Case Report: Imaging immune checkpoint inhibitor-induced yin-yang effects in the brain

Background

Treatment with immune checkpoint inhibitors (ICI) can induce durable responses in cancer patients, but it is commonly associated with serious immune-related side effects. Both effects are suggested to be mediated by CD8+ T-cell infiltration. Whole body CD8+ T-cell distribution can be visualized by PET imaging of a 89Zr-labeled anti-humanCD8a minibody, currently investigated in a phase 2b trial.

Main body

An adult patient diagnosed with metastatic melanoma developed ICI-related hypophysitis after two courses of combined immunotherapy (ipilimumab (3 mg/kg) and nivolumab (1 mg/kg) at 3 weeks interval). On a [⁸⁹Zr]Zr-crefmirlimab berdoxam PET/CT scan, made 8 days before clinical symptoms occurred, increased CD8+ T-cell infiltration in the pituitary gland was detected. Simultaneously, tracer uptake in a cerebral metastasis was increased, indicating ICI-induced tumor infiltration by CD8+ T-cells.

Conclusions

The observations in this case report underscore the role of CD8+ T-cell in non-tumor tissues in ICI-related toxicity. In addition, it illustrates a potential role for molecular imaging by PET/CT for investigation and monitoring of ICI-induced effects.

Real-World Treatment Patterns, Outcomes, Resource Utilization and Costs in Treatment-Resistant Major Depressive Disorder: PATTERN, a Retrospective Cohort Study in Belgium

OBJECTIVE

Treatment-resistant depression (TRD), a subgroup of major depressive disorder (MDD) that does not adequately respond to treatment, has a substantial impact on the quality of life of patients and is associated with higher medical and mental health care costs. This study aimed to report real-world treatment patterns, outcomes, resource utilization, and costs in the management of TRD by psychiatrists in Belgium.

METHODS

We conducted a retrospective, non-interventional cohort study of patients ≥ 18 years, with diagnosed MDD who are treatment-resistant, defined as not responding to two different antidepressant treatments in the current moderate to severe major depressive episode (MDE). Data obtained from medical records of patients included patient health state (MDE, response, remission, and recovery) and resource use (number of consultations and emergency room visits, non-drug and drug interventions, and hospitalizations).

RESULTS

One hundred and twenty-five patients were enrolled in nine sites, with an average observation period of 34 months. During the MDE, 89.7% of patients were treated with selective serotonin reuptake inhibitors, 63.2% with serotonin-norepinephrine reuptake inhibitors, and 60.8% with anti-psychotics. Twenty-four percent of patients did not respond to any treatment; 76% responded, of whom 61% experienced a relapse; 28% of patients reached recovery, of whom 31.4% experienced recurrence. The average yearly direct cost of a TRD patient is €9012, mainly driven by hospitalization in the MDE. The observed absenteeism relates to a high indirect cost, representing 70% of the total MDE cost.

CONCLUSION

TRD is associated with a high unmet need and economic burden for patients and society, with highest costs in the MDE health state driven by absenteeism.

P3599Minicare high sensitivity troponin: a novel point-of-care tool to improve ACS workflows

Background

Cardiac troponin (cTn) has been broadly accepted as the biomarker of choice in the diagnosis of patients presenting with Acute Coronary Syndrome (ACS). Point-of-care (POC) cTn testing, defined as testing near the patient with rapid availability of results, has attracted a strong interest in the emergency department (ED) setting. It offers the potential to improve workflows, expedite clinical decisions and to reduce the length of stay. Workflows could be further optimized when a first measurement can already be performed by the emergency medical services prior to admission to the hospital.

Advances in assay technology have led to high sensitive (HS) cTn assays that have a profound impact on clinical practice, providing early results at presentation and 1 hour after admission which speed up clinical decision-making. Here we evaluate the Minicare HS cTnI POC test under development, which has the potential to combine the benefits of HS-cTnI protocols with a POC workflow.

Objective

Evaluate the analytical and clinical capability of the Minicare HS-cTnI test under development to meet the criteria‡ for HS cTn of having a 10% CV <99th percentile and a percentage measurable (>LoD) of >50%.

Methods

The evaluation is based on the Clinical Laboratory Standards Institute (CLSI) guidelines. Li-heparin whole blood and Li-heparin plasma samples were used to establish LoB, LoD, and LoQ, sample matrix comparison and linearity in the low range. The clinical performance for Minicare HS-cTnI was assessed and compared to Abbott Architect high-sensitivity troponin using banked samples from patients with ACS and collected at t=2–4h after admission. The percentage measurable was assessed and compared to Abbott Architect high-sensitivity troponin in a healthy population of 165 individuals.

Results

With a time to result within 10 minutes, the LoB is determined at 1.0 ng/L and the LoD at 2.1 ng/L. Plasma and whole blood results correlated well and showed comparable results. The 10% and 20% CV LoQ are established at 7.9 ng/L and 3.1 ng/L, well below the anticipated 99th percentile of 26 ng/L. With a percentage measurable of 77%, the criteria for a HS-cTnI assay are met in a POC device. A sensitivity of 93% and an NPV of 99% are found for Minicare HS-cTnI for a t=2–4h protocol vs 90% and 98% for Abbott Architect high-sensitivity troponin. In this study the area under the curve is 0.98 for Minicare HS-cTnI and 0.97 for Architect HS-cTnI.

ROC curve t=2-4 h

Conclusions

With HS-cTnI capability on the Minicare platform, we show the potential to support a 0/1 h sampling protocol, combined with the speed of a POC workflow. This may enable even more rapid and safe rule-out of patients with ACS.

Physical activity after mild traumatic brain injury: What are the relationships with fatigue and sleep quality?

OBJECTIVES

To determine self-reported physical activity (PA) levels and relationships with fatigue and sleep quality in adolescents and young adults after mild traumatic brain injury (mTBI).

SETTING

Follow-up 6-18 months after visiting the emergency department of one of 2 general hospitals.

PARTICIPANTS

Forty-nine adolescents and young adults aged 12-25 years (mean 18.4 years), 22 (45%) male with mTBI.

DESIGN

Cross-sectional survey study.

MAIN OUTCOME MEASURES

The Activity Questionnaire for Adults and Adolescents (AQuAA), with results dichotomized into meeting or not meeting Dutch Health Enhancing PA recommendations (D-HEPA), the Checklist Individual Strength (CIS, 4 subscores) and the Pittsburgh Sleep Quality Index (PSQI, total score) were administered.

RESULTS

Twenty-five participants (51%) did not meet the D-HEPA recommendations. After adjusting for sex, BMI and age, not meeting the recommendations was associated with a higher CIS Total Score (OR 1.04 95%CI 1.01, 1.07) but not with PSQI Total Score (OR 0.99, 95%CI 0.80, 1.21).

CONCLUSIONS

In adolescents and young adults with mTBI the level of reported PA is associated with fatigue but not with sleep quality. It remains to be established whether interventions aiming to promote PA should primarily be focused on PA or fatigue or both.

VALHUDES: A protocol for validation of human papillomavirus assays and collection devices for HPV testing on self-samples and urine samples

BACK GROUND

Systematic reviews have concluded that hrHPV DNA testing using target-amplification tests is as accurate on vaginal self-samples as on clinician-taken specimens for the detection of cervical precancer. However, insufficient evidence is available for specific HPV assay/self-sample device combinations.

OBJECTIVES

The VALHUDES protocol is designed as a diagnostic test accuracy study that aims to compare the clinical sensitivity and specificity of particular hrHPV assay(s) on vaginal self-samples and first-void-urine, collected in agreement with standardized protocols, with hrHPV testing on matched clinician-taken samples.

STUDY DESIGN

Five hundred enrolled women referred to a colposcopy clinic are invited to collect a first-void urine sample and one or more vaginal self-samples with particular devices before collection of a cervical sample by a clinician. Sample sets are subsequently analysed in a laboratory accredited for HPV testing. Disease verification for all enrolled patients is provided by colposcopy combined with histological assessment of biopsies.

RESULTS

A first VALHUDES study has started in Belgium in December 2017 with enrolment from four colposcopy centres. The following assays are foreseen to be evaluated: RealTime High Risk HPV assay (Abbott), cobas-4800 and -6800 (Roche), Onclarity (BD), Xpert HPV (Cepheid) and Anyplex II HPV HR (Seegene).

CONCLUSION

Given empirical evidence that the relative accuracy of HPV-testing on self- vs clinician-samples is robust across clinical settings, the VALHUDES protocol offers a framework for validation of HPV assay/self-sample device combinations that can be translated to a primary screening setting.

Electronic visual analogue scales for pain, fatigue, anxiety and quality of life in people with multiple sclerosis using smartphone and tablet: a reliability and feasibility study

Objective:

To explore the reliability and feasibility of electronic visual analogue scales in people with multiple sclerosis (MS) and healthy individuals.

Design:

Cross-sectional observational study

Setting:

Clinical setting

Subjects:

Convenience sample of 52 people with MS and 52 matched healthy controls

Interventions:

NA

Main measures:

Participants scored 15 statements assessing fatigue, pain, anxiety and quality of life on an electronic visual analogue scale (eVAS), either using a smartphone or a tablet (randomly allocated). To check for test-retest reliability, statements were administered in two separate randomly ordered groups. Subjects completed a feasibility questionnaire.

Results:

Mean (SD) eVAS scores ranged from 35 (28.1) to 80 (22.1) in MS group, and from 57 (28.0) to 86 (13.2) in controls. Intra Class Correlations ranged from 0.73 to 0.95 in MS sample; 0.61 to 0.92 in controls. For most statements, Bland-Altman plots indicated no systematic error, but relatively large random error of the eVAS scores (exceeding 20mm). Considerable ceiling effects (i.e. better health) were found in healthy controls. Similar reliability was found among smartphone or tablet, different demographic groups and the experience-groups.

Conclusion:

Electronic visual analogue scales are reliable and useful for people with MS to register fatigue, pain, anxiety and quality of life.

Improved tabletability after a polymorphic transition of delta-mannitol during twin screw granulation

In most formulations processed via continuous twin screw granulation microcrystalline cellulose (MCC) and/or lactose are used as excipients, but mannitol is also a preferred excipient for wet granulation and tableting due to its non-hygroscopicity and inertness. Therefore, the aim of the current study was to investigate the influence of process parameters on critical quality attributes of granules (moisture content, solid state, morphology, size distribution, specific surface area, friability, flowability and hygroscopicity) and tablets (tensile strength and friability) after twin screw granulation of δ-mannitol. The δ-polymorph was selected since a moisture-induced transformation to β-mannitol was observed during batch wet granulation, which exhibited a unique morphology with a large surface area and improved tabletability. A full factorial experimental design was performed, varying screw speed (400-900rpm), granulation temperature (25-40°C), number of kneading elements (6 or 12) and liquid-to-solid (L/S) ratio, on the granulation unit of a ConsiGma™-25 line (a continuous powder-to-tablet manufacturing system). After tray drying the granules were milled and tableted. The results showed that the polymorphic transition from δ- to β-mannitol also occurred during twin screw granulation, although the residence time and L/S ratios were much lower in continuous twin screw granulation compared to batch processing. However, the polymorphic transition was not complete in all experiments and depended on the L/S ratio, screw speed and number of kneading elements. Nevertheless all granules exhibited the unique morphology linked to the polymorphic transition and had a superior tabletability compared to granules produced with β-mannitol as starting material. This was attributed to enhanced plastic deformation of the granules manufactured using δ-mannitol as starting material. In addition, it was concluded that mannitol was granulated via a different mechanism than other, less-soluble, excipients (e.g. lactose, microcrystalline cellulose) due to its high solubility and dissolution rate as the influence of process parameters on the mannitol granule characteristics was different.

Analysis of the safety and efficacy of diabetic ketoacidosis management in a Community General Hospital, 2001-2010: a descriptive study

BACKGROUND

The recommended place for treatment of diabetic ketoacidosis in children is a paediatric High Dependency Unit. This facility is not available in all areas where children with type 1 diabetes mellitus are cared for.

AIMS

This study investigates the safety and efficacy of diabetic ketoacidosis management in a community general hospital without a paediatric high dependency unit.

METHODS

Data from children with diabetic ketoacidosis were collected from all diabetes related admissions in Dr Gray's Hospital, Elgin from 2001 to 2010. Observations were compared with safety indicators (pH, bicarbonate, glucose, electrolytes and cerebral oedema) and were reviewed for the recovery to normal values (pH, bicarbonate), without abnormal fluctuation (electrolytes, glucose) and without neurological complications (cerebral oedema).

RESULTS

The 114 patients generated 251 diabetes-related admissions, 118 for diabetic ketoacidosis treatment of whom 99 patients were treated with intravenous fluids and insulin. The mean time to recover to a pH of at least 7.30 was 655 minutes (120-1410 min). There were 79 (4.37% of 1808) glucose readings dropping more than 5.0 mmol/l per hour. There were six hypoglycaemic events (2.3-2.9 mmol/l) and in one case potassium dropped to 2.2 mmol/l. There was no case which developed into cerebral oedema.

CONCLUSION

Treatment of diabetic ketoacidosis in a community general hospital managed with a protocol for fluids, insulin and strict monitoring has shown to be effective in achieving recovery and to safely avoid complications.

Damage-associated molecular pattern and innate cytokine release in the airways of competitive swimmers

BACKGROUND

Daily intensive exercise by elite athletes can result in exercise-induced asthma especially in elite swimmers and this may be linked to epithelial damage.

OBJECTIVE

To study airway epithelial damage and release of damage-associated molecular patterns (DAMPs) after intensive exercise in elite athletes and controls.

METHODS

We recruited competitive swimmers (n = 26), competitive indoor athletes (n = 13) and controls (n = 15) without any history of asthma. Lung function was measured before, immediately after and 24 h after a 90-min intensive exercise protocol. Sputum induction was performed at baseline and 24 h after exercise. Exercise-induced bronchoconstriction (EIB) was assessed by the eucapnic voluntary hyperventilation test.

RESULTS

Baseline sputum uric acid, high mobility group box-1, CXCL8 mRNA, sputum neutrophils and serum Clara cell protein-16 (CC-16) were significantly higher in competitive swimmers compared with controls. Intensive swimming for 90 min resulted in an increase of sputum IL-1β, IL-6 and TNF mRNA in competitive swimmers, and of sputum IL-6 mRNA and sputum neutrophils in controls. Although all participants were asymptomatic, seven competitive swimmers, one indoor athlete and one control met the criteria for EIB.

CONCLUSION

Our findings show that the intensive training combined with exposure to by-products of chlorination induces airway epithelial damage in competitive swimmers. This is associated with increased damage-associated molecular patterns, innate cytokine release and neutrophilic airway inflammation.

Het couperen van de staart bij lammeren: staarteigenschappen, (contra) indicaties, wetgeving en alternatieve managementmaatregelen

Hoewel het couperen van de staart bij vrouwelijke lammeren in de Belgische schapenhouderij nog steeds wordt uitgevoerd, dienen er toch vragen over de effectiviteit van het couperen en daardoor ook over de noodzakelijkheid van deze ingreep te worden gesteld. Het couperen van lammerstaarten is eerder te beschouwen als een cosmetische behandeling dan een behandeling ter preventie van myiasis. Om de myiasisincidentie bij schapen effectief te beperken, dient de focus op andere bedrijfsmaatregelen dan het couperen van staarten te worden gelegd. In dit artikel wordt het couperen van lammerstaarten ter discussie gesteld en alternatieven, die al dan niet onmiddellijk implementeerbaar zijn, worden belicht. De dierenarts kan de schapenhouder adviseren om meer doeltreffende managementmaatregelen in de strijd tegen myiasis te nemen. Een frequente controle van de dieren, het beperken van de bevuiling van de achterhand, het preventief gebruik van antiparasitaire middelen, scheermanagement en het gebruik van vliegenvallen zijn daarbij belangrijk.

Sperm motility after laparoscopic inguinal hernia repair with lightweight meshes: 3-year follow-up of a randomised clinical trial

PURPOSE

To analyse the effects of lightweight meshes in laparoscopic inguinal hernia repair on male fertility aspects, chronic pain development and recurrence at 3-year follow-up.

METHODS

Fifty-nine male patients with a primary, unilateral or bilateral inguinal hernia were randomised to laparoscopic inguinal hernia repair using a standard polypropylene (Marlex(®)) or lightweight mesh (VyproII(®), TiMesh(®)). Patients attended clinical follow-up 3 years postoperatively, at which male fertility aspects, by semen analysis and scrotal ultrasound, chronic pain status (McGill Pain Questionnaire), quality of life (SF-36) and recurrence were assessed, or completed quality of life, pain and hernia-specific questionnaires at home.

RESULTS

In total, 49 patients (83.1 %) completed follow-up (median follow-up = 39.1 months), by questionnaire and/or clinical follow-up. As other semen parameters and scrotal ultrasound results, sperm motility was unchanged compared to 1 year postoperatively, but not significantly different between VyproII(®) and TiMesh(®) versus Marlex(®) patients (-8.5 % and -8 % vs. -2.8 %; P = 0.23). Pain perception and quality of life were comparable between the heavyweight and lightweight groups, and no change was noted in comparison with 1 year postoperatively. Chronic pain incidence was 6.1 % (3 patients), without occurrence of disabling pain. Three patients were clinically diagnosed with a recurrent hernia (5.9 %).

CONCLUSIONS

The decrease in sperm motility in patients operated on with a lightweight mesh compared to patients operated on with a heavyweight mesh 1 year after laparoscopic inguinal hernia repair could not be confirmed at 3 years follow-up. Furthermore, heavyweight and lightweight groups were comparable regarding quality of life, chronic pain and recurrence rate.

Continuous twin screw granulation: influence of process variables on granule and tablet quality

The aim of the current study was to screen theophylline (125 mg) tablets manufactured via twin screw granulation in order to improve process understanding and knowledge of process variables that determine granule and tablet quality. A premix of theophylline anhydrate, α-lactose monohydrate and PVP (ratio: 30/67.5/2.5,w/w) was granulated with demineralized water. Experiments were done using the high-shear wet granulation module (based on twin screw granulation) of the ConsiGma™-25 unit (a continuous tablet manufacturing system) for particle size enlargement. After drying, granules were compressed using a MODUL™ P tablet press (compression force: 10 kN, tablet diameter: 12 mm). Using a D-optimal experimental design, the effect of several process variables (throughput (10-25 kg/h), screw speed (600-950 rpm), screw configuration (number (2, 4, 6 and 12) and angle (30°, 60° and 90°) of kneading elements), barrel temperature (25-40°C) and method of binder addition (dry versus wet)) on the granulation process (torque and temperature increase in barrel wall), granule (particle size distribution, friability and flowability) and tablet (tensile strength, porosity, friability, disintegration time and dissolution) quality was evaluated. The results showed that the quality of granules and tablets can be optimized by adjusting specific process variables (number of kneading elements, barrel temperature and binder addition method) during a granulation process using a continuous twin screw granulator.

Case-matched analysis of outcome after open retropubic radical prostatectomy in patients with previous preperitoneal inguinal hernia repair

Background

The impact of preperitoneal mesh repair for inguinal hernia on future pelvic surgery is debatable. This retrospective study investigated the impact of previous preperitoneal inguinal hernia repair (PIHR) on outcome after open retropubic radical prostatectomy (RRP) for prostatic cancer.

Methods

Patients who had open RRP and who had previously undergone PIHR were identified. They were compared with a control group of patients matched for age, body mass index and tumour risk profile who had no history of inguinal hernia repair. Outcome measures included intraoperative data, histopathology and results at follow-up.

Results

Sixty patients who had undergone open RRP after a previous PIHR were compared with 60 control patients. Operations lasted longer in the PIHR group (median (interquartile range, i.q.r.) 100 (90–120) versus 90 (85–100) min respectively; P &lt; 0·001) and the operation was assessed as more difficult by the surgeon (P = 0·022). Hospital stay was longer for patients who had undergone PIHR (median (i.q.r.) 7 (6–9) versus 6 (5–7) days; P = 0·012) and urinary catheterization was prolonged (13 (11–14) versus 11 (11–12) days; P = 0·006). Among patients with intermediate- and high-risk disease, fewer lymph nodes were excised in the PIHR group than in the control group (median (i.q.r.) 2 (0–7) versus 8 (5–12) nodes; P &lt; 0·001).

Conclusion

Open RRP for prostatic cancer was more difficult to perform after previous PIHR, and was associated with a longer hospital stay and less adequate lymphadenectomy for intermediate- and high-risk prostatic cancer.

Identifying non-alcoholic fatty liver disease among asymptomatic overweight and obese individuals by clinical and biochemical characteristics

OBJECTIVE

To determine the prevalence of liver steatosis among asymptomatic individuals attending an out-patient clinic for a problem of overweight, and to define the discriminatory value of several characteristics for predicting liver steatosis among them.

DESIGN AND PARTICIPANTS

Consecutive patients Swith a body mass index (BMI) of > or =25 kg/m2 who consented to undergo liver ultrasound and blood tests were recruited for inclusion. Receiver operating characteristic (ROC) curves were generated and statistical indices of diagnostic performance and their corresponding 95% confidence intervals (95% CI) were computed. Logistic regression analyses were performed to determine whether a combination of characteristics could improve diagnostic accuracy.

RESULTS

We enrolled sixty-eight subjects (mean BMI, 37.5 kg/m2), of whom 39 (57.4%) had liver steatosis on ultrasound. Logistic regression analyses indicated that only 3 variables were significantly and independently correlated with liver steatosis: female gender, low adiponectin levels, and high insulin resistance index. A composite index for predicting liver steatosis was calculated by summing the risk factors of female gender, low adiponectin, and insulin resistance index (FAIR score). The accuracy of this score was determined by ROC analysis to be 0.85 (95% CI, 0.74-0.96; P < 0.001). The presence of two or more risk factors (FAIR score > or =2) had a sensitivity, specificity, positive predictive value, and negative predictive value of 77%, 91%, 92%, and 74%, respectively. The likelihood ratio for a positive result was 8.43.

CONCLUSIONS

Among asymptomatic overweight individuals attending an out-patient clinic, the prevalence of liver steatosis on ultrasound is 57%. Female gender, the insulin resistance index, and low adiponectin are significant and independent predictors of liver steatosis. A combination of these three factors allows sensitivity and specificity for non alcoholic fatty liver of 77% and 91%, respectively.

Prognostic factors after a first attack of inflammatory CNS demyelination in children

OBJECTIVE

To identify clinical, radiologic, or CSF factors that predict conversion to multiple sclerosis (MS) after a first attack of inflammatory demyelination in children.

METHODS

In this nationwide retrospective multicenter study in the Netherlands, 117 children below age 16 were included. Fifty-four children presented with a monofocal clinically isolated syndrome (CIS) and 63 children with a polyfocal CIS (PCIS).

RESULTS

A second MS-defining attack occurred in 43% of the CIS cases, compared to 21% of the patients with PCIS onset (p < 0.006). Basal ganglia and thalamic lesions and lesions larger than 2 cm on MRI (considered typical of ADEM) were observed during PCIS, irrespective of the presence of encephalopathy. No significant difference in developing MS was found in children with PCIS with or without encephalopathy. Elevated IgG index and presence of oligoclonal CSF bands were more often observed in children who developed MS. Both Barkhof and KIDMUS MRI criteria shared a high specificity and had a high positive predictive value for conversion to MS. In children under the age of 10, the Barkhof criteria had a higher sensitivity than the KIDMUS criteria, but still lower than in older children.

CONCLUSIONS

Barkhof and KIDMUS MRI criteria share a high specificity and positive prognostic value for conversion to multiple sclerosis (MS). Sensitivity of these criteria is poor, especially in children below 10 years of age. Basal ganglia lesions can occur in patients who later develop MS. A substantial number of patients presenting with polyfocal onset and no encephalopathy remained monophasic.

Men with atherosclerotic stenosis of the carotid artery have lower testosterone levels compared with controls

AIM

There is evidence to suggest an inverse association between serum levels of testosterone and coronary heart disease. The aim of this study was to compare endogenous sex hormone levels of men with severe internal carotid artery (ICA) atherosclerosis with age-matched controls.

METHODS

Metabolic parameters and sex hormones were measured or calculated in 124 male patients undergoing carotid endarterectomy for high grade ICA stenosis and in 124 age-matched male controls. The presence or absence of atherosclerotic stenosis of ICA was determined by high resolution B-mode ultrasound.

RESULTS

The cases had statistically significant lower levels of total testosterone (TT) (medians: 3.8 microg/L versus 4.3 microg/L, P=0.005) and sex hormone binding globulin (SHBG) (means: 39.8+/-17.2 versus 54.3+/-34.3 nmol/L, P<0.001) compared to controls. Multivariate linear regression analysis, adjusted for all clinical and physiologic parameters, showed a significant inverse association between ICA stenosis and TT (b=-0.158, P=0.013) and SHBG (beta=-0.259, P<0.001).

CONCLUSION

This study provides evidence of a positive association between low serum androgen levels and severe ICA atherosclerosis in men. It suggests that higher, but physiological, levels of androgens could have a protective role in the development of atherosclerosis.

Influence of supplemental magnesium, tryptophan, vitamin C, and vitamin E on stress responses of pigs to vibration

Our objectives were to investigate and compare the effects of supplemental Mg, Trp, vitamin E (vit E), and vitamin C (vit C) on stress responses of pigs undergoing transport simulation. In this study, 126 pigs (25.1 +/- 4.4 kg BW) were allocated to one of the six following treatments: 1) negative control (no supplementation); 2) positive control (i.m. injection with 0.5 mg of carazolol/20 kg BW 12 h before vibration, beta-blocker); 3) Trp (additional amount of 6 g/kg of feed for 5 d, as-fed basis); 4) Mg (3 g/L drinking water for 2 d); 5) vit E (additional amount of 150 mg/kg of feed for 21 d, as-fed basis); 6) or vit C (additional amount of 300 mg/kg of feed for 21 d, as-fed basis). Pigs were treated in groups of three, and each treatment was replicated seven times. Feed and water intake were not different among treatments. Heart rate variables (mean, peak, and minimum heart rate, ventricular ectopic beats, and ST elevation of Channels A and B) and heart rate variability were registered from the night before vibration. Pigs were subjected to vibration in a transport simulator (8 Hz, 3 m/s) for 2 h and allowed to recover for 2 h. Generally, the positive control pigs had the lowest heart rate values (mean, peak, minimum heart rate, ST elevation of Channel A; P < 0.05), whereas Mg and Trp decreased ventricular ectopic beats and ST elevation of Channel B, respectively. The effect of vit C and E as vagal stimulators was clearly visible, whereas carazolol and Mg clearly blocked the sympathetic pathways of the autonomic nervous system. During vibration, the negative control pigs lay the least, and Mg pigs the most (P < 0.05). Salivary cortisol concentrations (taken before and after vibration and after recovery) showed that vit E pigs produced the least cortisol during stress periods. Intermediary metabolites (glucose, lactate, creatine kinase, and NEFA) were analyzed in plasma from blood taken before and after vibration. At the two sampling points, the vit E and Mg pigs had the lowest NEFA concentrations (P < 0.05), and the vit E pigs also had the lowest lactate concentrations before vibration. Urine samples were collected before and after vibration to determine catecholamine concentrations; only negative control pigs had an increase (P = 0.04) in epinephrine concentration, despite large individual variation. In general, these results indicate that the supplementation of Trp, Mg, vit E, or vit C improved coping ability of pigs during vibration comparison with the negative control treatment. A muscular injection of carazolol influenced only the heart rate variables.

Bilateral putaminal necrosis due to methanol abuse

Symmetrical lesions in the basal ganglia are accepted as the characteristic radiological feature of methanol toxicity. A case of chronic deliberate repeated methanol ingestion is presented. The typical MRI findings of basal ganglia lesions on T1 and T2 weighted images, FLAIR, diffusion and T1-weighted post Gadolinium images are presented. To our knowledge, this is the first case in which late diffusion and post contrast MRI images, showing necrotic sequelae due to methanol ingestion, are reported.

Influence of supplemental magnesium, tryptophan, vitamin C, vitamin E, and herbs on stress responses and pork quality

This study investigated the effects of supplemental Mg, Trp, vitamin C, vitamin E, and herbs on stress responses, skin lesions, and meat quality of slaughter pigs (106.0 +/- 8.6 kg of BW). These 5 supplements were tested in 4 similar experiments. In Exp. 1, 2 treatments were tested: 1) control treatment without supplementation, and 2) supplementation of an herbal product (2.5 g/L of drinking water for 2 d). Eighty-eight pigs per treatment were involved, of which 40 were selected for meat quality measurements (over 4 replicates). The experimental design of Exp. 2 and 3 was the same as Exp. 1, except that in Exp. 2 Mg (3 g/L of drinking water for 2 d) was supplemented and in Exp. 3 Trp (6 g/kg of feed, as-fed basis) was supplemented. In Exp. 4, 3 treatments were tested: 1) control treatment without supplementation, 2) supplementation of vitamin C (300 mg/kg of feed for 21 d, as-fed basis), and 3) supplementation of vitamin E (150 mg/kg of feed for 21 d, as-fed basis). In Exp. 4, 66 pigs per treatment were used, of which 42 were evaluated for meat quality (over 6 replicates). Pigs supplemented with vitamin E ate less than control (P = 0.03) or vitamin C-supplemented pigs (P = 0.03). Pigs were transported to a commercial slaughterhouse and were slaughtered after a lairage period. Blood sampling at slaughter revealed no differences between the control and supplemented pigs in plasma cortisol, glucose, lactate, or creatine kinase concentrations. Pigs provided with Mg (P = 0.002) or Trp (P = 0.04) had lower plasma NEFA concentrations than control pigs, and pigs supplemented with vitamin C had greater concentrations than the control (P = 0.03) or vitamin E-supplemented pigs (P = 0.01). Supplementation of the herbal product increased the frequency of pigs with shoulder (P = 0.05) and loin lesions (P = 0.03), whereas Mg lowered the incidence of loin lesions (P = 0.01). Measurements of pH and temperature in the LM and biceps femoris 45 min postmortem revealed no differences among treatments, and no influence of treatments on LM pH, electrical conductivity, and water holding capacity was observed 48 h postmortem. Compared with the control loins, loins of pigs supplemented with vitamin C (Japanese color scale, L*, and a* value; P < 0.05) or vitamin E (Japanese color scale and a* value; P < 0.03) were redder and less pale, and the loin of vitamin E-supplemented pigs was more yellow (b* value; P = 0.04). Generally, Mg could lower loin damage, whereas vitamin C and vitamin E supplementation resulted in a color improvement of the loin.

Demonstration of tissue alterations by ultrasonography, magnetic resonance imaging and spectroscopy, and histology in breast cancer patients without lymphedema after axillary node dissection

Estimates of the incidence of arm swelling after axillary lymph node dissection for breast cancer range from 10 to 37%. Yet the subjective sensation of edema is described in at least 54% of patients. The purpose of this research was to examine the structural changes occurring in the subcutaneous tissue that might explain these subjective complaints using multiple imaging modalities. Two female cadavers with unilateral breast amputation and axillary dissection were studied. The dermal and subcutaneous layers of both arms were visualized with high frequency ultrasonography, and magnetic resonance imaging and spectroscopy (MRS), and tissue biopsies were taken for histological evaluation. On the operated side, ultrasound imaging showed a hyperechogenic subcutis and the fat-to-water relationship in adipose cells was higher as measured by MRS. Dissection of the arms revealed structural adipose tissue changes, which were confirmed by microscopic evaluation.

Head current during and blood splashes after electrical stunning in relation to characteristics of the pig's body

In order to evaluate electrical stunning in relation to the incidence of blood splashes, meat quality and carcass quality parameters, 2035 pigs, heterozygous for the halothane gene, were observed during slaughter at a commercial slaughterhouse. The head current during electrical stunning is significantly higher (P<0.01) in gilts with a lower live weight (P<0.0001) or cold carcass weight (P<0.0001) and a higher lean meat percentage (P<0.0001). Also the incidence of blood splashes in the ham is significantly higher in gilts (P<0.0001) with a higher lean meat percentage (P=0.0028; odds ratio=1.11), a lower live weight (P=0.003; odds ratio=0.98) and a lower type number (P=0.0074; odds ratio=0.64). For barrows, no significant parameters were revealed. These results suggest that the variability in incidence of blood splashes can be explained by the variability of current density depending both on sex and body characteristics. Thus, electrical stunning can be improved by providing an energy level, based on the body characteristics of the pig.

A study of the family burden of 150 family members of schizophrenic patients

PURPOSE

Investigation into the family burden (FB) of schizophrenic patients has recently risen sharply. Nevertheless, to date there has been little consensus as to what factors influence the FB. The purpose of this study is to acquire a greater insight into the variables that influence the FB.

SUBJECTS/METHODS

The FB was measured with the interview for the family burden (Kluiter H, Kramer JJAM, Wiersma D, et al. Interview voor de belasting van de familie 1997 [Interview for the burden on the family]. Department Sociale Psychiatrie. Groningen: Rijksuniversiteit). One hundred and fifty family members (parents/partners) of schizophrenic patients participated in the study.

RESULTS

The results of our study show (1) that family members experience burden both on a practical and an emotional level, (2) a highly significant correlation between the amount of symptomatic behaviour of the patient and FB, (3) that parents had taken on more tasks, had contributed more financially and had experienced a tenser atmosphere at home than partners did and (4) that family members of patients who have been treated for less than 1 year worry more about the other members of their family than family members of patients who have been receiving treatment for more than 1 year.

CONCLUSIONS

Family members of schizophrenic patients experience burden on a practical, financial and emotional level and the extent of the burden is closely linked to the amount of symptomatic behaviour of the patient.

Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers

STUDY DESIGN

Prospective MR analysis of the cervical spine of 30 asymptomatic volunteers.

OBJECTIVES

To evaluate the prevalence of annular tears, bulging discs, disc herniations and medullary compression on T2-weighted and gadolinium-enhanced T1-weighted magnetic resonance (MR) images of the cervical spine in symptom free volunteers.

SUMMARY OF BACKGROUND DATA

Few studies have reported the prevalence of cervical disc herniations in asymptomatic people, none have reported the prevalence of cervical annular tears on MR images of symptom free volunteers.

MATERIALS AND METHODS

Thirty symptom-free volunteers (no history or symptoms related to the cervical spine) were examined using sagittal T2-weighted fast spin-echo (SE), sagittal gadolinium-enhanced T1-weighted SE imaging and axial T2(*)-weighted gradient echo (GRE). The prevalence of bulging discs, focal protrusions, extrusions, nonenhancing or enhancing annular tears and medullary compression were assessed.

RESULTS

The prevalence of bulging disk and focal disk protrusions was 73% (22 volunteers) and 50% (15 volunteers), respectively. There was one extrusion (3%). Eleven volunteers had annular tears at one or more levels (37%) and 94% of the annular tears enhanced after contrast injection. Asymptomatic medullary compression was found in four patients (13%).

CONCLUSION

Annular tears and focal disk protrusions are frequently found on MR imaging of the cervical spine, with or without contrast enhancement, in asymptomatic population. The extruded disk herniation and medullary compression are unusual findings in a symptom-free population.

Effect of supplemental tryptophan, vitamin E, and a herbal product on responses by pigs to vibration1

Economic losses related to increased stress during the transport of pigs are well documented. The effects of supplementing of tryptophan (Trp), vitamin E, or a herbal product via feed or drinking water were investigated in terms of effects on stress response in pigs during transport simulation. The study consisted of three analogous experiments. For the testing in each experiment, the pigs (23.5+/-3.2 kg) were allocated to one of two treatments, with and without supplementation of a product. The applied doses were Trp (5 g/L drinking water for 3 d), vitamin E (additional amount of 300 mg/kg feed for 21 d, as-fed basis), and Sedafit (2.5 g/L drinking water for 2 d). Sedafit is a commercial herbal product containing Valeriana officinalis L. and Passiflora incarnata L. as active components. In each experiment of the study, at least 47 pigs were involved, which were treated in groups of 3. The day before transport simulation, a Holter device was attached to the pigs to produce an electrocardiogram during the night (rest values), as well as during vibration in the transport simulator (1.2 Hz, 1 m/s2), where the behavior of the pigs (standing-sitting-lying) was also observed. Samples of saliva (taken before, during, and after [3x] vibration) and blood (taken before and after vibration) were analyzed for cortisol and intermediate metabolites (glucose, lactate, creatine kinase, and nonesterified fatty acids), respectively. Pigs supplemented with Trp tended to spend more time lying down during the second hour of vibration (P < 0.05). Vitamin E decreased the peak heart rate (P < 0.05), ventricular ectopic beats (P < 0.01), and ST elevation (P < 0.10). The supplementation of Sedafit resulted in smaller increases of the investigated heart variables (minimum heart rate, P < 0.05; ventricular ectopic beats, P < 0.05; ST elevation, P < 0.01) during and after stress evocation compared with the control group. None of the tested products influenced the intermediate metabolites; one possible explanation for this finding may be that peak values were reached before the time of bleeding. In conclusion, Trp had a positive behavioral effect in this experiment, and vitamin E and Sedafit mediated an increase in some heart variables, suggesting sedative and antianxiety effects.

Diffusion-weighted MR imaging of an acute venous stroke: case report

A patient with a superior sagittal sinus thrombosis had progressively worsening symptoms and signs that resolved after IV heparin therapy. MR imaging revealed abnormalities in diffusion, similar to those seen with acute arterial stroke. Abnormalities shown on a T2-weighted fast spin-echo and fluid-attenuated inversion recovery images resolved completely. The findings in this report contradict those from previous reports that suggest diffusion-weighted imaging with quantitative apparent diffusion coefficients may be used in selecting patients for dural venous sinus thrombolysis.

Primary pancreatic and renal non-Hodgkin's lymphoma: CT and MR findings

Primary malignant non-Hodgkin's lymphoma of the pancreas or the kidney is uncommon. We describe a case of primary non-Hodgkin's lymphoma of the pancreas consisting of 3 masses and causing acute pancreatitis, combined with a primary non-Hodgkin's lymphoma of the left kidney, without the presence of abdominal lymphadenopathies. Our case report is documented with CT as well as MR images.

Treatment of epileptic seizures as medical emergencies: a prospective analysis of a decision tree for nonmedically trained staff

The aim of this study was to evaluate the benefit of treating every epileptic seizure as an emergency and to propose a decision tree for use by nonmedical staff. Published literature on emergency medical treatment for seizures was reviewed. A detailed decision tree was developed for use by nonmedical staff. Its effectiveness was prospectively analysed over 16 months. Each seizure was logged, and its duration and severity were recorded. Type, dose, and time of antiepileptic treatment were noted. Results were compared with a 6-month retrospective review. Initiation of antiepileptic drug treatment 5 or 7 minutes after seizure onset was indicated in the tree. Rectal diazepam or lorazepam, or fast-dissolving lorazepam was used. Use of the decision tree resulted in decreased duration of seizures, which lasted up to 18 hours in the retrospective review compared with only 37 minutes in the prospective study. Using this tree, nonmedical staff can appropriately treat adults experiencing seizures. Duration, severity, and frequency of seizures decreased when every seizure was treated as a medical emergency. Implementation of a decision tree is recommended for establishments with patients prone to seizures. It can also be taught to caregivers and parents of patients with well-known epilepsy.

Demographic characteristics and prognosis in a Flemish amyotrophic lateral sclerosis population

We describe the genetic and demographic characteristics of patients with amyotrophic lateral sclerosis (ALS) in Flanders, Belgium. Prognostic factors related to survival are examined. ALS was familial in 8.6% of all MND patients. In 6 of 8 apparently unrelated families, an SOD1 mutation was found. In sporadic ALS, mean age at onset was 57.1 years. There was a male preponderance (1.2:1) and the disease had a bulbar onset in 19%. Median survival was 32 months (95% CI 26-46). The presence of an APOE-epsilon 4 allele was not associated with a bulbar onset of ALS, an earlier age at onset or a shorter median survival. Variables examined in a multivariate analysis included age, sex, site of onset, delay from onset to diagnosis, and % forced vital capacity. Shorter survival was independently associated with higher age, bulbar onset, a short diagnostic delay, and a lower percent-predicted vital capacity at study entry. Simple clinical baseline characteristics can assist the clinician in estimating prognosis in ALS. The demographic characteristics of the Flemish ALS population do not seem to differ from those described in other parts of the world.

Evolution of motor and sensory deficits in amyotrophic lateral sclerosis estimated by neurophysiological techniques

Although amyotrophic lateral sclerosis is a degenerative disease of the upper and lower motor neurons, there is evidence that the disease can affect other systems, including the sensory system. On the other hand, within the motor neuron pool there is possibly a predilection of the degenerative process for the motor neurons fibers with the fastest conduction velocity (MNFCV). We studied these two aspects of the disease in a group of 50 patients by prospectively assessing several sensory indices and by studying the selectivity of the spinal motor neuron loss. At baseline, nerve conduction studies and somatosensory evoked potentials showed abnormal slowing in the peripheral and central sensory pathways. Thermal thresholds for heating were elevated but were normal for cooling. In more than 60% of the patients at least one of the sensory tests studied was abnormal. However, except for a significant decrease in the amplitude of the sensory nerve action potentials of the sural nerves, these afferent dysfunctions were not progressive over the follow-up period of 6 months, in contrast to the marked deterioration in motor functions. Three different statistical models were applied to evaluate the presence of demyelination, selective loss of MNFCV, or the purely random degeneration of fast- and slow-conducting motor neurons. These data indicate a selective loss of the MNFCV and suggest that subclinical abnormalities of the sensory system in ALS are often present but almost nonprogressive. Furthermore, the amyotrophic lateral sclerosis disease process seems preferentially to affect MNFCV.