Alterations in blood-brain barrier glucose transport in SIV-infected macaques

The neurological manifestations of HIV infection may be in part due to alterations in the blood-brain barrier. These may be caused by structural changes in the barrier or may consist of subtle metabolic or biochemical disturbances in barrier function. In the CNS, the family of glucose transporter proteins plays a key role in controlling movement of glucose across cell membranes. The 55 kDa isoform of glucose transporter 1 (GLUT1) regulates import of glucose from blood to brain across the endothelial cells of the blood-brain barrier (BBB), whereas the 45 kDa form of GLUT1 predominantly regulates nonvascular glial glucose uptake. In this study, expression of 55 and 45 kDa forms of GLUT1 in different regions of the brain from 18 SIV-infected macaques was measured by quantitative immunoblot and then compared with the severity of SIV encephalitis to determine whether neurologic disease is related to altered glucose metabolism at the BBB and in brain parenchyma. An inverse relationship was found between severity of SIV encephalitis and expression of the endothelial 55 kDa isoform of GLUT1 at the BBB in cortical grey matter, caudate nucleus, and cerebellum. A similar relationship also was found for the glial 45 kDa GLUT1 isoform in cortical grey matter. In addition, a significant increase in 55 kDa GLUT1 expression was found in caudate nucleus during the early stages of infection. In the brains of macaques with moderate to severe encephalitis, 55 kDa GLUT1 expression had declined to pre-infection levels. These GLUT1 alterations at the BBB and in glial cells may reflect severe disturbances in the CNS microenvironment that contribute to CNS dysfunction.

A South Australian population survey of the ownership of asthma action plans

OBJECTIVE

To examine the relationships between ownership of written asthma action plans, asthma morbidity, use of devices, and patients' perceptions of their asthma management.

DESIGN AND SETTING

A random population survey (in 1996) of the South Australian population aged 15 years or over, using interviewers to administer a questionnaire.

PARTICIPANTS

People who reported that they had current, doctor-diagnosed asthma.

MAIN OUTCOME MEASURES

Prevalence of written asthma action plans; night-time awakenings from asthma; ownership of peak flow meters; and people's perceptions of their asthma management.

RESULTS

The ownership of asthma action plans by people with self-reported asthma was 33% and has declined since 1995 (42%; P < 0.001). Fifteen per cent were awakened weekly or more frequently by asthma symptoms. These people were more likely to have a peak flow meter and a written action plan, but less likely to consider they had been provided with enough information about their asthma, to feel comfortable managing their asthma, or to find it easy to see their doctor. Having a written asthma action plan was associated with regular corticosteroid use, understanding asthma, having enough information and owning a peak flow meter.

CONCLUSIONS

Ownership of asthma action plans in South Australia is suboptimal. Before we develop new strategies to improve asthma outcomes, we must determine whether there is a need to target people with less severe asthma and/or improve the use of guidelines by health professionals.

Measles virus infection in rhesus macaques: altered immune responses and comparison of the virulence of six different virus strains

Measles remains a major cause of childhood mortality, with questions about virus virulence and pathogenesis still requiring answers. Rhesus macaques were infected with 5 different culture-adapted strains of measles virus, including 2 from patients with progressive vaccine-induced disease, and a sixth nonculture-adapted strain, Bilthoven. All caused infection detectable by reverse transcriptase-polymerase chain reaction and induction of antibody. Chicago-1 and Bilthoven induced viremias detectable by leukocyte cocultivation. Bilthoven induced Koplik's spots, conjunctivitis, and rash. Lymphopenia and depressed interleukin (IL)-2 production were followed by monocytosis and eosinophilia. All monkeys, including 41 involved in a primate facility outbreak, showed suppressed responses to phytohemagglutinin. As the rash resolved production of IL-2, IL-1beta, tumor necrosis factor-alpha, IL-6, and IL-5 mRNA increased. Monkeys are useful for studies of measles immunopathogenesis, but virus strains must be carefully chosen. Increased virulence of vaccine strains isolated from immunocompromised infants with fatal infections was not evident.

Sterilization and disinfection in general practice in Northern Ireland

In view of the recent trend towards more minor surgery being carried out in general practice we decided to conduct a postal survey to assess the level of knowledge of sterilization and disinfection and the use of benchtop sterilizers in general practice in Northern Ireland. The survey, of all 366 practices in the Province, was carried out in January/March 1998. One hundred and eleven (30%) completed questionnaires were returned. All practices performed at least one of a range of procedures requiring sterilization or disinfection, e.g., minor surgery 95%, cervical smear taking 98%, syringing of ears 98%. Only 76% of practices had a benchtop sterilizer and 39% did not have access to a sterile supply department (SSD); 32% of the latter had no desire to utilize such a service. Only 25% and 34% correctly identified the Medical Devices Agency (MDA) definitions of sterilization and disinfection respectively. The MDA Device Bulletin on benchtop sterilizers had been read by only 26% of respondents. There was an 86% interest in attending a workshop on sterilization and disinfection. The concepts and practice of sterilization and disinfection appear not to be clearly understood. We conclude that resources must be identified to provide appropriate education in this important area for primary care staff.

Production of atypical measles in rhesus macaques: evidence for disease mediated by immune complex formation and eosinophils in the presence of fusion-inhibiting antibody

The severe disease atypical measles occurred when individuals immunized with a poorly protective inactivated vaccine contracted measles, and was postulated to be due to a lack of fusion-inhibiting antibodies. Here, rhesus macaques immunized with formalin-inactivated measles vaccine developed transient neutralizing and fusion-inhibiting antibodies, but no cytotoxic T-cell response. Subsequent infection with measles virus caused an atypical rash and pneumonitis, accompanied by immune complex deposition and an increase in eosinophils. Fusion-inhibiting antibody appeared earlier in these monkeys than in non-immunized monkeys. These data indicate that atypical measles results from previous priming for a nonprotective type 2 CD4 T-cell response rather than from lack of functional antibody against the fusion protein.

Pathogenesis of simian immunodeficiency virus pneumonia: an immunopathological response to virus

Although many human immunodeficiency virus-infected individuals develop lymphocytic interstitial pneumonia, the roles of host and viral factors in the pathogenesis of pneumonia are not well defined. Human immunodeficiency virus-infected children with lymphocytic interstitial pneumonia have human immunodeficiency virus-specific cytotoxic T cells in pulmonary infiltrates, increased survival time, and a reduced incidence of opportunistic infections, suggesting that lymphocytic interstitial pneumonia may reflect an effective antiviral immune response. In this study, 20 macaques were inoculated with related macrophage-tropic simian immunodeficiency viruses and examined for pulmonary lesions and virus gene expression. Ten macaques developed moderate to severe pneumonia characterized by perivascular, peribronchial, and interstitial infiltrates of lymphocytes and macrophages. Large numbers of pulmonary cytotoxic lymphocytes were demonstrated in macaques with moderate to severe pneumonia (P < 0.05) by immunostaining for TIA-1. There was no difference in viral load between macaques with moderate to severe pneumonia and those with mild to no pulmonary lesions. In five macaques inoculated with the same virus swarm, there was a significant (P < 0.05) inverse correlation between the percentage decline in CD4+ T-cell counts and the severity of pulmonary lesions. Pulmonary infiltrates of cytotoxic lymphocytes, the lack of correlation between severity of pulmonary lesions and virus gene expression, and the inverse relationship between pneumonia and inmune status suggest that simian immunodeficiency virus pneumonia may represent an immunopathological response to macrophage-tropic virus.

Measuring individual differences in change with multidimensional Rasch models

Item response models have been developed to explore change measurement, including those proposed by Fischer and his colleagues (e.g., Fischer & Pazer, 1991; Fischer & Ponocny, 1994), Andersen (1985) and Embretson (1991). In this article, we propose another multidimensional Rasch model, the multidimensional random coefficient multinomial logit (MRCML) model (Adams, Wilson, & Wang, 1997). All these models are briefly reviewed and compared. The MRCML can be applied to not only polytomous items but also investigation of variations in item difficulties. Based on variations in difficulties across occasions and items, five kinds of models are proposed. Some simulation studies were conducted to examine parameter recovery of the MRCML model under various testing situations. All the parameters were recovered very well. A real data set was analyzed to show applications of the MRCML to measuring individual differences in change.

A modified card procedure for measuring human infant color vision

To improve test efficiency, we modified our previously introduced contrast/color card test by including a patterned test stimulus and reducing the number of stimuli in both experimental phases. Compared with the prototype, completion rate improved substantially (79 vs. 37%) but test time decreased only modestly (19 vs. 21 min). Achromatic contrast discrimination improved threefold (mean, 0.06 vs. 0.20 log units), but the percentage of 2-month-old infants who discriminated (from gray) 660-nm red (86 vs. 80%) and 580-nm yellow (52 vs. 55%) was consistent. In addition, 48% discriminated 574-nm yellow-green. Moreover, because 88% of infants' failures included the respective adult brightness/luminance match, a small range of relative luminances is adequate for testing infant color vision.

Prevention of a first stroke by transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography

BACKGROUND

Blood transfusions prevent recurrent stroke in children with sickle cell anemia, but the value of transfusions in preventing a first stroke is unknown. We used transcranial Doppler ultrasonography to identify children with sickle cell anemia who were at high risk for stroke and then randomly assigned them to receive standard care or transfusions to prevent a first stroke.

METHODS

To enter the study, children with sickle cell anemia and no history of stroke had to have undergone two transcranial Doppler studies that showed that the time-averaged mean blood-flow velocity in the internal carotid or middle cerebral artery was 200 cm per second or higher. The patients were randomly assigned to receive standard care or transfusions to reduce the hemoglobin S concentration to less than 30 percent of the total hemoglobin concentration. The incidence of stroke (cerebral infarction or intracranial hemorrhage) was compared between the two groups.

RESULTS

A total of 130 children (mean [+/-SD] age, 8.3+/-3.3 years) were enrolled; 63 were randomly assigned to receive transfusions and 67 to receive standard care. At base line, the transfusion group had a slightly lower mean hemoglobin concentration (7.2 vs. 7.6 g per deciliter, P=0.001) and hematocrit (20.4 vs. 21.7 percent, P=0.002). Ten patients dropped out of the transfusion group, and two patients crossed over from the standard-care group to the transfusion group. There were 10 cerebral infarctions and 1 intracerebral hematoma in the standard-care group, as compared with 1 infarction in the transfusion group -- a 92 percent difference in the risk of stroke (P<0.001). This result led to the early termination of the trial.

CONCLUSIONS

Transfusion greatly reduces the risk of a first stroke in children with sickle cell anemia who have abnormal results on transcranial Doppler ultrasonography.

Oriented cell divisions and cellular morphogenesis in the zebrafish gastrula and neurula: a time-lapse analysis

We have taken advantage of the optical transparency of zebrafish embryos to investigate the patterns of cell division, movement and shape during early stages of development of the central nervous system. The surface-most epiblast cells of gastrula and neurula stage embryos were imaged and analysed using a computer-based, time-lapse acquisition system attached to a differential interference contrast (DIC) microscope. We find that the onset of gastrulation is accompanied by major changes in cell behaviour. Cells collect into a cohesive sheet, apparently losing independent motility and integrating their behaviour to move coherently over the yolk in a direction that is the result of two influences: towards the vegetal pole in the movements of epiboly and towards the dorsal midline in convergent movements that strengthen throughout gastrulation. Coincidentally, the plane of cell division becomes aligned to the surface plane of the embryo and oriented in the anterior-posterior (AP) direction. These behaviours begin at the blastoderm margin and propagate in a gradient towards the animal pole. Later in gastrulation, cells undergo increasingly mediolateral-directed elongation and autonomous convergence movements towards the dorsal midline leading to an enormous extension of the neural axis. Around the equator and along the dorsal midline of the gastrula, persistent AP orientation of divisions suggests that a common mechanism may be involved but that neither oriented cell movements nor shape can account for this alignment. When the neural plate begins to differentiate, there is a gradual transition in the direction of cell division from AP to the mediolateral circumference (ML). ML divisions occur in both the ventral epidermis and dorsal neural plate. In the neural plate, ML becomes the predominant orientation of division during neural keel and nerve rod stages and, from late neural keel stage, divisions are concentrated at the dorsal midline and generate bilateral progeny (C. Papan and J. A. Campos-Ortega (1994) Roux's Arch. Dev. Biol. 203, 178–186). Coincidentally, cells on the ventral surface also orient their divisions in the ML direction, cleaving perpendicular to the direction in which they are elongated. The ML alignment of epidermal divisions is well correlated with cell shape but ML divisions within the neuroepithelium appear to be better correlated with changes in tissue morphology associated with neurulation.

The evolving role of transcranial doppler in stroke prevention and treatment

Without focusing on established indications for transcranial Doppler (TCD) such as monitoring vasospasm after subarachnoid hemorrhage and detecting intracranial stenosis (sickle cell disease, stroke, etc.), we describe the role of TCD in carotid endarterectomy (CEA) and angioplasty, acute ischemic stroke, as well as competence and the practice of TCD. In addition to duplex ultrasound and angiography TCD can be used to select patients for CEA because it detects hemodynamically significant extracranial stenosis and tandem intracranial stenoses, and identifies asymptomatic patients at potentially high risk of stroke because of exhausted vasomotor reactivity or brain microembolization. TCD identifies in real time brain hypoperfusion, embolism, and hyperperfusion and thus may be helpful in reducing cerebrovascular complications of CEA/angioplasty. In acute ischemic stroke, TCD can reliably identify the patency of middle cerebral and basilar arteries, high resistance flow patterns due to increased intracranial pressure, and progression to cerebral circulatory arrest. TCD also can monitor spontaneous or induced arterial recanalization. Limitations include operator and interpreter dependency, absent temporal "windows" leading to unsuccessful insonation in 10% to 15% of patients older than 60 years, as well as difficulties with probe positioning and fixation for monitoring. However, the use of ultrasound contrast agents and improved probe fixation devices help avoid these factors. The key to the successful practice of TCD is training of technical personnel and education of the interpreting and referring physicians as to when to use TCD and what to expect from it. The advantages of TCD should be given particular consideration: portability, repeatability, long-term monitoring, emboli detection, and inexpensiveness. TCD machines and transducers need to be tuned to the target disorders; that is, larger sample volume, higher power, and so forth, and TCD technology should be implemented in phases I to II as well as in phase III trials of preventive interventions and stroke therapies.

Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial. RANTTAS Investigators

BACKGROUND AND PURPOSE

Medical and neurological complications after acute ischemic stroke may adversely impact outcome and in some cases may be preventable. Limited data exist regarding the frequency of such complications occurring in the first days after the ictus and the relationship of these complications to outcome. Our objective was to identify the types, severity, and frequency of medical and neurological complications following acute ischemic stroke and to determine their role in mortality and functional outcome.

METHODS

Rates of serious (life-threatening) and nonserious medical and neurological complications and mortality were derived from the placebo limb of the Randomized Trial of Tirilazad Mesylate in Acute Stroke (RANTTAS) database (n=279). Complications were correlated with clinical outcome using logistic regression techniques.

RESULTS

Of all patients, 95% had at least one complication. The most common serious medical complication was pneumonia (5%), and the most common serious neurological complication was new cerebral infarction or extension of the admission infarction (5%). The 3-month mortality was 14%; 51% of these deaths were attributed primarily to medical complications. Outcome was significantly worse in patients with serious medical complications, after adjustment for baseline imbalances, as measured by the Barthel Index (odds ratio [OR], 6.1; 95% confidence interval [CI], 2.5 to 15.1) and by the Glasgow Outcome Scale (OR, 11.6; 95% CI, 4.3 to 30.9). After death was discounted, serious medical complications were associated with severe disability at 3 months as determined by the Glasgow Outcome Scale (OR, 4.4; 95% CI, 1.3 to 14.8).

CONCLUSIONS

Medical complications that follow ischemic stroke not only influence mortality but may influence functional outcome.

Stroke prevention trial in sickle cell anemia

Stroke occurs in 7-8% of children with Sickle Cell Disease (Hb SS) and is a major cause of morbidity. Rates of recurrence have been reduced from 46-90% to less than 10% through chronic blood transfusions. Prevention of first stroke, however, would be preferable because even one stroke can cause irreversible brain injury. Transcranial Doppler (TCD) ultrasound can detect arterial blood flow rates associated with subsequent stroke risk. By combining TCD screening and a potentially effective treatment, first stroke may be prevented. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) is the first stroke prevention trial in Hb SS and the first randomized, controlled use of transfusion in Hb SS. This multi-center trial is designed to test whether reducing sickle hemoglobin to 30% or less with periodic blood transfusions will reduce first-time stroke by at least 70% compared to standard care. Primary endpoints will be clinically evident symptoms of cerebral infarction with consistent findings on Magnetic Resonance Imaging and Angiography (MRI/MRA) or symptomatic intracranial hemorrhage. Secondary endpoints will be asymptomatic brain lesions detected by MRI in brain areas not involved in primary endpoints. The design calls for a 6-month start-up interval, 18 months of TCD screening and randomization, and observation for stroke from entry through month 54. Key features of the trial are standardized TCD and MRI/MRA protocols interpreted blindly, and blinded adjudication of endpoints. The sample size (60 per treatment group) is based on prospective data relating TCD velocity to risk of stroke. A time-averaged mean velocity of > or = 200 cm/sec is associated with a 46% risk of cerebral infarction over 39 months. The sample size is sufficient to detect 70% reduction in the primary endpoint at 90% power. This trial will determine if transfusion is effective in the primary prevention of stroke. Secondary aims may further the understanding of the effects of transfusion on the brain and guide future research into cerebrovascular disease in Hb SS.

Human newborn color vision: measurement with chromatic stimuli varying in excitation purity

Groups of newborn human infants (N = 180) were habituated to large 16 degrees achromatic ("white") lights of varying luminance (0.35 to 1.16 log cd/m2) and then tested for recovery of habituation to 16 degrees green (dominant lambda = 545 nm), yellow (dominant lambda = 585 nm) or red (dominant lambda = 650 nm) lights which varied in the level of excitation purity (range = 32 to 83%). Results showed that newborns discriminated the chromatic stimuli from white only when excitation purity values exceeded at least 41% for 545-nm green, 47% for 650-nm red, and 65% for 585-nm yellow, limits much higher than those for adults (<1%). Taken together with the results from previous experiments, these saturation discrimination data (with the exception of the yellow data), provide some support for an expanded MacAdam ellipse model of early color discrimination (Brown, 1993; Teller & Lindsey, 1993). This helps reinforce the current view that neonates' vision is based on general rather than selective immaturities or inefficiencies within the requisite optical, photoreceptoral and neural mechanisms.

Pathogenesis of ovine lentiviral encephalitis: derivation of a neurovirulent strain by in vivo passage

The lentiviruses of sheep replicate almost exclusively in macrophages and cause chronic interstitial pneumonia, arthritis, and mastitis, but only rarely encephalitis. This study was undertaken to determine whether a non-neurovirulent field strain of ovine lentivirus isolated from joint fluid that replicated productively in lung and joint macrophages could be adapted to enter and replicate in the brain and cause encephalitis. The field isolate was passed seven times sequentially by intracerebral inoculation of sheep. The neuroadapted strain of virus caused severe encephalitis typical of visna in four of four sheep inoculated intracerebrally. The virus replicated to high titers in the brains of these animals and in cultured microglia. The inflammatory response in the brain was characterized by intense infiltrates of macrophages and CD8+ and CD4+ T cells. Many of the perivascular macrophages demonstrated TNF-alpha expression and there was upregulation of MHC Class II antigen expression on both inflammatory cells and endothelium. Inoculation of this neuroadapted virus into the bone marrow of three animals resulted in persistent infection and cell-associated viremia, but not encephalitis. Virus was not detected in brains from these animals, indicating that the virus was not neuroinvasive. These data suggest that neuroinvasiveness and neurovirulence are separate pathogenic determinants, both of which are required for the development of encephalitis during natural infection.

Long-term stroke risk in children with sickle cell disease screened with transcranial Doppler

Stroke is an important complication of sickle cell disease. Stroke prediction is clinically important because it offers the possibility of primary prevention. In 1992, transcranial Doppler (TCD) evidence of elevated intracranial internal carotid or middle cerebral artery velocity was demonstrated to be associated strongly with an increased risk of ischemic stroke. This study extends the original study and includes 125 more children, longer follow-up, and intracranial hemorrhage in the stroke-risk model. Elevated time averaged mean maximum blood flow velocity, especially when velocity is 200 cm/sec or greater by TCD, was associated strongly with stroke risk. The cases not predicted by TCD point to the need for more information on the optimal timing of TCD surveillance for stroke risk.

Internal carotid artery occlusion in a child with sickle cell disease: case report and immunohistochemical study

PURPOSE

The purpose of this report is to describe the clinical and pathologic features of a patient with acute thrombosis of both internal carotid arteries leading to death.

METHODS

This is a case report of special interest because of extensive brain vessel pathologic examination.

RESULTS

The analysis of this case showed that the brain had suffered massive infarction and cerebral edema. The internal carotid arteries (ICAs) were occluded by acute thrombus. The arterial wall of the left ICA, studied at its distal segment, showed a small amount of intimal hyperplasia which did not cause encroachment on the lumen. Immunohistochemical stains indicated that this lesion was formed by proliferative vascular smooth muscle rather than incremental thrombus formation.

CONCLUSION

Acute thrombus formation can occur in the large cerebral arteries of children with sickle cell disease in the presence of only minimal intimal hyperplasia. The intimal hyperplasia which forms the sickle related vasculopathy seen on angiography or detected by Transcranial Doppler may be more related to stimulation of smooth muscle cells than dysregulation of thromboregulation at the endothelial surface. Implications for preventive treatment are discussed.

Contrast sensitivity in infants and children with Down syndrome

A new contrast sensitivity (CS) card test was used to estimate contrast sensitivity in 18 infants and children with Down syndrome (DS). The results showed that although the overall shape of the contrast sensitivity functions (CSFs) of the subjects with DS was the typical inverted-U, their CSFs were depressed in comparison to control subjects and this relative loss became larger with increasing spatial frequency. In addition, there was little improvement in CS with age and the mean CSF among children with DS (mean age = 7.3 years) was equivalent statistically to a group of 12-month-olds without DS. The Teller Acuity Cards (TAC) were also used to assess visual acuity in 17 of the 18 children in our sample. The results of these tests showed that their visual acuity (VA) was significantly lower than normal, but was consistent with that extrapolated from each subject's CSF. Taken together with previous anatomical and developmental findings, our results suggest that the deficits in spatial vision among children with DS is due primarily to restricted cortical development, and secondarily, to the additional accommodative and ocular conditions that are prevalent in this population.

Visual acuity in extremely low birth weight infants

The increased viability of extremely low birth weight (ELBW) infants (those weighing less than 1,000 g) and the associated increased risk of visual impairment has highlighted the need for reliable indices of visual functioning for this population. By use of the Teller Acuity Cards, we assessed grating visual acuity in 26 survivors of extreme prematurity (corrected age, 2-42 mo) and found that although most scores were within the normal range, they were significantly lower than those of full-term infants of equivalent postconceptional age, especially after 9 months of age. Moreover, the number of complications in the neonatal period (especially bronchopulmonary dysplasia) and the Neonatal Medical Index classification were associated with below-average visual acuity in infancy and early childhood.

Metaphase spindles rotate in the neuroepithelium of rat cerebral cortex

Time-lapse confocal microscopy has been used to image cells in mitosis at the apical surface of neuroepithelium from the rat cerebral cortex during the period of neurogenesis. Staining with vital chromatin dyes reveals that mitotic spindles that are aligned parallel to the surface of the tissue are highly motile, rotating within the plane of the epithelium throughout metaphase, and come to rest only as anaphase begins. Spindles may make several complete turns, parallel to the epithelium, but only rarely tumble into an orientation perpendicular to the epithelial sheet. Analysis shows that spindles do not rotate randomly; rather, they spend most of their time aligned parallel or antiparallel to the direction in which they will later enter anaphase and undergo cell division. This conclusion is strongly supported by statistical analyses of the data. Stereotyped movements of this kind show that the direction of division is determined early in mitosis. This suggests the existence of intracellular and perhaps intercellular signals that define the polarity of the cell both in the apico-basal direction and within the plane of the epithelium. Such mechanisms may be important for maintaining the structure of the epithelium and cell-cell communication during development and may also provide a mechanism for the precise distribution of cytoplasmic determinants that might influence the fate of the daughter cells at a time when neuronal fate is being determined.