Fatal cerebral hemorrhage associated with autonomic hyperreflexia during surgery in the prone position in a quadriplegic patient: a case report

Intracerebral hemorrhage is an unusual complication of autonomic hyperreflexia (AHR), which can be fatal if massive bleeding occurs with subsequent brain herniation. Episodes of AHR are most often triggered by bladder and rectal distention. We present a case of a 45-year-old quadriplegic male who suffered left basal ganglia and thalamic hemorrhage associated with AHR during surgery for pressure sore defects in the prone position under local anesthesia. Early recognition and removal of triggering factors of AHR failed to bring his blood pressure under control. The patient continued to deteriorate neurologically and died 9 days after the attack. A preventive measure rather than episodic treatment of AHR may be of paramount importance to avoid life-threatening complications, especially when a patient with a history of AHR is undergoing surgery in the prone position.

Second-order schedules with fixed-ratio components: variation of component size

Key pecking by pigeons was reinforced with food under second-order schedules with fixed-ratio units. A constant total number of key pecks was required for reinforcement under each condition, but the size and, inversely, number of fixed-ratio components were varied. The total response requirement of 256 pecks was divided into fixed-ratio units of 128, 64, 32, 8, and 2 responses. A brief stimulus, which always preceded food reinforcement, was presented upon completion of each fixed-ratio unit. Under most conditions, the pattern of within-unit responding was typical of that under simple fixed-ratio schedules. Overall response rate was an inverted U-shaped function of component size. That is, response rates were highest under moderate sized units (fixed ratio 128 and 64). This relationship is consistent with previous determinations of rate as a function of fixed-ratio value for simple fixed-ratio schedules.

Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study

Bone pain and spinal axial deformity are major concerns in aged patients suffering from osteoporotic vertebral compression fracture (VCF). Pain can be relieved by vertebroplasty or kyphoplasty procedures, in which the compressed vertebral body is filled with substitutes. We randomly assigned 100 patients with osteoporotic compression fracture at the thoraco-lumbar (T-L) junction into two groups: vertebroplasty and kyphoplasty; we used polymethylmethacrylate (PMMA) as the bone filler. Pain before and after treatment was assessed with visual analog scale (VAS) scores and vertebral body height and kyphotic wedge angle were measured from reconstructed computed tomography images. More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.56 +/- 0.62 vs. 4.91 +/- 0.65 mL, p < 0.001). Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001). VAS pain scores did not differ significantly between the treatment groups. The duration of follow-up was 6 months. Two patients in the kyphoplasty group had an adjacent segment fracture. In terms of clinical outcome there was little difference between the treatment groups. Thus, owing to the higher cost of the kyphotic balloon procedure, we recommend vertebroplasty over kyphoplasty for the treatment of osteoporotic VCFs.

INTRODUCTION

Spinal axial deformities are major concerns in aged patients suffering from osteoporotic vertebral compression fracture. Pain may be relieved by vertebroplasty or kyphoplasty. We investigated the radiological and clinical outcomes of these procedures.

METHODS

One hundred cases of VCF at the thoraco-lumbar junction were randomly assigned into two groups: vertebroplasty or kyphoplasty (50 cases each). We used polymethylmethacrylate as the bone filler. Pain before and after treatment was assessed with visual analog scale scores and vertebral body height and kyphotic wedge angle were measured from reconstructed computed tomography images.

RESULTS

More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.56 +/- 0.62 vs. 4.91 +/- 0.65 mL, p < 0.001). Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001). VAS pain scores did not differ significantly between the treatment groups. The duration of follow-up was 6 months. Two patients in the kyphoplasty group had an adjacent segment fracture.

CONCLUSIONS

In terms of clinical outcome there was little difference between the treatment groups. Thus, with the higher cost of the kyphotic balloon procedure, we recommend vertebroplasty over kyphoplasty for the treatment of osteoporotic VCFs.

Primary serous papillary carcinoma of the peritoneum mimicking pelvic actinomycosis: a case report and brief literature review

Primary serous papillary carcinoma of the peritoneum is a rare tumor, histologically similar to primary ovarian carcinoma. Pelvic CT and MRI are helpful to diagnose primary carcinoma of the peritoneum. We present a case of primary serous carcinoma of the peritoneum mimicking pelvic actinomycosis in a 59-year-old woman. Pelvic CT and MRI suggested pelvic actinomycosis. Exploratory laparotomy was performed to remove the mass and the diagnosis was confirmed by pathology. A subtotal hysterectomy, left salpingo-oophorectomy and omentectomy were performed. Histopathology examination revealed peritoneal carcinomatosis and primary serous carcinoma of the peritoneum. Pelvic CT and MRI were limited in their ability to differentiate inflammation, such as actinomycosis, from primary carcinoma of the peritoneum.

Histone deacetylase inhibitors decrease the antigen presenting activity of murine bone marrow derived dendritic cells

Once activated by infected pathogens, dendritic cells (DCs) undergo activation and release inflammatory mediators responsible for the signs of inflammation. Our aim was to elucidate whether histone deacetylase inhibitors (HDACIs), trichostatine-A (TSA), scriptaid (ST) and sodium butylate (SB) regulate the inflammatory response of DCs. Pre-treatment with TSA and ST reduced the syngeneic and allogeneic-antigen presenting activity of LPS-stimulated DCs in a dose dependent manner to statistical significance. SB also reduced the antigen presenting activity of DCs, but not significantly. HDACIs mediate their effects through the modulation of DC maturation and pre-treatment of the DCs with TSA or ST prior to treatment with LPS reduced the expressions of DC mature markers to the level of immature dendritic cells (iDCs). Moreover, TSA and ST reduced the IL-2 production from LPS-stimulated mature DCs. Our results suggest that HDACIs may actively modulate the DC-induced inflammatory response through inhibition of phenotypical or functional maturation.

Gaussian-Taylor signal-to-noise ratio estimation for scanning electron microscope images

A new and robust parameter estimation technique, named Gaussian-Taylor interpolation, is proposed to predict the signal-to-noise ratio (SNR) of scanning electron microscope images. The results of SNR and variance estimation values are tested and compared with piecewise cubic Hermite interpolation, quadratic spline interpolation, autoregressive moving average and moving average. Overall, the proposed estimations for noise-free peak and SNR are most consistent and accurate to within a certain acceptable degree compared with the others.

Anaesthetic requirement and stress hormone responses in patients undergoing lumbar spine surgery: anterior vs. posterior approach

BACKGROUND

The intensity of nociceptive stimuli reflects the severity of tissue injury. The anaesthetic requirement and stress hormonal responses were determined to learn whether they differ according to different surgical approaches (anterior vs. posterior) during the spinal surgery.

METHODS

Patients undergoing lumbar spine surgery without neurological deficits were divided into two groups: one having posterior (n=13) and the other having anterior fusion (n=13). The end-tidal sevoflurane concentrations (ET(SEVO)) required to maintain the bispectral index score at 40-50 were determined. Mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), serum osmolality and plasma concentrations of catecholamines, cortisol and vasopressin (AVP) were measured.

RESULTS

There were no differences in MAP, HR, CVP and serum osmolality between the groups. ET(SEVO) was higher in the anterior than in the posterior group (P<0.05). The plasma concentrations of norepinephrine and cortisol increased in both groups during the surgery, whereas those of epinephrine remained unchanged. AVP concentrations increased during the surgery in the anterior group, and remained unaltered in the posterior group. The anterior group needed more analgesics (P<0.01) during the first 1 h after the operation.

CONCLUSIONS

The anterior approach required a deeper level of anaesthesia while undergoing spinal surgery and more use of post-operative analgesics than the posterior approach. It was also associated with a more pronounced AVP release during the surgery.

Synthesis and photoluminescence properties of spherical fine red (Y(1-x-y)Gd(x)EU(y))BO3 (0 < or = x < or = 0.36, 0.06 < or = y < or = 0.13) phosphors using ultrasonic spray pyrolysis

The post-heat treated (Y(1-x-y)Gd(x)Eu(y))BO3 (0 < or = x < or = 0.36, 0.06 < or = y < or = 0.13) powders crystallized in a solution of (Y(1-x-y)Gd(x)Eu(y))BO3 with the hexagonal vaterite crystal structure, irrespective of composition. The lattice parameter of the (Y(0.9-x)Gd(x)Eu(0.1))BO3 (0 < or = x < or = 0.36) powders slightly increased with an increase in Gd content. The average powder sizes were sub-micron order and the powders showed relatively uniform size distribution and smooth surface. We obtained improved powder morphologies by adding organic additives such as ethylene glycol and citric acid. For the post-treated (Y(0.9-x)Gd(x)Eu(0.1))BO3, the emission intensity became stronger with increasing Gd content up to x = 0.27. In addition, for the post-treated (Y(0.73-y)Gd(0.27)Eu(y))BO3, the emission intensity gradually increased with Eu content up to y = 0.13. In particular, the emission intensity of the (Y(0.6)Gd)0.27)Eu(0.13))BO3 powders synthesized was higher than that of the commercial (Y,Gd)BO3:Eu3+ product.

How do we interpret an elevated carbohydrate antigen 19-9 level in asymptomatic subjects?

AIM

This prospective cohort study aimed to evaluate the etiology of elevated CA 19-9 levels and to present appropriate guidelines for the asymptomatic patients.

METHODS

Between January 2004 and March 2007, we enrolled consecutive asymptomatic patients who had elevated CA 19-9 levels >37 U/mL. To evaluate the etiology, the CA 19-9 level was rechecked and further studies were carried out. If the CA 19-9 level decreased to the normal range, or if it showed a decreasing trend, then it was monitored annually. Yet, if the CA 19-9 level showed an increasing trend, then the level was monitored at intervals of 1, 3, and 6 months until no evidence of malignancy was proven.

RESULTS

Of the 62,976 patients, 501 (0.8%) subjects showed an elevated CA 19-9 level. This prospective analysis was conducted on 353 subjects (70.5%) who were followed up for at least 6 months. Ten patients (2.8%) were diagnosed with malignancies. There were 97 patients (27.5%) with benign diseases and 246 patients (69.7%) were deemed non-specific.

CONCLUSIONS

CA 19-9 should not be used as a screening tool. In the case of a persistently elevated CA 19-9 level, further work-up for determining the etiology should be done.

Chylous ascites: a late complication of intra-abdominal Mycobacterium avium complex immune reconstitution syndrome in HIV-infected patients

Chylous ascites related to Mycobacterium avium complex (MAC) in HIV-infected patients is rare, with only six cases reported in the English literature. We report a series of six cases from a single institution. During the past six years, chylous ascites was diagnosed in six (35%) of 17 AIDS patients, all of whom had previously been diagnosed with intra-abdominal MAC immune reconstitution syndrome (MAC-IRS). A review of medical records identified no other cases of chylous ascites among HIV-positive patients over the past 13 years (1994–2007), and the incidence was estimated at one in 2248 HIV-positive admissions. The ascitic fluid had a milky appearance and a median triglyceride level of 4.07 mmol/L (range 3.19–29.6 mmol/L) (360 mg/dL, range 282–2620 mg/dL). After a median follow-up of 20 months, five (83%) of six patients survived. Chylous ascites is a late complication of intra-abdominal MAC-IRS, and is usually associated with a favourable prognosis.

Production of TGF-beta1 as a Mechanism for Defective Antigen-presenting Cell Function of Macrophages Generated in vitro with M-CSF

Background

Macrophages generated in vitro using macrophage-colony stimulating factor (M-CSF) and interleukin (IL)-6 from bone marrow cells (BM-Mp) are defective in antigen presenting cell (APC) function as shown by their ability to induce the proliferation of anti-CD3 mAb-primed syngeneic T cells. However, they do express major histocompatibility (MHC) class I and II molecules, accessory molecules and intracellular adhesion molecules. Here we demonstrate that the defective APC function of macrophages is mainly due to production of TGF-β1 by BM-Mp.

Methods

Microarray analysis showed that TGF-β1 was highly expressed in BM-Mp, compared to a macrophage cell line, B6D, which exerted efficient APC function. Production of TGF-β1 by BM-Mp was confirmed by neutralization experiments of TGF-β1 as well as by real time-polymerase chain reaction (PCR).

Results

Addition of anti-TGF-β1 monoclonal antibody to cultures of BM-Mp and anti-CD3 mAb-primed syngeneic T cells efficiently induced the proliferation of syngeneic T cells. Conversely, the APC function of B6D cells was almost completely suppressed by addition of TGF-β1. Quantitative real time-PCR analysis also confirmed the enhanced expression of TGF-β1 in BM-Mp.

Conclusion

The defective APC function of macrophages generated in vitro with M-CSF and IL-6 was mainly due to the production of TGF-β1 by macrophages.

Luminescence properties of Ca(Y(0.915-x)Gd(x)Al0.025Eu0.06)BO4 phosphors under VUV irradiation

The major phase of post-treated Ca(Y(0.915-x)Gd(x)A10.025Eu0.06)BO4 (0 < or = x < or = 0.3) phosphors was solid solutions of the constituent oxides, which had an orthorhombic warwickite-like structure. The calculated crystallite size of the Ca(Y(0.915-x)Gd(x)Al0.025Eu0.06)BO4 phosphors was approximately 36 nm. The Gd additive significantly enhanced both the charge transfer (CT) transition of O2(-) -Eu3+ and the absorption of the host materials, thereby resulting in an increase in emission intensity. The Ca(Y(0.715)Gd0.2Al0.025Eu0.06)BO4 phosphor showed the highest emission intensity at 593 nm, which was over five times as strong as that of a Gd-free Ca(Y0.915Al0.025Eu0.06)BO4 phosphor. The addition of Gd was desirable for improving the photoluminescent properties of red-emitting Ca(Y0.915Al0.025Eu0.06)BO4 phosphors.

Photoluminescent properties of (la(1-x)Y(x))(0.94)Tb(0.06)PO4 phosphor powders prepared by ultrasonic spray pyrolysis

The calculated crystallite sizes of (La(1-x)Y(x))(0.94)Tb(0.06)PO4 (0 < or = x < or = 1.0) phosphors ranged from 37-39 nm. Annealed (La(1-x)Y(x))(0.94)Tb(0.06)PO4 (0 < or = x < or = 1.0) phosphors showed a smooth, regular, and spherical morphology. Strong excitation peaks were appeared at 226 and 270 nm for all the phosphors. These were caused by the crystal splitting of 7D and 9D of 4f75d1 configuration in Tb3+, respectively. The characteristic emission peaks were observed at 489, 543, 585, and 621 nm, which were caused by the 5D4-7F(j) (j = 6-3) transitions of Tb3+, respectively. The emission intensity at 543 nm increased with an increase in Y content up to 0.5 and then decreased for a higher Y content.

A clinical audit of neurosurgical bed usage

AIM

To investigate inefficiencies during patients' stay in neurosurgical beds.

METHODS

A prospective audit of neurosurgical inpatients was conducted over approximately 2 months. We recorded the causes and duration of inappropriate delays, defined as actions requiring more that 24 h from initiation until completion.

RESULTS

One-hundred-and-thirty-eight patients were studied (61 elective and 77 emergency admissions). The audited patients were in hospital for a total of 1665 days. Of these, 482 days (29%) were due to delays. 92.5% of these wasted days involved emergency admissions. The main categories of delay were transfer back to referring hospital (46% of all delays), operative (26%) and radiological (19%). Our own hospital was responsible for the longest transfer delays (6.3 days/patient compared with an average of 2.8 for all hospitals). Operative waits arose because of problems with both the timing and capacity of lists. Radiological delays resulted in particular from waits for MRI scans and neuroradiologist-performed procedures. The effect of eliminating all these inappropriate delays would be equivalent to liberating 10.7 of our 37 neurosurgical beds at any one time.

CONCLUSIONS

Clinician-led analysis of organizational aspects of patient care has revealed serious structure, process and capacity problems in efficient bed usage, We have made proposals to address the cause of the inappropriate delays.

Controlled microaspiration for high-pressure freezing: a new method for ultrastructural preservation of fragile and sparse tissues for TEM and electron tomography

High-pressure freezing is the preferred method to prepare thick biological specimens for ultrastructural studies. However, the advantages obtained by this method often prove unattainable for samples that are difficult to handle during the freezing and substitution protocols. Delicate and sparse samples are difficult to manipulate and maintain intact throughout the sequence of freezing, infiltration, embedding and final orientation for sectioning and subsequent transmission electron microscopy. An established approach to surmount these difficulties is the use of cellulose microdialysis tubing to transport the sample. With an inner diameter of 200 microm, the tubing protects small and fragile samples within the thickness constraints of high-pressure freezing, and the tube ends can be sealed to avoid loss of sample. Importantly, the transparency of the tubing allows optical study of the specimen at different steps in the process. Here, we describe the use of a micromanipulator and microinjection apparatus to handle and position delicate specimens within the tubing. We report two biologically significant examples that benefit from this approach, 3D cultures of mammary epithelial cells and cochlear outer hair cells. We illustrate the potential for correlative light and electron microscopy as well as electron tomography.

A model of the effect of temperature on the growth of pathogenic and nonpathogenic Vibrio parahaemolyticus isolated from oysters in Korea

Vibrio parahaemolyticus is recognized as the leading cause of human gastroenteritis associated with the consumption of seafood. The objective of this study was to model the growth kinetics of pathogenic and nonpathogenic V. parahaemolyticus in broth and oyster slurry. Primary growth models of V. parahaemolyticus in broth and oyster slurry fit well to a modified Gomperz equation (broth R(2)=0.99; oyster slurry R(2)=0.96). The lag time (LT), specific growth rate (SGR), and maximum population density (MPD) of each primary model were compared. The growth of nonpathogenic V. parahaemolyticus was found to be more rapid than that of pathogenic V. parahaemolyticus, regardless of the model medium. In addition, significant (P<0.05) differences in the growth kinetics between pathogenic and nonpathogenic V. parahaemolyticus in broth were observed at 10 degrees C. When compared to growth in broth, the growth of V. parahaemolyticus was delayed in oyster slurry, and growth was not observed at 10 or 15 degrees C. The Davey and square root models were identified as appropriate secondary models for predicting the LT and SGR, respectively. For the broth model, the average B(f) and A(f) values for LT were found to be 0.97 and 1.3, respectively, whereas the average B(f) and A(f) values for SGR were 1.05 and 1.11, respectively. The model generated in this study predicted an LT that was shorter and an SGR that was similar to those that were actually observed, which indicates that these models provide a reliable and safe prediction of V. parahaemolyticus growth.

Efficient intracytoplasmic labeling of human umbilical cord blood mesenchymal stromal cells with ferumoxides

Mesenchymal stromal cells (MSCs) are multipotent cells found in several adult tissues; they have the capacity to differentiate into mesodermal, ectodermal, and endodermal tissues in vitro. There have been several reports that MSCs have therapeutic effects in a variety of diseases. Therefore, using a cell labeling technique, monitoring their temporal and spatial migration in vivo, would be useful in the clinical setting. Magnetic resonance imaging (MRI)--tracking of superparamagnetic iron oxide (SPIO)-labeled cells--is a noninvasive technique for determining the location and migration of transplanted cells. In the present study, we evaluated the influence and toxicity of SPIO (ferumoxides) labeling on multiple differentiated MSCs. To evaluate the influence and toxicity of ferumoxides labeling on differentiation of MSCs, a variety of concentrations of ferumoxides were used for labeling MSCs. We found that the cytoplasm of adherent cells was effectively labeled at low concentrations of ferumoxides. Compared with unlabeled controls, the ferumoxides-labeled MSCs exhibited a similar proliferation rate and apoptotic progression. The labeled MSCs differentiated into osteoblasts and adipocytes in an identical fashion as the unlabeled cells. However, chondrogenesis and neurogenesis were inhibited at high concentrations of ferumoxides. Our results suggest the effective concentration for ferumoxides use in tracking MSCs.

First Report of Chestnut Ink Disease by Phytophthora katsurae on Chestnut in Korea

Since the late 1970s, chestnut (Castanea spp.) has been one of the most commonly cultivated nuts for human consumption in Korea. In 1998, as much as 100,000 t of chestnut seeds were produced from 79,000 ha of plantations for export (2). Most cultivated chestnuts are hybrids of Castanea crenata and C. mollissima that have resulted in 27 cultivars commonly grown in Korea. In 2004, dead trees of two cultivars (Tsukuba and Ginyose) from different locations were found with black ooze emanating from reddish, sunken tissues on the trunks. When the bark was peeled off, a distinct necrotic region was observed on the basal trunk with the discoloration extending up and girdling the trunk. In November 2006, a Phytophthora species was isolated from the necrotic areas with a CARP selective medium (4). Eleven isolates were obtained from three locations: Hadong, Hapcheon, and Youngqwang. The isolates produced numerous homothallic oogonia (34.0 to 46.2 × 21.9 to 26.7 μm) with warty protuberances on the surface. Antheridia were amphigynous with long, funnel-shaped stalks at the base of the oogonia. The formation of papillate, ovoid to obpyriform sporangia (17.0 to 38.9 × 14.6 to 29.2 μm) was induced by cold treatment in filtered (through 25-μm particle retention) creek water or deionized water. Chlamydospores were not observed. Comparison of the rDNA ITS sequence using ITS1/4 (3) showed 99.6% similarity to P. katsurae (GenBank Accession No. AF266771) with three base pair differences. All eleven isolates showed identical ITS sequences. Pathogenicity studies were conducted on excised three 15-cm-long × 5-cm-diameter logs from each of three chestnut cultivars (Moriwase, Parkmi 2, and Ibuki). Bark (5 mm in diameter) was taken with a cork borer on each log followed by inoculation with a 5-mm agar disk of two isolates, PH.K01 and PH.K07. The logs were placed in a moist chamber for 7 days. Noninoculated controls consisted of log sections from each cultivar treated with agar disks. The pathogencity test was repeated three times. The entire log of cv. Parkmi 2 became necrotic, whereas the other two cultivars developed only small lesions (P < 0.0001). The noninoculated control logs of each cultivar did not develop lesions and no pathogen was reisolated from them. This suggests that cultivars differ in susceptibility. P. katsurae (synonym = P. castaneae) was first described from Japan in 1931. P. cambivora, P. cinnamomi, and P. katsurae are commonly responsible for ink disease on chestnut species in Europe, the United States, and Asia (1). The impact of P. katsurae on chestnut production in Korea is currently unknown. References: (1) A. Boutard et al. The West. Chestnut. 3:6, 2001. (2) S. H. Lee et al. J. Korean For. Soc. 95:61, 2006. (3) E. Oh et al. Forest Pathol. 36:388, 2006. (4) T. J. White et al. Page 315 in: PCR Protocols. Academic Press Inc., New York, 1990.

Effect of glass phase on the dissolution of hydroxyapatite

Nano size defect formation at grain boundary during the dissolution of hydroxyapatite in water was evaluated by adding several sintering additives for sinterability enhancement. In the case of sintered pure hydroxyapatite, significant dissolution occurred after immersion in distilled water or in simulated body fluid. The dissolution initiated at the grain boundaries creating nano-size defects like small pores that afterwards grew up to micro scale by increasing immersion time. This dissolution resulted in grain separation at the surfaces and finally in fracture. The dissolution concentrated on the grains adjacent to pores rather than those in the dense region. So hydroxyapatite ceramics containing glass powders were prepared to prevent the dissolution by strengthening grain boundary. Calcium silicate and phosphate glasses were added at 0 to 10 mass% and sintered at 1200 degrees C for 2 h in air with moisture protection. Glass phase was incorporated into hydroxyapatite to act as the sintering aid followed by crystallization in order to improve the mechanical properties without reducing biocompatibility. Dissolution tests, as well as X-ray diffraction and SEM showed little decomposition of hydroxyapatite to secondary phases and the fracture toughness increased compared to pure hydroxyapatite.