Effects of Integrated Vector Management in the Control of Malaria Infection: An Intervention Study in a Malaria Endemic Community in Nigeria

BACKGROUND/AIM

Malaria is a vector borne disease with high morbidity and mortality in endemic regions. In view to eliminating the disease, integrated vector and environmental hygiene practices have been advocated. There is paucity of studies on the effect of vector control measures on asymptomatic malaria infection which has been observed to be a reflection of malaria transmission.

METHODS

Longitudinal community-based intervention study carried out from October to December 2017. Study participants were 477 individuals living in 100 households selected by snow-balling sampling methods. Pre-intervention period included training of all heads of households on vector control methods. During the intervention period, each household received waste bins, two long lasting insecticide bed nets and had wire screen on their doors and windows; every household member was screened for malaria (antigen) using the pf rapid diagnostic test kits. Each household were monitored to ensure they comply with the environmental hygiene practices they were taught. Post-intervention malaria infection was obtained at 8 week being end of the intervention period.

RESULTS

Of the 100 households selected, 54.0% were from the lower social class, 45.0% middle class and only 1.0% upper class. Mean age [±] of the heads of the households was 37.1 ± 11.0 (range 16-68) years. There were 477 individuals recruited in the study from the 100 households; 234 (49.0%) females and 243 (51.0%) males; median age was 20.0 (range 1-100) years. Prevalence of malaria infection using mRDT during pre-intervention was 16.8% and an incidence of 1.3% post-intervention. There was 92.0% reduction in asymptomatic malaria infection showing marked reduction in malaria transmission in the study locale.

CONCLUSION

Some integrated vector control measures such as use of insecticide-treated net and sanitation were found effective methods for reducing malaria infection and transmission in endemic region.

Early Childhood Exposures to Fluorides and Child Behavioral Development and Executive Function: A Population-Based Longitudinal Study

It is important to both protect the healthy development and maintain the oral health of the child population. The study examined the effect of early childhood exposures to water fluoridation on measures of school-age executive functioning and emotional and behavioral development in a population-based sample. This longitudinal follow-up study used information from Australia's National Child Oral Health Study 2012-14. Children aged 5 to 10 y at baseline were contacted again after 7 to 8 y, before they had turned 18 y of age. Percent lifetime exposed to fluoridated water (%LEFW) from birth to the age 5 y was estimated from residential history and postcode-level fluoride levels in public tap water. Measures of children's emotional and behavioral development were assessed by the Strength and Difficulties Questionnaire (SDQ), and executive functioning was measured by the Behavior Rating Inventory of Executive Function (BRIEF). Multivariable regression models were generated to compare the associations between the exposure and the primary outcomes and controlled for covariates. An equivalence test was also conducted to compare the primary outcomes of those who had 100% LEFW against those with 0% LEFW. Sensitivity analysis was also conducted. A total of 2,682 children completed the SDQ and BRIEF, with mean scores of 7.0 (95% confidence interval, 6.6-7.4) and 45.3 (44.7-45.8), respectively. Those with lower %LEFW tended to have poorer scores of the SDQ and BRIEF. Multivariable regression models reported no association between exposure to fluoridated water and the SDQ and BRIEF scores. Low household income, identifying as Indigenous, and having a neurodevelopmental diagnosis were associated with poorer SDQ/BRIEF scores. An equivalence test confirmed that the SDQ/BRIEF scores among those with 100% LEFW were equivalent to that of those who had 0% LEFW. Exposure to fluoridated water during the first 5 y of life was not associated with altered measures of child emotional and behavioral development and executive functioning.

IgG1 pan-neurofascin antibodies define a severe and frequently fatal GBS-like neuropathy which responds to rituximab

Importance

Disease modifying treatments in Guillain-Barré syndrome (GBS) are not tailored to the different pathological subtypes. Strategies to prospectively identify sub-sets of patients with specific disease mecha- nisms and inform the use of non-standard therapies may lead to improved outcomes. We present a case series of seven patients with IgG1 subclass pan-neurofascin antibodies.

Results

All seven patients presented with a severe, acute or sub-acute onset, predominantly motor, autoimmune neuropathy. In all but one case the neuropathy was severe enough to warrant mechanical ventilation and intensive care support. Cranial nerve deficits were universally present and autonomic dysfunction was common. Although clinically resembling GBS, the response to standard GBS therapies was poor. Four patients received the B-cell depleting therapy rituximab and showed significant and sustained functional improvement within weeks of treatment. The three remaining patients who did not receive rituximab died.

Conclusions and Relevance

These observations should lead to a re-evaluation of the benefit of nodal/paranodal antibody testing in neuropathies with acute onset, GBS-like presentations. We believe that such testing should form part of the routine diagnostic work up of such patients, and that the identifica- tion of a distinct, serologically-defined disease sub-type should prompt consideration of more targeted immunotherapy. The apparent benefit of rituximab reported here should be evaluated in a well-conduc- ted clinical trial, the design of which must consider the potentially grave outcome in pan-neurofascin antibody-positive patients receiving only standard therapies.

simon.rinaldi@nhs.net

Fatigue and anxiety mediate the effect of dyspnea on quality of life in amyotrophic lateral sclerosis

Introduction: Dyspnea (or breathlessness) due to progressive neuromuscular respiratory failure is common in amyotrophic lateral sclerosis (ALS). It is associated with anxiety, depression and reduced quality of life (QoL). For effective treatment, it is essential to understand the relationships between dyspnea, anxiety, depression and QoL.Methods: The UK Trajectories of Outcomes in Neurological Conditions-ALS study (TONiC-ALS) collected self-report measures from patients with ALS. Ordinal scales were transformed to interval-scaled estimates by the Rasch Measurement model. They were subsequently included in a series of path models where the focal relationships were dyspnea to QoL and dyspnea to depression.Results: Path analyses using 1022 participants showed that 60.5% of the variance of QoL was explained by fatigue, anxiety, dyspnea and disability. For depression, 54.1% of the variance was explained by a model of these factors. Dyspnea played an important but mostly indirect role in influencing QoL and depressive symptoms. Disability was dominated by all other factors in the model.Discussion: Dyspnea in ALS influences quality of life and depression largely through indirect effects, principally acting via anxiety and fatigue. Recognition of this is essential for clinicians to understand where to intervene for greatest benefit. Researchers must be aware that studies of the effect of dyspnea on QoL and depression require path models, measuring both direct and indirect effects, as the impact of dyspnea is likely to be significantly miscalculated if only direct effects are assessed.

IgG1 pan-neurofascin antibodies identify a severe yet treatable neuropathy with a high mortality

OBJECTIVES

We aimed to define the clinical and serological characteristics of pan-neurofascin antibody-positive patients.

METHODS

We tested serum from patients with suspected immune-mediated neuropathies for antibodies directed against nodal/paranodal protein antigens using a live cell-based assay and solid-phase platform. The clinical and serological characteristics of antibody-positive and seronegative patients were then compared. Sera positive for pan-neurofascin were also tested against live myelinated human stem cell-derived sensory neurons for antibody binding.

RESULTS

Eight patients with IgG₁-subclass antibodies directed against both isoforms of the nodal/paranodal cell adhesion molecule neurofascin were identified. All developed rapidly progressive tetraplegia. Cranial nerve deficits (100% vs 26%), autonomic dysfunction (75% vs 13%) and respiratory involvement (88% vs 14%) were more common than in seronegative patients. Four patients died despite treatment with one or more modalities of standard immunotherapy (intravenous immunoglobulin, steroids and/or plasmapheresis), whereas the four patients who later went on to receive the B cell-depleting therapy rituximab then began to show progressive functional improvements within weeks, became seronegative and ultimately became functionally independent.

CONCLUSIONS

IgG₁ pan-neurofascin antibodies define a very severe autoimmune neuropathy. We urgently recommend trials of targeted immunotherapy for this serologically classified patient group.

Freezing kinetics and microstructure of ice cream from high-pressure-jet processing of ice cream mix

The effect of high-pressure-jet (HPJ) processing (0-500 MPa) on low-fat (6% fat) ice cream was studied by evaluating physiochemical properties before freezing, during dynamic freezing, and after hardening. An HPJ treatment ≥400 MPa decreased the density, increased the apparent size of colloidal particles, and altered rheological behavior (increased non-Newtonian behavior and consistency coefficients) of low-fat ice cream mix before freezing. During dynamic freezing, the particle size and consistency coefficient decreased but remained higher in 400 MPa-treated samples vs. non-HPJ-treated controls at the conclusion of freezing. The resulting ice creams (400 and 500 MPa-treated) had similar hardness values (3,372 ± 25 and 3,825 ± 14 g) and increased melting rates (2.91 ± 0.13 and 2.61 ± 0.31 g/min) compared with a control sample containing polysorbate 80 (3,887 ± 2 and 1.62 ± 0.25 g/min). Visualization of ice cream samples using transmission electron microscopy provided evidence of casein micelle and fat droplet disruption by HPJ treatment ≥400 MPa. In the 400 MPa-treated samples, a unique microstructure consisting of dispersed protein congregated around coalesced fat globules likely contributed to the altered physiochemical properties of this ice cream. High-pressure-jet processing can alter the microstructure, rheological properties, and hardness of a low-fat ice cream, and further modification of the formulation and processing parameters may allow the development of products with enhanced properties.

A modular testbed for mechanized spreading of powder layers for additive manufacturing

Powder bed additive manufacturing (AM) processes, including binder jetting (BJAM) and powder bed fusion (PBF), can manufacture complex three-dimensional components from a variety of materials. A fundamental understanding of the spreading of thin powder layers is essential to develop robust process parameters for powder bed AM and to assess the influence of powder feedstock characteristics on the subsequent process outcomes. Toward meeting these needs, this work presents the design, fabrication, and qualification of a testbed for modular, mechanized, multi-layer powder spreading. The testbed is designed to replicate the operating conditions of commercial AM equipment, yet features full control over motion parameters including the translation and rotation of a roller spreading tool and precision motion of a feed piston and the build platform. The powder spreading mechanism is interchangeable and therefore can be customized, including the capability for dispensing of fine, cohesive powders using a vibrating hopper. Validation of the resolution and accuracy of the machine and its subsystems, as well as the spreading of exemplary layers from a range of powder sizes typical of BJAM and PBF processes, are described. The precision engineered testbed can therefore enable the optimization of powder spreading parameters for AM and correlation to build process parameters in future work, as well as exploration of spreading of specialized powders for AM and other techniques.

Identifying Risk Factors for Anthracycline Chemotherapy-induced Phlebitis in Women with Breast Cancer: An Observational Study

AIMS

Anthracycline chemotherapy administered via a peripheral cannula results in severe anthracycline chemotherapy-induced phlebitis (ACIP) in about 20-30% of patients. Administering chemotherapy via a central venous catheter (CVC) prevents ACIP. However, CVCs are associated with an increased risk of thrombosis and sepsis. Our aim was to identify risk factors associated with severe ACIP and to provide evidence about the individual risk of developing symptoms.

MATERIALS AND METHODS

A prospective observational study of 263 women with breast cancer receiving peripheral administration of anthracycline chemotherapy at a UK cancer centre was conducted between May 2016 and January 2018. Data were collected at baseline and every 3 weeks following each chemotherapy treatment, using both healthcare professional- and participant-reported symptom assessments.

RESULTS

After three cycles of chemotherapy, 27% of participants experienced severe ACIP. Factors associated with symptom severity were identified as: arm used for chemotherapy administration, epirubicin dose, age, pre-existing hypertension, comorbidity, ethnic group and pain during chemotherapy administration. The sequence of arm used for chemotherapy administration was the single most significant factor (P < 0.001). When alternating arms were used no other risk factor was influential. Where alternating arms were not used, younger age and higher dose were associated with higher-grade symptoms, with age being more influential than dose. The cumulative effect of increasing symptom severity with repeated cycles was also identified (P < 0.001).

CONCLUSION

It is recommended that a CVC is not routinely required for women with breast cancer who have not undergone an axillary node clearance and receive chemotherapy in alternate arms. The need for a CVC for women who are planned to receive all anthracycline chemotherapy cycles in the same arm should be assessed in the light of peripheral venous access assessment and the key risk factors of age, dose and number of cycles.

Fit for purpose? A cross-sectional study to evaluate the acceptability and usability of HeadUp, a novel neck support collar for neurological neck weakness

The HeadUp collar (previously known as the Sheffield Support Snood) provides support for neck weakness caused by amyotrophic lateral sclerosis (ALS) and has shown to be superior to alternative options in a small cohort of patients from one single center. Here we report the assessment of the HeadUp collar in a larger cohort of patients, exploring the use in other neurological conditions and expanding to other centers across the UK and Ireland. An interventional cross-sectional study design was implemented to investigate the usability and acceptability of the HeadUp collar. A total of 139 patients were recruited for the study, 117 patients had a diagnosis of ALS and 22 patients presented with neck weakness due to other neurological conditions. Participants were assessed at baseline, fitted a HeadUp collar and followed-up one month later. The performance of the HeadUp collar was rated favorably compared to previously worn collars in terms of the ability to eat, drink and swallow. Findings suggest that the collar also permitted a more acceptable range of head movements whilst maintaining a good level of support. We conclude that the HeadUp collar is a suitable option for patients with neck weakness due to ALS and other neurological conditions.

African-Caribbean Cancer Consortium Scientific and Training Conference 2017

The sixth International African-Caribbean Cancer Consortium (AC3) Conference was held 6-9 October 2017 in Miami, Florida, U.S.A. The conference was open to all researchers, trainees, clinical and public health professionals, and community members, and served as an international hub for the United States, the Caribbean, and Africa. Sessions included AC3 collaboration meetings, cancer surveillance and research skills training workshops, and a community cancer prevention conference.

Potential for children with intellectual disability to engage in cognitive behaviour therapy: the parent perspective

BACKGROUND

This study aimed to obtain the opinions of parents and carers of children with intellectual disability (ID) as to whether cognitive behaviour therapy (CBT) could be useful for their children.

METHODS

A mixed qualitative and quantitative method was employed. Twenty-one carers of children aged 10 to 17 having borderline to moderate intellectual functioning responded to an online questionnaire. Participants were provided with information about CBT and asked to respond to open-ended questions. Quantitative data pertained to questions about their child's ability to identify and describe thoughts, feelings and behaviours. Thematic analysis of responses was conducted using an inductive method of identifying themes from the qualitative data collected.

RESULTS

Five themes emerged from the qualitative analysis: Emotional Attunement (i.e. parent's understanding and recognition of their child's emotions), Role of the Therapist (i.e. ways therapists could facilitate the intervention), Role of the Parent (i.e. ways parents could engage in the therapy process), Anticipated Obstacles (i.e. what may get in the way of the therapy) and Suggested Adaptations for Therapy (i.e. how CBT can be adapted to suit the needs of children with ID). Seventy-six per cent agreed that their child would be able to engage in CBT with assistance.

CONCLUSIONS

The majority of parents believed that CBT is an intervention that children with ID could engage in, provided the therapy is adapted, and the therapist accommodates their needs.

1.5mile run time and body mass predict 8mile loaded march performance, irrespective of sex

OBJECTIVES

To develop a statistical model to predict 8mile Loaded March (LM) performance and quantify differences in physical characteristics for men and women British Army Personnel.

DESIGN

135 trained soldiers (87 men; 48 women) completed two sessions, seven days apart.

METHODS

Session 1: Participants' stature, body mass, Fat Free Mass (FFM) [by dual-energy X-ray absorptiometry], Single Lift (SL), Water Can Carry (WCC), and 1.5mile run performance were measured. Session 2: Participants completed an 8mile LM, carrying 25kg (4miles paced and 4miles individual best effort). Sex differences were compared using independent samples t-tests and 8mile LM performance time was predicted using various multiple linear regression analysis: hierarchical forced entry multiple ordinary least squares, principal component and ordinary least products.

RESULTS

A combination of 1.5mile run time and body mass were the strongest predictors of 8mile LM time (R²=0.71; SEE=4.17min; p<0.001). Including stature, FFM, sex, SL score, or WCC score did not further improve predictions (p>0.05). Compared to women, men had faster mean 1.5mile run and LM times, greater body mass and total FFM and higher SL and WCC scores (p<0.001), however some women outperformed men.

CONCLUSION

1.5mile run time and body mass predict 8mile LM performance with no further improvement gained in the model by including sex as a variable.

Medical Databases

An entity relationship level design is given for medical information systems. This design is aimed at-conceptual-integration of hospital information systems, patient history record keeping systems, future diagnosis systems, etc. In particular, it lays out a foundation for distributed databases.

Evaluation of Positive Contrast Arthrography in Canine Cranial Cruciate Ligament Disease

Arthrographic and intraoperative evaluations of stifles affected with cranial cruciate disease were compared. Arthrography did not appear to be helpful in predicting cranial cruciate ligament pathology. The caudal cruciate ligament was consistently not visualized in the arthrograms and was normal at surgery. The menisci were visualized consistently in the arthrograms, but conclusions could not be made as to the benefit of arthrography in predicting meniscal pathology. Arthrography was not helpful in predicting joint capsule and femoral articular surface pathology. Survey radiographic evaluation was better than arthrography in evaluating joint pathology. When cruciate injury is suspected, after history and physical examination, survey radiographs are better than positive contrast arthrograms at supporting the diagnosis.

Positive contrast arthrography was evaluated as a diagnostic aid in canine cranial cruciate ligament disease. It did not appear to be useful in predicting joint pathology. With arthrography, both menisci could be visualized and evaluated for abnormalities. Joint effusion and presence of osteophytes evaluated on survey radiographs was better than arthrography in evaluating joint pathology.

Comparison of the ecarin chromogenic assay and diluted thrombin time for quantification of dabigatran concentrations

Essentials Routine monitoring is unnecessary but measuring dabigatran levels is helpful in certain situations. We compared ecarin chromogenic assay (STA-ECA-II) and dilute thrombin time (dTT) in patient samples. Both tests provided accurate measurements over a wide range of dabigatran concentrations. Adoption of STA-ECA-II and dTT into routine clinical practice will improve patient care.

SUMMARY

Background Although routine coagulation monitoring is unnecessary, measuring plasma dabigatran concentrations can be useful for detecting drug accumulation in renal failure or overdose, assessing the contribution of dabigatran to serious bleeding, planning the timing of urgent surgery or intervention, or determining the suitability for thrombolytic therapy for acute ischemic stroke. Dabigatran concentrations can be quantified using chromogenic or clot-based tests, such as the ecarin chromogenic assay (ECA) and the diluted thrombin time (dTT), respectively. Objective The purpose of this study was to compare the results of these assays with dabigatran concentrations measured by the reference standard of mass spectrometry in samples from 50 dabigatran-treated patients collected at peak and trough after at least 4 months of drug intake. Methods Drug levels measured with either the STA Ecarin Chromogenic Assay-II (STA-ECA-II) or dTT were linearly correlated with those determined by mass spectrometry over a wide range of concentrations. Results and Conclusions For detection of levels below 50 ng mL-1 both tests have specificities of at least 96%, suggesting that they accurately detect even low levels of drug. Therefore, regardless of whether a chromogenic or clot-based platform is preferred, the STA-ECA-II and dTT are useful tests for measuring dabigatran concentrations. Unfortunately, neither test is licensed by the United States Food and Drug Administration. Although approved in other jurisdictions, the dTT and STA-ECA-II are not widely or rapidly available in most hospitals. Therefore, cooperation between regulators and hospitals is urgently needed to render these tests readily available to inform patient care.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Mid-trimester residual cervical length and the risk of preterm birth in pregnancies after abdominal radical trachelectomy: a retrospective analysis

OBJECTIVE

To investigate the association between mid-trimester residual cervical length (CL) and the risk of preterm birth in pregnancies after abdominal radical trachelectomy (RT).

DESIGN

Retrospective cohort study.

SETTING

University hospital.

POPULATION

A total of 33 deliveries after 22 weeks' gestation in 30 women who underwent abdominal RT including prophylactic cervical cerclage and perinatal care between January 2002 and May 2016.

METHODS

The association between mid-trimester residual CL (the distance between the cerclage and the external cervical os) and gestational age at delivery was investigated. Receiver-operating characteristics (ROC) curve analysis was performed to estimate the optimal cut-off values of the mid-trimester residual CL for the prediction of preterm birth.

MAIN OUTCOME MEASURES

Preterm birth before 34 weeks' gestation.

RESULTS

Mid-trimester residual CL showed a significant correlation with gestational age at delivery (r = 0.36, P < 0.05). There was a significant difference in residual CL between women who did and those who did not give birth before 34 weeks (P < 0.05). Mid-trimester residual CL < 13 mm was a good predictor of birth before 34 weeks, with a sensitivity of 67%, specificity of 75%, positive predictive value of 55% and negative predictive value of 86% (area under ROC curve, 0.75).

CONCLUSIONS

Mid-trimester residual CL is significantly correlated with gestational age at delivery. Residual CL assessment could be used to reassure physicians and women that there is only a small chance of preterm birth in pregnancies after abdominal RT.

TWEETABLE ABSTRACT

Mid-trimester residual cervical length is a good predictor of preterm birth after radical trachelectomy.

Combined Carotid Endarterectomy and Vertebral Transposition or Bypass for Cerebral and Vertebrobasilar Insufficiency

The purpose of this report is to determine the indication for a combined carotid endarterectomy and vertebral transposition or bypass in patients who have transient ischemic attack (TIA) or stroke and intractable vertebral ischemic symptoms of dizziness and syncope. A retrospective review was made on 49 patients with the combined symptoms of generalized global ischemia, TIA, amaurosis fugax or stroke, and vertebral basilar insufficiency manifested as syncope, intractable dizziness, and unsteady gait. Diagnostic studies employed were carotid duplex scan, computed tomography (CT) or magnetic resonance imaging (MRI) brain scan, xenon blood flow study, transcranial Doppler analysis, electronystagmography, electroencephalography, and cardiac arrhythmia evaluation. Twenty-one of 49 patients (43%) with internal carotid occlusion underwent carotid endarterectomy plus vein patch or internal carotid to external carotid onlay patch angioplasty and proximal vertebral to common carotid artery transposition (n: 19), or bypass (n:2). Twenty-seven of 49 patients (57%) received carotid endarterec tomy and vertebral transposition (n:27) or bypass (n:2) for carotid and vertebral stenosis. There was no operative mortality, stroke, or neurologic deficit following the carotid and vertebral operations in the 49 patients. Six patients had transient palpebral ptosis. Postoperative cerebral angiogram or magnetic resonance angiogram showed patent vertebral arteries. All 49 patients have resolution of TIA, dizziness, syncope, and unsteady gait. Combined carotid endarterectomy and vertebral transposition or bypass should be considered in patients with solitary, dominant, or bilateral vertebral artery critical stenosis whose symptoms are unrelated to vestibular, cardiac, or seizure disorders and lateralized TIA or stroke.

Cell-specific abnormalities of glutamate transporters in schizophrenia: sick astrocytes and compensating relay neurons?

Excitatory amino-acid transporters (EAATs) bind and transport glutamate, limiting spillover from synapses due to their dense perisynaptic expression primarily on astroglia. Converging evidence suggests that abnormalities in the astroglial glutamate transporter localization and function may underlie a disease mechanism with pathological glutamate spillover as well as alterations in the kinetics of perisynaptic glutamate buffering and uptake contributing to dysfunction of thalamo-cortical circuits in schizophrenia. We explored this hypothesis by performing cell- and region-level studies of EAAT1 and EAAT2 expression in the mediodorsal nucleus of the thalamus in an elderly cohort of subjects with schizophrenia. We found decreased protein expression for the typically astroglial-localized glutamate transporters in the mediodorsal and ventral tier nuclei. We next used laser-capture microdissection and quantitative polymerase chain reaction to assess cell-level expression of the transporters and their splice variants. In the mediodorsal nucleus, we found lower expression of transporter transcripts in a population of cells enriched for astrocytes, and higher expression of transporter transcripts in a population of cells enriched for relay neurons. We confirmed expression of transporter protein in neurons in schizophrenia using dual-label immunofluorescence. Finally, the pattern of transporter mRNA and protein expression in rodents treated for 9 months with antipsychotic medication suggests that our findings are not due to the effects of antipsychotic treatment. We found a compensatory increase in transporter expression in neurons that might be secondary to a loss of transporter expression in astrocytes. These changes suggest a profound abnormality in astrocyte functions that support, nourish and maintain neuronal fidelity and synaptic activity.

Liver Transplantation in a Patient With CD40 Ligand Deficiency and Hyper-IgM Syndrome: Clinical and Immunological Assessments

Monoclonal antibodies that disrupt CD40-CD40 ligand (CD40L) interactions are likely to have use in human transplantation. However, the extent of the immunosuppressive effects of CD40-CD40L blockade in humans is unknown. Hyper-IgM syndrome (HIGM) is a rare primary immunodeficiency syndrome characterized by defects in the CD40-CD40L pathway, severe immune deficiency (IgG), and high or normal IgM levels. However, the effects of CD40L deficiency on T- and natural killer (NK)-cell function is not established. Here, we present a patient with HIGM syndrome who underwent liver transplantation for hepatitis C virus infection. Posttransplantation, NK-cell antibody-dependent cytokine release (γ-interferon) to alloantigens and T cell responses to viral antigens and mitogens were assessed and showed normal CD4⁺ , CD8⁺ , and NK-cell responses. We also examined antibody-dependent cellular cytotoxicity against a CD40⁺ and HLA-expressing cell line. These experiments confirmed that the patient's NK cells were equivalent to those of normal subjects in mediating antibody-dependent cellular cytotoxicity despite the absence of CD40-CD40L interactions. Mitogenic stimulation of the patient's peripheral blood mononuclear cells showed no expression of CD40L on T and NK cells compared with increased expression in normal subjects. Taken together, these data suggest that absence of CD40L expression is responsible for aberrant B cell immunity but had little impact on NK- and T cell immune responses in vitro.

Association Between Time to Reperfusion and Outcome Is Primarily Driven by the Time From Imaging to Reperfusion

Background and Purpose—

A progressive decline in the odds of favorable outcome as time to reperfusion increases is well known. However, the impact of specific workflow intervals is not clear.

Methods—

We studied the mechanical thrombectomy group (n=103) of the prospective, randomized REVASCAT (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset) trial. We defined 3 workflow metrics: time from symptom onset to reperfusion (OTR), time from symptom onset to computed tomography, and time from computed tomography (CT) to reperfusion. Clinical characteristics, core laboratory-evaluated Alberta Stroke Program Early CT Scores (ASPECTS) and 90-day outcome data were analyzed. The effect of time on favorable outcome (modified Rankin scale, 0–2) was described via adjusted odds ratios (ORs) for every 30-minute delay.

Results—

Median admission National Institutes of Health Stroke Scale was 17.0 (14.0–20.0), reperfusion rate was 66%, and rate of favorable outcome was 43.7%. Mean (SD) workflow times were as follows: OTR: 342 (107) minute, onset to CT: 204 (93) minute, and CT to reperfusion: 138 (56) minute. Longer OTR time was associated with a reduced likelihood of good outcome (OR for 30-minute delay, 0.74; 95% confidence interval [CI], 0.59–0.93). The onset to CT time did not show a significant association with clinical outcome (OR, 0.87; 95% CI, 0.67–1.12), whereas the CT to reperfusion interval showed a negative association with favorable outcome (OR, 0.72; 95% CI, 0.54–0.95). A similar subgroup analysis according to admission ASPECTS showed this relationship for OTR time in ASPECTS<8 patients (OR, 0.56; 95% CI, 0.35–0.9) but not in ASPECTS≥8 (OR, 0.99; 95% CI, 0.68–1.44).

Conclusions—

Time to reperfusion is negatively associated with favorable outcome, being CT to reperfusion, as opposed to onset to CT, the main determinant of this association. In addition, OTR was strongly associated to outcome in patients with low ASPECTS scores but not in patients with high ASPECTS scores.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01692379.

A morphological and immunohistochemical evaluation of gastric carcinoma in the Western Cape province of South Africa

BACKGROUND

Gastric resections for carcinoma are common, but gastric carcinoma in South Africa, and particularly within the Western Cape province, has not been well documented.

METHOD

The objective of the study was to immunohistochemically evaluate HER2/ neu overexpression, determine aberrations in β-catenin and epithelial-cadherin (E-cadherin) expression, and correlate these fi ndings with gastric carcinoma subtypes.

RESULTS

Ninety-seven gastric adenocarcinoma resections were morphologically categorised as intestinal-, diffuse- or mixed-type adenocarcinomas, and immunohistochemically stained for β-catenin, E-cadherin (extracellular and cytoplasmic domains) and HER2/neu. The results of staining were compared between the subtypes for statistically signifi cant differences. All 97 cases were confi rmed as gastric adenocarcinomas, with 39 (40%) intestinal- type, 51 (53%) diffuse-type, and 7 (7%) mixed-type tumours identifi ed. Patient ages ranged from 18-84 years. HER2/neu was overexpressed in 12 (12%) cases, with intestinal-type morphology (p = 0.017) reported in nine. Fourteen cases (14%) demonstrated abnormal β-catenin localisation. Aberrant E-cadherin (extracellular domain) localisation occurred in 36 (37%) cases. Diffuse-type morphology was associated with a signifi cantly high proportion (p = ≤ 0.001). Aberrant E-cadherin (cytoplasmic domain) localisation occurred in 7 (7%) cases. A signifi cantly high proportion (six of these cases) (p = 0.023) of these was diffuse-type morphology. Eleven (11%) adenocarcinomas occurred in patients aged ≤ 40 years, with intestinal morphology reported in nine of these 11. Aberrant E-cadherin (extracellular domain) localisation was noted in seven of the 11, a signifi cantly high proportion when compared to that in the older patients (p = 0.025).

CONCLUSION

Distinct immunomorphological correlations are apparent in tumours demonstrating HER2/neu overexpression or abnormal E-cadherin localisation. Intestinal morphology, poor differentiation and E-cadherin abnormalities are frequently demonstrated in tumours occurring in younger individuals.