Group interpersonal psychotherapy (IPT-G) for borderline personality disorder: A randomized controlled study

Recent evidence supported the notion that add-on group therapy should be provided to individuals with borderline personality disorder (BPD) who already undergo individual psychotherapy. The present 20 week-study was aimed to evaluate the efficacy of the adjunction of group interpersonal psychotherapy (IPT-G) to individual interpersonal psychotherapy adapted for BPD - revised (IPT-BPD-R) in comparison with individual IPT-BPD-R alone in a group of BPD patients. In addition, demographical and clinical characteristics that can be considered predictors of response to add-on group therapy were investigated. Forty-six patients were randomly assigned to 1) IPT-BPD-R plus IPT-G or to 2) IPT-BPD-R in the waiting list for IPT-G. Patients were assessed at baseline and after 20 weeks with: the Clinical Global Impression Scale, Severity item (CGI-S); the Social Occupational Functioning Assessment Scale (SOFAS); the Satisfaction Profile (SAT-P); the Borderline Personality Disorder Severity Index (BPDSI); the Modified Overt Aggression Scale (MOAS); the Childhood Trauma Questionnaire - Short Form (CTQ-SF); the Inventory of Interpersonal Problems (IIP-32); and the Reading the Mind in the Eyes Test (RMET). Statistical analyses included: ANOVA for repeated measures to compare score changes of the rating scales within groups (trial duration) and between groups (treatment modalities), and multiple regression analysis to identify which clinical factors are significantly and independently related to the difference of BPDSI score between baseline and week 20 (Δ BPDSI). The significance level was P ≤ 0.05. Both significant within-subjects effects (duration) and between-subjects effects (treatment modalities) were found for the following rating scales: MOAS; BPDSI items "feelings of emptiness", "outbursts of anger," and "affective instability"; RMET; SAT-P items "work" and "sleep, food, free time"; and IIP-32 scale "domineering/controlling". At the multiple regression analysis BPDSI item "impulsivity", RMET, and the subscale "socially inhibited" of the IIP-32 were significantly and independently related to Δ BPDSI score. In conclusion, the add-on of IPT-G produced higher improvement in core BPD symptoms, social cognition, a dysfunctional interpersonal style, and subjective quality of life. Subjects who were less impulsive, less socially inhibited, and with higher abilities in social cognition obtained greater benefits from the adjunction of group therapy. CLINICAL TRIALS REGISTRATION NUMBER: ACTRN12623000002684, Australian New Zealand Clinical Trials Registry (ANZCTR).

Video self-confrontation as a therapeutic tool in schizophrenia: A randomized parallel-arm single-blind trial

BACKGROUND

Lack of insight is a barrier to treating psychosis. Preliminary studies have suggested that showing people videos of their psychotic behaviour may improve personal insight. This clinical trial aimed to assess the effect of video self-confrontation.

METHODS

Inpatients between 18 and 65 years old with schizophrenia or schizoaffective disorder were filmed upon admission to two psychiatric hospitals while experiencing acute psychosis. After stabilization, individuals were randomized 1:1 to the "self-video" group where they watched their own video or to the "no video" control group. The primary outcome was the Scale to assess Unawareness of Mental Disorder (SUMD) at 48 h by a blinded assessor. Secondary objectives included psychotic and depressive symptoms, medication adherence and functioning using the Functional Remission of General Schizophrenia. Patients were followed up for four months.

RESULTS

60 participants were randomized and the level of insight did not differ between groups at 48 h (p = 0.98). There was no impact on SUMD subscores or the other insight questionnaires at any timepoint, nor on psychopathology or medication adherence. At one month, the level of functioning of those in the "self-video" group (n = 23) was higher (61.8 vs 53.5, p = 0.02), especially concerning "Treatment" and "Daily life". No adverse effects were reported. After video self-confrontation, people expressed more positive than negative emotions and were less lost to follow-up.

CONCLUSION

Video self-confrontation did not change levels of insight, but may have a therapeutic impact nonetheless, by improving levels of self-care and adherence to care, indicating that this innovative therapeutic tool requires further study.

TRIAL REGISTRATION NUMBER

NCT02664129.

Seven Day Safety Net Service

A seven day safety net telephone service was developed in an acute medical unit at a university hospital in London. The service attempts to provide all patients discharged from acute medicine with patient activated access to a member of the acute medical team. This allows patients to flag deterioration triggering further review in the ambulatory clinic or to ask for advice on symptoms or medication. Here we evaluate the first sixteen months of the service and report on its benefits and limitations.

Impact of temporary mechanical circulatory support on mortality in cardiogenic shock: an emulated target trial with a prospective, multicenter, French cohort study

Background

The field of temporary mechanical circulatory support (TMCS) has advanced in last decade justifying that TMCS is increasingly used for treatment of refractory cardiogenic shock (CS). Nevertheless, the efficacy of TMCS (extracorporeal life support (ECLS) and Impella) in CS remains controversial due to the lack of high-quality evidence. The aim of this prospective multicenter observational study simulating a randomized trial was to assess the impact of TMCS on the hospital mortality in patients with CS.

Methods

This study (ClinicalTrials.gov ID: NCT03528291) was conducted at 3 TMCS centers organized in a cardiac assistance network, one as a level 1 TMCS center (expert center), and 2 as level 2 centers (hub centers). The study was designed and led by the heart team of the expert center with input from the hub centers.

All patients admitted to an intensive care unit between July 2017 and May 2020 either directly at the TMCS centers or after transfer from a non-specialized hospital, were screened for TMCS indication provided they were admitted for CS. CS was defined according to the European Society of Cardiology criteria. Were excluded patients younger than 18 years, CS after cardiac surgery, or after cardiac arrest if it was refractory or with a no flow >3 min and/or out-of-hospital cardiac arrest with non-shockable rhythm, or CS in the context of myocardial infarction complications, massive pulmonary embolism, and if TMCS was contraindicated

TMCS indication was decided after a multidisciplinary discussion carried out by the “heart team”. Implantation of TMCS resulted from an agreement of the heart team within the first 24 hours after admission mainly based on the initial severity of the CS, or if CS was refractory to the medical treatment.

The primary outcome was in-hospital survival. A propensity score-weighted analysis was done for treatment-effect estimation. This method, which weights each patient according to their propensity score, includes all participants in the analysis.

Results

246 patients with CS were included in the study: 121 in TMCS group (72% ECLS, 14% Impella, 14% both ECLS and Impella) and 125 in control group. After adjustment by a propensity score, hospital mortality was comparable in the two groups (32% TMCS group vs 27% control group; Odds ratio with TMCS, 1.28; 95% confidence interval, 0.87 to 1.88; p=0.21). Mortality at D180 was also similar in the two group (33% vs 30% respectively; p=0.51). Thromboembolic events were significantly higher in the TCMS group (14% vs 4%; p<0.01) as well as the transfusion rate ((median (IQR); 4.0 (0.0; 9.0) vs 0.0 (0.0; 0.0); p<0.01).

Conclusion

In our study, the use of TMCS does not seem to improve hospital survival in patients with cardiogenic shock. Thus, TMCS, which are iatrogenic side effects providers, should be reserved for the most severe patient and discussed by a multidisciplinary team.

Funding Acknowledgement

Type of funding sources: None. Flow chart

Teledentistry and forensic odontology: Cross-sectional observational comparative pilot study

Forensic dentistry is the branch of forensic science concerned with the study of teeth and jaws. To facilitate the work of experts, new comparative identification tools are emerging, with digital techniques such as the intra-oral camera, which are revolutionising current techniques in forensic dentistry.

OBJECTIVE

The aim of this study is to evaluate the diagnostic quality of the post-mortem odontogram carried out remotely via a video of the oral cavity using an intra-oral camera. The gold standard is the post-mortem odontogram obtained via the standard identification technique during the clinical examination.

MATERIALS AND METHODS

25 deceased patients were included in the study and the data were collected in the Forensic Medicine and Thanatology Department at the University Hospital of Montpellier. The protocol was divided into three stages: the gold standard consultation, the recording of videos with the Soprocare® camera, and the remote analysis of the images obtained. The gold standard consultation and the remote analysis were carried out by two separate dental surgeons responsible for completing a clinical file, used to establish the odontogram of the deceased patient.

RESULTS

The study was carried out on 25 deceased subjects, between 13 May and 12 June 2019. Our sample was composed of 68% men and 32% women. A sensitivity threshold of 0.97 was observed for the performance of the odontogram, i.e., for all the teeth actually present in the mouth for all subjects in the study, 97% of them were identified with the videos taken using the intraoral camera. The examination with the intra-oral camera demonstrated a good diagnostic performance in the detection of missing teeth with a PPV of 97.9% and a NPV of 98.2%. Practitioner became more skilled at recording the videos with the intra-oral camera. One can therefore note an ease in the handling of this digital tool, which gradually improved with the number of subjects included in the study CONCLUSIONS: The Soprocare® intraoral camera has an acceptable diagnostic validity in establishing the odontogram of the deceased. It enables fundamental elements to be detected with optimal efficiency. However, several points still need to be improved, in order to make the use of the camera during data collection as easy and efficient as possible.

28 Evaluation invitro of two protocols of vitrification from alpaca (Vicugna pacos) embryos

The reproductive efficiency of South American camelids as the alpaca is low, with a few number of animals having a good genetic characteristic. The transfer of cryopreserved embryos has great potential to disseminate valuable genetic, but the suitable protocol for such cryopreservation still needs to be developed. In this study, two protocols of vitrification of alpaca embryos were tested. Day 6.5 post-mating, embryos (n=66) were recovered from 14 female alpacas through a non-surgical technique and classified according to the characteristics of old world camelids reported by Skidmore et al. 2004 (Reprod. Fertil. Dev. 16, 605–609). Only quality 1 and 2 embryos were used for the study. They were placed together in 50-µL drops of holding medium for 30min and transferred to a 100-µL drop of equilibration solution 1, consisting of 7.5% (v/v) ethylene glycol (EG) + 0.25M sucrose. After 1min, embryos were transferred to equilibration solution 2, consisting of 15% (v/v) EG + 0.5M sucrose. After 2min, embryos were transferred into 2 consecutive drops of vitrification solutions A [SA: 30% (v/v) EG + 1M sucrose] for 20s each, then in 2 other drops of vitrification solution B [SB: 30% (v/v) EG + 3% glycerol + 1M sucrose] for 20s each. Thereafter, embryos were quickly loaded into open pulled straws (OPS) in a volume of 10µL and then plunged into liquid nitrogen. For warming, the OPS were held in air for 5s and subsequently thawed at 37°C for 50s. Straws were emptied into 1mL of prewarmed holding medium solution (HMS1) containing 1M sucrose for wash and the thawed blastocysts were transferred into a second 1mL of prewarmed HMS1. After 5min incubation at 37°C, the blastocysts were transferred into 1mL of warmed Holding medium solution 2 (HMS2) containing 0.5M sucrose maintained at room temperature (∼24°C) for evaluation. Data were analysed by the Chi-squared test. Post-thaw embryo expansion results were 81.3% and 58.8% for SA and SB (P<0.05), respectively. Post-thaw embryo quality (1 and 2) were found at 62.5% and 29.1% with SA and SB, respectively (P<0.05). In conclusion, the vitrification of alpaca embryos with the ethylene glycol:sucrose solution results in better post-thaw outcomes than the ethylene glycol:sucrose:glycerol. Further experiments with embryo transfer are needed. This research was funded by FONDECYT project no. 149-2017.

Short-course antibiotic treatment of bone and joint infections in children: a retrospective study at Montpellier University Hospital from 2009 to 2013

BACKGROUND

Acute haematogenous bone and joint infections (AHBJI) represent a diagnostic and therapeutic emergency in children, with significant potential sequelae in the case of delayed treatment. Although historically the recommendations for treatment have been based on surgery and prolonged antibiotic therapy, recent studies have demonstrated that short-course antibiotic therapy is also effective.

OBJECTIVES

We evaluated a short-term antibiotic protocol for both osteomyelitis and septic arthritis in a 6 year retrospective study at the University Hospital of Montpellier.

METHODS

This protocol was based on an initial intravenous treatment with a re-evaluation after 48 h and an early switch to oral therapy in the case of a favourable clinical course for a minimum total duration of 15 days. Antibiotics were selected based on local microbiological epidemiology and systematically adapted to bacteriological results.

RESULTS

One hundred and seventy-six cases of AHBJI were included, comprising 56 patients with osteomyelitis, 95 with septic arthritis and 25 who had both of these. The aetiological agent was identified in 42% of the cases, with the main pathogens being Staphylococcus aureus (39%) and Kingella kingae (27%). The mean intravenous treatment duration was 4 days, while the total treatment duration was 15 days. There were no treatment failures, mild sequelae occurred in 1% of the cases and the secondary surgical revision rate was 7%.

CONCLUSIONS

The results of this study are comparable to those reported for evaluations of prolonged antibiotic therapy protocols, thus indicating that a common short-term antimicrobial therapy for the management of both osteomyelitis and septic arthritis (minimum of 15 days) is a viable option for treating AHBJI in children. Further prospective studies to confirm these findings are hence warranted.

Évaluer l’efficacité des mesures barrières pour limiter la transmission nosocomiale du SARS-CoV-2 : étude EMBELLIE

Introduction

La pandémie de COVID-19 a justifié, à partir du 17 mars 2020, l’instauration d’un confinement en France. Le personnel soignant a été rapidement identifié à risque d’infection du SARS-CoV-2, imposant des mesures barrières adaptées aux types d’exposition vis-à-vis des patients et des personnels de santé. L’objectif de cette étude était d’évaluer la séroprévalence des infections COVID-19 chez des personnels de santé ayant différents niveaux d’exposition au SARS-CoV-2.

Matériels et méthodes

Étude monocentrique et transversale comparant la séroprévalence du COVID-19 auprès de trois groupes de personnels de santé de notre CHU travaillant dans une unité COVID (fortement exposés), non COVID (faiblement exposés) et sans contact patients (non exposés). Le dépistage sérologique a été proposé au personnel soignant sur la base d’une information généralisée dans chacun des services présélectionnés. Le critère de jugement principal était la présence d’anticorps par test sérologique satisfaisant aux critères de performances de la HAS (ID Screen® SARS-CoV-2-N IgG Indirect [ID.Vet]). Pour l’ensemble des cas positifs, une enquête individuelle a tenté de déterminer l’origine professionnelle ou non de l’infection. Le nombre de sujets à inclure était estimé à 156 par groupe sur la base d’une séroprévalence estimée à 7 % ± 4 %. Les prévalences ont été comparées entre les trois groupes à l’aide d’un test exact de Fisher. Afin d’ajuster sur l’âge, le sexe et la profession (médecin/interne, paramédical ou autre), une régression logistique a été réalisée.

Résultats

Entre le 21 avril et le 3 juin 2020, 647 personnes ont été incluses dans l’étude : 261 dans le groupe exposé, 227 dans le groupe faiblement exposé et 159 dans le groupe non exposé. L’âge médian était de 36 ans (écart interquartile [EIQ] : 29–47), 496 (76 %) étaient des femmes. Dix personnes présentaient des IgG anti-nucléocapisdes du SARS-CoV-2 dans le groupe exposé, deux chez les faiblement exposés et une chez les non-exposés, soit des prévalences respectives pour chaque groupe de 3,91 %, 0,88 % et 0,63 % (p = 0,022, test exact Fisher). Après ajustement sur l’âge, le sexe et la profession, le fait d’être fortement exposé était toujours significativement associé à une sérologie positive (odds ratio = 4,43 [intervalle de confiance à 95 % = 1,15–17,06] [p = 0,031]). Après enquête, 7 des 13 cas avec des sérologies positives étaient d’acquisition probablement professionnelle.

Conclusion

L’étude mets en évidence un risque d’infection professionnelle du SARS-CoV-2 dans un contexte de faible incidence régionale du COVID-19 en population générale. Cependant, la séroprévalence SARS-CoV-2 est très faible chez les personnels de santé travaillant en secteur COVID, et souvent d’acquisition extrahospitalière. Les mesures barrières ont donc permis de fortement limiter la transmission nosocomiale. Nos résultats sont à interpréter avec précaution en raison de biais d’échantillonnage possible.

Assessing forest availability for wood supply in Europe

The quantification of forests available for wood supply (FAWS) is essential for decision-making with regard to the maintenance and enhancement of forest resources and their contribution to the global carbon cycle. The provision of harmonized forest statistics is necessary for the development of forest associated policies and to support decision-making. Based on the National Forest Inventory (NFI) data from 13 European countries, we quantify and compare the areas and aboveground dry biomass (AGB) of FAWS and forest not available for wood supply (FNAWS) according to national and reference definitions by determining the restrictions and associated thresholds considered at country level to classify forests as FAWS or FNAWS. FAWS represent between 75 and 95 % of forest area and AGB for most of the countries in this study. Economic restrictions are the main factor limiting the availability of forests for wood supply, accounting for 67 % of the total FNAWS area and 56 % of the total FNAWS AGB, followed by environmental restrictions. Profitability, slope and accessibility as economic restrictions, and protected areas as environmental restrictions are the factors most frequently considered to distinguish between FAWS and FNAWS. With respect to the area of FNAWS associated with each type of restriction, an overlap among the restrictions of 13.7 % was identified. For most countries, the differences in the FNAWS areas and AGB estimates between national and reference definitions ranged from 0 to 5 %. These results highlight the applicability and reliability of a FAWS reference definition for most of the European countries studied, thereby facilitating a consistent approach to assess forests available for supply for the purpose of international reporting.

504 Intramural hematoma post transcatheter valve replacement

Background

Transcatheter valve replacement (TAVR ) is currently the optimal treatment for patients with severe aortic stenosis who are considered to have an intermediate to high operative risk for surgical intervention. Intramural hematoma secondary to balloon-expandable TAVR is a poorly reported complication with unknown outcome. Among the risk factors associated with this complication are advanced age, female gender, bulky calcifications, significant basal hypertrophy and severe prothesis oversizing.

Case report

We report the case of a 84 year old woman with a history of permanent atrial fibrillation, who was diagnosed with severe aortic stenosis symptomatic with heart failure NYHA class III. An important comorbidity was liver cirrhosis of viral etiology (hepatitis C virus) with secondary thrombocytopenia.

Transthoracic and transoesophageal echocardiography (TEE) showed severe aortic stenosis with asymmetric calcifications, with preserved gradient (a peak velocity of 4.7 m/s, mean gradient of 63.3mmHg), mild left ventricular disfunction (ejection fraction 45%), and calculated aortic valve area of 0,9 cm2.

As a frail, high risk patient, the heart team recommended transcatheter aortic valve implantation. After complete computer tomographic evaluation, a 26 mm Edwards Sapien 3 valve was implanted through a femoral approach.

Intraprocedural transesophageal echocardiography showed the developement of an intramural hematoma in the aortic root (right coronary and noncoronary sinuses), associated with a small pericardial effusion. After administration of Protamine, betablockers and strict blood pressure control, no extension of the hematoma was noted.

Serial TEE showed significant regression of the hematoma and of the pericardial effusion, with normal parametres of the prothesis, with a transprothetic gradient of 23 mmHg, no aortic leak, no other complications.The patient was discharged 12 days after the procedure, clinically stable.

Conclusion

Aortic intramural hematoma may occur during intra-TAVR procedure. Although it may have a benign course, timely recognition and adequate imaging follow-up are mandatory in order to limit the extent and prevent life-threatening complications.

P1305 Rare complication of a frequent disease

Introduction

Splenic abcess represents a rare complication of left-sided infective endocarditis. Unlike splenic infarction, which is a more benign condition, splenic abcess requires rapid diagnosis and treatment as its course can be fatal.

We present the case of a 52- year old male, with diabetes and hypertension, admitted for shortness of breath and fever in the past two months.

Clinical examination revealed respiratory distress, tachypnea, diastolic murmur on the left sternal border. Baseline laboratory investigations showed elevated inflammation markers, leukocytosis and thrombocytosis. Enterococcus faecalis was isolated from the hemocultures.

Transthoracic echocardiography revealed a dilated left ventricle (LV), with preserved LV ejection fraction, with severe aortic regurgitation due to valve destruction. A large (11mm diameter) vegetation-like structure attached to the ventricular side of the right coronary cusp, protruding into the left ventricular outflow tract was identified. Further evaluation by transoesopahgeal echocardiography did not identify other lesions, except for secondary moderate mitral regurgitation, with intact mitral leaflets. Dual antibiotic therapy with Ampicilin and Gentamycin was initiated. Surgery was planned after infection control.

The first three days were uneventful, with rapid resolution of fever and inflammatory markers, but on the fourth day, the patient developed severe abdominal pain, with its focal point in the left hypochondrium. Contrast abdominal CT was performed and large multiple subcapsular lesions were identified. These findings, correlated with the symptomatology, suggested embolic splenic abcess and infarction.

The patient successfully underwent laparoscopic splenectomy, but soon after he developed sepsis with respiratory failure and neurological deterioration (with normal CT scan) and was admitted to the intensive care unit, where he was intubated and mechanically ventilated.

Consensus after discussions between cardiology, cardiac surgery and neurology services was to immediately replace the aortic valve, given the inability to otherwise control the infection. Intraoperative images were consistent with perforation of the right coronary cusp.

During hospitalization in the ICU following cardiac surgery, the patient was extubated and his neurological function markedly improved. Repeated TTE and TEE showed normal prosthetic valve function and resolution of mitral regurgitation. The patient continued to improve clinically until his discharge.

Conclusions

We presented a case of a rare pathogenic entity- splenic abscess and infarction- due to systemic embolization from infective aortic valve endocarditis. Multidisciplinary teamwork was required between cardiologist, intensive care specialist, neurologist, infectionist, general surgeon and cardiac surgeon. Splenectomy was performed before valve replacement, a treatment-course characteristic in the occurrence of these rare cases.

T cell leukemia control via Ras-Raf pathway inhibition with peptides

RATIONALE

RAS-RAF-MEK-ERK pathway has been considered a promising target for anticancer therapy. However, tumor cells may develop resistance against such drugs via hyperactivation of N-Ras, which explains why novel therapeut-ic approaches. In this sense, the Institute Curie- Université Pierre et Marie Curie (Paris 6) designed peptides in order to disturb Ras/Raf interaction which showed pro-apoptotic properties. These peptides were patented as WO2015001045 A2 (PCT/EP2014/064243)5.

OBJECTIVE

In order to check the anti-tumoral action of WO2015001045 A2 peptides in a very aggressive BALB/c mice spontaneous leukemia called LB, we performed the present study.

METHOD & RESULTS

50 BALB/c mice inoculated with 106 LB tumor cells were randomly assigned either to control (placebo) or treatment group (that daily received 3 mg of peptide per kg of mice) during 30 days. By day 15 only 24% of the control group was alive vs. 100% of the treatment group. The average survival in treated group was 20,27 days while in control group the mean survival was 15,48 days. Either bone marrow, spleen or axillary nodes demonstrated a higher level of malignant T cell presence compare with treated group (89,78% ; 95,64% & 77,68% versus 72,45%, 80,23% & 63.44% respectively for each organ inspected.

DISCUSSION

Our study demonstrated an improvement in survival curves in mice model affected by spontaneous T lymphoid leukemia when peptides WO2015001045 A2 were used. These peptides might be a valid option to become part of the therapeutic armory for malignant lymphoproliferative diseases control.

Comparison of anti-interleukin-5 therapies in patients with severe asthma: global and indirect meta-analyses of randomized placebo-controlled trials

Inconsistent results have been reported regarding IL-5 blockade treatment in asthma. There were no direct between-treatment comparisons. Only differences between each drug and placebo were studied. We identified all RCTs with anti-IL5 treatments for patients with asthma over the 1990-September 2015 period. RCTs were searched on Medline, Cochrane and Embase. At least 50 patients were enrolled in each study. Outcomes considered were exacerbation rate reduction, FEV₁ changes, ACQ-5 improvement, adverse events and serious adverse events. A global meta-analysis was first conducted followed by an indirect comparison of each IL-5-targeting drug: benralizumab, reslizumab and mepolizumab. Further eosinophilic subgroup analysis and sensitivity analysis were also conducted in case of heterogeneity. Ten trials involving 3421 patients were eligible for meta-analysis. IL-5 blockade significantly reduced annual exacerbation rates vs. placebo by 40% [29-50] (P < 0.01, I² = 0.61). ACQ-5 was significantly improved vs. placebo but below the recognized MCID level (-0.31 [-0.41, -0.21], P < 0.01, I² = 0.11). FEV₁ changes from baseline were improved vs. placebo by 0.09 L [0.05-0.12] (P < 0.01, I² = 0.28). The subgroup analysis identified a slight additional improvement in mean treatment effects in eosinophilic (> 300 mm³ /L) patients with severe asthma. Similar patterns and rates of adverse events and severe adverse events were reported with the three drugs. The data interpretations were not affected by the sensitivity analysis. IL-5 blockade appears to be a relevant treatment strategy to improve severe asthma management, particularly for eosinophilic patients. No clear superiority appeared between the drugs when appropriate doses were compared.

Health Care Utilization by Low-Income Clients of a Community Clinic: An Archival Study

An archival study was done of 500 medical records from a community clinic serving a low-income predominantly Hispanic area of Los Angeles. Data collected included demographic characteristics and presenting symptoms or reasons for visit, as well as diagnoses and treatment. Patients tended to be young, poor, female Hispanics. The majority of patient visits were for family planning services, with smaller proportions for pediatric, general medical, or pregnancy testing services. Return rates for family planning and other services were not as high as desirable, with more than half of the sample having made only one clinic visit. A careful analysis of the demographic characteristics of oral contraceptive acceptors who returned or did not return for services indicated that the two groups were similar to each other except that married women were more likely to return than single women. One quarter of positive pregnancy tests were done on women who were more than 12 weeks pregnant, while another quarter of positive tests were referred for abortion. The data highlighted certain changes needed in service delivery, such as the need for a pre- and postnatal care component of service and a need to attract more older and male patients. In the future, collection of archival data from this same clinic could facilitate the evaluation of certain policy changes, since those data could be compared with the present findings.

Characterization of Hemorrhagic Complications after Surgery for Temporal Lobe Epilepsy

OBJECTIVES

To assess the significance of symptomatic hemorrhagic complications occurring after different temporal resections for temporal lobe epilepsy (TLE) and to compare this data to findings with postoperative hematomas after temporal surgery for mostly glial or metastatic tumors.

PATIENTS AND METHODS

Patient charts were retrospectively reviewed for 442 patients who underwent surgery for refractory TLE between 1995 and 2000. Procedures were 247 transsylvian amygdalohippocampectomies (AH), 40 transcortical AH, 57 anterior temporal lobectomies (ATL), 23 lesionectomies plus AH, and 75 lesionectomies without AH. All patients with delayed awakening or new neurological deficits due to hemorrhages were included in the study. An identical procedure was performed to detect symptomatic hemorrhages after 208 procedures for temporal tumor resection during the same time period.

RESULTS

Symptomatic postoperative hemorrhages were found in 17 patients (3.8 %) undergoing epilepsy surgery, while the incidence was 3.0 % in a group with space-occupying temporal tumors (six patients). Hemorrhages showed a characteristic distribution after epilepsy surgery: in eight patients they were located remote from the site of surgery in the upper cerebellar vermis and foliae. Five typical hemorrhages associated with dysphasia were found in the left frontal operculum, only three patients had hematomas in the resection cavity, and one was located epidurally. Two patients had more than one location of hemorrhage. Transsylvian AH and ATL had a similar risk for postoperative hemorrhage, whereas none was found after lateral lesionectomies or transcortical AH. Intraoperative manipulations were associated with opercular hemorrhages; the only predisposing factor for resection site hematomas was older age, whereas cerebellar hemorrhages were associated with cerebrospinal fluid (CSF) loss during AH and ATL. There was no mortality in the TLE group, and 0.75 % permanent mild deficits. Seizure outcome did not differ from the rest of the group (82.5 % satisfactory seizure control). In contrast, all intraaxial hematomas after tumor surgery (N = 4, incidence 1.9 %) were located in or adjacent to the resection cavity. Prognosis was much worse with parenchymal hemorrhages after tumor surgery: three of four patients died, one survived with a severe hemiparesis, only two patients with extraaxial hematomas (incidence 1 %) had a complete recovery. The 3 % incidence of symptomatic hemorrhages was only insignificantly lower compared to the TLE group, patients with tumor surgery were older than TLE patients (49 versus 33 years), and in five of six patients only incomplete tumor resection was achieved.

CONCLUSION

Although associated with a low permanent morbidity, features of postoperative hemorrhages after TLE surgery are characteristically different to complications after surgery for other indications, which has to be kept in mind for patient counseling and obtaining informed consent.

Does the choice of treatment influence survival of patients with small hepatocellular carcinoma in compensated cirrhosis?

OBJECTIVE

Untreated patients with small, single hepatocellular carcinoma (HCC) in compensated cirrhosis are characterized by a relatively good prognosis.

METHODS

We report the findings generated in a retrospective study on a cohort of 186 consecutive patients with small (< 5 cm) HCC in Child A or B cirrhosis, who were transplanted (four), underwent surgery (15), or were treated with percutaneous ethanol injection (117), lipiodol chemoembolization (44) or best supportive care (six), depending on their clinical features.

RESULTS

Overall survival was 26% at 5 years (31% Child A, 20% Child B), with a mean and median survival of 44 and 38 months, respectively. The longest survival was obtained with transplantation and surgery, and the worst with best supportive care. When untreated patients were not considered, no significant differences were observed between the different types of treatment, however, even when patients in the Child A group were considered alone. Almost all the patients who underwent surgery relapsed. No significant difference was observed in relation to the stage of the disease, while alpha-fetoprotein levels were singled out as the only relevant prognostic factor in a multivariate Cox's regression model. Costs per year of life saved were extremely high for transplantation and lowest for ethanol injection, with surgery being less expensive than chemoembolization.

CONCLUSIONS

This study confirms that patients with single, small HCC nodules in well compensated cirrhosis should be treated. The choice of type of treatment should be based on the availability of local resources and expertise, and on the patients' preference, after they have been properly informed on the survival, morbidity and mortality related to each treatment option. The relative cost of the procedures should also be considered.

Evaluation of inverse methods and head models for EEG source localization using a human skull phantom

We used a real-skull phantom head to investigate the performances of representative methods for EEG source localization when considering various head models. We describe several experiments using a montage with current sources located at multiple positions and orientations inside a human skull filled with a conductive medium. The robustness of selected methods based on distributed source models is evaluated as various solutions to the forward problem (from the sphere to the finite element method) are considered. Experimental results indicate that inverse methods using appropriate cortex-based source models are almost always able to locate the active source with excellent precision, with little or no spurious activity in close or distant regions, even when two sources are simultaneously active. Superior regularization schemes for solving the inverse problem can dramatically help the estimation of sparse and focal active zones, despite significant approximation of the head geometry and the conductivity properties of the head tissues. Realistic head models are necessary, though, to fit the data with a reasonable level of residual variance.

Spatiotemporal profile of synaptic activation produced by the electrical and visual stimulation of retinal inputs to the optic tectum: a current source density analysis in the pigeon (Columba livia)

The optic tectum of the pigeon is a highly organized, multilayered structure that receives a massive polystratified afference of at least five different populations of retinal ganglion cells and gives rise to various anatomically segregated efferent systems. The synaptic organization of retino-tectal circuitry is, at present, mostly unknown. To investigate the spatiotemporal profile of synaptic activation produced by differential (electrical and visual) stimulation of the retinal inputs, we performed a high-spatial-resolution current source density analysis in the optic tectum of the anaesthetized pigeon. Electrical stimuli consisted of brief pulses of different durations applied to the optic nerve head, while visual stimuli consisted of light flashes of different intensities. Electrical stimulation generated sinks confined to retinorecipient layers. The temporal structure, spatial location and thresholds of these sinks indicated that they are all due to primary tectal synapses of retinal fibers with different conduction velocities. Sinks evoked by the fastest retinal axons were more superficially located than sinks produced by slower retinal fibers. Visual stimulation, on the other hand, resulted in a more complex pattern of current sinks, with various sinks located in the retinorecipient layers and also well below. Visual stimulation induced action potentials at superficial as well as deep tectal levels. We conclude that electrical stimulation activates most of the populations of ganglion cells as well as their primary tectal synapses, but is unable to elicit a significant activation of secondary tectal synapses. Visual stimulation, on the contrary, activates just some of the incoming retinal populations, but in a way that produces noticeable secondary activation of intratectal circuits. Laminar segregation of retinally evoked tectal activity, as reported here, has also been found in other vertebrates. Similarities and differences with previous studies are discussed.

Reversible mechanical fixation of eye position in awake head-restrained pigeons (Columba livia)

Here we describe a method to fix gaze positions and to significantly reduce saccadic oscillations in pigeons. The procedure consists of a mechanical immobilization of the eye through the use of an electromagnet that exerts a radial force upon a small metal rectangle glued to the dorsal part of the eye. The method can be used in avian visual neurophysiology in order to hold the eye immobilized for periods of time, long enough to map the properties of visual receptive fields and investigate the possible functions of saccadic oscillations.

Combined MEG and EEG source imaging by minimization of mutual information

Though very frequently assumed, the necessity to operate a joint processing of simultaneous magnetoencephalography (MEG) and electroencephalography (EEG) recordings for functional brain imaging has never been clearly demonstrated. However, the very last generation of MEG instruments allows the simultaneous recording of brain magnetic fields and electrical potentials on the scalp. But the general fear regarding the fusion between MEG and EEG data is that the drawbacks from one modality will systematically spoil the performances of the other one without any consequent improvement. This is the case for instance for the estimation of deeper or radial sources with MEG. In this paper, we propose a method for a cooperative processing of MEG and EEG in a distributed source model. First, the evaluation of the respective performances of each modality for the estimation of every dipole in the source pattern is made using a conditional entropy criterion. Then, the algorithm operates a preprocessing of the MEG and EEG gain matrices which minimizes the mutual information between these two transfer functions, by a selective weighting of the MEG and EEG lead fields. This new combined EEG/MEG modality brings major improvements to the localization of active sources, together with reduced sensitivity to perturbations on data.

Genetic variation and bill size dimorphism in a passerine bird, the reed bunting Emberiza schoeniclus

In passerine birds morphological differentiation in bill size within species is not commonly observed. Bill size is usually associated with a trophic niche, and strong differences in it may reflect the process of genetic differentiation and, possibly, speciation. We used both mitochondrial DNA (mtDNA) and nuclear microsatellites to study genetic variation between two subspecies of reed bunting, Emberiza schoeniclus schoeniclus and E.s. intermedia, along their distributional boundary in western Europe. These two subspecies are characterized by a high dimorphism in bill size and, although breeding populations of the two subspecies are found very close to each other in northern Italy, apparently no interbreeding occurs. The observed morphological pattern between the two subspecies may be maintained by geographically varying selective forces or, alternatively, may be the result of a long geographical separation followed by a secondary contact. MtDNA sequences of cytochrome b and ND5 (515 bp) showed little variation and did not discriminate between the two subspecies, indicating a divergence time of less than 500 000 years. The analysis of four microsatellite loci suggested a clear, although weak, degree of genetic differentiation in the large- and small-billed populations, as indicated by FST and RST values and genetic distances. The correlation between bill size and genetic distance between populations remained significant after accounting for the geographical distances between sampling localities. Altogether, these results indicate a very recent genetic differentiation between the two bill morphs and suggest that a strong selection for large bills in the southern part of the breeding range is probably involved in maintaining the geographical differentiation of this species.

Surgical second look in ovarian cancer: a randomized study in patients with laparoscopic complete remission--a Northeastern Oncology Cooperative Group-Ovarian Cancer Cooperative Group Study

PURPOSE

The usefulness of extensive and repetitive surgery for patients with ovarian cancer still remains unproven (at least for some conditions). We planned an accurate prospective test of the hypothesis that patients with advanced-stage disease, after they had reached a clinical complete remission (CR), may benefit from surgical second look (SSL).

PATIENTS AND METHODS

One hundred two patients in CR (as assessed by clinical findings, markers, and visualization by computed tomographic [CT] scan and laparoscopy), after initial debulking and first-line chemotherapy, were randomized to two arms, which were well balanced for predictive criteria such as age, stage at presentation, histology, grading, date of randomization, and residua after first surgery. Forty-eight patients were randomly assigned to receive follow-up evaluation only, while 54 were assigned to receive second surgery (eight of them refused). Of 46 surgical patients, 35 had negative and 11 positive surgical findings (24% clinically false-negative).

RESULTS

Despite the microscopic residua found at open surgery, and the fact that the patients were then treated with second-line chemotherapy, SSL did not increase the probability of survival in this setting. In an analysis of the results according to the intention-to-treat criteria, after a 60-month follow-up period, the overall survival rates in the two groups of patients (SSL v no SSL) were 65% and 78%, respectively (P = .14). Multivariate analysis according to predictive criteria confirmed there was no significant difference between the two groups (P = .39).

CONCLUSION

Our study shows the following: (1) our second-line treatment is scarcely effective; (2) SSL accurately defines complete responders to first-line chemotherapy; (3) SSL per se does not prolong survival; and (4) if confirmed, a less invasive procedure could replace SSL as a valuable method in new first-line regimens in ovarian cancer patients with clinical CR confirmed by laparoscopy.

Pulmonary valvular stenosis associated with Takayasu's Disease. Favorable response to corticosteroids. A case report

The authors describe the first reported case of type IV Takayasu's arteritis with pulmonary valve stenosis. After thirty months under corticosteroid therapy the disappearance of the pulmonary valve stenosis signs was observed in the patient. In the same patient coarctation of the aorta, aortic insufficiency, stenosis of both pulmonary arteries, and left coronary artery stenosis were observed. This case illustrates the extensive cardiovascular involvement that can occur in Takayasu's arteritis and suggests that pulmonary valvular stenosis could be secondary to the same inflammatory process.

Evaluation of patch testing in patients with chronic vulvar symptoms

The Dermogynaecology Clinic was established at the Mercy Hospital for Women in 1989. Since its inception, 700 patients have been investigated and 15% were clinically diagnosed as having contact dermatitis. Primary irritant dermatitis was regarded as the common cause but to investigate the place of contact allergy 50 patients were patch tested to a standard battery, medicaments, preservatives, corticosteroids and miscellaneous allergens. Twenty-one patients (42%) had a total of 44 positive tests. The most common positive reactions were to nickel (22%), cobalt (6%), fragrances (12%), caine mix (6%) and ethylenediamine (8%). Medicaments and fragrances were regarded as important allergens. Corticosteroid and imidazole allergy was not a problem in this series of patients.

Hepatocellular carcinoma and cirrhosis in 746 patients: long-term results of percutaneous ethanol injection

PURPOSE

To define indications for percutaneous ethanol injection (PEI) in patients with hepatocellular carcinoma (HCC) and cirrhosis.

MATERIALS AND METHODS

Survival rates were determined in 746 patients who had undergone PEI (567 men, 179 women; mean age, 64.3 years; mean follow-up, 36 months).

RESULTS

In patients with Child A (n = 293), B (n = 149), or C (n = 20) cirrhosis and single HCCs 5 cm or smaller, the 3-5 year survival rate was 47%-79%, 29%-63%, and 0%-12%, respectively. In patients with Child A cirrhosis, it was 36%-68% for multiple HCCs (n = 121), 30%-53% for single HCCs larger than 5 cm (n = 28), and 0%-16% for advanced HCC (n = 16). Treatment was associated with a 1.7% rate of severe complications and a 0.1% mortality rate.

CONCLUSION

PEI proved safe, effective, and repeatable and had a low cost. Survival after PEI was comparable to that after surgery, probably because of a balancing between greater radicality of surgery and absence of early mortality and liver damage of PEI.

[Cardiac lipoma of the septum with systemic and pulmonary emboli]

Cardiac lipoma is an uncommon tumor and is rarely a source of either lung or systemic emboli. A 46-year-old woman hospitalized because of left hemiplegia is presented. CT scan revealed a right temporo-parietal infarction. Chest x-ray showed a left lower lobe infiltrate. Pulmonary perfusion-ventilation scan indicated "high probability" of pulmonary embolism. Because brain and lung emboli are often associated, an echocardiogram was made and a 2 x 2 cm mass in the apical septum was found, confirmed by transesophageal echocardiogram. At operation a septal lipoma was resected. When pulmonary emboli occurs in association with systemic emboli, lipoma of the septum, although very rare, should be considered.

The effects of estrogen priming and puberty on the growth hormone response to standardized treadmill exercise and arginine-insulin in normal girls and boys

To determine the effects of puberty and estrogen priming on the GH response to standardized treadmill exercise and arginine-insulin in normal boys and girls, we performed tests in 84 normal children (41 girls and 43 boys) representing all stages of puberty. A subset of the prepubertal children received the tests twice, with or without the administration of ethinyl estradiol (40 micrograms/m2 daily) for 2 days before the tests. The peak GH response to the three tests increased significantly with pubertal stage (r = 0.57; P < 0.0001), but did not differ between boys and girls at the same stage. With advancing puberty, the percentage of normal children who failed to attain a GH level greater than 7 micrograms/L during any of the three tests declined from 61% at pubertal stage 1 to 44% at stage 2, 11% at stage 3, and 0% at stages 4 and 5. Administration of estrogen to the prepubertal subjects raised the normal range for the peak GH response to the three tests from 1.9-20.3 to 7.2-40.5 micrograms/L. We conclude that both puberty and estrogen administration significantly increase the peak GH response to exercise, arginine, or insulin in normal subjects. Moreover, the conventional criterion that the peak GH response to three stimulation tests should exceed 7 micrograms/L was applicable in our study only to subjects who had attained pubertal stage 4 or 5 or who had received estrogen administration.

The retinal targets of centrifugal neurons and the retinal neurons projecting to the accessory optic system

In birds, neurons of the isthmo-optic nucleus (ION), as well as "ectopic" neurons, send axons to the retina, where they synapse on cells in the inner nuclear layer (INL). Previous work has shown that centrifugal axons can be divided into two anatomically distinct types depending on their model of termination: either "convergent" or "divergent" (Ramon y Cajal, 1889; Maturana & Frenk, 1965). We show that cytochrome-oxidase histochemistry specifically labels "convergent" centrifugal axons and target neurons which appear to be amacrine cells, as well as three "types" of ganglion cells: two types found in the INL (displaced ganglion cells) and one in the ganglion cell layer. Labeled target amacrine cells have distinct darkly labeled "nests" of boutons enveloping the somas, are associated with labeled centrifugal fibers, and are confined to central retina. Lesions of the isthmo-optic tract abolish the cytochrome-oxidase labeling in the centrifugal axons and in the target amacrine cells but not in the ganglion cells. Cytochrome-oxidase-labeled ganglion cells in the INL are large; one type is oval and similar to the classical displaced ganglion cells of Dogiel, which have been reported to receive centrifugal input; the other type is rounder. Rhodamine beads injected into the accessory optic system results in retrograde label in both types of cells, showing that two distinct types of displaced ganglion cells project to the accessory optic system in chickens. The ganglion cells in the ganglion cell layer that label for cytochrome oxidase also project to the accessory optic system. These have proximal dendrites that ramify in the outer inner plexiform layer.(ABSTRACT TRUNCATED AT 250 WORDS)

Thyroid function and attention-deficit hyperactivity disorder

OBJECTIVE

To examine thyroid indices in a community referred sample of boys with attention-deficit hyperactivity disorder (ADHD) for evidence of generalized resistance to thyroid hormone (GRTH).

METHOD

TSH, T3, and T4 values were gathered prospectively in 53 physician, school, and/or parent referred ADHD subjects, and in 41 age and gender-matched normal controls.

RESULTS

None were in the range suggestive of global or pituitary thyroid hormone resistance.

CONCLUSIONS

GRTH is rare, and thyroid function should not be measured routinely in nonfamilial ADHD.