Re-exposure to recombinant (r)-hirudin in antihirudin antibody-positive patients with a history of heparin-induced thrombocytopenia

Patients with a history of heparin-induced thrombocytopenia (HIT) and antibodies to hirudin were re-exposed to recombinant (r)-hirudin for prophylaxis of thromboembolism. Four patients were re-exposed to 2 x 25 mg of subcutaneous r-hirudin for 8-27 d. Two patients were re-exposed once, one patient twice and one four times. Re-exposure was well tolerated in all patients and no thromboembolism occurred. Antihirudin IgG (4/4 patients), IgA and IgM (1/4 patients) antibody levels increased. Baseline ecarin clotting times showed high variability. Patients with antibodies to hirudin may be re-exposed but anticoagulant monitoring is mandatory.

Mitochondrial cytopathy combined with Fanconi's syndrome

Severe muscle weakness in Fanconi's syndrome is rarely the result of mitochondrial cytopathy. We describe a rare case of a 9-year-old male with early onset of Fanconi's syndrome. He developed severe proximal muscle weakness exacerbated by hypokalemia and hypophosphatemia in childhood. The muscle biopsy revealed increased accumulation of abnormal mitochondria and fat droplets in histochemical stains and electron microscopy. Mitochondrial cytopathy cannot be excluded in Fanconi's syndrome with late onset of muscular impairment. Long-term follow-up of his clinical course is suggested to understand the natural history of this unusual case.

Determination of serotonin release from platelets by enzyme immunoassay in the diagnosis of heparin-induced thrombocytopenia

[14C]-Serotonin release assay (14C-SRA) from platelets is considered to be the most sensitive test for laboratory confirmation of heparin-induced thrombocytopenia (HIT). This study compared 14C-SRA with an enzyme immunoassay (EIA) to determine the release of serotonin from platelets in the presence of heparin and serum from HIT patients. The normal range (median, 2.5 and 97.5 percentiles) of serotonin release from platelets in healthy subjects (n = 149) is 38 ng/ml (19 and 62) measured by EIA-SRA. Serum from HIT patients (n = 42) released 2548 ng/ml (244 and 7987) serotonin in the presence of 0.1 IU/ml heparin and 29 ng/ml (13 and 76) in the presence of 100 IU/ml heparin. One hundred per cent and 15% of HIT samples exhibited an elevated serotonin release from platelets in the presence of 0.1 IU/ml low molecular weight (LMW) heparin, 2100 ng/ml (869 and 5968), or danaparoid, 272 ng/ml (143 and 403), respectively. The sensitivity and specificity of the EIA-SRA was 100% and 97.4% and of the 14C-SRA 100% and 92.9% in HIT patients. No false-positive results were found in patients receiving heparin (n = 28), in patients with elevated levels of bilirubin (n = 5), in patients with antiphospholipid antibody syndrome (n = 10) or in non-HIT patients (n = 78) with both assays. The EIA technique to quantify serotonin release from platelets provides a reliable non-radioactive method to diagnose heparin-induced thrombocytopenia and to assess in vitro crossreactivity of low molecular weight heparins and heparinoid.

Effects of hetastarch and mannitol on prolonging survival in stable hypothermia in rats

In rats, prolonged stable hypothermia ( approximately 24 h at body temperature of 19 degrees C) is characterized by a time-dependent increase in hematocrit, plasma osmolality, and red blood cell fragility and a decrease in plasma volume. These changes impede tissue microcirculation and could limit survival. As a countermeasure, we used plasma volume expanders of both long (hetastarch)- and short-lasting (mannitol) characteristics to improve microcirculation and hopefully hypothermia survival. Infusion of 6% hetastarch at hour 3 in hypothermia significantly (P < 0.05) enhanced survival over saline control (33.5 vs. 23.8 h); a significant delay in the increases of hematocrit and cell fragility was also observed compared with those in saline controls. Treating the animal with 6% hetastarch at hour 20 during hypothermia caused a similar but less-effective improvement in survival. In contrast, treating the rats with 6% mannitol at hour 3 or 20 during hypothermia failed to enhance survival over saline control, although transient improvement in plasma volume was observed. Our results indicate that by using a long-lasting volume expander, which tends to better maintain plasma volume and rheological parameters governing microcirculation than does saline or a short-lasting volume expander, hypothermia survival can be significantly improved.

Treatment of an acute flush reaction caused by subcutaneous r-hirudin with pegylated hirudin

We report a patient who was treated with recombinant (r)-hirudin for heparin-induced thrombocytopenia and developed a flush reaction twice upon re-exposure to 25 mg of subcutaneous r-hirudin. Antihirudin IgG antibodies developed. The patient received 50 mg of PEG-hirudin subcutaneously over 2 days. No side-effects occurred. The level of IgG antihirudin antibodies increased. Ecarin clotting time and thrombin inhibition S2238 assay were not influenced by the patient's IgG antihirudin antibody. PEG-hirudin may be used in patients with intolerance to r-hirudin because of a dissociation of the allergenic and immunogenic properties of the pegylated drug.

Effect of ginseng saponins on cold tolerance in young and elderly rats

Acute systemic injection of ginseng saponin (GS) significantly elevated both the total and maximum heat production in young rats (3-6 months) and improved their cold tolerance under severe cold (-10 degrees C under helium-oxygen). However, pretreating the animal with the optimal dose (10 mg/kg) of GS devoid of Rg1 and Rb1 failed to elicit any beneficial effect in improving the cold tolerance. Pretreating the animal with Rb1, but not Rg1, increased thermogenesis as well as cold tolerance in young rats. A similar beneficial effect in improving cold tolerance was also observed when old rats (26-28 months) were pretreated with the same doses of Rb1 (2.5 and 5.0 mg/kg). Our results indicate that Rb1 is the key ingredient in GS-mediated enhancement in thermogenic capacity and that both young and old rats can benefit from this treatment for enhanced cold tolerance.

Appropriateness of medication selection for older persons in an urban academic emergency department

OBJECTIVES

To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes.

METHODS

The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy-nine percent of the patients were African-American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug-disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health-related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study.

RESULTS

Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug-disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug-disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death.

CONCLUSIONS

Suboptimal medication selection was fairly common and was associated with worse patient-reported health-related quality of life.

[Heparin-induced thrombocytopenia after elective hip joint replacement with postoperative prevention of thromboembolism with low-molecular-weight heparin]

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is a severe side effect of the prophylaxis of venous thromboembolism with unfractionated heparin. The aim of the present study is to gain more information on the incidence of HIT during prophylaxis of venous thromboembolism with low-molecular-weight heparin in elective hip surgery.

METHODS

586 consecutive patients were included into the prospective study, who were admitted to hospital for elective hip replacement. The incidence of thrombocytopenia, clinically manifest venous thromboembolism and of the heparin-induced IgG antibodies were analysed during prophylaxis with low molecular-weight heparin. Patients received once daily subcutaneously low molecular-weight heparin for a mean of 28 days postoperatively. Platelet counts and clinical examinations for the presence of venous thromboembolism were done at days 0, 2, 7 (+/- 1) and 12 (+/- 2). Heparin-induced IgG antibodies were determined before and after a 12 (+/- 2) days prophylaxis with low molecular-weight heparin in 265 of 586 patients randomly. Patients were reexamined for thromboembolic complications after 3 and 6 months. The clinical suspicion of thromboembolic complication was documented objectively.

RESULTS

None of the patients developed a decrease of platelets of < 50% of the initial value. Ten of 265 patients had elevated IgG antibodies against heparin/platelet factor 4 before prophylaxis (3.8%). After the 12 (+/- 2) days prophylaxis 13 of 265 patients had elevated IgG antibodies (4.9%). C14 serotonin assay was positive in 0 of 10 patients before treatment and in 3 of 19 patients at day 12 (+/- 2). Ten patients developed venous thromboembolism postoperatively (8 x deep venous thrombosis, 2 x pulmonary embolism, no fatal embolism). Only 1/19 patients with elevated antiheparin IgG titres developed venous thromboembolism. The C14 serotonin assay was negative in this patient. Two patients died in the postoperative phase due to underlying cardiovascular diseases.

CONCLUSIONS

In patients with elective hip replacement prophylaxis of venous thromboembolism with low molecular-weight heparin was associated with a very low incidence of HIT, and hence screening for HIT antibodies is not required.

Substance P- and 5-hydroxytryptamine-mediated depolarization in sympathetic ganglion neurons

By means of intracellular recordings from sympathetic ganglion in vitro, the present study was to investigate whether the receptors of substance P (SP) and 5-hydroxytryptamine (5-HT) exist in the same neuron or separately in different neurons of guinea pig celiac ganglion (CG) and inferior mesenteric ganglion (IMG) and whether there are some interactions between the two transmitters. Of the 133 neurons of CG, 66 (49.6%) responded to both SP and 5-HT, 40 (30.1%) only to SP or 5-HT, 27 (20.3%) insensitive to both. The corresponding numbers of the corresponding groups of neurons of the 129 IMG neurons are 47 (36.4%), 65 (50.4%) and 17 (13.2%). Continuous superfusion of IMG with 5-HT did not affect SP depolarization, while continuous superfusion of IMG with SP did not affect 5-HT depolarization. The results indicate that SP receptor and 5-HT receptor may exist in the same neuron, and neither affects each other.

Mixed germ cell tumor presenting as intratumoral hemorrhage: report of a case originated from the pineal region

A 17-year-old male patient was brought to our clinic because of sudden onset of headache, vomiting, followed by transient loss of consciousness during a strenuous exercise. Neurologic examinations revealed that the patient had severe sensorimotor and brain stem dysfunction. Examinations of cranial CT and MR imaging showed a huge heterogeneously enhanced tumor originated from the pineal region with tumoral hemorrhage. The tumor markers were found to be high in AFP but not the beta-HCG and CEA. A clinical diagnosis highly suggestive of germ cell tumor was made. Prior to the planned emergency radiation therapy, he received an external ventricular drainage (EVD) and open biopsy of the tumor. Due to a postoperative complication of cerebellar hemorrhage observed 8 hours later, another maneuver was therefore required to extirpate the pineal tumor and cerebellar hematoma. The histological diagnosis proved to be a mixed germ cell tumor with tumoral hemorrhage. Spontaneous intratumoral hemorrhage in germ cell tumor of the pineal region is rare, probably due to compromised venous circulation within the tumor. The bleeding propensity, which may contribute to the formation of cerebellar hematoma, warrants a special attention when a biopsy procedure is to be performed.

Immunologic response to recombinant hirudin in HIT type II patients during long-term treatment

We prospectively investigated 27 patients with heparin-induced thrombocytopenia (HIT) type II who were subsequently treated with r-hirudin. Patients with venous or arterial thromboembolism were treated with activated partial thromboplastin time (aPTT)-controlled intravenous r-hirudin (n = 19; mean 19.3 d) followed by subcutaneous r-hirudin (n = 6; mean 22.5 d) and oral anticoagulation. Patients without thromboembolism were treated with subcutaneous r-hirudin (n = 8; mean 25.9 d). Four patients were readmitted to subcutaneous r-hirudin for a mean duration of 32 d. The incidence of r-hirudin antibodies was 84% for intravenously treated patients and 50% in subcutaneously treated patients. The patients (n = 27) showed a 74% overall incidence of r-hirudin antibodies, mainly of the IgG-subclass, without seroconversion before day 6 and after day 32 of r-hirudin treatment or during r-hirudin treatment. None of the patients showed onset or recurrence of venous or arterial thromboembolism, systemic allergic reactions or IgE-antibody development. During intravenous and subcutaneous administration of r-hirudin the aPTT and the ecarin clotting time was increased in the antibody-positive patients compared to antibody-negative patients. Therefore we assume that r-hirudin antibodies may reduce r-hirudin metabolism.

Signalling by the RET receptor tyrosine kinase and its role in the development of the mammalian enteric nervous system

RET is a member of the receptor tyrosine kinase (RTK) superfamily, which can transduce signalling by glial cell line-derived neurotrophic factor (GDNF) and neurturin (NTN) in cultured cells. In order to determine whether in addition to being sufficient, RET is also necessary for signalling by these growth factors, we studied the response to GDNF and NTN of primary neuronal cultures (peripheral sensory and central dopaminergic neurons) derived from wild-type and RET-deficient mice. Our experiments show that absence of a functional RET receptor abrogates the biological responses of neuronal cells to both GDNF and NTN. Despite the established role of the RET signal transduction pathway in the development of the mammalian enteric nervous system (ENS), very little is known regarding its cellular mechanism(s) of action. Here, we have studied the effects of GDNF and NTN on cultures of neural crest (NC)-derived cells isolated from the gut of rat embryos. Our findings suggest that GDNF and NTN promote the survival of enteric neurons as well as the survival, proliferation and differentiation of multipotential ENS progenitors present in the gut of E12.5-13.5 rat embryos. However, the effects of these growth factors are stage-specific, since similar ENS cultures established from later stage embryos (E14. 5–15.5), show markedly diminished response to GDNF and NTN. To examine whether the in vitro effects of RET activation reflect the in vivo function(s) of this receptor, the extent of programmed cell death was examined in the gut of wild-type and RET-deficient mouse embryos by TUNEL histochemistry. Our experiments show that a subpopulation of enteric NC undergoes apoptotic cell death specifically in the foregut of embryos lacking the RET receptor. We suggest that normal function of the RET RTK is required in vivo during early stages of ENS histogenesis for the survival of undifferentiated enteric NC and their derivatives.

5-HT1P receptor-mediated slow depolarization in neurons of guinea pig inferior mesenteric ganglion

AIM

To study the effects of several 5-hydroxytryptamine (5-HT) receptor subtype antagonists on 5-HT-induced depolarization and the effects of 5-HT1P receptor agonist on the membrane potential in the neurons of guinea pig inferior mesenteric ganglion (IMG).

METHODS

Intracellular recordings were made from neurons of the isolated guinea pig IMG.

RESULTS

Cyproheptadine (5-HT1/2 antagonist 10 mumol.L-1, n = 7) and BRL 24924 (5-HT1P antagonist 10 mumol.L-1, n = 19) reversibly suppressed 5-HT slow response; pressure ejection of MCPP (5-HT1P agonist 10 mmol.L-1) induced a slow depolarization in most of 5-HT sensitive neurons (10/14).

CONCLUSION

5-HT-induced slow depolarization is mediated by 5-HT1P receptor.

Amoebiasis among institutionalized psychiatric patients in Taiwan

Although information on amoebiasis among institutionalized psychiatric patients is available, reports on the relationship between behaviour and this infection are not abundant. From July 1995 to June 1996, stool and blood samples were collected from 565 patients in three psychiatric hospitals of North Taiwan. Stool samples were examined using the direct smear and formalin-ethyl acetate sedimentation techniques as well as ProSpecT Entamoeba histolytica Microplate Assay kit. Blood samples were examined by the Amebiasis Serology Microwell ELISA kit. Among these patients, 14 (2.5%) harboured one or two species of intestinal parasites. There were 6 (1.1%) E. histolytica/E. dispar cyst passers: 5 positive in stool ELISA test and 2 with antibodies against E. histolytica. Among demographic factors, type of psychiatric disorder and disability, only a significant sexual difference in seropositivity of E. histolytica was observed. These findings indicate that the infected patients acquired the infections before they entered the hospitals.

Intersections between blood cell development and leukemia genes

Hematopoietic development is regulated in large part by transcription factors that control cell fate decisions and cellular differentiation. Several genes first discovered in the context of chromosomal translocations in leukemia also serve important functions in blood cell development. Gene-targeting experiments related to two of these factors, SCL/tal-1 and translocation-ets-leukemia (TEL), are reviewed here. SCL/tal-1, a T-cell basic helix-loop-helix oncoprotein, is required for the formation of all hematopoietic lineages. In addition, it is essential for angiogenesis in the yolk sac, indicating a dual function in blood and vessel development. TEL, an ets-related factor which is translocated to a variety of other genes in leukemias, is also required for proper angiogenesis in the yolk sac. Additional studies, however, demonstrate that TEL function is necessary for hematopoiesis to be established in the bone marrow microenvironment. These studies emphasize the intrinsic roles of leukemia-associated transcription factors in normal blood cell and vessel development.

Determination of heparin-induced IgG antibody in heparin-induced thrombocytopenia type II

BACKGROUND

Heparin-induced thrombocytopenia is a relatively uncommon but severe side-effect of heparin therapy. Heparin-induced IgG antibody has been elucidated to be the main isotype and the most pathogenic antibody in the pathophysiology. As affected patients are at high risk of developing thrombotic events, confirmation of the clinical diagnosis and avoidance of heparin re-exposure are important and desirable.

MATERIALS AND METHODS

In the present study, heparin-induced IgG was measured by the binding of neoantigens, which were prepared by incubating FITC-heparin with platelet factor 4 present in normal serum. The cross-reactivities of heparin-induced IgG with low-molecular-weight heparin and danaparoid were analysed by competitive binding.

RESULTS

A total of 81 clinically suspected heparin-induced thrombocytopenia type II patients were analysed. Thirty-seven of 38 heparin-induced thrombocytopenia type II patients, in whom thromboembolism was confirmed by objective methods, had elevated relative fluorescence intensity ratios (patient normal control) and 36 had positive heparin-induced platelet activation results. The prevalence of heparin-induced IgG in heparin-induced thrombocytopenia type II patients was 97.4%. Positive heparin-induced IgG results were: 0/319 healthy volunteers, 0/38 other thrombo-cytopenia and 2/56 heparin/low-molecular-weight heparin-receiving patients without thrombocytopenia, 2/41 hyperbilirubinaemic patients and 2/50 hyperlipidaemic patients. A small amount of cross-reaction assays showed similar results as obtained in heparin-induced platelet activation.

CONCLUSION

Our results suggest that a very high frequency of heparin-induced IgG in heparin-induced thrombocytopenia type II patients can be detected using a novel antigen assay. The rapid determination of pathogenic heparin-induced IgG may be a useful tool for the rapid diagnosis of heparin-induced thrombocytopenia type II that could facilitate further management of the patients.

Which form of dopamine is the substrate for the human dopamine transporter: the cationic or the uncharged species?

The question of which is the active form of dopamine for the neuronal dopamine transporter is addressed in HEK-293 cells expressing the human dopamine transporter. The Km value for [3H]dopamine uptake fell sharply when the pH was increased from 6.0 to 7.4 and then changed less between pH 7.4 and 8.2. The KI for dopamine in inhibiting the cocaine analog [3H]2beta-carbomethoxy-3beta-(4-fluorophenyl)tropane binding displayed an identical pH dependence, suggesting that changes in uptake result from changes in dopamine recognition. Dopamine can exist in the anionic, neutral, cationic, or zwitterionic form, and the contribution of each form was calculated. The contribution of the anion is extremely low (</=0.1%), and its pH dependence differs radically from that of dopamine binding. The increase in the neutral form upon raising the pH can model the results only when the pKa1 (equilibrium neutral-charged) is set to a much lower value (6.8) than reported for dopamine in solution (8.86). The sum of cationic and zwitterionic dopamine concentrations remained constant over the entire pH range studied. These forms are the likely transporter substrates with pH-dependent changes occurring in their interaction with the transporter. The binding of dopamine, a hydroxylated phenylethylamine derivative, displays the same pH dependence as guanethidine, a heptamethyleniminoethyl- guanidine derivative fully protonated under our conditions. An ionizable residue in the transporter could be involved that does not interact with or impact the binding of bretylium, a quaternary ammonium phenylmethylamine derivative that is always positively charged and shows only a minor reduction in KI upon increasing pH.

Improvements in the infectivity of cryopreserved third-stage larvae of Angiostrongylus cantonensis using a programmable freezer

Although there have been some advances in the cryopreservation of Angiostrongylus cantonensis, the degrees of viability and infectivity of the cryopreserved developmental stages have not been high. A two-step freezing protocol using a programmable freezer was determined to be effective in improving the infectivity of the cryopreserved third-stage larvae of this parasite. After washing steps and suspension in 10% (v/v) dimethylsulfoxide and equilibrium at room temperature the larvae were placed into the freezer. The temperature was lowered first at 0.8 degrees C/min from room temperature to -40 degrees C and then at 10 degrees C/min to -70 degrees C. The samples were plunged into liquid nitrogen. After storage in liquid nitrogen for 7-15 days the larvae were thawed rapidly in 37 degrees C water and 27.6% were found to show vigorous "S-shape" movement without significant changes in appearance. These larvae (50/rodent) could develop to the fifth stage in mice (42.6%) and establish patent infection in rats (40.4%). Moreover, there was no significant difference in the recovery rates of cryopreserved worms and their unfrozen counterparts. These findings indicate that steady precooling conditions may decrease damage with regard to the infectivity of cryptopreserved third-stage larvae of A. cantonensis.

Singlet oxygen is the major species participating in the induction of DNA strand breakage and 8-hydroxydeoxyguanosine adduct by lead acetate

To investigate DNA damage induced by Pb2+ and its prevention by scavengers, we determined DNA strand breakage and the formation of 8-hydroxydeoxyguanosine (8-OHdG) in DNA using plasmid relaxation assay and HPLC with electrochemical detection, respectively. Lead acetate induced DNA strand breakage in 10 mM of Hepes buffer, pH 6.8, in a time- and dose-dependent manner. Compared with lead, zinc acetate did not significantly induce DNA breakage. The singlet oxygen scavengers NaN3 and 2,2,6,6-tetramethyl-4-piperidone (TEMP) inhibited lead-induced DNA breakage more efficiently than the hydroxyl radical scavengers mannitol and DMPO. Deuterium oxide (D2O), a singlet oxygen enhancer, potentiated lead-induced DNA breakage. At low ratios to Pb2+, NADPH, glutathione, and 2-mercaptoethanol enhanced lead-induced DNA breakage, whereas high ratios of these agents protected it. Catalase and superoxide dismutase (SOD) did not protect DNA breaks induced by Pb2+. Lead-induced DNA breakage was markedly enhanced by H2O2, and this induction was inhibited by NaN3, TEMP, EDTA, catalase, BSA, and glutathione. In contrast, mannitol and SOD potentiated Pb2+/H2O2-induced DNA breaks. The results indicate that singlet oxygen, lead, and H2O2 are all involved in the reaction system, whereas hydroxyl radical and superoxide did not. Lead could cause a small amount of 8-OHdG formation in calf thymus DNA and dose-dependently induced the formation of this adduct in the presence of H2O2. Singlet oxygen scavengers were more effective than hydroxyl radical scavengers in protection from lead/H2O2-induced 8-OHdG adducts. Taken together, these results suggest that lead may induce DNA damage through a Fenton-like reaction and that singlet oxygen is the principal species involved.

Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery

OBJECTIVE

To determine the prognostic factors of the functional outcome of patients surgically treated for acute epidural hematomas.

METHODS

Two hundred patients who consecutively underwent neurosurgery for acute epidural hematomas over the past 9-year period were studied. Clinical characteristics, radiologic findings, and the time intervals with regard to treatment course were investigated to determine the interactions between all these factors and functional outcome.

RESULTS

Functional outcome showed a significant correlation with preoperative consciousness state, Glasgow Coma Scale score, pupillary sizes, and motor posturing (chi2 test, p < 0.05). Functional outcome correlated with the period of brain herniation, the length of time of the operation, as well as the period of hospitalization (chi2 test, p < 0.05), but not with the length of time of craniotomy decompression relative to the length of time from the injury until admission. The radiologic findings of the associated brain injury, the size and the density of the clot, the degree of the brain shift, and the obliteration of the basal cisterns significantly correlated with functional outcome (chi2 test, p < 0.05), whereas no significance was attributable to skull fracture. Multivariate analysis indicated that the following four factors independently correlated with functional outcome: (1) associated brain injury, (2) best motor response, (3) hematoma volume, and (4) period of hospitalization (chi2 test, p < 0.05). A combination of the four factors led to the prediction of the functional outcome with 91% accuracy (1.5 % falsely pessimistic predictions and 7.5 % falsely optimistic prediction) and 82.1% at over 90% confidence level. These four parameters correlated significantly with preoperative neurologic deterioration (chi2 test, p < 0.05).

CONCLUSION

This study identifies the risk factors involved in the functional outcome of patients who underwent surgical treatment for acute epidural hematomas. Our results indicate that associated brain injury plus best motor response are the optimal set of two prognostic indicants, with 87% correct predictions and 70.1% at over a 90% confidence level. Prevention of in-hospital neurologic deterioration would improve the patients' functional outcome with a resultant unfavorable recovery rate ranging from 11.5% to 17%.

Orbital rhinocerebral mucormycosis associated with diabetic ketoacidosis: report of survival of a 10-year-old boy

Cerebral mucormycosis is a rare fungal infection that occurs mostly in association with diabetic ketoacidosis. This central nervous system infection is characterized by a rapid decline in clinical status, and has been recognized as a uniformly fatal event if aggressive therapy is not instituted. We report a diabetic child who presented with blurred vision, chemosis, and pain in the left periorbital region noted for about 1 week during an episode of ketocidosis. Neurologic examinations revealed that there was a decreased range of motion in the upward and lateral gaze, along with incomplete pupillary dilatation and papilledema of the left eye. Imaging studies demonstrated left-side orbital cellulitis, paranasal sinusitis, and a large lobulated abscess in the left frontal lobe. Two surgical procedures, including functional endoscopic sinus surgery for sinus debridement and a subsequent open craniotomy for abscess resection were performed. Pathologic specimens obtained from the abscess wall revealed necrotic inflammation and wide, nonseptate hyphae with right angle branching, which are typical characteristics of the family Mucoraceae. Postoperatively, the patient was treated with 1.5 g of amphotericin B over a 7-week period, and aggressive diabetic control for 2 months. Through the combination of medical and surgical treatment the child made an uneventful recovery.

The TEL/ETV6 gene is required specifically for hematopoiesis in the bone marrow

The TEL (translocation-Ets-leukemia or ETV6) locus, which encodes an Ets family transcription factor, is frequently rearranged in human leukemias of myeloid or lymphoid origins. By gene targeting in mice, we previously showed that TEL-/- mice are embryonic lethal because of a yolk sac angiogenic defect. TEL also appears essential for the survival of selected neural and mesenchymal populations within the embryo proper. Here, we have generated mouse chimeras with TEL-/- ES cells to examine a possible requirement in adult hematopoiesis. Although not required for the intrinsic proliferation and/or differentiation of adult-type hematopoietic lineages in the yolk sac and fetal liver, TEL function is essential for the establishment of hematopoiesis of all lineages in the bone marrow. This defect is manifest within the first week of postnatal life. Our data pinpoint a critical role for TEL in the normal transition of hematopoietic activity from fetal liver to bone marrow. This might reflect an inability of TEL-/- hematopoietic stem cells or progenitors to migrate or home to the bone marrow or, more likely, the failure of these cells to respond appropriately and/or survive within the bone marrow microenvironment. These data establish TEL as the first transcription factor required specifically for hematopoiesis within the bone marrow, as opposed to other sites of hematopoietic activity during development.

Neurturin exerts potent actions on survival and function of midbrain dopaminergic neurons

Glial cell line-derived neurotrophic factor (GDNF) exhibits potent effects on survival and function of midbrain dopaminergic (DA) neurons in a variety of models. Although other growth factors expressed in the vicinity of developing DA neurons have been reported to support survival of DA neurons in vitro, to date none of these factors duplicate the potent and selective actions of GDNF in vivo. We report here that neurturin (NTN), a homolog of GDNF, is expressed in the nigrostriatal system, and that NTN exerts potent effects on survival and function of midbrain DA neurons. Our findings indicate that NTN mRNA is sequentially expressed in the ventral midbrain and striatum during development and that NTN exhibits survival-promoting actions on both developing and mature DA neurons. In vitro, NTN supports survival of embryonic DA neurons, and in vivo, direct injection of NTN into the substantia nigra protects mature DA neurons from cell death induced by 6-OHDA. Furthermore, administration of NTN into the striatum of intact adult animals induces behavioral and biochemical changes associated with functional upregulation of nigral DA neurons. The similarity in potency and efficacy of NTN and GDNF on DA neurons in several paradigms stands in contrast to the differential distribution of the receptor components GDNF Family Receptor alpha1 (GFRalpha1) and GFRalpha2 within the ventral mesencephalon. These results suggest that NTN is an endogenous trophic factor for midbrain DA neurons and point to the possibility that GDNF and NTN may exert redundant trophic influences on nigral DA neurons acting via a receptor complex that includes GFRalpha1.

GFRalpha1 is an essential receptor component for GDNF in the developing nervous system and kidney

Glial cell line-derived neurotrophic factor (GDNF) is a distant member of the TGFbeta protein family that is essential for neuronal survival and renal morphogenesis. We show that mice who are deficient in the glycosyl-phosphatidyl inositol (GPI) -linked protein GFRalpha1 (GDNFRalpha) display deficits in the kidneys, the enteric nervous system, and spinal motor and sensory neurons that are strikingly similar to those of the GDNF- and Ret-deficient mice. GFRalpha1-deficient dopaminergic and nodose sensory ganglia neurons no longer respond to GDNF or to the structurally related protein neurturin (NTN) but can be rescued when exposed to GDNF or neurturin in the presence of soluble GFRalpha1. In contrast, GFRalpha1-deficient submandibular parasympathetic neurons retain normal response to these two factors. Taken together with the available genetic and biochemical data, these findings support the idea that GFRalpha1 and the transmembrane tyrosine kinase Ret are both necessary receptor components for GDNF in the developing kidney and nervous system, and that GDNF and neurturin can mediate some of their activities through a second receptor.

Improvement in the identification of intestinal parasites by a concentrated merthiolate-iodine-formaldehyde technique

To increase the sensitivity of the merthiolate-iodine formaldehyde (MIF) technique in detecting various stages of intestinal parasites in stool specimens, a concentration step was added before preserving the stool specimen with MIF solution. This step involved mixing the stool specimen in 10% formalin, filtering the mixture through a double-layered cotton filter, and removing most of the liquid content. This modification was evaluated in a large screening program. Its positive identification of 10 helminths and 2 protozoa was comparable to formalin-ethyl acetate (FEA) sedimentation and hookworm eggs were readily recognizable. Although the modified MIF technique requires an overnight drying procedure, only a few simple procedures are involved in the concentrating step. This technique is relatively simple and suitable for large-scale screening programs or epidemiologic studies.