Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Impact of Intravenous Aspirin Administration on Ventriculostomy-Associated Hemorrhage in Coiled Acute Subarachnoid Hemorrhage Patients

Purpose

Aspirin has beneficial effects on coiling, even in acute subarachnoid hemorrhage, but there is also a perceived risk of increased bleeding and, importantly, a concern regarding ventriculostomy-associated hemorrhage (VAH) in those with complicating hydrocephalus. We aimed to assess the rate and extent of VAH in patients specifically treated with procedural intravenous aspirin during endovascular coiling of ruptured intracranial aneurysms.

Materials and Methods

This was a single neurovascular center retrospective observational study of consecutive patients treated over a three-year period. The rate of VAH assessed using computed tomography and clinical outcomes were compared in patients receiving intraprocedural intravenous aspirin loading (n=90) versus those that did not receive the drug (n=40).

Results

There was a significantly elevated rate of VAH in patients receiving intravenous aspirin (30% vs. 2.5%, odds ratio 16.7 [95% confidence interval: 2.2–128.0], P<0.0001). The majority of VAH was <10 mm in size (70%) with the largest bleed measuring 20 mm. No hematoma required surgical evacuation. No difference in favorable outcome at discharge was demonstrated. There was no difference in mortality between the 2 groups.

Conclusion

Loading with intravenous aspirin during endovascular treatment of ruptured intracranial aneurysms significantly increases the risk of VAH, but most are small with minimal impact on clinical outcome at discharge. Intravenous aspirin should probably be reserved for selected cases but should not be withheld based on risk of VAH.

FRI0333 ACHIEVEMENT OF VERY LOW DISEASE ACTIVITY AND REMISSION TREATMENT TARGETS IS ASSOCIATED WITH REDUCED RADIOGRAPHIC PROGRESSION IN PATIENTS WITH PSORIATIC ARTHRITIS TREATED WITH CERTOLIZUMAB PEGOL

Background:

Several disease activity measures and thresholds have been recommended as psoriatic arthritis (PsA) treatment targets, although consensus on the most appropriate assessment tool is lacking.1Reports suggest low disease activity (LDA) and remission may be associated with minimal structural progression in PsA.2

Objectives:

To report the relationship between PsA disease activity and structural progression over 216 weeks’ (wks) treatment with certolizumab pegol (CZP), an Fc-free, PEGylated, tumour necrosis factor inhibitor (TNFi) that has shown long-term efficacy and safety in PsA.3

Methods:

Patients (pts) enrolled in RAPID-PsA (NCT01087788) with active PsA (≥3 tender joints; ≥3 swollen joints; ESR ≥28 mm/hour and/or CRP >upper limit of normal) who had failed treatment with ≥1 csDMARD were randomised 1:1:1 to CZP 200 mg every 2 wks (Q2W), CZP 400 mg every 4 wks (Q4W), or placebo (PBO). All CZP pts received CZP 400 mg at Wks 0/2/4. PBO pts were re-randomised to CZP 200 mg Q2W or 400 mg Q4W at Wk 16 or 24.3

Pts were heterogenous for structural damage and disease duration at baseline. Disease activity was assessed using minimal disease activity (MDA) criteria (MDA: 5–6/7 criteria; very LDA [VLDA]: 7/7 criteria), Psoriatic Arthritis Disease Activity Score (PASDAS) (LDA: >1.9–≤3.2; remission: ≤1.9), or Disease Activity Index for Psoriatic Arthritis (DAPSA) (LDA: >4–≤14; remission: ≤4). Radiographs were read in four reading campaigns using the van der Heijde modified Total Sharp Score (mTSS) for PsA. A risk of structural progression (RSP) subgroup (baseline mTSS >median for all pts) was also assessed. Mean change from baseline (CFB) in mTSS and associations with disease activity states were estimated using a hierarchical linear mixed effects model (fixed effects: reading campaign/interactions of concurrent disease activity levels with time; random effects: pt/reading campaign nested within pt) which allowed mean mTSS trajectory, and impact of disease activity levels on this, to differ over time.

Results:

407/409 randomised pts were assessed for mTSS at least once. At Wk 0, mean (standard deviation) DAPSA=44.5 (22.7), PASDAS=6.0 (1.1). 3/409 (0.7%) pts reported MDA. The proportion of pts achieving remission/VLDA states increased to Wk 216, as did estimated mean mTSS. Estimated mean mTSS CFB remained low overall (0.46 at Wk 216; standard error 0.16;Figure). Across disease activity measures, remission/VLDA states were associated with mTSS estimated mean CFB ≤0 in both the overall group and RSP subgroup (Table).

Conclusion:

These data indicate that achievement of remission in PsA is important to prevent further structural damage, particularly in pts with pre-existing structural changes. This supports the rationale for strict disease activity targets.

References:

[1]Coates L. Arthritis Rheumatol 2018;70:345–55;2.Tucker LJ. Curr Rheumatol Rep 2018;20:71;3.van der Heijde D. RMD Open 2018;4:e000582.

Table.

Estimated mTSS (mixed effects model)

mTSS estimated mean CFB (standard error)All patients(N=407)RSP(n=202)PASDASRemission-0.20 (0.25)-0.55 (0.49)LDA0.01 (0.23)-0.07 (0.47)>LDA1.31 (0.22)2.54 (0.43)DAPSARemission-0.34 (0.23)-0.67 (0.46)LDA0.40 (0.22)0.81 (0.44)>LDA1.37 (0.24)2.46 (0.48)MDAVLDA-0.40 (0.28)-0.84 (0.55)MDA0.39 (0.24)0.55 (0.48)>MDA0.89 (0.20)1.73 (0.39)

mTSS estimated mean CFB: ≤0; ≤0.5; >0.5. Data to Wk 216 pooled for all pts randomised.

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Laura C Coates: None declared, Joseph F. Merola Consultant of: Merck, AbbVie, Dermavant, Eli Lilly, Novartis, Janssen, UCB Pharma, Celgene, Sanofi, Regeneron, Arena, Sun Pharma, Biogen, Pfizer, EMD Sorono, Avotres and LEO Pharma, Arthur Kavanaugh Grant/research support from: Abbott, Amgen, AstraZeneca, BMS, Celgene Corporation, Centocor-Janssen, Pfizer, Roche, UCB – grant/research support, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Owen Davies Employee of: UCB Pharma, Oscar Irvin-Sellers Employee of: UCB Pharma, Tommi Nurminen Employee of: UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV

52 A Community Cure for Frequent Reattenders: Developing An Interface Geriatrics Service

Topic

Setting up an interface geriatrics service in a seaside area with a large elderly population. Many elderly patients are readmitted due to the challenge of managing their chronic health conditions in the community. These patients are frail, with frequently exacerbated chronic conditions causing regular readmissions. We noted that treatment was rarely changed during these admissions and patients were not uniformly managed.

Aims

Aims for this project were to improve care for older people, reduce readmissions and produce clear patient care plans.

Interventions

Our first PDSA cycle involved implementing geriatrician presence at community MDTs (involving social services, GPs, intermediate care teams, and various others). This generated home visits to several patients, with a mix of acute and chronic issues. We offered Advance Care planning where appropriate to these patients. We noted several patients were repeatedly discussed at MDT. This brought into focus frequent attenders who were usually well-known to the community. In the next cycle we introduced ‘frequent attender’ plans for these patients, ensuring a unified approach to their management. Subsequent cycles involved geriatrician presence at the ‘frequent attenders’ steering group, and further links with community teams. Our primary intervention has been Advance care & frequent attender plans offering tailored management for complex patients. These are completed by a geriatrician discussing patients wishes for treatment and future care.

Improvements

Readmission rates show up to 90% reduction in admissions/ED attendances for patients following care plan implementation. Feedback from families and patients is positive – the service is ‘pragmatic and supportive’, delivering ‘empathetic care’.

Discussion

Implementing an interface geriatrics service highlights the importance of caring for frail patients in their preferred place of care, reducing unnecessary/inappropriate hospitalisations. Geriatrician presence at community MDTs has improved care by offering prompt access to medical advice and review of complex patients. It highlights patients presenting frequently to services, allowing us to work with patients and families to improve management. A frequent attender list generated by the hospital helps target patients for whom intervention will give significant benefit. We plan to extend this further by working with nursing homes that have high conveyancing rates. The service is being extended to more areas within our region, and we are working with GPs and care homes to further offer advance care planning to vulnerable and frail patients.

Factors increasing risk of failure following hip arthroscopy: a case control study

We aimed to identify factors such as pre-arthroscopy and intra-operative variables that were associated with failure of hip arthroscopy as a joint preserving operation. We performed a retrospective analysis of a database containing 344 consecutive hip arthroscopies performed at our institution. Forty-four hips were identified that underwent a subsequent arthroplasty procedure following their hip arthroscopy (cases). Sixty-six control hips (hip arthroscopy with no subsequent arthroplasty) were randomly selected from the same database. Cases and controls were matched for age, sex and follow-up (P = 0.59, 0.48, 0.10, respectively). Pre-operative radiographs/MRI scans plus intra-operative findings were analysed to identify factors associated with failure. Both a lower centre edge angle and higher acetabular index on pre-operative radiographs were associated with higher rates of failure (P < 0.001). The presence of any acetabular wear at operation was also associated with failure (P < 0.001). Highest rates of failure were seen in hips with both features of dysplasia on pre-operative radiographs and any intra-operative acetabular wear (relative risk: 5, odds ratio: 9.13, P < 0.001). Dysplastic features on pre-operative radiographs and the finding of acetabular wear at hip arthroscopy increase the risk of subsequent arthroplasty. Identification of these features pre-operatively with evolving imaging techniques would improve the results of hip arthroscopy as joint preserving surgery.

Prognostic significance of clinical presentation, induction and rescue treatment in 42 cases of canine centroblastic diffuse large B-cell multicentric lymphoma in the United Kingdom

Canine lymphoma is a heterogeneous group of diseases and many previous studies have evaluated the response of a mixed population of lymphoma cases to one specific treatment protocol. The aim of this retrospective study was to describe the outcome and prognostic factors in 42 cases of multicentric centroblastic diffuse large B-cell lymphoma treated with either a COP-type (35%) or CHOP-type (64%) induction chemotherapy. The objective response rate to induction therapy was 94%; entire dogs had a greater rate of complete vs partial remissions than neutered dogs (P = .017). Median progression-free survival for the first remission (PFS1) was 182 days; absence of anaemia at diagnosis (P = .002) and pretreatment neutrophil:lymphocyte ratio (NLR) below 9.44 (P = .015) were independently predictive of longer PFS1. Fifty-eight percent of dogs received rescue protocols with an objective response rate of 81%; 31% of dogs received further rescue protocols (up to a total of 5) and the median number of protocols administered were 2. Median overall survival (OS) was 322 days, the 1-year survival rate was 38% and the 2-year survival rate was 9%. Lymphocyte:monocyte ratio above 1.43 (P = .031), NLR below 11.44 (P = .009), the combination of induction and rescue therapy (P = .030) and the total number of doxorubicin doses used (P = .002) were independently predictive of longer OS. Use of a COP-type protocol induction compared with CHOP did not undermine OS providing doxorubicin was used as rescue therapy.

Observed Incidence of Uveitis Following Certolizumab Pegol Treatment in Patients With Axial Spondyloarthritis

Objective

Axial spondyloarthritis (axial SpA) is characterized by inflammation of the spine and sacroiliac joints and can also affect extraarticular sites, with the most common manifestation being uveitis. Here we report the incidence of uveitis flares in axial SpA patients from the RAPID‐axSpA trial, including ankylosing spondylitis (AS) and nonradiographic (nr) axial SpA.

Methods

The RAPID‐axSpA (NCT01087762) trial is double‐blind and placebo‐controlled to week 24, dose‐blind to week 48, and open‐label to week 204. Patients were randomized to certolizumab pegol (CZP) or placebo. Placebo patients entering the dose‐blind phase were re‐randomized to CZP. Uveitis events were recorded on extraarticular manifestation or adverse event forms. Events were analyzed in patients with/without history of uveitis, and rates reported per 100 patient‐years.

Results

At baseline, 38 of 218 CZP‐randomized patients (17.4%) and 31 of 107 placebo‐randomized patients (29.0%) had past uveitis history. During the 24‐week double‐blind phase, the rate of uveitis flares was lower in CZP (3.0 [95% confidence interval (95% CI) 0.6–8.8] per 100 patient‐years) than in placebo (10.3 [95% CI 2.8–26.3] per 100 patient‐years). All cases observed during the 24‐week double‐blind phase were in patients with a history of uveitis; in these patients, rates were similarly lower for CZP (17.1 [95% CI 3.5–50.1] per 100 patient‐years) than placebo (38.5 [95% CI 10.5–98.5] per 100 patient‐years). Rates of uveitis flares remained low up to week 96 (4.9 [95% CI 3.2–7.4] per 100 patient‐years) and were similar between AS (4.4 [95% CI 2.3–7.7] per 100 patient‐years) and nr‐axial SpA (5.6 [95% CI 2.9–9.8] per 100 patient‐years).

Conclusion

The rate of uveitis flares was lower for axial SpA patients treated with CZP than placebo during the randomized controlled phase. Incidence of uveitis flares remained low to week 96 and was comparable to rates reported for AS patients receiving other anti–tumor necrosis factor antibodies.

Early Disease Activity or Clinical Response as Predictors of Long-Term Outcomes With Certolizumab Pegol in Axial Spondyloarthritis or Psoriatic Arthritis

Objective

Early identification of patients unlikely to achieve good long‐term disease control with anti–tumor necrosis factor therapy in axial spondyloarthritis (SpA) and psoriatic arthritis (PsA) is important for physicians following treat‐to‐target recommendations. Here we assess associations between disease activity or clinical response during the first 12 weeks of treatment and attainment of treatment targets at week 48 in axial SpA and PsA patients receiving certolizumab pegol.

Methods

The relationship between disease activity or clinical response during the first 12 weeks of treatment and achievement of week‐48 targets (for axial SpA: inactive disease based on Ankylosing Spondylitis Disease Activity Score [ASDAS] using the C‐reactive protein [CRP] level, or Bath Ankylosing Spondylitis Disease Activity Index <2 with normal CRP level; and for PsA: minimal disease activity) was assessed post hoc using RAPID‐axSpA and RAPID‐PsA trial data.

Results

A clear relationship between disease activity from week 2 to 12 and achievement of week‐48 treatment targets was observed in both axial SpA and PsA populations. In axial SpA, week‐48 ASDAS inactive disease was achieved by 0% of patients (0 of 21) with ASDAS very high disease activity at week 12, compared to 68% of patients (34 of 50) with week‐12 ASDAS inactive disease. For PsA, week‐48 minimal disease activity was achieved by 0% of patients (0 of 26) with Disease Activity Score in 28 joints (DAS28) using the CRP level >5.1 at week 12, compared to 73% of patients (57 of 78) with DAS28‐CRP <2.6. Similar results were observed regardless of the disease activity measure used. Clinical response at week 12 also predicted week‐48 outcomes, though to a lesser extent than disease activity.

Conclusion

Using disease activity and the clinical response state during the first 12 weeks of certolizumab pegol treatment, it was possible to identify a subset of axial SpA and PsA patients unlikely to achieve long‐term treatment goals.

Long-term follow-up of the Copeland mark III shoulder resurfacing hemi-arthroplasty

BACKGROUND

Shoulder humeral resurfacing is being performed in increasing numbers. We report the long-term outcome of patients with the Copeland mark III humeral resurfacing hemi-arthroplasty.

METHODS

Ninety-five shoulder hemi-arthroplasties were performed in 85 patients, from 1994 to 2003. Oxford Shoulder Score (OSS) and short form 12 (SF-12) questionnaires were administered.

RESULTS

At 12-year follow-up, 49 patients were alive. The OSS was 35.2 and SF-12 score was 83. There were 3 revision operations and 95% survivorship at 18 years.

CONCLUSION

This prosthesis has a low revision rate with few post-operative complications and good patient-reported outcome in an elderly population.

Two dosing regimens of certolizumab pegol in patients with active rheumatoid arthritis

Objective

To investigate clinical efficacy and safety of 2 certolizumab pegol (CZP) maintenance dosing regimens plus methotrexate (MTX) in active rheumatoid arthritis (RA) patients achieving the American College of Rheumatology 20% improvement criteria (ACR20) after the CZP 200 mg every 2 weeks open-label run-in period.

Methods

DOSEFLEX (dosing flexibility) was a double-blind, placebo-controlled randomized study with an open-label run-in phase. During the run-in phase, all patients received CZP 400 mg (weeks 0, 2, and 4) and 200 mg every 2 weeks to week 16. Week 16 ACR20 responders were randomized 1:1:1 at week 18 to CZP 200 mg every 2 weeks, 400 mg every 4 weeks, or placebo.

Results

A total of 209 (of 333) patients were randomized at week 18 (CZP: 200 mg, n = 70; 400 mg, n = 70; placebo, n = 69). Groups had similar baseline characteristics (week 0). Week 34 ACR20 response rates were comparable between the CZP 200 mg every 2 weeks and the 400 mg every 4 weeks groups (67.1% versus 65.2%), which was significantly higher than placebo (44.9%; P = 0.009 and P = 0.017). ACR50/70 and remission criteria were met more frequently in CZP groups than placebo at week 34, with similar responses between anti–tumor necrosis factor–experienced and naive patients. Improvements from baseline Disease Activity Score in 28 joints using the erythrocyte sedimentation rate and Health Assessment Questionnaire disability index scores were maintained in CZP groups from week 16 to 34 while worsening on placebo. Adverse event (AE) rates in the double-blind phase were 62.9% versus 60.9% versus 62.3%; serious AE rates were 7.1% versus 2.9% versus 0.0% (CZP 200 mg, 400 mg, and placebo groups).

Conclusion

In active RA patients with an incomplete MTX response, CZP 200 mg every 2 weeks and 400 mg every 4 weeks were comparable and better than placebo for maintaining clinical response to week 4 following a 16-week, open-label run-in phase.

Stroke physician versus stroke neurologist: can anyone thrombolyse?

BACKGROUND/AIM

The aim of this study is to compare the outcomes of thrombolysis under standard clinical settings between subjects treated by a stroke neurologist versus those treated by a non-neurologist stroke physician.

METHODS

Single-centre, observational cohort study of subjects thrombolysed in a calendar year, stratified according to the physician type authorising thrombolysis. Endpoints measured include proportion of subjects with symptomatic intracranial haemorrhage, door-to-needle time, change in National Institute of Health Stroke Scale and discharge destination.

RESULTS

Forty-nine subjects with a mean age 76 ± 16 years underwent thrombolysis, 21 were under the care of a stroke neurologist and 28 by a non-neurologist stroke physician. No symptomatic intracranial haemorrhages were observed. There was no difference in terms of door-to-needle time, proportion of individuals with haemorrhagic transformation, mortality or discharge destination between the two groups.

CONCLUSION

Due to the single-centre, observational nature of this study, the equivalent outcomes between those thrombolysed by a stroke neurologist versus those thrombolysed by a stroke physician must be interpreted with caution pending further studies. Nevertheless, in the current setting, no signal for harm has been detected. This study is unique as it is the first to our knowledge comparing outcomes between a neurologist and non-neurologist following thrombolysis.

Size matching in lung transplantation: an evidence-based review

The evidence base for size matching between donors and recipients in lung transplantation has not recently been reviewed in a comprehensive manner. Our aim in this study was to assimilate published studies that have addressed size matching of donors to recipients and to establish a pragmatic understanding of the range of lung sizes that may be used for lung transplantation. A comprehensive literature search was performed using Medline and PubMed up to and including September 2012, to identify scientific articles that relate to size matching between donors and lung transplant recipients. Seventy-two articles were identified, of which 21 had addressed the question of the impact of size mismatching on outcomes in lung transplantation. No study has specifically tested the consequences of intentionally mismatching above or below the hypothetical limits for double lung transplantation of a predicted total lung capacity for the donor of between 75% and 125% of the recipient predicted total lung capacity as set out in the ISHLT consensus report on lung donor acceptability criteria. Research is lacking that has robustly defined limits for size mismatch for single lung transplantation and for recipients with restrictive lung pathologies such as pulmonary fibrosis. Published research on the impact of size mismatching between lung transplant donors and recipients is limited by study design and size. It is centered on addressing the issue of mismatch in double lung transplantation in cohorts with a diagnostically heterogeneous make-up and in single lung transplant patients with chronic obstructive pulmonary disease.

Full recovery after severe serotonin syndrome, severe rhabdomyolysis, multi-organ failure and disseminated intravascular coagulopathy from MDMA

3, 4-methylenedioxymethamphetamine (MDMA), popularly known as "ecstasy" is a synthetic, psychoactive drug used recreationally for its euphoric and "energy increasing" effects. MDMA has been linked to several severe adverse effects including the development of serotonin syndrome and sudden death. Individuals of Asian descent have been shown to have a predisposition for these severe adverse effects. We present a case of a young Asian-American male who following MDMA ingestion presented with severe rhabdomyolysis (CK 130,350 U/L), multiple organ failure and severe serotonin syndrome with one of the highest recorded temperatures '108.9 °F (42.7 °C)' in a survivor of severe serotonin syndrome. The patient initially received supportive care including ventilatory support; he eventually needed hemodialysis, but went on to make a full recovery within 3 weeks. This case shows and emphasizes the importance of 'aggressive' supportive care on patient prognosis particularly for patients on the extreme end of the serotonin syndrome.

Mating increases neuronal tyrosine hydroxylase expression and selectively gates transmission of male chemosensory information in female mice

Exposure to chemosensory signals from unfamiliar males can terminate pregnancy in recently mated female mice. The number of tyrosine hydroxylase-positive neurons in the main olfactory bulb has been found to increase following mating and has been implicated in preventing male-induced pregnancy block during the post-implantation period. In contrast, pre-implantation pregnancy block is mediated by the vomeronasal system, and is thought to be prevented by selective inhibition of the mate’s pregnancy blocking chemosignals, at the level of the accessory olfactory bulb. The objectives of this study were firstly to identify the level of the vomeronasal pathway at which selective inhibition of the mate’s pregnancy blocking chemosignals occurs. Secondly, to determine whether a post-mating increase in tyrosine hydroxylase-positive neurons is observed in the vomeronasal system, which could play a role in preventing pre-implantation pregnancy block. Immunohistochemical staining revealed that mating induced an increase in tyrosine-hydroxylase positive neurons in the arcuate hypothalamus of BALB/c females, and suppressed c-Fos expression in these neurons in response to mating male chemosignals. This selective suppression of c-Fos response to mating male chemosignals was not apparent at earlier levels of the pregnancy-blocking neural pathway in the accessory olfactory bulb or corticomedial amygdala. Immunohistochemical staining revealed an increase in the number of tyrosine hydroxylase-positive neurons in the accessory olfactory bulb of BALB/c female mice following mating. However, increased dopamine-mediated inhibition in the accessory olfactory bulb is unlikely to account for the prevention of pregnancy block to the mating male, as tyrosine hydroxylase expression did not increase in females of the C57BL/6 strain, which show normal mate recognition. These findings reveal an association of mating with increased dopaminergic modulation in the pregnancy block pathway and support the hypothesis that mate recognition prevents pregnancy block by suppressing the activation of arcuate dopamine release.

An economic assessment of twin births in British dairy herds

The effect of twinning on the subsequent health, production and reproductive performance of dairy cattle was studied by analysing the data derived from 19,755 calvings which occurred during three years on 37 farms. The data formed part of the database of a veterinary practice operating the DAISY dairy cow recording scheme for its dairy farmer clients. The average twinning rate was 2.5 per cent. For first calf heifers the rate was 0.9 per cent, and the rate increased with increasing parity to over 5 per cent for cows calving for their sixth and subsequent lactations. Although they produced more milk than their contemporaries, twin-bearing cows suffered an increased incidence of retained placenta and vulval discharges and their calving to conception interval was extended by 33 days. Furthermore, 35 per cent of these cows were culled compared with 21 per cent of their contemporaries. The benefit of having more calves for sale was reduced owing to 15 per cent of them being born dead. It is calculated that producing twins resulted in an average loss of income of 74 pounds/cow, a deficit of 15 per cent compared with cows having single calves.