The anaesthetic management of a patient with Emery-Dreifuss muscular dystrophy

PURPOSE

This case report presents a patient with Emery-Dreifuss Muscular Dystrophy and describes the anaesthetic considerations.

CLINICAL FEATURES

The features of Emery-Dreifuss Muscular Dystrophy are contractures, humeroperoneal muscle weakness and cardiomyopathy. The anaesthetic considerations for this syndrome are difficult tracheal intubation, difficult spinal anaesthetic, heart block, gastric reflux, rhabdomyolysis, and unproved malignant hyperthermia susceptibility.

CONCLUSION

The major anaesthetic problem for the patient with Emery-Dreifuss Muscular Dystrophy could be a life-threatening cardiomyopathy.

MIB-1 expression and iododeoxyuridine labelling in soft tissue sarcomas: an immunohistochemical study including correlations with p53, bcl-2 and histological characteristics

We investigated the relationship between immunohistochemical estimates of proliferative activity and expression of bcl-2 protein and mutant p53 protein in 23 cases of soft tissue sarcoma. Furthermore, the reproducibility of estimates of proliferative activity was analysed and correlations between the variables and with mitotic score were investigated. Proliferative activity was assessed by use of monoclonal antibody MIB-1 and staining for iododeoxyuridine (IdUrd), and evaluated in multiple, random, systematically sampled fields of vision. MIB-1 indices were higher than those of IdUrd but for each case the two values were positively correlated (r = 0.78). The MIB-1 index correlated positively with mitotic score (2P < 0.001) and malignancy grade (2P = 0.001). The intraobserver reproducibility of the MIB-1 and IdUrd indices were excellent (r = 0.98 and r = 0.90, respectively). p53 expression was detected in 43% and strong bcl-2 expression was present in 57% of the studied cases. Expression of p53 and bcl-2 were not significantly correlated to proliferative activity or the histological features. We conclude, that the MIB-1 index is a reliable and reproducible estimate of proliferative activity and might improve the accuracy of conventional malignancy grading of soft tissue sarcomas. Furthermore, the results indicate that neither mutant p53 protein nor bcl-2 oncogene alone are sufficient to induce increased proliferation in these sarcomas.

Stereologic estimation of breast tumor size

OBJECTIVE

The largest tumor diameter, D(T), is a variable of great clinical value in breast cancer but a biased and imprecise estimator of real tumor size. Three-dimensional, shape-independent estimates would more realistically reflect the tumor bulk and provide more accurate clinical staging. For experimental oncology, the measurements may be useful for precise assessment of tumor burden.

STUDY DESIGN

In 64 prospectively collected breast cancers, unbiased stereology was used for estimating the gross tumor volume, V(T), cutting specimens into parallel, equally thick sections with subsequent determination of total tumor sectional area. For comparison, the volume of invasive tumor epithelium, "V"(epi), was obtained by microscopic examination of systematically sampled tissue fractions of the same tumors, embedded in both methacrylate and paraffin.

RESULTS

The median D(T) was 2.2 cm, and the median V(T) was 6.72 cm3. The correlation between these variables was not very close (r = .77), and the slope of the regression line was steeper than expected, presumably reflecting a change in tumor shape with growing size. The sampling scheme used for estimation of V(T) proved highly efficient, yielding a mean error coefficient of 9%. The median "V"(epi) in methacrylate was 1.19 cm3, 21% larger than in paraffin. Estimates of "V" (epi) were highly reproducible (r = .97) and correlated highly with point counting-based estimates of the feature (r = .96). "V"(epi) correlated with V(T) (r > or = .75), but the slopes of the regression lines were steeper than expected, corresponding with the correlation found between epithelial volume fraction and tumor size (r = .26). On average, about 25% of the gross tumor was composed of invasive epithelium, but with a wide range.

CONCLUSION

In breast cancer, realistic estimates of tumor volume, volume of invasive epithelium and epithelial volume fraction can be obtained by efficient stereologic techniques, which seem useful for clinical and experimental oncology. In the present methodologic study, baseline data were generated. Further studies are needed to assess the clinical value of stereologic tumor size estimates as compared with traditional staging parameters.

Quantitative histopathology in lymph node-negative breast cancer. Prognostic significance of mitotic counts

Reliable prognostic factors are needed to improve the stratification of patients with lymph node-negative breast cancer to different therapy modalities. We investigated the prognostic value of quantitative histopathology in a retrospective study of 98 "low-risk" breast cancer patients (T1+2N0M0) with a median follow-up of 9 years. An interactive video system and stereological and morphometric techniques were used to obtain estimates of four nuclear features (mean volume, mean profile area, volume fraction, and profile density), and two mitotic counts [mitotic profile frequency (MF) and mitotic profile density (MD)]. All measurements were performed in fields of vision sampled systematically from the whole tumour area of a routine histological section. Histological grade, histological type, and oestrogen receptor (ER) status was reassessed, whereas tumour diameter and age at diagnosis were recorded from the files. We found that all quantitative histopathological variables and ER status were correlated with histological grade. Single-factor prognostic analyses showed a highly significant value of MF (2p = 0.001) and a marginally significant value of MD (2p = 0.09), whereas no other variable approached statistical significance (2p > or = 0.25). In a multivariate Cox analysis, MF was the only parameter of significant independent prognostic value (2p = 0.03). Thus, the prognostic value of nuclear features found in previous studies could not be reproduced, whereas the marked value of mitotic counts for prediction of the outcome in patients with breast cancer was confirmed. Mitotic counts are easily obtained and may be of clinical value for identification of high-risk cases among patients with lymph node-negative breast cancer.

Impairment of synaptic vesicle clustering and of synaptic transmission, and increased seizure propensity, in synapsin I-deficient mice

Synapsin I has been proposed to be involved in the modulation of neurotransmitter release by controlling the availability of synaptic vesicles for exocytosis. To further understand the role of synapsin I in the function of adult nerve terminals, we studied synapsin I-deficient mice generated by homologous recombination. The organization of synaptic vesicles at presynaptic terminals of synapsin I-deficient mice was markedly altered: densely packed vesicles were only present in a narrow rim at active zones, whereas the majority of vesicles were dispersed throughout the terminal area. This was in contrast to the organized vesicle clusters present in terminals of wild-type animals. Release of glutamate from nerve endings, induced by K+,4-aminopyridine, or a Ca2+ ionophore, was markedly decreased in synapsin I mutant mice. The recovery of synaptic transmission after depletion of neurotransmitter by high-frequency stimulation was greatly delayed. Finally, synapsin I-deficient mice exhibited a strikingly increased response to electrical stimulation, as measured by electrographic and behavioral seizures. These results provide strong support for the hypothesis that synapsin I plays a key role in the regulation of nerve terminal function in mature synapses.

The prognostic value of oncogenic antigen 519 (OA-519) expression and proliferative activity detected by antibody MIB-1 in node-negative breast cancer

The prognostic value of oncogenic antigen 519 (OA-519) expression and tumour proliferative activity was evaluated in a retrospective series of 118 patients with low-risk breast cancer. Low risk was defined as negative axillary nodes, tumour diameter < or = 50 mm, and no histological evidence of invasion of skin or deep fascia (= T1N0M0 and T2N0M0). The median follow-up time was 104 months (range 5-143 months). Immunohistochemical analysis of OA-519 expression was performed on formalin-fixed, paraffin-embedded tissue. The proliferative activity was estimated using a Ki-67 equivalent monoclonal antibody (MIB-1), which is applicable on formalin-fixed, paraffin-embedded tissue after microwave pretreatment. OA-519 was expressed in about one-third of the tumours and the percentage of proliferating cells (the MIB-1 index) ranged between 1 and 72 per cent (median 17 per cent). Using multivariate Cox analysis, both the MIB-1 index and OA-519 expression were of independent prognostic value (2p < or = 0.01), and the combined immunohistological approach may therefore be useful in selecting patients with node-negative breast cancer who might benefit from adjuvant therapy.

Reducing specialty bed use

Saint Joseph Hospital is a tertiary care teaching facility with 602 licensed beds. In 1992 it was noted that there was a significant rise in the use of specialty beds within the hospital. Guidelines for selection, initiation, and termination were nonexistent. In an effort to reduce high costs associated with specialty bed use a study was conducted to determine appropriate selection criteria and monitor patient outcomes.

Immunohistochemical quantitation of oestrogen receptors and proliferative activity in oestrogen receptor positive breast cancer

AIM

To evaluate the effect of the duration of formalin fixation and of tumour heterogeneity on quantitative estimates of oestrogen receptor content (oestrogen receptor index) and proliferative activity (MIB-1 index) in breast cancer.

METHODS

Two monoclonal antibodies, MIB-1 and oestrogen receptor, were applied to formalin fixed, paraffin wax embedded tissue from 25 prospectively collected oestrogen receptor positive breast carcinomas, using a microwave antigen retrieval method. Tumour tissue was allocated systematically to different periods of fixation to ensure minimal intraspecimen variation. The percentages of MIB-1 positive and oestrogen receptor positive nuclei were estimated in fields of vision sampled systematically from the entire specimen and from the whole tumour area of one "representative" cross-section.

RESULTS

No correlation was found between the oestrogen receptor and MIB-1 indices and the duration of formalin fixation. The estimated MIB-1 and oestrogen receptor indices in tissue sampled systematically from the entire tumour were closely correlated with estimates obtained in a "representative" section. The intra- and interobserver correlation of the MIB-1 index was good, although a slight systematical error at the second assessment of the intraobserver study was noted.

CONCLUSION

Quantitative estimates of oestrogen receptor content and proliferative activity are not significantly influenced by the period of fixation in formalin, varying from less than four hours to more than 48 hours. The MIB-1 and the oestrogen receptor indices obtained in a "representative" section do not deviate significantly from average indices determined in tissue samples from the entire tumour. Finally, the estimation of MIB-1 index is reproducible, justifying its routine use.

Analysis of dendritic spines in rat CA1 pyramidal cells intracellularly filled with a fluorescent dye

The dendritic branching pattern and the distribution of dendritic spines were studied in hippocampal neurones with an improved technique. In slices taken from adult Wistar rats, CA1 pyramidal cells were filled with Lucifer yellow and examined under a laser-scanning confocal microscope. The basal dendrites were found evenly distributed inside a regular cupola-shaped volume. Their total length was about 4,500 microns. The branches divided between one and three times, with the initial segments comprising less than 2%, and the long terminal segments (mean length, 119 microns) including more than 80% of the total length of the basal dendrites. The apical dendritic branches emerged obliquely from the main shaft, ran for a distance of 50 to 250 microns, and made up a total length of about 5,100 microns in stratum radiatum and between 1,100 and 3,200 microns in stratum lacunosum-moleculare. The mean total length of the dendritic tree was 11,900 microns. All values were corrected for shrinkage. Shrinkage was measured in three dimensions and was 20.2% in the horizontal (x/y) plane and 40.9% in the vertical (z) plane. Both the basal and the apical dendritic branches were covered by regularly spaced spines. When corrected for dehydration-induced shrinkage and for hidden spines, the density was 1.80 and 2.00 spines/microns dendritic length for the basal and apical dendritic branches, respectively. Apart from the initial parts of the branches, which had few or no spines, the spines were remarkably evenly spaced. In particular, the distance between spine heads was significantly different from a random distribution, suggesting a regulatory process for the spacing of spines.

Goldhelox: a soft x-ray solar telescope

The Goldhelox Project is the construction and use of a near-normal incidence soft x-ray robotic solar telescope by undergraduate students at Brigham Young University. Once it is completed and tested, it will be deployed from a Get-Away-Special (GAS) canister in the bay of a space shuttle. It will image the sun at a wavelength of 171-181Å with a time resolution of 1 sec and a spatial resolution of 2.5 arcsec. The observational bandpass was chosen to image x-rays from highly ionized coronal Fe lines. The data will be an aid in better understanding the beginning phases of solar flares and how flaring relates to the physics of the corona-chromosphere transition region. Goldhelox is tentatively scheduled to fly on a space shuttle sometime in 1995 or 1996. This paper outlines the project goals, basic instrument design, and the unique aspects of making this an undergraduate endeavor.

Specificity of protein kinase inhibitor peptides and induction of long-term potentiation

Previous studies have used synthetic peptide analogs, corresponding to sequences within the pseudosubstrate domain of protein kinase C (PKC) or the autoregulatory domain of Ca2+/calmodulin-dependent protein kinase II (CaMKII), in attempts to define the contribution of each of these protein kinases to induction of long-term potentiation (LTP). However, the specificity of these inhibitor peptides is not absolute. Using intracellular delivery to rat CA1 hippocampal neurons, we have determined the relative potency of two protein kinase inhibitor peptides, PKC-(19-36) and [Ala286]CaMKII-(281-302), as inhibitors of the induction of LTP. Both peptides blocked the induction of LTP; however, PKC-(19-36) was 30-fold more potent than [Ala286]CaMKII-(281-302). The relative specificity of PKC-(19-36), [Ala286]CaMKII-(281-302), and several other CaMKII peptide analogs for protein kinase inhibition in vitro was also determined. A comparison of the potencies of PKC-(19-36) and [Ala286]CaMKII-(281-302) in the physiological assay with their Ki values for protein kinase inhibition in vitro indicates that the blockade of induction of LTP observed for each peptide is attributable to inhibition of PKC.

Tardy posterior interosseous nerve palsy as a result of an unreduced radial head dislocation in Monteggia fractures: a report of two cases

Tardy palsy of the posterior interosseous nerve after a malunited Monteggia fracture with an unreduced dislocation of the radial head is considered to be extremely rare. Four earlier cases were treated by excision of the radial head or by tendon transfers. Another two cases have been reported, both treated successfully by decompression of the nerve in the radial tunnel between the two heads of the supinator. This simple operation should be given a trial before tendon transfers are considered, even if the palsy has been of long duration.

Influence of moderate alcohol intake on wakening plasma thiopental concentration

In an earlier study, an inverse correlation between thiopental-induced sleeping time and alcohol intake in the preceding week was demonstrated in women undergoing termination of pregnancy. In order to investigate the mechanism behind the apparent cross-tolerance, the relationship between alcohol consumption in the week preceding thiopental/nitrous oxide/oxygen anesthesia and wakening plasma thiopental concentration on one hand and sleeping time on the other was examined in 68 women scheduled for termination of pregnancy and in 37 women scheduled for diagnostic uterine dilatation and curettage. In terms of pure alcohol, the weekly intake (mean +/- s.d.) was 1.17 +/- 2.07 ml . kg-1 in the former and 1.49 +/- 1.70 ml . kg-1 in the latter group. A positive correlation between alcohol consumption and wakening plasma thiopental concentration was found in both groups, reaching statistical significance (P less than 0.05) in the group undergoing termination of pregnancy, but not in the other. The inverse correlation found earlier between alcohol intake and sleeping time was not reproduced significantly in any of the groups. The results indicate that moderate alcohol intake may induce cerebral tolerance to thiopental.

Femoral-femoral cardiopulmonary bypass prior to induction of anaesthesia in the management of upper airway obstruction

A case is presented of a female with respiratory distress who was initially treated as having asthma. Her chest x-ray was normal but tracheal tomograms revealed a tracheal tumour almost completely occluding the tracheal lumen. The impending tracheal occlusion was managed with femoral-femoral cardiopulmonary bypass instituted under local anaesthesia prior to induction of anaesthesia and diagnostic bronchoscopy and airway establishment with tracheal intubation. Other indications for the use of cardiopulmonary bypass prior to the induction of anaesthesia are reviewed.

Influence of moderate alcohol intake on thiopental anesthesia

The relationship between alcohol intake over the week preceding anesthesia and various anesthetic parameters was examined in 119 women scheduled for termination of pregnancy under thiopental-nitrous oxide anesthesia. In terms of pure alcohol, the weekly intake was 1.03 +/- 1.09 ml.kg-1 (mean +/- s.d.), range 0-5.93, i.e. below average consumption in Denmark. Alcohol intake was negatively correlated with anesthetic sleeping time (P less than 0.01). Time and quality of anesthesia induction and frequency of anesthetic complications were not significantly correlated with the use of alcohol. Preanesthetic anxiety was not significantly correlated with any of the above data. Induction time and postoperative awareness were positively and sleeping time negatively correlated with age (P less than 0.05). The results indicate cross-tolerance between alcohol and thiopental, even when the regular intake of the former is low, and increasing thiopental requirements with increasing age.

A study of the rate of carbon dioxide output during mineralization of some organic materials in soil

Soil respiration (CO2-evolution) was measured at different intervals during mineralization of organic materials in an Egyptian clay-loam soil. The rate of CO2 output was found to decline by time, and a linear negative correlation was found between the logarithm of time and the logarithm of the rate of CO2 output. Applying the linear regression equation it was possible to describe this relationship mathematically. A significant positive correlation was also found between the rate of CO2 output and the total plate count of bacteria and the ATP content of the soil.

The redox potential of growing cultures of Streptococcus bovis Orla-Jensen compared with other facultative anaerobes

The changes of redox potential were measured in growing cultures of three strains of Streptococcus bovis, together with three strains of Staphylococcus aureus and one strain of each of Lactobacillus plantaram, Lactobacillus casei, and Eschericia coli. It was found that both S. aureus and E. coli could reduce the redox potential of the growth medium to very low values (between —400 mv and —600 mv), whereas the streptococci and lactobacilli were able to cause only slight or insignificant changes of the redox potential. Respirometric measurements confirmed that the capacity of oxygen consumption of S. bovis was very small compared to that of E. coli and S. aureus. On this basis the authors conclude that S. bovis in all probability is unable to contribute significantly to maintenance of the low redox potential of its natural habitat, the rumen. This function must be carried out by other bacteria, such as enterobacteria or staphylococci, which are capable of performing a true, aerobic respiration.