Altered Decorin Biology in Proliferative Vitreoretinopathy: A Mechanistic and Cohort Study

Purpose

To determine if vitreous levels of the pro-fibrotic cytokine transforming growth factor beta2 (TGF-β2) and its opposing regulator decorin predict subsequent proliferative vitreoretinopathy (PVR) development in patients with rhegmatogenous retinal detachment (RRD).

Methods

We examined the effect of TGF-β2 and decorin on epithelial-mesenchymal transition (EMT) and collagen expression in vitro using ARPE-19 cells, and we analyzed extracellular matrix marker expression in PVR membrane and internal limiting membrane patient samples. We performed a prospective noninterventional cohort study, recruiting 125 patients undergoing vitrectomy for RRD and macular hole surgery, measured vitreous levels of TGF-β2 and decorin by ELISA, and followed them up for 6 months. Patients who did not develop PVR were compared to those who did, in order to determine whether vitreous TGF-β2 and decorin levels predicted PVR development.

Results

In vitro, TGF-β2 induced EMT and collagen production. Decorin strongly inhibited EMT and collagen production at high levels. PVR membranes expressed high levels of fibrosis-associated proteins, consistent with EMT. Vitreous TGF-β2 levels were unchanged between patients with macular holes and RRD who did or did not subsequently develop PVR. Average decorin levels were higher in the vitreous of RRD patients who subsequently developed PVR compared to those who did not, but at the measured vitreous concentrations (1-2 μg/mL), decorin did not demonstrate an in vitro inhibitory effect on EMT.

Conclusions

In vitro, high concentrations of decorin inhibited EMT and fibrosis. At the levels seen in human vitreous, decorin did not prevent fibrosis or EMT in vitro, and higher initial vitreous decorin levels were associated with the development of postoperative PVR after vitrectomy to treat RRD, but did not reliably predict the outcome.

Split-graft liver transplantation from an adult donor with an unrecognized UCD to a pediatric and adult recipient

We report the outcomes of an adult and pediatric split liver transplant from an adult male donor who died due to an unrecognized UCD, OTC deficiency. Recognizing inborn errors of metabolism can be challenging, especially in adult centers where such disorders are rarely encountered. Shortage of donors for liver transplantation has led to procedures to maximize donor utilization, such as split and live donor grafts. The cause of death should be ascertained before accepting a cadaveric donor organ.

Superficial layers of the medial entorhinal cortex replay independently of the hippocampus

The hippocampus is thought to initiate systems-wide mnemonic processes through the reactivation of previously acquired spatial and episodic memory traces, which can recruit the entorhinal cortex as a first stage of memory redistribution to other brain areas. Hippocampal reactivation occurs during sharp wave-ripples, in which synchronous network firing encodes sequences of places. We investigated the coordination of this replay by recording assembly activity simultaneously in the CA1 region of the hippocampus and superficial layers of the medial entorhinal cortex. We found that entorhinal cell assemblies can replay trajectories independently of the hippocampus and sharp wave-ripples. This suggests that the hippocampus is not the sole initiator of spatial and episodic memory trace reactivation. Memory systems involved in these processes may include nonhierarchical, parallel components.

Mechanisms of cognitive-behavioral therapy for obsessive-compulsive disorder involve robust and extensive increases in brain network connectivity

Cognitive-behavioral therapy (CBT) is effective for obsessive compulsive disorder (OCD); however, little is understood about its mechanisms related to brain network connectivity. We examined connectivity changes from resting-state functional magnetic resonance imaging data pre-to-post-CBT in 43 OCD participants, randomized to receive either 4 weeks of intensive CBT or 4 weeks waitlist followed by 4 weeks of CBT, and 24 healthy controls before and after 4 weeks of no treatment. Network-based-statistic analysis revealed large-magnitude increases in OCD connectivity in eight networks. Strongest increases involved connectivity between the cerebellum and caudate/putamen, and between the cerebellum and dorsolateral/ventrolateral prefrontal cortices. Connectivity increases were associated with increased resistance to compulsions. Mechanisms of CBT may involve enhanced cross-network integration, both within and outside of classical cortico-striatal-thalamo-cortical regions; those involving cerebellar to striatal and prefrontal regions may reflect acquisition of new non-compulsive goal-directed behaviors and thought patterns. Our findings have implications for identifying targets for enhancing treatment efficacy and monitoring treatment progress.

Performance characteristics of serum C4 and FGF19 measurements to exclude the diagnosis of bile acid diarrhoea in IBS-diarrhoea and functional diarrhoea

BACKGROUND

The serum biomarkers, elevated 7αC4 (C4) and decreased FGF19, have been proposed as screening tests for bile acid diarrhoea.

AIM

To analyse prevalence, specificity and reproducibility of fasting C4 and FGF19 in identifying bile acid diarrhoea in patients with irritable bowel syndrome with predominant diarrhoea or functional diarrhoea (summarised as IBS-D).

METHODS

We prospectively studied fasting serum C4 and FGF19 in 101 IBS-D patients; we reviewed data from 37 of the 101 patients with prior fasting serum C4 and FGF19 and from 30 of the 101 patients with prior faecal bile acids per 48 hours. We compared results with normal values (C4 ≥52.5 ng/mL [n=184], FGF-19 ≤61.7 pg/mL [n=50]). We used Spearman correlation and Bland-Altman plots to appraise reproducibility.

RESULTS

Among the 101 patients, there was a negative correlation between serum C4 and FGF19 (Rs=-.342, P=.0005). Bile acid diarrhoea was diagnosed in 10 patients based on elevated serum C4 levels (mean 23.5±23.1 [SD] ng/mL) and 21 patients based on decreased FGF19 levels (121.6±84.2 pg/mL). With replicate tests in patients with stable IBS-D, 78% of C4 and 70% of FGF19 measurements remained concordant, with 3% and 11% respectively consistently positive for bile acid diarrhoea in the 101 patients. Compared to 48 hours faecal bile acids, specificity for C4 and FGF19 was 83% and 78%, respectively. Bland-Altman plots demonstrated greater reliability of C4 than FGF19.

CONCLUSIONS

Among 101 patents with IBS-D, fasting FGF19 and C4 levels had good specificity and negative predictive value, suggesting utility as screening tests to exclude bile acid diarrhoea.

A Retrospective Audit of In-Hospital 30-day Mortality from Acute Myocardial Infarction in Connolly Hospital Blanchardstown

In 2015, The Department of Health published the first annual report of the "National Healthcare Quality Reporting System." Connolly Hospital was reported to a mortality rate within 30 days post-Acute Myocardial Infarction (AMI) of 9.87 per 100 cases which was statistically significantly higher than the national rate. We carried out a retrospective audit of patients who were HIPE-coded as having died within 30 days of AMI from 2011-2013 and identified 42 patients. On review, only 23 patients (54.8%) were confirmed as having had an AMI. We identified 12 patients who had AMI included on death certificate without any evidence for same. If the 22 patients incorrectly coded were excluded, the mortality rate within 30 days post-AMI in CHB would fall to 4.14 deaths per 100 cases, well below the national average. Inaccuracies of data collection can lead to erroneous conclusions when examining healthcare data.

The use of cold coagulation for the treatment of cervical intraepithelial neoplasia

In 2015, Cold Coagulation was introduced as a treatment for cervical intraepithelial neoplasia (CIN) at our colposcopy clinic. We reviewed the 6-month follow up data of the first 200 women who underwent Cold Coagulation using cytology and HPV status as tests of cure (TOC). A random sample of 200 patients treated by Large Loop Excision of the Transformation Zone (LLETZ) during the same period was used to compare treatment outcome. Six months following treatment,173 (86.5%) of the women treated by CC and 167 (83.5%) treated by LLETZ had negative cytology. (x2= P>0.05). 148 (74%) treated by Cold Coagulation and 166 (83%) treated by LLETZ were HPV negative (x2= P<0.05). One hundred and thirty-nine (70%) women treated by Cold Coagulation and 152 (76%) treated with LLETZ had normal cytology and were HPV negative. This audit of our initial experience supports the observation that Cold Coagulation is as effective as LLETZ in the management of CIN when cervical cytology is used as a test of cure.

Acute Headache and Subarachnoid Haemorrhage: A Retrospective Review of CT and Lumbar Puncture Findings

Aim: Assess and correlate the clinical presentation, cranial CT and lumbar puncture (LP) findings in patients presenting with acute headache, clinically suspicious of subarachnoid haemorrhage, from the Accident and Emergency (A/E) department of a main teaching hospital. Method: We retrospectively reviewed over a 1-year period all patients referred for cranial CT from the A/E department, with clinically suspected nontraumatic SAH. Patients with a negative CT, with a diagnosis of SAH on LP, had their initial CT examination reassessed in a double blind review. Results: 116 consecutive patients were included in the study. Patients were divided into 3 groups post CT results: diagnostic of SAH (19), abnormal without evidence of SAH (16) and normal (81). The clinical management of the latter group was analysed with particular emphasis on the performance and results of lumbar puncture (LP). 81 patients, clinically suspicious of SAH in our study had a normal cranial CT and were eligible for LP. 49% had an LP, which was positive in 13% and contributed 24% to the total number diagnosed with SAH. LP was not performed in 51% of eligible patients. Conclusion: This study reviews the varying clinical presentations of SAH and the difficulty in clinically diagnosing SAH where headache is the only symptom. We review the wide differential diagnosis on cranial CT and on discharge of patients presenting with symptoms clinically suspicious of SAH. In addition this study identifies a high proportion of patients without detailed clinical notes and discharged without a diagnosis. The study reaffirms that a significant proportion of patients are diagnosed on LP and stress the importance of performing a LP in all cases with clinically suspected SAH with a negative CT. This latter point requires highlighting in the medical literature as over half of eligible patients did not have a LP performed despite this being accepted diagnostic protocol.

siRNA-Mediated Knockdown of the mTOR Inhibitor RTP801 Promotes Retinal Ganglion Cell Survival and Axon Elongation by Direct and Indirect Mechanisms

PURPOSE

To investigate, using in vivo and in vitro models, retinal ganglion cell (RGC) neuroprotective and axon regenerative effects and underlying mechanisms of siRTP801, a translatable small-interfering RNA (siRNA) targeting the mTOR negative regulator RTP801.

METHODS

Adult rats underwent optic nerve (ON) crush (ONC) followed by intravitreal siRTP801 or control siRNA (siEGFP) every 8 days, with Brn3a+ RGC survival, GFAP+ reactive gliosis, and GAP43+ regenerating axons analyzed immunohistochemically 24 days after injury. Retinal cultures, prepared from uninjured animals or 5 days after ONC to activate retinal glia, were treated with siRTP801/controls in the presence/absence of rapamycin and subsequently assessed for RGC survival and neurite outgrowth, RTP801 expression, glial responses, and mTOR activity. Conditioned medium was analyzed for neurotrophin titers by ELISA.

RESULTS

Intravitreal siRTP801 enabled 82% RGC survival compared to 45% with siEGFP 24 days after ONC, correlated with greater GAP43+ axon regeneration at 400 to 1200 μm beyond the ONC site, and potentiated the reactive GFAP+ Müller glial response. In culture, siRTP801 had a direct RGC neuroprotective effect, but required GFAP+ activated glia to stimulate neurite elongation. The siRTP801-induced neuroprotection was significantly reduced, but not abolished, by rapamycin. The siRTP801 potentiated the production and release of neurotrophins NGF, NT-3, and BDNF, and prevented downregulation of RGC mTOR activity.

CONCLUSIONS

The RTP801 knockdown promoted RGC survival and axon elongation after ONC, without increasing de novo regenerative sprouting. The neuroprotection was predominantly direct, with mTORC1-dependent and -independent components. Enhanced neurite/axon elongation by siRTP801 required the presence of activated retinal glia and was mediated by potentiated secretion of neurotrophic factors.

Unicortical fixation of metacarpal fractures: is it strong enough?

Unicortical fixation has some practical and theoretical advantages over bicortical fixation. Questions have been raised to its adequacy for post-operative mobilization. We hypothesized that fixation using a plate and eight unicortical screws would be as strong as using a plate and four bicortical screws. A total of 40 unicortical and 40 bicortical fixations were compared using a cadaveric metacarpal model. Unicortical fixation was performed using an eight-hole parallel plate and bicortical fixation with a four-hole straight plate. Fixations were tested to failure using four-point bending load. The mean load to failure was 414 N SD 38(SE) for the unicortical group and 296 N SD 29(SE) for the bicortical group. Significant differences between these two constructs were observed. The mean stiffness of the fixation was higher for the bicortical group than the unicortical, although this difference did not reach significance. Unicortical fixation alone is sufficient to enable early post-operative mobilization in a live model.

Brain potentials evoked by intraepidermal electrical stimuli reflect the central sensitization of nociceptive pathways

Secondary mechanical punctate hyperalgesia is a cardinal sign of central sensitization (CS), an important mechanism of chronic pain. Our study demonstrates that hyperalgesia from intraepidermal electrical stimulation coexists with mechanical punctate hyperalgesia and elicits electroencephalographic (EEG) potentials that predict the occurrence of punctate hyperalgesia in a human experimental model of CS. These findings inform clinical development of EEG-based biomarkers of CS.

Central sensitization (CS), the increased sensitivity of the central nervous system to somatosensory inputs, accounts for secondary hyperalgesia, a typical sign of several painful clinical conditions. Brain potentials elicited by mechanical punctate stimulation using flat-tip probes can provide neural correlates of CS, but their signal-to-noise ratio is limited by poor synchronization of the afferent nociceptive input. Additionally, mechanical punctate stimulation does not activate nociceptors exclusively. In contrast, low-intensity intraepidermal electrical stimulation (IES) allows selective activation of type II Aδ-mechano-heat nociceptors (II-AMHs) and elicits reproducible brain potentials. However, it is unclear whether hyperalgesia from IES occurs and coexists with secondary mechanical punctate hyperalgesia, and whether the magnitude of the electroencephalographic (EEG) responses evoked by IES within the hyperalgesic area is increased. To address these questions, we explored the modulation of the psychophysical and EEG responses to IES by intraepidermal injection of capsaicin in healthy human subjects. We obtained three main results. First, the intensity of the sensation elicited by IES was significantly increased in participants who developed robust mechanical punctate hyperalgesia after capsaicin injection (i.e., responders), indicating that hyperalgesia from IES coexists with punctate mechanical hyperalgesia. Second, the N2 peak magnitude of the EEG responses elicited by IES was significantly increased after the intraepidermal injection of capsaicin in responders only. Third, a receiver-operator characteristics analysis showed that the N2 peak amplitude is clearly predictive of the presence of CS. These findings suggest that the EEG responses elicited by IES reflect secondary hyperalgesia and therefore represent an objective correlate of CS.

Feasibility of actigraphy wristband monitoring of atopic dermatitis in children

BACKGROUND/PURPOSE

Actigraphy monitors are used to monitor sleep and scratching. Previous studies have implemented these monitors to evaluate behavior in adult patients with atopic dermatitis. However, such monitoring devices have been implemented in a paucity of studies involving pediatric patients with atopic dermatitis. The purpose of this study was to assess the feasibility of actigraphy monitoring in children with mild-to-severe atopic dermatitis.

METHODS

A total of six pediatric subjects were recruited. The severity of atopic dermatitis at the wrist area was assessed prior to placement of the wristband monitor. After wearing the wristbands for 7 days, subjects returned to clinic to undergo reassessment of the wrist area to determine if atopic dermatitis was exacerbated by the wrist-worn device. Data on sleep quality and how often patients wore the wristband monitors were also collected. No subjective data from the subjects or parents/caregivers were collected on tolerability of the monitors.

RESULTS

None of the subjects exhibited exacerbation of atopic dermatitis at the wrist area after wearing the actigraphy monitors for 7 days. No adverse events were reported. Pediatric patients with atopic dermatitis exhibited less total sleep time compared with children evaluated in previous actigraphy studies.

CONCLUSION

Actigraphy wristband monitoring can be used to continuously assess disease severity in children with atopic dermatitis.

A silent myocardial infarction in the diabetes outpatient clinic: case report and review of the literature

Silent myocardial ischaemia (SMI), defined as objective evidence of myocardial ischaemia in the absence of symptoms, has important clinical implications for the patient with coronary artery disease. We present a dramatic case of SMI in a diabetes patient who attended annual review clinic with ST elevation myocardial infarction. His troponin was normal on admission but raised to 10.7 ng/ml (normal <0.5) when repeated the next day. His angiogram showed diffused coronary artery disease. We here discuss the implications of silent ischaemia for the patient and for the physician caring for patients with diabetes.

Voice use in professional soccer management

Vocal load related to heavy voice use in particular professions increases the risk of occupational voice disorders. Research on professional voice use has primarily focused on educators, singers, and call-centre advisors. This paper describes the daily experiences of professional soccer managers' occupational voice use through qualitative methods. Four global themes were identified: 1) voice uses, 2) factors affecting voice change, 3) impact of voice use, and 4) the importance of voice in soccer management. All describe the nature of soccer managers' vocal demands. Risk factors for voice disorders include intense and prolonged voice use in environments with adverse acoustic properties for speakers and poor phonation methods. Research on vocal behaviours and early prevention programmes for this population group is warranted.

Adherence to adalimumab in patients with moderate to severe psoriasis

Background The chronic and relapsing course of psoriasis is often associated with poor adherence to treatment. Adherence to topical treatment is abysmal. Adherence to systemic treatments also decreases over time, with an overall adherence rate of 67% for injectable biologic medications. Whereas overall trends in poor adherence have been documented, the fine details of adherence in individual patients is not well characterized. Purpose To assess adherence to adalimumab in patients with moderate to severe psoriasis. Methods Data on adherence were obtained from a 1-year open label trial including seven patients with moderate to severe psoriasis who agreed to participate in a randomized trial of standard physician education materials plus extended nurse education versus standard physician education materials alone. Adherence to treatment was recorded with electronic monitoring via Medication Event Monitoring System (MEMS) caps undisclosed to the patients. Patients were also instructed to note the time and date they used treatment in a journal. Results The subjects exhibited a broad range of adherence behaviors. Conclusions Adherence to adalimumab therapy for moderate-to-severe psoriasis is variable and can be very poor. The clinical impact of poor adherence to injectable biologic medications is not yet well characterized.

Sleep disturbances in psoriasis

BACKGROUND

Psoriasis negatively impacts sleep, but the factors that cause this sleep disturbance are not well characterized.

PURPOSE

To assess sleep quality in subjects with psoriasis.

METHODS

35 outpatients diagnosed with chronic plaque psoriasis affecting at least 10 percent BSA and 44 controls completed the Pittsburgh Sleep Quality Index, Patient Health Questionnaire, Itch Severity Scale, Insomnia Severity Index, and Epworth Sleepiness Scale. For multiple testing, alpha was set at 0.008.

RESULTS

Adjusting for age, BMI, and gender, patients with psoriasis had 4.3 times the odds to score in a higher insomnia category (OR 95% CI: 1.7, 11.2; p=0.01), a trend toward experiencing "poor sleep" (p=0.04), and no difference in odds to be "sleepy" (p=0.83). Patients with psoriasis had greater itch than those without psoriasis (mean ISS 8.5 vs. 2.0; p<0.0001). When adjusting for age, BMI, gender, and depression, those with psoriasis were not more likely to experience poor sleep quality (p=0.25), nor to score in a higher insomnia category (p=0.20) or be more "sleepy" (p=0.53).

CONCLUSIONS

Patients with psoriasis suffer from sleep disturbances and pruritus more than those without psoriasis. Although sleep disturbances are more prevalent, this may be secondary to depression rather than related to a direct effect of psoriasis.

Neuroretinal cell death in a murine model of closed globe injury: pathological and functional characterization

PURPOSE

Blunt ocular trauma causes severe retinal injury with death of neuroretinal tissue, scarring, and permanent visual loss. The mechanisms of cell death are not known, and there are no therapeutic interventions that improve visual outcome. We aimed to study the extent, distribution, and functional consequences of cell death by developing and characterizing a rat model of retinal injury caused by blunt ocular trauma.

METHODS

The eyes of anesthetized adult rats were injured by either weight drop or low-velocity ballistic trauma and assessed by clinical examination, electroretinography, light microscopy, electron microscopy, and TUNEL. Projectile velocity was measured and standardized.

RESULTS

Weight drop did not cause reproducible retinal injury, and the energy threshold for retinal injury was similar to that for rupture. Low-velocity ballistic trauma to the inferior sclera created a reproducible retinal injury, with central sclopetaria retinae, retinal necrosis, and surrounding commotio retinae with specific photoreceptor cell death and sparing of cells in the other retinal layers. The extent of photoreceptor cell death declined and necrosis progressed to apoptosis with increasing distance from the impact site.

CONCLUSIONS

This is the only murine model of closed globe injury and the only model of retinal trauma with specific photoreceptor cell death. The clinical appearance mirrors that in severe retinal injury after blunt ocular trauma in humans, and the ultrastructural features are consistent with human and animal studies of commotio retinae. After ocular trauma, photoreceptor apoptosis may be prevented and visual outcomes improved by blocking of the cell death pathways.

Role of the MotB linker in the assembly and activation of the bacterial flagellar motor

Bacterial flagella are driven by an ion influx through the peptidoglycan (PG)-tethered MotA/MotB stator. Stator precomplexes assemble in the membrane and remain inactive until they incorporate into the motor, upon which MotA/MotB changes conformation. The nature of this change and the mechanism of inhibition of the PG-binding and ion-conducting activities of the precomplexes are unknown. Here, the structural analysis of a series of N-terminally truncated MotB fragments is presented, the mechanism of inhibition by the linker is identified and the structural basis for the formation of the PG-binding-competent open-channel MotA/MotB conformation via a mechanism that entails linker unfolding and rotational displacement of MotB transmembrane helices is uncovered.

Treatment of moderate-to-severe psoriasis with alefacept for up to one year: a case series

BACKGROUND

Alefacept has an established efficacy and safety profile for 12 weeks of treatment of severe chronic plaque type psoriasis. The effectiveness and safety of longer-term continuous use is not well characterized.

METHODS

Fifteen subjects with moderate-to-severe chronic plaque type psoriasis were given weekly 15 mg alefacept injections for 16 consecutive weeks followed by monthly 15 mg injections for up to eight consecutive months, along with clobetasol propionate spray 0.05% twice daily for the first four weeks. Disease severity was measured using the Psoriasis Area and Severity Index (PASI) and the Investigator Global Assessment (IGA).

RESULTS

Mean PASI scores improved 33 percent overall during the first month with combination treatment. There was an overall 21 percent worsening in PASI scores after the transition from weekly to monthly medication administration. Of the 15 initially enrolled patients, 27 percent achieved PASI 75 by end of study. No patients achieved an IGA of 0 or 1 by end of study. Two major adverse events were reported: low CD4 count and severe allergic dermatitis.

CONCLUSION

Topical clobetasol propionate 0.05% was only partially effective at augmenting the early treatment effect of alefacept. The authors did not observe marked benefit or major side effects by continuing additional monthly alefacept treatments beyond 16 weeks of weekly treatment.

Variation between centres in access to renal transplantation in UK: longitudinal cohort study

OBJECTIVE

To assess whether equity exists in access to renal transplantation in the UK after adjustment for case mix in incident patients with end stage renal disease.

DESIGN

Longitudinal cohort study.

SETTING

UK Renal Registry and UK Transplant Registry.

PARTICIPANTS

All incident renal replacement treatment patients (n=16 202) from 65 renal centres submitting data to the UK Renal Registry between 1 January 2003 and 31 December 2005, followed until 31 December 2008 (or until transplantation or death, whichever was earliest).

OUTCOME MEASURES

Proportion of incident dialysis patients at each renal centre who were registered on the national transplant list; time taken to achieve registration; and proportion of patients subsequently transplanted.

RESULTS

We found that recipients' age, ethnicity, and primary renal diagnosis were associated with the likelihood of accessing the waiting list or receiving a transplant. After adjustment for case mix, significant inter-centre variability existed in access to the transplant list (change in -2LogL=89.9, df=1, P<0.001), in the time taken to register patients on the waiting list (change in -2LogL=247.4, df=64, P<0.001), in receipt of a renal transplant from a donor after brain stem death (change in -2LogL=15.1, df=1, P=0.001), and in receipt of a renal transplant from a living donor or a donor after cardiac death (change in -2LogL=46.1, df=1, P<0.001).

CONCLUSIONS

Significant variation in access to renal transplantation exists between centres within the UK that cannot be explained by differences in case mix.

ALA-PDT for the treatment of cutaneous pseudolymphoma: a case report

Cutaneous pseudolymphoma (CPL) is a benign skin condition that may cause cosmetic disfigurement, severe itch and, albeit rarely, transformation to malignant lymphoma. The usual treatment modalities for CPL have been associated with adverse effects including skin atrophy and scarring. This article reports the case of a patient with CPL on the cheek, which was treated with 5-aminolevulinic acid photodynamic therapy (ALA-PDT). Clinically significant improvement in lesion size and symptoms was noted, with few side effects. Controlled trials and long-term monitoring are warranted to further explore this treatment modality for CPL.

Proton MRS in twin pairs discordant for schizophrenia

Proton magnetic resonance spectroscopy ((1)H MRS) neurometabolite abnormalities have been detected widely in subjects with and at risk for schizophrenia. We hypothesized that such abnormalities would be present both in patients with schizophrenia and in their unaffected twin siblings. We acquired magnetic resonance spectra (TR/TE=3000/30 ms) at voxels in the mesial prefrontal gray matter, left prefrontal white matter and left hippocampus in 14 twin pairs discordant for schizophrenia (2 monozygotic, 12 dizygotic), 13 healthy twin pairs (4 monozygotic, 9 dizygotic) and 1 additional unaffected co-twin of a schizophrenia proband. In the mesial prefrontal gray matter voxel, N-acetylaspartate (NAA), creatine+phosphocreatine (Cr), glycerophosphocholine+phosphocholine (Cho) and myo-inositol (mI) did not differ significantly between patients with schizophrenia, their unaffected co-twins or healthy controls. However, glutamate (Glu) was significantly lower in patients with schizophrenia (31%, percent difference) and unaffected co-twins (21%) than in healthy controls (collapsed across twin pairs). In the left hippocampus voxel, levels of NAA (23%), Cr (22%) and Cho (36%) were higher in schizophrenia patients compared with controls. Hippocampal NAA (25%), Cr (22%) and Cho (37%) were also significantly higher in patients than in their unaffected co-twins. Region-to-region differences in metabolite levels were also notable within all three diagnosis groups. These findings suggest that (1)H MRS neurometabolite abnormalities are present not only in patients with schizophrenia, but also in their unaffected co-twins. Thus, reduced mesial prefrontal cortical Glu and elevated hippocampal NAA, Cr and Cho may represent trait markers of schizophrenia risk and, when exacerbated, state markers of schizophrenia itself.