The course and prognostic factors of familial amyloid polyneuropathy after liver transplantation

Familial amyloid polyneuropathy (FAP) associated with mutations of the transthyretin (TTR) gene is the most common type of FAP, a devastating disease causing death within 10 years after the first symptoms. Because most of the amyloidogenic mutated TTR is secreted by the liver, transplantation is widely used to treat these patients, but long-term quantitative evaluation of the effects of liver transplantation on the progression of the neuropathy are not available. We have treated 45 patients with symptomatic TTR-FAP, including 43 with the Met30 TTR gene mutation, and report on the results of periodic evaluation of markers of neuropathy in 25 of them, who have been followed for more than 2 years after liver transplantation (mean follow-up 4 years). The overall survival rates at 1 and 5 years were 82 and 60%, respectively. Urinary incontinence and a low Norris score at liver transplantation were associated with poorer outcome. The motor score stabilized in seven of 11 patients (64%) with mild sensorimotor neuropathy (walking unaided) and in two of the eight patients (25%) with severe sensorimotor deficit (walking with aid) at liver transplantation. In five other patients, deterioration of motor deficit occurred only within the first year after liver transplantation, but was progressive after this interval in two patients. None of the six patients with pure sensory neuropathy developed motor loss and superficial sensory loss remained unchanged. Two years after liver transplantation, the rate of myelinated axon loss in nerve biopsy specimens was markedly lower in seven transplanted patients (0.9/mm(2) of endoneurial area/month) than in non-transplanted patients (70/mm(2) of endoneurial area/month). Symptoms of dysautonomia and quantitated cardiocirculatory autonomic tests remained unchanged. In all patients, serum mutated TTR decreased to 2.5% of pre-liver transplantation values and remained at this level during follow-up. We presently recommend liver transplantation in FAP patients at onset of first symptoms and exclusion of those with a Norris score below 55 and/or with urinary incontinence.

New transthyretin variants SER 91 and SER 116 associated with familial amyloidotic polyneuropathy. Mutations in brief no. 151. Online

Mutations of the transthyretin (TTR) gene are associated with familial amyloidotic polyneuropathy (FAP). Two new mutations were detected in French patients with TTR amyloidosis. The first patient was a 72 year old man who presented with severe and rapidly evolving sensory motor polyneuropathy of the 4 limbs, a bilateral carpal tunnel syndrome and a restrictive cardiomyopathy. His father died after a clinical history suggestive in retrospect of TTR amyloidosis. The second patient was a 75 year old man who presented with axonal sensory neuropathy of the 4 limbs and a bilateral carpal tunnel syndrome. In both cases immunohistochemistry performed on a nerve biopsy reveled TTR positive amyloid. Direct genomic sequencing of the full TTR gene coding region indicated two heterozygous transversions encoding Ser for Ala 91 substitution in the third exon of the gene in patient 1 and Ser for Tyr 116 substitution in the fourth exon of the gene in patient 2. The mutations were confirmed by digesting PCR products with restriction enzymes and were not found in a control population of 100 unrelated individuals. The Ser 116 substitution was also detected in the daughter and the 70 year old sister of the proband. However the absence of symptomatology suggestive of TTR amyloidosis may be related to the late onset of the disease. The clinical immunohistochemical and molecular studies in both patients are highly suggestive of an association between the Ser 91 and Ser 116 TTR variants with amyloidosis.

Optimal gestational age for twin delivery

OBJECTIVE

We evaluated the timing of twin delivery associated with perinatal outcome in gestations of at least 36 completed weeks.

STUDY DESIGN

This was a retrospective analysis of infant and maternal hospital records for a consecutive series of twin deliveries at New York Hospital-Cornell Medical Center. The inclusion criteria were delivery after 36 weeks' gestation during a 7-year period (1987 to 1993), without congenital anomalies or early fetal demise. Adverse perinatal outcomes were compared between deliveries before 38 weeks' gestational age and those at or after 38 weeks' gestation.

RESULTS

Of 776 twin deliveries during the study period, 329 met the inclusion criteria. Adverse perinatal outcome was significantly higher among the twin pregnancies that delivered before 38 weeks' gestation compared with those that delivered at or after 38 weeks' gestation. Twin pregnancies that delivered between 36 and 37 weeks' gestation were 13 times more likely to require neonatal intensive care compared with those who delivered at or after 38 weeks' gestation (95% confidence interval 1.8 to 95.9; p < 0.001).

CONCLUSION

In uncomplicated twin gestations, delivery at between 36 and 37 weeks' gestation was not associated with a reduction in neonatal complications compared with deliveries at or after 38 weeks' gestation.

Phylogeography of mitochondrial DNA variation in brown bears and polar bears

We analyzed 286 nucleotides of the middle portion of the mitochondrial cytochrome b gene of 61 brown bears from three locations in Alaska and 55 polar bears from Arctic Canada and Arctic Siberia to test our earlier observations of paraphyly between polar bears and brown bears as well as to test the extreme uniqueness of mitochondrial DNA types of brown bears on Admiralty, Baranof, and Chichagof (ABC) islands of southeastern Alaska. We also investigated the phylogeography of brown bears of Alaska's Kenai Peninsula in relation to other Alaskan brown bears because the former are being threatened by increased human development. We predicted that: (1) mtDNA paraphyly between brown bears and polar bears would be upheld, (2) the mtDNA uniqueness of brown bears of the ABC islands would be upheld, and (3) brown bears of the Kenai Peninsula would belong to either clade II or clade III of brown bears of our earlier studies of mtDNA. All of our predictions were upheld through the analysis of these additional samples.

[Familial amyloid polyneuropathy type I complicated by chronic glaucoma: 3 cases]

PURPOSE

We report 3 cases of familial amyloid polyneuropathy type I (FAP) with amyloid infiltration of the vitreum and glaucoma.

PATIENTS AND METHODS

We reviewed the records of three patients, 2 females and one male, aged 41, 47 and 83 years respectively. The 3 patients had familial amyloid polyneuropathy type I with vitreous infiltration and open angle glaucoma. The two women underwent a liver graft four years earlier. Vitrectomy allowed confirmation of the diagnosis in the 83-year-old patient. Two patients underwent trabeculectomy, histological analysis of the iris and the trabeculum was obtained for one patient.

RESULTS

The tree patients presented a polyneuropathy, vitreous infiltration and open angle glaucoma. Results of light microscopy of the iris and the trabeculum showed amyloid deposits in the iris and the trabecular meshworks.

CONCLUSION

Familial amyloid polyneuropathy is a hereditary disease which may have a wide range of ocular manifestations. Glaucoma is among the most serious complications of familial amyloid polyneuropathy.

Domino liver transplants for metabolic disorders: experience with familial amyloidotic polyneuropathy

BACKGROUND

Shortage of liver donors means that new methods of liver procurement must be explored. In domino transplantation, organs explanted during transplantation in one patient are transplanted into a second patient. Domino procedures can be performed with livers from patients having transplantation for hepatic metabolic disorders that cause systemic disease without affecting other liver functions. Familial amyloidotic polyneuropathy (FAP) type I is one of these.

STUDY DESIGN

We reviewed the Paul Brousse experience with a domino liver transplant program for FAP, hoping to extend the approach to other metabolic disorders.

RESULTS

Livers from 10 patients transplanted for FAP type 1 were used for domino transplants to patients with unresectable primary or metastatic liver cancers. There was no perioperative mortality. Neuropathy or cardiomyopathy did not increase the morbidity of the domino liver explant and transplant procedures. Morbidity for the domino recipients did not appear to be increased. Variant transthyretin was detected in the serum in FAP liver recipients, with no immediate clinical consequences.

CONCLUSIONS

The domino approach is feasible and requires careful planning of the surgical procedures for liver explantation, particularly for the nature and site of vascular anastomoses. Domino transplantation of metabolically dysfunctional livers creates new categories of potential donors and potential recipients. It raises new ethical, technical, and societal issues. The domino approach could be used in several genetic or biochemical disorders now treated by liver transplantation. It has the potential to increase the number of liver grafts available for transplantation.

Effects of smoking on local delivery of controlled-release doxycycline as compared to scaling and root planing

This paper examines the effects of smoking on the treatment outcomes of two nonsurgical therapies: (1) scaling and root planing alone (SRP) or (2) controlled-release of subgingivally delivered doxycycline hyclate in a polylactic acid based polymer gel. Subjects from 2 9-month multicenter studies were classified as nonsmokers (never smoked: 100 subjects), former smokers (137 subjects), and current smokers (> or = 10 cigarettes/day: 121 subjects). Clinical parameters were analyzed for treated sites with baseline probing depths > or = 5 mm and for a subset of treated sites with baseline probing depths of > or = 7 mm. Clinical parameters (plaque levels, clinical attachment levels, pocket depths, and bleeding on probing) were analyzed at baseline, 4, 6, and 9 months. In the doxycycline treated group in general, there were neither marked significant differences in clinical attachment gain nor differences in probing depth reduction among the 3 smoking groups. On the other hand, in the scaling and root planing treated group in general, there were significant differences in clinical attachment gain and pocket depth reduction, with non-smokers responding better than former smokers and current smokers at 6 and 9 months. These differences in clinical response between scaling and root planing alone versus controlled-release of locally-delivered doxycycline hyclate among these 3 smoking groups are discussed in relation to treatment implications for smokers.

Increased lower denture security using the Myoloc system

PURPOSE OF THE STUDY

To assess whether the Myoloc System. Improves the stability of the mandibular complete denture.

METHOD

Unstable dentures move during function causing pain and discomfort to patients resulting in decreased denture security. Improvement in patients' perceived denture security was used to assess if the Myoloc System improved the stability of the mandibular complete denture. Complete dentures were constructed for 27 patients (20 female and seven male) by conventional methods. Patients were asked to mark a point on a visual analogue scale to indicate their denture security. Following this, copies of the mandibular dentures were made and Myoloc wings added to the dentures. Denture security was recorded once again. The two responses were statistically analysed for significant improvement.

RESULT

A statistically significant improvement in denture security was found to occur after addition of the Myoloc wings to the mandibular denture.

CONCLUSION

The Myoloc System improves the stability of the mandibular complete denture and may prove useful when conventional methods fail to provide adequate denture stability and the patient is not a candidate for surgery.

Three-dimensional model of the ligand binding domain of the nuclear receptor for 1alpha,25-dihydroxy-vitamin D(3)

A three-dimensional model for residues 142-427 of the ligand binding domain (LBD) of the human nuclear receptor for 1alpha, 25-dihydroxy-vitamin D(3) [VDR] has been generated based on the X-ray crystallographic atomic coordinates of the LBD of the rat alpha1 thyroid receptor (TR). The VDR LBD model is an elongated globular shape comprised of an antiparallel alpha-helical triple sandwich topology, made up of 12 alpha-helical elements linked by short loop structures; collectively these structural features are similar to the characteristic secondary and tertiary structures for six nuclear receptors with known X-ray structures. The model has been used to describe the interaction of the conformationally flexible natural hormone, 1alpha,25-dihydroxy-vitamin D(3) [1alpha, 25(OH)(2)D(3)], and a number of related analogs with the VDR LBD. The optimal orientation of the 1alpha,25(OH)(2)D(3) in the LBD is with its A-ring directed towards the interior and its flexible side chain pointing towards and interacting with helix-12, site of the activation function-2 domain (AF-2) of the VDR. Mapping of four natural and one experimental point mutations of the VDR LBD, which result in ligand-related receptor dysfunction, indicates the close proximity of these amino acids to the bound ligand.

A comparison of the interpretation of digitized and videotape recorded echocardiograms

Conventional echocardiograms are typically recorded on videotape and later reviewed and interpreted by a physician. Although videotape recording is an excellent medium for this purpose, it does have several disadvantages, which may be overcome by digital storage. This study compared the diagnostic accuracy of digitized and videotape recorded echocardiograms. Echocardiographic examinations (n = 110) were recorded simulta-neously on videotape and were digitized with a commercially available frame grabber system. Images were transmitted by an Ethernet link to the network-based computer system and compressed with a nondestructive compression algorithm. Images were reviewed on a personal computer. Images were interpreted by 3 observers, and differences in interpretation were documented. There were 274 findings in 110 patients. Exact agreement in interpretation was found in 83%. A major discrepancy occurred in 2%, and a minor discrepancy occurred in 15%. Most discrepancies occurred in the setting of valvular heart disease. When compared with a consensus interpretation, no significant difference was seen in the number of errors between the digital and videotape interpretation. We conclude that the interpretation of a properly recorded digitized echocardiographic examination yields interpretations equivalent to those of videotape recordings.

Trends in indications and outcomes in the Whipple procedure over a 40-year period

There have been increasing changes in the role of pancreatoduodenectomy (PD) in the management of benign and malignant pancreatic disease. The aim of this paper was to compare the current role of PD with that of our earlier experience. The records of patients undergoing PD at our institution between 1983 and 1996 (Group A) were reviewed and compared with cases between 1956 and 1982 (Group B). Student's t test was used to analyze differences between groups. A total of 153 PDs were performed with 98 (64%) in Group A (88% of these in the last 6 years) and 55 (36%) in Group B. Carcinoma of the head of the pancreas was the most common indication for surgery in both periods (43% and 47% for Groups A and B, respectively). In Group A, the next most common indication was chronic pancreatitis, accounting for 28 per cent versus 13 per cent in Group B. Carcinoma of ampulla of Vater was also a common indication, making up 21 per cent of the cases in Group A and 20 per cent in Group B. Preoperative biliary drainage was performed in 62 per cent of Group A and 3 per cent of Group B patients (P < 0.001). Postoperative complications were comparable in both groups: delayed gastric emptying (22%), wound infection (17%), pancreatic fistula (13%), gastrointestinal bleeding (8%), and intestinal obstruction (3%). The perioperative mortality rate was significantly different between the two groups: 1 per cent in Group A versus 16 per cent in Group B (P < 0.001). Mean postoperative length of stay was 17 days in Group A (22 days for benign disease) and 25 days for Group B (P < 0.01). In the last 40 years, there has been a rise in the use of PD for chronic pancreatitis and a significant decrease in postoperative mortality and hospital length of stay. These data support the safety of PD in the management of patients with both benign and malignant periampullary disease.

The Wisconsin Card Sorting Test in stroke rehabilitation: factor structure and relationship to outcome

The present study attempted to replicate the findings of previous factor analytic studies of the Wisconsin Card Sorting Test (WCST) in a homogeneous sample of patients suffering recent cerebrovascular accidents and being treated in a comprehensive inpatient physical rehabilitation program. In addition this study examined the relationship of the WCST to standard measures of functional ability used in many rehabilitation programs. The results confirmed the previously reported three-factor structure and replicated past findings concerning the test's construct validity. A small but significant relationship was noted between the WCST and functional status, though the WCST did not make a unique contribution to the prediction of functional status at discharge. This study highlights the similarities and differences in WCST factor structure in a stroke sample compared to a more general neurological sample and raises questions about the utility of the WCST in stroke rehabilitation.

Structure-activity relationships of omega-conotoxins MVIIA, MVIIC and 14 loop splice hybrids at N and P/Q-type calcium channels

The omega-conotoxins are a set of structurally related, four-loop, six cysteine containing peptides, that have a range of selectivities for different subtypes of the voltage-sensitive calcium channel (VSCC). To investigate the basis of the selectivity displayed by these peptides, we have studied the binding affinities of two naturally occurring omega-conotoxins, MVIIA and MVIIC and a series of 14 MVIIA/MVIIC loop hybrids using radioligand binding assays for N and P/Q-type Ca2+channels in rat brain tissue. A selectivity profile was developed from the ratio of relative potencies at N-type VSCCs (using [125I]GVIA radioligand binding assays) and P/Q-type VSCCs (using [125I]MVIIC radioligand binding assays). In these peptides, loops 2 and 4 make the greatest contribution to VSCC subtype selectivity, while the effects of loops 1 and 3 are negligible. Peptides with homogenous combinations of loop 2 and 4 display clear selectivity preferences, while those with heterogeneous combinations of loops 2 and 4 are less discriminatory. 1H NMR spectroscopy revealed that the global folds of MVIIA, MVIIC and the 14 loop hybrid peptides were similar; however, several differences in local structure were identified. Based on the binding data and the 3D structures of MVIIA, GVIA and MVIIC, we have developed a preliminary pharmacophore based on the omega-conotoxin residues most likely to interact with the N-type VSCC.

[Lacrimal gland hypertrophy: revealing sarcoidosis]

We present a case of systemic sarcoidosis in a 34-year-old woman initially presenting with bilateral and symmetric proptosis caused by lacrimal gland enlargement. Based upon clinical, biological and radiological findings, sarcoidosis was suspected with lacrymal gland, parotid and pulmonary lesions. Biopsy of enlarged lacrimal gland for histological examination revealed a non caseating granuloma compatible with the diagnosis of sarcoidosis. Sarcoid lesions regressed with corticosteroid therapy.

Managing alcohol withdrawal in the acutely ill hospitalized adult

Managing individuals with acute illness who are at high risk for alcohol withdrawal presents multiple challenges to the treatment teams caring for them. Following realization that management of this group was often characterized by severe withdrawal symptoms (delirium tremens, seizures and the need for leather restraints), a Task Force developed protocols to guide care. Its principal goal was to avoid cardiorespiratory and neurologic morbidities associated with severe withdrawal. The first 441 episodes of care treated after protocol implementation are described in this report. There were no instances of oversedation requiring pharmacological reversal or intubation, few individuals suffered seizures outside of the emergency department and the use of leather restraints declined dramatically. Outstanding issues arising from analysis include the necessity of subjecting the symptom severity instrument to rigorous psychometric study and reconsideration of the appropriateness of a symptom-triggered approach in treating this population. Our experience suggests that use of a nonprescriptive approach by educated and motivated nursing and medical staffs can reduce serious morbidity in this at-risk population.

Cardiac sympathetic denervation in familial amyloid polyneuropathy assessed by iodine-123 metaiodobenzylguanidine scintigraphy and heart rate variability

Familial amyloid polyneuropathy (FAP) is a rare and severe hereditary form of amyloidosis, due to nervous deposits of a genetic variant transthyretin produced by the liver and characterized by both sensorimotor and autonomic neuropathy. Left ventricular systolic dysfunction is rare, but conduction disturbances and sudden deaths can occur. The neurological status of the heart has not been elucidated, and an alteration of the sympathetic nerves may be involved. We studied 17 patients (42+/-12 years) before liver transplantation by iodine-123 metaiodobenzylguanidine (MIBG) scintigraphy, heart rate variability analysis, coronary angiography, radionuclide ventriculography, rest thallium single-photon emission tomography (SPET) and echocardiography. Coronary arteries, left ventricular systolic function and rest thallium SPET were normal in all patients. Only mild evidence of amyloid infiltration was found at echocardiographic examination. Cardiac MIBG uptake was dramatically decreased in patients compared with age-matched control subjects (heart-to-mediastinum activity ratio at 4 h: 1.36+/-0.26 versus 1.98+/-0.35, P<0.001), while there was no difference in MIBG washout rate. Heart rate variability analysis showed a considerable scatter of values, with high values in four patients despite cardiac sympathetic denervation as assessed by MIBG imaging. The clinical severity of the polyneuropathy correlated with MIBG uptake at 4 h but not with the heart rate variability indices. Cardiac MIBG uptake and the heart rate variability indices did not differ according to the presence or absence of conduction disturbances. Patients with FAP have sympathetic cardiac denervation as assessed by MIBG imaging despite a preserved left ventricular systolic function and cardiac perfusion, without correlation with conduction disturbances. Results of the heart rate variability analysis were more variable and this technique does not seem to be the best way to evaluate the extent of cardiac sympathetic denervation in FAP patients.

5-hydroxytryptamine stimulation of phospholipase D activity in the rabbit isolated mesenteric artery

1. The involvement of phospholipase D (PLD) in the 5-hydroxytryptamine 5-HT1B/5-HT1D-signalling pathway was assessed in the rabbit isolated mesenteric artery. 2. RT-PCR analysis of mesenteric smooth muscle cells revealed a strong signal corresponding to mRNA transcript for the 5-HT1B receptor. The PCR fragment corresponded to the known sequence for the 5-HT1B receptor. No signal corresponding to 5-HT1D mRNA was detected. 3. Neither 5-HT (3 microM) nor KCl (45 mM) individually stimulated any significant increase in the smooth muscle concentration of [33P]-PtdBut to reflect PLD activity. However, in the presence of KCl (45 mM), 5-HT evoked a concentration-dependent increase in [33P]-PtdBut, to a maximum of 84% with 5-HT (3 microM). 4. [33P]-PtdBut accumulation evoked by 5-HT in the presence of KCl was abolished in nominally calcium-free Krebs-Henseleit Buffer (KHB) or with the selective protein kinase C inhibitor, Ro-31 8220 (10 microM, 20 min). 5. 5-HT (3 microM) in the presence of KCl (45 mM) failed to increase either the accumulation of [33P]-phosphatidic acid in the presence of butanol, or total [3H]-inositol phosphates ([3H]-InsP) in the presence of LiCl (10 mM). 6. 5-HT (0.1-1 microM) abolished forskolin (1 microM) stimulated increases in cyclic AMP (15 fold increase), an action which was pertussis toxin-sensitive. 7. Therefore, in the presence of raised extracellular potassium 5-HT can stimulate PLD via 5-HT1B receptors in the rabbit mesenteric artery. This action requires extracellular calcium and the activation of protein kinase C. These characteristics are identical to the profile for 5-HT1B/5-HT1D-receptor evoked contraction in vascular smooth muscle cells, suggesting a role for PLD in this response to 5-HT.

Clinicopathologic findings and prognosis of chronic inflammatory demyelinating polyneuropathy

OBJECTIVE

To evaluate the clinicopathologic features and prognostic factors of 100 patients with chronic inflammatory demyelinating polyneuropathy (CIDP).

METHODS

Comparison of clinical and biopsy findings with functional score evaluated an average of 6 years after referral.

RESULTS

CIDP followed a relapsing course in 14% of the patients and a progressive course in 45%. After progressive onset, little change was noted during follow-up in the others. Five patients had symptomatic involvement of the CNS. Teased fiber preparations of nerve biopsy specimens showed that 68 patients had purely demyelinative lesions, 20 had mixed axonal and demyelinative lesions, and 5 had predominantly axonal lesions. Axonal loss was a common finding, with 47% of the patients retaining less than half of the normal density of fibers. Inflammatory infiltrates, found in 18 samples, were prominent only in 4. Of the 83 patients evaluated an average of 6 years after onset, 56 were in good condition; 24 had deteriorated and failed to respond to treatment, including 9 patients who died as a consequence of their neurologic deficit. Progressive course, CNS involvement, high proportion of fibers showing active demyelination on nerve biopsy, and axonal loss overall correlated with higher disability.

CONCLUSION

Axonal loss is the major long-term pejorative prognostic factor in CIDP.

Genotypic-phenotypic variations in a series of 65 patients with familial amyloid polyneuropathy

OBJECTIVE

To investigate the genotypic-phenotypic variations in a series of patients with familial amyloid polyneuropathy (FAP).

BACKGROUND

Progress in molecular genetics has led to the identification of point mutations in the transthyretin (TTR) gene in FAP--a dominantly inherited neuropathy with a fatal outcome. These findings have modified the management of patients with small-fiber neuropathy and allow genetic counseling.

METHODS

We performed a clinical and molecular genetic study with screening of the TTR gene mutations and associated haplotypes in 65 patients from 29 unrelated families of French ancestry.

RESULTS

We detected nine heterozygous point mutations segregating with FAP. Fourteen families (48%) carried the common methionine (Met) 30 substitution. Seven kindreds (24%) had previously unreported TTR variants, namely asparagine 35, serine (Ser) 91, phenylalanine (Phe) 77, and Ser 116. At least two different haplotypes were associated with each of the following: Met 30, Phe 77, and valine 107, suggesting that multiple founders occurred for each variant. Only 35% of the index patients had affected relatives. Other patients had a sporadic presentation. All progressed to a severe sensorimotor and autonomic neuropathy with frequent cardiac involvement (80%). On average, a late age at onset (54.3 +/- 13.3 years) and a disease duration shorter than 10 years were observed for virtually all variants.

CONCLUSION

The heterogeneity of the TTR variants, the late age at onset, and the short duration of the disease found in our patients contrast with the presentation of FAP in Portugal. These findings must be taken into account in the management of both patients and asymptomatic carriers.

Assessing priorities for allocation of donor liver grafts: survey of public and clinicians

OBJECTIVES

To compare the priorities of the general public, family doctors, and gastroenterologists in allocating donor livers to potential recipients of liver allograft.

DESIGN

Representative quota sampling of 1000 members of the general public and 200 family doctors, and a postal questionnaire of 100 gastroenterologists.

SUBJECTS

Respondents were given eight hypothetical case histories (based on real patients) and asked to select recipients for four donor livers. Cases were selected to identify controversial areas such as extremes of age, misuse of alcohol, and intravenous drugs. Respondents were also asked to select the least deserving case and which of seven possible factors (time on waiting list, outcome, age, value to society, return to work, previous use of illicit drugs, and involvement of alcohol in the liver damage) should be used to select patients already listed for transplantation. Focus groups were also held to explore further the reasons for the choices given.

RESULTS

There were considerable differences between the three groups in the choice of the recipients, although alcohol use and antisocial behaviour always rated low. For selection of recipients the general public thought that, in decreasing order of importance, age, outcome, and time on the waiting list were the most important factors in selecting recipients; family doctors rated outcome, age, and likely work status after transplantation and the gastroenterologists outcome, work status, and non-involvement of alcohol in the cause of the liver disease as the most important factors.

CONCLUSIONS

The views of the public are at variance with those of clinicians. Further debate is required to ensure an equitable and appropriate distribution of a scarce resource.

Apical mural thrombus: technical pitfalls

A left ventricular thrombus can occur in a variety of clinical settings and, when small, may be difficult to document. Understanding the clinical scenarios of when these thrombi form and how to optimise echocardiographic scanning techniques will increase the sensitivity and specificity of the examination (tables 1 and 2).

The delirious cardiac surgical patient: theoretical aspects and principles of management

Delirium, an etiologically nonspecific disorder of consciousness characterized by prominent deficits in attention, cognition, and perception, affects more than one-third of adult cardiac surgical patients. Despite the frequency of occurrence and the increased morbidity and mortality associated with it, the diagnosis is commonly late or missed, and management is less than optimal. This article addresses the recognition and management of delirium. Nurses who develop an index of suspicion for the diagnosis and acquire the diagnostic and interventional skills required to address this cerebral complication of cardiac surgery may well decrease its incidence and severity.

Ultrastructural characterisation of the M protein in nerve biopsy of patients with POEMS syndrome

To learn more about the mechanisms of nerve lesions in POEMS syndrome, nerve specimens from four patients were studied with an immunogold method at the ultrastructural level to detect and localise the M protein in the different nerve compartments. An indirect immunolabelling technique was applied on 4% PFA fixed and LR White embedded nerve specimens. Antisera against IgG, IgA, IgM, and lambda and kappa light chains were used as primary antisera. Morphological studies disclosed an important axonal loss in association with the demyelinative process. Endoneurial deposits of immunoglobulins were found in all cases. In the patient with the most severe form of neuropathy, diffuse deposits were present in the endoneurial space, especially in the subperineurial area. In the other patients, occasional deposits of the M protein were found in the myelin sheath (n=2); or between cells (n=1). No deposit was found in the axons. The class of the M protein labelled in the nerve corresponded to that detected in the serum in three of four patients, with labelling of two heavy chains in one patient. Immunolabelling of the M protein on the myelin sheath, Schwann cells, and in the endoneurial space favour a direct role of the M component in the lesions of nerve fibres, and justify active treatment of the plasmacytic proliferation.

Modulation of spasmogen-stimulated Ins(1,4,5)P3 generation and functional responses by selective inhibitors of types 3 and 4 phosphodiesterase in airways smooth muscle

1. The effects of isoenzyme-selective inhibitors of phosphodiesterases PDE3 and PDE4 on cyclic AMP concentration, two indices of phosphoinositide hydrolysis, and contractile responses to spasmogens have been investigated in bovine tracheal smooth muscle (BTSM). 2. Neither the PDE3-selective inhibitor ORG 9935, nor the PDE4-selective inhibitor rolipram increased cyclic AMP levels in BTSM. However, rolipram addition in the presence of PDE3 inhibition (ORG 9935; 1 microM) concentration-dependently (-log EC50 (M), 6.55+/-0.15; n = 3) increased cyclic AMP levels to about 70% of the maximal response to the beta-adrenoceptor agonist isoprenaline. 3. Rolipram per se inhibited histamine-stimulated [3H]-inositol (poly)phosphate ([3H]-InsP(X)) accumulation by > 80% (-log EC50 (M), 6.92+/-0.11; n = 3). Although ORG 9935 (1 microM) had little effect on histamine-stimulated [3H]-InsP(X) accumulation alone it greatly facilitated the inhibitory action of rolipram (-log EC50 (M), 8.82+/-0.39; n = 3). The effects of PDE3 and/or PDE4 inhibition on [3H]-InsP(X) accumulation stimulated by muscarinic acetylcholine (mACh) receptor activation were less marked. However, combined PDE3/4 inhibition significantly decreased this response at a submaximal concentration of mACh receptor agonist (carbachol; 1 microM). 4. The greater-than-additive effect of combined PDE3/4 inhibition was also observed at the level of contractile responses to histamine and carbachol. In experiments designed to investigate the effects of PDE3 and/or 4 inhibitors on the carbachol-mediated phasic contraction, additions of rolipram (10 microM) or ORG 9935 (1 microM) were without effect, whereas added together the inhibitors caused a significant (P < 0.01) 40% reduction in the peak phasic contractile response. 5. The effect on contraction correlated with a substantial inhibitory effect of PDE3/4 inhibition on the initial increase in inositol 1,4,5-trisphosphate (InsP3) accumulation stimulated by spasmogen. Thus, in the presence of ORG 9935 (1 microM) rolipram concentration-dependently inhibited carbachol-stimulated InsP3 accumulation by > or = 50% (-log EC50 (M), 6.77+/-0.21; n = 4). 6. Carbachol (100 microM) addition caused a rapid decrease (by 67% at 10 s) in BTSM cyclic AMP level in the presence of PDE3/4 inhibition. However, omission of Ca2+ from the incubation medium prevented the carbachol-evoked decrease in cyclic AMP and this coincided with a greater inhibition (> or = 80%) of the carbachol-stimulated InsP3 response. 7. These data indicate that combined PDE3 and PDE4 inhibition has greater-than-additive effects on second messenger and functional responses to spasmogens in BTSM. Furthermore, the ability of PDE3/4 inhibition significantly to attenuate mACh receptor-mediated contractile responses, may be, at least in part, attributed to an effect exerted at the level of InsP3 generation.

Migraine-like symptoms triggered by occipital lobe seizures: response to sumatriptan

BACKGROUND

The relationship of ictal and post-ictal cephalic pain to migraine remains debatable. We hereby report 2 patients, a 27-year-old woman and 41-year-old man were referred for assessment of migraine of 10 years and 4 years duration, respectively. The man described a recent episode of "vacant stare" and the woman has sensitivity to bright colours and light. Neurological examination, visual field testing, CAT scan, MRI scan, and prolonged EEG recordings were accomplished for each patient.

RESULTS

The man had a spontaneous seizure with ictal discharge arising from the right occipital lobe. Bilateral occipital spikes, associated with palinopsia was triggered in the woman by photic stimulation. Both patients developed post-ictal headaches with symptoms similar to their migraines. The symptoms subsided following treatment with oral sumatriptan.

CONCLUSION

Migraine-like symptoms occurring following occipital lobe seizures may share similar pathophysiological substrates with idiopathic migraine. Serotonergic mechanisms may be implicated.

The swing-lock removable partial denture in clinical practice

The authors of this article consider that the swing-lock partial denture has a useful place in contemporary clinical dental practice and offers many advantages compared with conventional removable partial dentures in terms of retention and stability, especially in the extremely compromised dentitions. Here they describe the concept of the swing-lock removable partial denture, together with the indications, contraindications, technical and clinical considerations.

Evaluation of 31P metabolite differences in human cerebral gray and white matter

31P NMR is commonly used to study brain energetics in health and disease. Due to sensitivity constraints, the NMR measurements are typically made in volumes that do not contain pure gray or white matter. For accurate evaluation of abnormalities in brain metabolite levels, it is necessary to consider the differences in normal levels of 31P metabolites in gray and white matter. In this study, voxels from a three-dimensional spectroscopic image acquisition were analyzed for their dependence on tissue type to assess differences in metabolite levels between gray and white matter. Specifically, gray matter was found to have significantly higher ratios of phosphocreatine (PCr) to gamma-ATP and PCr to the total 31P metabolite signal, whereas pH and the ratio of PCr to inorganic phosphate (Pi) were found to differ insignificantly between gray and white matter. Thus, tissue type can be an important factor to consider for alterations in bioenergetics by 31P NMR spectroscopic studies of the brain.

Platelet and neutrophil activation during cardiac surgical procedures: impact of cardiopulmonary bypass

BACKGROUND

Platelet and neutrophil activation plays a crucial role in reperfusion injury. To determine whether platelet and neutrophil activation occurs in the coronary circulation after cold cardioplegic arrest and reperfusion, we studied 22 patients undergoing coronary artery bypass or valve procedures, or both procedures.

METHODS

Blood was sampled from the coronary sinus and the radial artery (A) before bypass; (B) immediately after cross-clamp release; and (C) 5 minutes after cross-clamp release; and was analyzed for surface markers of platelet (CD62P) and neutrophil (CD11b) activation.

RESULTS

During bypass, platelet activation increased significantly (p < 0.01) over prebypass values, but no difference was seen between arterial and coronary sinus samples. Neutrophil activation also increased significantly (p < 0.001) during bypass, but there was no difference between arterial and coronary sinus samples.

CONCLUSIONS

Cellular activation occurs locally in the coronary circulation during bypass, but no more so after cold cardioplegic arrest and reperfusion.

Rapid, fluorometric DNA determination for chick limb-bud mesenchymal-cell microcultures

Micromass cultures of chick and mouse limb-bud mesenchymal cells are commonly used for in vitro studies of cellular differentiation. Previously, adaptation of these cultures to 96-well plates facilitated analyses of various aspects of cellular behavior and the effects of different media components in these cultures. These adjustments allowed development of a serum-free medium for chick limb-bud mesenchymal cells and substantially decreased costs associated with media and reagents. Here we report a further development for this model system; a Hoechst 33342-based in situ DNA assay that provides reliable data much more quickly and with considerably less effort than had been feasible in the past. Because it allows quantitation of products of cellular differentiation and DNA in the same cultures, the number of cultures needed to provide the same data is essentially halved and the accuracy of normalized values for quantitative estimates of markers of differentiation is improved. Studies of the effects of retinoic acid on chick limb-bud mesenchymal cells were performed to document the usefulness of this method.

Cell adhesion and migration. IV. Lymphocyte trafficking in the intestine and liver

Naive lymphocytes patrol continuously between the blood and different lymphatic tissues to sample the whole body for foreign antigens. During inflammation, leukocyte recruitment into tissue is enhanced to promote the recruitment of a range of effector cells into the affected area. The complex recirculatory pathways that underlie this process are governed by adhesion receptors on blood-borne leukocytes and by their specific ligands expressed on the luminal aspect of endothelial cells lining the vessels. Gut-associated lymphatic tissues are positioned strategically at the major port of entry for foreign antigens. They form a functionally unified entity that utilizes both the afferent and efferent arms of the immune response to respond to the large array of antigens entering via the gut under normal conditions as well as during inflammation. Once antigens have been absorbed from the gut, they may enter the portal vein and the liver where the immune response can be further regulated by the resident immune cells of the liver. Thus the gut and liver form an important barrier to enteral antigens, and leukocyte recruitment to these sites will need to be carefully regulated to ensure effective immune surveillance. In this article, we describe the current concepts of lymphocyte adhesion in these two organs as revealed by animal models. Subsequently, we discuss how well these principles apply to the lymphocyte-endothelial cell interactions in humans and what additional insights can be obtained from human studies.

Maternal and professional assessment of breastfeeding

This study explored the relationships among maternal and professional breastfeeding assessments and maternal reports of satisfaction with breastfeeding. Participants were 35 first-time breastfeeding mothers. The LATCH Breastfeeding Documentation Tool was used for data collection. This tool was used in its original version for professional assessment and in a modified version for maternal reporting. Results show high percentages (85.7 to 100) of agreement among lactation consultants using the LATCH tool which supports the reliability of the tool. Correlation coefficients between professional scores and maternal scores ranged from 0.18 for "A" (Audible swallowing) to 0.67 for "L" (Latch). It appears that, unlike lactation consultants, new mothers evaluate breastfeeding based upon their somatic experience rather than observation of infant behavior.

Higher doses of alpha-interferon do not increase the activity of the weekly cisplatin-interferon combination in advanced malignant mesothelioma

Management of advanced malignant mesothelioma (MM) still requires innovative systemic therapy as its prognosis is poorly affected by currently available chemotherapy. The combination cisplatin and alpha-interferon (alpha-INF) has synergistic antitumoral activity in preclinical models and interesting activity in phase I-II clinical trials. Weekly CDDP (60 mg/m2) and alpha-IFN (3 MUI/d: d1-d4) in combination was tested in a previous phase I-II study in 23 MM patients, with a 36% objective response rate (ORR). A trial with higher doses of alpha-IFN in the same combination schedule was conducted to explore an incrementalist hypothesis. Thirty patients with MM received the same CDDP dose (60 mg/m2/w) and doubled doses of alpha-IFN (6 MUI/d: d1-d4). The treatment protocol consisted of two cycles of 4 weeks on/4 weeks off followed by two shorter cycles of 3 weeks on/3 weeks off, in the absence of life-threatening toxicity or progressive disease. All patients were evaluable for toxicity. The main treatment-limiting side-effects were digestive intolerance (nausea, vomiting) and severe asthenia. Antitumoral efficacy was not increased (ORR = 27%). Haematological and neurological toxicities were moderate and manageable. The antitumoral activity of the CDDP-alpha-IFN combination with higher doses of the latter is similar to our previous experience, but tolerance issues make it a poorer choice for eventual comparative trials, or as a standard therapeutic indication.

[Multifocal motor neuropathies with conduction blocks. 39 cases]

Clinical, biological and electrophysiological features from a cohort of 39 multifocal motor neuropathies with conduction blocks (NMM with CB) have been studied. There were 29 males and 10 females with an average of 47.3. At the first evaluation, the mean duration of the symptoms was of 8 years with extremes between 1 and 28. Pain and paresthesias were present in respectively 10 and 18 p. 100 of the patients. Fasciculations and cramps were observed in more than 2/3 of the cases. Three patients had tremor at rest. Upper limb muscular weakness was the predominant initial symptom (84.6 p. 100). The weakness always affected distal and unilateral muscles. Radial and cubital nerve distribution are mainly affected and in half of the cases an unilateral motor deficit in the lower limb was associated. Muscle atrophy was frequent (74 p. 100) and rapidly developed in the first 2 years. Reflexes were decreased or absent in 64 p. 100. In 78 p. 100 of cases, biological study showed normal serum immunoelectrophoresis and CSF. IgM anti-GM1 antibodies were found in 24/36 patients. Very high titres were found in 5 cases. All patients had CB in upper limbs. The preferential localizations of the CB were equally at the median and ulnar nerves. Only 7 patients had CB localized to the lower limbs. In many cases, marked reduction of the motor amplitude prevented the detection of CB, marked reduction of the motor amplitude prevented the detection of CB. Moderate fibrillation potentials were found in 28 p. 100 of patients. Giant muscular unit potentials were frequent (21/39). F-waves in nerve with CB were always abnormal with marked increased latencies. Late responses sometimes seemed to be repeater F-waves. Axon reflexes were detected in 5 cases. The late responses abnormalities could precede the block. Clinical, biological and electrophysiological described arguments could may distinguish NMM with CB from motor neuron disease and relate them to the group of chronic demyelinating neuropathies.