Use of Rituximab as an off-Label medication in Glomerular Diseases: Clinical Perspective

Objectives: We review rituximab (RTX) use and outcomes in immune-mediated glomerular diseases (GN) and compare it to established literature. Methods: Adult GN patients who received RTX between January 2014 and January 2018 in three public hospitals were reviewed. Membranous nephropathy (MN) and minimal change disease (MCD) were considered diseases with literature supporting RTX use. Lupus nephritis (LN), 1o focal segmental glomerulosclerosis (1o FSGS), IgA nephropathy (IgAN), IgG4 related disease, and C3GN had insufficient literature support for RTX use. Clinical Remission was assessed six months after receiving RTX. Results: A total of 61 cases analyzed. RTX was an add on therapy in 87%. Remission rate was 95% in MCD and MN vs. 56 % in off-label group (P=.002). LN patients had a mean initial eGFR of 69mL/min. All class III LN achieved remission, and 11 of 21 class IV achieved remission. Mean initial eGFR for 1o FSGS was 33mL/min and it did not improve, and only 2 of 5 had partial resolution of proteinuria. Proteinuria improved in 3 of 5 IgG4-related disease cases with eGFR stabilization but failed to improve in C3GN cases with eGFR deterioration. Vasculitis cases (6 ANCA-associated vasculitis and 2 IgA vasculitis) were analyzed separately. Remission achieved in only 2 ANCA vasculitis cases, and none in IgA vasculitis cases. Conclusion: Our data support RTX use in resistant MCD and MN. RTX showed success in LN and IgG4 related disease, but not FSGS or C3GN. The small vasculitis cases number does not allow drawing a conclusion on RTX effectiveness.

COVID-19 AND THE HUMAN EYE – CONJUNCTIVITIS A LONE COVID-19 FINDING - A case-control study

Background: The worldwide sudden appearance and drastic increase in the number of infected cases with the severe acute respiratory syndrome-Coronavirus 2 (SARS-CoV-2) determined the World Health Organization to declare it as a pandemic situation. The ‘Corona Virus Disease 2019’ (COVID-19) has varied clinical manifestations, from asymptomatic to severe cases, and conjunctivitis, seems not only to be one of them, but sometimes found to be lone initial symptom present. Aim and method: The aim was to identify the prevalence of conjunctivitis as the first symptom in COVID-19 patients, in a primary healthcare unit. A retrospective study was conducted analyzing the presenting complains/symptoms and results of COVID-19 confirmatory tests. Results: Out of the 672 cases that were sent for RT-PCR testing only 121 (18%) were found to be positive. Among this 2.67% of patients who had both conjunctivitis and COVID-19, 77.77% of patients had unilateral eye affected while 22.22% had bilateral conjunctivitis of varying degrees. 15 patients diagnosed to have both acute conjunctivitis and COVID-19, presented other symptoms associated with COVID-19 infection. While 3 patients had only acute conjunctivitis during their entire course of COVID-19. Conclusions: Conjunctivitis is a symptom of COVID-19 and maybe the first sign of the infection, until the onset of the classical manifestations, the patient serves to be a viral reservoir. The physicians should not miss unilateral conjunctivitis, as it can be the only presenting complain of the COVID-19 disease at the initial phase, which might worsen if underwent undetected and can aid in the spread of the contagion.

Quality of Life of Adult Patients with Type 2 Diabetes Mellitus in Kuwait

Objectives: This study aimed to evaluate the Quality of Life (QoL) on Kuwaiti adult patients with Type 2 Diabetes Mellitus (T2DM), aged ≥ 45 years of both genders, who attended primary healthcare centers and to identify factors associated with QoL. Methods: This is a cross-sectional study conducted on a random sample stratified by gender, consisting of 604 Kuwaiti adult patients with T2DM, aged ≥ 45 years, diagnosed by physicians as diabetics for ≥ 6 months. A validated demographic and WHOQOL-BREF questionnaires were used to assess the QoL. Results: The sample consisted of both genders with equal proportions, the age of 46% of patients was within 56-65 years’ class. Only 24% of the participants had secondary school, while 57% were retired, and the income of 54% exceeds 1000 KD/month. The majority of patients (76%) were married, and 99% were living with their families. Obesity was reported in 54% of patients, and 16% were smokers. Only oral antidiabetic drugs were used by 50% of patients, and 24% of the sample had complications, 11% of them developed retinopathy. A family history of diabetes was reported in 74% of patients, and 45% of them have a duration of diabetes >10 years. Regarding the QoL, the median score was 71, around 77% of the sample has a good QoL. Conclusion: There is more need for public health action to control the disease, thus improving their QoL; this can be achieved by improving the patients’ health status and maintaining their abilities.

Radiographic Detection of the Relationship Between Tonsilloliths and Dental Plaque-Related Pathologies in a Series of Digital Panoramic Radiographs

Objective: The purpose of this study was to analyse the prevalence of tonsilloliths and to determine radiographically whether there is a relationship between tonsilloliths and dental plaque-related pathologies in a series of digital panoramic radiographs. Materials and Methods: This retrospective study included digital panoramic radiographs of 859 patients admitted for a routine dental examination. The panoramic images were examined for both the presence of tonsilloliths and the number of decayed, missing, restored tooth and apical periodontitis. Periodontal bone loss was also measured in thirds of optimal bone height according to the root length and finally a percentage of bone loss was obtained for each panoramic radiograph evaluated. Results: Tonsilloliths were observed in 141 (16.4%) of all individuals. While there was no significant difference regarding the number of decayed teeth and restored teeth between tonsillolith cases (TT) and cases without tonsillolith (TC), the number of missing teeth and apical periodontitis in TT was significantly higher than TC (p: 0.004, p: 0.030, respectively). There was a significant difference between the groups in terms of the mean percentage of bone loss (p: 0.001; p< 0.05). In addition, cases showing bone loss between one-third and two-thirds of the optimal bone height in the TT group (52.5%) were significantly higher than those in TC (45.5%) (p: 0.035; p< 0.05). Conclusion: The relationship between dental plaque-related pathologies and tonsilloliths, observed in this retrospective study, should be confirmed by Computed Tomography studies and randomized, prospective, clinical trials conducted in a multidisciplinary manner.

Ten Famous Composers of the Romantic Era and their Cause of Death

The musical composers in the Romantic Era (1800-1910) strived for compositions that expressed human life, including happiness, harmony and despair. They lived in a period in which freedom of thinking, expression of emotion and inspiration by nature predominate. During this period, intensive trading with other parts of the world brought new microorganisms along, which made infections and epidemics very common. This article serves to address the cause of death and relevant biographic data of a number of well- known Romantic composers. Primarily, this review refers to clinically significant findings using reports that were retrieved from Pubmed, Embase and Google over the 19th, 20th and 21st century till 14th June 2021. Here, this text dwells on diseases and the cause of death of ten composers, namely Mozart, Beethoven, Chopin, Schubert, Schumann, Mendelssohn, Brahms, Liszt, Mahler and Bruckner. It is evident that, in the sight of modern medicine, symptoms and forensic facts are not complete, but witnesses' reports and recent medical research have provided passable and plausible clarity. Although many questions will remain unanswered, it appears that the diseases of these composers and their causes of death have their origins in alcohol abuses, age, epidemics (like tuberculosis) and syphilis.

The role of serum Galectin-3 levels in patients with sarcoidosis

introduction: Galectin-3 is a multi-functional protein and previous studies have suggested that levels of serum galectin-3 increase in the presence of diseases that progress with pulmonary fibrosis. Therefore, the role of galectin-3 levels in the staging and assessing of the severity of sarcoidosis is investigated in the present study. Methods and Subjects: The present study was conducted on a total of 73 subjects, including 25 healthy individuals and 48 patients with a pathologically confirmed diagnosis of sarcoidosis in which other potential causes had been ruled out. Galectin-3 levels of all subjects were measured and compared in terms of such parameters as hemogram, biochemistry, age, body mass index and smoking status. Intervention: In our study, no intervention was made to the patients. Main Outcome Measures: The mean galectin-3 levels of the sarcoidosis patients (14.87±5.57) were significantly higher than those measured in the healthy subjects (11.81± 2.67), and themean galectin-3 levels differed significantly among those at different stages of the disease (p<0.05). In particular, the average level of galectin-3 sarcoidosis patients had grade 2 and above significantly higher. Results: In addition, serum galectin-3 levels in the sarcoidosis patients had significant positive correlations with blood BUN, ALP, WBC, RBC, HGB and neutrophil levels (34.9% [p<0.05]; 40.1% [p<0.05]; 41.2% [p<0.01]; 43.3% [p<0.01]; 34.7% [p<0.05] and 40.6% [p<0.01], respectively),and a significant negative correlation with PDW levels (p<0.05). Conclusion: Serum galectin-3 levels are significantly elevated in sarcoidosis patients with parenchymal involvement at stages 2 or higher, suggesting that serum galectin-3 levels can be used to estimate disease severity in sarcoidosis.

SARS-CoV-2 Clinical Characteristics and Viral Shedding in Kuwait

Objectives: We aimed to describe the clinical characteristics of SARS-CoV-2 infection and estimate viral shedding duration in respiratory specimens. Methods: A retrospective cohort study was performed from Feb 25th to March 25th, 2020. In Kuwait, all suspected coronavirus disease 2019 (COVID-19) cases, contacts of cases, and returning travelers were systematically tested for SARS-CoV-2 by RT-PCR. All infected persons, regardless of symptoms, were hospitalized and serially tested until they had two negative results. Descriptive statistics and regression analyses were performed. Results: 207 cases of SARS-CoV-2 infection were identified. About half of cases were asymptomatic and 1.9% died. The median time to negative RT-PCR was 22 days. Increasing age, ARDS, and low peripheral white blood cell count were associated with prolonged PCR positivity. Conclusion: Predictors for prolonged RT-PCR positivity included increasing age, ARDS, and low white blood cell count. The findings of this study may aid in better understanding SARS-CoV-2 infection epidemiology and molecular testing dynamics.

New association between idiopathic scoliosis and Luckenschadel skull (lacunar skull)

Objective: Luckenschadel skull is a skull that is radiologically characterized by lacunae in the cranial vault. To date, although the association between neurological abnormalities and scoliosis is well-recognized, no relationship between idiopathic scoliosis and a lacunar skull has been defined. We explored the incidence and time courses of lacunar skulls in patients with idiopathic scoliosis. Materials and Methods: Spinal X-rays of 3,170 children aged 6 to 16 years with idiopathic scoliosis evaluated from October 2010 to August 2020 were examined for the presence of an irregular inner calvarial table indicative of a Luckenschadel skull. A total of 1,760 (55.5%) of the 3,170 images included the skull. We also explored the frequency of intraspinal abnormalities in children with lacunar skull images who underwent spinal magnetic resonance imaging. Results: The study population consisted of 1,760 children, 1,203 girls (68.4%) and 557 (31.6%) boys. A total of 268 (15.2%) clearly evidenced lacunar skulls in their radiographs; 186 (69.4%) girls(11.3±4.3 years) and 82 (30.6%) boys(12.6±3.3 years). In total, 2 of 56 patients (3.6%) who underwent spinal MRI had intraspinal abnormalities (isolated Chiari malformation-I). No additional neurological problems were detected in children with lacunar skulls. Conclusion: We are the first to report that the lacunar skull is very common in children with idiopathic scoliosis who lack any other neurological pathology. The lacunar skull does not disappear even in adolescence. Although previous publications have stated that lacunar skull disappears over time in radiographic images, we found that it became more noticeable over time in children with scoliosis.

No local birth sex ratio changes following the August 2019 shootings in Montgomery county, Ohio and in El Paso county, Texas

Objective In humans, males are born slightly in excess of females. Many factors have been shown to affect this ratio, including stressful events such as terrorist attacks. Two shootings in 2019 occurred in early August 2019 in the United States: in the Oregon District in Dayton, Montgomery county, Ohio and in El Paso county, Texas. This study was carried out in order to identify whether there were any effects on sex ratio at birth at state or county level 3-5 months later. Subject and Methods Births by sex, month of birth (2015-2019) and county were obtained for Ohio and Texas from the website of Centers for Disease Control and Prevention. Ordinary linear logistic regression was used to assess the time trend in the probability of boys and to investigate changes in the trend functions. Poisson regression (SAS GENMOD) and linear logistic regression using SAS procedure LOGISTIC was applied. Results This study analysed 2,623,714 live births, 1,939,938 in Texas (sex odds (SO) 1.044) and 683,776 in Ohio (SO 1.045). The only significant effect noted was seasonality (month) at the state level. Conclusion It has been postulated that male foetal loss in pregnant women during stressful periods may occur in accordance with the Trivers-Willard Hypothesis. Several studies have found significant effects after terrorist attacks in the United States (as well as in other countries) but this study failed to do so. This may be due to several reasons including underpowered datasets and the possibility that populations may be becoming relatively immured to these events.

INCREASED CIRCULATING COPEPTIN LEVELS ARE ASSOCIATED WITH VASO-OCCLUSIVE CRISIS AND RIGHT VENTRICULAR DYSFUNCTION IN SICKLE CELL ANEMIA

Objective Vaso-occlusive crisis (VOC) is a common clinical manifestation of sickle cell anemia (SCA) and is associated with increased proinflammatory mediators. Copeptin is the C-terminal part of the prohormone for pro-vasopressin and seems clinically relevant in various clinical conditions. Right ventricular (RV) dysfunction significantly appears in SCA patients due to pulmonary hypertension. This study aimed to investigate the association of copeptin levels in VOC patients and evaluate RV dysfunction. Materials and Methods A total of 108 patients were enrolled in the study. Twenty-eight SCA patients in steady state (30.2±10.9 years), 25 SCA patients in VOC (36.8±11.8 years), and 55 healthy individuals (31.9±9.4 years) with HbAA genotype were included. Clinical, echocardiographic, and laboratory data were recorded. ELISA was used for the determination of serum levels of copeptin. Results VOC patients had significantly higher copeptin level compared both with controls and SCA subjects in steady-state (22.6±13.0 vs. 11.3±5.7 pmol/l, 22.6±13.0 vs. 12.4±5.8 pmol/l, p=0.009 for both). Additionally, the copeptin level was significantly higher in SCA patients with RV dysfunction than those without RV dysfunction (23.2±12.2 vs. 15.3±9.5 pmol/l, p=0.024). Multiple logistic regression analysis revealed that hs-CRP and copeptin levels were found to be associated with VOC. Conclusion The study showed that copeptin and hs-CRP levels were increased in patients with VOC, and a significant relationship was found between RV dysfunction in VOC patients. As a conclusion copeptin can be used as a potential biomarker in predicting VOC crisis in SCA patients and in early detection of patients with SCA who have the potential to develop RV dysfunction.