A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease

BACKGROUND

Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity.

METHODS

We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy.

CONCLUSION

Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.

Factors Related to Faculty Work Life Balance as a Reason to Leave a School of Medicine

Mentoring can help promote faculty retention at academic health centers (AHCs). Faculty retention is important to optimize patient care and reduce replacement costs. Nationally "work life balance" (WLB) is identified by faculty as a reason to leave (ARTL) AHCs (Alexander & Lang, 2008). To help mitigate faculty attrition at AHCs, we examined work life balance as a reason to leave (WLB-ARTL) and other associated factors at the University of New Mexico School of Medicine (UNM SOM). Faculty responses from 255 faculty that left UNM SOM between July 2017 and December 2020 were analyzed using logistic regression with the outcome WLB-ARTL. Distributions of each variable were tabulated. Odds ratio associations from logistic regression between WLB-ARTL and each variable were obtained. Multivariate logistic regression modeling was performed with backward selection at p<0.05. Of the 255 faculty who exited the University of New Mexico School of Medicine (UNM SOM), 25% had WLB-ARTL, 48% were women, 72% were physicians, 58% were clinician-educators, and 13% were from racial/ethnic underrepresented minorities (URMs). Multivariate modeling found four factors associated with increased WLB-ARTL: compensation, time for academic pursuits, spousal and family support, and dislike of patient care conditions and environment. Two factors associated with lower WLB-ARTL were better leadership and periodic reviews addressing job satisfaction. Gender, URM, and physician status were not found to be significant. Similar to previous studies (Whittaker et al., n.d.), we found that WLB-ARTL at UNM SOM was associated with specific "work" and "life" factors. Faculty retention efforts should focus on "work" factors such as providing protected time for academic pursuits and improving patient care conditions, and "life" factors such as addressing compensation and supporting families.

Applying model approaches in non-model systems: A review and case study on coral cell culture

Model systems approaches search for commonality in patterns underlying biological diversity and complexity led by common evolutionary paths. The success of the approach does not rest on the species chosen but on the scalability of the model and methods used to develop the model and engage research. Fine-tuning approaches to improve coral cell cultures will provide a robust platform for studying symbiosis breakdown, the calcification mechanism and its disruption, protein interactions, micronutrient transport/exchange, and the toxicity of nanoparticles, among other key biological aspects, with the added advantage of minimizing the ethical conundrum of repeated testing on ecologically threatened organisms. The work presented here aimed to lay the foundation towards development of effective methods to sort and culture reef-building coral cells with the ultimate goal of obtaining immortal cell lines for the study of bleaching, disease and toxicity at the cellular and polyp levels. To achieve this objective, the team conducted a thorough review and tested the available methods (i.e. cell dissociation, isolation, sorting, attachment and proliferation). The most effective and reproducible techniques were combined to consolidate culture methods and generate uncontaminated coral cell cultures for ~7 days (10 days maximum). The tests were conducted on scleractinian corals Pocillopora acuta of the same genotype to harmonize results and reduce variation linked to genetic diversity. The development of cell separation and identification methods in conjunction with further investigations into coral cell-type specific metabolic requirements will allow us to tailor growth media for optimized monocultures as a tool for studying essential reef-building coral traits such as symbiosis, wound healing and calcification at multiple scales.

Combination percutaneous and medical management of cardiac rhabdomyomas obstructing tricuspid valve inflow: Case report

BACKGROUND

Cardiac rhabdomyomas can be prenatally diagnosed in patients with tuberous sclerosis complex. Many neonates require no intervention in early life other than close monitoring for regression of tumor over the period of months to years. In rare instances, cardiac rhabdomyomas can result in obstruction to blood flow or decreased ventricular function.

CASE REPORT

We describe the case of a neonate who was prenatally diagnosed with multiple large cardiac rhabdomyomas, one of which caused clinically significant obstruction to prograde blood flow across the tricuspid valve in the newborn period. To address the disturbance to prograde pulmonary blood flow, the patient underwent successful ductal stent placement in the neonatal period. A troponin elevation was noted shortly after birth, but no evidence of coronary compression or involvement was demonstrated by coronary angiography. The patient has subsequently been treated with sirolimus over a period of three months, with noted regression in tumors and improvement in tricuspid valve inflow.

CONCLUSIONS

A brief review of the literature regarding the diagnosis, treatment, and management of neonatal patients with cardiac rhabdomyomas is presented. A combined percutaneous and medical management approach may be of benefit in future cases of rhabdomyomas causing obstruction to pulmonary blood flow.

Composite grid designs for adaptive computer experiments with fast inference

Experiments are often used to produce emulators of deterministic computer code. This article introduces composite grid experimental designs and a sequential method for building the designs for accurate emulation. Computational methods are developed that enable fast and exact Gaussian process inference even with large sample sizes. We demonstrate that the proposed approach can produce emulators that are orders of magnitude more accurate than current approximations at a comparable computational cost.

Advancing Fusion with Machine Learning Research Needs Workshop Report

Machine learning and artificial intelligence (ML/AI) methods have been used successfully in recent years to solve problems in many areas, including image recognition, unsupervised and supervised classification, game-playing, system identification and prediction, and autonomous vehicle control. Data-driven machine learning methods have also been applied to fusion energy research for over 2 decades, including significant advances in the areas of disruption prediction, surrogate model generation, and experimental planning. The advent of powerful and dedicated computers specialized for large-scale parallel computation, as well as advances in statistical inference algorithms, have greatly enhanced the capabilities of these computational approaches to extract scientific knowledge and bridge gaps between theoretical models and practical implementations. Large-scale commercial success of various ML/AI applications in recent years, including robotics, industrial processes, online image recognition, financial system prediction, and autonomous vehicles, have further demonstrated the potential for data-driven methods to produce dramatic transformations in many fields. These advances, along with the urgency of need to bridge key gaps in knowledge for design and operation of reactors such as ITER, have driven planned expansion of efforts in ML/AI within the US government and around the world. The Department of Energy (DOE) Office of Science programs in Fusion Energy Sciences (FES) and Advanced Scientific Computing Research (ASCR) have organized several activities to identify best strategies and approaches for applying ML/AI methods to fusion energy research. This paper describes the results of a joint FES/ASCR DOE-sponsored Research Needs Workshop on Advancing Fusion with Machine Learning, held April 30–May 2, 2019, in Gaithersburg, MD (full report available at https://science.osti.gov/-/media/fes/pdf/workshop-reports/FES_ASCR_Machine_Learning_Report.pdf). The workshop drew on broad representation from both FES and ASCR scientific communities, and identified seven Priority Research Opportunities (PRO’s) with high potential for advancing fusion energy. In addition to the PRO topics themselves, the workshop identified research guidelines to maximize the effectiveness of ML/AI methods in fusion energy science, which include focusing on uncertainty quantification, methods for quantifying regions of validity of models and algorithms, and applying highly integrated teams of ML/AI mathematicians, computer scientists, and fusion energy scientists with domain expertise in the relevant areas.

Foot burns and diabetes: a retrospective study

BACKGROUND

Diabetes in conjunction with a foot burn can compound the challenges in wound healing; however, the impact of diabetes on outcomes of patients with foot burns has not been examined.

METHODS

A retrospective notes audit was conducted at the Concord Hospital Burns Unit for patients with foot burns who were admitted from 1(st) January 2012 to 31(st) December 2013. Data were collected for 15 subjects with foot burns and diabetes and 18 subjects with foot burns and no diabetes as a control group. Subjects were matched for percentage total body surface area of burns.

RESULTS

The mean inpatient and total lengths of stay for the diabetic group were 21.27 days and 64.80 days, which were significantly longer (P = 0.090 and P = 0.054) than the 9.61 days and 30.56 days in the control, based on a significance level of 0.10. The diabetic group was significantly older (P = 0.001), at 56.60 years versus 39.44 years in the control. Significantly (P = 0.033) more patients with diabetes were not working (n = 12/15 or 80.00 % versus n = 7/18 or 38.89 %) compared to the control. The diabetic group had higher rates of regrafting (n = 3/15 or 20.00 % versus n = 1/18 or 5.55 %) than the control and significantly (P = 0.013) more amputations (n = 5/15 or 33.33 % versus n = 0 or 0.00 %) compared to the control. Fewer patients with diabetes were prescribed pressure garments (n = 2/15 or 13.33 % versus n = 9/18 or 50.00 %), which was significant (P = 0.034). The increased age of patients in the diabetic group correlates with results from other studies. Healing time may be reflected by total length of stay, which was more than double for patients with diabetes, increasing demand and cost of inpatient and outpatient services.

CONCLUSION

This study highlights the importance of recognizing the potential for poorer outcomes for patients with diabetes and indicates the need for more burn prevention education and promotion in this 'at risk' patient group.

Quantitative study of guide-field effects on Hall reconnection in a laboratory plasma

The effect of guide field on magnetic reconnection is quantitatively studied by systematically varying an applied guide field in the Magnetic Reconnection Experiment (MRX). The quadrupole field, a signature of two-fluid reconnection at zero guide field, is altered by a finite guide field. It is shown that the reconnection rate is significantly reduced with increasing guide field, and this dependence is explained by a combination of local and global physics: locally, the in-plane Hall currents are reduced, while globally guide field compression produces an increased pressure both within and downstream of the reconnection region.

The relationship between changes in self-reported disability (measured by the Health Assessment Questionnaire - HAQ) in scleroderma and improvement of disease status in clinical practice

OBJECTIVES

To determine if a low Health Assessment Questionnaire Disability Index (HAQ-DI) score predicts subsequent improvement over the next one to two years in clinical practice and if a low HAQ is predictive of improvement in early, late, diffuse and limited SSc subsets.

METHODS

HAQs collected at one site annually were used to determine serial relationships in low baseline HAQ and improvement in overall status over the following one to two years. Data were divided into early (< or =3 years) and late, and then further into limited and diffuse SSc subgroups. We verified our results in the Canadian Scleroderma Research Group (CSRG) database.

RESULTS

120 SSc patients had a baseline HAQ-DI of 0.97+/-0.07 (SEM). Low HAQs predicted improvement in overall HAQ at one and two years, but was not statistically significant in predicting physician improvement rating. However, improving HAQs were associated with improvement in physician assessment (better vs. same vs. worse) for overall SSc (p=0.005), early diffuse SSc (p=0.008), overall limited SSc (p=0.02) and late limited SSc (p=0.03) at 1 year (but not at 2 years). The relationship was similar for severity of disease where changes in damage were related to changes in HAQ only over the first year for all 4 subgroups.

CONCLUSION

The HAQ is a useful 'marker' of change in status in clinical practice, where an improved HAQ is associated with improved physician global assessment. The relationship is only helpful for an interval of one year. Low HAQ did not predict subsequent improvement by physician rating in SSc patients.

The effect of feeding crude glycerol on growth performance and nutrient digestibility in weaned pigs

The effects of substituting wheat with crude glycerol as a dietary energy source were evaluated. Seventy-two weaned pigs were fed for 4 wk one of three pelleted wheat-based diets containing 0, 4, or 8% glycerol and formulated to 2.28 Mcal kg-1 net energy (NE) and 5.02 g standardized ileal digestible lysine Mcal-1 NE. For day 0 to 28, body weight increased linearly (P = 0.04); pigs fed 8% glycerol were 1.11 kg heavier than pigs fed 0% glycerol. Glycerol inclusion tended to increase average daily gain linearly (P = 0.066) and increased average daily feed intake quadratically (P = 0.037) without affecting feed efficiency (P > 0.10). Feeding up to 8% dietary crude glycerol by substituting wheat can enhance the growth performance of weaned pigs. Key words: Co-product, digestibility, glycerol, weaned pig

Clinical determinants of long-term quality of life after stroke

OBJECTIVES

To determine factors that independently predict health-related quality of life (HRQOL) 1 and 3 years after stroke.

METHODS

Subjects numbering 397, from a population-based register of first-ever strokes were assessed for HRQOL using the Short Form 36 (SF36) 1 year after stroke. Physical (PHSS) and mental health (MHSS) summary scores were derived from the eight domains of HRQOL in the SF36. Multivariate stepwise regression analyses were conducted to determine independent predictors of these scores; beta coefficients with 95% CI were obtained.beta coefficient is the difference between average value of the variable (e.g. male) and average value under consideration (e.g. female). Demographic and stroke risk factors, neurological impairments and cognitive impairment (MMSE <24) were included in the models. Similar analyses were undertaken on 150 subjects 3 years post-stroke.

RESULTS

A year after stroke, independent predictors of the worst PHSS were of females (beta coefficient -3.3: 95% CI -5.7 to -0.8), manual workers (-3.2: -5.9 to -0.4), diabetes (-4.2: -7.7 to -0.8), right hemispheric lesions (-4.9: -8.7 to -1.2), urinary incontinence (-7.8: -11.6 to -4.1) and cognitive impairment (-2.7: -5.5 to -0.1); the worst MHSS were associated with being Asian (-11.8: -20.6 to -3.0), ischaemic heart disease (-2.7: -5.4 to -0.03), cognitive impairment (-3.04: -5.8 to -0.3). Subjects aged 65-75 years (5.4: 2.5 to -8.4) had better MHSS than those <65 years. Three years post-stroke, independent predictors of worse PHSS were hypertension (-8.7: -13.5 to -3.9), urinary incontinence (-8.1: -15 to -1.1) and cognitive impairment (-8.3: -13.2 to -3.5).

CONCLUSIONS

Determinants of HRQOL vary both over time after stroke and whether physical or psychosocial aspects of HRQOL are being considered. This study provides valuable information on factors predicting long-term HRQOL, which can be taken into consideration in audits of clinical practice or in future interventional studies aiming to improve HRQOL after stroke.

A prospective study of the effects of anterior temporal lobectomy on emotion recognition and theory of mind

Nineteen patients evaluated facial emotional expressions and performed 'theory of mind' reasoning tasks before and after a temporal lobectomy for medically intractable epilepsy, and results were compared with the performance of 19 healthy controls. Following operation, which in all cases resulted in excision of the entire amygdala, there was no change in the ability to reason about the mental states of others, in line with the suggestion that the anterior temporal lobe is not necessary for theory of mind reasoning. However, following a left anterior temporal lobectomy, patients evaluated fearful facial expressions in a more normative manner. This may reflect the excision of a 'hyper-excitable' amygdala which pre-operatively misinterprets fearful expressions as containing blends of other emotions. Alternatively the results may represent an improvement in function of the right amygdala following the excision of a noxious inhibitory epileptogenic focus on the left. The finding complements earlier demonstrations that damage to the right amygdala is associated with impaired processing of fear; amelioration of right amygdala function may conversely be associated with an improvement.

Relationships between long-term stroke disability, handicap and health-related quality of life

OBJECTIVES

To estimate levels of disability, handicap and health-related quality of life (HRQOL) up to 3 years after stroke and examine the relationships between these domains.

DESIGN

A longitudinal, observational study

SETTING

Population-based register of first-ever strokes

METHODS

Subjects, registered between 1 January 1995 and 31 December 1997, were assessed at 1 year (n = 490) and 3 years (n = 342) post-stroke for disability [Barthel index (BI)], handicap [Frenchay activity index (FAI)] and HRQOL (SF-36). BI was categorised as severe, moderate, mild and independent (0-9, 10-14, 15-19 and 20); FAI was categorised as inactive, moderately active and very active (0-15, 16-30 and 31-45). SF-36 domains include: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). Physical (PHSS) and Mental Health (MHSS) Summary Scores were computed.

RESULTS

at 1 and 3 years, 26.1 and 26.3%, respectively, were disabled (BI < 15); 55 and 51%, respectively, were handicapped (FAI = 0-15); and survivors had low mean PHSS (37.1 and 37.9), but satisfactory mean MHSS (46.6 and 47.7). There was a graded positive relationship between all SF-36 domains and the categories of BI and FAI. Spearman rank correlations were significant between BI and all SF-36 domains at both time points: strong (r > 0.70) with PF, moderate (r = 0.31-0.70) with RP, SF and PHSS, but weak (r < 0.30) with other domains. Correlations between FAI and SF-36 domains were strong with PF, weak with BP, RE and MHSS, and moderate with other domains.

CONCLUSIONS

Disability and handicap remain highly prevalent up to 3 years after stroke. Patients' perception of physical health is persistently low, but mental health perception is satisfactory up to 3 years. Due to variable correlations between different HRQOL domains with disability and handicap, it is suggested that disability, handicap and HRQOL should all be assessed to acquire a broader measure of stroke outcome.

Effect of three treatment schedules of recombinant methionyl human leptin on body weight in obese adults: a randomized, placebo-controlled trial

AIM

The aim of this study was to evaluate the effect on body weight and safety of subcutaneously administered recombinant leptin in obese adults and to evaluate whether the timing of recombinant leptin administration influences efficacy.

METHODS

A randomized, double-blind, placebo-controlled, multicentre study was designed, comprising of a 3-week dietary lead-in followed by a 12-week leptin or placebo treatment period. A total of 284 overweight and obese (body mass index 27-37.0 kg/m(2)) predominantly white (98%) women (66%) and men (34%) with a mean (+/-s.d.) 46.8+/-10.4 years of age were randomized into three treatment groups with three matching placebo groups. Recombinant leptin was administered by subcutaneous injection [10 mg/morning, 10 mg/evening or 20 mg/day (10 mg twice daily)]. Patients were counselled at baseline to reduce dietary intake by 2,100 kJ/day (500 kcal/day), and dietary advice was reinforced every 2-4 weeks.

RESULTS

No statistically significant change in body weight occurred with recombinant leptin treatment compared with placebo treatment in any treatment group. No clinically significant adverse effects were observed with the exception of an increase in injection-site reactions in patients treated with recombinant leptin (83%) vs. placebo (36%).

CONCLUSIONS

Administration of recombinant leptin to an overweight and obese population, in addition to a mildly energy-restricted diet, was not efficacious in terms of weight loss at the doses and schedules studied. The hypothesis that nocturnal administration of recombinant leptin might have a specific effect on weight loss was not supported.

Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register

OBJECTIVE

To identify sociodemographic differences in the incidence of the subtypes of first ever stroke in a multiethnic population.

METHODS

A prospective community stroke register (1995-8) was developed using multiple notification sources and pathological and clinical classifications of stroke. Standardisation of rates was to European and World populations and adjusted for age, sex and socioeconomic status in multivariate analyses. A multiethnic population of 234 533 in south London, of whom 21% are black was studied.

RESULTS

A total of 1254 cases were registered. The average age of stroke was 71.7 years with black patients being 11.3 years younger than white patients (p<0.0001). The incidence rate/1000 population was 1.33 (crude) (95% CI 1.26 to 1.41), 1.28 (European adjusted) (95% CI 1.2 to 1.35) with a 2.18 (95% CI 1.86 to 2.56) (p<0.0001) age and sex adjusted incidence rate ratio in the black population. Radiological diagnosis was confirmatory in 1107 (88.3%) with 862 (68.7%) infarction, 168 (13.4%) primary intracerebral haemorrhage, and 77 (6.2%) subarachnoid haemorrhage. Of the cerebral infarction cases 189 (21.9%) were total anterior circulatory, 250 (29%) partial anterior, 141 (16.4%) posterior (POCI) and 282 (32.7%) lacunar infarcts. The black group had a significantly higher incidence of all subtypes of stroke except for POCI and unclassified strokes. The incidence rate ratio (IRR) for men compared with women was 1.34 (95% confidence interval (95% CI) 1.19 to 1.50; p<0.001). The IRR for manual versus non-manual occupations in those aged 35-64 years was 1.64 (95%CI 1.22 to 2.23; p<0.0001). There was a borderline significant increase in adjusted survival at 6 months in the black group 95% (CI 0.61 to 1.03, p=0.078) with a hazard ratio of 0.79 after adjustment and stratification.

CONCLUSIONS

Although the black population is at increased risk of stroke and most subtypes of stroke, this is not translated into significant differences in survival. Hence black/white differences in mortality are mainly driven by incidence of stroke. There are striking demographic inequalities in the risk of stroke in this multiethnic inner city population that need to be tackled through interagency working. Although the reasons for the increased risk in the black population are unclear, demographic factors such as socioeconomic status do seem to play a significant independent part.

Effect of angiotensin type I-receptor blockade on left ventricular remodeling in pressure overload hypertrophy

BACKGROUND

The renin-angiotensin system is involved in cardiac remodeling. In contrast to the well-recognized salutary effects of angiotensin-converting enzyme inhibition, the value of angiotensin II type I (AT(1))-receptor blockade on left ventricular (LV) hypertrophy and dysfunction is controversial.

METHODS AND RESULTS

Descending thoracic aorta-banded and sham-operated guinea pigs were given either losartan (30 mg x kg(-1) x day(-1) intraperitoneally) or vehicle for 8 weeks (n = 7 in each group). LV end-diastolic and end-systolic dimensions and wall thicknesses were measured echocardiographically, and LV fractional shortening, relative wall thickness, and LV mass normalized by body weight were calculated. Isolated heart function (Langendorff perfusion) was studied 8 weeks after surgery, and LV performance was assessed by maximum LV pressure and +/-dP/dt normalized by LV mass. Eight weeks after banding guinea pigs developed concentric LV hypertrophy and had decreased maximum LV pressure and +/-dP/dt normalized by LV mass; LV end-diastolic dimension and LV fractional shortening were unchanged. In band-operated guinea pigs treatment with losartan had no significant effects on any of these measurements.

CONCLUSIONS

In guinea pigs with descending aortic banding, treatment with losartan for 8 weeks neither attenuates progression of pressure overload hypertrophy nor significantly improves impaired mass-normalized pressure-derived indices of LV contraction and relaxation.

The natural history and associations of sleep disordered breathing in first ever stroke

Although the prevalence of sleep-disordered breathing (SDB) in patients following stroke has been found to be high, there are few data about whether these changes persist in the months that follow stroke. The present study aims to confirm the prevalence of SDB following first ever stroke, to investigate an association between SDB and subtype of stroke and to determine the change in SDB three months following a first ever stroke.

Recovery from poststroke urinary incontinence: associated factors and impact on outcome

OBJECTIVES

To determine factors associated with recovery from poststroke urinary incontinence and to estimate the impact of this recovery on stroke outcome at 3 months.

DESIGN

Prospective, observational study.

SETTING

Population-based stroke register.

PARTICIPANTS

Three hundred twenty-four incident cases of stroke with incontinence 1 week poststroke were identified from the register between January 1, 1995, and December 31, 1998.

MEASUREMENTS

At 3 months, 105 patients were dead and 12 were lost to follow-up. The remaining patients were classified by continence status; those who had regained continence (n = 127) were compared with those who remained incontinent (n = 80) in terms of demographic details, stroke risk factors, premorbid disability, neurological impairments, and Oxfordshire Community Stroke Project stroke subtypes. Data at 3 months included disability using the modified Barthel Index (BI) (without its urinary continence component) and the Frenchay Activity Index (FAI), and institutionalization.

RESULTS

Multivariate analysis showed being age 75 and older (odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.17-0.83) was associated with poor recovery from incontinence. Compared with subjects with total anterior circulatory infarctions, those with lacunar infarctions were more likely to regain continence (OR = 3.66; 95% CI =1.10-12.2), and compared with subjects with a BI between 0 and 14, those with a BI between 15 and 18 were also more likely to regain continence (OR = 21.8; 95% CI = 5.95-79.7). At 3 months, the incontinent group had greater institutionalization rates (27 (34%) vs 9 (7%), P <.001) and worse disability, measured with BI and FAI (BI: P <.001, FAI: P =.002).

CONCLUSIONS

Age 75 and older is independently associated with poor recovery from poststroke urinary incontinence. Further clinical trials are required to explore underlying mechanisms and efficacy of possible interventions for this group of stroke survivors. Recovery from poststroke urinary incontinence should be a major goal of stroke professionals because it is associated with lower institutionalization rates and less disability at 3 months.

Tall cell papillary thyroid carcinoma metastatic to femur: evidence for thyroid hormone synthesis within the femur

A 67-year old man with a 3-month history of left hip pain had a history of Graves disease, treated with 131I 20 years before admission, and papillary thyroid carcinoma, treated with cervical lymphadenopathy 9 years before admission. Removal of a 3.5- x 5-cm mass from the left femur revealed it to be a tall cell variant of papillary thyroid carcinoma. Removal of this mass resulted in his thyrotropin level increasing from 2 (presurgery) to 23 mIU/mL, whereas his thyroxine level simultaneously decreased from 5.79 (presurgery) to 2.29 microg/dL 12 days after surgery despite continuation of levothyroxine of 0.137 mg/day. On histological examination, the tall cell variant in the femur was producing abundant thyroglobulin. This first case of a metastatic papillary thyroid carcinoma in bone producing thyroid hormone to the extent that the patient became hypothyroid after removal of this metastasis illustrates that metastatic thyroid lesion(s) may produce significant amounts of thyroid hormone.

Physical aggression and marital dysfunction: a longitudinal analysis

Shortly after marriage, 56 couples provided data on physical aggression and other predictors of marital adjustment. At 6-month intervals over the next 4 years, spouses reported on their marital quality and stability. Results indicated that marital dysfunction was more common among aggressive than among nonaggressive couples (70% vs. 38%) and among severely aggressive than among moderately aggressive couples (93% vs. 46%). Aggression remained a reliable predictor of marital outcomes after the authors controlled for stressful events and negative communication. These findings help to refine developmental models of marital dysfunction, which often overlook the role of aggression, and can provide information for prevention programs for marital distress, which typically do not distinguish between aggressive and nonaggressive couples.

Cerebrovascular risk factors and stroke subtypes: differences between ethnic groups

BACKGROUND AND PURPOSE

The excess risk of stroke seen in the black population has not been explained by differences in age, sex, and social class, although differences in the frequency of cerebrovascular risk factors may be partly responsible. Data on risk factor profiles for the UK black stroke population are sparse. Previous studies have contrasted the association of cerebrovascular risk factors between hemorrhagic and ischemic stroke and between etiologic subtypes of infarct. The relationship of cerebrovascular risk factors to clinical classifications of stroke, however, has been little examined. The aim of this study was to establish the frequency of cerebrovascular risk factors in patients with first-ever strokes in the South London, UK, population and to examine the relationship of these risk factors to both ethnicity and Bamford stroke subtype.

METHODS

The study included 1254 first-ever stroke patients registered in the South London Community Stroke Register between 1995 and 1998; 995 patients (79.3%) were white, 203 (16.2%) were black, 52 (4.1%) were of other ethnic origin, and 4 (0. 3%) were of unknown ethnic origin.

RESULTS

In multivariate analysis, increasing age (P:<0.001) and previous cerebrovascular disease (P:=0.007) were independently associated with infarct rather than hemorrhage. Atrial fibrillation was associated with all nonlacunar (P:=0.02), total anterior circulation (P:=0.007), and partial anterior circulation infarcts (P:=0.02) compared with the lacunar group. All other risk factors were similar between infarct subtypes. Risk factors for hemorrhage subtypes were similar in multivariate analysis; increasing age was the only factor associated with primary intracerebral hemorrhage over subarachnoid hemorrhage (P:<0.001). The black stroke population suffered significantly less atrial fibrillation (P:=0.001) and engaged in less alcohol excess (P:<0. 001) and were less likely to have ever smoked (P:<0.001). Hypertension (P:<0.001) and diabetes mellitus (P:<0.001) were more prevalent in the black population.

CONCLUSIONS

Physiological cerebrovascular risk factors for the UK black population are similar to those of the US black population, but behavioral risk factors differ. Risk factors differ between ethnic groups in the United Kingdom, and future measures for secondary prevention should take this into consideration. Bamford clinical subtypes bear little association with cerebrovascular risk factors. Other classification systems, such as those that classify stroke by etiology, may be more useful in explaining the excess risk of stroke and the scope for its prevention.

Neutrophils released from the bone marrow by granulocyte colony-stimulating factor sequester in lung microvessels but are slow to migrate

Inflammatory mediators such as granulocyte colony-stimulating factor (G-CSF) release polymorphonuclear leukocytes (PMNL) from the bone marrow. This growth factor is used to promote the host response to infection but its effect on the behaviour of leukocytes at the inflammatory site is unclear. This study examined the sequestration and migration of PMNL released from the bone marrow by G-CSF in a model of streptococcal pneumonia. Eight hours following the administration of either human G-CSF (n=6) or saline (n=3) in rabbits, a focal Streptococcus pneumoniae pneumonia was induced and the animals were followed for 2 h. The thymidine analogue 5'-bromo-2'-deoxyuridine (BrdU) was used to label PMNL (PMNL(BrdU)) in the marrow and as a marker of PMNL newly released by the bone marrow. The PMNL(BrdU) in the lung and blood were identified using immunohistochemistry. G-CSF pretreatment elevated the circulating PMNL (3.6+/-0.4 (mean+/-SEM) to 8.3+/-1X10(9) x L(-1), p<0.05) and PMNL(BrdU) (5.4+/-2.1 to 12.5+/-3.1%, p<0.05) counts at 8 h with little further increase caused by the subsequent 2 h pneumonia. These counts did not change in the control group. Morphometric studies of the lung showed that the total number of PMNL sequestered in lung capillaries were increased in the G-CSF group and the percentage of the these PMNL that were BrdU-labelled, was higher than in circulating blood (p<0.05). In the G-CSF group, only 11.2+/-2.6% of the PMNL that migrated into the airspaces were PMNL(BrdU) compared to 50.8+/-8% PMNL(BrdU) in the pulmonary capillaries. In vitro studies showed PMNL(BrdU) released from the bone marrow by G-CSF are less deformable than unlabelled circulating PMNL (p<0.01). It is concluded that granulocyte colony-stimulating factor treatment causes the marrow to release polymorphonuclear leukocytes that preferentially sequester in lung microvessels but are slow to migrate out of the vascular space into the airspace at the pneumonic site.

Vitiligo is not caused by mutations in GTP-cyclohydrolase I gene

GTP-cyclohydrolase I (GTP-CH I) is the initial and rate-limiting enzyme in the synthesis of tetrahydrobiopterin, which regulates melanin biosynthesis. GTP-CH I is therefore a candidate gene for vitiligo. We have carried out DNA sequencing of all six exons and the promoter region of this gene, comprising 1759 base pairs, in 25 nonsyndromic vitiligo patients. However, contrary to an earlier report in which mutations were found in syndromic patients (vitiligo with dopa-responsive dystonia) belonging to two unrelated families, no mutation in the GTP-CH I gene was found.

Antithrombotic and antihypertensive management 3 months after ischemic stroke : a prospective study in an inner city population

BACKGROUND AND PURPOSE

We sought to examine the frequency, predictors, and effects of nontreatment with antithrombotic and antihypertensive therapies 3 months after ischemic stroke.

METHODS

The population-based South London Community Stroke Register prospectively collected data on first-in-a-lifetime strokes between 1995 and 1997. Among patients registered with ischemic stroke, treatment status with antithrombotic and antihypertensive therapies was examined 3 months after the event.

RESULTS

In a cohort of 457 patients with ischemic stroke, 393 (86.0%) were considered appropriate for antiplatelet medication, 32 (7.0%) for anticoagulant medication, and 254 (55.9%) for antihypertensive medication. The rates of nontreatment observed 3 months after the event were 24.4% for antiplatelet, 59.4% for anticoagulant, and 29.5% for antihypertensive medication. Independent risk factors for nontreatment with antithrombotic therapies (antiplatelets and anticoagulants) were the subtype of stroke (nonlacunar infarct: OR=1. 60, 95% CI 1.07 to 2.54), stroke severity measured by the Glasgow Coma Scale (GCS) score (GCS </=13: OR 2.08, 95% CI 1.18 to 3.66) and the Barthel Index (BI) score 5 days after the event (BI </=10: OR 1. 85, 95% CI 1.17 to 2.93). For antihypertensive therapies the stroke subtype (OR 2.46, 95% CI 1.33 to 4.54), GCS score (OR 2.97, 95% CI 1. 35 to 6.53), BI score (OR 2.33, 95% CI 1.27 to 4.29), and ethnicity (Caucasian: OR 2.43, 95% CI 1.15 to 5.14) were independently associated with nontreatment. Cox regression modeling showed no significant association between the treatment status and recurrence-free 3-year survival rates after controlling for severity and subtype of stroke.

CONCLUSIONS

Secondary prevention for a common disease such as stroke appears to be inadequate in the study area. Healthcare professionals need to consider antithrombotic and antihypertensive therapies for all stroke patients.

The enhancement of traditional behavioral couples therapy: consideration of individual factors and dyadic development

There has been little effort by behavior therapists to develop couple interventions that view marriage from a content-relevant or developmental perspective. Consequently, we have delineated ways in which a perspective of intimate relationships including individual factors and dyadic development might guide the enhancement of traditional behavioral couples therapy (TBCT) with novel and improved techniques that will ultimately allows us to reach a wider range of distressed couples than our current interventions allows. Specifically, we examined the potential benefits to intervention that could occur by considering the impact of individual factors on relationship quality, using the literature on attachment patterns as an example. Further, we have discussed the potential gains to couple interventions that could occur by considering the impact of dyadic development on relationship satisfaction. We first addressed gradual changes in marriage, using intimacy as an example. Next we examined "stage of marriage" issues, using child behavior problems as an example. Finally, we considered whether or not a problem was chronic. Throughout, we have proposed utilizing TBCT as a starting point, and considering ways to enhance TBCT specifically, as it is the marital therapy for which we have the most information and empirical support.

Polymorphonuclear leukocytes released from the bone marrow preferentially sequester in lung microvessels

OBJECTIVE

A hallmark of the systemic response to an inflammatory stimulus is the release of polymorphonuclear leukocytes (PMNs) from the bone marrow. This study was designed to measure the release of PMNs from the bone marrow and to determine their sequestration in the lung after an intravenous injection of either endotoxin (n = 5) or saline (n = 5).

METHODS AND RESULTS

The thymidine analogue 5'-bromo-2-deoxyuridine (BrdU) was used to pulse label dividing PMNs in the bone marrow of rabbits (n = 13), and immunohistochemistry and morphometry were used to detect the release of BrdU-labeled PMNs into the circulation and to determine their sequestration in the lung. Endotoxin treatment caused a drop in the circulating PMN counts (3.3 +/- 0.08 at baseline to 0.12 +/- 0.02 x 10(9)/L at 1 hour after endotoxin), which was followed by a neutrophilia at 8 hours (6.3 +/- 1.1 x 10(9)/L, P < 0.01), an increase in circulating band cells (0.12 +/- 0.01 at baseline to 2.18 +/- 0.4 x 1(9)/L at 8 hours, p < 0.001), and an increase in the percentage of BrdU-labeled PMNs (0.01% +/- 0.004% at baseline to 26.1% +/- 3.2% at 8 hours, p < 0.001). Endotoxemia caused an arteriovenous difference in BrdU-labeled PMNs across the lung (35.9% +/- 2.9% versus 26.1% +/- 3.1%, mixed venous versus arterial, p < 0.02). Morphometric studies showed that endotoxin caused sequestration of PMNs in the lung (2.2 +/- 0.4 versus 1.0 +/- 0.2 x 10(10), endotoxin versus saline, p < 0.03) with preferential retention of BrdU-labeled PMNs (0.79 +/- 0.21 versus 0.039 +/- 0.016 x 10(10), endotoxin versus saline, p < 0.05). The percentage of BrdU-labeled PMNs in the alveolocapillary walls was higher than in circulating blood (64.01% +/- 4.3% versus 26.1% +/- 3.2%, p < 0.01) in the endotoxin group. In vitro filtration of cells through 5-mm pore size filters showed that circulating BrdU-labeled PMNs, 8 hours after endotoxin, were preferentially retained in the filters (p < 0.01).

CONCLUSIONS

We conclude that endotoxemia stimulates the bone marrow to release mature and immature PMNs. Compared to PMNs released from the bone marrow during normal turnover, these PMNs are less deformable and preferentially sequester in the lung microvessels.

Practical approach to electron beam dosimetry at extended SSD

This paper presents a practical approach to clinical dosimetry for electron beams at extended source-to-surface distance (SSD). Characteristics of electron beams from a Siemens MD-2 accelerator are presented at a nominal SSD of 100 cm and an extended SSD of 115 cm. Relative output factors are measured at both 100 and 115 cm SSDs for a range of square field sizes for each beam energy. The change of output with SSD does not follow the inverse square law, if the nominal SSD is used. This deviation is larger for lower beam energy and smaller field sizes. An effective SSD, SSDeff, has been determined at dmax for each beam energy as a function of field size. A comprehensive approach to treatment time calculations is proposed.

Three secretory phospholipase A(2) genes that map to human chromosome 1P35-36 are not mutated in individuals with attenuated adenomatous polyposis coli

Mutation of Pla2g2a, a secretory phospholipase A(2) gene, dramatically increases the number of intestinal polyps that develop in the multiple intestinal neoplasia (Min) mouse, a murine model for adenomatous polyposis coli in humans. We tested the hypothesis that mutation of the human homologue(s) of this gene might be responsible for the more severe phenotype (hundreds of polyps) seen in a subset of individuals with attenuated adenomatous polyposis coli (AAPC). DNA sequence analysis demonstrated that alterations of PLA2G2A, as well as related genes PLA2G2C and PLA2G5, were evenly distributed between three classes of AAPC subjects: those with small, intermediate, and large numbers of adenomatous colonic polyps. Among 67 additional unrelated AAPC subjects, a stop mutation in PLA2G2C did not correlate with an increased burden of adenomatous polyps. Therefore, mutation of the human homologue(s) of murine Pla2g2a does not appear to be responsible for phenotypic variation among subjects with AAPC.

Polymorphonuclear leukocyte (PMN) migration in streptococcal pneumonia: comparison of older PMN with those recently released from the marrow

In acute bacterial pneumonia, polymorphonuclear leukocytes (PMN) sequester in the lung and migrate into the alveolar airspaces. These local events are accompanied by a systemic response that includes release of PMN from the bone marrow into the circulation. The present study was designed to compare the sequestration and migration of these newly released PMN with those already in the circulation in a model of acute streptococcal pneumonia in rabbits. PMN were labeled in the mitotic pool in the marrow by administration of 5'-bromo-2'-deoxyuridine (BrdU 100 mg/kg) and the labeled cells were detected in blood and tissues by immunohistochemistry. The proportion of BrdU-labeled PMN (PMN BrdU) that sequestered and migrated in the lung tissue infected with Streptococcus pneumoniae and the uninfected lung was measured using morphometric techniques. The results show an increase in the proportion of PMN BrdU (6.0 +/- 1.0% to 17.3 +/- 3.8%, P<0.05) in the circulation 5 h following the induction of a pneumonia and the PMN expressed a higher concentration of L-selectin (9.3 +/- 0.7 to 14.9 +/- 0.8 MFI, P<0.05). The proportion of PMN BrdU in the control tissue was not different from the proportion in the systemic circulation (11.4 +/- 1.6%). The PMN BrdU increased in the pneumonic site at 5 h (19.9 +/- 3.4%, P<0.05) and 8 h (26.6 +/- 1.5%, P<0.05) after treatment. Only 2.8 +/- 0.3% and 2.8 +/- 0.6% of the PMN that migrated into the airspace at 5 and 8 h were PMN BrdU. We conclude that PMN released into the circulation as part of the systemic response to a local streptococcal pneumonia sequester normally but may be slow to migrate into the airspaces at the inflammatory site.

Evidence for ETA and ETB receptors in rat skin and an investigation of their function in the cutaneous microvasculature

1. The relative contribution of ETA and ETB receptors in the response of rat skin to endothelins was investigated by use of the selective ETB agonist IRL-1620 and the selective ETA antagonist BQ-123. 2. Binding data suggest the presence of ETA and ETB receptors as preincubation with [Ala3,11,18Nle7]-endothelin-1 reduced ET-1 binding by approximately 40%. 3. Intradermal injection of endothelin-1 (ET-1, 1-10 pmol/site) and ET-3 (3-100 pmol/site) induced a dose-dependent decrease in local blood flow assessed by 133Xe clearance at test sites in rat skin. 4. The endothelin analogue [Ala3,11,18Nle7]-ET-1 (30-1000 pmol/site) induced significant vasoconstriction (P < 0.05) at the highest doses used and the selective ETB receptor agonist, IRL-1620 [Suc[Glu9,Ala11,15] endothelin (8-21)], (0.01-100 pmol/site) acted in a potent manner to induce a significant (P < 0.01) dose-dependent decrease in 133Xe clearance. 5. Co-injection with the selective ETA receptor antagonist, BQ-123 (1 nmol/site), completely abolished the vasoconstriction to ET-1 and partially to ET-3, but had no effect on IRL-1620-induced vasoconstriction. In addition, IRL-1620 responses were not altered at sites treated with submaximal doses of a nitric oxide synthase inhibitor or a prostaglandin synthase inhibitor. 6. ET-1 and IRL-1620 (100 fmol-1 pmol/site) did not induce oedema formation as measured by [125I]-albumin accumulation in the presence or absence of the vasodilator, calcitonin gene-related peptide (CGRP). ET-1 (1-3 pmol/site) inhibited substance P-induced oedema formation and this effect,suggested to be secondary to a vasoconstrictor effect, was significantly reversed by BQ-123 (1 nmol/site).7. The findings in this study indicate that there are ETA and ETB receptors in rat skin and agents which activate either receptor act to mediate a decrease in cutaneous blood flow, but have no effect on increased microvascular permeability.

A strategy for constructing high-resolution genetic maps of the human genome: a genetic map of chromosome 17p, ordered with meiotic breakpoint-mapping panels

Genetic linkage analyses with genotypic data obtained from four CEPH reference families initially assigned 24 new PCR-based markers to chromosome 17 and located the markers at specific intervals of an existing genetic map of chromosome 17p. Each marker was additionally genotyped with an ordered set of obligate, phase-known recombinant chromosomes. The breakpoint-mapping panels for each family consisted of two parents, one sib with a nonrecombinant chromosome, and one or more sibs with obligate recombinant chromosomes. The relative order of markers was determined by sorting segregation patterns of new markers and ordered anchor markers and by minimizing double-recombination events. Consistency of segregation patterns with multiple flanking loci constituted support for order. A genetic map of chromosome 17p was completed with 39 markers in 23 clusters, with an average space of 3 cM between clusters. The collection of informative genotypes was highly efficient, requiring fivefold fewer genotypes than would be collected with all the CEPH families. Given the availability of large numbers of highly informative PCR-based markers, meiotic breakpoint mapping should facilitate construction of a human genomic map with 1-cM resolution.

Luteinizing hormone-releasing hormone agonist inhibits cyclophosphamide-induced ovarian follicular depletion in rhesus monkeys

Several investigators have demonstrated that LHRH agonists (LHRHa) inhibit ovarian follicular depletion induced by chemotherapeutic agents in rodents. It is not clear whether or not the same effects occur in primates. Six adult female rhesus monkeys underwent unilateral ovariectomy and were divided into two groups that received monthly injections of either Lupron depot (LHRHa) or placebo vehicle. Both groups received cyclophosphamide (CTX) injections. Weekly blood samples were assayed for FSH, estradiol and progesterone. Mean serum FSH levels significantly increased in the CTX group and significantly decreased in the LHRHa+CTX group. At the end of treatment, the remaining ovary was removed and serially sectioned, and ovarian follicle number and size were analyzed. CTX resulted in a significant reduction of nonprimordial follicles < 50 microns in diameter. The rate of loss of primordial follicles was expressed as a percentage of the original follicle count. During the treatment period, 64.6 +/- 2.8% of the total primordial follicles were lost in the CTX group compared to only 28.9 +/- 9.1% in the LHRHa+CTX group (p < 0.05). The percentage rate of decline per day was 0.120 +/- 0.012 for the CTX group compared to 0.057 +/- 0.019 (p < 0.05) for the LHRHa+CTX group. The findings indicate that LHRHa can protect the ovary against CTX-induced damage in rhesus monkeys.

Physical and genetic mapping of human chromosome 3 loci containing microsatellite repeats

One hundred and six microsatellite repeat-containing loci, including 59 CA-containing repeats from the CEPH/Genethon collection, were regionally assigned on human chromosome 3 using a somatic cell hybrid mapping panel, diving the chromosome into 14 intervals. The others were dinucleotide and tetranucleotide repeat-containing loci newly developed for human chromosome 3, of which 26 were also localized by means of genetic linkage analysis against selected CEPH microsatellites. The regional assignment of these two marker sets in a common mapping panel facilitates their integration. Incorporation of these highly polymorphic loci into the developing physical and genetic maps should provide useful information for studies of various diseases involving chromosome 3.

Effect of BQ-123 and Ro 47-0203 (bosentan) on endothelin-induced vasoconstriction in the rat skin

The effectiveness of intradermal (i.d.) BQ-123 (cyclo[D-Asp-Pro-D-Val-Leu-D-Trp]) and i.d. Ro 47-0203 (bosentan, 4-tert-butyl-N-[6-(2-hydroxy-ethoxy)-5-(2-methoxy-phenoxy)-2,2'-bipyr imidin-4 - yl]-benzene-sulfonamide) has been evaluated on local microvascular responses to endothelin-1 and endothelin-3, measured by a multiple site 133Xe clearance technique in rat skin in vivo. Intradermal injection of endothelin-1 (0.3 pmol/site) and endothelin-3 (10 pmol/site) induced a similar (approximately 50-60%) decrease in basal blood flow in rat skin. BQ-123 (3-1000 pmol/site), a selective endothelin ETA receptor antagonist, caused a significant dose-dependent decrease in the vasoconstriction induced by endothelin-1 (P < 0.05) but was less effective on vasoconstriction induced by endothelin-3. Bosentan (3-1000 pmol/site), a new non-peptide mixed antagonist of endothelin ETA and endothelin ETB receptors, significantly reduced the vasoconstriction induced by endothelin-1 but was less effective than BQ-123. BQ-123 and bosentan were similarly effective as antagonists of endothelin-3. BQ-123 and bosentan had no effect on basal blood flow and no inhibitory activity on vasoconstriction induced by vasopressin (0.03 pmol/site) or phenylephrine (300 pmol/site). These findings indicate that BQ-123 and bosentan are effective and selective inhibitors of the vasoconstriction induced by endothelins in the rat skin microvasculature.

Genetic mapping of the BRCA1 region on chromosome 17q21

Chromosome 17q21 harbors a gene (BRCA1) associated with a hereditary form of breast cancer. As a step toward identification of this gene itself we developed a number of simple-sequence-repeat (SSR) markers for chromosome 17 and constructed a high-resolution genetic map of a 40-cM region around 17q21. As part of this effort we captured genotypes from five of the markers by using an ABI sequencing instrument and stored them in a locally developed database, as a step toward automated genotyping. In addition, YACs that physically link some of the SSR markers were identified. The results provided by this study should facilitate physical mapping of the BRCA1 region and isolation of the BRCA1 gene.