Emotion recognition and eye tracking of static and dynamic facial affect: A comparison of individuals with and without traumatic brain injury.

Diminished social functioning is often seen after traumatic brain injury (TBI). Mechanisms contributing to these deficits are poorly understood but thought to relate to impaired ability to recognize facial expressions. Static stimuli are often used to investigate ability post-TBI, and there is less evidence using more real-life dynamic stimuli. In addition, most studies rely on behavioral responses alone. The present study investigated the performance of a TBI group and matched non-TBI group on static and dynamic tasks using eye-tracking technology alongside behavioral measures. This is the first study to use eye tracking methodology alongside behavioral measures in emotion recognition tasks in people with brain injury. Eighteen individuals with heterogeneous TBI and 18 matched non-TBI participants were recruited. Stimuli representing six core emotions (Anger, Disgust, Fear, Happy, Sad, and Surprise faces) were selected from the Amsterdam Dynamic Facial Expression Set (ADFES). Participants were instructed to identify the emotion displayed correctly whilst eye movement metrics were recorded. RESULTS: Results of analyses showed that TBI patients had First Fixation to nose for all emotion stimuli, shorter Fixation Duration and lower Fixation Count to eyes, were generally slower to classify stimuli, and less accurate than non-TBI group for the static task. Those with TBI were also less accurate at identifying Angry, Disgust, and Fear stimulus faces compared to the non-TBI group during the dynamic unfolding of an emotion. CONCLUSION: In the present study, those with TBI had atypical eye scan patterns during emotion identification in the static emotion recognition task compared to the non-TBI group and were associated with lower identification accuracy on behavioral measures in both static and dynamic tasks. Findings suggest potential disruption to oculomotor systems vital for first stage perceptual processing. Arguably, these impairments may contribute to diminished social functioning.

Intermediate and long-term outcomes following uterine artery fibroid embolization.

OBJECTIVE: To assess patients' satisfaction and the intermediate and long-term patterns of symptom progression following uterine artery fibroid embolization (UAE). STUDY DESIGN: Intermediate (2-6 years) and long-term (9-14 years) follow-up questionnaire survey to women who underwent UAE during the period 1996-2000, at a tertiary referral centre. RESULTS: The mean (SD) age of women at the time of embolization was 43 (5.58) years. A total of 142/197 (72.1%) women had the embolization in view of heavy menstrual periods, while 87/197 (44%) indicated a desire to retain fertility. 160/197 (81.7%) women who completed Q1 reported an improvement in menstrual symptoms compared to 41/80 (51.2%) for Q2 [p<0.01]. The majority indicated they would recommend the procedure to a friend (Q1: 165 (83.8%), Q2: 62/80 (77.5%)) [p=0.75]. 23/80 (28.8%) required further surgical treatment following UAE, and within the latter group, only 7/23 (30.4%) were satisfied with the embolization. 22/80 (27.5%) tried for a pregnancy following the procedure, and of these 3/22 (13.6%) had a live birth. The mean (SD) age at the menopause for women who returned Q2 was 49.1 (4.91) years. CONCLUSIONS: The majority of women were satisfied with the embolization and noted an improvement in menstrual symptoms. However, this improvement diminished over time following the embolization, and over a quarter of women required further surgical intervention. Findings from this study may provide useful information in counselling women undergoing UAE and help guide clinicians in their patient selection criteria when discussing the procedure.

A review of the relationship between alcohol and oral cancer.

This paper aims to review the current literature regarding the association between alcohol consumption and oral cancer. The authors have discussed the constituents of alcohol-containing beverages, the metabolism of ethanol and its effect on the oral microflora. The local and systemic carcinogenic effects of alcohol have been detailed. The beneficial effects of alcohol consumption on general health have also been considered. A possible relationship between alcohol-containing mouthrinses and oral cancer has been suggested in the literature. The authors conclude that this relationship has not yet been firmly established. However, the use of alcohol-containing mouthrinses in high-risk populations should be restricted, pending the outcome of further research.

Long-term surveillance with computed tomography after endovascular aneurysm repair may not be justified.

BACKGROUND: There is a common perception that a large number of secondary interventions are needed following endovascular aortic aneurysm repair. METHODS: Prospective data were collected for a cohort of 417 consecutive elective patients undergoing infrarenal aortic endograft repair between April 2000 and May 2008. The rate of secondary interventions, associated morbidity and need for reintervention following surveillance imaging were analysed. RESULTS: The male : female ratio was 11 : 1, median age 76 (range 40-93) years and median aneurysm diameter 6.1 (5.3-11) cm. The overall 30-day mortality rate was 1.7 per cent (seven of 417). Secondary interventions were performed in 31 patients (7.4 per cent), of which six (1.4 per cent) were detected by surveillance. Endoleaks requiring reintervention occurred in 12 patients (2.9 per cent; ten type I and two type III endoleaks). Limb ischaemia secondary to graft occlusion occurred in 17 patients (4.1 per cent); extra-anatomical bypass was needed in 15 patients (3.6 per cent) and the remaining two had an amputation. Graft explantation following late infection was required in two patients (0.5 per cent). CONCLUSION: Endoluminal repair of infrarenal aortic aneurysms can be performed with a low reintervention rate. The value of prolonged surveillance seems limited and current surveillance protocols may require revision.

Successful endovascular repair of acute type B aortic dissection in undiagnosed Ehlers-Danlos syndrome type IV.

A 61-year-old man presented with an acute type B aortic dissection for which a stent-graft was introduced. He remains complication-free 4 years onwards and has since been diagnosed with Ehlers-Danlos syndrome type IV (EDS IV). His particular mutation is predicted to result in lesser levels of normal collagen and may explain his favourable outcome from endovascular intervention. Understanding the genotype-phenotype correlation may influence the choice of therapy offered to patients with EDS IV.

Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery?

BACKGROUND: Retroperitoneal haematoma is a rare clinical entity with variable aetiology, which is increasing in incidence mainly due to complications related to interventional procedures. There is no general consensus as to the best management plan for patients with retroperitoneal haematoma. METHODS: A literature review was undertaken using MEDLINE, all relevant papers on retroperitoneal haemorrhage or haematoma were used. RESULTS: The diagnosis is often delayed as symptoms are nonspecific. Retroperitoneal haematoma should be suspected in patients with significant groin, flank, abdominal, back pain or haemodynamic instability following an interventional procedure. Spontaneous haemorrhage usually occurs in patients who are anticoagulated. Multi-slice CT and arteriography are important for diagnosis. Most haemodynamically stable patients can be managed with fluid resuscitation, correction of coagulopathy and blood transfusion. Endovascular treatment involving selective intra-arterial embolisation or the deployment of stent-grafts over the punctured vessel is attaining an increasingly important role. Open repair of retroperitoneal bleeding vessels should be reserved for cases when there is failure of conservative or endovascular measures to control the bleeding. Open repair is also required if endovascular facilities or expertise is unavailable and in cases where the patient is unstable. If treated inappropriately, the mortality of patients with retroperitoneal haematoma remains high. CONCLUSION: There is a lack of level I evidence for the best management plans for retroperitoneal haematoma, and evidence is based on small cohort series or isolated case reports. Conservative management should only be reserved for patients who are stable. Interventional radiology with intra-arterial embolisation or stent-grafting is the treatment of choice. Open surgery is now rarely required.

Endoluminal repair of distal aortic arch aneurysms causing aorto-vocal syndrome.

PURPOSE: We have evaluated the efficacy of endovascular repair of distal aortic arch aneurysms (DAAA) causing recurrent laryngeal nerve palsy. MATERIAL AND METHODS: Eight patients (five male and three female) with median age of 72 years (range: 59-80) presented with left recurrent laryngeal nerve palsy associated with DAAA. All patients were considered unfit for open surgery. The median aneurysm size was 5.9 cm (range: 5-7.3). Thirteen stents were deployed: eight Gore, four Endofit and one Talent. Epidural anaesthesia was used in all patients. The left subclavian artery was covered in all and the left common carotid in three who had a preliminary right to left carotid-carotid bypass. Routine follow-up (FU) was with computed tomography (CT) at 3-6 months and yearly thereafter. RESULTS: Exclusion of the aneurysm sac was achieved in all patients. Thirty-day mortality was 0%, with no paraplegia or stroke. Early complications included: rupture of the external iliac artery (one) and common femoral artery thrombectomy (one). One patient died of unknown cause at 17 months. The mean FU in the remaining seven patients was 21 months (range: 6-51). Aneurysm size decreased in five, was unchanged in one and increased in one. Three patients had improvement in voice quality postoperatively. One patient had a recurrent type 1 endoleak which was restented twice. No late deaths have occurred. CONCLUSION: Though technically the procedures involved were more complicated, endovascular repair of DAAA causing aorto-vocal syndrome is safe and offers a realistic alternative to open surgery. Hoarseness of the voice can improve postoperatively and is associated with reduction in aortic sac diameter.

Temporal variability in urinary concentrations of phthalate metabolites, phytoestrogens and phenols among minority children in the United States.

BACKGROUND: Exposure to endocrine disruptors (EDs), including some phthalates, phytoestrogens and phenols can be quantified using biomarkers of exposure. However, reliability in the use of these biomarkers requires an understanding of the timeframe of exposure represented by one measurement. Data on the temporal variability of ED biomarkers are sparse, especially among children. OBJECTIVE: To evaluate intraindividual temporal variability in 19 individual urinary biomarkers (eight phthalate metabolites from six phthalate diesters, six phytoestrogens (two lignans and four isoflavones) and five phenols) among New York City children. METHODS: Healthy Hispanic and Black children (N=35; 6-10 years old) donated several urine samples over 6 months. To assess temporal variability we used three statistical methods: intraclass correlation coefficient (ICC), Spearman correlation coefficients (SCC) between concentrations measured at different timepoints, and surrogate category analysis to determine how well the tertile categories based on a single measurement represented a 6-month average concentration. RESULTS: Surrogate category analysis indicated that a single sample provides reliable ranking for all analytes; at least three of four surrogate samples predicted the 6-month mean concentration. Of the 19 analytes, the ICC was >0.2 for 18 analytes and >0.3 for 10 analytes. Correlations among sample concentrations throughout the 6-month period were observed for all analytes; 14 analyte concentrations were correlated at 16 weeks. CONCLUSIONS: The reasonable degree of temporal reliability and the wide range of concentrations of phthalate metabolites, phytoestrogens and phenols suggest that these biomarkers are appropriate for use in epidemiologic studies of environmental exposures in relation to health outcomes in children.

Assessment of human exposure to di-isodecyl phthalate using oxidative metabolites as biomarkers.

Di-isodecyl phthalate (DiDP), primarily used as a plasticiser, is a mixture of isomers with predominantly ten-carbon branched side chains. Assessment of DiDP exposure has not been conducted before because adequate biomarkers were lacking. In 129 adult volunteers with no known exposure to DiDP, the urinary concentrations of three oxidative metabolites of DiDP: monocarboxyisononyl phthalate (MCiNP), monooxoisodecyl phthalate (MOiDP) and monohydroxyisodecyl phthalate (MHiDP), previously identified in DiDP-dosed rats, were estimated by solid-phase extraction coupled to high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) using the respective oxidative metabolites of di(2-ethylhexyl)phthalate since authentic standards of the DiDP oxidative metabolites were unavailable. Interestingly, the hydrolytic monoester of DiDP, monoisodecyl phthalate (MiDP), was not detected in any of the samples, while MCiNP, MHiDP and MOiDP were detected in 98%, 96% and 85%, respectively, of the samples tested. MCiNP was excreted predominantly in its free form, whereas MOiDP was excreted as its glucuronide. MCiNP, MHiDP and MOiDP eluted as clusters of multiple peaks from the HPLC column probably due to the presence of numerous structurally similar isomers present in commercial DiDP formulations. The urinary concentrations of these oxidative metabolites correlated significantly (p < 0.0001) with each other, thus confirming a common precursor. The urinary concentrations of these DiDP oxidative metabolites also correlated significantly (p < 0.0001) with oxidative metabolites of di-isononyl phthalate (DiNP) suggesting the potential presence of DiNP isomers in commercial DiDP or simultaneous use of DiDP and DiNP in consumer products. The concentrations presented are semiquantitative estimates and should be interpreted cautiously. Nevertheless, the higher frequency of detection and higher urinary concentrations of MCiNP, MHiDP and MOiDP than of MiDP suggest that these oxidative metabolites are better biomarkers for DiDP exposure assessment than MiDP. These data also suggest that unless oxidative metabolites are measured, the prevalence of exposure to DiDP will probably be underestimated.

Neurological complications following endoluminal repair of thoracic aortic disease.

Open surgery for thoracic aortic disease is associated with significant morbidity and the reported rates for paraplegia and stroke are 3%-19% and 6%-11%, respectively. Spinal cord ischemia and stroke have also been reported following endoluminal repair. This study reviews the incidence of paraplegia and stroke in a series of 186 patients treated with thoracic stent grafts. From July 1997 to September 2006, 186 patients (125 men) underwent endoluminal repair of thoracic aortic pathology. Mean age was 71 years (range, 17-90 years). One hundred twenty-eight patients were treated electively and 58 patients had urgent procedures. Anesthesia was epidural in 131, general in 50, and local in 5 patients. Seven patients developed paraplegia (3.8%; two urgent and five elective). All occurred in-hospital apart from one associated with severe hypotension after a myocardial infarction at 3 weeks. Four of these recovered with cerebrospinal fluid (CSF) drainage. One patient with paraplegia died and two had permanent neurological deficit. The rate of permanent paraplegia and death was 1.6%. There were seven strokes (3.8%; four urgent and three elective). Three patients made a complete recovery, one had permanent expressive dysphasia, and three died. The rate of permanent stroke and death was 2.1%. Endoluminal treatment of thoracic aortic disease is an attractive alternative to open surgery; however, there is still a risk of paraplegia and stroke. Permanent neurological deficits and death occurred in 3.7% of the patients in this series. We conclude that prompt recognition of paraplegia and immediate insertion of a CSF drain can be an effective way of recovering spinal cord function and improving the prognosis.

Hybrid repair of type B dissecting aneurysm with associated Kommerell's diverticulum.

Endovascular therapy has revolutionised vascular surgery. Complex open surgical procedures may be replaced with a combination of extra-anatomical reconstruction and endovascular treatment. This minimally invasive approach is associated with a lower peri-operative morbidity and mortality than open repair. We describe a novel 2-stage treatment in a patient with Type B thoracic aortic dissection with subsequent aneurysmal dilatation and the added difficulty of a concomitant aneurysmal aberrant right subclavian artery (Kommerell's diverticulum).

Successful stent-graft placement for the treatment of a superior gluteal artery pseudoaneurysm in a patient following complex pelvic surgery.

Aneurysms of the gluteal arteries are rare and were previously managed with open surgical procedures. Recently percutaneous embolisation techniques have helped reduce morbidity and mortality. A case is presented of a 63-year-old man who presented with haemorrhage and had developed a superior gluteal artery aneurysm following treatment for an invasive squamous cell carcinoma in the sacral area. There was concern that embolisation of the aneurysm might compromise the survival of the myocutaneous buttock rotation flaps that had been used for reconstruction. To overcome this, an endovascular stent was deployed to successfully close off the aneurysm whilst at the same time maintaining blood flow through the superior gluteal artery. Aneurysms in larger peripheral vessels have been managed with stents. However, this is the first reported case of this method of treatment being used in the management of gluteal artery aneurysms.

Large infra-renal abdominal aortic aneurysms: endovascular vs. open repair--single centre experience.

Endovascular aneurysm repair (EVAR) has become an established alternative to open repair (OR). We present a consecutive series of 486 elective patients with large infra-renal aortic abdominal aneurysm, comparing OR with EVAR. Prospective data collected during an 8-year period from January 1997 to October 2005 was reviewed. Statistical analysis performed using SPSS data editor with chi(2) tests and Mann-Whitney U-tests. There were 486 patients with 329 OR (293 males, 36 females) with median age of 72 years with median diameter 6.3 cm and 157 EVAR (148 males, 9 females) with median age 75 years with median diameter 6.1 cm. Mortality was 13 (4%) for OR and 5 (3.2%) for EVAR (three of whom were in the UK EVAR 2 trial). Blood loss was significantly less for EVAR 500 ml vs. 1500 ml for OR. Sixty-five (19.8%) patients with OR had significantly more peri-operative complications compared with 14 (8.9%) with EVAR. The length of stay in hospital was significantly less for EVAR. This non-randomised study shows that although EVAR does not have a statistically significantly lower mortality, it does have statistically significantly lower complication rates compared with OR. EVAR can be achieved with good primary success, but long-term follow-up is essential to assess durability.

Measurement of eight urinary metabolites of di(2-ethylhexyl) phthalate as biomarkers for human exposure assessment.

Human metabolism of di(2-ethylhexyl) phthalate (DEHP) is complex and yields mono(2-ethylhexyl) phthalate (MEHP) and numerous oxidative metabolites. The oxidative metabolites, mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono(2-ethyl-5-carboxypentyl) phthalate (MECPP) and mono(2-carboxymethylhexyl) phthalate (MCMHP), have been considered to be better biomarkers for DEHP exposure assessment than MEHP because urinary levels of these metabolites are generally higher than MEHP, and their measurements are not subject to contamination. The urinary levels of the above metabolites, and of three other recently identified DEHP oxidative metabolites, mono(2-ethyl-3-carboxypropyl) phthalate (MECPrP), mono-2-(1-oxoethylhexyl) phthalate (MOEHP), and mono(2-ethyl-4-carboxybutyl) phthalate (MECBP), were measured in 129 adults. MECPP, MCMHP and MEHHP were present in all the samples analysed. MEHP and the other oxidative metabolites were detected less frequently: MEOHP (99%), MECBP (88%), MECPrP (84%), MEHP (83%) and MOEHP (77%). The levels of all DEHP metabolites were highly correlated (p<0.0001) with each other, confirming a common parent. The ? and ?-1 oxidative metabolites (MECPP, MCMHP, MEHHP and MEOHP) comprised 87.1% of all metabolites measured, and thus are most likely the best biomarkers for DEHP exposure assessment. The percentage of the unglucuronidated free form excreted in urine was higher for the ester linkage carboxylated DEHP metabolites compared with alcoholic and ketonic DEHP metabolites. The percentage of the unglucuronidated free form excreted in urine was higher for the DEHP metabolites with a carboxylated ester side-chain compared with alcoholic and ketonic metabolites. Further, differences were found between the DEHP metabolite profile between this adult population and that of six neonates exposed to high doses of DEHP through extensive medical treatment. In the neonates, MEHP represented 0.6% and MECPP 65.5% of the eight DEHP metabolites measured compared to 6.6% (MEHP) and 31.8% (MECPP) in the adults. Whether the observed differences reflect differences in route/duration of the exposure, age and/or health status of the individuals is presently unknown.

Refining diagnoses: applying the DC-LD to an Irish population with intellectual disability.

BACKGROUND: The diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation (DC-LD) is a diagnostic tool developed in 2001 to improve upon existing classification systems for adults with learning disability. The aim of this study was to apply the classification system described by the DC-LD to a residential intellectual disability (ID) population to examine whether it improved our diagnostic understanding of residents. METHODS: Chart reviews of 113 of 178 people in a residential ID service were conducted. For each resident, information was recorded according to the DC-LD multi-axial system. Each resident's case was then discussed with a member of nursing staff familiar with the resident. If diagnosis was unclear, the case was discussed with a senior clinical psychiatrist. RESULTS: The percentage of residents with a moderate to profound ID was 87.6%. In total, 94 diagnoses of psychiatric illness (Axis III, Level B, DC-LD) were made. Of those 94 diagnoses, seven new diagnoses were found because of DC-LD criteria. Of the total number of psychiatric diagnoses made, 72.3% were non-specific, residual category diagnoses. A total of 79 residents (69.9%) had at least one behaviour problem diagnosed on Axis III, Level D, Problem behaviours. Fifty-six (49.6%) of residents in this sample had co-morbid epilepsy. CONCLUSIONS: In people with moderate to profound learning disabilities, diagnosis continues to be challenging. The DC-LD is a useful tool in helping to clarify diagnoses in this population by providing revised criteria and a system to classify problem behaviours. The DC-LD would be more helpful if specific axes were included to document medical and psychosocial problems independently from other diagnoses. Further research is warranted to determine whether the DC-LD hierarchical approach to diagnosis improves diagnostic validity.

Treatment of mycotic aortic aneurysms with endoluminal grafts.

PURPOSE: To report the benefit of endoluminal repair of mycotic aortic aneurysms and highlight the need for a registry. METHODS: Nine patients (five female) were identified over 5 years (1998-2003) as having presumed mycotic aortic aneurysms (12 in total) suitable for endoluminal grafting. A total of nine thoracic and three abdominal were grafted and followed up for a median of 36 months. RESULTS: Six of the aneurysms have resolved and one was converted to an open repair. There was one early death from rupture of a second undiagnosed aneurysm and two late deaths from rupture due to persistent inflammation. Long-term antibiotics have not been mandatory to ensure survival. CONCLUSIONS: Mycotic aortic aneurysms of the thoracic and abdominal aorta do benefit from endoluminal repair, particularly when arising in previously normal aortic tissue. Endoluminal grafting also has a role in the palliation of secondarily infected aortas and so to prove its efficacy in the treatment of all these rare cases a registry is required.