Congenital midline cleft of the posterior arch of atlas: a rare cause of symptomatic cervical canal stenosis

Developmental symptomatic C1 canal stenosis is very rare. We describe the computed tomography (CT) and magnetic resonance imaging (MRI) appearances in a 8-year-old child who presented with progressive upper and lower limb neurological symptoms and in whom imaging revealed the medial posterior hemiarches of a bifid C1 to be inturned and compressing the cervical cord. This particular configuration of the posterior arch of atlas is frequently associated with other craniocervical bony anomalies and presents with neurological symptoms early in life. Early CT or MRI examination of patients with symptomatic posterior arch of C1 defects is necessary, in order to detect such an appearance, since surgical treatment may prevent neurological deterioration.

Synthesis of antitumor dendritic imides

Dendritic imides were synthesized and evaluated as antitumor compounds. Compounds 8 and 11 showing a promising profile as inhibitors of lck but their antiproliferative activity against HT-29 was not so relevant.

High-meat, low-carbohydrate diet in pregnancy: relation to adult blood pressure in the offspring

To examine the hypothesis that a high-animal protein, low-carbohydrate diet in pregnancy is associated with raised blood pressure in the adult offspring, we performed a follow-up study of 626 men and women in Motherwell, Scotland, whose mothers' food intake had been recorded during pregnancy. The mothers had taken part in a dietary intervention in which they were advised to eat 1 lb (0.45 kg) of red meat per day and to avoid carbohydrate-rich foods during pregnancy. The offspring were followed up at age 27 to 30 years, and their systolic and diastolic blood pressures were measured. Women who reported greater consumption of meat and fish in the second half of pregnancy had offspring with higher systolic blood pressure in adult life (regression coefficient, 0.19 mm Hg per portion per week; 95% confidence interval, 0.04 to 0.35; P=0.02). High maternal consumption of fish, but not meat, was associated with higher diastolic blood pressure in the offspring (regression coefficient, 1.00 mm Hg per portion per week; 95% confidence interval, 0.18 to 1.82; P=0.02). These associations were independent of maternal blood pressure, body size, and smoking habits during pregnancy. Although we cannot exclude confounding by maternal saturated fat or salt intake, the findings support those of a study in Aberdeen showing higher blood pressure in men and women whose mothers had eaten a high-animal protein, low-carbohydrate diet in late pregnancy. These associations may reflect the metabolic stress imposed on the mother by an unbalanced diet in which high intakes of essential amino acids are not accompanied by the nutrients required to utilize them.

Ex vivo purging by adenoviral p53 gene therapy does not affect NOD-SCID repopulating activity of human CD34+ cells

Co-incubation of a replication-deficient, recombinant adenovirus carrying the wild-type p53 gene (rAd-p53) and hematopoietic stem cell (HSC) products from patients with breast cancer can significantly reduce tumor cell contamination. Whereas this approach provides a powerful tumor cell purging strategy, potential detrimental effects on the HSC population have not been investigated. The ability of human HSC to reconstitute hematopoiesis in severe combined immunodeficient (SCID) mice and to undergo secondary transplantation provides the only nonclinical measure of self-renewing, stem cell function. The objective of this study was to investigate whether co-incubation with rAd-p53 compromised the SCID repopulating activity (SRA) of HSC. Granulocyte colony-stimulating factor-mobilized human CD34+ cells were co-cultured with rAd-p53 at our targeted clinical dose, and the ability of these cells to establish multilineage hematopoiesis in sublethally irradiated, nonobese diabetic (NOD)-SCID mice was investigated. The persistence of human cells in the mice was investigated by flow cytometry, granulocyte-macrophage colony-forming unit assay, and polymerase chain reaction of human Alu sequences. Further, limiting dilution analysis provided a quantitative comparison between the SRA of CD34+ cells co-incubated with rAd-p53 and control CD34+ cells (no rAd-p53 co-incubation). We conclude that co-incubation with rAd-p53 has little effect on the SRA of HSC.

A commonly recognized simian immunodeficiency virus Nef epitope presented to cytotoxic T lymphocytes of Indian-origin rhesus monkeys by the prevalent major histocompatibility complex class I allele Mamu-A*02

The ability to monitor vaccine-elicited CD8(+) cytotoxic T-lymphocyte (CTL) responses in simian immunodeficiency virus (SIV)- and simian-human immunodeficiency virus (SHIV)-infected rhesus monkeys has been limited by our knowledge of viral epitopes predictably presented to those lymphocytes by common rhesus monkey MHC class I alleles. We now define an SIV and SHIV Nef CTL epitope (YTSGPGIRY) that is presented to CD8(+) T lymphocytes by the common rhesus monkey MHC class I molecule Mamu-A*02. All seven infected Mamu-A*02(+) monkeys evaluated demonstrated this response, and peptide-stimulated interferon gamma Elispot assays indicated that the response represents a large proportion of the entire CD8(+) T-lymphocyte SIV- or SHIV-specific immune response of these animals. Knowledge of this epitope and MHC class I allele substantially increases the number of available rhesus monkeys that can be used for testing prototype HIV vaccines in this important animal model.

Excessive T cell depletion of peripheral blood stem cells has an adverse effect upon outcome following allogeneic stem cell transplantation

We evaluated the outcome of two modes of T cell depletion for HLA-identical sibling stem cell transplants in 34 consecutive adult patients: group A (n = 11) received PBSC post CliniMACs immuno-magnetic enrichment of CD34(+) cells and group B (n = 23) received bone marrow following in vitro incubation with CAMPATH-1M and complement. All patients received an identical conditioning regimen which consisted of in vivoCAMPATH-1H 20 mg over 5 days, thiotepa 10 mg/kg, cyclophosphamide 120 mg/kg and 14.4 Gy TBI. No additional graft-versus-host disease prophylaxis was given. The mean T cell dose administered was 0.02 +/- 0.05 x 10(6)/kg for group A and 2.8 +/- 2.8 10(6)/kg for group B (P < 0.001). With a median follow-up of 28 months overall survival was 36.4% for group A at 12 months compared to 78.3% for group B (P = 0.001). Transplant-related mortality in group A at 12 months was 63.6% as compared to 18.0% in group B (P = 0.003). Most of the procedure-related deaths in group A occurred secondary to infection. These results suggest that extensive in vitro T cell depletion of peripheral blood stem cells in combination with in vivo T cell depletion may have profound effects upon the incidence of infections following allogeneic stem cell transplantation and this may adversely effect transplant-related mortality.

Blockade of NMDA receptors by MK-801 reverses the changes in striatal glutamate immunolabeling in 6-OHDA-lesioned rats

A lesion of the dopamine (DA)-containing nigrostriatal pathway with 6-hydroxydopamine (6-OHDA) results in an increase in the density of nerve terminal glutamate immunolabeling and in the mean percentage of asymmetrical synapses containing a discontinuous postsynaptic density [Meshul et al. (1999) Neuroscience 88:1-16]. Similar alterations in striatal glutamate synapses have been reported following blockade of striatal DA D-2 receptors with subchronic haloperidol treatment [Meshul et al. (1994) Brain Res 648:181-195]. The haloperidol-induced change in glutamate synapses was blocked by coadministration of the N-methyl-D-aspartate (NMDA) noncompetitive receptor antagonist MK-801. In order to determine if blockade of NMDA receptors could alter the density of nerve terminal glutamate immunolabeling following a 6-OHDA lesion of the nigrostriatal pathway, MK-801 was administered to lesioned animals for 14 days. In addition, the number of apomorphine-induced contralateral rotations was determined prior to and following the administration of MK-801. MK-801 administration reversed the increase in the density of nerve terminal glutamate immunolabeling due to a 6-OHDA lesion. There was a small but significant decrease in the number of apomorphine-induced contralateral rotations following administration of MK-801 compared to the number of rotations prior to treatment with the NMDA antagonist. These results demonstrate that blockade of postsynaptic NMDA receptors affects the density of presynaptic glutamate immunolabeling and that this change in nerve terminal glutamate density is associated with a decreased behavioral response to direct DA receptor stimulation. Whether the effect of MK-801 is directly on the striatum or acts through other excitatory pathways of the basal ganglia remains unclear.

Outpatient nurses: from handmaiden to autonomous practitioner

Little seems to have been written about health promotion in outpatients' departments. This article argues that outpatient nurses have the potential to play a significant part in promoting people's health. Outpatient nurses may be the first hospital nurses that an individual meets. What people observe and how they are treated may make a difference to both their experience of hospital care and their health. Outpatient nurses may have been perceived as the doctors' handmaidens of yesterday, but today they are evolving into an effective force for change. For example, evaluation of nurse-led outpatients' clinics is showing that they have the potential to complement doctor-led clinics and improve the healthcare experience of patients. It is argued that the health-promoting role of the outpatient nurse can be enhanced by a department that is a health-promoting environment.

[Non-neoplastic arthropathies of the temporomandibular joint]

The pathologic conditions that involve the TMJ are similar to those conditions that involve other joints in the body. Therefore, many of the radiologic characteristics are also similar. Nevertheless, because of the complex structure and function of this small joint, it is essential to know the variety of diseases that can involve the temporomandibular joint. It is also important to understand that functionally both TMJ's act as a single unit and that any alteration in function caused by a pathologic process on one side may lead to dysfunction on the contralateral side. It is essential that the radiologist is familiar with the principles of TMJ function as well as TMJ pathology.

[Postoperative temporomandibular joint diagnosis]

Postoperative management of patients suffering from symptoms of the temporomandibular joint does not differ considerably from the one of preoperative examination protocols. Knowledge of previous surgery helps to plan patient work-up and to interpret normal postoperative findings (eminectomy, discectomy, susceptibility artefacts from metallic residues...) and typical complications (intraarticular loose bodies, dislocations, avascular necrosis, foreign body granulomatous reactions) appropriately.

[Traumatic temporomandibular joint injuries]

Injuries of the temporomandibular joint are mostly due to injuries or fractures of the mandibular condyle. Fractures of the skull base involving the temporomandibular joint are rare. Classification of fractures refers to their anatomical positions and the presence or absence of a luxation. Further, it is important whether the fracture is intra- or extra-capsular. The primary imaging method should be orthopantomography. As for therapy planning, especially surgery, also evaluation of soft tissue is necessary, computed tomography is the imaging method of choice. For diagnosis of complications or internal derangement of the temporomandibular joint, magnetic resonance imaging is to be recommended.

Neonatal bone mass: influence of parental birthweight, maternal smoking, body composition, and activity during pregnancy

Evidence is accumulating that intrauterine growth and development may influence an individual's risk of osteoporosis in later adult life. To examine maternal and paternal influences on intrauterine skeletal growth, we used dual-energy X-ray absorptiometry to measure the neonatal bone mineral content (BMC) and bone mineral density (BMD) of 145 infants born at term. Independently of the infant's duration of gestation at birth, the birthweights of both parents and the height of the father were positively correlated with neonatal whole body BMC. Women who smoked during pregnancy had infants with a lower whole body BMC and BMD; overall, there was a 7.1-g (11%) average difference between whole body BMC of infants whose mothers did and did not smoke during pregnancy (p = 0.005). Women with thinner triceps skinfold thicknesses (reflecting lower fat stores) and those who reported a faster walking pace and more frequent vigorous activity in late pregnancy also tended to have infants with a lower BMC and BMD (p values for BMC; 0.02, 0.03, and 0.05, respectively). Maternal thinness and faster walking pace but not maternal smoking or parental birthweight also were associated with lower bone mineral apparent density (BMAD). The influences on skeletal growth and mineralization were independent of placental weight, a marker of the placental capacity to deliver nutrients to the fetus. These observations point to a combination of genetic and intrauterine environmental influences on prenatal skeletal development and suggest that environmental modulation, even at this early stage of life, may reduce the risk of osteoporosis in adulthood.

[Internal derangement of the temporomandibular joint]

Internal Derangement is one of the most common disorders of the Temporomandibular joint. It is defined as an abnormal anatomical relationship between the discus articularis and the other structures of the temporomandibular joint. More than 2/3 of patients with clinical symptoms of the temporomandibular joint have an internal derangement. The most frequent finding in internal derangement is an anterior dislocation of the disc with reduction after mouth opening. In more severe cases a complete anterior dislocation is found without reduction of the disc. Internal derangement is a risk factor for developing osteoarthritis with remodeling of the condylus and the fossa mandibularis. The most important modalities of radiologic diagnosis are arthrography, CT and MRI. The diagnosis of craniofacial dysfunction has been improved dramatically by modern imaging techniques, which have become essential tools for primary diagnostic and evaluation after conservative or surgical therapy. MRI has become the gold standard.

Isolated familial hypomagnesaemia with novel neurological features: causal link or chance concurrence?

We report a patient with isolated familial hypomagnesaemia with hypocalciuria, a rare congenital disorder of magnesium metabolism. During adolescence the patient developed neurological and ophthalmological features not hitherto reported in this condition, including seizures, myoclonus, and retinal pigmentary degeneration. These suggested the phenotype of mitochondrial disease, which has been occasionally reported in association with hypomagnesaemia, but subsequent investigations of mitochondrial function were normal. The pathogenesis of this unusual neurological and ophthalmological syndrome therefore remains uncertain.

Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London

OBJECTIVE

To examine the maternal and foetal risks of adverse pregnancy outcome in relation to maternal obesity, expressed as body mass index (BMI, kg/m(2)) in a large unselected geographical population.

DESIGN

Retrospective analysis of data from a validated maternity database system which includes all but one of the maternity units in the North West Thames Region. A comparison of pregnancy outcomes was made on the basis of maternal BMI at booking.

SUBJECTS

A total of 287,213 completed singleton pregnancies were studied including 176,923 (61.6%) normal weight (BMI 20--24.9), 79 014 (27.5%) moderately obese (BMI 25--29.9) and 31,276 (10.9%) very obese (BMI> or =30) women.

MEASUREMENTS

Ante-natal complications, intervention in labour, maternal morbidity and neonatal outcome were examined and data presented as raw frequencies and adjusted odds ratios with 99% confidence intervals following logistic regression analysis to account for confounding variables.

RESULTS

Compared to women with normal BMI, the following outcomes were significantly more common in obese pregnant women (odds ratio (99% confidence interval) for BMI 25--30 and BMI> or =30 respectively): gestational diabetes mellitus (1.68 (1.53--1.84), 3.6 (3.25--3.98)); proteinuric pre-eclampsia (1.44 (1.28--1.62), 2.14 (1.85--2.47)); induction of labour (2.14 (1.85--2.47), 1.70 (1.64--1.76)); delivery by emergency caesarian section (1.30 (1.25--1.34), 1.83 (1.74--1.93)); postpartum haemorrhage (1.16 (1.12--1.21), 1.39 (1.32--1.46)); genital tract infection (1.24 (1.09--1.41), 1.30 (1.07--1.56)); urinary tract infection (1.17 (1.04-1.33), 1.39 (1.18--1.63)); wound infection (1.27 (1.09--1.48), 2.24 (1.91--2.64)); birthweight above the 90th centile (1.57 (1.50--1.64), 2.36 (2.23--2.50)), and intrauterine death (1.10 (0.94--1.28), 1.40 (1.14--1.71)). However, delivery before 32 weeks' gestation (0.73 (0.65--0.82), 0.81 (0.69--0.95)) and breastfeeding at discharge (0.86 (0.84--0.88), 0.58 (0.56--0.60)) were significantly less likely in the overweight groups. In all cases, increasing maternal BMI was associated with increased magnitude of risk.

CONCLUSION

Maternal obesity carries significant risks for the mother and foetus. The risk increases with the degree of obesity and persists after accounting for other confounding demographic factors. The basis of many of the complications is likely to be related to the altered metabolic state associated with morbid obesity.

Comparison of selective media for the recovery and enumeration of probiotic yeasts from animal feed

Six selective media (acidified malt extract agar, CHROMagar Candida, dichloran rose bengal chloramphenicol, molybdate, oxytetracycline glucose yeast extract and Petrifilm Yeast and Mould agar) were examined for the recovery of three yeasts commonly used in animal feeds as probiotic additives (Candida pintolopesii, C. saitoana and Saccharomyces cerevisiae). The highest recovery was obtained on oxytetracycline glucose yeast extract agar, although this was susceptible to overgrowth by moulds. CHROMagar Candida also gave good recovery and species were easily discriminated by the differential colour formation of colonies.

Cerebellar fits in children with Chiari I malformation

OBJECT

The authors describe a series of children with Chiari I malformation who presented with fulminating symptoms of "cerebellar fits" characterized by drop attacks with or without deterioration of consciousness, opisthotonic posturing, and varying degrees of respiratory compromise.

METHODS

A retrospective analysis was undertaken of the medical records of 47 consecutive patients undergoing surgery for symptomatic Chiari I malformations at Rainbow Babies and Children's Hospital. Thirteen (28%) of the 47 patients presented with complaints consistent with cerebellar fits. Before the correct diagnosis was made, nine (69%) of the 13 children had previously undergone evaluation with electroencephalography and/or electrocardicography and Holter monitoring because of suspected cortical epilepsy or cardiogenic syncope. In each of the 13 children magnetic resonance imaging demonstrated pegged cerebellar tonsils herniated below the foramen magnum. A deep indentation or blanched discoloration of the cerebellar tonsils was noted in five (38%) of these 13 patients at the time of surgery. Of patients with symptomatic Chiari I malformations, the mean degree of tonsillar herniation was significantly less for those in whom cerebellar fits occurred than those in whom they were absent (8.8 mm and 13.9 mm, respectively; p = 0.007). In only one of the patients with cerebellar fits was a syrinx present, and this was a small focal lower thoracic collection. Spells resolved after surgery in all patients who presented with cerebellar fits.

CONCLUSIONS

Cerebellar fits may mimic other disorders such as cardiogenic syncope and epileptic seizures. The correct diagnosis may be delayed or the conditions may be misdiagnosed by those who fail to consider Chiari I malformation as a cause of drop attacks, abnormal extensor posturing, and apneic spells in children. The response to decompressive surgery in these patients is gratifying.

Prospective study of recovery following neonatal brachial plexus injury

The prognosis for recovery from brachial plexus injury sustained at or before birth is generally favorable. However, roughly 10% of these infants remain profoundly weak and later exhibit functional disability in the affected arm. Early identification of these at-risk infants would be helpful in selecting patients for surgical management. In our prospective study, 80 infants with brachial plexus injury were examined on a monthly basis. Complete recovery occurred in 53 (66%); in 9 (11%), mild weakness persisted. In each child, recovery to antigravity strength in the biceps, triceps, and deltoid was noted by 6 months of age. Moderate arm weakness persisted in 7 children (9%); none had antigravity strength in the deltoid at age 6 months. Eleven children (14%) had severe permanent weakness (mean follow-up: 4.4 years). At age 6 months, these individuals exhibited at best 2/5 strength proximally and typically 0-1/5 strength in the wrist and finger extensors. Our results demonstrate that detailed strength testing up to 6 months of age predicts not only complete recovery of neonatal brachial plexus injury but also those children destined for long-term severe disability.