Epsom Hospital,Epsom and St Helier University Hospitals NHS Trust

Glaucoma is a common condition that damages the optic nerve, usually as a result of an increase in intraocular pressure (IOP). It can be divided into two types: open-angle glaucoma (OAG) and acute angle-closure glaucoma (AACG). OAG is believed to occur due to dysfunction in aqueous outflow through the trabecular meshwork (TM) of the eye as it flows from the posterior to the anterior chamber. AACG manifests when a bulging iris blocks the iridocorneal angle, commonly caused by pupillary block due to pupil dilation, leading to fluid buildup and increased IOP, potentially resulting in complete vision loss. As a result of an aging population, chronic conditions are increasing in number, necessitating the use of systemic medications to treat them. However, many of these medications may affect the eye, predisposing it to different ocular morbidities. This narrative review will examine the effects of these medications on glaucoma development, specifically focusing on the effects of corticosteroids on OAG through increased aqueous humor resistance in the TM and the effects of sulfonamides, anticholinergics, antidepressants, cholinergics, anticoagulants, and certain supplements on AACG as a result of their sympathomimetic properties and the disruption of the lens-iris structure.

BACKGROUND:The objectives were to evaluate whether the EQ-5D-3L questionnaire demonstrated a ceiling effect after total hip arthroplasty (THA), identify which patients were more likely to reach the ceiling score, and determine whether this limited assessment of potential improvement, relative to baseline, in their outcomes. METHODS:A cohort of 7,871 primary THAs was identified from an institutional arthroplasty database. Patient demographics, American Society of Anesthesiologists grade, socioeconomic status, Oxford Hip Score (OHS), and EQ-5D-3L were prospectively collected preoperatively and one and two years postoperatively. Regression analyses were performed to determine which preoperative factors were independently associated with achieving a ceiling score. RESULTS:The median preoperative EQ-5D-3L was 0.516, improving significantly at one year to 0.850 (P < 0.001), with nonsignificant change at two years (median, 0.883; P = 0.075). A ceiling effect was observed in 47.5% (n = 2,961) at one year, increasing to 48.6% (n = 2,853) at two years. Women, younger age, lower socioeconomic deprivation, and higher preoperative OHS, EQ-5D, and EQ-VAS were independent predictors of achieving a ceiling EQ-5D. Receiver operating characteristic curve analyses indicated that a preoperative EQ-5D score (≥ 0.534) predicted postoperative ceiling scores at one and two years (area under the receiver operating characteristic curve, 65.6 and 64.1%, respectively; P < 0.001). Patients who reached the postoperative EQ-5D ceiling had significant improvements in OHS, EQ-5D, and EQ-VAS and were more likely to achieve minimal important change and a patient-acceptable symptom state compared with those below the ceiling. CONCLUSIONS:The EQ-5D showed moderate ceiling effects at one and two years following THA, with higher preoperative scores being associated with ceiling attainment. Patients who reached the ceiling experienced greater improvements from baseline and were more likely to achieve clinically meaningful outcomes.

Abstract Pulmonary Alveolar Proteinosis (PAP) is rare lung condition characterized by alveolar filling with macrophages due to abnormal accumulation of surfactant in the alveolar space. Classical radiologic findings include ground-glass opacities and interlobular septal thickening. This is a case of a 44-year old gentleman with a 30-pack year smoking history who presented to his local hospital with persistent cough and worsening shortness of breath. He had pulmonary tuberculosis in 2022 but otherwise had an unremarkable medical history. He previously worked as a stone mason for 19 years. CT imaging revealed ground glass opacities and diffuse cysts and he was initially managed as a case of smoking-related ILD with oral and intravenous steroids. A bronchioalveolar (BAL) fluid culture had heavy growth of S pneumoniae and K oxytoca and he was commenced on IV antibiotics and antifungals on suspicion of an atypical chest infection. Autoimmune screen was negative. The patient however continued to deteriorate and was put on high flow nasal oxygen due to increasing oxygen requirements; in parallel, a repeat CT scan showed worsening ground glass change and cystic disease. The patient was referred to our institution and discussed in our ILD multidisciplinary team meeting. A serial review of his scans showed progressive changes suspicious for mucinous adenocarcinoma. A CT-guided biopsy was done and histology showed alveolar spaces filled with granular material which stained strongly for periodic acid-Schiff (PAS). The patient underwent a whole lung lavage with subsequent clinical improvement. Supplemental oxygen requirement decreased to 2 liters/min. Serological testing for Granulocyte-Macrophage Colony Stimulation Factor (GM-CSF) autoantibodies was done and later returned positive. A genetic screen was also done due to the unusual radiological presentation. The patient was discharged on ambulatory oxygen with a clinic follow up for definitive treatment with inhaled GM-CSF. The presence of diffuse ground-glass opacities without the classic crazy-paving pattern, accompanied by cystic changes in histologically-confirmed pulmonary alveolar proteinosis (PAP), is exceedingly rare in literature. This finding emphasizes the need to consider PAP in the differential diagnosis, even when imaging features overlap with other conditions. Anti-GM-CSF antibodies demonstrate 100% sensitivity and specificity for autoimmune PAP in the appropriate clinical context. Although biopsy is typically unnecessary in classic PAP cases, this should be considered when the diagnosis is uncertain. Furthermore, the patient’s marked improvement following therapeutic whole-lung lavage highlights the effectiveness of this treatment, even in atypical presentations of the disease. This abstract is funded by: None

Hypertension is the most common modifiable risk factor for stroke. However, whether different classes of antihypertensive drugs provide equal protection against stroke remains controversial. This review aimed to systematically compare the effects of various antihypertensive drug classes on stroke prevention through a contemporary meta-analysis of randomized controlled trials (RCTs). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search was conducted in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus for studies published since January 2000. Eligible RCTs compared angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), or diuretics with another drug class or placebo and reported stroke incidence. Data were pooled using a random-effects model. Subgroup analyses were performed based on prevention type, baseline risk, and differences in achieved blood pressure. A total of 10 RCTs (N=180,342 participants) were included. The pooled meta-analysis showed no statistically significant difference in stroke risk among the drug classes (risk ratio (RR): 0.94; 95% confidence interval (CI): 0.83-1.05), although heterogeneity was substantial (I²=65%). Subgroup analyses revealed no effect modification by prevention type or baseline risk. However, studies with a moderate to significant between-group difference in systolic blood pressure (SBP) (>2 mmHg) demonstrated a substantial reduction in stroke risk (RR: 0.78; 95% CI: 0.71-0.85), whereas studies with a minimal difference (<2 mmHg) did not (RR: 1.02: 95% CI: 0.90-1.14; p for subgroup difference=0.001). No antihypertensive drug class was found to be superior for stroke prevention overall. The magnitude of achieved SBP reduction, rather than the drug class itself, appears to be the primary determinant of benefit.

Age-related macular degeneration (AMD) is a progressive retinal condition characterised by degeneration of the macula, leading to central vision loss. Whilst the underlying mechanism of AMD is not fully understood, oxidative stress is believed to be the main driving force behind retinal damage. Although the prevalence of AMD increases with factors such as age, smoking, and sun exposure, these alone do not fully explain individual risk. Nutritional factors, in particular dietary antioxidant intake, have been shown to influence the progression of dry AMD by mitigating oxidative stress and supporting retinal cellular function. By considering the effects of nutrition on retinal health and disease outcomes, we can further our understanding of AMD pathogenesis.