Single-Pill Combination Therapy of Amlodipine, Telmisartan, and Chlorthalidone in the Management of Hypertension: A Systematic Review of Randomized Controlled Trials.

Hypertension is a major cause of cardiovascular disease and death worldwide. Low-dose combination therapy is a promising approach for managing hypertension due to its safety and efficacy. This systematic review evaluates the safety and efficacy of a single-pill, low-dose combination of amlodipine, telmisartan, and chlorthalidone for essential hypertension based on evidence from randomized controlled trials (RCTs). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched the Cochrane, Scopus, PubMed, and Web of Science databases until July 01, 2024, using the following search string: (telmisartan) AND (amlodipine) AND (chlorthalidone) AND (randomized OR randomly). The quality of the RCTs was assessed using the revised Cochrane risk of bias tool. The primary endpoint was the mean change in sitting systolic blood pressure (BP), with secondary endpoints including BP target achievement rates, BP response rates, and serious treatment-related adverse events. Overall, three RCTs met the inclusion criteria and exhibited a low risk of bias. The doses in the combination pill ranged from 2.5 to 5 mg of amlodipine, 20 to 80 mg of telmisartan, and 4.167 to 25 mg of chlorthalidone. Control groups varied, including usual care, amlodipine 10 mg, and dual therapy of telmisartan and amlodipine. Results showed significant reductions in mean sitting systolic and diastolic BP, improved BP control and response rates, and a generally safe profile with no significant differences in serious adverse events. Despite encouraging data, results should be interpreted with caution due to heterogeneity in doses and control groups. Further research should address the long-term effects and explore predictors of response to this therapy.

Comparison of eyelid function following frontalis suspension and levator dissection-resection in congenital ptosis with poor levator function.

PURPOSE: A levator dissection-resection technique (LDR) in which the levator is dissected free from all fibrous attachments including Whitnall's ligament was compared to two commonly used frontalis-based procedures in the management of congenital ptosis with poor levator function. METHODS: Thirty patients having congenital ptosis with poor levator function were randomized to one of the three surgical groups (ten patients for each group), namely, frontalis sling (FS), frontalis advancement flap (FAF), and (LDR) technique. Marginal reflex distance-one (MRD-1), levator function, symmetry in different levels of vertical gaze, lagophthalmos, and any other surgical complications were assessed 6 months following the intervention. RESULTS: Patients in the three groups achieved statistically significant improvement in MRD-1 in the primary position of gaze (p = 0.001 for FS, 0.003 for FAF, 0.001 for LDR). Patients who underwent a frontalis-based procedure acquired an additional ability to elevate the upper eyelid by using their eyebrows. Patients who underwent LDR technique have acquired an additional mean of 5.79 ± 1 mm improvement in levator function with better symmetry during up and down gaze in unilateral cases. Patients from all groups had an equal degree of lagophthalmos with forced eyelid closure, and during sleep. CONCLUSION: Patients with ptosis and poor levator function who were managed with LDR technique achieved a similar degree of eyelid elevation in the primary gaze to that of frontalis-based procedures, acquired additional levator function, achieved more symmetry in up and down gaze in unilateral cases, and had no additional risk to the cornea.

Lacrimal gland injection of platelet rich plasma for treatment of severe dry eye: a comparative clinical study.

BACKGROUND: We aimed to assess the efficacy of the injections of platelet rich plasma (PRP) for the treatment of severe dry eye disease (DED). RESULTS: In this retrospecitve interventional clinincal study, we included 28 eyes of 14 patients with severe DED who were diagnosed with Sjogren syndrome. Each patient received unilateral lacrimal gland injection of PRP at days 0, 30, 60 and 90 days while the other eye served as control group who received preservative free eye drops. We objectively assessed parameters at baseline, 1 month, 2 months and 3 months including ocular surface analyzer (OSA) namely; noninvasive tear breakup times (NIBUT), tear meniscus height (TMH), lipid layer thickness (LLT) in addition to the Schirmer test I, corneal fluorescein staining (CFS) and meiboscore. The mean age was 43.4 ± .7.85 years. Comparing different parameters, baseline data showed non-significant difference between injected eye group and control group. After 1 and 3 months of follow up, there were significant differences between both groups regarding NITBUT, TMH, LLT, CFS and Schirmer test, with p <  0.001 in favor of PRP group. CONCLUSION: Injection of PRP in lacrimal gland is simple, safe, and effective technique in treatment of severe dry eye; proved by improvement of tear film parameters through subjective and objective assessment. Further studies are needed to standardize the technique and to confirm these results.

Ocular Surface Changes in Patients with Thyroid Eye Disease: An Observational Clinical Study.

BACKGROUND: This study aimed to compare ocular surface parameter changes in active and inactive thyroid eye disease (TED) patients and controls. METHODS: This is an observational clinical study that included 60 eyes divided into three groups following clinical activity score (CAS) assessment. The first group (Group A) comprised 20 eyes with active TED (CAS score ≥3/7), while the second group (Group B) comprised 20 eyes with inactive TED (CAS score <3/7) and the third group (Group C) comprised 20 eyes of controls without dry eye manifestations. The palpebral fissure height, degree of proptosis, degree of lagophthalmos, ocular surface disease index (OSDI), Schirmer test without anesthesia, corneal fluorescein staining (CFS), non-invasive tear break-up time (NITBUT), tear meniscus height (TMH), lipid layer thickness (LLT), meiboscore, meibomian gland dysfunction (MGD), and thyroid antibodies were assessed and data were compared between study participants. RESULTS: The mean OSDI was 40.0 ±5.80 in Group A, which significantly differed from Group B with a mean of 26.5 ±5.10 (p=0.02). There were significant differences between the two groups regarding palpebral fissure height (p=0.02), amount of proptosis (p=0.008), and degree of lagophthalmos (p=0.001). Similarly, active TED patients had more decreased tear secretion than inactive TED patients (p=0.012). Moreover, active TED patients showed a significant increase in Meibomian gland loss areas in both upper and lower eyelids compared with inactive TED patients (p=0.001). Corneal fluorescein staining also revealed a statistically significant difference between the studied groups (p=0.0001). CONCLUSION: This study showed differences regarding ocular surface parameter changes between both active and inactive TED and compared to controls. Further studies are needed to confirm these results.

Inhouse Bridging Thrombolysis Is Associated With Improved Functional Outcome in Patients With Large Vessel Occlusion Stroke: Findings From the German Stroke Registry.

Background: Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective. To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone. The aim of our study was to specifically address the question, whether bridging IVT directly prior to EVT has additional positive effects on reperfusion times, successful reperfusion, and functional outcomes compared with EVT alone. Methods: Patients with LVOS in the anterior circulation eligible for EVT with and without prior IVT and direct admission to endovascular centers (mothership) were included in this multicentric, retrospective study. Patient data was derived from the German Stroke Registry (an open, multicenter, and prospective observational study). Outcome parameters included groin-to-reperfusion time, successful reperfusion [defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3], change in National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and mortality at 90 days. Results: Of the 881 included mothership patients with anterior circulation LVOS, 486 (55.2%) received bridging therapy with i.v.-rtPA prior to EVT, and 395 (44.8%) received EVT alone. Adjusted, multivariate linear mixed effect models revealed no difference in groin-to-reperfusion time between the groups (48 ± 36 vs. 49 ± 34 min; p = 0.299). Rates of successful reperfusion (TICI ≥ 2b) were higher in patients with bridging IVT (fixed effects estimate 0.410, 95% CI, 0.070; 0.750, p = 0.018). There was a trend toward a higher improvement in the NIHSS during hospitalization [ΔNIHSS: bridging-IVT group 8 (IQR, 9.8) vs. 4 (IQR 11) points in the EVT alone group; fixed effects estimate 1.370, 95% CI, -0.490; 3.240, p = 0.149]. mRS at 90 days follow-up was lower in the bridging IVT group [3 (IQR, 4) vs. 4 (IQR, 4); fixed effects estimate -0.350, 95% CI, -0.680; -0.010, p = 0.041]. There was a non-significantly lower 90 day mortality in the bridging IVT group compared with the EVT alone group (22.4% vs. 33.6%; fixed effects estimate 0.980, 95% CI -0.610; 2.580, p = 0.351). Rates of any intracerebral hemorrhage did not differ between both groups (4.1% vs. 3.8%, p = 0.864). Conclusions: This study provides evidence that bridging IVT might improve rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation LVOS eligible for EVT.

Optic nerve sheath fenestration in leukemic patients having increased intracranial pressure: a prospective clinical trial.

PURPOSE: This study aimed to assess the safety and efficacy of optic nerve sheath fenestration (ONSF) in leukemic children having increased intracranial pressure with severe uncontrolled visual loss on medical treatment and not eligible for venous sinus stenting. METHODS: In this non-randomized clinical trial, we included patients presenting with severe sight-threatening papilledema due to increased intracranial pressure following leukemia treatment. All included patients were subjected to a complete history taking, assessment of the visual acuity and fundus examination with fundus photography and grading of papilledema using Frisen scale. Patients were evaluated at 2 weeks and 3 months postoperative by recording the best-corrected visual acuity, assessment of the pupillary reaction and fundus examination and fundus photography with grading of papilledema. RESULTS: Among 20 patients included in this study, there was a statistically significant improvement in visual acuity of both eyes in all patients. The mean postoperative visual acuity was 0.28 ± 0.10 two weeks after surgery in the right eye and it was 0.42 ± 0.16 in the left eye. The mean visual acuity in the right eye three months after surgery was 0.78 ± 0.19 and it was 0.87 ± 0.17 in the left eye. Three months postoperatively, papilledema resolved completely in both eyes. There were no recorded ocular complications. CONCLUSION: In this study, ONSF was sight-saving procedure in all leukemic patients with a significant improvement in the visual acuity, stabilization of the visual function and resolving of the papilledema over follow-up period. There were no recorded intraoperative or postoperative complications. Further well-designed studies are needed to assert upon these results.

The Role of the Flash Visual Evoked Potential in Evaluating Visual Function in Patients with Indirect Traumatic Optic Neuropathy.

PURPOSE: To assess the value of the flash visual evoked potential (FVEP) in determining final visual prognosis in patients with indirect traumatic optic neuropathy (TON). SUBJECTS AND METHODS: We included 30 patients diagnosed with indirect TON. Within one week of the onset of the trauma, visual acuity was recorded, pupillary reactions were assessed, FVEP was performed in both eyes. The amplitudes (N1p1 and N2P2) and the latency of P2 for each eye were recorded and amplitude ratio of N2P2 between the affected and normal eye was calculated. In follow-up visits, the cases underwent a complete ophthalmic examination, assessment of visual acuity, pupillary reaction, and FVEP. RESULTS: The study included 22 males (73.3%) and 8 females (26.7%). The right eye was involved in 16 patients (53.3%) and left eye was involved in 14 cases (46.7%). According to the findings of FVEP, there was a direct correlation between final visual acuity and initial amplitude of N1p1 and N2P2 and negative correlation with latency of P2 wave. In 20 patients in whom the N1P1 and N2P2 amplitude was within the normal range and amplitude ratio of N2P2 of normal and fellow eye was at least 0.5 and the P2 implicit time was less than 140 ms, they achieved better visual outcome and visual acuity improved in the affected eye. In other 10 patients in whom the N1P1 and N2P2 amplitude was below normal range and the N2P2 amplitude ratio between the normal and the affected eye was less than 0.5 and the P2 implicit time was more than 140 ms, the visual acuity in the affected eye was less than 0.01 and these patients achieved less or no improvement in their visual function. CONCLUSION: Cases with TON usually present with severe loss of vision. FVEP is highly predictive of final visual outcome in patients having indirect TON given that the other eye is normal to be used as the patients' internal control. More studies are needed to confirm these results.

Comparing the diagnostic value of Echocardiography In Stroke (CEIS) - results of a prospective observatory cohort study.

BACKGROUND: Echocardiography is one of the main diagnostic tools for the diagnostic workup of stroke and is already well integrated into the clinical workup. However, the value of transthoracic vs. transesophageal echocardiography (TTE/TEE) in stroke patients is still a matter of debate. Aim of this study was to characterize relevant findings of TTE and TEE in the management of stroke patients and to correlate them with subsequent clinical decisions and therapies. METHODS: We evaluated n = 107 patients admitted with an ischemic stroke or transient ischemic attack to our stroke unit of our university medical center. They underwent TTE and TEE examination by different blinded investigators. RESULTS: Major cardiac risk factors were found in 8 of 98 (8.2%) patients and minor cardiac risk factors for stroke were found in 108 cases. We found a change in therapeutic regime after TTE or TEE in 22 (22.5%) cases, in 5 (5%) cases TEE leads to the change of therapeutic regime, in 4 (4%) TTE and in 13 cases (13.3%) TTE and TEE lead to the same change in therapeutic regime. The major therapy change was the indication to close a patent foramen ovale (PFO) in 9 (9.2%) patients with TTE and in 10 (10.2%) patients with TEE (p = 1.000). CONCLUSION: Major finding with clinical impact on therapy change is the detection of PFO. But for the detection of PFO, TTE is non inferior to TEE, implicating that TTE serves as a good screening tool for detection of PFO, especially in young age patients. TRIAL REGISTRATION: The trial was registered and approved prior to inclusion by our local ethics committee (1/3/17).