Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Preliminary screening of antioxidant and cytotoxic potential of green seaweed, Halimeda opuntia (Linnaeus) Lamouroux

Marine natural products have displayed numerous advantageous effects on biological activities, including antioxidants and cytotoxicity. The total lipids, carotenoids, chlorophyll a and b content, total phenolic content (TPC), total flavonoid content (TFC), and antioxidant activity of methanolic crude extract of the green seaweed Halimeda opuntia were all measured in this study. The TPC of the extracts was determined according to the Folin-Ciocalteu method, yielding a result of 55.04 ± 0.98 mg GAE/g of extract. As determined by the aluminium chloride colorimetric method, the TFC of the extract was 40.02 ± 0.02 mg QE/g of extract. Antioxidant activity was determined by using a 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay with different concentrations that ranged between 200 and 1000 µg/mL, noted H. opuntia as the highest in DPPH reduction (63.61 %) at 1000 µg/mL concentration. Total antioxidant capacity (TAC) of the extract was 57.36 ± 0.004 mg AAE/g extract at concentration of 1.0 mg/mL. The cytotoxic activity of this seaweed was pre-screened against a panel of cell lines including estrogen receptor-positive human breast adenocarcinoma (MCF-7), estrogen negative human breast adenocarcinoma (MDA-MB-231), human colorectal adenocarcinoma (HT-29), human hepatocellular carcinoma (HepG2), and mouse embryonic fibroblast (3T3) using the MTT assay. The content of total lipids in H. opuntia was 1.60 ± 0.002 %. Total carotenoids were 115.57 ± 0.98 µg/g, while chlorophyll a and b were 148.73 ± 2.60 µg/g and 290.83 ± 9.46 µg/g, respectively. In terms of cytotoxicity activity, methanolic extract of H. opuntia was found to be highly cytotoxic to MCF-7 cells, with an IC₅₀ of 25.14 ± 1.02 g/mL, and slightly less so to 3T3 cells (IC₅₀ 65.23 ± 0.25 µg/mL). This study's findings suggest that natural pigments (carotenoids and chlorophyll), phytochemicals like phenolic and flavonoid compounds found in this species may play an important role and could be used as a natural cancer treatment.

Prevalence of growth hormone deficiency in patients with unexplained chronic fatigue after undergoing bone marrow transplantation in adulthood

PURPOSE

Many patients who undergo bone marrow transplantation (BMT) in adulthood experience unexplained chronic fatigue which can have a major impact on their health-related quality of life (QoL). Pre-BMT treatment regimens increase the risk of developing acquired growth hormone deficiency (GHD), which results in a clinical syndrome with decreased energy and has additionally been linked to metabolic syndrome.

METHODS

Using the gold-standard insulin hypoglycemic test (IHT), we evaluated the prevalence of GHD in 18 post-BMT adult patients with unexplained chronic fatigue, as well as the correlation between peak serum GH response and QoL scores, the metabolic syndrome, and insulin resistance. Peak serum GH cut-point less than 3.0 ug/L was used for the diagnosis of severe GHD. The Fatigue Severity Scale and Quality of Life in Adult GHD Assessment questionnaires were used to quantify fatigue symptoms.

RESULTS

The prevalence of severe GHD within this sample of 18 patients was 50%. A trend between lower peak serum GH response and higher fatigue and QoL-AGHDA scores was observed.

CONCLUSIONS

GHD may represent a remediable contributor to post-BMT chronic fatigue in adults, further studies are needed to evaluate the potential role of screening and GH replacement therapy in this vulnerable patient population.

IMPLICATIONS FOR CANCER SURVIVORS

GHD may be a treatable explanation for disabling post-BMT fatigue pending results of intervention studies.

Blueberry red ringspot virus genomes from Florida inferred through analysis of blueberry root transcriptomes

A growing number of metagenomics-based approaches have been used for the discovery of viruses in insects, cultivated plants, and water in agricultural production systems. In this study, sixteen blueberry root transcriptomes from eight clonally propagated blueberry plants of cultivar 'Emerald' (interspecific hybrid of Vaccinium corymbosum and V. darrowi) generated as part of a separate study on varietal tolerance to soil salinity were analyzed for plant viral sequences. The objective was to determine if the asymptomatic plants harbored the latent blueberry red ringspot virus (BRRV) in their roots. The only currently known mechanism of transmission of BRRV is through vegetative propagation; however, the virus can remain latent for years with some plants of 'Emerald' never developing red ringspot symptoms. Bioinformatic analyses of 'Emerald' transcriptomes using de novo assembly and reference-based mapping approaches yielded eight complete viral genomes of BRRV (genus Soymovirus, family Caulimoviridae). Validation in vitro by PCR confirmed the presence of BRRV in 100% of the 'Emerald' root samples. Sequence and phylogenetic analyses showed 94% to 97% nucleotide identity between BRRV genomes from Florida and sequences from Czech Republic, Japan, Poland, Slovenia, and the United States. Taken together, this study documented the first detection of a complete BRRV genome from roots of asymptomatic blueberry plants and in Florida through in silico analysis of plant transcriptomes.

Enzyme-Assisted Extraction of Bioactive Compounds from Raspberry (Rubus idaeus L.) Pomace

Industrial processing of raspberries into juice and jam results in the production of with high content of lipophilic and hydrophilic phytochemicals. Usually considered as waste, raspberry pomace is occasionally cold-pressed to recover specialty oil. However, the resulting pomace press-cake (PPC) still contains 30% to 35% of lipophilic compounds, such as essential fatty acids, tocols, phytosterols, and ellagitannins initially present in pomace. In a perspective of sustainable development, we investigate an eco-friendly process using an aqueous enzyme-assisted extraction (AEAE) to simultaneously and effectively recover lipophilic compounds and polyphenols from the PPC. The performance of different combinations of carbohydrases and proteases was compared. After selecting the best enzymatic system, a definitive screening design involving six factors was then implemented to optimize the process. Under optimized conditions, 1.2 units of thermostable alkaline protease/100 g PPC, pH 9, 60 °C, and 2 hr hydrolysis, more than 38% of total PPC lipophilic content were recovered in the aqueous medium. The recovery of polyphenols and antioxidant activity was, respectively, 48% and 25% higher than obtained by extraction with methanol/acetone/water mixture. Such an AEAE extract might prove useful in food and nutraceutical applications. PRACTICAL APPLICATION: Raspberry pomace, a food industrial by-product, is often considered as waste. However, it is a rich source of phytochemicals, such as tocols, polyphenols, and polyunsaturated fatty acids. To overcome the drawbacks of organic solvent use, an enzyme-assisted extraction process was developed as an eco-friendly alternative to recover these bioactive compounds. Definitive screening design experimental design was used to enhance polyphenols and lipophilics extraction yields while reducing process costs. This extract is an oil-in-water emulsion, with high content in antioxidant phytochemicals, which might have potential for use in nutraceutical applications. Therefore, this green process developed for the valorization of raspberry pomace is considered as a perspective of sustainable development.

Effect of motion artifact on digital camera based heart rate measurement

Remote health monitoring is an emerging field in biomedical technology. Digital camera based heart rate measurement method is a recent development which would make remote health monitoring reliable and sustainable in future. This paper presents an investigation on the effect of motion artifact on digital camera-based heart rate measurement. The paper will discuss details on the principles and effects of motion artifacts on photoplethysmography signals. An experiment is conducted using publicly available MAHNOB-HCI database. We have investigated the effects of static scenarios, scenarios involving rigid motion and scenarios involving non-rigid motion. The experiment was tested on state of the art digital camera based heart rate measuring methods. The results showed the effectiveness of the methods and provide a direction to overcome/minimize the effect of motion artifacts for future research.

Single Stage Nipple-Sparing Mastectomy and Reduction Mastopexy in the Ptotic Breast

PURPOSE

Given the proposed increased risk of nipple-areolar complex (NAC) necrosis, nipple-sparing mastectomy (NSM) is generally not recommended for patients with large or significantly ptotic breasts. NAC preserving strategies in this subgroup include staged or simultaneous NSM and reduction mastopexy. We present a novel approach towards simultaneous NSM and reduction mastopexy in patients with large, ptotic breasts.

METHODS

Literature pertaining to NSM for women with large, ptotic breasts was reviewed and a surgical approach was designed to allow for simultaneous NSM and reduction mastopexy in such patients.

RESULTS

Eight patients underwent bilateral NSM with simultaneous reduction mammaplasty and immediate reconstruction. The majority of breasts demonstrated advanced ptosis (69% grade III, 31% grade II) and the average breast volume excised was 760 grams. In those patients without a history of smoking, NAC necrosis rates were 0%. In those patients with a history of smoking, 83% of breasts experienced NAC necrosis (60% total, 40% partial). One hundred percent of patients who smoked experienced some degree of NAC necrosis. Among breasts with grade II versus grade III ptosis, NAC necrosis rates were roughly equal.

CONCLUSIONS

Historically, patients with large, ptotic breasts were excluded from NSM due to the proposed increased risk of NAC necrosis. This study demonstrates a safe approach towards NSM and reduction mastopexy using an inferior, wide-based, epithelialized pedicle. While all patients eventually achieved satisfactory results, there was an association between smoking and NAC necrosis. Smoking cessation is paramount to the operation's success.

Novel health monitoring method using an RGB camera

In this paper we present a novel health monitoring method by estimating the heart rate and respiratory rate using an RGB camera. The heart rate and the respiratory rate are estimated from the photoplethysmography (PPG) and the respiratory motion. The method mainly operates by using the green spectrum of the RGB camera to generate a multivariate PPG signal to perform multivariate de-noising on the video signal to extract the resultant PPG signal. A periodicity based voting scheme (PVS) was used to measure the heart rate and respiratory rate from the estimated PPG signal. We evaluated our proposed method with a state of the art heart rate measuring method for two scenarios using the MAHNOB-HCI database and a self collected naturalistic environment database. The methods were furthermore evaluated for various scenarios at naturalistic environments such as a motion variance session and a skin tone variance session. Our proposed method operated robustly during the experiments and outperformed the state of the art heart rate measuring methods by compensating the effects of the naturalistic environment.

The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study

AIMS

People with diabetes and poor glycaemic control are at higher risk of diabetes-related complications and incur higher healthcare costs. An understanding of the sociodemographic and clinical characteristics associated with poor glycaemic control is needed to overcome the barriers to achieving care goals in this population.

METHODS

We used linked administrative and laboratory data to create a provincial cohort of adults with prevalent diabetes, and a measure of HbA_1c that occurred at least 1 year following the date of diagnosis. The primary outcome was poor glycaemic control, defined as at least two consecutive HbA_1c measurements ≥ 86 mmol/mol (10%), not including the index measurement, spanning a minimum of 90 days. We used multivariable Cox proportional hazards models to evaluate the association between baseline sociodemographic and clinical factors and poor glycaemic control.

RESULTS

In this population-based cohort of 169 890 people, younger age was significantly associated with sustained poor glycaemic control, with a hazard ratio (HR) of 3.08, 95% CI (2.79-3.39) for age 18-39 years compared with age ≥ 75 years. Longer duration of diabetes, First Nations status, lower neighbourhood income quintile, history of substance abuse, mood disorder, cardiovascular disease, albuminuria and high LDL cholesterol were also associated with poor glycaemic control.

CONCLUSIONS

Although our results may be limited by the observational nature of the study, the large geographically defined sample size, longitudinal design and robust definition of poor glycaemic control are important strengths. These findings demonstrate the complexity associated with poor glycaemic control and indicate a need for tailored interventions.

Hepatic venous outflow obstruction in pediatric liver transplantation: technical considerations in prevention, diagnosis, and management

HVOO creates significant diagnostic and management dilemmas in pediatric liver transplant recipients, particularly with TVGs (split or reduced-size grafts). Numerous technical variations for the hepatic vein to IVC anastomosis have been described to minimize the incidence of this complication, but no consensus for an optimal anastomotic technique exists. One hundred and thirty-four liver transplants (70 TVGs) were performed in 124 patients between 1994 and 2011. These were divided into two cohorts. Group 1 (95 transplants, 41 TVGs) utilized a continuous running anastomosis. Group 2 (39 transplants, 29 TVGs) implemented a triangulated (three-stitch) anastomosis. All were reviewed for demographics, diagnostics, interventions, and outcome. The overall HVOO incidence was seven of 134 transplants (5.2%) and six of 70 transplants utilizing TVGs (8.6%). Group 1 incidence was five of 41 (12.2%) compared with one of 29 (3.4%; p = 0.20, OR 3.89) in Group 2. Liver Doppler was employed in all patients, and only three suggested HVOO. All patients with HVOO underwent venogram, at a median of 81 days post-transplant. All underwent percutaneous venoplasty and required 1-6 treatments, all resulting in HVOO resolution. Incidence of HVOO has improved since adopting the triangulated anastomosis, although not to a level of statistical significance. US is not adequately sensitive to exclude HVOO. Venogram is recommended in patients with prolonged ascites, and venoplasty has been highly successful in HVOO treatment.

Global transmission and reflection coefficients of the ultrasonic component in porous media: a new approach

The purpose of this paper is to propose a new approach to determining the global ultrasonic transmission and reflection coefficients in a random porous medium. Boundary conditions at the interface of the medium were used to determine local transmission and reflection coefficients. A study of the behavior of different waves inside the medium was carried out to derive a new global formulation that takes interior phenomena into consideration. All the results were obtained independently of the geometrical and physical characteristics of the medium so that the method can be applied to any two-phase porous medium. This study is based on normal incidence ultrasonic wave propagation.

Lactobacillus plantarum 299v surface-bound GAPDH: a new insight into enzyme cell walls location

The aim of this study was to provide new insight into the mechanism whereby the housekeeping enzyme glyceraldehyde-3-phosphate dehydrogenase (GAPDH) locates to cell walls of Lactobacillus plantarum 299v. After purification, cytosolic and cell wall GAPDH (cw-GAPDH) forms were characterized and shown to be identical homotetrameric active enzymes. GAPDH concentration on cell walls was growth-time dependent. Free GAPDH was not observed on the culture supernatant at any time during growth, and provoked cell lysis was not concomitant with any reassociation of GAPDH onto the cell surface. Hence, with the possibility of cw-GAPDH resulting from autolysis being unlikely, entrapment of intracellular GAPDH on the cell wall after a passive efflux through altered plasma membrane was investigated. Flow cytometry was used to assess L. plantarum 299v membrane permeabilization after labeling with propidium iodide (PI). By combining PI uptake and cw-GAPDH activity measurements, we demonstrate here that the increase in cw-GAPDH concentration from the early exponential phase to the late stationary phase is closely related to an increase in plasma membrane permeability during growth. Moreover, we observed that increases in both plasma membrane permeability and cw-GAPDH activity were delayed when glucose was added during L. plantarum 299v growth. Using a double labeling of L. plantarum 299v cells with anti-GAPDH antibodies and propidium iodide, we established unambiguously that cells with impaired membrane manifest five times more cw-GAPDH than unaltered cells. Our results show that plasma membrane permeability appears to be closely related to the efflux of GAPDH on the bacterial cell surface, offering new insight into the understanding of the cell wall location of this enzyme.

Fractionated stereotactic radiotherapy boost and weekly paclitaxel in malignant gliomas clinical and pharmacokinetics results

Management of Malignant Gliomas continues to be a challenge. We prospectively studied the role of adding weekly Paclitaxel to Fractionated Stereotactic Radiation Therapy (FSRT) in the treatment of Malignant Gliomas. Twenty-three Glioblastoma Multiforme and two Anaplastic Astrocytoma were studied. Patients received 46 Gy at 2 Gy/fraction followed by a boost utilizing FSRT at a fraction of 2.5 Gy for 8 fractions. Paclitaxel is delivered concomitantly at 150 mg/m(2) weekly for six cycles. Eighteen patients had pharmacokinetic assays of Paclitaxel levels. All patients were followed until death or for a maximum of 36 months. The overall survival of the whole group was 14 months. The median survival for RPA prognostic classes III, IV, V, and VI were 20, 14, 12, and 11 months. Higher survival (14 months) was noted in the subtherapeutic phenytoin level group compared to 10 months in the therapeutic group (P=0.271). No grade 4 CTCAE (version 3.0) toxicities were observed. Enhanced survival was demonstrated with gross tumor resection (20.8 months), KPS > or =80 (18.7 months) and age < or =60 years (27 months) as compared to subtotal resection or biopsy (12.1 months, P< 0.005), KPS < or =70 (10.8 months, P=0. 005) and older age > 60 (10.46 months, P=0.006), respectively. Our study suggests that: i) the use of weekly Paclitaxel and FSRT in Gliomas is well tolerated with a survival of 14 months; ii) the regimen resulted in improvement of survival of RPA classes IV, V, VI; and iii) the use of FSRT boost may be studied with other chemotherapeutic agents to see if superior results can be attained.

Hypertrichose lanugineuse acquise et adénocarcinome gastrique

INTRODUCTION

Acquired hypertrichosis lanuginosa is a form of obligatorily paraneoplastic disease characterised by the recurrence of lanuga hair during adulthood. We report a case in which this hypertrichosis allowed diagnosis of gastric cancer.

OBSERVATION

A 51 year-old woman was seen for hypertrichosis present for 3 months. Clinical examination led to diagnosis of acquired hypertrichosis lanuginosa, which subsequently resulted in the discovery of gastric adenocarcinoma. Surgical excision of the tumour resulted in the disappearance of hypertrichosis with no recurrence during the ensuing 13 months.

DISCUSSION

Acquired hypertrichosis lanuginosa is rare, with only 50 or so cases reported in the literature since the condition was first described in 1865 by Turner. These cases confirm the obligatorily paraneoplastic nature of this particular dermatosis. Our finding is original since it is the first recorded case of association with gastric adenocarcinoma. It is also unique in terms of the strictly parallel development of acquired hypertrichosis lanuginosa and the tumour, with complete disappearance of the hypertrichosis in the weeks following surgical removal of the tumour, and in terms of prolonged survival (complete remission 17 months after the onset of symptoms). The mechanism responsible for acquired hypertrichosis lanuginosa is unknown. Two hypotheses have nevertheless been suggested: acquired hypertrichosis lanuginosa could be associated with secretion by the tumour of an as yet unidentified serum factor, or with a nutritional deficiency that may accompany this form of cancer.

Metastatic choriocarcinoma: A rare cause of stroke in the young adult

A 20-year old woman presented with acute right hemiplegia 10 weeks after intrauterine fetal death at 34-weeks gestation (G1P0). A brain MRI showed a typical acute infarct in the left middle cerebral artery territory. A CT pulmonary angiography carried out 1 week later for sudden cardiopulmonary deterioration showed disseminated pulmonary metastases. The CT was extended to the abdomen and pelvis, which showed a uterine mass with bilateral theca lutein cysts. The radiological diagnosis of metastatic choriocarcinoma was made and was subsequently confirmed with the markedly increased serum beta-human chorionic gonadotrophin. A serum beta-human chorionic gonadotrophin is therefore considered worthwhile in any young female adult who presents with stroke.

[Diagnostic strategy in persistent hyperparathyroidism. Report of two cases and review of the literature]

Ectopic adenoma is the main cause of surgery failure in the treatment of primary hyperparathyroidism (HPT). Localization of the abnormal glands is therefore necessary before a reoperation. We report two cases illustrating the interest of MRI and selective venous sampling of parathormone. In two patients with persistent hyperparathyroidism, ultrasound and sestamibi scanning failed to localize the ectopic glands. MRI suggested the presence of an adenoma in the mediastinum for the first patient and inside the thyroid for the second. In both cases, the localisation was confirmed by venous sampling and the reoperation was a success. We review the recent literature on this topic and we propose a diagnostic approach of persistent HPT.

Bilateral inferior insertion of lateral rectus muscles associated with schizencephaly

A 5-year-old boy with a large V-pattern exotropia is described. He has a background of congenital left hemiparesis associated with schizencephaly. At the time of surgery the lateral recti were found to be abnormally inferiorly positioned. Accordingly, both lateral rectus muscles were recessed 6.5 mm and supraplaced. A V-pattern exotropia persisted postoperatively with clinical overaction of the inferior obliques. To our knowledge this is the first known case of extraocular muscle abnormalities associated with schizencephaly.

The acute effect of intravenously administered recombinant human erythropoietin on the immune response of uremic patients maintained on regular hemodialysis

The uremic patient on regular hemodialysis (RHD) is subjected to a wide range of immune modulators including the uremic state per se, multiple transfusions and exposure to bioincompatible materials and endotoxins. Erythropoietin (EPO) therapy may raise concern about its potential influence on this complex scenario. To envisage this issue, 15 adequately selected patients, stable on RHD, were randomly assigned in a 2:1 ratio into EPO and placebo groups. After initial assessment and determination of baseline values, they received, in a double-blind manner, either EPO or normal saline as an intravenous bolus immediately after termination of dialysis for 30 successive sessions. Thirty minutes later, following sessions 1, 10, 20, and 30, samples were obtained for determination of blood counts, red cell indices, peripheral lymphocyte counts (PLC), CD4/CD8 ratios, blood EPO levels, and serum concentrations of interleukins (IL) IL-2r, IL-3, and IL-6, tumor necrosis factor (TNFs and TNFalpha), and neopterin (NPT). Blood EPO levels displayed the predicted rise in the EPO group, which correlated with partial improvement of red cell parameters. The mean total leukocyte count and PLCs was significantly increased in the EPO group (p < 0.05) but not in the placebo group. CD4/CD8 ratios were not significantly changed in either group. The serum concentrations of IL-2r, IL-3, and NPT remained fairly stable while that of IL-6 was widely variable in both study groups. The mean serum concentrations of TNF and particularly TNFalpha showed a steady and statistically significant increment in the EPO group from 6 to 41 pg/ml (p < 0.05) and 93 to 128 pg/ml (p < 0.03), respectively. No significant change was noticed in the control group. It is concluded that intravenous administration of EPO under the conditions of this study may have an immune stimulating effect. This is shown by the release of TNFs, which in turn may be responsible, through different potential mechanisms, for the increase in the mean peripheral neutrophil count and the blunting of erythroid responsiveness to EPO therapy.

[Locoregional anesthesia for endoscopic surgery of the carpal tunnel]

Local anaesthesia for surgical endoscopic release of carpal ligament is obtained with a block of the median nerve associated with subcutaneous infiltration of the areas of entrance and exit of the endoscope. A palmar application of Emla cream makes the needle puncture painless. The accidental puncture of the median nerve, which occurs when the needle is inserted too rapidly, is the only potential complication. It is easily prevented by pushing the needle gently forward and orientating the bevel parallel to the axis of the nerve. The use of a neurostimulator and needle with a blunt tip can be an alternative. We used this technique in more than 1,500 patients. Only one accidental puncture of the nerve due to a technical error occurred.

Midbrain angioma with disconjugate vertical gaze palsy

Loss of depression in one eye with contralateral loss of elevation is rare. It has been attributed to a subnuclear lesion of the oculomotor nerve nuclear complex. We present a patient with these signs who has an arteriovenous malformation occupying his rostral midbrain. We argue that attributing these findings to a subnuclear lesion of the oculomotor nerve complex does not take into consideration the secondary, vertical action of the obliques.

Medial rectus electromyographic abnormalities in Duane syndrome

We report on four patients from the botulinum toxin clinic at Moorfields Eye Hospital with Duane syndrome, who exhibited paradoxical medial rectus activity. EMGs were performed with a standard toxin needle and were qualitative in nature. Current physiodynamic theories as to the etiology of Duane syndrome are based on an aberrant innervation of the lateral rectus. Paradoxical electromyographic activity of the medial rectus may occur in Duane type I syndrome. A possible explanation for this finding is that the medial rectus may receive aberrant innervation but this may not be physiodynamically significant. We postulate that peripheral innervational anomalies may be secondary to, or coexist with, a brain stem anomaly. If an extraocular muscle possesses a dual innervation, then electromyographic abnormalities, without physiodynamic significance, may occur if the recording electrode comes into contact with muscle fibers innervated by a nerve that supplies a small segment of muscle.

The role of botulinum toxin in third nerve palsy

Isolated third nerve paresis is a rare diagnosis among patients presenting to the Botulinum Toxin Clinic at Moorfields Eye Hospital. Ten patients with this diagnosis are reviewed in this study. Head trauma is a common cause of third nerve palsy and is often severe enough to cause damage to fusion potential. If fusion is present and there is adequate adduction of the divergent eye, then botulinum toxin injection of the lateral rectus may induce long-term control of the ocular deviation. Three of the four patients who experienced long-term control of their ocular deviation following toxin injection shared these features. Toxin injected into the lateral rectus did not, however, reliably assess medial rectus function and therefore predict the outcome of horizontal squint surgery. Reasons for this are discussed.

Saphenous bicephalic aortocoronary graft in the treatment of right coronary bifurcation stenosis

We describe a surgical maneuver suitable for stenosis of the bifurcation of the right coronary artery. The distal end of a saphenous vein graft is prepared to obtain a two-headed shape. The anastomosis achieves enlargement of the bifurcation, providing complete distal revascularization.

Electrode comparison in pattern electroretinography

In recent years, there has been great interest in recording the pattern electroretinogram (PERG) in glaucomatous and diabetic populations. The Dawson, Trick, and Litzkow thread electrode (DTLTE) and the gold foil electrode (GFE), commonly used for recording PERGs, were compared for variations in amplitude of response, test-retest variability, and patient comfort. Two study centers collected data on a total of 32 normal subjects. The subjects from the London center showed a slight (but not significant) preference for the DTLTE, and the Houston subjects also found the DTLTE to be significantly more comfortable (chi-square = 39, P less than 0.001). In both study groups, the GFE was found to produce a statistically larger amplitude of response than that obtained with the DTLTE. Significant differences were found regardless of the slow (transient, 3.1 Hz; F = 6.24; P = 0.0192) or fast (steady state, 8.3 Hz; F = 18.38; P = 0.0001) stimulus-presentation rate. Larger differences between the two electrodes occurred under steady-state conditions. Although there is no consensus as to the optimum recording conditions to obtain the subtle PERG, it appears the the GFE records larger responses than the DTLTE. However, test-retest data confirmed that the GFE records twice the amplitude of the DTLTE, and it also produced twice the variability (average percent difference over time for GFE, 15%; for DTLTE, 8%).

Diffuse neonatal haemangiomatosis: successful management with high dose corticosteroids

We report two cases of diffuse neonatal haemangiomatosis. The multiple cutaneous lesions were associated with massive hepatic involvement and congestive heart failure in one, while in the other laryngeal haemangiomas caused stridor and inspiratory distress. A significant regression in vascular lesions was achieved with high dose corticosteroid therapy.

Adult penicillinase-producing gonococcal keratoconjunctivitis

The case is described of a 22-year-old man who presented with ulcerative keratitis as a complication of conjunctivitis that was caused by penicillinase-producing Neisseria gonorrhoeae. The need for first-line treatment with antibiotic agents that are resistant to beta-lactamase breakdown is discussed.