Response to treatment and outcomes of infantile spasms in Down syndrome

AIM

To estimate the prevalence, and evaluate presentation, treatment response, treatment side effects, and long-term seizure outcomes in all known cases of children with Down syndrome and infantile spasms on the island of Ireland.

METHOD

This was a 10-year retrospective multicentre review of clinical records and investigations, focusing on treatment response, side effects, and long-term outcomes.

RESULTS

The prevalence of infantile spasms in Down syndrome was 3.0% during the study period. Fifty-four infants were identified with median age of spasm onset at 201 days (interquartile range [IQR] 156-242). Spasm cessation was achieved in 88% (n=46) at a median of 110 days (IQR 5-66). The most common first-line medications were prednisolone (n=20, 37%), vigabatrin (n=18, 33.3%), and sodium valproate (n=9, 16.7%). At follow-up (median age 23.7mo; IQR 13.4-40.6), 25% had ongoing seizures and 85% had developmental concerns. Treatment within 60 days did not correlate with spasm cessation. Seventeen children (31%) experienced medication side effects, with vigabatrin accounting for 52%.

INTERPRETATION

Prednisolone is an effective and well-tolerated medication for treating infantile spasms in Down syndrome. Despite the high percentage of spasm cessation, developmental concerns and ongoing seizures were common.

1101 Closed Traumatic Avulsion of Both Flexor Digitorum Tendons: A Novel Treatment Method

Case Report

Closed tendon avulsion of both flexor tendons (Flexor Digitorum profundus [FDP] and Flexor Digitorum superficialais [FDS]) in the same finger is an extremely rare condition. We are proposing this subtype of injury be added as a type VI to the current Leddy and Packer classification for FDP avulsion injuries. The objective of this being an increase in awareness to avoid misdiagnosis and to aid in the subsequent management if encountered. We present the case of a 27-year-old male who presented with an avulsion of both flexor tendons from their respective insertions in the ring finger following a sporting injury causing hyperextension against an actively flexed distal interphalangeal joint. This condition has previously been reported twelve times in the literature. We propose a novel treatment method not described for previous cases and examine the successful method of treatment in this case.

Urogenital function following robotic and laparoscopic rectal cancer surgery: meta-analysis

BACKGROUND

Mixed results are reported on clinical and cancer outcomes in laparoscopic rectal cancer surgery (LRCS) compared with robotic rectal cancer surgery (RRCS). However, more favourable functional outcomes are reported following RRCS. This study compared urinary and sexual function following RRCS and LRCS in male and female patients.

METHODS

A systematic review and meta-analysis of urinary and sexual function after RRCS and LRCS was performed following PRISMA and MOOSE guidelines, and registered prospectively with PROSPERO (ID:CRD42020164285). The functional outcome reporting tools most commonly included: the International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI). Mean scores and changes in mean scores from baseline were analysed using RevMan version 5.3.

RESULTS

Ten studies were included reporting on 1286 patients. Some 672 patients underwent LRCS, of whom 380 (56.5 per cent) were men and 116 (17.3 per cent) were women (gender not specified in 176 patients, 26.2 per cent). A total of 614 patients underwent RRCS, of whom 356 (58.0 per cent) were men and 83 (13.5 per cent) were women (gender not specified in 175 patients, 28.5 per cent). Regarding urinary function in men at 6 months after surgery, IPSS scores were significantly better in the RRCS group than in the LRCS group (mean difference (MD) -1.36, 95 per cent c.i. -2.31 to -0.40; P = 0.005), a trend that persisted at 12 months (MD -1.08, -1.85 to -0.30; P = 0.007). ΔIIEF scores significantly favoured RRCS at 6 months [MD -3.11 (95%CI -5.77, -0.44) P <0.021] and 12 months [MD -2.76 (95%CI -3.63, -1.88) P <0.001] post-operatively. Mixed urinary and sexual function outcomes were reported for women.

CONCLUSION

This meta-analysis identified more favourable urinary and erectile function in men who undergo robotic compared with conventional laparoscopic surgery for rectal cancer. Outcomes in women did not identify a consistently more favourable outcome in either group. As robotic rectal cancer surgery may offer more favourable functional outcomes it should be considered and discussed with patients.

Superconducting Nanowire Spiking Element for Neural Networks

As the limits of traditional von Neumann computing come into view, the brain's ability to communicate vast quantities of information using low-power spikes has become an increasing source of inspiration for alternative architectures. Key to the success of these largescale neural networks is a power-efficient spiking element that is scalable and easily interfaced with traditional control electronics. In this work, we present a spiking element fabricated from superconducting nanowires that has pulse energies on the order of ∼10 aJ. We demonstrate that the device reproduces essential characteristics of biological neurons, such as a refractory period and a firing threshold. Through simulations using experimentally measured device parameters, we show how nanowire-based networks may be used for inference in image recognition and that the probabilistic nature of nanowire switching may be exploited for modeling biological processes and for applications that rely on stochasticity.

A retrospective, observational study of supine percutaneous nephrolithotomy

Objective:

The objective of this study is to assess stone clearance and perioperative complication rates of supine percutaneous nephrolithotomy (PCNL).

Methods:

This was a retrospective, observational study of supine PCNL performed in a surgical unit at a district general hospital by two surgeons in the United Kingdom. Data collected included patient demographics, comorbidities, complexity of renal calculi, perioperative complications and stone clearance rates.

Results:

A total of 112 supine PCNL procedures were observed in this study. The mean (SD) American Society of Anesthesiologists (ASA) grade and Guy’s Stone Score were 2.0 (0.75) and 2.3 (1.06) respectively. The median (interquartile range (IQR)) duration of in-patient admission was four (one) nights. Complete stone clearance was achieved in 74 (67.3%) of the procedures, while more than 90% clearance of the renal stone burden was achieved in a further eight (7.3%). The most common perioperative complications recorded were blood loss requiring blood transfusion (three (2.7%)) and postoperative fever (two (1.8%)).

Conclusion:

This case series shows that supine PCNL can lead to good stone clearance and low complication rates.

Locally advanced rectal cancer: a cooperative surgical approach to a complex surgical procedure

Single stage en bloc abdominoperineal resection and sacrectomy, with a myocutaneous flap closure is a relatively uncommon procedure. Our case study of a 77 year old man with a locally invasive rectal adenocarcinoma highlights the complex intraoperative management of such a patient.

Learning safe practice by improving care: student-led intervention on oxygen prescribing in a respiratory ward

BACKGROUND AND OBJECTIVE

The primary aim of this intervention was to improve oxygen prescribing in accordance with the 2008 British Thoracic Society guidelines for the prescription of emergency oxygen in adults.

METHODS

Eight final year medical students reviewed the drug charts of all patients admitted to the respiratory ward on a daily basis in order to collect data on five audit questions: (1) Has oxygen (O2) been prescribed? (2) Has an O2 target saturation level been indicated? (3) Has O2 been prescribed as an 'as required' (PRN) or 'continuous therapy'? (4) Has the prescription been signed? (5) Has O2 been signed for in every drug round since the original prescription? Following an initial audit cycle an educational poster was distributed to all clinical staff via email and hard copies of the poster were placed strategically throughout the ward before its effectiveness was measured.

RESULTS

During the pre-intervention phase, compliance with all five measures varied from 0 to 25%. There was an increase in the variation in compliance after the poster intervention to 14-44%; however, this masked better overall compliance with all five investigative questions with figures of 44%, 39% and 42% being recorded in three of the four post-intervention days. Overall there was increased compliance with four of the five audit questions. Indeed compliance with question 3 rose from 14% to 83%.

CONCLUSIONS

The poster intervention was marginally effective while also showing that students can improve prescribing in a clinical setting.

Oral fungal infections: an update for the general practitioner

Oral candidosis is the most common fungal infection encountered in general dental practice. It manifests in a variety of clinical presentations which may mimic more sinister diseases, and can occasionally be refractory to treatment requiring the attention of an oral medicine specialist. Management of oral candidosis should always include a thorough investigation of underlying predisposing conditions, as the disease often presents when the patient is systemically compromised. This update highlights the pathogenesis, clinical presentation, and management strategies of oral Candidal lesions commonly encountered in dental practice.

Acute demyelinating events with rhombencephalitis: a high-risk subgroup in children

Acute, acquired demyelination of central nervous system in childhood leads to a variety of clinical phenotypes dependant on the site of demyelination and presence of encephalopathy. Posterior fossa involvement is seen in over third of cases in childhood. We report on four children who had cerebellar involvement with significant mass effect in posterior fossa on CT and MRI brain. This subgroup of children have significant cerebellar and brainstem swelling (rhombencephalitis) and is difficult to distinguish entirely on clinical grounds from other children with acute demyelinating events at presentation.

Audit of the management of suspected giant cell arteritis in a large teaching hospital

BACKGROUND

The diagnosis of giant cell arteritis (GCA) is often confirmed by an early temporal artery (TA) biopsy of adequate length. Treatment of this condition with high-dose corticosteroids may be associated with significant morbidity, including osteoporosis.

AIM

To audit current management of patients with suspected GCA at Auckland Healthcare, a large teaching hospital.

METHODS

We performed a retrospective chart review of all TA biopsies from January 1996 to June 2000. A total of 117 biopsies from 111 patients was audited. Of these patients, 37/111 (33%) had a final clinical diagnosis of GCA (GCA patients). The areas of interest for audit were waiting time for TA biopsy, length of sample, initial corticosteroid therapy and osteoporosis prophylaxis.

RESULTS

The mean waiting time for biopsy for all patients was 5.6 days (range 0-42 days). This time varied from 9.3 days for rheumatology patients to 2.6 days for ophthalmology patients (P = 0.003). Only 44/117 (37.6%) specimens measured more than 10 mm. For GCA patients, the median initial oral prednisone dose was 60 mg/day. Osteoporosis prophylaxis was prescribed in 24/37 (65%) GCA patients, most commonly cyclical etidronate.

CONCLUSIONS

There is significant variation in the management of GCA within our institution. This audit has highlighted several areas where improvement could be made, particularly in streamlining the process of obtaining TA biopsy and in promoting the use of osteoporosis prophylaxis.

Detection of a promoter polymorphism in the gene of intestinal fatty acid binding protein (I-FABP)

Postprandial fat absorption is supposed to be a major factor in the development of the metabolic syndrome. In recent years, the assimilation of plasma triglycerides has been the focus of several groups, revealing a number of specific fat or fatty acid transporters. The intestinal fatty acid binding protein, I-FABP-2, participates in the absorption of nutritional fats. The influence of a coding polymorphism has been investigated intensively. However, it remains still unclear whether this polymorphism has a major impact on postprandial TG levels in humans. We found a polymorphism in the promoter of FABP-2, which might involve the retinoid receptor in the transcriptional activity. In functional analysis, we have been able to demonstrate that the various promoter alleles develop different activities in the human intestinal epithelial cells and that the postprandial appearance of plasma TGs in healthy subjects also depends on their genotype. Since the distribution of the identified promoter polymorphism does not differ in subjects suffering from type 2 diabetes, the overall influence on the development of the metabolic syndrome seems to be minor.

Fatigue effects on motor unit activity during submaximal contractions

OBJECTIVE

To examine motor unit changes during the development of fatigue in healthy subjects.

DESIGN

Automated decomposition-enhanced spike-triggered averaging was used to characterize motor unit size and firing rate in the dominant vastus medialis during maintained contractions at 10% and 30% of maxima voluntary contraction (MVC).

SETTING

Academic outpatient neuromuscular clinic.

PARTICIPANTS

Healthy laboratory personnel.

MAIN OUTCOME MEASURES

Surface electromyogram, surface-detected motor unit action potential amplitude (S-MUAP), mean firing rate, force (MVC), motor unit index.

RESULTS

Surface electromyogram values and S-MUAP amplitudes increased during both 10% and 30% MVC fatiguing contractions, while mean firing rates decreased. A motor unit index, indicating the degree of motor unit pool activation, increased similarly to S-MUAP size, implying that new and larger units were recruited to maintain the contraction. Repeated contractions led to earlier motor unit changes and fatigue.

CONCLUSION

During submaximal fatiguing contractions, additional motor units are activated to maintain strength. These changes begin early, within the first minute, particularly after a previous fatiguing effort.

Microfibril-associated protein 4 is present in lung washings and binds to the collagen region of lung surfactant protein D

We have purified a glycoprotein from bovine lung washings using affinity chromatography on a maltose-affinity column. On SDS-polyacrylamide gel electrophoresis the protein showed a molecular mass of 36 kDa in the reduced state and 66 kDa in the unreduced state. On gel permeation chromatography the apparent molecular mass was 250 kDa. N-terminal sequencing showed homology to the human matrix protein microfibril-associated protein (hMFAP4), and the glycoprotein was designated bovine MFAP4 (bMFAP4). Lung surfactant protein D (SP-D) was also purified from lung washings, and calcium-dependent binding was demonstrated between bMFAP4 and SP-D. hMFAP4 was cloned, and recombinant hMFAP4 showed the same binding pattern to SP-D as bMFAP4. No binding was seen to recombinant SP-D composed of the neck region and carbohydrate recognition domain of SP-D, indicating that the interaction between MFAP4 and SP-D is mediated via the collagen region of SP-D. MFAP4 also showed calcium-dependent binding to mannan, which was partially inhibited by maltose. Our findings indicate that MFAP4 has two binding specificities, one for collagen and one for carbohydrate, and we suggest that MFAP4 may fix the collectins in the extracellular compartment during inflammation.

Muscle quality and age: cross-sectional and longitudinal comparisons

We addressed whether muscle quality (force per unit muscle mass) changes with age in cross-sectional and longitudinal analyses from three groups from the Baltimore Longitudinal Study of Aging: (1) Isometric arm strength studied cross-sectionally in 617 subjects with muscle mass estimated by cross-sectional area (CSA) from arm circumference and by 24-hour urinary creatinine excretion (CREAT); (2) longitudinal study for 10 to 25 years in 412 men using the same measures as the first group; and (3) isometric knee extensor strength studied cross-sectionally in 675 subjects; muscle mass estimated by CREAT, CSA from thigh circumference, and leg nonosseous fat free mass (FFM) from dual energy x-ray absorptiometry. Muscle quality declined in both arm and leg with age in cross-sectional analyses using CSA and FFM, but not CREAT. No age-associated arm muscle quality declines were observed longitudinally using CREAT or CSA. The relationship between muscle quality and age is dependent on how muscle mass is estimated and on whether subjects are studied cross-sectionally or longitudinally. In addition, CREAT may measure a muscle property not accounted for by CSA or FFM.

Mutation screening of interferon-gamma (IFNgamma) as a candidate gene for asthma

BACKGROUND

Reduced levels of interferon gamma (IFNgamma) mRNA and protein have been detected in the bronchoalveolar lavage fluid of atopic asthmatics. IFNgamma is secreted by TH1 cells while IL-4 and IL-5 are secreted by TH2 cells and an imbalance in the TH1/TH2 response may be responsible for atopic asthma. The gene for IFNgamma is located on chromosome 12; a region of the genome which has been shown in linkage studies to be associated with asthma.

OBJECTIVE

To determine if there are any mutations present in the coding exons and 5' flanking region of the IFNgamma gene in atopic asthmatic subjects compared with controls to explain the lower levels of this cytokine as an inherited, rather than acquired, factor in the asthmatic subjects.

METHODS

The four exons and 5' flanking region of the IFNgamma gene were amplified by polymerase chain reaction (PCR) from genomic DNA of 265 individuals from a Western Australian and a Venezuelan population. The PCR products were examined by single strand conformational polymorphism and heteroduplex analyses to see if there were any changes in the DNA migration patterns which would suggest the presence of a sequence variation.

RESULTS

The four exons and the 5' flanking region of the IFNgamma gene were amplified from 265 individuals from two populations. Single strand conformational polymorphism and heteroduplex analyses did not reveal any mutations in the regions examined.

CONCLUSION

The gene for IFNgamma appears to be highly conserved as no sequence variations were detected in 265 individuals. These results suggest that mutations of the IFNgamma gene are unlikely to be a significant cause of an inherited asthma diathesis.

Application of flow cytometry and fluorescent in situ hybridization for assessment of exposures to airborne bacteria

Current limitations in the methodology for enumeration and identification of airborne bacteria compromise the precision and accuracy of bioaerosol exposure assessment. In this study, flow cytometry and fluorescent in situ hybridization (FISH) were evaluated for the assessment of exposures to airborne bacteria. Laboratory-generated two-component bioaerosols in exposures chambers and complex native bioaerosols in swine barns were sampled with two types of liquid impingers (all-glass impinger-30 and May 3-stage impinger). Aliquots of collection media were processed and enumerated by a standard culture technique, microscopy, or flow cytometry after nucleic acid staining with 4',6-diamidino-2-phenylindole (DAPI) and identified taxonomically by FISH. DAPI-labeled impinger samples yielded comparable estimates of bioaerosol concentrations when enumerated by microscopy or flow cytometry. The standard culture method underestimated bioaerosol concentrations by 2 orders of magnitude when compared to microscopy or flow cytometry. In the FISH method, aliquots of collection media were incubated with a probe universally complementary to eubacteria, a probe specific for several Pseudomonas species, and a probe complementary to eubacteria for detection of nonspecific binding. With these probes, FISH allowed quantitative identification of Pseudomonas aeruginosa and Escherichia coli bioaerosols in the exposure chamber without measurable nonspecific binding. Impinger samples from the swine barn demonstrated the efficacy of the FISH method for the identification of eubacteria in a complex organic dust. This work demonstrates the potential of emerging molecular techniques to complement traditional methods of bioaerosol exposure assessment.

MR imaged neurovascular relationships at the cerebellopontine angle

Improvements in MR imaging techniques allow visualisation of the anatomy of the cerebellopontine angle (CPA) in increasingly accurate detail, revealing the complex interrelationship of the neurovascular structures in this region. We wished to assess whether vessels and vascular loops intimately associated with cranial nerves VII and VIII, corresponded to any abnormality or symptom pattern, and thus had any clinical significance. The MR scans of 108 patients were retrospectively reviewed and the imaging status of VII, VIII, the vessels, presence of vascular loops and their relationship to the nerves, coded and recorded. The patients' records were independently reviewed and the presence and "sidedness' of asymmetrical hearing loss, tinnitus, vertigo, and the results of caloric and brain stem evoked responses recorded. The vessels were closely associated with VII and VIII in over 30% of this sample with vascular loops imaged in 21% of patients, and clearly imaged entering the IAM in 7% of both right and left CPAs studied. There was no statistically significant relationship demonstrated between the proximity of the vessels, or vascular loops, to the nerves and a symptom, or symptom pattern. These findings should be considered a normal variant on MR scanning.

Long-term efficacy of haloperidol in autistic children: continuous versus discontinuous drug administration

The aim of this study was to evaluate the long-term efficacy of haloperidol in autistic children and to determine whether discontinuous drug administration was as effective as continuous drug administration. Sixty children, 48 males and 12 females, ages 2.3 to 7.9 years (X 5.1) completed the study. They received haloperidol over a period of 6 months followed by a 4-week drug withdrawal/placebo period. Haloperidol remained effective, and the discontinuous treatment schedule did not diminish its efficacy. Children with prominent symptoms of irritability, angry and labile affect, and uncooperativeness were the best responders to haloperidol.

Discrepancies in nude mice

With the increasing number of publications in which nude mice are used, there is a growing list of apparent discrepencies. To avoid such problems, we propose the use of nude mouse populations with a large gene pool which will leave, if possible, the nude allele as the only homozygote. All phenotypic characters consistently different between nu/nu, nu/+ and +/+ mice could then, with more certainty, be linked with the nude mutation.

[Treatment of solid tumours by intratumoral injection of immunostimulants]

Intra-lesional injections of immunostimulants--BCG or Corynebacterium parpum--induced a local cure of the McFiFj2(S) tumour and a remote therapeutic effect. When applied to rats multigrafted with the McFiFi2(S) tumour, local and distant cures were obtained in some situations. This indicates the likely intervention of a specific immune mechanism. Quantilating the pulmonary metastasis in combination with local treatment of Lewis mouse tumours showed that BCG plus C. parvum injected into the tumour and followed by surgical resection was more efficient than either of these individual or otherwise associated antitumoural procedures.

Intra-lesional injection of immunostimulants in bilateral rat tumors

Rats grafted with either two or six fragments of isogenic methylcholanthrene-induced transplantable fibrosarcomas were treated IT1 with living BCG or killed C. parvum or a mixture of both immunostimulants. Various tumor combination and therapeutic agent dosages were compared. When two fragments of the same tumor McFiFi2 (S) were grafted simultaneously, IT treatment of one of these with 2 mg of BCG induced cure of both in 50% of the animals, but IT injection of 2 X 10(9) C. parvum was completely without effect in this situation. The prognosis was however, improved when the dose of immunostimulant was increased. The best results were obtained when each individual tumor in rats with two or six simultaneous identical grafts were treated with a mixture of BCG and C. parvum. The combination of IT immunostimulant treatment and surgical excision of the treated lesion demonstrated a persistence of the curative effect on the remote untreated tumor. Double grafting with isologous non-identical tumors revealed the influence of tumor burden and of the specificity of anti-tumor action of the treatment. The distant specific regression obtained in this system implies a specific immunological mechanism mediated by effector cells and/or antibodies which can circulate, identify the target cell and destroy it. This is in accordance with morphological observations. The intimate contact between BCG and the growing structured tumor is necessary for the therapeutic phenomenon.