Successful treatment approaches for tumoral calcinosis in children and young people: A condition of diverse pathogenesis

BACKGROUND

Ectopic calcification is inappropriate biomineralization of soft tissues occurring due to genetic or acquired causes of hyperphosphataemia and rarely in normophosphataemic individuals. Tumoral Calcinosis (TC) is a rare metabolic bone disorder commonly presenting in childhood and adolescence with periarticular extra-capsular calcinosis. Three subtypes of TC have been recognised: primary hyperphosphataemic familial TC (HFTC), primary normophosphataemic familial TC and secondary TC most commonly seen in chronic renal failure. In the absence of established treatment, management is challenging due to variable success rates with medical therapies and recurrence following surgery.

AIM

We outline the successful treatment approaches in four children with TC (2 normophosphatemic TC, 2 HFTC) aged 2.5-10 years at initial presentation.

CASES

Patient 1 (P1) presented at 10 years with a painless lump behind the right knee, P2 with swelling of the right knee anteriorly at 9 years, P3 and P4 with pain and swelling over the right elbow at 5 and 2.5 years respectively. All patients were of Black African-Caribbean origin and were previously reported to be fit and well with no family history of TC.

RESULTS

P1, P2 had normophosphataemic TC and P3, P4 had HFTC with genetically confirmed GALNT3 mutation. All four patients had initial surgical resection with TC confirmed on histology. P1 had complete surgical resection with no recurrence at 27 months post-operatively. P2 had significant overgrowth of the tumour following surgery and was subsequently successfully managed with 25 % topical sodium metabisulphite (total duration of 8 months with a 4 month gap during which there was recurrence). P3 had post-surgical recurrence of TC on the right elbow and a new lesion on left elbow which resolved with oral acetazolamide monotherapy (15-20 mg/kg/day). P4 had recurrence of right elbow lesion following surgery and developed an extensive new hip lesion on sevelamer therapy which resolved completely with additional acetazolamide therapy (18-33 mg/kg/day). Acetazolamide was well tolerated with normal growth for 5 years in P3 and 6.5 years in P4 and no recurrence of lesions.

CONCLUSION

The frequent post-surgical recurrence in TC and successful medical therapy on the other hand indicates that medical management as first line therapy should be adopted. Monotherapies with topical 25 % sodium metabisulphite in normophosphataemic and oral acetazolamide in HFTC are effective treatment strategies which are well tolerated.

A Phase-IV Non-interventional Study to Assess Virological Effectiveness, Safety, and Tolerability of DTG-based Antiretroviral Therapy in HIV-1 Infected Indian Persons Living with HIV

BACKGROUND

Dolutegravir (DTG) is a novel yet preferential first-and-second-line treatment for persons living with HIV (PLH). Owing to its recent introduction, DTG-based regimens have not undergone a comprehensive, systematic evaluation regarding their real-world utilization and safety profile among a sizeable Indian population.

OBJECTIVE

This study aimed to assess the 24-week immunovirological outcomes, anthropometric and metabolic changes, tolerability, and adverse events (AEs) of DTG-based antiretroviral (ART) regimens.

METHODS

A single-centre phase-IV non-interventional observational study involving 322 ART-- naïve and treatment-experienced PLH initiating DTG-based-regimens until October 2022 were followed up for outcomes at 24 weeks.

RESULTS

At 24 weeks, all PLH (n=113) in the naïve group, all PLH (n=67) in the first-line substitution group, 93.9% PLH (n=46) in the first-line failure group, and 95.7% PLH (n=89) in the second- line substitution group were virologically suppressed to plasma HIV-RNA <1000 copies/mL. Virological suppression rates to plasma HIV-RNA <200 copies/mL and <50 copies/mL were consistent among PLH who received DTG as first- or second-line ART. The mean-unadjusted weight gain observed was 3.5 kg (SE: 0.330), and it was significantly higher in PLH with poorer health at baseline (either HIV-RNA ≥ 1000 copies/ml or CD4 cell count <350 cells/μL). Overall, 27.3% PLH (n=88) gained ≥10% of their baseline body weight, corresponding to 3.7% incidence (n=10) of treatment-emergent clinical obesity [1]. DTG had an overall lipid-neutral effect, with an advantageous effect being observed in PLH switching from non-nucleoside analogue reverse-transcriptase inhibitors (NNRTI) or ritonavir-boosted protease inhibitors (b/PI), especially in dyslipidemic pre-treated PLH (median change in total cholesterol: 28.5 mg/dL and triglycerides: 51 mg/dL), possibly emanating from the withdrawal of the offending ART. The incidence of DTG-specific AEs, including CNS AEs, was low. Two PLH developed proximal myopathy and one developed transaminitis, warranting DTG discontinuation. Asymptomatic serum-CPK elevation and drug-induced transaminitis were seen in 25.2% (n=27) and 3.2% (n=10) PLH, respectively. No apparent negative effects on renal function were detected.

CONCLUSION

Our results from a large Indian cohort indicate a favourable virological and metabolic response, with good tolerance of DTG-based ART at 24 weeks.

Physical function and physical activity in adults with X-linked hypophosphatemia

We described physical function and activity in UK adults with X-linked hypophosphatemia (XLH). Our data indicate that low physical activity and impaired mobility are common in adults with XLH. Deficits in lower limbs muscle power and functional capacity contribute to the loss of physical function in adults with XLH.

INTRODUCTION

There is a dearth of literature on physical function and physical activity in adults with X-linked hypophosphatemia (XLH). We described muscle strength and power, functional capacity, mobility and physical activity level and explored the relationships among these variables in adults with XLH.

METHODS

Participants were recruited as part of a UK-based prospective cohort study, the RUDY Study. They underwent a clinical visit and physical examination, including assessment of handgrip strength, jump power (mechanography), six-minute walk test (6MWT) and short physical performance battery (SPPB), and completed the International Physical Activity Questionnaire (IPAQ). Performance data were analysed using parametric and non-parametric tests, whereas correlations were assessed by univariate analysis.

RESULTS

Twenty-six adults with XLH (50% males) with a mean age of 44 ± 16.1 years were recruited. Jump power and 6MWT distances (p < 0.0001) were 54.4% and 38.6% lower respectively in individuals with XLH compared with normative values. These deficits were not associated with age or sex. Handgrip strength values were similar to expected values. Deficits in muscle power were more pronounced than those reported at 6MWT (p < 0.0001). Univariate analysis revealed only a correlation between total physical activity and muscle power (r = 0.545, p = 0.019).

CONCLUSIONS

Adults with XLH have a marked deficit in lower limb muscle power and a reduced functional capacity, with a high incidence of impaired mobility and inactivity. In addition to metabolic effects of XLH, low physical activity may contribute to deficits in lower limb power. Further studies are required to develop novel treatment approaches to improve physical function and mobility.

OP0246 TO SCAN OR NOT TO SCAN (BOTH HIPS) – A BRISTOL EXPERIENCE

Background

The current International Society of Clinical Densitometry (ISCD) recommendation for bone densitometry practice is that single hip measurement is sufficient in clinical practice, as there is overall a good correlation between the two hip bone mineral densities (BMD) (1) (2). However, discordance in individual T- scores and BMD between the 2 hips due to increasing age and osteoarthritis (3)-(5) is well recognised.

Objectives

We aimed to identify whether discordant hip BMD values would lead to differences in the FRAX risk assessment score between the two hips, and thereby impact treatment decisions in clinical practice.

Methods

We looked at all DXA scans performed at our centre for 2 months between 23/7/21 and 23/9/21. Cases in which both hips were scanned and anti-resorptive treatment was advised were included in our study. The femoral neck with the lower BMD is used to calculate the FRAX score and this was referred to as the ‘reported’ hip. The FRAX score for ‘reported’ and ‘unreported’ hip were calculated and the T-score of the spine was also noted. Our local treatment threshold is set at 20% for a major osteoporotic fracture and 5% for hip fracture. Cases of difference in scores crossing the 20%/5% FRAX threshold were highlighted and reviewed in more detail.

Results

DXA scans were performed in 328 patients over the 2 month period, of which 201 patients had both of their hips scanned. Of these, 50 patients were advised to start anti-resorptive treatment. The majority of the treatment decisions (60%; 30/50 cases) were based on the hip/femoral neck BMD value, while 40% (20/50 cases) were based on the spine T-score.

Where the treatment decision was based on hip/femoral neck BMD, 20% (6/30 cases) were found to have a FRAX risk above the treatment threshold at one hip only, meaning that treatment may not have been offered if both hips had not been scanned. Similarly, where treatment was advised based on spinal T-scores, 20% (4/20 cases) had a FRAX risk above treatment threshold at one hip only.

Mean age across these 10 cases with a discordant FRAX risk between the two hips was 72 years (range 59 – 83); 80% (8/10) were female. Steroid use and chronic inflammatory co-morbidities were the predominant indications for these DXA Scans.

Conclusion

A significant proportion of patients in our cohort (20%; 10/50) may not have been offered treatment if only one hip was scanned. Scanning both hips does not require much additional time and can help mitigate the risk of undertreating patients. The recommendation for best practice for DXA BMD measurements should be reviewed to consider lumbar spine and dual hip BMD as standard of care.

References

[1]E. Michael Lewiecki, Nelson B. Watts, Michael R. McClung, Steven M. Petak, Laura K. Bachrach, John A. Shepherd, Robert W. Downs, Jr., Official Positions of the International Society for Clinical Densitometry, The Journal of Clinical Endocrinology & Metabolism, Volume 89, Issue 8, 1 August 2004, Pages 3651–3655, https://doi.org/10.1210/jc.2004-0124

[2]Rao AD, Reddy S, Rao DS. Is there a difference between right and left femoral bone density? J Clin Densitom. 2000 Spring;3(1):57-61. doi: 10.1385/jcd:3:1:057. PMID: 10745302.

[3]Chen W, Khan Z, Freund J, Pocock N. Dual Hip DXA. Is it Time to Change Standard Protocol? J Clin Densitom. 2021 Jul 24:S1094-6950(21)00060-3. doi: 10.1016/j.jocd.2021.07.006. Epub ahead of print. PMID: 34391641.

[4]Mounach A, Rezqi A, Ghozlani I, Achemlal L, Bezza A, El Maghraoui A. Prevalence and Risk Factors of Discordance between Left- and Right-Hip Bone Mineral Density Using DXA. ISRN Rheumatol. 2012;2012:617535. doi: 10.5402/2012/617535. Epub 2012 Jun 17. PMID: 22778990; PMCID: PMC3384949.

[5]Nishizawa K, Harato K, Morishige Y, Kobayashi S, Niki Y, Nagura T. Correlation between weight-bearing asymmetry and bone mineral density in patients with bilateral knee osteoarthritis. J Orthop Surg Res. 2021;16(1):102. Published 2021 Feb 2. doi:10.1186/s13018-021-02252-5.

Disclosure of Interests

Aishwarya Anilkumar: None declared, Sadaf Saeed: None declared, Ehsan Elsayed: None declared, Chandrin N. R. Jayatilleke: None declared, Stuart Webber: None declared, Mathew A. Roy Consultant of: Worked as a paid consultant for Kyowa Kirin.

AB0589 TOCILIZUMAB FOR GIANT CELL ARTERITIS: BASELINE AND TWELVE MONTH AUDIT DATA FROM THE UK BRISTOL AND BATH MULTIDISCIPLINARY MEETING

Background

Giant Cell Arteritis (GCA) is a systemic vasculitis involving large and medium-sized blood vessels. Treatment is with high dose glucocorticoids. Steroid-sparing agents and Tocilizumab (TCZ) are used for refractory or relapsing cases. NHS England requires all GCA patients to be discussed in a regional multidisciplinary team meeting (MDT) prior to commencing TCZ. TCZ has only been permitted for a maximum of one year; this time limitation was extended during the Covid-19 pandemic (1). The monthly virtual Bristol and Bath regional MDT started in November 2018.

Objectives

We aimed to review: 1) Baseline data on all patients referred to the Bristol and Bath TCZ for GCA MDT, including demographics, clinical presentation and previous steroid-sparing agents used and 2) 12 month follow up data including number of completions, adverse effects, and flares on treatment.

Methods

The TCZ MDT referral proforma, adapted from the NHS England Blueteq approval form, was reviewed for all patients referred. 12 month follow up data was obtained from clinic letters.

Results

Baseline data

Thirty-eight cases were referred between November 2018 and September 2021. Of these, 31 were approved for TCZ usage; 100% fulfilled the criteria for either refractory (n=11) or relapsing (n=20) disease. Mean age was 74 years and 74.2% were female. Average disease duration was 161.5 days for the refractory and 827.3 days for the relapsing group.

77.4% had cranial GCA, 48.4% had large vessel involvement, 45.2% had visual symptoms and 25.8% had ischaemic visual loss. The positive investigations were PET-CT (48.4%), temporal artery ultrasound (41.9%) and temporal artery biopsy (32.3%).

64.5% had trialled a steroid-sparing agent at time of referral (61.3 % methotrexate, 9.7% azathioprine, 6.5% leflunomide), 35.5% had received intravenous methylprednisolone and 58% were receiving greater than 40mg prednisolone at the time of referral.

Glucocorticoid adverse effects of osteoporosis, weight gain, cataracts and hypertension were each seen in 19.4%; whilst diabetes, neuropsychiatric symptoms and sleep disturbance were each reported in 16.1%.

Those with ocular involvement tended to be referred earlier than those without (478.2 days vs 648.1 days), were referred on higher doses of glucocorticoids (71.4% vs 47.1% on ≥ 40mg) and had less steroid-sparing agents prior to referral.

Follow up data

In December 2021, a follow-up audit revealed 14/31 patients had completed at least 12 months of tocilizumab; 5 of these had had an extension under Covid-19 exceptional guidance (mean duration of 5.2 months). Of the remaining 17: 3 patients had stopped early (1 death, 1 moved away, 1 due to adverse effects of headache and gastro-intestinal side effects), 4 had not started tocilizumab and 10 had not completed 12 months of treatment at that point.

Adverse events in the 14 patients at 12 months included: liver abnormalities (2/14; 14.3%), neutropenia (2/14; 14.3%), thrombocytopaenia (1/14; 7.1%), soft tissue infections (3/14; 21.4%), urinary tract infection (1/14; 7.1%) and lipid derangement (4/14 28.6%). One case of GCA relapse occurred on TCZ (mild headache and raised inflammatory markers settled on small increase in prednisolone). After 12 months, mean prednisolone dose was 3mg (range 0-15mg).

Conclusion

All patients approved for Tocilizumab in the GCA MDT fulfilled NHS England criteria for either relapsing or refractory disease. The majority of cases had cranial disease, but almost half had either ocular or large vessel involvement, reflecting a severe spectrum of disease. Cases showed a high burden of glucocorticoid toxicity. Follow up data suggests that TCZ was effective in allowing glucocorticoid weaning and disease control, but with some adverse effects. Future work to follow up patients after stopping Tocilizumab would be informative, as the twelve month limitation on treatment is likely to be re-instated.

References

[1]https://www.england.nhs.uk/coronavirus/publication/tocilizumab-for-giant-cell-arteritis-gca-during-the-covid-19-pandemic-rps-2007/

Disclosure of Interests

Chandrin N. R. Jayatilleke: None declared, Aishwarya Anilkumar: None declared, Shalini Janagan: None declared, Robert W Marshall: None declared, Sarah Skeoch: None declared, Catherine Guly Grant/research support from: Eli Lilly and Company - paid consultant for a research trial, Fang En Sin: None declared, Keziah Austin: None declared, Laith Al-Sweedan: None declared, Alexandra Bourn: None declared, Lynsey Clarke: None declared, Harsha Gunawardena: None declared, Baashar Boyce: None declared, Sally Knights: None declared, John D Pauling: None declared, Elizabeth Reilly: None declared, Timothy D Reynolds: None declared, Sarah Villar: None declared, Joanna C Robson: None declared

QTc interval in survivors of out of hospital cardiac arrest

BACKGROUND

QTc interval (QTc) prolongation is seen on the post-arrest electrocardiogram (ECG) of many out of hospital cardiac arrest (OHCA) survivors. It remains unclear whether this is a transient phenomenon or a manifestation of an underlying arrhythmic substrate. This observational study assessed the trend of QTc in an unselected group of patients presenting with OHCA. We sought to identify any relationship between QTc, gender and aetiology of arrest. We observed whether targeted temperature management (TTM) is associated with malignant arrhythmia.

METHOD

We analysed 60 patients presenting with OHCA to the Bristol Heart Institute during a 20-month period. We measured QTc on admission and assessed for persistence, development and resolution of prolongation at up to 5 time points post-OHCA. Aetiology of arrest was divided into coronary, non-coronary or primary arrhythmic to investigate for patterns in QTc behaviour.

RESULTS

81.7% (49/60) of arrests were attributed to an acute coronary event. 55% (33/60) had QTc prolongation on admission, of which 79% resolved. There were no significant differences in QTc behaviour by aetiology. One patient presenting with a normal QTc, developed prolongation during admission and received a genetic diagnosis of Long QT Syndrome. TTM was employed in 57/60, with no increased incidence of malignant arrhythmia.

CONCLUSIONS

Prolonged QTc on admission does not imply a primary arrhythmic aetiology and resolves in the majority pre-discharge. However, an initial normal QTc post-OHCA does not preclude a diagnosis of Long QT syndrome, highlighting the importance of thorough investigations in these patients. TTM appears safe from a cardiac perspective.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

MIP-1α and MCP-1 as salivary biomarkers in periodontal disease

Aim

Chemokines released by different host cells when exposed to the components of periodontopathic bacteria induce and maintain an inflammatory response in the periodontium. The aim of the study was to estimate the salivary levels of two chemokines, macrophage inflammatory protein-1 alpha (MIP-1α) and monocyte chemo attractant protein-1 (MCP-1) in health, gingivitis and periodontitis and to evaluate their role as reliable salivary biomarkers in discriminating gingivitis and periodontitis from health.

Methods

A cross sectional study was designed to estimate the levels of MIP-1α and MCP-1 in whole unstimulated saliva from 75 patients who were divided into healthy (Group 1, n = 25), gingivitis (Group 2, n = 25) and chronic generalized periodontitis (Group 3, n = 25). MIP-1α and MCP-1 levels were estimated by using ELISA and were correlated with clinical parameters. ROC curve analysis was done to determine the sensitivity and specificity of these biomarkers in distinguishing periodontal disease from health.

Results

Both the biomarkers were detected in all the saliva samples. There was a statistically significant difference in the concentration of both the analytes in Group 3 and Group 2 compared with Group 1 (p < 0.001). ROC curve analysis showed 100% sensitivity and specificity for MIP-1α and MCP-1 in discriminating periodontitis from health. For discriminating gingivitis from health, MIP-1α had a higher sensitivity and specificity (100% & 88% respectively) compared to MCP-1(84.1% & 80% respectively).

Conclusion

There is a substantial increase in the concentration of both MIP-1α and MCP-1 with increasing severity of periodontal disease. Both the analytes showed promising results as biomarkers for discriminating periodontal disease from health.

Variation in prevalence of chromosome 22q11 deletion in subtypes of conotruncal defect in 254 children

AIM

To determine the frequency of chromosomal aberrations particularly 22q11 deletion in Indian children ≤2 years with different types of conotruncal malformations and their association with abnormal aortic arch. Additionally, extracardiac features were also studied.

METHODS

Conventional cytogenetic and fluorescence in situ hybridization analyses were performed in 254 patients with conotruncal defects. Multivariable logistic regression analysis was performed to ascertain extracardiac features helpful in identifying high-risk patients with deletion.

RESULTS

Chromosomal abnormalities were identified in 52 (21%) children, of whom 49 (94%) showed 22q11 deletion and 3 (6%) had abnormalities of chromosome 6, 2 and X. None of the 11/254 children with tetralogy of Fallot with absent pulmonary valve showed deletion. The association of 22q11 deletion with right sidedness of the aortic arch varied with the type of conotruncal defect. The eight extracardiac features in combination showed 93.5% agreement with the presence of deletion.

CONCLUSION

The extracardiac features along with specific type of conotruncal defect and associated cardiovascular anomaly should alert the clinician for 22q11 deletion testing. However, if deletion analysis is not possible, specific extracardiac features (six dysmorphic facial features, thin long fingers and hypocalcemia) can help to identify an increased risk of 22q11 deletion in patients with conotruncal defect.

The relationship of structural alterations to cognitive deficits in schizophrenia: a voxel-based morphometry study

BACKGROUND

Region of interest studies have identified a number of structure-cognition associations in schizophrenia and revealed alterations in structure-cognition relationship in this population.

METHODS

We examined the relationship of structural brain alterations, identified using voxel-based morphometry, to cognitive deficits in 45 schizophrenia patients relative to 43 healthy control subjects and tested the hypothesis that structure-cognition relationship is altered in schizophrenia.

RESULTS

Patients had smaller total brain, gray matter, and white matter volumes. Regional alterations were left-hemisphere specific, including: gray matter reduction of inferior frontal, lingual, and anterior superior temporal gyri; white matter reduction of posterior and occipital lobes; and gray matter increase of the putamen and the precuneus. Smaller whole brain and gray matter volumes were associated with lower premorbid intelligence quotient (IQ) and poorer performance on IQ-dependent cognitive measures in patients and to a similar extent in control subjects. Larger precuneus was associated with better immediate verbal memory in patients, whereas verbal and nonverbal memory were positively associated with inferior frontal gyrus volume in control subjects. Smaller occipital white matter volume was associated with slower information processing speed in patients but not in control subjects.

CONCLUSIONS

Regional volume alterations are associated with specific cognitive deficits in schizophrenia. Some structure-cognition relationships differentiate this population from healthy control subjects.