Optimization of Gamma knife treatment planning via guided evolutionary simulated annealing

We present a method for generating optimized Gamma Knife (Elekta, Stockholm, Sweden) radiosurgery treatment plans. This semiautomatic method produces a highly conformal shot packing plan for the irradiation of an intracranial tumor. We simulate optimal treatment planning criteria with a probability function that is linked to every voxel in a volumetric (MR or CT) region of interest. This sigmoidal P+ parameter models the requirement of conformality (i.e., tumor ablation and normal tissue sparing). After determination of initial radiosurgery treatment parameters, a guided evolutionary simulated annealing (GESA) algorithm is used to find the optimal size, position, and weight for each shot. The three-dimensional GESA algorithm searches the shot parameter space more thoroughly than is possible during manual shot packing and provides one plan that is suitable to the treatment criteria of the attending neurosurgeon and radiation oncologist. The result is a more conformal plan, which also reduces redundancy, and saves treatment administration time.

Immune response to chlamydial 60-kilodalton heat shock protein in tears from Nepali trachoma patients

Although the host immune response to the 60-kDa chlamydial heat shock protein (hsp60) has been implicated in trachoma pathogenesis, no studies have examined mucosal immune responses to hsp60 in populations for which chlamydia is endemic. Tears and sera from Nepali villagers were reacted against hsp60 fusion proteins, whole hsp60, and the major outer membrane protein (MOMP). Tears from villagers without disease were anti-hsp60 immunoglobulin G (IgG) reactive in 6 (38%) of 16 villagers compared with 36 (90%) of 40 with follicular trachoma (TF) (P < 0.001); 47 (89%) of 53 with inflammatory trachoma (TI) (P < 0.001); and 31 (84%) of 37 with conjunctival scarring (TS) (P = 0.002). By multivariate analysis, odds ratios for tear hsp60 IgG immunoreactivity in villagers with TF, TI, and TS were 49.2 (confidence interval [CI], 2.7 to 898), 22.6 (CI, 3 to 170), and 13.6 (CI, 1.4 to 133), respectively. There were no significant differences for tear IgA or secretory IgA (sIgA) reactivity to hsp60 or for tear sIgA and IgG reactivity to MOMP. Serum anti-hsp60 IgG immunoreactivity was associated with TI only. These data suggest that anti-hsp60 IgG immunoreactivity represents largely locally derived antibodies, which may promote disease pathology. In contrast, nonspecific high rates of anti-hsp60 sIgA antibodies suggest chronic or repeat stimulation from an endemic source of organisms.

Paraneoplastic pemphigus: an association with fludarabine?

Paraneoplastic pemphigus is a relatively recently described immunobullous disease with characteristic features. We report three cases of paraneoplastic pemphigus in adult men with chronic lymphocytic leukaemia arising within a week of completion of treatment with fludarabine. In all cases, withdrawal of fludarabine and treatment of the blistering was associated with marked cutaneous improvement. Fludarabine, a synthetic nucleoside analogue, which has only been available in Britain since 1994, is known to be associated with autoimmune phenomena and may have been involved in the development of paraneoplastic pemphigus in these cases.

Alterations in fibrillin as well as collagens I and III and elastin occur in vulval lichen sclerosus

BACKGROUND

The clinical features of lichen sclerosus, which include atrophy, scarring, fragility and tendency to form ecchymoses with only slight trauma, suggest that there is an alteration in the extracellular matrix fibres that are responsible for the tensile strength of the dermis. However, the precise nature of these changes is poorly understood.

METHODS

Biopsies from 16 patients with untreated, histologically confirmed, vulval lichen sclerosus were examined immunohistochemically using polyclonal antibodies to collagens I and III and a monoclonal antibody to elastin. Twelve of the lichen sclerosus specimens were also stained with a monoclonal antibody to fibrillin. Normal vulva tissue and patients' uninvolved thigh were used as controls.

RESULTS

In the lichen sclerosus specimens, collagens I and III stained with a more homogeneous pattern than in the control tissues. Reduced numbers of elastin fibres were seen in the zone of sclerosus in 15 of the 16 lichen sclerosus specimens. In the control tissue fibrillin fibres were seen as a fine network of fibres in the upper dermis arranged at right angles to and inserting into the basement membrane and forming a fine network throughout the dermis. In the lichen sclerosus specimens, although fibrillin microfibrils were still seen inserting at right angles into the basement membrane, below this the fibrillin staining was reduced in the upper dermis in 11 of the 12 lichen sclerosus specimens. The zone of reduced fibrillin staining was greatest in those specimens where the band of inflammation was deep in the dermis.

CONCLUSIONS

The distribution of collagens I and III, elastin and fibrillin are altered in lichen sclerosus and this is likely to contribute to the fragility, scarring and atrophy seen clinically in lichen sclerosus.

Persistent Chlamydia trachomatis infections resist apoptotic stimuli

Microbial modulation of apoptosis has added a new dimension of understanding to the dynamic interaction between the human host and its microbial invaders. Persistent infection can be a by-product of inhibition of apoptosis and may significantly impact the pathogenesis of diseases caused by organisms such as Chlamydia trachomatis. We compared apoptotic responses among HeLa 229 cells acutely and persistently infected and mock infected with serovar A/HAR-13. Persistence was induced by gamma interferon at 0.2 and 2.0 ng/ml. Cells were treated with etoposide or staurosporine at 24-h intervals and assayed for apoptosis by cell count, DNA ladder formation, and cytochrome c translocation. From the 24- to 120-h time points, infected cultures were 87 and 90% viable for etoposide and staurosporine treatment, respectively, and produced no DNA ladder, and cytochrome c remained in the mitochondria. In contrast, mock-infected cells were 22 and 37% viable for etoposide (P = 0.0001) and staurosporine (P = 0.01), respectively, and displayed characteristic DNA ladders, and cytochrome c was translocated. We found that resistance to apoptotic stimuli was identical in acute and persistent infections. Since cytochrome c was not translocated from the mitochondrion, caspase-9 activity was likely not involved. The expression of chlamydial hsp60, a known stimulator of inflammation in vivo, was measured in both active and persistent infections by Western blot, with increased production in the latter with or without staurosporine treatment. Chlamydial disregulation of apoptosis and the ensuing persistence of organisms offer an alternative pathogenic mechanism for chlamydial scarring observed in trachoma and infertility populations via sustained inflammation induced by immunoreactive molecules such as hsp60.

A survey of spinal and epidural techniques in adult cardiac surgery

OBJECTIVE

To determine if a significant number of anesthesiologists are performing spinal and epidural techniques in adults undergoing cardiac surgery and if any neurologic injuries have been associated with these techniques.

DESIGN

Anonymous survey of clinical practice.

SETTING

Data collected via mail from members of the Society of Cardiovascular Anesthesiologists.

PARTICIPANTS

Attending anesthesiologists.

INTERVENTIONS

Anesthesiologists completed an anonymous survey of their use of spinal and epidural techniques in adult patients undergoing cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Of 3974 anesthesiologists, 974 (24%) responded to the questionnaire; 892 are at institutions that perform cardiac surgery. Of the 892 responders, 68 (7.6%) reported they use spinal techniques, whereas 62 (7%) reported they use epidural techniques. Nine (1%) anesthesiologists reported they use both techniques. There were no reports of neurologic complications related to the use of spinal or epidural techniques performed by the anesthesiologists responding to the survey.

CONCLUSIONS

A significant number of anesthesiologists are performing spinal and epidural techniques in adult patients undergoing cardiac surgery. Prospective, controlled trials should be performed to evaluate the benefits and risks of spinal and epidural techniques in this population.

Mixed immunobullous disease of childhood: a good response to antimicrobials

BACKGROUND

Immunobullous diseases are uncommon in childhood. In contrast to adults, the most commonly seen is IgA-mediated chronic bullous disease of childhood (CBDC), while IgG-mediated bullous pemphigoid (BP), cicatricial pemphigoid (CP) and epidermolysis bullosa acquisita (EBA) are rare. We have demonstrated both IgG and IgA autoantibodies to basement membrane zone target antigens in eight children with 'mixed immunobullous disease of childhood'.

OBJECTIVES

To elucidate whether a dual antibody response makes these patients distinct regarding their presentation, immunopathology, course and prognosis.

METHODS

We compared the eight children showing the double antibody response with 62 children with CBDC, BP, CP and EBA in whom only one antibody isotype was demonstrated. Clinical information at presentation, clinical course and response to treatment were recorded, and immunoblotting and direct and indirect immunofluorescence (IF) were performed.

RESULTS

Six of the eight patients presented with clinical features of CBDC. In two others, it was uncertain whether they had CBDC or BP. Seven of the eight demonstrated a dual antibody response on indirect IF and three on direct IF. Immunoblotting revealed a variety of epidermal and dermal target antigens (BP230, BP180, 97-kDa protein and laminin 5). Five of the eight responded well to dapsone, two to sulphonamides, and one to systemic erythromycin alone. The clinical course was not protracted. Five are in remission 1-4 years following treatment, and three still have active disease suppressed by treatment after 6 months-2 years.

CONCLUSIONS

Although we do not know why these children have 'mixed immunobullous disease' (the dual antibody response), our results indicate that the presence of IgA is associated with a good response to treatment with antimicrobials (dapsone, sulphonamides, erythromycin), and the clinical course is no more protracted than that found in children with a single antibody response.

Alterations in distribution of tenascin, fibronectin and fibrinogen in vulval lichen sclerosus

BACKGROUND

The pathophysiology of lichen sclerosus remains uncertain. The clinical features, including increased fragility and scarring, and the histology suggest that significant reorganisation of the extracellular matrix is occurring. Tenascin, fibrinogen and fibronectin are extracellular matrix components that play a significant role in tissue remodelling, for example during wound repair.

AIM

To examine the distribution of tenascin, fibrinogen and fibronectin in vulval lichen sclerosus.

MATERIALS AND METHODS

Immunohistochemical staining was performed to study the distribution of tenascin, fibronectin and fibrinogen in 16 specimens of untreated vulval lichen sclerosus and 1 specimen of extragenital lichen sclerosus. Haematoxylin and eosin staining of the specimens was also performed to identify the position of the pale staining homogenous zone/zone of sclerosis and the inflammatory infiltrate below this. The control tissues studied included biopsies taken from the uninvolved thigh of 13 of the lichen sclerosus patients and 6 samples of normal vulva tissue obtained during gynaecological procedures from women of similar age to the lichen sclerosus women.

RESULTS

All the lichen sclerosus specimens demonstrated increased immunostaining of tenascin in the upper dermis and comparing this with the haematoxylin and eosin staining this corresponded to the zone of sclerosis with relatively little tenascin staining associated with the inflammatory band. In 14 out of the 16 vulval lichen sclerosus specimens and the extragenital lichen sclerosus specimen fibrinogen immunostaining was increased in the upper dermis which corresponded--in haematoxylin and eosin staining --to the zone of sclerosis. There was also slightly increased fibrinogen staining in the mid dermis which corresponded to the inflammatory band. Fibronectin staining was reduced in the upper dermis of 12 of the vulval lichen sclerosus specimens and the extragenital lichen sclerosus specimen which corresponded to the zone of sclerosis. However, in 14 of the vulval lichen sclerosus specimens and the extragenital lichen sclerosus specimen, fibronectin was slightly increased in the mid and deeper dermis which corresponded to the zone of inflammatory cells and the area below this. There was also increased fibronectin staining around blood vessel walls both in the mid dermis and within the zone of sclerosis.

CONCLUSION

The distribution of tenascin, fibrinogen and fibronectin is altered in lichen sclerosus and the alteration in these extracellular matrix components may be relevant to the initiation of scarring in lichen sclerosus and the associated increased skin fragility.

Distribution of transforming growth factor-beta isoforms TGF-beta 1, TGF-beta 2 and TGF-beta 3 and vascular endothelial growth factor in vulvar lichen sclerosus

OBJECTIVE

To study the distribution of transforming growth factor beta (TGF-beta) isoforms TGF-beta 1, TGF-beta 2 and TGF-beta 3 and vascular endothelial growth factor (VEGF) in vulvar lichen sclerosus.

STUDY DESIGN

Biopsies were obtained from 10 patients with vulvar lichen sclerosus, snap frozen and stained with polyclonal antibodies to TGF-beta 1, TGF-beta 2, TGF-beta 3 and VEGF. Control tissues used were uninvolved thigh tissue from two of the lichen sclerosus patients and normal vulvar tissue obtained from eight patients during gynecologic procedures. Two specimens of morphea were also examined.

RESULTS

Weak TGF-beta 1 staining was demonstrated in the epidermis of all the lichen sclerosus, morphea, thigh and five of the eight normal vulvar specimens. Slight increase in TGF-beta 1 staining was seen in the upper and middermis in 6 of the 10 lichen sclerosus specimens and in the morphea specimens as compared to the control tissue, and this staining was localized within cells. TGF-beta 2 staining was present throughout the epidermis in all the normal thigh, normal vulva, lichen sclerosus and morphea specimens. TGF-beta 2 staining was increased within cells in the upper and middermis of the lichen sclerosus and morphea specimens. TGF-beta 3 staining occurred in the basal half of the epidermis of all the control, lichen sclerosus and morphea specimens, and only slight upper dermal staining of a few individual cells was seen in 3 of the 10 lichen sclerosus specimens. VEGF staining was similar in the normal tissues, lichen sclerosus and morphea.

CONCLUSION

These results suggest that TGF-beta may.

Studies on the metabolism of troglitazone to reactive intermediates in vitro and in vivo. Evidence for novel biotransformation pathways involving quinone methide formation and thiazolidinedione ring scission

Therapy with the oral antidiabetic agent troglitazone (Rezulin) has been associated with cases of severe hepatotoxicity and drug-induced liver failure, which led to the recent withdrawal of the product from the U.S. market. While the mechanism of this toxicity remains unknown, it is possible that chemically reactive metabolites of the drug play a causative role. In an effort to address this possibility, this study was undertaken to determine whether troglitazone undergoes metabolism in human liver microsomal preparations to electrophilic intermediates. Following incubation of troglitazone with human liver microsomes and with cDNA-expressed cytochrome P450 isoforms in the presence of glutathione (GSH), a total of five GSH conjugates (M1-M5) were detected and identified tentatively by LC-MS/MS analysis. In two cases (M1 and M5), the structures of the adducts were confirmed by NMR spectroscopy and/or by comparison with an authentic standard prepared by synthesis. The formation of GSH conjugates M1-M5 revealed the operation of two distinct metabolic activation pathways for troglitazone, one of which involves oxidation of the substituted chromane ring system to a reactive o-quinone methide derivative, while the second involves a novel oxidative cleavage of the thiazolidinedione (TZD) ring, potentially generating highly electrophilic alpha-ketoisocyanate and sulfenic acid intermediates. When troglitazone was administered orally to a rat, samples of bile were found to contain GSH conjugates which reflected the operation of these same metabolic pathways in vivo. The finding that metabolism of the TZD ring of troglitazone was catalyzed selectively by P450 3A enzymes is significant in light of the recent report that troglitazone is an inducer of this isoform in human hepatocytes. The implications of these results are discussed in the context of the potential for troglitazone to covalently modify hepatic proteins and to cause oxidative stress through redox cycling processes, either of which may play a role in drug-induced liver injury.

A procedure to average 3D anatomical structures

Creating a feature-preserving average of three dimensional anatomical surfaces extracted from volume image data is a complex task. Unlike individual images, averages present right-left symmetry and smooth surfaces which give insight into typical proportions. Averaging multiple biological surface images requires careful superimposition and sampling of homologous regions. Our approach to biological surface image averaging grows out of a wireframe surface tessellation approach by Cutting et al. (1993). The surface delineating wires represent high curvature crestlines. By adding tile boundaries in flatter areas the 3D image surface is parametrized into anatomically labeled (homology mapped) grids. We extend the Cutting et al. wireframe approach by encoding the entire surface as a series of B-spline space curves. The crestline averaging algorithm developed by Cutting et al. may then be used for the entire surface. Shape preserving averaging of multiple surfaces requires careful positioning of homologous surface regions such as these B-spline space curves. We test the precision of this new procedure and its ability to appropriately position groups of surfaces in order to produce a shape-preserving average. Our result provides an average that well represents the source images and may be useful clinically as a deformable model or for animation.

Evidence for long-term cervical persistence of Chlamydia trachomatis by omp1 genotyping

Recurrent Chlamydia trachomatis infections are common among sexually active women. Although recurrences with a new chlamydial serovar indicate reinfection, same-serovar recurrences may be due to persistence. Because persistence has important implications for pathogenesis and patient management, we identified 552 women with >3 recurrences over 2 years. Among these, 130 women (24%) had same-serovar recurrences; 58 (45%) were C class serovars (odds ratio, 2.4; 95% confidence interval, 1.7-3.5; P<.0001). Forty-five isolates from 7 women with 3-10 repeated, same-serovar infections over 2-5 years were studied. As determined by omp1 genotyping, 4 women had identical genotypes at each recurrence; 2 women had 1 or 2 amino acid changes following treatment, and one was persistently infected with a unique genotype, Ja. Many intervening culture-negative samples were positive when tested by ligase chain reaction, which suggests persistence. These data demonstrate that cervical infections with C class serovars can persist for years and may have specific biologic properties that allow for modulation of the major outer membrane protein in response to immune selection.

Overview of the epidemiology, microbiology, and pathogenesis of Leptospira spp. in humans

Leptospirosis is probably the world's most widespread zoonosis. It remains underdiagnosed largely due to the broad spectrum of signs and symptoms attributable to this spirochetal pathogen. Leptospira spp. cause a diversity of diseases from flu-like illness to Weil's syndrome with multi-organ failure. Recent epidemics may herald a change in virulence or an alteration in the balance between humans and their interactions with other host species and the environment.

Exercise diminishes the activity of acetyl-CoA carboxylase in human muscle

Studies in rats suggest that increases in fatty acid oxidation in skeletal muscle during exercise are related to the phosphorylation and inhibition of acetyl-CoA carboxylase (ACC), and secondary to this, a decrease in the concentration of malonyl-CoA. Studies in human muscle have not revealed a consistent decrease in the concentration of malonyl-CoA during exercise; however, measurements of ACC activity have not been reported. Thus, whether the same mechanism operates in human muscle in response to physical activity remains uncertain. To investigate this question, ACC was immunoprecipitated from muscle of human volunteers and its activity assayed in the same individual at rest and after one-legged knee-extensor exercise at 60, 85, and 100% of knee extensor VO2max. ACC activity was diminished by 50-75% during exercise with the magnitude of the decrease generally paralleling exercise intensity. Treatment of the immunoprecipitated enzyme with protein phosphatase 2A restored activity to resting values, suggesting the decrease in activity was due to phosphorylation. The measurement of malonyl-CoA in the muscles revealed that its concentration is 1/10 of that in rats, and that it is diminished (12-17%) during the higher-intensity exercises. The respiratory exchange ratio increased with increasing exercise intensity from 0.84 +/- 0.02 at 60% to 0.99 0.04 at 100% VO2max. Calculated rates of whole-body fatty acid oxidation were 121 mg/min at rest and 258 +/- 35, 264 +/- 63, and 174 +/- 76 mg/min at 60, 85, and 100% VO2max, respectively. The results show that ACC activity, and to a lesser extent malonyl-CoA concentration, in human skeletal muscle decrease during exercise. Although these changes may contribute to the increases in fat oxidation from rest to exercise, they do not appear to explain the shift from mixed fuel to predominantly carbohydrate utilization when exercise intensity is increased.

Malonyl-CoA content and fatty acid oxidation in rat muscle and liver in vivo

Malonyl-CoA acutely regulates fatty acid oxidation in liver in vivo by inhibiting carnitine palmitoyltransferase. Thus rapid increases in the concentration of malonyl-CoA, accompanied by decreases in long-chain fatty acyl carnitine (LCFA-carnitine) and fatty acid oxidation have been observed in liver of fasted-refed rats. It is less clear that it plays a similar role in skeletal muscle. To examine this question, whole body respiratory quotients (RQ) and the concentrations of malonyl-CoA and LCFA-carnitine in muscle were determined in 48-h-starved rats before and at various times after refeeding. RQ values were 0.82 at baseline and increased to 0.93, 1. 0, 1.05, and 1.09 after 1, 3, 12, and 18 h of refeeding, respectively, suggesting inhibition of fat oxidation in all tissues. The increases in RQ at each time point correlated closely (r = 0.98) with increases (50-250%) in the concentration of malonyl-CoA in soleus and gastrocnemius muscles and decreases in plasma FFA and muscle LCFA-carnitine levels. Similar changes in malonyl-CoA and LCFA-carnitine were observed in liver. The increases in malonyl-CoA in muscle during refeeding were not associated with increases in the assayable activity of acetyl-CoA carboxylase (ACC) or decreases in the activity of malonyl-CoA decarboxylase (MCD). The results suggest that, during refeeding after a fast, decreases in fatty acid oxidation occur rapidly in muscle and are attributable both to decreases in plasma FFA and increases in the concentration of malonyl-CoA. They also suggest that the increase in malonyl-CoA in this situation is not due to changes in the assayable activity of either ACC or MCD or an increase in the cytosolic concentration of citrate.

Do plasminogen activators play a role in lichen sclerosus?

The histological changes of lichen sclerosus suggest that significant remodelling of the extracellular matrix is occurring. As the proteases of the plasminogen activator system have been implicated in tissue remodelling, cell migration and tumour invasion, we performed an immunohistochemical study to look for evidence of alteration in the expression of plasminogen/plasmin, urokinase-type plasminogen activator, tissue-type plasminogen activator and alpha2-antiplasmin in biopsies of clinically typical vulval lichen sclerosus obtained from 11 untreated adult women. Normal vulva obtained from gynaecological procedures and samples of the patients' uninvolved thigh tissue were used as controls. No significant difference was seen in the staining pattern between the lichen sclerosus tissue and control tissue. However, although we found no immunohistochemical evidence that the plasminogen activator system is involved in the pathogenesis of vulval lichen sclerosus, it may be that other proteases are involved.

Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group

BACKGROUND

The acute chest syndrome is the leading cause of death among patients with sickle cell disease. Since its cause is largely unknown, therapy is supportive. Pilot studies with improved diagnostic techniques suggest that infection and fat embolism are underdiagnosed in patients with the syndrome.

METHODS

In a 30-center study, we analyzed 671 episodes of the acute chest syndrome in 538 patients with sickle cell disease to determine the cause, outcome, and response to therapy. We evaluated a treatment protocol that included matched transfusions, bronchodilators, and bronchoscopy. Samples of blood and respiratory tract secretions were sent to central laboratories for antibody testing, culture, DNA testing, and histopathological analyses.

RESULTS

Nearly half the patients were initially admitted for another reason, mainly pain. When the acute chest syndrome was diagnosed, patients had hypoxia, decreasing hemoglobin values, and progressive multilobar pneumonia. The mean length of hospitalization was 10.5 days. Thirteen percent of patients required mechanical ventilation, and 3 percent died. Patients who were 20 or more years of age had a more severe course than those who were younger. Neurologic events occurred in 11 percent of patients, among whom 46 percent had respiratory failure. Treatment with phenotypically matched transfusions improved oxygenation, with a 1 percent rate of alloimmunization. One fifth of the patients who were treated with bronchodilators had clinical improvement. Eighty-one percent of patients who required mechanical ventilation recovered. A specific cause of the acute chest syndrome was identified in 38 percent of all episodes and 70 percent of episodes with complete data. Among the specific causes were pulmonary fat embolism and 27 different infectious pathogens. Eighteen patients died, and the most common causes of death were pulmonary emboli and infectious bronchopneumonia. Infection was a contributing factor in 56 percent of the deaths.

CONCLUSIONS

Among patients with sickle cell disease, the acute chest syndrome is commonly precipitated by fat embolism and infection, especially community-acquired pneumonia. Among older patients and those with neurologic symptoms, the syndrome often progresses to respiratory failure. Treatment with transfusions and bronchodilators improves oxygenation, and with aggressive treatment, most patients who have respiratory failure recover.

The unreliability of clinical measures of muscle tone: implications for stroke therapy

BACKGROUND

the central tenet of the neurofacilitatory approach to stroke therapy is that muscle tone needs to be normal before normal movement can occur. A reliable clinical measure of the full spectrum of muscle tone is needed to test: (i) the purported relationship between muscle tone, other motor impairments and disability, and (ii) the effectiveness of stroke therapy to restore movement.

AIM

the purpose of the study was to test the inter-rater reliability of clinical categorization of muscle tone (spastic/normal/flaccid) and also a visual analogue scale with anchor points of 'lowest tone possible' (score 0) and 'highest tone possible' (score 100).

METHODS

four independent raters assessed tone of elbow flexors and knee extensors of 14 stroke rehabilitation inpatients using the categorical scale. Six independent raters assessed tone of elbow flexors and knee extensors of 25 chronic stroke patients and two healthy volunteers using the visual analogue scale. All assessment orders were randomized.

RESULTS

both scales were unreliable, with K coefficients for the categorical scale ranging from -0.046 to 0.56 for the categorical scale, and intra-class correlation coefficients for the visual analogue scale of 0.595 for elbow flexors and 0.451 for knee extensors. Assessment order effects for the visual analogue scale were non-significant for elbow flexors (P= 0.545) and knee extensors (P= 0.911).

CONCLUSIONS

these results, and those of earlier studies, suggest that clinical measures of muscle tone are consistently unreliable. Systematic investigation of the therapy rationale for planning and evaluating treatment is required before relevant clinical measures can be developed.

Three-dimensional Bolton-Brush Growth Study landmark data: ontogeny and sexual dimorphism of the Bolton standards cohort

OBJECTIVE

The treatment of craniofacial reconstructive surgery patients may benefit from comparison to average referent three-dimensional landmark data. These data may be useful for diagnosis, treatment planning, prosthetic design, or outcomes assessment. With regard to subadult patients, we hypothesize that the pattern of ontogenetic shape change of same sex, same ethnicity, referent populations will show gross uniformity. We present a preliminary shape analysis of 50 three-dimensional landmarks derived from 317 Bolton-Brush Growth Study biorthogonal image pairs. We determine which landmarks can be collected from scanned radiographs reliably by four operators for the precisely locatable points, ontogenetic trends in landmark configuration shape change, and patterns of sexual dimorphism.

PARTICIPANTS

Participants were Bolton standards individuals (16 male and 16 female) who contributed biplane cephalograms seven or more times with annual or greater spacing between ages 3 and 18 years.

DESIGN

After removing outliers, we searched for ontogenetic heterogeneity, including sexual dimorphism and within sex-specific Procrustes coordinate shape spaces.

RESULTS

A cut-off of 4.3-mm interoperator error left 32 landmarks in our analysis. Three different approaches (principal component analysis, age-trend analysis, and principal components of age residuals) all found no patterns of individual variation around sex-specific average trends of shape change. Male shape change peaks at age 15, a correlate of the growth spurt.

CONCLUSIONS

Simultaneous frontal and lateral anatomic landmark identification improves three-dimensional localization reliability. Three-dimensional craniodental shape change from ages 8 to 18 within the Bolton standards presents little heterogeneity. Considerations of ethnicity aside, these may be initial grounds for use of these data as a normative referent.

Optimization of folate-conjugated liposomal vectors for folate receptor-mediated gene therapy

A folate-targeted transfection complex that is internalized by certain cancer cells and displays several properties reminiscent of enveloped viruses has been developed. These liposomal vectors are comprised of a polycation-condensed DNA plasmid associated with a mixture of neutral and anionic lipids supplemented with folate-poly(ethylene glycol)-dioleylphosphatidylethanolamine for tumor cell-specific targeting. N-Citraconyl-dioleylphosphatidylethanolamine is also included for pH-dependent release of endosome-entrapped DNA into the cytoplasm, and a novel plasmid containing a 366-bp segment from SV40 DNA has been employed to facilitate transport of the plasmid into the nucleus. Because formation of the DNA core is an important step in the assembly of liposomal vectors, considerable effort was devoted to comparing the transfection efficiencies of various DNA condensing agents. It was found that complexation of plasmid DNA with high molecular weight polymers such as acylated-polylysine and cationic dendrimers leads to higher folate-mediated transfection efficiency than DNA complexed with unmodified polylysine. In contrast, compaction of plasmid DNA with small cationic molecules such as spermine, spermidine, or gramicidin S yields only weakly active folate-targeted liposomal vectors. Compared to analogous liposomal vector preparations lacking an optimally compacted DNA core, a cell-specific targeting ligand, a caged fusogenic lipid, and a nucleotide sequence that facilitates nuclear uptake, these modified liposomal vectors display greatly improved transfection efficiencies and target cell specificity.

Factors that may discourage annual mammography among low-income women with access to free mammograms: a study using multi-ethnic, multiracial focus groups

Age-eligible women enrolled in the National Breast and Cervical Cancer Early Detection Program can obtain free or low-cost mammograms annually, but many do not routinely complete rescreening. This study investigated the rescreening behavior of low-income women by conducting 8 focus groups in Texas with enrollees who had access to free mammograms. Concerns mentioned in the focus groups included fear of radiation, anxiety that the test might not find a cancer that was there, and worries that cancer might be detected. In all groups, some women mentioned the embarrassment, discomfort, or pain they experienced during a prior mammogram, although no one indicated they would refuse to have another mammogram because of these concerns. Findings highlight the useful insights that can be obtained from focus groups and underscore the need for more research on aspects of the experience of mammography that may affect rescreening.

Identification of bacterial pathogens in patients with endophthalmitis by 16S ribosomal DNA typing

PURPOSE

To determine whether sequence analysis of 16S ribosomal DNA (rDNA) can be used to detect bacterial pathogens in patients with postoperative endophthalmitis.

METHODS

In 10 eyes of 10 patients, vitreous specimens were collected for culture and rDNA typing. Variable segments of each ribosomal DNA specimen were amplified by polymerase chain reaction (PCR), sequenced, and aligned by BLAST, a computer alignment program, against sequences in GenBank at the National Institutes of Health.

RESULTS

Specimens were available from five eyes with bacterial endophthalmitis diagnosed by Gram stain or culture. Amplified 16s rDNA sequences from the eyes of three patients were identical to microbiologic results. Polymerase chain reaction results were negative in two cases in which unusual organisms were detected. All five control specimens from patients with nonbacterial endophthalmitis or uveitis were PCR negative. Approximately 48 to 72 hours are required under ideal conditions for final species identification with this ribosomal typing technique.

CONCLUSIONS

16S rDNA typing shows potential as a relatively rapid technique for identifying bacteria in vitreous samples.

Osseointegration of preformed polymethylmethacrylate craniofacial prostheses coated with bone marrow-impregnated poly (DL-lactic-co-glycolic acid) foam

Osseointegration of bone marrow-PLGA-coated, preformed polymethylmethacrylate cranioplasties offers the possibility of reducing: operative time, periimplant seroma and infection, metallic fixation, and periprosthetic resorption following surgical skull remodeling. These alloplastic materials are FDA-approved but previously have not been used together to promote cranioplasty incorporation. The objective of this study was to determine whether the use of PLGA foam coating improves host osseointegration of preformed, textured, polymethylmethacrylate prosthetic cranioplasties. A critical-sized cranial defect was created in two groups of 10 and one group of three rabbits. The defect was filled with either a textured, preformed polymethylmethacrylate disc or a textured, preformed polymethylmethacrylate disc coated with poly (DL-lactic-co-glycolic acid). Both implants were immersed in autologous bone marrow for 20 minutes before implantation. Half of each group of 10 were killed at 3 weeks, and the remainder at 6 weeks. A third group of three rabbits with excised periosteum was evaluated at 6 weeks. Histologic analysis of the discs determined relative amounts of cancellous bone formation adjacent to the prostheses. Woven trabecular bone was present at each host bone to implant perimeter interface at 3 weeks, with fine fibrous capsular formation around the implants. Thicker, lamellar trabeculae were present at 6 weeks with an increased fibrous layer surrounding both types of implants. Bone formed on the superficial and deep implant surfaces in a noncontiguous fashion. Two of five measures showed that total bone formation was significantly greater in the PLGA-coated implants. Polymethylmethacrylate discs coated with bone marrow-impregnated PLGA foam demonstrate increased bone formation at 3 and 6 weeks as compared with non-coated preformed polymethylmethacrylate discs. Only implants with preserved periosteum showed bone formation away from the host-implant interface (centrally) on the superficial surface at 6 weeks.

Cytosolic citrate and malonyl-CoA regulation in rat muscle in vivo

In liver, insulin and glucose acutely increase the concentration of malonyl-CoA by dephosphorylating and activating acetyl-CoA carboxylase (ACC). In contrast, in incubated rat skeletal muscle, they appear to act by increasing the cytosolic concentration of citrate, an allosteric activator of ACC, as reflected by increases in the whole cell concentrations of citrate and malate [Saha, A. K., D. Vavvas, T. G. Kurowski, A. Apazidis, L. A. Witters, E. Shafrir, and N. B. Ruderman. Am. J. Physiol. 272 (Endocrinol. Metab. 35): E641-E648, 1997]. We report here that sustained increases in plasma insulin and glucose may also increase the concentration of malonyl-CoA in rat skeletal muscle in vivo by this mechanism. Thus 70 and 125% increases in malonyl-CoA induced in skeletal muscle by infusions of glucose for 1 and 4 days, respectively, and a twofold increase in its concentration during a 90-min euglycemic-hyperinsulinemic clamp were all associated with significant increases in the sum of whole cell concentrations of citrate and/or malate. Similar correlations were observed in muscle of the hyperinsulinemic fa/fa rat, in denervated muscle, and in muscle of rats infused with insulin for 5 h. In muscle of 48-h-starved rats 3 and 24 h after refeeding, increases in malonyl-CoA were not accompanied by consistent increases in the concentrations of malate or citrate. However, they were associated with a decrease in the whole cell concentration of long-chain fatty acyl-CoA (LCFA-CoA), an allosteric inhibitor of ACC. The results suggest that increases in the concentration of malonyl-CoA, caused in rat muscle in vivo by sustained increases in plasma insulin and glucose or denervation, may be due to increases in the cytosolic concentration of citrate. In contrast, during refeeding after starvation, the increase in malonyl-CoA in muscle is probably due to another mechanism.

Lichen sclerosus: evidence that immunological changes occur at all levels of the skin

An immunohistochemical approach was used to characterize the inflammatory infiltrate in vulval lichen sclerosus, using monoclonal antibodies to CD3, CD4, CD8, CD68 and HLA-DR. Significant numbers of CD4 + and CD8 + lymphocytes were observed in the dermal band of inflammatory cells in approximately equal proportions. Less numerous CD4 + and CD8 + lymphocytes also occurred adjacent to the dermoepidermal junction and occasionally in the lower epidermis. Increased numbers of cells staining with the monocyte/macrophage marker CD68 were also present in the band of inflammatory cells as well as being scattered diffusely throughout the sclerotic region. Expression of HLA-DR in the lichen sclerosus specimens was increased within the inflammatory infiltrate and around blood vessels in the dermis. All the vulval lichen sclerosus specimens also demonstrated some HLA-DR expression around the keratinocytes, suggesting that these keratinocytes might be involved in antigen presentation. We also studied the expression of CD44 and its isoforms 3G5 (marker of V3), 8G5 (marker of V6), 3D2 (marker of V4/5) and IE8 (marker of V8/9). CD44 has been proposed to play a part in lymphocyte homing, cell-matrix interaction (particularly with hyaluronic acid), lymphocyte activation and malignant progression of certain tumours. The epidermis of the lichen sclerosus specimens appeared to demonstrate a greater intensity of staining with the pan-CD44 marker F10-44, and reduced staining with 3G5, 3D2 and IE8 compared with normal skin. Like normal skin, the dermis of the lichen sclerosus specimens did not demonstrate staining with 3G5, 3D2, 8G5 or 1E8, but did show staining with F10-44. However, the pattern of the dermal staining with F10-44 reflected the position of the inflammatory infiltrate and was sparse in the five sections where there was a prominent sclerotic zone, but increased in the three sections where there was a prominent band of inflammation cells. Our results demonstrate evidence of immunological changes at all levels of skin involved by lichen sclerosus, including the epidermis.

1-[N, O-bis-(5-isoquinolinesulphonyl)-N-methyl-L-tyrosyl]-4- phenylpiperazine (KN-62), an inhibitor of calcium-dependent camodulin protein kinase II, inhibits both insulin- and hypoxia-stimulated glucose transport in skeletal muscle

Previous studies have indicated a role for calmodulin in hypoxia-and insulin-stimulated glucose transport. However, since calmodulin interacts with multiple protein targets, it is unknown which of these targets is involved in the regulation of glucose transport. In the present study, we have used the calcium-dependent calmodulin protein kinase II (CAMKII) inhibitor 1-[N, O-bis-(5-isoquinolinesulphonyl) -N-methyl-L-tyrosyl]-4-phenylpiperazine (KN-62) to investigate the possible role of this enzyme in the regulation of glucose transport in isolated rat soleus and epitrochlearis muscles. KN-62 did not affect basal 2-deoxyglucose transport, but it did inhibit both insulin- and hypoxia-stimulated glucose transport activity by 46 and 40% respectively. 1-[N,O-Bis-(1, 5-isoquinolinesulphonyl)-N-methyl-l-tyrosyl]-4-phenylpiperazine (KN-04), a structural analogue of KN-62 that does not inhibit CAMKII, had no effect on hypoxia-or insulin-stimulated glucose transport. Accordingly, KN-62 decreased the stimulated cell-surface GLUT4 labelling by a similar extent as the inhibition of glucose transport (insulin, 49% and hypoxia, 54%). Additional experiments showed that KN-62 also inhibited insulin- and hypoxia-stimulated transport by 37 and 40% respectively in isolated rat epitrochlearis (a fast-twitch muscle), indicating that the effect of KN-62 was not limited to the slow-twitch fibres of the soleus. The inhibitory effect of KN-62 on hypoxia-stimulated glucose transport appears to be specific to CAMKII, since KN-62 did not inhibit hypoxia-stimulated 45Ca efflux from muscles pre-loaded with 45Ca, or hypoxia-stimulated glycogen breakdown. Additionally, KN-62 affected neither insulin-stimulated phosphoinositide 3-kinase nor Akt activity, suggesting that the effects of KN-62 are not due to non-specific effects of this inhibitor on these regions of the insulin-signalling cascade. The results of the present study suggest that CAMKII might have a distinct role in insulin- and hypoxia-stimulated glucose transport, possibly in the vesicular trafficking of GLUT4.

Malonyl CoA, long chain fatty acyl CoA and insulin resistance in skeletal muscle

Malonyl CoA is an inhibitor of carnitine palmitoyl transferase 1 (CPT1), the enzyme that regulates the transfer of long chain fatty acyl CoA into mitochondria. By virtue of this effect, it is thought to play a key role in regulating fatty acid oxidation. Thus, when the supply of glucose to muscle is increased, malonyl CoA levels increase in keeping with a decreased need for fatty acid oxidation, and fatty acids are preferentially esterified to form diaglycerol and triglycerides. In contrast, during exercise, when the need for fatty acid oxidation is increased, malonyl CoA levels fall. Changes in glucose supply regulate malonyl CoA by modulating the concentration of cytosolic citrate, an allosteric activator of acetyl CoA carboxylase (ACC), the rate-limiting enzyme for malonyl CoA formation and a precursor of its substrate cytosolic acetyl CoA. Conversely, exercise lowers the concentration of malonyl CoA, by activating an AMP-activated protein kinase, which phosphorylates and inhibits ACC. A number of reports have linked sustained increases in the concentration of malonyl CoA in muscle to insulin resistance. In this paper, we review these reports, as well as the notion that changes in malonyl CoA contribute to the increases in long chain fatty acyl CoA, (LCFA CoA), diacylglycerol and triglyceride content and changes in protein kinase C activity and distribution observed in insulin-resistant muscle. We also review the implications of the malonyl CoA/LCFA CoA hypothesis to two other proposed mechanisms for insulin resistance, the glucose-fatty acid cycle and the hexosamine theory.

Assessment of polycyclic aromatic hydrocarbon content of smoked fish by means of a fast HPLC/HPLC method

Polycyclic aromatic hydrocarbon (PAH) concentrations in smoked food can reach levels hazardous for the human health, especially when the smoking procedure is carried out under uncontrolled conditions. In this work a simple and rapid method for the determination of PAHs in smoked fish samples is described. PAHs were extracted from the insoluble samples (together with fat substances) by homogenization with acidified chloroform. The fat extract was then submitted to a first LC sample preparation step (performed on a large silica column) to isolate PAHs from triglycerides. After reconcentration, the PAH fraction was finally injected into the reverse-phase analytical column. The proposed method, which presents good characteristics of recoveries and repeatability, was also used to analyze PAH content of some smoked trout samples packed under vacuum.

Three-dimensional magnetic resonance-based morphometrics and ventricular dysmorphology in schizophrenia

BACKGROUND

Recent methodological refinements in magnetic resonance (MR) imaging have led to brain averaging and morphometric approaches that are sensitive to subtle anatomical distinctions in schizophrenia.

METHODS

Using a novel morphometric technique for surface analysis, 48 selected landmarks of the rendered ventricular system were extracted and compared between the ventricles of 20 patients with schizophrenia and 20 normal subjects.

RESULTS

There was no significant difference in ventricular shape between groups, but significant (p = .015) and highly localized shape deformity was detected at the foramen of Monro and at the proximal temporal horn of the lateral ventricle of male (but not female) patients relative to controls.

CONCLUSIONS

Three-dimensional MR-based morphometrics complements established volumetric approaches and can detect minute shape deformities that may be associated with schizophrenia.

16S ribosomal DNA typing for identification of pathogens in patients with bacterial keratitis

The identification of pathogens in patients with bacterial keratitis remains problematic because standard diagnostic tests are negative for 40 to 60% of patients. A cross-sectional study was undertaken to determine if PCR and sequence analysis of 16S ribosomal DNA (rDNA) could be used to detect bacterial pathogens in patients with keratitis. Corneal specimens were collected for culture and rDNA typing. Variable segments of each rDNA specimen were amplified by PCR, sequenced, and aligned with the sequences in GenBank. Eleven patients had microbiologically documented bacterial keratitis, while 17 patients had keratitis due to other causes. Nine (82%) of 11 bacterial keratitis patients were PCR positive; each sequencing result matched the culture results. Seventeen (100%) patients with nonbacterial keratitis were PCR negative. Our data suggest that 16S rDNA typing holds promise as a rapid alternative to culture for identifying pathogens in patients with bacterial keratitis.

Spruce budworm elastase precipitates Bacillus thuringiensis delta-endotoxin by specifically recognizing the C-terminal region

A gut juice protein from Choristoneura fumiferana (spruce budworm) larvae that precipitates certain delta-endotoxins shows a unique specificity for the C-terminal amino acid sequence. Using homolog scanning mutants, we have identified a contiguous region of the Cry1Aa toxin which interacts with the 75-kDa toxin precipitating protein (TPP-75)' resulting in precipitation. The contiguous region from Cry1Aa can be transferred to Cry1Ac and results in an identical precipitation reaction. The precipitation reaction occurs rapidly and is unique in that the ratio of precipitating protein to toxin is low (estimated at 0.01), unlike antibody-antigen reactions which exhibit mole ratios close to 1. TPP-75 has been characterized as an elastase-like serine protease. We have taken advantage of this serine protease character and incorporated a radiolabel using an irreversible inhibitor. The radiolabel has allowed us to show the coincidence of the catalytically-inhibited TPP-75 with the toxin in a blotting assay and to follow the degradation of TPP-75 during storage. TPP-75 represents the first evidence that gut juice proteins may selectively attenuate the activity of delta-endotoxins, prior to binding to putative receptors on susceptible cells. TPP-75 should be evaluated as a possible resistance mechanism for those larvae that do not exhibit a receptor-based resistance.

Transmission of Chlamydia trachomatis and Neisseria gonorrhoeae among men with urethritis and their female sex partners

Transmission of Chlamydia trachomatis and Neisseria gonorrhoeae among infected men and their female sex partners was examined using a design enhancing the likelihood that spread was directed from men to women. Chlamydia culture-negative specimens were examined using DNA amplification tests. Infection rates in women exposed to male sex partners with Chlamydia only were 65% (20/31) and with gonorrhea only were 73% (33/45). Infection of women by either agent was not influenced by the number of sexual exposures to or coinfection in men. There was a 98% (40/41) concordance of N. gonorrhoeae isolates among partners by auxotype and serovar. Chlamydia isolates were serotyped using ELISA and immunofluorescence testing and confirmed by nested polymerase chain reaction: 50% (6/12) of men and 57% (8/14) of women yielded mixed serovars. Sixty-four percent of pairs (9/14) were infected with identical serovars and an additional 28% shared at least one serovar. Multiple serovars of C. trachomatis, but not of N. gonorrhoeae, were common in sex partners and exchanged frequently.

Conjunctival impression cytology for vitamin A deficiency in the presence of infectious trachoma

BACKGROUND/AIMS

Increased morbidity and mortality from a number of infectious diseases have been associated with vitamin A deficiency. Trachoma and vitamin A deficiency are both important causes of blindness in Nepal. The purpose of this study was to determine the association between the diagnosis of vitamin A deficiency by conjunctival impression cytology and the diagnosis of infectious trachoma by the polymerase chain reaction (PCR) in the Lumbini zone of Nepal.

METHODS

70 children under the age of 11 in a rural village in the Lumbini zone were examined for clinical evidence of active trachoma. The conjunctiva of each child was tested for ocular Chlamydia trachomatis infection using PCR, and for loss of goblet cells (a sign of subclinical vitamin A deficiency) using conjunctival impression cytology.

RESULTS

The presence of infectious trachoma was associated with the loss of goblet cells on conjunctival impression cytology (p = 0.02). This relation was present and significant even when adjusted for age (p = 0.05) and degree of inflammation (p = 0.02). In fact, even subclinical infection with chlamydia was associated with an abnormal conjunctival impression cytology (p = 0.02).

CONCLUSIONS

Children with infectious trachoma are significantly more likely to have an abnormal conjunctival impression cytology, even if the infection is subclinical. Thus, the diagnosis of vitamin A deficiency from conjunctival impression cytology alone should be made with some caution in areas with endemic trachoma. Further studies will be needed to determine the cause of this association.

Validation of object-induced MR distortion correction for frameless stereotactic neurosurgery

Spatial fidelity is a paramount issue in image guided neurosurgery. Until recently, three-dimensional computed tomography (3D CT) has been the primary modality because it provides fast volume capture with pixel level (1 mm) accuracy. While three-dimensional magnetic resonance (3D MR) images provide superior anatomic information, published image capture protocols are time consuming and result in scanner- and object-induced magnetic field inhomogeneities which raise inaccuracy above pixel size. Using available scanner calibration software, a volumetric algorithm to correct for object-based geometric distortion, and a Fast Low Angle SHot (FLASH) 3D MR-scan protocol, we were able to reduce mean CT to MR skin-adhesed fiducial marker registration error from 1.36 to 1.09 mm. After dropping the worst one or two of six fiducial markers, mean registration error dropped to 0.62 mm (subpixel accuracy). Three dimensional object-induced error maps present highest 3D MR spatial infidelity at the tissue interfaces (skin/air, scalp/skull) where frameless stereotactic fiducial markers are commonly applied. The algorithm produced similar results in two patient 3D MR-scans.

Average African American three-dimensional computed tomography skull images: the potential clinical importance of ethnicity and sex

The production of average 'normative' three-dimensional (3D) computed tomography surface images of the bony skull has only recently been explored. The authors wish to determine the effect of using sex- and ethnicity-specific adult average 3D skull images for comparisons with patient images at various stages of craniofacial surgical management (i.e., diagnosis, treatment planning, prosthetic design, image-guided operative procedures, and outcomes assessment). Craniofacial surgical reconstruction for abnormal patterns of development, cancer resection, or trauma are most likely to benefit from these comparisons. To morphometrically test the significance of separating normative 3D skull data by sex and ethnicity, the authors collected 52 3D, anatomical landmarks from 3D computed tomography scans of dry skulls of 20 Americans of European ethnicity and 20 Americans of primarily African (i.e., primarily African and some European) ethnicity. A Procrustes-based morphometric analysis of shape detects 1.2 times as much interethnic variance as intersex variance. The African American sample presents 4.2% more dolichocephaly, wider orbits, flatter nasal area, larger gnathic anatomy, and more procumbent dentition. Pooling the sexes across both groups, it is seen that men tend to have less bulbous crania, more protruding brows, noses, and masticatory muscle attachments, and relatively less protrusive palettes and anterior mandibles. Despite a small sample size (N = 40), the authors' results are statistically significant (P approximately 0.001 overall) for both of the main factors, sex and ethnicity, separately.

Chronic follicular conjunctivitis associated with Chlamydia psittaci or Chlamydia pneumoniae

We determined whether patients with chronic conjunctivitis in whom direct fluorescent antibody (DFA) tests revealed genus-specific chlamydial antigens (but not species-specific Chlamydia trachomatis antigens) were infected with Chlamydia psittaci or Chlamydia pneumoniae. Patients were divided into a case group of possible non-trachomatis chlamydial conjunctivitis and a control group of nonchlamydial conjunctivitis on the basis of examination and DFA testing. Species-specific primers were used to amplify C. trachomatis, C. psittaci, and C. pneumoniae DNA with polymerase chain reaction (PCR). Four (27%) of 15 samples from the case group were positive for C. psittaci or C. pneumoniae DNA, whereas none of 24 control samples were positive. Sequencing revealed a C. pneumoniae, an avian C. psittaci, and two mammalian C. psittaci strains. A short course of oral antibiotic treatment appears to be inadequate for patients with non-trachomatis chlamydial conjunctivitis. Ocular infections due to C. pneumoniae and C. psittaci may be more common than previously recognized and can be identified by DFA and PCR.

On the phylogenetic position of the pre-Neandertal specimen from Reilingen, Germany

This paper describes the morphology and phylogenetic significance of a well-preserved fossil human cranium found near Reilingen, Germany in 1978. The specimen consists of two complete parietals, most of the right temporal, and 70% of the occipital. The specimen displays several features characteristic of early "archaic" Homo sapiens: maximum breadth at the supramastoid crests, roughly pentagonal occipital view, an angular torus, superoinferiorly elongate/ anteroposterior shortened squamous temporal, strong mastoid, and separation of the tympanic and mastoid temporal portions. Other features align the Reilingen cranium with the "classic" Neandertals: developed suprainiac fossa, bilaterally protuberant occipital torus, strong juxtamastoid eminence, a highly convex occipital plane, and lambdoid flattening. This morphology and our cephalometric analysis support the assignment of this specimen to a Stage 2 "pre-Neandertal" group (e.g., Steinheim, Swanscombe, and Atapuerca [SH site]). Following an "Accretion Model" of European hominid evolution, Stage 2 succeeds Stage 1 European "early-pre-Neandertals" (e.g., Mauer and Petralona), and precedes both the Saale-Eem Stage 3 "early Neandertals" (e.g., Biache 1), which present greater platycephaly, a reduced mastoid process, an enlarged juxtamastoid eminence, and true "en-bombe" (parieto-occipital form), and Weichsel Stage 4 "Neandertals" (sensu stricto, i.e., "classic" Neandertals).

Identification of Leptospira species in the pathogenesis of uveitis and determination of clinical ocular characteristics in south India

Uveitis is considered a rare complication of leptospirosis. This report describes an epidemic of uveitis among patients with leptospirosis and provides data, using polymerase chain reaction (PCR) amplification of Leptospira DNA, that the pathogenesis is associated with anterior chamber spirochetes. Forty-six uveitis patients, 49 uveitis controls, and 54 cataract controls were enrolled at Aravind Eye Hospital (Madurai, India). Leptospiral DNA was detected by PCR of aqueous humor; serum antibody titers were determined by ELISA and microagglutination (MAT). Thirty-seven uveitis patients (80%) demonstrated leptospiral DNA compared with 5 controls (8%; P < .001). Thirty-three uveitis patients (72%) had positive serology compared with 10 uveitis controls (20%) and 13 cataract controls (24%; P < .001). This report describes the largest cluster of patients with leptospiral uveitis and identifies six clinical characteristics that provide a diagnostic profile for leptospiral uveitis. This profile will be important for determining treatment regimens in countries where PCR and MAT are not available.

Mammalian fauna and biostratigraphy of the pre-Neandertal site of Reilingen, Germany

In 1978 three well-preserved pieces of a fossil human cranium (i.e., fused parietals, occipital and temporal) were found in a gravel pit near the southwest German town of Reilingen. It was recovered, with an accompanying mammalian fauna, as a side-product of commercial gravel mining. The sample was sorted from the dredgings of a boat-mounted crane reaching to a depth of 28 m below the surface. Here we present the mammalian fauna and discuss its biostratigraphical relevance. The fauna represents a mixture of Holstein interglacial to Würm glacial species. The occurrence of Holsteinian faunal components is indicated by presence of the extinct beaver, Trogontherium. Given the good preservation of specimens found at the lowest levels we can rule out reworking. The accompanying fauna indicates a Holstein to Würm time span bracketing the fossil hominid population.

Investigation of the role of delayed-type-hypersensitivity responses to myelin in the pathogenesis of Theiler's virus-induced demyelinating disease

The contribution of autoimmune responses to the pathogenesis of Theiler's virus-induced demyelinating disease was investigated. Delayed-type hypersensitivity responses to myelin were examined in both symptomatic and asymptomatic mice at different times post-infection, in order to determine whether autoreactivity correlates with the development of demyelination. The results indicate that although autoimmune responses probably do not play a major role in the initiation of demyelination at early times post-infection, autoreactivity to myelin antigens dose eventually develop in symptomatic animals, perhaps through the mechanism of epitope spreading. Autoimmunity to myelin components is therefore an additional factor that may contribute to lesion progression in chronically diseased animals.

Characterization of a strain of Chlamydia pneumoniae isolated from a coronary atheroma by analysis of the omp1 gene and biological activity in human endothelial cells

Chlamydia pneumoniae is a respiratory pathogen that has been associated with chronic inflammatory diseases such as asthma and atherosclerosis. Recent isolation of C. pneumoniae from human carotid and coronary atheromas provides additional support for a role of this organism in atherogenesis. We characterized the coronary strain C. pneumoniae A-03 by sequence analysis of the major outer membrane protein gene (omp1). In addition, the in vitro activities of A-03 and three respiratory strains of C. pneumoniae (BAL-16, TW-183, and T-2634) were examined in infected human umbilical vein endothelial cells (HUVEC) by analysis of the production of interleukin-8 (IL-8), monocyte chemotactic protein 1 (MCP-1), and soluble intercellular cell adhesion molecule 1 (sICAM-1). Sequence analysis of omp1 of C. pneumoniae A-03, compared to prototype strains TW-183 and AR-39, revealed five nucleotide changes resulting in nonsynonymous codons. Of interest was a nonconservative amino acid substitution (Ser to Pro) in position 61 of variable segment 1. In vitro, the extent of MCP-1, IL-8, and sICAM-1 production was dependent on the C. pneumoniae strain examined at low multiplicities of infection following 24 h of incubation. Strain A-03 displayed the lowest stimulatory activity in infected HUVEC, while T-2634 induced the highest levels of MCP-1, IL-8, and sICAM-1 among all strains examined. Heat-inactivated C. pneumoniae failed to stimulate production of these proteins by all strains tested. In contrast, only partial inhibition was observed by UV-inactivated organisms. Results from this study demonstrate that unlike prototype respiratory strains of C. pneumoniae, the coronary strain A-03 displays divergence in the omp1 gene. In addition, the stimulation of chemokines and adhesion molecules involved in the recruitment of leukocytes to sites of inflammation by C. pneumoniae may be important in the pathogenesis of diseases associated with this organism, including atherosclerosis.

Comparison of performance and cost-effectiveness of direct fluorescent-antibody, ligase chain reaction, and PCR assays for verification of chlamydial enzyme immunoassay results for populations with a low to moderate prevalence of Chlamydia trachomatis infection

Many laboratories use a commercial enzyme immunoassay (EIA) with verification testing to diagnose Chlamydia trachomatis infections in an effort to contain costs. This study was designed to compare the performance and cost-effectiveness of direct fluorescent-antibody assay (DFA), commercial PCR, and ligase chain reaction (LCR) for the verification of EIA results. Cervical specimens were screened by EIA. DFA, PCR, and LCR were compared as verification tests for EIA-reactive specimens and negative greyzone (NGZ) specimens at 50% below the cutoff value. These samples were also tested by in-house PCR, which was used in the analysis of verification results. A total of 477 (7%) of 6,571 samples were reactive or within the NGZ. EIA results with verification by DFA testing (EIA/DFA results) agreed with 93% of the true results compared with 97% for EIA/PCR results for one set of 242 samples; there was 97% agreement with true results for EIA/DFA results versus 95% for EIA/LCR results for another set of 235 samples. Ten samples were false positive by LCR. Time and costs were equivalent for EIA with the DFA, PCR, or LCR as the verification test but were two- to threefold greater for PCR or LCR alone than for EIA with verification. Since it is important to balance cost containment with public health objectives, DFA, PCR, and LCR as EIA verification tests for cervical samples offer acceptable sensitivities and specificities at reasonable cost for low- to moderate-risk populations and therefore can be extended to a broader spectrum of at-risk populations.

Efficacy of OKT3 as primary therapy for histologically confirmed acute renal allograft rejection

BACKGROUND

OKT3 is often used as primary treatment for acute renal allograft rejection. In a retrospective study, we sought to determine the efficacy of OKT3 as a first-line agent in reversing histologically confirmed acute renal allograft rejection.

METHODS

Patients with mild to moderate, moderate, or severe acute cellular and acute vascular rejection who had not received any other anti-rejection treatment were included in this analysis. A total of 88 patients, who received OKT3 between 1987 and 1995, fulfilled these criteria.

RESULT

Seventy of these patients were renal transplant recipients, and 18 were combined kidney and pancreas transplant recipients. The median time to the diagnosis of rejection from transplantation was 32 days (range, 6 days to 13 years). On histology, 6 were graded as mild to moderate, 36 as moderate, 29 as moderate to severe, and 17 as severe rejection. The mean baseline serum creatinine was 1.62 mg/dl (range, 0.7-10.1 mg/dl), and the mean serum creatinine at the time of diagnosis of rejection was 2.60 mg/dl (range, 1.4-12.7 mg/dl) (P=<0.0001). The mean duration of OKT3 treatment was 11.2 days (range, 8-18 days). The mean serum creatinine at the end of OKT3 treatment was 1.73 mg/dl (range, 0.6-5.0 mg/dl; P=0.24 compared with baseline serum creatinine). Rejection was reversed in 86 (98%) patients. Graft survival at 1 year after OKT3 therapy was 87.5% (77 of 88). At a mean follow-up of 38 months, 8 patients had died and 26 grafts were lost. The mean serum creatinine level in the 64 patients with a functioning graft was 1.76 mg/dl (range, 0.8-4.0 mg/dl) at the last follow-up.

CONCLUSION

OKT3 when utilized as first-line therapy reversed 98% of the acute rejection episodes, with a 1-year post-OKT3 graft survival of 87.5%.

Management after myocardial infarction: a controlled trial of the effect of group psychotherapy

A controlled clinical trial was conducted to determine the feasibility of offering group psychotherapy to post-myocardial infarction patients for one year, and to test its effects upon prognosis. Shortly after discharge from a coronary care unit, 118 patients were approximately equally allocated to therapy and control groups. The acceptance, the average attendance at the weekly sessions, and the drop-out rates per cent were 84, 69 and 15.5 respectively. No statistically significant changes were shown in the physiological and psychological factors. Favorable effects were suggested by survival experience, changes in social alienation, length of hospital stay and the patients' reported attitudes toward this form of therapy.