Preoperative oral antibiotic bowel preparation in elective resectional colorectal surgery reduces rates of surgical site infections: a single-centre experience with a cost-effectiveness analysis

INTRODUCTION

Surgical site infections cause considerable postoperative morbidity and mortality. The aim of this study was to determine the effect on surgical site infection rates following introduction of a departmental oral antibiotic bowel preparation protocol.

METHODS

A prospective single-centre study was performed for elective colorectal resections between May 2016-April 2018; with a control group with mechanical bowel preparation and treatment group with oral antibiotic bowel preparation (neomycin and metronidazole) and mechanical bowel preparation. The primary outcome of surgical site infection and secondary outcomes of anastomotic leak, length of stay and mortality rate were analysed using Fisher's exact test and independent samples t-tests. A cost-effectiveness analysis was also performed.

RESULTS

A total of 311 patients were included; 156 in the mechanical bowel preparation group and 155 in the mechanical bowel preparation plus oral antibiotic bowel preparation group. The study included 180 (57.9%) men and 131 (42.1%) women with a mean age of 68 years. There was a significant reduction in surgical site infection rates (mechanical bowel preparation 16.0% vs mechanical bowel preparation plus oral antibiotic bowel preparation 4.5%; P = 0.001) and mean length of stay (mechanical bowel preparation 10.2 days vs mechanical bowel preparation plus oral antibiotic bowel preparation 8.2 days; P = 0.012). There was also a reduction in anastomotic leak and mortality rates. Subgroup analyses demonstrated significantly reduced surgical site infection rates in laparoscopic resections (P = 0.008). There was an estimated cost saving of £239.13 per patient and £37,065 for our institution over a one-year period.

CONCLUSION

Oral antibiotic bowel preparation is a feasible and cost-effective intervention shown to significantly reduce the rates of surgical site infection and length of stay in elective colorectal surgery.

B-26 Predictors of Cognitive Decline Over a 2-year Follow up: Olfaction and Scans Without Evidence of Dopaminergic Deficit Status (SWEDD)

Objective

Given the high discriminatory power of olfaction assessments in movement disorders, the current study sought to determine whether olfaction dysfunction differentially predicted cognitive decline in patients who have scans without evidence of dopaminergic deficit (SWEDD). Dopamine depletion is a major neuropathological feature of Parkinson’s disease (PD); however, 15% of patients with a clinical PD diagnosis have neuroimaging evidence of intact dopaminergic function. Recent work has suggested that patients with SWEDD are at a greater risk of cognitive impairment relative to those with PD.

Methods

Archival data were obtained from the Parkinson’s Progression Markers Initiative database. The total sample included three groups: PD (n = 401), SWEDD (n = 51), and HC (n = 175). Participants were categorized into non-impaired (-) or impaired (+) olfaction groups based on performance on the University of Pennsylvania Smell Identification Test, corrected for age and gender. Participants were administered the Montreal Cognitive Assessment twice and change scores were calculated to examine changes in cognition over time (baseline – two-year follow-up).

Results

A bootstrapped analysis of variance (ANOVA) revealed that the SWEDD+ group had lower MoCA scores than PD+ and HC+ groups at baseline (ps < .05). A bootstrapped ANOVA indicated that group differences were not significant at follow-up; rather, impaired baseline olfaction predicted cognitive decline across all study participants (p < .05), regardless of diagnosis.

Conclusions

Future studies are needed to assess whether the profile of motor and non-motor symptoms in SWEDD patients, including olfaction, is deserving of its own syndrome, or whether individual patients may fit better under alternative, existing diagnoses.

Do preoperative oral antibiotics increase Clostridium difficile infection rates? An analysis of 13 959 colectomy patients

AIM

The aim of this study was to determine whether or not preoperative oral antibiotic preparation (POAP) increases the rate of Clostridium difficile colitis (CDC) in patients undergoing colectomy.

METHOD

In 2015, data for colectomies had been collected prospectively and recorded in the targeted colectomy option of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This was available for retrospective analysis. Data available for analysis included elective and emergency status, POAP, surgical approach, primary anastomosis and CDC status. The effect of POAP on CDC was analysed and risk adjusted for 14 separate preoperative variables.

RESULTS

In all, 13 959 adult patients underwent a colectomy in 2015 (POAP group 5311 and non- POAP group 8648). The overall rate of CDC in colectomy patients was 1.6% (227/13 959). On univariate analysis, CDC was significantly less common in the POAP group than in the non-POAP group (1.2% vs 1.9%, P = 0.003). Univariate analysis of a further 41 preoperative variables revealed 14 to be associated with CDC. However, after risk adjustment with these 14 variables, POAP lost its statistical significance (adjusted OR 0.902, 95% CI 0.584-1.486, P = 0.685). Only patients with pre-existing systemic inflammatory response syndrome appeared to be at increased risk of CDC (adjusted OR 2.154, 95% CI 1.139-4.074, P = 0.018).

CONCLUSION

At the very least this study suggests it is safe to use POAP in colectomy patients without increasing the rate of CDC unless they have pre-existing systemic inflammatory response syndrome.

Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients

AIM

A large, prospectively collected, clinical database was analysed to determine the various pre- and intra-operative factors affecting anastomotic leakage (AL) in colorectal surgery.

METHOD

Data on 17 518 patients having a colorectal resection with anastomosis, taken from the 2013 American College of Surgeons National Surgical Quality Improvement Program database, were included in the study. Multivariable logistic regression analysis was carried out to identify risk-adjusted predictive factors for AL. Statistical significance was set at P < 0.05 and confidence intervals were reported at the 95% level.

RESULTS

The AL rate was 3.9% (687/17 518). Younger patients, male gender and an American Society of Anesthesiology (ASA) score of ≥ 3 (P < 0.001), smoking (P = 0.001), diabetes (P = 0.035), a preoperative serum albumin level of < 4 g/dl (P = 0.030), elective rectal cancer surgery (P = 0.024), emergency colectomy for bleeding (P = 0.013) and splenic flexure mobilization (P = 0.043) were associated with an increased risk of AL. Preoperative oral antibiotics (P < 0.001), right hemicolectomy (open or laparoscopic) and laparoscopic partial colectomy were associated with a reduced risk of AL compared with the entire group. Body mass index, preoperative chemotherapy, emergency surgery and mechanical bowel preparation were not related to AL.

CONCLUSION

In contrast to most studies, younger age was found to be an independent risk factor for AL. The risk for AL was lower with laparoscopic partial colectomy and open or laparoscopic right hemicolectomy. Preoperative oral antibiotic preparation significantly reduces the risk of AL and should be incorporated as a standard protocol.

Psychometric Analysis of the Visual Form Discrimination Test

The Visual Form Discrimination Test is a matching-to-sample test involving visual discrimination. Although normative information has been presented, limited psychometric data have been available. The current study estimated the internal consistency and additional psychometric properties of the test in a sample of 66 persons with acute traumatic brain injury. Internal consistency as measured by alpha was .66. A homogeneous sample and a restricted range of scores likely attenuated this estimate. Using the standard cutoff score, only 32% of the sample showed impaired performance. Visual form discrimination as measured by this test may be affected less by traumatic brain injury than other cognitive processes such as attention and memory.

Pulmonary radiofrequency ablation in a district general hospital: is it a safe and effective treatment?

AIM

To analyse the technical success of ablation therapy and the incidence of complications in patients treated with pulmonary ablation and to assess factors affecting local disease control and patient survival in a subgroup with metastatic colorectal cancer.

MATERIALS AND METHODS

Technical success and complications in all patients undergoing lung ablation between June 2009 and July 2015 were recorded. Overall survival and local disease control in a subgroup with metastases from a colorectal primary were calculated. Factors influencing outcome were explored.

RESULTS

Two hundred and seven pulmonary ablations were performed in 86 patients at 156 attendances. Technical success was achieved in 207/207 (100%). Thirty and 90-day mortality was 0%. The major complication rate was 13/86 (15%). One hundred and one metastases were treated in 46 patients with a colorectal primary. This group had a mean ± standard error survival time of 53.58±3.47 months with a 1, 2, 3, 4, and 5-year survival rate of 97.4%, 91.3%, 81.5%, 59.8%, and 48%. There was no statistically significant difference in survival regarding time to development of metastatic disease, the total number of lesions ablated, the initial number of lesions ablated, the maximum size of lesion treated, or unilateral versus bilateral disease. Patients with extrapulmonary disease were found to have a shorter survival from the primary diagnosis. Seventy-eight (77.2%) of the 101 lesions were stable after first RFA. Local relapse was more likely when a metastasis was close to a large (>3 mm) vessel.

CONCLUSION

RFA is a safe and effective procedure that can be performed without on-site cardiothoracic support. Good outcomes depend upon careful patient selection. This study supports its use in oligometastatic disease.

Motivational engagement in Parkinson's disease: Preparation for motivated action

The current study investigated whether motivational dysfunction in Parkinson's patients is related to a deficit in preparing for motivated behavior. Based on previous studies, it was hypothesized that PD patients would show reduced preparation for action specifically when faced with threat (of loss) and that reduced action preparation would relate to self-report of apathy symptoms. The study measured an electrocortical correlate of preparation for action (CNV amplitude) in PD patients and healthy controls, as well as defensive and appetitive activation during emotional perception (LPP amplitude). The sample included 18 non-demented PD patients (tested on dopaminergic medications) and 15 healthy controls who responded as quickly as possible to cues signaling threat of loss or reward, in which the speed of the response determined the outcome. Results indicated that, whereas PD patients showed similar enhanced action preparation with the addition of incentives to controls, PD patients showed generally reduced action preparation, evidenced by reduced CNV amplitude overall. Results suggest that PD patients may have behavioral issues due to globally impaired action preparation but that this deficit is not emotion-specific, and movement preparation may be aided by incentive in PD patients.

Effect of simulated deployment patrols on gastric mucosa of explosive detection dogs

Exercise-induced gastric disease is well-recognised in dogs performing ultra-endurance racing, but has not been described in dogs performing non-competitive athletic activities. Explosive detection dogs often perform prolonged periods of exercise and are reported to have chronic inappetance and weight-loss consistent with gastric disease. Seven privately-owned Labrador Retrievers trained for off-leash explosive detection activities were used to test the hypothesis that explosive detection dogs develop exercise-induced gastric disease while performing routine duties. Gastroscopy was performed on dogs before and after a 5-day exercise challenge designed to simulate routine military deployment activities. Five days of sustained submaximal exercise resulted in substantial gastric disease. These results demonstrate that dogs performing prolonged submaximal exercise consistent with off-leash explosive detection patrols are susceptible to exercise-induced gastric disease. Exercise-induced gastric disease may explain the anecdotal reports of poor thrift in these types of dogs during military deployment, and prophylactic acid suppression therapy should be considered in dogs participating in these activities.

The late positive potential, emotion and apathy in Parkinson's disease

Parkinson's disease is associated with emotional changes including depression, apathy, and anxiety. The current study investigated emotional processing in non-demented individuals with Parkinson disease (PD) using an electrophysiological measure, the centro-parietal late positive potential (LPP). Non-demented patients with Parkinson's disease (n=17) and healthy control participants (n=16) viewed pleasant, neutral, and unpleasant pictures while EEG was recorded from a 64-channel geodesic net. The Parkinson patients did not differ from controls in terms of early electrophysiological components that index perceptual processing (occipital P100, N150, P250). Parkinson patients, however, showed reduced LPP amplitude specifically when viewing unpleasant, compared to pleasant, pictures as well as when compared to controls, consistent with previous studies suggesting a specific difference in aversive processing between PD patients and healthy controls. Importantly, LPP amplitude during unpleasant picture viewing was most attenuated for patients reporting high apathy. The data suggest that apathy in PD may be related to a deficit in defensive activation, and may be indexed cortically using event-related potentials.

Health comorbidities and cognition in 1948 patients with idiopathic Parkinson's disease

BACKGROUND

Health comorbidities, particularly cardiovascular factors, are well known to pose risks for cognitive decline in older adults. This study examined the prevalence and contribution of comorbidities on cognitive performance in a large cohort of Parkinson patients.

METHODS

Data on 1948 PD patients were obtained from the National Parkinson Foundation Quality Improvement Initiative (NPF-QII) registry, a multi-site initiative from NPF Centers of Excellence. Available comorbidity data included six common conditions (heart/circulation problems, diabetes, arthritis, cancer, respiratory disease, and other neurologic disease) that were clinician-rated for presence and severity. Available cognitive measures included semantic fluency and a 5-word recall memory task. The unique effects of comorbidities on cognition were analyzed (multiple hierarchical regression) controlling for demographic, PD disease severity (duration, Hoehn-Yahr), and medication status.

RESULTS

The two most reported comorbidities were arthritis (46.6%) and heart/circulation problems (36.3%), with diabetes affecting 9% of the sample. Severity of heart/circulation problems independently contributed to worse delayed recall performance (p = 0.03). A trend emerged for more severe diabetes as contributing to worse semantic fluency scores (p = 0.06).

CONCLUSIONS

This study with a large cohort of PD patients provides evidence for a small detrimental influence of specific health comorbidities, particularly heart/circulatory and diabetes, on general measures of cognition. This effect is present, above and beyond the influences of basic demographic information (age), duration and staging of PD, and medication status. Future studies involving more refined cognitive indices and direct assessment of comorbidities are warranted.

Emotion and ocular responses in Parkinson's disease

Parkinson's disease (PD) is a neurodegenerative disease that affects motor, cognitive, and emotional functioning. Previous studies reported reduced skin conductance responses in PD patients, compared to healthy older adults when viewing emotionally arousing pictures. Attenuated skin conductance changes in PD may reflect peripheral autonomic dysfunction (e.g., reduced nerve endings at the sweat gland) or, alternatively, a more central emotional deficit. The aim of the current study was to investigate a second measure of sympathetic arousal-change in pupil dilation. Eye movements, a motor-based correlate of emotional processing, were also assessed. Results indicated that pupil dilation was significantly greater when viewing emotional, compared to neutral pictures for both PD patients and controls. On the other hand, PD patients made fewer fixations with shorter scan paths, particularly when viewing pleasant pictures. These results suggest that PD patients show normal sympathetic arousal to affective stimuli (indexed by pupil diameter), but differences in motor correlates of emotion (eye movements).

Cyclosporine versus tacrolimus treated liver transplant recipients with chronic hepatitis C: outcomes analysis of the UNOS/OPTN database

Recurrent hepatitis C virus (HCV) remains a problematic cause of morbidity and mortality for liver transplant patients. Immunosuppression including calcineurin-inhibitors has been implicated in the acceleration of recurrent HCV. Recent studies suggest that outcomes may be better with cyclosporine (CSA-ME) compared to tacrolimus (TAC), but the data are inconclusive. We retrospectively analyzed data received from the United Network for Organ Sharing on 8809 chronic HCV liver transplant recipients receiving either cyclosporine microemulsion (CSA-ME) or tacrolimus (TAC) as maintenance immunosuppression prior to discharge. We analyzed patient death, graft failure, failure due recurrent disease and acute cellular rejection (ACR) for CSA-ME versus TAC treated patients. Three-year unadjusted patient and graft survival rates were 76.8% and 71.5%, respectively, in the CSA-ME group versus 79.9% and 75.0% in the TAC group. Propensity score-adjusted results suggest CSA-ME treated patients are at increased risk of patient death and graft failure [Hazards ratio (HR) = 1.17; 95% CI = 1.01-1.36 and HR = 1.19; 95% CI = 1.04-1.35, respectively] and biopsy-confirmed AR (HR = 2.03; 95% CI = 1.54-2.67) compared to TAC treated patients. These results provide evidence to reconsider the targeted administration of CSA-ME to HCV-infected liver transplant recipients.

Cyclosporine versus tacrolimus treated liver transplant recipients with chronic hepatitis C: outcomes analysis of the UNOS/OPTN database

Recurrent hepatitis C virus (HCV) remains a problematic cause of morbidity and mortality for liver transplant patients. Immunosuppression including calcineurin-inhibitors has been implicated in the acceleration of recurrent HCV. Recent studies suggest that outcomes may be better with cyclosporine (CSA-ME) compared to tacrolimus (TAC), but the data are inconclusive. We retrospectively analyzed data received from the United Network for Organ Sharing on 8809 chronic HCV liver transplant recipients receiving either cyclosporine microemulsion (CSA-ME) or tacrolimus (TAC) as maintenance immunosuppression prior to discharge. We analyzed patient death, graft failure, failure due recurrent disease and acute cellular rejection (ACR) for CSA-ME versus TAC treated patients. Three-year unadjusted patient and graft survival rates were 76.8% and 71.5%, respectively, in the CSA-ME group versus 79.9% and 75.0% in the TAC group. Propensity score-adjusted results suggest CSA-ME treated patients are at increased risk of patient death and graft failure [Hazards ratio (HR) = 1.17; 95% CI = 1.01-1.36 and HR = 1.19; 95% CI = 1.04-1.35, respectively] and biopsy-confirmed AR (HR = 2.03; 95% CI = 1.54-2.67) compared to TAC treated patients. These results provide evidence to reconsider the targeted administration of CSA-ME to HCV-infected liver transplant recipients.

The trajectory of apathy after deep brain stimulation: from pre-surgery to 6 months post-surgery in Parkinson's disease

Deep brain stimulation (DBS) has been associated with increased apathy in patients with PD, yet studies lack longitudinal data and have not assessed differences between sites of implantation (i.e. STN versus GPi). We assessed apathy prior to surgery and 6 months post-surgery using a longitudinal design-latent growth curve modeling. We hypothesized that apathy would increase post-surgery, and be related to subthalamic nucleus (versus globus pallidus interna) implantation. Forty-eight PD patients underwent unilateral surgery to either GPi or STN and completed the Apathy Scale prior to surgery and 2, 4, and 6 months post-surgery. Forty-eight matched PD controls completed the Apathy Scale at a 6-month interval. Results indicated apathy increased linearly from pre- to 6-months post-DBS by .66 points bi-monthly, while apathy in the control group did not change. There was no relationship between apathy and DBS site. Higher baseline depression was associated with higher baseline apathy, but not with change in apathy. Middle-aged adults (<65) had a steeper trajectory of apathy than older adults (≥ 65). Apathy trajectory was not related to motor severity, laterality of DBS, levodopa medication reduction, or motor changes after surgery.

Patient-specific analysis of the relationship between the volume of tissue activated during DBS and verbal fluency

Deep brain stimulation (DBS) for the treatment of advanced Parkinson's disease involves implantation of a lead with four small contacts usually within the subthalamic nucleus (STN) or globus pallidus internus (GPi). While generally safe from a cognitive standpoint, STN DBS has been commonly associated with a decrease in the speeded production of words, a skill referred to as verbal fluency. Virtually all studies comparing presurgical to postsurgical verbal fluency performance have detected a decrease with DBS. The decline may be attributable in part to the surgical procedures, yet the relative contributions of stimulation effects are not known. In the present study, we used patient-specific DBS computer models to investigate the effects of stimulation on verbal fluency performance. Specifically, we investigated relationships of the volume and locus of activated STN tissue to verbal fluency outcome. Stimulation of different electrode contacts within the STN did not affect total verbal fluency scores. However, models of activation revealed subtle relationships between the locus and volume of activated tissue and verbal fluency performance. At ventral contacts, more tissue activation inside the STN was associated with decreased letter fluency performance. At optimal contacts, more tissue activation within the STN was associated with improved letter fluency performance. These findings suggest subtle effects of stimulation on verbal fluency performance, consistent with the functional nonmotor subregions/somatotopy of the STN.

Mood and motor effects of thalamic deep brain stimulation surgery for essential tremor

PURPOSE

The aim of this study was to evaluate the effects of unilateral and bilateral ventralis intermedius (Vim) deep brain stimulation (DBS) on mood and motor function.

METHODS

Thirty-one consecutive medication refractory patients with essential tremor who underwent unilateral or bilateral Vim DBS at University of Florida and returned for at least 6 -month follow-up completed the Visual Analog Mood (VAMS), the Beck Depression Inventory (BDI), and the Tremor Rating Scale (TRS) before and after surgery. We excluded all patients who were implanted at other institutions.

RESULTS

The tense subscale of the VAMS improved significantly in both the unilateral and bilateral DBS groups (P < 0.001). On the VAMS afraid subscale, only the bilateral group trended toward improvement (P = 0.075). There were no significant changes for either group for the happy, confused, sad, angry, energetic or tired VAMS scores. TRS subscale scores all improved after unilateral and bilateral Vim DBS surgery (P < 0.001).

CONCLUSIONS

Feelings of tenseness, tremor severity and ADLs improved following unilateral or bilateral Vim DBS for ET.

Is the n-back task a valid neuropsychological measure for assessing working memory?

The n-back is a putative working memory task frequently used in neuroimaging research; however, literature addressing n-back use in clinical neuropsychological evaluation is sparse. We examined convergent validity of the n-back with an established measure of working memory, digit span backward. The relationship between n-back performance and scores on measures of processing speed was also examined, as was the ability of the n-back to detect potential between-groups differences in control and Parkinson's disease (PD) groups. Results revealed no correlation between n-back performance and digit span backward. N-back accuracy significantly correlated with a measure of processing speed (Trail Making Test Part A) at the 2-back load. Relative to controls, PD patients performed less accurately on the n-back and showed a trend toward slower reaction times, but did not differ on any of the neuropsychological measures. Results suggest the n-back is not a pure measure of working memory, but may be able to detect subtle differences in cognitive functioning between PD patients and controls.

Startle reflex hyporeactivity in Parkinson's disease: an emotion-specific or arousal-modulated deficit?

We previously reported that patients with Parkinson's disease (PD) demonstrate reduced psychophysiologic reactivity to unpleasant pictures as indexed by diminished startle eyeblink magnitude [Bowers, D., Miller, K., Bosch, W., Gokcay, D., Pedraza, O., Springer, U., et al. (2006). Faces of emotion in Parkinsons disease: Micro-expressivity and bradykinesia during voluntary facial expressions. Journal of the International Neuropsychological Society, 12(6), 765-773; Bowers, D., Miller, K., Mikos, A., Kirsch-Darrow, L., Springer, U., Fernandez, H., et al. (2006). Startling facts about emotion in Parkinson's disease: Blunted reactivity to aversive stimuli. Brain, 129(Pt 12), 3356-3365]. In the present study, we tested the hypothesis that this hyporeactivity was primarily driven by diminished reactivity to fear-eliciting stimuli as opposed to other types of aversive pictures. This hypothesis was based on previous evidence suggesting amygdalar abnormalities in PD patients, coupled with the known role of the amygdala in fear processing. To test this hypothesis, 24 patients with Parkinson's disease and 24 controls viewed standardized sets of emotional pictures that depicted fear, disgust (mutilations, contaminations), pleasant, and neutral contents. Startle eyeblinks were elicited while subjects viewed these emotional pictures. Results did not support the hypothesis of a specific emotional reactivity deficit to fear pictures. Instead, the PD patients showed reduced reactivity to mutilation pictures relative to other types of negative pictures in the context of normal subjective ratings. Further analyses revealed that controls displayed a pattern of increased startle eyeblink magnitude for "high arousal" versus "low arousal" negative pictures, regardless of picture category, whereas startle eyeblink magnitude in the PD group did not vary by arousal level. These results suggest that previous findings of decreased aversion-modulated startle is driven by reduced reactivity to highly arousing negative stimuli rather than to a specific category (i.e., fear or disgust) of emotion stimuli.

Does laterality of motor impairment tell us something about cognition in Parkinson disease?

This cross-sectional study investigates the relationship between severity of right- and left-sided motor symptoms and deficits in global cognitive function as well as individual cognitive domains in 117 Parkinson disease patients. Items of the Unified Parkinson Disease Rating Scale Part III were divided into right- and left-sided total scores. Composite scores in verbal fluency, verbal memory, executive function, and visuoperceptual skills were obtained from a full neuropsychological battery. We observed a significant association between right-sided motor impairment and verbal memory, visuoperceptual skills, and verbal fluency, but not executive function. The relationship between right symptoms and verbal fluency was fully mediated by cognitive status, while the relationship between right symptoms and verbal memory as well as visuoperceptual skills was not. Left-sided motor symptoms were not significantly related to any composite cognitive domain. When patients were divided into groups based on the side of predominant symptoms, no group differences were found in performance on the specific cognitive domains. This suggests that the degree of right-sided symptoms is more correlated to specific cognitive domains than is group classification of laterality.

The effect of high-dose enteral glutamine on the incidence and severity of mucositis in paediatric oncology patients

BACKGROUND/OBJECTIVE

The study was conducted to determine if enteral glutamine, 0.65 g kg(-1) daily for 7 days, is effective in reducing the incidence and severity of mucositis in paediatric oncology patients when given alongside chemotherapy. The study was carried out at St James's University Hospital, Leeds, UK.

SUBJECTS/METHODS

This was a randomized study using the patients as their own controls. Seventy-six patients undergoing treatment for paediatric malignancy having at least two identical courses of chemotherapy and at risk of developing mucositis participated in the study. Patients received one course of chemotherapy with glutamine and an identical course without. Alternate patients were allocated to have glutamine with course 1 or with course 2. The severity of symptoms of mucositis and the duration of enteral and parenteral nutrition were recorded. Daily ammonia levels were measured.

RESULTS

Fifty patients completed the study. No statistical significance with regard to symptoms of mucositis was found. Fewer children receiving glutamine required parenteral nutrition (P=0.049), and the duration of parenteral nutrition was less (P=0.023). No adverse effects attributed to taking the glutamine were observed.

CONCLUSIONS

The study showed that high-dose enteral glutamine did not reduce the incidence and severity of oral mucositis as determined by subjective toxicity measurements, but did show a significant reduction in parenteral nutrition usage. No adverse cumulative effect of this oral glutamine dose was observed.

Dissociating apathy and depression in Parkinson disease

OBJECTIVE

To examine the hypothesis that apathy is a core feature of Parkinson disease (PD) and that apathy can be dissociated from depression.

METHODS

Eighty patients with PD and 20 patients with dystonia completed depression and apathy measures including the Marin Apathy Evaluation Scale (AES), Beck Depression Inventory (BDI), and Centers for Epidemiologic Studies-Depression Scale (CES-D).

RESULTS

There was a significantly higher severity and frequency of apathy in PD (frequency = 51%, 41/80) than in dystonia (frequency = 20%, 4/20). Apathy in the absence of depression was frequent in PD and did not occur in dystonia (PD = 28.8%, dystonia = 0%).

CONCLUSIONS

Patients with Parkinson disease (PD) experienced significantly higher frequency and severity of apathy when compared with patients with dystonia. Apathy may be a "core" feature of PD and occurs in the absence of depression.

Panic and fear induced by deep brain stimulation

BACKGROUND

Mood, cognitive, and behavioural changes have been reported with deep brain stimulation (DBS) in the thalamus, globus pallidus interna, and anterior limb of the internal capsule/nucleus accumbens region.

OBJECTIVE

To investigate panic and fear resulting from DBS.

METHODS

Intraoperative DBS in the region of the right and then left anterior limb of the internal capsule and nucleus accumbens region was undertaken to treat a 52 year old man with treatment refractory obsessive-compulsive disorder (OCD). Mood, anxiety, OCD, alertness, heart rate, and subjective feelings were recorded during intraoperative test stimulation and at follow up programming sessions.

RESULTS

DBS at the distal (0) contact (cathode 0-, anode 2+, pulse width 210 ms, rate 135 Hz, at 6 volts) elicited a panic attack (only seen at the (0) contact). The patient felt flushed, hot, fearful, and described himself as having a "panic attack." His heart rate increased from 53 to 111. The effect (present with either device) was witnessed immediately after turning the device on, and abruptly ceased in the off condition

CONCLUSIONS

DBS of the anterior limb of the internal capsule and nucleus accumbens region caused severe "panic." This response may result from activation of limbic and autonomic networks.

Mood and cognitive changes with deep brain stimulation. What we know and where we should go

AIM

The aim of this study was to completely review the literature on cognitive and mood changes resulting from deep brain stimulation (DBS), and to examine the factors that might lead to these changes. DBS has been shown to improve motor symptoms in many movement disorders. Despite the widespread use of this technique, there are relatively few well controlled studies describing the potential cognitive, mood and behavioral consequences that may result from DBS. Additionally, the factors that may influence these changes have not been carefully studied.

METHODS

A complete survey of the articles exploring the effects of DBS on mood and cognition was performed. Each study identified was examined and categories of factors that may have influenced mood and cognition were noted. These factors included surgical target, number of patients studied, whether procedures were unilateral or bilateral, average age of patients, diagnosis, condition of the DBS during the study (on or off), pre-operative screening tests (e.g., dementia rating scale, mini mental state exam), and changes on mood and cognitive tests (categorized as no change, improved, or worsened). Studies were divided into evidence-based categories.

RESULTS

There are many mood and cognitive changes that may result from DBS. Due to methodological limitations of existing studies there are important unanswered questions about cognitive and mood changes resulting from this type of surgery. The predominant amount of data regarding changes in mood and cognition with DBS is level 3 or case based evidence.

CONCLUSIONS

There exists a paucity of well-controlled studies addressing the mood and cognitive changes that result from DBS. Carefully performed prospective studies may help us to understand the effects of DBS on mood and cognition.

Growth hormone treatment after cesarean delivery in rats increases the strength of the uterine scar

OBJECTIVE

We sought to determine whether postcesarean treatment of rats with growth hormone (GH) affected the strength of the uterine incision in the puerperium and in a subsequent pregnancy.

STUDY DESIGN

Forty-eight near-term pregnant rats were delivered by cesarean section. Half received subcutaneous recombinant human GH (2.0 mg x kg(-1) x d(-1)) for 7 days; control animals received saline injections. Four weeks after delivery, the uterine bursting pressure was determined in 5 treated and 5 control animals. Eight rats in each group were used to study uterine hydroxyproline concentrations and the histologic characteristics of the scar. Twenty-two animals were rebred 30 to 40 days after their cesarean sections. After repeat cesarean delivery, on day 19, the bursting pressure and hydroxyproline concentrations of the previous hysterotomy scar were determined.

RESULTS

The uterine horn bursting pressure in the GH-treated animals was significantly greater than that in the control animals both 28 days postpartum and near term in a subsequent pregnancy. The uterine hydroxyproline concentrations followed the same pattern. Histologic study of the scars showed they were thicker and had less cellularity in the treated animals than in the control animals.

CONCLUSION

Postcesarean treatment with GH increased the bursting strength of rat uterine incisions. This effect was accompanied by a significant increase in collagen content and persisted through a subsequent pregnancy.

Emotional conversations in Parkinson's disease

OBJECTIVE

To learn how PD influences verbal description of emotional events.

BACKGROUND

Individuals with PD exhibit emotional processing deficits. Emotional experience likely involves several dimensions (e.g., valence, arousal, motor activation) subserved by a distributed modular network involving cortical, limbic, basal ganglia, diencephalic, and mesencephalic regions. Although the neurodegeneration in PD likely affects components in this network, little is known about how PD influences emotional processing. Because PD is associated with activation deficits, one could predict that the discourse of emotional experiences involving high activation would be reduced in patients with PD compared to control subjects. Alternatively, because patients with PD exhibit paradoxical sensitivity to externally evoked motor activation (kinesia paradoxica), it is possible that emotional stimuli may facilitate verbal emotional expression more so in patients with PD than in control subjects.

METHODS

The authors measured verbal descriptions of personal emotional experiences in subjects with PD and normal controls.

RESULTS

Compared with control subjects, individuals with PD showed a relative increase in the number of words spoken and in discourse duration when talking about emotional experiences that are usually associated with high levels of arousal and motor activation. Although the authors did not measure arousal or activation, prior research has shown that, when asked to recall an emotional experience, people will often re-experience the emotion previously experienced during that episode.

CONCLUSIONS

Recalling emotional episodes induces verbal kinesia paradoxica in patients with PD. Although recall of these emotional episodes may have been associated with increased arousal and activation, the mechanism underlying emotional verbal kinesia paradoxica is unclear.

Verbal encoding deficits in a patient with a left retrosplenial lesion

Over the past decade, memory impairments associated with retrosplenial damage have received increased attention among neuroscientists, although the exact role of the retrosplenial region in memory has not been clearly defined. Evidence from lesion studies and functional neuroimaging has implicated the retrosplenial region in verbal episodic memory, temporal ordering of information, and topographical memory. In addition, recent positron emission tomography studies have shown increased activation of the retrosplenial cortex during tasks involving both the encoding and retrieval of episodic information. The objective of this study was to define more clearly the nature of memory impairments observed in retrosplenial amnesia. A 47-year-old amnesic male with a left retrosplenial arteriovenous malformation was examined on neurocognitive tasks of automatic and directed encoding, temporal ordering of information, and remote memory. Despite normal performance on frontal cognitive tasks, intact memory for remote information, and a superior IQ, this individual exhibited a profound deficit in the encoding of information, evidenced by poor release from proactive interference, poor category clustering on word list recall, poor semantic encoding on a levels of processing task, and mild impairments in temporal ordering. These results imply that the retrosplenial region plays a role in the verbal encoding of information, which contributes to the profound verbal memory impairment reported in previous case studies of patients with retrosplenial damage.

Emotional and physiological responses to false feedback

The relationship between autonomic-visceral arousal and emotional experience is unclear. The attribution or cognitive-arousal theory of emotional experience posits that emotional experience is dependent on both visceral-autonomic nervous system feedback and the cognitive interpretation of the stimulus that induced this visceral activation. The finding that false cardiac feedback can alter emotional experience suggests that it may be the conscious perception that one is aroused, together with the cognitive interpretation of the stimulus that are important in developing emotional experience. Because the right hemisphere appears to play a special role in modulating arousal and interpreting emotional stimuli, it is possible that right hemisphere damage may interfere with developing the computations needed for emotional experience. To test this hypothesis we exposed men, both neurologically intact and those with right and left hemisphere lesions, to emotionally provocative pictures that were paired with false cardiac feedback, and examined the effects of this false feedback on their ratings of attractiveness of these pictures and their cardiac reactivity to this information. Subjects with left hemisphere damage, but not right hemisphere damage, showed significant changes in their emotional rating whereas control subjects showed marginal reactivity in their emotional ratings. Subjects with left hemisphere damage also showed significant changes in their cardiac reactivity. This finding is consistent with prior reports that indicate, when compared to right hemisphere damaged patients and normal controls, patients with left hemisphere lesions have an increased visceral-autonomic response to stimuli. These findings further provide support for the postulate that it is the cognitive interpretation of perceived physiological arousal together with the cognitive interpretation of the stimulus that is important in the development of emotional judgment and experience. These results do not support the approach-left hemisphere/avoidance-right hemisphere dichotomy, but instead suggest that left hemisphere damage increases reactivity to false feedback, and that the intact right hemisphere function integrates the cognitive interpretation of the emotional information and perceived arousal that lead to that emotional judgment. That these subjects showed no consistent relationship between their measures of cardiac reactivity and their ratings of attractiveness detracts from the James-Lange and attribution theories. These subjects also showed no consistent relationship between their knowledge of affective physiological reactivity and their ratings of attractiveness, or between their knowledge of physiological reactivity and actual measures of cardiac reactivity, suggesting that other neuropsychological factors are involved in making an emotional judgment.

Digitizing the moving face during dynamic displays of emotion

Humans typically decode facial signals during dynamic interactions in which the face moves. In this study, we digitized real time video signals in order to examine movement asymmetries across the face during emotional and nonemotional expressions. Forty dextral males were tested. For each expression, a 400 ms video segment was analyzed for changes in signal value (pixel intensity) over consecutive frames. The upper and lower face regions were examined separately due to differences in the cortical enervation of facial muscles in the upper (bilateral) vs lower face (contralateral). Results revealed distinctly different movement asymmetries over the lower and upper hemiface. In the upper face, more movement occurred over the right side for most facial expressions, regardless of emotionality. The latter finding questions the assumption that muscles of the upper face are symmetrical and/or bilaterally enervated in a symmetrical manner. In the lower face, negative expressions linked to fight-flight emotions (i.e. fear, anger) were associated with greater left sided movement, whereas happiness tended to be associated with more right sided movement. No consistent pattern of movement asymmetry occurred for nonemotional expressions. Although the valence-related movement asymmetries in the lower face are consistent with neuropsychological models of emotional expressivity, it remains unclear whether they reflect activation or inhibitory hemispheric mechanisms. Taken together, these data suggest that multiple factors may contribute to expressive movement asymmetries of the face.

Cognitive and vestibulo-proprioceptive components of spatial ability in Parkinson's disease

Visual-spatial deficits are often associated with Parkinson's Disease (PD). Recent theories suggest that frontal-basal ganglionic dysfunction affects cognition in PD. Although this hypothesis does not entirely explain spatial deficits in PD, the inappropriate utilization of cues associated with executive dysfunction may induce spatial deficits. Alternatively, the vestibular system is also involved in spatial cognition, and vestibular dysfunction may affect visual-spatial ability in PD. To test these hypotheses, we administered the Water Jar Test, while perturbing vestibulo-proprioceptive input. Non-demented PD patients were significantly less accurate than controls in judging horizontal, and appeared to inappropriately utilize cues. No group effect was found for head tilt. These findings suggest the visual-spatial difficulties seen in PD are related to executive dysfunction that is associated with a disruption of the frontal-basal ganglionic and frontal-parietal systems.

Immunoglobulin heavy-chain consensus probes for real-time PCR quantification of residual disease in acute lymphoblastic leukemia

Tumor-related immunoglobulin heavy-chain (IgH) rearrangements are markers for polymerase chain reaction (PCR) detection of minimal residual disease (MRD) in B-cell malignancies. Nested PCR with patient IgH allele-specific oligonucleotide primers can detect 1 tumor cell in 10(4) to 10(6) normal cells. In childhood acute lymphoblastic leukemia (ALL), persistence of PCR-detectable disease is associated with increased risk of relapse. The clinical significance of qualitative PCR data can be limited, however, because patients can harbor detectable MRD for prolonged periods without relapse. Recent studies indicate that a quantitative rise in tumor burden identifies patients who are at high risk for relapse. Therefore, an efficient and reliable PCR method for MRD quantification is needed for ALL patients. We have developed a real-time PCR method to quantify MRD with IgH V(H) gene family consensus fluorogenically labeled probes. With this method, a small number of probes can be used to quantify MRD in a large number of different patients. The assay was found to be both accurate and reproducible over a wide range and capable of detecting approximately 1 tumor cell in 5 x 10(4) normal cells. We demonstrate that this methodology can discriminate between patients with persistence of MRD who relapse and those who do not. This technique is generally applicable to B-cell malignancies and is currently being used to quantify MRD in a number of prospective clinical studies at our institution. (Blood. 2000;95:2651-2658)

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Hyaluronic acid-carboxymethylcellulose film and perianastomotic adhesions in previously irradiated rats

OBJECTIVE

Postoperative intra-abdominal adhesions are a major source of postsurgical morbidity. Pelvic irradiation increases the likelihood of adhesion development. The purpose of this study was to evaluate the effects of hyaluronic acid-carboxymethylcellulose film, which was designed as a barrier to prevent adhesions, on the healing of ileal anastomoses performed on irradiated rat bowel.

STUDY DESIGN

Sixty-eight female Sprague-Dawley rats underwent whole pelvic irradiation with a single fraction of 1700 cGy. Twenty weeks later the rats underwent exploratory laparotomy with segmental ileal resection and reanastomosis. Eighteen of the anastomoses were wrapped in hyaluronic acid-carboxymethylcellulose film. Fifty anastomoses were not treated with any adhesion-inhibiting barrier. On the fifth postoperative day the animals underwent another laparotomy for evaluation of the anastomotic sites.

RESULTS

At the second laparotomy 93% of the rats treated with hyaluronic acid-carboxymethylcellulose film were found to have perianastomotic abscesses. In the non-hyaluronic acid-carboxymethylcellulose film group the perianastomotic abscess rate was 24% (P <.0001).

CONCLUSION

Among previously irradiated rats undergoing small-bowel resection and anastomosis, hyaluronic acid-carboxymethylcellulose film was associated with a markedly increased rate of abscess formation at the operative site.