Clinical progressive supranuclear palsy: differential diagnosis by IBZM-SPECT and MRI

In order to in vivo identify subgroups in eight patients with the clinical diagnosis of progressive supranuclear palsy (PSP), we have performed 123I-iodobenzamide single photon emission computed tomography (IBZM-SPECT), a nuclear medicine technique, to visualize dopamine D2 receptors in vivo, and high resolution (TE/TR 2900/20-90) magnetic resonance imaging (MRI) to evaluate morphological CNS changes. All patients exhibited similar clinical features including supranuclear vertical gaze palsy, especially of downward gaze, predominantly axial rigidity especially in the neck, bradykinesia, instability of balance with easy falls, and poor response to dopaminergic drugs. Specific striatal dopamine D2 receptor binding in IBZM-SPECT, as calculated by a basal ganglia to frontal cortex ratio (BG/FC) was reduced in 5 patients, but normal in 3 patients. In MRI, these 3 patients exhibited multiple hyperintense white matter lesions; 2 of them had no midbrain atrophy. In contrast, all 5 patients with reduced IBZM binding lacked multiple white matter lesions in MRI, but 4 of them showed marked midbrain atrophy. This pilot study with IBZM-SPECT for in vivo imaging of striatal dopamine D2 receptors and T2-weighted MRI supports published neuropathological findings that clinical signs of PSP appeared to be due to heterogeneous neuropathology.

123I-iodobenzamide-SPECT in 83 patients with de novo parkinsonism

Single photon emission computed tomography (SPECT) with 123I-iodobenzamide (123I-IBZM) was used in a prospective study to investigate 83 patients with parkinsonism (Hoehn and Yahr stages I to III) who had not been previously treated with dopamimetic drugs. All patients had clinical signs that were compatible with Parkinson's disease. An additional 13 patients had clinical signs of another basal ganglia disorder, such as progressive supranuclear palsy or multisystem atrophy. 123I-IBZM-SPECT results were compared with clinical responses to subcutaneous injections of the D1/D2-receptor agonist apomorphine (83 patients) and to long-term oral dopamimetic therapy (62 patients). Results from 123I-IBZM-SPECT predicted a positive or negative response to apomorphine in 69 of 76 patients (apomorphine responses were equivocal in 7 patients) and a response to dopamimetic therapy in 54 of 62 patients. All patients with a clinical diagnosis of progressive supranuclear palsy or multisystem atrophy had reduced 123I-IBZM binding. In six of these patients, the response to apomorphine was negative, and none clearly benefited from long-term oral levodopa therapy. Imaging of dopamine D2 receptors with 123I-IBZM-SPECT appears to distinguish between patients with de novo parkinsonism that is levodopa-responsive (probably Parkinson's disease of Lewy body type) and that which does not respond to levodopa therapy.

Reversible hyperkinesia in a patient with autoimmune polyglandular syndrome type I

Autoimmune polyglandular syndrome is characterized by a failure of multiple endocrine organs and the presence of circulating organ-specific autoantibodies targeted against the failing organs. Here we describe a patient with autoimmune polyglandular syndrome type I with the endocrine manifestations of hypoparathyroidism, adrenocortical insufficiency, and insulin-dependent diabetes mellitus. Long-standing hypoparathyroidism led to extensive calcification of the basal ganglia which resulted in the clinical presentation of an extrapyramidal movement disorder (choreoathetotic and hemiballistic hyperkinesia of the left extremities). Interestingly, parallel to rehydration and the initiation of cortisol replacement therapy a complete reversion of the hyperkinetic signs was achieved. This case shows a rare multiendocrine organ failure with complex metabolic interactions resulting in marked neurological signs. Furthermore, this case demonstrates for the first time that a hyperkinetic syndrome--most likely due to hypoparathyroidism-induced basal ganglia calcification--can be reversed solely by adequate treatment of the concomitant endocrine failures.

3H-spiperone binding to lymphocytes fails in the differential diagnosis of de novo Parkinson syndromes

In order to investigate the diagnostic value of 3H-spiperone binding capacity to lymphocytes in the differential diagnosis of de novo Parkinson's disease (idiopathic Parkinson syndrome, PD), we performed a double blind prospective study of spiperone binding capacity of 123 patients and 23 healthy control persons, belonging to different diagnostic groups (PD, Parkinsonian syndrome due to vascular lesions, multiple system atrophy [MSA], essential tremor). Diagnoses were based on medical history, clinical examination, CT or MRI scan, acute response to dopamimetic drugs, one year follow up, and long term response to L-DOPA treatment. Spiperone binding was assayed using ten different concentrations (0.03-3 nmol) in absence or presence of 1 mumol (+)-butaclamol to determine nonspecific binding. There was no significant difference in spiperone binding between patients with PD not treated with L-DOPA, and patients with other basal ganglia disorders including parkinsonian syndrome due to vascular lesions, multiple system atrophy, or progressive supranuclear palsy, and age matched controls. Binding was significantly higher in parkinsonian patients with PD treated with L-DOPA and patients with essential tremor. It is concluded that at present 3H-spiperone binding gives no further information in the differential diagnosis of de novo Parkinson's disease.

Investigation of the origin of variant, truncated estrogen receptor-like mRNAs identified in some human breast cancer biopsy samples

Variant, smaller sized, estrogen receptor-like mRNAs have been previously cloned and sequenced from human breast cancer biopsy samples. In this study we have found that one variant estrogen receptor-like mRNA, clone 24, which is expressed in only one tumor, consists of sequences from the normal ER gene which is found on chromosome 6 and sequences unrelated to the ER which are found normally on chromosome 12. A more commonly occurring variant estrogen receptor-like mRNA, clone 4, contains sequences from the normal ER gene and LINE-1 sequences. Similar but not identical LINE-1 sequences have been found in some of the intervening sequences of the normal ER gene. The generation of these transcripts may involve either alternative splicing or trans-splicing mechanisms.

Decrease of D2 receptors indicated by 123I-iodobenzamide single-photon emission computed tomography relates to neurological deficit in treated Wilson's disease

Single-photon emission computed tomography with 123I-iodobenzamide, a dopamine D2 receptor antagonist, was employed to study dopamine D2 receptor densities in 17 patients with biochemically proved Wilson's disease and stable neurological status with therapy and in 5 age-matched control subjects. Of the 17 patients with Wilson's disease, 5 were neurologically asymptomatic, 3 had cerebellar signs, 1 exhibited a mild parkinsonian syndrome, 7 showed a parkinsonian syndrome and cerebellar signs, and 1 had generalized dystonia and a parkinsonian syndrome. In 5 age-matched control subjects specific isotope binding as calculated by the basal ganglia to frontal cortex ratio was 1.57 +/- 0.04 (mean +/- standard deviation). The ratio in patients with Wilson's disease ranged from 1.56 +/- 0.05 (n = 5, asymptomatic patients) to 1.17 +/- 0.02 (n = 4, marked neurological impairment). We observed an almost linear correlation between the reduction of 123I-iodobenzamide (IBZM) binding and the severity of neurological signs at the time of IBZM-SPECT (correlation coefficient, -0.84; p < 0.01). We suggest that the reduction of postsynaptic striatal dopamine D2 receptors as detected by IBZM-SPECT reflects striatal neuronal damage in Wilson's disease.

Students can learn medicine with computers. Evaluation of an interactive computer learning package in geriatric medicine

OBJECTIVE

To assess the effectiveness of a computer-aided learning program on dementia.

DESIGN

Fourth year medical students were arbitrarily assigned to groups that used a computer-aided learning program (65) or had a tutorial covering similar material (73). These sessions were in addition to a base curriculum in a two-week course in geriatric medicine.

MAIN OUTCOME MEASURES

The effectiveness of the teaching sessions was judged by the performance on a multiple choice questionnaire about dementia, given to the students on two occasions, one at the beginning and one at the end of the two-week course.

RESULTS

Both groups of students scored significantly better on the second test (computer group, 66% [95% confidence interval, 64-69] to 81% [79-83] and tutorial group, 66% [63-67] to 74% [73-77]). The difference between the groups at the start of the course was not significant (F1,136 = 0.61, P = 0.61); however, there was a significant difference between the groups at the end of the course (F1,136 = 21.83, P < 0.001).

CONCLUSION

Both groups improved their knowledge of dementia during the two-week course. Students who used the computer-aided learning programs showed a greater improvement in score. Computer learning programs are effective learning tools and are a useful addition to traditional teaching methods. Further study is required to assess the effects of computer-aided learning programs in long-term studies of dementia knowledge.

Apomorphine test for dopaminergic responsiveness in patients with previously untreated Parkinson's disease

We prospectively examined the predictive value of the apomorphine test for the therapeutic efficacy of sustained oral levodopa treatment in 62 patients with de novo Parkinson syndrome (no additional neurological deficit) who had not previously been treated with dopaminergic medication. Patients received 2 to 5 mg of apomorphine hydrochloride subcutaneously and a subsequent trial of oral levodopa of at least 3 months' duration. In three patients, response to apomorphine could not be evaluated owing to side effects experienced during the test. In the remaining 59 patients, the best predictor of response to oral levodopa was the apomorphine-induced relative decrease in the scores on the motor examination part of the Unified Parkinson Disease Rating Scale (UPDRS). At a cutoff value of 20% improvement in UPDRS scores, the test predicted the response to levodopa correctly in 50 patients (85%). The sensitivity of the test was 90%, specificity 88%. The positive predictive value was 95%. However, seven of 19 apomorphine test-negative patients experienced a good (n = 4) or partial (n = 3) improvement with levodopa therapy. Thus, the negative predictive value was only 63%. We conclude that response to apomorphine has a high predictive value for response to sustained oral levodopa treatment in most previously untreated patients, but a negative test should not preclude an adequate trial of oral levodopa.

Evaluation of the effects of low molecular weight heparin on inflammation and collagen deposition in chronic coxsackievirus B3-induced myocarditis in A/J mice

Coxsackievirus, Group B, type 3 (CVB3) infection of A/J male mice induces chronic myocarditis with increased interstitial fibrosis and collagen deposition. Heparin, a naturally occurring sulfated glycosaminoglycan, has both anti-inflammatory and antifibrotic activities besides its well-known anticoagulant activity. This study determined whether heparin treatment could decrease either cardiac inflammation or fibrosis in chronic CVB3-induced myocarditis. Control mice were either untreated or treated with heparin (4 micrograms/g body weight, subcutaneously 5 times weekly) beginning 2 days before infection of other groups. Additional groups received either virus only (1 x 10(4) plaque-forming units [PFU]), virus followed by heparin beginning 14 days after CVB3 inoculation, or virus and heparin beginning 2 days before CVB3 inoculation. Animals were sacrificed 14, 28, and 58 days after infection. Heparin treatment begun either before or after virus inoculation reduced animal mortality by approximately 20%. Heparin did not alter virus infection or replication in the heart. Histologically, only animals treated with heparin before virus inoculation showed reduced myocardial inflammation, and only at day 58. However, heparin treatment begun either before or after virus infection significantly decreased collagen deposition in the heart (fibrosis).

[Drug modification of post-traumatic edema of the extremities by the proteinase inhibitor aprotinin. An animal experiment study]

Posttraumatic edema remains a serious problem in traumatology. Unrecognized or improperly treated, edema poses a threat to the survival of any extremity, particularly the hand, where a number of intricate functional structures are at stake. This study, as well as other recent clinical and experimental work, show that aprotinin, a proteinase inhibitor, is valuable in the treatment of posttraumatic edema, provided it is given as early as possible and in an adequate dosage.

Molecular cloning and functional expression of mouse connexin40, a second gap junction gene preferentially expressed in lung

From a mouse genomic library, a clone has been isolated that codes for a connexin-homologous sequence of 358 amino acids. Because of its theoretical molecular mass of 40.418 kD it is named connexin40 (Cx40). Based on both protein and nucleotide sequence, mouse Cx40 is more closely related to mouse Cx43 (alpha subgroup of connexins) than to mouse Cx32 (beta subgroup). The highest overall homology detected, however, was to chick Cx42 (67% amino acid and 86% nucleotide identity), raising the possibility that Cx40 may be the mouse analogue. The coding region of Cx40 is uninterrupted by introns and is detected as a single copy gene in the mouse genome. High stringency hybridization of Northern blots with the coding sequence of Cx40 identified a single transcript of 3.5 kb that is at least 16-fold more abundant in lung-similar to mouse Cx37-than in other adult tissues (kidney, heart, and skin). In embryonic kidney, skin, and liver the level of the Cx40 transcript is two- to fourfold higher than in the corresponding adult tissues. Microinjection of Cx40 cRNA into Xenopus oocytes induced functional cell-to-cell channels between pairs. These channels show a symmetrical and markedly cooperative closure in response to transjunctional voltage (Boltzmann parameters of Vo = +/- 35 mV; A = 0.32) which is also fast relative to other connexin channels recorded similarly (tau = 580 ms at Vj of +/- 50 mV). Although Cx40-expressing oocytes did not couple efficiently with oocytes expressing endogenous connexins, they did couple well to Cx37-expressing oocytes. The heterotypic channels which formed had voltage-gating properties modified from those of the original homotypic forms. Transfection of mouse Cx40 DNA, under control of the SV-40 early promoter, into coupling-deficient human HeLa or SK-Hep-1 cells resulted in expression of the expected transcript and restoration of fluorescent dye transfer in transfected clones.

Folinic acid therapy fails to improve early Parkinson's disease: a two week placebo controlled clinical trial

Folinic acid (15 mg bid, po) was administered in a two week, double-blind, placebocontrolled, cross over clinical trial in 5 patients with Parkinson's disease (Hoehn and Yahr stage I or II). 4 patients had not been on L-dopa treatment prior to entering this trial and one patient was on a small dose of L-dopa. No significant improvement could be detected in this pilot study by clinical evaluation and motor performance assessed by a computer assisted motor performance test.

123I-iodobenzamide-SPECT predicts dopaminergic responsiveness in patients with de novo parkinsonism

We used 123I-iodobenzamide-single photon emission computed tomography (IBZM-SPECT) in a prospective study to investigate 38 patients with parkinsonism (Hoehn and Yahr stage I to III) not previously treated with dopamimetic drugs. Thirty-four patients only showed symptoms of Parkinson's disease, and four patients showed, in addition, subtle clinical signs of progressive supranuclear palsy or multisystem atrophy. IBZM is a dopamine D2 receptor antagonist detectable by SPECT. We compared IBZM-SPECT results with clinical response to subcutaneous injections of the D1/D2 dopamine receptor agonist apomorphine (38 patients) and long-term dopamimetic therapy (31 patients). IBZM-SPECT results predicted a positive or negative response to apomorphine in 30 of 34 patients (apomorphine response in four patients was equivocal) and response to dopamimetic therapy in 27 of 31 patients. Thus, imaging of dopamine D2 receptors using readily available IBZM-SPECT seems to distinguish between L-dopa-responsive (most likely Parkinson's disease of Lewy body type) and L-dopa-unresponsive parkinsonism in patients not previously treated with dopamimetic drugs.

Marked reduction of striatal dopamine D2 receptors as detected by 123IBZM-SPECT in a Wilson's disease patient with generalized dystonia

[123I]iodobenzamide-single photon emission computed tomography (IBZM-SPECT) was employed to study the distribution of dopamine D2 receptors in a patient with biochemically proven Wilson's disease presenting with generalized dystonia. IBZM is a dopamine D2 receptor antagonist with high affinity and specific binding to basal ganglia detectable by SPECT. IBZM-SPECT in this patient (age, 20 years) displayed a striatum to frontal cortex ratio of 1.2 compared to 1.55 +/- 0.05 (mean +/- SD) in normal controls (n = 7; mean age, 53.3 years). In parallel with this finding, MRI with heavily T2-weighted sequences showed atrophy and low signal intensity changes of the basal ganglia. There was no improvement of dystonia after a subcutaneous injection of apomorphine. In contrast, IBZM-SPECT of a neurologically asymptomatic Wilson's disease patient (age, 21 years) displayed a striatum to frontal cortex ratio of 1.6. The MRI scan of this patient was normal. It is suggested that the observed apomorphine-unresponsive generalized dystonia in this Wilson's disease patient is related to striatal lesions proven by IBZM-SPECT and MRI.

SPECT imaging of dopamine D2 receptors with 123I-IBZM: initial experience in controls and patients with Parkinson's syndrome and Wilson's disease

123I-(S-)-2-hydroxy-3-iodo-6-methoxy-N[(1-ethyl-2-pyrrolidinyl) methyl]-benzamide (123I-IBZM) is a highly selective CNS D2 dopamine receptor ligand suitable for SPECT. This study reports on IBZM-SPECT findings in 60 patients including eight controls and 52 patients presenting with disorders of the dopaminergic system, including idiopathic Parkinson's syndrome (IPS) (n = 18), Parkinson's syndromes of other aetiology (PS) (n = 24) and Wilson's disease (n = 10). SPECT was performed 2 h p.i. of 185 MBq 123I-IBZM. For semiquantitative evaluation basal ganglia to frontal cortex ratios (BG/FC ratios) were calculated. In controls BG/FC ratios of 1.55 +/- 0.05 S.D. were observed. Findings in IPS patients (BG/FC ratio: 1.51 +/- 0.05) were not different from controls. In PS patients striatal IBZM binding (BG/FC ratio: 1.35 +/- 0.11) was significantly (P less than 0.001) lower compared to the control and IPS groups. Asymptomatic patients with Wilson's disease presented normal IBZM binding. In those with neurologic symptoms IBZM fixation was markedly reduced. IBZM-SPECT has shown to be a suitable means for in vivo imaging of striatal dopamine D2 receptors in controls and various disorders of the dopaminergic system. Our preliminary data suggest that IBZM-SPECT is potentially useful for discriminating between IPS and PS (sensitivity: 100%; specificity: 83%). In patients with Wilson's disease IBZM accumulation seems to correlate with the presence of neurologic symptoms.

Cardiac myofibroblasts express alpha smooth muscle actin during right ventricular pressure overload in the rabbit

A number of changes occur in contractile proteins and mechanical performance of the heart within 2 weeks of right ventricular pressure overload in 8- to 12-week-old rabbits. These changes are accompanied by increases in collagen concentration and the ratio of type I to type III collagen. The purpose of the present study was to evaluate the evolution of these connective tissue changes morphologically and to characterize the interstitial cells that might be responsible. The myocardium is infiltrated by mononuclear inflammatory cells 2 days after banding, accompanied by focal myocyte necrosis. By 7 days, the inflammatory infiltrates subside and the damaged myocytes seen at 2 days are replaced by new collagen and a population of spindle-shaped cells, with ultrastructural features of myofibroblasts. A significant proportion of these cells contain alpha smooth muscle actin by immunohistochemical analysis. At 14 days, there is a large increase in stainable collagen with complex remodeling and reduplication of the collagen fiber network of the interstitium. Alpha smooth muscle actin-containing myofibroblasts persist, but their immunoreactivity appears reduced compared with day 7. The authors hypothesize that the interstitial fibroblasts that acquire smooth-muscle-like features in this model play a critical role in the heart's response to severe and sudden mechanical stress and are at least partly responsible for the changes in connective tissue that occur as a result of pressure overload in this model.

[Analysis of environmentally-conditioned and genetic influences on the frequency of hip joint dysplasia in German Shepherd dogs]

The importance of environmental and genetic influences on the frequency of hip dysplasia was studied in 10,595 German shepherd dogs. Systematic effects were analysed using mixed linear and mixed nonlinear threshold models. Following effects were regarded in the models applied: sire and mother of the dog as random effects, age at x-raying, sex, birth year and season of the x-rayed dogs, litter size, percentage of x-rayed dogs in each litter and sex ratio of the litter as fixed effects. Sire, mother, sex and age at x-raying showed significant influence on the occurrence of hip dysplasia. The heritability estimates in a hierarchical data design (sire, mother within sire) for the polychotomous trait hip dysplasia were for full sibs h2 = 0.30, for maternal half sibs h2 = 0, 48, and for paternal half sibs h2 = 0.11. Only the heritability estimates of the paternal half sibs seem to be reliable because kennel and breeder effects are confounded with the mother effect. Analysing the frequency of hip dysplasia as all-or-none traits, the heritability estimates were usually lowered by 50%. Selection programmes to reduce frequency of hip dysplasia can be improved if the estimation of breeding values with respect to environmental effects and frequency of hip dysplasia in all relatives will be implemented.

[Design of and involvement in an interventional study on health education in basic schools: the Pforzheim Study]

We report the design and the determinants of participation in a controlled, randomized trial evaluating the efficiency of a school-based health education and promotion program. The health education program "Gesund leben macht Spass" ("Healthy living is fun") was developed by the AOK Pforzheim, a statutory health insurance organization in South West Germany. In this 7 week program, the body structure is presented systematically, and the children themselves are asked to correlate structure with function. During the fall of 1988, 490 pupils in 22 third grade level classes at 11 primary schools in Pforzheim and vicinity were invited to participate in a health survey (378 consenting parents = 77.1%). Ten schools with 19 classes and 413 students were admitted to the study (333 participating students = 80.6%). One year later, 290 children (70.2%) were available for follow up. Both examinations covered body weight and height, blood pressure level, total cholesterol, and the assessment of health related knowledge, attitudes and behavior by a repeat questionnaire. Parental consent rates in participating schools varied between 66.7% and 100%. Initial student participation was distinctly higher in schools in a rural (85.2%) as compared to an urban environment (73.2%), and among children of German nationals (83.2%) as compared to children of other nationalities (70.9%). After one year, participation rates in these groups approached each other. Schools in the intervention and control groups were similar in sociodemographic characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)