Proton magnetic resonance spectroscopy of the primary motor cortex in patients with motor neuron disease: subgroup analysis and follow-up measurements

OBJECTIVES

To determine the motor cortex degeneration in patients with amyotrophic lateral sclerosis (ALS) using proton magnetic resonance spectroscopy, and to prove that proton magnetic resonance spectroscopy is suited to monitor the course of disease with follow-up examinations.

MATERIALS AND METHODS

We studied 33 patients with ALS whose conditions were diagnosed according to the El Escorial World Federation of Neurology criteria. Nine patients with ALS were followed up for up to 2 years. The control group included 20 healthy volunteers and 4 patients with multifocal motor neuropathy. Proton magnetic resonance spectroscopy determined levels of the brain metabolites N-acetylaspartate (NAA), choline, inositol-containing compounds, glutamate/glutamine, and phosphocreatine.

RESULTS

Patients with ALS showed a significant reduction in the NAA-choline (P <.001) and NAA-phosphocreatine (P <.005) metabolite ratios and significantly elevated choline-phosphocreatine (P <.005) ratios compared with controls. Inositol-phosphocreatine ratios were also elevated in case patients, but the increase was less pronounced (P <.05). No differences in glutamate/glutamine-phosphocreatine ratios were detected between case patients and controls. An analysis of subgroups demonstrated less significant differences in NAA-choline metabolite ratios (P<.05), even in patients with pure lower motor neuron syndrome (suspected ALS). No changes in metabolite T1 and T2 relaxation times were observed. Patients with multifocal motor neuropathy showed normal metabolic ratios. Progressive alterations in affected metabolite ratios could be documented in the follow-up examinations.

CONCLUSIONS

Spectroscopic changes in the motor cortices of patients with ALS correspond with a reduction in levels of NAA and an elevation in levels of choline and inositol compounds. Since NAA is exclusively expressed in neurons, the observed decrease of NAA reflects neuronal loss or dysfunction. Inositol and choline are associated with plasma membrane metabolism, so the release of these compounds may be related to membrane disorders.

[A rational study of the great abdominal veins using 2D-TOF- and turbo-spin-echo sequences]

PURPOSE

Development of a fast and reliable protocol for the detection and exclusion of abdominal venous thrombosis with an optimised T2-TSE- and 2D-TOF sequence.

MATERIAL AND METHOD

Evaluation of the flow-void phenomenon with a flow phantom on a 1.5 and 0.5 Tesla system using different echo times. Examination of 22 patients with suspected abdominal shunt- or abdominal vein-thrombosis with a optimum T2-TSE- and 2D-TOF sequence with a 1.5 or 0.5 Tesla system. Confirmation of thrombosis with contrast-enhanced computed tomography or digital subtraction angiography.

RESULTS

The most effective combination of strong flow-void phenomena, signal/noise ratio and scan time was found with the following parameters: TE 120 ms, TR 2000 ms, 5 mm slice gap. In the patient group two complete and two partial thromboses were diagnosed with both sequences. One wrong positive thrombosis occurred in a stenotic anastomosis with the 2D-inflow sequence.

CONCLUSION

With optimum parameters the T2-TSE sequence produces a strong "flow-void" phenomenon suitable for "black-blood"-MRA. The use of this sequence alone or in combination with 2D-inflow MRA, if "bright-blood" MRA is recommended, allows a reliable evaluation of thrombosis in abdominal veins without high-tech MRA equipment and contrast media.

[Diffusion-weighted MR tomography: navigated multi-shot SE-EPI technique for clinical use]

PURPOSE

Evaluation of a navigated multi-shot SE EPI sequence for routine clinical use in MR diffusion imaging.

METHODS

We compared a multi-shot SE EPI sequence with the conventional SE sequence as well as with a single-shot SE EPI sequence on a standard 1.5 Tesla MR-scanner (ACS-NT, Philips Medical Systems) with a conventional gradient system (10 mT/m). Image quality and the reproducibility of the apparent diffusion coefficient were analysed with phantoms and with healthy volunteers. The diffusion coefficients of different brain areas were determined in a group of twenty volunteers.

RESULTS

The multi-shot SE EPI sequence showed considerably shorter measurement times and smaller motion artifacts than the SE sequence and was less sensitive to susceptibility artifacts than the single-shot version. The reproducibility of the diffusion coefficients was better than 10%.

CONCLUSION

The navigated multi-shot SE technique is more practicable and meaningful than the SE and the single-shot SE EPI techniques on a standard 1.5 Tesla MR-scanner with a conventional gradient system. In our opinion it is now the best method for diffusion imaging and should be preferred in clinical use. The determination of diffusion coefficients yields reliable results and characteristic values for different tissue can be obtained.

[Improved diagnosis of early cerebral infarct by the combined use of diffusion and perfusion]

PURPOSE

To evaluate the feasibility and the diagnostic efficacy of multislice diffusion-weighted and perfusion imaging in addition to FLAIR-TSE, T2w-GraSE and MR-angiography in the diagnosis of acute stroke.

METHODS

18 patients with acute stroke were examined at 1.5 Tesla (Gyroscan ACS-NT, Philips Medical Systems) within 6 (n = 9) and 6-48 (n = 9) hours, respectively, and followed at regular intervals. For diffusion imaging we used a multislice multishot EPI-SE sequence with navigator echo correction and cardiac gating. Perfusion imaging was done by means of a FFE-EPI sequence after bolus injection of Gd-DTPA.

RESULTS

The diagnostic value of diffusion-weighted and perfusion imaging was significantly higher compared with FLAIR-TSE (p = 0.0023) and GraSE (p = 0.0012) during the first 6 hours. With FLAIR-TSE and GraSE first pathologic changes were seen after 4 hours. We detected perfusion deficit (rCBV < 10%) and a corresponding drop of the ADC in all infarcts larger than 1 cm in diameter. Within the area of low rCBV the combined analysis of diffusion and perfusion imaging allows to identify an infarct region with characteristics of a penumbra and one with characteristics of the infarct core. TTP was increased in the surrounding tissue. However, parts of this area were rarely included in the infarct. The final extension of the untreated infarct, as revealed by computed tomography, corresponded well to the perfusion deficit.

CONCLUSIONS

Early ischaemic cerebral infarcts can be diagnosed with diffusion and perfusion imaging before pathological changes are visualized with other imaging modalities. The combined use may allow to distinguish the infarct core from surrounding, potentially salvageable tissue.

Effectiveness of treatments of depression in older ambulatory patients

OBJECTIVE

To determine the effectiveness of acute-phase pharmacological and psychological treatments of depression in older ambulatory patients by systematically reviewing original research relevant to this topic.

METHODS

Searches in MEDLINE and PsycINFO and manual reviews of bibliographies located 233 articles. Of these, 40 (37 different studies) met our 8 inclusion criteria: original research, written in English or French, subjects 55 years and older, diagnosis of depression, outpatient or community setting, prospective controlled study design, acute-phase pharmacological or psychological treatment, and outcome measure of depression. Two independent reviewers assessed the methodological quality of each article using a standard form and a quality score was computed. Quantitative data on levels of depression at the end of treatment were abstracted. Results were grouped by specific treatment comparison (type of treatment and type of control group). For comparisons that used the Hamilton Depression Rating Scale, we computed mean posttreatment differences. Effect sizes were computed from the Hamilton Depression Rating Scale or an alternative scale.

RESULTS

In studies that compared active drugs with placebo, the heterocyclic drugs significantly reduced the posttreatment Hamilton Depression Rating Scale score (mean difference, -5.78; 95% confidence interval, -8.31 to -3.25); other drugs had smaller effects. In studies that compared active drugs, there were no significant differences overall between different classes of drugs; selective serotonin reuptake inhibitors appeared to be as effective as heterocyclic drugs. Rational psychological treatments performed significantly better than no treatment (mean posttreatment Hamilton Depression Rating Scale difference, -7.25; 95% confidence interval, -10.10 to -4.40) but not significantly better than that for controls who received similar attention. Adjustment for the study quality score did not affect these results.

CONCLUSIONS

Based on comparisons with untreated controls, heterocyclic antidepressants and rational psychological therapies appear to be the most effective treatments for older ambulatory patients with mild to moderate depression. Based on drug-drug comparisons, selective serotonin reuptake inhibitors appear to be as effective as heterocyclic drugs. However, overall, the magnitude of the treatment effects is modest. Limitations in the quantity and quality of appropriate studies suggest a sober approach to treatment in this population.

[31P-mr spectroscopy of peripheral skeletal musculature under load: demonstration of normal energy metabolites compared with metabolic muscle diseases]

PURPOSE

31P-MR spectroscopy of skeletal muscle under exercise was used to obtain the range of normal variation and comparison was made for different neuromuscular diseases.

METHODS

41 examinations of 24 volunteers and 41 investigations in 35 patients were performed on 1.5 T MR systems (Gyroscan 515 und S15/ACSII, Philips). Localised 31P-MR spectra of the calf muscle were obtained in time series with a resolution of 12 s.

RESULTS

Two types of muscle energy metabolism were identified from the pattern of spectroscopic time course in volunteers: While the first group was characterised by a remarkable decline to lower pH values during exercise, the second group showed only small pH shifts (minimum pH: 6.48 +/- 0.13 vs 6.87 +/- 0.07, p < 10(-6)) although comparable workload conditions were maintained. The pH-values correlated well with blood lactate analysis. Patients with metabolic disorders and chronic fatigue syndrome (CFS) showed decreased resting values of PCr/(PCr + Pi) and increased pH levels during exercise. PCr recovery was significantly delayed (0.31 vs 0.65 min-1, p < 0.00005) in metabolic muscle disorders but was normal in CFS patients.

CONCLUSION

Findings in volunteers indicate utilisation of different metabolic pathways which seems to be related to the fibre type composition of muscle. Reduced resting levels for PCr/(PCr + Pi), altered pH time courses, and decreased PCr recovery seem to be helpful indicators for diagnosis of metabolic muscle disorders.

Inflammatory bowel disease: no association between allele combinations of the interleukin (IL) I beta and IL-I receptor antagonist gene polymorphisms

BACKGROUND

Interleukin 1 (IL-1) and its physiological antagonist interleukin-1 receptor antagonist (IL-1 ra) play a crucial role in the pathogenesis of inflammatory bowel disease. Polymorphisms in the genes coding for these cytokines, the restriction enzyme TaqI polymorphism for IL-1 beta and the variable number of tandem repeats (VNTR) polymorphism for IL-1 ra, have been shown to influence cytokine synthesis in vitro. Recently, an association has been described for distinct allele combinations of these two polymorphisms in patients with ulcerative colitis and with Crohn's disease but not in healthy control subjects.

METHODS

We studied 56 patients with ulcerative colitis, 64 patients with Crohn's disease and 196 healthy control subjects. All were unrelated Caucasians of European ancestry. After polymerase chain reaction (PCR) the amplification products were analysed on agarose gels. For the IL-1 beta polymorphism the PCR product was additionally digested using the restriction enzyme TaqI.

RESULTS

The allele and genotype frequencies as well as the carriage rates of the IL-1 beta TaqI polymorphism in healthy control subjects were in agreement with previous findings in other populations. Allele and genotype frequencies of the IL-1 beta polymorphism were not different in inflammatory bowel disease patients compared with healthy control subjects. Comparing allele combinations of both polymorphisms no association could be identified either within healthy control subjects or in the groups of patients with ulcerative colitis or Crohn's disease.

CONCLUSION

Thus, we could not confirm the results of a previous study reporting an association between the IL-1ra and IL-1 beta gene polymorphisms in patients with inflammatory bowel disease.

Effect of haemodialysis after contrast medium administration in patients with renal insufficiency

BACKGROUND

The study was designed to investigate the influence of haemodialysis on the pharmacokinetics of the non-ionic contrast medium iopentol and the outcome of radiocontrast nephropathy in patients at risk undergoing angiography.

METHODS

We prospectively studied 30 patients with reduced renal function (mean serum creatinine concentration (+/- SEM), 2.4 +/- 0.16 mg/dl (212 +/- 14 mumol/l)). Patients were randomly assigned to receive either a haemodialysis procedure for 3 h, started as soon as possible (63 +/- 6 min) after administration of contrast medium, or a conservative treatment. Serum concentrations of iopentol and creatinine were followed for up to 14 days.

RESULTS

The extracorporal plasma clearance of contrast medium was 71 +/- 2.5 ml/min. The fraction of the dose eliminated was 32 +/- 3%. The rate of radiocontrast nephropathy (defined as serum creatinine increase of > or = 0.5 mg/dl (44 mumol/l) within 48 h) after administration of contrast medium was similar in both groups (53 and 40% in group 1 (haemodialysis) and group 2 (conservative treatment) respectively). The course of absolute changes in serum creatinine over the whole observation period was not different in both groups.

CONCLUSIONS

The data indicate that haemodialysis eliminates contrast medium effectively, but it may not influence the incidence or outcome of contrast induced nephropathy.

The status of iodine nutrition in newborn infants, schoolchildren, adolescents and adults in former East Germany

In the former East Germany (GDR) like in the former West Germany (FRG) iodine deficiency and endemic goiter have been described since more than 2 decades. After a program of salt iodization which was started in East Germany in 1985 the urinary iodine excretion of the population increased significantly. The thyroid gland of the newborn is much more sensible to changes of the iodine supply than the thyroid of older children. A total of 1732 subjects was enrolled in the study. After the implementation of the mandatory salt iodization the goiter prevalence in newborns decreased markedly to less than 1%. After the reunification of Germany in 1990 the mandatory prophylaxis was stopped and the urinary iodine excretion in newborns, school-children, adolescents and adults diminished markedly. So in newborns the renal iodine excretion decreased to 2.82 micrograms I/dl in 1992. Since 1994 a reasonable improvement of the iodine supply is observed in the region of Leipzig. In school-children, adolescents and adults the mean value of the urinary iodine excretion is now above 10.0 micrograms I/dl. This value may be considered as an indicator for a normal iodine supply. In a small cohort (n = 28) of newborns infants we found a renal iodine excretion of 18.74 micrograms/dl in 1997. That value also means a significant increase since 1992 and a normal iodine supply in the fetal period. The present results from the region of Leipzig/Saxonia are not representative for the whole of East Germany. To provide an optimal iodine nutrition the use of iodized salt for food manufacturing must be significantly increased.

Efficiency of haemoperfusion materials at removing the fungal toxin orellanine from human plasma

Orellanine is the main toxin of various Cortinarius mushrooms and responsible for their nephrotoxicity. The present study was undertaken to estimate the value of haemoperfusion in Cortinarius intoxications. The efficiency of the haemoperfusion materials activated charcoal (DHP-1) and Amberlite XAD 4 resin at removing orellanine from plasma was tested in an in vitro model. Quantification of the toxin in plasma samples was carried out following a previously reported fluorodensitometric TLC method. Orellanine is sufficiently bound to both haemoperfusion materials. However, the rate of orellanine adsorption was four times higher on activated charcoal (DHP-1) compared to Amberlite XAD 4 resin.

The Nuclear Receptor Resource: a growing family

Last year, the original Glucocorticoid Receptor Resource was expanded into a comprehensive project: the Nuclear Receptor Resource (NRR, http:// nrr.georgetown.edu/nrr/nrr.html ). The NRR has since been offering comprehensive information on nuclear receptor structure and function, as well as general facts of interest to the scientific community on meetings, funding and employment opportunities. The project now includes individual resources as part of a network which integrates information on glucocorticoid, androgen, mineralocorticoid, thyroid hormone, Vitamin D and peroxisome-proliferator activated receptors. Many investigators have joined the NRR network by filling the Who is who? form available in the NRR home page. This has facilitated communication among scientists in the field and dissemination of data nor otherwise published. Because several investigators have contacted NRR authors over the past few months asking for advice and materials for educational purposes, we have recently decided to include in our project an educational resource on nuclear receptors termed the 'Graphics Library'. The input and suggestions of NRR users do shape the future direction of the project, so we encourage user to give us feedback.

Measurement of serum exon 3-retaining growth hormone-binding protein in children and adolescents by radioimmunoassay

Recently described assays for the determination of growth hormone-binding protein (GHBP) show a wide variety of normal ranges. Their results depend on the assay design and in the case of ligand-immunofunctional assay (LIFA), probably also on the binding characteristics, i.e. epitope specificity and affinity of the employed antibody. These facts underline the necessity to look for more accurate and specific assays. In this report we describe an accurate and simple radioimmunoassay (RIA) which allows the specific quantitation of the exon 3-retaining GHBP isoform (E3-GHBP). Data of the E3-GHBP RIA were compared to those of a LIFA measuring undifferentiated functional forms of GHBP. Our results demonstrate significant relationships between GHBP and age, BMI and IGF-I as determined by RIA and by LIFA in normal children and adolescents (n = 115, p < 0.001). Moreover, BMI is the only regulating factor of GHBP for both methods as shown by multiple regression analysis (p < 0.001). All our data suggest a qualitatively paralleled regulation of E3-GHBP and undifferentiated functional GHBP forms. This finding was confirmed by a good correlation between RIA and LIFA data (r = 0.74, p < 0.001). Children with idiopathic short stature (ISS, n = 47) had significantly lower GHBP levels than normal controls (n = 58) measured by the E3-GHBP RIA (p < 0.0001) and by LIFA (p < 0.01). We conclude that (1) ISS children may have a structural or quantitative defect at the level of the GHR, and (2) the highly specific assay for E3-GHBP immunoreactivity provides a sensitive diagnostic tool in conditions with partial GH insensitivity.

[Neurogenic disorders of heart and lung function in acute cerebral lesions]

Incidence and clinical significance of cardiopulmonary complications of acute cerebral lesions are still unclear. Neurogenic pulmonary edema (NPE) is characterized as an acute, protein-rich lung edema occurring shortly after cerebral lesions associated with an acute rise of intracranial pressure. NPE is infrequently diagnosed, usually in association with head trauma. Pathophysiological mechanisms include a rise of the pulmonary vascular hydrostatic pressure either due to sympathetic innervation with pulmonary vasoconstriction or increased left-atrial pressure following systemic arterial hypertension or an increase in pulmonary capillary permeability. In contrast to NPE, cardiac complications are frequently observed, most consistently in patients with subarachnoid hemorrhage. Typical ECG changes are repolarization abnormalities, similar to those observed in coronary heart disease, and cardiac arrhythmias. The CK-MB may be slightly elevated; echocardiographic findings show a depressed left-ventricular function. Pathological examination reveals myofibrillar necrosis. Cardiac complications are explained with overactivity of the sympathetic innervation and high levels of circulating catecholamines. For adequate treatment, close cardiac monitoring is required in all patients with acute cerebral lesions.

[MR relaxation time measurements with and without selective fat suppression (SPIR) in endocrine orbitopathy]

PURPOSE

To determine the value and utility of relaxation time measurements with magnetic resonance (MR) imaging in patients with Graves' ophthalmopathy (G.O.).

MATERIALS AND METHODS

20 orbits were studied in control subjects and 58 orbits in patients with G.O. T2 relaxation times of extraocular muscles and retrobulbar fat tissue were calculated. The thickness of the eye muscles was correlated with the calculated T2 times. 18 orbits were measured before and after retro-orbital radiation therapy.

RESULTS

Upper limits of determined normal T2 values were 60 ms in extraocular eye muscles and 40 ms in retrobulbar fat tissue. 89% (17/19) of the patients with G.O. had prolonged T2 times in extraocular eye muscles. The retrobulbar fat tissue in 5 of 38 orbits revealed minimal edema with the use of fat saturated sequences. T2 relaxation times decreased significantly (p < 10(-4)) after 10 Gy radiation therapy. No correlation was found between enlargement and T2 relaxation times in extraocular eye muscles (r = 0.44 in patients before radiation therapy).

CONCLUSION

In patients with G.O. the determination of the enlargement of extraocular eye muscles in computed tomography is not a sufficient parameter for an antiinflammatory therapy, since CT cannot visualise eye muscle edema. T2 relaxation time measurements with MR imaging allow differentiation between edematous and fibrotic changes. This is the diagnostic method of choice in patients with Graves' ophthalmopathy.

[Craniocervical dissections: study strategies in MR imaging and MR angiography]

PURPOSE

To define the diagnostic efficacy of MR imaging, "time of flight" (TOF) and phase contrast (PC) MR angiography in craniocervical arterial dissections.

MATERIAL AND METHODS

The MR examinations of 16 patients with proven arterial dissections (n = 20) were retrospectively analysed by three independent readers. The MR protocol included T1w spin echo sequences with and without fat saturation (SPIR), T2w-turbo-spin echo, 2D- and 3D-TOF- and 3D-PC-MRA. The study was undertaken to assess the diagnostic sensitivity of each technique in detecting typical pathological features.

RESULTS

The overall sensitivity was best in 3D-PC-MRA; reaching 88% of all possible points. Intramural haematoma could be easily detected with T1W spin echo with fat saturation (100%). Intimal flap and lumen narrowing was best defined with 3D-TOF-MRA in 86% resp. 96% and 3D-PC-MRA in 69% resp. 97%. 3D-PC-MRA was superior to all other sequences in 5 cases of aneurysmal dissection (100%).

CONCLUSIONS

An accurate evaluation of craniocervical arterial dissections should rely on a combined protocol including T1w spin echo with fat saturation and an axial 3D-MR angiography (if possible 3D-phase contrast MRA).

Increased serum GHBP levels in obese pubertal children and adolescents: relationship to body composition, leptin and indicators of metabolic disturbances

OBJECTIVE

The serum concentration of the high-affinity growth hormone-binding protein (GHBP) is increased in obesity but the mechanisms are poorly understood. This study assessed the physiological mechanisms involved in the regulation of GHBP in adiposity.

SUBJECTS AND MEASUREMENTS

We tested a number of obesity specific parameters for their association with GHBP. In this study, 199 normal or overweight children and adolescents (101 boys, 98 girls, aged (mean +/- s.d.): 13.7 +/- 2.3 y) underwent an anthropometric evaluation (circumference measurements and bioimpedance analysis) combined with blood withdrawal for the measurement of insulin-like growth factor-I (IGF-I), insulin, leptin and GHBP (by specific RIA), uric acid, triglycerides and cholesterol.

RESULTS

By linear regression analysis GHBP correlated significantly (P < 0.001) with percent body fat mass (r = 0.71), waist (r = 0.73) and hip (r = 0.69) circumference, weight (r = 0.61) waist hip ratio (WHR) (r = 0.54), as well as with the serum concentrations of leptin (r = 0.64), uric acid (r = 0.54), insulin (r = 0.45), LDL-cholesterol (r = 0.43), cholesterol (r =0.33), LDL/HDL ratio (r = 0.47), triglycerides (r = 0.30) and with height standard deviations scores (SDS) (r = 0.23). Age, gender and pubertal stage had no impact on GHBP. In a multiple regression analysis containing age and gender, as well as the anthropometric variables, percent fat mass and waist circumference, as independent variables, associations between GHBP and leptin (P < 0.001), cholesterol (P < 0.01), LDL-cholesterol (P = 0.01), LDL/HDL ratio (P = 0.02), triglycerides (P = 0.01) remained significant. In a final model using the stepwise analysis involving age, gender and all the independent predictors of GHBP, waist circumference (P < 0.001), accounted for 49.5% of the 60.0% total variability in GHBP, while the implication of leptin (P < 0.001), age (P < 0.01) and cholesterol (P < 0.05) increased the predicted variability for 7.5%, 1.9%, and 1.0%, respectively. Serum GHBP was significantly reduced in a subgroup of 104 overweight or obese patients during a diet-induced weight loss programme, the coefficient of correlation between GHBP and leptin after (r = 0.45, P < 0.001) and before weight reduction (r = 0.41, P < 0.001) were comparable.

CONCLUSION

Waist circumference, an indicator of abdominal body fat mass, is a major determinant of GHBP levels during childhood, while leptin may be one candidate for a signal linking adipocytes to the growth hormone receptor related GHBP release. Additionally, elevated serum levels of GHBP may reflect metabolic disturbances of adiposity.

An assessment of the use and impact of ancillary prenatal care services to Medicaid women in managed care

OBJECTIVES

Managed care plans under Medicaid are becoming a usual source of care for low-income pregnant women. This study describes an ancillary prenatal care service intervention developed by one managed care organization (MCO) for Medicaid-enrolled women, assesses the extent to which the intervention services were used, and appraises the influence of the intervention on prenatal care participation.

METHOD

There were 226 intervention and 258 control women with a single live birth delivered between 28 and 44 weeks gestation who (1) were enrolled in the MCO's Medicaid program, (2) were high-risk based on a prenatal risk assessment, and (3) started prenatal care prior to 26 weeks gestation. Less than adequate and intensive prenatal care utilization were chosen as intervention outcomes measures.

RESULTS

Family planning, a 2-month postpartum baby visit, a maternal postpartum visit, and a WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) referral were among the most self-selected intervention services for this population; home health aide and breast-feeding support were the least requested services. Over 90% of those needing family planning or breast-feeding services received the services, while over 20% of the intervention group refused child care, food assistance and family violence referrals, and home health aide and smoking cessation services. The intervention group had a significantly lower risk of less than adequate utilization of prenatal care (OR = .32; 95% CI: 0.17-0.60) and was more likely to have an intensive number of prenatal care visits (OR = 1.61; 95% CI: 1.05-2.48).

CONCLUSIONS

The ability of managed care organizations to provide ongoing prenatal care to Medicaid populations in a cost-effective manner depends partly on their development of packages of prenatal services that foster positive preventive health care utilization behaviors and good pregnancy outcomes. The results of this project suggest that the intervention was beneficial in the area of improving utilization of prenatal care.

Transcription termination factor Rho is essential for Micrococcus luteus

The growth of Micrococcus luteus, a soil microorganism that belongs to the high-G+C gram-positive phylogenetic group, is prevented by bicyclomycin, an antibiotic that inhibits the activity of the M. luteus transcription termination factor Rho. A mutant that can grow in 0.3 mM bicyclomycin has a Rho that is insensitive to bicyclomycin and has the single amino acid residue change of Asp474 to Gly. These results indicate that the function of its Rho factor is essential for M. luteus and that growth of a gram-positive organism can be blocked by bicyclomycin.

Intracerebral capillary telangiectasia and venous malformation: a rare association

BACKGROUND

The vascular malformations of the brain have been classified into arteriovenous, venous, cavernous, and capillary malformations as four discrete entities. Various combinations of two discrete malformations in one lesion have been reported, some of which can be considered as established associations, while others appear to be very rare. Mixed vascular malformations evoke reflections on possible interrelations in the pathogenesis of the discrete components.

CASE DESCRIPTIONS

We report a case of intracerebral capillary telangiectasia associated with a venous malformation in a supratentorial paraventricular location in a 45-year-old woman with a history of headache. The capillary telangiectasia was diagnosed by stereotactic biopsy. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) strongly suggested the presence of a venous malformation by demonstrating a transcerebral draining vein running through the center of the capillary telangiectasia. The association of capillary telangiectasia and venous malformation has been reported only twice before and exclusively in the posterior fossa, as opposed to the more frequent, established associations of capillary telangiectasia and cavernous malformation, and venous malformation and cavernous malformation, respectively.

CONCLUSIONS

Against the background of the established associations, this rare observation possibly places capillary telangiectasias, cavernous malformations, and venous malformations within the spectrum of a single disease. The common pathogenetic role of a focal venous outflow obstruction is discussed.