Health care access, psychosocial outcomes and mental health in adults living with epilepsy during the COVID-19 pandemic

PURPOSE

People living with epilepsy (PLWE) have a higher prevalence of mental health comorbidities and poorer psychosocial outcomes compared to the general population. The aim of this study was to examine psychosocial outcomes, mental health, healthcare accessibility, and seizure burden in PLWE during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional study of adults with epilepsy treated in an urban multicenter health system from 2021 to 2022. A standardized questionnaire assessed for COVID-19 history, comorbidities, access to antiseizure medications (ASMs) and neurological care, seizure burden, and psychosocial outcomes (e.g., employment, social and financial support). The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were administered to evaluate for depression and anxiety. Frequency and proportions for categorical variables and median and interquartile ranges for continuous variables were calculated.

RESULTS

Fifty-five PLWE participated (95 % response rate). Median age was 40 years (IQR 31.5-66.5), 61.8 % were women, 47.3 % had a bachelor's degree or higher and 29.1 % each had Medicaid and Medicare insurance. Race (from highest to lowest %) was: 32.7 % White, 20 % Black, 20 % Latinx, 14.5 % Asian, and 12.7 % selected "other" or "prefer not to say." COVID-19 had been diagnosed in 21.8 % of participants. Symptoms of anxiety and depression were self-reported by 43.6 % and 34.5 % of patients, respectively, with many describing this symptom as new post-pandemic (37.5 % and 31.6 %, respectively). Using validated scales, 52.7 % had depression (PHQ-9 score ≥ 5) with 30.9 % having moderate/severe depression (PHQ-9 score ≥ 10), while 29.1 % had probable generalized anxiety disorder (GAD-7 score ≥ 8). Seizure burden increased in 21.8 % of participants, while 20 % reported fewer seizures and 29.1 % were seizure free since the COVID-19 pandemic. Economic impacts of the pandemic included job loss (25 % amongst those employed at onset of pandemic), new or worsened financial difficulties (40 %), and new or worsened social support issues (30.9 %). Of all participants, 18.2 % reported difficulties accessing ASMs and 25.5 % cancelled visits, but of those with cancelled visits, 78.6 % had their appointments rescheduled as a telehealth visit.

CONCLUSION

Our cohort of PLWE experienced some challenges during the COVID-19 pandemic including poorer mental health and financial and employment-related stressors. Encouragingly, healthcare access was relatively spared during the COVID-19 crisis, with some patients even reporting a reduction in seizure burden. However, PLWE require ongoing psychosocial support with particular attention to decompensation of mental health and social stressors that may be exacerbated by the COVID-19 pandemic.

POS0017 SEVERE GENERALIZED EDEMA AS INITIAL PRESENTING SYMPTOM IN POLYMYOSITIS

Background

53 year old female developed pain and swelling of the metacarpophalangeal and proximal interphalangeal joints of both hands. She was diagnosed to have possible inflammatory arthropathy since her workup showed elevated inflammatory markers with CRP 2.2 and ESR 35. Rheumatoid factor and antiCCP antibody were negative. She was treated with hydroxychloroquine, methotrexate followed by leflunomide. She had non pitting edema around both ankles at initial presentation which later spread to the thighs, abdomen and chest. There was no erythema of the skin, tenderness or skin rash. BNP was normal at 58. TSH was normal. Echocardiogram was normal. Blood and urine cultures were negative. CT scan of the chest, abdomen and pelvis showed moderate subcutaneous edema. She was noted to have elevated liver enzymes with AST 438 and ALT 245. Hepatitis panel was negative. Smooth muscle antibody and antimitochondrial antibody were negative. Ultrasound abdomen showed diffusley increased echogenicity throughout the liver. Liver biopsy showed mildly active steatohepatitis centrizonal and portal/periportal fibrosis. ANA was positive 1:640 speckled pattern. ENA showed a positive antiRNP antibody. ANCA was negative. CK was elevated at 853 U/L. Myomarker panel was negative for antiJo, Anti Mi2, antiSRP, antiNXP and anti Ku antibodies. She had a workup for malignancy including CT chest, abdomen and pelvis, mammogram and colonoscopy which were negative.

Objectives

About 4 months after she presented with edema, she developed progressive proximal muscle weakness of both lower extremities which later involved both upper extremities. She also had neck muscle weakness. She also complained of difficulty swallowing. Swallow evaluation was normal. She did not have any skin rashes.

Methods

Concentric needle electromyography showed abnormal spontaneous activity; small amplitude and often polyphasic motor unit action potentials, along with increased recruitment pattern in tibialis anterior, vastus lateralis, medial gastrocnemius, tibialis posterior and short head biceps femoris muscle in the left lower extremity. The findings were suggestive of myopathy. She underwent a muscle biopsy from the left deltoid muscle which showed dense perimysial and endomysial lymphoplasmacytic inflammatory infiltrates with degenerating myofibers.

Results

Patient has proximal muscle weakness in both upper and lower extremities along with elevated CK, EMG findings suggestive of an underlying myopathy and biopsy evidence of inflammation and a diagnosis of polymyositis was made.She was initiated on treatment with a tapering course of prednisone starting at 60 mg daily. Her edema has improved. Liver function tests and CK have improved. Muscle strength has improved in both upper extremities with some residual weakness in the proximal muscles of lower extremities.

Conclusion

Patient presented with severe generalized edema as the initial presenting symptom of polymyositis. Rheumatologists should be aware of subcutaneous edema as a presenting manifestation of inflammatory myopathy and may precede the development of muscle weakness. Previously reported cases of edematous inflammatory myopathy were mostly dermatomyositis. This case demonstrates that polymyositis could also present as subcutaneous edema.

References:

[1] O Gorelik 1, D Almoznino-Sarafian, I Alon, M J Rapoport, G Goltsman, M Herbert, D Modai, N Cohen. Acute inflammatory myopathy with severe subcutaneous edema, a new variant? Report of two cases and review of the literature. Rheumatol Int (2001) 20: 163-166.

[2] Chai Y, Bertorini TE, Li YD, Mitchell C, Guan H (2011). Limb edema and anasarca associated with severe dermatomyositis: report of four cases. Neuromuscul Disord 21:439–442.

Disclosure of Interests

None declared

Healthcare-associated infection impact with bioaerosol treatment and COVID-19 mitigation measures

BACKGROUND

The real-world impact of breathing zone air purification and coronavirus disease 2019 (COVID-19) mitigation measures on healthcare-associated infections is not well documented. Engineering solutions to treat airborne transmission of disease may yield results in controlled test chambers or single rooms, but have not been reported on hospital-wide applications, and the impact of COVID-19 mitigation measures on healthcare-associated infection rates is unknown.

AIM

To determine the impact of hospital-wide bioaerosol treatment and COVID-19 mitigation measures on clinical outcomes.

METHODS

The impact of the step-wise addition of air disinfection technology and COVID-19 mitigation measures to standard multi-modal infection control on particle counts, viral and bacterial bioburden, and healthcare-associated infection rates was investigated in a 124-bed hospital (>100,000 patient-days over 30 months).

FINDINGS AND CONCLUSION

The addition of air disinfection technology and COVID-19 mitigation measures reduced airborne ultrafine particles, altered hospital bioburden, and reduced healthcare-associated infections from 11.9 to 6.6 (per 1000 patient-days) and from 6.6 to 1.0 (per 1000 patient-days), respectively (P<0.0001, R2=0.86). No single technology, tool or procedure will eliminate healthcare-associated infections, but the addition of a ubiquitous facility-wide engineering solution at limited expense and with no alteration to patient, visitor or staff traffic or workflow patterns reduced infections by 45%. A similar impact was documented with the addition of comprehensive, restrictive, and labour- and material-intensive COVID-19 mitigation measures. To the authors' knowledge, this is the first direct comparison between traditional infection control, an engineering solution and COVID-19 mitigation measures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tenosynovial giant cell tumours of the hand: A multicentre case-control study

Many factors have been proposed to contribute to the risk of recurrent tenosynovial giant cell tumours (TSGCT); however, we remain unable to predict those at risk, which formed the rationale for this multicentre retrospective case-control study of 28 patients with recurrence. We included cases of recurrence in a 1:1 ratio matched for age and sex with controls over 10 years. Using Cox regression, we present hazard ratios (HRs) for recurrence with 95% confidence intervals (CIs). Out of 285 cases, 28 individuals developed recurrence after a median of 2.4 years. Recurrent TSGCT had a higher mitotic count/mm² in the primary tumour (median increase of 3 [IQR 1, 7]). Mitotic count in the primary tumour was associated with the risk of recurrence (adjusted HR 1.1 [95% CI 1.1, 1.2]) meaning that for every additional mitosis, the risk of recurrence increased by 10% per annum. We recommend a prospective cohort study to validate our findings.

E-cadherin, actin, microtubules and FAK dominate different spheroid formation phases and important elements of tissue integrity

Spheroids resemble features of tissues and serve as model systems to study cell–cell and cell–ECM interactions in non-adhesive three-dimensional environments. Although it is generally accepted that mature spheroids resemble tissue properties very well, no studies relate different phases in the spheroid formation processes that contribute to tissue integrity. Tissue integrity involves the cellular processes adhesion formation, adhesion reinforcement, rearrangement as well as proliferation. They maintain the structure and function of tissues and, upon dysregulation, contribute to malignancy. We investigated spheroid formation dynamics in cell lines of different metastatic potential. We dissected spheroid formation into phases of aggregation, compaction and growth to identify the respective contributions of E-cadherin, actin, microtubules and FAK. E-cadherin, actin and microtubules drive the first two phases. Microtubules and FAK are involved in the proliferation phase. FAK activity correlates with the metastatic potential of the cells. A robust computational model based on a very large number of experiments reveals the temporal resolution of cell adhesion. Our results provide novel hypotheses to unveil the general mechanisms that contribute to tissue integrity.

Summary: The phases of spheroid formation resemble different stages of cell contact formation. This facilitates studying the temporal contribution of molecules in this process.

Robust and automated three-dimensional segmentation of densely packed cell nuclei in different biological specimens with Lines-of-Sight decomposition

Background

Due to the large amount of data produced by advanced microscopy, automated image analysis is crucial in modern biology. Most applications require reliable cell nuclei segmentation. However, in many biological specimens cell nuclei are densely packed and appear to touch one another in the images. Therefore, a major difficulty of three-dimensional cell nuclei segmentation is the decomposition of cell nuclei that apparently touch each other. Current methods are highly adapted to a certain biological specimen or a specific microscope. They do not ensure similarly accurate segmentation performance, i.e. their robustness for different datasets is not guaranteed. Hence, these methods require elaborate adjustments to each dataset.

Results

We present an advanced three-dimensional cell nuclei segmentation algorithm that is accurate and robust. Our approach combines local adaptive pre-processing with decomposition based on Lines-of-Sight (LoS) to separate apparently touching cell nuclei into approximately convex parts. We demonstrate the superior performance of our algorithm using data from different specimens recorded with different microscopes. The three-dimensional images were recorded with confocal and light sheet-based fluorescence microscopes. The specimens are an early mouse embryo and two different cellular spheroids. We compared the segmentation accuracy of our algorithm with ground truth data for the test images and results from state-of-the-art methods. The analysis shows that our method is accurate throughout all test datasets (mean F-measure: 91 %) whereas the other methods each failed for at least one dataset (F-measure ≤ 69 %). Furthermore, nuclei volume measurements are improved for LoS decomposition. The state-of-the-art methods required laborious adjustments of parameter values to achieve these results. Our LoS algorithm did not require parameter value adjustments. The accurate performance was achieved with one fixed set of parameter values.

Conclusion

We developed a novel and fully automated three-dimensional cell nuclei segmentation method incorporating LoS decomposition. LoS are easily accessible features that ensure correct splitting of apparently touching cell nuclei independent of their shape, size or intensity. Our method showed superior performance compared to state-of-the-art methods, performing accurately for a variety of test images. Hence, our LoS approach can be readily applied to quantitative evaluation in drug testing, developmental and cell biology.

Electronic supplementary material

The online version of this article (doi:10.1186/s12859-015-0617-x) contains supplementary material, which is available to authorized users.

Design, Synthesis, Toxicity Estimation and Molecular Docking Studies of N-(furan-2-yl)-1-(5-substituted) phenyl-1,3,4-oxadiazol-2-yl) methanimine as Antitubercular Agents

A series of novel N-(furan-2-yl)-1-(5-substituted) phenyl-1,3,4-oxadiazol-2-yl) methanimines (Fa-e) were synthesized and evaluated for antitubercular activity against Mycobacterium tuberculosis (H37Rv) strain by using alamar blue assay. The synthesized compounds were characterized based on IR, (1)HMR and mass spectral analysis. The toxicity profile was predicted by organic chemistry portal, a web based application for predicting in silico absorption, distribution, metabolism, excretion and toxicity, and the novel derivatives under study did not show any toxicity issues. The mechanism of action of the titled derivatives was predicted by docking on the Mycobacterium tuberculosis Enoyl-ACP reductase enzyme. The docking study concluded that Fb and Fa possessed good binding energy indicating more prominent interaction towards the active sites NAD and TYR 158. The antitubercular studies showed that the both Fa and Fb possessed significant activity with the MIC as low as 3.125 μg/ml.

A rare case of primary malignant melanoma in an ileostomy

The vast majority of malignant melanomas occur in the skin. These are associated with sunlight exposure and thought to be due to ultraviolet radiation. Melanomas in rare instances (1.3-1.4 percent) may originate from extracutaneous tissues such as the leptomeninges.(1) They have also been reported arising from gastrointestinal, respiratory and genitourinary mucosa. Sunlight is not an aetiologic factor with mucosal melanomas. Herein, we report an extremely rare example of malignant melanoma arising from the mucocutaneous junction of an ileostomy. Only one such case has been reported in the literature.(2).

Diuretic activity of leaves of garcinia cambogia in rats

The present study was undertaken to establish the diuretic activity of ethanol and aqueous extract of dried leaves of Garcinia cambogia in rats. Aqueous and ethanol extracts of leaves were administered to experimental rats orally at doses of 100 and 200 mg/kg and compared with furosemide (20 mg/kg, intraperitoneally) as the standard. The parameters measured for diuretic activity were total urine volume, urine concentration electrolytes such as sodium, potassium and chloride have been evaluated . The rats treated with ethanol extract of Garcinia cambogia and aqueous extract of Garcinia cambogia in a dose of 100 and 200 mg/kg showed higher urine output when compared to the respective control. Both ethanol and aqueous extracts have showed a significant dose-dependent increase in the excretion of electrolytes when compared to the control group.

Stem cell-based treatments for Type 1 diabetes mellitus: bone marrow, embryonic, hepatic, pancreatic and induced pluripotent stem cells

Type 1 diabetes mellitus--characterized by the permanent destruction of insulin-secreting β-cells--is responsive to cell-based treatments that replace lost β-cell populations. The current gold standard of pancreas transplantation provides only temporary independence from exogenous insulin and is fraught with complications, including increased mortality. Stem cells offer a number of theoretical advantages over current therapies. Our review will focus on the development of treatments involving tissue stem cells from bone marrow, liver and pancreatic cells, as well as the potential use of embryonic and induced pluripotent stem cells for Type 1 diabetes therapy. While the body of research involving stem cells is at once promising and inconsistent, bone marrow-derived mesenchymal stem cell transplantation seems to offer the most compelling evidence of efficacy. These cells have been demonstrated to increase endogenous insulin production, while partially mitigating the autoimmune destruction of newly formed β-cells. However, recently successful experiments involving induced pluripotent stem cells could quickly move them into the foreground of therapeutic research. We address the limitations encountered by present research and look toward the future of stem cell treatments for Type 1 diabetes.

Interactions of monensin with dietary fat and carbohydrate components on ruminal fermentation and production responses by dairy cows

Variation in milk fat percentage resulting from monensin supplementation to lactating dairy cows could be due to altered ruminal fermentation with interactions of monensin with ruminal biohydrogenation of fat and ruminal carbohydrate availability. The objective of the study was to determine the effects of feeding monensin as Rumensin (R) in diets differing in starch availability (ground or steam-flaked corn), effective fiber (long or short alfalfa hay, LAH or SAH), and 4% fat (F) from distillers grains, roasted soybeans, and an animal-vegetable blend on ruminal fermentation characteristics and milk production in lactating dairy cows. Six ruminally cannulated lactating Holstein cows were used in a balanced 6×6 Latin square design with 21-d periods. The cows were fed 6 diets: (1) C=control diet with ground corn and LAH, (2) CR=C plus R, (3) CRFL=CR plus F, (4) CRFS=ground corn, R, F, and SAH, (5) SRFL=steam-flaked corn, R, F, and LAH, and (6) SRFS=steam-flaked corn, R, F, and SAH. Mean particle size of LAH was 5.00 mm and 1.36 mm for SAH. All diets were formulated to have 21% forage NDF and 40% NFC. The R tended to decrease DMI, decreased milk fat yield, and numerically lowered milk fat percentage (3.41 vs. 2.98%). Addition of F to R diets did not affect milk fat percentage. By feeding diets containing R and F, SAH tended to increase milk fat percentage for the ground-corn diet, but SAH tended to decrease milk fat percentage with steam-flaked corn (CRFL+SRFS vs. CRFS+SRFL). The steam-flaked corn increased total-tract NDF digestibility (CRFL + CRFS vs. SRFL+SRFS; 51.1 vs. 56%). Addition of F with R decreased total VFA concentration and increased rumen pH. Fat addition with R decreased rumen NH3N and MUN (12.8 vs. 13.9 mg/dL), and SFC decreased NH3N concentration compared with ground corn. Although R caused milk fat depression, addition of F did not further exacerbate milk fat depression. Fatty acid analysis did not implicate any particular biohydrogenation intermediate as the causative factor for the milk fat depression.

Modulation of CD4+ T-cell activation by CD95 co-stimulation

CD95 is a dual-function receptor that exerts pro- or antiapoptotic effects depending on the cellular context, the state of activation, the signal threshold and the mode of ligation. In this study, we report that CD95 engagement modulates TCR/CD3-driven signaling pathways in resting T lymphocytes in a dose-dependent manner. While high doses of immobilized CD95 agonists silence T cells, lower concentrations augment activation and proliferation. We analyzed the co-stimulatory capacity of CD95 in detail in resting human CD4(+) T cells, and demonstrate that low-dose ligand-induced co-internalization of CD95 and TCR/CD3 complexes enables non-apoptotic caspase activation, the prolonged activation of MAP kinases, the upregulation of antiapoptotic proteins associated with apoptosis resistance, and the activation of transcription factors and cell-cycle regulators for the induction of proliferation and cytokine production. We propose that the levels of CD95L on antigen-presenting cells (APCs), neighboring T cells or epithelial cells regulate inhibitory or co-stimulatory CD95 signaling, which in turn is crucial for fine-tuning of primary T-cell activation.

Expression of p53 in leukoplakia and squamous cell carcinoma of the oral mucosa: correlation with expression of Ki67

Aim-To study p53 expression in relation to proliferative status in normal and nondysplastic, dysplastic and malignant lesions of the oral mucosa.Method-The standard avidin-biotin complex (ABC) immunohistochemical staining method was used to study the expression of p53 and Ki67 on frozen sections of oral leukoplakias and carcinomas.Results-Of the leukoplakia and carcinoma samples, 70% expressed p53 in over 5% of cells. In normal mucosa less than 5% of cells expressed p53. The proliferation index, as assessed by expression of Ki67, was highest in the malignant lesions (43%) and lowest in normal mucosa (11%). Statistical analysis revealed that expression of both p53 and Ki67 was correlated significantly with the histopathological stage of the tumour. However, expression of p53 was not correlated with that of Ki67. In leukoplakia lesions with proliferative features p53 immunostaining was less intense than in non-proliferative lesions; this difference was statistically significant.Conclusions-These results emphasise the potential of Ki67 and p53 as biomarkers of carcinogenesis in oral cancer and may also serve as intermediate points for cancer prevention programmes, such as the oral chemopreventive trials. Factors other than p53 may have a more important role in the deregulation of proliferation in pre-malignant oral lesions.

The impact of care on carers of patients treated for aneurysmal subarachnoid haemorrhage

Over the last decade there has been an increasing awareness that psychosocial problems may persist in patients who have made apparently good recoveries after aneurysmal subarachnoid haemorrhage (ASAH). The caregivers of these patients are often relatives and it is becoming apparent that these carers frequently suffer psychosocial stress with associated morbidity. Previous studies have looked primarily at patients and few have included carers. We exclusively studied carers using simple validated questionnaires. We measured the effect on general and psychosocial health of the carers of patients treated for ASAH, 2-3 years after discharge. The majority of the carers (88.1%) were close relatives; 53.8% were experiencing social or emotional stress and 46.4% of these felt completely overwhelmed. The level of stress correlated positively with management complications, but not site of aneurysm or other aspects of treatment. We conclude that there is an argument for priority assistance for those carers predicted to be vulnerable to stress.

The Plate cage Benezech implant as an alternative to autologous bone graft in the treatment of cervical spondylosis: clinical and functional outcome

Plate cage Benezech (PCB) is a titanium-made implant introduced recently in spinal surgery as a new substitute for autograft in cervical spine interbody fusion. It has a plate attached to the anterior surface of the cage to prevent any displacement of the cage, and to provide additional support in patients with dynamic instability. A small number of studies have shown the PCB cage is safe and efficient. We conducted a retrospective study on 54 consecutive patients with cervical spondylosis who underwent anterior cervical discectomy and interbody fusion (ACDF) with a PCB cage between the year 2001 and 2005 with a mean follow up of 24 months (9-62 months). The mean age was 51 years, 27 patients presented with radiculopathy, 15 patients with myelopathy, and eight patients with both. Clinical and functional outcomes were assessed by using Prolo scale, Japanese orthopaedic association (JOA) score, and Visual analogue scale (VAS). Prolo results were documented good to excellent in 43 (86%) of cases and poor in 7 (14%) of cases. Mean preoperative Prolo scale of 4.7 (SD 1.63) improved postoperatively to 8.22 (SD 2.12.) The average preoperative JOA score was 11.7 (SD 2.51) compared with 15.42 (SD 2.20) postoperatively with a mean recovery rate of 76.3%. VAS score improved from 6.65 (SD 1.77) to 1.76 (SD 2.40). All the results were statistically significant (p-value <0.0001).This study suggests that Plate cage Benezech implant is a safe and effective device for anterior cervical discectomy and interbody fusion.

Efficacy and durability of fluoroscopically guided cervical nerve root block

The objective of the study was to assess the long-term efficacy of fluoroscopically-guided cervical nerve root block as a non-surgical treatment for cervical radicular pain. This was a retrospective study of 19 consecutive patients who had undergone cervical nerve root blocks over a period of 18 months, at a regional neurosurgery referral centre in the UK. Two of these patients underwent a second procedure; therefore, the number of total nerve root blocks was 21. Data regarding age, sex and diagnosis were obtained from medical records. MR reports formed the basis for imaging findings. Patients were contacted by telephone and post in order to obtain information about their 'pain relief. This was measured by using a 100-point Visual Analogue Scale (VAS). Four points in time were chosen in order to determine the time course of pain relief, i.e. before procedure, at 2 weeks, at 2 months and at 6 months following the procedure. Mean VAS scores at 6 month follow-up were broken up into 3 categories to indicate the level of pain relief. These categories were: VAS decrease of less than 20 points indicating no relief (12 procedures, 57.1%); VAS decrease 20 - 40 points, i.e. moderate relief (three procedures, 14.3%); VAS decrease of greater than 40 points, i.e. significant relief (six procedures, 28.6%). CNRB has limited efficacy for definitive treatment of nerve root pain, but may lead to significant short term relief, in a subgroup of such patients.

Obesity-hypertension: emerging concepts in pathophysiology and treatment

The incidence and prevalence of obesity has risen markedly in the last decade, and this epidemic represents a serious health hazard with significant morbidity and mortality. Although hypertension is recognized as one of the most serious consequences of obesity, its pathophysiology remains incompletely understood. Contemporary research suggests that the recently discovered hormone leptin may represent a common link between these 2 pathologic conditions. Leptin is primarily synthesized and secreted by adipocytes. One of the major functions of this hormone is the control of energy balance. By binding to receptors in the hypothalamus, it reduces food intake and promotes elevation in temperature and energy expenditure. In addition, increasing evidence suggests that leptin, through both direct and indirect actions, may play an important role in cardiovascular and renal functions. Although the relevance of endogenous leptin needs further clarification for the control of renal sodium excretion and vascular tone, it appears to be a potential pressure and volume-regulating factor in normal situations. However, in conditions of chronic hyperleptinemia, such as obesity, leptin may function pathophysiologically for the development of hypertension as well as cardiac and renal disease. Thus, in addition to weight control, reduction of circulating leptin may confer cardiovascular and renal protective effects in patients with obesity-hypertension.

Stem cells: a regenerative pharmaceutical

Stem cells (SC), found in both adult and fetal tissues, are self-renewing elements that can generate the various cell types in the body. There are 3 classes of SC: totipotent, multipotent, and pluripotent. The SC with a significant developmental potential are the embryonic stem (ES) cells, which are derived from the early stages of mammalian embryo. SC possess regenerative properties and this offers unprecedented opportunities for developing medical therapies for debilitating diseases. Hematopoietic SC have been used successfully in bone marrow transplants for over 40 years. Pluripotent SC offer renewable source of replacement of cells and tissues to treat a myriad of diseases. However there are limiting factors. Adult SC are rare and cannot multiply as the ES. Pluripotent SC have great therapeutic potential, but face technical challenges. A serious concern is the ethical issue since they are derived from human embryos or fetal tissue. Quite often SC have been targets of mutations and risk carcinogenesis. Various markers have been identified based on the uniqueness of SC receptors and in vivo tracking studies using nanocolloids and radioactive tracers have been performed. Though 111In-oxine has been used to image SC transplants, PET with a high spatial resolution would be ideal. Currently 2 agents are being studied, 18F-FDG and 64Cu-Pyruvaldehyde bi(N4-methylthiosemicarbazone). The following few pages bring forth the various limitations and summarize progress made in SC utilization so as to create awareness of SC research in ISORBE community and to foster strategy that ISORBE community can disseminate information and exchange knowledge on radio labeled SC.

99mTc-Fanolesomab: affinity, pharmacokinetics and preliminary evaluation

Localization of infection is critical for both diagnosis and treatment. Several radioactive compounds such as (67)Gallium citrate, (111I)ndium and (99m)Technetium-labeled leukocytes, peptides and antibodies have been used to localize sites of bacterial infection and phlegmons when anatomical imaging techniques failed. With labeled leukocytes the major concern besides the cost, was the in vitro procedure requiring more than 2 h and trained personnel to handle blood samples. Such limitations paved the way for the emergence of new agents like human immunoglobulin, interleukin-1, peptides and monoclonal antibodies. Following the intensive study of 10 monoclonal antibodies the anti SSEA-1 antibody specific for CD15 antigen was found to have a high Kd value of 1.6x10(-11) M for human neutrophils. Labeling of anti CD15 antibody (NeutroSpec) with (99m)Tc and its FDA approval was a boon to diagnostic imaging as it promised to eliminate many of the well known drawbacks of the in vitro WBC labeling. This antibody has a large number of antigenic binding sites: 5.1x10(5) per circulating human neutrophil. It has been established that very little CD15 antigen is expressed on the other blood cell lines. Upon intravenous administration to patients there was no adverse reaction except in those with underlying cardiovascular compromise or chronic pulmonary obstructive disease. Another advantage is that, this particular monoclonal antibody has not produced significant human antimouse antibody in research volunteers and patients. Twenty-four hour imaging, SPECT or planar was not required. The following pages describe the various stages of the research activity carried out towards NeutroSpec.

Painful third nerve palsy in a patient with perimesencephalic subarachnoid haemorrhage

A patient with perimesencephalic subarachnoid haemorrhage (PMSAH) developed a delayed third nerve palsy. Three formal cerebral angiograms, a computed tomography cerebral angiogram and a magnetic resonance angiogram all failed to reveal a vascular abnormality. Further investigations did not show any medical cause for the palsy. This appears to be the first case report of a patient with PMSAH presenting with a painful third nerve palsy.

Angiotensin Receptor Blockers in Congestive Heart Failure

Heart failure results in neurohormonal activation of which the renin-angiotensin-aldosterone system (RAS) is the main mediator. Activation of this system leads to the production of angiotensin II (ATII), which leads to multiple adverse short-term and long-term effects, including hemodynamic dysfunction, renal dysfunction, inflammation, and cardiac remodeling. Angiotensin-converting enzyme inhibitors (ACEIs) exert favorable effects in congestive heart failure (CHF) by inhibiting the production of ATII. It has been shown that ACEIs may not be able to suppress the production of ATII completely because there are RAS-independent mechanisms of ATII production. Hence, it was thought that angiotensin receptor blockers (ARBs) might be more useful in CHF because they directly block the ATII receptors. Many studies have been done to evaluate the role of ARBs in CHF. We reviewed these studies and have attempted to define the place and ARBs in the therapy for CHF.

Nonsurgical carotid revascularization

Carotid endarterectomy is a well-established treatment of improving the carotid luminal diameter and preventing strokes, and the indications and complications are well-defined. Carotid angioplasty and stent placements are relatively newer ways of treating carotid artery stenosis. In certain contexts, they may have some advantages over carotid endarterectomy. However, the success rates, morbidity, and mortality associated with these procedures are less well characterized. In earlier comparative studies, the incidence of ipsilateral stroke rate was higher with angioplasty, but in later studies, this trend is reversing. Angioplasty may also have an edge in specific situations like patients with coexisting significant coronary arterial disease, contralateral carotid artery occlusion, and in instances when the narrowing is long and at multiple sites. Protective devices like distal occlusion balloon and filter protection devices may reduce the incidence of stroke. We are still awaiting the results of some major randomized head-to-head trials comparing carotid endarterectomy and stenting.

Elevation of the Tumor Marker CA125 in Right Heart Failure

Carbohydrate antigen 125, known as a marker for ovarian cancer, has been reported to be elevated in heart failure caused by left ventricular dysfunction. A case of elevated carbohydrate antigen 125 in isolated right heart failure due to atrial septal defect with preserved left ventricular function is reported.

Socioeconomic status, lifestyle factors and oral premalignant lesions

Several studies have suggested that low socioeconomic status (SES) is associated with a higher risk of oral cancer, but the association with oral premalignant lesions has not yet been explored. The aim of this study was to examine the association of education, occupation, income and SES index with oral premalignant lesions. A case-control study was conducted with data from the baseline screening of a randomized oral cancer screening trial in Kerala, India. There were a total of 927 oral leukoplakia, 170 oral submucous fibrosis, 100 erythroplakia and 115 multiple oral premalignant lesion cases and 47,773 controls. Subjects with high SES index had protective ORs for oral premalignant lesions, ranging from 0.6 to 0.7, after adjustment for age, sex, BMI, tobacco chewing, smoking, drinking and fruit/vegetable intake. Higher education levels were also associated with decreased risk of all four oral premalignant lesions. Protective ORs for income were observed for oral leukoplakia and possibly oral submucous fibrosis and erythroplakia. SES may be associated with oral premalignant lesions because of access to medical care, health related behaviors, living environment or psychosocial factors. Though the mechanism for the association is not clear, higher SES index, education and income were associated with decreased risk of oral premalignant lesions in our study.

The spread of a mupirocin-resistant/methicillin-resistant Staphylococcus aureus clone in Kuwait hospitals

High-level mupirocin- and methicillin-resistant Staphylococcus aureus (MRSA) isolated from five hospitals in Kuwait were studied by pulsed-field gel electrophoresis (PFGE) to determine their relatedness to one another and to high-level mupirocin-resistant MRSA isolated previously in a Burns Unit. The genetic location of mupirocin resistance determinant was also determined. All of the isolates were resistant to gentamicin, kanamycin, streptomycin, tetracycline and cadmium, and contained plasmids of 38, 26 and 2.8 kb. Two isolates contained additional 4.4-kb plasmids. Transfer experiments demonstrated that the 38-kb plasmid encoded high-level mupirocin resistance and the 4.4-kb plasmid encoded chloramphenicol resistance. PFGE typing of representative isolates from the five hospitals demonstrated that the majority of them had identical or closely related pulsed-field patterns suggesting that they had a common origin. However, they differed from high-level mupirocin-resistant MRSA isolated previously in the Burns Unit in their resistance and pulsed-field patterns. Whereas the majority of the previous isolates were susceptible to ciprofloxacin and resistant to trimethoprim and chloramphenicol, the majority of the current isolates were susceptible to trimethoprim and chloramphenicol, and resistant to ciprofloxacin. Only one of the current isolates had identical pulsed-field pattern to the majority of isolates obtained previously in the Burns Unit. The results suggested that a previously dominant clone of high-level mupirocin-resistant MRSA has been replaced in the Burns Unit by a new clone, which also spread in four other hospitals.

Genetic analysis of methicillin-resistant Staphylococcus aureus expressing high- and low-level mupirocin resistance

Clinical strains of methicillin-resistant Staphylococcus aureus (MRSA) expressing high- and low-level mupirocin resistance were studied to determine the genetic location of mupirocin and other resistance determinants. Mupirocin resistance was confirmed by MIC determination with E-test strips. Curing and transfer experiments were used to establish the genetic location of the resistance determinants and the PCR with mupA-specific primers was used to detect the presence of mupA genes. High-level mupirocin-resistant isolates had MICs >1024 mg/L, whereas the low-level resistant isolates had MICs of 32-128 mg/L. The isolates carried plasmids ranging from 2.8 to 38 kb in size. All of them carried 26- and 3.0-kb plasmids, but only the high-level mupirocin-resistant isolates carried a 38-kb plasmid. Curing and transfer experiments revealed that the 26-kb plasmid encoded resistance to cadmium, mercuric chloride, propamidine isethionate and ethidium bromide and the 38-kb plasmid was a conjugative plasmid encoding high-level mupirocin resistance. One isolate, IBN287, carried both plasmid-borne high-level and chromosomal low-level mupirocin resistance. The mupA gene was detected on the 38-kb plasmid DNA but not in the genomic DNA of the low-level mupirocin-resistant isolates. The genomic DNA of strain IBN287 cured of the 38-kb mupirocin resistance plasmid did not contain mupA. The results suggest that different genes encoded low- and high-level mupirocin resistance in these isolates.

Balloon atrial septostomy in end-stage pulmonary hypertension guided by a novel intracardiac echocardiographic transducer

Blade and balloon atrial septostomy has been used to reduce cardiopulmonary symptoms and as a bridge to lung or heart lung transplant in primary pulmonary hypertension. Due to severe right atrial dilatation and resultant loss of anatomical landmarks, the procedure is technically difficult, and the reported postprocedure mortality rate varies between 5% and 50%. Among others, marked systemic desaturation and systemic hypotension presumably secondary to an excessively large atrial septal defect have been reported as causes of postprocedure death. We report a case where a novel intracardiac catheter-based phased-array 5.5--10 MHz transducer with spectral and color-flow Doppler capabilities was used to assist a balloon atrial septostomy and to obtain hemodynamic data in a patient with end-stage pulmonary hypertension.

Aneurysmal bone cyst of the sphenoid sinus

Aneurysmal bone cysts of the sphenoid sinus are very rare, with only six cases described in the literature. We present a case of an aneurysmal bone cyst of the sphenoid sinus with associated fibrous dysplasia in which the radiological findings had some features of a mucocoele. We discuss the differences in pathogenesis, clinical presentation and radiological appearances between these two lesions, and propose a simple drainage procedure as an effective modality of treatment.

Changing patterns of airway accidents in intubated ICU patients

OBJECTIVE

To document the changes in patterns of airway accidents in intubated patients.

DESIGN

Prospective recording of all airway accidents over two periods: 1994-1997 and 1998-1999.

PATIENTS

Ventilated patients (5,046) intubated for 9,289 days over 4 years (1994-1997) and 2,932 ventilated patients intubated for 6,339 days over 2 years (1998-1999).

MEASUREMENTS

The incidence and pattern of airway accidents over a 2-year period were compared to an earlier similar analysis done in the previous 4 years.

RESULTS

The total accident rate in the 1994-1997 period was 36 in 5,046 patients over 9,289 intubated-patient days. The total accident rate in the period 1998-1999 was 20 in 2,932 patients over 6,339 intubated-patient days. The frequency of blocked tracheal tube increased to equal that of unplanned extubation (UE) of endotracheal tube (ETT) as the commonest airway accident. There were nine episodes of blocked tracheal tube in the two current years compared to four in the previous 4 years and there were nine episodes of UE in the two current years compared to 15 in the previous 4 years. There were a total of 18 ETT accidents in 2,930 patients over 5,309 ETT days compared to a total of two tracheostomy accidents in 67 patients over 1,030 tracheostomy days.

CONCLUSIONS

We noted a change of the pattern of airway accidents. We noted an increasing trend in the incidence of blocked tracheal tubes, associated with an increased duration of heat and moisture exchanger-filters use. We also noted that the incidence of tracheostomy tube accidents was similar to that of ETT accidents in the current study, unlike the earlier study where tracheostomy tube accidents were more frequent than ETT accidents. This was due to the elimination of tracheostomy tube displacements during the later study period. We associated this with the use of adjustable tracheostomy length tubes.

Evaluation of surgical excision of non-homogeneous oral leukoplakia in a screening intervention trial, Kerala, India

It is well established that most invasive oral cancers arise from precancerous lesions such as leukoplakia, erythroplakia and oral submucous fibrosis. One of the approaches for control of oral cancer is to detect oral precancerous lesions early in their development and prevent their malignant transformation to invasive cancer either by chemoprevention or by surgical excision of the lesions, with concurrent control of tobacco and alcohol use and other specific aetiological factors. However, the value of specific approaches such surgery in long-term control of lesions and prevention of malignant transformation is not known. We describe our experience with cold knife surgical excision of 59 cases of non-homogeneous leukoplakia of the oral cavity diagnosed in the context of a community-based oral cancer cluster randomised oral cancer screening trial in Kerala, India. Two-thirds of these revealed dysplasia on histology. After a minimum follow-up of 12 months (range 12-37 months) after surgical excision, 44 (74.8%) were remaining disease free with no evidence of recurrent/new lesions; during follow-up, three (5%) developed new luekoplakic lesions, and six (10.1%) developed recurrent lesions, while six (10.1%) could not be traced after treatment. There was no event of malignant change during follow-up. The proportion of subjects remaining with no evidence of disease at 3 years by Kaplan-Meier method of analysis was 62.1% (95% CI: 0.36-0.87). Accrual and long-term follow-up of large number of surgically treated cases may provide valuable leads to management policies of oral leukoplakia, since, as of now, the added value of specific treatments over and above primary prevention by tobacco and alcohol control remains to be established.

Combined proton MR spectroscopy and dynamic contrast enhanced MR imaging of human intracranial tumours in vivo

A study was undertaken to determine if the vascular characteristics measured by dynamic contrast-enhanced magnetic resonance imaging (primarily permeability surface area product and extracellular-extravascular tissue volume fraction) would be beneficial in explaining the inter-lesion metabolic heterogeneity displayed by human intracranial tumours. Magnetic resonance spectroscopy was carried out using a single-voxel STEAM sequence and dynamic imaging was carried out using a combination of pre-contrast proton density-weighted FSPGR images (to remove the influence of native tissue T1), bolus injection of Gd-DTPA and subsequent T1-weighted FSPGR dynamic imaging. A two-compartment pharmacokinetic model was employed to determine vascular characteristics. Results obtained from 12 meningiomas suggest a possible correlation between the level of lipids/macromolecules and permeability surface area product, although the confounding issue of extra-voxel contamination arising from lipids in the scalp and skull marrow cannot be ruled out in the more superficial lesions. Results obtained from 11 gliomas (four low and seven high grade) demonstrate that permeability surface area product is not specific for the range of vascular characteristics and metabolite profiles observed in gliomas and is therefore unable to explain metabolic heterogeneity in these lesions.

Alcohol drinking, body mass index and the risk of oral leukoplakia in an Indian population

Although tobacco habits have been associated with the risk of oral leukoplakia, alcohol drinking and body mass index (BMI) as risk factors have not been well established. The purpose of this study is to evaluate the independent effects of drinking, BMI, tobacco chewing and smoking on the risk of oral leukoplakia. A case-control study was conducted, with data from an ongoing randomized oral cancer screening trial in Kerala, India. Trained health workers conducted interviews and performed oral visual inspections to identify oral premalignant lesions such as leukoplakia. The logistic regression model in SAS was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI). A total of 927 leukoplakia cases and 47,773 controls were included in the analysis. Ever alcohol drinking was a significant risk factor for oral leukoplakia among nonsmokers (OR=2.1, 95%CI=1.3, 3.4) and non-chewers (OR=1.8, 95%CI=1. 3, 2.5) after adjusting for age, sex, education, BMI and tobacco habits. The association with alcohol drinking was stronger among women (OR=3.9, 95%CI=1.5, 10.4) than men (OR=1.5, 95%CI=1.3, 1.9). An inverse dose-response relationship was observed between BMI and the risk of oral leukoplakia (p for trend=0.0075). Tobacco chewing was a stronger risk factor for women (OR=37.7, 95%CI=24.2, 58.7) than for men (OR=3.4, 95%CI=2.8, 4.1). Smoking was a slightly stronger risk factor for men (OR=3.3, 95%CI=2.5, 4.3) than for women (OR=2.0, 95%CI=1.5, 2.9). In conclusion, alcohol drinking was found to be an independent risk factor while BMI might be inversely associated with the risk of oral leukoplakia in an Indian population.

A cadmium resistance plasmid, pXU5, in Staphylococcus aureus, strain ATCC25923

A 25.9-kb plasmid, pXU5, encoding high level cadmium resistance was isolated from Staphylococcus aureus strain ATCC25923. A labelled cadA probe from plasmid pI258 hybridised to a 2.3-kb EcoRI fragment of pXU5. pXU5 was incompatible with an S. aureus incompatibility group 1 plasmid.

Chewing tobacco, alcohol, and the risk of erythroplakia

Although chewing tobacco, smoking, and alcohol drinking have been suggested as risk factors for oral cancer, no study has examined the relationship between those factors and the risk of erythroplakia, an uncommon but severe oral premalignant lesion. In this study, we have analyzed the effects of chewing tobacco, smoking, alcohol drinking, body mass index, and vegetable, fruit, and vitamin/iron intake on the risk of erythroplakia and explored potential interactions between those factors in an Indian population. A case-control study including 100 erythroplakia cases and 47,773 controls was conducted, as part of an on-going randomized oral cancer screening trial in Kerala, India. The analysis was based on the data from the baseline screening for the intervention group, where the diagnostic information was available. The information on epidemiological risk factors was collected with interviews conducted by trained health workers. The erythroplakia cases were identified by health workers with oral visual inspections, and then confirmed by dentists and oncologists who made the final diagnosis. The odds ratios (OR) and their 95% confidence intervals (CIs) were calculated by the logistic regression model using SAS software. The adjusted OR for erythroplakia was 19.8 (95% CI, 9.8-40.0) for individuals who had ever chewed tobacco, after controlling for age, sex, education, body mass index, smoking, and drinking. The adjusted OR for ever-alcohol-drinkers was 3.0 (95% CI, 1.6-5.7) after controlling for age, sex, education, body mass index, chewing tobacco, and smoking. For ever-smokers, the adjusted OR was 1.6 (95% CI, 0.9-2.9). A more than additive interaction on the risk of erythroplakia was suggested between tobacco chewing and low vegetable intake, whereas a more than multiplicative interaction was indicated between alcohol drinking and low vegetable intake, and between drinking and low fruit intake. We concluded that tobacco chewing and alcohol drinking are strong risk factors for erythroplakia in the Indian population. Because the CIs of interaction terms were wide and overlapping with those of the main effects, only potential interactions are suggested.

Rapid detection of methicillin resistance in staphylococci using a slide latex agglutination kit

The slide latex agglutination test, MRSA-Screen, was compared with the mecA polymerase chain reaction (PCR) and traditional susceptibility test methods for the detection of methicillin resistance in Staphylococcus aureus and coagulase-negative staphylococci. The MRSA-Screen test detected the same number of methicillin-resistant S. aureus as the mecA PCR and the traditional susceptibility tests. It correctly identified all 21 methicillin-susceptible S. aureus as being sensitive. It also produced the same result as the mecA PCR in identifying a methicillin-resistant S. aureus among six isolates classified as borderline resistant by traditional susceptibility tests. The MRSA-Screen test and mecA PCR detected methicillin resistance in 10 and 15 of 17 methicillin-resistant coagulase-negative staphylococci, respectively. From these results, it is concluded that the MRSA-Screen is a very accurate, reliable and rapid method of detecting methicillin resistance in S. aureus and is suitable for use in clinical microbiology laboratories. Further study of its use in detecting methicillin resistance in coagulase-negative staphylococci is required.