Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4) Blocking Agents in the Treatment of Cancer

Neoplasms are able to spread by blocking the ability of the immune system to fight off the cancer.  Jim Allison, currently with MD Anderson, discovered how that process works.[1]



Ipilimumab

 Under ideal circumstances, cytotoxic T lymphocytes (CTLs) are able to recognize and destroy cancer cells. However, there is also an inhibitory mechanism that interrupts this destruction. Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4), is a protein receptor that downregulates CTLs. Ipilimumab, a CTLA-4 blocker, turns off this inhibitory mechanism and allows CTLs to continue to destroy cancer cells.  Another CTLA-4 blocker being researched is Tremelimumab.

CTLA-4 Blocking Agents in the Treatment of Cancer (PubMed)
    Clinical Trials (Pubmed)
    Systematic Reviews (Pubmed)
    Reviews (PubMed)
    Meta-Analysis (Pubmed)

Current Clinical Trials

Methicillin-sensitive and Methicillin-resistant S. aureus in Impetigo

Methicillin-sensitive  and Methicillin-resistant S. aureus in Impetigo (PubMed):

("Impetigo"[Mesh] OR impetigo) AND ("Methicillin-Resistant Staphylococcus aureus"[MeSH] OR Methicillin-Resistant OR Methicillin-Resistance OR "Methicillin Resistance"[MeSH]) AND (Methicillin-sensitive OR methicillin sensitivity OR methicillin susceptible OR methicillin susceptibility) Filters activated: Humans, English

Results
Reviews

Key article on trends in bacterial resistance:

Bacterial resistance and impetigo treatment trends: a review. (PDF)

Bangert S, Levy M, Hebert AA.

Pediatr Dermatol. 2012 May-Jun;29(3):243-8. Epub 2012 Feb 3. Review. PMID: 22299710

Cited by (Google Scholar)

Impetigo and the Metagenome:

1.

Compartmentalized control of skin immunity by resident commensals. (PDF)

Naik S, Bouladoux N, Wilhelm C, Molloy MJ, Salcedo R, Kastenmuller W, Deming C, Quinones M, Koo L, Conlan S, Spencer S, Hall JA, Dzutsev A, Kong H, Campbell DJ, Trinchieri G, Segre JA, Belkaid Y.

Science. 2012 Aug 31;337(6098):1115-9. Epub 2012 Jul 26. PMID: 22837383

2.

Host-pathogen interactions between the skin and Staphylococcus aureus.

Krishna S, Miller LS. Curr Opin Microbiol. 2012 Feb;15(1):28-35. Epub 2011 Dec 1. Review. PMID: 22137885

Impetigo and the Immune System:

1.

Innate and adaptive immune responses against Staphylococcus aureus skin infections.

Krishna S, Miller LS. Semin Immunopathol. 2012 Mar;34(2):261-80. Epub 2011 Nov 6. Review. PMID: 22057887 [PubMed - indexed for MEDLINE]

2.

Immunity against Staphylococcus aureus cutaneous infections.

Miller LS, Cho JS. Nat Rev Immunol. 2011 Jul 1;11(8):505-18. Review. PMID: 21720387

[PubMed - indexed for MEDLINE]

3.

Selective immunoglobulin M deficiency presenting with recurrent impetigo: a case report and review of the literature.

Belgemen T, Suskan E, Dogu F, Ikinciogullari A. Int Arch Allergy Immunol. 2009;149(3):283-8. Epub 2009 Feb 12. Review. PMID: 19218822

4.

The Staphylococcus aureus surface protein IsdA mediates resistance to innate defenses of human skin.

Clarke SR, Mohamed R, Bian L, Routh AF, Kokai-Kun JF, Mond JJ, Tarkowski A, Foster SJ. Cell Host Microbe. 2007 May 17;1(3):199-212. PMID: 18005699

5.

Staphylococcus aureus: a blemish on skin immunity.

Zinkernagel AS, Nizet V. Cell Host Microbe. 2007 May 17;1(3):161-2. PMID: 18005694

6.

Staphylococcus aureus virulence factors associated with infected skin lesions: influence on the local immune response.

Mertz PM, Cardenas TC, Snyder RV, Kinney MA, Davis SC, Plano LR. Arch Dermatol. 2007 Oct;143(10):1259-63. PMID: 17938339  

D-dimer Pretest Probability for Diagnosing Pulmonary Embolisms

Broad Pubmed Search

("Pulmonary Embolism/diagnosis"[MAJR] OR ("Pulmonary Embolism"[MAJR] AND ("Diagnosis, Differential"[MeSH] OR diagnosis OR diagnose OR diagnostic OR differential OR decision OR "Early Diagnosis"[MeSH]))) AND ("Fibrin Fibrinogen Degradation Products/analysis"[MAJR] OR D-dimer OR "fibrin fragment D" [Supplementary Concept]) AND ("Predictive Value of Tests"[MeSH] OR "Sensitivity and Specificity"[MeSH] OR "Probability"[MeSH] OR probability OR predict* OR sensitivity specificity OR pretest OR pre-test) AND ("Tomography, X-Ray Computed"[MAJR] OR CT[ti] OR computed-tomography OR CT-scan OR "Diagnostic Imaging"[MeSH] OR "Angiography, Digital Subtraction"[MeSH]) AND ("Tomography, X-Ray Computed"[MAJR] OR CT[ti] OR computed-tomography OR CT-scan OR "Diagnostic Imaging"[MeSH] OR "Angiography, Digital Subtraction"[MeSH]) Filters: English

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("Pulmonary Embolism/diagnosis"[MAJR] OR ("Pulmonary Embolism"[MAJR] AND ("Diagnosis, Differential"[MAJR] OR diagnosis[ti] OR diagnose[ti] OR diagnostic[ti] OR differential[ti] OR decision[ti] OR "Early Diagnosis"[MAJR]))) AND ("Fibrin Fibrinogen Degradation Products/analysis"[MAJR] OR D-dimer[ti] OR "fibrin fragment D" [Supplementary Concept]) AND ("Predictive Value of Tests"[MAJR] OR "Sensitivity and Specificity"[MAJR] OR "Probability"[MAJR] OR probability[ti] OR predict*[ti] OR sensitivity[ti] OR specificity[ti] OR pretest[ti] OR pre-test[ti]) AND ("Tomography, X-Ray Computed"[MAJR] OR CT[ti] OR computed-tomography[ti] OR "Diagnostic Imaging"[MeSH] OR "Angiography, Digital Subtraction"[MeSH]) Filters: English

Results

Results with inclusion of algorithm search terms

6 Articles of Possible Clinical Significance:
1.

ACR Appropriateness Criteria® acute chest pain--suspected pulmonary embolism

Bettmann MA, Baginski SG, White RD, Woodard PK, Abbara S, Atalay MK, Dorbala S, Haramati LB, Hendel RC, Martin ET 3rd, Ryan T, Steiner RM.

J Thorac Imaging. 2012 Mar;27(2):W28-31. doi: 10.1097/RTI.0b013e31823efeb6. Review. Erratum in: J Thorac Imaging. 2012 Jul;27(4):W86. Baginski, Scott G [added].

PMID: 22343403

2.
Current approach to the diagnosis of acute nonmassive pulmonary embolism.

Moores LK, King CS, Holley AB.

Chest. 2011 Aug;140(2):509-18.

PMID:

21813530

[PubMed - indexed for MEDLINE]

Related citations

3.

D-dimer assays--a help or hindrance in suspected pulmonary thromboembolism assessment?

Bayes HK, O'Dowd CA, Glassford NJ, McKay A, Davidson S.

J Postgrad Med. 2011 Apr-Jun;57(2):109-14.

PMID:

21654131

[PubMed - indexed for MEDLINE]

Free Article

Related citations

4.

Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism.

Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW; American College of Emergency Physicians.

Ann Emerg Med. 2011 Jun;57(6):628-652.e75.

PMID:

21621092

[PubMed - indexed for MEDLINE]

Related citations

5.

Does a clinical decision rule using D-dimer level improve the yield of pulmonary CT angiography?

Hoo GW, Wu CC, Vazirani S, Li Z, Barack BM.

AJR Am J Roentgenol. 2011 May;196(5):1059-64.

PMID:

21512071

[PubMed - indexed for MEDLINE]

Free Article

Related citations

6.

Effectiveness and acceptability of a computerized decision support system using modified Wells criteria for evaluation of suspected pulmonary embolism.
Drescher FS, Chandrika S, Weir ID, Weintraub JT, Berman L, Lee R, Van Buskirk PD, Wang Y, Adewunmi A, Fine JM.

Ann Emerg Med. 2011 Jun;57(6):613-21. Epub 2010 Nov 2.

PMID:

21050624

[PubMed - indexed for MEDLINE]

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Outpatient Anticoagulation Therapy for Pulmonary Embolism

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("Home Infusion Therapy"[MAJR] OR "Ambulatory Care"[MAJR] OR "Outpatients"[MAJR] OR outpatient[ti] OR outpatients[ti] OR out-patient[ti] OR out-patients[ti]) AND ("Pulmonary Embolism/drug therapy"[MAJR] OR "Pulmonary Embolism/prevention and control"[MAJR] OR "Pulmonary Embolism/therapy"[MAJR])

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National Guideline Clearinghouse

Effects of Altitude on Embolic Events

Broad PubMed Search

("Mountaineering"[Mesh] OR "Altitude Sickness"[Mesh] OR "Altitude"[Mesh] OR altitude OR mountain OR mountains OR altitudes) AND ("Embolism and Thrombosis"[Mesh] OR "Embolism"[Mesh] OR "Thromboembolism"[Mesh] OR "Pulmonary Embolism"[Mesh] OR "Thrombosis"[Mesh] OR embolism OR thrombosis OR Thromboembolism)

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("Mountaineering"[MAJR] OR "Altitude Sickness"[MAJR] OR "Altitude"[MAJR]) AND ("Embolism and Thrombosis"[MAJR] OR "Embolism"[MAJR] OR "Thromboembolism"[MAJR] OR "Pulmonary Embolism"[MAJR] OR "Thrombosis"[MAJR])

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Review articles

PubMed Articles Not Yet Indexed and Placed in Medline

("Mountaineering"[Mesh] OR "Altitude Sickness"[Mesh] OR "Altitude"[Mesh] OR altitude OR mountain OR mountains OR altitudes) AND ("Embolism and Thrombosis"[Mesh] OR "Embolism"[Mesh] OR "Thromboembolism"[Mesh] OR "Pulmonary Embolism"[Mesh] OR "Thrombosis"[Mesh] OR embolism OR thrombosis OR Thromboembolism) NOT medline[sb]

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Military Related Articles (PubMed)

("Mountaineering"[Mesh] OR "Altitude Sickness"[Mesh] OR "Altitude"[Mesh] OR altitude OR mountain OR mountains OR altitudes) AND ("Embolism and Thrombosis"[Mesh] OR "Embolism"[Mesh] OR "Thromboembolism"[Mesh] OR "Pulmonary Embolism"[Mesh] OR "Thrombosis"[Mesh] OR embolism OR thrombosis OR Thromboembolism) AND ("Military Medicine"[Mesh] OR "Hospitals, Military"[Mesh] OR "Military Personnel"[Mesh] OR Armed-Forces OR Army OR Coast Guard OR navy OR naval OR submarine* OR army OR sailor* OR soldier* OR Air-Force OR Marines OR military OR ships OR cadet OR midshipman OR troops)

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DTIC Search (requires registration with .mil email address)

(key:(ALTITUDE SICKNESS) OR key:(HIGH ALTITUDE) OR key(mountains) OR key:(mountain sickness) OR : "high altitude") AND (key:(PULMONARY EMBOLISM) OR (key:(Embolism) AND (key:(lung) OR key:(pulmonary))) OR key:(THROMBOEMBOLISM) OR (key:(Embolism) AND key:(thrombus)) OR "pulmonary embolism")

Results: 67

Top 5 DTIC titles sorted by relevence listed below:

1. Cardiovascular responses to high altitude 07-Nov-1969 

2. Medical Aspects of Harsh Environments. Volume 2 2002

3. Notes on high elevation research with selected bibliography 1965

4. Women at Altitude: Effects of Menstrual Cycle Phase and Alpha-Adrenergic Blockade on High Altitude Acclimatization 1996

5. Biomedicine problems of high terrestrial elevations 1969

Patient Values and Preferences in Decision Making for Antithrombotic Therapy: A Systematic ReviewPatient Values for Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR; American College of Chest Physicians. Chest. 2012 Feb;141(2 Suppl):e419S-94S. PMID: 22315268

Cited by

Cited by with inclusion of phrase "pulmonary embolism"

Sensitivity/specificity of MR-imaging for Multiple Sclerosis Plaques

PubMed search with no filters:
Search Terms: ("Multiple Sclerosis/diagnosis"[MAJR] AND "Magnetic Resonance Imaging"[MAJR] AND ("Sensitivity and Specificity"[MeSH] OR "Diagnosis, Differential"[MeSH] OR "Early Diagnosis"[MeSH]))
Results

PubMed search for Systematic Reviews:
Search Terms: ("Multiple Sclerosis/diagnosis"[MAJR] AND "Magnetic Resonance Imaging"[MAJR] AND ("Sensitivity and Specificity"[MeSH] OR "Diagnosis, Differential"[MeSH] OR "Early Diagnosis"[MeSH])) Filters: Systematic Reviews
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PubMed search for Practice Guidelines:
Search Terms: ("Multiple Sclerosis/diagnosis"[MAJR] AND "Magnetic Resonance Imaging"[MAJR] AND ("Sensitivity and Specificity"[MeSH] OR "Diagnosis, Differential"[MeSH] OR "Early Diagnosis"[MeSH])) Filters: Practice Guideline
Results

PubMed search for articles not indexed and pu into Medline (includes very recent articles)
Search Terms: (Multiple Sclerosis AND (diagnosis OR diagnostic)) AND (Magnetic Resonance Imaging OR MR-imaging OR MRI) AND ((sensitivity AND specificity) OR differential OR early-diagnostic OR early-diagnosis) NOT medline[sb] Filters: English
Results

Google Scholar search for citations of two key articles:
1. Standardized MR imaging protocol for multiple sclerosis: Consortium of MS Centers consensus guidelines

JH Simon, D Li, A Traboulsee… - American journal …, 2006 - Am Soc Neuroradiology MR imaging has played an important role in contributing to our understanding of the natural history of multiple sclerosis (MS) in the brain and spinal cord, including its expression as both a focal (plaque) and more diffuse disease affecting normal-appearing white and gray ...

Cited by 113 

Above 113 citations limite by inclusion of terms: Sensitivity Specificity OR differential OR differentiation OR "early diagnosis" OR "early diagnostic"

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2. Differentiation of Multiple Sclerosis from Other Inflammatory Disorders and Cerebrovascular Disease: Value of Spinal MR Imaging

JCJ Bot, F Barkhof, GL à Nijeholt… - …, 2002 - radiology.rsna.org

Differentiation of Multiple Sclerosis from Other Inflammatory Disorders and Cerebrovascular Disease: Value of Spinal MR Imaging1. Joost CJ Bot, MD,; Frederik Barkhof, MD, PhD,; Geert Lycklama à Nijeholt, MD, PhD,; Dirkjan

Cited by 92

Above 92 citations limite by inclusion of terms: Sensitivity Specificity OR differential OR differentiation OR "early diagnosis"

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National Guideline Clearinghouse

Search Terms:"multiple sclerosis" AND ("mr imaging" or mri or magnetic resonance imaging) AND ((sensitivity and specificity) OR differential)

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Clinical Trials
Search Terms: multiple sclerosis and ("mr imaging" or mri or magnetic resonance imaging)
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Dietary Prevention of Renal Calculi: recent publications and research

Current Clinical Trials - where the new research is heading.

National Guideline Clearinghouse

High dietary magnesium intake decreases hyperoxaluria in patients with nephrolithiasis.
Eisner BH, Sheth S, Dretler SP, Herrick B, Pais VM Jr. Urology. 2012 Oct;80(4):780-3. Epub 2012 Aug 22. PMID: 22921695 Conclusion: Increasing magnesium intake was associated with decreasing hyperoxaluria in this population of patients with stone formation. Our findings showed that high magnesium intake might be required to observe clinically significant effects from magnesium. PDF

The impact of obesity on urine composition and nephrolithiasis management.
Al-Hayek S, Jackman SV, Averch TD. J Endourol. 2012 Sep 11. [Epub ahead of print] PMID: 22967041
Conclusion: OW and obese patients have different stone composition with increased excretion of stone promoters in the urine. Stone prevention measures should be introduced during metabolic syndrome evaluation.

Noncitrus alkaline fruit: a dietary alternative for the treatment of hypocitraturic stone formers.
Baia Lda C, Baxmann AC, Moreira SR, Holmes RP, Heilberg IP. J Endourol. 2012 Sep;26(9):1221-6. Epub 2012 Jun 4. PMID: 22500592
Conclusion: These findings suggested that melon, a noncitrus source of potassium, citrate, and malate, yielded an increase in urinary citrate excretion equivalent to that provided by orange, and hence represents another dietary alternative for the treatment of hypocitraturic stone-formers. Despite its low potassium content, lime also produced comparable increases in citraturia possibly because of its high citric acid content.

Recurrent Nephrolithiasis in Adults: Comparative Effectiveness of Preventive Medical Strategies [Internet].
Fink HA, Wilt TJ, Eidman KE, Garimella PS, MacDonald R, Rutks IR, Brasure M, Kane RL, Monga M. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. PMID: 22896859
Conclusion: Increased fluid intake, reduced soft drink consumption, thiazide diuretics, citrate pharmacotherapy, and allopurinol reduce risk of recurrent calcium stones. Effects of other dietary interventions appear mixed. We identified no RCTs for uric acid or cystine stones. Data regarding whether baseline or followup biochemistries predict treatment efficacy is extremely limited. PDF

Impact of nutritional factors on incident kidney stone formation: a report from the WHI OS.
Sorensen MD, Kahn AJ, Reiner AP, Tseng TY, Shikany JM, Wallace RB, Chi T, Wactawski-Wende J, Jackson RD, O'Sullivan MJ, Sadetsky N, Stoller ML; WHI Working Group. J Urol. 2012 May;187(5):1645-9. Epub 2012 Mar 14. PMID: 22425103
Conclusion: This study adds to the growing evidence underscoring the importance of maintaining adequate fluid and dietary calcium intake. Greater dietary calcium intake significantly decreased the risk of incident kidney stones. In contrast, excess sodium intake increased the risk of incident nephrolithiasis, especially in women with the highest intake. Animal protein intake was not independently associated with nephrolithiasis. PDF

Treatment and prevention of kidney stones: an update.
Frassetto L, Kohlstadt I. Am Fam Physician. 2011 Dec 1;84(11):1234-42. PMID: 22150656 Conclusion: For prevention of calcium oxalate, cystine, and uric acid stones, urine should be alkalinized by eating a diet high in fruits and vegetables, taking supplemental or prescription citrate, or drinking alkaline mineral waters. For prevention of calcium phosphate and struvite stones, urine should be acidified; cranberry juice or betaine can lower urine pH. PDF

Demystifying the medical management of nephrolithiasis.
Lipkin ME, Preminger GM. Rev Urol. 2011;13(1):34-8. PMID: 21826126 [PubMed]. Duke Comprehensive Kidney Stone Center, Durham, NC
Abstract: Nephrolithiasis is a common problem associated with significant costs to the health care system. Its prevalence continues to increase, particularly in women, which is attributed to changes in diet and lifestyle. The costs associated with the evaluation and management of nephrolithiasis in the United States has been estimated to be $1.83 billion, and, without any intervention, the risk of recurrence is high. This article reviews the management options for nephrolithiasis including a new formulation of potassium citrate, Urocit®-K 15 mEq, that allows for dosing flexibility which can lead to improved compliance and tolerability. PDF

Ambient temperature as a contributor to kidney stone formation: implications of global warming.
Fakheri RJ, Goldfarb DS. Kidney Int. 2011 Jun;79(11):1178-85. Epub 2011 Mar 30. Review. PMID: 21451456 
Abstract: Nephrolithiasis is a common disease across the world that is becoming more prevalent. Although the underlying cause for most stones is not known, a body of literature suggests a role of heat and climate as significant risk factors for lithogenesis. Recently, estimates from computer models predicted up to a 10% increase in the prevalence rate in the next half century secondary to the effects of global warming, with a coinciding 25% increase in health-care expenditures.

Evaluation and medical management of the kidney stone patient.
Paterson R, Fernandez A, Razvi H, Sutton R. Can Urol Assoc J. 2010 Dec;4(6):375-9. No abstract available. PMID: 21191493 [PubMed - in process]
Dietary Counselling Statement

All calcium stone formers should be counselled on dietary interventions to reduce stone recurrence or progression. Dietary recommendations include (Level 1–3 Evidence, Grade A–C recommendation):

• Increased fluid intake with a goal urine output of >2 litres per day
• Reduced salt ingestion (<2300 mg sodium daily)
• Reduced animal protein intake (no more than 2 meals daily with less than 6 to 8 ounces per day)
• Moderate calcium intake (1000 to 1200 mg/day)
• Moderate consumption of high-oxalate content foods (spinach, strawberries, nuts, rhubarb, wheat germ, dark chocolate, cocoa, brewed tea) with limited vitamin C intake to <1000 mg daily
• Increased intake of citrate-rich fluids (lemonade, orange juice) PDF

Diet, fluid, or supplements for secondary prevention of nephrolithiasis: a systematic review and meta-analysis of randomized trials.
Fink HA, Akornor JW, Garimella PS, MacDonald R, Cutting A, Rutks IR, Monga M, Wilt TJ. Eur Urol. 2009 Jul;56(1):72-80. Epub 2009 Mar 13. Review. PMID: 19321253 [PubMed - indexed for MEDLINE]
Conclusion: High fluid intake decreased risk of recurrent nephrolithiasis. Reduced soft drink intake lowered risk in patients with high baseline consumption. Data for other dietary interventions were inconclusive, although limited data suggest possible benefit from dietary calcium. PDF

Calcium supplementation and incident kidney stone risk: a systematic review.
Heaney RP. J Am Coll Nutr. 2008 Oct;27(5):519-27. Review. PMID: 18845701 [PubMed - indexed for MEDLINE]
Conclusion: Stone risk in postmenopausal women has increased substantially in the past 40 years, but absolute population incidence estimates vary widely from a low of about 70 incidents/100,000/yr for Olmsted County, MN, today, to a concurrent high of approximately 190/100,000/yr for the Nurses' Health Study II. Reported WHI incidence rates are higher still, with values around 300/100,000/yr for various WHI subgroupings. The reasons for these discordances are unclear. Despite this uncertainty about background rate, most of the studies show no increase in stone risk with high calcium intake (from either diet or supplements). Contrariwise there is a substantial body of evidence, both from controlled trials and from observational studies, indicating that there is an inverse relationship between calcium intake and stone risk. PDF

Kidney Stone type	Population	Circumstances	Details
Calcium oxalate	80%	when urine is acidic (low pH)	Some of the oxalate in urine is produced by the body. Calcium and oxalate in the diet play a part but are not the only factors that affect the formation of calcium oxalate stones. Dietary oxalate is an organic molecule found in many vegetables, fruits, and nuts. Calcium from bone may also play a role in kidney stone formation.
Calcium phosphate	___%	when urine is alkaline (high pH)
Uric acid	5-10%	when urine is persistently acidic	Diets rich in animal proteins and purines: substances found naturally in all food but especially in organ meats, fish, and shellfish.
Struvite	10-15%	infections in the kidney	Preventing struvite stones depends on staying infection-free. Diet has not been shown to affect struvite stone formation.
Cystine	___%	rare genetic disorder	Cystine, an amino acid (one of the building blocks of protein), leaks through the kidneys and into the urine to form crystals.

Reilly Jr. RF, Chapter 13: Nephrolithiasis, pp. 192–207 in Reilly Jr. and Perazella (2005)

Hyperbaric Oxygen Treatment of Central Artery Occlusions (CAO)



Acute central retinal artery

 occlusion

 Hyperbaric Oxygen Treatment of CAO (PubMed)

Time Factors (PubMed)

Algorithms (PubMed)

Current Clinical Trials

Recent Article

Central retinal artery occlusion treated with oxygen: a literature review and treatment algorithm.

Central retinal artery occlusion (CRAO) is an uncommon eye disorder, but one that typically produces severe and irreversible vision loss in the affected eye. The retina has a dual blood supply, with the retinal circulation supplying the inner layers and the choroidal circulation supplying the outer layers. In CRAO, vision loss results from cell death in the inner retinal layers despite relative sparing of the outer layers. If supplemental oxygen is provided, however, oxygen from the choroidal circulation may diffuse in adequate quantity to the inner layers of the retina to maintain retinal function and restore vision. In some patients this can be achieved with normobaric hyperoxia; in others, hyperbaric oxygen (HBO2) may be required. The challenge is to provide the supplemental oxygen early enough after the onset of vision loss to prevent irreversible damage to the retina. In experimental models of complete CRAO, the ischemic time window before permanent retinal damage occurs is just over 90 minutes; in the clinical setting where occlusion may be incomplete, return of vision may be achieved even after delays of eight to 24 hours. In patients with a clinical picture of CRAO who present within 24 hours of vision loss, supplemental oxygen should be started immediately at the highest possible fraction of inspired oxygen (FiO2). If vision is not quickly restored, emergent HBO2 should be undertaken if feasible. If the patient responds to HBO2, follow-up treatment with supplemental oxygen should be customized to maintain retinal viability until the obstructed retinal artery recanalizes, which typically occurs within the first 72 hours. This paper reviews the pertinent literature on CRAO and HBO2 and provides a treatment algorithm. Murphy-Lavoie H, Butler F, Hagan C. Undersea Hyperb Med. 2012 Sep-Oct;39(5):943-53. Review. PMID: 23045923