Magnetic resonance imaging and dynamic CT scan in cervical artery dissections

BACKGROUND AND PURPOSE

The typical magnetic resonance imaging picture of arterial dissection, namely, a narrowed eccentric signal void surrounded by a semilunar signal hyper-intensity (corresponding to the mural hematoma) on T1- and T2-weighted images, has been repeatedly reported, but the sensitivity of magnetic resonance imaging for the diagnosis of cervical dissection is poorly known. Another technique, dynamic computed tomography, may provide evidence of mural hematoma, but there has been no systematic evaluation of this technique. The aims of this study were to assess both the sensitivity of routine 0.5-T magnetic resonance imaging for the detection of a typical picture of cervical artery dissection and the value of dynamic computed tomographic scans to provide evidence of dissecting hematoma.

METHODS

Fifteen consecutive patients with angiographically confirmed extracranial internal carotid (n = 9) or vertebral (n = 10) dissections were studied using a standardized 0.5-T spin-echo magnetic resonance imaging protocol with axial slices. Twelve of these patients had dynamic computed tomographic scans at the site of the dissection suggested by angiography.

RESULTS

A typical magnetic resonance imaging picture of cervical artery dissection was observed in 12 of 15 (80%) patients and in 13 of 19 (68%) dissected vessels. The sensitivity of magnetic resonance imaging was higher in internal carotid (78%) than in vertebral (60%) dissections and in stenotic-type dissections (85%) than in occlusive or aneurysmal-type dissections. The dynamic computed tomographic scan showed the mural hematoma in 11 of the 12 (92%) patients and in 12 of 15 (80%) dissected vessels.

CONCLUSIONS

Routine 0.5-T magnetic resonance imaging with axial slices is a sensitive technique for the diagnosis of dissection, but in about 20% of patients with cervical artery dissection magnetic resonance imaging will demonstrate no typical abnormality. Dynamic computed tomographic scans are a sensitive neuroimaging procedure to confirm the presence of the mural hematoma, but it needs to be directed by prior angiography.

Cytokine gene transcription in renal cell carcinoma

Cytokines are powerful modulators of immune responses, the local production of which could be relevant to the interaction between tumour and immune system. This study investigated the transcription of genes encoding interleukin (IL) 2, IL-4, IL-10 and interferon (IFN) gamma in lymphocyte-infiltrated renal cell carcinoma biopsies from ten patients using the reverse polymerase chain reaction technique. Autologous peripheral blood mononuclear cells and healthy renal parenchyma tissue were tested in parallel. The beta-actin gene, used as a positive control, was transcribed in all samples. In contrast, transcription of cytokine genes was confined to tumour biopsies: IL-2 gene transcripts were detectable in five biopsies and IL-10 transcripts in seven. IL-4 and IFN-gamma gene transcripts were detectable in one biopsy each. In two patients no cytokine gene transcription could be identified. These data underline that heterogeneous patterns of cytokine gene transcription can be observed in renal cell carcinoma biopsies. Although transcription of an immunostimulatory lymphokine such as IL-2 was observed in 50 per cent of biopsies, the most frequently transcribed cytokine gene coded for an inhibitory factor, IL-10.

Elevated levels of xanthine oxidase in serum of patients with inflammatory and autoimmune rheumatic diseases

Sera of patients with various inflammatory and autoimmune rheumatic diseases were screened for the presence of xanthine oxidase (XOD) and compared to sera from healthy donors and patients with nonrheumatic diseases including AIDS, internal diseases, and different carcinomas. Up to 50-fold higher levels of XOD were detected in rheumatic sera (P < 0.001). In addition, serum sulfhydryls (SH) were determined as sensitive markers of oxidative stress. The SH status in rheumatic patients was diminished by 45-75% (P < 0.001) and inversely correlated to the concentration of serum XOD (R = 0.73), suggesting a causal interrelation. The depletion of serum sulfhydryls by the oxyradical-producing XOD/acetaldehyde system was mimicked successfully ex vivo in human serum from healthy donors. Cortisone treatment of patients suffering from systemic lupus erythematosus and rheumatoid arthritis impressively normalized elevated XOD concentrations in rheumatic sera to those of healthy controls. The participation of xanthine oxidase in the depletion of serum antioxidants in rheumatic patients is discussed in the light of substrate availability and Km values.

Botulinum antibodies in dystonic patients treated with type A botulinum toxin: frequency and significance

We measured serum antibodies to botulinum toxin (ABT) in 96 patients with focal dystonia who had been treated with type A botulinum toxin. The frequency of detectable ABT was 3% (three patients). Patients with ABT had received more than 50 ng of botulinum toxin, and the shortest time between two injections was significantly less than in patients without ABT. The clinical evolution of the three patients was heterogeneous: one had decreased effectiveness with repeated injections, another had persistent improvement, and the third never responded to toxin injections.

Atrial natriuretic peptide release and volume regulation following kidney transplantation

The major stimulus for atrial natriuretic peptide (ANP) release is atrial stretch and increased values are observed in volume overload states such as chronic renal failure. Since successful kidney transplantation restores volume homeostasis, we compared the effects of human cadaveric kidney transplantation on time course and changes of plasma ANP in the early postoperative period in 4 patients with successful and 4 patients with failed transplantation. ANP concentrations were elevated before transplantation in both groups (91 +/- 16 and 70 +/- 32 pmol/l) and decreased after successful (50 +/- 27 pmol/l, day 16) but increased after failed transplantation (146 +/- 45 pmol/l, day 16). Moreover, there was a close correlation between changes of body weight and ANP concentrations. Plasma renin activity decreased and plasma noradrenaline increased non-significantly in both groups, the latter more so after failed transplantation (116 +/- 42 to 194 +/- 156 vs 156 +/- 157 to 425 +/- 287 ng/l). No correlation was found between changes of renin activity or plasma catecholamines and ANP concentrations. The results indicate that the mechanisms governing release of atrial natriuretic peptide are operative in patients with chronic end-stage renal failure and after successful kidney transplantation with a return of atrial natriuretic peptide concentrations towards normal in the latter.

Reactive nitrogen intermediates, antinuclear antibodies and copper-thionein in serum of patients with rheumatic diseases

Sera from 354 patients with various inflammatory and autoimmune rheumatic diseases were screened for the presence of reactive nitrogen intermediates, antinuclear antibodies and the anti-oxidase copper-thionein (Cu-thionein), and compared to sera from healthy donors and patients with non-rheumatic diseases including AIDS, various internal as well as neurological diseases and carcinoma of different organs. When compared to healthy individuals, the levels of nitric oxides in sera from patients with autoimmune rheumatic diseases were elevated by 240-600% (P < 0.01). The status of reactive nitrogen intermediates (NOx, RNI) in sera from donors with inflammatory rheumatic diseases was increased by 170-540%, but was also significantly enhanced in sera of patients with non-rheumatic diseases, indicating a general inflammatory mechanism that is predominantly triggered by inducible nitric oxide (NO) syntheses of phagocytes. All rheumatic sera were dramatically depleted of the anti-oxidase Cu-thionein (P < 0.001), a powerful consumer of hydroxyl radicals and singlet oxygen and an efficient superoxide dismutase. The NOx levels were positively correlated with the serum titers of antinuclear antibodies (r = 0.77) and negatively correlated with Cu-thionein levels (r = 0.94), reflecting a high steady-state concentration of free radicals generated during inflammatory and autoimmune rheumatic diseases.

Differential effects of interleukin-2 and CD3 triggering on cytokine gene transcription and secretion in cultured tumor infiltrating lymphocytes

The therapeutic potential of tumor-infiltrating lymphocytes (TIL) is currently under investigation. TIL have been reported to display characteristic functional defects, including impairments of activation mechanisms. In animal models, therapeutic efficacy of adoptive TIL transfer has been correlated with their capacity to produce cytokines rather than with their in vitro cytotoxic potential. In this work we assayed cytokine gene transcription and protein production in eight cultured TIL populations stimulated with recombinant human IL-2 (rhIL-2), solid-phase-bound anti-CD3 monoclonal antibodies (mAb), or a combination of the two. By using a sensitive reverse polymerase chain reaction technique, we observed that transcription of IL-5, GM-CSF, and TNF-alpha could be detected in unstimulated, IL-2-starved TIL from all cultures, while IL-4 and IFN-gamma genes were found to be transcribed in two cultures out of eight. A 50 U/ml dose of rhIL-2 was sufficient to induce IL-4 and IFN-gamma gene transcription in the remaining six cultures and in four more TIL populations, respectively. In contrast, rhIL-2 could not induce IL-2 gene transcription in five of eight TIL cultures. Furthermore, it could not induce IL-10 gene transcription in any TIL population. Anti-CD3 mAb triggering, however, induced transcription of all these cytokine genes. On the other hand, IL-6, IL-7, or TGF-beta 2 gene transcription could not be induced by any of the stimuli used, including the combination of anti-CD3 and rhIL-2. Despite detection of their gene transcripts, GM-CSF, IFN-gamma, or TNF-alpha was never detectable, at the protein level, in unstimulated TIL. Stimulation by rhIL-2 induced GM-CSF secretion, albeit to different extents, in all TIL populations. In contrast, rhIL-2 induced IFN-gamma and TNF-alpha production in three and one TIL population, respectively. CD3 triggering however, induced cytokine production in all TIL populations. Addition of rhIL-2 significantly increased production of GM-CSF, but not of IFN-gamma and TNF-alpha. These data underline that stimulation with a moderate dose of rhIL-2 reveals considerable heterogeneity of TIL populations regarding cytokine gene transcription and secretion. On the other hand, triggering of the CD3-T-cell receptor complex induces transcription of an extended panel of cytokine genes in all TIL populations and secretion of GM-CSF, IFN-gamma and TNF-alpha in virtually all cultures. Thus, if stimulated by properly presented antigenic peptides, TIL are capable of mounting an efficient response in terms of cytokine gene expression and protein production.

Copper-dependent antioxidase defenses in inflammatory and autoimmune rheumatic diseases

Gel-filtered sera of patients with various inflammatory and autoimmune rheumatic diseases (N = 354) were screened for the presence of the inflammation marker Cu-thionein. The concentrations of Cu-thionein were significantly diminished in patients with connective tissue diseases (P < 0.001). Sera of patients suffering from inflammatory rheumatic diseases were almost totally depleted of this low-molecular-weight copper protein that exerts pronounced superoxide dismutase activity and scavenges effectively hydroxyl radicals and singlet oxygen. Cortisone treatment of patients with rheumatoid arthritis, systemic lupus erythematosus, and polymyalgia rheumatica replenished impressively the serum concentration of Cu-thionein. The partial oxidation of the EPR-silent Cu(I)-chromophore to Cu(II)/Cu(I)-thionein, which is essential for the catalytic dismutation of superoxide, was monitored by electron paramagnetic resonance in the presence of activated neutrophils and monocytes. Release of Cu-thionein during the oxidative burst of peripheral blood monocytes was demonstrated in vitro. The role of prooxidant-antioxidant imbalances in the pathogenesis of rheumatic diseases is discussed.

[Increased level of nitrogen radicals in serum of patients with rheumatic diseases and AIDS]

354 sera from venous blood of patients with various rheumatic diseases and AIDS were assayed for the presence of reactive nitrogen intermediates. Compared to healthy individuals, the serum levels of nitric oxides from patients with connective tissue diseases and inflammatory rheumatic diseases were elevated (P < 0.01) by 170-600% and those from HIV-infected patients by 220%.

T-cell receptor V-gene usage in neoplasms of the central nervous system. A comparative analysis in cultured tumor infiltrating and peripheral blood T cells

The use of tumor-infiltrating lymphocytes in the treatment of central nervous system (CNS) neoplasms has met with serious obstacles due to difficulty of culture and poor characterization. Since in other tumors the therapeutic effects of tumor-infiltrating lymphocytes have been shown to rely on T-cell receptor engagement, the authors addressed the question as to whether expression of T-cell receptor variable (V) domains in cultured tumor-infiltrating lymphocytes from CNS is different from that of autologous cultured peripheral blood mononuclear cells. Infiltrating lymphocytes from CNS neoplasms, including primary malignancies, metastatic cancers, and meningiomas, were cultured in the presence of interleukin-2 and anti-CD3 monoclonal antibodies (MoAb's) in order to obtain optimum growth of T cells. Autologous peripheral blood mononuclear cells from the same patients were similarly cultured. After 4 to 5 weeks of culture, 97.3% +/- 2.6% (mean +/- standard deviation) of the resulting cell populations were CD3-positive lymphocytes. The expression of T-cell receptor V domains was then studied by using a panel of 12 MoAb recognizing gene products from T-cell receptor V-alpha 2, V-beta 5, 6, 8, and 12, V-gamma 4 and 9 families, and from two subfamilies of V-delta 2. Remarkably, in over 70% of all paired measurements, percentages of T cells expressing discrete T-cell receptor V-gene products were found to be virtually identical in tumor- and peripheral blood-derived cultured cell populations, with differences never exceeding 1%. In contrast, a different expression of individual V-gene products, concerning both alpha/beta and gamma/delta T-cell receptors, could be detected between cultured tumor-infiltrating lymphocytes and autologous peripheral blood-derived T lymphocytes in seven of 12 patients. In two cases, significant differences between the two populations were also observed in the proliferative responses obtained upon stimulation with staphylococcal enterotoxins that trigger defined V-beta T-cell receptors. Altogether, these data suggest that the T-cell receptor repertoire of cultured tumor-infiltrating lymphocytes from CNS tumors, suitable for use in adoptive immunotherapies, differs from that of autologous cultured peripheral blood mononuclear cells.

On the relative roles of interleukin-2 and interleukin-10 in the generation of lymphokine-activated killer cell activity

Induction of cytokine gene transcription by recombinant human IL-2 (rhIL-2) in peripheral blood mononuclear cells (PBMC) from healthy donors was studied by qualitative polymerase chain reaction. In all donors tested, optimal doses of rhIL-2-induced transcription of genes encoding for IL-5, GM-CSF, IFN-gamma, and TNF-alpha whereas transcription of IL-1-alpha, IL-3, IL-4, and IL-6 genes could only be detected in about half of the donors. Moreover, we observed that different doses of rhIL-2 were needed to induce transcription of different cytokine genes. In contrast, transcription of IL-2 and IL-10 genes was only observed in a minority of donors, irrespective of the concentration of rhIL-2 used. Since IL-10 displays a well-characterized inhibitory activity on the synthesis of cytokines possibly involved in the generation of lymphokine-activated killer (LAK) cells, we asked whether the absence of IL-10 gene transcription plays a role in the induction of LAK cells. Thus, we tested the effects of different doses of rhIL-10 on the rhIL-2-driven generation of LAK activity. Interestingly, rhIL-10 dose-dependently inhibited the production of IFN-gamma and TNF-alpha induced by IL-2, but had no effects on PBMC proliferation and generation of LAK activity. Similarly, purified CD3-/CD16+ lymphocytes, the precursors of LAK effector cells, could be optimally induced by low doses of rhIL-2 to proliferate and generate MHC-unrestricted cytotoxic activity against NK-resistant targets in the presence of rhIL-10. Altogether, our results indicate that rhIL-2 induces transcription of a preferential pattern of cytokine genes, with the IL-10 gene being infrequently transcribed. On the other hand, rhIL-10 shows diverse effects on rhIL-2-triggered PBMC activation, in that it inhibits IFN-gamma and TNF-alpha production but does not affect PBMC proliferation or generation of LAK activity.

Recurrent bleeding after variceal hemorrhage: predictive value of portal venous duplex sonography

OBJECTIVE

Risk assessment of recurrent variceal bleeding is essential for therapeutic decisions and is usually performed by endoscopy of the upper gastrointestinal tract. We studied the value of portal venous duplex sonography in predicting subsequent variceal bleeding in patients with cirrhosis.

SUBJECTS AND METHODS

Thirty patients with cirrhosis who received sclerotherapy because of acute variceal hemorrhage for the first time (hemorrhage group), 30 patients with cirrhosis who had no previous hemorrhage (nonhemorrhage group), and 30 control subjects were examined prospectively. With the use of portal duplex and color Doppler sonography, flow direction, flow velocity, vein diameter, and response to respiration of portal vein vessels were measured and portosystemic collaterals and thrombosis of portal vessels were visualized. The results of these measurements and imaging findings were combined into a Doppler sonoscore. At entry into the study, all patients were classified on the basis of a sonoscore as having a low (sonoscore, < 4) or a high (sonoscore, > or = 4) risk for subsequent hemorrhage. During a mean follow-up period of 2 years (range, 15-36 months), the predictive value of this Doppler sonoscore was studied.

RESULTS

In the hemorrhage group, the prevalence of recurrent hemorrhage was 40%, despite sclerotherapy, and the mortality rate was 60%. In patients with a Doppler sonoscore of 4 or more, the prevalence of recurrent hemorrhage was 67%, whereas in patients with a score less than 4, the prevalence was only 22% (p < .02). After sclerotherapy, endoscopic criteria showed no significant correlation with the prevalence of bleeding. In the nonhemorrhage group, the prevalence of variceal hemorrhage occurring was 13%, and Doppler sonographic criteria showed no significant correlation with the prevalence of subsequent hemorrhage.

CONCLUSION

We conclude that Doppler sonography, performed after the first occurrence of variceal hemorrhage, provides useful prognostic information regarding the risk of recurrent hemorrhage. If these results are confirmed, Doppler sonography may be used to select the best method of treatment.

Cytokine gene expression in primary brain tumours, metastases and meningiomas suggests specific transcription patterns

To obtain an insight into the network of cytokine gene transcription in the brain tumour microenvironment, we investigated the expression of genes encoding for interleukin (IL)-1 alpha, IL-1 beta, IL-2, IL-4, IL-5, IL-6, IL-10, interferon (IFN)-gamma, granulocyte-macrophage colony-stimulating factor, tumour necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta 1, -beta 2 and -beta 3 in freshly excised brain tumour samples and autologous peripheral blood mononuclear cells. Tissue specimens from 15 primary brain tumours, three brain metastases, five meningiomas, autologous peripheral blood mononuclear cells (PBMC) and three brain tumour cell lines were tested by reverse polymerase chain reaction. Despite the presence of T-lymphocytes, cytokine gene transcripts typically detectable upon T cell receptor triggering could not be observed in central nervous system tumours of diverse histology. In primary brain neoplasms, transcription of genes encoding for the inhibitory cytokines TGF-beta and IL-10 was detectable in more than 50% of samples. IL-6 transcripts could only be detected in malignant gliomas. In brain metastases, virtually no cytokine gene transcripts could be observed. Surprisingly, TGF-beta transcripts were also detected in all meningiomas. Thus, transcription of genes encoding for inhibitory factors appears to prevail in primary brain neoplasms.

Effects of different culture protocols on the expression of discrete T-cell receptor variable regions in human tumour infiltrating lymphocytes

Therapeutic effects of tumour infiltrating lymphocytes (TIL) rely on T-cell receptor (TCR) engagement. In this work, the expression of five TCR alpha/beta variable (V) domains was quantitatively analysed by means of a panel of monoclonal antibodies (Mab) recognising gene products from TCR V alpha 2, V beta 5, V beta 6, V beta 8 and V beta 12 families in freshly isolated TIL and in autologous peripheral blood mononuclear cells (PBMC) from patients with neoplasms. In 3 out of 6 cases, differences in the expression of V beta 5, V beta 6, V beta 8 or V beta 12 could be detected. TIL populations were expanded by using recombinant human interleukin-2 (rhIL-2) alone or in addition to solid phase bound anti-CD3 Mab. Cultured TIL showed similar CD4/CD8 ratios and cytotoxic activity against autologous neoplastic target cells, regardless of the activation protocol. In 4 patients, the expression of TCR alpha/beta V gene products, as compared with TIL from freshly excised tumours, was found to be modified in cultured TIL, especially in cell populations activated with rhIL-2 only. These results indicate that TCR V gene usage in TIL may quantitatively differ from that in PBMC. TIL culture protocols using rhIL-2 alone or in combination with solid phase bound anti-CD3 may result in differential expression of discrete TCR V families.

[Anti-arrhythmia treatment using L-carnitine in acute myocardial infarct]

Carnitine, a quaternary amine (3-hydroxy-4-N-trimethylaminobutyric acid), plays an important physiologic role in fatty acid transport and metabolism as well as in energy production of the myocardial cell. L-carnitine in high doses has been postulated to have an antiarrhythmic effect and this has also been clinically proven. We studied 20 patients with acute myocardial infarction (AMI), 4-12 hours after onset of pain. The patients were randomized and treated double-blind with 5 g L-carnitine (n = 12) or placebo (n = 8) at hours 0, 12, 24, 36, and with 2 x 3 g on days 3 to 7 by intravenous infusion over 2 hours. The two groups were similar for age, sex, infarct site, maximum CPK and conventional antiarrhythmic therapy. 24-hour Holter-ECG was performed on days 1, 2 and 7 and showed no significant difference between the two groups with respect to incidence of ventricular premature beats (VPB) per hour. On the second day following AMI, however, only 4 of 12 carnitine-treated patients showed high-grade VPB (Lown IVa and IVb), in comparison with 7 of 8 patients in the placebo group. The difference is significant: p = 0.028 (Fisher's Exact Test). Carnitine was well tolerated and the efficacy demonstrated on the second day following AMI must be interpreted with caution.

Positive antinuclear antibodies in malignancies

Images

Frequency of central lesions in polyneuropathy associated with IgM monoclonal gammopathy: an MRI, neurophysiological and immunochemical study

CNS lesions were studied in polyneuropathy associated with IgM monoclonal gammopathy. Eleven out of 12 patients with IgM MGUS and one patient with Waldenstrom's disease had clinical and electrophysiological features indicating a demyelinating polyneuropathy. MRI showed CNS white matter lesions in two cases. Antibodies reacting against glycolipids present in CNS white matter were present in five cases, two of which had abnormal MRI. Central conduction times cortex-C7, obtained by magnetic stimulation, were prolonged in 3/8 patients, of which two patients had anti-CNS glycolipid antibodies.

[Ambulatory transesophageal echocardiography. Diagnostic possibilities of a novel study method]

Transesophageal echocardiography has become now a routine outpatient method to augment the diagnostic power of transthoracic echocardiography in 10-15 minutes. Indications are native and prosthetic valvular heart disease and congenital heart disease, the evaluation of embolic events and suspicion of aortic dissection.

Influence of long-term amelioration of anemia and blood pressure control on left ventricular hypertrophy in hemodialyzed patients

The course of left ventricular hypertrophy was investigated in anemic hemodialysis patients treated with recombinant human erythropoietin (r-huEPO). 12 patients, aged 60.8 +/- 9.9 years (mean +/- SD) were treated for 18.8 +/- 2.7 months. Left ventricular size was estimated by echocardiography performed before treatment and at least 12 months after relieving anemia. Patients had signs of left ventricular and/or asymmetric septal hypertrophy when compared with a nonanemic and normotensive control group matched for sex and age. At baseline, hemoglobin (Hb) was 8.6 +/- 0.7 g/dl; interventricular septum thickness (IVST) was 1.75 +/- 0.34 cm, left ventricular posterior wall thickness (LVPWT) 1.32 +/- 0.19 cm, left ventricular muscle mass index (LVMI) 222.7 +/- 41 g/m2 and blood pressure (BP) 146.4 +/- 10/81.6 +/- 6 mm Hg. Hb rose to 11.4 +/- 1.2 g/dl (p less than 0.001); IVST and LVMI decreased to 1.42 +/- 0.35 cm (p less than 0.02) and 155.4 +/- 25.1 g/m2 (p less than 0.001); LVPWT and BP remained unchanged (1.30 +/- 0.26 cm and 146.8 +/- 16.9/81.2 +/- 7.8 mm Hg) at the end of the study. During the observation period, two groups of 5 and 7 patients differed from each other. The group of 5 patients had higher BP values (158.9 +/- 9.8/86.5 +/- 5.3 vs. 140.0 +/- 9.5/79.2 +/- 6.8 mm Hg, p less than 0.01), and the period with Hb values above 10 g/dl was shorter (14.5 +/- 2.4 vs. 17.8 +/- 2.4 months, p less than 0.05). These 5 patients failed to show a significant decrease in IVST and LVMI.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and genetic heterogeneity of Charcot-Marie-Tooth disease

The autosomal dominant forms of hereditary motor and sensory neuropathies include the hypertrophic form (CMT1) and the neuronal form of Charcot-Marie-Tooth disease (CMT2). While at least two distinct loci have been shown to be linked to the CMT1 phenotype (CMT1A and CMT1B, on chromosomes 17 and 1, respectively), whether the CMT2 phenotype results from mutations allelic to either of the CMT1 genes remains unknown. Studying one CMT1 and two CMT2 pedigrees, we were able to exclude the CMT2 disease locus from the region of chromosome 17 (Z = -2.80 at theta = 0.05 for D17S58) where the CMT1A gene maps (Z = +3.67 at theta = 0.00). Similarly, negative lod score values were obtained in CMT2 for the region of chromosome 1 where the CMT1B gene has been located (Z = -3.09 at theta = 0.05 for D1S61). The present study therefore provides evidence for genetic heterogeneity between the hypertrophic and the neuronal forms of Charcot-Marie-Tooth disease and demonstrates that the CMT2 gene is not allelic to either of the CMT1 genes mapped to date.

Coronary vasodilatation and improved myocardial lactate metabolism after angiotensin converting enzyme inhibition with cilazapril in patients with congestive heart failure

The effects of angiotensin converting enzyme inhibition on systemic and coronary hemodynamics and on myocardial lactate metabolism were investigated before and 2 and 6 hours after cilazapril at rest and during supine submaximal exercise in 10 patients with New York Heart Association class II or III chronic congestive heart failure. Angiotensin converting enzyme inhibition, indicated by a significant increase in plasma renin activity, resulted in significant reductions in blood pressure and systemic vascular resistance. Myocardial oxygen demand decreased (resting double product 10.9 +/- 3.7 vs 12.2 +/- 3.8 mm Hg beats/min 10(-3); p less than 0.05), but coronary sinus blood flow remained unchanged and calculated coronary resistance decreased (0.45 vs 0.5 units, rest 6 hours; p less than 0.05) suggesting coronary vasodilatation. Changes in coronary vascular resistance were directly related to changes in systemic vascular resistance (r = 0.75, p less than 0.5). Myocardial lactate extraction increased at rest (47 +/- 60 vs 134 +/- 132 mumol/min; p less than 0.5) and during exercise (27 +/- 54 vs 491 +/- 317 mumol/min; p less than 0.05) both in patients with coronary artery disease (n = 5) and idiopathic dilated cardiomyopathy (n = 5). Resting lactate production was converted to lactate extraction in two patients with coronary artery disease. Neither plasma catecholamine nor atrial natriuretic peptide concentrations changed significantly. The results suggest coronary vasodilation and improved aerobic myocardial metabolism by angiotensin converting enzyme inhibition in patients with congestive heart failure.

Auditory evoked responses (AER) and augmenting-reducing phenomenon in patients with progressive supranuclear palsy (PSP)

Variations in amplitude and latency of P1, N1 and P2 waves of AER induced by increasing the stimulus intensity (augmenting-reducing) were measured in PSP patients and compared to those observed in normal subjects. The studied population included 17 patients (10 male, 7 female, mean age 66 +/- 8 yr) with a typical PSP symptomatology and 17 normal subjects (10 male, 7 female, mean age 66 +/- 9 yr). All subjects from both the groups showed a normal auditory threshold (less than 30 db SPL or a moderately increased threshold never exceeding 10 db SPL). Nine patients had normal BAER; 4 patients showed an abnormal III wave; 3 patients showed an abnormal V wave. One patient had a poorly individualized BAER. Latencies and amplitudes of P1, N1 and P2 waves derived from Cz and Fz (linked ear reference) were studied with 50, 60, 70 and 80 db intensities and for each patient slopes of amplitude-stimulus intensity and latency-stimulus intensity curves were studied. Although patients showed decreased AER amplitudes, the augmenting-reducing phenomenon was not different from controls regarding either latency or amplitude changes with increasing stimulus intensity. Previous studies had established a negative correlation between the augmenting-reducing responses and HVA levels in the cerebrospinal fluid (CSF). Similarity of augmenting-reducing mechanisms in PSP and normal subjects favors the hypothesis of unimpaired mesocortical and mesolimbic dopaminergic pathways in PSP. This hypothesis is also supported by postmortem studies using biochemical markers.

Prolonged myocardial stunning after thrombolysis: can left ventricular function be assessed definitely at hospital discharge?

To assess whether myocardial dysfunction after acute reperfusion ('stunning') may show delayed recovery, 33 patients of the European Cooperative Study (rtPA vs placebo) had radionuclide angiocardiography on day 9 and after 3-6 months. Sixteen patients (13 inferior, three anterior infarcts) had a normal left ventricular ejection fraction (LVEF) which remained unchanged (55.4 vs 53.9%). In contrast, LVEF of 17 patients (10 inferior, seven anterior infarcts) with depressed values on day 9 improved during follow-up from 38.8 to 45.2% (P less than 0.01). Improvement was only observed in patients with early reperfusion defined a priori as peak creatine kinase value less than or equal to 15 h of pain onset (from 40.9 to 49.3%; P less than 0.05) in contrast to patients without reperfusion (from 34.0 to 35.2%; ns). Accordingly, LVEF increased in patients with open infarct-related arteries at hospital discharge (n = 8; P = 0.053) but not with persistent occlusion (n = 7; P = 0.11). Thus, a depressed LVEF observed 9 days after reperfusion may show delayed recovery due to prolonged stunning. Therefore, after thrombolysis, left ventricular function may not be evaluated definitively at hospital discharge; results of such studies should be interpreted with caution.

Cilazapril in congestive heart failure. A pilot study

The haemodynamic effects of a single dose of cilazapril 2.5 or 5 mg were studied in 33 patients with stable chronic congestive heart failure who were receiving digitalis and diuretics. Subsequently, a double-blind comparison of the haemodynamic and clinical effects of 3 months' treatment with cilazapril 1.25 to 5 mg daily or placebo in 24 evaluable patients revealed that the acute haemodynamic improvement produced by a single dose of cilazapril was maintained in patients receiving repeated administration of the drug, but not in those randomly allocated the placebo. Acute cilazapril significantly decreased mean arterial pressure, systemic vascular resistance, pulmonary capillary wedge pressure, pulmonary artery pressure and right atrial pressure, while cardiac index and stroke volume index increased at rest and during submaximal exercise. After 3 months' treatment 11 of 13 cilazapril recipients improved their New York Heart Association (NYHA) class compared with 2 of 11 patients treated with placebo. This functional improvement was paralleled by a patient-perceived improvement in general well-being.

Observer disagreement in rating neurologic impairment in multiple sclerosis: facts and consequences

The interobserver variability of the expanded disability status scale (EDSS) was studied in 59 patients with multiple sclerosis (MS). Interrater agreement was measured by the kappa coefficient. Agreement was low in patients with mild disability (EDSS less than 5); it was higher in patients with EDSS equal to or greater than 5. The difference between ratings of 2 independent examiners was equal to at least 1 point in 34% of the MS cases. This variability must be taken into consideration in designing clinical trials in MS.

[Echocardiography in emergency medicine: tool or toy?]

In cardiovascular emergency medicine echocardiography allows in many patients a quick and gentle bedside examination. In particular in patients with acute arterial hypotension, suspected or known acute coronary heart disease and its complications and in patients with acute heart failure due to valvular heart disease a valuable narrowing down of the differential diagnosis can be achieved by the use of echocardiography. However, the use of echocardiography in acutely ill patients demands highly skilled investigators to avoid potentially dangerous errors. The echocardiographic examination in intensive or emergency care patients represents an invaluable diagnostic tool today and becomes a toy only in inexperienced hands.

Analysis of mutations in the ninR region of bacteriophage lambda that bypass a requirement for lambda N antitermination

Two mutations in the ninR region of bacteriophage lambda that bypass a requirement for antitermination have been studied. One mutation, byp, has been cloned and mapped by marker rescue to a 417-base-pair segment in the ninR region of the genome. Analysis of the byp mutation by using promoter detection vectors, DNA sequencing, and S1 nuclease analysis showed that the byp mutation created a new promoter that transcribed gene Q. The second mutation analyzed was the deletion nin3. Sequence analysis revealed that 2,485 base pairs of the ninR region were removed, beginning within the ren gene and ending in an open reading frame termed ninG. The tR2 and tR3 terminators, and probably others, were removed by the nin3 deletion, thereby allowing the phage to be N independent and to grow in hosts defective for Nus antitermination factors.

[Transesophageal echocardiography]

Transesophageal echocardiography is a new, semi-invasive technique for the examination of the heart and the aorta. Within 10-15 minutes it is possible to obtain good pictures of the anatomy and function of the heart. Diagnostic indications are native and prosthetic valvular heart disease; the method is particularly suitable for visualization of endocarditic vegetations, evaluation of embolic events or congenital heart disease and assessment of aortic dissection. In the intensive care unit transesophageal echocardiography is a new window to the heart, yielding instantaneous information on cardiac status. For the anesthetist it is the first method to provide perioperative beat to beat analysis of ventricular function.

[Technique of bile duct revision]

In view of the progress of endoscopic treatment of common bile duct pathologies the management of retained common duct stones following simple cholecystectomy has become a minor problem. Nevertheless duct stones should be recognized and removed during the cholecystectomy procedure. High risk patients or extreme forms of acute inflammation are an exception. For this purpose a standardized technique of revision of the common bile duct is recommended. We describe such a technique of the exploration of the common bile duct by means of manual extraction, Fogarty catheter, irrigation, distension--irrigation and flexible choledochoscopy.

[Emergency diagnosis of cecal volvulus]

Twelve cases of coecal volvulus have been analysed. Given typical signs, plain radiography of the abdomen should assure diagnosis. Chronic volvulus requires a colon contrast enema for confirmation of diagnosis.. Immediate laparotomy is mandatory.

[Cerebellar atrophies]

Cerebellar atrophy is often discovered at computerized tomography or MRI of the brain, but its exact cause is frequently difficult to determine. Alcoholism is the predominant factor, but numerous other diseases may also be considered. The diseases fall into two main categories: primary cerebellar degeneration with, in particular, olivo-ponto-cerebellar atrophy, and acquired atrophy which may be of paraneoplastic or endocrine origin or caused by toxic agents other than alcohol. In this review paper the stress is placed on the clinical, paraclinical and histological distinctive features of the different types of cerebellar atrophy. The modalities of onset and the course of these lesions are of particular importance. The authors propose a practical aid to the diagnosis in the form of a deliberately simplified diagram.