Unilateral deep brain stimulation (DBS) of nucleus ventralis intermedius thalami (Vim) for the treatment of post-traumatic tremor in children: a multicentre experience

PURPOSE

Deep brain stimulation (DBS) of nucleus ventralis intermedius thalami (Vim) is a validated technique for the treatment of essential tremor (ET) in adults. Conversely, its use for post traumatic tremor (PTT) and in paediatric patients is still debated. We evaluated the efficacy of Vim-DBS for lesional tremor in three paediatric patients with drug-resistant post-traumatic unilateral tremor.

METHODS

We retrospectively collected data regarding three patients with unilateral tremor due to severe head injury, with no MRI evidence of basal ganglia lesions. The three patients underwent stereotactic frame-based robot-assisted DBS of Vim contralateral to the tremor side.

RESULTS

Mean follow-up was 48 months (range: 36-60 months). Tremor was reduced in all patients with a better control of voluntary movements and improvement of functional status (mean FIM scale improvement + 7 points). No surgical complications occurred.

CONCLUSION

Unilateral contralateral DBS of Vim could be efficacious in post-traumatic tremor, even in paediatric patients and should be offered in PTT drug-resistant patients.

OP0065 INTER-RATER RELIABILITY AND VALIDITY OF MEDIAL AND LATERAL FEMORAL BONE MARROW LESIONS IN PATIENTS WITH OSTEOARTHRITIS UNDERGOING TIBIAL OSTEOTOMY USING THE KNEE INFLAMMATION MRI SCORING SYSTEM (KIMRISS)

Background:

The Knee Inflammation MRI Scoring System (KIMRISS) is a semi-quantitative grading tool (range 0-500) used to measure features of inflammation in knee osteoarthritis (OA), including compartment-specific BML scores.

Objectives:

To investigate; 1) Inter-rater reliability of KIMRISS BML change scores including expert readers and a trainee reader, 2) Validity of KIMRISS BML scores by comparing medial and lateral femoral compartments in surgical and contralateral limbs before and 1 year after medial opening wedge high tibial osteotomy (HTO).

Methods:

We included 27 patients with varus alignment and medial compartment knee OA [preoperative Kellgren-Lawrence grades ≤3, age = 53.1 ± 5.9, 22 males (81%), body mass index = 29.9 ± 4.3] undergoing unilateral HTO. Sagittal 2D turbo spin-echo sequences were acquired at 3-Tesla in both knees pre and 1-year post HTO after surgical removal of hardware. Femoral BML scores in the medial and lateral compartments were assessed on images blinded to limb and time by masking surgical evidence. Three reviewers independently graded the same 108 images (27 patients, 2 limbs, 2 time points). We evaluated reliability pre-to-post HTO BML change scores in the medial and lateral femur by calculating intraclass correlation coefficients (ICC) and Bland-Altman plots with 80% Limits of Agreement (LoA) for each rater pair.

Results:

Means and standard deviations are shown in Figure 1. Cumulative percent distribution plots of changes after surgery show both increases and decreases in the medial and lateral femur (Figure 2). When combining all raters, the ICC (95% confidence interval (CI)) for the change in BML score for the surgical knee was 0.81(0.64, 0.91) in the medial femur and 0.73 (0.49, 0.87) in the lateral femur. 80% LOA for change in BML score in the surgical knee was -3.56 to 5.44. ICCs and LoAs for rater pairs are in Table 1. The surgical limb medial femur BML score was significantly greater than all other scores pre and post HTO (Figure 1). There were no significant changes after HTO. The mean change (95% CI) in medial femur BML score of the surgical knee was 1.08 (-1.21, 3.38). Using the mean scores of all raters, we compared BML scores in surgical and contralateral limbs before and after HTO using a 2-way repeated measures (limb by time) ANOVA, seperately for the medial and lateral compartments.

Table.

Intraclass Correlation Coefficients (95% Confidence Intervals) and 80% Limits of Agreement for change in BMLs scores in the surgical knee.

a)Medial compartment12310.63 (0.34, 0.81)230.69 (0.43, 0.85)0.42 (0.06, 0.69)b)Lateral compartment123120.67 (0.41, 0.83)30.79 (0.60, 0.90)0.47 (0.11, 0.72)c)Medial compartment12313-6.09, 8.614-8.10, 9.65-6.03, 7.58d)Lateral compartment12312-3.49, 5.413-4.73, 6.99-3.43, 4.95

ICCs in the medial (a) and lateral (b) compartments, and 80% LoA in the medial (c) and lateral (d) compartments. Rater 1 = trainee reader, raters 2-3 = expert readers (one MSK radiologist and one rheumatologist).

Fig 1.

Means and standard deviations for KIMRISS femoral BML scores in the medial and lateral compartment for the surgical and contralateral knee.

Fig 2.

Probability plots for the 12-month change after surgery in femoral BML score in the medial (a) and lateral (b) compartments of the surgical knee. Change scores from each of the three raters is shown, as well as the average of all four raters.

Conclusion:

The KIMRISS can reliably detect differences between femoral BML scores in symptomatic and contralateral limbs, supporting the inter-rater reliability, feasibility and validity of compartment-specific BML scores.

Disclosure of Interests:

Jenna Schulz: None declared, Trevor Birmingham: None declared, Walter P Maksymowych Grant/research support from: Received research and/or educational grants from Abbvie, Novartis, Pfizer, UCB, Consultant of: WPM is Chief Medical Officer of CARE Arthritis Limited, has received consultant/participated in advisory boards for Abbvie, Boehringer, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Received speaker fees from Abbvie, Janssen, Novartis, Pfizer, UCB., Robert G Lambert: None declared, Stephany Pritchett: None declared, Frank Beier: None declared, J. Robert Giffin: None declared, Thomas Appleton Grant/research support from: AbbVie and Pfizer

The facilitating factors and barriers influencing change in dental practice in a sample of English general dental practitioners

AIM

The objective of this study was to investigate the barriers and facilitators to change in dental practices among a sample of general dental practitioners (GDPs) from three regions of England.

METHOD

In-depth face-to-face interviews with 60 GDPs were undertaken. The sample was selected from a group of 317 GDPs who had completed a questionnaire in the first phase of this study. The participants were selected to reflect diversity regarding the number and extent of self-reported changes reported in the questionnaire, and personal and practice characteristics. Of the 92 attempted contacts, 60 (65%) of the interviews were successfully completed. The interview schedule formed the basis of the interview. All the interviews and notes were transferred on to NUD*IST QSR version 4, a qualitative analysis package.

RESULTS

No single factor was identified as being more important than another in facilitating change. The main facilitators for change were: financial factors, regular patient attendance, particularly a core patient group, staff loyalty, having regular staff meetings and open communication and having access to peer support. The main barriers to change were the reverse of the facilitators plus not having a financial stakehold in the practice.

CONCLUSIONS

A range of factors were identified as influencing change in general dental practice. These include GDPs' attitudes and experience of change, patient factors, organisational issues, contact with peers and access to appropriate training courses.

The prevalence and nature of recent self-reported changes in general dental practice in a sample of English general dental practitioners

OBJECTIVE

To determine the extent and types of change in seven domains of dental practice in a sample of English general dental practitioners (GDPs).

METHODS

A postal questionnaire was sent to 561 GDPs on the dental lists of three health authorities in diverse regions of England. Information collected included demographic details on personal and practice characteristics, self-rating of amount of change in the seven domains of practice and factors influencing change.

RESULTS

The response rate was 60%. Fifty-six per cent of the sample were under 40 years old. Over a third of respondents reported "changing a lot or completely" certain clinical activities, practice management arrangements and practice amenities. The highest self-reported level of change was in clinical activities. Of the GDPs who reported changing their clinical activities, 56% reported an increase in preventive care, followed by crown and bridge (44%), periodontics (44%) and endodontics (43%). Practice management rated second in the mean rank scores for self-reported change. The main changes reported were the introduction of computer systems and employment of practice managers. A sizeable percentage (66%) reported increasing the amount of information they provided to patients and the time spent discussing care. Quality assurance activities were the area of practice least likely to have changed over a 5-year period. Over half the sample reported not being involved in any quality assurance activities in the previous 5 years. Those respondents who were younger, had a postgraduate qualification and earned more than 20% of their income from private practice reported higher levels of change.

CONCLUSIONS

General dental practitioners' work patterns are dynamic and appear to be responding to changing needs and demands on their service. The main changes were in the types of clinical procedures being carried out. The low prevalence of changes reported in auditing and peer review activities needs to be investigated further.

What child is this? What interval was that? Familiar tunes and music perception in novice listeners

In the laboratory, musical novices often seem insensitive even to basic structural elements of music (octaves, intervals, etc.), undermining long-held theories of music perception, and threatening to leave current theories applicable only to experts. Consequently it is important to demonstrate novices' basic listening competence where possible. Two experiments examined the perception of musical intervals (minor thirds, major thirds and perfect fourths) by musical novices. Subjects received either standard instructions or familiar folk-tune labels to aid performance. The folk-tune labels greatly improved identification performance, producing expert-caliber performance by some musically inexperienced subjects. The effectiveness of the folk-tune manipulation was much more limited in a difficult discrimination task. The results suggest that novices do have some basic competence when assayed appropriately, and that familiar musical tokens may be a critical element in such assays. Larger implications of the role of familiarity in novices' competence are discussed, including those that relate to music cognition and aesthetics.

Corticosteroid supplementation during cardiac arrest in rats

HYPOTHESIS

Corticosteroids will improve the rate of resuscitation from cardiac arrest.

DESIGN

Prospective blinded randomized placebo-controlled trial.

INTERVENTION

An 8-min cardiac arrest was induced by KCl infusion and chest restriction in 36 male Sprague-Dawley rats with continuous EKG and arterial blood pressure monitoring. At the start of CPR the rats received one of three study drugs: normal saline (placebo); 0.05 mg hydrocortisone (Group A) and 0.25 mg hydrocortisone (Group B). Mechanical ventilation, chest compressions and ACLS drug administration were provided following a standardized algorithm.

RESULTS

The resuscitation rate was significantly higher (P < 0.05) in Group B (92%) compared to Group A (50%) and placebo (50%). For the rats resuscitated, the duration of CPR (placebo = 163 s, Group A = 126 s, Group B = 120 s) and the amount of epinephrine used (placebo = 0.007 mg, Group A = 0.005 mg, Group B = 0.005 mg) did not reach statistical significance (P = 0.15 and P = 0.21).

CONCLUSION

Hydrocortisone significantly increased the rate of ROSC from cardiac arrest. There also appears to be a trend of decreasing duration of CPR and epinephrine requirements with hydrocortisone. Further studies evaluating the mechanism of action and long term effects of hydrocortisone in cardiac arrest need to be conducted.

Counselling, care in infertility: the ethic of care

Infertility is a health-care problem which has very definite physiological, psychological and social implications. Infertile couples are continually reminded of their plight--the structure of society is based on the family unit; simple activities such as shopping are a constant reminder, the shops being geared to the family; the neighbours fill their cars with all the paraphernalia which accompanies children--the stigma of infertility often leads to mental disharmony, marital difficulties, divorce, and in some cultures to ostracism. The suffering experienced by infertile people is very real. We need to remind ourselves that we are treating 'people who are infertile' rather than 'infertility'. Our care goes beyond their physical treatment--their stresses and strains are our concern and we must be careful not to add additional stress to their existing problems. Successful treatment can transform their lives: 'They are bright, healthy, beautiful children--a dream come true. Our lives are transformed and complete. Thank you a million times.' Failure after years of trying is all the more painful. The availability of effective, informed, independent and involved counselling is essential.

Calcification in an ageing Ligula intestinalis (L) plerocercoid from a bream (Abramis brama L.)

Light and transmission electron microscopy of the strobila of a large old Ligula intestinalis plerocercoid has revealed microcrystals with a morphology similar to that of microapatite crystals from vertebrates. Analysis of the microcrystals with EMMA-4 showed them to contain calcium and phosphorus. The tissue in the immediate vicinity of the microcrystals shows signs of necrosis while further away it is histologically normal.