134 Quantitative Assessment of Visual Function for Pituitary Macroadenomas: A Practical Scoring Algorithm

Introduction

There is a myriad of existing terms by which visual capacity is recorded. The lack of a standardised categorisation of observations commonly results in ambiguities. We report the utility of a visual function score (VFS) in patients managed by transsphenoidal surgery.

Method

A VFS (expressed as a percentage) with a maximum score of 20 was calculated for each eye using the Snellen VA (40% weighting: score 0-8) and Humphrey Allergan 30-2 automated visual field (60% weighting: score 0-12).

Results

280 patients (560 eyes) underwent transsphenoidal pituitary adenoma resections with complete pre- and post-operative visual function assessment. Mean age 56 years; 56.4% male. 26.1% were treated by endoscopic technique and 73.9% were treated by microscopic technique. Pre-operative vision was normal in 38.0% eyes. All these had full post-operative vision. In patients with pre-operative visual loss (347 eyes), the mean pre-operative VFS rose from 70.8% to 87.5% post-operatively. 43.8% eyes attained full post-operative vision, 28% improved, and 25.6% remained unchanged. 9 patients (2.6%) had worse immediate post-operative vision.

Conclusions

The VFS is a convenient single measure of visual function that may facilitate local and national audit of transsphenoidal surgery. Studies are planned to correlate this with patient reported visual quality of life measures.

Pleomorphic liposarcoma of bone: a rare primary malignant bone tumour

BACKGROUND

Liposarcoma is an extremely rare primary bone sarcoma.

CASE PRESENTATION

We report a case of primary pleomorphic liposarcoma that arose in an 18 year old male in the metaphysis of the left tibia. Plain radiographs showed a partly sclerotic lesion and MR imaging a heterogeneous tumour predominantly isointense on T1- and high-signal on T2-weighted sequences with focal areas of increased T1 signal that suppressed with fat saturation. PET/CT showed marked FDG uptake (SUV = 17.1) in the primary tumour as well as a metastasis in the right distal femur and multiple small pulmonary metastases. Histologically, the tumour was a pleomorphic liposarcoma containing large tumour cells with vacuolated cytoplasm and hyperchromatic pleomorphic nuclei as well as numerous lipoblasts and scattered brown fat-like cells. Tumour cells strongly expressed FABP4/aP2, a marker of adipocyte differentiation, and UCP1, a marker of brown fat, but not S100. The case was treated with neoadjuvant MAP chemotherapy, resulting in extensive (> 95%) necrosis in the primary tumour and almost complete resolution of the femoral and pulmonary metastases.

CONCLUSIONS

Pleomorphic liposarcoma can present as a sclerotic primary malignant bone tumour; markers of adipose differentiation are useful in histological diagnosis and neoadjuvant MAP chemotherapy results in significant tumor necrosis.

Prevalence of spinous process impingement in thoracic vertebrae on radiographs of clinically-unaffected dogs

OBJECTIVES

To assess the prevalence of impinged spinous processes in asymptomatic dogs.

METHODS

One hundred and ninety lateral thoracic radiographs of asymptomatic dogs radiographed for reasons other than spinal pain, were retrospectively reviewed by two board-certified radiologists. Images were assessed for impinged spinous processes and graded for narrowing, sclerosis or remodelling of the spinous processes.

RESULTS

The prevalence of impinged spinous processes in unaffected dogs was 33·2%. Seventy-five of 79 (95%) lesions were located between T8 and T11. Impingement of the spinous processes was more common in older dogs and larger dogs displayed more frequent and more severe impingement of the spinous processes compared with smaller breeds.

CLINICAL SIGNIFICANCE

Spinous process impingement is common in animals with no history of spinal pain, indicating that this radiographic finding should be interpreted with caution.

Survivors of childhood leukaemia treated with haematopoietic stem cell transplantation and total body irradiation should undergo screening for diabetes by oral glucose tolerance tests

AIMS

Childhood cancer survivors treated with haematopoietic stem cell transplantation (HSCT) and total body irradiation are at an increased risk of developing diabetes early in life due to insulin resistance and β-cell dysfunction, but the optimal screening method is unknown. The National Institute for Health and Care Excellence guidelines for community diabetes screening recommend using fasting glucose ≥ 7 mmol/l and/or HbA1c ≥ 48 mmol/mol (6.5%) for diagnosis and, fasting glucose 5.5-6.9 mmol/l or HbA1c 42-47 mmol/mol (6-6.5%) to indicate high risk. This study aimed to evaluate the sensitivities of fasting glucose and HbA1c in the diagnosis of diabetes and impaired glucose tolerance in childhood HSCT survivors.

METHOD

The patients were 35 (male = 19) HSCT survivors from a single UK centre under follow-up from 2006 to 2013. Patients had a median age (range) of 19.2 (13.1-26.2) years and had been treated for acute lymphoblastic (n = 31) or myeloid (n = 4) leukaemia when aged 7.8 (2.4-16.7) years. The outcome measures were oral glucose tolerance test (OGTT), fasting glucose and HbA1c .

RESULTS

OGTT identified 6 patients with diabetes (120-min glucose ≥ 11.1 mmol/l), 12 with impaired glucose tolerance (120-min glucose 7.8-11.0 mmol/l) and 2 with impaired fasting glucose (≥ 7 mmol/l). Fasting glucose ≥ 7 mmol/l or HbA1c ≥ 48 mmol/mol identified two of the six patients with diabetes diagnosed on OGTT. Fasting glucose ≥ 5.5 mmol/l and HbA1c ≥ 42 mmol/mol identified three and two patients, respectively, with diabetes. Only 1 of 12 patients with impaired glucose tolerance had a fasting glucose ≥ 5.5 mmol/l and none had HbA1c ≥ 42 mmol/mol (≥ 6%).

CONCLUSIONS

The fasting glucose and HbA1c cut-offs used in UK population screening only identified one-third of HSCT survivors with diabetes and do not identify those at risk. Diabetes screening in HSCT survivors requires standard OGTTs.

Assessment of Arbovirus Surveillance 13 Years after Introduction of West Nile Virus, United States

Many states cannot rapidly detect and respond to this virus and other emerging arboviral threats.

Before 1999, the United States had no appropriated funding for arboviral surveillance, and many states conducted no such surveillance. After emergence of West Nile virus (WNV), federal funding was distributed to state and selected local health departments to build WNV surveillance systems. The Council of State and Territorial Epidemiologists conducted assessments of surveillance capacity of resulting systems in 2004 and in 2012; the assessment in 2012 was conducted after a 61% decrease in federal funding. In 2004, nearly all states and assessed local health departments had well-developed animal, mosquito, and human surveillance systems to monitor WNV activity and anticipate outbreaks. In 2012, many health departments had decreased mosquito surveillance and laboratory testing capacity and had no systematic disease-based surveillance for other arboviruses. Arboviral surveillance in many states might no longer be sufficient to rapidly detect and provide information needed to fully respond to WNV outbreaks and other arboviral threats (e.g., dengue, chikungunya).

A case-control study of risk factors for death from 2009 pandemic influenza A(H1N1): is American Indian racial status an independent risk factor?

Historically, American Indian/Alaska Native (AI/AN) populations have suffered excess morbidity and mortality from influenza. We investigated the risk factors for death from 2009 pandemic influenza A(H1N1) in persons residing in five states with substantial AI/AN populations. We conducted a case-control investigation using pandemic influenza fatalities from 2009 in Alaska, Arizona, New Mexico, Oklahoma and Wyoming. Controls were outpatients with influenza. We reviewed medical records and interviewed case proxies and controls. We used multiple imputation to predict missing data and multivariable conditional logistic regression to determine risk factors. We included 145 fatal cases and 236 controls; 22% of cases were AI/AN. Risk factors (P 45 years vs. <18 years], pre-existing medical conditions (mOR 7·1), smoking (mOR 3·0), delayed receipt of antivirals (mOR 6·5), and barriers to healthcare access (mOR 5·3). AI/AN race was not significantly associated with death. The increased influenza mortality in AI/AN individuals was due to factors other than racial status. Prevention of influenza deaths should focus on modifiable factors (smoking, early antiviral use, access to care) and identifying high-risk persons for immunization and prompt medical attention.

An Updated Checklist of the Mosquitoes of Oklahoma Including New State Records and West Nile Virus Vectors, 2003-06

The mosquito fauna of Oklahoma has not been evaluated since 1965 and no report has been published concerning species associated with urban areas in the state. Mosquito collections were conducted as part of the West Nile virus (WNV) surveillance program between April and November from 2003 to 2006, using standard collection methods. A total of 74,756 adults were collected in 26 urban centers in 16 counties of Oklahoma. Altogether, 40 species were recorded during this study period, bringing the total mosquito species recorded in Oklahoma to 62 species in 9 different genera and 18 subgenera. An updated checklist of Oklahoma mosquito fauna is included with a comparison to historical records. New state records include 3 species: Aedes muelleri, Anopheles perplexens, and Culex coronator. In addition to updating the checklist, 12 species of mosquitoes were tested for WNV. Pools of Culex pipiens complex represented the highest proportion testing positive for WNV (134/766, 17.5%), followed by Cx. tarsalis (13/192, 6.8%) and Aedes albopictus (5/215, 2.3%). West Nile virus-positive mosquitoes were detected earliest in June 2005 and latest in November 2004. Infected Cx. pipiens complex testing positive for WNV were more prevalent in the eastern and central areas of Oklahoma, whereas positive Cx. tarsalis were found mainly in the western areas of the state. This distinct geographical difference needs to be monitored and followed up to ensure optimal mosquito control efforts in Oklahoma communities with mosquito control capabilities.

Blood Donor Screening for West NiIe Virus in Oklahoma and Its Contribution to Disease Surveillance, 2003 -2013

Upon recognition that West Nile virus (WNV) was transmissible by transfusion, universal testing of blood donors by nucleic acid testing (NAT) was initiated in 2003. A retrospective review of 2003-2013 blood donor records and public health surveillance data in Oklahoma was undertaken to determine the percentage of WNV-positive blood donors who developed clinical symptoms post-donation and to examine the incidence and timing of WNV viremic donors in the context of WNV disease reported statewide. Among all WNV NAT-positive blood donors, 19% had self-described symptoms consistent with WNV disease. A viremic blood donor was the seasonal index case of WNV transmission in Oklahoma during one year [2006] of the study period. Blood donors remain an important surveillance component for epidemiologic monitoring of WNV in Oklahoma.

Salivary gland myoepithelial carcinoma

Salivary gland myoepithelial carcinoma (MC) or malignant myoepithelioma is a rare entity. MC usually presents as a slow-growing painless mass arising in the parotid gland, but may involve other salivary glands. This tumour may be particularly locally aggressive, but its clinical and biological features are not yet fully understood. MC may arise from pre-existing benign lesions, such as pleomorphic adenomas or benign myoepitheliomas, or may arise de novo. It usually affects patients over 50 years old, with no gender preference. Because it is often asymptomatic, the presentation and diagnosis can be delayed by months, even years. The current WHO classification considers MC to be an intermediate- to high-grade malignancy. Other published data suggest it is likely to be a high-grade neoplasm, consistent with its aggressive behaviour. Its epidemiology, histopathological features, immunohistochemical profile, clinical behaviour and optimal management are not well understood. Following review of the current literature we aim to address these.

Age and sex differences in c-Fos expression and serum corticosterone concentration following LPS treatment

Exposure to an immune challenge during peripuberty/adolescence, but not in adulthood, can cause enduring alterations in reproductive and non-reproductive behaviors. This suggests that the peripubertal/adolescent brain might respond differently to a stressor, like an immune challenge, than the adult brain. The goal of this study was to examine whether there are age and sex differences in the acute response to an immune challenge. To examine this research question, we investigated c-Fos expression in various brain regions. Corticosterone (CORT) concentration in the serum was quantified to examine hypothalamic-pituitary-adrenal axis (HPA-axis) responsiveness. Results showed that lipopolysaccharide (LPS; a bacterial endotoxin) treatment, induced a significant increase in the number of c-Fos immunoreactive cells in adult male and female mice compared to their saline controls. However, in peripubertal/adolescent mice, LPS treatment failed to increase the number of c-Fos immunoreactive cells in both male and female mice compared to their saline controls. LPS treatment also significantly increased serum CORT concentration in all mice regardless of sex and age. However, adult female mice treated with LPS showed significantly greater serum CORT concentration compared to adult and peripubertal/adolescent males and peripubertal/adolescent females treated with LPS. These findings support our hypothesis and suggest that there are important age and sex differences in acute immune response, which may allude to mechanisms for the enduring behavioral alterations, observed previously in mice exposed to an immune challenge during puberty but not in adulthood.

Updated Distribution of Aedes albopictus in Oklahoma, and Implications in Arbovirus Transmission

A series of statewide surveys were conducted in Oklahoma in the summers between 1991 and 2004 to identify the distribution of Aedes albopictus. Adult mosquitoes were identified in 63 counties, bringing the currently known distribution of Ae. albopictus in the state to 69 of 77 counties. The widespread presence of Ae. albopictus in Oklahoma has important current and future public and veterinary health implications for surveillance and control efforts.

National capacity for surveillance, prevention, and control of West Nile virus and other arbovirus infections--United States, 2004 and 2012

In the first 5 years after its introduction in the United States in 1999, West Nile virus (WNV) spread to the 48 contiguous states, resulting in 667 reported deaths. To establish detection and response capacity, WNV surveillance and prevention was supported through CDC Epidemiology and Laboratory Capacity (ELC) cooperative agreements with all 50 states and six large cities/counties. In 2005, the Council of State and Territorial Epidemiologists (CSTE) conducted an assessment of ELC recipients and determined that, since 1999, all had developed WNV surveillance and control programs, resulting in a national arboviral surveillance infrastructure. From 2004 to 2012, ELC funding for WNV surveillance decreased by 61%. In 2012, the United States had its most severe WNV season since 2003, prompting a follow-up assessment of the capacity of ELC-supported WNV programs. Since the first assessment, 22% of jurisdictions had stopped conducting active human surveillance, 13% had stopped mosquito surveillance, 70% had reduced mosquito trapping and testing, and 64% had eliminated avian mortality surveillance. Reduction in early detection capacity compromises local and national ability to rapidly detect changes in WNV and other arboviral activity and to initiate prevention measures. Each jurisdiction is encouraged to review its current surveillance systems in light of the local threat of WNV and emerging arboviruses (e.g., dengue and chikungunya) and ensure it is able to rapidly detect and respond to critical changes in arbovirus activity.

Rapid Needs Assessment of Hurricane Katrina Evacuees—Oklahoma, September 2005

Introduction:

On 04 September 2005, 1,589 Hurricane Katrina evacuees from the New Orleans area arrived in Oklahoma. The Oklahoma State Department of Health conducted a rapid needs assessment of the evacuees housed at a National Guard training facility to determine the medical and social needs of the population in order to allocate resources appropriately.

Methods:

A standardized questionnaire that focused on individual and household evacuee characteristics was developed. Households from each shel-ter building were targeted for surveying, and a convenience sample was used.

Results:

Data were collected on 197 households and 373 persons. When com-pared with the population of Orleans Parish, Louisiana, the evacuees sampled were more likely to be male, black, and 45–64 years of age. They also were less likely to report receiving a high school education and being employed pre-hurricane. Of those households of <1 persons, 63% had at least one missing household member. Fifty-six percent of adults and 21% of children reported having at least one chronic disease. Adult women and non-black persons were more likely to report a pre-existing mental health condition. Fourteen percent of adult evacuees reported a mental illness that required medication pre-hur-ricane, and eight adults indicated that they either had been physically or sex-ually assaulted after the hurricane. Approximately half of adults reported that they had witnessed someone being severely injured or dead, and 10% of per-sons reported that someone close to them (family or friend) had died since the hurricane. Of the adults answering questions related to acute stress disor-der, 50% indicated that they suffered at least one symptom of the disorder.

Conclusions:

The results from this needs assessment highlight that the evac-uees surveyed predominantly were black, of lower socio-economic status, and had substantial, pre-existing medical and mental health concerns. The evac-uees experienced multiple emotional traumas, including witnessing grotesque scenes and the disruption of social systems, and had pre-existing psy-chopathologies that predisposed this population to post-traumatic stress dis-order (Post-traumatic Stress Disorder).x When disaster populations are displaced, mental health and social service providers should be available immediately upon the arrival of the evacuees, and should be integrally coordinated with the relief response. Because the displaced population is at high risk for disaster-related mental health problems, it should be monitored closely for persons with PTSD. This displaced population will likely require a substantial re-establishment of financial, medical, and educational resources in new communities or upon their return to Louisiana.

Phase I study of concurrent motexafin gadolinium (MGd) with radiation therapy for children with newly diagnosed brain stem gliomas (BSG): A Children’s Oncology Group study

9014

Background: MGd, a radiosensitizer that selectively accumulates in tumors, generates reactive oxygen species intracellularly. In preclinical experiments, MGd enhances RT-induced apoptosis. Methods: A multi-institutional Phase I dose escalation and pharmacokinetic (PK) study was performed in children with newly diagnosed BSG to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of MGd administered i.v. 2 to 5 hours prior to involved field radiotherapy (RT) (1.8 Gy/day, total 54 Gy). Cohort 1 received MGd, 1.7 mg/kg/dose M-F × 3 wks and cohort 2 received the same dose M, W and F × 6 wks. The 6 subsequent cohorts of 3 to 6 pts received MGd M-F × 6 weeks at doses of 1.9, 3.4, 4.4, 5.5, 7.1 and 9.2 mg/kg/dose. Serum for PK analysis, and MRI scans (MGd is detectable by MR), were obtained for analysis of drug accumulation and responses. Results: 44 pts (42 fully evaluable for toxicity) with a median age of 6 years (range 2–20) were enrolled. At the 9.2 mg/kg/dose, 2/2 pts experienced DLT. During subsequent expansion of the 7.1 and 5.5 mg/kg/dose cohorts, DLTs, including transaminitis, hypertension and urticaria, were observed in 2/5 and 2/6 pts. At the MTD of 4.4 mg/kg/dose, 1/6 pts had reversible grade 3 serum transaminase elevations. PK analysis showed biphasic elimination with a terminal t 1/2 of 6.4 h. At the MTD, serum MGd concentrations were >250 ng/ml for 24 h. Serum clearance and steady-state volume of distribution were 0.0243 L/h/kg and 0.162 L/kg. MRI for intra-tumoral MGd distribution is ongoing. One patient had a CR and 4 had a PR. The estimated median survival is 10.3 months (95% confidence interval: 8.1 months-11.5 months). Conclusions: The recommended phase II dose of MGd for children with BSG is 4.4 mg/kg/d administered M-F × 6 weeks with involved field RT. A COG phase II trial is planned.

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Investigation of nasal disease in the cat--a retrospective study of 77 cases

A retrospective study was undertaken to determine the prevalence of different diseases in cats referred for investigation of chronic nasal disease, to identify historical, clinical and diagnostic features which may assist in making a diagnosis, and to provide information pertaining to outcome in these cats. Diagnoses included neoplasia (30 cases), chronic rhinitis (27), foreign body (8), nasopharyngeal stenosis (5), Actinomyces infection (2), nasal polyps (2), stenotic nares (2), and rhinitis subsequent to trauma (1). The most common neoplasia was lymphosarcoma (21 cases), with a median survival of 98 days for cats treated with multiagent chemotherapy. Cats with neoplasia were older on average than the other cats, and were more likely to be dyspnoeic and have a haemorrhagic and/or unilateral nasal discharge than cats with chronic rhinitis. Cats with neoplasia were more likely to have radiographic evidence of nasal turbinate destruction, septal changes, or severe increases in soft tissue density than cats with chronic rhinitis. It was unusual for cats with diseases other than neoplasia to be euthanased as a result of their nasal disease.

Creutzfeldt-Jakob disease in unusually young patients who consumed venison

BACKGROUND

Creutzfeldt-Jakob disease (CJD) in humans and chronic wasting disease (CWD) in deer and elk occur in the United States. Recent reports of 3 unusually young patients with CJD who regularly consumed deer or elk meat created concern about the possible zoonotic transmission of CWD.

OBJECTIVE

To examine the possible transmission of CWD to humans.

PATIENTS

Three unusually young patients (aged 28, 28, and 30 years) with CJD in the United States during 1997-2000.

METHODS

We reviewed medical records and interviewed family members and state wildlife and agriculture officials. Brain tissue samples were tested using histopathologic, immunohistochemical, immunoblot, or prion protein gene analyses.

MAIN OUTCOME MEASURES

Presence or absence of established CJD risk factors, deer and elk hunting in CWD-endemic areas, and comparison of the evidence for the 3 patients with that of a zoonotic link between new variant CJD and bovine spongiform encephalopathy.

RESULTS

None of the patients had established CJD risk factors or a history of travel to Europe. Two patients hunted game animals and 1 was a daughter of a hunter. Unlike patients with new variant CJD, the 3 patients did not have a unique neuropathologic manifestation, clinicopathologic homogeneity, uniformity in the codon 129 of the prion protein gene, or prion characteristics different from those of classic variants.

CONCLUSIONS

Although the occurrence of 3 unusually young patients with CJD who consumed venison suggested a possible relationship with CWD, our follow-up investigation found no strong evidence for a causal link. Ongoing CJD surveillance remains important for continuing to assess the risk, if any, of CWD transmission to humans.

Developing and implementing a comprehensive program for children and adolescents with eating disorders

TOPIC

Treatment of eating disorders in children and adolescents across a continuum of care.

PURPOSE

To describe the development and implementation of a comprehensive pilot program for children and adolescents with eating disorders.

SOURCES

Published literature and clinical experience.

CONCLUSIONS

The pilot program to provide comprehensive care to children and adolescents has been successful. As of November 2000, the inpatient modal eating disorder census has been 4 (highest = 10, lowest = 1). With the focus on prevention and early intervention, the multidisciplinary team continues to educate the public and providers.

Impact of troponin T determinations on hospital resource utilization and costs in the evaluation of patients with suspected myocardial ischemia

The evaluation and triage of patients with suspected myocardial ischemia in the emergency department remains challenging and costly. Previous studies of cardiac troponins have focused predominantly on patients with chest pain and have not randomized patients to different diagnostic strategies. Eight hundred fifty-six patients with suspected myocardial ischemia were prospectively randomized to receive a standard evaluation, including serial electrocardiographic and creatine phosphokinase-MB determinations (controls) or a standard evaluation with the addition of serial troponin T determinations (troponin group). The primary end points were length of stay and hospital charges. Significant reductions in length of hospital stay were seen in troponin T patients both with (3.6 vs 4.7 days; p = 0.01) and without (1.2 vs 1.6 days; p = 0.03) acute coronary syndromes compared with controls. Total hospital charges were reduced in a similar fashion in troponin patients with and without acute coronary syndromes ($15,004 vs $19,202; p = 0.01, and $4,487 vs $6,187; p = 0.17, respectively) compared with controls. Troponin patients without acute coronary syndromes had fewer hospital admissions (25% vs 31%; p = 0.04), whereas troponin patients with acute coronary syndromes had shorter telemetry and coronary care unit lengths of stay (3.5 vs 4.5 days; p = 0.03) compared with controls. Thus, utilization of troponin T in a broad spectrum of emergency department patients with suspected myocardial ischemia improves hospital resource utilization and reduces costs.

The Fas-FasL death receptor and PI3K pathways independently regulate monocyte homeostasis

Peripheral blood-derived monocytes spontaneously undergo apoptosis mediated by Fas-Fas ligand (FasL) interactions. Activation of monocytes by LPS or TNF-alpha prevents spontaneous monocyte apoptosis through an unknown mechanism. Here, we demonstrate that LPS and TNF-alpha up-regulate Flip and suppress spontaneous Fas-FasL mediated monocyte apoptosis and caspase 8 and 3 activation. Flip was responsible for this protection, since inhibition of Flip by antisense oligonucleotides in the presence of LPS or TNF-alpha restored monocyte sensitivity to spontaneous apoptosis. We also investigated whether the PI3K pathway contributes to the suppression of spontaneous monocyte apoptosis mediated by LPS and TNF-alpha. Monocytes treated with a reversible PI3K inhibitor (LY294002) displayed enhanced apoptosis, while LPS and TNF-alpha partially protected against apoptosis mediated by LY294002. However, direct suppression of Fas-FasL interactions by addition of neutralizing anti-FasL antibody did not further suppress LY294002-induced apoptosis in the presence of LPS or TNF-alpha. Collectively, these data demonstrate that LPS or TNF-alpha protect monocytes from death receptor-mediated apoptosis through the up-regulation of Flip, but not apoptosis initiated by inhibition of the PI3K pathway.