P33 A female with a drooping eyelid and positive autoantibodies: mystery solved?

Case report - Introduction

The presence of autoantibodies in IgG4-related disease (IgG4-RD) can lead to confusion and we present a case to highlight the diagnostic difficulty in this condition.

Case report - Case description

A 63-year-old Indian female presented with progressive ptosis and swelling of the left eyelid for 2 months. She was referred to the stroke clinic where she was found to have left ptosis with associated swelling. An MRI of the orbit revealed an enlarged left lacrimal gland and mucosal thickening in paranasal sinuses. Her ESR was 20, CRP 2, 15% peripheral eosinophils and IgG 17.55 g/L (6-16). A referral was made to rheumatology due to an abnormal immunological profile: cANCA +, MPO ANCA positive 32 IU/ml (0-3.5) and a strongly positive anti-Ro antibody >600 U/ml (0-10). Differential diagnosis considered: ANCA associated vasculitis (AAV), Primary Sjögren’s syndrome (SS), and IgG4-related orbital disease. She was assessed by the ENT surgeon and there was no sinusitis or evidence of vasculitis. Chest X-ray and CT scan of chest were normal.

A left lacrimal gland biopsy revealed reactive lymphoid hyperplasia with numerous plasma cells and eosinophils. Immunohistochemistry revealed over 50% of plasma cells to be IgG4-positive (approximately 100/HPF) suggestive of IgG4-RD. There was no evidence of granuloma formation or malignancy. Serum IgG4 was raised 6.82 g/l (<1.3). A review by ophthalmology revealed no objective evidence of dry eyes. She was treated as IgG4-RD and demonstrated a marked improvement following treatment with oral steroids and azathioprine.

Case report - Discussion

IgG4-RD is an immune-mediated systemic fibro inflammatory disease characterised by tumefactive lesions with abundant IgG4-positive plasma cells infiltrating into multiple organs. Isolated IgG4-related ophthalmic disease is present in 23% of patients with IgG4-RD, in whom the lacrimal gland is the most commonly involved structure, followed by orbital fat and extraocular muscles. IgG4-related ophthalmic disease is rare and we need to exclude commoner causes of orbital inflammation (such as thyroid ophthalmopathy, granulomatosis with poly-angiitis, sarcoidosis, and tuberculosis) or malignancy.

Case report - Key learning points

The diagnosis of IgG4-RD is often challenging. It is well recognised that small vessel vasculitis can increase the number of IgG4-positive plasma cells in tissue biopsies. Additionally, literature reveals biopsy-proven IgG4-RD can have ANCA positivity with and without concomitant presence of ANCA-associated vasculitis and there are case reports of patients who fulfil criteria for both Sjogren’s syndrome and IgG4-RD. As such, diagnosis requires careful correlation of clinical, radiologic and histological features due to the overlapping features in differential diagnoses.

History of early life adversity is associated with increased food addiction and sex-specific alterations in reward network connectivity in obesity

BACKGROUND

Neuroimaging studies have identified obesity-related differences in the brain's resting state activity. An imbalance between homeostatic and reward aspects of ingestive behaviour may contribute to obesity and food addiction. The interactions between early life adversity (ELA), the reward network and food addiction were investigated to identify obesity and sex-related differences, which may drive obesity and food addiction.

METHODS

Functional resting state magnetic resonance imaging was acquired in 186 participants (high body mass index [BMI]: ≥25: 53 women and 54 men; normal BMI: 18.50-24.99: 49 women and 30 men). Participants completed questionnaires to assess ELA (Early Traumatic Inventory) and food addiction (Yale Food Addiction Scale). A tripartite network analysis based on graph theory was used to investigate the interaction between ELA, brain connectivity and food addiction. Interactions were determined by computing Spearman rank correlations, thresholded at q < 0.05 corrected for multiple comparisons.

RESULTS

Participants with high BMI demonstrate an association between ELA and food addiction, with reward regions playing a role in this interaction. Among women with high BMI, increased ELA was associated with increased centrality of reward and emotion regulation regions. Men with high BMI showed associations between ELA and food addiction with somatosensory regions playing a role in this interaction.

CONCLUSIONS

The findings suggest that ELA may alter brain networks, leading to increased vulnerability for food addiction and obesity later in life. These alterations are sex specific and involve brain regions influenced by dopaminergic or serotonergic signalling.

Transforming the Perioperative Treatment Paradigm in Non-Metastatic RCC-A Possible Path Forward

In 2017, there is no adjuvant systemic therapy proven to increase overall survival in non-metastatic renal cell carcinoma (RCC). The anti-PD-1 antibody nivolumab improves overall survival in metastatic treatment refractory RCC and is generally tolerable. Mouse solid tumor models have revealed a benefit with a short course of neoadjuvant PD-1 blockade compared to adjuvant therapy. Two ongoing phase 2 studies of perioperative nivolumab in RCC patients have shown preliminary feasibility and safety with no surgical delays or complications. The recently opened PROSPER RCC trial (A Phase 3 RandOmized Study Comparing PERioperative Nivolumab vs. Observation in Patients with Localized Renal Cell Carcinoma Undergoing Nephrectomy; EA8143) will examine if the addition of perioperative nivolumab to radical or partial nephrectomy can improve clinical outcomes in patients with high risk localized and locally advanced RCC. With the goal of increasing cure and recurrence-free survival (RFS) rates in non-metastatic RCC, we are executing a three-pronged, multidisciplinary approach of presurgical priming with nivolumab followed by resection and adjuvant PD-1 blockade. We plan to enroll 766 patients with clinical stage ≥T2 or node positive M0 RCC of any histology in this global, randomized, unblinded, phase 3 National Clinical Trials Network study. The investigational arm will receive two doses of nivolumab 240 mg IV prior to surgery followed by adjuvant nivolumab for 9 months. The control arm will undergo the current standard of care: surgical resection followed by observation. Patients are stratified by clinical T stage, node positivity, and histology. The trial is powered to detect a 14.4% absolute benefit in the primary endpoint of RFS from the ASSURE historical control of 55.8% to 70.2% at 5 years (HR = 0.70). The study is also powered to detect a significant overall survival benefit (HR 0.67). Key safety, feasibility, and quality of life endpoints are incorporated. PROSPER RCC exemplifies team science with a host of planned correlative work to investigate the impact of the baseline immune milieu and changes after neoadjuvant priming on clinical outcomes.

Effect of Yb doping on the refractive index and thermo-optic coefficient of YVO4 single crystals

Single crystals of YVO₄ with different doping concentrations of Yb (1.5, 3.0, 8.0, and 15.0 at. %) and with good crystalline quality (FWHM ∼43-55 arc sec of rocking curve) were grown by the optical floating zone technique. Refractive index measurements were carried out at four wavelengths as a function of temperature. The measurements show that as the doping concentration of Yb is increased, the refractive index varies marginally for n_e whereas there is a significant change in the value of n_o. The thermo-optic coefficient (dn/dT) was found to be positive with a value ∼10^-5/°C, which is 1 order higher than that for the undoped YVO₄ crystal. The thermo-optic coefficient is higher for n_e compared to that of n_o. Also, a set of relations describing the wavelength dependence of the thermo-optic coefficient were established that are useful for calculating the thermo-optic coefficient at any temperature in the range 30°C-150°C and at any wavelength in the range 532-1551 nm.

Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial

AIMS

The objective of this double-blind randomised controlled trial was to assess whether ultrasound guidance improved the efficacy of corticosteroid injections for Morton's neuroma (MN).

PATIENTS AND METHODS

In all, 50 feet (40 patients) were recruited for this study but five feet were excluded due to the patients declining further participation. The mean age of the remaining 36 patients (45 feet) was 57.8 years (standard deviation (sd) 12.9) with a female preponderance (33F:12M). All patients were followed-up for 12 months. Treatment was randomised to an ultrasound guided (Group A) or non-ultrasound guided (Group B) injection of 40 mg triamcinolone acetonide and 2 ml 1% lignocaine, following ultrasound confirmation of the diagnosis.

RESULTS

The mean visual analogue score for pain improved significantly in both groups (Group A - from 64 mm, sd 25 mm to 29 mm, sd 27; Group B - from 69 mm, sd 23 mm to 37 mm, sd 25) with no statistical difference between them at all time-points. The failure rate within 12 months of treatment was 11/23 (48%) and 12/22 (55%) in Groups A and B, respectively (p = 0.458). The improvement in Manchester Oxford Foot Questionnaire Index and patient satisfaction favoured Group A in the short-term (three months) that almost reached statistical significance (p = 0.059 and 0.066 respectively). However, this difference was not observed beyond three months.

CONCLUSION

This study has shown that ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with MN.

TAKE HOME MESSAGE

In the presence of a clear diagnosis of MN, a trained clinician who understands the forefoot anatomy may perform an injection without ultrasound guidance with good and safe results.

Crystal growth of Ru-doped congruent LiNbO3and investigation of crystalline perfection and optical properties

Single crystals of undoped and Ru-doped congruent LiNbO3(LN) were successfully grown by the Czochralski method. The axial and radial gradient of the radio frequency furnace was controlled in order to obtain crack-free single crystals. Wafers were cut from the grown Ru-doped single crystal at different axial positions along the growth direction and subjected to various characterization analyses. Good optical homogeneity and low residual strain in the grown crystal is confirmed by the conoscopy patterns. Further, it is confirmed that Ru doping does not influence the optical sign of the crystal. From a high-resolution X-ray diffractometry analysis, it is evident that the as-grown undoped LN crystal exhibited better crystalline perfection with a single and sharp diffraction curve in comparison to the Ru-doped crystals, which are characterized by a broader diffraction curve. Absorption coefficient and band-gap analysis across the axial length revealed a concentration variation of Ru across the length. Refractive index measurements carried out using a prism coupler showed variation in the optical birefringence, also due to the variation of Ru concentration at different positions of the grown single crystal.

Enhanced thermoelectric properties of selenium-deficient layered TiSe(2-x): a charge-density-wave material

In the present work, we report on the investigation of low-temperature (300-5 K) thermoelectric properties of hot-pressed TiSe2, a charge-density-wave (CDW) material. We demonstrate that, with increasing hot-pressing temperature, the density of TiSe2 increases and becomes nonstoichiometric owing to the loss of selenium. X-ray diffraction, scanning electron microscopy, and transimission electron microscopy results show that the material consists of a layered microstructure with several defects. Increasing the hot-press temperature in nonstoichiometric TiSe2 leads to a reduction of the resistivity and enhancement of the Seebeck coefficient in concomitent with suppression of CDW. Samples hot-pressed at 850 °C exhibited a minimum thermal conductivity (κ) of 1.5 W/m·K at 300 K that, in turn, resulted in a figure-of-merit (ZT) value of 0.14. This value is higher by 6 orders of magnitude compared to 1.49 × 10(-7) obtained for cold-pressed samples annealed at 850 °C. The enhancement of ZT in hot-pressed samples is attributed to (i) a reduced thermal conductivity owing to enhanced phonon scattering and (ii) improved power factor (α(2)σ).

Thermoelectric performance of layered SrxTiSe2 above 300 K

In this paper we report the thermoelectric performance of Sr intercalated TiSe(2) above 300 K. Refined x-ray diffraction, high resolution transmission electron microscopy and scanning electron microscopy images show well oriented polycrystalline grains along a (0 0 l) direction and layered growth of the sample. Intercalation of Sr in TiSe(2) shows an improved Seebeck coefficient (α) value without altering the polarity of the majority charge carrier. A drastic reduction in the thermal conductivity (κ) from 3.8 W m K(-1) to 1.2 W m K(-1) (at 650 K) was observed which is ascribed to the: (i) scattering of the phonon by natural layer interfaces, grain boundaries and lattice defects and (ii) rattling of intercalated Sr atoms among weakly bound TiSe(2) layers. This led to the maximum ZT of ~0.08 at 650 K for Sr(x)TiSe(2) (x > 0.1) which is almost twice as high as the parent TiSe(2).

Effect of Mg doping on the growth aspects, crystalline perfection, and optical and thermal properties of congruent LiNbO3single crystals

Mg-doped congruent lithium niobate single crystals were grown by the Czochralski technique. High-quality single crystals were grown using a novel seeding technique in a resistive heating furnace. Analysis of crystalline perfection carried out by a multi-crystal X-ray diffractometer revealed that the grown crystals do not contain any structural grain boundaries but do contain point defects. The transmission characteristics showed an enhancement of band gap with an increase in Mg concentration. Conoscopy patterns revealed that the grown crystals are homogeneous and the incorporation of Mg into the lattice does not affect the optical sign (negative uniaxial) of the crystal. The refractive index measurements carried out using a prism coupler showed an increase in the optical birefringence (Δn), while the refractive index was found to decrease with the increase in doping concentration. Further, thermal conductivity was found to decrease with Mg incorporation in the lattice owing to phonon scattering from the Mg ions and, as a consequence, at high concentrations (>4 mol%) crack formation occurred. However, optimization of growth conditions reveals that a slower pulling rate leads to crack-free lithium niobate crystals even at 6 mol% Mg doping.

Structural, optical and thermal properties of Zr–Fe co-doped congruent LiNbO3single crystals

Zr–Fe-doped congruent lithium niobate single crystals were grown by the Czochralski technique. The crystal structure and lattice parameter of the grown crystals were assessed by powder X-ray diffraction and the strain developed as a result of doping has been calculated (−1.19 × 10−3) by using the Williamson–Hall relation. The incorporated dopant concentration along with the dopant distribution in the specimen crystal was estimated by X-ray florescence spectrometry. A multi-crystal X-ray diffraction analysis was carried out to identify the crystalline perfection of the sample and revealed that the investigated crystal does not contain any structural grain boundaries but does contain point defects and micrometre size mosaic blocks. Birefringence measurements were carried out using a prism coupler spectrometer and found that the optical birefringence is 0.0822 for 532 nm and 0.705 for 1064 nm. A thermal conductivity (κ) study reveals that the doped sample has a lower κ value than the undoped equivalent.

Temperature-dependent index of refraction of monoclinic Ga2O3 single crystal

We present temperature-dependent refractive index along crystallographic b[010] and a direction perpendicular to (100)-plane for monoclinic phase (β) Ga(2)O(3) single crystal grown by the optical floating zone technique. The experimental results are consistent with the theoretical result of Litimein et al.1. Also, the Sellmeier equation for wavelengths in the range of 0.4-1.55 μm is formulated at different temperatures in the range of 30-175 °C. The thermal coefficient of refractive index in the above specified range is ~10(-5)/°C.

Swift heavy ions for controlled modification of soft magnetic properties of Fe₀.₈₅N₀.₁₅ thin film

It is shown that the soft magnetic properties of amorphous Fe₀.₈₅N₀.₁₅ film can be modified in a controlled manner by irradiation with 120 MeV Ag ions. Irradiation causes relaxation of short range as well as long range stresses, resulting in an improvement in the soft magnetic properties. Nuclear resonance reflectivity has been used to measure the diffusion length of Fe atoms as a function of irradiation fluence. It is found that the atomic motion associated with irradiation is not expected to modify significantly the interfaces with substrate or other layers.

The pathology of breast cancer in Jamaica: the National Public Health Laboratory study

OBJECTIVE

To document the pathologic features of breast cancer in Jamaica.

METHODS

The pathology reports and slides of all patients diagnosed with breast cancer at the National Public Health Laboratory between January 1999 and December 2002 were reviewed. Patient age and gender side involved, number of tumours identified, tumour size, histologic type, histologic grade, degree of lymph node involvement and parish of origin of the specimens were documented.

RESULTS

There were 772 patients, 762 females and 10 males; age range 21 to 96 (mean 57.9 +/- 15.9) years. There were 778 specimens (6 bilateral cases), the majority of whom originated from Kingston and St Andrew (34.7%). Manchester (22.9%), St Catherine (13.9%) and St Ann (7.3%) were the next most common sources. The left breast was involved in 50.5% of cases. Gross tumour was identified in 641 (82.4%) specimens, the number of tumours ranging from 1 - 6 (mean 1.1 +/- 0.6). The maximum gross tumour dimension ranged from 0.3 to 15 cm (mean 4.1 +/- 2.7 cm). Infiltrating duct carcinoma was the predominant histologic type (69.3 %); 13.3%, 49.5% and 37.2 % of all infiltrating tumours were well, moderately and poorly differentiated respectively. In-situ lesions (7.1% of tumours) were all of the ductal phenotype. Axillary lymph nodes were submitted in 296 (38.1%) cases; metastatic disease was identified in 224 (75.7%) of these. The total number of nodes submitted ranged from 1 - 34 (mean 10.8 +/- 6.7) with an average of 6.1 (+/- 5.8) being positive for metastases (range 1 - 29).

CONCLUSIONS

The pathologic features of breast cancer documented in this series including average tumour size, histologic types and grade and the degree of lymph node involvement are consistent with patient presentation at relatively advanced stages of disease and highlight the urgent need for public health intervention including a national screening programme.

Underdiagnosis of vertebral collapse on routine multidetector computed tomography scan of the abdomen

BACKGROUND

Vertebral fractures are commonly associated with osteoporosis and have significant morbidity and mortality rates. Osteoporotic vertebral fractures are presently considered as a treatable and preventable condition, and early detection is vital for further management. The evaluation of vertebral compression on multidetector computed tomography (MDCT) scans of the abdomen has, to our knowledge, not been reported before.

PURPOSE

To assess the prevalence of vertebral collapse on routine abdominal CT scans, and to evaluate the usefulness of the multiplanar reconstruction (MPR) capability of MDCT scans in accurately identifying vertebral abnormalities such as vertebral collapse, spondylolisthesis, and retrolisthesis.

MATERIAL AND METHODS

A retrospective review of 307 MDCT scans of the abdomen was carried out at a university teaching hospital. Identifiable patient information was anonymized for data protection. All images were reviewed on a picture archiving and communications system (PACS) using sagittal MPR and bone window for the assessment of the vertebrae. Data were collected from the Computerized Radiology Information System (CRIS).

RESULTS

Vertebral collapse was seen in 42 (13.6%) of the 307 patients undergoing routine MDCT of the abdomen. Multilevel and single-level collapses were seen in 24 and 18 patients, respectively. Spondylolisthesis was identified in 5.5% (n = 17), and retrolisthesis was seen in 0.6% (n = 2). All patients with vertebral fracture were older than 50 years. Women were more commonly affected than men.

CONCLUSION

A significant number of patients with vertebral collapse were diagnosed using MPR on MDCT routine scans of the abdomen.

The role of ultrasound in the management of flexor tendon injuries

The use of ultrasound scanning to establish tendon pathologies was assessed retrospectively in 17 patients in 18 digits. The ultrasound scan demonstrated four patterns: (1) normal intact tendons in four, (2) ruptured tendons in three, (3) tendons in continuity but attenuated in five and (4) tendons in continuity but thickened with fibrosis and decreased movement representing adhesions in five patients. Surgery was undertaken in only three cases, confirming the ultrasound diagnosis in two. Surgery was offered to all three patients with ruptures but was declined by two. Ultrasound imaging helped to avoid surgery in 14 cases by excluding flexor tendon re-ruptures. This allowed on-going mobilisation, leading to recovery of function.

Abscessed porous polyethylene (Medpor) orbital implant: a case report

We report the evolution of clinical features of orbital implant infection in a 42-year-old man. Despite appropriate treatment recurrent conjunctival dehiscence could not be prevented. Explanation of the implant resulted in complete resolution of symptoms. Histopathological examination confirmed focal necrotising acute inflammation with the presence of colonies of the organism in the deep substance of the implant.

3-D irradiated lung and heart volume predictions from 2-D datasets: Value of CT-based treatment planning in postmastectomy tangential beam radiation therapy

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Background: Lung and heart complications in breast cancer treatment are directly related to the irradiated volumes, technique, total radiation dose and type of chemotherapy. 3D dose calcuations allow computation of the DVH’s & a realistic NTCP associated with breast cancer RT. 1) Study aims to evaluate the impact of the 2-D radiographic parameters on the volumetric dose of the lung and heart, for patients undergoing postmastectomy,postchemo radiation therapy. (2)To deduce the analytical equations for the quick estimation of the irradiated volume based on the distances obtained from the digitally reconstructed radiographs. Methods: Between August 2002–2006, 162 postmastectomy patients underwent 5wk course of tangential CW irradiation ± Axillary / SCL radiation to a total dose of 50gy/25#. After adequate immobilization on the CT compatable breast board, CT scans with 1cm slice intervalsof the chest were performed, covering lung apex to lung base. The ipsilateral total lung area and the lung area included within the treatment port were countered on each CT slice.It is multiplied by slice thickness, and then integrated in all CT slices to give volumes.Parameters used to deduce irradited lung volume (n=104) studied from the DRR included Central lung distance-CLD, Maximum perpendicular distance-MPD, Length of the lung-L & Parameters related to heart are measured only in left breast irradiation (n=58) included: Maximum heart distance-MHD, Maximum heart length MHL.Linear regression analysis is applied to test relationship between the percentage of ipsilateral lung volume involved and the CLD / MPD / L and similarly between MHD / MHL and the cardiac volume in irradiation. Results: Predicted irradiated volume for: Right Lung = 4.0118+6.6474(CLD) OR -5.965 + 6.827(MLD) Left Lung = 6.6395(CLD) OR 5.431(MLD) Heart = 7.325(MHD) OR 6.742(CLD) Conclusions: The conclusion of the present study, to the best of our knowledge, is the largest series reported so far in the literature. CLD and MLD deduced from the DRR, are the direct measures of the lung volumes irradiated in tangential breast irradiation ( r2=0.91 & 0.79).While MHD and CLD appear to be direct measure of the irraidiated heart volume (r2=0.98 & 0.91).

No significant financial relationships to disclose.

Evidence-based practice in acute ophthalmology

AIM

To study the overall level of evidence-based practice in an accident and emergency eye unit in the UK and evaluate the extent of evidence-based practice by ophthalmologists and nurse practitioners (NPs).

METHODS

The case notes of all new patients attending our accident and emergency department for a period of 1 week were reviewed prospectively. For each case, the diagnosis at presentation and its intervention was ascertained. A literature search using Medline and Cochrane library was performed to assess the level of evidence provided for each diagnosis-intervention pair. Each diagnosis-intervention pair was evaluated and graded to assess the best level of evidence provided.

RESULTS

A total of 474 new patients attended the eye casualty during the study period. No diagnosis was made in 27 cases and they were excluded from the analysis. Out of 447 patients, 308 (68.9%) cases were managed by NPs and 139 (31.1%) by doctors. A total of 294 (65.8%) patient interventions were based on evidence from systematic reviews, meta-analysis and randomised-controlled trials, of which 223 were managed by NPs and 71 by ophthalmologists. This difference was statistically significant with P<0.001. One hundred and seven (23.9%) interventions were supported by evidence from prospective and retrospective trials.

CONCLUSION

This study demonstrated that two-thirds of interventions were based on the highest level of evidence and was comparable to studies performed in other specialities. It also highlights the advanced role of trained NPs in acute ophthalmology.

An uncommon cause of back pain in pregnancy

Back pain is a major cause of disability worldwide. A case of a 29 year old Caucasian woman with low back pain secondary to an uncommon benign condition called osteitis condensans ilii is presented and the literature is reviewed. Limited information in the literature combined with poor awareness across the specialty and among the primary care physicians leads to an extensive investigation and misdiagnosis of this benign condition. This report emphasis the salient features and the differential diagnosis in diagnosing and managing this rare condition.

Amygdaloid kindled seizures induce weight gain that reflects left hemisphere dominance in rats

The present study sought to determine the effects of kindled seizures generated from the left and right amygdala upon weight gain in rat. Seventy-five female Sprague-Dawley rats were implanted with electrodes in basal amygdala of the left and right hemispheres. A kindling paradigm was employed in which electrical stimulation was applied once per day for 30 days after Stage 5 seizures. An electrode was implanted into the basal amygdala of the control rats but no stimulation was applied. All rats were weighed daily during the course of the experiment and changes in weight during this period were recorded for all rats. The results demonstrated that kindling from either the left or right amygdala induced significant increases in weight gain relative to the control rats. However, kindling from the left basal amygdala induced increases in body weight that were four times greater than control rats and two times greater than the rats kindled from the right side of the basal amygdala. Likewise, serum leptin levels, which were highly correlated with weight gain, also showed significantly greater increases in left amygdaloid kindled rats relative to rats kindled from the right amygdala and control rats. These findings demonstrate that basal amygdaloid kindling induces significant increases in weight gain and that the magnitude of these effects is linked to the dominance of the left hemisphere.

Perceptions of Indian women regarding menstruation

Although menstruation is still considered a natural event by women in India, perceptions about menstruation are changing. We report on our study of 1150 urban and 850 rural women. The urban women included high school and college students, professional women, and housewives. A 10-point questionnaire was pretested in a clinic setting and then administered to the study group. The responses show that 80% of high school and college students and professional women wish to have infrequent menses or no menses at all. In contrast, 70% of rural women prefer to have monthly menses. The authors wish to initiate a debate on this issue among health care providers and women's groups.

Developmental shifts in cortical loci for face and object recognition

Information on normal functional organization and development of the ventral processing stream in 5- to 11-year-old children is minimal. The present fMRI study identified neural correlates for face and object processing in children aged 5-8 and 9-11 years, with data from a similar adult study used for comparison. All age groups showed face-preferential activation in the ventral processing stream, but adults and children aged 9-11 years showed face-preferential loci near the classically defined fusiform face area, whereas children aged 5-8 years showed this activation in the posterior ventral processing stream. In addition, the degree of category-selectivity in other brain regions increased with age. Collectively, these developmental changes may reflect fine-tuning in visual recognition processes based on learning and experience.

Prospective survey of adverse reactions to topical antiglaucoma medications in a hospital population

AIM

To identify the relative incidence and profile of adverse drug reaction (ADR) to various topical ocular hypotensives in a hospital setting.

METHODS

All the patients presenting in outpatients clinic and accident and emergency with an ADR to topical hypotensive agent from August 2000 to January 2001 were included in the study. Details regarding the type date of commencing the treatment, the date of developing ADR, time to resolution of the ADR were noted.

RESULTS

Over the period of 6 months, 66 patients presented with 73 ADRs. Brimonidine was the most frequent offending agent. In total, 23 (34.8%) presented with ADR after being commenced on treatment for more than 12 months. In all, 16 (24%) patients had IOP > 21 on presentation, eight (12%) patients underwent filtration surgery following the development of ADR.

CONCLUSION

Adverse drug reaction to ocular hypotensive agents is not uncommon and can have a major impact on glaucoma management. Delayed presentation and association with raised intraocular pressure presentation emphasise the need for effective patient education to encourage prompt reporting of ADR.

Use of inhaled nitrous oxide for minor eyelid surgery: a placebo-controlled study

BACKGROUND

Pain from local anaesthetic injection for minor eyelid surgery can often be severe enough to be the most unpleasant part of the procedure. This study was aimed at assessing the efficacy of 50 : 50 N(2)O/O( 2) (Entonox) in relieving such pain.

METHODS

In this randomised placebo-controlled double blind trial, 100 patients were randomised to receive either Entonox or air. Questions regarding pain during the administration of local anaesthetic, discomfort during the procedure and side effects experienced were asked by an investigator who was blinded to the type of gas inhaled.

RESULTS

The difference in pain score between the Entonox and control groups was not statistically significant (p = 0.474). The difference in discomfort score between the two groups was also not statistically significant (p = 0.948). More side effects were noted with Entonox than with air (p = 0.003, statistically significant). However, this was not clinically significant.

CONCLUSION

Entonox has been used effectively in different specialties for pain relief. However, our study was unable to show this beneficial effect in relieving pain from local anaesthetic injections for minor eyelid surgery.

An audit of hip radiographs performed for general practitioners

AIM

We carried out a prospective study of the GP referrals for hip radiographs to find out the proportion of radiographs falling within the RCR guidelines and to ascertain the reasons for not following the guidelines.

MATERIALS AND METHODS

One thousand two hundred and fifty six consecutive hip radiographs were performed for GPs over a 12-month period. Questionnaires were sent to GPs for 873 referrals during an audit period of 18 months Four hundred and fifty three questionnaires were returned with adequate information. The proportion of change in management between the patients falling within the guidelines and those outside the guidelines was compared using Fisher's Exact Test (SPSS Package Version 9) and the corresponding 95% confidence interval (CI) was calculated.

RESULTS

Only 194 (43%) of the 453 referrals were within RCR guidelines and 259 (57%) were outside guidelines. In the group where RCR guidelines were followed, 60% were normal, 34% had degenerative changes and 6% other diagnoses. The radiological reports changed management in 44%. In the group where guidelines were not followed 76% were normal, 18% had degenerative changes and 6% other diagnoses. The radiological reports changed management in 37%. There was no evidence of difference in the change in management between these two groups. Twenty per cent of the radiographs showed abnormalities other than hip changes. Of these, only 17% were abnormalities other than degenerative changes and considered significant.

CONCLUSIONS

This audit does not reveal why the majority of the requests fell outside guidelines. This may be due to lack of awareness amongst GPs about guidelines, patient pressure, medico-legal problems and the need for reassurance. However, the audit does not show any evidence that following guidelines would increase efficiency of referral.

Water-soluble poly-(L-glutamic acid)-Gly-camptothecin conjugates enhance camptothecin stability and efficacy in vivo

The therapeutic efficacy of 20(s)-camptothecin (CPT) is limited in humans by the instability of the active lactone form due to preferential binding of the carboxylate to serum albumin and by difficulty in formulation. Formation of an ester bond with an amino acid via the hydroxyl group at carbon 20 of CPT stabilizes the lactone. Linking CPT to a high molecular weight (MW) anionic polymer enhances solubility and improves distribution to the tumor through enhanced permeability and retention (EPR effect). Poly-(L-glutamic acid) (PG) is an anionic homo-polymer that can theoretically bind one molecule of a drug via the gamma carboxylic acid of each monomeric subunit. It has been used to make a water-soluble PG-paclitaxel conjugate currently in Phase II clinical trials that contains 37% paclitaxel by weight and is administered in a 10 min infusion without pre-medication. We evaluated the anti-tumor activity of PG conjugates of CPT after a single intraperitoneal injection using subcutaneous murine B-16 melanoma tumor growth as an indicator. Interposition of a glycine (gly) linker allowed CPT loading up to 50% w/w on the polymer. Increasing the PG MW from 33 to 49 kDa enhanced the efficacy without altering the maximum tolerated dose (MTD). In athymic mice bearing ectopic human colon or lung tumors, efficacy was enhanced compared to free camptothecin. Thus, as with paclitaxel, conjugation of CPT to PG enhanced pharmaceutical properties and preclinical efficacy.

Involvement of adrenal and thyroid activity in the annual testicular regression of red headed bunting (Emberiza bruniceps)

Thyroid and adrenal activities are closely associated with reproductive cycle and any alteration in these endocrine functions may cause changes in the pituitary-gonadal axis. To understand this interrelationship during testicular senstive phase (month of April) male birds were injected with metapyrone(corticosterone synthesis blocks 1 microg/bird/day & 10 microg/bird/day) and newmercazol (thyroxine synthesis blocks 10 microg/bird/day) over a period of 12 weeks. During late breeding phase (month of August) two sets of birds having large gonad (photosensitive) and regressed gonad (photorefractory) were injected with metapyrone (10 microg/bird/alternate day). Results indicate that decreased activity of both adrenal and thyroid, extended the breeding phase but rate of regression decreased only in the case of bird receiving higher level of metapyrone.However,in the second group rate of gonadal regression was slow only in those bird where treatment was started during photosensitive phase. It may be suggested that optimum level of activity of adrenal and thyroid function are essential for termination of reproduction and any alteration in these function may alter seasonal pattern of neuroendocrine gonadal axis.

Conjugation of camptothecins to poly-(L-glutamic acid)

Conjugation of water-insoluble cancer chemotherapeutic drugs to macromolecular polymers can lead to improved pharmaceutical properties and improved therapeutic ratios due to accumulation of the polymer-drug conjugate in tumor tissue through the enhanced permeability and retention (EPR) to macromolecules associated with tumor vasculature. Pharmaceutical shortcomings of certain active camptothecins including difficulty in formulation and instability of the active lactone form due to interactions with human albumin might be improved by conjugation to polymers. In this report, conjugations of camptothecin (CPT), 10-hydroxy-CPT, and 9-amino-CPT to poly-(L-glutamic acid) (PG) are described; coupling was accomplished either through the 20(S)-hydroxyl or 9 and 10 substituents with and without the use of a glycine linker. Studies using a PG paclitaxel conjugate (PG-TXL), which is currently in Phase I testing, demonstrated that PG enhanced aqueous solubility, prolonged plasma residence time, and greatly increased the distribution of paclitaxel to tumor tissue in a murine model. In this report, we describe the use of similar conjugation technology for CPT derivatives and demonstrate that these difficult to formulate compounds can be rendered water soluble, that their maximum tolerated doses are increased, and that they retain substantial anti-tumor activity in syngeneic and xenogeneic tumor models. Preliminary data suggest that PG with molecular weights between 37 and 50 kDa with CPT loading between 14% and 37% with or without glycine linkers display enhanced efficacy compared with nonconjugated camptothecins administered at their maximum tolerated dose.

Correlation of bone scintigraphy and histological findings in medial tibial syndrome

OBJECTIVE

To correlate bone scintigraphy and histopathological findings in patients with medial tibial syndrome.

METHODS

Twenty patients (32 limbs) with a clinical diagnosis of medial tibial syndrome had surgery. Bone scintigraphy before the operation was compared with the histological appearance of bone and periosteal specimens obtained at surgery.

RESULTS

Delayed bone scintigraphy showed normal appearance in 11 limbs, characteristic diffuse tubular pattern uptake in 16 limbs, and focal uptake in five. Periosteal histology disclosed fibrous thickening as the most common finding associated with increased vascularity, occasionally with chronic inflammatory cell infiltration, haemosiderin, and acid mucopolysaccharide deposition. Loss of osteocytes was the main finding of bone histology associated with some enlargement of lacunae and lamellar structure disruption. A grading system was used to score normal and abnormal histological appearance. For analysis the findings were regrouped to provide tables using Fisher's exact test. There was no correlation between bone scintigraphy and the histology of bone and periosteum, but two interesting observations were noted. Those cases with periosteal thickening had mostly normal bone scan appearance (p = 0.0028). Those cases with low levels of osteocyte loss had mostly abnormal bone scintigraphy.

CONCLUSION

Abnormal histological appearance of bone and periosteum is a feature of medial tibial syndrome. These histological findings show poor correlation with bone scintigraphy. The exact pathogenesis of this syndrome remains unclear.

Graded compression stockings in elective orthopaedic surgery

We recruited 89 patients who had hip or knee replacements to assess the performance of below-knee graded compression stockings. The pressure gradients generated by the stockings were measured and all patients had venography of the ipsilateral leg.

We found that 98% of stockings failed to produce the ‘ideal’ pressure gradient (± 20%) of 18, 14 and 8 mmHg from the ankle to the knee, while 54% produced a ‘reversed gradient’ on at least one occasion during the course of the study. The overall rate of deep-venous thrombosis was 16.7%. Stockings which produced reversed gradients were associated with a significantly higher incidence of deep-venous thrombosis (p = 0.026) than those with the correct gradient (25.6% v 6.1%). This suggests that the performance of graded compression stockings can be improved if reversed pressure gradients are detected and prevented.

Graded compression stockings in elective orthopaedic surgery. An assessment of the in vivo performance of commercially available stockings in patients having hip and knee arthroplasty

We recruited 89 patients who had hip or knee replacements to assess the performance of below-knee graded compression stockings. The pressure gradients generated by the stockings were measured and all patients had venography of the ipsilateral leg. We found that 98% of stockings failed to produce the 'ideal' pressure gradient (+/- 20%) of 18, 14 and 8 mmHg from the ankle to the knee, while 54% produced a 'reversed gradient' on at least one occasion during the course of the study. The overall rate of deep-venous thrombosis was 16.7%. Stockings which produced reversed gradients were associated with a significantly higher incidence of deep-venous thrombosis (p = 0.026) than those with the correct gradient (25.6% v 6.1%). This suggests that the performance of graded compression stockings can be improved if reversed pressure gradients are detected and prevented.