Spasmodic torticollis and other idiopathic torsion dystonias. Medical management

The pathophysiologic mechanisms of spasmodic torticollis and other idiopathic torsion dystonias remain unknown. Thus, a variety of drugs have been used alone or in combination on an empirical basis to treat these disorders, but to date none have efficacy that is proven and consistent. The drugs in use include anti-cholinergics, benzodiazepines, dopaminergics , and neuroleptics. The variable responses that have been observed are due in part to the heterogeneous nature of these disorders. Trial of several agents or combinations of agents may be necessary before symptoms are satisfactorily controlled. Only when a patient's symptoms are refractory to all medical treatment should he or she be considered a candidate for neurosurgical procedures.

Analysis of the anti-alpha 1 leads to 3 dextran response with monoclonal anti-idiotype antibodies

The antibody response to alpha 1 leads to 3 dextran (DEX) in BALB/c mice consists of a family of closely related yet highly heterogeneous molecules. Although these antibodies have been previously characterized both idiotypically and structurally, detailed analysis of responding clones has not been possible using conventional anti-idiotype antibodies. Monoclonal syngeneic and allogeneic anti-idiotype antibodies (MAIDs) specific for anti-DEX antibodies were used in this study to dissect the serum antibody response to DEX in BALB/c mice. The constructed MAIDs showed considerable heterogeneity by isoelectric focusing and by their binding characteristics to a series of DEX specific myeloma and hybridoma proteins. The predominant heavy chain isotype of these MAIDs was gamma 1. These antibodies were used to identify individual idiotypic structures (IdI) on J558, or M104E as well as cross-reactive determinants common to both (IdX). Although both IdX and IdI MAIDs were obtained, IdI specific antibodies were obtained more frequently. BALB/c mice immunized with DEX produced antibodies expressing both IdI but in highly variable amounts. A large percentage of, but not all DEX specific antibody, could be accounted for by IdX bearing antibodies. Suppression of adult and neonatal mice by IdI specific MAIDs was effective with precise elimination of only those clones expressing IdI determinants leaving the total lambda bearing anti-DEX response intact. Suppression of adults and neonates by an IdX specific MAID resulted in a temporary and partial suppression of the total lambda bearing anti-DEX response along with total suppression of the IdX portion of the response. Unlike other systems these monoclonal antibodies produce only suppression, and under a variety of conditions enhancement of anti-DEX responses has not been observed.

Analysis of the anti-alpha 1 leads to 3 dextran response with monoclonal anti-idiotype antibodies

The antibody response to alpha 1 leads to 3 dextran (DEX) in BALB/c mice consists of a family of closely related yet highly heterogeneous molecules. Although these antibodies have been previously characterized both idiotypically and structurally, detailed analysis of responding clones has not been possible using conventional anti-idiotype antibodies. Monoclonal syngeneic and allogeneic anti-idiotype antibodies (MAIDs) specific for anti-DEX antibodies were used in this study to dissect the serum antibody response to DEX in BALB/c mice. The constructed MAIDs showed considerable heterogeneity by isoelectric focusing and by their binding characteristics to a series of DEX specific myeloma and hybridoma proteins. The predominant heavy chain isotype of these MAIDs was gamma 1. These antibodies were used to identify individual idiotypic structures (IdI) on J558, or M104E as well as cross-reactive determinants common to both (IdX). Although both IdX and IdI MAIDs were obtained, IdI specific antibodies were obtained more frequently. BALB/c mice immunized with DEX produced antibodies expressing both IdI but in highly variable amounts. A large percentage of, but not all DEX specific antibody, could be accounted for by IdX bearing antibodies. Suppression of adult and neonatal mice by IdI specific MAIDs was effective with precise elimination of only those clones expressing IdI determinants leaving the total lambda bearing anti-DEX response intact. Suppression of adults and neonates by an IdX specific MAID resulted in a temporary and partial suppression of the total lambda bearing anti-DEX response along with total suppression of the IdX portion of the response. Unlike other systems these monoclonal antibodies produce only suppression, and under a variety of conditions enhancement of anti-DEX responses has not been observed.

Pregnancy-related changes in the mouse oviduct and uterus revealed by differential binding of fluoresceinated lectins

The binding of 20 fluorescein isothiocyanate (FITC)-labeled lectins to various portions of the pregnant and non-pregnant murine oviduct and uterus was studied by fluorescence microscopy. Five lectins (from Ricinus communis (RCA-I), Maclura pomifera (MPA), Triticum vulgare (wheat germ-WGA), Bauhinia purpurea (BPA), and Ulex europeus (UEA-I] reacted differentially with the epithelium of pregnant as compared with the non-pregnant uterus. The binding of RCA-I, MPA and WGA delineated pregnancy-related changes in the distal oviduct and colliculus tubaris. WGA recognized also pregnancy related changes in the proximal oviduct. The reactivity of the remaining 15 lectins did not distinguish the pregnant and non-pregnant oviduct and uterus, although some of them served to identify specific components of the mouse genital tract. Thus, Soybean lectin (SBA) reacted almost exclusively with the colliculus tubaris. UEA-I alone reacted exclusively with the epithelium of the non-pregnant uterus. RCA-II reacted preferentially with the epithelium of the oviduct and uterus as compared with its weak reactivity with the stroma. Two lectins (from Pisum sativum and Lens culinaris) reacted selectively with stromal cells of the uterus and oviduct. Present data indicate that the differential binding properties of these FITC-labeled lectins can be exploited to identify certain components of the mouse oviduct and uterus and to indicate changes in the cell surface and/or cytoplasm in these structures during pregnancy.

Is angiotensin essential in drinking induced by water deprivation and caval ligation?

The role of the renin-angiotensin system in drinking induced by water deprivation and caval ligation was assessed by infusion of saralasin into the lateral ventricles of rats. This technique was first validated by demonstrating its capability to specifically antagonize drinking to both systemic and central angiotensin II. However, neither the latency to drink nor the amount of water consumed following 24- or 30-h water deprivation was affected by saralasin. Furthermore, saralasin had no significant effect on the recovery of blood pressure or on the water intake following ligation of the abdominal vena cava. These observations suggest that the renin-angiotensin system alone does not play an essential role in the control of drinking following water deprivation or caval ligation in rats.

Altered cerebral inhibition of respiratory and cardiac responses to hypercapnia in acute stroke

Ventilatory and heart-rate responses to hypercapnia were evaluated by a CO2 rebreathing technique in 56 patients with acute ischemic stroke and 14 normal controls. Both ventilatory and heart-rate responses were increased in patients with hemispheral lesions, but not in patients with brainstem lesions. In patients with hemispheral infarct, there was a decrease in CO2 sensitivity 1 to 3 weeks later. Acute hemisphere lesions may result in a transient decrease of cerebral inhibition of brainstem-mediated autonomic responses to a chemical stimulus.

Hypercapnic alteration of visual evoked responses in acute cerebral infarction

To determine the effect of inhaled carbon dioxide on acute ischemic cerebral injury, we have compared occipital visual evoked responses (VER) at baseline and during hypercapnia in 20 patients with acute unilateral cerebral infarction (ten with and ten without homonymous hemianopsia) and in ten normal controls. Visual evoked responses were judged on the basis of interhemispheral symmetry. In eight of ten controls and six of 20 patients, baseline VERs were symmetrical and remained unchanged during hypercapnia. In 14 patients with asymmetrical baseline VERs, hypercapnia caused improvement of symmetry in five, worsening in three, and no change in six. Hypercapnic vasodilation may be either beneficial or deleterious to cerebral function in patients with acute cerebral infarction.

Superficial temporal artery to superior cerebellar artery anastomosis for distal basilar artery stenosis

The conceptualization, rationale and surgical technique involved with a superficial temporal artery to superior cerebellar artery anastomosis for midbrain ischemia in a patient with symptomatic mid-basilar artery stenosis is described and discussed.

Superficial temporal-middle cerebral artery bypass. A detailed analysis of multiple pre- and postoperative angiograms in 40 consecutive patients

Pre- and postoperative angiograms on 40 patients undergoing superficial temporal-middle cerebral artery (STA-MCA) bypass surgery have been examined in detail. Multiple postoperative angiograms have been obtained to evaluate the change in both the bypass circuit and the intracranial circulation over time. A reproducible system for evaluating the degree of intracranial vascular filling via the bypass is introduced. The study shows that the STA and its anastomotic branch increase in size over time, measured in months, in the majority of patients. This is paralleled by a progressive increase in the degree of intracranial vascular filling. These changes are proportional to the severity of the vascular disease before surgery. The pattern of preoperative collateral circulation may change over time following the addition of the bypass circuit. The progressive change over time suggests that a static analysis at one time may belie the true effect of the surgery. The change of collateral circulation with augmentation of blood supply to areas of the brain other than those affected by the recent ischemic event, means that a total cerebral evaluation including neuropsychological testing may be necessary for adequate evaluation of the effect of the bypass surgery.

Superficial temporal to middle cerebral artery anastomosis. Clinical outcome in patients with ischemia of infarction in internal carotid artery distribution

The clinical outcome of our first 40 patients (six with transient ischemic attacks, 22 with mild ischemic infarctions, and 12 with moderate ischemic infarctions) treated with a superficial temporal artery-middle cerebral artery anastomosis was analyzed. All cerebral ischemias or infarctions occurred in the internal carotid artery distribution. An independent neurologist observer recorded the patients preoperative and postoperative medical and neurological histories and objective neurological findings. There was no operative mortality. During the period of observation (up to 36 months), four patients died of probable myocardial infarction. No patient suffered from recurrent cerebral infarction. Three patients experienced a single ischemic event postoperatively. Neurological deficits were either unchanged (21 patients) or improved (19 patients). Postoperative angiograms showed patency in 97% of the anastomoses.

Respiratory rate and pattern disturbances in acute brain stem infarction

Respiratory rates and patterns were studied in 23 patients with acute brain stem infarction using impedance pneumography. Autopsy was obtained in six of eight fatal cases. Pontine lesions were present in all patients, with coexistent infarction of midbrain in four and of medulla in nine. Respiratory rate and pattern abnormalities observed included Cheyne-Stokes respiration, Cheynb-Stokes variant pattern and tachypnea. Abnormalities of respiratory rate and pattern of varying duration were observed at some time in all patients. All patients in whom prominent Cheyne-Stokes respiration or tachypnea were observed had extensive bilateral pontine lesions involving both basal and tegmental portions. However, not all patients with large pontine infarcts had Cheyne-Stokes respiration or tachypnea. Cheyne-Stokes respiration was prominent in four patients (two fatal, two nonfatal). Cheyne-Stokes variant pattern was present frequently in four patients (one fatal, three nonfatal). Sustained tachypnea developed in five patients, four of whom died. In ten patients (one fatal, nine nonfatal), normal respiratory rate and pattern predominated with only rare or occasional apperance of Cheyne-Stokes respiration or Cheyne-Stokes variant pattern, especially during sleep. The types of respiratory rate and pattern abnormalities in acute brain stem infarction were not specifically related to the level of lesions, but rather to the size and bilaterality of the lesions. Respiratory alkalosis was present in varying degrees in most patients with either tachypnea or prominent CSR.

Cerebrospinal fluid in cerebral hemorrhage and infarction

Cerebrospinal fluid (CSF) abnormalities were correlated with pathological diagnoses in 61 patients with autopsy-verified intracerebral hemorrhage or cerebral infarction. Lumbar punctures were performed within one week of onset of symptoms. The CSF color and red blood cell counts were the most useful CSF parameters in differentiating between intracerebral hemorrhage and cerebral infarction. In 75% of the patients with intracerebral hemorrhage, the CSF was either grossly bloody or xanthochromic; in 25%, the CSF was clear. In patients with cerebral infarction, the CSF was never grossly bloody; in two patients with hemorrhagic infarction, the CSF was xanthochromic. The CSF pressure, protein values and leukocyte counts were less useful in differentiating intracerebral hemorrhage from cerebral infarction. Cases with hemorrhagic infarction could not be separated from those with ischemic infarction on the basis of CSF analysis. In clear CSF, the polymorphonuclear neutrophilic leukocyte (PNL) counts were never greater than 20 per cubic millimeter. In xanthochromic or cloudy CSF, leukocyte counts, especially PNLs, were frequently elevated, occasionally to the high levels.

Respiratory pattern disturbances in ischemic cerebral vascular disease

Impedance pneumography was used to monitor respiratory rates and patterns in 49 patients with acute ischemic cerebral vascular disease. Nine patients had clinical evidence of bilateral ischemic cerebral disease. In one of these, normal respiratory pattern was present at all times; in five, there was intermittent Cheyne-Stokes respiration; in two, there were variants of Cheyne-Stokes pattern, and one patient eventually developed sustained tachypnea with probable hyperpnea. Twenty-eight patients had unilateral cerebral infarct. In five of these, normal respiratory pattern was present at all times; in 15, there was intermittent Cheyne-Stokes respiration; six had a variant of Cheyne-Stokes respiration; two had sustained tachypnea with probable hyperpnea. In 12 patients with brainstem infarcts, Cheyne-Stokes respiration was intermittently present in four, Cheyne-Stokes variant patterns were observed in two, and sustained tachypnea with probable hyperpnea developed in six. Abnormalities of respiratory patterns occurred more frequently during sleep, in the presence of a depressed sensorium, and in patients with severe neurological deficits. Respiratory alkalosis of variable degree was present in all patients with Cheyne-Stokes respiration or sustained tachypnea with probable hyperpnea. Cheyne-Stokes respiration was not always related to bilateral cerebral lesions. Intermittent Cheyne-Stokes respiration was not closely related to immediate prognosis. Sustained tachypnea with respiratory alkalosis was associated with the highest mortality rate among patients with respiratory pattern abnormalities.

Ineffectiveness of dexamethasone for treatment of experimental cerebral infarction

Ischemic cerebral edema occurring with cerebral infarction may cause increases of intracranial pressure and neurological deficits or death. Certain other types of cerebral edema are influenced by adrenal glucocorticoids; there is conflicting evidence about effects on ischemic edema, largely due to differences in experimental models and dosages. Therefore, dexamethasone in large doses was studied in 15 cats with experimental cerebral ischemia and infarction produced by transorbital occlusion of one middle cerebral artery (MCA). Five cats received dexamethasone, 4 mg per kilogram intramuscularly, twice daily for two weeks before and two weeks after MCA occlusion; five received dexamethasone for two weeks after occlusion; and five received no dexamethasone. There were no apparent differences among the three groups in the neurological deficits resulting from MCA occlusion, and no statistically significant differences in the sizes of cerebral infarcts. Dexamethasone is ineffective for the treatment of experimental cerebral ischemia produced by MCA occlusion.

Estrogen and progesterone receptor expression in breast carcinoma

Background: Breast carcinoma is the most common malignancy diagnosed among women worldwide and second leading cause of cancer mortality. One of the hallmarks of the disease is expression of estrogen receptor and progesterone receptor that ultimately drives prognosis and treatment modalities of the patient. The objective of this study was to determine the Estrogen and Progesterone receptor status in relation to histological grade of tumor. Materials and Methods: This was an observational study, carried out in the department of Pathology, BP Koirala Memorial cancer Hospital, Bharatpur, from January 2010 to December 2010. A total of 136 patients with histological proven diagnosis of breast carcinoma was included in this study. These cases were graded according to the modified Bloom and Richardson criteria into three histological grades. We used immunohistochemistry to evaluate the expression of Estrogen and Progesterone in relation to histological grade of tumor. Results: Out of 136 cases, there were 131 (96%) cases of infiltrating ductal carcinoma with mean age of 48 years. Majority of cases were grade II (59%) followed by grade III (21%) and grade I (20%). Estrogen Receptor and Progesterone Receptor expression were seen in 28% and 19% respectively. In grade I, 16 (59%) and 10 (37%) cases out of 27 were Estrogen Receptor and Progesterone Receptor positive respectively. In grade II, 21 (26%) and 15(19%) out of 80 cases were Estrogen Receptor and Progesterone Receptor positive respectively. In grade III, 1(3%) and 1 (3%) cases were positive for Estrogen Receptor and Progesterone Receptor respectively. Conclusions: Expression of estrogen and progesterone is comparable to west with Estrogen and Progesterone showing inverse association with histological grades of tumor. Keywords: Breast carcinoma; Estrogen receptor; Progesterone receptor DOI: http://dx.doi.org/10.3126/jpn.v1i2.5401 JPN 2011; 1(2): 100-103

Squamous cell carcinoma arising in ovarian mature cystic teratoma: report of three cases

Malignant transformation of mature cystic teratoma of the ovary is rare. A wide variety of malignant tumors may arise within benign mature cystic teratoma. The most common form of malignant transformation of a mature cystic teratoma is squamous cell carcinoma. We report a series of three cases that developed squamous cell carcinoma in a benign ovarian cystic teratoma. Two of the carcinomas occurred in postmenopausal women: 51-year-old (case # 2) and 60 year-old (case # 3). The first case occurred in a 33-year-old woman. Histologically, all three cases were moderately differentiated squamous cell carcinomas and were confined to the ovaries. The aim of this study was to review our experience with this disease and to review the literature. DOI: http://dx.doi.org/10.3126/jpn.v2i3.6032 JPN 2012; 2(3): 248-250