Sociodemographic disparities and potential biases in persistent pain estimates: Findings from 5 waves of the Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Pain is a prevalent, debilitating condition among older adults. Much evidence on this topic comes from cohort studies, which may be affected by attrition and measurement bias. Little is known about the impact of these biases on pain estimates for European older adults. Additionally, there is a lack of longitudinal research on pain and sociodemographic disparities in Irish older adults.

METHODS

We analysed data from 8171 participants (aged ≥50 at baseline) across five waves of the Irish Longitudinal Study on Ageing. Longitudinal pain severity and sociodemographic disparities in pain were explored visually and using a latent growth curve model. Using multivariate logistic regression, we examined bias due to attrition at later waves associated with reported pain at Wave 1. Measurement biases due to reporting heterogeneity were assessed by investigating associations between sociodemographic factors and pain-related disability for given pain levels.

RESULTS

Wave 1 severe pain was associated with increased odds of attrition due to death by Wave 5 (AOR: 1.63, 95% CI: 1.20, 2.19). Not having private health insurance was associated with increased odds of pain-related disability at Wave 1, controlling for pain severity (AOR: 1.37, 95% CI: 1.15, 1.64). These results suggested mortality bias and reporting heterogeneity measurement bias, respectively. Sex, education level, and private health insurance status disparities in pain were observed longitudinally.

CONCLUSIONS

Mortality bias and reporting heterogeneity measurement bias must be accounted for to improve older adult pain estimates. There is a need for policymakers to address sociodemographic disparities in older adult pain levels.

SIGNIFICANCE

This study highlights a need to address bias in the estimation of pain in observational studies of older adults. Understanding the sources and extent of these biases is important so that health practices and policies to address pain disparities can be guided by accurate estimates. Women, those with lower educational attainment, and those without private health insurance were found to have the highest pain burden longitudinally, suggesting a need for targeted interventions for these groups in Ireland and internationally.

Education as Risk Factor of Mild Cognitive Impairment: The Link to the Gut Microbiome

BACKGROUND

With differences apparent in the gut microbiome in mild cognitive impairment (MCI) and dementia, and risk factors of dementia linked to alterations of the gut microbiome, the question remains if gut microbiome characteristics may mediate associations of education with MCI.

OBJECTIVES

We sought to examine potential mediation of the association of education and MCI by gut microbiome diversity or composition.

DESIGN

Cross-sectional study.

SETTING

Luxembourg, the Greater Region (surrounding areas in Belgium, France, Germany).

PARTICIPANTS

Control participants of the Luxembourg Parkinson's Study.

MEASUREMENTS

Gut microbiome composition, ascertained with 16S rRNA gene amplicon sequencing. Differential abundance, assessed across education groups (0-10, 11-16, 16+ years of education). Alpha diversity (Chao1, Shannon and inverse Simpson indices). Mediation analysis with effect decomposition was conducted with education as exposure, MCI as outcome and gut microbiome metrics as mediators.

RESULTS

After exclusion of participants below 50, or with missing data, n=258 participants (n=58 MCI) were included (M [SD] Age=64.6 [8.3] years). Higher education (16+ years) was associated with MCI (Odds ratio natural direct effect=0.35 [95% CI 0.15-0.81]. Streptococcus and Lachnospiraceae-UCG-001 genera were more abundant in higher education.

CONCLUSIONS

Education is associated with gut microbiome composition and MCI risk without clear evidence for mediation. However, our results suggest signatures of the gut microbiome that have been identified previously in AD and MCI to be reflected in lower education and suggest education as important covariate in microbiome studies.

Cancer-associated mesothelial cells are regulated by the anti-Müllerian hormone axis

Cancer-associated mesothelial cells (CAMCs) in the tumor microenvironment are thought to promote growth and immune evasion. We find that, in mouse and human ovarian tumors, cancer cells express anti-Müllerian hormone (AMH) while CAMCs express its receptor AMHR2, suggesting a paracrine axis. Factors secreted by cancer cells induce AMHR2 expression during their reprogramming into CAMCs in mouse and human in vitro models. Overexpression of AMHR2 in the Met5a mesothelial cell line is sufficient to induce expression of immunosuppressive cytokines and growth factors that stimulate ovarian cancer cell growth in an AMH-dependent way. Finally, syngeneic cancer cells implanted in transgenic mice with Amhr2-/- CAMCs grow significantly slower than in wild-type hosts. The cytokine profile of Amhr2-/- tumor-bearing mice is altered and their tumors express less immune checkpoint markers programmed-cell-death 1 (PD1) and cytotoxic T lymphocyte-associated protein 4 (CTLA4). Taken together, these data suggest that the AMH/AMHR2 axis plays a critical role in regulating the pro-tumoral function of CAMCs in ovarian cancer.

Developing an application for the UK Pre-Doctoral Clinical and Practitioner Academic Fellowship (PCAF): the collective experience of a community of physiotherapists

For physiotherapists and other healthcare professionals, developing capability and expertise in research can be challenging. However, involvement in research is beneficial at organisational and individual levels, both for clinicians and patients. One way to embark on research is to apply for a personal fellowship such as the National Institute for Health and Care Research (NIHR) Pre-Doctoral Clinical Academic Fellowship (PCAF). While the NIHR has guidance on how to complete the application form, it can be difficult to implement this guidance and understand what a competitive application looks like. As a group of physiotherapists and academic supervisors, who have applied for NIHR PCAFs, what follows is a supportive resource, to inform others who might be thinking of applying. CONTRIBUTION OF PAPER.

Alterations of oral microbiota and impact on the gut microbiome in type 1 diabetes mellitus revealed by integrated multi-omic analyses

BACKGROUND

Alterations to the gut microbiome have been linked to multiple chronic diseases. However, the drivers of such changes remain largely unknown. The oral cavity acts as a major route of exposure to exogenous factors including pathogens, and processes therein may affect the communities in the subsequent compartments of the gastrointestinal tract. Here, we perform strain-resolved, integrated meta-genomic, transcriptomic, and proteomic analyses of paired saliva and stool samples collected from 35 individuals from eight families with multiple cases of type 1 diabetes mellitus (T1DM).

RESULTS

We identified distinct oral microbiota mostly reflecting competition between streptococcal species. More specifically, we found a decreased abundance of the commensal Streptococcus salivarius in the oral cavity of T1DM individuals, which is linked to its apparent competition with the pathobiont Streptococcus mutans. The decrease in S. salivarius in the oral cavity was also associated with its decrease in the gut as well as higher abundances in facultative anaerobes including Enterobacteria. In addition, we found evidence of gut inflammation in T1DM as reflected in the expression profiles of the Enterobacteria as well as in the human gut proteome. Finally, we were able to follow transmitted strain-variants from the oral cavity to the gut at the individual omic levels, highlighting not only the transfer, but also the activity of the transmitted taxa along the gastrointestinal tract.

CONCLUSIONS

Alterations of the oral microbiome in the context of T1DM impact the microbial communities in the lower gut, in particular through the reduction of "mouth-to-gut" transfer of Streptococcus salivarius. Our results indicate that the observed oral-cavity-driven gut microbiome changes may contribute towards the inflammatory processes involved in T1DM. Through the integration of multi-omic analyses, we resolve strain-variant "mouth-to-gut" transfer in a disease context. Video Abstract.

Age at onset as stratifier in idiopathic Parkinson’s disease – effect of ageing and polygenic risk score on clinical phenotypes

Several phenotypic differences observed in Parkinson’s disease (PD) patients have been linked to age at onset (AAO). We endeavoured to find out whether these differences are due to the ageing process itself by using a combined dataset of idiopathic PD (n = 430) and healthy controls (HC; n = 556) excluding carriers of known PD-linked genetic mutations in both groups. We found several significant effects of AAO on motor and non-motor symptoms in PD, but when comparing the effects of age on these symptoms with HC (using age at assessment, AAA), only positive associations of AAA with burden of motor symptoms and cognitive impairment were significantly different between PD vs HC. Furthermore, we explored a potential effect of polygenic risk score (PRS) on clinical phenotype and identified a significant inverse correlation of AAO and PRS in PD. No significant association between PRS and severity of clinical symptoms was found. We conclude that the observed non-motor phenotypic differences in PD based on AAO are largely driven by the ageing process itself and not by a specific profile of neurodegeneration linked to AAO in the idiopathic PD patients.

An analysis of publicly available National Health Service information leaflets for patients following an upper arm break

BACKGROUND

Recovery following an upper arm break can be prolonged and cause loss of independence. Appropriate information provision to empower and enable active participation in rehabilitation is vital to achieve the best clinical outcomes.

OBJECTIVES

To identify and analyse, through the lens of health literacy, publicly available information leaflets produced for patients following upper arm breaks in the United Kingdom National Health Service (NHS) to understand their fitness for purpose.

METHOD

An electronic search of online search engines was undertaken using search terms to identify information leaflets for upper arm breaks. Relevant leaflets were retrieved and a thematic analysis was undertaken from a health literacy perspective. To complement this, each information leaflet was also formally assessed for readability.

RESULTS

Thirty-five information leaflets were analysed. Two main themes were generated: 'Empowerment' and 'Language Use', with subthemes of promoting recovery, readability and risk of misinterpretation. The information presented in these leaflets was often complicated and sometimes contradictory. Less than half (46%) of the information leaflets were presented at a level that would be understood by the general population.

CONCLUSIONS

Current information leaflets made available for patients following upper arm breaks are not fit for purpose and are written in a way that the general population would not readily understand. There is an urgent need to understand the information needs of patients and present such information in an accessible way to optimise clinical outcomes following upper arm breaks.

Place of death in Europe: trends and associations in a 30-country panel (2005-2017)

Background

End-of-life care attracts major policy interest. Place of death is an important metric of individual experience and health system performance. Most people prefer to die at home, but hospital is the most common place of death in high-income countries. Little is known about international trends in place of death over time.

Methods

We aimed to collate population-level data on place of death in Europe for the years 2005-2017, and to evaluate association with national characteristics and policy choices. We sought outcome data from the 32 European Economic Area countries. We identified national economic, societal, demographic and health system predictors from Eurostat, OECD and the WHO. We analysed these cross-national panel data using linear regression with panel-corrected standard errors.

Results

Our analytic dataset included 30 countries accounting for over 95% of Europe's population and economic activity. Average national proportion of deaths occurring in hospital in the study period ranged from 26% to 68%, with a median of 52%. Trends vary markedly by region and wealth, with low and decreasing hospital deaths in the North-West, and high and increasing prevalence in the South and East. Controlling for demographic and economic factors, strong palliative care provision and generous government finance of long-term care were associated with fewer hospital deaths.

Conclusions

We found modifiable policy choices associated with hospital mortality, as well as wider structural economic and societal factors. Policymakers can act to curb worrisome trends in-hospital mortality. Data on places of death outside hospital can improve future research, policy and practice.

Key messages

Cross-national longitudinal analysis. Trends of hospital deaths in Europe, association between hospital mortality rate, palliative care and other healthcare factors.

Health and social care near the end of life: Can policies reduce costs and improve outcomes?

Background

A key concern related to population ageing is how it will impact on health and social care use and expenditure trends. The belief that older people are more costly for health and social care systems than younger people is pervasive, and so the logic goes that having a larger share of the population at older ages may unsustainably accelerate growth in public health spending. In reality, the evidence suggests that the effects of ageing on health care costs will be modest and growth will be slow, but there will naturally be some additional care needs. Health and social care costs can nevertheless be particularly high for people near the end of life. In fact, the costs associated with end of life care largely explain why health and social care expenditures per person, on average, are higher for older people than for younger people, since most people die at older ages.

Methods

Literature review of patterns of service use and costs of care at the end of life; how needs for end of life care are likely to change with population ageing; and effects of end of life care interventions on patterns and costs of care.

Results

The evidence suggests that costs near the end of life vary greatly, and high overall costs are driven by service use by a small proportion of decedents.

Conclusions

Although the numbers of people with needs for palliative and end of life care will rise with population ageing, a review of the literature indicates that it is possible to reduce use of services and costs, and to improve patient experiences with well-designed palliative and end of life care interventions.

Electromagnetic Navigated Versus Conventional Total Knee Arthroplasty-A Five-Year Follow-Up of a Single-Blind Randomized Control Trial

BACKGROUND

The objective of this study is to provide the 5-year follow-up results of a randomized study comparing conventional versus electromagnetic computer navigated total knee arthroplasty.

METHODS

Analysis of 127 patients (66 navigated and 61 conventional surgeries) was performed from a prospective, single-blinded, randomized controlled trial. Patient-reported outcome measures were collected at 5 years after surgery and compared with previously published 1-year clinical outcomes. Five-year surgical revision rates were collated and compared between intervention groups.

RESULTS

Overall, there have been continued improvements in the clinical scores of patients in both groups when compared with clinical data at 1 year; however, at 5 years, there is no statistical difference in any of the patient-reported outcome measures between conventional and navigated surgery. Interestingly, improved implant survivorship was observed in the navigated (0% revision rate) compared with the conventional group (4.9% all-cause revision rate).

CONCLUSION

Electromagnetic computer navigated technology produces similar clinical outcomes compared with traditional surgery. Further work is required to monitor implant survivorship, and clinical outcomes with long-term follow-up, to determine the cost effectiveness of this technology.

Immunisation Status of Children with Cerebral Palsy in Rural Bangladesh: Results from the Bangladesh Cerebral Palsy Register (BCPR)

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disability in childhood, with an estimated 17 million cases worldwide. There is limited data concerning the general health of this population and the immunisation status of children with CP is largely unknown.

OBJECTIVE

We aimed to assess the immunisation status of children with CP in rural Bangladesh and determine the predictors of non-immunisation.

METHODS

This study is part of the Bangladesh CP Register (BCPR) study; a population based CP register commenced in January 2015 in the Shahjadpur sub-district of Bangladesh. As part of BCPR registration, all children with CP in the catchment area were assessed by a paediatrician and their clinical and immunisation history were collected.

RESULTS

Between January and December 2015, 615 children with CP were registered on the BCPR. The median age of the children was 7.5 years, and 38.5% were female. 91.7% of those children had a BCG vaccine scar (as an objective marker for immunisation at birth). However, only 43.2% reported to have received the rubella vaccine during the 2014 national rubella immunisation campaign. Timing of CP diagnosis was found to be an independent predictor for immunisation uptake; those diagnosed before the age of 3 were more likely to have received the rubella vaccine (95% confidence interval [CI] 1.6 - 4.3, odds ratio [OR] 2.6, p <0.0001).

CONCLUSIONS

To the best of our knowledge, this is the first paper to use a formal CP register to examine the relationship between CP and immunisation status in a low or middle income country like Bangladesh. Our data suggest that more than half of children with CP in rural Bangladesh did not receive immunisation during a recent national campaign.

Rehabilitation following proximal humeral fracture in the UK National Health Service: A survey of publicly facing information

INTRODUCTION

Proximal humeral fractures (PHF) are a common injury in the older population but there is limited research evaluating rehabilitation following PHF. The aim of this study was to understand current National Health Service (NHS) practice for rehabilitation following PHF as a platform for conducting future research.

METHODS

Two reviewers independently undertook electronic searches for publicly available information sheets (PIS) from websites of NHS Trusts that included detail about rehabilitation following PHF, for example, duration of immobilisation. One reviewer extracted data and a second reviewer verified this.

RESULTS

Seventeen PIS from 17 different NHS trusts were identified. All provided some information on the method of immobilisation but only six provided guidance on duration of immobilisation with the median time being 2 weeks (range 0-6). The median time to commencement of passive exercise was 2 weeks (range 0-4) and 9 weeks (range 6-12) for active exercise. Only one PIS reported on the time for commencement of resisted exercises and this was reported as 6 weeks. The median time recommended return to work was 7.5 weeks (range 6-12).

CONCLUSION

This study found limited publicly available information for rehabilitation following PHF in the NHS but offers some insight into current approaches. Our results will facilitate development of relevant information for patients and evaluation of rehabilitation strategies in future research.

Opportunistic QCT Bone Mineral Density Measurements Predicting Osteoporotic Fractures: A Use Case in a Prospective Clinical Cohort

PURPOSE

To assess whether volumetric vertebral bone mineral density (BMD) measured with opportunistic quantitative computed tomography (QCT) (i.e., CT acquired for other reasons) can predict osteoporotic fracture occurrence in a prospective clinical cohort and how this performs in comparison to dual-energy X-ray absorptiometry (DXA) measurements.

METHODS

In the database of our fracture liaison service, 58 patients (73 ± 11 years, 72% women) were identified that had at least one prevalent low-energy fracture and had undergone CT of the spine. BMD was determined by converting HU using scanner-specific conversion equations. Baseline DXA was available for 31 patients. During a 3-year follow-up, new fractures were diagnosed either by (i) recent in-house imaging or (ii) clinical follow-up with validated external reports. Associations were assessed using logistic regression models, and cut-off values were determined with ROC/Youden analyses.

RESULTS

Within 3 years, 20 of 58 patients presented new low-energy fractures (34%). Mean QCT BMD of patients with fractures was significantly lower (56 ± 20 vs. 91 ± 38 mg/cm³; p = 0.003) and age was higher (77 ± 10 vs. 71 ± 11 years; p = 0.037). QCT BMD was significantly associated with the occurrence of new fractures, and the OR for developing a new fracture during follow-up was 1.034 (95% CI, 1.010-1.058, p = 0.005), suggesting 3% higher odds for every unit of BMD decrease (1 mg/cm³). Age and sex showed no association. For the differentiation between patients with and without new fractures, ROC showed an AUC of 0.76 and a Youden's Index of J = 0.48, suggesting an optimal cut-off value of 82 mg/cm³. DXA T-scores showed no significant association with fracture occurrence in analogous regression models.

CONCLUSION

In this use case, opportunistic BMD measurements attained through QCT predicted fractures during a 3-year follow-up. This suggests that opportunistic measurements are useful to reduce the diagnostic gap and evaluate the fracture risk in osteoporotic patients.

Attitudes and Knowledge of Healthcare Professionals Regarding Organ Donation. A Survey of the Saolta University Health Care Group

Organ donation saves lives and healthcare professionals (HCPs) play a vital role in that process. Therefore, the purpose of this study was to assess the attitudes and level of knowledge of HCPs regarding organ donation. An online anonymous self-administered questionnaire containing 40 questions on organ donation using google forms was created. The survey was distributed to HCPs working in the Saolta University Health Care Group. A hundred and thirty-nine responses were received giving a response rate of 11.8%. HCPs willingness to donate their organs was at 93% compared to 97% willing to receive a transplant. More HCPs understood or had knowledge of the term donation after brain death (64%) than donation after circulatory death (49%). HCPs working in intensive care knew more about the management of brain dead donors than other specialties (p<0.0001). Over 60% of HCPs when asked either disagreed or strongly disagreed with the adequacy of training in organ donation and transplant. Overall, HCPs surveyed had positive attitudes towards organ donation but there was a lack of knowledge particularly among non-intensive care professionals. This study highlights the need to increase awareness along with implementation of educational programmes among HCPs regarding organ donation and transplant.

'Finishing up' on country: challenges and compromises

A core consideration in the care of Indigenous patients at the end of life is their place of death. Dying in community can be of paramount importance to Indigenous people. This paper reports the experiences of the Top End Palliative Care Service with respect to the barriers and solutions in the return of Indigenous patients to community for end-of-life care. These barriers include not only those associated with the significant distances and remoteness in the Northern Territory but, also, spiritual and cultural factors, which often influence healthcare delivery.

Plantar keloids: diagnostic and therapeutic issues in six patients

BACKGROUND

Keloids are benign fibro-proliferative skin lesions that very rarely occur on the soles. Because of their rarity, the diagnosis of plantar keloids can be difficult. We describe the clinical and histopathological characteristics of eight plantar keloids.

METHODS

All patients presenting with plantar keloids between 2005 and 2012 in our Dermatology unit were retrospectively included. Diagnosis was definitely established by re-reading of pathological slides in all cases. Clinical characteristics, histopathological features, treatments given and their results were collected.

RESULTS

Six patients were included. Five patients had a single plantar keloid and one had three lesions. They all were of African descent. Only one patient remembered of a previous injury at the site of the keloid. Three patients presented with associated extra-plantar keloids. In four patients, the diagnosis of keloid was not initially suspected clinically or histologically. Re-reading of the clinical photographs showed that the eight plantar keloids shared common morphological features, leading to a distinctive clinical picture, defined by a hardened lesion of rounded or polycyclic shape, with a pink surface crossed by keratotic furrows and the presence of a hyperkeratotic rim. Concerning pathological features, typical hyalinized collagen can be missing and deep fibrosis should not rule out the diagnosis of keloid. Intralesional injection of triamcinolone acetonide and orthopaedic shoes were useful. All patients who had surgical excision presented recurrence.

CONCLUSION

The knowledge of the clinical features of plantar keloids is helpful to the diagnosis. There is no well-established treatment, but supportive measures are important.

Reducing surgical margins in dermatofibrosarcoma protuberans using the pathological analysis technique 'vertical modified technique': a 5-year experience

BACKGROUND

For the treatment of dermatofibrosarcoma protuberans (DFSP), wide surgical excision has been recommended, with 3-5-cm margins, including the first underlying clear fascia. Since 2006, a technical improvement in pathological analysis called the vertical modified technique (VMT) has allowed us to reduce the surgical margin without increased oncological risk.

METHODS

Between 2006 and 2011, 66 cases of DFSP were analysed in our hospital, using VMT. We reviewed patient records, considering the initial margin, total margin, number of surgeries and outcomes. Functional and aesthetic consequences were assessed by the surgeon and by the patients.

RESULTS

Mean initial margin for the first resection was 18 mm (10-30 mm). First resection allowed complete resection of the tumour in 52 cases (78.8%). Mean total surgical margin was 21.3 mm (10-60 mm). There were no cases of local tumour recurrence at a median follow-up of 30 months. Reconstruction was performed using direct sutures in 53 cases (80.3%), split-thickness skin grafts in six cases (9.1%), full-thickness skin grafts in five cases (7.6%) and flaps in two patients (3%). For 90.9% of the patients, the aesthetic result was acceptable, whereas 84.8% patients were satisfied with the functional result.

CONCLUSION

VMT reduces surgical margins and allows for extensive analysis of margins. This technique represents a safe and reliable strategy in DFSP, without increasing the risk of recurrence. The outcomes of our study have confirmed the data from the literature regarding oncological safety.

Learning in fully recurrent neural networks by approaching tangent planes to constraint surfaces

In this paper we present a new variant of the online real time recurrent learning algorithm proposed by Williams and Zipser (1989). Whilst the original algorithm utilises gradient information to guide the search towards the minimum training error, it is very slow in most applications and often gets stuck in local minima of the search space. It is also sensitive to the choice of learning rate and requires careful tuning. The new variant adjusts weights by moving to the tangent planes to constraint surfaces. It is simple to implement and requires no parameters to be set manually. Experimental results show that this new algorithm gives significantly faster convergence whilst avoiding problems like local minima.

Management strategies for recurrent ependymoma in the paediatric population

INTRODUCTION

The management of recurrent ependymoma within the paediatric population remains a therapeutic challenge. The options available are varied and patients may have already received prior radio- or chemotherapy. As yet, no consensus exists regarding their optimal treatment. We review the literature and present our contemporary management strategies for this interesting group of patients.

RESULTS AND DISCUSSION

Survival following recurrence is poor and those prognostic factors that predispose to recurrence include extent of surgical resection and the timing of administration of adjuvant therapy. The extent of resection at re-operation can confer a survival advantage, without a necessary increase in morbidity. Strategies aimed at improving surgical resection at first diagnosis include improving and centralising post-surgical radiological review, defining what are true residuals, and centralising surgical review of incompletely resected tumours. Re-irradiation can improve survival, and with the use of conformal radiation fields need not necessarily lead to neuropsychological damage. Cisplatin and etoposide remain the most effective chemotherapeutic agents to date and with an increase in the understanding of tumour biology this may improve further. Because of the complex nature of this group of patients, decisions regarding their management require the involvement of a paediatric neurosurgeon, paediatric neuro-oncologist and paediatric radiation oncologist.

Two-component dynamics of the order parameter of high temperature Bi2Sr2CaCu2O8+delta superconductors revealed by time-resolved Raman scattering

We study the dynamics of the superconducting order parameter in the high-Tc cuprate Bi2Sr2CaCu2O8+delta by employing a novel time-resolved pump-probe Raman experiment. We find two different coupling mechanisms that contribute equally to the pair-breaking peak. One coupling sets in very fast at 2 ps and relaxes slowly, while the other one is delayed and sets in roughly at 5 ps and relaxes fast. A model that couples holes through phonons is able to reproduce one part of the condensate dynamics; thus, we argue that hole-spin interactions are of importance as well.

Spontaneous resolution of a small extradural haematoma in a child

We report the rapid spontaneous resolution of a small extradural haematoma (EDH) in a 19-month-old child. The haematoma was managed conservatively. The child went on to make a full recovery. The authors discuss the significance of this surprising clinical finding.

Relief of severe retro-orbital pain and vision improvement after optic-nerve decompression in polyostotic fibrous dysplasia: case report and review of the literature

INTRODUCTION

We describe a case of a 9-year-old girl who developed progressive severe retro-orbital pain and partial visual loss in association with left optic-nerve compression due to polyostotic fibrous dysplasia of the skull.

MATERIALS AND METHODS

Intradural decompression of the optic nerve resulted in immediate and complete resolution of the pain as well as a vast visual improvement.

CONCLUSION

In cases of fibrous dysplasia of the skull with evidence of optic-nerve compression, relief of retro-orbital pain should be an additional consideration when deciding to proceed with surgical management.

[Excision skin margin and recurrence rate of skin cancer: a prospective study of 844 cases]

OBJECTIVES

In order to evaluate recurrence rates after a mean follow-up period of five years, the aim of this unicentric prospective study was to collect data of the surgical procedure concerning both skin basal cell carcinomas (BCC) and squamous cell carcinomas (SCC).

PATIENTS AND METHOD

Eight hundred and fourty-four patients were included and data were retrospectively analyzed. During the surgical procedure, the peripheral clinical clearance margin was, respectively, 4mm for the skin basal cell carcinomas, 8 mm for the sclerodermiform type and 10mm for the squamous cell carcinomas.

RESULTS

Basal cell carcinomas (BCC) were represented in 80% and the most frequent locations were the nasal area (30%). On average, the BCC measured 13.2mm. The peripheral histological clearance margin average was 4.1mm. The rate of recurrence was 3.8% after follow-up at an average of 36 months. Squamous cell carcinomas were represented in 20% cases and their locations were mainly located on the lips, the cheeks, the genital region and the extremities. On average, the SCC measured 22.45 mm. The peripheral histological clearance margin average was 10.26 mm. The rate of recurrence was 5% after follow-up at an average of 33 months.

CONCLUSION

In our study, the rate of recurrence was less than 5% after follow-up of five years. To avoid repetitive operations and the risk of recurrence in anatomically sensitive areas, these tumors should be treated with standard wide margins chosen between 4 and 10 mm, function of the histological type.

Conditional animal models for the study of lipid metabolism and lipid disorders

The advent of technologies that allow conditional mutagenesis has revolutionized our ability to explore gene functions and to establish animal models of human diseases. Both aspects have proven to be of particular importance in the study of lipid-related disorders. Classical approaches to gene inactivation by conventional gene targeting strategies have been successfully applied to generate animal models like the LDL receptor- and the apolipoprotein E-knockout mice, which are still widely used to study diverse aspects of atherosclerosis, lipid transport, and neurodegenerative disease. In many cases, however, simply inactivating the gene of interest has resulted in early lethal or complex phenotypes which are difficult to interpret. In recent years, additional tools have therefore been developed that allow the spatiotemporally controlled manipulation of the genome, as described in detail in Part I of this volume. Our aim is to provide an exemplary survey of the application of different conditional mutagenesis techniques in lipid research in order to illustrate their potential to unravel physiological functions of a broad range of genes involved in lipid homeostasis.

Macrophage low-density lipoprotein receptor-related protein deficiency enhances atherosclerosis in ApoE/LDLR double knockout mice

OBJECTIVE

In vitro studies implicate that the low-density lipoprotein receptor (LDLR)-related protein (LRP) in macrophages has a pro-atherogenic potential. In the present study, we investigated the in vivo role of macrophage specific LRP in atherogenesis independent of its role in the uptake of lipoproteins.

METHODS AND RESULTS

We generated macrophage-specific LRP-deficient mice on an apoE/LDLR double-deficient background. Macrophage LRP deletion did not affect plasma cholesterol and triglyceride levels, lipoprotein distribution, and blood monocyte counts. Nevertheless, macrophage LRP deficiency resulted in a 1.8-fold increase in total atherosclerotic lesion area in the aortic root of 18-week-old mice. Moreover, LRP deficiency also resulted in a relatively higher number of advanced lesions. Whereas macrophage and smooth muscle cell content did not differ between LRP-deficient mice and control littermates, a 1.7-fold increase in collagen content and 2.3-fold decrease in relative number of CD3+ T cells were observed in lesions from macrophage specific LRP-deficient mice.

CONCLUSIONS

Our data demonstrate that independent of its role in lipoprotein uptake, absence of LRP in macrophages resulted in more advanced atherosclerosis and in lesions that contained more collagen and less CD3+ T cells. In contrast to previous in vitro studies, we conclude that macrophage LRP has an atheroprotective potential and may modulate the extracellular matrix in the atherosclerotic lesions.

Molecular mechanisms of lipoprotein receptor signalling

The low-density lipoprotein (LDL) receptor is the prototype of a classical endocytosis receptor that mediates the uptake of extracellular ligands. Other members of the LDL receptor gene family, on the other hand, have been shown to regulate intracellular signalling cascades. Among these are the LDL receptor-related protein 1, LRP1, a promiscuous and ubiquitously expressed receptor which is critically involved in a multitude of diverse physiological processes; the Reelin receptors ApoER2 and VLDL receptor, which participate in neuronal development; and megalin, a multifunctional receptor expressed in various epithelia. In this review, we focus on recent developments that highlight similarities and differences between these related receptors and their biological function, and discuss open questions as to the underlying molecular mechanisms.

Prospective comparison of methods of closure of the coronal flap after craniofacial surgery in children

The coronal flap in children may be closed with clips or sutures. The results of closure with clips in patients treated during 1 year at the paediatric craniofacial unit, Liverpool, UK, were audited. Eight of 43 required a further general anaesthetic for removal of clips. A prospective audit the following year of patients whose wounds were closed with a rapidly-absorbed polyglactin suture (Vicryl rapide) showed that 3 out of 39 required re-suture of the wound in theatre (two following trauma from falls). There was one infection in each group. Neither of these patients required formal debridement of the wound in theatre. Rapidly-absorbed polyglactin is a safe alternative to clips for wound closure after craniofacial surgery in children and the morbidity is less because fewer patients have to return to theatre than closure with surgical clips.

Sudden death secondary to delayed closure of endoscopic third ventriculostomy

An 11-year-old boy who underwent an initially successful endoscopic third ventriculostomy (ETV) died 4 months later secondary to acute hydrocephalus. This is the first report of sudden death caused by delayed closure of ETV. Guidelines to patients, parents and primary caregivers should include the possibility of ETV failure and encourage early neurosurgical consultation when symptoms of raised intracranial pressure occur.