Selective Tibial Neurotomy for Spastic Equinovarus Foot: Operative Technique

BACKGROUND AND OBJECTIVES

Spastic equinovarus foot (SEF) is a common complication of stroke and other upper motor neuron injuries. It is characterized by a plantigrade and inverted foot, often with toe curling, causing significant disability from pain, gait, and balance difficulties. Management includes physical therapy, antispasticity drugs, orthoses, chemical neurolysis, or botulinum toxin, all of which may be insufficient, sedating, or transient. Selective tibial neurotomy (STN) provides a surgical option that is effective and long-lasting. Our goal is to provide a concise description of our technique for performing the STN for treatment of SEF. We discuss the standard posterior approach with surgical variations used by other groups and a medial approach, should the posterior approach be insufficient.

METHODS

A posterior leg approach allows access to the tibial nerve and its branches to the bilateral gastrocnemius muscles, soleus, posterior tibialis, and extrinsic toe flexors. A medial approach is used if the toe flexors cannot be accessed sufficiently from the posterior approach. Nerve branch targets identified by preoperative functional assessment are carefully exposed and fully neurolysed distally to identify all terminal branches to each muscle of interest before neurotomy.

RESULTS

The STN is a powerful tool for treating SEF, with an immediate and lasting effect. Approximately 80% of the target muscle should be denervated to ensure long-term efficacy while maintaining adequate function of the muscle through collateral innervation.

CONCLUSION

The STN is a safe and effective outpatient procedure that can be performed by an experienced nerve surgeon to improve balance and ambulation and reduce pain for patients with SEF. Large clinical trials are necessary to further establish this underutilized procedure in the United States.

A141 IS SURGERY STILL THE ONLY TREATMENT OPTION FOR CURABLE RECTAL CANCER?

Background

Rectal cancer is curable by standard surgery with Total Mesorectal Excision (TME). However, there are well known associated long-term bowel and sexual dysfunctions. Non-operative management (NOM) is an emerging treatment for patients with operable rectal cancer. There is evidence supporting dose response for tumor control in rectal adenocarcinoma.

Aims

In the era of modern technologies, Image-guided adaptive endorectal brachytherapy is a means to deliver local radiotherapy boost treatments. We explored its role in a randomized phase II/III trial (NCT03051464) for patients aiming to achieve cure without surgery. Total Mesorectal Excision (TME) free survival at 2 years was the primary endpoint. We now present the interim analysis upon accrual of the first 40 patients.

Methods

In randomized trial, patients with operable cT2-3ab N0 M0 rectal cancer received 45 Gy in 25 fractions of pelvic external beam radiotherapy (EBRT) with concurrent 5-FU/ Capecitabine. They were randomized to receive either an EBRT boost of 9 Gy in 5 fractions (Arm A), or three weekly adaptive brachytherapy boosts for a total of 30 Gy in 3 fractions (Arm B).

Results

Forty patients were included (20 per arm). The median age was 66 years; baseline characteristics were well balanced in terms of age, tumor location, T stage and tumor size (Table 1). The acute treatment related toxicities are similar as shown in table 2 but in arm B, there were two deaths: one patient died during his chemotherapy and external beam treatment from congestive heart failure and one patient from a heart attack after treatment prior to salvage TME surgery. The proportion of complete clinical response was 50% (n=10/20) in Arm A and 90% in Arm B (n=18/20). With a median follow-up of 2.2 years, local regrowth at 2 years occurred in 4/10 patients (40%) in Arm A and 4/18 patients (22%) in Arm B. TME-free survival rate at 2 years was 45.9% in Arm A and 85.1% in Arm B (p=0.0036) (Figure 1).

Conclusions

The interim analysis of this trial suggests that these two strategies of radiation dose escalation are feasible and lead to high chances of organ preservation in patients with operable rectal cancer. The Independent Monitoring Comittee (IDMC) approved the continuation of patient recruitment in the phase III study as planned.

Funding Agencies

Elekta

Reduced sociability and social agency encoding in adult Shank3-mutant mice are restored through gene re-expression in real time

Despite a growing understanding of the molecular and developmental basis of autism spectrum disorder (ASD), how the neuronal encoding of social information is disrupted in ASD and whether it contributes to abnormal social behavior remains unclear. Here, we disrupted and then restored expression of the ASD-associated gene Shank3 in adult male mice while tracking the encoding dynamics of neurons in the medial prefrontal cortex (mPFC) over weeks. We find that Shank3 disruption led to a reduction of neurons encoding the experience of other mice and an increase in neurons encoding the animal's own experience. This shift was associated with a loss of ability by neurons to distinguish other from self and, therefore, the inability to encode social agency. Restoration of Shank3 expression in the mPFC reversed this encoding imbalance and increased sociability over 5-8 weeks. These findings reveal a neuronal-encoding process that is necessary for social behavior and that may be disrupted in ASD.

A157 REAL-WORLD TIGHT OBJECTIVE MONITORING WITH ADALIMUMAB LEADS TO EARLIER DOSE OPTIMIZATION AND HIGHER CLINICAL REMISSION RATES AT 12 MONTHS

Background

Data suggests that tight objective monitoring of inflammatory bowel diseases (IBD) may improve one-year clinical outcomes.

Aims

The goal of this study is to assess the adherence to serial tight objective monitoring, via clinical symptoms and biomarkers, and the effect of such tight monitoring on one year outcome in IBD patients at an academic and an university-affiliated center.

Methods

We retrospectively reviewed the chart of 428 consecutive IBD patients who started adalimumaby at the McGill University Health Center and Jewish General Hospital (Montreal, Canada) between January 1, 2015 and January 1, 2019 [338 Crohn’s disease(CD), 90 ulcerative colitis(UC)]. Clinical symptoms (assessed by Harvey-Bradshaw-Index and partial Mayo), C-Reactive Protein(CRP), and fecal calprotectin(FCAL) were captured at treatment initiation and at 3, 6, 9, and 12 months. Combined adherence was defined as the evaluation of ≥2 of 3 parameters(clinical, CRP, FCAL). Dose optimization and drug sustainability curves were plotted by Kaplan-Meier method.

Results

Clinical symptoms were assessed in nearly all patients at 3 (CD-UC:95-94%), 6 (90-83%), 9 (86-85%) and 12 (96-89%) months. CRP was also available for most patients but the frequency of assessment decreased in CD patients over the study period. In comparison, compliance to serial FCAL testing was low throughout the follow-up period. Clinical remission at one-year was significantly higher in patients who were adherent to early assessment visit at 3 months (p=0.001 both for CD and UC). Adherence to early follow-up also resulted in earlier dose optimisation in both CD and UC patients(pLogrank=0.026 for UC and p=0.09 for CD). However, the overall drug sustainability did not differ.

Conclusions

Clinical assessment and CRP, but not FCAL, were frequently assessed in patients starting adalimumab. Adherence to early objective combined follow-up visits resulted in earlier dose optimization and improved one-year clinical outcomes but did not change drug sustainability rates.

Funding Agencies

None

Pilot study to evaluate a plasma device for the treatment of onychomycosis

Onychomycosis is a fungal infection of the nail unit, and is the most common of the nail disorders. Current therapies for onychomycosis have less than ideal efficacy and have the potential for adverse effects. As previous studies have shown that nonthermal plasma inhibits the in vitro growth of Trichophyton rubrum, we conducted a pilot study on 19 participants with toenail onychomycosis. The primary endpoint was safety of the device, and secondary outcome measures were clinical efficacy and mycological cure. Patient satisfaction was measured using questionnaires at the completion of the study. All but one patient met the primary endpoint of safety and there were no long-term sequelae. The overall clinical cure was 53.8% and the mycological cure was 15.4%. The majority of patients were satisfied with the treatment. Our conclusions are that nonthermal plasma is a safe treatment and may have a beneficial effect on toenail onychomycosis.

The Generalizability of the Paediatric Developmental Passport: A Multi-Site Randomized Controlled Trial

BACKGROUND: The Pediatric Developmental Passport (passport) is an innovative tracking tool for families of children with autism spectrum disorder (ASD). It provides a mechanism for clearly communicating appropriate regional developmental services, an opportunity track progress in accessing these developmental services and a valuable summary of the developmental care received by that child for pediatrician. A qualitative study with parents and health professionals (developmental pediatricians, developmental nurses, pediatricians) lead to the design and iterative review of the passport.

OBJECTIVES: The objective of this study was to determine the general-izability and effectiveness of the passport compared to placebo in a multi-site pragmatic randomized control trial.

DESIGN/METHODS: A pragmatic multi-site randomized controlled trial was conducted with families of children between 0-6 years of age diagnosed with ASD. Families from two different models of developmental care were enrolled into the study. One site was a sub-urban developmental consultation clinic and the second site was a shared-care model between developmental pediatricians and general pediatricians in an urban resource restricted area. All families included in the study were randomized to receive the passport or placebo (blank card). Agencies providing Autism specific behaviour therapy (ABA) within each site were contacted directly to obtain accurate contact and access status of recommended developmental services. To determine passport effectivenes a pearson’s chi square test was conducted using a significant p value of <0.05.

RESULTS: Forty children with ASD were included and followed in this study. The passport proved to be significantly more effective in aiding families to contact developmental services than the placebo (blank card). A significantly larger portion of families (90.5%) with the passport contacted agencies for ABA (applied behaviour analysis) therapy compared to families with the placebo (61.9%, (p value significant at <0.05). More families with the passport tended to contact ABA in less than 2 months (48%) than the placebo group (35%), but this was not statistically significant.

CONCLUSION: The pediatric developmental passport enables families of children newly diagnosed with Autism to contact necessary behavioural services more often than those who did not receive the passport after diagnosis.

Guidelines for maintenance of adult patients with brain death and potential for multiple organ donations: the Task Force of the Brazilian Association of Intensive Medicine the Brazilian Association of Organs Transplantation, and the Transplantation Center of Santa Catarina

INTRODUCTION

The organ shortage for transplantation, the principal factor that increases waiting lists, has become a serious public health problem. In this scenario, the intensivist occupies a prominent position as one of the professionals that first has a chance to identify brain death and to be responsible for the maintenance of the potential deceased donor.

OBJECTIVE

This report attempts to establish guidelines for care and maintenance of adult deceased donor organs guiding and standardizing care provided to patients with brain death.

METHOD

These guidelines were composed by intensivists, transplant coordinators, professionals from various transplant teams, and used transplant center. The formulated questions were forwarded to all members and recommendations were constructed after an extensive literature review selecting articles with the highest degree of evidence.

RESULTS

Guidelines were developed in the form of questions reflecting frequent experiences in clinical intensive care practices. The main questions were: Is there an optimal interval for keeping organs of deceased donors viable? What actions are considered essential for maintaining deceased donors in this period? What are the limits of body temperature? How should the patient be warmed? Which laboratory tests should be performed? What is the collection interval? What are the limits in the laboratory and the capture scenario? What are the limits of blood pressure? When and how should one use catecholamines?

CONCLUSIONS

This pioneer project involved a multidisciplinary team working in organ transplantation seeking to provide treatment guidance to increase the number of viable organs from deceased adult donors.

Comparison of low and high dose cosyntropin stimulation tests in the diagnosis of adrenal insufficiency in septic shock patients

Stress situations such as septic shock are accompanied by activation of the HPA axis. Some patients do not activate this axis in stress situations. This blunted response is currently designated as critical illness-related corticosteroid insufficiency (CIRCI). Currently the 250 μg cosyntropin stimulation test is the preferred diagnostic test for CIRCI. Few papers explored the role of the 1 μg cosyntropin test in septic shock patients. In this study, we compared both tests in septic shock patients taking a special interest in the population with intermediary baseline cortisol. Prospective noninterventional study included 74 septic shock patients. After measurement of baseline cortisol all patients received 1 μg of cosyntropin i. v. and 4 h later 249 μg of cosyntropin. We compared the cortisol increase after each test and its relation to mortality and vasopressor therapy. There was a moderate correlation in response to low and high dose cosyntropin, r(s)=0.55. This correlation in patients with baseline cortisol between 10-34 μg/dl is, r(s)=0.67. The increase induced by both tests was equally accurate to identify mortality and time of vasopressor withdrawal. Low and high dose cosyntropin tests presented a moderate correlation in patients with baseline cortisol between 10-34 μg/dl. Both tests are equally accurate to identify mortality and time of vasopressor therapy. These results suggest that both tests could be used to diagnose CIRCI.

Nonconverging hysteresis cycles in random spin networks

Behavior of hysteretic trajectories for cyclical input is investigated as a function of the internal structure of a system modeled by the classical random network of binary spins. Different regimes of hysteretic behavior are discovered for different network connectivity and topology. Surprisingly, hysteretic trajectories which do not converge at all are observed. They are shown to be associated with the presence of specific topological elements in the network structure, particularly with the fully interconnected spin groups of size equal to or greater than 4.

Cooperativity in the adsorption of magnetic colloidal particles

In this paper we investigate the adsorption of magnetic particles onto magnetically patterned substrates. We find that the adsorption process is cooperative, where the probability of adsorption decreases with increasing substrate occupancy (namely, density of adsorbed particles). The effect of cooperativity can be accounted for by a simple modification of the adsorption probability as manifested by the binomial distribution. The negative cooperativity found in the magnetic particle adsorption is not due to direct repulsion between particles, but to screening of the surface's magnetic field by previously adsorbed particles. Thus, the adsorption of magnetic colloids on magnetic substrates is a self-limiting process.

Adaptive Support Ventilation as the sole mode of ventilatory support in chronically ventilated patients

OBJECTIVE

To describe the outcome of patients admitted to a new private facility for chronically ventilated patients in the Ashdod area of Israel.

METHODS

On arrival, all patients were placed on Adaptive Support Ventilation (ASV) at 90% of target minute ventilation for lean body weight, reducing progressively in weekly decrements of 10% down to 60% of target minute ventilation if adequate spontaneous ventilation was maintained by the patient.

RESULTS

Almost half (12/27) of these patients admitted in the first 12 months following establishment of the facility were successfully weaned from mechanical ventilation within 2 weeks to 2 months of admission.

CONCLUSIONS

The cost effectiveness of this form of closed loop mechanical ventilation in achieving weaning automatically, without the need for respiratory therapists or continuous attendance by intensive care specialists to conduct weaning trials is demonstrated by these results.

The kinetics and saturation of reversible adsorption on patterned (heterogeneous) surfaces

We analytically examine the time-dependent adsorption of analyte (solute) on a finite-sized adsorption region as a model for sensors utilizing patterned or heterogeneous surfaces. We account for both reversible adsorption (assuming first-order reaction) and saturation of the adsorption patch that may arise either from packing constraints (finite area) or because of a finite number of binding sites (ligands). Our main conclusions include the following: (1) Saturation effects, due to either finite patch size or finite number of binding sites, become significant at extremely short times. (2) Increasing the strength of binding between the analyte and the adsorption sites increases the adsorbed amount at short times, but, at long times, the mass adsorbed on a weakly binding patch is higher than that on a strongly binding one. (3) The sensitivity of detection, as defined by the adsorption of the minimal analyte mass required for signaling, over a fixed period of time, does not scale as 1/detection time. As a result, increasing the time over which adsorption occurs increases sensitivity, but not linearly. Sensitivity of detection also increases with increasing patch area and initial binding strength.

Methotrexate related adverse effects in patients with rheumatoid arthritis are associated with the A1298C polymorphism of the MTHFR gene

BACKGROUND

There is an association between C677T polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene and methotrexate related toxicity.

OBJECTIVE

To examine the relations between the recently described A1298C polymorphism of the MTHFR gene, plasma homocysteine, methotrexate toxicity, and disease activity in patients with rheumatoid arthritis.

DESIGN

A cross sectional study on 93 methotrexate treated patients with rheumatoid arthritis, comprising a clinical interview and physical examination to determine disease activity and methotrexate related adverse reactions. Genotype analysis of the MTHFR gene was carried out and fasting plasma homocysteine and serum folate concentrations were measured. The data were analysed using univariate analysis. Allele and genotype distributions were compared with those of a healthy control group.

RESULTS

The frequency of the 1298CC genotype (24.7%) in the rheumatoid study group was greater than expected in the general population (12.8%, p<0.001). This genotype was associated with a significantly low rate of methotrexate related side effects. The odds ratio for side effects in patients with wild type 1298AA genotype v 1298CC genotype was 5.24 (95% confidence interval, 1.38 to 20). No correlation of disease activity variables or plasma homocysteine with MTHFR A1298C and C677T polymorphisms was observed.

CONCLUSIONS

1298CC polymorphism was more common in methotrexate treated rheumatoid patients than expected in the population, and was associated with a reduction in methotrexate related adverse effects. The A1298C polymorphism of the MTHFR gene may indicate a need to adjust the dose of methotrexate given to patients with rheumatoid arthritis.

There is no difference in the disease severity of gastro-oesophageal reflux disease between patients infected and not infected with Helicobacter pylori

BACKGROUND

The role of Helicobacter pylori in gastro-oesophageal reflux disease (GERD) is controversial.

AIM

To compare the severity of GERD in infected vs. non-infected patients, as part of an ongoing randomized controlled trial that examines the impact of H. pylori eradication on GERD-related outcomes.

METHODS

Consecutive GERD patients underwent urea breath testing and completed validated GERD symptom severity, and quality of life questionnaires as well as, 24-h pH-metry. These parameters, as well as demographics and endoscopic findings were assessed in double-blinded fashion and compared between H. pylori-infected and non-infected subjects.

RESULTS

Helicobacter pylori-infected GERD patients (n=50) were significantly older and less educated than non-infected patients (n=51). They also used proton pump inhibitors less often but had no difference in symptoms (as measured with both the Spechler's Activity Index and the Gastrointestinal Symptom Rating Scale), quality of life, endoscopic findings or 24-h pH-metry findings.

CONCLUSION

This prospective, double-blind study demonstrates, using excellent GERD quantifying measures including validated symptom severity scores, endoscopy, and 24-h pH-metry, that there exist no clinically significant differences in clinical or laboratory-related GERD manifestations between H. pylori-infected and non-infected GERD patients.

Cell death in cultured human Saos2 osteoblasts exposed to low-density lipoprotein

Osteoporosis (OP) and atherosclerotic-cardiovascular diseases (and possibly dementia) constitute emerging age-related co-morbidity states that might share risk factors. Blood-born lipids, like LDL involved in atherosclerosis and apolipoprotein-E4 (ApoE4) involved in dementia, may also be implicated in development of OP. We examined osteoblast cell lines as a culture model for OP by exposure to lipoproteins. ApoE expression in Saos2 and U2OS osteoblasts was confirmed by PCR. ApoE4 did decrease cell counts relatively to ApoE3, especially in Saos2 cells in which it was less selective for cells with higher alkaline phosphatase (ALP, an osteoblast marker) activity than ApoE3. This associates with ApoE4, being a risk factor for both dementia and OP. Saos2, but not U2OS, showed a decrease in cell counts after 48 h exposure to native LDL (NLDL). Both cell lines had decreased cell counts already after 24 h when exposed to oxidized-LDL (OxLDL) for which Saos2 also showed a higher sensitivity than U2OS. Exposure of Saos2 to both, OxLDL at low concentration (5 microg/ml) and NLDL revealed a shrunken size cell fraction of 17-23% on the fluorescence-activated cell sorter (FACS) analysis. Such shrunken cell fraction was not seen when Saos2 cells were exposed to 50 microg/ml of OxLDL or to OxLDL combined with 10 nM dexamethasone (DEX, a stimulator of osteoprogenitor differentiation). DEX treatment has lysed the cells earlier than 24 h post exposure and has selected more resistant cells that did not show apoptotic shrinkage in the FACS analysis done after 24 h. We interpret this as a failure to detect the apoptotic cell fraction due to their lysis prior to the FACS analysis. Western blots performed at different time points (10 min, 30 min, 4 h, 24 h, and 48 h) under OxLDL + DEX revealed a fall in the positive regulator of pp60Src-kinase phosphotyrosine (pY)418 relative to the DEX controls during the first 4 h. This is consistent with DEX osteogenic induction, known to be negatively regulated by c-Src, although the pY418/pY529 ratios (negative/positive kinase regulation) fell only at the 10 min time point. Contrarily the pY418/pY529 ratio increased, relative to untreated controls, under 5 microg/ml and 50 microg/ml of NLDL at the 4 h time point and under 50 microg/ml NLDL only at the 10 min time point, being consistent with the ability of a higher dose of LDL to antagonize osteoblast differentiation. This could be even more acceptable if the NLDL would have become minimally oxidized during its long purification procedure. Under NLDL, the Bcl-2/Bax ratio was pro-apoptotic at 10 min, 30 min, and 4 h only under 50 microg/ml, whereas under OxLDL + DEX it was pro-apoptotic only after 4 h suggesting that additional pathways contribute to cell death. These results indicate that lipid effects on human osteoblast lines in culture may be used as a model to identify molecular targets shared between OP and atherosclerosis for intervention in this co-morbidity.

Acute haemodynamic effects of a hypertonic saline/dextran solution in stable patients with severe sepsis

OBJECTIVE

To study the haemodynamic effects of a hypertonic saline/dextran solution compared with a normal saline solution in patients with severe sepsis.

DESIGN

Prospective double blind and control-randomised study.

SETTING

Adult intensive care unit in a university hospital.

PATIENTS

Twenty-nine patients with sepsis with a pulmonary artery occlusion pressure (PAOP) lower than 12 mmHg.

INTERVENTIONS

Patients were randomised to receive 250 ml of blinded solutions of either normal saline (SS group, n=16) or hypertonic saline (NaCl 7.5%)/dextran 70 8% (HSS group, n=13) solutions.

MEASUREMENTS AND RESULTS

Haemodynamic, blood gas, and sodium data were collected at the following time points: baseline, 30 min, 60 min, 120 min, and 180 min. PAOP was higher in the HSS group at 30 min (10.7+/-3.2 mmHg vs 6.8+/-3.2 mmHg) and 60 min (10.3+/-3 mmHg vs 7.4+/-2.9 mmHg); P<0.05. The cardiac index increased in the HSS group and it was greater than the SS group at 30 min (6.5+/-4.7 l min(-1) m(-2) vs 3.8+/-3.4 l min(-1) m(-2)), 60 min (4.9+/-4.5 l min(-1) m(-2) vs 3.7+/-3.3 l min(-1) m(-2)), and 120 min (5.0+/-4.3 l min(-1) m(-2) vs 4.1+/-3.4 l min(-1) m(-2)); P<0.05. The stroke volume index followed a comparable course and it was higher at 30 min [53.6(39.2-62.8) ml m(-2) vs 35.6(31.2-49.2) ml m(-2)] and 60 min [46.8(39.7-56.6) ml m(-2) vs 33.9(32.2-47.7) ml m(-2)]; P<0.05. Systemic vascular resistance decreased in the HSS group and became significantly lower at 30 min (824+/-277 dyne s(-1) cm(-5) m(-2) vs 1139+/-245 dyne s(-1) cm(-5) m(-2)), 60 min (921+/-256 dyne s(-1) cm(-5) m(-2) vs 1246+/-308 dyne s(-1) cm(-5) m(-2)), and 120 min (925+/-226 dyne s(-1) cm(-5) m(-2) vs 1269+/-494 dyne s(-1) cm(-5) m(-2)). Sodium levels increased in the HSS group (P=0.056) and were higher than in the SS group at 30 min (145+/-3 mEq l(-1)vs 137+/-7 mEq l(-1)), 60 min (143+/-4 mEq l(-1) vs 136+/-7 mEq l(-1)), 120 (142+/-5 mEq l(-1)vs 136+/-7 mEq l(-1)), and 180 min (142+/-5 mEq l(-1) vs 136+/-8 mEq l(-1)).

CONCLUSION

Hypertonic saline/dextran solution may improve cardiovascular performance in severe sepsis without significant side effects. The haemodynamic effect appears related mainly to a volume effect.

The common mutations C677T and A1298C in the human methylenetetrahydrofolate reductase gene are associated with hyperhomocysteinemia and cardiovascular disease in hemodialysis patients

BACKGROUND

Plasma total homocysteine (tHcy) level might be an important risk factor for the development of cardiovascular disease (CVD) in dialysis patients. While both renal failure and mutations of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene may result in hyperhomocysteinemia and CVD, the distinct roles of the thermolabile MTHFR mutation at nucleotide C677T and the more recently described mutation at nucleotide A1298C have not been evaluated concurrently in patients on hemodialysis.

METHODS

A cross-sectional study was performed in 120 maintenance HD patients to determine the prevalence of MTHFR C677T and A1298C mutations and their relative association to hyperhomocysteinemia and CVD.

RESULTS

Both mutations, the C677T and the A1298C, were highly prevalent in HD patients with allele frequencies of 0.41 and 0.27, respectively. The prevalence of CVD in HD patients was 55% and its significant risk factors included, in descending order, hyperhomocysteinemia, MTHFR C677T mutation, low serum folate levels, diabetes mellitus, hypertension, and double heterozygote state for both MTHFR mutations (677CT/1298AC). MTHFR A1298C mutation alone and gender were not associated with either hyperhomocysteinemia or increased CVD risk, but the HD patients with homozygotes 1298CC and wild alleles 677CC (677CC/1298CC) have significant increase of tHcy (37.7 +/- 12) and high prevalence of CVD.

CONCLUSIONS

Hyperhomocysteinemia, serum folate levels and both C677T and A1298C MTHFR mutations are associated with CVD in HD patients.

Patient satisfaction after MRCP and ERCP

OBJECTIVE

Magnetic resonance cholangiopancreatography (MRCP) is an accurate diagnostic test for detecting abnormalities of the pancreaticobiliary system. Because it is noninvasive, MRCP appears to be more tolerable than ERCP, although this has not been studied. The purpose of this study is to compare patient satisfaction after MRCP and ERCP performed sequentially.

METHODS

We prospectively recruited 34 patients undergoing ERCP, for whom an MRCP was able to be performed before ERCP. Patient satisfaction was assessed by validated questionnaires using seven-point Likhert scales (individual ratings and direct comparisons). The following dimensions were explored: anxiety, pain, discomfort, tolerability (relative to expectations), willingness to repeat the procedure, and overall preference. Chi2 and Student's t tests (paired and unpaired) were performed, and 95% CIs were provided.

RESULTS

Two patients (5.9%) were unable to undergo MRCP because of claustrophobia. The remaining 32 completed both tests (94% same day) and all questionnaires. Average age was 56+/-18 yr, and 66% were women. In 23 patients, some degree of biliary obstruction was suspected; nine patients had pancreatitis. Patients reported a lower degree of pain (p < 0.001) and discomfort (p = 0.047) with MRCP, but MRCP was more difficult than they expected (p = 0.0 12). Patients were marginally more willing to repeat MRCP (ns, p = 0.09). On direct comparisons, patients were more satisfied with MRCP regarding anxiety (p = 0.04) and pain (p = 0.001). Patients displayed a higher overall preference for MRCP compared with ERCP (p = 0.01); however, only 59% clearly preferred MRCP over ERCP. The most common problem with MRCP was claustrophobia or noise (n = 15), and the differences were more striking in the subgroup without this problem. The subgroup undergoing purely diagnostic ERCPs showed clear preferences for MRCP.

CONCLUSIONS

In many respects, MRCP is well tolerated, and certain subgroups, especially those undergoing diagnostic ERCPs, prefer MRCP over ERCP. As an endoscopist, one needs to be aware of the limitations of MRCP and relay these to the patient, as it seems that patients find MRCP more difficult than anticipated, and a significant number still prefer ERCP over MRCP. Patient satisfaction may be further improved by reducing noise and claustrophobia with selective premedication, earplugs, and the use of the new quieter fenestrated magnetic resonance imaging scanners.

Neurochemical characterization of traumatic brain injury in humans

Trauma is the leading cause of death in individuals between the ages of 1 and 44 years. And, in the case of severe head injury mortality can reach as high as 35-70%. Despite this fact, there has been little progress in the development of effective pharmacological agents to protect brain injured patients. To date, there is little data on the mechanisms involved in neuronal cellular insult after severe head injury, especially in humans. Glutamate acts both as a primary excitatory neurotransmitter and a potential neurotoxin within the mammalian brain. Evidence indicates that hyperactivity of the glutamate system contributes to neuronal death in brain trauma. Also, in animal models of neurotrauma, this neural injury is followed by gliosis which has been linked to the severity of brain injury. To investigate the glutamate system in brain trauma, we carried out [3H]glutamate and [3H]MK801 (a noncompetitive NMDA-receptor antagonist) binding and [3H]glutamate uptake assays in human cerebral cortex preparations obtained from severely brain injured and control victims. Additionally, to investigate gliosis following brain injury, we performed GFAP immunohistochemistry. There were no significant differences in [3H]glutamate binding (affinity or density of sites) between the control and head injured groups. In contrast, cerebral cortical [3H]MK801 binding revealed both a significant increase in the density of sites (Bmax) and a decrease in the dissociation constant (Kd) in the head injured group when compared to controls. There were no significant differences in [3H]glutamate uptake between groups. The injured brains presented an increased number of GFAP-positive astrocytes and more intense GFAP reaction in comparison to control brains. In the context of traumatic brain injury, our results encourage further investigation into compounds capable of selective modulation of NMDA receptor subtype in humans while also therapeutically manipulating glial cell responses following brain trauma.

Increased serum S100beta protein concentrations following severe head injury in humans: a biochemical marker of brain death?

This study investigated S100beta protein as a biochemical serum marker of brain damage in severe head injury and brain death victims. Blood samples obtained from 15 patients with severe head injury admitted to the trauma intensive care unit (ICU), five patients with a diagnosis of brain death due to hemorrhage following cerebral aneurysm rupture, and five healthy individuals were investigated. The S100beta protein serum concentrations were analyzed with a immunoradiometric assay kit. The 15 patients with severe head injury were followed up for 6 months. Outcome was considered either death or recovery with ICU discharge. S100beta concentrations were closely related to brain damage. Among the severe head injury victims, higher S100beta concentrations were detected in those patients that progressed to death. The individuals with brain death had similar mean S100beta concentrations, irrespective of its cause (either trauma or vascular rupture). S100beta protein is a promising serum outcome predictor for severe head injury victims and may contribute to the early diagnosis of brain death.

Ageing and the mismatch repair system

Age-related accumulation of mutations has been extensively documented, and it has been proposed as one of the prominent causes of malignancies in old age. The present review is focused on the particular case of DNA mismatch repair system (MMR), that has drawn increased attention for its possible relevance to malignancy. We also report on our own observations on an age-associated genomic instability that develops with age in the MMR system. Our study was performed on DNA samples that were prepared from peripheral blood cells, obtained at a 10-year interval from young and old human subjects. The two DNA samples from each individual were examined comparatively. The older individuals showed a significantly higher rate of microsatellite instability (MSI) in several loci examined, whereas no difference was found between the paired samples of any of the young subjects. We suggest that this increase in MSI with age may indicate an overall genomic instability in the elderly.

Macrophage cholesterol metabolism, apolipoprotein E, and scavenger receptor AI/II mRNA in atherosclerosis-susceptible and -resistant mice

Female mice known to be susceptible (C57BL) and resistant (C3H and BALB/c) to diet-induced atherosclerosis were studied. Feeding of a cholate-containing atherogenic diet for 1 month resulted in an increase in plasma total cholesterol, little or no change in total phospholipids and high density lipoprotein (HDL) cholesterol, and a fall in HDL phospholipid, which was most pronounced in the C57BL strain. In elicited macrophages, cholesterol esterification was lower with acetylated low density lipoprotein (acLDL) and higher with beta-very low density lipoprotein (beta-VLDL) in C57BL than in C3H or BALB/C strains. In resident macrophages, acLDL enhanced cholesterol esterification more than did rabbit beta-VLDL. With acLDL, more apolipoprotein E (apoE) was recovered in all macrophage cultures. In macrophages from chow-fed mice, most apoE was in the medium, whereas in mice fed an atherogenic diet, half of the apoE was in the cells. ApoE protein was highest in macrophages from BALB/c mice fed an atherogenic diet; an increase in apoE mRNA occurred in BALB/c and C3H macrophages. Scavenger receptor AI/II mRNA was significantly higher in macrophages from atherosclerosis-resistant mice. Thus, higher HDL phospholipid and plasma apoE levels (reported by others), together with high macrophage scavenger receptor AI/II mRNA, could inhibit accretion of cholesterol in the vessel wall in the 2 resistant strains.

The association between two common mutations C677T and A1298C in human methylenetetrahydrofolate reductase gene and the risk for diabetic nephropathy in type II diabetic patients

Mutations of the methylenetetrahydrofolate reductase (MTHFR) gene have been shown to be associated with a predisposition to developing diabetic nephropathy (DN) in specific populations. The frequency of two MTHFR mutations, a recently described mutation in the human MTHFR gene A1298C and C677T, whose association with DN is already known, was determined in an Israeli Jewish population with type 2 diabetes mellitus (DM). Both A1298C and C677T are highly prevalent in the diabetic population with allele frequencies of 0.35 and 0.36, respectively. The genotype frequency and allele frequency for these two polymorphisms in patients who are normoalbuminuric (n = 55) were compared with those of patients who had either micro- or macroalbuminuria (n = 43). For both polymorphisms, there were no significant differences in either the genotype distribution or allele frequency in patients with or without DN. However, in patients with serum folate <15.4 nmol/L, there was a greater incidence of DN in those patients who were homozygous or heterozygous for the C677T mutation. For the A1298C mutation, there is evidence suggesting that the homozygous state may be protective in patients with low-normal serum folate. Folate supplementation in diabetic patients with the C677T mutation and low-normal serum folate may prevent the onset or retard the progression of DN.