Cessation Of Corticosteroids Research Articles

Changes in weight secondary to improved odor perception in chronic rhinosinusitis with nasal polyps' patients treated with Dupilumab.

The advent of biologic therapies, notably Dupilumab, has transformed therapeutic approaches to nasal polyposis. This retrospective multicentric study aimed to investigate weight changes in CRSwNP patients undergoing Dupilumab treatment and explore potential correlations with olfactory improvement. Ninety-six patients with CRSwNP were followed for at least 12 months, with assessments including BMI (Body Mass Index), olfactory function, and disease severity. Significant increases in BMI and olfactory perception were observed after 1 year of Dupilumab treatment (p < .001). Subgroup analysis showed that patients with hyposmia and normosmia at T12 (1-year follow up) experienced significant weight gain (p < .001) alongside improved olfaction (both p < .001). Conversely, patients with anosmia after 1 year of therapy and also patients with stable or worsened olfaction did not show significant BMI changes (respectively p = .201 and p = .107). While these findings suggest a correlation between olfactory improvement and weight gain/BMI, factors like improved nasal airflow and corticosteroid cessation under Dupilumab treatment may also influence weight in CRPwNP patients. The study highlights the need for further research to elucidate the causal relationship and long-term implications of Dupilumab-induced olfactory improvement on weight regulation.

Vitreoretinal Lymphoma Masquerading as Central Serous Chorioretinopathy.

The following is a case of vitreoretinal lymphoma masquerading as central serous chorioretinopathy (CSCR). A 74-year-old man presented with blurred vision in the left eye with unilateral subretinal fluid in the setting of exogenous corticosteroid use, which was diagnosed as CSCR and resolved with corticosteroid cessation. He later experienced a similar self-limited episode in the right eye. Subsequently, he developed bilateral vitritis with yellow-white subretinal pigment epithelial infiltrates. Vitreous biopsy confirmed a diagnosis of large B-cell lymphoma. Vitreoretinal lymphoma can masquerade as a number of ocular pathologies, including CSCR. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Efficacy of Rituximab for Minimal Change Disease and Focal Segmental Glomerulosclerosis with Frequently Relapsing or Steroid-Dependent Nephrotic Syndrome in Adults: A Chinese Multicenter Retrospective Study

Introduction: Rituximab has been proven effective and safe in pediatric patients with frequently relapsing or steroid-dependent nephrotic syndrome (FR/SDNS). We aimed to analyze the efficacy and safety of rituximab in adult FR/SDNS patients with minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). Methods: A retrospective cohort study at three nephrology centers in China included adult FR/SDNS patients with biopsy-proven MCD or FSGS. Primary outcomes were relapse frequency and first relapse-free survival time. Adverse events were well recorded, and logistic regression analyses were used to investigate the risk factors of relapse. Results: Eighty-one patients (age, 25.0 years; interquartile range, 20.0–40.5; 67% males; 82.7% MCD) received an average rituximab dose of 1,393.8 ± 618.7 mg/2 years during the 2-year follow-up period. The relapse frequency, calculated as the ratio of relapse times to follow-up years, significantly decreased after rituximab treatment (0.04 [0.00, 0.08] vs. 1.71 [1.00, 2.45], p < 0.001). The first relapse-free survival time was 16.7 ± 8.0 months. Fifty-seven patients (70.4%) achieved cessation of corticosteroids and immunosuppressants within 3 months after the first rituximab infusion. Adverse events were mostly mild, and no severe treatment-related adverse events were observed. Low serum albumin level before rituximab and high CD56⁺CD16⁺ natural killer cell count after rituximab were independent risk factors of relapse within 2 years after rituximab treatment. Conclusion: Rituximab was proven an effective and safe treatment option for adult FR/SDNS patients with MCD or FSGS in maintaining disease remission and minimizing corticosteroid exposure.

SURG-32. EFFICACY OF LASER INTERSTITIAL THERMAL THERAPY (LITT) FOR BIOPSY-PROVEN RADIATION NECROSIS IN RADIOGRAPHICALLY RECURRENT BRAIN METASTASES

Abstract BACKGROUND Evidence is growing for the efficacy of laser interstitial thermal therapy (LITT) for radiation necrosis (RN) following stereotactic radiosurgery (SRS) for patients with brain metastases. Questions remain regarding local control, symptom control, and concurrent use of therapies. METHODS Demographics, intraprocedural data, safety, Karnofsky performance status (KPS) and survival data were prospectively collected from the LAANTERN multi-center registry (NCT02392078) then analyzed on patients consented between 2016-2020 and who were undergoing LITT for biopsy-proven RN at one of 14 U.S. centers. Data was monitored for accuracy. Statistical analysis included individual variable summaries, multivariable Fine and Gray analysis, and Kaplan Meier estimated survival. RESULTS Ninety patients met inclusion criteria. Median hospitalization time was 32.5hrs. Median time to corticosteroid cessation after LITT was 13 days (range 0 - 1229) and cumulative incidence of lesional progression was 19% at 1-year. Median post-procedure overall-survival was 2.6 years [1.7, NR] and 77% at one year as estimated by Kaplan Meier. Median KPS remained 80 through 2-year follow-up. Seizure prevalence improved from 34.4% pre-procedure to 12% 1-month post-LITT and 7.9% at 3-months. There was no significant difference in risk of radiographic progression in total and near-total ablations (91% or greater ablative coverage) versus sub-total ablations (&amp;lt; 90%). Lesion size was not a significant predictor of future radiographic progression. CONCLUSIONS LITT is an effective, minimally invasive, safe treatment for RN, in terms of both local control and symptom management. LITT is effective in the management of lesion-related seizures in addition to averting expected neurological death. LITT facilitates ongoing systemic therapy (particularly immunotherapy) by enabling the rapid cessation of corticosteroids. Effective management options for RN could facilitate the more aggressive use of combined systemic and radiotherapeutic treatment options for brain metastases patients in order to avoid failure due to tumor recurrence and extend survival.

Case Series: Recurrence of Cardiac Sarcoidosis After Orthotopic Heart Transplantation

Orthotopic heart transplantation for cardiac sarcoidosis (CS) is becoming increasingly common. Historically, there have been concerns regarding disease recurrence within the allograft. Although rarely reported in the literature, cases of recurrent CS tend to be observed in patients after dose reduction of immunosuppressive therapy and cessation of corticosteroids. Here, we present 2 cases of recurrent CS after orthotopic heart transplantation, confirmed on endomyocardial biopsy. Case 1 reports a 50-year-old man with a fulminant course of giant cell myocarditis who developed allograft recurrence with granulomas 5 years after transplantation despite maintenance corticosteroid therapy. Case 2 reports a 47-year-old man with CS who developed recurrence with the presence of giant cells 2 years after transplantation, with a benign clinical course. With these cases, we demonstrate the clinical overlap between CS and giant cell myocarditis and highlight the spectrum of the disease process. We also demonstrate that CS can recur despite corticosteroid maintenance therapy.

Episod maniacal indus prin corticoterapie postalblaţie de meningiom spinal. Rolul realităţii virtuale în psihoterapia anxietăţii postoperatorii

Corticosteroids have been linked to various neuropsychiatric adverse effects, including mood disorders. This case study describes a post-surgical manic episode (spinal meningioma ablation D11-D12) in a 57-year-old female patient on corticosteroids. This presentation aims to highlight corticosteroids’ potential psychiatric adverse effects and to emphasize the importance of recognizing and treating such complications. In this case, the management strategy involved discontinuing corticosteroids, initiating mood-stabilizing medications, and closely monitoring the symptoms. A mood stabilizer and a second-generation antipsychotic were administered to the patient to treat transient manic symptoms and prevent relapse. After discontinuing corticosteroids and beginning therapy with mood stabilizers, the patient’s bipolar symptoms improved. Psychoeducation and therapeutic support were provided to aid the patient in managing acute symptoms and encourage adherence to the treatment plan. As anxiety persisted after manic symptoms were controlled, the case management involved a psychotherapy technique facilitated by virtual reality. Relaxation breathing techniques were emulated through a virtual reality Oculus Quest 2 headset, improving patient-physician trust, subjectively relieving correlated anxiety, and ensuring therapeutic compliance during the admission and at home. Healthcare professionals must be vigilant to identify and effectively treat these complications of steroid anti-inflammatory medication. Immediate cessation of corticosteroids, the initiation of mood stabilizers and psychoeducation are essential for managing these cases. By presenting this case report, we hope to increase healthcare professionals’ awareness on the psychiatric consequences of corticosteroid use, the necessity of a multidisciplinary therapeutic approach, and the role of add-on virtual reality as integrated, personalized patient care to alleviate anxiety.

Efficacy of laser interstitial thermal therapy for biopsy-proven radiation necrosis in radiographically recurrent brain metastases.

Laser interstitial thermal therapy (LITT) in the setting of post-SRS radiation necrosis (RN) for patients with brain metastases has growing evidence for efficacy. However, questions remain regarding hospitalization, local control, symptom control, and concurrent use of therapies. Demographics, intraprocedural data, safety, Karnofsky performance status (KPS), and survival data were prospectively collected and then analyzed on patients who consented between 2016-2020 and who were undergoing LITT for biopsy-proven RN at one of 14 US centers. Data were monitored for accuracy. Statistical analysis included individual variable summaries, multivariable Fine and Gray analysis, and Kaplan-Meier estimated survival. Ninety patients met the inclusion criteria. Four patients underwent 2 ablations on the same day. Median hospitalization time was 32.5 hours. The median time to corticosteroid cessation after LITT was 13.0 days (0.0, 1229.0) and cumulative incidence of lesional progression was 19% at 1 year. Median post-procedure overall survival was 2.55 years [1.66, infinity] and 77.1% at one year as estimated by KaplanMeier. Median KPS remained at 80 through 2-year follow-up. Seizure prevalence was 12% within 1-month post-LITT and 7.9% at 3 months; down from 34.4% within 60-day prior to procedure. LITT for RN was not only again found to be safe with low patient morbidity but was also a highly effective treatment for RN for both local control and symptom management (including seizures). In addition to averting expected neurological death, LITT facilitates ongoing systemic therapy (in particular immunotherapy) by enabling the rapid cessation of steroids, thereby facilitating maximal possible survival for these patients.

Clinical features of COVID-19 patients with rebound phenomenon after corticosteroid therapy

RationalCorticosteroid therapy plays a key role in the treatment of COVID-19 patients with respiratory failure. However, a rebound phenomenon after steroid cessation rarely occurs. Here, we investigated the clinical features...

Bortezomib for the Management of Relapsed or Refractory Warm Autoimmune Hemolytic Anemia: A Scoping Review

Background:Auto-immune hemolytic anemia (AIHA) may be complicated with a relapsed or refractory course and may lead to life-threatening complications. The management of severe cases refractory to multiple lines of therapy is challenging, and data on the use of subsequent therapeutic agents remains scarce. Plasma cells have been postulated as potential therapeutic targets due to their role in auto-antibody production. Studies on plasma-cell directed therapies, such as bortezomib (BTZ), for the management of AIHA are lacking, and clinical trials remain ongoing.Objectives:To perform a scoping review on existing literature on the use of BTZ in the management of warm AIHA (wAIHA) and its outcomes, and to report an additional case of successful use of BTZ at our institution.Methods:We performed an extensive literature search using MEDLINE (Ovid), Embase, Scopus, and PubMed on all existing reports on BTZ use in wAIHA. Patients with hematopoietic cell transplant-associated AIHA were excluded.We defined complete response (CR) as a hemoglobin (Hb) > 10 g/dL, Hb increase of > 2 g/dL, and a complete cessation of corticosteroids (CS) or other immunosuppression (IS). We defined partial response (PR) as a Hb rise > 2 g/dL, with stable or decreased long-term IS requirements. Onset of response was defined as the time in days after first BTZ dose when a Hb increase of > 2 g/dL was first noted. Duration of response was defined as the time from response onset until relapse or cessation of follow-up. We applied our definitions uniformly across the original data (whenever reported) in the included studies. BTZ used as monotherapy or in addition to prior long-term IS was labeled “single-agent”, and BTZ combined with rituximab (RTX) or cyclophosphamide (CTX) was labeled “combination regimen”.Case Description:A 25-year-old male with Evans syndrome and prior therapy with CS, intravenous immunoglobulin (IVIG), splenectomy, cyclosporine, RTX and vincristine presented with severe thrombocytopenia and recurrent wAIHA. Despite receiving high-dose CS, IVIG, mycophenolate mofetil, RTX, CTX, and danazol, his AIHA persisted severely, while platelets normalized with romiplostim. He was then treated with BTZ 1.3 g/m2 (days 1, 4, 8, 11 every three weeks x 6 cycles) and his Hb improved from 5.8 g/dL to 14.4 g/dL currently, with an onset of response within 19 days and sustained response of 6 months until today. However, he continues to require maintenance BTZ and prednisone.Results:We identified 10 case series/reports (n=29, our patient included) in which BTZ was used to treat wAIHA, with a total of 32 evaluable incidents of BTZ use .The median number of prior therapies was 5 (range: 1-8). BTZ was used in variable regimens and induction durations (Table 1), including single-agent BTZ (n=14), combination regimen (n=16), shorter induction (<30 days) (n=13), and longer induction courses (n=13). 37.5% of responding patients required additional maintenance BTZ.Response rates (Figure 1a):Overall response rate (ORR) of cohort = 78%, CR = 43.8%, PR = 34.4%CR with single-agent BTZ = 20%, combination regimen = 64.7%Median onset of response (Figure 1b):Overall cohort: 21 days [IQR: 13-35]Single-agent BTZ: 21 days [IQR: 19-47]Combination-regimen BTZ: 15 days [IQR: 7-21]Duration of response (Figure 1c):Overall cohort: 150 days [IQR: 120-426]Single-agent BTZ: 272 days [IQR: 129-565]*, Combination-regimen: 150 days [IQR: 90-280]*Short induction: 135 [IQR: 90-228], ongoing response at time of publication = 54%Long induction: 365 [IQR: 132-555], ongoing response = 91%*83% of single-agent arm received longer induction, vs 20% of combination group, potentially confounding results. Controlling for induction duration was not possible due to small numbers.Safety:No serious side effects were reported in our cohort. There were 2 deaths unrelated to BTZ.Conclusion:Limited data suggest that BTZ may be used as a subsequent therapy to treat relapsed or refractory wAIHA, and may offer complete or partial response in cases refractory to multiple therapeutic lines. BTZ combined with RTX or CTX seemed to offer higher rates of CR as well as faster onset of response in comparison to single-agent BTZ. The median time to onset of response was 2 to 3 weeks, and the median response duration was five months. Longer induction (>30 days) was associated with longer durations of response. Our study is limited by publication bias, study heterogeneity, and small numbers. [Display omitted] DisclosuresShah: AstraZeneca: Research Funding; Seattle Genetics: Research Funding; Epizyme: Research Funding. OffLabel Disclosure:bortezomib for autoimmune hemolytic anemia

CYP3A-status is associated with blood concentration and dose-requirement of tacrolimus in heart transplant recipients

High inter-individual variability in tacrolimus clearance is attributed to genetic polymorphisms of CYP3A enzymes. However, due to CYP3A phenoconversion induced by non-genetic factors, continuous changes in tacrolimus-metabolizing capacity entail frequent dose-refinement for optimal immunosuppression. In heart transplant recipients, the contribution of patients’ CYP3A-status (CYP3A5 genotype and CYP3A4 expression) to tacrolimus blood concentration and dose-requirement was evaluated in the early and late post-operative period. In low CYP3A4 expressers carrying CYP3A5*3/*3, the dose-corrected tacrolimus level was significantly higher than in normal CYP3A4 expressers or in those with CYP3A5*1. Modification of the initial tacrolimus dose was required for all patients: dose reduction by 20% for low CYP3A4 expressers, a 40% increase for normal expressers and a 2.4-fold increase for CYP3A5*1 carriers. The perioperative high-dose corticosteroid therapy was assumed to ameliorate the low initial tacrolimus-metabolizing capacity during the first month. The fluctuation of CYP3A4 expression and tacrolimus blood concentration (C0/D) was found to be associated with tapering and cessation of corticosteroid in CYP3A5 non-expressers, but not in those carrying CYP3A5*1. Although monitoring of tacrolimus blood concentration cannot be omitted, assaying recipients’ CYP3A-status can guide optimization of the initial tacrolimus dose, and can facilitate personalized tacrolimus therapy during steroid withdrawal in the late post-operative period.

A novel technique of full-thickness scleral debridement in fulminant necrotising infectious scleritis and its outcomes-a consecutive case series.

To report the outcomes of a novel technique of scleral debridement in five consecutive cases of relentlessly progressive and fulminant infectious scleritis following corticosteroid exposure. Five consecutive patients of infectious scleritis with a common history of corticosteroids exposure, resulting from either an initial misdiagnosis of autoimmune scleritis or as anti-inflammatory adjunct to specific antimicrobial therapy. Data collection included presentation details such as photographs, clinical findings, microbiological analysis, treatment details and audit of surgical videos. Cases with undisputed diagnosis of infectious scleritis with microbiological evidence, without corticosteroid use, were excluded from thestudy. After full-thickness scleral debridement and cessation of corticosteroids, favourable anatomical and visual outcome was observed in all cases; however, two patients required multiple scleral debridements due to progressive scleritis. Scleral patch graft was not used in any case. Microbiology detected infective organisms in two cases, while the remaining revealed negative results. Therefore, specific antimicrobial therapy was initiated in former, whereas empirical broad-spectrum regimen in patients with repeatedly negative microbiologicalresults. No recurrence of scleritis or development of ciliary staphyloma was noted and anatomical integrity was maintained with normal intraocular pressure during follow-up. This study highlights the fulminant and relentlessly progressive clinical course, that infectious scleritis can metamorphose into, despite specific antimicrobial therapy, if inadvertent corticosteroid therapy is administered. Full-thickness debridement without scleral patch graft, could achieve elimination of infectious foci, with favourable long-term anatomical and visual outcome. This technique could offer a potential last-resort approach in such cases where standard therapeutic modalities have not been successful.

Liver Transplantation and Development of Diabetes in an Adolescent Male With HNF1B Disease

Mutations in the hepatocyte nuclear factor-1-beta (HNF1B) gene cause a variety of diseases in different organ systems. Mutations have been described as causing neonatal cholestasis, maturity-onset diabetes of the young (type 5), cortical renal cysts, urogenital abnormalities, liver dysfunction, and atrophy of the pancreas. We describe a male patient who presented with cholestatic liver disease in infancy which progressed by age 14 to end-stage liver disease due to HNF1B disease. He subsequently underwent liver transplantation at age 15 and then developed diabetes requiring insulin which did not resolve after cessation of corticosteroids. To our knowledge, this is the first case reported of liver transplantation for decompensated cirrhosis secondary to HNF1B disease.

OP30 Lyophilised orally administered faecal microbiota transplantation for Active Ulcerative Colitis (LOTUS study)

BackgroundFaecal microbiota transplantation (FMT) administered via the lower GI tract effectively induces remission in ulcerative colitis (UC). Orally administered FMT capsules may improve patient tolerability and facilitate maintenance therapy while it is unclear if pre-FMT antibiotics enhance therapeutic efficacy.MethodsWe performed a dual-centre randomised, double blind, placebo-controlled trial of oral lyophilised FMT in adults with mild-moderately active UC (total Mayo 4–10). All subjects received 2-weeks of pre-FMT antibiotics (amoxycillin, metronidazole and doxycycline) before 1:1 randomisation to either oral FMT (0.35g stool content per capsule from 1 of 2 healthy donors) or identical placebo for 8 weeks. Enforced tapering and cessation of corticosteroids was mandated. The primary endpoint was week 8 steroid-free clinical remission with endoscopic remission or response (total Mayo score ≤2 with subscores ≤ 1 for rectal bleeding, stool frequency and endoscopic appearance, and ≥1-point reduction from baseline in endoscopy subscore). Responders to FMT induction were re-randomised to either continue maintenance FMT or withdrawal of FMT with final outcomes assessed at week 56.ResultsRecruitment was paused due to the COVID-19 pandemic. 37 patients were randomised. Baseline patient and disease characteristics were balanced between the randomised groups. The primary outcome was achieved in 8/16 (50%) receiving FMT versus 3/19 (16%) receiving placebo (OR: 4.63; 95%CI: 1.74–12.30; P=0.002). Steroid-free clinical remission rates and endoscopic remission rates were 69% vs 26% (P=0.012) and 44% vs 16% (P=0.074) in the FMT and placebo arms, respectively. Reported SAE were worsening colitis (2 FMT, 1 placebo) and PR bleeding relating to previous anal surgery (placebo). Ten patients entered the maintenance withdrawal study. Steroid-free clinical, endoscopic and histologic remission was achieved in 4/4 patients who continued daily oral FMT, with all 6 patients randomised to FMT withdrawal having a flare of disease with a median time to relapse of 6 months.ConclusionOral lyophilised FMT following antibiotic pre-treatment for mild-moderately active ulcerative colitis was associated with a significant increased rate of clinical remission with endoscopic remission or response versus antibiotic treatment alone at week 8. Pre-treatment antibiotics had an additive impact upon treatment efficacy compared with previous studies utilising FMT. Maintenance FMT therapy was associated with sustained clinical, endoscopic and histologic remission at week 56. Treatment was well tolerated and there were no new safety signals related to FMT therapy.

Avascular Necrosis of Bone in Patients with Uveitis Treated with Systemic Corticosteroids

ABSTRACT Purpose: To identify the prevalence, risk factors and outcomes of avascular necrosis (AVN) in patients with chronic uveitis. Methods: A retrospective study of patients with corticosteroid-induced AVN treated at Manchester Uveitis Clinic between 1991 and 2019. Results: From a cohort of 4478 patients, 1698 had been treated with systemic corticosteroids. Five patients with AVN were identified (prevalence 0.29%). The mean age at diagnosis of AVN was 49 years. All 5 patients were using systemic immunosuppression. Four patients developed femoral head AVN in 7 joints, one had bilateral knee osteonecrosis. The mean duration of corticosteroid before AVN was 38 months; the mean dose at onset was 17mg/day and the mean cumulative dose was 18,860mg. Three patients required total hip replacements but management was conservative for others. There was no permanent disability. Conclusions: AVN is a rare but severe complication of corticosteroid therapy. Clinicians should be vigilant for symptoms of bone pain as early detection and cessation of corticosteroids can reverse incipient AVN and avoid surgery.

Early Corticosteroid Cessation vs Long-term Corticosteroid Therapy in Kidney Transplant Recipients

The complications of corticosteroids make the inclusion of these drugs in immunosuppressive protocols for kidney transplant patients undesirable. However, cessation of corticosteroids is associated with a higher risk of short-term rejection, and the long-term outcomes of patients withdrawn from corticosteroids remain uncertain. To compare long-term kidney transplant outcomes of patients randomized to continue or withdraw corticosteroids. This prospective multicenter randomized double-blind placebo-controlled trial was conducted between November 1999 and December 2002 with linkage to a mandatory national registry with validated outcome ascertainment until June 8, 2018. The study included 28 kidney transplant centers in the United States, including 386 low- to moderate-immune risk adult recipients of a living or deceased donor kidney transplant without delayed graft function or short-term rejection in the first week after transplant. Analyses were intention to treat. Analysis began September 2018 and ended June 2019. Patients were randomized to receive tacrolimus and mycophenolate mofetil with or without corticosteroids 7 days after transplant. Kidney allograft failure from any cause including death and allograft failure censored for patient death defined by the requirement for long-term dialysis or repeat transplant. Of 385 patients, 191 were assigned to withdraw from corticosteroids (mean [SD] age, 46.5 [12.1] years), and 194 patients were assigned to continued corticosteroids (mean [SD] age, 46.3 [12.6] years). The median (interquartile range) follow-up time was 15.8 (12.0-16.3) years after transplant. The adjusted hazard ratios of allograft failure from any cause including death was 0.83 (95% CI, 0.62-1.10; P = .19) and for allograft failure censored for patient death was 0.78 (95% CI, 0.52-1.19; P = .25) and did not differ between the patients assigned to withdraw from corticosteroids vs assigned to continued corticosteroids. Results were consistent in a per-protocol analysis among 223 patients who continued the trial-assigned treatment of corticosteroid withdrawal (n = 114) or corticosteroids (n = 109) through at least 5 years after transplant. The outcomes of trial participants in either treatment group did not differ from similarly treated contemporary registry patients who met trial eligibility criteria and were treated with the same immunosuppressive drugs. Long-term corticosteroids may not be necessary as part of a calcineurin-based multiple drug immunosuppressive regimen in low- to moderate-immune risk kidney transplant recipients.

The role of adjuvant systemic steroids in the management of periorbital cellulitis secondary to sinusitis: a systematic review and meta-analysis.

The role of adjuvant systemic corticosteroids in the management of periorbital cellulitis and subperiosteal/orbital abscesses secondary to sinonasal infections is not well understood. Our objective was to systematically review the current evidence on the efficacy and side effects of systemic steroids when used in the management of periorbital cellulitis. A systematic review of literature was conducted in accordance with PRISMA guidance. A systematic search of MEDLINE, Embase and Cochrane databases, MetaRegister and ISI conference proceedings was conducted. The outcomes of interest were duration of inpatient stay, requirement for surgical intervention, adverse effects and recurrent/residual symptoms. Four studies were identified involving 118 patients. Of these, 78 underwent treatment with systemic corticosteroids and 40 were controls. Meta-analysis demonstrated that the mean duration of inpatient stay was significantly shorter in the steroid group (WMD -2.90days; 95% CI -3.07, -2.73; p < 0.00001). There were no significant differences in requirement for surgical intervention (RR 0.93; 95% CI 0.50, 1.75; p = 0.83). Side effects were reported in 6/78 patients (7.7%), with 5 patients showing signs of hyperactivity and 1 patient with insomnia. These were mild except in one case, which required early cessation of corticosteroids. There was one case of recurrence of symptoms in each cohort (steroid vs. non-steroid) following discharge. The evidence suggests that systemic corticosteroids may offer some benefit in the management of periorbital cellulitis secondary to sinonasal infections. However, there is significant heterogeneity and risk of bias. A well-designed randomised controlled trial may provide a better insight into the efficacy of systemic steroids for this condition.

Severe pemphigus vulgaris requiring multiple rituximab infusions – A case report

Rituximab has demonstrated efficacy in pemphigus vulgaris (PV) but a significant number of patients eventually relapse requiring further treatment. We present the case of a 39-year-old male who originally presented to us in 2013 with a 3-year history of severe generalised mucocutaneous PV, refractory to first line treatment with oral prednisolone and mycophenolate. Immunosuppression was escalated to rituximab (1 g weekly × 2) leading to disease remission and cessation of corticosteroids. Between 2013 and 2018, he experienced multiple relapses at regular intervals, requiring seven further rituximab infusions. Each of the first six infusions was able to induce remission without additional immunosuppression but relapse inevitably occurred after B-cell return in the peripheral blood. Interestingly, his desmoglein (dsg) antibody levels, which were initially significantly elevated, steadily declined with each rituximab infusion. After completing the 7th infusion in April 2018, he was able to remain in remission despite B-cell return. This corresponded to normalisation of his dsg antibodies. We hypothesise that repeated treatment with rituximab has eradicated the ‘clone’ of pathogenic autoantibody-producing B cells, leading to sustained remission.

Permanent immunosuppression in SLA/LP-positive autoimmune hepatitis is required although overall response and survival are similar.

Antibodies against soluble liver antigen/liver pancreas (anti-SLA/LP) are highly specific for autoimmune hepatitis (AIH) and have been linked with a more severe clinical course of the disease, frequent relapses after treatment withdrawal and worse outcome. To address definitely the clinical significance of anti-SLA/LP, we investigated a large number of anti-SLA/LP-positive and -negative patients followed in three referral centres. Prospectively collected data from 89 anti-SLA/LP-positive AIH patients (29 from Hamburg-Germany, 20 from Bologna-Italy and 40 from Larissa-Greece) were analysed retrospectively. Age- and sex-matched anti-SLA/LP-negative patients served as disease controls (n=230; 1:2.5 ratio). In respect to baseline characteristics, anti-SLA/LP-positive patients were more frequently asymptomatic compared to anti-SLA/LP-negative (P<.05). However, anti-SLA/LP-positive patients did not differ from anti-SLA/LP-negative in terms of the overall response to treatment, disease progression and survival even though, they were less likely to achieve corticosteroid withdrawal (P<.05), needed longer treatment duration to achieve first complete response (P<.001) and relapsed more frequently after treatment withdrawal compared to anti-SLA/LP-negative patients (P=<.001). We showed that anti-SLA/LP antibodies do not characterize a group of AIH patients with distinct features and cannot identify patients with a more severe form of the disease or worse survival. Most importantly, however, anti-SLA/LP-positive patients appear to require lifelong immunosuppression as they are less likely to achieve the cessation of corticosteroids and present higher relapse rates after treatment withdrawal. Therefore, close long-term monitoring should be advised in all anti-SLA/LP-positive patients after withdrawal of immunosuppressive treatment.

Early postoperative intraocular pressure elevation following cataract surgery.

The aim of this review was to assess the risk factors and course of postoperative intraocular pressure (IOP) increase in order to determine the optimal the treatment. Early postoperative IOP elevation following cataract surgery is a frequent adverse event, and might represent 88% early postoperative complications. The risk factors for IOP elevation following phacoemulsification cataract surgery include residual viscoelastic material, resident performed surgery, glaucoma, pseudoexfoliation syndrome, axial length over 25 mm, tamsulosin intake, topical steroid application in steroid responders. A day-1 postoperative follow-up might be questioned, even in glaucoma patients, as in IOP spikes the topmost IOP elevation occurs 3-4 h postoperatively. Several IOP-lowering agents have been evaluated, but none has completely prevented the occurrence of IOP spikes. We recommend applying a combination of dorzolamide/timolol and brinzolamide topically in high-risk patients, particularly with preexisting optic nerve damage. Corticosteroid cessation usually results in a reduction of the IOP to normal levels in steroid responders. Additional studies are required to assess the optimal treatment, especially in glaucoma patients.

Diagnosed a Patient with Central Serous Chorioretinopathy? Now What?: Management of Central Serous Chorioretinopathy.

The goal of this paper is to provide a comprehensive review of the management options for central serous chorioretinopathy (CSCR). The majority of cases of acute CSCR may be managed with observation and cessation of corticosteroids, if possible, as well as life-style modifications including stress reduction and control of hypertension. The management of chronic disease is more challenging and may include either medication or laser-based treatment. Management of CSCR necessitates an individualized and selective treatment approach. There is overall poor evidence for the use of systemic and intravitreal medications. From this class of treatments, mineralocorticoid receptor antagonists appear to have the greatest potential. Although conventional thermal photocoagulation may be used in select cases, the most promising treatment options at this time for chronic CSCR are photodynamic therapy, either half-dose or half-fluence, and non-damaging (subthreshold) retinal laser therapy.