Improved adherence to hip fracture standards reduces mortality after hip fractures

BACKGROUND

Hip fractures are increasing in incidence due to increasing life expectancy. Mortality continues to improve but it is important to explore which factors are responsible for driving improvements.

METHODS

A cohort of hip fracture patients predating SARS-CoV-2 was examined to determine the predictors of adherence to the six Irish Hip Fracture Standards (IHFS) and the impact of adherence on short (30 day) and long term (1 year) mortality. Our primary aim was assess the impact of a single HFS and cumulative number of HFS on mortality after hip fracture. Our secondary aim was to determine the impact of the HFS which are intrinsically linked to specialist Geriatric care.

RESULTS

Across 962 patients, over 5 years, the factors which were associated with adherence to HFS were female gender, increasing ASA grade and being nursed on an orthopaedic ward. Patients with increasing ASA were more likely to have met HFS 4-6 (Geriatrician review HFS4, bone health HFS5 & specialist falls assessment HFS6), less likely to have surgery within 48 h are more likely to develop a pressure ulcer. If the patient was not nursed on an orthopaedic ward all HFS were less likely to be met. At 30 days HFS 4-6 were associated with a statistically significant odds ratio (OR) of being alive, while at one year HFS 1 (admitted to an orthopaedic ward within 4 h), 5 and 6 were associated with a statistically significant OR of being alive. As increasing numbers of hip fracture standards were met patients were more likely to be alive at 30 days and one year.

CONCLUSION

This study has identified that improved adherence to hip fracture standards are associated with improved mortality at 30 days and one year.

Do Misconceptions About Health-Related Quality of Life Affect General Population Valuations of Health States?

OBJECTIVES

Healthcare resource allocation decisions are often informed by the expected gains in patients' quality-adjusted life-years. Misconceptions about ill-health's consequences for quality of life (QOL) may however affect evaluations of health states by the general population and hence affect resource allocation decisions informed by quality-adjusted life-years. We examine whether people selectively misestimate the QOL consequences of moderate anxiety or depression compared with other dimensions of health, and we test whether informing people of actual changes in QOL associated with health states changes appraisals of their relative undesirability.

METHODS

UK general population participants (N = 1259; in 2017) expressed preferences over moderate problems: anxiety or depression, self-care, and pain or discomfort. A randomized control trial design was used whereby a control group was given a functional description of each health state, and 2 intervention groups were additionally given information on the actual differences in either life satisfaction (LS) or day affect (DA) associated with experiencing each health state.

RESULTS

The LS (DA) group reported a higher preference for avoiding living with moderate anxiety or depression, being 13.4% (13.9%) more likely to choose it as most undesirable.

CONCLUSION

Informing people of the change in LS or DA associated with health states before they appraise them is a feasible way to obtain informed preferences.

Depressive Symptoms and Risk of Acute Stroke: INTERSTROKE Case-Control Study

BACKGROUND AND OBJECTIVES

Depression has been reported to be a risk factor of acute stroke, based largely on studies in high-income countries. In the INTERSTROKE study, we explored the contribution of depressive symptoms to acute stroke risk and 1-month outcome across regions of the world, within subpopulations and by stroke type.

METHODS

The INTERSTROKE is an international case-control study of risk factors of first acute stroke, conducted in 32 countries. Cases were patients with CT- or MRI-confirmed incident acute hospitalized stroke, and controls were matched for age, sex, and within sites. Standardized questions asked about self-reported depressive symptoms during the previous 12 months and the use of prescribed antidepressant medications were recorded. Multivariable conditional logistic regression was used to determine the association of prestroke depressive symptoms with acute stroke risk. Adjusted ordinal logistic regression was used to explore the association of prestroke depressive symptoms with poststroke functional outcome, measured with the modified Rankin scale at 1 month after stroke.

RESULTS

Of 26,877 participants, 40.4% were women, and the mean age was 61.7 ± 13.4 years. The prevalence of depressive symptoms within the last 12 months was higher in cases compared with that in controls (18.3% vs 14.1%, p < 0.001) and differed by region (p interaction <0.001), with lowest prevalence in China (6.9% in controls) and highest in South America (32.2% of controls). In multivariable analyses, prestroke depressive symptoms were associated with greater odds of acute stroke (odds ratio [OR] 1.46, 95% CI 1.34-1.58), which was significant for both intracerebral hemorrhage (OR 1.56, 95% CI 1.28-1.91) and ischemic stroke (OR 1.44, 95% CI 1.31-1.58). A larger magnitude of association with stroke was seen in patients with a greater burden of depressive symptoms. While preadmission depressive symptoms were not associated with a greater odds of worse baseline stroke severity (OR 1.02, 95% CI 0.94-1.10), they were associated with a greater odds of poor functional outcome at 1 month after acute stroke (OR 1.09, 95% CI 1.01-1.19).

DISCUSSION

In this global study, we recorded that depressive symptoms are an important risk factor of acute stroke, including both ischemic and hemorrhagic stroke. Preadmission depressive symptoms were associated with poorer functional outcome, but not baseline stroke severity, suggesting an adverse role of depressive symptoms in poststroke recovery.

Effect of a Run-In Period on Estimated Treatment Effects in Cardiovascular Randomized Clinical Trials: A Meta-Analytic Review

Background A run-in period may increase adherence to intervention and reduce loss to follow-up. Whether use of a run-in period affects the magnitude of treatment effects is unknown. Methods and Results We conducted a meta-analysis comparing treatment effects from 11 systematic reviews of cardiovascular prevention trials using a run-in period with matched trials not using a run-in period. We matched run-in with non-run-in trials by population, intervention, control, and outcome. We calculated a ratio of relative risks (RRRs) using a random-effects meta-analysis. Our primary outcome was a composite of cardiovascular events, and the primary analysis was a matched comparison of clinical trials using a run-in period versus without a run-in period. We identified 66 run-in trials and 111 non-run-in trials (n=668 901). On meta-analysis there was no statistically significant difference in the magnitude of treatment effect between run-in trials (relative risk [RR], 0.83 [95% CI, 0.80-0.87]) compared with non-run-in trials (RR, 0.88 [95% CI, 0.84-0.91]; RRR, 0.95 [95% CI, 0.90-1.01]). There was no significant difference in the RRR for secondary outcomes of all-cause mortality (RRR, 0.97 [95% CI, 0.91-1.03]) or medication discontinuation because of adverse events (RRR, 1.05 [95% CI, 0.85-1.21]). Post hoc exploratory univariate meta-regression showed that on average a run-in period is associated with a statistically significant difference in treatment effect (RRR, 0.94 [95% CI, 0.90-0.99]) for cardiovascular composite outcome, but this was not statistically significant on multivariable meta-regression analysis (RRR, 0.95 [95% CI, 0.90-1.0]). Conclusions The use of a run-in period was not associated with a difference in the magnitude of treatment effect among cardiovascular prevention trials.

Total Knee Arthroplasty in Hemophilia: Survivorship and Outcomes-A Systematic Review and Meta-Analysis

BACKGROUND

Patients with hemophilia (PWHs) may experience spontaneous or traumatic bleeding episodes. Recurrent bleeding can lead to end-stage hemophilic arthropathy and total knee replacement (TKR) provides an effective treatment. The aim of this study is to investigate outcomes in PWHs who undergo TKR.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study outcomes included patient-reported functional outcomes, implant survivorship, and complications. Subgroup analysis was performed assessing the effect of recombinant prophylaxis medication by comparing studies that included only TKRs performed after the year 2000 (period A), to those that included TKRs before 2000 (period B).

RESULTS

Twenty-eight studies were included, with a total of 1210 TKRs performed in 917 PWHs. The mean age of patients was 38.5 years (standard deviation 5.1) with a mean length of follow-up of 7.1 years (standard deviation 2.9). The total complication rate was 28.7%, with 19.3% requiring a further procedure. Hospital for Special Surgery Knee Score improved by 44.6 points (confidence interval 38.9-50.4) and Knee Society Score function improved by 35.9 points (confidence interval 30.1-41.8). Total range of motion improved by 22.3°. The most common complication was post-operative hemarthrosis (7.6%, 92 TKRs). Deep infection (6.2% vs 3.9%) and aseptic loosening (3.8% vs 2.1%) rates fell between period B and period A.

CONCLUSION

TKR in PWHs is a successful procedure improving function, reducing pain, and improving range of motion. PWHs undergo TKR at a younger age and have a higher risk of complications, though contemporary treatment has reduced these risks. PWHs can expect similar survivorship to the general population.

A meta-analysis of influenza vaccination following correspondence: Considerations for COVID-19

Background

High vaccination rates are needed to protect against influenza and to end the COVID-19 pandemic. Health authorities need to know if supplementing mass communications with direct correspondence to the community would increase uptake.

Objectives

The primary objective is to determine if sending a single written message directly to individuals increases influenza vaccine uptake, and a secondary objective is to identify any identified content shown to increase influenza vaccine uptake.

Methods

MEDLINE, Embase, Cochrane CENTRAL, PsycINFO, and PubMed were searched for RCTs testing a single correspondence for members of the community in OECD countries to obtain influenza vaccination. A meta-analysis with inverse-variance, random-effects modelling was used to estimate a mean, weighted risk ratio effect size measure of vaccine uptake. Studies were quality assessed and analysis was undertaken to account for potential publication bias.

Results

Twenty-eight randomized controlled trials were included, covering 45 interventions. Of the 45 interventions, 37 (82.2%) report an increase in influenza vaccination rates. A formal meta-analysis shows that sending a single written message increased influenza vaccine uptake by 16%, relative to the no contact comparator group (RR = 1.16, 95% CI [1.13-1.20], Z = 9.25, p < .001). Analysis shows that the intervention is effective across correspondence type, age group, time, and location, and after allowing for risk of publication bias.

Limitations

The generalizability of results across the OECD may be questioned.

Conclusions and implications

The implication for public health authorities organizing vaccination programs for influenza, and arguably also for COVID-19, is that sending written vaccination correspondence to members of the community is likely to increase uptake. Keywords: vaccine uptake, COVID-19, influenza, direct correspondence, meta-analysis.

This study is pre-registered on osf.io; details can be found at https://osf.io/98mr7

Stroke Severity in Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Objectives

An assessment of the comparative incidence of fatal or disabling stroke may influence choice of intervention for patients with severe aortic stenosis. We explored whether transcatheter aortic valve implantation (TAVI) is associated with a lower incidence of fatal or disabling stroke, compared to surgical aortic valve replacement (SAVR).

Materials & Methods

We classified stroke into two categories; fatal or disabling, or non-disabling, and completed meta-analyses for each. We explored randomised controlled trials to assess the effect publication year, predicted operative risk, and route of TAVI access.

Results

There was no difference between treatment groups per 100 person years of follow up for disabling or non-disabling stroke outcomes. In a stratified analysis by year of publication, there was a lower rate of fatal or disabling stroke with TAVI in trials published after 2015, compared to those published in 2015 or before (p-interaction = 0.01 at 30 days). Higher proportions of transfemoral route access (>90%), more common in recent trials, were associated with a lower rate of fatal or disabling stroke (p-interaction = 0.03 at 30 days). Lower average surgical risk scores were associated with lower rates of fatal or disabling stroke (p = 0.02 at 30 days).

Conclusion

We found that treatment of aortic stenosis with TAVI compared with SAVR was not associated with an overall reduced risk in fatal or disabling stroke. Subgroup analyses suggested a lower risk of fatal or disabling stroke with TAVI in situations which reflect contemporary practice.

Perioperative Mortality After Cemented or Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures-A Systematic Review and Meta-analysis

BACKGROUND

Debate surrounds the use of cemented or uncemented prostheses for the treatment of displaced femoral neck fractures (FNF). Many guidelines recommend the use of the cemented hemiarthroplasty (CHA). Proponents of CHA point out the increased re-operation rate while proponents of uncemented hemiarthroplasty (HA) highlight the increased mortality rate in the perioperative period. The aim of this study was to systematically review the literature to evaluate perioperative mortality after HA for displaced FNFs.

METHODS

A systematic review and meta-analysis was performed of MEDLINE, Cochrane Library, and Embase databases evaluating perioperative mortality after HA for displaced FNFs. Randomized control trials and observational studies were included comparing current-generation stem designs. A meta-analysis was performed on studies that directly compared the different modes of fixation.

RESULTS

Twenty-two studies were included (seven randomized control trials and 15 observational studies), with a total of 183,167 HAs for treatment of a displaced FNF. Fourteen studies were included in the meta-analysis. There was a higher cumulative odds of death within the first 48 hours in those with CHA compared with uncemented HA (OR: 1.64; 95% CI: 1.35, 2.00; P ≤ .01). No difference was found in mortality at 7 days, 30 days, and one year.

CONCLUSION

CHA is associated with an increased mortality rate within the first two days of surgery with no difference at 7 days, 30 days, and one year. Surgeons should consider tailoring their stem choice based on the physiological status of the patient when planning HA for FNFs. Techniques to reduce the risk of bone cement implantation syndrome should be used.

Increased Salt Intake for Orthostatic Intolerance Syndromes: A Systematic Review and Meta-Analysis

BACKGROUND

Guidelines recommend increased salt intake as a first-line recommendation in the management of symptomatic orthostatic hypotension and recurrent syncope. There have been no systematic reviews of this intervention. We sought to summarize the evidence for increased salt intake in patients with orthostatic intolerance syndromes.

METHODS

We conducted a systematic review and meta-analysis of studies in PubMed, EMBASE, and CINAHL. Interventional studies that increased salt intake in individuals with orthostatic intolerance syndromes were included. Primary outcome measures included incidence of falls and injuries, and rates of syncope and presyncope. Secondary outcome measures included other orthostatic intolerance symptoms, blood pressure, and heart rate.

RESULTS

A total of 14 studies were eligible, including participants with orthostatic hypotension, syncope, postural orthostatic tachycardia syndrome, and idiopathic orthostatic tachycardia (n = 391). Mean age was 35.6 (± 15) years. All studies were small and short-term (<60 mins-90 days). No study reported on the effect of increased salt intake on falls or injuries. Meta-analysis demonstrated that during head-up tilt, mean time to presyncope with salt intake increased by 1.57 minutes (95% confidence interval [CI], 1.26-1.88), mean systolic blood pressure increased by 12.27 mm Hg (95% CI, 10.86-13.68), and mean heart rate decreased by -3.97 beats per minute (95% CI, -4.08 to -3.86), compared with control. Increased salt increased supine blood pressure by 1.03 mm Hg (95% CI, 0.81 to 1.25). Increased salt intake resulted in an improvement or resolution of symptoms in 62.3% (95% CI, 51.6 to 72.6) of participants in short-term follow-up studies (mean follow-up of 44.3 days, 6 studies; n=91). Methodological quality of studies were low with high statistical heterogeneity in all meta-analyses.

CONCLUSIONS

Our meta-analysis provides low-quality evidence of a short-term improvement in orthostatic intolerance with increased salt intake. There were no clinical trials demonstrating the efficacy and safety of increased salt intake on long-term clinical outcomes. Overall, there is a paucity of clinical trial evidence to support a cornerstone recommendation in the management of orthostatic intolerance syndromes.

Virtual geriatric clinics and the COVID-19 catalyst: a rapid review

Background

During the current COVID-19 health crisis virtual geriatric clinics have become increasingly utilised to complete outpatient consultations, although concerns exist about feasibility of such virtual consultations for older people. The aim of this rapid review is to describe the satisfaction, clinic productivity, clinical benefit, and costs associated with the virtual geriatric clinic model of care.

Methods

A rapid review of PubMed, MEDLINE and CINAHL databases was conducted up to April 2020. Two independent reviewers extracted the information. Four subdomains were focused on: satisfaction with the virtual geriatric clinic, clinic productivity, clinical benefit to patients, costs and any challenges associated with the virtual clinic process.

Results

Nine studies with 975 patients met our inclusion criteria. All were observational studies. Seven studies reported patients were satisfied with the virtual geriatric clinic model of care. Productivity outcomes included reports of cost-effectiveness, savings on transport, and improved waiting list metrics. Clinical benefits included successful polypharmacy reviews, and reductions in acute hospitalisation rates. Varying challenges were reported for both clinicians and patients in eight of the nine studies. Hearing impairments and difficulty with technology added to anxieties experienced by patients. Physicians missed the added value of a thorough physical examination and had concerns about confidentiality.

Conclusion

Virtual geriatric clinics demonstrate evidence of productivity, benefit to patients, cost effectiveness and patient satisfaction with the treatment provided. In the current suboptimal pandemic climate, virtual geriatric clinics may allow Geriatricians to continue to provide an outpatient service, despite the encountered inherent challenges.

Adaptive design methods in dialysis clinical trials: a systematic review protocol

INTRODUCTION

Adaptive design methods are a potential solution to improve efficiency of clinical trials but their uptake in dialysis is unknown. We aim to investigate the use of adaptive design methods in dialysis clinical trials and to cultivate further adoption of adaptive design methods by the nephrology community.

METHODS AND ANALYSIS

We will adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines and the Cochrane Collaboration Handbook. We will perform a literature search through MEDLINE (PubMed), EMBASE and CENTRAL, a detailed data extraction of trial characteristics and a narrative synthesis of the data. There will be no language restrictions. We will estimate the percentage of adaptive clinical trials per year in dialysis. Subgroup analysis will be performed by dialysis modality, funder and geographical location.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this study as data will be obtained from publicly available clinical trials. We will disseminate our results in a peer-reviewed publication. PROSPERO REGISTRATION NUMBER.

Key Service Improvements After the Introduction of an Integrated Orthogeriatric Service

Introduction:

Models of orthogeriatric care have been shown to improve functional outcomes for patients after hip fractures and can improve compliance with best practice guidelines for hip fracture care.

Methods:

We evaluated improvements to key performance indicators in hip fracture care after implementation of a formal orthogeriatric service. Compliance with Irish Hip Fracture standards of care was reviewed, and additional outcomes such as length of stay, access to rehabilitation, and discharge destination were evaluated.

Results:

Improvements were observed in all of the hip fracture standards of care. Mean length of stay decreased from 19 to 15.5 days (mean difference 3.5 days; P < .05). A higher proportion of patients were admitted to rehabilitation (16.7% vs 7.9%, P < .05), and this happened in a timelier fashion (17.8 vs 24.8 days, P < .05). We found that less patients required convalescence post-hip fracture.

Discussion:

A standardized approach to integrated post-hip fracture care with orthogeriatrics has improved standards of care for patients.

Conclusion:

Introduction of orthogeriatric services has resulted in meaningful improvements in clinical outcomes for older people with hip fractures.

Does Google™ Have the Answers? The Internet-based Information on Pelvic and Acetabular Fractures

Introduction

The aim of this study is to assess the readability and reliability of internet-based information on pelvic and acetabular fractures.

Methods

The three most popular English-based internet search engines are Google, Yahoo, and Bing. Quality was assessed using the DISCERN tool, the Journal of the American Medical Association tool, and the presence of the Health on the Net Code (HONcode) seal. Readability was assessed using a combination of the Flesch Reading Ease Score and the Flesch-Kincaid grade level. Inclusion criteria included English language websites with the relevant search terms. We excluded videos, YouTube links, or sponsored advertisements. Search terms included acetabular fracture/fractured acetabulum and pelvic fracture/fractured pelvis. The top 25 websites in each search engine were reviewed. The searches for acetabular fractures and pelvic fractures generated 75 websites in total. Duplicates were excluded.

Results

The search for acetabular fracture revealed 36 discrete websites among the three search engines, and the search for pelvic fractures revealed 45 websites. Overall, the average reading grade was 9.7 for acetabular websites and 13.6 for pelvis websites. The quality of the websites was poor across all key performance indicators studied.

Conclusion

Physicians should be aware of the quality of medical information available to patients via internet searches because physicians should play a central role in the navigation of poor quality information to help direct patient-centered care.

Valuing the Q in QALYs: Does providing patients' ratings affect population values?

OBJECTIVE

Quality-adjusted life years (QALYs) are used to measure the health benefits associated with treatments. QALYs are derived from objective mortality data weighted by assessments made by the general population of the impact on health-related quality of life associated with particular health states. In this study, a simple change is introduced to improve the validity of QALYs by giving raters information about how people living in the health states rate the health states.

METHOD

Participants from the general population (N = 155) judged 3 health states using a standard valuation technique after being randomly allocated to 1 of 2 groups. The intervention group was given patients' mean ratings of their own health states from worst to best imaginable health (0-100 scale) before providing their valuations, while the control group was given this information only after providing their valuations. The participants in both groups also indicated whether patients' mean ratings were higher, broadly similar, or lower than they previously expected.

RESULTS

When the mean ratings given by patients were higher (lower) than expected, participants in the intervention group provided significantly higher (lower) valuations than participants in the control group. These findings show that participants adjust their valuations of a health state in the direction of the appraisals of those experiencing that state.

CONCLUSION

Insofar as policymakers are committed to valuing health states using valuations given by people from the general population, it is desirable to elicit more informed values by providing people with information on how patients rate those states. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A High-pressure Solution for a High-pressure Situation: Management of Cerebral Air Embolism with Hyperbaric Oxygen Therapy

Cerebral air embolism can complicate many medical procedures, including cardiac surgery, venous and arterial access, and laparoscopic surgery. It can be a devastating diagnosis and can cause a life-threatening compromise to the cardiac, respiratory, or cerebrovascular system. It is a rare complication of central venous vascular access manipulation. A cerebral air embolism can lead to acute ischemic and cerebral oedema, which mimics other stroke syndromes, but the acute treatment differs, with prompt administration of hyperbaric oxygen therapy being the mainstay of treatment. A 59-year-old male became acutely unresponsive followed by the emergence of evolving neurology with fixed gaze palsy and a dense 0/5 left-sided hemiparesis. This occurred shortly after a right internal jugular central venous catheter (CVC) was removed (against protocol) during inspiration and sitting upright. Computed tomography (CT) imaging showed air in the right internal jugular vein, as well as intraparenchymal air. Treatment with hyperbaric oxygen was instituted within six hours. There was an excellent recovery of neurologic function, with power improving to 4+/5 over the course of the following week. Clinical staff need to be aware of the policy for central line removal, as well as having a high index of suspicion for air embolism in patients with evolving neurology immediately post-line removal. Early consideration of hyperbaric oxygen can result in improved functional outcomes.

Profile of von Willebrand factor antigen and von Willebrand factor propeptide in an overall TIA and ischaemic stroke population and amongst subtypes

INTRODUCTION

Von Willebrand factor propeptide (VWF:Ag II) is proposed to be a more sensitive marker of acute endothelial activation than von Willebrand factor antigen (VWF:Ag). Simultaneous data on VWF:Ag and VWF:Ag II profiles are very limited following TIA and ischaemic stroke.

METHODS

In this prospective, observational, case-control study, plasma VWF:Ag and VWF:Ag II levels were quantified in 164 patients≤4weeks of TIA or ischaemic stroke (baseline), and then ≥14days (14d) and ≥90days (90d) later, and compared with those from 27 healthy controls. TIA and stroke subtyping was performed according to the TOAST classification. The relationship between VWF:Ag and VWF:Ag II levels and platelet activation status was assessed.

RESULTS

'Unadjusted' VWF:Ag and VWF:Ag II levels were higher in patients at baseline, 14d and 90d than in controls (p≤0.03). VWF:Ag levels remained higher in patients than controls at baseline (p≤0.03), but not at 14d or 90d after controlling for differences in age or hypertension, and were higher in patients at baseline and 90d after controlling for smoking status (p≤0.04). 'Adjusted' VWF:Ag II levels were not higher in patients than controls after controlling for age, hypertension or smoking (p≥0.1). Patients with symptomatic carotid stenosis (N=46) had higher VWF:Ag and VWF:Ag II levels than controls at all time-points (p≤0.002). There was no significant correlation between platelet activation status and VWF:Ag or VWF:Ag II levels.

CONCLUSIONS

VWF:Ag and VWF:Ag II levels are increased in an overall TIA and ischaemic stroke population, especially in patients with recently symptomatic carotid stenosis. VWF:Ag II was not superior to VWF:Ag at detecting acute endothelial activation in this cohort and might reflect timing of blood sampling in our study.

The effect of dietary supplementation of algae rich in docosahexaenoic acid on boar fertility

The objective of this study was to assess the effects of dietary supplementation of a commercial algal product rich in docosahexaenoic acid (DHA) on boar fertility as assessed in vitro and in vivo. Boars were fed one of three experimental diets for 19 weeks: (i) Control (Ctl) diet (n = 31), (ii) Ctl diet plus 75g All-G-Rich per day (n = 31) or (iii) Ctl diet plus 150g All-G-Rich per day (n = 30). Parameters assessed were (i) raw semen quality; volume, sperm concentration, total motility and morphology (ii) liquid semen quality; progressive motility, viability, hypotonic resistance and acrosomal integrity (iii) frozen-thawed semen quality; motility, thermal stress, viability, membrane fluidity and mitochondrial activity (iv) sperm and seminal plasma (SP) fatty acid composition (FAC) (v) total antioxidant capacity (TAC) of SP and (vi) farrowing rates and litter sizes of sows (n = 1158) inseminated with liquid semen. Boars consuming 75g All-G-Rich had a larger semen volume (P < 0.05) and a higher total sperm number (P < 0.01) than the Ctl treatment, however, there was no effect of treatment on any other semen quality parameter (P > 0.05). There was no effect of dietary treatment on the FAC and TAC of SP or on farrowing rate and litter size (P > 0.05). There was an effect of dietary treatment on the FAC of sperm, represented by an 1.72 and 1.60 fold increase in the DHA content for 75 and 150g treatments, respectively, compared to the Ctl treatment. In conclusion, a significant increase in semen volume and total sperm number in boars supplemented 75g All-G-Rich daily, resulted in an increase in production of 3 to 4 more doses per ejaculate, thus, indicating that the feeding regime described within this study has the potential for increasing the output of boar studs.

Increased thrombin generation potential in symptomatic versus asymptomatic moderate or severe carotid stenosis and relationship with cerebral microemboli

INTRODUCTION

The importance of thrombin generation in the pathogenesis of TIA or stroke and its relationship with cerebral microembolic signals (MES) in asymptomatic and symptomatic carotid stenosis has not been comprehensively assessed.

METHODS

Plasma thrombin generation parameters from patients with moderate or severe (≥ 50%) asymptomatic carotid stenosis were compared with those from patients with symptomatic carotid stenosis in the early (≤ 4 weeks) and late phases (≥ 3 months) after TIA or stroke in this prospective, pilot observational study. Thrombin generation profile was longitudinally assessed in symptomatic patients with data at each time point. Bilateral transcranial Doppler ultrasound monitoring of the middle cerebral arteries was performed whenever possible to classify patients as MES-positive or MES-negative.

RESULTS

Data from 31 asymptomatic, 46 'early symptomatic' and 35 'late symptomatic' patients were analysed. Peak thrombin (344.2 nM vs 305.3 nM; p = 0.01) and endogenous thrombin potential (1772.4 vs 1589.7; p = 0.047) were higher in early symptomatic than asymptomatic patients. Peak thrombin production decreased in symptomatic patients followed up from the early to late phase after TIA or stroke (339.7 nM vs 308.6 nM; p = 0.02). Transcranial Doppler ultrasound data were available in 25 asymptomatic, 31 early symptomatic and 27 late symptomatic patients. Early symptomatic MES-positive patients had a shorter 'time-to-peak thrombin' than asymptomatic MES-positive patients (p=0.04), suggesting a more procoagulant state in this early symptomatic subgroup.

DISCUSSION

Thrombin generation potential is greater in patients with recently symptomatic than asymptomatic carotid stenosis, and decreases over time following TIA or stroke associated with carotid stenosis. These data improve our understanding of the haemostatic/thrombotic biomarker profile in moderate-severe carotid stenosis.

Longitudinal assessment of von Willebrand factor antigen and von Willebrand factor propeptide in response to alteration of antiplatelet therapy after TIA or ischaemic stroke

The impact of commencing or changing antiplatelet therapy on von Willebrand factor antigen (VWF:Ag) and von Willebrand factor propeptide (VWF:Ag II) levels has not been comprehensively assessed following TIA or ischaemic stroke. In this pilot, longitudinal, observational analytical study, VWF:Ag and VWF:Ag II levels were simultaneously quantified in platelet poor plasma by ELISA in patients within 4 weeks of TIA or ischaemic stroke (baseline), and then 14 days (14d) and >90 days (90d) after altering antiplatelet therapy. Ninety-one patients were recruited. Eighteen were initially assessed on no antiplatelet therapy, and then after 14d (N = 17) and 90d (N = 8) on aspirin monotherapy; 21 patients were assessed on aspirin and after 14d and 90d on clopidogrel; 52 were assessed on aspirin monotherapy, and after 14d and 90d on aspirin and dipyridamole combination therapy. VWF:Ag, VWF:Ag II levels and VWF:Ag/VWF:Ag II ratio were unchanged at 14d and 90d in the overall study population (p ≥ 0.1). VWF:Ag and VWF:Ag II levels remained stable at 14d and 90d after commencing aspirin (p ≥ 0.054), and after changing from aspirin to clopidogrel (p ≥ 0.2). Following the addition of dipyridamole MR to aspirin, there was a significant reduction in VWF:Ag levels at 14d (p = 0.03) and 90d (p = 0.005), but not in VWF:Ag II levels (p ≥ 0.3). The addition of dipyridamole to aspirin led to a persistent reduction in VWF:Ag but not in VWF:Ag II levels, suggesting that dipyridamole may inhibit release of platelet-derived VWF:Ag following TIA or ischaemic stroke.

Increased endothelial activation in recently symptomatic versus asymptomatic carotid artery stenosis and in cerebral microembolic-signal-negative patient subgroups

BACKGROUND AND PURPOSE

von Willebrand factor propeptide (VWF:Ag II) is potentially a more sensitive marker of acute endothelial activation than von Willebrand factor antigen (VWF:Ag). These biomarkers have not been simultaneously assessed in asymptomatic versus symptomatic carotid stenosis patients. The relationship between endothelial activation and cerebral microembolic signals (MESs) detected on transcranial Doppler ultrasound is unknown.

METHODS

In this multicentre observational analytical study, plasma VWF:Ag and VWF:Ag II levels in patients with ≥50% asymptomatic carotid stenosis were compared with those from patients with ≥50% symptomatic carotid stenosis in the 'early' (≤4 weeks) and 'late' (≥3 months) phases after transient ischaemic attack or ischaemic stroke. Endothelial activation was also longitudinally assessed in symptomatic patients during follow-up. Transcranial Doppler ultrasound monitoring classified patients as MES-positive or MES-negative.

RESULTS

Data from 31 asymptomatic patients were compared with those from 46 early symptomatic and 35 late phase symptomatic carotid stenosis patients, 23 of whom had undergone carotid intervention. VWF:Ag II levels were higher in early (12.8 μg/ml; P < 0.001), late (10.6 μg/ml; P = 0.01) and late post-intervention (10.6 μg/ml; P = 0.038) symptomatic patients than asymptomatic patients (8.9 μg/ml). VWF:Ag levels decreased in symptomatic patients followed up from the early to late phase after symptom onset (P = 0.048). Early symptomatic MES-negative patients had higher VWF: Ag II levels (13.3 vs. 9.0 μg/ml; P < 0.001) than asymptomatic MES-negative patients.

CONCLUSIONS

Endothelial activation is enhanced in symptomatic versus asymptomatic carotid stenosis patients, in early symptomatic versus asymptomatic MES-negative patients, and decreases over time in symptomatic patients. VWF:Ag II levels are a more sensitive marker of endothelial activation than VWF:Ag levels in carotid stenosis. The potential value of endothelial biomarkers and concurrent cerebral MES detection at predicting stroke risk in carotid stenosis warrants further study.

Increased platelet activation in early symptomatic vs. asymptomatic carotid stenosis and relationship with microembolic status: results from the Platelets and Carotid Stenosis Study

BACKGROUND

Cerebral microembolic signals (MES) may predict increased stroke risk in carotid stenosis. However, the relationship between platelet counts or platelet activation status and MES in symptomatic vs. asymptomatic carotid stenosis has not been comprehensively assessed.

SETTING

University teaching hospitals.

METHODS

This prospective, pilot observational study assessed platelet counts and platelet activation status, and the relationship between platelet activation and MES in asymptomatic vs. early (≤ 4 weeks after TIA/stroke) and late phase (≥ 3 months) symptomatic moderate or severe (≥ 50%) carotid stenosis patients. Full blood count measurements were performed, and whole blood flow cytometry was used to quantify platelet surface activation marker expression (CD62P and CD63) and circulating leucocyte-platelet complexes. Bilateral simultaneous transcranial Doppler ultrasound monitoring of the middle cerebral arteries was performed for 1 h to classify patients as MES positive or MES negative.

RESULTS

Data from 31 asymptomatic patients were compared with 46 symptomatic patients in the early phase, and 35 of these patients were followed up to the late phase after symptom onset. The median platelet count (211 vs. 200 × 10(9)  L(-1) ; P = 0.03) and the median percentage of lymphocyte-platelet complexes was higher in early symptomatic than asymptomatic patients (2.8 vs. 2.4%; P = 0.001). The percentage of lymphocyte-platelet complexes was higher in early symptomatic than in asymptomatic patients with ≥ 70% carotid stenosis (P = 0.0005) and symptomatic patients recruited within 7 days of symptom onset (P = 0.028). Complete TCD data were available in 25 asymptomatic, 31 early phase symptomatic and 27 late phase symptomatic patients. Twelve per cent of asymptomatic vs. 32% of early phase symptomatic (P = 0.02) and 19% of late phase symptomatic patients (P = 0.2) were MES positive. Early symptomatic MES-negative patients had a higher percentage of lymphocyte-platelet complexes than asymptomatic MES-negative patients (2.8 vs. 2.3%; P = 0.0085).

DISCUSSION

Recently, symptomatic carotid stenosis patients have had higher platelet counts (potentially reflecting increased platelet production, mobilization or reduced clearance) and platelet activation status than asymptomatic patients. MES were more frequently detected in early symptomatic than asymptomatic patients, but the differences between late symptomatic and asymptomatic groups were not significant. Increased lymphocyte-platelet complex formation in recently symptomatic vs. asymptomatic MES-negative patients indicates enhanced platelet activation in this early symptomatic subgroup. Platelet biomarkers, in combination with TCD, have the potential to aid risk-stratification in asymptomatic and symptomatic carotid stenosis patients.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

The development of myelin repair agents for treatment of multiple sclerosis: progress and challenges

Multiple Sclerosis (MS) is an inflammatory demyelinating disorder which affects the central nervous system. Multiple sclerosis treatment has traditionally focused on preventing inflammatory damage to the myelin sheath. Indeed, all currently available disease modifying agents are immunomodulators. However, the limitations of this approach are becoming increasingly clear, leading to the exploration of other potential therapeutic strategies. In particular, targeting the endogenous remyelination system to promote replacement of the lost myelin sheath has shown much promise. As our understanding of remyelination biology advances, the realization of a remyelinating therapeutic comes closer to fruition. In our review, we aim to summarize the limitations of the current immune focused treatment strategy and discuss the potential of remyelination as a new treatment method. Finally, we aim to highlight the challenges in the identification and development of such therapeutics.

Longitudinal assessment of thrombin generation potential in response to alteration of antiplatelet therapy after TIA or ischaemic stroke

The impact of changing antiplatelet therapy on thrombin generation potential in patients with ischaemic cerebrovascular disease (CVD) is unclear. We assessed patients within 4 weeks of TIA or ischaemic stroke (baseline), and then 14 days (14d) and >90 days (90d) after altering antiplatelet therapy. Thrombin generation was assessed in platelet poor plasma. Ninety-one patients were recruited. Twenty-four were initially assessed on no antiplatelet therapy, and then after 14d (N = 23) and 90d (N = 8) on aspirin monotherapy; 52 were assessed on aspirin monotherapy, and after 14 and 90 days on aspirin and dipyridamole combination therapy; 21 patients were assessed on aspirin and after 14 days (N = 21) and 90 days (N = 19) on clopidogrel. Peak thrombin generation and endogenous thrombin potential were reduced at 14 and 90 days (p ≤ 0.04) in the overall cohort. We assessed the impact of individual antiplatelet regimens on thrombin generation parameters to investigate the cause of this effect. Lag time and time-to-peak thrombin generation were unchanged at 14 days, but reduced 90 days after commencing aspirin (p ≤ 0.009). Lag time, peak thrombin generation and endogenous thrombin potential were reduced at both 14 and 90 days after adding dipyridamole to aspirin (p ≤ 0.01). Lag time was reduced 14 days after changing from aspirin to clopidogrel (p = 0.045), but this effect was not maintained at 90 days (p = 0.2). This pilot study did not show any consistent effects of commencing aspirin, or of changing from aspirin to clopidogrel on thrombin generation potential during follow-up. The addition of dipyridamole to aspirin led to a persistent reduction in peak and total thrombin generation ex vivo, and illustrates the diverse, potentially beneficial, newly recognised 'anti-coagulant' effects of dipyridamole in ischaemic CVD.

Retrospective comparison of the original and revised McDonald criteria in a general neurology practice in Ireland

BACKGROUND

The McDonald criteria were introduced in 2001 as guidelines to facilitate early and accurate diagnosis of multiple sclerosis (MS). They were revised in 2005. Although validated in a number of research-focused clinical centres, their adequacy and utility in the general neurology setting is less certain.

OBJECTIVE

In this study, we assessed new diagnoses of MS in our practice for compliance with both the original and the revised criteria.

METHODS

We retrospectively identified new diagnoses of MS from 2001. Clinical notes and imaging were evaluated for compliance with McDonald criteria.

RESULTS

Sixty-two patients were included: 53 with ;practice-definite' and nine with ;practice-possible' diagnoses of MS. At the time of diagnosis, 47% of the ;practice-definite' group fulfilled the 2001 criteria and 49% the revised criteria. Among patients not satisfying the criteria at time of diagnosis, 21% went on to fulfil the McDonald criteria over the 23-month follow-up.

CONCLUSIONS

There is a considerable gap between the clinical diagnosis of MS in a general neurology setting and compliance with the McDonald criteria. Failure to perform follow-up MRI on patients with clinically isolated syndromes is a sizeable factor in this diagnostic-gap and needs to be improved. In this setting, practical differences between the original and revised criteria appear to be small.

Cost of disorders of the brain in Ireland

The "Cost of Disorders of the Brain in Europe" (CBDE) study was conducted by the European Brain Council (EBC) to estimate prevalence and cost of the twelve leading disorders encountered in Neurology, Neurosurgery, and Psychiatry. The data for Ireland are presented here. Prevalence and costing information was obtained by structured review of published literature for each country. Where such information was lacking, figures were estimated from European data. Costs included direct medical, direct non-medical, and indirect costs. None of the costs presented here are directly from Irish data and the prevalence figures are mostly estimated from known European rates. In 2004, 1.1 million people in Ireland were affected by a disorder of the brain. Total cost of included disorders in Ireland was 3.0 billion Euro, representing 3% of gross national product, and costing each Irish citizen Euro 775 per year. Brain disorders are prevalent and pose significant economic burden in Ireland.

Histopathology and regression of retinal hard exudates in diabetic retinopathy after reduction of elevated serum lipid levels

PURPOSE

To describe a regression of retinal hard exudates in 2 patients with diabetic maculopathy, and to report immunohistologic findings reflecting lipid deposition in the retina.

DESIGN

Two interventional case reports.

METHODS

Two patients with exudative diabetic maculopathy were treated to normalize serum lipids. Histologic examination and immunohistochemistry of each patient's eyes were performed to assess the localization of apolipoprotein B and cholesteryl ester, both of which are principal components of low-density lipoprotein.

RESULTS

Both patients showed a dramatic regression of retinal hard exudates after correction of dyslipidemia. Histopathology revealed diffuse lipids and cholesteryl ester in the retina. Apolipoprotein B and macrophages were colocalized in the perivascular space.

CONCLUSIONS

The regression of hard exudates was most likely due to the aggressive lipid lowering in both patients. The novel histopathologic findings of hard exudate and diabetic maculopathy are similar to the pathologic changes observed in larger atherosclerotic lesions, except that they occur in the intraretinal perivascular space.

The long-term effects of laser photocoagulation treatment in patients with diabetic retinopathy: the early treatment diabetic retinopathy follow-up study

OBJECTIVES

To evaluate the long-term natural history and effects of laser photocoagulation treatment in patients with diabetic retinopathy.

DESIGN

Follow-up study of the 214 surviving patients enrolled originally at the Johns Hopkins Clinical Center for the Early Treatment Diabetic Retinopathy Study (ETDRS), which was a clinical trial designed to evaluate the role of laser photocoagulation and aspirin treatment in patients with diabetic retinopathy.

METHODS

Early Treatment Diabetic Retinopathy Study patients enrolled in the Johns Hopkins Clinical Center had complete eye examinations, including best-corrected visual acuity measurements, fundus photographs, and medical questionnaires throughout the 7-year study. They had the same examinations at the final long-term follow-up visit at the National Eye Institute, National Institutes of Health, 13 to 19.5 years after the initial laser photocoagulation (median, 16.7 years).

MAIN OUTCOME MEASURES

The major outcomes were mortality and the rates of moderate and severe vision loss. The secondary outcomes were progression of diabetic retinopathy and need for other eye surgery.

RESULTS

Of the 214 patients who were alive at the end of the original ETDRS in 1989, 130 (61%) were deceased at the time of the re-examination. Of the 84 who were alive, 71 (85%) were examined at their long-term follow-up visit at the National Institutes of Health. At the long-term follow-up examination, 42% had visual acuity of 20/20 or better, and 84% had visual acuity of 20/40 or better in the better eye. Compared with baseline, 20% of patients had moderate vision loss (loss of 3 lines or more vision) in the better eye at follow-up. Only one patient had visual acuity of 20/200 bilaterally. He had visual acuity loss secondary to age-related macular degeneration. No patient had severe vision loss (worse than 5/200). All the initially untreated eyes of patients who had severe nonproliferative diabetic retinopathy or worse by the time of the ETDRS closeout visit of the original study received scatter photocoagulation treatment. Focal photocoagulation was performed in 43% bilaterally and 22% unilaterally. Cataract surgery was performed in 31% of the patients, vitrectomy in 17%, and glaucoma surgery in one patient.

CONCLUSIONS

As previously reported, the mortality rate of patients with diabetic retinopathy is much higher than that of the general population. For those who survived, aggressive follow-up, with treatment when indicated, seems to be associated with maintenance of good long-term visual acuity for most patients. The need for laser scatter photocoagulation with long-term follow-up seems to be high.

Surgical management of macular holes: a report by the American Academy of Ophthalmology

OBJECTIVE

The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique.

METHODS

A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented.

RESULTS

There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%).

CONCLUSIONS

The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.

Scleral outfolding for macular translocation

PURPOSE

To report experimental study and clinical observation of scleral outfolding for macular translocation.

METHODS

In six human cadaver eyes, circumferential mattress sutures to create sclera infoldings were compared with radial-interrupted mattress sutures to create scleral outfoldings. In a 75-year-old man with macular degeneration and choroidal neovascular membrane, radial-interrupted mattress sutures were used for macular translocation.

RESULTS

In the human cadaver eyes, circumferential mattress sutures for scleral infolding created an average decrease in corresponding internal anteroposterior retinal contour of 0.36 mm. Radial-interrupted mattress sutures for scleral outfoldings created an average decrease in the corresponding internal anteroposterior retinal contour of 4. 61 mm. The statistical significance of the difference between infoldings of the sclera versus outfoldings of the sclera had a P value of.0001.

CONCLUSIONS

Initial experimental and clinical study suggests that radial-interrupted mattress sutures may generate more shortening of the internal scleral surface and greater macular translocation than circumferential mattress sutures. Additional studies are needed to evaluate the long-term effects of radial-interrupted mattress sutures and macular translocation for treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration.

Typical Friedreich's ataxia without GAA expansions and GAA expansion without typical Friedreich's ataxia

We clinically assessed and performed polymerase chain reaction analysis for the GAA trinucleotide repeat expansion in 103 patients from 73 families in Ireland, with a prior clinical diagnosis of Friedreich's ataxia (FA) or an unclassified progressive ataxic syndrome. The patients were classified as "typical" or "atypical" FA according to Harding's mandatory clinical diagnostic criteria. All patients underwent blood glucose analysis, and electrocardiography and echocardiography was performed in 99 and 101 patients, respectively. Mutation screening for expanded CAG trinucleotide repeats, associated with spinocerebellar ataxia (SCA) 1, 2, 3 and 6 was performed in 86 patients overall, including all GAA negative patients. Forty-nine of 56 typical patients and 13 of 47 atypical patients were either homozygous or heterozygous for the GAA expansion. Seven patients with a typical FA phenotype were negative for the GAA expansion. Although one of these patients had vitamin E deficiency, and two had raised alpha-fetoprotein levels, three other GAA negative patients with a typical FA phenotype had no other identifiable cause for their ataxia, once again raising the possibility of locus heterogeneity in FA. It is also possible that these patients have two point mutations in the X25 gene, or that they have another ataxic syndrome mimicking the FA phenotype. Two families who were homozygous for the GAA expansion exhibited intrafamilial phenotypic variability. Only one GAA negative patient had the SCA 3 mutation, and this was the only patient in the study with a possible autosomal dominant inheritance pattern. In the homozygous GAA population typical patients had significantly more repeats on the smaller allele than atypical patients, and there was an inverse relationship between the number of repeats on the smaller allele and the age at presentation. There was also an inverse relationship between the repeat size on both the larger and the smaller of the two alleles and the age at becoming wheelchair bound. There was no significant relationship between repeat size and the other indices of disease severity, including the presence or absence of diabetes or cardiomyopathy. This is the first large study of an Irish population with progressive ataxia that has shown a similar phenotype/genotype relationship to studies of FA in other European and non-European populations. The relatively low sensitivity and specificity of Harding's clinical diagnostic criteria must be appreciated when clinically assessing patients with a progressive ataxic syndrome. Although molecular genetic analysis now plays an essential role in diagnosis and classification, patients with a typical FA phenotype without any identifiable cause for their ataxia exist.

Microsatellite instability in sporadic colorectal carcinoma is not an indicator of prognosis

Fifty sporadic colorectal carcinomas diagnosed in 1991 were analysed for microsatellite instability at four loci. Five of 50 (10 per cent) tumours showed replication errors (RERs) at two or more loci and were classed as RER-positive (RER+). A further five showed RERs at one locus only. A significant association (Fisher exact test) was found between RER+ tumours and location in the proximal colon, exophytic shape, size >5 cm, histological margin, lymphoid reaction, and near-diploid DNA content. There was no significant difference for age, sex, grade, mucin production, p53 protein overexpression or Duke's stage. There was no significant difference in survival as measured over a 60-month follow-up period. The findings, though limited by the small case numbers involved, show an association between RER positivity in sporadic colorectal tumours and certain clinico-pathological features. They do not suggest a better clinical outcome for sporadic RER+ tumours.

An automated heteroduplex assay for the Pi(A) polymorphism of glycoprotein IIb/IIIa, multiplexed with two prothrombotic genetic markers

Screening for the PIA polymorphism has been made faster and simpler with the advent of heteroduplex technology. Simultaneous screening for three common prothrombotic polymorphisms pl(A), factor V Leiden, and MTHFR(C677T) has been achieved with multiplex heteroduplex analysis. We describe a quick and simple method for PlA heteroduplex probe production. The probe was multiplexed with heteroduplex probes for MTHFR(C677T) and factor V Leiden polymorphisms in a one tube assay, allowing rapid automated genotyping of all three. This automated multiplex assay was applied to a cohort of 165 patients and showed excellent correlation with gel-based assays, both PAGE and RFLP. This approach will facilitate the analysis of multiple polymorphisms in complex disease in large populations.

Prospective evaluation of the risk conferred by factor V Leiden and thermolabile methylenetetrahydrofolate reductase polymorphisms in pregnancy

Factor V (FV) Leiden and thermolabile methylenetetrahydrofolate reductase (MTHFR) are 2 common polymorphisms that have been implicated in vascular thrombosis. We determined whether these mutations predicted an adverse outcome in pregnancy. Second, we looked for an interaction between these 2 mutations in patients with recurrent fetal loss or thrombosis in pregnancy. Primigravid subjects at their booking visit to the National Maternity Hospital (Holles Street, Dublin, Ireland) were screened for the polymorphisms. Thermolabile MTHFR and FV Leiden genotypes were detected by either restriction fragment length polymorphism or heteroduplex capillary chromatography. The carrier frequency of FV Leiden in the screened primigravid population was 2.7% (allele frequency 1.36%), all being heterozygous for the mutation. This value was lower than expected from previous studies in European populations. Forty-nine percent of the screened population (289 of 584) were heterozygous for thermolabile MTHFR, and 10.6% were homozygous (62 of 584). The frequency of the 2 polymorphisms was no higher in those who subsequently developed preeclampsia (n=12) or intrauterine growth retardation (n=9), and none of the screened population developed thrombosis. However, the frequency of FV Leiden was higher in patients who subsequently miscarried after the first trimester of pregnancy (allele frequency of 5.5%, P=0.0356). Among those positive for FV Leiden, 3 of 27 miscarried, compared with 24 of 572 of FV Leiden-negative patients (11% versus 4.2%). No interaction was found between the 2 mutations in the control or patient populations. In patients with a prior history of venous thrombosis, the carrier rate of FV Leiden was increased (4 of 33, allele frequency of 7.6%, P=0. 0115). In contrast, the carrier frequency for thermolabile MTHFR was no higher, and there was no interaction between the 2 mutations. Neither mutation occurred at a significantly higher frequency in patients with a prior history of recurrent fetal loss. In conclusion, FV Leiden is a risk factor for thrombosis in pregnancy and possibly for second-trimester miscarriage independent of thermolabile MTHFR. However, prospective analysis suggests that the risk conferred by FV Leiden is low in a primigravid population. The thermolabile MTHFR genotype was not implicated in any adverse outcome.

Photodynamic therapy: a new approach to the treatment of choroidal neovascularization secondary to age-related macular degeneration

Visual loss as a result of choroidal neovascularization secondary to age-related macular degeneration continues to be a major challenge for all ophthalmologists. Photodynamic therapy represents an exciting and novel technique that uses light-activated drugs and nonthermal light to achieve the selective destruction of choroidal neovascularization with minimal effects on the surrounding normal tissues. In Phase I-II clinical trials of photodynamic therapy with both benzoporphyrin derivative and tin ethyl etiopurpurin, closure of choroidal neovascularization was seen 24 hours after the treatment. However, recurrence of choroidal neovascularization can occur 2 to 3 months after treatment. Double-blind, multicenter, randomized Phase III clinical trials with benzoporphyrin derivative and tin ethyl etiopurpurin are currently underway.

Microsatellite instability in sporadic colorectal carcinoma is not an indicator of prognosis

Fifty sporadic colorectal carcinomas diagnosed in 1991 were analysed for microsatellite instability at four loci. Five of 50 (10 per cent) tumours showed replication errors (RERs) at two or more loci and were classed as RER-positive (RER+). A further five showed RERs at one locus only. A significant association (Fisher exact test) was found between RER+ tumours and location in the proximal colon, exophytic shape, size >5 cm, histological margin, lymphoid reaction, and near-diploid DNA content. There was no significant difference for age, sex, grade, mucin production, p53 protein overexpression or Duke's stage. There was no significant difference in survival as measured over a 60-month follow-up period. The findings, though limited by the small case numbers involved, show an association between RER positivity in sporadic colorectal tumours and certain clinico-pathological features. They do not suggest a better clinical outcome for sporadic RER+ tumours.

Disparity between fundus camera and scanning laser ophthalmoscope indocyanine green imaging of retinal pigment epithelium detachments

PURPOSE

Indocyanine green (ICG) angiograms of each of five patients with retinal pigment epithelium (RPE) detachments were made using first a Topcon fundus camera and then a Heidelberg scanning laser ophthalmoscope (SLO); for each patient, both types of angiograms were obtained on the same day. In each case, the serous fluid appeared bright throughout the fundus camera studies and dark throughout the SLO studies. This study sought to explain the disparity in the appearance of the lesions in the two kinds of images and to determine whether there was dye in the serous fluid.

METHODS

Simple model eyes were constructed to demonstrate the effects of Mie light scatter and integrating sphere behavior of the sclera on ICG image formation by the fundus camera and SLO optics. Analysis was made of both the clinical angiograms and model eye images to structure an explanation for the disparate RPE detachment angiographic images.

RESULTS

Indocyanine green fluorescent light from choroidal vessels adjacent to the lesions and scattered by the turbid serous fluid accounted for the lesion brightness seen in the fundus camera images. The models confirmed that SLOs suppress scattered light.

CONCLUSIONS

The apparent fluorescence of serous fluid beneath RPE detachments in fundus camera early-phase ICG angiogram images is not attributable to the presence of dye; rather, it appears to be attributable to serous fluid light scatter of fluorescent light arising from adjacent fluorescent structures. This light scatter is a consequence of the fundus camera illumination and recording optics and is not present in SLO-generated images. The necessity of understanding such phenomena as absorption, diffraction, polarization, and scatter of light and routinely applying them to ICG angiogram interpretation is underscored when it is shown that they offer simple explanations for unusual or unexpected angiographic results, as in the case of the patients with RPE detachment discussed here.

Free radicals in inflammatory neurological disease: increased lipid peroxidation and haptoglobin levels in Guillain Barré syndrome

Oxidative damage in three inflammatory neurological disorders; Guillain Barré syndrome (GBS), multiple sclerosis and aseptic meningitis, were assessed by measuring the peroxidation of lipids in body fluids. The results were compared to a control group consisting of patients with either migraine, chronic/tension headaches, benign intracranial hypertension or psychological disorders. Antioxidant status was assessed by the measurement of the extracellular proteins, haptoglobin, albumin, caeruloplasmin and transferrin. The results of the study suggested that firstly, haptoglobin levels might be a useful, easily obtainable marker to aid the diagnosis of GBS. Secondly, free radical damage may be implicated in the pathology of GBS and therefore appropriate free radical scavenging might have beneficial effects.