Diagnostic accuracy of 3D time-of-flight MR angiography compared with digital subtraction angiography for follow-up of coiled intracranial aneurysms: influence of aneurysm size

BACKGROUND AND PURPOSE

3D time-of-flight MR angiography (3D TOF MRA) may be used as noninvasive alternative to digital subtraction angiography (DSA) for the follow-up of patients with intracranial aneurysms treated with Guglielmi detachable coils (GDCs). We aimed to determine the influence of aneurysm size and location on diagnostic accuracy of 3D TOF MRA for follow-up of intracranial aneurysms treated with GDCs.

MATERIALS AND METHODS

Two hundred and one 3D TOF MRAs in 127 consecutive patients with 136 aneurysms were compared with DSA as standard of reference. Sensitivity and specificity of 3D TOF MRA for detection of residual or reperfusion of the aneurysms was calculated with regard to aneurysm size and location.

RESULTS

Overall sensitivity and specificity of MRA was 88.5% and 92.9%, respectively. Sensitivity was lower for aneurysms <or=5 mm (72.2%) and <or=3 mm (63.6%). In addition to the small aneurysm size, interpretation of MR angiograms was compromised by susceptibility artifacts at the air-bone interface, arterial overlap, and pulsation-induced artifacts. The small number of disagreements between MRA and DSA hampered reliable interpretation of the possible influence of aneurysm location on MRA accuracy.

CONCLUSION

The sensitivity of 3D TOF MRA for detection of reperfusion or residual perfusion of coiled intracranial aneurysms varies considerably depending on the size of the aneurysms. No conclusions can be drawn regarding a possible influence of aneurysm location on diagnostic accuracy of 3D TOF MRA. These findings may influence the decision about whether to replace DSA by 3D TOF MRA for the follow-up of patients with intracranial aneurysms treated with GDCs.

The A20R protein is a stoichiometric component of the processive form of vaccinia virus DNA polymerase

In vitro analysis of the catalytic DNA polymerase encoded by vaccinia virus has demonstrated that it is innately distributive, catalyzing the addition of <10 nucleotides per primer-template binding event in the presence of 8 mM MgCl(2) or 40 mM NaCl (W. F. McDonald and P. Traktman, J. Biol. Chem. 269:31190-31197, 1994). In contrast, cytoplasmic extracts isolated from vaccinia virus-infected cells contain a highly processive form of DNA polymerase, able to catalyze the replication of a 7-kb template per binding event under similar conditions. To study this holoenzyme, we were interested in purifying and characterizing the vaccinia virus processivity factor (VPF). Our previous studies indicated that VPF is expressed early after infection and has a native molecular mass of approximately 48 kDa (W. F. McDonald, N. Klemperer, and P. Traktman, Virology 234:168-175, 1997). Using these criteria, we established a six-step chromatographic purification procedure, in which a prominent approximately 45-kDa band was found to copurify with processive polymerase activity. This species was identified as the product of the A20 gene. By use of recombinant viruses that direct the overexpression of A20 and/or the DNA polymerase, we verified the physical interaction between the two proteins in coimmunoprecipitation experiments. We also demonstrated that simultaneous overexpression of A20 and the DNA polymerase leads to a specific and robust increase in levels of processive polymerase activity. Taken together, we conclude that the A20 gene encodes a component of the processive DNA polymerase complex. Genetic data that further support this conclusion are presented in the accompanying report, which documents that temperature-sensitive mutants with lesions in the A20 gene have a DNA(-) phenotype that correlates with a deficit in processive polymerase activity (A. Punjabi et al, J. Virol. 75:12308-12318, 2001).

Clustered charge-to-alanine mutagenesis of the vaccinia virus A20 gene: temperature-sensitive mutants have a DNA-minus phenotype and are defective in the production of processive DNA polymerase activity

Although the vaccinia virus DNA polymerase is inherently distributive, a highly processive form of the enzyme exists within the cytoplasm of infected cells (W. F. McDonald, N. Klemperer, and P. Traktman, Virology 234:168-175, 1997). In the accompanying report we outline the purification of the 49-kDa A20 protein as a stoichiometric component of the processive polymerase complex (N. Klemperer, W. McDonald, K. Boyle, B. Unger, and P. Traktman, J. Virol. 75:12298-12307, 2001). To complement this biochemical analysis, we undertook a genetic approach to the analysis of the structure and function of the A20 protein. Here we report the application of clustered charge-to-alanine mutagenesis of the A20 gene. Eight mutant viruses containing altered A20 alleles were isolated using this approach; two of these, tsA20-6 and tsA20-ER5, have tight temperature-sensitive phenotypes. At the nonpermissive temperature, neither virus forms macroscopic plaques and the yield of infectious virus is <1% of that obtained at the permissive temperature. Both viruses show a profound defect in the accumulation of viral DNA at the nonpermissive temperature, although both the A20 protein and DNA polymerase accumulate to wild-type levels. Cytoplasmic extracts prepared from cells infected with the tsA20 viruses show a defect in processive polymerase activity; they are unable to direct the formation of RFII product using a singly primed M13 template. In sum, these data indicate that the A20 protein plays an essential role in the viral life cycle and that viruses with A20 lesions exhibit a DNA(-) phenotype that is correlated with a loss in processive polymerase activity as assayed in vitro. The vaccinia virus A20 protein can, therefore, be considered a new member of the family of proteins (E9, B1, D4, and D5) with essential roles in vaccinia virus DNA replication.

Quantitative gram stain interpretation criteria used by microbiology laboratories in Alberta, Canada

Microbiology laboratories in Alberta, Canada, were surveyed to determine the quantitative interpretive criteria used to routinely read and report Gram stains. There was a wide variability in the quantitative reporting criteria cited for both cells and bacteria, with only 11 of 32 (34.4%) laboratories surveyed using the criteria recommended by the external proficiency-testing program. Lack of standardized criteria not only poses a problem in the grading of proficiency testing results but may also impact the quality of patient care.

Unsafe sleep practices and an analysis of bedsharing among infants dying suddenly and unexpectedly: results of a four-year, population-based, death-scene investigation study of sudden infant death syndrome and related deaths

BACKGROUND

Prone sleep and unsafe sleep surfaces increase the risk of sudden infant death. Recent epidemiologic studies also suggest that when an infant's head or face is covered by bedding, or when a sleep surface is shared with others, the risk of dying increases. The inference of a causal role for these risk factors is supported by physiologic studies and by the consistent finding that fewer infants die when risk factors are reduced. The prevalence of most of these risk factors in infant deaths in the United States is uncertain.

OBJECTIVE

To describe the prevalence of several important risk factors related to sleep practices among a defined population of infants dying suddenly and unexpectedly.

METHODS

In this population-based study, we retrospectively reviewed death-scene information and medical examiners' investigations of deaths in the city of St Louis and St Louis County between January 1, 1994 and December 31, 1997. Because of the potential for diagnostic overlap, all deaths involving infants <2 years old with the diagnoses of sudden infant death syndrome (SIDS), accidental suffocation, or cause undetermined were included.

RESULTS

The deaths of 119 infants were studied. Their mean age was 109.3 days (range: 6-350). The diagnoses were SIDS in 88 deaths, accidental suffocation in 16, and undetermined in 15. Infants were found prone in 61.1% of cases and were found on a sleep surface not designed for infants in 75.9%. The head or face was covered by bedding in 29.4%. A shared sleep surface was the site of death in 47.1%. Only 8.4% of deaths involved infants found nonprone and alone, with head and face uncovered.

CONCLUSIONS

Using detailed death-scene descriptions, we found that similar unsafe sleeping practices occurred in the large majority of cases diagnosed as SIDS, accidental suffocation, and cause undetermined. Considering these diagnoses together may be useful in public health campaigns during a time when there may be diagnostic overlap. Regardless of the diagnosis, recommendations that infants sleep supine on firm sleep surfaces that lessen the risk of entrapment or head covering have the potential to save many lives. Campaigns are needed to heighten awareness of these messages and of the risks of dangerous bedsharing.

A novel type of carbohydrate-protein linkage region in the tyrosine-bound S-layer glycan of Thermoanaerobacterium thermosaccharolyticum D120-70

The surface-layer (S-layer) protein of Thermoanaerobacterium thermosaccharolyticum D120-70 contains glycosidically linked glycan chains with the repeating unit structure -->4)[alpha-D-Galp-(1-->2)]-alpha-L-Rhap-(1-->3)[beta-D-Glcp-(1--> 6)] -beta-D-Manp-(1-->4)-alpha-L-Rhap-(1-->3)-alpha-D-Glcp-(1--> . After proteolytic degradation of the S-layer glycoprotein, three glycopeptide pools were isolated, which were analyzed for their carbohydrate and amino-acid compositions. In all three pools, tyrosine was identified as the amino-acid constituent, and the carbohydrate compositions corresponded to the above structure. Native polysaccharide PAGE showed the specific heterogeneity of each pool. For examination of the carbohydrate-protein linkage region, the S-layer glycan chain was partially hydrolyzed with trifluoroacetic acid. 1D and 2D NMR spectroscopy, including a novel diffusion-edited difference experiment, showed the O-glycosidic linkage region beta-D-glucopyranose-->O-tyrosine. No evidence was found of additional sugars originating from a putative core region between the glycan repeating units and the S-layer polypeptide. For the determination of chain-length variability in the S-layer glycan, the different glycopeptide pools were investigated by matrix-assisted laser desorption ionization-time of flight mass spectrometry, revealing that the degree of polymerization of the S-layer glycan repeats varied between three and 10. All masses were assigned to multiples of the repeating units plus the peptide portion. This result implies that no core structure is present and thus supports the data from the NMR spectroscopy analyses. This is the first observation of a bacterial S-layer glycan without a core region connecting the carbohydrate moiety with the polypeptide portion.

Elucidating the essential role of the A14 phosphoprotein in vaccinia virus morphogenesis: construction and characterization of a tetracycline-inducible recombinant

We have previously reported the construction and characterization of vindH1, an inducible recombinant in which expression of the vaccinia virus H1 phosphatase is regulated experimentally by IPTG (isopropyl-beta-D-thiogalactopyranoside) (35). In the absence of H1 expression, the transcriptional competence and infectivity of nascent virions are severely compromised. We have sought to identify H1 substrates by characterizing proteins that are hyperphosphorylated in H1-deficient virions. Here, we demonstrate that the A14 protein, a component of the virion membrane, is indeed an H1 phosphatase substrate in vivo and in vitro. A14 is hyperphosphorylated on serine residues in the absence of H1 expression. To enable a genetic analysis of A14's function during the viral life cycle, we have adopted the regulatory components of the tetracycline (TET) operon and created new reagents for the construction of TET-inducible vaccinia virus recombinants. In the context of a virus expressing the TET repressor (tetR), insertion of the TET operator between the transcriptional and translational start sites of a late viral gene enables its expression to be tightly regulated by TET. We constructed a TET-inducible recombinant for the A14 gene, vindA14. In the absence of TET, vindA14 fails to form plaques and the 24-h yield of infectious progeny is reduced by 3 orders of magnitude. The infection arrests early during viral morphogenesis, with the accumulation of large numbers of vesicles and the appearance of "empty" crescents that appear to adhere only loosely to virosomes. This phenotype corresponds closely to that observed for an IPTG-inducible A14 recombinant whose construction and characterization were reported while our work was ongoing (47). The consistency in the phenotypes seen for the IPTG- and TET-inducible recombinants confirms the efficacy of the TET-inducible system and reinforces the value of having a second, independent system available for generating inducible recombinants.

Effects of restructuring on the performance of microbiology laboratories in Alberta

OBJECTIVE

To evaluate the error rates of organism identification and antibiotic susceptibility proficiency testing challenges before, during, and after microbiology laboratory restructuring in Alberta.

METHODS

Alberta Health substantially reduced and redistributed laboratory funds to the regional health authorities in 1995, forcing a dramatic restructure of services. Many rural hospitals expanded their microbiology test menus, and urban centers consolidated microbiology testing into a centralized high-volume laboratory. The Laboratory Proficiency Testing Program of the College of Physicians and Surgeons of Alberta mailed regular test profile surveys to microbiology laboratories during the restructure period to determine the type and extent of changes in services. Based on the types of tests and the extent of analysis being done, most rural B-level and some C-level laboratories were reclassified to the A level. The Laboratory Proficiency Testing Program reviewed the error rates of proficiency challenges based on the performance of different levels of laboratories before and after the period of restructure.

RESULTS

Overall performance has improved according to the number of errors documented on identification and susceptibility challenges for laboratories that remained at the same classification (ie, A or C). The number of major identification errors for laboratories that were reclassified increased, but the rate of major susceptibility errors decreased. More reclassified laboratories do not have dedicated registered technologist(s) who perform microbiology testing and are not supervised by an on-site pathologist and/or medical microbiologist compared with laboratories that remained at the same classification.

CONCLUSIONS

Microbiology laboratory restructuring will have adverse effects on the quality of complex testing if experienced technologists are not retained and services are not medically supervised.

[Differential diagnosis of space-occupying adrenal masses]

Computed tomography (CT) and magnetic resonance (MR) imaging are first line modalities in the evaluation of patients with adrenal gland masses, and have the potential to be very accurate for the localization of adrenal gland masses in patients with diseases associated with hyperfunctioning conditions of the adrenal gland. Both CT and MR imaging allow a specific diagnosis of acute adrenal hemorrhage, adrenal myelolipoma, and adrenal cysts. CT is also helpful in the assessment of patients with Addison's disease, particularly the subacute form secondary to granulomatous diseases. Quantitative evaluation of adrenal masses on unenhanced CT scans and/or qualitative analysis on chemical-shift MR imaging have been shown to be accurate in distinguishing adrenal adenomas from non-adenomas. Attenuation of 11 HE or less on unenhanced CT scans and/or signal loss on opposed phase MR images indicate adenoma with a high specificity and acceptable sensitivity. More recently, delayed-enhanced CT has yielded higher sensitivity and specificity values in distinguishing between adrenal adenomas and non-adenomas than both unenhanced CT and chemical-shift MR imaging do. On delayed-enhanced CT scans, adrenal adenomas exhibit a greater washout of contrast material than do adrenal non-adenomas. Therefore, adrenal non-adenomas have significantly higher attenuation than adenomas on delayed-enhanced CT scans obtained at several arbitrarily chosen time points (3-60 min) after the initiation of contrast material administration.

[Radiologic staging of renal cell carcinoma]

The routine staging work-up for renal cancer includes a contrast-enhanced multiphasic spiral CT and a chest radiograph. If there is doubt regarding the presence and extent of (supradiaphragmatic) IVC thrombus, MR imaging should be performed. Dynamic contrast-enhanced MR imaging should be used in place of CT in any patient with severe renal dysfunction, symptomatic polycystic kidney disease, or a history of allergy to iodinated contrast media. Cavography is no longer needed in the era of (adaptive array detector) spiral CT and MR venography.

[Digital 3D rotational angiography for the preoperative and preinterventional clarification of cerebral arterial aneurysms]

OBJECTIVE

Does the recently introduced 3D angiography provide additional information beyond standard angiography (DSA) for the diagnosis of cerebral aneurysms?

METHODS

During a 3-months period DSA and 3D-angiography were performed in 40 patients harbouring a total of 49 aneurysms. Vascular regions that presented an aneurysm diagnosed by DSA were reevaluated by 3D-angiography.

RESULTS

In two patients, vessel-loops previously described as aneurysms by DSA could be identified by 3D-angiography. In one patient, an aneurysm was diagnosed that could not be detected by DSA. In another case, the definitive diagnosis of an aneurysm was obtained only with 3D-angiography. In one patient, an aneurysm was diagnosed that could not be detected by DSA. In another case, the diagnosis of an aneurysm was obtained only with 3D-angiography. In two cases, aneurysms could be definitively excluded by 3D-angiography, whereas in another aneurysm a vessel originating from this lesion was identified. The size of the aneurysms measured by both methods was identical.

CONCLUSIONS

Multiple projections of 3D-angiography provide a better evaluation of the anatomic situation regarding the base of the aneurysm as well as the relationship of an aneurysm to neighbouring vessels. Further, an exact differentiation between a vessel loop and an aneurysm can be made. Therefore, 3D-angiography is a valuable tool when used in conjunction with DSA.

Increased cell proliferation characterizes Crohn's disease

Patients with long-standing Crohn's disease (CD), a chronic inflammatory intestinal disease, are at increased risk for intestinal cancer. The neoplasia likely results, in part, from deregulated cell proliferation, which allows mutations to become fixed in the crypt progenitor cells. We postulated that tissues derived from patients with CD would exhibit increased mucosal proliferation. Therefore, we examined specimens from 27 consecutive patients with chronic CD with a monoclonal antibody directed against the proliferation marker, Ki-67. The tissues were evaluated histologically, and the Ki-67 immunostaining patterns were recorded. The antibody to Ki-67 stained the bases of the crypts in both the small and large intestines. The mean number of Ki-67 immunoreactive cells in the normal crypt was 34.1 versus 95.1 in the regenerative mucosa and O in areas of pyloric metaplasia (P < .00001). Ki-67 staining of the mucosa of patients with CD confirmed that cell proliferation is markedly increased and that the replicating compartment of each crypt during regeneration is expanded. We concluded that the increased cell proliferation might predispose the mucosa to mutational events, thereby increasing the cancer risk in these patients. The lack of proliferation in areas of pyloric metaplasia might represent a mucosal adaptive response of the lower crypt that decreases the number of cycling cells vulnerable to genetic damage. Furthermore, growth factors produced by these cells might promote healing of the damaged mucosa.

[Nutritional status of Danish patients with rheumatoid arthritis and effects of a diet adjusted in energy intake, fish content and antioxidants]

This study deals with the nutritional status of Danish rheumatoid arthritis (RA) patients and addresses the question whether or not RA can be directly influenced by dietary manipulation. In a prospective, single-blinded study of six months' duration, 109 patients with active RA were randomly assigned to treatment with or without a specialized diet. The energy consumption was adjusted to normal standards for body-weight and the intake of fish and antioxidants was increased. A daily food diary was completed by the patients, and the total intake of 47 different food-elements was calculated. Nutritional status together with disease activity parameters were recorded. At baseline, the Danish RA-patients had neglected food habits with a significant reduction in intake of total energy, of D-vitamin and of E-vitamin. A very low intake of n-3 fatty acids was also found. During the study, 28 of the 109 patients dropped out, introducing a confounding effect on the overall result. In the remaining 81, those following the diet demonstrated a significant improvement in the duration of morning stiffness, the number of swollen joints, the pain status and reduced the cost of medicine, while doctors' global assessment, laboratory data, X-ray and the daily activities were unaltered. In conclusion, dietary analysis and appropriate, corrective advice should be offered to Danish RA patients.

Nutritional status of Danish rheumatoid arthritis patients and effects of a diet adjusted in energy intake, fish-meal, and antioxidants

This study deals with the nutritional status of Danish RA patients and address the question of whether or not RA can be directly influenced by dietary manipulation. In a prospective, single-blinded study of 6 months duration, 109 patients with active RA were randomly assigned to either treatment with or without a specialized diet. The energy consumption was adjusted to normal standards of body weights and the intake of fish meals and antioxidants were increased. A daily food diary was completed by the patients, and the total intake of 47 different food-elements was calculated. Nutritional status together with disease activity parameters were recorded. At baseline, the Danish RA-patients had neglected food habits with a significant reduction in intake of total energy, of D-vitamin and of E-vitamin. A very low intake of n-3 fatty acids was also found. During the study, 28 of the 109 patients dropped out, introducing a confounding effect on the overall result. In the remaining 81, those following the diet demonstrated a significant improvement in the duration of morning stiffness, number of swollen joints, pain status, and reduced cost of medicine, while doctors global assessment, laboratory data, X-ray, and daily activities were unaltered. In conclusion, dietary analysis and appropriate, corrective advice should be offered to Danish RA patients.

A double-blind comparative study of hydroxychloroquine and dapsone, alone and in combination, in rheumatoid arthritis

Eighty patients with active rheumatoid arthritis (RA) entered a double-blind randomized study of 24 weeks duration, to compare the efficacy and toxicity of hydroxychloroquine, dapsone, and a combination of both drugs in treatment of RA. Evaluation of changes in clinical, laboratory and radiologic variables was based on 63 patients completing the trial. There was no clear difference between the three therapy groups in most inflammatory variables after 24 weeks. However, only patients receiving the combination therapy improved significantly in all clinical and laboratory variables. Nine patients in the combination group and four in each single drug group discontinued during the trial, mainly because of toxicity. Four patients taking the combination therapy withdrew because of hemolytic anemia, and none in the dapsone group. These findings suggest that hydroxychloroquine in combination with dapsone is somewhat more effective and less tolerated than single drug treatments.

Incidence of work-related low back pain in physical therapists

The purpose of this study was to determine the incidence of work-related low back pain (LBP) in physical therapists and to identify common characteristics of therapists who reported work-related LBP. Questionnaires were mailed to a random sample of 500 registered physical therapists. Of the 344 (69%) questionnaires returned, 29 percent reported work-related LBP. The initial onset most frequently occurred between the ages of 21 and 30 years and within the first four years of experience as a physical therapist. Eighty-three percent of the therapists first incurred work-related LBP during treatment of patients, primarily in acute care and rehabilitation facilities. "Lifting with sudden maximal effort" and "bending and twisting" were frequent mechanisms of injury. Further research is necessary to investigate the effect work-related LBP has on productivity and quality of patient care within facilities and to identify preventive measures to decrease the incidence of work-related LBP.

Heterologous repressor-operator recognition among four classes of tetracycline resistance determinants

Homologous and heterologous repressor-operator interactions among four different classes of tetracycline resistance determinants have been compared. These are represented by RP1/Tn1721 (class A), R222/Tn10 (class B), pSC101/pBR322 (class C), and RA1 (class D). By the use of the purified repressor proteins of class A (TetRA) and class B (TetRB), operator sequences of all four classes are recognized by both with an identical stoichiometry of four repressor subunits per control sequence, but with different affinities. In vitro transcription has been used to demonstrate regulatory activities of TetRA and TetRB upon all four classes of tet genes. Tetracycline acted as an inducer. A functional relationship among the tet regulatory systems was also shown in vivo by complementation of a class A tetR'-galK fusion mutant with the tetR genes of classes A, B, and C. Repression of tetRA-linked galactokinase was ca. 80% in the presence of tetRA or tetRC, and ca. 50% in the presence of tetRB. Taken together, these results demonstrate heterologous repressor-operator interaction, suggesting close relationships among the four classes of Tcr determinants.