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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Learning from mistakes when reporting urgent and emergency vascular studies

The majority of out-of-hours cases relate to neurological, chest, and gastrointestinal pathologies with acute vascular cases being encountered less commonly. Trainees and exposure of non-vascular/interventional radiology (IR) consultants to angiographic imaging is often limited in working hours and this may lead to reporting on-call cases outside of normal daytime practice. In a recent local review, a number on-call vascular studies were found to contain a number of vascular-related discrepancies. Vascular reporting is a complex subspecialty, which comprises many clear diagnoses (large vessel occlusions, large vessel aneurysms, or dissections); however, also several subtle and complex abnormalities. These more subtle abnormalities, at times, require dedicated vascular specialist review to ensure subtle findings are communicated appropriately to the clinical team. The recent increased complexity of endovascular treatments and their complications has also provided further challenge for the non-specialist reporter. Similarly, improved imaging techniques have allowed for non-obvious but significant findings that may require urgent management, such as small aneurysms and dissection flaps. We will review a range of key vascular findings that demonstrate learning opportunities, particularly within the acute and on-call settings. These will include gastrointestinal haemorrhage, subtle aortic pathologies, head and neck vascular emergencies, small to mid-sized vessel injuries and imaging of post-procedural complications. Educational hints and tips will be provided to enable learning from mistakes encountered by trainees and non-vascular specialist radiologists in the on-call or urgent reporting settings, and these will be reviewed with reference to the literature.

From Salt to Stroke-Evaluation of a Media Campaign for Sodium Reduction in Philadelphia

Excess dietary sodium contributes to the burden of chronic disease, including cardiovascular disease and stroke. Media-based health education campaigns are one strategy to raise awareness among populations at greater risk for stroke, including African Americans. During 2014–2015, the Philadelphia Department of Public Health conducted a health education campaign using radio, print news, and transit ads, to promote awareness of the link between dietary sodium, hypertension and stroke, and encourage reduced consumption of high sodium foods. Using a repeated cross-sectional design, street intercept surveys were conducted with ~400 Philadelphia residents representing the campaign's priority audience (African Americans ages 35–55) before and 6–13 weeks after the campaign, to evaluate both process (campaign exposure) and impact (recall of key health messages). Thirty percent of post-campaign respondents reported familiarity with one of the most engaging radio spots, and 17% provided accurate unaided recall of its key content, with greater recall among older respondents and frequent radio listeners. Forty-one percent of post-campaign respondents named stroke as a consequence of excess salt consumption, compared to only 17% of pre-campaign respondents, with greater awareness of the salt-stroke connection among those accurately recalling the radio spot from the campaign. Results suggest that priority populations for sodium reduction can be effectively reached through radio and transit campaigns. From a pragmatic perspective, street intercept surveys may offer one low resource strategy for evaluating public health education campaigns conducted by local health departments, especially among urban populations.

141 Diet supplementation alters oocyte lipid content and developmental competence in mares

The equine oocyte is dense in lipids, which may serve as an energy source for oocyte maturation and later embryonic development. However, the association between lipid content and fertility remains to be determined, as does the extent that diet can modify oocyte lipids. We hypothesised that diet supplementation can alter the oocyte lipid profile and subsequent developmental potential. In Study 1, we examined if oocyte triglyceride (TG) relative abundance was affected by dietary supplementation. Mares (16–22 years, n=9) were fed grass/alfalfa hay and supplemented daily with a combination of commercially available feed additives designed to promote equine wellness and fertility [Equine GI™ (147g daily), Potency® (28g daily), Motility Plus® (23g daily), Healthy Weight Oil (60mL daily), Platinum Performance Inc.]. Oocytes were collected from the mares before (PRE) and after ≥8 weeks (POST) of supplementation during the natural breeding season. In Study 2, we compared oocyte developmental potential after injection of sperm into oocytes obtained from mares supplemented for ≥8 weeks with the same additives (ADD, 18–24 yr, n=5) or from a similar group of mares supplemented with a grain control diet (450g of grain mix and 60ml of corn oil daily, GRN, 19–23 years, n=5). Oocytes were collected from dominant follicles (≥35mm) during oestrus and at 20±2 h after induction of follicular maturation. In Study 1, oocytes were denuded of cumulus cells after collection, snap frozen, and assessed for TG composition by nontargeted liquid chromatography-mass spectrometry using an Acquity UPLC system (Waters). In Study 2, recovered oocytes were placed in maturation medium for 22±2h before being injected with sperm from one stallion, and blastocyst formation was assessed in 7 or 8 days. A total of 100 annotated TG species were identified. Normalized peak areas for PRE and POST oocyte TG were compared using two-tailed, paired t-tests. Blastocyst development rates were compared by Fisher’s exact test. Relative abundance of 71 TG species differed (P ≤ 0.05) between PRE and POST; all TG species as well as total relative abundance of TG were higher in oocytes from PRE compared with POST. Blastocyst rates per sperm-injected oocyte were greater (P=0.03) for ADD (40%, 6/15) than for GRN (5%, 1/19). Dietary supplementation of the complex mix of nutrients to middle-aged and older mares resulted in reduced relative abundance of TG in oocytes and improved developmental potential. We determined that oocyte lipid content can be modified through diet. The extent that diet supplementation improved oocyte competence by altering the lipid profile is still to be determined.

98 Effects of maternal age on oxygen consumption of oocytes and invitro-produced equine embryos

Mitochondrial replication is arrested during early cleavage stages, leaving the embryo dependent on maternally derived mitochondria for oxidative phosphorylation. Numbers of mitochondrial DNA (mtDNA) are used as indicators of functional mitochondria; however, direct comparisons for mtDNA and oxygen consumption rate (OCR) have not been performed for horses. The objectives of this study were to compare equine oocyte mtDNA copy numbers with a measure of mitochondrial function (OCR) and to determine whether maternal age of the oocyte donor impacts OCR of early-stage embryos. We hypothesised that (1) OCR in oocytes is not directly associated with mitochondrial numbers and (2) aerobic metabolism (OCR) is lower in early embryos from old than from young mares. Mares ages 6-13 years (Young, n=7) and=20 years (Old, n=8) were used as oocyte donors. Oocytes were collected from dominant follicles (=35mm) during oestrus and at 16±2h after induction of follicular maturation. Recovered oocytes were incubated in tissue culture medium 199 with 10% fetal calf serum, 25mgmL−1 of gentamicin, and 0.2mM pyruvate for 26±2h. Metaphase II oocytes (Young, n=14; Old, n=15) were fertilized by intracytoplasmic sperm injection (ICSI) using frozen-thawed sperm from one stallion. Presumptive zygotes were cultured in global medium (LifeGlobal Group). Other oocytes and early embryos were used for OCR. A microchamber containing an electrochemical sensor was used to measure OCR from individual oocytes (Young, n=9; Old, n=14) and early embryos (Young, n=8; Old, n=10). After analyses, oocytes were snap frozen, and mtDNA was later quantified by qPCR. Metabolic assays of embryos that cleaved were performed at Day 2 after ICSI. After the assay, embryos were placed back to culture until blastocyst formation at Day 7 or 8. Two-tailed Student's t-tests were used for OCR and mtDNA comparisons, and Fisher's exact tests were used to compare development rates. We found that OCR was higher (P=0.007) for oocytes from Young (mean±s.e.m.: 1.8±0.2) than from Old (1.3±0.1 fmol s−1). However, mtDNA numbers were not different (P=0.3) for Young (5.6±0.4×105) and Old (6.2±0.4×105). Cleavage rates were similar (P=0.6) between Young (11 out of 14, 79%) and Old (13 of 15, 87%). Day 2 embryos from Young had higher basal OCR compared with Old (3.8±0.1 and 3.2±0.2 fmol s−1, respectively; P=0.05). Blastocyst rates per cleaved oocytes were similar for Young (5 of 11, 45%) and Old (4 of 13, 31%; P=0.7). Lower OCR was observed in oocytes and early embryos from Old, which indicates that mitochondrial metabolic function is reduced for mitochondria originating in the oocytes of Old compared with Young. Use of mtDNA was not indicative of mitochondrial metabolic function. Although sample numbers were limited, cleavage and blastocyst development were not significantly different between Young and Old. Further developmental competence was not determined, although the compromised metabolic capacity of oocytes and embryos from old mares could ultimately contribute to lower fertility outcomes.

Cytoarchitectonically-driven MRI atlas of nonhuman primate hippocampus: Preservation of subfield volumes in aging

Identification of primate hippocampal subfields in vivo using structural MRI imaging relies on variable anatomical guidelines, signal intensity differences, and heuristics to differentiate between regions (Yushkevich et al., 2015a). Thus, a clear anatomically-driven basis for subfield demarcation is lacking. Recent work, however, has begun to develop methods to use ex vivo histology or ex vivo MRI (Adler et al., 2014; Iglesias et al., 2015) that have the potential to inform subfield demarcations of in vivo images. For optimal results, however, ex vivo and in vivo images should ideally be matched within the same healthy brains, with the goal to develop a neuroanatomically-driven basis for in vivo structural MRI images. Here, we address this issue in young and aging rhesus macaques (young n = 5 and old n = 5) using ex vivo Nissl-stained sections in which we identified the dentate gyrus, CA3, CA2, CA1, subiculum, presubiculum, and parasubiculum guided by morphological cell properties (30 μm thick sections spaced at 240 μm intervals and imaged at 161 nm/pixel). The histologically identified boundaries were merged with in vivo structural MRIs (0.625 × 0.625 × 1 mm) from the same subjects via iterative rigid and diffeomorphic registration resulting in probabilistic atlases of young and old rhesus macaques. Our results indicate stability in hippocampal subfield volumes over an age range of 13 to 32 years, consistent with previous results showing preserved whole hippocampal volume in aged macaques (Shamy et al., 2006). Together, our methods provide a novel approach for identifying hippocampal subfields in non-human primates and a potential 'ground truth' for more accurate identification of hippocampal subfield boundaries on in vivo MRIs. This could, in turn, have applications in humans where accurately identifying hippocampal subfields in vivo is a critical research goal.

180 Stallion sperm phospholipase C zeta affects cleavage rates after intracytoplasmic injection in bovine oocytes

Phospholipase C zeta (PLCz) is a sperm protein linked to oocyte activation and zygote development in diverse species. Human intracytoplasmic sperm injection (ICSI) success is poor when sperm PLCz is reduced or mutated. We hypothesised that the expression of PLCz in stallion sperm corresponds with cleavage rates after ICSI. For this study, we selected sperm from 4 of 21 stallions for which frozen-thawed sperm were evaluated using flow cytometry to assess mean fluorescence intensity (MFI) and percentage of sperm positively labelled with PLCz. Before flow cytometric assessment, Western blotting and immunofluorescence were performed to validate antibody binding and to identify PLCz as a 71-kDa protein in stallion sperm, located in the acrosomal and postacrosomal region, and the tail (Gonzalez-Castro et al. 2017 Reprod. Fertil. Dev. 30, 228). Frozen sperm from 4 stallions were selected based on MFI and percentage of PLCz-labelled sperm per total sperm population, respectively (High, 87% with 10,384 MFI and 84% with 10,784 MFI; Low, 56% with 4,789 MFI and 59% with 5,360 MFI). The samples were selected so that other fertility indicators, such as normal morphology (&gt; 70%), DNA integrity (&lt;8%, flow cytometric evaluation using sperm chromatin structure assay), and viability (SYBR14+/propidium iodide-, flow cytometric assessment) were similar for High and Low. Bovine ovaries were transported at 25°C before collection of oocytes from 2- to 8-mm follicles. Oocyte maturation and embryo culture were done as previously described using a bovine system with chemically defined media (De La Torre-Sanchez et al. 2006 Reprod. Fertil. Dev. 18, 585-596). Oocytes were matured for 22 to 24h at 38.5°C in 5% CO2 and air before removal of cumulus cells. Before ICSI, straws of frozen sperm were cut under liquid nitrogen, with a small section thawed directly in medium. Oocytes were selected based on normal morphology and an extruded polar body. Before injection, individual sperm were selected at 200× based on normal morphology and progressive motility. Oocytes were injected with sperm from High (n=62 oocytes) and Low (n=56). A third group of oocytes (n=43) were sham injected (no sperm) to determine the rate of parthenogenetic cleavage. Cleavage rates were compared using chi-squared test. Cleavage rates differed (P&lt;0.0001) among groups, with 53% (33/62) for High, 34% (19/56) for Low, and 0% (0/43) for sham injections. Sperm populations from the High group had higher (P&lt;0.04) cleavage rates than those from the Low group. We concluded that PLCz in stallion sperm populations is a valuable indicator of ICSI success, and this protein is important factor for oocyte activation and initiation of embryo development after assisted fertilization.

Search and recovery of autobiographical and laboratory memories: Shared and distinct neural components

Functional neuroimaging evidence suggests that there are differences in the neural correlates of episodic memory for laboratory stimuli (laboratory memory) and for events from one's own life (autobiographical memory). However, this evidence is scarce and often confounded with differences in memory testing procedures. Here, we directly compared the neural mechanisms underlying the search and recovery of autobiographical and laboratory memories while minimizing testing differences. Before scanning, participants completed a laboratory memory encoding task in which they studied four-word "chains" spread across three word pairs. During scanning, participants completed a laboratory memory retrieval task, in which they recalled the word chains, and an autobiographical memory retrieval task, in which they recalled specific personal events associated with word cues. Importantly, response times were similar in the two tasks, allowing for a direct comparison of the activation time courses. We found that during memory search (searching for the memory target), similar brain regions were activated during both the autobiographical and laboratory tasks, whereas during memory recovery (accessing the memory traces; i.e., ecphory), clear differences emerged: regions of the default mode network (DMN) were activated greater during autobiographical than laboratory memory, whereas the bilateral superior parietal lobules were activated greater during laboratory than autobiographical memory. Also, multivariate functional connectivity analyses revealed that regardless of memory stage, the DMN and ventral attention network exhibited a more integrated topology in the functional network underlying autobiographical (vs. laboratory) memory retrieval, whereas the fronto-parietal task control network exhibited a more integrated topology in the functional network underlying laboratory (vs. autobiographical) memory retrieval. These findings further characterize the shared and distinct neural components underlying autobiographical and laboratory memories, and suggest that differences in autobiographical vs. laboratory memory brain activation previously reported in the literature reflect memory recovery rather than search differences.

A Tale of Two Temporal Coding Strategies: Common and Dissociable Brain Regions Involved in Recency versus Associative Temporal Order Retrieval Strategies

Numerous studies indicate the importance of the hippocampus to temporal order retrieval. However, behavioral studies suggest that there are different ways to retrieve temporal order information from encoded sequences, one involving an associative strategy (retrieving associations using neighboring items in a list) and another involving a recency strategy (determining which of two items came first). It remains unresolved, however, whether both strategies recruit the hippocampus or only associative strategies, consistent with the hippocampus's role in relational processing. To address this, we developed a paradigm in which we dissociated associative versus recency-based retrieval, involving the same stimulus presentation during retrieval. Associative retrieval involved an increase in RT (and decrease in performance) with greater distances between intervals, consistent with the need to retrieve intervening associations. Recency-based retrieval involved an increase in RT (and decrease in performance) with shorter distances between intervals, suggesting the use of a strength-based coding mechanism to retrieve information. We employed fMRI to determine the neural basis of the different strategies. Both strategies showed significant levels of hippocampal activation and connectivity that did not differ between tasks. In contrast, both univariate and connectivity pattern analyses revealed differences in extrahippocampal areas such as parietal and frontal cortices. A covariate analysis suggested that differences could not be explained by task difficulty alone. Together, these findings suggest that the hippocampus plays a role in both forms of temporal order retrieval, with neocortical networks mediating the different cognitive demands for associative versus recency-based temporal order retrieval.

Complementary roles of human hippocampal subfields in differentiation and integration of spatial context

The unique circuitry of the hippocampus is thought to support the encoding and retrieval of context-rich episodic memories. Given the neuroanatomical differences between the hippocampal subfields, determining their functional roles during representation of contextual features in humans is an important yet unaddressed research goal. Prior studies suggest that, during the acquisition of information from the environment, the dentate gyrus (DG) and CA3 subfields rapidly differentiate competing contextual representations, whereas CA1, situated downstream from CA3/DG, is believed to process input from both CA3 and neocortical areas via the temporoammonic pathway. To further explore the functionality of these roles, we used high-resolution fMRI to investigate multivariate response patterns within CA3/DG and CA1 during the processing of spatial context. While undergoing functional imaging, participants viewed videos of virtual environments and were asked to discriminate between similar yet geometrically distinct cities. We manipulated a single contextual feature by systematically morphing the city configurations from one common geometric shape to another, resulting in four cities--two distinctively shaped cities and two intermediate "morphed" cities. Pattern similarity within CA3/DG scaled with geometric changes to the environment. In contrast, CA1 pattern similarity, as well as interregional pattern similarity between CA1 and parahippocampal cortex, increased for the regularly shaped configurations compared with the morphs. These results highlight different roles for subfields CA3/DG and CA1 in memory and advance our understanding of how subcomponents of the human hippocampal circuit represent contextual features of memories.

Analytical validation of a quantitative reverse transcriptase polymerase chain reaction assay for evaluation of T-cell targeted immunosuppressive therapy in the dog

Cyclosporine is an immunosuppressive agent that inhibits T-cell function by decreasing production of cytokines such as interleukin-2 (IL-2) and interferon-γ(IFN-γ). In dogs, there is currently no reliable analytical method for determining effective cyclosporine dosages in individual patients. Our laboratory has developed a quantitative reverse transcriptase polymerase chain reaction (RT-qPCR) assay that measures IL-2 and IFN-γ gene expression, with the goal of quantifying immunosuppression in dogs treated with cyclosporine. This study focuses on analytical validation of our assay, and on the effects of sample storage conditions on cyclosporine-exposed samples. Heparinized whole blood collected from healthy adult dogs was exposed to a typical post-treatment blood concentration for cyclosporine(500 ng/mL) for 1 h, and then stored for 0, 24, and 48 h at both room temperature and 4 ◦C.The study was then repeated using a cyclosporine concentration of 75 ng/mL, with sample storage for 0, 24, and 48 h at 4 ◦C. Cytokine gene expression was measured using RT-qPCR,and assay efficiency and inter- and intra-assay variability were determined. Storage for upto 24 h at room temperature, and up to 48 h at 4 ◦C, did not significantly alter results compared to samples that were processed immediately. Validation studies showed our assay to be highly efficient and reproducible and robust enough to be feasible under standard practice submission conditions.

Neural correlates of opposing effects of emotional distraction on working memory and episodic memory: an event-related FMRI investigation

A fundamental question in the emotional memory literature is why emotion enhances memory in some conditions but disrupts memory in other conditions. For example, separate studies have shown that emotional stimuli tend to be better remembered in long-term episodic memory (EM), whereas emotional distracters tend to impair working memory (WM) maintenance. The first goal of this study was to directly compare the neural correlates of EM enhancement (EME) and WM impairing (WMI) effects, and the second goal was to explore individual differences in these mechanisms. During event-related functional magnetic resonance imaging (fMRI), participants maintained faces in WM while being distracted by emotional or neutral pictures presented during the delay period. EM for the distracting pictures was tested after scanning and was used to identify successful encoding activity for the picture distracters. The first goal yielded two findings: (1) emotional pictures that disrupted face WM but enhanced subsequent EM were associated with increased amygdala (AMY) and hippocampal activity (ventral system) coupled with reduced dorsolateral PFC (dlPFC) activity (dorsal system); (2) trials in which emotion enhanced EM without disrupting WM were associated with increased ventrolateral PFC activity. The ventral-dorsal switch can explain EME and WMI, while the ventrolateral PFC effect suggests a coping mechanism. The second goal yielded two additional findings: (3) participants who were more susceptible to WMI showed greater amygdala increases and PFC reductions; (4) AMY activity increased and dlPFC activity decreased with measures of attentional impulsivity. Taken together, these results clarify the mechanisms linking the enhancing and impairing effects of emotion on memory, and provide insights into the role of individual differences in the impact of emotional distraction.

Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

OBJECTIVES

Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework.

DESIGN

Single centre, randomised controlled, two-arm trial.

SETTING

Elective surgery PAC in a Brisbane-based tertiary hospital.

PARTICIPANTS

400 adults scheduled for elective surgery were randomised to intervention or control.

INTERVENTION

A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers.

OUTCOME MEASURES

Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing.

RESULTS

There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29).

CONCLUSIONS

Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups.

TRIAL REGISTRATION

Registered with ANZCTR-ACTR Number ACTRN12609000426280.

Cyclooxygenase expression and platelet function in healthy dogs receiving low-dose aspirin

BACKGROUND

Low-dose aspirin is used to prevent thromboembolic complications in dogs, but some animals are nonresponsive to the antiplatelet effects of aspirin ("aspirin resistance").

HYPOTHESIS/OBJECTIVES

That low-dose aspirin would inhibit platelet function, decrease thromboxane synthesis, and alter platelet cyclooxygenase (COX) expression.

ANIMALS

Twenty-four healthy dogs.

METHODS

A repeated measures study. Platelet function (PFA-100 closure time, collagen/epinephrine), platelet COX-1 and COX-2 expression, and urine 11-dehydro-thromboxane B(2) (11-dTXB(2)) were evaluated before and during aspirin administration (1 mg/kg Q24 hours PO, 10 days). Based on prolongation of closure times after aspirin administration, dogs were divided into categories according to aspirin responsiveness: responders, nonresponders, and inconsistent responders.

RESULTS

Low-dose aspirin increased closure times significantly (62% by Day 10, P < .001), with an equal distribution among aspirin responsiveness categories, 8 dogs per group. Platelet COX-1 mean fluorescent intensity (MFI) increased significantly during treatment, 13% on Day 3 (range, -29.7-136.1%) (P = .047) and 72% on Day 10 (range, -0.37-210%) (P < .001). Platelet COX-2 MFI increased significantly by 34% (range, -29.2-270%) on Day 3 (P = .003) and 74% (range, -19.7-226%) on Day 10 (P < .001). Urinary 11-dTXB(2) concentrations significantly (P = .005, P < .001) decreased at both time points. There was no difference between aspirin responsiveness and either platelet COX expression or thromboxane production.

CONCLUSIONS AND CLINICAL IMPORTANCE

Low-dose aspirin consistently inhibits platelet function in approximately one-third of healthy dogs, despite decreased thromboxane synthesis and increased platelet COX expression in most dogs. COX isoform expression before treatment did not predict aspirin resistance.

Processing of emotional distraction is both automatic and modulated by attention: evidence from an event-related fMRI investigation

Traditionally, emotional stimuli have been thought to be automatically processed via a bottom-up automatic "capture of attention" mechanism. Recently, this view has been challenged by evidence that emotion processing depends on the availability of attentional resources. Although these two views are not mutually exclusive, direct evidence reconciling them is lacking. One limitation of previous investigations supporting the traditional or competing views is that they have not systematically investigated the impact of emotional charge of task-irrelevant distraction in conjunction with manipulations of attentional demands. Using event-related fMRI, we investigated the nature of emotion-cognition interactions in a perceptual discrimination task with emotional distraction by manipulating both the emotional charge of the distracting information and the demands of the main task. Our findings show that emotion processing is both automatic and modulated by attention, but emotion and attention were only found to interact when finer assessments of emotional charge (comparison of most vs. least emotional conditions) were considered along with an effective manipulation of processing load (high vs. low). The study also identified brain regions reflecting the detrimental impact of emotional distraction on performance as well as regions involved in coping with such distraction. Activity in the dorsomedial pFC and ventrolateral pFC was linked to a detrimental impact of emotional distraction, whereas the dorsal ACC and lateral occipital cortex were involved in helping with emotional distraction. These findings demonstrate that task-irrelevant emotion processing is subjective to both the emotional content of distraction and the level of attentional demand.

Development and validation of an instrument to measure the impact of genetic testing on self-concept in Lynch syndrome

A positive genetic test result may impact on a person's self-concept and affect quality of life. The purpose of the study was to develop a self-concept scale to measure such impact for individuals carrying mutations for a heritable colorectal cancer Lynch syndrome (LS). Two distinct phases were involved: Phase 1 generated specific colorectal self-concept candidate scale items from interviews with eight LS carriers and five genetic counselors, which were added to a previously developed self-concept scale for BRCA1/2 mutation carriers, Phase II had 115 LS carriers complete the candidate scale and a battery of validating measures. A 20-item scale was developed with two dimensions identified through factor analysis: stigma/vulnerability and bowel symptom-related anxiety. The scale showed excellent reliability (Cronbach's α = 0.93), good convergent validity by a high correlation with impact of event scale (r(102) = 0.55, p < 0.001) and Rosenberg self-esteem scale (r(108) = -0.59, p < 0.001), and a low correlation with the Fear questionnaire (r(108) = 0.37, p < 0.001). The scale's performance was stable across participant characteristics. This new scale for measuring self-concept has potential to be used as a clinical tool and as a measure for future studies.

Neural correlates of confidence during item recognition and source memory retrieval: evidence for both dual-process and strength memory theories

Although the medial-temporal lobes (MTL), PFC, and parietal cortex are considered primary nodes in the episodic memory network, there is much debate regarding the contributions of MTL, PFC, and parietal subregions to recollection versus familiarity (dual-process theory) and the feasibility of accounts on the basis of a single memory strength process (strength theory). To investigate these issues, the current fMRI study measured activity during retrieval of memories that differed quantitatively in terms of strength (high vs. low-confidence trials) and qualitatively in terms of recollection versus familiarity (source vs. item memory tasks). Support for each theory varied depending on which node of the episodic memory network was considered. Results from MTL best fit a dual-process account, as a dissociation was found between a right hippocampal region showing high-confidence activity during the source memory task and bilateral rhinal regions showing high-confidence activity during the item memory task. Within PFC, several left-lateralized regions showed greater activity for source than item memory, consistent with recollective orienting, whereas a right-lateralized ventrolateral area showed low-confidence activity in both tasks, consistent with monitoring processes. Parietal findings were generally consistent with strength theory, with dorsal areas showing low-confidence activity and ventral areas showing high-confidence activity in both tasks. This dissociation fits with an attentional account of parietal functions during episodic retrieval. The results suggest that both dual-process and strength theories are partly correct, highlighting the need for an integrated model that links to more general cognitive theories to account for observed neural activity during episodic memory retrieval.

Overlapping parietal activity in memory and perception: evidence for the attention to memory model

The specific role of different parietal regions to episodic retrieval is a topic of intense debate. According to the Attention to Memory (AtoM) model, dorsal parietal cortex (DPC) mediates top-down attention processes guided by retrieval goals, whereas ventral parietal cortex (VPC) mediates bottom-up attention processes captured by the retrieval output or the retrieval cue. This model also hypothesizes that the attentional functions of DPC and VPC are similar for memory and perception. To investigate this last hypothesis, we scanned participants with event-related fMRI whereas they performed memory and perception tasks, each comprising an orienting phase (top-down attention) and a detection phase (bottom-up attention). The study yielded two main findings. First, consistent with the AtoM model, orienting-related activity for memory and perception overlapped in DPC, whereas detection-related activity for memory and perception overlapped in VPC. The DPC overlap was greater in the left intraparietal sulcus, and the VPC overlap in the left TPJ. Around overlapping areas, there were differences in the spatial distribution of memory and perception activations, which were consistent with trends reported in the literature. Second, both DPC and VPC showed stronger connectivity with medial-temporal lobe during the memory task and with visual cortex during the perception task. These findings suggest that, during memory tasks, some parietal regions mediate similar attentional control processes to those involved in perception tasks (orienting in DPC vs. detection in VPC), although on different types of information (mnemonic vs. sensory).

Standardized classroom management program: Social validation and replication studies in Utah and Oregon

A comprehensive validation study was conducted of the Program for Academic Survival Skills (PASS), a consultant-based, teacher-mediated program for student classroom behavior. The study addressed questions related to: (a) brief consultant training, (b) subsequent teacher training by consultants using PASS manuals, (c) contrasts between PASS experimental teachers and students and equivalent controls on measures of teacher management skills, student classroom behavior, teacher ratings of student problem behaviors, and academic achievement, (d) reported satisfaction of participants, and (e) replication of effects across two separate school sites. Results indicated that in both sites significant effects were noted in favor of the PASS experimental group for (a) teacher approval, (b) student appropriate classroom behavior, and (c) four categories of student inappropriate behavior. Program satisfaction ratings of students, teachers, and consultants were uniformly positive, and continued use of the program was reported a year later. Discussion focused upon issues of cost-effectiveness, differential site effects, and the relationship between appropriate classroom behavior and academic achievement.

IMMUNITY IN MUMPS : VI. EXPERIMENTS ON THE VACCINATION OF HUMAN BEINGS WITH FORMOLIZED MUMPS VIRUS

The results observed after experimental inoculation of active mumps virus into 41 vaccinated and 32 unvaccinated children,-with the consent of their parents or guardians,-indicated that formol-inactivated mumps virus obtained from the parotid gland of the infected monkey and employed as a vaccine in the manner which has been described increased the resistance of about half of those to whom it was administered.

IMMUNITY IN MUMPS : V. THE CORRELATION OF THE PRESENCE OF DERMAL HYPERSENSITIVITY AND RESISTANCE TO MUMPS

The results of skin tests read at 48 hours on several hundred adults and children in which heat-inactivated mumps virus was the antigen have been presented and discussed. They can be summarized as follows:— Of 89 persons tested before the onset of mumps, 89 per cent exhibited erythematous reactions 10 mm. or less in diameter and 95 per cent, reactions 15 mm. or less in diameter. Of 40 persons tested during the first 5 days of mumps, 95 per cent exhibited reactions 10 mm. or less and 98 per cent reactions 15 mm. or less. Of 480 exposed persons the attack rate of mumps was 46 per cent among 340 with reactions 10 mm. or less and 10 per cent among 240 with reactions greater than 10 mm. The attack rate was only 2 per cent among 161 with reactions exceeding 15 mm. The attack rates in 13 skin-tested groups which were exposed to mumps tended to be inversely proportional to the incidence of reactions exceeding 10 mm. The incidence of reactions exceeding 10 mm. was approximately twice as high among 529 adults (persons 18 years or older) as it was among 306 children (persons under 18 years). Of 179 adults giving positive histories of mumps, 82 per cent exhibited skin reactions exceeding 10 mm. In certain groups the correlation between history and positive skin test was as high as 0.9. Of 132 adults giving negative histories, 58 per cent exhibited skin reactions of this magnitude. The proportion of reactions exceeding 10 mm. in a small number of children giving positive histories was 75 per cent. The proportion of reactions less than 10 mm. was 15 per cent. Of 167 adults with positive complement fixation tests, 87 per cent exhibited skin reactions exceeding 10 mm. Of 111 adults with negative complement fixation tests, 52 per cent exhibited reactions exceeding 10 mm. Of 43 children with positive complement fixation tests, the skin test reactions exceeded 10 mm. in 70 per cent. The skin reactions exceeded 10 mm. in 29 per cent of 105 children with negative complement fixation tests. In 69 of 72 individuals in whom skin reactions exceeded 10 mm., complement-fixing antibody either appeared in the blood or increased in amount within about 2 weeks after the tests were done. Such antibody responses likewise were observed in 34 of 76 individuals in whom skin reactions were 10 mm. or less. The data summarized up to this point were obtained with virus derived from the infected parotid gland of monkeys. The results of simultaneous tests in 82 individuals employing materials prepared from infected monkey parotid gland and amniotic membrane of chick embryos infected with mumps virus indicated in general that the same individual responded in a similar manner to both antigens. In many instances, however, the membrane material produced weaker reactions. Occasionally an individual failed to react at all to one of these materials but did respond to the other.

IMMUNITY IN MUMPS : IV. THE CORRELATION OF THE PRESENCE OF COMPLEMENT-FIXING ANTIBODY AND RESISTANCE TO MUMPS IN HUMAN BEINGS

Of 163 persons giving positive complement fixation tests who were exposed to mumps, 1 afterwards developed the disease; of 285 negative reactors similarly exposed, 56 afterwards came down with mumps. Of 78 individuals subjected to intimate exposure to mumps whose tests were originally negative and who failed to develop the disease, 41 per cent gave positive reactions when tested 1 month later. Seventy-seven per cent of complement fixation tests done on the sera of 565 normal adults who admitted a previous attack of mumps were positive. A similar correlation was recorded in tests on the sera of a small group of children with positive histories. Of 356 medical students admitting previous attacks, 80 per cent gave positive tests. Of 386 normal adults who denied previous attacks, 42 per cent gave positive tests; of 85 children giving negative histories, 38 per cent reacted positively. The results of complement fixation tests on the sera of 1665 normal adults (over 17 years) and 679 children (1 to 17 years) are recorded. It has been shown that 63 per cent of the adults and 57 per cent of the children had antibody in their blood which reacted with the virus of mumps. In groups in which exceptionally intense exposure was not known to have occurred in the past, the proportions of positive reactors were: adults, 61 per cent; children, 49 per cent. In contrast to these normal persons, the incidence of positive reactors among permanently institutionalized mental defectives was 38 per cent of 356 adults and 32 per cent of 475 children. In only 2 per cent of 320 normal adults and children did the titer of complement-fixing antibody reach 1-192. In no instance in which the endpoint was determined was a higher titer recorded. The results of complement fixation tests on the sera of mother and newborn infant were essentially the same in 5 instances.

Hazards of obesity--the Framingham experience

Measurements of height, weight, skinfolds and waist girth were used as indicators of general and regional obesity in the Framingham study population of 5,209 men and women. Mean values of cholesterol, blood pressure, blood glucose and uric acid increased with increasing body mass index (BMI). Weight gain was associated with increases and weight loss with decreases in these risk factors. Cigarette smoking was more prevalent in men and women with low quintile BMI. Upper quintile values of BMI, subscapular skinfolds, and waist girth were associated with increased relative risks of death from all causes, coronary heart disease (CHD) and cerebrovascular disease but relative risks for intermittent claudication were not increased. General and central obesity each made independent contributions to risk of CHD but central obesity was a better predictor in males. BMI, cholesterol, systolic blood pressure and blood glucose were significantly independent predictors of CHD. These data show that increased relative weight and central obesity are associated with elevated levels of risk factors, with increased incidence of cardiovascular disease and with increased death rates for all causes combined. Mortality rates are also increased among the leanest members of the population, especially among older men.

Congenital Corneal Anesthesia

Congenital corneal anesthesia is a rare clinical entity that poses a diagnostic dilemma, particularly in the pediatric age group. The sensory deficit may be confined to the cornea, or extend to other divisions of the trigeminal nerve. The sensory deficit may occur as an isolated abnormality, as part of a complex neurological syndrome, or it may occur in association with multiple somatic abnormalities and congenital insensitivity to pain. This condition usually presents between the ages of 8 to 12 months. Poor vision, photophobia, conjunctival injection, and corneal ulceration in the absence of pain and distress in a child should alert the clinician to the possibility of anesthetic cornea. In the early stages of presentation, punctuate keratopathy is the main feature, which may progress to non-healing persistent corneal epithelial defects. This stage may progress to acute corneal lysis and perforation. In most patients, conservative approaches such as copious lubrication, prevention of self-harm and cautious use of bandage contact lenses are effective in preventing progressive corneal damage. Tarsorrhapy is effective in promoting epithelial healing and permanent lateral tarsorraphy may prevent further development of epithelial defects. Amniotic membrane graft may be considered in order to improve epithelial healing. Corneal grafts carry a poor prognosis. Accurate initial diagnosis, evaluation, and proper management are paramount to prevent visual loss due to long-term complications of corneal anesthesia. This review of the literature outlines the problems and approaches in diagnosis, evaluation, and management of this rare condition.