Clinical and health care utilization variables can predict 90-day hospital re-admission in adults with Crohn's disease for point of care risk evaluation

BACKGROUND

Hospital re-admission for persons with Crohn's disease (CD) is a significant contributor to morbidity and healthcare costs. We derived prediction models of risk of 90-day re-hospitalization among persons with CD that could be applied at hospital discharge to target outpatient interventions mitigating this risk.

METHODS

We performed a retrospective study in persons with CD admitted between 2009 and 2016 for an acute CD-related indication. Demographic, clinical, and health services predictor variables were ascertained through chart review and linkage to administrative health databases. We derived and internally validated a multivariable logistic regression model of 90-day CD-related re-hospitalization. We selected the optimal probability cut-point to maximize Youden's index.

RESULTS

There were 524 CD hospitalizations and 57 (10.9%) CD re-hospitalizations within 90 days of discharge. Our final model included hospitalization within the prior year (adjusted odds ratio [aOR] 3.27, 95% confidence interval [CI] 1.76-6.08), gastroenterologist consultation within the prior year (aOR 0.185, 95% CI 0.0950-0.360), intra-abdominal surgery during index hospitalization (aOR 0.216, 95% CI 0.0500-0.934), and new diagnosis of CD during index hospitalization (aOR 0.327, 95% CI 0.0950-1.13). The model demonstrated good discrimination (optimism-corrected c-statistic value 0.726) and excellent calibration (Hosmer-Lemeshow goodness-of-fit p-value 0.990). The optimal model probability cut point allowed for a sensitivity of 71.9% and specificity of 70.9% for identifying 90-day re-hospitalization, at a false positivity rate of 29.1% and false negativity rate of 28.1%.

CONCLUSIONS

Demographic, clinical, and health services variables can help discriminate persons with CD at risk of early re-hospitalization, which could permit targeted post-discharge intervention.

Comparison of mechanical properties and host tissue response to OviTex™ and Strattice™ surgical meshes

PURPOSE

This study compared the in vitro/benchtop and in vivo mechanical properties and host biologic response to ovine rumen-derived/polymer mesh hybrid OviTex™ with porcine-derived acellular dermal matrix Strattice™ Firm.

METHODS

OviTex 2S Resorbable (OviTex 2S-R) and Strattice morphology were examined in vitro using histology and scanning electron microscopy; mechanical properties were assessed via tensile test; in vivo host biologic response and explant mechanics were evaluated in a rodent subcutaneous model. Separately, OviTex 1S Permanent (OviTex 1S-P) and Strattice were evaluated in a primate abdominal wall repair model.

RESULTS

OviTex 2S-R demonstrated layer separation, whereas Strattice retained its structural integrity and demonstrated higher maximum load than OviTex 2S-R out-of-package (124.8 ± 11.1 N/cm vs 37.9 ± 5.5 N/cm, p < 0.001), 24 h (55.7 ± 7.4 N/cm vs 5.6 ± 3.8 N/cm, p < 0.001), 48 h (45.3 ± 14.8 N/cm vs 2.8 ± 2.6 N/cm, p = 0.003), and 72 h (29.2 ± 10.5 N/cm vs 3.2 ± 3.1 N/cm, p = 0.006) following collagenase digestion. In rodents, inflammatory cell infiltration was observed between OviTex 2S-R layers, while Strattice induced a minimal inflammatory response. Strattice retained higher maximum load at 3 (46.3 ± 27.4 N/cm vs 9.5 ± 3.2 N/cm, p = 0.041) and 6 weeks (28.6 ± 14.1 N/cm vs 7.0 ± 3.0 N/cm, p = 0.029). In primates, OviTex 1S-P exhibited loss of composite mesh integrity whereas Strattice integrated into host tissue with minimal inflammation and retained higher maximum load at 1 month than OviTex 1S-P (66.8 ± 43.4 N/cm vs 9.6 ± 4.4 N/cm; p = 0.151).

CONCLUSIONS

Strattice retained greater mechanical strength as shown by lower susceptibility to collagenase degradation than OviTex 2S-R in vitro, as well as higher maximum load and improved host biologic response than OviTex 2S-R in rodents and OviTex 1S-P in primates.

A166 RISK STRATIFICATION OF EARLY RE-HOSPITALIZATION IN PERSONS WITH INFLAMMATORY BOWEL DISEASES USING MULTIVARIABLE MODELS

Background

Hospitalization for persons with inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is a significant contributor to morbidity and health care costs in Canada. Recognition of individuals at high risk of re-hospitalization could help inform targeted outpatient interventions that mitigate this risk.

Purpose

The aim of our study is to derive prediction models of risk of early (90-day) re-hospitalization among persons with IBD.

Method

We conducted a retrospective cohort study of all adult persons with IBD admitted to The Ottawa Hospital, Canada, for an acute IBD-related indication between April 2009 - March 2016. Demographic, clinical, and health services variables were obtained through chart review. Persons were linked to population-based health administrative datasets to identify historical and future IBD-related hospitalizations across the greater Ottawa region. Multivariable logistic regression models of 90-day re-hospitalization in persons with CD and UC were derived, and candidate predictors that demonstrated an independent association with the outcome at a p-value of 0.1 were retained. Bootstrap internal validation (200 iterations) was performed on the final models. Model performance and calibration were evaluated using the optimism-corrected c-statistic value and Hosmer-Lemeshow goodness of fit test, respectively. Adjusted odds ratios are reported with 95% confidence intervals (CI). Optimal probability cut points for re-hospitalization were selected to optimize sensitivity, specificity, and the J (Youden’s) index.

Result(s)

There were 524 CD and 248 UC hospitalizations during the study period. Of these, 57 (10.9%) CD and 27 (10.9%) UC hospitalizations were associated with re-hospitalization within 90 days of discharge. Forty-two candidate predictors were tested among CD hospitalizations, and 35 were tested among UC hospitalizations. Four variables were retained in each of the final models. Model performance and calibration for each variable are described in Table 1. The optimal range of probability cut points allowed for a sensitivity/positive predictive value (PPV)/false positive rate (FPR) of 0.72/0.23/0.29 (maximum J-index of 0.43) in the model for CD, and 0.78/0.33/0.19 (maximum J-index of 0.59) in the model for UC, respectively.

Image

Conclusion(s)

Demographic, clinical, and health services variables at the time of discharge have the potential to help identify persons with IBD at risk of early re-hospitalization, thereby permitting targeted outpatient intervention. Application of the models to our reference cohorts would earmark 1/3 or less of patients for early post-discharge intervention, with the potential to benefit more than 70% of patients destined for early re-hospitalization. Although the PPVs of our models were low, the models incorrectly predicted early re-hospitalization in less than 30% of patients. We are in process of externally validating these models in other jurisdictions across Ontario to test their generalizability.

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Disclosure of Interest

None Declared

A222 ASSOCIATION BETWEEN PROTON PUMP INHIBITOR USE AND DEVELOPMENT OF HEPATIC ENCEPHALOPATHY AND SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED PATIENTS WITH CIRRHOSIS

Background

Proton pump inhibitors (PPIs) are commonly prescribed medications which are indicated in various different gastrointestinal (GI) diseases, including peptic ulcer disease, gastroesophageal reflux disorder and upper GI bleeding. There is some evidence to suggest that PPI use in cirrhosis may predispose to the development of hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), albeit with some controversy.

Aims

We aim to conduct a retrospective epidemiological analysis of the association between PPI use in hospitalized patients with cirrhosis and prevalence of HE and SBP.

Methods

This was a retrospective cohort study of 953 adult patients (mean age 62.3 (SD=12.2)) with cirrhosis admitted to the Ottawa Hospital between January 1, 2011 and December 31, 2015. A chart review was conducted and relevant information extracted.

Results

Average MELD-Na on admission was 17.4 (SD = 7.5) with no significant differences when stratified by in-hospital PPI use (p=0.53). 14.7% of patients had a prior history of HE, 5.4% SBP, 31.6% ascites, 9.3% hepatocellular carcinoma and 1.2% hepatorenal syndrome. 26.4% of patients had a history of varices, of which 34.4% had previous variceal bleeding. 45.4% of patients were on a PPI prior to admission and 69.8% during their hospitalization. Patients with a previous history of HE (16.8% vs. 9.6% p=0.006), varices (31.4% vs. 14.2% p&lt;0.001) and variceal bleed (11.6% vs. 3.1% p&lt;0.001) were more likely to be exposed to a PPI in-hospital. Mortality rate during index admission was 19.4%.

There was no significant association noted between the incidence of HE (31.2% vs. 25.0% p=0.06) or SBP (10.4% vs. 8.0% p=0.25) and in-hospital PPI use. There was also no significant association between PPI use and infectious complications, including bacteremia (8.6% vs. 7.6% p=0.63), pneumonia (12.7% vs. 12.5% p=0.95), urinary tract infections (9.2% vs. 6.6% p=0.19) and clostridium difficile (3.8% vs. 2.1% p=0.18). Patients on a PPI had greater in-hospital mortality (22.0% vs. 13. 5% p=0.002), although there was no significance between cause of death (p=0.31) nor death from infectious complications (18.5% vs. 23.1% p=0.52) between groups. Length of stay (LOS) was longer in patients exposed to PPI (median (IQR) 7 (4–17) vs 6 (3–13) p=0.03). Similar findings were noted on subgroup analysis of decompensated patients.

Conclusions

We did not observe a significant difference in HE, SBP or infectious complications among this cohort of cirrhotic patients by in-hospital PPI use. However, there was a significantly higher mortality rate noted in hospital and longer LOS, despite similar baseline MELD-Na and causes of death. Further study and judicious PPI prescribing practices in this vulnerable population of patients is warranted.

Funding Agencies

None

A70 ASSOCIATION BETWEEN PROTON PUMP INHIBITOR USE IN HOSPITALIZED CIRRHOTICS AND DEVELOPMENT OF HEPATIC ENCEPHALOPATHY AND SPONTANEOUS BACTERIAL PERITONITIS

Background

Proton pump inhibitors (PPI) are commonly prescribed medications which are indicated in various different gastrointestinal (GI) diseases, including peptic ulcer disease, gastroesophageal reflux disorder and upper GI bleeding. There is some evidence to suggest that PPI use in cirrhosis may predispose to the development of hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), albeit with some controversy.

Aims

We aim to conduct a retrospective epidemiological analysis of the association between PPI use in hospitalized patients with cirrhosis, and prevalence of HE and SBP.

Methods

This was a retrospective cohort study of 600 adult patients (mean age 61.4 (SD=12.2)) admitted the Ottawa Hospital between January 1, 2011 and December 31, 2015 with cirrhosis. A chart review was conducted and relevant information extracted.

Results

Average MELD-Na on admission was 16.2 (sd=6.7). 14.8% of patients had a history of HE, 5.0% SBP, 7.8% with history of hepatocellular carcinoma and 1.0% with history of hepatorenal syndrome. 28.5% of patients had a history of varices, of which 11.0% had previous variceal bleeding. 69.3% of patients were on a PPI during their hospitalization. Not surprisingly, patients admitted with variceal bleeding were more likely to be exposed to PPI in hospital (97.2% vs 63.2%, p&lt;0.01) Patients with a diagnosis of cirrhosis prior to index admission were more likely to be on a PPI in hospital (p=0.001) and on discharge (p=0.001). Patients with ascites were less likely to be on a PPI than those without ascites (64.1% vs 77.6%, p&lt;0.01). There was no significant correlation between in hospital PPI use and MELD score (p=0.42). Amongst patients on PPI in hospital, 85.9% remained on a PPI at discharge. Although numerically greater, no statistically significant differences were observed in terms of prevalence of HE (21.3% in patients on PPI vs 8.3% in those not on PPI (p=0.37)), nor SBP (5.7% on PPI vs. 3.7% in those not on PPI (p=0.29)).

Conclusions

We did not observe a significant difference in HE and SBP among this cohort of cirrhotic patients by in-hospital PPI use. We did however note significantly higher PPI use in patients with previous diagnosis of cirrhosis as compared to those who were newly diagnosed, as well as those whose admissions were related to bleeding. Patients with ascites had lower prevalence of PPI use. Prescribing patterns for PPIs in patients with cirrhosis warrant further attention, including clinical utility and longer-term risks and benefits of this therapy.

Funding Agencies

None

Interface structure, precursor rheology and dielectric properties of BaTiO3/PVDF–hfp nanocomposite films prepared from colloidal perovskite nanoparticles

A novel and greatly simplified strategy was developed to fabricate high-permittivity dielectric nanocomposites. Interface structure, precursor rheology and dielectric properties of the 0–3 BaTiO₃/PVDF–hfp nanocomposite film were investigated.

Correction: Interface structure, precursor rheology and dielectric properties of BaTiO3/PVDF–hfp nanocomposite films prepared from colloidal perovskite nanoparticles

Correction for ‘Interface structure, precursor rheology and dielectric properties of BaTiO₃/PVDF–hfp nanocomposite films prepared from colloidal perovskite nanoparticles’ by Y. N. Hao et al., RSC Adv., 2017, 7, 32886–32892.

Clinical and immunological effects of a synthetic Beta-human chorionic-gonadotropin vaccine

We treated 23 patients with non-trophoblastic cancers with escalating doses of a synthetic vaccine consisting of the carboxy-terminal peptide of beta human chorionic gonadotropin conjugated to diphtheria toroid (CTP37), a muramyl dipeptide as an adjuvant, and squalene/mannide monooleate as a vehicle. Toxicity consisted of pain and sterile abscess formation at the injection site and of constitutional symptoms. Diphtheria toxoid hypersensitivity developed in one patient. Immunizations elicited anti-beta hCG IgG antibody which persisted for more than 10 months. Disappearance of circulating hCG present pre-immunization and tumor regressions were observed. Active specific immunotherapy with CTP37 vaccine is well-tolerated and has biological activity in patients with cancer.

Has arteriography gotten a bad name? Current accuracy and morbidity of diagnostic contrast arteriography for aortoiliac and lower extremity arterial disease

Recently, contrast arteriography has been challenged as the diagnostic test of choice for lower extremity arterial disease because of its associated morbidity and questionable accuracy in identifying suitable distal outflow arteries. The purpose of this report was to analyze our experience to determine if these concerns were justified. We reviewed 500 consecutive contrast arteriograms performed at our hospital for aortoiliac and lower extremity arterial disease between November 1994 and November 1998. Arteriograms performed in conjunction with therapeutic procedures such as balloon angioplasty, stent placement, and thrombolysis were excluded, leaving 244 diagnostic cases for analysis. Forty-six percent (112) of patients had diabetes mellitus, 14% (34) had an elevated baseline serum creatinine (> or =1.5 mg/dL), and an additional 7% (17) were dialysis dependent. Radiologists limited contrast volume by imaging only the symptomatic extremity when appropriate and using digital subtraction techniques as indicated. Our results showed that diagnostic contrast arteriography is associated with an acceptably low morbidity, has an accuracy that is unlikely to be surpassed by other modalities, and remains the diagnostic test of choice for lower extremity arterial disease.

Optimization of force constants with an Urey-Bradley force field avoiding normal mode crossings

We present a method that simplifies the refinement of force constants in normal mode calculations and makes the results more reliable. The method avoids normal mode crossings by constraining the force constants during refinement. It was tested with pyrrole, imidazole, benzene, pyridine, pyrimidine, aniline and adenine using a Urey-Bradley force field. The global error of the frequency fit for these molecules was 0.61%. The method reproduced with fewer parameters the accuracy of similar calculations of the single ring aromatic compounds. It improved the accuracy and isotopic shifts of previous empirical calculations of adenine by 40%. The C-C and C-N stretchings differed by less than 7% from the values of force constant-bond length empirical relations.

Converting from general anesthesia to cervical block anesthesia for carotid endarterectomy

Between January 1, 1992 and June 30, 1998, vascular and general surgery residents performed 401 carotid endarterectomies (185 cervical block, 216 general anesthesia) under supervision of vascular attending surgeons. In January 1995, cervical block anesthesia was newly instituted. Initially anesthesiologists were randomly assigned to these cases and anesthetic technique was not standardized. At the surgeons' insistence later in the series, three specially trained anesthesiologists routinely administered cervical block anesthesia. As experience grew, surgeons realized that operating time greater than 2 hours and high neck dissections requiring mandibular retraction were poorly tolerated by cervical block anesthesia patients but that repeat carotid endarterectomies could be safely performed. Shunts were selectively inserted if significant electroencephalographic changes occurred or carotid stump pressures were less than 50 mm Hg systolic when general anesthesia was used; neurologic changes occurred when cervical block anesthesia was used; or there was a history of ipsilateral stroke for either anesthetic method. Despite an initial learning curve with cervical block anesthesia, the stroke-mortality rate was similar between the two groups (general anesthesia: 1.9% [four cerebrovascular accidents, two deaths]; cervical block anesthesia: 1.6% [two cerebrovascular accidents, two deaths]). Eight (12%) of the first 66 cervical block anesthesia patients were converted to general anesthesia compared to 2 (1.7%) of the most recent 119 patients with cervical block anesthesia (p = 0.03). After cervical block anesthesia was initiated, seven of the first eight repeat carotid endarterectomies were performed using general anesthesia compared to one of the most recent six repeat cases (p = 0.02). As surgeons' comfort with cervical block anesthesia increased, 94% (100) of the most recent consecutive 106 carotid endarterectomies were performed using this technique. These results suggest that carotid endarterectomy can be performed as safely using cervical block anesthesia as general anesthesia, specialized anesthesiologists are essential to achieve a successful outcome, selected repeat carotid endarterectomies can be performed using cervical block anesthesia, very cephalad lesions are best treated using general anesthesia, and surgical trainees can safely perform carotid endarterectomy under attending surgeon supervision if the operation is carried out expeditiously.

Abnormal duplex findings at the proximal anastomosis of infrainguinal bypass grafts: does revision enhance patency?

Using color duplex ultrasound (CDU) surveillance of autogenous infrainguinal bypasses, a peak systolic flow velocity (PSFV) ratio of greater than 3 to 1 within the graft relative to adjacent PSFV has been accepted as predicting significant stenosis mandating revision. At the proximal anastomosis, where significant vessel diameter differences and turbulent flow exist, the validity of these criteria is less clear. Our purpose was to review our experience with proximal anastomotic abnormalities in a CDU surveillance protocol. Routine CDU surveillance for all infrainguinal bypass gratis consisted of evaluation in an accredited vascular laboratory at 1 month postoperatively, every 3 months for the first year, every 6 months in the second year, and annually thereafter. Grafts with a PSFV ratio of >3 at the proximal anastomosis on any CDU study were included in this review. From our results we conclude that currently accepted CDU criteria for graft-threatening stenosis may not be valid for abnormalities at the proximal anastomosis of infrainguinal grafts. Regression of these abnormalities is common. Better CDU criteria are needed for predicting not only severity of proximal anastomotic stenosis but also likelihood of graft thrombosis.

Chemical characterization and biological activity of Macfadyena unguis-cati (Bignoniaceae)

Macfadyena unguis-cati (L.) has been widely used in folk medicine as an anti-inflammatory, antimalarial and antivenereal. The purpose of this study was to chemically characterize the main plant components, and to evaluate the biological properties of some of the fractions derived from leaves (MACb) and liana (MACa) of this plant. Chemical characterization allowed the identification of the compounds corymboside, vicenin-2, quercitrin, chlorogenic acid, isochlorogenic acid, lupeol, beta-sitosterol, beta-sitosterylglucoside, allantoin and lapachol. The biological screening of fractions and/or purified substances derived from fractions revealed antitumoral and antitrypanosomal activities in fractions MACa/lapachol and MACb/MACb21, respectively. The anti-lipoxygenase and anti-cyclooxygenase effect seen in fractions MACa and MACb showed a partial correlation with the anti-inflammatory property attributed to this plant.

Verbal fluency deficits in geriatric and nongeriatric chronic schizophrenic patients

This study examined age-related differences and correlates of deficits on phonological and category fluency tasks performed by schizophrenic patients. Equal numbers (n = 41) of geriatric (age > 64) and nongeriatric chronically hospitalized schizophrenic patients were examined with tests of phonological and category fluency, verbal learning and delayed recall, confrontation naming, and reading, as well as overall estimates of cognitive impairment. Both types of fluency tests were performed very poorly by both groups. Age-related differences were found to be statistically significant. In both groups, category fluency impairments were correlated with deficits in naming, while phonological fluency deficits were best predicted by memory impairments. These data suggest that category fluency impairments are part of a general profile of impaired semantic functioning, whereas phonological fluency deficits may be induced by alterations in information processing capacity.

Age-related differences in formal thought disorder in chronically hospitalized schizophrenic patients: a cross-sectional study across nine decades

OBJECTIVE

This study used a cross-sectional design to examine the frequency of occurrence and severity of 10 different signs of thought disorder in schizophrenic patients across the lifespan.

METHOD

Schizophrenic patients, who ranged in age from 19 to 96 years (N = 392), were examined with the Scale for Assessment of Thought, Language, and Communication. The cognitive functioning of the geriatric patients (patients over the age of 64, N = 120) was also assessed.

RESULTS

Poverty of speech was more common and more severe in geriatric patients, while four different signs of thought disorder that reflect disconnected speech were less common and less severe in geriatric patients. Analysis of covariance found that the lower severity of disconnection thought disorders in the older patients was not attributable to differences in the amount of speech produced.

CONCLUSIONS

Aspects of disconnected speech were less severe in older patients, while the severity and frequency of poverty of speech were greater. These findings suggest that the two previously identified separate dimensions of communication disorder in schizophrenia vary differently with age and possibly in their cognitive and biological underpinnings.

Cognitive impairment and negative symptoms in geriatric chronic schizophrenic patients: a follow-up study

Cognitive impairment is increasingly recognized as an important aspect of schizophrenia. Since cognitive impairment has many features in common with the negative symptoms of the illness, it is possible that some of the characteristics attributed to negative symptoms are due to an association with cognitive impairments. In order to test this hypothesis, 174 chronically hospitalized geriatric schizophrenic patients were examined twice at a 1-year follow-up with ratings of the severity of their symptoms (using the Positive and Negative Syndrome Scale: PANSS) and assessments of cognitive functions with the Mini-Mental State Examination and a brief neuropsychological battery aimed at the typical impairments seen in dementia. Positive symptoms were unassociated with any of the cognitive variables, while negative symptom severity was correlated with each of the cognitive measures. In the cross-temporal analyses, cognitive impairments were more stable over time than negative symptom scores, but cognitive impairment did not predict the severity of any negative symptom over time. At each assessment, however, cognitive impairment was strongly correlated with each of the seven negative symptoms studied. These data indicate that cognitive impairments and negative symptoms are related, but discriminable, features in schizophrenia and that the considerable overlap between some negative symptoms and estimates of cognitive function may suggest a rethinking of the definition of some of these symptoms.

How much does inferior capsular shift reduce shoulder volume?

The purpose of this study was to quantitate the effect of inferior capsular shift on shoulder volume. Four fresh frozen cadaveric shoulders were analyzed. Volume before and after shift was determined using 3 techniques: (1) Magnetic resonance imaging sequences were digitized to computer and analyzed for volume via a 35-mm camera using Cue 2 software. The capsule was delineated by contrast between light and dark regions. Volume was calculated by summing the total area of respective slices. (2) Ultrasound images, obtained after surgical exposure of the capsule, were digitized. Volume was calculated using the formula for a prolate ellipsoid. (3) An 18-gauge needle was used to inject and evacuate saline via an anterior approach. Quantity of aspirated fluid provided a direct measure of volume. Inferior capsular shift was performed. After the operation, measurements were repeated. Inferior capsular shift reduced volume in all shoulders with each technique. On average, inferior capsular shift reduced joint volume by 57 %). A measurable reduction in shoulder joint volume is an effect of capsular shift. This measurement may have clinical application if volume is an indicator of instability or laxity.

Age disorientation in chronically hospitalized patients with mood disorders

Age disorientation was studied in 45 geriatric patients with chronic mood disorders. In a yearly assessment of cognitive functions, subjects were questioned about their age, year of birth, and the current year. Patients who misstated their age by > or = 5 years were considered age disoriented. Among the 45 patients, age-disorientation data were available for 32 patients, with the remainder either stating that they did not know their age or providing age-delusional responses. Six of the 32 patients were characterized as age disoriented at baseline and again at 12- to 18-month follow-up assessment. Age-disoriented patients performed worse overall on the Mini-Mental State Examination compared with patients who did not show age disorientation. Future studies of brain function and structure should include poor-outcome patients with mood disorders as well as patients with schizophrenia in attempts to identify the possible neurological dysfunctions that may underlie the phenomenon of age disorientation.

Cognitive functioning in chronically hospitalized schizophrenic patients: age-related changes and age disorientation as a predictor of impairment

Although schizophrenic patients manifest cognitive impairments, there is considerable variability across patients in the severity of this impairment. Very chronic patients with a poor outcome, particularly geriatric patients, manifest the most severe impairments, which have often been characterized as resembling dementia. This study examined age-related changes in cognitive functioning in a sample of schizophrenic patients (n = 393) ranging from 25 to 95 years of age, with a specific focus on identifying aspects of performance that were impaired in the youngest patients and preserved in the oldest patients. Age disorientation was examined in detail because it was previously found to predict global intellectual impairment in chronic patients. All 22 test items changed linearly over time (with age), with aspects of orientation, concentration, and delayed recall most impaired in young patients and naming and sentence repetition most preserved in the oldest patients. Age disoriented patients had more severe cognitive impairments at each age and the age-related changes in global impairment were more severe for these patients. The prevalence of age disorientation was consistent with previous reports and a one-year retest of the sample found that age disorientation was extremely stable over time within patients. The types of functions that are preserved in the oldest patients underscore previous findings of differences between geriatric schizophrenic patients and patients with degenerative diseases and the stability of age disorientation suggests that it is a trait of a subset of schizophrenic patients, those who appear to have the most severely declining course of illness.

[Cardiac involvement in juvenile rheumatoid arthritis]

Four cases with cardiac involvement in patients suffering from systemic outset of juvenile rheumatoid arthritis are reported. The cases were chosen out of 83 juvenile rheumatoid arthritis patients studied from 1975 to 1988. They developed respectively myopericarditis (case 1), myocarditis (case 2), endopericarditis (case 3), myopericarditis (case 4). The drug employed in the acute disease phase was exclusively prednisone; in all subjects the acute inflammatory stage resolved.

[Sjögren's syndrome in childhood. Description of a clinical case]

A case is reported of Sjögren's syndrome in childhood. According to Fox's classification, this patient presented all four inclusion criteria for the diagnosis of the disease. The Authors report the satisfactory evolution of the disease using therapy with FANS and corticosteroids and immunosuppressors during acute exacerbations.

The trophotaenial placenta of a viviparous goodeid fish. III: Protein uptake by trophotaeniae, the embryonic component

Protein uptake and degradation by trophotaenial cells of the viviparous goodeid fish Ameca splendens were studied colorimetrically and ultrastructurally using horseradish peroxidase (HRP) as a tracer and acid (ACPase) and alkaline (ALPase) phosphatase cytochemistry. Trophotaeniae are ribbon-like external projections of the embryonic gut that are equivalent to greatly hypertrophied intestinal villi. During gestation within the ovarian lumen, trophotaeniae are directly apposed to the internal ovarian epithelium (IOE) where they establish a placental association between the developing embryo and maternal organism. Trophotaenial absorptive cells possess an ALPase reactive brush border, an endocytotic apparatus, and ACPase reactive standing lysosomes. Ultrastructural studies of protein uptake indicate that cells of the trophotaenial epithelium take up HRP by micropinocytosis and degrade it within lysosomes. Initially (from 1.5-10 min), HRP is taken up in vitro at 22 degrees C at the apical cell surface and passes via endocytotic vesicles into an apical canalicular system. From 1.5 to 10 min exposure, HRP passes passes from the apical canalicular system to a series of small collecting vesicles. After 10 min, HRP is detected within large ACPase reactive supranuclear lysosomes. Three hours after an initial 1 h exposure to HRP, most peroxidase activity within supranuclear lysosomes is no longer detected. Presence of Golgi complexes, residual bodies, and secretory granules in the infranuclear cytoplasm suggest that products of protein uptake and hydrolysis are discharged across basal and lateral cell surfaces and into the trophotaenial circulation. Trophotaeniae of embryos incubated in vitro in HRP-saline take up HRP at an initial rate of 13.5 ng HRP/mg trophotaenial protein/min. The system becomes saturated after 3 h. Trophotaeniae incubated at 4 degrees C show little or no uptake. In trophotaeniae continuously pulsed with HRP for 1 h, then incubated in HRP-free saline, levels of absorbed peroxidase declined at a rate of 0.5 ng/mg trophotaenial protein/min. HRP does not appear to enter the embryo via extra-trophotaenial routes. These findings are consistent with the putative role of trophotaeniae as the embryonic component of the functional placenta of goodeid fishes. Trophotaenial uptake of maternal nutrients accounts for a massive (15,000%) increase in embryonic dry weight during gestation.

The trophotaenial placenta of a viviparous goodeid fish. II. Ultrastructure of trophotaeniae, the embryonic component

Embryos of the viviparous goodeid fish Ameca spendens develop within the ovarian lumen, where they establish a placental association with the maternal organism and undergo a 15,000% increase in embryonic dry weight. The placenta consists of an embryonic component, the trophotaeniae, and a maternal component, the internal ovarian epithelium. Examination with light microscopy and with transmission and scanning electron microscopy reveals that trophotaeniae of A. splendens are extraembryonic membranes consisting of five ribbon-like processes originating from a tube-like mass of tissue that extends outward from the perianal region of developing embryos. There are two sets of lateral processes and a longer single median process. Trophotaeniae possess an outer epithelium that surrounds a highly vascularized core of loose connective tissue. Epithelial cells possess apical microvilli and a pronounced endocytotic apparatus. Cells of the trophotaenial epithelium are either tightly apposed along their lateral margins or separated by enlarged intercellular spaces. Regions of the trophotaenial epithelium possessing enlarged intercellular spaces are distributed in patches. The trophotaenial epithelium is continuous with the embryonic hindgut epithelium and is considered to be derived from it. Comparison of trophotaenial morphology in A. splendens with that reported in Xenotoca eiseni reveals differences in histological organization. The former possess unsheathed trophotaeniae, whereas the latter are sheathed. We postulate that the apposition of trophotaenial epithelium to the internal ovarian epithelium constitutes a placental association equivalent to a noninvasive, epithelioform of an inverted yolk sac placenta. Structural relationships of embryonic and maternal tissues of the trophotaenial placenta are discussed in relation to maternal-embryonic nutrient transfer processes.

The trophotaenial placenta of a viviparous goodeid fish. I. Ultrastructure of the internal ovarian epithelium, the maternal component

Embryos of goodeid fishes develop to term within the ovarian lumen, where they undergo considerable increase in weight due to transfer of maternal nutrients across a trophotaenial placenta. The placenta consists of an embryonic component, the trophotaeniae, and a maternal component, the ovarian lining. The latter was examined by transmission electron microscopy, scanning electron microscopy, and light microscopy in both gravid and nongravid ovaries of the viviparous goodeid fish, Ameca splendens. The single median ovary of A. splendens is a hollow structure whose lumen is divided into lateral chambers by a highly folded longitudinal ovarian septum. Germinal tissue occurs within folds of the ovarian lining that extend into each of the two lateral chambers. Matrotrophic embryonic development takes place within ovarian chambers. During gestation, the lining of the ovarian lumen is in direct apposition to body surfaces and trophotaenial epithelia of developing embryos. The ovarian lining consists of a simple cuboidal epithelium, termed the internal ovarian epithelium (IOE), overlying a well-vascularized bed of connective tissue. Cells of the IOE are apically convex. Well-developed granular and agranular endoplasmic reticula and numerous large membrane-bound vesicles with electron-dense content occupy the apical cytoplasm of IOE cells. Two functional states of the same cell type are distinguished within the IOE. Phase I cells contain few, if any, large apically situated vesicles; Phase II cells contain many. Secretory products of the IOE are presumed to be an important source of nutrients for embryonic development. Structural and functional relationships of the IOE to the trophotaenial epithelium of developing embryos are discussed in relation to maternal-embryonic nutrient transfer processes.

Manifestations of pseudoxanthoma elasticum during pregnancy: a case report and review of the literature

A 30-year-old white woman with pseudoxanthoma elasticum (PXE) was followed throughout her pregnancy with several fetal ultrasonographic examinations and other diagnostic studies; these showed normal development up to the 26th wk and then a marked deceleration of fetal growth. The ultrasonographic appearance of the placenta was abnormal at all times probably related to the microscopic changes. The baby, born at 36 wk, showed severe intrauterine growth retardation as a probable consequence of the abnormal placenta detected by ultrasound and corroborated at birth. The cotyledons were small and more numerous than normal. One third of the placenta was hypoplastic or atrophic, with focal calcification in septa, stroma, villi, and decidua, and increased deposition of fibrin around villi. The most striking change was the increased number of septa and the abnormal elastic tissue.