Caring for the patient with Paget's disease of the bone

Approximately 1 to 3 million Americans suffer from Paget's disease of the bone. This chronic disease often results in pain, deformity, and mobility impairments, and can dramatically impair a patient's quality of life. The primary care provider plays a pivotal role in diagnosing and managing the patient with Paget's disease. This article discusses Paget's disease diagnosis, management, pharmacologic therapy, referral, and follow-up.

Are genetic factors important in the aetiology of leukoaraiosis? Results from a memory clinic population

OBJECTIVE

To discover whether polymorphism in either the apolipoprotein E (ApoE) or angiotensin-converting enzyme (ACE) genes is associated with leukoaraiosis, white matter lesions visible on neuroimaging of the brain, which is commonly seen in dementia as well as some normal elderly subjects.

DESIGN

Prospective study of consecutive patients attending our memory disorders clinic, to examine the relationship between leukoaraiosis and polymorphism of the ApoE and ACE genes.

SETTING

Memory disorders clinic in Bristol, UK.

PATIENTS

182 patients attending the memory disorders clinic for investigation of possible dementia of whom 75% were suffering from dementia, 20% from memory impairment but no dementia and in 5% of whom a dementing illness was thought to be unlikely; 38% of all patients had visible white matter lesions and 16% had cerebral infarcts.

MEASURES

Patients and/or carers who agreed to participate in the study had their ACE and ApoE genotype determined and their brain CT/MRI scans were assessed by a neuroradiologist, blind to the result of the genotyping, for the presence or absence of white matter low attenuation.

RESULTS

There was a significant association between white matter lesions and the DD genotype (p < 0.05), but not the ApoE genotype. However, this relationship with the DD genotype was only significant for patients with a previous infarct.

CONCLUSION

Homozygosity of ACE gene deletion polymorphism is a risk factor for white matter lesions when it is associated with cerebral infarction. This suggests that it may be possible to identify subjects who are at greater risk of developing white matter lesions and are at risk of cognitive impairment and possibly dementia.

The hospitalist: will inpatient specialists improve care?

The number of hospitalists--i.e., practitioners who specialize in the care of hospital inpatients--is growing rapidly in the United States. In part a response to managed care's push for better health outcomes with a minimum waste of time, effort, and money, this new specialty has its own national organization, affiliated with the American College of Physicians. Challenges to hospitalists include minimizing the use of consultations and unnecessary laboratory tests for inpatient care, and ensuring continuity of care once patients leave the hospital.

Mapping of a minimal AU-rich sequence required for lipopolysaccharide-induced binding of a 55-kDa protein on tumor necrosis factor-alpha mRNA

In monocyte/macrophage cells, the translation of tumor necrosis factor-alpha (TNF-alpha) mRNA is tightly controlled. In unstimulated cells, TNF-alpha mRNA is translationally repressed. However, upon stimulation of the cells with various agents (e.g. lipopolysaccharides (LPS) and viruses), this repression is overcome and translation occurs. The key element in this regulation is the AU-rich sequence present in the 3'-untranslated region of TNF-alpha mRNA. Several groups have described the binding of proteins on AU-rich elements (AREs). We have previously reported the binding of two cytosolic protein complexes (1 and 2) to the TNF-alpha mRNA ARE, one of which (complex 2) is observed only following induction of TNF-alpha production by LPS. In this report, we have demonstrated that complex 1 involves a long fragment of the ARE, whereas the formation of the LPS-inducible complex 2 requires a minimal sequence which corresponds to the nonanucleotide UUAUUUAUU. Furthermore, we show that the RNA-binding protein involved in complex 2 has an apparent molecular mass of 55 kDa. Finally, we tested other AREs for their ability to form complex 2. We observed that the ARE derived from granulocyte/macrophage colony-stimulating factor mRNA, which does contain the nonanucleotide, is able to sustain the LPS-induced binding of the 55-kDa protein. However, c-myc mRNA, which does not contain the nonanucleotide, is unable to promote the formation of any LPS-induced complex.

Cross-cascade activation of ERKs and ternary complex factors by Rho family proteins

Mitogens promote cell growth through integrated signal transduction networks that alter cellular metabolism, gene expression and cytoskeletal organization. Many such signals are propagated through activation of MAP kinase cascades partly regulated by upstream small GTP-binding proteins. Interactions among cascades are suspected but not defined. Here we show that Rho family small G proteins such as Rac1 and Cdc42hs, which activate the JNK/SAPK pathway, cooperate with Raf-1 to activate the ERK pathway. This causes activation of ternary complex factors (TCFs), which regulate c-fos gene expression through the serum response element. Examination of ERK pathway kinases shows that neither MEK1 nor Ras will synergize with Rho-type proteins, and that only MEK1 is fully activated, indicating that MEKs are a focal point for cross-cascade regulation. Rho family proteins utilize PAKs for this effect, as expression of an active PAK1 mutant can substitute for Rho family small G proteins, and expression of an interfering PAK1 mutant blocks Rho-type protein stimulation of ERKs. PAK1 phosphorylates MEK1 on Ser298, a site important for binding of Raf-1 to MEK1 in vivo. Expression of interfering PAK1 also reduces stimulation of TCF function by serum growth factors, while expression of active PAK1 enhances EGF-stimulated MEK1 activity. This demonstrates interaction among MAP kinase pathway elements not previously recognized and suggests an explanation for the cooperative effect of Raf-1 and Rho family proteins on cellular transformation.

Eosinophilia-myalgia syndrome: selective cognitive impairment, longitudinal effects, and neuroimaging findings

OBJECTIVE

To identify the specific nature of the neurocognitive impairments of eosinophilia-myalgia syndrome (EMS) in an unselected population, and to present longitudinal patterns.

METHODS

A consecutive sample of 23 patients with EMS and 18 age and education matched control subjects were assessed on a comprehensive neuropsychological battery. Longitudinal results were gathered from six patients.

RESULTS

Neurocognitive impairments were found which represent a subset of deficits reported in previous group and case study reports. Deficits were limited to complex visual memory, conceptual set shifting, and attention, which suggest a selective dysexecutive syndrome. The motor slowing and verbal memory deficits previously reported were not found. Although depression, fatigue, sleep deprivation, and pain were significant symptoms, they were unassociated with deficits with the exception of an association of depression with one deficit. There was no pattern of overall decline over time in a subset of the group, although considerable heterogeneity in the longitudinal patterns of neurocognitive tests was found. Abnormalities of white matter appeared in the MRI of eight of 12 patients.

CONCLUSIONS

The neurocognitive and neuroimaging findings contribute to the evidence which indicates that the neural substrate of EMS is white matter damage.

The presence of leuko-araiosis in patients with Alzheimer's disease predicts poor tolerance to tacrine, but does not discriminate responders from non-responders

BACKGROUND

approximately one-third of patients with Alzheimer's disease (AD) respond favourably to the anticholinesterase tacrine, but the drug's usefulness is marred by a high incidence of side-effects.

OBJECTIVE

to discover if AD patients with white matter low attenuation (WMLA) represents a subgroup that responds differently to tacrine from those with no WMLA.

DESIGN

the results come from a combination of double-blind and open studies. Seventy-two AD patients prescribed tacrine in our centre were divided into two groups according to the presence or absence of WMLA on brain CT scans. We compared the rate of response to and withdrawal from tacrine between the groups. Response was defined as an improvement in the Mini-Mental State Examination score of three or more points at 3 months.

RESULTS

18 of the 72 patients were found to have WMLA. There was no significant difference in the proportion of patients responding to tacrine in each group (28.5% in those with WMLA and 31% in those without), but the rate of withdrawal from tacrine did differ: 11 patients with WMLA (61%) had to be withdrawn prematurely, compared with 14 patients (26%) in the group without evidence of WMLA (P = 0.015).

CONCLUSION

AD patients with WMLA can still respond to tacrine, although the rate of withdrawal from treatment is much higher in such patients.

Do agoraphobics interpret the environment in large shops and supermarkets differently?

Agoraphobics typically have difficulties in visiting supermarkets. The brief report presents results of a survey investigating the properties of supermarkets which provoke or ease anxiety-related responses in shoppers (N = 500) and two further groups: agoraphobics (N = 40) and participants responding to a local press advert (N = 54). Results showed that layout features, stairways and diminished access were rated as more anxiety provoking in the agoraphobic-type groups compared to general shoppers. The safety-signal model of agoraphobic behaviour was supported although some evidence of dysfunction of spatial orientation was found.

Field intubation of trauma patients: complications, indications, and outcomes

Neither the success nor the complication rate for field intubation of trauma patients is known with any certainty. A retrospective audit of 94 severely injured patients who required field intubation was undertaken. Fifty percent (13 of 26) of survivors and 67% (37 of 71) of nonsurvivors were successfully intubated in the field (not significant). Mechanism of injury was similar in both groups, but survivors were younger (27 v 60 years, P= .049) and less critically injured, as reflected by their Injury Severity Scale scores, their Trauma Scores, and their field Glasgow Coma Scale scores (22.1 v 30.8, P = .0035; 7.7 v 4.2, P < .0002; and 6.3 v 3.3, P < .0001). When compared with previously published studies of medical patients with cardiac arrest, the success rate was lower in our trauma patients. When compared with patients having similar injuries intubated at the trauma center, field intubation was three times more likely to be associated with the development of nosocomial pneumonia than was hospital intubation.

The effect of white matter low attenuation on cognitive performance in dementia of the Alzheimer type

The effect of leukoaraiosis or white matter low attenuation (WMLA) on cognitive function is not fully understood. We compared the neuropsychological performance of 37 Alzheimer's disease patients with WMLA on CT brain scans with a similar group of 31 Alzheimer's disease patients with no evidence of white matter lesions. Patients with WMLA performed significantly worse on tests of visuospatial function (Cube Analysis test, p = 0.004), and cognitive speed (Kenrick Digit Copying test, p = 0.05) compared to those with no visible white matter lesions. Patients with widespread WMLA performed generally worse in tests of cognitive function than those with frontal or a mixture of frontal and occipital WMLA. This was most significant in the areas of attention (forward digit span, p = 0.003), visual recognition (p = 0.004), and cognitive speed (p = 0.03). There is an association between impaired cognitive performance and the presence of WMLA in Alzheimer's disease patients, with WMLA probably contributing to the cognitive impairment. This is most evident in patients with widespread white matter lesions.

Bromocriptine in the treatment of post-polio fatigue: a pilot study with implications for the pathophysiology of fatigue

Fatigue is the most commonly reported and most disabling of all post-polio sequelae (PPS). Bromocriptine mesylate (Parlodel) was employed in a placebo-controlled trial in five survivors of paralytic polio who continued to report moderate to severe daily fatigue after complying with the conservative treatments prescribed for PPS. Placebo was given for 4 wk followed by increasing doses of bromocriptine mesylate, administered at 12:00 pm for 28 days, which reached a total dose of 12.5 mg/day. Three subjects reported marked symptom improvement on bromocriptine but not on placebo. Their reported difficulty with attention, concentration, word finding, mind wandering, memory, thinking clearly, and fatigue on awakening was significantly negatively correlated with days on bromocriptine but not with days on placebo. Before the drug trial began, responders had clinically impaired performance on neuropsychologic tests of attention and information processing speed, more than twice as many hyperintensities on magnetic resonance imaging of the brain, abnormally low fasting adrenocorticotropic hormone levels, and nearly double the mean plasma prolactin level compared with nonresponders. The implications of these findings for the pathophysiology of fatigue are discussed. A double-blind, placebo-controlled, multicenter study will be needed to confirm bromocriptine's efficacy in treating attentionally and neurophysiologically impaired polio survivors whose severe and disabling fatigue does not respond to conservative therapies.

Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome

To assess the efficacy of emergency thoracotomy performed for thoracic trauma in the accident and emergency department, a retrospective analysis of patients who underwent this procedure and were brought to hospital by the Helicopter Emergency Medical Service was carried out. Between 1991 and 1994, 16 patients had emergency thoracotomy performed in the accident department. Twelve patients had sustained blunt trauma and four patients had sustained penetrating injuries. Three patients first assessed at the scene and 11 patients on arrival at the emergency department had Glasgow Coma Scores < 3. Eight thoracotomies were performed by the cardiothoracic team and eight by the trauma team. There was one survivor in this group; he had been stabbed at multiple sites and emergency thoracotomy was required to control bleeding from an intercostal vessel. Our results demonstrate experience of one of the first phase Level One trauma centres in the United Kingdom. From our small series, we believe that selection criteria for emergency thoracotomy in trauma patients need to be revised. From this series and a review of the literature, patients with penetrating injuries, vital signs at the scene and those with a high index of suspicion for tamponade seem to benefit most from thoracotomy in the emergency setting.

Preliminary synthetic studies of methyllycaconitine, a potent nicotinic acetylcholine receptor antagonist: rapid syntheses of AE-bicyclic analogues

A series of bicyclic analogues incorporating the homocholine motif of methyllycaconitine has been prepared to test the hypothesis that this is the essential pharmacophore of this potent, selective nicotinic receptor antagonist. A double Mannich reaction has been employed to construct the 3-azabicyclo[3.3.1]-nonane ring system, containing an N-ethylpiperidine moiety. The neopentyl-like alcohol was then esterified, using isatoic anhydride under basic conditions, to afford the corresponding anthranilate.

Affect, attachment, memory: contributions toward psychobiologic integration

Recent decades have seen a marked expansion in knowledge regarding human neurophysiology, and psychiatry is currently challenged with the task of integrating this information with a psychodynamic understanding of emotional life. In this paper we review portions of the relevant literature regarding the basic brain functions of affect, memory, and attachment, and we consider the implications of these data for integrated psychobiologic conceptualizations of emotional dysfunction and its treatment. In particular, data from these three areas of study point to the possibility that implicit memory of the early attachment relationship, communicated via the language of affect, is an enduring neural structure that influences both emotional self-regulation and behavior related to relatedness. Finally, we consider the implications of this proposition for the nature of psychotherapy, which from a psychobiologic view might be profitably conceptualized as a directed attachment relationship whose purpose is the revision of the implicit emotional memory of attachment.

Passive immunization of Ebola virus-infected cynomolgus monkeys with immunoglobulin from hyperimmune horses

A commercially available immunoglobulin G (IgG) from horses, hyperimmunized to Ebola virus, was evaluated for its ability to protect cynomolgus monkeys against disease following i.m. inoculation with 1 000 PFU Ebola virus (Zaire '95 strain). Six monkeys were treated immediately after infection by i.m. infection of 6.0 ml IgG; these animals developed passive ELISA titers of 1:160 to 1:320 to Ebola, two days afer inoculation. However, the beneficial effects of IgG treatment were limited to a delay in onset of viremia and clinical signs, in comparison with untreated controls. The six IgG recipients had no detectable viremia day 5, in contrast with three virus infected controls whose viremias exceeded 7.0 log10 PFU/ml that day. The controls died on days 6, 6, and 7, while two IgG recipients died day 7 and the remaining 4 died day 8, all with high viremias. These results document that passively acquired antibody can have a beneficial effect in reducing the viral burden in Ebola-infected primates; however, effective treatment of human patients may require antibodies with higher specific activities and more favorable pharmacokinetic properties than the presently available equine IgG.

Hereditary spinal osteochondromas in diaphyseal aclasia

We present cases of cervical cord compression in father and son with diaphyseal aclasia. Both patients were investigated with plain radiography, CT and MRI. We believe this to be the first report of spinal cord compression in first-degree relatives with diaphyseal aclasia.

Prolapse of an aortic dissection flap imaged by transoesophageal echocardiography

Images

Event-related potentials--neurophysiological tools for predicting emergence and early outcome from traumatic coma

OBJECTIVE

To determine the prognostic value of multimodal evoked potentials (EPs) and event-related (ERPs) potentials in coma (Glasgow Coma Score <8), after severe traumatic brain injury (TBI).

DESIGN

Prospective, longitudinal study of neurophysiological responses recorded during traumatic coma.

SETTING

Intensive Care Unit, Frenchay Hospital, Bristol, UK.

PARTICIPANTS

Fifty-four comatose TBI patients (age range 1-80 years, mean 36.4).

METHODS

Neurophysiological responses were recorded from 11 scalp electrodes with earlobe reference. Conduction times were measured for brainstem auditory, flash visual and somatosensory, short-latency EPs. Peak latencies and amplitudes were determined for long-latency components of visual and auditory ERPs, generated by passive "oddball" paradigms. These neurophysiological and various clinical parameters were correlated with patient outcome using Pearson's coefficient.

MAIN OUTCOME MEASURE

Three month Glasgow Outcome Scale (GOS).

RESULTS AND CONCLUSION

Highly significant (P <0.001) correlations exist between long-latency ERP components and 3-month outcome. Short-latency EPs, brainstem (wave I-V) and somatosensory conduction times also correlate significantly with the GOS (P <0.01). Of the clinical measurements, pupillary response patterns, APACHE II and Glasgow Coma Scores (GCS) correlate significantly with outcome, as do the retrospective measures of duration of coma and post-traumatic amnesia (PTA) in survivors. Unfortunately, due to variance of long-latency responses, even in controls, absolute values cannot be relied upon as prognosticators. The presence of "mismatch negativity" predicted the return of consciousness (89.7% sensitivity and 100% specificity) and preceded changes in GCS. Its latency was the single best indicator of 90-day outcome from coma (r = -0.641).

An HPLC assay for the norditerpenoid alkaloid methyllycaconitine, a potent nicotinic acetylcholine receptor antagonist

The extremely potent and selective nicotinic acetylcholine receptor antagonist methyllycaconitine, MLA, and related norditerpene alkaloids are finding increasing use as neurochemical probes and as targets for structure-activity relationship studies. In this work, an assay procedure for MLA which utilises ion suppression reverse-phase HPLC with UV absorbance detection at 270 nm is described. The method detected 280 ng MLA on column.

The relationship between white matter low attenuation on brain CT and vascular risk factors: a memory clinic study

In order to discover the prevalence of white matter low attenuation (WMLA) in the brain and its relationship to vascular risk factors in our Memory Disorders Clinic patients we assessed brain CT scans of 202 patients referred to our clinic between January 1991 and December 1992. One hundred patients (49.5%) had WMLA, and the prevalence increased with increasing severity of cognitive impairment. It was 12% in patients with no evidence of dementia, 32% in those with isolated memory loss, and 59%) in patients with possible or probable dementia. There was a correlation between WMLA and systolic blood pressure, heart disease, peripheral vascular disease, focal neurological signs on examination and central atrophy on CT. No correlation was found between WMLA and low blood pressure, blood glucose or cholesterol level. Our findings indicate that WMLA probably plays an important role in cognitive impairment, and that thromboembolic rather than haemodynamic factors are probably more important in its pathogenesis.

XCL100, an inducible nuclear MAP kinase phosphatase from Xenopus laevis: its role in MAP kinase inactivation in differentiated cells and its expression during early development

We have cloned the Xenopus laevis homologue (XCL100) of the human CL100 (Thr/Tyr) MAP kinase phosphatase. Expression of the XCL100 mRNA and protein is inducible by serum stimulation and oxidative/heat stress in a X. laevis kidney cell line. In contrast, XCL100 is constitutively expressed in growing Xenopus oocytes. Recombinant XCL100 protein is able to dephosphorylate both tyrosine and threonine residues of activated p42 MAP kinase in vitro and both the Xenopus and human CL100 proteins were localised predominantly in the nucleus in transfected COS-1 cells. As nuclear translocation of activated MAP kinase is necessary for some of its essential functions in proliferation and cell differentiation our results indicate a role for CL100 in the regulation of these nuclear signalling events. In Xenopus kidney cells both heat shock and serum stimulation lead to transient activation of MAP kinase. However, in contrast to results previously reported from studies on mammalian fibroblasts the inactivation of MAP kinase in these epitheloid cells is rapid and is not dependent on synthesis of new protein. These results indicate that the induction of CL100 (or CL100-like enzymes) may not be required for MAP kinase inactivation in all cell types. Finally, during early embryogenesis, levels of XCL100 mRNA are greatly increased at the mid-blastula transition, suggesting that this enzyme may be involved in the regulation of MAP kinase activity during early development.