The Dorsal Bed Nucleus of the Stria Terminalis in Depressed and Non-Depressed Temporal Lobe Epilepsy Patients

OBJECTIVES

Temporal lobe epilepsy (TLE) and depression are common comorbid disorders whose underlying shared neural network has yet to be determined. While animal studies demonstrate a role for the dorsal bed nucleus of the stria terminalis (dBNST) in both seizures and depression, and humans clinical studies demonstrate a therapeutic effect of stimulating this region on treatment-resistant depression, the role for the dBNST in depressed and non-depressed TLE patients is still unclear. Here, we tested the hypothesis that this structure is morphologically abnormal in these epilepsy patients, with an increased abnormality in TLE patients with comorbid depression.

METHODS

In this case-controlled study, three Tesla structural magnetic resonance imaging scans were obtained from TLE patients with no depression (TLEonly), with depression (TLEdep) and healthy comparison subjects (HC). TLE subjects were recruited from the Yale University Comprehensive Epilepsy Center, diagnosed with the International League Against Epilepsy 2014 Diagnostic Guidelines, and confirmed by video electroencephalography. Diagnosis of major depressive disorder was confirmed by a trained neuropsychologist through a Mini International Neuropsychiatric Interview based on the DSM-IV. The dBNST was delineated manually by reliable raters using Bioimage Suite software.

RESULTS

The number of patients and subjects included 35 TLEonly patients, 20 TLEdep patients, and 102 HC subjects. Both TLEonly and TLEdep patients had higher dBNST volumes compared to HC subjects, unilaterally in the left hemisphere in the TLEonly patients (p=0.003), and bilaterally in the TLEdep patients (p<0·0001). Furthermore, the TLEdep patients had a higher dBNST volume than the TLEonly patients in the right hemisphere (p=0.02).

SIGNIFICANCE

Here we demonstrate an abnormality of the dBNST in TLE patients, both without depression (left enlargement) and with depression (bilateral enlargement). Our results demonstrate this region to underlie both temporal lobe epilepsy with and without depression, implicating it as a target to treat the comorbidity between these two disorders.

Depth Electrode Guided Anterior Insulectomy: 2-Dimensional Operative Video

The insula is well established as an epileptogenic area.1 Insular epilepsy surgery demands precise anatomic knowledge2-4 and tailored removal of the epileptic zone with careful neuromonitoring.5 We present an operative video illustrating an intracranial electroencephalogram (EEG) depth electrode guided anterior insulectomy.  We report a 17-yr-old right-handed woman with a 4-yr history of medically refractory epilepsy. The patient reported daily nocturnal ictal vocalization preceded by an indescribable feeling. Preoperative evaluation was suggestive of a right frontal-temporal onset, but the noninvasive results were discordant. She underwent a combined intracranial EEG study with a frontal-parietal grid, with strips and depth electrodes covering the entire right hemisphere. Epileptiform activity was observed in contact 6 of the anterior insula electrode. The patient consented to the procedure and to the publication of her images.  A right anterior insulectomy was performed. First, a portion of the frontal operculum was resected and neuronavigation was used for the initial insula localization. However, due to unreliable neuronavigation (ie, brain shift), the medial and anterior borders of the insular resection were guided by the depth electrode reference. The patient was discharged 3 d after surgery with no neurological deficits and remains seizure free.  We demonstrate that depth electrode guided insular surgery is a safe and precise technique, leading to an optimal outcome.

99mTc-labelled glucosamine in the assessment of systemic sclerosis inflammatory lung disease: a novel inexpensive investigative tool with predictive value

OBJECTIVE

To evaluate the role of ^99mTc-labelled glucosamine [^99mTc-ECDG] as a clinical biomarker for the early detection of interstitial lung disease (ILD) in systemic sclerosis (SSc).

METHODS

In this prospective pilot study, glucosamine scanning (GS) was performed in 15 SSc patients, with and without ILD. Collected data included patient disease characteristics, autoantibody profile, GS results, high-resolution computerised tomography [HRCT], pulmonary function tests [PFT], and transthoracic echocardiogram [TTE]. Glucosamine results were correlated with patient clinical profile, HRCT, and PFT's findings.

RESULTS

Lung uptake of ^99mTc-ECDG was high in 4 patients, moderate in 3, mild in 5, and normal in 3 with SSc, respectively. Of the patients with high and moderate uptake there was a 100% correlation between ^99mTc-ECDG uptake and HRCT showing ILD. Of the 5 patients with mild ^99mTc-ECDG uptake, 4 patients had aspiration pneumonia, and 1 had early ILD using HRCT. Of the 3 patients with normal ^99mTc-ECDG, 2 had normal HRCTs; the third had severe pulmonary arterial hypertension with minimal HRCT changes of ILD. High and moderate ^99mTc-ECDG lung uptake predicted abnormal PFT's in 100% of cases. In 3 patients, there was less extensive disease depicted on the ^99mTc-ECDG scans than on the HRCT. These patients demonstrated a more favourable outcome than would have been expected from the HRCT scans alone. Mild ^99mTc-ECDG lung uptake correlated with abnormal PFT's in 60% of cases. The pattern of ^99mTc-ECDG uptake was excellent (100%) at distinguishing metabolically active ILD from aspiration pneumonia. Diffuse uptake was noted in the former and patchy uptake in the latter disease entity.

CONCLUSION

Increased ^99mTc-ECDG uptake in scleroderma lung correlated positively with both structural and functional changes. ^99mTc-ECDG is a useful adjunct helping elucidate inflammation secondary to aspiration pneumonia and/or other causes of abnormal PFT's.

Single-Cell Analyses of Colon and Blood Reveal Distinct Immune Cell Signatures of Ulcerative Colitis and Crohn's Disease

BACKGROUND & AIMS

Studies are needed to determine the mechanisms of mucosal dysregulation in patients with inflammatory bowel diseases (IBDs) and differences in inflammatory responses of patients with ulcerative colitis (UC) vs Crohn's disease (CD). We used mass cytometry (CyTOF) to characterize and compare immune cell populations in the mucosa and blood from patients with IBD and without IBD (controls) at single-cell resolution.

METHODS

We performed CyTOF analysis of colonic mucosa samples (n = 87) and peripheral blood mononuclear cells (n = 85) from patients with active or inactive UC or CD and controls. We also performed single-cell RNA sequencing, flow cytometry, and RNA in situ hybridization analyses to validate key findings. We used random forest modeling to identify differences in signatures across subject groups.

RESULTS

Compared with controls, colonic mucosa samples from patients with IBD had increased abundances of HLA-DR+CD38+ T cells, including T-regulatory cells that produce inflammatory cytokines; CXCR3+ plasmablasts; and IL1B+ macrophages and monocytes. Colonic mucosa samples from patients with UC were characterized by expansion of IL17A+ CD161+ effector memory T cells and IL17A+ T-regulatory cells; expansion of HLA-DR+CD56+ granulocytes; and reductions in type 3 innate lymphoid cells. Mucosal samples from patients with active CD were characterized by IL1B+HLA-DR+CD38+ T cells, IL1B+TNF+IFNG⁺ naïve B cells, IL1B+ dendritic cells (DCs), and IL1B+ plasmacytoid DCs. Peripheral blood mononuclear cells from patients with active CD differed from those of active UC in that the peripheral blood mononuclear cells from patients with CD had increased IL1B+ T-regulatory cells, IL1B+ DCs and IL1B+ plasmacytoid DCs, IL1B+ monocytes, and fewer group 1 innate lymphoid cells. Random forest modeling differentiated active UC from active CD in colonic mucosa and blood samples; top discriminating features included many of the cellular populations identified above.

CONCLUSIONS

We used single-cell technologies to identify immune cell populations specific to mucosa and blood samples from patients with active or inactive CD and UC and controls. This information might be used to develop therapies that target specific cell populations in patients with different types of IBD.

The design of a line velocity interferometer for any reflector for inertial confinement experiments on the Z-machine

A line VISAR (Velocity Interferometer System for Any Reflector) has been designed and commissioned at the Sandia National Laboratory's Z-machine. The instrument consists of an F/2 collection system, beam transport, and an interferometer table that contains two Mach-Zehnder type interferometers and an eight channel Gated Optical Imaging (GOI) system. The VISAR probe laser operates at the 532 nm wavelength, and the GOI bandpass is 540-600 nm. The output of each interferometer is passed to an optical streak camera with four selectable sweep speeds. The system is designed with three interchangeable optics modules to select a full field of view of 1 mm, 2 mm, or 4 mm. The optical beam transport system connects the target image plane to the interferometers and the gated optical imagers. The target is integrated into a sacrificial final optics assembly that is integral to the transport beamline.

How technology is driving the landscape of epilepsy surgery

This article emphasizes the role of the technological progress in changing the landscape of epilepsy surgery and provides a critical appraisal of robotic applications, laser interstitial thermal therapy, intraoperative imaging, wireless recording, new neuromodulation techniques, and high-intensity focused ultrasound. Specifically, (a) it relativizes the current hype in using robots for stereo-electroencephalography (SEEG) to increase the accuracy of depth electrode placement and save operating time; (b) discusses the drawback of laser interstitial thermal therapy (LITT) when it comes to the need for adequate histopathologic specimen and the fact that the concept of stereotactic disconnection is not new; (c) addresses the ratio between the benefits and expenditure of using intraoperative magnetic resonance imaging (MRI), that is, the high technical and personnel expertise needed that might restrict its use to centers with a high case load, including those unrelated to epilepsy; (d) soberly reviews the advantages, disadvantages, and future potentials of neuromodulation techniques with special emphasis on the differences between closed and open-loop systems; and (e) provides a critical outlook on the clinical implications of focused ultrasound, wireless recording, and multipurpose electrodes that are already on the horizon. This outlook shows that although current ultrasonic systems do have some limitations in delivering the acoustic energy, further advance of this technique may lead to novel treatment paradigms. Furthermore, it highlights that new data streams from multipurpose electrodes and wireless transmission of intracranial recordings will become available soon once some critical developments will be achieved such as electrode fidelity, data processing and storage, heat conduction as well as rechargeable technology. A better understanding of modern epilepsy surgery will help to demystify epilepsy surgery for the patients and the treating physicians and thereby reduce the surgical treatment gap.

More than "petty squabbles" - Developing a contextual understanding of conflict and aggression among older women in low-income assisted living

Dominant approaches to relational aggression among older adults tend to conceptualize the problem as a behavioral or interpersonal issue, and can inadvertently infantilize the phenomenon as 'bullying.' In this article we use a narrative approach and the conceptual lens of precarity to develop an in-depth, theoretically informed analysis of relational aggression between older women in low-income assisted living. The analysis of the narratives of tenants (and a manager) indicated that past life experiences and intersecting threats to power and identity shaped and could intensify tenants' interpretations of and reactions to others' actions and comments. Conflicts over a) unequal distributions of caring labor, b) control of social activities, and c) access to appreciation are complex and rational responses to precarious contextual conditions. Findings contribute empirically to the body of research on relational aggression among older adults, expanding this field through connecting it to critical gerontological conceptualizations of precarity. Preventing relational aggression requires increased public investment in formal social supports for older adults, challenging dominant discourses that privilege independence, and recognizing how the legacies of past disadvantage and contextual precarity (as opposed to mental illness or dementia) shape social interactions with and responses to others.

Dielectric characterization of Plasmodium falciparum-infected red blood cells using microfluidic impedance cytometry

Although malaria is the world's most life-threatening parasitic disease, there is no clear understanding of how certain biophysical properties of infected cells change during the malaria infection cycle. In this article, we use microfluidic impedance cytometry to measure the dielectric properties of Plasmodium falciparum-infected red blood cells (i-RBCs) at specific time points during the infection cycle. Individual parasites were identified within i-RBCs using green fluorescent protein (GFP) emission. The dielectric properties of cell sub-populations were determined using the multi-shell model. Analysis showed that the membrane capacitance and cytoplasmic conductivity of i-RBCs increased along the infection time course, due to membrane alterations caused by parasite infection. The volume ratio occupied by the parasite was estimated to vary from less than 10% at earlier stages, to approximately 90% at later stages. This knowledge could be used to develop new label-free cell sorting techniques for sample pre-enrichment, improving diagnosis.

Long-term outcomes of tissue-based ACTH-antibody assay-guided transsphenoidal resection of pituitary adenomas in Cushing disease

OBJECTIVE Cushing disease is caused by a pituitary micro- or macroadenoma that hypersecretes adrenocorticotropic hormone (ACTH), resulting in hypercortisolemia. For decades, transsphenoidal resection (TSR) has been an efficacious treatment but with certain limitations, namely precise tumor localization and complete excision. The authors evaluated the novel use of a double-antibody sandwich assay for the real-time quantitation of ACTH in resected pituitary specimens with the goals of augmenting pathological diagnosis and ultimately improving long-term patient outcome. METHODS This study involved a retrospective review of records and an analysis of assay values, pathology slides, and MRI studies of patients with Cushing disease who had undergone TSR in the period from 2009 to 2014 and had at least 1 year of follow-up in coordination with an endocrinologist. In the operating room, biopsy specimens from the patients had been analyzed for tissue ACTH concentration. Additional samples were simultaneously sent for frozen-section pathological analysis. The ACTH assay performance was compared against pathology assessments of surgical tumor samples using receiver operating characteristic (ROC) analysis and against pre- and postoperative MRI studies. RESULTS Fourteen patients underwent TSR with guidance by ACTH-antibody assay and pathological assessment of 127 biopsy samples and were followed up for an average of 3 years. The ACTH threshold for discriminating adenomatous from normal tissue was 290,000 pg/mg of tissue, based on jointly maximized sensitivity (95.0%) and specificity (71.3%). Lateralization discordance between preoperative MRI studies and surgical visualization was noted in 3 patients, confirming the impression that MRI alone may not achieve optimal localization. A majority of the patients (85.7%) attained long-term disease remission based on urinary free cortisol levels, plasma cortisol levels, and long-term corticosteroid therapy. Comparisons of patient-months of remission and treatment failure showed that the remission rate in the study sample statistically exceeds the rate in historical controls (71.9%; p = 0.0007, Fisher's exact test). Long-term unexpected hormonal deficiencies were statistically similar between study patients (29%) and those in a meta-analysis (25%; p = 0.7596, Fisher's exact test). CONCLUSIONS These preliminary findings reflect the promising potential of tissue-based ACTH-antibody-guided assay for improving the cure rates of Cushing disease patients undergoing TSR. Further studies with larger sample sizes, further refinements of assay interpretation, and longer-term follow-ups are needed.

Analysis of Parasitic Protozoa at the Single-cell Level using Microfluidic Impedance Cytometry

At present, there are few technologies which enable the detection, identification and viability analysis of protozoan pathogens including Cryptosporidium and/or Giardia at the single (oo)cyst level. We report the use of Microfluidic Impedance Cytometry (MIC) to characterise the AC electrical (impedance) properties of single parasites and demonstrate rapid discrimination based on viability and species. Specifically, MIC was used to identify live and inactive C. parvum oocysts with over 90% certainty, whilst also detecting damaged and/or excysted oocysts. Furthermore, discrimination of Cryptosporidium parvum, Cryptosporidium muris and Giardia lamblia, with over 92% certainty was achieved. Enumeration and identification of (oo)cysts can be achieved in a few minutes, which offers a reduction in identification time and labour demands when compared to existing detection methods.

Surgical outcome in adolescents with mesial temporal sclerosis: Is it different?

There are extensive studies evaluating mesial temporal sclerosis (MTS) in adults and limited studies in children, with adolescents being included within both patient populations. Our aim was to evaluate predictors of surgical outcome solely in adolescent patients with MRI- and pathology -proven MTS. The Yale Epilepsy Surgery Database was reviewed from 1987 to 2012 for adolescent patients with confirmed MTS on MRI and pathology who underwent temporal lobectomy and had greater than two-year postsurgical follow-up. Clinical and electrographic data were reviewed. Eighteen patients were identified. Eleven patients (61%) were seizure-free. All seven patients (39%) who were not seizure-free free were found to have lateralized ictal onset within one hemisphere involving two or more lobes on scalp EEG (p<0.001). Of the 7 patients who were not seizure-free, 4 had a history of status epilepticus (compared to 1/11 seizure-free patients; p=0.047), and 4 had lateralized hypometabolism involving two or more lobes within a hemisphere seen on PET (compared to 0/8 seizure-free patients; p=0.002). A novel finding in our study was that lateralized (rather than localized) ictal onset on scalp EEG, lateralized hypometabolism on PET, and history of status epilepticus were risk factors for not attaining seizure freedom in adolescents with MTS who underwent temporal lobectomy.

Changes in elevated cholesterol in the era of tenofovir in South Africa: risk factors, clinical management and outcomes

OBJECTIVES

Antiretroviral therapy (ART) has been associated with unfavourable lipid profile changes and increased risk of cardiovascular disease (CVD). With a growing population on ART in South Africa, there has been concern about the increase in noncommunicable diseases such as CVD. We determined risk factors associated with increased total cholesterol (TC) in a large cohort on ART and describe the clinical management thereof.

METHODS

We conducted an observational cohort study of ART-naïve adults initiating standard first-line ART in a large urban clinic in Johannesburg, South Africa. TC was measured annually for most patients. A proportional hazards regression model was used to determine risk factors associated with incident high TC (≥ 6 mmol/L).

RESULTS

Significant risk factors included initial regimen non-tenofovir vs. tenofovir [hazard ratio (HR) 1.54; 95% confidence interval (CI) 1.14-2.08], age ≥40 vs. <30 years (HR 3.22; 95% CI 2.07-4.99), body mass index (BMI) ≥ 30 kg/m² (HR 1.65; 95% CI 1.18-2.31) and BMI 25-29.9 kg/m² (HR 1.70; 95% CI 1.30-2.23) vs. 18-24.9 kg/m² , and baseline CD4 count < 50 cells/μL (HR 1.55; 95% CI 1.10-2.20) and 50-99 cells/μL (HR 1.40; 95% CI 1.00-1.97) vs. > 200 cells/μL. Two-thirds of patients with high TC were given cholesterol-lowering drugs, after repeat TC measurements about 12 months apart, while 31.8% were likely to have received dietary counselling only.

CONCLUSIONS

Older age, higher BMI, lower CD4 count and a non-tenofovir regimen were risk factors for incident elevated TC. Current guidelines do not indicate regular cholesterol testing at ART clinic visits, which are the main exposure to regular clinical monitoring for most HIV-positive individuals. If regular cholesterol monitoring is conducted, improvements can be made to identify and treat patients sooner.

Antithymidylate resistance enables transgene selection and cell survival for T cells in the presence of 5-fluorouracil and antifolates

Antithymidylates (AThy) constitute a class of drugs used in the treatment of cancers such as lung, colon, breast and pancreas. These drugs inhibit DNA synthesis by targeting the enzymes dihydrofolate reductase (DHFR) and/or thymidylate synthase (TYMS). AThys effectively inhibit cancer cells, and also inhibit T cells, preventing anticancer immunity, which might otherwise develop from AThy-induced cancer destruction. We establish that T cells expressing mutant DHFR--DHFR L22F, F31S (DHFR(FS))--and/or mutant TYMS--TYMS T51S, G52S (TYMS(SS))-effectively survive in toxic concentrations of AThys methotrexate, pemetrexed and 5-fluorouracil. Furthermore, we show that DHFR(FS) permitted rapid selection of an inducible suicide transgene in T cells. These findings demonstrate that AThy resistances prevent AThy cytotoxicity to T cells while permitting selection of important transgenes. This technological development could enhance in vitro and in vivo survival and selection of T-cell therapeutics being designed for a broad range of cancers.

The evolution of epilepsy surgery between 1991 and 2011 in nine major epilepsy centers across the United States, Germany, and Australia

OBJECTIVE

Epilepsy surgery is the most effective treatment for select patients with drug-resistant epilepsy. In this article, we aim to provide an accurate understanding of the current epidemiologic characteristics of this intervention, as this knowledge is critical for guiding educational, academic, and resource priorities.

METHODS

We profile the practice of epilepsy surgery between 1991 and 2011 in nine major epilepsy surgery centers in the United States, Germany, and Australia. Clinical, imaging, surgical, and histopathologic data were derived from the surgical databases at various centers.

RESULTS

Although five of the centers performed their highest number of surgeries for mesial temporal sclerosis (MTS) in 1991, and three had their highest number of MTS surgeries in 2001, only one center achieved its peak number of MTS surgeries in 2011. The most productive year for MTS surgeries varied then by center; overall, the nine centers surveyed performed 48% (95% confidence interval [CI] -27.3% to -67.4%) fewer such surgeries in 2011 compared to either 1991 or 2001, whichever was higher. There was a parallel increase in the performance of surgery for nonlesional epilepsy. Further analysis of 5/9 centers showed a yearly increase of 0.6 ± 0.07% in the performance of invasive electroencephalography (EEG) without subsequent resections. Overall, although MTS was the main surgical substrate in 1991 and 2001 (proportion of total surgeries in study centers ranging from 33.3% to 70.2%); it occupied only 33.6% of all resections in 2011 in the context of an overall stable total surgical volume.

SIGNIFICANCE

These findings highlight the major aspects of the evolution of epilepsy surgery across the past two decades in a sample of well-established epilepsy surgery centers, and the critical current challenges of this treatment option in addressing complex epilepsy cases requiring detailed evaluations. Possible causes and implications of these findings are discussed.

X-ray power and yield measurements at the refurbished Z machine

Advancements have been made in the diagnostic techniques to measure accurately the total radiated x-ray yield and power from z-pinch implosion experiments at the Z machine with high accuracy. The Z machine is capable of outputting 2 MJ and 330 TW of x-ray yield and power, and accurately measuring these quantities is imperative. We will describe work over the past several years which include the development of new diagnostics, improvements to existing diagnostics, and implementation of automated data analysis routines. A set of experiments on the Z machine were conducted in which the load and machine configuration were held constant. During this shot series, it was observed that the total z-pinch x-ray emission power determined from the two common techniques for inferring the x-ray power, a Kimfol filtered x-ray diode diagnostic and the total power and energy diagnostic, gave 449 TW and 323 TW, respectively. Our analysis shows the latter to be the more accurate interpretation. More broadly, the comparison demonstrates the necessity to consider spectral response and field of view when inferring x-ray powers from z-pinch sources.

Acute gross painless transudative ascites in a patient with lupus

Gross ascites is a rare presentation of lupus. Ascites in lupus may be due to lupus peritonitis or secondary to one of the complications including nephrotic syndrome. The ascites due to lupus peritonitis has been described as exudative with a serum-ascites albumin gradient (SAAG) below 11 g/L, unless associated with nephrotic syndrome. We report an unusual case of lupus ascites in a 23-year-old woman who presented with acute painless gross ascites with no constitutional, skin or musculoskeletal symptoms of a lupus flare. The ascites was a transudate with SAAG above 11 g/L with no associated nephrotic syndrome. She was treated with corticosteroids, mycophenolate mofetil and diuretics with a good response and no recurrence of her ascites.

Racial and ethnic minority medical students' perceptions of and interest in careers in academic medicine

PURPOSE

To describe diverse medical students' perceptions of and interest in careers in academic medicine.

METHOD

In 2010, the authors invited students attending three national medical student conferences to respond to a survey and participate in six focus groups. The authors identified trends in data through bivariate analyses of the quantitative dataset and using a grounded theory approach in their analysis of focus group transcripts.

RESULTS

The 601 survey respondents represented 103 U.S. medical schools. The majority (72%) were in their first or second year; 34% were black and 17% were Hispanic. Many respondents (64%) expressed interest in careers in academic medicine; teaching and research were viewed as positive influences on that interest. However, black and Hispanic respondents felt they would have a harder time succeeding in academia. The 73 focus group participants (25% black, 29% Hispanic) described individual- and institutional-level challenges to academic medicine careers and offered recommendations. They desired deliberate and coordinated exposure to academic career paths, research training, clarification of the promotion process, mentorship, protected time for faculty to provide teaching and research training, and an enhanced infrastructure to support diversity and inclusion.

CONCLUSIONS

Medical students expressed an early interest in academic medicine but lacked clarity about the career path. Black and Hispanic students' perceptions of having greater difficulty succeeding in academia may be an obstacle to engaging them in the prospective pool of academicians. Strategic and dedicated institutional resources are needed to encourage racial and ethnic minority medical students to explore careers in academic medicine.

New onset sarcoid-like granulomatosis developing during anti-TNF therapy: an under-recognised complication

Tumour necrosis factor-alpha (TNF-a) antagonists have advanced the treatment of inflammatory arthropathies, and are even considered for use in refractory sarcoidosis with some success. Paradoxically, cases of new onset sarcoidosis-like diseases are increasingly reported in patients receiving TNF-a antagonists. Here, we report three cases of sarcoid-like granulomatosis that developed during treatment with TNF-a antagonists. Review of the Biologics clinic data base at Westmead, Sydney, Australia identified three patients whom, during anti-TNF therapy, developed non-caseating granulomas consistent with sarcoidosis. These three cases are described with review of the literature from 2000 to 2009 using PubMed. One hundred and sixty-nine patients within our data base were reviewed for the period 2003–2009. Sarcoidosis-like granulomas developed in three patients within a period of 3 to 36 months of treatment with etanercept and/or adalimumab. All cases demonstrated non-infective, non-caseating granulomas on renal or lymph node biopsy. Improvement was seen in two cases upon cessation of TNF-a antagonist and steroid therapy. Interestingly, clinical deterioration was noted upon re-challenge with the same TNF-a antagonist in one patient. To date, a total of 37 cases of sarcoid-like granuloma development after anti-TNF therapy have been reported in the literature. Development of sarcoidosis-like granulomatosis in patients treated with TNF-a antagonists is a phenomenon previously under-recognised. All three anti-TNF agents have been observed to cause this phenomenon, suggesting a ‘class effect’ rather than being drug specific.

Respiratory medicines for children: current evidence, unlicensed use and research priorities

This European Respiratory Society task force has reviewed the evidence for paediatric medicines in respiratory disease occurring in adults and children. We describe off-licence use, research priorities and ongoing studies. Off-licence and off-label prescribing in children is widespread and potentially harmful. Research areas in asthma include novel formulations and regimens, and individualised prescribing. In cystic fibrosis, future studies will focus on screened infants and robust outcome measures are needed. Other areas include new enzyme and antibiotic formulations and the basic defect. Research into pneumonia should include evaluation of new antibacterials and regimens, rapid diagnostic tests and, in pleural infection, antibiotic penetration, fibrinolytics and surveillance. In uncommon conditions, such as primary ciliary dyskinesia, congenital pulmonary abnormalities or neuromuscular disorders, drugs indicated for other conditions (e.g. dornase alfa) are commonly used and trials are needed. In neuromuscular disorders, the beta-agonists may enhance muscle strength and are in need of evaluation. Studies of antibiotic prophylaxis, immunoglobulin and antifungal drugs are needed in immune deficiency. We hope that this summary of the evidence for respiratory medicines in children, highlighting gaps and research priorities, will be useful for the pharmaceutical industry, the paediatric committee of the European Medicines Agency, academic investigators and the lay public.

Accuracy and comprehensiveness of pathology reportage after lung cancer resection

6523

Background: Decisions about prognosis, adjuvant chemo/radiation therapy and clinical trial eligibility require careful examination of the surgical resection specimen. In January 2004, the College of American Pathologists (CAP) and the American College of Surgeons Committee on Cancer mandated reportage of specific items after resection of lung cancer. The extent of compliance is unknown. Methods: We examined final pathology reports for all lung cancer resections in the Memphis Metropolitan Area from January 2004 to December 2007. End-points were the percentage of reports with each CAP item and the 6 most vital determinants of post-operative management and accuracy of TNM staging. Chi-square test was used for year to year comparisons. Results: Table 1 shows frequency of reportage of CAP items. Of those with reported pT stage, it was accurate in 242 of 263 (92.02%) identified as T1; 193 of 208 (92.79%) T2; 21 of 24 (87.5%) T3; 11 of 11 (100%) T4. The most common T-staging error, understaging of satellite nodules (T4), occurred in 12 of 21 (57%) mis-staged as T1, 11 of 15 (73%) T2, 3 of 3 (100%) T3. Overall, 62.6% of reports accurately identified pT-stage. Of those with reported pN-stage, 351 of 352 (99.7%) accurately identified N0; 69 of 81 (85.2%) accurately identified N1, 12 of 81 (14.81%) N1 designations were actually N2; 27 of 27 (100%) N2 designations were accurate; 31 of 34 (91.2%) identified as Nx (no lymph nodes in the specimen) were accurate, 3 (8.8%) were truly N0. Overall, 64.08% of reports accurately identified pN-stage. 4 of 503 identified as pMx (0.8%) had pM1. There was no change in proportion of incomplete and/or inaccurate pathology reports over the 4 years of analysis. Conclusions: Pathology evaluation of lung cancer resection specimens is frequently incomplete or inaccurate, potentially impairing clinical decision-making. Satellite nodules are often understaged. Simple corrective interventions such as enforcement of mandatory institutional utilization of the CAP checklist and AJCC staging manual need to be investigated.

[Table: see text]

[Table: see text]

Epidemiology of community-acquired pneumonia in children seen in hospital

There is little UK data on hospital admission rates for childhood pneumonia, lobar pneumonia, severity or risk factors. From 13 hospitals serving the catchment population, demographic and clinical details were prospectively collected between 2001 and 2002 for children aged 0-15 years, seen by a paediatrician with community-acquired pneumonia (CAP) and consistent chest X-ray changes. From 750 children assessed in hospital, incidence of CAP was 14.4 (95% CI 13.4-15.4)/10,000 children per year and 33.8 (95% CI 31.1-36.7) for <5-year-olds; with an incidence for admission to hospital of 12.2 (95% CI 11.3-13.2) and 28.7 (95% CI 26.2-31.4) respectively. Where ascertainment was confirmed, incidence of CAP assessed in hospital was 16.1 (95% CI 14.9-17.3) and 41.0 (95% CI 37.7-44.5) in the 0-4 years age group, whilst incidence for hospital admission was 13.5 (95% CI 12.4-14.6) and 32 (95% CI 29.1-35.1) respectively. In the <5 years age group incidence of lobar pneumonia was 5.6 (95% CI 4.5-6.8)/10,000 per year and severe disease 19.4 (95% CI 17.4-21.7)/10,000 per year. Risk of severe CAP was significantly increased for those aged <5 years (OR 1.50, 95% CI 1.07-2.11) and with prematurity, OR 4.02 (95% CI 1.16-13.85). It also varied significantly by county of residence. This is a unique insight into the burden of hospital assessments and admissions caused by childhood pneumonia in the United Kingdom and will help inform future preventative strategies.

A paper that changed my practice: S McKenzie. Cough but is it asthma? Arch Dis Child 1994;70:1-2

Most doctors can identify key papers that have influenced their approach to the management of a particular clinical problem, although sometimes the gestation period of this effect can be very prolonged. In this short review I discuss the effects of a seminal paper by Sheila Mackenzie from the early 1990s on my current approach to the diagnosis and management of chronic cough in children.

Nonrigid 3D brain registration using intensity/feature information

The brain deforms non-rigidly during neurosurgery, preventing preoperatively acquired images from accurately depicting the intraoperative brain. If the deformed brain surface can be detected, biomechanical models can be applied to calculate the resulting volumetric deformation. The reliability of this volumetric calculation is dependent on the accuracy of the surface detection. This work presents a surface tracking algorithm which relies on Bayesian analysis to track cortical surface movement. The inputs to the model are 3D preoperative brain images and intraoperative stereo camera images. The addition of a camera calibration optimization term creates a more robust model, capable of tracking the cortical surface in the presence of camera calibration error.

Distribution of chlorophyll-bearing organelles in the shoot apex of a range of dicotyledonous plants

Confocal laser scanning microscopy was used to study the distribution of the smallest detectable autofluorescing, chlorophyll-bearing structures in fresh, 40 microm thick longitudinal sections of the shoot apex of four dicotyledonous plants (Arabidopsis thaliana, Nicotiana glauca, Lupinus alba, and Spinacia oleracea). In all species, the smallest chlorophyll-bearing particles were found in the outermost cell layers (L1 and L2) of the shoot apex. Their distribution between these layers differed in each species. The smallest such particles were about 0.5-1.0 microm in maximum dimension, approximating the size of a single granum in the developing leaf. Their size and abundance increased with increasing cell age and distance from the peak of the apex. Immediately beneath the L1 and L2 layers was a zone largely devoid of these particles. Below this nonfluorescing zone, in the region where the derivatives of the meristematic zone differentiate into cells of the central pith region, the size and abundance of the chlorophyll-bearing particles increased progressively with increasing distance from the nonfluorescing zone. The presence of these small autofluorescing particles in the L1 and L2 cell layers of the shoot apex places the development of photosystem II fluorescence at an earlier stage of leaf development than previously observed. The use of confocal laser scanning microscopy to study unfixed sections provides another useful metabolic marker for mapping patterns of differentiation and development in the cells of the shoot apex.