Noninvasive ventilation allows gastrostomy tube placement in patients with advanced ALS

The use of noninvasive positive pressure ventilation for ventilatory support during percutaneous endoscopic gastrostomy (PEG) tube placement is described in five patients with advanced ALS, four having significant bulbar symptoms. No respiratory complications occurred in any of these patients, who were considered to be at high risk for PEG placement because of severe ventilatory impairment and might not otherwise have been considered for this procedure.

Chromosomal duplication involving the forkhead transcription factor gene FOXC1 causes iris hypoplasia and glaucoma

The forkhead transcription factor gene FOXC1 (formerly FKHL7) is responsible for a number of glaucoma phenotypes in families in which the disease maps to 6p25, although mutations have not been found in all families in which the disease maps to this region. In a large pedigree with iris hypoplasia and glaucoma mapping to 6p25 (peak LOD score 6.20 [recombination fraction 0] at D6S967), no FOXC1 mutations were detected by direct sequencing. However, genotyping with microsatellite repeat markers suggested the presence of a chromosomal duplication that segregated with the disease phenotype. The duplication was confirmed in affected individuals by FISH with markers encompassing FOXC1. These results provide evidence of gene duplication causing developmental disease in humans, with increased gene dosage of either FOXC1 or other, as yet unknown genes within the duplicated segment being the probable mechanism responsible for the phenotype.

A survey of basic life support training in various undergraduate health care professions

Basic life support (BLS) is a core skill in which all healthcare professionals should be proficient. It is logical to provide BLS training during undergraduate years ensuring basic competence in all graduating healthcare students. Previous surveys of medical and dental schools have highlighted deficiencies in BLS training. This survey sought to assess the level of BLS training provided for students across a broad range of disciplines in the North West region of the UK. This included courses leading to an entry qualification into medicine, dentistry, nursing, midwifery or a profession allied to medicine (PAM). Information was collected by self-administered postal questionnaire with a response rate of 87%. The survey highlighted major variations in BLS training provided at undergraduate level across disciplines.

A novel locus for Leber congenital amaurosis (LCA4) with anterior keratoconus mapping to chromosome 17p13

PURPOSE

A two-generation consanguineous Pakistani family with autosomal recessive Leber congenital amaurosis (LCA, MIM 204,000) and keratoconus was identified. All affected individuals have bilateral keratoconus and congenital pigmentary retinopathy. The goal of this study was to link the disease phenotype in this family.

METHODS

Genomic DNA was amplified across the polymorphic microsatellite poly-CA regions identified by markers. Polymerase chain reaction (PCR) products were separated by nondenaturing polyacrylamide gel electrophoresis. Alleles were assigned to individuals, which allowed calculation of LOD scores using the Cyrillic and MLINK software program. The retinal guanylate cyclase (RETGC-1, GDB symbol GUC2D) and pigment epithelium-derived factor (PEDF) genes were analyzed by heteroduplex analysis and direct sequencing for mutations in diseased individuals.

RESULTS

Based on a whole genome linkage analysis the first locus for this combined phenotype has been mapped to chromosome 17p13. Linkage analysis gave a two point LOD score of 3.21 for marker D17S829. Surrounding this marker is a region of homozygosity of 15.77 cM, between the markers D17S1866 and D17S960; however, the crossover for the marker D17S1529 refines the region to 10.77 cM within which the disease gene is predicted to lie. Mutation screening of the nearby RETGC-1 gene, which has been shown to be associated with LCA1, revealed no mutations in the affected individuals of this family. Similarly, another prime candidate in the region PEDF was also screened for mutations. The factor has been shown to be involved in the photoreceptor differentiation and neuronal survival. No mutations were found in this gene either. Furthermore, RETGC-1 was physically excluded from the critical disease region based on the existing physical map.

CONCLUSIONS

It is therefore suggested that this combined phenotype maps to a new locus and is due to an as yet uncharacterized gene within the 17p13 chromosomal region.

Mutations of the forkhead/winged-helix gene, FKHL7, in patients with Axenfeld-Rieger anomaly

Genetic linkage, genome mismatch scanning, and analysis of patients with alterations of chromosome 6 have indicated that a major locus for development of the anterior segment of the eye, IRID1, is located at 6p25. Abnormalities of this locus lead to glaucoma. FKHL7 (also called "FREAC3"), a member of the forkhead/winged-helix transcription-factor family, has also been mapped to 6p25. DNA sequencing of FKHL7 in five IRID1 families and 16 sporadic patients with anterior-segment defects revealed three mutations: a 10-bp deletion predicted to cause a frameshift and premature protein truncation prior to the FKHL7 forkhead DNA-binding domain, as well as two missense mutations of conserved amino acids within the FKHL7 forkhead domain. Mf1, the murine homologue of FKHL7, is expressed in the developing brain, skeletal system, and eye, consistent with FKHL7 having a role in ocular development. However, mutational screening and genetic-linkage analyses excluded FKHL7 from underlying the anterior-segment disorders in two IRID1 families with linkage to 6p25. Our findings demonstrate that, although mutations of FKHL7 result in anterior-segment defects and glaucoma in some patients, it is probable that at least one more locus involved in the regulation of eye development is also located at 6p25.

Familial glaucoma iridogoniodysplasia maps to a 6p25 region implicated in primary congenital glaucoma and iridogoniodysgenesis anomaly

Familial glaucoma iridogoniodysplasia (FGI) is a form of open-angle glaucoma in which developmental anomalies of the iris and irido-corneal angle are associated with a juvenile-onset glaucoma transmitted as an autosomal dominant trait. A single large family with this disorder was examined for genetic linkage to microsatellite markers. A peak LOD score of 11.63 at a recombination fraction of 0 was obtained with marker D6S967 mapping to chromosome 6p25. Haplotype analysis places the disease gene in a 6.4-cM interval between the markers D6S1713 and D6S1600. Two novel clinical appearances extend the phenotypic range and provide evidence of variable expressivity. The chromosome 6p25 region is now implicated in FGI, primary congenital glaucoma, and iridogoniodysgenesis anomaly. This may indicate the presence of a common causative gene or, alternatively, a cluster of genes involved in eye development/function.

A competitive chemiluminescent enzyme-linked immunosorbent assay for the determination of RMP-7 in human blood

RMP-7, a bradykinin agonist, is a synthetic nonapeptide designed to enhance the delivery of therapeutics to the central nervous system. A sensitive, competitive chemiluminescent enzyme-linked immunosorbent assay (ELISA) for quantifying RMP-7 in human blood samples has been developed. Rabbit antibodies against RMP-7 were produced using the conjugate of RMP-7 to keyhole limpet hemocyanin through glutaraldehyde. Biotinylated RMP-7, conjugated via N-hydroxysuccinimide ester, was used as the tracer. A premixed solution of biotinylated alkaline phosphatase and avidin was used to quantify the tracer, with a dioxetane-based compound as the chemiluminescent substrate. The method involves treating blood samples with organic solvents to precipitate proteins, evaporating the supernatants to dryness, reconstituting residues in PBS and assaying the buffer solutions with the ELISA. The assay, using 1.0 ml of whole blood, has precision and accuracy within +/- 20% over the concentration range 25-800 pg ml-1. There are no significant endogenous interferences. The assay has been successfully used to support clinical trials of RMP-7.

Clinical presentation of experimentally induced rabies in horses

Twelve naive and nine test-vaccinated horses which developed clinical signs of rabies as a result of the required protocol of a vaccine trial were prospectively observed. Nineteen of the 21 cases were confirmed positive for rabies infection of the brain by fluorescent antibody test. The two horses with negative results had ganglioneuritis of the trigeminal ganglion or lymphocytic perivascular cuffing in the brain stem in addition to clinical signs. Average incubation period was 12.3 days and average morbidity was 5.5 days. Naive animals had significantly shorter incubation and morbidity periods (P < 0.05). Muzzle tremors were the most frequently observed (81%) and most common initial sign. Other common signs were pharyngeal spasm or pharyngeal paresis (71%), ataxia or paresis (71%), lethargy or somnolence (71%). The furious form was manifested in 43% of rabid horses and some of these furious animals initially manifested the dumb form. The paralytic form was not observed. Histopathology was characteristics for rabies. The results of this trial do not reflect on the efficacy of commercially licensed equine rabies vaccines.

Peters' anomaly

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Clinical features of experimentally induced rabies in cattle and sheep

A total of 20 cattle and five sheep out of a larger group of animals that were experimentally challenged with virus as part of the required protocol for a vaccine trial developed clinical signs of rabies. All five sheep and 18 of the cattle tested positive for rabies in a direct fluorescent antibody (FA) test. The remaining two cattle had suspicious FA results. Prospective observations are reported in this study. In the diseased cattle, the average incubation period was 15.1 days and the average morbidity period was 3.7 days. Of those, the naive cattle had significantly shorter incubation and morbidity periods than the test-vaccinated cattle. Major clinical signs included excessive salivation (100%), behavioural change (100%), muzzle tremors (80%), vocalization (bellowing; 70%), aggression, hyperaesthesia and/or hyperexcitability (70%), and pharyngeal paresis/paralysis (60%). The furious form of rabies was seen in 70% of the cattle. In the diseased sheep, the average incubation period was 10.0 days and the average morbidity period was 3.25 days. Major clinical signs included muzzle and/or head tremors (80%), aggressiveness, hyperexcitability, and/or hyperaesthesia (80%), trismus (60%), salivation (60%), vocalization (60%) and recumbency (40%). The furious form of rabies manifested in 80% of the sheep. Current rabies vaccines on the market contain higher effective doses than that utilized for the test vaccine and the results of this study do not reflect in any way on commercially available ruminant rabies vaccines.

Preparation and measurement of artificial enamel lesions, a four-laboratory ring test

Transversal microradiography is the most widely accepted method used to study changes in mineral content profiles. In spite of its widespread use, relatively little information is available on its validity and reproducibility. Following the recommendation of the Consensus Conference on Intraoral Model Systems, this study was designed to explore reproducibility of lesion analysis within a laboratory and comparability of analysis among various laboratories. Incipient enamel lesions were produced by four research groups using both a common ('standard') and a local ('preferred') protocol. Sections were produced by each group and allocated to 'mixed' bags of specimens, which were analysed by the groups. With the chosen scheme some sections were analysed six times by the same group (as an internal reference standard) while others were analysed by all four groups. The data for the mineral content profiles were expressed as the integrated mineral loss (IML) value and lesion depth. The results showed the lesions produced with the standard protocol to be in the range 2,000-3,000 vol% mineral x microns for IML. The IML of the lesions produced with the preferred protocol varied between 1,800 and 6,300 vol% mineral x microns. Variation in IML values could be attributed to the biological variation between lesions, but also to time (of microradiograph production) and measurement effects, calibration of the magnification of the specimens, and the parameters used in the algorithm to calculate IML. Some of these parameters also affected the lesion depth. It is advised to standardise (or at least report) the method of calculation of IML, and to include a reference lesion between analyses in a longitudinal study as an internal standard. With the data produced, it was calculated that the number of lesions required to differentiate between preventive treatments varied substantially among laboratories. The recommendations given will improve the power of the screening methods for caries-preventive agents for which microradiography is an essential analytical method.

Ultraviolet resonance Raman spectroscopy of delta 5-3-ketosteroid isomerase revisited: substrate polarization by active-site residues

The delta 5-3-ketosteroid isomerase (EC 5.3.3.1) of Pseudomonas testosteroni promotes extremely rapid conversion of delta 5- to delta 4-3-ketosteroids by a conservative intramolecular proton transfer via an enolic intermediate. The competitive inhibitor 19-nortestosterone displays marked spectroscopic changes upon binding to the enzyme, but the mechanisms responsible for these changes have not been unequivocally established. Ultraviolet resonance Raman (UVRR) spectra are reported for 19-nortestosterone in acid solutions and for this ligand when bound to delta 5-3-ketosteroid isomerase, as well as to its D38N and Y14F/D38N mutants. The frequencies of UVRR bands associated with C = O and C = C stretching can be used to monitor the state of polarization of the enone fragment of the steroid and the effects of the catalytic side chains, Tyr-14 and Asp-38, on these polarizations. Strong polarization is indicated by marked frequency downshifts of the C = O and C = C bands in the native protein; the downshifts are diminished by the mutations of these catalytic residues. The lower polarizing effects of the Y14F and D38N single mutants and the Y14F/D38N double mutant indicate that most of the polarization of the conjugated ketone is attributable to hydrogen-bond donation by the hydroxyl group of Tyr-14. A smaller contribution of Asp-38 is detected which is, in part, cooperative with that of Tyr-14. Reference spectra of hydrogen-bonded and protonated forms of 19-nortestosterone are reassigned, on the basis of the species identification of D. C. Hawkinson and R. M. Pollack [(1993) Biochemistry 32, 694-698].(ABSTRACT TRUNCATED AT 250 WORDS)

Secondary and tertiary structure of the A-state of cytochrome c from resonance Raman spectroscopy

Ferricytochrome c can be converted to the partially folded A-state at pH 2.2 in the presence of 1.5 M NaCl. The structure of the A-state has been studied in comparison with the native and unfolded states, using resonance Raman spectroscopy with visible and ultraviolet excitation wavelengths. Spectra obtained with 200 nm excitation show a decrease in amide II intensity consistent with loss of structure for the 50s and 70s helices. The 230-nm spectra contain information on vibrational modes of the single Trp 59 side chain and the four tyrosine side chains (Tyr 48, 67, 74, and 97). The Trp 59 modes indicate that the side chain remains in a hydrophobic environment but loses its tertiary hydrogen bond and is rotationally disordered. The tyrosine modes Y8b and Y9a show disruption of tertiary hydrogen bonding for the Tyr 48, 67, and 74 side chains. The high-wavenumber region of the 406.7-nm resonance Raman spectrum reveals a mixed spin heme iron atom, which arises from axial coordination to His 18 and a water molecule. The low-frequency spectral region reports on heme distortions and indicates a reduced degree of interaction between the heme and the polypeptide chain. A structural model for the A-state is proposed in which a folded protein subdomain, consisting of the heme and the N-terminal, C-terminal, and 60s helices, is stabilized through nonbonding interactions between helices and with the heme.

Mutations at the PAX6 locus are found in heterogeneous anterior segment malformations including Peters' anomaly

Mutation or deletion of the PAX6 gene underlies many cases of aniridia. Three lines of evidence now converge to implicate PAX6 more widely in anterior segment malformations including Peters' anomaly. First, a child with Peters' anomaly is deleted for one copy of PAX6. Second, affected members of a family with dominantly inherited anterior segment malformations, including Peters' anomaly are heterozygous for an R26G mutation in the PAX6 paired box. Third, a proportion of Sey/+ Smalleye mice, heterozygous for a nonsense mutation in murine Pax-6, have an ocular phenotype resembling Peters' anomaly. We therefore propose that a variety of anterior segment anomalies may be associated with PAX6 mutations.

The human PAX6 gene is mutated in two patients with aniridia

Aniridia is an inherited ocular disorder of variable expressivity characterized by iris hypoplasia. A candidate aniridia gene, AN, which is the human homologue of the mouse Pax-6 gene, has recently been isolated by positional cloning from the WAGR region of 11p13. Here we describe mutations in this gene in two cases of sporadic aniridia, one detected at the DNA level and one at the RNA level, both of which are predicted to affect protein function. Mutations in Pax-6 have been described previously in Small eye, the proposed mouse model for aniridia. We present new phenotypic evidence for the validity of this mouse model.

Positional cloning and characterization of a paired box- and homeobox-containing gene from the aniridia region

Based on the map location of the aniridia (AN) locus in human chromosomal band 11p13, we have cloned a candidate AN cDNA (D11S812E) that is completely or partially deleted in two patients with AN. The less than 70 kb smallest region of overlap between the two deletions encompasses the 3' coding region of the cDNA. This cDNA, which spans over 50 kb of genomic DNA, detects a 2.7 kb message specifically within all tissues affected in AN. The predicted polypeptide product possesses a paired domain, a homeodomain, and a serine/threonine-rich carboxy-terminal domain, structural motifs characteristic of certain transcription factors. The concordance between expression and pathology, map location, structure, and predicted function argues that the cDNA corresponds to the AN gene.

Mouse small eye results from mutations in a paired-like homeobox-containing gene

Small eye (Sey) in mouse is a semidominant mutation which in the homozygous condition results in the complete lack of eyes and nasal primordia. On the basis of comparative mapping studies and on phenotypic similarities, Sey has been suggested to be homologous to congenital aniridia (lack of iris) in human. A candidate gene for the aniridia (AN) locus at 11p13 has been isolated by positional cloning and its sequence and that of the mouse homologue has been established (C.T., manuscript in preparation). This gene belongs to the paired-like class of developmental genes first described in Drosophila which contain two highly conserved motifs, the paired box and the homeobox. In vertebrates, genes which encode the single paired domain as well as those which express both motifs have been described as the Pax multigene family. A Pax gene recently described as Pax-6 is identical to the mouse homologue of the candidate aniridia gene. Here we report the analysis of three independent Sey alleles and show that indeed this gene is mutated and that the mutations would predictably interrupt gene function.

Occupational tuberculous infections among pulmonary physicians in training

The invasion of the lower respiratory tract by procedures and support measures such as fiberoptic bronchoscopy, endotracheal intubation, and mechanical ventilation generates respiratory aerosols. These aerosols have a potential for the transmission of tuberculosis and other infections. The follow-up of tuberculin skin test status among staff with exposure to this millieu was observed in hope of delineating whether a significant problem does exist. A questionnaire survey of tuberculin skin test status of graduating pulmonary fellows was performed. Graduating Infectious Disease Fellows formed the control group. Training programs situated in the top 25 cities for tuberculosis in 1983 were chosen if the Fellows spent a major proportion of their time in a large receiving/public hospital. The data returned were analyzed if the individual programs had both Pulmonary and Infectious Disease Fellows in training. Fourteen training programs supplied usable data over a 3-yr period. Seven of 62 (11%) of Pulmonary Fellows at risk converted their tuberculin skin test as opposed to one of 42 (2.4%) of Infectious Disease Fellows. This observation raises concern that more fastidious precautions are needed to isolate patients under these conditions of respiratory aerosol generation. The available armamentarium of nonrecirculated fresh air ventilation and ultraviolet light irradiation in addition to simply wearing face masks should be increasingly utilized. Further studies are warranted to substantiate the applicability of these measures to the current situation.

Mucosal melanoma of the head and neck

From 1972 to 1988, 15 patients presented to the Duke University Melanoma Clinic, Durham, NC, with malignant melanoma of the mucus membranes of the upper aerodigestive tract. Eleven patients had a nasopharyngeal origin of their melanoma, while 4 patients had oropharyngeal lesions. The average age of the patients was 58.4 years. Median survival for the patients was 1.8 years, with a 5-year survival of approximately 10%. Survival was found to be independent of sex, tumor site, and extent of disease at presentation. Recurrence occurred in 80% of the patients and the median time to recurrence was 10 months. The median survival following recurrence was 13 months and was independent of the site of recurrence. Mucosal melanoma of the head and neck continues to result in a poor prognosis in spite of aggressive treatment.

Frequency distribution of individuals aged 20-70 years according to severity of periodontal disease

This study is an analysis of the findings in an epidemiologic investigation covering a random sample of 600 individuals aged 20-70 years resident in the city of Jönköping, Sweden. The frequency distribution of individuals according to severity of periodontal disease was determined. The analysis was based on clinical registration of gingivitis, pocket depths and qualitative and quantitative changes of the alveolar bone in a full mouth intraoral survey. In the age groups 20 and 30 years, 96% and 85% of the individuals, respectively, had healthy periodontal tissues or were grouped as having gingivitis without signs of lowering of the periodontal bone level. In the age groups 40, 50 and 70 years none of the subjects was free from signs of gingivitis/periodontitis but, as for all age groups, strikingly few cases (at most 8%) of severe destructive periodontitis were found. The need for periodontal treatment is discussed as well as the role of specific etiologic agents in the development of destructive periodontal disease.

Improved economics of HBsAg screening with commercial radioimmunoassay reagents

Commercial 125I anti-HBs was processed to yield a sixfold improvement in economy without significant loss of sensitivity or specificity. Additional polystyrene beads were coupled with commercially supplied anti-HBs. The modified assay (Mod-RIA) was compared with commercial RIA, EIA, and RPHA using established HBsAg panels. Mod-RIA was also compared with HEPATEST (RPHA) for screening 71 200 fresh blood donations during an 11.5-month period.

Comparison of radioimmunoassay and enzyme immunoassay for detecting hepatitis B surface antigen in serum from freshly donated blood and selected blood products

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Age differences in visual and kinesthetic short-term memory

30 elderly subjects were matched with 30 young subjects and tested on a kinesthetic short-term memory task which required the replication of criterion moves after a variable retention interval under conditions of either rest, differing interpolated movement tasks, or mental activity. A visual control condition was used. Differing interference and temporal decrements were observed. Both old and young subjects differed significantly between sighted and blindfold conditions; however, there was no difference between the performance of the old and the young in the blindfold (kinesthetic) condition. These findings were discussed with respect to practical implications for the retraining of old subjects on certain motor tasks.

[Diagnosis and first aid in stroke during the prehospital phase]

In the GDR the apoplexy occupies the 4th place in the statistics of causes of death. It is an acute pathological process and has a firm place in emergency medicine (urgent home visit service and urgent medical aid). The symptomatology is multiform and under ambulatory conditions it may lead to considerable differential-diagnostic difficulties. In the present paper references are given taking into consideration the anamnesis (factors of risk), the clinical examination of the patient, first differential-diagnostic aspects, therapeutic methods resulting from this and suitable possibilities of hospitalisation.

[Diagnostic and therapeutic aspects of subarachnoidal hemorrhage from the viewpoint of emergency medicine]

The subarchnoidal haemorrhage is an acute disease which has a high lethality and, therefore, in every case presents an indication for admission into an intensive-therapeutic department. It often occurs in younger age groups and appears more frequently than is assumed in general. Despite impressive clinical symptoms (suddenly beginning stabbing headache, vomiting and disturbances of consciousness of various degree of severity) the picture of the disease is not exactly diagnosed almost in every case. From 1970 to 1974 we treated 105 patients with subarachnoidal haemorrhages. In this paper is referred to the most important clinical and paraclinical parameters. Diagnostic and therapeutic possibilities are discussed.

[A contribution to acute glutethimide (Elrodorm) intoxication]

Following a short discussion of hitherto known facts about glutethimid intoxications, two own cases are described. In these cases minimal amounts (2.5 and 5 g) caused haemorrhagic diatheses and acute insufficiency of the liver, which in one case were combined with acute renal insufficiency. Possible causes are discussed.