Trade-offs between succulent and non-succulent epiphytes underlie variation in drought tolerance and avoidance

Epiphyte communities comprise important components of many forest ecosystems in terms of biomass and diversity, but little is known regarding trade-offs that underlie diversity and structure in these communities or the impact that microclimate has on epiphyte trait allocation. We measured 22 functional traits in vascular epiphyte communities across six sites that span a microclimatic gradient in a tropical montane cloud forest region in Costa Rica. We quantified traits that relate to carbon and nitrogen allocation, gas exchange, water storage, and drought tolerance. Functional diversity was high in all but the lowest elevation site where drought likely limits the success of certain species with particular trait combinations. For most traits, variation was explained by relationships with other traits, rather than differences in microclimate across sites. Although there were significant differences in microclimate, epiphyte abundance, and diversity, we found substantial overlap in multivariate trait space across five of the sites. We found significant correlations between functional traits, many of which related to water storage (leaf water content, leaf thickness, hydrenchymal thickness), drought tolerance (turgor loss point), and carbon allocation (specific leaf area, leaf dry matter content). This suite of trait correlations suggests that the epiphyte community has evolved functional strategies along with a drought avoidance versus drought tolerance continuum where leaf succulence emerged as a pivotal overall trait.

Comparison of exacerbation phenotypes among patients with severe asthma

Background: Exacerbation phenotypes among patients with severe asthma have been largely characterized during stable periods. Little is known about severe asthma patients during exacerbation periods. Objective: To compare persistently frequent exacerbators (PFE), non-persistently frequent exacerbators (NPFE), and infrequent exacerbators (IFE) among patients with severe asthma during stable and exacerbation periods. Methods: Patients with severe asthma who were admitted for asthma exacerbations from 2011 to 2017 and on follow up at Singapore General Hospital were recruited and categorized as PFEs (two or more exacerbations per year over 2 consecutive years), NPFEs (two or more exacerbations in 1 year only), or IFEs (fewer than two exacerbations per year over 2 consecutive years). Demographic, clinical, and laboratory data were collected at baseline and during exacerbation periods. Results: The participants were categorized as the following: 20 PFEs, 36 NPFEs, and 57 IFEs, with no significant demographic differences. The participants as PFEs (versus NPFEs and IFEs) were characterized by having a higher prevalence of psychiatric disorders (25% versus 8% versus 5%; p = 0.046), more comorbidities (7 versus 4 versus 2; p < 0.001), and a higher steroid burden per year (1150 versus 456 versus 350 mg; p < 0.001). The participants who were PFEs (versus IFEs) had a higher total immunoglobulin E (IgE) level (625 versus 232 IU/mL; p = 0.046) and longer duration of admission stay (3 versus 2 days; p = 0.009). All three groups had higher blood neutrophil counts during exacerbation periods than during stable periods (p = 0.008 versus p < 0.001 versus p = 0.004). Conclusion: The participants categorized as PFEs were characterized by comorbidities, higher steroid burden, IgE levels, and longer hospital stays. Exacerbations in the participants with severe asthma, regardless of exacerbation phenotype, were characterized by neutrophilia. These findings provided insights into potential therapeutic strategies to reduce exacerbations in patients with severe asthma.

Impact of a Formal Advance Care Planning Program on End-of-Life Care for Patients With Heart Failure: Results From a Randomized Controlled Trial

BACKGROUND

There is no evidence on effectiveness of advance care planning (ACP) among patients with heart failure (HF). We examined the effect of an ACP program in facilitating end of life (EOL) care consistent with the preferences of patients with HF (primary aim), and on their decisional conflict, discussion with surrogates, illness understanding, anxiety, depression, and quality of life (secondary aims).

METHODS

We randomized 282 patients with HF to receive ACP (n=93) or usual care (control arm, n=189). Primary outcomes were assessed among deceased (n=89) and secondary outcomes from baseline and 6 follow-ups conducted every 4 months.

RESULTS

Deceased patients in the ACP arm were no more likely than those in control arm to have wishes followed for EOL treatments (ACP: 35%, Control: 44%; P= .47), or place of death (ACP: 52%, Control: 51%; P = .1.00). A higher proportion in the ACP arm had wishes followed for cardiopulmonary resuscitation (ACP: 83%, Control: 62%; P = .12). At first follow-up, patients with ACP had lower decisional conflict (β = -10.8, P< .01) and were more likely to discuss preferences with surrogates (β = 1.3, P = .04). ACP did not influence other outcomes.

CONCLUSION

This trial did not confirm that our ACP program was effective in facilitating EOL care consistent with patient preferences. The program led to short-term improvements in the decision-making.

Factors driving frequent attendance at emergency departments for patients with head and neck cancer

BACKGROUND

Patients with head and neck cancer have a higher risk of emergency department (ED) frequent attender (FA). We hypothesized that FAs present with issues different from non-FAs.

METHODS

A retrospective cohort study was conducted on Singapore residents with head and neck cancers using de-identified registry merged with electronic medical record data. A competing risk regression analysis was performed to identify factors associated with FA. Aggregated primary diagnoses were compared for patients with and without FA risk factors.

RESULTS

Thirteen percent of patients with head and neck cancer were FAs. FA risk factors were Charlson comorbidity index (3+), and socioeconomic status (SES). FAs had a higher proportion of respiratory infections. The spectrum of diagnosis was similar for patients with low and high SES. Current smokers had a greater proportion of respiratory complaints, relative to never smokers.

CONCLUSION

Patients with greater comorbidity scores or higher SES were more likely to be FA. FAs were more likely to present with respiratory complaints, likely related to cancer treatment, or smoking status.

Integrating advance care planning as part of comprehensive geriatric assessment for hospitalised frail elderly patients: findings of a cross-sectional study

INTRODUCTION

The integration of advance care planning (ACP) as part of the comprehensive geriatric assessment (CGA) of hospitalised frail elderly patients, together with the clinical and demographic factors that determine successful ACP discussion, has not been previously explored.

METHODS

A cross-sectional study on patients and family caregivers admitted under the geriatric medicine department of a tertiary hospital was conducted from October 2015 to December 2016.

RESULTS

Among 311 eligible patients, 116 (37.3%) patients completed ACP discussion while 166 (53.4%) patients declined, with 62 (37.3%) of the decliners providing reasons for refusal. Univariate logistic regression analysis showed that older age, higher Charlson Comorbidity Index, poorer functional status and cognitive impairment had statistically significant associations with agreeing to ACP discussion (p < 0.05). On multivariate logistic regression analysis, only poorer functional status was significantly associated (odds ratio 2.22 [95% confidence interval 1.27-3.87]; p = 0.005). Among those who completed ACP discussion, a majority declined cardiopulmonary resuscitation (79.3%), preferred limited medical intervention or comfort care (82.8%), and opted for blood transfusion (62.9%), antibiotics (73.3%) and intravenous fluid (74.1%) but declined haemodialysis (50.9%). Decision-making was divided for enteral feeding. Among decliners, the main reasons for refusal were 'not keen' (33.9%), 'deferring to doctors' decision' (11.3%) and 'lack of ACP awareness' (11.3%).

CONCLUSION

The feasibility and utility of integrating ACP as part of CGA has been demonstrated. Poorer functional status is significantly associated with successful ACP discussion. Greater public education on end-of-life care choices (besides cardiopulmonary resuscitation) and follow-up with decliners are recommended.

The price of personal mobility: burden of injury and mortality from personal mobility devices in Singapore - a nationwide cohort study

BACKGROUND

Personal mobility devices (PMDs) like skate-scooters, electric bicycles (e-bikes) or motorised scooters (e-scooters) have become widely available globally. There are several studies describing the rising incidence of injury from such devices. The aim of our study was to examine PMD user factors between motorised (MotPMDs) vs non-motorised PMDs (NonPMDs) as risk factors for severe injury and the need for hospital admission.

METHODS

We analysed de-identified National Trauma Registry data (2015 to 2017) from all public sector hospitals in Singapore for patients aged 12 and above presenting to emergency departments with PMD-related injuries. Multivariable logistic regression was used to identify risk factors for the primary outcome of interest (higher injury severity, defined as Injury Severity Score / ISS > =9), and the secondary outcome of interest (need for hospital admission). Additional subgroup analysis was conducted comparing only scooters (manual vs electric), the most common sub-type of PMD in our study.

RESULTS

Of the 614 patients in our study, majority were male (74%), median age 33 years, with 136 (22%) sustaining injuries with ISS > =9; 185 (30%) admitted [median stay length 3 days (IQR: 1-6)] and 93 (15%) required surgery. MotPMDs were more common (480, 78%), with e-scooters being the most common motorised device (393, 64%). There were 6 deaths, all in MotPMD users. On both univariate and multivariable regression, MotPMD users [OR 3.82, 95% CI 1.51-12.9, p = 0.01] and older users (> = 60 years) [OR 9.47, 95% CI 2.45-62.9, p = 0.004] were more likely to sustain injuries with ISS > =9, and more likely to need admission (MotPMD users [OR 1.8, 95% CI 1.04-3.29, p = 0.045], age > =60 years [OR 4.72, 95% CI 1.86-13.0, p = 0.002]).

CONCLUSION

MotPMDs tripled the risk of severe injury and doubled the risk of requiring hospitalisation, compared to NonPMDs, likely due to higher travelling speeds. Increased age was also associated with severe injury and requiring hospitalisation.

Predictors of Change in Functional Outcome at six months and twelve months after Severe Injury: A Retrospective Cohort Study

Background

There is increasing focus on long-term survival, function and quality-of-life for trauma patients. There are few studies tracking longitudinal changes in functional outcome over time. The goal of our study was to compare the Glasgow Outcome Scale-Extended (GOSE) at 6 months and 12 months in blunt trauma survivors with an Injury Severity Score (ISS) of more than 15.

Methods

Using the Singapore National Trauma Registry 2011–2013, patients with 6-month GOSE and 12-month GOSE scores were analysed. Patients were grouped into three categories—those with the same score at 6 months and 12 months, an improvement in score, and a worse score at 12 months. Ordinal regression was used to identify risk factors for improved score. Patients with missing scores at either 6 months or 12 months were excluded.

Results

We identified 478 patients: 174 had an improvement in score, 233 stayed the same, and 71 had worse scores at 12 months compared to 6 months. On univariate ordinal regression, the following variables were associated with same or better function at 12-months compared to 6-months: male gender, being employed pre-injury, thoracic Abbreviated Injury Scale (AIS) of 3 or more, anatomical polytrauma (AIS of 3 or more in 2 or more body regions), and road traffic injury mechanism. Older age, low fall, increasing Charlson comorbidity scores, new injury severity score, and head and neck AIS of 3 or more were associated with worse function at 12 months compared to 6 months. ISS and revised trauma score were not significant predictors on univariate or multivariable analysis.

On multivariable ordinal regression, motor vehicle mechanism (OR 2.78, 1.51–5.12, p = 0.001) was associated with improved function, while male gender (OR 1.36, 95% CI 1.02–1.82, p = 0.039) predicted improved function at 12 months.

Conclusions

Females experience worse functional outcomes at 12 months, potentially due to majority of female injuries being low falls in the elderly. In contrast, motor vehicle injury patients had better functional outcomes at 12 months. Additional interventional strategies for high-risk groups should be explored.

Nasal high-mobility group box 1 and caspase in bronchiolitis

OBJECTIVE

Nasal biomarkers have potential to add objectivity to the clinical assessment of the child with bronchiolitis. We aim to study, if nasal caspase and high-mobility group box 1 protein (HMGB1) levels differ between patients who were hospitalized and those discharged from the emergency department (ED), among patients with bronchiolitis.

METHODS

Using an observational cross-sectional study design, we recruited patients younger than 24 months presenting to the ED from September 1, 2015 to May 31, 2017 with a diagnosis of acute bronchiolitis. We described the patients' clinical severity measured by the modified respiratory index score (RIS), and performed standardized collection and analysis of nasal caspase and HMGB1 levels.

RESULTS

Among 85 patients recruited, the median age was 5.0 months (interquartile range, IQR 3.3-7.2) and the median modified RIS score was 3 (IQR 2-4). Hospitalized patients had a 2.4-fold higher HMGB1 level than patients who were discharged from the ED (2.558 μg/mL [IQR 1.038-5.125] vs 1.056 μg/mL [IQR 0.409-2.395], P = 0.0013). There was no difference in median caspase level between hospitalized and discharged patients. The Area Under the Receiver Operating Characteristics curve predicting hospitalization was 0.7021 for HMGB1 compared to 0.5709 for RIS in this bronchiolitis cohort.

CONCLUSIONS

Our study findings show that nasal HMGB1 levels significantly differentiate between young children with bronchiolitis who were hospitalized compared to those fit for discharge. This exploratory study holds potential for future research on nasal HMGB1 for severity stratification in young children with acute bronchiolitis.

Charlson Comorbidity Index Predicts 5-Year Survivorship of Surgically Treated Hip Fracture Patients

Introduction:

This study aims to assess the correlation of the age-adjusted Charlson comorbidity index (ACCI) with 5-year mortality in a surgically treated hip fracture population.

Materials and Methods:

A retrospective analysis was performed on 1057 patients aged 60 years and above who underwent surgery for hip fracture with a minimum of 5-year follow-up (92.2% 5-year follow-up rate) in a tertiary hospital. Manual review of patients’ electronic hospital records was performed to record demographic data, comorbidities, and length of stay. Mortality data were extracted from the hospital’s electronic medical records and corroborated with the National Electronic Health Record.

Results:

Of the 1057 patients, 283 (26.8%) were male. The majority of patients were 80 years of age and above (42.5%), with the oldest patient operated on age 102 with a mean age of 77.8 (8.6) years. Four hundred eighteen (39.5%) patients sustained extracapsular intertrochanteric fractures. The mean follow-up duration was 8 years and 3 days with an overall survivorship of 37.2%. A multiple regression model constructed with ACCI, age, gender, and fracture pattern demonstrated satisfactory predictive ability with a concordance statistic of 0.68. Patients with a higher ACCI category (≥6) had an increased 5-year mortality rate (41.8%) with an odds ratio of 13.6 (6.7-31.8, P < .001) compared to those with an ACCI category of 3 and below (89.3%).

Discussion:

The study demonstrates that ACCI correlated with 5-year mortality after surgical treatment of hip fracture. This information is pertinent in the counseling of patients with regard to their midterm survival following hip fracture surgery and may inform policy makers of the varied midterm survival rates in patients with differing ACCI scores and educate the allocation of health-care resources.

Conclusion:

The ACCI correlates with 5-year mortality after surgical treatment of hip fracture.

Survival of Patients With Head and Neck Squamous Cell Carcinoma by Housing Subsidy in a Tiered Public Housing System

Background: Socioeconomic status affects survival in patients diagnosed with head and neck squamous cell carcinoma (HNSCC), even in health systems with universal health care. Singapore has a tiered subsidized housing system, in which income determines eligibility for subsidies by size of apartment. Aim: The objective of this study was to assess whether a patient's residential type (heavily subsidized public housing, moderately subsidized public housing, minimally subsidized or private residential housing type) was associated with mortality. A secondary analysis examined whether patients in more heavily subsidized apartments were more likely to present with advanced disease. Methods: An historical cohort study of patients in a tertiary referral center with HNSCC was identified in the multidisciplinary cancer database from 1992 to 2014. Clinicopathologic data were extracted for analysis. Patient residential postal codes were matched to type of housing. Logistic regression was performed to evaluate the relationship between all-cause mortality and the predictors of interest as well as the association between housing type and disease stage at presentation. Results: Of the 758 patients identified, most were men (73.4%), the median age was 64 years, 30.5% were smokers and 15.2% were ex-smokers. Over one-half (56.8%) of patients presented with advanced disease. Male gender (OR 2.01, 95% CI 1.16-3.48, P = 0.01), age (OR 1.03, 95% CI 1.01-1.05, P < 0.001), stage at presentation (stage 4, reference stage 1, OR 2.03, 95% CI 1.11-3.72, P = 0.02), smoker status (smoker, reference nonsmoker, OR 2.53, 95% CI 1.33-4.87, P < 0.01) and housing subsidy type (living in minimally subsidized or private residences, relative to heavily subsidized public housing, OR 0.36, 95% CI 0.15-0.78, P = 0.01) were significantly associated with increased mortality. Kaplan-Meier curves showed that patients living in the smaller, higher subsidy apartments had the worst adjusted survival, followed by patients in moderately subsidized housing, with those in minimally subsidized or private residences having the best adjusted survival. Patients in higher-subsidy apartments were not more likely to present with advanced disease, suggesting that the survival difference was not because of delayed presentation. Conclusion: Patients with HNSCC living in higher-subsidy residences have worse survival despite no apparent delays in presentation. First published: Cancer. 2017 Jun 1;123(11):1998-2005. doi: 10.1002/cncr.30557 . Epub 2017 Jan 30. Survival of patients with head and neck squamous cell carcinoma by housing subsidy in a tiered public housing system. Wong TH, Skanthakumar T, Nadkarni N, Nguyen HV, Iyer NG.

Study protocol for a cohort study of patients with advanced heart failure in Singapore

INTRODUCTIO

Understanding the symptom and health expenditure burden among patients with advanced congestive heart failure (CHF) and their family caregivers is essential to reform policy and practice needed to provide quality care to these patients at affordable prices. The proposed cohort study titled Singapore Cohort of Patients with Advanced Heart Failure aims to describe trajectories of quality of life among patients and their primary informal caregivers, quantify healthcare utilisation and expenditures, assess changes in patient and caregiver awareness of and preferences for knowing diagnostic and prognostic information, awareness and utilisation of palliative care services, preferences for treatments and decision making, perceived quality of care, self-care, caregiver psychological distress and caregiver burden.

METHODS

This cohort study will recruit 250 patients with New York Heart Association Classification class III and IV CHF from inpatient wards at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are being surveyed every 4 months until patients' death; caregivers are followed until 8 weeks postpatient death. Medical and billing records of patients are obtained and merged with patients' survey data.

ETHICS AND DISSEMINATION

The study has been approved by an ethics board. Results from the study will be disseminated through publications and presentations targeting researchers, policy makers and clinicians interested in understanding and improving care for patients with advanced CHF.

TRIAL REGISTRATION NUMBER

NCT03089034.

Effectiveness of bariatric surgery in diabetes prevention in high-risk Asian individuals

INTRODUCTION

Obesity is a key risk factor in the development of Type 2 diabetes mellitus (T2DM). Bariatric surgery causes a large amount of durable weight loss in those with clinically severe obesity. We reported the effect of weight loss via bariatric surgery on DM prevention in those at high risk of developing DM.

METHODS

This was a retrospective cohort study of 44 patients with obesity (mean body mass index 43.8 kg/m2) and pre-DM who underwent bariatric surgery and were followed up for up to three years. We also reviewed a non-surgical cohort of patients with obesity and pre-DM seen at the weight management clinic.

RESULTS

91% of patients attained normal glycaemic status at one year after bariatric surgery. At the three-year follow-up, 87.5% of the patients maintained normoglycaemia. None of the patients developed T2DM after surgery. 26.9% of patients achieved absolute weight loss at one year after bariatric surgery and maintained this at two and three years post surgery (p < 0.001 vs. baseline). The homeostatic model assessment-insulin resistance index in patients also decreased from 5.50 at baseline to 1.20, 1.14 and 1.44 at one, two and three years, respectively (p < 0.001).

CONCLUSION

Bariatric surgery produces significant weight loss, and leads to reversion from the pre-diabetic state to normal glycaemic status and reduction of the incident DM rate in those with pre-DM and morbid obesity.

BCLC subclassification and tumour characteristics to provide prognostication of outcomes in an Asian population of locally advanced hepatocellular carcinoma treated using selective internal radiation therapy with Yttrium-90

443

Background: Selective internal radiation therapy (SIRT) with Yttrium-90 (Y90) is preferentially used in locally advanced hepatocellular carcinoma (HCC) patients in the Barcelona clinic liver cancer (BCLC) B or C cohort. However, the BCLC B cohort has a wide heterogeneity. To address this, Bolondi et al. proposed a BCLC B subclassification system. Additionally, the BCLC C cohort is also diverse in their Child-Pugh (CP) stage and extent of portal vein thrombosis (PVT). The effect of these subclassifications on survival outcomes has not been studied in HCC patients treated using SIRT. Methods: 392 HCC patients treated using SIRT from 1st January 2008 to 17th March 2017 were analyzed. These patients were classified according to the proposed subclassification system for the BCLC B cohort, and CP stage for the BCLC C cohort, and their survival outcomes reviewed. Results: 293 patients met the study’s inclusion criteria. For B1/B2/B3/B4/ C CP-A and C CP-B, the median OS was 48.3/28.7/14.4/13.7/12.8 and 6.6 months respectively. Overall comparison between the subgroups for median OS reached statistical significance (p < 0.001). The Cox proportional-hazards regression analysis found that tumour location defined as unilobar or bilobar disease significantly influenced median OS. In the BCLC C cohort, the extent of portal vein invasion significantly influenced median OS (p < 0.001). For the BCLC C CP-A group, median OS for segmental/sectoral branch invasion, right and/or left portal vein invasion and main portal vein trunk invasion was 24.1, 12.8 and 6.5 months respectively. Conclusions: Bolondi et al.’s subclassification system optimizes prognostic prediction by reducing the clinical heterogeneity in BCLC B HCC patients treated using SIRT. However tumour location, unaccounted for in the proposed subclassification, is also an important prognosticator. For the BCLC C cohort CP stage, extent of PVT, and tumour location were important predictors of treatment outcomes.

The modified respiratory index score (RIS) guides resource allocation in acute bronchiolitis

BACKGROUND AND OBJECTIVE

Bronchiolitis is a common disease in early childhood with increasing healthcare utilization. We aim to study how well a simple and improved respiratory score (the modified Respiratory Index Score [RIS]) would perform when predicting for a warranted admission.

METHODS

This is an observational prospective study, from June 2015 to December 2015 in a paediatric emergency department (ED) of a large tertiary hospital in Singapore. We included children aged less than 2 years old, presenting with typical symptoms and signs of bronchiolitis but excluded children with four or more previous wheezes, a gestation of <35 weeks, and known cardiopulmonary disease. We also performed a sensitivity analysis for children presenting with their first wheeze. We defined a warranted admission as a composite of: The need for airway intervention, intravenous hydration, and a hospital stay of 2 days or more.

RESULTS

Among 1,818 patients, the median age was 10.8 months (IQR 7.2-15.9). The median modified RIS score was 4.0 (IQR 3.0-5.0). A total of 19 (1.0%) children required respiratory support, 101 (5.6%) received intravenous hydration, and 571 (31.4%) required a hospital stay of 2 days or more. After adjusting for age and duration of illness, a modified RIS score of >4 predicted significantly for a warranted admission (adjusted Odds Ratio: 3.28, 95% confidence interval: 2.62-4.12). The association remained significant among children presenting with their first wheeze.

CONCLUSIONS

This simple respiratory tool predicts for the need for respiratory support, intravenous hydration, and a significant hospital stay of 2 days or more. Pediatr Pulmonol. 2017; 52:954-961. © 2017 Wiley Periodicals, Inc.

Survival of patients with head and neck squamous cell carcinoma by housing subsidy in a tiered public housing system

BACKGROUND

Socioeconomic status affects survival in patients diagnosed with head and neck squamous cell carcinoma (HNSCC), even in health systems with universal health care. Singapore has a tiered subsidized housing system, in which income determines eligibility for subsidies by size of apartment. The objective of this study was to assess whether a patient's residential type (small/heavily subsidized, medium/moderate subsidy, large/minimal or no subsidy) influenced mortality. A secondary analysis examined whether patients in smaller subsidized apartments were more likely to present with advanced disease.

METHODS

An historical cohort study of patients in a tertiary referral center with HNSCC was identified in the multidisciplinary cancer database from 1992 to 2014. Clinicopathologic data were extracted for analysis. Patient residential postal codes were matched to type of housing. Logistic regression was performed to evaluate the relationship between all-cause mortality and the predictors of interest as well as the association between housing type and disease stage at presentation.

RESULTS

Of the 758 patients identified, most were men (73.4%), the median age was 64 years, 30.5% and 15.2% were smokers and former smokers, respectively. Over one-half (56.8%) of patients presented with advanced disease. Male gender, age, stage at presentation, survival time from diagnosis, and smoker status were significant predictors of mortality. Patients living in the smaller, higher subsidy apartments had poorer survival, although they were not more likely to present with advanced disease, suggesting that the survival difference was not because of delayed presentation.

CONCLUSIONS

Patients with HNSCC living in smaller, higher-subsidy apartments have poorer survival despite no apparent delays in presentation. Cancer 2017;123:1998-2005. © 2017 American Cancer Society.

Deterministic Tractography of the Nigrostriatal-Nigropallidal Pathway in Parkinson's Disease

We hypothesized that deterministic tractography is practical and sensitive to changes in the complex nigrostriatal and nigropallidal pathway (NSP) in Parkinson’s disease (PD). Using diffusion tensor imaging (DTI) tractography, we investigated the NSP to evaluate differences between PD patients and controls, and examined their clinico-radiologic correlation. Structural and DTI brain scans were obtained in 40 subjects (21 PD patients and 19 healthy controls). We isolated the NSP using a user-friendly DTI toolkit based on deterministic brute-force tractography. DTI parameters of fractional anisotropy (FA), mean, axial, and radial diffusivity, and streamline count of the NSP were measured. Average FA (p < 0.01) and streamline count (p < 0.001) were significantly lower in the PD compared to control group. Mean diffusivity and radial diffusivity were significantly higher in the PD group (p < 0.05). Average streamline count correlated with the United Parkinson’s Disease Rating Scale motor score (p < 0.05). Point-to-point FA profiles of the tract demonstrated peak divergence between PD and control towards the tract midpoint rather than the distal grey matter. Our findings demonstrated a clinically and radiologically practical application of DTI tractography to the NSP in PD, without requiring complex imaging sequences for anatomical localization or segmentation software.

Control of Blood Pressure and Risk Attenuation: Post Trial Follow-Up of Randomized Groups

Background

Evidence on long term effectiveness of public health strategies for lowering blood pressure (BP) is scarce. In the Control of Blood Pressure and Risk Attenuation (COBRA) Trial, a 2 x 2 factorial, cluster randomized controlled trial, the combined home health education (HHE) and trained general practitioner (GP) intervention delivered over 2 years was more effective than no intervention (usual care) in lowering systolic BP among adults with hypertension in urban Pakistan. However, it was not clear whether the effect would be sustained after the cessation of intervention. We conducted 7 years follow-up inclusive of 5 years of post intervention period of COBRA trial participants to assess the effectiveness of the interventions on BP during extended follow-up.

Methods

A total of 1341 individuals 40 years or older with hypertension (systolic BP 140 mm Hg or greater, diastolic BP 90 mm Hg or greater, or already receiving treatment) were followed by trained research staff masked to randomization status. BP was measured thrice with a calibrated automated device (Omron HEM-737 IntelliSense) in the sitting position after 5 minutes of rest. BP measurements were repeated after two weeks. Generalized estimating equations (GEE) were used to analyze the primary outcome of change in systolic BP from baseline to 7- year follow-up. The multivariable model was adjusted for clustering, age at baseline, sex, baseline systolic and diastolic BP, and presence of diabetes.

Findings

After 7 years of follow-up, systolic BP levels among those randomised to combined HHE plus trained GP intervention were significantly lower (2.1 [4.1–0.1] mm Hg) compared to those randomised to usual care, (P = 0.04). Participants receiving the combined intervention compared to usual care had a greater reduction in LDL-cholesterol (2.7 [4.8 to 0.6] mg/dl.

Conclusions

The benefit in systolic BP reduction observed in the original cohort assigned to the combined intervention was attenuated but still evident at 7- year follow-up. These findings highlight the potential for scaling-up simple strategies for cardiovascular risk reduction in low- and middle- income countries.

Trial Registration

ClinicalTrials.gov NCT00327574

Montreal Cognitive Assessment for the screening and prediction of cognitive decline in early Parkinson's disease

BACKGROUND

Early diagnosis of cognitive impairment in PD would allow appropriate monitoring and timely intervention to reduce the progression to dementia (PDD).

OBJECTIVE

To study the usefulness of the Montreal Cognitive Assessment (MoCA) in the screening for mild cognitive impairment (PD-MCI) and its predictive utility in determining longitudinal cognitive decline in PD.

METHODS

Prospective longitudinal study of patients with mild PD. PD-MCI and PDD was diagnosed based on the Movement Disorder taskforce (MDS) criteria. Receiver Operating Characteristic analyses and Cox regression analyses were performed.

RESULTS

95 patients; mean age 66.37 (SD 7.86); mean H&Y score of 1.99 (SD 0.45) were studied. At baseline, 34 patients fulfilled the MDS criteria for PD-MCI. MoCA, compared to the MMSE had a high discriminatory power in detecting PD-MCI [Area Under Curve (AUC) of 0.912, p < 0.001]. A MoCA score of ≤26 provided a sensitivity of 93.1% for the diagnosis of PD-MCI. In the longitudinal cohort over 2 years, baseline MOCA was useful in predicting cognitive decline (AUC of 0.707, p = 0.05). With Cox regression analyses, a 1-point lower score on baseline MoCA was associated with a 34% increased risk of cognitive decline [Hazard ratio (HR) 1.34; 95% CI: 1.03-1.74: p = 0.029]. A baseline MoCA ≤26 was highly predictive of progressive cognitive decline (HR 3.47, 95% CI: 2.38-5.07; p < 0.01).

CONCLUSIONS

MoCA is a reliable tool in predicting cognitive decline in early PD. A MoCA score of ≤26 significantly increases the risk for progressive cognitive decline.

Inhibition of food intake induced by acute stress in rats is due to satiation effects

Acute mild stress induces an inhibition of food intake in rats. In most studies, the cumulative daily food intake is measured but this only provides a quantitative assessment of ingestive behavior. The present study was designed to analyze the reduction in food intake induced by acute stress and to understand which behavioral and central mechanisms are responsible for it. Two different stressors, restraint stress (RS) and forced swimming stress (FSS), were applied acutely to male Wistar rats. We first measured corticosterone and ACTH in plasma samples collected immediately after acute RS and FSS in order to validate our stress models. We measured food intake after RS and FSS and determined meal patterns and behavioral satiety sequences. The expressions of CRF, NPY and POMC in the hypothalamus were also determined immediately after acute RS and FSS. The rise in corticosterone and ACTH levels after both acute RS and FSS validated our models. Furthermore, we showed that acute stress induced a reduction in cumulative food intake which lasted the whole day for RS but only for the first hour after FSS. For both stressors, this stress-induced food intake inhibition was explained by a decrease in meal size and duration, but there was no difference in ingestion speed. The behavioral satiety sequence was preserved after RS and FSS but grooming was markedly increased, which thus competed with, and could reduce, other behaviors, including eating. Lastly, we showed that RS induced an increase in hypothalamic POMC expression. These results suggest that acute stress may affect ingestive behavior by increasing satiation and to some extent by enhancing grooming, and this may be due to stimulation of the hypothalamic POMC neurons.

Peripherally injected cholecystokinin-induced neuronal activation is modified by dietary composition in mice

The aim of this study was to investigate the effect of long-term nutrient intake on the central response to the anorexigenic gut hormone CCK. C57BL/6 mice were fed one of three diets for 6 weeks: standard high carbohydrate (HC), high fat (HF), or high protein (HP). Assessment of brain response to cholecystokinin (CCK) by manganese-enhanced MRI (MEMRI) showed a reduction in neuronal activity both in an appetite-related area (ventromedial nucleus of the hypothalamus) and areas associated with reward (nucleus accumbens and striatum) regardless of diet. When comparing diet effects, while the HF diet did not induce any change in activity, reductions in MEMRI-associated signal were found in the paraventricular nucleus (PVN) and lateral hypothalamic area (LHA) when comparing the HP to the HC diet. In addition, a significant interaction was found between CCK administration and the HF diet, shown by an increased activation in the PVN, which suggests a decrease the inhibiting action of CCK. Our results put forward that the long-term intake of an HP diet leads to a reduction in basal hypothalamic activation while a high-fat diet leads to desensitization to CCK-induced effects in the hypothalamus.

Impaired capacity for upregulation of MHC class II in tumor-associated microglia

Immunotherapy for malignant gliomas is being studied as a possible adjunctive therapy for this highly fatal disease. Thus far, inadequate understanding of brain tumor immunology has hindered the design of such therapies. For instance, the role of microglia and macrophages, which comprise a significant proportion of tumor-infiltrating inflammatory cells, in the regulation of the local anti-tumor immune response is poorly understood. To study the response of microglia and macrophages to known activators in brain tumors, we injected CpG oligodeoxynucleotide (ODN), interferon-gamma (IFN-gamma), and IFN-gamma/LPS into normal and intracranial RG2 glioma-bearing rodents. Microglia/macrophage infiltration and their surface expression of MHC class II B7.1 and B7.2 was examined by flow cytometry. Each agent evaluated yielded a distinct microglia/macrophage response: CpG ODN was the most potent inducer of microglia/macrophage infiltration and B7.1 expression, while IFN-gamma resulted in the highest MHC-II expression in both normal and tumors. Regardless of the agent injected, however, MHC-II induction was significantly muted in tumor microglia/macrophage as compared with normal brain. These data suggest that microglia/macrophage responsiveness to activators can vary in brain tumors when compared with normal brain. Understanding the mechanism of these differences may be critical in the development of novel immunotherapies for malignant glioma.

The Frontal Behavioral Inventory in the differential diagnosis of frontotemporal dementia

A personality and behavioral disorder is an important and defining feature of frontal lobe dementia (FLD) or frontotemporal degeneration (FTD). The diagnosis usually depends on the progressive development of various behavioral symptoms rather than a set of neuropsychological measures. Quantification of the personality-behavior disorder is important for standardizing the diagnosis. An inventory was constructed to capture the major positive and negative behaviors and personality change, and it was administered prospectively to caregivers of 108 patients in a cognitive neurology clinic, at the time of first diagnostic assessment. The prevalence and extent of behavioral abnormality was quantitated in the clinic population of FLD, vascular dementia (VaD), Alzheimer's disease (AD), primary progressive aphasia (PPA), and depressive disorder (DD) patients. The mean scores of FLD patients were significantly above all other groups. Scores in VaD were also higher than in AD, PPA, and DD. Interrater reliability (Cohen's kappa of .90) and item consistency (a Cronbach alpha of .89) were both high. Perseveration, indifference, inattention, inappropriateness, and loss of insight rated highest in FLD, significantly different from all other groups. Apathy, aspontaneity, inflexibility, disorganization, impulsivity, personal neglect, and poor judgment were also significantly higher in FLD. Discriminant function correctly classified 92.7% versus all other patients (NON-FLD) in the study. A total of 18.8% of VaD patients were misclassified as FLD. Indifference, alien hand, and inappropriateness were the highest discriminant functions. Perseveration and verbal apraxia were important discriminatory items for FLD and PPA, respectively. The FBI is a standardized behavioral inventory useful to diagnose FLD, to differentiate it from other dementias, and to quantify the behavior disorder.

Solid and papillary epithelial neoplasm of the pancreas. Report of a case with diagnosis by fine needle aspiration cytology

BACKGROUND

Solid and papillary epithelial neoplasm of the pancreas is a distinct clinicopathologic entity. It has a benign clinical course, and surgical resection can be curative.

CASE

A 17-year-old female presented with a mass measuring about 12 cm in the epigastrium and left hypochondrium. Fine needle aspiration cytology (FNAC) showed papillae with a central fibrovascular core and lined with many layers of bland-appearing cells exhibiting nuclear grooving. These features, along with ultrasound and computed tomographic findings, led to an accurate preoperative diagnosis.

CONCLUSION

In the setting of typical clinical and radiologic findings, it is possible to make a correct preoperative diagnosis by FNAC. Doing so has important implications for management.

Amyloidosis causing a progressive myopathy

A 62-year-old woman developed profound weakness secondary to a progressive myopathy associated with primary systemic amyloidosis. The characteristic apple-green birefringent amyloid deposits were demonstrated surrounding individual muscle fibers in Congo red stained sections. Electron microscopy demonstrated amyloid filaments in close apposition to muscle fibers exhibiting excessive corrugations of the sarcolemmal membrane. The pathological features of progressive amyloid myopathy associated with primary systemic amyloidosis are distinct from the intracellular amyloid deposits characteristic of sporadic inclusion body myositis and inherited inclusion body myopathy.

The impact of molecular genetics on the care of patients with muscle disease

Clinical medicine is currently undergoing an enormous upheaval as a result of molecular genetics. Identifying the gene causing a specific disease almost immediately provides knowledge of the gene product and insight into pathogenesis. Mutations of the gene and measurable abnormalities of the gene product provide specific methods for diagnosis, prenatal counseling, and carrier detection. Perhaps, most importantly, new treatment strategies can be devised. In the review that follows, an update is provided on molecular findings in muscle diseases and how they can be applied in clinical practice.

Linkage mapping of the spinal muscular atrophy gene

Spinal muscular atrophy (SMA) is a common autosomal recessive disorder resulting in loss of motor neurons. We have performed linkage analysis on a panel of families using nine markers that are closely linked to the SMA gene. The highest lod score was obtained with the marker D5S351 (Zmax = 10.04 at theta = O excluding two unlinked families, and Zmax = 8.77 at theta = 0.007 with all families). One type III family did not show linkage to the 5q13 markers, and in one type I consanguineous family the affected individual did not show homozygosity except for the marker D5S435. Three recombinants were identified with the closet centromeric marker, D5S435, which position the gene telomeric of this marker. These recombinants will facilitate finer mapping of the location of the SMA gene. Lastly, two families provide strong evidence for a remarkable variability in presentation of the SMA phenotype, with the age at onset in one family varying from 17 months to 13 years.