Unveiling Rare Complications: Pancreatic Pseudocysts and Monomicrobial Non-neutrocytic Bacterascites in Decompensated Cirrhosis

One frequent side effect of chronic pancreatitis is pancreatic pseudocyst. Abdominal pain and vomiting are common complaints that the patient presents with. However, atypical manifestations of pancreatic pseudocyst still confound medical professionals worldwide, making identification challenging and ultimately increasing the risk of fatal consequences. We describe the case of a 41-year-old man who had decompensated liver cirrhosis linked to alcohol intake. The patient presented with dysphagia and yellowish skin discolouration, which, upon further investigation, turned out to be peripancreatic pseudocysts extending into the mediastinum. Diagnostic challenges arose due to the rare occurrence of a pancreatic pseudocyst located in the mediastinum. Patient was treated with a culture-sensitive antibiotic and on follow up he was doing well.

Immersive Innovations: Exploring the Diverse Applications of Virtual Reality (VR) in Healthcare

Virtual reality (VR) has experienced a remarkable evolution over recent decades, evolving from its initial applications in specific military domains to becoming a ubiquitous and easily accessible technology. This thorough review delves into the intricate domain of VR within healthcare, seeking to offer a comprehensive understanding of its historical evolution, theoretical foundations, and current adoption status. The examination explores the advantages of VR in enhancing the educational experience for medical students, with a particular focus on skill acquisition and retention. Within this exploration, the review dissects the applications of VR across diverse medical disciplines, highlighting its role in surgical training and anatomy/physiology education. While navigating the expansive landscape of VR, the review addresses challenges related to technology and pedagogy, providing insights into overcoming technical hurdles and seamlessly integrating VR into healthcare practices. Additionally, the review looks ahead to future directions and emerging trends, examining the potential impact of technological advancements and innovative applications in healthcare. This review illuminates the transformative potential of VR as a tool poised to revolutionize healthcare practices.

Navigating the Enigma: A Comprehensive Review of Idiopathic Intracranial Hypertension

An unidentified source of increased intracranial pressure is a hallmark of idiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri. It mainly affects young, obese women, yet it can happen to anyone, regardless of age, gender, or weight. IIH presents with symptoms such as headaches, visual disturbances, and pulsatile tinnitus and can lead to severe complications, including vision loss, if left untreated. Diagnosis involves clinical evaluation, neuroimaging, and lumbar puncture, while management options include medical interventions and surgical procedures. This review provides a comprehensive overview of IIH, including its etiology, clinical presentation, epidemiology, complications, management approaches, and challenges. Increased awareness among healthcare professionals, standardized diagnostic criteria, and further research efforts are essential for improving outcomes and quality of life for individuals with IIH.

Acute Necrotizing Pancreatitis Presenting as Gastrocolic Fistula: A Rare Occurrence

Tissue necrosis and ischemia are hallmarks of acute necrotizing pancreatitis, which frequently results in fatal infections. In this case, we describe a man in his 40s who had diffuse pain in the abdomen, intractable vomiting, diarrhoea, and intermittent fever. His abdominal computed tomography revealed acute pancreatitis with peripancreatic fluid collection, gastric perforation, and fistula formation between the greater curvature of the stomach and transverse colon. His upper gastrointestinal (GI) endoscopy confirmed a gastrocolic fistula.

Surviving a Rare Case: Successful Endovascular Treatment for Multiple Dural Venous Sinus Thrombosis With Dural Arteriovenous Fistula

Vascular anomalies known as dural arteriovenous fistulas (DAVFs) occur when arteries that emerge from carotid or vertebral artery branches empty straight into the dural venous sinuses. A 16-year-old male patient at the center of this case study initially arrived at the hospital with symptoms of generalized tonic-clonic seizures and headaches accompanied by vomiting, followed by right-sided hemiparesis and subsequently left-sided hemiparesis. An MRI brain with MR angiography was performed, revealing an abnormal fistulous connection between the sigmoid and transverse sinus and the branches of the bilateral external carotid and right internal carotid artery. Embolization was performed using a mixture of glue and lipoid to address the issue.

Navigating the Cytokine Storm: A Comprehensive Review of Chemokines and Cytokines in Sepsis

This comprehensive review thoroughly explores the intricate relationship between chemokines, cytokines, and the cytokine storm in sepsis, offering a nuanced understanding of the molecular mechanisms underpinning this life-threatening syndrome. Beginning with examining sepsis stages and immune response dynamics, the review emphasizes the dysregulation leading to the cytokine storm, where pro- and anti-inflammatory cytokines disrupt the delicate immune equilibrium. Delving into chemokines, the discussion encompasses subfamilies, receptors, and functions, highlighting their critical roles in immune cell migration and activation during sepsis. The implications for clinical practice are substantial, suggesting avenues for targeted diagnostics and therapeutic interventions. The review identifies areas for future research, including the search for novel biomarkers, deeper insights into cytokine regulation, and the pursuit of personalized medicine approaches. This comprehensive exploration aims to guide clinicians, researchers, and policymakers in navigating the complexities of sepsis, fostering a foundation for transformative advancements in understanding and managing this formidable clinical challenge.

Navigating Nutritional Strategies: A Comprehensive Review of Early and Delayed Enteral Feeding in Acute Pancreatitis

This review critically examines enteral feeding strategies in managing acute pancreatitis, focusing on the contrasting early and delayed initiation approaches. Acute pancreatitis, marked by pancreatic inflammation, poses complex challenges, and nutritional interventions are pivotal in patient outcomes. Early enteral feeding, initiated within 24-48 hours, is associated with positive outcomes such as shortened hospital stays and reduced complications. However, controversies persist, with studies questioning its universal benefits. Conversely, delayed enteral feeding, employing a cautious approach, gains prominence in high-risk and severe cases. The identification of high-risk patients becomes paramount in decision-making. Practical recommendations for clinicians advocate an individualized approach, considering the severity of pancreatitis and regular monitoring. As the landscape of acute pancreatitis management evolves, staying abreast of emerging guidelines is essential. This review aims to provide a comprehensive understanding of critical findings, offering practical insights to guide clinicians in navigating the complexities of enteral feeding decisions in acute pancreatitis.

O085 CD10 expression in carcinomas of the pancreas, bile duct and ampulla

Introduction

Pancreatic cancer and cholangiocarcinoma including, cancer of ampulla of Vater, are very aggressive and have a dismal prognosis; hence improved methods of patient stratification are required.

Methods

We assessed the expression of CD10 in stromal and epithelial cells of two patient cohorts using immunohistochemistry on tissue microarrays. The first cohort was composed of 68 pancreatic adenocarcinomas and the second cohort was composed of 120 cancers of the bile duct and ampulla.

Results

In bile duct and ampullary carcinomas an association was observed between CD10 stromal expression and patient age (p =0.009). The CD10 stromal expression was associated with poor disease specific survival (DSS) (p =0.05). In multivariate Cox model for DSS, stromal CD10 expression (p = 0.037) was independently associated with poor outcome. In multivariate Cox model for disease free survival (DFS), CD10 stromal expression (p = 0.012), and nodal status (p = 0.025) were independently associated with poor outcome. In pancreatic cancer, no statistically significant association was observed between CD 10 stromal expression and clinicopathological variables such as tumour size (p = 0.099), T stage (p = 0.393), N stage (p = 0.860), Vascular invasion (p = 0.904), perineural invasion (p = 0.532) and grade (0.168). In multivariate Cox model for DSS, T stage (p = 0.042) was independently associated with poor outcome.

Conclusion

The results suggest that CD10 stromal expression may have prognostic significance in cholangiocarcinoma. The findings of this study warrant a larger follow-up study.

Take-home message

The results suggest that CD10 stromal expression may have prognostic significance in cholangiocarcinoma. The findings of this study warrant a larger follow-up study.

AB1397 WORK SMARTER NOT HARDER

Background

In 2014 we were a small team with only 1 WTE (Whole Time Equivalent) CNS (Clinical Nurse Specialist) and 2 WTE consultants for a population of 220,000. Most CNS clinic appointments were taken up for drug counselling. Waiting times were approx. 6 weeks for drug counselling. Consultants would often counsel for DMARDs.

That year at a national meeting a virtual group MDT (multidisciplinary) was presented by the team at Manchester Royal infirmary (MRI). They used a good quality presentation for patients starting bDMARDs as a tool for drug counselling.

After having to put on an extra clinic to counsel 5 patients, all for rituximab, frustratingly I asked why can’t I get them all in the same room to save time? We needed to work smarter, not harder, utilise time & space to ensure best practice but also ensure gold standard, patient centered care continued. We modified the format used at MRI to a face to face group education and counselling of patients to improve waiting times and patient flow.

Objectives

Reduce the amount of clinic appointments used to counsel patients for sDMARDs (synthetic disease modifying anti-rheumatic drugs) and bDMARDs (biologic).

Free up clinic appointments for follow up/ review and flares.

Standardise information given out to ensure they are all given the same gold standard information and education.

Methods

We visited the team at MRI to view the format of their virtual clinic. It didn’t meet the needs of our service so we modified and adapted the presentation.

Set up a group education session to discuss the most common sDMARDs and bDMARDs used for Inflammatory Arthritis.

I developed a power point presentation and booklet that can be used by CNS- ensuring the same information is given to every patient, both attending the group session and those not suitable for group session (ie Language barriers) who would be seen individually. We use a screening proforma to ensure safety of commencement for the individual prior to attending clinics which has a tick list for screening requirements.

The session is undertaken in our education centre. Pre Covid the session could accommodate up to 10 patients per session per week, uptake on average 8-10 patients for sDMARDs and 5-6 for bDMARDs. We alternated biologic and sDMARD sessions, if demand required, we changed a session to accommodate. The room is booked for 1½ hours every week, the sDMARD presentation lasts approximately ½ an hour & bDMARD session 50 minutes, time is allowed for group & individual questions if required at the end. This contrasts with 25 minute appointment for sDMARD & 50 minute for bDMARD counselling 1:1.

The booklet, along with information pack, is given at the group session to all patients. This includes all the information the patient requires (advice line information, blood forms). Prior to the group clinic admin team prepare the patient packs for the CNS to give to patients.

Results

We received 102 anonymous responses back from 136 patients asked. (75% response)

Following these sessions we found less calls to the advice line regarding medication queries, able to add in further cDMARDs or switch to alternate due to S/Es over the telephone

Feedback from patients.-120 comments received.

Clear simple information about a number of possible drugs used to treat my condition not just the 1 I am prescribed. If my medication needs changing I already know about it.

The lecture aspect of the types/contra-indications of meds was very useful & removed the ‘fear’ attached to these specialist drugs.

The session with other patients present stopped me from feeling alone in this position. The booklet is brilliant as it includes everything that was in the session. Also it took away the ‘fear’ of the side effects.

Conclusion

7 years on we feel that Group Counselling has been a huge success, we noticed how successful this was once we had to deal with the pandemic and cancel the group sessions. Patients feedback proves that they like the session and find them valuable. Whilst being beneficial and impoving work productivity and streamling the service.

Acknowledgements

The Rheumatology Team at The Kellgren Centre Manchester Royal Infirmary

Disclosure of Interests

Kelly Tempest Speakers bureau: Abbvie

Sanofi

Galapogos, Hanu Reddy: None declared, Samantha Johns: None declared, Kathryn Wright: None declared, Shabina Sultan Speakers bureau: Amgen, Grant/research support from: lilly

Algal biofuels from urban wastewaters: maximizing biomass yield using nutrients recycled from hydrothermal processing of biomass

Recent studies have proposed algal cultivation in urban wastewaters for the dual purpose of waste treatment and bioenergy production from the resulting biomass. This study proposes an enhancement to this approach that integrates cultivation of an acidophilic strain, Galdieria sulphuraria 5587.1, in a closed photobioreactor (PBR); hydrothermal liquefaction (HTL) of the wet algal biomass; and recirculation of the nutrient-rich aqueous product (AP) of HTL to the PBR to achieve higher biomass productivity than that could be achieved with raw wastewater. The premise is that recycling nutrients in the AP can maintain optimal C, N and P levels in the PBR to maximize biomass growth to increase energy returns. Growth studies on the test species validated growth on AP derived from HTL at temperatures from 180 to 300°C. Doubling N and P concentrations over normal levels in wastewater resulted in biomass productivity gains of 20-25% while N and P removal rates also doubled.

Severity of polymorphic light eruption in pre- and post-menopausal women: a comparative study

BACKGROUND

Polymorphic light eruption (PLE) is approximately four times more common in women than in men and often begins in young adult life. It is hypothesized that patients with PLE have an inherent resistance to UVL-induced immunosuppression, which is a physiological phenomenon in normal healthy individuals. Consequently, in PLE there is a delayed-type hypersensitivity reaction to a UVL-modified skin antigen, which results in an inflammatory reaction and a variable rash. The female hormone, 17β-oestradiol, has been shown to inhibit UVL-induced physiological suppression of contact hypersensitivity responses. This has been postulated to account for the female preponderance of PLE. If 17β-oestradiol plays a significant part in the disease, one might hypothesize that the severity of PLE might reduce in women after menopause.

OBJECTIVES

To compare the severity of PLE in pre-menopausal women with that in post-menopausal women.

METHODS

Eighteen pre-menopausal and 18 post-menopausal women with PLE had their Polymorphic Light Eruption Severity Index (PLESI) scored by a single investigator.

RESULTS

Pre-menopausal women (mean age 40 years; range 25-50) had a mean PLESI of 54.8 (range 0-86, SD 20.2). Post-menopausal women (mean age 63 years; range 53-78) had a mean PLESI of 36.8 (range 0-74, SD 18.2). A significant difference in mean PLESI values between pre- and post-menopausal women was noted (18.0; 95% CI 4.9-31.0; P = 0.008). At the time of the study, three subjects in the pre-menopausal group and one subject in the post-menopausal group were on oestrogen preparations. Even after excluding the four patients on oral oestrogens, there remained a statistically significant difference in the mean PLESI scores between the pre-menopausal and post-menopausal groups (55.10 vs. 36.64; difference of 18.46, 95% CI: 4.0-32.91; P = 0.014).

CONCLUSIONS

The severity of PLE was significantly less in post-menopausal women as compared with pre-menopausal women.

Prevalence of hand disorders in type 2 diabetes mellitus and its correlation with microvascular complications

Background:

Physicians have long recognized the association between diabetes mellitus and several pathologic conditions of the hand. The most commonly recognized maladies are limited joint mobility (LJM), Dupuytren's disease (DD), trigger finger (TF), and carpal tunnel syndrome (CTS). Incidence of these hand disorders has increased in the setting of diabetes. Collectively, these are described as diabetic hand syndrome.

Aim:

The aims were to find out the prevalence of hand disorders in diabetic patients, and to study the relation of these hand disorders with microvascular complications.

Subjects and Methods:

This is an observational cross-sectional case-control study done over a period of 1 year Patients of type 2 DM, of age < 65 years, who visited Gandhi Memorial Hospital, Lucknow were enrolled and were described as cases. Age- and sex-matched nondiabetic individuals were taken in the control group. The data were analyzed using software SPSS. SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc. Means and standard deviations were computed; the Student t-test and Chi-square (χ²) test were used as appropriate.

Results:

A total of 400 subjects were studied, 200 each in the case and control groups. Of total 200 diabetic patients, 30% (60/200) patients had neuropathy, 37.5% (75/200) had nephropathy, and 44.5% (89/200) patients had retinopathy. In the study population, 67% patients were having one or more hand disorders, in which LJM was found in 40.5% (81/200) patients, DD was found in 19% (38/200) patients, TF in 16.5% (33/200), and CTS in 14% (28/200) patients.

Conclusions:

This study shows a high prevalence of hand disorders in diabetic patients and also correlates with the duration of type 2 DM, LJM being the most common hand disorder and more common in patients who have microvascular complications.

Mechanical thrombectomy of an infected deep venous thrombosis: a novel technique of source control in sepsis

A young i.v. drug abuser presented with an extensive iliofemoral deep vein thrombosis and signs of severe sepsis. Subsequent investigations revealed multiple septic emboli in his lungs originating from infected thrombus in his leg. Despite systemic anti-coagulation and appropriate parenteral antibiotics, he continued to show signs of worsening acute infection. Percutaneous mechanical thrombectomy was performed successfully and resulted in an immediate improvement in his condition. In this report, we discuss the novel use of this technique for source control in a patient with septic shock secondary to infected thrombus.

Simulations of liquid nanocylinder breakup with dissipative particle dynamics

In this work, we use a dissipative-particle-dynamics-based model for two-phase flows to simulate the breakup of liquid nanocylinders. Rayleigh's criterion for capillary breakup of inviscid liquid cylinders is shown to apply for the cases considered, in agreement with prior molecular dynamics (MD) simulations. Also, as shown previously through MD simulations, satellite drops are not observed, because of the dominant role played by thermal fluctuations which lead to a symmetric breakup of the neck joining the two main drops. The parameters varied in this study are the domain size, cylinder radius, thermal length scale, viscosity, and surface tension. The breakup time does not show the same scaling dependence as in capillary breakup of liquid cylinders at the macroscale. The time variation of the radius at the point of breakup agrees with prior theoretical predictions from expressions derived with the assumption that thermal fluctuations lead to breakup.

Multimodal pain stimulations in patients with grade B oesophagitis

AIM

To obtain a better understanding of nociceptive processing in patients with oesophagitis.

PATIENTS AND METHODS

Eleven patients with grade B oesophagitis were compared with an age and sex matched group of 16 healthy subjects. A probe was positioned in the lower part of the oesophagus. After preconditioning of the tissue, painful mechanical stimuli were applied as distensions with a bag using an impedance planimetric method. Distensions were done before and after pharmacological impairment of distension induced smooth muscle contractions. Thermal stimulation was performed by recirculating water at 1 and 60 degrees C in the bag. The area under the temperature curve (AUC) represented caloric load. The referred pain area (being a proxy for the central pain mechanisms) to the mechanical stimuli was drawn at maximum pain intensities.

RESULTS

Patients were hyposensitive to mechanical stimuli, as assessed by the distending volume (F=8.1, p=0.005). After relaxation of smooth muscle with butylscopolamine, the difference between the two groups was more evident (F=27.4, p<0.001). AUC for cold stimulation was 1048.6 (242.7) degrees Cxs in controls and 889.8 (202.6) degrees Cxs in patients (p=0.5). For heat stimuli, AUC values were 323.3 (104.1) and 81.3 (32.3) degrees Cxs in controls and patients, respectively (p=0.04). The referred pain area to the mechanical stimulations was larger and more widespread in patients (49.3 (6.2) cm2 compared with controls 23.9 (7) cm2; p=0.02).

CONCLUSIONS

The data indicate that peripheral sensitisation of heat sensitive receptors and pathways combined with facilitation of central pain mechanisms may explain the symptoms in patients with oesophagitis.

Pathogen inactivation of Leishmania donovani infantum in plasma and platelet concentrates using riboflavin and ultraviolet light

BACKGROUND AND OBJECTIVES

Leishmania is transmitted by the bite of the phlebotomine sandfly or by transfusion of infected blood products. Leishmaniasis currently poses a significant problem in several parts of the world, and is an emerging problem in others. The Mirasol PRT technology is based on the use of riboflavin and ultraviolet light to generate chemical reactions in the nucleic acids of pathogens, which prevents replication and leads to inactivation. The intent of this study was to examine the ability of the Mirasol PRT System to kill the Leishmania parasite in human plasma and platelet concentrates.

MATERIALS AND METHODS

In visceral Leishmaniasis, amastigotes are present in the blood and in the reticuloendothelial system within monocytes. For each unit of plasma or platelets treated, isolated mononuclear cells obtained from 100 ml of normal donor whole blood were incubated with 1.0 x 10(8) Leishmania donovani infantum promastigotes to produce amastigote-laden macrophages. The infected macrophages were added to 250 ml of human plasma or to 250 ml of platelet concentrates. Infected units were cultured pretreatment in 10-fold serial dilutions to determine the limits of detection. Thirty millilitres of 500 microM riboflavin was added to each unit, which was then illuminated with 5.9 J/cm2 of ultraviolet light (6.24 J/ml). After treatment and after 2 months of frozen storage, plasma units were cultured in 10-fold serial dilutions. Platelets were cultured on the day of treatment and on day 5 of storage post-illumination.

RESULTS

A 5 log reduction of Leishmania was demonstrated in five of six units of plasma, and a 7 log reduction of Leishmania was demonstrated in one plasma unit. A 5 log reduction of Leishmania was demonstrated in five of six units of platelets, and a 6 log reduction of Leishmania was demonstrated in one unit.

CONCLUSIONS

There is no donor screen for Leishmania and other pathogens constantly emerging in our blood supply. The Mirasol PRT System for Platelets and Plasma is an effective means of killing Leishmania and other emerging pathogens in these blood products.

Non-invasive mapping of brain functions and brain recovery: applying lessons from cognitive neuroscience to neurorehabilitation

Modern cognitive neuroscience provides a powerful framework in which biological models of recovery and neurorehabilitation can be constructed and tested. The widespread availability, relatively low cost and informativeness of functional magnetic resonance imaging (fMRI) has made it the most popular of the techniques available to help with this task. Here, on the basis of functional imaging studies of stroke, diffuse microvascular disease and multiple sclerosis, we argue that processes of motor control and learning in the healthy brain share common mechanisms with those for adaptive functional reorganisation during spontaneous recovery after brain injury or with neurorehabilitation. Relatively stringent criteria can be met to confirm that adaptive functional reorganisation limits disability even in the adult brain: functional brain changes are related to disease burden, can be found in patients with demonstrable pathology but no clinical deficits and can be defined (in motor cortex) even in the absence of volitional recruitment. Initial studies of neurorehabilitation responses using fMRI and transcranial magnetic stimulation demonstrate that adaptive reorganisation can be manipulated directly with both pharmacological and behavioural interventions. The combination of strategies based on a strong biological rational with monitoring their effects using highly informative functional brain imaging methods heralds a new era of scientifically-founded neurorehabilitation.

Functional brain reorganization for hand movement in patients with multiple sclerosis: defining distinct effects of injury and disability

Previous work has demonstrated potentially adaptive cortical plasticity that increases with brain injury in patients with multiple sclerosis. However, animal studies showing use-dependent changes in motor cortex organization suggest that functional changes also may occur in response to disability. We therefore wished to test whether brain injury and disability lead to distinguishable patterns of activation with hand movement in patients with multiple sclerosis. By employing a passive as well as an active movement task, we also wished to test whether these changes were independent of voluntary recruitment and thus more likely to reflect true functional reorganization. Fourteen patients [Extended Disability Status Score (EDSS) 0-7.5] with relapsing-remitting multiple sclerosis were selected on the basis of pathology load and hand functional impairment for three study groups: group 1, low diffuse central brain injury (DCBI) as assessed from relative N-acetylaspartate concentration (a marker of axonal integrity) and normal hand function (n = 6); group 2, greater DCBI and normal hand function (n = 4); and group 3, greater DCBI and impaired hand function (n = 4). Functional MRI (fMRI) was used to map brain activation with a four-finger and both one-finger passive and active flexion-extension movement tasks for the three groups. Considering all the patients, we found increased activity in ipsilateral premotor and ipsilateral motor cortex (IMC) and in the ipsilateral inferior parietal lobule with increasing global disability (as assessed from the EDSS score). These changes appear to define true functional reorganization, as fMRI activations in IMC (r = 0.87, P < 0.001) and in the contralateral motor cortex (r = 0.67, P < 0.007) were highly correlated between active and passive single finger movements. We attempted to disambiguate any distinct effects of disability and brain injury by direct contrasts between patients differing predominantly in one or the other. To make these contrasts as powerful as possible, we used impairment of finger tapping as a measure of disability specific to the hand tested. A direct contrast of patients matched for DCBI, but differing in hand disability (group 3 - group 2) showed greater bilateral primary and secondary somatosensory cortex activation with greater disability alone. A contrast matched for hand disability, but differing in DCBI (group 2 - group 1) showed a different pattern of changes with relative ipsilateral premotor cortex and bilateral supplementary motor area activity. We conclude that the pattern of brain activity with finger movements changes both with increasing DCBI and with hand disability in patients with multiple sclerosis, and that these changes are distinct. Those related directly to disability may reflect responses to altered patterns of use. As injury- and disability-related activation changes are found even with passive finger movements, they may reflect true brain reorganization.

Functional reorganization of motor cortex increases with greater axonal injury from CADASIL

BACKGROUND AND PURPOSE

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited small-artery disease that clinically involves only the brain. Particularly early in the disease, patients can show substantial or complete recovery after individual strokes. Cortical functional reorganization may contribute to limiting disability with such ischemic injury. We sought to test whether the extent of any functional changes in the motor cortex increases with greater brain axonal injury from CADASIL.

METHODS

Functional MRI (fMRI) was used to characterize cortical activation during a simple hand-tapping task. Disease-associated pathology in subcortical white matter was assessed with the use of conventional fluid-attenuated inversion recovery (FLAIR) MRI and MR spectroscopic imaging for measurement of N-acetyl aspartate decreases, a relatively specific measure of axonal injury.

RESULTS

There was evidence for variable but substantial hyperintense white matter signal in all of the patients with FLAIR imaging. With the use of fMRI, the brain regions activated during motor tasks were similar for the 9 CADASIL patients and 7 controls, except that most (6 of 9) patients showed primary motor cortex activation both ipsilateral and contralateral to the hand moved, a finding in only 1 of 7 healthy controls. Ipsilateral motor cortex activation increased (r=-0.77, P<0.05) and motor cortex activation lateralization index decreased (r=0.68, P<0.02) with greater white matter injury (as assessed from decreases in the relative N-acetyl aspartate concentration) in a region of interest including descending motor fibers of the corticospinal pathway.

CONCLUSIONS

The extent of functional reorganization of motor cortex increases with increasing axonal injury, consistent with an adaptive role for these changes. Increased functional recruitment of cortex ipsilateral to the limb moved therefore may contribute to limiting motor impairment from the subcortical injury of CADASIL.

An expanded cortical representation for hand movement after peripheral motor denervation

OBJECTIVES

Functional reorganisation of the motor or sensory cortex has been demonstrated in animals after section of mixed peripheral nerves. Here functional changes in the motor cortex specifically after peripheral motor denervation in humans are investigated.

METHODS

Functional MRI (fMRI) was used to study brain activation during a finger flexion-extension task in patients with a late onset, acquired pure motor neuropathy (n=6), contrasting results with those from patients with pure sensory neuropathies (n=4) or healthy controls (n=7).

RESULTS

Increases in the extent of activation in the motor cortex both ipsilateral and contralateral to the hand moved were found in the patients with motor neuropathy. The neuroanatomical localisation of the mixed contralateral sensorimotor cortex activation volume was more posterior for the patients with motor neuropathy than for the healthy controls (mean difference, 12 mm, p<0.05). The pure sensory neuropathy group by contrast showed no change in the extent of activation relative to healthy controls and a trend for more anterior primary sensorimotor cortex activation (p<0.06). To test whether the increased activation volumes found in patients with motor neuropathy were a result simply of factors such as increased effort with movement rather than the motor denervation, patients with hand weakness from inclusion body myositis (n=4) were studied while making similar hand movements. No differences in either the numbers of significantly activated voxels or in their localisation were found relative to healthy controls (n=10).

CONCLUSIONS

These results provide a novel demonstration that peripheral denervation (as distinguished from factors related to weakness) leads to functional reorganisation of the sensorimotor cortex in the adult brain. This suggests that adaptive responses to motor denervation involve the central as well as the peripheral nervous system.

Altered cortical activation with finger movement after peripheral denervation: comparison of active and passive tasks

We wished to contrast cortical activation during hand movements in profoundly weak patients with motor neuropathy and in normal controls using a paradigm that is behaviourally matched between the two groups. Previous work has suggested that a passive movement task could be appropriate. Using functional magnetic resonance imaging (fMRI), we first characterised patterns of brain activation during active and passive index finger movements in healthy controls (n=10). Although the relative activation differences were highly variable, there was a trend for the mean number of significantly activated voxels in the primary motor cortex contralateral to the hand moved (CMC) to be lower for the passive than for the active task (40% relative decrease, P=0.09). There was a small posterior shift in the centre of mass of the CMC (mean, 8 mm, P<0.02) and of the ipsilateral sensorimotor cortex (IMC) (mean, 11 mm, P<0.05). No activation with passive movement was found in the patients with severe distal sensory neuropathy (n=2), suggesting that activation with passive movements is dependent on sensory feedback and unlikely to be due to mental imagery alone. In contrast, patients with severe pure motor neuropathies (MN, n=2) showed substantial increases in the volumes of activation compared to controls. The relative increases in numbers of voxels activated above threshold in different regions of interest for both the active (MN/controls: CMC, 2. 1; IMC, 8.1; supplementary motor area [SMA], 5.2) and passive (CMC, 2.6; IMC, 8.0; SMA, 5.1) tasks were similar. These results confirm expansion of cortical representation for finger movement in patients with motor neuropathy and demonstrate central reorganisation as a consequence of the motor nerve loss. An expanded representation for finger movement in the primary motor cortex with peripheral weakness suggests the possibility that the primary motor cortex may encode motor unit activation rather directly.

Selectivity of 4,5,6,7-tetrabromobenzotriazole, an ATP site-directed inhibitor of protein kinase CK2 ('casein kinase-2')

The specificity of 4,5,6,7-tetrabromo-2-azabenzimidazole (TBB), an ATP/GTP competitive inhibitor of protein kinase casein kinase-2 (CK2), has been examined against a panel of 33 protein kinases, either Ser/Thr- or Tyr-specific. In the presence of 10 microM TBB (and 100 microM ATP) only CK2 was drastically inhibited (>85%) whereas three kinases (phosphorylase kinase, glycogen synthase kinase 3 beta and cyclin-dependent kinase 2/cyclin A) underwent moderate inhibition, with IC(50) values one--two orders of magnitude higher than CK2 (IC(50)=0.9 microM). TBB also inhibits endogenous CK2 in cultured Jurkat cells. A CK2 mutant in which Val66 has been replaced by alanine is much less susceptible to inhibition by TBB as well as by another ATP competitive inhibitor, emodin. These data show that TBB is a quite selective inhibitor of CK2, that can be used in cell-based assays.

Continuing medical education. What do Minnesota physicians want?

CONTEXT

Continuing medical education (CME) is necessary for ongoing licensure and is critical in maintaining professional expertise. However, educators may not always consider their students preferences when developing new programs.

OBJECTIVE

To determine physician preference for the format of CME programs and to learn what factors contribute to selecting a CME activity.

DESIGN

Survey with 12 multiple response items pertaining to educational objectives, past educational experiences, and demographic information.

PARTICIPANTS

A total of 1,967 Minnesota physicians were sent the survey; 385 physicians returned surveys within 2 months of mailing date (20% return rate).

RESULTS

The vast majority of respondents reported participating in traditional CME programs during the preceding two years, and most said they planned to attend a traditional program in the next two years.

CONCLUSIONS

Minnesota physicians overwhelmingly prefer attending traditional CME programs to participating in more interactive, technology-based activities. Before new technology such as the Internet can be widely used in CME, it must be made attractive to the practicing physician.