The effect of sphenopalatine postganglionic neurotomy on the alteration of local cerebral blood flow of normotensive and hypertensive rats in acute cold stress

The cold season of a year has been reported to have the highest incidence of strokes. Present studies were designed to test whether the parasympathetic denervation plays any role in the regulation of local cerebral blood flow (LCBF) in anesthetized animals exposed to a cold environment. Each species of Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) was divided into four groups: sphenopalatine postganglionic neurotomy (SPNx) or a control group at room temperature (20 degrees C) or in a cold environment (5 degrees C), respectively. LCBF in 14 brain structures was measured using the [14C] iodoantipyrine technique and tissue dissecting methods. Our results show that SPNx did not significantly alter physiological parameters and LCBF in WKY and SHR kept at either 20 degrees C or 5 degrees C. However, 30 minutes of cold exposure caused a significant decrease in the core body temperature of both the WKY and SHR groups (P < 0.05, Student's paired t-test) and a significant decrease in LCBF in 3 of 14 brain areas: the temporal cortex (TC), inferior colliculus (IC) and vermis (VER) of both WKY and SHR (P < 0.05, MANOVA). The percentages of decrease were 24% (TC), 12% (IC), 12% (VER) and 19% (TC), 16% (IC), 15% (VER), respectively. Our findings indicate that in a cold environment, the lower LCBFs in some areas of the brain may be related to decreased body temperature. Whether they are related to the higher prevalence of stroke in winter needs further investigation.

Absence of expression of the Wiskott-Aldrich syndrome protein in peripheral blood cells of Wiskott-Aldrich syndrome patients

Wiskott-Aldrich syndrome (WAS) is an X-linked primary immunodeficiency that is usually associated with thrombocytopenia and eczema. The very variable phenotype of WAS results from defects in the WAS protein (WASP), the function of which is not well understood. In many cases causative mutations have now been identified in the WAS gene. Attempts have been made to correlate the nature of the mutations with the severity of the disease. In this study we investigated mutations in 13 patients with WAS and analyzed the expression of WASP in patient blood samples by immunoblot analysis. We found that despite extensive variation in the nature of the mutations in patients with severe WAS symptoms, none express the protein. However, in 1 patient with a mild clinical phenotype WASP expression was detected. Such an analysis could be used as an initial screening procedure for the diagnosis of WAS prior to genotypic analysis.

The use of antibodies to the polypyrimidine tract binding protein (PTB) to analyze the protein components that assemble on alternatively spliced pre-mRNAs that use distant branch points

We are using the rat beta-tropomyosin (beta-TM) gene as a model system to study the mechanism of alternative splicing. Previous studies demonstrated that the use of the muscle-specific exon is associated with the use of distant branch points located 147-153 nt upstream of the 3' splice site. In addition, at least one protein, the polypyrimidine tract binding protein (PTB), specifically interacts with critical cis-acting sequences upstream of exon 7 that are involved in blocking the use of this alternative exon in nonmuscle cells. In order to further study the role of PTB, monoclonal antibodies to PTB were prepared. Anti-PTB antibodies did not inhibit the binding of PTB to RNA because they were able to supershift RNA-PTB complexes. To determine if additional proteins interact with sequences within the pre-mRNA, 35S-met-labeled nuclear extracts from HeLa cells were mixed with RNAs and the RNA-protein complexes were recovered by immunoprecipitation using antibodies to PTB. When RNAs containing intron 6 were added to an 35S-met-labeled nuclear extract, precipitation with PTB antibodies showed a novel set of proteins. By contrast, addition of RNAs containing introns 5 or 7 gave the same results as no RNA, indicating that these RNAs are unable to form stable complexes with PTB. These results are in agreement with our previous studies demonstrating that PTB interacts with sequences within intron 6, but not with sequences within introns 5 and 7. When 35S-met-labeled HeLa nuclear extracts were mixed with biotinylated RNA containing intron 6 and the RNA-protein complexes were recovered using streptavidin-agarose beads, an identical pattern of proteins was observed when compared with the immunoprecipitation assay. Analysis of the proteins that assembled on introns 5, 6, or 7 using biotinylated RNA revealed a unique set of proteins that interact with each of these sequences. The composition of proteins interacting with sequences associated with the use of the 3' splice site of intron 6 included proteins of 30, 40, 55, 60, 65, 70, 80, and 100 kDa. Microsequencing identified two of the proteins to be Sam68 and the Far Upstream Element Binding Protein (FBP) from the c-myc gene. In addition, a comparison of the proteins that assemble on introns from the alpha- and beta-TM genes that utilize distant branch points revealed common as well as unique proteins that assemble on these introns. These studies identify a set of proteins, in addition to PTB, that are likely involved in the use of distant branch sites associated with the use of alternatively spliced introns.

Microsurgical management of intracranial epidermoid cysts

BACKGROUND

Intracranial epidermoid cysts are slow-growing congenital neoplasms that usually spread and adhere to critical neurovascular structures along the basal cistern, particularly the cerebellopontine angle (CPA) and parasellar region. Clinical symptoms include trigeminal neuralgia, headache and dizziness, progressive hemiparesis, unstable gait and hemifacial spasm. With the aid of modern imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), an effective microsurgical approach can be planned preoperatively to completely remove tumors and avoid complications.

METHODS

Twenty-six patients with intracranial epidermoid cysts were microsurgically treated between July 1984 and June 1997. Diagnostic procedures included enhanced CT and/or CT cisternography and MRI. All patients underwent microsurgical treatment for tumor removal.

RESULTS

Total tumor removal was achieved in 12 patients (46.2%), near-total removal in seven (26.9%), partial removal in six (23.1%) and stereotactic biopsy in one patient (3.8%). Postoperative deterioration of the neurologic condition was found in three patients who required further surgery, aseptic meningitis in four patients and communicating hydrocephalus requiring shunting in three patients. The functional prognoses were excellent in 23 patients (88.5%), good in two patients (7.7%) and fair in one patient (3.8%). Among the 26 patients, three died of pneumonia three, six and nine months after surgery, respectively.

CONCLUSIONS

MRI is particularly useful for defining the anatomic limits of tumor tissue and surgical planning. The surgical results were excellent in patients with near-total tumor removal, as well as in patients with total removal. Aggressive surgical tumor removal may result in transient, but significant, cranial nerve palsy and should be avoided. Perioperative administration of steroids and wound protection may be beneficial for preventing the development of postoperative aseptic meningitis and hydrocephalus.

Search for mutations near the alternatively spliced 8-amino-acid exon in the GABAA receptor gamma 2 subunit gene and lack of allelic association with alcoholism among four aboriginal groups and Han Chinese in Taiwan

The alternatively spliced 8-amino-acid exon for the GABAA receptor gamma2 subunit gene (GABRC2) has been postulated to mediate behavioral actions of alcohol. A rapid search for splice-junction mutations near the 8-amino-acid exon using restriction enzymes which normally recognize sequences near or in the exon gave negative results among 217 alcoholics in four aboriginal groups (Ami, Atayal, Bunun and Paiwan) and Han Chinese in Taiwan. The role of the GABRC2 gene in alcoholism was further assessed by a comparison of allelic frequencies revealed by a NciI RFLP between case and control groups. No significant association of alcohol dependence with GABRC2 alleles was observed. These results suggest that the GABRC2 gene probably does not play an essential role in predisposition to alcoholism in the sample population.

Ticlopidine-associated aplastic anemia. A case report and review of literature

Serious hematologic complications associated with ticlopidine have been reported, including aplastic anemia. We report here an additional case of fatal aplastic anemia due to ticlopidine. A 66-year-old male patient developed fever and pancytopenia 2 months after ticlopidine was started. Despite the administration of granulocyte colony-stimulating factor (G-CSF) and broad-spectrum antibiotics, as well as aggressive red cell and platelet transfusions, the patient died 16 days after admission due to septic shock. Eighteen other cases of ticlopidine-induced aplastic anemia published in the English literature are also reviewed and presented here. Eight of the total 19 patients (including the one reported here) have died, mostly due to infection. Of the seven who received supportive treatment only, four had spontaneous recovery. Nine cases were treated with G-CSF or granulocyte-macrophage colony-stimulating factor (GM-CSF), and response was observed in only four of them. Several other cases were treated with high-dose corticosteroids or androgens; however, it was not possible to evaluate the efficacy of these treatments because of the limited number of cases. In the absence of satisfactory treatment for ticlopidine-induced aplastic anemia at present, it may be reasonable to try antilymphocyte globulin or cyclosporine. Also, great efforts should be made in the prevention and management of infection accompanying this disease.

High frequency of deletion mutations in p53 gene from squamous cell lung cancer patients in Taiwan

Lung cancer is the leading and second-leading cause of cancer deaths among women and men in Taiwan, respectively. However, the molecular mechanisms involved in lung tumorigenesis in Taiwan remain poorly defined. A study that analyzed the mutation spectrum of the p53 tumor suppressor gene in 35 female lung cancer patients in Hong Kong showed that a high proportion of the mutations observed were deletions, suggesting the possible involvement of a distinct mutagenic factor(s) in Chinese female lung cancer patients (Y. Takagi et al., Cancer Res., 55: 5354-5357, 1995). Therefore, to gain insight into the role of the p53 tumor suppressor gene and possible etiological factors in lung tumorigenesis in Taiwan, we investigated the mutation spectra of exons 4-11 in the p53 tumor suppressor gene of 60 lung cancer patients in Taiwan. These data were also correlated with clinical pathological characteristics of patients. Lung tumors were surgically resected, genomic DNA was isolated, and their mutation spectra were examined using PCR/single-strand conformational polymorphism analysis and direct sequencing. The frequency of p53 gene mutation was 18% (11 of 60). However, distinct patterns of p53 gene mutation were observed. Seven of 11 mutations detected (64%) were deletions of 1-12 bp at G:C bp or at bp in the immediate vicinity of repetitive sequences and/or tandem repeat sequences. In addition, two patients (2 of 11, 18%) exhibited nonsense mutations. In contrast to the frequent occurrence of missense mutations in the p53 gene reported in the literature, the majority (82%) of the mutations in lung cancer patients in Taiwan were nonmissense mutations, ie., deletions and nonsense mutations. Immunohistochemical staining indicated that p53 mutations including non-in-frame deletions and nonsense mutations all resulted in no expression of p53 protein. Notably, mutations occurred more frequently in patients suffering from squamous cell carcinoma (SQ). Nine of 31 SQ patients (29%) exhibited deletions or nonsense mutations, suggesting that deletions and nonsense mutations in the p53 gene are involved in the formation of SQ in Taiwan. In addition, mutations occurred more frequently in patients with stage III or IV lung cancer. However, mutations were not correlated with patients' smoking habits. Our data suggest that p53 gene mutation involved in the formation of SQ and distinct environmental factor(s) and/or genetic factor(s) that induced specific short deletions in repeat sequences may be involved in lung tumorigenesis in Taiwan.

Surgical management of intracranial arteriovenous malformation associated with aneurysms

BACKGROUND

The association of intracranial arteriovenous malformation (AVM) with aneurysm(s) is hazardous, and various forms of treatment have been suggested. Most authors agree that surgery for these combined lesions should be directed toward the symptomatic lesion first. This may be difficult, however, especially when the source of the hemorrhage is unclear.

METHODS

Between 1985 and 1996, 12 patients with combined AVM and aneurysm(s) were treated at this institution. Clinical presentations included headache and hemorrhage in all patients, limb weakness in three patients, and seizure in one patient. Hemorrhage types included subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH). To avoid the intraoperative rupture of aneurysms during resection of the AVM, these were routinely clipped first, followed by total extirpation of the AVM.

RESULTS

SAH, ICH and/or IVH simultaneously presented in seven patients (58.3%). According to the surgical findings, bleeding resulted from the aneurysm in 10 patients and AVM in two patients. There was a high incidence of combined lesions in the posterior circulation (67%) in our series. Among the patients with combined lesions in the posterior circulation, half had multiple aneurysms. A total of 21 aneurysms were found in the 12 patients, with five patients harboring multiple aneurysms. Among the 12 patients, 10 had good results. Eight patients received one-stage operations and two received two-stage operations. Two patients died, one of massive rebleeding from multiple giant aneurysms with SAH, IVH and ICH after ventricular drainage, and the other died of massive bleeding during resection of a large AVM.

CONCLUSIONS

It is difficult to predict bleeding sources preoperatively by radiologic images. Our experience has led to the belief that the safest approach is to treat the aneurysm before microsurgical resection of the AVM. Most of our patients were surgically treated in one approach and showed good results.

Tuberculum sellae meningiomas: clinical manifestation, radiologic diagnosis, surgery and visual outcome

BACKGROUND

Most patients with tuberculum sellae meningioma (TSM) present with visual symptoms mimicking a pituitary macroadenoma. Accurate preoperative differentiation is important because TSM requires a craniotomy, whereas the transsphenoidal route is preferred for removal of most pituitary macroadenomas.

METHODS

From 1989 to 1994, five patients with TSM were treated at Taichung Veterans General Hospital. All were female, ranging in age from 20 to 60 years. This paper is a retrospective review of clinical features, diagnostic methods, treatment and postoperative visual recovery.

RESULTS

The most common symptom, with a duration of one month to two years, was asymmetrical visual loss. Abnormal endocrine levels were found in one patient (prolactin: 47.91 ng/ml). Another patient was misdiagnosed as having a pituitary adenoma by coronal view computed tomography (CT) and underwent a transsphenoidal operation. Later, an accurate diagnosis was made using magnetic resonance imaging (MRI). She then underwent another operation--unilateral subfrontal craniotomy with total removal of the tumor. The other patients were preoperatively diagnosed as having meningioma by MRI. They also underwent unilateral subfrontal craniotomy with total removal of tumor. All patients showed good visual improvement after their operation. The extent of visual improvement was closely related to the duration of preoperative visual loss. There was no tumor recurrence after a follow-up period of six months to five years (mean, two years and six months).

CONCLUSIONS

It should be emphasized that the diagnosis of TSM must first be based on clinical symptoms and signs, or "chiasma-syndrome". It can be accurately diagnosed preoperatively by sagittal view MRI. Early diagnosis will increase the chances of a good postoperative visual outcome.

Differential development of the enhanced metabolic response during amphetamine sensitization

Behavioral sensitization elicited by repeated administration of amphetamine does not fully develop until a period after discontinuation of amphetamine, but then persists undiminished for a long time. This experiment investigated the regional metabolic changes in rats pretreated with amphetamine and challenged after different abstinence periods (2, 7 and 28 days), using the 2-[14C]deoxyglucose method. The results demonstrated that chronic amphetamine administration enhanced rates of local cerebral glucose utilization in specific cerebral regions. The magnitude and distribution of effects varied with the abstinence period. A challenge dose of d-amphetamine 2 days after pretreatment was found to have no more, or only mildly elevated, local cerebral glucose utilization compared with that following a single acute dose. In rats challenged at the 7th and 28th day, a supersensitive metabolic response was found in dopaminergic and non-dopaminergic areas. This finding suggested regional differences in the development of sensitization and underscored the importance of an abstinence period in the study of sensitization and amphetamine psychosis.

Leptomeningeal malignant melanoma arising in neurocutaneous melanocytosis: a case report

A rare case of histology-proved giant congenital melanocytic nevus (GCMN) with symptomatic leptomeningeal melanocytosis is reported. A 26-year-old man had had a large patch of pigmented nevus over his back and left arm since birth. He had begun to have seizures as well as symptoms and signs of increased intracranial pressure about six months before admission. Serial computed tomography of brain showed hydrocephalus, diffuse leptomeningeal enhancement and multiple well-enhanced, rapid-growing nodules on the surface of the cerebellum and left parietal lobe. Magnetic resonance imaging (MRI) revealed T1 shortening of leptomeninges on precontrast T1 weighted imaging. Skin biopsy was done twice and showed intradermal nevus. Biopsy on one of the intracranial nodules revealed malignant melanoma arising in the melanocytosis. He died one year after the onset of neurologic symptoms. For early diagnosis of neurocutaneous melanocytosis, we suggest 1) MRI, and 2) leptomeningeal biopsy in patients with suspected leptomeningeal malignant melanoma.

A nationwide epidemiological study of spinal cord injuries in Taiwan from July 1992 to June 1996

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out by recruiting patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. A total of 6,410 cases of traumatic spinal fracture were registered among which were 1,586 new cases of SCI. The results represented 70% of the scope of SCI in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million population. The mean age was 46.1 years-old with a plateau distribution for over 20 years and older. Geriatric victims are a major group of SCI in Taiwan. The male to female ratio was 3 to 1. The leading causes of SCI were traffic accidents and accidental falls. Motorcycle collisions accounted for 62% of the traffic accidents, and as most of the motorcycle riders were not helmet users, head injury became the major associated injury of SCI in Taiwan. The effectiveness of the comprehensive care system for SCI patients in Taiwan is relatively good, as reflected by the low rates of complications of SCI, the low mortality rate (6.6%) and the high percentage (67.4%) of SCI patients achieving self-care ultimately at home after rehabilitation. The analysis of person days healthy life loss and quality adjusted survival time revealed that SCI patients in Taiwan required 4 years to cope with the morbidity, and on average, could return to the main stream of life for another 30 years.

A nationwide epidemiological study of spinal cord injury in geriatric patients in Taiwan

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out among patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. In all, 1,586 new cases of SCI were registered, representing about 70% of all possible SCI cases in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million people, whereas it was 47.5 for the geriatric section. The mean age was 46.1 years with a plateau distribution after 20 years and older. Geriatric victims (297 cases, 18.7%, group II) formed a major section of SCI cases in Taiwan. Another group of younger SCI patients (15-64 years old, 1,232 cases, group I) was selected for comparison. The results showed that the male-to-female ratio, pattern of neurological deficits, and causes of injury and death of geriatric SCI patients differed significantly from those of the younger SCI group. Elderly women were exposed to a higher risk of SCI than younger women (M/F ratio 1.7:1). Falls were the leading cause of geriatric SCI, and two thirds of them occurred on level ground. Traffic accidents accounted for a third of SCI cases, half of which involved motorcycle accidents, a fifth of them pedestrians. Quadriplegia and quadriparesis occurred more frequently among elderly cases of SCI than in the younger group and a higher proportion of them died of SCI complications. Two thirds of elderly SCI patients recovered well enough after comprehensive treatment to be able to take care of themselves at home. The government should initiate programs of prevention to reduce the prevalence of geriatric SCI in Taiwan.

Polymorphisms and intron sequences flanking the alternatively spliced 8-amino-acid exon of gamma2 subunit gene for GABAA receptors

Gamma-amminobutyric acid (GABA) is a major inhibitory neurotransmitter. Two alternatively spliced forms of the gamma2 subunit of GABAA receptor (gamma2L and gamma2S), which differ by an exon of eight amino acids, show different sensitivities to modulatory effects of ethanol on receptor activities. A 2.7 kb DNA fragment and an 1.7 kb DNA fragment covering respectively the introns upstream and downstream from the 8-amino-acid exon were obtained through PCR-amplification of human genomic DNA using primers derived from cDNA sequences. Total sequencing of these fragments showed a composite 4.2 kb segment containing the 8-amino-acid exon and consensus sequences for RNA splice junctions. Restriction fragment length polymorphisms (RFLP) based on NciI restriction digestion were found among Chinese in Taiwan. This RFLP provides a useful DNA marker for allelic association or linkage analyses of the role of GABAA receptors in predisposition to alcoholism or other neuropsychiatric disorders.

Macrodystrophia lipomatosa. MR imaging in three patients

Radiographs and magnetic resonance (MR) imaging of three patients with macrodystrophia lipomatosa are presented. Radiographs of involved extremities and digits demonstrated prominent soft tissues and bony hypertrophy. MR images showed hypertrophy of fatty tissue, cortical bone thickening and fatty infiltration of muscle.

Assessment of neutralizing antibodies elicited by a vaccine (Nakayama) strain of Japanese encephalitis virus in Taiwan

A total of 368 blood specimens were resampled from a serum collection containing 2914 blood samples which were collected by a random sampling in Taiwan in 1991. The plaque reduction neutralization test was applied to evaluate the neutralizing ability to two strains of Japanese encephalitis viruses, i.e. Nakayama (the present vaccine strain) and JE5 (a Taiwan isolate). The result revealed that antibodies against JE virus were present in each stratified age group. Antibody positive rates were both highest in the group older than 70 years although the lowest rates were located in different groups. In addition, the result showed that the immunogenicity potency of the antibody induced by the vaccine strain did not have a good coverage against JE5. The rate of neutralizing antibodies above the level of protective efficacy of the present vaccine was limited as low as 37.93%. Efficacy of the vaccine used at present was apparently not efficient. Consideration of a more promising vaccine may be necessary.

Characterization of proteins binding to the ZII element in the Epstein-Barr virus BZLF1 promoter: transactivation by ATF1

Previous studies have shown that the ZII element in the BZLF1 promoter (P1) is responsive to TPA and anti-immunoglobulin induction. In this report, we have studied the DNA/protein complexes formed when ZII is used as a binding site. Twelve distinct DNA/protein complexes were seen in mobility shift experiments using Akata cell nuclear extracts and radiolabeled ZII. Eleven of these complexes were also formed when either BJAB or Raji cell nuclear extracts were used in the binding reaction. Six DNA/protein complexes were affected by mutations in the core TGACATCA motif of ZII which abolish responsiveness to TPA, anti-immunoglobulin treatment, and HHV6 transactivation. The relative sizes of the proteins in the DNA/protein complexes were determined by UV crosslinking. Four distinct specific binding proteins affected by core mutations in ZII were identified as ATFa, ATF1, ATF2, and c-jun. Overexpression of ATF1 in cotransfection experiments caused transactivation of the wild-type P1 promoter but had no effect on a promoter containing a mutant ZII element. An ATF1 mutant with a deleted DNA binding domain failed to transactivate P1. Overexpression of c-jun, ATFa, or ATF2 had no effect on the wild-type or mutant P1 promoter. Our results suggest that ATF1 interacts with the ZII element and may be involved in Epstein-Barr virus reactivation.

Comparison of the APACHE III, APACHE II and Glasgow Coma Scale in acute head injury for prediction of mortality and functional outcome

OBJECTIVES

This study examines the efficacy of the predicting power for hospital mortality and functional outcome of three different scoring systems for head injury in a neurosurgical intensive care unit (NICU).

DESIGN

On the day of admission, data were collected from each patient to compute the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as the deaths of patients before discharge from hospital. Early mortality was defined as death before the 14th day after admission. Late mortality was defined as death after the 15th day from admission. Functional outcome was evaluated by Index of Independence in Activities of Daily Living (Index of ADL).

SETTING

An 8-bed NICU in a 1270-bed medical center in Taichung Veterans General Hospital.

PATIENTS AND PARTICIPANTS

Two hundred non-selected patients with acute head injury were included in our study in a consecutive period of 2 years. Patients less than 14 years old were not included.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Sensitivity, specificity and correct prediction outcome were measured by the chi-square method in three scoring systems. The Youden index was also obtained. The best cut-off point in each scoring system was determined by the Youden index. The difference in Youden index was calculated by Z score. A difference was also considered if the probability value was less than 0.05. The area under Receiver Operating Characteristic (ROC) curve was computed. Then the area under ROC of each scoring system was compared by Z score. There was statistical significance if p was less than 0.05. For prediction of hospital mortality, the best cut-off points are 55 for APACHE III, 17 for APACHE II and 5 for GCS. The correct prediction outcome is 82.4% in APACHE III, 78.4% in APACHE II and 81.9% in the GCS. The Youden index has best cut-off points at 0.68 for APACHE III 0.59 for APACHE II, and 0.56 for GCS. The area under Receiver Operating Characteristic (ROC) curve is 0.90 in the APACHE III, 0.84 in the APACHE II and 0.86 in the GVS. There are no statistical differences among APACHE III and II, and GCS in terms of correct prediction outcome, Youden Index and the area under the ROC curve. Other physiological variables excluding GCS in APACHE III and II (AP III-GCS, AP II-GCS) have less statistical value in the determination of mortality for acute head injury. For the prediction of late mortality, APACHE III and II yield significantly better results in the area under the ROC curve, correct prediction and Youden index than those of GCS. Other physiological variables (AP III-GCS and AP II-GCS) play an important role in the prediction of late mortality in APACHE scores. For prediction of the functional outcome of surviving patients with acute head injury, the APACHE III yields the best results of correct prediction outcome, Youden index and the area under the ROC curve.

CONCLUSION

The APACHE III and II may not replace the role of GCS in cases of acute head injury for hospital or early mortality assessment. But for prediction of the late mortality, the APACHE III and II have better accuracy than GCS. Other physiological variables excluding GCS in the APACHE system play a crucial contribution for late mortality. GCS is simple, less time-consuming and economical for patients with acute head injury for the prediction of hospital and early mortality. The APACHE III provides better prediction for severe morbidity than GCS and APACHE II. Therefore, the APACHE III provides a good assessment not only for hospital and late mortality, but also for functional outcome.

Primary intrasellar mixed germ-cell tumor with precocious puberty and diabetes insipidus

We report an 8-year-old boy with a primary intrasellar mixed germ-cell tumor who underwent the trans-sphenoidal approach for tumor removal. Initially he suffered from diabetes insipidus. Precocious puberty and left abducens nerve palsy were also observed. Elevation of serum testosterone, beta-human chorionic gonadotropin (HCG), and alpha-fetoprotein (AFP) were found on admission. The histological study revealed mixed cellular types of tumor including germinoma, choriocarcinoma, embryonic cell carcinoma, and teratoma. Postoperative radiation to a total of 5000 cGy was performed. Adjuvant chemotherapy was administered before and after radiation. The boy was disease-free during a 6-month follow-up period. Follow-up magnetic resonance imaging showed no presence of tumor. The signs of precocious puberty disappeared, and the diabetes insipidus was easily controlled. The abducens nerve regained normal function. Serum HCG, AFP, and testosterone levels all returned to normal. Serum antidiuretic hormone increased to reach the lower limit of the normal range.

Evaluation of laser and radiofrequency induced dorsal root entry zone lesion for pain control in rats

BACKGROUND

Dorsal root entry zone (DREZ) lesions have been believed to be effective for control of intractable pain. These lesions are usually made using radiofrequency (RF) technique. Theoretically, laser can provide very fast, precise, reproducible and easy control of photothermal effect, possibly achieving better pain control than RF. The objective here was to learn more about the effect of pain control among the RF, carbon dioxide (CO2) laser and potassium titanyl phosphate (KTP) laser in rats.

METHODS

The adult rat was anesthetized and the dorsal spinal cord from C5 to T1 was exposed under a microscope. The DREZ lesions were created in each group of eight including sham, RF thermocoagulation, CO2 laser and KTP laser. The latency of pain withdrawal in the fore-paw by a hot-plate test was recorded before the DREZ lesions and three weeks afterward.

RESULTS

The data showed that RF, CO2 and KTP laser could significantly reduce pain in rats (p < 0.05, one-way ANOVA and Dunnett's test). Latencies of pain withdrawal in the fore-paw by the hot-plate test before, and three weeks after, DREZ lesions were 13.9 +/- 1.4 sec and 65.2 +/- 4.9 sec in the RF group, 15.9 +/- 1.4 sec and 59.0 +/- 5.9 sec in the CO2 laser group, and 14.1 +/- 0.9 sec and 64.8 +/- 5.7 sec in the KTP group, respectively.

CONCLUSIONS

The density of opioid receptor in DREZ lesions cord showed no significant change three weeks after operation in the sham and CO2 laser groups. It was concluded that DREZ lesions caused by RF, CO2 laser and KTP laser can achieve pain control significantly in the rats. The effect of KTP laser was close to RF, followed by CO2 laser.

Inhibition of initiation of simian virus 40 DNA replication during acute response of cells irradiated by ultraviolet light

To study the mechanism by which ultraviolet (UV) light inhibits DNA replication, we examined the effects of UV 254 nm irradiation on the replication of simian virus 40 (SV40) DNA and SV40-based plasmid in monkey cells. The study was designed to determine the relative contributions made by inhibition of replication initiation and chain elongation to the immediate inhibition of DNA replication following UV irradiation. We used two-dimensional neutral-alkaline electrophoresis to examine the behaviour of replication intermediates unambiguously. Kinetic analysis using this technique showed that initiation of replication started to decline at 15 min post-irradiation. When the pulse label incorporated in SV40 replication intermediates before irradiation was chased for 1 h, most of the label was found in mature Form I and II molecules. This indicated that replication elongation took place on damaged template. We also used a transfection technique to show that heavily irradiated plasmids replicated efficiently in unirradiated transfected cells. By the transfection technique, we observed that UV irradiation of host cells dose-dependently inhibited replication of transfected non-irradiated plasmids, suggesting that the inhibition of DNA replication is due to a global change in cellular physiology induced by UV. This change was also apparent from poor staining of the chromatin by fluorescent-DNA-binding dyes immediately after UV irradiation of intact cells. We conclude that a significant fraction of chain elongation proceeds on damaged templates and DNA replication during the acute response of cells irradiated with UV is mainly controlled by the inhibition of replication initiation.

Tarsometatarsal joint: anatomic details on MR images

PURPOSE

To evaluate the diagnostic capabilities of magnetic resonance (MR) imaging in the tarsometatarsal ([TMT] Lisfranc) joint with close anatomic correlation.

MATERIALS AND METHODS

Six normal cadaveric feet were imaged by using T1-weighted spin-echo (oblique axial) and three-dimensional spoiled gradient-recalled acquisition in the steady state ([SPGR] coronal, sagittal) sequences. Subsequently, gadolinium-enhanced arthrography was performed in three specimens followed by T1-weighted spin-echo and SPGR MR imaging. Specimens were sectioned in all three planes followed by correlation of the MR imaging results with gross anatomic findings.

RESULTS

In all specimens, the oblique axial and, less effectively, the coronal and sagittal planes allowed visualization of the Lisfranc ligament. Intermetatarsal ligaments were seen almost exclusively on the coronal images, and TMT ligaments on the sagittal images. Bone alignment could be assessed on the oblique axial images.

CONCLUSION

MR imaging reliably depicts the anatomy of the TMT joint including ligamentous and osseous structures.

[Cyclin-dependent kinase inhibitors in mammal cells]

In recent two years, a group of protein factors have been found to combine with the cyclin-dependent kinases (CDKs) and block the activation of cyclin/CDK complexes. They are named CDK inhibitors (CKIs) as p21, p16, p15, p27 and CDI1. The p21 and p27 have certain homology and can inhibit the activity of multiple CDKs; p16 and p15 have higher homology and can specifically combine with CDK4 and CDK6; and the combination specificity of CDI1 needs further research. The expression of p21 is regulated positively by p53. TGF-beta can upregulate the expression of p15 and the inhibitory activity of p27. The above findings demonstrate that CKIs are not only the regulators of CDKs' activity but also the direct linkers between cancer inhibitors and cell-cycle regulation.

Comparison of the rate of excision of major UV photoproducts in the strands of the human HPRT gene of normal and xeroderma pigmentosum variant cells

Xeroderma pigmentosum (XP) variant patients are genetically predisposed to sunlight-induced skin cancer. Fibroblasts from such patients are extremely sensitive to mutations induced by UV radiation, and the spectrum of mutations induced in their hypoxanthine phosphoribosyltransferase (HPRT) gene differs significantly from that seen in normal cells. To determine if this UV hypermutability reflects abnormally slow excision repair of cyclobutane pyrimidine dimers (CPD) or 6-4 pyrimidine-pyrimidones (6-4s) in that gene, we synchronized XP variant and normal fibroblasts, irradiated them in early G1-phase, 12 or more hours prior to the scheduled onset of S phase, harvested them immediately or after allowing various times for repair, and analyzed the DNA for photoproducts in the HPRT gene, using quantitative Southern blotting. To incise the DNA at CPD, we used T4 endonuclease V; to incise at 6-4s, we first used photolyase and UV365nm to reverse CPD and then UvrABC excinuclease. Excision of CPD was rapid, preferential, and strand-specific, but there was no significant difference in rate between the two kinds of cells. The half life was 4 h in the transcribed strand of the gene and 6.5 h in the nontranscribed strand. For excision of CPD in the genome overall, this value is 12 h. Excision of 6-4s from either strand of the HPRT gene was extremely rapid and preferential in both kinds of cells, with a half life of approximately 30 min. The results indicate that the UV hypermutability of the XP variant cells cannot be caused by slower rates of repair of CPD and/or 6-4s in the target gene for mutagenesis.

Induction of autologous tumor-specific cytotoxic T-lymphocyte activity against a human renal carcinoma cell line by B7-1 (CD8O) costimulation

Recently mouse models have shown that expression of costimulatory molecules such as B7-1 on tumor cells can induce tumor-specific immunity, suggesting that tumor cells modified to express costimulatory molecules can be a potential tumor vaccine. To investigate the importance of B7-1 co-stimulation in induction of autologous tumor immunity in humans, we established a renal carcinoma cell line, RCC-1, from a tumor resection and studied the patient's antitumor immune responses in vitro. The RCC-1 cell line constitutively expressed major histocompatibility complex (MHC) class I, intercellular adhesion molecule (ICAM)-1, and leukocyte function-associated antigen (LFA)-3 molecules, and MHC class II molecules were induced by interferon-gamma (IFN-gamma) treatment in vitro. However, neither RCC-1- nor IFN-gamma-treated RCC-1 cells expressed B7-1, and both failed to induce T-cell proliferative responses in mixed lymphocyte and tumor cell reaction (MLTR) assays, suggesting that the costimulatory signals provided by cell adhesion molecules such as ICAM-1 and LFA-3 were not sufficient to elicit an antitumor immune response. However, on transfection of the human B7-1 into RCC-1, these cells were able to induce a significant T-cell proliferation in MLTR assays. This T-cell response could be blocked by anti-B7 mAb treatment of the tumor cells. RCC-1B7 cells also induced the generation of tumor-specific cytolytic T lymphocytes to the parent RCC-1 cells in vitro, with little nonspecific cytolysis of an unrelated RCC line, A498, or autologous phytohemagglutinin (PHA) blasts. This specific cytotoxicity could be abrogated by anti-CD8 mAb and complement treatment. In summary, our study indicates that B7-1-CD28 interaction plays a critical role in induction of autologous tumor-specific cytotoxic T lymphocytes (CTLs) in humans, suggesting that the costimulatory molecule transfected tumor cells could be useful in expanding tumor-specific autologous CTL in vitro for adoptive tumor immunotherapy.

Alteration of cerebral microcirculation by hemodilution with hemosome in awake rats

Our study showed that hemodilution with modified fluid gelatin resulted in an increase in local cerebral blood flow (LCBF), but no change at all in local cerebral oxygen delivery (LCOD) in rats. Hemosome, a lecithin encapsulated hemoglobin having the oxygen-carrying capacity, was developed to improve LCOD by hemodilution. Therefore, we have hypothesized that LCBF & LCOD would be increased by hemodilution with hemosome. To test this hypothesis, adult male Sprague-Dawley rats weighing approximately 350g were used and divided into the hemodilution and the control groups. Hemosome was made from pig red blood cells and lecithin. It's mean diameter was approximately 0.3 um and hemoglobin concentration was approximately 4g/dl. Isovolemic hemodilution, which lowered the systemic hematocrit from approximately 50% to approximately 30%, was achieved by rapidly replacing blood with the same volume of hemosome. Ten min later, LCBF in 14 brain structures were measured using the 14C-iodoantipyrine technique. Our results showed that LCBF of the control group ranged from 115 +/- 11 ml/100g/min in the medulla to 260 +/- 31 ml/100g/min in the occipital cortex. LCBFs were generally higher (p < 0.05, MANOVA) by 16% in the hemodilution group than in the control group. However LCODs were generally decreased (p < 0.05, MANOVA) by 18% in the hemodilution group than in the control. In conclusion, hemodilution with hemosome indeed improves LCBF but lowers LCOD in awake rats.

Cerebrospinal fluid interleukin-6, interleukin-8, and tumor necrosis factor-alpha in children with central nervous system infections

Concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-alpha) in cerebrospinal (CSF) samples were determined from 11 control and 42 children with central nervous system infections including 11 patients with bacterial meningitis, 20 patients with aseptic meningitis, 11 patients with encephalitis. The CSF IL-6, IL-8 and TNF-alpha concentrations in patients with bacterial meningitis were significantly higher than those with aseptic meningitis, encephalitis and the control groups. CSF IL-6, IL-8 and TNF-alpha levels in patients with aseptic meningitis were also significantly higher than those in the control group. There was no significant increase of CSF IL-6, IL-8 and TNF-alpha concentrations in patients with encephalitis compared to the control group. CSF IL-6 and TNF-alpha concentrations were decreased in patients with bacterial meningitis after treatment. CSF IL-8 levels were significantly decreased in both bacterial and aseptic meningitis groups at recovery period. There were no correlation between CSF IL-6, IL-8 and TNF-alpha levels and other parameters including CSF leukocytes, protein, sugar, IgG levels and IgG indexes in patients with bacterial meningitis. These results suggest that IL-6, IL-8 and TNF-alpha are important mediators in the meningeal inflammatory process in patients with meningitis. The levels of these mediators are good indicators for the extent of the meningeal inflammation.

Effects of ONO-1078, a leukotriene antagonist, on cardiovascular responses induced by vagal stimulation, capsaicin, and substance P in guinea pigs

AIM

To determine the role of ONO-1078, 4-oxo-8 -[p-(4-phenylbutyloxy) benzoylamino]- 2-(tetrazol-5-yl) -4H-1-benzopyran hemihydrate, in cardiovascular responses induced by vagal stimulation, capsaicin, and substance P.

METHODS

Evans blue extravasation in the atrium and ventricle, and mean arterial pressure (MAP) were observed.

RESULTS

Electric stimulation of vagus (ESV, 10 Hz, 5 ms, 2 or 10 V, for 90 s) increased Evans blue extravasation in the hearts of atropine (1 mg.kg-1, i.v.)-pretreated guinea pigs. Capsaicin (0.05 mg.kg-1, i.v.) and substance P (1 microgram.kg-1, i.v.) enhanced the dye extravasation and elicited a drop in MAP. ONO-1078 (0.03 and 0.1 mg.kg-1, i.v.) inhibited ESV-induced response, especially at stimulation of 2 V. ONO-1078 (0.03 mg.kg-1) attenuated capsaicin-induced cardiac microvascular leakage and hypotensive response, but failed to inhibit substance P-induced responses.

CONCLUSION

ONO-1078 can modulate the cardiovascular responses in neurogenic inflammation, possibly mediated by inhibiting sensory neuropeptide release.

Intradural metastasis to the cauda equina from carcinoma of the anus

STUDY DESIGN

This is a report of a man with carcinoma of the anus and intradural metastasis to the cauda equina.

OBJECTIVE

To perform a laminectomy with tumor removal for relief of pain.

SUMMARY OF BACKGROUND DATA

Only 25 cases of intradural spinal metastasis have been reported in the English literature. This is the first report of a metastatic case, moving from the carcinoma of the anus to the cauda equina.

METHODS

Magnetic resonance imaging showed an ill-defined mass, with central necrosis, to the cauda equina. The possibility of intradural metastasis to the cauda equina was indicated by unique pain symptoms.

RESULTS

The patient's back pain subsided after total laminectomy of L3-L5 with subtotal removal of the tumor. The residual tumor became smaller with postoperative radiation.

CONCLUSION

Magnetic resonance imaging is a good diagnostic choice in this situation. The cause of the metastasis was unclear, but it was presumed to have occurred through the perineural lymphatic ducts. Laminectomy with tumor removal is feasible for relieving pain and demonstrating pathology.

[Relationship between CENP-B gene expression and the cell cycle]

The centromere/kinetochore is a specialized structure at the primary constriction of mammalian chromosomes. It participates in and is necessary for the mitotic chromosome movement. Centromere Protein B(CENP-B) is a highly conserved protein located at the centromere/kinetochore region. In this article, we explore the relationship between CENP-B expression and cell proliferation. HeLa cells were synchronized at different phases of the cell cycle and the synchronized cells were examined by flow cytometry and 3H-TdR labelling. ACA immunostaining showed the discrete single spots in nuclei of the cells at G1 and S phase, and spots in pairs mostly in those at G2 phase. Dot blot and Northern blot indicated that CENP-B gene was expressed at all phases of the cell cycle, but the expression level very much different with the highest at G2 phase and the lowest at S phase. Interestingly relatively high expression of CENP-B gene was also found in M phase, showing the continuity of the CENP-B gene expression during the cell cycle. This continuity implies a possibility that the assembly of the new centromere/kinetochore can not occur until centromere proteins reach a critical concentration when cells enter S phase and G 2 phase. Also, the continuous expression of centromere proteins may be necessary for the centromere/kinetochore function. In addition, the relationship between CENP-B gene expression and the nuclear skeleton was investigated. The nuclear skeleton-associated DNA extracted after Bam HI digestion were hybridized with 32P-labelled cDNA of CENP-B gene by means of Southern blot technique. The results that there stronger positive hybridization reaction in G 2 phase than in S phase indicated that CENP-B gene was more closely associated with the nuclear skeleton in G 2 phase cells than in S phase cells, which was in consistence with the level of the CENP-B gene expression at G 2 and S phase cells.

Construction, purification, and functional incorporation on tumor cells of glycolipid-anchored human B7-1 (CD80)

To generate a potent cell-mediated immune response, at least two signals are required by T cells. One is engagement of the T-cell receptor with peptide-bearing major histocompatibility complex molecules. The other signal can be delivered by various molecules on the antigen-presenting cell, such as B7-1 (CD80). Many tumor cells escape immune recognition by failing to express these costimulatory molecules. Transfection of the B7 gene into some murine tumor cells allows for immune recognition and subsequent rejection of the parental tumor. We have studied an alternative approach for the introduction of B7-1 onto the surface of tumor cells. This method involves purified glycosyl-phosphatidylinositol (GPI)-anchored proteins which can spontaneously incorporate their lipid tail into cell membranes. We have created and purified a GPI-anchored B7-1 molecule (called GPI-B7) which is able to bind its cognate ligand, CD28, and incorporate itself into tumor cell membranes after a short incubation. Tumor cells that have been reconstituted with GPI-B7 can provide the costimulatory signal needed to stimulate T cells. These findings suggest an approach for the introduction of new proteins onto cell membranes to create an effective tumor vaccine for potential use in human immunotherapy.

Magnetic resonance imaging of acoustic schwannomas

The magnetic resonance imaging (MRI) findings of 27 histologically proven acoustic schwannomas in 24 patients (13 men, 11 women, age 20-79 yr) are described in detail. Three patients had bilateral tumors. Twenty-two tumors (82%) had intra- and extracanalicular components, three tumors (11%) were limited to the internal auditory canal (IAC) and two tumors (7%) were limited to the cerebellopontine angle (CPA). The diameters of extracanalicular lesions in the CPA ranged from 12 to 50 mm, and most of them were round in shape. All IAC portions of CPA tumors had a funnel-shaped appearance on the axial images and short-club-shaped configuration on the coronal images. There was strong homogeneous contrast enhancement of the solid components in 12 tumors (44%) and heterogeneous enhancement in 15 tumors (56%). The cystic components of the tumors correlated well with the histologic features. All tumors could be demonstrated in their enterity by MRI. The "short-club sign", first described in this study, helped to confirm the intracanalicular component of acoustic schwannomas, which were usually found in the cerebellar cistern. The results of this study show that MRI is a sensitive imaging modality for the assessment of acoustic schwannomas located at the CPA or IAC, or in both regions. MRI is non-invasive and does not involve ionizing radiation. It should be considered the imaging examination of choice to evaluate patients with suspected acoustic schwannomas.

Magnocellular and parvocellular divisions of pigeon nucleus isthmi differentially modulate visual responses in the tectum

The electrophysiological responses of 162 tectal cells to computer-generated visual stimuli were extracellularly recorded from 24 homing pigeons before and after injecting either lidocaine or N-methyl-D-aspartate (NMDA) into the nucleus isthmi pars magnocellularis (Imc) or the nucleus isthmi pars parvocellularis (Ipc). Micro-injections of lidocaine into Imc resulted in a significant reduction of firing rate in 80% of tectal cells, whose excitatory receptive fields (ERFs) were localized within the ERF of the Imc cell where the lidocaine was injected. In contrast, when lidocaine was injected into Ipc under identical circumstances it had no effect on the visually driven activity of 68% of tectal cells. However, when the excitatory amino acid NMDA was injected into Ipc it produced a significant reduction in the visually driven firing of 75% of tectal neurons when their ERFs were within the isthmic ERF, while similar application of NMDA into Imc had no effect on the visually driven response of 94% of tectal neurons. When the ERFs of tectal cells were localized outside the ERF of the isthmic cell where the chemical was injected, Imc-injected lidocaine had no effect in 9 out of 10 tectal cells, whereas Ipc-injected NMDA increased firing in 7 out of 17 tectal cells. Therefore, it is suggested that the Imc-tectal fibers participate in a positive feedback pathway and the Ipc-tectal fibers are involved in a negative feedback pathway.

Expression of heat-stable antigen on tumor cells provides co-stimulation for tumor-specific T cell proliferation and cytotoxicity in mice

Heat-stable antigen (HSA/J11d/possibly homologous to CD24), a cell adhesion molecule capable of providing a co-stimulatory signal for T cell proliferation, is expressed on B cells, activated T cells, monocytes, granulocytes, Langerhans cells and thymocytes. Recent studies have demonstrated that co-stimulatory signals provided by cell adhesion molecules such as B7-1 play an essential role in generation of an anti-tumor immune response. To examine whether the co-stimulatory signal provided by HSA can induce an anti-tumor immune response, we have transfected HSA cDNA into the murine melanoma cell line K1735M2, and examined the ability of this transfected cell line to induce tumor-specific T cell responses. The results demonstrate that spleen cells from mice immunized with HSA-transfected K1735M2 cells showed enhanced T cell proliferation in a mixed lymphocyte tumor reaction (MLTR) assay and also demonstrated a significant anti-tumor cytotoxicity to the parent tumor cell (K1735M2). This anti-tumor cytolytic activity could be abrogated by pretreatment of effector cells with anti-mouse CD8 monoclonal antibody and complement. Under similar conditions, spleen cells from C3H mice immunized with vector-transfected K1735M2 cells neither actively proliferate in an MLTR assay, nor did they exert significant cytolytic activity against the respective tumor cells. In summary, our study demonstrated that HSA can provide a co-stimulatory signal for the T cell immune response against tumor cells in a murine model.

Brown-Séquard syndrome associated with Horner's syndrome in cervical epidural hematoma

STUDY DESIGN

This report analyzed the likely locations of lesions that cause a combination of Horner's and Brown-Séquard syndromes. One must know the anatomic structure of spinal cord and the sympathetic nerve chain.

OBJECTIVES

A hypertensive patient had Brown-Séquard and Horner's syndromes after neck trauma. The magnetic resonance imaging and surgical findings showed the correlation between the clinical symptoms and the likely lesion.

METHODS

The patient underwent right hemilaminectomy from C2 to C6 with total removal of hematoma.

CONCLUSION

The spinal epidural hematoma rarely is a surgical emergency. The patient presented with Brown-Séquard and Horner's syndromes. Magnetic resonance imaging made a rapid and correct diagnosis. The patient received an emergent right hemilaminectomy from C2 to C6 with removal of hematoma and subsequently made a complete recovery.

Comparison of APACHE III, II and the Glasgow Coma Scale for prediction of mortality in a neurosurgical intensive care unit

OBJECTIVES

This study examined the efficacy of predicting power for hospital mortality of three different scoring systems in a neurosurgical intensive care unit (NICU).

SETTING

An eight-bed NICU in a 1,270-bed medical centre (Taichung Veterans General Hospital).

SUBJECTS

Two hundred patients with head injury, brain tumour, hypertensive intracerebral haemorrhage, rupture of aneurysm or arteriovenous malformation, or other categories were included in our study in a consecutive period of 14 months. Patients less than 14 years old were not included.

DESIGN

On the first day of admission, data were collected from each patient to compute the Acute Physiology and Chronic Health (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as when death occurred before discharge from hospital.

INTERVENTIONS

none.

MEASUREMENTS

Sensitivity, specificity and correct prediction outcomes were measured by logistic regression in three scoring systems. The Youden index was also obtained. The best cutoff point in each scoring system was determined by logistic regression or by the Youden index. Data obtained by logistic regression were compared by McNemar's test. The differences in Youden index were calculated by the Student's t-test. The area under the Receiver Operating Characteristic (ROC) curve was computed and the area of each scoring system was then compared by the Wilcoxon Mann-Whitney test.

MAIN RESULTS

The correct prediction of outcome was 85.5% in APACHE III, 77.5% in APACHE II and 75.0% in GCS. The area under the Receiver Operating Characteristic (ROC) curve was 0.892 in APACHE III, 0.826 in APACHE II and 0.868 in GCS. For the prediction of dead patients at the best cutoff point, APACHE III and GCS were better than APACHE II, (both p < 0.01 respectively). For the prediction of alive patients at the best cutoff point, APACHE III was better than GCS and APACHE II (p < 0.01 respectively).

CONCLUSION

The APACHE III system seems to be the most reliable. The results reveal that the APACHE III system is better in predicting power for hospital mortality than either the GCS or APACHE II systems in our NICU patients.

Epidemiological study of head injuries in central Taiwan

BACKGROUND

Head injury plays a major role in emergency neurosurgery and is the leading cause of neurosurgical mortality at Taichung Veterans General Hospital. Statistical data show that a similar condition exists in other teaching hospitals in the central Taiwan area, which includes more than one-quarter of the entire population and has more than one-third of the total land of Taiwan. A clinical statistical survey of head injuries in this area may provide a better understanding of the realistic situation in Taiwan. Reports on head injuries in Taipei City, Taipei area, and Hualian County are also cited for comparison.

METHODS

The present study is based on a cooperative investigation of head injuries by 18 teaching hospitals in central Taiwan from July 1991 to June 1993. All patients received a neurological examination including the Glasgow coma scale (GCS), with recording by 20 Board-certified neurosurgeons.

RESULTS

The 7050 cases collected included 5322 hospitalized cases, 1694 cases seen in the Emergency Room, and 34 deaths on arrival. The leading cause of head injuries was traffic accidents (5354 cases, 76.3%). Motorcycles contributed to the highest number of cases (3661, 68.4%); and trains contributed to the lowest number (8, 0.1%). Helmets were used in only 5.2% of 3503 motorcycle accidents. Based on the patients' or families' description in 4835 cases, the leading cause of the accident was careless driving (1180 cases, 24.4%). The 1088 cases of severe head injury were classified with a score less than 8 by the GCS; 498 of them died, or an 86.6% mortality (575 cases).

CONCLUSIONS

Traffic accidents are the leading cause of head injuries, and motorcycles contribute to the major part of it in central Taiwan. Similar conclusions can be drawn for other areas including Taipei City, Taipei area, and Hualian County.

Decompressive craniotomy for acute shaken/impact baby syndrome

To estimate the surgical efficacy of decompressive craniotomy, 23 children under 2 years of age with acute shaken/impact baby syndrome were treated with medical or surgical methods over the past 6 years. Six children (group A) with lower intracranial pressure (ICP, less than 30 mm Hg) were treated with medical therapy, and 17 children with high ICP (more than 30 mm Hg) of which 7 children were treated with medical therapy (group B) and another 10 children (group C) were treated with decompressive craniotomy. Bifrontal craniotomy was performed on 5 children with generalized brain swelling. A large frontotemporoparietal craniotomy was performed on another 5 children with unilateral swelling. A mean of 32 ml of subdural hematoma was removed. The mean ICP was reduced by 80% in the craniotomy group, p < 0.05. Children in groups A and C performed better on the Children's Outcome Scale than those in group B, p < 0.05. Mortality was significantly lower (0/10) in group C than in group B (3/7), p < 0.05. Hearing preservation was better in group C than in group B, p < 0.05. Bifrontal and frontotemporoparietal craniotomies may reduce mortality and morbidity for acute shaken/impact baby syndrome with high ICP. Patients with ICP less than 30 mm Hg may be treated successfully with medical therapy and patients with ICP more than 30 mm Hg are better treated with decompressive craniotomy.

Dose-dependent effects of chronic amphetamine administration in local cerebral glucose utilization in rat

The daily dose of amphetamine pretreatment may affect the development of behavioral-sensitized patterns in rodents and amphetamine psychosis in humans. This experiment investigated the regional cerebral metabolic changes in rats after pretreatment with different doses of amphetamine by the 2-[14C]deoxyglucose method. Rates of local cerebral glucose utilization were examined in 37 regions of the rat brain. The result showed generally maximal metabolic augmentation in the 5.0 mg/kg group instead of in the 1.0 or the 10.0 mg/kg groups. Behavioral testing using motor activity cages in rats with the same regimen found no difference among groups. The findings demonstrate that there might be a window effect by daily amphetamine dose on the development of drug dependence and amphetamine psychosis. It was suggested that the 2(-)[14C]deoxyglucose method could be used for further study of animal models of amphetamine psychosis.

The study of pollen and Der p mite-specific IgE antibodies in children with allergic rhinitis

The role of pollens and house dust mites in perennial chronic rhinitis has been investigated for the Taipei area. Fifty-four serum specimens were collected from children with chronic rhinitis. EIA kits (Phadezyme RAST) were used to detect specific IgE antibody of nine allergens, including house dust mite (Der p) and eight common pollens. The children were divided into allergic (AR) and nonallergic (NAR) groups, based on the results of skin tests, inhalant allergen-specific IgE screen (Phadiatop), physical examination, past history and family history. The results showed: (1) 41 (76%) patients were defined as allergic rhinitis; (2) Der p specific IgE was detected in 41 (100%) AR patients and 7 (54%) NAR patients (P < 0.005), a strong positive reaction (> 2+) in 83% AR and none NAR patients (P < 0.005); (3) one, or more than one, pollen-specific IgE were found in 13 (32%) AR and 4 (31%) NAR patients. No strong positive reaction was detected in either group.

THE CONCLUSION

(1) three-fourths of the children with chronic rhinitis are allergic by nature; (2) house dust mite is the major allergen of allergic rhinitis; (3) in the Taipei area, pollen does not play an important role for children with allergic rhinitis.

Mammalian DNA ligase II is highly homologous with vaccinia DNA ligase. Identification of the DNA ligase II active site for enzyme-adenylate formation

Mammalian cells contain three biochemically distinct DNA ligases. In this report we describe the purification of DNA ligase II to homogeneity from bovine liver nuclei. This enzyme interacts with ATP to form an enzyme-AMP complex, in which the AMP moiety is covalently linked to a lysine residue. An adenylylated peptide from DNA ligase II contains the sequence, Lys-Tyr-Asp-Gly-Glu-Arg, which is homologous to the active site motif conserved in ATP-dependent DNA ligases. The sequences adjacent to this motif in DNA ligase II are different from the comparable sequences in DNA ligase I, demonstrating that these enzymes are encoded by separate genes. The amino acid sequences of 15 DNA ligase II peptides exhibit striking homology (65% overall identity) with vaccinia DNA ligase. These peptides are also homologous (31% overall identity) with the catalytic domain of mammalian DNA ligase I, indicating that the genes encoding DNA ligases I and II probably evolved from a common ancestral gene. Since vaccinia DNA ligase is not required for DNA replication but influences the ability of the virus to survive DNA damage, the homology between this enzyme and DNA ligase II suggests that DNA ligase II may be involved in DNA repair.

Repeat operations in failed microvascular decompression for trigeminal neuralgia

For the study of pathogenesis and treatment of recurrent trigeminal neuralgia, we performed 31 repeat operations from among 400 patients with trigeminal neuralgia in the past 10 years. Initially, of these 400 patients, 376 underwent microvascular decompression only, and 24 underwent partial sensory rhizotomy with or without microvascular decompression. Fifty-three patients (14%) had recurrences after microvascular decompression, of which 31 patients underwent repeat operations. Among the repeat operations, there was negative exploration in 16 patients (52%), arterial loop compression in 7 (22%), venous compression in 4 (13%), and Teflon compression or adhesion in 4 (13%). Twenty-one patients had early recurrences within 1 year, and 10 patients had late recurrences. Negative exploration and arterial compression were more likely in early recurrence (P = 0.01). Continuing demyelination might occur in patients with negative exploration, even when adequate decompression had been initially performed. Seventy percent of the patients had no recurring pain by way of partial sensory rhizotomy for negative explorations, redecompression of arterial loops, division of offending veins, or lysis and reposition of Teflon. About half of the patients had positive findings that were amenable without rhizotomy in the repeat operations. A repeat operation for failed microvascular decompression is a good choice if the condition of the patient is tolerant.

Brachial plexus neuropathy secondary to septic arthritis and osteomyelitis: report of two cases

Two infants, delivered uneventfully, later developed right brachial plexus palsy secondary to pyogenic osteomyelitis and arthritis of the right shoulder joint. Weakness of right arms occurred at the sixth and tenth days of age respectively. Both had right arm tenderness on palpation and passive movement. Roentgenograms of their right shoulder joints showed irregular radiolucency of the proximal margin of right humerus head. In both cases, electromyography revealed various degrees of significant denervation pattern for the C5-C7 innervated muscles. Pus culture from right shoulder joints grew Streptococcus viridans and Staphylococcus aureus, respectively. After antibiotic therapy and arthrotomy with drainage, weakness improved gradually following continuous rehabilitation. Follow-up at six months of age showed almost complete recovery of right upper extremity function in one patient, but mild residual weakness in the other. Follow-up electromyography studies showed continued improvement. The possible mechanism of this rare occurrence is discussed.

Subependymal giant cell astrocytoma with tuberous sclerosis--case report

Tuberous sclerosis is a rare disease of autosomal dominant inheritance and may affect any organ, and less than 2% have a subependymal giant cell astrocytoma. In the present report, a 6-year-old girl with clinical features of tuberous sclerosis had an intraventricular tumor. CT scan and MRI of brain showed a tumor in the lateral ventricles extended into the Foramina of Monro and third ventricle causing severe hydrocephalus. She underwent left frontal craniotomy with partial removal of the tumor. The pathology was subependymal giant cell astrocytoma. Patient's neurological condition improved postoperatively and postoperative CT scan showed no hydrocephalus. Clinical and radiological follow-up of patients with tuberous sclerosis who had subependymal nodules in early childhood is important due to its possibility of subsequent transformation into intraventricular tumor.