Cerebral venous thrombosis and pulmonary thromboembolism with thyrotoxicosis

An elevated level of factor VIII is a recognised risk factor for thromboembolism. This case report describes a patient with elevated factor VIII levels secondary to hyperthyroidism. She presented with a triad of clinical hyperthyroidism, pulmonary emboli and cerebral venous thrombosis. This case highlights the importance of considering thromboprophylaxis in patients with clinical hyperthyroidism.

Proposed diagnostic criteria for apathy in Alzheimer's disease and other neuropsychiatric disorders

There is wide acknowledgement that apathy is an important behavioural syndrome in Alzheimer's disease and in various neuropsychiatric disorders. In light of recent research and the renewed interest in the correlates and impacts of apathy, and in its treatments, it is important to develop criteria for apathy that will be widely accepted, have clear operational steps, and that will be easily applied in practice and research settings. Meeting these needs is the focus of the task force work reported here. The task force includes members of the Association Française de Psychiatrie Biologique, the European Psychiatric Association, the European Alzheimer's Disease Consortium and experts from Europe, Australia and North America. An advanced draft was discussed at the consensus meeting (during the EPA conference in April 7th 2008) and a final agreement reached concerning operational definitions and hierarchy of the criteria. Apathy is defined as a disorder of motivation that persists over time and should meet the following requirements. Firstly, the core feature of apathy, diminished motivation, must be present for at least four weeks; secondly two of the three dimensions of apathy (reduced goal-directed behaviour, goal-directed cognitive activity, and emotions) must also be present; thirdly there should be identifiable functional impairments attributable to the apathy. Finally, exclusion criteria are specified to exclude symptoms and states that mimic apathy.

Development of a multi--electrode electrical stimulation device to improve chronic wound healing

A new device has been developed for the application of Electrical Stimulation to improve healing of chronic wounds. The device enables the creation of a composite electrode hence matching the electrode(s) to the size and shape of the wound. Up to 49 electrodes in an array can be combined, delivering High Voltage Pulsed Current (HVPC) in the range 60-120 Hz with a pulse duration range from 90-110 mus and the possibility of treating the patient with direct current instead of HVPC. In addition, the software can import the measurements from the ImpediMap device, analysing the electrical impedance of the tissues involved. A test on healthy volunteers did not prove a statistically significant rise in skin temperature, TcPO2 or impedance due to the stimulation, even though a slight reddening of the stimulated site was observed.

Long term outcome for extra-anatomic arch reconstruction. An analysis of 143 procedures

PURPOSE

With the FDA approval of thoracic endografts, extra-anatomic reconstruction of the aortic arch has allowed for more suitable proximal landing zones and increased applicability of thoracic endovascular procedures. We evaluated our short term and long term results of extra-anatomic reconstruction of the carotid and subclavian vessels.

METHODS

One hundred and forty three (143) procedures were performed for extra-anatomic carotid and subclavian reconstruction. Of these 143 operations: 85 were carotid subclavian reconstructions, 22 were carotid crossover bypasses, 30 were subclavian carotid reconstructions and 6 were carotid subclavian transpositions. Sixty (42%) were male, 20 (14%) were diabetic, and 63 (44%) were current smokers. Mean age was 63 (SD +/- 12.3). Indication for surgery was primarily for occlusive or embolic disease (97%). In those patients undergoing bypass graft, prosthetic (ePTFE) was used in 93%. Follow-up was performed at 3 and 6 month intervals by ultrasound and pulse volume recordings where indicated. Life table analyses were used to analyze patency.

RESULTS

Of the 143 reconstructions operative mortality was 1 (0.7%). Non-fatal complications included 3 (2.1%) for bleeding, 1 (0.7%) wound infection, 2 (1.4%) TIA, 1 (0.7%) suffered a non-fatal stroke, 2 (1.4%) had postoperative myocardial infarctions, and 6 (4.3%) late (>30-day) occlusions. Follow-up was 1 to 124 months (mean: 39 months). Primary patency at 1 year was 98%, 3 years 96%, and 5 years was 92%.

CONCLUSION

Extra-anatomic arch reconstruction can be performed safely and appears to be durable over long term follow-up. Its use with endovascular grafting should provide a durable reconstruction for patients who require aortic "debranching" prior endovascular thoracic aortic aneurysm repair.

Fecundity of males after treatment for childhood cancer. A report from the Childhood Cancer Survivor Study (CCSS)

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Background: Determine the proportion of male (M) survivors with impaired fecundity (IF). Methods: 6,555 CCSS M participants and 1,606 M siblings (S) were classified as surgically sterile (SS) for contraceptive purpose, SS for non-contraceptive purpose, IF (ongoing attempts to become pregnant for a period of one year without success or use of medication to help achieve a pregnancy), or fecund (F). Odds ratios (OR) were estimated using logistic regression, controlling for education level, marital status, age at baseline questionnaire, race/ethnicity and smoking status. Results: M were 6–29 years from cancer diagnosis (mean-16.3 years) and 15–44 years of age at the time of study (mean-25.4 years). 331 (5.0%) M or their partners were SS, 487 (7.4%) had IF and 5,737 (87.5%) were F. The OR (95% confidence interval (CI)) for being F was 0.66 (95% CI, 0.54–0.80) (p<0.0001) compared to F MS. Among M, the OR for IF was 2.60 (95% CI, 1.97–3.42) (p<0.0001) compared to F MS. The OR for IF was increased among those with a testicular (T) radiation dose (RD) of 0.1–499 cGy (OR=1.42; 95% CI 1.07–1.89; p=0.015), 500–599 cGy (OR=3.16; 95% CI 1.48–6.72; p=0.0028), 600–1,499 cGy (OR=2.53; 95% CI 1.26–5.09; p=0.009) and ≥ 2,400 cGy (OR=3.04; 95% CI 1.39–6.64; p=0.0054), pituitary (P) RD of 0.1–499 cGy (OR=1.89; 95% CI 1.41–2.55; p<0.0001), CCNU (OR=2.14; 95% CI 1.25–3.66; p=0.0054), cyclophosphamide (OR=1.56;95% CI 1.23–1.97; p=0.0002), nitrogen mustard (OR=2.88;95% CI 2.08- 4.00; p<0.0001), procarbazine (OR=2.97; 95% CI 2.24–3.93; p<0.0001), vinblastine (OR=2.07;95% CI 1.41–3.04; p=0.00022), vincristine (OR=1.90; 95% CI 1.45–2.49; p<0.0001) and melphalan (OR=2.43; 95% CI 1.09–5.43; p=0.03). The OR for IF increased with increasing alkylating agent score (AAS) (1st tertile OR=1.70; 95% CI 1.19–2.43; p=0.0035; 2nd tertile OR=2.63; 95% CI 1.82–3.81; p<0.0001; 3rd tertile OR=3.42; 95% CI 2.41–4.86; p<0.0001). Multivariate analysis demonstrated that the combination of P ≥ 500 cGy and T ≥ 500 cGy (OR= 2.65; 95% CI 1.44–4.86; p=0.0017) and increasing AAS (1st tertile OR=1.56; 95% CI 1.04–2.34; p=0.031; 2nd tertile OR= 2.22; 95% CI 1.43–3.44; p=0.00036; 3rd tertile OR=2.72;95% CI 1.74–4.25; p<0.0001) were associated with IF. Conclusions: M have IF due in part to TRD and PRD and increasing AAS.

No significant financial relationships to disclose.

Cardiac safety in patients (pts) with metastatic breast cancer (MBC) treated with lapatinib (L) and trastuzumab (TRA)

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Background: Clearly defined standards for assessing cardiac toxicity do not exist for newer agents used as treatment for BC, e.g., tyrosine kinase inhibitors. To evaluate the usefulness of increased cardiac monitoring and cardiac function (LVEF) in pts treated with L+TRA, data from 4 trials were analyzed. Methods: From July 2003 to Dec 2006, 238 pts received L+TRA (n=203) or L+TRA with paclitaxel or docetaxel (n=35) for HER2-positive MBC. LVEF was evaluated at screening, every 8 weeks after starting L+TRA, and at withdrawal via multiple-gated acquisition scans or echocardiograms. Rate of symptomatic cardiac events (CE; NCI CTCAE Grade 3 or 4 LV systolic dysfunction) or asymptomatic LVEF decreases (=20% relative to baseline and below the institution’s lower limit of normal) were assessed. Results: None of the 238 pts had a symptomatic CE. Four pts had a single asymptomatic LVEF decrease and 1 pt had 2 asymptomatic LVEF decreases, totaling 6 decreases in 5 (2.1%) pts. These pts were women aged 36–64 years and had previously received anthracyclines (A; n=2), A+TRA (n=2), or unknown therapy (n=1). Median time to onset of LVEF decrease was 83 days; all but 1 decrease occurred within 75 days after initiating L+TRA (range: 18–221 days). Baseline LVEFs of 62%, 60%, 62%, 74% and 58% decreased to 47%, 46%, 45%, 45%, and 45%, respectively. L+TRA was temporarily interrupted in 3 pts and continued in 2 pts despite LVEF decrease. Per investigators, LVEF decrease resolved with no further sequelae in 4 pts (59%, 56%, 60%, and 50%) and was ongoing in 1 pt. Conclusion: Initial data indicate L+TRA or L+TRA with taxanes does not constitute a serious incremental cardiac risk and may not require more stringent cardiac monitoring than is used for A or TRA alone. The combined effect of HER2 inhibition with L+TRA appears not to increase the risk of CE in this population.

No significant financial relationships to disclose.

Findings from aCGH in patients with congenital diaphragmatic hernia (CDH): a possible locus for Fryns syndrome

Congenital diaphragmatic hernia (CDH) is a common and often devastating birth defect that can occur in isolation or as part of a malformation complex. Considerable progress is being made in the identification of genetic causes of CDH. We applied array-based comparative genomic hybridization (aCGH) of approximately 1Mb resolution to 29 CDH patients with prior normal karyotypes who had been recruited into our multi-site study. One patient, clinically diagnosed with Fryns syndrome, demonstrated a de novo 5Mb deletion at chromosome region 1q41-q42.12 that was confirmed by FISH. Given prior reports of CDH in association with cytogenetic abnormalities in this region, we propose that this represents a locus for Fryns syndrome, a Fryns syndrome phenocopy, or CDH.

62 REPROGRAMMING EVENTS AND DEVELOPMENTAL COMPETENCE OF RHESUS MONKEY EMBRYOS PRODUCED BY SOMATIC CELL NUCLEAR TRANSFER

Successful reprogramming of somatic cell nuclei after nuclear transfer requires active remodeling by factors present in the nonactivated cytoplast. High levels of maturation promoting factor (MPF) activity are associated with this remodeling process which includes nuclear envelope breakdown (NEBD), premature chromosome condensation (PCC), and spindle formation. In this study, we examined the extent of nuclear remodeling in monkey somatic cell nuclear transfer (SCNT) embryos by monitoring the dynamics of lamin A/C appearance, as detected immunocytochemically, following fusion of donor cells with recipient cytoplasts. In the control, intracytoplasmic sperm injection (ICSI) fertilized embryos, lamin A/C was readily detected at the pronuclear stage but disappeared in early cleaving embryos only to reappear by the morula stage in association with the activation of the embryonic genome. We initially documented lack or incomplete NEBD and PCC in SCNT embryos in the form of retention of lamin A/C signal emanating from the donor nucleus. This observation was consistent with premature cytoplast activation due to the manipulation procedures. SCNT embryos produced by this approach typically arrested at the morula stage. Significant modifications in nuclear transfer protocols were then employed. Optimization of procedures resulted in robust NEBD and PCC, as indicated by loss of lamin A/C signal from the donor cell. Also, significant improvement of SCNT embryo development in vitro was observed, with a markedly improved blastocyst formation rate (21%). Several different fetal and adult somatic cell types screened as nuclear donors supported blastocyst development. SCNT blastocysts displayed a pattern of Oct-4 expression similar to that of sperm fertilized counterparts, indicative of efficient nuclear reprogramming. However, no pregnancies were established following a preliminary trial of 8 embryo transfers with 48 cloned embryos. Nevertheless, our results represent a breakthrough in efforts to produce cloned monkeys and should provide the resources required for the derivation of embryonic stem cells from SCNT blastocysts.

Current and future water issues in the Oldman River Basin of Alberta, Canada

Long-term trends in alpine and prairie snow pack accumulation and melt are affecting streamflow within the Oldman River Basin in southern Alberta, Canada. Unchecked rural and urban development also has contributed to changes in water quality, including enhanced microbial populations and increased waterborne pathogen occurrence. In this study we look at changing environment within the Oldman River Basin and its impact on water quality and quantity. The cumulative effects include a decline in net water supplies, and declining quality resulting in increased risk of disease. Our data indicates that decreases in the rate of flow of water can result in sedimentation of bacterial contaminants within the water column. Water for ecosystems, urban consumption, recreation and distribution through irrigation is often drawn from waterholding facilities such as dams and weirs, and concern must be expressed over the potential for contaminate build-up and disproportionate potential of these structures to pose a risk to human and animal health. With disruption of natural flow rates for water resulting from environmental change such as global warming and/or human intervention, increased attention needs to be paid to use of best management practices to protect source water supplies.

Use of in-stream reservoirs to reduce bacterial contamination of rural watersheds

An investigation into bacterial water quality problems was conducted on an interconnected stream and irrigation system within the Oldman River Basin of southern Alberta, Canada. Levels of indicator bacteria, including fecal coliforms, generic Escherichia coli and fecal streptococci, were repeatedly measured in streams and irrigation return canals of this river basin during the summer of 2001. Bacterial-loading segments of the irrigation/stream system were identified through a comparison of indicator bacteria levels in pairs of upstream and downstream sites. Mann-Whitney U-tests indicated that reservoirs significantly reduced bacterial counts. A temporal comparison of E. coli counts and river discharges suggested that these indicator bacteria do not originate from within in-stream sediments. Site-specific as well as cumulative inputs from a variety of non-point sources are likely to be responsible for the high downstream levels of indicator bacteria in this water system. The use of management practices such as in-stream reservoirs may significantly reduce contamination, and increase the quality of limited rural water supplies to allow their reuse and safe discharge into downstream water sources. The identification of bacteria-loading river/canal segments could also be used to prioritize restoration projects.