Disease progression in mothers of children enrolled in the Research Registry for Neonatal Lupus

OBJECTIVE

To evaluate autoimmune disease progression in asymptomatic and pauci-symptomatic mothers of children with neonatal lupus (NL).

METHODS

Clinical information on mothers enrolled in the Research Registry for NL (RRNL) was obtained from medical records. Genotyping was performed for -308A/G tumour necrosis factor (TNF)alpha, 869T/C transforming growth factor (TGF)beta and -889C/T interleukin (IL)1alpha.

RESULTS

Of the 321 mothers enrolled, 229 had at least 6 months of follow-up. Of the 51 mothers who were asymptomatic at the NL child's birth, 26 progressed: 12 developed pauci-undifferentiated autoimmune syndrome (pauci-UAS), 2 poly-UAS, 7 SS, 4 SLE and 1 SLE/SS. The median time to develop any symptom was 3.15 years. Of the 37 mothers classified as pauci-UAS at the NL child's birth, 16 progressed: 5 developed poly-UAS, 6 Sjögren syndrome (SS), 4 systemic lupus erythematosus (SLE) and 1 SLE/SS. Of the pauci-UAS mothers enrolled within 1 year, the median time to progression was 6.7 years. Four mothers developed lupus nephritis (two asymptomatic, two pauci-UAS). The probability of an asymptomatic mother developing SLE by 10 years was 18.6%, and developing probable/definite SS was 27.9%. NL manifestations did not predict disease progression in an asymptomatic mother. Mothers with anti-Sjögren syndrome A antigen (SSA/)Ro and anti-Sjögren syndrome B antigen (SSB)/La were nearly twice as likely to develop an autoimmune disease as mothers with anti-SSA/Ro only. Only TGFbetaT/T was significantly higher in SLE mothers compared to asymptomatic mothers (p = 0.03).

CONCLUSIONS

Continued follow-up of asymptomatic NL mothers is warranted since nearly half progress, albeit few develop SLE. While the anti-SSB/La antibodies may be a risk factor for progression, further work is needed to determine reliable biomarkers in otherwise healthy women with anti-SSA/Ro antibodies identified solely because of an NL child.

Measuring attentional bias to peripheral facial deformities

OBJECTIVES

Introduce a novel method for objectively evaluating attentional bias to peripheral facial deformities using an established metric of attention.

METHODS

The SMI eye-tracker system (SensoMotoric Inc., Boston, MA) was used to record the eye movement patterns, called scanpaths, of eight naïve observers gazing at pictures of faces with or without peripheral surgical deformities. The scanpaths of observers gazing on those novel faces were compared, and the fixation durations for different facial regions were compared between faces.

RESULTS

There were statistically significant differences in the mean fixation times between the faces considered normal and those considered abnormal (those with an obvious defect). When multivariate analysis of variance was performed with dependent variables total fixation time, fixation time in central triangle, and fixation time in the defect region and the independent variable face, all four tests were highly statistically significant. When univariate analysis of variance was performed to test the hypothesis that defect fixation times varied by face, the results were highly statistically significant (F = 8.79, P = .0003).

CONCLUSIONS

Observers gazing on faces typically focus their attention on discriminating features, such as eyes, nose, and mouth. The well-established method of eye movement recordings was applied in a novel way to provide quantitative data showing changes in observer gaze patterns to focus on deformities. These gaze patterns are a direct reflection of observer attention. This is the first objective method to quantify the amount of distraction caused by peripheral facial deformities and may provide insight into the perception of facial deformity.

Pregnancy and cystic fibrosis

A 20-year old parturient with moderate to severe cystic fibrosis presented for an Elective Caesarean Delivery at 31 weeks gestation due to intra-uterine growth retardation and persistent maternal weight loss. The procedure was successfully performed using a combined spinal-epidural anaesthetic technique. A review of the literature is presented and the anaesthetic implications of pregnancy in cystic fibrosis patients are discussed.

S114 – Thresholds for Visual Perception of Facial Asymmetry

Objectives

To determine the degree of facial asymmetry which is required to trigger conscious perception in the observer.

Methods

A normal face was manipulated typical to facial paralysis changes, using advanced computer program to create progressive images of increasing asymmetry, in one millimeter increments, up to 10 mm. This was performed on 1) brow, 2) oral commissure, and 3) combined brow and oral commissure. The study included both altered and unaltered versions of the model face, in addition to other unaltered images. Images were presented to volunteer observers unaware of the purpose of the study.

Results

I) Oral commissure asymmetry: the threshold for visual perception was 3 mm by the majority of people (73%) when each image was presented for 10 seconds. When up to 4 mm of mouth angle asymmetry was noticed, it was perceived as “noticeable, but acceptable” by 83%, while 6 mm or greater of asymmetry was perceived as “unacceptable” by 60%. Presenting the images for 2 sec/image (quick look) demonstrated that 53% detected the asymmetry at 5 mm. II) Brow asymmetry: 70% perceived the asymmetry at 3 mm. III) Combined oral commissure and eye brow: 100% of people perceived the oral commissure asymmetry at a lower threshold than the brow asymmetry.

Conclusions

The pilot data and the discussion will provide insight into the processes of visual perception of facial asymmetry, and guidance for surgeons and patients sorting through their options. Further efforts are under way to pursue these concepts in 3-dimensional, dynamic subjects.

Pharmacokinetics of acetyl-L-carnitine given in single or multiple doses to HIV-1 Infected patients with toxic peripheral polyneuropathy

The use of nucleoside reverse transcriptase inhibitors in the treatment of HIV infection is associated with antiretroviral toxic polyneuropathy (ATN). Previous studies suggest that long term treatment with Acetyl-L-carnitine (ALCAR) 1.5 gram twice daily improves symptoms and promotes nerve regeneration. It is unknown whether the drug’s pharmacokinetic profile would allow for a once daily administration. Twenty three HIV-1 infected subjects taking ALCAR for ATN were enrolled in a cross over trial and switched from twice to once daily dosing. Their regimen was changed from 1.5g twice daily to 1g (4 patients), 2g (7), and 3g (12) once daily, respectively. Twelve healthy volunteers served as control. Plasma levels of ALCAR and its metabolite L-carnitine were measured. Patients receiving ALCAR had higher pre-dose levels than control subjects. Post dose levels were not significantly higher than pre dose levels in any treatment group. The pre / post dose ALCAR concentrations were 7.6 / 7.7, 7.1 / 6.8, 7.7 / 6.8, and 7.1 / 7.5 µmol/l for 1.5g twice daily, 1g once daily, 2g once daily, and 3g once daily, respectively. All values were significantly higher than the mean concentration in the control group (4.3 µmol/l). For ALCAR and L-carnitine, measurements for once daily regimens did not differ from the twice daily regimen. Once daily dosing of ALCAR can achieve similar plasma levels as twice daily dosing but intra-mitochondrial levels remain unknown. The pharmacokinetic profile of orally administered ALCAR is complex and likely to be highly affected by endogenous concentrations.

A principle for learning egocentric-allocentric transformation

Numerous single-unit recording studies have found mammalian hippocampal neurons that fire selectively for the animal's location in space, independent of its orientation. The population of such neurons, commonly known as place cells, is thought to maintain an allocentric, or orientation-independent, internal representation of the animal's location in space, as well as mediating long-term storage of spatial memories. The fact that spatial information from the environment must reach the brain via sensory receptors in an inherently egocentric, or viewpoint-dependent, fashion leads to the question of how the brain learns to transform egocentric sensory representations into allocentric ones for long-term memory storage. Additionally, if these long-term memory representations of space are to be useful in guiding motor behavior, then the reverse transformation, from allocentric to egocentric coordinates, must also be learned. We propose that orientation-invariant representations can be learned by neural circuits that follow two learning principles: minimization of reconstruction error and maximization of representational temporal inertia. Two different neural network models are presented that adhere to these learning principles, the first by direct optimization through gradient descent and the second using a more biologically realistic circuit based on the restricted Boltzmann machine (Hinton, 2002; Smolensky, 1986). Both models lead to orientation-invariant representations, with the latter demonstrating place-cell-like responses when trained on a linear track environment.

The prognostic impact of occult lymph node metastasis in cancer of the esophagus or esophago-gastric junction: systematic review and meta-analysis

Attempts to define the clinical significance of occult lymph node metastasis have yielded mixed results. We set out to quantify the influence on disease-free survival of occult lymph node metastasis in cases of esophageal or gastro-esophageal cancer previously staged as lymph node-negative by conventional H&E staining. We performed a systematic review and meta-analysis of observational studies published between 1966 and 2006 (identified through Medline and Embase). Twelve suitable cohort studies were identified. These studies suggest there is a significant (P < 0.001) association between occult lymph node metastasis and prognosis in cancer of the esophagus or esophago-gastric junction (pooled hazard ratio 3.16 with 95% confidence intervals of 2.25-4.42). We did not demonstrate study quality, number of nodes examined or number of lymph node sections examined to be significant sources of intertrial heterogeneity. Data from observational studies suggest that occult lymph node metastasis is an important prognostic factor in cancer of the esophagus or gastro-esophagus. Meta-analysis using individual patient data can now be justified.

Quality assurance of computed and digital radiography systems

Computed radiography (CR) and digital radiography (DR) are replacing traditional film screen radiography as hospitals move towards digital imaging and picture archiving and communication systems (PACS). Both IPEM and KCARE have recently published quality assurance and acceptance testing guidelines for DR. In this paper, the performance of a range of CR and DR systems is compared. Six different manufacturers are included. Particular attention is paid to the performance of the systems under automatic exposure control (AEC). The patient is simulated using a range of thicknesses of tissue equivalent material. Image quality assessment was based on detector assessment protocols and includes pixel value measures as well as subjective assessment using Leeds Test Objects. The protocols for detector assessment cover a broad range of tests and in general detectors (whether DR or CR) performed satisfactorily. The chief limitation in performing these tests was that not all systems provided ready access to pixel values. Subjective tests include the use of the Leeds TO20. As part of this work, suggested reference values are provided to calculate the TO20 image quality factor. One consequence of moving from film screen to digital technologies is that the dynamic range of digital detectors is much wider, and increased exposures are no longer evident from changes in image quality. As such, AEC is a key parameter for CR and DR. Dose was measured using a standard phantom as a basic means of comparing systems. In order to assess the AEC performance, exit doses were also measured while varying phantom thickness. Signal-to-noise ratios (SNRs) were calculated on a number of systems where pixel values were available. SNR was affected by the selection of acquisition protocol. Comparisons between different technologies and collation of data will help refine acceptance thresholds and contribute to optimising dose and image quality.

The Maudsley early onset schizophrenia study. Predictors of psychosocial outcome at 4-year follow-up

OBJECTIVE

To examine the contribution of premorbid function, duration of untreated psychosis (DUP), age of onset, severity of symptoms at presentation, and number of subsequent hospitalisations to the outcome of early onset schizophrenia (EOS; onset before 17th birthday).

METHOD

Twenty-three EOS patients (mean age at onset 15.16 +/- 1.39 years) were re-assessed after a mean interval of 4 +/- 1.08 years. At baseline and follow-up clinical diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Axis I Disorders and symptoms were assessed with the Positive and Negative Syndrome Scale. Premorbid function, as measured with the Premorbid Adjustment Scale, age of onset and DUP were assessed at baseline only. Outcome was evaluated using the Social Adaptation Self-Evaluation Scale (SASS) and the Global Assessment of Functioning (GAF) Scale.

RESULTS

Mean DUP was 2.95 +/- 3.59 months and mean total PAS score was 6.65 +/- 3.02. They had an average of 2.09 +/- 1.44 hospitalisations and their mean SASS and GAF scores were 37.27 +/- 6.5 and 54.19 +/- 18.99, respectively. Poor childhood premorbid function and the severity of negative symptoms at baseline were correlated with worse SASS and GAF scores. No other significant associations were found.

CONCLUSIONS

Poor childhood function is the most significant predictor of outcome in EOS.

Remembering the past and imagining the future: a neural model of spatial memory and imagery

The authors model the neural mechanisms underlying spatial cognition, integrating neuronal systems and behavioral data, and address the relationships between long-term memory, short-term memory, and imagery, and between egocentric and allocentric and visual and ideothetic representations. Long-term spatial memory is modeled as attractor dynamics within medial-temporal allocentric representations, and short-term memory is modeled as egocentric parietal representations driven by perception, retrieval, and imagery and modulated by directed attention. Both encoding and retrieval/imagery require translation between egocentric and allocentric representations, which are mediated by posterior parietal and retrosplenial areas and the use of head direction representations in Papez's circuit. Thus, the hippocampus effectively indexes information by real or imagined location, whereas Papez's circuit translates to imagery or from perception according to the direction of view. Modulation of this translation by motor efference allows spatial updating of representations, whereas prefrontal simulated motor efference allows mental exploration. The alternating temporal-parietal flows of information are organized by the theta rhythm. Simulations demonstrate the retrieval and updating of familiar spatial scenes, hemispatial neglect in memory, and the effects on hippocampal place cell firing of lesioned head direction representations and of conflicting visual and ideothetic inputs.

[Technology in the background of the improvement of anemia treatment]

The Renal Anaemia Management (RAM) Programme is a unique service available in 18 major renal centres around Australia. Since its inception some 6 years ago, the software package has been modified to accommodate the needs of the renal team and the renal patient population. In addition, with the support of nephrologists, the RAM software has created a specialised role, that of the Renal Anaemia Coordinator (RAC). The RAM software collects clinical data and patient characteristics from patients with anaemia associated with renal disease. This is an integral part of a national exchange of information for the optimal management of the overall health of the renal patient population. The RAM database is a valuable tool that has changed the practice of anaemia management and improved the outcomes of patients with renal insufficiency. RAM provides a rapid method of reviewing haematological and biological parameters on a regular basis with a multidisciplinary approach. At a glance, RACs can now detect trends in determining vascular access programming, dietetic review, and patient education and support services. This has allowed the Renal Anaemia service to reach common goals and improve outcomes. The RAC provides a point of contact and education for patient, family members and their general practitioner's regarding erythropoietin therapy. This advancement in technology has revolutionised the collection of information about individual patients and their presenting history of renal failure. It has also allowed for earlier recognition and treatment of renal disease.

Hydroview lens implant calcification: 186 exchanges at a district general hospital

AIM

This paper describes the experience at a district general hospital of coping with an abrupt onset of calcification of Hydroview intraocular lens (IOL) implants requiring exchange surgery mostly for symptoms of glare, even though the visual acuities were relatively good.

METHODS

In this retrospective study, the operative details of 174 consecutive lens exchanges by one surgeon were retrieved from the surgeon's notes. Of these, pre and post-operative details of 106 consecutive patients were obtained from the hospital notes.

RESULTS

Of the 174 lens exchanges, all were sutureless except one and 31 eyes (18%) had had previous capsulotomies. Of 143 eyes with intact posterior capsules, eight (5.6%) needed anterior vitrectomy. Lens replacements were in the bag in 136 (95%), in the sulcus in five (3.5%), and in the anterior chamber in two (1.5%). Of the 31 eyes with previous capsulotomies, 10 (32%) needed anterior vitrectomy. Lens replacements were in the bag in 22 (71%) and in the sulcus in the remaining nine cases (29%). Postoperatively the best-corrected visual acuity was improved in 53%, remained the same in 35%, and deteriorated in 12%.

CONCLUSION

The lens exchange procedure was mostly predictable with satisfactory visual results allowing preoperative counselling of risks to be similar to that for cataract surgery. The onset and resolution of the period of implantation of lenses requiring exchange has not been explained.

Smoking and alcohol in pregnancy. Survey in the immediate post-partum period

This was a questionnaire-based study of 151 postnatal women. We found 42% of women were smokers prior to pregnancy and only 37% of these women succeeded in quitting smoking during pregnancy. Success in quitting was significantly related to the number of cigarettes smoked (p<0.05). However, 71% of pregnant smokers were aware of the associated risks. Alcohol was consumed by 89% of women and 10% admitted to binge drinking during pregnancy. Only 44% of the study group were aware of the associated risks of alcohol. We propose that we need to change our social acceptance of these behaviours before pregnancy, and provide support to those women during pregnancy.

Study of ovarian cancer management

Ovarian cancer is the most lethal gynecological malignancy. Many patients present at an advanced stage as the symptoms of early stage disease can be vague. AIM We evaluated the demographics, treatment regimens and survival rates of ovarian cancer patients attending Beaumont Hospital Dublin over a nine year period. A retrospective chart review of ovarian cancer patients attending Beaumont Hospital between 11/10/94 and 30/6/3 was performed. Patients were selected from pathology records. Patients with borderline histology and those who died of unrelated causes were excluded. 31% of individuals presented with distension as their only clinical sign. 20% presented with a mass as their only clinical sign. The most common cell type was papillary serous adenocarcinoma in two thirds of cases. 54% presented with advanced disease [stage IIl-IV]. Treatment involved surgical clearance or debulking +/- chemotherapy. 5 year survival for Stage I was 95% versus 19% for Stage IlI. This highlights the importance of early diagnosis.

Neoadjuvant chemoradiation may increase the risk of respiratory complications and sepsis after transthoracic esophagectomy

BACKGROUND

The role of neoadjuvant chemotherapy and radiation therapy before resection in esophageal cancer remains controversial. Operative risks may be increased, but this has not been systematically addressed in published trials or reports.

METHODS

This was a prospective, nonrandomized, restricted cohort design of patients (n = 200) from 1997 to 2003 with resectable cancer of the esophagus or esophagogastric junction. A total of 102 patients underwent multimodal therapy with 5-fluorouracil, cisplatin, and radiation therapy before surgery, and 98 patients opted for surgery alone. In-hospital mortality and morbidity were the primary end points, and cancer survival was a secondary end point.

RESULTS

In patient cohorts matched for operative risk factors, the odds ratio for postoperative sepsis (P = .007), respiratory failure (P = .009), and acute respiratory distress syndrome (P = .02) was increased in the multimodal group. There was no significant difference between groups comparing median and 1-, 2-, and 3-year survivals.

CONCLUSIONS

Multimodal therapy was associated with increased respiratory and septic complications compared with a surgery-only cohort undergoing the equivalent surgery. Respiratory failure was in most cases idiopathic. The data suggest that efforts should be made to limit radiation lung exposure in multimodal regimens, and to understand and modulate the local and systemic effects of preoperative chemoradiation.

Is vaginal breech delivery outdated for all singletons and twins? The current kaleidoscope of obstetric thinking

The best practice for the delivery of a term breech in singleton and twin pregnancies is still controversial. We sought the opinions of obstetricians working in Ireland. A questionnaire was used to address the management of the obstetrician's "own hypothetical pregnancy" in three different scenarios. We also inquired about factors which might influence the decision on mode of delivery. The response rate was 104/174 (60%). In the scenario of a singleton fetus presenting by the breech in a nulliparous woman, 15/84 (18%) of obstetricians would chose a spontaneous vaginal delivery compared to 40/80 (50%) for a multiparous woman (p < 0.01). In the scenario of a second twin in breech presentation (nulliparous and multiparous), 75/93 (81%) would choose a spontaneous vaginal delivery. When asked about a singleton cephalic presentation, 85/91 (93%) would choose a spontaneous vaginal delivery. These decisions were influenced by concerns about perinatal morbidity [91/100 (91%)], published evidence [73/98 (75%)], the delivery doctor's inexperience [56/94 (60%)], but not by gender. Our study indicates that obstetricians in Ireland consider that there is a role for vaginal breech delivery in selected scenarios.

Pregnancy outcome in immigrant women in the Rotunda Hospital

In recent years the numbers of immigrants attending maternity hospitals has risen. The amount of antenatal care these women receive varies widely. Analysis was performed of deliveries to immigrant women in the Rotunda Hospital in 2002. Women were sub-divided depending on antenatal care received in Ireland. Women who received no antenatal care were 'unbooked', those who attended the hospital two to 28 days before delivery were 'late bookers'. The remaining women were 'booked'. There were 1,954 deliveries to immigrant women; 1,1 73 (60%) 'booked', 391 (20%) 'late bookers' and 390 (20%) 'unbooked'. 'Unbooked' women had a higher rate of spontaneous vertex delivery (63%) (p < 0.01). 'Late bookers' had a higher rate of caesarean section (27.6%) (p < 0.01). The 'late bookers' infants were more likely to be preterm, low birth weight and had a higher rate of neonatal ICU (NICU) admissions (p < 0.01). This study has identified 'late booker' immigrants as a high-risk group.

Image-guided osteoplastic frontal sinusotomy

BACKGROUND

A 6-ft Caldwell radiograph template and transillumination, typically, are used to elucidate the frontal sinus outline for osteoplastic frontal sinusotomy (OFS). These techniques can be fraught with imprecision. The consequences of imprecise OFS may result in significant complications. Computer-aided surgery may offer a safe and accurate alternative to these techniques in selected cases. Several disadvantages were noted with early computer-aided assistance. Current infrared and electromagnetic systems have eliminated many of these disadvantages. We describe our technique and experience with an infrared image-guidance system (The LandmarX Evolution; Medtronic Xomed, Jacksonville, FL) to create a precise OFS that maximizes exposure while minimizing morbidity.

METHODS

We describe the use of an infrared image guidance system, the LandmarX Evolution for OFS in three cases.

RESULTS

The LandmarX Evolution allowed for accurate placement of the OFS in each of the three cases and successful treatment of two symptomatic frontal sinus osteomas and a recurrent inverted papilloma. No complications were encountered.

CONCLUSION

Image-guided OFS results in a confident and accurate entry into the frontal sinus. Image-guided OFS creation should be considered for select cases (i.e., complete opacification and altered anatomy) where performing an OFS by standard techniques may increase the complication rate. More experience with the technique and increased accessibility to image-guided equipment must be made possible before establishing this technique as a standard.