Association between Hypertension and Stroke Recurrence as Modified by Pro-oxidant-Antioxidant Balance: A Multi-Center Study.

BACKGROUND: Hypertension and oxidative stress are involved in the pathophysiological mechanism of stroke. We aimed to investigate the modification impact of the pro-oxidant-anti-oxidant balance (PAB) on the association between hypertension and stroke recurrence (SR). METHODS: A cross-sectional design was conducted from December 2019 to December 2020 in 951 stroke patients in six hospitals across Vietnam. Hypertension was defined using antihypertensive medication or systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg. PAB was estimated using weighting methods based on smoking, drinking, and overweight/obesity with pro-oxidant capacity, diet quality, fruit intake, vegetable intake, and physical activity with antioxidant capacity. The higher PAB scores indicated a beneficial balance shifting toward antioxidant dominance. SR was diagnosed by neurologists. Moreover, sociodemographic and health conditions were included as covariates. Multiple logistic regression analyses were used to explore the associations and interactions. RESULTS: The hypertension and SR proportions were 72.8% and 17.5%, respectively. hypertension was associated with an increased SR likelihood (odds ratio (OR) = 1.93; p = 0.004), whereas a higher PAB score was associated with a lowered SR likelihood (OR = 0.87; p = 0.003). Moreover, hypertension interacting with every one-point increment of PAB was associated with a lowered SR likelihood (OR = 0.83; p = 0.022). CONCLUSIONS: The harmful impact of hypertension on SR could be alleviated by PAB. The interplay of health behaviors should be highlighted in the intervention strategies for stroke prevention.

Negative Impact of Comorbidity on Health-Related Quality of Life Among Patients With Stroke as Modified by Good Diet Quality.

Background: Comorbidity, along with aging, affects stroke-induced health-related quality of life (HRQoL). We examined the potential role of diet quality in modifying the association between comorbidity and HRQoL in patients with stroke. Methods: A cross-sectional study was conducted on 951 patients with stroke from December 2019 to December 2020 across Vietnam. Comorbidity was assessed using the Charlson Comorbidity Index (CCI) items and classified into two groups (none vs. one or more). Diet quality was evaluated using the Dietary Approaches to Stop Hypertension Quality (DASH-Q) questionnaire, and HRQoL was measured using the RAND-36, with a higher score indicating better diet quality or HRQoL, respectively. Besides, socio-demographics, health-related behaviors (e.g., physical activity, smoking, and drinking), disability (using WHODAS 2.0), and health literacy were also assessed. Linear regression analysis was utilized to explore the associations and interactions. Results: The proportion of patients with stroke aged ≥65 years and having comorbidity were 53.7 and 49.9%, respectively. The HRQoL scores were 44.4 ± 17.4. The diet quality was associated with higher HRQoL score (regression coefficient, B, 0.14; (95% confidence interval, 95% CI, 0.04, 0.23; p = 0.004), whereas comorbidity was associated with lower HRQoL score (B, -7.36; 95% CI, -9.50, -5.23; p < 0.001). In interaction analysis, compared to patients without comorbidity and having the lowest DASH-Q score, those with comorbidity and higher DASH-Q score had a higher HRQoL score (B, 0.21; 95% CI, 0.03, 0.39; p = 0.021). Conclusion: The findings showed that good diet quality could modify the adverse impact of comorbidity on HRQoL in patients with stroke. Diet quality should be considered as a strategic intervention to improve the HRQoL of patients with stroke, especially those with comorbidity, and to promote healthier aging.

Physical Activity and Diet Quality Modify the Association between Comorbidity and Disability among Stroke Patients.

BACKGROUND: Comorbidity is common and causes poor stroke outcomes. We aimed to examine the modifying impacts of physical activity (PA) and diet quality on the association between comorbidity and disability in stroke patients. METHODS: A cross-sectional study was conducted on 951 stable stroke patients in Vietnam from December 2019 to December 2020. The survey questionnaires were administered to assess patients' characteristics, clinical parameters (e.g., Charlson Comorbidity Index items), health-related behaviors (e.g., PA using the International Physical Activity Questionnaire- short version), health literacy, diet quality (using the Dietary Approaches to Stop Hypertension Quality (DASH-Q) questionnaire), and disability (using the World Health Organization Disability Assessment Schedule II (WHODAS II)). Linear regression models were used to analyze the associations and interactions. RESULTS: The proportion of comorbidity was 49.9% (475/951). The scores of DASH-Q and WHODAS II were 29.2 ± 11.8, 32.3 ± 13.5, respectively. Patients with comorbidity had a higher score of disability (regression coefficient, B, 8.24; 95% confidence interval, 95%CI, 6.66, 9.83; p < 0.001) as compared with those without comorbidity. Patients with comorbidity and higher tertiles of PA (B, -4.65 to -5.48; p < 0.05), and a higher DASH-Q score (B, -0.32; p < 0.001) had a lower disability score, as compared with those without comorbidity and the lowest tertile of PA, and the lowest score of DASH-Q, respectively. CONCLUSIONS: Physical activity and diet quality significantly modified the negative impact of comorbidity on disability in stroke patients. Strategic approaches are required to promote physical activity and healthy diet which further improve stroke rehabilitation outcomes.

[Bilateral uveitis associated with nivolumab therapy]. / Uvéite bilatérale associée à un traitement par nivolumab.

Immune-related adverse events (IRAEs) are rare but serious adverse events that may be associated with inhibitors of few immune control points. The purpose here is to report the case of an inflammatory ocular disease, potentially linked to the immunity and use of nivolumab, a new immunological agent used for the treatment of a solid tumor. In spite of the involvement of this treatment in the onset of inflammation, we must always seek another cause. It is possible to continue this treatment by considering the benefit/risk balance for each patient. Close collaboration between oncologists and ophthalmologists is necessary in the diagnosis and rapid management of these IRAE ocular related to these new emerging therapies.

Bilateral uveitis associated with nivolumab therapy.

New anticancer therapies, immune pathway inhibitors, may cause immune-related adverse events (IRAE). Immune-related ocular toxicities are rare but are potentially serious adverse events. The purpose of this article is to report a case of ocular inflammatory involvement potentially related to the immune response and the use of nivolumab, a new immunologic agent used for the treatment of a solid tumor. Despite the implication of this therapy in the occurrence of inflammation, other causes must always be ruled out. It is possible to continue this therapy in consideration of the risk/benefit ratio for each patient. Close collaboration between oncologists and ophthalmologists is necessary in the diagnosis and timely management of IRAE related to these new emerging therapies.

[Comparison of early management of central retinal vein occlusion with ranibizumab versus hemodilution]. / Comparaison de la prise en charge précoce des occlusions de la veine centrale de la rétine par ranibizumab et/ou hémodilution.

PURPOSE: This study was designed to evaluate and compare the efficacy of early treatment of CRVO with either hemodilution by erythrocytopheresis or intravitreal (IVT) ranibizumab, or both. MATERIAL AND METHODS: A multicentric prospective randomized study including patients with CRVO for less than 1 month was designed. Patients were randomized into 3 treatment groups: hemodilution (HD group), 3 monthly intravitreal injections of ranibizumab followed by PRN treatment (IVT group), or combined treatment (IVT+HD group). A monthly evaluation during a 6-month follow-up included best-corrected visual acuity (BCVA) and macular thickness measurements with OCT. Fluorescein angiography was performed at baseline, month 2 and month 6. Local and systemic tolerability of the different treatments were also compared. RESULTS: Forty-four CRVO patients were included between February 2010 and June 2013: 20 in the IVT group, 13 in the HD group and 11 in the HD+IVT group. The mean duration of CRVO at baseline was 10 days and 16 days at the time of treatment without any significant difference between groups. Retinal ischemia was present at baseline in 40% of eyes in each group. After a 6-month follow-up, no difference between the 3 groups was observed in BCVA (10.5 ETDRS letters, 14.6 and 14.1 in the IVT group, HD group and IVT+HD group respectively, P=0.726) or in macular thickness (398 µ, 440 µ and 379 µ respectively, P=0.465). The time until treatment from CRVO onset, ranging from 1 to 35 days, was not correlated to final outcomes. No significant difference in the mean number of IVT (3.2 in the IVT+HD group vs 3.7 in the IVT group) was observed at 6 months. CONCLUSION: No difference in BCVA nor in macular thickness was seen at M6 between the study groups. The duration of CRVO at the time of the initiation of the treatment was not correlated to better visual outcomes. Therefore, etiologic treatment with HD can still be proposed as a first-line treatment in young patients, which allows delaying or avoiding the IVT treatment and its potential side effects. Anti-VEGF IVT still remains an effective option in every case and can be started one month after the beginning of the CRVO.

Efficacy of anti-TNF alpha in severe and/or refractory Behçet's disease: Multicenter study of 124 patients.

OBJECTIVE: To report the efficacy and safety of anti-TNF agents in patients with severe and/or refractory manifestations of Behçet's disease (BD). METHODS: We performed a multicenter study of main characteristics and outcomes of anti-TNF alpha treatments [mainly infliximab (62%), and adalimumab (30%)] in 124 BD patients [48% of men; median age of 33.5 (28-40) years]. RESULTS: Overall response (i.e. complete and partial) rate was 90.4%. Clinical responses were observed in 96.3%, 88%, 70%, 77.8%, 92.3% and 66.7% of patients with severe and/or refractory ocular, mucocutaneous, joint, gastro-intestinal manifestations, central nervous system manifestations and cardiovascular manifestations, respectively. No significant difference was found with respect to the efficacy of anti-TNF used as monotherapy or in association with an immunosuppressive agent. The incidence of BD flares/patient/year was significantly lower during anti-TNF treatment (0.2 ± 0.5 vs 1.7 ± 2.4 before the use of anti-TNF, p < 0.0001). The prednisone dose was significantly reduced at 6 and 12 months (p < 0.0001). In multivariate analysis, retinal vasculitis was negatively associated with complete response to anti-TNF (OR = 0.33 [0.12-0.89]; p = 0.03). The efficacy and relapse free survival were similar regardless of the type of anti-TNF agent used. After a median follow-up of 21 [7-36] months, side effects were reported in 28% of patients, including infections (16.3%) and hypersensitivity reactions (4.1%). Serious adverse events were reported in 13% of cases. CONCLUSION: Anti-TNF alpha therapy is efficient in all severe and refractory BD manifestations. Efficacy appears to be similar regardless of the anti-TNF agent used (infliximab or adalimumab).

PCR-based detection of Toxoplasma gondii DNA in blood and ocular samples for diagnosis of ocular toxoplasmosis.

PCR detection of Toxoplasma gondii in blood has been suggested as a possibly efficient method for the diagnosis of ocular toxoplasmosis (OT) and furthermore for genotyping the strain involved in the disease. To assess this hypothesis, we performed PCR with 121 peripheral blood samples from 104 patients showing clinical and/or biological evidence of ocular toxoplasmosis and from 284 (258 patients) controls. We tested 2 different extraction protocols, using either 200 µl (small volume) or 2 ml (large volume) of whole blood. Sensitivity was poor, i.e., 4.1% and 25% for the small- and large-volume extractions, respectively. In comparison, PCR with ocular samples yielded 35.9% sensitivity, while immunoblotting and calculation of the Goldmann-Witmer coefficient yielded 47.6% and 72.3% sensitivities, respectively. Performing these three methods together provided 89.4% sensitivity. Whatever the origin of the sample (ocular or blood), PCR provided higher sensitivity for immunocompromised patients than for their immunocompetent counterparts. Consequently, PCR detection of Toxoplasma gondii in blood samples cannot currently be considered a sufficient tool for the diagnosis of OT, and ocular sampling remains necessary for the biological diagnosis of OT.

[Bitemporal hemianopia as presenting sign of severe ethambutol toxicity]. / Hémianopsie bitemporale révélatrice d'une atteinte toxique sévère à l'éthambutol.

INTRODUCTION: Optic neuropathy is a severe and well-known complication of ethambutol treatment. If not detected early, it may lead to profound and irreversible vision loss. CASE REPORT: We report the case of a 83-year-old female patient, referred for rapidly progressive, painless, bilateral visual loss, unimproved after bilateral cataract surgery. Automated Humphrey 24-2 visual field demonstrated bitemporal hemianopia associated with bilateral central scotoma. Brain MRI did not demonstrate any compressive lesion in the chiasmal region. However, on T2-weighted sequences, an area of elevated signal intensity appeared within the optic chiasm, enhancing after gadolinium injection. On detailed history, it was noted that the patient had been on ethambutol for the last 18months, for the treatment of a Mycobacterium avium-related pneumonitis. DISCUSSION: The incidence of ethambutol-related toxic optic neuropathy has dramatically decreased since the recommendations for regular follow-up of patients treated with ethambutol. This treatment is classically responsible for bilateral central or ceco-central scotoma due to optic neuropathy, although a few cases of bitemporal hemianopia have been reported in the literature, mimicking a compressive chiasmal lesion. However, none of these cases demonstrated a hypersignal in the optic chiasm on brain magnetic resonance imaging (MRI). CONCLUSION: Bitemporal hemianopia on visual field testing is very suggestive of a chiasmal lesion, which is generally due to a compressive, or more rarely inflammatory, lesion in the sellar region. Toxic chiasmal lesions are rare, but in the absence of any tumoral lesion in the sellar area, a detailed history must be obtained in order to rule out drug toxicity, so as to prevent irreversible visual loss.

Direct genotyping of Toxoplasma gondii in ocular fluid samples from 20 patients with ocular toxoplasmosis: predominance of type II in France.

We report the direct genotyping analysis of Toxoplasma gondii in ocular samples collected from 20 patients, as well as associated clinical and epidemiological data. This work was aimed at better understanding the impact of genotypes of Toxoplasma gondii strains on toxoplasmic retinochoroiditis. For this purpose, we studied the aqueous humor (AH) or vitreous humor (VH) of 20 patients presenting with ocular toxoplasmosis (OT) in 2 hospitals in France. Genetic characterization was obtained with microsatellite markers in a multiplex PCR assay. In contrast to the results of previous studies, we found no association between atypical Toxoplasma gondii genotypes and the occurrence of OT. Considering the local epidemiological data, our OT patients seemed to be infected more frequently by ordinary type II strains found in the environment. In conclusion, direct genotyping of Toxoplasma gondii strains from aqueous or vitreous humor showed a predominance of the type II genotype in ocular toxoplasmosis; this may be due to a high exposure rate of this genotype in humans.

Azathioprine in severe uveitis of Behçet's disease.

OBJECTIVE: To investigate the efficacy and tolerance of azathioprine in severe uveitis related to Behçet's disease (BD). METHODS: We reported 157 consecutive patients with severe uveitis (active posterior uveitis or panuveitis) fulfilling the international criteria for BD and treated with corticosteroids (0.5-1 mg/kg/day) and azathioprine (2.5 mg/kg/day). Long-term outcome and factors associated with complete remission were assessed. RESULTS: Mean±SD age at diagnosis was 29.9±10.1 years, with 71.3% men. At baseline, 59 patients (37.6%) had loss of useful vision, 54 (34.4%) had retinal vasculitis, 66 (42.0%) had panuveitis, and 132 (84.1%) had bilateral uveitis. Following azathioprine therapy, 81 patients (51.6%) were complete responders, 65 (41.4%) were partial responders, and 11 (7%) were nonresponders. The visual acuity significantly improved (P<0.001), and a significant decrease in the mean oral prednisone dosage (55.3 to 10.5 mg/day; P<0.001) was observed after therapy. Patients with retinal vasculitis (odds ratio [OR] 0.45 [95% confidence interval (95% CI) 0.2-0.9], P=0.02) and severe visual loss (OR 0.28 [95% CI 0.2-0.7], P<0.0001) at diagnosis were less likely to be complete responders. Azathioprine was well tolerated, with only 3 withdrawals due to hepatotoxic effects (n=2) and bacterial septicemia (n=1). CONCLUSION: Azathioprine represents an effective and safe therapy in patients with severe uveitis of BD.

Comparison of immunoblotting, calculation of the Goldmann-Witmer coefficient, and real-time PCR using aqueous humor samples for diagnosis of ocular toxoplasmosis.

We compared three biological methods for the diagnosis of ocular toxoplasmosis (OT). Paired aqueous humor and serum samples from 34 patients with OT and from 76 patients with other ocular disorders were analyzed by three methods: immunoblotting or Western blotting (WB), the calculation of the Goldmann-Witmer coefficient (GWC), and PCR. WB and GWC each revealed the intraocular production of specific anti-Toxoplasma immunoglobulin G in 81% of samples (30 of 37). PCR detected toxoplasmic DNA in 38% of samples (13 of 34). Nine of the 13 PCR-positive patients were immunocompetent. Combining the techniques significantly improved the diagnostic sensitivity, to 92% for the GWC-WB combination, 90% for the WB-PCR combination, and 93% for the GWC-PCR combination. The combination of all three techniques improved the sensitivity to 97%.

Comparison of the efficacy and safety of two formulations of diclofenac sodium 0.1% eyedrops in controlling postoperative inflammation after cataract surgery.

PURPOSE: To compare the efficacy and safety of diclofenac sodium 0.1% eyedrops packaged in an Abak multidose container without preservative (Dicloabak) with the reference product, sodium merthiolate-preserved diclofenac sodium 0.1% eyedrops, in controlling postoperative inflammation after cataract surgery. METHODS: The multicenter, controlled, randomized, single-masked study included 194 patients (Dicloabak 96, preserved diclofenac 98) scheduled to have cataract surgery by phacoemulsification with foldable intraocular lens. All were evaluated preoperatively and postoperatively after 1, 7, and 28 days. Postoperative inflammation was measured by the total score of anterior chamber cells and flare. Ocular plin, conjunctival hyperemia and ciliary flush were also assessed. Postoperative patient assessments also included visual acuity, objective tolerance by slit-lamp, fluorescein test, and subjective evaluation of local tolerance. RESULTS: There was no statistically significant difference between the groups in the total score of flare and cells or the degree of conjunctival hyperemia and ciliary flush at any study visit. Dicloabak was demonstrated to be not inferior to preserved diclofenac at all assessment times. The overall assessment of local tolerance was similar for both study medications. CONCLUSIONS: Preservative suppression did not alter diclofenac efficacy. Results support the good safety profile of both formulations when dosed three times daily for 4 weeks in absence of concomitant use of drugs potentially toxic for cornea. Preservative-free formulations like Dicloabak should be preferred to generic diclofenac formulations including other ingredients and may improve the safety profile of this topical nonsteroid anti-inflammatory drug.

Complete bilateral horizontal gaze paralysis disclosing multiple sclerosis.

Two women presented with bilateral internuclear ophthalmoplegia evolving in a few days to complete bilateral horizontal gaze paralysis. Convergence and vertical eye movements were normal. Cerebral MRI showed a few small white matter lesions in the lateral ventricle regions, and, at the brainstem level, a single, small, bilateral lesion affecting the posterior part of the medial pontine tegmentum and responsible for the clinical syndrome. The condition gradually improved in both patients, following a similar progression as at the onset: improvement first involved the adduction movements in both eyes, whereas bilateral abduction paresis still persisted for a few weeks, before complete recovery of eye movements. Bilateral damage to the medial longitudinal fasciculus and subsequent lateral extent of damage to the region of the two abducens emerging fibres may explain the clinical findings. In both cases, the cause was probably multiple sclerosis.

[Birdshot chorioretinopathy: a case with delayed detection]. / Choriorétinopathie de Birdshot: un cas de découverte tardive.

We report a case of birdshot retinochoroidopathy following a cataract surgery in a 78-year-old man. Low-grade forms of the affection may be discovered lately on a recurrence of the inflammation following any event as an ocular surgical procedure. Medical management of cataract surgery in uveitis is then discussed.

[Endogenous infectious endophthalmitis]. / Endophtalmie infectieuse endogène.

INTRODUCTION: Endogenous endophthtalmitis is an intraocular infection of hematogenous origin. EXEGESIS: It is generally a panuveitis that may be mixed-up with a non-infectious inflammatory disease, promoting delayed treatment and compromising the visual prognosis, as the visual loss rate reaches up to 37.5%. Antibiotherapy should be started immediately after bacteriological examinations and without waiting for vitrectomy. Identification of the causative microorganism is absolutely necessary. It may require aqueous or vitreous culture if cultures from other body fluids are negative and infection progresses. The most common infections are endocarditis and digestive and renal diseases. Virectomy is indicated for first line treatment of ocular abcess and improvement of antibiotic absorption. However, it may lead to retinal detachment. Vitrectomy is also indicated in case of unsuccessful therapy. To decrease the inflammatory reaction and risks of vitreous organization, local or systemic corticotherapy is prescribed after control of the infection. CONCLUSION: Although rare, endogenous endophthalmitis should be diagnosed as it may be mixed-up with inflammatory uveitis, leading to inappropriate corticotherapy. Furthermore, antibiotherapy with good intraocular penetration should be started immediately, but it should be kept in mind that the functional prognosis is poor.