Prognostic value of echocardiographic parameters in congenital diaphragmatic hernia: a systematic review and meta-analysis

BACKGROUND

Prognostication of mortality and decision to offer extracorporeal membrane oxygenation (ECMO) treatment in infants with congenital diaphragmatic hernia (CDH) can inform clinical management.

OBJECTIVE

To summarise the prognostic value of echocardiography in infants with CDH.

METHODS

Electronic databases Ovid MEDLINE, Embase, Scopus, CINAHL, the Cochrane Library and conference proceedings up to July 2022 were searched. Studies evaluating the prognostic performance of echocardiographic parameters in newborn infants were included. Risk of bias and applicability were assessed using the Quality Assessment of Prognostic Studies tool. We used a random-effect model for meta-analysis to compute mean differences (MDs) for continuous outcomes and relative risk (RR) for binary outcomes with 95% CIs. Our primary outcome was mortality; secondary outcomes were need for ECMO, duration of ventilation, length of stay, and need for oxygen and/or inhaled nitric oxide.

RESULTS

Twenty-six studies were included that were of acceptable methodological quality. Increased diameters of the right and left pulmonary arteries at birth (mm), MD 0.95 (95% CI 0.45 and 1.46) and MD 0.79 (95% CI 0.58 to 0.99), respectively) were associated with survival. Left ventricular (LV) dysfunction, RR 2.40, (95% CI 1.98 to 2.91), right ventricular (RV) dysfunction, RR 1.83 (95% CI 1.29 to 2.60) and severe pulmonary hypertension (PH), RR 1.69, (95% CI 1.53 to 1.86) were associated with mortality. Left and RV dysfunctions, RR 3.30 (95% CI 2.19 to 4.98) and RR 2.16 (95% CI 1.85 to 2.52), respectively, significantly predicted decision to offer ECMO treatment. Limitations are lack of consensus on what parameter is optimal and standardisation of echo assessments.

CONCLUSIONS

LV and RV dysfunctions, PH and pulmonary artery diameter are useful prognostic factors among patients with CDH.

Delayed skeletal development and IGF-1 deficiency in a mouse model of lysinuric protein intolerance

SLC7A7 deficiency, or lysinuric protein intolerance (LPI), causes loss of function of the y+LAT1 transporter critical for efflux of arginine, lysine and ornithine in certain cells. LPI is characterized by urea cycle dysfunction, renal disease, immune dysregulation, growth failure, delayed bone age and osteoporosis. We previously reported that Slc7a7 knockout mice (C57BL/6×129/SvEv F2) recapitulate LPI phenotypes, including growth failure. Our main objective in this study was to characterize the skeletal phenotype in these mice. Compared to wild-type littermates, juvenile Slc7a7 knockout mice demonstrated 70% lower body weights, 87% lower plasma IGF-1 concentrations and delayed skeletal development. Because poor survival prevents evaluation of mature knockout mice, we generated a conditional Slc7a7 deletion in mature osteoblasts or mesenchymal cells of the osteo-chondroprogenitor lineage, but no differences in bone architecture were observed. Overall, global Slc7a7 deficiency caused growth failure with low plasma IGF-1 concentrations and delayed skeletal development, but Slc7a7 deficiency in the osteoblastic lineage was not a major contributor to these phenotypes. Future studies utilizing additional tissue-specific Slc7a7 knockout models may help dissect cell-autonomous and non-cell-autonomous mechanisms underlying phenotypes in LPI.

Quality Improvement at the Laboratory’s Specimen Reception Station

Introduction/Objective

In our 1000-bed acute care tertiary hospital, physicians order laboratory tests via the computerized-provider-order-entry (CPOE) system and print barcode labels (patient demographics/tests ordered) at the computer-on-wheel printer. When tubes with unsuitable barcodes (misaligned, poor quality) are received at the laboratory specimen reception area a fresh barcode is re-printed by our laboratory staff. An incident involving a re- printed barcode label pasted on the wrong blood tube prompted an investigation into the quality of barcodes.

Methods/Case Report

We initiated ‘an opportunity for improvement (OFI) project’ at the laboratory specimen reception station. The OFI team involved Nursing, Information Technology (IT) and Pathology departments aimed to eliminate re-printing of barcode labels by 75% within 6 months. We collated and analyzed reasons for re-printing of barcodes on 3 separate 48-hour periods (27-28 April 2020, 24-25 June 2020, and 13-14 June 2022). A series of interventions and initiatives were implemented.

Results (if a Case Study enter NA)

Re-printed barcodes were from the Emergency Department (56%), Out-patient clinics (7%) and Wards (57%). Root cause analysis(RCA) using the “5 whys” technique categorized re-print causes into staff-related (misaligned barcodes) and printer-related (faint barcodes lines/truncated un-verifiable patient demographics). The team mass-emailed clinicians an educational “Do-You-Know” guide on proper pasting of barcodes on blood tubes and instructions on how to obtain help for printer rectification. These guide documents were placed in the hospital-wide document-sharing portal - Docupedia. Immediate close follow-up with sites that had poor barcodes was done in real-time. Barcode reprints decreased 83% within 2 months - from 174 (27-28 Apr 2020) to 30 (24-25 Jun 2020). A recent audit showed sustained elimination of barcode re-printing: 25 cases (13-14 Jun 2022).

Conclusion

The OFI project has successfully raised the quality of CPOE labels on specimen tubes contributing to process efficiency and safer patient care. Close communication with all care sites and their representatives on the OFI team are critical success factors.

Higher long-term mortality in patients with concomitant acute coronary syndrome and aortic stenosis

Background

Aortic stenosis (AS) and acute coronary syndrome (ACS) share similar cardiovascular risk factors, and their concomitant presentation is increasing in incidence with the aging population. Yet literature regarding the prognosis of patients with concomitant ACS and AS remains scarce.

Methods

This retrospective cohort study examined consecutive patients presenting with ACS (ST-segment elevation myocardial infarction [STEMI] and non-STEMI [NSTEMI]) and concomitant AS between 1 January 2011 and 31 March 2021 in a tertiary hospital. The cohort was divided into mild, moderate and severe AS based on index echocardiogram. The primary outcome was all-cause mortality. Kaplan-Meier curves were constructed to compare all-cause mortality among the three groups of patients, based on ACS type and left ventricular ejection fraction (LVEF). Multivariable Cox regression was performed to identify independent predictors of all-cause mortality.

Results

Of a total of 563 patients, 264 had mild (46.9%), 193 moderate (34.3%) and 106 severe AS (18.8%). The mean follow-up duration was 2.5 (± 2.4) years. Majority of patients (72.5%) presented with NSTEMI. Patients with moderate and severe AS had higher rates of all-cause mortality compared to those with mild AS (49.7% vs. 51.4% vs. 35.6% respectively, p=0.002). Concomitant moderate (HR 1.439, 95% CI 1.012–2.048, p=0.043) and severe AS (HR 1.844, 95% CI 1.159–2.933, p=0.010) were independent predictors of all-cause mortality after adjusting for age, gender, LVEF, ACS type, chronic kidney disease, diabetes, hypertension, coronary artery bypass grafting and aortic valve replacement as a time-dependent variable. The Kaplan-Meier curves demonstrated excess mortality in moderate and severe AS, compared to the mild AS group (p<0.001), with similar survival trends observed in the STEMI and the NSTEMI groups, as well as those with preserved LVEF.

Conclusion

Regardless of the ACS presentation type, long-term excess mortality in those with concomitant moderate or severe AS was observed. The adverse prognosis typically observed in patients with concomitant severe AS, in the setting of ACS, extends to patients with moderate AS.

Funding Acknowledgement

Type of funding sources: None.

Anticancer Activity of Continentalic Acid in B-Cell Lymphoma

Aralia continentalis has been used in Korea as a folk remedy for arthralgia, rheumatism, and inflammation. However, its anti-lymphoma effect remains uncharacterized. Here, we demonstrate that A. continentalis extract and its three diterpenes efficiently kill B-lymphoma cells. Our in vitro and in vivo results suggest that the cytotoxic activities of continentalic acid, a major diterpene from A. continentalis extract, are specific towards cancer cells while leaving normal murine cells and tissues unharmed. Mechanistically, continentalic acid represses the expression of pro-survival Bcl-2 family members, such as Mcl-1 and Bcl-xL. It dissociates the mitochondrial membrane potential, leading to the stimulation of effector caspase 3/7 activities and, ultimately, cell death. Intriguingly, this agent therapeutically synergizes with roflumilast, a pan-PDE4 inhibitor that has been successfully repurposed for the treatment of aggressive B-cell malignancies in recent clinical tests. Our findings unveiled that A. continentalis extract and three of the plant’s diterpenes exhibit anti-cancer activities. We also demonstrate the synergistic inhibitory effect of continentalic acid on the survival of B-lymphoma cells when combined with roflumilast. Taken in conjunction, continentalic acid may hold significant potential for the treatment of B-cell lymphoma.

Differences in Coagulation and Haemostatic Parameters in Normal Women of Childbearing Age from Different Ethnic Groups and Geographical Locations

A comparative study of coagulation and fibrinolytic laboratory parameters was undertaken in four countries (Salvador, Brazil; Singapore; Santiago, Chile and Dublin, Ireland) among apparently healthy women of reproductive age. A continuous external quality control scheme of the laboratory measurements was employed to permit comparison among centres. Significant and consistent differences were found between the four centres. In Dublin, the prothrombin time and activated partial thromboplastin time (APTT) were accelerated, and the specific factor assays showed more activity, whereas the antiprotease levels were higher than in the other centres. In Salvador, a contrasting tendency was found with longer prothrombin times and APTT and lower Factor VII and antiprotease levels. The results from the other two centres were approximately midway between these two extremes. The study has revealed important differences in the coagulation and haemostatic tests between women from widely diverse geographical areas. It is not certain whether these are due to ethnic, nutritional or economic factors but they may be related to the apparent varying incidence of thrombosis in these ethnic groups.

Effectiveness of antibacterial prophylaxis with non-absorbable polymyxin B compared to levofloxacin after allogeneic hematopoietic stem cell transplantation

BACKGROUND

Fluoroquinolones are widely used for antibacterial prophylaxis during neutropenia following hematopoietic stem cell transplantation (HSCT). Nevertheless, data are inadequate as to whether fluoroquinolones decrease mortality rate compared with other antibiotics.

METHODS

We retrospectively compared the efficacy of antibacterial prophylaxis using non-absorbable polymyxin B (PB) (n = 106) or systemic levofloxacin (LVFX) (n = 140) after allogeneic SCT at our institute between 2004 and 2013.

RESULTS

No significant difference was observed between the 2 groups in the cumulative incidences of failure of prophylaxis (P = 0.21), clinically documented infections (P = 0.70), or non-relapse mortality within the first 100 days after transplantation (P = 0.42). With bacteremia, the rate of resistance to LVFX was 82% in the PB group and 100% in the LVFX group (P = 0.41). Also, no significant difference was found in overall survival between the 2 groups (P = 0.78).

CONCLUSION

Our results indicate no difference in the effectiveness of antibacterial prophylaxis between systemic antibiotic LVFX and non-absorbable antibiotic PB.

5 DISRUPTION OF THE HIGH MOBILITY GROUP AT-HOOK 2 (HMGA2) GENE IN SWINE REDUCES POSTNATAL GROWTH

The high mobility group AT-hook 2 (HMGA2) protein has been shown to be a crucial gene for cell growth, proliferation, and apoptosis; HMGA2 is also a strong biological candidate for growth, because mutations in this gene alter body size in mice and humans. Compared with wild-type controls, adult mice lacking HMGA2 are 60% smaller, and adult heterozygous mutants are 20% smaller. In humans, HMGA2 has been associated with adult and childhood height without any other deleterious effect. Additionally, a microdeletion in the HMGA2 gene in a human patient resulted in short stature, with no dysmorphologies and normal puberty. In order to determine the effect of HMGA2 on fetal and adult growth in pigs, a transgenic pig line deficient in HMGA2 expression was generated by gene targeting in fetal fibroblasts (FF). Using a targeting vector carrying a reporter gene, and homology arms specific to HMGA2, heterozygous mutant cell lines were generated. The cell lines were then used to generate 6 heterozygous females by somatic cell nuclear transfer (SCNT). Bodyweights and lengths from snout to base of tail were measured every 2 weeks for a year for mutant (n = 6) and wild-type farm gilts (n = 6). Data were analysed by one-way ANOVA. As in mice, disruption of one allele of the HMGA2 gene resulted in 25% reduction in weight (P < 0.0001) and 14% reduction in length (P < 0.0001). Early in postnatal growth (2 months), weights of mutants were not different than wild-type. However, mutants were 20 to 35% lighter (P < 0.05) during mid stages (6 months) and 25 to 30% (P < 0.0001) in late stages (3 months). The same insertional mutation generated 8 heterozygous male clones by SCNT. In addition, 7 nontransgenic males from the same FF line were generated as SCNT controls. Bodyweights and lengths were measured every 2 weeks for 30 weeks for HMGA2 heterozygous mutants (n = 8), control SCNT (n = 7) and wild-type farm boars (n = 5). The weight curve of boars showed similar pattern as for mutant gilts. At 30-week postnatal stage, mutants were 17% (P < 0.05) and 16% (P < 0.05) lighter in weight compared with littermate and wild-type animals, respectively. We are presently developing homozygous HMGA2 mutant lines. Currently, 3 of 6 heterozygous gilts have been bred with heterozygous boars, with 1 confirmed pregnancy. The expectation is that the homozygous animals will, like mice, be 60% smaller than the wild-type animals. The approach described here will result not only in a valuable large-animal model of dwarfism, but also in a tool to reduce the size of existing transgenic and nontransgenic swine lines. This, in turn, will increase the receptivity of valuable transgenic lines by the biomedical community. Funding for this work was provided by NIH grant R21-OD010553 to JP.

Formation of TiSi2 During Rapid Thermal Annealing: In Situ Resistance Measurements at Heating Rates From 1°C/S to 100°C/S

In VLSI technology, there is interest in monitoring the sequence of phase formation of TiSi2 (c-Ti ⇒ a-TiSi ⇒ C49 TiSi2 ⇒ C54 TiSi2), with the prospect of reducing the temperature of formation of the stable C54 TiSi2 phase. In this study, phase formation characteristics of TiSi2 during rapid thermal annealing(RTA) of Ti-Si bilayers are investigated by means of in situ four point probe resistance measurements. Ex situ X-ray diffraction(XRD) was used for phase identification and characterization. Results indicate that the same multi-step sequence of transformations precede the formation of the C54 TiSi2 phase for heating rates from 1°C/s to 100°C/s. Also, all intermediate and metastable phases which occur at l°C/s also occur at 100°C/s. Temperature dependence and kinetics of the C49 TiSi2 and the C54 TiSi2 phase formation were studied over a wide range of heating rates. Activation energies estimated for the two processes were ∼2eV and ∼5eV respectively. Finally, a new Electrical Thermal Annealing(ETA) technique for heating at rates up to 30000°C/s is introduced. Preliminary in situ resistivity measurement results of TiSi2 formation at these high heating rates are also presented.

Biodegradation of 2,4-Dichlorophenol through a Distal meta-Fission Pathway

Alcaligenes eutrophus JMP222, a derivative of A. eutrophus JMP134 which has lost plasmid pJP4 (encoding the tfd genes for the ortho fission pathway), was induced for the meta fission pathway when grown on o-cresol. Resting cell suspensions, grown on o-cresol, oxidized 2,4-dichlorophenol (2,4-DCP), a degradation product of 2,4-dichlorophenoxyacetic acid, to 3,5-dichlorocatechol. Further degradation of 3,5-dichlorocatechol was observed by the production of a yellow ring fission product with liberation of chloride. Oxidation of 2,4-DCP (305 (mu)M) in 47 hs resulted in 69% dehalogenation through this pathway. The ring fission product was characterized as 2-hydroxy-3,5-dichloro-6-oxo-hexa-2,4-dienoic acid by gas chromatography-mass spectrometry and gas chromatography-Fourier transform infrared spectroscopy. These data indicate that 2,4-DCP is degraded through a distal meta ring fission pathway, in contrast to either a suicidal proximal fission or the standard ortho fission pathway.

Trigger digits in diabetes: their incidence and characteristics

The purpose of this study was to investigate the incidence and characteristics of trigger digits in patients with diabetes. A questionnaire about trigger digit was completed by 544 patients with diabetes. Ten percent of the patients had a history of trigger digits and 4% had multiple digit involvement. The risk was significantly higher in insulin-dependent patients. The average duration of diabetes was significantly longer in the multiple digit group. Independently, the medical records of 132 trigger digit patients who underwent surgery were reviewed. Twenty-seven patients had diabetes, and 62 patients had multiple digit involvement. Involvement of more than three digits was significantly related to co-existing diabetes. In patients with diabetes, the incidence of trigger digits was about four times higher than in the general population. Screening for diabetes may be warranted in patients with involvement of more than three digits.

Accuracy of amplitude integrated EEG in a neonatal cohort

OBJECTIVE

To determine the sensitivity and specificity of amplitude integrated electroencephalogram (aEEG) compared to simultaneous standard electroencephalogram (sEEG) for seizure detection and background discontinuity.

DESIGN

Prospective paired cohort.

SETTING

Tertiary academic neonatal intensive care unit.

PATIENTS

Infants were recruited from 2005 to 2008. Neonates requiring sEEG were recruited for simultaneous aEEG.

INTERVENTIONS

Following sEEG and aEEG, seizures were recorded as present or absent, and background was recorded as normal or discontinuous in each format.

MAIN OUTCOME MEASURES

Presence of at least one seizure during recording. The background activity was reported as normal or discontinuous. Discontinuity of brain activity was further ranked as mild, moderate or severe.

RESULTS

51 sEEG and aEEG studies were completed. 44 studies were analysed for presence of seizures and 46 were analysed for background discontinuity. Sensitivity for presence of seizures by aEEG was 80% and specificity was 50%. The proportion of infants with seizures were overdiagnosed by aEEG (63.6% vs 45.5% for sEEG p=0.045). Discontinuity of background activity had higher sensitivity (88.6%) and specificity (54.5%) when compared with seizure detection. When stratified by indication for EEG, hypoxic episode (n=14) or suspected seizures (n=33), similar sensitivity for presence of seizure (80%) was noted by aEEG and sEEG. However the specificity of aEEG for seizure detection was higher in neonates undergoing EEG for suspected seizures (66.7% vs 22.2%).

CONCLUSIONS

Background abnormalities were detected with fair accuracy by aEEG but aEEG criteria alone would result in the overdiagnosis of neonatal seizures. Therefore seizures noted on aEEG require sEEG confirmation prior to implementing anticonvulsant therapy for neonatal seizures.

FDG-PET/MRI coregistration improves detection of cortical dysplasia in patients with epilepsy

OBJECTIVE

Patients with cortical dysplasia (CD) are difficult to treat because the MRI abnormality may be undetectable. This study determined whether fluorodeoxyglucose (FDG)-PET/MRI coregistration enhanced the recognition of CD in epilepsy surgery patients.

METHODS

Patients from 2004-2007 in whom FDG-PET/MRI coregistration was a component of the presurgical evaluation were compared with patients from 2000-2003 without this technique. For the 2004-2007 cohort, neuroimaging and clinical variables were compared between patients with mild Palmini type I and severe Palmini type II CD.

RESULTS

Compared with the 2000-2003 cohort, from 2004-2007 more CD patients were detected, most had type I CD, and fewer cases required intracranial electrodes. From 2004-2007, 85% of type I CD cases had normal non-University of California, Los Angeles (UCLA) MRI scans. UCLA MRI identified CD in 78% of patients, and 37% of type I CD cases had normal UCLA scans. EEG and neuroimaging findings were concordant in 52% of type I CD patients, compared with 89% of type II CD patients. FDG-PET scans were positive in 71% of CD cases, and type I CD patients had less hypometabolism compared with type II CD patients. Postoperative seizure freedom occurred in 82% of patients, without differences between type I and type II CD cases.

CONCLUSIONS

Incorporating fluorodeoxyglucose-PET/MRI coregistration into the multimodality presurgical evaluation enhanced the noninvasive identification and successful surgical treatment of patients with cortical dysplasia (CD), especially for the 33% of patients with nonconcordant findings and those with normal MRI scans from mild type I CD.

234 PARTHENOGENETIC ACTIVATION OF DOMESTIC CAT OOCYTES USING STRONTIUM

Cloning domestic cats is useful in comparative medicine programs as it may provide insight into unique disease mechanisms and facilitate investigation of new therapeutic options. It is also believed to be beneficial for the conservation of precious animal models. However, as in many species, low birth rates after nuclear transfer remain a formidable challenge. One potential reason for the low efficiency is poor embryo development following activation of the reconstructed oocytes. The number of methods available to induce a transient increase in the oocytes' cytosolic free calcium level to stimulate development is rather limited. Although strontium has been reported to successfully activate the developmental program of mature mouse and rat oocytes, it was without effect in all other species studied. Here we investigated the effect of strontium on mature cat oocytes. Oocytes collected from the cat ovaries were matured in vitro in Feline Optimized Culture Medium (FOCM) supplemented with 0.6 mm cysteine, 0.1 mm cysteamine, 1 IU mL–1 eCG, 2 IU mL–1 hCG, 25 ng mL–1 epidermal growth factor (EGF) for 24 h. For intracellular calcium measurements, mature oocytes were incubated in the presence of 2 µ m fura-2Am, a calcium indicator dye, and 0.02% pluronic F-127 for 40 min. Individual oocytes were transferred into calcium-free HEPES, and SrCl2 was added to the medium at a final concentration of 20 mm. Changes in the intracellular free calcium levels were then monitored using an InCyt Im2™ fluorescence imaging system (Intracellular Imaging, Cincinnati, OH, USA). Preimplantation embryonic development was also evaluated by incubating the oocytes with 20 mm SrCl2 in calcium-free HEPES medium supplemented with 7.5 µg mL–1 cytochalasin B for 6 h. Control oocytes were activated by two 20-µs-long, 100 kV cm–1 direct current pulses and incubated in the presence of 7.5 µg mL–1 cytochalasin B for 6 h. After activation, the oocytes were cultured in FOCM for 6 days. At the end of the culture period, embryonic development was recorded; the nuclear number of the embryos was also determined after staining with Hoechst 33342. Data were subjected to one-way ANOVA, and differences between treatments were analyzed using the Tukey test. We found that strontium triggered a transient rise in the intracellular free calcium concentration in all oocytes tested (N = 20). Strontium treatment also induced cleavage in 49.7% (92/185) of the oocytes, while 4.9% (9/185) of the activated oocytes developed to the blastocyst stage. In the electroporated group, cleavage frequency was 57.1% (104/182) and blastocyst formation was 8.8% (16/182). Data analysis showed that there was no significant difference between the two groups in terms of cleavage frequency and blastocyst formation. This is the first study to demonstrate that strontium can induce cytoplasmic calcium increase in cat oocytes and trigger development up to the blastocyst stage. The results also indicate that SrCl2 may be useful for oocyte activation during cat nuclear transfer. Additional studies are needed to determine whether SrCl2 can trigger development more effectively than current activation techniques.

Development of symptom assessment tool for terminal cancer patients

19634

Background: A symptom assessment is important to control the terminal cancer patients’ symptoms successfully and improve their quality of life. Our research team has developed the objective assessment method for the terminal patients’ symptoms and compared the results with the patient self-reported outcomes using Memorial Symptom Assessment Scale (MSAS). Methods: From September in 2004, the 121 inpatients without anti-cancer therapy in terminal stage of cancer were evaluated in Kangnam St. Mary's Hospital. The 17 common symptoms were graded as four categories; none(0), mild(1), moderate(2), and severe(3) with reference to NCI-CTC and WHO toxicity criteria. An attending physician assessed 17 symptoms at the similar hour every day. Among the inpatients, those who had clear consciousness and could communicate normally were investigated every week to evaluate the frequency and severity of common symptoms and their distress degree using MSAS. Results: Only 54 patients (44.6%) could be examined to evaluate the symptoms by MSAS. However, the symptoms estimated by our assessment tool were less serious in the terms of severity and distress degree than that patients felt actually. This tendency was shown more obviously in the mental symptoms; Drowsiness (p=0.0001), Nervousness (p=0.0001), and Anxiety (p=0.005). However, the physical symptoms had no statistical difference between the results from patients and physician. Conclusions: Patient-reported outcomes using MSAS could be obtained from 44.6% of the inpatients with terminal cancer every week. However, the objective assessment tool to evaluate the common symptoms of terminal cancer patients can be applied for all patients including the incommunicable, every day. Furthermore, this assessment tool may be more suitable for examining the physical symptoms of terminal cancer patients.

No significant financial relationships to disclose.

Infantile spasm-associated microencephaly in tuberous sclerosis complex and cortical dysplasia

OBJECTIVE

In children with and without infantile spasms, this study determined brain volumes and cell densities in epilepsy surgery patients with tuberous sclerosis complex (TSC) and cortical dysplasia with balloon cells (CD).

METHODS

We compared TSC (n = 18) and CD (n = 17) patients with normal/autopsy controls (n = 20) for MRI gray and white matter volumes and neuronal nuclei (NeuN) cell densities.

RESULTS

In patients without a history of infantile spasms, TSC cases showed decreased gray and white matter volumes (-16%). In cases with a history of infantile spasms, both CD (-25%) and TSC (-35%) patients showed microencephaly. This was confirmed in monozygotic twins with TSC, where the twin with a history of spasms had cerebral volumes less (-16%) than the twin without a history of seizures. Regardless of seizure history, TSC patients showed decreased NeuN cell densities in lower gray matter (-36%), whereas CD patients had increased densities in upper cortical (+52%) and white matter regions (+65%). For TSC patients, decreased lower gray matter NeuN densities correlated with reduced MRI volumes.

CONCLUSIONS

Patients with tuberous sclerosis without spasms showed microencephaly associated with decreased cortical neuronal densities. In contrast, cortical dysplasia patients without spasms were normocephalic with increased cell densities. This supports the concept that tuberous sclerosis and cortical dysplasia have different pathogenetic mechanisms despite similarities in refractory epilepsy and postnatal histopathology. Furthermore, a history of infantile spasms was associated with reduced cerebral volumes in both cortical dysplasia and tuberous sclerosis patients, suggesting that spasms or their treatment may contribute to microencephaly independent of etiology.

Death predicictive factor in terminal cancer patients

18627

Background: One of the most important role of a end-of-life care is to control physical symptoms of patients and help them to face comfortable end. In terminally ill cancer patients, accurate prediction of survival is necessary for clinical and ethical reasons, especially in helping to avoid harm, discomfort and inappropriate therapies and in planning specific care strategies. The aim of the study was to investigate prognostic factor of death for the patients with terminal cancer. Methods: We enrolled 121 patients with the terminal cancer of Kangnam St. Mary’s Hospital from September 2004 until their death. We observed symptoms shown in dying patients and assess 17 common symptoms shown in terminally ill cancer patients, performance status, pain and analgesic use. The common symptoms were measured in a score of 0-none, 1-mild, 2-moderate, 3-severe or 4-severe by objective criteria. Results: Mean period from enrollment to death was 34.7days. The most important prognostic factor is performance status (KPS), average KPS at enrollment is 52.2% and at last 48hours is 29.8%. Physical symptoms that have significant prognostic importance are weakness, anorexia, dry mouth, dysphagia, dyspnea. VAS and analgesic use dose not impact on the prognosis. But cognitive impairment and delirium are the reliable prognostic factor. Especially weakness, dry mouth, poor oral intake, drowsiness, edema, dyspnea, ascites, icterua gradually worsened with significance. Dying patients showed markedly decreased blood pressure, cyanosis, cold extremity, death rattle, abnormal respiration frequently at 48hours before death. Conclusions: Terminally ill cancer patients have various prognostic factor and the most important factor is performance status. The death predictive symptoms such as markedly decreased pressure, cyanosis, cold extremity, death rattle, abnormal respiration appeared at last 48hours. If we assess the symptoms more carefully, we can predict the more accurate prognosis. The communication about the prognostic information will influence the personal therapeutic decision and specific care planning.

No significant financial relationships to disclose.

Magnetic source imaging localizes epileptogenic zone in children with tuberous sclerosis complex

The authors assessed whether magnetoencephalography/magnetic source imaging (MEG/MSI) identified epileptogenic zones in patients with tuberous sclerosis complex (TSC). In six TSC children with focal seizures, ictal video-EEG predicted the region of resection with 56% sensitivity, 80% specificity, and 77% accuracy (p = 0.02), whereas interictal MEG/MSI fared better (100%, 94%, and 95%, respectively; p < 0.0001). Interictal MEG/MSI seems to identify epileptogenic zones more accurately in children with TSC and focal intractable epilepsy.