Obstetric outcomes in women with rheumatic disease and COVID-19 in the context of vaccination status.

OBJECTIVE: To describe obstetric outcomes based on COVID-19 vaccination status, in women with rheumatic and musculoskeletal diseases (RMDs) who developed COVID-19 during pregnancy. METHODS: Data regarding pregnant women entered into the COVID-19 Global Rheumatology Alliance registry from 24 March 2020-25 February 2022 were analysed. Obstetric outcomes were stratified by number of COVID-19 vaccine doses received prior to COVID-19 infection in pregnancy. Descriptive differences between groups were tested using the chi-squared or Fisher's exact test. RESULTS: There were 73 pregnancies in 73 women with RMD and COVID-19. Overall, 24.7% (18) of pregnancies were ongoing, while of the 55 completed pregnancies, 90.9% (50) of pregnancies resulted in livebirths. At the time of COVID-19 diagnosis, 60.3% (n = 44) of women were unvaccinated, 4.1% (n = 3) had received one vaccine dose while 35.6% (n = 26) had two or more doses. Although 83.6% (n = 61) of women required no treatment for COVID-19, 20.5% (n = 15) required hospital admission. COVID-19 resulted in delivery in 6.8% (n = 3) of unvaccinated women and 3.8% (n = 1) of fully vaccinated women. There was a greater number of preterm births (PTB) in unvaccinated women compared with fully vaccinated 29.5% (n = 13) vs 18.2% (n = 2). CONCLUSIONS: In this descriptive study, unvaccinated pregnant women with RMD and COVID-19 had a greater number of PTB compared with those fully vaccinated against COVID-19. Additionally, the need for COVID-19 pharmacological treatment was uncommon in pregnant women with RMD regardless of vaccination status. These results support active promotion of COVID-19 vaccination in women with RMD who are pregnant or planning a pregnancy.

Advances in treatment of axial spondyloarthritis are associated with improved patient outcomes: data from the Ankylosing Spondylitis Registry of Ireland (ASRI).

The Ankylosing Spondylitis Registry of Ireland (ASRI) captures both radiographic and non-radiographic axial spondyloarthritis (axSpA) in a large, well characterised cohort. This is a valuable resource for studies in therapeutics and burden of disease, following a period of rapid change in the field of axSpA. This study aims to perform a focused analysis on patient outcomes and pattern of medication usage in axSpA. This is a cross-sectional study of registry data on 885 patients with confirmed axSpA as per the ASAS criteria for axSpA, as diagnosed by a Rheumatologist. Analysis was performed using IBM SPSS version 26. Patients were analysed on the basis of treatment categorised as: no medication, NSAIDs, biologics or combination therapy. Statistical significance was indicated by p value of < 0.05. Currently 885 patients are enrolled in the ASRI, made up of 72.5% (642) males and 26.9% (238) females. The majority of the cohort was categorized as radiographic axSpA 78.3% (693), with 21.7% (192) meeting criteria for non-radiographic disease. Overall 40.6% (359) reported at least one comorbidity. Older age was associated with no medications compared to those on biologic therapy (50.3 vs 45, p = 0.01). Lower levels of disease activity and higher quality of life were noted in those on biologics as compared to NSAIDs alone. This analysis provides detailed epidemiological data on axSpA from a large national registry. These results detail significant differences in prescribing patterns and impact on patient outcomes in axSpA. Ongoing development of registries provides a valuable insight into the real-world effects of axSpA.

The genetic backbone of ankylosing spondylitis: how knowledge of genetic susceptibility informs our understanding and management of disease.

Ankylosing spondylitis (AS) is a seronegative, chronic inflammatory arthritis with high genetic burden. A strong association with HLA-B27 has long been established, but to date its contribution to disease aetiology remains unresolved. Recent insights through genome wide studies reveal an increasing array of immunogenetic risk variants extraneous to the HLA complex in AS cohorts. These genetic traits build a complex profile of disease causality, highlighting several molecular pathways associated with the condition. This and other evidence strongly implicates T-cell-driven pathology, revolving around the T helper 17 cell subset as an important contributor to disease. This prominence of the T helper 17 cell subset has presented the opportunity for therapeutic intervention through inhibition of interleukins 17 and 23 which drive T helper 17 activity. While targeting of interleukin 17 has proven effective, this success has not been replicated with interleukin 23 inhibition in AS patients. Evidence points to significant genetic diversity between AS patients which may, in part, explain the observed refractoriness among a proportion of patients. In this review we discuss the impact of genetics on our understanding of AS and its relationship with closely linked pathologies. We further explore how genetics can be used in the development of therapeutics and as a tool to assist in the diagnosis and management of patients. This evidence indicates that genetic profiling should play a role in the clinician's choice of therapy as part of a precision medicine strategy towards disease management.

COVID-19: What Do Rheumatologists Need to Know?

PURPOSE OF REVIEW: Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) emerged in December 2019, rapidly reaching global pandemic proportions. Coronavirus disease 2019 (COVID-19) has presented unique challenges to the rheumatology community. It is known that many individuals with rheumatic disease are at increased risk of severe disease from other infections, sparking a similar fear for COVID-19. In addition, medications routinely used in rheumatology practice are being trialled as treatments, with the potential for drug shortages for rheumatology patients. RECENT FINDINGS: Underlying comorbidities and active disease are associated with worse COVID-19 outcomes in patients with rheumatic disease. Tocilizumab and hydroxychloroquine have not proven to be effective treatments in the management of COVID-19. Telehealth has become an essential tool for the rheumatology community to monitor patients during the pandemic. In this article, we summarise the available COVID-19 evidence that is of relevance to the rheumatology community. We discuss the risk of contracting COVID-19 in individuals with rheumatic disease, along with presenting features and clinical outcomes. We provide an overview of the treatments for COVID-19 which have significance for rheumatology. We highlight published recommendations which can guide our management of rheumatic disease populations during this pandemic. Finally, we discuss the challenges in delivering effective care virtually and present methods and tools which could be adapted for use.

Discrete choice experiment for eliciting preference for health services for patients with ALS and their informal caregivers.

BACKGROUND: Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative condition with a mean life expectancy of 3 years from first symptom. Understanding the factors that are important to both patients and their caregivers has the potential to enhance service delivery and engagement, and improve efficiency. The Discrete Choice Experiment (DCE) is a stated preferences method which asks service users to make trade-offs for various attributes of health services. This method is used to quantify preferences and shows the relative importance of the attributes in the experiment, to the service user. METHODS: A DCE with nine choice sets was developed to measure the preferences for health services of ALS patients and their caregivers and the relative importance of various aspects of care, such as timing of care, availability of services, and decision making. The DCE was presented to patients with ALS, and their caregivers, recruited from a national multidisciplinary clinic. A random effects probit model was applied to estimate the impact of each attribute on a participant's choice. RESULTS: Patients demonstrated the strongest preferences about timing of receiving information about ALS. A strong preference was also placed on seeing the hospice care team later rather than early on in the illness. Patients also indicated their willingness to consider the use of communication devices. Grouping by stage of disease, patients who were in earlier stages of disease showed a strong preference for receipt of extensive information about ALS at the time of diagnosis. Caregivers showed a strong preference for engagement with healthcare professionals, an attribute that was not prioritised by patients. CONCLUSIONS: The DCE method can be useful in uncovering priorities of patients and caregivers with ALS. Patients and caregivers have different priorities relating to health services and the provision of care in ALS, and patient preferences differ based on the stage and duration of their illness. Multidisciplinary teams must calibrate the delivery of care in the context of the differing expectations, needs and priorities of the patient/caregiver dyad.

Behaviour change interventions targeting physical activity in adults with fibromyalgia: a systematic review.

Physical activity (PA) and exercise programmes are recommended for the management of fibromyalgia. Despite positive effects on symptoms and function, PA promotion remains a significant clinical challenge. Behaviour change theories and techniques are recommended as part of complex health interventions; their integration into interventions aimed at PA behaviour in people with fibromyalgia is not known. This review explored behaviour change interventions targeting PA in adults with fibromyalgia. A systematic review was conducted; randomized and quasi-randomized controlled trials with at least one behaviour change intervention targeting PA were included. MEDLINE/OVID, EMBASE, PEDro, PsychINFO, CINAHL, Scopus, Web of Science, the Cochrane Central Register of Controlled Trials and relevant conference abstracts were searched. Two authors independently screened studies for inclusion and performed risk of bias assessments. Articles were reviewed for their use of behaviour change theory and behaviour change techniques (BCTs). The search identified 2491 records, from which eight studies (1416 participants) were included. PA and exercise behaviours were the primary focus of four interventions and were components of broader interventions in four studies. Behaviour change theories informed four interventions. Thirty-two different BCTs were used across studies. Five studies reported improvements in PA either post-intervention or at follow-up. Two studies used objective PA measures and seven studies used self-report measures. Short-term benefits in pain, quality of life, and physical fitness were also observed. Behaviour change interventions targeting PA in people with fibromyalgia have had limited success to date. With significant variations in intervention designs, the optimal intervention remains unknown.

The Effect of Alcohol Consumption on Clinical Outcomes and Structural Damage in Patients with Axial Spondyloarthritis: A Systematic Literature Review and Meta-Analysis.

OBJECTIVE: To systematically review the effects of alcohol consumption (AC) on disease-specific outcomes in axial spondyloarthritis (axSpA). METHODS: A systematic review of observational studies on axSpA and AC was conducted. Multiple electronic databases were searched for keywords. Two investigators reviewed articles to assess for inclusion eligibility. The Joanna Briggs Institute Critical Appraisal checklist was employed to evaluate the risk of bias. Standardized mean differences (SMD) were used to synthesize the data and I² was used to ascertain heterogeneity. Spinal pain, disease activity as measured by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS), and spinal radiographic progression based on the modified Stokes Ankylosing Spondylitis Spinal Score (mSASSS) were examined as outcomes. RESULTS: Search strategy identified 703 records; 13 articles were assessed for eligibility. Five studies (n = 3858) were included. Compared to non-consumers, axSpA patients who consumed alcohol had lower BASDAI (SMD -0.19, 95% CI -0.37 to -0.02, I²=72.5%) and lower spinal pain (SMD -0.17, 95% CI -0.24 to -0.09, I² = 0%). No significant difference was found for ASDAS (SMD -0.19, 95% CI -0.39 to 0.00, I² = 36%). One cohort study on the spinal radiographic progression indicated greater radiographic progression among consumers (SMD 0.35, 95% CI 0.08 to 0.62). CONCLUSION: AC appears to be associated with lower disease activity and spinal pain. However, these findings may reflect confounding by sex and smoking. Further longitudinal cohort studies with standardized measures for AC are warranted to assess the direction of alcohol's effect on structural damage progression.

Characteristics and burden of disease in patients with radiographic versus non-radiographic axial spondyloarthritis in the ASRI cohort.

BACKGROUND: Axial spondyloarthritis (axSpA) comprises patients with both radiographic and non-radiographic features. Previous studies have shown similar burden of disease between these two groups. AIMS: The Ankylosing Spondylitis Registry of Ireland (ASRI) was formed with the objective to measure the burden of axial spondyloarthritis in the population and identify early predictors of a poor outcome. For this analysis, the ASRI database was used to compare the characteristics and burden of disease in patients with radiographic versus non-radiographic axial spondyloarthritis. METHODS: Patients with radiographic axial spondyloarthritis (r-axSpA) were defined as those with X-ray evidence of sacroiliitis. Patients with non-radiographic axial spondyloarthritis (nr-axSpA) were defined as having MRI evidence of sacroiliitis but no X-ray evidence of sacroiliitis. RESULTS: In total, 764 patients were included. Analysis of radiographic status showed 88.1% (n = 673) of patients with r-axSpA and 11.9% (n = 91) with nr-axSpA (Table 1). Patients with nr-axSpA were younger (41.3 vs. 46.6 years, p < 0.01), had shorter disease duration (14.8 vs. 20.2 years, p < 0.01) and had lower proportion of males (66.6% vs. 78.4%, p = 0.02) with lower frequency of HLA-B27 positivity (73.6% vs. 90.5%, p < 0.01). The nr-axSpA group had lower BASDAI (3.37 vs. 4.05, p = 0.01), BASFI (2.46 vs. 3.88, p < 0.01), BASMI (2.33 vs. 4.34, p < 0.01), ASQoL (5.2 vs. 6.67, p = 0.02) and HAQ scores (0.38 vs. 0.57, p < 0.01). There were no significant differences in the prevalence of extra-musculoskeletal manifestations or use of medications. CONCLUSIONS: This study provides evidence to suggest that the burden of disease is less in patients with non-radiographic axial spondyloarthritis than radiographic axial spondyloarthritis.

Enhanced Type 1 Interferon Signature in Axial Spondyloarthritis Patients Unresponsive to Secukinumab Treatment.

OBJECTIVE: Axial spondyloarthritis (axSpA) is an inflammatory disease in which overactive interleukin (IL)-17A-producing cells are implicated in a central role. Therapeutically, biologics that target IL-17A, such as secukinumab, have demonstrated improved clinical outcomes. Despite this translational success, there is a gap in understanding why some patients with axSpA do not respond to IL-17A-blocking therapy. Our study aims to discriminate immune profiles between secukinumab responders (SEC-R) and nonresponders (SEC-NR). METHODS: Peripheral blood mononuclear cells were collected from 30 patients with axSpA before and 24 weeks after secukinumab treatment. Frequency of CD4+ subsets were compared between SEC-R and SEC-NR using flow cytometry. Mature CD45RO+CD45RA-CD4+ T cells were fluorescent-activated cell sorting sorted, and RNA was measured using NanoString analysis. RESULTS: SEC-NR had an increased frequency of IL-17A-producing RORγt+CD4+ T cells compared to healthy controls before secukinumab treatment (P < 0.01). SEC-NR had a significant increase of CXCR3+ CD4+ T cells before secukinumab treatment compared to SEC-R (P < 0.01). Differentially expressed gene analysis revealed up-regulation of type 1 interferon (IFN)-regulated genes in SEC-NR patients compared to SEC-R patients after receiving the biologic. SEC-R patients had an up-regulated cytotoxic CD4+ T cell gene signature before receiving secukinumab treatment compared to SEC-NR patients. CONCLUSION: The increased frequency of IL-17A-producing cells in SEC-NR patients suggests a larger inflammatory burden than SEC-R patients. With treatment, SEC-NR patients have a more pronounced type 1 IFN signature than SEC-R patients, suggesting a mechanism contributing to this larger inflammatory burden. The results point toward more immune heterogeneity in axSpA than has been recognized and highlights the need for precision therapeutics in this disease.

Pregnancy & neonatal outcomes in spondyloarthritis.

Limited research has been conducted on the impact of spondylitis (SpA) on fertility, but some studies suggest a higher risk of subfertility in women with SpA compared to the general population. Factors associated with impaired fertility in SpA include pain, fatigue, stiffness, functional disorders, depression, anxiety, negative body image, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) preconceptionally, while TNF alpha inhibitors may play a role in improving fertility in certain cases. There has been a recent increase in clinical research focused on pregnancy outcomes in SpA. However, clear trends in terms of risk of pregnancy and fetal complications have been slow to emerge and many questions remain for women with SpA planning a pregnancy. This article discusses the current evidence for risk of specific pregnancy and fetal complications in women with axial and psoriatic SpA.

Effectiveness of Ultrasound-guided versus Landmark-based Glucocorticoid Injection in the Treatment of First Carpometacarpal Joint Osteoarthritis.

Background: Osteoarthritis is a debilitating degenerative disease more pronounced in elderly affecting many joints. The first carpometacarpal joint (CMC1) is commonly affected. Pain is the major complaint, which can impact patient's daily activities. Intra-articular glucocorticoid injection can be considered if conservative measures fail and ultrasound guided injection might be superior to the traditional anatomic landmark-guided technique. Objective: The aim of this study is to evaluate the effectiveness of ultrasound-guided versus landmark-based approach to intra-articular CMC1 injection using the Australian Canadian osteoarthritis hand index (AUSCAN). Methods: Adult patients diagnosed with symptomatic CMC1 osteoarthritis who failed conservative measures were enrolled. In this prospective observational cohort study, utilizing a convenience sample, intra-articular corticosteroid injection was administered either by ultrasound-guided technique or landmark-based approach. Pain, stiffness and function in 10-points scale at baseline, 6 and 12 weeks were collected and analyzed using descriptive analysis. Results: There were 33 patients enrolled. Mean age was 63 years, with females making up the majority of participants (n = 28, 84.8%). Mean duration of CMC1 pain was 10 months (SD=2.5) up to the point of receiving the injection. Ultrasound guided injection was performed in 60.6% (n=20), while 39.4% (n=13) had the landmark approach. Both groups achieved a statistically and clinically significant level of change in AUSCAN score at week 6 (P≤ 0.05) but with a recurrence of symptoms at week 12 (P ≤ 0.05). At both intervals the AUSCAN scores were better than baseline (P ≤ 0.05). There was no difference between the two groups regarding baseline pain VAS score (mean ultrasound group= 6.6 vs landmark group= 7.5; P = 0.18). No significant differences were identified between two groups in terms of changes from baseline to 6, 12 and between 6 to 12 weeks in pain, stiffness and hand function (P > 0.05). Conclusion: No difference was found between the ultrasound-guided and landmark-based approaches for CMC1 injection on pain score, stiffness, or function.

Asymmetric cortical surface area and morphology changes in mesial temporal lobe epilepsy with hippocampal sclerosis.

PURPOSE: To date, magnetic resonance imaging (MRI)-based studies of the cerebral cortex in mesial temporal lobe epilepsy (MTLE) have focused primarily on investigating cortical volume and thickness. However, volume is a composite of surface area and thickness, each reflecting distinct neurobiologic and genetic processes. The goal of this study was to investigate cerebral cortex (1) surface area, (2) surface geometric distortion, and (3) thickness in MTLE with hippocampal sclerosis (HS). METHODS: Seventy patients with "sporadic" unilateral MTLE + HS and 40 healthy controls underwent T(1) -weighted MRI. Processing MR images using an automated cortical surface reconstruction method (FreeSurfer), we quantified cortical surface area, surface geometric distortion (metric distortion), and thickness at each vertex across the entire cortex. Differences between patients and controls were determined using generalized linear models. Separate linear regression models were employed to assess the relationship between cortical surface area and hippocampal volume as well as a series of important clinical features of the condition. KEY FINDINGS: We detected an asymmetric reduction in cortical surface area, predominantly in ipsilateral mesial and anterior temporal lobe subregions, of patients with MTLE + HS. Changes in surface geometric features were also evident and closely mirrored surface area patterns. In contrast, cortical thinning appeared dispersed across the cortex bilaterally. The regression models revealed that ipsilateral hippocampal volume was a significant predictor of temporal lobe surface area changes. SIGNIFICANCE: Our findings indicate that contraction in surface area, rather than cortical thinning, explains ipsilateral mesial and anterior temporal lobe atrophy in patients with MTLE with HS. Furthermore, the alterations in surface geometry indicate folding abnormality involving the same regions. Cortical surface changes may represent sequelae of the disease or deviant cortical development.

Central Obesity in Axial Spondyloarthritis: The Missing Link to Understanding Worse Outcomes in Women?

OBJECTIVE: To determine (1) the prevalence of central obesity in axial spondyloarthritis (axSpA) and its effect on disease-related outcomes and (2) how this differs between sexes. METHODS: Data were extracted from the Ankylosing Spondylitis Registry of Ireland. Patients with physical measurements for the calculation of anthropometric measures were included. BMI and waist-to-hip ratio (WHR) were used to compare classifications of obesity. Comparison analyses based on sex and central obesity were carried out. Multivariate analysis examined the effects of these factors on the following patient-reported outcomes: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire, and the Health Assessment Questionnaire (HAQ). RESULTS: In total, 753 patients were included in the analysis. Of these patients, 29.6% (n = 223) were classified as obese based on their BMI, and 41.3% (n = 311) were classified as centrally obese according to the WHR. The prevalence of central obesity was significantly higher among women with axSpA compared to men (71.6% vs 29.9%, P < 0.01). Central obesity had a clear effect on patient outcomes, regardless of sex. Presence of central obesity was associated with significantly worse BASFI scores (P < 0.01), HAQ scores (P < 0.01), and ASQoL questionnaire scores (P = 0.01), with a nonsignificant trend toward worse BASDAI scores (P = 0.07). CONCLUSION: There was a high prevalence of central obesity as assessed by the WHR in axSpA, most notably among women with axSpA. This modifiable comorbidity was significantly associated with worse quality of life, greater impairment of functional ability, and a trend toward worse disease activity. Regular use of the WHR to screen for central obesity as part of an axSpA assessment would provide an opportunity for prompt identification and intervention for at-risk patients.

Tender to touch-Prevalence and impact of concomitant fibromyalgia and enthesitis in spondyloarthritis: An ancillary analysis of the ASAS PerSpA study.

OBJECTIVES: The primary objective was to evaluate the co-existence of fibromyalgia (FM) & enthesitis in individuals with spondyloarthritis (SpA). Secondary objectives were to identify clinical features associated with the presence of FM in enthesitis and analyse sex-specific differences. METHODS: This was an ancillary analysis of the Assessment of SpondyloArthritis International Society Peripheral Involvement in SpA (PerSpA) study. Enthesitis was defined as the presence of enthesitis ever. Clinical FM was defined as the rheumatologist's confirmation of the presence of FM. A score of≥5/6 on the Fibromyalgia Rapid Screening Test (FiRST) defined a positive screening test for FM. RESULTS: Enthesitis ever and FM (EFM) co-existed in 10.3% (n=425) of the cohort using FiRST criteria and 5.3% using clinical diagnosis of FM. More individuals with FM by clinical diagnosis had imaging-confirmed enthesitis ever than by FiRST criteria. More females had EFM than males, defined clinically (76.9% vs 23.1%) or by FiRST criteria (62.6% vs 37.4%). Individuals with EFM had more severe disease across all measures compared to those with enthesitis only, with no significant difference between sexes. EFM was significantly associated with age, female sex, BMI, BASDAI and region. CONCLUSION: FM is an important comorbidity in the setting of enthesitis in SpA. While EFM is more common in females, it is not a rare condition in males. EFM is associated with worse disease severity measures in SpA in both males and females. Recognition of FM in the setting of enthesitis is essential to prevent overtreatment and optimise patient outcomes.

What to expect when women with axial spondyloarthritis are expecting: Prevalence of complications of pregnancies in women with axial spondyloarthritis.

BACKGROUND: Understanding of axSpA is evolving rapidly. Unfortunately, for women with axSpA there is limited data available on pregnancy complications. The Ankylosing Spondylitis Registry of Ireland (ASRI) is a source of epidemiological data on axSpA in Ireland. The aim of this study was to examine the prevalence of pregnancy and fetal complications in axSpA women. METHODS: The ASRI records cross-sectional information on demographics, imaging, treatment, and patient outcomes. A dedicated section collects data on pregnancy, fertility and breastfeeding. For each axSpA woman, data on all pregnancies was recorded. Results were compared to global reference norms (GRN). All patients were diagnosed with axSpA by a Rheumatologist and met the ASAS classification criteria. Informed consent was obtained from all patients, with ethical approval obtained from local hospital ethics committees. RESULTS: Data was available on 98 women with axSpA. There were 335 pregnancies resulting in 279 live births. Of these pregnancies 51.6% (173) were uncomplicated and 48.5% (162) were complicated, with 13.1% (44) encountering multiple complications. Preterm birth (12.5 % vs 5.2%, p<0.01) and preeclampsia (6.8 % vs 2.8%, p<0.01) were more prevalent in axSpA pregnancies than GRN. Low birth weight was more prevalent in axSpA pregnancies (8.2 % vs 2.9%, p<0.01), however small for gestational age was less prevalent (5.4 % vs 11%, p<0.01). CONCLUSIONS: Preterm birth, preeclampsia and low birth weight are significantly more prevalent in pregnancies of axSpA women. Furthermore, there is a high prevalence of complications in axSpA pregnancies overall. These results provide essential insight into the impact of axSpA in pregnancy and call for further research to understand the pathogenesis of these complications.

Cortical curvature analysis in MRI-negative temporal lobe epilepsy: a surrogate marker for malformations of cortical development.

PURPOSE: To investigate cerebral cortical surface morphology in a magnetic resonance (MRI)-negative temporal lobe epilepsy (TLE) cohort, and to differentiate between the effects on cortical morphology of cerebral volume loss associated with TLE, and abnormalities suggestive of malformations of cortical development (MCDs). METHODS: MRI data was gathered for 29 MRI-negative patients and 40 neurologically normal controls. Automated methods of surface reconstruction were applied to all MRI data for the purposes of localized analysis of cortical curvature. As an adjunct to this analysis, measures of whole-brain gray and white matter volumes, as well as cortical thickness, were also generated to determine the degree of whole-brain volume loss in TLE, and its impact on cortical morphology. RESULTS: Automated analysis of the average cortical surface of the patient group revealed an area of abnormal cortical curvature in the basal left temporal lobe. The presence of whole-brain volume loss in TLE was confirmed and found not to contribute to the cortical curvature abnormality in the temporal lobe. These results support the hypothesis that cortical curvature abnormalities in TLE may be indicative of a subtle MCD. DISCUSSION: Subtle MCDs such as abnormal indices of curvature may be associated with partial epilepsy. Analysis of these parameters may increase the diagnostic yield from MRI.

Technical communication: respiratory variation in pulse pressure and plethysmographic waveforms: intraoperative applicability in a North American academic center.

Dynamic variables are the best predictors of fluid responsiveness in patients under general anesthesia and mechanical ventilation; namely, respiratory variations in pulse pressure and in the plethysmographic waveform. However, these variables have potential limitations. Our aim was to evaluate their intraoperative applicability. We extracted clinical data from all anesthesia procedures performed at our institution in 2009 and identified the number of cases that presented predetermined conditions of application. Among the 12,308 procedures, 39% met the criteria for the noninvasive monitoring of variations in the plethysmographic waveform of which 23% had arterial lines and met the criteria for the invasive monitoring of variations in pulse pressure.