Expectation and Patient Preference – does it Matter?1

Admission to clinical trials is often based on the assumption of homogeneity of the population. A group of 60 patients, all with pain in the neck or shoulder of at least 3 months duration, were studied. Expectation was graded before treatments were started by sharing out 100 points between freedom from side effects, pain relief, depression relief, improved mobility, improved sleep and speed of action. A double-blind crossover study of two established anti-inflammatory analgesics and placebo was carried out. Using analogue scales, patients were asked to grade their response. Side effects were recorded, and preference was established at the end of the study.Although all the patients were in sufficient pain to require medical attention, some rated relief of depression, improvement in sleep or lack of side effects as more important than pain relief. Differences between drug and placebo were most clearly demonstrated in those patients whose main concern was improved mobility. In our view it is important to select patients who are in need of a dominant property of a drug for a trial of this property and this may have ramifications across the medical spectrum.

Antimicrobial-resistant Faecal Organisms in Algae Products Marketed as Health Supplements

Dietary supplements are increasingly popular in Irish society. One of these is blue-green algae which is used with a variety health benefits in mind. A batch of Chlorella powder was found to be contaminated with Salmonella species in Ireland in 2015. This prompted additional testing of a total of 8 samples of three different products (Chlorella, Spirulina and Super Greens), for other faecal flora and antimicrobial resistance in any bacteria isolated. All 8 samples cultured enteric flora such as Enterococci, Enterobacteriaceae and Clostridium species. Antimicrobial susceptibility testing revealed one isolate with extended-spectrum ?-lactamase (ESBL) activity and one with carbapenemase activity. Clinicians caring for vulnerable patients should be aware of the potential risk of exposure to antimicrobial resistant bacteria associated with these products.

Low Dose Intraarterial Thrombolysis with Tissue Plasminogen Activator: Does It Deliver as Promised?

The widespread use of intraarterial thrombolytic therapy has been based on perceived benefits over operative treatment and the downgrading of the magnitude of subsequent surgery. Thirty-three patients who had thrombolysis for peripheral artery occlusion were retrospectively analyzed at St. James's Hospital from 1991 to 1997. One patient received streptokinase unsuccessfully. Five other patient's records were inadequate for analysis. Twenty-seven patient's notes were analyzed for risk, duration of occlusion, duration of treatment, dosage of tissue plasminogen activator (tPA) and conduits thrombolysed. There were 15 males and 12 females. The mean age was 62 years (range, 20-87). Fourteen were current or reformed smokers. Five were diabetic. Indications for treatment included acute graft occlusion (n = 13), embolus (n = 6), and primary and secondary arterial thrombosis (n = 8). Duration of occlusion was less than 24 hours in seven, 1 to 7 days in ten, and more than 7 days in ten patients. Twelve (44.44%) patients had complete clot lysis, four (14.81%) had partial clearance, and 1 1 (40.74%) remained occluded. Eight (29.63%) had serious complications including one death. Eighteen (66.66%) patients needed further surgical intervention to maintain graft patency. Data were analyzed using the chi-square and pooled t test. No significant difference was observed in results from thrombolysis from different conduits, gender, etiology, or smoking history. Increased duration of tPA administration was associated with an increased risk of failure. Administration of total dosages greater than 60 mg was associated with a higher risk of failure. Diabetics had a poor outcome (p=0.0520). Only 44% of patients successfully underwent lysis. A primary surgical option may be a more sensible course than lysis, given that the vast majority of patients ended up having surgery anyway.

Further evidence of validity of the Gait Deviation Index

In this paper, the relationship of the Gait Deviation Index (GDI) to gross motor function and its ability to distinguish between different Gross Motor Function Classification System (GMFCS) levels was determined. A representative sample of 184 ambulant children with CP in GMFCS levels I (n=57), II (n=91), III (n=22) and IV (n=14) were recruited as part of a population-based study. Representative gait cycles were selected following a 3D gait analysis and gross motor function was assessed using the Gross Motor Function Measure (GMFM). GDI scores were calculated in Matlab. Valid 3D kinematic data were obtained for 173 participants and both kinematic and GMFM data were obtained for 150 participants. A substantial relationship between mean GDI and GMFM-66 scores was demonstrated (r=0.70; p<0.001) with significant differences in mean GDI scores between GMFCS levels (p<0.001) indicating increasing levels of gait deviation in subjects less functionally able. The relationship between the GDI, GMFM and GMFCS in a representative sample of ambulators, lends further weight to the validity of the GDI scoring system. Furthermore it suggests that the subtleties of gait may not be wholly accounted for by gross motor function evaluation alone. Gait specific tools such as the GDI more likely capture both the functional and aesthetic components of walking.

2-(4-Hydroxyphenyl)-Benzo[b]thiophen-6-ol, an Estrogen-Like Compound, Induces Apoptosis in T47D/PKCα Breast Cancer Cells

Background: Tamoxifen (TAM) treatment failure is a major obstacle encountered in the clinical setting. Our lab has previously shown that constitutive overexpression of PKCα imparts a TAM resistant/ hormone independent phenotype in the T47D:A18 breast cancer cell line. Furthermore 17β-estradiol (E2) inhibits tumor growth in vivo as well as inhibits colony formation when cells are grown in 3D Matrigel (Zhang, 2009). Before TAM treatment was introduced, breast cancer patients received high-dose E2 and diesthystilbesterol (DES) treatment. DES treated patients may have a survival advantage over TAM treated patients in the long term (Peethambaram,1999). Others have shown that E2 can have inhibitory effects on MCF-7 cells both in vitro and in vivo (Lewis-Wambi, 2009). Taken together, this suggests an estrogenic compound may be efficacious for TAM-resistant breast cancer. The present study was designed to evaluate the effect of an estrogenic compound, 2-(4-hydroxyphenyl)-benzo[b]thiophen-6-ol (BTC), related to the SERMs raloxifene and arzoxifene, on the T47D:A18/PKCα breast cancer cell line.Methods: To determine if BTC can activate estrogen regulated genes we preformed an ERE-luciferase reporter assay 24 hours after BTC treatment. 3D Matrigel colony formation assay was performed to determine if BTC could inhibit colony formation. Colonies were stained and counted on day 10. To determine if apoptosis was occurring, cells were grown in Matrigel and the TUNEL Assay was performed on Day 6.Results: T47D:A18/PKCα cells showed a 31-fold induction in ERE-luciferase reporter activity when treated with BTC (10-7M) compared to 7-fold induction when treated with E2. In the T47D:A18/Neo parental cell line, BTC induced a 40-fold induction whereas estradiol induced a 96-fold induction. In the Matrigel colony formation assay T47D:A18/PKCα cells formed significantly fewer colonies when treated with BTC. Conversely, in the T47D:A18/Neo parental cell line BTC enhanced colony formation similar to E2 treatment. Our results indicate that BTC was able to induce significant apoptosis on day 6 (P= 0.038) as determined by the TUNEL Assay. Therefore BTC acts similarly to estradiol by inhibiting T47D:A18/PKCα colony formation and inducing apoptosis when cells are grown in Matrigel.Conclusion: These findings suggest that BTC is a potential lead compound in the treatment of PKCα overexpressing breast cancer. Furthermore, BTC was shown to be a potent inducer of the cytoprotective enzyme NQO1 in the Hepa 1c1c7 cell system as well as a strong activator of antioxidant responsive elements (Yu, 2007) indicating it may have the added benefit of chemoprotective effects which are absent in estradiol treatment. Further understanding of the mechanism in which BTC induces apoptosis in the T47D:A18/PKCα cell line may result in a clinical advantage to estradiol treatment including fewer side effects.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5140.

Consensus Statement on Concussion in Sport – the 3rd International Conference on Concussion in Sport held in Zurich, November 2008

No Abstract.

Consensus Statement on Concussion in Sport – the 3rd International Conference on Concussion in Sport held in Zurich, November 2008

No Abstract.

Identification of candidate biomarkers of therapeutic response to docetaxel in hormone-refractory prostate cancer by proteomic profiling

11010

Background: Docetaxel (DTX)-based chemotherapy improves symptoms and survival in men with advanced hormone-refractory prostate cancer (HRPC). However, approximately 50% of patients do not respond to DTX but are exposed to significant toxicity without direct benefit. This study aimed to identify novel therapeutic targets and predictive biomarkers of DTX-resistance in HRPC. Methods: Protein profiling using iTRAQ mass spectrometry compared the PC3-Rx and DTX-sensitive PC3 cells and DTX-resistant PC3-Rx developed by DTX dose-escalation. Functional validation experiments were performed using recombinant protein treatment and siRNA knockdown experiments. Plasma/serum samples were collected from 41 men with metastatic HRPC treated with DTX-based chemotherapy (36 with paired samples pre- and post- cycle 1 DTX). Serum/plasma levels of MIC-1 were measured by ELISA. The association between MIC-1 levels, PSA response and overall survival (OS) were assessed by non-parametric tests and Kaplan-Meier survival analysis. Results: The IC50 for DTX in PC3-Rx was 10-fold higher than that in parent PC-3 cells. Protein profiling identified that MIC-1 levels were elevated 2.4 fold and AGR2 decreased 2.4 fold in DTX resistant cells. Knockdown of AGR2 expression in PC3 cells resulted in increased DTX resistance (p=0.03). PC-3 cells treated with recombinant MIC-1 also became resistant to DTX (p=0.001). Conversely, treating PC3-Rx cells with MIC1-siRNA restored sensitivity to DTX (p=0.002). In HRPC patients, pre-treatment MIC-1 levels did not correlate with PSA response to treatment (p=0.6). In contrast, increased serum/plasma levels of MIC-1 after cycle one of chemotherapy were associated with DTX resistance (p=0.006) and shorter overall survival (p=0.002). Conclusions: These results suggest that both AGR2 and MIC-1 play a role in DTX resistance in HRPC. Furthermore, changes in serum/plasma MIC-1 levels are associated with DTX resistance in a correlative human cohort. While a larger study is needed to validate these findings, the data provide evidence that MIC-1 as a potential predictive biomarker and both MIC-1 and AGR2 are potential therapeutic targets in DTX resistance.

No significant financial relationships to disclose.

A closer look at the number of lymph nodes examined in colorectal cancer: A VAMC experience

e15117

Background: Retrieval of 12 lymph nodes (LN) is a current benchmark in colorectal cancer (CRC) resections according to the National Quality Forum (NQF). Series of multiple institutions contain variability in surgical and pathologic techniques for lymph node retrieval. To ensure consistency in retrieving lymph nodes for satisfactory staging, we present a 12 year experience by a single surgeon and single pathology lab at one VAMC on 157 patients (mean age 67) undergoing CRC resection. Furthermore, the use of chemotherapy for Stage II patients <12 LN retrieved is controversial and yields only a small survival benefit. Methods: The records of 157 patients from one surgeon's case log from 1994–2007 were reviewed. Strict guidelines were applied to remove the same distribution of pericolonic fat. The lab followed a two step approach to LN dissection: Step 1 search for grossly identifiable LN; Step 2 overnight Carnoy's immersion to find smaller LN. Statview and SAS software analyzed 1)Overall survival (OS) and association with finding >12LN; 2)Number of LN identified and impact on AJCC tumor stage (TS) and overall survival; 3)Number of LN and WHO tumor grade (TG) with OS; 4)The impact of number of positive LN on OS. Results: Our mean LN found (14.75) is higher than the 12 recommended by the NQF and is not significantly associated with OS regardless of AJCC TS(p=0.06). The mean LN per TS was I=13.4(N=41)/II=16.3(N=56)/ III=14.3(N=38)/IV 14.2(N=22). Number of LN identified was not statistically significant in predicting TS(p=0.42) or OS(p=0.24). WHO TG is significantly associated to decreased OS, but only in AJCC TS II/III/IV and not stage I (Ip>0.05/IIp=0.008/ IIIp=0.01/IVp=0.025). Higher number of positive LN was associated with lower OS (per each +LN, survival decreases by 0.15 months p=0.001) Conclusions: Contrary to multicenter studies, total number of LN identified does not impact AJCC TS or OS. Higher WHO TG and higher number of positive LN is associated with worse OS. This suggests that the tumor biology is more indicative of OS rather than host response (reactive lymphoid tissue) to the tumor. Stage II patients <12 LN may not be ‘high risk’ and adjuvant chemotherapy based on this factor alone should be reconsidered. Further studies would be warranted.

No significant financial relationships to disclose.

High levels of Lymphotoxin-Beta (LT-Beta) gene expression in rheumatoid arthritis synovium: clinical and cytokine correlations

Lymphotoxin-Beta (LT-Beta) is implicated in lymphoid follicle development, production of pro-inflammatory cytokines, and can enhance the proliferation of fibroblasts and synoviocytes. The objective of this study was to investigate LT-Beta and LT-BetaReceptor (LT-BetaR) gene expression in RA patient synovium and blood samples compared with control individuals, and correlate with LT-Alpha and TNF-Alpha gene expression and disease parameters. RT-PCR was used to investigate the gene expression of LT-Beta, LT-BetaR, TNF-Alpha and LT-Alpha in the blood and synovium of RA patients and a control group of individuals. LT-Beta gene expression was significantly higher in RA patient synovium compared to control synovium (P = 0.005). There was a significant positive correlation between LT-Beta and LT-Alpha gene expression in both the synovium (P = 0.001) and blood (P = 0.002) of RA patients. LT-Beta gene expression was significantly higher in RA patient synovial samples that were inflamed to a moderately severe degree compared to those inflamed to a minimal degree (P = 0.02). Analysis of clinical variables revealed a significant positive correlation between LT-BetaR gene expression in RA patient synovium and Pain VAS Score (P = 0.01) and also HAQ Score (P = 0.01). Increased LT-Beta gene expression occurs in RA synovium and correlates with the degree of inflammation. LT-Beta may play a role in RA disease pathogenesis by contributing to a more intense inflammatory reaction in the synovium.

A comparison of paediatric soccer, gaelic football and rugby injuries presenting to an emergency department in Ireland

OBJECTIVES

Children presenting with sport related injuries (SRIs) as a result of soccer, rugby and gaelic football are frequently seen in an emergency medicine (EM) setting in Ireland. A comparison of the demographics of injuries in these three sports has however not previously been performed. The purpose of this study was to provide up-to-date data on the nature of these SRIs.

METHOD

Data was collected retrospectively on all children (<17 years of age), injured in these three sports, presenting to an emergency medicine department over 6 months, and was entered into a database for analysis.

RESULTS

Retrospective analysis was performed on 23,000 charts, and 409 SRIs were identified over a 6-month period. None of the children reported using any form of protective gear, and 27% reported a previous presentation to the emergency department with a SRI. Most injuries were as a result of soccer (56%), with 24% occurring in gaelic football, and 20% occurring in rugby. The predominant mechanism of injury was different in each sport, in soccer-falls (38%), in gaelic football-collisions with objects (balls) (37%), and in rugby-collision with persons (55%). Although the predominant type of injury in soccer and gaelic football was a fracture, accounting for 50% and 42% of injuries, respectively, in rugby however, skin/soft tissue injuries presented more commonly, accounting for 44% of injuries. When the general site of injury was investigated, the upper limb accounted for the majority of SRIs in each sport. In the management of SRIs, oral analgesics were prescribed in 50%, however, it was observed that no use was made of topical, intramuscular or rectal analgesic routes of administration. In addition it was observed that RICE/general injury advice was given in only 27%, physiotherapy was requested in 2%, and no injury prevention advice was given to any child. Overall, 8% required admission.

CONCLUSIONS

The data provided from this study may raise awareness of the nature of SRIs affecting children in each of these three sports, and may be useful in formulating much needed injury prevention strategies.

The impact of a gluten-free diet on adults with coeliac disease: results of a national survey

OBJECTIVE We sought to evaluate the impact of the gluten-free diet on the 5,240 members of the Canadian Celiac Association (CCA). Data are presented on 2,681 adults (>or=16 years) with biopsy-proven celiac disease (CD).

METHODS

A mail-out survey was used. Quality of life was evaluated using the 'SF12', and celiac-specific questions.

RESULTS

Mean age was 56 years, mean age at diagnosis was 45 years, and 75% were female. The 'SF12' summary scores were similar to normative Canadian data, but were significantly lower for females and newly diagnosed patients. Respondents reported: following a gluten-free (GF) diet (90%), improvement on the diet (83%), and difficulties following the diet (44%), which included: determining if foods were GF (85%), finding GF foods in stores (83%), avoiding restaurants (79%), and avoiding travel (38%). Most common reactions to consumed gluten (among 73%) included pain, diarrhea, bloating, fatigue, nausea, and headache. Excellent information on CD and its treatment was provided by the CCA (64%), gastroenterologists (28%), dietitians (26%) and family doctor (12%).

CONCLUSIONS

Quality of life in those with CD could be increased with early diagnosis, increased availability of gluten-free foods, improved food labelling, and better dietary instruction. Education of physicians and dietitians about CD and its treatment is essential.

Dual energy X-ray absorptiometry analysis of peri-prosthetic stress shielding in the Birmingham resurfacing hip replacement

INTRODUCTION

Numerous reports in the literature refer to the femoral neck fracture rate in hip resurfacing. The aim of this study was to determine the bone mineral density and evidence of stress shielding around the femoral component of the Birmingham resurfacing prosthesis.

MATERIAL AND METHODS

Twenty-eight patients with primary unilateral osteoarthritis had a Birmingham resurfacing prosthesis. DEXA analysis of the proximal femur and femoral neck was performed and compared with the opposite unaffected side.

RESULTS

Total periprosthetic bone mineral density was 0.49% greater than the control, but this did not achieve statistical significance. Although the BMD of the femoral neck was slightly increased on the prosthetic side (1.002 g/cm2) as opposed to the control side, this difference did not reach statistical significance.

CONCLUSION

The Birmingham resurfacing prosthesis does not appear to reduce femoral neck bone mineral density in comparison to the normal femoral neck bone density. We conclude that femoral neck fractures are unlikely to be due to stress shielding related to the prosthesis.

The prevalence of coeliac disease among female subjects having bone densitometry

BACKGROUND

Osteoporosis frequently complicates coeliac disease but most studies focus on symptomatic patients at the time of diagnosis. Screening tests have revealed that many individuals with coeliac disease have mild, atypical, or absent symptoms.

AIM

To evaluate the relationship between coeliac disease and osteopenia or osteoporosis in female subjects attending for bone densitometry.

METHODS

We studied 371 female subjects attending for bone densitometry, without secondary causes of osteoporosis and included those with normal and with reduced bone mineral density. Mineral density was measured by dual energy X-ray absorptiometry. Screening for coeliac disease was by measurement of anti-endomysial antibody by indirect immunofluorescence.

RESULTS

Two of 115 (1.7%) female subjects with normal bone density and five of 256 (1.9%) female subjects with sub-normal bone density were positive for endomysial antibody. Five subjects who underwent small bowel biopsy had histological changes suggestive of coeliac disease.

CONCLUSIONS

In females referred for bone densitometry, endomysial antibody positivity was not more prevalent among those with reduced bone mineral density. Examining only patients with clinically detected coeliac disease may overestimate the frequency of complications. This study does not support population screening for coeliac disease in an area with a high frequency of the condition.

Capacitative calcium entry in guinea pig gallbladder smooth muscle in vitro

This study investigates the involvement of capacitative Ca2+ entry in excitation-contraction coupling in guinea pig gallbladder smooth muscle. Thapsigargin (0.1 nM-1 microM, a sarcoplasmic reticulum Ca(2+)-ATPase inhibitor) produced slowly developing sustained tonic contractions in guinea pig isolated gallbladder strips. All contractions approached 50% of the response to carbachol (10 microM) after 55 min. Contractile responses to thapsigargin (1 microM) were abolished in a Ca(2+)-free medium. Subsequent re-addition of Ca2+ (2.5 mM) produced a sustained tonic contraction (99 +/- 6% of the carbachol response). The contractile response to Ca2+ re-addition following incubation of tissues in a Ca(2+)-free bathing solution in the absence of thapsigargin was significantly less than in its presence (79 +/- 4 % vs 100 +/- 7 % of carbachol; p < 0.05). Contractile responses to Ca2+ re-addition following treatment with thapsigargin were attenuated by (a) the L-type voltage-operated Ca2+ channel antagonist, nifedipine (10 microM) and (b) the general inhibitor of Ca2+ entry channels including store-operated channels, SK&F96365 (50 microM and 100 microM). In separate experiments, responses to Ca2+ re-addition were essentially abolished by the tyrosine kinase inhibitor, genistein (100 microM). These results suggest that capacitative Ca2+ entry provides a source of activator Ca2+ for guinea pig gallbladder smooth muscle contraction. Contractile responses to Ca2+ re-addition following depletion of sarcoplasmic reticulum Ca2+ stores with thapsigargin, are mediated in part by Ca2+ entry through voltage-operated Ca2+ channels and by capacitative Ca2+ entry through store-operated Ca2+ channels which can be blocked by SK&F96365. Furthermore, capacitative Ca2+ entry in this tissue may be modulated by tyrosine kinase.

Pectoralis major tendon ruptures: when to operate

The treatment of pectoralis major tendon ruptures has been the subject of much debate. The classical history of the injury is forced abduction and external rotation. The cases of two patients (an amateur rugby union player and a recreational snowboarder) are reported. The diagnosis was made by clinical examination in both patients, and both were operated on more than two weeks after injury. After surgery and a graduated rehabilitation programme, both men were able to return to their sporting activities. These two cases highlight the advantage of operative management in this uncommon condition.

Brain effects of TMS delivered over prefrontal cortex in depressed adults: role of stimulation frequency and coil-cortex distance

Relative regional brain blood flow was measured in 23 clinically depressed adults by using ECD SPECT at baseline and again during actual prefrontal transcranial magnetic stimulation (TMS) following 5 daily sessions of TMS. TMS over prefrontal cortex caused increased activity in cortex directly under the stimulation (inversely correlated with distance from scalp to cortex) and decreased activity in remote regions (anterior cingulate and anterior temporal poles). High-frequency rTMS (20 Hz) caused more relative flow immediately below the TMS coil than did low-frequency rTMS (5 Hz). Confirming the hypotheses tested, repeated daily TMS over the prefrontal cortex in medication-free depressed adults appears to change both local and remote blood flow in a manner that may also depend on the frequency of stimulation and coil to outer cortex distance.

Use of inferior vena cava filters in thromboembolic disease two case reports with a literature review

Inferior Vena Cava (IVC) filters are used in cases of documented pulmonary embolism (PE) where anticoagulation is contraindicated or has failed. Increasingly, they are being used prophylactically in preoperative patients at high risk of embolism. This latter group includes patients with free-floating caval, iliac or femoral vein thrombi. Filters may be permanent (eg Greenfield), temporary (eg Antheor, Gunther) or retrievable (eg Gunther Tulip). This last type of filter is becoming increasingly popular. We present two recent cases in which retrievable filters were intentionally used, with good results. A recent literature review is included.

Pseudo-Kaposi's sarcoma: the association of arterio-venous malformations with skin lesions resembling Kaposi's sarcoma

A patient is described with skin lesions resembling Kaposi's sarcoma (KS). Arteriography revealed multiple arteriovenous malformations in the affected limb. This condition has been termed pseudo-Kaposi's sarcoma. Although reports of this condition have appeared in dermatological journals, as yet we are unaware of any account in the radiological literature. This paper presents a case and reviews the literature. In suspected cases of KS in which the history or clinical features are atypical, this unusual condition should be considered and a search made for the diagnostic vascular lesions.

Dantrolene reduces serum TNFalpha and corticosterone levels and muscle calcium, calpain gene expression, and protein breakdown in septic rats

The effects of dantrolene on serum TNFalpha and corticosterone levels and on muscle calcium, calpain gene expression, and protein breakdown were studied in rats with abdominal sepsis induced by cecal ligation and puncture. Treatment of rats with 10 mg/kg of dantrolene 2 h before and 8 h after induction of sepsis reduced serum TNFalpha and corticosterone, muscle calcium levels, mRNA levels for m- and mu-calpain, and the muscle specific calpain p94, as well as total and myofibrillar protein breakdown rates, determined as release of tyrosine and 3-methylhistidine, respectively, from incubated extensor digitorum longus muscles. The results support the concept that increased calcium concentrations may be an important mechanism of sepsis-induced muscle protein breakdown. The data also indicate that other mechanisms, in addition to reduced muscle calcium concentrations such as decreased levels of TNFalpha and glucocorticoids, may contribute to the anti-catabolic effects of dantrolene during sepsis. The observations are important from a clinical standpoint because they suggest that the catabolic response in skeletal muscle during sepsis may be prevented by treatment with a calcium antagonist.

Divalproex sodium augmentation of haloperidol in hospitalized patients with schizophrenia: clinical and economic implications

Divalproex sodium has been approved for use in treating bipolar disorder. Its usefulness in schizophrenia has yet to be adequately assessed. Three days after initiating haloperidol treatment, patients who were hospitalized for an acute exacerbation of schizophrenia received either valproate augmentation (early-augmentation group) or continued to receive haloperidol alone (no-augmentation group). Patients in the no-augmentation group who failed to respond 14 days after the dose of haloperidol reached 20 mg/day received valproate augmentation (delayed-augmentation group). By day 14, the early-augmentation group improved 32.4% more than the no-augmentation group. Fifty percent of the patients in the no-augmentation group failed to respond to haloperidol alone for 2 weeks. They improved by 29% upon the addition of valproate. Compared with those who received no or delayed augmentation, the early-augmentation group required 44.8% fewer inpatient days from the initiation of haloperidol treatment. Patient response to treatment was particularly noted in suspiciousness, hallucinations, unusual thought content, and emotional withdrawal. Early augmentation with valproate may reduce the length of inpatient stays and provide substantially better therapeutic outcomes. It is, however, premature to recommend changes in the standard clinical management of schizophrenia on the basis of the data provided herein, in view of the small sample and open-label nature of the report.

A double-blind placebo-controlled case study of the use of donepezil to improve cognition in a schizoaffective disorder patient: functional MRI correlates

Cognitive impairment in multiple domains is common in patients with schizophrenia and may be a powerful determinant of poor functional ability and quality of life. We report a double-blind, placebo-controlled, cross-over study of donepezil augmentation in a schizoaffective disorder patient stabilized on olanzapine pharmacotherapy. The patient showed significant improvements in several cognitive measures and increased activation of prefrontal cortex and basal ganglia on functional MRI during the donepezil augmentation. In addition, the donepezil augmentation resulted in a reduction of depressive symptoms and in significant improvements in functional abilities and quality of life. Further studies of donepezil augmentation of neuroleptics in schizophrenia are warranted.

A controlled trial of daily left prefrontal cortex TMS for treating depression

BACKGROUND

Transcranial magnetic stimulation (TMS) is a new technology for noninvasively stimulating the brain. Several studies have suggested that daily stimulation of the left prefrontal cortex with TMS for 2 weeks has probable antidepressant effects. We conducted a parallel-design, double-masked, sham-controlled study to address whether 2 weeks of daily TMS over the left prefrontal cortex has antidepressant activity greater than sham.

METHODS

Thirty medication-free adult outpatients with nonpsychotic, major depressive (n = 21) or bipolar (n = 9) (depressed phase) disorder who were in a current major depression (Hamilton Rating Scale for Depression [HRSD] 21-item score of >18) were treated each weekday for 2 weeks. Subjects were randomly assigned to receive either daily active (20 subjects) or sham (10 subjects) stimulation. Additionally, the 20 active subjects were equally divided between slower (5 Hz) and faster (20 Hz) frequency treatment. Antidepressant response was defined as greater than a 50% improvement in the baseline HRSD.

RESULTS

Active TMS resulted in significantly more responders (9/20) than did sham (0/10) (chi(2) = 6.42, p <.01). The number of responders did not differ significantly between the two active cells (3/10 faster and 6/10 slower). Expressed as a percent change from baseline, active TMS subjects had significantly greater improvement on the Beck Depression Inventory as well as the Hamilton Anxiety Rating Scale than did those who received sham.

CONCLUSIONS

Daily left prefrontal TMS for 2 weeks significantly reduced depression symptoms greater than did sham. The two forms of active TMS treatment did not differ significantly.

How coil-cortex distance relates to age, motor threshold, and antidepressant response to repetitive transcranial magnetic stimulation

Repetitive transcranial magnetic stimulation (rTMS) is a tool with antidepressant potential that uses a coil placed on the scalp to produce a powerful magnetic field that directly stimulates only the outermost cortex. MRI scans were obtained in 29 depressed adults involved in an rTMS antidepressant clinical treatment. These scans were analyzed to investigate the effect of distance from coil to cortex on clinical parameters. Longer motor cortex distance, but not prefrontal distance, strongly correlated with increased motor threshold (P<0.01). Clinical antidepressant response did not correlate with either distance. The rTMS antidepressant responders, however, were significantly younger (t=-2.430, P<0.05), and there appears to be a maximum threshold of age and distance to prefrontal cortex for response.

Suprarenal mycotic aneurysm exclusion using a stent with a partial autologous covering

PURPOSE

To report a combined endovascular and open technique to manage a suprarenal mycotic aortic aneurysm using a stent-graft partially covered with a section of autologous artery.

METHODS AND RESULTS

A 50-year-old was hospitalized for staphylococcal septicemia and severe back pain. A previously diagnosed 3-cm abdominal aortic aneurysm was found to have expanded 2 cm in 3 weeks. Aortography documented some periaortic thickening and 2 mycotic aneurysms, one posterior at the level of the superior mesenteric artery and the second at the aortic bifurcation. After intensive antibiotic therapy, an endovascular approach to exclude the suprarenal mycotic aneurysm was undertaken in tandem with surgical excision of the infrarenal aneurysm. The harvested right common iliac artery was used to partially cover a Palmaz stent, which was deployed under direct vision just above the renal artery ostia so that the covered portion of the stent excluded the aneurysm. A right axillofemoral bypass with a femorofemoral bypass completed the revascularization. Postoperatively, the patient developed renal failure, ischemic colitis necessitating a left hemicolectomy, and paraplegia. Although the patient is paralyzed, the aneurysm remains excluded with patent visceral vessels at 12 months following surgery. No organisms were grown from excised aortic tissue, and no signs of recurrent infection have been seen.

CONCLUSIONS

Stent-graft repair may be able to lessen the invasiveness and reduce the morbidity associated with treatment of mycotic aortic aneurysms.

Endovascular management of rare sciatic artery aneurysm

PURPOSE

To present a rare case of complete persistent sciatic artery aneurysm successfully treated by coil embolization and to suggest a new classification for this anomaly that encompasses both clinical and pathological factors.

METHODS AND RESULTS

A 77-year-old female presented with sudden onset of sharp, throbbing left thigh and foot pain. A nontender 10.0- x 7.0-cm pulsatile mass was found over the inferolateral aspect of the left buttock on examination in the right lateral decubitus position. Angiography demonstrated a 6.9-cm sciatic artery aneurysm with the distal sciatic artery completely thrombosed. Before planned bypass grafting, the aneurysm and distal segment of the internal iliac artery were successfully embolized with coils through a left percutaneous approach. The patient's symptoms resolved with no deterioration in limb perfusion, and further revascularization was unnecessary. Postembolization imaging showed complete occlusion of the aneurysm, which has continued for 19 months.

CONCLUSIONS

The application of endovascular techniques and surgical revascularization procedures provides numerous management options for the treatment of an aneurysmal persistent sciatic artery. This case demonstrates that clinical evaluation between staged procedures may obviate the need for further intervention.