NOTCH1, NOTCH2, TP53, FAT1 and PPM1D and also identified mutations in four genes  that we hypothesize are selected for in squamous epithelium irrespective of disease status. Finally, we describe a mutational signature of psoralens—a class of chemicals previously found in some sunscreens and which are used as part of PUVA  photochemotherapy treatment for psoriasis.Somatic mutations are hypothesized to play a role in many non-neoplastic diseases. We performed whole-exome sequencing of 1,182 microbiopsies dissected from lesional and nonlesional epidermis from 111 patients with psoriasis to search for evidence that somatic mutations in keratinocytes may influence the disease process. Lesional skin remained highly polyclonal, showing no evidence of large-scale spread of clones carrying potentially pathogenic mutations. The mutation rate of keratinocytes was similarly only modestly affected by the disease. We found evidence of positive selection in previously reported driver genes  Analysis of the somatic mutations landscape of 111 patients with psoriasis vulgaris shows that the disease is unlikely to be driven by clonal expansions caused by somatic mutations in keratinocytes. A mutational footprint associated with psoralen treatment was observed and characterized. These have shown that driver mutations, which provide cells with a competitive advantage over their neighbors, are common in non-neoplastic tissues and sometimes represent sizable fractions of all cells sampled.Recent studies have advanced our understanding of the somatic mutation landscapes of phenotypically normal tissues, including blood24. Exposure to environmental insults such as drugs or inflammation may influence somatic mutation landscapes and be correlated with disease. For example, azathioprine, which is used to treat several immune-related conditions, leaves a characteristic mutational signature on the genomes of exposed cells in both the skin25 and colon26.Widespread replacement of wild-type cells with mutant clones can have functional consequences for the tissue, potentially contributing to common complex disease risk or influencing disease progression or response to treatment9 and inflammatory bowel disease (IBD)28. In both conditions, disease results in increased mutagenesis and large-scale replacement of wild-type cells with clones carrying somatic mutations in metabolic and immune-related pathways, respectively. In IBD, chronic inflammation drives the expansion of clones carrying somatic mutations affecting the toll-like receptor and interleukin-17 signaling pathways within the colonic mucosa28.We and others have recently shown how somatic mutation landscapes of affected tissues are altered profoundly in nonalchoholic fatty liver diseaseHere, we further characterize the somatic mutation landscape of diseased tissues by studying chronically inflamed psoriatic skin. We use whole-exome sequencing (WES) of hundreds of microbiopsies of epidermis isolated from lesional and nonlesional skin of psoriasis patients to explore the extent to which somatic mutations affect the disease process in psoriasis. We also describe the mutagenic processes that are active in psoriatic skin, including the mutagenic effects of psoralen exposure, which is a part of commonly used phototreatment for psoriasis.n = 111) and adjacent nonlesional (n = 106) skin  phototreatment, which is used to treat psoriasis and other diseases of the skin. We found no evidence that other common treatments, including methotrexate or topical steroid use, cause somatic mutations in the skin . It is characterized by T > A, T > C and T > G mutations at TpA sites  activation (SBS2 and SBS13), which have been found occasionally to be present in a range of normal tissues35. While the APOBEC signatures account for only 0.5% of the mutations in the dataset as a whole, 22 clones had over 50 exonic mutations attributed to SBS2/SBS13, accounting for up to 28% of mutations in the exposed clones. This indicates that members of the APOBEC family of proteins can be activated occasionally in the skin, as shown across a range of other normal tissues35.The remaining prevalent signatures identified are the result of cell-intrinsic mutational processes. One is a mix of the clock-like SBS1 and SBS5 signatures that are found ubiquitously in normal tissues, including proliferative and postmitotic tissuesP = 4.3 × 10–9, LMMs; Supplementary Note 35.To assess whether psoriasis is associated with difference in the mutation burden of the skin, we fitted linear mixed effects models (LMMs) to estimate the independent effects of age, disease duration and anatomical location of the biopsies while accounting for the fact that samples are not independent but display a hierarchical structure by patients and biopsies . We therefore fitted a model using only the mutation burden attributed to SBS1/5 and found that psoriasis increases the mutation burden of these signatures by 0.16 mutations per exome per year of disease duration  of psoriasis as well as other severe skin diseases such as eczema, vitiligo and graft-versus-host disease. Psoralens were also included as tanning activators in some tanning lotions and sunscreens until a limit on their use was imposed by European safety regulations in 1996. Psoralens are used as mutagens in molecular biology research and both PUVA treatment and the use of psoralen-containing sunscreens are known to increase the risk of skin cancers33. Out of the 111 donors, 24 showed evidence of the signature. As with UV-light-related mutations, proximal cell clones sometimes show large variation in the number of psoralen-related mutations, with some showing extremely high mutation burdens. In the most extreme case, over 12,000 exonic mutations attributed to psoralen were found in two related cell clones from patient 34, who has a history of extensive PUVA treatment (>200 sessions). These clones did not show a higher-than-expected burden of double-base substitutions or indels. Across the dataset in general, the indel mutation spectrum is identical (cosine similarity >0.99) between clones with high and low burden of the substitution psoralen signature  and, although only the group with >200 cycles of PUVA had a significantly higher psoralen mutation burden than those without history of PUVA treatment (616 extra (exonic) mutations per clone, 407–826, 95% CI), we observed a trend for increased mutation burden with the number of PUVA cycles  in the Hartwig Medical Foundation (HMF) cohort41, HMF003357A, did show clear evidence of the signature ure Fig. . A HMF sTo further characterize the mutagenic effects of psoralen exposure in vivo, we performed whole-genome sequencing (WGS) of 16 microbiopsies from three patients who showed clear evidence of the signature in the whole-exome data and two of whom have histories of PUVA treatment Fig. . We founWe found a strong effect of transcription on psoralen-related mutagenesis in the WGS data, with 1.72 times more mutations occurring on the untranscribed strand than on the transcribed on average Fig. . This isIn addition to the effects of transcription, there was an effect of replication on psoralen-related mutagenesis. The leading strand accumulates 9% more mutations compared with the lagging strand, and late-replicating regions consistently showed higher mutation rates than early replicating regions  or normal skin  after accounting for sequence context and regional differences in mutation rate across the genome  have been shown previously to be under positive selection in normal skin in studies that have used deep sequencing of targeted gene panels15. Four additional genes  that were not a part of the targeted panels or have not been previously reported reached significance in the current study. To explore whether mutations in these four genes are uniquely under positive selection in lesional skin, we repeated the selection analysis using only samples from lesional skin or nonlesional skin. No additional genes reached significance in these restricted analyses but ZFP36L2 and GXYLT1 did not reach significance when nonlesional microbiopsies were excluded  in nonlesional skin, suggesting that mutations in these genes are not specifically selected for under conditions of inflammation and that our failure to detect significant evidence of positive selection is probably driven by lower power due to the reduced sample size.We used dNdScv softwareWe next carried out a pathway-level dN/dS analysis, searching for enrichment of missense and truncating variants across 11 genesets that were defined a priori because of their relevance in either keratinocyte cancers or psoriasis pathology Fig. ; MethodsBased on the VAFs of individual mutations and the volume of the microbiopsies in which they were detected, we estimated for each patient the fraction of cells that carry a mutation in each gene Fig. ; Methods45 but our results support the view that this increase in risk may be due predominantly to the effects of treatment rather than features of the disease per se.We have used WES of microbiopsies of epidermis derived from 111 patients with psoriasis vulgaris to study the effects of this chronic disease on the somatic mutation landscape of the skin. Our analyses suggest that psoriasis is unlikely to have a major impact on the lateral spread of keratinocyte clones in the skin, that disease effects on the mutation burden are modest and that similar mutations confer selective advantage on cells in psoriasis as in healthy skin. Psoriasis is associated with modestly increased risk of keratinocyte cancers35. Here we found that disease duration of psoriasis, our best proxy for inflammation exposure, is associated with increased mutation burden of SBS1/5. We estimate that psoriasis disease duration is associated with an additional 0.16 mutations per exome per year, which is approximately a quarter of the age effect of these signatures. However, this estimate is dependent on certain assumptions about the clonal structures of the microbiopsies (Supplementary Note Although the effects of UV light (SBS7) unsurprisingly dominate in the skin, other mutational processes also affect keratinocytes and may be affected by disease. There is evidence from other diseases that inflammation is associated with increased mutation burden of the clock-like signatures SBS1 and SBS5, which represent cell-intrinsic processes and are found in all cells of the bodyWe discovered that mutations in four genes that have not been reported before in studies of normal epidermis are under positive selection in our dataset. We hypothesize that nonsynonymous mutations in these genes are under positive selection in squamous epithelia in general and are not specific to psoriasis or selected as a consequence of the inflammatory environment . Mutations in genes of the IL-17 pathway are not positively selected in psoriasis, underscoring the seemingly different role of this cytokine in these two diseases. It is worth noting that while IL-17 inhibitors work well for psoriasis, clinical trials of these drugs in IBD have either shown the drugs to not be effective or that they worsen the disease54. Importantly, our data does not exclude a role for somatic mutations in immune cells in psoriasis pathogenesis55. Emerging data from other autoimmune diseases suggests that somatic mutations may sometimes enable lymphocytes to bypass tolerance checkpoints, resulting in expansion of autoreactive clones57. Determining whether similar mechanisms are at play in psoriasis is an important direction of future work.Genome-wide association studies have revealed both disease specific and widespread sharing of disease mechanisms between immune-mediated diseases. Many pathways and disease mechanisms are shared across several autoimmune conditions but the extent to which these relationships manifest in the somatic mutation landscape of affected tissues is not clear. Comparison with our earlier work on IBD shows that, although they are both Th17-mediated chronic inflammatory diseases of epithelial tissues, and share several genome-wide association study loci in commonThis study complies with all relevant ethical regulations. All donors gave informed consent for genetic research of the material and the study was approved by the research ethics committee of Christian-Albrechts University in Kiel (A100/12), the National Health Service (NHS) Research Ethics Committee  and by the Wellcome Trust Sanger Institute Human Materials and Data Management Committee .This is a descriptive study with no interventions. No randomization of patients was applied. All dependent variables were generated computationally and no blinding was applied. Sample size was not predetermined. We excluded from the whole study six microbiopsies suspected of being sample swaps and/or contaminated with external DNA. A total of 101 microbiopsies were excluded only from the analysis of structural variants either due to the inability of the algorithm to find an optimal solution or if the goodness-of-fit for the optimal solution was <90%.Round punch biopsies, 4 mm in diameter, from lesional and adjacent nonlesional skin were donated by psoriasis patients presenting to the Department of Dermatology, University Hospital Schleswig-Holstein, Kiel between 2017 and 2019. Biopsies were fixed in RNAlater  upon collection following the manufacturer’s instructions and frozen. Patients were not compensated for participation in the study.Skin biopsies were processed using a Tissue Tek VIP 6 AI tissue processor (Sakura Finetek) and embedded in paraffin. The blocks were sectioned into 10-μm-thick sections using an Accu-Cut SRM 200 microtome (Sakura Finetek). Sections were fixed to 4 μm PEN membrane slides . Slides were stained with hematoxylin and eosin and imaged using a NanoZoomer 2.0-HT slide scanner (Hamamatsu Photonics). Samples of epidermis were dissected from this material using LCM microscopy . Cells were lysed using Arcturus PicoPure DNA extraction kit  according to the manufacturer’s instructions.58. PCR duplicates were marked using biobambam59 and duplicate statistics were calculated using Picard (v.1.131) (http://broadinstitute.github.io/picard/). Sample contamination estimates were calculated using VerifyBamID (v.1.1.3)60 and the on-target coverage was calculated using Samtools (v.1.11) depth command, considering only reads with base quality and mapping quality >30. The median on-target coverage for all samples was 56×  for the dataset as a whole but 58× and 46× for microbiopsies from lesional and nonlesional skin, respectively. The difference in coverage is due to the greater volume of the microbiopsies from lesional skin  who showed the signature of PUVA exposure in the WES data. The sequencing of these samples is further described in Supplementary Note https://cancerit.github.io/CaVEMan/)61. Mutations were called against an unmatched normal with the copy number options set manually to 10 and 2 for the mutant and wild-type copy numbers, respectively. The samples were compared against a normal panel consisting of 75 unrelated normal samples to remove common SNPs. Mutations were further filtered if the reads reporting the mutations had a median alignment score <140 or if >50% of the reads were clipped.Substitutions were called using CaVEMan (v.1.15.1) (Cancer Variants through Expectation Maximization) (62 R package (v.1.40.0) to generate pileups of all sites mutated in any sample using only mapped reads that had base quality and mapping quality >30 and which were mapped in a proper pair, were not PCR duplicates, were the primary alignment and which passed platform quality check . After these filters, we required a coverage of at least four times at the site and at least three reads reporting the alternate allele in at least one sample from a donor to call a mutation.All mutations passing these filters in any sample from a donor were next genotyped in all samples from that donor. We used the bam2R function of the deepSNVAdjacent substitutions called in the same sample were merged into a double-base substitution call if the number of reads reporting the reference and alternative alleles was not significantly different (Fisher test).https://github.com/cancerit/cgpPindel)63 using the same unmatched normal sample that was used to call substitutions. We generated pileups of the indel calls in the same way as described above for substitutions and required a coverage of at least four times and at least three reads reporting the alternate allele in at least one sample from a donor to call a mutation as before.Indels were called using cgpPindel (v.3.5.0)  in a grid-based way 26. Calls with ρ < 0.1 were filtered as probably artifactual.To filter rare germline variants not removed by the comparison with the normal panel we applied an exact binomial test of the number of reads reporting each mutationThe sensitivity of the mutation calling postfiltering was estimated at 89% as described in the Supplementary Note 64(https://github.com/VanLoo-lab/ascat) as further described in Supplementary Notes Structural variants were called using allele-specific copy number analysis of tumors8. Briefly, clones of cells are present across different microbiopsies and this manifests as clusters of mutations that are found at similar VAFs within a microbiopsy. For every mutation, we have two vectors, one containing the number of reads reporting the alternate allele in each microbiopsy and another containing the total sequencing depth at each microbiopsy. We assume that each mutation can be assigned to exactly one cluster but the number of clusters is unknown. We aim to estimate the number of clusters present across all the microbiopsies dissected from a patient, the location of each cluster in the n-dimensional VAF hypercube and the allocation of mutations to each cluster.We implemented a nonparametric Bayesian hierarchical Dirichlet process (HDP) to cluster autosomal SBSs with similar VAFs. The full mathematical and implementation details of the model are described in a previous publicationWe model the data using an N-dimensional Dirichlet process clustering model, where the distribution of clone sizes and numbers follows a Dirichlet process. This has the advantage that there is no need to prespecify the number of clusters present. Instead, mutations are moved around the clusters and, in each sampling iteration, there is a defined probability that a mutation will initiate a new cluster that was not present in previous iterations. Clusters can also cease to exist if all member mutations are assigned to other clusters. Thus, the number of clusters varies throughout the sampling chain. Details of the implementation are provided in the Supplementary Note Each cluster of single-base-substitutions identified by the N-dimensional Dirichlet process algorithm represents a branch of the phylogenetic tree for that patient. We applied the statistical piegonhole principle to infer phylogenetic relationships between clusters. Given clusters A and B, if the combined mutant cell fraction (CF) of both is >100% (VAF > 0.5) in the same microdissections and B consistently shows a lower CF than A, then that is strong evidence that B is nested within A, that is, mutation cluster B represents a subclone of clone A. If the combined mutant CF is ≤100%, only weak evidence of nesting exists. If B is found at a higher VAF than A in some microdissections but at lower VAF in others, the clusters are interpreted as being independent clones without nesting. We treated each tip of the phylogenetic tree for each patient as a clone. The length of the branches from the root (germline) was used in the mutation burden calculations.Some clusters are present at VAFs too low for the pigeonhole principle to be incontrovertible . In these cases, there is a risk that the cluster does not represent a single clone as assumed above, but a mixture of clones present at similar VAFs. We reconstructed the phylogenetic trees after pruning away branches where there is doubt about the validity of the pigeonhole principle. We retained nested clusters only if the sum of the cellular fraction estimates exceeds 1. Un-nested clusters  were retained if the median VAF of the cluster is >0.3.65, as implemented in the HDP (v.0.1.5) R package (https://github.com/nicolaroberts/hdp). The data were organized into a tree structure where the root contained all the mutations in the dataset. This node had, as children, one node that represented the most recent common ancestor of all the patients and frozen pseudocount nodes for signatures that are to be used as priors in the model. The pseudonodes contained 10,000 pseudocounts each. We used COSMIC signatures 1, 5, 2, 13, 7a, 7b, 7c, 7d, 17a, 17b, 18 and 38 as priors. During the Dirichlet process, mutations from the dataset may join the pseudocount clusters, but the pseudocounts are frozen such that they are unable to leave the initial cluster. The patient ancestor node had, as children one node for each of the patients, and each patient node had as children one node for each branch of the phylogenetic tree. The parameters used are provided in Supplementary Note To extract mutational signatures and estimate the exposure of each signature, we used a second hierarchical Dirichlet process HDP v.0..5 R packThe model extracted nine signature components in addition to the unassigned component  together with BSgenome (v.1.60.0). To calculate the transcriptional strand bias, we used the gene definitions from the R package TxDb.Hsapiens.UCSC.hg38.knownGene (v.3.13.0) and the strand_occurrences and strand_bias_test functions from MutationalPatterns.To visualize the trinucleotide and pentanucleotide spectrums associated with psoralen exposure, we used the R package MutationalPatterns67. We divided protein-coding genes into quintiles by ascending expression in sun-exposed skin from the GTEx dataset68 (v.8). We extracted the transcriptional start site (TSS) and the strand of each gene from Gencode (v.27) and defined ten 1 kb bins upstream and downstream of the TSSs. We pooled T > (ACG) and A > (CGT) mutations at TpA or ApT sites from all whole-genome sequenced samples. If the gene is on the (–) strand, the transcribed strand is the reference and we counted the number of T > (ACG) mutations overlapping each 1 kb bin. If the gene is on the (+) strand, the transcribed strand is the complement of the reference and we counted the number of A > (CGT) mutations. This was reversed for the untranscribed strand. We observed a drop in the mutation rate on the transcribed strand upstream of the TSSs, indicating TCR. However, we also found an increased mutation burden on the untranscribed strand, indicative of TCD of this strand. To test the statistical significance of the increased mutation burden, we fit two linear models with and without a parameter indicating whether each position was upstream or downstream of the TSSs and used a likelihood ratio test to test whether the fit of the model was improved. Figure To test for TCD, we carried out a similar analysis to that used originally to describe TCD in liver cancers68 (v.8). We split protein-coding genes into ten equally sized bins by ascending levels of expression. We used the Bedtools69 intersect function (v.2.18) to count the number of mutations overlapping genes in each bin. Figure To test the effect of gene expression levels on PUVA mutagenesis we again used expression data from sun-exposed skin from the GTEx datasettion v.2.8 to counAJUBA, ARID2, ASXL1, CASP8, CDKN2A, FAT1, KMT2D, NOTCH1, NOTCH2, NOTCH3, PPM1D, RB1, RBM10, TP53 and TP63.To assess the potential functional effects of the psoralen signature relative to other main signatures in the skin Fig. , we usedTo see whether psoralen exposure was associated with increased levels of clonal spread after controlling for age, we estimated the median VAF for microbiopsies dissected from each patient and regressed this against the age of the patient in a linear model. We then fitted a second linear model which also included as covariate whether the psoralen signature was seen in that patient. We used a likelihood ratio test to see whether this improved the fit of the model Fig. .We used linear mixed effect models to compare the mutation burdens of lesional and nonlesional skin and test for an effect of disease duration. We used as response variables the estimates of the mutation burdens of SBS7 and SBS1/5 after correcting for VAF and coverage as described in Supplementary Notes 43 (https://github.com/im3sanger/dndscv) to identify genes enriched in nonsynonymous mutations, indicative of positive selection. We first calculated dN/dS ratios across all coding genes using mutations identified in either lesional or nonlesional skin, identifying positive selection of mutations in nine genes  software.0 softwaWe compared the fraction of cells that carry mutations in any of the nine genes that showed a significant enrichment of mutations between lesional and nonlesional skin. We calculated the fraction of mutated cells separately in lesional and nonlesional biopsies from each individual by multiplying twice the VAF of each mutation in each microbiopsy by the volume of the microbiopsy and dividing that by the total volume of microbiopsies dissected from that patient. For clones that carry more than one mutation in the same gene, we counted only the mutation with higher VAF.Further information on research design is available in the Any methods, additional references, Nature Portfolio reporting summaries, source data, extended data, supplementary information, acknowledgements, peer review information; details of author contributions and competing interests; and statements of data and code availability are available at 10.1038/s41588-023-01545-1.Supplementary InformationA more extensive description of the methods used in this study, extended results and discussion and R-markdown notebooks describing the key analyses supporting the manuscript.Reporting SummaryPeer Review FileSupplementary TablesSupplementary Tables 1–7.Source Data Fig. 1VAFs, pairwise distances and fraction of mutations shared by microbiopsy pairs.Source Data Fig. 2Mutation counts for each signature for each clone, ages of the patients from which the clones are derived and effect estimates from the linear mixed effect models.Source Data Fig. 3Statistical source data for various characterizations of the psoralen mutational signature.Source Data Fig. 4Mutation counts, dN/dS estimates and fraction of mutated cells for genes and pathways.Source Data Extended Data Fig. 1Clinical characteristics of the cohorts, sizes and coverage of the microbiopsies and sensitivity estimates from technical near-replicates.Source Data Extended Data Fig. 2The 96-class mutational classes for each HDP component identified in the mutational signature extraction process.Source Data Extended Data Fig. 3The estimated mutation burden for each signature in every clone in the dataset (same as Supplementary Table 3)Source Data Extended Data Fig. 4Indel counts in different mutation classes, substitution counts for different mutation classes of the extended sequence context, mutation counts by replication strand and by bins of ascending replication timing.Source Data Extended Data Fig. 5Fraction of mutated cells for each patient and the location and functional characteristics of mutations in genes showing significant enrichment of mutations.


Differentiated thyroid carcinoma (DTC) is the most frequent endocrine neoplasm. Its treatment is based on surgery with consequent impact on patients’ quality of life (QoL) and aesthetic implication. The aim of the present study is to assess scar satisfaction in patients affected by DTC who underwent total or partial thyroidectomy. A comparison was also made between scar satisfaction with different subcuticular suture. Validated questionnaires have been employed during a 3-month follow-up: Patient and Observer Scar Assessment Scale (POSAS) and the Patient Scar Assessment Questionnaire (PSAQ). Eventually, the impact of thyroid cancer on QoL of patients was performed in the studied population employing the Thyroid-related patient-reported outcome questionnaire (ThyPRO) and European Organisation for Research Additionally, Treatment of Cancer—Quality of Life questionnaire-C30 (EORTC QLQ-C30). It was conducted in a single center observational study considering 74 patients respecting inclusion criteria. Overall scar satisfaction was found to improve during follow-up, reaching the best scores at 3 months from surgery. Subcuticular suture does not seem to influence the scar satisfaction. In our study male patients seem to be more satisfied, on the other hand age does not seem to influence satisfaction. Overall, the ThyPRO questionnaire and EORTC QLQ-C30 scores did not statistically differ between preoperative and postoperative suggesting a small impact of DTC in QoL. Thyroid carcinoma is the most frequent endocrine neoplasm (approximately 90% of cases) . It is eMore than 95% of thyroid cancer is constituted by differentiated thyroid cancer (DTC) . The mosThe vast majority of thyroid cancers present as indolent thyroid nodules that sometimes could be detected incidentally by the physician during physical examination for other ENT referred symptoms, or as unexpected radiological findings. Only ∼5–10% of thyroid nodules resulted in malignancy in the general population, but males and very young or very old patients are at higher risk .In order to distinguish between low- and high-risk nodules, a thorough patient history, a complete physical examination, laboratory investigations, neck ultrasonography, and, for selected patients, fine-needle aspiration (FNA), are needed .A history of a rapid increase in nodule size, dyspnea, dysphagia, or hoarseness, or the development of Horner’s syndrome, albeit not specific for malignancy, are worrisome but rare findings. Concerning the neck examination, a firm, slightly mobile, and large nodule, associated with adherence to surrounding structures and the presence of lymphadenopathy, should induce the physician to consider the presence of thyroid carcinoma. Every patient suspected of thyroid malignancy should undergo fibre optic, in order to exclude the presence of vocal cord paralysis that is generally associated with advanced thyroid malignancy .The treatment of thyroid carcinomas mainly consists of partial or total thyroidectomy, either associated or not with nodal dissection of the central neck compartment .Thyroid surgery presents a low percentage of permanent complications. Two classical complications of thyroidectomy are due to the close anatomic proximity to the thyroid gland and other involved structures: recurrent laryngeal nerves (RLN) injuries and hypo-parathyroidism following the damage of parathyroid glands. Temporary hypoparathyroidism occurs in between 20 and 30% of cases and may be permanent in between 1 and 4% of cases. Postoperative compressive hematoma with acute dyspnea is a rare but severe complication that may result in death or severe long-term sequelae .In thyroid surgery, aesthetic outcome is particularly relevant, considering that patients who undergo this kind of surgery are mostly women and young adults and that the skin incision is in a highly visible anatomic location: this aspect is frequently underestimated, considering it is less important for the patient’s global health. In order to guarantee a better cosmetic result of the scar appearance, minimally invasive approaches (MIT) for thyroid surgery have been developed over the last decade ,10 in orMoreover, the method of skin closure contributes to the overall aesthetic outcome and patient’s satisfaction. Different methods of skin closure have been described and compared in published series with the aim of identifying the suture that can reach the best aesthetic outcome for patients .Another aspect of great relevance is the evaluation of how thyroid cancer impacts the quality of life (QoL) of patients. In fact, the diagnosis of carcinomas and its perception can strongly impact patients’ everyday life, causing changes both in the physical and the psychological aspect.The aim of this study was to compare the aesthetic appearance of cervical incision closed with three different suture techniques in patients affected by differentiated thyroid cancers (DTCs) that underwent surgery. As a secondary aim, we evaluated how the pathology and related treatment influenced QoL in these patients.The study has been conducted as a single centre observational study in the ENT Department in Maggiore della Carità Hospital in Novara, Italy.A series of consecutive 74 patients being affected by differentiated thyroid cancer from 1 August 2020 to 30 August 2022 who underwent cervicotomy for total or partial thyroidectomy were considered.Age ≥ 18 yearsDiagnosis of well differentiated thyroid cancerTotal or partial thyroidectomyInformed consentThe inclusion criteria were:Previous surgery of the neckDiagnosis of benign thyroid diseaseAbsence of informed consentLateral neck dissectionThe exclusion criteria were:Before surgery all patients underwent ultrasound examination of the thyroid gland, fine-needle aspiration cytological examination of the thyroid nodules, thyroid specific blood tests , and in some specific cases CT scan was performed.The operation was performed through a minimal open cervical incision (length <6 cm). Meticulous haemostasis was achieved before approximation and closure of skin layers. In all patients, skin closure comes after suturing the strap muscles and subcutaneous layer with interrupted absorbable suture (Monocryl 3.0) with a single resorbable stitch. Subcuticular suturing, in the present study, varies among the populations. A single administration of prophylactic antibiotic (cefazolin 2 g) was pre-operatively administered. After the operation, patients received a standard postoperative protocol and analgesic regime.Absorbable subcuticular suture with Monocryl 3.0Non-absorbable subcuticular suture with Prolene 3.0®Steri stripEnrolled patients were randomly assigned through a series of random numbers generated by an electronic worksheet to have their wound closed with:The surgeon was informed of the allocation of each patient to a type of method only at the moment of closure.The primary endpoint was the appearance of wounds in post-operative weeks assessed through two validated scar assessment scales, the Patient and Observer Scar Assessment Scale (POSAS) and the Patient Scar Assessment Questionnaire (PSAQ). Both questionnaires were submitted to all patients 10 days, 1 month and 3 months after surgery.POSAS has been used and validated for several different types of wounds ,14. It iPractitioners were trained in the use of OSAS on a series of patients before the start of this study, until they achieved a good level of agreement. Surgeons responsible for surgery could not evaluate OSAS of the patients in order to avoid possible conflicts of interest and bias in the present study. PSAS was assessed during follow-up visits with the patient in front of a mirror, while one of the observers was asking the questions .The Patient Scar Assessment Questionnaire (PSAQ) with five subscales  was constructed using multiple categorical response items. Each subscale consists of a set of items with 4-point categorical responses, scoring from 1 to 4 points (with 1 point assigned to the most favourable category and 4 assigned to the least favourable). Each subscale also contains a single global assessment item that is not included in the summary subscale score but is used to provide a clinically meaningful descriptor for the summary score generated and is also used for internal validation analysis .Considering the second endpoint (patient’s QoL), the Thyroid-related patient-reported outcome questionnaire (ThyPRO) questionnaire is self-administered and measures QoL with 13 scales, covering physical and mental symptoms, well-being, and function as well as impact of thyroid disease on participation  and overall QoL. It consists of 84 items and, on average, takes 14 min to complete. Each scale ranges 0–100 with increasing scores indicating decreasing QoL  .Moreover, the European Organisation For Research And Treatment Of Cancer—Quality of Life questionnaire-C30 (EORTC QLQ-C30) version 3.0 was used: this is a cancer-specific measure of QoL tool  that conInformed consent was obtained from all patients during a preoperative assessment visit. The study had ethical approval by the Ethical Committee (CE 133/22). The study was carried out in accordance with the ethical standards of the Helsinki Declaration.p > 0.05). The t-test for paired samples and ANOVA test were used for normally distributed data. All results are reported as mean ± standard deviation (SD). Statistical significance was assumed for p-values < 0.05.The analysis was performed using SPSS for Windows . Normality of continuous variables was verified with the Shapiro–Wilk test .One third of patients (23/74) who underwent surgery for DTC were considered voice professionals considering the importance of the voice in their daily work activity .The great majority of patients were affected by papillary carcinoma (83.43%); the incidence of histotype is shown in At the time of diagnosis, more than 90% of patients presented with a low T staging disease (T1 and T2 cancer). In this case, no one presented with T4 at diagnosis .In 19 patients, diagnosis of DTC was made incidentally. In these patients, thyroidectomy was performed because of the presence of hyperfunctioning thyroid goiter or deforming trachea goiter.Sixty-three patients underwent total thyroidectomy (85.1%) and the remaining 11 lobo isthmectomy (14.9%).In 29 cases, on the basis of the cytological result, nodule, and patients’ characteristics, a unilateral or bilateral dissection of the central compartment nodes was performed; no case of lateral neck dissection  was recommended because of nodal involvement of disease. Among 29 central neck dissections, nodal involvement was histologically documented in 13 patients (44.83%) .None of the patients experienced a revision surgery because of post-surgical bleeding. No cases of scar infection were observed.In all patients, scar assessment was performed 10 days (T1), 1 month (T2) and 3 (T3) months after surgery. Overall satisfaction of the scar was good in the entire sample since the first evaluation at 10 days. The initial scores of PSAQ were 60.8 on a maximum score of 136 points, mean values of OSAS and PSAS at first evaluation were, respectively, 11 and 14.3; it was observed that with the running time all scores employed decreased, reaching the lowest score at 3 months. These data suggest that after 3 months from the surgery there is the maximum satisfaction of the scar and consequently the lowest impact on patients’ QoL.In PSAQ investigates five different items: aspect of the scar, symptoms related to scar, perception of the scar, satisfaction with the aspect of the scar, and satisfaction with symptoms of the scar. Each aspect has been analysed separately during follow up. All categories of PSAQ showed a significantly decreasing score during follow-up .After the analysis of the general population, the attention was focused on the impact of scars depending on the suture techniques employed.The three populations were compared in terms of age, gender distribution, and surgical procedure as summarized in In all three populations (identified by the subcuticular suture technique employed), a significant decrease in PSAQ, PSAS, and OSAS during follow-up was observed. On the basis of statistical analysis, the suture technique does not significantly impact on satisfaction and QoL of patients at any time of follow-up .Female gender seems to be significantly associated with a lower scar satisfaction and a heavier impact on QoL during follow-up. In fact, both OSAS and PSAS female scores were significantly higher at 1 month and at 3 months after surgery. In the PSAQ score this trend is present but does not reach statistical significance .As far as the influence of age on the satisfaction of scars and its impact on QoL, it was found that no statistical significance is present in PSAQ, OSAS, and PSAS among patients younger and older than 50. In both populations a significant reduction in scores during follow-up is evident .The impact of DTC on the QoL of patients has been investigated with the ThyPRO questionnaire and EORTC QLQ-C30 questionnaire.ThyPRO questionnaire was administered before surgery (T0) and 1 month after surgery (T1). Thy PRO total score at T0 was 61.2 and it did not show statistical difference with T1 score of 58.9. Separately analysing each one of the 13 items, it is possible to observe that none of them presented a statistical difference between T0 score and T1 score, except for anxiety. In fact, the anxiety score decreases from a mean value of 6.37 (T0) to 3.89 (T1).p = 0.87)  and 1 month after surgery (T1). At T0 the score was 50.5 ± 7.9. At T1 no statistical difference was recorded  .p < 0.05) between the PSAQ score obtained at T1 and that obtained at T3, thus confirming a better perception of the wound by the patients at the third follow up. Furthermore, analysing the scores obtained in the individual PSAQ subcategories, it can be seen that there is a statistically significant decrease in each of the five subclasses (p < 0.05) when comparing the score obtained at T1 with that obtained at T3.Thyroidectomy is the surgical technique of choice for many thyroid diseases, including DTC. In most cases the operation involves the complete excision of the gland for therapeutic purposes or in order to limit recurrences and simplify the follow-up . The opep > 0.05) in PSAQ and POSAQ scores, thus suggesting that patient satisfaction with the wound does not depend on the type of suture. To the best of our knowledge there are still no studies in the literature that evaluate the global PSAQ score in relation to the type of suture used; however there are studies on the evaluation of POSAQ: Teoh LY et al. reported that the use of adhesive materials versus an absorbable suture did not influence the overall satisfaction of the 96 patients included in the study [p < 0.05) in POSAS scores with female gender presenting higher scores. Regarding PSAQ scores presents the same trend but, in this case, it does not reach a statistical significance.The analysis obtained by stratifying the patients according to the type of suture has instead demonstrated how the different types of sutures  do not provide statistically significant variations  as suggested by some authors .p > 0.05) regarding the PSAQ and POSAS scores. This data is confirmed with the study by Felix et al.: the 48 enrolled patients obtained PSAQ scores without significant differences when compared on the basis of age [The analysis obtained by comparing the results divided by age provided no statistically significant data  and 30 days after surgery (T1). EORTC QLQ-C30 decreased from 50.5 ± 7.9 at T1 to 48.8 ± 8.9 at T1. ThyPRO scores went from 61.2 ± 6.9. (T0) to 58.9 ±7.1 (T2). The fact that patients’ QoL does not vary before and after surgery could be explained by the fact that the majority of DTC are diagnosed in early stage, sometimes incidentally and in consequence no or light symptoms influence life of patients. In fact, as shown in our analysis the only item that significantly decreases after surgery is anxiety. This is justified by the malignant nature of the pathology and the consequent relief after surgery with the perception of recovery from disease.Our study has allowed us to evaluate how in the analysed populations the general perception of injury is good and it improves with the running time, reaching the best scores after 3 months. Scar perception can change in relation to gender, but age and the type of suture performed seem to be irrelevant.Our research presents some limitations: first of all, patients involved in the study are Caucasian and in consequence our data do not consider the possible influence of other cultural factors regarding the scar perception in an exposed anatomical site. Moreover, in our population it was not considered a psychological evaluation which could evidence depressive disorder or dysmorphophobic disorder potentially influencing scar perception.It would be interesting to stratify the population, also on the basis of the profession, dividing for example the patients into those who perform a “public” job in comparison with those who have more limited social relations.Another further starting point would be to compare patients with different cultural levels, thus trying to understand if the level of education can modify the evaluation in any way. Finally, with a larger sample, the population could be divided according to ethnicity or phenotypic characteristics, and evaluation of how this correlates with the quality of healing process and the perception of the wound could be explored.Eventually, scar cosmesis perception after transcervical is also a relevant issue to be considered, even more so in the era of remote access robotic or trans-oral approaches.In conclusion, scars associated with thyroid surgery are well accepted by the patients. Patients seem to be satisfied with surgical scars even at the first postoperative follow up and their satisfaction seems to improve over time. Subcuticular suture technique does not seem to influence scar satisfaction. Female gender seems to be significantly associated with a lower scar satisfaction and a heavier impact on QoL during follow-up; however, age does not seem to influence scar satisfaction. In our study the diagnosis of thyroid carcinoma does not seem to influence the patient’s QoL. All these data could suggest that even if thyroid surgery-related scars are clearly visible, the patient’s satisfaction and the low impact on QoL permit the surgeon to safely employ the conventional neck approach rather than mini-invasive or robotic assisted surgeries that are reported to be more aesthetic but technically complex, expensive, and time consuming.


Cognitive impairment occurs in 40%–70% of persons with multiple sclerosis (MS).To examine the effectiveness of natalizumab compared with other disease-modifying treatments (DMTs) on improving cognition as measured by the Symbol Digit Modalities Test (SDMT).Data were collected as part of Swedish nationwide phase IV surveillance studies (2007–2020). An increase in SDMT score by ⩾10% of the difference between maximum score possible (110) and the baseline value was defined as cognitive improvement. The likelihood of improvement was compared between natalizumab-treated individuals and individuals treated with other DMTs using mixed effect logistic regression. Trend in odds of improvement was investigated using slope analyses.We included 2100 persons with relapsing-remitting MS treated with natalizumab and 2622 persons treated with other DMTs. At 6 months, 45% reached improvement. The natalizumab group showed largest odds of improvement during follow-up : 1.5–3.5). The odds of improvement increased by 7% (95% CI: 6–7) per month of natalizumab treatment. The equivalent estimate was 4% (95% CI: 2–5) for other monoclonal antibodies and nonsignificant for oral or platform therapies.Treatment with natalizumab or other monoclonal antibodies is associated with a significantly faster likelihood of cognitive improvement than platform or oral DMTs. It is associated with stress, decline in standards of living, loss of employment, and withdrawal from social activities.3 Cognitive impairment occurs in all stages of the disease5 often independent of physical disability.Cognitive decline occurs in 40–70% of persons with multiple sclerosis (MS). used as a highly potent disease-modifying treatment (DMT) in persons with active MS. Natalizumab has been shown to efficiently reduce the risk of sustained progression of physical disability and the rate of clinical relapses in relapsing-remitting multiple sclerosis (RRMS).Natalizumab is a humanized monoclonal antibody912 However, the findings are mainly reported in non-randomized observational studies with short-term follow-ups and small sample sizes. In general, evidence on the effect of DMTs on cognitive improvement in MS is lacking, particularly from randomized controlled trials. Furthermore, no study has investigated the comparative effectiveness of natalizumab on cognition with other DMTs. Hence, the objective of this study was to determine and compare the long-term effectiveness of natalizumab on cognition as measured by the Symbol Digit Modalities Test (SDMT)15 in a large population-based cohort of individuals with MS. The SDMT has been shown to be associated with several clinical and patient-centered outcomes in MS, such as income, employment, and daily activity.17 In MS, performance on the SDMT is shown to be predictive of future cognitive decline. The SDMT has been found to be the most sensitive individual cognitive measure for use in MS.20 In this work, we examined the effectiveness of natalizumab on the improvement of cognition and compared its effect to the effects seen by using platform therapies, other monoclonal antibodies, and oral DMTs.Studies have also shown that natalizumab decreases the risk of cognitive decline and is associated with clinically meaningful improvement in cognition in individuals with MS.Immunomodulation and MS Epidemiology (IMSE) study.22 The IMSE cohorts are prospective recruitments of all individuals with MS throughout Sweden who start on natalizumab, fingolimod, alemtuzumab, teriflunomid, dimetyl fumarate, peginterferon beta-1a, rituximab, daclizumab, ocrelizumab, or cladribin. Based on total sold doses, it has been estimated that more than 95% of the Swedish MS patients who started on natalizumab are part of the IMSE cohort. In IMSE, patients are evaluated at baseline (treatment initiation), 6 months and annually thereafter until treatment discontinuation. A neurologist performs clinical evaluation at each time point, which includes recording of number of relapses, Expanded Disability Status Scale (EDSS) score, and possible adverse events. A trained MS nurse performs the SDMT as well as performing the blood sampling. Data collection, storage, and reports of adverse events are performed using the infrastructure provided by the Swedish MS Registry (SMSreg) web platform.Data for this study were collected from a Swedish post-market surveillance study of the long-term effectiveness and safety of DMTs, which started in 2006, the ali.manouchehrinia@ki.se).Data related to this article are available from Tomas Olsson, Karolinska Institutet. To share data from the IMSE cohorts and Swedish MS registry, a data transfer agreement must be completed between Karolinska Institutet and the institution requesting data access. This is in accordance with the data protection legislation in Europe . Persons interested in obtaining access to the data should contact Ali Manouchehrinia , ocrelizumab, alemtuzumab, daclizumab, and ofatumumab), oral DMTs , and platform therapies . All included individuals were required to have (1) no SDMT test performed prior to the baseline SDMT test to avoid learning effects, (2) baseline SDMT test performed at most 90 days prior to respective treatment initiation, (3) baseline SDMT score ⩾24 and ⩽90 (mean ± 2 standard deviations) to reduce potential reporting errors caused by outliers, and (4) at least three SDMT tests performed during treatment. All included participants had MS fulfilling the McDonald criteria2325 as judged by their neurologist.Included in this study were RRMS participants from the IMSE natalizumab-treated cohort, treated with natalizumab for minimum of 6 months and naïve to treatment with other monoclonal antibodies and a randomly selected population of natalizumab-naïve individuals with MS who had received other therapies  identified from the Swedish MS registry for the comparative effectiveness analysis. Treatment categories were defined in accordance with categorization used previouslyWe evaluated cognition by investigating the changes in SDMT performance over time, specifically likelihood of cognitive improvement at each follow-up visit. The SDMT ranges from 0 to 110, with a higher score indicating better cognitive performance. SDMTs are completed at baseline, at 6th month, and on an approximately annual basis during treatment with natalizumab or other therapies . Because MS centers performed the SDMT test as either an oral or a written test, giving rise to some inconsistency in the score, we included follow-up periods of only one SDMT type  and all statistical analyses were controlled for the type of test that each participant completed. Cognitive improvement was defined as an increase in the SDMT score by ⩾10% of the difference between the maximum possible score (110) and the baseline SDMT score (at the time of treatment initiation). That is ⩾6 SDMT score improvement for a person with a baseline score of 50 and ⩾5 SDMT score improvement for a person with a baseline score of 60. The choice of relative cut-off for measuring improvement (as opposed to a fixed ⩾4- or ⩾8-point improvement) prevented ceiling effect, obscuring the improvement in persons with relatively high SDMT scores at baseline.We assessed the impact of natalizumab and other therapies on the likelihood of cognitive improvement using two methods. First, we started by investigating the proportion of patients treated with natalizumab who reached cognitive improvement (see above) at 6 months up to 126 months post-treatment initiation. We compared the basic clinical and demographic characteristics of patients who reached cognitive improvement at 6 months post-treatment initiation compared to those who did not show improvement using parametric or non-parametric tests.We then proceeded to evaluate the effect of natalizumab on likelihood of cognitive improvement by fitting (1) a mixed-effects logistic regression model to obtain the likelihood (in terms of odds ratios) of cognitive improvement over the follow-up time and (2) simple slope analyses with treatment and time interaction to calculate the odds of cognitive improvement per each follow-up month for natalizumab-treated persons and persons treated with other treatments. All models were adjusted for sex, age at onset of MS, age at treatment initiation, baseline SDMT score, presence of relapse within 120 days of test, number of tests performed during follow-up, time for follow-up, and type of SDMT test performed.We finally investigated the differences in the proportion of persons with cognitive improvement at each follow-up time between treatment groups using the chi-square tests.To ensure the robustness of the findings, we conducted three sensitivity analyses. In the first analysis, similar models but on a propensity score-matched population was fitted. The second sensitivity analysis was performed on a subset of individuals from the original study population who were classified as cognitively impaired at baseline (the baseline SDMT score <1.5 standard deviations of sample mean). The third sensitivity analysis was performed on those who performed only oral version of the SDMT test.All statistical analyses were performed using R version 4.0. Ethical approval was obtained from the Stockholm ethical committee (EPN) at Karolinska Institutet.A summary of the demographic and clinical characteristics of the study population is presented in Natalizumab treatment was associated with a significant improvement in the SDMT performance. Approximately 45% of patients (806 persons of 1779 with SDMT score at 6 month) reached improvement (increase in the SDMT score by ⩾10% of the difference between maximum possible score and the baseline score) at 6 months after treatment initiation . Figure Characteristics of the natalizumab-treated and natalizumab-naïve individuals, before and after matching, are presented in The odds of cognitive improvement  for natalizumab-treated individuals increased by 7% (95% CI: 6–7) per month of therapy (follow-up). The equivalent estimates were 4% (95% CI: 2–5) for other monoclonal antibodies, 2% (95% CI: –1 to 4) for platform DMTs, and 1% (95% CI: –1 to 1) in those receiving oral DMTs . Progresn = 309) were classified as being cognitively impaired at baseline (baseline SDMT score < 1.5 standard deviation of cohort mean). While we did not observe an overall difference between treatments in odds of improvement over the follow-up time   , the oddle size) . We did le size) .In summary, similar results to those obtained before matching were found after propensity score matching . The twoUsing a large, nationwide population-based cohort of persons with RRMS treated with natalizumab, we found that treatment with natalizumab or other monoclonal antibodies was associated with a significantly better rate of improvement in cognition. Natalizumab and other monoclonal antibodies showed superior performance in improving cognition compared to platform therapies or oral DMTs during the follow-up time. While the trend in progression of odds of cognitive improvement was significantly higher in those receiving natalizumab and other monoclonal antibodies compared to those on platform or oral therapies, we observed an overall greater odds of having cognitive improvement in the natalizumab-treated individuals. These results remained mainly unchanged after a rigorous propensity score matching analysis. We also found beneficial effects of natalizumab and other monoclonal antibodies in improving cognition in those with major cognitive impairments, albeit with smaller effect sizes. Even though the study included 17 (out of 44 included studies) randomized control trials, no statistically significant difference between platform and highly potent DMTs was observed. A similar conclusion has been reached in a recent systematic review of studies investigating the effects of DMT on cognition in MS. Contrary to a meta-analysis which may carry forward the limitation of included studies, the results from this study suggest that monoclonal antibodies can improve cognition in MS compared with the platform or oral therapies. Our result is consistent with results of smaller previous observational studies showing significant improvements in cognitive function after natalizumab treatment.2729Despite the availability of DMTs for more than two decades, their effect on cognitive decline in MS is mostly unknown. A recent systematic review and meta-analysis of the effect of DMTs on cognitive performance in RRMS showed a minimal positive effect of DMTs on SDMT score. as seen for physical disability, and both physical and cognitive deteriorations exhibit marked between and inter-patient variability. Hence, evaluating the effect of different treatments on cognition is important to improve the possibility of choosing a favorable treatment for each patient.The majority of patients with MS show a similar progressive decline of cognitionFormer studies have used an improvement of ⩾4 SDMT score from baseline as a definition of reaching clinically meaningful improvement. We found that this approach gives individuals with a lower baseline SDMT artificially higher chance of reaching clinically meaningful improvement as it is easier to improve ⩾4 when they score lower at baseline. To handle this problem, we used the definition of cognitive improvement as an increase in SDMT by ⩾10% of the difference between maximum possible score and the baseline score which makes the impact of baseline SDMT score on cognitive improvement less significant. The learning effect, caused by repeated testing, could influence the performance on SDMT score. However, in a comparative study design, this should affect all groups equally to bias the estimates. As the models and the case–control propensity score matching were controlled for number of tests performed and duration of follow-up (i.e. treatment duration), we therefore do not think that the learning effect has significantly affected the results of our analyses.Strengths of this study include a large nationwide population-based cohort of MS patients treated with natalizumab, longitudinal follow-up, multiple analysis methods with similar results and a large, population-based, matched control cohort of MS patients never treated with natalizumab. However, this study has some limitations. Due to cohort matching, we had to exclude many participants. We did not have information and therefore did not control for the effect of educational level, socioeconomic factors and other factors that could potentially influence cognition, which could impact the SDMT performance. However, given the Swedish population’s socioeconomic and educational homogeneity, we do not think these factors have substantially confounded our results. Furthermore, this study examined the effect of natalizumab on cognition in persons with MS as one homogeneous population and compared to patients on other DMTs. Although all patients had relapsing-remitting course and active disease, it is possible that type and severity of cognitive dysfunction may have been unevenly distributed in this cohort. It is quite likely that the characteristics of the cognitive problems affected the choice of therapy in the first place which could interfere with the results of this study beyond what our analyses could be adjusted for. Therefore, additional studies and ideally randomized trials are needed to examine further the impact of different DMTs on cognition in MS.In conclusion, we observed that treatment with natalizumab and other monoclonal antibodies is associated with significant improvement in cognitive performance in persons with RRMS as measured by the SDMT score. The effect of these treatments on cognitive improvement was superior to the platform or oral therapies.


An Emergency Use Authorization (EUA) was issued by the FDA on December 22, 2021 for the investigational antiviral drug nirmatrelvir copackaged with the HIV-1 protease inhibitor ritonavir (Paxlovid - Pfizer) for outpatient treatment of mild to moderate COVID-19 in children 12 years and old that are high risk of severe disease. Due to the effects, Paxlovid has on liver metabolism it has a copious amount of drug-to-drug interactions. Here we present a rare case of a patient that was given Paxlovid and continued to take her Ranolazine at home. She presented to the emergency department obtunded and after an initial workup, it was determined to be secondary to ranolazine toxicity. She eventually recovered over 54 hours and returned to her baseline.  Coronavirus is classified as a single positive-stranded, enveloped RNA virus, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a type with high pathogenicity . SARS-CoA 70-year-old female patient with a past medical history of type 1 diabetes, hypertension, coronary artery disease (coronary artery bypass grafting seven years ago), and chronic kidney disease stage II presented from home by emergency medical services (EMS) to the emergency department with altered mental status. She initially went to her primary care provider (PCP) six days ago with complaints of fatigue, generalized weakness, non-productive cough, and muscle aches. The patient was diagnosed with COVID-19 in the office and her PCP prescribed Paxlovid. The husband reported that she was on day 3 of Paxlovid when she started to become slightly confused and not acting herself, but the family thought it was all due to her COVID-19 infection. She completed all five days of Paxlovid, and on the evening of the fifth day, she was completely altered and non-vocal. At this time husband confirmed she had taken Ranexa and atorvastatin with Paxlovid all five days. The husband reported that all he could do was to get her to open her eyes. At this time, the husband called EMS, and when they arrived the patient oxygen saturation was 80% on room air and she was placed on a 2-liter nasal cannula. Once the patient arrived at the Emergency department her vitals were 97.9 degrees Fahrenheit, heart rate was sinus bradycardia 52 beats per minute, her respiratory rate 15, her blood pressure 166/66, and her oxygen saturation 95% on 2 liters oxygen. Initial blood work can be seen in Table Due to her altered mental status CT scan of the head without contrast was performed and showed no acute intracranial abnormality. CT scan of the chest with and without contrast was done to rule out pulmonary embolism due to her recent history of COVID-19 and hypoxia, and results showed no evidence of central pulmonary embolism. At this time, poison control was called with concern of Ranexa toxicity due to consumption of Ranexa and Paxlovid simultaneously. Poison control recommended supportive therapy because Ranexa is too highly protein bound to be dialyzed off. The patient was admitted to the floor for monitoring. The patient remained hemodynamically stable throughout hospitalization and was eventually transitioned to room air. After approximately 54 hours she returned to her baseline. The patient was then discharged to subacute nursing facility to complete physical therapy.As a treatment for chronic stable angina, ranolazine was approved by the FDA in 2006 . In the The most common side effects associated with ranolazine use are headaches (5.5%), dizziness 1% to 6%), constipation (5%), and nausea  %, consti. Just asNirmatrelvir/ritonavir received an Emergency Use Authorization (EUA) from the FDA on December 22, 2021 for treating COVID-19 . When syHere we present an interesting case of a patient that took Paxlovid with Ranolazine which resulted in Ranolazine toxicity. With the patient's initial presentation, innumerable differentials could be crossing a physician's mind. It is important to always go over the patient's home medications and any new additional medications. It is also important to warn patients about potential drug side effects and interactions when prescribing new medications. The FDA currently has a prescriber sheet to review before prescribing this medication to patients to avoid any unnecessary cross-drug reactions. Our patient and family initially thought that her confusion was part of the viral symptoms that come with COVID-19 and never thought about potential drug interactions.


The COVID-19 pandemic created a requirement for reduced patient contact and reduced capacity in clinics. We previously published results of an Image-Based Eyelid Lesion Management Service (IBELMS) which was found non-inferior to traditional face-to-face clinic at diagnosing lesions and identifying eyelid malignancies. We now present first-year safety and efficacy data from this service.th September 2020 to 29th September 2021, including referral source and diagnosis, time to clinic review, treatment and patient outcomes.Data were collected retrospectively on all patients seen in NHS Greater Glasgow and Clyde eyelid photography clinics from 30p ≤ 0.0001). 266 (33%) of patients were discharged following photographs, 45 (6%) were discharged for non-attendance and 371 (46%) were booked for a minor procedure. 13 biopsy-confirmed malignant lesions were identified; only 3 had been referred as suspected malignancy. 23 patients out of 330 with at least 6 months follow up (7%) were re-referred within 6 months of treatment or discharge; however, none of them with a missed periocular malignancy.808 patients were included in the study. Chalazion was the most common diagnoses recorded (38.4%). There was a statistically significant decrease in mean time from referral to appointment time between the first 4 months and last 4 months of the service (93 days to 22 days, Eyelid photography clinics effectively reduce patient waiting times and maximise clinic capacity. They accurately identify eyelid lesions including malignancies with a low re-referral rate. We propose that an image-based service for eyelid lesions is a safe and effective way of managing such patients. Uptake of tele-medicine has long been a feature in ophthalmic clinical practice; however, the COVID-19 pandemic provided a catalyst to the rapid expansion of virtual services both in ophthalmology and the wider medical world. In March 2020, the NHS was directed to “reduce provision of outpatient services and direct health resources and personnel to acute care [In early 2020, NHS Greater Glasgow and Clyde (NHSGGC) conducted a pilot study comparing usual standard of care  to a consultation with a hospital optometrist and review of eyelid lesion photographs by a consultant ophthalmologist and a technician led eyelid photograph clinic with images reviewed later by a consultant ophthalmologist , 4.To calculate the effect of this service on the waiting time for management of eyelid lesions in NHSGGCTo understand the nature of lesions seen within the service and the sources of referralTo determine the safety of this service by analysing the numbers of eyelid malignancies that were diagnosed and using a surrogate marker to identify missed malignanciesTo determine the rate of re-referral following discharge or management within the serviceThe department, on the basis of this pilot, decided to implement a technician-led Image Based Eyelid Lesion Service (IBELMS) in September 2020 and we report the data from the first year of this service. Our aims were:th September 2020 and 29th September 2021 at NHS Greater Glasgow and Clyde were included in the study. Any referrals from other clinicians  that explicitly mentioned a ‘suspected malignancy’ were fast-tracked to a separate pathway and hence excluded. Patients who did not consent to undergo clinical photography were also excluded.This is a retrospective cohort study. All patients vetted to attend the eyelid photography clinic between 30The IBELMS clinic pathway started with patients attending for an appointment at the eyelid photography clinic. The trained medical photographers filled in a questionnaire regarding their symptoms, duration of lesion, change in size of lesion and previous history of skin malignancies. The photographer took consent for clinical photography and photographed the lesion and the eyelids. The clinical photographs and completed questionnaires were then reviewed asynchronously by a consultant oculoplastic surgeon. One of the following outcomes were communicated to the patient and referrer by letter: (1) discharge with advice (2) book to a face-to-face clinic (3) book for minor operations clinic (4) book for a procedure in main operating theatre. Written information  was included as required.Data was collected from the board’s electronic medical record  on the referral source and referrer diagnosis, clinician diagnosis, histological diagnoses (where available) and management. Referral-to-appointment and referral-to-treatment time was also calculated. Re-attendance rates were based upon those patients who had attended the eyelid photography clinic in the first 6 months of the data collection period. Statistical analysis was performed using Microsoft Excel  and Medcalc for Windows . This study formed part of a service evaluation, individual patient consent was therefore not required and the research and ethics committee at NHSGGC did not deem formal approval necessary. The study adheres to the tenets of the Declaration of Helsinki.809 patients were included in the study. There was a slight female predominance . Referral sources are shown in Fig. 808 appointments were offered to 789 patients in the eyelid photography clinic. 45 (5.5%) of appointments were not attended and patients were discharged back to the referrer with the option of re-referral as appropriate. 22 (2.7%) of appointments were not attended but were rebooked and all patients attended a subsequent appointment. Therefore, the non-attendance rate was 8.3% of appointments. 6 (1%) of appointments had insufficient data and 1 patient died prior to attending his appointment following referral. This left 734 patients available for analysis. A breakdown of the outcome of all patients referred to the eyelid lesion clinic is shown in Fig. p ≤ 0.01, Comparison of Means). The latter is more likely to reflect the waiting time of the service in the long run.In the initial few months, the service was catering to the backlog of patients on the waiting list created by the pandemic. During the first 4 months of the service, the average time from referral-to-assessment was 93 days. During the last 4 months of this study period, the mean time from referral to assessment was 22 days . Of the patients referred from IBELMS for an eyelid procedure, 22 were found not to require the procedure when they attended giving a false positive rate  of 5.7%. However, the lesion (in particular Meibomian cysts) may well have resolved by the time the patient was seen for intervention.310 (41.8%) patients underwent a surgical procedure. The mean waiting time from referral-to-procedure was 194 days at months 1–4, and 122 days from months 8–12.  of the remaining 138 cases the histological diagnosed matched that recorded by the clinician from the IBELMS clinic. In the remaining 54 cases, the diagnosis differed; however, in 53 of these (98.1%) both the clinical and histopathological diagnoses were benign.6-month data on re-referral was available for 330 patients. Of these, 24 (7.3%) patients were re-referred. 18 (75%) of re-referrals were for enlarging or non-resolving lesions, 4 (16.7%) for unrelated pathology and 2 (8.3%) at the patient’s request for further advice or discussion. We consider the false negative rate, patients who were initially discharged without face-to-face review or interventional treatment who were later referred and required interventional treatment for their original lesion as 4.5%. No patient was re-referred with suspected malignancy in the periocular region.This study demonstrates that a photographer-led eyelid lesion clinic is a safe and effective way of assessing patients referred to secondary care with an eyelid lesion which is felt likely to be benign. We demonstrate that such a service can significantly reduce the time patients wait for assessment and interventional treatment if required. We show that it is effective at the identification of eyelid malignancies with a rate of missed malignancy of 0.13%. We consider a 6 months re-referral rate of 9% to be reasonable, especially given around 20% of these re-referrals were for an unrelated pathology. However, our appointment non-attendance rate of 8.3% was slightly higher than the 6.8% recorded in Scotland in the first quarter of 2019/20 , the lasOur figure of 60.9% correlation between clinical and histopathological diagnosis is lower than that reported in series such as Banerjee et al. . FurtherThis study was not specifically designed to assess cost implications of our IBELMS service however we feel the service is likely to be more cost-effective than a traditional face-to-face model. Prior to the introduction of the service, a proportion of these patients would have been seen in a face-to-face consultant-led clinic and a proportion would have been referred directly to a nurse-led minor operations clinic. Many patients would have had an image of their eyelid lesion recorded for documentation. In the IBELMS model around 3.5 times as many patients can be reviewed by a consultant in a session than in a face-to-face model (40 IBELMS patients vs 12 patients in a standard clinic profile). The number of patients booked for surgery who do not need or qualify for surgery is likely to be lower with prior secondary care evaluation. These savings are partially offset by the cost of increased medical illustration staff and time in the IBELMS model however. There were no capital costs associated with the IBELMS service as it uses existing equipment and software. We would advocate a study designed to specifically assess cost implications of this model to support introduction in other units.Several studies have reported on the utility and safety of telemedicine for the assessment of eyelid lesions. Kang et al.  in a stuWe believe this study to be the largest to date looking at asynchronous remote evaluation of eyelid lesions. Whilst it was performed at a single centre, there were a number of photographers and consultant reviewers who evaluated patients so we feel these findings could be replicated at other units and the results are not likely influenced by any individual photographer or clinician. We feel that this study would be representative of the UK population as a whole as it would have captured the majority of referrals with eyelid lesions within the Greater Glasgow area during this period, as no other public sector provider treats patients for periocular lesions in the region. In planning an image-based eyelid lesion service, the reported 7–8% rate of re-referrals must be factored in.Asynchronous and synchronous telemedicine both have advantages and disadvantages. As demonstrated by Ah-Kye et al.’s study  synchronLimitations include the fact that the study was retrospective and recording was not complete for all patients. 6 months follow up data was only available for less than half of the studied patients and, given that not all patients had a biopsy or excision procedure performed, the exact diagnosis of their lid lesions cannot be confirmed. The study did not evaluate patient satisfaction rates in this cohort; however surrogate measures for satisfaction, including re-referral rates, were low.In conclusion, we demonstrate that an image-based asynchronous teleconsultation model for the assessment of patients with presumed benign eyelid lesions is efficient and safe. It Is able to reduce waiting times for an assessment appointment, allow clinicians to work flexibly and minimise use of clinic consultation space whilst accurately identifying periocular malignancies requiring prompt treatment. We recommend that other units with an increasing waiting list of patients with eyelid lesions or restricted by face-to-face clinic capacity consider adopting this model.Telemedicine is widely used within different subspecialties in ophthalmology Different telemedicine methods have been reported to be successful in the field of oculoplastics Photography-based eyelid lesion clinics are non inferior than face-to-face clinics when diagnosing eyelid lesions.Photography-based eyelid lesion clinics are able to pick up eyelid malignancies reliably Photography-based clinics are an effective way to reduce referral to assessment and referral to treatment times for patients with eyelid lesions Patients assessed with photography are rarely re-referred for further assessment and treatment.