence future basic and clinical studies as well as the implementation of OCTA disease markers.

Individual and Systems-Based Risk Factors for Diabetic Vitrectomy in an Urban Safety-Net Hospital.

OBJECTIVE: To identify individual and systems-focused risk factors for pars plana vitrectomy among patients with proliferative diabetic retinopathy (PDR) in a diverse, urban, safety-net hospital setting. DESIGN: Single-center, retrospective, observational, case-control study at Zuckerberg San Francisco General Hospital and Trauma Center between 2017 and 2022. SUBJECTS: Two hundred twenty-two patients with PDR over a 5-year span (2017-2022), consisting of 111 cases who underwent vitrectomy for vision-threatening complications (tractional retinal detachment, nonclearing vitreous hemorrhage, and neovascular glaucoma) and 111 controls with PDR with no history of vitrectomy or vision-threatening complications. Controls were matched 1:1 through incidence density sampling. METHODS: Medical records were reviewed from time of entry into hospital system to vitrectomy date (or date-matched clinic visit for controls). Individual-focused exposures included age, gender, ethnicity, language, homelessness, incarceration, smoking status, area deprivation index, insurance status, baseline retinopathy stage, baseline visual acuity, baseline hemoglobin A1c, panretinal photocoagulation status, and cumulative anti-VEGF treatments. System-focused exposures included external department involvement, referral route, time within hospital and ophthalmology systems, interval between screening and ophthalmology appointment, interval between conversion to proliferative disease and panretinal photocoagulation or first treatment, and loss-to-follow-up in intervals of active proliferative disease. MAIN OUTCOME MEASURES: Odds ratios (ORs) for each exposure on vision-threatening diabetic complications requiring vitrectomy. RESULTS: The absence of panretinal photocoagulation was the primary significant individual-focused risk factor for vitrectomy in the multivariable analysis (OR, 4.78; P = 0.011). Systems-focused risk factors included longer interval between PDR diagnosis and initial treatment (weeks; OR, 1.06; P = 0.024) and greater cumulative duration of loss-to-follow-up during intervals of active PDR (months; OR, 1.10; P = 0.002). Greater duration in the ophthalmology system was the primary systems-focused protective factor against vitrectomy (years; OR, 0.75; P = 0.035). CONCLUSIONS: Largely modifiable variables modulate risk of complications requiring diabetic vitrectomy. Each additional month of loss-to-follow-up for patients with active proliferative disease increased odds of vitrectomy by 10%. Optimizing modifiable factors to promote earlier treatment and maintain critical follow-up in proliferative disease may reduce vision-threatening complications requiring vitrectomy in a safety-net hospital setting. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinical and Visual Field Outcomes Following Minimally Invasive Glaucoma Surgery Combined with Cataract Surgery.

Purpose: To determine the change in Humphrey visual field and clinical parameters after minimally invasive glaucoma surgery combined with cataract surgery. Patients and Methods: Patients undergoing minimally invasive glaucoma surgery combined with cataract surgery in a multicenter retrospective case series between 2013 and 2021 with reliable preoperative and 12 to 18 month postoperative visual field measurements were included. Devices included iStent, XEN, and Hydrus. Clinical parameters were compared with a generalized linear model with generalized estimating equations between preoperative and postoperative visits including best corrected visual acuity, intraocular pressure, number of glaucoma medications and visual fields. Visual field metrics included mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), and Collaborative Initial Glaucoma Treatment Study (CIGTS) score of total deviation probability and pattern deviation probability. Results: Forty-four eyes from 39 patients were included. During the follow up period, visual acuity improved from 0.23±0.17 to 0.10±0.14 logMAR (mean ± standard deviation, p<0.001), number of glaucoma medications was reduced from 2.68±1.06 to 1.46±1.32 (p<0.001), and intraocular pressure decreased from 17.08±4.23 mmHg to 14.92±3.13 mmHg (p=0.003). Differences across devices were negligible. The only significant difference was a greater reduction in number of glaucoma medications in the XEN group (p<0.001). There were no significant changes in the global parameters of VFI, MD, PSD, or CIGTS. Conclusion: Overall, minimally invasive glaucoma surgery combined with cataract surgery appears to be effective at stabilizing visual field function, reducing intraocular pressure, reducing number of glaucoma medications, and improving visual acuity over a 12 to 18 month follow-up period across MIGS devices.

Concomitant renal and splenic infarctions in a COVID-19-patient with a catastrophic thrombotic syndrome.

Since the outbreak of the COVID-19 pandemic, thrombotic events have been accurately described in patients infected by the SARS-CoV-2, especially venous thromboembolism. However, the mystery of arterial thrombosis is still unclear. Here, we report the case of a 59-year-old man with diabetes mellitus, admitted for COVID-19-pneumonia complicated by pulmonary embolism, a thrombus in the aortic isthmus, the descending thoracic aorta associated with splenic and left renal infarctions, and an acute right limb ischemia. The etiological assessment of this catastrophic thrombotic syndrome showed no evidence for preexisting inherited or acquired thrombophilia. Our case emphasizes the hypercoagulability state in COVID-19-patient leading to both arterial and venous thromboembolisms and the need to establish adequate strategies for the diagnosis and management of thrombo-embolisms to prevent these potentially fatal complications.

Late-onset mycotic aneurysm of brachial artery secondary to infective endocarditis: case report.

Infective endocarditis remains a dreaded and severe disease because of its course, its complications, its need for good antibiotic management, as well as its morbidity. Peripheral mycotic aneurysm is a rare complication of infective endocarditis. We report the case of a 62-year-old female patient who presented with Streptococcus SPP infective endocarditis treated by antibiotics. Two months later, she presented with a mycotic aneurysm of the right brachial artery with the same germ, we have performed a brachial artery ligation, then a complete revascularization by graft of the saphenous vein. Through this case, we should not forget that the lesional assessment is always necessary to avoid missing serious complications that could threaten the functional prognosis, even vital.

Popliteal artery entrapment syndrome: a case report with literature review.

Popliteal artery entrapment syndrome generally causes calf claudication in young active adult. It is resulting of the anatomical relationship between the popliteal artery and adjacent muscles or fibrous bands in the popliteal fossa. We present the case of a 36-year-old male with left calf claudication limb in whom popliteal artery entrapment syndrome was diagnosed, and successfully treated surgically.